She left the room and walked down the hall to the ER.
No one was there. The front desk was unmanned, the waiting room deserted. “Hello?” she called.
“Dr. Harper?” answered a voice over the intercom.
“Where is everyone?”
“We’re in the staff room. Could you come back here?”
“Don’t I have a patient to see?”
“We have a problem. We need you now.”
Problem? Toby didn’t like the sound of that word. At once her pulse kicked into high gear. She hurried toward the staff room and pushed open the door.
A camera flashbulb went off. She froze in place as a chorus of voices began to sing:
“Happy birthday to you! Happy birthday to you. . .”
Toby looked up at the red and green streamers fluttering overhead. Then she looked at the cake, glittering with lit candles—dozens of them. As the last notes of “Happy Birthday” faded away, she covered her face with her hand and groaned. “I don’t believe this. I completely forgot.”
“Well we didn’t,” said Maudeen, snapping off another picture with her Instamatic. “You’re seventeen, right?”
“I wish. Who’s the joker who put on a zillion candles?”
Morty, the lab tech, raised his pudgy hand. “Hey, no one told me when to stop.”
“See, Morty wanted to test our sprinkler system—”
“Actually, this is a pulmonary function test,” said Val, the other ER nurse. “In order to pass, Toby, you have to blow ’em all out with a single breath.”
“And if I don’t?”
“Then we’re gonna intubate!”
“C’mon, Toby. Make a wish!” urged Maudeen. “And make him tall, dark, and handsome.”
“At my age, I’d settle for short, fat, and rich.”
Arlo, the security guard, piped up: “Hey! I’ve got two out of three qualifications!”
“You’ve also got a wife,” shot back Maudeen.
“Go, Tobe! Make a wish!”
“Yeah, make a wish!”
Toby sat down in front of the cake. The other four gathered around her, giggling and jostling like rowdy kids. They were her second family, related to her not by blood but by years of shared crises in the Emergency Room. The Nanny Brigade was what Arlo called the night ER team. Maudeen and Val and the lady doc. God help the male patient who came in with a urologic complaint.
A wish, thought Toby. What do I wish for? Where do I start? She took a breath and blew. All the candles puffed out to a burst of applause.
“Way to go,” said Val, and she began plucking out the candles. Suddenly she glanced at the window. So did everyone else.
A Newton police car, blue lights flashing, had just pulled into the ER parking lot.
“We got a customer,” said Maudeen.
“Okay,” sighed Val, “the ladies gotta go to work. Don’t you boys eat all the cake while we’re gone.”
Arlo leaned toward Morty and whispered, “Aw, those girls are always on a diet anyway. . . .”
Toby led the charge down the hall. The three women reached the front desk just as the automatic ER doors whisked open.
A young cop poked his head inside. “Hey, we got this old guy out in the car. Found him wandering in the park. You ladies wanna take a look at him?”
Toby followed the cop outside, into the parking lot. “Is he hurt?”
“Doesn’t seem to be. But he’s pretty confused. I didn’t smell alcohol, so I’m thinking maybe Alzheimer’s. Or diabetic shock.”
Great, thought Toby. A cop who thinks he’s a doctor. “Is he fully conscious?” she asked.
“Yeah. We got him in the backseat.” The cop opened the rear door of the patrol car.
The man was completely nude. He sat curled into a ball of thin arms and legs, his bald head bobbing back and forth. He was muttering to himself, but she could not quite make out what he was saying. Something about having to get ready for bed.
“Found him on a park bench,” said the other cop, who looked even younger than his partner. “He was wearing his underwear then, but he took it off in the car. We found the rest of his clothes in the park. They’re on the front seat.”
“Okay, we’d better get him inside.” Toby nodded to Val, who already had a wheelchair waiting.
“C’mon, buddy,” the cop urged. “These nice ladies are gonna take care of you.”
The man hugged himself tighter and began to rock on his skinny buttocks. “Can’t find my pajamas. . .”
“We’ll get you some pajamas,” said Toby. “You come inside with us, sir. We’ll give you a ride in this chair.”
