Harvest

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.

She said: "That boy makes me think of Pete. Pete was a Red Sox fan."

"Who?"

"My brother."

Mark said nothing. He sat with shoulders hunched in obvious discomfort. He'd never been at ease with the subject of Pete. But then, death was not a comfortable subject for doctors. Every day we play a game of tag with that word, she thought. We say 'expired' or 'could not resuscitate' or 'terminal event'. But we seldom use that word: died.

"He was crazy about the Red Sox," she said. "He had all these baseball cards. He'd save his lunch money to buy them. And then he'd spend a fortune on little plastic covers to keep them safe. A five-cent cover for a one-cent piece of cardboard. I guess that's the logic of a ten-year-old for you."

Mark took a sip of wine. He sat wrapped in his discomfort, insulated against her attempts at conversation.

The celebration dinner was a bust. They ate with scarcely another word between them.

Back in the house they shared in Cambridge, Mark retreated behind his stack of surgical journals. That was the way he always reacted to their disagreements — withdrawal. Damn it, she didn't mind a good, healthy fight. The DiMatteo family, with its three headstrong daughters and little Pete, had weathered more than its share of adolescent conflicts and sibling rivalries, but their love for each other had never been in doubt.

It was silence she couldn't stand.

In frustration she went into the kitchen and scrubbed the sink. I'm turning into my mother, she thought in disgust. I get angry and what do I do? I clean the kitchen. She wiped the stove top, then dismantled the burners and scrubbed those as well. She had the whole damn kitchen sparkling by the time she heard Mark finally head upstairs to the bedroom.

She followed him.

In darkness they lay side by side, not touching. His silence had rubbed off on her and she could think of no way to break through it without seeming like the needy one, the weak one. But she couldn't stand it any longer.

"I hate it when you do this," she said.

"Please, Abby. I'm tired."

"So am I.We're both tired. It seems like we're always tired. But I can't go to sleep this way. And neither can you."

"All right. What do you want me to say?"

"Anything! I just want you to keep talking to me."

"I don't see the point of talking things to death."

"There are things I need to talk about."

"Fine. I'm listening."

"But you're doing it through a wall. I feel like I'm in confession. Talking through a grate to some guy I can't see." She sighed and stared up at the darkness. She had the sudden, dizzying sensation that she was floating free, unattached. Unconnected. "The boy's in MICU," she said. "He's only seventeen."

Mark said nothing.

"He reminds me so much of my brother. Pete was a lot younger. But there's this sort of fake courage that all boys have. That Pete had."

"It's not my decision alone," he said. "There are others involved. The whole transplant team. Aaron Levi, Bill Archer. Even Jeremiah Parr."

"Why the hospital president?"

"Parr wants our statistics to look good. And all the research shows that outpatients are more likely to survive a transplant."

"Without a transplant, Josh O" Day's not going to survive at all."

"I know it's a tragedy. But that's life."

She lay very still, stunned by his matter-of-fact tone.

He reached out to touch her hand. She pulled away.

"You could change their minds," she said. "You could talk them into--'

"It's too late. The team's decided."

"What/s this team, anyway? God?"

There was a long silence. Quietly, Mark said: "Be careful what you say, Abby."

"You mean about the holy team?"

"The other night, at Archer's, we all meant what we said. In fact, Archer told me later that you're the best fellowship material he's seen in three years. But Archer's careful about which people he recruits, and I don't blame him. We need people who'll work with us. Not against us."

"Even if I don't agree with the rest of you?"

"It's part of being on a team, Abby. We all have our points of view. But we make the decisions together. And we stick by them." He reached out again to touch her hand. This time she didn't pull away. Neither did she return his squeeze. "Come on, Abby," he said softly. "There are residents out there who'd kill for a transplant fellowship at Bayside. Here you're practically handed one on a platter. It is what you want, isn't it?"

