Elena knew the moment she walked into the treatment room that this was no case of simple acid reflux. According to his paperwork, the man on the gurney was in his mid-50s, but he looked ten years older than that. His complexion was ashen and dotted with beads of perspiration. The collar of his dress shirt was loose, his tie at half-mast.
One glance at the monitors above the patient's head confirmed her suspicion. Definite T-wave inversion, ST elevation- myocardial ischemia for certain. No Q waves yet, so it was early. Blood pressure down a bit, although she had no idea what his normal level was. Pulse a little rapid.
Elena ran her eyes down the chart. Oxygen by mask, an aspirin chewed and swallowed, IV started but no drugs given yet, lab work drawn and sent stat. "Nice job, Glenna. But will you raise the oxygen flow to eight liters per minute?"
The ER nurse adjusted a dial. "Our standard protocol is six. Will eight be your usual?"
"Yes, please." Nice. No argument. Elena addressed the patient for the first time. "Mr. Nix, I'm Doctor Gardner, Doctor Sewell's new associate. Tell me what happened."
A middle-aged woman stood beside the patient. Her hands fluttered about like frightened birds. She responded before Nix had a chance to speak. "I'm his wife. He came home for lunch, and right after his first bite of chicken fried steak he clutched his chest and slumped over. That's when I called 911."
Mrs. Nix looked younger than her husband. Elena figured there might have been some nips and tucks along the way to help that image. A few dark roots showed that the woman's blonde hair owed more to Clairol than to Nordic genes. Mrs. Nix would call herself "pleasingly plump." Elena's assessment was "running to middle-age spread."
Elena turned back to Nix. "Are you having any pain?"
He pointed to the midpoint of his chest.
"Anywhere else?"
"My neck and jaw." He indicated his left side.
"Are you on any medications?"
Mrs. Nix dug into her purse and pulled out two bottles. "I thought you'd want to see these."
"Let's have a look." Elena studied the labels. Generic versions of Digoxin and Toprol. "So Dr. Sewell has been treating you for heart failure and high blood pressure."
Nix forced out the words through clenched teeth. "Dr. Sewell, and Doc Gladstone before that."
"Excuse me, Doctor." The ward clerk hurried in and handed Elena a slip of paper with several values written on it. "The lab just phoned with the results of Mr. Nix's chemistries."
"Thank you." Elena studied the figures for a moment. The enzyme levels were rising but were not too high yet. "Mr. Nix, right now you're in the early stages of a heart attack. So far there's been very little heart damage. We need to keep it that way."
"How?" Nix grunted.
"A heart attack occurs when the blood flow to the heart is interrupted. The blockage can be due to a blood clot or an obstruction by what we call plaque-hardening of the arteries. What we need to do is unblock the vessels and get circulation restored." Elena turned to Glenna. "Get some tPA ready, please."
"May I speak with you, Doctor?" Without waiting for a reply, Glenna stepped into the hall.
Elena excused herself and joined her. "What's the matter?"
"You probably don't know this yet, but we have an interventional radiologist on staff. Dr. Rosenberg does all our cardiac angiography. I thought I'd better tell you before you ordered tPA."
Elena felt like kicking herself. She needed to get out of the mindset that when she left Southwestern Medical Center to practice in a smaller community hospital she'd be without all the modern technology on which she'd depended. She silently blessed Glenna for discreetly pointing out the availability of cardiac angiography. If she'd given Nix the "clot buster," the risk of hemorrhage with any subsequent procedure would be multiplied. The angiogram should come first, if one was available.
"Thank you, Glenna. That's my mistake for not asking. Would you please page Dr. Rosenberg for me? And I might as well ask: Do the internists here normally follow these patients, or do FP privileges extend to post-MI care?"
Glenna grinned. "Dr. Sewell fought this battle when she came here. Those patients can be cared for by either family practitioners or internists."
"Good. Since Mr. Nix is already Dr. Sewell's patient, we'll keep his care in the practice. In the meantime, let's get Dr. Rosenberg down here. We have ninety minutes from symptom onset to get an angioplasty done, and the clock's running."
A gentle tapping noise diverted Cathy's attention from the lab reports spread out on her desk. "Yes?"
Jane stood in the open doorway. "Doctor Sewell, there's a call on line one. It's Dr. Gardner."
