The Piano, Chapter 7
House’s face relaxes into a rare expression of unguarded
pleasure, something only music seems to bring him anymore.
“I got plenty o’nuthin, nuthin’s plenty for me.”
Mel Torme’s baritone is like really, really good whiskey, dark and velvety and intoxicating.
“I got no car, got no mule, I got no misery.”
House is lying on the floor, feet propped on his chair. It is the oddest of his usual positions for relaxation, and one of his favorites. Not only is he mostly hidden behind his desk - a casual glance by someone looking to give him work to do would reveal only an empty office - but the position eases the muscles of his thigh, hip, and back.
The weather has turned cold, and the arrival of winter always means a few weeks of intractable, bone-deep ache in his leg, until the maimed nerves and muscles adjust to the season. More pain in his leg means he compensates by abusing the rest of his body, limping harder and relying more on the cane. By late afternoon everything hurts, more or less, and he takes any respite he can find. With his feet up and back flat, shutting out the world with closed eyes and rich music in his earphones, he is almost comfortable.
The iPod brings up Ain’t Misbehavin’ next. This is Satchmo’s version, the muted trumpet flirting with the piano and giving the lie to the title - there’s no way those saucy riffs aren’t hinting at all sorts of entertaining misbehaviors. House smiles to himself. Even trumpets, it seems, are not exempt from the rule that everybody lies.
His smile fades as he remembers his rather unsatisfying conversation that morning with Ella Morgen. She may not have lied, but she is very good at deflecting conversation away from truths she doesn’t want to discuss - almost as good as he is, in fact.
He still hasn’t parsed her relationship with Wilson, but he doesn’t like the pattern. Wilson has been spending too much time at the hospital for a man who is trying to save his marriage, and too much time in Morgen’s company. Solve for M, he reminds himself. He needs more data.
House turns his head to glance out the window. The angle of the light suggests sunset is not far off. About four-thirty then. She is probably in her office.
With a sigh, he lifts his crossed legs off the chair, letting his left leg do the work of carrying the right leg to the floor. This is the major drawback to relaxing in this position: it’s hard to get up. Rolling into a kneel, he touches the desk for balance and pushes himself up, left leg taking his weight. The maneuver has the smoothness of long practice; a casual observer would probably never guess at the careful choreography required for such an ordinary thing.
He grabs his cane and limps into the hall. Not only will needling Morgen give him more information to work with, it will also provide an entertaining distraction to occupy him until he can take another Vicodin.
Her office is lamp-lit, with a warm and welcoming atmosphere designed to put nervous patients at ease. It looks nothing at all like his own office.
House leans in the open doorway, watching her work. She is reviewing patient charts, meticulously making notes in each. Also nothing like his office.
“So why does a fourth-year medical student up and murder her husband?”
She freezes for the barest instant, then continues writing in the chart before her. A less careful observer would have missed the pause, but not House. He knows he’s gotten to her, however skilled she may be at covering it.
Without looking at him, she replies, “You’re the diagnostic mind of a generation, Dr. House. You tell me.”
“Okay.” He pushes off from the doorframe and moves to a chair across the desk from her. He sprawls casually in it, exuding lazy confidence.
“I think he hit you. A lot.”
Her pen scratches steadily across the page. She doesn’t so much as glance up, but her silence is an affirmation.
“Lots of battered wives want to kill their husbands, I’m sure, but surprisingly few of them actually do. Mostly they just leave.” He lets the comment hang there, knowing she’ll understand it for the question - almost an accusation - that it is.
House watches the top of her bent head, his right hand rocking the cane back and forth. Sooner or later she’ll respond. He can wait.
At last Morgen closes the chart and meets his eyes, folding her hands on the blotter. “Did you know that eighty-five percent of the women who die at the hands of an abusive partner are killed after they leave him?”
The cane stills. After a long moment he looks down, ducking his head in something that is almost half a nod. That is a fair - and rather tragic - point, one he bets most counselors at battered women’s shelters don’t mention to their clients. He wonders if more of those clients would kill their husbands if they knew that statistic.
His eyes flick up to meet hers again. “But you didn’t call the police, didn’t file assault charges.”
A bitter laugh escapes her. “He was the police. He’d stop home mid-shift for a quickie and -” She bites off whatever she’d been about to say. With a deep exhalation, she shifts uncomfortably in her chair and looks down at her hands. “I should have. I figured out later I could have gone to his squad, showed them the bruises. They would have helped.”
