Extreme Measures (5 page)

“As soon as bloods are off to the lab, get an arterial line in him. Then a catheter,” Eric ordered.

Feldman set to work cannulating the man’s radial artery, while a second resident numbed a spot near his navel and thrust a tube into the abdominal cavity. A flush of saline through the tube showed no evidence of internal bleeding.

Eric nodded. The test had ruled out a ruptured spleen or liver, and had made an aortic tear less likely. The possibility of pericardial tamponade as the cause of Russell Cowley’s shock had just increased several-fold.

Terri Dillard rushed into the room.

“How’s he doing?” she asked breathlessly.

“No better, no worse,” Eric said. “He’s tamponading.”

“You sure?”

“Not yet, but almost. And if it’s true, hold on to your hat. You’re going to get to see something no one has ever seen—not even me. That is, providing goddam Subarsky gets down here in time.”

“Well, I hope whatever it is happens quickly,” Terri said, “because we just got a call on the Batphone. Boston Rescue is on the way in with another Priority One—a man found in an alley in the North End. No pulse, no respiration. They’re doing CPR.”

“A drift diver?” Eric asked, his concentration still focused on the residents and technicians.

The term referred to the derelicts pulled from snowdrifts throughout the Boston winter. Most of the time they were well beyond salvation.

“I think so,” Terri said. “The rescue people refuse to incriminate themselves over the radio, but they did say there was a nearly empty bottle of Thunderbird in the man’s coat pocket.”

“Is he warm?”

“I have my doubts. Rescue made it sound like they were only working on him because their protocol demands it.”

“EKG?”

“Essentially straight-line, with an occasional agonal beat.”

“Pupils?”

“Dilated and fixed.”

“Lord, Terri, isn’t there someone else around to work on him? This is big stuff going on here. This guy’s the president of a company, a trustee of this hospital, and he’s got treatable injuries. I don’t want him shortchanged while I go through the motions with a wino who probably died hours ago.”

Terri’s eyes narrowed.

“You’re the only senior person around,” she said
coolly. “If you need help, Dr. Kaiser is next door doing walk-ins.”

“Well, tell him to take charge of the diver. If this guy needs his pericardium drained, I’m going to do it.”

“Eric, come on,” she said. “Gary Kaiser’s been here a year and a half, and he still gets flustered taking care of strep throats. We all think his father must have endowed a building or something. There’s no other explanation for his getting an internship here.”

“Well, just tell him it’s time to be a goddam doctor. That’s what he came here to be. Anyhow, it sounds like this diver’s going to be just another DOA. Terri, for chrissakes, don’t make that face. Okay, look, I’ll be over to help him as soon as—Wait, there’s Subarsky. If things go the way I hope, we may be done before the diver arrives.”

Dave Subarsky lumbered into the room, hauling a cart laden with complex machinery. Subarsky had a Ph.D. in biochemistry from M.I.T., but at six foot two or three, with a full beard and massive gut, he looked more like a professional wrestler. He and Eric had grown up just a few doors from each other in Watertown. And although they had entered grammar school the same year, by the time Eric graduated from high school, Subarsky was in his third year of college. It was an unexpected perk of Eric’s residency appointment to find his old friend doing independent research in one of White Memorial’s labs.

“Yo, David,” Eric called out. “You have the right dye? Great. Run into your boss at all? No? Perfect. Okay, then, set up right there. We’re going to go for it. June, is that arterial fine in yet?”

“Right now,” she answered. “One more second and … 
Voila!”

A low, rapid wave-tracing appeared on the oscilloscope beneath Russell Cowley’s EKG pattern. Next to it were the numbers 50 and 0. Systolic and diastolic
pressures. Cowley himself had lost consciousness, but his respiration remained steady and reasonably effective. The violet in his face, however, had deepened.

“Call the O.R. and have them mobilize the cardiac surgical team,” Eric said. “If this doesn’t work, we’ll try a needle. But they’d best be ready to open this man’s chest. Okay, David, this is it. Everybody listen up. This is Dave Subarsky. He’s a biologist from M.I.T., and this is a new kind of laser he’s helped develop. We’re going to use it to open a window in this man’s pericardium and drain the blood out from around his heart and into his chest cavity, where it will simply get absorbed.”

