Fatal

by Michael Palmer

  The commotion in the ER seemed to have leveled off, and the moaning from the injured miners was much less.

  “How’s he doing?” Blaine LeBlanc asked as they passed.

  “Later,” Matt said.

  “You talk to me before you do anything heroic, you hear? That . . . that weirdo killed one and maybe two of my men.”

  “Sure, Dr. God,” Matt said. “I’ll be certain to consult with you.”

  He turned his back on LeBlanc and spoke softly to the nurse. From what he could discern, blood was building up between the lining of Teague’s heart and the heart muscle itself. The resultant constriction of the heart muscle was keeping it from filling properly between each beat.

  “Laura, this guy’s got a pericardial tamponade.”

  “How do you know?”

  “That’s what it’s got to be. We need to stick a needle into it and drain the blood.”

  “Can’t we wait for Dr. Crook?”

  “Unless we can be sure he’s going to be here in the next five minutes, the answer is no.”

  “What about some tests? An ultrasound?”

  “Radiology is in the OR. I don’t trust the tech or me to read one with certainty. Besides, I don’t think we have time. This kid is going out.”

  “Maybe that’s for the best,” Laura said.

  “Now, don’t let us get started on that,” Matt said. “Please get me a pericardial drainage kit.”

  “Matt, I don’t like this at all. How many times have you done this procedure?”

  “A few during my residency,” Matt lied. “I can do it.”

  “Pressure’s not reading,” Lee called out. “EKG is showing many extra beats.”

  “Please,” Matt said, heading back to room 10.

  “If you’re ordering it, I’ll be right there with the kit.”

  “Remember what I told you,” LeBlanc said as Matt passed him.

  Matt knelt at the head of Darryl Teague’s bed and skillfully slid a breathing tube down his throat and between his vocal cords. The respiratory tech then hooked the tube to a breathing bag and oxygen, and began to pump. Teague’s chest expanded much more than it had been, but his blood pressure only rose to 50.

  “Nice intubation, Doctor.”

  Hal Sawyer stood just inside the doorway. With his dark hair graying at the temples, his carefully trimmed mustache, his gold-rimmed glasses and knee-length lab coat, Uncle Hal looked as professorial as did any medical school dean. In fact, he did have a clinical teaching position at one of the medical schools, but for the most part he stayed pretty close to Belinda, where he was chief of pathology (there was one other full-time pathologist) as well as the Montgomery County medical examiner. Hal was also erudite, well-read, and adventurous. He seldom spoke up at hospital staff meetings, but when he did, people generally listened.

  Never married, Hal didn’t seem to lack for company. His latest girlfriend, Heidi, was a pretty, young thing he had met on some sort of rafting trip. The gossipers in Belinda went on about his personal life, but he never seemed to care, just as he didn’t care when the rumors started going around some years ago that he was gay. Hal was very much his own man, and Matt credited him with fostering his own sense of independence.

  “Hey, Hal,” Matt said, “thanks for coming over. This is the guy who went berserk in the mine and caused this nightmare. People say he’s been acting paranoid for months. Paranoid insanity coupled with diffuse neurofibromatosis of the face and scalp. Ring any bells?”

  “Just like that cliff diver.”

  “Exactly. His name was Rideout. Teddy Rideout. And where did he work?”

  “As I recall,” Hal said, palpating the lumps, “he, too, was a miner.”

  “He was most definitely that. BC and C, to be exact.”

  “My, my,” Hal said.

  Some months ago Matt had been cruising on his Harley down a particularly winding mountain road when Rideout sped past him on the inside, traveling much faster than the road ahead would tolerate. A minute or so later, Matt came upon the shattered guardrail and saw the car lying on its roof several hundred feet below. Rideout lay well beyond resuscitation. His striking facial lumps were identical to Teague’s, and subsequent discussion with his family revealed a history of rapidly progressive paranoia and irrational, aggressive behavior. At the man’s autopsy, Matt wondered out loud to his uncle if Rideout might be toxic from something at the mine.

  Hal had promised to run some extra tests, which came back negative. It was Hal’s belief that the man was one of a kind—a very unusual case, but just a single fluke point on the graph of life.

