Sacred Trust

“But they had just celebrated their wedding anniversary before she died,” Shelly said. “And her birthday was two weeks before their anniversary. We celebrated it with them.”

“Okay, thank you, Shelly. Lauren, set him up for a CBC, a comprehensive chemistry panel, a portable chest, and a drug screen. Then set up a heplock. I want him to have a milligram of Romazicon at 0.2 milligrams per minute. We’ll repeat the dose after twenty minutes.”

“What’s that for, Doctor?” Shelly asked.

“Romazicon is the antidote for benzodiazepine overdose, just in case.” At her blank look, he explained gently, “He may have taken too many of these tranquilizers. I don’t want to dismiss the possibility and take a chance on being wrong.”

He glanced at Frankie’s prescription bottle again. Dr. Robert Simeon had prescribed the drug. “Lauren, also put a call in to Dr. Simeon’s office. He’s the family doc. I’m going to check on Cowboy, then look in on the cancer patient. Would you see if that permission to treat has come in for the track student? We’ll need a CT head scan on Frankie if our workup is negative.”

Dr. Wong entered the E.R. and greeted Lukas with a cheery smile and warm handshake. “Lukas, I hear you have one of my favorite patients visiting with you this morning.”

“Yes, and your patient is already asking for some clothes. Beverly will assist you.”

As soon as Cowboy was settled with his new doctor, Lukas heard Beverly’s cajoling voice through the door.

“Dr. Wong, you’re a kindhearted person,” she said. “What time do you get off?”

“Um, excuse me? Hold it, Beverly, you know I’m married.”

“I know that, silly. How would you like to help out a hungry house pet?”

“Forget it. I know all about Cowboy’s house pets. He just happens to be here because that ‘pet’ mistook his thigh for a drumstick. Isn’t that right, Cowboy?”

Lukas chuckled as he walked back to the central desk. Beverly wanted that Mustang.

His laughter died when he entered exam room eight with a chart for Mrs. Jane Conn. The eighty-six-year-old woman lay moaning in pain in spite of the morphine Lauren had just injected at Lukas’s order. A smooth, shiny sheath of mottled scar tissue obliterated half of Mrs. Conn’s face and showed up plainly beneath the nonrebreather oxygen mask she had received upon arrival. She had been brought here from her daughter’s home about thirty minutes ago, her pain unresponsive to oral medication or morphine suppositories. Lauren had established an IV where dark bruises attested to the failure of the new paramedic to do so.

Since Lauren and Beverly were both busy, Lukas checked the blood pressure himself. It was going down, and the heart rate was dropping, probably due to a decrease in pain—or Mrs. Conn was dying.

Lukas found Lauren and gave instructions for blood tests and X-rays. “You did say Mrs. Conn had filled out a do-not-resuscitate form for her family, didn’t you?”

“Yes, but we haven’t received it yet.” Lauren wrote his instructions down on a sheet. “Her daughter, Ivy Richmond, should have it.”

“I’ll need to get it from her, or we’ll have to take measures to resuscitate if…” He shrugged, hoping they would have no trouble getting the DNR form. He’d been forced to run codes on late-stage cancer patients before, and it had been very painful for everyone, especially for the patient.

As Lauren ran orders for the tests, Lukas listened once again to Mrs. Conn’s chest. He glanced up, and to his surprise, he saw her one unaffected eye watching him.

He took her hand. “Mrs. Conn, we’re trying to reduce your pain. How does—”

“Let me…” her damaged mouth twisted in an effort to form the hoarse words “…go.” Her eye held him a few seconds, then glazed over and closed.

Sadness overwhelmed Lukas as he watched her. He hated to see the pain, had always hated to see suffering of any kind. It was one of the things that had driven him to be a doc in the first place, and ironically, it had been one of his worst hindrances in premed vertebrate physiology. He’d always been physically sick afterward, even though the animals were anesthetized and even though he reminded himself over and over again that human lives would be saved because of the sacrifice.

Mrs. Conn’s moaning had stopped. Lukas placed a hand on her frail arm, then looked over to find the eye watching him again. He couldn’t read the expression, for there was little expression to be displayed on the harsh mask.

She moved her mouth.

Lukas leaned closer to hear her.

“Ready.” The word wasn’t even a whisper, but a breath of sound that barely carried past the barrier of the transparent oxygen mask. “I’m…ready.”

