"Okay. I'll be next door. Frank, thanks for your help. I hope things with Lisette get straightened out."
"Not to worry. Just get on in there and do whatever you have to."
The two of them left room 8. Zack entered the trauma room and Frank crossed the E. R. to the X-ray department. The Judge had been moved, on the transfer board, to the X-ray table. "I need a minute alone with him,
" Frank said, motioning Suzande and the technician away. "Judge, listen,
" he whispered, when the others were out of earshot. "I tried to reason with Zack about not seeing Robillard, but he just won't listen. I'm on your side on this one. One hundred percent. Just relax and let them take your pictures. I'll keep trying to make Zack see what's right."
The rescue team, nurses, and emergency physician cleared a path as Zack entered the trauma room. His programming in the evaluation of nervous system damage was in reflex operation before he reached the bedside.
Beau Robillard, lying nude on the trauma room litter, was disheveled, covered with cuts and abrasions, and even worse off than Zack had anticipated. Comatose… respirations shallow, minimally effective… barely responsive to deep pain… tight pupil, two millimeters, left pupil, five millimeters, sluggishly reactive… "Was he ever awake, Wilton?"
"Absolutely, " Marshfield said. "He was awake when the police found him, and moaning and incoherent when he arrived here. Then he seized."…
Some purposeless movement on the left side, no movement on the iight..
.. Babinski reflex absent both sides… deep scalp laceration left paiietal region… "Could I have a pair of gloves, please. Size eight.
Also, get set to intubate him. Number seven point five tube. Wilton, can I see his films?"
"We haven't had a chance to get them, what with your father coming in first and this creep looking a helluva lot better than he does right now. Do you know who he is?"
"Yeah, yeah, " Zack said. "I know."
"When this… this thing here was a boy, " Marshfield said, "He and his cronies beat up on my nephew so many times that my brother finally ended up having to send the kid to St. Michael's Academy. I'm telling you, he was really a creep. So were those two older. Robillard boys."
Zack explored the deep scalp gash with his gloved fingers, and felt the distinctive click of bone fragments. "Well, I don't care if he's the reincarnation of Jack the Ripper and Attila the Hun rolled into one," he said. "He's got a subdural or epidural hematoma expanding on the left.
He needs Burr hole drainage, and quickly. Also, see if you can get Greg Ormesby in here just in case something's going on in his abdomen."
The nurse set a tray of equipment by Zack's right hand. He hunched over the head of the litter, positioned the steel blade of the laryngoscope against Robillard's tongue, and in seconds slid the polystyrene breathing tube through the man's vocal cords into his trachea.
"Hyperventilate him, please, " Zack said, connecting a breathing bag to the tube and turning it over to the respiratory technician. Burr holes!
An hour in the operating room. More if there was trouble. Zack backed away from the bed, a stranglehold of indecision tightening about his chest. Both Beau Robillard and the Judge needed surgery that, of those at Ultramed-Davis, he was by far the most qualified to perform. From a purely medical perspective, there was no dilemma, no doubt about the priorities of the moment. Without immediate intervention, Robillard would die. It was that simple. But thanks to Judge Clayton Iverson, it wasn't that simple at all.
"Keep bagging him, " Zack mumbled, rubbing at the ache that had suddenly materialized between his temples. "Be sure there are two teams available for the O. R. I'll be right back."
He glanced into room 8. It was still empty. Please, he was thinking as he headed toward the X-ray department. Let that chunk of metal be just below the skin. Let it be someplace where anyone with a scalpel and a little training can get it out. Suzanne was standing by one of the department's banks of view boxes, studying the films. Even from a distance, Zack could see that the position of the metal fragment was trouble. "How's he doing? " he asked. "Okay. He's complaining of some heaviness in his legs, but I think you might have put that symptom in his head. Your mother's here. Frank's got her in the quiet room, I think. That metal's not in such a good spot, huh?"
"It's in near the cord, if that's what you mean. See right here how it's chipped the edge of the vertebral transverse process?
