Harvest

CHAPTER TWO

It was midnight, and Karen Terrio was fighting to keep her eyes open. Fighting to stay on the road.

She had been driving for the better part of two days now, had left right after Aunt Dorothy's funeral, and she hadn't stopped except to pull over for a quick nap or a hamburger and coffee. Lots of coffee. Her aunt's funeral had receded to a two-day-old blur of memories. Wilting gladioli. Nameless cousins. Stale finger sandwiches. Obligations, so damn many obligations.

Now all she wanted was to go home.

She knew she should pull off again, should try to catch another quick nap before pressing onward, but she was so close, only a hundred miles from Boston. At the last Dunkin Donuts, she'd tanked up on three more cups of coffee. That had helped, a little; it had given her just enough of a buzz to get her from Springfield to Sturbridge. Now the caffeine was starting to wear off, and even though she thought she was awake, every so often her head would dip in a sharp bob, and she knew she'd fallen asleep, if only for a second.

A Burger King sign beckoned from the darkness ahead. She pulled off the highway.

Inside she ordered coffee and a blueberry muffin and sat down at a table. At this hour of night, there were only a few patrons in the dining room, all of them wearing the same pasty masks of exhaustion. Highway ghosts, thought Karen. The same tired souls who seemed to haunt every highway rest stop. It was eerily quiet in that dining room, everyone focused on trying to stay awake and get back on the road.

At the next table sat a depressed-looking woman with two small children, both of them quietly chewing on cookies. Those children, so well behaved, so blond, made Karen think of her own daughters. It was their birthday tomorrow. Tonight, asleep in their beds, she thought, they are only a day away from being thirteen. A day further from their childhood.

When you wake up, she thought, I'll be home.

She refilled her coffee cup, snapped on a plastic cover, and walked out to her car.

Her head felt clear now. She could make it. An hour, fifty miles, and she'd be walking in her front door. She started the engine and pulled out of the parking lot. A hundred miles, she thought. Only a hundred miles.

Twenty miles away, parked behind a 7-11,Vince Lawry and Chuck Servis finished off the last six pack. They'd been going at it for four straight hours, just a little friendly competition to see who could toss back the most Buds without puking it all up again. Chuck was ahead by one. They'd lost track of the total; they'd have to figure it out in the morning when they tallied up the beer cans mounded in the back seat.

But Chuck was definitely ahead, and he was gloating about it, which pissed Vince off, because Chuck was better at every fucking thing. And this wasn't a fair contest. Vince could've gone another round, but the Bud had run out, and now Chuck was wearing that eat-shit grin of his, even though he knew it wasn't a fair contest.

Vince shoved open the car door and climbed out of the driver's seat.

"Where you going?" asked Chuck.

"T'get some more."

"You can't handle no more."

"Fuck you," said Vince, and stumbled across the parking lot towards the 7-11's front door.

Chuck laughed. "You can't even walk!" he yelled out the window. Asshole, thought Vince. What the fuck, he could walk. See, he was walking fine. He'd just stroll into the 7-11 and pick up two more sixes. Maybe three.Yeah, he could do three, easy. His stomach was iron, and except for having to piss every few minutes, he didn't feel the effects at all.

He tripped going in the door — goddamn high threshold, they could get sued for that — but he picked himself right up. He got three six packs from the cooler and swaggered over to the cash register. He plunked down a twenty-dollar bill.

The clerk looked at the money and shook his head. "Can't take it," he said.

"What do you mean, can't take it?"

"Can't sell beer to an intoxicated customer."

"Are you saying I'm drunk?"

"That's right."

"Look, it's money, isn't it?You don't want my fucking money?"

"I don't wanna get sued. You just put the beer back, son, OK? Better yet, why don't you buy a cup of coffee or something? A hot dog."

"I don't want a fucking hot dog."

"Then just walk on out, boy. Go on."

Vince shoved one of the six packs across the countertop. It slid off the edge and crashed to the floor. He was about to launch another six pack off the counter when the clerk pulled out a gun.

Vince stood staring at it, his body poised in mid-shove.

"Go on, get the hell out," said the clerk.

