by Robin Cook
“We’ve got almost nothing on EKG,” one of the residents announced, standing by the machine mounted on the crash cart. EKG tape was spewing out the side, tracing poorly formed complexes.
Caitlin grabbed a quick look. Whatever she saw pushed her over the edge into Jack’s camp, and she began barking out orders that had the nurses scurrying. She wanted calcium gluconate; she wanted twenty units of regular insulin along with a fifty-gram dose of glucose; she wanted sodium bicarbonate; she wanted cation-exchange resin set up for a retention enema; she wanted blood sent for stat electrolytes; and, most important from Jack’s perspective, she wanted a surgical resident paged to help with emergency peritoneal dialysis. In Jack’s mind, it was the dialysis that could potentially save the day.
While the nurses were busy carrying out the orders and obtaining and drawing up all the medication, one of the male residents climbed up on the bed and relieved a reluctant Jack, but as soon as the man started his compressions, Jack acknowledged the resident was probably doing a better job. As an ophthalmologist-turned-medical examiner, Jack was out of practice when it came to CPR. He was also exhausted, but it was hard for him to stand there at the foot of the bed and do nothing while Laurie’s life hung in the balance. While concentrating on doing the chest compressions, he’d been less able to think about the potential tragedy of what he was witnessing.
Jack hadn’t run all the way from the OCME to the Manhattan General Hospital, but he had run quite far just the same. He’d run almost ten blocks up First Avenue without seeing an empty taxi. A number of cars had passed him and sprayed him with water, but none had stopped. Then his luck changed. Near the UN headquarters, a police patrol car had pulled over in front of him, apparently thinking he was fleeing from a crime. When Jack flashed his medical examiner badge and breathlessly said he was on an emergency run to the Manhattan General, the police had told him to jump in. They took him nonstop with their siren blaring. If it had crossed their minds why a medical examiner who deals with dead bodies had an emergency in the middle of the night requiring him to sprint up First Avenue, they hadn’t let on.
As Laurie’s hyperkalemic treatment began to bring down the high potassium that Jack feared was coursing around in her blood, an anesthesiologist showed up. He proceeded to deftly intubate Laurie so she could be respired with more certainty. When he straightened up after finishing the procedure, Jack caught his name. It was José Cabreo, and Jack did a double take. He remembered the man’s name from Roger’s lists. Jack found himself watching José’s every move and was relieved when the anesthesiologist quickly left.
The peritoneal dialysis was started percutaneously without a hitch, using a large bore trocar. Jack averted his eyes as the trocar was punched through Laurie’s abdominal wall, but he was close enough to hear the popping sound it made as it went through the fascia, and he winced. A moment later, he watched as isotonic fluid free of potassium was then run into her abdomen. Jack secretly crossed his fingers and prayed that the procedure would help. He was aware that with the extensive surface area within the abdomen as a result of the loops of intestine combined with the rich plexus of blood vessels, peritoneal dialysis was the most efficient even if passive way to lower potassium or any other elevated electrolyte in the blood.
Unfortunately, after ten minutes of the aggressive therapy, there was disappointingly little change in Laurie’s status. Caitlin ordered more calcium gluconate and injected it herself. Jack heard this from afar, as he’d begun pacing between Laurie’s bed in front of the nurses’ station and the elevator lobby. It wasn’t the caffeine that was propelling him now, it was his mounting fear and guilt. His nagging concern was that this episode might be another instance of his being a jinx to those he loved. The thought haunted him mercilessly. In one night, he already had lost a potential child; now he was on the verge of losing the person he loved. To make matters worse, he knew he was at least partially to blame.
When the stat bloodwork came back, Caitlin brought it over to Jack. “Well, you were absolutely right,” she said while pointing to the highlighted abnormally high potassium level. “That’s about as high as I’ve ever seen it. After this is all over, I’d like to hear how you knew.”
“I’ll be happy to tell you,” Jack said, “provided Miss Montgomery pulls through.” If Laurie didn’t make it, he didn’t know if he’d be willing to talk to anybody.