Her lips twist as she meets his gaze. “But I was young, I’d seen one too many movies about the silence of the thin blue line.”
So she’d decided to kill him.
It must have felt too dangerous to stay, even more dangerous to leave, the police potential enemies as much as potential rescuers. She had done the math.
Morgen is watching him steadily, no trace of nervousness in her posture now. “What do you want, House?”
The cane resumes its rocking.
“You were never arrested.” Probably the police had waited for the district attorney to weigh in; they wouldn’t have wanted to arrest a cop’s wife, even with his blood literally on her hands.
The corners of her mouth twitch, but her eyes never leave him. “He’d beaten me bloody.”
House admires the cold logic of it, even as he’s faintly appalled. She had let him beat her, maybe even provoked him, then killed him. The D.A. had likely taken one look at the marks on her and called it self-defense.
He wonders if Wilson knows how calculated her decision had been.
“What do you want?” she repeats.
He had guessed right about her husband, she’d even confirmed his suspicion that the death had been premeditated.
Wilson is a real bastard in some ways - as all of his wives could attest - but he is also charmingly idealistic. Had the same naïve optimism that had taken Wilson to the chupah three times in fifteen years let him accept the self-defense story at face value?
“So it’s what, some kind of misguided penance that you never remarried? A lifetime of self-denial to make up for the sin of killing a brutal son of a bitch who deserved what he got? Or maybe it’s just cowardice. Once bitten, blah blah blah.”
Her face is very still, but the whitened knuckles of her folded hands give her anger away. “Oh, please. Let’s not pretend you’re actually interested in my love life, Dr. House. You just want to know why I haven’t fucked James. Look, word around the hospital is that you’re a first class misanthrope, so I understand this may be a foreign concept: James and I are friends. Why the hell that bothers you so much, I don’t know, but for his sake I wish you’d get over it.”
House opens his mouth to respond, but she runs right over him, leaning forward with an oddly intent expression. “Do you really think so little of James that you can’t imagine a woman would be interested in him for anything else?”
Morgen is an anomaly, an aberrant datum on the scatterplot of Wilson’s life. She breaks the pattern of his relationships with women.
House knows she had been a hematology fellow at Hopkins when Wilson was an intern, that they had worked a few cases together on his oncology rotation. The grapevine says she is a gifted teacher; maybe Wilson had developed a touch of hero-worship. Certainly House has watched more than one young doctor get revoltingly starry-eyed over Wilson, and there is a certain amusement in picturing the confident oncologist in the role of awestruck mentee. But hero-worship wears off. In the dozen or so years since their time together at Hopkins, the two of them have obviously stayed in touch, have stayed close enough to fall easily into a comfortable rapport.
“I think that says more about my opinion of women,” he counters.
“Or maybe,” she continues, as if he hadn’t spoken. “Maybe it’s more that you don’t think enough of James to imagine that he would be interested in a woman for anything else.”
Her eyes narrow, and House suddenly recognizes that intent expression. It’s the same one he gets when he’s certain he has figured something out.
“Or does it just piss you off that he’s having lunch with me, instead of you?”
He stands abruptly. “Save your breath,” he says in a voice dripping with scorn. “I’m not interested in your pearls of pop-psychology wisdom. I certainly couldn’t care less about your love life, I’m just fascinated by the novelty of having a murderess on grand rounds.”
The barb was meant to sting, but Morgen looks suddenly relaxed, a tiny smile playing at the corners of her mouth.
“Good night, Dr. House,” she says, and opens another patient chart.
He watches her work for a moment, then turns with a wry smile to leave.
----------------------------------------
The early morning oncology rounds find Wilson facing Ella across the bed of an increasingly ill Seth Greer, fresh labs in hand. The chief resident, leading her gaggle of young doctors, raises her eyebrows in surprise to find two attendings - including her department head - already in the room.
“Dr. Wilson, Dr. Morgen, I’m sorry for interrupting. We can come back, if…”
Wilson waves off her apology. “Go ahead, Dr. Reed.”
She nods, and turns expectantly to the intern assigned to the case.
“Seth Greer, age eight,” the young man begins. “Entered a clinical trial of chemotherapy eight days ago to treat recurrent small noncleaved cell lymphoma. He was moved to the PICU two days ago for close monitoring when he contracted a cephalosporin-resistant staph infection. He responded well to vancomycin, but developed DIC with apparently localized renal microvascular thrombosis. After administration of heparin, his platelet count rebounded and renal function showed some improvement, and he received the second round of chemo yesterday, on schedule.”
