Harvest

CHAPTER SIX

Never before had Abby dreaded going to work, but as she walked into Bayside Hospital that morning, she felt she was walking straight into the fire. Last night Jeremiah Parr had threatened repercussions; today she'd have to face them. But until Wetfig actually stripped her of her hospital privileges, she was determined to carry on as usual with her duties. She had patients to round on and cases scheduled for the OR. Tonight she was on call. Damn it, she was going to do her job, and do it well. She owed it to her patients — and to Vivian: Only an hour ago, they had spoken on the phone, and Vivian's last words to her were: "Someone there has to speak up for the Josh O" Days. Stay with it, DiMatteo. For both of us."

The moment Abby walked into the SICU, she heard the instantaneous lowering of voices. By now, everyone must know about Josh O" Day. Though no one said a word to Abby, she could hear the nurses' quiet murmurings, could see their uneasy looks. She went to the rack and gathered her patient charts for rounds. It took every ounce of concentration for her to complete that one task. She placed the charts in a rolling cart and wheeled it out of the station, to the cubicle of the first patient on her list. It was a relief just to step inside, away from everyone's gaze. She shut the curtains, blocking the view through the doorway, and turned to the patient.

Mary Allen lay on the bed, her eyes closed, her sticklike arms and legs drawn up in a foetal position. Mary's open lung biopsy two days ago had been followed by two brief episodes of hypotension, so she'd been kept in the SICU for close observation. According to the nurse's notes, Mary's blood pressure had remained stable for the past twenty-four hours and no abnormal cardiac rhythms had been noted. Chances were, Mary could be transferred today to an unmonitored room in the surgery ward.

Abby went to the bedside and said, "Mrs Allen?"

The woman stirred awake. "Dr. DiMatteo," she murmured.

"How are you feeling today?"

"Not so good. It still hurts, you know."

"Where?"

"My chest. My head. Now my back. It hurts all over."

Abby saw from the chart that the nurses had been giving morphine around the clock. Obviously it wasn't enough; Abby would have to order a higher dose.

"We'll give you more medicine for the pain," said Abby. "As much as you need to keep you comfortable."

"To help me sleep, too. I can't sleep." Mary gave a sigh of profound weariness and closed her eyes. "I just want to go to sleep, Doctor. And not wake up…"

"Mrs Allen? Mary?"

"Couldn't you do that for me?You're my doctor. You could make it so easy. So simple."

"We can make the pain go away," said Abby.

"But you can't take away the cancer. Can you?" The eyes opened again, and regarded Abby with a look that pleaded for undiluted honesty.

"No," said Abby. "We can't take that away. The cancer's spread too many places. We can give you chemotherapy, to slow it down. Gain some time for you."

"Time?" Mary gave a resigned laugh. "What do I need time for? To lie here another week, another month? I'd rather have it done and over with."

Abby took Mary' s hand. It felt like bones wrapped in parchment, no flesh at all. "Let's take care of the pain first. If we do that, it could make everything else seem different."

In answer, Mary simply turned on her side, away from Abby. She was closing her off, shutting her out. "I suppose you want to listen to my lungs," was all she said.

They both knew the exam was merely a formality. It was a useless ceremony, the stethoscope on the chest, on the heart. Abby went through the motions anyway. She had little else to offer Mary Allen except this laying on of hands. When she was finished, her patient still lay with her back turned.

"We'll be transferring you out of the SICU," said Abby. "You can go to a room on the ward. It'll be quieter there. Not so many disturbances."

No answer. Just a deep breath, a long sigh.

Abby left the cubicle feeling more defeated, more useless than ever. There was so little she could do. An absence of pain was the best she had to offer. That, and a promise to let nature take its course.

She opened Mary's chart and wrote: "Patient expresses wish to die. Will increase morphine sulphate for pain control and change code status to do not resuscitate." She wrote the transfer orders and handed them to Cecily, Mary's nurse.

"I want her kept comfortable," said Abby. "Titrate the dose to her pain. Give her as much as she needs to sleep."

'what's our upper limit?"

Abby paused. Considered the fine line between comfort and unconsciousness, between sleep and coma. She said, "No upper limit. She's dying, Cecily. She wants to die. If the morphine makes it easier, then that's what we should give her. Even if it means the end comes a little sooner."

