Michael Palmer

by The Last Surgeon

  Nick passed out a sheet of instructions for the next class, and asked his three students to check it over while he was gone.

  “What do you have?” Nick asked as he approached the curtain.

  Junie did not pull her head back.

  “I have a kid that I think has mono.”

  “Did you draw bloods?”

  “A mono test, CBC and liver chems, plus an amylase and lipase.”

  “Throat?”

  “Classic, if there is such a thing. I cultured it and gave him a supply of penicillin, a rinse, and some Motrin.”

  “Enlarged spleen?”

  “I don’t think so, but you know I’m not the best at that unless it’s the size of a football.”

  “You done good. Let’s see him.”

  Junie did not move. When she spoke again, it was in a near whisper.

  “I looked out a couple of minutes ago,” she said, “and you were staring up at Umberto’s poster. You okay?”

  “Hanging in there. The class is a nice distraction—especially these guys—but that nightmare I had on the way here is still resonating. Good thing I don’t have to hold a full cup of hot coffee.”

  “Have you tried your eye exercises?”

  Nick kissed her on the forehead and motioned to the examining room.

  “I’m doing fine. Now, let’s go kick some mononucleosis butt.”

  Not surprisingly, Junie was spot-on in her assessment of the seventeen-year-old, whose residence was listed as the 24 Hotel—night-by-night cots for homeless men. With no major trouble swallowing, and no striking enlargement of his spleen, the youth was sent out with a “mono sheet” of do’s and don’ts. As with most of their patients, the caregivers could only hope that he kept his follow-up appointment.

  Nick was back giving final instructions to his class when the mono patient passed by them and left, followed moments later by Junie, carrying her umbrella.

  “I’m going to grab the next victim,” she said. “I’m thinking of stopping by Dunkin’ Donuts across the street to see if they can donate a Box O’ Joe to our waiting room out there. They’ve done it before.”

  “Like they have a chance against you.”

  A gust of chilly, wet air blew in as she opened and closed the passenger side door.

  Just a few minutes later, the door opened again and a short, stocky, balding man entered. He was wearing a tan trench coat and shaking off an umbrella. He was followed immediately by Phillip MacCandliss.

  “Good evening, Garrity,” MacCandliss said, fixing Nick with dark narrow ferret eyes. “May I introduce Mr. Janus Fielding.” He increased his volume so that anyone in the rear of the RV could hear. “He’s with the D.C. Department of Health.”

  CHAPTER 5

  The sight of MacCandliss turned Nick’s stomach. It wasn’t the first unannounced visit he had made to the RV—two other times over the past few years he had “just stopped by to see what this operation is all about.” But this was the first time he had arrived accompanied.

  “We’re very busy, MacCandliss,” Nick said. “Why didn’t you phone ahead for an appointment?”

  “Now that wouldn’t be a very good way to go about holding a surprise inspection, would it?”

  The VA claims evaluator, infamous among the GIs for his hard-nosed refusal to grant disability benefits, remained in the stairwell behind Janus Fielding. MacCandliss was swarthy and thinly built, and looked slightly ridiculous in a tweed walking cap, but Nick knew better than to take the man lightly. He was devious and unpredictable except in his unswerving drive to put himself first in any situation.

  Nick sized up the moment and considered whether it was worth stalling until Junie’s return. Still shaky, he wondered if he could control his temper, which was known to be hair-trigger when he was dealing with the confounding symptoms of his PTSD. He glanced out at the bus stop waiting area, but she was probably still in Dunkin’.

  Damn you, MacCandliss, he barely kept from hollering out, why tonight?

  “Okay, Mr. Fielding,” Nick said instead, sighing audibly, “why don’t we start at the beginning. Credentials?”

  Fielding flipped open a dedicated leather case, revealing a Health Department badge and a photo ID.

  Facilities Inspector, Department of Health.

  “Exactly what is it you want, Mr. Janus Fielding?” Nick asked, recalling from a mythology course at Stanford that Janus was the Roman god of, among other things, doors and gates, and wondering how the man’s parents could have come up with so prophetic a name.

