Brian bolted from the line, trying to move quickly without calling attention to himself. Leon was wearing the same outfit—jeans and a blue dress shirt—he had worn that evening by the machine canteen. Whether he was checking to see if he was being followed, or searching for Brian, there was no way to tell, but he stopped a couple of times to look around. He moved into the main corridor and turned in the direction of Boston Heart—back toward the spot where Brian had first seen him. Brian hung back a good distance, now almost certain that Leon was headed toward the staircase to the subbasement.
As they approached the basement of Boston Heart, the corridor was virtually deserted. Brian had to hold back so far that he actually lost sight of the killer. Finally, he reached the stairway to the subbasement. To his right was the stairway up to the ground floor of BHI, and thirty or forty feet past it were the cath lab, the cath film library, and the elevator doors. Ahead and to the left was the machine canteen, and at the far end of the hall was the animal facility. Leon was nowhere in sight. Almost certainly, he had headed down.
Brian descended the staircase cautiously, expecting at any moment to have Leon appear below him, pocked face grinning, gun leveled. Hospital subbasements frequently housed the laundry, central equipment supply, and some portion of the power plant. Leon could be working in any of those units, although Brian couldn’t see why they would be located in the BHI subbasement and not beneath the main hospital.
The subbasement of Boston Heart was somewhat dimly lit by incandescent bulbs set into the concrete ceiling and diffused by opaque, flush-mounted plastic covers. The hallway itself was unpainted cement, and completely unadorned. There were no doors except for the one from the stairwell and a steel door some distance away on the right, at a spot roughly beneath where the cath lab was. The elevator apparently stopped at the floor above.
Brian took a few tentative steps forward. The steel door had a recessed grip that suggested it slid open. Two more steps, then Brian hesitated, opened his briefcase, and removed the snub-nosed revolver from its covering, dropping it into his coat pocket next to his stethoscope. He was no more than twenty feet away from the door now. The corridor beyond it seemed to dead-end at what would correspond to the animal facility a floor above. If someone came down the staircase now, he would be trapped. He slipped his hand inside his pocket and gripped the revolver. Did it have a safety—something he had to release to fire it? This was a hell of a moment not to know, he thought. Flattened against one wall, he took another step.
Suddenly, his code-call beeper began sounding, nearly startling him into a coronary standstill. Somewhere in the hospital, there was a cardiac arrest or dire emergency. His hand shot down and quickly deactivated the sound. Then he risked glancing down at the LED display.
BHI-7, it read. The cardiac surgical floor of Boston Heart. There was a cardiac crisis in Laj Randa’s kingdom. Of all the places in the entire hospital, BHI-7 was the one where Brian knew he would be the most superfluous at a Code 99. Randa had a virtual army of postdoctorals, fellows, and surgical residents. Besides, Randa had so little respect for him, it was doubtful the man would even want Brian anywhere on his service.
He hesitated. One possibility was watching the doorway from the stairwell. Another was going over and trying the door. The options rumbled through his head, but he could not seem to get past the issue of whether he was capable of ignoring a code call. No, he decided—not even one for which they probably didn’t need him.
He turned to head back to the staircase and froze. Behind him, mounted on the ceiling, virtually concealed in the corner between the ceiling and a concrete support, was the nozzle of a small video-surveillance camera, virtually identical to the one in the Vasclear clinic.
At that moment, the metal door behind him began sliding open.
CHAPTER THIRTY-THREE
BRIAN MOVED QUICKLY BACK TOWARD THE STAIRWELL, passing beneath the overhead camera, then out of its range. Even though he felt certain the person about to emerge from behind the sliding door was a 230-pound professional bent on killing him, he had the irrational urge to stand his ground—to pull the revolver from his pocket, gain an advantage on the man, and demand some answers. The code-call page on his belt sounded once again, snapping him back to reality. Without waiting for Leon to show himself, he whirled and bolted up the stairs, expecting any moment to hear the crack of a gun and feel an explosion of pain from the small of his back.