Cecily nodded, a look of unspoken agreement in her eyes.

As Abby started towards the next cubicle, she heard Cecily call out: "Dr. DiMatteo?"

Abby turned. "Yes?"

"I… just wanted to tell you. I think you should know that, well. ." Nervously Cecily glanced around the SICU. She saw that some of the other nurses were watching. Waiting. Cecily cleared her throat. "I wanted you to know that we think you and Dr. Chao did the right thing. Giving the heart to Josh O" Day."

Abby blinked away an unexpected flash of tears. She whispered, "Thank you. Thank you so much."

Only then, as Abby looked around the room, did she see all the nods of approval.

"You're one of the best residents we've ever had, Dr. D.," said Cecily. "We wanted you to know that, too."

In the hush that followed, a pair of hands started clapping. Another joined in, then another. Abby stood speechless, clutching a chart to her chest, as all the SICU nurses burst out in loud and spontaneous applause. They were applauding her.

It was a standing ovation.

"I want her off the staff and out of this hospital," said Victor Voss. "And I'll do whatever the hell it takes to accomplish that."

Jeremiah Parr had faced numerous crises during his eight-year tenure as president of Bayside Medical Centre. He'd dealt with two nursing strikes, several multimillion-dollar malpractice suits, and militant Right-to-Lifers rampaging through the lobby, but never had he faced such outright fury as he saw now in the face of Victor Voss. At 10 a.m. Voss, flanked by his two attorneys, had marched into Parr's off.ace and demanded a conference. It was now close to noon and the group had expanded to include Surgical Residency Director ColinWettig and Susan Casado, the attorney representing Bayside. Calling Susan was Parr's idea. As yet there was no talk of any legal action, but Parr couldn't be too cautious. Especially when dealing with someone as powerful as VictorVoss.

"My wife is dying," said Voss. "Do you understand? Dying. She may not survive another night. I lay the blame squarely on those two residents."

"Dr. DiMatteo is only in her second year," said Wettig. "She wasn't the one who made the decision. Our Chief Resident did. Dr. Chao is no longer in our programme."

"I want Dr. DiMatteo's resignation as well."

"She hasn't offered it."

"Then find a reason to fire her."

"Dr. Wetfig," said Parr, calmly. Reasonably. "We must be able to find some basis for termination."

"There's no basis at all," said Wetfig, stubbornly holding his ground. "All her evaluations have been outstanding and they're all on record. Mr Voss, I know this is a painful situation for you. I know it's only normal to want to lay blame somewhere. But I think your anger is misdirected. The real problem lies in the shortage of organs. Thousands of people need new hearts and there are only a few to go around. Consider what would happen if we did fire Dr. DiMatteo. She could lodge an appeal. The matter would go to higher review. They look at this case and they'll ask questions. They'll ask why a seventeen-year-old boy didn't get that heart from the beginning."

There was a pause. "Jesus," murmured Parr.

"You understand what I'm saying?" said Wettig. "It looks bad. It makes the hospital look bad. This isn't the sort of thing we want to see in the newspapers. Hints of class warfare. The poor getting the short end of the stick. That's how they'll play it up. Whether or not it's true." Wettig looked questioningly around the table. No one said a thing.

Our silence speaks volumes, thought Parr.

"Of course we can't allow people to get the wrong impression," said Susan. "Outrageous as it may seem, even the appearance of human organ deals would kill us in the press."

"I'm just telling you how it looks," said Wettig.

"I don't care how it looks," said Voss. "They stole that heart."

"It was a directed donation. MrTerrio had every right to specify the recipient."

"My wife was guaranteed that heart."

"Guaranteed?" Wettig frowned at Parr. "Is there something I don't know about?"

"It was decided before her admission," Parr said. "The match was perfect."

"So was the boy's," countered Wetfig.

Voss shot to his feet. "Let me explain something to you people. My wife is dying because of Abby DiMatteo. Now, you people don't know me very well. But let me tell you, no one screws me or my family and gets away with-'

"Mr Voss," interjected one of his attorneys. "Perhaps we should discuss this in-'

"Goddamn it! Let me finish!"

"Please, Mr Voss. This isn't in your best interests."

Voss glared at his attorney. With apparent effort, he broke off his attack and sat back down. "I want something done about Dr. DiMatteo," he said. And he looked straight at Parr.

