Heart Attack.
MI.
Like most people, Niles had always believed this sort of thing never happened to doctors, any more than right-thinking clergymen fried in hell. But here he was, propped up in bed in the Med Center Coronary Care Unit with his chest and legs shaved bald, a catheter draining his bladder and an I-MED pump squirting some very serious drugs into his bloodstream. Nasal prongs fed oxygen into his lungs and five sticky electrodes gave a running record of his heart’s activity.
He glanced at the monitor and a needling sweat broke out in his armpits. Christ, look at all those PVCs. In his busy cardiology practice Niles saw dozens of tracings like this every day and did little more than shake his head. But my, how the story changed when those malignant little blips belonged to you.
Niles thought about dying.
The hell of it was, a life in medicine did little to prepare a person for his own certain end. If anything, it made the task more onerous. Niles knew too much, that was the problem. Your average Joe, once he’s rolled through those emergency room doors, believes his troubles are over. Sure, he’s afraid. But does he realize that the plastic tip of an IV catheter, the most fundamental piece of invasive equipment used in any hospital, can shear loose and take the red cell express to his lungs? Has anybody told him the Foley catheter they snake into his bladder can cause a potentially lethal infection? Does he understand that when they operate on your heart, the fucking thing stops for more than an hour? Does he have even the dimmest inkling of the hundred other things that can go wrong at any stage in the game? Of course not. To your average Joe, it all comes down to nostrums, alchemy, magic...and of course, to God.
But Niles wasn’t ready to put his faith in God or in anyone else. Yet facts were facts. He’d seen the angios himself. His first attack had been a mild one, but the next one could put him away for good. And it could strike at any time. It was too late for low cholesterol diets, too late for modified life styles, too late even for prayer. It was surgery or certain death.
Still, lying here with the clock chipping away at the minutes until his eight o’clock appointment with the knife (bonesaw sounds like babies screaming), the temptation to put his clothes on and slip out of the hospital was almost overpowering.
He closed his eyes and wished he’d never assisted at cardiac surgery, because now he could see it all in his mind’s eye. The assistant laying open his inner thigh from scrotum to kneecap, dissecting out the length of vein that would be used for the grafts. And the surgeon himself, splitting Niles’s sternum with that infernal chattering saw, baring his heart and slicing into it, making holes in it, jamming rigid pipes into it and then slopping in a basinful of ice cold, potassium rich cardioplegic to stop his heart, stop it dead. How like a discarded sock the heart looked when it lay flaccid in that salty bath. How like a putrid, rotting sock.
Oh, Christ, what if it doesn’t start beating again?
Then there was the pump. Somehow the pump terrified Niles most of all. While the surgeon did his thing the pump took over the work of the heart and lungs. And what a low, slick, tube-sprouting monstrosity that baby was. It looked more like something you’d expect to find chugging away in a rural cheese factory than a mechanical heart-lung.
Imagine all the blood in your body being sucked out through clear plastic hoses, then driven under pressure through an oxygenating device that looks like an oversized Mr. Coffee, a shabby excuse for a lung under any circumstances, then being churned back into your aorta. What if a connection blew? What if air got into the damned thing? There must be fifty connections that could leak or admit lethal air into the system. What actually happens to your blood cells in there?
Niles made a grab at his chest, as if to pluck out the encroaching pain before it sunk in its teeth. He took a series of slow, deep breaths. Then he glanced at the clock: 7:38 AM.
And now he heard a dry squeak of wheels.
This is it. They’re coming for me.
Niles started to pray.
* * *
Jerry Tilton arrived at the Med Center CCU every morning at six-thirty. He was the only perfusionist who did. The others sauntered in around seven, changed into greens and spent another ten minutes fueling up on hospital coffee, all of which left them about twenty minutes to point-check, prime and pressure-test their bypass circuits. Jerry didn’t know how they got away with it. Before he took over the function of a patient’s heart and lungs he had to be ready. And that meant going over his machine with a fine-tooth comb. His coworkers razzed him about this all the time, predicting that after he got a few more years under his belt—Jerry had been in solo practice only a year—he’d turn into a slacker like the rest of them. But Jerry knew that would never happen. The professor he’d trained under at the Michener Institute was a perfectionist, and Jerry liked to see himself in that light.
