Chapter 1
Lucy Wagner knew exactly when she would hold the heart in her hands, its hard muscle churning against her palm, its moist heat warming her fingers. Knew when its rhythmic twisting would stagger and fall silent as the drugs brought it to a standstill. Frozen in time.
She just didn’t know it would be this heart or under these circumstances.
John Doe changed everything. John Doe couldn’t wait. John Doe bumped her 7:30 elective coronary bypass until later. Probably much later.
Thirty-five minutes earlier, Doe had been found down, face down, on the ER entry ramp at the Remington Medical Center. Purple, breath coming in shallow gasps, pulse barely palpable, and spiraling toward death. Circling the drain in medical slang. The heroic efforts of ER Director Dr. Jeffrey Dukes and his staff, pumping Doe full of fluids and blood, restoring just enough blood pressure to feed Doe’s weak but tenacious spark of life, somehow stabilized him long enough to reach Lucy’s operating table in OR Suite 3.
Now, the scalpel she held in her rock-steady hand hovered near the old man’s flesh. Tinted reddish brown by the hasty pre-op Betadine scrub, the parchment-thin skin and its underlying age-wilted muscles were all that separated the blade from the torn aorta and the massive pool of blood she knew waited within Doe’s abdominal cavity. A cardiovascular surgeon’s worst nightmare. The elderly man had little chance of getting through this alive but absolutely none if Lucy didn’t jump right in. As one of her fellowship mentors at Vanderbilt had been fond of saying, “They’re are times to contemplate and times to slash and grunge.”
This was slash and grunge time.
Prayer wouldn’t hurt.
Scrub nurse Rosa Lopez adjusted the round bank of overhead lights to better illuminate the surgical field. Across the table stood Dr. Herb Dorsey, Remington’s oldest and most respected general surgeon. He had been in the OR, waiting for his elective gall bladder case to begin, and had volunteered to help.
“How’s he doing, Raj?” Lucy asked anesthesiologist Dr. Raja Singh.
Raj peered over the curtain of surgical drapes that separated his little world of monitors, anesthetic gas and oxygen canisters, and whooshing ventilator tubes from the sterile field that was Lucy’s domain. “BP up to eighty, heart rate one-thirty, sinus tach. Four units of blood in. Two more on the way.” He shrugged. “Not too bad considering.”
Lucy smiled into her mask. Typical Raj. Always understated, always unflappable. She looked at Herb. “You ready to dive in?”
He nodded.
Rosa picked up the suction cannula, an angulated plastic nozzle connected by a clear plastic tube to a suction bottle near her feet. “Crank this baby up all the way,” she shot over her shoulder to the circulating nurse. “It’s going to be a gusher.”
Damn right, Lucy thought. John Doe’s atherosclerosis had finally caught up with him. His hard and brittle aorta had cracked and split and ripped and pumped nearly his entire blood volume into his abdomen, swelling it to pregnant proportions. He was, as the locals say, “As swollen as a chigger on a blue-tick hound.”
It was going to be bloody.
God, she loved this. Always had. The adrenalin rush that had enticed her into surgery in the first place. As far back as high school she had thought being a surgeon would be cool. Even the word surgeon was cool. When she shared these dreams with her classmates, most nodded politely and told her that was a wonderful ambition. But she knew they believed she’d never do it. She was a marginal student, interested in athletics and boys more than academics. Track and softball were her sports. Things changed in college where she majored in chemistry and focused on her grades. Straight A’s opened the door to medical school.
During med school, she tried to keep an open mind, accepting of all medical and surgical specialities. Until her junior year surgical rotation. Trauma surgery. Run and gun. Do first, think later. She was hooked and dropped all pretense of considering another branch of medicine. As she climbed the medical food chain from student to intern to surgical resident, cardiac surgery stepped to the forefront. So here she stood, ready to dive elbows-deep into John Doe’s belly.
Lucy drew the scalpel blade down the center of the Doe’s belly, dividing the skin and subcutaneous tissues. She extended the incision from the lower end of his sternum to his pubis. Dark blood leaked from the slash.
