As he entered, the patient’s wife, mother-in-law and three kids all looked at him, their eyes filled with desperate hope. They were surrounded by about ten cops, who looked at him with flat, level gazes, clearly expecting the worst.
“It’s going well,” Kurtz said. “Probably another hour or so until he’s out of surgery. He’s stable.”
Figueroa’s wife gave a little sigh and bowed her head over a string of rosary beads. The cops sat back. Kurtz glanced at Barent and Harry Moran, then gave a nod toward the door. The two cops rose to their feet and followed him out.
“No way for me to tell how much of his brain is going to be left after this,” Kurtz said. “You know that, right?”
Moran winced. Barent looked away. “Yeah,” he said.
“The surgeon is Allen Wong. He’s good.”
Barent grimaced. “We’ll see,” he said.
“Yeah,” Kurtz said. “We’ll see.”
Iosif Kozlov was angry. He was angry at the three idiots who had allowed themselves to be tailed to the meeting place of his recently acquired associates. He was angry at the supposedly competent sniper who had shot the undercover cop in the head without, somehow or other, killing him. Not that they had known he was a cop, of course. He had been dressed like a bum, which was what his idiotic henchmen had assumed him to be. It wasn’t until the news hit the internet in the morning that any of them had put two and two together and realized that they had shot a cop in the head.
Yes, Iosif Kozlov was angry. In the normal course of things, the still breathing cop would have been swiftly carried away and never seen again, his dead body buried in a landfill or ground down into dogfood. In this case, however, a group of six young men passing by had immediately stumbled upon the bleeding cop and called the police. The Colombians had decided that killing an additional six men, some of whom might have been armed for all any of them knew, just to dispose of some random vagrant, would be an inappropriate escalation. The meeting had been abruptly ended, the building evacuated of both their personnel.
He took a deep breath. Calm, he told himself. His primary enforcer and personal bodyguard, Grigory Mazlov, stood to the side. The three idiots stood in front of his desk, their faces blank.
“Why?” Kozlov asked.
One of the men frowned. The two others remained outwardly impassive. The first man cleared his throat. “We didn’t see him.”
“Did you see anything? Did you look?”
“We did.” The first man gave the two others an uncertain glance. “He was good.”
The cop probably had been good, Iosif Kozlov conceded. It didn’t matter. He and his men were operating in a foreign country, surrounded by enemies. You stayed alert. You were better than the opposition. You had to be. Or you died.
“Hold up your left hand,” Iosif Kozlov said. “All of you.”
All of them did so, their faces grim. They were sweating. One of them drew a deep breath.
“It remains to be seen if you can redeem yourselves from this failure,” Kozlov said. He opened the middle drawer of his desk and pulled out a bolt cutter. He waved it lazily in front of his face, then put it down on the desk and slid it across. All three men stared at it. “Pick it up,” Kozlov said.
Slowly, the first man, the one who had spoken, reached out. He picked up the bolt cutter with his right hand.
“Before we go any further,” Kozlov said, “I wish you to understand a few things. First, we must be strong.” He stopped, leaned back and stared for a moment into space. “I have reason to know that all of you are strong. Second, we must be brave.” He smiled. “And I also know that you are brave, but strength and courage are the most basic, the most common attributes that we must possess. We must also be dedicated, to ourselves and to our cause. We must be obedient to those who have been placed above us and we must be loyal to the organization of which we are privileged to be a part. All of these qualities, you are about to demonstrate. In addition, however, there are other qualities that are not only useful, but vital to the work that we are called upon to do. We must be intelligent. We must understand our environment and our world and the requirements of success, and perhaps most of all, we must know ourselves. We must know of what we are capable and we must know our limitations, as soldiers and as men.” Iosif Kozlof’s lips quirked upward. “You underestimated the enemy. You are allowed to make such a mistake only once. Do you understand?”
Grigory Mazlov remained impassive, watching all three men with hooded eyes. All three nodded their heads. “This is good,” Kozlov said gently. “Now go ahead.”
Slowly, the first man put the little finger of his left hand between the jaws of the bolt cutter and squeezed the handle.
