Toxin

ELEVEN

Friday, January 23rd

Kim paused for a moment to get his breath. He glanced up at the institutional clock on the tiled OR wall. It was nearly two o'clock in the afternoon. He was making good progress. This was the last of three cases.

Kim looked back into the depths of the wound. The heart was fully exposed. He was in the process of putting the patient on cardiopulmonary bypass. As soon as he was finished, the heart could be stopped and opened. At that point he would replace the damaged valve.

The next step was particularly critical: the placement of the arterial infusion cannula into the aorta to perfuse the coronary arteries. It would be through this cannula that the cardioplegia solution would be introduced that would stop the heart with its high potassium, cool it, and nourish it during the procedure. The problem was that the arterial pressure had to be dealt with.

"Scalpel," Kim said.

The scrub nurse slapped the scalpel with the appropriate blade into his waiting palm.

Kim lowered the razor-sharp instrument into the wound and directed it toward the aorta. The knife trembled in his hand; Kim wondered if Tom noticed.

Kim made a quick stab into the aorta then covered the incision with the tip of his left index finger. He did it quickly so that there was little blood loss. The little blood that appeared was cleared by Tom.

"Arterial infusion cannula," Kim said.

The instrument was placed in his waiting hand. He introduced it into the wound and positioned it next to his finger, occluding the stab wound into the aorta. Sliding the tip under his finger, he tried to push it into the pulsating vessel. For reasons not clear to him, the cannula would not penetrate the vessel wall. Arterial blood was now spurting out.

Uncharacteristically, Kim panicked. With blood filling the wound, he pushed too hard with the instrument and tore the aorta, enlarging the opening. Now the stab wound was too big to seal around the cannula's bulbous tip. Blood squirted high enough to splatter against Kim's plastic face shield.

Kim now faced a surgical emergency. Instead of panicking more, his experience kicked in. Rapidly recovering his composure, he reached into the wound with his left hand. Blindly his finger found the hole in the pulsating vessel, and he pressed against it, partially stemming the blood. Tom rapidly sucked out enough of the blood to give Kim a partial view.

"Suture!" Kim barked.

A needle-holder trailing a length of black silk was pressed into his hand. Deftly he passed the needle's tip into the vessel's wall. He did this several times so that when he pulled up on the suture the hole was closed.

With the emergency quickly contained, Kim and Tom eyed each other across the patient. Tom motioned with his head, and Kim nodded. To the surprise of the team, Kim and Tom stepped away from the operative field. They kept their sterile gloved hands pressed against their sterile gowned chests.

"Kim, why don't you let me finish this last case?" Tom whispered. It was a suggestion for Kim's ears only. "I can pay you back for doing the same for me a couple of weeks ago when I was coming down with the flu. Remember?"

"Sure I remember," Kim said.

"You're understandably bushed," Tom said.

It was true: Kim was exhausted. He had spent most of the night in the ICU waiting room with Tracy. When it had become apparent that Becky's condition had stabilized, Tracy convinced Kim to get a few hours' rest in one of the resident on-call rooms. She'd also been the one to convince Kim to go ahead with his planned surgery, arguing that his patients needed him. She'd insisted that it was best for Kim to stay busy since there wasn't anything he could do for Becky besides wait. Her most convincing point had been that he'd be in the hospital and available if needed.

"How did we do this as residents?" Kim asked. "We never had any sleep."

"The benefit of youth," Tom said. "The problem is we're no longer young."

"How true," Kim commented. He paused for a moment. Turning his case over to anyone, even to someone as qualified as Tom, was not an easy decision for him. "All right," he said at length. "You take over. But I'll be watching you like a hawk."

"I wouldn't expect anything different," Tom joked. He knew Kim well enough to recognize his style of humor.

The two surgeons returned to the operating table. This time Tom was on the patient's right.

"All right, everybody," Tom said. "Let's get that cannula in. Scalpel, please!"

With Tom at the helm, the operation went smoothly. Although Kim was on the patient's left, he was the one who positioned the valve and placed the initial sutures. Tom did the rest. As soon as the sternum was closed, Tom suggested Kim should bow out.

"You don't mind?" Kim asked.

"Hell, no," Tom said. "Get over there and check on Becky."

"Thanks," Kim said. He stepped back and pulled off his gown and gloves.

As Kim pulled open the heavy OR door, Tom called out: "Between myself and Jane, we'll write the post-op orders. If there's anything else I can do, just call."

