She said: “I was just about to examine Mrs. Voss. She’s running a fever.”
“Yes, they told me about it.” Again there was a pause.
She plunged into that void, determined to keep their conversation purely professional. “I’ll do the usual fever workup,” she said. “I’ll examine her. Order a CBC and cultures, urine, and chest X ray. As soon as I have the results I’ll call you back.”
“All right,” he finally said. “I’ll be waiting for your call.”
Abby donned an isolation gown and stepped into Nina Voss’s cubicle. A single lamp had been left on, and it shone dimly above the bed. Under that soft cone of light, Nina Voss’s hair was a silvery streak across the pillow. Her eyelids were shut, her hands crossed over her body in a strange semblance of holy repose. The princess in the sepulchre, thought Abby.
She moved to the side of the bed and said softly: “Mrs. Voss?”
Nina opened her eyes. Slowly her gaze focused on Abby. “Yes?”
“I’m Dr. DiMatteo,” said Abby. “I’m one of the surgical residents.” She saw the flicker of recognition in the other woman’s eyes. She knows my name, thought Abby. She knows who I am. The grave robber. The body thief.
Nina Voss said nothing, merely looked at her with those fathomless eyes.
“You have a fever,” explained Abby. “We need to find out why. How are you feeling, Mrs. Voss?”
“I’m . . . tired. That’s all,” whispered Nina. “Just tired.”
“I’ll have to check your incision.” Abby turned up the lights and gently peeled the bandages off the chest wound. The incision looked clean, no redness, no swelling. She pulled out her stethoscope and moved on to the rest of the fever workup. She heard the normal rush of air in and out of the lungs. Felt the abdomen. Peered into the ears, nose, and throat. She found nothing alarming, nothing that would cause a fever. Through it all, Nina remained silent, her gaze following Abby’s every move.
At last Abby straightened and said: “Everything seems to be fine. But there must be a reason for the fever. We’ll be getting a chest X ray and collecting three different blood samples for cultures.” She smiled apologetically. “I’m afraid you’re not going to get much sleep tonight.”
Nina shook her head. “I don’t sleep much, anyway. All the dreams. So many dreams . . .”
“Bad dreams?”
Nina took in a breath, slowly let it out. “About the boy.”
“Which boy, Mrs. Voss?”
“This boy.” Softly she touched her hand to her chest. “They told me it was a boy’s. I don’t even know his name. Or how he died. All I know is, this was a boy’s.” She looked at Abby. “It was. Wasn’t it?”
Abby nodded. “That’s what I heard in the operating room.”
“You were there?”
“I assisted Dr. Hodell.”
A small smile formed on Nina’s lips. “Strange. That you should be there, after . . .” Her voice faded.
Neither one of them spoke for a moment, Abby silenced by guilt, Nina Voss by . . . what? The irony of this meeting? Abby dimmed the lights. Once again the cubicle took on its sepulchral gloom.
“Mrs. Voss,” said Abby. “What happened a few days ago. The other heart, the first heart . . .” She looked away, unable to meet the other woman’s gaze. “There was a boy. Seventeen. Boys that age, they want cars or girlfriends. But this boy, all he wanted was to go home. Nothing else, just to go home.” She sighed. “In the end, I couldn’t let it happen. I didn’t know you, Mrs. Voss. You weren’t the one lying in that bed. He was. And I had to make a choice.” She blinked, felt tears wet her lashes.
“He lived?”
“Yes. He lived.”
Nina nodded. Again she touched her own chest. She seemed to be conferring with her heart. Listening, communicating. She said, “This boy. This boy’s alive, too. I’m so aware of his heart. Every beat. Some people believe that the heart is where the soul lives. Maybe that’s what his parents believe. I think about them, too. And how hard it must be. I never had a son. I never had a child.” She closed her hand into a fist, pressed it against the bandages. “Don’t you think it would be a comfort, to know that some part of him is still alive? If it was my son, I’d want to know. I’d want to know.” She was crying now, the tears a sparkling trickle down her temple.
