Extreme Measures

by Michael Palmer

  He hoped no one would take much notice of a derelict wandering about the East Boston docks. At least not until he had his hands on that video.

  Unwilling to return to his room, he checked into a seedy hotel to await the night. As he lay down on the musty mattress, he finally began to appreciate the heavy toll the events on the dock had taken on him.

  His headache was constant, but manageable. His legs were leaden, although that feeling, too, he could cope with. what disturbed him most, and was beginning to frighten him was a bandlike tightness constricting his chest. He endured several fits of coughing, then sank off into a fitful sleep.

  NOrth awoke and fell back to sleep twice before he was finally able to leave the hotel and take a cab to a spot near the docks. The tightness in his chest was constant now, and every breath was an effort. He moved toward the lot where the receiver was hidden, and then he froze. There were men everywhere-two that he saw inside the fence, another across the road, not far from the receiver, and one more just cruising in a car with its headlights off. Biting almost through his lower lip to keep from coughing, North backed away and headed toward East Boston center.

  He would have to wait for things to cool down; a day, maybe more.

  Just over a block away, he stopped and leaned against a lamppost, winded. It was crazy, he thought, During a recent screening at Plan B, he had held his breath for more than two minutes. Now he couldn't seem to get enough air. He forced himself to move on, but again had to stop.

  This time, without warning, he began to cough. And for several minutes, he could do nothing else.

  "You all right, buddy?"

  North, who was doubled over, looked up. A derelict, dressed in clothes similar to his own, was looking at him with concern.

  "I… I'm fine, thanks. A cold. That's all."

  "Could I have a hit of that?"

  "Huh? Oh, sure. Here."

  North handed over his bottle. The man took a long swig, wiped his mouth with the back of his hand, and headed off.

  Slowly, North made his way down the street. By the time he reached the downtown area he was doubled over again, coughing mercilessly.

  February 27

  White Memorial, this is MedEvac helicopter. Nurse Specialist Burns speaking.

  We are enroute to your facility from Interstate Four-five with a Priority One motor vehicle accident victim. Male, age forty-four.

  Driver and only occupant.

  Multiple injuries. Definite left fractured femur. Definite right fractured forearm. No definite head or neck injuries. Hypotensive at seventy by Doppler, with no E.K.G is sinus tach actate IVs times two are running wide open.

  MAST trousers are in place. Repeat, this is Priority One traffic.

  Our E.T.A at your helipad is twelve minutes…

  Priority One-immediately life-threatening illness or injury. The words, as always, sent a surge of energy through the White Memorial Hospital emergency room.

  Priority One another chance to validate WMH's reputation as the finest trauma center in Boston, in the state, and according to many, in the world.

  Before the radio report was complete, the E.R. team was in action.

  Arms folded, Eric Najarian stood alone to one side of the gleaming receiving area, savoring the immense pride and confidence of the technicians, nurses, and residents as they prepared for battle that February morning.

  The image of the emergency room as a feudal castle under siege had first arisen in Eric's mind during his second year of residency, and had grown in complexity and color over the two years that followed.

  The technicians-E.K.G, respiratory, and laboratory-had become the support troops and intelligence agents, gathering information and transporting arms and other gear to the militia, the nurses. The interns and junior residents were the officers-the lieutenants and captains.

  And above them all, watching more than doing-waiting for the moment when the encounter with death hung on a single major decision, on one brilliant tactic-stood the lord of the castle, the trauma team leader.

  Over the years of his apprenticeship at White Memorial, Eric had driven himself to the limit with thoughts of the day when he would hold that position.

  Now, six months into his tenure as one of the two chief residents on the emergency service, he drove himself even harder.

  He had grown up in Watertown, not ten miles from the hospital, and was the first in his family even to attend college, let alone graduate school. He had started way at the back of the pack, but after eight years of schooling, every one of them as a full scholarship student, and five more years of the most grueling residency, he was finally beginning to make his mark. And Reed Marshall, the other chief resident, notwithstanding, there were those who now regarded Eric as perhaps the best that White Memorial had ever trained-the best in a hospital that had spawned 150 years of the finest physicians anywhere.

  Tern Dillard, the charge nurse on the shift, finished issuing a set of orders to her staff and then spotted Eric.

