Critical Judgment (1996) (41 page)

There were half a dozen neighbors standing around
the living room. None of them had seen anything unusual around Kelly’s house. In fact, none of them had even seen her come home. There was going to be no way to fix the length of exposure. Abby knew they all expected her to do something heroic. But without oxygen and some way to deliver it in high concentrations, there wasn’t much she could do except continually monitor Kelly’s pulse and be prepared to institute CPR at the first sign of a loss of blood pressure. She did have the presence of mind to send one of the men over to Kelly’s car and house to look for pills.

“Open the car door carefully and don’t touch anything except with a cloth,” she warned.

“You mean you don’t think this was an attempted suicide?” he asked.

“I don’t know,” she lied. “But let’s not assume anything.”

Abby wiped the rain from her cheeks with the back of her hand. Thank God it was Lew waiting there in the ER and not McCabe or Jill Anderson. Together they would do what they could do. She looked down at Kelly, who was laboring to breathe once again, and adjusted the jacket beneath her neck. The woman was a few years older than Abby, but without her tortoiseshell glasses it was easy to appreciate her youthful skin and fine, somehow innocent, little-girl’s face.

You shouldn’t have done it, Kelly
, Abby was thinking.
You shouldn’t have gone down there alone
.

Abby forced herself to stay focused. She was angry, shocked, and frightened, but determined not to be distracted by any emotion. This was the time to do things precisely right.

The immediate goal would be to get a breathing tube in and get Kelly onto a cardiac monitor. Next would be to deliver 100 percent oxygen and treat any cardiac irregularities. Once in the ER, they would measure the amount of circulating carboxyhemoglobin, as well as Kelly’s blood pH. The low pH could be corrected, but
the dissociation of oxygen from hemoglobin was another story. The oxygen concentration of room air was about 20 percent. In a hospital setting they could deliver pure oxygen—100 percent. Unfortunately, even pure oxygen was often not enough to break apart the carboxyhemoglobin in time to prevent serious brain damage. There was, however, a way to deliver
more
than 100 percent, and that was by giving 100 percent oxygen under increased atmospheric pressure. Hypersaturation, it was called. The technique would require transporting Kelly to a hyperbaric decompression chamber. Somebody at the hospital would know where the nearest ones were. There she would undergo a series of what amounted to deep dives into a sea of pure oxygen. The carboxyhemoglobin would yield to the technique much more quickly than it would to oxygen delivered at sea-level pressures, or worse, at the atmospheric pressure in Patience, which was located several hundred feet
above
sea level.

The key was remembering that carbon-monoxide poisoning was insidious. Patients could look fine, and even test fine in some respects. But until the oxygen-hemoglobin balance was restored to normal, irreversible brain-cell damage would continue to progress. Hundreds of fire fighters and victims of fires had had life as they knew it preserved by tenacious ER docs who got them into chambers despite no clinical evidence that they were in danger. They were breathing, their heart was generating a blood pressure, and they were awake and alert. Why push?

Abby knew why. She reached down and cradled Kelly’s head in her hand. The woman remained motionless. From somewhere in the distance she heard the first siren.

“Okay,” she said to the neighbors. “If you could all move away to give us room to work, that would be a help.”

The man whom she had sent back to Kelly’s car and
house rushed in, carefully holding a pill bottle with a washcloth.

“I couldn’t find anything in the house except Tylenol. But this was on the floor of the car,” he said, breathless.

There were two pills in the rust-colored clear-plastic vial. Two pills and no label. Abby had no doubt the carefully placed tablets would coincide perfectly with whatever was depressing Kelly’s respirations and constricting her pupils. And, of course, no one in the crack, unbiased Patience police department would question why a woman bent on suicide would bother to swallow the entire contents of a bottle of pills … except two.

The siren grew louder, and at least one more could now be heard. In seconds the strobes of the ambulance flashed through the windows. Abby remained kneeling beside Kelly until the three-person rescue squad rushed in. One of the paramedics was Tom Webb, whose feelings she had hurt during the resuscitation of the insurance man, Bill Tracy. She had gone out of her way that day to apologize for anything she might have done or said in the heat of battle. And since that time even after the Peggy Wheaton debacle, there seemed to be a decent relationship between the two of them. Now, seeing him was a boost.

