The Edge of Death: (Sequel to ADRENALINE)

by John Benedict

  He had long ago severed ties with his old med school classmates. His counterparts in clinical medicine—real medicine, as they liked to refer to it—were busy furthering their careers, putting feathers in their caps and, let’s not forget, saving lives. He had long since wearied of their insults and believed he had heard them all. The favorite one went something like this: “Pathology—good field for you, Mueller. Can’t kill ’em if they’re already dead.” Then they’d slap him on the back. Yuckity-yuck.

  Gunter shook his head again. He had a big talk to give in a few hours and should be preparing. The press, TV cameras and all, would be there along with all his esteemed colleagues. And here he was, holed up in his little office, sidetracked by these stupid films and painful memories of earlier years. Should he add the MRI slides to his lecture? He had been wrestling with this decision ever since he had gaped in astonishment at the first MRI. Of course he should. Gunter was, if nothing else, a play-it-by-the-book researcher. Let the facts lead where the facts may lead.

  Finally, surprising himself, Gunter stood and yanked the MRI prints from the viewbox. A loud grinding noise, louder than he would’ve thought possible and even sounding a touch accusatory, came from the heavy duty paper shredder as he fed scan after scan into the machine. He glanced guiltily around the room several times, ensuring there were no unwanted visitors. Gunter also wondered where Chandler was at this moment.

  C H A P T E R 1 4

  Friday, 9:10 a.m.

  Chip and Kristin trotted down the hallway toward the McKleester Auditorium, ten minutes late because Kristin hadn’t shown up on time. Something about feeding her dog. As they approached, Chip’s fears were confirmed—the lecture hall was packed, people spilling out the open doors at the back of the room into the carpeted reception area. Definitely standing room only.

  “C’mon, let’s go,” Chip said.

  “I’ll follow you,” Kristin replied.

  Chip maneuvered through the tangle of people clogging the doorway, with Kristin right behind. Several people shot them glares as they pushed their way into the darkened auditorium. Once inside, they found a spot to stand on the back wall. As Chip’s eyes adjusted to the dim light, he made out the usual assortment of med students, residents, and faculty. However, reporters from the various local newspapers, TV, and radio stations were also here, sitting down in the front row. A camera crew from WGAL TV-8 was off to the far right. Word had definitely spread about this event. But then, murder had a way of attracting attention. Even one of the cleaning staff, with her little cart, was perched just inside the doorway, presumably to hear what Dr. Gunter Mueller had to say.

  The focus of all the attention stood hunched over the podium, light from the slide projector reflecting off his glasses and shiny bald head. Mueller was a short guy in his sixties with a noticeable paunch. “Next slide, please,” Mueller said. His voice quavered slightly and Chip thought he seemed nervous.

  “This slide is key,” Mueller said in a monotone. “What you’re seeing here is a high power micrograph of cardiac muscle cells.” His presentation style was definitely not what you would call electric, and Chip wondered if this would turn out to be a complete waste of time. “The mitochondria are actively utilizing ATP molecules, the endoplasmic reticulum is busy synthesizing new proteins, etcetera.” Mueller attempted to point these structures out with his laser pointer, but his hands shook, and the little red dot danced about the screen so badly that he quickly abandoned this technique.

  “Notice that the cells exhibit clear signs of life.” Mueller paused to wipe his brow with a handkerchief. “The point is that this slide was obtained from a patient who had been pronounced dead one hour previously.” There was a collective gasp from the audience and a hush fell over the room. Boring delivery aside, people suddenly sat forward in their seats.

  Mueller continued. “We simply don’t see any evidence of cellular death. In fact, these cells don’t actually die until several hours later.”

  Murmurs rippled through the audience. Chip shot Kristin a glance. “That’s unbelievable,” she whispered back.

  “So, this begs the question, why can’t we do a better job of resuscitating someone, if their cells survive for hours, not minutes?” Mueller said. “In med school, we’re taught that if you deprive someone of oxygen for four or five minutes, irreversible brain death and heart damage ensues, rapidly killing the patient. This is simply not the case.”

