Urgent Care Page 4

  NORA WANTED TO RUN AND HIDE, SLIP AWAY AND find a dark corner empty of memories. Instead, she straightened her shoulders and turned to walk away. She had to get back to work. To her patients.

  Seth stopped her. “Nora. You didn’t kill Karen. It’s not your fault.”

  She didn’t want to lash out at him, but her anger and frustration had no other target. “You can’t say that. You don’t know anything.”

  “I want to. I want to know everything.” He reached for her with both hands, but she pulled away, shaking her head.

  “No. No, you don’t.” She clawed at the neck of the surgical gown she still wore, fighting for air. Her pulse rushed through her, drowning out all sound with its thundering.

  Seth didn’t try to argue or use logic. Instead he stepped forward, wrapping his arms tight around her. He said nothing, merely held her, filling her with his presence. Slowly, one heartbeat at a time, she relaxed, now able to hear the rustle of his breathing, feeling the comforting rhythm of his heart as she pressed her face against his chest. The familiar tang of his sweat—God how she loved that smell, the taste of him—competed against the memory of the sharp, sweet scent of fresh paint, the odor of fear, the taste of her own blood.

  She pushed him away. She was the one who should be comforting him, not the other way around. Besides, she didn’t need him, didn’t need anyone.

  “Nora—” Seth reached for her.

  “No.” The word emerged in a brittle waver. “No,” she repeated, stronger this time. She couldn’t risk it; Seth knew her weaknesses all too well.

  The door banged open, harsh light crashing in on them.

  “What do you want, Lazarov?” Seth asked over her shoulder, addressing the intruder.

  “The cops are looking for you two,” Jim Lazarov, one of the emergency medicine interns, said, with no hint of apology for disturbing them. “They’re pretty mad.”

  Nora clamped down on the emotions the morning had unleashed and turned to face Jim. She vaguely remembered Jim hovering on the periphery of Karen’s resuscitation. “Mad? About what?”

  “Something about chain of evidence—”

  “Chain of custody.” Nora rushed past him, Seth close on her heels as she jogged down the hallway toward OR 13.

  “Nora, what is it?”

  “Oh God, this can’t be happening,” she muttered, her mind spinning with recriminations. She pushed through the door to the OR. Jerry Boyle and his partner were arguing with Miguel.

  “All I do is clean the floor,” Miguel was saying, his face clouded with distrust. “That’s my job. I never touched anything, just mopped the floor.”

  “Who told you to clean in here?” Jerry’s partner, Janet, demanded.

  Miguel pointed at Nora. “She did. She said to wash the floor. I wash the floor.”

  Nora groaned. She turned to the detectives. “I asked him to watch the door.” How could she have been so stupid? “It wasn’t his fault. Miguel was just doing his job.” A job that didn’t normally include standing guard in front of an OR.

  She glanced around and saw that the floor was smeared with soapy water. The only blood came from her own footsteps, her street shoes still carrying traces of it. Karen’s body lay where they had left it, looking untouched—but who could know for sure?

  “Thanks to you, even if we catch this creep, he’ll walk.” Janet Kwon paced the room, agitation bouncing off her.

  “Why?” Seth asked. Jim Lazarov stood behind him, eyes gleaming as he watched.

  “Because there was no chain of custody,” Nora answered him, her voice tight. “We left her alone, Seth. They won’t be able to use any evidence they get from her body.”

  “The autopsy doesn’t do us any good when a defense attorney can argue that someone may have tampered with the body before the medical examiner got to it,” Jerry explained. “But you did a rape kit, right?”

  “Nora did one,” Seth answered.

  “Where is it?” Nora asked, turning to the steel table where she had left the rape kit. “Miguel, did you see a small white box, size of a shoebox? Big yellow sticker on it?”

  He shook his head. “No, ma’am. I didn’t touch anything. All I do is the floor, that’s my job.”

  Nora searched the debris surrounding Karen’s body. Nothing. “It’s gone.”

  THE SCHOOL NURSE, MRS. PRITCHARD, WHO MET them in the hallway outside the Heinz Prep infirmary was different from the one Gina had known when she’d been a student here more than a decade ago, but otherwise, nothing had changed. This nurse wore the same starched white uniform and white stockings, even a nurse’s cap. She looked more like Hollywood’s idea of a nurse than any of the real nurses Gina worked with every day.

