“Not until today,” I whispered and threw up.
Everybody jumped back. Dave stepped outside the cubicle and asked somebody to call Housekeeping, and then he looked down at the mess on the floor. “That’s got blood in it,” he observed.
I lay back and wiped my mouth. “My thumb probably dripped on the floor.” One could only hope. Cleopatra, Queen of Denial.
Dave said, “Not that much.” He threw a towel on the floor to cover up the vomit and then removed the new ice pack he had put on my thumb. It was soaked with blood.
“I can’t sew that up until the bleeding stops,” he said, “but I can at least anesthetize it.” He injected some Xylocaine, which hurt more than the cut did for the first few minutes. The bleeding continued unabated. Dave shook his head.
“I’m gonna try something here, Toni, that’s contraindicated, but I don’t know what else to do. I’m gonna shoot some Xylocaine with epinephrine in here. I know we don’t usually do that in the extremities, but despite the risk of gangrene, it looks like we could use some vasoconstriction right about now.”
I nodded without speaking. I would have done the same thing in his place.
It worked. The bleeding stopped. Dave stitched the skin flap back onto the tip of my thumb, wrapped it in a huge bandage that went all the way around my hand and looped around my wrist, and told me to elevate it and keep ice on it.
At this point I expected him to get up and leave, but he didn’t. He just sat there, looking worried. Finally he spoke.
“Toni, have you ever had a bleeding problem before?”
“No.”
“Anybody in your family?”
“No.”
“You’re not on any anticoagulants, are you?”
“It’s possible,” I said. “I ate some cookies earlier that might have rivaroxaban in them.”
“Rivaroxaban?”
“It’s an oral form of heparin that’s in clinical trials.”
“Oh, yeah,” he said. “I think George actually has a patient that’s on it. And you think it’s in the cookies you ate?”
“If you get an anti-Xa on me,” I said, “and it comes back positive, you’ll know.”
“Huh. Who the hell would put rivaroxaban in a batch of cookies?” he wondered aloud.
“Someone who wants to kill the people who eat them,” I said. “I think you need to call the police.”
“You got it,” he said abruptly, rising from the stool he was sitting on. “And after that I’m gonna get the lab down here and draw some blood, and by that time the cops should be here.”
“Hal,” I began.
“I know,” he said. He hauled out his cell phone. “I need to make sure nobody else eats those cookies.”
“Also make sure nobody touches that cookie jar. It’s got fingerprints on it, and they’re not all mine.”
“Fiona?” Hal said. “Don’t let anybody eat those cookies. They’re what made Toni bleed. Yes, apparently Ruthie made them and gave them to Kathleen. No, don’t touch it. The police will want to test it for fingerprints. Yes, that would be a good place for it. Wear gloves and try not to smudge it. Thanks. No, she’s not bleeding any more. I don’t know. She might have to stay here tonight. You’ll know as soon as I do. Bye.” He closed the phone and looked at me. “What do you suppose he’s gonna test you for?”
“Probably a pro-time and a PTT, maybe a d-dimer to see if I’ve got DIC, and the anti-Xa.”
Hal nodded, but Jodi asked, “What’s DIC?”
“Disseminated intravascular coagulation,” I said. “It’s a condition where blood clots in the blood vessels and uses up all the clotting factors and platelets so that the blood can’t clot any more. The d-dimer is a breakdown product of fibrin that shows up in DIC.”
“Wow,” Jodi said. “What causes it?”
“Trauma or surgery, especially if some kind of cancer is involved.”
“You did have trauma,” Hal commented.
I snorted. “This is nothing; I’m talking about major trauma, like a car accident, with crushed organs and broken bones and stuff like that.”
Someone from Housekeeping came in and mopped up the floor. As she left, Brenda came in. “Doctor! What are you doing here?”
“Bleeding,” I said economically, and Hal added, “She cut herself, and it wouldn’t stop bleeding.”
“Oh,” she said. “That explains it.”
“Explains what?”