Abby reached for the woman’s hand and was startled by the force of Nina’s grasp, the skin feverish, the fingers tight with need. Nina was looking up at her, a gaze that seemed to shine with its own strange fire. If I had known you then, thought Abby, If I had watched you dying in one bed and Josh O’Day in another, which one of you would I have chosen?
I don’t know.
Above the bed, a line skipped across the green glow of the oscilloscope. The heart of an unknown boy, beating a hundred times a minute, pumping fevered blood through a stranger’s veins.
Abby, holding Nina’s hand, could feel the throb of a pulse. A slow, steady pulse.
Not Nina’s, but her own.
It took twenty minutes for the X-ray tech to arrive and shoot the portable chest film, and another fifteen minutes before Abby had the developed X ray in hand. She clipped it to the SICU viewing box and examined it for signs of pneumonia. She saw none.
It was three A.M. She called Aaron Levi’s house.
Aaron’s wife answered, her voice husky with sleep. “Hello?”
“Elaine, this is Abby DiMatteo. I’m sorry to bother you at this hour. May I speak with Aaron?”
“He left for the hospital.”
“How long ago?”
“Uh . . . it was just after the second phone call. Isn’t he there?”
“I haven’t seen him,” said Abby.
There was a silence on the other end of the line. “He left home an hour ago,” said Elaine. “He should be there.”
“I’ll page his beeper. Don’t worry about it, Elaine.” Abby hung up, then dialed Aaron’s beeper and waited for the phone to ring.
By three-fifteen, he still hadn’t answered.
“Dr. D.?” said Sheila, Nina Voss’s nurse. “The last blood culture’s been drawn. Is there anything else you want to order?”
What have I missed? thought Abby. She leaned forward against the desk and massaged her temples, struggling to stay awake. Think. A postop fever. Where was the infection coming from? What had she overlooked?
“What about the organ?” said Sheila.
Abby looked up. “The heart?”
“It was just something that occurred to me. But I guess it’s not very likely . . .”
“What are you thinking, Sheila?”
The nurse hesitated. “I’ve never seen it happen here. But before I came to Bayside, I used to work with a renal transplant service in Mayo. I remember we had this patient. A kidney recipient with postop fevers. We didn’t figure out what his infection was until after he died. It turned out to be fungal. Later they tracked down the donor record and found out the donor’s blood cultures were positive, but the results didn’t come back until a week after the kidney was harvested. By then it was too late for the recipient. Our patient.”
Abby thought it over for a moment. She looked at the bank of monitors, at the heart tracing of Bed 15 dancing across the screen.
“Where’s the donor information kept?” asked Abby.
“It would be in the transplant coordinator’s office downstairs. The nursing supervisor has the key.”
“Could you ask her to get the file for me?”
Abby reopened Nina Voss’s chart. She turned to the New England Organ Bank donor form—the sheet that had accompanied the heart from Vermont. Recorded there was the ABO blood type, HIV status, syphilis antibody titers, and a long list of other lab screens for various viral infections. The donor was not identified.
Fifteen minutes later, the phone rang. It was the nursing supervisor, calling for Abby.
“I can’t find the donor file,” she said.
“Isn’t it under Nina Voss’s name?”
> “They’re filed under the recipient’s medical record number. There’s nothing here under Mrs. Voss’s number.”
“Could it be misfiled?”
“I’ve looked in all the kidney and liver transplant files too. And I double-checked that record number. Are you sure it isn’t somewhere up in the SICU?”
“I’ll ask them to look. Thanks.” Abby hung up and sighed. Missing paperwork. It was the last thing she felt like dealing with at this time of the morning. She looked at the SICU records shelf, where files from current patients’ previous hospitalizations were kept. If the missing file was buried somewhere in that, she could be searching for an hour.
Or she could call the donor hospital directly. They could pull the record, tell her the donor’s medical history and lab tests.
Directory assistance gave her the number for Wilcox Memorial. She dialed the number and asked for the nursing supervisor.
A moment later a woman answered: “Gail DeLeon speaking.”