"Thanks. Would you close the door on your way out?" Cathy punched the flashing button on the phone. "Elena, what happened? Where are you? We tried to call, but you didn't answer your cell phone."
"I'm at Summers County General. Apparently cell phone reception inside the hospital isn't very good. I've had to step outside to get a signal."
"Okay, that explains where you are. Now, why are you there?" Cathy heard the exasperation creeping into her voice. "I'm sorry. I didn't mean to come off sounding like your mother."
"My mother's been dead for so many years, I have no recollection of how she sounded."
Score one for Elena. "I apologize. Poor choice of words. What happened?"
She listened to Elena's story of Milton Nix's myocardial infarction. "Dr. Rosenberg did a cardiac cath. There was a forty percent blockage of the anterior descending coronary artery. Rosenberg was able to open it with a balloon angioplasty. He didn't think a stent was necessary."
"How did Mr. Nix come through it?"
"So far, so good. He's in the cardiac care unit. They tell me that FPs can take care of their own post-MI patients here. I'd imagine you'd want that, but if you'd feel better passing Nix off to an internist, I'll contact one. Your call."
"No, tell him and his wife that I'll be by this evening after I finish in the office."
"Do you want to do that? I can make sure he's okay before I leave, and you can see him on rounds in the morning."
"Fine. Be sure to call me if you have any questions. And thanks for taking care of this."
Cathy was about to hang up when she heard Elena's voice. "What was that?"
"I said I'm going to need a ride to pick up my car when I leave the hospital."
"Why is that?"
Elena cleared her throat. "Well, I was at lunch with Frank Perrin when I got the call. He took me to the hospital, but my car's still back at the office."
Cathy had her choice of sharp retorts, but she bit back all those words. She fought to keep her voice level. "Do you think you'll be finished in another hour?"
"Should be."
"Be at the ER door at that time. I'll ask Will to come by and pick you up."
"Thanks."
Cathy hung up the phone and leaned back. She'd hoped Elena's relationship with Frank Perrin would be limited to the time they'd already spent together. It was nice of J. C. Dunaway to have someone guide the new doctor until she got her bearings. But why did he pick Frank Perrin? Surely J. C. was aware of the rumors.
Of course, Cathy knew they were more than rumors. She had some facts. But how much could she tell Elena?
She picked up the phone again and punched in Will's number. Bless his heart, he was always there to help out-with a ride for a stranded colleague or with advice for his wife who found herself facing an ethical dilemma.
Will pulled his pickup into one of the parking spots designated "Medical Staff." He'd decided long ago that when he was acting as Cathy's agent he was sort of a medical staff member by proxy. Thinking like a lawyer, again. He was out of the vehicle and halfway to the emergency room door when it opened and Elena hurried out.
She climbed in and had buckled her seat belt by the time he resumed his spot behind the wheel. "Thanks for coming by," she said. "I guess I could have walked, but it's a bit too far. Besides that, there's a pretty good chance I'd get lost."
Will stifled a smile. He couldn't imagine anyone getting lost in this town. Then again, he'd lived here pretty much all his life. "It's not that bad. We'll drive you around and help you get your bearings. Pretty soon you'll know our fair city like the back of your hand." Will pulled out of the parking lot, turned left, and pointed. "The office is building is up there, less than a mile away."
Elena ignored Will's pointing finger. "Cathy seemed angry that I had lunch with Frank Perrin. Was it because I didn't accept her invitation to lunch? Did I violate some sort of unwritten rule?"
"I don't recall putting anything into your employment contract about mandatory lunches with your associate. No, I think she was concerned that the person you ate with was Frank Perrin."
Will sensed more than saw Elena grow tense beside him. "Wow. I've made one friend since I arrived in town, and Cathy doesn't like him. Why?"
"Elena, none of us likes to spread rumors, and that's all I have."
"I understand, and I can make up my own mind when I have more facts, but what's the basis for those rumors? Does he kick dogs, take candy away from little children, give tickets for three miles an hour over the speed limit? What?"
Will wondered if this was a mistake, but Elena deserved to at least have more than a nonspecific warning. "All I can say is the consensus around town is that nice women don't go out with Frank Perrin."
Elena kept silent through the remainder of the trip. When Will pulled into the professional building's parking lot, she had the door open almost before the vehicle had rocked to a halt. "Thanks for coming by for me."
