Tuesday, September 3, 2013

Treating Murder Book excerpt

TREATING MURDER Chapter 1 Things would have been so much easier if I had known that the condition I was treating was in fact, murder. The outcome for the patient, well— all involved, but especially the patient—could have been so much better. I don’t blame myself for this…anymore. Unaccustomed to the bright sunlight, I started sneezing as I walked out of the medical school library, and cursed under my breath at the hypersensitivity of my pale, blue eyes. A med student strolling up the stairs in his short, white intern’s coat glanced up, saying, ‘God bless’ as he passed. I had just spent the last several hours searching the stacks for information on different treatments for multiple sclerosis. In fact, I had spent the last few months researching online, and in all of my medical journals, and had found nothing that would help me treat Sarah Summers. This morning, I had driven down to my alma mater to see what else I could learn. Now, having failed in the library, I had one last resort, my friend and mentor Ellen Krauss. I walked across the grassy quadrangle toward her office, reminiscing about my days in school. I missed being a carefree student, and only wished I still looked like one. Not that I look too bad now at thirty-two, but my cheekbones are certainly more prominent, and several brunette hairs have defected to gray around my temples. At the entrance to the old stone building, I paused to let another student pass. He held the door open for me. “Thanks,” I said as I maneuvered past him to climb the four flights of stairs. At the landing, I stopped again, gulping air and letting the burn in my calves subside. My daily jogging should have made that climb easier. As I glanced down the hall, an amused “Ha!” escaped my lips before I could stop it. There were several disheveled stacks of journals piled outside the door. Dr. Ellen Krauss’ papers had finally succeeded in overtaking her office, and were on their way to conquering the fourth floor. I always knew they would. The woman was an incurable packrat, if not quite a hoarder. “Nic? Is that you?” called a disembodied voice. “Yes,” I answered, smiling and hurrying the rest of the way to her door. I picked my way carefully around the stacks as I crossed the threshold. “Foof!” I blew out an upward breath, lifting my slightly damp bangs off my forehead. “Yes, it’s me. How’d you know?” “Why would I no’?” She smiled and gestured at an overflowing chair. There was the hint of a lilting burr in her voice that identified her as a Scotswoman. “I never forget a laugh, and I’m sure no one could ever forget yours; ye sound like a goose choking when you laugh. It’s been a while since I last heard it, though. Your practice must be keeping you busy.” Krauss stood as she spoke, and took a couple of chilled cans of Coke from a tiny refrigerator in the corner—a corner which was nearly hidden beneath its own stack of journals. She handed me one, then popped hers open with a hiss, a ritual of ours that had become automatic over the years. “So what brings you nearly a hundred miles to see me? Not a social visit, I suppose?” Before replying, I took a long sip of the icy Coke, taking a moment to savor the unique pleasure of that first tangy bite. I scooped a pile of files off an old wooden school chair she gestured to, and stacked them on another pile nearby. “No. I wish.” Plopping down in the seat the way I had a thousand times, first as a student, then as a resident, I said, “I came here to do some research. When I finished in the library, I thought I’d drop by.” Krauss sat down and chuckled, “Alright, my wee information hound. What kind of research would bring ye all the way down here?” I smiled. Our friendship had grown out of our mutual thirst for answers. The kind of thirst that slakes itself on stacks of journals, and then not yet satisfied, saves them all in case it might later discover a missed drop of knowledge. For the record, however, my journal collection is actually filed and organized on my laptop. I said, “The kind of research I was hoping you could help me with.” Dr. Krauss smiled and raised an eyebrow. “I have a patient with multiple sclerosis. For years she’s been stable, with only infrequent mild attacks that we controlled well. Now, for the past several months, she has had a completely downhill course—no remissions, no rebounds. Every medication has stopped working, and I’ve tried everything out there. I was looking for another approach, something that may not have hit the mainstream yet. I don’t know what to do, and frankly we’ve run out of options.” Krauss nodded and leaned forward on her desk, pushing her reading glasses up on her nose. “So what did you find out?” The window behind her needed washing. I stared past the grime as I considered what to say. Same