Time to Die

Browne

Prologue

It was foreboding.

For the third night in a row, the ancient Inuit woman asked to be carried outside at the start of the brief Arctic night. This evening, two of her grandsons set her down gently on layers of sealskin and watched, frowning, as she stared at the aurora borealis streaming from the polar cap. The old woman was dressed in a hooded caribou coat trimmed with wolverine fur to repel the moisture and to keep her frozen breath from encrusting the hood—her mother had made the coat seventy-five years before. Only the older members of her family understood what was happening.

The great-grandmother had noticed blood, sixteen months before. She was taken to the medicine people and the treatments helped, but there was really no cure. However, she was able to live a fairly normal life for almost a year. Now, in the last three months, her stomach hurt more and more and the gnawing pain made the wrinkles in her face even more pronounced.

Inupiats venerate their eldest citizens as repositories of knowledge and keepers of Inuit history. To lose such a person is particularly tragic. Even though the family tried to convince her that more things … other cures … should be tried—she simply shook her head.

A week later, the family thought they might have better luck if they included all the grandchildren and great-grandchildren. All those little eyes looking at her with adoration would surely have a positive effect. Their hopes rose as the old woman said she would consult the spirits and give them an answer. It was now the third time she asked to be carried outside to view the aurora borealis.

The Northern Lights were especially beautiful that night. The streams of color seemed to flicker, dance and twist in the sky, fold into themselves, and move off in various directions.

The ancient Inupiat, gazing at the lights, had seen a polar bear and a bowhead whale, but that was not what she was here for. Spirits of the dead can appear in the dazzling spectacle and she was waiting for their counsel. A domed jet of blue appeared on the left side of the panorama and she knew it was happening because her mother was left-handed and her favorite color was blue. The old woman had come out of her mother, and now her mother was coming to her. Indeed, the ancient could see her mother's face and feel her voice. She blinked away tears, smiled, and raised her hands to the lights. The two grandsons knew she had the answer, so they picked her up and brought her inside. She said nothing, only asked to be helped to her room. The family gathered for her decision.

The old woman struggled out of her coat, which she placed on her lap with the outside fur away from her. She put her hand all the way through the sleeve and grabbed its outer end. She began to pull, which was not easy, because her fingers were curled and swollen with arthritis, and spasms of abdominal pain made her pause. She worked with both sleeves, until the coat was inside out. It took even longer to get her arms back into the coat and to nudge it over her shoulders.

When she appeared in the doorway, dressed in her inside out coat, there was a gasp from the older members and snickers from the young. Her sons and daughters, and some of her grandchildren knew what this meant. She had made the choice NOT to get any further treatment and her decision could no longer be questioned.

Chapter One

February 2010

It was time.

The man, after a year of planning, was ready to light the way … to do what must be done to end the suffering.

He hesitated a moment, tenderly touching his gray wig and beard before entering the Three North floor of the Mar Vista Hospital, a teaching center outside of San Diego. The patients on this floor were all in private rooms while the corridors pulsed with the ebb and flow of doctors, nurses, lab technicians and social workers. If there was any talking at all, the voices were muted. For the most part, there was only the crackle of paper at the nurse's station, the clicking of a keyboard and the shuffle of feet in the hall.

Three North was not the hospice section, but it gave the outward appearance of it. All the patients on this floor were terminally ill, but were being given full medical treatment … including resuscitation. Neither the patients, nor their closest relatives had agreed to hospice treatment and the physicians were legally obligated, no matter what their feelings, to continue maximum care. Even the patients in extreme discomfort were receiving only enough morphine sulfate to keep them from audibly groaning. An overdose could risk a lawsuit. This was not an easy job, because if any of these unfortunate people cried out when their relatives were visiting, the nurses would hear about it. Several of the thirty odd patients on this floor had been there for months.

The man, of average height and wearing a white lab coat with an identification badge clipped to his breast pocket, strode down the corridor and entered room 306. He was carrying a plastic bag containing packed red cells labeled A Positive. Abraham Myers, lying in the bed, was pale and thin, but alert enough to say in his low gravelly voice, What are you doing to me now?

