They rolled her straight into the trauma room and slid her onto the table. A confusing chorus of voices was shouting simultaneously as the woman’s clothes were cut away, the EKG leads and oxygen lines connected, a BP cuff wrapped around one arm. A rapid sinus rhythm raced across the cardiac monitor.
“Systolic’s seventy!” a nurse called out.
“Drawing the type and cross!” said Claire. She grabbed a sixteen-gauge IV catheter off the tray and snapped a tourniquet around the patient’s arm. The vein barely plumped up; the patient was in shock. She stabbed the vein with the IV needle and slid the plastic catheter into place. With a syringe, she withdrew several tubes of blood, then attached the IV tubing to the catheter. “Another lactated Ringer’s going in, wide open!” she called out.
“Systolic’s sixty, barely palpable!”
The surgeon said, “Belly’s distended. I think it’s full of blood. Open that surgical tray, and get suction ready!” He looked at McNally. “You’re first assist.”
“But she needs to be in the OR—”
“No time. We have to find out where the blood’s coming from.”
“I’ve lost her BP!” a nurse yelled.
The first incision was swift and brutal, one long slash down the center of the abdomen, parting the skin. With a deeper incision, the surgeon cut through the yellow layer of subcutaneous fat, and slit into the peritoneum.
Blood spilled out, streaming onto the floor.
“I can’t see where it’s coming from!”
The suction wasn’t clearing the blood fast enough. In desperation, McNally stuffed two sterile towels into the abdomen and pulled them out again, soaking red and dripping.
“Okay, I think I see it. Bullet nicked the aorta—”
“Jesus, it’s gushing!”
A ward clerk yelled through the doorway, “Two more have arrived! They’re wheeling them in now!”
McNally glanced across the table at Claire, and she saw panic in his eyes. “You’re it,” he snapped. “Go, Claire.”
With her heart in her throat, she pushed out of the trauma room and saw the first stretcher being wheeled into one of the treatment rooms. The patient was a sobbing red-haired boy, shirt cut away, blood soaking through the bandage on his shoulder. Now a second stretcher whisked in the door—a blond teenage girl, half her face covered with blood.
Children, she thought. These are only children. My god, what has happened?
She went first to the girl, who was crying but able to move all her extremities. At that first glimpse of blood on the girl’s face, Claire nearly panicked, thinking: gunshot wound to the head. She forced herself to pause and take the girl’s hand, to calmly ask her name, even while her own heart was thundering. It took only a few questions to confirm that Amelia Reid was fully oriented, and her mental status was clear. The wound was just a superficial graze of the temple, which Claire quickly cleaned and dressed.
Turning her attention to the red-haired boy, she saw that he was already being attended to by the pediatrician.
“Are there any others on the way?” she asked the ward clerk.
“None en route. There may be more at the scene …”
A second surgeon arrived, trotting in through the ER doors and announcing: “I’m here! Who needs me?”
“Trauma room!” said Claire. “Dr. McNally needs to be relieved.”
He was just about to push through the door when a nurse popped out, almost slamming into him.
“Do we have that O-neg blood for Horatio yet?” she yelled to the ward clerk.
Horatio? Claire hadn’t recognized the patient under all that surgical tape, but she knew the name, Dorothy Horatio.
My son’s biology teacher. She looked at the clock and saw it was eleven-thirty. Period three. Noah would be in biology—in Mrs. Horatio’s class.
Another doctor arrived, another pair of hands—the obstetrician from Two Hills. She took one last glance around the room, and saw that the situation was under control.
She made the only decision a panicked mother could make.
She ran outside to her car.
The twenty-mile drive passed in a blur of autumn fields, the mist rising in wisps, stands of pine trees. Here and there farmhouses with tumbling porches. She had driven this country road every day for eight months, but never at this speed, never with her hands shaking and her heart sick with fear. She took the last rise with the accelerator floored and her Subaru leaped past the familiar sign:
You Are Now Leaving Two Hills. Come Back Soon!
And then, a hundred yards beyond that, a second sign, smaller, paint chipping.