By now Parr was sweating. God, it would be so easy just to fire that resident. Unfortunately, the General wasn't going to play ball with them. Damn these surgeons and their egos; they resented anyone else calling the shots. Why was Wetfig being so stubborn about this?

"MrVoss," said Susan Casado in her silkiest voice. Her tame-the-savage-beast voice. "May! suggest we all take some time to think this over? Rushing into legal action is seldom the best course. In a few days, we may be able to resolve your concerns." Susan looked pointedly at Wetrig.

The General just as pointedly ignored her.

"In a few days," said Voss, 'my wife may be dead." He rose to his feet and regarded Parr with a look of contempt. "I don't need to think this over. I want something done about Dr. DiMatteo. And I want it done soon."

"I see the bullet," said Abby.

Mark redirected the light beam, focusing it on the posterior reaches of the thoracic cavity. Something metallic glinted back at them, then vanished behind the inflating lung.

"Sharp eyes, Abby. Since you spotted it, you want to do the honours?"

Abby took a pair of needle forceps off the instrument tray. The lungs had expanded again, blocking off her view of the cavity. "I need deflation. Just for a sec."

"You got it," said the anaesthesiologist.

Abby plunged her hand deep into the thorax, following the inner curve of the ribs. As Mark gently retracted the right lung, Abby clamped the forceps tips around the metal fragment and carefully withdrew it from the cavity.

The bullet, a flattened twenty-two, clattered into the metal basin. "No bleeding. Looks like we can close," said Abby.

"This is one lucky guy," Mark said, eyeing the probable trajectory. "Entry hole just right of the sternum. Rib must have deflected it or something. And it tumbled free along the pleural space. All he gets is a pneumothorax."

"Hope he learned his lesson," said Abby.

"What lesson?"

"Never piss off your wife."

"She was the shooter?"

"Hey, we've come a long way, baby."

They were closing the chest now, working together with the companionable ease of two people who know each other well. It was 4 p.m. Abby had been on duty since seven that morning. Already her calves ached from standing all day, and she had another twenty-four hours on duty to go. But she was on a high right now, buoyed by the success of this operation — and by the chance to operate with Mark. This was exactly how she'd pictured their future together: working hand in hand, confident of themselves and each other. Mark was a superb surgeon, swift yet meticulous. From the very first day she'd scrubbed in with him, Abby had been impressed by the comfortable atmosphere in his OR. Mark never lost his cool, never yelled at a nurse, never even raised his voice. She'd decided then that if she ever had to go under the knife, Mark Hodell was the one surgeon she'd want to be holding the scalpel.

Now she was working right beside him, her gloved hand brushing against his, their heads bent close. This was the man she loved, the work she loved. Just for this moment, she could forget Victor Voss and the crisis shadowing her career. Perhaps the crisis was over. No axe had yet fallen, no ominous message had been issued from Parr's office. In fact, ColinWettig had taken her aside this morning to tell her, in his usual gruff way, that she'd received outstanding evaluations for trauma rotation.

It will all work out, she thought as she watched the patient wheeled out to Recovery. Somehow, this will all turn out just fine.

"Excellent job, DiMatteo," said Mark, stripping off his OR gown. "I bet you say that to all the residents."

"Here's something I never say to the other residents." He leaned towards her and whispered: "Meet me in the call room."

"Uh… Dr. DiMatteo?"

Abby and Mark, both flushing, turned and looked at the circulating nurse, who'd just poked her head in the door.

"There's a call for you from Mr Parr's secretary. They want to see you in Administration."

"Now?"

"They're waiting for you," said the nurse, and she left.

Abby shot Mark a look of apprehension. "Oh God. Now what?"

"Don't let 'em rattle you. I'm sure it'll be OK. Want me to come with you?"

She thought it over a moment, then shook her head. "I'm a big girl. I should be able to handle this."

"If there's any problem, page me. I'll be right there." He gave her hand a squeeze. "That's a promise."

She managed to return the thinnest of smiles. Then she pushed through the OR door and headed grimly for the elevator.

With the same feeling of dread she'd felt last night, she stepped off onto the second floor and headed up the carpeted hall to Jeremiah Parr's office. Parr's secretary directed her around the corner to the meeting room. Abby knocked on the door.

"Come in," she heard Parr say.

