On the monitor, the tracing shot up, then slid back to a rapid sinus tachycardia. Both Claire and the EMT released loud sighs of relief.
“That rhythm’s not going to hold,” said Claire. “We need the IV.”
Fighting to keep his balance in the swaying ambulance, he wound the tourniquet around the opposite arm and again searched for a vein. “I can’t find one.”
“Not even the antecubital?”
“It’s already blown. We lost it trying to get the IV started earlier.”
She glanced up at the monitor. PVCs were beginning to march across the screen again. They were still miles away from the ER, and the girl’s rhythm was deteriorating. They had to get an IV in her now.
“Take over CPR,” she said. “I’ll start a subclavian line.”
They scrambled to switch positions.
Claire’s heart was hammering as she crouched beside Kitty’s chest and stared down at the collarbone. It had been years since she’d inserted a child’s central venous line. She would have to insert a needle under the clavicle, angling the tip toward the large subclavian vein, while running the danger of puncturing the lung. Her hands were already trembling; in the swaying ambulance, they would be even less steady.
The girl is in shock, and dying. I have no choice.
She opened the central venous line kit, swabbed the skin with Betadine, and snapped on sterile gloves. Then she took a shaky breath. “Hold compressions,” she said. She placed the tip of the needle beneath the collarbone and pierced the skin. With steady pressure she advanced the needle, the whole time gently applying suction to the attached syringe.
Dark blood suddenly flashed back.
“I’m in the vein.”
The alarm squealed. “Hurry! She’s in V. tach!” said the EMT.
Lord, don’t send us over a pothole. Not now. Holding the needle absolutely still, she removed the syringe and threaded the J wire through the hollow needle, into the subclavian vein. Her guide wire was in position; the most delicate part of the procedure was over. Moving swiftly now, she slid the catheter into place, withdrew the wire, and connected the IV tubing.
“Good show, doc!”
“Lidocaine’s going in. Ringer’s at wide open.” Claire glanced at the monitor.
Still in V. tach. She reached for the paddles, and was just placing them on Kitty’s chest when the EMT said, “Wait.”
She looked at the monitor. The lidocaine was taking effect; the V. tach had stopped.
The abrupt lurch of the braking ambulance alerted them to their arrival. Claire braced herself as the vehicle swung around and backed up into the ER bay.
The door swung open and suddenly McNally and his staff were there, half a dozen pairs of hands reaching to pull the stretcher out of the vehicle.
They had only a bare-bones surgical team waiting in the trauma room, but it was the best McNally could round up on such short notice: an anesthetist, two obstetrical nurses, and Dr. Byrne, a general surgeon.
At once Byrne moved into action. With a scalpel, he slashed the skin above Kitty’s rib and with almost savage force shoved in a plastic chest tube. Blood gushed through the tube and poured into the glass reservoir. He took one look at the rapidly accumulating blood and said, “We have to crack the chest.”
They had no time for the ritual hand scrub. While McNally performed a cutdown on the girl’s arm for another IV line, and a unit of O-neg blood pumped in, Claire slipped into a surgical gown, thrust her hands into sterile gloves, and took her place across from Byrne. She could see from his white face that he was scared. He was not a thoracic surgeon, and clearly he knew he was in over his head. But Kitty was dying, and there was no one else to turn to.
“Hail Mary, full of grace,” he muttered, and started up the sternal saw.
Wincing at the whine of the saw, Claire squinted against the spray of bone dust, into the widening gap of Kitty’s chest cavity. All she could see was blood, glistening like red satin under the lights. A massive hemothorax. As Byrne positioned the retractors, widening the gap, Claire suctioned, temporarily clearing the cavity.
“Where’s it coming from?” muttered Byrne. “The heart looks undamaged.”
And so small, thought Claire with sudden anguish. This child is so very small …
“We’ve got to clear away this blood.”
As Claire suctioned deeper, a tiny spurt suddenly appeared from the lacerated lung, pumping out an arc of blood.
“I see it,” he said, and snapped on a clamp.
Another spurt appeared, fresh blood swirling bright red into the darker pool.
“That’s two,” he said with a tense note of triumph, clamping off the second bleeder.
“I’m hearing a BP!” said a nurse. “Systolic’s seventy!”
“Hanging the second unit of O-neg.”
“There,” said Claire, and Byrne clamped off the third telltale spurt.
Claire suctioned again. For a moment they watched the open chest, waiting in dread for the blood to reaccumulate. Everyone in the room fell silent. The seconds ticked by.
Then Byrne glanced across at her. “You know that Hail Mary I just said?”
“Yes?”
“It seems to be working.”
Pete Sparks was waiting for her when Claire finally emerged from the trauma room. Her clothes were splattered with blood, but he didn’t seem to notice it; they had seen so much violence that night, perhaps they could no longer be shocked by the sight of gore.
“How’s the girl?” he asked.
“She made it through surgery. As soon as her blood pressure’s stabilized, they’ll be transferring her to Bangor.” Claire gave him a tired smile. “I think she’ll be fine, Pete.”
“We brought the boy here,” he said.
“Scotty?”
