Host

1

Monday, April 6, 6:30 A.M.

Spring in Charleston, South Carolina, is a resplendent affair, and by the beginning of April, it is always well under way. The azaleas, camellias, hyacinths, early-blooming magnolias, and forsythias, as if competing for attention, all contribute to the riot of color and fragrance. And on this particular day, as the sun prepared to rise, there was the promise that it would be glorious for almost everyone in this scenic, historic town. Everyone, that is, except for Carl Vandermeer, a successful young lawyer who had grown up in nearby West Ashley.

Most mornings, regardless of the time of the year but particularly in the springtime, Carl would be part of a sizable group of joggers who ran along the Battery, which was located at the southern tip of Charleston’s peninsula. The Battery fronted that portion of the expansive Charleston Harbor formed by the confluence of the Cooper and the Ashley Rivers. Lined with restored nineteenth-century mansions and boasting a public garden, the Battery was one of the city’s most attractive and popular locales.

Like most of his fellow runners, Carl lived in the immediate and charming residential neighborhood known to the locals as SOB, the acronym for “South of Broad.” Broad Street was a thoroughfare that ran east to west across the Charleston peninsula between the two rivers.

The reason Carl was not jogging this beautiful spring morning was the same reason he had not been jogging for the previous month. He had torn the anterior cruciate ligament in his right knee during the final basketball game of the past season. He and a half dozen other athletically inclined lawyers had formed a team to play in a city league.

Carl had always been into sports through high school and Duke University, where he played Division 1 lacrosse with considerable renown. Having made it a point to keep himself in shape even during law school, he thought of himself as generally immune to injury, especially since he was only twenty-nine years old. Throughout his athletic career he had never suffered more than a couple of sprained ankles.

So the knee injury had come as an unwelcome surprise. One minute he was perfectly fine, having played the entire first half of the game and scoring eighteen points in the process. With the ball in his possession, he had faked the fellow guarding him to the left and then went to the right, to drive to the basket. He never made it. The next thing he knew, he was sprawled on the floor, unsure of what had happened. Embarrassed, he got right to his feet. There was some discomfort in his right knee, but it wasn’t bad. He took a few steps to walk it out and immediately collapsed a second time. That was when he knew it was serious.

A visit to Dr. Gordon Weaver, an orthopedic surgeon, had confirmed the diagnosis to be a torn anterior cruciate ligament. Even Carl, a complete medical novice by choice, had been able to see it on the MRI. The bad news was that he’d have to have surgery if he wanted to play any kind of sports. Dr. Weaver said the best operation involved diverting a portion of his own patellar tendon up through his joint. The only good news was that his health plan would cover the whole deal, including the rehab. His bosses at the law firm where he worked were not thrilled about the necessary downtime, but missing work was not what bothered Carl. What bothered Carl was that he had a particularly strong distaste for anything having to do with medicine and needles. He had been known to pass out from merely having blood drawn, and he didn’t even like the smell of rubbing alcohol because of its associations. He had never been hospitalized, but he had visited friends who had been, and the experience had freaked him out, so going into the hospital that morning for surgery was going to be a challenge, to say the very least.

The irony of his embarrassing and secret medical phobia was that his steady girlfriend for the last two years, Lynn Peirce, was a fourth-year medical student. She often made him light-headed with her stories of her daily experiences at the Mason-Dixon Medical Center, where Carl was scheduled to have his surgery in a few hours. She had been the one who had recommended Dr. Weaver and had explained in agonizing detail exactly how Carl’s knee was going to be repaired.

It also had been at Lynn’s insistence that he request that his operation be Dr. Weaver’s first case on a Monday morning. The rationale, she explained, was that everyone would be fresh and on the ball, meaning there would be less chance for mistakes or scheduling problems. Carl knew that Lynn meant well with all this, but her comments only made him even more nervous.

Lynn had offered to spend the night as she had on Saturday night to make sure Carl followed his pre-op orders and got to the hospital on time, but Carl had begged off. He was afraid she might end up innocently saying something that would make him even more worried than he already was. But he didn’t tell her that. He said he thought he’d sleep better alone and reassured her that he would follow his pre-op instructions to the letter. She had accepted gracefully and said that she’d come visit him in his hospital room as soon as he came back from the PACU, or post-anesthesia care unit.

Carl had never mentioned his medical phobia to Lynn for fear that she, at a minimum, would laugh at him. Nor did he let on how anxious he felt about his upcoming surgery. To preserve his ego, there were some things better left unsaid.

Carl let the alarm ring unabated for a time out of fear of falling back asleep. He’d slept poorly and had had trouble getting to sleep the night before. His instructions from Dr. Weaver’s nurse were to have nothing by mouth after midnight except water and to take a good, hot shower with antimicrobial soap when he got up with particular attention paid to his right leg. He was supposed to arrive at the hospital no later than seven, which was going to be a rush, since it was already six-thirty. He wanted it to be a rush, thinking he’d have less chance to think, but here he was, not even out of bed and already anxious.

As if sensing his distress, Pep, his nimble eight-year-old Burmese cat, awoke at the foot of the bed and came up to rub her wet nose against Carl’s stubbled chin.

“Thank you, girl,” Carl said, tossing back the covers and making a beeline to the bathroom. Pep tagged along as always. Carl had saved the cat at the end of his undergraduate senior year at Duke when one of his classmates was going to abandon her at the pound after graduation in the hope that it would be adopted. Carl couldn’t abide by the plan, considering it a possible death sentence. He took the cat home for the summer, became hopelessly enamored with her, and ended up taking her along to law school. Frank Giordano, a close friend and fellow basketball-playing lawyer, who would be arriving shortly to drive Carl to the hospital, had volunteered to take care of the cat by coming to Carl’s house and making sure it had food and water until Carl’s homecoming in three days. Everything was in order, or so Carl thought.

As Carl Vandermeer eased into a hot shower, Dr. Sandra Wykoff leaped out of her BMW X3. She was in a hurry not because she was late but because she was enamored with her work. Unlike Carl Vandermeer, she loved medicine so much that she had not taken a real vacation in the three years she’d been on staff at the Mason-Dixon Medical Center. She was a board-certified anesthesiologist who had trained across town at the older Medical University of South Carolina. She was thirty-five years old, a workaholic, and relatively recently divorced after a short marriage to a surgeon.

From her reserved parking spot on the first floor of the parking garage, she avoided the elevator and took the stairs. It was only one flight, and she liked the exercise. The state-of-the-art operating rooms of the medical center, which was built just after the millennium, were on the second floor. In the surgical lounge she gazed up at the monitor displaying the image of the operating room’s white board. She was assigned to OR 12 for four cases, the first being a right anterior cruciate repair with a patellar allograph by Gordon Weaver under general anesthesia. She was pleased. She particularly liked Gordon Weaver. Like most of the orthopedic guys, he was a gregarious fellow who enjoyed his work. Most importantly, from Sandra’s perspective, he didn’t dawdle and was vocal if there was more blood loss than expected. To her, such communication was important, but not every surgeon was as cooperative. Like all anesthesiologists, she knew that she was the one responsible for the patient’s well-being during an operation, not the surgeon, and she appreciated being informed if anything occurred with the surgery that was out of the ordinary.

Using her tablet PC, Sandra typed in the patient’s name, Carl Vandermeer, along with his hospital number and her PIN to access his nascent EMR, electronic medical record. She wanted to look at his pre-op history. A moment later she knew what she was dealing with: a healthy twenty-nine-year-old male with no drug allergies and no previous anesthesia. In fact there had been no previous hospitalizations for any reason whatsoever. It was going to be an easy, straightforward case.

After changing into her scrubs, she made her way into the OR proper, passing the OR desk commandeered by the extraordinarily competent OR supervisor, Geraldine Montgomery. On her right she passed the entrance to the PACU, which used to be called more simply the recovery room. The pre-operative holding area was on the left. There was a lot of frenetic activity in both rooms. A bevy of nurses and orderlies were preparing for the soon-to-begin and inevitably busy Monday-morning schedule.

As a generally friendly although private person, Sandra greeted anyone who caught her eye, but she didn’t stop to chat or even slow down. She was on her usual early-morning mission. She was eager to check out the anesthesia machine she would be using for the day, something all anesthesiologists and nurse anesthetists were required to do. The difference was that Sandra was more conscientious than most and couldn’t wait to start.

Sandra worshipped the newer anesthesia machine, which was essentially computer driven. In fact it was the expanding role that the computer played in anesthesia that had attracted her to the specialty in the first place. As her father’s daughter, Sandra was also attracted to most everything mechanical. Her father, Steven Wykoff, was an automotive engineer brought to Spartanburg, South Carolina, from Detroit, Michigan, by BMW in 1993. The fact that computers were destined to become more and more involved in medicine was the reason she went to medical school. It was during her third-year surgery rotation that she was introduced to anesthesia, and she was captivated from the start. The specialty was a perfect blend of physiology, pharmacology, computers, and mechanical devices, all of which suited Sandra just fine.

Entering OR 12, Sandra greeted Claire Beauregard, the assigned circulating nurse, who was already busy setting up for the case. But there was no conversation. Sandra stepped over to her trusted mechanical partner, with which she was going to spend most of the day. It bristled with varicolored cylinders of gas, multiple monitors, meters, gauges, and valves. The machine, like all the equipment in the relatively new hospital complex, was a state-of-the-art computer-controlled model. It was number 37 out of nearly 100 total. The number was on a sticker on the machine’s side, which also included its service history.

From Sandra’s perspective the apparatus in front of her was a marvel of engineering. Among its many features was an automatic checklist function that satisfied what the FDA required before use, akin in many respects to the checklist required in a modern aircraft before takeoff to make certain all systems functioned properly. But Sandra did not turn on the machine immediately to initiate the automatic checklist. She liked to check the machine the old-fashioned way, particularly the high-pressure and the low-pressure systems, just to be 100 percent certain everything was in order. She liked to physically touch and operate all the valves. Her hands-on inspection made her feel much more confident than relying on a computer-controlled algorithm.

Satisfied with what she found, Sandra rolled over the stool that would be her perch for the day, sat down, and pulled herself directly up to the anesthesia machine’s front. Only then did she turn on the machine. Spellbound as usual, her eyes stayed glued to the monitor as the apparatus went through its own automated checklist, which included most of what she had already done. A few minutes later the machine indicated all was in order, including the alarms for trouble, such as changes in the patient’s blood pressure and heart function or low oxygen levels in the blood.

Sandra was pleased. When something was amiss, even a minor thing, she was obliged to contact the Clinical Engineering Department, which serviced the anesthesia machines. She found the technicians to be a weird bunch. Those she had had interaction with were all expat Russians with varying fluency in English, most of whom seemed like the teenage computer nerds of her youth. She particularly did not like Misha Zotov, who had sought her out in the hospital cafeteria to engage her in conversation the day after she’d gone down to the department to ask a simple service-related question. He gave her the creeps, even more so by calling her at home a few days later to ask her to have a drink with him. How he’d gotten her unlisted number she had no idea. Her response was to fib and say she was in a committed relationship.

With the anesthesia machine ready to go, Sandra then began checking her supplies and pharmaceuticals with equal diligence. She liked to touch everything she might need so she would know where it was. If there was an emergency, she didn’t want to search for anything. She wanted everything at her fingertips.

Want me to park and come in with you?” Frank Giordano asked Carl as he turned into the Mason-Dixon Medical Center a few minutes after seven. They had been driving in silence. Initially Frank had tried to make conversation as they started northward up King Street, but Carl wasn’t holding up his side. Frank guessed that Carl was stressed out about his upcoming surgery, especially after Carl admitted he was as nervous as hell before they had started out.

“Thanks, but no,” Carl said. “I’m a little late, which I hope means I’m not going to be sitting around.” It was clear he was agitated.

“Hey, man,” Frank said, “you got to relax! It’s no big deal. I had my tonsils out when I was ten. It was a piece of cake. I remember being told to count backward from fifty. I got to about forty-six and the next thing I knew I was being awakened, and it was all done.”

“I have a bad feeling about this,” Carl said. He turned to look at Frank.

“Shit, man, why are you going to go and say something stupid like that? Be positive! Look, you got to get it done, and you got to get it done now so, come next December, you’re good to go for the next basketball season. We need you healthy.”

Carl didn’t respond. There was a line of cars backed up under the porte cochere. People were getting out with overnight bags. Carl guessed they, too, were arriving for surgery. He wished he could take it all in stride as it appeared others were doing. He glanced at his cell phone. It was now almost five after seven. He had meant to arrive exactly on time so there would be no sitting around.

“I’ll get out here,” Carl said suddenly, opening the passenger-side door as he spoke. He climbed out.

“I’ll have you at the door in thirty seconds,” Frank said.

“I don’t think so. It will be faster if I walk.” Carl slammed the car door and opened the trunk. He lifted the backpack containing his essentials and slung it over his shoulder. “Don’t forget about the cat!”

“No worries,” Frank said as he, too, alighted from the car. He came around and gave Carl a quick hug. Carl didn’t respond, just looked him in the eye when his friend stepped back. But when Frank raised a fist, Carl followed suit. Their knuckles touched in a fist bump. “Later, dude!” Frank added. “You’re going to be fine.”

Carl nodded, turned, and negotiated the small tangle of cars waiting to get closer to the front door to disgorge their passengers. As he entered the hospital he remembered reading Dante’s description of hell in civilization class at Duke.

A pink-smocked volunteer directed him down the hall to surgical admitting. Carl gave his name to one of the clerks seated behind a chest-high counter.

“You’re late,” the woman said with a mildly accusatory tone of voice. She had an uncanny visual resemblance to Carl’s sixth-grade teacher, Miss Gillespie. The association made him feel as if he were going back to an earlier stage in his life when he truly wasn’t in control of his fate. Carl had been an irrepressible twelve-year-old and had clashed with Miss Gillespie. The clerk picked up a packet of paperwork that was on the desk in front of her and handed it to Carl. “Take a seat! A nurse will be with you shortly.”

Although similarly as bossy as the clerk, the nurse was significantly more congenial. She smiled when she asked Carl to follow her back to a curtained-off area where there was a gurney made up with fresh sheets and a pillow. Draped across it was the infamous hospital johnny. After checking his picture ID and asking his name and birth date, she put a name tag on his wrist. Once that was done, she told him to put his valuables in a zippered canvas bag that was also on the gurney, take off his clothes, put on the johnny, and lie down. From the inside, she pulled the curtain around to allow privacy. She watched as Carl picked up the johnny and tried to figure out how it was supposed to be worn.

“The opening should be in the back,” the nurse said, as if that were going to solve Carl’s confusion. “I’ll be back shortly when you are done.” She then disappeared through the curtain. It was apparent she was in a hurry.

Carl did as he was told but had trouble with the johnny, particularly in terms of figuring out how to secure it. One tie was at the neck, the other at the waist, which made no sense. He did the best he could. No sooner had he gotten onto the gurney and pulled the sheet up around his torso than the nurse was outside the curtain, calling to ask if he was finished.

Back inside the curtain, the nurse then went through a litany of questions: Did you eat anything this morning? Do you have any allergies? Do you have any drug intolerance? Do you have any removable dentures? Do you smoke? Have you ever had anesthesia? Have you had any aspirin in the last twenty-four hours? It went on and and on, with Carl dutifully answering no over and over until she queried how he felt.

“What do you mean?” Carl asked. He was taken aback. It was an unexpected question. “I feel nervous. Is that what you are asking?”

The nurse laughed. “No, no, no! I mean do you feel well right now and did you feel normal during the night. What I’m trying to ask is whether or not you feel like you might be coming down with something. Have you had any chills? Do you feel like you have a fever? Anything like that?”

“I get it,” Carl said, feeling embarrassingly naive. “Unfortunately I feel fine health-wise, so there’s no excuse not to go forward with all this. To be honest I’m just anxious.”

The nurse looked up from her tablet, where she had been recording all of Carl’s responses. “How anxious do you feel?”

“How anxious should I feel?”

“Some people find the hospital stressful. We who work here don’t because being here is an everyday event. You tell me, say on a scale of one to ten.”

“Maybe eight! To be honest, I’m really nervous. I don’t like needles or any other medical paraphernalia.”

“Have you ever had a hypotensive episode in a medical setting?”

“You’ll have to translate that into English.”

“Like fainting?”

“I’m afraid so. Twice. Once having my blood drawn for some tests in the college infirmary, and once trying to give blood in college.”

“I’m going to note this in your record. If you’d like, I’m sure they will give you something to calm you down.”

“That would be nice,” Carl said, and he meant it.

The nurse took Carl’s blood pressure and pulse, which she remarked were normal. She then had a conversation with Carl about which knee was to be operated on, and when Carl pointed to his right knee, she made an X with a permanent marker on Carl’s thigh, four inches above his right kneecap. “We want to be sure not to operate on the wrong knee,” she said.

“Me too,” Carl responded with alarm. “Has that ever happened?”

“I’m afraid so,” the nurse said. “Not here, but it has happened.”

Holy fuck, Carl thought. Now he had something else to worry about. As nervous as he felt, he wondered if he had been wrong in discouraging Lynn from coming by to at least say hello before the procedure. Maybe he needed an ombudsman.

Dr. Wykoff, the patient is in the CSPC,” Claire said, coming back into OR 12, referring to the center for surgical patient care, an extra-long name for the patient holding area.

“How about Dr. Weaver?” Sandra responded.

“He’s changing. We’re good to go.”

“Perfect,” Sandra said. She stood and picked up her computer tablet. “How are you doing, Jennifer?” Jennifer Donovan was the scrub nurse, who was already gowned, gloved, and setting out the sterilized instruments. It was 7:21 A.M.

“I’ll be ready,” Jennifer said.

As Sandra walked back down the central corridor, she checked Carl’s EMR and noticed the admitting nurse’s entries. There were no red flags for trouble. The only thing she picked up on was that the patient was unusually anxious and had a history of several hypotensive episodes in the past associated with drawing blood. In Sandra’s experience she’d come across a number of men with such a phobia, but it had never been a problem. People rarely fainted when lying down. As far as she was concerned, anxiety was par for the course. That’s why she liked midazolam, or Versed, so much. It worked like a charm, relaxing even the most skittish patients. In the pocket of her scrubs she had a syringe with the proper dose, according to Carl’s weight.

She found Carl Vandermeer in one of the pre-op bays of the CSPC. She couldn’t help but notice that he was a handsome man with dark, thick hair and startlingly wide-open blue eyes. Except for his apparent anxiety, he was the picture of health. The thought went through her mind that working with him was going to be a pleasure.

“Good morning, Mr. Vandermeer,” Sandra said. “I’m Dr. Wykoff, I will be your anesthesiologist.”

“I want to be asleep!” Carl stated with as much authority as he could muster under the circumstances. “I went over this with Dr. Weaver, and he promised me that I would be asleep. I don’t want an epidural.”

“No problem,” Sandra said. “We’re all prepared. I understand you are a little anxious.”

Carl gave a short, mirthless laugh. “I think that is an understatement.”

“We can help you, but it does require me to give you an injection. I know you don’t like needles, but are you okay with getting one? It will help, I guarantee.”

“To be truthful, I’m not excited about it. Where will you give it?”

“Your arm will be fine.”

Steeling himself, Carl dutifully exposed his left arm and looked away to avoid seeing the syringe. After a quick swipe with an antiseptic wipe, Sandra gave the injection.

Carl turned back. “That was easy. Are you finished already?”

“All done! Now I want to go over with you the material the admitting nurse recorded.”

Rapidly Sandra asked the same questions about Carl not having had anything to eat since midnight, about allergies, about drug intolerance, about medical problems, about previous anesthesia, about removable dentures, on and on. By the time Sandra got to the end, Carl’s attitude had completely changed, thanks to the midazolam. Not only was he no longer anxious, he was now finding the whole situation entertaining.

At that point, Sandra started her IV. Carl couldn’t have cared less and watched her preparations with a sense of detachment. It helped that she was extremely confident and competent with the procedure. She always made a point to start her own so she could trust it. She used an indwelling catheter rather than a simple IV. Carl never stopped talking through the process, particularly about his girlfriend, Lynn Peirce, who he said was a fourth-year medical student and the best-looking woman in her class. Sandra diplomatically let the issue drop.

A few minutes later Dr. Gordon Weaver appeared to have a few words with Carl, including which knee they were going to work on. He checked that the X that the admitting nurse had made with the permanent marker was on the proper thigh.

“You people are really hung up on which knee,” Carl joked.

“You better believe it, my friend,” Dr. Weaver said.

With Sandra guiding in the front and Dr. Weaver pushing from the back, they wheeled Carl down and into OR 12, stopping alongside the operating table directly under the operating room light. Somewhere en route Carl had drifted off into light sleep in midsentence, again reminding Sandra why she was so fond of the midazolam. Only much later would Sandra question the dose she had given in the process of reviewing everything she had done. Sandra, Dr. Weaver, and Claire Beauregard moved Carl over onto the operating table with practiced efficiency.

When Dr. Weaver went out to scrub, Sandra pulled the anesthesia machine close to Carl’s head. This was the part of the case that she liked the best. She was center stage and about to prove once again the validity of the science of pharmacology. Anesthesia was a specialty marked by extreme attention to detail; periods of intensive activity, like what she was now beginning; and then long segments of relative boredom, which required dedicated effort to stay focused. Whenever she thought about it, the analogy of being a pilot came to mind. At the moment she was about to take off. After that had been accomplished she would be in the equivalent of midflight autopilot and have little to do besides scanning the monitor and the gauges. It wouldn’t be until the landing that she’d again be called upon for intense activity and attention to detail.

Since there were no specific contraindications to any of the current anesthetic agents, she planned on using isoflurane, supplemented with nitrous oxide and oxygen. She had used the combination in thousands of cases and felt comfortable with it. There was no need for any paralyzing drugs because a knee operation didn’t require any muscular relaxation like with an abdominal operation, and she wasn’t going to use an endotracheal tube. Instead she would use what was known as a laryngeal mask airway, or LMA. Sandra was a stickler for detail in all aspects of her life but most specifically for anesthesia, and had never had a major complication.

Like all anesthetists who are specially trained nurses and anesthesiologists who are specially trained doctors, Sandra knew that the ideal anesthetic gas should be nonflammable, should be soluble in fat to facilitate going into the brain, but not too soluble in blood so that it could be reversed quickly, should have as little as possible toxicity to various organs, and should not be an irritant to breathing passageways. She also knew that no current anesthetic agent perfectly fulfilled all these criteria. Yet the combination she intended to use with Carl came close.

The first thing that Sandra did was to set up all the patient monitoring so that she would have a constant readout of Carl’s pulse, ECG, blood oxygen saturation, body temperature, and blood pressure, both systolic and diastolic. The anesthesia machine would monitor the rest of the levels that needed to be watched, such as oxygen and carbon dioxide levels in inspired and expired gases and ventilation supply variables.

As Sandra positioned the monitors, particularly the ECG leads and the blood pressure cuff, Carl became conscious. There was no anxiety on his part. He even joked that with everyone wearing masks it was like being at a Halloween party.

“I’m going to give you some oxygen,” Sandra said as she gently placed the black breathing mask over Carl’s nose and mouth. “Then I will be putting you asleep.” Patients liked that comfortable metaphor rather than what Sandra knew anesthesia really to be: essentially being poisoned under controlled and reversible circumstances.

Carl didn’t complain and closed his eyes.

At that point Sandra injected the propofol, a fabulous drug in her estimation that was unfortunately made infamous by the Michael Jackson tragedy. Knowing what propofol did to arterial blood pressure, ventilation drive, and cerebral hemodynamics, Sandra would never give the drug to someone without appropriate physiologic monitors and a primed and ready anesthesia machine.

In the induction phase, Sandra was now in her most attentive mode. With an eagle eye on all the monitors she continued to use the black breathing mask to allow Carl to breathe pure oxygen. In the background she was vaguely aware of Dr. Weaver coming into the room and putting on his sterile gown and gloves. After approximately five minutes, Sandra put the breathing mask aside and picked up the appropriately sized LMA. In a practiced fashion she inserted the triangular, inflatable tip into Carl’s mouth and pushed it into place with her middle finger. Quickly she inflated the tube’s cuff and attached the tube from the anesthesia machine. The immediate detection of carbon dioxide by the anesthesia machine in the exhaled gas suggested the LMA was properly seated. But to be sure, Sandra listened to breath sounds with her stethoscope. Satisfied, she taped the LMA tube to Carl’s cheek so that it could not be moved. She then dialed in the proper levels of isoflurane, nitrous oxide, and oxygen. The nitrous oxide had some anesthetic properties but not enough to be used on its own. What it did do was lessen the amount of isoflurane needed, which was helpful, because the isoflurane did have some mild irritant effects on breathing passageways. She then taped Carl’s eyes shut after putting in a bit of antibiotic ointment to protect his corneas from drying.

Sandra watched the anesthesia machine with its readout of all the vital signs. Everything was in order. The takeoff had been smooth. Metaphorically they were nearing cruising altitude and soon the seat belt sign could go off. Sandra’s pulse, which had jumped considerably during the induction of anesthesia, dropped back to normal. It had been a tense few minutes, as it always was, yet it provided her a shot of euphoria of a job well done and a patient well served.

“Everything okay?” Dr. Weaver questioned. He was eager to begin.

Sandra gave a thumbs-up as she manually checked Carl’s blood pressure yet again. She then helped Claire put up the anesthesia screen, which would be covered with sterile drapes to isolate the patient’s head from the sterile operative field. After the screen was in place she sat back down. She was now in midflight.

As he worked during the course of the operation, Dr. Weaver kept up a mostly one-sided conversation with everyone in the room. He talked about what he was doing technically as he fashioned the patellar graft, he talked about his kids, and he talked about his weekend house on Folly Island.

Sandra listened with half an ear, as she imagined the scrub nurse and circulating nurse did as well. Sandra spoke up only once when there was a break in Dr. Weaver’s monologue. She took the opportunity to ask how long he thought he’d be.

The surgeon straightened up, paused briefly, and assessed his progress. “I’d guess another forty minutes or so. It’s all going smoothly. Everything okay up there with you?”

“Everything is fine,” Sandra said. She glanced down at her notes. The machine did the anesthesia report in contrast to the old days, but she kept her own record for her own use and to remain focused. Another forty minutes would put the total time for the procedure at just a little more than an hour and a half, meaning Dr. Weaver was acting true to form. There were other orthopedic guys who would take nearly double his time.

