Patient One (22 page)

Twenty-four

Marci was fighting frantically
for air. With every shallow inspiration she made a rasping, agonal sound. Her condition was so dire David thought her next breath would be her last.

“We’ve got to do something,” Carolyn pleaded in a low voice, squeezing Marci’s hand and trying to comfort her. “We’ve got to try!”

David shrugged helplessly. They had already tried increasing the flow of oxygen and more IV Solu-Medrol, but her symptoms had only worsened. “Without a long needle, there’s nothing we can do.”

“Can’t you just use a regular needle to go through her chest wall and drain the effusion?”

David shook his head. “I could kill her doing that. At the very least, she’d end up with a collapsed lung, and then she couldn’t breathe at all.”

Carolyn patted Marci’s hand and smiled, as if everything was going to turn out all right. But she could tell the young woman knew otherwise. Marci had that frightened look that said she realized death was coming. And soon.

Marci began panting for more oxygen, her skin color growing duskier. Between gasps she asked weakly, “Can … can you give me some medicine, please?”

“In a minute,” Carolyn lied, then turned to David and hissed quietly, “Jesus! Do something!”

David hesitated briefly, then sighed and accepted the fact that what he was about to do could instantly kill Marci. “What’s the longest eighteen-gauge needle you’ve got?”

“An inch and a half,” Carolyn answered. “That’s plenty long enough to go through Marci’s chest wall.”

And plenty big enough to cause a large pneumothorax in the process
, David thought glumly. Then he’d have to put in a chest tube to re-expand the collapsed lung, but it would be too late. Marci would be dead before he could do it. Again he hesitated. “Don’t you have a thoracentesis tray up here? That would have a longer needle.”

“We don’t keep any trays on the Pavilion,” Carolyn informed. “We order them up as we need them.”

David thought for a moment, then rapidly blinked. “Wait a minute! Didn’t you order a paracentesis tray on Diana Dunn? You know, to remove some of her ascitic fluid?”

Carolyn shook her head. “That was canceled because she developed a fever and started acting strangely. The resident decided to do a lumbar puncture to rule out meningitis as a cause. So we ordered up a—” She stopped in mid-sentence, her eyes widening. “We ordered up an LP tray!”

“Which would have a very long needle,” David said in a rush.

Carolyn nodded quickly. “Six inches worth.”

“Is the tray up here?” David asked at once.

“I’m … I’m not sure,” Carolyn stammered. “The lumbar puncture was put on hold because her fever subsided. The tray may have been sent back down.”

“Find out,” David urged. “If it’s still here grab it, along with a 50-cc syringe.”

Carolyn ran for the door. David leaned over and rapidly examined Marci. She continued to suck for air, her lips now a cyanotic color. And her neck veins were markedly distended because the pericardial effusion was so severe it was pressing on the heart and not allowing blood to flow in from the body’s large veins. And there was a simple equation when it came to the heart. No blood in, no blood out.
How was this girl managing to stay alive?

“Dr. Ballineau,” Marci muttered softly, “are you going to get this fluid off my heart?”

“As soon as the nurse returns,” David said, silently praying that the LP tray was still on the Pavilion. It was Marci’s only chance.

“Will it hurt?” Marci gasped.

“A little,” David replied. “But it will be worth it for you to breathe normally again, won’t it?”

“Yeah,” she said, her voice so weak it was barely audible. “No pain, no gain, huh?”

David smiled down at Marci, whom he had grown to really like. She was pretty and smart and full of life, despite her illness. She was a fighter. His gaze went to her face and as usual focused in on her doe-like eyes. He had seen those same eyes way back in the past. They reminded him of his wife, Marianne.

A hacking cough came from the doorway.

David glanced over and saw the balding terrorist looking in at them. He still seemed befuddled, just as he had been when David and Carolyn ran by him in the corridor earlier. And rather than shoot or shout at the pair, he simply followed them into Marci’s room. He wasn’t too bright, David decided. But that didn’t make him any less deadly. On Aliev’s command, he would happily kill a nurse and a doctor. And a President.

Marci began choking, her hands desperately clutching for her throat. Her lips were turning a deep blue.

It’s the end
, David thought sadly.