grime, same streaks. It felt like home here, but this was not the same old school debate on another interesting academic conundrum. A life depended on the answers, so my tension did not lift, and the pleasure of our meeting was not what it could have been. “Well, nothing helpful. Everything I saw was old news. I’ve tried my ABC’s, then the rest of the alphabet.” I smiled wryly. “Tysabri worked best, but lately, nothing helps. Rebif helped some… for a while.” I took another drink of my Coke. “Sometime back, I saw a Newsweek article that mentioned someone doing bone marrow transplants with some success, but I can’t find anything on it in my journals. I don’t know who did the research, but I’ve got to find it, to see what they did, and if it really worked. I feel like it could be her last chance.” Krauss wrinkled her nose and nodded slowly. “Aye. I’ve seen something about that. Wait a minute, let me think.” She got up and turned slowly around the room, not really focused on anything, looking for all the world as if she was listening to someone I could not see. “Let’s see,” she muttered, continuing the slow spin. “Here.” She stabbed a pile of journals with a finger like a divining rod. I shook my head although I had seen the strange ritual before. Housekeeping was absolutely banned from the office. Years ago, she’d nearly gotten one poor girl fired for coming in and cleaning off her desk. “Here it is.” She pulled a journal from somewhere near the bottom of a stack and handed it to me. “They didn’t do it here at Emory, but it looked like a good study. I think the general conclusion was that it was effective in survivors, but too risky for the average MS patient because the mortality was rather high.” I slouched in my chair and flipped through the journal. “I guessed as much, but she is dying. It’s hardly increasing her risk.” Suddenly, all I could see was Sarah Summer’s wasted body at her last visit. She had vision in only one eye; a plaque on the optic nerve blinded the other. Her crumpled posture in the wheelchair spoke volumes, accusing me of failure. Even her graying skin haunted me. Sarah had been my patient for years, beginning when I was still a resident. Then she followed me to my new practice, after she wound up in Rome herself. Her loyalty gave my professional pride a boost in my first year of practice, but the price of that boost was the crushing sense of responsibility I felt now. Her life and mine were linked; her decline felt like mine as well. Sarah was twenty-four, and had a job at a mill, Ness Inc., where she loaded plastic rolls into a machine that meted them out into squares for packaging. When her legs became too unsteady to walk a straight line, much less stand for eight hours a day, she moved to a sorting table where she could remain seated. But with her hands so unsteady, she managed next to nothing. Ellen cleared her throat, startling me. I looked around and remembered where I was. “What?” I asked. “I said, what have the rheumatologists said?” “She quit seeing the one I sent her to, and refuses to go back. I’ve kept him in the loop though. He says he’s baffled by the acceleration of her symptoms too.” I shrugged. “He doesn’t really have much to add.” Krauss frowned, contemplating for a long moment, and then clasped her hands under her chin and propped her elbows on the desk. “Nic, is this the same MS patient ye were treating when you were here as a resident?” “Yes.” Krauss nodded. “She was a pretty young girl. That was a good catch ye made, picking up her diagnosis so quickly. Remarkable really. So, she followed you into private practice? Wise of her.” Krauss paused again. “Harder for you though, hmm?” I nodded, willing myself not to picture the healthy, vibrant girl Sarah had been when I met her. “Nic, ye spent a lot of time on her while she was here. She was a fairly needy case as far as I can recall.” I nodded. “I assume that she remained so?” “Yes.” I said. Krauss bit her lip considering what to say next. “Ye have a tendency to get too wrapped up in your cases, aye? This one in particular you had trouble with before. Ye need to distance yourself a bit.” I ducked my head slightly, abashed. “I know. You’ve told me before. I try to stay detached. I just feel such a responsibility.” “Yes, but ye’ll burn yourself out. To quote Hippocrates, ‘Life is short, the art long, opportunity fleeting, experiment treacherous, judgment difficult.’ Be careful, my dear.” I got up and nodded again, leaving the unspoken possibility of Sarah's death hanging in the air. “Thanks, Ellen.” I smiled at her warmly. “I appreciate everything.” Sarah’s visit came a week later. I’d been rehearsing what I had to say all morning, and forgot it all the moment she arrived. I took her into my private office, where my old medical textbooks are lined up in a glass-front bookcase across from the desk. I enjoy my office. It’s the place where I feel most happy and comfortable, and consequently, I guess paradoxically, where I deliver the most bad news to my patients. There are two mahogany framed chairs of teal, slubby cotton in front of my desk for patients and family members. Beside the desk a large picture window that lets plenty of light in, as well as a view of the Appalachian Mountains. I hope it is tranquil and different enough from the sterile, white exam rooms to put patients at ease, and make it easier for them to hear whatever news I might have for them. I’d brought Sarah into my office multiple times to discuss her condition, and so I hoped that she was comfortable in there by now. What I was going to say required her complete attention and comprehension. Sarah rolled her wheelchair up beside my desk, and I took a seat by her in one of the teal chairs. I leaned in toward her, searching for the right words. She regarded me dully. “Sarah, you know that I went down to Atlanta looking for help.” A nod. “I didn’t find much.” Another nod. Sarah picked at her sweater with her better hand. She wouldn’t meet my gaze. I twisted slightly in my seat. The sunlight seemed too strong now. Too blatantly optimistic. “We’ve, uh, run out of options.” My throat felt like someone had wrapped a rubber band around it. I swallowed hard, put on my confident face, and went on. “We have to make some decisions about how to proceed.” Sarah looked up to meet my eyes. “I don’t want to die.” She leaned on one hand to shift her weight in the wheelchair, grunting with the effort. I cleared my throat, looking away first this time. Inhaling deeply, I forged on. “There has been some work done with bone marrow transplant in multiple sclerosis cases. The actual transplant protocol is well established. The centers that tried transplant in MS did see good results...in the survivors.” I could feel Sarah’s eyes on me. “It's extremely risky. We have to kill all of your bone marrow first. The theory is that it’s your own misdirected white blood cells that cause the damage to your neurological system. Once those are eradicated, new, normal cells are introduced, and there are no more attacks on your nerves.” I clamped my lips together before going on. “The catch is that during the period while the new cells are taking over, your immune system will be practically nonexistent. If you were to catch a cold or get an infection during that time, or if the transplant failed, you could die.” Sarah looked over at my bookshelf and squinted with her good eye trying to read the title on the spine of the book nearest her. “Like one of those cancer patients?” I nodded. “And if I don’t do it?” I tilted my head slightly, “Your condition will probably continue to worsen. It is possible that it could remit and you could return to your former baseline, but I think that’s unlikely considering your recent history.” Sarah swallowed hard, but managed a brave smile. “Then I really don’t have a choice, do I? Every day I lose another piece of me.” She paused for a breath. Her face was ashy, with a sickly grayish tinge to it. “And you say my memory will go too? Then what? A nursing home? I can’t do that, I’m not even twenty-five years old!” I straightened up in my seat. “So you want to try the transplant?” She nodded. “Then we’ll plan to do it.” I put on my brightest smile, and headed over to page Vickie, my office manager. Sarah looked up at me. “Dr. Lane?” “Yes?” I paused. Sarah’s eyes wavered. She started to speak, stopped, started again. “Thank you, Dr. Lane, for taking care of me. I just, I mean, you mean so much to me. Nobody’s ever cared for me so much. You’re everything to me. Thanks.” I flushed slightly, flabbergasted. “Thank you, Sarah. That means a lot to me.” I sat back down and held her hand. “I’ll do the best I can for you.” “I know. You always do.” I closed my eyes for a long moment to prevent the tears I felt forming, and called Vickie, quickly resuming my composed facade. Then I walked around behind Sarah to push the wheelchair. My hands shook slightly on the handles as I took her back to the nurse’s station and assured her that we would start setting up her admission to the hospital and would let her know in a few days. Oh Lord, this had better go well. I mumbled a prayer, hoping there was someone out there to hear it.   