Finally, she thought dazedly.
He dashed from view and returned with a needle to take another blood test.
Jesus. She felt furious at him again.
Janet reappeared back at her side. "We're heading to the OR now!"
Everyone scrambled frantically to pile what they'd need for the trip onto the bed- monitors, oxygen tanks, IV poles.
"Give her an IV shot of phytonadione," Stewart ordered.
Jane knew that stuff- it was another name for vitamin K. In ER they used it to reverse the effects of Coumadin, a drug that thins the blood by interfering with the role vitamin K and other components play in normal clot formation. "But I've never taken Coumadin in my life-"
"Relax," he interrupted. "You were probably born with low prothrombin levels. That mimics a Coumadin overdose on testing, and phytonadione will shore up the effectiveness of the bit you have. People deficient in it often don't find out until a time like this. Do you normally bleed a lot when you cut yourself?"
"I don't know if I'd say that."
"How about your periods? Are they heavy?"
"Sometimes, but-"
"Hi, J.S.," said another familiar voice, putting an end to Deloram's annoying questions. Then a gloved hand, warm even through the latex, grabbed hers.
"Hey, Jimmy," she replied, her own words sounding like a distant echo. "Tell me this isn't a professional call."
His eyes crinkled at the corners. "No, I'm here just as a friend."
"I need a friend."
"Then I'm your guy."
"You're sure, now that I've practically got a scarlet A on my forehead?"
His grip on her hand tightened. "Hey, enough of that. We'll soon be having coffee together as usual."
Just twelve hours ago they'd been sharing a pot of tea in the lunchroom set aside for ER staff.
"And when you're better, I want a match to this." He flicked his earring with a gloved fingertip. "You've no idea what a hit it makes me with the old ladies in Geriatrics."
She tried to grin at him. No one had given her a mask. He might be the last person on earth to see her smile.
Janet leaned in close again. "Okay, here's the score. In the OR I'll do a D and C, and once the plasma kicks in, the bleeding will stop. Bottom line, you're not going to die, and there will be more babies."
Shivering, she felt her head swim again. "Sure hope so."
"And if these ER cowboys are finished spearing you," Janet continued, but much louder, "perhaps we could get the lady a blanket?"
She started to lose consciousness, and tightened her grip on Jimmy's hand, but he couldn't hold her out of the darkness.
Chapter 13
Janet dashed through the corridor, guiding the stretcher around corners, the race a deadly earnest repeat of what they'd done in jest through the streets of Buffalo two Saturdays ago.
Even Jimmy helped, setting intravenous bottles swaying in the turns as he muscled their precious cargo along.
Stewart Deloram adjusted IV rates on the run.
Janet continued to utter a steady stream of comforting words- reassuring J.S. that all would be well, that they'd beaten these odds many, many times before, that this would soon be little more than an unpleasant memory. But she couldn't be sure her patient even heard, and she estimated they had ten minutes to stop the flow of blood or J.S. would die.
They commandeered an elevator and seconds later were met by a team of nurses and an anesthetist who ushered them into an OR.
The bleeding continued.
Changing, scrubbing, then redonning sterile gowns, gloves, and masks cost more precious minutes.
"Pressure's down to sixty-two," called out one of the OB nurses.
Stewart rushed to open up the IVs as wide as they'd go.
Jimmy hustled back to J.S.'s side. No stranger to keeping out of the way, he hovered discreetly by her head, holding her hand and talking quietly to her, until a nod from the anesthetist indicated she'd finally been put under. He then stepped back into a corner, apparently determined to stay and observe, his dark eyes glistening.
Janet recognized in them what she'd never seen him show before: fear.
My God, he's in love with her, she thought.
"Ready for you, Doctor," said the anesthetist, his voice clipped and urgent. "Pressure's falling, sixty over zip." He had the requisite wisps of gray hair sticking out from under his cap to tell her she hadn't pulled a rookie.
