Against Doctor's Orders Page 17

  Harper pulled down the sheets to just below his navel and moved her stethoscope over his chest and abdomen, right side, left side, all the way down to the top of his Spider-Man pj’s. When she was done, she swung the stethoscope around her neck and put her hand on his belly. “I’m going to press and you tell me if it hurts. If it does, I’ll stop right away, okay?”

  He nodded. Her touch appeared sure and gentle as she examined his upper abdomen and then lower down. At one point he told her it felt funny.

  “Funny, like hurt?” Harper asked.

  He shook his head. “Just funny. Like…sore, a little.”

  “Okay.” She shone a light in his eyes and his throat and felt his neck. When done, she put her stethoscope back in the bag and smiled at him. “You were terrific. I’m going to talk to your mom and dad outside for a few minutes, okay?”

  “Sure,” he said and closed his eyes.

  Presley stepped aside until Don and Emmy Reynolds filed out into the hall with Harper behind them. She slipped out, and Harper slowly closed the door. Presley’s heart kicked in her chest and she realized her palms were damp. She couldn’t even imagine how the boy’s parents must feel. Harper hadn’t given any indication that anything was wrong, but in that moment, when everything hinged on what Harper was about to say, the hall felt suffocating. Harper had become the center of these people’s world. Presley tried to imagine what that responsibility must feel like, the burden it must be to carry, and the cost it must extract in emotional coin.

  “Jimmy has some enlargement of his spleen,” Harper said immediately, her tone calm and matter-of-fact. “That’s an organ in his belly like the glands we have in our neck that get swollen when we have a cold. I’m not finding anything else that might be causing his problems. There are a lot of things that could cause his symptoms, and I think we need to put him in the hospital to do some tests.”

  “Hospital?” Emmy grabbed her husband’s arm with one hand and reached for Harper with the other. “God, Harper. Is it bad?”

  Harper took her hand. Don Reynolds slid his arm around his wife’s shoulders almost as if he needed to lean on her to keep standing as much as to comfort her.

  “I can’t tell, Emmy,” Harper said. “It might be something as simple as a virus or it could be something else. Whatever it is, I want to find out quickly so we can start to take care of things. Can you get someone to come stay with Darla so you can take him over to the hospital?”

  “Tonight?” Don Reynolds’s voice cracked. “You want to take him to the hospital tonight?”

  “I think that would be best. He hasn’t been eating, and he’s probably dehydrated. He’ll feel better when we give him some intravenous fluid, and I can get the tests I want started right away.”

  Don looked at Emmy, his expression stunned. “I…I can call my mother. She’ll come over.”

  “Good,” Harper said.

  “Don, honey,” Emmy said soothingly, “why don’t you go call your mom. I’ll talk to Jimmy.”

  “Okay, sure. I can do that. Sure.”

  Emmy watched her husband trudge away before asking Harper, “Can I stay with him in the hospital?”

  “Absolutely. Once we get him settled, we’ll have the nurses bring a cot into his room for you.”

  Tears glistened on Emmy’s lashes, and she brushed at them impatiently. She stared down the hall as if checking to see they were still alone. “Harper, I want the truth.”

  Harper brushed Emmy’s shoulder. “I’m telling you the truth, Emmy. I don’t know what’s wrong.”

  “But you suspect something, don’t you.”

  Harper smiled, still calm and unruffled. “It’s my job to be suspicious. That’s why I want him in the hospital. My guessing right now is not going to help him or you.”

  “We don’t have insurance. Last year’s crops were so bad, we had to let it go.”

  “There are ways to handle that. And now is not the time to worry about it. What matters is Jimmy.”

  “I want you to tell me first, soon as you know. Don…” Her voice shook. “Don is the best husband I could ever want, but he’s not strong about some things. He won’t…if it’s bad, he won’t do good.”

  “You first, I promise.”

  “All right, I’ll go talk to Jimmy alone if you don’t mind. If I need you, I’ll call.”

