Mercy

CHAPTER 37

The automatic doors of the ICU swung open and in came Shirley Mitchell. Shirley was not Julie’s first patient to come back to the unit on a hospital bed, nor would she be the last. This time, instead of pneumonia coupled with peripheral artery disease, Shirley had returned to the ICU with serious GI bleeding. The nurses watched her carefully throughout the morning, but her bleeding persisted and her blood pressure had begun to drop. Shirley received one unit of blood and two more were on the way.

Julie put on her protective equipment: a blue plastic gown, gloves, and mask with a splatter shield. She would be prepared for any brisk bleeding. During the initial examination, Shirley was agitated, swatting at the nurses, refusing to have leads placed for telemetry, and making a grab to pull out the IV. At one point she yelled, “The movie is over and I don’t want any popcorn!”

Clearly, Shirley was not at all herself. Julie checked the readouts after the nurses finally attached her to the telemetry monitor, blood pressure cuff, and pulse oximeter.

Oxygen level was only about 87 percent on three liters nasal cannula. Her heart rhythm was irregular and fast, alternating between 115 to 120 with frequent bursts to the 140s. Blood pressure rang off as critical: seventy-eight over forty-four. They were behind. The bleeding was obviously profuse and Julie needed all hands on deck. She started with the litany of orders needed to save Shirley’s life.

“Nancy-hang two liters of nasal saline, wide open.”

“Vicky-call the blood bank and tell them to send two units of blood superstat. And to prep for four more units.”

Marie, the secretary, poked her head around the corner. “Dr. Devereux, I seated the family in the waiting room. I told them it would be a while until she stabilizes. Anything else you need?”

“Thanks, Marie, I’m good.”

Julie examined Shirley’s battered arms. No nurse would be successful in finding another IV site anytime soon. Placing a central line seemed inevitable. But to start, Julie needed to develop a plan of attack to stop the bleeding.

Her first phone call was to the gastroenterologist, Dr. Morgan. After some negotiation (necessary when dealing with a specialist) it was decided to proceed with a CT scan of the abdomen, to be followed by a colonoscopy after the patient stabilized. Dr. Morgan was betting on diverticulosis as the cause, which in 90 percent of cases would stop bleeding on its own. But when Julie got a call from the lab, plans needed to change quickly.

“Shirley Mitchell’s troponin is ten point four,” the lab tech reported. “And her hematocrit is only twenty-two.”

Julie, her face grave, announced the news to her team. The job of keeping the blood going into Shirley’s body from coming out was easy to say, but harder to do. Those labs indicated the job was far from complete. The CT came back as expected: nonspecific findings. Julie gave Dr. Morgan another call.

“I would consider a colo,” Dr. Morgan said, “but right now, with her lung disease and her heart in bad shape, it’s just too risky. She’ll arrest on my OR table.”

“But, Jim, she needs a better blood count to stop the heart attack, which won’t happen unless you get in there and stop the bleeding.”

“Seriously, Julie, this lady is a train wreck. I don’t need the quality safety committee after me when she dies from the colonoscopy. Call interventional radiology, I think Kim is on. She’ll help you.”

Julie picked up the phone and was connected to Dr. Kim Sung in interventional radiology. Arrangements were made and soon enough Shirley was carted off to radiology. After two hours, Julie took a call from Dr. Sung.

“Hey Julie, I tried my best. I coiled a couple of places, but she is oozing everywhere. She’s like a pincushion. Nothing seemed to help. I think you’ve got to get surgery in on this. I have a page for you. Sorry I couldn’t get it done.”

Julie thanked Dr. Sung for her efforts, but had her doubts about the surgery. If GI would not consider a colonoscopy because of Shirley’s cardiac and pulmonary risk factors, it was likely she would get even more pushback from surgical consults.

Only one option remained-Shirley would have to stay in the ICU, get drugged up, get more swollen, and deal with the pain and bleeding as it came and went like the tides. Julie could provide little in the way of meaningful therapy.

Shirley was brought back to the ICU and awake when Julie checked up on her again. Her eyes were open, but dull as if they were covered with film. Her short hair lay matted and without luster. Her lips were two bloodless threads on a starkly sallow face.

“Shirley, how are you holding up?” Julie asked.

“I want to die,” Shirley managed to say in a weak, gravelly voice.

The words hit Julie hard, and of course she thought of Sam.

“Well, we don’t want that to happen,” Julie said.

“I do. The pain is horrible. I want to be with my Bobby. I want to go with him.”

Bobby was Shirley’s husband of fifty years. There were children and grandchildren in the picture, some now in the waiting room, but in this condition Shirley took no joy from them. Everything hurt, and hurt horribly.

Julie locked eyes with Amber, the young nurse who had cared for Shirley the last time. Shirley’s predicament was indeed dire, and Julie believed the sick woman was justified in her wish to end her suffering. All Julie could do now was manage the pain with a little help from Dilaudid.

While conducting her exam, Julie noticed significant erythema on the back of Shirley’s left hand ringing the 18-G IV. It had not been present at the last check. The red inflammation looked similar to Sam’s outbreak of hives, but distinct enough for Julie to know it was not the same condition.

