Life Support (22 page)

Witnesses in the hallway saw him dive headfirst through window. He was found in the parking lot, unresponsive and bleeding from multiple lacerations.

After being intubated and stabilized in the ER, patient was admitted to trauma service with multiple skull fractures as well as probable spinal compression fractures....

The physical exam had been recorded in typically terse surgical style, a rapid rundown of the patient's injuries and neurologic findings.

Lacerated scalp and face. Open fractures of the parietal and coronal bones with extrusion of gray matter. A blown pupil on the right. No spontaneous respirations, no response to painful stimuli. The patient's injuries, thought Brace, were consistent with a headfirst landing in the parking lot.

Flipping further, he saw the surgeon's note, "X-ray report, spinal compression fractures C6, C7, T8. That too, indicated a headfirst landing with the force of the fall transmitted straight down the spinal column.

Stanley Mackie's hospital course was a weeklong deterioration of multiple organ systems. Comatose and on a ventilator, he never reawakened. First his kidneys shut down, probably due to the shock of his injuries. Then he developed pneumonia and his BP dropped out tsvice, causing a bowel infarct. Finally, seven days alter his plunge through the fourth-story window, his heart went into arrest.

He flipped to the back of the chart, where the lab results were filed.

There were seven days' worth of computer printouts, a running log of electrolytes and blood chemistries, cell counts, and urinalyses. He kept turning pages, scanning thousands of dollars' worth of lab tests done on a man whose death had been, from the very first day, inevitable.

He paused at a lab report marked, Pathology.

Liver (postmortem), Gross appearance, Weight, 1600 gin pale, pinpoint surface areas of acute hemorrhage. No evidence chronic fibrotic changes.

Microscopic, On H and E stain, there are scattered areas of poorly stained mummified hepatocytes. This is consistent with focal coagulative necrosis, probably secondary to ischemia.

Brace turned the page and found a blood count report, out of sequence.

He turned another page, and found himself staring at the back cover.

There were no pages left.

He flipped toward the front of the record, searching for other postmortem reports, but could find only the page describing the liver.

This didn't make sense. Why would Pathology do a postmortem on a single organ? Where were the reports for lungs, the heart, the brain?

He asked at the desk if there were more files for Stanley Mackie.

"That's the only one," said the clerk.

"But some of the Pathology reports are missing."

"You can check directly with Path. They keep copies of all their reports."

The Pathology Department, located in the basement, was a lowceilinged warren of rooms, the walls painted white and decorated with lushly photographed travel posters. Mist over the Serengeti. A rainbow arching above Kauai. An island of mangroves in a turquoiSe sea. A radio was playing soft rock music. The lone technician at work in that room seemed absurdly cheerful, considering the nature of her job. She herself was another bright splash of color, with rouged cheeks and eyelids powdered a sparkly green.

"I'm trying to locate an autopsy report done back in March," said Brace. "It's not in the patient's file. Medical Records suggested I check with you."

"What was the patient's name?"

"Stanley Mackie."

The technician shook her head as she crossed to a filing cabinet. "He was such a nice man. We all felt awful about that."

"You knew him?"

"The surgeons always come down to check path reports on their patients.

We got to know Dr. Mackie pretty well." She pulled open a drawer and began thumbing through files. "He bought us our department coffeemaker for Christmas. We call it the Mackie Memorial Mr. Coffee." She straightened and stood frowning at the open drawer. "That's frustrating."

"What?"

"I can't find it." She closed the drawer. "I'm sure an autopsy was done on Dr. Mackie."

"Could it be misfiled? Under S for Stanley?"

She opened a different drawer, searched the files, then closed it again. She turned as another technician entered the lab. "Hey, Tim, have you seen the autopsy report for Dr. Mackie?"

"Wasn't that done way back?"

"It was early this year."

"Then it should still be in the files." He set a tray of slides on the countertop. "Try checking Herman."

"Why didn't I think of Herman?" she sighed, and crossed the lab into one of the offices.

Brace followed her. "Who's Herman?"

"He's not a who but a what." She flipped on the lights, revealing a desk with a personal computer. "That's Herman. It's Dr. Seibert's pet project."

