Michael Palmer: Fatal

Sandersonville was twenty minutes from the hospital and Crook was hardly the sort who would simply jump into a pair of sweats and race on in — especially when there was no definite indication in any of the victims that a cardiologist would be needed.

"Dr. Rutledge?"

Lee gestured at the monitor — 70/30.

"Prepare to intubate him, Jon. Anesthesia around?"

"In the OR."

"Radiology?"

"Same. She's doing some sort of procedure with Dr. Terry."

Inwardly Matt groaned. He had intubated dozens or patients, many of them critical, so that was no problem. But his ability to interpret an ultrasound was average at best. In a life-and-death situation like this one, he would want a radiologist's opinion.

"No problem," he said. "Get me a seven-point-five tube, please. Laura, could we talk out there?"

The nurse looked at him curiously.

"Of course," she said.

"Jon, just shout if you need me."

Matt walked Laura to the nurses' station. She was a straight-laced grandmother in her early fifties, traditional in her approach to medicine, and a damn fine nurse. She was never comfortable with Matt's open style, manner, and dress, she had said so on several occasions. Still, over the years, they had managed to co-exist with few problems. Now, he knew, he was about to put their mutual respect to the test.

The commotion in the ER seemed to have leveled off, and the moaning from the injured miners was much less.

"How's he doing?" Elaine LeBlanc asked as they passed.

"Later," Matt said.

"You talk to me before you do anything heroic, you hear? That… that weirdo killed one and maybe two of my men."

"Sure, Dr. God," Matt said. "I'll be certain to consult with you."

He turned his back on LeBlanc and spoke softly to the nurse. From what he could discern, blood was building up between the lining of Teague's heart and the heart muscle itself. The resultant constriction of the heart muscle was keeping it from filling properly between each beat.

"Laura, this guy's got a pericardial tamponade."

"How do you know?"

"That's what it's got to be. We need to stick a needle into it and drain the blood."

"Can't we wait for Dr. Crook?"

"Unless we can be sure he's going to be here in the next five minutes, the answer is no."

"What about some tests? An ultrasound?"

"Radiology is in the OR. I don't trust the tech or me to read one with certainty. Besides, I don't think we have time. This kid is going out."

"Maybe that's for the best," Laura said.

"Now, don't let us get started on that," Matt said. "Please get me a pericardial drainage kit."

"Matt, I don't like this at all. How many times have you done this procedure?"

"A few during my residency," Matt lied. "I can do it."

"Pressure's not reading," Lee called out. "EKG is showing many extra beats."

"Please," Matt said, heading back to room 10.

"If you're ordering it, I'll be right there with the kit."

"Remember what I told you," LeBlanc said as Matt passed him.

Matt knelt at the head of Darryl Teague's bed and skillfully slid a breathing tube down his throat and between his vocal cords. The respiratory tech then hooked the tube to a breathing bag and oxygen, and began to pump. Teague's chest expanded much more than it had been, but his blood pressure only rose to 50.

"Nice intubation, Doctor."

Hal Sawyer stood just inside the doorway. With his dark hair graying at the temples, his carefully trimmed mustache, his gold-rimmed glasses and knee-length lab coat, Uncle Hal looked as professorial as did any medical school dean. In fact, he did have a clinical teaching position at one of the medical schools, but for the most part he stayed pretty close to Belinda, where he was chief of pathology (there was one other full-time pathologist) as well as the Montgomery County medical examiner. Hal was also erudite, well-read, and adventurous. He seldom spoke up at hospital staff meetings, but when he did, people generally listened.

Never married, Hal didn't seem to lack for company. His latest girlfriend, Heidi, was a pretty, young thing he had met on some sort of rafting trip. The gossipers in Belinda went on about his personal life, but he never seemed to care, just as he didn't care when the rumors started going around some years ago that he was gay. Hal was very much his own man, and Matt credited him with fostering his own sense of independence.

"Hey, Hal," Matt said, "thanks for coming over. This is the guy who went berserk in the mine and caused this nightmare. People say he's been acting paranoid for months. Paranoid insanity coupled with diffuse neurofibromatosis of the face and scalp. Ring any bells?"

"Just like that cliff diver."

"Exactly. His name was Rideout. Teddy Rideout. And where did he work?"

"As I recall," Hal said, palpating the lumps, "he, too, was a miner."

"He was most definitely that. BC and C, to be exact."

"My, my," Hal said.

Some months ago Matt had been cruising on his Harley down a particularly winding mountain road when Rideout sped past him on the inside, traveling much faster than the road ahead would tolerate. A minute or so later, Matt came upon the shattered guardrail and saw the car lying on its roof several hundred feet below. Rideout lay well beyond resuscitation. His striking facial lumps were identical to Teague's, and subsequent discussion with his family revealed a history of rapidly progressive paranoia and irrational, aggressive behavior. At the man's autopsy, Matt wondered out loud to his uncle if Rideout might be toxic from something at the mine.

Hal had promised to run some extra tests, which came back negative. It was Hal's belief that the man was one of a kind — a very unusual case, but just a single fluke point on the graph of life.

Well, Matt thought now, here's dot number two.

"I'll see what I can dig up about Mr. Rideout," Hal said. "I don't recall anything unusual in the autopsy except for those neurofibromas, which were only of interest because of their numbers, not their microscopic appearance."

"Here's the kit," Laura said, setting the tray marked PERICARDIO-CENTESIS down on the stainless-steel stand.

"Any sign of Crook?"

"He could be here any minute. Are you sure you — "

"But he's not here now. This guy's BP is back down to zero. He's firing extra beats. I say we go."

"Suit yourself," Laura said coolly.

In fact, Matt had attempted pericardial taps a number of times as the last gasp maneuver in cardiac arrest patients who were about to die despite the most heroic resuscitative measures. But never had the procedure located any unsuspected pericardial blood. And never had any of the patients survived.

"Need any help?" Hal offered.

"Will Robert Crook to stroll into the ER right now," Matt said. "I just don't think we can wait."

Beyond Hal, just a few feet outside the door, Matt could see Elaine LeBlanc, watching, waiting.

"I'm still not getting any pressure at all," Lee reported. "Ventricular extra beats in pairs."

Sometimes you just got to do what you got to do, Matt was thinking.

He attached a four-inch-long, wide-bore cardiac needle to a 20cc syringe and hooked an alligator clamp to the base of it. He would know he was wrong about there being pericardial blood only after he had driven the heavy needle through the tissue-thin pericardial membrane and into the base of Teague's heart. The electrocardiogram would react immediately to the trauma, and hopefully, he would have time to stop and withdraw the needle before any major damage was done to the cardiac muscle. Hopefully. But if he pierced the muscle and hit a coronary artery, the resulting heart attack would give Teague almost no chance at all.

Matt forced the needle through the skin at the V formed by Teague's left lower ribs and the tip of his sternum. Then he angled it toward his left shoulder. Keeping the pressure constant, he advanced the needle through the diaphragm toward what he envisioned was the base of the heart.