Flashback

CHAPTER NINETEEN

The Emergency Ward was bedlam. Nearly every bed was full, as was the waiting room. Nurses, some of whom Zack recognized as having been called down from the floors, were hurrying between patients, the med locker, and the supply room. EKG and portable X-ray technicians were standing by their equipment in the hallway. Several blue-clad rescue team members were assisting the nurses while several more sat perched on countertops filling out forms. Two of the rooms seemed to be the foci of most of the activity. "The Judge is over there, in eight, " Frank said as he and Zack crossed the lobby. "What in the hell was he doing driving around at this hour without Mom, anyhow?"

"I don't know, Zack. You can ask him. He's all bandaged and splinted up, but he's perfectly with it. He must be. He's already told me that if we couldn't get a hold of his-son-the-neurosurgeon, he wanted to be transferred to another hospital."

"Frank, it's okay not to be snide right now, all right?

Who's with him?"

"Not sure. Marshfield was, but I see him over there in trauma. The other guy from the accident has just been brought in."

"Well, do you want to call Mom now, or wait until we know what's going on?"

"The later the better as far as I'm concerned."

"Okay. Well, maybe you can call Lisette and have her go over and get her."

"Lisette's… gone."

Zack checked his watch. "Well, when will she be back?"

"No," Frank said. "She's gone, as in, gone. It's a temporary thing.

Listen, you go ahead in with the Judge. I'll take care of Mom… And Zack?"

"Yes?"

"Too bad things aren't working out for that kid." Without waiting for a response, Frank turned and crossed the emergency ward to where two uniformed troopers were speaking with a reporter from the White Mountains Gazette. "Yeah, Frank, " Zack muttered, flashing briefly on the bizarre, sub rosa interplay between his brother and Jack Pearl. "Too bad."

He was heading toward room 8 when the curtain drew back and the nurse, Doreen Lavalley, emerged. "Oh, Dr. Iverson, I'tn glad you were able to get down here so quickly, " she said. "They called me down because I used to do E. R. work, but it's been a few years and-"

"I'm sure you're doing great. What's the story?"

"Well, I've been in there since just after they brought your father in.

The rescue people found him sitting propped against a tree about fifty feet from the crash. They suspect he was thrown out of the car and then walked or crawled over there. He almost certainly has a fractured wrist.

The rescue people also report there's a huge gash in his lower back, but nobody's had the chance yet to move him off the board to check it, Dr.

Marshfield had to go in with the fellow from the other car. From a distance, at least, that guy doesn't look good at all."

Zack moved to a spot just outside the doorway to room 8. Through it, he could see his father, strapped to a transfer board, with his head and neck secured in excellent first aid fashion. One arm was wrapped and splinted, the other fitted just above the wrist with an IV line. A monitor was in place and chronicling a perfectly normal rate and rhythm.

"Did Dr. Marshfleld have the chance to get any films?"

Doreen Lavalley consulted a scrap of paper. "He got a portable shoot-through of his neck and a view approximately over where that gash is. I had the lab draw a blood count and chemistries."

"Blood bank, too?"

"Yes. I asked them to type him and crossmatch him for four units."

"Nice going, Doreen. I'm glad to see you're still working here."

"Just one more week, " she said, somewhat sadly. "I've taken a job with the Visiting Nurse Association."

"Well, that's going to be Davis's loss."

"Thank you. I'll miss this place. At least the way it used to be, I will. I'll see if I can get those films."

If Clayton Iverson was relieved to see his son, he showed little evidence of it. Zack was not surprised. It had always been that way, and regardless of the circumstances, it would be that way this night. "H'lo, Judge."

Zack leaned against the bed rail, assessing his father-the slight pallor about his lips, the deepened creases at the corner of his eyes. The man was in some pain, and probably still bordering on shock. Reflexively, Zack reached across and increased the intravenous flow. "Zachary…"

The Judge spoke through teeth nearly clenched by the bandages pulled tightly across his forehead and beneath his chin to stabilize his neck.

"Do you think you could get rid of this damn stuff?"

"As soon as I've seen the film of your neck, Judge. Apparently you weren't all that coherent when the police arrived. You could have hurt your neck and not know it. You in much discomfort?"

"Mostly my back-right through here…" He motioned with his unsplinted hand at a spot just above his navel. "Does your mother know I'm here?"

"Frank went to take care of that."

"Have him tell her to wait at home, and that I'll call her later."

"Judge, just relax and let us take care of things. Okay? Now, what happened?"

