Scarcity (Jack Randall #3) (37 page)

—TWENTY-NINE—

D
ayo continued the surgery at his usual steady and unhurried rate. The wall of Oscar’s old heart was mated successfully with the window he had cut in the donor heart. Following that, he had placed a catheter through one of the pulmonary veins of the donor heart, past the connection he had just completed, and on into the left ventricle. They were now pumping in saline at 4 degrees Celsius to further preserve the heart while the team labored to make the remaining connections. Jennifer scooped a couple handfuls of ice into the chest cavity to help the process. The heart was starting to look as if it belonged there. The only connections left were the pulmonary artery and the aorta.

The surgeon shoved some stray ice aside before grasping the aorta. Now was the time. He could see Raina’s hands waiting with a fresh length of 4.0 prolene suture. It was 54 inches long, usually more than enough to finish the job despite the full-thickness bites he would be taking. Making what he hoped was a casual examination, he leaned over the table and hid Jennifer’s view of his work.

“Metz please.”

“Metz?” Raina retracted the suture she was holding.

“I just need to freshen up this edge.”

Raina had the scissors in his hand a second later, and he carefully began trimming the edge of Oscar’s aorta. But as soon as his two assistants returned to their conversation, he changed course.

Leaving the uncompleted edge hanging, he rotated the scissors and inserted them into the aorta itself. Similar in construction to a garden hose, the aorta had three layers. His scissors found and snipped through the first two inner layers in the area he would soon be suturing. After three centimeters he stopped and returned to the edge he was trimming. The conversation around him had not slowed, and he wordlessly exchanged the metz for the waiting suture. He placed the first stitch through the end of the cut he had made and gently brought the two vessels together. After a few more there was no way for Jennifer or Raina to see what he had done.

Switching from a forehand to a backhand grip, he continued the double-armed running suture until the posterior wall was almost complete.

“We can start re-warming, Brian.”

“Okay.”

With a pause to work his neck around a little, he continued on and stopped one stitch short of finishing the anterior wall before standing straight.

“Trendelemburg?” Dryer asked.

“Yeah, we’re ready.”

The head of the bed lowered, and Dayo watched as air escaped from the remaining stitch, producing a stream of frothy pink bubbles. They slowly trickled to a stop and he completed the final stitch. Jen removed the vent before removing the last of the melted ice. The heart looked like it belonged to Frankenstein with all the large black sutures crisscrossing its surface. A meat baseball he had heard it called once. Dayo tapped it with a finger and it responded with a faint quiver.

It wanted to live.

He allowed himself a brief grin behind his surgical mask as he finished. He had just doomed the man on the table, and he had done it in front of a room full of people, without them even knowing.

The aorta should hold until Oscar left the operating room. The cut he had made would survive the low pressures it would be subject to when they weaned him off the bypass machine. But once he was upstairs in the CVICU, and the pressure was allowed to climb, the blood would be forced into the cut. At that point it would widen, peeling the layers apart as the pressure increased and worked its way across the vessel. The pain would be excruciating if one were awake to experience it. Unfortunately, Oscar would still be under sedation, and unable to feel the sensation as his aorta was slowly torn apart by his new heart.

He would also be unable to warn his caregivers.

The balloon pump that had been in place to aid in the perfusion of his failing heart would be activated to assist his new one, unknowingly increasing the pressure feeding the fault. Eventually, the dissection would weaken the remaining wall of the aorta to the point that the force would rupture the vessel and seal Oscar’s fate. Even if it were to happen in front of a trained surgeon, the man would have little chance of survival. He would bleed out in a matter of seconds.

Dr. Dayo had no intention of being anywhere close by when it happened.

There would be an autopsy. That he was sure of. He would also likely have to present the case at the next Mortality and Morbidity meeting of his peers. But with the first stitch placed where he had put it, it would appear that it had simply pulled through the tissue causing the failure that led to the rupture. He was comfortable that his name and reputation would see him through any scrutiny that followed.

