Instantly the room was totally quiet. Abby bent down, her lips next to Claire's ear.
"Claire, can you hear me?" No response. No movement. "Claire, you're going to feel a plastic tube inside your nose. It's to help you breathe." Still no reaction.
There was no time left for explanations. And no need. Claire Buchanan, though her jaws were still rigidly locked, was on the brink. The two nurses who could backed out of the room to allow more work space. Abby took the lubricated tube in one hand and slid it into Claire's right nostril. The one-time Rockette barely moved. Next, Abby slipped her free hand beneath the woman's head and cradled it. The tube caught briefly on one of the nasal ridges, but a little rotating and some gentle pressure freed it and allowed Abby to advance it into the back of Claire's throat. Step one was done--the easy part.
Abby hunched over now, her ear just above the opening of the tube.
"All right, Mrs. Wilder," she said into the silence, "compress about once every three seconds."
Faintly, Abby heard the puff of air. She advanced the tube another half inch. This time she heard nothing. She guessed that she had gone behind the opening of the trachea into the beginning of the esophagus. She withdrew the tube an inch and rotated it slightly to angle the tip more forward.
"Dr. Dolan, I'm not feeling a femoral pulse anymore."
Abby checked Claire's carotid pulse. It was still there, but very faint. Time was just about up.
"Hold off on the compressions, Mrs. Wilder," she said. "If we have to race to the ER, we're going to do it without any CPR until we get there. So everyone get ready."
She was down to it. One more try, ten more seconds, and she would have to make the time-consuming sprint to the ER and perform a tracheotomy under the worst circumstances.
"Quiet, everyone," she said again, although there was hardly any noise. "Okay, Mrs. Wilder, compressions, please."
Abby hunched over the tube opening once more.
The nurse squeezed down rhythmically, once, then again. Claire Buchanan's arms and legs were twitching spasmodically now, purposelessly. Suddenly Abby heard it again, the faint hiss of moving air. She advanced the tube down a quarter of an inch. The sound was louder. Suddenly she encountered resistance again. Was she against the epiglottis, deep in the throat? The bony ridge above the larynx? Or perhaps even the swollen vocal cords themselves?
Abby felt herself beginning to panic once more. This whole thing was a nightmare. An absolute disaster. Should she try forcing the tube down, hoping she was against the vocal cords, or give up and risk the mad dash to the ER for an emergency tracheotomy by a doctor who hadn't performed one in years? She waited for another wisp of air, and when she heard it, forced the tube down as hard as she dared. If she fractured or tore a crucial structure, with possibly fatal hemorrhage into Claire's lungs, she would bear the full responsibility.
There was momentary, total resistance. Then, with a soft popping sound, the tube advanced almost an inch. Abby knew she was in. The tip had pushed between the obstructing vocal cords and was now in the lower trachea, just above its split into the main bronchial tubes to Claire's right and left lungs. There might be some swelling in those tubes, but with epinephrine already on board, the blockage shouldn't be enough to keep them from ventilating her.
"Ambu bag, please," she said. "Quickly!"
Mary Wilder passed over the breathing bag. Abby attached it to the top of the tube and began ventilating as fast as she could. There was a tank of oxygen beneath the stretcher. Abby connected it to the breathing bag through a plastic tube.
"I think I feel a femoral pulse," the nurse called out.
"Excellent. Jill, you've got one more shot at that subclavian. Then, in or out, we make tracks for the ER. Take your time. I know you can do it. Just like the epi."
Jill Anderson, her tears no longer flowing, seemed as if she were about to back off entirely. Then, with a glance at Abby, she located her landmarks and slid the needle in beneath Claire's collarbone. The blood return was immediate. A perfect shot.
"Yes!" Jill exclaimed unabashedly. "Yes!"
One nurse applauded.
With a good intravenous route established, the steroids, some more epinephrine, and the antihistamine, Benadryl, could be given IV.
In less than a minute Claire began more purposeful movements of her limbs.
