Stigma

by Philip Hawley Jr.

“Be sure to let us know if he turns out to have some exotic infection,” a transport nurse said. “We were in pretty tight quarters on the way over here.”

  Susan said, “I’ve heard enough. Everyone puts on a mask and gown.” She opened a cabinet and started tossing the infection control gear into waiting arms.

  “O-2 sat is slipping, now at seventy-eight percent,” the respiratory therapist called out. “He’s working way too hard to breathe. I’m starting full-strength Albuterol.”

  As she slipped on her mask, Megan swept the length of the boy’s body with her eyes, looking for some physical sign that hinted at the cause of his illness. The skin over his ribs was drawn tight from exertion, skewing a crude crescent-shaped tattoo on his upper chest.

  But what seized her attention was his face, which was turning ashen. Oh, God.

  “Put him on a non-rebreathing mask,” she said. The specialized mask’s one-way valves and balloon reservoir would allow them to deliver twice as much oxygen as a regular mask.

  “Already working on it.” The therapist held it up for Megan to see as she dug into one of the drawers of her portable cabinet and came up with a connector of some type.

  Susan grabbed for the wall phone. “I’m calling to find out where McKenna is.”

  Megan wasn’t listening. “What’s the boy’s name?” she asked.

  “Josue Chaca,” the transport nurse called out.

  Megan looked into his eyes, enormous brown eyes teeming with fear.

  She laid a hand on his forehead. “No se preocupe, Josue. Vamos á tomar el buen cuidado de tú,” she said, using the passable Spanish most residents learned while working at University Children’s. “Don’t worry, Josue. We’re going to take good care of you,” she repeated to herself.

  The boy locked eyes with Megan. He didn’t say anything. He couldn’t say anything. He was too busy gulping air.

  It was happening too fast. She was losing him.

  4

  As soon as McKenna emerged from the treatment room, his eyes fixed on the hulking figure standing over the E.R. check-in desk.

  Smack. The man’s fist slammed onto the desktop as he shouted across the counter at the desk clerk. “Where’s my wife? Goddammit, I wanna see my wife and kid. Now.” His voice was as gargantuan as his bulk.

  A nurse standing off to the side grabbed a red wall-mounted phone — Security.

  Luke walked toward the desk. A nervous crowd of onlookers edged in the opposite direction.

  Chewy Nelson, a skinny young intern to McKenna’s left, plopped a handful of M&Ms into his mouth and mumbled through a mouthful of chocolate: “Damn, that’s Lloyd Erickson.”

  Luke recognized the name. Anyone who had even a passing familiarity with professional football had heard of the NFL linebacker. His career-ending tackles on the field drew almost as much media attention as his erratic, violent behavior during the off-season.

  Erickson stood at least six-foot-four and had a thickly sculpted physique that reeked of steroids. He was big for a linebacker, even an NFL linebacker, and his blazing red hair sat on a head that was three sizes too small for his body.

  When Luke reached the desk, he gestured with his eyes and signaled the desk clerk to leave. She rocketed out of her chair and disappeared around a corner.

  Erickson was sputtering with rage, shaking his arms wildly in convulsive spasms, half his words unintelligible. He leaned into McKenna’s face, his massive torso dwarfing Luke’s wiry six-foot frame.

  Luke just stood there, staring back at the linebacker, trying to restrain his own swelling rage.

  This he was able to do until Erickson grabbed his white coat.

  Then reflexes took over and McKenna discharged like a coiled spring.

  His left hand clutched the linebacker’s wrist while his right forearm came up from below and slammed into Erickson’s locked elbow.

  A snapping sound echoed off the walls and Erickson let out a thunderous groan. His grip on Luke’s coat loosened for an instant.

  It was long enough. Luke stepped inside, spun around, and arced his flexed elbow behind him and into the linebacker’s jaw.

  Erickson’s eyes bulged from their sockets as he registered the sound of his teeth shattering. He spit a bloodied tooth onto the floor, then let out a roar and lunged at McKenna like a lion going in for the kill.

