Michael Palmer: Fatal

Slowly… slowly…

"Lots of extra beats," the nurse reported.

"Are you hitting his heart right now?" Laura asked.

Matt checked the monitor.

J sure hope not, he thought.

"No," he said assuredly.

"Are you sure?"

Without warning, the syringe filled with blood.

Yes!

Matt switched the three-way valve on the syringe to empty and injected its crimson contents into a small glass cup. Then he withdrew another 25cc of blood from Teague and squirted it into a larger beaker.

"How do you know you're not drawing blood directly from his heart?" Laura asked.

The woman simply wasn't going to let up.

Hal stepped forward.

"Ms. Williams," he said calmly, "it looks very much like Dr. Rutledge knows what he is about. There is one way to tell right here where that needle tip is. If that blood Dr. Rutledge just removed was sitting in this man's pericardial space, it probably won't clot. If it's directly from the ventricle of the heart, it will."

"How long will that take to know?"

Matt ignored the question and drew off another syringeful. Teague's condition remained unchanged. To his left, Lee tried again to hear a pressure, then shook his head gravely.

"If he's in shock and you might be taking blood from his heart, won't that make the situation even worse?" Laura asked.

Back off! Matt wanted to scream. The nurse was quite obviously protecting herself against Robert Crook's certain onslaught.

I tried to reason with him, Dr. Crook, really I did.

Matt slid a thin plastic catheter through the needle and into what he hoped was the pericardial space. Then, carefully, he withdrew the needle and fixed the catheter in place with a single suture through the skin of Teague's chest. Blood oozed from the catheter opening and soaked an expanding stain into the sterile drape. For several seconds there was nothing but a tense silence.

"Pressure's still zero," Lee reported at the moment Robert Crook charged into the room.

A rotund, ruddy-faced man, Crook had dense, sandy-gray brows that always looked to Matt like giant woolly caterpillars about to do battle. Along the margin of his left jaw were several fresh clots from where he had nicked himself shaving, as well as a tiny, bloodstained flake of tissue paper. His response to the emergency at MCRH had clearly been to charge into the bathroom and break out his razor and shaving mug.

"Rutledge, what's going on?" he demanded.

Matt shrugged.

"He lost his blood pressure and I couldn't figure out why. I decided he had a pericardial tamponade, so I tapped him."

"You… tapped him?"

"Still no pressure," Lee called out.

"Be sure the dopamine is open all the way," Matt ordered.

"It is."

"Did you see pericardial fluid on his echo?" Crook asked, ignoring the sterile field and the thin catheter in order to listen with his stethoscope.

"I… wasn't able to get an echo. No time."

Crook erupted.

"Jesus Christ! How can you be sure you've stuck that needle into his pericardial space and not into his friggin' heart?"

"I did what I thought was right," Matt responded as steadily as he could manage. "I did what I thought was needed, and I did it the best I could."

"The best you could? Rutledge, you're not a doctor. You're a goddamn cowboy. A loose cannon. And I want you to know that I fully intend to report your actions to — "

"Wait," the nurse cried out. "I hear a pressure. It's loud and clear at sixty… No, now it's eighty. It's eighty."

At that moment, Darryl Teague lifted one arm and turned his head.

"Mornin, Kim," Matt said to the efficient, empathetic clerk of the ICU.

"Good morning, Doctor" was the chilly reply.

Matt considered confronting the woman. Kim West had always been at least cordial to him, if not downright friendly. But there was no sense in singling out her rudeness. The Belinda Coal and Coke Company was the lifeblood of the valley. In one way or another, all of Montgomery County was linked to it. Over the three days since he saved the life of Darryl Teague, the coolness toward him on the streets of Belinda had grown increasingly unpleasant. Teague had never been a favorite son of the town, and now two young men were dead because of him. And because of Matt, he wasn't. The gas station, Scotty's Diner, the dry cleaner — wherever he went, there were whispers and tension, even in the hospital, where people should have known better about the choices doctors should and should not be making.

Within hours of the incident in the ER, Robert Crook had sent a memo to the entire hospital staff decrying Matt's behavior and judgment. He even speculated that poor technique in doing the pericardial aspiration had placed the man in as much jeopardy as had the accident itself.

Teague was officially Crook's patient, and the cardiologist had gone out of his way to involve an internist other than Matt in his care. Still, Matt had made it a point to visit Teague twice a day since the disaster. Helping to save a person's life forged a connection only those who had been in that situation could completely understand.

Ignoring the distasteful glare from one of the older nurses — a miner's mother, Matt recalled — he went directly to room 6. The lights were out, save for a dim fluorescent over the bed. Teague, his monstrously deformed face battered and bruised, lay on his back breathing shallowly and irregularly on a ventilator. He was unconscious, as he had been since shortly after his transfer up from the ER. From what Matt could tell, there was no decent explanation for his lapse into a coma. Initially, blunt head trauma was the likely suspect, and that certainly remained a possibility. Still, there had been no order for an MRI or CT scan, or even for a consultation with the neurologist. Robert Crook certainly wasn't going to win any Doctor of the Year award for his attention to this case, although he might well receive a good citizen medal from the townsfolk.

Matt stood in the gloom, looking down at Darryl Teague.

What happened to you, Darryl? he asked silently. What did you and Teddy Rideout inhale? What did you drink? What did you rub onto your skin?

Matt took Teague's wrist and checked his pulse, which was quite strong. The torn vessel that had caused the nearly lethal cardiac tamponade had clotted, and the narrow drain, which had been placed under the pericardial membrane, had been removed. Now, to all intents, Teague's mysterious coma was all that was standing between him and a transfer out of MCRH — probably to some prison hospital. Matt did a brief neurological check. Nothing alarming — no focal signs that would suggest a slowly increasing hemorrhage between the skull and brain. He reached up and gently touched the hard, fleshy lump above Teague's left eyebrow, then the one on his chin. Had the man ever bothered to see a doctor for this bizarre condition, or did his rapidly progressive mental illness prevent him from acting rationally?

"What's the deal, Darryl?" Matt whispered. "Come on. Wake up and tell me… What's the deal?"

He picked up the bedside phone, hesitated, then called the pathology lab. In seconds his uncle was on the line.

"Hal, how're you doing?"

"Well, I don't have half the town wanting to tar and feather me for just doing my job, if that's what you mean."

"There's a nurse right outside who'll be happy to smear the first glob on me. Listen, Hal, I'm here in Teague's ICU cubicle. You may already know this, but he's been in a coma since right after he was moved up here from the ER. I'm wondering if someone's medicating him."

"Why?"

"First if, then why. Is there any way you could have one of your techs draw an extra tube and run a drug screen on it?"

"Without telling Crook?"

"That's the idea. I would draw it myself, but there would be hell to pay if a nurse walked in on me while I was doing it."