Fatal (3 page)

Easterly thrust out her gravid belly and arched her back, trying to relieve some tightness somewhere.

“Not that I can tell,” she replied, still whispering. “He drove some piece of heavy equipment over two guys. No one knows why. One of them’s dead. The other’s up in the OR right now, and I don’t think he’s going to make it. After he did that, he knocked down some supports and the roof collapsed. He was trapped beneath a load of rock. The rescue guys said his BP was all right on the way in. I think the triage nurse assigned him to me because he looked pretty good when he got here.”

“Not anymore. Obvious fractures?”

In addition to the usual sources of hidden blood loss—the chest and abdominal cavities—a fractured leg, or even an arm in some cases, could cause enough bleeding into muscle to throw a victim into shock.

“None,” Easterly said. “He’s moving all extremities. Joe Terry was just hanging around waiting for the OR to be ready for his case, so I had him put an arterial line in.”

“Nicely done.”

Matt meant the compliment, although it was also obvious that except for the arterial line, Easterly hadn’t been nearly aggressive enough with a man this hurt. At the moment she seemed close to tears.

“You know,” she said, “if I had known I was going to end up with this sort of crunch in the very guy responsible for the disaster, I would have stayed home.”

“Listen, Judy, why don’t you go ahead home right now,” Matt said. “You’ve got things under reasonable control here, and it looks as if you and the kid could use some rest.”

Easterly started to protest, then suddenly thanked him.

“Bloods are off for the usual labs plus six units,” she said rapidly. “I ordered a portable of his chest and abdomen. I really appreciate this.”

“Just name your kid after me,” Matt said.

“Matthewina,” Easterly said. “I think she’d like that. Hey, thanks. Good luck.”

Before Matt could even respond, she was gone. It was just as well. She clearly had other things on her mind and was already hovering between not-much-help and downright dangerous. He glanced again at the monitor and moved into Easterly’s spot at the bedside, across from Jon Lee. Then he stopped short, staring down in disbelief at the man whose insane rage had just killed one and possibly two co-workers. Darryl Teague’s face was covered with fleshy lumps, at least twenty of them, some pea-sized, but some quite a bit larger, and one, just in front of his left ear, approximating a walnut. Almost certainly they were neurofibromas—bundles of nerve tissue mixed with spindly fibrous cells. Cause: unknown. Cure: none known. Darryl Teague was well on his way to becoming an Elephant Man.

Even more startling to Matt was that Teague was the second case of such a condition he had seen in the past four or five months.

“Laura, Dr. Hal Sawyer is part of our disaster team. Could you please call him in the lab and ask if he can come over as soon as possible.”

“You’ve got it.”

Matt quickly turned his attention to the miner. Teague was conscious and still breathing on his own, but his skin was mottled and his lips were a grayish purple.

“Jon, anything ordered for his pressure?”

“Nothing yet, Doctor.” Lee’s tone made it quite clear that he was grateful for the change in medical command.

“Hang some dopamine, standard drip. Run it wide open until we see what happens. Get a catheter in him and keep his volume up.”

Laura Williams returned. “Dr. Sawyer will be over shortly,” she said.

Matt peered up at the EKG monitor. The size of the beats on the tracing appeared much smaller than normal. He filed the information away for the moment and began an efficient exam. Teague’s heart sounds were muffled and distant. There was tenderness in the center of his sternum—enough tenderness to cause the semi-comatose man to cry out when the spot was pressed. His belly was soft and not the least bit tender. His lungs were clear. Legs, arms, unremarkable. Skull and scalp also normal, except that there were a dozen or more neurofibromas hidden beneath Teague’s long, strawlike, dirty blond hair.

In short, there was no evidence for bleeding anywhere. So why was Teague in shock?

The likely answer at the moment centered around trauma to the miner’s breastbone, and beneath it, his heart.

“Laura, where’s Dr. Crook?” he asked.

“On his way in. Turns out his beeper was accidentally shut off, and his phone wasn’t working. The Sandersonville police went out to his place and woke him up.”

Sandersonville was twenty minutes from the hospital and Crook was hardly the sort who would simply jump into a pair of sweats and race on in—especially when there was no definite indication in any of the victims that a cardiologist would be needed.

