Warning Signs

by C. J. Lyons

  Great. Not only was she doomed to spend the month with Lucas Stone, who seemed unable to remember her name, she now had to deal with Jim “I Love to Use and Abuse Scut-Monkeys” Lazarov.

  “Guess you’d better get to work, Amanda,” he said, obviously relishing his role as her “boss.” “Why don’t you start down in pathology? I’ll let you know if anything exciting happens with our patient.”

  Relegating her to the musty basement and even mustier pathologists—they all seemed dried out or pickled from inhaling too much formalin—while Jim got to do all the exciting stuff.

  The MRI started up again, quaking the floor beneath them. Amanda glanced through the window. The machine had swallowed Tracey whole. This wasn’t a competition. She didn’t care if she had to do all the work and give Jim all the credit—which given his track record was exactly what would happen. It was all meaningless unless they discovered what was killing their patient.

  FIVE

  Thursday, 8:57 A.M.

  “ELISE, YOU CAN’T BE ACCUSING LUCAS STONE of deliberately hurting his patients?” Nora’s head ached at the thought, the very idea of a doctor doing something like that. Any doctor. But Lucas Stone? Never.

  Besides, Lucas was a friend—well, technically he’d been Seth’s best friend—but he and Nora had grown close while Lucas was struggling through his divorce. Who inherited the friends after you found your boyfriend sleeping with someone else, anyway? “I can’t believe it.”

  Elise looked serious, crow’s feet bracketing her eyes in an otherwise flawless face. Much like Nora, Elise took anything that affected her patients personally. “I don’t know that it’s deliberate.”

  “Glad to see you’re keeping an open mind before accusing a doctor of being a serial killer.” Nora glanced through the window in the closed door, making sure no one at the nurses’ station was within hearing distance. “Get serious. We’re talking about Lucas Stone. Not some stranger lurking in the shadows.”

  “All I know is that I reviewed the charts and there’s no reason why these two girls died.”

  “What was the official COD?”

  “The only thing listed under cause of death was cardiopulmonary arrest, origin indeterminate.”

  Pathologists were second only to radiologists when it came to the fine art of doublespeak. Nora tugged her fingers through her hair, yanking on her scalp as if the pain might counteract the headache squeezing her brain in a vise. “What do you want me to do?”

  “I thought maybe you could pull the charts for the monthly ER QA review. See what a physician, an objective pair of eyes, says.”

  Part of being charge nurse was to collect charts for a quality assurance review by an ER attending. “This month’s QA attending is Lydia Fiore. She’s as suspicious and paranoid as they come—if there is something going on, she’s the one to find it.”

  Elise’s face relaxed slightly. “Good. In the meantime, I’ll try my best to keep an eye on Tracey Parker.”

  “I’ll talk to Amanda, she’s on neuro this month. Maybe she can help.”

  “Isn’t she only a medical student?”

  “She’s good. You can trust her.” Nora scowled as the trauma radio on her belt squawked. Motor vehicle collision, multiple casualties. “I’ve got to go.”

  “T-BONE MVC, INTRUSION INTO THE PASSENGER side, adult driver, restrained, two kids aged seven months and two years in car seats,” Lydia’s trauma radio squawked, the sounds of sirens almost drowning out Med Seven’s report. “We’ve got the baby; her car seat flipped, trapping her between it and the front seat. Unresponsive, initial respiratory arrest but heart rate of one sixty-two, we’re tubing her, no IV yet. No obvious injuries except petechial hemorrhaging around the face. ETA two minutes.”

  Lydia left her sore throat and muscle aches—a guy in his twenties who wanted a note to skip work—and sped down the hall to the resuscitation rooms, where she was glad to find Nora already there dividing the troops.

  “We’ve got three coming in, one adult, two peds, at least one critical,” Nora was telling the staff as they set up the first room with pediatric equipment.

  Kids were always tricky. They came in so many sizes and shapes that it was hard to predict ahead of time what you would need. And this baby sounded bad off—unresponsive in an infant often meant very bad things, usually involving brain damage.

  “Get me the cooling equipment from the NICU,” Lydia ordered one of the nurses. “And see if the PICU has anyone they can spare.”

