Sleight of Hand (43 page)

Before she could move forward to take it, Virginia plunged the needle into the large vein in her own forearm.  Again her finger hovered over the plunger.

"Prove it, Doctor," she said.  "Show me how important my life is to you.  How important is the life of my baby?"

"What do you want me to do?" Cassie asked.

Her eyes darted from Cassie to Drake and back again.  "You two make such a cute couple.  But I wonder how Detective Drake will feel about you, Dr. Hart, after you're branded a murderer."  

Before either of them could respond, Charlie's monitor began to alarm.

Cassie focused on the green lights tracing the boy's heartbeat.  "Ventricular tachycardia.  Get a code team here," she called out to Johnson.  "Damn it, what did you give him?"  She took another step toward Charlie.

"Come any closer and you'll be killing me and my unborn child in front of all these witnesses," Virginia said, her voice raised to carry out into the hallway where there was a crowd gathering.  "Our deaths will be on your head.  It's your choice: one life or two?"

Cassie looked at the unconscious child, his golden curls spread out on the pillow like an angel's halo.  Then she met the gaze of the monster who was his mother.  Would Virginia Ulrich do it?  Actually kill herself and her baby just to prove herself better than Cassie according to her warped brand of logic? 

Did it matter?  Charlie was her patient, he was the one she knew to be in immediate danger.  Was she really going to allow Virginia to manipulate her like this, with a little boy's life on the line? 

Maybe Cassie had lied when she told Virginia that she'd save her life.  Maybe she wasn't a good physician, maybe she didn't value all life as equal, because suddenly the choice was very clear and very easy to make.

"To hell with you," she muttered, lunging forward and pulling the IV line from Charlie's arm.  

Drake rushed past her, tackling Virginia.  He grabbed for Virginia's arm, shoving her away from Charlie and Cassie.  When they separated, Drake held the syringe.  Cassie stared in horror–it was empty, the plunger all the way down.

"My babies will always be with me," Virginia said, slumping against the wall.  "You'll never take them from me now."  

The pulse ox monitor blared as Charlie stopped breathing.  Cassie fumbled for the bag valve mask at the bedside and began to pump oxygen into the boy.  

"Potassium?" she shouted at Virginia, looking over her shoulder from where she worked on Charlie.  "Was that it?"

Virginia didn't answer.  Her eyes stared at Cassie with hatred.

"Bag that for evidence," Drake told Johnson, gingerly handing him the syringe, restraining Virginia with his other hand.  "What should I do?" he asked Cassie.

"Get me a crash cart," Cassie ordered.   "I need some help here!  And someone stat page  OB."  

Several of the bystanders pushed past the police officers to enter the room.  Two of the nurses went directly to Virginia.  They turned and glared at Cassie.  

"Check her pockets.  See if you can find out what she used," Cassie told Drake who looked on, helpless as Virginia Ulrich slumped, unconscious.  The nurses cradled her body, easing it to the floor and checked her vital signs.   They tried to push him away, but Drake ignored them as he  scoured Virginia's lab coat.

The pediatric code team and crash cart arrived, adding to the crush of people crowded into the small room.

"Get the adult team here with another crash cart," Cassie ordered just as Charlie's heart went into fibrillation.  "Someone start CPR on him.  I think it's potassium," she told the bewildered pediatric resident who'd responded to the code.

The nurses began CPR, sliding a board under the boy's back to support his body.  

"No pulse," someone announced, and Cassie saw that it was one of the nurses working on Virginia.  They quickly began chest compressions and mouth to mask ventilation on Charlie's mother.

This was turning into Cassie's worst nightmare.

The resident seemed stunned, so Cassie took charge.  As she worked on Charlie, she tried furiously to think about the effects of potassium on a fetus.  How much time would they have before the drugs in Virginia's system circulated into the baby inside her?

"Give me twenty of bicarb, twenty cc's of D50, and one unit of insulin," she snapped, grabbing the defibrillator paddles.  "Charge to twenty."  Cassie shocked the boy.  

"No response."

