"On a heart transplant?" The quick shot of adrenalin was exactly what Abby needed to shake off her depression. She gave Mark an emphatic nod. "I'd be thrilled."
"There's only one small problem," said Archer. "The patient is NinaVoss."
Abby stared at him. "They found her a heart so soon?"
"We got lucky. The heart's coming in from Burlington. Victor Voss would probably have a stroke if he knew we were using you. But we're calling the shots right now. And we may need another pair of hands in that OR. On such short notice, you're the obvious choice."
"Are you still up for it?" asked Mark.
Abby didn't even hesitate. "Absolutely," she said.
"OK," said Archer. "Looks like we got our assistant." He nodded to Mark. "Meet you both in OR 3. Twenty minutes."
At 11.30 p.m., they got the call from the thoracic surgeon at Wilcox Memorial Hospital in Burlington, Vermont. The donor harvest was completed; the organ appeared to be in excellent shape and was being rushed to the airport. Preserved at four degrees centigrade, its beating temporarily paralysed by a concentrated potassium flush, the heart could be kept viable for only four to five hours. Without blood flow to the coronary arteries, every minute that passed -ischemic time - could result in the death of a few more myocardial cells. The longer the ischemic time, the less likely the heart would function in NinaVoss's chest.
The flight, by emergency charter, was expected to take a maximum of an hour and a half.
By midnight, the Bayside Hospital transplant team was assembled and dressed in surgical greens. Along with Bill Archer, Mark, and anaesthesiologist Frank Zwick, there was a small army of support staff: nurses, a perfusion technician, cardiologist Aaron Levi, and bby.
Nina Voss was wheeled to OR 3.
At one-thirty, the call came in from Logan International: the plane had landed safely.
That was the cue for the surgeons to head to the scrub area. As Abby washed her hands at the sink, she could look through the window into OR 3, where the rest of the transplant team was already busy with preparations. The nurses were laying out instrument trays and tearing open packets of sterile drapes. The perfusionist was re-calibrating the cabinet-like bypass machine. A fifth-year resident, already scrubbed in, stood by waiting to prep the surgical site.
On the operating table, at the centre of a tangle of EKG wires and IV lines, lay Nina Voss. She seemed oblivious to the activity around her. Dr. Zwick stood at Nina's head, murmuring to her gently as he injected a bolus of pentobarb into her IV line. Her eyelids flickered shut. Zwick placed the mask over her mouth and nose. With the ambu-bag he pumped a few breaths of oxygen in quick succession, then removed the mask.
The next step had to be performed swiftly. The patient was unconscious now, unable to breathe on her own. Tilting her head back, Zwick slipped a curved laryngoscope blade into her throat, located the vocal cords, and inserted the plastic endotracheal tube. An air-inflated cuff would keep the tube in place in her trachea. Zwick connected the tube to the ventilator and her chest began to rise and fall with the whoosh of the bellows. The intubation had taken less than thirty seconds.
The operating lights were turned on and directed at the table. Bathed in that brilliant glow, Nina seemed unearthly. Spectral. A nurse pulled off the sheet draping Nina's body and exposed the torso, the ribs archirig beneath pale skin, the breasts small, almost shrunken. The resident proceeded to disinfect the operative site, painting broad strokes of iodine across the skin.
The OR doors banged open as Mark, Archer, and Abby, freshly scrubbed, walked in with hands held up, elbows dripping water. They were greeted with sterile towels, gowns, and gloves. By the time everyone was fully garbed, Nina Voss had been prepped and draped.
Archer moved to the operating table. "Is it here yet?" he asked. "Still waiting for it," said a nurse.
"It's only a twenty-minute drive from Logan."
"Maybe they got caught in a traffic jam."
"At two in the morning?"
"Jesus," said Mark. "That's all we need now. An accident." Archer peered up at the monitors. "Happened at Mayo. Had a kidney flown in all the way from Texas. Right out of the airport, ambulance hits a truck. Organ gets squashed. Perfectly matched one, too."
"You're kidding," said Zwick.
"Hey, would I kid about a kidney?"
The fifth-year resident glanced up at the wall clock. "We're going on three hours since harvest."
"Wait. Just wait," said Archer.
The phone rang. Everyone's head swivelled to watch as the nurse answered it. Seconds later she hung up and announced: "It's downstairs. The courier's on his way up from the ER."
"OK," snapped Archer. "Let's cut."
From where Abby stood, she caught only a slanted glimpse of the procedure, and even then her view was intermittent, cut off by Mark's shoulder. Archer and Mark were working swiftly and in concert, making a midline sternotomy incision, exposing fascia, then bone.
The wall intercom buzzed. "Dr. Mapes from the harvest team is here with a special delivery," came the message from the OR front desk.
"We're cannulating," said Mark. "Have him join the fun."