  “Sure. You go ahead. Pack enough clothes for a few days.”

  Emmy stopped and gave Harper a hard look, but finally disappeared.

  When the door closed, Harper sighed tiredly and rubbed her face. Presley wished she could help her—help all of them somehow—and had never felt quite so useless in her life.

  “We’ll be ready to go in just a few minutes,” Emmy said when she came out. “As soon as Don’s mother gets here.”

  “All right, I’ll meet you at the hospital,” Harper said.

  Emmy Reynolds nodded distractedly. “I’m going to get Darla ready to go to Sally’s.”

  Harper and Presley let themselves out. When they reached the truck, Harper said, “I’ll take you home.”

  “No,” Presley said. “I’m in the opposite direction from the hospital. The family will need you to be there when they get there, and I’m sure you have things that you need to do before they arrive.”

  “I could be there a while.”

  Presley opened her door and climbed into the truck. “Then we should get going.”

  Harper got behind the wheel, grateful that Presley understood without her needing to tell her what was happening. Cases like this were some of the hardest she ever had to deal with. Emmy was scared, Don was terrified, and she feared she wouldn’t have good news for them. She started the truck and headed for the Rivers.

  “Can you tell me what you suspect?” Presley asked.

  Harper sighed. “Both his spleen and liver are enlarged. A boy his age, with his symptoms, we have to worry that he’s got leukemia or lymphoma. Either one is dangerous. It might be something simpler, but…”

  “But you don’t think so.”

  “No,” Harper said, “I don’t think so.”

  “Are these things treatable?”

  “Yes, and a lot more successfully than ten or twenty years ago, depending on exactly what he has. No matter what the type, though, if he has leukemia, he’s in for a rough ride. So are his parents.”

  “God, that’s horrible.”

  “Yes, it is.” Harper glanced over at Presley. “I’m sorry, this is going to take a few hours. Your night will be shot.”

  “Don’t be silly. Just do what you have to do. I’ll be fine.” Presley clasped Harper’s wrist. “If I were home, I’d probably be working. I can do that while I wait just as well at the hospital.”

  “You work too much.”

  “Says the doctor who makes house calls on Saturday night.”

  “I can see why my father liked company. It helps.” Harper turned her hand over to grasp Presley’s. Presley’s fingers on her forearm were comforting, a connection she welcomed as she thought about the night ahead and the pain she was likely to bring to Don and Emmy. Pain not of her doing, but pain she would have to deliver all the same. And she worried about Jimmy, a boy who shouldn’t have to deal with anything more serious than improving his baseball swing and what he would do on summer vacation. She held Presley’s hand a moment longer and let go.

  “I’m glad it helps,” Presley said softly. “And I’m glad I’m here.”

  Chapter Nineteen

  “I’ll be in my office,” Presley told Harper as they stopped in front of the ER entrance. “I’m sure you’ll be tied up awhile, so don’t worry about calling.”

  “I will when I’ve finished,” Harper said. “But if you want to leave—”

  “I won’t, but if I do, my car is here. So don’t worry about me. I’ll be fine.”

  The big red-and-white sign overhead painted Harper’s face in stark relief. Gone was the quiet, careful woman who favored a secluded hideaway up among the branches of a great oak
. Her jaw was set in granite and a hard light burned in her eyes. The warrior had emerged, and seeing her this way was enough to make Presley believe she was undefeatable. The family would believe that too, she had no doubt. “If I can do anything—”

  “You have.” Harper stared up at the blazing sign and the building looming beyond. “I love this place, but there’s a lot of pain inside these walls.” She glanced at Presley. “Sometimes it’s lonely.”

  Presley’s throat tightened. Had she ever been this brave? Had she ever admitted, even to herself, all the things she longed for? “Not tonight.”

  Harper touched her hand. “No. Not tonight.”

  “Go, do what you need to do. I’ll be here.”

  “Thanks,” Harper said.