  Dr. Alvarez, the current chief of cardiology and president of the medical staff, practically jumped out of his seat. “Excuse me for interrupting, Dr. Mueller, but what you’re saying flies in the face of everything we know clinically. You’re a pathologist, not a clinician.” He delivered the word “pathologist” with a faint, but measurable, amount of disdain. Alvarez turned and scanned the audience, as if trying to enlist support before continuing. “When someone doesn’t breathe, they die quickly—in a matter of minutes. Every med student knows this.”

  “You’re absolutely right, Dr. Alvarez. Everyone knows this—and this might be the problem.” Mueller stared down at Alvarez, a wry look spreading across his face. “What’s the first thing clinicians do for someone in cardiac arrest?” Dr. Mueller paused for effect, then answered his own question. “Why, they try to reestablish breathing and administer oxygen, don’t they? Pulse oximeters are rapidly applied. The oxygen saturation level is key and felt to be intimately tied to survival.”

  Dr. Mueller removed his spectacles and looked over the audience. “Gentlemen, ladies, what if we have all of this backwards?” He let that sink in before continuing. Chip had to admit the guy was fascinating. “What if our very efforts to save a life actually work against us? Perhaps we need to apply some creative logic here—think outside the box, if you will.”

  Now on a roll, Mueller no longer seemed hampered by nervousness. “Here we see a slide of a cardiac cell that has just been reperfused with blood and flooded with oxygen. What do you see?” He reached for the laser pointer again. “You’ll note there is widespread evidence of cell death—degraded cellular proteins, lysosomal membrane ruptures and so forth, everywhere you look.” This time, he successfully pointed out the structures. The audience was absolutely silent.

  “What precisely is going on here?” Again, Mueller looked out over the audience. “In my lab, I have shown that mitochondria control a very important process known as apoptosis. Apoptosis is simply the programmed death of abnormal cells. It’s the body’s primary defense against cancer. When the mitochondria detect that a cell has undergone a cancerous transformation, they throw a switch that initiates cell death. What seems to be happening here is that the cellular surveillance mechanism has become confused and cannot tell the difference between a cell becoming cancerous and a cell being reperfused with oxygen. So the oxygen actually triggers apoptosis, or cell death.”

  “Preposterous,” Alvarez blurted.

  “Is it?” Mueller continued, unfazed. “Perhaps you recall the so-called diving reflex of mammalian systems? When a mammal holds its breath and simultaneously has its face subjected to very cold temperatures—such as immersing its head in icy water—the heart rate and metabolic rate slow down dramatically, allowing the mammal to stay alive without organ damage for twenty to thirty minutes. You’ve all heard stories of people being pulled from the freezing water after falling through the ice. They are miraculously revived an hour later with no significant brain damage. That, my friends, is the mammalian diving reflex at work.”

  Mueller paused to take a sip from his bottled water. “The reflex is felt to be an evolutionary holdover from more primitive cold-blooded reptilian or amphibian species. And this is what led us to examine the whole question of oxygen reperfusion in detail.”

  “So, you’re saying oxygen is bad?” one of the residents asked.

  “No, not at all,” Mueller replied.

  “You mean we shouldn’t give oxygen at a code?” another resident said.

  “No, no, of course not.” Mueller shook his head
vigorously. “I think I see the confusion here. Let me explain. It’s not that oxygen is bad, per se. When it is given right away, it is life-saving, and this is what all you good doctors are referring to. What I’m talking about is the situation where there is first oxygen deprivation, say for five or ten minutes. This is then followed by a flooding of oxygen in a reperfused state. This is an entirely different clinical entity. Do you see the difference?”

  Several in the audience nodded.

  “So we’re back to the original question. Can we do a better job resuscitating people? Next slide, please. Here you see in schematic form what we’re doing in the lab. Basically we’ve slowed down the process of resuscitation. First, we cool the body down—way down—to 27 degrees Celsius. Then, just as the heart is beginning to fibrillate from the cold, we place the patient on a heart-lung machine, initiating cardiopulmonary bypass. Next, we infuse an iced cardioplegic solution directly into the coronary arteries, thereby stopping the heart. Up until this point, this is very similar to what happens when one has open-heart surgery.” Several of the cardiac surgeons up front were nodding their assent.