“We’re doing our best,” Caitlin said. “At least her color is good and her pupils have definitely come down.”
As the minutes inexorably passed, Jack kept his distance. As a bystander, it was progressively upsetting to him to see Laurie splayed out on the bed with a stranger pounding on her chest and another dispassionately squeezing the breathing bag. The ambulatory patients who had earlier come to their respective doors to watch the unfolding drama had gone back to their beds. Most of the floor nurses had also been called away by the needs of their own patients.
It was twenty minutes to six when the first truly optimistic sign occurred, and it was Caitlin who noticed it. “Hey! Gang!” she shouted. “We’re getting some electrical activity in the heart!” The medical resident who was not currently doing either the closed chest massage or the breathing-bag compression rushed over to the EKG machine to look over Caitlin’s shoulder. “Send off another stat potassium level,” Caitlin yelled to the nurse who was assisting them.
“Wow! Those complexes are starting to look quite normal,” the resident said to Caitlin, who nodded in agreement. “And they are getting better.”
“Hold up on the compressions!” Caitlin called out to the resident, who was kneeling on the bed over Laurie. “See if she’s got a pulse!”
The resident who had been breathing for Laurie also stopped long enough to feel along Laurie’s neck for a pulse. “She’s got a pulse! And, my gosh, she’s breathing on her own!” He took the mask away from the end of the endotracheal tube. With his palm, he could feel the amount of air she was breathing in and out. “She’s breathing pretty darn normally, and she’s bucking the endotracheal tube.”
“Deflate it and pull it out!” Caitlin ordered. “Her EKG now looks completely normal.”
The resident quickly followed orders and slipped the tube out of Laurie’s mouth but still held her chin back to make sure her airway stayed open. Laurie coughed several times.
Hearing these exchanges, Jack rushed back from where he was pacing in the darkened elevator lobby and went behind the nurses’ station desk. Laurie had been connected to one of the monitors built in over the desk, but to see it, one had to be on the opposite side of the counter from where the action was. A half hour earlier when he’d looked at it, the blips for the blood pressure and pulse had been tracing straight lines across the screen. It was different now, and his heart leaped in his chest. Laurie had both a pulse and blood pressure!
“Hold up on the peritoneal dialysis!” Caitlin ordered. “And drain out the cation exchange resin. We don’t want to overshoot and then have to worry about too low a potassium level.”
Jack rounded the nurses’ station counter. There was once again a flurry around Laurie as Caitlin’s latest orders were carried out. Jack didn’t want to get in the way, but as hopeful as these developments were, he wanted to be close to her.
“Hallelujah!” said the resident who had been most recently breathing for Laurie. “She’s waking up!”
Unable to hold himself back, Jack crowded in at the head of Laurie’s bed that had been backed up against the nurses’ station countertop. He looked down and saw what he thought was a miracle. Laurie’s eyes were open, and they were moving from one face poised over her to another and reflected not a little confusion and fear. Unexpectedly, Jack burst into tears such that it was hard for him to see. All he could do was shake his head when he tried to talk.
“Release her wrists,” ordered Caitlin, who had pushed in across from Jack. The restraints had been left in place during the ordeal. Caitlin bent over Laurie and gave her shoulder a reassuring squeeze. “Ever
ything is okay. Just relax. We’ve got things under control. You’re going to be all right.”
Laurie tried to speak, but her voice was barely audible. Caitlin had to bend down to put her ear next to Laurie’s mouth. “You’re in the Manhattan General Hospital,” Caitlin said. “Do you know your name and what year it is?” Caitlin listened, and then straightened up. She looked across at Jack, who had calmed enough to control his crying and wipe away the tears. “This is looking very good indeed. She’s oriented. I have to say your rapid diagnosis undoubtedly saved the day. With as high as her potassium was when we started, she surely wouldn’t have been able to be resuscitated.”