Wilson notes with approval that if the intern is nervous at presenting directly to the Head of Oncology, he doesn’t show it. “How are his morning labs?”
“Not great,” the intern admits. “Platelets look fine, but his potassium and uric acid are both somewhat elevated. His kidneys are still having trouble, and the ECG shows mildly peaked T-waves from the hyperkalemia.”
“Your assessment?”
“The chemotherapy and vancomycin have seriously challenged his kidneys, which were compromised by the DIC. I think he’s got renal insufficiency.”
“What’s your plan?”
“Allopurinol to help his kidneys out, continue pushing fluids, and monitor closely. If his renal function doesn’t improve in the next four hours, call nephrology to request dialysis.”
Wilson nods. It isn’t a bad plan, but he thinks the inexperienced doctor has allowed himself to get too focused on the DIC and forget about other potential complications.
“Dr. Morgen, do you concur?”
Ella doesn’t respond directly, but turns to the intern. “Why is his uric acid high?”
The intern swallows. Wilson can see in his face that he understands he has missed something but hasn’t figured out yet where Ella is going.
“The renal insufficiency means his kidneys aren’t excreting it fast enough.”
Ella lifts one eyebrow. “Where are his BUN and creatinine?”
“Mildly elevated.”
“And his uric acid to creatinine ratio?”
The intern looks at the chart. “Uh, 0.83.”
“What is the reference range of that ratio for hyperuricemia secondary to renal insufficiency?”
There is a long silence, and finally Ella looks at the chief resident expectantly.
“A ratio of less than 0.7 would indicate underexcretion, Dr. Morgen,” supplies Reed. “Something as high as 0.83 suggests overproduction.”
Ella gives Reed a satisfied nod and returns her attention to the intern. “And hyperuricemia by overproduction and hyperkalemia usually means what in a cancer patient?”
Wilson can almost see the light bulb go on over the intern’s head.
“Possible tumor lysis syndrome.”
“Yes.” Ella turns grave eyes to Wilson. “His platelet count is good, BUN and creatinine are barely above normal; this isn’t the DIC.”
Wilson blows out a long breath. “I didn’t think it was, but I wanted the hematology consult to be sure. Dr. Reed, nephrology has already been paged for the dialysis. Finish your rounds, then come present your plan for monitoring and treatment.”
He parts ways with Ella outside the PICU, taking the stairs and making his way to the Diagnostic Medicine conference room. House has better coffee - and better distractions - than the oncology lounge. But the room is empty when he arrives, and the whiteboard bears a laundry list of symptoms. House and his team must have gotten a good case this morning.
Okay, so no distraction, but he might as well enjoy the Sulawesi. He pours himself a mug of the dark, rich coffee and crosses to House’s office, dropping into the big yellow chair with a sigh. He closes his eyes and lets his head drop back against the cushion. It smells faintly like its usual occupant, a warm and familiar scent.
Tumor lysis is not good news, and Wilson knows he’ll spend the day dreading a 911 page to the PICU. The problem is, ironically, the result of the chemotherapy’s success. Chemo kills the lymphoma, and dying tumor cells slough off into the bloodstream, shedding their toxic contents faster than the body can filter and excrete them. With any luck, the prophylactic measures they’ve taken will head off serious complications, and Seth will be able to weather it out.
He tries not to think of how little luck Seth has enjoyed in the last few months.
Eight hours later, he can think of nothing else.
Wilson stands at the foot of Seth’s bed, watching the pediatric intensivist replace the defibrillator paddles in their cradle. Seth’s mother is just outside, wailing a denial of the words Wilson is about to say.
“Time of death, 15:49.”
The tumor lysis had lain quiet most of the day, until some unknowable balance was upset and the toxins had come pouring into Seth’s system, spiking his phosphorus, uric acid, and potassium levels. The potassium was the most critical; hyperkalemia had induced cardiac arrest. The intensivist had brought him back once, and briefly controlled the arrhythmia with drugs, but hadn’t been able to keep ahead of the multi-system organ failure.
He feels drained, as if his body has suddenly recalled all the fitful, restless nights of the last weeks.
