She could barely hear it beating.
Glancing up again at the monitor, she saw a fast sinus rhythm tracing across the screen. The heart’s electrical system was intact. Why didn’t the woman have a pulse? Either the patient was in shock from blood loss. Or . . .
Toby focused on the neck, and the answer instantly became apparent to her. The woman’s obesity had obscured the fact that her jugular veins were bulging.
“You said she had an MI six weeks ago?” Toby asked.
“Yeah,” the driver grunted out as he resumed chest compressions. “That’s what the husband said.”
“Any other meds besides Digoxin?”
“There was a big bottle of aspirin on the nightstand. I think she’s arthritic.”
That’s it, thought Toby. “Maudeen, get me a fifty cc syringe and a cardiac needle.”
“Gotcha.”
“And toss me some gloves and a Betadine wipe!”
The packet flew toward her. Toby caught it in midair and ripped it open. “Stop compressions,” she ordered.
The driver stepped back.
Toby gave the skin a quick swab of Betadine, then she pulled on the gloves and reached for the 50-cc syringe. She glanced one last time at the monitor. The rhythm was still a rapid sinus. She took a deep breath. “Okay. Let’s see if this helps . . .” Using the bony protrusion of the xiphoid process as her landmark, she pierced the skin and angled the needle tip straight toward the heart. She could feel her own pulse hammering as she slowly advanced the needle. At the same time she was pulling back on the plunger, exerting gentle negative pressure.
A flash of blood shot into the syringe.
She stopped right where she was. Her hands were absolutely steady. God, let the needle be in the right place. She pulled back on the plunger, gradually suctioning blood into the syringe. Twenty cc’s. Thirty. Thirty-five . . .
“Blood pressure?” she called out, and heard the rapid whiff, whiff of the cuff being inflated.
“Yes! I’m getting one!” said Val. “Eighty over fifty!”
“I guess we know what we’ve got now,” said Toby. “We need a surgeon. Maudeen, get Dr. Carey on the line. Tell him we’ve got a pericardial tamponade.”
“From the MI?” asked the ambulance driver.
“Plus she’s on high-dose aspirin, so she’s prone to bleeding. She probably ruptured a hole in her myocardium.” Surrounded by blood in the closed sac of the pericardium, the heart would be unable to expand. Unable to pump.
The syringe was full. Toby withdrew the needle.
“Pressure’s up to ninety-five,” said Val.
Maudeen hung up the wall phone. “Dr. Carey’s coming in now. So’s his team. He says to keep her stabilized.”
“Easier said than done,” muttered Toby, her fingers probing for a pulse. She could feel one, but it remained thready. “She’s probably reaccumulating. I’ll need another syringe and needle pretty quick. Can we get her typed and crossed? And let’s get a STAT CBC and lytes while we’re at it.”
Maudeen pulled out a fistful of blood tubes. “Eight units?”
“At least. Whole blood if we can get it. And send down some fresh frozen plasma.”
“Pressure’s falling to eighty-five,” said Val.
“Shit. We’ll need to do it again.”
Toby ripped open a packet with a fresh syringe and tossed the wrapping aside. Already the floor was piling up with the debris of paper and plastic that accumulated during every code. How many times will I have to repeat this? she wondered as she positioned the needle. Get your butt over here, Carey. I can’t save this woman on my own. . .
Toby wasn’t sure Dr. Carey could save the patient either. If the woman had blown a hole in her ventricular wall, then she needed more than just a thoracic surgeon—she needed a full cardiac bypass team. Springer Hospital was a small suburban facility, perfectly capable of dealing with cesareans or simple gallbladder resections, but it was unequipped to deal with major surgery. Ambulance teams transporting serious trauma victims would normally bypass Springer Hospital and head straight for one of the larger medical centers like Brigham or Mass General.
This morning, though, the ambulance had unknowingly delivered a surgical crisis right to Toby’s doorstep. And she didn’t have the training—or the staff—to save this woman’s life.
The second syringe was already filled with blood. Another fifty cc’s of it—and it didn’t clot.