“He looks a little desaturated,” she said. “What’s his O2 sat?”
“Eighty-four percent,” Raj said. “He’s on sixty percent O2. I’ll bump it to a hundred.”
Lucy continued dissecting downward through the old man’s tissues until she reached the peritoneum, the membranous sac that lined the abdominal cavity.
She glanced up at Herb. “Here we go.”
The blade punctured the membrane. Liquid blood erupted through the breach, dragging with it thick maroon clots that looked like over-fed leeches. The suction cannula jerked, squealed, and gurgled as it drew blood from the distended belly. The clots swirled down the plastic tube and into the collection bottle beneath the table.
This was the critical time. With the lessening of the tension inside the abdomen, the pressure on the torn aorta would fall. Pressure, which like the proverbial thumb in the dyke, had held the bleeding in check. At least somewhat. Now the flow of blood from the ruptured vessel would dramatically increase and Doe could bleed out in a minute. Literally.
In two swift motions Lucy elongated the incision in the peritoneum, first north and then south. Herb scooped up the intestines and tugged them aside, giving Lucy access to the deeper regions where the aorta lay along the back wall of the abdomen. She dipped both hands into the blood pool, her experienced fingers quickly finding the aorta. The squealing of the suction cannula grew louder.
“Jesus,” Lucy said as she located the tear. “He blew out the lateral wall and it’s extended superiorly.” Her hands worked upward along the vessel. Blood welled in the abdomen faster than the suction cannula could remove it. Lucy’s fingers painted the picture for her. “Left renal artery is trashed.” He hands worked higher. “It’s dissected up through the diaphragm.”
She exhaled heavily. Doe’s chance of survival had just dropped to near zero. An acutely ruptured abdominal aorta carried a mortality of 95% or more, but if the breach extended up and into the chest, that figure rose to near 100%.
Lucy looked across at Herb. The narrowed eyes that stared back from above his surgical mask and the sweat that stained the front edge of his cap said it all. Herb had performed thousands of surgeries and knew when things were going sideways. His look reflected that. Not fear, experienced surgeons being immune to that emotion, but a healthy dose of anxiety.
“BP is down to 60,” Raj said. “I’ll up the Dopamine and the Epinephrine.”
“We’re going to have to open his chest,” Lucy said. “I’ve got to get above the dissection and cross-clamp the aorta if we’re going to stop this bleeding.”
“Some ectopic beats,” Raj added.
Lucy glanced at the cardiac monitor. The blips that indicated the cardiac rhythm, which before had raced across the screen in a rapid but steady pace, now showed irregularity. Then an angry burst of wide and rapid complexes appeared.
“And salvos of V-Tach,” Lucy said. “Give him some lido, Raj.”
“Got it.” He shoved the needle into the IV port and depressed the plunger. “Lido one hundred milligrams on board.”
“Scalpel,” Lucy said.
Rosa slapped it into her open palm. Lucy divided the skin over the chest down to the sternum. Herb handed her the sternal saw. Lucy fitted the knob, designed to protect the heart and lungs from the blade, into the sternal notch and flipped on the saw. Its high-pitched whine cut through the room and echoed off the tiled walls. The scream of the saw blade slowed and dropped an octave or two as she drew it along the length of the sternum, dividing it cleanly. The acrid smell of burning bone filled the room.
Rosa had the sternal retractor ready. Lucy hooked it beneath each half of the divided sternum and Herb twisted the crank. The chest yawned opened. The exposed heart churned rhythmically. At first. Then it gave several spasmodic jerks and fell into a fine quiver.
“V-Fib,” Raj said.
Lucy examined the monitor again. The EKG no longer showed the blips of cardiac electrical activity, but rather the fuzzy, wavering line of ventricular fibrillation, the most lethal of all cardiac rhythms. Beneath that, a second line, the blood pressure monitor, was now flat.
“Let’s rock and roll,” Lucy said.