He nodded. “The nurses put him in that exam room over there. Lincoln thought you’d better take a look at him. There’s something wrong.”
With growing apprehension, she crossed the ER and came to an abrupt halt in the exam room doorway. There she stood staring into the room, saying nothing, a chill rising up her spine.
She almost jumped when Pete said, quietly, “You see what I mean?”
“What about his mother?” she asked. “Did you find Faye?”
“Yes, we found her.”
“Where?”
“In the cellar. She was still in her wheelchair.” Pete looked into the exam room, and as if repelled by what he saw, he took a fearful step backwards. “Her neck was broken. He pushed her down the stairs.”
10
From the other side of the X-ray viewing window, Claire and the CT technician watched Scotty Braxton’s head disappear into the mouth of the scanner. His limbs and chest were firmly strapped to the table, but his hands continued to twist against the leather restraints and his wrists had already been chafed raw, streaking the leather with blood.
“We’re not going to get any decent shots,” said the tech. “Still too much movement. Maybe you can give him some more Valium?”
“He’s already got five milligrams on board. I hate to obscure his neuro status,” said Claire.
“It’s either that or no CT.”
She had no choice. She filled the syringe and entered the scan room. Through the window, she saw the state trooper watching her. She approached the table and reached for the IV port. Without warning the boy’s hand shot open. She jerked away just as his fingers clamped down like a trap.
The cop stepped into the room. “Dr. Elliot?”
“I’m okay,” she said, heart pounding. “He just startled me.”
“I’m right here. Go ahead and give him the medicine.”
Quickly she snatched up the IV line, plunged the needle in the rubber dam, and injected the full two milligrams.
The boy’s hand finally fell still.
From behind the window, she watched as the scanner began to whir and click, bombarding his head with a shifting sequence of X-ray beams. The first slice, from the
top of the cranium, appeared on the computer screen.
“Looks normal so far,” said the tech. “What are you expecting to see?”
“Any anatomical abnormality that might explain his behavior. A mass, a tumor. There has to be a reason for this. He’s the second boy I’ve seen with uncontrollable aggression.”
They all turned as Lincoln came into the CT room. The tragedy had taken its toll on him; she could see it in his face, in the shadows under his eyes and the sadness of his gaze. For him, the death of Faye Braxton had been only the start of an endless night of press conferences and meetings with state police investigators. He shut the door and seemed to breathe a sigh of relief that he had at last found a quiet, albeit temporary, retreat.
He crossed to the window and gazed at the boy lying on the table. “What have you found so far?”
“The preliminary drug screens were just called back from Bangor. His blood’s negative for amphetamines, phencyclidine, and cocaine. The usual drugs associated with violence. Now we have to rule out other causes for his behavior.” She looked through the glass at her patient. “It’s just like Taylor Darnell. And this boy has never been on Ritalin.”
“Are you sure?”
“I’m their family doctor. I have all Scotty’s records from Dr. Pomeroy’s files.”
They both stood with shoulders propped wearily against the window, conserving energy for the hours that lay ahead. It was the only time they ever seemed to interact, she realized. When they were both tired or scared or distracted by crisis. Neither one of them looking his best. They held no illusions about each other, because they had been through the worst together. And I’ve only learned to admire him more, she thought with surprise.
The tech said, “Here come the final cuts.”
Both Claire and Lincoln stirred from their exhausted daze and crossed to the computer terminal. She sat down to watch as the cross sections of brain appeared on the screen. Lincoln moved behind her, his hands resting on the back of her chair, his breath warming her hair.
“So what do you see?” asked Lincoln.
“No midline shift,” she said. “No masses. No bleeding.”
“How can you tell what you’re looking at?”
“The whiter it is, the denser it is. Bone is white, air is black. As you cut lower in the cranium, you’ll begin to see parts of the sphenoid bone appearing, at the base of the brain. What I’m looking for is symmetry. Since most pathology affects only one side of the brain, I check for differences between the two sides.”
A new cut appeared. Lincoln said, “That view doesn’t look symmetrical to me.”
“You’re right, it isn’t. But I don’t worry about that particular asymmetry because it doesn’t involve the brain. It’s in one of the bony sinuses.”
“What are you looking at?” asked the tech.
“The right maxillary sinus. You see? It’s not completely lucent. There seems to be something clouding it.”
“A mucoid cyst, I’d guess,” said the tech. “We see that sometimes in patients with chronic allergies.”
“It certainly wouldn’t explain his behavior,” said Claire.
The phone rang. It was Anthony, calling from the lab.
“You might want to come down and look at this, Dr. Elliot,” he said. “It’s the gas chromatogram on your patient.”
“Has something shown up in his blood?”
“I’m not sure.”
“Explain this test to me,” said Lincoln. “What are you measuring here?”
Anthony patted the boxlike gas chromatograph and grinned like a proud father. The tabletop instrument was a recent acquisition, a valuable hand-me-down from Eastern Maine Medical Center in Bangor, and he hovered over it protectively. “What this piece of equipment does,” he explained, “is separate mixtures into their individual components. It does this by making use of each molecule’s known equilibrium between the liquid phase and the gas phase. You remember high school chemistry?”