Abby glanced towards the OR door. Through the viewing window, she could see the scrub area beyond, where a man stood waiting. Beside him, on a gurney, was a small Igloo cooler. The same sort of cooler in which she'd transported KarenTerrio's heart. "He'll be in," said the desk nurse. "As soon as he changes clothes." Moments later, Dr. Mapes entered, now wearing greens. He was a small man with an almost Neanderthalic brow and a nose that jutted out like a hawk's beak under the surgical mask. "Welcome to Boston," said Archer, glancing up at the visitor. "I'm Bill Archer. This is Mark Hodell."
"Leonard Mapes. I scrubbed with Dr. Nicholls at Wilcox."
"Good flight, Len?"
"Could've used a beverage service."
Archer cracked a smile, visible even through his mask. "So what'd you bring us for Christmas, Len?"
"Nice one. I think you'll be pleased."
"Let me finish cannulating and I'll take a look."
Cannulation of the ascending aorta was the first step to connecting the patient to the bypass machine.That squat box, under control of the perfusion technician, would temporarily assume the job of the heart and lungs, collecting venous blood, replenishing its oxygen, and pumping it back into the patient's aorta.
Archer, using silk sutures, sewed two concentric 'purse strings' in the wall of the ascending aorta. With a scalpel tip he made a tiny stab in the vessel. Bright blood spurted out. Swiftly he inserted the arterial cannula into the incision and tightened the 'purse strings'. The bleeding slowed to an ooze, then stopped as he sewed the cannula tip in place. The other end of the cannula was connected to the bypass machine's arterial line.
Mark, with Abby retracting, was already starting on the venous cannulation.
"OK," said Archer, moving from the table. "Let's unwrap our present."
A nurse unpacked the Igloo cooler and lifted out the organ, wrapped in two ordinary plastic bags. She untwisted the ties and slid the naked organ into a basin of sterile saline.
GentlyArcher lifted the chilled heart from its bath. "Nice excision job," he noted. "You guys did good work."
"Thanks," said Mapes.
Archer ran his gloved finger over the surface. "Arteries soft and smooth. Clean as a whistle."
"Seems a bit on the small side, doesn't it?" said Abby, glancing across the table. "How big was the donor?"
"Forty-four kilogrammes," said Dr. Mapes.
Abby frowned. "Adult?"
"An adolescent, previously healthy. A boy."
Abby caught the flicker of distress in Archer's eyes. She remembered then that he had two teenage sons. Gently he lay the organ back in its bath of chilled saline.
"We won't let this one go to waste," he said. And he turned his attention back to Nina.
By then, Mark and Abby were already finishing up the venous cannulation. Two Tygon tubes fitted with metal baskets at the end were inserted through stab wounds in the right atria, and secured by purse-string sutures. Venous blood would be collected by these cannula and directed to the pump-oxygenator.
Working together now, Archer and Mark snared shut the inferior and superior vena cava, cutting off return blood to the heart.
"Cross-clamping aorta," announced Mark as he closed off the ascending aorta.
The heart, cut off from both venous inflow and arterial outflow, was now a useless sac. Nina Voss's circulation was under the complete control of the perfusionist and her magical machine. Also under her control was the body temperature. By chilling the fluids, the body could be slowly cooled down to twenty-five degrees centigrade - profound hypothermia. This would preserve the newly implanted myocardial cells and lessen the body's oxygen consumption.
Zwick turned off the ventilator. The rhythmic wheeze of the bellows ceased. There was no need to pump air into the lungs when the bypass machine was doing the work. Transplantation could now proceed.
Archer cut the aorta and pulmonary arteries. Blood gushed out into the chest, spilled onto the floor. At once a nurse threw a towel down to soak up the mess. Archer kept working, oblivious to the sweat beading his forehead, to the lights burning down. Next he transected the atria. More blood, darker, splashed Archer's gown. He reached elbow deep into the chest cavity. NinaVoss's sick heart, pale and flabby, was now lifted away and dropped into a basin. What remained was a gaping hollow.
Abby glanced up at the monitor screen and felt an automatic rush of alarm at the flat EKG line. Of course there was no tracing. There was no heart. In fact, all the classic signs of life had ceased. The lungs were still. The heart was gone. Yet the patient still lived.
Mark lifted the donor heart from the basin and lowered it into the chest. "Some folks call this procedure a glorified plumbing job," he said, rotating the heart to match up the left atrial chambers.
"They think it's like stitching together a stuffed animal or something. But you let your attention slip for a minute, and before you realize it, you're sewing the heart in backwards." The fifth-year resident laughed. "Not funny. It's happened."
"Saline," said Archer, and a nurse poured a basin of chilled saline over the heart to keep it cold under the lights.
