Critical Condition
By Peter Clement
Contents
Dedication
Prologue
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
Epilogue
To the constants of my life: Sean, James, and Vyta
Prologue
As a doctor, he knew how to wake up.
Especially when the phone was ringing.
Except It didn't sound like a phone. More like the whine of a mosquito, or a dentist's drill.
And he couldn't seem to come out of the sleep that held him.
In fact he knew he shouldn't.
There was pain waiting for him up there. Better he stay In the darkness down here.
But he was surfacing anyway.
First he felt his throat hurt. So what's a sore throat? Two aspirins and call me in the morning stuff. Nothing to worry about.
The pain burned across his neck and up his face. He swallowed, and felt he'd downed a mouthful of fire. What the hell, he said, but seemed to be speaking flames instead of words, their heat searing a hole out the front of his larynx with a loud hiss.
His head began to throb. And his arms. They were aching all the way from the shoulders, as if someone had grabbed his hands, yanked them over his head, and was pulling him out of the deep blackness where he wanted to stay.
He remembered. Waking up in the early gray of dawn and seeing someone by his bed who shouldn't have been there. He'd been about to shout, when a white explosion went off in his brain. He tried to call out again, alert someone now that there had been an intruder, but the hissing under his chin returned, and the pulling on his arms continued.
He attempted to run. His feet seemed stuck together.
And the noise continued. A high-pitched whir that he definitely knew was out of place.
Suddenly he was rocketing upward toward the light, unable to stop. His eyes flew open. He was in his shower stall, naked, suspended by his arms from the nozzle above, his ankles taped together. The whine of what sounded like a small electrical motor came from outside the frosted glass door of the cubicle, and he could see a shadowy form approaching. He screamed for help, sending another gush of air wheezing out from below his chin. Someone had cut a hole in his trachea.
The door opened, and in stepped a figure clad in full surgical gear carrying a rotary bone saw. He had no idea who it was. The eyes above the mask were as giitteringiy cold as any he'd ever seen. He began to writhe and buck against his restraints as the small spinning disc of steel was brought up to his sternum. His shrieks when its teeth tore through the skin and bit into the underlying ribs made no more sound than the morning breeze that stirred the bathroom window curtains.
Chapter 1
Two Weeks Earlier,
Wednesday, June 13, 6:45 a.m.
She felt the sound more than heard it.
It came from deep within her brain, and in the first few seconds seemed to have no more significance than the tiny popping noise a congested sinus makes when it clears, or the slight creak that even a healthy neck can produce after the muscles and tendons have stiffened from being too long in one position.
So Kathleen Sullivan ignored it, automatically relegating the minute sensation to the background trivia of everyday life, deeming it part of approaching forty, unimportant, therefore not to be heeded, and resumed making love to Richard Steele, whom she sat astride watching his eyes glitter in the gray traces of morning light that had begun to creep into her still-darkened bedroom.
God, she loved him. Their sex seemed always such a celebration of how they matched each other in life.
Then the pain hit her at the base of her skull with the force of a two-by-four. "Oh, my God!" she screamed, clasping the back of her head and freezing. She felt him initially increase his movements, then slow when she failed to respond, his flushed, smiling features growing puzzled.
A swirl of dizziness sent her reeling to the right as if she'd been slapped. She toppled off him. Nausea overwhelmed her, and vomit arched out of her mouth as if shot from a hose. She flopped down, half on and half off his chest. Blackness came quickly, but it took longer before she lost sensation enough to stop feeling the pain entirely.
And she could still hear.
"Kathleen! Kathleen, what's the matter?" he cried from somewhere far off.
Someone's prying open my skull from the inside, she tried to tell him just before the pressure squeezed all consciousness out of her.
The pain, like roots, ate deep into her sleep, and tendrils of harsh light ripped her out of the merciful dark. She tried to scream, but no sound came. She could see racks of bottles, bags of fluid, and coils of plastic tubing lining the walls of whatever little room they were in, yet everything looked wrong, as if outlined in double. She blinked to clear her vision; it made no difference. She couldn't shift her eyes from side to side, but she could look up and down. She tried to move her hands, but not even her fingers would budge. Had they tied her to the bed?
Someone loomed over her and placed a black mask on her face, then pumped air into her mouth and down her throat.
"Her breathing's labored," she heard Richard say from a place beyond her line of sight. "Step on it!"
"We're a minute from the door, Doc!"
She felt the room sway hard to the left, and realized they were in an ambulance. Probably on the way to Richard's ER. But why couldn't she look at him? Move anything? God, what had happened to her?
"It's okay, Kathleen," she heard him say. "We've got you. Just relax and let us help you breathe."
Volleys of air forced their way past the base of her tongue and down into her larynx. Each one felt big as a tennis ball and filled her with the urge to gag, but her pharynx stayed flaccid, refusing to respond. She wanted to shake off the mask and gasp for breath, yet couldn't.
