Miracle Cure

by Michael Palmer

  … My bet is you do that ’n you’ll find yourself on unemployment quicker than you can say junkie.…

  … Real life can be pretty damn cruel at times.…

  The words continued reverberating in his head as Brian entered the hospital through the White Memorial lobby. He was still shaken by what had happened in the animal lab the night before, but he knew that whatever he had to endure, he would. All he had ever asked was to get his foot back in the door of medicine. Now, it was time to begin proving himself. And if proving himself meant turning the other cheek to bastards like the animal keeper, that’s what he would do. There was simply too much at stake not to—for him and for his father.

  At eight-fifteen the previous evening, when Brian arrived home from his orientation, he had found Jack asleep in his chair. Sally Johansen, the neighbor on duty, put a finger to her lips, then pointed to the nitroglycerin vial and put up three fingers. Three episodes of pain. Brian thanked her silently, kissed her on the cheek, and waved her out. Then he gently woke Jack up to give him his Oreo cone. Jack stayed awake long enough to wolf down the ice cream and then allowed Brian to walk him to bed, a concession that was totally out of character. The man was failing. Difficult decisions could not be postponed much longer.

  Brian set a stack of cardiology texts and journals on the floor by the couch. Then, suddenly restless, he had pulled on a pair of sweats and gone for a slow three-mile jog through the balmy evening—the first time in months he had run. The encounter with Earl was tough to shuck, but finally, after half a mile or so, he managed to get his mind to drift into hazy images of what life would be like once he had a private practice again and a few years of decent income.

  Back at home, he had showered, then settled in for what turned out to be several hours of studying. He was dozing on the living-room couch when he heard Jack groan, shuffle to the bathroom, then back to bed. Brian finished the chapter he was reviewing and went to the doorway to check on him. His father was propped against the headboard, the tiny vial of nitroglycerin in his hand.

  “Pain wake you up?” Brian asked, startling him.

  “Oh, hi … no … I mean, a little. Yesterday wasn’t my best.”

  “Mine, either,” Brian said before he could edit himself.

  “What do you mean by that? You said over the phone that things were going great.”

  “They’re fine. Everything’s fine … except you and that angina.”

  “I’ll tell you what,” Jack said, slipping a nitro under his tongue, “when you level with me, I’ll level with you.”

  He closed his eyes and slid back down on the pillow, waiting for the medication to dilate his coronary arteries and bring a little extra blood to his oxygen-starved heart muscle. In just a few minutes he was asleep on his back, snoring. Brian stood there for a time, looking down at him.

  What if I hadn’t changed that play that you called? he was thinking.

  Brian arrived at the cath lab after making rounds on the eighteen patients on the clinical ward with Phil, a cardiac fellow, two residents, two medical students, and the nurses. He was not surprised that his old friend was an excellent teacher and compassionate physician. Only two of the eighteen patients were part of the Vasclear study, and although both were quite ill from cardiac disease, both were in the gamma group, which Phil said was almost certainly placebo. If anything, the bedside discussion of Vasclear and the consistent lack of side effects in the beta group made him even more certain that Jack would benefit from treatment with it.

  The case he would be assisting Carolyn Jessup on was a routine eighteen-month, post-Vasclear cath study in a sixty-nine-year-old woman named Nellie Hennessey. Brian walked down to the basement from the fifth floor, with the faces of Earl the animal keeper and the pockmarked man flashing alternately in his mind like a neon sign.

  Before entering the cath suite, he glanced down the corridor at the animal facility. Number 4386. Was it worth speaking to anyone about the pathetic chimpanzee, or, for that matter, about Earl’s abominable behavior? At this moment in his brief history at Boston Heart, the answer to both questions was a resounding No. If he was going to make waves about anything, it would be about getting Jack randomized into the Vasclear study.

  Andrew, the cath tech, was changing into his scrubs in the men’s locker room.

  “Morning, Dr. Holbrook,” he said. “Welcome to the staff.”

