The following is the first of a collection of short stories that are like “Final Destination” meets “The Monkey’s Paw” (W. W. Jacobs, 1902). As such, they are tragedies more than either mysteries or horror, and would appeal most to readers who enjoy the inexorable pull of a story arc that leads to doom. In each story, a protagonist makes a wish that comes true with fatal results for someone, often the person making the wish. Nothing supernatural, but just how things work out. (Or is it?) The technical details surrounding the fatal (or near fatal) event are drawn from real cases in the US OSHA incident report database and are therefore entirely realistic even if seemingly outlandish. The plots draw lightly from cultural beliefs around actions such as pointing at someone with a stick or knife, wishing in front of a mirror, or stepping on a crack.

Ruth is a nurse and for years has dealt with the results of Edwin beating his wife, but now that Edwin is her patient,
will she use her skills to take, rather than save his life?

Ruth stood at the edge of the weathered concrete path; sharp gusts of cold Atlantic air toyed with her chestnut ponytail. She spread her hands on the rusted metal guard rail and closed her eyes. It was done, and he was dead.

Ruth probed her own emotions. Did she feel guilty? Elation? No, she thought, this was sadness and satisfaction. The cards would play out as they may, and time would tell if she would be discovered as a murderer.

Edwin had been in a car accident and admitted to a ward that Ruth served as a floating nurse. He was also well known as a wife beater, and every nurse on the floor had at some point worked on Amy. A broken arm here, a split lip there, and a long miserable inventory of cuts, scrapes, and bruises.

Initially, these events were reported and followed up, and then after years of Amy refusing to press charges, further incidents were just flagged in the system. Ruth and other nurses had begged Amy to file a report and press charges, but Amy gave them a humorless smile and explained that reporting Edwin would result in an ineffectual police response and almost certainly get her murdered.

This time, both Amy and Edwin were in the hospital. They had gone out to dinner that night. It wasn’t anything too fancy, but Edwin was apologizing for hitting her the day before. It had been a fight over food, and Edwin had accused her of trying to poison him. It started with Amy running out of canola oil and using extra virgin olive oil instead. Edwin reacted with suspicion to the slightly bitter taste. “I’m going to die with poison in my veins, right?” Amy tried to wisecrack her way out of the tension by saying “Yes, I see it in a vision: death by poison,” and Edwin had backhanded her. When all was explained, he was grudgingly apologetic and suggested dinner out.

Dinner went fine, and Edwin hadn’t even commented on the price or the slow service, but he had a few beers too many to drive home. Her driving irritated him though. He thought she was too hesitant, too slow, and she took a stupid route. At one point, he had yelled at her, and it seemed like he was going to backhand her again. She flinched and took her hands off the wheel. The car drifted to the left, and he grabbed the wheel, and yanked it. She had also grabbed and yanked, and between the two of them, they completely overcorrected. The car spun out, and hit a barrier solidly on the passenger side.

Ruth was primarily a phlebotomist and drew blood and other samples across the entire hospital wing, but she was also their quality and safety lead. Ruth routinely investigated medical accidents and errors as a daily focus. The worst were accidents leading to patient death, wrong site or wrong patient surgery, and hospital-acquired serious infection. Thankfully, these were rare, and Ruth only investigated one every few months. What she saw every week, though, were the medication errors. Almost daily, she saw errors related to wrong dose, incompatible combinations, and drug allergies, but most were caught in time or had minimal effects.

As one of the key people involved with investigating accidents and errors, Ruth knew that many drugs were easily confused. Some came in bottles or ampules of similar size, shape, color, or labels but had wildly different potency or effects. A consistent risk on all the floors was getting medications mixed up, and just a week before, a patient received saline instead of insulin. The mistake was caught quickly, but this kind of mistake could be fatal, and sometimes was.

Seeing Edwin that Friday night, in her hospital, in this ward, in one of these beds, set off a train of thought. It felt necessary, obligatory, almost natural, that she should make sure that he never left. Ruth set in motion a plan that fitted her skills and experience. She saw it like one of the process flow diagrams she drew almost every day, and it started with an act and ended with Edwin’s death.

