by L Jan Eira
A feeling of doom came over Jack. He quickened his steps to the office where he would avail himself of cold fresh water. He needed it desperately.
*****
10:42 AM
“Finally a break in the case,” said an excited voice. Susan looked at Herb expectantly.
“What is it, Mike?” she asked into her cell phone.
“We finally got the son of a bitch. I found out about the gun. It was purchased illegally and without paperwork or registration by, you guessed it—”
“Dr. Ian Rupert,” interjected Susan, pleased. Herb smiled imitatively.
“Dr. Rupert, indeed. We got him now. Will you file for an APB on him and get a warrant for his arrest?”
“We’ll do it right now. We’ll pick him up and call you when we have him.” As soon as Susan ended the call with Mike, she turned to Herb to give him details. His smile intensified.
Herb turned the unmarked police car towards the Evansville Court House. They were not far and would be there in no time.
Susan dialed the DA to get the necessary paperwork in motion. As she was waiting for the call to connect, loud sirens grew louder, indicating that emergency vehicles were approaching. It was a red Evansville Fire Truck. Behind this red truck was another and behind it a third one sped by, with lights and sirens. Hanging on were several firefighters with the typical hard hats and yellow Scott Air Tanks.
*****
11:05 AM
After drinking some cold water and taking a break from work, Jack almost felt normal. He walked back and joined the others at ongoing ward rounds.
“Are you feeling better, Jack?” asked Jill.
“Much better, thanks.” Jack did have some color back and the beads of sweat had dissipated from his face.
All looked concerned, but remained silent for a moment.
“Okay, what did I miss?” Jack broke the stillness of the moment.
“We were talking about Mrs. Agnes Baldwin. She is an eighty-eight-year-old woman who presented with fever and confusion.” This patient had been relegated to Christopher O’Neal, one of the medical students assigned to this team. Chris was presenting the relevant medical data.
“Okay, go ahead.” Jack was back in his groove.
“On admission, her BP was 70 with a heart rate of 125. We were called for the rapid heartbeat. It was unclear what the rhythm was at the time.” This said, Chris handed the electrocardiogram to Jack, who perused the tracing for a few seconds.
“What do you think it is?” Jack asked.
“I wasn’t sure, but I was thinking atrial flutter,” answered Chris.
“What else? Anybody have any other ideas?” inquired Jack.
“Atrial tachycardia,” volunteered Pete.
“Both are possibilities. Do we have an old electrocardiogram?” posed Jack.
“Yes.” Chris was ready for this eventuality and immediately produced a tracing from the old records. This EKG was obtained on the patient four months earlier.
“Now, let’s compare P-waves between the two tracings. Look at the twelve leads and see which are different.” Jack held up the tracing as the others approached to analyze and scrutinize them.
“The P-waves look exactly the same, then and now,” said Jill, all others nodding in agreement.
“So, now what do you think about today’s tracing?” solicited Jack.
“Since the tracing was definitely sinus back then and the P-waves are identical in all leads, this must be sinus tachycardia.” Peter appeared confident and cocky, neglecting the fact that he was wrong the first go-around.
“Correct. Tell us what all this means now and how we should treat this lady.” Jack looked at Chris.
“Since this is sinus tachycardia and not an arrhythmia, her low blood pressure is probably what is causing the rapid rate,” said the medical student.
“This is an instant patient.” Jack spoke as he approached the bedside and visually examined the elderly woman.
“What’s an instant patient?” asked Chris.
“Just add water and she perks up. Look how dry her skin, tongue, and lips are. She has no edema and her jugular veins in her neck are flat. All signs of dehydration.” He looked around the bed to find the Foley bag. He picked it up showing the scanty dark yellow urine.
“Low urine amount and very concentrated urine. Dehydration. You’re right. Her renal blood work is also consistent with that.” Chris seemed to have developed a light bulb over his head.
“That’s why she has a rapid heart rate and hypotension. And that’s why she is confused. Let’s change her intravenous fluids to saline and start out with a bolus of five hundred CCs. What else do you want to do? Is she on a diuretic?” asked Jack.
“Yes, she’s on Lasix. I’ll stop it. She just had a normal echocardiogram. Let’s just see how she is by tomorrow with intravenous hydration. We can follow her blood tests and clinical findings.” Chris recommended.
“I agree. By tomorrow, she will be talking and telling us all kinds of tales. What tests will you order for tomorrow and why?” persisted Jack.
“I can get a BMP, TSH, BNP and—”
Christopher’s statements were rudely interrupted by loud beeps in unison from all the pagers: “Code Blue, emergency department, trauma room 1. Code Blue, emergency department, trauma room 1. Code Blue…”
The group placed all the charts down and made a beeline to the ED. On their arrival, a bloody patient was receiving CPR. The ED staff was working diligently to save the man’s life. His expensive suit had been extensively torn and cut up to allow rapid access to the chest and abdomen by the emergency personnel. Tubes entered the mouth and left nostril. An emergency physician was inserting a chest tube. He spoke first addressing the newly arrived cardiology team of doctors.