"I appreciate it," Kim said. He hurried into the surgical locker room where he picked up a long white coat to pull on over his scrubs. He was eager to get to the ICU and didn't want to take the time to change back into his street clothes.

Kim had visited the intensive-care unit prior to and between each of his surgeries. Becky had shown some improvement, and there was some talk of trying to wean her off the respirator. Kim hadn't allowed himself to become too hopeful, knowing she'd been on for less than twenty-four hours.

Kim had even found time prior to his first case to phone George again to ask if he could think of anything else they could do for Becky. Unfortunately he hadn't had any suggestions, except for plasmaphoresis, which he didn't recommend.

Kim had come across plasmaphoresis for E. coli 0157:H7 toxemia in his research in the library during Becky's surgery. It involved replacing the patient's plasma with pooled fresh frozen plasma. Unfortunately it was a controversial treatment considered experimental with an enormous attendant risk of HIV since the new plasma came from hundreds of different donors.

The doors to the elevator opened and Kim was dismayed to join a group of happy staffers leaving the hospital at the end of the day shift. He knew it was unreasonable of him, but he couldn't help but be annoyed by their cheerful babble.

Getting off the elevator, Kim started down the hall. The closer he got to the ICU, the more nervous he became. He was almost beginning to feel a premonition.

He paused at the waiting-room threshold to see if Tracy was there. He knew she'd planned on going home to clean up and change clothes.

Kim saw her sitting in a chair near the window. She spotted him at almost the same moment and stood up. As she approached, Kim could see there'd been fresh tears. They streaked the side of her face.

"What's wrong now?" he asked with dismay. "Has there been a change?"

For a moment Tracy could not speak. Kim's question brought forth new tears that she had to choke back. "She's worse," Tracy managed. "Dr. Stevens talked about a cascading pattern of major organ failure. It was so much mumbo-jumbo to me, but she said that we should prepare ourselves. I think she was saying that Becky may die!"

"Becky's not going to die!" Kim said with vehemence that bordered on anger. "What happened to make her suggest such a thing?"

"Becky has had a stroke," Tracy said. "They think she's blind."

Kim shut his eyes hard. The idea of his ten-year-old daughter having a stroke seemed beyond any realm of possibility. Yet Kim well understood that her clinical course had been spiraling downward from the outset. That she may have reached the point of no return was not entirely surprising.

Leaving Tracy in the waiting room, Kim strode across the hall and entered the ICU. Mirroring the previous afternoon, a gaggle of doctors were pressed into Becky's cubicle. Kim pushed his way in. He saw a new face: Dr. Sidney Hampton, neurology.

"Dr. Reggis," Claire called.

Kim ignored the pediatrician. He muscled his way to the bedside and looked at his daughter. She was a pitiful shadow of her former self, lost within the wires and tubes, and the technology. Liquid crystal displays and monitor screens flashed their information in the form of digital readouts and tracing cursors.

Becky's eyes were closed. Her skin was a translucent bluish white.

"Becky, it's me, Dad," Kim whispered into her ear. He studied her frozen face. She didn't register any sign of hearing him.

"Unfortunately she's unresponsive," Claire said.

Kim straightened up. His breaths were shallow and rapid. "You think she's had a stroke?"

"Every indication suggests as much," Sidney said.

Kim had to remind himself not to blame the messenger.

"The basic problem is that the toxin seems to be destroying her platelets as fast as we give them," Walter said.

"It's true," Sidney said. "There's no way to know if this was an intracranial hemorrhage or a platelet embolus."

"Or a combination of the two," Walter suggested.

"That's a possibility," Sidney admitted.

"One way or another," Walter added, "the rapid destruction of her platelets must be forming a sludge in her microcirculation. We're into that cascading major organ failure situation that we hate to see.

"Kidney and liver function is definitely going down," Arthur said. "The peritoneal dialysis is not keeping up."

Kim had to steel himself to curtail his anger at this self-serving dialectic. It certainly wasn't helping his daughter. He tried to think and remain rational.

"If the peritoneal dialysis is not working," Kim said in a deceptively calm voice, "perhaps we should transfer her to the Suburban Hospital and get her on a dialysis machine."

"That's out of the question," Claire said. "She's too critical to be transferred."

"Well, it seems to me we-have to do something," Kim shot back, his anger bubbling to the surface.

"I think we are doing all we can," Claire said. "We're actively supporting her respiratory and kidney functions, and replacing her platelets."

"What about plasmaphoresis?" Kim said.

