Miracle Cure

by Michael Palmer

  Brian glanced at the monitor. The elevation in the ST segment of the cardiographic tracing was less striking—definitely a good omen.

  “If this place serves typical hospital food,” he said, “you stand to win twice.”

  He helped the team transfer Jack to his bed, then stood off to one side as a resident named Ethan Prince began his rapid preliminary evaluation. Brian grudgingly gave the young man high marks for speed and thoroughness. Then he remembered where he was. Suburban was a decent enough hospital, but not one of the interns or residents there would ever get a call-back interview at White Memorial. Slip below the top ten percent of your medical school class and you didn’t even bother applying.

  “You know anybody here?” Jack asked Brian.

  The resident, listening through his stethoscope, shushed him.

  I hope not, Brian thought.

  “I don’t think so,” he whispered.

  As if on cue, he heard his name being called and looked over at the doorway. Standing there, hands on hips, was Sherry Gordon, not much older than Brian, but a grandmother several times over. She was right up there with the sharpest ER nurses Brian had ever worked with.

  “Hey, you’re a Suburban girl,” he said, crossing to her and accepting a warm hug and kiss on the cheek. “What’re you doing here?”

  “Cream rises to the top. They’d had my application on file for years. Openings don’t come too frequently in this place.”

  “You like it?”

  She gestured to the chaos and smiled.

  “What do you think?” She studied him intently. “So, how about you? Are you okay?”

  Brian held her gaze.

  “It took three months in a rehab,” he replied, softly enough that only she could hear, “and about a billion AA and NA meetings, but yeah, I’m okay.”

  “I’m happy to hear that, Brian. Real happy. That’s your dad, right? I remember that nightmare he went through at Suburban.”

  “Six years ago. He had an MI four years before that, then gradually his angina became too severe to bear and we went for the surgery. And you’re right. It was a nightmare. And to make matters worse, the bypass wasn’t even that successful. He’s probably having a small MI now.”

  “Well, he’s got a crackerjack resident going over him. Kid reminds me of you.”

  “I wish.”

  “Tell him to look into getting your dad put on Vasclear. Everyone around here has started talking about it. Listen, I’ve got to get back to help Dr. Gianatasio. He’s got a real sick lady down the hall.”

  “Phil Gianatasio?”

  “That’s right. You know him?”

  “From years ago, when we were interns, then residents, together. I had no idea he was even in Boston. This is like old home week for me. Please tell him I’m here, Sherry. I’ll stop by when I’m certain my pop’s stable. Would that be okay?”

  “I don’t see why not. Got to run. Good luck with your dad.”

  Vasclear. Brian knew next to nothing about the drug, and most of what he did know he had learned from the newspapers. He wasn’t as medically current as in the days when he was attending cardiology rounds twice a week and reading or skimming a dozen different journals. But he had kept up fairly well through tapes and two courses, and Vasclear, the latest in a long line of experimental drugs aimed at reducing arteriosclerosis, simply hadn’t been written about widely.

  Ethan Prince freed his stethoscope from his ears, reviewed Jack’s EKG again, then passed it over to Brian. Brian accepted it calmly, consciously trying to keep his eagerness and gratitude hidden from the younger physician. There was still a persistent two-millimeter elevation in the ST segment in several of the twelve standard views in the tracing.

  “Looks like some persistent anterior injury,” Brian said.

  “I agree. I’ll get the wheels in motion for his admission. Meanwhile, we’ve got to decide whether to attempt to melt the blockage. Before we do that, I’ll try and get him a cardiologist. Dr. Gianatasio is on first backup, but he’s got all he can handle with a very sick woman in four. I’ll have to find out who’s on second call.” He turned to Jack, whose color had improved significantly. “Mr. Holbrook, it appears you’re having a very small blockage, and as a result a part of your heart is not getting enough blood.”

  “A heart attack,” Jack said. “It’s okay. You can say it.”

  “Actually, we won’t be certain it’s a full heart attack until we see some blood tests and another cardiogram.”

  “Two bucks says it is.”

  “Pardon?”

  “Never mind him,” Brian said, taking Jack’s hand again. “He was a football lineman in school—offense and defense. Too many blows to the helmet.”