“Dr. Rutledge?”

Lee gestured at the monitor—70/30.

“Prepare to intubate him, Jon. Anesthesia around?”

“In the OR.”

“Radiology?”

“Same. She’s doing some sort of procedure with Dr. Terry.”

Inwardly Matt groaned. He had intubated dozens of patients, many of them critical, so that was no problem. But his ability to interpret an ultrasound was average at best. In a life-and-death situation like this one, he would want a radiologist’s opinion.

“No problem,” he said. “Get me a seven-point-five tube, please. Laura, could we talk out there?”

The nurse looked at him curiously.

“Of course,” she said.

“Jon, just shout if you need me.”

Matt walked Laura to the nurses’ station. She was a straight-laced grandmother in her early fifties, traditional in her approach to medicine, and a damn fine nurse. She was never comfortable with Matt’s open style, manner, and dress, and she had said so on several occasions. Still, over the years, they had managed to co-exist with few problems. Now, he knew, he was about to put their mutual respect to the test.

The commotion in the ER seemed to have leveled off, and the moaning from the injured miners was much less.

“How’s he doing?” Blaine LeBlanc asked as they passed.

“Later,” Matt said.

“You talk to me before you do anything heroic, you hear? That . . . that weirdo killed one and maybe two of my men.”

“Sure, Dr. God,” Matt said. “I’ll be certain to consult with you.”

He turned his back on LeBlanc and spoke softly to the nurse. From what he could discern, blood was building up between the lining of Teague’s heart and the heart muscle itself. The resultant constriction of the heart muscle was keeping it from filling properly between each beat.

“Laura, this guy’s got a pericardial tamponade.”

“How do you know?”

“That’s what it’s got to be. We need to stick a needle into it and drain the blood.”

“Can’t we wait for Dr. Crook?”

“Unless we can be sure he’s going to be here in the next five minutes, the answer is no.”

“What about some tests? An ultrasound?”

“Radiology is in the OR. I don’t trust the tech or me to read one with certainty. Besides, I don’t think we have time. This kid is going out.”

“Maybe that’s for the best,” Laura said.

“Now, don’t let us get started on that,” Matt said. “Please get me a pericardial drainage kit.”

“Matt, I don’t like this at all. How many times have you done this procedure?”

“A few during my residency,” Matt lied. “I can do it.”

“Pressure’s not reading,” Lee called out. “EKG is showing many extra beats.”

“Please,” Matt said, heading back to room 10.

“If you’re ordering it, I’ll be right there with the kit.”

“Remember what I told you,” LeBlanc said as Matt passed him.

Matt knelt at the head of Darryl Teague’s bed and skillfully slid a breathing tube down his throat and between his vocal cords. The respiratory tech then hooked the tube to a breathing bag and oxygen, and began to pump. Teague’s chest expanded much more than it had been, but his blood pressure only rose to 50.

“Nice intubation, Doctor.”

Hal Sawyer stood just inside the doorway. With his dark hair graying at the temples, his carefully trimmed mustache, his gold-rimmed glasses and knee-length lab coat, Uncle Hal looked as professorial as did any medical school dean. In fact, he did have a clinical teaching position at one of the medical schools, but for the most part he stayed pretty close to Belinda, where he was chief of pathology (there was one other full-time pathologist) as well as the Montgomery County medical examiner. Hal was also erudite, well-read, and adventurous. He seldom spoke up at hospital staff meetings, but when he did, people generally listened.

Never married, Hal didn’t seem to lack for company. His latest girlfriend, Heidi, was a pretty, young thing he had met on some sort of rafting trip. The gossipers in Belinda went on about his personal life, but he never seemed to care, just as he didn’t care when the rumors started going around some years ago that he was gay. Hal was very much his own man, and Matt credited him with fostering his own sense of independence.

“Hey, Hal,” Matt said, “thanks for coming over. This is the guy who went berserk in the mine and caused this nightmare. People say he’s been acting paranoid for months. Paranoid insanity coupled with diffuse neurofibromatosis of the face and scalp. Ring any bells?”

“Just like that cliff diver.”

“Exactly. His name was Rideout. Teddy Rideout. And where did he work?”

“As I recall,” Hal said, palpating the lumps, “he, too, was a miner.”