Sandra moved a bit to keep her circulation going and stretched out her legs. She had the option of having someone come and relieve her for a few minutes if she so desired, but she rarely took advantage of the opportunity and wouldn’t now, even though everything was going perfectly smoothly.

Sandra heard the sound of the drill start, meaning Dr. Weaver was creating a pathway through bone into which he would thread the patellar allograph. Knowing that the periosteum was richly enervated with pain fibers, Sandra looked up at the integrated patient monitor screen to see if there were any observable changes to suggest Carl’s level of anesthesia wasn’t what it should be. All the tracings were exactly as they had been throughout the case. She homed in on the heart rate. It was at seventy-two, without the slightest change. But as she was watching, the screen did something she had never seen it do before. It seemed to blink, as if for a split second it had lost its feed.

A bit concerned about this blip, Sandra leaned closer to get a better look as her own pulse ratcheted upward. The idea of losing all the monitors in the middle of the case was not a happy thought. Holding her breath, she watched to see if there was another episode. A few seconds went by and then a few minutes. There wasn’t another blink.

After five minutes she began to relax, especially since the tracings on the monitor all stayed completely normal, including the ECG. Whatever it had been clearly hadn’t happened again. The only change, and she wasn’t even sure there had been a change, was that all the tracings appeared very slightly higher on the screen than they had been, as if there had been a slight baseline or calibration change. But that couldn’t have happened, because she hadn’t changed anything.

Sandra shook her head as if to loosen imagined cobwebs. Maybe she did need a break. Yet her fear that the possible artifact had been real kept her glued to her seat and watching the patient monitor closely. It was mesmerizing as the tracings raced across the screen, particularly the ECG, with its rapid, repetitive, staccato up-and-down movements.

After about ten minutes Dr. Weaver got Sandra’s attention by telling her that he was within twenty minutes from closing the skin. That meant that her second most busy time had arrived. She shut off the isoflurane but maintained the nitrous oxide and oxygen. The second she did so, disaster struck! The blood oxygen alarm went off, making Sandra jump.

Sandra’s eyes shot to the monitor. The oxygen had suddenly gone from nearly 100 percent down to 92 percent. That wasn’t terrible, but it was a change, as it had been pegged at maximum during the whole case. It was also encouraging that it was now at 93 percent and already heading upward. But why did it drop? Sandra didn’t have the foggiest notion. That was when she noticed the ECG had changed, too. At the same moment the oxygen level had fallen, there was sudden tenting of the T wave, suggesting endocardial ischemia, meaning lack of adequate oxygen to the heart. That was not good. But how could it be? How the hell could the heart be lacking oxygen when the blood level hadn’t changed but an instant earlier and not by much? This was nuts!

Sandra forced herself to be calm by sheer force of will. She had to think. Something was wrong, that was clear. But what? Quickly she upped the oxygen percentage, cutting back on the nitrous oxide. That was when she noticed the tidal volume was seemingly falling, meaning Carl wasn’t taking as deep breaths as he had been. Immediately Sandra dialed in ventilation assist. She wanted to push in more oxygen to get the low-oxygen alarm to turn off.

“Hey!” Dr. Weaver yelled out with alarm. “Both his legs are hyperextending. Is he seizing? What the hell is going on?”

“Oh, God, no!” Sandra cried out silently. She leaped up, snatching a penlight in the process. Pulling off the tape holding Carl’s eyelids closed, she shined a beam of light into his pupils. What she saw terrified her. Both pupils were widely dilated and only sluggishly reactive! She felt a sudden weakness in her legs, requiring her to momentarily support herself by grabbing the edge of the operating table. Her fear was that the hyperextension of the legs was something called decorticate rigidity, suggesting that the cortex of the brain, the most sensitive part, was not getting the oxygen it needed. When the cerebral cortex of the brain is deprived of oxygen, the millions of brain cells don’t merely malfunction like the heart — they die!

2

Monday, April 6, 9:20 A.M.

Lynn Peirce and the friends she was sitting with burst out laughing. Unfortunately for her, she had just taken a sip of coffee and ended up spraying a small arc of it onto the table in front of her. She was mortified and couldn’t quite believe what she had done. “I’m so sorry,” she managed while wiping her lips with a napkin. Michael Pender, positioned directly opposite her, leaped back, overreacting for dramatic effect, knocking over his chair in the process. Everyone laughed even harder, to the point where they garnered disapproving looks from people nearby.

Lynn and Michael were sitting with four other fourth-year medical students in the popular ground-floor coffee shop of the Mason-Dixon University Medical Center. It was an 800-bed hospital, run by Middleton Healthcare, which owned and operated a total of thirty-two hospitals sprinkled throughout the southeastern corner of the United States. The students were crowded around a four-top table, having pulled over a couple of extra chairs for a celebratory coffee break. The floor-to-ceiling sliding glass windows directly next to them were pushed open, allowing warm air from outside to permeate the room, and affording an unobstructed view over the meticulously landscaped hospital grounds.

The hospital was situated in the northeastern corner of Charleston, South Carolina, with a bit of the “Holy City” visible over a row of magnolias that lined the street. It was called the Holy City because of all the churches, and even from the hospital coffee shop, a number of steeples could be seen jutting up from among the historic homes. It was a gorgeous morning, like most Charleston spring mornings, filled with sunshine, flowers, and the sounds of songbirds.

What had made Lynn laugh so suddenly was an off-color joke about an angel who had traded in her harp for an upright organ. It had been told by Ronald Metzner, the jokester of the class, who had a phenomenal memory for jokes. What caught Lynn by surprise was that, although she usually didn’t find his jokes funny, somehow this one touched a nerve without her knowing exactly why, and only later would she realize it was because of suppressed tension she was trying to ignore.

Apologizing again to her companions for what she thought was a major faux pas, Lynn picked up her coffee cup and saucer to wipe off the table. She noticed that Ronald had a big, contented smile on his face, obviously pleased with the effect he had had on her and on the group as a whole.

The six medical students, four women and two men, appropriately dressed in their white coats, were hyped up and goofing off. For them, the almost four years of work, doubt, discovery, and challenge were all but over. Just over two weeks previously they had gotten the results of the National Residency Matching Program, so their uncertainty was behind them. They all knew where they were going for the next and, perhaps, most important part of their professional training.

For the final couple of months before graduation the group and several dozen other fourth-year students on the same rotation were supposedly getting their introduction to ophthalmology; ear, nose, and throat; and dermatology. But the rotation was not as organized or as important as had been the case in other, more basic disciplines, such as third-year internal medicine and surgery. They also had no real patient responsibilities, at least not yet. So far there had only been what they considered rather poorly planned and uninspiring lectures and demonstrations in the three specialties. That morning they had decided to skip the lecture to enjoy their sense of accomplishment. Truth be known, they were essentially in a cruise mode until getting their diplomas.

“I never knew you were interested in orthopedics,” Karen Washington said to Lynn after the group had recovered. Karen’s tone had a slightly captious tinge that only Lynn could detect. Just before the angel joke, Lynn had revealed her residency plans, which she hadn’t shared until that moment, and it had come as a surprise for Karen. She and Lynn were both from Atlanta and had known each other from high school and their undergraduate college days at Duke. They had been close friends during high school and their college freshman year, but when they both had decided on medicine as a career, competitiveness had interfered. But it wasn’t the only thing that came between them. Financial problems with Lynn’s family during sophomore year at college had impacted every aspect of her life, including her relationship with Karen, whose family was particularly well off.

Although Lynn and Karen ended up at the same medical school, their close friendship had never truly revived, as Karen’s keen competiveness continued. Instead Lynn had gravitated toward a close, platonic connection with Michael Pender. At one point during the first year of medical school Karen had confided to Lynn that she would have understood better if it had involved romance. Lynn’s response was that she was the one who was most surprised to have such a close, nonromantic friendship with a male, although Lynn’s boyfriend, Carl Vandermeer, had come in at a close second. Lynn had confided to Karen that Carl initially had a lot of trouble accepting the situation.

It had all started innocently enough and was based on the alphabetical proximity of their surnames, Peirce and Pender. As a consequence, from day one Lynn and Michael had been thrown together for everything that required medical students to pair up, mostly for labs and physical diagnosis. Although never romantic, they became a real team, somewhat like a brother and sister, making sure they had the same rotations, covering for each other, and studying together to the partial and unintended exclusion of others. The result was that Lynn and Michael had been saddled with the nickname “the twins.”

“Really? Orthopedics?” Karen continued, with disbelief. “It caught me totally by surprise, as much or more so than if you had told me you were going into urology. I always thought you were sure to become one of those brainy internal-medicine people.”

“I don’t know why it should have been a surprise,” Lynn responded, sensing a bit of the old hurt feelings on Karen’s part. “You of all people know that I was always a jock in high school and college, especially with my interest in lacrosse. Sports have always been a part of my persona. But what sealed the deal was doing orthopedics as my elective this fall. It surprised me how much I liked it. To me it is happy medicine, at least for the most part. That’s appealing.”

“But the surgery,” Karen complained with an exaggerated expression of distaste. “It’s not like what people expect surgery to be. It certainly wasn’t for me. It’s like a bunch of carpenters with hammers and saws, banging in nails and then having X-ray come and see where they went. Whereas ophthalmology! What a difference! That is surgery at its best: precise, bloodless, and you get to sit down while you operate.” Everyone knew Karen was off to Emory in Atlanta for a residency in ophthalmology.

“To each his own,” Lynn said. She was not going to be baited into a comparison of the two specialties.

“And you are staying here?” Karen asked, with continued incredulity. “Actually, for me that was even more of a shock. I thought you were destined for some Ivy League — affiliated hospital, like Mass General in Boston, considering your rank in class.” Everybody knew that Lynn was very near the top of the class, scholastically. She and Michael were always neck and neck in the ranking: two peas in the pod in more ways than one.

“I’m going to leave both internal medicine and the Ivy League to Michael,” Lynn said, acknowledging her partner’s coup. Michael smiled contentedly at the recognition. Everyone at the table knew that few people got a slot at Mass General and Harvard from Mason-Dixon University School of Medicine, whose stated goal was to supply well-trained physicians for South Carolina and its environs, and not for medical academia. “For me, I’m happy staying right here at Mason-Dixon,” Lynn continued. “And you should talk, Karen. Emory for ophthalmology! Not too shabby.” It was also common knowledge that, academically, Karen was in the top ten of the class as well.

“Everybody knows why Lynn is staying here for her residency,” Ronald said with artificial disdain. “Like the angel, she traded in her harp for Carl Vandermeer’s upright organ!”

There was another burst of laughter, this time at Lynn’s expense, although she too was smiling. She pelted Ronald with a balled-up napkin as he basked in the glory of having again gotten everyone to laugh over the same mildly salacious joke.

“Am I to gather that you and Carl Vandermeer are still going to be an item come graduation?” Karen questioned while struggling to control her laughter. The group’s outburst had again attracted disapproval from others in the coffee shop. It was, after all, a hospital.

Most of the class had met Carl Vandermeer through Lynn at various social functions over the course of their four years of medical school. It was common knowledge that Lynn and Carl had first met at Duke when Lynn was a sophomore and he a first-year law student. It had also been common knowledge that over the last couple of years they were seeing each other exclusively. What wasn’t known was the long-term seriousness of the relationship. Even Lynn didn’t know for certain. As close as they were, Carl was always evasive on the subject.

“We’ll see what happens,” Lynn said, tossing her long brunette tresses away from her face. She had yet to pull her hair back in a barrette, the way she always wore it in the hospital. What she didn’t say was that she felt rather strongly that it better work out with Carl, because the real reason she hadn’t applied for a training program in Atlanta or Boston was because Carl was committed to his job in Charleston. From her perspective there was no doubt it was a sacrifice. Truth be told, she had expected an engagement and wondered if it would be coming for graduation. In her mind, it would be a wonderful graduation present. As a competitive, modern woman, Lynn didn’t feel she needed love, but, having serendipitously found it with Carl, she wanted it. She also had enough self-awareness to suspect that her eagerness to create her own nuclear family had something to do with losing her father when she was in college. She and her father had been close, and it had been because of his early death that she had decided to become a doctor.

“Any specific plans we should know about?” Karen questioned, needling her friend. When the love affair with Carl had begun back at Duke, Karen had accepted the diminution of Lynn’s friendship much more than these last four years when it had expanded to involve Michael. Karen had never lost a girlfriend to a member of the opposite sex with no romance involved. She couldn’t help but wonder if there was some element of romance between the two, even if they both denied it.

Lynn responded by holding up both hands, palms toward her. “No ring, no specific plans. Like all of us, I’m going to be very busy next year being a first-year resident. That’s job numero uno.”

“Hey, everybody,” Ronald said, “have you heard the one about the urology transplant surgeon?”

It was now Karen’s turn to throw her napkin at Ronald. “Quit while you’re ahead, my man!” she said. “I even remember that joke, and it ain’t funny because it is based on a pathetic male fantasy.”

“It’s a good thing we are graduating soon,” Michael said. “Ronald is running out of jokes.”

“Oh, shit!” Lynn said, catching sight of her watch. “It’s going to ten already. I have to go!” She scrambled to her feet and gathered her dishes together.

“You’re not going to the ophthalmology lecture and make us all look bad, are you?” Alice Wong, one of the other women, asked.

“Hell no!” Lynn said. “Carl had a little operation this morning, and I want to be available when he gets to his room.”

“Really?” Karen questioned. “You never said anything about him having surgery.”

“It was his decision,” Lynn said. “He didn’t want it to be common knowledge.”

“Catch you later,” Michael said. He fist-bumped with Lynn but didn’t get up. He knew that Carl was to be operated on, but he was the only one who did.

“Give him our best,” Karen called out to Lynn, who was already on her way to drop off her dirty dishes, as the coffee shop was run like a school cafeteria.

Lynn waved over her head in acknowledgment but didn’t turn around. She was in a hurry. She was tense because of Carl, and feared she might have whiled away too much time having coffee. Knowing how fast Weaver was and knowing that the less time a patient was under anesthesia, the shorter the recovery time, she wouldn’t be surprised if she got there and found Carl already in his room. She hoped that would not be the case.

3

Monday, April 6, 9:48 A.M.

Lynn moved quickly toward the main bank of elevators. It was crowded as it always was at that time in the morning, especially on a Monday morning. Lynn was well aware that the hospital, along with Medical University of South Carolina on the other side of town, served as the tertiary-care centers for the metropolitan area, with a population soon to be pushing a million. Charleston was growing, as its manufacturing and biotech base expanded, particularly in the northern suburbs. Boeing was enlarging its 787 assembly plant, and the multinational drug giant, Sidereal Pharmaceuticals, had just announced it was adding a thousand new jobs to its expanding biologics manufacturing plant.

There was another reason the hospital was busy. Answering what was considered a national need, Middleton Healthcare had built a state-of-the-art facility, called the Shapiro Institute, for the care of persistent vegetative state, or PVS, and had physically connected it to the Mason-Dixon University Medical Center. It had been built with a huge philanthropic grant from Sidereal Pharmaceuticals. Although the institute was for the most part self-contained, it did use the center’s clinical laboratory and operating rooms when necessary. Although Lynn and her buddies knew little about the establishment, since it was not used for teaching purposes, she did know that patients from all over the United States arrived on a regular basis along with their families and were admitted through the hospital.

During her second year of medical school Lynn and her fellow classmates had been given one visit, presumably to encourage them to refer their vegetative patients to the facility when they went into practice. Their guide was one of the institute’s hospitalists, but the tour had been very limited. Its purpose was mainly to impress upon the medical students how computerized and mechanized the place was, and how that made it possible to take care of so many patients with so little staff.

Accustomed to multitasking, Lynn slipped her computer tablet out of its pocket as she hustled along and entered Carl’s name to get his room number. When no number came up, she wasn’t concerned. She knew how the system worked. On day-of-surgery admissions, a room wasn’t assigned until the patient was ready to leave the PACU. That meant that Carl was probably still there. But sometimes during the busy morning hours, data entry for room assignments lagged as much as an hour behind more important data entry. Even without a specific room, she was not going to go to the PACU. It was one of the areas of the hospital that medical students were discouraged from visiting, even when rotating on surgery during their third year. Instead Lynn would head up to the fifth floor, where orthopedic cases were sent after surgery, provided a room was available.

“Excuse me,” a pleasant voice said amid the general din. At the same moment Lynn felt a tug on her arm and found herself looking down at an older woman with blue-tinted white hair. At five feet ten inches tall, Lynn looked down on a lot of women. “Can you help me, Doctor?” the woman added when she had Lynn’s attention. She was clutching some lab slips.

“I’m not a doctor yet,” Lynn said. Lynn was honest to a fault. “But how can I help?”

“You look like a doctor to me even if you are much too young. I need to have some blood work done, but I don’t know where to go. They told me at the front desk, but I’ve already forgotten.”

For a moment Lynn hesitated. If she was still going to be in time to welcome Carl, she needed to get herself up to the fifth floor. Yet, sensing the woman’s panic, she relented. “Of course I’ll show you.” Lynn took the woman’s free hand and marched her back the way they had come. From the main entrance foyer, they crossed over the connecting bridge into the outpatient clinic building. Once inside, Lynn took the woman to see one of the clerks behind the main check-in desk.

“I will be happy to show this young lady where she needs to be,” the clerk said.

Lynn quickly retraced her steps, and after a short wait, boarded one of the main elevators on her way up to five. Unfortunately it was a local, stopping at every floor to discharge or pick up people. Pressed into the back of the car, Lynn tried again with her tablet to see if Carl had been assigned a room yet, but he hadn’t. She expected it was going to happen at any moment.

Once on five, she went directly to the main desk. Like the rest of the hospital, the floor could not have been any busier. To add to the chaos, the breakfast trays were in the process of being collected. The nurses who had long since finished report were getting some patients down to surgery, welcoming others back from the PACU, attending to doctors’ orders, distributing medications, and arranging transportation to radiology and physical therapy. It was comparative bedlam.

Lynn knew many of the people who worked on the floor from her monthlong elective back in October. She looked for the head nurse, Colleen McPherson, with whom she had gotten along well, but didn’t see her. When she asked another floor nurse, she learned that Colleen was in with a hip replacement patient whom they were trying to mobilize. Instead Lynn went back behind the desk to chat with Hank Thompson, the ward clerk. In the hospital hierarchy run by the nurses, medical students were low on the totem pole, but Hank had never treated her that way. He was a student at the College of Charleston and doing his own version of a work-study program.

Like everyone else, Hank was doing six things at once. He was on the phone, with a number of people on hold. While waiting, Lynn pulled up the master list of all the patients on the fifth floor on one of the monitors. It was organized according to room number. She ran her finger down all the names, looking for Vandermeer. It wasn’t there. But there were several vacant rooms, so she thought there wasn’t going to be a problem. She was pleased. It was best for orthopedic patients to be on the fifth floor because the nurses and aides were well versed in handling the usual problems that had to be faced by post-operative orthopedic patients, like dealing with the CPM, or continuous passive motion machines, which flexed and extended joints immediately after surgery. Lynn knew that Carl would have one because Weaver used them with all his ACL cases.

When Hank finished with the people on hold, he started to punch in the numbers to make another call. Lynn grabbed his arm.

“Two seconds of your time, Hank! A patient by the name of Carl Vandermeer will be coming to the floor shortly, unless he is already here. Does the name ring a bell?”

“Not that I remember,” Hank said with a shake of his head. “Who’s the doctor?”

“Weaver.”

Hank grabbed the master OR list and scanned it. “Yeah, here it is. It was a seven-thirty case.” He looked at his watch. “Should be coming up any minute, unless there was a complication.”

“It was a straightforward case. First operation. Healthy, young guy.”

“Shouldn’t be a problem. We have several rooms vacated this morning, and they have already been serviced, so they are clean and waiting.”

Lynn nodded and absently played with a paper clip. Hank turned his attention back to the phone. It occupied 90 percent of his day every day.

Lynn knew she should probably head over to the eye clinic. The lecture would be over and patients were probably lined up to be presented and examined by the medical students. Yet she knew she wouldn’t be able to concentrate until she was certain Carl was comfortable and all was in order.

Suddenly she stood up. Feeling she couldn’t just sit there, she decided she’d go down to the second floor and at least check the OR schedule. There could have been a delay in getting started. What if Weaver had come in late for some reason? What if the OR was short of nurses? There could be millions of reasons why a case could be delayed.

Lynn took an elevator down three floors. Feeling a bit like a fish out of water, she walked into the surgical lounge. It was another one of those places medical students didn’t wander around unaccompanied. Like the rest of the hospital, it too was crowded, since the OR was in full swing. Most or all of the lounge-style chairs and couches were occupied by doctors and nurses. All were in scrubs. A TV in the corner was tuned to CNN with the volume turned way down. Most people were reading newspapers, either waiting to begin or taking a quick break in the middle of cases already under way.

Fearful of calling attention to herself and possibly being ordered to leave, Lynn didn’t hesitate. She stepped into the room far enough to see the image of the OR white board in the monitor mounted on the wall. She looked for Weaver’s name and found it in OR 12. He was doing an anterior cruciate ligament, all right, but the patient’s name was Harper Landry, not Carl Vandermeer. So obviously Carl’s case was over.

Lynn’s eyes scanned around the room for a familiar face, somebody, anybody she might know however vaguely from either her orthopedic elective or from third-year surgery. But she didn’t recognize anyone. With sudden resolve she went into the women’s changing room.

Getting some scrubs, she changed quickly, using an empty locker for her clothes. After tucking her moderately long hair into a cap and grabbing a surgical mask, she checked herself in the mirror. The almost-white surgical hat emphasized her olive complexion, and without the benefit of her thick hair to frame her face, she thought her youthful, angled features and slightly upturned nose made her appear younger than she was. Combined with her height, she worried she was going to stand out like a sore thumb as a first-year medical student who didn’t belong. More to conceal her identity than to be aseptic, she put on the mask.

Satisfied, she returned to the lounge. Without hesitating, for fear she would lose her nerve, as Lynn generally followed rules, she walked out of the lounge and pushed her way through the double doors into the OR suite. She had been there before on numerous occasions during her monthlong orthopedic elective and even a few times during third-year surgery, but always accompanied. She had even assisted Weaver as well as a few other surgeons to get a close-up idea of orthopedic surgery. To her, orthopedic surgery was a lot different from what Karen had suggested. It wasn’t eye surgery, to be sure, but with newer tools it was considerably more precise than it had been.

Lynn half expected that she would be challenged, but she wasn’t. She kept moving at a good clip with the belief that any hesitation on her part would be a tip-off that she was an interloper. Her destination was the PACU, and she headed directly for it. She pushed through the second set of double swinging doors as if she belonged, but then stopped a few feet inside the room.

For most people, Lynn included, the PACU was a busy, alien world of high tech, which made students feel incompetent. The patients were on elevated beds with side rails. Most of the beds were occupied. There were no dividers between the beds. Each seemingly sleeping patient had at least one nurse, many with a nursing assistant as well. Fresh bandages covered varying areas of the patients’ bodies. Clusters of intravenous containers that appeared like plastic fruit hung on the tops of metal poles. The lines snaked down to run mostly into exposed arms, although a few were central lines going into the neck. Monitors were clustered on the wall over the head of each bed, with various electronic blips tracing lines across their screens. Plastic bags hung under the beds for drainage and urine. Several of the patients had ventilators for assisted respiration. The sounds in the room were a mixture of the electronic beeping, the cycling of respirators, muted voices of the nurses, and a low hum of powerful HVAC motors keeping the air in the room clean and cool.

Right behind Lynn, a gurney came crashing through the swinging doors, bringing in a fresh post-op patient and making Lynn jump out of the way. An OR nurse was pulling at the front. In the back was an anesthetist pushing while making sure that the patient’s breathing was not being compromised. A nurse from behind the central desk came around to help guide the gurney alongside an empty bed.

As the patient was efficiently moved from the gurney onto the bed, Lynn took a quick loop around the room, trying not to be conspicuous. None of the staff seemed to notice her. Carl was not there. She would have recognized him immediately. There were two people who had had knee surgery with CPM machines to keep their knees constantly flexing and extending. Neither was Carl.

Confused and not knowing exactly what to do, Lynn wandered over to the counter facing the central desk. She assumed she would soon be challenged, but felt it no longer made a difference. If Carl was not in the PACU or on the fifth floor, then where the hell was he? And why was he not on the orthopedic floor? There were beds available, according to Hank. Of course maybe Carl had been finished so soon that it was before the beds on five were ready. Hank had said that they had been vacated just that morning. Lynn felt that had to be the explanation. Yet the ongoing mystery was starting to upset her, fanning the subliminal tension she had felt upon awakening that morning, the same tension that had made her laugh so hard at Ronald’s off-color joke about the angel.

“Can I help you?” a voice questioned.

Lynn turned to face a PACU nurse almost as tall as she. The nurse was gowned over her scrubs. She regarded Lynn with a questioning, steady gaze.

“I hope so,” Lynn said. “I’m looking for Dr. Weaver’s first case. A man named Carl Vandermeer.”

“And who are you?” The woman’s voice wasn’t challenging or truculent, just authoritative.

“I’m Lynn Peirce, a medical student. I did a rotation in orthopedics and scrubbed with Dr. Weaver.” It was the first thought that came to her mind. It wasn’t a real explanation, but it sounded good.

The nurse eyed Lynn for a moment, then went behind the desk. “The name is not familiar to me,” she said. She took a quick look at the PACU log and found it. “He was Gloria’s case,” she said to Lynn, and then called loudly across the room. “Gloria! What was the dispensation of the Vandermeer case?”

“The neuro consult guys took him to the neuro ICU,” Gloria called back.

Lynn reached out and grabbed onto the edge of the desk to help support herself. The neuro ICU! What the hell did that mean? As she turned and fled from the PACU, she tried not to think. The problem was that she had a pretty good idea of what it meant for Carl to be in the neuro ICU.

4

Monday, April 6, 11:05 A.M.

Lynn was in a hurry. It was a way to avoid thinking. Without bothering to change back to her street clothes, she went directly to the main elevators, where a number of people were waiting. To avoid the possibility of getting into a conversation, she avoided any eye contact, keeping her attention glued to the floor indicators above the elevator doors. Nervously she continuously pressed the up button. None of the cars appeared to be moving up or down.

“That’s not going to get the elevator here any faster,” a woman said. Lynn closed her eyes, hoping that by not responding she would be spared having to try to be pleasant while her mind was in turmoil. There was nothing about Carl being in the neuro ICU that could be good news, and it was difficult not to imagine the worst.