  “I see.… Well, I’d better get going. I need to find out who’s on cardiology backup and I need to get back in with Dr. Gianatasio.”

  “Just one quick thing. Sherry Gordon said I should look into Vasclear.”

  The resident shrugged. “You probably know as much about it as I do. It’s a Boston Heart research drug. Rumor has it the results have been really promising.”

  “Thanks.”

  “Anesthesia,” the overhead page sounded … “Anesthesia to the ER stat.…”

  “That lady in four must be going down the chute. I guess they’re calling anesthesia to intubate her.”

  Ethan Prince hurried away, leaving a nurse tending to Jack. Brian shifted uncomfortably from one foot to the other, aware of feeling impotent and embarrassed. Just down the hall a cardiac patient was in serious trouble. Brian was another pair of skilled hands, another cardiologist for Phil Gianatasio to bat ideas off of. Yet for all the good he could do anyone at this point, he might as well be a high school dropout.

  “Dr. Holbrook?”

  The stocky, dark-haired nurse standing by the door had the bearing of someone with authority. Her expression was grim.

  “Yes?”

  “Dr. Holbrook, I’m Carol Benoit, the head nurse down here. I’m sorry to interrupt, but Dr. Prince told me your father was quite stable. Could I speak with you for a moment?”

  “Of course.”

  “Dr. Holbrook, there’s a critically ill woman in room four. Dr. Gianatasio asked if you’d mind going in there.”

  Brian felt an immediate adrenaline rush.

  “I’d be happy to,” he replied, perhaps too eagerly.

  He glanced at Jack, who was resting comfortably, eyes closed. His respirations were not at all labored and his monitor pattern was regular. There would be no problem in leaving him for a short while. Brian took a step toward the door, but the head nurse continued to block his way. She motioned him to a spot in the hall, out of earshot of both Jack and the staff.

  “Before you go in there,” she said in a stern half-whisper, “I want you to know that I insisted Sherry Gordon tell me who you are and at what hospital you are working. She told me you had lost your license.”

  “So?”

  “And when I pushed her for an explanation, she told me why.”

  Brian’s reaction to the woman had blossomed from a kernel of wariness into full-blown mistrust. He pulled himself up to his full height plus half an inch or so.

  “Get to the point,” he said.

  “I don’t want anyone without a valid license practicing medicine on any patient on my emergency ward.”

  “Frankly, I don’t see where sharing my experience and ideas is practicing medicine.”

  Carol Benoit’s eyes were hard.

  “I’ll be in there watching,” she said.

  Brian stepped back into the room to reassure Jack that he’d be nearby and would be right back. Then he flexed a bit of tension from his neck and headed over to room 4.

  It had been ten years since Brian and Phil Gianatasio were in training at Eastern Mass Medical Center. They had worked well together during those two years. Phil seemed at ease with Brian’s flamboyance and self-confidence, and Brian appreciated that Phil, more steady and meticulous than brilliant,
always worked within his limitations and was never afraid to ask for help. After residency, Brian had won a cardiac fellowship at one of the finest hospitals in Chicago, and Phil had temporized by enlisting in the service—the Army, Brian thought. At first, they had exchanged a few letters and calls. Gradually, though, their connection weakened, then simply vanished.

  Phil greeted him from the far side of the gurney. He had always been overweight, but since residency he must have gained twenty pounds. His dark hair was yielding to an expanding bald spot on top and was longer in the back than Brian remembered. One thing that hadn’t changed a bit was the warmth and kindness in his face. At this moment, though, Phil looked worried. It was not difficult to see why.

  On the gurney, unconscious and clearly toxic, was a disheveled woman with graying red hair in her late sixties or early seventies. Her grunting respirations were barely moving air, and the paleness around her eyes and mouth were a frightening contrast to the crimson of the rest of her face. Also in the room were Dr. Ethan Prince, Sherry, another nurse, the anesthesiologist, and, over in one corner, an older man with a rumpled suit and a stethoscope protruding from his jacket pocket. The woman’s private physician, Brian guessed. It was just a snap judgment, but the man seemed ill at ease in the face of such a crisis. Just inside the doorway, observing more than participating, stood Carol Benoit.

