Patient One (9 page)

“If it’s PVCs, lidocaine should work,” Carolyn thought aloud.

Warren nodded, his eyes closing.

“Do you know the dose?” Carolyn asked hastily.

Warren shook his head.

Carolyn desperately tried to remember the correct dose of lidocaine to treat multiple premature ventricular contractions. She recalled that a patient had received the drug intravenously a week earlier on the Pavilion, and that it was given initially as a bolus. But the dose escaped her.

Jarrin barreled into the room, pushing a wheelchair in front of him. His wounded upper arm was now tightly wrapped in a strip of towel. Blood was still seeping through.

Aliev quickly moved in front of the wheelchair and stared down at Carolyn. “What do you think you are doing?” he demanded.

“We have to put him in a room and start treatment,” Carolyn replied.

“You are to treat only the President and his family,” Aliev snarled. “No one else. No exceptions.”

“But he’s having a heart attack,” Carolyn pleaded.

“Too bad,” Aliev said stonily.

What a bastard!
Carolyn seethed to herself. She took Warren’s pulse again. It was still irregular, maybe even more so than before.
Without lidocaine he’ll go into ventricular tachycardia
, she thought. “He’ll die if he’s not given the necessary drugs.”

Aliev shrugged. “So he dies.”

Oh, God!
How do I get him into a room and start lidocaine? How?
A sudden idea came to Carolyn. Use the President’s illness. “He’s the only doctor we’ve got on the Pavilion. I’ll need his instructions on how to keep the President and his family alive.”

Aliev considered this proposal but still didn’t appear to budge.

“And he’s no threat to you,” Carolyn added. “He’s so weak he can barely stand.”

Aliev hesitated a while longer, then reluctantly gave in. “Put him in a room, but your first priority is the President. Understood?”

“Understood,” Carolyn said and rapidly turned to Jarrin. “You can draw blood, can’t you?”

Jarrin nodded. “Do it all the time in the clinic.”

“Good. Then you can insert an IV line for us,” Carolyn said. “It looks like Dr. Warren is having a myocardial infarction. I want you to help him into your wheelchair and put him in the room where we’d planned to house the First Daughter’s date. Then start an IV with five-percent glucose in water. After that, I want you to hustle down to the nurses’ station and get out the cardiology handbook and find the dose of lidocaine for PVCs. Write it down for me.”

“Got it.” Jarrin gently lifted Warren off the floor and seated him in the wheelchair. He gave Warren a reassuring pat on the shoulder and said, “I’ll have you set up before you know it, doctor.”

Jarrin and the wheelchair were halfway to the door when the President retched and brought up another mouthful of blood. He spat it into the metal basin, which was now close to overflowing. Then more blood came up, most from his mouth, some from his nose.

Carolyn glanced over to the cardiac monitors. The President’s pulse was 124 beats per minute, his blood pressure dropping to 88/50.
Oh, Christ! He’s going out on us.
She hurriedly turned to Aliev. “We need a specialist for him, now!”

“No,” Aliev said with a firm shake of his head.

“He’s going to bleed to death!” Carolyn screamed at the terrorist.

“Then you had better give him some medicine to stop it,” Aliev suggested, showing little concern.

What a bastard!
Carolyn thought again.
What do I do? What can I do? The President is hemorrhaging, and he’s got a coagulation defect. Oh, God! What can I do? He needs blood, and we don’t
… Suddenly she remembered the dead messenger from the blood bank.

She dashed out of the room and down the corridor.
Maybe the plastic bags of blood in the messenger’s container hadn’t been punctured by bullets.
But Carolyn knew that was wishful thinking.
If the President continues to bleed and there’s no blood to transfuse him, he’ll die, right here, right in front of my eyes. And there’s nothing I can do but watch.
Carolyn’s heart was pounding so hard she thought it would jump out of her chest.

She came to the bank of elevators and went over to the messenger’s container, which was laying on its side with two bullet holes in it. There was a puddle of dark red blood beneath it. “Oh, shit!” Carolyn groaned, as she turned the container right side up and removed its lid. Sticky red blood was everywhere. The two bags on top had been punctured by bullets, their contents emptied out. Carolyn threw them aside and dug deeper into the goo. Then she felt a fullness, then another. One bag of blood and one bag of fresh plasma were still intact.

As she was about to stand, her eyes went to the bank of elevators. The terrorists had driven metal spikes into the bases of the doors, jamming them shut and making a rescue attempt via the elevator shafts impossible. Carolyn quickly glanced over to the nurses’ station. Jarrin and Yudenko were watching her every move. The terrorist guarding them had his back to her. She hurriedly tried to extract the spikes by hand, but they wouldn’t budge.
Damn it!
she growled at her futile effort. Then her gaze focused in on the sturdy lid of the messenger’s container.

