“Someone get McKenna,” Megan shouted. “Drag him in here if you have to.”
“Right here.” Luke stepped up beside her.
Megan’s eyes showed a blend of puzzlement and irritation. “How long—”
“Let’s divide and conquer,” he said while stepping over to the surgical tray. “Go ahead and intubate the patient. I’ll put in the central line.”
Megan said, “I was about to—”
“You comfortable intubating the patient?” Luke asked. His gaze had settled on the instrument tray, but he could feel Megan’s stare.
After a moment, she said, “Yeah…sure.”
Luke quickly scrubbed the boy’s upper thigh, found the femoral vein, injected an anesthetic, made a quick stab, and inserted the line.
Megan said, “As soon as Dr. McKenna has that line secured, give the patient a normal saline bolus, as fast as it’ll run. Call out the blood pressure every minute until it’s back above ninety.”
Luke glanced at the boy’s face. He’d slipped into unconsciousness. They had no time to give the drugs normally used to sedate and anesthetize a patient undergoing intubation. He hoped Megan realized that.
Holding the laryngoscope in her left hand, Megan called out, “Ready.”
The therapist removed the Ambu bag from the patient’s face and stood back.
Megan inserted the laryngoscope into the boy’s mouth, taking a deep breath as she did so. “Hand me the tube.”
The therapist passed it to her, and Megan immediately slipped the endotracheal tube down the patient’s throat.
The respiratory therapist connected the Ambu bag to the end of the tube and began squeezing and releasing it with her left hand, her movements practiced and rhythmic.
Megan ran her stethoscope over both sides of the boy’s chest.
“Tube’s in position,” she said, exhaling heavily. “Let’s hyperventilate him for a few minutes.” Then she called out antibiotics to be given stat.
Susan glanced at Luke for confirmation of the antibiotics order, and he returned a subtle nod, which he hoped Megan didn’t notice.
Megan said to the X-ray technician, “We’re ready now.” She waved her arm in a circle as if directing the man through a busy intersection.
The tech sauntered over to the table with his film casings, displaying the same energy and enthusiasm as someone standing in line at the post office. He said, “By the way, folks, there was a beat-down slugfest at the other end of the hall. Some guy got into it with one of our docs. I heard maybe one of ’em’s dead.”
“No one’s dead,” Luke said. “Let’s focus on our work here.”
Megan glanced at him, or more specifically, the tear in his lapel.
• • •
Dr. Henry Barnesdale, chairman of University Children’s medical staff, sat at the antique burled-walnut desk that dominated one end of his cavernous office and stared at a list of E.R. patients on his computer screen.
Patient number 134—Josue Chaca—stared back at him.
“He’s in the E.R.,” Barnesdale said into the phone. “What do you want me to do?”
“Nothing,” the Zenavax CEO said.
“But—”
“I said leave it alone.” A heavy breath came through the phone. “But in the future, stay away from my test sites. It’s a big world out there. Your hospital can find another place to do its charity work.”
Barnesdale’s oblong shadow jiggered on the far wall of his office, swimming in a pale green halo of light seeping from the banker’s lamp on the credenza behind him. He was usually the one wielding the power, and didn’t like playing serf to this man. He couldn’t help it that the boy and his mother had marched fifty miles through mountainous terrain to reach the hospital’s clinic. But he wasn’t about to say that to the Zenavax CEO.
The man didn’t like hearing that he had no control over the Guatemalan clinic. For that matter, neither did Barnesdale, but he had no say in the matter. Caleb Fagan, the head of Immunology at University Children’s, had funded the clinic using outside donations since its inception five years ago. It was the only clinical budget item outside of Barnesdale’s reach.
The clinic seemed to be part of some mid-life crisis for Fagan, who had taken up the mantle of healthcare in developing countries with the same zeal that had propelled him to near celebrity status in the field of immunology. Despite his seeming conversion to humanitarian causes, Barnesdale didn’t trust the man’s motives. Caleb was a self-important jerk.