“Is it dangerous?” one of the nurses asked.

“Not in David’s hands. It was developed for vascular work, but I got the idea to adapt it for pericardiocentesis. I have total confidence in our ability to do this. We—Dave and I—have been doing animal work with it for months, mostly at three or four in the morning.”

Dave Subarsky, adjusting the dials on the machine, smiled behind his beard.

As soon as it received FDA approval for general use, the combination X-ray and coaxial, flash-lamp, pumped-dye lasers would, Eric hoped, become known as the Subarsky/Najarian laser.

First, though, the technique had to work.

“I want you all to know,” Eric went on, “that this procedure is virtually noninvasive—far safer and more accurate than the needle approach you’re all familiar with. In that lower machine, there, we are using a dye specific for the protein in the pericardium. This upper component is an X-ray laser beam that will carry the dye laser beam through the intervening structures, right to the pericardium.”

“What should we expect to see?” the same nurse asked.

“Well, for starters, a drop in his CVP, and something a little more effective than a systolic pressure of
fifty,” Eric replied, barely masking his growing irritation with the woman. “Now, if you’d all just move back a—”

Terri Dillard hurried into the room.

“Eric, the other Priority One is in Six. Gary Kaiser’s working on him.”

“What’s his temp?”

“Ninety-six two.”

“EKG?”

“Straight-line with a rare agonal beat.”

“Tell Kaiser to pronounce the guy if that’s all he’s got.”

“Yes, but—”

“Is the cardiac team on standby for this man?”

“Eric, we just lost his pressure,” June Feldman said. “Do you want me to start CPR?”

To her right, the wave formation on the oscilloscope was a straight line. The systolic and diastolic readouts both showed zero. The heart rate began to slow. Cowley’s respiration grew shallow.

“Damn,” Eric whispered. “Okay, everyone, this is it. Terri, you’ll just have to tell Kaiser to do his best. Then call the cardiac people and get them down here. We may have to open his chest right here. Also, get some blood. They should have him typed by now. Tell them to forget the cross-match on two units and get them over. June, keep a finger on his carotid. Ready, David?”

“Ready.”

“Go for it.”

Dave Subarsky hit one switch, then another. A faint blue beam shot from the upper laser, followed almost instantly by a red one from the lower. The beams intersected at a spot just above Russell Cowley’s lowest left rib, and disappeared into his chest.

For five seconds, ten, there was nothing.

Eric shifted nervously and moved forward with the cardiac needle.

“More power?” he asked.

“I don’t think so, Doc,” Subarsky replied.

“Jesus. Okay, I’m going in,” Eric said. “Someone page the cardiac people.
Stat
.”

“Wait!” June Feldman was staring down at her fingertips. “Wait … Yes, I’ve got a pulse. I’ve got a pulse.”

At virtually the same instant, the central venous pressure level began to drop. The arterial pressure monitor kicked in at 70 over 30. Seconds later, it read 90.

Subarsky, cool as snow, nodded as if the whole affair were routine, but two of the nurses began to applaud.

“I’ve never seen anything like that in my life,” one of them exclaimed. “Never.”

“Neither have I,” Eric muttered, softly enough for no one to hear.

Russell Cowley’s coloring improved almost as dramatically as had his blood pressure and CVR His breathing grew strong and steady. And within two minutes, his eyes fluttered open.

No one spoke. Eric studied the faces around him. Their expressions were a wonderful mix of awe and jubilation. It was the prolonged silence of a concert audience who had just experienced the music of a master.

And Eric relished every bit of it.

Through the open doorway, he saw Terri Dillard approaching.

No, not yet, dammit
, his thoughts hollered.
This is my moment. Not yet
.

“Everything okay?” Terri asked.

“Look for yourself.”

He motioned toward Cowley.

“Nice going. Eric, the cardiac people are on their way down. You’ve really got to come in and help Kaiser.”