Jack nodded. He still couldn’t talk. Instead, he bent down and put his forehead on Laurie’s. Now that her hands were free, Laurie reached up and patted the side of his head and whispered in a scratchy voice: “Why are you so upset? What’s going on?”
Laurie’s questions unleashed another wave of tears. All he could do for the moment was squeeze Laurie’s hand.
A nurse at the nurses’ station desk stood up behind the counter. She’d just answered the phone. “Dr. Burroughs,” she called. “The stat potassium on Montgomery is four milli-equivalents.”
“My word,” Caitlin exclaimed. “That’s darn near perfect.” She turned to her three resident underlings. “Okay, here’s what we are going to do! While I call the attending physician and give her an update, you three get the patient down to the cardiac care unit and get her set up on the monitor. I’ll want another potassium level as soon as you get there, and I’ll be there as soon as I finish here so we can decide on her fluids.”
As the preparations were quickly made to move Laurie, Jack found his voice. “I’m not upset,” he whispered in Laurie’s ear. “I’m happy you’re okay. You gave us a scare.”
“I did?” Laurie questioned. Her voice was returning as well, but it hurt her to talk.
“You were unconscious for a while,” Jack said. “What was the last thing you remember?”
“I remember leaving the PACU, but nothing after that. What happened?”
“I’ll explain everything I know at the first opportunity,” Jack promised as the bed started to move.
“Are you coming?” Laurie asked, holding on to Jack’s arm.
“You’d better believe it,” Jack said as he walked alongside. A nurse ran up and handed Jack his damp coat and jacket.
They used a patient elevator to take Laurie down to the third floor, where the CCU was located. At the door to the CCU, there was a holdup. The charge nurse would not let Jack come in, although he would be able to visit once she was situated. At first Jack had balked at the idea. He wanted to stay by Laurie’s side, considering what had transpired when he hadn’t. Eventually, Jack relented, convinced that Laurie would be in good hands. The resuscitation residents assured him that one of them would be at the bedside continually.
“I’ll be right here,” Jack assured Laurie, pointing out a small waiting room just opposite the CCU door.
Laurie nodded, preoccupied with her physical symptoms, which had become progressively more bothersome as her mind had cleared. What she wanted at the moment was some ice chips for her dry mouth and sore throat, as well as something for the pain she felt at her incision site and in her chest. As far as her memory was concerned, it was still a blank after leaving the PACU.
Jack went into the waiting room, which was empty of visitors. A clock on the wall indicated it was six-fifteen in the morning. There were several couches and a number of chairs. A mixture of old magazines littered a coffee table. Complimentary coffee was available in a corner. Jack tossed his coat and jacket on the arm of one of the sofas and sat down, letting out a heavy groan in the process. He leaned back, put his hands behind his head, and closed his eyes. He felt shell-shocked. He’d never had such stress combined with such physical exertion and wide swings of emotion. Making matters worse were the residual effects of the caffeine, which were enough to make him sick.
The process of closing his eyes made it possible for Jack to think about the sheer criminality of what Laurie had luckily endured. With the immediacy of taking care of her, he hadn’t thought about it until that moment. In his mind’s eye, he could see the tanned nurse in Laurie’s room when he’d barged in. In the dim light, she’d appeared almost gaunt, with dark, short hair, deeply set eyes, and startling white teeth. What he remembered the most was the pillow in one hand and the large syringe in the other. He knew there could be many explanations for why she had been holding such things, just as there could be an explanation for her apparent paralysis in the face of what was obviously a life-and-death emergency. Jack had seen others freeze like that when he was a resident. In fact, he had done essentially the same thing on his first cardiac arrest after graduating from medical school. Yet under the circumstances, Jack couldn’t help but think of her actions as being suspicious. He’d seen her again during the nerve-wracking resuscitation, but only for brief glimpses when she’d appeared at the nurses’ station to go into the drug room to use the computerized dispenser. She’d not participated in the resuscitation. Jack had asked one of the nurses who had helped what the tanned nurse’s name was. When she told him, Jack was even more suspicious. It was another name on Roger’s lists.