"If you can hear me, Kathleen, we've called ahead to the hospital, and the chief of neurosurgery is waiting for us. You've suffered some kind of stroke, probably hemorrhagic from the way it's affected your eyes, but you'll make it okay, Kathleen. Count on it!" His voice trembled and broke, leaving her wondering if he'd sobbed. Squeeze after squeeze of air went down her throat. "Hyperventilating you like this blows off carbon dioxide and constricts arteries in the brain," Richard continued, his words coming in fragments as if they were catching on something sharp. "That'll slow the bleeding."
With a squeal of brakes the vehicle lurched to a stop. Instantly she heard the doors at her feet snap open and felt the cool morning air flow into the vehicle. Only then did she realize she was nude under a blanket.
The attendant went on ventilating her and a half dozen men and women in white clustered around to help lift out the stretcher. "Where's Tony Hamlin?" she heard Richard ask.
"In resus, ready and waiting with his neurosurgical team," someone answered as they raced into the ER and down a corridor, the sweep of the ceiling past her vertical stare adding to her dizziness. She could feel Richard's hands against her face as he took over holding the mask tightly in place around her mouth and nose. By straining her eyes upward she could see him. His expression grim, he snapped off orders to his staff as he ran. Even when he glanced down at her and tried to smile it was a miserable attempt to reassure her.
> My God, she thought, the poor man. He thinks I'm going to die, just like his wife.
They wheeled her into a vacuous cool chamber filled with a dozen people in green gowns, masks, and surgical gloves. Everyone grabbed a part of her and worked on it as if she was a race car at a pit stop. While IVs went in her arms, a tube was shoved down her throat, and what looked liked tiny spigots were stuck into her wrists. Once more she felt she had to gag, but not even a cough or sound of any kind emerged. She lay as motionless as a corpse, yet aware.
"We've got her stable, Richard. Why don't you let us take it now?" said a man with long white hair standing by her head.
"Right, of course, Tony," she heard her lover reply, his voice more strained and uncertain than ever.
No, don't leave me alone, she wanted to cry out.
His face once more came into view, his handsome features as tense and pale as latex stretched over a skull. "Kathleen, our chief of neurosurgery, Tony Hamlin, is right here to take care of you."
"Hi, Kathleen," Hamlin said. "Sorry to meet you in such circumstances."
"These people are the best," Richard continued. "They'll get you through this." He leaned closer and whispered, "I love you."
Please stay!
He turned, and out of the corner of her fixed field of vision she watched him disappear.
Then a nurse whipped off her blanket and proceeded to insert a catheter up her urethra. "Did the event happen during intercourse?" she asked coldly, examining the secretions she'd picked up between her gloved fingers.
"Isn't that one of the classic presentations of an arterial rupture?" asked a curly-haired man in a short clinical jacket as he adjusted her IV. He didn't look much older than her daughter Lisa, who'd just turned nineteen. Christ, Richard had left her in the hands of a kid.
"When you've finished what you're doing, Doctor, why not step outside and get a proper history from Dr. Steele?" said the white-haired man behind her head as he proceeded to shine a penlight into her eyes. Despite the glare, she couldn't avert her gaze, only blink. His face looked to be in pieces, like a Picasso. Richard stood in the corridor slumped against the wall. His taking charge in the ambulance had been both critically necessary and a retreat into action, his concentration on technique keeping his terror at bay. Now he had nothing to divert him from facing what had happened, not as a doctor, but as her lover. At the center of the domain where he'd spent his professional life resuscitating others from the dead, he began to tremble with helplessness.
A nurse with closely cropped gray hair and rectangular, gold-rimmed glasses came steaming out of the room he'd just left. "Dr. Steele, let's sit together in your office. I'll get you a coffee." Her name tag read Josephine O'Brien, but she'd been around the department longer than he, and everyone with whom she was friendly called her Jo. "Dr. Sullivan's completely lined, we've wired her to every monitor we have, and her vitals are holding. A CT's next, so there'll be nothing new to report until then."
A much younger colleague followed on her heels. "She's in good hands with Dr. Hamlin," she added. "You're doing her and yourself no good hanging around the doorway."
They spoke with exactly the mix of firmness and compassion that he expected everyone in his department to use when dealing with frightened family and friends of patients. He mumbled his thanks for their support, and had he not been a physician, might even have felt reassured. The trouble was, like most good ER doctors, he knew the odds. No niceties on the part of his staff could stop the percentages from pummeling his brain.
Mortality for this type of intracranial bleed— eighty percent.
Morbidity or permanent brain damage in those that survived— almost certain.
Chances of a fatal rebleed— high.
A cold empty feeling settled into the pit of his stomach. As the two women led him down the hallway, he had to watch his step the way a drunk man does. The numbers literally staggered him. At his door he fumbled his keys until Jo took them and unlocked it for him.
Don't die on me, Kathleen, he kept saying to himself. Please, don't die on me.
