Life Support (23 page)

"Just arrived. I'll hang it now�"

"Toby," whispered Val. Systolic's down to eighty-five."

"Come on, come on. Let's pour in that blood!"

The door sprang open and Doug Carey walked it. "What've you got here?" he snapped.

"Gunshot wounds to chest and back," said Toby. "Three bullets show up on X ray, but I counted four entry holes. Tension pneumothorax.

And that"�she pointed to the chest tube reservoir, where 100 cc's of blood had already accumulated�"that's just in the last few minutes. Systolic's slipping."

Carey glanced at the X ray hanging on the light box. "Let's crack the chest," he said.

"We'd need a full cardiac team�maybe bypass�"

"Can't wait. Have to stop the bleeding now." He looked straight at Toby, and she felt the old dislike welling up inside her. Doug suppress her own emotions, to concentrate on her job. This time, though, she could not ignore the fear in her patient's eyes. This was a man she knew, a man she'd grown to like.

"Everything will be all right," she said. "You have to believe me. I won't let anything go wrong." Gently she cradled his face between her hands and smiled.

"Counting . . . on you . . . Harper," he murmured.

She nodded. "You do that, Robbie. Now, are you ready to go to sleep?"

"Wake me . . . when it's over . . ."

"It'll seem like no time at all." She nodded to the anesthetist, who injected the Etomidate into the IV line. "Go to sleep, Robbie. That's it. I'll be right here when you wake up . . ."

His gaze remained focused on her. She would be the last image he'd register, the last face he'd see. She watched as consciousness faded from his eyes, as his muscles slowly went slack and his eyelids drifted shut.

I won't let anything go wrong.

She removed the oxygen mask. At once the anesthetist tipped Robbie's head back and slid the laryngoscope blade into the throat. It took her only seconds to identify the vocal cords, to thread the ET tube into the tr chea. Then the oxygen was connected and the tube taped into place.

The ventilator would take over now, breathing for him, forcing into his lungs a precise mixture of oxygen and halothane.

I won't let anything go wrong Toby released a tense breath of her own. Then she quickly gowned up. She knew they were breaking sterile conditions left and right, but it couldn't be helped. No time to scrub�she snapped on gloves and moved to the table.

She stood right across from Doug Carey. The patient's chest had been hastily painted with Betadine and sterile drapes were laid over the operative site.

Carey made his incision, a single clean slice down the sternum. There was no time to be elegant, the blood pressure was falling� down to seventy systolic with three big-bore IVs pouring in saline and whole blood. Toby had witnessed emergency thoracotomies before, and the brutality of it never failed to appall her. She watched with a twinge of nausea as Carey wielded the saw, as the sternum was split in a mist of bone dust and flying blood.

"Shit," said Carey, looking into the chest cavity. "There's at least a liter of blood in here. Suction! Hand me some sterile towels!"

The gurgle of the suction catheter was so loud Toby could barely hear the beep-beep of Robbie's heartbeat on the cardiac monitor. As Val suctioned, Maudeen ripped open the sterile seal on a bundle of towels.

Carey stuffed one into the chest cavity. When he pulled it out, it was sopping red. He tossed it on the floor, thrust in another towel. Again it came out soaked with blood.

"Okay. Okay, I think I see where it's coming from. Looks like the ascending aorta�leaking fast. Toby, I need more exposure . . ."

The suction catheter was still gurgling. Though most of the blood had been cleared out, a steady stream of it was spilling out of the aorta.

"I don't see a bullet," said Carey. He glanced at the X ray, then stared into the open chest. "There's the leak, but where's the fucking bullet?"

"Can't you just patch it?"

"It could still be lodged somewhere in the aortic wall. We patch and close, another hole could rip open later." He reached for the needle clamp and sutures. "Okay, let's shut off this leak first. Then we'll look around . . ."

Toby retracted the lung while Carey worked. He sewed quickly, his suture needle nipping in and out of the aortic wall. As he tied off and the bleeding stopped, everyone in the room gave a simultaneous sigh of relief "BP?" he called out.

"Holding at seventy-five," said Val.

"Keep that O-neg going in. We got more units?"

"On the way."

"Okay." Carey took a breath. "Let's see what else we got in here . . ."