Removing it should be reasonably straightforward, but it certainly won't be any smash and grab. The area's got to be explored to be sure there's no bleeding around the cord. Damn, but I wish this wasn't happening.
That Robillard is going out. A Burr hole procedure now is his only chance, and not such a huge one at that."
"Are you going to do it?"
"Suzanne, I don't have any choice. Of course I'm going to do it. Did you find out who's on for orthopedics?"
"Sam Christian's the only one around, but he's in the O. R. over at Clarion County. Apparently he just started an open reduction."
"Damn. Well, listen, keep your eye on the Judge, okay? I'm going to call John Burris in Concord. He's an excellent neurosurgeon, and with that Beechcraft of his, he can be up here in an hour or less.
Meanwhile, go ahead, call in the radiologist and get a CT scan of the area. See if we can assess the extent of bleeding. This day is really the pits, do you know that?"
"Zack?"
"What?"
"The Judge and Frank told me what kind of a person this Robillard is. If he's really as bad off as you say, maybe you should accept the inevitable and devote your energy to making sure your father's all right."
"Suzanne, I can't believe you're saying that."
"Really?
Well, what if it were me lying in there with a piece of metal up against my spinal cord? Zack, this is your father we're talking about."
"Suzanne, that man in there's dying."
"You know, there are such things in this world as love and loyalty. they're allowed. According to some people, they're even worthwhile virtues to have.
Even physicians are allowed to be human. That man you want to operate on steals and beats up on people, Zachary. That's what he does. The police say that the cab of his pickup was littered with empty beer cans…"
Zack glared at her. "I can't believe you're saying that. I just can't believe it." He turned and stalked into the room where his father lay beneath the X-ray camera. "Dad, how're you doing?"
"My back aches, and my legs feel a little heavy."
Zack tapped his reflex hammer against the Judge's Achilles' tendons, documenting once again through the reassuring flick of each foot that the ankle to spinal cord and spinal cord-to-ankle circuits were intact.
"Wiggle your toes, please… Good. Other foot… good."
"What's the story? " the Judge asked. "Well, your wrist is broken, but it will keep until Sam Christian gets done at Clarion County. However, that piece of metal in your back ought to come out soon."
"I thought so. You going to do it?"
Zack hesitated, and then shook his head, triggering a jackhammer pain between his eyes. "No, Dad, " he said. "I've got to do that man first or he's dead. Besides, we're not encouraged to operate on our own family if we can avoid it. I'm going to call John Burris up from Concord."
"I want you."
"Judge, please, don't make this any harder. You're quite stable right now. Robillard's dying."
"Let him die."
"I can't do that. Clayton Iverson stared stonily at the ceiling. In the silence, Zack became aware of others in the room. He turned. Frank and Suzanne stood just inside the doorway, watching and listening. "Suzanne, please arrange the CT scan, " Zack said, trying to ignore the disapproval in her eyes. "I've got to call Burris and then get into the O. R. I can see by your face what you want to say to me. Don't bother.
I'm doing the one thing we are taught always to do-I'm doing what I think is right… Judge, I love you, and I'll be keeping track of things. With luck, by th
e time Burris gets here I'll be done with what I have to do, and I can assist him. Meanwhile, just hang in there."
He turned and left, brushing past Suzanne. She followed him for several steps, but then, shaking her head in resignation and frustration, headed for the radiology office. "Ma's here, " Frank said, approaching the bed.
"Judge, I'm sorry. I tried to help him see reason."
"Forget it, Frank, " Clayton Iverson said. "Just leave me alone."
"But Judge-"
"Dammit, Frank, I said leave me alone." Nothing felt normal or comfortable. The room, O. R. 4, seemed far too warm, the surgical team far too quiet. The blades and scissors and drill bits were too dull, the hemostats and needle holders unacceptably stiff or loose. Zachary struggled to ignore his throbbing headache and his sodden scrub suit and to focus on the situation at hand. The circulating nurse, no longer waiting for his request, was mopping perspiration from his forehead and cheeks every two or three minutes. They were nearly an hour into the Burr hole drainage procedure on Beau Robillard, and still there was no word that John Burris had arrived from Concord. Down the hall, in O. R. 2, a second surgical team stood ready. "Valerie, " Zack said to the circulator, "could you go on down to the E. R., please, and see what you can find out about Dr. Burris. He should have been here by now."
