The Diagnosis is Murder (A Dr. Valorian Mystery Book 1) Read online

  “We found him outside a bar, lying on the ground. Two nurses were doing CPR. He had no ID on him, no wallet. There was no blood anywhere, no sign of trauma.”

  While listening to the report, Laura looked the patient over again. A person’s appearance was quite different when supine and unconscious than when upright and alert. Laura moved closer to the man and studied his face. She gasped.

  Lying on the stretcher was Laura’s surgeon nemesis—Dr. Roderick Preswick—who’d been alive and well in Laura’s ER earlier that very day.

  Chapter 3

  “Let’s do this right.” Laura realized that she was yelling. “And someone call his wife.”

  She directed the resuscitation attempt, checking the carotid pulse repeatedly to ensure that effective chest compressions were performed to circulate blood to the brain. Paramedics had pushed two doses of intravenous epinephrine while en route to the hospital.

  “Give another epi, one amp,” Laura said to the medication nurse. “Follow that with 40 units of vasopressin. If we can just get his heart beating again.” She felt dampness on her forehead.

  Laura reviewed the arterial blood gas results. “We’re doing well with ventilation and oxygenation.”

  She and Derek examined the body, hoping to find a reason for the dying heart.

  “I see no signs of trauma to his body,” Laura said in a calmer voice. “No bruises, no lacerations or hematomas. His wallet may’ve been stolen, but there’s no evidence of a violent mugging.”

  “You think he had a heart attack?” Derek said.

  “That’s possible. Myocardial infarction, or heart attack, followed by an abnormal heart rhythm is a common cause of sudden death. Unless effective cardiac activity is restored, the brain and other organs soon die from inadequate oxygen. In most cases, basic CPR alone can maintain brain viability for only a short period of time.”

  “The monitor shows asystole, doesn’t it? No electrical activity at all?”

  “Yes. He’s been in asystole since he arrived,” Laura said.

  “Should we try to shock him once, just in case he’s really in an unrecognizable v-fib?”

  “Absolutely.”

  A nurse pressed on the defibrillation pads to make certain they were secured to the upper right and lower left of the chest wall.

  “Set the power at maximum, and stop CPR.” Derek looked around the room. “Clear,” he yelled to warn everyone away from the stretcher. He pushed the defibrillator button, and the inert patient lurched. All eyes were glued to the monitor.

  “I don’t feel a pulse. He’s still in asystole,” Derek said.

  Despite more epinephrine and CPR, and despite the pleading stares of the nurses as if to will the monitor to show some—any—signs of life, the heart didn’t respond—the monitor remained flat-line.

  Derek, his fingers indenting the skin over a carotid artery in the neck, glanced at Laura and shook his head.

  “He’s gone,” Laura said. She addressed the nurses and respiratory therapists. “I’m calling the code. Stop the resuscitation.”

  She turned to Derek. “He never showed any response to pain or any spontaneous movements or respiratory efforts. Do you know what that means?”

  “That his brain was dead, right?”

  “Yes, and more specifically, his entire brain including the brain stem, which is the lower region that controls automatic activities such as breathing. If he never resumes any breaths at all on his own, then his brain stem is dead.”

  They stood by the bedside and gazed down at the lean, muscular—and lifeless—body of Roderick Preswick.

  Laura’s vision blurred. The walls seemed to recede, and the only object in focus was the body on the stretcher. Here was one of her own medical colleagues lying dead before her. What is it like to die, Roderick Preswick? His face was pasty white. No longer did blood course through his vessels or thoughts through his mind. Laura wondered if his soul was gazing down at her now.

  She became aware that Derek was watching her.

  “Are you okay?” he said.

  Her eyes focused. She’d been staring up at the ceiling. “I’m fine.” She stepped back from the bedside. “I think he may’ve been dead for a while before he was discovered. His heart and brain didn’t respond to CPR or advanced life support—no response at all.”

  “Dr. Valorian.” The evening ER clerk had poked her head into the resuscitation room. “Dr. Preswick’s wife is on the phone. Will you speak with her, or should I just tell her to come right away?”