Claire looked at Walter.

"AmeriCare is reluctant to authorize it," Walter said.

"Screw AmeriCare," Kim spat. "If there's a chance you think it could help, let's do it."

"Hold on, Dr. Reggis," Walter said. The gray-haired man shifted his weight. He was obviously uncomfortable about this issue. "AmeriCare owns this hospital. We can't just go thumbing our noses at their rules. Plasmaphoresis is expensive and experimental. With lay families, I'm not even supposed to bring it up."

"How do we go about getting them to authorize it?" Kim questioned. "I'll pay for it myself if it can help."

"I'd have to call Dr. Norman Shapiro," Walter said. "He's the chairman of the AmeriCare Review Board."

"Call him!" Kim barked. "Right now!"

Walter looked at Claire. Claire shrugged. "I suppose a call can't hurt."

"Okay by me," Walter said. He left the room to use the phone at the ICU desk.

"Dr. Reggis, plasmaphoresis is grasping at straws," Claire said. "I think it's only fair to tell you and your former wife that you should be preparing yourselves for all eventualities."

Kim saw red. He was in no frame of mind to "prepare himself" as Claire euphemistically suggested. Instead he wanted to strike out at the people responsible for Becky's sorry state, and at that moment his nearest targets were the doctors in that very room.

"You do understand what I'm saying, don't you?" Claire asked gently.

Kim didn't answer. In a suddenly clairvoyant moment, he comprehended the absurdity of blaming these doctors for Becky's plight, especially when he knew where the fault lay.

Without warning, Kim broke away from Claire and rushed out of the ICU. He was beside himself with anger, frustration, and his humiliating sense of impotence. He started down the hall.

Tracy was still in the waiting room. She spotted Kim's hasty exit and immediately knew he was in a rage. When he passed by without a glance, she ran to catch up to him. She was afraid of what he might do.

"Kim. stop! Where are you going?" She pulled on his sleeve.

"Out," he said, breaking away.

"Where?"

Tracy had to run merely to keep up with Kim's determined stride. The look on his face frightened her. For the moment she forgot her own grief.

"I've got to do something," he said. "I can't just sit here and wring my hands. Right now I can't help Becky medically, but by God I'm going to find out how she got sick."

"How are you going to find out?" Tracy asked. "Kim, you have to calm down."

"Kathleen told me the E. coli problem is mainly a problem with ground meat," Kim said.

"Everybody knows that," Tracy said.

"Yeah, well, I guess I didn't," Kim said. "And remember when I told you that a week ago I took Becky to the Onion Ring on Prairie Highway? She had a burger, and it was rare. That had to have been when she got sick."

"So you mean to tell me you're going to the Onion Ring restaurant now?" Tracy asked incredulously.

"Obviously," Kim said. "If that's where Becky got sick, that's where I'm going."

"Right now, it doesn't matter where Becky got sick," Tracy said. "What matters is she is sick. We can worry about the how and the why some other time."

"It might not matter to you," Kim said. "But it matters to me."

"Kim, you're out of control," Tracy said with exasperation. "Just once can't you think of someone else besides yourself?"

"What the hell do you mean?" Kim snapped, feeling even more enraged.

"This is about you, not about Becky. It's about you and your doctor ego."

"The hell it is," Kim growled. "I'm in no mood to listen to any of your psychological nonsense. Not now!"

"You're not helping anyone by running off like this," Tracy said. "You're a threat even to yourself. If you have to go, at least wait until you have calmed down."

"I'm going in hopes it can calm me down," Kim said. "And maybe even give me an ounce of satisfaction."

The elevator arrived, and Kim boarded.

"But you haven't even changed out of your scrub clothes," Tracy said, hoping to find some way to delay him for his own good.

"I'm going," Kim said. "Right now. Nobody's going to stop me!"

Kim pulled into the Onion Ring parking lot fast enough to bottom out on the lip of the driveway. There was a muffled thump, and a shudder went through the car. Kim didn't care. He took the first parking spot he came to.

After putting on the emergency brake and turning off the ignition, Kim sat in the car for a moment and looked out the windshield at the restaurant. It was as crowded as it had been a week earlier.

The drive from the hospital had blunted the edge of his anger but not his determination. He thought about what he'd do once he was inside and then got out of the car. Passing through the main entrance, he found the lines at the cash registers stretched almost to the door. Unwilling to wait, he pushed his way to the front. Some of the customers complained. Kim ignored them.