Beneath his green paper mask, Zack's jaw was clenched. He was right in what he was doing, dammit. He was a physician, a surgeon, not judge and jury. Why, then, was everyone acting as if his decision were some sort of mortal sin? Surely they understood that he wasn't choosing this man's life over his father's. The Judge was stable, perfectly stable. Beau Robillard was dying. "Pressure's down a bit, " Jack Pearl cautioned. The words brought Zack's thoughts back in tune with his hands. "Feel free to transfuse him a unit if you need to, " he responded. "I've aspirated a fair amount through these Burr holes, but his brain's not showing any signs of reexpanding. If there's no action in a few more minutes, we're going to have to push ahead with a full craniotomy."
The circulating nurse, Valerie, reentered the O. R. through the scrub room. "Dr. Iverson, " she said, "there's a problem downstairs."
Zack shuddered. "Yes, go ahead. "I was told to tell you that Judge Iverson's feet have gone numb. He's unable to move his toes."
"Who's with him?"
The urgency in his voice bordered on panic. He glanced down at the persisting space between Beau Robillard's skull and brain surface, and begged himself to calm down. "Dr. Cole and Dr. Marshfield, " the woman answered. And where in the hell is-" Zack breathe deeply and exhaled.
"Where is Dr. Burris? " he asked more evenly. The eyes of everyone on the surgical team were fixed on him. There was, they all knew, little chance he could break scrub and leave the operating room without killing Robillard. "The weather's gotten worse. Apparently there was a problem with Dr. Burris's plane, " the nurse explained. "He's gotten someone to fly him up, but they lost some time."
"How much till he's here?"
"Twenty minutes."
"Damn, " Zack murmured. It would take another hour to complete the craniotomy-the open procedure he now felt certain was necessary. And even with the proce, Beau Robillard's chances of survival as anything more than a vegetable were growing dimmer each second. "Have them give Judge Iverson five amps of Narcan IV, and get him up to the operating room now."
"Five? But the usual dose is-"
"Dammit, I know what the usual dose is." He took a deep breath. "Sorry.
I didn't mean to snap at you. The high dose is to help keep down the swelling in his cord. Also, please ask Dr. Cole if she can come up here and tell me exactly what's going on."
In truth, Zack had little doubt as to what was going on. An epidural bleed, not predictable at all from his initial exam, was compressing the Judge's spinal cord. Had he missed something? Had there been a clue?
Uncertainty and self-doubt hardened around Zack's hands like cement.
With Burris less than twenty minutes away, could any significant change be effected now by scrubbing out on Robillard and going after the Judge's bleed?
Zack gazed down at the man for whose life he had chosen to be responsible. Having made that choice, did he even have the right now to renege on it?
The doors to the O. R. burst open, and Suzanne, dressed in scrubs, stepped inside. "The Judge can't move his legs, " she said. "Burris is about to land. A cruiser's waiting for him at the airport."
"Reflexes?"
"A flicker, " she said. "It would seem, Doctor, that unless John Burris works a minor miracle, your father might well end up paralyzed from the waist down."
At that moment, Jack Pearl called out, "Dr. Iverson, his rate's dropping. I can't get a pressure."
"Give him an amp of epinephrine."
"Already done."
"Get ready for CPR."
"Pulse is dropping. Dropping more."
"Damn… Begin CPR."
