change in her over just fourteen hours, even allowing for her accident, was terrifying. She was disoriented and combative, her speech was thick and slurred. Her gray hair was matted against her scalp with perspiration and bits of feces.
From the doorway, Zack watched as Don Norman struggled to examine Annie's chest. The portly internist had stripped off his suitcoat and rolled up his shirt-sleeves, but he was still wearing his tie, vest, and gold watch fob. Beads of sweat dotted his fleshy forehead and upper lip.
A young nurse stood off to one side, her face drawn and pale. 'Need an extra pair of hands? ' Zack asked as Norman stepped back from the bed.
The man looked down at Annie and then shook his head. 'No, thank you, Doctor, ' he said. 'I'm just about done.'
'She okay?'
'If you mean is she going to die, the answer is no… at least not tonight. Since we got a line in and gave her some fluid, her pressure has come up. But she's extended her old coronary. There's not much question about that. And I guess you know that she's fractured her hip.'
She's extended her coronary. She's fractured her hip. Norman's emotionless statement-his tacit implication that Annie was responsible for her own misfortune-instantly rekindled the dislike Zack had developed toward the man during their interview many months before.
Still, there could be no arguing the truth in his grim assessment of her situation and prognosis. Pneumonia, stroke, embolism, heart failure, while orthopedists could work near-miracles with hips in the operating room, physicians and nurses knew all too well that immobilization of any sort was the deadliest enemy of advancing age. Zack moved to within two feet of the bed. 'Is she making any sense?'
'Nope. Strictly word salad.'
'Stroke? '
'I don't think so.'
'Is there any evidence she hit her head?'
Norman shifted uncomfortably. cci. I haven't really checked,' he said.
'As you can see, she's not the easiest thing in the world to examine right now.'
'Mind if I try?'
'Try anything you want, ' Norman responded somewhat testily. Then he glanced over at the nurse. Zack caught the look and warned himself against doing anything that would embarrass the man. He took Annie's hand. Instantly, she dug her nails into his palm. 'Hey, Annie D, leggo!
It's me. It's Zack. I need that hand for my coin tricks.'
She looked up at him, blinking as if struggling to peer through a haze.
Then, slowly, she loosened her grip. 'Do you recognize me?' Zack said, already speeding through a neurologic exam. Annie did not respond.
'Well, you should.' He checked her scalp for any telltale lumps, and her neck for any points of tenderness. 'You used to wipe my runny nose and drag me back to the bathroom to wash behind my ears. Remember that?'
Although it remained uncertain whether or not Annie recognized him, there could be no doubt that his words had calmed her down. She lay reasonably still as he checked her eardrums and retinae. 'Well?' Norman asked. His arms were folded tightly across his chest. Zack smoothed Annie's matted hair off her forehead. 'There are — no focal neurologic signs. Let's go out to the nurses' station and talk, ekay?'
'Is it… all right if I listen in? ' the nurse asked, pausing between words to clear a huskiness from her voice. 'Fine with me, if Dr. Norman doesn't mind.'
Norman hesitated and then shook his head. 'We haven't met, ' Zack went on. 'My name's Iverson, Zack Iverson. I'm the new neurosurgeon on the block.'
'I'm Doreen Lavalley, ' she said. 'Annie was my patient up on four. I feel sick about what happened. We had her tucked in with the side rails up. She soiled herself. I think she was trying to get to the bathroom when she fell. We were all in with a post-op patient who had started hemorrhaging, and our routine bed check was delayed almost an hour, and … and we're just She bit at her lower lip and d away. 'Go on, ' Zack said as they walked from the cubicle to the nurses' station. For a moment, it seemed as if the young woman was going to cry. Then a flash of anger mixed with the anguish in her eyes. 'Dammit, ' she said, 'I knew something like this was going to happen.'
'What do you mean?'
She glanced over at Donald Norman and then turned again to Zack. 'We're short, ' she blurted. 'That's what I mean. We're short a nurse on every shift on every tloor except the unit here. It's been that way for more than a year. First they got rid of the union with all those promises of increased pay and benefits and staffing, Then, just slowly enough so that none of us could organize to complain, they began to cut back on nursing. I knew something like this was going to happen. I just knew it … Her fists were clenched in frustration. 'Who's they'? ' Zack asked.
'The hospital, that's who… the administration… Mr. Iver-' She stopped in midword and looked sheepishly at Zack. 'Oh, great… Way to go, Doreen… Brother?' Zack nodded. 'Sorry, ' she said. 'Don't be.
Don, you're the chief of staff. Are the physicians aware that this has been going on?'
Norman's face was pinched and flushed. However, his indignation was directed not at the situation, but at the nurse. 'If Miss Lavalley has complaints about this hospital or the way it is run, ' he said, his back almost turned to her, 'there are channels established for her to voice those concerns. She's worked here for enough years to know that-and also to know that airing her own distorted point of view in the middle of the intensive care unit is not one of those channels. Now, Doctor, if you'd care to share your thoughts on Mrs. Doucette with me, I can get on with the business of trying to save her life.'
The woman tensed at Norman's rebuke, but said nothing. Zack wrestled against the urge to defend her, and won a narrow victory.
The issue at hand was getting Annie Doucette diagnosed, treated, and stabilized. The nurse's charges, disturbing though they were, could wait. He thought about calling Suzanne in, but quickly tabled the notion. Annie's monitor pattern was regular, at least for the moment, and Donald Norman, as thin-skinned as he was thick-wasted, seemed hardly the sort to welcome any encroachment on his authority. 'So?
' Norman asked impatiently, 'Well, there's no evidence for a stroke or for head trauma, ' Zack said, 'but she's clearly disoriented, I guess if I had to put a label on what's going on, I would say she's sundowning-especially if her blood chemistries all come back normal.'
Out of the corner of his eye, Zack saw Doreen Lavalley nodding in vigorous agreement. Sundowning was not a medical diagnosis in the pure sense. Nevertheless, to anyone dealing with elderly, hospitalized patients, the disorientation and psychotic behavior stemming from unfamiliar surroundings and the diminished sensory input of evening were as real and reproducible a phenomenon as a strep throat. 'Excellent,'
Norman said, his expression and patronizing tone making it clear that Zack had added nothing to his assessment of the case. 'Good job. Listen, Doctor, why don't you dictate a note, and I'll put a formal request for a consultation in her chart.' He unrolled his sleeves and retrieved his suitcoat. 'If there's nothing else, I'm going to see another patient.
I'll stop back on my way out.'
Zack, engrossed in Annie's chart, did not respond. 'What are you looking for? ' Norman asked. 'An explanation.'
'For what? ' Zack glanced up. 'Don, this woman's been here almost two weeks, during which time she's been totally with it. Don't you think it's a little strange that she should have taken this long to sundown?'
'On second thought, ' Norman said, 'why don't you just forget about the consult. We'll discuss this whole thing in the morning.'
'It's there, Dr. Iverson, ' the nurse said. Norman shot her a withering glare. 'What is? ' Zack asked. 'The explanation. Look on the med sheet.'
'Give me that chart,' Norman snapped. 'Miss Lavalley, you don't know a good thing when you have it, do you? You just get the hell out of here.
I'll deal with you tomorrow.'
'You can deal with me tonight, Dr. Norman, because I've had enough. I quit.'