"Of course it's what I want. It scares me how much I want it. The crazy thing is, I never knew I did, not until Archer raised the possibility…" She took a deep breath, released it in a long sigh. "I hate the way I keep wanting more. Always wanting more. There's something that keeps pulling me and pulling me. First it was getting into college, then med school. Then a surgery residency. And now, it's this fellowship. It's moved so far from where I started. When I just wanted to be a doctor…"

"It's not enough any more. Is it?"

"No. I wish it was. But it isn't."

"Then don't blow it, Abby. Please. For both our sakes."

"You make it sound as if you're the one with everything to lose."

"I'm the one who suggested your name. I told them you're the best choice they could make." He looked at her. "I still think so."

For a moment they lay without talking, only their hands in contact. Then he reached over and caressed her hip. Not a real embrace, but an attempt at one.

It was enough. She let him take her into his arms.

The simultaneous squeal of half a dozen pocket pagers was followed by the curt announcement over the hospital speaker system: Code Blue, MICU. Code Blue, MICU.

Abby joined the other surgical residents in a dash for the stairway. By the time she'd jogged into the MICU, a crowd of medical personnel was already thronging the area. A glance told her there were more than enough people here to deal with a Code Blue. Most of the residents were starting to drift out of the room. Abby, too, would have left.

Had she not seen that the code was in Bed 4. Joshua O" Day's cubicle.

She pushed into the knot of white coats and scrub suits. At their centre lay Joshua O" Day, his frail body fully exposed to the glare of overhead lights. Hannah Love was administering chest compressions, her blonde hair whipping forward with every thrust. Another nurse was frantically rummaging through the crash cart drawers, pulling out drug vials and syringes and passing them to the medical residents. Abby glanced up at the cardiac monitor screen.

Ventricular fibrillation. The pattern of a dying heart.

"Seven and a half ET tube!" a voice yelled.

Only then did Abby notice Vivian Chao crouched behind Joshua's head. Vivian already had the laryngoscope ready.

The crash cart nurse ripped the plastic cover off an ET tube and passed it to Vivian.

"Keep bagging him!" Vivian ordered.

The respiratory tech, holding an anaesthesia mask to Josh's face, continued squeezing the balloon-like reservoir a few times, manually pumping oxygen into the boy's lungs.

"OK," said Vivian. "Let's intubate."

The tech pulled the mask away. Within seconds, Vivian had the ET tube in place, the oxygen connected.

"Lidocaine's in," said a nurse.

The medical resident glanced up at the monitor. "Shit. Still in V. fib. Let's have the paddles again. 200 joules." A nurse handed him the defibrillator paddles. He slapped them onto the chest. The placement was already marked by conductive gel pads: one paddle near the sternum, the other outside the nipple. "Everyone back."

The burst of electricity shot through Joshua O" Day's body, jolting every muscle into a simultaneous spasm. He gave a grotesque jerk and then lay still.

Everyone's gaze shot to the monitor screen.

"Still in V. fib," someone said. "Bretylium, 2502 Hannah automatically resumed chest compressions. She was flushed, sweating, her expression numb with fear. "I can take over," Abby offered. Nodding, Hannah stepped aside.

Abby climbed onto the footstool and positioned her hands on Joshua's chest, her palm on the lower third of the sternum. His chest felt thin and brittle, as though it would crack under a few vigorous thrusts; she was almost afraid to lean against it.

She began to pump. It was a task that required no mental exertion. Just that repetitive motion of lean forward, release, lean forward, release. The alpha rhythm of CPR. She was a participant in the chaos yet she was apart from it, her mind pulling back, withdrawing. She could not bring herself to look at the boy's face, to watch as Vivian taped the ET tube in place. She could only focus on his chest, on that point of contact between his sternum and her clasped hands. Sternums were anonymous. This could be anyone's chest. An old man's. A stranger's. Lean, release. She concentrated. Lean, release.

"Everyone back again!" someone yelled.

Abby pulled away. Another jolt of the paddles, another grotesque spasm.

Ventricular fibrillation. The heart signalling that it cannot hold on.

Abby crossed her hands and placed them again on the boy's chest. Lean, release. Come back, Joshua, her hands were saying to him. Come back to us.

