Patient (18 page)

Chapter 24

ALTHOUGH SHE WASN’T ON CALL, JESSIE HAD chosen to spend the night in the hospital. Her closest friend had vanished. No note, no call, no signs of personal trouble, no hints of emotional instability, no evidence of an abduction—just a phone call to Emily at home ... then she was gone. Jessie had been too worried to go home.

It was not yet six-thirty in the morning when she awoke in one of the windowless on-call cubicles, momentarily disoriented in the pitch darkness, her mouth desert dry, her lungs burning from four hours of inhaling stale air. She switched on the bedside lamp and was grateful to see the cup of water she had left on the scarred table beside it. Wetting her fingertips, she rubbed some water on her eyelids, then drank the rest and sank back onto the pillow. Dreamlike, the highly charged events of the previous night drifted into focus.

Eastman Tolliver had taken the unfortunate news of his MRI results about as Jessie had expected-a dismayed, softly uttered curse, followed by an attempt at a brave smile, and finally a resigned declaration that he would do whatever it took to beat the tumor. These were, Jessie knew, only baby steps in the process of coming to grips with the nearly unfathomable diagnosis of a brain tumor. The heavy work would take place over the few days remaining before surgery. And while the depth of the success of that work was unpredictable from patient to patient, it often had a major bearing on the outcome of the treatment.

“Maybe it’s all the time I’ve been spending around the patients here,” Tolliver said, “but while they were wheeling me down here, I had this feeling it was going to be ...”

His voice drifted away, and for a brief while, he stared up at the ceiling. He then stated his decision to stay in Boston and have his surgery performed at EMMC. Gilbride made several hardly subtle efforts to insert himself as the physician of record, but Tolliver would have none of it.

“I’ve made up my mind, Carl,” he said. “I know what happened to poor Count Hermann could have happened with any surgeon, but I’ve watched Dr. Copeland in the operating room, and I’ve spoken with her patients, and I have chosen Dr. Copeland to do it. It’s as simple as that. It says a good deal about you that you have a surgeon of her caliber on your staff.”

“Whatever you say,” Gilbride managed, barely unclenching his jaws.

“However, when I do go into the operating room,” Tolliver went on, “I’d like to know that you’ll be there as a consultant.”

“Of course.”

Jessie suggested an immediate admission to the neurosurgical service, and promised to schedule Tolliver’s operation as soon as possible. Tolliver convinced her instead to allow him to return to his room to gather some things and to call his wife, Kathleen. She would then fly in from California as soon as she could arrange for someone to take her place in caring for her mother, who was incapacitated by Alzheimer’s disease. However, Tolliver was quick to add, setting a time for surgery should not be predicated on his wife’s arrival. He wanted it done as quickly as possible.

“Just get this thing out of my head,” he said.

Two hours after his release from the emergency room, Eastman Tolliver had returned to EMMC and was admitted as a patient to Surgical Seven.

Meanwhile, Jessie had left the hospital and driven over to the modest two-story house Emily shared with her husband, Ed, and their two sons. Jessie felt that Ed, a software engineer at a firm in Cambridge, responded to the crisis less emotionally and more analytically than Emily would have done had he been the one to have disappeared. But there was no misinterpreting his anxiousness. At Jessie’s urging, he called the Brookline police and an hour later an officer did stop by more out of courtesy than concern. The man had clearly encountered too many of these situations to get worked up about this one at this point.

“It’s almost always some sort of misunderstanding,” he said, in a clumsy and totally ineffective attempt to calm everyone. “A meeting or an appointment that Mrs. DelGreco’s certain she told you about, but didn’t—something like that.”

Jessie rolled her eyes. Emily was as meticulously organized as anyone she knew, and considerate to a fault.

The policeman then pulled Ed and Jessie away from the boys and asked them about the possibility that Emily was seeing someone else.

“I suppose anything’s possible,” Ed replied clinically.

“Nonsense!” Jessie exclaimed. “Emily tells me when a
movie star
is attractive to her. If she was involved with someone else I guarantee you I’d know about it. I suspect it’s police procedure to wait a certain amount of time before considering a person actually missing, but in this case you shouldn’t waste time waiting, Officer. Emily is an incredibly responsible woman. She would never disappear like this without telling anyone—unless she didn’t have the chance.”

The policeman had responded with patronizing reassurance that they would do whatever was necessary as soon as it was clear Emily had been missing at least twenty-four hours.

