Deadly Diversion
by Eleanor Sullivan

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When a small-time crook dies suddenly before he can tell police who committed a long ago murder and her staff comes under suspicion, head nurse Monika Everhardt investigates.  Is the perpetrator a disgruntled worker? A local mob figure? Or could it even be her demanding supervisor?  Join Monika as she searches for a killer in a fast-paced intensive care unit full of critically-ill patients.

REVIEWS

 “The telling and characters are expertly handled, and the specialized background is rendered in warts- and-all detail.” ~ Ellery Queen Mystery Magazine, July, 2005

“… a medical mystery that rings with authenticity, and a spunky, likable, interesting nurse-protagonist… May we see much more of Monika Everhardt!” ~ Aaron Elkins, Edgar award winner

“Monika must try to hold together her overworked staff while patients are dying mysteriously…one of the dead patients is a mafia don with a vindictive family. Forget malpractice suits, these guys go for the throat, literally.” ~ Heartland Reviews, March, 2005

"…the mystery’s an intriguing one…the characters are very well done…DEADLY DIVERSION is recommended reading.” ~ Bill Crider, Anthony award winner

“…her second mystery, DEADLY DIVERSION, features fictional St. Louis nurse Monika Everhardt, who figures out why patients are dying when they shouldn't be.” ~ St. Louis Post-Dispatch, Dec 29, 2004

“DEADLY DIVERSION crackles with authenticity.  Death in the ICU may be part of the job for her protagonist, Monika Everhardt, but it's a difference case entirely when the diagnosis is murder." ~ Susan McBride, author of A GOOD GIRLS GUIDE TO MURDER

Prologue 

The loud speaker woke him.  It was happening again, another one was trying to die.  They’d left the curtain open because it was night time and they thought all the patients were asleep.  But not him.  With the first sound, his training had kicked in, propelling him awake, alert. 

After a few minutes he knew something was wrong.  The nurse was competent, that he could tell from the swift, sure movements.  But it was all going down too quickly.  Much, much too quickly.  Each task required specific steps in exactly the correct order.  Otherwise, the mission can go wrong and someone can get hurt or die.  He’d learned that long ago.   

He knew who the patient was because the family had been in and out for the past few days and he had recognized them.  But he’d kept quiet, concealing his presence.

Now he lay quietly and watched.  He was good at that.  And listened.  He was good at that, too.     

Chapter 1

Wednesday, 08 August, 0645 Hours

“Guardino’s gone.”  Bart said, giving me a quick glance.

“Gone?  Where?” 

“Dead,” Bart replied, continuing to write in the chart in front of him.

I sat down hard, rattling the chair back.  “What happened?”

Bart shrugged.  An experienced critical care nurse, Bart had moved to St. Louis to study anesthesia in graduate school and had started work at St. Teresa’s Hospital six months ago.  He’d wanted to work nights so he could go to school during the day.  Few nurses wanted the night shift so I was glad to give it to him.

“Where’s his chart?”

“Why?” Bart asked, turning to face me. 

“I want to know what happened.”

“As soon as I finish.”  Bart shifted his attention back to the chart. 

“Where’s the body?” I asked, looking around for a gurney from the morgue.

“I sent it on down,” he said, writing as he spoke.  “I wanted to get it out of here before everyone arrived.”

“So what happened?” 

“Here.  See for yourself.”  He closed up the chart and tossed it onto the counter in front of me.  It landed with a clatter. 

“The chart’s supposed to go with him,” I said, opening it up.

I had started out at St. Teresa’s straight out of nursing school more than twenty years earlier, working on medical-surgical floors until I’d been able to get my clinical legs under me, then I’d transferred to intensive care where the rush of adrenaline fed my need for excitement.  Head nurse—now called patient care manager—for the last five years, I found the job becoming more and more difficult as managed care squeezed ever-increasing dollars out of our budget, and the nursing shortage meant each shift was a gamble.

“I’ll take it down when I leave.”  Bart stretched his arms above his head, muscles rippling under his green scrub suit top.  He closed the fat textbook that lay on the counter and stacked a yellow legal pad covered with notes on top of it. 

