Читать книгу Hunting for Hippocrates - Warren J. Stucki - Страница 10

Moe dressed for work the next morning without having ever closed his eyes. He had finally flopped on the bed at about 3:00 a.m., but sleep did not come. The only possible positive spin of Casey’s murder (yes, it had to be murder) was it had occupied his mind. As a consequence, he had spent little time dwelling on the funeral and his miserable relationship with his father and his family in general. Lying in bed with his eyes wide open, he’d whiled away hours trying to answer the questions, who and why?

The when was easy. Probably the entire week he’d been in Salt Lake City to be at his father’s bedside and subsequent funeral. In a way, that tied into the who. It had to be someone who knew he was going to be out of town, someone he was familiar with. But the why, had him completely baffled. To do something so cruel, so heinous, pointed to someone who literally hated him. Someone who was mentally warped and at least marginally, if not a full blown, psychotic. Someone who was unpredictable and dangerous. Would the killing of Casey satisfy his or her vendetta? Or would there be more?

Moe searched his brain, looking for enemies. Sure there were a few people who didn’t like him: the occasional disgruntled patient, the neighbor with the ranch to the west (not the Rheinhart’s) with whom he had a boundary dispute a few years ago and his ex-wife, Annie. That was about it, except his office nurse who had been harboring a grudge for a few months and Rusty, his partner. They had never got along. But murder a defenseless baby colt, Moe just couldn’t imagine any of them being capable of that. And try as he might, he could think of no one else.

Without stopping to taste, Moe wolfed down a bowl of cornflakes sweetened with Nutrasweet. If he hurried, he could stop by the pathology department before clinic started and give Ray the gastric fluid sample. But it was probably a waste of time. Toxicology would undoubtedly confirm what he already knew. Casey had been overdosed with Coumadin..

At the front door Moe suddenly stopped. He had forgotten to take his insulin this morning, and last night as well. God, his blood sugar must be three hundred. Quickly, he pricked his left middle finger, squeezed out a drop of blood and ran it through the glucometer. Two hundred and sixty-three. Not as bad as he thought. Adroitly, he drew up twenty-five units of regular insulin (five more than his usual dose) and fifteen of lente, bunched the skin of his abdomen between his thumb and forefinger, and injected the insulin. Tossing the syringe in a plastic sharps container, he then sprinted out the door for the garage.

A little late, Moe trudged through the door marked Private Entrance, Moses A. Maihis, M.D. Normally he liked going to the office, seeing patients and his work in general, but not today. Today he was irritable and depressed. Why shouldn’t he be? He glanced at the waiting room for a moment, then immediately felt guilty for what he was thinking. It reminded him of a scene from his childhood. On Tuesdays his father would sometimes take him and Abe to the cattle auction in Cedar City. Prior to the auction, they would corral the cattle in a holding pen. There the cows would sniff each other, mill about and bellow. Usually, they bawled at nothing in particular, except to express their general displeasure at being confined in this strange environment. In a way, Moe thought of his waiting room as a holding pen for patients to trample about, bellow and to voice their displeasure.

Today, the patients seemed especially restless, wandering about, grumbling to each other about the already long wait and debating their excessively high bills with Sally. No doubt about it, this was going to be another impossible day. Lately, they had all been like this, and after taking a week off, today would be worse than usual. Moe scanned the waiting room once again. Would there ever be an end to this uninterrupted stampede of patients? He couldn’t help but think of a story he had heard years ago in world civics class: If all the Red Chinese were assembled in a straight line and then marched into the sea, the line would never end. Just the sheer numbers from childbirth would make it self-perpetuating. Surely, this anecdote would apply to his patients, specifically his Medicare patients. Thousands of people were turning sixty-five every day.

Fortunately, Moe realized that today was a bad day and tomorrow he would not feel this way. Sighing, he looked up at his office wall clock. Though it was only 9:30 a.m., he was already tired. It had been one-hell-of-a-week. Rusty had been in New Orleans at the annual American Urological Association convention, leaving the entire load to Moe. Then he had to cancel out for the funeral, so they were way behind. If it wasn’t for the enormous amount of work, Moe would be just as happy if Rusty never returned. Unfortunately, that was unlikely. Rusty had such a sweet deal with Moe, why go anywhere else? For bad or worse, he was due to return this evening.