Jessie finished the last of the water from the bedside table, and forced herself to use the narrow, molded-plastic shower.

What in the hell happened to Emily?

The question overrode all her other thoughts. She searched with little success for an explanation that worked with all she knew of the woman. Finally, she began ticking through a list of scenarios that didn’t jibe with what she knew. Maybe there was another man. Ed DelGreco was a decent-looking guy, and certainly bright, but he was dry as toast. It wasn’t an impossible stretch to believe that Em could have left Ed and run off with someone. But it was inconceivable that she could have done it to her boys. No, something bad had happened to her. Jessie felt almost certain of it.

Was it possible that Emily’s disappearance had something to do with the Count and Orlis Hermann? Had she seen or heard something she shouldn’t have? Jessie pondered those questions for a time, then toweled off, pulled on a fresh set of scrubs, and fished out the number Alex had given her.

“Four-two-six-nine-four-four-four,” a woman’s sterile voice said.

“Alex Bishop, please.”

“You may leave a message.”

“Can you get it to him?”

“You may leave a message.”

“Okay, okay. Ask Mr. Bishop to page Dr. Copeland, please.” Jessie hesitated, then added, “Tell him it’s important.”

Em, where in the hell are you?

Jessie joined the breakfast bunch in the cafeteria, but found it impossible this day to tolerate their humor. Making rounds on Surgical Seven was the only thing she felt she could handle. With the exception of Ben Rasheed, who would remain a ticking bomb until his surgery later that day, her service—nine patients right now—was in excellent shape. Making rounds on the group would have to be a boost to her spirits, and starting early would give her some extra time to talk with each of them.

As always since Sara’s surgery, Jessie started her rounds in NICU room 6. Although it was only seven-thirty, she was not that surprised to find Lisa Brandon at work, using lotion to massage Sara’s back.

“So, how’s my patient?”

“Just ... good,” Sara said.

Lisa helped her onto her back and cranked up the bed.

“I’m going to see if the nurses have anything for me to do,” she said. “See you later, Dr. Copeland.”

“Thank you, Lisa.”

Sara’s neurologic exam showed signs, albeit not striking ones, of continuing improvement in many areas. Voluntary movement present in all extremities with some decent leg strength. ... Cognition good. ... Speech somewhat disjointed but largely discernible. ... All twelve pairs of cranial nerves intact. Clearly, Sara was nearing the edge of the woods. She was certainly ready to be moved out of the unit and, barring a major complication, could be in a rehab facility within a week.

One friend a virtual miracle, one friend missing. ...
Patrons with heart conditions should refrain from taking this ride.

The two women talked for a time, although Jessie carried most of the conversation. They spoke about the weather and movies, Sara’s kids and Jessie’s personal life, and even what it was like to be operated on while awake. And finally, Sara drifted into an exhausted sleep. Jessie pushed herself up from the edge of the bed and was heading out of the room when she noticed a thin volume on the bedside table, folded open, with a passage circled in pencil. It was Shakespeare’s
Richard III
. The marked passage was probably one Barry Devereau had read to his wife—perhaps many times.

True hope is swift, and flies with swallow’s wings;

Kings it makes gods, and meaner creatures kings.

“Hang in there, Sara,” Jessie whispered. She headed into the hallway, then added, “Em, you hang in there, too.”

“Dr. Copeland, there’s trouble in two,” a nurse called out.

Jessie hurried to Rolf Hermann’s bedside. His daughter was asleep in the guest chair, a pillow bunched beneath her head. A cardiac pacemaker wire, inserted after the code 99, had been added to Hermann’s array of tubes and monitor cables. It was a temporary wire, inserted through a blind stick into the subclavian vein beneath the Count’s right collarbone and threaded down until it made contact with the inner lining of his heart. The pacer control box to which the wire was connected was taped to his upper arm.

Pacemaker, IV, breathing tube, mechanical ventilation, catheter, feeding tube, eyes taped shut. Rolf Hermann or Claude Malloche—whoever he was—was more dead than alive. The code 99 had been a success, but the underlying cause of his cardiac degeneration, which was most likely a disruption of the nerve pathways from the brain regulating his heart rhythm, remained unchanged. And now, another grave situation was developing. His blood pressure, as displayed on the monitor screen from the cannula in his radial artery, was 75/30 ... and dropping.