Taking a shaky breath, she stepped inside.

Parr rose from his seat at the conference table. Also in the room were Colin Wetfig and a woman whom Abby did not recognize, a fortyish brunette in a nicely tailored blue suit. Nothing she saw in those faces gave Abby the slightest clue as to the purpose of this meeting, but every instinct told her this session would not be a pleasant one.

"Dr. DiMatteo," said Parr, "Let me introduce you to Susan Casado, the hospital's corporate attorney."

An attorney? This is not good.

The two women shook hands. Ms Casado's grip felt unnaturally warm against Abby's icy skin.

Abby took a chair next to Wetfig. There was a brief silence, punctuated by the lawyer's rattling of papers and Wettig's gruff throat-clearing.

Then Parr said, "Dr. DiMatteo, perhaps you could tell us what you recall about your role in the care of a Mrs Karen Terrio."

Abby frowned. This was not at all what she'd expected. "I performed the initial evaluation on Mrs Terrio," she said. "Then I referred her to Neurosurgery. They took over her case."

"So how long was she under your care?"

"Officially? About two hours. More or less."

"And during those two hours, what did you do, exactly?"

"I stabilized her. Ordered the necessary labs. It would be in the medical record."

"Yes, we have a copy," said Susan Casado. She patted the chart lying on the table.

"You'll find it all documented in there," said Abby. "My admitting notes and orders."

"Everything you did?" said Susan.

"Yes. Everything."

"Do you remember anything you did that might have negatively affected the patient's course?"

"No."

"Anything you should have done? In retrospect?"

"No."

"I understand the patient expired."

"She'd suffered massive head trauma. A motor vehicle accident.

She was declared brain dead."

"After you cared for her."

In frustration, Abby glanced around the table. "Could someone please tell me what's going on?"

"What's going on," said Parr, 'is that our insurance carrier, Vanguard Mutual — that's your carrier as well — received written notification just a few hours ago. It was hand-delivered and signed by an attorney from Hawkes, Craig and Sussman. I'm sorry to tell you this, Dr. DiMatteo, but it appears as if you — and Bayside — are about to be sued for malpractice."

The air went out of Abby's lungs in a sickening rush. She found herself gripping the table, fighting the sudden nausea rising in her stomach. She knew they were waiting for her to respond, but all she could manage was a shocked look and a disbelieving shake of her head.

"I take it you weren't expecting this," said Susan Casado. "I…" Abby swallowed. "No. No."

"It's only the preliminary notification," said Susan Casado. "You understand, of course, that there are a number of formalities that lead up to any actual trial. First, the case will be reviewed by a state screening panel to determine whether or not this is, in fact, malpractice. If the panel decides there was none, this whole thing may stop right there. But the plaintiff still has the right to proceed to trial, regardless."

"The plaintiff," murmured Abby. "Who is the plaintiff?."

"The husband. Joseph Terrio."

"There has to be a mistake. A misunderstanding-'

"Damn right there's a misunderstanding," said Wettig. Everyone looked at the General, who had, until then, sat in stony silence. "I've reviewed the record myself. Every page of it. There's no malpractice there. Dr. DiMatteo did everything she should have done."

"Then why is she the only doctor named in the lawsuit?" said Parr.

"I'm the only one?" Abby looked at the attorney. "What about neurosurgery? The emergency room? No one else was named?"

"Just you, Doctor," said Susan. "And your employer. Bayside." Abby sat back, stunned. "I don't believe this…"

"Neither do I," said Wettig. "This isn't the way it's done and we all know it. Damn lawyers usually take the shotgun approach, name every MD who came within a mile of the patient. There's something wrong here. Something else is going on."

"It's Victor Voss," said Abby softly.

"Voss?" Wetfig gave a dismissive wave. "He has no stake in this case."

"He's out to ruin me. That's his stake." She looked around the table. "Why do you think I'm the only doctor named? Somehow Voss has gotten to JoeTerrio. Convinced him I did something wrong. If I could just talk to Joe-'

"Absolutely not," said Susan. "It would be a sign of desperation.

A tipoff to the plaintiff that you know you're in trouble."

"I am in trouble!"

"No. Not yet. If there's really no malpractice here, it will all blow over sooner or later. Once the panel rules in your favour, chances are, the other side will drop the suit."

