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Critical Conditions Excerpt

     Adrenaline affects my friend Adrienne in the same paradoxical way that Ritalin affects hyperactive kids. It seems to calm her down.
     On Saturday morning, as I was pushing my bicycle through the front door after doing ninety hard minutes on the hilly roads of eastern Boulder County, the phone rang. I was tempted to let the machine catch the call; I wanted to get out of my sweaty Lycra, I needed fluids, and I was desperate for a shower. But I answered anyway, hoping it might be Lauren with some news about her mother.
     Adrienne said, "Hey, Alan, how you doing? It's me." The casualness of her greeting alerted me that something might be up; as often as not she didn't even bother to say hello when she phoned. "Hey, you doing anything? You busy right now? I have someone I think you should see."
     I paused a second as I greeted my dog, Emily, who was pushing her flank against me forcefully, as though I were a sheep she was planning to herd to a different pasture. My pause was also intended to allow Adrienne an opportunity to explain what she wanted. When she didn't, I said, "I just got in from a ride. Where are you, at your house? What's up?"
     Adrienne, a urologist, and her young son, Jonas, were our only nearby neighbors. They lived just up the hill from Lauren and me, in a renovated farmhouse that sat on a rise across the gravel and dirt lane.
     "No, I'm at the hospital. Been playing Zorro with bladder cancer in the OR since seven. Just when I finished up the operation Marty Klein found me and asked me to consult on an ER case, an adolescent female overdose. You know Marty, don't, you?"
     "Yeah, I know—"
     "I'm still here doing the consult, and I think you should see her, too — the kid."
     "Isn't there a psychiatrist on call for that?" Although I did occasional psychological liaison work at the hospital, I didn't routinely consult in the hospital ER, probably hadn't seen a case there in two years.
     Impatience crept into Adrienne's voice. "I didn't say I think somebody should see her, Alan. I said I think you should. Can you hear the difference?" She paused. "Anyway, Levitt's on call."
     Whenever Adrienne had an impulse to assail the mental health profession—not an infrequent urge on her part—Natt Levitt, M.D., was her incompetent-practice poster child.  His name at the top of the ER on-call roster helped explain why I was being drafted to see the adolescent overdose.
     I asked, "What's the kid's condition?"
     "She's critical. Her vitals are ... her vitals are shit. Consciousness is waxing and waning. Her kidney function is way whacked, and she has gross hematuria, which is why Marty wanted me onboard. She's on her way to the ICU soon."
     The severity of the girl's condition was unnerving. Adolescent suicidal behavior is a crapshoot. Sometimes it's manipulative and benign, sometimes it's lethal as hell. Sometimes the kid screws up and actually kills herself when she doesn't really intend to.
     I asked, "Why does she have blood in her urine? She take aspirin?"
     "Don't know what she took. But ultrasound indicates a perinephric hematoma. We'll confirm with CT."
     "Which means what in English?"
     "She has a mild renal contusion, a little rip in her kidney.  So she's bleeding into her bladder."
     "What can cause that?"
     "Fifty different things. Little traumas. Falling out of bed, tripping over a cat. Punch in the gut."
     "Any idea about the precipitant? What does the family have to say? Did she just break up with someone? Problem at school? What?"
     "We don't know anything. Family isn't here. Police say a frantic kid— called herself a girlfriend—found the patient unresponsive, called 911. The friend left the front door of the house open for the ambulance, but she wasn't there when the paramedics arrived. The kid's parents are nowhere to be found. The police are trying to find everybody involved. But we're pretty much in the dark."
     "Has she been oriented enough to say anything since she was brought in?"
     "Not to me. Marty said she asked about her sister. Twice, I think he said. She said, 'Is she all right?' Something like that."
     "And her sister's not around?"
     "No, I haven't seen anybody with her, you know, visiting."
     "Has anyone checked the house for the sister? This could have been some kind of suicide pact."
     "I hadn't thought of that. The police went over to the house after the ambulance picked her up. I'll phone and make sure that they looked around real well."
    "The kid hasn't spoken to you, Ren?"
     "No, since I've been down here she's been in the ozone."
     "Is she going to make it?"
     "She's just a girl, Alan. She damn well better make it."
     "What did she take?"
     "Like I said, we don't know; it's polydrug, probably a cocktail. She responded to Narcan, so some narcotics for sure, and it looks like three, four, five other drugs, maybe more. There was a lot of stuff in the house. We'll be sorting out the toxicology for a while."
     "Because I think you're the right one to see her. That's why."
     "That's not what I was about to ask." It actually was, but I wasn't about to admit it. "What about the attending? You said it's Marty Klein? Is he okay with me seeing his patient? He's the one who'll have to absorb the flack when Natt Levitt finds out he wasn't called first."
     "Done. Marty doesn't like Natt any more than I do. Does anybody like Natt? What keeps him around? I don't get it. Since when is having a medical license supposed to provide as much security as having tenure? But Natt's not your problem, he's mine. The order is written."
     Adrienne laughed. "Most of the time I'm irresistible, aren't I?"
     Adrienne was a true friend. And she asked for few favors, professionally or otherwise. "Yes, Ren, you are." I glanced at my watch. "I have to shower first. I'll try and be there by eleven."
     "I'm sure she'll be in the ICU by then. Look for us upstairs. And Alan, one more thing."
     "I don't think it's too likely you'll get reimbursed on this."
     So what else is new. "No insurance?"
     "Worse, I'm afraid. We're not totally sure of her identity, but if she's who we think she is, admission records for a previous ER visit for a finger laceration show that, back then at least, she was MedExcel. Are you a provider?" 
     "I was. MedExcel and I didn't see eye to eye."
     "What do you mean?"
     "Slight difference in philosophy. They wanted to run the treatment and I sort of thought that was my role. I wanted to be paid and they thought that was pushy of me. Little conflicts like that."
     Her tone was mildly admonishing as she said, "You're just too sensitive for the current managed care environment. There are worse companies than MedExcel, let me tell you."
     "I don't want to know about them."
     "But you'll see her anyway?"
     "Sure, I'll send you the bill, Ren. You're rich."
     She found my threat amusing, "Go right ahead. If you think insurance companies are hard to deal with, wait till you try to get a dime out of me."
     I took a quick shower and thought about Lauren. She was, I guessed, sitting by her mother's bedside in a hospital in eastern Washington. Had she been home, I think she might have said something to caution me about what I was doing.

