The plane taxied out to the active runway and after a brief pause started its takeoff roll. With added power, the low hum of the engines became an earsplitting whine. Sixty seconds later the jet was in a steep climb, leaving the island of Saint Kitts far below. It wasn’t until they leveled off above the clouds that Jack’s pulse slowed to a normal rate.
“Something to drink?” Mike asked.
“No, thanks. I’m good,” he answered, noticing the small slit-like scar over Mike’s eyebrow—an injury he had sustained in high school when Jack accidentally had caught him with an elbow in a heated one-on-one basketball game.
Jack had spent an hour online the previous evening learning as much as he could about the outbreak. From a medical standpoint the information was limited but there was enough to give him a sense of what questions to ask.
“Did you have any clue Tess was ill before you got the call?”
“Hell, Jack. I don’t know. You’re the last person I need to tell what Tess has gone through the last twelve years to get pregnant. Two second trimester miscarriages and traveling for weeks on end seeing every fertility expert in the country.” He lowered his chin. “I . . . I had no idea anything was wrong.”
Sensing his guilt, Jack said, “If it makes you feel any better, most of the doctors I know have a hard time deciphering between illness and a routine pregnancy. Assume for a minute that Tess wasn’t pregnant, would you say her behavior and mental functions have been normal?”
“She seemed a little . . . a little confused maybe for the past couple of days, but I thought she was just preoccupied.”
“What was she confused about?”
“She mixed up some of her friends’ names and messed up her daily schedule a few times. I mentioned it to her, but I think I embarrassed her. She kind of blew me off. You know Tess. She never complained about anything and I stupidly didn’t press the issue.”
“Have you guys done any traveling in the last few weeks?”
Mike shook his head and then laced his fingers behind his head.
“Has Tess had any recent flu symptoms, like a cough or a fever or trouble breathing?”
“The Everglades aren’t too far from the house. When we found out she was pregnant, we began taking a walk every evening. We had to stop a week or so ago. She said there was an odor in the air that was making her sick to her stomach and a little short of breath.”
“Did the symptoms go away when you stopped taking the walk?”
“Totally.”
“Is she taking any new medications, homeopathic compounds, herbal remedies—things like that?”
“Christ, Jack,” he said with a corded neck. “There are hundreds of women around the country with this thing. I don’t think this is about Tess’s travel schedule or drinking herbal tea. None of this is fair. Tess is the kindest, gentlest human being in the . . .” With a pained expression, Mike turned his head and stared out the window.
“I’ve seen countless family members drive themselves crazy looking for justice when it comes to illness. It’s never there.” It crossed Jack’s mind to continue to try and persuade Mike to stop beating himself up, but he knew he’d be shouting at the rain.
Jack’s mind continued to fill with a host of unanswered questions, but he could see Mike needed a break. He knew he could talk himself blue in the face trying to convince him that Tess would recover. But even as kids, their relationship had always been an honest one free of pretense. To blow sunshine in his best friend’s direction would be at the very least transparent and at worst insulting.
In smooth air, the Hawker jetted effortlessly toward South Florida. With a strengthening sense of confidence, Jack lifted the shade and peered out. Below him, a gathering of willowy gray clouds partially obscured the white caps.
Mike had reclined his seat and was still looking out of his window. If asked, Jack would be the first to say that Mike was an intelligent and pragmatic man who hadn’t achieved his success by requiring others to connect the dots for him. Thinking about their conversation, Jack realized two things. The first was that Mike hadn’t asked him if Tess might die. The second was that his failure to do so wasn’t an oversight.
8
Harbordale General Hospital
Spokane, Washington
Working in the ICU was the only job Lori Case had had since graduating nursing school. After fifteen years, she was a battle-hardened veteran who was completely unflappable. For the past two days, she had been taking care of Lizette Bordene, Harbordale General’s fourth patient admitted with GNS. Lizette was the assistant manager of a small clothing boutique and the mother of two. Until a few days ago, she had never been seriously ill in her life.
Lori returned from her break to find Lizette’s mother exactly where she’d left her, sitting forward in a small plastic chair at the foot of the bed.
“Why don’t you go home and get some rest?” Lori suggested. “I’ll call you if there are any changes.”
“I’m . . . I’m not sure. Maybe I should—”
Lori put her hand on Gail Bordene’s shoulder. “Go ahead. She’ll be fine. You need some rest.”
Gail reluctantly came to her feet. With an empty stare, she looked at her daughter. After a few seconds, she removed her purse from the back of the chair.
“I’ll be back in a few hours. You have my cell phone number.”
“It’s written on the board and it’s in my phone book,” Lori assured Gail as she walked her to the door with her arm around her shoulders.
For the next two hours, Lizette’s condition was stable. Lori had resigned herself to another long but uneventful shift. But all of that abruptly changed when, without any warning, Lizette’s blood pressure went into an uncontrolled free fall.
