Still there was no cardiac activity. As Jerry opened the outer cover of the sterile packaging holding a transvenous pacemaker electrode, he wished he had never begun the charade. Intuitively he knew the patient was too far gone. But now he had started, he had to finish.
“I’m going to need a fourteen-gauge intercath,” said Jerry. With betadine on a cotton sponge, he began to prepare the entry site on the left side of Bruce’s neck.
“Would you like me to do that?” asked the surgical resident, speaking for the first time.
“I think we have it under control,” said Jerry, trying to project more confidence than he felt.
Pamela began helping him on with a pair of surgical gloves. They were just about to drape the patient when a figure appeared at the doorway and pushed past the medical student. Jerry’s attention was drawn by the surgical resident’s response: the ass-kisser did everything but salute. Even the nurses had perceptively straightened up as Thomas Kingsley, the hospital’s most noted cardiac surgeon, strode into the room.
He was dressed in scrub clothes, obviously having come directly from the OR. He approached the bed and softly laid a hand on Bruce’s forearm as if through the mere touch he could divine the problem.
“What are you doing?” he asked Jerry.
“I’m passing a transvenous pacemaker,” said Jerry, shocked and impressed by Dr. Kingsley’s presence. Staff members usually did not respond to cardiac arrests, especially in the middle of the night.
“Looks like total cardiac standstill,” said Dr. Kingsley, running a portion of the voluminous EKG tape through his hands. “No evidence of any type of AV block. The chance of a transvenous pacemaker being successful is infinitesimally small. I think you’re wasting your time.” Dr. Kingsley then felt for a pulse at Bruce’s groin. Glancing up at Peter, who was perspiring by this time, Dr. Kingsley said, “Pulse is strong. You must be doing a good job.” Turning to Pamela he said: “Size eights, please.”
Pamela produced the gloves without delay. Dr. Kingsley pulled them on and asked for the crash cart scalpel.
“Could you pull off the dressing?” said Dr. Kingsley to Peter. To Pamela he said he needed some sterile heavy dressing scissors.
Peter glanced at Jerry for confirmation, then paused in his massage, and pulled off the tangle of adhesive and gauze over the patient’s sternum.
Dr. Kingsley stepped up to the bed and fingered the scalpel. Without further delay he buried the tip of the knife in the top of the healing wound and decisively drew it down to the base. There was an audible snap as he cut each of the translucent blue nylon sutures. Peter slid off the bed to get out of the way.
“Scissors,” said Dr. Kingsley calmly as his audience watched in shocked silence. This was the kind of scene they’d read about but had never seen. Dr. Kingsley snipped through the wire sutures holding the split sternum together. Then he pushed both hands into the wound and forcibly pulled the sternum apart. There was a sharp cracking noise. Jerry Donovan tried to glance into Bruce’s chest but Dr. Kingsley had obscured the view. The one thing Jerry could tell was that there was no bleeding whatsoever.
Dr. Kingsley eased his hand, fingers first, into Bruce’s chest and cupped the apex of the heart. Rhythmically he began to compress it, nodding to Rose when she should inflate the lungs. “Check the pulse now,” said Dr. Kingsley.
Peter dutifully stepped forward. “Strong,” he said.
“I’d like some epinephrine, please,” said Dr. Kingsley. “But it doesn’t look good. I think this patient arrested some time ago.”
Jerry Donovan thought about saying he had the same impression but decided against it.
“Call the EEG lab,” said Dr. Kingsley, continuing to massage the heart.
“Let’s see if there’s any brain activity at all.”
Trudy went to the phone. Dr. Kingsley injected the epinephrine but could see that there was no effect on the EKG. “Whose patient is this?” he asked.
“Dr. Ballantine’s,” said Pamela.
Bending over, Dr. Kingsley peered into the wound. Jerry guessed he was assessing the surgical repair. It was common hospital knowledge that on a scale of one to ten, as far as operative technique was concerned, Kingsley was a ten, and Ballantine, despite the fact that he was chief of the cardiac surgery department, was about a three.