  Monitor pattern … cardiac rate … pulse oximeter reading … complexion … fingernail-bed coloring … cooling blanket.… By the time Brian had gone from the doorway to the bedside, his mind had processed a hundred bits of information. He breathed in the action and the urgency. It would only be for a few fleeting minutes, but for now that didn’t matter.

  “Brian, you’re a sight for sore eyes,” Phil said. “Like one of those gods in Greek tragedy who pops out of the wall of the theater just when he’s needed.”

  “Hey, careful. I’m through doing the god thing. It ended up causing me nothing but trouble. What’s the scoop here?”

  “Well, Mrs. Violet Corcoran is a sixty-eight-year-old patient of Dr. Dixon’s. That’s Fred Dixon right there. Fred, Brian Holbrook.” Brian and the older doctor exchanged nods. “As far as Fred knows, she’s never been really sick before this week.”

  Something in Phil’s tone suggested that merely having Dixon as one’s physician carried with it certain health risks. But the man had come in to see his patient on a Sunday afternoon, and in Brian’s mind, that negated a certain amount of clinical incompetence.

  “He was treating her with some erythro for an upper-respiratory infection,” Phil went on. “A couple of hours ago her husband called in that she wasn’t looking so good. Her temp’s one-oh-four. Pulse one-forty. She’s got a pretty dense left-lower-lobe pneumonia. BP was one-sixty. Now it’s down to one hundred.”

  “Septic shock?”

  “Probably. But look what she’s doing.”

  Phil indicated the cardiac-monitor screen, which now showed a heart-rhythm pattern Brian was almost certain was sustained ventricular tachycardia. V. tach of this sort was very unstable in most situations, and was often a precursor of full-blown cardiac arrest.

  “I read V. tach,” Brian said.

  “We all agree. She’s been in and out of it since she arrived. Short bursts at first. Now, more prolonged.”

  “Treatment?”

  “We’re working our way through the pharmacy. So far we’ve tried Xylocaine, bretylium, and Pronestyl, and we’re about to give her a hit of digitalis. Nothing’s touched it.”

  “She’s going too fast to guide her out of it with a pacemaker.”

  “Exactly.”

  Brian motioned toward Phil’s stethoscope.

  “May I?”

  Carol Benoit had seen and heard enough.

  “Dr. Gianatasio,” she cut in, “I’m sorry to have to remind you, but Dr. Holbrook has no license to be treating or touching our patients.”

  For a few seconds there was no movement in the room, no sound save for the soft gurgle of the oxygen bottle. Then Gianatasio slipped his stethoscope from his neck, rounded the gurney, and handed it to the head nurse.

  “Okay, then, Ms. Benoit,” he said without rancor, “suppose you evaluate this woman and give us your considered opinion.”

  Benoit’s face grew pinched and flushed. She pushed the proffered instrument back at Phil and moved away.

  “Suit yourself,” she said. “But I’m holding you responsible for whatever happens.”

  “I’ll take my chances. Brian, if you don’t come up with something we haven’t tried, I’m going to have Sule, here, intubate her and we’ll take a crack at shocking her out of this.”

  Brian took Phil’s Littmann stethoscope and moved to the bedside.

  “Without figuring out the underlying reason she’s in that rhythm and doing something about it,” he said, “I don’t think zapping her with a lightning bolt would make any difference.”

  “It could be just massive infection in a woman with some preexisting heart disease.”

  “Maybe.”

  “Whatever it is, be quick, Brian. She’s in it again.”

  Brian first scanned Violet Corcoran, head to feet. There was something about her, something that reminded him of a case he had seen somewhere in his training. Where? What was it? He felt over her heart, then her neck, then the arterial pulses at her elbow, wrist, and groin. Finally, he slipped the earpieces of Gianatasio’s Littmann into place, and worked the diaphragm side of the stethoscope over her heart, chest, and neck. Next he repeated the exam using the bell side.

  “Sule, go ahead and intubate her,” Phil said. “Then we’ve got to try shocking her. Damn! This is getting out of hand fast.”