Breathless, Brian reached the main lobby of BHI. There were still seven flights to go to the surgical floor. His knee was beginning to throb. The elevator was the obvious way to go, but the notion of being trapped in a steel box with Leon somewhere in pursuit made him uneasy.
Yielding to his own imagination, he hurried back to the stairwell. He made the seven flights with a single stop on three to catch a few extra breaths and listen for footsteps. Nothing. But now, thanks to the subbasement surveillance camera, they knew he was getting closer. Maybe it was for the best, he thought. He was armed and had no intention of going anywhere in the hospital that wasn’t full of people. There was no way Leon, or whichever killer was emerging from that door, would be able to take him by surprise. And if they acted hastily and took risks to stop him, there was a heightened chance they would make a mistake.
Who was that guy in the TV series trying to convince people that there were aliens infiltrating Earth in human form?… Vinson. That was it, Roy Vinson.
All Brian needed was one captured alien—one of Newbury’s Russian killers trying to explain to the police what he was doing behind a steel door in the Boston Heart Institute subbasement, and why he or one of his pals had murdered Angus MacLanahan and Bill Elovitz and was trying to murder Brian Holbrook.
The surgical unit was identical in its layout to the medical one except that the nurses’ station was larger and the rooms had glass walls and doors on the hallway side.
The crisis, evidenced by a crash cart and two medical students by the door, was at the far end of the corridor in room 703. Brian was relieved he had answered the page when he saw that inside the room there were three nurses, a lab technician, and only one physician—a resident. On the bed was a middle-aged man, supine and naked, who appeared near death. He had a recent sternotomy incision running from the top of his breastbone to the bottom. The skin was held together by a railroad-tie arrangement of dozens of two-inch paper-tape strips, stained with dry blood. A similarly closed incision ran down the inside of the man’s right thigh—the site where a vein had been harvested for bypass grafting.
Two or three days post-op, Brian thought immediately, noting that the chest tubes, routinely inserted at the time of surgery, had already been removed. The heart rate on the monitor screen was quite rapid—130, 135—but the cardiographic pattern of the beats looked surprisingly regular. The man’s color was awful—his skin mottled, his lips purplish. His breathing was labored. Severe shock..
Brian identified himself to the resident, who was clearly rattled.
“I’m Mark Lewellen,” the man said. He looked to Brian like a teenager. “I’m a first-year resident and I’m really glad you’re here. Usually there are lots more surgeons on the floor. One of our teams is at the main hospital in the OR. Dr. Randa and the rest of the staff were at a conference at Boston City, but it ended fifteen minutes ago, so they’ve gotta be on their way back.”
“I’m not getting any pressure,” the nurse kneeling by the bed said.
Brian had already checked the pulses at the man’s neck, elbows, wrists, and groin. Now he pulled out his stethoscope and listened briefly.
“Get a catheter in him, please,” Brian said evenly to the nurses. “Hang a dopamine drip, open his IV wide, and have someone call down to see if there’s any blood still cross-matched for him. If there’s just a unit or two, we need four more stat. Make that six.” He turned to Mark Lewellen. “Okay, talk. Quickly.”
The resident cleared gravel from his throat.
“Mr. Paul Wilansky,” he began, “is a fift
y-five-year-old married accountant who—”
“I’m going to need the condensed version,” Brian said, continuing his examination.
At that moment, Carolyn Jessup entered the room, breathing hard. She was dressed identically to Brian—scrubs, sneakers, and a knee-length coat.
“I was just finishing a case when the clerk here called down looking for help,” she explained. “The elevator took forever.”
“I’m glad you’re here,” Brian said. “Go ahead, Mark. Hurry, please.”
“He had a semi-elective quadruple bypass done by Dr. Randa two and a half days ago. No complications. Moved here to the step-down unit last night. Scheduled for discharge the day after tomorrow. He was fine. Then suddenly, his pulse started going up and he complained about feeling light-headed and nauseous. A few minutes later he lost consciousness.”