“We have another problem,” the CEO said. “It’s Tartaglia.”
The starch in Barnesdale’s shirt collar began to give way to the warm moisture forming on his neck. “Oh, Christ.”
“Tartaglia’s not giving up. It looks like she’s going to tell her fairy tale to people outside the company.”
“Is it a fairy tale?”
During the long silence that followed, Barnesdale felt as if someone had lit a road flare inside his stomach.
When the CEO finally spoke, his voice was like molten steel. “There’s nothing wrong with our vaccines. It concerns me, Henry, that you doubt me.”
Barnesdale pulled a handkerchief from his breast pocket and wiped his forehead.
“You see,” the executive continued, “in exactly two weeks, we cross the finish line. I’m not letting anything get in our way.”
Barnesdale wasted no time bringing the discussion back to Tartaglia. “How do you know that she’s talking to people?”
“Not people—person,” the man said. “I have someone monitoring the situation. Two hours ago she sent an e-mail from her home. There’s a photograph attached.”
“Who—Who did she send it to?”
“Someone at your hospital—Luke McKenna.” A pause, then, “Any relation to Elmer?”
“That’s Elmer’s son.”
“Why would Tartaglia send the information to him?” the CEO asked.
“Luke McKenna’s one of our E.R. doctors.” Barnesdale pulled up the staffing roster on his computer screen. “He’s working Trauma tonight, which means he’s probably downstairs with the kid right now.”
Another heavy breath came through the phone. “So, unless you believe in coincidences, Tartaglia knows about the boy. She knew he was coming to the hospital.”
“What are you going to do?”
“You mean, what are we going to do? We both have a problem here,” the CEO said. “And I think you know what needs to be done.”
The phone line went dead.
Barnesdale’s eyelids fell closed. What did I get myself into?
When Zenavax had approached him four years ago, he was in no position to turn down the company’s “business proposition.” Several years earlier, a drunk driver had decimated not only his wife’s brain, but also their meager savings. Once the cost of her skilled nursing facility care had reached the lifetime limits of their insurance plan, it wasn’t long before he spent through his financial reserves, and then the proceeds from a heavily leveraged second mortgage. When the Zenavax CEO had made his offer, Barnesdale was despondent and on the brink of bankruptcy.
And the bastard knew it.
Life being what it is, his wife had died just one month after he traded his integrity and self-respect for a hefty bribe. He hadn’t had a decent night’s sleep since.
The intercom on his desk sounded. “Dr. Barnesdale, I’m sorry to interrupt, but you’re needed on the phone.”
“Tell them I’m busy.”
“I already have, sir. It’s the emergency room and they say it can’t wait. One of our doctors just got into a scuffle with someone.”
• • •
“Blood pressure is coming back,” Susan announced. “Systolic is now eighty-eight.”
As in most battles, the momentum tends to work for you or against you, and the tone of the nurse’s voice told Luke that she too could feel the tide turning in their favor.
Megan pulled her mask off, wiped her face with a four-by-four gauze, then
shot a glance at Luke.
He gave her a nod.
She suppressed a small grin that looked as if it was fighting the urge to become a full-fledged smile.
Luke had never thought of Megan as classically beautiful—except, that is, when she smiled. Her agreeable face would suddenly become strikingly pretty. In the past three months she had rarely shown him anything but a resolute and dogged temperament. God, he missed her.
Megan said to the therapist, “Let’s get another blood gas.”
Luke sidled up to her. “So what do you think?” Seeing the question on Megan’s face, he elaborated. “We have a four-year-old boy, apparently breathing well a few hours ago, who suddenly decompensates. What are the most likely causes?”
“A chronic lung disease like cystic fibrosis might look like this, but not if he was breathing fine a few hours ago. It wouldn’t happen that fast.” She tapped the edge of the table a few times, staring at the boy. “Leukemia could explain this. It would set him up for sepsis, which in turn might lead to acute respiratory distress syndrome. That would explain most of his pulmonary and cardiovascular symptoms.”
“Am I hearing a ‘but’ somewhere in there?”