“You are a fourth-year med student, if I’m not mistaken,” the voice said, undeterred by Lynn’s silence.

Reluctantly Lynn turned to face the woman. As soon as she did, she recognized her as one of the surgical attendings. She was wearing a long white lab coat over scrubs. Lynn assumed she was between cases and heading up to the surgery floor to check on a patient.

Lynn tried to smile in an attempt to be sociable. Her pulse was throbbing in her temples. She wondered if her face was red or pale. It had to be one extreme or the other, as she was experiencing an adrenaline rush. She was aware she was hyperventilating. She nodded. “I am,” she said distractedly. What the hell could be holding up the elevators? Still none had moved from the various floors where they had been when she first hit the button.

“Lynn Peirce,” the surgeon said, bending forward and reading Lynn’s ID hanging from a lanyard around her neck. “Actually, I remember you from your third-year surgery rotation. I’m Dr. Patricia Scott.”

“I remember you for sure,” Lynn managed. “Your lectures were terrific, especially your slides.” Lynn forced another half smile at the tall, elegant woman before returning her attention to the elevator floor indicator. She hoped her anxiousness wasn’t too apparent. She didn’t want to explain herself.

“Thank you. You must have been paying attention. I remember you did extremely well. I understand you got your residency notification a couple of weeks ago. Considering how well you did in your surgery rotation, I hope you gave surgery some consideration.”

“Orthopedics, actually,” Lynn said.

“Indeed! That’s terrific. We need more women in all the surgical fields, particularly orthopedics, where we are not very well represented. Where will you be going for your training?”

“I’m staying here,” Lynn said.

“Wonderful,” Dr. Scott said sincerely. “That’s super. I’ll look forward to having you scrub with me during your first year of general surgery.”

“I’m sure I will enjoy that, Dr. Scott,” Lynn said, hoping she didn’t appear as preoccupied and stressed as she felt. Finally one of the elevators that had seemingly been parked on the first floor began to ascend.

“You can call me Patricia now that you will be part of the house staff. And, for the record, my office is always open if you need any advice. It wasn’t that long ago I went through the training gauntlet, and unfortunately surgery is still anachronistically considered by some to be a men’s club.”

“I appreciate your thoughtfulness,” Lynn said.

The elevator’s doors opened. The car was jam-packed. Dr. Scott gestured for Lynn to precede her, and both had to literally squeeze in to allow the doors to close. Lynn was briefly tempted to ask Dr. Scott what it meant for a patient to go to the neuro ICU directly from the PACU, but she didn’t. The trouble was, she could guess. It had to have been some kind of anesthesia problem or disaster. Yet she still maintained a certain amount of hope it could have been something less worrisome. Could a nerve in Carl’s leg have been damaged with the bone drill? As bad as that might be, it was better than other possibilities she was trying to avoid imagining.

By the time they got up to the sixth floor, where neurology and neurosurgery were located, the elevator had emptied considerably. Lynn thanked Patricia Scott before getting off. She walked quickly. She knew where the neuro ICU was located. She’d been there on a few occasions during her neurology rotation and again during her stint on neurosurgery.

Most visitors to the floor were expected to check in at the main nurses’ station. But Lynn decided on the spur of the moment to act the same way she had down in the PACU: as if she belonged. Without hesitation she pushed into the ICU directly.

The neuro ICU appeared superficially similar to the PACU in terms of its prominent high-tech equipment, but here patients stayed much longer, sometimes weeks, even months on occasion. There were separate cubicles defined by glass walls, and not all the patients were sporting bandages. There was also less frantic activity from constant arrival and departure. Instead, a kind of heavy silence reigned, broken only by the distant beeping of monitors and the rhythms of the ventilators. A central circular desk was positioned to afford a view into each of the sixteen individual bays. All were occupied. At least half had nurses in direct attendance.

As Lynn glanced around the room she saw that each cubicle had an ID slot with the patient’s name printed in bold letters. Almost at once she zeroed in on VANDERMEER, cubicle 8. Slowly she advanced. Carl was supine. She could not see his face. As she had expected, there was a CPM apparatus constantly flexing and extending his operated leg. Seeing it gave her a modicum of premature hope that everything was as it should be, but it didn’t last long.

Two people were in attendance. An ICU nurse was on Carl’s right, checking the blood pressure by hand, even though there was a BP readout on the monitor. On Carl’s left was a resident physician dressed all in white. He was using a penlight and shining it alternately into each of Carl’s eyes. It didn’t take Lynn long to recognize that Carl was unconscious. She could also see that he was evidencing some low-amplitude myoclonic jerks with his free leg. His free arm and wrist were flexed across his body. The other arm with the IV was secured to the bed rail.

Coming up to the foot of the bed, Lynn looked at the monitor. Blood pressure was normal. The same with pulse and the ECG, as far as she could tell, but she was no expert with ECGs. She could see that oxygen saturation was down a little but still reasonable at more than 97 percent. Carl seemed to be breathing normally. She forced herself to glance at his face, which she could now plainly see. His color wasn’t bad, maybe a little pale. The worst part was that it was definitely Carl and not someone else.

As the resident straightened up he noticed Lynn. Slipping his penlight into his jacket pocket, he asked, “Are you from radiology?” Then without waiting for an answer, he added, “We are going to need an MRI or a CT scan ASAP.” Lynn could read his name tag: Dr. Charles Stuart, neurology. He was a slight man with thinning hair, small features, and rimless glasses.

“I’m not from radiology,” Lynn managed. Seeing Carl unconscious and possibly seizing was almost too much to bear. “I’m a medical student,” she added. She reached out and grasped the railing at the foot of the bed to steady herself. As she had in the PACU, she felt suddenly light-headed. A hospital was a place of tragedy as well as hope, but this was turning out to be all tragedy. “What is going on?” she asked as casually as she could.

“It’s not looking good,” Charles said. “It seems that we are dealing with a delayed return to consciousness after reportedly uneventful anesthesia for a routine ACL repair. So far it is a mystery as to why.”

“So he hasn’t awakened?” Lynn asked, not knowing what else to say, yet feeling as if she had to say something to warrant standing there.

“That’s the long and short of it,” Charles said flippantly. Lynn didn’t fault him. She’d come to learn that it was one of the ways house officers shielded themselves from the reality of human tragedy, which they were forced to face on a daily basis. Another way was to become consumed by academic detail, which he then evidenced by saying, “He’s completely unresponsive to spoken word and normal touch, except for a slight corneal reflex. On the positive side, he has retained some pupillary response to light. Seems that the brain stem is working, but with his decorticate posturing and flexion response to deep pain, it doesn’t look good for his cortex. It must have been a global insult, and we feel it was most likely hypoxic in origin, despite what the anesthesiology report suggests. It can’t have been embolic, as his deep tendon reflexes are not only preserved but also symmetrical. The problem is that he has a Glasgow Coma Scale sum of only five. As you probably know, that’s nothing to write home about.”

Lynn nodded. The reality was that she had little understanding of anything the neurology resident was talking about except the concept of an insult to Carl’s brain from hypoxia, meaning lack of oxygen. Neurology had been a short rotation and more applied neuro-anatomy than clinical.

“How could there be hypoxic damage if, as you say, the anesthesia was uneventful?” Lynn asked, more by medical-student reflex than anything else. Medical students were expected to ask questions.

“Your guess is as good as mine,” the resident said, reverting back to flippancy. “I’m afraid that’s going to be the million-dollar question.”

The nurse finished checking Carl’s blood pressure and headed back toward the central desk. She glanced briefly at Lynn but didn’t say anything. Lynn moved alongside the bed where the nurse had been, forcing herself to look back down at Carl’s face.

From his expression he appeared to be asleep and totally relaxed, despite the movement of his free leg. It was apparent he hadn’t shaved that morning, which was how he looked most Sundays when the two of them awoke. She associated his appearance with intimacy, which was totally out of place in the current environment and circumstance.

Lynn had to fight the urge to reach out and shake him awake, to talk to him, to yell at him to get him to respond and prove the neurology resident wrong about his not being responsive. What made the situation worse was that Carl’s face looked so achingly normal, just as it had yesterday morning when she had awakened and had watched him for a time as he slept, admiring his handsomely masculine features.

“Are you one of Dr. Marshall’s neurology preceptor group?” Charles asked, watching Lynn from across Carl’s bed. It seemed to Lynn that he was sensing something unprofessional about her behavior.

“Yes,” Lynn responded without elaboration. She had been in Dr. Marshall’s preceptor group, except it was a year ago. It wasn’t easy for her to be deceptive, but she assumed that she would be kicked out of the ICU if she wasn’t there for official teaching purposes. The hospital was strict about confidentiality issues, and she wasn’t technically family, at least not yet. With effort, she avoided eye contact with Charles for the moment. She could tell the resident was watching her.

Hesitantly Lynn reached out and lightly touched Carl’s cheek with her right hand. His skin felt cool but otherwise normal. She was afraid it would feel rubbery and unreal.

“Have you done an EEG?” Lynn asked, falling back into the protective medical-student persona by asking a question. She was suddenly worried that her touching Carl’s face might have seemed strange to the neurology resident. She didn’t say electroencephalogram because that wasn’t how house staff referred to the test of brain function.

“There was an EEG done on an emergency basis. Unfortunately it showed very low amplitude and slow delta background. I mean it wasn’t completely flat, but it shows diffuse abnormality.”

Lynn raised her eyes, forcing herself to look across at Charles despite her discomfort in doing so. In the most professional tone she could manage to camouflage her roiling emotions she asked: “What’s your guess at the prognosis?”

“With a Glasgow score of only five I’d have to say pretty dismal,” Charles said. “That’s been our experience with comatose patients not involving trauma. My guess is that when we get a brain MRI we are going to see extensive laminar necrosis of the cortex.”

Lynn nodded as if she understood what Charles was saying. She had never heard the term laminar necrosis, but she very well knew that necrosis meant death, so extensive laminar necrosis must have meant extensive brain death. With some difficulty she swallowed. She wanted to shout “No, no, no!” But she didn’t. She wanted to run away but she didn’t. Lynn considered herself a modern woman, aware of current-day female opportunity, and she had “taken the ball and run with it,” acing high school, college, and medical school. Her approach was to work as hard as she could, and when she confronted problems or obstacles, which she most certainly had experienced, her reaction was just to strive that much harder. But here was perhaps one of the biggest challenges of her life. Here the man with whom she had come to believe she might share her life was possibly brain dead, and there was nothing she could do.

“Hey,” Charles said suddenly. “You know what? This is a perfect teaching case to demonstrate doll’s eye movement as a test for brain stem function with comatose patients. Have you ever seen it?”

“No,” Lynn forced herself to say. Nor did she think she wanted to see it with Carl as the subject, since it would only make his status that much more real, but she didn’t think she could refuse without possibly betraying that she was there under false pretenses.

“Then let me show you,” Charles said. “But I need your help. You hold his eyes open while I rotate his head.”

As if touching something forbidden, Lynn used the thumb and the first finger of her left hand to elevate gingerly Carl’s upper lids. She stared down into blankness of his mildly dilated pupils. It gave her an eerie feeling, as if she were violating his personhood. Silently she shouted for him to wake up, to smile, and to talk and say that this whole episode was a sham and a joke. But there was no reaction, just his rhythmical breathing.

“Okay, good,” Charles said. He bent over Carl’s chest and put his hands on either side of his head. He first rotated Carl’s head toward Lynn and then back toward himself. “There, did you see it?”

“What am I seeing?” Lynn asked in a hesitant voice. It was all she could do to keep from recoiling and running from the room.

“Notice that when I rotate the head, the eyes move in the opposite direction.” Charles rotated Carl’s head again.

It was now easy for Lynn to see that Carl’s eyes did rotate as Charles had described, blankly staring upward as his head went to the side.

“It’s a vestibulo-ocular reflex,” Charles said in a didactic-medical monotone that was all too familiar to Lynn. “It means that the brain stem and the involved cranial nerves are operating as they should. If the patient is malingering, acting as if unconscious, something you will see on occasion in the ER, the eyes move in the direction of the rotation. If the brain stem is not functioning, then the eyes don’t move at all. Rather dramatic, wouldn’t you say? I could also show you the same phenomena using caloric stimulation, meaning putting cold water into his ears. Would you like to see that as well?”

“This is quite enough,” Lynn said. She pulled her hand back, allowing Carl’s eyelids to close slowly. She had to get away. To where, she didn’t know. As a member of the hospital community and soon to be a doctor, she felt a responsibility in Carl’s disaster above and beyond her recommending Dr. Weaver and the Mason-Dixon Medical Center.

“I have all the paraphernalia available,” Charles said. “It will only take a second to get it. It’s no imposition whatsoever.”

“Thank you,” Lynn said, backing up from the bed. “I appreciate your taking the time to show me what you have, but I have to go. I’m sorry.”

“That’s quite all right,” Charles said. He stared at Lynn and furrowed his brows. It was obvious he was confused about her behavior. “If any of the other members of your preceptor group would care to see this classic doll’s eye movement, I’d be happy to show it to them.”

“Thank you,” Lynn said. “I’ll let the others know.”

Lynn fled out of the ICU. Once in the hall, she stopped and took a few deep breaths. It was somehow comforting to be back in the usual commotion of the hospital with patients, nurses, and orderlies passing her. Her heart was still racing. There was nothing she could do to help Carl, and her first thought was that she had to find Michael. She needed an anchor, someone to hold on to during this storm of uncertainty and emotion.

5

Monday, April 6, 12:25 P.M.

Lynn found Michael in the cafeteria. She had first gone back to check the coffee shop, but he and the others had left. She thought about texting him but had no idea what to say. Instead she wanted just to find him. Maybe she wouldn’t even say anything for a time.

Considering the hour, she had decided the cafeteria was the best bet, as the food was considerably cheaper there than at the coffee shop, and Michael rarely missed a meal. As usual the room was crowded with its usual lunchtime rush. It had taken her a moment but she managed to locate him in the food line. She felt lucky he was by himself. The other members of the earlier coffee-shop group were nowhere to be seen. She was glad about that. She wanted to talk only to Michael.

“Hey, Lynn. How’s Carl doing?” he asked when he turned to look who had tapped him on his shoulder.

“I need to talk,” Lynn said, her voice faltering. “Privately.”

“Okay, no problem,” Michael said. Knowing her as well as he did, he immediately sensed her brittle emotional state. He eyed her. “You okay?”

“That remains to be seen,” Lynn said. There was an audible catch in her voice.

“How about grabbing some lunch and hanging with me?”

“I’m not hungry at the moment.”

“Do you mind if I eat while we talk?”

“Of course not!”

“Then let me settle up for these vittles. Then we can sit over there in left field by the far wall. I see a couple of free tables.”

Lynn glanced in the direction and nodded. The cafeteria was as good as anyplace else in the hospital for a talk with Michael. The hubbub might actually help her keep her emotions in check.

Although Lynn wasn’t hungry, she was thirsty, and she got herself some water before sitting at one of the free tables they had seen from the steam-table line. The area was farthest away from the windows, which looked out onto a sumptuously landscaped interior garden. A number of tables in the garden were the most popular, and were the first to fill up when the weather was as good as it was. Lynn could see quite a few of her classmates outside.

As she sat waiting for Michael to pay, she watched him in the checkout line. He was a commanding presence and stood out from the similarly white-coated medical students. The main reason was a combination of his size and the fact that he was black. In Lynn’s class there were only three African American males along with five females of color, making up only 6 percent of the class despite the school’s active recruitment efforts. Michael was a muscular man with a thick neck who Lynn learned had played football at the University of Florida and who had had a shot at playing professionally had he not set his heart on becoming a doctor. Lynn knew that the career choice was a debt he owed to his mother. His features were broad, his skin a dark mahogany, and his hair was relatively long and worn in what Lynn had come to know was a lock-twist. Initially she thought they were short dreadlocks but now she was the wiser.

Back on the second day of medical school when Lynn had first spoken with Michael when paired with him for the anatomy lab, she had been mildly intimidated. Not only was he a sizable man, but he seemed to her to have an animus toward her right out of the gate. From their first words he complained about her attitude, so she did the same. During the initial days they merely tolerated each other, and both had to make an effort just to get along well enough to work together.

Lynn had never considered herself racist, but over time Michael had made her see that she had been to an extent, and that racism was unfortunately alive and well in America. Michael for his part learned from her that he was so accustomed to having to deal with patronizing attitudes that he often evoked it. He also came to learn from her that despite fifty-plus years of feminism, misogyny and gender discrimination had not disappeared. Both came to understand that with racism and gender issues, one had to be a member of the oppressed to really appreciate the subtleties and the not-so-subtleties of discrimination that had so influenced their respective lives. Throughout her life, Lynn always felt she had to do a bit better than the men with whom she was competing whereas Michael always felt he had to do much better than everybody.

As Lynn and Michael came to understand they were kindred spirits, they began to appreciate each other’s idiosyncrasies apart from race and gender, stemming from their different backgrounds: Lynn, from a middle-class Atlanta upbringing, with two siblings who ultimately fell on hard times; and Michael, from a single-parent household from the South Carolina Low Country, with five siblings who had had to struggle to keep a roof over their heads and food on the table. They also became aware of their similarities besides their being extremely motivated hard workers who strived for excellence. Both had defied stereotypes and had responded to STEM programs in their schooling, meaning science, technology, engineering, and math. Both early on liked computer gaming and had an interest and facility in coding. Both had aced college. In medical school both were on full scholarships, which was the main reason they were at Mason-Dixon University. Both of them had been accepted at all the medical schools to which they had applied, but Mason-Dixon had had the best offer financially. Finally, although Lynn had been close to her father, she also knew what it was like not to have one.

As Michael approached, Lynn felt thankful for their relationship and grateful to the school for having paired them up. She had never had a male friend like Michael, and valued their relationship, as he had truly expanded her life in so many ways. And now, if the neurology resident was right in his prognosis of Carl’s condition, she was going to need Michael’s support more than ever.

“Okay, whassup?” Michael said, affecting nonchalance while sliding his tray onto the table. He settled his solid two-hundred-pound frame onto the chair, which squeaked in protest. He picked up his sandwich and took a healthy bite.

For a minute Lynn was unable to speak. She wasn’t one to cry often, possibly because of a reaction to the stereotype, and she didn’t want to cry now. She felt torn. She wanted Michael’s support to avoid the sense of isolation that she was already feeling from the shock of this unfolding calamity, yet she worried that telling Michael about what had happened would make it more real. As a medical student, she knew enough about the psychology of the grief reaction to know that she was still solidly in the early denial stage.

Michael did not press her. He chewed his sandwich and took another bite, seemingly ignoring her. He was content to wait. He knew her well enough to be concerned. Something significant was in the wind, and it had to do with Carl and his surgery.

Lynn took a drink of water and then closed her eyes tightly. When she opened them she let the facts flow out, explaining about Carl’s apparent anesthesia disaster and how she had gone up to the neuro ICU and talked with the neurology resident. She concluded by saying that Carl’s Glasgow score was only five and that the neurology resident said the prognosis was dismal.

Michael put his sandwich down and pushed his plate away as if he had lost his appetite. “That’s a low Glasgow score.”

Lynn stared at her friend. There were lots of times that he amazed her, and this was an example. She had never heard of a Glasgow score, and Michael apparently had, despite the fact that they both had taken the same neurology rotation during their third year. He had a facility to remember facts no matter how obscure. “How do you know about the Glasgow score? I don’t think I have ever heard of it.”

“Let’s just say I had reason. It is a way to evaluate people in a coma. What was the neurology resident’s name?”

“Charles Stuart, I think. I don’t know for sure. My mind isn’t working at full speed.”

“I don’t think we had him for any part of our neurology rotation.”

“I know for sure we didn’t. I had never seen him before.”

“What else did he say besides the Glasgow score and that the prognosis was not good?”

“He said that he expected to see extensive laminar necrosis on the MRI when they do it.”

“I don’t know what laminar necrosis is.”

“I don’t, either, but it is not hard to guess.”

Michael nodded. “Did you talk to anyone else, like the surgeon or the anesthesiologist?”

“I haven’t spoken to anyone. I wanted to talk to you first.”

“Did you look at the anesthesia record?”

“No. All I did was see if it was Carl, and it is. He’s in a freaking coma, for Chrissake! And I was the one who recommended the doctor and encouraged him to get his fucking knee fixed here at Mason-Dixon.”

Michael reached out and enveloped Lynn’s comparatively narrow wrist with his large hand. His grip was firm. “Listen, sister,” he began. When they were alone together they jokingly called each other sister and bro, a bit of Black argot that Michael had instigated as a sign of their platonic intimacy and comfort with each other. As a further sign of their closeness, he also treated her to basketball metaphors he’d used with his buddies in high school. “I can tell you right off the top, you are not responsible for whatever happened during today’s game. You weren’t a player. No fucking way!”

Despite her efforts at control, tears brimmed and some spilled over Lynn’s cheeks. She wiped away the moisture with a knuckle of her first finger. “I know I’m going to feel a certain amount of guilt no matter what; I know myself well enough. But what about his parents? They had wanted him to have his surgery over at Roper Hospital. Why did I interfere?”

Carl’s father was a lawyer in Charleston like his son but at a different firm and involved in a different specialty. The father’s area of interest was litigation and criminal law, unlike Carl’s emphasis on real estate and corporate law. His mother was an elementary school teacher. The parents lived in the same house in West Ashley where Carl had grown up. Lynn had met them on numerous occasions, particularly over the last several years, as Lynn and Carl’s relationship had solidified. Even Michael had met them for a couple of celebratory birthday dinners.

“The Vandermeers are smart people,” Michael said. “And it’s easy to see they care for you. They are not going to blame you. No way!”

“I’m not sure I wouldn’t if I were them.”

“But we’re jumping the gun here. We don’t really know as an absolute certainty what’s going on. Here’s my take: Let’s hightail it up to the neuro ICU before our dermatology lecture and check out Carl’s chart.” Mason-Dixon Medical Center had a fully integrated EMR, but there were still physical charts for inpatients while they were in the hospital. There had been some talk of completely phasing out the charts, but it hadn’t happened, at least not yet.

“What will that accomplish?” Lynn wasn’t sure she could go back quite so soon. Seeing Carl in a comatose state was enormously unsettling, to say the very least.

“I don’t know, but we will have a better idea of what happened. There has to be an anesthesia record in the chart. I mean, there must be some explanation. Come on!” Michael started to get to his feet.

Lynn grabbed Michael by the sleeve of his white coat. “They are not going to look kindly on two medical students appearing without authorization to look at a chart in the ICU.”

“Leave it to me,” Michael said. “As I’ve told you in the past, most people think I’m either a token or a Tom. Sometimes it causes problems, but sometimes it helps. This is one of the times it will help. Trust me! Besides, I’ve done it before.”

“In the neuro ICU?”

“Yes.”

“When?”

“About three months ago.”

“Why?”

“We’ll talk about that later. Let’s go up there and see Carl and hope to hell Doc Stuart is wrong.” Michael got to his feet and tugged on Lynn’s arm to get her to stand. To Michael she looked like a deer caught in headlights. He picked up his tray and carried it over to the window. Lynn followed. She appreciated that someone else was making the decisions.

6

Monday, April 6, 12:40 P.M.

As they ascended in the elevator, Michael glanced at Lynn. She was watching the floor indicator above the door. Her eyes were red and watery. The elevator was crowded, putting a lid on any conversation about their mission. For Michael there was a strange, uncomfortable sense of déjà vu, and he hoped any similarities to the events he was thinking about would be minimal.

When the doors opened on the sixth floor, Michael and Lynn were not the only people to get off. Lynn grabbed Michael’s arm to hold him back as the other passengers proceeded toward their respective destinations, most going to the central desk. The place was as busy as it had been earlier.

“We have to have a plan here,” Lynn said, lowering her voice so as not to be heard. Several people were standing nearby, waiting for a down elevator. “I got away with going into the ICU earlier because the resident assumed I was on a neurology rotation. You are not going to get away with that. They’re going to remember you because you stand out. How do you plan on handling this? You know we medical students are not welcome in the ICU unless we have an official reason.”

“I’m counting on not having a problem, provided we don’t act hesitant or indecisive.”

“What is it you want to do, exactly?”

“Mainly I just want to look at the chart. But we’re not just going directly to the desk and grab the chart without checking out the patient. That’s not cool. It’s not the way it’s done. You know what I’m saying? Do you remember where Carl is? That would be a help. We don’t want to draw attention to ourselves by acting lost.”

“He’s in cubicle number eight, I believe, but I could be wrong. My mind’s in turmoil.”

“All right, here’s the plan. We head directly into cubicle eight. Provided it’s the right address, we check out Carl’s current status. If it’s not, we find him, fast! You okay with that? You don’t have to do anything. Just hang. I’ll do something appropriate to make it look official.”

“All right,” Lynn agreed, although she wasn’t entirely sure her emotions wouldn’t take over.

“Let’s do it!” Michael said with conviction.

With Michael half a step ahead and moving at a quick pace, they passed the busy sixth-floor central desk and headed for the ICU. At the door Michael hesitated for a split second to glance at Lynn, arching his eyebrow. Lynn assumed he was questioning her mental state, so she nodded. She was as ready as she was going to be.

Michael pushed through the heavy door. Inside was a different world. Gone were the noise of the lunch carts, the babble of voices, and the sense of commotion. In its place were the muted electronic sounds of the monitoring and the to-and-fro cycle of a couple of ventilators. Otherwise a heavy stillness reigned. The patients were all completely immobile.

As he had said, Michael made a beeline for cubicle 8. Lynn’s memory had served her well. Carl was in the bed and momentarily alone. The half dozen nurses and an equal number of aides on duty were occupied with other patients.

Michael went to Carl’s right, and Lynn to his left. Carl appeared to be sleeping as he had before, save for the jerking of his free leg. Again Lynn had to suppress the almost irresistible urge to reach out and shake him awake. For the briefest moment she felt a twinge of anger, as if Carl were doing this on purpose.

“Deceptively peaceful,” Michael said.

Lynn nodded. Tears again threatened. She tried to think objectively about what might be going on in Carl’s brain. She watched as Michael took out his penlight. After raising both of Carl’s upper lids, he shined the light alternately in each eye. “Pupils are equal and maybe sluggish, but both react. Nothing to ‘fatmouth’ about, but it is something. At least the brain stem is still working.”