"Her pulse is much better now," the nurse exclaimed. "Much better."
"Great," Abby said. "Let's get her the hell out of this box and over to the ER. Mrs. Wilder, would you please lead the charge?"
The graying nurse looked over at Abby with unbridled relief.
"It's Mary," she said.
CHAPTER TWENTY-SIX
By the time Claire Buchanan was transferred from the ER to the ICU, her symptoms had begun to recede. She was groggy, but clearly awake. George Oleander, who had come in immediately to take over her care, expressed gratitude to Abby for her treatment success, but he had no explanation to offer for Claire's severe allergic reaction. He also made no defense of his insistence not to refer her for a dermatologic consult. Abby wanted to suggest sending off a cadmium-level stat, but given the controversy swirling around her, she decided the suggestion could wait.
Her actual shift in the ER wasn't scheduled to begin for a few more hours, and she was hardly in the mood to offer to take over early for Jill Anderson. Instead, she decided, she would go up to the unit to check on Claire, then maybe take a walk, and, finally, have dinner at the Peking Pagoda. With all she had been through today, the very least she could do for herself was a PuPu Platter.
Before heading up to the unit Abby went to a pay phone to check in with Sandy Stuart at St. John's. The toxicologist was at a conference for another two hours, and her secretary had no idea who would have been in charge of a cadmium assay. Abby left her beeper number and instructions for Sandy to call as soon as she had any information.
The unit was fairly quiet, due in part to Willie Cardoza's transfer. Abby immediately sensed a change in the attitude of the unit nurses toward her. Two of them made a point of coming over to congratulate her for "the save." One of them actually muttered something about "that Wheaton thing." Clearly, the pendulum of hospital opinion was swinging back in her favor. Abby wondered how far it would head in the other direction again if Henderson began leaking the lie that she had not only overestimated the severity of Peggy's head injuries, but that in her haste to tend to Peggy's murderer she had completely missed the constrictive hemopericardium that had probably cost the woman her life.
A wave of loneliness washed over her. She glanced at the time and wondered where Lew was. He had been working a fair amount at the state hospital lately because the main-coverage doctor had left without notice. She wondered what would happen to her embryonic relationship with him if she was forced to resign and move out of Patience. She believed something very special might be developing with Lew, but the two of them were hardly far enough along for her to stay in Patience just for him or for him to leave because of her. And, besides, the situation with Josh remained unresolved. Maybe it would be best if she simply ditched them all--Josh, Lew, the hospital, everything--and started over someplace. That notion was not very appealing, especially since leaving would vindicate the slimy methods of Joe Henderson, to say nothing of the heavy-handed approach of Mr. Ski Mask in his red pickup.
Love, marriage, kids, a reasonably interesting job, a nice place to live. Her goals in moving to Patience had always seemed perfectly straightforward--never farfetched or self-serving. And it had all started out so right, so innocent. How in the hell had all this happened?
Ironically, Claire Buchanan had been placed in the same cubicle Willie Cardoza had occupied. She still had the lifesaving NT tube in place, but Abby noted through the glass wall that the tube was now attached to moisturized oxygen, not to a ventilator. A very good sign. There was a beefy man in a turtleneck and sports coat seated next to her stroking her hand. Dennis Buchanan, the man who could sell iceboxes to Eskimos, the man
who had rescued Claire from the Rockettes. Watching his gentle, concerned attentiveness brought a bittersweet fullness to Abby's throat. Once upon a time Josh had cared for her like that. And knowing that he did had made almost every problem in life bearable.
She shook off her melancholy as best she could and moved closer to the glass. Claire's lips were much less swollen already, and her eyes, though still puffy, were open. The terrible inflammation in her skin had also begun to ebb. With any luck she would have the tube removed before long. Abby saw no sense in trying to speak with her at this point, especially while her husband was there. But later tonight she would stop by again. Even if the tube was still in, Claire would probably be alert and strong enough to communicate in writing. And there were a number of questions Abby wanted answered, the most pressing being: What happened?
