by Robin Cook
Jerry grunted and said, “Goin’ to be pulmonary embolism. I’m sure of it.”
“It’s a bad bet,” said Robert, shaking his head.
Switching his attention lower, Robert examined the main pulmonary vessels and the heart itself. “These are the bypass vessels sewn in place.” He leaned back so Cassi and Jerry could take a look.
Hefting a scalpel, Robert said: “Okay, Dr. Donovan. Better put your money on the table.” Robert bent over and opened the pulmonary arteries. There were no clots. Next he opened the right atrium of the heart. Again the blood was liquid. Finally he turned to the vena cava. There was a bit of tension as the knife slipped into the vessels, but they too were clear. There were no emboli.
“Crap!” said Jerry in disgust.
“That’s ten dollars you owe me,” said Robert smugly.
“What the hell could have bumped this guy off?” asked Jerry.
“I don’t think we’re going to find out,” said Robert. “I think we’ve got number eighteen here.”
“If we are going to find anything,” said Cassi, “it will be inside the head.”
“How do you figure?” asked Jerry.
“If the patient was really cyanotic,” said Cassi, “and we haven’t found a right-to-left circulatory shunt, then the problem has to be in the brain. The patient stopped breathing, but the heart kept pumping unoxygenated blood. Thus cyanosis.”
“What’s that old saying?” said Jerry. “Pathologists know everything and do everything but too late.”
“You forgot the first part,” said Cassi. “Surgeons know nothing but do everything. Internists know everything but do nothing. Then comes the part about pathologists.”
“And what about psychiatrists?” asked Robert.
“That’s easy,” laughed Jerry. “Psychiatrists know nothing and do nothing!”
Quickly Robert finished the autopsy. The brain appeared normal on close examination. No sign of clot or other trauma.
“Well?” asked Jerry, staring at the glistening convolution of Bruce’s brain. “Do you two hotshots have any other bright ideas?”
“Not really,” said Cassi. “Maybe Robert will find evidence of a heart attack.”
“Even if I do,” said Robert, “it wouldn’t explain the cyanosis.”
“That’s true,” said Jerry, as he scratched the side of his head. “Maybe the nurse was wrong. Maybe the guy was just ashen.”
“Those nurses on cardiac surgery are awfully competent,” said Cassi. “If they said the patient was dark blue, he was dark blue.”
“Then I give up,” said Jerry, taking out a ten-dollar bill and slipping it into the pocket of Robert’s white jacket.
“You don’t have to pay me,” said Robert. “I was just kidding.”
“Bullshit,” said Jerry. “If it had been a pulmonary embolism I’d have taken your money.” Jerry walked over to where he’d hung his white jacket.
“Congratulations, Robert,” said Cassi. “Looks like you got case number eighteen. Compared to the number of open-heart surgery cases they’ve done over the last ten years, that’s getting close to being statistically significant. You’ll get a paper out of this yet.”
“What do you mean ‘me’?” asked Robert. “You mean ‘us,’ don’t you?”
Cassi shook her head. “No, Robert. This whole thing has been your idea from the start. Besides, now that I’ve switched to psychiatry, I can’t hold up my end of the work.”
Robert looked glum.
“Cheer up,” said Cassi. “When the paper comes out, you’ll be glad you didn’t have to share authorship with a psychiatrist.”
“I was hoping this study would get you to come up here frequently.”
“Don’t be silly,” said Cassi. “I’ll still come up, especially when you find new SSD cases.”
“Cassi, let’s go,” called Jerry impatiently. He had the door held open with his foot.
Cassi gave Robert a peck on the cheek and ran out. Jerry took a playful swipe at her as she passed through the door. Not only did she evade the blow, but she managed to give Jerry’s necktie a sharp tug as she passed.
“Where’s your woman friend?” asked Jerry as they reached the main part of the pathology department. He was still struggling to straighten his tie.
“Probably in Robert’s office,” said Cassi. “She said she needed to sit down. I think the autopsy was a little much for her.”
Joan had been resting with her eyes closed. When she heard Cassi she got unsteadily to her feet. “Well, what did you learn?” She tried to sound casual.