  Mrs. Pritchard obviously also felt she knew more than a hospital nurse—or a pair of seasoned paramedics, not to mention a third-year emergency medicine resident. “I gave him a dose of ceftriaxone so as to not waste time,” she reported. “Here’s a complete copy of his chart. He has an IV in his left antecubital vein, and we’ll be starting the rest of the school on rifampin immediately.”

  Trey and Gina exchanged glances as Gecko made a grinding noise with his jaw and turned away to organize their equipment. “Under whose orders did you administer the ceftriaxone?” Trey asked in a nonjudgmental tone, as if he needed the information for his documentation.

  Gina was less diplomatic. “Who’s the idiot who decided to push a broad-spectrum antibiotic before we can document anything? You do realize all of our cultures will be useless now; we’ll have no way of verifying if the kid actually has meningococcemia.”

  Mrs. Pritchard gave a sniff, squared her shoulders, and ignored Gina. To Trey she said condescendingly, “Dr. Frantz is Harold’s private physician, and he gave me verbal orders. He also decided to prescribe the prophylactic antibiotic to protect the rest of the student population.”

  “Did he assess the patient first? Has anyone done anything to confirm your nursing diagnosis?” Gina asked.

  This time the nurse turned to stare at her with an appraising gaze that started at Gina’s cornrows and worked its way down to her black work boots. Then she pivoted on one foot, almost military style, to address Trey once more. “Dr. Frantz will examine Harold at Angels as soon as he’s free. He’s already arranging for an ICU bed to be made available.”

  Obviously, as far as the nurse was concerned, Gina didn’t exist. It was clear she didn’t realize Gina was a doctor. Probably thought her a medic—a junior one at that. Gina opened her mouth, ready to protest, to instruct the woman in the fine art of taking orders from a physician standing right before her rather than a distant voice on the phone, to inform Nurse Pritchard that Gina was once a student here and happened to be the daughter of the world-famous attorney and major Heinz Prep alumni fund contributor, Moses Freeman.

  Then she caught Trey’s warning gaze. He had obviously figured out what was going on three steps ahead of Gina and was, as usual, playing the role of diplomat. “Gina, why don’t you start the patient assessment?”

  She gave Mrs. Pritchard a final glare, pushed past her, and opened the door to the infirmary, Gecko behind her with the gurney. There, sitting up in bed, bouncing as he played a video game, was a skinny redheaded teenager. He punched the buttons and a triumphant cheer erupted from the game’s speakers.

  “Hoo-rah!” the kid cheered, slapping the mattress in victory. “Take that, mo’fuckers!”

  Gina glanced around. Besides them, the infirmary was empty.

  “This is our critically ill patient?” Gecko asked.

  “Like I said, be prepared for a disaster.”

  “LYDIA, CT SENT THE GIRL IN TWO BACK BECAUSE she keeps vomiting. You want to check her again?”

  “I’ll be right there; let me grab her chart,” Lydia said, trying to sound nonchalant. As if a nurse, one of their own, hadn’t died. As if Nora hadn’t lost a rape kit and potentially damaged evidence in a homicide—how the hell had that happened?

  As if Jerry Boyle hadn’t
told Lydia that in the eyes of the law, her own mother had never even existed. She rubbed her eyes, holding them shut for a long moment, long enough to breathe in, breathe out. “Did my ACS patient get up to the cath lab?”

  “Ten minutes ago. Some school nurse has called twice, said she’s sending in a kid with meningococcemia. Vitals normal except for a temp, and he has a rash she says is petechial.”

  “Is he coming by car?”

  “No. Med Seven is bringing him.”

  “Go ahead and set up the isolation room just in case. And let me know when they call in to report.” Lydia found Narolie Maxeke’s chart. The thirteen-year-old girl had been bequeathed to her by the night attending, who had spoken with the clinic doc and agreed it was all psych. But Lydia wasn’t so sure. Which was why she was going ahead with the brain CT and having the PICU look at her.

  She brushed back the curtain and joined Narolie and her aunt. They shared an ebony complexion darker than any Lydia had seen before, along with musical, softly lilting speech patterns. Although the aunt didn’t seem comfortable speaking English, she appeared to understand without difficulty.