Moe had been to those national conventions before and he knew they were basically a guise for a tax-deductible vacation, particularly in New Orleans. How could one hold a serious scientific session in New Orleans? However, knowing Rusty, he probably was actually going to the meetings and not taking in New Orleans’ notorious nightlife.

Rusty would return with some new, irritating, and currently fashionable procedure that he would want to try, hinting that if Urology Associates didn’t incorporate this procedure in their surgical repertoire, they were somehow practicing archaic medicine. In general, Rusty was becoming more and more annoying as the years went by.

“Morning, Sally. What’s the chance of canceling out the day?”

Sally was a small energetic woman with fading good looks. Her once empathetic smile had eroded to indifference, not from personal problems or excessive use of make-up, but from years of haggling with patients over bills, co-payments, secondary insurances, and over what indeed constituted an emergency.

“Don’t even think about it, Dr. Mathis.” She didn’t smile as she swung her right hand in an arc, gesturing at the waiting room. “You’re not leaving me with that. Anyway, I’m sorry about your father. It must be hard.”

“We were never very close,” Moe said. “But sometimes that makes it harder.”

“I know,” Sally smiled sympathetically. “Sometimes it drives you nuts, just trying to make sense of it all.”

“Thanks Sally. Looks like the patients are restless, I better get to work.”

“Moe, you look like hell. If you want me to cancel—”

“Nah, sometimes work is therapeutic. Occupies your mind.”

“At least you have real vacation coming up in three weeks.”

“Yeah, I really need some time away from this place.”

Not only as Sally had said, ‘you look like hell,” Moe also felt like hell. The week was a blur, like watching a movie with the VCR on fast-forward. He was vaguely disoriented and had no sense of balance or proportion. No time to assimilate the week’s events. With his father’s illness, his subsequent death and the murder of the colt, it was no wonder he felt like hell.

For the past week, in lieu of sleeping, he stared at the murky black ceiling of his motel, imagining it was a black hole. Everything he loved and had worked for these last forty-one years was being sucked through that hole and scattered somewhere off in space. Since his divorce, Moe had been spending a lot of time, too much time, on personal introspection. His life seemed empty and meaningless. At times he wondered why, and for whom, he worked so hard. Then he remembered, he worked this hard to pay his alimony and taxes. Now it all makes sense, Moe had thought bitterly, his life did have a purpose. Yes, right now he felt like hell and even worse, he suspected that things were not going to get any better, at least not in the foreseeable future.

After leaving the business office, Moe navigated the short distance to the back office. His office nurse was in the lab, peering at a urine sample through the microscope.

“Morning Diane.”

Diane glanced up. “Sorry about your father,” she said stiffly.

“Thanks.” Moe changed the subject immediately. He was tired of talking about his father and the funeral. “Who’s urine you looking at?”

“Julie McAllister. Room number two. Bed wetter.”

“See anything?”

“It’s clear, Dr. Mathis, just a few epithelial cells and some oxalate crystals,” Diane said coldly.

For twelve years Diane had assisted Moe. Five years ago she had dropped the formality of calling him Doctor in favor of the more intimate, Moe. That was, of course, until just the last few months, when he again became Dr.Mathis. Diane again calling him Doctor, reminded Moe of his mother. As a child he was Moe, except when she was displeased with him, then he instantly became Moses. Moe knew exactly what the problem was with Diane and why he was now again Dr. Mathis, but had no idea how to deal with it. Diane was hurt, offended and angry.

“What contestants do we have today? Any surprises behind any of the three doors this morning?” Moe bantered, gesturing at the patient exam rooms.

He was trying hard with this line. It used to be an inside joke but today, it only managed to scour a pinched smile from Diane. Though certainly not in the same league as Diane Parkinson of The Price Is Right, when she smiled, Diane instantly changed from a plain to an engaging, if not an overtly attractive, woman. However, there had been a paucity of smiles lately.

“Behind door number one,” she hissed. “We have Howard H. Swensen, here for a mildly elevated PSA of 8.7, referred by Dr. Holman. He’s an okay guy. He’s in my ward at church.”

“What’s got into Holman?” Moe asked. “He never sends me anything.”

“You know why, don’t you?” Diane asked.

“No. Why?”

“It’s simple. Dr. Holman is religious, a stake president. You’re not.”

“You really think that makes a difference?” Moe asked. “To men that have over twenty years of education.”

Diane shrugged indifferently. “What do you think?”

“I don’t,” Moe replied. “Maybe. What else you got?”