Lynn nodded again but didn’t speak. As a defense mechanism she thought about the doll’s eye movement that the neurology resident had shown her, and its implications.

“Vital signs are normal,” Michael said.

Lynn followed his gaze up to the monitor. Everything was as it had been earlier, including the oxygen saturation, at 97 percent.

“All right,” Michael said, lowering his voice and looking across at Lynn. “So far, so good.” The busy nurses seemed indifferent to their presence. “Let’s mosey over to the central desk. And try to relax, girl! You look like you are about to rob a bank.”

Lynn didn’t bother to answer. She tolerated his mildly disrespectful language just as he allowed her to call him “boy” on occasion. It was only when they were certain no one else was listening that they used such slang. It was another sign of their closeness and shared understanding of discrimination.

The circular central desk was usually dominated by the duo of the head nurse, Gwen Murphy, and the very capable long-term clerk, Peter Marshall, who had been around so long he felt proprietary. From their neurology rotation Michael and Lynn remembered both of them as efficient and professional and very helpful. At the moment only Peter was present. As usual, like all ward clerks, he was on the phone, but he raised his eyebrows questioningly as he gave them a once-over. At the moment Gwen was apparently occupied elsewhere.

Under the lip of the surrounding countertop were flat-screen monitors displaying the readouts of the vital signs of each patient. Lynn’s eyes went directly to 8. Everything was normal. On top of the countertop was a rotating chart rack.

“Hey, dude,” Michael said to Peter as a greeting, evoking a roll of the eyes on Peter’s part. Not giving him a chance to respond, Michael turned his attention to the chart rack, which he gave a deliberate spin. He stopped it so the slot for cubicle 8 was facing him. Without the slightest hesitation Michael withdrew the chart, grabbed a couple of chairs, and pulled them off to the side. He motioned to Lynn to take one, and he sat in the other. He opened the chart and rapidly leafed through to the anesthesia record.

As Michael was doing this, Lynn watched Peter out of the corner of her eye. As Michael had anticipated, he seemed to ignore them, at least until he finished his current phone conversation. Then he said, “Hey, can I help you guys?”

“We were told to check out the anesthesia record on Vandermeer,” Michael said. “And we got it right here. Thanks! Take a look, Lynn!”

Michael positioned the chart so that Lynn could see. There was a handwritten note by the anesthesiologist, Dr. Sandra Wykoff, as well as the three-page printed version done by the anesthesia machine. They read the handwritten note, which was thankfully easy to read in contrast to a lot of notes that they had had to read by doctors in hospital charts over the last couple of years:

Michael and Lynn finished at almost the same moment and looked up at each other. “I don’t know much about anesthesia,” Lynn said. “We only had that one lecture about the basics in our surgery rotation. I’m going to have to do some research to understand it all.”

“But the important point is that there was some documented hypoxia,” Michael said. “The O₂ level fell for a couple of minutes, and the ECG changed.”

“But not much. The O₂ only fell to ninety-two percent briefly and then went back up to ninety-seven percent. That is not a huge fall and probably about what people experience getting off the plane in Aspen, Colorado. And it was only for three minutes.” Lynn pointed to where it was noted in the handwritten summary.

“Then how come the ECG showed the T wave changes?”

Lynn shrugged. “I don’t know enough to even guess.”

“Let’s check out the machine-generated record.”

Michael turned to the relevant page of the three-page anesthesia record. What they were interested in was the intra-operative portion. Both knew that the modern anesthesia machine was computer driven and kept track of all the variables in real time, including what was portrayed on the monitor. At the end it printed it all out in graphic form. Everything that had happened was recorded, including gases, drugs, fluids used, and all the monitoring parameters.

“And what are you people doing?” a voice questioned. It was not antagonistic but definitely authoritative.

Both Lynn and Michael looked up. Looming over them was Gwen Murphy, the head nurse. She was a stout, ample woman with flame-red hair and rosy cheeks.

Without skipping a beat, Michael said, “We have been sent by anesthesia to check out this case of delayed emergence from anesthesia.”

Gwen eyed Lynn for a moment, then nodded as if buying Michael’s explanation. “The patient is scheduled for an MRI this afternoon.” Without elaboration she turned around and went back to her post in front of all the monitors.

Lynn leaned over to Michael and whispered: “How did you come up with that?” She was impressed. Knowing that what they were doing was more than merely frowned upon by the authorities, Gwen’s sudden appearance and challenge had scared her. She knew she would have tripped over her words had she tried to say anything. So she had been glad Michael had spoken up. She and all the other medical students had been warned they were not permitted to look at charts or electronic medical records, EMRs, unless specifically authorized, most specifically including those of friends or even family members. Patient confidentiality was taken quite seriously by the administration, and looking at records under false pretenses was a serious and punishable offense.

“Practice, I guess,” Michael said. “Did you notice she didn’t look at me?”

“Now that you mention it, I guess I do. I can tell you; she definitely stared at me. I thought it was because I was feeling so guilty that it showed.”

“I don’t think so,” Michael said. “I believe her not looking at me is that unconscious discrimination at work that I’ve mentioned to you. Senior staff, both doctors and nurses, often don’t look at me. But it is okay. I’m used to it. And sometimes it helps, like letting us get away with what we’re doing right now.”

“I’m sorry,” Lynn said.

“Hey, it’s not your fault. And it doesn’t bother me anymore. Anyway, let’s get back to why we’re here.”

Without another word, the two students turned their attention back to the printed anesthesia record. Both could plainly see where the oxygen saturation suddenly fell to 92 percent. Running their eyes down to the associated ECG recording of the heart, they could appreciate the changes that coincided.

“Is that a hypoxic change on the ECG?” Michael asked.

“I believe so,” Lynn said. “I’ll need to find out for sure. I certainly have my work cut out for me.”

“What do you mean?”

“Just what I said. I’m going to figure out why this happened.”

“I’ve seen a case just like this before.”

Lynn looked up at Michael. She was surprised. “Really! When?”

Without answering, Michael looked over at Gwen and Peter. Both were occupied. Taking advantage of the situation, Michael pulled out his smartphone. After quickly turning off both the sound and the flash, he took a photo of the anesthesia record. In the next instant the phone disappeared.

“Jesus!” Lynn croaked in a forced whisper. “Why did you risk that?” Nervously she glanced back at Gwen and Peter. She was relieved to see that Gwen was involved in a conversation with another one of the ICU nurses, and Peter was on the phone busily taking dictation.

“We may need it,” Michael said cryptically. “Are you finished with the chart?”

“I’d like to read the neurology consult, even though I already have a pretty good idea what it says.”

“Let’s do it and hightail it out of here. Then I’ll tell you about the other case.”

7

Monday, April 6, 12:55 P.M.

As soon as the heavy ICU door closed behind them, Lynn peppered Michael with questions about the supposedly similar case, wanting to know exactly how similar it had been.

“It was exactly the same,” Michael said as they walked along the crowded sixth-floor hallway, skirting lunch carts.

“Was it a delayed emergence from anesthesia?”

“Absolutely. I’m telling you, it was just the same.”

“When was it?”

“About three months back, when we were on pediatrics.”

Lynn was about to ask how Michael had known about the case when she looked ahead. Coming toward them was Dr. Gordon Weaver and, most alarmingly, Markus and Leanne Vandermeer, Carl’s parents.

Like a scared rabbit, Lynn froze. They had not yet seen her, as they were far enough away and there was enough commotion in the corridor between them to create a significant distraction. For a second Lynn thought about turning and running in the opposite direction. Having yet to come to terms with her own raw emotions by any stretch of the imagination, she didn’t know how she would respond should there be any criticism or blame. There was little doubt in her mind that they would be as devastated as she was.

Sensing Lynn’s reaction, and recognizing the parents, Michael firmly grabbed her arm. “Play it cool, sister,” he whispered.

“I’m not sure I’m ready to deal with this,” Lynn croaked. She tried to pull out of Michael’s grasp, but he held on.

“Hang!” Michael said definitively. “You can handle it, and it’s better to get it over with here in the hospital.”

Her pulse racing, Lynn watched them approach. The first to recognize her was Leanne. She was a slight woman wearing a gray, conservative suit, looking like the elementary school teacher she was. When she caught sight of Lynn, her drawn face revived from grief to concerned sympathy. Without the slightest hesitation she came directly at Lynn and enveloped her in a sustained embrace. Lynn was pleasantly surprised. Previously Leanne had never given her more than a slight kiss on the cheek.

“How are you managing, my dear?” Leanne asked, still holding on to Lynn’s arms after the lengthy hug. She was a good six inches shorter than Lynn and had to look up into her face. “Now, I want you to promise me you are going to take this bump in the road in stride. He’ll be waking up soon. Trust me! Everything is going to work out just fine. I’m sure of it. I know how busy you are. Patients are depending on you. You have to take care of yourself and get back to your work.”

Lynn glanced at Michael for support. Thanks to Carl’s descriptions, she was aware Leanne was controlling, but this seemed beyond the pale. The woman was telling her how to respond to the disaster.

“I’m so sorry for you this mild complication had to occur,” Leanne said. “But it will be over soon. I’m certain.”

“I’m sorry, too,” Lynn said. Leanne’s apparent denial of the reality of Carl’s condition was such a surprise that it made it easier for Lynn to control her emotions. Lynn had feared censure and blame but was experiencing empathy. She was both relieved and thankful.

“You must be just devastated,” Leanne continued. “Have you seen him?”

Lynn nodded, hesitant to admit she had in front of Dr. Weaver, who she thought might recognize her having done so as a violation of hospital rules, but Dr. Weaver, obviously having his own problems, didn’t respond.

“How does he seem?” Leanne asked. Her expression of concern morphed back to grief.

“Very calm,” Lynn said. “He looks like he’s asleep.”

Leanne let Lynn go, and Markus gave her a second hug. Carl’s father was a sizable man like his son but heavier boned. His face was lined and always tan. He was an inveterate golfer who loved his bourbon. In contrast to his wife, he looked thoroughly shell-shocked and chose not to speak.

“Has there been any change?” Leanne asked when Markus let her go.

“I’m afraid not,” Lynn said. She gestured to Michael. “You remember Michael Pender, of course.”

“Yes, of course,” Leanne said, briefly acknowledging Michael but immediately turning back to Lynn. “We are going to make sure that the best doctors are involved in Carl’s care. I’m sure there will be a change for the better very soon.”

“I hope so,” Lynn said, nodding her head. She looked at Dr. Weaver, who was still dressed in scrubs. He didn’t meet her gaze and encouraged the older Vandermeers to move on toward the neuro ICU, saying there was only a small window of opportunity for their visit.

After promises to get together, the Vandermeer parents continued down the hall. Lynn and Michael headed in the opposite direction toward the elevators.

“Now, that wasn’t half-bad,” Michael said.

“They were very generous,” Lynn admitted. Quickly her mind reverted to what they had been talking about before catching sight of the Vandermeers. “What were the details of that similar case you mentioned, and how did you hear about it?”

“It was an African American female in her late twenties or early thirties, generally about the same age as Carl. She was operated on with general anesthesia after being shot in both knees. She didn’t wake up. There was an episode of hypoxia just like with Carl, and that was it.”

“She was operated on here at Mason-Dixon Medical Center?”

“Yes. I’m telling you, the case was a mirror image.”

They arrived at the elevators. Lynn tugged on Michael’s coat to get him to stop. She didn’t want to talk about a case on a crowded elevator, but she wanted to hear more. “Well, how did you hear about it?”

“My mamma called me from Beaufort to tell me a distant relation was having a major complication after surgery here. She asked me to look into it, so I did.”

“What was the woman’s name?”

“Ashanti Davis.”

“What kind of relation was she to you?”

“Very distant and only by marriage. Cousin of the brother of an in-law on my mother’s side of the family or something obscure like that. I knew her a little in high school because we went to the same regional school, but she was ahead of me and never finished, and we ran in different circles.”

“Shot in the knees? Was that the result of some sort of gang war?”

“Someone had a serious beef with her — that much is clear.”

“What’s happened to her?”

“She permanently gorked out after the operation. Within days they moved her over to the Shapiro Institute.”

“That’s awful,” Lynn said. “And is she still there?”

“As far as I know. I don’t think anybody visits or asks. Nobody in her family wants to pay the kind of bread they get for room and board, if you know what I’m saying. She wasn’t very popular in her family, to put it mildly, even in her surviving immediate family. In high school she was considered a slut with a penchant for dating all the aspiring gang members. I kept my distance. She even got one of my cousins shot dead, so her getting shot wasn’t all that unexpected considering the people she ran with. She was a bad apple.”

“What an awful story,” Lynn said. “Before getting shot, was she generally healthy, like Carl?”

“As far as I know.”

Lynn shook her head. The fact that there were two healthy people at Mason-Dixon who within months of each other did not wake up from anesthesia was more than disturbing; it was downright frightening. And it was terrifying to think of Carl being transferred over to the Shapiro. After the brief visit, she and her medical-student colleagues equated it to being shipped off to Hades.

“I would love to have a look at Ashanti’s hospital record,” Lynn said.

“Whoa!” Michael said, leaning away from Lynn as if she might be contagious. “That’s the kind of thing that could get you kicked out of medical school. Carl’s chart is different, as it is an active case, with all sorts of people having access. With Ashanti, it would be a totally different ball game. You’d have to use the EMR, and you would be caught right away.”

“I wouldn’t do it myself,” Lynn said, thinking about who might be willing to get such a record for her. Earlier Dr. Scott had offered to help her, saying her office was always open. And Lynn thought about the anesthesiologist who had taken care of Carl. Maybe she would be interested, provided she wasn’t the one who administered the anesthesia to Ashanti.

“I do have a photo of her intra-operative anesthesia record someplace,” Michael said. “I took it in the neuro ICU the same way I just took Carl’s.”

“Really?” Lynn said with surprise. “Where is it? Could you find it?”

“I’ll have to look. As I recall, it’s either on my PC or on a flash drive that’s got to be someplace in my room.” As full-time scholarship students, both Michael and Lynn were expected to live in the dorm, a separate building on the medical center’s expansive campus. Most of the other fourth-year students had moved out to private apartments. Lynn had not minded remaining since it was convenient when on call to sleep in her own bed rather than in the on-call room. Besides, she had been staying at Carl’s most weekends.

“You’ll look?”

“Of course I’ll look. But not now, if that’s what you’re thinking.” Michael glanced at his watch. “We’re already late for the ophthalmology lecture. We better get our asses over to the clinic building.”

“I’m not going to the lecture,” Lynn said in a tone that did not brook argument. “There’s no way I could sit still for an hour in my state of mind. I’m fried.”

“What are you going to do?”

“I’m going to ride my bike down to Carl’s house and try to chill.” Lynn said. “I need to read up on anesthetic complications, particularly delayed emergence, and I can do it using his PC. I’ll feel closer to him there. I might even pray a little. I’m that desperate.”

Michael looked askance at Lynn. Religion had been a frequent topic of discussion for them, especially during their third year, when they were on pediatrics, and more recently during their advanced pediatric elective. Having to deal with suffering children with cancer had made them feel there could not be a God, at least not a loving, caring God that might be swayed by prayer.

“I know,” Lynn said, anticipating what Michael was thinking. “It goes against what I said during all those late-night talks of ours, yet seeing Carl in the state he is in makes me want to cover all the bases.”

Michael nodded. He thought he understood. This episode had cast his friend emotionally adrift.

8

Monday, April 6, 1:16 P.M.

Lynn changed out of her scrubs and put on street clothes, anger bubbling up inside her. She was furious at the anesthesiologist, at the hospital, at medicine in general, and was reminded of how she had felt after her father died. She wanted to kick the locker where her clothes had been. She wanted to break something as she combed her hair with quick, angry strokes.

The trouble was in some respects that she knew too much. If she weren’t a medical student she could have hoped he would just wake up and be fine, which was what the Vandermeers were apparently assuming. Lynn wished she could indulge in such optimism, but she couldn’t. She knew that wasn’t going to happen. The neurology resident expected the MRI to show in detail extensive laminar necrosis of the cortex, whatever the hell that was. Yet she was knowledgeable enough to know that it meant the death of a lot of cells in the part of the brain that made people human.

Translated, it meant that even if Carl were to wake up, he wasn’t going to be the same Carl. There wasn’t going to be a happy ending, no matter what. It was a lose-lose situation. For a brief second she thought that it would have been better had he died, but then she quickly amended the thought, embarrassed at its selfishness. At least now there was a glimmer of hope, no matter how unlikely. He was, after all, still alive. Maybe there could be a miracle.

Pulling on her white coat, Lynn looked back at her image in the mirror. Her lips, normally full, were compressed in a grim line. Her green eyes stared back with hostile intensity. She was now clearly in the anger stage of her grief reaction, having already abandoned the first stage of denial. She couldn’t help but feel that the American medical system had failed her again. The first time had been in relation to her father, Ned, who had been unlucky enough to have had a rare genetic blood disease called by the acronym PNH. It was one of the so-called orphan diseases that affected fewer than ten thousand patients worldwide. After almost four years of medical school, Lynn knew a lot more about the disease than she did when she was in college. She understood now how the disease destroyed red blood cells during the night. She also knew she didn’t have it and wasn’t a carrier.

In 2008, when Lynn was a sophomore at college and the recession hit, Ned had lost his job and, with it, his health insurance. The health insurance had been paying the extraordinarily high cost of the medication that was keeping him alive. Although Ned had been able to pay the premiums himself for a year, the insurance company voided the policy as soon as they could, as it was before the Affordable Care Act. That meant no lifesaving drug, which ultimately meant Ned’s death. At the time Lynn didn’t know all of these details, just that the family was in difficult economic straits. When she did learn what had happened, it helped solidify her desire to go into medicine to try to change the system, especially after learning that the exorbitantly priced drug was so much cheaper in Europe and even in Canada. Now she felt the US health-care system had come back to bite her again.

To pull herself together, Lynn splashed cold water on her face. Behind her she saw the tall figure of Dr. Scott come into the changing room and go to her locker. For a moment Lynn debated whether she should go over to talk with her and ask if she would help look into what had happened to Carl, but Lynn rapidly changed her mind. It was too soon. She recognized she didn’t know enough even to ask intelligent questions, like how often something like Carl’s case occurred around the country. At the moment all she knew was that it had happened twice at Mason-Dixon Medical Center, only a few months apart.

Instead of talking to the surgeon, Lynn concentrated on leaving before Dr. Scott happened to see her. She didn’t want to talk to her or anyone. She knew she was on thin ice emotionally, especially now that her anger was trumping her denial.

Lynn used the stairs to avoid running into anyone she knew in the elevator. Once on the ground level, she ducked through the clinic building, which provided a shortcut to the dorm. She made it a point to steer well clear of the clinical amphitheater, where the ophthalmology lecture was being held.

Emerging from the hospital confines into the glorious Charleston mid-spring sunshine, Lynn felt a modicum of relief just to be outside. With the birds singing and the warm sunshine knifing down through the flowering trees in the landscaped quadrangle of the medical center, she tried not to think. But it was an effort to keep her thoughts at bay, and it didn’t last. Off to her right was the immense hulk of the Shapiro Institute, loudly reminding her of the plight of the brain dead.

In sharp contrast to all the other buildings forming the Mason-Dixon Medical Center complex, the Shapiro Institute seemed to be only two or three stories tall. It was hard to determine, since it had almost no windows, making it appear as a monstrous rectangle of polished granite. Lots of flowering trees and shrubs were planted around its perimeter in an attempt to soften its stark lines. There was only a single, solid, blank entrance door set back under a stone arch along its facade. There had been times when Lynn and Michael were walking back from the hospital when shifts at the institute must have been changing, and they saw personnel emerge. There were never many people. Those they did see were always dressed in unique white uniforms, something akin to surgical scrubs but more stylish and form-fitting even though they were one-piece coveralls.

Stopping for a moment, Lynn stared at the building, wondering if Ashanti Davis was still there, and if she was, how she was doing. Lynn shuddered, wondering what it would be like for Carl if he were moved into the facility and whether she would be allowed to visit. She doubted she would, since she was not immediate family.

She thought back again to the single second-year official tour that she and Michael had had, along with their classmates. She clearly remembered the details of the story behind the name. It was in honor of Arnold Shapiro, a twenty-one-year-old college student from Texas, who ended up in a persistent vegetative state for fifteen years. The immediate cause of his condition was thought to have been hypoxia. His heart had stopped spontaneously and there had been a delay for an unknown period of time before he’d been resuscitated by EMTs. The case had ignited a fierce legal battle between Arnold’s divorced parents whether to maintain him indefinitely or to discontinue the feeding tube and let him die. Ironically the case became a poster for both sides of the issue. Lynn and Michael had been told that the rationale for naming the facility after Arnold Shapiro was because throughout his ordeal Arnold had received excellent care from being in the spotlight. The goal of the Shapiro Institute was to give that same level of care to anyone who needed it, whether famous or not.

Thinking of Carl possibly getting shuttered away for years made Lynn shudder again and turn away from staring at the building. Quickly she recommenced walking toward the medical school dorm. She knew she had to get a grip on herself.

The dorm room she had occupied from the first day she had arrived at medical school was on the fourth floor. It was small but pleasant, and most important it had an en suite bathroom. The window looked out across the Cooper River with a view of the graceful Arthur J. Ravenel Jr. Bridge arching over to Mount Pleasant. The river was wide at that point and looked more like a huge lake.

There was a framed photo of Carl on top of the bureau. Carl was laughing and holding up a pina colada, complete with a pineapple wedge, a maraschino cherry, and a miniature paper umbrella. The photo had been taken that past summer on his twenty-ninth birthday at Folly Beach, a popular nearby resort. They had rented a small but charming cottage for the weekend.

Lynn reached out and turned the photo over. It was painfully reminiscent of a different time and place. After tossing her white coat over the back of her desk chair, she changed into more appropriate biking clothes and grabbed her helmet, backpack, and sunglasses. In the backpack went her cell phone, a fresh legal tablet, and a couple of pencils. Other than her bike helmet, she didn’t need anything else, since she had gradually stocked some basic clothing and toiletries at Carl’s house.

Lynn biked due south until she could veer off onto Morrison Drive, which eventually turned into East Bay Street and finally into East Battery. It was a progressively scenic route the farther south she went, especially when she reached the historic downtown district. When she got below Broad Street, where most of the historic homes were located, she passed the area called Rainbow Row, a series of early-eighteenth-century row houses that had been built on the edge of the Cooper River. They were all painted in historically accurate pastel Caribbean colors, a legacy of the English settlers from Barbados. Lynn’s mood cheered a smidgen. Charleston was a beguilingly beautiful city.

9

Monday, April 6, 2:05 P.M.

Michael slipped his pen into the pocket of his white coat. He had tried taking notes to keep focused, but it wasn’t working. The main problem was that the lecture wasn’t about clinical ophthalmology, as he had expected. Rather it was a tedious review of the anatomy of the eyeball and its connections to the brain. It was material Michael and his classmates had studied extensively during their first year.

One of the secrets to Michael’s academic success was that he could speed-read with remarkable retention. He had worked laboriously on the skill from early childhood, always careful to keep his developing proficiency a secret from his friends, particularly his male friends and particularly in high school. In the social circles he ran in, being a good student and the effort it took weren’t assets. On the contrary, they were suspect.

As far back as Michael could remember, his hardworking mother, who cleaned houses and washed other people’s clothes, had harped on the belief that education was the express train out of the ghetto poverty trap, and that speed-reading was the ticket. Michael had taken the advice to heart, and, thanks to good genetics inherited from his mother and the father he had never really known, he had had the ability to master it. Now, with his medical residency in the bag, suffering through a two-hour marathon review of material he had already been sufficiently exposed to was a ball-buster. The reality was that he could relearn what was being presented on his own in a fraction of the time and with better recall. It was also true that his mind was wandering. He couldn’t stop thinking about Lynn, Carl, and, of all people, Ashanti Davis.

Michael glanced around at his classmates. It was obvious that just about the whole team was suffering. Those students who weren’t sleeping had glazed eyes, suggesting to him that only a handful of neurons in their brains were functioning. “Fuck this,” Michael said to himself. “I’m breaking out!”

Taking advantage of the dimming of the lights for yet another series of computer-generated images, Michael impulsively got to his feet and left. It took only a moment since he had taken an aisle seat in the rear, near the exit. Still, he knew he risked being noticed. As a black man entering into a profession where the percentages of black male physicians were low and falling, anonymity for him was rarely an option.

The clinic was in full swing. Every available chair was occupied by a patient. A number of them looked up hopefully when they glimpsed Michael and his white coat in hopes that their waiting was about to end. None of them had any idea their waiting was due to a lecture. Many of the white patients quickly averted their gaze. It was similar to the lack of eye contact with the attending physicians, the vast majority of whom were white, that had bothered Michael during his first year, when there was an introduction to patient contact. Now he took it in stride. He correctly realized it was their problem, not his.

Michael had good rapport with patients white and black once they got over the initial hesitation his blackness occasionally engendered. In fact sometimes the white patients adjusted faster. Some blacks would assume that Michael was an “Oreo,” a black-vernacular label for someone overly assimilated, or “black on the outside and white on the inside.” But that surely wasn’t the case. Michael fully identified with his roots and the black community, and intended to serve it by bringing Harvard know-how back to Beaufort, South Carolina.

Intending to head over to his dorm room to search for Ashanti’s anesthesia record, Michael left the clinic by the same exit that Lynn had used earlier. As if further mimicking her, he stopped in the landscaped courtyard at just about the same spot that she had and gazed at the Shapiro Institute for the same exact reasons. He wondered if Ashanti Davis was still in there, being kept alive by the wizardry of modern medicine. He also worried whether Carl was destined to be transferred in there as well. He knew that would be a major stumbling block for Lynn.

Michael was well aware, at least theoretically, that a patient in a vegetative state could be kept alive almost indefinitely. He knew there had been a patient who had been kept alive for thirty-seven years. What it required was not rocket science but merely a careful balance of the body’s internal environment, meaning proper hydration and electrolyte balance, appropriate nutrition, and careful skin care. For long-term nutritional needs, the best solution was a percutaneous gastrostomy tube, placed by surgery through the abdominal wall directly into the stomach.

Of course, another major requirement was to keep all the various microorganisms at bay, such as bacteria, fungi, and viruses, since it was often the case with such patients that their immune systems weren’t up to snuff. Appropriate drugs such as antibiotics and antivirals were used when needed, but the main defense was accomplished with reverse precautions, meaning to keep the bad bugs away from the patients. Prevention of infectious disease was the reason visits to the institute were restricted to immediate family, and even these were discouraged for the patients’ collective benefit. Immediate family had to view their stricken loved ones through a plate-glass window.