“We need to intubate her, Tom,” she said. “I have no idea how long she was in that garage. Maybe we should get her right on a monitor, too. The monoxide and the acidosis can wreak havoc on her cardiac rhythm. Also, she looks like a possible narcotics overdose. We’re going to need an IV and oh-point-four of Narcan to reverse that. Have someone remember to repeat the dose in two minutes if she’s no better, even if I forget to ask for it.”

The young man just nodded and relayed her orders to the other two. Despite the minor clash over the technique used in pumping Bill Tracy’s heart, the squad was damn good. In less than a minute one of them—a slight woman old enough to be Tom’s mother—had a good IV
line in place and the narcotic antagonist injected. A second paramedic worked on hooking up the portable monitor/defibrillator.

Tom Webb set out the equipment for tracheal intubation. All the paramedics were trained in performing the procedure, and every one Abby had ever known took great pride in being able to do it in the field. But after anesthesiologists, who intubated almost every surgical patient in the operating room, ER doctors were generally the next-most skilled. Abby had always had confidence in her ability to intubate anyone in any situation.

“Here you are, Doctor,” Webb said, handing her the laryngoscope and a tube.

Abby looked over at the young man. Kelly was still breathing on her own, which made the situation a bit less critical. Several weeks ago she had inadvertently embarrassed Tom in front of a number of his co-workers. She was The Professor then, still operating on university mean time. Now she really was becoming someone else. And one of many lessons she was learning at PRH was how important reputations were in a closed community, and how fragile.

“Go for it, Tom,” she said. “I’ll assist. She’s still moving air, so we have time to get her up onto the stretcher if it would be easier for you.”

She hoped he would know that she was telling him not to try to intubate Kelly while stretching himself out on the rug. If he attempted to do it that way and missed, she would have to step in and take over. If he missed while Kelly was up on the stretcher, she would have to decide whether or not Kelly’s condition allowed him a second pass.

“Help me get her on the stretcher,” Tom ordered.

With Abby holding Kelly’s neck steady at just the right angle, the paramedic knelt at the head of the stretcher and got his body in perfect position. Then he slid the lighted, curved laryngoscope blade along Kelly’s tongue and applied just enough upward pressure
to lift her epiglottis away from the opening of her trachea. Abby could tell from his position and technique that he had given himself an excellent view of Kelly’s vocal cords. She placed the breathing tube in his hand.

“Steady on,” she whispered. “You’re doing great.”

The paramedic slipped the tube smoothly into place between the cords. The woman who had inserted the IV had a breathing bag in hand with portable oxygen already attached.

“Nice shot, Tom,” she said. Then she looked over at Abby and mouthed the word,
Thanks
.

By the time they wheeled Kelly out of the house and hoisted her into the ambulance, her pupils seemed a bit less constricted and her color was a tad better. But she still had not regained consciousness.

Abby knew that was a bad sign.

The moment Kelly’s stretcher was pulled from the ambulance and into the ER, the dam that had been holding back Abby’s emotions burst. Nearly consumed by fury, she paced behind the nurses’ station. Lew stood nearby, keeping a constant eye on the ER. It was considerably busier than it had been just two hours ago.

“She found something,” Abby said. “She found something in those caverns beneath Colstar, and that bastard Quinn tried to kill her.”

Across from the nurses’ station, in major medical, almost lost among the wires and the tubes, Kelly Franklin’s profile was just visible. She had not moved voluntarily for the forty-five minutes since their arrival in the ER. Above Kelly a monitor scanned out a heartbeat that had been in nightmarish irregularity. To make matters much worse, they were having a hell of a time finding an accessible decompression chamber where the staff was willing to handle a patient as unstable and unresponsive as Kelly. And because of the low cloud ceiling and poor
visibility, it was uncertain whether or not MedFlight would even be able to fly.

Abby felt tense, frantic, and absolutely helpless to alter the scenario that was unfolding around them. If she hadn’t been so aggressive about condemning Colstar to Kelly … if she had tracked Kelly down and insisted that she not take any chances … if she had simply left town … if … if … if …

“Is there any chance she actually could have done this to herself?” Lew asked.

Abby whirled like a startled cat and nearly leaped at him.