  Luke sidestepped the attack and unleashed his cocked leg in an impossibly fast motion. His right foot went through the linebacker’s face like a wrecking ball.

  The impact lifted Erickson off his feet. He landed on his back with a dull thud.

  He wasn’t moving.

  It was over. The skirmish had lasted less than three seconds.

  People rushed out of exam rooms. A plump security guard rounded the corner, panting from what probably had been a very short jog. When he saw the hulking mass on the floor, the guard froze for a moment, then slowly tiptoed toward Erickson as if approaching an unexploded bomb.

  Another doctor joined the guard. They knelt at the linebacker’s side, checking the enormous body for signs of life. “He’s breathing,” shouted the doctor, sounding out of breath himself.

  Luke wasn’t paying any attention. He studied the floor around him, looking for the stethoscope that had flown out of his pocket during the clash. He glanced down at his white coat. There was a tear in the lapel.

  The swarm of onlookers grew. The E.R. director, Dr. Keller, vaulted out of a room and took in the scene. “What the hell?” he yelled. “What happened to that guy?”

  Still staring at his lapel, Luke said, “He’ll be okay.”

  Suddenly remembering the intercom page, he turned and started toward the Trauma Unit. As he trotted away, he called back over his shoulder, “I’d slap some restraints on Godzilla once you figure out how to lift him onto a gurney. He may be a little restless when he wakes up.”

  * * *

  Calderon scanned the parking structure for a spotter, someone with overly attentive eyes marking pigeons for the pickpocket. No one fit the profile.

  He watched as the pickpocket collided with a harried traveler who was pulling luggage from the trunk of his car. Calderon admired the thief’s skill. The hapless victim had no inkling that his wallet was gone.

  “So what about the boy?” he asked his client. Calderon poked the air with a finger and shook his head as he walked along a parallel row of cars. To all the world, he appeared a man absorbed in his phone conversation, oblivious to everything around him, even as his eyes fixed on the pickpocket. Calderon realized he had been the perfect mark: a chauffeur standing near a crowded exit, looking for his passengers, desensitized by the occasional brush with a bag-laden traveler; his loose-fitting black coat, unbuttoned, assumed to be holding a wallet bursting with tips from wealthy clientele; his mind elsewhere, displaying the telltale signs of distraction.

  “Let me worry about the boy,” his client replied.

  The pickpocket, now forty feet in front of him, glanced occasionally to each side, probably watching for tails as he hugged a row of cars on his way to the rear of the structure. The money was of no significance to Calderon, and the driver’s license and credit cards described a nonexistent person. But that could also become a problem. False IDs were designed to stand up to visual scrutiny, not investigative inquiry. The police, responding to some overeager Good Samaritan trying to return the wallet to its rightful owner, would discover that the driver’s license with his picture belonged to a nonperson.

  Questions might arise, his picture circulated and studied. He couldn’t have that.

  “But I am worried,” Calderon said. “This is the second time I’ve had to go chasing after test subjects that — how shall I put this? — strayed from the herd.”

  He didn’t need to remind his client of the girl who was still missing. After a moment, he added, “Maybe it’s time you let me deal with this problem, yes?”

  The pickpocket glanced back, but not quickly enough. Calderon had crouched behind a van. A woman pus
hing a stroller paid little attention to a man retying his shoe.

  “Perhaps you’re right,” his client said. “I’ll give it some thought.”

  When Calderon rose to his feet, the pickpocket was gone. An exit sign flickered over a concrete archway.

  Calderon rushed to the exit just in time to hear a muffled crunch—a footfall. He stood to one side and surveyed the darkness outside. A twenty-foot walkway led into an adjoining parking structure with wide unlit alleys on either side. He looked up and saw no security cameras.

  He moved through the exit noiselessly.

  Another sound, more distinct — a shoe stepping on a shard of glass — came from behind a trash container on his right. Then the faint beat of rap music. An Adidas shoe peeked out from the corner of the large metal container, tapping to the music.

  He edged along the bin.

  “The important work is going well,” his client offered. “In another two weeks, the project moves to full-scale production. There’re always problems. We’ll deal with them.”