The nurses secured J.S.'s legs in stirrups and positioned an OR stool adjusted for Janet's height between them. Taking her seat, Janet prepared to do the definitive treatment- scrape any pieces of afterbirth off the inner lining of the uterus. With nothing left in the way, the organ could clamp down tight on itself and tamponade the bleeding sites, like pressure on a cut.
The os of the cervix hung open, pouring blood, and tissue trailed out its orifice, debris caught in a stream.
"Suction," she ordered.
Catheters drained everything away with the sound a straw makes at the bottom of a milk shake, and the crimson flow receded.
Janet quickly inserted a dilator to widen the passage, then went into the vault with a curette to clean out any remaining material.
"Still sixty over zip, and pulse climbing to one sixty. You may not have much time." The anesthetist spoke the grim warning with glacial cool.
"Keep calling out the readings." She retrieved only small amounts of tissue, yet blood continued to pour over her hands, warm and fluid with not a clot in sight.
Definitely something wrong with her coagulation.
"Any repeat on the INR?" she asked.
"Still high, but the rest is okay," Stewart replied. In other words, low prothrombin remained the problem, not the more horrific DIC, at least so far.
He continued to work frantically with the IVs- replacing spent packets of red cells and plasma, binding the new ones in pneumatic cuffs that accelerated their flow, hanging up more liters of saline to pour in as much volume as possible- all to keep her circulation from collapsing completely. The dread in his eyes said, I'm losing!
"Fifty-five over zip."
Janet finished raking the curette over the inner uterine wall and pulled out the last segments of the afterbirth, none of it enough to explain such a copious hemorrhage. There should have been some improvement by now.
Unless…
"BP down to fifty, pulse is still high… one fifty-five… one sixty…"
She'd soon arrest.
A cold sweat crept up Janet's back.
Either the coagulation problem hadn't corrected at all, or in doing the curettage, she'd shoved the instrument right through the uterine wall and opened up a new bleed. Pliant enough to expand and accommodate the size of a baby, the tissue is delicate, and a curette could penetrate it without her ever feeling the pop of the metal tip punching all the way through. She'd never made the mistake before, but shit happens when you least want it.
She'd have to go in and check.
"A number eleven scalpel," she ordered, removing the curette. "Prepare for a laparotomy and a repair of a possible uterine puncture."
She heard the indrawn breaths as everyone's pupils pulsed wider, but nobody said a word. From now on she'd be the only one to speak.
The nurse at her side snapped a pointed blade onto a stainless-steel handle and laid it flat in her outstretched hand.
Her colleagues shoved the additional instrument trays they'd need into easy reach and whipped off the sterile covers. One of them quickly prepped the area she'd be cutting.
Stewart slid a nail-sized needle under J.S.'s collarbone and into her subclavian vein to start a sixth IV.
"Get ready to tamponade the incision with gauze, and give me suction, plenty of it."
In a single move Janet made a four-inch horizontal slice through the skin into a yellow layer of subcutaneous fat, following along the top of the pelvis, the so-called bikini cut. Immediately the trench filled with blood, but the nurses' fingers pulled the edges apart and pressed folded white
gauze into the incision, soaking up the flow as fast as it appeared.
In a second pass she cut deeper, parting the yellow globules where she'd left off down to the glistening white fascia that lined the abdominal muscle. Across this layer she made a third sweep with just the tip of her blade, and the diaphanous sheet sprang open, permitting strands of maroon-bellied muscle to bulge out. Handing back the scalpel, she quickly separated them with her fingers, working around the catheters that noisily sucked out the blood, making her way down to the pearl-gray membrane that lined the pelvic cavity. Without needing to be asked, two nurses assumed the task of holding the tissue apart with small stainless-steel claws as she went.
Once she'd cleared enough space, a third nurse slapped a pair of pointed tweezers into Janet's left hand and surgical scissors into her right. Using the former to snag the membrane, she lifted it enough to make a tiny tent and snipped another four-inch opening.
Retracting the edges with her fingers, she brought the dark maroon surface of the pear-shaped uterus into view. Gleaming like new, it lay in a blood-free bed of ligaments and ocher-colored membranes.