"XXrhat if they insist on going to trial anyway?"

"It would make no sense. The legal expenses alone would-' "Don't you see, Voss must be footing the bill? He doesn't care about winning or losing! He could pay an army of lawyers, just to keep me running scared. Joe Terrio may be only the first lawsuit. Victor Voss could track down every patient I've ever cared for. Convince every single one of them to file suit against me."

"And we're her employer. Which means they'll file suit against Bayside as well," said Parr. He looked ill. Almost as ill as Abby felt.

"There's got to be a way to defuse this," said Susan. "Some way to approach MrVoss and cool down the situation."

No one said anything. But Abby, looking at Parr's face, could read the thought going through his head: The fastest way to cool this down is to fire you.

She waited for the blow to fall, expected it to fall. It didn't. Parr and Susan merely exchanged glances.

Then Susan said, "We're still early in the game. We have months to manoeuvre. Months to plan a response. In the meantime…" She looked at Abby. "You'll be assigned counsel by Vanguard Mutual. I suggest you meet with their attorney as soon as possible.You may also consider hiring your own private counsel."

"Do you think I need to?"

"Yes."

Abby swallowed. "I don't know how I'm going to afford to hire an attorney…"

"In your particular situation, Dr. DiMatteo," said Susan, 'you can't afford not to."

For Abby, being on call that night was a blessing in disguise. A flurry of calls and pages kept her on the run all evening, attending to everything from a pneumothorax in the medical ICU to a post-op fever in the surgical ward. There was little time for her to brood over Joe Terrio's lawsuit. But every so often, when there was a lull in the phone calls, she would find herself hovering dangerously close to tears. Of all the grieving spouses she'd comforted and counselled, Joe Terrio was the last one she'd expected to sue her. What did I do wrong? she wondered. Could I have been more compassionate? More caring?

Damn it, Joe, what else did you want from me?

Whatever it was, she knew she could not have given more of herself. She'd done the very best job she could have done. And for all her anguish over Karen Terrio, she was being rewarded with a slap in the face.

She was angry now, at the attorneys, at Victor Voss, even at Joe. She felt sorry for Joe Terrio, but she also felt betrayed by him. By the very man whose suffering she had so acutely felt.

At ten o'clock she was finally free to retreat to the on-call room. Too upset to read her journals, too demoralized to talk to anyone, even Mark, she lay down on the bed and stared at the ceiling. Her legs felt paralysed, her whole body lifeless. How the hell do I get through this night, she wondered, when I can't even bring myself to move from this bed?

But move she did when, at ten-thirty, the phone rang. She sat up and reached for the receiver. "Dr. DiMatteo."

"This is the OR. Drs Archer and Hodell need you up here."

"Now?"

"ASAE They've got a case brewing."

"I'll be there." Abby hung up. Sighing, she ran both her hands through her hair. Any other time, any other evening, she'd already be on her feet and faring to scrub. Tonight she could barely stand the thought of facing Mark and Archer across an operating table. Damn it, you're a surgeon, DiMatteo. So act like one.t It was self disgust that finally propelled her to her feet and out of the call room.

She found Mark and Archer upstairs in the surgeons' lounge. They were standing by the microwave, their voices lowered in quiet conversation. She knew, just by the way their heads jerked up as she entered, that their conversation was meant to be private. But the instant they saw her, both of them smiled.

"There you are," said Archer. "All quiet in the trenches?"

"For the moment," said Abby. "I hear you two have a case coming up."

"Transplant," said Mark. "The team's coming in now. Trouble is, we can't get hold of Mohandas. A fifth-year resident's going to be standing in for him, but we may need you to assist as well. Feel up to scrubbing in?"

"On a heart transplant?" The quick shot of adrenalin was exactly what Abby needed to shake off her depression. She gave Mark an emphatic nod. "I'd be thrilled."

"There's only one small problem," said Archer. "The patient is NinaVoss."

Abby stared at him. "They found her a heart so soon?"

"We got lucky. The heart's coming in from Burlington. Victor Voss would probably have a stroke if he knew we were using you. But we're calling the shots right now. And we may need another pair of hands in that OR. On such short notice, you're the obvious choice."

"Are you still up for it?" asked Mark.

Abby didn't even hesitate. "Absolutely," she said.

