Highland Memorial Hospital is in the throes of changing its name, replacing memorial with something a bit more optimistic like community, and as an acronym HCH rolls of the tongue a bit easier than HMH. Nothing’s been decided yet, though a consulting group is pushing for something along the name of Highland Regional Health Center, more of a branding statement than a terminus as memorial might imply. If trends mean anything in healthcare, the more the consulting group is paid, the more likely their suggestions will be adopted, though HRHC is a bit of a mouthful. Highland Memorial has the area’s newborn and pediatric intensive care units, a second home to the McDaniels over the course of Virginia’s living, though, this morning, Ian is an outsider, both figuratively and literally, as he waits on the pedestrian side of the secured doors of the PICU. This is bold for Ian, breaking the sanctity of a place that some believe is tended by angels. He knows the routines of this floor, its temporal patterns of both its staff and the parents, grandparents and guardians of its conscripts. It is shift change, a time when the secured doors of the PICU are more susceptible to be piggy-backed, following in a properly credentialed caregiver as the magnetic lock charges, clicks and frees its massive door to open and allow entrance with just the swipe of a card. But, Ian does not. It’s his rules-and-manners thing that would upset Linda more often than not, especially when it came to second guessing first opinions on Virginia’s condition.
Instead, he has an image in mind and a name from a file that hangs on the wall of a storage unit and he is looking to see who in the ins-and-outs of the PICU threshold might come close to fitting that image. In a context as intimate as the PICU there are only a couple degrees of separation. Say a patient’s name two or three times and someone’s bound to make a connection. The door clicks and opens and mingled amongst the shift change are other worn caregivers, parents. Ian stops one, a man, a rare find on the floor.
“Excuse me, Mr. Jacobsen?” he asks, but the man walks on. From the other direction is a woman entering the PICU. “Are you Laura Jacobsen?” She shakes her head and enters and the door closes and locks shut behind her.
“Sir, is there something I can help you with?” The query is from an astute unit secretary starting a shift in the PICU. She has observed his last approach and she has engaged him per HMH protocol.
“No, I’m fine,” he says, though he is clearly conflicted to not only be there, but to have his presence now called out.
“Do you have family here?”
“I did-” and he checks himself. There is a level of fraternity in the chambers behind that door, a solidarity of parents engaged in their most treacherous of stewardships. It is a community, happily transient though heartbreakingly consistent in its population. Support groups form here – without the intervention of social workers – with offers to break roommates for the cafeteria run or a power nap, a system from which Ian has been absent for five years. He is no longer a familiar face here, not only due to the turnover in staff, but due to the change of the guard as well. “-um, I’m just waiting for someone.”
He’s harmless. She unclips her badge and holds it against the card reader and the bolt is thrown. The unit secretary enters the PICU, and just before the bolt knocks secure against the door as it returns to its jamb it opens wide enough for the small frame of a young mother much older than her years to slip into.
“Are you looking for me?” she asks Ian.
WHILE IAN McDANIEL MAKES Laura Jacobsen’s acquaintance, Detective Alvarez is getting started on the list of hundreds. His state SUV is parked in front of two storage units, the doors of both are wide open. They are the standard ten feet wide, but thirty feet deep. Cardboard file boxes are stacked on metal adjustable shelves that line the walls and are stacked in between, back to back, three rows thirty feet deep in each unit. The boxes are stacked four high to the ceiling, each one displaying a code and a listing pasted on the front. More boxes than not have a red dot sticker, some have multiple red dots and others have yellow dots.
Down one of the aisles is the detective along with Elaine. She knows these files by heart. She touches a box.
“CNS dysgenesis. Baby died at seven weeks.” She touches another of the several dots on this box. “Twins. Girls. Premature labor. Doctor Reagan waited too long to go C-section. The babies and the mom dc’d.” She touches another across the aisle. “Still birth to a young mother, seventeen years, placenta abruption. The mother delivered without anyone in the room. It was over twenty minutes before a nurse found her with her stillborn baby and placenta between her legs.” Another box. Elaine hesitates on this one. Alvarez is reading her every signal. Her eyes fix on the listing and she knows her hesitation has given something away, so she leans more stoic in her description to compensate.
