by Gary Birken
Thirty minutes after his patient had been placed on the operating table, Dr. McBride, scalpel in hand, was ready to begin. The only thing delaying him from making an incision was the go-ahead from the anesthesiologist, Mike Quintana.
After checking his equipment and measuring Wallace’s vital signs one last time, Quintana looked up and said, “We’re good to go.”
In the next instant, McBride made a deep incision directly down the middle of Tony’s chest. He then used a special air-powered high-speed saw to divide his breastbone and expose his heart. The final step before going on bypass was to place the large plastic tubing into the heart and the aorta, the largest artery in the body.
When McBride was finished, he looked over at Todd Ket tering, the chief pump technician.
“Are we ready?” he asked him.
Todd gave him the thumbs-up and answered, “You’re good to go, Boss.”
McBride, short in stature but long on confidence, looked over the top of the anesthesia screen at Quintana.
“Go ahead and give him the heparin. Let me know when he’s fully anticoagulated.”
“Ten thousand units going in,” Quintana answered as he pushed five cc’s of the heparin into the IV tubing.
A minute passed. Dr. McBride looked over his shoulder at Todd. “Can we go on bypass?”
“The ACT’s greater than four-eighty. The patient’s fully anticoagulated. We can go on whenever you’re ready,” Todd assured him.
“What’s the heparin for?” one of three medical students standing behind Todd whispered.
Continuing to check his systems and without looking at her, he asked. “What happens to your blood if you cut your finger?”
“It bleeds,” she responded.
“Forever?”
“No. Until it clots.”
“Exactly,” Todd said. “This heart and lung bypass machine that you’re looking at is just like a giant water pump that makes a fountain work. What do you think would happen to our imaginary fountain if we were pumping hundreds of gallons of water and, all of a sudden, that water turned to ice?”
“I guess the pump would jam and the fountain would stop.”
“That’s right. And the same is true here. If Mr. Wallace’s blood should clot, we wouldn’t be able to circulate it. That’s why we give heparin. It thins out the blood and prevents it from clotting.”
Dr. McBride said, “What do you say, Todd? If today’s lecture on heparin’s over, I’d like to get on with this operation.”
Todd had known McBride for years and was well aware that his sarcastic sense of humor was harmless.
“We’re ready,” he answered.
“Here we go,” McBride said, releasing the large clamps on the tubing. The result was to immediately allow the blood to flow from Tony Wallace’s heart, through the tubing, and into the pump where it would receive oxygen before being returned to his body.
“We’re up to speed on the flow,” Todd said.
“Go ahead and give the cardioplegia,” McBride told Quintana, who then injected a highly concentrated solution of ice-cold potassium into Tony’s bloodstream. The effect was to bring his heart to a complete standstill.
“Why do they have to stop the heart?” the student asked Todd.
“Because it’s delicate work trying to sew the grafts in. It would be impossible to do with the heart pounding away.”
With his magnifying glasses in place, McBride began sewing in the three separate vein grafts that would bridge Tony’s blocked arteries. Forty-five minutes after he had placed the first stitch, he tied the final suture.
“I’m done here. Let’s give him a couple of units of blood and start re-warming.”
The process generally took a few minutes and would be the necessary last step before Quintana and McBride would work together to start Tony’s heart beating on its own again.
It was at this point that McBride felt comfortable enough to step back from the table and relax for a few minutes.
“Have you started the nitroglycerine drip yet?” he asked Quintana.
“Just hanging it now,” he answered.
With his arms crossed in front of him, McBride closed his eyes and took a few deep breaths. His mind drifted to the Mediterranean cruise he and his wife were scheduled to take next month. It was a vacation he felt he deserved and one that his wife insisted he desperately needed.
McBride opened his eyes and glanced down at the operative field.
“Shit,” he yelled. “I’ve got huge blood clots in the pericardial well. What the hell’s going on, Todd?”
Todd’s voice and manner were equally distressed.
“I don’t know, Boss, but I got the same thing here in the tubing. This guy’s making clots like crazy. The whole God damn pump’s clotting off.”
McBride’s eyes flashed back to Quintana. “You said you gave the heparin.”
“I did,” he insisted, scanning the monitors and checking his IV lines. “This shouldn’t be happening.”
“We gotta get this guy off bypass right now,” McBride shouted at Todd, knowing that was the one small chance Tony Wallace had of surviving. “He’ll need to go back on as soon as you’ve changed all the tubing.”
“I’m already working on it,” Todd answered.
“He’s too cold,” McBride said, pounding his fists together. “His heart will never start on its own. We’ve probably already stroked him out by showering his brain with clots. I’m clamping the tubing. I’ll massage the heart until you get the circuit changed and we can go back on bypass.”
McBride and Quintana exchanged a desperate glance. McBride knew they were both thinking the same thing; Tony Wallace’s chances of making it out of the operating room were rapidly approaching zero. “Give him another bolus of heparin right now,” McBride said.
Quintana held up an empty syringe. “It’s already in.”
Cradling Tony’s lifeless heart in both of his hands, McBride continued to squeeze the flaccid organ once every second.