“No surprise, I guess,” I said.

Mr. Guardino had come in three days before, unconscious from a stroke.  Since he’d arrived his body had been shutting down, one organ system after another, in spite of our best efforts to keep him alive.

“My god!”

“What?” Bart asked, wadding up some scraps of paper.  He tossed them toward the trash can under the counter.  They fell short.

“You didn’t intubate him?  Or shock him?”

“He was a B code, wasn’t he?” Bart asked, referring to the A, B, C system of coding we’d recently adopted to designate what should be done in case of a cardiac or respiratory arrest. 

“No!  The family was emphatic—full resuscitation.  He was an A.”

An A code required that everything medically possible be done to resuscitate the patient.  B codes, generally used for patients unlikely to survive, specified limited resuscitation efforts; and with a C code, previously designated as a “do not resuscitate” order, no resuscitation would be attempted. 

“It wouldn’t have helped anyway,” Bart said.  “He couldn’t have been resuscitated, no matter what the code was.” 

Determination of the appropriate code was based on the patient’s condition and likelihood of recovery as well as his or her previously-stated wishes and the family’s desires at the time.  It wasn’t a perfect system, by any means.  Such life-and-death decisions are difficult even if they are discussed ahead of time, but under the stress of a critical illness families and staff alike find themselves torn between wanting to keep the person alive and accepting the futility of trying.  And seldom do all those involved agree.

I wiped my hand across my face.  “You didn’t know that.  I’ve seen them come back from. . . .  Anyway, it was your job to know which code to use and to follow it.”

“Do you know how much care he required?” Bart asked, going on without waiting for my reply.  “The constant juggling act it took to keep all those drips going?  Keep his pressure up, they say, we’ve got to save what viable brain he has, they say, but not too high, they say, or he might stroke out.”  He flung his arms outward and heaved a sigh

“I know all that—”

“You don’t know the half of it, Monika.  Do you know how many meds he was on?  Antibiotics, muscle relaxants, a beta blocker—that was for the heart damage from the defibrillator they used in the ER to restart his heart—and more.”  He rubbed the stubble on his chin.  “And me here in charge alone on nights.  It’s all we can do to keep up with the ones who are recovering. as understaffed as we are.”  Bart stood and reached for his lab coat draped across the counter.  “I did the best I could.  No one can ask for more than that.”  He swung the lab coat over his shoulder and started toward the door.

“I’ve got to write you up for this.”  I reached for the incident report forms in the drawer. 

He turned toward me, and I caught a flicker of anger.  Just as quickly it was gone. 

I stared at the form.  Damn.  This was the last thing I wanted to do—write up a competent nurse of whom I had far too few.

“Listen,” he said, coming back.  “Are you really going to screw things up for me over some old man who was dying anyway?”

“Policy, Bart.  And the law.  It’s not your decision.”  I looked back down at the form in front of me.

He dropped his book on the counter and leaned over me on the desk, fingers splayed.  Wisps of blond hair curled on the backs of his hands.  “I need this paycheck ’til I finish grad school,” he said, “and you’re not going to mess me up!”

Two nurses on the day shift came through the door. 

“You keep quiet,” Bart said, then he picked up his book and papers and left the unit.

Ruby banged through the swinging doors carrying an insulated lunch bag.   “What’s he in such a hurry for?” she asked, tossing a bulky red-white-and-blue cardigan over one chair and arranging herself in another.  A ward clerk since before I had come to St. T’s, Ruby kept tabs on everything.  And everyone.  “Whose is that?” she asked, pointing to the chart in front of me. 

“Guardino’s.  He’s dead.”  I took in a deep breath and let it out slowly, looking up at the ceiling.

“Hey, you ain’t that upset over him, are you?”

I shook my head as much to clear it as to tell her no.

“What’s it doing up here?  And where’s the body?” Ruby asked, glancing toward Guardino’s room.

“Bart was going to take it down—”

“Here. Gimme,” Ruby said.  “I’ll take it down to the morgue.” 

I handed her the chart.  “Just don’t go visiting all your friends on the way.”