“Behind door number two, there is Julie McCallister, an eight-year-old referred by Dr. Greenfeldt for enuresis, your favorite non-disease. This is her urine. Big surprise, it’s normal. And finally, behind door number three, is another elevated PSA. Mr. Robert E. Robinson, referred by, believe it or not, Dr. Butras.

“Not from Dr. Butras,” Moe joked. “I hate calling him back about his referrals.”

“Fortunately, he writes more clearly than he speaks. The referral form is on the chart. You won’t have to call him, just send back the form.”

“Whatever you say.” Moe smiled.

Diane pushed past him. “I’ve got to post this urinalysis slip in Julie’s chart.” Then almost immediately she turned back and sneered, “Oh, I almost forgot, in your office, there is a pretty drug detail woman from Merck.”

“What’s eating you, Diane?” Moe asked, though he already knew the answer.

“Could you just drop the references to “The Price Is Right” and Diane Parkinson. And I don’t care who you see first, but Mr. Swensen has the first appointment.”

“Who did you say was in my office?”

“A Merck rep. She’s been here before. She’s just your type, blonde and big boobs.” Diane glared at Moe for a moment, then she was gone.

Moe bent over to turn off the light switch to the microscope. Impulsively, he slid open the cabinet drawer just below the scope, the one Diane used for personal items. At the back of the drawer, Moe spotted a brown plastic medicine vial. Feeling a little guilty, he grabbed the vial and read the label. Dan Henrie—Coumadin-5mg—Sig, one po qd.

Coumadin! He’d completely forgotten Diane’s husband was on Coumadin. For atrial fibrillation, or something. What was that vial doing in Diane’s drawer? Better not jump to conclusions, Moe thought. Probably, she was just getting Dan’s prescription filled at the hospital pharmacy. But—but Casey had been murdered with Coumadin! With his mind grappling with the possible implications, Moe replaced the vial and closed the drawer.

“Dr. Mathis!”

Moe jumped. He hadn’t heard Diane return.

“Don’t you think you had better start seeing patients? We’re already backed up.”

Slightly unnerved, he waved at Diane and quickly retreated from the lab. Had she seen him rifling through her drawer? So what if she had. After all, it was still his office. But was it just a coincidence that Diane had Coumadin in her drawer? Probably so. A lot of people had access to Coumadin; it was a pretty common drug. Even so, it made one think.

Standing before the first exam room, Moe reviewed the chart of Howard H. Swensen. Mr. Swensen was sixty-seven years old and still an active land developer and real estate broker. He had a medical history of gout, high cholesterol, hypertension and bladder tumors. Mr. Swensen had no known allergies, and his medications included Allopurinol, Lipitor, Lopressor and Cardura. I’ve been in the business too long, Moe mused. I can pretty much fill in the blanks on Mr. Swensen right now. As he often did, Moe began a game of patient sleuthing. Undoubtedly, because of his surname and the gout, he has a fair, florid complexion with blond hair and probably some graying due to age. Also the gout, high cholesterol and the hypertension all indicate he’s probably overweight. He has to be a smoker, or at least had been a smoker, because of the history of bladder tumors. And, he probably has some prostatic enlargement due to his age and because Dr. Holman has chosen Cardura along with Lopressor as the drugs to treat his hypertension. Moe sighed, then entered the exam room; no surprises here, Mr. Howard H. Swensen was exactly as Moe had imagined.

“Morning Mr. Swensen, I’m Dr. Mathis. How are you today?”

Howard Swensen fidgeted in his chair and tugged at the loose skin hanging from his neck. “I don’t know, Doc, that’s what I’m here to find out. That’s why they pay you all the big bucks.”

Moe always found that answer irritating, particularly on a day like today, but he maintained his composure and sat on a stool facing Mr. Swensen. He glanced through Mr. Swensen’s brand new chart. “Dr. Holman sent you to see me because a blood test, the one that checks on the prostate, came back a little high. Do you know much about the PSA blood test?”

“I’ve read a little about it in the Mayo Clinic Newsletter, Doc.”

Add that to the list of Mr. Swensen’s characteristics, some education and at least a passing interest in medicine; Moe was impressed. Maybe he would have to change his first impression of the man. “Well, let me take a little time and tell you about the PSA, what it means, and where we go from here.”