He suctioned off the pooled blood, clearing the field for easier inspection. Then, gently applying traction for a better view, he took a sponge and dabbed along the aorta.

Suddenly his hands froze. "Fuck," he said. "The bullet�"

"What?"

"It's right here! It's almost through the opposite wall!" He started to withdraw his hand.

A fountain of blood suddenly exploded upward, splattering them both in the face.

"No!" cried Toby.

Panicked, Carey grabbed a clamp off the tray and reached in through the rushing blood, but he was working blind, groping in a shimmering sea of red. It spilled out of the thorax and soaked into Toby's gown.

"Can't stop it�feels like he's got a rip along the whole fucking wall�"

"Clamp it! Can't you clamp it?"

"Clamp what? The aorta's shredded�" The cardiac monitor squealed.

The anesthetist said, "Asystole! We've got asystole!"

Toby's gaze shot to the screen. The heart tracing had gone flat.

She reached into that hot pool of blood and grasped the heart. She squeezed, once, twice, her hand taking over for Robbie's heartbeat.

"Don't!" said Carey. "You're only making him bleed out!"

"He's in arrest�"

"You can't change that."

"Then what the fuck do we do?

The monitor was still squealing. Carey looked down at the open chest At the glistening pool of red. Since Toby had ceased cardiac massage, the fountaining had stopped. There was only the slow drip, drip of blood spilling out of the open thorax onto the floor.

"It's over," he said. Quietly he stepped away from the body. His gown was saturated to the waist. "There was nothing to sew up, Toby. The whole aorta was dissecting. It just blew apart."

Toby looked at Robbie's face. His eyelids were partly open, his jaw slack. The ventilator was still cycling, automatically blowing air into a dead body.

The anesthetist flipped off the switch. Silence fell over the room.

Toby lay her hand on Robbie's shoulder. Through the sterile drapes, his flesh felt solid, and still warm.

I won't let anything go wrong.

"I'm sorry," she whispered. "I'm so sorry . . ."

The police showed up before Robbie's wife did. Within minutes of their arrival, the first two patrolmen had secured the crime scene and were busy cordoning off half the parking lot. By the time Greta Brace hurried into the ER, the parking lot was already awash in the flashing lights of half a dozen police cars from both the Newton and the Boston PD. Toby was standing by the front desk talking to one of the detectives when she spotted Greta stepping through the ER doors, her red hair in windblown disarray. The waiting area was filled with cops, plus a few bewildered ER patients, and Greta sobbed and cursed as she pushed her way across the room.

"Where is he?" she cried.

Toby broke off her conversation with the detective and crossed toward Greta. "I'm so sorry�" aWhere is he?"

"He's still in the trauma room. Greta, no! Don't go back there yet.

Give us some time to�"

"He's my husband. I have to see him."

"Greta�" But the other woman pushed past her and headed into the treatment area with Toby in pursuit. Greta didn't know which way to go, she zigzagged back and forth, frantically searching the rooms.

At last she spotted the door labeled, TRAUMA. She pushed straight into the room.

Toby was right behind her. Dr. Daniel Dvorak, gowned and gloved, looked up from the body as the two women entered. Robbie lay undraped, his chest gaping open, his face slack with death.

"No," said Greta, and her voice rose from a moan to a high, keening wall. "No . . ."

Toby reached for her arm and tried to lead her out of the room, but Greta shook her off and stumbled to her husband's side. She cradled his face in her hands, kissed his eyes, his forehead. The ET tube was still in place, the tip of it protruding from his mouth. She tried to unpeel the tape, to remove the offending piece of plastic.

Daniel Dvorak put his hand on hers to stop her. "I'm sorry," he said quietly. "It has to remain."

"I want this thing out of my husband's throat!"

"It has to stay for now. I'll remove it when I finish my exam."

"Who the fuck are you?"

"I'm the medical examiner. Dr. Dvorak." He looked at the homicide detective, who'd just stepped into the trauma room.

"Mrs. Brace?" said the cop. "I'm Detective Sheehan. Why don't you and I go someplace quiet. Where we can sit down."