Slowly the old man turned and focused on her. “But I don’t know you.”
“I’m Dr. Harper. Why don’t you let me help you out of the car?” She held out her hand to him.
He studied it, as though he’d never seen a hand before. At last he reached for it. She slipped her arm around his waist and helped him out of the car. It was like lifting a bundle of dry twigs. Val scurried forward with the wheelchair just as the man’s legs seemed to buckle beneath him. They strapped him into the chair and set his bare feet on the footrests. Then Val wheeled him through the ER doors. Toby and one of the baby-faced cops followed a few paces behind.
“Any history?” Toby asked him.
“No, Ma’am. He couldn’t give us any. Didn’t seem like he’d hurt himself or anything.”
“Does he have any ID?”
“There’s a wallet in his pants pocket.”
“Okay, we’ll need to contact his next of kin and find out if he has any medical problems.”
“I’ll get his things out of the car.”
Toby walked into the exam room.
Maudeen and Val had already put the patient on the gurney and were now tying his wrist restraints to the siderails. He was still babbling about his pajamas and making halfhearted attempts to sit up. Except for a sheet discreetly draped across his groin, he was naked. Spasms of gooseflesh intermittently stippled his bare chest and arms.
“He says his name is Harry,” said Maudeen, slipping a blood pressure cuff around the man’s arm. “No wedding ring. No obvious bruises. Smells like he could use a bath.”
“Harry,” said Toby. “Do you hurt anywhere? Are you in any pain?”
“Turn off the lights. I want to go to bed.”
“Harry—”
“Can’t sleep with those damn lights on.”
“Blood pressure one fifty over eighty,” said Maudeen. “Pulse is a hundred and regular.” She reached for the electronic thermometer. “C’mon, sweetie. Put this in your mouth.”
“I’m not hungry.”
“You don’t eat it, dear. I’m going to take your temperature.”
Toby stood back for a moment and just watched the man. He was moving all four limbs, and although he was on the thin side, he seemed adequately nourished, his muscles lean and wiry. It was his hygiene that bothered her. He had at least a week’s worth of gray beard stubbling his face, and his fingernails were dirty and unclipped. Maudeen was right about that smell. Harry definitely needed a bath.
The electronic thermometer beeped. Maudeen took it out of the man’s mouth and frowned at the reading. “Thirty seven point nine. You feel okay, hon?”
“Where are my pajamas?”
“Boy, you do have a one-track mind.”
Toby shone a penlight in the man’s mouth and saw the gleam of gold crowns—five of them. You could tell a lot about a patient’s socioeconomic status just by looking at the teeth. Fillings and gold crowns meant middle class or better. Rotten teeth and gum disease said empty bank account. Or a morbid fear of dentists. She smelled no alcohol on his breath, no fruity odors that would indicate diabetic ketosis.
She began her physical exam at his head. Running her fingers across his scalp, she detected no obvious fractures or lumps. With her penlight she tested his pupillary reactions. Normal. So were his extraocular movements and gag reflex. All the cranial nerves s
eemed intact.
“Why don’t you go away,” he said. “I want to sleep.”
“Did you hurt yourself, Harry?”
“Can’t find my damn pajamas. Did you take my pajamas?”
Toby looked at Maudeen. “Okay, let’s get some bloods cooking. CBC, lytes, glucose STAT. Couple of extra red tops for an SMA and tox screen. We’ll probably have to cath him for a urine.”
“Gotcha.” Maudeen already had the tourniquet and Vacutainer syringe ready. While Val immobilized the man’s arm, Maudeen drew the blood. The patient scarcely seemed to feel the needle going in.
“All right, honey,” said Maudeen, applying a bandage to the puncture site. “You’re a very good patient.”
“You know where I put my pajamas?”
“I’m gonna get you a fresh set, right now. You just wait.” Maudeen gathered up the blood tubes. “I’ll send these up under John Doe.”
