“This is Dr. Mark Roper, and I’m bringing in an eighty-year-old woman who’s been in an explosion and has first- and second-degree burns to the head and trunk, but with more severe airway involvement…”
His own voice sounded far away as he continued to brief the triage nurse, kneeling over Nell and watching Lucy at the wheel as they sped along the deserted road. Riddles and ghosts continued to circle, threatening to come in from the darkness.
He continually had to reposition Nell’s head to prevent her tongue from falling backward where it might obstruct her breathing; only then did he realize she’d finally worn her damn plate.
“Roper’s special,” the triage nurse called into her intercom the minute she saw Mark jump out of the Jeep in the ambulance bay.
Lucy frowned.
Instantly orderlies, nurses, and two doctors arrived to help.
“I thought only doctors who didn’t want your patients called them Roper’s specials,” she said to him as they transferred Nell to a stretcher and raced her down the hall.
One of the physicians, a tall ebony-skinned woman with a long gray braid down to her waist gave her an incredulous look. “Where are you from, gal? In ER it means when Mark sends us someone he can’t handle alone, we better be on our toes.”
“Dr. Lucy O’Connor, meet Dr. Carla Moore, one of the few in this establishment who don’t always consider me and my patients to be a pain in the ass.” He tried to sound calm, yet he still quaked inside, trying to keep memory from intruding on what had to be done now.
Nell’s respirations were already down to a squeak. “Seems like we need to intubate this one,” Carla said, as they skidded into a resuscitation room the size of a shoe box lined with racks of equipment, everything – lines, monitors, IVs – within easy reach.
Carla shoved an anesthetic tray at him. On it were different-sized endotracheal tubes spread out in a semicircle around a laryngoscope. “Will you do the honors? I could use your help.”
He nodded, slipped on a pair of sterile gloves, then positioned Nell’s head and neck as if she were leaning forward to sniff a flower, maximally opening her airway. He reached for a silver suction probe to clear away her saliva, his fingers fumbling the instrument as he worked.
Stepping to his side, Lucy quickly grabbed a ventilation bag and mask. “Let me help you,” she said, handing them to him. For a second, he felt her hands linger on his and give them a squeeze. The orchestrated chaos and noise of a resuscitation swirled about them – people shouting orders, running to draw bloods, sticking in needles, snapping on electrodes.
Her touch steadied him.
He placed the mask on Nell’s face and squeezed a few trial puffs of oxygen into the woman’s lungs. There was a lot of resistance, the effect of her airway closing off. He scissored her mouth open with his fingers, removing the partial plate. But his thoughts finally slipped his control and streaked unchecked toward reckless conclusions he never would have even considered twenty-four hours ago.
The explosion must have been deliberate, to prevent her from telling him anything, just as someone had silenced Victor Feldt and Bessie McDonald. What’s more, he and Lucy would also have been in the blast had they arrived on time. That couldn’t be an accident either.
Lucy handed him the laryngoscope, snapping it open and illuminating the blade.
Taking it with his free hand and keeping Nell’s mouth pried wide apart with his fingers, he slid the instrument along the side of her cracked and swollen tongue. This was going be a difficult intubation. As calculating as a computer, his brain flashed to the alternative, a tracheotomy, or cutting a hole directly into her windpipe.
Nell’s eyes snapped open, her pupils wide with fear, and she grabbed at his hand. Her lips moved around the blade of the scope as if she were trying to say something.
He took it out.
Her attempts to form words continued.
He bent down to hear, once more fighting back his nausea at the terrible smell.
In a high-pitched whisper no louder than a breath, he heard her say, “What’s my chances?”
He involuntarily glanced along a length of her blackened skin where it had split open and glistened in its own juices. The rest remained intact. She might survive the burn, the tub having protected her, but not the ordeal on the respirator that lay ahead, pneumonia being the most likely cause of death. Beyond that, if the burns were truly just second-degree, she’d avoid painful skin grafts and a protracted recovery. Comfort her with a lie, or give her the truth? Or a bit of both. He usually had more time to make such calls.
