It was 3 p.m., sixty-two hours since a drunk driver had slammed into KarenTerrio's car. She was thirty-four years old, HIV negative, cancer free, infection free. She was also brain dead. In short, she was a living supermarket of healthy donor organs. Heart and lungs. Kidneys. Pancreas. Liver. Bone. Corneas. Skin. With one terrible harvest, half a dozen different lives could be saved or changed for the better.
Abby pulled up a stool and sat down across from him. She was the only doctor who'd actually spent much time talking with Joe, so she was the one the nurses had called to speak to him now. To convince him to sign the papers and allow his wife to die. She sat quietly with him for a moment. Karen Terrio's body stretched between them, her chest rising and falling at a preselected twenty breaths per minute.
"You're right, Joe," said Abby. "Her heart is strong. It could keep going for some time. But not forever. Eventually the body knows. The body understands."
Joe looked across at her, his eyes red-rimmed with tears and sleeplessness. "Understands?"
"That the brain is dead. That there's no reason for the heart to keep beating."
"How would it know?"
"We need our brains. Not just to think and feel, but also to give the rest of our body a purpose. When that purpose is gone, the heart, the lungs, they start to fail." Abby looked at the ventilator. "The machine is breathing for her."
"I know." Joe rubbed his face with his hands. "I know, I know. I know . . ."
Abby said nothing, Joe was rocking back and forth in his chair now, his hands in his hair, his throat squeezing out little grunts and whimpers, the closest thing to sobs a man could allow himself. When he raised his head again, clumps of his hair stood up damp and stiff with tears.
He looked up at the monitor again. The one spot in the room he seemed to feel was safe to stare at. "It all seems too soon."
"It isn't. There's only a certain amount of time before the organs start to go bad. Then they can't be used. And no one is helped by that, Joe."
He looked at her, across the body of his wife. "Did you bring the papers?"
"I have them."
He scarcely looked at the forms. He merely signed his name at the bottom and handed the papers back. An ICU nurse and Abby witnessed the signature. Copies of the form would go into Karen Terrio's record, to the New England Organ Bank, and Bayside's Transplant Co-ordinator files. Then the organs would be harvested.
Long after KarenTerrio was buried, bits and pieces of her would go on living. The heart that she'd once felt thudding in her chest when she'd played as a five-year-old, married as a twenty-year-old, and strained at childbirth as a twenty-one-year-old, would go on beating in the chest of a stranger. It was as close as one could come to immortality.
But it was scarcely much comfort to Joseph Terrio, who continued his silent vigil at the bedside of his wife.
Abby found Vivian Chao undressing in the OR locker room. Vivian had just emerged from four hours of emergency surgery, yet not a single blot of sweat stained the discarded scrub clothes lying on the bench beside her.
Abby said, "We have consent for the harvest."
"The papers are signed?" asked Vivian. "Yes."
"Good. I'll order the lymphocyte crossmatch." Vivian reached for a fresh scrub top. She was dressed only in her bra and underwear, and every rib seemed to stand out on her frail, flat chest. Honorary manhood, thought Abby, is a state of mind, not body. "How are her vitals?" asked Vivian.
"They're holding steady."
"Have to keep her blood pressure up. Kidneys perfused. It's not every day a nice pair of AB positive kidneys comes along." Vivian pulled on a pair of drawstring trousers and tucked in her shirt. Every movement she made was precise. Elegant.
"Will you be scrubbing in on the harvest?" asked Abby.
"If my patient gets the heart, I will. The harvest is the easy part. It's reattaching the plumbing that gets interesting." Vivian closed the locker door and snapped the padlock shut. "You have a minute?
I'll introduce you to Josh."
"Josh?"
"My patient on the teaching service. He's up in MICU."
They left the locker room and headed down the hall towards the elevator. Vivian made up for her short legs by her quick, almost fierce stride. "You can't judge the success of a heart transplant until you've seen the before and the after," said Vivian. "So I'm going to show you the before. Maybe it'll make things easier for you." 'what do you mean?"
"Your woman has a heart but no brain. My boy has a brain and practically no heart."The elevator door opened. Vivian stepped in. "Once you get past the tragedy, it all makes sense."
They rode the elevator in silence.
