Dave Subarsky lumbered into the room, hauling a cart laden with complex machinery. Subarsky had a Ph.D. in biochemistry from M.I.T., but at six foot two or three, with a full beard and massive gut, he looked more like a professional wrestler. He and Eric had grown up just a few doors from each other in Watertown. And although they had entered grammar school the same year, by the time Eric graduated from high school, Subarsky was in his third year of college. It was an unexpected perk of Eric's residency appointment to find his old friend doing independent research in one of White Memorial's labs.
"Yo, David," Eric called out. "You have the right dye? Great. Run into your boss at all? No? Perfect. Okay, then, set up right there. We're going to go for it. June, is that arterial fine in yet?"
"Right now," she answered. "One more second and ... Voila!"
A low, rapid wave-tracing appeared on the oscilloscope beneath Russell Cowley's EKG pattern. Next to it were the numbers 50 and 0. Systolic and diastolic pressures. Cowley himself had lost consciousness, but his respiration remained steady and reasonably effective. The violet in his face, however, had deepened.
"Call the O.R. and have them mobilize the cardiac surgical team," Eric said. "If this doesn't work, we'll try a needle. But they'd best be ready to open this man's chest. Okay, David, this is it. Everybody listen up. This is Dave Subarsky. He's a biologist from M.I.T., and this is a new kind of laser he's helped develop. We're going to use it to open a window in this man's pericardium and drain the blood out from around his heart and into his chest cavity, where it will simply get absorbed."
"Is it dangerous?" one of the nurses asked.
"Not in David's hands. It was developed for vascular work, but I got the idea to adapt it for pericardiocentesis. I have total confidence in our ability to do this. We--Dave and I--have been doing animal work with it for months, mostly at three or four in the morning."
Dave Subarsky, adjusting the dials on the machine, smiled behind his beard.
As soon as it received FDA approval for general use, the combination X-ray and coaxial, flash-lamp, pumped-dye lasers would, Eric hoped, become known as the Subarsky/Najarian laser.
First, though, the technique had to work.
"I want you all to know," Eric went on, "that this procedure is virtually noninvasive--far safer and more accurate than the needle approach you're all familiar with. In that lower machine, there, we are using a dye specific for the protein in the pericardium. This upper component is an X-ray laser beam that will carry the dye laser beam through the intervening structures, right to the pericardium."
"What should we expect to see?" the same nurse asked.
"Well, for starters, a drop in his CVP, and something a little more effective than a systolic pressure of fifty," Eric replied, barely masking his growing irritation with the woman. "Now, if you'd all just move back a--"
Terri Dillard hurried into the room.
"Eric, the other Priority One is in Six. Gary Kaiser's working on him."
"What's his temp?"
"Ninety-six two."
"EKG?"
"Straight-line with a rare agonal beat."
"Tell Kaiser to pronounce the guy if that's all he's got."
"Yes, but--"
"Is the cardiac team on standby for this man?"
"Eric, we just lost his pressure," June Feldman said. "Do you want me to start CPR?"
To her right, the wave formation on the oscilloscope was a straight line. The systolic and diastolic readouts both showed zero. The heart rate began to slow. Cowley's respiration grew shallow.
"Damn," Eric whispered. "Okay, everyone, this is it. Terri, you'll just have to tell Kaiser to do his best. Then call the cardiac people and get them down here. We may have to open his chest right here. Also, get some blood. They should have him typed by now. Tell them to forget the cross-match on two units and get them over. June, keep a finger on his carotid. Ready, David?"
"Ready."
"Go for it."
Dave Subarsky hit one switch, then another. A faint blue beam shot from the upper laser, followed almost instantly by a red one from the lower. The beams intersected at a spot just above Russell Cowley's lowest left rib, and disappeared into his chest.
For five seconds, ten, there was nothing.
Eric shifted nervously and moved forward with the cardiac needle.
"More power?" he asked.
"I don't think so, Doc," Subarsky replied.