And today was a day for perfection. Today the patient was a doctor. Not that doctors deserve preferential treatment, Jerry thought as he switched on the monitors and inspected the membrane oxygenator; when you got right down to it, they were human like the rest of us. But tensions ran higher when the patient was a colleague or a staff member’s relative or friend. And it created an atmosphere in which things were more likely to go wrong.
Jerry fixed the oxygenator to the pump and checked the system for leaks. As he did this the nursing team entered the suite, the three of them giggling over some juicy bit of gossip they’d picked up at morning coffee. Brisk greetings were exchanged, then the girls set about their business.
While connecting the oxygen, compressed air and CO2 lines to the pump, Jerry noticed that the power line had not been disconnected the night before. Sloppy, he thought, and the thought made him realize how keyed up he was. He followed the cord to the wall outlet and grasped the stout rubber plug, making sure it was securely seated.
Then he opened the tubing pack, allowing the scrub nurse to remove and fix the patient ends, which were sterile. He made all the necessary connections, then threaded the tubing into the circular pump heads, each of which contained a set of sturdy rollers that propelled the blood through the system, then back into the anesthetized patient. Finally, he primed the pump with a crystalloid solution and went after the air bubbles, milking them out of the system.
When he was done, fifteen minutes ahead of time, Jerry sat in the abandoned locker room and recited a brief prayer.
* * *
“Okay, Niles,” Dr. Ryan Hirsh said. “You’ll feel yourself drifting off. You may notice the mask on your face as you go, but don’t be concerned. It’s only oxygen.”
Niles tried to shape a response, but whatever they’d premedicated him with had spilled syrup into his relays. Still, Ryan’s voice sounded soothing and good. He and Niles had been friends since med school at McMaster and Niles felt a measure of relief knowing Ryan would be at the helm. He let the potent narcotic cocktail raft him away.
“Deep breath,” Ryan said. “No worries. By this time next week you’ll be dancing the polka.”
But Niles didn’t hear him.
* * *
It took the surgeon, Dr. Theodore Harris, thirty minutes to split the sternum, insert the chest retractor and cannulate Niles McRae’s aorta and right atrium. Harris, one of the unit’s founding fathers, was a short, intolerant man with the stubby hands of a school boy. But in the disaster-fraught precinct of cardiac surgery, he knew no peer. Most who worked with him learned to overlook his constant sniping and occasional tantrums. If such was the cost of excellence, they agreed, then so be it. Only Jerry took the man’s acid comments to heart. He dreaded working with Harris and added that to his list of apprehensions on this gloomy Tuesday.
“Ready for extracorporeal bypass,” Harris said without looking up.
Jerry stiffened, thinking two thoughts at once: This is it, and, Why can’t the little prick call it a “pump” like everyone else?
“Begin cooling now,” Harris said.
Jerry adjusted the temperature of the water-co
oled system to thirty-two degrees, then said “On pump,” in his firmest voice, watching for Harris’ acknowledging nod. That done, he removed the clamp on the venous line, watching as dark blood flooded the tubing. Then he turned on the mixed gas flow and started the arterial pump, gradually increasing its speed to match that of the venous inflow from the patient. When he had the flow rates stabilized he informed Dr. Hirsh, who switched the ventilator off.
The patient’s life, the life of a physician, was now in Jerry’s clammy hands.
Harris selected the grafts from the vein his assistant had stripped from Niles’s thigh and tailored them to fit the lengths of coronary artery he’d be replacing. Then he said, “Okay, stop the heart,” and his assistant poured the cardioplegic into the chest cavity.