A normal heartbeat pattern on the monitor with a falling blood pressure. Cardiac pump failure—the sort of circulatory collapse that-not even a pacemaker could help. Rolf Hermann was on the barge, as the residents often put it—on the barge and about to cross the river of no return.

“Hang a dopamine infusion, please,” Jessie said to the nurse. “Then call the cardiology fellow, the neurosurgical resident, and Dr. Gilbride.”

Hermann’s daughter woke up with a start, and appeared lost and alarmed. She was in her early to mid-twenties, lithe, with short, straight brown hair and an aquiline nose that dominated her face. Jessie patted her shoulder to calm her, then led her out into the hall and turned her over to one of the nurses, with instructions to go find Orlis and to bring the whole group to the family room. Rolf Hermann’s heartbeat hadn’t stopped yet, but it was going to.

Jessie sighed and turned to the unit secretary. There was no sense in just sitting around waiting for the inevitable.

“Code ninety-nine, NICU two,” she said. “Please call it in.”

Chapter 25

AFTER THE MEDICAL NIGHTMARE COUNT ROLF Hermann had been through, his death would be almost anticlimactic. With his ventilator-driven respirations, the cardiac meds, and the pacemaker, he was essentially being continuously resuscitated. He could go on indefinitely this way so long as his heart continued to circulate blood with enough force to perfuse his organs. But the drop in blood pressure was a signal that his pump was failing. Speeding up his heart rate with the pacemaker might help for a while, Jessie thought—long enough at least for the room to fill up once again with the usual crush of combatants and onlookers. But the ultimate negative outcome was approaching rapidly.

The cardiology fellow, Joe Milano, was still on call, and in fact had been on his way up to check on Hermann and his pacemaker when the code 99 was broadcast. He rushed into the room, checked the monitor screen, then slid into place beside Jessie.

“I had the pacer set to take over if he dropped below seventy,” he said. “Now he’s pacing at one-twenty.”

“His pressure had dropped to seventy-five,” Jessie replied. “We’ve hung some dopamine, and since there’s no fluid in his chest that I can hear, we’re pushing fluid to increase his circulating volume. But I thought that increasing his rate with the pacemaker might drive up his pressure some.”

“And look, it has,” Milano said, gesturing to the pressure readout of 79. “That was a heck of a good move—especially for a neurosurgeon.”

“I was a doctor once, remember? Any other ideas?”

Milano checked the clear plastic urine collector hanging from the bed frame.

“There’s not much pee. Has this been emptied recently?”

“Three hours ago,” a nurse responded. “There wasn’t much output then either.”

“We can push the pressors and start pumping on his chest,” Milano said. “If we do that, we’re sort of committed to a balloon pump assist as well. As usual, it’s hard to know where to draw the line.”

“The family wants everything possible done,” Jessie said.

“Is it worth trying to put a shunt into his head? It’s almost certain the fallout from his cerebral hemorrhage is causing this, along with some underlying cardiac disease.”

“There’s no evidence for an acute obstruction of the outflow of spinal fluid from his brain. That would be the only neurosurgical condition we might be able to remediate in the OR. His problem is massive brain swelling, not acute hydrocephalus. A shunt wouldn’t help.”

“And his brain swelling’s not going away?”

Jessie shook her head. “No,” she said, glancing over at the doorway and wondering when Gilbride might appear. “It doesn’t look like it.”

“In that case it seems like we’re swimming against the tide regardless of what we do.”

“Pressure’s down to seventy again,” the nurse said.

Her tone was a none-too-subtle request that one of the physicians in charge make a decision whether to plow ahead with meds and chest compressions or stand back and let Hermann’s pressure keep on dropping.

“It’s too bad,” Milano said softly. “The guy comes all the way over here from Germany to have his operation, and ends up like this.”

“Sixty-five,” the nurse said.

“I don’t know,” Jessie said. “My head is telling me we’d better pull out all the stops. My heart says that doing that is a cruel and expensive exercise in futility.”

She looked past the crowd to the hallway again. Carl Gilbride wasn’t there, but Alex Bishop was, dressed in his brown security force uniform. He caught her eye and asked the obvious question with a gesture. She replied with a barely perceptible shake of her head. At that moment, Gilbride strode past Alex and into the room. Despite having left the hospital at ten last night for what Jessie assumed was a decent night’s sleep, and despite his spotless lab coat and designer shirt, he looked haggard and edgy.