  “Let her know that he’s critical, and that we need to speak with her in person, here in the ER.” Laura left the resuscitation room. “Call the medical examiner, please,” she said to the clerk. “This is an unexplained and unexpected death. It has to be reported to the ME.”

  She and Derek walked back to the office to collect their thoughts. The night ER doctor had arrived and was already examining patients.

  “Did you notice anything unusual about Dr. Preswick?” Laura said.

  Derek visualized the scene again. “No, not really. Why do you ask?”

  “Well, it may be nothing, but his pupils were small, very small, even pinpoint. Do you know the term for small pupils?”

  “Miosis?”

  “Correct. And what pupillary reaction do you expect to see after cardiac arrest and brain death, especially after drugs such as epinephrine are given?”

  “Dilated pupils? Mydriasis?”

  “Correct again. You get an ‘A’ your first day.”

  “Then why did he have miosis?”

  Laura sighed. “I don’t know. Possibly some unusual brain stem injury, possibly drug effect. I’ve ordered a drug screen.” Urine and blood samples had been sent to the laboratory for drug testing. She turned to Derek. “You can go home any time now. Our shift is over, except that I have to stay and talk with Mrs. Preswick and the ME. You don’t need to hang around for that.”

  Derek hesitated.

  “I appreciate that you’d like to stay,” Laura said. “But when giving bad news to family members, it’s often better to limit other people in the room to the chaplain and the main doctor.”

  “I understand.” Derek left the office.

  “ME on the line,” the ER clerk yelled out.

  Laura picked up the receiver. “Dr. Stiles? This is Laura Valorian.”

  “Hello. What’ve you got?”

  “A dead surgeon, Dr. Roderick Preswick. I don’t know why he died. He was found on the ground outside a local bar.”

  After a short pause, Dr. Stiles said, “Yes, I know him. What a tragedy. Okay, I’ll do the autopsy. And Laura . . .”

  “Yes.”

  “You know you can count on me. I’ll find the answer. I always do. I never fail.”

  “Sure, thanks.” Laura replaced the receiver and stared at the telephone. Oh, boy. I’ll bet you haven’t been taking your bipolar meds. She recalled a previous episode when Dr. Stiles’ mind had gone off the rails. Lucky for everyone, his psychiatrist had been able to stabilize him. Sometimes, however, he cycled back to normalcy on his own. Laura decided to keep an eye on him.

  Laura explained the unsettling events to the night physician and the evening ER nurses. After a few minutes, one of the registration clerks stepped into the office and said, “Mrs. Preswick is in the family room. The chaplain’s there, too.”

  ERs have designated areas for imparting bad news. In Laura’s ER, a dimly lit family room with one door served for that depressing function. Two chairs and a couch faced a coffee table, which was bare except for a box of tissues and a tattered children’s picture book perched on one corner. Three paintings on the walls showed expansive landscapes: snow-capped mountains, an ocean beach with white sand, and a silver stream snaking through forested hills. None of the paintings had any sign of human life.

  Laura’s legs wobbled as she approached the room, which was tucked away in a corner not far from the critical care room. She studied the new widow standing in front of the couch
, her hands clenched together. Mrs. Preswick wore a black silk evening gown.

  She could’ve come here straight from the opera. No way could I afford a dress like that. Laura admired Mrs. Preswick’s short black hair with curls and her unblemished skin—fair flesh that had probably never suffered a sunburn or been at risk from the wrinkling ravages of smoking.

  Laura stepped into the room and nodded at the chaplain.

  Mrs. Preswick’s hands flew apart. “What’s happened? Something about my husband?”

  “Let’s sit down,” Laura said. The two women sat together on the couch, and the chaplain eased into a chair nearby.

  “Mrs. Preswick, I’m so sorry to have to tell you this. I don’t know yet what happened to your husband, but he was found unresponsive.”

  “Unresponsive.”

  “His heart had stopped . . . He died suddenly.”

  Mrs. Preswick’s eyes widened, and she leaned forward. “He died? What do you mean?”