"OK," said Archer. "Looks like we got our assistant." He nodded to Mark. "Meet you both in OR 3. Twenty minutes."

At 11.30 p.m., they got the call from the thoracic surgeon at Wilcox Memorial Hospital in Burlington, Vermont. The donor harvest was completed; the organ appeared to be in excellent shape and was being rushed to the airport. Preserved at four degrees centigrade, its beating temporarily paralysed by a concentrated potassium flush, the heart could be kept viable for only four to five hours. Without blood flow to the coronary arteries, every minute that passed — ischemic time — could result in the death of a few more myocardial cells. The longer the ischemic time, the less likely the heart would function in NinaVoss's chest.

The flight, by emergency charter, was expected to take a maximum of an hour and a half.

By midnight, the Bayside Hospital transplant team was assembled and dressed in surgical greens. Along with Bill Archer, Mark, and anaesthesiologist Frank Zwick, there was a small army of support staff: nurses, a perfusion technician, cardiologist Aaron Levi, and bby.

Nina Voss was wheeled to OR 3.

At one-thirty, the call came in from Logan International: the plane had landed safely.

That was the cue for the surgeons to head to the scrub area. As Abby washed her hands at the sink, she could look through the window into OR 3, where the rest of the transplant team was already busy with preparations. The nurses were laying out instrument trays and tearing open packets of sterile drapes. The perfusionist was re-calibrating the cabinet-like bypass machine. A fifth-year resident, already scrubbed in, stood by waiting to prep the surgical site.

On the operating table, at the centre of a tangle of EKG wires and IV lines, lay Nina Voss. She seemed oblivious to the activity around her. Dr. Zwick stood at Nina's head, murmuring to her gently as he injected a bolus of pentobarb into her IV line. Her eyelids flickered shut. Zwick placed the mask over her mouth and nose. With the ambubag he pumped a few breaths of oxygen in quick succession, then removed the mask.

The next step had to be performed swiftly. The patient was unconscious now, unable to breathe on her own. Tilting her head back, Zwick slipped a curved laryngoscope blade into her throat, located the vocal cords, and inserted the plastic endotracheal tube. An air-inflated cuff would keep the tube in place in her trachea. Zwick connected the tube to the ventilator and her chest began to rise and fall with the whoosh of the bellows. The intubation had taken less than thirty seconds.

The operating lights were turned on and directed at the table. Bathed in that brilliant glow, Nina seemed unearthly. Spectral. A nurse pulled off the sheet draping Nina's body and exposed the torso, the ribs archirig beneath pale skin, the breasts small, almost shrunken. The resident proceeded to disinfect the operative site, painting broad strokes of iodine across the skin.

The OR doors banged open as Mark, Archer, and Abby, freshly scrubbed, walked in with hands held up, elbows dripping water. They were greeted with sterile towels, gowns, and gloves. By the time everyone was fully garbed, Nina Voss had been prepped and draped.

Archer moved to the operating table. "Is it here yet?" he asked. "Still waiting for it," said a nurse.

"It's only a twenty-minute drive from Logan."

"Maybe they got caught in a traffic jam."

"At two in the morning?"

"Jesus," said Mark. "That's all we need now. An accident." Archer peered up at the monitors. "Happened at Mayo. Had a kidney flown in all the way from Texas. Right out of the airport, ambulance hits a truck. Organ gets squashed. Perfectly matched one, too."

"You're kidding," said Zwick.

"Hey, would I kid about a kidney?"

The fifth-year resident glanced up at the wall clock. "We're going on three hours since harvest."

"Wait. Just wait," said Archer.

The phone rang. Everyone's head swivelled to watch as the nurse answered it. Seconds later she hung up and announced: "It's downstairs. The courier's on his way up from the ER."

"OK," snapped Archer. "Let's cut."

From where Abby stood, she caught only a slanted glimpse of the procedure, and even then her view was intermittent, cut off by Mark's shoulder. Archer and Mark were working swiftly and in concert, making a midline sternotomy incision, exposing fascia, then bone.

The wall intercom buzzed. "Dr. Mapes from the harvest team is here with a special delivery," came the message from the OR front desk.

"We're cannulating," said Mark. "Have him join the fun."