Abby started out of the unit. Then, bothered by the persistent gnawing feeling that she was missing something, she suddenly turned and went to the nurses' station. Claire's old hospital record was in a slot just below the loose-leaf-bound current record. The old record wasn't large. There were no inpatient stays before this one, except for the delivery of a healthy baby girl sixteen years before, and only five emergency-room visits: the two in which Abby had been her doctor, a sprained ankle, removal of a piece of glass from her foot, and an episode of upper-abdominal pain that was believed to be gastritis.
Gastritis. Claire had said something about that, something that Abby thought was unusual at the time. She flipped through the laboratory and X-ray reports. Blood counts had been done on the evening Claire had come into the ER with belly pain. Then, a day later, she'd had an MRI, which was normal. That was it. That was what had seemed so weird when Claire had first mentioned it.
An MRI, appropriate when a doctor suspected a condition not easily visualized by conventional X rays, seemed an odd and extravagantly expensive choice in view of Claire's symptoms. And for someone with claustrophobia, like Claire, it was bound to be an ordeal. In addition, the time required to run each study meant that there was often a long waiting period to get one done. Yet George Oleander had ordered an MRI without first going to an upper GI series, or even, from what Abby could tell, a trial course of treatment. Why?
And why had he ordered a second MRI today?
Abby left the unit and returned to the MRI suite. It occurred to her for the first time how unusual it was for a hospital the size of Patience Regional to have its own MRI machine at all. Granted, the facility served a fairly large geographic area. But as far as she knew, most hospitals this size referred patients to a freestanding MRI center that served several hospitals. And some facilities actually contracted with a mobile unit that was built inside a tractor trailer and hauled from hospital to hospital. Yet here was PRH with not only an MRI, but a very up-to-date CT scanner as well. And there was a great deal of crossover in the diagnostic capabilities of the two techniques.
The room housing the gleaming MRI unit showed no hint of the drama that had unfolded there just two hours before. The floor was polished and the machine was already in operation again. Del Marshall sat outside the room at a console, checking the remarkably precise images as the machine produced them. Inside, the sheet-covered feet of the patient could be seen just inside the cylinder.
"Hi," Abby said. "How're you doing?"
Marshall looked up at her and smiled warmly. He was a lean, fatherly man, with Ben Franklin glasses and razor-cut gray hair.
"I didn't have a coronary in there, if that's what you mean."
"You actually seemed to be handling yourself pretty well."
"That's kind of you to say, but I know better. It's one thing to take all those courses in CPR and advanced CPR. It's quite another to be confronted with a flesh-and-blood patient who's stopped breathing--especially when it happens in your MRI machine. I can understand my being a basket case, but I confess I was a little surprised Jill Anderson wasn't more up to the task. I don't know what would have become of that poor Buchanan woman if you hadn't been there."
"Thanks. Del, do you have any idea what happened in there?"
"No, no idea at all," he responded with knee-jerk quickness. "One moment she was perfectly peaceful, the next she was thrashing about violently, kicking the inside of the tube. We pulled her out, and she was already swelling up and turning beet-red."
"Well, I just stopped by the unit, and she seems to be making a nice recovery. I was wondering if you would happen to have Mrs. Buchanan's request sheet in there. I just want to get some data for my dictation."
Abby phrased the question carefully. She had no idea how connected the radiologist was to Henderson or to George Oleander. And the last thing she wanted was for either of them to know she was poking around for more information.
Marshall called up Claire's sheet on one of the screens. The specific line Abby was looking for was Provisional Diagnosis. According to it, Oleander had requested the study for recurrent hives, possible occult malignancy.
The diagnosis of possible occult malignancy was reasonable enough. Hives sometimes were the outward manifestation of serious internal disease. But this MRI, like Claire's previous one, seemed to have been ordered prematurely. Of course, there could have been any number of diagnostic studies done through Oleander's office of which Abby would have been unaware. But she sensed that was not the case. Oleander had a strange predilection for ordering MRIs, as did the other physicians with NIWW patients. But there was something else about the MRIs--something that seemed to be floating just beyond her grasp.