When he looked at her eye it was closed again. For some reason, some infinitesimal sign relayed itself to him—some lightening of expression on that scarred mask? He felt almost…a peace…assurance. Or was he just trying to comfort himself? Cancer was the hardest of all to take since Mom’s days of suffering. Lord, help her.

“Dr. Bower?”

He turned to find the X-ray tech waiting to do the portable chest. Lauren stepped into the room behind her.

“Lauren, where is Mrs. Conn’s daughter?” he asked.

“She’s in the private waiting room. I’m surprised Dr. Mercy isn’t already with her.”

“Dr. Mercy?”

“She’s Mercy Richmond, Ivy Richmond’s daughter and Mrs. Conn’s granddaughter. Dr. Mercy is a nickname a lot of her patients and staff members called her to keep from confusing her with her father, who was also a physician. He was Dr. Cliff, she was Dr. Mercy. If you haven’t met her yet, you will. She hasn’t had an E.R. shift in a couple of weeks. She has a family practice across the street.”

“Good,” replied Lukas. “We can call her when we need to. But I’m going to need to see Ivy Richmond soon. I need that DNR sheet, and she needs to be prepared.”

Lauren stood gazing at Mrs. Conn. “This has been a rough one. Everyone knows and loves Mrs. Conn. She used to do a lot of volunteer work here. Her daughter Ivy has made several large contributions to the hospital in the five years since her husband died.”

The X-ray tech finished her work in the room, and Lauren took Mrs. Conn’s vitals once more. “Down again. BP is 95 over 55 with a 90 pulse.”

“Thanks, Lauren. I’ll go have a talk with her daughter as soon as I check the test results.”

“Okay, I’ll go see Frankie again.” Lauren gave Mrs. Conn another sad look and walked out of the room.

Had there been time, Lukas would have sat with the patient, but he had to return to reassure the mother with the sick baby, talk to the girl with the sprain, and check on Frankie. Where was Mrs. Conn’s daughter, Mrs. Richmond? Why wasn’t she in here? More than likely she was exhausted and had found a sofa or chair on which to sleep.

When Lukas finished his round of the patients, he returned to Mrs. Conn and read the test results. As expected, they looked normal for an elderly woman with late-stage cancer. She continued to rest peacefully, but her blood pressure and respiration were falling.

He found the E.R. secretary at the central desk. “Carol, would you please call Dr. Richmond’s office and advise her of her grandmother’s condition? I’m going—”

Carol raised a hand. “Wait a minute, Dr. Bower. We received permission to treat Cindy Hawkins with the injured wrist. Also, I have Dr. Simeon on the line. You wanted to talk with him about his patient, Mr. Verris?”

After a quick consultation with Dr. Simeon, Lukas made arrangements to have Franklin Verris, the possible suicide attempt, admitted to ICU, then went back to check on the seventy-three-year-old gentleman one more time.

Shelly kept her vigil at her neighbor’s bedside. Lauren stood at the other side of the bed, adjusting an IV line.

“Any change, Lauren?” Lukas asked.

“I’m not sure. There’s no difference in his vitals, but his breathing seemed to change a moment ago. It’s been twenty minutes, and I’m getting ready to give him the next dose. Do you want me to go ahead with it?”

Lukas bent over Mr. Verris and gently raised his right eyelid. He took out a penlight and shone a beam directly at the pupil. There was a faint reaction. The man didn’t look as pale as he had looked before. But according to Dr. Simeon an overdose was highly unlikely. He had disagreed with Lukas’s request for Romazicon. However, Lauren was prepared for another dose, and since Lukas had already given the order, he decided to carry it out.

“Go for it, Lauren. I need to stay and watch him, but I also need to talk to Mrs. Richmond. I’ll be back.”

Chapter Two

L ukas opened the door to the private waiting room and saw a tall, slender woman pacing the floor. Her casual attire of jeans, jogging shoes and a “Hiking is Life” T-shirt skewed the impression he’d formed in his mind of a wealthy, polished benefactress of the hospital.

Mrs. Richmond’s long, dark brown hair was pulled back into a ponytail at the nape of her neck. She turned to face him, and he saw that the hair was liberally streaked with gray around the temples. Her large, dark eyes met his with deep gravity. She was at least sixty, and the gaunt face told him of recent weight loss. The prominent dark circles under her eyes told him she probably hadn’t slept well for weeks.