In the hall, he pauses to put a hand on Mrs. Greer’s shoulder. “I’m sorry,” he murmurs, knowing she doesn’t really hear.
He takes a deep breath and exhales slowly. It is all the grief he has time for; another patient is waiting.
----------------------------------------
Ella finds him in his office.
He sits on the couch, head bowed, elbows resting on his knees. The last honeyed rays of the setting sun cast an incongruously lovely glow over his hunched form. She lets the door come to rest on her shoulder as she pauses on the threshold. “James.”
He doesn’t look up. “He was eight years old.” Heartbreak is in his voice.
The door drifts shut behind her. She walks slowly into the office, tucking her hands into the pockets of her lab coat. “He was unlucky.”
James lifts his face to her, his usually boyish features engraved with lines. “Do you ever wish you’d picked a different specialty?”
“One that doesn’t hurt so much?” She is silent for a moment, considering the question, then shakes her head with a wry grimace. “No. Not really. And neither do you. We’re good at what we do, James. And the unlucky ones would still be dying even if you and I were in practice together as podiatrists.”
His lips turn up slightly at the corners, but it couldn’t really be called a smile. In a frustrated gesture she has seen a thousand times, his hand comes up to pinch the bridge of his nose as he draws and releases a deep breath. “Yeah.” The hand falls to his lap, and he watches as she moves to sit on his right, a careful space between her leg and his.
She looks at him, and doesn’t say anything. She doesn’t have to, knowing he’ll see in her eyes the weight of her own cloak of ghosts. He nods slightly, then lets his head drop again.
They sit wordlessly in the gathering darkness. After a time, her left hand moves to cover his right, cool fingers settling gently over his warmer ones. He sighs as if a burden has been lifted, and does not look up.
----------------------------------------
House makes his way to Wilson’s office, cane tapping a staccato rhythm. He heard about the cancer kid’s death, and knows his friend will take this one hard. Even the most toughened doctor’s heart breaks just a little when a child dies under his care. House pauses when he sees someone already in the office with Wilson, stops altogether when he sees who it is. Ella Morgen is sitting next to Wilson on the couch. They aren’t speaking, but… Wilson is holding her hand?
House’s eyes narrow, and his mouth tightens fractionally. He watches them a few moments more, then moves on, cane tapping just a little harder as he limps to his own office.
Chapter 8
“I got plenty o’nuthin, nuthin’s plenty for me.”
Mel Torme’s baritone is like really, really good whiskey, dark and velvety and intoxicating.
“I got no car, got no mule, I got no misery.”
House is lying on the floor, feet propped on his chair. It is the oddest of his usual positions for relaxation, and one of his favorites. Not only is he mostly hidden behind his desk - a casual glance by someone looking to give him work to do would reveal only an empty office - but the position eases the muscles of his thigh, hip, and back.
The weather has turned cold, and the arrival of winter always means a few weeks of intractable, bone-deep ache in his leg, until the maimed nerves and muscles adjust to the season. More pain in his leg means he compensates by abusing the rest of his body, limping harder and relying more on the cane. By late afternoon everything hurts, more or less, and he takes any respite he can find. With his feet up and back flat, shutting out the world with closed eyes and rich music in his earphones, he is almost comfortable.
The iPod brings up Ain’t Misbehavin’ next. This is Satchmo’s version, the muted trumpet flirting with the piano and giving the lie to the title - there’s no way those saucy riffs aren’t hinting at all sorts of entertaining misbehaviors. House smiles to himself. Even trumpets, it seems, are not exempt from the rule that everybody lies.
His smile fades as he remembers his rather unsatisfying conversation that morning with Ella Morgen. She may not have lied, but she is very good at deflecting conversation away from truths she doesn’t want to discuss - almost as good as he is, in fact.
He still hasn’t parsed her relationship with Wilson, but he doesn’t like the pattern. Wilson has been spending too much time at the hospital for a man who is trying to save his marriage, and too much time in Morgen’s company. Solve for M, he reminds himself. He needs more data.
House turns his head to glance out the window. The angle of the light suggests sunset is not far off. About four-thirty then. She is probably in her office.
With a sigh, he lifts his crossed legs off the chair, letting his left leg do the work of carrying the right leg to the floor. This is the major drawback to relaxing in this position: it’s hard to get up. Rolling into a kneel, he touches the desk for balance and pushes himself up, left leg taking his weight. The maneuver has the smoothness of long practice; a casual observer would probably never guess at the careful choreography required for such an ordinary thing.