The room instantly reverberated with a cacophony of alarms and alerts. Lori’s eyes flashed to the cardiac monitor. In addition to a dangerously low blood pressure, her pulse was erratic. As a reflex more than anything else, Lori smacked the Code Blue button on the wall summoning the rapid response team. She had barely gotten back to the bedside when Dr. Stephen Arrani and two nurses charged through the door. Lori held Arrani in higher regard than most of the other doctors she worked with because he was knowledgeable and decisive, which were skills that seemed to be lost on many of the newer physicians.
“What’s going on?” he asked, snatching the stethoscope that lay draped across his shoulders.
“She’s crashing,” Lori told him, checking the IV tubing. “Her pressure suddenly took a dive for no reason. It’s down to sixty, and her cardiac rhythm’s all over the place.”
“Looks ventricular. What was her last potassium level?” he asked, cranking up the oxygen to one hundred percent as he snugged the mask around Maggie’s nose and mouth.
“I drew one a couple of hours ago. It was normal.”
By this time, a respiratory therapist and a pharmacist had dashed into the room and had taken up their assigned positions for a Code Blue.
“Looks like she’s in V-tach,” Arrani said. “Give her a dose of lidocaine.”
“I’ve already drawn it up,” the pharmacist said, handing the syringe to Lori who immediately injected it into the IV port. Silence settled over the room as everyone’s eyes locked on the monitor waiting to see if the medication would correct the irregular heart rhythm.
“She’s still in V-tach,” Arrani announced, his voice building in intensity.
“Her pressure’s down to thirty,” Lori said.
“Start chest compressions,” Arrani ordered. “And get a ventilator set up. She’s going to need it.”
Lori was all too familiar with the razor-sharp pinch in the pit of her stomach she was now feeling. As a seasoned ICU nurse, she had taken care of countless patients who had taken an unexpected turn for the worse, but it was something she had never gotten used to.
“She’s not breath
ing. We need to tube her right now,” Arrani said, craning his neck in the direction of the door. “Who’s here from anesthesia?” Carrie Sherman, the nurse anesthetist on call, moved to the head of the bed. “Are any of the obstetricians in house?” he asked.
“I saw Dr. Crossman up on labor and delivery about twenty minutes ago,” Carrie answered. “He was just finishing up a delivery. He’s probably still here.”
“Tell the unit secretary to find him stat. If we can’t get her heart rhythm back to normal and her blood pressure up in the next five minutes, she’s going to need a crash C-section.”
While Arrani continued to shout out orders, Lori carefully slid a metal scope in Lizette’s mouth. The highly practiced maneuver brought her vocal cords into clear view. She reached for a curved plastic tube and eased it between the cords and down into her windpipe. As soon as she had it securely taped into place, she connected it to the ventilator. Lizette was now completely dependent on the machine for every breath of air that filled her lungs.
“Her pressure’s still thirty,” Arrani called out. “We’re losing her. Where the hell’s Crossman?” He turned back to Lori. “Give her an amp of epinephrine and keep going with the chest compressions.”
Arrani’s words were still suspended in air when Jim Crossman burst into the room with his chief resident in tow. Crossman was one of only three obstetricians on staff who agreed to cover the trauma center. After responding to dozens of critically injured pregnant women who were the victims of serious car accidents, gunshot wounds and stabbings, he was no stranger to performing a crash C-section to save the baby of a dying mother.
“Somebody talk to me,” Crossman said, making his way to the bed.
“She’s a thirty-year-old with GNS,” Arrani answered between quick breaths.
“How far along is she?”
“Twenty-nine weeks.”
“What happened?”
“She went into V-tach and her blood pressure dropped.” He shook his head. “I’m trying, but I can’t get it back up.” His eyes shifted to the cardiac monitor. “She’s going to arrest.”
“How long has her blood pressure been that low?” Crossman asked.
“Four minutes.”
“Any chance you can reverse all this in the next minute or so?”
“I doubt it.”
“Keep up the chest compressions,” he ordered. “If we don’t keep Mom’s heart pumping, the baby doesn’t have a chance.”
At that same moment, two nurses from the operating room with a huge metal box of sterile instruments came through the door.
“I think we should get her ready and move her to the operating room,” Arrani said.
“The operating room is two floors away,” Crossman reminded him. “From what I’m looking at, she wouldn’t survive a change of socks at the moment, let alone a trip to the OR. We’re doing the section right here.” He stole a quick glance around the room. “I need everybody who doesn’t absolutely need to be here to get the hell out right now. What do you say, Carrie? Can I start?”
“Go. She’s not going to move.”
By this time, his scrub nurse, Kate, had carved a path to the front of the room and had set up two sterile trays of instruments.
“We’re ready,” she told him.
“Somebody call the neonatal ICU,” he said, slipping on his sterile gown and gloves. “Dr. Armbrister’s on call. Tell her to get her butt down here right now.”
The stalwart look on his face left no room for misinterpretation. His decision to proceed with the emergency C-section was not up for discussion. “Don’t stop for me,” he told Dr. Arrani. “The sooner you get her heart rhythm fixed, the better chance she and the baby have of surviving.”
He then reached his hand behind him. Kate handed him a sterile metal basin filled to the top with iodine prep solution. There was no time for the usual neat application of a coat or two. Crossman tossed the entire contents of the basin across Lizette’s abdomen. And then, except for the rhythmic snap of the backboard with each compression of her chest, the room again became silent.
