The Patient

by Michael Palmer

  “Can my nurse, here, go to check the woman in seven thirty-seven?”

  “If Arlette says it’s okay.”

  Derrick radioed down the hall, and in a minute, Grace appeared at the door.

  “Tell her I’ll be down as soon as I’ve changed,” Jessie said.

  As Derrick followed Emily down the hall, Jessie checked the ceiling, half expecting to see it stained with Alex’s blood. How much prophecy was there in her dream? She also wondered if Tamika had managed to send the message about Mark Naehring before her laptop was destroyed. If so, they had a chance. If not, there was really nothing else she could think of to do. She would just have to perform the best surgery she could and pray that ARTIE functioned to its potential, and that Malloche recovered and made it out of the country without any more killing. Deep inside, though, she knew that praying for no more killing was wishful thinking. Claude and Arlette Malloche were animals—animals with their teeth on the throat of the hospital and, indeed, of the city.

  Grace closed the door to the hallway and stood by the open bathroom doorway while Jessie undressed and stepped into the shower. Hot water, soap, and shampoo did good things for her flagging morale. Alex and Emily were still alive, and even Carl had survived. Tamika Bing had broken through her horrible depression, and had helped put a long-shot plan in motion. Jessie closed her eyes for a time and let the hot water beat against her face. She was toweling off when Emily came bursting into the room.

  “Jess, come quick,” she said, breathlessly. “It’s Sara. She’s in big trouble. I think she may be going out.”

  Jessie grabbed her glasses, pulled on the fresh scrubs, and bolted past Grace and down the hall. Sara indeed was in extremis. She lay motionless in bed, unconscious and unresponsive to voice or touch. Her respirations were labored. Her pupils were dilated and barely reactive to light—a sign that there was massive brain swelling, which was pressing a portion of her brain stem up against a bony ridge on the floor of her skull.

  “Acute hydrocephalus,” Jessie said. “I’d bet the ranch on it.”

  Something—possibly a small clot or piece of scar tissue—was obstructing the flow and drainage of Sara’s spinal fluid. The fluid, which was formed in the choroid plexus organ in the brain, was now blocked from flowing throughout the central nervous system and down around the spinal cord. But production of fluid by the plexus was continuing, and the resulting buildup of pressure within the rigid containment of her skull was about to become lethal. Jessie cursed herself for not being more aggressive last night when she had sensed that something in her friend’s condition might be changing.

  “I’ll call the OR,” Emily said. “The team should all be in by now.”

  “You’ll do no such thing!”

  Arlette Malloche barged into the room and confronted Jessie.

  “This woman must have an immediate drainage procedure to relieve the pressure that’s building up in her brain,” Jessie said. “She needs to be brought to the OR right now.”

  “The only person who will be brought to any OR right now is my husband,” Arlette said.

  Jessie was about to beg for her friend’s life, but she stopped abruptly. To people like Arlette Malloche and her husband, begging was nothing but a sign of weakness—certainly nothing to be respected. Instead, Jessie confronted the woman with all the hatred, all the fire, that had been building inside her.

  “Arlette,” she said, “I’m drawing the line here. Claude’s operation can wait until I perform the drainage procedure on this woman. I swear that if you allow her to die, there is no way I will operate on your husband, no matter what you do to me.”

  Arlette gave her the haughty look of an Olympian goddess confronted by the demands of a mere mortal. Then she calmly took her weapon from her shoulder and forced the barrel of it between Sara’s teeth and deep into her throat. Sara’s reaction to the violent insult was a faint, impotent gag and some involuntary movement of her arms.

  “My husband is due to head down to the operating room in fifteen minutes,” Arlette said. “If you are not there with him, I will begin killing one person on this floor every minute until you are, beginning with this woman right here. Do you understand?”

  Jessie and Emily exchanged looks.

  Is it worth calling her bluff? they asked one another. Right here—right now, simply refuse to operate on the man.