Will watched Elena beep her car unlocked, climb in, and drive away. Maybe he'd said too much. On the other hand, maybe he hadn't said enough.
"Good morning." Elena felt her words drop like icicles from a roof, cold and sharp. So be it. That was how she felt.
"Morning," Cathy replied, her voice about thirty degrees warmer than Elena's. "Why don't you get a cup of coffee and join me in my office? I'd like to clear the air about yesterday."
In a few minutes, Elena was looking across the desk at Cathy. Were they going to butt heads over something as insignificant as the person with whom Elena had had lunch? If that was the case, better to find out now instead of later.
Cathy leaned across the desk. "I'm afraid I came off a bit strong yesterday. First, let me repeat that I appreciate the way you handled Mr. Nix's case. This morning I spoke with Dr. Rosenberg, and he transferred care back to me. I plan to send Nix home tomorrow. Dr. Rosenberg agrees with me that you did a nice job."
"Thank you."
"I know you're miffed because I showed my disapproval of your having lunch with Frank Perrin. Let me make it clear. You're free to see anyone you want, so long as it doesn't keep you from your responsibilities to the patients in this practice."
Elena gripped her coffee mug tighter. "Then what was it? Because even though you didn't say it in so many words, you disapprove of Frank Perrin. Why?"
"What you've heard so far is only based on rumors, and that's unfair to you and to Frank." Cathy tented her fingers beneath her chin. "I guess it's time to give you more information."
"I finally got Will to admit that the consensus around town was that 'nice women don't go out with Frank Perrin.' Would you care to elaborate?"
Cathy drew in a deep breath and exhaled through pursed lips. "Okay. Part of this is covered by doctor-patient confidentiality, but since you're now my associate I suppose you're entitled to the information as well, since it concerns this practice."
Elena struggled to keep her tone neutral. "Thank you."
"Since I've been here, I've had two pregnant women come to me wanting abortions. I managed to convince one of them to carry the baby to term, but the other was adamant. I later learned that she drove to Dallas for the procedure."
"What does that have to do with Frank?" Elena said.
"I'm coming to that. Both women were divorced, had been for a couple of years. Neither would name the person responsible for the pregnancy. One followed my recommendation to have the baby. Milton Gaines did the prenatal care and delivery. I later learned from him that Frank Perrin paid that bill."
Elena pondered this. "So Frank was a nice person helping out a woman who made a mistake. I'd think that would be a mark in his favor."
"The clinic in Dallas that terminated the pregnancy of the other woman called our office for information. It seems the receptionist accidentally transposed some numbers and their bill to the responsible party was returned." Cathy's lips tightened. "They wondered if we had the correct address for Frank Perrin."
Elena turned this over in her mind. "That's not exactly firm evidence that he was the father."
"Perhaps, but there are other rumors, ones I can't substantiate, so I won't repeat them. I guess I'd just encourage you to be careful."
"I think I've learned how to assess men," Elena said. Of course, I thought I'd done a good job when I chose Mark, but look how that turned out. No, she had to put that aside and move on. "But I appreciate your concern. So far, Frank has been the perfect gentleman. If I see any evidence that's about to change, I'll back away. Fair enough?"
"Fine," Cathy said. She picked up her mug, took a swallow, and grimaced. "I'm not especially fond of herbal tea, and I hate it when it's cold. I need to nuke this."
Elena rose and followed Cathy out of the office. So this attractive man, one who seemed to be interested in her, might be trouble? Well, she was used to trouble-dealt with it on a regular basis in the ER. She was sure she could handle it. And if it got too bad, she'd take the advice of a former president: "Just say no."
"Dr. Gardner, thank you for coming in." Nathan Godwin gestured Elena to a chair on the other side of his desk.
It struck Elena that what she'd observed before held true here: the smaller the man, the larger the desk. Maybe Godwin was compensating for his stature with a desk that appeared to be large enough to require its own ZIP code. Then again, perhaps he had a lot to do and needed room to work. She put that idea aside when she observed that the vast expanse of mahogany was unencumbered by papers. It held a phone with a handful of pushbuttons, a handsome pen and pencil desk set, and a single photo, the frame angled so she couldn't see it.
