RIC HATLEY'S LAST DAY ALIVE BEGAN ROUTINELY ENOUGH.
He paused beside his brown delivery truck, shifted the bulky package, and turned in a tight circle to search for the right apartment.
Shouts filled the air. Firecrackers exploded all around him. A dozen red-hot pokers bored holes through his gut.
The package flew from his arms. He crumpled into a privet hedge at the edge of the sidewalk, clutching his midsection and recoiling when his fingers encountered something wet and slimy.
A wave of nausea swept over him. Cold sweat engulfed him.
Eric managed one strangled cry before everything faded to black.
Dr. Anna McIntyre bumped the swinging door with her hip and backed into Parkland Hospital's Operating Room Six, her dripping hands held in front of her, palms inward. "Luc, tell me what you've got."
Chief surgical resident, Dr. Luc Nguyn, didn't look up from the rectangle of abdomen outlined by green draping sheets and illuminated by strong surgical lights. "UPS driver, making a delivery in the Projects. Got caught in the crossfire of a gang rumble. Took four bullets in the belly. Pretty shocky by the time he got here."
"Find the bleeding source?"
"Most of it was from the gastric artery. Just finished tying it off."
Anna took a sterile towel from the scrub nurse and began the ritual of gowning and gloving made automatic by countless repetitions. "How about fluids and blood replacement?"
Luc held out his hand, and the nurse slapped a clamp into it. "Lactated Ringer's still running wide open. We've already pushed one unit of unmatched O negative. He's finishing his first unit of cross-matched blood. We've got another one ready and four more holding in the blood bank."
"How's he responding?"
"BP is still low but stable, pulse is slower. I think we're catching up with the blood loss."
Anna plunged her hands into thin surgical gloves. "Lab work?"
"Hematocrit was a little over ten on admission, but I don't think he'd had time to fully hemodilute. My guess is he was nine or less."
Anna turned slightly to allow the circulating nurse to tie her surgical gown. "Bowel perforations?"
"So far I see four holes in the small intestine, two in the colon." "Okay, he'll need antibiotic coverage. Got that started?"
Luc shrugged. "Not yet. We don't know about drug allergies. His wallet had ID, but we're still working on contacting next of kin. Meanwhile, I have Medical Records checking his name in the hospital computer for previous visits."
"And if he's allergic—"
The nursing supervisor pushed through the swinging doors, already reading from the slip of paper in her hand. "They found one prior visit for an Eric Hatley, same address and date of birth as on this man's driver's license. Seen in the ER two weeks ago for a venereal disease. No history of drug allergy. They gave him IM Omnilex. No problems."
The medical student who'd been assisting moved two steps to his left. Anna took his place across the operating table from Luc.
Luc glanced toward the anesthesiologist. "Two grams of Omnilex IV please."
Anna followed Luc's gaze to the head of the operating table."I don't believe I know you. I'm Dr. McIntyre."
The doctor kept his eyes on the syringe he was filling. "Yes, ma'am. I'm JeffMurray, first- year anesthesia resident."
A first-year resident on his own? Where was the staffman? "Keep a close eye on the blood and fluids. Let us know if there's a problem." Anna picked up a surgical sponge and blotted a bit of blood from the edge of the operative area. "Okay, Luc. Let's see what you've got."
In the operating room, Anna was in her element. The green tile walls, the bright lights, the soft beep of the monitors and whoosh of the respirator, the squeak of rubber soles as the circulating nurse moved about the room—all these were as natural to her as water to a fish or air to a bird. Under Anna's direction, the team worked together smoothly. Conversation was at a minimum, something she appreciated. Do the job in the OR, talk in the surgeons' lounge.
"I think that's got it," Luc said.
"Let's check." Anna's fingertips explored the depths of the patient's belly with the delicate touch of a concert violinist. Her eyes roamed the operative field, missing nothing. Luc had done an excellent job. He'd do well in practice when he finished his training in three months.
Anna stepped away from the table. "I think you're through. Routine closure, leave a couple of drains in. Keep him on antibiotic coverage for the next few days."
Luc didn't need to hear that, but she figured the medical student did. She might as well earn her assistant professor's salary with a little low-key teaching.
She stripped off her gloves and tossed them in the waste bucket at the end of the operating table. "If you need me—"
"Luc, we've got a problem. Blood pressure's dropping, pulse is rapid." A hint of panic rose in the anesthesiologist's voice.
The scrub nurse held out fresh gloves, and Anna plunged her hands into them. "He must be bleeding again. Maybe one of the ligatures slipped off." "No way," Luc said. "Everything was double-tied, with a stick-tie on the major vessels. You saw yourself; the wound was dry when we finished."
"Well, we've got to go back in and look." Anna turned to the anesthesiologist. "Run the IV wide open. Hang another unit of blood and send for at least two more. Keep him oxygenated. And get your staffman in here. Now!"