  Jessie was well aware of the answer. The price of that hollow victory was hardly one she was willing to pay. She cared about the lives of others, and Arlette knew that as well as she did, just as she knew that Arlette cared not at all. The clash of wills, at this moment at least, on this battleground, was no contest.

  “I understand,” Jessie said quickly. “Now please, take that out of Sara’s mouth.”

  “Fifteen minutes,” Arlette said, withdrawing the muzzle. “Don’t test me on this.”

  She turned toward the door.

  “Wait!” Jessie cried. “There is something I can try right here.”

  Arlette made a regal turn and assessed the faces around her. It was as if she saw the chance to become something of a benevolent despot in the eyes of the staff and her people. There was everything for her to gain by relenting here and nothing to lose.

  “You have ten minutes,” she said. “At five of six, I want you out of here, accompanying my husband to the operating room.”

  “One thing.”

  “Yes?”

  “Your people took a piece of equipment from me that I need right now—a twist drill. It looks like a big screwdriver with a black handle and a drill bit at the other end.”

  “It looked like a dagger to us.”

  “I’ll need some other equipment, too.”

  Arlette nodded to Grace, who motioned Jessie out of the room and followed her off down the hall.

  “Don’t do anything stupid,” Arlette called after them.

  By the time Jessie returned with her twist drill, a scissors, a prep razor, a hemostat, and a Silastic catheter, three minutes of her ten had elapsed. Even worse, one of Sara’s pupils had become larger than the other and no longer constricted in response to the beam from Jessie’s penlight. The lethal brain-stem herniation and compression was happening. Perhaps sensing that death was in the offing, Arlette had chosen to remain in the room to monitor the procedure.

  “I should have made this diagnosis last night,” Jessie muttered as she and Emily shaved away some fine new hair from the top of Sara’s scalp, an inch back from her front hairline, and just to the right side of the midline. “I could have taken her to the OR and done this right. Now it’s too late. It … it was just crazy here last night. I should have taken a stand then.”

  “Just do what you can do, Jess,” Emily said. “We both know she still has a chance.”

  They pulled Sara down in the bed. Jessie gloved, then climbed up on the mattress, beside Sara’s head. Next she squirted some russet-colored Betadine antiseptic on the spot and on her drill, and began manually twisting a hole into Sara’s skull. There were less than five minutes left. The procedure did not go quickly. The twist drill was as much standard equipment to a neurosurgeon as a stethoscope was to an internist. But it was used infrequently and only in the most dire emergencies. Jessie began to wonder if she had the arm strength to complete the procedure.

  Across the room, Arlette, positioning herself so that Jessie could hardly miss the movement, brought her weapon off her shoulder, and cradled it in front of her.

  “Two minutes,” she said.

  “Hand me that catheter and a hemostat, Em, please. I’m through the dural membrane.”

  Jessie snapped one end of the catheter into the hemostat, tunneled for an inch beneath Sara’s scalp, and pushed it through the skin to the outside. Then she grasped the other end and worked it through the hole she had just made in the skull and dura, and down toward the ventricle chamber, where the mounting pressure was greatest.

  “One more minute and you’re done here,” Arlette said. “And I mean it. I ga
ve you your chance.”

  “Go for it, Jess,” Emily said.

  Jessie gripped the catheter and with a twisting motion forced it into the ventricle. Instantly, spinal fluid under high pressure shot through the catheter, actually hitting Emily on the sleeve.

  “Yes!” she exclaimed. “Oh, yes!”

  Quickly, Emily fixed the catheter to a drainage system.

  “Time’s up!” Arlette announced. “Let’s go, Doctor.”

  “I can’t leave her yet,” Jessie implored.

  Arlette readied her weapon and strode to the bedside, clearly ready to finish Sara off.

  “I’ll stay with her,” Emily said quickly.

  Arlette glared at her.

  “You’ll do nothing of the sort. I want you both out of here and on your way to the operating room.”

  Her voice was strident now. Jessie was certain that at any moment she would simply raise her weapon to Sara’s head and blow it apart. But the drainage catheter hadn’t even been sutured down yet. What if it got pulled out, or plugged? What about antibiotic coverage for what was hardly a sterile procedure? What about steroids or other treatment for brain swelling?