  Rapid hypothermia had been shown to help adult stroke patients with hypoxic brain injury as well as newborns. From Med Seven’s report, it sounded as if her patient had been asphyxiated when she was pinned inside the car—making her a good candidate to try the protocol.

  If there was a protocol. Which there wasn’t, not for kids beyond the newborn period and not for traumatic asphyxiation.

  Nora was quick to point that out. “There’s no standard of care, and it’s experimental. How are you going to get consent?”

  “Not even sure if we’ll use it,” Lydia said, arranging her airway equipment and inserting the pediatric needle into the EZ-IO drill. Kids were notoriously hard to get rapid venous access in, so the intraosseous device provided a quick alternative by using the bone marrow cavity instead. “I like to have options.”

  “Options? That’s no option, it’s a million-to-one long shot.”

  Lydia didn’t wait to hear any more from the by-the-book charge nurse. Her two minutes were almost up. She strode down the hall, trauma gown billowing behind her, to meet Med Seven in the ambulance bay.

  Sirens sliced through the crisp October morning before the red flashing lights appeared. They hadn’t had time to call in any more of a report, but she wasn’t surprised—in a scoop-and-run situation like this, the medics would be scrambling to assess and treat simultaneously.

  There was a screech of brakes and the beep-beep-beep of the ambulance backing up. Lydia jumped forward, opening the rear door as soon as it stopped. She was pleased to see that two of her favorite medics, Gecko and Ollie, were working today. And not so pleased when she realized that they were alone except for the firefighter they’d drafted to drive. Gina Freeman, one of her residents, had been scheduled to work with them today.

  Lydia pushed aside questions about her errant emergency medicine resident and focused on her patient, helping them lift the stretcher out. Scott Dellano—aka Gecko, nicknamed that for his rock-climbing skills—was bagging oxygen into the baby through an endotracheal tube. There was no IV, but she could see that they’d tried. As the new medical director for Pittsburgh’s EMS, she wanted to get the EZ-IO drills onto all the units, but they were still working on funding.

  “Idiot father put her car seat in the front seat and didn’t secure it,” Ollie was saying as he pushed the gurney. He was a rotund man who usually had a perpetually sunny disposition—except when his patients were kids. “When the front seat gave, she flipped forward, choked on the car seat straps, and was pinned upside down until we could extricate her.”

  “She was apneic and bradycardic when we got her out,” Gecko continued the report. “Heart rate came up with bagging, we never had to start CPR, and I tubed her with a four-point-oh uncuffed tube. Couldn’t get a BP on her, heart rate has been steady in the one-sixties, pulse ox ninety-four percent.”

  Lydia flicked her fingers against the bottom of the baby’s naked foot. No response. Despite the good oxygen level, the baby’s color was ashen, making the dark purple-red dots of petechiae, the broken blood vessels on her face, stand out like flecks of red paint splattered against porcelain.

  “Good work, guys,” she told them as they whisked the stretcher into the trauma room. She meant it—another minute down and the baby probably would have been in full arrest. “Any word on the other victims?”

  “Should be right behind us. The dad seemed okay, the older sister was screaming but I didn’t see or hear what was going on with her.”

  They moved the baby
onto the ER’s bed and quickly attached her to their monitors. “Get me c-spine, chest, abdomen, a trauma panel, and blood gas,” Lydia ordered.

  The neonatal cooling blanket and chilled saline were ready and waiting just as she’d instructed earlier. Might just come to that, she thought as she quickly drilled an intraosseous into the girl’s leg bone and started fluids running directly into the marrow cavity. The baby didn’t flinch or respond in any way to their interventions. Not good.

  Her team worked efficiently, moving in and around the patient in well-rehearsed steps as the X-ray techs arrived and shot their films, lab techs hustled away with their specimens, and Lydia completed a head-to-toe examination. No signs of anything except the traumatic asphyxiation.

  The X rays confirmed her findings. As did the blood work. Which meant everything they did to keep this baby alive might be in vain if her brain was already dead or dying.