On a visit to the hospital pharmacy, Ruth palmed a bag of intravenous colchicine, a discontinued drug known for incidents of accidental overdose. She later dropped it into one of the plastic bins in Edwin’s medication cart. Because the bin was replenished daily, and four bags from that tray were used on Edwin each day, Ruth figured the colchicine bag stood about a one in eight chance of being selected each time, but the cumulative odds over his full expected length of stay were around 93%. Not absolute, but the odds satisfied Ruth’s sense of justice.

On the third day and the third drug round that took place deep into the night shift, Becky, one of the night nurses, connected up the colchicine. Mistaking it for one of the piggyback drips, Becky hung the bag, connected the tubes, and set the thumb valve wide open.

It may be worth noting, in a sense of irony, that had Becky followed the checklist that Ruth had presented 3 months earlier, she would have noticed that the new bag didn’t match the old bag or the drug order list. The checklist was specifically designed to eliminate exactly this kind of mistake. Ruth had demonstrated the procedure–check each drug against the patient record, then for IV drugs, visually compare the old bag with the new. In the demonstration, Ruth held up two bags and called out a difference. Everything was similar, but the names and a single thin blue bar. “That,” she emphasized, “is the difference between cure and catastrophe.”

She did everything else perfectly, but by this point in the shift, Becky was tired, she was hungry, she was thirsty, she was rushed, and she needed the toilet. She simply didn’t remember to stop and cross-check bags.

By the mid-morning rounds, Becky was home and asleep, the empty colchicine bag was replaced by the morning shift, and Edwin was in poor shape. He had started with waves of nausea, shortly followed by vomiting. In the context that he had been in a car accident, the symptoms were interpreted as possibly relating to internal bleeding.

It may again be worth reflecting that had the morning shift used Ruth’s checklist, Edwin might have been in a good place. But as usual, they were short-staffed and there were just too many tasks, too little time, too few nurses. Mike had not compared the new bag to the old, and Edwin’s situation was therefore not discovered. Mike had attended Ruth’s presentation, but right now, he was rushed, a patient had thrown their breakfast at him, and he desperately needed to pee.

Edwin was rushed down for an MRI to identify where the bleed might be. He would under other circumstances have had stomach pain but was already on painkillers. While he was in the MRI, he copiously shat himself. At this point, Edwin was diverted to the emergency department, because as he was being pulled from the bespattered MRI, he went into convulsions.

The ED followed its own efficient logic, and their testing and evaluations soon ruled out internal hemorrhage. The clinical picture included dangerously low platelet and white blood cell counts, and simultaneous low red blood count and very odd heart rhythms. His kidneys were shutting down, his liver was showing signs of stress, and his breathing had become erratic.

“This looks a lot more like toxicity than trauma,” Dr. Choo, the ED director, mused. “Do another blood draw, and take urine and stool, and look for poisons.” She turned on her heel and marched on to the next patient, one whose symptoms clearly reflected their gunshot wounds. On her way back, she had another thought. “His facial injuries from the initial accident are re-bleeding; double-check for toxins that interfere with clotting factor.”

By afternoon, Edwin was in the ICU, intubated and mostly comatose. His body was not making new red cells, and the only reason he wasn’t constantly vomiting was the potent drugs designed to stop that. By midnight, his seizures were uncontrollable though, and then he had a massive and irreversible heart attack.

Ruth followed her own protocol and initiated an audit that turned up the empty colchicine bag. This didn’t prove that it was the cause, but the facts matched closely enough to make a finding and roughly sketch the likely events.

A follow-up review panel ruled the death due to medical mistake, and they accepted Ruth’s recommendations, including a mandate for the use of her checklist and the adoption of a barcode system for drug administration.

The gusting wind was cold on Ruth’s face and matched her mood. She stared out over the ocean and let out a long sigh. She had always seen herself as a sort of angel of mercy, a protector of life, but she was slowly coming to terms with the fact that she was also an angel of death, a taker of life. Ruth turned slowly and followed the grey concrete path back to her car, and her next shift.