"OK?Vince stepped back, both hands raised in submission. "OK, I hear you."

He tripped on the damn threshold again as he went out the door.

"So where is it?" asked Chuck as Vince climbed back in the car. "They're outta beer."

"They can't be out of beer."

"They're fucking out, OK?Vince started the car and goosed the accelerator. They squealed out of the lot.

"Where we going now?" asked Chuck.

"Find another store." He squinted ahead at the darkness. "Where's the onramp? Gotta be around here somewhere."

"Man, give it up. No way you'll go another round without puking." "Where's the fucking onramp?"

"I think you passed it."

"No, there it is." Vince veered left, tyres squealing over the pavement.

"Hey," said Chuck. "Hey, I don't think-'

"Got twenty fucking bucks left to blow. They'll take it. Someone'll take it."

"Vince, you're going the wrong way!"

"What?"

Chuck yelled, "You're going the wrong way!"

Vince gave his head a shake and tried to focus on the road. But the lights were too bright and they were shining right in his eyes. They seemed to be getting brighter.

"Pull right!" screamed Chuck. "It's a car! Pull right!" Vince veered right. So did the lights.

He heard a shriek, unfamiliar, unearthly.

Not Chuck's, but his own.

Dr. Abby DiMatteo was tired, more tired than she'd ever been in her life. She had been awake for thirty straight hours, if one didn't count her ten-minute nap in the X-ray lounge, and she knew her exhaustion showed. While washing her hands in the SICU sink, she had glimpsed herself in the mirror and had been dismayed by the smudges of fatigue under her dark eyes, by the disarray of her hair, which now hung in a tangled black mane. It was already 10 a.m., and she had not yet showered or even brushed her teeth. Breakfast had been a hardboiled egg and a cup of sweet coffee, handed to her an hour ago by a thoughtful surgical ICU nurse. Abby would be lucky to find time for lunch, luckier still to get out of the hospital by five and home by six. Just to sink into a chair right now would be luxury.

But one did not sit during Monday morning attending rounds. Certainly not when the attending was Dr. ColinWettig, Chairman of Bayside Hospital's Surgical Residency Programme. A retired Army general, Dr. Wetrig had a reputation for crisp and merciless questions. Abby was terrified of the General. So were all the other surgical residents.

Eleven residents now stood in the SICU, forming a semicircle of white coats and green scrub suits. Their gazes were all trained on the residency chairman. They knew that any one of them could be ambushed with a question. To be caught without an answer was to be subjected to a prolonged session of personalized humiliation.

The group had already rounded on four post-op patients, had discussed treatment plans and prognoses. Now they stood assembled beside SICU Bed 11. Abby's new admission. It was her turn to present the case.

Though she held a clipboard in her arms, she did not refer to her notes. She presented the case by memory, her gaze focused on the General's unsmiling face.

"The patient is a thirty-four-year-old Caucasian female, admitted at one this morning via the trauma service after a high-speed head-on collision on Route 90. She was intubated and stabilized in the field, then airlifted here. On arrival to the ER, she had evidence of multiple trauma. There were compound and depressed skull fractures, fractures of the left clavicle and humerus, and severe facial lacerations. On my initial exam, I found her to be a well nourished white female, medium build. She was unresponsive to all stimuli with the exception of some questionable extensor posturing-'

"Questionable?" asked Dr. Wetfig. "What does that mean? Did she or did she not have extensor posturing?"

Abby felt her heart hammering. Shit, he was already on her case. She swallowed and explained, "Sometimes the patient's limbs would extend on painful stimuli. Sometimes they wouldn't."

"How do you interpret that? Using the Glasgow Coma Scale for motor response?"

"Well. Since a nil response is rated a one, and extensor posturing is a two, I suppose the patient could be considered a… one and a half."

There was a ripple of uneasy laughter among the circle of residents.

"There is no such score as a one and a half," said Dr. Wettig.

"I'm aware of that," said Abby. "But this patient doesn't fit neatly into-'

"Just continue with your exam," he cut in.