Chapter 2 Vickie called the insurance company for pre-approval, and got turned down immediately by Kinder Benefit Health Care. They refused consent because it was, as they said, ‘experimental therapy’. As soon as Vickie reported back, I called them myself. This was going to take some serious pushing. “KBHC. This is Fiona Crawford. How can I help you?” “This is Dr. Lane. We just called to pre-authorize hospitalization for Sarah Summers. She’s being scheduled for bone marrow transplant.” I drummed my fingers on the desk while the woman tapped on her computer. At least she didn’t put me on hold. I glanced up. Damn, there’s a new stain on the ceiling. The roof’s gotta be fixed again. “I have your request in the computer. Again, we will not be able to approve that because of the experimental nature of the therapy.” I snorted. “Bone marrow transplant is expensive, not experimental. It’s been an approved technique for a number of years now. Maybe you should update your computers.” Okay, that was a little snarky. “We’ve looked at Ms. Summers’ policy. There is no exclusion.” I toyed with the coil on the handset. “Dr. Lane, it is not linked with multiple sclerosis. The approval is for cancer.” I sighed and rolled my eyes at the phone. “You and I both know that new uses for meds don’t go back through the FDA. It’s too expensive. And we both know that off-label uses are covered by insurance so long as the medication itself is approved. Bone marrow transplant has been shown to be beneficial in multiple sclerosis. It destroys the white blood cells that are attacking the nervous system in the same way that it destroys the cancerous white blood cells in leukemia. I will be happy to fax you copies of the journal articles if you would like.” I paused, then added, “We’re talking about the life of a young woman.” I’d played the insurance game often enough to know how to get approval. Kinder Benefit was one of the major carriers in the area, so I’d had discussions with Crawford many times, not just over Sarah. I’d dealt with one of her co-workers too. He was a buddy of my ex-husband Steve, and not on my nice list. “I’m not going to be able to approve it,” said Crawford. “It’s not on my list.” She sounded impatient. She was probably tired of these battles too. I took a deep breath and held it. I didn’t have time to argue my way up the chain of command at the moment. “Okay, thank you.” I hung up. Sometimes it helped to pressure the company with the possibility of legal action, particularly if they were making a call in what might be considered a gray area like this. I would get some advice from my friend Jacqueline, a lawyer, before I called back. After the last patient of the day finally left, I collapsed into my desk chair and leaned back to rest my eyes for a few minutes. I dialed Jacqueline’s number by rote, and spoke with her for a few minutes before calling Kinder Benefit back. Out the window, the sunset reflected shades of purple off the surrounding foothills. I enjoyed the view as I dialed the number for KBHC. I got Fiona Crawford on the phone again—a surprise given how late in the day it was—but again she denied her ability to approve the claim. “If you can’t approve it, then find me someone with the authority to approve it. Legally this treatment should be covered under her benefits.” I all but growled into the telephone receiver. “I’ve spoken to my attorney about it.” “Okay, Dr. Lane.” Crawford sounded irritated. “I’ll speak to my department head and get back to you.” “I’ll have her in the hospital two weeks from Monday to start treatment,” I said, giving them a time limit for their decision. Otherwise, they would try to wait me out, attempting a filibuster with all the gravity of congress. I hung up the phone and sighed, more annoyed than I had expected to be. Sometimes trying to explain the medical side of a decision to business people required more patience than I had. Two weeks from Monday came and went. After making several more phone calls and threatening them with wrongful denial of a claim, I finally got approval. Then another two weeks went before we were able to admit Sarah to the hospital. The week before my original admission deadline, Dr. Denby had seen Sarah in his office. It was unlikely that he would find a bone marrow donor, he'd said, because Sarah had no living relatives. Great. All that, and we couldn't do the transplant because we had nothing to do it with. But two weeks later, Dr. Denby called to say he’d found a compatible match on the national registry. Dr. Denby was around seventy. He could have retired, but he loved what he did so he continued to practice. The first time I ever saw him, he was shuffling down the hall on rounds, greeting every nurse by name. There were stories among the nurses that dying patients would hang on through the night just to see him on his rounds, and that many had expired after his visit, as though they had delayed death just to see him one last time. Sarah’s first round of chemotherapy, to destroy the original defective cells, was scheduled by Dr. Denby to begin early on the first day of her admission. I planned to stop by on my rounds after office hours to talk to Sarah, and relate more about what to expect during the week. Just after five o’clock, I arrived in the medical records department