From his rotation in the ICU during third-year surgery, Michael was well aware that the biggest threats for long-term care of unconscious patients were pneumonia and the lowly bedsore. Patients had to be turned constantly to avoid being in one position for too long, because that was how infections and pneumonia were fostered. The more mobilization, the better, which was why such care was generally considered labor intensive, except in the Shapiro Institute. On Michael’s one and only visit during the second year, he had learned that the Shapiro’s secret was computerization and automation. What that really meant, he wasn’t sure, because he and his classmates didn’t get to see any real patients. The visit had been limited to a didactic lecture and a short stint in a family visitation area, where a dummy had been used for demonstration purposes.

Thinking about Ashanti Davis and her ignominious end reminded Michael of his own success at having defied the odds. Here he was, about to finish medical school and head up to a medical residency in the lofty Ivy League while most of his childhood acquaintances were either already dead or in prison, or with severely compromised futures, like Ashanti. About a week earlier, as a way to chill out after the anxiety of the residency matching program, he had hidden in his room and social-surfed himself to near brain death, looking up as many of his old friends as he could, using multiple sources. It had been a depressing pastime, and it made him really question how he had been so lucky.

Mostly Michael gave credit to his mother and the way she ragged on him about education and reading skills. But he also gave himself some credit for not falling prey to the culture in which he had found himself immersed. Things could have worked out very differently, and he very well could have ended up a hashtag in Beaufort, South Carolina’s, homicide statistics. As a young, skinny teenager he had dealt drugs for a while, as it was an easy way to help support the family. He was also good in sports, and both activities pushed him to the head of the pack. But being at the head also meant trouble, and protecting his honor required quick response to threats. At first going to blows with fisticuffs was adequate, but by the eighth grade it meant having to pack.

For Michael, the meld of pistols and passion was what changed the game. He was judicious enough to understand that packing heat was a no-win situation, especially after his cousin had been shot dead by a supposed friend and fellow hoopster who had mistakenly become enamored with the flighty Ashanti. From that moment Michael had no more truck with drugs, would-be gangstas, guns, or hot spots. He was no longer interested in running wild. He avoided all situations that could lead to confrontation, like messing with any girls who dated gang members, or even trash-talking opponents on the b-ball court, or gloating over accomplishments of any sort.

As if waking up from the trance that his reverie had spawned, Michael found himself sprawled out on one of the many park benches that lined the quadrangle’s walkways, still transfixed by the Shapiro Institute. He was taken aback by what his thinking about Ashanti had engendered. And as he reflected some more, he found himself wondering if it had been his mother’s words or his own inclinations that had kept him from being killed or killing someone who he might have felt had somehow slighted him. He didn’t know the answers. But it all certainly raised the question in his mind of how his life might have been different had he not learned to speed-read or if he had a father, and if he had, whether it would have helped or hindered. One way or the other, Michael felt he was one lucky dude.

10

Monday, April 6, 2:20 P.M.

After applying her bike brakes, Lynn turned into the brick driveway that ran alongside Carl’s house and led to the carriage house in the back. She had not come to the house directly as she had originally planned. As she had ridden south, she’d come to question whether going to Carl’s was appropriate. So instead she had biked down to the base of East Battery Street and spent some time sitting on the seawall to try to come to terms with her roiling thoughts and emotions. From that vantage point, looking out over Charleston Harbor, she could just make out Fort Sumter in the distance at the easternmost end of James Island. It was a comforting place, as she’d gone there often with Carl. She knew it was his favorite place in the city.

Something had occurred to her that shocked her as she had cycled. She had tried to put it out of her mind but couldn’t. Unwelcome, it kept coming back to torment her and demand her attention like the mental equivalent of a toothache. It was the idea of her sudden freedom stemming from the realization that if Carl ended up as she feared, being shut away in the Shapiro Institute, the whole reason she had decided to abandon an academic career and stay at the Mason-Dixon Medical Center for her residency training was moot. And even if he wasn’t shut away but needed around-the-clock care, was she cut out for such a role? Hell, she thought, they weren’t even engaged, and she truly didn’t know if it had been in the cards. Whenever she’d brought up the issue of the future, Carl always changed the subject, which had made her plans for her residency extremely difficult.

These were disturbing thoughts and made her wonder if she was a selfish and bad person to be thinking such things, and so soon. Yet as she sat at the Battery, the peaceful scene and its association with Carl ultimately convinced her it would be good to be around all the things that helped define Carl as the person he was before that morning’s events. It also convinced her that it would be far worse emotionally for her to return to her dorm room knowing that a comatose Carl was nearby, suffering from recent brain damage for which she felt she bore some responsibility. Had Carl gone to Roper Hospital, he’d probably be watching TV now and itching to be discharged.

Lynn had garage and house keys on a key ring along with her dorm key. She put her bike inside the garage next to Carl’s red Jeep Cherokee. Then she headed for the house.

By far Carl’s favorite arena of law was real estate, and the real estate scene in Charlestown was booming. A large number of the eighteenth- and nineteenth-century homes had been renovated, and those that had yet to be redone were in high demand. Carl had participated in many of the sales, and his intimate knowledge of the market and personal acquaintance with a number of the owners had given him the opportunity to buy one of the most coveted properties. The house was on Church Street, a particularly scenic lane. The style was called a single house. Because Charleston property taxes in the early days were determined by footage on the street, the original Charleston inhabitants built their houses with the long axis perpendicular to the street and only a single room wide. Along one side of the house, long verandas called piazzas were built on each floor. Before air-conditioning, Charlestonians lived as much outdoors as they did indoors during the long, muggy summers.

What made Carl’s house so desirable were two things. Although it needed modern renovation, its period detail had not been lost over the years as its infrastructure had been slowly improved. And second, its original owners had acquired the neighboring lot and turned it into a large, formal garden, complete with a lily pond, a gazebo, shade trees, and various types of palms. Although the garden had not been tended for nearly a half century, it was an invaluable asset of which Carl had schemed to take full advantage.

After walking back around to the front of the house, Lynn keyed open what, for all intents and purposes, looked like the front door. Yet the only location the locked door led to was an open veranda, which, according to its design, a visitor could access as easily by climbing over the balustrade. It was another curious characteristic of a Charlestonian single house. She had to walk along the ground-floor piazza to the true front door located in the middle of the lengthwise porch. To her left was the tangled, overgrown garden, which sounded like an aviary, as it was a haven for a good portion of the local bird population.

Once inside, Lynn closed the second door and stood for a moment, listening to the silence of the house and smelling its familiar aroma. In contrast to herself, Carl was a meticulous housekeeper and had the place cleaned twice a week. Because of the tall shade trees, little sun managed to get inside, which was a distinct benefit during the hot months, but as a consequence it was quite dark. Lynn had to wait to allow her eyes to adjust from the bright sunlight outside. Slowly the details of the interior emerged from the relative gloom of the high-ceilinged room. Suddenly she jumped and let out a small scream. Something had brushed up against her leg.

“Oh, my God,” Lynn said in relief. Mildly embarrassed at her reaction, Lynn reached down to pet Pep and apologize to the cat for scaring it. “I forgot about you,” she added. Pep pressed up against Lynn’s hand as she stroked the animal. “I guess you’re lonely. I’m afraid it’s going to be just you and me tonight.”

The first thing that Lynn did was go into the kitchen to check if there was dry food and water for the cat. There was, and there was a note addressed to Frank Giordano about how much food to put in the cat’s bowl. She made a mental note to give Frank a call to let him know that he was off the hook as far as the cat was concerned. She was not looking forward to that conversation as she anticipated that Frank would undoubtedly be full of questions that she would be unable to answer.

With the cat issue taken care of, Lynn returned to the front hall and mounted the main stairs to the second floor. She was dreading going into the master bedroom.

As she stepped into the room, she marveled that Carl had taken the time to make the bed. It was so typical of him. It had been the one difference between them that Lynn had been mildly worried about, wondering whether her casualness about such details would wear on him or his compulsiveness on her. She was fastidious about her person and her work, but with mundane things such as making the bed, or folding and hanging her bath towel, or dealing with her soiled clothes she wasn’t so exacting.

On the bureau was a picture of her that had been taken the same weekend at Folly Beach as her picture of him. She appeared to be as happy as he did in his, and she wondered whether she would ever feel that way again. Just as she had done back in her dorm room, she turned the photo over. Looking at it could only bring pain when she came back to the room later that night. She was going to sleep there to feel close to Carl and help convince herself she wasn’t as selfish as she worried.

Next, Lynn made her way down the second-floor hallway to one of the smaller bedrooms that Carl had turned into a study. It was a large house with another three bedrooms up on the third floor, and two more in the dormered attic space. The bedroom Carl had turned into his work space had a door out onto the veranda, as most of the bedrooms did. The room had a very masculine feel. It was paneled in dark mahogany. One wall had floor-to-ceiling bookcases in which one shelf was filled with sports trophies he had won, starting with Pee Wee Football and Little League Baseball.

Lynn sat down at Carl’s very neat, expansive desk and turned on his PC. She got her cell phone, legal tablet, and pencils out of her backpack. As the PC was warming up, she scrolled through her contacts in her phone until she got to Giordano and tapped his work number. Knowing herself and her tendency to put off unpleasant chores, she wanted to get it over with so that she could concentrate on immersing herself in Carl’s medical situation.

The phone was answered by a secretary. Lynn gave her name and said that the call was personal. A moment later Frank was on the line.

“What’s up?” Frank asked. Lynn sensed his concern. She knew he had taken Carl to the hospital that morning.

“I’m afraid there has been a complication...” Lynn began.

“Don’t tell me!” Frank interrupted. “Carl had a premonition things were not going to go right. What happened?”

“There was a problem with the anesthesia,” Lynn said. “His oxygen level dropped during the surgery, and he hasn’t woken up. He’s in a coma.”

“Oh, fuck!” Frank blurted out. “What’s going to happen?”

“I spoke briefly with a neurology resident who was on the case. He’s convinced there was brain damage. There’s going to be an MRI this afternoon.”

“Double fuck! Holy shit!”

“I’m sorry to lay this on you,” Lynn continued. “I can’t tell you any more. I’m in the dark myself. I didn’t know enough to even ask the right questions, but I’m going to rectify that tonight. Maybe tomorrow I’ll know more. I’ll keep you posted.”

“Please do! Jesus Christ! Do his parents know?” Frank and gone to elementary school and high school with Carl and knew the parents well.

“They know.”

“Oh, my God! You must be devastated. I’m so sorry, Lynn. How are you doing?”

“I’m a basket case,” Lynn admitted. “On top of everything else I feel responsible, since I recommended the surgeon.” Her concern about her being selfish went through her mind, but she didn’t mention it.

“That’s crap!” Frank said without hesitation, mirroring Michael’s reaction. “This is not your fault. No fucking way! I mean, I could just as much say it was my fault because I was the one who drove him to the hospital. That’s bullshit! Give yourself a break!”

“I’ll try, but I’m overwhelmed. The problem is I’m not fully in control of my feelings.”

“Where are you now?” he asked.

“I’m here at Carl’s. Which reminds me: you are off the hook about Pep. I’ll see to her needs.”

“Do you want me to come and pick you up? You could stay with Naomi and me.” Frank had a single house similar to Carl’s and not that far away. “You can stay as long as you want. We have plenty of room.”

“I appreciate the offer, but I want to stay here.”

“Are you sure?”

“As sure as I can be at the moment. I’m going to take it hour by hour, day by day. I’ll call you if I need to talk. Meanwhile I’m going to occupy myself learning as much as I can about his medical situation.”

“You have my cell. Call me anytime you want. Truly: anytime. It doesn’t matter. And if you don’t mind, I’ll check in with you later this evening.”

“I don’t mind,” Lynn said.

“Okay, catch you later. And I’m sorry.”

“Thank you,” Lynn said before she clicked off.

Turning her attention back to the computer screen, Lynn first made sure of the Internet connection, then brought up Google Chrome. Before she could initiate the first of what was going to be many searches, she jumped in fright. Sudden movement off to her left caused her to leap to her feet, sending the desk chair skidding backward on its casters and crashing loudly into the bookcase. A few books that had been balanced upright to display their front covers fell to the floor. The cat who had initiated this chain reaction howled in equivalent fright and fled the room.

“Holy shit,” Lynn voiced, pressing an open palm against her chest. Her heart was racing. For the second time the cat had innocently enough terrorized her, this time by leaping up onto the desk. The intensity of her reaction gave her an idea of the extent of her anxiety. She bent over and picked up the volumes that had fallen and returned them to the shelf. Next she pulled the chair back to the desk and sat down.

For a few moments she let herself recover before getting to work. She had three main areas of interest. The first was the incidence of complications involving anesthesia. The second was the specialty of anesthesia itself so that she could go over Carl’s record with full understanding. She particularly wanted to know about problems related to hypoxia or low oxygen and what could cause them. Apparently that was the current explanation of Carl’s delayed return to consciousness. And finally she wanted to read about the Glasgow Coma Scale.

A few minutes later Pep wandered back into the room. This time when she jumped up onto the desk to sprawl on its surface, Lynn didn’t even notice. She was deep into a piece on hospital complications. The statistics floored her and even embarrassed her about the profession she had been working so hard to enter. She had known complications were a problem in some hospitals but nowhere near the extent that she now knew existed. It made her wonder why there had never been a formal lecture about it or even any discussions in her preceptor groups. The more she read, the more shocked she became.

Lynn had been furiously taking notes and suddenly needed an eraser. Assuming there would be one in the desk, she pulled out the drawer to look. Not unexpectedly there were several. She picked one up and was about to close the drawer when her eye caught something else. It was a small signature-blue Tiffany box.

Lynn froze, staring at the box. After a moment’s hesitation and with a shaking hand, she reached into the drawer and lifted it out. Sliding off the white bow, she opened it. Inside, as she guessed, was a small, black, felt-covered box containing a diamond engagement ring. With a loud snap, Lynn closed it, put it back in its blue carton, and replaced it in the drawer.

For a moment she stared off into space. Now she knew for sure there was going to be an engagement that had been derailed by the events that morning. For a moment she struggled with a combination of overwhelming sadness and paralyzing anger, each trying to best the other. But instead of giving vent to either, she closed the desk drawer to return to her Internet search. She felt a renewed commitment to the task of finding out exactly what had happened to Carl and who was responsible as a way to avoid even thinking about lost opportunity and the disturbing freedom issue.

11

Monday, April 6, 2:53 P.M.

For almost a half hour Michael stayed where he was on the park bench, staring at the Shapiro Institute and mulling over the realities of his childhood that had been awakened by thinking about Ashanti Davis. He was truly amazed at how lucky he’d been to escape the near hopeless, self-fulfilling web of poverty in which he and his friends had been enmeshed and the self-destructive methods that had evolved to deal with it.

Suddenly Michael sat bolt upright. In his direct line of vision, a man emerged from the single Shapiro Institute door. Considering the time of day, it was a rare sight and rarer still because the man was by himself and wasn’t wearing the typical white outfit Michael had seen before. Instead of white scrublike clothes, this man was “flamed up,” sporting a black leather suit jacket over expensive-looking jeans.

Surprising himself to a degree with his spontaneity, Michael called out, “Hey! Sir! Hold up!” Using his hands to restrain the collection of pens and other paraphernalia in his pockets, including his digital tablet, Michael ran toward the man, who was walking quickly, parallel to the building, apparently en route to the parking area on the other side. “Excuse me!” Michael added as he fell in alongside. “Can I speak to you for a moment?”

The man stopped and regarded Michael. He had on sunglasses and Michael could not see his eyes. He was a white, muscular fellow with heavy features and dark, lank hair. He had a goatee not dissimilar to the kind Michael had been tempted to grow on occasion. He was wearing earbuds with the wire looping down and disappearing inside his jacket, and carrying a laptop computer in his right hand and a soft leather briefcase in his left.

“I saw you came out of the Shapiro Institute,” Michael said, slightly out of breath. “I’m a fourth-year medical student, Michael Lamar Pender. I have always been fascinated by the place.”

The man took out one of his earbuds, and Michael could hear jazz at a not insignificant volume. The man cocked his head with a frown. Michael repeated his comment. He hoped a little friendly chitchat would open the man up as a potential source of information, but no luck. Not only did the man not say anything, he kept frowning.

“We medical students visited the institute during our second year. We learned a bit about the place but...”

Michael trailed off, hoping for some response. There wasn’t any. “Do you work in the institute?” he added in desperation.

“No,” the man said finally.

“Were you just visiting?” Michael persisted. “Do you have a relative who is a patient?”

“I don’t understand question,” the man said with a strong accent. “I am computer programmer. I fix problem.”

“Cool,” Michael said, and he meant it. Michael was suddenly more interested as he recognized the Russian accent. Over the years a number of Russians had been hired by the Mason-Dixon Medical Center to staff the Department of Clinical Engineering, which included IT. Michael had spoken with a couple of them on a number of occasions and found them generally friendly and very competent.

With the sizable computer servers associated with the hospital’s electronic health records and all the other hospital equipment that were essentially computers, such as the anesthesia machines, MRI units, CT scans, and the like, the hospital needed a team of truly computer-savvy individuals. And Michael knew that Russians generally were talented with computer code. They had even become somewhat infamous of late with their involvement with high-frequency trading on Wall Street. Some of the hospital team had even been recruited from there.

“So you work here in the main hospital?” Michael said, speaking slowly and loudly, gesturing over his shoulder toward the main eight-story hospital tower behind them.

“No,” the man said without elaboration.

“Cool,” Michael repeated, nodding as if agreeing. It suddenly occurred to him that the man didn’t speak nearly as much English as the Russians he had spoken with in the main hospital. Yet Michael didn’t want to break off the conversation. Meeting this dude popping out of the Shapiro seemed so serendipitous, considering his sudden interest in finding out about Ashanti Davis. He thought that the chances were better than good that the man had administrator status with the Shapiro’s computer system. He’d have to, if he was working on it.

“Is the computer fixed?” Michael asked to make conversation. If this guy was a computer admin guy, he could be very helpful if he was inclined. Michael was well aware that people, like himself, who had reasonable access to the main hospital system could not access the Shapiro Institute’s. He knew it because he had tried several months back when he briefly attempted to find out about Ashanti.

“Computer not yet fixed,” the man said. “But it work okay.”

“Cool!” Michael repeated yet again, trying to figure out how he was going to get on this guy’s good side. He was encouraged by something he had learned from hanging with the Russians in the hospital, namely that Russians generally admired black men and black culture. It had to do with the ambivalence Russians harbored about America, giving weight to the adage, the enemy of my enemy is my friend. It was common knowledge in Russia that the United States historically had not done right by its African American citizens. “I have met some Russians in the hospital,” Michael added, again speaking slowly and loudly. “Who do you work for?”

The man quickly glanced around as if concerned someone might overhear. Michael took it as encouraging behavior, as if they were sharing a secret between them, but then the man did something Michael didn’t expect. Instead of answering verbally the man put down his laptop and briefcase, then took out his smartphone. He opened an app and began typing. When he was done, he held the phone out toward Michael so that Michael could read what was on the screen. On the upper portion was a paragraph in Cyrillic. Below, presumably a translation: “I work for Sidereal Pharmaceuticals in North Charleston.”

Michael nodded. It made sense. It was common knowledge that there was an ongoing relationship between Sidereal Pharmaceuticals and Middleton Healthcare. Not only had Sidereal funded a large portion of the Shapiro’s construction, there was talk about Sidereal, with its deep pockets, gaining a controlling interest in the hospital chain.

Michael took the man’s phone and quickly figured out how to type a message in English and have it appear below in Russian, and they began an electronic conversation:

Michael: My name is Michael Lamar Pender. I’m a fourth-year medical student. What’s your name and where are you from?

Vladimir: My name is Vladimir Malaklov. I am from Yekaterinburg, Sverdlovsk Oblast, Russia.

Michael: How long have you been in the United States?

Vladimir: Short time. I came to New York and then here three months ago.

Michael: Were you brought over here for a specific reason?

Vladimir: I am a specialist in the MUMPS computer language. The system here is coded in MUMPS.

Michael: It must be hard for you being here to communicate.

Vladimir: English is a struggle. I studied some in Russia before I came, but it hasn’t helped very much. I am trying to learn, but it is difficult.

Michael: Do you know any of the Russians who work in the hospital?

Vladimir: Yes. I know several from the same university where I trained. I am staying with one of them, which is difficult. He says that after all day he is tired of talking English, so I do not get to practice.

Michael: I’m about to finish medical school and have some free time. Maybe I can teach you some black-talk.

Vladimir: I do not understand. What is “black-talk”?

Michael: It is the way we African American sisters and brothers talk to each other. It’s like the words in rap music. You like rap?

Vladimir: I love rap music. Here, listen!

Vladimir changed the app, took out the second earbud, and handed both over to Michael. Michael held one of the buds close to his ear. He recognized the tune and the artist immediately. It was Jay-Z belting out “Hard Knock Life,” a piece Michael knew well.

Michael took out his own phone with an attached Beats headset, brought up the same tune, and handed the earplugs to Vladimir. Vladimir’s face quickly broke into a contented smile and his head bobbed to the beat. Michael wasn’t surprised. He knew that the quality of his headset was far superior to the one the Russian was using. It was like night and day.

Michael motioned toward Vladimir’s phone and pantomimed tapping the screen and then looking at it. At first Vladimir didn’t understand, but then caught on when Michael said: “English to Russian.”

Michael: The music is better with my headset.

Vladimir nodded and gave a thumbs-up, indicating he agreed. He was still bobbing to the percussive beat with a slight smile on his face. He was enjoying himself, and Michael was ready to reel him in.

Michael: I give you the headset as a welcome present to the United States.

Vladimir: I cannot accept. You are too kind.

Michael: You have to take it. You dishonor me if you don’t, and that would be a problem. In rap-talk we’d have a fucking beef, which means that I might have to shoot you, since everybody and his uncle packs a gun in this country.

Michael watched Vladimir’s face as he read the translation, wondering how the last sentence would be translated into Russian. He smiled inwardly, thinking that beef might be translated as steak or hamburger, neither of which would make any sense whatsoever. But a broad smile lit up Vladimir’s face. The Russian then typed into his screen before holding the phone up for Michael to see.

Vladimir: I accept with pleasure to avoid a fucking filet mignon, whatever that means, but you must accept a gift from me as well. I have some souvenirs I brought from Russia.

Michael after a good laugh: Whatever. Russian souvenir would be nice. How about a selfie with you and me?

Vladimir: I do not understand selfie.

Michael alternately pointing to himself and to Vladimir: A photo. The two of us. To demonstrate, Michael quickly snapped a selfie picture of himself and showed it to Vladimir. Michael wanted a photo of this Russian fellow, thinking that Lynn was not going to believe his meeting this guy.

Vladimir: Yes, photo, but with my camera as well.

Michael first held his own smartphone at arm’s distance, put his arm around Vladimir’s shoulder, and took a photo. Then Vladimir did the same. Michael took Vladimir’s phone back and typed into the translator app:

Michael: I also have a collection of all of Jay-Z’s albums on my PC that I can share, if you are interested.

Vladimir: Very interested.

Michael: How will I get in touch with you, say tomorrow or the next day?

Vladimir: I give you my mobile number and my e-mail address.

Michael: Perfect. And I will give you mine.

For the next few minutes the two men concentrated on getting each other’s information into their phone’s contacts. Michael noted that the country code for Russia was 7, followed by ten digits. He wondered how much texting the man was going to cost. Although Michael bolstered his meager finances with various jobs around the medical center, like working at the blood bank, by the end of the month he was always a bit short.

When he and Vladimir finished exchanging their mobile numbers and e-mail addresses, Michael pantomimed he had more to say. Vladimir brought up the translating app once again on his phone.

Michael: Pleasure to meet you. In black-talk we say good-bye as “catch you later!”

Vladimir: Okay! Catch later! And thank you for the headset.

With a broad smile on his face, Vladimir stuck out his hand and vigorously pumped Michael’s. When Vladimir let go, Michael balled the Russian’s fingers, did the same with his own, and then proceeded to bump fists with him.

“That’s how we black folks do it,” Michael explained.

Vladimir kept it up, nodding and smiling. “Catch you later,” he repeated in his accented, halting English.

“Cool,” Michael said with a laugh. The guy was a piece of work.

Vladimir picked up his laptop and briefcase from the ground and insisted on bumping fists again, which necessitated tucking his laptop under his arm to free up a hand. As he managed this, he never stopped smiling, obviously enjoying himself. Then, with a final wave, he turned and headed off in his original direction.

Michael deliberately waited until the Russian was about thirty feet away. Then he called out the man’s name and jogged toward him, struggling once more to keep his medical-student paraphernalia from flying out of his pockets. When he reached him, he motioned again that he wanted to use Vladimir’s smartphone translation app. When he got it he typed in:

Michael: I just thought of something. I have a distant relative who was taken into the Shapiro Institute a few months back. I haven’t heard anything about her and promised my mother I’d find out if she was still there and doing okay, but I haven’t been able to do it. When you go back into the institute, would you mind just finding out if she is still there so I can let my mother know.

Vladimir: I would need the name.

Michael: Ashanti Davis.

Vladimir: We could find out now if you would like.

Michael: I would be very grateful. Since I am not immediate family I haven’t been able to visit her. How could we check about her today?

Vladimir: We can go back into the institute, and I can quickly find out.

Michael: I can go in with you?

Vladimir: If you would like, but it is not necessary. It will only take a few moments. You can wait here if it is better for you.

Michael: I would be interested to come with you. I didn’t think I would be allowed.

Vladimir: Who is to know? There is rarely anyone in the institute’s NOC, or network operations center, and I know there is no one there now. The institute’s servers are also monitored in the main hospital NOC. I’ve been working in the Shapiro NOC for a month and haven’t seen anyone. The door that I came out leads directly to it.

Michael: I’m with you. Let’s do it!

Following a half step behind, Michael followed Vladimir back to the blank door. Just to the right of the frame, at chest height, was a small, hinged metal housing. Vladimir lifted the front. Beneath was a touch screen. Vladimir pressed his right thumb against it, and almost instantaneously a click sounded as the door unlocked. Vladimir pushed it open and motioned for Michael to follow. Michael was not impressed. He thought that the ultra-futuristic Shapiro Institute would have had something a bit more up to date than decade-old thumbprint security.

