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Leah Ruth Robinson's UNNATURAL CAUSES
An Evelyn Sutcliffe Medical Suspense Novel
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Unnatural Causes
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Even Death can become bored.
Death is a very busy person. Just pick up the newspaper any day of the week and turn to the obituaries. Death beckons to the dying after a fall in the home, after a long illness, after a brief illness, after cancer, AIDS, Alzheimer's. There are heart attacks, asthmatic attacks, strokes, thrown emboli. The possibilities seem endless.
But every now and then, there's an obituary that makes you wonder if maybe Death got up that Morning and said, I'm bored. Let's do something just a little bit different.
Which might explain how Death arrived shortly before seven A.M. one cool, wet Saturday in early October driving a car, although it would be days before we knew that.
Specifically, driving a car into the parking garage under the Storrs Pavilion of University Hospital, on Manhattan's Upper West Side. Death parked and got out. He or she-for a long time the sex of the individual wasn't clear-unlocked a fire door at the far end of the garage, using a key that only hospital personnel are issued, and descended into an underground tunnel that connected the Storrs Pavilion to the main hospital complex across Amsterdam Avenue. A little while later, this same person returned to the parking garage, now wearing a white clinical coat with a physician's ID badge clipped to the breast pocket. She-or he-opened the back of the car-it was, we later found out, a station wagon-took out a strange wig of dubious quality, donned it, and also put on very dark sunglasses.
Thus attired, and carrying a large, woven basket, Death returned to the tunnel and this time followed it to a second fire door leading into the basement of the doctors' residence. A key was required for this door as well.
The basket contained, among other things, poisonous and hallucinogenic mushrooms.
But we didn't know that then.
Six hours after Death drove into the parking garage, what we did know was this: It was very, very quiet in the hospital's emergency room.
Which always made the docs and nurses very nervous.
Oh, we had patients. I was juggling four of them, in fact. But they were all walk-ins. We hadn't seen one single ambulance since the shift began at seven A.m. No gunshot wounds. No stabbings, assaults, or motor vehicle accidents. Not one single attempted suicide. No heart attacks. No strokes.
Not yet.
But emergency room physicians are nothing if not brave. Even while we snuck anxious glances at the ambulance bay door, we carried on as usual, as if we had stabbings, assaults, and MVAs galore. There were the usual quiet conversations, the usual boisterous exchanges. And those of us who had other things bothering us went right on being bothered, quiet or no.
"Ev, thanks again for going to bat for me when I almost
killed that patient the other day," Dr. Mark Ramsey said for the fifth or sixth time that morning. "I really appreciate it."
I sighed. Ramsey was one of my new interns; as his "Three," or third-year resident, I was responsible for overseeing the care he rendered. "First, you didn't almost kill the patient," I said. "Second, what's done is done. just be more careful next time."
"Is anything bothering you?"
"No." At least nothing I wanted to discuss with Mark Ramsey.
My boyfriend, Phil Carchiollo. Today was the anniversary of our first date. That evening, my brother Alan, a student at the Culinary Institute, was hosting a celebratory dinner for us and a small group of friends in my apartment in the doctors' residence. The only problem was, Phil and I had had yet another quarrel over breakfast and were barely speaking. Phil wanted to marry me. I wasn't ready for marriage, which wounded him grievously. And celebrating the anniversary of our first date just seemed to grind salt into the wound.
The upcoming hospital merger talks. University Hospital was wooing two potential merger partners, Mount Scopus Hospital downtown, and St. Eustace Hospital uptown. Our entire hospital staff down to the last janitor was polarized either for or against one potential partner or the other. My own personal stake was the emergency medicine residency program. Currently, as residents, we were affiliated with the University College of Physicians and Surgeons, as were the emergency medicine residents at St. Eustace. If we merged with Scopus, we'd all have to "reaffiliate"-in other words, switch to the residency program at Mount Scopus's Albert Schweitzer School of Medicine. Our program was three years; theirs was four. I didn't even want to think about the problems reaffiliation would cause.
The twenty-four-hour nurses' strike, scheduled for the fol lowing Monday. My best pal in the emergency room, Gary Seligman, R.N., was the nurses' union rep. Some docs, particularly the residents, were showing their support for the nurses by wearing buttons that said "Some Cuts Never Heal." We planned to join the picket line on our lunch breaks. But many docs were vociferously against the nurses. As if we didn't have enough polarization and acrimony already from the merger talks.
And then there was that worrisome note, Ut quod ali cibus est aliis fuat acre venenum, "What is food to one is to others bitter poison," or "One man's meat is another man's poison." Someone had slipped it under the door to my apartment a week ago Thursday. I still didn't know who--or why. Somehow, though, it didn't sound friendly.
All that, and an ominous quiet in the ER, too. Who could ask for anything more?
"Something's bothering you," Mark insisted. "You can't fool me."
"I can try," I said.
"Maybe. But why would you want to?"