Abby paused and glanced around at the circle of faces. Had she screwed up already? She couldn't be sure. She took a breath and continued. "Vital signs were blood pressure of ninety over sixty and pulse of a hundred. She was already intubated. She had no spontaneous respirations. Her rate was fully supported by mechanical ventilation at twenty-five breaths per minute."

"Why was a rate of twenty-five selected?"

"To keep her hyperventilated."

"Why?"

"To lower her blood carbon dioxide. That would minimize brain edema."

"Go on."

"Head exam, as I mentioned, revealed both depressed and compound skull fractures of the left parietal and temporal bones. Severe swelling and lacerations of the face made it difficult to evaluate facial fractures. Her pupils were midposition and unreactive. Her nose and throat-' "Oculocephalic

"reflexes?"

"I didn't test them."

"You didn't?"

"No, sir. I didn't want to manipulate the neck. I was concerned about possible spinal dislocation."

She saw, by his slight nod, that her answer had been acceptable.

She described the physical findings. The normal breath sounds. The unremarkable heart. The benign abdomen. Dr. Wettig did not interrupt. By the time she'd finished describing the neurologic findings, she was feeling more self-assured. Almost cocky. And why shouldn't she? She knew what the hell she'd been doing.

"So what was your impression?" asked Dr. Wettig. "Before you saw any x-ray results?"

"Based on the midposition and unreactive pupils," said Abby, "I felt there was probable midbrain compression. Most likely from an acute subdural or epidural haematoma." She paused, and added with a quiet note of confidence, "The CT scan confirmed it. A large left-sided subdural with severe midline shift. Neurosurgery was called in. They performed an emergency evacuation of the clot."

"So you're saying your initial impression was absolutely correct, Dr. DiMatteo?"

Abby nodded.

"Let's take a look at how things are this morning," said Dr. Wettig, moving to the bedside. He shone a penlight into the patient's eyes. "Pupils unresponsive," he said. He pressed a knuckle, hard, against the breastbone. She remained flaccid, unmoving. "No response to pain. Extensor or otherwise."

All the other residents had edged forward, but Abby remained at the foot of the bed, her gaze focused on the patient's bandaged head. WhileWettig continued his exam, tapping on tendons with a rubber hammer, flexing elbows and knees, Abby felt her attention drift away on a tide of fatigue. She kept staring at the woman's head, recently shorn of hair. The hair had been a thick brown, she remembered, clotted with blood and glass. There had been glass ground into the clothes as well. In the ER, Abby had helped cut away the blouse. It was a blue and white silk with a Donna Karan label. That last detail was what seemed to linger inAbby's memory. Not the blood nor the broken bones nor the shattered face. It was that label. Donna Karan. A brand she herself had once purchased. She thought of how, sometime, somewhere, this woman must once have stood in a shop, flipping through blouses, listening to the hangers squeak as they slid across the rack…

Dr. Wetrig straightened and looked at the SICU nurse. "When was the haematoma drained?"

"She came out of Recovery about 4 a.m."

"Six hours ago?"

"Yes, that would make it six hours."

Wetrig turned to Abby. "Then why has nothing changed?" Abby stirred from her daze and saw that everyone was watching her. She looked down at the patient. Watched the chest rise and fall, rise and fall with every wheeze of the ventilator bellows.

"There… may be some post-op swelling," she said, and glanced at the monitor. "The intracranial pressure is slightly elevated at twenty millimetres."

"Do you think that's high enough to cause pupillary changes?"

"No. But-'

"Did you examine her immediately post-op?"

"No, sir. Her care was transferred to Neurosurgery service. I spoke to their resident after surgery, and he told me-'

"I'm not asking the neurosurgery resident. I'm asking you, Dr. DiMatteo. You diagnosed a subdural haematoma. It's been evacuated. So why are her pupils still midposition and unreactive six hours post-op?"

Abby hesitated. The General watched her. So did everyone else. The humiliating silence was punctuated only by the whoosh of the ventilator.

Dr. Wettig glanced imperiously at the circle of residents. "Is there anyone here who can help Dr. DiMatteo answer the question?"

Abby's spine straightened. '! "I can answer the question myself," she said.

Dr. Wettig turned to her, his eyebrow raised. "Yes?"