Beyond the door was a hallway. The walls were all white, and the hallway was illuminated by bright LED light behind translucent ceiling panels. As he walked, Michael’s eyes roamed the ceiling for signs of video devices. He saw what he thought had to be one in the middle of the ceiling, about twenty feet from the door. If it was one, Vladimir was unconcerned, although as someone knowledgeable about the institute’s IT system, he had to know about security. Michael shrugged. If Vladimir wasn’t worried, he wouldn’t be, either. Maybe over the years there had been no intrusions and they had become lax.

Pushing through the first door they came to, Michael found himself in a relatively small room housing four multiscreened computer terminals, each with a small work desk and an ergonomic chair. Like the hallway, the walls were all white and the illumination came from translucent ceiling panels. Opposite the door was a large window that looked into the server room, with its stacks of processors and storage devices. The room was air-conditioned to the point of feeling as cold as a walk-in refrigerator.

Without hesitation Vladimir sat down at one of the workstations, and Michael came up directly behind him. If Michael’s proximity looking over Vladimir’s shoulder bothered the Russian, he didn’t let on. Quickly the Russian typed in his user name, which Michael could see was his e-mail address. Then, as he was about to type in his password, Michael stepped to the side so he could see the keyboard. The password started with a 7, and Michael tried to concentrate on the series of digits. With his speed-reading forte, this was an exercise he was relatively good at. By the time Vladimir got to the sixth digit, Michael realized it was the dude’s mobile number. After eleven digits Vladimir switched to lowercase letters, the first one being M. Soon Michael recognized he didn’t have to remember that, either. The Russian was merely spelling out his last name. So much for tight security.

“Okay, we good,” Vladimir said as he navigated the task bar. When prompted, he typed in Ashanti Davis, which he had written out on a piece of scrap paper before logging in. A second later Ashanti’s home page came up: Cluster 4-B 32. Beneath that was: DROZITUMAB +4 ACTIVE. “She still here,” the Russian said.

“Right on!” Michael said, looking at the screen, wondering what Cluster 4-B 32 meant as well as the meaning of drozitumab +4 active. Taking the initiative, Michael reached out for the mouse and moved the cursor to HEALTH STATUS on the menu bar and clicked. He then clicked on VITAL SIGNS in the drop-down. A second later he and Vladimir were looking at an active graph of the woman’s vital signs, which were being followed in real time. Blood pressure, heart rate, breathing rate, oxygen saturation were all within normal range.

“Seems she is still in the game,” Michael said. Without giving up the mouse, he went back to the drop-down menu under HEALTH STATUS and clicked on COMPLICATIONS. A moment later he and Vladimir were looking at a list of problems — some active, some solved. What jumped out at him among expected conditions like BACTERIAL PNEUMONIA/CURED, CYSTITIS/CURED, was the ominous diagnosis of multiple myeloma. Michael knew that it was a serious type of blood cancer seen more often in African Americans than among Caucasians, but more in males than females and very rarely in young people.

Michael pulled out his cell phone and made a motion as if to use it to take a screen shot. He treated Vladimir to a questioning expression with the explanation: “So I can tell my mamma how she is doing.”

Vladimir seemed to understand the gesture. Responding with a shrug he said: “Okay.”

Michael took the shot and checked to see if it came out adequately enough to read. It seemed to be fine. He would have liked to look at more of the record, but didn’t want to push his luck. He had already accomplished far more than he could have dreamed of a half hour previously, and he surely did not want to alienate his new Russian buddy.

“We go?” Vladimir questioned.

Michael responded with a double thumbs-up. He couldn’t believe his luck. Lynn was going to be shocked.

12

Monday, April 6, 11:48 P.M.

As far as Darko Lebedev was concerned, the weather had totally cooperated. Although it had been a bright, clear spring day, early evening had witnessed a sudden change. The wind had shifted, blowing in moist, tropical air from the south that quickly turned into a dense fog. Now, as Darko looked out the windshield of the nondescript Ford van, he could see swirls of vapor enveloping the trees and scrubs around the target house, 1440 Bay View Drive. The moon was conveniently blotted out. The circumstances couldn’t have been more perfect for what was about to happen.

Darko and his partner, Leonid Shubin, had driven about twenty miles north from Charleston earlier that evening to a town called Summerville, where they stole the van they were now using. It was dark blue with no markings whatsoever, which was the reason they had selected it. From Summerville they had driven to Mount Pleasant and had made a few drive-bys of the house they had targeted, to check it out. It was the last residence on a dead-end street, with only one way in and one way out, the single minor complication for what they were planning: a home invasion.

After their last drive-by a half hour earlier, they had pulled over to the side of the road in front of the closest neighboring house and killed the engine. They were waiting for signs that the family was in the process of turning in for the night. They didn’t have long to wait.

“The lights just went out in what must be the master bedroom,” Leonid said in Russian. Both men had become adept at English, as they had been living in the Charleston area for a bit more than five years, but when they were alone, they preferred Russian. They had known each other for almost fifteen years, having met as members of the Russian Spetsgruppa “B” Vega, in which they had served almost ten years in Chechnya, where they had done dozens of home invasions. They considered the process their specialty. In the north Caucasus, suspected terrorists were simply eliminated along with their families without any attempt at due process. It was the Russian way of dealing with what they labeled terrorism.

“Go!” Darko barked in Russian. Both men leaped from the van. They had been ready to move for almost an hour. They were dressed in black jumpsuits and black cross-trainer shoes. They carried everything they needed, including stun grenades and Russian-made AF-1 automatic pistols with noise suppressors. As they exited the vehicle, both pulled their black balaclavas down over their faces and activated their night-vision goggles. They were thrilled to be doing what they had been highly trained to do. In their minds they had been underutilized since their arrival in America.

Darko, the larger of the two, was in the lead as the men ran up the driveway, past the Mercedes sedan parked outside the garage, and up the walkway toward the front door. Both were in superb physical shape, working out and biking or running every day. As planned, Darko went to the right of the door and Leonid to the left. With practiced efficiency Leonid placed a small C4 explosive charge in the angle between the door and the jamb just to the side of the doorknob.

After a nod from Darko, Leonid detonated the charge. The report seemed loud in the silence but was not much worse than the bursting of a birthday balloon. In the next instant, both men were inside the house. It was key to incapacitate the adults as soon as possible and then deal with an alarm if there was one. In Chechnya, alarms were few and far between, but they did go off every now and then. Even if an automatic phone call was made to security people, they weren’t particularly bothered. They would be long gone before anybody came to the house to check. If there was no alarm system or if it was off, then they could take their time and enjoy themselves.

Having observed the house during their drive-bys, they had a reasonable idea of its layout. From their observation of the persistent light in one of the windows on the second floor, especially during the last half hour, they assumed that that was where the master bedroom was located. Accordingly they went directly up the stairs in a headlong rush with pistols at the ready. There had been no sound of an alarm as they breached the front door. A few seconds later they burst into the bedroom.

The king-size bed was directly across from the door to the hall. Kate and Robert Hurley were sitting up in bed, totally startled, with eyes thrown wide open and mouths agape.

Darko found a light switch and turned on a small crystal chandelier.

When Kate Hurley caught sight of the Russians, she gasped. Darko pushed up his night-vision goggles.

“What is this?” Robert Hurley shouted. “What the hell is going on?”

Darko didn’t answer but rather nodded to Leonid. Everything was going according to plan. An instant later, Leonid was back out the door. It was his job to take care of the kids. The assassins had been told there were two boys.

“How dare you!” Robert snapped, trying to sound authoritative. Kate gripped his arm to get him to shut up, but it didn’t work. “What the hell is a SWAT team doing in our house?” he demanded.

Darko still didn’t answer. Instead he looked at the alarm system’s keypad on the wall to the right of the door. It was in the off position. They could take their time.

Robert threw back the bedcovers and started to get out of bed.

Darko leveled his automatic at him and told him in a heavy accent, “Stay put!”

“Where are you from?” Robert demanded angrily, but he followed orders. He’d never had a gun pointed at him. It was unnerving, to say the very least. “Are you police or what?”

The next instant there were two loud thudding noises that sounded like someone hitting a couch with a baseball bat. Darko knew what the sounds meant, but the parents didn’t. A moment later Leonid reappeared and merely nodded to Darko, meaning the job was done.

“Where is your computer?” Darko asked.

Robert glanced at his wife with a questioning expression as if to say “Can you believe these guys?”

“And do you have a laptop? What about a tablet? And your mobile phone: we want them all.”

“Is that what this is about?” Robert demanded. He was incensed. “You people came in here to steal our computers? Fine! Take them!”

“Where are they?” Darko asked, keeping his voice calm. Things were going well and he didn’t want to upset Robert unnecessarily. They needed his cooperation.

“Downstairs in the study,” Robert said.

“Show me!” Darko said. He motioned toward the door with his pistol.

“I’ll be right back,” Robert said to Kate as he climbed out of bed, put on a bathrobe, and guided his feet into slippers. He gave Darko and Leonid a dirty look as he passed them, heading out into the hall.

“Have fun!” Darko said to Leonid in Russian as he turned and followed Robert. Before they had come into the house they had flipped a coin to decide who did what. The loser had to do the kids, but as compensation he also got to do the wife. The point was that they had to make it all look like a horrid home invasion and not an assassination. Akin to a number of infamous episodes, the last one being in Connecticut, violence was key, including rape and murder with robbery as an afterthought. It was important to convince the media.

“I intend to have fun,” Leonid said also in Russian. “It’s not going to be hard. She’s not bad-looking.”

Darko followed Robert down the stairs and into the study, where Robert switched on the light. He gestured to his PC on the desk.

“What about the laptop, the tablet, and the smartphone?” Darko said.

Without comment, Robert left the study and went into the kitchen. Darko followed, pistol in his hand but at his side. He didn’t expect Robert to try anything, but he seemed less intimidated than the people Darko and Leonid had dealt with back in Chechnya. Of course in Chechnya people knew what was going to happen, and Robert didn’t.

With all the electronic gear in his hand, Robert was forced to return to the study, where Darko made him sit down at his PC on the desk.

“I want you to access your files at your office,” Darko said. He again used the pistol to gesture.

“You’re joking,” Robert said. His expression was of complete disbelief.

“No joke,” Darko said. “Do it!”

Robert eyed the gun in Darko’s grip. Hesitated for a moment then did as he had been told.

Darko watched the screen over Robert’s shoulder. “Now,” Darko said, his voice still calm, “I want you to find and delete all files and documents you have relating to Middleton Healthcare and the Mason-Dixon Medical Center, both in your office and on this machine.”

“Okay,” Robert said. He was flabbergasted and began wondering who could be behind this bizarre situation. There was a bit more than a week’s worth of work involved on the class-action case, but he was confident he could put it all back together rather easily because he remembered all the sources. With that in mind, he did as he was told without hesitation. When he was finished he looked up at Darko. “All done,” he said flippantly, as if he didn’t care.

“Not all done,” Darko said. He pointed with the barrel of his gun toward the other electronic devices. “All documents and all files off all devices.”

“You and your bosses are too much,” Robert said with a shake of his head. “Who exactly has put you up to this? Let me guess: Josh Feinberg, the CEO of the medical center? This is fucking crazy. Yet it’s okay. I don’t mind.” Robert first turned his attention to his laptop. When that was done, he picked up his smartphone. “There!” he said when he was completely finished. He tossed the phone onto the desk. “Nothing’s on the tablet. I hardly use it except to play games. That means all Middleton Healthcare and Mason-Dixon Medical Center documents and files have been deleted. I hope you are happy.”

As someone reasonably competent with computers and other electronic devices, Darko was quite sure Robert was telling the truth, so he was “happy,” although satisfied would have been a better description. He reached over in front of Robert and moved the laptop and smartphone to the side. Just as Darko did so, a scream came from upstairs, followed by a dull thud similar to the one Robert and Kate had heard before, when Leonid went to take care of the kids.

Robert’s eyes shot up as if he thought he could see through the ceiling. “What the hell?” he demanded as he started to get to his feet.

Darko didn’t answer but rather raised his pistol and pointed it at Robert’s face. The sound it made was more of a hiss than a bang. Robert’s head snapped back, and his body went limp in the chair, arms dangling to the side. A red dot the size of a marble appeared in the middle of his forehead, just between his eyes.

Quickly Darko went through the desk to find objects worth taking besides the laptop and the smartphone. It was important to make the event seem like a burglary. Leonid appeared a moment later, zipping up his jumpsuit.

“How was it?” Darko asked, reverting to Russian as he picked up the electronic gear to carry it out to the van.

“I like young Chechen girls better,” Leonid said. “More fight. Maybe you want to run up and take a turn. She’s still warm.”

“Fuck you,” Darko said. He flashed his partner a middle finger. “Did you remember to look for any jewelry?”

“Yes, and I found some. Not a lot, but I got what I could, including the lawyer’s wallet and his Rolex.”

“That should be enough. Let’s get the hell out of here!”

13

Tuesday, April 7, 5:45 A.M.

At first Michael tried to incorporate the thumping sound into a very enjoyable dream, but it didn’t work. Reluctantly he acknowledged that someone was intermittently knocking on his door. “Shit,” he said under his breath.

Assuming his tormentor was not going to go away, Michael swung his legs out from under the covers and glanced at the clock. It wasn’t even six, and the dermatology lecture wasn’t going to start until nine. “Shit,” he repeated, hoisting himself to his feet. He couldn’t imagine who could be disturbing him or why. Despite being clad only in skivvies, he threw the door wide open. To his surprise he was face-to-face with Lynn, who was sporting an exasperated expression that it had taken him so long to open the door. She was the last person Michael had expected to see.

The evening before, Michael had checked Lynn’s room on several occasions to see if she had returned. Her room was only three doors down the hall from his. When she hadn’t appeared by eleven P.M., he had thought about calling or texting to make sure she was okay. He was also eager to tell her about his serendipitous meeting up with Vladimir and getting into the Shapiro Institute. But by then he assumed she was going to spend the night at Carl’s and worried that she might already have been asleep or at the least needed some private time. After all, she had Michael’s mobile number if she had wanted contact.

“We need to talk!” Lynn said. She pushed past the surprised Michael and threw herself into Michael’s desk chair, turning on his desktop gaming computer. She was sporting a fresh white medical student’s coat.

“Why don’t you come on in and make yourself at home,” Michael said sarcastically.

“I want you to read an article, but first get your ass in the shower or whatever you do when you wake up. We need to check on Carl, and then go get some breakfast. I’m famished. I didn’t have anything to eat last night.”

“Nothing? Why not?”

“I was too busy. I learned a lot of shit that I want to throw at you. So get a move on!”

“Yes, sir!” Michael said, saluting. Michael’s father, of whom he only had the dimmest recollection, had been in the Marines, and was stationed at Parris Island, about five miles away from Beaufort, where Michael had grown up. He had only been four when his parents parted ways, but he still remembered his father saluting him on occasion as if he too were a Marine.

Michael quickly showered, shaved, and dealt with his hair, which didn’t need much attention. When he reemerged from the bathroom, Lynn was at the window, tapping her foot. It was apparent she was juiced and impatient and couldn’t have cared less that Michael was butt naked, save for his shower towel. He went to his bureau, got out clean drawers and socks, and then went to the closet for the rest of his threads and kicks. When he was finished, he informed Lynn, who seemed mesmerized by the view across the harbor to Mount Pleasant, as if she had never seen the same panorama from her own room for almost four years.

“The article I want you to read is on your screen. Read it quickly and then let’s jet over to the hospital.”

Michael could tell that Lynn was in no mood to argue, so he took his seat and started reading. He was aware that Lynn had come up behind him, looking over his shoulder.

The article had the Scientific American logo at the top, which lent it strong credibility. Michael was well aware that the main trouble with the Internet was often not knowing the sources of material and hence its veracity. This article, however, was most likely legit. The title of the relatively short piece was “How Many Die from Medical Mistakes in U.S. Hospitals?” He was finished in less than a minute, and he looked up at Lynn.

“Oh, come on,” Lynn said. “You can’t be finished already.”

“Slam dunk,” Michael responded.

“Okay, smart-ass! What’s the upper limit of estimated deaths for people going into U.S. hospitals each year and suffering a ‘preventable adverse event,’ a euphemism if ever I heard one? They should call it like they did in the title: a goddamn mistake!”

“Four hundred and forty thousand,” Michael said without hesitation.

“Geez!” Lynn complained. “How the hell do you read so fast and still remember everything? That’s discouraging for us mortals.”

“Like I told you, my mamma taught me.”

“Mammas don’t teach that kind of skill. But regardless. Don’t you find that statistic startling and embarrassing? Like the article says, that would make deaths from hospital errors the third leading cause of mortality in this country.”

“So let me guess. You are now convinced that Carl suffered a mistake, or more accurately, a major screwup. Is that what I’m reading between the lines?”

“Of course!” Lynn said. “A strapping, athletic, healthy twenty-nine-year-old male has a simple knee operation and ends up in a coma. Somebody fucked up big-time, and if Carl doesn’t wake up, he’s going to change the statistic you just quoted to four hundred and forty thousand and one this year, and that’s after a routine ACL repair!”

“Sweet Jesus, Lynn, you’re jumping to conclusions. It’s not even twenty-four hours, and Carl is sure as hell not dead. Maybe when we go back, he’ll be sitting up in bed, taking nourishment, wondering how the hell Monday disappeared.”

“Wouldn’t that be nice,” Lynn said sarcastically. “The neurology resident thinks there was extensive brain necrosis. I hate to say this to burst your bubble, but Carl’s not going to be sitting up having breakfast this morning.”

“Medicine is an imperfect science. If we’ve learned anything over the last four years, it’s that. Everybody is unique according to their DNA. Maybe Carl reacted negatively in an unexpected way to the anesthesia and whatever else he was given. Maybe there was a mistake but maybe not. Maybe the anesthesia machine malfunctioned. Maybe a thousand things, but it wasn’t necessarily a medical error.”

“I think the anesthesiologist fucked up somehow,” Lynn said. “My intuition tells me this is a ‘people’ problem just like the article suggests, not an idiosyncratic reaction or a technical problem. Mistakes are made by people.”

“That’s a possibility, too. But there are lots of possibilities. There are system mistakes as well as people mistakes. Even computers make mistakes.”

“Well, I can tell you this,” Lynn said with conviction bordering on anger, “we are going to find out what happened, meaning who screwed up, and we are going to see that they are held accountable so it doesn’t happen again.”

“Hold on a second!” Michael said with a wry smile. “What do you mean we, white man?” It was the punch line for the only joke Ronald Metzner had told during medical school that Michael had found truly funny. It was about the Lone Ranger and his Native American sidekick, Tonto, when the two of them found themselves caught in a box canyon, surrounded by a slew of bloodthirsty Indians intent on doing them in. The punch line was Tonto’s response to the Lone Ranger saying: “It looks like we are in deep shit.”

For a second Lynn was silent, hardly in the mood to respond to being reminded of one of Ronald’s stupid jokes. She was disbelieving and crestfallen at Michael’s attitude. “Aren’t you as pissed off about Carl’s condition as I am?” she demanded.

“My point is that in many respects it is a little early in this developing tragedy to go off the deep end, making all sorts of assumptions.”

“Well, I don’t know about you,” Lynn said, “but I can’t sit around on my butt, waiting for Carl to wake up, which I don’t think he is going to do, and let the trail go cold. I’m going to find out what happened, and I’m not going to rest until I do. I owe that to Carl. The way I got to where I am today is by being a ‘doer,’ just like you, I might add.”

“Listen! I can understand your feelings,” Michael said. “You have every right to be pissed. But as your friend and probably your closest friend, I have to try to rein you in. You could be jeopardizing your medical career. No one is going to take kindly to your efforts. Everybody is going to be touchy about this affair. And to make matters worse, let me remind you, violating HIPAA under false pretenses, which we have done, is a class-five felony. You’re going to be going for bad, girl. You know what I’m saying?”

“Are you finished?” Lynn asked, arms akimbo.

“For now,” Michael said. “Let’s get our asses over to the cafeteria. I think your blood sugar must be zero and it’s affecting your good sense.”

For a few minutes, Lynn held her tongue, but in the dorm elevator she was back at it. “I find it extraordinary that we as medical students have been given so little information about hospital mistakes. And errors resulting in death are just the tip of the iceberg. Think of all the patients who go into the hospital for one thing and come out with another, totally different major health problem. That statistic is over a million. That’s obscene.”

“I don’t find it so surprising that such statistics are not ballyhooed,” Michael said. “A lot of hospitals, including this one, are owned by for-profit companies. Even the so-called nonprofit hospitals are money mills in disguise. That means there’s a built-in conflict of interest situation to avoid publicizing such statistics, like so many things in health care. Hospitals don’t want to talk about their shortcomings. We fledgling medical students are still under the delusion that medicine is a calling whereas, if truth be told, it is a business, a big business, and not a fair business from the public’s perspective. Most everybody is mainly out to make a buck.”

“I didn’t realize you were such a fucking cynic,” Lynn said.

“As a black man trying to break into an overwhelmingly white man’s profession, I have had to be a realist!”

“That’s fine, dude, but it’s the kind of attitude that makes change impossible.”

Michael smiled. “You outta control, girl.”

“I’m angry,” Lynn admitted. She took a deep breath. “I’m sorry if I sound like a bitch. I’m really having a problem with this and learning what I have learned. I knew there were problems with American health care but not this bad.”

“That’s cool, Blondie, but you have to chill, at least in the short run.”

“I don’t see it that way. I’m going to find out what happened.”

“Let’s get you some vittles. Your cerebrum isn’t working much better than Carl’s, and I’ve got some interesting shit to tell you about.”

14

Tuesday, April 7, 6:12 A.M.

The sun was threatening to rise within the hour as Lynn and Michael exited their dorm building. It was promising to be another gorgeous spring day, with not a cloud in the pastel inverted bowl of the gradually lightening sky. But the fabulous weather was lost on Lynn, as her mind was churning. She had already decided for sure that if Michael wouldn’t help her find out the truth about Carl’s disaster, then she would do it herself. It was an absolute must to keep her demons at bay.

“You know what else I learned last night?” Lynn said. She had to talk louder than normal to compete with the cacophony of the birds announcing the coming dawn.

“I’m afraid to ask,” Michael responded.

“The usual major-complication rate for anesthesia for a healthy patient is one in two hundred thousand surgeries. If we take only your relative, Ashanti Davis, and Carl, that’s two in about five thousand cases, considering that about one hundred surgeries are done here per day. Do you know what kind of multiple that means?”

“I guess a lot,” Michael admitted. Doing math in his head was not one of his strong suits.

“It’s eighty times the normal. Eighty times! And we don’t even know if there weren’t others, which would make it even worse.”

“Speaking of Ashanti,” Michael said, no longer able to keep his news to himself. He could tell Lynn was getting juiced all over again. “I found out she is still hanging out in the Shapiro Institute with normal vitals but a bad diagnosis of multiple myeloma.”

“How the hell did you find out?”

“A strange way,” Michael said. “Yesterday afternoon I ducked out of the ophthalmology lecture, which was shit, by the way. Just a neuro-anatomy review, so you didn’t miss anything. On my way back to my room to look for the JPEG of Ashanti’s anesthesia record, I ended up in the Shapiro Institute.”

Lynn stopped in her tracks, looking at Michael as if he had just told her he had dined with the pope. “How in God’s name did you manage that?”

Michael laughed. “I got into a little one-on-one with a Russian dude who’s only been over here for a couple of months. He’s a computer wonk brought here to fix a glitch or two in the Shapiro computer network. He came out the Shapiro door just as I was eyeballing the place.” Michael pointed to the door in question.

“And you just started a conversation out of the blue?”

“It wasn’t much of one. The dude can’t speak English worth shit. We communicated with a Google translation app on his smartphone. But I knew you might not believe me, so I took a selfie.” Michael got out his phone and pulled up the photo. “He’s been working in the Shapiro network operations center.”

Lynn took the phone and studied the photo. “Which one is the Russian?” she asked.

Michael grabbed his phone back and pocketed it. “Smart-ass!”

“Did you get to see Ashanti?”

“Hell no! I just saw the inside of the Shapiro network operations center and a couple of pages of her Shapiro electronic medical record.”

“And you are warning me about HIPAA violations,” Lynn said wryly.

“Hey, I didn’t hack the system. The Russian dude logged in legit.”

“You merely asked him, and he agreed.”

“I buttered him up a bit,” Michael admitted. “I gave him a Beats headset and told him I’d be willing to share my Jay-Z music file. I figured he had admin status with the network and could check out Ashanti sometime. I never expected him to invite me into the place on the spot.”

“Did you get his name? God! He could be so useful.”

“Vladimir Malaklov. I also got his e-mail and mobile number.”

“Fabulous! But wasn’t he concerned about security issues?”

“Didn’t seem to be. My guess is that he knows that security inside the institute is lax. I mean, I saw a video cam in the ceiling outside the NOC, but it didn’t bother him when we walked under it. Maybe he knows no one is watching the feed. And he said he has never seen another person in the network operations center the whole time he has been here.”

“Strange,” Lynn said. “I had the feeling that security was important for the Shapiro. That was what they implied during our tour, and the place is built like a bank vault.” She glanced at the massive but squat granite structure with not a window in sight from where they were standing.

“Maybe security was big in the beginning, but since there haven’t been any problems over the eight or so years it has been in operation, they’ve let things slide. Even security for the outside door isn’t much. Thumbprint touchscreen access. That technology is really out of date.”

“So how did you learn she has multiple myeloma?”

“Vladimir brought up her home page, and I got to click on her health status and then vital signs and complications. I would have liked to look further, but I knew I’d be pushing my luck. I did take a screen shot of her complications page.”

“Let me see it!”

Michael pulled out his phone again and brought up the image. Lynn tried to examine it. “It’s a bit hard to read out here.”

“It’s better indoors,” Michael agreed.

“I can’t believe you managed this,” Lynn repeated.

“Her home page had Cluster 4-B 32.”

“I see. What does it mean?”

“Not a clue. The home page also says drozitumab plus four active. I didn’t know what the hell drozitumab was but looked it up last night. Drozitumab is a human monoclonal antibody used to treat cancer.”

“Maybe that is what they are using to treat her multiple myeloma.”

“I doubt it,” Michael said. “In the articles I read, it was developed for a type of muscle cancer.”

“Then I don’t know what it refers to,” Lynn said. She handed the phone back to Michael. “But tell me: didn’t this Vladimir have any concerns about patient confidentiality?”