Of course it makes sense, thoughtAbby. It makes perfect sense. Vivian sees it clearly. But I can't seem to get past the image of two little girls standing by their mother's bed. Afraid to touch her... Vivian led the way to the Medical ICU. Joshua O"Day was asleep in Bed 4.
"He's sleeping a lot these days," whispered the nurse, a sweet faced blonde with Hannah Love, RN, on her nametag.
"Change in meds?" asked Vivian.
"I think it's depression." Hannah shook her head and sighed. "I've been his nurse for weeks. Ever since he was admitted. He's such a terrific kid, you know? Really nice. A little goofy. But lately, all he does is sleep. Or stare at his trophies." She nodded at the bedside stand, where a display of various awards and ribbons had been lovingly arranged. One ribbon went all the way back to the third grade - an honourable mention for a Cub Scout Pinewood Derby. Abby knew about pinewood derbies. Like Joshua O"Day, her brother had been a Cub Scout.
Abby moved to the bedside. The boy looked much younger than she had expected. Seventeen, according to the birthdate on Hannah Love's clipboard. He could have passed for fourteen. A thicket of plastic tubes surrounded his bed, IV's and arterial and Swan-Ganz lines. The last was used to monitor pressures in the right atrium and pulmonary artery. On the screen overhead, Abby could read the right atrial pressure. It was high. The boy's heart was too weak to pump effectively, and blood had backed up in his venous system. Even without the monitor, she could have reached that conclusion by a glance at his neck veins. They were bulging.
"You're looking at Redding High School's baseball star from two years ago," said Vivian. "I'm not into the game so I don't really know how to judge his batting average. But his dad seems pretty proud of it."
"Oh, his dad/s proud," said Hannah. "He was in here the other day with a ball and mitt. I had to kick him out when they started a game of catch." Hannah laughed. "The dad's as crazy as the kid!"
"How long has he been sick?" asked Abby.
"He hasn't been to school in a year," said Vivian. "The virus hit him about two years ago. CoxsackieVirus B. Within six months, he was in congestive heart failure. He's been in the ICU for a month now, just waiting for a heart." Vivian paused. And smiled. "Right, Josh?"
The boy's eyes were open. He seemed to be looking at them as though through layers of gauze. He blinked a few times, then smiled at Vivian. "Hey, Dr. Chao."
"I see some new ribbons on display," said Vivian.
"Oh. Those." Josh rolled his eyes. "I don't know where my Mom digs those up. She keeps everything, you know. She even has this plastic bag with all my baby teeth. I think it's pretty gross."
"Josh, I brought someone along to meet you. This is Dr. DiMatteo, one of our surgical residents."
"Hello, Josh," said Abby.
It seemed to take the boy a moment to fully refocus his gaze. He didn't say anything.
"Is it OK for Dr. DiMatteo to examine you?" asked Vivian. "Why?"
"When you get your new heart, you'll be like that crazy Road Runner on TV. We won't be able to tie you down long enough for an exam."
Josh smiled. "You're so full of it."
Abby moved to the bedside. Already, Josh had pulled up his gown and bared his chest. It was white and haitiess, not a teenager's chest but a boy's. She lay her hand over his heart and felt it fluttering like bird's wings against the cage of ribs. She lay her stethoscope against it and listened to the heartbeat, the whole time aware of the boy's gaze, wary and untrusting. She had seen such looks from children who have been too long in paediatric wards, children who've learned that every new pair of hands brings a new variety of pain. When she finally straightened and slipped her stethoscope back in her pocket, she saw the look of relief in the boy's face. "Is that all?" he said.
"That's all." Abby smoothed down his hospital gown. "So. Who's your favourite team, Josh?"
"Who else?"
"Ah. Red Sox."
"My dad taped all their games for me. We used to go to the park together, my dad and me. When I get home, I'm going to watch 'era all. All those tapes. Three straight days of baseball..." He took a deep breath of oxygen-infused air and looked up at the ceiling.
Softly he said, "I want to go home, Dr. Chao."
"I know," said Vivian.
"I want to see my room again. I miss my room." He swallowed, but he couldn't hold back the sob. "I want to see my room. That's all. I just want to see my room."
At once Hannah moved to his side. She gathered the boy into her arms and held him, rocked him. He was fighting not to cry, his fists clenched, his face buried in her hair. "It's OK," murmured Hannah. "Baby, you just go ahead and cry. I'm right here with you. I'm going to stay right here, Josh. As long as you need me. It's OK." Hannah's gaze met Abby's over the boy's shoulder. The tears on the nurse's face weren't Josh's, but her own.