Godwin fiddled with the cufflinks on a spotless white dress shirt. "We have in hand your application for privileges at Summers County General Hospital, and they will be acted upon in the usual fashion. But right now we need to address an irregularity."
There was a discreet tap at the door. "Nathan, sorry I'm a bit late. I know how you hate to be kept waiting."
The speaker, a middle-aged man, was tall and muscular, a marked contrast to Godwin. Beneath his white lab coat, he wore an Izod golf shirt and khaki slacks. His wavy brown hair receded ever so slightly in a widow's peak. Rimless glasses did little to hide brown eyes that smiled, despite his neutral expression.
Godwin remained seated while he gestured the newcomer to the chair beside Elena. "Come in, Marcus. Dr. Elena Gardner, this is Dr. Marcus Bell. He's a general surgeon who also functions as our hospital chief of staff."
Bell offered his hand. "Pleasure to meet you, Dr. Gardner. I'm glad Cathy is getting some help. I was afraid she planned to work right up to the time of her delivery."
Before Elena could reply, Godwin cleared his throat and said, "Now that Dr. Bell is here, let's get down to business." He produced a thin folder from his desk drawer, centered it carefully on his desk, and tapped it with a manicured forefinger. "This is your application for privileges. It seems to be in order, but there's one problem."
Elena felt a vein in her temple begin to throb and wondered idly if either of the two men could see it. Had what she'd hoped to leave behind in Dallas reached out to grab her already?
Bell hitched himself forward in his chair and picked up the folder. "What Nathan is trying to say is that you saved Milton Nix's life yesterday before you jumped through all the hoops to be formally granted hospital privileges to do so. I've told him that the awarding of those privileges-already scheduled for the next Credentials Committee meeting-is a slam-dunk."
Godwin drew himself up to his full height, a difficult feat when sitting, and doubly difficult when you're only five six. "Dr. Bell, surely you recognize that privileges are granted to each physician based upon their training and qualifications. We've only had Dr. Gardner's application for a short time. I have not yet seen all her references."
Dr. Bell didn't move, yet gave the impression of a lion crouched to spring on a helpless small animal. "Nathan, I liked it a lot better when our old administrator administered and left oversight of the medical staff to me. But, since you want to make this a contest of wills, I've talked with Dr. Amy Gross, the chair of the Family Practice Department where Dr. Gardner trained. She assures me that when her letter reaches me, along with those of others at that medical center, there will be no question of granting the requested privileges."
"But-"
Bell held up his hand like a traffic cop. "No 'buts,' Nathan. Just before coming here, I spoke by phone with each member of the Credentials Committee." He turned to Elena. "Dr. Gardner, it's my pleasure to advise you that, in a special called vote, all your requested privileges have been granted, retroactive to the moment you walked into the Emergency Room yesterday and took over Milton Nix's care." He beamed, perhaps as much at his triumph over Godwin as in welcome to Elena, and extended his hand. "Welcome aboard."
Elena felt the atmosphere in Godwin's office chill as though an unseen hand had run the thermostat to its lowest level. She tuned out as Godwin and Bell exchanged words that were far from pleasant.
Bell rose. "Well, Nathan, take this to the Board if you want to, but I'm sure you know that your margin there is razor-thin. I'd pick my battles if I were you." He touched Elena lightly on the arm. "Doctor Gardner, let's get out of here."
Godwin was still talking, although with less assurance, as the door closed behind them. Bell steered Elena past the elevators and said, "Let's get some coffee. I'd like to give you a better welcome to the staff than our esteemed administrator has."
They settled in at a table in the back of the cafeteria, each with a cup of coffee. Elena sipped hers and decided that it would never win any competitions for taste.
Bell apparently saw her grimace. "I know. Hospital coffee. And this was probably made for lunch, which was…" He consulted his watch. "Which was at least three or four hours ago."
"That's okay. I've had worse," Elena said. "Thanks for defending me to Mr. Godwin."
"My pleasure. As Chief of Staff, I count the day lost when I can't do battle with our Little Napoleon. But don't let him hear you call him Mr. Godwin. Our esteemed administrator is a physician, or so the diploma on his wall from St. George's University certifies."
"I don't believe I've heard of that one. Where is it?"
There was a twinkle in Marcus's eyes that his glasses couldn't fully hide. "Grenada."