“Lord. Any change in the diver?”

“No.”

“So what’s to help?”

“Eric, please.”

“Okay, okay. June, have the cardiac service admit this guy to them with ortho as consult. I’ll be back in a few minutes.” He glanced over at Terri. “Maybe sooner.”

Gary Kaiser annoyed Eric more than any resident he had ever known. He was immature, indecisive, and nervous as hell in all but the most routine situations.

It was no surprise to see him running a full Code 99 on a derelict who looked as if he had been dead for hours.

“Gary, what gives?” Eric asked.

The scene was subdued, in sharp contrast to the action and energy surrounding Russell Cowley. A nurse was doing CPR while a respiratory therapist was ventilating the man through an endotracheal tube. Nursing supervisor Norma Cullinet was assisting another nurse in keeping notes on the code and administering meds.

Kaiser, a rosy-cheeked enlargement of the Pillsbury Doughboy, glanced down at the EKG machine.

“Nothing,” he said.

“Nothing? Do you think this is the result of a coronary?”

“I … I imagine so.”

The EKG pattern showed a straight line with an ineffectual electrical pulse every ten or fifteen seconds. It was the sort of complex that often persisted for hours after a patient was clinically dead.

“Who is this man?”

Reflexively, Eric motioned the nurse to stop her CPR while he checked the man’s groin and neck for pulses. There were none. He motioned her to start up again.

“A John Doe,” Kaiser said. “We’ve been working on him for almost fifteen minutes.”

“Why?”

“Why?” Kaiser shifted nervously. “Well, he had those beats on his EKG.”

“Those beats mean nothing more than a dead heart.”

“And … and his temp was only ninety-six. I … I thought we should try to warm him up a bit before calling off the code.”

As usual, Kaiser was performing mindless, cookbook medicine. It was a maxim in most hypothermic situations to warm the patient before calling off a resuscitation. But ninety-six was hardly hypothermia, and this man was clearly beyond help.

“So,” Eric said, “what do you want to do?”

He checked the man’s pupils, which were wide and lifeless.

“Do? Well, I … I was sort of hoping you’d take over here so I could get back to the walk-ins.”

“Kaiser, what branch of medicine are you going into?”

“Well, I … I’ve just been accepted in a dermatology residency for next year.”

“Excellent. I think that’s a perfect spot for you. You’re excused.”

“What?”

“I said, leave. Go back to your walk-ins. I’ll take over here.”

“You sure it’s okay?”

“It’s more than okay, Gary. It’s an order.”

His moon face flushed with crimson, Gary Kaiser backed from the room.

“Dermatology,” Eric muttered as he turned his attention to the derelict. “Thank God for dermatology.”

The man, unshaven and unkempt, smelled of the alleys. He was dressed in soiled long johns, a frayed checked hunting jacket, and tattered pants, all of which had been cut away during his attempted resuscitation. He had a scar on his abdomen—possibly from an old exploratory. There was a tattoo on one hip and
a bruise and healing abrasion on his forehead. Eric flashed on the corporation president lying two rooms away, and wondered what the cardiac team was saying about the remarkable save.

“Eric, do you want me to keep pumping?” the nurse asked.

“Huh? Oh, keep at it for a few moments more while I get oriented. Thanks. You’re doing a great job. Did Kaiser give him anything?” Eric asked the second nurse.

“The usual. Epinephrine, atropine. There’s an Isuprel drip running now.”

“Right by the ol’ cookbook.”

“Pardon?”

“Nothing. Norma, do we know who this man is?”

“John Doe. That’s all we have.”

“Well, for my money this is an exercise in futility. Any objections if I call it off, and we all go about trying to save the living? Good.”

Eric studied the end-stage cardiac activity for a few more moments. With the most vigorous efforts, and a great deal of luck, they might be able to reestablish some sort of more effective heartbeat. But with no blood pressure and fixed, dilated pupils, what then? The time for battle had passed, probably well before the rescue squad had even arrived. He sighed and then reached up and flipped off the monitor.