Abby glanced towards the OR door. Through the viewing window, she could see the scrub area beyond, where a man stood waiting. Beside him, on a gurney, was a small Igloo cooler. The same sort of cooler in which she'd transported KarenTerrio's heart. "He'll be in," said the desk nurse. "As soon as he changes clothes." Moments later, Dr. Mapes entered, now wearing greens. He was a small man with an almost Neanderthalic brow and a nose that jutted out like a hawk's beak under the surgical mask. "Welcome to Boston," said Archer, glancing up at the visitor. "I'm Bill Archer. This is Mark Hodell."

"Leonard Mapes. I scrubbed with Dr. Nicholls at Wilcox."

"Good flight, Len?"

"Could've used a beverage service."

Archer cracked a smile, visible even through his mask. "So what'd you bring us for Christmas, Len?"

"Nice one. I think you'll be pleased."

"Let me finish cannulating and I'll take a look."

Cannulation of the ascending aorta was the first step to connecting the patient to the bypass machine.That squat box, under control of the perfusion technician, would temporarily assume the job of the heart and lungs, collecting venous blood, replenishing its oxygen, and pumping it back into the patient's aorta.

Archer, using silk sutures, sewed two concentric 'purse strings' in the wall of the ascending aorta. With a scalpel tip he made a tiny stab in the vessel. Bright blood spurted out. Swiftly he inserted the arterial cannula into the incision and tightened the 'purse strings'. The bleeding slowed to an ooze, then stopped as he sewed the cannula tip in place. The other end of the cannula was connected to the bypass machine's arterial line.

Mark, with Abby retracting, was already starting on the venous cannulation.

"OK," said Archer, moving from the table. "Let's unwrap our present."

A nurse unpacked the Igloo cooler and lifted out the organ, wrapped in two ordinary plastic bags. She untwisted the ties and slid the naked organ into a basin of sterile saline.

GentlyArcher lifted the chilled heart from its bath. "Nice excision job," he noted. "You guys did good work."

"Thanks," said Mapes.

Archer ran his gloved finger over the surface. "Arteries soft and smooth. Clean as a whistle."

"Seems a bit on the small side, doesn't it?" said Abby, glancing across the table. "How big was the donor?"

"Forty-four kilogrammes," said Dr. Mapes.

Abby frowned. "Adult?"

"An adolescent, previously healthy. A boy."

Abby caught the flicker of distress in Archer's eyes. She remembered then that he had two teenage sons. Gently he lay the organ back in its bath of chilled saline.

"We won't let this one go to waste," he said. And he turned his attention back to Nina.

By then, Mark and Abby were already finishing up the venous cannulation. Two Tygon tubes fitted with metal baskets at the end were inserted through stab wounds in the right atria, and secured by purse-string sutures. Venous blood would be collected by these cannula and directed to the pump-oxygenator.

Working together now, Archer and Mark snared shut the inferior and superior vena cava, cutting off return blood to the heart.

"Cross-clamping aorta," announced Mark as he closed off the ascending aorta.

The heart, cut off from both venous inflow and arterial outflow, was now a useless sac. Nina Voss's circulation was under the complete control of the perfusionist and her magical machine. Also under her control was the body temperature. By chilling the fluids, the body could be slowly cooled down to twenty-five degrees centigrade — profound hypothermia. This would preserve the newly implanted myocardial cells and lessen the body's oxygen consumption.

Zwick turned off the ventilator. The rhythmic wheeze of the bellows ceased. There was no need to pump air into the lungs when the bypass machine was doing the work. Transplantation could now proceed.

Archer cut the aorta and pulmonary arteries. Blood gushed out into the chest, spilled onto the floor. At once a nurse threw a towel down to soak up the mess. Archer kept working, oblivious to the sweat beading his forehead, to the lights burning down. Next he transected the atria. More blood, darker, splashed Archer's gown. He reached elbow deep into the chest cavity. NinaVoss's sick heart, pale and flabby, was now lifted away and dropped into a basin. What remained was a gaping hollow.

Abby glanced up at the monitor screen and felt an automatic rush of alarm at the flat EKG line. Of course there was no tracing. There was no heart. In fact, all the classic signs of life had ceased. The lungs were still. The heart was gone. Yet the patient still lived.

Mark lifted the donor heart from the basin and lowered it into the chest. "Some folks call this procedure a glorified plumbing job," he said, rotating the heart to match up the left atrial chambers.