"So he doesn't-"
"I think he may have a license to practice in some state, probably the one with the most lenient board exam, but apparently Dr. Godwin decided early in his career he was more cut out to be an administrator than a practicing doctor." Marcus pushed away his cup, still almost full. "Speaking of medical education, one of the responsibilities I'm saddled with is staff education. How about teaching the next CPR class? The groups are usually pretty small-mainly nurses who need to get certified or renew their certification in basic cardiopulmonary resuscitation."
"I guess I could do that."
"Deal. I'll have my secretary call your office with the details. And since we discussed hospital business, now I can turn in a voucher to get reimbursed for the two dollars I spent for your coffee." Marcus laughed. "I wish I could see Nathan's face when that comes across his desk."
Elena pushed back her chair and reached for her purse. "I guess I'd better be running along. It was nice meeting you. And thanks for the coffee."
Marcus gestured for her to stay seated. "I've enjoyed it too, although I don't think either of us had much of an opportunity to get acquainted with the other. Why don't we rectify that by having dinner together sometime?"
Elena wondered how to handle this. She plastered a smile on her face. "Marcus, I'm flattered. But could I have a little time before I take you up on that?"
"Sure. I guess this is sort of a hectic time, getting settled in and all."
Might as well come right out with it. "I don't guess Cathy told anyone. I'm newly widowed. My husband died six months ago."
Marcus's expression didn't change-score one for him. He reached out and covered her hand with his own. "I'm so sorry. You have no way to know this, either, but I'm a widower, although my wound isn't as fresh as yours. If you'd like to get together sometime for a meal and to talk, please call me. But we won't call it a date. We'll call it therapy."
"You hardly touched your dinner," Mrs. Kennedy said.
Elena forced a smile. "I'm sorry. Your cooking is wonderful, but I'm just not hungry. It's been a long day."
Matthew Kennedy blotted his lips and folded his napkin. "Would you like to talk about it?"
"No, I think I'd like to get some rest. Would you excuse me?"
In her room, Elena made a stab at rearranging her things, but she had no heart for activity of any kind. She kicked off her shoes and sprawled on the bed. Her eyes were closed, but she still saw the drama that was her life as it unfolded like the scenes of a particularly bad soap opera.
The ring of her cell phone brought her back to reality. She dug it out of her bag and answered the call.
"Elena, this is David. Are you free to talk?"
She almost cried. She'd come close to breaking down and dumping her problems on Pastor Kennedy, but something- some innate caution about letting anyone into her world-kept her from doing it. But David knew her innermost secrets. Well, almost all. And he'd be sympathetic.
"I'm free to talk as long as you want, or at least as long as my battery holds out." She added a second pillow under her head. "I never thought I'd say this, but I already miss the medical center."
"I figured you'd be glad to have your residency behind you. No more early morning rounds. No more poring over textbooks and journals to be able to answer the questions of your staff doctor. No more-"
"I still get up early, but it's to make rounds on my own patients. And if I have a question, there's no calling the staff doctor. I'm my own staff doctor. I have to look up the answers, chase down the weird symptoms."
"In other words, now you're a grownup."
Elena realized that what she felt wasn't a longing for the life she'd left behind. What she really missed was the feeling of security that fled with Mark's death. And she had no idea when-or if-that would come again.
"Enough about me," she said. "How about you? What's new? When will you be coming here? Can I do anything to help you get settled in?"
They talked on and on. That was one of the things she missed about having David near. They never seemed to run out of things to talk about.
"And have you heard that Dean Dunston is retiring?" David asked.
"Oh, I have some insider news on that front," she said. "It seems-"
She heard a click on the line and saw there was another call ringing through. The Caller ID read Sum Gen Hosp. "David, the hospital's calling. I'm covering the ER for Cathy, so I need to take it. I'll call you tomorrow."
She pushed the button to answer the new call. "Dr. Gardner."
A familiar voice responded. "Doctor, this is Glenna in the ER. The EMTs just brought in an elderly man found unconscious by his wife. They don't have a family doctor. Could you come in?"
"I'll be there in five minutes. Meanwhile, please-"
"We'll get an IV going, start him on oxygen, draw blood for a stat CBC and chemistries, put radiology on standby for an MRI of the head. Anything else?"
"Glenna, you're a wonder. I'm on my way."
