“Did you do the DONT?”

“The what, sir?”

“The DONT. Dextrose, oxygen, narcan, and thiamine.” He was stating an anagram he always used to teach residents the basic ER approach to coma, listing the first variables to be thought of whenever a patient presented with an altered level of consciousness. An IV bolus of dextrose, or sugar, would have corrected hypoglycemia. A measure of her O₂ saturation would have signaled any respiratory causes for the coma, and the administration of oxygen possibly turned them around. Narcan would be the antidote to reverse a narcotic overdose, and thiamine administration treated a deficiency of the vitamin that sometimes caused persistent confusional states in malnourished individuals, such as alcoholics.

Dr. P. Roy flushed. “Well, no, not exactly, sir. I did make sure her airway and O₂ were okay. But it seemed pretty obvious she’d had another stroke and seized.”

“Really? Any focal signs in your neurological exam, now or then?” Earl referred to the abnormalities of sensation, movement, and reflexes that would have occurred in the specific region of her body controlled by whatever part of the brain a recent embolus might have injured.

“No, at least not any new ones that I could tell. She did have some minor abnormal reflexes from her previous event.”

“Shouldn’t there have been at least a change in those, if you attributed her seizure to another massive embolus? And it would have to have been massive to leave her comatose, wouldn’t it?”

“Well, yes-”

“Did you do bloods at all that morning?”

His face brightened. “Of course. They were all normal, including her sugar.”

“Was that sample drawn before or after you gave her an IV?”

Roy grew red in the face again. “After.”

“How long?”

He swallowed. “About an hour later.”

“An hour?”

“I ordered they be taken stat, but, well, on this ward, especially at night, we aren’t given much of a priority by the lab-”

“Could you excuse us a minute, nurse?”

Tanya nodded, then slipped out the door.

Earl closed it behind her. “You should have insisted they make it a priority, Dr. Roy.” He had no patience for that kind of passivity in his own department, and always taught his residents to stand up to it.

“Why-”

“Had she signed a do not resuscitate order?”

“No, but I figured-”

“Figured you were her last stop before she got to God, and she deserved your best shot at bringing her around.”

“But-”

“What was in the IV?”

“Two-thirds, one-third,” he answered, referring to a common intravenous mixture of sodium chloride and glucose.

“So even if she was hypoglycemic when she’d seized, you’d expect a normal level of glucose afterward, since you had been infusing her with it.”

Roy flushed some more. “Yes, I guess, except why would this patient be hypoglycemic in the first place? She didn’t have a history of diabetes, let alone diabetic medications.”

“Ever hear of a medication error?”

Roy went an even deeper shade of red.

“The point is,” Earl continued, “at the time of finding someone comatose, you can’t presume anything about how the person got that way, especially since they can’t tell you what happened. So you ‘do the DONT’ as we say, running through all the possibilities beginning with checking her serum glucose. And if you haven’t got a dextrose stick handy, you still can figure that a single rapid bolus of concentrated IV glucose never hurt anyone, even a diabetic.” Untreated, nerve cells die by the millions for every second hypoglycemia is allowed to persist, and the patient is at risk to seize, choke to death, or lose enough brain tissue to end up a living vegetable. Every first-year medical student knows this, so Earl saw no need to point it out to Roy. “It’s good you at least gave her some sugar,” he continued, “but it was too slow and too little, as far as being any therapeutic benefit to her. All you accomplished was to wipe out any evidence that her level had been low in the first place.” Any medical student would also know that if Dr. P. Roy had acted properly, Bessie McDonald might not be in her current state. No point to rubbing it in. This guy looked sunburned enough already, and no one could ever prove it. But that’s what he would have trouble living with, once he digested all the facts. He’d never be able to disprove it either.

“Hey, I did do an O₂ sat, and it was fine just as it is now, and if she mistakenly got a narcotic overdose, her respirations would have been suppressed,” he said, beginning to sound more annoyed than defensive. “As for thiamine, she sure as hell hadn’t been malnourished or gone on a recent bender…”

Earl ignored whatever lame excuses the kid offered up – chances were good he wouldn’t screw up his next coma case – and refocused on what bothered him most about Bessie McDonald – her lack of focal signs. “What’s her level of consciousness today?” he asked, referring to a scoring system by which a patient’s response to verbal and painful stimuli was measured.

Roy looked taken aback, having built up a good head of indignation trying to justify himself and implying that an outsider who wasn’t on staff had no business berating him anyway. “Lousy,” he said after a few seconds, his face sullen. “She’s a three, exactly like the night we found her.”

A dead body would earn as much, just for being there.

“You ordered a CT scan?”

“What was the point? I thought I knew the diagnosis – a massive stroke – plus the lady was gorked.”

“Has your differential expanded any, after our discussion?”

He sighed heavily. Deflated, he seemed a shirt size smaller and an inch shorter, as did most kiddie-docs foolish enough to attempt a head-butt with a veteran rather than admit a mistake. “A CT will be done later today, sir,” he said, his unconditional capitulation made evident by the sudden disappearance of the word “but” from his vocabulary. “And an EEG.”

The former would visualize the extent of damage from a recent blood clot, if that was the cause. The latter, an electrical encephalogram, would pick up any remaining spark of electrical activity in the cortex of her brain, the stuff of walking and talking.

Earl asked Tanya to come back in the room. “You said she was found on the floor by the door?”

“Yes. We think she knew something wasn’t right and was trying to get help.”

“She didn’t use the call button?”

“They found it unplugged.”

“I think she must have pulled it out by accident when she reached for it,” Roy added.

Tanya’s brow arched, but she said nothing.

Earl followed her back toward the nursing station. “Anybody see Chaz Braden around here that night?”

She immediately slowed. “So you agree with me, that it’s possible he did this to her?” she whispered, once they were side by side.

“I agree only that it doesn’t look like a stroke, nothing more. For God’s sake, don’t go spouting crazy ideas.”

She gave him a “yeah, right” look.

“So did somebody see him?”

“No. I already checked. But that doesn’t mean he wasn’t on the floor. Coverage is minimal that shift, and he could easily have sneaked in.”

“Care to tell me now why you’re so down on him?”

“Why? My reasons have nothing to do with Bessie.”

“I want to know the extent of your beef with the man, and if that might cloud your judgment toward him.”

She walked a few steps farther without saying anything, then slowed her pace until they were walking alongside each other. “I worked in cardiac ICU before being transferred here. He’s a slimeball. Put his hands on me one night. I complained, and got transferred for my trouble. Not that I mind it here. I like old people. But my training is in critical care.”

He eyed the procession of elderly men and women tottering back and forth along the corridor and wondered how he’d feel if someone pulled him out of ER to plunk him down in their midst. “Quite a culture shock,” he said.