When the icy bath struck it Niles McRae’s heart stiffened like a small, vigorous animal shot point-blank in the spine. It’s meaty chambers bulged in a brief clonic spasm and the entire organ began to quiver, an ineffectual activity punctuated by several more feeble attempts at normal beats. For a moment the heart appeared to try to lift itself out of its cold drowning pool and flee. Then it was still.
Harris said, “Give me the first graft,” and bent to his task.
* * *
So far so good, Jerry thought as he checked and rechecked his dials, gauges and flowmeters. So far so good. As the procedure wore on the thought became a kind of chant, a luck-bringing mantra that filled his mind so completely he nearly missed the subtle signal that heralded disaster.
From deep within the squat chrome console came a tiny pop! followed by a whiff of ozone. Alarmed, Jerry made a quick scan of his control panel, but could find nothing amiss.
A moment later a tremendous bang—the sound of a cherry bomb going off inside a garbage tin—whipped Jerry around in time to see sparks spewing out of the wall socket. The scrub nurse squealed and dropped an instrument. Harris cursed furiously before turning to see what the commotion was.
“What is it, Tilton?”
“I don’t know,” Jerry said. “Some kind of back surge—”
Jerry looked at the arterial pump. It was running at twice normal speed now, forcing blood into the patient’s aorta under tremendous pressure. He cranked the control knob to zero, but nothing happened. The pump continued to surge.
Runaway pump, Jerry thought. This was every perfusionist’s worst nightmare, the one that happened only in the text books, never to you.
“What the fuck is it?” Harris roared.
Jerry slammed the stop button with the heel of his hand, but the pump continued to whirl. He tried the breaker switch next.
Jammed.
A glance at the reservoir told him the outflow was rapidly out-pacing the inflow and in a matter of seconds he’d be pumping air into his patient’s arteries.
Soaked in panic now, Jerry lunged for the wall plug, but the back surge had welded it to the wall.
“Merciful Jesus,” Harris said. “Do something.”
Desperate now, Jerry flipped open the pump head’s protective cover and reached into the raceway, intending to pluck the tubing free. With any luck no real damage had been done yet. They could wheel in the back-up pump and have the patient on line again in under five minutes, plenty of time with a core temperature of thirty-two degr—
The whirring rubber rollers snagged the first three fingers of Jerry’s hand and degloved them, neatly avulsing the skin. The pain trebled Jerry’s panic and he flailed sideways into the instrument table, scattering its contents everywhere, including the open chest cavity. His scream echoed off the sterile walls.
Stripped of options, Harris tore the cannula from his patient’s aorta. The cannula, fashioned of flexible plastic, flopped and writhed under the pressure of the pump, painting the suite and everyone in it with blood. It pattered from the ceiling like red rain. The scrub nurse, a novice who’d scrubbed-in solo only twice before today, took a stream of it square in the face. The pressure tore her mask away and she recoiled from the table like a rioter caught in a blast from a fire hose. Her head struck a glass-fronted cabinet, shattering it, before she sagged unconscious to the floor.
The cardiac suites were the only ORs in the Med Center with windows to the outside, a homey touch insisted upon by the unit’s director. A group of rain-suited grade-schoolers, assembled on the lawn below for a tour of the hospital, followed the pointing finger of one of their number and uttered a chorused shriek. Their teacher, a spare woman with gray hair and John Lennon glasses, followed suit. A jet of blood had struck the glass up there and now it dripped and oozed in a sudden bloom of sunlight.
Ryan Hirsh, who’d left the room while his patient was on pump, returned on the run when the circulating nurse sounded the alarm.
But by then it was too late for Niles McRae.
8
KIM WAS WATCHING TV WHEN her father came home on Tuesday evening. He’d been at work since early the previous morning and she thought how tired he must be. She rose from the couch to greet him, but he turned his back on her and began opening his mail. Stung, Kim returned to her seat. As she did, the telephone rang. Jack picked it up in the family room. He said hello, then snapped his fingers at Kim.