Mr. Myers, age eighty-four, had end-stage chronic lymphatic leukemia. Chemotherapy resulted in several remissions over the previous five years, but the last treatment had no effect and two bouts of pneumonia were the consequence of his depleted immune system. The second nearly cost him his life. This was his third admission for a serious lung infection. His two daughters had lost their mother three years before and they were not about to give up their father without a fight. He was anorexic, in constant pain, and too weak to overrule their insistence that he continue treatment. Stubble on his chin and along his jaw line accentuated his wasted body. There was a sweet/sour odor in the room generated from the skin and lungs of the dying man. Under it all, was the mixed chemical smell from medication, intravenous fluid and room disinfectant. He was being given blood transfusions, along with oxygen, to relieve his shortness of breath, and painkillers to treat the anguish in his bones. His daughters threatened to sue if the doctors didn't continue chemotherapy. He kept asking for something stronger for pain.

I am here, Sir, to give you some more blood. You'll feel a lot more comfortable when this takes effect. To calm the patient and to keep him from shouting, the white coated man placed reassuring fingers on the patient's bare left forearm. Suddenly, an electric current seemed to pass between them, totally immobilizing the visitor and opening a small window into his residual sanity. The patient's skin was warm and the man could feel muscles moving underneath. For the first time, he saw Abraham as an actual person—a man with intelligence and feelings who, at birth, had been given the promise of a life which would only end when nature decreed. He's real. What am I doing?

Stretched out seconds went by and the spell was only broken when the dying man said, Help me … the pain.

The pale visitor jerked his fingers from the old man's forearm, clamped off the intravenous line, hung a bag of red cells from the IV pole, connected it to the line running into the patient's arm, opened the valve all the way and watched the blood surge into the vein. Myers frowned and looked up when the man took his left hand, stretched it open and wrote KATTITUYOK with a black fine-point permanent marker on the patient's palm. The white-coated figure glanced at the sign over the bed, BLOOD TYPE O ONLY, and then left the room and entered the corridor. He headed for the exit without looking around. He stopped briefly in the restroom adjacent to the bank of elevators, removed his white coat and placed it in a paper grocery bag. He was out of the hospital in a few minutes and no one took the least notice.

Myers looked at the letters on his hand, but could make no sense of it. He glanced at the blood hanging from the IV pole and grimaced as he felt deep pain in both flanks. His shortness of breath was supposed to get better, but it was worsening—he was dizzy and beginning to shake. Myers thought he was having a transfusion reaction and tried to reach the call button … but it was somehow out of his reach … on the other side of his nightstand. As he stretched his arm out in desperation, he saw a rivulet of blood snake out of the site where the intravenous catheter entered his arm. The redness began to drip steadily onto his sheet. The patient was not aware, as he fell back onto his pillow, that his face was bright red, his urinary catheter was filling with blood and his blood pressure had fallen to shock levels.

The man with the grocery bag had parked his car several blocks away on a side street. This would avoid any surveillance cameras in the hospital parking lots. It was a gray seven-year-old nondescript Toyota Corolla which was nearly invisible anywhere. Twenty minutes later, he left the car in a three-story parking garage and walked to his small apartment on the second floor of an aging building across town. Access to the upper apartments was by metal stairs on the outside of the building. The structure was painted an outlandish two-tone green which had been bleached and peeled by the sun over many decades. His apartment was in the rear of the building and consisted of a bedroom, a combination living room/kitchen and a bathroom. The view from the living room was depressing—it looked into an alley—but the bathroom window had an advantage. A person could easily access the fire escape through the window. The furnishings were hodgepodge, all from Goodwill, and probably third or fourth hand at best. There was a thin film of dust over every flat surface, except for the seat of one wooden chair. Interestingly, the framed—and some unframed—pictures on the wall were all photographs taken in the Arctic. There were pictures of native Inuit peoples, children, skin-covered boats, Bowhead whales and a young woman standing in front of an Inukshuk, the large and vaguely human stone figure which was used above the Arctic Circle as a landmark in an otherwise barren terrain. The most arresting photograph was of an ancient Inuit woman sitting outside of her home, dressed in peculiar looking clothes.