  There was genuine warmth in his expression. Brian extended his hand and the man gripped it firmly. When they met at Jack’s cath, Brian had liked Andrew immediately. Now, he felt a twinge of discomfort that, like everyone else in the institute, Andrew had probably encountered some version of his life story. Get used to it, he thought, paraphrasing something Freeman had said to him more than once. Get used to it, then get over it.

  “It’s Brian,” he said.

  “Very well, then, Brian. How’s your father doing?”

  “Well, you saw his cath.”

  “I did. I hope the show Dr. Randa put on didn’t frighten you both out of following his recommendation. He’s just like that.”

  “As a matter of fact, Randa did send me scrambling to get my dad into the Vasclear program.”

  “And?”

  “I haven’t heard yet. Apparently his prior bypass surgery is a problem.”

  “I’m sorry to hear that. Vasclear sure has been a wonder. Mrs. Hennessey, who we’re doing this morning, looked just about as bad as your father before we started treatment. And now, just wait till you see.”

  “Is she here yet?” Brian asked.

  “Right outside in the holding area with Jennifer, the cath nurse. Lauren will be operating the console in the control room. Both of them were here when we did your father.”

  “Well, I’m ready.”

  “Dr. Jessup’s here, too. I just saw her go into the locker room, so it shouldn’t be too long before we’re ready to go. That Mrs. Hennessey’s a nice lady. Real nice.”

  Brian entered the cath lab just as Nellie Hennessey was being helped from the stretcher onto the cath table. He had seen her pleasant, impish face before, although it took him a few seconds to remember where. She was the Vasclear poster child featured in the video. Brian remembered her snapping blue eyes.

  “Nellie, look at these two men,” Jennifer said. “Twin towers. They look like basketball players.”

  Nellie Hennessey pointed up at Brian.

  “Andrew I know, darlin’,” she said. “But who’s he?”

  “A new doctor here. Dr. Holbrook. He’s going to be assisting Dr. Jessup with your cath.”

  Nellie motioned Jennifer to bend closer.

  “He’s very cute,” Brian heard her say in a stage whisper.

  “Mrs. Hennessey, it’s nice to meet you,” he said, taking her hand. “But I think I sort of met you yesterday when I watched the film about Vasclear.”

  “Oh, yes,” Nellie said. “My fifteen minutes of fame. How long have you been a doctor?”

  “Quite a while. But I’m new here.”

  She thought about that for a moment.

  “Well,” she said, “Dr. Jessup’s the best. She’ll teach you all you need to know about doing this.”

  “Why thank you, Nellie,” Jessup said, sweeping into the room, scrubbed, capped, and masked. “Good morning, everyone. I assume you all remember Dr. Holbrook. Brian, why don’t you scrub. We’ll be ready to go as soon as you do.”

  There was a small prep area between the locker room and the lab. Brian donned a mask and hair-cover and did a four-minute scrub over the stainless-steel sink. Despite the fact that he had performed a thousand or more cardiac caths, and even though he was only going to assist today, his heart was doing the flamenco in his chest. He shook the water from his hands, backed into the cath lab, and allowed the scrub nurse to help him gown and glove.

  “Okay, gang,” Carolyn said, “let’s get started. Nellie, are you ready?”

  “My back’s already starting to ache. So let’s get this over.”

&nb
sp; “Grumble, grumble.”

  Jessup gave Nellie Hennessey’s history as she worked.

  “Mrs. H. is a sixty-nine-year-old retired schoolteacher—”

  “Sixty-eight-and-a-half,” Nellie interjected.

  “Sixty-eight-and-a-half, who was referred to me almost two years ago for chest pain—”

  “Actually, it was up here in my shoulder and sometimes my neck,” Nellie said, her speech beginning to thicken. “Never really in my chest.”

  Jessup put two fingers over Nellie’s femoral artery pulse and smoothly slipped the large-bore needle through the anesthetized skin beneath her fingers and into the vessel. Then she advanced the arterial catheter through the needle and up toward the left-side chambers of Nellie’s heart.

  “Having Nellie as a patient,” she said, “is like being back in school. You get marked off for everything.”

  “You still get an A, dear,” Nellie said, her tongue and mouth now parchment-dry.

