Scarcity (Jack Randall #3) (32 page)

“Hold,” Fong voiced.

Unsure as to who the order was for, both Stephanie and Tony grabbed for the cannula at the same time, and as a result, neither got a hand on it as the surgeon let go. It popped free and the blood jetted across the chest of the surgeon before moving on to the overhead light and over the drape to land on Dr. Jacobs. The whine of the bypass machine changed with the rapid loss of pressure.

“Dammit!” Fong quickly grabbed the errant cannula and stuck a finger in the gushing stab wound just before it disappeared. The chest cavity was now full of blood and he felt, more than saw, his way to what he needed. Stephanie returned with the suction in time to clear the way for him to re-insert the tubing.

“Hang two units!”

He held the cannula in while Stephanie attempted to clear the field, but there was just too much blood. He felt his way around the anatomy and performed the re-cannulation blind.

“Turn the pump sucker way up!”

The blood was clearing, but not quickly enough for the surgeon’s liking.

“We’re drowning here, give me another one.”

“Are you in, John?” Jacobs asked as he opened the clamp on the blood he had just hung, sending it through the IV.

“I’m in. I just can’t see anything.”

Jacobs stood up and gazed over the drape to see a bloody pool. The surgeon’s hands were working beneath its surface with the tubing protruding. As the blood was sucked away the connection appeared.

“We’ve got some air,” Mike announced.

“How bad?” Fong inquired.

“I can walk it out I think.”

“Okay . . . Stephanie,
you
hold this. Tony?”

“Right here.”

“Some 3-0 please, forehand. Then it’ll be a scalpel and some more 3-0.”

“Okay.”

Working quickly, Dr. Fong secured the cannula in with the suture as his gloves were repeatedly doused with saline to keep them free of blood. He cinched it down tight for the best seal he could get, but time was short. Ignoring the offered scissors, he left the ends and grabbed the next cannula while he located the superior vena cava, the large vein returning blood to the heart. He made another stab incision before inserting one fork of the cannula in. This one he held in place himself.

“I’m in, Mike,” he informed the perfusionist.

“Bypass on,” he replied, glancing at the clock.

Dr. Fong glanced at the monitor screen and was rewarded with a climb in the blood pressure.

“Our flow sucks,” Mike voiced.

“We got more air?”

“No, it’s clear.”

“Are you up against the wall?” Stephanie asked.

Fong adjusted his angle slightly.

“No . . . are we loosing blood?”

They both examined the chest cavity, looking for any bleeding they may have missed.

“We don’t see a bleed. She got volume?”

“Should have plenty,” Mike replied.

“Pressure’s climbing, but it’s doing it slowly,” Jacobs chimed in.

Fong made a decision. “I’m adding the IVC.”

Retrieving the scalpel from Tony, Dr. Fong repeated the stab and cannulate procedure again on the inferior vena cava and quickly connected the other fork. Holding both in place, he again scrutinized the monitor as Stephanie removed the clamp. The red number increased its pace and they were soon within normal limits. The tension in the room ratcheted down slightly.

The surgeon took stock of the situation and determined they were out of the woods for the moment. It was basic plumbing. They had just replaced the heart with a machine, clamping off the lines going in and out of the girl’s heart and redirecting them through the bypass machine. The only problem now was that they were committed to the transplant. If there was something wrong with the donor heart, they had no choice but to use it. He pushed the thought aside for the moment. Taking his gaze away from the chest cavity, he examined the faces of his team. Some of them were streaked with blood, sweat, or a combination of both.

“Time?”

“She was down two, maybe three minutes. I think we’re okay,” Jacobs answered as he whipped blood from his face.

“Okay . . . let’s try not to do that again.”

“I’ll agree with you there.”

“Tony?”

“Yeah boss?”

“I could use that 3-0 now . . . and some clean underwear.”