After the man entered his apartment, he went into the bedroom, tossed the paper bag on his bed and stood for almost a minute, struggling in vain to let the tension drain from his mind and body. His eyes saw Abraham Myers again, his ears heard his voice and his fingers felt the flesh of his bare forearm. His skin prickled—a bed of nails—as the full impact of what he had done seeped into the core of his being. He began to slide again into sanity's cool waters and then remembered Mr. Myers' last words: Help me. He squeezed his eyes shut for a moment and then looked up, grimly and purposefully, at the picture of the Inuit woman … finally nodding his head and stepping back from the edge. I AM helping. He was unaware of the musty stale smell that fogged every nook and cranny in the room. His gaze turned to a small rounded figure on a shelf in front of him. At least it seemed to be a figure. It was not clearly male or female, but there seemed to be a head, stubby legs and short protuberances which could have been arms outstretched to each side. The object might have been an ancient sculpture, a fetish figures, or simply a found stone that had been pummeled by surf or carved by the Ice Age.

The man stepped into the tiny kitchen and opened the refrigerator, which only contained one thing—a glass of water, the favored drink of traditional Inuit peoples. The evening before, he had filled the white frosted glass with ice from the freezer. He placed it on the wooden table and sat in the single wooden chair, sipping slowly and reverently until the glass was empty. He could taste a flavor … no … it was more of a sensation. It was the same sensation he felt when he first gazed upon the dying Inuit woman in her strange looking clothes. The man was honoring, in tiny sips, his selfless mission and the courage of the old woman.

After the man drained the last drops from the glass, he washed it and put it back in the fridge. He removed his shoes, his clothes, his gray wig and beard and then took a long hot shower. The mirror was fogged by warm vapor so he used a hair dryer to clear a spot in the center. He smiled at his delicate features and ran his hand over his shaved scalp and down over his hairless face, chest and smooth legs. There was no stubble and he would not have to shave or use Nair on his body for another day. He habitually shaved twice a day, but his beard was very light and with a coating of makeup, it was impossible to tell he had any hair on his face at all. He checked himself thoroughly in the full-length mirror on the back of his closet door and then walked into his living room.

Still naked, he moved a five-foot high bookcase to one side, exposing a two-foot hole which had been cut through the wall. After pushing away a bureau on the other side, the man wiggled through into the adjoining apartment. He got to his feet, went to a closet and dressed quickly, putting on tight reinforced panties which kept his genitals down between his thighs, a padded bra, a loose blouse and slacks. He used makeup and lipstick before putting on a soft brown wig. The transformed man pulled the bookcase in the next apartment back to the wall and moved the bureau on his side to cover the hole. He stood up and smoothed the slacks around his hips before adjusting his wig in front of the mirror.

This small apartment, the mirror image of the one next door, was meticulously clean with yellow walls, made even more joyful with lively posters in colorful metal frames hung about the room. The drapes in the living room were a deep pink, almost orange, and coordinated nicely with the beige and brown rugs. The furniture was Danish modern and there were magazines on the coffee table, food in the refrigerator and clothes in the closet. In the bedroom, the bedspread was pink and green in a flowery pattern. This was a lived-in place, occupied by a fastidious female.

A minute later, an attractive young woman emerged from the second apartment and went down the outside flight of stairs to the mailboxes in the first floor entranceway. She removed several envelopes and an advertising flyer and placed them in an upscale, dark green purse. They were addressed to Shila Thomas, his nom de guerre. For his job at the hospital and his plans for the future, it was best to materialize as a woman.

Chapter Two

Marion Walsh RN, after hearing a crash and a cry down the corridor to her right, looked up suddenly from the chart and her half-finished nurse's notes. She jumped up and jogged down the corridor, her concentration intensifying when she saw a young nurse's aide backing out of room 306.

I'm sorry, Marion, said the aide, but I think he's dead. I dropped the tray and I'm sorry, but he looked so …

It's all right, said Marion. Go up to the nurse's station and sit down and I'll take care of this.