The terrorist at the nurses’ station yelled at her in Chechen.

Carolyn held up her hands and showed him her blood-covered palms, then reached into the container and pretended to search it further.

The terrorist uttered a few words and turned away.

Carolyn grabbed the lid of the container and forced it under a metal spike. Slowly she pried the spike up, but left it loosely in place so that just a shove on the door would cause it to fall out. Now one elevator door could be opened, giving the Secret Service a way in.

Carolyn picked up the bags of blood and plasma and sprinted back down the hall, passing Aliev, who was giving orders to another terrorist outside the President’s suite. Once inside the room, she tried to close the door, out of habit, but Aliev kicked it open. “Watch her!” he instructed the other terrorist.

Carolyn ran into the bathroom and washed the blood off the sticky bags, then checked again to make sure they were intact. They were. Dashing back to the bedside, she glanced over to the President, who was retching up a bloody froth. His blood pressure was down to 85/50.

“Which do I give first?” she asked herself aloud. “The blood or the plasma?”

The terrorist at the door looked over his shoulder at her, then turned back and faced the corridor.

“Jesus, Carolyn!” she berated herself. “Make up your damn mind! Which? Or does it matter?”

“The blood first,” she decided finally. “He needs the red blood cells most of all.”

As she held up the bag of blood to check the name on the label, she saw a slip of paper floating down from the ceiling. It landed on the floor between her and the guard. Quietly, she tiptoed over to the slip and picked it up. It was a prescription blank from University Hospital. On it was written:

1) Administer plasma first, run in as fast as possible.

2) Give Warren aspirin 325 mg.

Get EKG

Hold lidocaine

DAVID

Carolyn jerked her head up to the ceiling just as one of the panels slid aside.

David looked down at her with a finger pressed over his lips.

Then the panel moved back into place.

Eight

“We’re stuck up here
with no way out,” Karen Kellerman whispered into David’s ear. “Like mice caught in a cage.”

“Except mice don’t have to worry about Uzi submachine guns being pointed at them,” David whispered back.

“Do you think they’re done shooting?” Karen asked nervously.

“For now,” David said, his voice barely audible. “But it’ll start again if someone does something stupid.”

“But even then, they won’t shoot up the ceiling.”

“Don’t count on it, particularly if they decide to fire over people’s heads.”

Karen gazed around the dim ceiling crawlspace, with its maze of metal pipes and electric wires. Even if the stray shots missed them, the bullets would shred pipes and wires and turn the crawlspace into an uninhabitable hell. “If we surrendered, they probably wouldn’t hurt us,” she suggested weakly. “After all, they’ll need doctors to keep the President alive.”

“Do you want to die?”

“No.”

“Well, that’s what will happen if we go down there. In all likelihood, nobody will leave the Beaumont Pavilion alive.”

Karen swallowed hard. “They won’t kill the President, will they?”

“Sure they will,” David told her. “Our government is not going to negotiate with the terrorists. They’ll stall for time, then attempt a rescue that will almost certainly fail. There’ll be a big firefight and everybody on the Pavilion will end up dead, including the President.”

“How do you know that?”

“Because I’ve been there,” David said vaguely. “Now stop asking dumb questions.”

“There’s one more thing.”

“What?” David asked, becoming annoyed.

“My asthma.”

“Oh, Christ! I forgot.”

David knew all about Karen’s asthma. It was an acute asthma attack that brought Karen to the medical center’s ER where she met and was treated by David. She had a moderately severe form of the disease that required therapy with both pills and inhalers. “Have you got your inhaler with you?”

“No. I left it in my purse.”

“Shit,” David muttered and glanced around the crawlspace. It was windowless with no discernible cross-ventilation. The stale air barely moved and was filled with particulate matter. It was an ideal environment to bring on an asthmatic attack. “The first thing we have to do is get you to a place where there’s some circulation of the air from below.”

“Is there such a place up here?”

“Yeah,” he answered and pointed to his left. “At the far end of the space over the kitchen area. I felt a draft coming up between the panels. I want you to go over there and stay put. Try to actually breathe in the draft.”

“That by itself is not going to work,” Karen warned. “I can already feel my chest tightening. I’ll need my inhaler soon.”

“The next time I send a note down to Carolyn, I’ll see if they have an inhaler in the Pavilion.”

“And if they don’t?”

“Then we’ve got double trouble,” David said candidly. “Now scoot over to the place I told you about and remain there. Don’t even twitch a muscle while I scout around and see how the other patients are doing.”

“David,” Karen said too loudly. “I’m—”

“Shhh!” He hushed her at once. “Talk only when you absolutely have to, and then do it in a whisper. Any wrong sound that comes from this space and we’re both dead. You understand
dead
,
don’t you?”