“This is Dr. DiMatteo calling from Bayside Hospital in Boston,” said Abby. “We have a heart transplant recipient here who’s running a postop fever. We know the donor heart came from your OR. I need a little more information on the donor’s medical history. I wonder if you might know the patient’s name.”
“The organ harvest was done here?”
“Yes. Three days ago. The donor was a boy. An adolescent.”
“Let me check the OR log. I’ll call you back.”
Ten minutes later, she did—not with an answer but with a question: “Are you sure you have the right hospital, doctor?”
Abby glanced down at Nina’s chart. “It says right here. Donor hospital was Wilcox Memorial. Burlington, Vermont.”
“Well, that’s us. But I don’t see a harvest on the log.”
“Can you check your OR schedule? The date would have been . . .” Abby looked at the form. “September twenty-fourth. The harvest would’ve been done sometime around midnight.”
“Hold on.”
Over the receiver, Abby heard the sound of turning pages and the nurse’s intermittent throat clearing. The voice came back. “Hello?”
“I’m here,” said Abby.
“I’ve checked the schedule for September twenty-third, twenty-fourth, and twenty-fifth. There are a couple of appendectomies, a cholecystectomy, and two cesareans. But there’s no organ harvest anywhere.”
“There has to be. We got the heart.”
“We’re not the ones who sent it.”
Abby scanned the OR nurses’ notes and saw the notation: 0105: Dr. Leonard Mapes arrived from Wilcox Memorial. She said, “One of the surgeons who scrubbed on the harvest was Dr. Leonard Mapes. That’s the same guy who delivered it.”
“We don’t have any Dr. Mapes on our staff.”
“He’s a thoracic surgeon—”
“Look, there’s no Dr. Mapes here. In fact, I don’t know of any Dr. Mapes practicing anywhere in Burlington. I don’t know where you’re getting your info, doctor, but it’s obviously wrong. Maybe you should check again.”
“But—”
“Try another hospital.”
Slowly Abby hung up.
For a long time she sat staring at the phone. She thought about Victor Voss and his money, about all the things that money could buy. She thought about the amazing confluence of events that had granted Nina Voss a new heart. A matched heart.
She reached, once again, for the telephone.
9
“You’re overreacting,” said Mark, flipping through Nina Voss’s SICU chart. “There has to be a reasonable explanation for all of this.”
“I’d like to know what it is,” said Abby.
“It was a good excision. The heart came packed right, delivered right. And there were donor papers.”
“Which now seem to be missing.”
“The transplant coordinator will be in at nine. We can ask her about the papers then. I’m sure they’re around somewhere.”
“Mark, there’s one more thing. I called the donor hospital. There’s no surgeon named Leonard Mapes practicing there. In fact, there’s no such surgeon practicing in Burlington.” She paused. Softly she said, “Do we really know where that heart came from?”
Mark said nothing. He seemed too dazed, too tired to be thinking straight. It was four-fifteen. After Abby’s phone call, he’d dragged himself out of bed and driven to Bayside. Postop fevers required immediate attention, and although he trusted Abby’s findings, he had wanted to see the patient for himself. Now Mark sat in the gloom of the SICU, struggling to make sense of the paperwork in Nina Voss’s chart. A bank of heart monitors faced him on the countertop, and three bright green lines traced across the reflection in his glasses. In the semidarkness nurses moved like shadows and spoke in hushed voices.
Mark closed the chart. Sighing, he pulled off his glasses and rubbed his eyes. “This fever. What the hell is causing the fever? That’s what really concerns me.”
“Could it be an infection passed from the donor?”
“Unlikely. I’ve never seen it happen with a heart.”
“But we don’t know anything about the donor. Or his medical history. We don’t even know which hospital that heart came from.”
“Abby, you’re going off the deep end here. I know Archer spoke on the phone to the harvesting surgeon. I also know there were papers. They came in this brown envelope.”
“I remember seeing it.”
“All right. Then we saw the same thing.”
“Where’s the envelope now?”
“Hey, I was the one operating, OK? I’m up to my elbows in blood. I can’t keep track of some goddamn envelope.”
