Extreme Measures (1991)

by Michael Palmer

  The woman still seemed dazed. Laura stepped closer to hand her the purse. Not ten feet away, a tall man dressed in a windbreaker and jeans ducked quickly into a doorway, out of her sight. Laura checked to be certain the old woman could walk. Then, barely aware of the smattering of applause, she headed off down Boylston.

  A beat later, the man in jeans stepped out from the doorway and followed.

  The pin was no bigger than Eric's fingernail, but in its remarkable detail and craftsmanship it was a work of art. Set in black stone, the caduceus was hand-sculpted in gold, with fine enamel accents at the head of the staff and along the wings flaring out from just beneath it. The intertwining serpents below the wings were etched so meticulously that under a microscope, Eric could discern their scales, and even the facets in the flecks of ruby that highlighted their eyes.

  We are Caduceus, your brothers and sisters in medicine. We care about the things you care about. We care about you.

  The words had echoed in Eric's mind since the unexpected decision by the search committee to hold off for several weeks in making their selection. And although he had been unable to recall with exactitude all the phrases spoken by that eerie electronic voice, the sense of the message was clear. Some kind of secret work was going on at White Memorial, something arcane but important; something that he could be a part of if he was willing to step beyond currently allowable medical therapies to administer an unusual treatment to a patient.

  Joe Silver, Haven Darden, Sara Teagarden--they were the heaviest of the heavyweights at the hospital, and at least one of them, Eric felt certain, was part of Caduceus. At least one of them stood ready to assure his selection as associate director of emergency services.

  Over the four days that had followed the search committee meeting, Eric had kept the caduceus pin in his desk. And although he had tried to ignore it, to approach his job in a business-as-usual fashion, rationalizations for pinning it on his clinic coat reverberated in his mind like distant ocean waves. He reflected on the physicians who made major breakthroughs by flying in the face of medical convention. He reasoned that in point of fact, by using the pericardial laser, he had already demonstrated to others, and to himself, his potential for similar vision and action. He argued that once he learned what Caduceus had in mind, he could always refuse to get involved.

  But in the end, neither the promise of the promotion nor any amount of rationalization was persuasive enough. This was not the laser he had developed himself and knew so intimately. It was someone else's work--someone else's priorities. The struggle within him was constant, but again and again his inner voice kept at bay the urge to find out what Caduceus was up to. More than five years of study and total dedication to his work had proved, as far as he was concerned, that he was the better man for the E.R. job. And he continued to cling to the hope and the belief that ultimately that would be enough.

  It was early evening. The emergency room, which had enjoyed a few hours of atypical quiet, had suddenly begun to pulse again. Eric had signed out to Reed Marshall, but an accident on the expressway had brought in two major casualties. Until things leveled off, Eric had volunteered to man the minor medical desk, working with the triage nurse to screen walk-ins and treat those who did not need extensive evaluation. He had three examining rooms going at once, and several more patients waiting for laboratory results. Still, the pile of charts in the to-be-seen box on his desk continued to grow.

  "Kristen, would you give me a quick moon check?" he asked, dashing off prescriptions and clinic referral forms for several patients at once.

  "Full moon tomorrow," the nurse said. "Can't you tell?"

  Eric glanced up at the waiting room, which was nearly packed.

  "I can tell," he said. "Senora Martinez," he called out, "traiga a su padre aqui, por favor."

  The woman, cradling an infant in one arm, helped her father limp over to the desk. Of all the courses Eric had ever taken--including all the biochemistry, biology, physics, and calculus--the one that seemed the most valuable to him as a physician was his four years of high-school Spanish.

  "Es gout, Senora. La gota" he said, handing over two prescriptions and a referral slip. "Es muy dolorosa, pero no es grave."

  The woman thanked him twice in Spanish, hesitated, and then squeezed his hand and kissed him on the cheek.

  "That was very nice. Or should I say, Fue muy simpatico."

  Eric turned to find Dr. Haven Darden standing just to his right.