Iosif Kozlov smiled.
Chapter 2
“Strange,” Vinnie Steinberg said.
Kurtz looked up. “What is?”
Steinberg frowned. “This guy’s not taking any anesthesia at all.”
The comment rolled around the back of Kurtz’ brain but at the moment, a small artery in the abdominal wound began to spurt. “Clamp,” Kurtz said.
The nurse handed him a clamp and he clicked it tight around the artery. The spurting stopped. Kurtz looked up at Steinberg. “What do you mean?” he said.
“I mean the guy’s anesthetized. His vital signs are stable. The BIS monitor is in the teens, but I’ve got the gas turned down almost to zero.”
Kurtz wrinkled his brow. The patient was a middle-aged male named Jeffrey McDonald, who had come into the ER with a ruptured spleen, courtesy of being hit by a car while crossing a street in midtown. A much younger girlfriend had accompanied him but the girlfriend couldn’t tell them much about the guy’s medical history.
“Maybe you should call his ex-wife,” she had reluctantly said.
A good idea. Kurtz had spoken to Christy McDonald on the phone while the ER staff cut off the guy’s clothes, started IV’s and did the preliminary workup. The patient had stopped breathing at the scene and was already intubated on arrival, the ventilator next to his head pumping a steady stream of oxygen into his lungs.
“He’s forty-seven years old,” Christy McDonald had said. “He had what I believe they refer to as a ‘mid-life crisis.’” Her voice was flat. “You know what that means? Mid-life crisis?”
“I do,” Kurtz said.
She went on as if Kurtz had not spoken. “It means that he’s not making as much money as he thinks he deserves. It means that his hair is thinning, his waistline is expanding, and he’s desperately trying to recapture the triumphs of his lost, lamented youth, not that he was ever such hot stuff back in what he sometimes nostalgically referred to as the ‘glory days.’” Christy McDonald sniffed. “It means that he wants a pretty young thing that will look up to him and think he’s wonderful because he’s so experienced and so worldly and so sophisticated, not that he was ever very experienced, worldly or sophisticated. Let’s see how long that lasts. Jackass.”
This was not exactly what Kurtz had been hoping to hear. “Does he have any medical problems?” he asked.
“Mitral valve prolapse,” Christy McDonald said. “He’s supposed to take antibiotics if he has any medical procedures. Also, his cholesterol is high.”
“Good to know,” Kurtz said. “Anything else?”
“No.”
“Alright then. Thank you.”
Christy McDonald sniffed again and hung up.
The case, all-in-all, was going smoothly, more smoothly than most such cases, at any rate, since a multiple trauma patient often had injuries that were not immediately apparent and the apparent injuries were often immediately life threatening. “The CAT scan of the brain was normal,” Kurtz said.
“Yeah,” Steinberg said, “but despite a normal CAT scan, he was unconscious at the scene. He wasn’t breathing, and now his anesthetic requirement is nil.”
Kurtz frowned. “How low is the BIS?”
‘BIS’ stood for ‘bi-spectral index,’ a computerized version of an EEG. The BIS m
onitor recorded brain waves, ran them through an algorithm and produced a number that supposedly correlated to depth of anesthesia. Anything below sixty was supposed to mean adequately anesthetized.
“At the moment, seventeen,” Steinberg said. “He doesn’t have any head trauma but he was unconscious at the scene and he’s not requiring any anesthesia at all. You know what that means…”
Kurtz sighed. “The tox screen will be interesting.” The tox screen would be back in an hour or so. The results wouldn’t affect the surgery but might help guide the post-op care.
“I imagine it will,” Steinberg said. “He’s high on something.”
And maybe by then the pretty young girlfriend would have a little more to say. Or maybe not.
“It’s unusual,” Kurtz said.
“But not unheard of,” Moran said.
Barent gave a small nod of his head, meant to convey agreement with Moran’s declaration and poured his glass full from the pitcher of beer sitting on the table. Both Barent and Moran were off duty and so felt free to enjoy a cold one after work. The bar was an upscale place that served excellent pub style food and an assortment of craft beers on tap. At the moment, they were drinking Captain Lawrence Imperial Stout, at a cool 12% alcohol by weight, not a beer for the faint of heart.