Mr. Myers, red-faced, was lying back on his pillow with his mouth open. He was not smiling. There was a pool of blood soaking into the sheets by his left arm and more blood by his right hip from a biopsy site. His urine bag was a quarter-full of bloody urine. She pressed her stethoscope against his bony chest and listened while at the same time staring at his dilated pupils. There was no heartbeat or respirations. Marion pressed the call button and asked another nurse to call the resident on duty. Dr. Ian MacDonald was in a conference, but answered his page immediately and was on his way. She knew the hopeless nature of Myers's diagnosis and wasn't about to call a Code Blue.

Marion was already thinking about cleaning up the area in case a relative arrived. She also began to worry about the cause of his sudden death. This wasn't the usual way a leukemic patient died. She noticed the empty bag of A positive blood dangling flaccidly from the IV pole … only a slight shift of her eyes brought into focus the BLOOD TYPE O ONLY sign.

Oh, my God! They've given him mismatched blood. They killed him. Marion could hear her own voice … high-pitched and far away. She backed out of the room, closing the door behind her. She walked—it was all she could do not to run—back to the nurse's station. Marion called the blood bank and they immediately sent up a technician. The tech, visibly shaken and staring at the sign over the bed, stated forcefully, This is impossible! I hung type O blood on this man myself this afternoon. The tech rushed back to the nurse's station and called the blood bank supervisor. She asked her boss to be sure all the bags in the bank were accounted for and to check every patient who received a transfusion that day. Dr. MacDonald arrived, slightly out of breath, and headed down to the patient's room with Marion in tow. After examining Mr. Myers, he agreed the patient had probably died a couple of hours before—resuscitation was out of the question.

We better notify the administration right away, he said. This is a serious malpractice case. There was a momentary pause and he added, I guess we don't get a new CT scanner this year.

Marion glanced sharply at the physician, thinking his remark was in very poor taste. MacDonald winced and said, I'm as upset as you at this tragedy—I was just trying to soften it a bit. We've got dozens of other patients to take care of. Sorry … truly.

Marion gave him a hint of a smile and they both walked back to the station. The blood bank tech called and said, There's no blood missing from the bank and only two A positive transfusions and one O have been given today. One of my colleagues is already on the way to check the other two rooms. In less than five minutes, the phone rang and a nurse from the fifth floor said, A surgical patient who had an abdominal aneurysm resected two days ago received a unit of packed cells. He has type A blood, but received a unit of O which is still hanging. There was no transfusion reaction because type O is a universal donor. The only conclusion I can come to is that somebody purposely switched the blood transfusions … or else the blood bank technician made TWO serious mistakes on the same day.

Ian MacDonald was a second-year surgical resident who was assigned to Three North for a three-month term. He saw all of the patients twice a day, assisted fourth-year residents in big cancer operations, did minor surgeries and biopsies and inserted IV lines. He was also familiarizing himself with nonsurgical treatments such as chemotherapy and both internal and external radiation. He immediately called the chief of oncology, Dr. Valya Tschorn, who was nationally known and a stickler for protocol. Her rumpled clothes and ill-combed hair belied her formidable intellect. She agreed that the hospital administrator, Richard English, should be notified right away and it wasn't long before they both appeared at the Three North nurses' station. The blood bank supervisor was already there and she was as distressed as everyone else at what appeared to be a horrendous medical mistake.

The group went briefly into room 306 and then retreated into a small conference room on the floor. The supervisor said, All of you know what happened here today, but what I can't figure out is HOW it happened. My technician has never made a mistake in the four years she's been working in the blood bank. She swears she hung the correct blood type for both patients. She has done this hundreds of times and has been taught to check—and re-check—each patient before starting all transfusions. And two mistakes within an hour? Mr. Myers is … I mean was … a terminally ill patient who was perhaps days away from dying. The patient on the fifth floor is recovering nicely from vascular surgery and there seems to be no question, especially after improving his blood count with the transfusion, he will recover and go home on schedule. The mismatched blood that he received—type O—can be given to anyone and will do him no harm. Something doesn't make sense here.