“His name’s Harry Slotkin,” said one of the cops. He had returned from the patrol car and now stood in the doorway, holding up Harry’s trousers. “Checked his wallet. According to the ID, he’s seventy-two years old and he lives at 119 Titwillow Lane. That’s right up the road, in that new Brant Hill development.”
“Next of kin?”
“There’s an emergency contact here. Someone named Daniel Slotkin. It’s a Boston phone number.”
“I’ll give him a call,” said Val. She left the room, sliding the privacy curtains shut behind her.
Toby was left alone with the patient. She resumed the physical exam. She listened to the heart and lungs, felt the abdomen, tapped on tendons. She poked and prodded and squeezed, and found nothing out of the ordinary. Perhaps this is just Alzheimer’s, she thought, standing back to study the patient. She knew the signs of Alzheimer’s all too well: the crumbling memory, the nocturnal wanderings. The personality fracturing, breaking off a piece at a time. Darkness was distressing for these patients. As daylight faded, so did their visual links to reality. Perhaps Harry Slotkin was a victim of sundowning—the nighttime psychosis so common to Alzheimer’s patients.
Toby picked up the ER clipboard and began to write, using the cryptic code of medical shorthand. VSS for vital signs stable. PERRL for pupils equal, round, and reactive to light.
“Toby?” called Val through the curtain. “I’ve got Mr. Slotkin’s son on the phone.”
“Coming,” said Toby. She turned to pull aside the curtain. She didn’t realize an instrument stand was right on the other side. She knocked against the tray; a steel emesis basin fell off and clanged loudly to the floor.
As Toby bent down to pick it up, she heard another noise behind her—a strange, rhythmic rattling. She looked at the gurney.
Harry Slotkin’s right leg was jerking back and forth.
Is he having a seizure?
“Mr. Slotkin!” said Toby. “Look at me. Harry, look at me!”
The man’s gaze focused on her face. He was still conscious, still able to follow commands. Though his lips moved, silently forming words, no sound came out.
The jerking suddenly stopped, and the leg lay still.
“Harry?”
“I’m so tired,” he said.
“What just happened, Harry? Were you trying to move your leg?”
He closed his eyes and sighed. “Turn off the lights.”
Toby frowned at him. Had it been a seizure? Or merely an attempt to free his restrained ankle? He seemed calm enough now, both legs lying motionless.
She stepped through the privacy curtain and went to the nurses’ desk.
“The son’s on line three,” said Val.
Toby picked up the receiver. “Hello, Mr. Slotkin? This is Dr. Harper at Springer Hospital. Your father was brought to our ER a short time ago. He doesn’t seem to be hurt, but he—”
“What’s wrong with him?”
Toby paused, surprised by the sharpness of Daniel Slotkin’s response. Was it irritation or fear that she heard in his voice? She answered calmly, “He was found in a park and brought here by the police. He’s agitated and confused. I can’t find any focal neurologic problems. Does your father have a history of Alzheimer’s? Or any medical problems?”
“No. No, he’s never been sick.”
“And there’s no history of dementia?”
“My father is sharper than I am.”
“When did you last see him?”
“I don’t know. A few months ago, I guess.”
Toby absorbed that information in silence. If Daniel Slotkin resided in Boston, then he lived less than twenty miles away. Certainly not a distance that would explain such infrequent contact between father and son.
As though sensing her unspoken question, Daniel Slotkin added: “My father leads a very busy life. Golf. Daily poker at the country club. It’s not always easy for us to get together.”
“He was mentally sharp a few months ago?”
“Let’s put it this way. The last time I saw my father, he gave me a lecture on investment strategies. Everything from stock options to the price of soybeans. It went over my head.”
“Is he on any medications?”
“Not that I know of.”
“Do you know the name of his doctor?”
“He goes to a specialist in that private clinic at Brant Hill, where he lives. I think the doctor’s name is Wallenberg. Look, just how confused is my father?”
“The police found him on a park bench. He’d taken off his clothes.”
There was a long silence. “Jesus.”