Carolyn dashed into the room, holding a cloth-bound tray. “Got it!”

A second terrorist suddenly appeared in the doorway. He yelled angrily in Chechen at the guard and shoved him down the corridor. Then he came back to David and Carolyn and motioned them to the door with his Uzi. “Out!”

“But this patient desperately needs our help,” Carolyn pleaded, turning toward Marci. “Without us she’ll—”

“Out!” The terrorist backhanded Carolyn across her forehead, and sent her flying into David’s arms.

David was knocked off balance, but somehow managed to steady himself and hold onto Carolyn. Quickly, he asked her, “Are you all right?”

“More scared than hurt,” she breathed, although a red welt was forming over her temple area.

“I will not say a third time,” the terrorist threatened, now pointing his Uzi directly at them.

Supporting Carolyn, David headed for the door and asked the terrorist, “Where do you want us to go?”

“To roof, to see Aliev.”

“For what?”

The terrorist smiled malevolently, then held his hand up high, cupped it, and slowly let it drop.

“Oh Jesus!” Carolyn whimpered. “I think he plans to throw us off the roof !”

“Yeah,” David said tonelessly, knowing it was Carolyn who would most likely be killed. To Aliev, a doctor was all that was required to keep the President alive. The nurse was expendable.

“M … maybe we can reason him out of it,” Carolyn hoped in a weak voice.

“Terrorists don’t reason, they kill.”

They walked across the corridor, which was silent and vacant, and entered the stairwell for the fire stairs. The terrorist nudged them toward the stairs with the barrel of his Uzi. “Nurse first,” he ordered.

David hesitated and tried to think of a way to disarm the terrorist. And he had to do it before they started up the stairs. With his back to the terrorist he stood no chance.

“Go!” The terrorist demanded.

Suddenly, a flashback from a similar situation long ago came to David. But he needed a distraction for it to work again. A big distraction.

Moving slowly, David helped Carolyn up the first step and said under his breath, “Pretend you’re going to throw up when your foot touches the next step.”

On cue, Carolyn forced herself to gag, then abruptly leaned over the railing and began retching.

For a moment the terrorist’s eyes went to Carolyn. When he brought his gaze back to David it was a second too late. David’s kick was already in midair, heading directly for the terrorist’s testicles. The man let out a muffled cry, then groped at his groin and fell onto the floor face first. David quickly pounced upon the terrorist. He held the man’s head up by its hair and delivered a powerful, precise blow to the upper neck, crushing the second and third cervical vertebrae and severing the spinal cord beneath them. The terrorist’s body convulsed, then went flaccid.

Carolyn stared at David, wide-eyed. “Did you kill … ?”

David waved his hand, quieting her. “We’ve got to get rid of the body, or we’ll both be dead.”

Swallowing back her fear, Carolyn hurriedly collected herself and looked over to the staircase. “Let’s throw him down the steps.”

David peered down the stairs and saw the multiple tripwires and photoelectric sensors that were connected to explosives taped to the walls. “It’s booby-trapped. The body will set off an explosion that will blow us to hell and back.”

“So what should we do?” Carolyn asked anxiously.

David glanced around the stairwell, with its thick plaster walls that had neither ducts nor crawlspaces. There weren’t any places to hide the dead terrorist, and it made no sense to drag the body across the corridor where it would surely be found. Shit! David grumbled silently, thinking they were trapped and bound to be discovered any moment now. Again, he surveyed the fire stairs, searching for a way out of the dilemma. Abruptly, his gaze stopped at the space between the staircases. He rapidly turned to Carolyn and said, “Help me pick him up.”

“What are we going to do?” Carolyn asked.

“You’ll see,” David replied. “Grab his legs.”

They lifted the body and moved it over to the railing, then rolled it over into the space between the staircases. The body fell straight down, then glanced off a rail and slammed into the landing on the floor below. It bounced up once and stayed within sight.

Carolyn asked, “Won’t the terrorists see the body when they start searching for their missing man?”

David shook his head. “The Secret Service has the floor beneath us covered. Chances are they’ll find the body and remove it.”

“And if they don’t?”

“Then we’re in big trouble.”

Carolyn pointed to the Uzi on the floor near the stairs. “Should we take his weapon?”