  “Okay, okay,” she pleaded. “Don’t shoot her. Please. We’re going. We’re going.”

  “I’ll take care of her.”

  Carl Gilbride spoke from the doorway, then stepped into the room, with Armand right behind him. His cheek was bandaged, and he looked disheveled in his bloodstained designer shirt and lab coat. But his eyes were clear, and the purpose in them unmistakable. For several seconds there was only silence.

  “Thank you, Carl,” Jessie said softly, pushing herself off the bed to make room for him. “Thank you.”

  “Now!” Arlette barked. “Let’s go.” She turned to Armand. “Let Dr. Gilbride do whatever he needs to her.”

  “Jessie,” Gilbride said as she reached the door, “what antibiotics do you want her on?”

  Jessie turned back to him and, for the first time in longer than she could remember, liked what she saw of the man.

  “You decide,” she said. “I trust your judgment.”

  CHAPTER 34

  THE TRANSPORT TEAM CONSISTED OF JESSIE AND Emily, Grace and Derrick. Armand and Arlette were to remain on Surgical Seven. Another terrorist—the one who had held Emily captive in a room somewhere in the subbasement of the hospital—was not accounted for. Jessie strongly suspected he was either keeping an eye on Richard Marcus, or was outside, somewhere in the city, positioning himself to detonate one or more of the vials of soman should anything go wrong.

  Just having Emily there with her made the entire ordeal more bearable, although since her arrival back on Surgical Seven, there hadn’t been one moment when the two of them could talk in private. Once they were in the OR, though, there would be a chance, thanks to the relative privacy of the space between the MRI tori.

  Although ARTIE was scheduled to perform the entire operation, Malloche’s head had been shaved as a precaution should Jessie have to go to a full craniotomy. He lay calmly on the stretcher, holding hands with Arlette. His headache had responded reasonably well to the narcotic injections, but he had needed to be kept almost constantly medicated throughout the night.

  “You’ve done a good job holding everything together,” he said to his wife in French. “I’m lucky to have you.”

  “No,” she replied, “we’re all lucky to have you.”

  Jessie refrained from letting them know her French was passable.

  Sweet monster love, she thought. Spare me!

  The elevator doors opened and Claude Malloche was wheeled inside.

  “Grace, you have the gun?” he asked.

  “Right here,” she replied, tapping the shoulder holster beneath her lab coat.

  “Wait a minute,” Jessie said. “If she’s planning on coming into the operating room, everything metal must be left outside. The electromagnet would pull that gun right through someone’s body.”

  “Correction,” Malloche said. “Everything magnetic must be left outside. Grace’s little thirty-eight is a custom order cast especially for our visit here. Titanium, I think, and goodness knows what else, but nothing magnetic. And trust me, Grace knows how to use that pistol well. I forget, Grace, how many people have you sanctioned since you came to work with us?”

  The slender American shrugged matter-of-factly.

  “I don’t know,” she said. “Nineteen? Twenty? I don’t keep count exactly. I just do what I’m told.”

  “Please let that serve as a warning to you, Dr. Copeland. Do my operation well—no, do it perfectly—and get me back up here to recover. If there is anything that seems the least bit out of place or subversive of our goals, Grace, here, has instructions to shoot Mrs. DelGreco. We will then send Dr. Gilbride down to help you finish my case. Is that clear?”

  “Clear.”

  “Good.”

  Jessie flashed a look of hatred down at Malloche, but his eyes had closed and his mellow half-smile suggested that he had allowed himself to yield to the euphoria of his pre-op medications.

  “Dr. Copeland,” Arlette said, “Derrick will be stationed outside the operating room. He is to be introduced to the others as being from hospital security, sent by Richard Marcus and his infection control team to ensure that no unauthorized personnel enter the operating room. Claude and I have reviewed this list you gave us of participants in his surgery. It will be Derrick’s responsibility to see that nobody who is not on the list is allowed in the operating room.”