“Pressure’s going down again,” said Val. “Eighty—”
“Doc, she’s in V-tach!” one of the EMTs cut in.
Toby’s gaze shot to the monitor. The rhythm had deteriorated to the jagged pattern of ventricular tachycardia. The heart was using only two of its four chambers now, beating too fast to be efficient.
“Defibrillator pads!” snapped Toby. “We’ll go with three hundred joules.”
Maudeen hit the charge button on the defibrillator. The needle climbed to three hundred watt-seconds.
Toby slapped two pads on the patient’s chest. Coated with gel, the pads ensured electrical contact with the skin. She positioned the paddles. “Back!” she said, and squeezed the discharge button.
The patient thrashed, all her muscles jerking simultaneously as the current shot through her body.
Toby glanced at the monitor. “Okay, we’re back in sinus—”
“No pulse. I’ve got no pulse,” said Val.
“Resume CPR!” said Toby. “Hand me another syringe.”
Even as she opened the packet and twisted on the pericardiocentesis needle, Toby knew they were losing the fight. She could suction out liters of blood, but more would accumulate, compressing the heart. Just keep her alive until the surgeon gets here, thought Toby, and the words became her mantra. Keep her alive. Keep her alive. . .
“Back in V-Tach!” said Val.
“Charge to three hundred. Get a lidocaine bolus in—”
The wall phone rang. Maudeen answered it. A moment later she called out: “Morty’s having trouble crossmatching that blood I sent up! The patient’s B negative!”
Shit. What else can go wrong? Toby slapped the paddles on the chest. “Everyone back!”
Again the woman’s body jerked. Again the rhythm settled back into rapid sinus.
“Getting a pulse,” said Val.
“Push that lidocaine now. Where’s our fresh frozen plasma?”
“Morty’s working on it,” said Maudeen.
Toby glanced at the clock. They’d been coding the patient for nearly twenty minutes. It seemed like hours. Surrounded by chaos, with the phone ringing and everyone talking at once, she felt a sudden flash of disorientation. Inside the gloves, her hands were sweating, and the rubber was clammy against her skin. The crisis was spiralling out of her control. . . .
Control was the word Toby lived by. She strove to keep her life in order, her ER in order. Now this code was falling apart under her command, and there was nothing she could do to salvage it. She wasn’t trained to crack a chest, to sew up a ruptured ventricle.
She looked at the woman’s face. It was mottled, the flabby jowls deepening to purple. Even as she watched, she knew the brain cells were starving. Dying.
The ambulance driver, exhausted from chest compressions, switched places with his fellow EMT. A fresh pair of hands began pumping.
On the monitor, the heart tracing deteriorated to a jaggedly chaotic line. Ventricular fibrillation. A fatal rhythm.
The team responded with the usual strategies. More boluses of antiarrhythmics. Lidocaine. Bretylium. Higher and higher jolts from the paddles. In desperation Toby withdrew another fifty cc’s of blood from the pericardium.
The heart tracing flattened out to a meandering line.
Toby glanced around at the other faces. They all knew it was over.
“All right.” Toby released a deep breath, and her voice sounded chillingly calm. “Let’s call it. What time?”
“Six-eleven,” said Maudeen.
We kept her going forty-
five minutes, thought Toby. That’s the best we could do. The best anyone could do.
The EMT stepped back. So did everyone else. It was almost a reflex, that physical retreat, those few seconds of respectful silence.
The door banged open and Dr. Carey, the thoracic surgeon, made his usual dramatic entrance. “Where’s the tamponade?” he snapped.
“She just expired,” said Toby.
“What? Didn’t you stabilize her?”
“We tried. We couldn’t keep her going.”
“Well, how long did you code her?”
“Believe me,” said Toby. “It was long enough.” She pushed past him and walked out of the room.
At the nurses’ desk she sat down to gather her thoughts for a moment before filling out the ER sheet. She could hear Dr. Carey in the trauma room, his voice raised in complaint. They’d dragged him out of bed at five-thirty in the morning, and for what? A patient who couldn’t be stabilized? Couldn’t they think first before they ruined his night’s sleep? Didn’t they know he had a full day in the OR coming up?