“Not much,” said Cassi. “Joan, are you all right?”
“Just a mortal wound to my pride,” said Joan. “I should have known better than watch an autopsy.”
“I’m terribly sorry…” began Cassi.
“Don’t be silly,” said Joan. “I came voluntarily. But I’d just as soon leave if you’re ready.”
They walked down to the elevators where Jerry decided to use the stairs since it was only four flights to the medical floor. He waved before disappearing into the stairwell.
“Joan,” said Cassi, turning back to her. “I really am sorry I forced you up here. I’d gotten so accustomed to autopsies as a path resident that I’d forgotten how awful they can be. I hope it didn’t upset you too much.”
“You didn’t force me up here,” said Joan. “Besides, my squeamishness is my problem, not yours. It’s just plain embarrassing. You’d think after four years of medical school I’d have gotten over it. Anyway, I should have admitted it and waited for you in Robert’s office. Instead I acted like a fool. I don’t know what I was trying to prove.”
“Autopsies were hard for me at first,” said Cassi, “but gradually it became easier. It is astounding what you can get used to if you do it enough, especially when you can intellectualize it.”
“For sure,” said Joan, eager to change the subject. “By the way, your men friends do run the gamut. What’s the story with Jerry Donovan? Is he available?”
“I think so,” said Cassi, punching the elevator button again. “He was married back in med school but then divorced.”
“I know the story,” said Joan.
“I’m not sure if he’s dating anyone in particular,” said Cassi. “But I could find out. Are you interested?”
“I wouldn’t mind asking him to dinner,” said Joan pensively. “But only if I could be sure he’d put out on the first date.”
It took a moment for Joan’s comment to penetrate before Cassi burst out laughing. “I think you sized him up pretty well,” she said.
“The macho medicine man,” said Joan. “What about Robert?” Joan lowered her voice as they got on the elevator. “Is he gay?”
“I suppose so,” said Cassi. “But we’ve never discussed it. He’s been such a good friend, it has never mattered. He used to rate my boyfriends back in medical school, and I used to listen until I met my husband because Robert was always right. But he must have been jealous of Thomas because he never liked him.”
“Does he still feel that way?” asked Joan.
“I can’t say,” said Cassi. “That’s the only other subject that we never talk about.”
Two
“The patient is ready for you in No. 3 cardiac cath room,” said one of the X-ray technicians. She didn’t come into the office but rather just stuck her head around the door. By the time Dr. Joseph Riggin turned to acknowledge the information, the girl was gone.
With a sigh, Joseph lifted his feet off his desk, tossed the journal he’d been reading onto the bookshelf, and took one last slug of coffee. From a hook behind the door he lifted his lead apron and put it on.
The radiology corridor at 10:30 A.M. reminded Joseph of a sale day at Bloomingdale’s. There were people everywhere waiting in chairs, waiting in lines, and waiting on gurneys. Their faces had a blank, expectant look. Joseph felt an unwelcome sense of boredom. He’d been doing radiology now for fourteen years and he was beginning to admit to h
imself that the excitement had gone out of it. Every day was like every other day. Nothing unique ever happened anymore. If it hadn’t been for the arrival of the CAT scanner a number of years ago, Joseph wondered if he’d have quit. As he pushed into No. 3, he tried to imagine what he could do if he left clinical radiology. Unfortunately he didn’t have any bright ideas.
The No. 3 cath room was the largest of the five rooms so equipped. It had the newest equipment as well as its own built-in viewer screens. As Joseph entered, he saw that someone else’s X rays had been left up. If he’d told his technicians once, he’d told them a thousand times that he wanted his room cleared of previous films before he did a study. Then, as if that wasn’t enough, Joseph noticed there was no technician.
Joseph felt his blood pressure soar. It was a cardinal rule that no patients were ever to be left unattended, “Dammit,” snarled Joseph under his breath. The patient was lying on the X-ray table, covered by a thin white blanket. He looked about fifteen years old, with a broad face and close-cropped hair. His dark eyes were watching Joseph intently. Next to the table was an IV bottle, and the plastic tube snaked under the blanket.
“Hello,” said Joseph, forcing a smile despite his frustration.
