by Daniel Kalla
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To my brothers,
Tim and Tony
Contents
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Acknowledgments
Chapter 1
The siren choked off in mid-wail. Within seconds, the flashing red light swept through the frosted glass of the ER’s sliding door like a disco ball on overdrive.
I heaved a self-pitying sigh. Ten minutes before the end of a long night shift, I’d counted on an uneventful and punctual exit. Any chance for either vanished when the ambulance stretcher and two paramedics burst through the main Emergency Room doors.
“Which room?” the tall scraggy paramedic yelled as they careened past the triage desk.
“Trauma Two,” the triage nurse called back.
I ran alongside the paramedics, but our pace wasn’t fast enough to outrun the acrid smells of urine and vomit wafting up from the stretcher. A woman of indeterminate age lay on her side, twitching and thrashing. Without the restraining hand of the female paramedic she might have bucked off the stretcher. Legs and arms jerked in violent rhythm. Her chin slammed into her chest. A mess of long brown hair covered her face. Her T-shirt was spattered with vomit. A chain of drool connected the corner of her mouth to the sheets. An image of Linda Blair from The Exorcist flashed in my mind.
“What’s the story?” I asked the baby-faced female paramedic running beside me.
“Seizing when we got to her. Found down at Cloud Nine.” She glanced at me, deciding I was old enough to require clarification. “It’s an after-hours club.”
“Thanks,” I grunted. “What’s she got on board?”
“Her sister says she dropped two tabs of Ecstasy about an hour before we got to her. First-time user. Otherwise the kid is healthy.”
“Kid?”
“Fourteen years.” She wiped her flushed brow with a palm. “Name’s Lara Maxwell.”
“How long has she been seizing?”
“Twenty minutes, give or take.”
Way too long. Within half an hour of a continuous seizure, or status epilepticus, irreversible brain damage can occur. “What have you given her?” I asked.
“Nothing. We scooped and ran. Impossible to get an IV in her in the back of our rig.” She flailed her own arms, as if the wildly twitching patient wasn’t explanation enough.
We wheeled into Trauma Two, one of St. Jude’s three identical resuscitation rooms. Nothing architecturally unique about this or any resuscitation bay I’ve ever seen; all are big bland rooms filled with medical supplies, lights, X-ray viewing boxes, and, at times like these, people. The place swarmed with them. Some moved with purpose, others—the usual array of wide-eyed students and ER lookie-loos (staff who find any excuse to turn up whenever something exciting rolls in)—just milled about.
Swaddling her in the ambulance stretcher’s sheet, the two paramedics swung the patient over to the room’s stretcher. Lara Maxwell was oblivious to her new surroundings; her arms and legs never missed a beat of their syncopated contraction.
Anne Bailey, arguably the poster girl for hardened frumpy ER nurses the world over, was the nurse in charge. She had no time for the bustling crowd. “If you don’t serve a purpose, get out!” Anne shouted and, on cue, the room thinned. She turned to the other nurses. “Lucy, two IVs. Jan, get an oral airway into her. Tommy, you record, okay? And where are my vital signs?” Anne turned to me, her lower jaw working side to side as if chewing a gob-stopper. “What meds do you want us to give, Ben?” Despite her businesslike tone, her eyes clouded over with urgency.
Relieved as I was to see Anne in charge, the rare show of concern on her face concerned me. “Lorazepam 4 mg IV push, now,” I said, referring to the Valium-like drug we use for seizures. “Full lab panel including calcium, magnesium, and phosphate. ECG. Chest X-ray. Blood gas. Urine drug screen ASAP, and—”
The nurse cut in from bedside. “Pulse is 140, pressure 260 on 140, respiratory rate of 28, and temperature of 38.4.” There was a pause as she fiddled with the oxygen saturation probe that kept slipping off Lara’s jerking finger. “Oxygen saturation is sitting at 88 percent.”
Not a normal vital sign in the bunch. “Sugar?” I asked.
“Glucometer was normal at the scene,” the scrawny paramedic piped up.
Damn! Gone was the most rectifiable cause for a seizure: low blood sugar.
I edged closer to my patient. The mingled odors of vomit and urine assaulted me, forcing me to breathe through my mouth. Lara’s hair had fallen back from her face, and I could see beyond the strands of drool and blood. The flickering eyelids and gnashing jaw belonged to the face of a child, someone who had no business being near after-hours clubs and their inevitable cache of designer drugs. I felt familiar stirrings. Fucking junk! I wanted to shout.
I glanced at the clock. Five minutes since arrival, twenty-five minutes since onset, and the seizure showed no sign of lessening. The drool at her mouth had begun to bubble, and became a rich froth like an exploding soda pop can. As I reached for my stethoscope, my worry meter crept higher.