Why are surgeons such assholes? Toby wondered, and she dropped her head in her hands. God, would the night never end? She had one more hour to go. . . .
Through the fatigue clouding her brain, she heard the whoosh of the ER doors swinging open. “Excuse me,” said a voice. “I’m here to see my father.”
Toby looked up at the man standing across from her. Thin-faced, unsmiling, he regarded her with an almost bitter tilt to his mouth.
Toby rose from the chair. “Are you Mr. Slotkin?”
“Yes.”
“I’m Dr. Toby Harper.” She held out her hand.
He shook it automatically, without any warmth. Even the touch of his skin was cold. Though he had to be at least thirty years younger than his father, the man’s resemblance to Harry Slotkin was immediately obvious. Daniel Slotkin’s face had the same sharply cut angles, the same narrow slash of a brow. But this man’s eyes were different. They were small and dark and unhappy.
“We’re still evaluating your father,” she said. “I haven’t seen any of his labs come back yet.”
He glanced around the ER and made a sound of impatience. “I need to be back in the city by eight. Can I see him now?”
“Of course.” She left the desk and led him to Harry Slotkin’s room. Pushing open the door, she saw that the room was empty. “They must have him in X-ray. Let me call over and see if he’s done.”
Slotkin followed her back to the front desk and stood watching her as she picked up the phone. His gaze made her uneasy. She turned away from him and dialed.
“X-ray,” answered Vince.
“This is Dr. Harper. How’s the scan coming?”
“Haven’t done it yet. I’m still getting things set up here.”
“The patient’s son wants to see him. I’ll send him over.”
“The patient isn’t here.”
“What?”
“I haven’t gotten him in here yet. He’s still in the ER.”
“But I just checked the room. He’s not . . .” Toby paused. Daniel Slotkin was listening, and he’d heard the dismay in her voice.
“Is there a problem?” asked Vince.
“No. No problem.” Toby hung up. She looked at Slotkin. “Excuse me,” she said, and headed up the hall to exam room three. She pushed open the door. There was no Harry Slotkin. But the gurney was there, and the sheet they’d used to cover him was lying crumpled on the floor.
Someone must have put him on a different gurney, moved him to a different room.
Toby crossed the hall to exam room four and shoved aside the curtain.
No Harry Slotkin.
She could feel her heart thudding as she moved down the hall to exam room two. The lights were off. No one would have put the patient in a dark room. Nevertheless she flicked on the wall switch.
Another empty gurney.
“Don’t you people know where you put my father?” snapped Daniel Slotkin, who had followed her into the hall.
Pointedly ignoring his question, she stepped into the trauma room and yanked the curtain shut behind her. “Where’s Mr. Slotkin?” Toby whispered to the nurse.
“The old guy?” asked Maudeen. “Didn’t Vince take him to X-ray?”
“He says he never got him. But I can’t find the man. And the son’s right outside.”
“Did you look in room three?”
“I looked in all the rooms!”
Maudeen and Val glanced at each other.
“We’d better check the hallways,” said Maudeen, and she and Val hurried out into the corridor.
Toby was left behind to deal with the son.
“Where is he?” demanded Slotkin.
“We’re trying to locate him.”
“I thought he was supposed to be in your ER.”
“There’s been some kind of mix-up—”
“Is he or isn’t he here?”
“Mr. Slotkin, why don’t you have a seat in the waiting room? I’ll bring you a cup of coffee—”
“I don’t want a cup of coffee. My father’s having some kind of medical crisis. And now you can’t find him?”
“The nurses are checking X-ray.”
“I thought you just called X-ray!”
“Please, if you’ll just have a seat in the waiting room, we’ll find out exactly what . . .” Toby’s voice trailed off as she caught sight of the two nurses hurrying back toward her.
“We called Morty,” said Val. “He and Arlo are checking the parking lot.”
“You didn’t find him?”
“He can’t have gone far.”