She seemed to sense his hesitation, widening her eyes and imploring him with her gaze to answer.
Before he hooked her lungs up to a machine, before he submitted her to the indignities of ventilators, catheters, and mind-numbing drugs, before he stole her voice by sticking an tube through it, she’d a right to say “Yes” or “No.”
“The skin doesn’t appear to be too bad, Nell. Your airway, though, needs help.”
“Odds?” she whispered back.
“Four to one against, for most eighty-year-olds. But you’re way better than most. And once the swelling goes down in your throat, they get way better.”
He wasn’t sure she’d heard him as a darkness seemed to gather behind her eyes again. But then she shook her head. “No lingering… on a chest pump… and don’t let me… choke to death.”
The sounds in the resuscitation room seemed to grow very distant.
“You understand what that means-”
Her stare silenced him.
What she wanted was clear as a shout. To be put out of her misery, pure and simple. He imagined Charles Braden leering over his shoulder. “Nell, I can’t do that,” he whispered.
She retreated into the black recesses where such final decisions are made, but not before he saw an unmistakable flash of contempt in her gaze.
“What’s the delay, Mark?” Carla asked.
“She refuses a respirator, but asks us to keep her from choking to death.”
“Wants to go to heaven, but doesn’t want to die,” muttered a young nurse behind him.
He ignored her and, agonizing over the ordeal he was sentencing Nell to, made his decision. “That means I sedate her with midazolam, we intubate to protect her airway, and you keep her topped off with morphine to combat her pain. Remember, she gets the same compassion you would give your own grandmother…”
As he spoke, looks of distaste spread over the faces of Carla and her staff. It was a gray call. No one in ER was ever comfortable with half measures that violated their pull-’em-back-from-the-brink-no-matter-what mentality. Little wonder. They didn’t see what some of their successes had to go through once they got upstairs. At the same time Nell would feel betrayed by his sticking a tube down her throat. Yet he wouldn’t give in to what she asked. He could no more commit active euthanasia than will his heart to a standstill. So he’d do what he could live with, no matter how anybody else in the business might second-guess him, or his patient despise him on her deathbed. And Charles Braden could go to hell.
“Nell, can you hear me? I’m going to make you sleep. Whenever you wake up, they’ll give you more medication to keep you under. But I’ve got to intubate…”
No response. Whether she ignored him, or had gone beyond hearing anything, he couldn’t tell.
He injected the fast-acting tranquilizer, followed by a shot of succinylcholine, a short-duration paralytic. Together they’d make it easier to open her jaw and visualize her vocal cords despite all the boggy swelling in her upper pharynx. Provided this time he could get by her tongue. The paralytic would also stop her breathing. If he bungled the procedure, he’d have precious little time to go in through the trachea, and Nell might end up with what she wanted in the first place.
He navigated around the tongue to where the lining of her throat bulged like a blackened frog belly. Parting the puffy tissues with the laryngoscope, he slid the endotracheal tube through the V of h
er cords and attached an Ambu bag, pumping hard and sending squeeze after squeeze of oxygen into her lungs until she recovered enough from the injections to breathe on her own.
Now he had Nell in the odd limbo of morality where doctors, himself included, willingly committed euthanasia, albeit the passive kind, withholding heroic treatment if it’s either futile or against the patient’s wishes, yet doing what’s necessary for comfort. If she continued to breathe by herself, she’d survive. If in the name of controlling her pain or sedation they suppressed her respiration, unintentionally hurrying her to her death, so be it. The law, most physicians, and he could live with that as well. Such were medical ethics in the “gray” zone. To the layperson it might sound like word games. To the one faced with pushing in the plunger, that nuance of intent meant being able to sleep at night. The best Mark could tell himself as he walked out of emergency? He’d saved her the agony of asphyxiation, and bought her a bit of time to have a change of mind about dying. As for the weeks and maybe months of suffering he’d imposed on her, that’s what would keep him awake at night. But for now, perhaps for all eternity, she wouldn’t be telling anyone what “tidbits” or “name” she’d claimed to have for him.