He grabs his cane and limps into the hall. Not only will needling Morgen give him more information to work with, it will also provide an entertaining distraction to occupy him until he can take another Vicodin.
Her office is lamp-lit, with a warm and welcoming atmosphere designed to put nervous patients at ease. It looks nothing at all like his own office.
House leans in the open doorway, watching her work. She is reviewing patient charts, meticulously making notes in each. Also nothing like his office.
“So why does a fourth-year medical student up and murder her husband?”
She freezes for the barest instant, then continues writing in the chart before her. A less careful observer would have missed the pause, but not House. He knows he’s gotten to her, however skilled she may be at covering it.
Without looking at him, she replies, “You’re the diagnostic mind of a generation, Dr. House. You tell me.”
“Okay.” He pushes off from the doorframe and moves to a chair across the desk from her. He sprawls casually in it, exuding lazy confidence.
“I think he hit you. A lot.”
Her pen scratches steadily across the page. She doesn’t so much as glance up, but her silence is an affirmation.
“Lots of battered wives want to kill their husbands, I’m sure, but surprisingly few of them actually do. Mostly they just leave.” He lets the comment hang there, knowing she’ll understand it for the question - almost an accusation - that it is.
House watches the top of her bent head, his right hand rocking the cane back and forth. Sooner or later she’ll respond. He can wait.
At last Morgen closes the chart and meets his eyes, folding her hands on the blotter. “Did you know that eighty-five percent of the women who die at the hands of an abusive partner are killed after they leave him?”
The cane stills. After a long moment he looks down, ducking his head in something that is almost half a nod. That is a fair - and rather tragic - point, one he bets most counselors at battered women’s shelters don’t mention to their clients. He wonders if more of those clients would kill their husbands if they knew that statistic.
His eyes flick up to meet hers again. “But you didn’t call the police, didn’t file assault charges.”
A bitter laugh escapes her. “He was the police. He’d stop home mid-shift for a quickie and -” She bites off whatever she’d been about to say. With a deep exhalation, she shifts uncomfortably in her chair and looks down at her hands. “I should have. I figured out later I could have gone to his squad, showed them the bruises. They would have helped.”
Her lips twist as she meets his gaze. “But I was young, I’d seen one too many movies about the silence of the thin blue line.”
So she’d decided to kill him.
It must have felt too dangerous to stay, even more dangerous to leave, the police potential enemies as much as potential rescuers. She had done the math.
Morgen is watching him steadily, no trace of nervousness in her posture now. “What do you want, House?”
The cane resumes its rocking.
“You were never arrested.” Probably the police had waited for the district attorney to weigh in; they wouldn’t have wanted to arrest a cop’s wife, even with his blood literally on her hands.
The corners of her mouth twitch, but her eyes never leave him. “He’d beaten me bloody.”
House admires the cold logic of it, even as he’s faintly appalled. She had let him beat her, maybe even provoked him, then killed him. The D.A. had likely taken one look at the marks on her and called it self-defense.
He wonders if Wilson knows how calculated her decision had been.
“What do you want?” she repeats.
He had guessed right about her husband, she’d even confirmed his suspicion that the death had been premeditated.
Wilson is a real bastard in some ways - as all of his wives could attest - but he is also charmingly idealistic. Had the same naïve optimism that had taken Wilson to the chupah three times in fifteen years let him accept the self-defense story at face value?
“So it’s what, some kind of misguided penance that you never remarried? A lifetime of self-denial to make up for the sin of killing a brutal son of a bitch who deserved what he got? Or maybe it’s just cowardice. Once bitten, blah blah blah.”
Her face is very still, but the whitened knuckles of her folded hands give her anger away. “Oh, please. Let’s not pretend you’re actually interested in my love life, Dr. House. You just want to know why I haven’t fucked James. Look, word around the hospital is that you’re a first class misanthrope, so I understand this may be a foreign concept: James and I are friends. Why the hell that bothers you so much, I don’t know, but for his sake I wish you’d get over it.”
House opens his mouth to respond, but she runs right over him, leaning forward with an oddly intent expression. “Do you really think so little of James that you can’t imagine a woman would be interested in him for anything else?”
Morgen is an anomaly, an aberrant datum on the scatterplot of Wilson’s life. She breaks the pattern of his relationships with women.