  “I understand.”

  “There is one name in the group that we are concerned about. Dr. Mark Naehring. Exactly who is he, and what will he be doing?”

  It was not the actual question that caught Jessie off guard, so much as the timing. She wasn’t at all certain Naehring would even show up in the OR, but she had decided it would be foolish to leave him off the list of participants that Malloche had demanded from her. As they were wheeling Malloche to the elevators, Jessie had allowed herself to believe that Naehring’s name had simply slipped past them. She should have known better. Now, she wondered how much truth should be laced into her response. If Malloche or Arlette had looked up Naehring in the annotated directory of EMMC physicians, they would know something of the man. Any contradiction now between what Jessie told them and what they had learned would be a red flag, and would almost certainly put an end to her already shaky plan.

  “Dr. Naehring is a psychopharmacologist,” she said carefully. “I intend to do a great deal of surgery with your husband awake and responsive. Dr. Naehring is more experienced and expert at administering medications that allow patients to be maintained at that level than anyone in anesthesia, including Dr. Booker.”

  Several frightening seconds passed during which Arlette assessed the information. Finally, she handed the list over to Derrick.

  The elevator doors closed, and the five of them—Malloche, Grace, Jessie, Emily, and Derrick—began the descent to the subbasement of the Surgical Tower. Ordinarily, before a difficult case, Jessie would have spent an hour, often more, in her office, poring over MRIs and neuroanatomy textbooks, setting up her plan for the surgery, and reviewing the anatomy she would encounter. Never before this moment had the elevator ride down to the OR doubled as her pre-op preparation.

  Random snatches of thought passed through her mind like a meteor shower, making it difficult to concentrate on ARTIE and on Claude Malloche’s meningioma. This was hardly the state of mind she wanted to be in for a major case—much less one that could have such grave consequences. Throughout the operation, her ability to stay focused would determine the outcome as much as her surgical skill.

  The elevator doors opened, depositing them just down the hall from the MRI-OR.

  “I will be with you every inch of the way,” Grace said to Jessie as they pushed the stretcher toward the OR.

  Jessie could see Michelle Booker waiting for them in the prep area, but there was no sign of Mark Naehring.

  Damn.<
br />
  It might well be academic now, Jessie realized, but Emily had no idea that Naehring had even been called in. She also reminded herself that at the moment, Michelle Booker might be sensing that this case was unusual, but she wouldn’t have a clue as to why. It was going to be essential to find ways to communicate the situation to each woman without endangering anyone. Fortunately, they were among the sharpest people she knew.

  What if the psychopharmacologist didn’t show up? she asked herself now. Was there any way she could handle the drugs? He used some sort of mixture of three hypnotics—or was it four? Clearly, the answer to her question was a resounding no. If she tried using drugs to interrogate Claude Malloche and somehow screwed up, there was no doubt in her mind that a great many people would die.

  Jessie introduced Grace to Michelle Booker as a biomechanics student from Chicago who had written her some time ago expressing an interest in ARTIE. Then, as instructed, she introduced Derrick to the console tech Holly as a hospital security officer, who was not going to allow anyone into the operating room other than those on the list she had provided for him. Neither of the lies would survive much conversation, but Holly and Michelle were usually all business anyhow, and the seriousness of the procedure was certain to keep them zeroed in on the patient.

  The first real opportunity Jessie had to pass any information to Emily was in the scrub room. With her identity as a biomechanics student established, Grace had to remain several paces away from them. Jessie began her scrub by turning up the water full force so that it splashed noisily in the stainless steel sink. Emily quickly followed suit.

  “I wish I knew how Sara was doing,” Jessie said, looking straight ahead as she spoke.

  “Me, too. Jess, I know you’re feeling guilty about not insisting on going in to see her last night, but you really had no choice. And you did a helluva job at getting that catheter in.”

  “Thanks. I don’t mind telling you now that I was scared stiff. Em, listen. I tried to get word to Alex last night to have Mark Naehring come down here.”

  “The drug doc who called you the other day?”