Mercy (15 page)

“Any pulse?” Julie asked.

“No pulse,” a nurse said. “Monitor looks like v-fib.”

Julie glanced at the monitor and confirmed the read was indeed ventricular fibrillation. The ventricles of Sam’s heart fibrillated, contracting in a rapid, unsynchronized way. The heart pumped little to no blood.

“Is the vasopressin ready? Give it now. Ready, charge to three hundred.” Julie’s voice was firm, but unagitated.

“Charging to three hundred joules,” a nurse announced.

The hum of the machine again increased in volume as the nurse recharged the defibrillator.

“Charging to three hundred, ready.”

“Clear!” Julie called out.

“All clear,” many repeated.

“Okay, shock!”

Julie depressed the red button, repeating the previous jolt. Sam’s body barely moved as a metallic
thunk
sounded like a distant thunderclap.

“Any pulse?” Julie asked. A feeling of dread hit so hard it was as if someone had put the paddles on her own chest.

“No pulse, Dr. Devereux,” a nurse announced. “He’s still in v-fib on the monitor.”

With alarm, Julie observed the jagged peaks and valleys of Sam’s telemetry readout. Ventricular rate two hundred beats a minute, atrial contractions not discernable, P waves notably absent. Grim as it appeared, Julie knew Sam still had a shockable rhythm. There was still a chance he could come back to her.

Julie began to order medications to be given through Sam’s intravenous lines. Epinephrine to help increase cardiac output, amiodarone to keep the heart beating normally, bicarbonate to counteract the lactic acid buildup, and even glucose, in case for some reason Sam’s blood sugar had dropped too low. This was followed closely by a 360-joule countershock.

“Yes! We got something,” a nurse announced with jubilation. “Monitor shows wide rhythm at forty-five. I can feel the femoral pulse, though it is weak and thready.”

Julie held in a breath and watched the monitor, half expecting the readout to return to v-fib status at any moment. For the time being, it appeared to hold steady.

“Great job!” Julie said, feeling her own pulse decelerate. But how much of his oxygen-deprived brain would reawaken? “Okay, let’s get IVF bolus five hundred milliliters of normal saline. And hang dopamine. Henry, please tube him now.”

Julie appraised the assembled team, working side by side, each person focused on a specific task. She had been through this scenario hundreds of times before, but never with so much at stake.

“Dr. Devereux, we lost his pulse!”

Julie gave the nurse a horrified look. “What do we have now on the monitor?” Her composure was slipping.

“Slow and wide rhythm in the twenties. PEA.”

Julie’s heart sank. Pulseless electrical activity—no pulse whatsoever. Every inch they had gained in this fight they had just lost.

“Start CPR!” Julie snapped. “Give him more epi, one milligram.”

Everything was done as Julie ordered, and with haste.

“Any pulse?”

“Sorry, Dr. Devereux, no.”

The cardiogram still showed that slow and wide rhythm. Julie’s body became damp with sweat.

“Let’s use an escalating dose of epi,” Julie said with force. “Three-milligram IV push. NOW!”

Chaos and pandemonium erupted.

“Hang an epi drip!” one nurse shouted. “Someone mix it, stat!”

The resident doing compressions had tired. Dr. Hayes took his place.

“Call cardiology,” Dr. Hayes said. “Tell them to come fast. Get echo here! We need echo!”

“Epinephrine, three milligrams in now, Dr. Devereux,” said a nurse. “We still don’t have a pulse.”

Julie tried to ignore the cold tickle of fear running down the back of her neck.

“Continue CPR,” she said. “Give two amps of bicarbonate. Continue CPR. Come on!”

Cardiology arrived. The crowded room heated up as more bodies crammed into the tight space, like canned sardines. The new contingent included Dr. Carrie Bryant from neurosurgery, a recent addition to the White Memorial staff.

“Keep up the compressions,” Julie said. “We can still get a pulse. He just needs more drugs. More epi—please, do it now!”

From the corner of her eye, Julie caught an exchange of nervous glances. The sense of urgency was receding.

Dr. Bryant approached Sam and lifted his lids to shine her penlight into his eyes. She stroked his cornea with a piece of cotton, then applied slight pressure to Sam’s forehead and nose. Her expression without optimism, Carrie stepped away from Sam’s bed and groped Julie’s arm.