“There’s no blood in the damn heart. It’s all clots. Does he have a blood pressure?” McBride asked.
“Of course not. The guy’s blood has turned to cement,” Quintana answered with equal frustration. “You need blood that circulates to have a pressure.”
“God damn it, Todd. How much more time do you need?”
“I’m changing the circuit as fast as I can, but it’ll take another four or five minutes.”
Kirby McBride felt his own heart racing. Todd might as well have told him he needed seven or eight hours because it wasn’t going to make a particle of difference. With sweat pouring down the back of his neck, McBride took a deep breath and continued squeezing the motionless heart.
Another five minutes passed. He looked over at Todd who was still working feverishly to replace the tubing. Finally, he gazed up toward the ceiling as if he were somehow seeking divine intervention. Without anybody having to say anything, the bedlam in the operating room changed to an eerie silence.
The heparin hadn’t worked. All of Tony Wallace’s blood had clotted.
McBride turned his eyes toward Quintana and asked in a defeated voice, “Is it possible that he accidentally got the protamine too soon?”
“C’mon, Kirby. I’m not a rookie, for God’s sake. We never reverse the heparin until the patient’s off the pump.”
“I’m . . . I’m sorry, Mike. I had to ask.”
McBride had done almost four thousand open-heart cases in his career and he had seen every mishap, complication, and disaster known to cardiac surgery. He was both knowledgeable and experienced on the subject of operating room calamities. Most of all, he knew the difference between a fixable complication and an irretrievable catastrophe. A heart and lung machine clotting off in the middle of a pump run was a clear example of the latter. He knew the moment he saw the first blood clot that irrespective of what he did, Tony Wallace’s fate had already been sealed.
McBride stood silently in front of his patient, his
eyes trained on the operating table.
Finally, he cleared his throat and announced, “We’re stopping. Please note the time.”
He looked over the top of the sterile drapes at Mike Quintana, who nodded and said, “I agree.”
McBride pulled off his gown and gloves and tossed them into a large bin. Walking toward the door, he knew the details of what had just happened would spread through the hospital like a brush fire in a high wind. He heaved a breath of despair and wondered how he’d tell the people waiting for news of Mr. Wallace’s operation that he had been killed by an inexcusable surgical debacle.
CHAPTER 12
DAY THREE
The moment Morgan Connolly walked into the waiting room of her father’s office, her mind was showered with painful images of his funeral.
Hundreds of Allen Hawkins’s friends, colleagues, and patients had crowded into the cathedral that he devotedly attended every Sunday to offer their respects to a much-loved man and a revered member of the community. Although it was the most difficult thing Morgan had ever done, she delivered a tender eulogy to the man who had always been her hero.
“Hi,” Annalisa Gregory said, snapping Morgan out of her dreamlike state. Annalisa had been her father’s office manager for the past ten years. Nobody knew Allen Hawkins’s professional side better or admired him more than she did. “How are you?”
“Things are starting to get back to normal,” Morgan answered.
Annalisa took her by the arm. “I was so happy you called. Let’s go back to my office. We can talk there.” Annalisa directed Morgan to a small love seat and then pulled up a chair and sat down directly across from her. They talked for a few minutes about the impact of her father’s death on the office and how different things were now. Although there were two other orthopedic surgeons in the practice, they were all business with respect to both their patients and the staff.
“You mentioned on the phone that there was something specific you wanted to talk to me about.”
Relieved that Annalisa had been the one to broach the topic, Morgan said, “I have some questions about what happened the day my father died.”
Annalisa looked circumspect. “Are you sure you want to talk about this, Morgan?”
“I’m sure.”
“Okay. I’ll answer whatever I can.”
“Can you tell me what you remember from the moment you knew something was wrong?”
“I was in my office when I heard all the commotion in the hall. I came running out and went straight to the exam room. We did CPR until the paramedics arrived.”
“According to the police, the man identified himself as Stuart Artesian,” Morgan said.
“That’s right.”
“Do you remember seeing him when he left the office?”
Annalisa shook her head. “The hallway was packed and the place was in chaos. I didn’t meet him when he signed in, and he wasn’t in the examination room when I got there.” She shook her head. “You might want to speak with Carrie. She did the initial evaluation.”
“If she’s available, I’d really appreciate it.”
“No problem,” Annalisa said, picking up the phone and paging Carrie overhead. She had barely set the phone down when a young lady with short, reddish blond hair and a coppery complexion appeared at the door. Annalisa gestured her to come in. “Dr. Connolly would like to talk with you about the day her father was attacked. Do you have a few minutes?”
“Of course,” she said, stepping into the office. Annalisa pointed to one of the two chairs in front of her desk. Carrie sat down.
Morgan had known Carrie Ahern since the day she had come to work for her father. She was two months shy of her nineteenth birthday at the time. It was largely because of Allen Hawkins’s encouragement that Carrie had completed her undergraduate education and then went on to become a certified physician’s assistant.
“Annalisa mentioned to me that you did the initial evaluation on Artesian,” Morgan began. “What do you remember about him?”
“He was a little strange, but it wasn’t like there were a bunch of alarms going off in my head.”
“What do you mean by strange?” Morgan asked her.