  “I have a list of complaints that have been filed against this medical facility, of which you are the owner.”

  “I’m assuming Mr. MacCandliss there is responsible for the complaints.”

  “The forms are all in order,” Fielding said, pointedly ignoring the statement.

  Behind him, MacCandliss was the very essence of smug.

  “You know, we’re very busy,” Nick said, gesturing to the three men in the dining area, and out the window toward the bus stop.

  Through the unremitting rain, he could see Junie approaching the shelter, carrying a large plastic bag and two ten-cup cartons of coffee. No surprise. Even if the staff at Dunkin’ was resistant, which they had never been in the past, they were outmatched.

  “To begin with,” Fielding said, “I’d like to do a walk-through and conduct an inspection of the way you are handling issues of cleanliness, as well as your equipment and pharmaceuticals. I am especially interested in assurance that the needles and syringes are properly locked.”

  “There’s really only room for one of you,” Nick said. “I’d appreciate it if Mr. MacCandliss stayed where he is, or better still, waited outside with the others.”

  Over the next few minutes, Fielding made his way down his checklist, without finding anything major amiss. He did suggest that the isopropyl alcohol swabs be kept locked with the syringes and needles, and that the file drawers holding the patient records be doubly protected against both theft and fire. Right from the beginning Nick could tell he was reaching.

  Bless you, Junie, he thought, reflecting on the thoroughness with which she insisted they prepare the RV.

  Fielding was certifying that the sharps disposal units and the trash receptacles were to code when the front door swung open. A thin, unshaven white man in a sodden peacoat entered and squeezed past MacCandliss, who took a decent soaking and looked as if being closer than a city block away from the fellow was too close. The man, whom Nick recognized from other visits, headed unsteadily toward the aft examining room. He was followed closely by Junie, who made enough eye contact with Nick to say several things at once, the most important of which was that she was worried about this latest patient.

  Nick felt the same way. The man, who Nick recalled was named Campbell, looked sick. His eyes were dark hollows and he had an odd tick at the corner of his mouth. Nick watched as Junie followed Campbell to the examining room. Then she turned at the last second and glanced back.

  Don’t wait long, she silently urged.

  Nick ushered Fielding back to where MacCandliss was waiting.

  “Okay, guys, looks like I’ve got some doctoring to do. Feel free to wait . . . or not. Mr. Fielding, I can save you some trouble by telling you that we read the HIPAA manual as a bedtime story and that our board of directors makes surprise inspections of the RV all the time. Tell whoever filed complaints against us that they’re wasting their time and yours. I’ll be back when I’m sure this man is okay.”

  Without waiting for a response, Nick headed to the examining room. Campbell, who smelled like the streets, was still standing, shifting from one foot to the other. Had there been much more room, he certainly would have been pacing. His eyes, pupils wide, were darting from one side of the space to the other.

  “Mike,” Junie said, “sit down and let me get your coat off. I need to check your blood pressure. Nick, this is Mike Campbell.”

  “We’ve met. When was it, Mike, a year ago?”


  “I don’t know,” Campbell mumbled.

  It was an overdose of some kind. Nick felt almost sure of it.

  “Mike, we want to help you. Give us a chance to help you. We’re on your side. Have a seat up here.”

  Hesitantly, Campbell pushed onto the edge of the examining table. Junie was just beginning to help him off with his coat when Nick saw the wet stain six inches below his armpit.

  “Glove,” he said simply, to the nurse.

  Without asking for an explanation, Junie slipped on a pair of latex gloves. Campbell reluctantly allowed her to remove his coat. The left side of his white Redskins T-shirt was soaked with an expanding oval of blood. At the center of the stain was a two-inch slit.

  “Pulse one ten. Pressure ninety over sixty.”