  “We’re going to cool her,” Lydia announced to the crowd. “Someone warn the peds ICU—but we’re not going to wait for them, we’ll start down here. Set me up for a femoral central line; in the meantime, switch the IO to chilled saline, and let’s get a core temperature probe in her and the cooling blanket around her head.”

  To their credit, none of her team hesitated even though they all knew she was flying blind. But they also knew that without the unorthodox treatment the outcome would be worse than dismal.

  Lydia ran her fingers through the baby’s sparse curls before turning to snap on a fresh pair of sterile gloves and prepping the groin area for the large intravenous line that would carry the chilled saline directly into the baby’s heart.

  She didn’t look up as Seth Cochran, the trauma resident on call, entered. Nora stiffened beside her, clenching the bed rail.

  “You guys okay?” Seth asked, stopping a few feet away from the bed. Or more likely, a few feet away from Nora. “I’ve got the dad and sister. Sister has a few bumps and bruises, her car seat saved her from worse. Dad’s asking to see this one.”

  “Do we even have a name yet?”

  “Alice Kazmierko,” Nora supplied. “I’ll call social services to help with dad.”

  “You guys clear him already?” Lydia asked Seth.

  “Yeah, he got away without a scratch. Not too happy about his police escort, though.”

  “DUI?” Drivers without significant injuries in a serious crash like this were often intoxicated, the drugs or alcohol relaxing their bodies on impact.

  “Definitely,” Seth said. “Cops say the accident was his fault, ran a red. Refused a Breathalyzer, we’re still waiting on a BAC. Trust me, he’s loaded. My money’s on at least a point two-oh.”

  Lydia didn’t have to look to know that Nora would be frowning at Seth for joking about a patient’s labs. Nora was a no-nonsense charge nurse, but she was only in her midtwenties, still in that earnest, play-by-the-rules stage of her career—and her life. Lydia had outgrown that stage in her early teens when, after trying desperately to fit in with the alien world of foster “family life” her mother’s death had thrust her into, she’d learned that playing by the rules was strictly for suckers—one of the few things that Maria, her fake-psychic con artist mother, had been right about.

  Lydia finished the delicate job of threading the catheter into Alice’s femoral vein. Vitals were stable, peds were on their way, not much more she could do down here. It was up to time, and the resilience of an infant brain, to decide Alice’s fate.

  Well, maybe there was one more thing. Her back to everyone else as she stripped her blood-stained gloves free and washed her hands, Lydia sent a quick prayer winging into the ether. Not exactly a prayer, more like a wish, a hope. Not that she was convinced that there was Anyone up there listening—or Who gave a damn. But it never hurt to hedge your bets—something she’d learned on her own since moving here to Pittsburgh and starting her life over.

  The peds ICU fellow arrived, an entourage of residents following him. “We’ll take it from here,” he said dismissively, his skepticism of Lydia’s use of the cerebral cooling protocol evident. “You heroes have done enough already. Don’t you realize it only makes it harder for the family to let go when we have to declare them brain dead upstairs? It wastes our resources.”

  “Don’t rule her out yet.”

  He shrugged his answer. “We’ll see. But I wouldn’t bet on it.”

  Hah. People had bet against Lydia her entire life and look where she’d ended up. But she said nothing to the ICU fellow; instead she merely smiled at baby Alice, ignoring the tubes sticking out of her mouth and nose, the IV lines, the monitor leads, the tape sealing her eyes shut. It was a miracle Alice had made it this far alive; Lydia wasn’t going to rule out anything.

  She stepped outside to find a man charging down the hall. “Where’s my baby?” he was shouting. “You can’t keep me from her.”

  Nora and Seth joined her outside the trauma room, Nora standing on Lydia’s opposite side as if she needed a buffer between herself and Seth.

  Lydia squared off, stopping the man from entering the resuscitation room. “Are you Mr. Kazmierko?”

  “Yes. Where’s Alice? I want to see my baby.”

  “The pediatric intensive care doctors are with her now, Mr. Kazmierko. We’ll get you inside as soon as possible. In the meantime, let’s go down the hall to a private room where I can tell you what’s going on with Alice.”

  He blinked rapidly as if warding off her words, then tried to push his way past her. “Like hell. I’m not going anywhere until I see my baby.”