Moe had recited this PSA narrative so many times he could literally mouth it, while in part thinking about other, more personal things. “The PSA is a relatively new blood test. I guess it’s been around for about ten years now, but has only been in widespread use for the last seven or eight years. PSA is short for prostatic specific antigen. Although it’s a blood test designed to pick up on cancer of the prostate, it’s not always accurate. In fact, the more experience we get with it, the more inaccurate we realize it is. However, it’s accurate enough of the time that it makes it worth doing. In other words, it’s not a totally worthless test.” Moe droned on, but had fleeting thoughts of Cozumel. Three weeks from now, he was leaving for Cozumel. And no pretense of going to a meeting. This was all vacation. It was about time that Rusty had a turn watching the store.

“A PSA of 8.7 is not sky high by anyone’s standards, but is high enough to warrant further testing. By further testing, what I mean is to perform an ultrasound of the prostate.” Judy would be going to Cozumel with him. They would do some diving and get caught up on some rare and much needed personal time. There had been a real dearth of that lately.

“Ultrasound has certain advantages over just the finger exam of the prostate. With the ultrasound, you can see the whole prostate, including the interior of the prostate, whereas with the finger exam you’re just feeling one surface, that being the surface next to the rectum. If there is anything suspicious, you can also biopsy using the ultrasound and place the needle, with pinpoint accuracy, right where you want. In fact, what’s recommended now days, even if you don’t see a suspicious area, is that you biopsy each section of the prostate. From your point of view, an ultrasound feels just like having a finger exam of the prostate. The whole procedure takes about five minutes. Obviously, it’s up to you, but I think we should go ahead with the ultrasound, Mr. Swensen.”

“You mean, you biopsy through the rectum?” Mr. Swensen grimaced slightly.

“Yes, that’s why Sally gave you some antibiotics to take when you made the appointment.”

“Whatever you say, Doc, but I can tell you right now, I won’t like it.”

“Well if you do, we could set aside some time and do it once a week,” Moe laughed, then stood to leave. He was beginning to like Mr. Swensen.

As he left the exam room, Moe was met by Diane who directed patient flow like a traffic cop. She suggested that he see the bed wetter in room two while she was getting the procedure room ready for Mr. Swensen’s ultrasound. Diane also reminded him of the Merck lady in his office, and at this point in time he was running approximately an hour late.

Moe made quick work of the bed wetter. Treating non-disease always irritated him. Then he trudged back his private office and his obligatory visit with the Merck drug detail lady. It was an unwritten law, no visit, no free samples.

Connie Swensen stood as Moe entered the room. She was a pretty, shapely woman of thirty-something, with flawless make-up, meticulously dressed and natural blonde hair. Today, she was wearing a light gray skirt and a loose, low-cut, gossamer white blouse. In spite of her captivating, albeit slightly cosmetic appearance, she had intelligent, blue eyes with just a hint of sadness laced in the lines of her face. This trace of sorrow tended to offset her Barbie Doll appearance and gave her the more tangible image of a real person. Faintly, Moe caught the bouquet of designer perfume.

Moe shook Connie’s hand as she offered him a Merck pen. During the exchange, the pen inadvertently clattered to the floor. Bending at the waist to retrieve the pen, she exposed the tops of her ample, bulging breasts straining against a delicate, white lace bra. Moe couldn’t help but notice. And though he realized this was part of her sales pitch, it always seemed to work. He consistently gave her more time than her male colleagues, and subconsciously, Moe knew he would favor her company’s products.

“How are you today, Dr. Mathis?” Connie said brightly, settling back into her chair.

“Fine,” Moe said with a sigh, depositing his tired body into the stuffed vinyl chair behind the desk.

“You’re seeing my father today. Obviously, I wouldn’t let him see any other urologist but you,” Connie bubbled. “So today, I guess, I’m wearing two hats, the caring daughter accompanying her father into the eerie Steven King world of the doctors’ office, and my usual role as a Merck representative.”

Moe looked puzzled. It took a minute for him to make the connection. “Oh, Swensen—Mr. Swensen is your father! If—if I would have known that, I wouldn’t have been quite so nice to him. You don’t look anything like him,” Moe laughed, stumbling through his embarrassment, then blushing as he recalled the view of her bending to retrieve the pen.

“I take more after my mother’s side, at least as far as physical appearance, but in personality, I’m more like my father,” Connie said warmly. “How’s Pop doing?”

“Well, he has a mildly elevated PSA, probably nothing, but to make sure, we’re going to ultrasound his prostate. It will only take a few minutes.”