  Well, Matt thought now, here’s dot number two.

  “I’ll see what I can dig up about Mr. Rideout,” Hal said. “I don’t recall anything unusual in the autopsy except for those neurofibromas, which were only of interest because of their numbers, not their microscopic appearance.”

  “Here’s the kit,” Laura said, setting the tray marked PERICARDIOCENTESIS down on the stainless-steel stand.

  “Any sign of Crook?”

  “He could be here any minute. Are you sure you—”

  “But he’s not here now. This guy’s BP is back down to zero. He’s firing extra beats. I say we go.”

  “Suit yourself,” Laura said coolly.

  In fact, Matt had attempted pericardial taps a number of times as the last gasp maneuver in cardiac arrest patients who were about to die despite the most heroic resuscitative measures. But never had the procedure located any unsuspected pericardial blood. And never had any of the patients survived.

  “Need any help?” Hal offered.

  “Will Robert Crook to stroll into the ER right now,” Matt said. “I just don’t think we can wait.”

  Beyond Hal, just a few feet outside the door, Matt could see Blaine LeBlanc, watching, waiting.

  “I’m still not getting any pressure at all,” Lee reported. “Ventricular extra beats in pairs.”

  Sometimes you just got to do what you got to do, Matt was thinking.

  He attached a four-inch-long, wide-bore cardiac needle to a 20cc syringe and hooked an alligator clamp to the base of it. He would know he was wrong about there being pericardial blood only after he had driven the heavy needle through the tissue-thin pericardial membrane and into the base of Teague’s heart. The electrocardiogram would react immediately to the trauma, and hopefully, he would have time to stop and withdraw the needle before any major damage was done to the cardiac muscle. Hopefully. But if he pierced the muscle and hit a coronary artery, the resulting heart attack would give Teague almost no chance at all.

  Matt forced the needle through the skin at the V formed by Teague’s left lower ribs and the tip of his sternum. Then he angled it toward his left shoulder. Keeping the pressure constant, he advanced the needle through the diaphragm toward what he envisioned was the base of the heart.

  Slowly . . . slowly . . .

  “Lots of extra beats,” the nurse reported.

  “Are you hitting his heart right now?” Laura asked.

  Matt checked the monitor.

  I sure hope not, he thought.

  “No,” he said assuredly.

  “Are you sure?”

  Without warning, the syringe filled with blood.

  Yes!

  Matt switched the three-way valve on the syringe to empty and injected its crimson contents into a small glass cup. Then he withdrew another 25cc of blood from Teague and squirted it into a larger beaker.

  “How do you know you’re not drawing blood directly from his heart?” Laura asked.

  The woman simply wasn’t going to let up.

  Hal stepped forward.

  “Ms. Williams,” he said calmly, “it looks very much like Dr. Rutledge knows what he is about. There is one way to tell right here where that needle tip is. If that blood Dr. Rutledge just removed was sitting in this man’s pericardial space, it probably won’t clot. If it’s directly from the ventricle of the heart, it will.”

  “Ho
w long will that take to know?”

  Matt ignored the question and drew off another syringeful. Teague’s condition remained unchanged. To his left, Lee tried again to hear a pressure, then shook his head gravely.

  “If he’s in shock and you might be taking blood from his heart, won’t that make the situation even worse?” Laura asked.

  Back off! Matt wanted to scream. The nurse was quite obviously protecting herself against Robert Crook’s certain onslaught.

  I tried to reason with him, Dr. Crook, really I did.

  Matt slid a thin plastic catheter through the needle and into what he hoped was the pericardial space. Then, carefully, he withdrew the needle and fixed the catheter in place with a single suture through the skin of Teague’s chest. Blood oozed from the catheter opening and soaked an expanding stain into the sterile drape. For several seconds there was nothing but a tense silence.

  “Pressure’s still zero,” Lee reported at the moment Robert Crook charged into the room.

  A rotund, ruddy-faced man, Crook had dense, sandy-gray brows that always looked to Matt like giant woolly caterpillars about to do battle. Along the margin of his left jaw were several fresh clots from where he had nicked himself shaving, as well as a tiny, bloodstained flake of tissue paper. His response to the emergency at MCRH had clearly been to charge into the bathroom and break out his razor and shaving mug.