A new voice joined in the bedlam. "Let's try a bolus of calcium chloride. 100 milligrammes," said Aaron Levi. He was standing near the footboard, his gaze fixed on the monitor.

"But he's on digoxin," said the medical resident.

"At this point, we've got nothing to lose."

A nurse filled a syringe and handed it to the resident. '100 milligrammes calcium chloride."

The bolus was injected into the IV line. A penny toss into the chemical wishing well.

"OK, try the paddles again," said Aaron. '400 joules this time." "Everyone back!"

Abby pulled away. The boy's limbs jerked, fell still.

"Again," said Aaron.

Another jolt. The tracing on the monitor shot straight up. As it settled back to baseline, there was a single blip — the jagged peak of a QRS complex. At once it deteriorated back to V. fib.

"One more time!" said Aaron.

The paddles were slapped on the chest. The body thrashed under the shock of 400 joules. There was a sudden hush as everyone's gaze shot to the monitor.

A QRS blipped across. Then another. And another.

"We're in sinus," said Aaron.

"I'm getting a pulse!" said a nurse. "I feel a pulse!"

"BP seventy over forty… up to ninety over fifty…"

A collective sigh seemed to wash through the room. At the foot of the bed, Hannah Love was crying unashamedly. Welcome back, Josh, Abby thought, her gaze blurred with tears.

Gradually the other residents filed out, but Abby couldn't bring herself to leave; she felt too drained to move on. In silence she helped the nurses gather up the used syringes and vials, all the bits of glass and plastic that are the aftermath of every Code Blue. Working beside her, Hannah Love sniffled as she wiped away the electrode paste, her washcloth stroking lovingly across Josh's chest. It was Vivian who broke the silence.

"He could be getting that heart right now," she said. Vivian was standing by the tray table of Joshua's trophies. She picked up the Cub Scout ribbon. Pinewood Derby, third grade. "He could've gone to the OR this morning. Had the transplant by ten o'clock. If we lose him, it's your fault, Aaron."Vivian looked at Aaron Levi, whose pen had frozen in the midst of signing the code sheet.

"Dr. Chao," said Aaron quietly. "Would you care to talk about this in private?"

"I don't care who's listening!The match is perfect.! wanted Josh on the table this morning. But you wouldn't give me a decision. You just delayed. And delayed. And fucking delayed." She took a deep breath and looked down at the award ribbon she was holding. '! don't know what the hell you think you're doing. Any of you."

"Until you calm down, I'm not going to discuss this with you," said Aaron. He turned and walked out.

"You are.You are going to," said Vivian, following him out of the cubicle.

Through the open doorway, Abby could hear Vivian's pursuit of Aaron across the MICU. Her angry questions. Her demands for an explanation.

Abby bent down and picked up the Pinewood Derby ribbon that Vivian had dropped on the floor. It was green — not a winner's ribbon, but merely an honourable mention for the hours spent labouring over a small block of wood, sanding it, painting it, greasing the axles, pounding in the lead fishing weights to make it tumble faster. All that effort must be rewarded. Little boys need their tender egos soothed.

Vivian came back into the cubicle. She was white-faced, silent. She stood at the foot of Josh's bed, staring down at the boy, watching his chest rise and fall with each whoosh of the ventilator.

"I'm transferring him," she said.

"What?" Abby looked at her in disbelief. "Where?"

"Massachusetts General. Transplant Service. Get Josh ready for the ambulance. I'm going to make the calls."

The two nurses didn't move. They were staring at Vivian. Hannah protested, "He's ha no condition to be moved."

"If he stays here, we're going to lose him," said Vivian. ' We are going to lose him. Are you willing to let that happen?"

Hannah looked down, at the frail chest rising and falling beneath her washcloth. "No," she said. "No. I want him to live."

"Ivan Tarasoft was my professor at Harvard Med," said Vivian. "He's head of their transplant team. If our team won't do it, then Tarasoffwill."