9
Two minutes after he had made an incision, Crossman held Lizette’s uterus cupped in his hands. Selecting an area between the engorged veins, he quickly made an incision just large enough for the baby to fit through. Working his way through the thick muscular wall, he entered the body cavity of the uterus. Carefully scooping the baby out of the organ, he clamped the umbilical cord and cut it.
“I’m right behind you,” Armbrister said, with her arms outstretched and draped with a sterile towel.
Crossman set the baby into her waiting arms. She was profoundly blue and limp as a Raggedy Ann doll. She made no sounds, not even a whisper of a cry. With the help of her nurse practitioner, Armbrister positioned the baby on a warming bed and swiftly slid a breathing tube through her graying lips and down into her trachea to assist her breathing.
“Talk to me, somebody. How’s the baby doing?” Crossman inquired without lifting his eyes from the operating field.
“She’s alive,” Armbrister answered, using a plastic bulb to suction out the baby’s nostrils and mouth. The instant she was finished, she transferred the baby from the warming bed to an incubator. “We’re out of here,” she announced.
“Does she have a chance?” Crossman asked.
“Ask me in about twenty minutes. Right now things aren’t looking so good.”
During the entire time the C-section was in progress, two medical residents alternated performing CPR on Lizette. At the same moment Crossman finished stapling closed her incision, her heart suddenly stopped. Arrani and the others continued to work like madmen for the next twenty minutes to restore a heartbeat but with no success.
Finally, he looked away from the monitor. His eyes dropped and in a monotone drenched in defeat, he said, “We can stop the chest compressions. I’m calling it. Somebody note the time of death for the record please.”
By this time, the floor was littered with empty medication boxes, paper heart tracing strips and an endless assortment of used medical supplies. Allowing a full breath to flow out from his lungs, he leaned over and picked up a box. As far as he knew, Lizette Bordene was the first death from GNS in the country.
After a minute or so, he crumpled the box in his hand and tossed it into the trash. As much as he dreaded doing it, he walked over to the phone to call Lizette’s mother.
10
The moment Jack stepped off the plane in West Palm Beach, he was struck by a squall of wind rich with the scent of ozone. Shading his eyes, he gazed to the east at the remnants of a rogue storm moving offshore.
“My car’s right over there,” Mike said, gesturing to a small gravel lot protected in part by a weather-beaten chain-link fence. “It’s only about a thirty minute ride to the hospital.”
• • •
When Mike turned his SUV into the Southeastern State University Medical Center, Jack was immediately taken back. The sprawling medical complex bore no resemblance to the small hospital he remembered. In addition to the new school of medicine, the medical center now boasted a six-hundred-bed teaching hospital, a seven-story research center, and a children’s hospital. To the west, Jack noticed a modernist building nearing completion. A large banner in front of it indicated it was the future home of Southeastern State University’s Women’s Cancer Hospital.
As they approached the valet parking area, Jack’s attention shifted to the dozens of media vehicles amassed in a parking lot alongside the hospital. Their antennae spiraled upward like the towering masts of a flotilla of great sailing ships. Around the vans and SUVs, dozens of broadcast personnel congregated in small groups. Some were dressed casually and stood with cameras hoisted on their shoulders. Those who were more formally attired gripped microphones in their hands. The largest group jockeyed for a preferred position directly in front of the main entranc
e to the hospital. The GNS outbreak was an enormous story. He wasn’t surprised that the prediction Helen Morales had made on the phone regarding the inevitability of a media circus at Southeastern State had come true.
Mike and Jack made the short walk from the parking lot and entered the hospital through a revolving glass door. They hadn’t taken more than a few steps when a slight woman wearing a teal-colored suit approached at a brisk pace.
“Jack, I’d like you to meet Dr. Helen Morales.”
A peculiar habit of Jack’s for as long as he could remember was conjuring up an image of a person’s appearance based on his or her telephone voice. He smiled to himself. As usual, he was light-years off of the mark. Helen wasn’t matronly, stout or on the fashion police’s most wanted list. She was just the opposite.
Helen took Jack’s extended hand and gave it a vigorous shake.
“Welcome back to South Florida. I can’t thank you enough for accepting our invitation.”
“It’s nice to meet you.”
With more than subtle apprehension in his voice, Mike asked, “How’s Tess doing?”
“I just came down from the ICU. I’d say she’s about the same.”
Mike pushed out a quick breath but said nothing. As well as Jack knew him, he couldn’t be sure if he was encouraged or dismayed by Helen’s report.
“Would it be all right if I catch up with you two a little later?” Mike asked. “I have a couple of things to take care of.” Mike took a few steps forward and gave Jack a brief hug. “I almost forgot,” he said. “I had some clothes sent over to your hotel. I figured your vacation attire might not be appropriate for the hospital. They may not fit perfectly but I think they’ll be close enough.”
“Thanks. I’m sure they’ll be fine,” Jack said, wondering if Mike really had something to do or if, for the moment, he just couldn’t bear seeing Tess.
Error in Diagnosis Page 4