  "Thanks," Eric said. "I just wish I'd had enough foresight not to drop the language when I entered college. It sounds as if you didn't make that mistake."

  The internist's round face crinkled in a smile.

  "We speak French in Haiti, remember?" he said. "Starting from there, the other romance languages aren't too difficult to master."

  Eric remembered reading in some magazine that the White Memorial chief of medicine had fluency in seven languages. He chose not to comment on the fact. Over his years at the hospital, he had spent some time training with Darden, but had never developed the closeness that he had with many other professors. In fact, Eric had been a bit uncomfortable around the man since the time when he and Reed Marshall were both rotating on Darden's service. Marshall had, quite in passing, mentioned the Harvard connection, and had let slip that Darden had invited him and his wife over for dinner.

  If a strong preference was held by anyone on the search committee for one candidate over the other, Eric believed, it had to be Darden's partiality to Reed.

  "Do you have a patient coming in?" Eric asked.

  Darden, meticulously dressed beneath his knee-length clinic coat, nodded.

  "A physician friend is bringing his fifteen-year-old daughter in with a high fever and a stiff neck."

  "Possible meningitis. I don't blame him for being worried."

  "Exactly."

  "Well, if I can help, just let me know."

  Darden glanced out at the waiting room.

  "At the moment, Eric, I would say that you are more the one in need of assistance. I'll tell you what. Give me two or three minutes in private, and then I shall do what I can to help you wade through that crowd out there."

  "WMH rule number one," Eric said. "Never refuse help. Just let me explain to the triage nurse, and have her do something to pacify that mob out there. We can go to my office."

  Haven Darden followed Eric back to the small chief resident's office that he shared with Reed Marshall.

  "Thank you for taking the time," Darden said, closing the door. "I won't keep you long. Eric, have you spoken with any of the other committee members since the meeting last Monday?"

  "Well, Joe Silver's always around here, so we've spoken several times. Yesterday I ate lunch at the same table as Sara Teagarden. Why?"

  "I'm curious if either of them said anything about what happened--why we told you both that we had made a decision, then announced that we needed more time?"

  "Not a word. Typical of the hospital grapevine, though--everyone around here seems to know what transpired. I think the nurses have a betting pool going. From what I can tell, they seem to be split about fifty-fifty, so both Reed and I get encouragement, depending on which of them we're working with."

  "Well," Darden said. "This may be an impropriety, but I want you to know that had the committee made its decision, Dr. Marshall would have been chosen." Eric felt a knot in his chest at the news. "Dr. Silver has seemed committed to him all along, and Dr. Teagarden had indicated she was leaning in his direction. Your use of that laser of yours did not sit well with them. You, however, are my choice. And that is why I am telling you this."

  "Thank you," Eric muttered, as surprised that Darden would turn out to be a supporter of his as he was shaken by the news of how close he had already come to losing out. He tried to factor in the information with what he already knew. There was no way Darden could have been the caller--no way, even electronically, that he could have masked his clipped, distinctive English. That meant that one of t
he other two ...

  "I have no strong sentiment against Dr. Marshall," Darden went on, "but I believe he lacks your commitment and dedication to medicine. I like the feel you have for your work--the flair, if you will. You have demonstrated a clinical aggressiveness--a willingness to take chances, to do whatever it takes to get a patient through a crisis--that appeals to me."

  "Thank you again," Eric said. "Can you say why Reed didn't get chosen?"

  "Not really. Joe Silver's the one who suddenly pushed for an extension. You might not know it, but it was Joe who railroaded Craig Worrell into that post a few years ago, past a lot of strong objections around the hospital, and he took a fair amount of flak when the choice went sour. Maybe he got cold feet about backing another loser."

  "Maybe ..." Eric said distantly.

  "If we can sway either of those votes, you're in. We've decided that a two-to-one vote will do it."

  "I appreciate your telling me all this," Eric said. "Needless to say, Reed and I were both wondering what had gone on."

