Toxin (17 page)

For a moment they stared into each others eyes. Now it was Kim's turn for tears. Tracy reached out, and they locked in a hug of fear and grief.

Friday, January 23
rd

K
im 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 O157: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.”