Dr. Tschorn opened her mouth to speak, but was interrupted by the impeccably dressed English who said, I'll tell you what I make of it! Your blood bank screwed up royally. You gave the wrong blood to the wrong patients and we are going to be skewered if this ever goes to trial. It's open and shut. The administrator looked over at Marion and continued, The only other option, other than settling the case for hundreds of thousands of dollars, is to take out the urine catheter and the IV line, put fresh sheets on the bed, and then call the family and tell them he died. Surely, from what you've told me, they must have expected this to happen at any moment. English moved his rimless spectacles to the bridge of his nose and shifted his gaze to the blood bank supervisor.

Marion looked stunned and glanced over at Ian. Dr. MacDonald started to get up from his chair and then sat back down before saying, Excuse me, Sir, but you know we can't do that. A lot of people, not just us, are going to know about this tomorrow. A cover … , the doctor hesitated … hiding this is going to cost you millions instead of thousands.

Dr. Tschorn noticed English's face flushing crimson and quickly spoke up, I know you mean no harm, Richard, but we are going to have to play this straight. All the professionals in this hospital know what financial strains even fine hospitals like this one are under these days. Keeping this whole thing quiet would probably be easier on the family, but we cannot compromise our values. I knew this man very well and the family may actually feel the tragedy is a blessing for all concerned … especially the patient.

Mr. English, trying to recover some dignity, replied, I didn't mean to suggest we cover anything up, but we can certainly clean up the scene so when the family arrives they don't see a man with his mouth open, blood all over the place and a mismatched transfusion bag hanging by his bedside.

I'll take care of all that myself, said Marion. I know it will make a big difference to his two daughters to see him at peace. He has been miserable for the last six weeks and I don't think they would even consider suing the hospital and hurting all of us. They know we have been treating him with kindness and respect.

Unless one of those damn malpractice lawyers gets hold of them, said English.

Dr. Tschorn looked over at Marion and said, I will discuss this with his family members myself and your caring presence would be a big help. Dr. MacDonald, you put his lines in and the family saw what good work you do—I would like you to join us. With any luck, the subject of malpractice will not come up. Richard, I will call you as soon as I finish talking with the daughters.

The oncology chief suddenly frowned and looked back over at the nurse again. Marion, what do you make of those letters on Mr. Myers's left hand? Maybe it's some kind of message to his family?

The nurse, shaking her head, answered, I have no idea. I recorded it in my nurse's notes and tried to figure it out. The letters make no sense to me—unless it's some kind of anagram or acronym. What's even more puzzling is that the letters were printed quite well for a dying man of his age—and I couldn't find a pen anywhere. I looked all around.

The administer shot to his feet and said, The cleaning crew will find it in a corner somewhere. Let's clean the room up and get to work stopping a lawsuit.

The rest of the group rose and left the room, leaving the administrator still mumbling under his breath as he headed for the elevators. Dr. Tschorn walked to the nurses' station to call the family and Marion and Ian went back to work.

Chapter Three

Mr. Myers' two daughters, after they received Dr. Tschorn's telephone call informing them of their father's passing, spent several minutes of private time with him in his hospital room. Now they were in the conference room with the oncology chief, Dr. MacDonald and Marion.

I know you are aware of your father's prognosis and the miserable time he was having in the last couple of weeks, said Dr. Tschorn. "I wish there was something more that modern medicine could have offered him … if not to cure him, at least to make him more comfortable. He asked us several times to stop all the treatments.

I don't know how this happened—maybe a greater power was involved—but Mr. Myers received a mismatched unit of blood today. He died very quickly because of it and there was no suffering. He was completely at peace.

The two daughters looked at each other, stunned, and dabbed at their eyes more furiously than ever. I don't quite understand, said the eldest, you mean he was killed by a blood transfusion?

Yes, said the oncologist, although we all expected him to die at any moment, the immediate cause of his dying today was that he was given type A blood instead of type O.

The younger daughter looked at her sister and said, "Father