"The… pupillary changes — the extensor posturing of the limbs — they were high midbrain signs. Last night I assumed it was because of the subdural haematoma, pressing downwards on the midbrain. But since the patient hasn't improved, I… I guess that indicates I was mistaken."

"You guess?"

She let out a breath. "I was mistaken."

"What's your diagnosis now?"

"A midbrain haemorrhage. It could be due to shearing forces. Or residual damage from the subdural haematoma. The changes might not show up yet on CT scan."

Dr. Wettig regarded her for a moment, his expression unreadable. Then he returned to the other residents. "A midbrain haemorrhage is a reasonable assumption. With a combined Glasgow Coma Scale of three…" He glanced at Abby '… and a half," he amended, 'the prognosis is nil. The patient has no spontaneous respirations, no spontaneous movements, and she appears to have lost all brainstem reflexes. At the moment, I have no suggestions other than life support. And consideration of organ harvest." He gave Abby a curt nod. Then he moved on to the next patient.

One of the other residents gave Abby's arm a squeeze. "Hey, DiMatteo," he whispered. "Flying colours."

Wearily Abby nodded. "Thanks."

Chief surgical resident Dr. Vivian Chao was a legend among the other residents at Bayside Hospital. As the story went, two days into her very first rotation as an intern, her fellow intern suffered a psychotic break and had to be carted off, sobbing uncontrollably, to the loony ward. Vivian was forced to pick up the slack. For twenty-nine straight days, she was the one and only orthopaedic resident on duty, around the clock. She moved her belongings into the call room and promptly lost five pounds on an unrelenting diet of cafeteria food. For twenty-nine straight days, she did not step out of the hospital front doors. On the thirtieth day her rotation ended, and she walked out to her car, only to discover that it had been towed away a week before. The parking lot attendant had assumed it was abandoned.

Four days into the next rotation, vascular surgery, Vivian's fellow intern was struck by a city bus and hospitalized with a broken pelvis. Again, someone had to take up the slack.

Vivian Chao moved right back into the hospital call room.

In the eyes of the other residents, she had thus achieved honorary manhood, a lofty status which was later acknowledged at the yearly awards dinner when she was presented with a boxed pair of steel balls.

When Abby first heard the Vivian Chao stories, she'd had a hard time reconciling that steel-balls reputation with what she saw: a laconic Chinese woman who was so petite she had to stand on a footstool to operate. ThoughVivian seldom spoke during attending rounds, she could always be found standing fearlessly at the very front of the group, wearing an expression of cool dispassion.

It was with her usual air of detachment that Vivian approached Abby in the SICU that afternoon. By then Abby was moving through a sea of exhaustion, every step a struggle, every decision an act of pure will. She didn't even notice Vivian was standing beside her until the other woman said, "I hear you admitted an AB positive head trauma."

Abby looked up from the chart where she'd been recording patient progress notes. "Yes. Last night."

"Is the patient still alive?"

Abby glanced towards Bed 1 l's cubicle. "It depends what you mean by alive."

"Heart and lungs in good shape?"

"They're functioning."

"How old?"

"She's thirty-four. Why?"

"I've been following a medical patient on the teaching service. Endstage congestive failure. Blood type AB positive. He's been waiting for a new heart?Vivian went over to the chart rack. "Which bed?"

"Eleven."

Vivian pulled the chart out of the rack and flipped open the metal cover. Her face belied no emotion as she scanned the pages.

"She's not my patient any more," said Abby. "I transferred her to Neurosurgery. They drained a subdural hematoma."

Vivian just kept reading the chart.

"She's only ten hours post-op," said Abby. "It seems a little early to be talking harvest."

"No neurologic changes so far, I see."

"No. But there's a chance…"

"With a Glasgow Scale of three? I don't think so."Vivian slid the chart back in the rack and crossed to Bed 11.

Abby followed her.

From the cubicle doorway she stood and watched as Vivian briskly performed a physical exam. It was the same way Vivian performed in the OR, wasting no time or effort. During Abby's first year — the year of her internship — she had often observed Vivian in surgery, and she had admired those small, swift hands, had watched in awe as those delicate fingers spun perfect knots. Abby felt clumsy by comparison. She invested hours of practice and yards and yards of thread, learning to tie surgical knots on the handles of her bureau drawers. Though she could manage the mechanics competently enough, she knew she would never have Vivian Chao's magical hands.