“He was way too familiar for a first-timer,” Carrie explained, pushing a few strands of hair from her forehead. “A lot of patients are talkative on their first visit, but it’s usually because they’re nervous. He seemed totally relaxed and he acted like he was some kind of expert on hospitals and doctors. He kept trying to impress your father with everything he knew about patient safety and Code Fifteens.” Carrie moved forward in her chair a couple of inches. “He said he knew you, Dr. Connolly.”
Annalisa and Morgan exchanged a curious look.
“Did he mention my name specifically?”
Carrie nodded. “He said you saw him in the emergency room, and that you had referred him to your father for further treatment of his hand.”
“Wait a minute. Are you saying he knew I was Dr. Hawkins’s daughter?”
“He absolutely knew. I remember because it surprised me.”
Morgan gazed over at Annalisa for a second time. “This doesn’t make any sense,” she insisted. “I don’t tell patients who my father is, and I would never refer a patient to him. The other orthopedic surgeons on ER call would have a meltdown if they thought I was showing favoritism.” Morgan stood up. She walked over to Annalisa’s desk and sat down on the corner. “Did he say anything else about me?”
“He knew you were chief of the Emergency Department and the chairperson of the Patient Safety Committee.”
“How in the world would he know that?” Morgan asked, without really expecting a response. “Why did you leave the exam room? Normally, you wouldn’t do that.”
“He told your father he had a personal health problem that he wanted to talk to him about. He didn’t actually ask me to leave but I took the hint.”
“Do you remember anything else he said?” Morgan inquired.
Carrie’s eyes narrowed in thought. “It wasn’t anything he said, but there was definitely something else weird about him.”
“What do you mean?”
“He didn’t look right.”
“What do you mean?” Annalisa asked.
“I’m in the gym six days a week. People’s faces can sometimes fool you but it’s different with their bodies. For an old guy hobbling around on a cane, he looked to be in pretty good shape.”
Carrie’s observations came as no surprise to Morgan. The police had already told her that based on the violent nature of the crime, they assumed Artesian was a younger man who had disguised his appearance.
“Anything else?” Morgan asked.
Carrie paused briefly and then added, “Only that he needed a good orthodontist.”
Morgan barely heard the overhead page requesting Carrie to come to the X-ray room. When she saw Carrie glance over at Annalisa, she pushed herself off the desk. She walked over to Carrie and extended her hand. “Thanks a lot. You’ve been a big help.”
“I’m very sorry about your father, Dr. Connolly. He did a lot for me over the years. I lost my dad last year.”
Morgan thanked her again and walked her to the door. She waited for Carrie to disappear down the hall before closing the door.
“Do you think she told the police all that?” she asked Annalisa.
“She must have. They interviewed her for almost an hour.”
Morgan shook her head. “I don’t remember treating anybody recently with a hand injury who might fit Artesian’s description.”
“That’s because you probably didn’t.”
“Excuse me?”
“Whoever this guy was—he lied about everything. I went over his patient information form with the police in detail. It was like reading a fairy tale. After we were done, one of the detectives called the medical records department over at the hospital to see if Artesian had ever been a patient. They said they had no record of anybody by that name ever being seen in the eme
rgency room.”
“He might have used a different name,” Morgan pointed out.
“I guess that’s possible.”
“I’m going to pull up my patient encounters by diagnostic code. It will show me all the hand injuries I’ve treated in the last year.”
“What do you think about Artesian claiming to have known you?”
“I had no idea,” Morgan said, pressing her palms and fingertips together. “But I’m not surprised. The police are pretty strict about sharing information about their investigations.”
“Did they tell you about the note?” she asked in a hesitant voice.
A look of bewilderment flashed across Morgan’s face. “What note?”
“He left a note, Morgan. Artesian left a note,” she repeated, stopping after each word.
“He put it on the counter. I didn’t notice it until right after the paramedics took your father over to the hospital. I gave it to the police.”
“Did you read it?”
She nodded. “Normally, my memory’s not that good, but I guess this is the kind of thing you never forget. It said, Hell is truth denied. Comes now the penance for the third of three. He signed it Gideon.”
“The third of three? What’s that supposed to mean? Three what?” Morgan asked, thinking to herself that whoever Stuart Artesian, or Gideon, as he called himself, really was, his plan to kill her father was very well orchestrated. Having spoken with both Carrie and Annalisa, Morgan didn’t feel there was any reason to talk with any of the other staff.
“Thanks for all your help.”
Annalisa met Morgan in the middle of the office and gave her a long hug. “Bill and I want to have you over for dinner.”
“As soon as things calm down,” Morgan promised, realizing that Annalisa’s invitation didn’t include Kevin and that she must have heard about their separation. Morgan was relieved Annalisa had the courtesy to spare her a barrage of questions about it.
They walked together through the lobby. “I’ll call you about dinner,” Morgan told her again when they reached the door.
Heavy in thought regarding the note Gideon had left, Morgan barely remembered leaving her father’s building and walking to her car. Before pulling out, she put the Thunderbird’s top down. With the warmth of the sun blanketing her shoulders, she thought about everything Carrie had said.