  “The difference is,” Mueller said, “we now apply ultra-cool temperatures, especially to the head, to stimulate the diving reflex, and we administer oxygen only very sparingly. We also administer cerebral protective drugs, inducing a barbiturate coma to lower the brain’s metabolism and hence its need for oxygen. We also give antithrombin drugs to prevent clotting of the cooled, sluggish blood. The idea here is to give the heart a chance to rest, repair some damage and clear toxic waste products that have accumulated. Then, after several days of this regimen, the body is slowly—and this is key—slowly brought back to normothermia. The heart is then restarted, and if all goes well, the heart-lung machine is removed.”

  The audience was still completely silent. Mueller took another drink and continued. “You may say this is impossible or that it contradicts every basic tenet of clinical medicine, but the fact of the matter is, I have demonstrated this technique in my lab. I am starting to see some amazing results that speak for themselves. Something is going on here that we are just beginning to understand.” Mueller took off his glasses, folded them up, and tucked them into his breast pocket. “I’ll take some questions now.”

  A man in the front row immediately raised his hand; his Blackberry was clutched in the other. “Joe Singleton, Patriot News. If these patients are declared dead and you bring them back to life, aren’t you playing God, doctor?”

  “Nonsense,” Mueller said. “Just trying to expand the envelope of science. Was saving someone’s life with penicillin playing God?”

  “How do you know when oxygen is a liability and no longer life-saving?” a familiar voice asked. Chip recognized Dr. Landry from the airway lecture the other day.

  “Excellent question,” Mueller said. “We are still trying to elucidate the precise timeline of this in the lab. Right now, it remains a judgement call.”

  Another reporter stood up and didn’t wait for Mueller to acknowledge him. “What about your patient who murdered a nurse and escaped from the ICU last week?”

  This one seemed to catch Mueller by surprise. He paled and gripped the sides of the podium. “H-how did you know about this? That information was not released.”

  Chip and Kristin exchanged glances again. Chip had read the account of Heather’s unfortunate death in the local papers, but there had been no mention of Mueller’s resuscitation lab.

  “I can’t reveal my confidential sources,” the reporter said. “Did something go wrong with this patient’s treatment? Did you make him violent?”

  Mueller just stood there, looking increasingly uncomfortable. Several times he started to say something, but nothing came out. Chip thought of Heather and felt a wave of pity for her.

  “Do you feel responsible for the nurse’s death?” another reporter shouted.

  “Should your lab be shut down?” a third called.

  Chip looked over at Kristin and whispered, “Holy shit.”

  The quiet, respectful, academic atmosphere in the lecture hall had vanished, replaced by outbursts of conversation and the noisy confusion of cell phone beeps and texts as reporters called in with the breaking news.

  A man in a gray suit hurriedly walked from offstage over to the podium and leaned over the mic. “I think that’s all the time we have for questions at the moment. Dr. Mueller is a busy man. Thank you all for attending. We have press releases for all the journalists that summarize Dr. Mueller’s lecture and cutting-edge research. You can pick these up in the back on your way out.” He took Mueller’s arm and escorted the rattled professor off the stage.

  C H A P T E R 1 5

  Friday, 9:10 a.m.

  Laura Landry pulled her Ford Edge into the parking lot at In Gear, the local bike shop in Hummelstown. She put the transmission in park and turned off the ignition, but didn’t get out of the vehicle. Now that she was here, she was having second thoughts about going through with this. Fear shivered through her. She hated the dreadful little devices and had sworn she’d never use them.