•      •      •

Manuel gazed around the parking lot behind the dark lenses of his sunglasses. With no time to change into more appropriate clothing, he was sweating heavily in the Florida heat. Summer had arrived early, and he was the only one in sight wearing long pants. He longed to return to the air conditioning of the rental car, but he had one quick task to perform first. He spotted the car right where he had first seen it and slowed his gait slightly as he approached. While the color was different, the make and model were the same, and that was what was important.

He kept his walk the same right up until he was at the car. Quickly stooping down, he pulled the screwdriver from his pocket and went to work on the screws holding the license plate. The screwdriver was not a perfect fit, but he managed to keep it from slipping enough to get the screws out quickly. Once the plate was free, he swept it under his jacket and into his belt at the small of his back. The screwdriver went into his pocket as he rose and continued his walk across the parking lot. Once across, he circled the store and found his rental car. The air inside was already warm despite the brief stop.

Fifteen minutes later he had found a secluded spot in a park. There was no one around. Evidently it was too warm for even the children to come out. Most likely they were at the beach. He quickly had the plate swapped out and then spent ten minutes carefully scraping the rental car stickers from the window and bumper.

Once the car was sterile, he felt better. Rental cars all carried plates that used specific numbers. Only those with such knowledge would be tipped off, but the man he had learned that from would notice the car immediately. And that didn’t fit into his plan. Using his Porsche was out of the question.

A quick stop at a fast food outlet for a gut-burger and another for plenty of drinks delayed him only slightly and he was soon looking at his target through the windshield as he ate. After finishing the food, he wadded up the wrapper before collecting the drinks and one other item from the car. Leaving the rental in plain sight, he walked across the parking lot, stopping at a trashcan before continuing on through the gate and out onto the dock. The sea breeze cooled the air slightly more than it was in town, but the humidity of the harbor kept it a sauna.

Manuel strolled down the docks, returning hellos from fellow boaters as he made his way to the slip he was searching for. He hopped on board the boat as if he owned it and walked immediately to the cockpit. Running a hand around the winch, he reached into the rope well and located the key stuck to the inside. He soon had the hatch unlocked and was inside the boat, closing and locking it behind him.

The dark interior felt at least twenty degrees hotter than outside, but he had no choice. Opening a window or turning on a fan was not an option. He stripped off his jacket and opened the first of his water bottles. Fetching a towel from the head, he found a seat facing the hatch. Making himself as comfortable as possible, he swabbed the sweat from his face before putting his sunglasses back on.

He was here until his friend showed up, or the heat killed him, whichever came first.

•      •      •

Brian reached out without looking to make an adjustment to his bypass machine, but when his hand failed to locate its target he was forced to look up. The machine he was using today was not his usual one as it was currently out for overhaul by the manufacturer. He would get it back tomorrow, but until then he was stuck with this older model. It was not really a problem as it was the model he had learned on over ten years ago and he knew it well. The hospital had several bypass machines, but most were designated to certain departments, and as much as he would have liked to use a newer model, personal preference did not trump policy. There was another machine sitting in an operating room down the hall, but it was designated to the trauma service, and God forbid he touch anything in their territory. The heart and trauma teams were considered the varsity here at Johns Hopkins, and, as such, they were provided whatever they needed equipment-wise. But bypass machines did not come cheap, so he would use this backup today and not complain. It had been returned from overhaul yesterday, and had so far proven to be reliable. Maybe next year’s budget would produce a new one.

He had set it up in his normal configuration. Pumphead 1 was the arterial, number 2 the vent, number 3 was the cardioplegia, number 4 was the suction and number 5 was the backup. He had wall water and an ice bath to control the blood temperature and it had been primed with crystalloid solution and albumin. The bubble oxygenator was such a simple device he seldom worried about it other than to eyeball it every day.