“He’s ordered a CBC, pro-time, PTT, fibrinogen, d-dimer, and anti-Xa,” she said. She gave me a long look. “Is this related to all those other anti-Xa’s?”
“You got it.”
Efficiently, she drew my blood. “Someday you’re gonna tell me all about this, right?”
After she left, a nurse came in and started an IV. She put an ice pack on my hand. She adjusted the bed and put another pillow behind my head. “Is there anything else you need, Dr. Day?”
I ran my tongue around my mouth. It tasted awful. Vomit’s bad enough without decomposing blood, which doesn’t taste any better than it smells. “Could I brush my teeth?”
She brought me a little kit that contained a toothbrush, a tiny tube of toothpaste, a tiny bottle of mouthwash, and a wipe, along with an emesis basin and a glass of water—all of which I accepted gratefully. While I was brushing my teeth, Dave came back in.
“The police are on the way. Also, I think I should admit you, at least for overnight, in case you bleed anymore. When the labs come back, we’ll know what to do next. While I was out there, I took the opportunity to look up rivaroxaban, and apparently protamine doesn’t work for that as well as it does with Lovenox or unfractionated heparin, and they recommend prothrombin complex concentrates instead. They can get that from the pharmacy. So once they get you all neutralized and you don’t have any adverse reactions, you’ll be good to go in the morning.”
“Who’s gonna take care of me up there?” I asked.
“Jeannie’s on call, but I called George too, since he’s the one who knows the most about rivaroxaban.”
Hal stood up. “I guess we might as well go home, then. Do you want me to bring you anything?”
“Oh, a couple of books—the one I’m reading and that new Dick Francis. And a ChapStick.”
“You got it.”
“Oh, and some Kleenex.”
“There’s some Kleenex right here,” Jodi said. She handed me the box. Hal kissed me good-bye, and Jodi hugged me. Then they were gone.
I grabbed a couple of tissues and blew my nose. Bloody. Terrific.
“Toni? Are you decent?” A familiar voice called from outside the curtain screening my cubicle.
“Come in, Bernie.”
Kincaid peered around the curtain as if to check that out for himself and then came in. He pulled up the chair that Dave had used and sat down, pulling out a notebook. He looked up at me just as I was trying to plug up a nostril with tissue to keep it from dripping. “Nosebleed?”
“Nosebleed, upper GI bleed, and stitches in my finger, which I cut while making salad,” I told him.
“Dr. Martin said something about poisoned cookies.”
“Yes. I ate six of them. Then I found out that Ruthie made them.”
“When did you find that out?” he asked.
“Just a few minutes ago,” I replied. “I thought they were Jodi’s, but Jodi told me just now that Ruthie had made them and given them to Kathleen.”
“So you’re in here because you’re bleeding?” he asked.
“I’m in here because I cut my finger and it wouldn’t stop bleeding. Then when I got here, I threw up blood. Now my nose is bleeding. I’m going to be admitted overnight so they can give me an antidote so I won’t bleed anymore.”
“So, Ruthie Brooks strikes again,” h
e said. “She seems to have it in for you, doesn’t she?”
“Well, I am the one who tattled on her to the police,” I said, “but this time I think I was an innocent bystander. Those cookies were meant for the Burkes, who apparently had already eaten some.”
“How do you know that?”
“They were in a big glass cookie jar, and it was half empty. Nobody else has gotten sick, so it had to be the Burkes who ate them. Then they ate the brownies too and ended up in the hospital. Have you heard anything about how they’re doing?”
“I think they’re still there, but stable,” Bernie said. “They might get out in time for Christmas dinner, who knows?”
“What about Ruthie?” I asked. “Are you going to arrest her again?”
“I wish we could,” he said with a sigh, “but all the evidence we have is circumstantial. That lawyer of hers would be all over us like a dirty shirt if we go after her again, suing us for false arrest and stuff like that. We’re practically gonna have to catch her in the act, like you caught Tiffany.”
Damn. “Who is her lawyer, anyway?”