Toby felt the blood slide from her cheeks. She was afraid to look at Daniel Slotkin. Afraid to meet his gaze. But she couldn’t shut out the sound of his anger.
“What is going on around here?” he demanded.
The two nurses said nothing. Both of them looked at Toby. Both of them knew that in the ER, the doctor was the captain of the ship. The one on whose shoulders rested ultimate responsibility. Ultimate blame.
“Where is my father?”
Slowly Toby turned to Daniel Slotkin. Her answer came out in barely a whisper. “I don’t know.”
It was dark, and his feet hurt, and he knew he had to get home. The trouble was, he could not remember how to get home. Harry Slotkin could not even remember how he’d come to be stumbling down this deserted street. He thought about stopping at one of the houses along the way to ask for help, but all the windows he passed were dark. Were he to knock at one of those doors and beg for help, there would be questions and bright lights and he would almost certainly be humiliated. Harry was a proud man. He was not a man to ask for anyone’s assistance. Nor did he volunteer assistance to others—not even to his own son. He’d always believed that charity, in the long run, was crippling, and he had not wanted to raise a cripple. Strength is independence. Independence is strength.
Somehow, he would find his own way home.
If only the angel would reappear.
She had come to him in that place of horrors, where he’d been put on a cold table and lights had blinded his eyes, the place where strangers had poked him with needles and jabbed him with their probing fingers. Then the angel had appeared. She hadn’t hurt him at all. Instead she had smiled at him as she untied his hands and feet, and she had whispered: “Go, Harry! Before they come back for you.”
Now he was free. He’d escaped, good for him!
He continued down the street of dark and silent houses, searching for some familiar landmark. Anything to tell him where he was.
I must have gotten turned around, he thought. Went out for a walk and lost my way.
Pain suddenly bit into his foot. He looked down and halted in amazement.
Beneath the glow of a streetlamp, he saw that he was wearing no shoes. Or socks, either. He stared at his bare feet. At his bare legs. At his penis, hanging limp and shriveled and utterly pitiful.
I’m not wearing any clothes!
> In panic he glanced around to see if anyone was looking at him. The street was deserted.
Cupping his hands over his genitals, he fled the street-lamp, seeking the cover of darkness. When had he lost his clothes? He couldn’t remember. He squatted down on the cold, clipped lawn of a front yard and tried to think, but panic had crowded out all memories of what had happened earlier that night. He began to whimper, soft little grunts and sobs as he rocked back and forth on his bare feet.
I want to go home. Please, oh please, if I could just wake up in my own bed. . .
He was hugging himself now, so lost in despair that he didn’t notice the headlights rounding the far corner. Only when the van braked to a stop right beside him did Harry realize he’d been spotted. He clasped his arms tighter, curling into a shivering self-embrace.
A voice called softly through the darkness. “Harry?”
He didn’t raise his head. He was afraid to unfold his body, afraid to reveal his humiliating state of undress. He tried to squeeze himself into a tighter and tighter ball.
“Harry, I’ve come to take you home.”
Slowly he raised his head. He could not make out the face of the driver, but the voice was one he knew. Or thought he knew.
“Step into the van, Harry.”
He rocked back and forth on his heels and felt the wet grass brush against his bare buttocks. His voice rose in a high, thin wail. “But I have no clothes!”
“You have clothes at home. A whole closet of suits. Remember?” There was a soft clunk, the whine of metal sliding across metal.
Harry looked up and saw that the van door was open. Darkness gaped beyond. The silhouette of a man was standing beside the vehicle. The man extended his hand in a gesture of invitation.
“Come, Harry,” he whispered. “Let’s go home.”
4
How hard can it be to find a naked man?
Toby sat in her car, squinting out at the hospital parking lot. It was already midmorning, and the sunlight seemed excruciatingly bright to her night-accustomed eyes. When had the sun come up? She hadn’t seen it rise, hadn’t enjoyed a single free moment to glance outside, and the daylight was a shock to her retinas. That’s what came of choosing the graveyard shift. She was transforming into a creature of the night.
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