“How long has she had this redness?” Julie asked Amber, a tinge of concern in her voice.

Amber looked at Julie, a little flummoxed. “I just noticed it now,” she said.

Julie called for a stat surgical consult and while waiting, began her procedures. She placed an internal jugular central venous access line and right radial arterial line. Shirley would need aggressive resuscitation for hemorrhagic shock using fluids and pressors. A full panel of lab work was repeated. Results came back fast, and one got Julie’s attention right away. Shirley’s blood gas reading showed her oxygen level was now below sixty millimeters of mercury, which meant respiratory failure. Shirley actually looked worse than her blood gas indicated. She was pale and sweaty, mottled on her arms and legs. Julie called out to the staff: “We need to intubate in here!”

Additional nursing staff charged into Shirley’s room. Tammy, the respiratory therapist, began bagging Shirley with an ambu bag while Julie set up her endotracheal tube. One nurse was drawing up etomidate and another busied herself with the suction tubing.

The intubation went as smoothly as expected given the circumstances. Shirley was heading toward unconsciousness and very little sedation was needed. Her blood pressure, however, tanked, as usually happens after an intubation, and additional boluses were given.

The surgeon, a handsome man with a Harvard pedigree, finally arrived to do his assessment.

It’s about time, Julie thought.

He was immediately distracted by Shirley’s arm.

“Julie, good thing you called. Looks like she has a NSTI infection.”

Necrotizing soft-tissue infections were increasingly more common at hospitals everywhere, for reasons Julie could not quite fathom. Poor woman. Not only did she have hemorrhagic shock, but septic shock as well. One hour later, Shirley was on her way to the OR for emergency debridement, a procedure she was deemed fit enough to survive despite her fragile condition. The timing of Shirley’s departure coincided with the end of Julie’s workday, but she was not headed for home. She had a stop to make first.

MCI Cedar Junction.

LUCY FOUND Dr. Becca Stinson with her eyes pressed against the lens of a microscope. She tapped the young resident on the shoulder, which caused a bit of a scare, but got her attention.

“Becca, do you have a minute?” Lucy asked.

The question was rhetorical. Everyone always had a minute for the boss.

“Yes, of course,” Becca said.

Lucy brought a clipboard that held printouts with the lab order for Sam Talbot’s stains. She handed the clipboard to Becca. “Do you recall doing these stains?”

As part of their training, residents learned the equipment and procedures by doing tests typically handled by the lab techs. For Becca and her peers, processing stains and reviewing path slides was as common a practice as checking e-mail. Equally common were long hours without sunlight. Lucy noticed Becca’s peaked complexion and how her wide eyes had rings around them, a mark of too many hours gazing through a microscope. Lucy brought the paper trail of Sam’s extensive lab tests, hoping a quick review would refresh Becca’s overtaxed memory.

“This is Sam Talbot, Julie Devereux’s husband, right?” Becca said, while leafing through the pages.

“Fiancé,” Lucy corrected. “And yes, that’s right. I was wondering if you remember anything about the stain.”

Becca’s expression went blank. “Like what?”

“Specifically if the eosinophils in the stain showed up pink.”

Becca strained, trying to recall.

“I think that’s right. It was a long time ago, though. I thought I had put something about allergic reaction in my lab report, but it’s not what’s indicated in the report you handed me, so I guess I’m mistaken.”

“Take a look at this, then. It’s the actual slide.”

Lucy went to the digital slide scanner and in no time had the slide of Sam’s heart on the display screen for Becca’s review. It was the same image Lucy had studied in her office after the autopsy and again moments ago. A sea of purple dots covered darker patches to indicate denser tissue morphology. Each slide was like a little painting, and Lucy found the variations, the differing contrasts, and abstract shapes endlessly fascinating. Like paintings, each slide had a story to tell, but the interpretations were seldom subjective. White Memorial used an automated system to apply the H &E stains, the gold standard for this procedure, and the slide on the screen clearly showed elevated neutrophils. The purple coloring was a common occurrence in myocardial infarctions, but also supported Lucy’s takotsubo theory. End of story. If Sam had experienced some sort of allergic reaction, as Julie speculated, the eosinophils in the slide would have stained pink during the chemical reaction, but such was not the case.

“Like I said, it was a while ago and I’ve done a lot of stains since then. So I guess my memory isn’t so great after all.”

Lucy thanked Becca, who did have a memory to rival Lucy’s. But slides were slides, and memories were not always to be trusted.

IT WAS a repeat of the last time Julie was here. It was how prison life was designed to be-the same thing, day in and day out. Julie had made the call forty-eight hours earlier and gotten on the visitors’ list. A different employee with the same stern look processed Julie’s ID through a standard series of checks. Julie was cleared to go inside. While waiting for the trap guard to show, she phoned Dr. Goodman in the ICU.

“How’s Shirley Mitchell?”

“She’s out of surgery but not hemodynamically stable. Could take another twenty-four hours.”

Or longer than that.