  From the beginning of his medical training, Nick constantly had to suppress the urge to jump in and get to work when a patient was bleeding. As it was, unless there were obvious indications, he still could not bring himself to allow an injured person to continue bleeding while he took maximum, time-consuming precautions against AIDS, such as donning a gown, an extra pair of gloves, and plastic full-face shield.

  “Mike, don’t be frightened. I’m going to glove and then I need to examine you, and quickly.”

  “Where am I?” Campbell rasped.

  Nick and Junie exchanged concerned glances.

  “You came to the Helping Hands medical van,” Junie said. “I’m Junie and this is Dr. Nick Garrity. We’re here to help you.”

  “Is this the hospital?”

  “This is the mobile medical van.”

  Campbell looked wildly about.

  “No hospital.”

  “We’re on your side,” Nick said, as Junie gingerly pulled off the man’s shirt. “Anything we do will be to keep you alive.”

  Nick could tell immediately that there was no way this wound could be properly evaluated outside of an ER, and possibly an OR. The chest cavity could easily hold a lethal amount of blood if the blade had gone through the chest wall. A lobe or an entire lung could have collapsed. He was relieved to see that Campbell’s trachea was midline—an excellent sign that for the moment at least, the lung was still inflated. His nail beds were fairly pink, another good sign.

  “Systolic pressure is still ninety,” Junie said, as if reading Nick’s mind. “He’s having a few extra beats.”

  “Hang in there, Mike,” Nick said. “We’ll explain everything in just a minute.”

  “No hospital,” Campbell said again, his speech marginally thicker than it was before.

  Nick carefully listened with his stethoscope. There were breath sounds out to the chest wall in all fields. He forced himself to take a step back. The knife wound could be nothing, or mortal. He knew that guessing at this point was a shortcut to disaster, but his clinical sense told him the wound was shallow. If so, the man’s low blood pressure, confusion, dilated pupils, and irregular heartbeat were out of proportion to the severity of his injury. Something else was going on.

  “Junie, could you get his record?” he asked, continuing his exam.

  There was no question that Campbell needed transportation to the hospital, and quickly. The trick would be getting him to agree. Nick checked his blood pressure again. Eighty-five. Maybe there was more internal bleeding than he thought. Without asking, he slipped an oxygen cannula into Campbell’s nostrils and turned the flow up to six liters. The man made no attempt to resist. Nick was preparing to start an IV when Junie opened Campbell’s chart and pointed to a section.

  Known heroin and benzo addict . . . History of multiple overdoses, especially meth . . . On probation. Terrified of going back to prison.

  “That explains why Mike is so reluctant to let us take him to the ER,” Junie said. “Is that right, Mike?”

  Nick could feel the tension in the man’s body.

  “Mike, I need to put an IV in your arm to give you fluid and medicine. Your blood pressure is really low.”

  Campbell’s expression was that of a caged animal.

  In seconds, Nick had inserted a two-inch IV catheter into a vein at Campbell’s wrist.

  “Extra wrap?” Junie asked.

  Nick nodded. As usual, she was ahead of the game.

  “Draw up one of Narcan and point three of flumazenil. Then hang a liter of saline and run it wide open,” he said.

  Junie unlocked the small crash cart and began drawing up the meds. At that instant, Campbell slid off the examining table and began turning frantically from one side to the other. Nick shelved his plan to anesthetize and probe the knife wound and instead tried to help the addict back onto the table. The exam could wait until the antidotes for the narcotics and Valium overdose were in.

  However, before anything more could be done, Campbell bolted.

  CHAPTER 6

  Mike Campbell, wide-eyed and beyond reason, bellowed and thrashed at invisible enemies as he charged from the examining room toward the front of the RV. Eddie Thompson, a hundred pounds heavier than the addict, rose to block his path, and was thrown aside like a child, stumbling against the table and down to the floor, sending coffee spraying from the mugs of the other two students.