“Well, yeah.” Her eyes flitted toward his. “There’re a few things that just don’t make sense. Why don’t his lungs sound worse? And if this is all due to leukemia, why didn’t they find any blasts in his blood?”
Luke had the same questions.
“Anything else you’d do right now?” Megan asked.
“I’d add something to cover him for the possibility of a fungal infection. We have a patient we know very little about, from a place we know even less about.”
The respiratory therapist handed Megan the results of another blood gas.
“Blood pressure is dropping again,” Susan broke in, the pitch of her voice a notch higher.
Megan ordered another bolus of IV fluid while checking the blood gas. “He’s still not ventilating. He’s becoming more acidotic.” She passed the results to Luke.
He scanned the monitors. “Susan, give him twenty milliequivalents of bicarb.” He turned to Megan. “This patient needs to be on a ventilator. Call the ICU and tell them they need to take this patient now.” He pointed at a computer monitor across the room. “And pull up his X-rays.”
He looked back at Josue. The boy’s left arm hung limply over the side of the table, and his near lifeless form was quickly taking on a grayish hue. Only his chest was moving, rising and falling in rhythm with the respiratory therapist’s compressions.
Luke took the Ambu bag from the therapist, to feel for himself how much pressure was required to push oxygen into the boy’s lungs. The patient’s lungs were becoming stiff.
Megan, a phone cradled on her shoulder, was talking to someone in the ICU while working a computer keyboard to pull up the boy’s chest X-ray. A moment later, the black-and-white picture popped onto the screen.
Luke studied the X-ray for several seconds, leaning closer to see that the name in the corner of the screen matched the patient on the table. He looked back at the boy. His confusion swelled.
Megan still had the phone against her ear and didn’t look overly pleased to be playing the role of messenger.
Gesturing toward the computer screen, Luke said to her, “Take a look at his X-ray and tell me what you—”
The blare of an alarm interrupted him. All eyes turned toward the monitor.
“Patient’s in V-Tach,” Luke called out as he felt the boy’s neck for a pulse. “No pulse. Susan, charge the defibrillator to forty joules. Megan, start chest compressions!”
6
As the staff elevator rumbled toward the first floor, Henry Barnesdale replayed in his mind the breathless voice of the nursing supervisor who had called him from the E.R. From the sound of things, it seemed that McKenna’s altercation had nothing to do with Josue Chaca. His head shook at the irony of using the bizarre antics of his medical staff—my doctors are brawling with parents, for Christ’s sake—as a pretext for coming to the E.R. to probe his real crisis, the one disguised as a small boy.
Barnesdale choked back the acid taste in his throat. He didn’t believe the Zenavax CEO for a moment. He was certain that the vaccine had triggered the Chaca boy’s illness.
If the boy lived—if somehow, someone discovered the cause of his illness—fear and panic would quickly spread across four continents and the aftershocks would ripple for decades.
His shoulders shuddered. Whatever the problem was, he had to hope that Zenavax had already discovered the cause and corrected it.
When the elevator doors finally opened onto a first-floor corridor just outside the E.R., Barnesdale jinked back like a moth singed by flame. It was chaos. Foot traffic was at a standstill. A growing clot of people filled the hallway. Three security guards in ill-fitting blue uniforms, one on the near side and two on the far side of the crowd, had their arms extended outward, marking the perimeter of the group but accomplishing little else.
Barnesdale stepped out of the elevator and pushed his way through the maze of unkempt humanity that stood between him and the E.R. A mother pleaded with him in Spanish, holding up her sick child and gesturing toward the emergency room. He didn’t understand a word.
He was reminded why he hadn’t chosen emergency medicine. As a practicing surgeon for the first twenty years of his career, he was used to the order and precision of an operating room. It was more like a battlefield down here. Maybe that’s what happens—E.R. doctors start to think of themselves as combatants, and before you know it…
When he emerged on the other side of the crowd, he was just in time to see the ambulance attendants struggling to raise a gurney that was holding—My God!—some sort of man-mountain.