  She pounded the steering wheel. Damn it! She hated herself for being so weak. She thought of Doug, and how excited he had been to go on a bike ride with her today. He had acted just like a little kid when she had asked him. She needed to buck up and support her man, who needed her now. She just needed to firmly set her mind to it. She smiled; Doug liked to tease her that she would frequently set her mind—except he always added “like concrete.” Well, she needed a little concrete right about now. Summoning her courage, Laura opened the car door and made her way into the cramped little store.

  “You mean you’re interested in clipless pedals?” asked the man behind the counter, a balding fellow with a big bushy beard who didn’t really look like he belonged at a bike shop.

  “No,” Laura said, trying to keep the exasperation out of her voice. Maybe he didn’t understand. She repeated herself, a little slower and louder. “I want the kind where my foot attaches to the pedals, like ski bindings, sort of.”

  “Right,” the man said. “They’re called clipless pedals.”

  “That’s dumb,” she said before checking her watch. This was turning out to be harder than she’d thought. “Who would call them that? Why not call them clip-on or something?”

  “Look, lady, I didn’t name them, okay? Do you want to see them or not?”

  “I do.”

  “Road bike or mountain bike?”

  “We’ll be riding on the road.”

  “Okay, fine.” He pulled out two boxes and set them on the countertop, then removed the box lids so she could see the contents. “These are the two most common brands we carry.”

  She fought the involuntary urge to cringe when she saw them. “And I need to use them today,” she added.

  He looked at her askance. “You’ll also need bike shoes with cleats.”

  “Of course.” Laura didn’t admit that she was unaware of this small detail.

  The man’s eyes narrowed. “You know, you should practice some before you take these out for a spin,” he said. “Like on the grass.”

  “I know—I will,” she lied.

  “Are you sure you want these?”

  “Yes, I’m sure.” Laura checked her watch again. “My husband uses them, so why shouldn’t I?”

  The man raised his eyebrows at this.

  “Look, I know it sounds dumb,” Laura said. “It’s a long story, but I want to surprise my husband. He’ll think it’s really cool that I’m that into it.”

  “Whatever you say, lady,” he said. “You’re the boss.”

  “Besides,” she said, “he says they make him go faster. I need to keep up with him.”

  This finally elicited a smile from the clerk.

  Laura’s phone rang; she fished it out of her purse and saw Doug’s name on the display. “Hello,” she said.

  “Hi honey. I should be home around noon. You still good to go?”

  “Absolute
ly,” she said. “The weather looks perfect. It’s a bit cool right now, but the sun is out and things are supposed to warm up nicely.”

  “OK, great,” Doug said. “See you at home in a little bit.”

  “And I have a surprise for you,” she said. There, she thought. No turning back now.

  “Okay, cool,” he said. “You know I like surprises.”

  “I’ll be home shortly. I just want to stop at CVS and pick up some Chapstick and Gatorade.” She pictured him smiling ear to ear as she ended the call.

  C H A P T E R 1 6

  Friday, 10:00 a.m.

  Chandler paced nervously in the parking lot of the CVS drugstore at the corner of Hockenberry and Chocolate Avenue in Hershey. He couldn’t shake the feeling that maybe this wasn’t the best idea. After all, the fricking Derry Township Police Department building was right across the street. But the store was relatively empty at the moment. Besides several employee cars parked behind the building, there were only two cars in the lot—an old Chevy Impala and a newer model Ford Edge. He walked around some more, chewing on his bottom lip.

  Chandler shot one more glance at the police station—everything appeared copasetic, no cruisers with lights flashing or SWAT team vans mobilizing—and fought to calm himself down, think this through. First of all, they hadn’t found him yet. The two nights he had spent hiding out in the woods behind the med center had done nothing to improve his disposition, but on the plus side, the downtime had bought his heart, lungs, and kidneys some valuable recovery time.

  They would’ve searched his apartment by now, but they wouldn’t have found anything of much use there—just a lot of empty beer and whiskey bottles, a small fritzy TV, and piles of dirty clothes. As he ticked off his possessions, a hard realization struck him like a bolt out of the blue: Was that how he really lived? Was that the total extent of his life? The answers were as painful as the pangs of hunger that gripped his stomach.