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 AND DEATH. MONEY 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 another pop, 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: EMERGENCY, 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.
13
Get 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 comprehension, 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 numbed the nerve endings. Toby heard a rush of escaping air and knew she was now in the chest cavity. She also knew she’d been correct; the bullet had punctured a lung, and with each breath Robbie took, air was leaking from the ruptured lung into the pleural space, building up enough pressure to shift the heart and great vessels, compressing whatever pulmonary tissue was still intact.
She slipped her finger through the incision to widen it, then slipped in the clear plastic chest tube. Val connected the other end to low-pressure suction. Immediately a stream of bright red shot 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—and fast.
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.
“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 Carey was a bastard, but right now she needed him. Robbie Brace needed him.
Toby nodded to the nurse-anesthetist. “Go ahead and intubate. We’ll get him prepped. Val, open that thoracotomy tray. . .”
As everyone scurried around the room in preparation, the anesthetist drew a dose of Etomidate into a syringe. The drug would rende
r Robbie fully unconscious for the intubation.
Toby loosened Robbie’s oxygen mask and saw that he was gazing up, his eyes focused desperately on hers. So many times before she had seen terror in a patient’s eyes and had forced herself to 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 trachea. 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—”
“Where 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 wail. “No. . .”
Toby reached for her arm and tri
ed 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.
“We 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 Robbie, 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. . .”