“How long ago?”
“Five minutes,” a nurse responded, indicating the code clock on the wall over the bed.
Brian slipped on a rubber glove, worked his hand between the man’s legs and under his scrotum, and did a rapid rectal exam. Then he smeared a bit of stool on a chemically impregnated card and added a drop of developer to test for blood.
“Negative,” he said to Jessup.
Sudden intestinal hemorrhage was moved well down the list of possibilities, although a massively bleeding stomach ulcer could still cause this kind of shock before the blood had time to reach the man’s rectum.
“Just in case this is upper GI bleeding,” Jessup said to one of the nurses, “please slip a nasogastric tube down into his stomach.”
“Still no pressure,” the nurse at the bedside called out.
“Dopamine’s up and wide open,” the third nurse said.
Brian scanned Wilansky’s EKG, then passed it over to Jessup.
“Some strain, some old damage, nothing new,” she said.
“Agreed.”
With no obvious acute damage on the cardiogram, a heart attack, highly unlikely in view of the recent bypass surgery, seemed more unlikely still.
“Mark, do you want us to run this code until the surgeons get here?” Brian asked.
“Sure. I mean, please, go ahead.”
“I think we’ve got to start pumping until we get this thing sorted out. He’s got to be bleeding someplace.”
Jessup checked the patient’s carotids and listened to his chest.
“I would think so, Brian,” she said, totally calm, totally focused. “Nothing else makes sense. When were his pacemaker wires taken out?”
The wires! Brian thought. Of course.
The pacer wires, inserted routinely during bypass surgery, were at one time removed as late as five or six days postoperatively. But in the era of managed care and shorter hospitalizations, two to three days had become the norm. Removing the wires that early was fine, Brian had often said sardonically, unless, of course, the patient subsequently needed them.
“The wires?” Lewellen replied. “Oh, Dr. Randa left orders to have them removed. I pulled them about an hour ago.”
“Bingo,” Brian said, nodding his appreciation of Carolyn’s assessment.
“We’ll see soon enough,” she said coolly.
Brian and she were standing elbow-to-elbow, functioning perfectly in tandem, each backing up the other, making certain no possibilities or actions were being overlooked.
“Mark,” Brian said, “I think you’d better start pumping on this man’s chest right now. Is anesthesia coming? If not, we need to intubate him.”
“Can you do that?” Carolyn asked Brian.
“I can do that.”
The resident moved to the bedside and began doing closed-chest compressions. The mottling of Paul Wilansky’s skin had given way now to a deep violet. With no blood pressure, he was on the edge, the very edge. And most disturbing was that there was no abnormal heartbeat rhythm for them to correct.
“Anesthesia is tied up in the OR,” the nurse said.
“Miss—” Brian read the head nurse’s name tag, “—Dixon, we think that while the pacemaker wires were being removed, one may have gotten tangled around the branch of a vein graft. If that’s the case, and this man is bleeding rapidly from a torn graft into his chest, we’re going to need an operating room and a bypass pump on standby for your surgeons. In the meantime, I need a seven-point-five endotracheal tube and a laryngoscope. Be sure to check the balloon on the tube for leaks.”
Brian pressed his fingers down on the patient’s groin, trying to feel if Mark Lewellen’s closed-chest compressions were pushing blood around forcefully enough to generate a pulse in the femoral artery.
“I’m not getting anything,” Brian said.
“The heart’s empty,” Carolyn said. “We need more volume. Use a large syringe to push in the Ringer’s lactate. Dr. Lewellen, can you do your cardiac compressions any harder?”
“I think I’ve already torn apart the wires that were holding his sternum together.”
The resident was unable to keep the panic from his voice.
“That’s okay,” Brian said reassuringly. “The surgeons can fix those.”
They can’t fix dead, he wanted to add but didn’t.
Like Jessup, he appreciated that the patient lying there had little chance of making it. And like the resident, he was feeling enormous tension. The trick was not letting that anxiety show too much, or more importantly, not letting it get in the way of thinking clearly. Whatever had to be done they would do. Having Carolyn Jessup working alongside him was like bringing a ship through treacherous waters with the help of a seasoned pilot.