“No. My sense is that he knows zip about our HIPAA rules. They probably don’t have anything like that in Russia. He doesn’t even have a secure user name or password that anyone who knows a few details about him couldn’t figure out. His user name is his e-mail address, and his password is his mobile number combined with his family name.”

“You amaze me. You sure you weren’t trained by the CIA?”

“You could have done the same thing. I’m telling you: he wasn’t concerned about security. I was standing there in full view of what he was doing while he typed in his user name and password. He didn’t give a shit.”

“So Ashanti is still in a coma,” Lynn said as she started walking again.

“Must be ’cuz she’s still in the Shapiro,” Michael said, falling in beside her.

“You didn’t learn anything about her coma, looking at her EMR? What a missed opportunity.”

“I’m telling you, I didn’t want to push him or my luck on the first go-around.”

“I’m not criticizing. It’s amazing you learned what you did.”

“I was surprised myself,” Michael admitted. “And I’m planning on hitting him up again.”

As they approached the door to the clinic building, Lynn asked, “What about the photo of Ashanti’s anesthesia record? Did you find it?”

“I did,” Michael said. “It was in my photo folder on my desktop. As I said, it looked a lot like Carl’s, but I want to print them both out so that I can really compare.”

“I’m eager to see it when you do.”

“I’ll think about it,” Michael teased.

They walked through the mostly deserted clinic. The only people they saw were housekeeping, polishing the floor and wiping down the chairs with antiseptic.

When Lynn and Michael crossed the connecting pedestrian bridge and entered the hospital proper from the clinic building, they were immediately enveloped in a crowd. Although the clinic was still closed, the hospital itself was a different story. Another busy day was already in the making.

As Michael headed toward the cafeteria, Lynn went in the opposite direction, toward the elevators. Michael was the first to notice their cross-purposes, and he turned, caught up to Lynn, and pulled her to a stop. People jostled them as they stood in the middle of the main hospital corridor. “I thought we were going to the cafeteria,” he said. He had to speak louder than usual over the general din.

“We need to check on Carl first,” Lynn said. “This is the best time. The shift will be changing, and they will be less likely to question our presence.”

“Good point,” Michael conceded. “But your blood sugar? You sure you can hang in there?”

“I’ll be fine,” Lynn assured him. “Come on!”

They started toward the elevators. It was difficult to stay together. Lynn talked to him over her shoulder. “Even with the shift changing in the ICU, someone might say something to us. If they do, let’s use the anesthesia explanation you came up with yesterday. I thought it was brilliant. But to lend it more credibility, we should put on scrubs and look the part.”

“Now, that’s slick,” Michael agreed. Instead of joining the throng waiting for an elevator, they went to the stairs. In the surgical lounge they separated.

As Lynn entered the women’s locker room, it was still well before seven, yet it was a busy place. Most of the women donning scrubs were nurses just coming on duty. The surgeons scheduled for seven-thirty cases wouldn’t arrive until around seven-fifteen, after making rounds on their post-op patients. Lynn found an empty visitors’ locker, and as she began to unbutton her blouse, the intercom crackled to life from a ceiling-mounted speaker. Since everyone had mobile phones, it wasn’t used much. The voice belonged to the head nurse out at the main desk in the OR: “Dr. Sandra Wykoff! This is Geraldine Montgomery. Are you in the changing area?”

“I am,” Dr. Wykoff said, talking loudly and directing her voice up toward the ceiling. As a courtesy, the buzz of voices coming from the other women in the room quieted.

Lynn turned around. The name provided instant recognition. Sandra Wykoff had been the anesthesiologist on Carl’s case. Lynn stared at the woman, who was no more than five or six feet away. She was petite, a good six inches shorter than Lynn, with small, sharp features and mousy hair, who nonetheless projected an intensity of purpose. Her bare arms were thin but muscular, making Lynn think she kept herself in shape, something that Lynn did as well. It was Lynn’s immediate impression that Sandra Wykoff was not someone easily intimidated despite her short stature.

“Dr. Wykoff,” Geraldine continued over the intercom, “you must have your mobile ringer turned off. I have Dorothy Wiggens from Same-Day Surgery Admitting on the other line. They have been trying to contact you.”

Lynn watched Wykoff fish her phone from her pocket and check it, “You are so right,” she said. “Apologize for me!”

“It isn’t a problem, except they wanted to let you know your first case has been canceled. The patient forgot her pre-op instructions and had a full breakfast.”

“Okay, I got it. I appreciate your letting me know.”

“We’ll let Dr. Barker, your second case, know as well. It is now scheduled for late morning. Maybe it can be moved up. We’ll keep you informed.”

“That would be terrific. Thank you.”

As if on cue, the moment the intercom clicked off, the murmur of other conversations in the locker room recommenced.

Dr. Wykoff looked over at Lynn, who was regarding her with a wide-eyed gaze. “Better to find that out in admitting rather than up here in the OR,” Dr. Wykoff said to make conversation.

“I suppose,” Lynn answered. She looked away, suddenly realizing she had been staring. What to do, was the question. It seemed much too serendipitous not to take advantage of this fortuitous meeting. She had spent a number of hours during the night reading up on standard anesthesia procedure, so she felt confident she could hold up her end of a technical conversation about Carl’s case. Yet was this the time and the place to bring up what would undoubtedly be a touchy subject, as Michael had reminded her? Lynn donned her white coat over her scrubs and closed the locker in which she had put her clothes. Impulsively she decided to give conversation a try. “Excuse me, Dr. Wykoff,” she began, still unsure of what she was going to say, especially while struggling to keep her emotions in check.

After closing her own locker, Dr. Wykoff directed her strikingly bright blue eyes at Lynn.

“I understand you were the anesthesiologist attending Carl Vandermeer yesterday,” Lynn said.

Instantly Dr. Wykoff’s eyes narrowed and bore into Lynn’s. She didn’t respond immediately but proceeded to look Lynn up and down, as if appraising her. She then warily nodded and said: “I was the attending. Yes. Why do you mention it?”

“I read your note in the chart in the neurology ICU yesterday. I need to talk to you about the case.”

“Really?” Dr. Wykoff questioned with a whiff of guarded incredulity. “And who are you?”

“My name is Lynn Peirce. I am a fourth-year medical student.” She specifically avoided making any reference to why she had been in the neuro ICU and why she had been looking at the chart. She knew that the excuse of being on an anesthesia rotation wouldn’t play with an anesthesia attending.

“Why exactly do you want to discuss this unfortunate case?” Dr. Wykoff asked warily.

“I’ve learned that a million people a year go into a hospital with one complaint and then end up with another serious medical issue they didn’t have before being admitted. I think it is an important issue that we medical students aren’t taught. The Vandermeer case might apply.”

“I suppose we could talk,” Dr. Wykoff said as she relaxed a degree. “But this is not the time or the place. You heard that my seven-thirty case has been canceled. If my next case is not moved up, I suppose I could speak with you this morning.”

“I would appreciate it,” Lynn said. “How will I get in touch with you?”

“Ask Geraldine at the OR desk. She’ll know where I am.” Then the anesthesiologist walked out.

15

Tuesday, April 7, 6:33 A.M.

Michael pulled his medical student white coat over his scrubs. When he emerged from the men’s locker room, he didn’t want to hang out in the surgical lounge for fear of getting into a conversation with someone who might feel obligated to ask what the hell Michael, as a fourth-year medical student, was doing in scrubs. Instead he went out into the hall by the elevator to wait. He didn’t have to wait long.

“Of all people, I bumped into infamous Dr. Sandra Wykoff,” Lynn said in a forced whisper when she appeared. As usual, there were other people waiting for an elevator. “She was changing right next to me.”

“And who might Dr. Wykoff be?” Michael asked, his voice rising for effect.

“Oh, come on!” Lynn complained irritably. “She was Carl’s fucking anesthesiologist, who was responsible for what happened. How could you forget?”

“I’m trying to make a point, my dear. You don’t know that she was responsible. That’s the kind of comment that is going to get you in a whole shitload of trouble.”

“Technically you’re right,” Lynn snapped. “But she was in charge when whatever happened happened. There’s no denying that. If she didn’t cause it, she could have stopped it or prevented it.”

“You don’t know that, girl. I’m telling you straight. You are going to crash and burn.”

The elevator doors opened. The car was full. Lynn and Michael and several others had to squeeze on as people reluctantly made room. The two students didn’t try to talk as the elevator rose, stopping on each floor. Once they got out on the sixth floor they walked slowly and let the other people who had gotten out pass by. Most were nurses and nursing assistants who were coming in for the morning shift.

“Wykoff’s first case for today was canceled,” Lynn said when she was sure no one would overhear. “She agreed to talk to me, provided her second case doesn’t get moved up.”

“I better come along just to keep you in line,” Michael said. “You are on a self-destructive roll.”

“Do you really want to come along?” Lynn said with a touch of disdain. “I thought you weren’t going to help.”

“Like I said. Somebody’s got to protect you from yourself and make sure you cut this woman some slack, you know what I’m saying?”

As they got closer to the neuro ICU, Lynn’s pulse began to rise and her anxiety ratcheted upward. If there had been a change in Carl’s status, she would not have heard one way or the other, as she wasn’t in the immediate family loop. Although she expected little change, she knew there was a slight chance that he could be better or worse. Unfortunately, with a provisional diagnosis of extensive brain necrosis, his chances of improvement were mighty slim, which left the downside much more probable.

Outside the double doors, Lynn hesitated out of worry about what she was going to confront. Michael sensed her reluctance. “You want me to go in and see what’s up?” he suggested. “Then I could fill you in.”

“No,” Lynn said. “I want to go in and see him. I’ll be all right.”

As Lynn and Michael had hoped, the nurses were busy at rounds. As the door closed behind the medical students, they could see that the nursing team going off-shift and the team coming on were all congregated in bay number 5, going over a new arrival. For the moment all the other patients, including Carl, were on their own.

At the central desk, the ward clerk, Peter Marshall, was already on duty, watching over the monitor feeds. His day had already begun, even though technically it wasn’t supposed to begin until seven. Lynn remembered that had never bothered Peter. He always arrived early to get a jump on the day.

A female attending physician was also at the desk, busy at work with a number of charts stacked in front of her and one open. Lynn and Michael could tell from her long white professorial coat that she was an attending, and not a resident. They didn’t recognize her.

The medical students went directly to cubicle 8, with Lynn lagging slightly behind, afraid of what she was going to see. Carl wasn’t sitting up having breakfast, but he wasn’t dead, either. He looked as serene as he had the day before, with his eyes closed, as if asleep. He was still in the exact same supine position, with the CPM flexing and extending his operated leg. His IV was running as it had been, but it had been repositioned as a central venous line and now went into his neck.

“Looks generally about the same as yesterday,” Michael commented. Lynn nodded, restraining herself from reaching out to touch Carl’s face. She noticed that his beard had darkened, and as her eyes traveled down his body, she observed that both arms were now relaxed. Apparently the decorticate posturing was gone. Whether that was a good sign or not, Lynn had no idea. The myoclonic jerks of his free leg had also stopped.

In order to look as if he were on a legitimate mission, Michael took out his penlight and tried Carl’s pupillary reflexes. While he was busy, Lynn glanced up at the monitor. She didn’t want to look into Carl’s unseeing eyes again, as doing so had unnerved her the day before. She saw that the blood pressure was normal as was the oxygen saturation. The ECG looked normal to her as well. It was then that she spotted the temperature graph. Carl had a fever of 103 degrees, and it had been as high as 105! She knew that wasn’t good news.

“Pupillary reflexes are better than yesterday,” Michael said, straightening up. “I wonder if that is a good sign.”

“His temperature is elevated,” Lynn said with concern, pointing up to the monitor.

“So it is,” Michael said after taking a look. “That can’t be good.”

“It’s not,” Lynn said. “Pneumonia is a big threat to people in a coma. I learned that last night.”

“You got that right. Sounds like you learned a lot in one night.”

“It is amazing what you can get done if you don’t eat or sleep.”

“Then let’s get you down to the cafeteria before you flatline.”

“Let’s check the chart first. I want to see the results of the MRI he was supposed to have had.”

Leaving Carl’s cubicle, the duo walked directly toward the central desk. As they traversed the room, Lynn made momentary eye contact with Gwen Murphy, who had moved on to cubicle 6, along with all the other nurses. Fortunately Murphy’s expression didn’t change. For Lynn, being an interloper was a nerve-racking experience. She was impressed that Michael seemed to be taking it in stride.

At the circular desk, Michael smiled at Peter, who smiled back. The clerk was on the phone with Clinical Chemistry, trying to get the latest lab values before they were even in the computer. The attending physician didn’t look up from her work. The stack of charts was still in front of her.

As he had done the previous day, Michael went directly to the circular chart rack and gave it a decisive spin. He stopped it at the slot for cubicle eight. There was no chart.

Tapping Peter’s shoulder, Michael silently mouthed, “Vandermeer,” and motioned toward the chart rack. Without interrupting his phone conversation, Peter pointed to the attending physician. Michael understood. The attending had Vandermeer’s chart, a new, potentially problematic complication.

With a shrug, Michael started toward the attending, only to have Lynn grab the sleeve of his white coat and restrain him.

“What are you going to say?” Lynn questioned in a whisper.

Michael shrugged again. “I’m going to wing it, as usual.”

“You can’t use the anesthesia ruse because she might be from anesthesia.”

“You are so right,” Michael said with a nod.

“Hold on,” Lynn said. She stepped over to Peter and scribbled on the notepad in front of the clerk: Who’s the attending, and what department is she from?

Without interrupting his conversation, Peter scribbled: Dr. Siri Erikson, hematology.

Lynn mouthed a “Thank you” to Peter and then took the note back to Michael.

“Hematology?” Michael questioned, still in a whisper. “What does that mean? Carl’s got a blood problem?”

“Who’s to know?” Lynn said. “I hope not. Maybe there is some association with the fever.”

“I would think a fever in a comatose patient would call for an infectious disease consult, not one from hematology.”

“I agree. Anyway, let’s see how friendly she is toward medical students.”

Both Lynn and Michael were well aware that some medical attendings savored the teaching role whereas others saw it as a burden and acted accordingly.

“The good news is that she’s not from anesthesia,” Michael said, “so our cover is okay if it comes to that.”

“You do the talking,” Lynn said. “You’re better at deception than I.”

“I’m going to pretend I didn’t hear that, girl.”

“That’s fine, boy!” Lynn responded.

Michael approached the hematologist. He cleared his throat to announce himself. “Excuse me, Dr. Erikson.”

The woman looked up from her work. She was attractive, somewhat heavyset mature woman in her late forties or early fifties. Consistent with her family name, she looked Scandinavian, with blond hair and a pale complexion. Her eyes were a clear cerulean blue. “Yes,” she said.

“My partner and I were wondering if we could take a quick look at Vandermeer’s chart if you are not using it at the moment.”

Dr. Erikson turned to the stack of charts in front of her and fished out Carl’s. She handed it up to Michael but maintained a hold on it. “I’m not finished with it,” she said. “So I need it back.”

“Of course,” Michael said. “We’ll just be a moment.”

“I assume you are medical students,” Dr. Erikson said, glancing briefly at Lynn. She had yet to let go of the chart. “What is your association with the case?”

“My name is Michael Pender and this is Lynn Peirce. We’ve been asked by anesthesia to follow the case.”

“I see,” Dr. Erikson said. She finally released her hold on the chart. “Is it because it is a case of delayed return to consciousness?”

“You got it,” Michael said. He smiled diplomatically, handed the chart to Lynn, and started to take a step away, hoping to end the conversation, but Dr. Erikson spoke up again: “Is it just Vandermeer you are interested in, or are you following Scarlett Morrison as well?”

“Should we be?” Michael asked.

“Not necessarily. But she is a similar case.”

“You mean she is another case of delayed recovery from anesthesia?” Michael asked. He shot a glance at Lynn, whose eyes had opened wider, despite her fatigue. She was obviously taken aback.

“Yes, she is,” Dr. Erikson said. “She was a Friday surgery. A very similar case, I’m afraid. I’m surprised someone in anesthesia didn’t tell you.”

“I’m surprised, too,” Michael said. “We certainly should be following her.” He glanced at Lynn, who looked as if someone had just slapped her.

“I’m using the Morrison chart at the moment,” Dr. Erikson said. “When you finish with Vandermeer’s, I’ll give it to you.”

“That’s a deal,” Michael said, grabbing Lynn by the arm and forcibly moving her away, over to a couple of empty chairs. The two of them sat down.

“If it is true there’s another case, this is worse than I thought,” Lynn said in an excited, horrified whisper. “If there was another case last week, then the incidence here at Mason-Dixon Medical Center is three in five thousand, meaning it is not eighty times the average, but one hundred twenty times!”

“Calm down!” Michael insisted, trying to keep his own voice low. He glanced over at Dr. Erikson in hopes she wasn’t paying any attention. Luckily she was again totally absorbed in her work. “Let’s take this one step at a time,” Michael said. “We came here to look at Carl’s chart. Let’s do it and get the hell out!”

Making an effort to follow Michael’s advice, Lynn opened the chart. The last entry was a short note by the neurology resident, Charles Stuart, who had been called during the night when Carl’s fever had spiked. Stuart had ordered an emergency portable chest X-ray, which was read as clear, so no pneumonia. He wrote that the operative site was not red or swollen. He sent away a urine sample for bacteriologic studies and drew blood for a blood count and for blood cultures. He concluded his note with the statement “Fever of unknown origin. Will follow. Consult requested.”

“Maybe Dr. Erikson is the consult,” Lynn said.

“Could be,” Michael said. “But hematology and not infectious disease? It doesn’t compute.”

Quickly Lynn flipped through the chart to get to the results of the studies, in particular the MRI, only to learn that a CT scan had been done as well. Laying the chart flat, she and Michael read the reports. Michael finished first and waited for Lynn to do the same.

“There are a lot of terms that I don’t understand,” Michael said.

“Likewise,” Lynn said. “But it’s pretty clear that it isn’t good news, even if we don’t understand all the details. The summary says the CT scan showed severe diffuse brain edema while the summary of the MRI says that the hyperintense cortical signal indicates extensive laminar necrosis. That’s what Dr. Stuart expected. It all translates to extensive brain death...” Lynn trailed off, unable to finish her sentence.

“I’m sorry,” Michael said as sincerely as he could.

“Thank you,” Lynn said. Her voice caught. With such terrible news, she was trying not to cry. She was supposed to be a dispassionate medical student.

“Want to look at anything else in the chart?” Michael asked.

Lynn shook her head. As far as she was concerned, there wasn’t any point. The verdict was in. Whether Carl would regain some level of consciousness or not was uncertain, but even if he did, he was never going to be the person she knew. Best-case scenario was probably his entering a persistent vegetative state, a horrid situation that she had read up on the evening before. He would have brain stem function without input from the higher or cortical areas. It would mean he might have sleep-wake cycles but still would be completely unaware of self and environment and need total care until death. In short, he would endure a dehumanized existence. Inwardly she shuddered, wondering if she could cope.

Michael stood up and gave Lynn’s shoulder a reassuring squeeze. He took Carl’s chart back over to Dr. Erikson, who gave him Scarlett Morrison’s chart. He brought it back to where Lynn was sitting and placed it in front of her. She was in a trance, staring ahead. “You okay?” he asked.

“As good as can be expected,” Lynn responded. Her voice quavered. Then, as if waking up, she shook her head, adjusted herself in her seat to be more upright, and opened the second chart.

16

Tuesday, April 7, 6:52 A.M.

At first they didn’t talk, but merely nodded to each other when they finished a page. The first question Lynn in particular wanted to know was why the neurology resident, Charles Stuart, hadn’t mentioned that there had been a very recent, similar case. The answer turned out to be simple: a different neurology resident, by the name of Dr. Mercedes Santiago, was involved. With what they both knew about interdepartmental communication, the Neurology Department might not know that there had been two similar cases until they had their grand rounds.

As Lynn and Michael read on, significant similarities between the cases began to surface. First of all, Scarlett Morrison was nearly the same age as Carl, and unmarried. Second, she was a healthy individual whose only problem was gallstones. Her surgery, like Carl’s, was elective, meaning it wasn’t an emergency. Her procedure had been a laparoscopic cholecystectomy, or a small-incision removal of her gallbladder. It had been done without complications, according to the operative note, just as Carl’s had been, and, like Carl’s, it had been a seven-thirty A.M. case, so everyone had been fresh and rested.

As they continued to read they noticed there was no handwritten anesthesia note by the anesthesiologist, Dr. Mark Pearlman, only a terse mention of the problem of delayed return of consciousness, followed by a list of the medications that had been tried in vain to reverse the sedative and the paralytic agents in case there had been an overdosage of either. For information about the course of anesthesia during the operation, Lynn and Michael had to turn to the record created in real time by the anesthesia machine.

What they learned was that, as in Carl’s case, the anesthesia had progressed normally until there was a sudden, unexplained decrease in the patient’s blood oxygenation about three-quarters of the way through the operation. Looking at the graph, they could see that the oxygenation fell precipitously from near 100 percent to 90 percent for a couple of minutes before returning to 98 percent. Just as with Carl, there had been a brief episode of heart irregularity from hypoxia at precisely the moment the oxygen saturation fell.

As they examined the record further, some specific differences from Carl’s case became apparent above and besides the fact that it had taken place in OR 18 instead of OR 12: First, the volatile anesthetic agent was desflurane instead of isoflurane; second, an endotracheal tube was used instead of a laryngeal mask; and third, a depolarizing muscle relaxant, succinylcholine, had been used to facilitate the intra-abdominal surgery. On the other hand, the preoperative medication, midazolam, and the induction agent, propofol, had been the same, with approximately the same doses administered according to weight.

When Lynn had finished studying the record, she looked up at Michael, who was holding his camera out of sight of Peter and Dr. Erikson. He motioned to Lynn to hold up Morrison’s chart so that he could snap a picture of the anesthesia record without having to stand up. She did but in the process felt anxiously guilty. Michael took the picture and the camera disappeared in a flash.

Both Michael and Lynn glanced over at Peter and Dr. Erikson to see if either had noticed. They hadn’t. Lynn breathed a sigh of relief. Michael seemed immune.

“What do you make of the differences?” Michael asked.

“From my reading last night I know that recovery from desflurane is actually faster than from isoflurane, so that’s not significant. And an endotracheal tube is more secure than a laryngeal mask, so there is no problem there. And the use of a paralyzing agent shouldn’t be a problem as long as the patient is respired. I don’t find the differences significant.”

“Man, girl, you sure covered some ground with your reading last night.”

“It was a lot of hours,” Lynn said. At that point, she turned to the page in the chart that had the graph of Morrison’s vital signs, recorded since she had been brought to the neuro ICU. Lynn pointed to the tracing of body temperature that showed that Scarlett Morrison had had a significant spike in temperature the night after her surgery, just like Carl, reaching the same high point of 105º F. Although the temperature stayed elevated over Sunday and Monday, it had gradually fallen and was now at 100º F, which most people would consider mildly elevated.

“I’m amazed,” Lynn murmured. “So far the Morrison and Vandermeer cases seem clinically to be mirror images. Could that happen by chance?”

Michael shrugged. “And as far as I can remember, they are both similar to Ashanti’s. I’m pretty sure she had a fever, too. Do you think it could be some kind of new, unknown reaction to anesthesia that also causes a fever?”

“Who’s to know at this point,” Lynn replied. She turned to the blood work section. “Seems there was an increase in her white count to go along with the fever. That suggests an infection.”

Michael nodded. “But there isn’t an increase in neutrophils or a shift to the left.” Both medical students knew that in the face of an infection the body usually responded with an immediate increase of neutrophils, the body’s cellular defense against bacteria infection. A shift to the left indicated newly mobilized cells responding to an acute microbial attack.

“But look,” Lynn said, “the increase in the white count is with lymphocytes, not neutrophils. Doesn’t an increase in lymphocytes usually happen later in an infection as a hormonal immune response?”

“That’s the way it’s supposed to work.”

“And look, the lymphocyte count went up progressively with each passing day. What do you make of that?”

“I need to cheat,” Michael said. He pulled out his tablet and Googled meaning of increased lymphocytes. Thanks to the Internet, he had multiple results in a fraction of a second. He read the conditions out loud: “Leukemia, mono, HIV, CMV, other viruses, TB, multiple myeloma, vasculitis, and whooping cough.”

When Lynn didn’t respond to his list, Michael glanced at her. She was busy reading the results of the infectious disease consult. “No source of infection was found,” she said. “Chest was clear on X-ray, urine normal, no infection of the operative incisions, no nothing.”

“Did you hear the list of what causes an increase in lymphocytes?” Michael asked.

Lynn shook her head. “Sorry. Come again!”

Michael repeated the list. Lynn listened and thought for a moment. “Well, we can ignore most. I suppose ‘other viruses’ and ‘vasculitis’ are the most probable.”

“Yeah,” Michael agreed, “but doesn’t something jump out at you?”

“What do you mean?”

“Multiple myeloma causes an increase in lymphocytes. That caught my eye because of what I learned yesterday — that Ashanti has multiple myeloma. Maybe Morrison has it, too.”

“Now, that would be too much of a coincidence,” Lynn said. “I’ve never seen a case of multiple myeloma and don’t know much about it other than it involves too many plasma cells. Isn’t it rather rare?”

“If I remember correctly, it’s not that rare,” Michael said. “Of course everything is relative. I remember the one lecture in pathology that included multiple myeloma.”

“You remember the lecture we had in pathology about multiple myeloma?” Lynn questioned with a touch of dismay.

“I don’t remember a lot, and not much more than that it involves plasma cells, like you said. But I do remember that among the brothers it is one of the top ten causes of cancer death. Maybe that’s why I remember it. Anyway, of all the conditions that I just read that cause an increase in lymphocytes, I couldn’t help but notice it.”

“I wonder if it is because of the increase in lymphocytes that Dr. Erikson is seeing the patient,” Lynn questioned.

“Makes sense,” Michael agreed. “Do you think we should risk asking her?”

Lynn looked over at the attending, who was still bent over a chart, dictating a note most likely for the EMR. A few minutes earlier she had been writing a note. Until the hospital fully adopted the computerized record and gave up on the physical chart, consults had to do both and complained bitterly.

“I don’t think we dare,” Lynn said after a pause. “If we actually engage her in a conversation, she’s bound to ask us more details of why we are here. As you said, people are going to be sensitive about these cases.”