"I don't know. I was on my way over to… ah… to talk with Frank and Lisette about some investments they're thinking of making. And just as I was passing by Cedar Street, boom. The next thing I really remember was the inside of the ambulance."… to talk with Frank and Lisette?…

Lisette's gone Judge. Who's lying? Frank to you, or you to me? "Did you hit your head?"

"Not that I know."

"Zack? " Suzanne stood by the doorway, the X rays in her hand. "I came down to see if I could be of any help. The nurse said she'd be next door if you need her."

"How's the boy?"

"Not awake at all, but still reasonably stable. Owen Walsh is trying to arrange a transfer, but I don't think he's been able to find a bed yet."

"Well, I'm glad you could get down. Have you seen the films?"

It was only then that he noticed the tension in her face. Something was wrong in the X rays. "Flip em right up there, " he said, motioning her to the two view boxes on the wall beside the Judge's litter. She illuminated the lateral shoot-through of the Judge's neck. Zack counted to be certain that all seven cervical vertebrae were displayed, and then checked the alignment and spacing of each. "Normal, " he said. "Perfect.

Looks like we're in luck, Judge. We'll get a complete set of films, just to be certain, but I suspect they'll be fine. I don't see any reason not to remove this harness they've rigged up. He reached for the restraint.

"Zack, you may want to wait on that," Suzanne said, snapping the second film into place. "There was a load of scrap metal in the pickup. The police wonder if maybe he fell on something."

"What is that thing? " the Judge asked. Still constrained by the harness, he was forcing his eyes far to the left in order to see the X ray. "It's a chunk of metal, Dad, " Zack said, studying the piece, which was stubby, wedge-shaped, and pointed on all three corners. The longest, sharpest point of the three was directly between two vertebrae, the twelfth dorsal and first lumbar. "A pretty big chunk, too. I'll need a lateral view to know how deep it is. Are you having any numbness or tingling in your legs at all?"

"I… I don't think so."

"Well, just the same, I think I'll leave you strapped in for now."

"If you have to. Am I going to be all right?"

"Of course you are. But I'll feel happier when we know exactly where that metal is and we've gotten someone to take it out."

"You're not going to do it?"

"Judge, first things first, okay? Suzanne, can you send in the portable unit for a lateral view? Meanwhile, I'll go over the rest of him."

"… Suction, I need suction! "… "Doctor, do you want another line?

"' "His pupil's dilating… Christ, I asked for suction.. The snatches of exchange between Wilton Marshfield and a nurse came from the trauma room… He's vomiting again. Doctor, I think he's seizing… … Get me ten of Valium for an IV push"

"Did you know that Dr. Iverson is in with his father?"

"Sounds like trouble, " the Judge said. "Are you going in there?"

"If they need me, they'll come and get me," Zack said. "I'm not leaving you alone. Suze, while you're out there can you please check on what's going on? If that's the other driver from the accident, find out who he is."

Zack was completing a rapid exam when the curtain flew back and Frank entered. "Oo-ee, what a zoo out there, " he said. "Police, reporters, the works. What gives here?"

"He's got a chunk of metal in his back-see? It looks like it shot in there during the crash, but maybe he fell on it or rolled over it. I won't know exactly where it is until I see some more views, but it obviously has to come out."

"Well, Judge, " Frank said, "even if it does, you got the better end of the deal in this one. "Ole Beau in there is a mess."

"Beau Robillard? " Zack and the Judge said the name in unison. "Yeah, didn't you know? Public nuisance number one is right in the next room.

That was his rust-bucket pickup you hit. If he's operating true to form, that scrap metal in the back of it was probably hot. Hey, Zack, remember how Robillard and his buddies used to follow you home after school and kick the daylights out of you?"

"Frank, that was junior high, for goodness sakes."

"He hasn't changed, " the Judge said. "I see him in my court every other week, it seems. He's as nasty as ever. Nastier. I should have put him away the last time I had the chance. Was there anyone in the truck with him?"

"Nope, " Frank answered. "The police say that while they were cutting him out of the cab he kept screaming that you ran the light at the bottom of the Mill Street hill."

"That's ridiculous."

At that moment, Suzanne reappeared at the doorway with the X-ray technician. "Zack, " she said, "Wilton asked if you could help him next door. The guy from the truck has a bad head injury. He's started seizing. His name's Robillard."

"Beau Robillard. We know. He used to beat me up in junior high."

"He's trash, " the Judge said. "Petty theft, assault, disturbing the peace. Zachary, I don't want you going in there."

"What?"