WELCOME TO TRANQUILITY
GATEWAY TO LOCUST LAKE POPULATION 910
She swerved onto School Road and saw the flashing lights of half a dozen emergency vehicles. Police cruisers were parked in a jumble near the high school’s red brick front entrance, along with two fire trucks—a fullscale disaster response.
Claire abandoned her car and ran toward the school’s front lawn, where dozens of stunned-looking students and teachers had gathered behind a tangle of police tape. Scanning the faces, she didn’t see Noah.
A Two Hills policeman stopped her at the front door. “No one’s allowed inside.”
“But I have to go in!”
“Only emergency personnel.”
She took a quick breath. “I’m Dr. Elliot,” she said, her voice steadier. “I’m a physician from Tranquility.”
He let her pass.
She pushed through the front door into the high school. The building was nearly a century old, and inside hung the musty odors of teenage sweat and dust stirred up by thousands of feet trudging up and down the staircase. She ran up the steps to the second floor.
The doorway to the biology classroom was crisscrossed by strands of police tape. Beyond the tape were overturned chairs, broken glass, and scattered papers. Frogs hopped through the debris.
There was blood—pools of it congealing in gelatinous lakes on the floor.
“Mom?”
Her heart leaped at the voice. She whirled to see her son standing at the far end of the hall. In the dim light of that long corridor, he seemed frighteningly small to her, his blood-streaked face pale and thin.
She ran to him and threw her arms around his rigid body, pulling him, forcing him, into an embrace. She felt his shoulders melt first, then his head drooped against her and he was crying. No sound came out; there was just the shuddering of his chest and warm tears sliding onto her neck. At last she felt his arms come around her, circle her waist. His shoulders might be as broad as a man’s, but it was a child who clung to her now, a child’s grief that spilled out in tears.
“Are you hurt?” she asked. “Noah, you’re bleeding. Are you hurt?”
“He’s fine, Claire. The blood isn’t his. It’s the teacher’s.”
She looked up and saw Lincoln Kelly standing in the hall, his grim expression reflecting the day’s terrible events. “Noah and I just finished going over what happened. I was about to call you, Claire.”
“I was at the hospital. I heard there was a shooting.”
“Your son grabbed the gun away from the boy,” said Lincoln. “It was a crazy thing to do. A brave thing to do. He probably saved a few lives.” Lincoln’s gaze dropped to Noah, and he added softly: “You should be proud of him.”
“I wasn’t brave,” blurted out Noah. He pulled away from Claire, ashamedly wiping his eyes. “I was scared. I don’t know why I did it. I didn’t know what I was doing …”
“But you did it, Noah.” Lincoln lay a hand on the boy’s shoulder. It was a man’s blessing, brusque and matter-of-fact. Noah seemed to draw sustenance from that simple touch. A mother, thought Claire, cannot knight her own son. It must be done by another man.
Slowly Noah straightened, his tears at last under control. “Is Amelia okay?” he asked her. “They took her in the ambulance.”
“She’s fine. Just a scratch on her face. I think the boy will be fine as
well.”
“And … Mrs. Horatio?”
She shook her head. And said, gently, “I don’t know.”
He took a deep breath and wiped an unsteady hand across his eyes. “I—I have to go wash my face …”
“You do that,” said Lincoln gently. “Take your time, Noah. Your mom will be waiting for you.”
Claire watched her son walk away down the hall. As he passed the biology classroom he slowed down, his gaze drawn, against his will, to the open doorway. For a few seconds he stood hypnotized by the terrible view beyond that police tape. Then, abruptly, he pushed into the boys’ restroom.
“Who was it?” said Claire, turning to Lincoln. “Who brought the gun to school?”
“It was Taylor Darnell.”
She stared at him. “Oh god. He’s my patient.”
“That’s what his father told us. Paul Darnell says the boy can’t be held responsible. That he has attention deficit disorder and can’t control his impulses. Is that true?”
“ADD doesn’t cause violent behavior. And Taylor doesn’t have it, anyway. But I can’t comment on this case, Lincoln. I’m betraying confidentiality.”