  “That Ward-Dunlop catheter really is slick,” Brian noted.

  “I expect you to use it exclusively when you start doing cases on your own.”

  “No problem there.”

  “Well, to continue, Nellie’s treadmill stress test was positive, and a subsequent cath showed fairly severe coronary artery disease. She was a perfect candidate for randomization into the Vasclear study. Right, Nellie?”

  Nellie, eyes closed, was breathing deeply and regularly.

  “Jennifer,” Jessup went on, “maybe we should be giving her a tad less pre-op medication. If I have to stay awake for this, everyone does.” She glanced over at the nurse, her eyes smiling. “Seriously, nice job. She’s perfect.… Anyhow, Brian, Nellie’s symptoms disappeared almost immediately and haven’t returned. This is her third and last follow-up cath. Then she becomes an alumna.”

  “What Vasclear group is she in?” Brian asked, already knowing the answer.

  “Beta. Okay, Doc, you’re on. Let’s switch sides. You do the right heart and afterward I’ll switch back and do the coronary-artery shots. Nellie’s asleep so you’re not being graded on this. Just relax and have fun.”

  “Thank you.”

  Surprised and pleased at being asked to do anything other than observe, Brian moved behind Carolyn to take her place at the table.

  “Everything on the Ward-Dunlop works pretty much like the one you’re used to,” she said, “except the controls are much more responsive, and the connections on the ports just click and lock.”

  “Impressive,” Brian said, proceeding with the pressure studies and dye injections.

  The nurse, Jennifer, was working beside him now, keeping a careful watch on Nellie, checking her blood pressure and IV.

  “Everything okay?” Brian asked her.

  “All systems are go,” she replied.

  Brian took some pressure measurements through the catheter, then injected some dye to check the tricuspid and pulmonic valves. The moment he had thought might never come was here. He was back in the cath lab, regaining control, piece by piece, of his own destiny.

  “You seem pretty comfortable there, pardner,” Jessup said, returning to her position to do the left heart and coronary-artery exam.

  “Just like riding a bike. She’s got a pretty healthy-looking heart.”

  “Wait till you see her coronary arteries. These pictures we’re about to shoot are going to be the eighteen-month-afters. The befores are in the cine-library through the door just past the women’s changing room. Did security give you a code for the keypad?”

  “They did.”

  “Great. Sometime soon, go and take a look at Nellie’s pre-Vasclear films. We’ve got two Vangard viewers in there. One for backup.”

  “I’m impressed,” Brian said. The viewers, from what he remembered, cost around twenty thousand dollars apiece.

  “You’ll be even more impressed when you review her films,” Carolyn said. “Now, let’s take a look at her left heart and coronarles.”

  The experimental Ward-Dunlop catheter was exceptionally easy to manipulate, and certainly showed up well on X ray.

  “Left anterior oblique cranial … right anterior oblique caudal …”

  Jessup called out each angle, waited for Andrew to position the X-ray camera, then injected some dye and activated the camera with her foot pedal. Overhead, one screen showed the bright white of the X-ray-opaque dye as it briefly filled Nellie’s coronary arteries before being washed away, and another traced her heartbeat, oxygenation, and other vital signs. In the glassed-in control room to their right, the other nurse, Lauren, monitored duplicate screens, and kept watch over the machine that was recording the injections on videotape. Later, the tape would be reviewed by Jessup, and a report dictated. The width of every significant artery and every blockage would be carefully measured by computer and recorded.

  “… Right anterior oblique cranial,” Carolyn said, completing the last of the five left coronary-artery views. “Okay, everyone, if there is anyone with reasons why this woman and this catheter should remain in holy matrimony, let him speak now or forever hold his peace.… There being no objections to removal of this line, I hereby do so.”

  Carolyn withdrew the catheter with the same smoothness, the same confidence, as she had displayed throughout the procedure. But quite suddenly, a brief flurry of extra heartbeats appeared on the screen. Then another burst.

  A few moments later, Nellie Hennessey moaned.

  Then she opened her eyes.