Greta didn't move. She stood murmuring softly, cradling Robbie's face in her hands, her expression hidden behind that fountain of red hair.

aWe need your help, Mrs. Brace, to find out what happened." Gently the cop touched her shoulder. "Let's go sit in another room. Where we can talk."

At last she allowed herself to be led away from the table. At the doorway she halted and looked at her husband.

"I'll be right back, Robbie," she said. Then she walked slowly out of the room.

Toby and Dvorak were left alone. "I didn't realize you were here," she said.

"I arrived about ten minutes ago. With so many people out there, you probably missed me in the crowd."

She looked at Robbiefl wondering if his flesh was still warm. "I wish we could just shut down the ER. I wish I could go home. But patients keep walking in. With their stomachaches and their sniffles.

And their goddamn piddly complaints..." Her vision suddenly blurred with tears. She wiped her face and turned toward the door.

"Toby?"

She halted, not answering. Not looking back.

"I need to talk to you. About what happened tonight."

"I've already spoken to half a dozen cops. No one on the staff saw what happened. We found him in the parking lot. He was crawling toward the building . . ."

"Do you agree with Dr. Carey that death resulted from aortic exsanguination? " She took a breath and reluctantly turned to face him. "Whatever Dr. Carey says."

"What do you remember about the surgery?"

"There was . . . a small nick in the aorta. He patched it up. But then we saw the bullet . . . had passed through . . . there was an intimal tear. An aortic dissection. Then the wall blew open . . ." She swallowed and looked away. "It was a nightmare."

He said nothing.

"I knew him," she whispered. "I'd been to his house. I'd met his wife.

Oh Jesus. " She pushed out of the room.

The only refuge she could find was the doctor's sleeping quarters.

She closed the door behind her and sat down on the bed, crying, rocking back and forth. She didn't even hear the knock on the door.

Dvorak came quietly into the room. He'd stripped off the gown and gloves, and now he stood by the bed, unsure of what to say.

"Are you all right?" he finally asked.

"No. I am not all right."

"I'm sorry about the questions. I had to ask them."

"You were so fucking cold-blooded about it."

"I needed to know, Toby. We can't help Dr. Brace, not now. But we can find the answers. We owe it to him."

She dropped her face in her hands and struggled to regain control, to stop crying. Her tears felt all the more humiliating because he was standing there, watching her. She heard the chair give a squeak as he sat down. When at last she managed to raise her head, she found herself looking straight into his eyes.

"I didn't realize you and the victim were acquainted," he said.

"He's not the 2^ictim. His name was Robbie."

"Okay. Robbie." He hesitated. "Were you good friends?"

"No. Not . . . not good friends."

"You seem to be taking this pretty hard."

"And you don't understand. Do you?"

"Not entirely."

She took a breath and slowly released it. "It catches up with us, you know. Most of the time, when we lose a patient, we can deal with it.

Then there'll be a child. Or someone we know. And suddenly we realize we can't handle it at all . . ." She wiped her hand across her eyes. "I have to get back to work. There must be patients waiting out there�" He grasped her hand. "Toby, if it makes a difference to you, I don't think there's anything you could have done to save him. The damage to his aorta was devastating."

She looked down at his hand, feeling faintly surprised that he was still touching her. He, too, seemed taken aback by that spontaneous contact, and he quickly released her wrist. They sat in silence for a moment.

"This hits too close to home," she said. Hugging herself, she found her gaze drawn, once again, to his. "I walk through that parking lot every evening. So do all the nurses. If this was a robbery attempt, any one of us would have made an easier target."

"Have there been other attacks at Springer?"

"Only one I can think of. A few years ago�a nurse was raped. But this isn't like downtown Boston. We don't worry about our safety here."

"Monsters live in the suburbs too."

The knock on the door startled them both. Toby opened the door to find Detective Sheehan.

"Dr. Harper, I need to ask you a few questions," he said and stepped inside, shutting the door behind him. The room suddenly seemed very crowded. "I just spoke to Mrs. Brace. She thinks her husband might have come here to see you."

Toby shook her head. "Why?"

"That's what we're wondering. He called her around six-thirty and told her he was driving to Wicklin Hospital, and that he'd be home late."

"Did he go to Wicklin?"

"We're checking that now. What we don't know is why he ended up here.