"She's got a lot of stuff in here."  Drake had several empty vials in his hands.  She heard the frustration in his voice but had no time to answer it.  Was his mother all right? the thought sped through her mind even as she considered the next step to treat her patient.  She looked down on the glistening vials Drake presented to her.  Succinylcholine, vecuronium, atropine and potassium chloride.  Enough to kill a small army.  Damn it, where was the adult team?

"Here's the bicarb and D50," the nurse handed Cassie the syringes, and she pushed the medications as the nurse drew up the epinephrine.  "There's no insulin on the crash cart, Megan went to get it."

"Give me some calcium and another twenty of bicarb.  Set up for intubation."  

Cassie looked over to Virginia's body.  There were so many people in the room that the two resuscitation teams were bumping into each other as they performed CPR on the woman.  

She took the defibrillation paddles again just as a nurse was reaching for them, presumably to use on Virginia.

"I need those."  

"So does her son," Cassie replied grimly.   

She shocked Charlie again. 
Come on, don't do this, don't die right here in front of me.  Damn it, you have to live.  After everything that's happened, you have to live!

CHAPTER 34

"Repeat epi and push ten of lidocaine," Cassie ordered.  "Charge to fifty and clear."  Another shock without response.  "Where the hell is that insulin?"  

The doorway jammed with people as the nurse with the insulin tried to get through at the same time as the adult code team arrived with another crash cart.

"Stop!" Cassie shouted.  This resuscitation was deteriorating into chaos.  

"Get her out of here," she indicated Virginia Ulrich.  "Take her to the treatment room where there's oxygen and a monitor.  And someone get that insulin in here!"  

The room became even more crowded momentarily as people surged forward to help carry Virginia's body out to the gurney waiting in the hallway.  Cassie noticed several of the Peds nurses crying as they saw Virginia, remaining with their friend rather than helping her with Charlie.  The police officers trailed out after their prisoner.  Except Drake.  He stayed with Cassie.

She felt as if she was finally able to breathe now that Virginia was gone and she had room to work on Charlie.  She gave the insulin, her eyes glued to the monitor.

Without being told to, Drake spelled the nurse giving CPR to Charlie.  His shoulders moved up and down in a steady rhythm, but his eyes never left Cassie's face.

"Hold CPR," she ordered.

Come on, come back, Charlie
, she prayed.    

They were rewarded with a definable heart rate on the monitor.  Cassie bit her lip.  "Pulse?" she asked, hoping for the right answer.  It seemed an eternity while the nurse palpated the carotid artery.

"Yes.  Faint, but it's there."

"Okay.   Let's get a complete set of vitals, hang an lidocaine drip and call the PICU to have a vent ready."  

She looked up at the clock.  It was hard to believe, but the elapsed time since Virginia Ulrich had poisoned her son was less than ten minutes.  That was the way with codes, it was like being in a time warp.  She could only pray that Charlie would pull through without serious brain damage from the hypoxia that occurred while his heart was stopped.

"Is he going to be all right?" Drake asked, his voice low.  One of his hands gently stroked Charlie's arm as if he were reassuring the unconscious boy.

"I wish to hell I knew."

<><><>

Cassie was helping the nurses move Charlie to the PICU when she heard her name called.

"Dr. Hart!"  It was the internal medicine resident who was in charge of Virginia's resuscitation.  He waved to her from the open door of the treatment room.  "We could use some help in here."

She wanted more than anything to pretend to not hear him, but she couldn't ignore the note of panic in his voice.  She sighed and allowed the pediatric resident and nurses to continue without her.

Virginia's resuscitation was going worse than Charlie's had.  For starters more people had crowded into the tiny room, but very few were actually working on the patient.  Cassie got to the doorway and had to push her way through the crowd to reach the patient.

"Everyone not touching the patient or a medication out!  Now!" she commanded.  "Drake, you don't let anyone in through that door unless I tell you."  He nodded and began to usher people out of the room.  Cassie could hear the snide comments directed at her, including several nurses who demanded to stay as witnesses to ensure Virginia's safety.

While Drake cleared the room, she conferred with the medical resident on what steps he'd already taken.  Virginia was in full arrest, the monitor showing a ventricular fibrillation, just as her son had experienced.  And Lord only knew what was going on with her unborn child.