“Some big shot from Boise, name of Chaim Rabinowitz.”
Chaim Rabinowitz? Jesus. Hal was gonna love that.
Bernie stood. “Well, I’ll be going over to your house now to collect that cookie jar. Hope you can manage to get some sleep. You look like you need it.”
I looked up at him, thinking it was marginally better than being told I looked like dog meat, when he leaned over quickly and kissed my cheek. “Good luck, Toni.”
“Thanks,” I said, and then I thought of something. “Bernie!”
“What?” He peeked around the curtain again.
“Did the fire department ever find any Lovenox in Ruthie’s house?”
“Nope, and we didn’t either.”
After he was gone, I wondered what my chances would be of finding something after both the fire department and the police department had failed to.
A snowball’s chance in hell? A needle in a haystack? A fart in a windstorm?
Nevertheless, if I ever got out of here, I resolved, I would look anyway. Sometime when Ruthie wasn’t around. Now when would that be? Now that the police couldn’t get her off the streets, I’d have to think of something to distract her for an hour or two. Maybe I could get Mum to take her to church on Christmas Eve or Christmas morning or—wait a minute. Lance’s funeral! When was Lance’s funeral? It had to be the day after Christmas at the earliest. They wouldn’t have a funeral on Christmas Eve or Christmas Day.
A young girl in a royal blue polo shirt with Transport over the breast pocket interrupted my train of thought. She looked barely old enough to even be in puberty. “I’ve come to take you upstairs,” she said. “You’re going to ICU.”
ICU? Was I that sick? Did anybody ever get to go home the morning after a night in ICU? I didn’t think so. Suddenly I felt like a prisoner, like I’d been kidnapped, like some evil mad scientist was going to use me for medical experiments.
To my dismay, that’s just about what happened that night.
Jeannie came in about five minutes after I’d been settled into my ICU bed and had been hooked up to monitors and an IVAC to regulate the flow of my IV. She took a fairly exhaustive history, which consisted mostly of negatives, since I’d never actually been sick before—except for the car accident three years earlier, which was in my chart already, and a physical exam that was, in her words, disgustingly normal. “Except for the fact that you’ve got a nosebleed, a cut finger, and hematemesis,” she said. “We need to get some more labs, because we need to know your electrolytes and your renal function. Your other labs should be back any time.”
She went to the nursing station and made a phone call.
When she came back, she said, “I’m getting you typed and screened, just in case we need to transfuse, and we’ll probably give you some fresh frozen plasma to replace your clotting factors. If your PTT is too high, we’ll have to consider protamine sulfate to neutralize the heparin in your blood.”
“No, no, no, no protamine,” George declaimed, Gnarly Finger in the air as he swept into ICU and screeched to a halt at my bedside. “This isn’t heparin as you and I know it, Jeannie. This is rivaroxaban, which is still in clinical trials, essentially an experimental drug. Protamine doesn’t work on it.”
“Well, how about FFP?” Jeannie asked.
“We can use FFP,” George said, “but PCCs would be better.”
“PCCs?” Jeannie asked.
“Prothrombin complex concentrates,” George lec-tured. The man was a walking differential diagnosis and never missed an opportunity to teach. “They contain prothrombin and factors VII, IX, and X, as well as proteins C and S—and a little heparin to prevent activation of the other clotting factors so you won’t get DVTs. We don’t want to go too far in the other direction, now, do we?”
“I guess not,” I said.
“Have we got any labs back?” George asked Jeannie, and she shook her head. Then she turned her head and looked toward the nursing station, where someone was trying to get her attention. “Oh. Maybe that’s them now,” and she took off at practically a dead run.
George stood looking after her and shook his head. “Where does she get all that energy?” Easy, I thought. She’s half your age. But I didn’t say it.
Jeannie came back with a printout in her hand. “Well, Toni, your white count’s normal, and your hemoglobin is thirteen-point-four, so I guess you don’t need transfusion quite yet. PTT’s only twenty-eight seconds, but the pro-time is elevated. INR is three-point-five. That’s weird.”