“What’s going on here?” he demanded.

“Pump’s failing,” Milano said.

“So, get it going.”

Gilbride looked reproachfully at Jessie.

“How long have you been here?” he demanded.

“Ten minutes or so.”

“And you’re not doing anything?”

“We were just discussing whether it was appropriate and fair to send for a balloon assist pump.”

“Milano, get him through this,” Gilbride ordered. “I don’t care what you have to do.” He turned to Jessie. “Because of you, I’ve canceled appearing on a panel in New York City that was very important to me. And now I get here and find you just standing around.”

“Begin compressions,” Milano said to the medical resident, the resignation in his voice making it clear the order was against his better judgment. “Someone please call down to the CCU and have the intra-aortic balloon pump brought up here. Might as well call the cardiac surg people as well to help with the insertion.”

“I’ll call them,” Jessie said quickly, anxious to get out of the room.

She was furious at Gilbride’s public rebuke, but she was also a bit sheepish that she hadn’t been as aggressive as he was being. Still, dead was dead. And the most exhaustive, expensive interventions in the world weren’t going to bring back Rolf Hermann’s brain or, for that matter, his heart.

She hurried past Alex with just a brief nod that he should follow. Then she stopped at the ward secretary’s desk, called the coronary care unit, and asked to have a nurse wheel up the balloon pump. The apparatus, a long balloon that was inserted into the abdominal aorta through an artery in the groin and inflated with each heartbeat, could raise the blood pressure in some cases of pump failure. Next Jessie put in a page for the cardiac surgery team. Finally, she walked down the hall to a small alcove opposite the only empty room in the NICU, and motioned to Alex that the coast was clear.

“Is he going to make it?” he asked at once.

“Define
make
it,” Jessie replied. “Joe Milano, the cardiologist, is damn good, but I don’t think anyone’s
that
good. Do you know that I called you early this morning?”

“I do, yes. I’m sorry. They just reached me with the message.”

“What were you doing?”

“I was off getting a hearse.”

“A hearse?”

“A hearse, the black dress suit, the subdued tie, the works—all courtesy of the greedy folks at Bowker and Hammersmith Funeral Parlor. They have even offered their cooler to stash Hermann’s body in until Jorge Cardoza gets here.”

“Very clever. When will he be arriving?”

“This afternoon. His plane lands at three. Is Hermann still going to be among the living by then?”

“Define
living
. I was ready to call it quits on the resuscitation before Carl got here. But he canceled an appearance in New York because of the Count, and now he’s determined the guy’s going to survive this.”

“It’ll be dangerous bringing Cardoza into the hospital. There’s a chance one or another of Hermann’s so-called family knows him.”

“Well, speaking as a betting woman, my money’s on your not having to.”

“Will you help me get Hermann out of the hospital? I know where the morgue is, but I don’t know much about the protocol.”

“Jesus, Alex. I’m still not even certain who you
are
, and you want me to risk my career by stealing a body from my own hospital?”

“Forget I asked.”

“I’ll do it. I’ll do it. But listen. You’ve got to help me, too. I’m very frightened about my nurse practitioner, Emily.”

“What do you mean?”

“She’s disappeared. According to her son, yesterday evening she got a phone call, then said she was going to the hospital. He assumed it was me calling, but it wasn’t. She hasn’t been heard from since, and I’m very worried.”

“Has her family called the police?”

“Yes, but they won’t do anything until she’s been missing at least twenty-four hours.”

“Missing, huh. That is a little worrisome. She’s never done anything like this before?”

“Never. That’s why I called you. I want to make a deal. If I help you with Hermann, I want you to get your FBI friends involved right away in finding Emily.”

“I don’t know if—”

“No deal, no body. And I mean it. I want them on the case today no matter what the Brookline police say.”

“I’ll do my best.”

“Look at me, Alex. Right here in my eyes. ... Dammit, I wish I could tell when you’re lying.”

The nurse from the coronary care unit raced by, pushing the orange-crate-sized intra-aortic balloon pump ahead of her.

“Go ahead back in there,” Alex said. “I won’t be far away.”

“Why don’t you use the time right now to keep your end of the bargain and call your FBI friends? Emily DelGreco. Her number’s listed in the Brookline directory under Edward DelGreco.”

“Okay. Okay. You’re like a frigging pit bull.”

“There’s a side of me that pit bulls run away from. You came dangerously close to bringing it out once. For both our sakes, don’t do it again.”