     I ate a banana and some toast and peanut butter, and poured a cup of coffee for the road. Emily's dish had plenty of fresh water. I have found every intensive care unit I have ever visited to be an eerie place. Almost by definition, ICUs are hallowed temples of tragedy or triumph. The final results of the labors there are binary, either a zero or a one. The practitioners are either heroes or they are failures. The mood in the space, in the area that exists between the linoleum tiles and the ceiling tiles, is subdued, as though the players — the doctors, the nurses, the therapists — don't even pause to acknowledge the immense stakes that are always on the table.
     I greeted the ward clerk in the Community Hospital ICU, identified myself, and asked where I could find the new transfer from the ER.  Without looking up from a duty roster, he asked, "Which one?"
     "Adolescent OD. Female. Don't have a name. I'm Dr. Gregory for a psych consult."
     He raised his head and gestured toward the far corner and said, "Ms. Doe. She's in bed four." As I walked past him he said, "Good luck." In the vernacular, I assumed he meant that for her more than me. A dividing curtain was partially pulled in front of the bed in the distance, so from the nursing station I couldn't see much more than the foot rail.
     I asked, "Is her chart here?"
     "No, her nurse has it out there."
     On the far side of the bed a stocky woman with red hair wearing a brilliant chartreuse top was adjusting the controls on an infusion pump. I wondered where Adrienne was.
     I turned back to the ward clerk and asked, "Is Dr. Arvin here?"
     "Is she the attending?"
     "No.  She's the urologist."
     "The little one?"
     "She's over there, I think, with the patient. Was a few minutes ago, at least. I haven't seen her come back out, but I was in the john for a minute."
     A glass wall separated the nursing station from the eight ICU beds. The moment I was through the glass door into the unit I was confronted with the familiar but disconcerting smells and sounds of last-chance medicine. My breathing grew more shallow.
     I found Adrienne behind the drawn curtain. She was sitting on the edge of a chair, her eyes fixed on the monitor above the bed. The indicator for number of respirations per minute read a sharp red "09."
     Way too low.
     She was holding her new patient's limp hand.
     Adrienne didn't turn, but she knew I was there. She said, "I didn't tell you before on the phone but, downstairs? She was in Cardiac Three. When they brought her in that's where they took her. And that's where I saw her. So this one's special to me. Okay?"
     Adrienne had become a widow in Cardiac 3, the number three cardiac treatment room of the Emergency Room. Peter — her husband, my friend — died in Cardiac 3 after a brutal knife attack.
     I said, "Okay," and touched Adrienne on the shoulder. With her free hand, she felt for my fingers.
     Staring at the bright red numbers on the monitor, I stated the obvious as I gestured at the pale figure on the bed. "She'll be on a ventilator soon, won't she?"
     Adrienne nodded gravely. "Her gag reflex is gone; she's stopped controlling her airway. They're setting up for the vent right now."
     On masking tape at the endrail of the bed someone had written, DOE, M. in bold capital letters.
     M. Doe was a tall girl. In unconsciousness, she seemed to stretch out over the length of the hospital bed. Monitor wires snaked from the upper end of her torso, which was immodestly covered by a pastel hospital gown that had seen about fifty too many washings before it had been pulled over her thin frame.
     "Do you mind covering her up a little better please, Ren?" I asked.
     The nurse turned and said, "I'll do it."
     I thanked her and introduced myself. She smiled at me with a patronizing face that said, "We have a lot of work to do before you're going to do any good."