“CNS dysgenesis. Baby girl. She lived ten years requiring care twenty-four/seven. Dc’d five years ago. Her mother exsanguinated in a bathtub just last week.”
Alvarez looks down the row. There are red dots everywhere, enough to make anyone incredulous, even him. This is a list that does the opposite of narrowing anyone down. Besides overwhelming this father of one little girl with a nauseating realization of his jurisdiction’s infant mortality, this list would only make his job investigating the disappearance of Doctor Reagan harder. What little crime that does happen under his purview is relatively innocuous even by suburban standards. Most of his cases of missing persons are related to the cooking and distribution of meth. But here, represented by red dots are more dead or dying than Alvarez will ever investigate over the course of his career, none of which fall under the legal definition of a crime.
“CNS dysgenesis?” asks Alvarez. The diagnosis has been a common denominator in Elaine’s narrative about the files.
“It’s a common side effect of pitocin or oxytocin overdose,” she says, but Alvarez still does not understand. “Pitocin and oxytocin are hormones used to induce labor. Mothers who have gone beyond term, mothers whose water has broken but failed to go into labor, or mothers who are stacked eight deep in labor and delivery are induced.”
“I’m sorry?” he replies, becoming more baffled in the revelation of the business of obstetrics.
“It’s a common practice at South Highland Women’s Center to induce labor. Deliveries can be scheduled that way. It’s convenient for everyone involved,” says Elaine, a line she’s delivered a thousand times, but this time it was without the vocal inflection implying that it was an actual benefit.
Alvarez is still trying to digest that last bit. He is causal in his deduction, the link between induction and the mortality represented by all those red dots. All kinds of questions are forming with enough noise in his head to distract him from the task at hand, investigating the disappearance of Doctor Gray Reagan, OB/GYN.
“You’re about due for another unit,” says a voice from the alley. It’s the lock-checking man just stepping into the opening and he has startled Elaine. “Getting pretty full, this one,” he says, and he moves on, his milk crate trailer in tow, to the next unit. Alvarez steps out of and watches the man continue down the long row, checking each lock and checking his list. After gathering his thoughts steps back in and tells Elaine, “I want to start with the twins and mom.”
“The father left town years ago,” says Elaine.
“I still want the file. And the stillborn file.” Elaine knows what this holds for the detective. Pandora has nothing on these boxes. She opens one for the twins’ case and another for the stillborn and retrieves the requested files. “And the suicide, the mother-in-the-bathtub.” She knows what this holds as well.
Outside, the lock-checking man continues his route and his charge descending down from the open unit where Alvarez and Elaine are finishing up, now a half-dozen doors away. Inside Gray’s storage unit the blurry projection from the peep-hole is eclipsed and the sound of a hand rattling a lock on a latch goes unnoticed by the doctor since he has passed out from his previous screaming. Just outside, no more than five paces away from the adirondack the lock-checking man looks at the number stenciled in black on the buff brick wall, finds the number on his green bar report, makes a note, and moves on.
Elaine and Alvarez exit the center’s unit, Alvarez with files in hand. Elaine rolls the door shut and locks it.
AT HIGHLAND MEMORIAL’S PICU, one year-old Adam sleeps on a reflux board in a stainless steel crib. Photographs have been taped to the interior of the cage, pictures of the boy with mom, another with dad, and shot of the big sister. A toy monkey has his arms around a side of the crib, his tail suspends down and when pulled music box-like tones play, “When You Look Upon a Star.” The inclined board is covered in a blue satin blanket upon which he sleeps. He’s held upright by an abductor between his tiny legs and a strap around his back keeping his head above his chest. He sleeps like this because of his reflux condition. He lacks the ability to keep anything down which is problematic because when he regurgitates he swallows the vomit down into his trachea instead of his esophagus creating aspiration pneumonia, the reason he is still there at Highland Memorial PICU. The incline helps him keep fluids down and out of his airway.
For Adam to survive he will soon be undergoing a Nissen fundoplication, a surgical procedure where the opening at the top of his stomach is wrapped around the lower esophageal opening. This makes it so whenever the stomach contracts to regurgitate, it closes off the esophagus keeping stomach contents where they belong instead of in the lower esophagus. This will take care of the issue of fluids moving up out of his stomach and into his airway, which is only half of the problem. Something else needs to be done to keep fluids from infiltrating the lungs from above, so, in addition to the fundoplication, the baby will also have a gastrostomy tube inserted through the wall of his abdomen into the wall of his stomach through which he can receive nutrition, fluids and medicine. After these two procedures all the Jacobsens will have to worry about is little Adam’s saliva and mucous secretions. Ian knows this because Virginia went through the very same thing.