“Hey, Jack. He has a pneumo with tracheal deviation. We have two large bore IV’s but could use a central line. His sternum is fractured, so he may have a cardiac contusion.”
“Give me a central line. I’ll get a subclavian line in.” Jack took off his while lab coat and approached the dying man. Jack suddenly gasped as he realized whom he had in front of him. The man on the stretcher was Dr. Ian Rupert. Rupert, the man he could have sworn was the root of all the recent hospital killings. Wow. Jack paused for a brief moment.
“Here you go, Jack.” Linda, the emergency room nurse assigned to Trauma Room 1 poured Betadine, a dark brown liquid used to disinfect the skin, generously in the area under the left collar bone. Another nurse with sterile gloves scrubbed the area vigorously.
By then, Jack had his sterile gloves on and was ready for action. In no time, a thin long intravenous tube was inserted into the main vein under the collarbone.
“Check the CVP, then let’s hang O-neg. blood.”
“What’s a CVP?” whispered Peter in Jill’s ear. She was standing next to him, observing and taking it all in.
“Central venous pressure. It’ll give us an idea about how much blood volume is inside his central circulation and how the heart is dealing with it,” answered the young doctor softly. The medical student nodded, satisfied with the answer. During the exchange, the students watched in awe the rapidity of the skilled actions of Jack and the ED staff, as they worked in harmony to accomplish the necessary tasks.
“CVP is zero,” read one of the nurses.
“Give the blood wide open,” commanded Jack.
“Are we getting any pressure with chest compressions?” asked one of the ED doctors.
“I don’t feel much of a femoral pulse,” replied an ED resident.
“He may have tamponade. Continue CPR and prepare for a thoracotomy. Page the CT surgeon on call, stat.” Jack looked intense.
Betadine was again used to paint and scrub the chest. Sterile drapes were used to attempt some form of a sterile field, although at this dismal time, infection was the least of all worries. Jack and the ED attending proceeded to use a chest-saw to cut the breastbone and expose Rupert’s dying heart.
�
�What are they doing?” asked Chris looking at Peter, then Jill.
“The patient is not responding to CPR, medications, or fluid and blood transfusions. They’re checking to see if there is blood around the heart. Sometimes, if the heart is lacerated, blood escapes out of the chambers into the sac around the heart. This can squeeze the heart and prevent it from pumping. This is called cardiac tamponade. The patient may also be bleeding into his chest from a major vessel. They are going to crack the chest cavity open to examine it and try to stop bleeding and open the pericardium, if there is tamponade.” Jill spoke softly, but concisely.
“I don’t feel so good.” Chris was pale and sickly looking.
“That’s okay. Let’s step outside and get you some water,” commanded Jill with a motherly tone of concern, walking the lightheaded medical student out of Trauma Room 1.
The thoracic cavity was full of blood, which was quickly suctioned. The descending aorta was cross-clamped above the site of brisk bleeding. The pericardial sac was inspected and found to be normal. The heart itself was empty despite all the fluid and blood that had been administered. The team worked efficiently and without words.
“Nothing,” said the ED resident palpating the pulse while Jack performed open massage of the heart. Bags of lactated ringers, saline and O-negative blood hung high and dripped fast.
“Flat line on the monitor,” said the ED attending.
“What’s the down time?” asked the ED resident.
“Sixty-three minutes,” announced the nurse documenting all orders and procedures.
“Damn,” said Jack in an audible whisper.
“We need to quit, Jack,” suggested the ED attending doctor.
“Do we have an ID on this man?” asked the head nurse.
“Ian Rupert. Dr. Ian Rupert,” declared Jack gravely.
*****
1:32 PM
The medical team assembled in the solace room in the Emergency department. This room was decorated and comfortable and was utilized for the doctors to meet with the families, traditionally to give bad news. This time there was no family to receive the reports.
Claire had text messaged Jack about lunch an hour before. When the resuscitation efforts ended, Jack retrieved the message and called her. Claire arrived in the conference room a few moments later and was now at Jack’s side. Susan and Herb walked in.
“Did you hear?” asked Jack solemnly, as the two detectives walked into the room and sat down.
“If you mean Rupert, yes. He had a car accident. Did he make it?” said Herb.
“No, we just pronounced him dead. Massive internal injuries.” Jack appeared dismayed.
“I’m sorry to hear that. We had a warrant for his arrest. It turns out he was linked to the murders. He was the one that purchased the gun and presumably gave it to the killer,” said Susan somberly.
“So, is the case closed now?” asked Claire.
A moment of silence ensued. The detectives were reluctant to discuss these matters in such an unprotected area.
“Does anybody else think it’s strange that this man has a fatal car accident the moment you find out he is involved with the previous crimes and get a warrant for his arrest?” said Jack tensely.
“It is a coincidence, isn’t it?” said Herb.
“Have you found out anything about the accident? Was it rigged?” asked Jack.
“We’re still investigating, but it looks like it was a legit accident. There is no evidence of foul play, but we cannot rule it out as yet either,” answered Susan.
“That leads us to our next point, Jack.” Herb was serious as he looked into Jack’s eyes. This may be getting dangerous. For your protection, we do not want you involved with this case any longer. We will call you, if we need you or when we have news to tell you. You have been of great assistance thus far. We appreciate all you’ve done. But you need to go back to work and back to your normal life.”