“Could you turn that thing down to a dull roar? I can’t hear myself think.”
Kim grabbed the remote and thumbed the mute button, silencing the blaring TV. She hadn’t realized she’d had it so loud. She felt stupid, childish, ashamed.
When he hung up she said, “Dad?”
“What is it?”
Kim drew a blank. She didn’t know. She just wanted to talk to him, share some part of herself with him. Her mind scrambled for something to say that would hold him.
“We had a test today, a pop quiz? It was on metamorphosis...” Good, you said it right. “I know all about—”
“That’s great, kid. Where’s your mother?”
“Upstairs. In the tub.”
“I’ve got some work to do in my office. Let me know when dinner’s ready.”
“Okay, Dad.”
Jack left her and headed downstairs.
* * *
Jenny could hardly keep her eyes open, the hot water drawing her inexorably toward sleep. She was exhausted. She’d been working in her darkroom this afternoon, developing the roll of film she’d shot yesterday after meeting Richard, and had almost ruined it by bathing it in the wrong sequence. She caught herself in time, but realized then just how frazzled she was.
Seeing Richard again had stirred up a lot of old feelings, and after leaving him Jenny found herself roaming the streets in a kind of melancholic daze, her favorite Nikon slung around her neck. She wound up shooting a group of toddlers having a very messy birthday picnic at Brighton Beach park. It started out as a diversionary tactic, an attempt to dispel the gloom in her heart, but several of the prints she ended up with were really quite good.
She’d always had a creative streak and, until she married Jack, had intended to channel it into a career as a professional photographer. She’d already signed up for the prerequisite courses at Algonquin College when she fell head over heels for him.
Jenny raised her left hand out of a drift of bubbles, her engagement diamond winking richly in the glow of the overhead spots. She smiled a little then, and when she closed her eyes again she remembered the night Jack had slipped the ring onto her willing finger...
* * *
“And once I finish my residency,” Jack was saying, “we can get you enrolled at the College.” They were parked on a secluded hilltop overlooking the city. It was January first, a cold, blustery night, but they were cozy in Jack’s aging Biscayne. “That’s just two years away, Jen. You’ll only be twenty-two.”
Jenny wanted to take in every word Jack was saying, but her eyes kept drifting to the ring he’d slipped onto her finger only moments before. It was an enormous diamond set in a cluster of smaller diamonds and it must have cost a fortune. Jenny was speechless. She would have said yes had he pushed a two dollar mood ring onto h
er finger.
But Jack hadn’t really popped the question yet. Not officially. He was running ahead, detailing his plans, and she could barely keep up with him.
“By the time you’re done with your courses,” he was saying, “I should have enough money socked away for a house, a proper house. Dr. Talbot has practically guaranteed me a position on staff at the Med Center. He says if I do an extra year of ICU, I’ll be eligible for the directorship in my first year.”
Jenny looked up from the ring. The gist of what Jack was saying had finally registered—he wanted her to put off her education—and she wanted to add her thoughts, set things straight from the outset. But she was afraid to blunt his enthusiasm. It had been hard enough to get close to him; she didn’t want to spoil the moment by raising doubts. She decided they could work out the details later.
“So what do you say, Jen?” He raised her hand between them, nudging her ring finger higher than its sisters. “Will you marry me? I’ll make you the happiest girl in town.”
“Oh, Jack, of course I will. You know I will...”
He kissed her gently. So gently.
“We’re going to be the best,” he said, kissing her again. “You and me. I’m going to make you so happy. You’re going to have my baby—babies—and we’re going to give the Fallon name some roots.”
What about my education?
But that once burning question seemed unimportant just now. They could work out the details later.
* * *
But the details never got worked out. “I want to start a family.” Jack’s voice, a stern echo down a corridor of lost years. They’d been married only six months. “How can we manage that with you taking courses full-time? Maybe you should think about correspondence courses. That way you’d never have to leave the house. We don’t need the extra money. I can make more than enough for both of us.”
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