“Y-yes,” Karen gulped shakily.

“Then move out like a mouse on tiptoes and stay on the metal grid,” David said and watched her disappear into the dimness. Slowly he glanced around the enclosed space, but his mind was still on Karen’s asthma. One bad attack and she’d make enough noise to attract every terrorist on the floor below. And the two of them would be goners. The terrorists would shoot first and ask questions later. David grumbled under his breath, hoping against hope that the asthma attack wouldn’t occur. But deep down he knew it would, and without an inhaler for Karen they would be dead ducks.

With care, David turned his body around and again studied the crawlspace between the Beaumont Pavilion and the roof of the hospital. It was slightly over four feet high, with a solid plaster ceiling and a floor that consisted of a thick metal grid upon which rested removable synthetic panels. Most of the space was taken up by rows of pipes and tubes and bundles of wires that were crisscrossed at varying distances by elevated tubes and pipes. Off to the right was a large metal container that David assumed was part of the ventilation system because it clicked off and on intermittently. There was no light except for the rays coming up through the openings for the ducts.

As he crawled away, David reached up and measured the height of the crawlspace once more. It stayed at just over four feet. There was plenty of room to crawl noiselessly over the grid, but not nearly enough to stand and move quickly, even in a severely crouched position.

David wriggled his way quietly along the metal grid in the ceiling above the Beaumont Pavilion. Peering down a ventilation duct, he saw the President’s wife below. Lucy Merrill was stretched out on her bed, a damp washcloth over her forehead, an IV running into her arm. On a nightstand beside her was a basin filled with vomit. David could hear her soft moans as he moved on.

Now he was over the corridor. He paused to study the terrorist standing guard between the rooms of the President and the First Lady. The man was stocky and balding, and he carried his Uzi submachine gun like an experienced fighter—low and at his waist, both hands on it and ready to fire at a moment’s notice. Tucked under his belt were two additional clips of ammunition, each holding thirty rounds. By himself, David thought grimly, the terrorist could fire ninety rounds in under a minute.

He moved on, squeezing past metal pipes and bundles of electrical wires, his mind still on the terrorist’s weapon and the damage it could inflict. The Secret Service agents never stood a chance, he told himself. The terrorists had come out blasting, filling the air with so many rounds from their Uzis that anybody who even peeked out of a doorway was dead.

Long ago David had learned how to distinguish one automatic weapon from another by the sound it made. The noises produced by an Uzi and by an AK-47 were the same to most people, but they were like night and day to David. So when he heard the automatic gunfire while he was in the treatment room, he knew it was Uzis and he knew there were a lot of them. His initial instinct was to go out the window, but there was no outside fire escape and the ground was ten stories down. So he opted for the crawlspace above the ceiling. He jumped onto the countertop and climbed into the space, pulling Karen up after him—and found himself trapped. There was no obvious exit to the roof. The only way out was down through the Beaumont Pavilion.

David continued to crawl through the metal grid, passing over the Secretary of State’s room and the room of the Russian president before coming to the suite where William Warren lay. A guard was outside the partially opened door, smoking a cigarette. David squirmed past him and peered down through a crack in the ceiling. Carolyn was slapping EKG leads on the bare-chested physician. A defibrillator was at the bedside, an IV line slowly dripping into his arm.

David nodded to himself. Getting an IV started was the first order of business, and Carolyn knew it. The line would be critical for administering drugs. If Warren had gone into shock initially, they would never have found a vein and the older physician would have certainly died.
Good for you, Carolyn
, David thought. She was smart as hell and twice as brave. Christ! The way she stood up to that terrorist to protect Sol Simcha! David kept his eyes on the attractive nurse, thinking that the only way to know what a person was really made of was to test that individual under the worst of conditions. A few people rose to the challenge. Most didn’t. Carolyn was one of the few.

For a moment David felt a twinge of guilt for not staying down on the floor with the others. In retrospect he knew he could have waited for things to settle down and surrendered and probably survived. But then he would have ended up being another doctor-prisoner who might well have been kept away from everyone except the President. From up in the crawlspace he could treat all the hostages. And he could do other things, too.

His gaze went over to William Warren, who was beginning to sweat profusely. His skin color was worsening, his breathing now more rapid.
Hurry up, Carolyn!
David urged.
Hurry!

Carolyn finished taking Warren’s EKG and tried to decipher its unusual rhythm. The R waves, which represented contractions of the ventricles, should have been tall and narrow and peaked, like skinny triangles. But here they appeared broad and peculiarly shaped, with an obviously irregular rhythm that Carolyn didn’t recognize. As a MedEvac nurse, she had been trained to read EKGs and had no problem diagnosing commonplace arrhythmias. But Warren’s arrhythmia was so bizarre and complex that it was impossible to interpret. It was unlike anything she’d ever encountered. Carolyn looked out to the guard in the corridor who had his back to her. Then quickly she stared up at the ceiling and, with an exaggerated shrug, motioned to the EKG, indicating her quandary.

