TheIndex Case

The man in bed fourteen was the color of an old newspaper, and the night resident had decided what was wrong with him before she pulled back the curtain.

It was ten past four in the morning, the hour when a hospital is quietest and the people working in it are at their worst. She had been awake for twenty-two hours. She had admitted nine patients since seven o'clock, and four of them had livers like this one, and three of those had lied to her about how much they drank. She was not proud of how quickly she could tell now. She was only tired, and good at it.

He was sixty-three. A university professor, the chart said, married, no prior history to speak of. Belly swollen tight with fluid. Whites of the eyes gone yellow. The bruises on his forearms that come when the liver stops making the things blood needs to clot. A little confusion in the evening, his wife had told the emergency room, though he was clear enough now. He watched her come in and he smiled, and the smile was the most polite thing she had seen all night.

"I'm sorry to keep you up," he said.

"You're not keeping me up. This is my job." She pulled the stool over and sat, because her feet hurt, and because her teachers had told her that patients say more to a doctor who sits. "Can I ask you some questions?"

"Of course."

She went through them. When had he first noticed the swelling. When had the color changed. Had he vomited blood, or seen blood in his stool. He answered each one exactly, no more, and then waited, like a man used to being on the other side of the questions.

Then she asked the one she had been waiting to ask.

"How much do you drink? Honestly. I'm not here to judge."

He laughed, a short, surprised sound. "A glass of wine at Christmas, if my wife pours it. She'll tell you I'm a very cheap date."

His wife was asleep in the chair by the window, her coat over her like a blanket. The resident looked at her and did not wake her. She had heard a glass at Christmas from a great many men, and some of their wives had backed them up, and some of those wives had believed it.

"Anything else? Anything new in the last year or two? Medicines, supplements, anything you've started?"

He thought about it, honestly, the way he seemed to do everything.

"I've been taking better care of myself than I ever have," he said. "That's the joke of it. I've never felt better in my life. Right up until this."

She nodded. Later she would type it into his history word for word, because it was a nice thing for a man to say, and it did not seem to mean anything.

At the nurses' station she opened his chart and typed the note the way she had typed it four times already that night. The history. The exam. The labs, which were bad and getting worse. Then the line at the bottom, the one the next doctor would read first and the one after that would copy without reading.

Decompensated cirrhosis. Presumed alcohol-related.

She looked at the word for a moment. It was the most likely answer. It was almost always the answer. She signed the note and went to see bed nine, who was throwing up.

In the morning his wife woke and told the day team that he had never been a drinker, not once in thirty-eight years. The day team wrote that down. So did the team after them, and the transplant coordinator, and the doctor who sat with her three weeks later and told her there was nothing more to be done.

None of them changed the word.

He was the first. It would be a long time before anybody counted him.

The man in Room 6 had been waiting four hours for someone to tell him he had a pulled muscle, and Dr. Wade Ashford was about to ruin his night.

"Says he's had back pain since lunch," the triage note read, in the flat shorthand of a waiting room that had been full since noon. LBP, lifting at work. Ambulatory. Pain 7/10. Tylenol at home, no relief. Somebody had already ordered the muscle relaxer. Somebody else had already started the discharge paperwork. On a Thursday night at Trinity Mercy, a man who could walk in on his own was a man who would be walking out.

Wade read it standing in the hall. Then he went in and sat down.

That was the first thing he did with every patient, and he had done it for nineteen years, and it had cost him, by the group's own reckoning, about four minutes per visit. The group had shown him the number once on a slide. He had looked at it and said that four minutes sounded about right.

Nobody at Trinity Mercy called him Dr. Ashford. Nobody in the whole group did. He was Dr. Wade in black marker on the board in every emergency room on the circuit, and Dr. Wade on a strip of tape on his mailbox, and Dr. Wade to his patients before they had been in the room five minutes. There was a reason for it, and the nurses at Trinity Mercy liked to tell it.

"Mr. Tillman. I'm Dr. Wade. Tell me about your back."

Mr. Tillman was sixty-eight and built like a man who had moved furniture for a living, which he had, for forty years. He sat on the edge of the stretcher in his work clothes with his hands on his knees and told it plainly. He had lifted a dresser at two o'clock. He had felt something in his back. It had not let up, and it was in a strange place, low and deep, and he was sorry to waste everybody's time.

"You're not wasting it," Wade said. "Lie back for me."

He did not look at the back. He looked at the belly. He put his right hand flat on it, above the navel, and pressed, gently, and waited.

There it was. Under his palm, where there should have been nothing but soft give, something pushed back. Not hard. Steady. A beat, and then another, in time with the pulse he could see ticking in the man's neck.