The dark thought passed quickly. There was every chance Shirley Mitchell would never be stable enough to be taken off mechanical ventilation. Julie’s conversation with the sick woman came back to her. “Let me die,” she had said, or something to that effect. Sam had asked the same of Julie, Julie had championed that very right, and Brandon Stahl might be imprisoned for fulfilling that very wish. Julie ended her call with Dr. Goodman and was soon led down a familiar corridor, stuck in the middle of a grim processional.

The trap guard escorted Julie to an empty partitioned section. She took a seat on a metal stool bolted to the floor, and waited. A loud buzzer went off. Looking to her left, Julie saw Brandon Stahl enter the room behind the glass. This time, Brandon did not need to prompt Julie to pick up the wall-mounted phone. He still looked frail to her with his mop-top hairdo, twiggy arms, and a face incapable of hiding his humanity.

“How are you, Brandon?”

Brandon’s expression was grave. “I should be asking you.”

“You heard the news about Sherri, I take it.”

“We may be locked up from the outside world, but we’re not cut off completely. Tragic.”

Julie returned a skeptical stare and said nothing for a time.

“You don’t think I had anything to do with her death, do you?” Brandon asked.

“Did you?”

“No,” Brandon said emphatically.

“I saw the bullet hole in Sherri’s head, and it’s not something that will leave me anytime soon.”

Brandon’s eyes flared. For the first time Julie saw in them a look befitting a hardened criminal.

“Have you come here to tell me you’re not going to try to help anymore?”

“No.”

“Good. Because I had nothing to do with that poor girl’s murder. I don’t care if she testified against me or not. What happened to her was a horrible crime. But I didn’t send any inflammatory messages to my so-called devotees, like some of the news reports implied. Contrary to popular belief, I do not want to be, nor should I be, the poster child for mercy killing. Don’t thrust that mantle on me.”

Brandon jabbed with his finger. “I never asked one person to stand outside the prison and protest on my behalf. They send me letters all the time with stories about their sick mothers and fathers, aunts, uncles, whatever, and ask for my advice on how to kill them. How do they get the drugs? How do they properly inject them with a needle? Like I’m Dr. Kevorkian’s protégé or something. That’s my legacy. I’m the how-to-do-it guy for murder.” Brandon shook his head in disgust. “That’s not me. That’s not who I am.” His eyes narrowed. “I’m just a nurse. That’s all I ever wanted to be.”

Tears almost came to Brandon’s eyes. He could cry, and would not be alone. On both sides of the partition tears flowed freely, and the emotions spilling out were raw and unfiltered.

“I want you to try and remember something for me,” Julie said.

“Okay.”

“Did Donald Colchester have any allergic reaction that you can remember?”

“Allergic reaction?”

“Anything that stood out in your mind.”

“That’s a long time ago, and I’ve had a lot on my mind since then.”

“Understood. But I’m looking for a link between Sam’s case and Donald’s.”

“And you think it could be allergy related?”

“We’re having a hard time coming up with an event that could cause these disabled men to have been scared or stressed to death.”

Brandon leaned back in his chair, lowered his gaze, and folded his arms. “Did you look at Sam’s medical record?”

“I did,” Julie said. “But nothing jumped out at me.”

Brandon rubbed his chin, deep in thought.

Julie’s mouth formed a grimace. She wanted an answer, a bit of light shined in the dark.

“Are you thinking an anaphylaxis-type allergic reaction?”

“Doesn’t even have to be that severe.”

“And there was nothing in Sam’s file?”

“No. And I looked it over very closely.”

“What about Colchester’s file, then? Did you look at that?”

“It’s gone.”

“Gone?”

“As in, deleted from the EMR system, or some glitch. IT can’t figure it out. Believe me, I’ve asked. Best I came away with is a help desk ticket, which is why I’m counting on your memory.”

“Seems funny, you know. You looking into this and then Colchester’s EMR file goes missing.”

“Yeah, though ‘suspicious’ was the word that popped into my mind. The doctor who took my copy of the file suddenly isn’t answering my calls and surprise, surprise, I can’t seem to get a meeting with him, either.”

“I don’t know.” Brandon held a breath. “I mean, we’re talking a long time ago. Years.”

“Just try.” Julie leaned forward and put her hand against the glass. “Was there anything?”

Brandon groaned, closed his eyes tight, and grabbed a clump of his hair as if it hurt to think that far in the past, to think about it at all. Then his eyes sprang open and he looked almost pleased.

“I got something,” he said. “I just remembered. It was horrible, too, because he was paralyzed.”

“What was horrible?”

“Urticaria,” Brandon said. “Hives. A bad case of them, too. They just broke out one day. We gave him antihistamines of course, but I spent a lot of time putting cold compresses and wet cloths on the affected areas.”

Julie’s stomach dropped at the same time her mouth fell open. So much had happened since the accident. It was all a blur. She had cared for Sam, eaten lunch with him, cried with him, nurtured him, brought in Michelle so he would stop begging to die-all while working her job and looking after Trevor. Of course it could slip her mind. Hives. And Julie now knew exactly what entry someone had deleted from Sam’s medical record.