Laughing, I took the chart he was holding out to me and opened it. "Thomas Kennaugh," I said, scanning Ramsey's notes. "Guy is a charming, well-dressed yuppie businessman, Rolex watch, Armani suit, Coach briefcase, the whole shtick. Three-day history of extreme weakness, nausea, lightheadedness. Alert and oriented, with slightly slurred speech. Reports one or two bouts of apnea in the car on his way here. Very anxious, and not just because he's having trouble breathing. Shoots heroin 'recreationally,' he says. So. What are you thinking?"
"He got some of the Mott Haven tainted heroin the cops are talking about."
"Good call. Most of the cases have been going to Lincoln in the Bronx, or Harlem Hospital. But we may start seeing some here. What are they saying the heroin's contaminated with?"
"Methyl fentanyl. Overwhelms opiate receptors in the brain, causing the user to stop breathing."
I snapped the chart shut and handed it back. "You seem on top of this. What do you want to do?"
"Opiate antagonist and release. You think it's quiet in here?"
"No, I think it's picking up," I said.
"Think so?"
"Oh, yeah, definitely. Usual crowd's here."
Ramsey and I stood shoulder to shoulder at the nurses' station. Swarming around us were a steady stream of doctors, patients, nurses, patients' family members, chaplains, you name it-talking, crying, whining, shouting, swearing, whispering, begging, apologizing, confessing, absolving. A fireman went by in full gear, pick ax and all. As usual, I was handling several things at once. Debriefing Ramsey. Writing a note in Patient One's chart. Waiting on hold for Patient Two's private physician to come to the phone. Trying to track down Patient Three's tab results. Squinting at Patient Four's X Rays.
It's not quiet at all, I told myself firmly, looking at my watch. Four minutes. Patient Two's physician had sixty seconds to come to the phone. Five minutes was my limit. "The cops are driving around Addict Land with loudspeakers announcing, 'Toxic heroin was sold, seek medical attention immediately!' You know what that means."
Ramsey nodded. "Next we get the ones who heard it was pure and potent, and copped a bag on purpose."
"Call the Organized Crime Control Bureau," I advised. "They're keeping stats. And let's discuss it at Morning Report."
"I don't know if I can wait that long," said Mark. "I think I'll go ahead and discuss it now." I shook my head as Ramsey trundled off to check Kennaugh, reviewing methyl fentanyl under his breath. For a moment, I considered administering a little methyl fentanyl to Ramsey. During my intern year, I had yammered, too-but Mark never shut up. He often kept right on talking whether or not anyone was listening. Sometimes he supplied both halves of the conversation himself, the one in his normal pleasant tenor and the other in a kind of gravely, stentorian baritone. "You never heard of the talking cure?" he asked people who commented. "It's talk or Prozac. Me, I don't like to selfmedicate."
I wondered as I often did how he ever managed to get through Yale. How did he get into Yale? Although he fit right in here, in the maws of Welcome-to-the-Big-Time-Medicine: Manhattan's University Hospital. IV drug abusers, tainted heroin, Organized Crime Control. Admittedly, probably not what the hospital's founding forefathers and mothers had in mind when they broke ground at the turn of the century on a bluff overlooking Harlem. There they built the original five buildings with exteriors ornately patterned after the Luxembourg Palace in Paris, while the interiors were-according to a contemporary assessment-exceedingly plain, as is right and proper in a place where war is to be waged on germs. Sure would like some of their old-fashioned idealism to fight the modern-day wars on drugs, AIDS, social ills. Not that I wasn't dedicated. I was. But
Brrt! My internal Cynicism Alarm went off.
Time to renew my vows.
Closing my eyes for a moment, I set in play my old medical school fantasy, scripted long ago, when the germ of the idea of actually becoming a doctor was first sprouting into reality:
Heartbeat. Heavy breathing. The sound of running. The twilight of a green-tiled hospital corridor, not quite day, not quite night. A tall slender woman rounds the corner and enters the homestretch. Overhead, the PA crackles with tension: "Dr. Evelyn Sutcliffe to the ER, Stat!" That's me. Light brown hair cut short but full, hazel eyes, tortoiseshell eyeglass frames. My stethoscope bounces on my neck. My hospital badge flaps on my breast pocket. My white coat floats around me like Superwoman's cape. The theme music from Chariots of Fire
"Dr. Sutcliffe?" the clerk's voice interrupted my reverie. "Call for you on one-eight-one-three."
Damn. It happened every time. just as I was about to give mouth-to-mouth to George Clooney....
Patient Two's doc still had me on hold; I hung up on him and pushed the blinking button for 1813. Evelyn F. Sutcliffe, M.D., physician to the stars. The stars just didn't happen to know it. Yet.
"This is Dr. Sutcliffe," I said.
"This true, Ramsey lost the guide wire trying to put in an arterial line?" Dr. Diana Clausson asked without preamble. "And the patient had to be taken to surgery to have it removed?"
In another life, Clausson could have been Annie Oakley: point, aim, shoot. In this life she busied herself with running the hospital's Ear, Nose and Throat Clinic, and keeping herself "informed," as she liked to say.