In silence, Abby and Vivian left the room.
At the MICU nurses' station, Abby watched as Vivian signed in duplicate the order for the lymphocyte crossmatch between Josh O"Day's and Karen Terrio's blood.
"How soon can he go to surgery?" asked Abby.
"We could be scrubbed and ready to cut by tomorrow morning. The sooner the better. The kid's had three episodes of V. tach in just the last day. With a heart rhythm that unstable, he doesn't have much time." Vivian swivelled around to face Abby. "I'd really like that boy to see another Red Sox game. Wouldn't you?"
Vivian's expression was as calm and unreadable as ever. She might be soft as slush inside, thought Abby, but Vivian would never show it.
"Dr. Chao?" said the ward clerk.
"Yes?"
"I just called SICU about that lymphocyte crossmatch. They said they're already running a match against Karen Terrio."
"Great. For once my intern's on the ball."
"But Dr. Chao, the crossmatch isn't with Josh O"Day."
Vivian turned and looked at the clerk. "What?"
"SICU says they're running it on someone else. Some private patient named Nina Voss."
"But Josh is critical! He's at the top of the list."
"All they said was the heart's going to that other patient." Vivian shot to her feet. In three quick steps she was at the telephone, punching in a number. A moment later, Abby heard her say:
"This is Dr. Chao. I want to know who ordered that lymphocyte crossmatch on Karen Terrio." She listened. Then, frowning, she hung up.
"Did you get the name?" asked Abby.
"Yes."
"Who ordered it?"
"Mark Hodell."
CHAPTER FOUR
Abby and Mark had made reservations that night for Casablanca's, a restaurant just down the road from their Cambridge house. Though it was meant to be a celebration, to mark the six month anniversary of their moving in together, the mood at their table was anything but cheerful.
"All I want to know," said Abby, 'is who the hell is Nina Voss?"
'! told you, I don't know," said Mark. "Now can we drop the subject?"
"The boy's critical. He's coding practically twice a day. He's been on the recipient list for a year. Now an AB positive heart finally becomes available, and you're bypassing the registry system? Giving the heart to some private patient who's still living at home?"
"We're not giving it away, OK? It was a clinical decision."
"Whose decision was it?"
"Aaron Levi's. He called me this afternoon. Told me that Nina Voss was being admitted tomorrow. He asked me to order the screening labs on the donor."
"That's all he told you?"
"Essentially." Mark reached for the bottle of wine and refilled his glass, sloshing burgundy onto the tablecloth. "Now can we change the subject?"
She watched him sip the wine. He wasn't looking at her, wasn't meeting her gaze.
"Who is this patient?" she asked. "How old is she?"
'! don't want to talk about it."
"You're the one taking her to surgery. You must know how old she is."
"Forty-six."
"From out of state?"
"Boston."
"I heard she was flying in from Rhode Island. That's what the nurses told me."
"She and her husband live in Newport during the summer."
"Who's her husband?"
"Some guy named Victor Voss. That's all I know about him, his name."
She paused. "How did Voss get his money?"
"Did I say anything about money?"
"A summer home in Newport? Give me a break, Mark."
He still wouldn't look at her, still wouldn't lift his gaze from that glass of wine. So many times before, she'd look across a table at him and see all the things that had first attracted her. The direct gaze. The forty-one years of laugh lines. The quick smile. But tonight, he wasn't even looking at her.
She said, "I didn't realize it was so easy to buy a heart."
"You're jumping to conclusions."
"Two patients need a heart. One is a poor, uninsured kid on the teaching service. The other has a summer home in Newport. So which one gets the prize? It's pretty obvious."
He reached again for the wine bottle and poured himself another glass - his third. For a man who prided himself on his temperate lifestyle, he was drinking like a lush. "Look," he said. "I spend all day in the hospital. The last thing I feel like doing is talking about it. So let's just drop the subject."
They both fell silent. The subject of Karen Terrio's heart was like a blanket snuffing out the sparks of any other conversation. Maybe we've already said everything there is to say to each other, she thought. Maybe they'd reached that dismal phase of a relationship when their life stories had been told and the time had come to dredge up new material. We've been together only six months, and already the silences have started.