Now, as she watched Vivian examine Karen Terrio, Abby found the efficiency of those hands profoundly chilling.

"No response to painful stimuli," Vivian observed.

"It's still early."

"Maybe. Maybe not." Vivian pulled a reflex hammer from her pocket and began tapping on tendons. "She/ AB positive?"

"Yes."

"A stroke of luck."

"I don't see how you can call it that."

"My patient in MICU is AB positive. He's been waiting a year for a heart. This is the best match that's come up for him."

Abby looked at Karen Terrio and she remembered, once again, the blue and white blouse. She wondered what the woman had been thinking as she'd buttoned it up that last time. Mundane thoughts, perhaps. Certainly not mortal thoughts. Not thoughts of a hospital bed or IV tubes or machines pumping air into her lungs.

"I'd like to go ahead with the lymphocyte crossmatch. Make sure they're compatible," said Vivian. "And we might as well start HLA typing for the other organs. The EEG's been done, hasn't it?"

"She's not on my service; said Abby. "And anyway, I think this is premature. No one's even talked to the husband about it."

"Someone's going to have to."

"She has kids. They'll need time for this to sink in."

"The organs don't have a lot of time."

"I know I know it's got to be done. But, as I said, she's only ten hours post-op."

Vivian went to the sink and washed her hands. "You aren't really expecting a miracle, are you?"

A SICU nurse appeared at the cubicle door. "The husband's back with the kids. They're waiting to visit. Will you be much longer?"

"I'm finished," saidVivian. She tossed the crumpled paper towel into the trash can and walked out.

"Can I send them in?" the nurse asked Abby.

Abby looked at KarenTerrio. In that instant she saw, with painful clarity, what a child would see gazing at that bed. "Wait," said Abby. "Not yet." She went to the bed and quickly smoothed out the blankets. She wet a paper towel in the sink and wiped away the flecks of dried mucus from the woman's cheek. She transferred the bag of urine around to the side of the bed, where it would not be so visible. Then, stepping back, she took one last look at KarenTerrio. And she realized that nothing she could do, nothing anyone could do, would lessen the pain of what was to come for those children.

She sighed and nodded to the nurse. "They can come in now."

By four-thirty that afternoon, Abby could barely concentrate on what she was writing, could barely keep her eyes focused. She had been on duty thirty-three and a half hours. Her afternoon rounds were completed. It was, at last, time to go home.

But as she closed the last chart, she found her gaze drawn, once again, to Bed 11. She stepped into the cubicle. There she lingered at the foot of the bed, gazing numbly at Karen Terrio. Trying to think of something else, anything else, that could be done.

She didn't hear the footsteps approaching from behind.

Only when a voice said: "Hello gorgeous," did Abby turn and see brown-haired, blue-eyed Dr. Mark Hodell smiling at her. It was a smile meant only for Abby, a smile she'd sorely missed seeing today. On most days, Abby and Mark managed to share a quick lunch together or, at the very least, exchange a wave in passing. Today, though, they had missed seeing each other entirely, and the sight of him now gave her a quiet rush of joy. He bent to kiss her. Then, stepping back, he eyed her uncombed hair and wrinkled scrub suit. "Must've been a bad night," he murmured sympathetically.

"How much sleep did you get?"

'! don't know. Half an hour."

"I heard rumours you batted a thousand with the General this morning."

She shrugged. "Let's just say he didn't use me to wipe the floor."

"That qualifies as a triumph."

She smiled. Then her gaze shifted back to Bed 11 and her smile faded. Karen Terrio was lost in all that equipment. The ventilator, the infusion pumps. The suction tubes and monitors for EKG and blood pressure and intracranial pressure. A gadget to measure every bodily function. In this new age of technology, why bother to feel for a pulse, to lay hands on a chest? What use were doctors when machines could do all the work?