  Lydia was close enough that she could smell the alcohol on his breath. Southern Comfort. She hated that stuff—it had been one of her mother’s favorite “indulgences.”

  “You need to calm down first, Mr. Kazmierko.” She understood his need to see his daughter, but she couldn’t let him near Alice if he was so out of control that he might interfere with her care.

  “Don’t you tell me to calm down! That’s my baby in there. You let me in there now, you bitch!”

  His fist shot out in a lumbering right hook that would have caught Lydia square in the jaw if she hadn’t seen it coming and stepped aside, pushing Nora out of the way. Kazmierko stumbled forward, the momentum of his missed punch carrying him off balance. A uniformed cop appeared down the hall, jogging toward them.

  Seth, his own fists up, made an easy target as the cop plowed into Kazmierko from behind. All three men fell to the floor, a mass of flailing limbs until the cop restrained Kazmierko and hauled him to his feet.

  “You okay, doc?” he asked Seth, who was sitting with his back to the wall, massaging his chin.

  “Yeah, just bit my tongue.”

  Nora was beside him in a flash, helping him up, offering a gauze 4×4 to wipe the blood from his lip.

  “C’mon,” the policeman said, handcuffing the distraught father, now sobbing incoherently. “Looks like visiting hours are over for you.”

  Nora and Seth walked off together, presumably to get the surgeon an ice pack. Lydia watched them go—she didn’t understand what was going on with them. She’d heard the rumors, but she wasn’t one to put much stake in gossip. Seth wrapped his arm around Nora’s shoulders as they walked. Nora shrugged him away, spinning on her heel, and glaring at him.

  Clearly, whatever had come between them wasn’t going to be healed anytime soon.

  “WHAT THE HELL WERE YOU THINKING, JUMPING in front of him like that?” Nora asked as she sat Seth onto an exam table and mopped the blood from his mouth. He flinched when she touched his lip. It was already swelling but hadn’t split.

  “What was I supposed to do? You could have gotten hurt.”

  “The guy was stumbling drunk, blind with fear about his daughter. Besides, Lydia and I can handle ourselves.”

  He wrapped his hand around her wrist, keeping her at bay before she could touch his lip again. “I worry about you.”

  That was all he said. Just four words. Four words that almost broke her resolve.

  H
er arm trembled in his grasp. She yanked free from him and rummaged through the supply cabinet, searching for some gel foam for his cut.

  She swallowed hard. “Stop it, Seth. You have no right to worry about me. Not anymore.”

  His sigh circled through the room. “You’re right.”

  The thud of his jumping down from the exam table hammered through her. She held her breath, surprised by how disappointed she was when his footsteps headed toward the door. She turned around, holding out the small packet of gel foam as if it were a peace offering.

  He stopped and took it from her, their fingers brushing. “Thanks.”

  “Please, Seth—” She stopped. She wanted to forgive him, to start over. She needed to end this, move on. “Don’t send me any more flowers.”

  He froze, mouth open as he held the tiny strip of gel foam against the edge of his tongue, stanching the bleeding. His eyes darkened, a V-shaped frown forming on his forehead.

  “Flowers?” He removed the gel foam and spat out a glob of blood and saliva into the piece of gauze he held. “Who’s sending you flowers?”

  GECKO AND OLLIE APPEARED, COFFEE CUPS IN their hands, on their way out to the ambulance bay. “Jeez, Lydia, whatcha do now?” Gecko teased her as the cops dragged Kazmierko, still screaming, out to their car. “Start another riot?”

  “Where the hell is Gina?” she asked, ignoring their gibes. Both paramedics had been with Gina in July when she’d been caught in the riot and drive-by shooting—which was why Lydia had assigned Gina to them for her ride-alongs. She thought the emergency medicine resident would feel safer with the men who had gone through the experience with her.

  Obviously she was wrong.

  Ollie shrugged. “Dunno. She never calls, never writes.” He heaved a melodramatic sigh. “What’s a guy to do?”

  “Seriously, doc, is she okay?” Gecko put in. “I tried to call her, but she doesn’t answer.”

  “Can’t be that she doesn’t want to work with us. We’re the freaking A-Team.”