“Why is there all this secrecy about the donor, anyway? We don’t have records. We don’t know his name.”
“That’s standard procedure. Donor records are confidential. They’re always kept separate from the recipient’s chart. Otherwise you’d have families contacting each other. The donor side would expect undying gratitude, the recipient side would either resent it or feel guilty. It leads to one giant emotional mess.” He sank back in his chair. “We’re wasting time on this issue. It’ll all be resolved in a few hours. So let’s concentrate on the fever.”
“All right. But if there’s any question about this, New England Organ Bank wants to discuss it with you.”
“How did NEOB get involved?”
“I called them. They have this twenty-four-hour line. I told them you or Archer would get back to them.”
“Archer can handle it. He’ll be here any minute.”
“He’s coming in?”
“He’s worried about the fever. And we can’t seem to get hold of Aaron. Have you paged him again?”
“Three times. No answer. Elaine told me he was driving in.”
“Well, I know he got here. I just saw his car down in the parking lot. Maybe he got busy on the medical floor.” Mark flipped through Nina Voss’s chart to the order sheets. “I’m going to move on this without him.”
Abby glanced toward Nina Voss’s cubicle. The patient’s eyes were closed, her chest rising and falling with the gentle rhythm of sleep.
“I’m starting antibiotics,” said Mark. “Broad-spectrum.”
“What infection are you treating?”
“I don’t know. It’s just a temporary bridge until the cultures come back. As immunosuppressed as she is, we can’t take a chance she’s infected somewhere.” In frustration, Mark rose from the chair and walked over to the cubicle window. He stood there a moment, staring in at Nina Voss. The sight of her seemed to calm him. Abby came to stand beside him. They were very close, almost touching each other, and yet separated by the gulf of this crisis. On the other side of the window, Nina Voss slept peacefully.
“It could be a drug reaction,” said Abby. “She’s on so many things. Any one of them could cause a fever.”
“That’s a possibility. But not likely on steroids and cyclosporine.”
“I couldn’t find any s
ource of infection. Anywhere.”
“She’s immunosuppressed. We miss something, she’s dead.” He turned to pick up the chart. “I’m starting the bug juice.”
At six A.M. the first dose of IV Azactam was dripping into Nina’s vein. A stat infectious disease consult was requested, and at seven-fifteen the consultant, Dr. Moore, arrived. He concurred with Mark’s decision. A fever in an immunosuppressed patient was too dangerous to go untreated.
At eight o’clock, a second antibiotic, piperacillin, was infused.
By then Abby was making morning SICU rounds, her wheeled cart piled six-deep with charts. It had been a bad call night—just one hour of sleep before that two A.M. phone call, and not a moment’s rest since then. Fueled by two cups of coffee and a view of the end in sight, she pushed her cart along the row of cubicles, thinking: Four hours and I’m out of here. Only four more hours until noon. She passed by Bed 15, and she glanced through the cubicle window.
Nina was awake. She saw Abby and weakly managed a beckoning wave.
Abby left her charts by the door, donned an isolation gown, and stepped into the cubicle.
“Good morning, Dr. DiMatteo,” murmured Nina. “I’m afraid you didn’t get much sleep because of me.”
Abby smiled. “That’s okay. I slept last week. How are you feeling?”
“Like quite the center of attention.” Nina glanced up at the bottle of IV antibiotics hanging over the bed. “Is that the cure?”
“We hope so. You’re getting a combination of piperacillin and Azactam. Broad-spectrum antibiotics. If you have an infection, that should take care of it.”
“And if this isn’t an infection?”
“Then the fever won’t respond. And we’ll try something else.”
“So you don’t really know what’s causing this.”
Abby paused. “No,” she admitted. “We don’t. It’s more of an educated shot in the dark.”
Nina nodded. “I thought you’d tell the truth. Dr. Archer wouldn’t, you know. He was here this morning, and he kept telling me not to worry. That everything was taken care of. He never admitted he didn’t know.” Nina gave a soft laugh, as though the fever, the antibiotics, all these tubes and machines were part of some whimsical illusion.