“Mrs. Richmond?”

“Yes.” Her voice held fear.

“I’m Dr. Bower, the emergency room physician on duty today. I need to speak with you about your mother.”

Mrs. Richmond nodded. “I should be in there with her, I know, but the moaning…I just couldn’t handle it, had to get away from it for a while.” She resumed her pacing. “She moaned all night. I gave her morphine suppositories twice as often as…” She turned back. “I’m sorry. I’m rambling. It’s just so hard to think straight these days.”

“I understand. Have you had an aide helping you with your mother at home?”

“No. I didn’t want my mother thinking I’d abandoned her to a stranger.”

“So you’ve been taking care of her yourself?”

“My daughter helps when she can.”

“I’m sure that’s very hard on you, Mrs. Richmond.”

“Call me Ivy. Is she still moaning?”

“She was peaceful when I left her a few minutes ago. We gave her an injection. We ran some tests to see if there might be a pneumonia or something else causing her deterioration.” He paused. “I’m sorry, Ivy, but none of the tests show a secondary problem. I’m afraid the cancer is taking her.”

Ivy nodded slowly. “Hard to believe a little mole on her cheek could do such damage. Melanoma, you know.”

“Yes. I’m sorry. Her oncologist is in Springfield?”

“Yes, but it’s no use calling him. He’ll just increase the morphine.” Fatigue sharpened her voice. “She’s not worth his time. She’s just an old woman.”

“We want to make her as comfortable as possible. I understand you have the DNR request she signed?”

Ivy grew still as her eyes flashed back to his face. Her chin lifted a fraction. “Why?”

“Would you like to sit down?”

“I’ll stand.”

“I know you must be tired. I want to honor your mother’s advance directive, and to do so, I need the DNR sheet. This is all just legalities, and I apologize for having to ask you for it at a time like this.”

“You mean to just let her die?”

Lukas flinched at the harsh tone of her voice and the sudden, angry-suspicious expression in her eyes.

“If her heart should stop,” he said gently, “we wish to honor her request not to restart it.”

“What’s this ‘we’ business? You’re the doctor. You call the shots. I don’t want my mother’s heart to stop, and if it does, I want you to start it again.”

He held her suddenly angry gaze for a moment. She couldn’t know what she was saying.

“Mrs. Richmond, I thought you understood about your mother’s request.”

“My mother is not capable of making that decision now. I have power of attorney, and I don’t want you to just let her die like some worthless old woman. She’s a living human being with a soul.”

“Of course she is.” He hadn’t foreseen this. How could he get through to her? “I’m not talking about euthanasia. I’m talking about allowing nature to take its course, allowing your mother to retain her dignity and keep her from unnecessary pain. I’ve asked a nurse to call your daughter, Dr. Richmond, and she should be here—”

“You did what?” Her dark eyes flashed, and fatigue tightened the tension in her voice.

Lukas blinked at her helplessly. This was not going well. She was clearly, and understandably, irrational from lack of sleep. There had to be some way to make her see, without becoming too graphic.

“I specifically delayed calling my daughter because I wanted to put her through as little heartache as possible,” Ivy said. “She’s been through enough. You had no right to call her.”

“I’m sorry you feel that way, but Mrs. Conn’s condition is getting worse. I felt family needed to be here.”

“Not yet!” She paused with a gasp, placing a hand on her chest.

He stepped toward her. “Are you okay?”

“I’m fine.” Lowering her hand, she took a deep breath and held his gaze. “I don’t care what the DNR form says. I have durable power of attorney, and I want you to do everything for my mother. She’s not ready to die. She’s not…”

“I didn’t mean for this to be so difficult.” Lukas kept his voice gentle, resisting the urge to ask if he could examine her. He’d seen this kind of family reaction before, during his oncology rotation, when a caregiver was so exhausted that they became confused and combative. They often blamed the physician for the pain of their dying loved one. “I will contact Mrs. Conn’s family physician and clarify the matter.” He turned to leave.

“You don’t believe I have power of attorney?” she challenged, her voice rising a decibel.

He paused with his hand on the door. Lord, give me compassion.

But what about Mrs. Conn? She would suffer even more pain if they managed to resuscitate her.