Once at the counter, Kim got the attention of one of the cash-register girls whose name tag said: HI, I'M DEBBIE. She was a nondescript teenager with bleached hair and mild acne. Her facial features were frozen into an expression of absolute boredom.

"Excuse me," Kim said, forcing himself to sound calm even though it was apparent he was not. "I'd like to speak to the manager."

"You have to wait in line to order," Debbie said. She glanced briefly at Kim but was completely insensitive to his state of mind.

"I don't want to order," Kim said slowly and deliberately. "I want to speak to the manager."

"He's like really busy right now," Debbie said. She turned her attention back to the person standing at the head of her line and asked that the order be repeated.

Kim slammed his open palm down on the countertop with such force that it caused several napkin holders to vibrate off and fall with a clatter to the floor. The sound was like a shotgun blast. In an instant the entire restaurant went silent like a freeze-frame in a movie. Debbie turned pearl white.

"I don't want to have to ask again," Kim said. "I want the manager.

A man stepped forward from a position next to the central island behind the row of cash registers. He was dressed in a two-tone Onion Ring uniform. His name tag said: HI, I'M ROGER.

"I'm the manager," he said. His head twitched nervously. "What's the problem?"

"It's my daughter," Kim said. "She happens to be in a coma at the moment, fighting for her life, all from eating a hamburger here one week ago."

Kim was loud enough to make himself heard throughout the restaurant. Those customers who were eating burgers eyed them suspiciously.

"I'm sorry to hear about your daughter," Roger said, "but there's no way she could have gotten sick here, least of all from one of our burgers."

"This is the only place she had ground meat," Kim said. "And she's sick with E. coli and that comes from hamburger."

"Well, I'm sorry," Roger said emphatically. "But our burgers are all cooked well-done, and we've got strict rules about cleanliness. We're inspected regularly by the department of health."

As abruptly as the restaurant had gone silent, it returned to its high level of background noise. Conversations recommenced as if the collective judgment was that whatever Kim's problem was, it didn't concern them.

"Her burger wasn't well-done," Kim said. "It was rare."

"Impossible," Roger contended, with a roll of his eyes. "I saw it myself," Kim said. "It was pink in the middle. What I'd like to ask…"

"It couldn't have been pink," Roger interjected, with a dismissive wave. "It's out of the question. Now, if you'll excuse me, I have to get back to work."

Roger began to turn away from the counter. Kim responded by lashing out and grabbing a handful of Roger's Onion Ring shirt. With his powerful arms, Kim pulled the startled manager over the counter so that his face was inches from Kim's. Instantly it began to empurple. Kim's iron-like grip was restricting blood flow in Roger's neck.

"A little remorse might be appropriate," Kim snarled. "Certainly not uninformed blanket denial."

Roger gurgled incomprehensibly while he ineffectually grappled with Kim's locked fingers.

Kim rudely pushed Roger back over the counter and let go of him, sending him to the floor. The cashiers, the rest of the kitchen staff, and the people waiting in line gasped but stood rooted in shocked immobility.

Kim rounded the end of the counter, intending to talk directly with the chef.

Roger scrambled to his feet, and seeing Kim coming into the kitchen area. he tried to confront him. "You can't come back here," he said gamely. "Only employees are allowed…"

Kim didn't give him time to finish. He simply shoved him out of the way, slamming the manager into the counter. The collision displaced a plastic juice machine which crashed to the tiles. Juice sloshed out in a wide arc across the floor. Those nearest jumped out of the way. The restaurant again quieted. A few of the patrons left hurriedly, taking their food with them.

"Call the police!" Roger croaked to the nearest cashier as he scrambled to his feet.

Kim continued around the central island to confront the wizened Paul. Kim took in the leathered face and the tattooed arm and wondered about the man's personal hygiene.

Like everyone else in the kitchen, Paul hadn't moved from the moment Kim had pounded the counter. Some of the burgers on the grill in front of him were smoking.

"My daughter had a rare burger here just about this time a week ago," Kim growled. "I want to know how that could have happened."

Roger came up behind Kim and tapped him on the shoulder. "You're going to have to leave," he said.

Kim spun around. He'd had quite enough of the pesky manager.

Roger wisely backed up. He raised his palms. "Okay, okay," he mumbled.

Kim turned back to Paul. "Any ideas?" he asked.

"No," Paul said. He'd seen people go crazy on oil rigs, and the look in Kim's eyes reminded him of these men.

"Come on," Kim snarled. "You must have been the cook. You have to have some idea."