"Jesus. Okay, I'm going in," Eric said. "Someone page the cardiac people. Stat."
"Wait!" June Feldman was staring down at her fingertips. "Wait ... Yes, I've got a pulse. I've got a pulse."
At virtually the same instant, the central venous pressure level began to drop. The arterial pressure monitor kicked in at 70 over 30. Seconds later, it read 90.
Subarsky, cool as snow, nodded as if the whole affair were routine, but two of the nurses began to applaud.
"I've never seen anything like that in my life," one of them exclaimed. "Never."
"Neither have I," Eric muttered, softly enough for no one to hear.
Russell Cowley's coloring improved almost as dramatically as had his blood pressure and CVR His breathing grew strong and steady. And within two minutes, his eyes fluttered open.
No one spoke. Eric studied the faces around him. Their expressions were a wonderful mix of awe and jubilation. It was the prolonged silence of a concert audience who had just experienced the music of a master.
And Eric relished every bit of it.
Through the open doorway, he saw Terri Dillard approaching.
No, not yet, dammit, his thoughts hollered. This is my moment. Not yet.
"Everything okay?" Terri asked.
"Look for yourself."
He motioned toward Cowley.
"Nice going. Eric, the cardiac people are on their way down. You've really got to come in and help Kaiser."
"Lord. Any change in the diver?"
"No."
"So what's to help?"
"Eric, please."
"Okay, okay. June, have the cardiac service admit this guy to them with ortho as consult. I'll be back in a few minutes." He glanced over at Terri. "Maybe sooner."
Gary Kaiser annoyed Eric more than any resident he had ever known. He was immature, indecisive, and nervous as hell in all but the most routine situations.
It was no surprise to see him running a full Code 99 on a derelict who looked as if he had been dead for hours.
"Gary, what gives?" Eric asked.
The scene was subdued, in sharp contrast to the action and energy surrounding Russell Cowley. A nurse was doing CPR while a respiratory therapist was ventilating the man through an endotracheal tube. Nursing supervisor Norma Cullinet was assisting another nurse in keeping notes on the code and administering meds.
Kaiser, a rosy-cheeked enlargement of the Pillsbury Doughboy, glanced down at the EKG machine.
"Nothing," he said.
"Nothing? Do you think this is the result of a coronary?"
"I ... I imagine so."
The EKG pattern showed a straight line with an ineffectual electrical pulse every ten or fifteen seconds. It was the sort of complex that often persisted for hours after a patient was clinically dead.
"Who is this man?"
Reflexively, Eric motioned the nurse to stop her CPR while he checked the man's groin and neck for pulses. There were none. He motioned her to start up again.
"A John Doe," Kaiser said. "We've been working on him for almost fifteen minutes."
"Why?"
"Why?" Kaiser shifted nervously. "Well, he had those beats on his EKG."
"Those beats mean nothing more than a dead heart."
"And ... and his temp was only ninety-six. I ... I thought we should try to warm him up a bit before calling off the code."
As usual, Kaiser was performing mindless, cookbook medicine. It was a maxim in most hypothermic situations to warm the patient before calling off a resuscitation. But ninety-six was hardly
hypothermia, and this man was clearly beyond help.
"So," Eric said, "what do you want to do?"
He checked the man's pupils, which were wide and lifeless.
"Do? Well, I ... I was sort of hoping you'd take over here so I could get back to the walk-ins."
"Kaiser, what branch of medicine are you going into?"
"Well, I ... I've just been accepted in a dermatology residency for next year."
"Excellent. I think that's a perfect spot for you. You're excused."
"What?"
"I said, leave. Go back to your walk-ins. I'll take over here."
"You sure it's okay?"
"It's more than okay, Gary. It's an order."
His moon face flushed with crimson, Gary Kaiser backed from the room.
"Dermatology," Eric muttered as he turned his attention to the derelict. "Thank God for dermatology."