There was just enough time before her ER shift to go home and review the data she had managed to gather so far--focusing this time on the MRIs. The PuPu Platter would have to wait for another day.
Abby thanked the radiologist and left the hospital trying to sort out what she was discovering, and what pieces were missing. Pending the results of the assay of Willie Cardoza's blood, she would try assuming for the moment that all of the NIWWs, including Cardoza, Claire Buchanan, and even Josh, were cadmium toxic to one degree or another. How could that possibly tie in with the inappropriate, excessively ordered MRIs?
Unlike standard X rays or even CT scans, which were a computerized integration of hundreds of individual X rays, magnetic resonance imaging involved placing the patient in a magnetic field and then bombarding that person with radio waves. The billions of hydrogen ions in the body, mostly located in water, would vibrate under the influence of the magnet in such a way that their density could be measured and then converted to incredibly detailed slices through the body. The slices were used to create three-dimensional pictures of any organ. The science behind an MRI was straight out of Star Trek, and for years many distinguished scholars had derided the believers. But scholars had laughed at Newton, too.
As far as Abby knew, no adverse effects of any real consequence had been attributed to magnetic resonance imaging. At a lecture on the technique sometime in the past year, she had learned that there was a slight but significant rise in body temperature in patients undergoing the test, possibly caused by the intense radio-wave bombardment. With time and a massive volume of cases it seemed possible something else would show up. But for the time being the temperature rise was it--except, of course, for the psychological trauma of lying in a metal tube for most of an hour, unable to move at all, surrounded by the echoing pings, hums, and clangs of the charging and discharging electromagnet.
The problem, as Abby saw it, was coming up with a workable explanation for how the MRIs fit in with the varied clinical presentations of the NIWWs. The understanding of the biochemistry of the brain was still in its infancy. Perhaps, she reasoned, the radio waves, the magnetic field, or even the claustrophobic effects of being slid into the narrow tube set off some sort of chemical discharge. And perhaps, in the presence of cadmium, that chemical discharge short-circuited the brain. Perhaps. Perhaps. Perhaps.
The truth was, the explanations she was conjuring up didn't make much sense. Some cases fit, some didn't. There simply wasn't an
y consistent pattern. Willie Cardoza had an MRI after his head injury. Josh had never been ill before coming to Patience, and had never had an MRI. Claire Buchanan seemed to be having trouble with her immune system--especially the immune chemicals in the skin. Other NIWW patients had nothing more than persistent fatigue, and still others, a chronic cough that was unresponsive to antibiotics.
By the time Abby arrived home, the best theory she had come up with was that she had stumbled by accident on a scam to raise revenues for the hospital or justify its MRI unit by ordering an excessive number of tests. What did the scam have to do with the NIWWs? Probably nothing.
Upon her hurried return home from the computer room at the community-college bookstore, Abby had searched for a spot to hide the loose-leaf notebook containing her data sheets. She thought there was a good chance that someone, probably Lyle Quinn, would try to find and destroy them. Finally she had settled on a hollowed-out area just behind the furnace in the basement. The spot would probably yield to a careful search, but the searcher would have to wade through a hell of a lot of junk first.
She carried the notebook upstairs to the dining-room table and brought out a blank sheet of paper. This time she would concentrate on just the MRIs. She jotted down the dates when the tests had been done, the doctor, the diagnosis, the results. Nothing. The only finding that looked like a pattern was that in most cases the study was negative. She rubbed at her eyes and paced around the house. Something was there. She felt certain of it. Maybe she needed more cases. But more likely she was approaching her work with a burden of preconceived notions. If she could only clear her mind of expectations ...
She was still pacing when her beeper went off. The return number was not local, but still in the 916 area. Lew answered on the first ring. Abby had never heard him so excited.
"I'm at the state hospital in Caledonia," he said. "And one of the patients we have here right now is Angela Cristoforo. Do you know who that is?"
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