"Even if Josh survives the transfer," said Abby, 'he still needs a donor heart."

"Then we'll have to get him one." Vivian looked straight at Abby. "Karen Terrio's."

That's when Abby understood exactly what she had to do. She nodded. "I'll talk to Joe Terrio now."

"It has to be in writing. Make sure he signs it."

"What about the harvest? We can't use the Bayside team."

"Tarasoft likes to send his own man for the harvest. We'll assist. We'll even deliver to his doorstep. There can't be any delay. We have to do it fast, before anyone here can stop us."

"Wait a minute," said the other nurse. "You can't authorize a transfer to Mass Gen."

"Yes I can," saidVivian. "Josh O" Day is on teaching service. Which means the Chief Residents are in charge. I'll take full responsibility. Just follow my orders and get him ready for ambulance transfer."

"Absolutely, Dr. Chao," said Hannah. "In fact, I'll ride with him."

"You do that." Vivian looked at Abby. "OK, DiMatteo," she snapped. "Go get us a heart."

Ninety minutes later, Abby was scrubbing in. She completed her final rinse and, elbows bent, backed through the swinging door into OR 3.

The donor lay on the table, her pale body washed in fluorescent light. A nurse-anaesthetist was changing IV bottles. No need for anaesthesia on this patient; Karen Terrio could feel no pain.

Vivian, gowned and gloved, stood at one side of the table. Dr. Lima kidney surgeon, stood on the other. Abby had worked with Lim on previous cases. A man of few words, he was known for his swift, silent work.

"Signed and sealed?" asked Vivian.

"In triplicate. It's in the chart." She herself had typed up the directed-donation consent, a statement specifying that Karen Terrio's heart be given to Josh O" Day, age seventeen.

It was the boy's age that had swayed JoeTerrio. He'd been sitting at his wife's bedside, holding her hand, and had listened to silence as Abby told him about a seventeen-year-old boy who loved baseball. Without saying a word, Joe had signed the paper.

And then he'd kissed his wife goodbye.

Abby was helped into a sterile gown and size six and a half gloves. "Who's doing the harvest?" she asked.

"Dr. Frobisher, from Tarasoff's team. I've worked with him before,"

said Vivian. "He's on his way now."

"Any word about Josh?"

"Tarasoft called ten minutes ago. They've got his blood typed and crossed and an OR cleared. They're standing by." She looked down impatiently at KarenTerrio. "Jesus, I could do the heart myself. Where the hell's Frobisher?"

They waited. Ten minutes, fifteen. The intercom buzzed with a call from Tarasoft at Mass Gert. Was the harvest proceeding? "Not yet," said Vivian. "Any minute now."

Again the intercom buzzed. "Dr. Frobisher's arrived," said the nurse. "He's scrubbing now."

Five minutes later, the OR door swung open and Frobisher pushed in, his hefty arms dripping water. "Size nine gloves," he snapped.

At once the atmosphere in the room stretched taut. No one except Vivian had ever worked with Frobisher before, and his fierce expression did not invite any conversation. With silent efficiency, the nurses helped him gown and glove.

He stepped to the table and critically eyed the prepped operative site. "Causing trouble again, Dr. Chao?" he said.

"As usual," saidVivian. She gestured to the others standing at the table. "Dr. Lim will do the kidneys. Dr. DiMatteo and I will assist as needed."

"History on this patient?"

"Head injury. Brain dead, donor forms all signed. She's thirty-four, previously healthy, and her blood's been screened."

He picked up a scalpel and paused over the chest. "Anything else I should know?"

"Not a thing. NEOB confirms it's a perfect match. Trust me."

"I hate it when people tell me that," muttered Frobisher. "OK, let's take a quick look at our heart, make sure it's in good shape. Then we'll move aside and let Dr. Lira do his thing first." He touched the scalpel blade to KarenTerrio's chest. In one swift slice, he cut straight down the centre, exposing the breastbone. "Sternal saw."