Wade kept his hand there a moment longer than he needed to, because he wanted to be sure, and because he had learned a long time ago that the first touch tells you and the second keeps you honest.

"Mr. Tillman," he said. "Has anybody ever told you that you have a weak spot in the big artery in your belly?"

The man looked at him. "My brother had something like that. They fixed it."

"Then we're going to get you a scan right now," Wade said, "and I'm going to call some people."

It took eleven minutes. The scan showed an aortic aneurysm the size of a grapefruit, leaking at its back wall into the space behind the belly, which was why it hurt in the back and not in the front. The vascular surgeon on call, a man Wade had known since residency and argued with ever since, came down from the fourth floor in scrubs and looked at the images on the screen and said a word that was not in any textbook. Mr. Tillman went upstairs at 11:52. He was on the table at 12:20.

The muscle relaxer was still in its little paper cup on the counter. Wade threw it away.

* * *

Trinity Mercy was the hospital people meant when they said the county hospital, though it had not belonged to the county for twenty years. It sat south of downtown, near the river, on a stretch of road where the gas stations had bars on the windows and the bus stopped every twelve minutes because so many of the riders were going there. The emergency room had thirty-two beds and a hallway that held twelve more stretchers when it had to, and it had to most nights. It saw a hundred and forty patients on a quiet day. It did not have quiet days.

Elm Fork Emergency Physicians staffed it, along with six other hospitals across the Dallas-Fort Worth area: Cedar Ridge in the suburbs up north, with its valet parking and its fountain in the lobby; Sutton Creek Community on the east side, where half the patients had a job and no insurance; Bluebonnet Regional out past the edge of the county, where the nearest specialist was forty minutes away; and three more in between. The group had a hundred and ten doctors and a rotation that sent each of them around the circuit. Wade worked them all. But he worked Trinity Mercy more than anyone, by choice, and the other doctors had stopped asking him why.

He could have told them. At Trinity Mercy nobody had a portal. Nobody had a printout. Nobody came in having already looked it up. They came in with a pain and a story and a family member who would not stop talking, and you had to sit down and find the thing yourself, with your eyes and your hands and your ears, the way the old men had taught him when he was young and the machines were dumb.

It was the only medicine he had ever believed in. It was what he was good at.

* * *

By two in the morning he had seen nineteen patients.

A girl of sixteen with abdominal pain whose mother answered every question for her. Wade asked the mother to step out for coffee, and then he asked the girl the question again, and she told him the truth, and it was not her appendix. A man who had been stabbed in the forearm outside a club on Lamar and was more worried about his jacket. A grandmother who had fallen in her kitchen and wanted to know whether she could be home before her grandson woke up. An eight-month-old with a fever, whose father held her like a bomb. Wade showed him how to hold her like a baby, and checked her ears, and found the reason.

He charted none of them as he went.

He knew he should. Everybody knew he should. There was a computer on a cart in every room and a computer on the wall in every hallway, and the group had spent a great deal of money teaching its doctors to type while they talked. Wade typed after. He kept the patients in his head, all of them, and at the end of a run he would sit down at the station and put them in, fast, in shorthand that the coders upstairs had complained about in writing.

At the far end of the station a nurse he did not know was reading the board. She was young, in new scrubs, with a travel agency's badge clipped beside the hospital's. She found his name on the board and frowned at it, and then she leaned toward Lupe Garza and asked, not quite quietly enough, "Why does everybody call him by his first name?"

"Because his last name was a mess," Lupe said, without looking up from her screen. "When he started with the group we had a Dr. Ashworth in Fort Worth and a Dr. Ashcroft up north, and then him. Ashworth, Ashcroft, Ashford. You try saying that over a bad phone line at three in the morning. Labs went to the wrong one. A pharmacy called the wrong one. One night a family got a phone call about their mama from a Dr. Ashcroft who had never laid eyes on her." She typed something and hit enter. "So we started saying Dr. Wade, so we'd know which one we meant. Ashworth retired to the coast. Ashcroft went to Houston. The name stayed."

"Does he mind?"

"Ask him."

The new nurse looked down the station at Wade. Wade did not look up.

"He doesn't mind," Lupe said. "He's the only one left."

68M, lifting injury, back pain. Pulsatile mass on exam. CT: AAA w/ rupture. Vasc aware, to OR.

That was the whole note. It was all true. It was all anybody needed.

"That's not a note," Lupe said behind him a minute later. "That's a telegram."

Lupe had been the charge nurse at Trinity Mercy for fourteen years, which meant she had outlasted three medical directors, two hospital owners, and every one of Wade's excuses. She was fifty-four and five foot one and she ran the floor the way a good conductor runs an orchestra, without ever seeming to raise her hands. She was standing behind him with a cup of coffee she had not brought for him.