So far the surgery was progressing as planned. Brian had been working with Dr. Dayo for many years now and they knew each other’s routines. The bypass had been initiated without any problems and the heart had been cooled to 28 degrees Celsius eight minutes after bypass was established. 750ccs of cardioplegia solution had been infused into the aortic root to stop the heart and now Dr. Dayo was busy removing the man’s diseased organ to make way for the new one beating in the tray next to him. Brian only half listened to the conversation at the table as he sat on the stool in front of the machine. He instead divided his attention between the readouts in front of him and the ones on the POPS machine next to him. The first time the machine had been wheeled into the room they had all stared in amazement at the heart beating in the tray on top. He and his colleague, Mike, had wanted to tear the skin off the machine and see how it worked, but the company representative had vetoed the request with a smile. After a dozen visits the rep had stopped coming, and despite the urge to do so, Brian had so far restrained himself from exposing the guts of the machine. He never had time anyway. As soon as the surgeon pulled the heart off the machine it would be shoved out in the hall by the circulating nurse, and the flight team would be gone with it long before they were done with the surgery.

Still, the heart beating in the tray constantly drew his attention, and as a result, it was his nose that first alerted him to the problem.

He smelled smoke.

Turning his attention back to his bypass machine, he saw small wisps of smoke curling out of the control panel. He sat frozen for a moment in amazement as it quickly got thicker and darker. The digital readouts for each pump began to flicker on and off and that shook him out of his daze. The elapsed time meters suddenly failed as did the water circulation readout.

“Paula!”

Paula halted her conversation and turned to see what he wanted. Brian was not one to yell, even outside the OR, but when she saw the smoke pouring out of the console she quickly forgot about it.

“Oh my god! Is it on fire?”

“I don’t know, go get an extinguisher!”

“Fire?” Dr. Dryer’s head popped up from behind the drape.

Brian produced a multi-tool from his pocket and began unscrewing the clamps on the console housing. He popped it open as they all watched and thick smoke billowed out, obscuring their view of him.

“Is the pump still running?” Dayo’s command voice cut though the chatter.

“I’m looking.”

Brian did a quick check. To his relief the arterial pump was still spinning and showed no signs of stopping. He quickly checked the other pumps, putting his hand on each. Number 4 was a little warmer than he would have liked, but still seemed to be running fine. He tapped a couple of the RPM readouts with the tool in his hand, but they refused to come back to life.

Dayo bit his tongue as he watched Brian work. He found himself half-hoping the machine would fail.

“Where we at?” Brian asked.

“We’re committed! I have to finish at this point,” Dayo answered.

“Shit . . .”

Brian weighed his options while Paula got on the phone and overhead paged everyone. They soon had other staff members looking in the window, and she put them to work opening the doors and fanning the smoke out of the room. An extinguisher hit the floor next to him, but the smoke had already begun to lessen, and he didn’t want to use it with an open chest on the table.

“Somebody run down to trauma and get me the other pump!”

“I’m on it,” Dr. Dryer voiced. He parked his anesthesia tech in his chair before rushing out the open door. He was the only one, besides Brian, that had some idea of how to run the machine.

Brian reviewed the problem. The loss of the timers was minor, he could do without them if need be. But the loss of the RPM gauges was critical. So was the water circulation. He swabbed his head with his sleeve and rubbed his eyes as they had started to burn from the smoke and the sweat forming on his forehead.

He looked up and saw a tech standing in the door. He pointed at him to remove any doubt of who he was addressing.

“Follow Dryer and tell him I need the portable cooling unit first. Go.”

The tech stopped fanning and took off down the hallway after Dr. Dryer. Another took his place and continued fanning the smoke out the door.

“Brian?” Dayo gently inquired to their status.

“We’re okay for now. Just . . . keep going, I’m on it.”

He looked for the cheat sheet he always made on each patient and found it on the floor. Snatching it up, he reviewed his math. The patient’s body surface area was 1.67m2 so he had calculated the flow to be 3650 milliliters per minute at 2.2 liters per minute per square meter. Okay, so that should place his speed control knob at . . .

“Tape, I need some tape and a marker!”

Paula scrambled to comply and found the necessary items in the desk drawer. She tossed them over the POPS machine to him. He tore off a strip and stuck it on the machine next to the RPM knob. Making a mark next on both the knob and the tape, he wrote 4LPM next to it.

“How fast is that?”