“Make sure someone lets me know if she regains consciousness,” he called back to Carla.
“You were great back there,” Lucy told him.
“I don’t think so.”
They sat side by side on a soft leather couch in the doctors’ lounge at Saratoga General, a room outfitted with tastefully upholstered chairs, potted plants, recessed lighting, and an espresso machine that would have done Starbucks proud. “Those were tough calls, and I doubt even an anesthetist could have pulled off that intubation-”
“That was how my father died,” he said, holding a mug of cappuccino with both hands as he took a sip. The warmth didn’t help the icy grip on his stomach any, nor the cold in his fingers, and his insides were still shaking. “Except there was no one there to help him.”
She went very quiet. “How did it happen?”
Unwanted flashbacks flickered to life: the boom that he heard a mile away, racing toward the smoke on his bike, the circle of people standing around something.
“It was an accident,” he said, trying to shut down the images. “And there’s nothing to talk about. I just wanted you to know why I wasn’t exactly a rock tonight.” The darkest notion of all continued to circle him, but he wouldn’t allow it even to take the shape of thought.
She watched him over the white mound of foam while taking small sips from her own cup, her dark gaze giving him the tell-me-your-story look that he’d seen work so magically with his patients.
Well, it wasn’t going to succeed with him.
Using a tone intended to be all business, he told her only what had been tumbling through his head while he’d worked on Nell, that the gas tank explosion had been deliberately set, intended to kill the three of them. Yet as he talked, his mind veered to the woman on the phone tonight. Whatever else Victor had found, it was what he discovered about the big companies and their executive health plans that seemed to be important. At least she seemed to think so, enough to believe someone could kill him over it.
His thoughts shifted to Charles Braden with those silver-spooned friends of his from the business elites of Manhattan. Maybe one had nothing to do with the other, but he found it impossible not to think that their corporations might be involved.
So he shared all this with Lucy as well.
It didn’t sound so outrageous laid it out in words.
He even talked about his turmoil over how to manage Nell in ER, including the way Braden had intruded on his thoughts because of the set-to they’d had over euthanasia while they were in the man’s library. “I thought he played devil’s advocate last night. But I’m not so sure he wouldn’t have granted Nell’s wish and put her out of her misery if he were running the resuscitation just now.”
“How do you mean?”
“He pontificated about how the line between right and wrong, even life and death, blurs with advances in technology and the times. To prove the point, he raised some pretty troubling issues about euthanasia. It was chilling, hearing him talk about how, in the past, country doctors had smothered deformed newborns to save the family the hardship of raising a handicapped child.”
“What?”
“You heard me right. He’s got this weird collection of medical atrocities he calls his ‘hall of shame’ – twisted eugenics, medical war crimes, that kind of thing – and he uses it to proselytize against deviant science.”
Lucy’s jaw fell, her eyes widened, and she dived for her purse. “Mark, I know what’s wrong!”
“What?”
She hauled out the folded spreadsheets of statistics she’d brought with her and spread them out on a nearby coffee table. “All along you’ve been preoccupied with Chaz, but what if it’s Daddy who has a secret?”
“How do you mean?”
She tapped the papers in front of her. “I didn’t want to tell you my suspicions about what I found here, because they seemed to have no context, and…” She stopped speaking, her cheeks flushed.
“Go on.”
She hesitated, then said, “It’s what we fought about earlier. I wasn’t a total klutz when I came here and stuck my nose in your investigation. I actually bent over backwards not to let my issues with Braden cloud your judgment about the man. So when I saw the discrepancy, I figured my own history with him had made me so biased I might be making too much of it, and I didn’t say anything.”
“Making too much of what?”
“Check this out.” She began to draw her finger down the various columns of numbers. “I think I discovered why your father had been interested in Braden Senior’s charitable works.”
He immediately leaned forward to see what she had.