  "I wish I knew," Darden said. "Eric, I don't think White Memorial can easily afford to lose a physician with your skill and commitment. And speaking for myself, I would love to have another faculty member with a philosophy so much like my own. The votes at staff meetings are always perilously close between the conservatives and those of us who believe this hospital must move ahead to stay ahead. Do you remember that AIDS outreach program I proposed a year or so ago?"

  "I heard about it, sure. I had planned to volunteer to help man the clinic when it was set up. In fact, I signed up on that list you sent around."

  "I know. It might not surprise you to learn that Reed Marshall did not. Well, regardless, what you may not know is that my proposal to the medical staff was defeated by just two votes."

  "That must have hurt, to come so close," Eric said.

  "No idea is ever dead until those who believe in it say it's dead," Darden replied. "Craig Worrell was one of the negative votes."

  "I see."

  "If I were you, and I wanted that position as much as you seem to, I would do whatever I could to sway the vote of either Dr. Silver or Dame Teagarden in my favor. Can you think of any way you might do that?"

  "No," Eric lied, glancing inadvertently at the drawer of his desk. "No, I can't."

  "Well, then ... I, um, I hope you understand that while I have great respect for Reed Marshall, if there is anything you know about him that would help influence either of my comrades on the committee ..."

  "No," Eric said, unable to conceal how startled he was. "No I don't." He hesitated, and then added, "Dr. Darden, I think you should know that over our years of working together, Reed and I have developed a pretty deep respect for each other. Even if I did know something damaging about him, which truthfully I don't, it's doubtful I would be able to share that information with anyone--even if it meant losing out on the job."

  "Well said!" the chief exclaimed. "That's precisely the response I wanted from you. And you have my apology for even bringing the subject up. Call it a final test if you want to, and consider yourself to have passed with flying colors. Just keep up your good work, Eric. I'll do what politicking I can. Then we'll cast our chips on the table and let them fall where they may."

  Before Eric could respond, there was an insistent knock on the office door.

  "Eric, it's Kristen."

  "Time to get to work," Haven Darden said, opening the door. "We'll talk again."

  The nurse was breathless.

  "Eric, Reed wants to see you in Trauma Two right away."

  "Go," Darden said. "I'll help Miss"--he read the nurse's name tag--"Baker plow through that waiting room."

  Eric hurried past the medical chief and down the hall to Trauma Two. He could smell the blood and feel the chaos and desperation in the room the moment he cleared the door. Reed, an intern named Stuart Spear, and two nurses were clustered about a litter bearing a woman who appeared to be in extremis. She was propped bolt upright and was gasping for breath through the blood cascading from her mouth.

  "What gives?" Eric asked, noting Reed Marshall's pale, wide-eyed face.

  Reed motioned the intern over to the head of the bed and handed him the rigid suction catheter.

  "Just keep sucking her out," he ordered. "Jill, get me three units. I don't care if they're cross-matched yet or not. I'll sign. Also, tell the respiratory therapist to get in here."

  He hurried over to where Eric stood.

  "She took the steering wheel in her neck," he whispered. "At first there was just a trickle, but all of a sudden she erupted."

  "She's drowning," Eric murmured. "Her larynx has probably been fractured."

  "I tried calling ENT down to trach her, but they're in the OR."

  "I don't think it's wise to put her head back and cut on her neck. Just paralyze her and put a tube in."

  "But ... but what if I paralyze her and then can't see past the blood to get the tube in?"

  "Of course you can get it in. I'll work the suction."

  "I ... I'm not so sure that's the right thing to do," Reed said.

  Eric glanced over at the patient and the two who were working on her. The respiratory therapist entered the room and began preparing his Ambu breathing bag.

  "Reed," Eric said softly, "it doesn't look like you have much time. A trach will be dangerous, messy as hell, and probably take too long. The balloon on the tube you put in will tamponade the bleeding. Call for the succinylcholine. You can do it. I know you can. I've seen you tube a hundred people."

  "Not like her. You do it."

  "You can do it, Reed," Eric whispered. "I'll be right there with you. Just order the sux."

  Marshall turned to the nurse.

