Balance of Power

TWENTY -FIVE

Dr. Callie Hines was staring at her office wall when the beeper went off.

She had just finished patching up a sixteen-year-old Asian kid with an abdominal knife wound—unusual in Callie's experience, which featured gunshot wounds at the rate of one a day. But this was the rhythm of an emergency room surgeon: crazy energy, stasis, then a beeper. She snatched it out of her pocket.

It was a nine hundred call; whoever they were bringing in was at risk of dying. Rising from her chair, Callie walked briskly to the elevator, a lean black woman with a model's figure, a smooth lineless face, and cool seen-it-all eyes. She had just reached the emergency room area when her cell phone rang.

This was the paramedic team. There had been a mass shooting at SFO; glancing at her watch, Callie envisioned Highway 101 at rush hour. In the background, she could hear the piercing whine of sirens. "Who's the patient?" Callie asked.

"A six-year-old girl." The woman's voice was taut. "It's a Room One case."

Inwardly, Callie winced. Gunshot wounds for teens were common, but not a child this small; Operating Room One was reserved for patients at death's door. "What kind of wound?" she asked.

"Abdominal. Her blood pressure's low—we intubated her, applied pressure to the wound, and started an IV."

"Is she conscious?"

"Yes." A slight pause. "This one's a VIP."

The remark was unusual—the ER was not a status-conscious place. "A VIP six-year-old?" Callie asked.

"It's Lara Kilcannon's niece. Her mother and one sister died at the scene."

Callie prided herself on nervelessness; now she drew a breath, calling on her reserves of calm. "I'll be waiting," she said.

• • •

"Mr. President."

Turning, Kerry saw a shadow walking quickly through the sea grass, backlit by the waxing moon above the sand dunes. "Mr. President," Peter Lake repeated, more softly now.

Something had happened, Kerry thought; perhaps they had found Al Anwar. He felt Lara's hand clasp his.

* * *

Peter knelt. In the darkness, Lara tensed: though he had called out to Kerry, Peter was looking at her.

"I have bad news." Peter's face was bleak, his voice hesitant and strained. "There's been a shooting at SFO. Your mother and Joan are dead."

"No . . ." For an instant Lara could not see; Kerry's grip tightened, as if to pull her back from some abyss.

"What about Mary?" she asked. "And Marie?"

Her voice sounded calm, as though someone else had posed the question. "Mary's all right," Peter answered, then glanced at Kerry. "But Marie was wounded. They're taking her to SF General."

Kerry pulled Lara close. Resistant, she twisted her face toward Peter. "Was it John?"

"Yes."

Lara felt her stomach knot, heard the thickness in Kerry's voice. "Get me the hospital," he demanded.

* * *

Callie Hines stood near the slick whiteboard, watching a resident enter the name of new patients in Magic Marker. In the last few minutes, she had seen a parade worthy of a Brueghel painting: two prisoners in manacles; a homeless black man with pneumonia; a twenty-year-old Hispanic woman with AIDS, overdosed on heroin; a bipolar white man, HIV positive, who had slashed his wrists; a cocaine addict pregnant with her fourth child, her left arm amputated.

This intake, though heavy, was lighter than in winter—with the chilly rains, the homeless would seek refuge in the waiting room or, in desperation, attempt to hide in the tunnels beneath the hospital. This was no place, Callie thought once more, for those who would close their eyes to pathology and poverty, hopelessness passed down from one generation to the next.

The ambulance bay burst open.

On the gurney lay a small dark-haired girl with tubes in her nose

and throat. She was conscious: her eyes were wide with shock—not simply to her body, Callie thought, but to her spirit, her sense of what the world was.

Callie rushed with her to the trauma room.

* * *

Mary Costello could not think or feel. Her only focus was Marie.

Two cops in a squad car sped her to the hospital. At the door of the emergency ward one of them punched numbered buttons on a panel; the door swung open, and a plump black woman took her to a sterile room with a telephone and pastoral pictures on otherwise bare walls. Mary felt claustrophobic.

"I need to see her," Mary said.

The social worker took her hand. "She's already in the trauma room. The prognosis isn't good. They'll have to operate as soon as possible . . ."

"I know that. That's why I have to be there."

The woman appraised her. "Will you be okay?" she asked.

"Not if I stay here."

The woman nodded. "All right," she said, and led Mary to the trauma room.

* * *

Marie lay on a gurney. She was surrounded by men and women in purple scrubs or white jackets, all wearing masks and leaded aprons; two cylindrical lamps and an X-ray machine extended toward her from the ceiling; a screen monitored her heartbeat. A blonde woman doctor directed the activity; to the side, a handsome, somewhat imperious black woman watched with folded arms.

Marie's bloody clothes were in a paper bag beside the gurney. An anesthesiologist stood at her head, administering oxygen. Marie moaned softly. "I'll get the morphine," someone said.

Stunned, Mary tried to absorb this. A young doctor in glasses turned to her. "You the aunt?" he asked.

"Yes."

"Do you know who her doctor is, or whether she's taking any medication?"

Helpless, Mary shook her head.

"What about allergies?"

"I don't know."

He turned away. Beneath the calm, Mary felt the pulse of urgency. "How much blood out?" the blonde doctor asked.

"About two in the tube, and two on the sheets. Maybe four hundred cc's—half the blood in her body."

A beeper went off. "Her pressure's dropping," someone said.

Marie's moaning ceased. An X ray appeared on the screen; to Mary, the white stain at its center looked like a starburst. The black woman studied it, eyes narrowing.