  Janus Fielding, moving with surprising quickness, reactively filled the spot vacated by Thompson, leaving Phillip MacCandliss exposed to the brunt of Campbell’s onslaught. The claims evaluator, caught in the passenger-side stairwell, was slammed backward against the door with enough force to snap the latch and fling it open. Helpless, he disappeared into the pelting rain, landing on his back in the mire of Jasper Yeo’s Dependable Used Autos sales lot. Campbell, naked from the waist up, stepped off the bottom stair and onto MacCandliss’s belly, falling heavily next to him in the mud. Then he scrambled to his feet and lurched off toward the busy five-way intersection.

  By the time Nick had taken the antidotes for overdoses of narcotics and Valium from Junie, Campbell was out of the van. Thank God she had taken the precaution of a bulky wrap around the IV, Nick thought. Thank that same God they had found a vein at the man’s wrist—one of the best spots to protect a line. If he could catch Campbell, there was a good chance that Junie’s maneuver might end up saving the man’s life.

  Eddie Thompson was awkwardly trying to return to his feet when Nick sprinted past. Two more strides and he was at the stairwell. Beyond the doorway, MacCandliss had managed to get unsteadily to one knee. Focused on Campbell, Nick leaped off the bottom step like a hurdler.

  The scene ahead of Nick unfolded in slow motion. Campbell, still moving forward in a bizarre, uneven gait, was stumbling from side to side like a prizefighter about to go down for the count.

  But he did not go down.

  Instead, he stepped off the curb and into traffic. Nick, closing the gap between them rapidly, saw the bus that was barreling through the rain toward Campbell from the right. His instantaneous estimation told him that his patient was better than even money to be dead in a matter of seconds. But his mind’s eye had locked on to something else as well—Sarah, coming from the OR, moving unaware across the path of a careening pickup truck, whose driver had no intention of stopping. The image of her being slammed in the midsection by the pickup froze him at the curb for what seemed an eternity.

  Suddenly, he broke free of the paralyzing image. With no real plan, fully expecting to be killed, he charged into the street. Campbell was just about in the location between the headlights where Sarah had been when she was hit, but there was still a gap between the man and the massive bumper of the bus.

  As he dashed across the road, Nick glanced to his right enough to see that the driver had spotted them and begun to react. She instinctively pulled the wheel to her left, just as Nick launched himself at Campbell, catching the half-naked addict by the waist. The two men pitched face-forward onto the rain-soaked tarmac and slid ahead half a dozen feet, past the speeding bus and into the next lane of traffic.

  Brakes and tires screeching, the bus rose up on the driver’s side wheels as it skidded sideways. For sev
eral terrible seconds, it hovered motionless, the front and rear wheels on the right side well off the road, its full length now at a right angle from the direction in which it had been headed.

  Nick’s chin snapped against the pavement and instantly split open. Dazed, he still managed to hold on to the two syringes. The SUV that had been following behind the bus spun out, with its passenger side wheels also lifting off the road. It smacked against the rear end of the bus. The impact kept both vehicles upright, and sent them skidding away from the two prone figures.

  Nick rolled Campbell over. The addict was unconscious now, breathing slowly and sonorously. Drops of blood from Nick’s chin landed on the man’s chest and were instantly washed away by the pelting rain. On all sides, cars had managed to stop, forming a cordon around the two men.

  Campbell’s respirations were getting shallower and more widely spaced. It was possible the problem was internal bleeding and not a drug overdose, but as things were, in this spot, one condition was treatable, one was not. Nick doubted the man was getting effective ventilation, which meant the four-minute clock of brain death had started. Something had to be done. First, though, he had to get some air into Campbell’s lungs. The addict’s pulse was faint, and no more than twenty beats a minute. Tilting Campbell’s head back, Nick closed off the man’s nose and administered several mouth-to-mouth breaths.

  The bus driver and a passenger had hit the street and were charging across to them. Many others were closing in as well, a number of them with open umbrellas. Nick took the syringe of Narcan and fixed it into the IV. The slight flow of blood from the end of the plastic cannula told him the line hadn’t clotted off, or worse, been pulled out of the vein.