"A hundred things can go wrong," said Mark, his suture needle taking deep, almost savage bites into the left atrium. "Drug reaction. Anaesthetic disasters. And damn it, the surgeon always gets the blame."
"Lot of blood pooling in here," said Archer. "Suction, Abby." The hiss of the suction machine gave way to a tense silence as the surgeons worked more quickly now. There was only the whir of the pump-oxygenator and the click of the needle clamps as the serrated jaws snapped shut with each new stitch. Despite Abby's repeated suctioning, blood kept soaking into the drapes and dribbling onto the floor. The towels at their feet were saturated. The surgeons kicked them aside and new towels were thrown down.
Archer snipped away the suture needle. "Right atrial anastomosis done."
"Perfusion catheter," said Mark.
A nurse handed him the catheter. He introduced it into the left atrium and infused four-degree-centigrade saline. The flood of chilled liquid cooled down the ventricle and flushed out any air pockets inside.
"Okey doke," said Archer, repositioning the heart to sew the aortic anastomosis. "Let's hook up these pipes."
Mark glanced up at the wall clock. "Look at that. We're ahead of schedule, folks. What a team."
The intercom buzzed. It was the OR desk nurse. "MrVoss wants to know how his wife is doing."
"Fine," called Archer. "No problems."
"How much longer, do you think?"
"An hour. Tell him to hang in there."
The intercom shut off. Archer glanced across at Mark. "He rubs me the wrong way."
"Voss?"
"Likes to be in control."
"No kidding."
Archer's suture needle curved in and out of the glistening aortic wall. "But then, I guess if I had his money, I'd call the shots too."
"Where does his money come from?" asked the fifth-year resident.
Archer glanced at him in surprise. "You don't know aboutVictor Voss? VMI International? Everything from chemicals to robotics."
"Is that what the V stands for in VMI?"
"You got it." Archer tied off and snipped the last suture. "Aorta done. Cross-clamp off."
"Perfusion catheter coming out," said Mark, and turned to Abby. "Get those two pacing wires ready for insertion."
Archer picked up a fresh suture needle from the tray and began the pulmonary anastomosis. He was just tying off when he noticed the organ balling up. "Look at that!" he said. "Ice cold and already a spontaneous contraction. This baby's rarin' to go."
"Pacing wires on," said Mark.
"Isuprel infusion going in," said Zwick. "Two microgrammes."
They watched and waited for the Isuprel to take effect, for the heart to repeat the contraction.
It lay inert as a limp sac.
"Come on," said Archer. "Don't let me down."
"Defibrillator?" asked a nurse. "No, give it a chance."
Slowly the heart tightened into a fist-sized knot, then fell flaccid. Zwick said, "Increasing Isuprel to three mics." There was one more contraction. Then nothing. "Go on," said Archer. "Flog it a little more."
"Four mics," said Zwick, dialling up the IV infusion.
The heart tightened, relaxed. Contracted, relaxed.
Zwick glanced up at the monitor. QRS spikes were now tracing across the screen. "Rate's up to fifty. Sixty-four. Seventy..." "Titrate to one-ten," said Mark.
"That's what I'm doing," said Zwick, adjusting the Isuprel.
Archer said to the circulation nurse: "Get on the intercom, will you? Tell Recovery we're about to close."
"Rate's one-ten," said Zwick.
"OK," said Mark. "Let's take her off bypass. Get those cannulae on."
Zwick flipped on the ventilator. Everyone in the room seemed to exhale a simultaneous sigh of relief.
"Let's just hope she and this heart get along," said Mark.
"We know how close the HL-A match is?" asked Archer. He turned around to look at Dr. Mapes.
There was no one standing behind him.
Abby had been so focused on the operation, she hadn't noticed the man had left.
"He walked out twenty minutes ago," one of the nurses said. "Just like that?"
"Maybe he had a plane to catch," she said.
"Didn't even get a chance to shake his hand," said Archer. He turned back to the patient on the table. "OK. Let's close."
CHAPTER SEVEN
Nadiya had had enough. All the whining, all the demands, all the pent-up boy energy that regularly erupted into swearing and shoving, had sucked away her strength. That, and now the seasickness. Gregor, the big ape, was sick as well, as were most of the boys. On the roughest days, when the ship's hull pounded like a hammer on the anvil of the North Sea, they all lay groaning in their bunks, the sounds and smells of their wretchedness penetrating even to the decks above. On such days, the mess hall below remained dark and half-deserted, the passageways were empty, and the ship was like some great and moaning ghost vessel, guided by the hands of a spirit crew.
Yakov had never had such a good time.