     An automated blood pressure cuff began to inflate on the girl's upper arm, a drain gurgled, and the infusion pump measured another dose of fluid into her IV tubing. A nice little ICU symphony.
     Adrienne said, "Don't you think she's lovely? I think she's really pretty."
     My first thought was that in these circumstances, no one was lovely. But I said, "Yes, she is," trying to imagine what M. Doe looked like twenty-four hours earlier, and what events, what pain, had brought her here.
     The child moaned and rolled her head to the side. She coughed once, a tiny cough, an infant's cough, before her eyes opened slowly and froze on me. Her eyes were puzzlingly clear, the same luminescent purple as my ex-wife's. And like Merideth's always had, this girl's eyes pierced me instantly in a way that compromised my balance.
     "Hello," I said, moving forward half a step.
     She blinked once before her eyes closed again.
     Adrienne said, "She's done that a few times so far. Don't be fooled, it doesn't mean anything."
     "Is she responsive to pain?"
     "Was earlier, now only minimally to deep pressure. But I haven't played any Barry Manilow CDs yet. That might get a scream out of her."
     I smiled.
     Behind us we heard the squeak and drone of rubber wheels on linoleum. I turned and saw Marty Klein accompanied by a scrub-suited doc whom I didn't know. Behind them, a respiratory therapist was pushing a ventilator and a treatment cart our way. I said, "Hello, Marty."
     He nodded. In other circumstances, I knew we would end up talking about bicycles, my passion, and golf, his. Not this time. He said, "Hi, Alan, thanks for coming, sorry she's not too talkative. We're here to get her on the vent. Step out a minute, please. Okay?"
     "Of course." I had no desire to watch what he was about to do. None.
     Adrienne asked, "Marty, do you need me?"
     "No, Adrienne. We're fine. I'll have somebody call you with the kidney functions as soon as they show any change."
     "You have my home phone?"
     "It's on the chart, right?"
     "Yes. I want to talk with the parents, too. When you find them."
     "I'll find you, don't worry. Get out of here. Go play catch with your son or something," he said as he pulled the curtain farther around the bed.
     I began to follow Adrienne away from the bed when I remembered why I was there. "Just a sec," I said. I walked back and reached inside the curtain and grabbed the chart and flipped a few pages. Beside me, Adrienne had begun pacing. I think Marty's admonition about spending time with Jonas had some special meaning as this young girl hovered near death with her parents nowhere to be found.
     "You have a pen?"
     She gave me one. I used it to sign onto the case and then scribbled a brief progress note that reported an apparent overdose, an unconscious patient, absent family, and no progress. On the order sheet, I wrote, "When patient attains consciousness: Suicide precautions should be in place, including 1:1 staffing x 24 hrs." I also left instructions that I be called immediately when the parents were located or the patient became oriented.
     Adrienne glanced at my notes. "You're ordering a full-time one-to-one? Nursing staff's gonna love that. And MedExcel? Yeah, they'll be thrilled. They're going to reimburse on this, mmm-hmmmm, sure. Probably cutting that check as we speak."
     "She may not be done trying to kill herself, Ren."
     "I know that. I'm just giving you a hard time. With Lauren out of town, somebody needs to, right? You heard from her?"
     "Not this morning, no."
     "You'll let me know?"
     "Of course, thanks."
     I turned back to the admissions data. The data field was mostly blank. But the first line read, "Doe, Merritt."
     Out loud, I said, "Her name is Merritt."


Critical Conditions (USA)

Signet Paperback,  ISBN: 0451191706

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