  Laura waited.

  “He can’t be dead,” she said, shaking her head. “Why, he was fine just this morning. There must be some mistake.” Her voice was pleading. “Maybe it’s somebody else?”

  “I’m sorry; it’s definitely him. He was found on the ground. He had no pulse, and his heart didn’t respond to resuscitation efforts. We couldn’t restart his heart.”

  “Oh, my god. I can’t believe this is happening. Oh, my god.” She began to sob softly, and then looked up at Laura with anguished eyes. “He’s really dead?”

  “Yes.” Laura handed Mrs. Preswick a tissue, which darkened with moisture against her face.

  “How did he die?”

  “I don’t know yet. Maybe a heart attack.”

  “A heart attack? But he was in such good health. It’s just too difficult to believe . . . a heart attack?”

  “Well, we don’t know yet for sure.”

  “You said he was found on the ground. Where was he?”

  “Outside a bar.”

  Mrs. Preswick slid to the edge of the couch. “Which bar?”

  Laura paused for a few seconds. “I’m not sure I heard which one. I can find out for you.”

  Mrs. Preswick shook her head. “No, that’s all right. It was a silly question. I’m not thinking clearly right now . . . It’s just too unbelievable.”

  Laura and the chaplain waited.

  “Can I see him?”

  “Sure, follow me,” Laura said.

  They walked—a grim procession—to the resuscitation room. Nurses and techs had cleaned the area and covered the body up to the neck with a sheet. Laura was struck by an eerie quiet in the room, in contrast to the clamor of a desperate resuscitation attempt in the same room just a short time before.

  “We have to leave all tubes and catheters in place.” Laura turned and left the room so that Mrs. Preswick could be alone with her husband’s body.

  After a while, Mrs. Preswick exited the room. Her eyes were red, and tears had left streaks down her cheeks.

  Laura approached her. “I’ve spoken to the medical examiner, since I was required to by law. He’ll do an autopsy to determine the cause of death.”

  Mrs. Preswick lifted her hand and started to say something. After a few seconds, she sighed and nodded.

  “Did your husband have any medical problems? Was he on any regular medications?”

  “No, he was healthy as far as I know. He took no medications.”

  “He had no heart problems, cholesterol problems?”

  “No.”

  “Any recent new illnesses, any complaints of chest discomfort?”

  “Not that I know of.”

  “How about a family history of heart or other diseases?”

  “I don’t think so. No, not really. Well, his father died of lung cancer.”

  “Did he drink much?”

  “He didn’t drink all that much, some evenings, several times a week. He didn’t get drunk.”

  “I’ve seen him smoking cigarettes.”

  “He did smoke, at least half-a-pack a day. He tried to stop several times, especially after his father died . . . He never smoked around me.”

  “I know this is a difficult time. Thanks for talking with me. Would you like to speak more with the chaplain? He can help you with some other details about what needs to be done now.”

  Mrs. Preswick nodded, and the chaplain escorted her back to the family room.

  Laura returned to the doctors’ office to complete her computer patient chart work. She felt uneasy, replaying in her mind the strange eyeball incident—and the nightmarish scene at the end of her shift.

  Her legs were unsteady as she left the gloomy atmosphere of the emergency room for the doctors’ parking lot. Was this death really so unusual? He probably died of a heart attack and rhythm disturbance. It happens many times every day in this country. Maybe bad genes and smoking caught up with him.

  She shook her head. Something was not right about those pupils. She decided to research that unusual eye finding and call the ER later for the results of the drug screen.

  Washington, D.C. in early April was a pleasant place, although some evenings were chilly. Laura pulled her blue sweater around her as she walked to her dated red Saturn. After easing into the front seat, she inserted the key and the engine jumped to life without a hiccup.

  As she backed out of her parking space, a movement caught the corner of her eye. She turned her head and spotted something just past the far corner of an outside wall of the ER. As her car crept toward the exit, a figure came into view. Propped against the wall, the figure was staring at her. Their eyes followed her down the road, and then—they nodded at her. She gasped, and the Saturn lurched as her right foot jammed the accelerator. Speeding out of the parking lot, she saw nothing unusual in her rearview mirror. After several blocks, she slowed her breathing and loosened her grip on the steering wheel. “Who the hell was that?”