  “Rutledge, what’s going on?” he demanded.

  Matt shrugged.

  “He lost his blood pressure and I couldn’t figure out why. I decided he had a pericardial tamponade, so I tapped him.”

  “You . . . tapped him?”

  “Still no pressure,” Lee called out.

  “Be sure the dopamine is open all the way,” Matt ordered.

  “It is.”

  “Did you see pericardial fluid on his echo?” Crook asked, ignoring the sterile field and the thin catheter in order to listen with his stethoscope.

  “I . . . wasn’t able to get an echo. No time.”

  Crook erupted.

  “Jesus Christ! How can you be sure you’ve stuck that needle into his pericardial space and not into his friggin’ heart?”

  “I did what I thought was right,” Matt responded as steadily as he could manage. “I did what I thought was needed, and I did it the best I could.”

  “The best you could? Rutledge, you’re not a doctor. You’re a goddamn cowboy. A loose cannon. And I want you to know that I fully intend to report your actions to—”

  “Wait,” the nurse cried out. “I hear a pressure. It’s loud and clear at sixty. . . . No, now it’s eighty. It’s eighty.”

  At that moment, Darryl Teague lifted one arm and turned his head.

  CHAPTER 3

  MORNIN’, KIM,” MATT SAID TO THE EFFICIENT, empathetic clerk of the ICU.

  “Good morning, Doctor” was the chilly reply.

  Matt considered confronting the woman. Kim West had always been at least cordial to him, if not downright friendly. But there was no sense in singling out her rudeness. The Belinda Coal and Coke Company was the lifeblood of the valley. In one way or another, all of Montgomery County was linked to it. Over the three days since he saved the life of Darryl Teague, the coolness toward him on the streets of Belinda had grown increasingly unpleasant. Teague had never been a favorite son of the town, and now two young men were dead because of him. And because of Matt, he wasn’t. The gas station, Scotty’s Diner, the dry cleaner—wherever he went, there were whispers and tension, even in the hospital, where people should have known better about the choices doctors should and should not be making.

  Within hours of the incident in the ER, Robert Crook had sent a memo to the entire hospital staff decrying Matt’s behavior and judgment. He even speculated that poor technique in doing the pericardial aspiration had placed the man in as much jeopardy as had the accident itself.

  Teague was officially Crook’s patient, and the cardiologist had gone out of his way to involve an internist other than Matt in his care. Still, Matt had made it a point to visit Teague twice a day since the disaster. Helping to save a person’s life forged a connection only those who had been in that situation could completely understand.

  Ignoring the distasteful glare from one of the older nurses—a miner’s mother, Matt recalled—he went directly to room 6. The lights were out, save for a dim fluorescent over the bed. Teague, his monstrously deformed face battered and bruised, lay on his back breathing shallowly and irregularly on a ventilator. He was unconscious, as he had been since shortly after his transfer up from the ER. From what Matt could tell, there was no decent explanation for his lapse into a coma. Initially, blunt head trauma was the likely suspect, and that certainly remained a possibility. Still, there had been no order for an MRI or CT scan, or even for a consultation with the neurologist. Robert Crook certainly wasn’t going to win any Doctor of the Year award for his attention to this case, although he might well receive a good citizen medal from the townsfolk.

  Matt stood in the gloom, looking down at Darryl Teague.

  What happened to you, Darryl? he asked silently. What did you and Teddy Rideout inhale? What did you drink? What did you rub onto your skin?

  Matt took Teague’s wrist and checked his pulse, which was quite strong. The torn vessel that had caused the nearly lethal cardiac tamponade had clotted, and the narrow drain, which had been placed under the pericardial membrane, had been removed. Now, to all intents, Teague’s mysterious coma was all that was standing between him and a transfer out of MCRH—probably to some prison hospital. Matt did a brief neurological check. Nothing alarming—no focal signs that would suggest a slowly increasing hemorrhage between the skull and brain. He reached up and gently touched the hard, fleshy lump above Teague’s left eyebrow, then the one on his chin. Had the man ever bothered to see a doctor for this bizarre condition, or did his rapidly progressive mental illness prevent him from acting rationally?