Turning, she ordered, "Get her to the OR—now."

* * *

Marie's eyes closed.

They hurried her to an elevator, the black doctor at her side. Mary and the social worker followed.

"She's crashing," someone said.

In the silence of the elevator, Mary looked into her niece's face, pale and still.

"Can I hold her hand?" Mary asked. When no one answered, she took the child's hand, cool to the touch.

The elevator rose two floors, then opened into a room with a long desk and steel doors marked "Room One." Slowly, Mary let Marie's fingers slip from hers.

The social worker took her arm. "I'm afraid this is as far as we can go."

Three nurses rushed the gurney inside the room, the black doctor following. Tears blurred Mary's vision. Blinking, she focused on the dark crown of Marie's head, and then the doors closed behind her.

* * *

In the dim-lit great room, Kerry gripped the telephone, watching Lara through the open door of the bedroom as she listened on another phone. Her face was pale, intent. To Kerry, the telephone was Lara's lifeline, Marie's struggle all that kept the grief and horror from crashing down on her.

"They're about to operate," the hospital director said. "All that I can tell you, Mr. President, is that Callie Hines is as good as they get."

In the bedroom, Lara's eyes closed, as if in a prayer. "As soon as you know," Kerry responded, "call us."

* * *

Struggling into her operating gown, Callie recalled the shooting of Kerry Kilcannon—cops surrounding the hospital; press jammed in the media room; the mayor of San Francisco hovering near Room One. It would happen again now. But Room One was empty and clean, a haven from chaos.

Marie lay on the table with her arms outflung. At her head three anesthesiologists administered a paralytic agent, a sedative, and a narcotic. A team of nurses ran blood to the OR. Another kept Marie's legs covered to fight the loss of body heat. The chief surgical resident, another resident and an intern watched Callie open an incision beneath the child's nipples. Perspiration began beading on her forehead—at Callie's orders, the temperature was cranked up to eighty, another measure against hypothermia. Their speech was clipped; their movements controlled. Soon they would sweat like athletes.

Callie's second cut went from the first incision to the pubis. As the head nurse inserted a retractor, dark blue blood of a hematoma erupted from Marie's abdomen.

"Clamp the aorta," Callie ordered.

The resident inserted a rib spreader, then cross-clamped the aorta to stop the flow of blood. Two others tried to staunch the bleeding with surgical packs so that Callie could do her work; a third began massaging the child's heart. Wearing double gloves, Callie searched for the bullet with a rubber tip extractor; the X ray had told her that to extract this bullet with her fingers might slash her tendons.

Callie found the bullet. Carefully, she removed it from amidst the roiling blood. Its tip had exploded into six metal shards, the pattern of a flower. Callie was tight-lipped with anger.

"Eagle's Claw," she said.

"What's that?" the intern asked.

"Quadruple the mortality rate." She had no time to explain that the shards ripped through vital organs like a buzz saw; that their jagged edges had ended surgical careers; that a shredded vena cava could be inoperable; that her chances of saving this child had slipped from probable to long; that the Eagle's Claw, in the words of her first mentor, was "God-awful," absolutely demoralizing to a surgeon; that the quiet which had descended at the name "Eagle's Claw" meant that only the young intern did not know this. "She's at 95 degrees," the head nurse said.

Racing against time, Callie searched for the wound.

* * *

On the telephone, Mary was sobbing. "I know," Lara said brokenly. "I know. But maybe they can save Marie."

She heard her sister struggle for control. "I'll adopt her . . ."

"I know you will. You'd be so good with her."

A ragged cry escaped. Grasping for hope, Lara said, "It's where they saved Kerry."

She felt his hand on her shoulder. Abruptly, her sister burst out. "You two made him so angry . . ."

* * *

The vena cava was shredded. Instead of a single clean rupture, there were three. Blood spurted from their ratty strands. The child's face was pale and still.

"No clotting," the chief resident said. "Temperature's at 94.5."

There was no time left to operate—Marie would die from hemorrhagic shock before Callie could suture the shredded vein. Sweat rolled down her face.

"Damage control," Callie snapped. Her last hope was to stop the bleeding, prop up the child's body temperature and hope the veins would begin to clot, so that tomorrow she could try to repair the wound. The head nurse pressed a plunger against the vena cava; two more nurses packed the shredded area with surgical pads; another placed a defibrillator on the child's heart, to shock it into action. Callie closed the flap of Marie's abdomen with towel clips. The child's lips fluttered.

"Ninety three degrees," the chief resident said urgently. "Her blood pressure's in free fall . . ."

Callie began to massage the child's heart. The only sound was the whirl of the ventilator.

* * *

Ten minutes later, leaving Room One, Callie Hines noticed the drops of blood on her shoes.

Cops ringed the OR. The hospital administrator and the mayor stood by the door. Callie stared at the mayor. "Get him out of here," she told her boss. "Then get me a telephone."

* * *

At eleven-oh-five, the telephone rang in Martha's Vineyard. In the living room, Kerry picked up first.

"Mr. President?" The voice was measured. "This is Callie Hines."

From the couch, Lara watched Kerry's face. "How is she?" Kerry asked.

"I'm very sorry," Hines answered softly. "But the wound simply wasn't survivable. All that I can offer you is that she felt no pain."

A numbness passed through Kerry. Gazing at Lara, he slowly shook his head. She doubled over, hands covering her face, emitting a cry of agony which made him shudder.

"The bullet was an Eagle's Claw," Hines told him. "In a child that small . . ."