Connie’s smile was dazzling. “Dr. Holman wanted to send him to Dr. Rasmussen, but I insisted on you.”

“I wondered about that,” Moe said.

“You’re my only doctor to see today, so take your time. Anyway, I know he is in good hands. The best.”

“Thank you,” Moe said weakly, annoyed that he felt tongue-tied around Connie, just as he did years ago in high school when he tired to talk to pretty girls.

“Sally tells me you have a trip planned for Cozumel. When are you leaving?” Connie said, abruptly changing the subject.

“In about three weeks—” Moe said, as his mind started to wander. He was mesmerized by Connie, and involuntarily he glanced to see how high her skirt had hiked up on her crossed, slender thighs which were tantalizingly packaged in sheer nylons. As expected, it was a pleasant sight. Moe had to forcibly remind himself that he just didn’t have time for small talk today.

“I’ve always wanted to go to Cozumel, but I’ve never been able to find anyone to go with. And I certainly don’t want to go by myself.” Connie gave Moe a ‘know-what-I-mean’ look. “Did you know I’m a certified diver?”

Moe wondered if this was a come-on. Someday, he really ought to ask Connie out. However, instead of pursuing that inclination, he said. “No, I didn’t. Maybe someday we’ll have to go diving. What do you have for me today?”

“I’m sorry, Dr. Mathis, I know you have a waiting room full of patients. I’ll be brief. Those recent studies down-playing the effectiveness of Proscar are somewhat skewed,” Connie stated. “There is a sub-population of patients for which Proscar works very well, those being the patients with the kind of prostatic enlargement that contains a lot of glandular tissue and not so much stroma. A majority of these patients had a substantial reduction in their prostate size and obstructive symptoms with a trial of Proscar. I hope you will continue to use Proscar, particularly on this sub-group of patients.”

Moe, though he had his doubts about the drug, assured her he would continue to use Proscar, and that he would also keep her updated on the results of her father’s tests. After looking at his watch, he stood and excused himself.

“Are you okay, Dr. Mathis? You look tired.”

Again Moe wondered if the girls had collaborated on their comments about his looks, or

if he really did look that bad. Right now, however, he did not want to get into another lengthy conversation about his father dying.

“Nah, I’m fine. Just my week on call,” Moe said lamely, then headed toward the third exam room with Mr. Robinson, and another lengthy monologue on the PSA blood test. Someday, he would be more efficient and video tape his discussion.

After Moe finished talking with Mr. Robinson, Diane was ready for the ultrasound on Mr. Swensen.

“Diane, as soon as we’re done here, we’ll have to do another ultrasound on Mr. Robinson.”

“Damn it!” Diane exploded. “Will Sally ever learn to schedule? We should never have two procedures back-to-back. Give me about fifteen minutes to get the room and patient ready,” She grabbed a patient gown for Mr. Swensen, then added derisively, “I suppose you’re going to use more Proscar now.”

“I just might,” Moe snapped as he followed Diane into the procedure room. He was getting a little tired of Diane’s attitude.

Moe told Mr. Swensen to relax, then he inserted the rectal probe. Mr. Swensen, only half-joking, noted that this was somewhat akin to a rapist asking his victim to relax. Rotating the probe ninety degrees, Moe obtained a sagittal view of the prostate, then he rotated it back again for a cross-sectional image. There was a small hypoechoic area, mid-gland, left side, in the transitional zone. After taking a biopsy of the suspicious area, Moe handed the needle to Diane, who dislodged the tissue from the needle and placed it into a small specimen container half-full of formalin. She then set the container on the blue, laminated counter-top next to the ultrasound machine, and swivelled her stool back to help Moe.

Finishing with Mr. Swensen, Diane cleaned the procedure room, then brought Mr. Robinson back to a room that was now saturated with the aroma of PineSol. After having Mr. Robinson strip from the waist down, she had him put on a white, disposable paper gown. As with Mr. Swensen, Moe found a suspicious lesion in Mr. Robinson’s prostate, also requiring a sonograph-guided biopsy. Again, the tissue was submerged in formalin by Diane, who then placed the specimen container on the same counter-top adjacent to Mr. Swensen’s container.

Moe and Diane then left the procedure room, giving Mr. Robinson some privacy to clean up and dress. There were still more patients to see. Starting the cycle over again, Moe ducked into room one to see an eighty-two-year-old man with hematuria, while Diane marched with grim face back to the lab to process his urine specimen.