  They parted company just inside. In her office, Presley settled behind her desk and pulled up the projections Preston’s team had provided along with the hospital financials she’d collected earlier. She keyed in data and ran various scenarios, looking for loss points and duplications, wide margins between billables and receivables, searching for the places where the cash flow might be converted from negative to positive. Unfortunately, one of those areas was the number of staff—an overabundance or poor allocation of staff was a drain on resources.

  She appreciated the importance of a low staff-to-patient ratio, but in some areas where patient outcome was not as critically impacted by a higher ratio, some of the nursing and technical staff could be reassigned or even eliminated. The same, she was certain, was going to show up in many areas of direct services. The physicians themselves were not salaried, being private practitioners with admitting privileges who consulted at the hospital and admitted patients when necessary. Those patients then funneled revenue into the system via their insurance or, in rare instances, direct pay. Unfortunately, as she scanned the accounts for the last five years, it was obvious the percentage of insured and/or direct pays was declining and the percentage with some kind of state or federal assistance rising. Patients on government subsidy had a very poor ratio of billables to receivables. And worst of all were the self-pays, which almost always meant no pay.

  She leaned back, thinking about Jimmy Reynolds. His mother had said they had no insurance. They were a prime example of the working poor who couldn’t afford insurance, despite being above the poverty line. Who would pay for his care? Should it be the hospital’s burden, when it meant that too many Jimmy Reynoldses would result in no hospital at all? Should the community shoulder the burden, through taxes paid to the state that were used to provide medical assistance for families like Jimmy’s? Or, as the current administration proposed, was the answer in federally guaranteed health care? Would health care for all result, as it had in so many other countries, in a two-tier system where those who could afford private insurance would always have it, and with it, greater access to the system—the best doctors, the hospitals of their choice, and the most expedient care? Presley couldn’t change the system, she could only figure out ways to work within—or more often around—it. And no matter how she aligned and realigned the numbers, the Rivers needed a new source of revenue and a way to stop the current losses, or as Preston had rightly predicted, it would die.

  A few days ago, that conclusion would have been not only inevitable, but totally acceptable. Now part of her wondered if there might be a different solution somewhere. At the very least, they could look at the reimbursement structure and perhaps find a way to cut the losses in that area during the transition. Carrie had already begun working on that. In the meantime, she would proceed with the current plan to convert ACH to a more lucrative institution. Ideally, SunView’s goal was to repurpose the physical plant with the least amount of construction. Usually, with staff already in place as it was here, that meant either a rehab center with long-term care potential or a retirement community with nursing care facilities.

  She’d need to put together a local construction team to look at the hospital blueprints and draw up plans for conversion. SunView had done this all over the country, and once preliminaries went back to the design department, she’d have something to work with within a month. On that kind of accelerated schedule, she had a bit of time before she’d need to close the ER to admissions and redirect the staff to discharge or transfer in-house patients. But in one month she had to be sure.

  An hour and a half later when she’d done as much as she could, she shut down the computer. Harper hadn’t called. She didn’t want to leave without finding out how Jimmy was doing, and she didn’t want to leave without seeing Harper. She already knew the family, so stopping in the ER wasn’t going to be intrusive. She packed her laptop and walked through the empty halls of the administrative wing into the clinical area. Unlike her office building at home where she was often the only one working late at night, the hospital was somnolent, but not asleep. Maintenance engineers pushed big machines with giant rotating brushes back and forth, polishing the worn tiled floors. Transport personnel pushed patients on litters and in wheelchairs toward X-ray and the elevators. Doctors and nurses talked in low voices as they passed. The lights in most of the hallways had been turned down, leaving the corners in shadow. Her footsteps seemed an intrusion on the solemn quiet.

  The bright lights of the ER entrance signaled a return to activity. A middle-aged woman in sweatpants and a wrinkled checked shirt sat in the waiting area adjacent to the treatment area with a teenage boy who was holding his left arm against his chest, a grimace on his face. Just as Presley went to press the red button on the wall to open the automatic ER doors, they swung toward her. She stepped aside as a husky blond in a scrub shirt and jeans strode out.