“His pupils are fixed and dilated,” Carrie said, looking Julie right in the eyes. “I’m so sorry, but he’s gone.”

Dr. Hayes came forward. “Julie, let me call it,” he said.

The only response Julie could muster was a nod. Carrie gave Julie an embrace.

“That’s it,” Dr. Hayes said, glancing at his watch. “Thank you, everybody, for your efforts. Time of death is one thirty-five.”

Defeated, Julie bowed her head and let her arms fall to her sides. The equipment was put away, the tube removed from Sam’s throat, and the room quickly cleared. Julie resisted the urge to pump on Sam’s chest herself.

Carrie said from the doorway, “You did everything you could, and you did everything right.” With that, she was gone.

Julie stayed behind, too numb to cry, too emotionally drained to do anything but gaze at Sam’s lifeless body. In one intense wave of emotion, the impact of what had just happened hit her full force. Her love was really gone.

He looked at peace. This brought Julie a measure of comfort. In the stillness of the moment, a thought struck Julie with force.

Sam’s heart and lungs had been functioning fine. What caused him to suffer a sudden cardiac arrest?

CHAPTER 19

Autopsy means “see for yourself,” and that was precisely what Lucy Abruzzo intended to do with Sam Talbot’s body. She would see for herself what had killed him. Gowned, gloved, and masked, Lucy looked like any surgeon about to perform a procedure, except her patient required no anesthesia and she had no support staff on hand to assist. Lucy preferred it this way. She thrived in solitude, which was why she was equally comfortable running long distances or tackling virtual opponents in a spirited game of online chess.

The endeavor at hand was a chess match of a different sort: Lucy vs. death. But death was a wily opponent, and safeguarded its secrets the way a grand master could obscure a strategy until checkmate became inevitable.

The cavernous autopsy suite had an industrial look, with its gray-tiled flooring, fourteen-foot-high ceilings, and exposed ductwork. Lucy liked the utility of it all. Nothing here was wasted or decorative. Everything had a proper place and purpose. The room had three brand-new autopsy tables, plenty of good light, top-of-the-line instruments, and lab equipment organized neatly on stainless steel tables, or in glass-fronted cabinets securely mounted to the walls. Most everything here was new or in pristine condition, thanks in large part to Roman Janowski’s skill at keeping the hospital coffers flush with cash. It was a fine place to work, and Lucy was ready for the task at hand.

As was her tradition prior to beginning, Lucy’s eyes went to a sign in Latin that hung on a nearby wall. It read:
Hic locus est ubi mors gaudet succurrere vitae
. Translated, it meant:
This is the place where death rejoices to help those who live
. The words mattered a great deal, reminding Lucy of her purpose here. Indeed, it was the very essence of her profession.

Ultimately—in a clinical sense, at least—everyone died of the same thing. The heart stopped beating, and blood stopped circulating through the body, two processes necessary for sustaining life. But many factors could come into play as life ended, and therein lay the value of an autopsy.

Autopsies had helped reveal misdiagnoses, uncover new diseases, and educate doctors—and humble them, and befuddle them—about the vast intricacies of the human body. Doctors, by their nature, did not easily embrace the possibility of being wrong. Over the years, Lucy had dug up plenty of medical evidence to wrinkle more than a few white lab coats. She had gone into pathology for the same reason she’d devoured mystery novels as a child. Lucy simply loved to figure out the real answers.

Because Sam Talbot was so severely injured, his death had not been a complete surprise. Cost and resources meant autopsies were rarely done without a compelling reason, such as death under suspicious circumstances, pending litigation, or a health threat to the general public. This procedure was a favor to a friend who’d requested it. Julie needed closure—deserved it, given all she had endured—so the stakes were high. Lucy was the boss, and did not have to ask anyone’s permission to grant Julie’s request.

Jordan, the diener, had already prepared the body, so when Lucy entered the autopsy suite she was able to get right to work. From her quick assessment, it was obvious Jordan deserved another raise. The x-rays were all visible on the viewing screen, and Lucy’s tools, including the fine saws and scalpels she favored, had been laid out in perfect order.

Never had Lucy met a diener so committed to excellence. The word “diener” was German and meant “helper,” which described Jordan to a T.