"You heard me. Tell Marshfield you're tied up in here and you can't help him."

"Judge, I can't do that. Zack paused, waiting for support for his position from Frank and Suzanne. There was none. "Listen, " he said finally, "I've got to go in and at least honor his request for help.

Besides, you need more X rays and maybe a CT scan, and… and the O. R. team's got to be mobilized. By the time all those studies are completed, I should be done in there, okay?"

"I already told you how I felt, " the Judge said. "Why are you asking if it's okay?"

"Zack, " Frank said, "let me talk to you outside for a minute."

"Okay, in just a second…" Zack felt shaken. "Please go ahead with a lateral of his thoraco-lumbar region and a shot of his wrist, " he said to the X-ray technician. "On second thought, why don't you forget the portable. Take him over and get a really good set of films. Suze, can you go with him?"

"Sure. Owen Walsh'il call me if anything develops in the unit."

"You might want to go over him for pre-op clearance. I don't think they've had time yet to get a full EKG."

"I'll take care of that."

"Also, find out who's on for orthopedics, if you can."

"Zachary, I meant what I said about Robillard, " the Judge said as Suzanne and the technician wheeled him from the room.

"I never meant anything more." Zack could only shake his head. "Hey, listen, " Frank said when the two of them were alone. "Just go in there and see Robillard, and do whatever you have to do. Leave the Judge to me."

"I know he's hurt and angry, Frank, but all the same, I can't believe he would talk like that. I just can't believe it."

"You've been away from here-away from the man-for a long time. Remember, buddy, we're not the only ones he keeps passing judgment on. Years and years of sentencing the same stiffs over and over again has done something to him. Listen, don't worry about him. I can handle things.

Just go on in there and play doctor."

"Did you call Mom? "

"I have one of the state troopers going to get her."

"Okay. I'll be next door. Frank, thanks for your help. I hope things with Lisette get straightened out."

"Not to worry. Just get on in there and do whatever you have to."

The two of them left room 8. Zack entered the trauma room and Frank crossed the E. R. to the X-ray department. The Judge had been moved, on the transfer board, to the X-ray table. "I need a minute alone with him,

" Frank said, motioning Suzande and the technician away. "Judge, listen,

" he whispered, when the others were out of earshot. "I tried to reason with Zack about not seeing Robillard, but he just won't listen. I'm on your side on this one. One hundred percent. Just relax and let them take your pictures. I'll keep trying to make Zack see what's right."

The rescue team, nurses, and emergency physician cleared a path as Zack entered the trauma room. His programming in the evaluation of nervous system damage was in reflex operation before he reached the bedside.

Beau Robillard, lying nude on the trauma room litter, was disheveled, covered with cuts and abrasions, and even worse off than Zack had anticipated. Comatose… respirations shallow, minimally effective… barely responsive to deep pain… tight pupil, two millimeters, left pupil, five millimeters, sluggishly reactive… "Was he ever awake, Wilton?"

"Absolutely, " Marshfield said. "He was awake when the police found him, and moaning and incoherent when he arrived here. Then he seized."…

Some purposeless movement on the left side, no movement on the iight..

.. Babinski reflex absent both sides… deep scalp laceration left paiietal region… "Could I have a pair of gloves, please. Size eight.

Also, get set to intubate him. Number seven point five tube. Wilton, can I see his films?"

"We haven't had a chance to get them, what with your father coming in first and this creep looking a helluva lot better than he does right now. Do you know who he is?"

"Yeah, yeah, " Zack said. "I know."

"When this… this thing here was a boy, " Marshfield said, "He and his cronies beat up on my nephew so many times that my brother finally ended up having to send the kid to St. Michael's Academy. I'm telling you, he was really a creep. So were those two older. Robillard boys."

Zack explored the deep scalp gash with his gloved fingers, and felt the distinctive click of bone fragments. "Well, I don't care if he's the reincarnation of Jack the Ripper and Attila the Hun rolled into one," he said. "He's got a subdural or epidural hematoma expanding on the left.

He needs Burr hole drainage, and quickly. Also, see if you can get Greg Ormesby in here just in case something's going on in his abdomen."

The nurse set a tray of equipment by Zack's right hand. He hunched over the head of the litter, positioned the steel blade of the laryngoscope against Robillard's tongue, and in seconds slid the polystyrene breathing tube through the man's vocal cords into his trachea.

"Hyperventilate him, please, " Zack said, connecting a breathing bag to the tube and turning it over to the respiratory technician. Burr holes!