“These are summaries of the births, deaths, and adoptions at the home; these, births and deaths at the center in Saratoga Springs. Like you, I first looked for the usual indicators of something wrong – a higher mortality-morbidity rate, that kind of thing. But as you said, the statistics are right on the norm for the home, and even lower than normal for the maternity center. In both instances, anyone looking at them would quickly conclude all was well.”
“Right.”
“So let’s say we give the guy credit for superb obstetrical skills on his moneyed patients.” Beside the mortality-morbidity numbers she placed yet another paper full of figures in her handwriting. “This is a synopsis of the actual delivery records your father had requisitioned from both places. I totaled all the infants pronounced normal, and here I itemized those with congenital abnormalities – heart defects; urinary tract anomalies; cleft lips and palates; limb aberrations, including club feet; neuronal tube defects of varying severity, some with only nominally open spines, others with fully open cords; and of course twenty-three trisomy where the mongoloid features were recognizable at birth.”
“You were busy!” Mark said with a whistle, realizing she must have stayed up most of the nights he’d left her working on them at the kitchen table.
“As I said, I got used to reading mass records at the camps. Now here’s the point. The guy’s maternity center is short on congenital abnormalities.”
“Short?”
“Yeah. Remember obstetrical statistics. Three percent of all newborns have some defect at birth. Out of the six thousand deliveries documented in these records, he should have recorded about a hundred and eighty with some kind of problem. He had barely a dozen. Good prenatal care can accomplish a lot, but change the rate of defects that much, no way. He had to be fudging his numbers. At least, that’s what I thought initially, but couldn’t see how or why.”
“Well, I’ll be.”
“And I figured your dad couldn’t pin him down, or he’d have done something about the place.”
He never got the chance, Mark thought.
“Which begged the question,” she continued, “why Braden woul
d care about anyone twigging to the discrepancy in his records at this late date, there being no obvious link with Kelly’s murder or anything else. At least it seemed that way, which is why I hesitated to even bring it up…”
As Lucy talked, the number 180 stuck in his mind. He’d found something of that amount when he reviewed the records himself. But what? He recalled it had to do with the home for unwed mothers, not the maternity center.
“… I did spot another connection, but it didn’t mean anything until just now, when you mentioned eugenics. Look at the total number of adoptions. Braden claimed to have made them directly out of the home for unwed mothers.” She flipped back a page and began to scan yet more lists of figures.
Mark reached over and laid his hand on her arm. He knew what the number would be. One hundred and eighty. His breathing slowed.
“Here it is,” she continued, obviously too charged up to heed his touch. “The number of private adoptions arranged from the home – 180! See what he might have been doing? Substituting healthy babies from the home for deformed ones at the maternity center. I mean, my God, can you imagine anything so hideous? It might actually have been legal if done on the up-and-up, couples from the maternity center putting their deformed kids up for immediate adoption, at the same time picking themselves up a healthy child from the home. Odious, but legal. The trouble is, there’s no records of the abnormal kids at either place. It’s as if they disappeared.”
Chapter 17
The same evening, Friday, November 23, 9:30 P.M.
New York City Hospital
“My potassium’s 2.1?” Earl felt a ripple of fear. At anything below 3.0, heart muscle became so twitchy the slightest stimulation could throw it into various sorts of fibrillation. Just like what happened to Bessie McDonald. Except hers had been limited to the upper chambers. His entire myocardium could end up squirming like a useless sack of worms, in other words, complete cardiac arrest. He broke out in a cold sweat that had nothing to do with his gut.
Instinctively he didn’t want to move. Any exertion at all could tip him over the edge. Already he could feel his pulse start to pound, the effect he’d expect from all the adrenaline that must be surging through his blood. Christ, slow the rate down, he thought, trying to calm himself, but that only made it tick up higher. His intestines kicked in with a snarl, and hinted at sending another wave of cramps his way. “Oh, great,” he muttered, pain being another surefire way to get his heart racing. “Tanya, I need IV potassium fast, maximal dose, sixty milliequivalents in a liter, run it in at ten to twenty milliequivalents an hour.” The rate had to be exact. Too much too fast could also stop a heart cold.
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