Unstricken by even the faintest twinge of nausea, he roamed freely throughout the ship. No one stopped him. Indeed, the crew seemed to enjoy his presence. He would visit Koubichev in the engine room, and in that noisy hell of grinding pistons and diesel fumes, the two of them played chess. Sometimes Yakov even won. When he got hungry, Yakov would wander into the galley where Lubi the cook would offer him tea and beet soup and medivnyk, the fragrant spiced honey cake from his native Ukraine. Lubi never said much. "More?" and "Enough, eh?" was the extent of his conversation. The food he served was eloquence enough. Then there was the dusty cargo hold to explore, and the radio room with its dials and knobs, and the deck with its tarp-covered lifeboats to hide in. The only place he could not wander was the far-aft section. He could not find any passage to get in there.
His favourite place of all was the bridge. Captain Dibrov and the navigator would greet Yakov with indulgent smiles and allow him to sit at the chart table. There he'd trace with the index finger of his one hand the course they had already sailed. From the port of Riga, down the Baltic Sea, through the channel past Malmo and Copenhagen, around the top of Denmark, and across the North Sea with its stepping stones of oil platforms with names like Montrose and Forties and Piper. The North Sea was bigger than he'd imagined. It was not just a little puddle of blue, the way it seemed on the chart. It was two days of water. And soon, the navigator told him, they'd be crossing an even bigger sea, the Atlantic Ocean.
"They won't live that long,"Yakov predicted.
"Who won't?"
"Nadiya and the other boys."
"Of course they will," said the navigator. "Everyone gets sick in the North Sea. After a while their stomachs settle. It has to do with the inner ear."
"What does the ear have to do with the stomach?"
"It senses motion. Too much motion makes it confused."
"How?"
"I don't really understand it. But that's how it works."
"I'm not sick. Is there something different about my inner ear?"
"You must be a born sailor."
Yakov looked down at the stump of his left arm and shook his head. "I don't think so."
The navigator smiled. "You have a good brain. Brains are far more important. You will need them, where you're going."
"Why?"
"In America, if you're clever, you can become rich. You want to be rich, don't you?"
'! don't know."
Both the navigator and the captain laughed.
"Maybe the boy doesn't have any brains after all," said the captain. Yakov looked at them without smiling. "It was just a joke," said the navigator. '! know."
"Why don't you ever laugh, boy? I never see you laugh."
"I never feel like it."
The captain snorted. "Lucky little bastard's going to some rich family in America. And he doesn't feel like laughing?What's wrong with him?"
Yakov shrugged and looked back at the chart. "I don't cry, either."
Aleksei was curled up on the lower bunk, clutching Shu-Shu to his chest. He was startled awake as Yakov sat down on the mattress. "Aren't you ever going to get up?" askedYakov. Aleksei closed his eyes. "I'm sick."
"Lubi made lamb dumplings for supper. I ate nine of them."
"Don't talk about it."
"Aren't you hungry?"
"Of course I'm hungry. But I'm too sick to eat."
Yakov sighed and looked around the cabin. There were eight bunk beds in the room, and six of them were occupied by boys too ill to play. Yakov had already visited the adjoining quarters and found the other boys equally incapacitated. Would it be this way all across the Atlantic?
"It's all because of your inner ear," saidYakov. "What are you talking about?" moaned Aleksei. "Your ear. It's making your stomach sick."
"My ears are fine."
"You've been sick four days now. You've got to get up and eat."
"Oh, leave me alone."
Yakov grabbed Shu-Shu and yanked it away. "Give him back!" wailed Aleksei. "Come and get him."
"Just give him back!"
"First you get up. Come on."Yakov scurried away from the bunk as Aleksei made a futile swipe for the stuffed dog. "You'll feel better if you're out of bed."
Aleksei sat up. For a moment he huddled at the edge of his mattress, his head swaying with every tilt of the ship. Suddenly he clapped his hand to his mouth, lurched to his feet, and scrambled across the room. He vomited into the sink. Groaning, he crawled back into his bunk.
Solemnly, Yakov handed back Shu-Shu.
Aleksei hugged the stuffed dog against his chest. "I told you I was sick. Now go away."
Yakov left the boys' quarters and wandered into the corridor. At Nadiya's stateroom door, he knocked. There was no answer. He moved on to Gregor's stateroom and knocked again.
"Who is it?" came a growl.
"It's me. Yakov. Are you still sick as well?"
"Get the fuck away from my door."
Yakov left. He wandered around the ship for a while, but Lubi had retired for the night. The captain and the navigator were too busy to talk to him. As usual Yakov was on his own.
He went down to visit Koubichev in the engine room.
They set up the chessboard. Yakov drew the first move, pawn to king four.
"Have you ever been to America?"Yakov asked over the rumble of the pistons.
"Twice," said Koubichev, moving his queen's pawn forward. "Did you like it there?"
"Wouldn't know. They always order us confined to quarters as soon as we get into port. I never see a fucking thing."
"Why does the captain order this?"
"The captain doesn't. It's those people in the aft cabin."