The man, unshaven and unkempt, smelled of the alleys. He was dressed in soiled long johns, a frayed checked hunting jacket, and tattered pants, all of which had been cut away during his attempted resuscitation. He had a scar on his abdomen--possibly from an old exploratory. There was a tattoo on one hip and a bruise and healing abrasion on his forehead. Eric flashed on the corporation president lying two rooms away, and wondered what the cardiac team was saying about the remarkable save.
"Eric, do you want me to keep pumping?" the nurse asked.
"Huh? Oh, keep at it for a few moments more while I get oriented. Thanks. You're doing a great job. Did Kaiser give him anything?" Eric asked the second nurse.
"The usual. Epinephrine, atropine. There's an Isuprel drip running now."
"Right by the ol' cookbook."
"Pardon?"
"Nothing. Norma, do we know who this man is?"
"John Doe. That's all we have."
"Well, for my money this is an exercise in futility. Any objections if I call it off, and we all go about trying to save the living? Good."
Eric studied the end-stage cardiac activity for a few more moments. With the most vigorous efforts, and a great deal of luck, they might be able to reestablish some sort of more effective heartbeat. But with no blood pressure and fixed, dilated pupils, what then? The time for battle had passed, probably well before the rescue squad had even arrived. He sighed and then reached up and flipped off the monitor.
"That's it," he said. "Thank you all. Norma, I want to get back in with that other Priority One. Can you take over and call the medical examiner about this guy?"
"No problem," the supervisor said.
"Also see what you can do about finding a next of kin. I'll talk to whoever it is, if you want."
Eric turned and hurried from the room without waiting for a reply. He wanted to be with his save for as long as possible before the cardiac team took the man away.
Norma Cullinet assisted one of the nurses in removing the derelict's IV and endotracheal tube. Then she wheeled the sheet-covered body out of the room.
You needn't worry about a next of kin, Dr. Najarian, she was thinking. You see, I know for a fact that there isn't any.
APRIL 8
Entering the crosswind leg of its landing sequence, the Delta 727 banked sharply, giving Laura Enders an expansive view of Washington, D.C. She had been there once as a ten-year-old, on the only trip she and Scott had ever taken with their parents, and had returned to their Missouri farm determined to become someone of importance. Now, she pressed her forehead against the Plexiglas window and tried to remember exactly what it was she had wanted to be.
Her flight from Little Cayman Island via Grand Cayman and Miami had been uneventful, but the few days preceding it--the phone calls, the trips to the bank on the main island, the search for someone to replace her at work--had ranged from hectic to frantic. For nearly three years she had been the scuba diving instructor and guide at the Charles Bay Club, the only resort on the tiny Caribbean paradise. It was an experience that had transformed her. But now--at least until she found Scott--it was over.
When she had first arrived at the club as a guest, she was pale, hollow-eyed, emotionally drained, and physically flabby. It took just ten days of vacation there for her to decide not to return for her fifth year of teaching special education at Montgomery High School. Now, at thirty, she was in the best shape of her life--tanned and solid. Her psyche, too, had responded to the peaceful magic of the Caribbean. And in part at Scott's urging, she had sent off a couple of inquiry letters to graduate schools in the States.
But now, all her plans were on hold. After years of nearly weekly postcards and at least once-a-month calls from her brother, more than six weeks had passed without a word from him. She had waited to act, perhaps longer than she should have; she reasoned that his globe-hopping job, setting up communications networks for a company in Virginia, could well have sent him to some inaccessible place. But now that April 3 had come and gone, and Delta had assured her that Scott had not canceled his longstanding reservation for arriving in the Caribbean on that date, there was no way she could remain passive.
Her isolation on Little Cayman had been self-imposed. But a byproduct of that exile, of her commitment to learning who Laura Enders was before allowing herself to choose another career or to fall in love again, was that Scott was all she had.