“Right on, girl!”

“Let’s see if she wrote a note in this chart. That could answer the question.”

Redirecting her attention to the chart in front of her, Lynn turned to the continuation notes, where progress reports were placed. The last note was from Dr. Erikson. The handwriting wasn’t good.

“What the fuck is a gammopathy or MGUS?” Michael asked with frustration. “I hate it when consults throw around these shit-ass esoteric words and acronyms to make you feel incompetent.”

“My turn to cheat,” Lynn said as she pulled out her tablet and Googled gammopathy. Although she didn’t know the exact meaning, she had a good idea. She selected the Wikipedia choice, and, placing her tablet on the desk, they both read the article titled “Monoclonal Gammopathy of Undetermined Significance.”

When Lynn was finished Michael asked: “What’s your take, besides knowing what MGUS stands for?”

“I’m so tired I’m having trouble thinking,” she confessed.

“It’s not surprising. You’re exhausted and you’re starving. Come on! Let’s go down and get you something to eat. You’re running on empty.”

“In a minute,” Lynn said, trying to rally herself. “At least I understood that MGUS involves a group of lymphocytes overproducing the same antibody. What surprises me is reading how prevalent it is, and I barely remember it even being mentioned in pathology.”

“But it is only prevalent in people over fifty. This patient is twenty-eight.”

“True,” Lynn said. “And I guess it’s not that serious.”

“It’s not serious unless it develops into multiple myeloma. It makes me wonder if Ashanti started out with this MGUS, which then led to the multiple myeloma.”

“I guess that is a possibility,” Lynn said. “Let’s look at the test Erikson mentions in her note: the protein electrophoresis. I know something about that from having used it to follow a patient with acute hepatitis last year in our medicine rotation.”

Lynn flipped back to the section of the chart for laboratory tests. It didn’t take her long to find the proper page with the results of the protein electrophoresis. The levels of the various plasma proteins were listed and also portrayed in a graphic schematic. She and Michael concentrated on the schematic. In the far right-hand portion where a smooth mound representing the gamma globulins was expected, there was a small, narrow peak at the mound’s crest.

“That’s easy to spot,” Michael said. “So the woman’s immune system is producing a specific antibody. What do you think is causing it?”

“Has to be an antigen of some kind. And maybe the antigen that stimulated the first lymphocyte to produce the specific immune globulin is still in Scarlett Morrison’s body, continuing to stimulate more and more antibodies. What do you think of that?”

“It’s definitely a possibility unless that first lymphocyte just went a little berserk, if you know what I am saying.”

“You mean, sorta like a cancer cell.”

“Something like that,” Michael said. “The cellular machinery to produce an antibody got turned on, and someone forgot to turn it off.”

“Going back to your question about whether the anesthesia could have caused the fever. Now the question is if the anesthesia could have turned on this monoclonal antibody?”

Michael stared at Lynn, understanding perfectly where she was coming from. She desperately needed an explanation for Carl’s sorry state and was willing to grasp at straws.

“I’m talking about some idiopathic reaction that has yet to be noticed.”

“No!” Michael said finally but firmly. “There’s nothing about anesthesia that could be antigenic. I’d like to say yes to get you off your collision course of thinking someone screwed up. But anesthesia agents have been used in too many people over too long a time for there to be an unrecognized immunological reaction that causes fever and monoclonal antibodies. Much less puts people into a coma. No way. Sorry, girl!”

“I knew you were going to say that.”

“I say it because it’s the truth. Now, let’s get down to the cafeteria. We have a dermatology lecture at nine.”

“I’m not finished,” Lynn said. She turned off her tablet and pocketed it. Next she turned to Morrison’s MRI. It was similar to Carl’s, showing extensive laminar necrosis. Closing the chart, Lynn looked over at Dr. Erikson, who was still alternatively writing a chart and dictating with her phone.

“I want to look at Carl’s chart again,” Lynn said impulsively, getting to her feet and picking up Scarlett Morrison’s chart in the process.

“But why?” Michael complained. He grabbed the arm of Lynn’s coat to restrain her. “Why risk it? Nothing will have changed.”

“We didn’t look at his blood work,” Lynn said, detaching her sleeve from Michael’s grasp. “And maybe she wrote something in the chart. If she did, I’d like to see it.”

17

Tuesday, April 7, 7:20 A.M.

Excuse me,” Lynn said as she came up to Dr. Erikson. She extended Morrison’s chart. “Thank you for calling our attention to this case. It is very similar to Vandermeer’s, and we should be following it for sure.”

The hematologist glanced up briefly.

“Should I put Morrison’s chart back in the rack or do you want it here with you?” Lynn asked.

Dr. Erikson pointed toward the desk next to her. “Here is fine,” she said distractedly without looking back up at Lynn.

“I hate to trouble you,” Lynn said, “but we would like to take another quick glance at Vandermeer’s. There’s something we missed.”

Dr. Erikson’s head popped up, and she regarded Lynn with icy blue eyes, and her nostrils flared. For a moment Lynn thought the woman was going to angrily deny her access to the chart. But then her expression softened.

“If it is a bother, we can come back later,” Lynn added quickly. Although she had not noticed it before, now that her attention had been drawn to the woman’s face, Lynn thought that the doctor did not look well. The paleness of her skin was striking, almost translucent, and her cheeks looked hollow. Beneath her eyes were purplish, dark circles. “I just thought you might be finished with it.”

“It’s not a bother,” Dr. Erikson said. She separated Carl’s chart from those in front of her and extended it toward Lynn, asking: “What year medical students are you two?”

“We’re fourth-year,” Lynn said. Her pulse quickened in anticipation of possible trouble. Now that she was close to the hematologist, she could see that the woman wasn’t exactly overweight, as she had thought earlier. It was more that her abdomen was distended, as if she might be four or five months pregnant, which seemed inappropriate, considering her age.

“And you are on a rotation in anesthesia?”

Lynn nodded. “The specialties are our final rotation before graduation.” She hoped Dr. Erikson would assume anesthesia was considered a specialty at Mason-Dixon, even though it wasn’t: just ophthalmology, ENT, and dermatology.

“Have you come to any conclusions why these patients have suffered comas?” Dr. Erikson asked.

“No, we haven’t,” Lynn said. She was nonplussed, wishing she had not gotten herself into conversation. “Have you any ideas?”

“Of course not,” Dr. Erikson snapped. “I’m a hematologist, not an anesthesiologist.”

Lynn wanted to leave but felt caught as Dr. Erikson was still holding on to Carl’s chart and staring at her with unblinking intensity. After a moment of strained silence the hematologist asked another question: “Do you have any hunches as to what might have happened?”

“Not so far,” Lynn said.

“If you come up with any particular ideas, let me know!” Dr. Erikson said. It was more of an order than a request. Finally she let go of Carl’s chart.

Relieved, Lynn said, “We’ll be happy to let you know if something occurs to us.”

“I’ll be counting on it,” Dr. Erikson said. Then she pulled a professional card from one of her pockets and handed it to Lynn. “Here are my contacts. Let me know right away if you come to any conclusion.”

“Thank you,” Lynn said, taking the card and glancing at it. She smiled uncomfortably and was about to flee back to Michael when Dr. Erikson added, “Do you have any questions for me?”

Despite her fatigue, Lynn tried to come up with a question. She desperately wanted to leave but thought it best to play the medical-student role and keep the conversation academic rather than take the risk of having it turn to what she and Michael were really doing: namely, violating rules and looking at unauthorized charts. “Well...” she began, “in your consult note in Morrison’s chart you mentioned a possible monoclonal gammopathy. Do you think that was caused by her having had anesthesia?”

“Absolutely not!” Dr. Erikson said with a dismissive chuckle, as if it were the most ridiculous idea she had heard in a long time. “There is no way anesthesia could cause a gammopathy. The patient had to have had the condition prior to her surgery. It just hadn’t been recognized. With an asymptomatic gammopathy, the only way it can be discovered is by a serum electrophoresis, a test she never had had until I ordered one because of her unexplained fever.”

“I see,” Lynn said, trying to think up another question. “Are you doing a hematology consult on Carl Vandermeer?”

“Why do you ask?” Dr. Erikson said.

“Because you have his chart and you did a consult on Scarlett Morrison.”

“The answer is no,” Dr. Erikson said. “I am only seeing the patient as a courtesy since the nursing staff has told me the patient has had a temperature elevation, like Scarlett Morrison, with no apparent signs of infection.”

“Do you think that her fever is due to her gammopathy?”

“Now, that is an excellent question,” Dr. Erikson said.

Lynn breathed a sigh of relief. Now she knew she could break off the conversation without leaving behind an irritated attending who otherwise might be tempted to ask questions and blow their cover.

“An immune response can indeed cause a temperature elevation,” Dr. Erikson said in a didactic monotone. “There is no way to know for sure, but since an infection has been ruled out, I think it is safe to say the elevated temperature is due to her gammopathy.”

“Is something stimulating her immune system and keeping her temperature elevated?”

“I would have to assume there was. Perhaps it’s the stress of what happened to her. But I really don’t know.”

“Is there any treatment for her gammopathy?”

“It is not necessary to treat it unless the elevated protein interrupts kidney function or if the gammopathy progresses to a blood cancer.”

“You mean like multiple myeloma.”

“Exactly. Multiple myeloma, lymphoma, or chronic lymphocytic leukemia.”

“Since Vandermeer has an elevated temperature and no immediate signs of infection, do you think he has a gammopathy?”

Dr. Erikson didn’t answer immediately, and Lynn feared the volatile woman was getting irritated all over again as her eyes had narrowed and her nostrils flared. Lynn berated herself for not leaving when she had the opportunity.

“Vandermeer’s infectious disease workup has just begun,” Dr. Erikson finally snapped. “We’ll just have to see.”

“Thank you for taking the time to talk with me,” Lynn said, and quickly returned to her seat. As she put Carl’s chart down on the desktop, she made eye contact with Michael, who was looking bored.

“Now, that was shooting some real shit,” Michael said, keeping his voice low.

“I’m sorry,” Lynn said with an equally low voice. “I couldn’t get away.”

“Yeah, sure.”

“I’m serious. First she held on to the chart like she did with you and grilled me. She wanted to know what year we were. I thought for sure she was going to question our supposed anesthesia rotation. Luckily she didn’t. One thing for sure, she’s a bit weird.”

“Really? Lay it on me!”

“It’s hard to explain. For a moment it seemed to me she was acting pissed we were here, looking at these charts, which made me fear for the worst. But then her attitude changed. At least I think it changed. Actually my mind is not working at full power as tired as I am, so maybe I’m making all this up. But let me ask you: does she look healthy to you?”

“It didn’t occur to me one way or the other,” Michael said. He started to turn to look over at Dr. Erikson, who was only about a dozen feet away, but Lynn restrained him.

“Don’t look!” Lynn ordered in a forced whisper. “Be cool! I’m telling you she’s weird and could be trouble. Trust me! Let’s not give her any more reason to question us. I really thought she was going to demand to know what we are doing here, looking at these charts. Luckily she didn’t. And tell me this: did you notice her abdomen is distended, almost like she is pregnant?”

“Really?” Michael said, raising his eyebrows. He started to turn to look at the doctor again, but for the second time Lynn stopped him.

“I’m telling you, don’t look!” Lynn snapped.

“I can’t imagine she is pregnant,” Michael said. “She’s no spring chicken.”

“I can’t imagine she is, either,” Lynn said. “Of course, with what’s happening in IVF, it’s not out of the question. My guess is that she has some kind of liver or kidney disease.”

“I suppose it is possible,” Michael said. He was growing bored with the whole situation. He was also starved.

“The strangest thing she said was that she wants to hear if you and I come to any conclusions to explain why Carl and Morrison didn’t wake up from their anesthesia.”

“I hope you didn’t say that you think someone fucked up.”

“I didn’t.”

“Thank the Lord.”

“I said we didn’t have any idea.”

“That’s God’s truth. You’re learning, girl.”

“She made me promise that if we did come up with something, we’d let her know. She even gave me her card.” Lynn showed the card to Michael, who merely shrugged. “You don’t find all this a bit odd?” Lynn questioned. “Why would she be interested in what a couple of medical students might dream up? As an attending she could go to anybody in anesthesia, from the department head on down.”

“Okay, it is strange,” Michael admitted. “Are you happy now?”

Lynn closed her eyes for a moment, as if she needed to reboot. When she opened them again she said: “The last question I asked was if Carl might have a gammopathy like Morrison to explain his fever. Her response was to look mad.”

“Now, that is odd. What did she say?”

“She said his infectious-disease workup had just begun, so we’d just have to wait and see. But she said it as if she was irritated I had asked.”

“Okay, you’ve made your point. She’s weird. Now, how about we make tracks for the cafeteria.”

“Let me look at Carl’s chart quickly.” Lynn opened the chart to the progress note section. There was nothing from Erikson, although when she turned to the orders page, there was a request for a serum electrophoresis, on Dr. Erikson’s order. Lynn looked off into the distance, as if thinking.

“Okay, are we finished?” Michael asked. “Come on! Let’s get out of here.”

“Just let me look at Carl’s blood work,” Lynn said, turning back to the lab section. “Okay,” she said after a moment. “His white count is eleven thousand. Some people may not consider that elevated, but I think it is. The key fact is that his lymphocytes are also elevated, at almost five thousand, which argues against an infection.”

“That’s great. Now can we go to breakfast?”

“All right, but let me return this chart.”

“Don’t get in another conversation,” Michael cautioned.

“Not on your life. I’m going to give the chart to Peter.”

Their departure was just in time. As they were leaving the central circular desk, all the nurses had finished their rounds and were filing in. Gwen Murphy, the head nurse, eyed the students but didn’t say anything, although she paused for a second to stare. Very little that happened in the neuro ICU went unnoticed during her shift.

Just before Lynn went through the heavy double doors leading out into the sixth-floor hallway, she stopped and hazarded another glance over at Carl. A nurse was at his side, adjusting something. Carl appeared as peaceful as he had earlier. The only discernible movement was from the flexing and extension of his operated leg.

Lynn shuddered. She knew all too well that his tranquillity was in sharp contrast to the mayhem that had occurred in his brain. The MRI and the CT scan had confirmed her worst fears, and the stark reality of his status gave her a new surge of energy and purpose. At the moment she didn’t care that part of her motivation might have stemmed from guilt of possibly equating his bleak future with academic freedom for her. Her intuition, which had always served her well in the past, was sending alarms that something was amiss in this whole affair. She sensed that the hospital was going to be content to let the issue die a natural death, but she was not going to allow it. She would find out what had happened. She owed as much to Carl and future patients.

“Come on!” Michael urged. “Now I’m in as much need of calories as you, and the dermatology lecture isn’t going to wait for us.”

“I’m coming,” Lynn said.

As they started down the hallway, the hospital PA system crackled to life, and like everyone else in the hospital, they stopped to listen. In the old days hospital PA systems provided a constant background of doctors being paged, but that was no longer the case, with smartphones and computer tablets. The Mason-Dixon Medical Center had a hospital-wide PA system, but it was only for disasters. So when the system came on, everyone in the hospital, even in the operating rooms, stopped to listen.

Lynn and Michael exchanged a hurried glance. “What do you think?” Michael asked. “Does that include us medical students?”

“We’re almost doctors,” Lynn shot back. “Let’s go!”

They ran down the hallway, effectively dodging nurses, orderlies, ambulatory patients, and food carts to the elevators, but instead of waiting for one, they ducked into the stairwell. As they thundered down the metal steps, they found themselves in a swelling bevy of stampeding doctors and nurses, with more joining at each floor.

18

Tuesday, April 7, 7:52 A.M.

The ER was a madhouse. A continuous stream of injured patients was being frantically wheeled in and distributed to various exam rooms. The trauma rooms had already been filled. Several of the senior ER physicians were doing quick triage out on the receiving dock, as patients were unloaded from ambulances. The more seriously injured were immediately handed off to waiting groups of doctors and nurses who started assessment and treatment even before the gurney got into an exam room. Those patients with relatively minor injuries were rolled off to the side to wait their turn.

Neither Lynn nor Michael had much experience with emergency medicine other than a brief didactic exposure in lectures and a short tour of the department during third-year surgery, and they didn’t know any of the emergency room personnel. Although the house officers they arrived with had a general idea of what to do, Lynn and Michael had no clue. Lacking any specific destination, they ran up to the front desk. At first no one paid them any attention. What they didn’t realize was with white coats over scrubs, the nursing staff took them for residents, not medical students.

“Can we help?” Lynn asked one of the harried nurses who seemed in charge, as she was directing traffic more than anyone else, hollering orders to various people. She was standing just behind the chest-high counter of the ER check-in desk along with a roiling crowd of almost twenty people. Everyone was busy with phones and paperwork, some abruptly racing off to one of the rooms while others arrived. Over the babel of voices the sounds of sirens could be heard, as more ambulances pulled up outside.

At first the nurse whom Lynn had addressed just looked at her but didn’t respond. Her eyes were distantly focused, suggesting her mind was processing too many things at once. As Lynn repeated her question, the woman recovered from her mini-trance. She reached out and snapped up a clipboard from a pile in front of her. She handed it to Lynn, saying, “Take care of this case! Exam room twenty-two. Male with a mild breathing difficulty. Blunt-force chest trauma.”

Before Lynn could respond, the charge nurse yelled to a colleague across the room to bring down several more portable X-ray machines from X-ray and to get them into the trauma rooms. Then she turned to another nurse behind her and told her to check on what was happening in Trauma Room 1 to see if the patient was ready to be sent up to surgery.

Lynn read the patient’s name: Clark Weston. It was scrawled in longhand on the ER admission form, along with a chief complaint: breathing difficulty, blunt trauma. Lynn noticed the blood pressure was normal although the heart rate was a bit high, at 100 beats a minute. A scribbled note said: mild dyspnea but good color. Sternal contusion but no point tenderness over individual ribs. No lacerations. Extremities normal. No broken bones. That was it. There was nothing else. After a quick glance to see if she could again get the head nurse’s attention — which she decided was unlikely, as she had momentarily disappeared — Lynn looked at Michael, who she knew had read what was on the clipboard over her shoulder. “What do you think?” she asked. “Can we handle it?”

“Let’s do it,” Michael said. Both realized that the head nurse had no idea they were medical students. Both were wearing lanyards with their ID cards around their necks, but one had to look at them closely to see that there was no MD after their names.

Despite the chaos and no one to ask for directions, they found Exam Room 22 without much difficulty. The door was closed. Lynn went in first, and Michael followed right behind her, pulling the door closed behind him. The room was an island of tranquillity in the middle of a storm.

Alone in the room, Clark Weston was supine on a gurney but propped up on both elbows, struggling to breathe with shallow, rapid respirations. He was a middle-aged blond man, mildly overweight, and fully dressed in a suit jacket, white shirt, tie, and dark slacks. The tie was loosened. The shirt was open and pushed to the side, revealing a pale, expanded chest with obvious central bruising. Both medical students immediately noticed the man’s color was not good, contrary to what was noted on the admission form. His skin had a bluish cast, as did his lips. His expression was one of desperation. Concentrating on trying to breathe, he couldn’t talk. It was obvious he thought he was about to die.

Lynn ran to one side of the gurney while Michael went to the other. Both felt an instantaneous rush of terror with that sudden realization that this was no mere difficulty breathing, and as neophytes, they were in totally over their heads, facing a patient in extremis.

“I hope you have some idea of what to do,” Michael croaked.

“I was counting on you,” Lynn said.

The patient, hearing this exchange, rolled his eyes before closing them to concentrate on trying to breathe.

“I better get a resident,” Michael blurted, and before Lynn could respond, he bolted from the room, leaving the door ajar.

Left on her own, Lynn dashed over to an oxygen source, turned on the cylinder, and then rushed back to put a nasal cannula around the patient’s head. Placing the bell of her stethoscope on the right side of his chest, she listened. The man was breathing so shallowly and rapidly, she could barely hear any sounds. The competing noise from the ruckus coming in through the open door didn’t help.

At that point Lynn realized how overly expanded the man’s chest was. It was as if he was blown up like a balloon. What did that mean? She tried to think and access her memory banks about what she had been taught in physical diagnosis, but her exhaustion combined with the terror engendered by her feelings of incompetence made it difficult. She vaguely remembered that an expanded chest meant something important, but what? She didn’t know.

Moving the bell of the stethoscope to the left side of the man’s chest, Lynn was surprised to hear almost nothing. At first she thought it was her problem, meaning she was doing something wrong, but then she compared the two sides. It was apparent that she could hear breathing sounds on the right, even if they were bearly discernible, and nothing, or close to nothing, on the left. Suddenly an idea of what was going on began to form in her mind. Taking the stethoscope out of her ears, she tried percussion: placing her left middle finger on the patient’s chest and taping it with the middle finger of her right hand. The resultant sounds between one side and the other were different. The left side was hyper-tympanic, like a drum, compared with what she heard on the right side.

Michael flew back into the room, panting from exertion. “I couldn’t find anyone free. The only person I found was an ER doc two doors down struggling with a dislocated shoulder. He promised he’d be here as soon as he got the arm back in the joint. How is the patient doing?”

“He’s getting oxygen, which should help some,” Lynn shot back. “But he is in trouble. But I think I know what is going on.”

“Clue me in!” Michael demanded.

“Listen to his chest! See what you think. But do it quickly.”

Michael struggled to get his stethoscope in his ears. While he listened first to the left side, then to the right, and then back to the left, he kept his eyes on Lynn, who was taking the man’s pulse. “There’s no breath sounds in the left side,” Michael said.

“Try percussion!” Lynn said. “But do it fast. His heart rate is up to one hundred twenty. That can’t be good.” Lynn could feel her own pulse in her temples beating almost as rapidly.

Michael quickly did as Lynn suggested. The hyper-resonance on the left was immediately apparent, and he said as much.

“Does that ring any bells to you?” Lynn said. “Especially since he has dilated neck veins.” She pointed.

“Tension pneumothorax!” Michael blurted.

“My thoughts exactly,” Lynn cried. “If so, it is a real emergency. His left lung must be collapsed, and with every breath, the right is being compressed. He needs an X-ray, but there’s no time.”

“He needs a needle thoracotomy on the left!” Michael shouted. “And he needs it now!”

In a panic, the two students regarded each other across the body of the patient. For a second they hesitated, even though they were frantic. Neither had ever seen a needle thoracotomy performed, much less done one. They’d read about it, but to go from book learning to actual performance was a giant step.

“How soon do you think the ER doctor might get in here?” Lynn demanded anxiously.

“I don’t know,” Michael said. Perspiration appeared on his forehead.

“Mr. Weston,” Lynn yelled as she gave the man’s shoulder a shake. The patient didn’t respond. Instead he collapsed supine onto the gurney, no longer supporting himself on his elbows. “Mr. Weston,” she called louder, with a more significant shake to his shoulder. Nothing. The patient was no longer responding.

“We can’t wait,” Lynn said.

“I agree,” Michael replied. The two of them rushed over to a crash cart that had all sorts of emergency equipment. They grabbed a large syringe, a sixteen-gauge intravenous cannula, and a handful of antiseptic pledgets. Then they rushed back to the patient.

“My memory is that it is supposed to be done in the second intercostal space between the second and third rib.”

“You do it!” Lynn yelled, thrusting the cannula into Michael’s hands. “How the hell do you remember such details?”

“I don’t know,” Michael retorted as he quickly snapped on a pair of sterile gloves. He then tore open the sterile wrapping on the cannula. It had a needle stylus to facilitate insertion.

“What if it is hemothorax and there is blood in there instead of air?” Lynn questioned anxiously. “Would we be making it worse?”

“I don’t know,” Michael admitted. “We’re in uncharted territory here. But we got to do something or he’s going to check out.”

Lynn tore open several alcohol pledgets and rapidly swabbed a wide area below the patient’s left collarbone. Michael positioned the tip of the cannula with its needle stylus over what he thought was the correct position. He’d located it by palpating the area and feeling the bony landmarks. Still he hesitated. It was a daunting task to blindly plunge a needle into someone’s chest, especially the left side, where the heart was.

“Do it!” Lynn snapped. She knew that she and Michael were an example of the blind leading the blind, but the needle thoracotomy had to be done, and it had to be done immediately. The patient’s color had deteriorated despite the oxygen.

Gritting his teeth, Michael pushed the catheter through the skin and advanced it until he felt the needle tip hit the rib. He then angled it upward slightly, and pushed again. He could actually feel a pop after advancing the needle another centimeter or so.

“I think I’m in,” Michael said.

“Great,” Lynn said. “Take out the stylus!”

Michael pulled out the stylus. Nothing!

“I guess I have to advance it a bit more,” Michael said. “I must not be in the pleural space yet.”

“That, or we have made the wrong diagnosis,” Lynn said.

“Now, that’s a happy thought,” Michael added sarcastically. He reinserted the stylus and then pushed deeper into the patient’s chest. He felt a second pop. This time when he removed the needle, both he and Lynn could hear a rush of air come out through the needle like a balloon being deflated.

Lynn and Michael’s eyes met. Both allowed a tentative smile. Over the next few minutes their smiles broadened as the patient’s breathing and heart rate improved, as did his color. He also slowly returned to consciousness. Lynn and Michael had to hold his hands to keep him from reaching up and touching the cannula sticking out of his chest while they waited.

“Maybe we should do a residency as a single person,” Michael said. “I think we make a good team.”

Lynn smiled weakly. “Maybe so,” she agreed, pushing away the thought that she wished she were heading up to Boston with Michael.

Just then a blood-spattered ER doctor by the name of Hank Cotter and a nurse rushed in. They went directly to the patient, crowding Lynn and Michael to the side. While the nurse took Clark’s blood pressure, Hank listened to the man’s chest. He saw the needle thoracotomy.

“Did you guys do this?” he questioned.

“We did,” both Lynn and Michael said in unison.

“Collectively we decided it was a tension pneumothorax,” Lynn explained.

“We thought we had to do something, as the patient was going downhill fast,” Michael added. “We didn’t think it could wait.”

“And you guys are medical students?” Hank asked. “I’m impressed. Have either of you rotated through the ER?”

Both Lynn and Michael shook their heads.

“I’m even more impressed,” Hank said. “Good pickup.” Then, turning to a nurse who had just entered, he said: “Let’s get a portable chest film stat and bring in a pack for inserting a chest tube.”

Hank turned back to Lynn and Michael. “Now, I’m going to have you guys insert a chest tube. Are you up for it?”