Chapter 8: Contraindications

Kenji Sato had written insomnia under REASON FOR VISIT in elegant, slanting handwriting. Under CURRENT PAIN, he had checked none.

His right hand remained curled beneath his left elbow.

Evan tapped the empty medication box. "Three hours of sleep last night. Four the night before. What aren't you telling us?"

"That's an improving trend."

Across the intake table, Su studied the arm he was hiding. "Your wrist is inflamed."

Kenji freed it with a sigh. "My wrist is employed."

Every folding chair in the rear clinic was occupied. Lan Pham waited near the privacy screen, her alterations bag between her shoes. Leon had given his rain shell a chair of its own because, according to him, coat hooks were where good clothes went to surrender.

Evan pulled his chair closer. "What happened?"

"Onion cases Sunday. Then prep. Then service. Nothing dramatic."

"Any cut or puncture? I'm asking because infection changes what we do."

"No."

The wrist was warm and faintly swollen along the flexor side. Kenji could close two fingers without trouble. The others followed late.

Su held out her hand. "May I?"

Kenji laid his wrist across her palm.

Her fingertips rested above his pulse. "The irritation extends into the forearm. The joint is not involved, and there is no infection."

Evan checked sensation, circulation, and movement. The tendons complained. The joint itself worked.

"What does your chef have you doing this week?" he asked.

"Everything. Then the festival zongzi line starts. Hundreds of little leaf-wrapped reasons I can't call out."

"Can you get lighter duty?"

"Sure. I can also grow another hand during family meal."

Su crossed to the medicine counter. She set out sliced root and a jar labeled WHITE WILLOW.

Evan looked again at the blank medication box. "What are you taking?"

"Nothing interesting."

"Prescription drugs. Over the counter. Supplements. Anything borrowed from a coworker."

Kenji examined the ceiling.

Su stopped with the willow jar in her hand.

"I went to urgent care yesterday," Kenji said. "They gave me naproxen. Five hundred twice a day."

"Taken with what?"

"Coffee."

"Coffee is not food."

"It had milk."

Evan held out his hand. Kenji produced the orange bottle from his jacket.

The label confirmed five hundred milligrams twice daily with food. Evan asked about the last dose, water intake, stomach pain, vomiting, dark stool, and dizziness. The answers were noon, almost none, and no to the rest.

Evan took the willow jar from beside Su's hand. "This can't go in."

"The quantity is small," she said.

"It still adds a salicylate to an anti-inflammatory. He's taking naproxen on an empty stomach after a hot shift with almost no water."

Kenji frowned. "I'm thirty."

"Your kidneys have read your birth certificate. They're unimpressed."

Kenji looked down at the bottle.

Su held out her palm. Evan returned the jar. She placed it in the drawer, removed two packets from the tray, and returned those as well.

"You said you could reduce the inflammation," Kenji said.

"I can also worsen a risk I did not ask about."

She said it to Kenji without defending herself to Evan.

Su brought out a folded linen wrap. She explained that the remaining preparation could ease surface pain but would not repair the tendon. Evan fitted a brace over the wrap and loosened it until Kenji could move his fingers without numbness.

"Brace during work," Evan said. "Off for bathing and sleep. Actual food with the naproxen. Water before your shift and during it."

"My chef will put me on the zongzi line anyway."

"I'll write no repetitive gripping or heavy lifting for forty-eight hours."

"He'll read that as garnish."

"I'll use smaller words."

Kenji tucked the note into his jacket.

"Return Thursday," Su said.

"I work Thursday."

"Then you have identified the conflict."

He looked from her to Evan. "Do either of you have patients who obey?"

Leon called from his chair, "They have me, baby. Adjust your expectations."

Kenji left with the brace visible beneath his sleeve and no promise about Thursday.

The front clock showed nine twelve. Evan stripped the used paper from the table while Su reset the cups at right angles. For the next patient, she asked about medication before opening a drawer.

At nine twenty, the front door struck the stopper hard enough to shake the glass.

A man in a work jacket caught himself against the frame. Sweat shone across his forehead despite the cold rain. His right hand was wrapped in a dish towel gone brown at the center.

Evan knew him from Harborview. Mr. Carver had left the emergency department six weeks ago with stitches, antibiotics, and instructions he had not been able to afford twice.

"I need the lady," Carver said.

"You need to sit." Evan took his left arm. "What happened to the hand?"

"Cut it Thursday. Sheet metal. I cleaned it."

The towel came away reluctantly.

A laceration crossed the heel of his hand. Its edges had swollen apart. Redness filled the palm and sent a bright streak along the inside of his forearm, past the elbow.

Su came beside Evan. Her face had emptied of everything but attention.

"When did the streak reach your elbow?" Evan asked.

"Wasn't there this morning."

"Any shaking chills? I'm checking how far this has spread."

"Cold all day."

Carver tried to pull his hand back. Evan kept his grip light and let him.

"I went to Harborview last time," Carver said. "They billed me four thousand."

His pulse ran fast beneath Evan's fingers. Too fast.

Su breathed in near the injured arm. Her hand rose a few inches, then stopped.

"What do you find?" Evan asked.

"The infection has passed beyond the wound and the vessels nearest it." She addressed Carver. "This one is inside the blood."

Carver held the ruined towel against his palm. "Can you draw it out?"

Su's fingers closed.

Evan had seen her take Lan's pain in a dark room, and watched her limp afterward. The answer mattered before the method did.

Su lowered her hand. "I cannot lift this."