  “What’s the deal, Darryl?” Matt whispered. “Come on. Wake up and tell me. . . . What’s the deal?”

  He picked up the bedside phone, hesitated, then called the pathology lab. In seconds his uncle was on the line.

  “Hal, how’re you doing?”

  “Well, I don’t have half the town wanting to tar and feather me for just doing my job, if that’s what you mean.”

  “There’s a nurse right outside who’ll be happy to smear the first glob on me. Listen, Hal, I’m here in Teague’s ICU cubicle. You may already know this, but he’s been in a coma since right after he was moved up here from the ER. I’m wondering if someone’s medicating him.”

  “Why?”

  “First if, then why. Is there any way you could have one of your techs draw an extra tube and run a drug screen on it?”

  “Without telling Crook?”

  “That’s the idea. I would draw it myself, but there would be hell to pay if a nurse walked in on me while I was doing it.”

  “I’ll do it, nephew, but I expect a pouch of premium tobacco next Christmas. No more ties.”

  “You sure? I think I still have three or four left in my closet.”

  “I’m sure.”

  “Okay, no more ties. Thanks, Unk.”

  MATT’S OFFICE OCCUPIED the first floor of a shingled old two-family just off Main Street, near the center of town. He parked his Harley by the garage in back and entered through the rear door. The moment he stepped inside, he could hear an animated exchange coming from his waiting room. The voice, a woman’s, was strident and shrill. Responding to her, evenly, civilly as always, was Mae Borden, his office manager and receptionist.

  “Now, Mrs. Goodwin,” Mae was saying, “I’m not trying to convince you not to switch doctors, but I do think you owe it to your husband to think things through.”

  Matt stopped just short of the door to his office and leaned against the wall in the hallway.

  “Charlie’s the one who made me come,” the woman said. “He’s very upset about what happened in the mine.”


  “You mean Dr. Rutledge saving that boy’s life?”

  “Yes. The two men Teague killed were friends a Charlie’s. An’ the mine’s been closed for three days now because a the damage Teague did down there. That’s money outta everyone’s pockets.”

  “I understand. Tell me something, Mrs. Goodwin. If your husband had been the one driving that equipment that night, would you have wanted Dr. Rutledge to do all he could?”

  “Well, I . . . I suppose I would.”

  “And has Dr. Rutledge always given you two the best of care?”

  “A course he has.”

  “And you want to switch doctors?”

  “Well, I—”

  “Mrs. Goodwin, supposin’ I keep your records here until Charlie comes in and speaks with me—or better still, with Dr. Rutledge. I’m not supposed to say this, but I know for a fact that the two of you are among his favorite patients. He’d hate to lose you.”

  “Well, the truth is, I’d hate to lose him, too.”

  “So?”

  “Mrs. Borden, I was really hopin’ you’d talk me outta this. I’ll tell Charlie if’n he wants to go through with it, he’s got t’ come in an’ face Dr. Rutledge hisself.”

  “I suspect he’ll be relieved you didn’t do it.”

  “I think he will, too. Thank you. Oh, thank you so much.”

  Matt heard the front door open and shut.

  “It’s okay, Matthew,” Mae called out. “She’s gone. You can come in here now.”

  Matt entered the modest waiting area and kissed his office manager on the cheek.

  “I have some Eskimos I want to sell refrigerators to,” he said. “I think you’re just the woman for the job.”

  “No thanks. I can’t stand the cold.”

  “Bless you for saving my practice.”

  “Oh, it’s not been that bad,” Mae replied in her melodic, Alabama drawl. “Six attempted defections so far, only three successful ones.”

  Mae had been Matt’s office manager since the day he entered practice. She was in her fifties, but her silver hair and conservative manner and dress added a decade to that. Over the years, the two of them had become bound by their differences as well as by a total devotion to the practice and their patients. In addition to making the best pot of coffee in town, Mae was a wizard at squeezing in any patient who needed to be seen, and at “adjusting” a bill for anyone who couldn’t pay.