A panel in the ceiling slid open and David’s face and hand appeared. He formed a circle with his thumb and index finger and gave her a
you’re doing fine
sign. Next he pointed to the EKG, then over to the IV pole, and made a
wraparound
gesture.

Carolyn spread her hands apart, gesturing back.
What does that mean?

David took a prescription slip and wrapped it around his finger, and again pointed to the IV pole. Then he signaled upward.

Carolyn nodded quickly and glanced over to the guard once more. He still had his back to her. She hurriedly wrapped the EKG strip around the top of the pole and lifted it toward the opening in the ceiling.

Just as David grabbed the strip, Warren opened his eyes and saw Carolyn holding the IV pole up. He didn’t notice the opened panel behind his bed. “Is something wrong with my IV?”

“No,” Carolyn lied easily. “I’m repositioning it so I can see the flow rate more clearly.”

Warren suddenly felt his heartbeat becoming more erratic, the tightness in his chest more noticeable. “I … I think I’d better take a nitroglycerine tablet.”

Carolyn looked up, as David nodded his approval. She searched for a nitroglycerine tablet from the crash cart and placed it under Warren’s tongue. Warren’s complexion was taking on a grayish hue.
A bad sign
, Carolyn thought. Death was coming.

David rapidly read the EKG. It showed an evolving myocardial infarction with a grossly abnormal rhythm. There were multifocal PVCs, which were occurring so frequently that in places the rhythm resembled a deadly ventricular tachycardia.

“I’m having trouble catching my breath,” Warren gasped.

Carolyn glanced over to the cardiac monitor. Warren’s blood pressure was bouncing around, the number changing by the moment. She wondered if the monitor was malfunctioning. Quickly, Carolyn reached for a stethoscope and placed a blood pressure cuff on Warren’s arm, then took a manual reading. 92/64. Warren was straining to fill his lungs, and his skin color was turning ashen. Again Carolyn hurriedly inflated the blood pressure cuff.
Whiff ! Whiff ! Whiff !
Then she slowly let the air out. The reading was 84/50 and barely audible. He was going into shock.

A gurgling noise came from Warren’s throat. It sounded agonal. Now his lips were blue.

A prescription blank floated down onto the bed.

Carolyn snatched it up and quickly read David’s orders.

• Give IV bolus of lidocaine 80 mg, followed if necess. by 40 mg bolus every 8–10 mins. to total dose of 200 mg

• Maintenance dose 2 mg/min.

• If it doesn’t work, use defibrillator set at 200 joules

Carolyn reached for a needle and syringe and drew up 80 milligrams from a vial of lidocaine. She injected it directly into Warren’s IV line. Then she waited. Seconds ticked off. Warren’s color was still poor, his breathing shallow.

Carolyn looked up at the ceiling and silently mouthed the question:
Should I give another bolus?

David held up an index finger, signaling her to wait.

Carolyn mouthed up,
defibrillator?

David shook his head, then pointed to the EKG and made a
turn it on
gesture.

Carolyn switched the EKG machine back on. And waited again. The strip started moving. It still showed bizarre complexes, but not as many as before. Then the R waves narrowed into slender triangles and became more normal-appearing. Carolyn could now clearly see the heart rate slowing. Warren was reverting to a normal sinus rhythm. Carolyn hurriedly took his blood pressure again. It was 100/70. Then again. 108/74.

She let out a sigh of relief and asked, “How are you doing, Dr. Warren?”

“Better,” Warren said softly. “I’m breathing much easier.”

“Good,” Carolyn told him, noticing that his facial complexion was turning pink. “You’re back to a sinus rhythm, thanks to a big bolus of lidocaine.”

“It’s you I should thank,” Warren said gratefully. “And I do.”

“You’re welcome,” Carolyn replied and glanced up at the ceiling. David gave her a
thumbs up
signal and moved the panel back into place.

He squirmed his way around a metal partition and headed for the corridor. Warren needed to be in a CCU where he could be constantly monitored and anticoagulated, and perhaps receive a thrombolytic agent that could dissolve away the clot blocking one of his coronary arteries. But the terrorists would never let that happen. Nobody was going to leave the Pavilion, regardless of the gravity of their illness. It sounded heartless, but it was the smart move. The terrorists realized that in order to secure an area, it had to be done absolutely and completely. One breach, one small opening, and all could be lost. They knew that a few could hold off many in a given area as long as all the entrances and exits were sealed. It was a basic tenet of guerrilla warfare.