An hour in the operating room. More if there was trouble. Zack backed away from the bed, a stranglehold of indecision tightening about his chest. Both Beau Robillard and the Judge needed surgery that, of those at Ultramed-Davis, he was by far the most qualified to perform. From a purely medical perspective, there was no dilemma, no doubt about the priorities of the moment. Without immediate intervention, Robillard would die. It was that simple. But thanks to Judge Clayton Iverson, it wasn't that simple at all.

"Keep bagging him, " Zack mumbled, rubbing at the ache that had suddenly materialized between his temples. "Be sure there are two teams available for the O. R. I'll be right back."

He glanced into room 8. It was still empty. Please, he was thinking as he headed toward the X-ray department. Let that chunk of metal be just below the skin. Let it be someplace where anyone with a scalpel and a little training can get it out. Suzanne was standing by one of the department's banks of view boxes, studying the films. Even from a distance, Zack could see that the position of the metal fragment was trouble. "How's he doing? " he asked. "Okay. He's complaining of some heaviness in his legs, but I think you might have put that symptom in his head. Your mother's here. Frank's got her in the quiet room, I think. That metal's not in such a good spot, huh?"

"It's in near the cord, if that's what you mean. See right here how it's chipped the edge of the vertebral transverse process?

Removing it should be reasonably straightforward, but it certainly won't be any smash and grab. The area's got to be explored to be sure there's no bleeding around the cord. Damn, but I wish this wasn't happening.

That Robillard is going out. A Burr hole procedure now is his only chance, and not such a huge one at that."

"Are you going to do it?"

"Suzanne, I don't have any choice. Of course I'm going to do it. Did you find out who's on for orthopedics?"

"Sam Christian's the only one around, but he's in the O. R. over at Clarion County. Apparently he just started an open reduction."

"Damn. Well, listen, keep your eye on the Judge, okay? I'm going to call John Burris in Concord. He's an excellent neurosurgeon, and with that Beechcraft of his, he can be up here in an hour or less.

Meanwhile, go ahead, call in the radiologist and get a CT scan of the area. See if we can assess the extent of bleeding. This day is really the pits, do you know that?"

"Zack?"

"What?"

"The Judge and Frank told me what kind of a person this Robillard is. If he's really as bad off as you say, maybe you should accept the inevitable and devote your energy to making sure your father's all right."

"Suzanne, I can't believe you're saying that."

"Really?

Well, what if it were me lying in there with a piece of metal up against my spinal cord? Zack, this is your father we're talking about."

"Suzanne, that man in there's dying."

"You know, there are such things in this world as love and loyalty. they're allowed. According to some people, they're even worthwhile virtues to have.

Even physicians are allowed to be human. That man you want to operate on steals and beats up on people, Zachary. That's what he does. The police say that the cab of his pickup was littered with empty beer cans…"

Zack glared at her. "I can't believe you're saying that. I just can't believe it." He turned and stalked into the room where his father lay beneath the X-ray camera. "Dad, how're you doing?"

"My back aches, and my legs feel a little heavy."

Zack tapped his reflex hammer against the Judge's Achilles' tendons, documenting once again through the reassuring flick of each foot that the ankle to spinal cord and spinal cord-to-ankle circuits were intact.

"Wiggle your toes, please… Good. Other foot… good."

"What's the story? " the Judge asked. "Well, your wrist is broken, but it will keep until Sam Christian gets done at Clarion County. However, that piece of metal in your back ought to come out soon."

"I thought so. You going to do it?"

Zack hesitated, and then shook his head, triggering a jackhammer pain between his eyes. "No, Dad, " he said. "I've got to do that man first or he's dead. Besides, we're not encouraged to operate on our own family if we can avoid it. I'm going to call John Burris up from Concord."

"I want you."

"Judge, please, don't make this any harder. You're quite stable right now. Robillard's dying."

"Let him die."

"I can't do that. Clayton Iverson stared stonily at the ceiling. In the silence, Zack became aware of others in the room. He turned. Frank and Suzanne stood just inside the doorway, watching and listening. "Suzanne, please arrange the CT scan, " Zack said, trying to ignore the disapproval in her eyes. "I've got to call Burris and then get into the O. R. I can see by your face what you want to say to me. Don't bother.

I'm doing the one thing we are taught always to do-I'm doing what I think is right… Judge, I love you, and I'll be keeping track of things. With luck, by the time Burris gets here I'll be done with what I have to do, and I can assist him. Meanwhile, just hang in there."