Perhaps she hadn't perforated it after all. To be sure, she delicately explored the slippery contours with her fingertips, checking for any tiny holes.
None.
She watched it for leakage.
Crimson seepage from severed vessels in the skin flowed into the space, but nothing else. The exterior remained intact, giving the appearance of a womb as ready to receive and grow life as always.
But from its interior the unrelenting flow persisted, silently coursing out between J.S.'s legs to spatter noisily into the most recent steel basin the nurses had placed there.
After the rush of activity, Janet felt overwhelmed with helplessness. She'd reached the limit of what she could do.
More vitamin K wouldn't help. It took hours to work.
Removing the uterus would produce more hemorrhages.
The sole hope for survival rested with the fresh frozen plasma- if the clotting factors kicked in soon enough.
She prepared herself for the hardest task a surgeon had to endure: to stand by and let time decide life or death.
"Pressure?"
"Fifty-five," the anesthetist reported, his voice as ice-smooth as ever.
No one else said a word.
In the silence, each squeeze of the ventilation bag seemed to become louder.
The tiny intervals between the rapid stream of beeps from the heart monitor grew so infinitesimal that the noise approached a continuous scream.
And the spatter of blood filling yet another basin ran steady as a faucet.
One of the nurses emptied it and recorded the amount.
Others counted the blood-soaked gauzes that lay in foot-high piles on the surrounding trays, estimating each to hold a twenty-cc loss. J.S.'s heart would either find enough volume of blood to pump or collapse in on itself, empty. And even if she continued to have a pulse, whether the rest of her vital organs- brain, kidneys, liver- could scavenge enough molecules of oxygen from the sparse circulation to survive intact, Janet had no idea.
With nothing to do but wait, she drew on raw nerve honed by years of experience to just stand there, outwardly calm but seething inside, suffocated under a sense of dread that she'd lost J.S.
Then she thought of Jimmy and what he must be going through.
When she glanced in his direction, he remained as still as a sentinel, yet gave her a nod, as if to say it would be all right.
J.S. went into full cardiac arrest at 4:10 a.m.
Stewart cracked open her chest, slid his gloved hand into the cavity, and did open-heart massage.
As he worked, the bleeding slowly subsided.
Because she's dying, Janet told herself.
Nearly five minutes later the anesthetist said, "You're getting a good pulse."
Thirty seconds after that the heart resumed pumping on its own, coming back to life in Stewart's hand.
As Jane's pressure climbed, everyone waited for the bleeding to resume.
It didn't.
Later that same morning, 7:30 a.m. The roof garden, St. Paul's Hospital
"I tell you, Earl, he was terrific," Janet said, throwing her arm around Stewart's shoulders. "Absolutely terrific."
The man reddened, but the corners of his eyes betrayed a smile. "Janet's the one who called the shots," he said, unusually muted in the face of praise.
Falling to the status of pariah and then reclaiming the mantle of hero in less than a day can have that effect on a person, even a resident prima donna, Earl thought, not exactly comfortable with Janet heaping such unqualified accolades on a man who still had a lot to answer for.
Stewart seemed uneasy as well, having difficulty looking him in the eye.
The sounds of morning traffic floated up from the street below, and overhead an azure sky stretched out over Lake Erie to where water and air became indistinguishable and the horizon disappeared in a blue haze. The coming day would be a scorcher, and as at the start of most shifts since the roof garden opened, a lot of staff had gathered here to talk and savor the coolness while it lasted. While some still gave Stewart a stink-eye scowl, many of the nurses who'd done the same yesterday now came up to him and said, "Thanks for saving her."
As for J.S., she lay in ICU, still unconscious, but, with her vitals stable and blood chemistry normal, expected to recover. Even the problematic INR had returned to a reasonable level, probably thanks to the vitamin K. The hematologists would be keeping an eye on it. "Thank God she'll be okay," Earl said to Stewart, his tone guardedly neutral. "Who got her pregnant?" he then asked, wanting to shift the conversation.