  Calderon stepped around the corner of the bin, making no effort to conceal his movements.

  The thief was sitting there, thumbing through Calderon’s wallet. Another one was waiting on his lap.

  “You mean, I’ll deal with them,” Calderon said to his client.

  The swarthy man looked up. Oddly, his dark eyes showed little surprise, even as he sprang to his feet and unfurled a butterfly knife in one, smooth acrobatic move.

  The man had very good reflexes, but not nearly good enough to react before Calderon’s iron-like fingers speared his throat.

  The pickpocket’s grip loosened, his knife clattered on the pavement, his eyes finally showing the shock and bewilderment that Calderon had expected.

  Calderon placed a finger to his lips and silently mouthed Shhhh, but it wasn’t necessary. The man couldn’t raise a whisper through his crushed windpipe.

  The thief started clawing at the deep depression where his Adam’s apple had once been, desperately trying to reopen his airway. He began to wobble.

  Calderon grabbed the thief’s neck in a viselike grip and steadied him.

  The man’s eyes bulged. His feet thrashed the ground wildly.

  Calderon’s right hand lifted the unlucky thief by the neck and held him against the concrete wall.

  “I have a flight back to Guatemala in the morning,” Calderon said to his client. “You can reach me at the project site.”

  “Cancel your flight.”

  The swarthy man’s feet floated just off the ground. His legs twitched and spasmed, and his eyes soon drifted in different directions as his muscles went limp in death.

  “Why?” Calderon asked.

  “Tartaglia. She’s become a problem. I need you to take care of it — quickly.”

  5

  Luke berated himself as he jogged toward the Trauma Unit, knowing that, on some level, the only difference between the football player and himself was a thin veneer of discipline. In both men, a malignant capacity for violence simmered just below the surface.

  He told himself every day that he wasn’t that person anymore, but it was a lie. Cutting short his military career and following his father into pediatrics hadn’t changed who he was. Burying his past in a dense grave of gray matter hadn’t put the warrior out of reach.

  The pneumatic doors swung open with a loud hiss just as Luke reached the entrance to Trauma One. A transport physician appeared in the doorway, dragging a gurney behind him.

  Luke pointed inside. “How’re we doing?”

  The man waggled his hand and launched into a clipped summary.

  Luke listened while looking over the doctor’s shoulder, taking in the scene. Susan, syringe in hand, stabbed the patient’s right arm repeatedly, a hint of frustration playing on her face. The other nurse tapped the patient’s left foot, searching for a vein. Megan was hunched over the table, her back to Luke, moving her stethoscope across the boy’s chest.

  “Any unusual rashes?” Luke asked. He was hoping he wouldn’t have to call in his father, who, as the head of Infectious Diseases, was the go-to person for tropical diseases. The man already worked too many hours.

  The transport physician shook his head while continuing his report.

  Luke cut him off in mid-sentence with a “Thanks” and walked into the room, taking a position well behind Megan. From ten feet away, nothing jumped out at him other than the boy’s wasted form and a crude tattoo on the left side of his chest. It was dark blue, about an inch across, and shaped like a crescent moon.

  Only Susan, who was facing Luke, seemed to notice his presence.

  “Patient’s moving air well,” Megan said, her tone a swirl of confusion. “A few faint wheezes, but otherwise his lungs are clear.”

  The respiratory therapist’s eyebrows angled downward, her expression bemused.

  Apparently, everyone shared the same question. What would normally have been good news was anything but. Despite good airflow into his lungs, their patient was oxygen starved.

  Susan showed Luke a peevish frown while fingering the stethoscope around her neck.

  Luke waved her off. There was no reason to usurp Megan’s role as team leader — at least not yet.

  “Is the blood gas ready?” Megan asked the therapist.

  “Just drew it. Have it in a moment.”

  The blood gas results would give them far more information about the patient’s lungs. It would reveal if the patient’s body was retaining carbon dioxide, and if so, whether his blood was becoming dangerously acidic.

  But it wouldn’t tell them why.

  Luke hoped that Megan didn’t spend too much time thinking about the unknowns, questions for which she didn’t have answers. She needed to focus on what she knew and could act upon.