He turned back to face Ivy, and he tried to keep his voice gentle. He knew his words were not. “What I believe is immaterial, Mrs. Richmond. For instance, I believe that to impose heroic measures onto a patient suffering the last stages of advanced carcinomatosis is not only transferring much-needed care from the living to the dying, it is inhumane to the dying.”

“Only if you don’t believe in hell.”

“Mrs. Richmond—”

“Ivy! My name’s Ivy!”

“I’m sorry, Ivy. I do believe in hell. I also believe that your mother is at peace about this. She told me she was ready to go.”

“What do you mean, she told you?” Ivy snapped. “Mother hasn’t spoken in days. What are you trying to pull here?”

Be gentle. Be patient. But what about Mrs. Conn? “Ivy, to try to resuscitate your mother at this stage would only cause greater, unnecessary suffering. And for what? A few more minutes or hours for the family to say goodbye? What about your mother’s feelings? She’s made her decision already.”

There. He’d done it again, him and his bad habit of stating his opinion to the wrong people at the wrong time. But if there was the slightest chance Ivy would listen…

She bent her head, her eyes closed for a moment. He watched her hopefully.

She reached into the right back pocket of her jeans and drew out a folded three-page form. “I had hoped it would never come to this.” The strength had left her voice. She unfolded the papers and held them out with shaking hands. “I have the power of attorney. Are you satisfied?”

Beverly caught up with Lukas as he reentered the E.R. proper. “That Mustang’s mine!”

Lukas struggled to work up some enthusiasm. “Don’t tell me you cajoled Dr. Wong—”

“Nope.” She jingled Cowboy’s keys. “Sweet-talked one of the new EMTs to help me. Buck likes animals.”

“Yes, but did you tell him this wasn’t a gerbil?”

She grimaced. “He knows it’s a big animal.”

“Horses are big animals. How will you feel if your helper comes back in here on a stretcher?”

“Awful.” She shrugged. “Dr. Wong’s finished with Cowboy. Got any patients for me?”

“Have I ever.” He gestured toward the charts at the desk. “Enjoy.”

He left her staring at the sudden overload and stepped back into exam room one to check on Mr. Verris. Shelly still sat there beside his bed, and Lauren entered behind Lukas, as if geared to his location by radar.

“Any change?” Lukas asked Lauren.

“Test results are in.”

Lukas checked the printouts. Nothing. Everything was normal. Even the drug screen was not helpful, because all it showed were benzodiazepines, and that was to be expected for someone who occasionally took them to sleep. Lukas could have done a quantitative drug screen, but that would have taken too long.

“BP’s gone up just a little, but not much,” Lauren continued. “Pulse and respiration are the same. They’ve called from upstairs to let us know they’re coming to take him to ICU.”

“Let’s make sure they know he still needs a CT scan.” Lukas did his own assessment. Was it his imagination, or was the man breathing more deeply? As he watched, Frankie’s head moved a fraction of an inch.

Lukas looked up to see if Lauren had noticed. “Has he moved like that before?”

“I don’t think so.”

He watched a moment longer. It was probably just a stimulation of the limbic system, a common event in a coma patient.

Lukas did an auscultation of Frankie’s chest one more time, then shook his head. With a nod at Shelly, he left the room. He was feeling more and more frustrated as the day progressed.

Lauren stepped out of the room behind him. “Dr. Bower? Some of the staff are getting together after this shift over at the cantina across the street. Want to join us?”

“Uh…sure. Yes, I’ll be there. Thank you for asking.” Lukas nodded and continued down the hall, knowing he would be kicking himself tonight when it came time to show up at the cantina. He would be starving when he got off, as usual, and since he always ate out anyway, this would be a good way to get better acquainted with the people who worked here. Unfortunately, he knew that by the time he arrived at the restaurant, he would be feeling so awkward about meeting with a group of near strangers, he would have lost his appetite. Almost.

Moving to a new place was lonely business, especially for him. Funny, he could face patients and coworkers all day long with no problem, but when his time was not regimented, he had trouble forcing himself to reach out to others. It wasn’t that he didn’t like people, because he did. The youngest of three boys in a loving Christian family, Lukas was the only shy one in the bunch, and he had often been teased about it. The teasing had only made him more self-conscious, turning him inward, and now his family despaired of ever seeing him married. But this was a new place, and no one here knew about his shyness. It was time to dig himself out of the rut—or pray that God would move him out.