“It wasn’t my favorite subject,” Lincoln admitted.
“Well, every substance can exist either as a liquid or a gas. For instance, if you heat water, you make steam—which is the gas phase of H-two-oh.”
“Okay, I’m following you.”
“Coiled inside this machine is a capillary column—a very long, very thin tube that, if you laid it out straight, would stretch about half the length of a football field. It’s filled with an inert gas that won’t react with anything. Now, what I do is inject the sample to be tested into this port here. It gets heated and vaporized to gas, and the different types of molecules travel along that tube at different rates of speed, depending on their mass. That separates them. As they come out the other end of the tube, they pass through a detector and it’s recorded on a strip-chart. The time it takes for each substance to emerge is called ‘retention time.’ We already know the retention times for hundreds of different drugs and toxins. This test clues us in to the presence of a particular substance in a patient’s blood.” He picked up a syringe and screwed it into the port. “Watch the screen. See what happens when I inject the patient’s sample.” Anthony squeezed down on the syringe.
On the computer screen, an uneven line appeared. They watched the tracing for a moment, but it only looked like “noise” to Claire—minor, nonspecific readings indicating the biochemical soup that makes up human plasma.
“Just be patient,” said Anthony. “It shows up at about one minute, ten seconds.”
“What does?” asked Claire.
He pointed to the screen. “That.”
Claire stared as the line suddenly shot up to a peak and promptly dropped back down again to the uneven baseline. “What was that?” she asked.
Anthony went to the printer, where a hard copy was being simultaneously recorded on paper. He tore off the sheet and spread it out on the lab counter for Claire and Lincoln to see.
“That peak,” he said, “is something I can’t identify. The retention time places it in the steroid class, but you can also see a similar peak for certain vitamins and endogenous testosterone. It’d take a more sophisticated lab to identify exactly what this is.”
“You mentioned endogenous testosterones,” said Claire. “Could this be an anabolic steroid? Something a teenage boy might abuse?” She looked at Lincoln. “It would explain the symptoms. Body builders sometimes use steroids to bulk up their muscle mass. Unfortunately it has side effects, one of them being uncontrollable aggression. They call it ’roid rage.”
“It’s something to consider,” said Anthony. “Some sort of anabolic steroid. Now look at this.” He went to his desk and retrieved another sheet of graph paper.
“What is it?”
“It’s Taylor Darnell’s gas chromatogram, taken the day he was admitted.” He lay the second sheet next to Scotty Braxton’s tracing.
The pattern was identical. A single, well-defined peak at one minute, ten seconds.
“Whatever this substance is,” said Anthony, “it’s in the blood of both boys.”
“The comprehensive drug screen on Taylor’s blood was reported negative.”
“Yeah, I called the reference lab about that. They questioned our results. As if I’m imagining this peak or something. I admit, this is an older machine, but these results are reproducible every time.”
“Who did you talk to?”
“A biochemist at Anson Biologicals.”
Claire looked down at the two graphs, the papers laid out one over the other, the tracings practically superimposed. Two boys with the same bizarre behavior. The same unidentifiable substance in their bloodstreams. “Send them Scotty Braxton’s blood,” she said. “I want to know what this peak is.”
Anthony nodded. “I’ve got the requisition right here for you to sign.”
By two A.M., Claire had reviewed every X-ray, every blood test, and was no closer to an answer. In exhaustion she lingered beside the boy’s bed, silently studying her patient. She tried to think of what she might have missed.
The lumbar puncture was normal, as were the blood chemistries and EEG. The CT scan had shown only the mucoid cyst in the right maxillary sinus—probably a result of chronic allergies. Allergies would also explain the one abnormality in his white blood cell count: a high percentage of eosinophils. Like Taylor Darnell, she suddenly recalled.
Scotty stirred from his Valium-induced sleep and opened his eyes. A few blinks, and his gaze fixed on Claire.
She turned off the light to leave. Even in the darkness, she could see the gleam of his eyes focused on her.
Then she realized it was not his eyes she saw glowing.
Slowly she crossed back to the bed. She could make out the white linen beneath his head, the darker shape of his head against the pillow. On his upper lip shimmered a brilliant patch of phosphorescent green.
“Sit down, Noah,” said Fern Cornwallis. “There’s something we need to discuss.”
Noah hesitated in the doorway, reluctant to step into the principal’s office. Enemy territory. He didn’t know why he’d been pulled out of class to see her, but judging by the expression on Miss C.’s face, he suspected it couldn’t be anything good.
The other kids had eyed him with speculative looks when the message had crackled over the intercom in band class: Noah Elliot, Miss Cornwallis wants to see you in her office. Now. Acutely aware of everyone’s gaze, he had set down his saxophone and made his way through the maze of chairs and music stands to the door. He knew his classmates were wondering what he’d done wrong.
He had no idea.
“Noah?” said Miss C., pointing to the chair.
He sat down. He didn’t look at her, but at her desk, which was neat beyond belief. No human had a desk like that.
“I received something in the mail today,” she said. “I need to ask you about it. I don’t know who sent it. But I’m glad they did, because I need to know when one of my students requires extra guidance.”