Robin Cook - Toxin

"She should do fine with the peritoneal dialysis," Arthur said.

"But she just had surgery for a perforation," Kim said.

"That was taken into consideration," Arthur said. "But the problem is AmeriCare only offers dialysis machines at Suburban Hospital. We'd have to transfer the patient there, which we surely don't recommend."

"The other major problem is her platelet count," Walter said. The blood specialist was a gray-haired older man who Kim guessed was in his seventies. "Her platelets have fallen precipitously to the point where we feel they must be replenished despite the inherent risks. Otherwise, we might have a bleeding problem on our hands."

"There's also the problem with her liver," Claire said. "Liver enzymes have risen remarkably, suggesting.."

Kim's mind was on overload. He was stunned to the extent that he was no longer absorbing the information being presented to him. He could see the doctors talking, but he didn't hear. It was the nightmare all over again, with Becky floundering in the dangerous, surging sea.

A half hour later, Kim stumbled out of the ICU into the ICU waiting room. Tracy got up the moment she saw him. He looked like a broken man.

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 23rd

Kim 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 0157: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.