  She decided that, in the future, she would ask for an escort to her car—a security guard, or maybe Derek if they were leaving at the same time. The hospital had a policy that any female could ask for a security guard escort to the parking lot.

  After a few minutes, her jitters eased. Maybe it’s nothing. He could be harmless. I’m just jumpy because of Dr. Preswick’s death.

  She drove along her familiar route west to Alexandria, Virginia. Laura lived in a town house in ‘Old Town,’ which was a small section of Alexandria abutting the Potomac River, east of Highway 1, an enclave of historic homes and churches and picturesque residential neighborhoods. Inhabitants of Old Town were surrounded by relics and reminders of important aspects of American history: especially the Revolution, the early presidents, and the Civil War.

  Laura’s town house was located within the true historic Old Town. Much of her salary went toward ownership of such a desirable property, and she felt privileged to live there.

  She parked in her garage, which had seen better days, its walls becoming more rickety as the months went by. Just about every nook and cranny was packed with odds and ends, boxes, old lamps, and Christmas house and lawn ornaments. Laura had just enough empty space for her car.

  “I have to get rid of most of this stuff.” She stepped out of her car and turned in a circle, frowning at the mountains of clutter around her. “Well, maybe I’ll start tomorrow . . . or in a few days.”

  As she walked through her back yard toward her house, the heaviness in her arms and legs lifted. A sweet scent from her flowerbeds lingered in the air, driving out other city odors. Cosmo greeted her at the back door, barking and wagging his tail. He was a sturdy Golden Retriever, ever game for company. Laura hugged and petted Cosmo and soon caught herself staring at her dog’s trusting pupils—and thinking of Dr. Preswick’s strange eyes.

  She let Cosmo outside and then phoned the hospital emergency room from her kitchen, which was just inside the back door. The evening clerk answered.

  “Any results yet on Dr. Preswick’s drug screen?” Laura said.

/>   “I think the results came back a few minutes ago. Let me get a nurse for you.”

  Laura heard another friendly voice. “Dr. Valorian, this is Brenda. It looks like the only positive on the drug tests is alcohol. He had a blood level of 0.12.”

  “There were no narcotics, opiates found? Or evidence of anything else?”

  “No other positives.”

  Laura replaced the receiver. She sighed. No morphine, heroin, or codeine. No opiate at all to explain those constricted pupils.

  In her dining room next to the kitchen, she ate a lettuce and tomato salad, more from an obligation for timely nourishment than from hunger. Her home was cozy enough, warm colors of gold, green and maroon on her furniture and in the pictures on her walls. It was just that mealtimes should be noisy with people chatting and laughing and moving about, like the Valorian family dinners had been when she was a child growing up in Oklahoma and Texas.

  “For now, it’s just you and me, Cosmo.”

  After dinner, she settled in her living room. From her couch, deep green with a pink flower pattern, she watched television with little interest, flipping through the channels with her remote.

  She jumped as her cell phone rang. “Hello?”

  “Laura, how are you?” Laura recognized the voice of her friend, Clarissa.

  “I’m well. Just putting my feet up after work.”

  “Speaking of feet, I need some new shoes. Why don’t we go shopping sometime soon?”

  Laura considered her aching feet. “Sure, I could go for some comfortable new shoes, and maybe some nice evening shoes, too.”

  “Now you’re talking. Us girls need new shoes every now and then.”

  Laura smiled. In your case, that’s once a month. But I’m not complaining.

  “What’s going on with Eric, your triathlete guy?” Clarissa said.

  “He’s not my guy. That’s over. I was just one of his many female interests.”

  “I knew that would happen. When you introduced me, I knew something wasn’t right about him. I didn’t trust him at all. Listen, I know the perfect guy for you—”

  “I don’t need any other perfect guys right now. I’m taking a break from dating for a while.”