Brian knelt at the head of the bed. He had moonlighted in various ERs for most of his medical career, and despite the eighteen-month layoff, intubating a critically ill patient was still second nature. He shifted Wilansky’s tongue aside with the lighted blade of the laryngoscope and then smoothly slipped the clear polystyrene breathing tube in place through his vocal cords.
“Nice shot,” Jessup said.
Brian attached the end of the tube to a breathing bag and began rapid, one-a-second ventilations to try and replace built-up carbon dioxide in the accountant’s lungs with oxygen.
Jessup checked Wilansky’s neck and groin for pulses and then shook her head. Still none.
Brian could tell what Carolyn was thinking. He was thinking the same thing. Wilansky was in EMD—electromechanical dissociation—the gravest of all cardiac emergencies. The cardiogram pattern said that the natural pacemaker and nerves in his heart were appropriately delivering electrical impulses to the muscle, but the muscle wasn’t responding with a contraction forceful enough to circulate blood. The explanation had to be that much of the man’s blood was in his abdomen or chest cavity. They had to buy some time until the underlying problem, which Brian assumed was a torn graft, could be corrected. And Lewellen’s external compressions, though technically well performed, weren’t doing the trick.
They had done almost everything they could do to save this man … almost everything.
“Have you ever done open massage?” he asked her.
She sighed deeply and shook her head. “Maybe way back in the old days when we were just switching over to closed-chest compressions. You?”
“Just once,” Brian replied, “but it was a few years ago. A gunshot wound I treated in the ER. Gang fight. Opening the guy’s chest went well enough, so did sewing up the two bullet holes in his heart.”
“And?”
“He never made it to the OR.”
“Well, Brian, maybe this man will.”
Shit.
Brian wasn’t certain whether he had spoken the word or just thought it. The way they saw it, there was simply no option left other than to open the man’s chest where he lay, clamp the bleeding bypass graft, continue massive fluid-volume replacement, and squeeze the heart manually until the surgeons could get him to the OR and onto a heart-lung bypass machine. The chance of Paul Wilansky surviving the chest crack would be slightly more than zero—especi
ally with a nonsurgeon performing it. But without control of the bleeding site and manual compressions of the heart, the EMD would soon degenerate into lethal ventricular fibrillation.
Brian thought about saying that he wasn’t up to trying the procedure, that Carolyn’s overall experience as a cardiologist more than offset his single, unsuccessful case. Instead, he checked the man’s pupils, which were not especially dilated, and bit the bullet. Maybe there was still time.
Brian’s mouth was desert-dry. Every muscle was tensed. Thoughts of Leon and the incident in the BHI subbasement were forced to the back of his mind.
“Miss Dixon, get set to open his chest, please,” he heard himself saying.
“Right away.”
“Chest set’s ready,” the nurse called out.
Brian slipped on a mask and gloves and picked up a scalpel. Then, suddenly, there was commotion and loud voices from the hall. Moments later, Laj Randa stormed into the room. His small black eyes were those of a hawk about to strike.
Randa quickly took in the scene surrounding his patient. Mark Lewellen was still pumping on Wilansky’s chest, but Randa ignored him. He turned to Brian.
“Why are you up here on my service?” he asked.
Brian felt foolish, standing gloved, gowned, and masked, scalpel poised in hand before one of the great surgeons in the world. In spite of towering over Randa, he felt himself shrink before the man’s obvious disapproval. What would have happened, he wondered, if he had cracked Wilansky’s chest and the man had died? Or worse still, if he had cracked Wilansky’s chest, their assessment of the situation had been wrong, and the man had died? Actually, he realized, nothing worse than what was probably going to happen anyway.
“I had the code-call beeper,” he replied with some defiance.
Randa evidently had heard enough from him.
“Carolyn. What’s going on?”
Miracle Cure Page 29