The scrub nurse handed him the electric saw. Abby took hold of the retractor. As Frobisher cut through the sternum, Abby couldn't help turning away. She felt vaguely nauseated by the whine of the blade, the smell of bone dust, neither of which seemed to bother Frobisher, whose hands moved with swift skill. In moments he was in the chest cavity, his scalpel poised over the pericardial sac.

Cutting through the sternum had seemed an act of brute force. What lay ahead was a far more delicate task. He slit open the membrane.

At his first glance at the beating heart, he gave a soft murmur of satisfaction. Glancing across at Vivian, he asked: "Opinion, Dr. Chao?"

With almost reverential silence, Vivian reached deep into the chest cavity. She seemed to caress the heart, her fingers stroking the walls, tracing the course of each coronary artery. The organ pulsed vigorously in her hands. "It's beautiful," she said softly. Eyes shining, she looked across at Abby. "It's just the heart for Josh."

The intercom buzzed. A nurse's voice said: "DrTarasoff's on the line."

"Tell him the heart looks free," said Frobisher. "We're just starting the kidney harvest."

"He wants to talk to one of the doctors. He says it's extremely urgent."

Vivian glanced at Abby. "Go ahead and break scrub. Take the call."

Abby peeled off her gloves and went to pick up the wall phone. "Hello, Dr. Tarasoft? This is Abby DiMatteo, one of the residents. The heart looks great. We should be at your doorstep in an hour and a half."

"That may not be soon enough," answered Tarasoft. Over the line, Abby could hear a lot of background noise: a rapid-fire exchange of voices, the clank of metal instruments. Tarasofthimself sounded tense, distracted. She heard him turn away, talk to someone else. Then he was back on the line. "The boy's coded twice in the last ten minutes. Right now we've got him back in sinus rhythm. But we can't wait any longer. Either we get him on the bypass machine now or we lose him. We may lose him in any event." Again he turned from the receiver, this time to listen to someone. When he came back on line, it was only to say: "We're going to cut. Just get here, OK?"

Abby hung up and said to Vivian: "They're putting Josh on bypass. He's coded twice. They need that heart now."

"It'll take me an hour to free up the kidneys," said Dr. Lim. "Screw the kidneys," snapped Vivian. "We go straight for the heart."

"But-'

"She's right," said Frobisher. He called to the nurse: "Iced saline! Get the Igloo ready. And someone better call an ambulance for transport."

"Shall I scrub in again?" asked Abby.

"No." Vivian reached for the retractor. "We'll be done in a few minutes. We need you for delivery."

"What about my patients?"

"I'll cover for you. Leave your beeper at the OR desk."

One nurse began to pack an Igloo cooler with ice. Another was arranging buckets of cold saline next to the operating table. Frobisher didn't need to issue any more orders; these were cardiac nurses. They knew exactly what to do.

Already, Frobisher's scalpel was moving swiftly, freeing up the heart in preparatory dissection. The organ was still pumping, each beat squeezing oxygen-rich blood into the arteries. Now it was time to stop it, time to shut down the last vestiges of life in Karen Terrio.

Frobisher injected five hundred cc's of a high-potassium solution into the aortic root. The heart beat once. Twice.

And it stopped. It was now flaccid, its muscles paralysed by the sudden infusion of potassium. Abby couldn't help glancing at the monitor. There was no EKG activity. KarenTerrio was finally, and clinically, dead.

A nurse poured a bucket of the iced solution into the chest cavity, quickly chilling the heart. Then Frobisher got to work, ligating, cutting.

Moments later, he lifted the heart out of the chest and slid it gently into a basin. Blood swirled in the cold saline. A nurse stepped forward, holding open a plastic bag. Frobisher gave the heart a few more swishes in the liquid, then eased the rinsed organ into the bag. More iced saline was poured in. The heart was double-bagged and placed in the Igloo.

"It's yours, DiMatteo," said Frobisher. "You ride in the ambulance. I'll follow in my car."

Abby picked up the Igloo. She was already pushing out the OR doors when she heard Vivian's voice calling after her:

"Don't drop it."