As soon as he stepped into his own small sanctuary— a carpeted shoe box with an oversized metal desk, two chairs, and a potted tree— he quickly raised a hand to his eyes, not wanting the nurses to see the tears brimming over his lower lids. But the streams were halfway down his cheeks before he could wipe them aside. "Please, just leave me be," he said quickly, straining to keep his voice steady while looking up to avoid their gaze. The tiny perforations in the ceiling tiles shimmered like black stars in a white universe.
"Not on your life, Richard," said Jo, one of the few who would dare use his first name. Keeping her hold on his arm, she added, "Now sit down and let us take care of you for a change, starting with the mug of hot caffeine we promised you." A jerk of the head toward the door sent her junior running down the hallway to fetch it. "And don't worry about letting down in front of me," she continued when they were alone. "As for Kathleen, let me be telling you, us Irish women have a stubborn strength that adds up to an edge for seein' us through any ordeal. It probably comes from dealing with all the ornery men in our lives. From what I've heard she's as good a fighter as any, and that's sure to help her survive."
Richard looked up at her lined face and kind brown eyes. His wife had had fight in her, too. What good did it do her?
At that moment there was a knock, and a young resident stuck his head in the door. "Dr. Hamlin sent me to ask you a few questions, Dr. Steele," he said.
"Not now!" Jo snapped.
He disappeared back out again.
"These kids they make into doctors nowadays," she muttered after he'd fled. "Know all the facts, and nothing about people."
Because the people part's too painful, Richard thought.
"It's a pontine bleed," Hamlin told Richard an hour later in that same office, referring to a specific part of the upper brain stem. "Her pupils are pinpoint and, for now, unreactive. She's quadriplegic, has lost her gag reflex along with her ability to swallow. Control of her pharyngeal and facial muscles is gone as well, to the point she can't speak or show any expression. But she's conscious, and moves her eyes up or down on command. She can also blink up a storm. That's what tipped me off when I examined her."
"A locked-in syndrome?" Richard asked, the fearful sensation at the core of his innards turning to ice.
Hamlin nodded. "Her respirations haven't deteriorated any further, though she still needs an assist from a ventilator. We had to leave her intubated anyway, to protect her airway from an aspiration of vomit— she can't even keep her saliva out of her lungs. We've also sedated her— it's obviously a hell of a panicky situation for her— but she can still signal with her eyes. We're using morphine to manage the pain at the same time, and she's indicated the headache's lessened. You know, I was telling the residents that Alexandre Dumas was the first to describe this condition—"
"What's her prognosis?" Richard cut in, unable to take anymore clinical detail, nor Hamlin's pompous tendency to lecture even when he was talking alone with a colleague. "And don't bother me with the general outcome for brain stem bleeds. I know that. Is the pons any less dismal?"
"Only time will tell," said Hamlin, assuming an even more professorial tone. "On her CAT scan the hemorrhage seems confined to that area. If it stays there, without penetrating into the fourth ventricle that's nearby, and she survives the next few hours, she might have a considerable recovery. We'll get a better view when she's stable enough for an MRI, and of course I've scheduled an angiogram. But if she rebleeds and the hemorrhage extends into the ventricular space where there's no stopping it . . ." He let his voice trail off.
Richard didn't need to be told that these were the ones with the highest death rates. "What's a 'considerable recovery'? " he asked, his mouth so dry he could barely speak.
"Sometimes it means that patients regain sufficient respiratory function to get off a ventilator. Sometimes they do much better and are left with a deficit only in the legs
, remaining paraplegic, or with luck, recover partial movement there as well. A small number actually walk again. In other words, I've seen instances where they win back almost full function, especially in the upper body, including the ability to swallow and talk. Of course, it's impossible to predict the outcome of any given case."
Hamlin's voice faded into the background as Richard's mind conjured an image for each scenario: Kathleen withering away on the end of a breathing tube, dragging her lifeless legs along on crutches; Kathleen feeding herself, garbed in a food-stained bib— nothing he hadn't seen before ... in strangers.
"Her angiogram will give us a better idea of the reason for the bleed, which I suspect is a congenital arterial malformation, probably a capsular angioma, since she's no history of hypertension. Of course I don't have to tell you it's got to come out. Unless this underlying deformity is removed in its entirety, the risk of another hemorrhage will always be there. But first we have to stabilize her enough for the OR and verify with imaging that we can get at it surgically without doing too much collateral damage."
Richard shuddered. The term collateral damage was code for an even more chilling outcome. If the many neural pathways and centers that passed within millimeters of each other in the section of the brain Hamlin cited, those controlling breathing, walking, voluntary bladder or bowel control, finger-hand-arm movements, speech, and eating, had survived the bleeds, they might not survive the surgery. His cutting out the tangle of abnormal vessels, the capsular angioma that he suspected, while leaving the rest of the anatomy intact, was so tricky the operation itself could further destroy neurons, making her worse off and possibly killing her.
Critical Condition Page 1