Pressing on the foot pedal, Lucy activated the overhead microphone and recorded the date, time, and location of the procedure: White Memorial Hospital.

“This is Dr. Lucy Abruzzo performing an autopsy on Mr. Samuel Talbot, who was deceased on Friday, the fourteenth of October, at one thirty-five
P.M
.”

Lucy studied the X-ray images and rattled off her assessment as if she was reading from a book.

“Review of the X-rays demonstrates healing of the C4 burst fracture, type-two fractures to the ilium and pubis, left radial and ulnar fractures, right radial and ulnar fractures, and left olecranon fracture. Left femur fracture with rod in place, healing. All appear consistent with prior injuries, and no new findings identified. New hairline fracture noted in the sternum and fracturing anteriorly of bilateral ribs T5 through T8. Likely occurring during the resuscitation attempt.”

CPR was a violent procedure that often cracked ribs and fractured the sternum. Pathology drilled home one undeniable fact: death was painless; living was not.

Lucy examined the body with her keen observational skills.

“First visual inspection shows a well-developed, well-nourished male in his forties. He is six feet tall, weighs one hundred ninety-five pounds, hair color light brown. Mild bruising appears on anterior chest, also likely a resuscitation injury. Significant bruising noted on the abdomen, most likely the result of injections and treatment for his spinal injury. Slight atrophy noted in the lower extremities, also consistent with his prior injuries and clinical history.”

Julie had asked to observe this procedure, but ultimately agreed with Lucy that she’d be better served by reading the report. She did not need to see her fiancé cut open with a scalpel from the shoulder to the lower end of the sternum, and then cut again in a straight line over the abdomen to the pubis. What was seen could not be unseen, Lucy had warned.

Except for a bit of blood drawn out by gravity, Lucy’s expert incisions produced almost no bleeding. A dead body has no blood pressure. Lucy was grateful that this was a limited autopsy, one that did not have to include the brain. It seemed invasive, especially on someone she knew, to open up the “black box” and poke around inside Sam’s skull.

“After standard Y incision is made, there appears to be perimortem fracturing of the sternum and ribs anteriorly, as described on the X-ray.”

Sam’s cause of death would not be found in the bones. It was time for Lucy to cut the cartilage joining the ribs to the breastbone so she could enter the chest cavity and get to the organs. The bone saw whirred to life and made the necessary cuts almost effortless.

It was proving difficult, Lucy found, to remain her typically detached self. After all, she had lunched with Sam and Julie, had greeted him warmly when he came to the hospital for a visit, and had planned to attend their wedding. Now she was using rib spreaders and cranking the handle so she could open up his sternum and bones to get a good view of the inside of his chest.

She closed off her personal feelings, shut them down the way she could tune out pain on a long run, and began her inspection of the internal organs.

“Pericardial sac intact. Lungs appear normal. Minimal pleural fluid noted and sent for analysis.” She made a new incision in the pericardium to conduct her examination of the heart. “Minimal fluid noted,” she said. “The heart appears normal in size.”

Then she moved over to the main vein, the inferior vena cava that carried blood from the lower body to the heart, and made another cut. “IVC appears normal in caliber and intact. After incision, no clot noted. Blood sent for routine toxicology and chemical analysis.”

Gathering samples for the labs was something Lucy would deal with after the fact, but she was required to record her observations in keeping with proper procedure.

Now Lucy turned her attention to the pulmonary arteries, an area of interest to her. Evidence had pointed to an acute myocardial infarction—a heart attack—on the basis of Sam’s EKG when he coded. But he had no indication of underlying, preexisting coronary disease, and the hole in Sam’s heart from the pericardiocentesis had been repaired. Lucy suspected a fatal pulmonary embolism as cause of death, a clot traveling from veins in the legs to the lungs, completely stopping blood flow.

With this in mind, Lucy felt the pulmonary arteries, but detected no palpable clot. She made her incision.

“The left and right pulmonary arteries are clear.”

Interesting.

She inspected the arteries lower down, in case the clot had been dispersed.

“Incision and inspection to the third-order branches are clear of clot,” Lucy observed.

Whatever had caused his heart to stop beating was not going to be found in the lungs. Lucy removed both lungs, one at a time, and weighed them before turning her attention to the heart.