  “Dr. Fiore,” Narolie said, shyly brushing back her hair and trying to shield the emesis basin’s noxious contents. As if Lydia were the one who needed taking care of instead of this too-thin girl who had already seen more horrors than most adult Americans could ever imagine. According to the social history in the clinic chart, the girl’s family was originally from Somalia and Narolie had been born in a refugee camp. In her young life, she’d already seen two siblings killed and another die of starvation. “I’m sorry, I tried—”

  “It’s okay, Narolie,” Lydia tried to reassure her. “Let me check you again and then we’ll get you more medicine to quiet your stomach. I think you’ll also feel better if we put a tube down your nose, to empty your stomach.”

  “Of course, anything you say.” The aunt, Mrs. Darbane, broke in with a long stream of Somali. “My aunt wants to know when I can go home. She has to get to work and doesn’t want to leave me alone.” Another exchange between the two. “But she can’t leave the boys with the neighbor much longer. They need to go to school.”

  “Who usually cares for the boys when your aunt is at work?”

  Narolie seemed surprised. “I do, of course. I’m the oldest. I take care of the house, watch the boys.” Her aunt must have gotten the gist of what Narolie was saying because she beamed at her niece with pride in her eyes, softly stroking her hair. “Back home I’d be married already, raising a family of my own. So this is good practice.”

  “We do things a little differently over here,” Lydia said with a smile. “Still, it must be hard, juggling school and everything at home.” She didn’t want to buy into the clinic doc’s theory that Narolie’s weight loss, vomiting, and mood swings were from an eating disorder and stress, but it was worth exploring the home situation.

  “Not hard at all—until I got sick. That’s why it’s so important that you find out what’s wrong with me. I want to go back to school. I miss my friends, my teachers. I just”—she hesitated, looking down and speaking softly—“I just want my life back.”

  The girl’s heartfelt whisper made Lydia wish she could promise that everything would be all right. “I understand. I hope this CAT scan will give us the answer. But I don’t think it’s wise for you to go home today no matter what it shows. I’d like for you to stay here in the hospital. Let us check everything out.”

  Narolie translated for her aunt, who looked both relieved and anxious. After a long moment the aunt nodded her head. She grabbed Lydia’s hand. “You make her better. All better.”

  “Yes, ma’am, I’m trying my best.”

  THE ER WAS ITS USUAL MIX OF CHAOS AND EFFICIENCY. But Amanda sensed an unusual undercurrent of anxiety. Two nurses huddled in a corner, heads bowed together as if the dropped suture tray on the floor between them were a disaster. Everyone moved slower than normal, half-oblivious to the calls from patients. Even Jason, the usually ebullient desk clerk, was strangely subdued.

  “Who died?” she asked him jokingly as she grabbed her patient’s chart.

  He pivoted on his stool to glare at her. Everyone at the nurses’ station stopped talking, and the sudden silence felt heavy. “You didn’t hear?”

  “Hear what?” she asked, distracted by the strange name on the chart. Narolie Maxeke. How do you pronounce that?

  “Karen Chisholm died. Was killed.”

  Karen? Amanda knew her—hadn’t liked her—Wait, she’d been killed? Surely she’d heard wrong. “Karen was killed?”

  “Stabbed and raped,” a nursing assistant put in. “Left for dead in the cemetery.”

  A cold finger skittered down Amanda’s spine. She walked past the cemetery every day. Often alone and in the dark. “Did they catch the guy?”

  “No,” said a nurse. “When they do, I hope he resists and the cops bring him here. Let him see the real meaning of suffering.” Despite her words, the nurse, who didn’t look much older than Amanda’s own twenty-five, seemed more frightened than angry.

  “They say she was grabbed while she was walking to her car in the parking garage last night,” one of the others said. “Amanda, you park in that garage. We’re starting a petition demanding better workplace security. Our union rep will take it to administration, but med students and residents are welcome to sign it as well.”

  Amanda scrawled her name on the form without really thinking as Lydia strode down the hall, scattering the staff with a glance. But even Lydia’s stride seemed less assured than usual.

