Robin Cook: Crisis

Patience's heart was still beating, but barely, when they arrived. A staff cardiologist whom Craig knew well had been summoned, and she met them on the unloading dock. Patience was rolled inside with dispatch, and an entire team began to work on her. Craig told the cardiologist what he could, including the results of the biomarker assay confirming the diagnosis of myocardial infarction, or heart attack.

As Craig had anticipated, Patience was first put on a respirator with one hundred percent oxygen followed by an external pacemaker. Unfortunately, it was quickly confirmed that she then had the problem of PEA, or pulseless electrical activity, meaning the pacemaker was creating an image on the electrocardiogram but the heart was not responding with any beats. One of the residents climbed up onto the table to start chest compressions. Blood work came back and the blood gases were not bad, but the acid level was close to the highest the cardiologist had ever seen.

Craig and the cardiologist looked at each other. Both knew from experience that PEA had a dismal outcome with a hospital inpatient, even when caught quickly. The situation with Patience was far worse, since she had come in by ambulance.

After several hours of attempting all possible efforts to get the heart to respond, the cardiologist took Craig aside. Craig was dressed in his formal shirt, complete with bow tie still in place. Blood spatter adorned the upper part of his right arm, and his tuxedo jacket hung on a spare IV pole against the wall.

"It must have been extensive cardiac muscle damage," the cardiologist said. "It's the only way to explain all the conduction abnormalities and the PEA. Things might well have been different if we had been able to start on her a bit sooner. From your description of the time course, I imagine the size of the initial infarct significantly grew."

Craig nodded. He looked back at the team that was still doing cardiopulmonary resuscitation on Patience's slim frame. Ironically, her color had returned to near normal with the oxygen and the chest compressions. Unfortunately, they had run out of things to try.

"Did she have a history of cardiovascular disease?"

"She had an equivocal stress test a few months ago," Craig said. "It was suggestive of a mild problem, but the patient refused any follow-up studies."

"To her detriment," the cardiologist said. "Unfortunately, her pupils have never come down, suggesting anoxic brain damage. With that in mind, what do you want to do? It's your call."

Craig took in a deep breath and let it out noisily as a reflection of his discouragement. "I think we should stop."

"I agree one hundred percent," the cardiologist said. She gave Craig's shoulder a reassuring squeeze, then walked back to the table to tell the team it was over.

Craig got his tuxedo jacket and walked over to the ER desk to sign the paperwork indicating the patient was deceased and that the cause was cardiac arrest following myocardial infarction. Then he went out into the emergency room waiting area. Leona was seated among the sick, the injured, and their families. She was flipping through an old magazine. Dressed as she was, she appeared to Craig like a nugget of gold among nondescript gravel. Her eyes rose up as he approached. He could tell she read his expression.

"No luck?" she said.

Craig shook his head. He scanned the waiting area. "Where is Jordan Stanhope?"

"He left over an hour ago."

"Really? Why? What did he say?"

"He said he preferred to be at home, where he would await your call. He said something about hospitals depressing him."

Craig gave a short laugh. "I guess that's consistent. I always thought of him as a rather cold, odd duck who was just going through the motions with his wife."

Leona tossed aside the magazine and followed Craig out into the night. He thought about saying something philosophical about life to Leona but changed his mind. He didn't think she'd understand, and he was worried he wouldn't be able to explain it. Neither spoke until they got to the car.

"Do you want me to drive?" Leona asked.

Craig shook his head, opened the passenger door for Leona, then walked around and climbed in behind the wheel. He didn't start the car immediately. "We obviously missed the concert," he said, staring out through the windshield.

"To say the least," Leona said. "It's after ten. What would you like to do?"

Craig didn't have any idea. But he knew he had to call Jordan Stanhope and wasn't looking forward to it.

"Losing a patient must be the hardest thing about being a doctor," Leona said.

"Sometimes it's dealing with the survivors," Craig responded, without any idea how prophetic his comment would turn out to be.

New York, New York7:10 p.m.

Dr. Jack Stapleton had been sitting in his cramped office on the fifth floor of the Office of the Chief Medical Examiner for more hours than he was willing to admit. His office mate, Dr. Chet McGovern, had deserted him just after four when Chet left for his workout at his posh Midtown gym. As was often the case, he'd badgered Jack to come along with glowing tales of the newest batch of nubile female members in his body-sculpting class with their skintight outfits that left nothing to the imagination, but Jack had begged off with his customary rejoinder that he preferred being a participant rather than an observer when it came to sports. He couldn't believe that Chet could still laugh at what had become such a hackneyed comeback.

At five o'clock Dr. Laurie Montgomery, Jack's colleague and soul mate, had poked her head in to say she was heading home to shower and change for the romantic rendezvous Jack had arranged for the two of them that evening at their favorite New York restaurant, Elio's, where they had had a number of memorable dinners over the years. She had suggested he come along to freshen up as well, but he again begged off, saying he was swamped with work and he'd meet her at the restaurant at eight. Unlike Chet, she didn't try to change his mind. From her perspective, it was such a rare event for Jack to be so resourceful on a weeknight that she wanted to bend over backward in hopes of encouraging such behavior. His usual evening plans included a death-defying dash home on his mountain bike, a strenuous run on the neighborhood basketball court with his neighborhood buddies, a quick salad at one of the Columbus Avenue restaurants around nine, followed soon after by a mute collapse into bed.

Despite what he had said, Jack didn't have that much to do and had been scrounging around to keep himself busy, particularly over the last hour. Even before he had sat down at his desk, he had been reasonably caught up with all his outstanding autopsy cases. The reason he was forcing himself to labor this particular afternoon was to keep his mind occupied in a vain attempt to control the anxiety he felt about his secret plans for the evening. The process of submerging himself in either his work or strenuous athletic activity had been his balm and salvation for more than fourteen years, so he wasn't about to abandon the ruse now. Unfortunately, his contrived work wasn't holding his interest, especially since he was running out of things to do. His mind was beginning to wander into forbidden areas, which began to torment him into having second thoughts about the evening's plans. It was at that moment that his cell phone came to life. He glanced at his watch. There was less than an hour to go before D-day. He felt his pulse accelerate. A phone call at that moment was an inauspicious sign. Since the chances of it being Laurie were nil, the chances were huge that it was someone who could throw the evening's schedule out of whack.

Pulling the phone from his belt clip, Jack eyed the LCD screen. Just as he feared, it was Allen Eisenberg. Allen was one of the pathology residents who was being paid by the Office of the Chief Medical Examiner to cover routine problems after hours, which the forensic investigator on duty thought needed the attention of a medical doctor. If the problem was beyond the pathology resident's comfort zone, then the medical examiner on call had to be contacted. Tonight, it was Jack.