Dr. Kingsley abruptly looked up and stared at the medical student as if he’d seen him for the first time. “How can you tell at the moment this isn’t a case of an AV block, Doctor?”
All color drained from the student’s face. “I don’t know,” he managed finally.
“Safe answer,” smiled Dr. Kingsley. “I wish I had had the courage to admit not knowing something when I was a medical student.” Turning to Jerry he asked: “What are his pupils doing?”
Jerry moved over and lifted Bruce’s eyelids. “Haven’t budged.”
“Run in another amp of bicarbonate,” ordered Dr. Kingsley. “I assume you gave some calcium.”
Jerry nodded.
For the next few minutes there was silence as Dr. Kingsley massaged the heart. Then a technician appeared at the doorway with an ancient EEG machine.
“I just want to know if there’s any electrical activity in the brain,” said Dr. Kingsley. The technician attached the scalp electrodes and turned on the machine. The brain wave tracings were flat, just like the EKG.
“Unfortunately, that’s that,” said Dr. Kingsley as he withdrew his hand from Bruce’s chest and stripped off his gloves. I think someone better call Dr. Ballantine. Thank you for your help.” He strode from the room.
For a moment no one spoke or moved. The EEG technician was first. Self-consciously he said he’d better get back to the lab. He unhooked his paraphernalia and left.
“I’ve never seen anything like that,” said Peter, staring at Bruce’s gaping chest.
“Me neither,” agreed Jerry. “Kinda takes your breath away.”
Both men stepped up to the bed and peered into the wound.
Jerry cleared his throat. “I don’t know what you need more, competence or self-confidence, to cut into someone like that.”
“Both,” said Pamela, pulling the plug on the EKG machine. “How about you fellows giving us some room to get this place in order. By the way, one thing I forgot to mention. When I found Mr. Wilkinson, his IV was running rapidly. It should have been barely open.” Pamela shrugged. “I don’t know if it was important or not but I thought I’d let you know.”
“Thanks,” said Jerry absently. He wasn’t listening. Daintily he stuck his index finger into the wound and touched Bruce’s heart. “People say Dr. Kingsley is an arrogant son of a bitch, but there is one thing I know for sure. If I needed a bypass tomorrow, he is the one I’d have do it.”
“Amen,” said Pamela, pushing her way between Jerry and the bed to begin preparation of the body.
CHAPTER 1
“THERE WAS ONE new admission last night,” said Cassandra Kingsley, glancing down at her preliminary work-up. She felt distinctly ill at ease, having been thrust into the spotlight of the early morning team meeting on the psychiatry ward, Clarkson Two. “His name is Colonel William Bentworth. He’s a fortyeight-year-old Caucasian male, thrice divorced, who’d been admitted through the ER after an altercation in a gay bar. He was acutely intoxicated and abusive to the ER personnel.”
“My God!” laughed Jacob Levine, the chief psychiatric resident. He took off his round, wire-rimmed glasses and rubbed his eyes. “Your first night on psychiatry call and you get Bentworth!”
“Trial by fire,” said Roxane Jefferson, the black, no-nonsense head nurse for Clarkson Two. “No one can say psychiatry at the Boston Memorial is a boring rotation.”
“He wasn’t my idea of a perfect patient,” admitted Cassi with a weak smile. Jacob’s and Roxane’s comments made her feel a bit more relaxed, sensing that if she made an ass of herself with her presentation, everyone would excuse her. Bentworth was no foreigner to Clarkson Two.
Cassi had been a psychiatry resident for less than a week. November wasn’t the usual time for people to begin a residency, but Cassi had not decided to switch from pathology to psychiatry until after the beginning of the medical year in July and had only been able to do so because one of the first-year residents had quit. At the time Cassi thought she’d been extraordinarily lucky. But now she wasn’t so sure. Starting a residency without other colleagues equally as inexperienced was more difficult than she’d anticipated. The other first-year residents had almost a five-month jump on her.
“I bet Bentworth had some choice words for you when you showed up,” sympathized Joan Widiker, a third-year resident who was currently running the psychiatric consultation service and who had taken an immediate liking to Cassi.