  “You down for my possible PICU admission?” she asked Amanda, pulling her aside to a dictation cubicle where they’d have some privacy. “It’s a touchy case. Thirteen-year-old, moved here eight months ago from a Somali refugee camp with her aunt’s family and her two younger siblings. Father missing, mother stayed behind with the rest of the family. She’s a straight-A student until the last three months when she began missing school for recurrent vomiting. Also, occasional headache and her aunt says she’s been very moody—irritable and depressed.”

  Amanda scribbled notes on an index card. It was unlike Lydia to go into such detail about a patient’s social history, so she assumed it was all relevant. “Has she seen a doctor?”

  “That’s the problem. She’s a clinic patient. Been seen there twelve times in the last ten weeks. Workup was all negative, except for a small calcification near her right ovary they found on her upper GI. Incidental finding—probably a feco lith; the rest of her labs have all been normal. They think she has depression, PTSD, and an eating disorder. In fact, she was scheduled to see a psychiatrist today but came in here because of severe vomiting and the worst headache of her life.”

  Amanda looked up at that. A headache that bad could mean lots of serious things, including a brain tumor or leaking aneurysm. Or it could be the exaggeration of a teenage girl with underlying psychiatric problems. “Is her neuro exam normal?”

  “Yes. And she’s still dry-heaving after three hours of fluids; her electrolytes revealed a bicarb of only twelve, so the vomiting was definitely for real; and her amylase and lipase are slightly elevated.”

  “You’re thinking pancreatitis?”

  Lydia hesitated—so unlike her. “Maybe a mild pancreatitis, but I don’t think that’s the underlying problem. I called the clinic doc to admit her. I want to get a head CT and if that’s normal, a scan of her belly, but he refused. Won’t even admit her, doesn’t want me to do anything but order a psych consult. Said he’d follow her up in the clinic.”

  Now Amanda understood the problem. If the patient’s attending physician refused to admit her, the only way Lydia could keep the girl in the hospital would be to get another attending to admit her—highly unlikely for a clinic patient—or to send the girl to the PICU.

  “She sounds sick,” Amanda agreed. Mainly because she trusted Lydia’s judgment. “Question is: is she sick enough for the ICU? It’s gonna be a hard sell since we only hav
e one open bed.”

  “Even if it’s only overnight, at least you could make sure she has a proper workup—more than I can do for her down here in the ER. I just have a feeling that there’s something going on. Something bad.”

  FOUR

  Thursday, 8:21 A.M.

  GINA KNEW SOMETHING WAS WRONG AS SOON AS they hit the ER. No nurses waiting for them—hell, knowing Lydia was on today, she’d expected the attending there herself. Instead, Jason, the desk clerk, simply waved them into the isolation room.

  The kid’s name was Harold Trenton III, but he’d told them to call him Tank—even though he was a skinny-assed, pimply, pale-faced fourteen-year-old. As they transferred him from the gurney to the hospital bed, Gina glanced through the glass walls. The ER was too quiet. There was no one laughing at the nurses’ station, no one hanging out in the hall, razzing lost interns or med students. Just an irritating quiet that made her palms itch.

  Amanda and Lydia stood across the hall, neither looking very happy. She rapped on the window, getting their attention and beckoning Lydia into the isolation room. Lydia nodded, said something to Amanda, then sent the med student into another patient’s room.

  “What’s up?” Lydia asked. “This isn’t the mening kid, is it?”

  “Yeah, didn’t you get our report?”

  Lydia grimaced. “Sorry, things have been a bit crazy around here this morning.”

  Trey looked up at that, but Lydia didn’t elaborate. He finished his run sheet as Gina gave the case summary. “Fourteen-year-old from Heinz Prep, previously healthy until this morning he developed body aches, dizziness, and a fever of one-oh-two. School nurse spotted petechiae on his arm, and we found more on his trunk and back.”

  Lydia was already examining Tank as she listened to Gina. She lifted his shirt, scrutinized the few lesions he had, looking for petechiae or broken blood vessels under the skin that form a reddish-purple pinpoint. “They don’t blanch, but they’re not classic. No purpura? If these are petechiae, there aren’t very many.” She turned to Tank and smiled. “That’s good news; it means we caught this early. How long have you had these red spots?”