“Another four of lorazepam. And hang a Dilantin drip. Run in a gram over fifteen minutes,” I said, calling for the heavy artillery of anti-seizure drugs. Pulling the stethoscope off my shoulders, I leaned over Lara’s jerking form and raced through a head-to-toe physical exam. Filled with fluid, her lungs were all gurgles and wheezes. A bluish tinge enveloped her fingers and lips. I glanced at the monitor. Her oxygen saturation had dipped into the seventies—respiratory failure territory—and her blood pressure had risen even higher. “We have to stop this seizure. Now!” That meant medically paralyzing the young girl. I recited the drugs and sequence I wanted them given.
“Dr. Dafoe, you better look at this….” Jan waved an ECG printout at me like it was a flag.
I studied the twelve squiggly lines, stunned by their implication. “A heart attack? At fourteen? She must have cocaine on board, too.” I looked to the respiratory technician. “Everything ready?”
She nodded, and pointed shakily to the tray beside me.
“Okay, Anne, give her 100 of sux.”
Anne stuck a syringe into one of the
four IV lines leading into Lara’s arms. She pushed on the plunger. Within seconds of administering the succinylcholine—a fast-acting drug that paralyzes muscles and renders patients into rag dolls—the twitching began to subside. Soon Lara lay still on the bed. As expected, she stopped breathing. What I didn’t foresee (but should have) was the fountain of foam spewing from her mouth, as her lungs passively expelled their fluid contents.
I grabbed for the scythe-shaped laryngoscope. The knuckles of my left hand ached, and I glanced down at the source: the healing jagged gash from my bike chain that ran across my knuckles like a jailhouse tattoo. Ignoring the pain, I clicked open the laryngoscope’s blade and eased it into Lara’s mouth, pushing her tongue out of the way. To pass the endotracheal tube into her windpipe, I needed to see her vocal cords, but I couldn’t visualize anything through the froth. I stuck a suction catheter in her mouth but it was as hopeless as trying to vacuum up water from a burst and still-spewing pipe. The monitor’s alarm screamed, warning me what I already knew: Lara’s oxygen level was dangerously low.
“Bag her!” I said to the respiratory technician who fumbled to cover Lara’s mouth with the clear face mask and pump oxygen in with a balloon-shaped Ambu-Bag.
I turned to Anne. “I have to do this retrograde.”
Anne’s eyes betrayed her skepticism as she reached for the retrograde intubation kit. Her doubt was well founded, too. It was a technically challenging procedure at the best of times, and I was firmly perched on the “wing and a prayer” side of the statistical success curve.
I took a long deep breath and willed my hands to steady. I reached for the open tray Anne held out for me. Setting it on the bedside, I scoured through it until I found the syringe with the long ominous attached needle. I slid an index finger along Lara’s soft damp neck until I felt it dip into the groove of her cricothyroid membrane.
The alarm throbbed in my ears.
With a slight tremor, I aimed the needle, directing it slightly upward for the skin over the cricothyroid membrane. I held my own breath as the needle pierced the skin. I felt a pop as I penetrated Lara’s windpipe. Suddenly the tension on the syringe’s plunger gave way, and air whooshed into its hub. I steadied the syringe and uncoupled it from the needle.
“Ben, her oxygen saturation is critical,” Anne said calmly over the shrieking alarm.
“Noted,” I grunted, as I reached for the soft metal guide-wire that looked like a loose coil of silver string. Steadying my hand, I threaded the guide-wire through the needle. “Stop bagging her,” I said, needing a clearer view of her mouth.
Hesitantly, the respiratory tech pulled the mask off Lara’s blue face.
I kept advancing the guide-wire through the needle until a glint of metal appeared through the froth of Lara’s mouth. Then more wire poked out. My hand shot out to grab it. I nodded to Anne, and she handed me the clear endotracheal tube. I snaked the wire through the length of the tube. Then, using the wire as a guide, I threaded the tube into Lara’s windpipe. Sighing with relief, I felt the welcome resistance of the cartilaginous tracheal rings as the tube bumped down the rest of her windpipe. The moment its tip reached her lungs, frothy white sputum erupted out of its end.
I grabbed the Ambu-Bag, attached it to the tube, and squeezed the balloon-like pump, meeting fierce resistance. My forearms ached as I fought to squeeze breath after breath of oxygen into Lara’s water-logged lungs. For a while, the abysmal oxygen reading held constant on the monitor, but slowly, almost reluctantly, it began to climb as pinkness crept back into her blue complexion. I passed the bag over to the respiratory tech, who pumped it feverishly. Lara’s color steadily improved. Even the monitor took a much-needed break from its relentless screaming.
Tasting the sweat drip into my mouth, I wiped my brow and turned to Anne. “What’s a child doing with this crap in her blood?” Though, of course, I knew as well as anybody.
“She were my daughter? I’d kill her soon as she gets out of the ICU.” Anne’s lips cracked slightly at the corners in what passed for her version of a smile. She nodded once at me. High praise indeed, coming from Anne.