Jeffsnapped out a couple of requests to the circulating nurse before turning back to Anna. "He's getting hard to ventilate. Do you think we might have overloaded him with fluid and blood? Could he be in pulmonary edema?"
"I want your staffdoctor in here now! Let him evaluate all that. We've got our hands full." Anna snatched a scalpel from the instrument tray and sliced through the half-dozen sutures Luc had just placed. "Deavor retractor." She shoved the curved arm of the instrument into the edge of the open wound and tapped the medical student's hand. "Hold this."
Anna grabbed a handful of gauze sponges, expecting a gusher of blood from the abdomen. There was none. No bleeding at all within the wound. So why was the blood pressure dropping?
"Pressure's down to almost nothing." The anesthesia resident's voice was strained. "And I'm really having trouble ventilating him."
Dr. Buddy Jenkins, one of the senior anesthesiologists, pushed through the swinging doors. "What's going on?"
Anna gave him the short version. "Blood pressure's dropping, pulse is climbing. We've gone back into the belly, but there's no bleeding. And there's a problem ventilating him."
Jenkins moved his resident aside, then slipped a stethoscope under the drapes and listened for a moment. "Wheezes. And no wonder. Look at his face."
Anna peeked over the screen that separated the patient's head and upper body from the operative field. Her heart skipped a beat when she saw the swelling of the lips and the red blotches on the man's face.
"It's not blood loss," Jenkins said. "He's having an anaphylactic reaction. Most likely the blood. Did you give him an antibiotic? Any other meds?"
Anna's mind was already churning, flipping through mental index cards. Anaphylaxis—a massive allergic reaction, when airways closed offand the heart struggled to pump blood. Death could come quickly. Treatment had to be immediate and aggressive.
"He had two grams of Omnilex," Luc said. "But his old chart showed—"
Jenkins was in action before Luc stopped speaking. "I'll give him a cc. of diluted epinephrine by IV push now, then more in a drip." He turned to the anesthesia resident. "Get that ready—one milligram of epinephrine in a hundred milliliters of saline."
"Luc, you two close the abdominal wound," Anna said. "I'm going to break scrub and help Dr. Jenkins."
Jenkins handed her a syringe. "Give him this Decadron, IV push. I need to adjust the ventilator."
Anna injected the contents into the patient's intravenous line. She said a quick prayer that the epinephrine and steroid would turn the tide, that they hadn't been too late in starting treatment.
The team battled for almost half an hour, at first gaining ground, then losing it steadily. Finally, Jenkins caught Anna's eye. They exchanged glances. There was no need for words.
She sighed and stepped away from the table. "I'm calling it."Her voice cracked. "Time of death is 11:07."
Luc let the instrument he'd been holding drop back onto the tray. Jenkins picked up the anesthesia record and began to scribble. Murray, the anesthesia resident, turned back to his supply table and started straightening the mess. The medical student looked at Anna. She nodded toward the door, and he slipped out of the room. She didn't blame him. This was probably the first patient he'd seen die.
Anna tossed her gloves and mask into the waste container. She shrugged, but the tension in her shoulders gripped tighter."Any idea why this happened? The blood was supposed to be compatible. He'd tolerated Omnilex before. What else could have caused it?"
No one offered an answer. And she certainly had none. But she intended to find out.
The OR charge nurse directed Anna to the family room, where she found Hatley's mother huddled in a corner, twisting a handkerchief and occasionally dabbing at her eyes. The room was small and quiet, the lighting was soft, and the chairs as comfortable as possible. A box of tissues sat on the table, along with a Bible and several inspirational magazines. Soft music playing in the background almost covered the hospital sounds drifting in from the nearby surgical suite.
Anna whispered a silent prayer. She'd done this dozens of times, but it never got any easier. She knelt in front of the woman. "Mrs. Hatley, I have bad news for you."
Anna stumbled through the next several minutes, trying to explain, doing her best to make sense of a situation that she herself couldn't fully understand. When it came to the matter of permission for an autopsy, Anna wasn't sure of the medicolegal situation here. Hatley had died after being shot, but his injuries weren't the cause of death. Would she have to call the County Medical Examiner and get him to order one? The weeping mother solved the problem by agreeing to allow a postmortem exam.
There was a light tap at the door, and the chaplain slipped into the room. "I'm sorry. I was delayed." He took the chair next to Mrs. Hatley and began speaking to her in a low voice.
Anna was happy to slip out of the room with a last "I'm so sorry." Outside, she paused and took several deep breaths.
It took another half-hour for Anna to write a chart note, dictate an operative report and final case summary, and change into clean scrubs. She was leaving the dressing room when her pager sounded. The display showed her office number followed by the suffix "911." A "stat" page respond immediately.
As she punched in the number, Anna wondered what else could possibly go wrong today. "Lisa, what's up?"
"Dr. McIntyre, there are two policemen here. They want to talk with you. And they say it's urgent."