  “Someone call X-ray again,” Megan said, “and while you’re at it, call Admitting and tell ’em to get an ICU bed ready.”

  “Megan, we’re not having any luck getting an IV started,” Susan said, her eyes aimed at Luke. “His perfusion’s poor. He’s clamping down.”

  The boy’s body was doing exactly what it was designed to do, diverting blood flow from the muscles and skin to more vital organs. Come on, Megan, it’s time to move on this.

  Susan shot another frustrated glance at Luke.

  Luke held out a palm.

  The nurse rolled her eyes, shook her head.

  A half second later the acoustic rhythm of the heart monitor broke its stride and played a few erratic beats. Luke’s eyes went to the electrical tracing and jagged lines. The boy’s heart was racing at 180 beats per minute, and his blood pressure was dangerously low.

  Megan said, “Get me a central line setup, and pull an endotracheal tube in case we need to intubate him.”

  Placing a central line into one of the larger, deeper blood vessels would allow them to deliver substantial amounts of fluids quickly. Luke wondered how many times Megan had done the procedure, if ever.

  The respiratory therapist handed a strip of paper to Megan. “Here’s your blood gas,” she said. “We’re going nowhere fast. O-2 sat is hovering in the low seventies and his CO-2 is climbing. I’m switching to an Ambu bag.”

  The therapist ripped off the patient’s oxygen mask and replaced it with a thicker one attached to the Ambu bag, alternately compressing and releasing the rubber oxygen reservoir.

  They were now breathing for Josue.

  Luke glanced at the boy’s face when the therapist removed the oxygen mask. The fear that had been there a minute ago was gone. He had a glazed, stuporous look. He no longer felt anything.

  Whoosh. The doors swung open. Five sets of eyes turned in unison.

  A high-pitched whir invaded the room when the X-ray technician guided the motor-driven X-ray machine into the room. Luke held out an outstretched arm, signaling the tech to stay put for the moment.

  “Blood pressure’s dropping,” Susan announced. “And his pulse is thready.”

  “Someone get McKe
nna,” Megan shouted. “Drag him in here if you have to.”

  “Right here.” Luke stepped up beside her.

  Megan’s eyes showed a blend of puzzlement and irritation. “How long—”

  “Let’s divide and conquer,” he said while stepping over to the surgical tray. “Go ahead and intubate the patient. I’ll put in the central line.”

  Megan said, “I was about to—”

  “You comfortable intubating the patient?” Luke asked. His gaze had settled on the instrument tray, but he could feel Megan’s stare.

  After a moment, she said, “Yeah…sure.”

  Luke quickly scrubbed the boy’s upper thigh, found the femoral vein, injected an anesthetic, made a quick stab, and inserted the line.

  Megan said, “As soon as Dr. McKenna has that line secured, give the patient a normal saline bolus, as fast as it’ll run. Call out the blood pressure every minute until it’s back above ninety.”

  Luke glanced at the boy’s face. He’d slipped into unconsciousness. They had no time to give the drugs normally used to sedate and anesthetize a patient undergoing intubation. He hoped Megan realized that.

  Holding the laryngoscope in her left hand, Megan called out, “Ready.”

  The therapist removed the Ambu bag from the patient’s face and stood back.

  Megan inserted the laryngoscope into the boy’s mouth, taking a deep breath as she did so. “Hand me the tube.”

  The therapist passed it to her, and Megan immediately slipped the endotracheal tube down the patient’s throat.

  The respiratory therapist connected the Ambu bag to the end of the tube and began squeezing and releasing it with her left hand, her movements practiced and rhythmic.

  Megan ran her stethoscope over both sides of the boy’s chest.

  “Tube’s in position,” she said, exhaling heavily. “Let’s hyperventilate him for a few minutes.” Then she called out antibiotics to be given stat.

  Susan glanced at Luke for confirmation of the antibiotics order, and he returned a subtle nod, which he hoped Megan didn’t notice.

  Megan said to the X-ray technician, “We’re ready now.” She waved her arm in a circle as if directing the man through a busy intersection.