  Then she began screaming.

  CHAPTER NINE

  “OH, MY GOD! … MY CHEST, MY CHEST! … OH, God, I can’t breathe!”

  Nellie Hennessey, wailing piteously, clutched at her chest and thrashed back and forth, slamming her arms and shoulders against the X-ray tube still positioned just above her. Overhead, the monitor continued to record salvos of extra heartbeats, often the prelude to a full-blown cardiac arrest.

  There was no doubt in Brian’s mind what was happening. The woman was having a coronary occlusion—a heart attack. But why? They had just examined her coronary arteries and they were virtually clear of arteriosclerosis. There were only two explanations that made sense.

  “Give her morphine,” Jessup ordered urgently. “Three IV. No, make it four. How’s her pressure?”

  “One-eighty over one-ten,” Jennifer replied.

  “Brian, what do you think?”

  “She’s either in coronary-artery spasm,” Brian said, “or the tip of that catheter broke off while you were pulling it out. Has that ever happened before?”

  “No,” Carolyn said, too quickly. “I mean, not here. Not in a while.… Nellie … Nellie! You’ve got to try and lie still. Jennifer, where’s that morphine?”

  “Four milligrams in.”

  “Hang a nitroglycerin drip up, please.”

  “Right away.”

  “Oh, my God!” Nellie shrieked. “Help me! … Please help me!”

  Brian knew he was just there to assist, and Carolyn Jessup was a seasoned specialist, a professor. Still, Nellie Hennessey’s life was at stake. He had spent seven years as a partner in a very active private practice, the last three of them as chief of a busy cath lab. If it became clear that he saw something Jessup didn’t, he wouldn’t hesitate to call her attention to it. But for the moment, she was handling things flawlessly. And regardless of who was in charge, Nellie Hennessey was in big, big trouble.

  “Let’s give her seventy-five of Xylocaine to do something about those extra beats,” Carolyn said. “Nellie, please, try to hold still! Andrew, give me an LAO caudal angle. I’ve got to see if the catheter tip has broken off and wedged itself in an artery.”

  Andrew moved the camera electronically to the left anterior oblique position. Nellie, perhaps responding to the IV morphine, settled back a bit, but continued moaning in pain. Jessup clicked the fluoroscopic camera on with the toe plate.

  “There,” Brian said.

  It took a few moments for the others to see the fragment, but there it was
—a small, bright white line on the black-and-white screen. It was three-quarters of an inch long, resting on top of the upper portion of the heart muscle, moving with each beat.

  “What do you think?” Jessup asked. “Left main?”

  “Hard to say, but yes. That’s my guess.”

  Almost certainly, the catheter tip had broken off and become lodged in the left main coronary artery—the Widowmaker.

  “Lauren, call the OR, please,” Jessup said to the control-room nurse. “Have them assemble the pump team and whichever surgeon’s available. We’re going after this, but I want them on standby as quickly as possible.”

  “Oh, sweet Jesus, I can’t breathe!” Nellie was crying. “Do something … My chest is being crushed! … Please, please, oh God, do something!”

  The tension in the room, already bowstring tight, was ratcheted even tighter by the woman’s unremitting cries. Brian was impressed and relieved to see that everyone on the team seemed able to handle the strain. For a moment, Andrew’s eyes met his. Although outwardly composed, there was no masking the technician’s concern.

  “Jennifer,” Jessup said, “if her pressure’s okay, give her another two of morphine.”

  “Given.”

  “Brian, what about intubating her? Are you sharp?”

  “I moonlighted in an ER for my first few years in practice. If anesthesia can’t get down here, I think I can do it.”

  “Lauren, page anesthesia. Andrew, get things ready for Dr. Holbrook to intubate. Be sure to check the balloon on the tube. Nellie, hang in there. Can you hear me?”—Nellie nodded weakly—“Good. Now listen, please. A piece of the catheter we used has broken off in one of your arteries and is blocking the flow of blood. We’re going to get it out. Understand?… Good. As soon as it’s out you’ll feel much better. Now, who came with you today?”

  “My … daughter.”