“Normal life? I don’t think I can ever have a normal life anymore,” said Jack poignantly. A long pause followed, terminated by the sound of the door to the room opening. James Miller was escorted into the small area by a nurse who accompanied the portly old man to where the others were. Once inside the room, James looked at all, one by one, with a serious concerned expression. The nurse closed the door behind her as she returned to work. For a short moment, the silence in the solace room was shattered by the distant loud buzz of the busy Emergency Department. When the door shut, silence and peace reigned once again.
“Is it true? Did Dr. Rupert have a car accident?” asked James, restless and apprehensive.
“I’m afraid so, Mr. Miller,” finally volunteered Claire, wishing to terminate the awkward silence provoked by the question.
“He arrived with massive internal injuries and could not be saved,” added Jack looking into the old man’s eyes.
“Did he have any last words? Was he able to speak?” asked James.
“No, he came in receiving CPR. He did not say anything here at the hospital,” said Jack.
The group sat in silence. With tearful eyes, James sobbed reticently, both hands covering his face. The reddened rash Jack noticed on the lab head tech’s right hand was now a bit more prominent. Claire offered a much-needed tissue, which James appreciatively accepted, weeping gloomily.
*****
3:09 PM
“So, where does this leave us?” asked Susan. The two Evansville detectives, Jack and Mike Ganz were gathered at Newton Memorial Hospital’s walkway to the main parking lot. A nearby gigantic oak tree provided shade and respite from the otherwise bustling activities on campus.
“Well, the accident seems legit. We’ll transport the car to our headquarters for further analysis. We’ll see if there is any foul play but preliminarily, it seems like any other accident. The evidence against Rupert is strong, so the case may be closed,” said Mike assertively.
“What evidence?” inquired Jack.
“Mike found out that Rupert had purchased the gun involved in the murder. We already knew Rupert was at the scene the morning of the shooting. So, he had the opportunity to give Butterworth the gun,” answered Susan.
“What about Major Rooner and Muhammad Akrim? What have you found out about them?” persisted Jack.
“Jack, we really do appreciate your help on this case. But, for your protection, we must insist that you go back to work. We’ll stay in touch with you and let you know how it turns out. If we need you for medical questions, we’ll come find you, okay?” Herb spoke like a determined, concerned patriarch.
“Oh, and Jack, I cannot over-emphasize this. Please do not discuss anything to do with this investigation with anyone. Even your wife or friends.” Mike was serious. Mike was always serious.
The three cops walked away still disputing the next step in the investigation. Herb and Susan got into their unmarked vehicle. Mike walked deeper into the parking lot in search of his car. Jack stood under the oak tree pensively, feeling unfinished. Unsettled.
*****
Three days ago
September 28
8:05 AM
“Back to your normal life.” Detective Herb Fuller’s words resounded in Jack’s mind.
The medical team was back in business. Morning Report was about to begin.
“Let’s hear about Mr. Carl Morrison, Howard,” asked Jack of the cardiology fellow on call and in charge the night before. Dr. Howard Hahn was a thin, muscular and bright young man, with the physical attributes of a marathon runner. His hair was cut short and he was clean-shaven, atypical for anyone just post-call. Howard gathered his papers and proceeded to the front of the room. After a moment, he commenced the case presentation.
“Mr. Morrison is a sixty-four-year-old diabetic man who presented to the Emergency department last night with congestive heart failure. This is a recurrent problem for him; he has had multiple such admissions. He is now on appropriate optimized medical therapy. His internist followed him for years with diabetes, hypertension and
hypercholesterolemia. Despite many warnings of the dangers of nicotine, he continued to smoke for years, though he quit two months ago. He was admitted in June with CHF. At that time, an echocardiogram showed a LVEF of twenty- to twenty-five percent.” Howard was interrupted.
“One of the students, remind us of what LVEF means.” Jack looked around for volunteers. Taylor beat the others to the punch.
“Left ventricular ejection fraction is a measure of how strong or weak the heart contractions are. Normal is fifty percent; at twenty- to twenty-five percent, there is significant heart muscle weakening.”
“Good, Taylor; please continue, Howard.”
“A cardiac cath in June showed the coronary arteries to be patent, so he has a non-ischemic dilated cardiomyopathy which is resistant to medical therapy. His present meds are Coreg CR, eighty milligrams daily, Altace, ten milligrams daily, spironolactone, fifty milligrams daily and Lipitor, forty milligrams daily. We added Lasix, forty milligrams IV last night and an IV drip of Natrecor. His symptoms improved, though he remained short of breath.”
“Good. What is the QRS duration?” asked Jack.
“It’s wide.” Howard paused to find the patient’s electrocardiogram tracing in the folder. As he did so, Dr. Mark Holden, a medical resident assigned to Howard’s on call group, placed a transparency on the projector so all could analyze the tracing.
“It measures 160 milliseconds,” said Howard finally, while Mark concurred using his pencil to draw on the transparency, indicating where the QRS complex started and ended, allowing for proper measurement of its duration.