"I admitted her last night," said Abby. "Thirty-four years old. A husband and two kids. Twin girls. They were here. I saw them just a little while ago. It's +strange, Mark, how they wouldn't touch her. They stood looking. Just looking at her. But they wouldn't touch her. I kept thinking, you have to. You have to touch her now because it could be your last chance. The last chance you'll ever have. But they wouldn't. And! think, someday, they're going to wish…" She shook her head. Quickly she ran her hand across her eyes. "I hear the other guy was driving the wrong way, drunk. You know what pisses me off, Mark?And it really pisses me off. He'll survive. Right now he's sitting upstairs in the orthopaedic ward, whining about a few fucking broken bones." Abby took another deep breath and with the sigh that followed, all her anger seemed to dissipate. "Jesus, I'm supposed to save lives. And here I am wishing that guy was smeared all over the highway." She turned from the bed. "It must be time to go home."

Mark ran his hand down her back, a gesture of both comfort and possession. "Come on," he said. "I'll walk you out."

They left the SICU and stepped onto the elevator. As the doors slid shut, she felt herself wobble and melt against him. At once he took her into the warm and familiar circle of his arms. It was a place where she felt safe, where she'd always felt safe.

A year ago, Mark Hodell had seemed a far from reassuring presence. Abby had been an intern. Mark had been a thoracic surgery attending — not just any attending physician, but a key surgeon on the Bayside cardiac transplant team. They'd met in the OR over a trauma case. The patient, a ten-year-old boy, had been rushed in by ambulance with an arrow protruding from his chest — the result of a sibling argument combined with a bad choice in birthday presents. Mark had already been scrubbed and gowned when Abby entered the OR. It was only her first week as an intern, and she'd been nervous, intimidated by the thought of assisting the distinguished Dr. Hodell. She'd stepped up to the table. Shyly she'd glanced at the man standing across from her. What she saw, above his mask, was a broad, intelligent forehead and a pair of beautiful blue eyes. Very direct. Very inquisitive.

Together they operated. The kid survived.

A month later, Mark asked Abby for a date. She turned him down twice. Not because she didn't want to go out with him, but because she didn't think she should go out with him.

A month went by. He asked her out again. This time temptation won out. She accepted.

Five and a half months ago, Abby moved into Mark's Cambridge home. It hadn't been easy at first, learning to live with a forty-one-year-old bachelor who'd never before shared his life — or his home — with a woman. But now, as she felt Mark holding her, supporting her, she could not imagine living with, or loving, anyone else.

"Poor baby," he murmured, his breath warm in her hair. "Brutal, isn't it?"

"I'm not cut out for this. What the hell do I think I'm doing here?"

"You're doing what you always dreamed about. That's what you told me."

"I don't even remember what the dream was any more. I keep losing sight of it."

"I believe it had something to do with saving lives?"

"Right. And here I am wishing that drunk in the other car was dead." She shook her head in self-disgust.

"Abby, you're going through the worst of it now. You've got two more days on Trauma. You just have to survive two more days."

"Big deal. Then I start Thoracic-'

"A piece of cake in comparison. Trauma's always been the killer. Tough it out like everyone else."

She burrowed deeper into his arms. "If I switched to Psychiatry, would you lose all respect for me?"

"All respect. No doubt about it."

"You're such a jerk."

Laughing, he kissed the top of her head. "Many people think it, but you're the only one allowed to say it."

They stepped off on the first floor and walked out of the hospital. It was autumn already, but Boston was sweltering in the sixth day of a late-September heat wave. As they crossed the parking lot, she could feel her last reserves of strength wilting away. By the time they reached her car, she was scarcely able to drag her feet across the pavement. This is what it does to us, she thought. It's the fire we walk through to become surgeons. The long days, the mental and emotional abuse, the hours of pushing onward while bits and pieces of our lives peel away from us. She knew it was simply a winnowing process, ruthless and necessary. Mark had survived it; so would she.

He gave her another hug, another kiss. "Sure you're safe driving home?" he asked.

"I'll just put the car on automatic pilot."

"I'll be home in an hour. Shall I pick up a pizza?" Yawning, she slid behind the wheel. "None for me."

"Don't you want supper?"

She started the engine. "All I want tonight," she sighed, 'is a bed."