  Brian didn’t respond. He was completely immersed in a sound—a sound coming from the front of Violet’s neck. And suddenly, he remembered. To his left, the anesthesiologist had slipped in an endotracheal breathing tube so smoothly that Brian had not even realized she was doing it.

  “We’ll try two hundred joules once, then go right to three-fifty,” Phil ordered.

  “Wait!” Brian said, indicating the spot on Violet’s neck. “Phil, listen to this.”

  The easily heard humming sound, Brian was nearly certain, was a bruit—the noise of turbulence caused in this case, he believed, by blood rushing through a markedly overactive thyroid gland.

  “Pressure’s dropping,” Sherry Gordon said. “Ninety.”

  Phil listened for a few seconds.

  “I heard that sound when I first examined her, but I thought it was a murmur transmitted up from her heart.”

  “I don’t.”

  “Thyroid?”

  “I’m almost sure of it. I’ve only seen one case of thyroid storm in my life, but this looks just like it. High temp, wild pulse, coma, increasing stretches of V. tach.”

  Gianatasio listened to the sound again.

  “Could be,” he said excitedly. “Dammit all, it just could be. Fred, does this lady have any history of hyperthyroidism?”

  Fred Dixon flipped through his office notes and lab reports.

  “Eighty,” Sherry called out.

  “Well,” Dixon said, his voice a bit shaky, “I noted a slightly elevated thyroid level at the time of her physical a year ago. But people her age get underactive thyroids, not overactive, and besides I didn’t think—”

  “Brian, where do we go from here?” Phil cut in.

  “Call an endocrinologist. But I would say in the meantime, massive doses of steroids, high doses of IV propranolol to block the effect of the hormone on her heart, and then some sort of specific chemical blockade of thyroid hormone production as well. The endocrinologist or a book can tell us what and how much.”

  “Let’s go with it,” Gianatasio said. “Ms. Benoit, find out who’s on for endocrine and get ’em down here or on the phone as quickly as possible. If it’s the phone, put Dr. Holbrook on. Then get over to the residents’ lounge, please, and get me Harrison’s Principles of Internal Medicine and the fattest endocrinol
ogy textbook you can find. If there’s none at least two inches thick, go to the library. The rest of you, listen up, please. We’re sailing into some uncharted waters.…”

  CHAPTER THREE

  “NO AUTOGRAPHS. NO AUTOGRAPHS, PLEASE. I’M SORRY, but Dr. Holbrook won’t be signing any more autographs today.”

  Fending off an imaginary crowd, Phil Gianatasio backed into room 6.

  Brian, alone in the room with Jack, watched from the bedside, amused.

  “If you don’t stop that shit,” he said, “I’m going to autograph that butt of yours.”

  “Ah, and what a butt it has become!” Gianatasio exclaimed, slapping himself on the behind. “A rhino rear. Hippo hindquarters. Magnificent! Why, you could sign your autograph and write your autobiography, and possibly still have room for a sonnet or two. God, Holbrook, what a save you just pulled off. What … a … save! Ol’ Violet hasn’t just dodged a bullet, she’s dodged a friggin’ howitzer shell!”

  “What’s going on?” Jack muttered, rousing from a Valium twilight.

  Jack hadn’t totally dodged his bullet, but it appeared he had suffered no more than a flesh wound. His initial blood tests had confirmed that, in fact, he had suffered a myocardial infarction—a coronary—although all indications were that the heart attack was a small one and not immediately life-threatening. But at sixty-three, with his history, Jack was definitely functioning on borrowed time.

  Even though Brian was thrilled over the Corcoran save, he remained determined to keep his feelings in check and to allow Gianatasio to display enough exuberance for both of them. He motioned Phil to sit down.

  “What’s the latest?” he asked.

  Gianatasio sank down gratefully.

  “The latest is that this guy just wandered down from the last row of the bleachers with the bases loaded and two outs in the bottom of the ninth inning and struck out the grim reaper on three pitches. That’s the latest.”

  Brian turned to his father.

  “Pop, this overgrown child here is Phil Gianatasio. You probably don’t remember, but we were residents together back in the dark ages.”

  “Of course I remember. Father owned a restaurant. Pretty dark-haired wife.”