"Do you have spies?" I asked. "Or are you just wired for sound?"
"Both. I hear Mikey Wells wanted to put Ramsey on probation, but you stood up for him."
Dr. Michael Wells was one of the ER's attending physicians. He considered it his job to get at least one intern a year kicked out of the program. Just to keep up standards, he said.
"Ramsey's honest," I said. "When he fucks up, he says so."
"I dunno, losing a lead wire ... That's serious. What if push comes to shove? You going to stand up for Ramsey?"
I tried to deduce the political ramifications of standing up for Ramsey; Clausson usually had political ramifications in mind when she wanted to know anything. She hated Vittorio von Laue, the trustee who chaired the hospital's Q&A--Quality Assurance Committee-before whom I would be standing up for Ramsey if it came to that. Von Laue, like Ramsey, was a Yalie, and they had even attended the same boarding school. Then again, Julian Case Hamilton, chairman of the board of trustees, also sat on that committee, was a Yalie, and also had attended that same boarding school. And Hamilton was the board's main advocate for a merger with Scopus
"Hel-lo," Clausson said in my ear.
Or maybe she was just interested in Ramsey for personal reasons. We were all still fanning ourselves over the Clausson-Ramsey affair that summer. Talk about torrid.
"Of course I'm going to stand up for him," I said. "He's certified to put in a central line."
"Who certified him?" Di asked.
"I did."
"For being proficient, or for making a good effort?"
I sighed. "He missed the vein repeated times. But he attempted five under supervision, so I gave him credit. Board policy allows me to do that."
"Don't sigh," Clausson ordered. "And get that defensive tone out of your voice."
"Di, what is this? Am I going before the Supreme Court?"
"Don't get exasperated, either. You want to convey your willingness to help them."
I put the phone down. Thrusting my left leg out behind me, I did a runners' stretch. Then I stretched the right leg. Picking the phone up again, I asked, "Who's 'them'?"
"The members of the Q-and-A. Just in case the matter comes to their attention, okay? Here's the rest of your argument. You realize that losing a wire is grave, but the system is designed with fallbacks to deal with this sort of thing. Thatin this instance the supervision put in place by the Bell Regulations actually worked exactly as it was designed to work. Because of close supervision of the intern, the resident was immediately made aware of the problem, and an adverse outcome was avoided." There was a click as she replaced the phone in its cradle,
"Why is that woman always so goddamned cryptic?" I complained aloud as I rifled through Patient Two's chart for his private physician's number again. "And why can't she learn the simple courtesy of saying hello and goodbye?"
Wait a minute.
The Latin note.
"You're the one who sent me that note," I fumed when I got Clausson back on the line. "Ut quod ali cibus est aliis fuat acre venenum. What is this supposed to be, a test of my Latin?"
"You could say hello, don't you think?" Clausson said.
"Why? You never do."
"I'm a honcho. You're not."
"I'm sure that's honcha. But don't change the subject. Phil had to call the priest at his church to find out what the damn thing meant. 'One man's meat is another man's poison.'"
"I'm sure that's 'One woman's meat is another woman's poison," Clausson drawled. "Other than that, though, I have no idea what you're talking about."
"C'mon. It's just like you to send a cryptic message like this."
"That's true, but it doesn't mean I sent it."
I counted to ten. "Fine. What do you think it means?"
"Well, I'm just talking off the top of my head here, but it could have to do with the hospital merger talks. The Saint Eustace faction's meat is Mount Scopus's poison. And vice versa." "But why send that message to me? I'm not a player in the merger talks."
"No, but Vittorio von Lane is. And he's your brother Alan's boyfriend."
"Still, why send it to me?"
Clausson thought a minute. "Could the note have to do with Phil? Doesn't he have some whacked-out patient who's in love with him and sends him weird notes?"
"Former patient," I corrected. "Phil's a shrink. It happens. But how do you know about that, Di?
"You know I never reveal my sources."
"Well, could you not reveal the goddamned substance, too?" I snapped. "I mean, just this once? Surely you've heard of patient confidentiality. Or is that a new concept for you?"
Clausson loved pushing people's buttons. I could almost hear her grinning on the phone. "Mum's the word," she assured me. "But think about it. 'One woman's meat is another woman's poison.' Phil might be meat to you, but he's poison to the former patient. Or vice versa."
She hung up before I could respond. I slammed the phone down. The most galling thing about Diana Clausson was, she was almost always right.
Leah Ruth Robinson's Unnatural Causes
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But Phil's patients and former patients were his own professional business, I told myself. He didn't need me to advise him on patients with "difficult transferences," as he called it.
I didn't know then how wrong I was. Any more than I knew that Death sometimes wore a frightful wig and carried a large basket.
For the next hour, I saw patients.
Then, since it was so quiet in the ER, I took twenty minutes for a very late lunch.
Tempting fate.

Copyright 2000 by Leah Ruth Robinson

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