He turned and left, brushing past Suzanne. She followed him for several steps, but then, shaking her head in resignation and frustration, headed for the radiology office. "Ma's here, " Frank said, approaching the bed.

"Judge, I'm sorry. I tried to help him see reason."

"Forget it, Frank, " Clayton Iverson said. "Just leave me alone."

"But Judge-"

"Dammit, Frank, I said leave me alone." Nothing felt normal or comfortable. The room, O. R. 4, seemed far too warm, the surgical team far too quiet. The blades and scissors and drill bits were too dull, the hemostats and needle holders unacceptably stiff or loose. Zachary struggled to ignore his throbbing headache and his sodden scrub suit and to focus on the situation at hand. The circulating nurse, no longer waiting for his request, was mopping perspiration from his forehead and cheeks every two or three minutes. They were nearly an hour into the Burr hole drainage procedure on Beau Robillard, and still there was no word that John Burris had arrived from Concord. Down the hall, in O. R. 2, a second surgical team stood ready. "Valerie, " Zack said to the circulator, "could you go on down to the E. R., please, and see what you can find out about Dr. Burris. He should have been here by now."

Beneath his green paper mask, Zack's jaw was clenched. He was right in what he was doing, dammit. He was a physician, a surgeon, not judge and jury. Why, then, was everyone acting as if his decision were some sort of mortal sin? Surely they understood that he wasn't choosing this man's life over his father's. The Judge was stable, perfectly stable. Beau Robillard was dying. "Pressure's down a bit, " Jack Pearl cautioned. The words brought Zack's thoughts back in tune with his hands. "Feel free to transfuse him a unit if you need to, " he responded. "I've aspirated a fair amount through these Burr holes, but his brain's not showing any signs of reexpanding. If there's no action in a few more minutes, we're going to have to push ahead with a full craniotomy."

The circulating nurse, Valerie, reentered the O. R. through the scrub room. "Dr. Iverson, " she said, "there's a problem downstairs."

Zack shuddered. "Yes, go ahead. "I was told to tell you that Judge Iverson's feet have gone numb. He's unable to move his toes."

"Who's with him?"

The urgency in his voice bordered on panic. He glanced down at the persisting space between Beau Robillard's skull and brain surface, and begged himself to calm down. "Dr. Cole and Dr. Marshfield, " the woman answered. And where in the hell is-" Zack breathe deeply and exhaled.

"Where is Dr. Burris? " he asked more evenly. The eyes of everyone on the surgical team were fixed on him. There was, they all knew, little chance he could break scrub and leave the operating room without killing Robillard. "The weather's gotten worse. Apparently there was a problem with Dr. Burris's plane, " the nurse explained. "He's gotten someone to fly him up, but they lost some time."

"How much till he's here?"

"Twenty minutes."

"Damn, " Zack murmured. It would take another hour to complete the craniotomy-the open procedure he now felt certain was necessary. And even with the proce, Beau Robillard's chances of survival as anything more than a vegetable were growing dimmer each second. "Have them give Judge Iverson five amps of Narcan IV, and get him up to the operating room now."

"Five? But the usual dose is-"

"Dammit, I know what the usual dose is." He took a deep breath. "Sorry.

I didn't mean to snap at you. The high dose is to help keep down the swelling in his cord. Also, please ask Dr. Cole if she can come up here and tell me exactly what's going on."

In truth, Zack had little doubt as to what was going on. An epidural bleed, not predictable at all from his initial exam, was compressing the Judge's spinal cord. Had he missed something? Had there been a clue?

Uncertainty and self-doubt hardened around Zack's hands like cement.

With Burris less than twenty minutes away, could any significant change be effected now by scrubbing out on Robillard and going after the Judge's bleed?

Zack gazed down at the man for whose life he had chosen to be responsible. Having made that choice, did he even have the right now to renege on it?

The doors to the O. R. burst open, and Suzanne, dressed in scrubs, stepped inside. "The Judge can't move his legs, " she said. "Burris is about to land. A cruiser's waiting for him at the airport."

"Reflexes?"

"A flicker, " she said. "It would seem, Doctor, that unless John Burris works a minor miracle, your father might well end up paralyzed from the waist down."

At that moment, Jack Pearl called out, "Dr. Iverson, his rate's dropping. I can't get a pressure."

"Give him an amp of epinephrine."

"Already done."

"Get ready for CPR."

"Pulse is dropping. Dropping more."

"Damn… Begin CPR."

"Doctor, he's straight line. "Another amp of epi. Give him another amp of epi. "