“No,” Kurtz conceded. “Certainly not unheard of.”
They took a moment to enjoy their food, a blue cheese burger for Kurtz, pastrami on rye for Barent and Moran.
“Any other middle-aged executive types OD’ing that you know of?” Kurtz asked.
Barent glanced at Moran. “Not at the moment,” he said.
Moran sighed. “No. Not at the moment,” he echoed.
“The tox screen showed low levels of Xanax, for which he has a prescription. Also, trace doses of heroin—nowhere near enough to explain his symptoms, but he’s definitely been using. Nothing else has shown up. He slept for a lot longer than would have been expected. He looked and acted like he overdosed on an opioid but the tests don’t show it. Aside from that, he admits nothing.” Kurtz grimaced. “The girlfriend looked concerned but if she knows anything at all, she’s not saying.”
Barent squinted at Kurtz. “Isn’t telling us this a HIPAA violation?”
“No,” Kurtz said. “Reporting of substance abuse is an allowable exception where there is a presumption of an imminent danger, either to the individual involved or the public. Unknown but presumably potent narcotics floating around is certainly an imminent danger.”
Barent, who had known this but who occasionally enjoyed pulling Kurtz’ leg, merely smiled and sipped his beer. “So why are we here?” Barent asked.
Kurtz shrugged. Truthfully, he wasn’t sure why they were here, except that Jeffrey McDonald gave him a bad feeling. “There are a lot of drugs that don’t show up on tox screens. There are specialized tests for almost all of them but they’re expensive and they aren’t run unless there are suspicions.” He shrugged again. “The normal tox screen picks up morphine, meperidine and heroin, the most commonly abused narcotics. If he had OD’d on something, it was something else.”
“We’ll keep an eye out,” Barent said.
“Okay,” Kurtz said. “Thanks.”
Arnaldo Figueroa was doing as well as could be expected, which was not, at this point, saying very much. He was still on the ventilator and still in a barbiturate coma. Barbiturates reduce intracranial pressure, which is almost always elevated after an injury to the brain. Barbiturate coma also reduces brain activity to essentially zero, and in doing so reduces the metabolic demand on the brain by approximately fifty percent. Barbiturate coma, among other therapeutic modalities such as reducing body temperature, has been shown on numerous studies to improve outcome after trauma to the brain.
Arnaldo Figueroa was a cop, and since he was assumed to have suffered his near fatal injury in the line of duty, two other cops in uniform stood guard at the entrance to the ICU at all times.
“How’s he doing?” Kurtz asked.
“No change,” Allen Wong said. “We’ll keep him under for a week. Then we’ll see.”
Hopefully, with a lot of luck, Arnaldo Figueroa would then wake up. With even more luck, he would recover. Whether he would ever recover enough to return to work, or even be able to walk, talk or go to the bathroom without assistance, was doubtful, but not beyond the realm of possibility.
“Alright,” Kurtz said. “Keep us informed if anything changes.”
“Will do,” Allen Wong said.
“Thanks.”
Kurtz’ first three cases the next morning were routine: two gallbladders followed by an inguinal hernia. He was finishing up the hernia, letting Linda Rodriguez suture the skin under Drew Johnson’s watchful eye, when Mahendra Patel poked his nose into the OR. He gingerly walked up to the table, being careful not to touch the field. Kurtz glanced at him. “What’s up, Manny?”
“Can you scrub out?” Patel asked.
Mahendra Patel was the Site Director for the Department of Anesthesiology at Easton. He looked concerned.
“Don’t worry about us,” Johnson said.
The skin was almost closed, and Johnson and Rodriguez were perfectly capable of finishing the case. “Sure,” Kurtz said. He pulled off his gown and gloves, dropped them in the wastebasket and followed Patel out into the hall. Once there, Patel seemed reluctant to speak. His eyes wandered around the scrub sink and the equipment carts lined up against the wall. Kurtz waited. Finally, Patel drew a sigh. “I’m not really supposed to get involved in this way, but could you wander into Room C?”