He took Mrs. Richmond’s papers to the secretary. “We’ll need copies of these, Carol. Please call Dr. Richmond back and tell her that she needs to be on standby. Her grandmother is holding her own at the moment, but she could deteriorate fast, and she’s now a full code.”

“Yes, sir.” Carol grabbed the papers from him, dark eyes glowering as she spun around to the copier. She muttered something under her breath.

Lukas watched the characteristically cheerful secretary in surprise. “Carol, are you okay?”

She put the first sheet into the copier and pressed the button. “Fine, just fine,” she mumbled. “We’re swamped, we’ve got patients dying back there, and all I hear are complaints that we’re not seeing people fast enough.” She indicated the waiting room. “Griping because you haven’t looked at their scalps yet. They’d be in here right now, except one of them had to step outside for a smoke. I get so tired—”

“Have they been signed in?”

“No, I’ve been too busy with these other—”

“I’ll take care of them.” Lukas glanced out the door, where one of the women he’d seen earlier stood smoking, talking to the other. He strolled out to join them.

“Hello, ladies, I’m Dr. Bower. I hear you’re unhappy about our service. What’s the emergency?”

The smoker quickly shoved her half-smoked cigarette into the receptacle like a school kid caught by the teacher.

“We need to be treated for head lice,” the nonsmoker said.

The patio was deserted, Lukas noticed. He took another step forward, carefully looked at first one over-permed head of hair, then at the smoker’s long, stringy brown hair.

He took out a notepad and a pen and wrote the name of a shampoo. He held it out toward the smoker. “Wash with it once, then wait a week and wash again. You can buy this at your local pharmacy.”

She stared at the note in his hand. “No prescription?”

“You don’t need a prescription for this. The two of you can share a bottle.”

“But we’ll have to pay for it.”

Lukas felt his skin tingle with growing irritation. He inhaled slowly, counting to ten as he placed the note on the top of a trash can nearby. It had suddenly become a stressful day, the worst he’d had in a long time. He couldn’t blame it all on these two misguided souls.

He turned and opened the heavy glass door. “Ladies, the shampoo costs less than a pack or two of your favorite brand of cigarettes.”

“But we have Medicaid cards,” the smoker called after him. “We can report you for refusing to treat us!”

He stopped midstride and slowly turned back toward them. “Feel free,” he said, keeping his voice calm. “I feel I should warn you, however, that when a card carrier tries to use the card in the E.R. for nonemergency care, she can lose her card. It’s called Medicaid abuse. I think you’ll find that shampoo works very well as long as you follow the directions.” He stepped inside and let the door close silently behind him.

There were other Medicaid cardholders—for instance, the little baby in exam room three—who needed treatment today, not next week, and Lukas saw to it that they received good care. Lots of Medicaids used the emergency room here because many family practitioners refused to take assignment. Those who did still limited their patients. Medicaid paid so little that a physician who took too many could go broke. The system didn’t work. Many times the people who behaved with integrity got left out entirely—both the honest Medicaid recipients and the honestly compassionate physicians. Greed was the culprit on all sides. Lawmakers spent their time writing more laws because people kept figuring out ways to take advantage of the system. It was frustrating. Lukas had to keep reminding himself not to blame the patients who sometimes misunderstood the constantly changing rules.

Lukas glanced around at the emergency department. He liked this little ten-bed setup. The exam rooms surrounded a large central station. Each room was well equipped. Five of the ten rooms had excellent cardiac equipment. There was a separate ambulance entrance and two physician call rooms.

Mrs. Estelle Pinkley, the hospital administrator, had done a remarkable job when she’d convinced the county to pay for this upgrade. Lukas had jumped at the chance to receive a dependable salary with benefits so far away from the congestion and stress and corruption of the city. Yes, he knew corruption was everywhere, but right now, with specific, damaging events so fresh in his memory, Kansas City represented everything painful.

Carol met Lukas as he entered the E.R. proper. “Dr. Bower, Mrs. Conn is getting worse. Lauren said to notify you.”

“Thanks, Carol. Please call Dr. Richmond back.”

“Lauren already did so.”

“Get ready to call a code if necessary.”

“Dr. Richmond will have a fit about that, you know.”

“Maybe she can do more about it than I was able to.”

Chapter Three

M ercy Richmond ran the block from her medical office to the hospital, not bothering to remove her lab coat. Mom had promised to call when the time came, but she hadn’t done so. Instead, Lauren had been the one to break the news.