Janet's eyes sparkled. "You're going to love this. As soon as his shift in ER ended,
Thomas Biggs showed up at her bedside, attentive as hell. Looks like you had a discreet romance under your nose."
"Thomas?"
"That's right. Surprised me too. For a moment, I even thought it might have been Jimmy, the way he stuck to her-"
"Well, if you'll excuse me, I'm going home," Stewart interrupted, sounding tired as he unfolded his tall frame from the bench. "At least now I ought to be able to sleep."
"You deserve it," Janet said warmly, giving his arm a squeeze.
"You're awfully friendly with him," Earl said after he'd left. He hadn't had a chance to talk with Janet privately since the events at death rounds yesterday morning.
"You believe what that Monica Yablonsky's saying?" she asked, the skeptical arch of her voice and eyebrows making her own opinion clear.
"I'm not sure."
"Only not sure? Come on!"
"Well, I agree that he wouldn't be so stupid as to rig a bunch of near-death experiences."
"But?"
"Even if he had nothing to do with that, I don't know how far he'd go to try and prevent that story from coming out."
Janet frowned. "You mean to say you think he knocked off the patients who reported those stories?"
"It's a terrible thought, but… yes."
"Jeez!" She looked out over the lake, her blue eyes darkening, growing as deep and faraway as the distant water. "I know he can sure get prickly over what people say about him, almost paranoid at times." She shook her head. "But to actually silence people, cause them to die or slip into comas… that's a hell of a leap." She exhaled hard, inflating her mask around her cheeks. "But the trouble with thinking the worst about someone is that once you start, it's hard to stop."
"Tell me about it. Better yet, tell me I'm wrong."
She breathed out a second time, hard, as if doing her breathing exercises in preparation for labor. "I can't say I don't know what you mean. Stewart has always been a difficult read. And if anyone could tweak a patient over the edge without leaving a trace, he's got the skills." A shudder passed through her. "As wonderful as what he pulled off with J.S. might be, it always kind of scared me, seeing how he throws himself into a case on the brink. There's a desperation to it. Oh, I know
anyone in our business who's really good has to be obsessive about getting all the details right- we all are- but I don't think I realized before just how consumed he is by what he does. It's like he hides in it. But would he kill to protect his right to play God?" She again shook her head. "I just don't know."
Earl felt more uneasy than ever. Part of him had hoped she would dismiss his concerns about Stewart. Time to once more change the topic. "What about supper tonight? Remember, I invited Thomas over. Are you going to be up for working on stats with him?"
She arched her back into a stretch and gave a big yawn. "He already told me to expect him."
Earl felt a flash of annoyance. "Really? You look exhausted."
"Don't worry. After I look in on a few patients, I'll sign out and go home to bed. Brendan will get another surprise treat when he comes back from school and finds me there, and we'll make the meal together."
"From what you said, I would have thought Thomas might want to be with J.S."
"There's that too. But seems he's more determined than ever to discover what's going on in Palliative Care. I got the impression he'd totally changed his mind about Stewart and wants to help clear his name, all because Stewart saved J.S. Ain't love grand?"
Earl frowned. "Wait a minute. He can't turn this into some damn personal crusade."
Janet got up to leave. "Don't worry. I'll keep Thomas in line. Besides, I already explained to him that a profile on Stewart's presence in the hospital wouldn't work. Trouble with a guy who has no life is that he's always here, so a cluster study on him wouldn't be valid."
Earl had an idea. "It might be if you look at when he's not here."
"What?"
Minutes later he stood leaning over her shoulder as she sat in front of her office computer screen and clicked up some of the Palliative Care statistics they'd been scrutinizing the last few days. "Locate the initial numbers that showed the first jump in the mortality rate six months ago, then go to the second increase, last
April, just after the SARS outbreak," he told her.
She brought them up on the screen. The first three columns showed a rise of eleven deaths a month that held steady, and the last three indicated the second increase of fourteen patients a month.
The Inquisitor Page 23