of the hospital to dictate some of my more delinquent charts before completing my evening rounds, and seeing Sarah. The record room overflowed with stacks of manila folders lined up along the walls with multi-colored ID numbers facing out like confetti. One day, hopefully soon, the hospital would catch up with technology. The charts needed to be put into an electronic medical record database in the worst kind of way. The only other person with me in the records department was a clerk behind her computer at the end of the cramped L-shaped room. She glanced up and offered a half-smile as I collected my pile of charts from the rack and found a carrel to start my dictation. Immediately, a metallic voice spoke overhead, startling me so that I stopped to listen to the announcement. “Code Stat 3A, Code Stat 3A.” That was the wing where Sarah was. My heart sped up. I hovered over my seat unsure whether to stay or go, waiting to hear whom it was. I jumped anyway when my phone buzzed in my pocket. I shoved my charts off to the side as I rushed out, not bothering to call back. The floor secretary on 3A would see me soon enough. Hurrying down the corridor, I reminded myself not to break into a run. I was mumbling to myself, trying to imagine what could have gone wrong so quickly, when I stepped through the doors of the elevator. Several heads turned to stare at me. One look at my distraught face, and lips moving inaudibly, probably convinced them that I was in need of medical, make that psychiatric, attention myself. I shut my mouth and stared straight ahead. In Sarah’s room, there was a full team of nurses and anesthetists already in action. They handed control of the code over to me when I arrived. The nurse anesthetist turned to me as he finished placing an endotracheal tube down Sarah's throat, and began squeezing a large purple air bag rhythmically between chest compressions, to simulate breaths. He said, “They called the code when the tech came in here and noticed Ms. Summers was not breathing. She was pulseless and apneic at that time, but we don't know how long she had been in that state since she was not on a cardiac monitor. Defibrillator pads showed asystole. We began CPR at once, but she’s still flatlined.” I pulled on a pair of gloves as he spoke, and turned to look at the monitor where occasional irregular waves were visible. “Hold compressions.” The patient care tech, who had initially triggered the alarm, straightened and glanced at me with a look of relief for her moment’s respite. The waveforms disappeared, replaced by an ominous straight line. “Resume compressions.” The tech bent back to her work, counting under her breath, and pausing regularly to allow for a breath cycle. I put my hand on Sarah's upper thigh palpating for her femoral pulse. Even though I knew that it was a false beat I felt, I was reassured by it. We were circulating oxygen, and that would sustain her brain and organs for the moment. “We have a pacemaker?” “Yes ma’am.” A nurse standing by the code cart held up the defibrillator pads, and passed them across the bed to me. I slid closer to the head of the bed and interrupted the tech and her compressions again to place the pads on Sarah’s chest. Another nurse quickly passed me the leads and we connected the transcutaneous pacemaker. If there was any electrical activity in her heart we would encourage it. “Okay. Clear.” I nodded to the nurse by the defibrillator. He clicked over to pace mode and pressed the button. I held my breath and watched the monitor. Five seconds, eight seconds, ten seconds. Still no waves. I let out my breath again. Damn. “Okay, resume compressions. Get me 1 of epi.” I glanced around the room, thankful to have such a well-trained code team present. Everyone knew their jobs, knew what was coming before I even said it, and moved swiftly without fumbling. “Epinephrine is in,” said the nurse by the cart. I nodded and repeated the pacer trial. Again we dosed the epinephrine. Then again, and again. My stomach clenched. Another nurse replaced the tech at her compressions. I stared at the monitor with every pause, willing Sarah’s heart to beat, to let the pacer spark a response. I wanted to kick the bed, to kickstart her heart back into action like a flooded engine. We cranked and pumped, cranked and pumped. Sarah! I wanted to scream at her. Sarah! Wake up! The nurse anesthetist looked at me. “Dr. Lane?