Cassie grabbed a small doppler unit and tried to get fetal heart tones.  They were there, but definitely too fast and too faint.

"We're not going to mess around in here," she decided after a moment's assessment.  "Sally," she addressed the charge nurse.  "Call OB, tell them we'll be there in five minutes and they'd better have a crash C-section ready to go.  No excuses.  And get someone from the ICU up to OB with a hemofiltration unit, that's our only chance at this point."

Sally nodded and got on the phone while the other staff members scrambled to prepare the patient for transport.  Minutes later they were rolling down the hallway to the elevator that would take them up to Obstetrics.  Cassie tried to monitor the fetal heartbeat as they moved, but it was progressively slowing and becoming more difficult to pick up.  She lost it just as they arrived at the OB operating room.

"Get her prepped," Cassie told the nurses as the OB resident emerged from the nurses' station with a puzzled and angry look on his face.

"Are you the one who keeps paging me to Peds?" he asked angrily.  "I don't respond to codes down there–"  He stopped as he saw the patient.  "What the hell?"

"Potassium overdose, I just lost the baby's heart beat," Cassie snapped.  "They're sending a hemofiltration team up from the ICU.  I'll work on getting lines into the mom while you get the baby out."

The resident nodded and turned to a nurse.  "Right–call neonatal, we need a full team here, now!"  

He and Cassie rushed through a quick scrub.  Through the windows into the C-section room she could see the nurses still giving Virginia chest compressions while the OR crew prepared for the stat C-section.  

"How far along is she?" the resident asked.

"I don't know, anywhere from twenty-eight to thirty-six weeks."

"You realize that even if we get this baby out, he doesn't have a snowball's chance in hell," he told her as they entered the room.

"We have to try."  

The neonatology team arrived and began to frantically gather their equipment, including some whole blood, Cassie saw.  Smart thinking.  It was actually possible in newborns to use the umbilical vessels to exchange the infant's entire blood volume.  The old blood, with the dangerous levels of potassium would be exchanged for fresh blood.  It was a risky procedure, but probably the baby's best chance–if they could keep the baby alive long enough to undergo the exchange transfusion.

The room echoed with a cacophony of noise as each team tried to perform their job: the OB crew cutting the baby out, the neonatal team preparing to resuscitate it, while Cassie and the anesthesiologist, David Allman, tried to keep Virginia's heart pumping enough blood and oxygen to keep the baby alive.

Cassie, David, and his nurse developed a graceful pattern of pushing meds, defibrillating, and drawing up more meds.  Another nurse had climbed onto a stool beside the table, a sterile sheet over top of her while she performed chest compressions.  Cassie inserted a central venous line while David placed the arterial cannula and they started hemofiltration.  Several minutes later, when Cassie looked up again, she saw that the baby was out and that the neonatal team was hard at work.

She looked at the clock.  Virginia Ulrich had been in arrest for twenty-six minutes.

"Let's check a pulse." Cassie sighed.  She heard the failure in her voice.  David and his nurse looked at her.  David nodded to halt the chest compressions.  The room was silent as he held his fingers over the carotid artery.

"Nothing," he said.  "Should we call it?"

The OB resident nodded.  "She's gone."

Cassie agreed, they had done everything they could.  "Time of death–"

"Stop!"  A voice echoed into the tile-walled room.  Everyone turned to look.  "Dr. Hart, step away from that patient."

It was Karl Sterling, one hand holding a mask over his face, standing in the doorway of the OR.  Beside him, at the scrub sinks, were Paul Ulrich and his assistant, Scott Thayer.

"There's nothing more we can do for her," Cassie protested.  Ulrich turned away and Thayer paled as he looked through the window at the carnage in the operating room.

"I don't care.  You all proceed with the resuscitation until I've had a chance to review the chart," Sterling ordered.

David Allman looked at the Pediatric Chairman.  "Dr. Sterling, I'm in charge of any codes in my OR.  There's nothing more we can do for this patient.  Time of death is 1158."  He extended a hand to help the nurse down. 

Cassie looked over to where the neonatologists worked on the baby.  Things didn't sound very promising.  She turned to join them, see if she could help in any way, when Sterling grabbed her by the arm.

"Don't you dare touch that baby!"