"They think it's like stitching together a stuffed animal or something. But you let your attention slip for a minute, and before you realize it, you're sewing the heart in backwards." The fifth-year resident laughed. "Not funny. It's happened."

"Saline," said Archer, and a nurse poured a basin of chilled saline over the heart to keep it cold under the lights.

"A hundred things can go wrong," said Mark, his suture needle taking deep, almost savage bites into the left atrium. "Drug reaction. Anaesthetic disasters. And damn it, the surgeon always gets the blame."

"Lot of blood pooling in here," said Archer. "Suction, Abby." The hiss of the suction machine gave way to a tense silence as the surgeons worked more quickly now. There was only the whir of the pump-oxygenator and the click of the needle clamps as the serrated jaws snapped shut with each new stitch. Despite Abby's repeated suctioning, blood kept soaking into the drapes and dribbling onto the floor. The towels at their feet were saturated. The surgeons kicked them aside and new towels were thrown down.

Archer snipped away the suture needle. "Right atrial anastomosis done."

"Perfusion catheter," said Mark.

A nurse handed him the catheter. He introduced it into the left atrium and infused four-degree-centigrade saline. The flood of chilled liquid cooled down the ventricle and flushed out any air pockets inside.

"Okey doke," said Archer, repositioning the heart to sew the aortic anastomosis. "Let's hook up these pipes."

Mark glanced up at the wall clock. "Look at that. We're ahead of schedule, folks. What a team."

The intercom buzzed. It was the OR desk nurse. "MrVoss wants to know how his wife is doing."

"Fine," called Archer. "No problems."

"How much longer, do you think?"

"An hour. Tell him to hang in there."

The intercom shut off. Archer glanced across at Mark. "He rubs me the wrong way."

"Voss?"

"Likes to be in control."

"No kidding."

Archer's suture needle curved in and out of the glistening aortic wall. "But then, I guess if I had his money, I'd call the shots too."

"Where does his money come from?" asked the fifth-year resident.

Archer glanced at him in surprise. "You don't know aboutVictor Voss? VMI International? Everything from chemicals to robotics."

"Is that what the V stands for in VMI?"

"You got it." Archer tied off and snipped the last suture. "Aorta done. Cross-clamp off."

"Perfusion catheter coming out," said Mark, and turned to Abby. "Get those two pacing wires ready for insertion."

Archer picked up a fresh suture needle from the tray and began the pulmonary anastomosis. He was just tying off when he noticed the organ balling up. "Look at that!" he said. "Ice cold and already a spontaneous contraction. This baby's rarin' to go."

"Pacing wires on," said Mark.

"Isuprel infusion going in," said Zwick. "Two microgrammes."

They watched and waited for the Isuprel to take effect, for the heart to repeat the contraction.

It lay inert as a limp sac.

"Come on," said Archer. "Don't let me down."

"Defibrillator?" asked a nurse. "No, give it a chance."

Slowly the heart tightened into a fist-sized knot, then fell flaccid. Zwick said, "Increasing Isuprel to three mics." There was one more contraction. Then nothing. "Go on," said Archer. "Flog it a little more."

"Four mics," said Zwick, dialling up the IV infusion.

The heart tightened, relaxed. Contracted, relaxed.

Zwick glanced up at the monitor. QRS spikes were now tracing across the screen. "Rate's up to fifty. Sixty-four. Seventy…" "Titrate to one-ten," said Mark.

"That's what I'm doing," said Zwick, adjusting the Isuprel.

Archer said to the circulation nurse: "Get on the intercom, will you? Tell Recovery we're about to close."

"Rate's one-ten," said Zwick.

"OK," said Mark. "Let's take her off bypass. Get those cannulae on."

Zwick flipped on the ventilator. Everyone in the room seemed to exhale a simultaneous sigh of relief.

"Let's just hope she and this heart get along," said Mark.

"We know how close the HL-A match is?" asked Archer. He turned around to look at Dr. Mapes.

There was no one standing behind him.

Abby had been so focused on the operation, she hadn't noticed the man had left.

"He walked out twenty minutes ago," one of the nurses said. "Just like that?"

"Maybe he had a plane to catch," she said.

"Didn't even get a chance to shake his hand," said Archer. He turned back to the patient on the table. "OK. Let's close."