  “Jason Smith?” he called.

  The boy and his mother stood up. Presley walked into the ER behind the trio as the man said, “Hi. I’m Will Eddy, a PA. You flipped your ATV, huh?”

  “Yeah,” the boy said. “I think maybe I broke my arm.”

  “Lucky he didn’t break his fool neck,” the woman muttered, stroking the boy’s hair as they walked.

  The PA led the mother and son down the hall toward the treatment areas. “We’ll get an X-ray of your arm and see what’s going on.”

  Presley checked the whiteboard. Three patients’ names were printed in precise black letters. Jimmy Reynolds was listed in room nine. No one was in sight, so she waited by the long counter opposite the board until someone turned up and she could ask about Jimmy. A minute passed and Harper came around the corner carrying a clipboard. She checked her watch when she saw Presley.

  “Sorry, the time got away from me,” Harper said.

  “That’s all right. I’ve been working. How are things going?”

  “His labs should be done by now. I was just about to pull them up on the computer.” Harper gestured to a row of black-vinyl-topped stools on the far side of the counter where several monitors and bins of loose papers stood in a line. “Have a look.”

  Presley followed Harper around the counter and sat next to her. Harper typed in her name and a password, then some other identifying data for Jimmy, and lab work appeared on the screen. Presley looked over the numbers, and she didn’t need to be a doctor to see the string of asterisks marking the abnormal values. WBC: 65,000. Blasts: 80%. She caught her breath.

  “We’ll need a bone marrow biopsy in the morning,” Harper muttered, “but it looks like AML.”

  “AML?”

  “Acute myeloblastic leukemia. He’s in crisis.” Her voice was flat and hard.

  “Meaning what?”

  Harper pushed back and rolled her shoulders. “Meaning he needs chemo right away, and maybe a stem cell transplant. That will be the hematologist’s call.”

  “Can you handle that here?” Presley thought of St. Joseph’s and Banner Good Sam and the other huge medical centers in Phoenix. The shiny glass-and-steel complexes, so different than this centuries-old stone-and-timber edifice, were cold and impersonal, but their very imposing size inspired confidence. But was newer always better?

  “It dep
ends on what the heme guy says,” Harper replied. “Chemotherapy is chemotherapy, and if Jimmy stays here, he’ll be closer to home. His parents have a seven-year-old at home, crops in the field, and animals to tend. They’ll want to be with him as much as they can, but they can’t leave everything behind, either.”

  “Where’s the hematologist?”

  “About thirty minutes away in Saratoga. They’ve got a satellite office near here and admit patients now and then. They’ll also see consults.”

  “Can you get one of them here tonight?”

  “For this, you bet.”

  “I’m going to wait.”

  Harper said, “It might be morning before we get this sorted.”

  “Are you going to be able to get any sleep?”

  “Probably not.”

  “Then we’ll have an early breakfast.”

  Harper studied her for a long moment. “I’m cooking, then.”

  “We’ll discuss it.”

  “Deal.” Harper rose. “There’s a staff lounge down the hall if you get tired of working. Bad TV and decent coffee, usually.”

  “Thanks, I’ll find it.”

  “I’m going to go tell his parents.”

  Presley grasped her arm. “Harper?”

  Harper stopped, a question in her eyes.

  “It’s good that it’s you. They trust you.”

  Harper blew out a breath. “Yeah.”

  *

  Presley contemplated going back to her office, but for once, the appeal of dry facts and figures eluded her. Her stomach was jittery with agitation, but she headed for the cafeteria for a cup of coffee anyhow. Compared to the rest of the first floor, the cafeteria was a beehive of activity. Not many tables were occupied, but cafeteria workers were slotting big aluminum trays of food into the wells in the long steam tables. The coffeemaker was perking away. Hospital personnel were straggling in, in pairs and small groups. Presley paused at the head of the food line, contemplating whether she was actually hungry or not. The pizza she’d shared had been hours ago, but she finally decided coffee was all her stomach could handle.