"What does Herman do?"

"He�it�is supposed to make retrospective studies a snap. Say you want to know how many perinatal deaths involved mothers who smoked. You type in the keywords smoker and perinatal and you'll get a list of relevant patients who've been autopsied."

"So all your autopsy data's in there?"

"Some of it. Dr. Seibert started inputting our data only two months ago. He's a long way from finishing." She sat down at the keyboard, typed in the name Mackie, Stanley, and clicked on Search.

A new screen appeared with identifying data. It was Stanley Mackie's autopsy report.

The technician vacated the seat. "It's all yours."

Brace sat down in front of the computer. According to the data on the screen, this report had been input six weeks ago, the actual file must have been lost since then. He hit Page Down and began to read.

The report described the body's gross appearance at postmortem, the multiple IV lines, the shaved head, the incision marks on the scalp left by the neurosurgeon's blade. The report continued with a description of the internal organs. The lungs were congested and swollen with inflammation. The heart showed a fresh infarct. The brain had multiple areas of hemorrhage. The findings at gross examination were consistent with the surgeons' diagnosis, massive head trauma with bilateral pneumonia. The fresh myocardial infarct had probably been the terminal event.

He clicked to the microscopic reports and found a summary of the same page he'd seen in the medical record, describing the liver. In addition there were reports that had not appeared in the medical record�microscopics of the liver, the heart, the lungs. No surprises, he thought. The man fell headfirst onto the pavement, he crushed his skull, and the neurologic trauma led to multiple organ failure.

He clicked to the microscopic report on the brain, and his eyes suddenly focused on a sentence buried within the description of traumatic injuries, ". . . variable vacuolation in the background neuropil. Some neuronal loss and reactive astrocytosis with kuru plaques, Congo-red positive, as seen in cerebellar sections."

At once he clicked to the last page and his gaze flew down to the final diagnoses, 1. Multiple intracerebral hemorrhages secondary to trauma. 2.

Preexisting Creutzfeldt-Jakob disease.

In the parking lot, Robbie Brace sat in his car, wondering what he should do next. Whether he should do anything next. He weighed all the possible consequences of his actions. This would be a devastating blow to Brant Hill's reputation. Surely the media would pick this up, and there'd be screaming headlines, RITZ AN DEATH. MoNEwf BuYs MAD Cow DISEASE.

He'd be out of a job.

You can't stay silent, man. Toby Harper is right. We have a deadly outbreak on our hands, and we don't know the source. The hormone injections? The food?

He reached under the seat for his cellular phone. He was still carrying Toby Harper's card, he punched in her home phone number.

A woman answered, "Harper residence."

"This is Dr. Brace from Brant Hill. May I speak to Toby Harper?"

"She's not here, but I can take a message. What's your number?"

"I'm in my car right now. Just tell her she was right. Tell her we've got a second case of CJD."

"Excuse me?"

"She'll know what it means." Headlights flickered in his rearview mirror. He turned and saw that a car was slowly moving along the next row. "What time's she getting home?" he asked.

"She's at work right now�"

"Oh. Then I'll swing by Springer Hospital. Never mind about the message." He disconnected, slid the phone under the seat, and started the car. As he pulled out of the driveway, he noticed those same headlights moving toward the parking lot exit. He quickly lost sight of them in the busy flow of traffic.

It was a half hour drive to Springer Hospital. By the time he turned into the parking lot, he'd developed a headache from hunger. He pulled into a stall in the visitors area. With the engine off, he sat for a moment in his car, massaging his temples. It was just a mild headache, but it reminded him he hadn't eaten since breakfast. He'd stay only a few minutes, just long enough to tell her what he'd learned, and then he'd let her carry the ball from there. All he wanted to do now was go home, eat supper. Play with his little girl.

He climbed out of the car, locked it, and started toward the ER entrance. He'd taken only a few steps when he heard the growl of a car behind him. Turning, he squinted at the slowly approaching headlights.

The car came to a stop beside him. He heard the electric hum of the driver's window as it rolled down.

A man with hair so blond it looked silvery under the parking lot light smiled at him. "I think I'm lost."