  "We're set for him in Four," she said, crossing to him "I told you we'd get one today," he responded, smiling. "I want the crowd in there kept to a minimum, Tern, okay? Have Dierking get in a CVP line and handle the peritoneal lavage. I don't want the other two yet, and I don't want to have to worry. June Feldman can meet the chopper and do the intubation if necessary. What did they say the guy's pressure was?"

  "Seventy."

  "Hmmm Eric stroked the mustache he had grown and shaved off half a dozen times in the past three years.

  He had no particular desire to have one, but there were times when he felt his authority was compromised by his looking years younger than his age, which on that day was a month shy of thirty-one.

  "What are you thinking about?" Tern Dillard asked.

  "Your eyes," he said absently.

  "I wish."

  It would be a surprise, she was thinking, if Eric Najarian ever thought about much of anything except medicine. During her nearly ten years as an E.R. nurse, she had seen all manner of residents come and go-flakes and philosophers; insecure jerks who needed to verbally abuse nurses; brilliant thinkers who came unglued at crunch time; soft-spoken young women to whom she would not hesitate to entrust her life. But this man was one of a kind. When he wasn't working killer shifts in the E.R he was in the library or the lab. If the E.R. was backed up at the end of his shift, he would pitch in and play intern for as many hours as it took to catch up.

  As a physician, Reed Marshall was good, very good; but he seldom stepped down from the pedestal of his position-seldom got "dirty." Eric was a barroom brawler. And although Tern knew nurses who had dated Eric, and even slept with him, she knew of none who had been able to compete with medicine as the love in his life.

  "why's he in shock?" Eric muttered, asking the question primarily of himself. "A spleen? A river?"

  "Aortic tear?" tern ventured.

  "Maybe…" His voice drifted off. "It's in his chest," he said suddenly.

  "How could you know that?"

  "I don't know it. I just feel it. God, I'd love to know what the steering wheel of that car looked like…

  "The steering wheel?"

  "Listen, I want you to do me a favor. Call Dave Subarsky's lab, extension four-eight-one-one, and see if you can get hold of him.

  Ask him to come down here right away, and tell him… Better still, just get him on the phone. I'll talk to him."

  He raced off toward the radio. As Tern picked up the phone, she heard him raise the MedEvac helicopter and ask about the accident-particularly about seat belts and the condition of the steering wheel.

  She knew from five years of watching him work, that with a Priority One just minutes away from arrival, Eric Najarian was operating in a zone few trauma specialists ever reached.

  Within seconds of the MedEvac chopper's touchdown on the roof of the Richter Building, the battle was underway. June Feldman, the junior resident, began her evaluation on the way to the elevator and had her report ready for
Eric by the time she and the rescue team exploded through the emergency room doors.

  The prize at stake was the life of a man named Russell Cowley, the president of one of the region's larger high-tech firms. Eric's pulse had speeded up a notch at that news, This man's rescue and subsequent resurrection would be the stuff of front-page headlines.

  According to the MedEvac crew, Cowley had been speeding north on the interstate, seat belt in place, when the right front tire of his Mercedes 450SL had blown. The car had careened through a snowbank and then the guardrail, sailed nearly fifty yards over an embankment, and then crashed into the base of a tree. The jaws of life had been needed to extricate him from the wreck. The steering wheel, bent almost in half, had pinned him to his seat.

  "Cowley… Russell Cowley," one of the residents had mused as they were awaiting the chopper. "I could swear he's a trustee of this place.

  In fact, I'm sure of it." Eric had taken in the information without reaction, but the look in his eyes grew even more intense.

  With Craig Norrell's abrupt dismissal and subsequent disappearance, the position of associate director of emergency services had suddenly come open. And everyone from the secretaries on up knew that only he and Reed Marshall were in the running for the job.

  Now, with the search committee struggling for justification to choose one or the other of them, a trustee had been dropped in his lap.

  You don't know it, Mr. Russell Cowley, he was thinking, but there is no way that you're going to die from this. Absolutely none.

  The Corporate executive howled in pain as he was transferred to the hospital gurney. Crystals of windshield glass sparkled in his hair.

  His face, beneath the smeared blood from several lacerations, was violet. He flailed his good arm and screamed again as a nurse inadvertently jostled his left leg. Gradually he drifted off, moaning softly, The orthopedic resident set about stabilizing the obvious fractures. Eric did a rapid exam and then stepped back. He had found nothing that argued against his notion that the impact of the steering wheel had bruised the man's heart, causing pericardial tamponade.