House knows she had been a hematology fellow at Hopkins when Wilson was an intern, that they had worked a few cases together on his oncology rotation. The grapevine says she is a gifted teacher; maybe Wilson had developed a touch of hero-worship. Certainly House has watched more than one young doctor get revoltingly starry-eyed over Wilson, and there is a certain amusement in picturing the confident oncologist in the role of awestruck mentee. But hero-worship wears off. In the dozen or so years since their time together at Hopkins, the two of them have obviously stayed in touch, have stayed close enough to fall easily into a comfortable rapport.
“I think that says more about my opinion of women,” he counters.
“Or maybe,” she continues, as if he hadn’t spoken. “Maybe it’s more that you don’t think enough of James to imagine that he would be interested in a woman for anything else.”
Her eyes narrow, and House suddenly recognizes that intent expression. It’s the same one he gets when he’s certain he has figured something out.
“Or does it just piss you off that he’s having lunch with me, instead of you?”
He stands abruptly. “Save your breath,” he says in a voice dripping with scorn. “I’m not interested in your pearls of pop-psychology wisdom. I certainly couldn’t care less about your love life, I’m just fascinated by the novelty of having a murderess on grand rounds.”
The barb was meant to sting, but Morgen looks suddenly relaxed, a tiny smile playing at the corners of her mouth.
“Good night, Dr. House,” she says, and opens another patient chart.
He watches her work for a moment, then turns with a wry smile to leave.
----------------------------------------
The early morning oncology rounds find Wilson facing Ella across the bed of an increasingly ill Seth Greer, fresh labs in hand. The chief resident, leading her gaggle of young doctors, raises her eyebrows in surprise to find two attendings - including her department head - already in the room.
“Dr. Wilson, Dr. Morgen, I’m sorry for interrupting. We can come back, if…”
Wilson waves off her apology. “Go ahead, Dr. Reed.”
She nods, and turns expectantly to the intern assigned to the case.
“Seth Greer, age eight,” the young man begins. “Entered a clinical trial of chemotherapy eight days ago to treat recurrent small noncleaved cell lymphoma. He was moved to the PICU two days ago for close monitoring when he contracted a cephalosporin-resistant staph infection. He responded well to vancomycin, but developed DIC with apparently localized renal microvascular thrombosis. After administration of heparin, his platelet count rebounded and renal function showed some improvement, and he received the second round of chemo yesterday, on schedule.”
Wilson notes with approval that if the intern is nervous at presenting directly to the Head of Oncology, he doesn’t show it. “How are his morning labs?”
“Not great,” the intern admits. “Platelets look fine, but his potassium and uric acid are both somewhat elevated. His kidneys are still having trouble, and the ECG shows mildly peaked T-waves from the hyperkalemia.”
“Your assessment?”
“The chemotherapy and vancomycin have seriously challenged his kidneys, which were compromised by the DIC. I think he’s got renal insufficiency.”
“What’s your plan?”
“Allopurinol to help his kidneys out, continue pushing fluids, and monitor closely. If his renal function doesn’t improve in the next four hours, call nephrology to request dialysis.”
Wilson nods. It isn’t a bad plan, but he thinks the inexperienced doctor has allowed himself to get too focused on the DIC and forget about other potential complications.
“Dr. Morgen, do you concur?”
Ella doesn’t respond directly, but turns to the intern. “Why is his uric acid high?”
The intern swallows. Wilson can see in his face that he understands he has missed something but hasn’t figured out yet where Ella is going.
“The renal insufficiency means his kidneys aren’t excreting it fast enough.”
Ella lifts one eyebrow. “Where are his BUN and creatinine?”
“Mildly elevated.”
“And his uric acid to creatinine ratio?”
The intern looks at the chart. “Uh, 0.83.”
“What is the reference range of that ratio for hyperuricemia secondary to renal insufficiency?”
There is a long silence, and finally Ella looks at the chief resident expectantly.
“A ratio of less than 0.7 would indicate underexcretion, Dr. Morgen,” supplies Reed. “Something as high as 0.83 suggests overproduction.”
Ella gives Reed a satisfied nod and returns her attention to the intern. “And hyperuricemia by overproduction and hyperkalemia usually means what in a cancer patient?”
Wilson can almost see the light bulb go on over the intern’s head.
“Possible tumor lysis syndrome.”
“Yes.” Ella turns grave eyes to Wilson. “His platelet count is good, BUN and creatinine are barely above normal; this isn’t the DIC.”