"Where you trying to get to?" asked Brace.

"Irving Street."

"You're nowhere near it." Brace took a step toward the open car window.

"You'll have to go back out to the road, turn right, and drive about four or five�" The pop, pop took him by surprise. So did the punch in the chest.

Brace jerked away, startled by the unprovoked blow. He touched his hand to his chest, where the pain was just beginning to assert itself, and found he could not draw in a deep breath. Warmth seeped from his shirt and dribbled onto his fingers. He looked down and saw that his hand was wet and glistening with dark liquid.

There was anotherpop, another punch in the chest.

Brace staggered. He tried to regain his footing, but his legs seemed to fold up beneath him. He dropped to his knees and saw the streetlamp begin to waver like water.

The last bullet slammed into his back.

He collapsed with his face pressed against the cold pavement, the gravel biting into his cheek. The car drove off, the purr of its engine fading into the night. He could feel his life spilling away in a hot stream. He pressed his hand to his chest, trying to stanch the flow, but the strength had left his arm. All he could manage was a feeble clasp.

God, not here, he thought. Not now.

He began to crawl toward the ER doors, at the same time trying to maintain pressure on his chest wound, but with every beat of his heart, he felt more heat gush out. He tried to keep his gaze fixed on the sign, EMERGENCt brightly lit in red, but his vision kept going out of focus, and the word began to waver like seeping blood.

The glass doors of the ER were straight ahead. Suddenly a figure appeared from that warm rectangle of light. It came to a halt only a few feet away. Desperately Brace reached out and whispered, "Help me.

Please."

He heard the woman yell "There's a man bleeding out here! I need assistance STAT!"

And then he heard footsteps running toward him.

G, et a third IV in!" yelled Toby. "Sixteen gauge! Ringer's lactate, wide open�"

"Lab says O-negative blood's on its way."

"Where the hell is Carey?"

"He was just in the hospital," said Maudeen. "I'll page him again."

Toby pulled on a pair of sterile gloves and reached for the scalpel.

Under the bright trauma room lights, Brace's face was glistening with sweat and fear. He stared up at her, his eyes wide above the hissing oxygen mask, his breaths coming in short, desperate puffs. The bandage over his chest was slowly seeping with red again. A nurse-anesthetist, called down from the obstetrics ward, was already preparing to intubate.

"Robbie, I'm going to put in a chest tube," said Toby. "You're getting a tension pneumothorax." She saw him give a quick nod of comprehensionX saw his jaw tighten in anticipation of more pain. But he didn't even flinch as her blade sliced through the skin above his rib, a subcutaneous injection of Xylocaine had already numbedCarey was a bastard, but right now she needed him. Robbie Brace the nerve endings. Toby heard a rush of escaping air and knew sheneeded him.

was now in the chest cavity. She also knew she'd been correct, theToby nodded to the nurse-anesthetist. "do ahead and intubate.

bullet had punctured a lung, and with each breath Robbie took, airWe'll get him prepped. Val, open that thoracotomy tray . . ."

was leaking from the ruptured lung into the pleural space, buildingAs everyone scurried around the room in preparation, the anesup enough pressure to shift the heart and great vessels, compress-thetist drew a dose of Etomidate into a syringe. The drug would ing whatever pulmonary tissue was still intact. render Robbie fully unconscious for the intubation.

She slipped her finger through the incision to widen it, thenToby loosened Robbie's oxygen mask and saw that he was gazslipped in the clear plastic chest tube. Val connected the other ending up, his eyes focused desperately on hers. So many times before to low-pressure suction. Immediately a stream of bright red shot|she had seen terror in a patient's eyes and had forced herself to into the tube and collected in the drain reservoir.

Toby and Val glanced at each other, both of them sharing the same thought, He's bleeding into his chest�andfast.

She looked at Robbie s face and saw he was watching her, that he'd registered her look of dismay.

"It's . . . not good," he whispered.

She squeezed his shoulder. "You're doing fine, Robbie. The surgeon'll be here any minute."

"Cold. Feel so cold . . ."

Maudeen threw a blanket over him.

"Where's that O-neg blood?" called Toby.