“Well, something’s wrong with the kid. If you’re his doctor, maybe you should take a look at him before he’s moved to the Youth Center.”
“Where is he now?”
“We’re holding him in the principal’s office.” Lincoln paused. “Just a word of warning, Claire. Don’t get too close.”
5
Taylor Darnell sat handcuffed to a chair, swinging his foot, bam, bam, bam! against the principal’s desk. He didn’t look up when Claire and Lincoln walked into the room, didn’t even seem to notice they were there. Two Maine state cops were in the room with him. They looked at Lincoln and shook their heads, their thoughts transparent: This one is totally bonkers.
“We just got a call from the hospital,” one of the state cops said to Lincoln. “The teacher’s dead.”
No one spoke for a moment; both Claire and Lincoln absorbed the terrible news in silence.
Then Claire asked, softly: “Where is Taylor’s mother?”
“She’s still on her way back from Portland. She drove down there on business.”
“And Mr. Darnell?”
“I think he’s rounding up a lawyer. They’re going to need one.”
Taylor was kicking his foot against the desk again in a ceaseless, accelerating beat.
Claire set her medical bag down on a chair and approached the boy. “You remember me, Taylor, don’t you? I’m Dr. Elliot.” He didn’t answer, just kept up that angry banging. Something was very wrong. This was more than adolescent rage she was looking at. It appeared to be some sort of drug-induced psychosis.
Without warning, Taylor’s gaze rose and locked on hers, focusing with predatory intensity. His pupils dilated, irises darkening to ebony pools. His lips curled up, canines gleaming, and from his throat escaped an animal sound, half hiss, half growl.
It happened so fast she had no time to react. He sprang to his feet, dragging the chair up with him, and lunged at her.
The impact of his body slamming into hers sent her toppling backwards to the floor. His teeth sank into her jacket, ripping the fabric, sending goose down and feathers flying in a white cloud. She caught a glimpse of three frantic faces as the cops struggled to separate them. They wrenched Taylor away, dragging him backwards even as he continued to thrash.
Lincoln grasped her arm and lifted her back to her feet. “Claire—Jesus—”
“I’m okay,” she said, coughing on goose down. “Really, I’m fine.”
One of the state cops yelped. “He just bit me! Look, I’m bleeding!”
Even cuffed to the chair, the boy was fighting, bucking against his restraints. “Let me go!” he shrieked. “I’ll kill you all if you don’t let me go!”
“He should be locked up in a freaking kennel!”
“No. No, there’s something seriously wrong here,” said Claire. “It looks like a drug psychosis to me. PCP or amphetamines.” She turned to Lincoln. “I want this boy moved to the hospital. Now.”
“Too much movement,” said Dr. Chapman, the radiologist. “We’re not going to get very clear definition here.”
Claire leaned forward, watching intently as the first cross-section of Taylor Darnell’s brain appeared on the computer screen. Each image was a compilation of pixels formed by thousands of tiny X-ray beams. Aimed at different angles along one plane, the beams distinguished between fluid and solid and air, and the various densities were reproduced in the image on the screen.
“See that fuzziness there?” said Chapman, pointing to the movement artifact.
“We can’t make him hold still unless we put him under anesthesia.”
“Well, that’s an option.”
Claire shook her head. “His mentation’s cloudy enough. I don’t want to risk anesthesia right now. I’m just trying to rule out any mass shifts before I do the lumbar puncture.”
“You really think encephalitis could explain these symptoms?” Chapman looked at her, and she saw skepticism in his eyes. In Baltimore, she’d been a respected family practitioner. But here she still had to prove herself. How long would it take before her new colleagues stopped questioning her judgment and learned to trust her?
“At this point, I have no choice,” she said. “The initial screen for both methamphetamine and PCP came back negative. But Dr. Forrest thinks this is clearly an organic psychosis, not psychiatric.”
Chapman was obviously unimpressed by Dr. Forrest’s clinical skills. “Psychiatry is hardly an exact science.”