The patient did not stir. As Joseph took the chart, he noticed that the boy’s neck was thick and muscular. Another glance at the boy’s face suggested that this was no ordinary patient. His eyes were abnormally tilted and his tongue, which partially protruded from his lips, was enormous.
“Well, what do we have here?” said Joseph with a wave of uneasiness. He wished the boy would say something or at least look away. Joseph flipped open the chart and read the admitting note.
“Sam Stevens is a twenty-two-year-old muscular Caucasian male institutionalized since age four with undiagnosed mental retardation, who is admitted for definitive work-up and repair of his congenital cardiac abnormality thought to be a septal defect…”
The door to the cath room banged open, and Sally Marcheson breezed in carrying a stack of cassettes. “Hi, Dr. Riggin,” she called.
“Why has this patient been left alone?”
Sally stopped short of the X-ray machine. “Alone?”
“Alone,” repeated Joseph with obvious anger.
“Where’s Gloria? She was supposed…”
“For Christ’s sake, Sally,” shouted Joseph. “Patients are never to be left alone. Can’t you understand that?”
Sally shrugged. “I’ve only been gone fifteen or twenty minutes.”
“And what about all these X rays? Why are they out?”
Sally glanced at the viewers. “I don’t know anything about them. They weren’t here when I left.”
Quickly Sally began pulling the X rays down and stuffing them in the envelope on the countertop. It was someone’s coronary angiogram, and she had no idea whatsoever why the X rays were there.
Still grumbling to himself, Joseph opened a sterile gown and pulled it on. Glancing back at the patient, he saw that the boy had not moved. His eyes still followed him wherever he moved.
With a frightful banging noise, Sally succeeded in loading the cassettes into the machine, then came back to pull off the sterile cover over the cath tray.
While Joseph pulled on rubber gloves, he moved over closer to the patient’s face. “How are you doing, Sam?” For some reason, knowing the boy was retarded made Joseph think he should speak louder than usual. But Sam didn’t respond.
“Do you feel okay, Sam?” called Joseph. “I’m going to have to stick you with a little needle, okay?”
Sam acted as if he were carved from granite.
“I want you to stay very still, okay?” persisted Joseph.
True to form, Sam didn’t budge. Joseph was about to return his attention to the cath tray when Sam’s tongue once again caught his attention. The protruding portion was cracked and dried. Looking closer, Joseph could see that Sam’s lips weren’t much better off. The boy looked like he’d been wandering around in a desert.
“You a little thirsty, Sam?” queried Joseph.
Joseph glanced up at the IV, noticing that it wasn’t running. With a flick of his wrist he turned it on. No sense in the kid becoming dehydrated.
Joseph stepped over to the cath tray and took the gauze out of the prep dishes.
A high-pitched, inhuman scream shattered the stillness of the cath room. Joseph whirled around, his heart in his mouth.
Sam had thrown off his blanket and was clawing at the arm that had the IV. His feet began to hammer up and down on the X-ray table. A shrill cry still issued from his lips.
Joseph collected himself enough to pull the fluoroscopy unit back away from Sam’s thrashing legs. He reached up and put his hands on Sam’s shoulders to push him back onto the table. Instead Sam grasped Joseph’s arm with such power that Joseph yelped out in pain. Powerless to prevent it, Joseph watched with horror as Sam pulled Joseph’s hand up to his mouth, then sank his teeth into the base of Joseph’s thumb.
It was now Joseph’s turn to scream. He struggled to pull his arm from Sam’s grasp, but the boy was far too strong. In desperation Joseph lifted a foot to the side of the X-ray table and pushed. He stumbled back and fell, pulling Sam on top of him.
Joseph felt Sam release his arm only to feel the boy’s hands close around his throat. Pressure built up inside of his head as the boy squeezed. Desperately he tried to pull Sam’s hands away, but they were like steel. The room began to spin. With a last reserve of strength, Joseph brought his knee up into the boy’s groin.
Almost simultaneously, Sam’s body heaved with a sudden contraction. It was rapidly followed by another and then another. Sam was having a grand mal seizure, and Joseph lay pinned to the floor beneath the heaving, convulsing body.