Wilson blows out a long breath. “I didn’t think it was, but I wanted the hematology consult to be sure. Dr. Reed, nephrology has already been paged for the dialysis. Finish your rounds, then come present your plan for monitoring and treatment.”
He parts ways with Ella outside the PICU, taking the stairs and making his way to the Diagnostic Medicine conference room. House has better coffee - and better distractions - than the oncology lounge. But the room is empty when he arrives, and the whiteboard bears a laundry list of symptoms. House and his team must have gotten a good case this morning.
Okay, so no distraction, but he might as well enjoy the Sulawesi. He pours himself a mug of the dark, rich coffee and crosses to House’s office, dropping into the big yellow chair with a sigh. He closes his eyes and lets his head drop back against the cushion. It smells faintly like its usual occupant, a warm and familiar scent.
Tumor lysis is not good news, and Wilson knows he’ll spend the day dreading a 911 page to the PICU. The problem is, ironically, the result of the chemotherapy’s success. Chemo kills the lymphoma, and dying tumor cells slough off into the bloodstream, shedding their toxic contents faster than the body can filter and excrete them. With any luck, the prophylactic measures they’ve taken will head off serious complications, and Seth will be able to weather it out.
He tries not to think of how little luck Seth has enjoyed in the last few months.
Eight hours later, he can think of nothing else.
Wilson stands at the foot of Seth’s bed, watching the pediatric intensivist replace the defibrillator paddles in their cradle. Seth’s mother is just outside, wailing a denial of the words Wilson is about to say.
“Time of death, 15:49.”
The tumor lysis had lain quiet most of the day, until some unknowable balance was upset and the toxins had come pouring into Seth’s system, spiking his phosphorus, uric acid, and potassium levels. The potassium was the most critical; hyperkalemia had induced cardiac arrest. The intensivist had brought him back once, and briefly controlled the arrhythmia with drugs, but hadn’t been able to keep ahead of the multi-system organ failure.
He feels drained, as if his body has suddenly recalled all the fitful, restless nights of the last weeks.
In the hall, he pauses to put a hand on Mrs. Greer’s shoulder. “I’m sorry,” he murmurs, knowing she doesn’t really hear.
He takes a deep breath and exhales slowly. It is all the grief he has time for; another patient is waiting.
----------------------------------------
Ella finds him in his office.
He sits on the couch, head bowed, elbows resting on his knees. The last honeyed rays of the setting sun cast an incongruously lovely glow over his hunched form. She lets the door come to rest on her shoulder as she pauses on the threshold. “James.”
He doesn’t look up. “He was eight years old.” Heartbreak is in his voice.
The door drifts shut behind her. She walks slowly into the office, tucking her hands into the pockets of her lab coat. “He was unlucky.”
James lifts his face to her, his usually boyish features engraved with lines. “Do you ever wish you’d picked a different specialty?”
“One that doesn’t hurt so much?” She is silent for a moment, considering the question, then shakes her head with a wry grimace. “No. Not really. And neither do you. We’re good at what we do, James. And the unlucky ones would still be dying even if you and I were in practice together as podiatrists.”
His lips turn up slightly at the corners, but it couldn’t really be called a smile. In a frustrated gesture she has seen a thousand times, his hand comes up to pinch the bridge of his nose as he draws and releases a deep breath. “Yeah.” The hand falls to his lap, and he watches as she moves to sit on his right, a careful space between her leg and his.
She looks at him, and doesn’t say anything. She doesn’t have to, knowing he’ll see in her eyes the weight of her own cloak of ghosts. He nods slightly, then lets his head drop again.
They sit wordlessly in the gathering darkness. After a time, her left hand moves to cover his right, cool fingers settling gently over his warmer ones. He sighs as if a burden has been lifted, and does not look up.
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House makes his way to Wilson’s office, cane tapping a staccato rhythm. He heard about the cancer kid’s death, and knows his friend will take this one hard. Even the most toughened doctor’s heart breaks just a little when a child dies under his care. House pauses when he sees someone already in the office with Wilson, stops altogether when he sees who it is. Ella Morgen is sitting next to Wilson on the couch. They aren’t speaking, but… Wilson is holding her hand?
House’s eyes narrow, and his mouth tightens fractionally. He watches them a few moments more, then moves on, cane tapping just a little harder as he limps to his own office.
Chapter 8