"Like Roger said," Paul asserted. "It couldn't have been rare. I cook all the burgers well-done. It's policy."

"You people are really starting to piss me off," Kim snapped. "I'm telling you it was rare. I didn't get this secondhand. I was here with my daughter. I saw it."

"But I time them," Paul said. He pointed with his spatula to the smoking patties on the grill.

Kim grabbed one of a half-dozen completed burgers that Paul had put on the shelf above the grill for Roger to place on order trays. Kim rudely broke the burger open and examined the inside of the meat patty. It was well-done. He repeated this three more times, slapping the broken hamburgers back onto the plates.

"You see," Roger said. "They're all well-done. Now, if you'll step out of the kitchen area, we can discuss this more calmly."

"We cook them to an inside temperature higher than the one proposed by the FDA," Paul said.

"How do you know the inside temperature?" Kim asked.

"We gauge it with a special five-pronged thermometer," Roger said. "We take the temperature randomly several times a day, and it's always the same: above a hundred and seventy degrees."

Paul put down his spatula and rummaged in a drawer below the grill. He produced the instrument and offered it to Kim.

Kim ignored the thermometer. He took another hamburger and broke it open. It too was well-done. "Where do you store the patties before they're cooked?"

Paul turned around and opened the refrigerator. Kim bent over and peered inside. He knew he was only looking at a small portion of the meat the Onion Ring had to have on hand.

"Where's the bulk of them?" Kim questioned.

"In the walk-in freezer," Paul said.

"Show me!" Kim commanded.

Paul looked at Roger.

"No way," Roger said. "The walk-in is off limits."

Kim gave Paul a shove in the chest with both hands, propelling the man toward the back of the kitchen. Paul stumbled backward. Then turned and started to walk. Kim followed.

"No you don't," Roger said. He'd caught up to Kim and pulled on his arm. "Only employees are allowed in the freezer."

Kim tried to shake Roger off his arm, but Roger hung on. Frustrated, Kim backhanded the manager across the face with significantly more force than he'd intended. The power of the blow snapped Roger's head around, split his upper lip and sent him crashing to the floor for the second time.

Without even a glance at the fallen manager, Kim followed after Paul who now had the freezer door open. Kim stepped inside.

Fearful of Kim's size and impulsiveness, Paul gave him a wide berth. Paul looked back at his manager, who was now sitting on the rubber kitchen mat dabbing at his bloodied lip. Unsure of what to do, he followed Kim into the freezer.

Kim was looking at the cartons lined up on the left side of the walk-in. Only the first was open. The labels read: MERCER MEATS: REG. 0.1 LB HAMBURGER PATTIES. EXTRA LEAN. LOT 2 BATCH 1-5. PRODUCTION: DEC. 29. USE BY MARCH 29.

"Would a hamburger last Friday night have come from this carton?" Kim asked.

Paul shrugged. "Probably, or one similar."

Kim stepped back into the depths of the freezer and saw another open carton nestled among the sealed ones. He opened it and looked in. He could see that the wrapping was also broken on one of the inner boxes. "How come this carton is open?" he asked.

"It was a mistake," Paul said. "We're supposed to use the oldest patties first so we never have to worry about the 'use by' date."

Kim looked at the label. It was similar to the previous one except for the production date. This one said "Jan. 12" instead of "Dec. 29." "Could a patty have come from this one last Friday?" he asked.

"Possibly," Paul said. "I don't remember the day it was mistakenly opened."

Slipping a pen and piece of paper from the pocket of his white coat, Kim wrote down the information on the labels of the two open cartons. Then he took a single patty from each. This wasn't easy because the patties were frozen in stacks separated by sheets of waxed paper. He pocketed the patties and the paper.

As Kim exited the freezer, he was vaguely aware of the muffled sound of a siren whining down. In his preoccupied state, he ignored it. "What's Mercer Meats?" he asked Paul.

Paul closed the freezer door. "It's a meat-processing company that supplies us with hamburger patties," he said. "In fact, they supply the entire Onion Ring chain."

"Is it in the state?" Kim asked.

"Sure is," Paul said. "It's right outside of town in Bartonville."

"That's convenient," Kim said.

As Kim walked back into the kitchen area, the front door of the restaurant burst open. Two uniformed police officers came charging in with their hands resting on their holstered revolvers. Their faces were grim. Roger trailed behind them, angrily gesturing toward Kim with his right hand while his left held a bloody napkin against his mouth.