Sally finally recovered from shock and helped Joseph squirm free. Sam’s eyes had disappeared up inside his head and blood sprayed in a gradually widening circle from his mangled tongue
“Get help,” gasped Joseph as he grasped his own wrist to stem the bleeding. Within the jagged edges of the wound he could see the glistening surface of exposed bone.
Before help arrived, Sam’s wrenching spasms weakened and all but stopped. By the time Joseph realized the boy was not breathing, the medical emergency team arrived. They worked feverishly but to no avail. After fifteen minutes, a reluctant Dr. Joseph Riggin was led away to have his hand sutured while Sally Marcheson removed the misplaced X rays.
As Thomas Kingsley scrubbed, he felt the surge of excitement that always possessed him before an operation. He had known he was born to be a surgeon the first time he’d assisted in the OR as an intern, and it hadn’t been long before his skill had been acknowledged throughout the hospital. Now as Boston Memorial’s foremost cardiovascular surgeon, he had an international reputation.
Rinsing off the suds, Thomas lifted his hands to prevent water from running down his arms. He opened the OR door with his hip. As he did so, he could hear the conversation in the room trail off into awed silence. He accepted a towel from the scrub nurse, Teresa Goldberg. For a second their eyes met above their face masks. Thomas liked Teresa. She had a wonderful body that even the bulky surgical gown she was wearing could not hide. Besides, he could yell at her if need be, knowing she wouldn’t burst into tears. She was also smart enough not only to recognize that Thomas was the best surgeon at the Memorial but to tell him so.
Thomas methodically dried his hands while he checked out the patient’s vital signs. Then, like a general reviewing his troops, he moved around the room, nodding to Phil Baxter, the perfusionist, who stood behind his heart-lung machine. It was primed and humming, ready to take over the job of oxygenating the patient’s blood and pumping it around the body while Thomas did his work.
Next Thomas eyed Terence Halainen, the anesthesiologist.
“Everything is stable,” said Terence, alternately squeezing the breathing bag.
“Good,” said Thomas.
Disposing of the towel, Thomas slipped on the ster
ile gown held by Teresa. Then he thrust his hands into special brown rubber gloves. As if on cue, Dr. Larry Owen, the senior cardiac surgery fellow, looked up from the operative field.
“Mr. Campbell is all ready for you,” said Larry, making room for Thomas to approach the OR table. The patient lay with his chest fully opened in preparation for the famous Dr. Kingsley to do a bypass procedure. At Boston Memorial it was customary for the senior resident or fellow to open as well as close such operations.
Thomas stepped up to his position on the patient’s right. As he always did at this point, he slowly reached into the wound and touched the beating heart. The wet surface of his rubber gloves offered no resistance, and he could feel all the mysterious movement in the pulsating organ.
The touch of the beating heart took Thomas’s mind back to his first major case as a resident in thoracic surgery. He had been involved in many operations prior to that, but always as the first assistant, or second assistant, or somewhere down the line of authority. Then a patient named Walter Nazzaro had been admitted to the hospital. Nazzaro had had a massive heart attack and was not expected to live. But he did. Not only did he survive his heart attack, but he survived the rigorous evaluation that the house staff doctors put him through. The results of the work-up were impressive. Everyone wondered how Walter Nazzaro had lived as long as he had. He had occlusive disease in his main left coronary artery, which had been responsible for his heart attack. He also had occlusive disease in his right coronary artery with evidence of an old heart attack. In addition he had mitral and aortic valve disease. Then, as if that weren’t enough, Walter had developed an aneurysm, or a ballooning of the wall, of his left ventricle of his heart as a result of the most recent heart attack. He also had an irregular heart rhythm, high blood pressure, and kidney disease.
Since Walter was such a fund of anatomic and physiologic pathology, he was presented at all the conferences with everyone offering various opinions. The only aspect of his case that everyone agreed upon was the fact that Walter was a walking time bomb. No one wanted to operate except a resident named Thomas Kingsley, who argued that surgery was Walter’s only chance to escape the death sentence. Thomas continued to argue until everyone was sick of hearing him. Finally the chief resident agreed to allow Thomas to do the case.