“Hey, I ain’t got no friends in the morgue.”  She chuckled.  “No, sir, I don’t want nothing to do with the dead ones,” she added, clutching the chart to her chest.  “I know some folks.  That’s how I find out stuff.  And you don’t seem to mind knowing what I find out, neither,” she added with a flip of her top-knot as she marched out the door.

Mr. Guardino had not had any hopes of recovery; that much was clear.  Undoubtedly we had just been keeping him alive until his heart stopped and he couldn’t be revived, or until the family agreed to let him die.  His death had been imminent, regardless of what code was assigned to him; Bart was right about that.

I’d have to report Bart to my boss, chief nurse Judyth Lancelot, and see what she wanted to do.  Although I only saw him briefly in the morning at change of shift, Bart hadn’t seemed to have any problems adjusting to our unit.  With the hospital’s accreditation on warning, I doubted Judyth would want to fire him over this incident.  We had received strong recommendations to improve in several areas, but our top mandate was to increase the number of nursing staff.  We were dangerously understaffed, and with the current shortage of nurses in the St. Louis area and our less-than-competitive salaries, we were struggling to find new hires. 

“Safety is the issue here,” one surveyor had said during her accreditation visit.  I had to agree.  And the team was due back any day, a surprise visit intended to catch us doing the right thing.  On top of that, a small group of nurses was threatening to unionize if staffing didn’t improve.

A new nurses aide, who had just started on Monday, came out of a patient’s room.  “Where are the blankets?” she asked me, popping gum.

“There should be some in the room.  If not, there’s more in the storage closet out in the hall.”

“He’s already got three but he wants another one,” she said, turning toward the door.

“Wait.  Who needs a blanket?” I asked.

“He does.”  She waved toward the room she’d just left.  “Says he’s, like, cold.” 

Jessie came out of the med room.  “Who’s cold?” she asked, setting her tray of syringes and medicine cups on the counter.  A small frown creased her forehead and her good eye looked at me, the other into the distance.

“Kleinfeldt.”

“Oh, my god, he’s got blood hanging.”  She hurried toward the room.  “Call the blood bank,” she yelled over her shoulder.

Serena, currently a student at a local nursing school, came up to the desk.  “What’s happening?” she asked me with alarm in her voice.  Serena had worked as a student assistant in ICU part-time during the school year and now was working full time for us through the summer. 

Waiting on the phone for the blood bank to answer, I quizzed her.  “Tell me, what’s his complaining of being cold mean?”

Serena ran her fingers through her spiked hair, a brilliant red this week.  “Uh . . . reaction!  He’s having a reaction to the blood.” 

Jessie came out of the patient’s room carrying a nearly full bag of blood and holding the tubing up so it wouldn’t drip.  “Yet another mistake,” she said, keeping her voice low.  The blood bank was short-staffed, too.

“What happens now?” Serena asked me.

“It depends on the mistake.  They might have made an error in typing or cross-matching his blood, or maybe they issued the wrong product.”

“You mean packed red blood cells instead of whole blood?” Serena asked.

“Exactly.  They’ll send someone up to draw another blood to type and cross match again and recheck the order.  I hope they get it right this time.” 

Jessie came back and I asked her to do the code-cart check.

“Didn’t you and Bart do it?”

“He got away before we did,” I replied.

“Oh?” 

I shook my head and she went to do it.  Jessie was one of several experienced nurses in the intensive care unit I could count on to do a good job no matter how busy we were.

Part of the change-of-shift routine required that the charge nurse going off and the one coming on check that the code cart was stocked with supplies, that the defibrillator was charging and delivering a charge, and report to pharmacy if the medication drawer needed restocking.  Bart and I had also neglected to sign off on the narcotics, which were supposed to be counted and recorded at the change of each shift.  These were serious infractions of the rules, but I had too much to do now to think about it. 

I had just finished checking the day’s roster of staff against patients’ conditions to see how much care they required when the doors swung open, crashing against a linen cart that had been left there. 

“Who killed my pop?” screamed Mr. Guardino’s son.

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