Carver stared at her. "You helped my back in January."

"This is not pain alone. Taking what I could reach would conceal how ill you are and leave the infection moving."

Evan crouched in front of him. "The red streak is lymphangitis. Your pulse is fast, and you're sweating. You need the ED now."

"I can't be four thousand dollars sick."

A horn sounded once in the alley.

Reina Morales appeared through the rear door two minutes early, keys bouncing from the blue coil at her waist. Her dark jacket carried reflective strips across the shoulders. Silver hoops flashed when she turned toward Carver.

She took in the towel, the streak, and Evan's face.

"How fast?"

"Now," Evan said.

Reina unclipped the keys. "I'm off the clock. Mr. Jackson, behind the driver. Mr. Carver, back bench. Ms. Pham, bring your bag. Copy?"

"Copy," Leon said, already reaching for his rain shell.

Lan stood with her alterations bag in one hand. "He sits first."

Carver shook his head. "I'm not paying for an ambulance and the hospital."

"No ambulance," Reina said. "My van, my fuel. Hold on."

Evan met Su's eyes. They had nearly harmed Kenji by offering separate answers in the wrong order. Carver needed both answers before fear chose for him.

He turned back to the chair. "Su says she can't remove this safely. I think you need IV antibiotics and blood work tonight. That's both assessments."

Carver pressed the towel harder against his palm.

"We haven't offered the plan yet," Su said.

Evan nodded. "Harborview now. I ride with you. I'll call ahead about charity care, and I stay until someone meets us at the door."

"You can't promise the bill."

"No. I can promise you won't walk in alone."

Carver looked at Su. "You sure you can't do anything?"

Her right palm settled flat on the counter. The wood gave a small creak beneath it.

"I am sure."

Carver rose.

Reina pointed once toward the alley. "Mr. Jackson, behind the driver. Mr. Carver, back bench. Ms. Pham, front right. Move."

Nobody argued with dispatch.

Evan called Marisol before he reached the van.

She answered over an alarm and two competing voices. "Xu."

"I've got a hand infection, streaking past the elbow, diaphoretic, tachy by palpation. He's refusing because of a prior four-thousand-dollar bill."

"Is he coming?"

"Reina has him in the van."

"Good. Choice first. Then improve the choice."

"I need a charity-care application and a social worker at the door."

A pause. Paper snapped near her phone.

"You need a miracle and parking. I can get one of those."

"Marisol."

"I heard you. West entrance. Ten minutes."

Reina pulled into traffic. Rain tapped the roof and smeared the taillights ahead into red bars. Carver sat hunched over his hand while Evan kept the arm raised and watched the red line.

At Fourth, Reina slowed before the dip under the viaduct. Water shone across the lowest lane.

"Not tonight," she said, and turned uphill without asking permission from traffic.

Carver looked down at his hand. "I can leave if they quote me four thousand."

"You can," Evan said. "Let's get you through the door first."

"You work there?"

"Tonight I work here."

Reina glanced at him in the mirror. "Six minutes."

The streak had advanced the width of Evan's thumb by the time Harborview came into view.

Marisol stood beneath the west entrance awning in navy scrubs, a clipboard tucked against her chest. A woman with a hospital badge waited beside her holding a thin packet.

Carver saw both of them and leaned back.

"That's the social worker," Evan said. "No forms before treatment. She'll start the application while they check you."

"And you?"

"I'm coming inside."

Reina opened the door. "Nobody gets left at a curb. Copy?"

Carver looked at the hospital, then at his hand.

"Copy."

Evan walked beside him through the doors.

It was after eleven when Evan returned to White Pine.

Su had left the rear light on. Qing sat on the counter eating the last of his sesame crackers while Su stood over the clothbound formula book.

"If the clinic continues improving at this rate," Qing said, "I may need duties."

"You have duties."

"I prefer the ones involving commentary."

"Carver's admitted," Evan said. "Antibiotics started. Marisol says the hand team is looking at him tonight."

Su's pen rested above the page. "Did he complete the financial application?"

"Half. The social worker took it upstairs. I told him I'd help with the rest."

Three hours ago he had not owed that man an evening of paperwork.

Su wrote one line beneath Kenji's formula: WHITE WILLOW WITHDRAWN WHILE TAKING NAPROXEN.

Then she closed the book.

"Medication reconciliation," she said. "Before I prepare any internal remedy."

"Share both assessments before offering the patient a plan," Evan said.

"No card?"

"The card already has three lines."

"Then you will have to remember."

Qing ate another cracker. "A grave burden for a man who labels batteries by purchase date."

Evan packed the blood pressure cuff. Su wiped the counter where her palm had pressed. The varnish there had split in a pale crescent.

"You could've tried," he said.

She folded the cloth once. "Yes."

He waited.

"I would have made him appear better while the infection continued," she said. "He might then have refused the hospital with greater confidence."

"And it would've hurt you."

Su aligned the closed formula book with the counter's edge. "That was not the contraindication."

Evan did not ask what it would have cost. She had answered the question Carver needed, and stopped when she could not help safely.

He took his rain shell from the hook and left through the rear door.

At the mouth of the alley, a figure stood under the edge of the awning.

Plain coat. Narrow shoulders. Perfectly still.

Evan turned toward him.

A bus crossed King Street, filling the alley mouth with light and wet metal. Evan walked faster. The bus cleared.

The figure was gone.

Under the streetlight lay a clean rectangle of dry pavement where someone had stood for a long time.