  Blood was collecting between the cardiac muscle and the pericardial membrane that surrounded it. The mounting pressure of that hemorrhage was compromising the filling and pumping power of the heart, and causing progressive shock.

  If that was in fact the case, then a pericardiocentesisrainage of the constricting blood-was in order. The standard procedure involved the insertion of an E.K.G-guided needle through the upper abdomen, just past the liver, then through the diaphragm, and finally through the pericardium-a tricky, potentially dangerous maneuver.

  Eric had other plans. He glanced toward the 'doorway, wondering what was taking Dave Subarsky so damn long.

  "Films first, films first," he said, forcing calm into his voice.

  "I need a good lateral of his neck right away.

  Have them shoot a chest and pelvis as well. June, I don't think he needs a tube yet, but he might. He looks like hell. What's his pressure?"

  June Feldman tried to find out with a cuff and Doppler electronic stethoscope, then shook her head.

  "As soon as bloods are off to the lab, get an arterial line in him.

  Then a catheter," Eric ordered.

  Feldman set to work cannulating the man's radial artery, while a second resident numbed a spot near his navel and thrust a tube into the abdominal cavity.

  A flush of saline through the tube showed no evidence of internal bleeding.

  Eric nodded. The test had ruled out a ruptured spleen or liver, and had made an aortic tear less likely.

  The possibility of pericardial tamponade as the cause of Russell Cowley's shock had just increased severalfold.

  Tern Dillard rushed into the room.

  "How's he doing?" she asked breathlessly.

  "No better, no worse," Eric said. "He's tamponading."

  "You sure?"

  "Not yet, but almost. And if it's true, hold on to your hat.

  'You're going to get to see something no one has ever seen-not even me.

  That is, providing goddam Subarsky gets down here in time."

  "Well, I hope whatever it is happens quickly," Tern said, "because we just got a call on the Batphone.

  Boston Rescue is on the way in with another Priority One-a man found in an alley in the North End. No pulse, no respiration. They're doing CPR."

  "A drift diver?" Eric asked, his concentration still focused on the residents and technicians.

  The term referred to the derelicts pulled from snowdrifts throughout the Boston winter. Most of the time they were well beyond salvation.

  "I think so," Terrf said. "The rescue people refuse to incriminate themselves over the radio, but they did say there was a nearly empty bottle of Thunderbird in the man's coat pocket."

  "Is he warm?"

  "I have my doubts. Rescue made it sound like they were only working on him because their protocol demands: it."

  "E.K.G?"

  "Essentially straight-line, with an occasional agonal beat."

  "Pupils?"

  "Dilated and fixed."

  "Lord. Tern, isn't there someone else around to work on him?

  This is big stuff going on here. This guy's the president of a company, a trustee of this hospital, and he's got treatable injuries.

  I don't want him shortchanged while I go through the motions with a wino who probably died hours ago."

  Tern's eyes narrowed.

  "You're the only senior person around," she said coolly. "If you need help, Dr. Kaiser is next door doing walk-ins." "tell him to take charge of the diver. If this guy needs his pericardium drained, I'm going to do it.

  "En'c, come on," she said. "Gary Kaiser's been here a year and a half, and he gets flustered taking care of strep throats. I think his father must have endowed a building or something. There's no other explanation for his getting an internship here."

  "well, just tell him it's time to be a goddam doctor.

  That's what he came here to be. Anyhow, it sounds like this diver's going to be just another D.O.A. Tern, for chrissakes, don't make that face. Okay, look, I'll be over to help him as soon as- Wait, there's Subarsky.

  If things go the way I hope, we may be done before the diver arrives."

  Dave Subarsky lumbered into the room, hauling a cart laden with complex machinery. Subarsky had a PhD. 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.

  "Ye, 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 line in yet?"

  "Right now," she answered. "One more second and… Voila!"

  A low, rapid wave-tracing appeared on the oscilloscope beneath Russell Cowley's E.K.G 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 Da
vid's hands. It was developed for vascula 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 F.D.A 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-I," Tern 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."

  "E.K.G?"

  "Straight-line with a rare agonal beat." god."

  "Tell Kaiser to pronounce the guy if that's all he's-" "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?" the wave formation on the oscinoscope was a straight line. The systolic and diastolic readouts both showed zero. The heart rate began to slow.