—It’s been thirty minutes.” Everyone paused with their eyes on me. I swallowed. “One more time.” He nodded faintly, and the motions resumed. A trifle less enthusiastically than before, I thought, but maybe I was imagining things. After all, they had to be tired, I was limp with fatigue. Again, the compressions paused. Again, I faced the monitor, the judge of all our efforts, as the final compression waveform traced its way across. I waited, and... nothing. I continued to stare at the traitorous monitor. The face of the grim reaper. And I did kick the bed. Hard. Startled, the others stopped and looked at me. “Okay.” I said in a strangled voice. “Call it.” The tension drained from the room immediately, quickly replaced by a sense of failure. The team members were silent as they began removing the various leads and tubes attached to Sarah’s dead body. I sank into the visitor’s chair and stared as people began to file from the room to return to whatever duties they had been attending before the code was called. Within two minutes, everyone except for nurse anesthetist was gone. He paused to give my shoulder a squeeze as he passed. Then I was alone. I stood to pull the curtain around the bed, and took Sarah’s hand in mine. On the bed lay Sarah—alone, orphaned, and now gone. Her dusky, white face was distorted by the disconnected ventilator tube, which reared its knobby, white head from her slack mouth like some kind of movie alien; its very presence a violence and a violation. The tiny room was hot and suffocating. More so now, because of the dull polyester curtain I had pulled closed around three sides of the bed, which now clung to the backs of my legs when I stood up. I felt trapped and edgy, verging on panic. I took a deep breath, trying to lift the pressure weighing on me. Stiffly, I released Sarah’s hand and started checking her body, lifting the sheets, looking for signs of allergic reaction: a puffiness of the legs or hives on the skin. I was looking for something other than the signs of malnutrition her body bore, something to explain why she was dead. There was nothing. I sighed, and sat down on the edge of the bed, staring for a long moment at her lifeless face. I yanked out the alien tube and bent over her. “I’m so sorry, Sarah,” I whispered. I turned and walked out into the glaring light of the hallway, avoiding the glances from the nurses at the station, to put a final note in Sarah Summers’ chart. My hand trembled as I turned the pages, but no one paid any attention. Dr. Peter Zacker appeared around a corner, still too far away to see my distress. I gave him a grave nod and looked back at my chart, hoping he would see that I was busy, and not stop to chat. He was a member of my call rotation and we spoke frequently, but we were not close, and I was not feeling sociable, to say the least. “Hi, Veronica. How’s it going?” I looked up with another stiff smile, pretending as always that his high-pitched voice didn’t grate on my nerves. “Hi, Peter. I’m just reviewing the chart on my patient.” “Was that the code I just heard up here?” “Yeah, it was.” I flipped a page and tried to look occupied. Sally, the nurse who had been in charge of Sarah Summers, chose that moment to appear. She cleared her throat to get my attention. “Dr. Lane, I can’t believe how she died. I’ve worked the cancer ward for eleven years, and I’ve never seen a patient go like that. One minute she was cheerful and talking, the next she was dead.” Sally stopped and looked at me clearly expecting an explanation. “What time did she get her chemotherapy?” I frowned in thought. “Two o’clock. The meds were delayed getting to the floor.” I scratched my head. “That’s about enough time for an allergic reaction, not much else, but I didn’t notice any edema or urticaria. Did she have any other symptoms?” Sally shook her head. “No. Nothing. She was smiling and talking at four-fifteen when I checked the room. I came back right after five and she was gone.” Before I could respond, a call bell rang and pulled Sally away to other duties. Zacker remained, hovering by my elbow during the exchange. He raised an eyebrow. “What was her story?” “We were going to do a bone marrow transplant for multiple sclerosis.” I answered. “You’re kidding?” Zacker’s voice screeched in disbelief. “What in hell were you thinking? Bone marrow transplant? Why weren’t you using Rebif?” I eyed him narrowly. Peter Zacker was a cookbook man. He carefully followed the path and pattern of those who had gone before. To him, practicing medicine was like following a recipe. It was satisfactory medicine, and I could trust my patients to his care when he was on call, but it lacked heart. Modern medicine was built on the backs of great innovators. Zacker’s kind would still be bleeding the evil humors out of people if they were the only practitioners. I blew my bangs off my forehead in consternation, one of my nervous habits. “I tried it. She failed everything, and this was her last shot. She knew the risks.” I closed the chart with a snap and stood in preparation to leave. I really didn't feel up to a debate of philosophy. Zacker obligingly stepped back, but I noticed that he tipped up the chart and read the nameplate as I started down the hallway to finish my rounds.