“He was most definitely that. BC and C, to be exact.”

“My, my,” Hal said.

Some months ago Matt had been cruising on his Harley down a particularly winding mountain road when Rideout sped past him on the inside, traveling much faster than the road ahead would tolerate. A minute or so later, Matt came upon the shattered guardrail and saw the car lying on its roof several hundred feet below. Rideout lay well beyond resuscitation. His striking facial lumps were identical to Teague’s, and subsequent discussion with his family revealed a history of rapidly progressive paranoia and irrational, aggressive behavior. At the man’s autopsy, Matt wondered out loud to his uncle if Rideout might be toxic from something at the mine.

Hal had promised to run some extra tests, which came back negative. It was Hal’s belief that the man was one of a kind—a very unusual case, but just a single fluke point on the graph of life.

Well,
Matt thought now,
here’s dot number two.

“I’ll see what I can dig up about Mr. Rideout,” Hal said. “I don’t recall anything unusual in the autopsy except for those neurofibromas, which were only of interest because of their numbers, not their microscopic appearance.”

“Here’s the kit,” Laura said, setting the tray marked
PERICARDIOCENTESIS
down on the stainless-steel stand.

“Any sign of Crook?”

“He could be here any minute. Are you sure you—”

“But he’s not here now. This guy’s BP is back down to zero. He’s firing extra beats. I say we go.”

“Suit yourself,” Laura said coolly.

In fact, Matt had attempted pericardial taps a number of times as the last gasp maneuver in cardiac arrest patients who were about to die despite the most heroic resuscitative measures. But never had the procedure located any unsuspected pericardial blood. And never had any of the patients survived.

“Need any help?” Hal offered.

“Will Robert Crook to stroll into the ER right now,” Matt said. “I just don’t think we can wait.”

Beyond Hal, just a few feet outside the door, Matt could see Blaine LeBlanc, watching, waiting.

“I’m still not getting any pressure at all,” Lee reported. “Ventricular extra beats in pairs.”

Sometimes you just got to do what you got to do,
Matt was thinking.

He attached a four-inch-long, wide-bore cardiac needle to a 20cc syringe and hooked an alligator clamp to the base of it. He would know he was wrong about there being pericardial blood only after he had driven the heavy needle through the tissue-thin pericardial membrane and into the base of Teague’s heart. The electrocardiogram would react immediately to the trauma, and hopefully, he would have time to stop and withdraw the needle before any major damage was done to the cardiac muscle. Hopefully. But if he pierced the muscle and hit a coronary artery, the resulting heart attack would give Teague almost no chance at all.

Matt forced the needle through the skin at the V formed by Teague’s left lower ribs and the tip of his sternum. Then he angled it toward his left shoulder. Keeping the pressure constant, he advanced the needle through the diaphragm toward what he envisioned was the base of the heart.

Slowly . . . slowly . . .

“Lots of extra beats,” the nurse reported.

“Are you hitting his heart right now?” Laura asked.

Matt checked the monitor.

I sure hope not,
he thought.

“No,” he said assuredly.

“Are you sure?”

Without warning, the syringe filled with blood.

Yes!

Matt switched the three-way valve on the syringe to empty and injected its crimson contents into a small glass cup. Then he withdrew another 25cc of blood from Teague and squirted it into a larger beaker.

“How do you know you’re not drawing blood directly from his heart?” Laura asked.

The woman simply wasn’t going to let up.

Hal stepped forward.

“Ms. Williams,” he said calmly, “it looks very much like Dr. Rutledge knows what he is about. There is one way to tell right here where that needle tip is. If that blood Dr. Rutledge just removed was sitting in this man’s pericardial space, it probably won’t clot. If it’s directly from the ventricle of the heart, it will.”

“How long will that take to know?”

Matt ignored the question and drew off another syringeful. Teague’s condition remained unchanged. To his left, Lee tried again to hear a pressure, then shook his head gravely.

“If he’s in shock and you might be taking blood from his heart, won’t that make the situation even worse?” Laura asked.

Back off!
Matt wanted to scream. The nurse was quite obviously protecting herself against Robert Crook’s certain onslaught.

I tried to reason with him, Dr. Crook, really I did.