He was twenty-two and she fourteen, when a kid, high on pills and beer, had jumped a median strip and snuffed out the lives of their parents. Until that day, she and her brother had never formed any real bond or friendship. Nevertheless, Scott had refused the offer of distant cousins to have her move to Kansas City and had instead taken a hardship discharge from the Special Forces and returned home. The next eight years of his life, including Laura's four years at the university, had been focused on her.
An accident ... a prolonged vacation in some out-of-the-way spot ... a romance ... a screw-up in the mails ... For perhaps the hundredth time Laura ticked through possible explanations for Scott's failure to contact her. None of them eased her foreboding.
It had been more than five months since his last vacation on Little Cayman, and it was on the final afternoon of that visit that they had made arrangements for his April 3 return. Then they had taken the club's small skiff and motored around Southwest Point to dive the sheer coral wall at Bloody Bay. The images from that day were still as clear in Laura's mind as the water in which they dived. It was a double-tank, decompression dive to 120 feet. The day was sparkling and warm, the visibility 200 feet or more. A pair of enormous eagle rays had glided by, near enough to be stroked. Soon after, a dozen or more curious dolphins knifed past and then returned again and again, tumbling and spinning through the crystal sea. It was as close to a perfect dive as Laura ever expected to have.
The next morning Scott had flown back home to D.C. And soon after, his usual weekly postcards began arriving--this time from Boston.
"... Ladies and gentlemen, the captain has turned on the fasten seat belt sign in preparation for our landing at Dulles International Airport. Please be sure that all carry-on baggage is securely stowed beneath your seat or in an overhead compartment, that your tray tables are locked, and that your seat-backs are in their full upright position...."
The businessman who had spent the first half hour of the flight trying to impress Laura with his attainments smiled over at her from the aisle seat and winked. Laura managed a thin smile and nod in return. During three years of working at a resort, she had been forced to hone her skills at being open and friendly to men without encouraging them in the least. But this day she was far too worried to be cordial.
Despite their frequent contact, she realized now that Scott had shared surprisingly little of his life with her. He knew movies and music, played chess well enough to beat her without paying much attention, and read voraciously in a number of areas. He occasionally spoke of royalty he had dealt with in various countries, but had a self-effacing way about him that warned against being impressed by anything he said or did. He was a whiz with computers--or so he had said. An
d except for a brief stab at marriage, he had apparently lived a life as solitary as her own.
He had a post office box in D.C. and a phone number that invariably was picked up by an answering service. Laura would not even have known the name of the company he worked for--Communigistics International, someplace in Virginia--had he not mentioned it once in passing.
As the 727 glided over the runway, Laura felt a knot of apprehension tighten in her gut. There was so little for her to go on. Almost certainly she was overreacting. Scott had probably left Boston weeks before, and was now on the Riviera, sipping cappuccino with a beautiful model. Maybe she should just take the return flight to Cayman and wait things out for another month or so. Make some more calls.
But in truth Laura knew there would be no turning back, and no calls. As it was, she had had to beg the operator to search harder for the number of a company called Communigistics, in Virginia, before the woman finally came up with one in the town of Laurel. Laura's call was routed to the person in charge of personnel, who was far less helpful, denying that anyone named Enders had ever worked there. In fact, when Laura pressed matters the woman had actually become rude, and finally as much as hung up on her. Laura had tried a second time, and a third, but her attempts to be connected with someone other than the personnel director were stonewalled. Now, she decided, Communigistics International would find her someone else to talk with, or deal with an all-night sit-in at their offices.
The cab ride to Laurel cost sixty dollars, ten of which was spent trying to find Communigistics. After stopping twice for directions, the cabbie at last turned into an industrial park, drove past several nondescript gray marble buildings, and pulled to a stop before one that was indistinguishable from the others except for the number 300 on a small sign in front. Then he offered to wait.
"I may be a while," Laura said.
"I got a meter."
"Okay," she said. "Here's twenty. If that gets used up, it's okay for you to take off."
Extreme Measures (1991) Page 4