"It says what happened," Wade said.

"It says what happened to you. It doesn't say what you saw. It doesn't say how big. It doesn't say what his pressure was when you felt it or why you thought to feel it." She leaned over his shoulder and read the next one, the grandmother, and made a small sound. "Mechanical fall. No LOC. Home. Did you ask her why she fell?"

"She tripped on a rug."

"Did you ask her if she's tripped before?"

He had not. He opened his mouth to say she had not seemed the type, and then he closed it, because Lupe was looking at him over the rim of the cup in the way that meant she had already looked it up.

"Three times this year," Lupe said. "Twice here, once at Cedar Ridge. She told the triage nurse. It's in the intake. You'd have seen it if you read it."

"I talked to her."

"You talked to her about tonight." Lupe put the coffee down on the counter, next to his elbow, which he understood was not a gift but a tactic. "You're the best doctor in this building at what's in front of you, Dr. Wade. Everybody knows that. You found that man's aneurysm with one hand. But you don't write anything down, and you don't read what anybody else writes down, and one of these days what's in front of you is going to be the wrong half of the story."

"Is that a threat?"

"It's a prediction," Lupe said. "I'm a nurse. We do those."

She went back to the floor. He sat there for a moment. Then he picked up the phone and called the grandmother's house, at 2:20 in the morning, and her grandson answered, and Wade asked him whether his grandmother had been dizzy lately when she stood up. The grandson said she had. Wade asked what pills she took. The grandson went and got them and read them off, one by one, and one of them was a blood pressure pill that a doctor across town had doubled in the spring.

Wade wrote it down. He wrote it all down. Then he called the pharmacy that opened at seven and left a message for the doctor across town, and sat back, and drank the coffee, which was terrible.

Lupe did not look over. She did not have to.

* * *

At four the run slowed down, the way it sometimes did at four, as if the city had finally run out of ways to hurt itself and was taking a breath before the morning. Wade went to the physicians' room to get his water bottle and found the mail.

Each of the doctors had a wooden box on the wall, with a name on it in label-maker tape. Most of the boxes said the doctor's last name. His said DR. WADE, on a strip of tape somebody had stuck over the old one years ago, and nobody had ever bothered to change it back. It was always full, because he never emptied it. He took out the stack and went through it standing up. A drug company dinner he would not attend. A newsletter from the group. A form about his continuing education hours, which were overdue. A reminder about the form. A thank-you card from a family he did not remember, which he put in his pocket to read later, because he always did read those.

Under all of it was a single sheet on the group's letterhead, folded once.

He read it twice.

He knew about LANTERN in the way everyone knew about it, which was from the hallway. Priya had been talking about it for a year. A software company out west, a contract the size of a hospital wing, a promise that a computer would find the things tired doctors missed at four in the morning. There had been an email in the spring. There had been a lunch with sandwiches that Wade had skipped.

He had nothing against Priya Varadan. That was the trouble. She had worked these same floors for ten years before she took the director's office, and she had been good, and she was not a woman who sold things she did not believe in. If she had signed this, she meant it.

He had seen tools like it before. Everybody had. There had been the sepsis alert, three years ago, which was supposed to catch infections early and instead fired on every patient with a fast heart rate and a fever. Every anxious teenager, every man who had run from the parking lot. It had fired so often that the nurses had learned to click through it without reading it, and so had he, and one night it had been right and nobody had noticed, because nobody looked at it anymore. The group had turned it off last fall. Priya had asked Wade to explain why to the whole group, because he had complained about the alert louder than anyone, and he had, for forty minutes at a Thursday conference, and somebody had filmed it. Most alarms are noise. Learn the patient. Trust the trend. They still played the video for new nurses at orientation. He had never watched it.

There had been the discharge tool, which wanted him to explain, in a drop-down menu, why a man with chest pain should go home. There had been the opioid tool, which locked his screen until he answered six questions he had already answered. Each of them had come with a memo like this one, on the same letterhead, with the same words in it. Does not replace your judgment. Each of them had replaced a little of it anyway, four minutes at a time.

He thought about Mr. Tillman on the stretcher with his hands on his knees, apologizing. About the muscle relaxer in its paper cup, ordered before anyone had touched him. About what a computer would have made of LBP, lifting at work, ambulatory, and how sure it would have been.

He thought, a little less comfortably, about Lupe, and the grandmother, and the intake note he had not read.

Then he folded the memo along the crease it already had, and dropped it in the trash can by the door, on top of the drug company dinner, and went back out onto the floor.

There were eleven people waiting. The first one was a boy with a cut on his hand who wanted to know whether he would still be able to play the guitar.

Wade sat down.

END OF SAMPLE