The behemoth’s shoulders spilled over the stretcher like a lava flow. He wasn’t moving. A woman stooping next to him had a badly bruised face and her left eye was swollen shut. A girl with a bandaged head—she was bug-eyed with fear and oddly quiet—was stuffed under the woman’s arm like a bag of dirty laundry.
Why hadn’t anyone mentioned the woman’s injuries? What the hell had McKenna done?
Just then, a squat woman with tired eyes—the hospital’s night nursing supervisor—marched up to him. Before she could speak, Barnesdale said, “Where’s McKenna?”
“He’s in Trauma One,” she said. “They just got Mr. Erickson onto a gurney. We were waiting for an ambulance. It arrived a few minutes ago. He’s being transported to—”
Barnesdale brushed past her in mid-sentence and started toward the Trauma Unit. When he turned the corner onto an adjoining hallway, he found Caleb Fagan fifteen feet ahead of him, passing through the doorway into Trauma One.
He was surprised to see the man who had just last week lunched with the U.S. Surgeon General slumming in their E.R. on a Friday night. It served him right. After all, it was Caleb’s volunteers who had arranged to transport the boy from Guatemala. The man had no inkling that his rat-hole clinic just triggered a cascade of events that had Barnesdale’s career—and life—teetering on a precipice.
He followed in Fagan’s wake. When he stepped through the doors into the trauma suite, a cacophony of alarms and high-pitched squeals hammered his ears. Monitors blared and metal wheels clanged as nurses slammed equipment into position. A respiratory therapist was shouting over the din.
In the eye of the storm, McKenna was standing over the Chaca boy, calling out orders in a clipped tone.
Crash.
An IV pole fell to the floor as a young doctor leapt onto the table and straddled the patient. Probably a resident, judging by her age and dress. And athletic, judging by her movements and taut figure. She started thrusting the heel of her hand into the boy’s chest, shouting the numbers one through five over and over again, in cadence with her compressions. Her voice cracked on the second “five,” jumping an octave.
One of the nurses screamed, “Defibrillator charged to forty.”
The resident jumped off the
table, grabbed the paddles, and placed them over bright orange conductive pads on the upper-right and lower-left corners of the boy’s chest.
She shouted, “Clear,” and sent a jolt of electricity through the boy.
Everyone turned to the monitors.
The female resident yelled, “Still in V-Tach,” and sprang onto the table in a motion as fast and graceful as a jaguar. She seemed possessed by an otherworldly force as she repeatedly drove her tightened fist into the boy’s chest.
One of the nurses was yanking syringes and drug vials from drawers in a red crash cart. Another nurse, with spiked orange hair and an idiotic nose ring, injected something into a central line, the next syringe held between his teeth.
Just then, McKenna’s glance swept past Barnesdale without acknowledgment and came to rest on Fagan. “Caleb, what do you know about this patient?”
“Less than you do, I’m afraid. The clinic called me, told me they were sending the boy up here. They said he was stable.”
Barnesdale glanced at the wall clock behind him. It was a large analog-type, like an old schoolhouse clock but with an extra hand—a red one used to measure the elapsed time in a resuscitation attempt. It was approaching the 3. Fifteen minutes had elapsed since the patient had coded.
When he turned back, Fagan was staring at him.
“Henry, what are you doing here?” Fagan said.
Barnesdale lifted his chin in McKenna’s direction. “Ask him. That mess in the hallway is his.”
Fagan’s eyes narrowed in a question, then anger. “Maybe you hadn’t noticed, but the boy on that table is fighting for his life. Whatever you’re here about, it can wait.”
Barnesdale stared at Josue Chaca, feigning an acquiescent expression.
A concealed wave of relief washed over him.
The boy was dying.
Barnesdale was already halfway to the door when the intercom unit sounded: “Dr. McKenna, I know you’re busy in there. I’m just letting you know that a Dr. Tartaglia has called twice since about five o’clock. Says it’s important and she needs to talk to you…”
• • •
Stigma Page 4