Dr. Colt—standing at Tim Schultz’s table with his hands behind his back, cheaters on the tip of his nose, closely observing the internal exam—looked up. “Dr. Cutty? Is there a problem?”
Livia pushed the skull back into place. She’d now have to run thick sutures through the scalp and, if possible, place a few staples into the skull when she was finished.
“No, sir,” Livia said. Dr. Colt drew his attention back to Tim’s decomp.
When she let go of the skullcap, it sloughed back onto the autopsy table and Livia peeled away the dura. She examined the brain and quickly documented the findings she knew would be present. A subarachnoid hemorrhage with midline shift of the brain—very typical of head trauma when elderly people fall and are not fast enough or strong enough to break their descent.
Worried about the extra time she needed to suture the skull, Livia performed the neuro exam quickly, removing and weighing the brain, and then taking appropriate photographs for afternoon rounds. With everything completed, she got busy putting the body back together. Making the head presentable proved challenging and time-consuming. When she finished—one hour and fifty-two minutes later—she was embarrassed by her work. A mediocre technician could have done a better job pulling the Y-incision together, and the skull was simply a mess of running sutures and staples the mortician would have to make presentable. Thankfully, Tim Schultz’s decomped overdose distracted Dr. Colt the entire morning.
*
With her paperwork completed, Livia created a zipped file of her fall victim’s case for afternoon rounds. As soon as she finished, she sat at her desk and cruised the Internet, searching for anything she could find about Casey Delevan. Pickings were slim as Mr. Delevan had little to no online presence aside from the fact that he was recently ID’d as the man fished from the bay at summer’s end.
“Well,” Tim said as he entered the fellows’ office. “That’s the last time I use the bathroom before morning rounds.”
Livia abandoned her search as Tim and Jen walked in.
“It’s been a while since Colt has doled out reprimands,” Jen said. “I think he was waiting for his first chance to stick it to one of us. Wrong time, wrong place.”
“No kidding,” Tim said. “That was the worst case I’ve seen.”
“Smelled like it,” Livia said.
“You’d better have your facts straight for rounds,” Jen said. “Your decomp is sure to get all the attention. And Colt is on a rampage.”
They worked through lunch and then made rotations through dermatopathology and neuropathology before meeting back in the cage for afternoon rounds. Indeed, Tim’s case got much of Dr. Colt’s attention. Tim spent a full hour in the front of the cage, albeit a calm sixty minutes where he successfully navigated the onslaught of questions. Tim had made obvious progress since fellowship began in July, and was no doubt aided today by Dr. Colt having spent the entire morning at his table.
Jen Tilly presented next. A fifty-year-old woman had died of cirrhosis due to chronic alcohol abuse. The presentation was fast and streamlined nicely by Jen’s meticulous preparation. Livia switched spots with her. It suddenly felt odd to be in the front of the cage. Although lately Livia had striven to be here, in front of Dr. Colt and her other teachers, today was an anomaly. All morning, throughout the autopsy and then during the afternoon when she prepared her presentation, her thoughts had been with Nicole. Like a computer application running in the background and drawing down her phone’s battery, the left-side analytical portion of her mind had been working all day on Casey Delevan and his connection to her sister. But now, with thirty sets of eyes on her as she stood in the glow of the Smart Board projector, Livia was finally forced to focus her mind on the fall victim she had autopsied. She was surprised to find such a scant amount of information to work from, as if suddenly she was taking that final exam from her dreams for a class she had never attended.
She fumbled through the findings of her external exam, covering the left-side lividity, the bruising, and the broken wrist. She went through the mostly unremarkable findings of the internal exam, noting the presumed time of death based on stomach content and suspected time of last meal. She moved to the neurological findings, covering with some confusion the midline shift she presented as the cause of death.
“What did the QuickTox tell you?” Dr. Colt asked from the darkened gallery of the cage.
Shit.
A QuickTox was an abbreviated toxicology report that quickly identified chemicals in the bloodstream, and was a precursor to the full toxicology report that typically took days to return. Livia had sent samples to the lab, but hadn’t run a QuickTox.
“I didn’t think to run one. I felt pretty certain in this case that the cause of death was midline shift.”
The moment of silence that followed her statement was the most uncomfortable time Livia had spent in the cage. She knew what was coming.
“Is that how we practice medicine, Dr. Cutty? By being ‘pretty certain’ about things?”
“No, sir.”
“Why is there no QuickTox in your presentation?”
“An oversight,” Livia said.
“A startling one, Dr. Cutty. Can you please tell us which medications your patient was taking?”
Livia stumbled with her words as she shifted through her notes. “I don’t have that information with me.”
“You don’t have that information with you?” Dr. Colt repeated. He referred to his notes. “This patient was taking eight different medications. One of which was a new Rx for OxyContin, given for recent onset of neck pain and headache. So we have an eighty-nine-year-old woman with a new onset of headache symptoms, prescribed likely too high a dose of an opioid analgesic, who possibly fell as a result of a drug interaction. And you don’t have that information in front of you?” Dr. Colt went back to his notes for reference. “She was also taking the acid reducer cimetidine, which is not meant to be taken with OxyContin. Cimetidine increases the blood levels of OxyContin, which can cause dizziness, low blood pressure, and fainting. All quite relevant to a fall victim.”
Dr. Colt continued as his voice elevated. “Or, we have a stroke victim who’s been having headaches for the past week and collapsed as a result of said stroke. However, the very examination performed to determine if any of these mechanisms played a role in her death didn’t actually cover any of these possibilities. So I ask you, Dr. Cutty: This morning, did you see someone’s mother on your table? Did you see someone’s wife? Or did you simply see an old woman who fell in her bathroom and hit her head?”
He looked back at his notes. “Did you simply see one hour and fifty-four minutes out of your day lying on that table? Because with the reckless manner in which you handled this case, I’m betting on the latter.”