"Doctor, he's straight line. "Another amp of epi. Give him another amp of epi. "
CHAPTER TWENTY
It was after two in the morning. The fine, misty rain drifting over the valley for hours had sapped most of the warmth remaining from the day. Zack lay sprawled on his living room floor, staring at nothing in particular. The only illumination in the room was from half a dozen candles and the red and green lights on his stereo receiver. For the two hours since his return from the hospital, he had been listening to Mendelssohn and Mahler, talking almost nonstop to Cheap dog, and drinking-at first several beers, then beer plus shots of Wild Turkey, and finally, the 110-proof Wild Turkey alone. "I didn't ask mush, y'know, Cheap?… Peace and quiet, some rocks to climb, a place to do my work without any hassles, the chance to make a difference… Don't look at me that way. I know I said that before. So what?… You're the dog, so you just have to sit there and listen… That's the way it is …"
Zack could count on the fingers of one hand the number of major league drinking bouts he had ever had, but he felt determined to add this night to the list. Beau Robillard had survived his cardiac arrests on the operating table, only to experience several more arrests in the recovery room. Zack had called off the resuscitation after intensive efforts failed to bring back any functional cardiac activity. In retrospect, given the extent of the cerebral contusion and hemorrhage Zack had discovered during surgery, it seemed that the die was cast for Robillard the moment the side of his head had connected with whatever it had.
Unfortunately, in the heat of battle, with no time to spare and a life on the line, there was simply no way for him to know that ahead of time.
You know what medicine's like, boy?'s like you come to rely on this wonderful woman who has promised you that if you treat her right, she'll always be there when you need her… So you do… You study, and no matter how exhausted you are, you don't take any shortcuts… And then, when you need her the most, when your own goddamn father's involved, you follow the system and use your clinical judgment, and do just what you're supposed to do, and poof! She's gone… Gone! Damn women…
Damn medicine…"
Zack had pronounced Beau Robillard dead just as John Burris was completing the removal of a jagged chunk of rusty metal from deep within the muscles of Clayton Iverson's back. Although there was no evidence that the fragment had pierced the dural lining of the spinal canal, apparently there had been some impairment of blood flow to the cord, because the Judge's paralysis had progressed and was now being regarded by Burris as total paraplegia. Whether the condition was permanent or not, Burris would not speculate, although both he and Zack knew all too well that the prognosis following such a development was not good. Word of Zack's decision, the Judge's paralysis, and Beau Robillard's death had spread through the hospital like wildfire. That Robillard's blood alcohol level had come back well below that of legal intoxication, while the Judge's was above the 0. 1 cutoff, was a fact lost in the rumors and the stories of the accident, and the virtually universal condemnation of Zack's disloyalty to his father. Suddenly, it seemed, there
was not a soul in all of Ultramed-Davis who did not have a bone or two to pick with Beaudelaire Robillard, Jr., nor one who had not been helped at one time or another by Judge Clayton Iverson. Throughout the hideous evening, which ended with a tense, one way conversation at his father's bedside, Zack did not hear so much as one word of support from anyone for the difficulty of his position or the rightness of his decision.
With Suzanne and Owen Walsh watching Toby, and John Burris staying the night in the guest room at the hospital, there was no reason for him to stay around. And there was every reason to come home and get drunk. In the morning, he would in all likelihood pack up and leave. If only there were some way he could take off for parts unknown without bringing himself along. With the heat turned off, and no fire in the hearth, the house had begun to absorb the chill of the night. Zack pushed himself up and shuffled to the bedroom for a sweater. He was surprised that although he had had more to drink over a shorter period of time than he could ever remember, he felt quite steady on his feet. There was a certain irony that on this particular night he was unable even to do a decent job of getting drunk. Returning to the living room, he laid a small fire, put on a slightly less morose album, and sipped another ounce of Wild Turkey. He could understand the Judge's stony castigation of him, and even his mother's. They had every right to be upset. But Suzanne's reaction was a bitter pill. She was a physician, to say nothing of being his lover. Even if no one else did, she should have had some compassion and understanding for his predicament. He poured another ounce. Years before, in the very beginning of his training, he had wrestled with the issues of making decisions in medicine, and had chosen to adopt the careful, objective, by-the-book approach over any of the more flamboyant, headline-grabbing tactics embraced by many of his surgical colleagues. The decision had not been that difficult. He was a second child, a plodder. He had done his best with what tools he had.
Why couldn't Suzanne understand that? Frank was the buccaneer in the family. He was a scholar. Frank danced on the wind. He needed a system.
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