She wrapped her fingers around the heart. A normal, strong, blood-filled heart is firm and churns and grinds against your hand. Not Doe’s. His was flabby and soft, indicating that the muscle was diseased and weakened and that his heart was nearly empty. Most of Doe’s blood now resided in his abdomen. Wouldn’t do much good there.
This was going badly.
Lucy began the cadenced squeezing motion of internal cardiac massage. The blood pressure monitor now displayed a weak pulse in time with Lucy’s compressions. Enough to keep him alive, but not for long.
“Defib paddles,” Lucy said.
Herb took them from Rosa, grasping the handles and fitting the business ends, flat metal discs, against opposite sides of the heart.
“Charged to thirty watt/seconds,” Raj said.
“Clear,” Herb said.
Lucy released the heart and withdrew her hands.
Herb depressed the paddle’s buttons, delivering an electric jolt directly to the heart. The monitor indicated a brief moment of cardiac rhythm, but quickly returned to V-Fib.
“Again,” Lucy said.
Herb fired the defibrillator a total of seven more times, Lucy continuing compressions between each while the device recharged. Raj injected more lidocaine, along with procainamide, metoprolol, and amiodarone. None of this restored a viable rhythm. Lucy continued to squeeze the heart, her hand serving as Doe’s only means of survival. With each compression, the heart became softer as blood continued to leak into the abdomen.
Sweat trickled into Lucy’s eye and she blinked it away. “Let’s cross-clamp the aorta. Maybe control some of this bleeding.”
“You think that’ll help?” Herb asked.
“No, but we’re running out of options.”
Lucy stopped her massaging efforts and snatched a curved vascular clamp from the surgical tray. In the tight quarters behind the heart and the left lung, she managed to slide the clamp around the thoracic aorta. So far so good. But when she attempted to squeeze the fragile vessel between the instrument’s jaws, the brittle tissues cracked, disintegrated. She resumed the cardiac massage and looked across the table at Herb. “Any other suggestions?”
He shrugged. “Call a priest.”
“Anyone else have any ideas?” Lucy asked.
Silence, a few heads shook.
Lucy nodded. “I guess that’s it.”
As she started to release her grip on Doe’s flabby heart, a cold sensation surged through her fingers as if she were holding a ball of ice. Her hands ached and the chill flowed up her arm and into her chest. A wave of nausea and dizziness racked her.
Somewhere in the distance she heard Raj say, “Time of death is eight twenty-four a.m.”
A flood of sweat popped out on her forehead and trickled down the side of her face. The lights dimmed and closed in. She wavered.
“You okay?” Rosa asked, her voice tinny and muffled.
Another wave of dizziness. Lucy took a deep gulp of air, another, shook her head, but she felt as if she were sinking and sensed her legs folding beneath her. Her world went black.
The next sensation she had was a cold hardness against her cheek. A bright, irritating light seemed to come from all directions. She felt shadows moving across her and heard voices, but couldn’t make out what they were saying. Several smudges of light blue shuffled before her. She heard someone call her name but couldn’t tell who or where it came from. Someone shook her shoulder. Her vision began to clear. The blue smudges became three pairs of surgical booties, each speckled with blood droplets. Again she heard her name, closer now, more distinct, and felt something clutching at her shoulder, shaking her again.
She rolled to her back. Three angels stood over her, their faces framed by bright haloes. They reached for her. One of the angels was Herb.
“Lucy. Lucy,” he said.
“What....” she began.
Someone said, “She’s coming back.”
Lucy looked up into Herb’s face, and then Rosa’s, each backlit by the overhead surgical lights. She looked around. She was on the floor of the operating room.
“What happened?” she asked, attempting to sit up. She realized someone had removed her surgical mask and cap.
Herb pushed against her shoulder. “Just lay there for a minute.”
“What happened?” Lucy asked again.
“You fainted,” he said. He reached behind her neck, untied the top of her surgical gown, and pulled it over her arms, taking her bloody gloves with it. “Just relax and take a few breaths.”
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