Thirty minutes later, Elena turned to Glenna and said, "I think he's had a stroke. And with his obesity and his uncontrolled hypertension, it's probably a hemorrhagic one. Let's get that stat MRI of the head, and I need to contact a neurosurgeon. Do we have one in town?"
"The closest one is Dr. Shelmire in Denton. Shall I try to get him on the phone?"
"Please ask the ward clerk to do that. Then I need some Labetalol. I'll give 20 milligrams slow IV push to see if we can drop his pressure some."
Glenna had the vial in her hand almost before Elena finished speaking.
Twenty minutes later, Elena cradled the phone against her shoulder as she reached for her cup of ultra-strong coffee from the ER break room. "I've got the MRI right here," she told Dr. Shelmire. She scanned the images. The story they told wasn't good. "It's definitely an intracerebral hemorrhage. I'm guessing a ruptured aneurysm or AVM."
"Okay, I'm leaving now," Shelmire said. "Talk with the family and tell them he's probably going to need an emergency craniotomy. And you might prepare them for the worst-case scenario."
Elena ended the call and headed for the waiting room where the patient's wife and two adult children waited. Although what Shelmire undoubtedly considered a worst-case scenario was death, she knew of an even worse outcome.
Elena swallowed hard to choke back the bitter taste of bad coffee and bile. She knew what she had to do. Talking with the family would be hard, but she'd done it before. Dealing with the consequences of the stroke and the surgery could be even harder, for them and for her.
Elena hovered behind Dr. Shelmire and admired the way he knelt to be on eye level with his patient's family. "Mr. Lambert is in the recovery room," he said. "A vessel in his brain burst, and the accumulation of blood pressed on some vital structures. Even though we got him to surgery within a couple of hours of the injury, some irreversible damage may have occurred."
The thin, elderly woman sat frozen as Shelmire delivered this news. A middle-aged man and woman flanked her, leaning in as though to keep her from falling. "How much damage?" she asked.
"We won't know until he begins to wake up… if he does. I don't look for him to regain consciousness for at least twenty-four hours. If he doesn't, we simply have to wait. Sometimes these patients surprise us."
And sometimes, they don't. Elena turned away and stared into the semidarkness of the waiting room. A television set mounted high in the corner, its sound muted, pelted the area around it with flickering strobes of color. Life moved on in the outside world. But here, for this family, life had come to a dead stop. Now all they could do was wait. Elena wondered if they'd pray, as she had. And if there was no apparent answer to those prayers, would these people ask her or Dr. Shelmire to end their loved one's misery?
Shelmire was patient with the family's questions, the answer to most of them being a simple "We have to wait and see."
He gave Elena a meaningful look, and she returned an almost imperceptible nod. He rose and nodded toward her. "Dr. Gardner practices here, and she'll be looking in on your husband. I'm in Denton, but I'll make it a point to come by every day. We'll consult freely by phone, and if I'm needed I'll come right over."
Elena spoke for the first time. "I haven't had time to have cards printed, but I'm entering the practice of Dr. Cathy Sewell. I'll write down my name and number for you. Feel free to call me anytime." She looked at her watch. A little past 1:00 a.m. "I'd suggest you go home, get a little sleep. This isn't a sprint. It's a marathon. We'll call you if something changes."
An hour later, Elena rubbed her eyes and yawned. Mr. Lambert's condition was stable. What seemed to be an excellent ICU nursing staff was monitoring his status. Maybe she could drive home for a quick nap-at least a shower and a change of clothes-before morning.
"If you need me in the next few hours, here's my cell phone number." Elena handed a card with the information to the charge nurse.
"Thanks, Dr. Gardner. We'll call you if there's any change. But we both know that's pretty unlikely."
Elena wove her way through the dark corridors of the hospital toward the parking lot where she'd left her car. As she stepped through the door, her cell phone chirped. Someone must have called while she was in the hospital and out of cell phone range. She leaned against the doorpost, luxuriating in the feel of the night air against her skin, and pressed the button to retrieve a voice mail message.
"You have one new call," the electronic voice proclaimed. "Wednesday, 12:01 a.m."
Elena wondered who could have called this late when she heard a whiskey alto voice that made her shiver despite the late June heat. "Don't think you can escape. I know what you've done, and you'll pay."