“I wouldn’t want to repeat them,” admitted Cassi, nodding toward Joan. “In fact he refused to talk with me at all, other than to tell me what he thought of psychiatry and psychiatrists. He did ask for a cigarette, which I gave him, thinking it might relax him, but instead of smoking it he proceeded to press the lighted end against his arms. Before I could get some help, he’d burned himself in six places.”
“He’s a charmer all right,” said Jacob. “Cassi, you should have called me. What time did he come in?”
“Two-thirty A.M.,” said Cassi.
“I take that back,” said Jacob. “You did the right thing.”
Everyone laughed, including Cassi. For once there wasn’t that substratum of hostile competition that had colored all her years of training. And none of the half-respectful, half-jealous commentary that had surrounded her relations at Boston Memorial since her marriage to Thomas Kingsley. Cassi hoped she would be able to repay their support.
“Anyway,” she said, trying to organize her thoughts. “Mr. Bentworth, or I should say Colonel Bentworth, U.S. Army, presented with acute alcohol intoxication, diffuse anxiety alternating with a depressionlike state, fulminating anger, self-mutilating behavior, and an eightpound chart of his previous hospitalizations.”
The group erupted with renewed laughter.
“One point to Colonel Bentworth’s credit,” said Jacob, “is that he has helped train a generation of psychiatrists.”
“I had that feeling,” admitted Cassi. “I tried to read the most important parts of the chart. I think it’s about the same length as War and Peace. At least it kept me from making a fool of myself and hazarding a diagnosis. He’s been classified as a borderline personality disorder with occasional brief psychotic states.
“On physical examination he had multiple contusions on his face and a small laceration of his upper lip. The rest of the physical examination was normal except for his recent self-inflicted burns. There were slight scars across both wrists. He refused to cooperate for a full neurological exam, but he was oriented to time, place, and person. Since the present admission mirrored the last admission in terms of symptoms and since amytal sodium was used on the previous admission with such success, half a gram was given slowly IV.”
At almost the exact instant that Cassi finished her presentation, her name floated out of the hospital page system. By reflex she started to get up, but Joan restrained her, saying the ward clerk would answer.
“Did you think Colonel Bentworth was a suicide risk?” asked Jacob.
“Not really,” said Cassi, knowing she was hedging. Cassi was well aware that her ability to estimate suicide risk was approximately the same as the man in the street’s. “Burning himself with his cigarette was self-mutilating rather than self-destructive.”
Jacob twirled a lock of his frizzed hair and glanced at Roxane, who had been on Clarkson Two longer than anyone else. She was recognized as an authority of sorts. That was another reason why Cassi enjoyed the psychiatry service. There wasn’t the stiff structure that existed elsewhere in the hospital, with physicians implacably at the top. Doctors, nurses, aides, everyone was part of the Clarkson Two team and respected as such.
“I’ve tended to ignore the distinction,” said Roxane, “but I suppose there is a difference. Still we should be careful. He’s an extremely complex man.”
“That’s an understatement,” said Jacob. “The guy had a meteoric rise in the military, especially during his multiple tours of duty in Vietnam. He was even decorated several times, but when I looked into his army record, it always seemed as if a disproportionate number of his own men were killed. His psychiatric problems didn’t seem to show up until he’d reached his present rank of colonel. It was as if success destroyed him.”
“Getting back to the risk of suicide,” said Roxane, turning to Cassi. “I think the degree of depression is the most important point.”
“It wasn’t typical depression,” said Cassi, knowing she was venturing out on thin ice. “He said he felt empty rather than sad. One minute he acted depressed and the next he’d erupt with anger and abusive language. He was inconsistent.”
“There you go,” said Jacob. It was one of his favorite phrases, and its meaning was related to how he stressed the words. In this instance he was pleased. “If you had to pick one word to characterize a borderline patient, I think ‘inconsistency’ would be the most appropriate.”
Cassi happily absorbed the praise. Her own ego had had very little to feed on during the previous week.
“Well, then,” said Jacob. “What are your plans for Colonel Bentworth?”
Cassi’s euphoria vanished.