  "Give her sixty of succinylcholine IV, please, and have respiratory set me up with a seven-point-five tube." He looked back at Eric, who shook his head a fraction. "Make that a six-point-five," Reed said. He crossed to the woman, whose respirations were growing less and less effective. "Mrs. Garber, we're going to put a tube in to help you breathe. In order to do that, we're giving you medicine that will make it impossible for you to move. Try not to be too frightened. You'll be breathing better in just a minute."

  Moments after the rapidly acting paralytic was injected, its effects began. The woman's muscles, including those that were enabling her to breathe, began to twitch, writhing without coordination or pattern. Then, in seconds, they all went slack. Eric set the litter back flat. Instantly, blood welled up in the woman's mouth. He took the suction and moved to Reed's right hand. The monitor pattern remained rapid and steady.

  "Go for it," he said, hunching next to Marshall's ear. "Just think of the anatomy. Look for your landmarks, and concentrate."

  Reed slid the broad blade of the laryngoscope along the edge of the woman's tongue as Eric stabilized her head with one hand and sucked the blood clear with the catheter in his other.

  "Take your time," Eric whispered, craning to see what Reed was looking at.

  "I ... I can't see."

  "Wipe off the laryngoscope light and do it again. It's only been ten seconds."

  Out of the corner of his eye, Eric saw the monitor rate begin to drop. Reed wiped the blood off the light at the tip of the blade and inserted it again. His left hand, clenched about the laryngoscope handle, was beginning to shake.

  Eric reached up and depressed the woman's larynx a bit.

  "There, look," he said. "That's her epiglottis right there. Just come up underneath it. Easy does it. That's it, that's it."

  Marshall began to nod excitedly.

  "I've got it.... I've got it," he said, slipping the polystyrene tube into place. "Sweet Jesus, I've got it."

  Quickly, the respiratory therapist blew up the balloon on the tube, attached the breathing bag, and began a series of rapid ventilations. Eric checked the woman's chest with his stethoscope to ensure the proper placement of the apparatus. Then he looked up at Reed and smiled.

  "Hell of a good shot, old boy,"
he said.

  Almost immediately the flow of blood began to abate. The woman's color improved. The relief and elation in the room were nearly palpable.

  "Yes, sir," Eric said, patting Reed on the shoulder, "one hell of a shot."

  "What gives?"

  The team turned toward the doorway, where Dr. Joe Silver stood appraising the scene.

  Unable to contain her enthusiasm, the nurse rushed over to him.

  "Dr. Silver," she gushed, "you just missed it. Reed just intubated this woman through a massive hemorrhage. One minute she was dying; the next ..."

  She gestured at the patient, who now was being ventilated quite easily.

  "Nice going, Reed," Silver said, striding to the bedside.

  "Actually, I don't think I could have done it without--"

  "What was it? Steering wheel to the neck?"

  "Exactly."

  "Gutsy move."

  "Eric here was the one who--"

  "Does she have any other injuries?"

  "We've only had time for C-spines and a chest film, but they were normal."

  "Excellent, Reed. Really fine work. Well then, why don't you get on with your secondary survey of her." He turned to Eric. "It's a madhouse out there. Your stand-in, Dr. Darden, has apparently forgotten how frantic our kind of work is. He left to examine his patient after seeing about three people in the time we see ten."

  "I'll get on it now," Eric said.

  "It doesn't look as if you ever had to leave."

  Eric started to respond, then just nodded and left the room.

  The flow of patients into the E.R. slowed, then virtually stopped. With Joe Silver pitching in, Eric was caught up in less than two hours. The E.R. chief gave no indication that he knew of Eric's role in the Garber woman's resuscitation. Instead, he told almost anyone who would listen about Reed Marshall's heroics. Eric was sure that Reed had spoken up for him, but it was clear that Silver had heard only what he wanted to hear.

  With a few final words to the triage nurse, Eric headed down the hall to his office, his back and legs aching from the long day. He glanced back at the front desk, where Joe Silver was orchestrating the care of what patients remained, and tried to imagine what life would be like for him should he be forced to leave White Memorial.