"An hour after the midazolam," she replied, "as you ordered."
"I ordered it to be administered the moment the midazolam started to wear off, which would have been approximately an hour later."
Monica Yablonsky wearily brought her gloved hands to her head and massaged her temples, theoretically contaminating herself, depending where the gloves had touched before coming in the room. Earl said nothing- that kind of unthinking gesture happening all over the hospital a hundred times a day- but some part of his brain registered that the battle to rid St. Paul's of SARS might already be a lost cause.
"That's what I meant," she said. "Mrs. Matthews received the morphine when she started to wake up."
"Yet the medication sheet lists the time as nine p.m. exactly. Mighty punctual of the lady, starting to rouse herself exactly on the hour."
"Are you insinuating-"
"I'm insisting you level with me about every detail of what happened here last night, down to the minute. Now when did you observe her coming around before administering the morphine?"
She drew her lips into a thin line and let out a long breath, making clear her exasperation. "Probably more like nine-ten."
"And afterward?"
"What do you mean?"
"Did you check on her?"
"Yes! Repeatedly. The larger dose worried me. And since you'd sent her husband home, I kept a close eye on her myself." Her disapproval of his having removed Mr. Matthews from the scene, thereby making it necessary for her to increase her own vigilance, hung heavily in the air.
"And?"
"She remained stable."
"Vitals and respiration normal?"
"Yes, as written on the patient's chart."
Check night nursing notes on any floor and the majority will have respirations listed as sixteen a minute, the average rate for adults who are awake, even though most people slow their breathing to twelve when they're asleep. The reason? A lot of caregivers, including doctors, never bother to count the actual number as long as they can eyeball that a person appears to be moving air in and out with no difficulty. "It says sixteen every time," Earl said, lowering his voice to a whisper. "How do you explain that?"
She flushed, yet didn't speak, having been around long enough to know exactly what he meant and to accept she'd been caught out on the point rather than argue about it.
"Obviously, whatever the rate," he continued, "the rise and fall of her chest seemed sufficiently vigorous that you didn't think the morphine had suppressed her breathing."
"No."
He looked back at the chart. "It says here you gave her the second injection at one a.m."
She swallowed, then nodded.
"Again, she started to moan at the top of the hour? The woman must have had a clock in her brain."
The skin around Yablonsky's eyes grew taut, purse-stringing her gaze into an angry stare. "All right. The morphine wore off sometime after midnight, but by then I had only two other nurses and an aide to help me- cutbacks you know- and we had to stay with some of the other patients you also medicated who were much nearer death." She didn't add, "Thanks to your injections," but her nasty scowl said as much.
"So you let her cry again. How long before you finally got to her?"
She drew in a long breath. "One-thirty." Her matter-of-fact tone held no admission of culpability for anything.
"Yet she had strong vitals, seemed no worse for wear from the first dose?"
"Her vitals were the same as before. And for your information, she'd fallen back to sleep. I remember thinking that the stronger dose hadn't worn off completely and maybe she didn't need the second shot just then, but went ahead with it anyway, given how she'd been screaming not half an hour earlier and you'd insisted we stay ahead of the pain." She'd resorted to pronouncing each word carefully and with perfect poise, as if speaking correctly could make what she'd done sound just fine.
Still, the plausibility of her explanation made him think that he'd probably gotten the truth from her. "And when did you next check her?"
Monica's face reddened to an even deeper shade of crimson.
"Let me guess," Earl said, feeling the pit of his stomach clench into a ball of muscle.
The taut defiance around her eyes slipped away, and, stealing a glance at the shrouded form, she seemed to age in front of him. "Six a.m.," she said, her voice reduced to a dry croak.
Jenny Fraser, chief of laboratories, had tracked Earl down in his office, where he'd retreated to think things over. "I have to warn you, Earl, Wyatt's riding my technician's ass for these results, but I heard what happened and wanted to get them to you first."
"That bad, are they?"
She gave a strained, tinny laugh. A small woman known for wearing pearls to a job that dealt with bodily fluids and slices of human anatomy, she also had a reputation for delivering bad news with the delicacy of a shark attack.
He braced himself.
"Unless the autopsy shows some catastrophic surprise, the cause of death will be morphine intoxication." Her slow cadence gave each word equal importance; it was a common technique used by clinical teachers in the belief it helped even the dimmest resident get the point. Except Jenny carried the practice over to talking with staff. "Her levels were double the normal therapeutic range."
"Shit."
"In your favor, her previous liver and renal tests showed normal function, so she should have theoretically been able to handle what you gave her, and no one could fault you for not thinking otherwise."
He knew all that, he thought as she continued to report her findings, had seen it in Elizabeth's chart before ever ordering the morphine. The truth was, Jenny couldn't provide the answers he needed now, such as how Elizabeth had survived the initial dose but not the second. How the first dose had worn off long enough to leave Elizabeth screaming with pain again, yet she'd managed to fall asleep before the second injection.
"Thanks, Jenny. I appreciate the heads-up," he said when she'd finished summarizing her take on the lab report.
After he put down the phone, a branching, cold logic took over his thinking, forking in various directions, and pointing to answers he didn't like.
He made a quick call to the operator, who connected him with the weekend nursing supervisor, Mrs. Louise Quint, as much a seasoned veteran at St. Paul's as himself. Like Earl, she harbored no illusions about the ruthlessness of hospital politics.
"Earl!" she said, her voice as hearty as ever. "I hear you're in the shithouse again. Just when I thought you finally got to the top of the crap pile. So much for my hopes the good guys might win a few for a change."
"Afraid so, Lou."
"What can I do to help?"
"I think Elizabeth Matthews may have gotten her dose of morphine twice."
"What!"
"You heard me."
"Why would you think that?"
"Because after midnight she woke up crying with pain again, the initial dose I ordered having worn off. Once she got like that, according to her husband, she couldn't rest. Yet around one she stopped crying, and Monica Yablonsky found her asleep when she finally went to check on her at one-thirty."
"So?"
"Apparently the staff had a busy night, especially during the time in question. I figure one of the other nurses might have given Matthews her injection after she first started to cry out, between midnight and one, but didn't sign it off in the order book or tell Yablonsky. Around one-thirty, when Yablonsky freed herself up from the other patients, she could have unwittingly given a second dose. Now they're both covering up."