“Why? What’s going on?”
“Steve Ryan is doing what was supposed to be a panniculectomy. It’s turned out to be a little more complicated than he thought.”
Steve Ryan…Inwardly, Kurtz winced. Steve Ryan was married to Donna Ryan, an old school friend of Lenore. The two couples occasionally socialized. “In what way?”
“The lady is morbidly obese. Turns out it’s not exactly a pannus. It’s an umbilical hernia. There are loops of bowel all around the thing. Steve seems a little out of his depth.”
How delicately Patel put it. Steve Ryan, Kurtz thought, was almost always just a little out of his depth. Steve Ryan was a very unfortunate and all too common phenomenon in the surgical field: a smart, enthusiastic, hard-working, well-meaning guy who loved surgery but had no talent for it whatsoever. Steve Ryan might not be stupid but he was definitely self-deluded. He probably would have made a crackerjack internist but he was, very sad to say, a lousy surgeon. Pity he didn’t seem to know it.
Luckily for all, Steve Ryan was a plastic surgeon, not a general surgeon, and as such, his procedures tended to be superficial and rarely invasive, which did not prevent his complication rate from bordering on the unacceptable, but even a good plastic surgeon would not be tackling an umbilical hernia on a morbidly obese patient without the assistance of a general surgeon, not unless it was a totally unexpected finding.
“And you want me to wander in there and just take over his case?”
“Yeah,” Patel said.
“You know I can’t do that.”
“Oh, for Christ’s sake.” Patel raised both hands, dropped them to his sides. “You can go in and ask him if he needs any help. If he’s not insane, he’ll say ‘Yes.’”
Kurtz sighed. “Okay. Sure. I suppose I can do that.”
Some cases start out bad and some turn slowly to shit. This one had started out bad. The lady weighed 650 pounds. Nothing is easy or routine on a patient who weighs 650 pounds. Her abdomen rose from the OR table like a solid, quivering dome. Her head sat on the pillow like a pumpkin. Steve Ryan stood on a step stool with his arms literally buried up to the elbow in an enormous sheet of quivering fat.
It did look like a pannus, which is essentially nothing more than a solid mass of overhanging abdominal tissue. It probably was a pannus, with all of that adipose concealing an umbilical hernia. An easy diagnosis to miss, if you were just going by physical exam, except that a
CAT scan or even just a simple abdominal x-ray should have shown loops of bowel inside the pannus…assuming that the x-rays were able to penetrate through all the fat.
“Crap,” Kurtz muttered to himself. This case was just begging for a malpractice suit, and anybody unfortunate enough to have his name on the chart was going to get drowned in the oncoming legal tsunami.
“Richard,” Steve Ryan said, his eyes lighting up, “could you lend a hand?”
“Sure,” Kurtz said, and squared his shoulders. “That’s why I’m here.”
“Thanks.”
“And then what?” Lenore said.
They were eating in a local Indian place that was both excellent and cheap, one of hundreds just like it throughout the five boroughs. Stolidly, Kurtz swallowed a mouthful of fiery shrimp vindaloo and followed it up with a gulp of ice cold beer. “Then we took her to the ICU and left her intubated. The idiot had gotten into the bowel at least twice before I arrived.” Kurtz dolefully shook his head. “We carved at least eighty pounds of fat off her but that’s not the problem. Fecal material was oozing out all over the abdomen. She’s going to get septic. The wound is going to get infected. The anastomoses are probably going to break down. It’s going to be a disaster.” He shook his head again. “It’s already a disaster.”
Lenore looked down at her lamb korma and winced.
“Sorry,” Kurtz said.
“Doctors have a different idea of dinner conversation.” She smiled weakly. “I’m sure I’ll get used to it, sooner or later.”
“Anyway,” Kurtz said. “Steve Ryan is one of those guys who looks good and sounds good but who’s spent his whole career faking it. He means well but he doesn’t know an ileum from an appendix. I just don’t get it. How did he ever finish a residency?”
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