“But I agree with him. The boy’s shown alarming personality changes in just the last few days. We have to rule out infection.”
“What’s the white cell count?”
“Thirteen thousand.”
“A little high, but not all that impressive. What about the differential?”
“His eosinophil count is high. Way off the scale, in fact, at thirty percent.”
“But he has a history of asthma, right? That could account for it. It’s some sort of allergic response.”
Claire had to agree. Eosinophils were a type of white blood cell that proliferated most commonly in response to allergic reactions or asthma. High eosinophil counts could also be caused by a variety of other illnesses such as cancer, parasitic infections, and autoimmune diseases. In some patients, no discernible cause was ever found.
“So what happens now?” asked the Maine state trooper, who’d been watching the procedure with a look of growing impatience. “Can we move him to the Youth Center or not?”
“We have more tests to run,” said Claire. “The boy could be seriously ill.”
“Or he could be faking it. That’s what it looks like to me.”
“And if he’s sick, you could find him dead in his cell. I wouldn’t want to make that mistake, would you?”
Without comment, the trooper turned and stared through the CT viewing window at his prisoner.
Taylor was lying on his back, wrists and ankles restrained. His head was hidden inside the CT cradle, but they could see the movement of his feet, twisting against the restraints. Now comes the hard part, she thought. How do we hold him in position long enough for the lumbar puncture?
“I can’t afford to miss a CNS infection,” said Claire. “With an elevated white blood count and changes in mental status, I have no choice but to do the spinal tap.”
Chapman at last seemed to agree. “From what I see here on the scan, it looks safe enough to proceed.”
They wheeled Taylor out of X-ray and into a private room. It took two nurses and a male orderly to transfer the struggling boy to the bed.
“Turn him on his side,” said Claire. “Fetal position.”
“He’s not going to lie still for this.”
“Then you’ll have to sit on him. We need this spinal tap.”
Together they rolled the boy on his side, his back to Claire. The orderly flexed Ta
ylor’s hips, forcibly pushing the knees toward the chest. One nurse pulled the shoulders forward. Taylor snapped at her hand, almost catching her finger in his jaws.
“Watch his teeth!”
“I’m trying to!”
Claire had to work fast; they couldn’t keep the boy immobilized much longer. She lifted the hospital gown, exposing his back. With his body curled into a fetal position, the vertebral spines poked out clearly under the skin. In rapid order she identified the space between the fourth and fifth spinous processes in the lower back, and swabbed the skin with Betadine, then alcohol. She snapped on sterile gloves and picked up the syringe with local anesthetic.
“I’m putting in the Xylocaine now. He’s not going to like this.”
Claire pricked the skin with the twenty-five-gauge needle and gently injected the local anesthetic. At the first sting of the drug, Taylor shrieked with rage. Claire saw one of the nurses glance up, fear in her eyes. None of them had ever dealt with anything like this, and the violence coursing through this boy’s body was frightening them all.
Claire reached for the spinal needle. It was three inches long, twenty-two-gauge gleaming steel, the hub end open to allow cerebrospinal fluid to drip out.
“Steady him. I’m doing the tap now.”
She pierced the skin. The Xylocaine had numbed the area, so he didn’t feel any pain—not yet. She kept pushing the needle deeper, aiming the tip between the spinous processes, toward the dura mater of the spinal cord. She felt a slight resistance, then a distinct pop as the needle penetrated the protective dura.
Taylor screamed again and began to thrash.
“Hold him! You have to hold him!”
“We’re trying! Can you hurry it up?”
“I’m already in. It’ll just be another minute now.” She held a test tube under the open hub of the needle and caught the first drop of CSF as it slid out. To her surprise, the fluid was crystal clear with no blood, no telltale cloudiness of infection. This was not an obvious case of meningitis. So what am I dealing with? she wondered as she carefully collected CSF in three different test tubes. The fluid would be sent immediately to the lab, where it would be analyzed for cell count and bacteria, glucose and protein. Just by looking at the fluid in the tubes, she knew that the results would be normal.