“Not really,” George said. “The two tests recommended for following rivaroxaban are the pro-time and the anti-Xa. Did Dave order one of those?” He peered nearsightedly at the printout. The lighting around the beds was not especially conducive to reading computer printouts at the best of times.
“Yes,” I said. George looked at me in surprise. “I asked him to. What was it?”
Jeannie said, “Holy shit. Eight-point-five. Reference range zero-point-four to one-point-one.” She looked shell-shocked.
George did too. “Toni. How did you know to ask Dave for an anti-Xa?”
I had to laugh. “Hello. I’m a pathologist. We’ve had the anti-Xa available in the lab for a year for you guys to monitor heparin with, and you keep ordering PTTs. That wouldn’t have done you much good here tonight, would it?”
Brenda came back to draw my blood for the other tests George and Jeannie had ordered, and before long I was receiving FFP through my IV. Four units dropped my anti-Xa down to five-something.
A little later I complained of nausea, and the nurse told me she had orders to put a nasogastric tube down if that happened. The drainage from the NG tube was bloody, and George decided to endoscope me. Right there in my bed. The nurse anesthetist on call came and gave me Versed, so I knew nothing until I woke up and the procedure was done.
The nurse, Leslie, came over and peered into my face. “She’s awake, Doctor,” she said, and George loomed over me. “Well, I’ll tell you what we found, Toni, even though I’m gonna have to tell you again in the morning because you won’t remember. You’re bleeding from the stomach and the colon, but I found no specific bleeding spot anywhere to embolize or cauterize. Some of that blood might even be swallowed blood from your nose. Anyway, the FFP helped some, but I’m gonna give you some PCC now, and then we’ll see. If we need to, we’ll give some more in the morning, but I don’t want to give more than that because all the clotting factors have different half-lives. Factor VII has only six hours, but prothrombin has sixty to seventy-two hours, and so it tends to build up and cause DVTs.”
Jeez, I thought. I was damned if I did and damned if I didn’t.
Wednesday, December 24
Chapter 31
Home is the place whe
re, when you have to go there,
they have to take you in.
—Robert Frost
In the morning my anti-Xa was down to two-point-seven.
After the second unit of PCC, it dropped to one-point-two, just above the upper limit of the therapeutic range. I got discharged shortly after lunch. Hal and Mum came to take me home.
It started snowing shortly thereafter and continued for the rest of the day. The wind howled around the corners of the house and in the chimney. The kids didn’t want to go outside. Actually, nobody wanted to go outside. It was just the kind of day that simply cried out for a roaring fire and wassail, and that is exactly what we did. We gathered around the TV, the kids and Killer on the floor with pillows and throws, and me snuggled under my afghan with Geraldine on the couch, drinking wassail or hot chocolate and watching our favorite Christmas DVDs: It’s a Wonderful Life, The Bishop’s Wife, Miracle on 34th Street (two versions), National Lampoon’s Christmas Vacation, A Christmas Story, White Christmas, and so on.
Hal had gone out and gotten quantities of hot wings, and that was our supper, along with chips and dips, crudités, nuts, and candy—none of it prepared by Ruthie.
Then we turned off all the lights—in order to better enjoy the ambiance of the Christmas tree lights and candles—and watched the old black-and-white version of Dickens’s A Christmas Carol on DVD, which was just as deliciously scary as it had been when I was little.
Grandma and Grandpa Day would turn off all but the Christmas lights, and we would gather around the old black-and-white TV with a big bowl of nuts, still in their shells. Grandma would hold me in her lap while Mum and Grandpa cracked shells and passed nuts around. With Grandma’s arms around me, I could wallow in the scariness knowing that nothing bad would happen to me.
But now I knew that wasn’t true. Scary things like murder and fire could happen to me. They’d been happening all around me, to people close to me. It had only been a matter of time before they happened to me.
Too Much Blood Page 25