“You sound like that policeman who just took a statement from me. Lew, she was supposed to meet me at seven. She was anxious, yes, but she was angry and excited, not depressed. She did not do this to herself. Something’s going on in that place.”

He quickly squeezed her hand.

“Sorry. I was just asking.”

The physician whom Lew had called in to take over Kelly’s care was a brilliant young cardiologist named Harvey Shulman. It had been a titanic struggle to tame Kelly’s irregular heart rhythms, but Shulman seemed to be prevailing. Now he emerged from her room and approached them, studying some lab slips. His thick black brows were knit almost together. Abby sensed trouble.

“Her pH is up from six-point-nine to seven-three,” he said. “That’s the good news. The bad news is we just got her carboxyhemoglobin level back. It’s thirty-five percent.”

Abby and Lew exchanged concerned glances. They had both been programmed with the same carboxyhemoglobin numbers. Guru living on an isolated Tibetan mountain, 0 percent. Average person exposed to secondhand cigarette smoke, 1 to 2. Heavy smoker, 9. Threshold for admission and serious consideration for hyperbaric treatment, 18. Potentially lethal, 30 percent and up.

“She needs a chamber,” Lew said.

“Any luck with that?”

Shulman’s question was directed at Abby, who had been working with the charge nurse to find something. Now Abby found herself too choked up to speak. Instead, she shook her head. Lew patted her gently on the back.

“Abby, you’re doing everything you can,” he said.

Shulman passed over the lab reports, all of which looked reasonable except for the 35 percent.

“Her depressed consciousness is almost as disturbing as those numbers,” he said. “I’ve got her on steroids to reduce any brain swelling. If we can’t line up a chamber and transportation in another ten or fifteen minutes, the nurses want her transferred out of the ER and up to the unit. We can’t keep them tied up like this.”

“No!” Abby said, far too vehemently. “Let us try again. We’ll find something.”

From behind his glasses Shulman’s dark eyes appraised her.

“Abby, I don’t think MedFlight will fly on a night like this. The last thing we want is to push them into flying and have something happen. Besides, Kelly needs a chamber in a well-staffed hospital setting. Her cardiac situation is still too unstable for anything less.”

Helpless to argue, Abby could only turn and head for the charge nurse’s office to make more calls. Ten minutes later she returned, shaking her head. Her eyes were red from fatigue, strain, and tears. She motioned Lew into the glass-enclosed dictation cubicle, where they could speak in private while he kept an eye on the ER.

“The best MedFlight can do is remain on standby until morning,” she said. “Sooner, if the weather breaks. The people at Eden Medical Center in Castro Valley say they might be able to handle her in their chamber by five or six tomorrow morning if we can transfer her safely. Patience can’t spare an ambulance and crew for an eight-to-ten-hour round trip. I just can’t believe this.”

“They’re coming down from the unit to get her in just a few minutes,”

“Lew, she’s not going to make it.”

“You don’t know that.”

“With that thirty-five-percent level, if she lives, we all might wish she hadn’t.”

“We’ve been able to reach her ex-husband. He’s driving up from San Francisco with her daughters.”

“Damn! I’d like to get my hands around Lyle Quinn’s throat. Right now.”

“Just don’t let anyone provoke you, Abby. We’re playing on their field with their ball and their referee. The only way we’re going to win is if we play that much smarter and more determined than they do.”

“I understand.”

Hidden from anyone’s view, Lew reached over and took her hand.

“Win or lose, I’m glad you’re with me,” he said.

“Don’t talk like that, Lew. We’re going to bring them down. I’m not going to have her end up like this for nothing.”

“Maybe when the results of Angela Cristoforo’s blood tests come back, we’ll be able to attract someone’s attention. Meanwhile, I don’t know what else we can do.”

“There is one thing. While I was waiting out in that park for Kelly, I tried to go over everything we’ve learned so far. One piece just wouldn’t fit.”

“Namely?”

“The MRIs.”

“What do you mean?”

“Lew, most of the cases on the Alliance’s list had an MRI
before
their symptoms developed. The reasons for ordering the tests in the first place were pretty damn thin in a lot of instances. From what you know, is there any way the MRI
itself
could be causing people to get sick?”