At nine A.M., three hours past the scheduled end of my shift, I still sat charting in Trauma Room Two. Though she awaited an ICU bed, Lara Maxwell was out of the woods. Her lungs had dried out, and the heart damage appeared to have been reversed after the amphetamines and cocaine (their presence confirmed on the lab tests) had cleared from her system.
The nurse had stepped out to restock the carts, leaving me alone in the room with Lara. She lay peacefully on her back. Wires, IV lines, and tubes ran to and from her, but medical gadgetry aside, she now looked like a typical fourteen-year-old. Tall and gangly with budding breasts and a few scattered pimples, she teetered at that awkward stage between childhood and adulthood. But her high cheekbones and full lips guaranteed she was going to mature into a beauty, providing she survived adolescence.
As I documented Lara’s rocky drug-induced ride along the brink of death, my frustration welled. Sleep deprived and adrenaline tanks empty, my temper control (shaky at the best of times) failed me. “Fourteen years old!” I snapped at the still-comatose teen. “What the hell were you doing at a rave, Lara?”
I dropped my pen and walked to her bedside. I glanced from the whirring, microwave-sized ventilator (that pumped oxygen in and out of her lungs) back to Lara. Staring at her naïve face, I suppressed the urge to shake her. “This the high you were looking for?” My voice rose. “God damn it, Lara, what were you doing there?!?”
I turned at the sound of the glass door sliding behind me. Anne stood at the doorway. She eyed me with an expression that questioned my sanity. Her left arm supported a waiflike girl, whose hair was dyed unnaturally red and whose legs swayed precariously.
“Lara?” The girl choked out the word before her voice dissolved into sobs. She scrambled to the opposite side of the bed, nearly yanking out two IVs and toppling the ventilator in the process. She grabbed Lara’s flaccid hand and squeezed it with both of hers.
“Dr. Dafoe, this is Isabelle,” Anne said. “Lara’s older sister.”
Isabelle gaped at me. With tears and mascara streaming down her cheeks, she could have passed for an underage drag queen. “Doctor…,” her voice wavered. “Will my sister be all right?”
I ignored her question. “You’re the one who took Lara to that club?”
“It wasn’t like that,” she sobbed. “Lara wanted to come. I had no idea that—”
“How old are you?”
“Eighteen, but—”
“Not even legal yourself! What possessed you to take your little sister there?”
Isabelle held up her hands helplessly. “She kept pushing. She was desperate to get to a rave. If I went with her, I thought it would be safer…” She dissolved into tears again.
“Safer? Safer?!? She’s your own flesh and blood. She just about died because of you. Your own sister!”
Isabelle’s head dropped. She buried her face in her sister’s gown. “I am so sorry…” Her muffled whimper was barely audible.
“Siblings look out for each other, don’t they?” I said, but I wasn’t talking about Isabelle or Lara anymore. I was remembering my own brother.
Anne had heard enough. She folded her arms over her chest and took two steps into the room. “You’ve made your point, Doctor.”
I looked from Anne to Isabelle and then nodded slowly. When I spoke again, my voice was calm. “Lara is going to pull through, Isabelle. But it will take time.”
Isabelle looked up at me and sniffed her relief.
“Where are your mom and dad?” I asked.
“They’re in New York for the week.” She dropped her head in her sister’s gown again, and added in a hush, “They left me in charge…I was supposed to look after Lara.”
I didn’t comment. My fury had dissipated. Replaced by guilt. Who am I, of all people, to criticize anyone for endangering their sibling? I reached across the bed and laid a hand on Isabelle’s vib
rating shoulder.
Tina, the young ditsy unit clerk, appeared behind Anne. “Phone call, Dr. D.,” she chirped.
“I’m tied up, Tina,” I said. “Can you take a message?”
“It’s a policewoman. Made it sound kinda urgent.”
Anne spoke up. “You go. I’ll cover.”
I walked over to the central nursing station. As soon as I picked up the receiver, Sergeant Helen Riddell boomed: “Benjamin! Hope I didn’t catch you at a bad time? You weren’t in the middle of pulling Christmas lights or a model airplane out of someone’s rear end?” She laughed heartily. “People sit on the darnedest things, huh?”
“No,” I sighed. “Just finished screaming at a comatose girl.”
“A coma, huh? Well, I’m sure she had it coming.” She chuckled again. “Doctors. You’re all a mystery to me.”
“What’s up, Helen?”
“Oh, yeah,” she said, as if she’d forgotten the purpose of her call. “We’re at a murder scene. Wanted your help.”
“A poisoning?”
“Who said anything about poisons?
“Why else would you call me?” As the toxicology consultant to the Seattle Police Department, I took calls only on poisonings.
“You know at least one of the victims.”
“What?”
“In the bedroom, where we found both bodies, there’s a photo of the female victim standing with an arm around you and your brother.”
I was overcome by a sense of déjà vu. My mind flashed to Helen’s call of two years earlier. The one regarding my twin brother, Aaron. I sat down in the chair by the desk. “Who?” I asked, but of course I already knew.
