Leaving the ICU, David started seeing his own patients. Each time he went into another room he felt anxious, only to be relieved when he discovered the patient was doing well. But when he went into Sandra's room the anxiety remained. Sandra's mental status had deteriorated.
David was appalled. The change was dramatic to him even though the nurses weren't impressed. When David had visited her early that morning she'd been bright and aware. Now she was apathetic to her surroundings and was drooling. Her eyes had lost their luster. Her temperature, which had fallen, had now crept back up over one hundred degrees.
When David tried to talk to her, she was vague. The only specific complaint he could elicit was abdominal cramps, a symptom that reminded him of other patients he'd been trying to forget. David felt his pulse quicken. He didn't think he could tolerate losing another patient.
Back at the nurses' station, David pored over Sandra's chart. The only new fact was that she'd apparently lost her appetite as evidenced by an entry in the nurses' notes that recorded she'd not eaten her lunch. David checked all the IV fluids she'd had; they were all appropriate. Then he went over all the laboratory tests; they were all normal. He was desperate for some clue to explain the change in her mental status, but there were no clues in the chart. The only idea that came to his mind was the possibility of early meningitis, or inflammation of the coverings of her brain. It was the fear of her developing meningitis that had moved him to admit her in the first place.
David re-examined her, and although he could not elicit any signs of meningitis, he went ahead with the definitive test. He did a lumbar puncture to obtain cerebrospinal fluid. He knew immediately the fluid was normal because of its clarity, but he sent it to the lab for a stat reading to be certain. The result was normal. So was a stat blood sugar.
The only thing Sandra wasn't apathetic about was pain when David palpated her abscess. Consequently, David added another antibiotic to her regimen. Beyond that he had no ideas. He felt lost. All he could do was hope.
Climbing on his bike, David cycled home. He knew he was depressed. He got no enjoyment from the ride. He felt heartsick about Caroline and concerned about Sandra. But as soon as he arrived he realized he could not wallow in self-pity. Nikki was slightly worse than she'd been at lunchtime when he'd brought home her oral antibiotic. Her congestion had increased and her temperature had reached one hundred degrees.
David phoned the ICU and got Dr. Pilsner on the line. David apologized for disturbing him but felt obliged to let him know the oral antibiotic wasn't helping.
"Let's up it," Dr. Pilsner said in a tired voice. "And I think we'd better use a mucolytic agent and a bronchodilator with her respiratory therapy."
"Any change with Caroline?" David asked.
"No change," Dr. Pilsner answered.
Angela didn't get home until almost seven o'clock. After she checked on Nikki, who was doing better after a respiratory therapy session with David, she went to take a shower. David followed her into the bathroom.
"Caroline is no better," David said as Angela stepped into the shower.
"I feel great compassion for the Helmsfords," Angela said. "They must be heartsick. I hope to heaven that Nikki doesn't come down with whatever Caroline got."
"I've got another patient-Sandra Hascher-who is scaring me the same way the others did."
Angela poked her head out of the shower. "What was her admitting diagnosis?"
"Abscessed tooth," David said. "It had responded nicely to antibiotics. Then this afternoon she suddenly had a mental status change."
"Disoriented?"
"Mostly just apathetic and vague," David said. "I know it doesn't sound like much, but to me it was dramatic."
"Meningitis?" Angela asked.
"That was the only thing I thought of," David said. "She hasn't had any headache or spiking fever. But I did a lumbar puncture just to be sure, and it was normal."
"What about a brain abscess?" Angela asked.
"Again, she's had little fever," David said. "But maybe I'll do an MRI tomorrow if she's not better. The problem is, she's reminding me of the other patients who died."
"I suppose you don't want to ask for any consults."
"Not unless I want to have her transferred to someone else," David said. "I might even get into trouble ordering the MRI."
"It's a lousy way to practice medicine," Angela said.
David didn't answer.
"The trip to Burlington went smoothly," Angela said.
"I'm glad," David replied without interest.
"The only trouble I had was when I got back. Wadley's being unreasonable. He even threatened to terminate me."
"No!" David said. He was aghast. "That would be a disaster."
"Don't worry," Angela said. "He's just blowing off steam. There's no way he could terminate me so soon after I complained about his sexual harassment. For that reason alone I'm glad I went to Cantor. The conversation officially established my complaint."
"That's not a lot of reassurance," David said. "I'd never even thought of the possibility of your being fired."
Later, when dinner was served, Nikki reported she wasn't hungry. Angela made her come to the table anyway, saying she could eat what she wanted. But during the dinner, Angela urged Nikki to eat more. David told Angela not to force her. Soon David and Angela exchanged words over the issue, causing Nikki to flee the table in tears.
David and Angela fumed, each blaming the other. For a while they didn't talk, preferring to turn on the TV and watch the news in silence. When it was time for Nikki to go to bed, Angela told David that she would see to Nikki's respiratory therapy while he cleaned up the kitchen.
David hardly had time to carry the soiled dishes into the kitchen when Angela returned.
"Nikki asked me a question I didn't know how to answer," Angela said. "She asked me if Caroline was coming home soon."
"What did you say?" David asked.
"I said I didn't know," Angela admitted. "With Nikki feeling as poorly as she is, I hate to tell her."
"Don't look at me," David said. "I don't want to tell her either. Let's wait until this bout of congestion is over."
"All right," Angela said. "I'll see what I can do." She left the kitchen and returned upstairs.
Around nine David called the hospital. He spoke at length with the head nurse who kept insisting that Sandra's condition had not changed, at least not dramatically. She did admit, however, that she'd not eaten her dinner.
After David had hung up the phone, Angela appeared from the kitchen.
"Would you like to look at the papers we got from Burlington today?" she asked.
"I'm not interested," David said.
"Thanks," Angela said. "You know this is important to me."
"I'm too preoccupied to worry about that stuff," David said.
"I have the time and energy to listen to your problems," Angela said. "You could at least extend the same courtesy to me."
"I hardly think the two issues are comparable," David said.
"How can you say that? You know how upset I am about this whole Hodges thing."
"I don't want to encourage you," David said. "I think I've been very clear about that."
"Oh, you're clear all right. What's important to you is important; what's important to me isn't."
"With everything else that's going on, I find it amazing that you are still fixated on Hodges. I think you have your priorities mixed up. While you're chasing off to Burlington, I'm here bringing antibiotics to our daughter while her friend is dying in the hospital."
"I can't believe you're saying this," Angela sputtered.
"And on top of it, you make light of Wadley threatening to fire you," David said. "All because it was so important to go to Burlington. I can tell you this: if you get fired it will be an unmitigated economic disaster. And that doesn't even account for the jeopardy you're putting us all in by pursuing this investigation."