“No.” David picked up the Uzi and tossed it over the railing. “If they find us anywhere near the weapon, they’ll figure out what happened and we’ll both be dead.”

“Couldn’t you have used it to shoot …”

David shook his head again, interrupting her. “There are too many of them. If just one of the terrorists is left standing, the President and his family will be carried out of here in body bags.”

Hurriedly turning for the door, neither of them noticed the smear of blood on the floor that had come from the dead terrorist’s mouth.

At the doorway, David peeked out into the corridor and saw a terrorist about to enter the nurses’ lounge. He quickly jerked his head back in and waited several seconds before peeking out again. The corridor was now clear. Taking Carolyn’s hand, he dashed across to Marci’s room.

Marci was grasping for air with shallow, rapid respirations. Her entire face was now deeply cyanotic.

“Lower the bed!” David directed. “And pull her gown up well away from her abdomen!”

David hastily opened the lumbar puncture tray and painted Marci’s abdomen and lower rib cage with an orange antiseptic. After slipping on latex gloves, he palpated the xiphoid process, the small cartilaginous structure at the very end of the sternum. Then he took a long needle and stuck it through the skin and muscle beneath the xiphoid process. Slowly he advanced it upward toward the heart, staying as close to the chest wall as possible. Be careful, he warned himself, trying to be even more deliberate. He didn’t want to puncture the heart or tear a hole in it.
Goddamn it! I need an echocardiogram to guide me! I’m blind without it, and I don’t know where I am anatomically.
He felt like he was practicing medicine in the Middle Ages.

Marci was gagging and choking, now unable to clear her airway. Her respirations sounded like squeals.

“David,” Carolyn warned, “she’s going out.”

“I know. I know.”

David pushed the needle up farther and felt the resistance of the diaphragm that separated the thoracic contents from the abdomen. He gave the long needle another thrust. The resistance vanished. But no fluid came out of the needle.
Oh, shit! I missed it! Am I inside the lung, or what?
The needle was in almost to the hub. Out of desperation he gave the needle a final push.

Clear fluid suddenly spurted from the end of the needle, gushing out in a steady stream. It slowed for a moment. Then the flow continued, pouring onto Marci’s abdomen and sheet. David stared in awe at the volume of pericardial fluid being extracted. It had to be 200 ccs, or more.
My God! How did she stay alive with an effusion that size?

The flow gradually diminished, until it was coming out in drops. David attached a large syringe to the needle and aspirated another 20 ccs.

“David! David!” Carolyn said excitedly. “You’ve got to see this!”

David looked over at Carolyn, who was motioning to Marci’s face. The girl’s cyanosis was disappearing right before their eyes, her lips and cheeks turning a rosy pink. And her neck veins were flattening to the point they were barely noticeable.

“Unbelievable!” Carolyn marveled.

“Oh,” David swooned softly, enjoying the moment.
A life almost gone. A life brought back. It was one of medicine’s magic moments.
With a nod of satisfaction, he removed the needle and bandaged the puncture site.
I was lucky,
he had to admit.
Just plain lucky. Blind man’s luck on the first try.
He put a smile on his face and gazed down at Marci, who was taking long, even breaths. “How are you doing, kiddo?”

“Better,” Marci replied, taking another deep breath and savoring the air. “A lot better.”

“So I can see.”

“Thank you for helping me, Dr. Ballineau.”

“You’re welcome.” David patted her shoulder and glanced up at her IV line. The plastic bag was nearly empty. He looked over to Carolyn and said, “Run a liter of saline into Marci. We’ve got to replace the fluid she’s lost.”

Carolyn hesitated. “Won’t it just go back into her pericardial sac?”

“No, it’ll stay in her intravascular space.”

David pushed himself up from the bed. He abruptly reeled as his weakness returned and the room started to sway. He grabbed Carolyn’s arm and tried to steady himself, but the wavering persisted.

“Are you okay?” Carolyn asked, alarmed.

“You’d better help me to the couch,” David said, leaning heavily on her.

Carolyn placed her arm around his waist and led him to the couch, where he plopped down. She sat beside him and said, “I think all that blood you lost is taking its toll. You’re the one who is going to need a transfusion.”