“I can’t find any injuries. Since you say there’s no history of dementia, there must be something acute going on. Maybe a small stroke. Or a metabolic problem.”
“Metabolic?”
“An abnormal blood sugar, for instance. Or a low sodium level. They can both cause confusion.”
She heard the man exhale deeply, a sound of weariness. And maybe frustration. It was five in the morning. To be awakened at such an hour, to face such a crisis, would exhaust anyone.
“It would be helpful if you came in,” said Toby. “He might find a familiar face comforting.”
The man was silent.
“Mr. Slotkin?”
He sighed. “I guess I’ll have to.”
“If there’s someone else in the family who can do it—”
“No, there’s no one else. Anyway, he’ll expect me to show up. To make sure everything’s done right.”
As Toby hung up, Daniel Slotkin’s last words struck her as faintly threatening: To make sure everything’s done right. And why wouldn’t she do everything right?
She picked up the telephone and left a message with the Brant Hill Clinic answering service, telling them their patient Harry Slotkin was in the ER, confused and disoriented. Then she punched in the beeper for the Springer Hospital X-ray tech.
A moment later, the tech called back from home, his voice groggy with sleep. “This is Vince. You beeped me?”
“This is Dr. Harper in the ER. We need you to come in and do a STAT CT head scan.”
“What’s the patient’s name?”
“Harry Slotkin. Seventy-two-year-old man with new-onset confusion.”
“Right. I’ll be there in ten minutes.”
Toby hung up and stared at her notes. What have I overlooked? she wondered. What else should I be searching for? She reviewed all the possible causes of new-onset dementia. Strokes. Tumors. Intracranial bleeds. Infections.
She glanced again at the vital signs. Maudeen had recorded an oral temperature of 37.9 degrees centigrade. Not quite a fever, but not quite normal, either. Harry would need a spinal tap—but not until the CT scan was done. If there was a mass in his skull, a spinal tap could lead to a catastrophic shift in pressure on the brain.
The wail of a siren made her glance up.
“Now what?” said Maudeen.
Toby shot to her feet and was already waiting at the ER entrance when the ambulance pulled up with a loud whoop. The vehicle’s rear door flew open.
&nb
sp; “We got a code in progress!” the driver yelled.
Everyone scrambled to unload the stretcher. Toby caught a quick glimpse of an obese woman, her face pale and limp-jawed. An ET tube was already taped in place.
“We lost her pressure en route—thought we’d better stop here instead of going on to Hahnemann—”
“What’s the history?” snapped Toby.
“Found on the floor. Had an MI six weeks ago. Husband says she’s on Digoxin—”
They rushed the patient through the ER doors, the driver pumping clumsily on the chest as the stretcher careened up the hall and swerved into the trauma room. Val hit the light switch. Overhead lamps flooded on, blindingly bright.
“Okay, you all got a grip? She’s a big one. Watch that IV! One, two, three, move!” yelled Maudeen.
In one smooth transfer, four pairs of hands slid the patient off the ambulance stretcher and onto the treatment table. No one had to be told what to do. Despite the seeming confusion of a Code Blue, there was order in chaos. The driver resumed chest compressions. The other EMT continued bagging the lungs, pumping in oxygen. Maudeen and Val scrambled around the table untangling IV lines and connecting EKG wires to the cardiac monitor.
“We’ve got sinus rhythm,” said Toby, glancing at the screen. “Stop compressions for a second.”
The driver stopped pumping on the chest.
“I’m barely getting a pulse,” said Val.
“Turn up that IV,” said Toby. “We got any pressure yet?”
Val glanced up from the arm cuff. “Fifty over zip. Dopamine drip?”
“Go for it. Resume compressions.”
The driver crossed his hands over the sternum and began to pump again. Maudeen scurried to the code cart and pulled out drug ampules and syringes.
Toby slapped her stethoscope on the chest and listened to the right lung field, then the left. She heard distinct breath sounds on both sides. That told her the ET tube was properly positioned and the lungs were filling with air. “Hold compressions,” she said and slid the stethoscope over to the heart.