She hurried away without waiting for a response, and rejoined the throng in room 2.

The blood pressure readout on the monitor showed 50 now. Rolf Hermann’s skin was gray, mottled with deep violet. His eyelids were taped closed. A respiratory tech was using a breathing bag to supply him with 100 percent oxygen. By any definition, the Count was far more dead than alive. Still, the team, driven by a frantic Carl Gilbride, pushed on. The resident continued pumping on Hermann’s chest while Joe Milano gave med orders to the nurses. And now a cardiac surgical resident was on the scene as well, preparing Hermann’s groin for the insertion of the intra-aortic balloon, and calling out his supply needs without checking to see if anyone was listening. It was a medical circus maximus, and at the center stood Carl Gilbride, no more effective than Nero might have been while watching Rome burn around him.

Jessie was torn between diving in to relieve the exhausted resident who was doing the chest compressions, and simply skulking off to a quiet corner of the hospital until the madness was over. Finally, she decided on a compromise, and moved to a spot next to Gilbride. There was a particular favor she wanted to offer him when it was appropriate to do so.

“Any change?” she asked.

“You might have started all this sooner,” Gilbride said, never turning away from the action.

“I’m sorry,” she replied, unwilling to take the bait and start up an argument about the definition of futility.

“It doesn’t look good.”

The pressure was down to 45—poor even for artificial external cardiac compressions.

“That chest pumper’s running down,” Jessie said. “I think I’ll take over.”

“Nonsense. You’re an assistant professor. Pumping is a resident’s job.”

He called out and caught the attention of the neurosurgical resident. Then he pointed at Hermann’s chest and pantomimed the order that the man take over the cardiac compressions. To Jessie, it was as if Nero was now demanding that a bucket of water be tossed on the conflagration. The personnel transfer took place on the bed without missing a beat, but the pressure readout remained essentially unchanged. Five more minutes passed. Fifteen people—residents, students, nurses, technicians, faculty—had been tied up for the better part of an hour now. Thousands of dollars in equipment, medications, and lab tests had been expended.

“Balloon’s in and functioning well,” the cardiac surgery resident announced.

“Stop pumping, please,” Joe Milano requested.

The room was suddenly silent save for the beeping of the monitor, the puffs of the Ambu breathing bag, and the soft thump of the intra-aortic balloon assist. Every eye was fixed on the monitor. For a time, maybe a minute, maybe two, the blood pressure reading stayed at 50. Then slowly, like the orbit of a dying satellite, it began to deteriorate. Down to 47 ... 42 ... 40. Seconds after the pressure hit 40, Rolf Hermann flat-lined. No one moved. The silence in the room continued as everyone on the resuscitation team waited for Carl Gilbride to decide whether or not it was over.

There was nothing from him. Not a word.

Finally, Joe Milano spoke up.

“Dr. Gilbride, I appreciate how much you want this guy to make it. But I’m not sure what else we can do.”

“This all should have been started sooner,” Gilbride said.

He turned and stalked from the room.

Jerk
.

“That’s it. Thank you, everyone,” Jessie blurted, hurrying after Gilbride, and catching up with him at the nurses’ station.

“Sorry,” she said, wanting to throttle the man.

“Where’re his wife and the others?”

“Waiting in the family room.”

“Well, I suppose I’d best get this over with.”

“Be careful. Remember what I told you about her.”

“What you told me is nonsense. Killers! Fake security guards! I just want to get this whole business over with. I never should have canceled my appearance in New York. Never. And now Mrs. Levin has developed a headache and a fever on the day she was supposed to be discharged. As soon as I finish with the Countess, I’m going to have to perform a spinal tap on her.”

“Would you like me to do it?”

“I think you’ve done enough for one day.”

“How about Orlis? Do you want me in there with you when you speak to her?”

“I think I can handle that myself as well.”

“Okay,” Jessie said. She crossed her fingers for luck and went for the brass ring. “How about the death certificate? Can I fill that out for you?”

Gilbride mulled the request over, then finally said, “I suppose so. As long as you make sure the cause of death is listed as cardiac, because that’s what it was.”

“Cardiac arrest, due to arteriosclerotic heart disease, with meningioma as a coincidentally existing condition. How does that sound?”

“It sounds like the way it should be. Now, if you’ll excuse me, I have a great deal to do.”

“So do I,” Jessie murmured as he walked away.