Adjacent the crib is a well worn recliner and around it are objects of a long-term stay. There’s a quilt, a couple of paperbacks sitting on a closed laptop that rests on a small table, an uncollected breakfast tray, a telephone, and behind the recliner a cot with bedding neatly made.
Baby Adam is the room’s only occupant tied to its context of observation by the telemetry of a heart monitor, a pulse-oximeter, along with an oxygen tube that delivers five liters a minute to the pediatric cannula under his nose. His little hands have socks over them, taped at the wrists to keep him from pulling the cannula off his nose that would deprive him of the oxygen he needs. This is what Ian sees as Laura introduces him.
The two stand at the door for a moment, long enough to pry memories of the same for Ian. Virginia was in this same room years ago, and so little has changed. They are silent in watching since Laura sensed there was no need for explanation of what Ian was seeing.
They turn out of the door and into the hallway where Laura continues the conversation they started a few moments ago. “Fourteen months,” she says. “I went into labor but wasn’t dilating. Doctor Reagan put me on pitocin, but I didn’t respond.”
The room, the baby, the smell, the sounds of the telemetry and now the story, all resonating in a core of Ian’s conviction in his task at hand.
“We had a case,” she continues. “We were told not to settle, to take it to a jury, but the case never made it. Reagan delivered the youngest child of the judge hearing the case, so he disqualified himself. Highland was so small at the time that they couldn’t find an impartial judge in the district. It got buried in an attempt to get it transferred, and our attorney advised us to drop it because of the fees we were racking up.”
Ian runs the risk of being overwhelmed by all the stimulus, old and new and leads Laura back out of the PICU to the mezzanine where they met. He’s able to breathe a bit deeper and summon the courage for what he’s about to offer her.
“When’s the last time you saw Doctor Reagan?” he asks.
“We haven’t seen him since the delivery. Our attorney advised us not to be in touch with him.”
He studies her. He wonders if fourteen months has been long enough. They’ve taken legal action, a cue to their disposition about Doctor Reagan. She stands there in clothes that serve both the purpose of sleep and tending, her hands to her sides, her feet apart, her body too tired for pretense. That what was for her will never be again.
“If I could make it so you could face Doctor Reagan, what would you say?” asks Ian.
Laura knows exactly what she would say, but she doesn’t waste it on Ian. They are words only for the OB. Instead, her nostrils flare, her eyes pivot in their search for veracity in Ian’s hypothetical question, her unpainted nails dig into her palms, her posture rises in her sweatshirt. Just as Ian reads her body’s response, the elevator doors open nearby and among those landing on this floor is Laura’s partner in care. She sees her husband leave the elevator and walk to the PICU door and she catches his attention, a shorthand of a nonverbal signal and will, and he changes his direction and approaches her and the stranger.
“Ian, this is my husband, Mark.” To her husband, “This is Ian McDaniel.” They shake hands, though Mark is more leery of Ian’s presence. No one just shows up here.
“He says he can take us to Doctor Reagan,” she says.
“What the hell for?” says Mark.
Ian’s premonition about the Jacobsens is confirmed. He looks down, studies the carpet at his feet while the emotion of this moment hits its flashpoint. He looks up at Mark, larger, more worn, more brittle, and now confused at Ian’s offer. Ian tries to clarify.
“I’ve been where you are now.” Mark’s rage wells in his eyes. Ian dares a bit more. “Doctor Reagan is in a position where he’ll listen to you.”
“I can’t,” Mark whispers, “I’d kill him where he sits.”
Laura breathes in as if she is about to say something. She looks at Mark but doesn’t console him, she has given up trying, instead she looks at her husband’s face and as she releases her breath she speaks through the relief of it.
“I want to. I want to face him,” she says.
Inside the PICU, Mark stands at the side of Adam’s crib. His boy rests in the rhythm of the sounds of his own telemetry. The three photos that were taped to the stainless steel bars are gone.