Jack’s eyes popped open. He fumbled in this coat pocket for his cell phone. Knowing Lou Soldano’s private home number in SoHo, and despite the hour, he quickly put in a call to him. After what he had witnessed, Lou had to get involved. There could be no more excuses. The phone rang six times before Lou picked up. His voice was gravelly, and Jack had to wait through a coughing jag on the detective’s part.
“Are you going to live?” Jack questioned when Lou finally fell silent.
“Cut the humor,” Lou growled. “This better be important.”
“It’s more than important,” Jack said. “Laurie had to have emergency surgery last night at the Manhattan General. Then a couple of hours ago, someone put her on the edge of the abyss and gave her a good shove. She came as close to dying and not dying as you can get. In fact, for a few seconds or maybe even minutes, she was dead.”
“My God!” Lou blurted, which initiated another fit of coughing.
“Do you cough like this every morning?” Jack asked when Lou came back on the line.
“Where is she now?” Lou asked, ignoring Jack’s question.
“She’s in the cardiac care unit on the third floor,” Jack said. “I’m sitting in a visitor’s room just opposite the door.”
“Is she in any danger?”
“Medically or otherwise?”
“Both.”
“Medically, I think they have things pretty much in hand. She lucked out with a particularly sharp cardiology resident who looks like she belongs in middle school. She’s the second person tonight that has made me feel over the hill. As far as the person who tried to kill Laurie getting another crack at it, I don’t think that’s a problem. Not in the cardiac care unit—there are too many people around, and I’m sitting outside the only door.”
“Do you have any idea who did it?”
“There’s one person, a nurse actually, who I’d be willing to put some money on, but it’s circumstantial. I’ll tell you the details when you get here. We’ve also got Roger’s lists, so your work is cut out for you. But the idea of Laurie’s series being hypothetical is no longer tenable. She almost became a statistic herself.”
“Do you know the name of this nurse?”
“Rakoczi.”
“What kind of name is that?”
“Beats me.”
“Does this Rakoczi know you suspect her?”
“I imagine,” Jack said. “She’s steered clear of me during Laurie’s resuscitation. She was in Laurie’s room when I got to Laurie and found her moribund.” Jack went on to briefly describe the scene as he remembered it.
“Well, she’ll be the first person I want to talk to,” Lou said. “I’ll be there as soon as possible, which will realistically be about a h
alf hour. Meanwhile, I’ll call the local precinct and have a couple of uniformed officers over there to stand outside the cardiac care unit door, in case you have to go to the can or something.”
“Sounds like a good plan.”
“Have you been up all night?”
“I have,” Jack admitted.
“All right, hang in there, and I’ll see you shortly.”
Jack was about to hang up when he heard Lou add, “One other thing. Don’t be a hero, okay! Just stay put.”
“Don’t worry,” Jack said. “After what I’ve been through already, I’m having trouble breathing in and out. I’m staying right here.”
Jack disconnected, put his phone away, and closed his eyes again. He felt a certain relief after having talked with Lou Soldano. The burden of the criminality of what had happened to Laurie and the other victims in Laurie’s series was off his shoulders. For Jack, it was a little like passing the baton in a relay race, meaning his contribution was over. What he didn’t know was how much he was going to regret not following his own advice.
twenty-five
EXCUSE ME,” CAITLIN SAID after giving Jack’s shoulder a nudge.
Jack blinked and pulled himself from the depths of sleep. He felt like death warmed over, but as his vision cleared and he became oriented to time, place, and person, he quickly straightened up. He was surprised and frankly aghast that he had fallen asleep.
“What’s the matter?” he sputtered. “Is she okay?”
“She’s fine,” Caitlin said. “Her repeat potassium was normal, and her vital signs have stayed rock-solid. She’s even had some fluid by mouth, which was ordered by Dr. Riley. The drain from her incision has also been removed, so she’s doing very well.”
“Fantastic,” Jack said as he slid forward to stand up.