But it would still be a failure for the team, and he already regretted what he was sentencing them to. It would be a no-win situation for both Jen and Dr. Dryer. Dr. Dryer was an anesthesiologist, not a surgeon. His hands would be tied to what he could do externally, which in this case was very little. Jen was his physician’s assistant, and while skilled in most aspects of surgery, she was not allowed to crack the patient’s chest without him in attendance. She might, though, if placed in the position he was putting her in. He hoped she didn’t step over the line too far, but if she did, he was ready to go to bat for her. But it was done. There was no turning back now.

He deeply regretted the heart he was wasting. Someone had died providing it, and there was a stringent system in place to ensure that they went to the right people. The fact that Oscar was somehow able to lie his way through the process made him wonder where these long-distance organs were really coming from. He had never questioned it before, nor had any of his colleagues. They didn’t really wish to know, they usually involved some tragedy, especially with the kids, and his team didn’t need that burden on their minds. They saw enough death as it was.

“What’s our temp now?”

“35. We really didn’t have time to get down too low,” Brian answered.

“Okay, let’s start weaning him off.”

•      •      •

“Okay, let’s air down,” Dr. Fong ordered.

“Flow coming down,” Mike responded. A simple adjustment to a clamp on the return line started the process. Dr. Jacobs thumbed the hydraulics to lower the head end of the table.

The surgeon watched carefully as the flow of blood returned to Tessa’s new heart. The new head-down position of the table worked to push any air that was left in the circuit out through the last remaining stitch in the aorta. Air was the enemy. If left in the heart it could travel to the brain or lungs, causing strokes or a loss of circulation, both of which could be quickly fatal. The frothy pink bubbles stopped and a steady trickle of blood replaced them before the surgeon moved in and completed the closure.

“Done here,” Fong spoke through the drape to Jacobs as he released clamps.

“Okay, Mike, let’s make her bump.”

Mike responded by making further adjustments, and as the flow of blood through the lungs increased, a wave form appeared on the overhead monitor. Small at first, the “bumps” increased in size with the rise in pressure. Dr. Jacobs watched closely, waiting for the numbers he wanted. His hands found the cardiac echo machine he had placed in Tessa’s esophagus at the beginning of the surgery. It would allow him to observe the flow of blood through the heart as well as alert them to any air that had failed to vent.

Tessa’s new heart chose that moment to wake up. A slight shiver ran over the muscle before it was still again.

“You see that?” Stephanie asked.

“Yeah, give it a poke,” Dr. Fong replied.

The heart once again quivered in the chest as it responded to the warmer temperature and the flow of blood.

“That’s fib,” Stephanie spoke before poking the right atrium with a finger. The heart responded with a beat and a shiver. She poked it again and this time the heart responded by beating. It showed no signs of stopping.

“Magic finger,” she announced with an unseen grin. She held it up for them all to see.

“Good flow,” Jacobs announced as he played the sensor around. “Little air left in the apex.”

“Tony?”

Tony paused long enough from his work in preparation of closing the chest to hand Dr. Fong a 19 gauge needle. The surgeon deftly inserted it through a fatty section covering the left ventricle. He was rewarded with another brief stream of frothy bubbles quickly followed by a pulsing stream of blood. Capping it with his finger, he pulled it clear. The fat worked to seal the puncture.

“Looks good.”

Dr. Fong looked up at the screen for only a second before the anesthesiologist began to pull it free. The sensor twisted, and a different view briefly flashed across the screen before disappearing.

“Wait a minute, go back.”

“What’d you see?”

“I’m not sure.”

Stephanie and Tony stopped their preparations and everyone looked as the multicolored display returned to the screen.

“What . . . is . . . that?” she asked.

Dr. Fong offered no answer. He just shook his head and turned to his perfusionist.

“Mike, we’re going back on bypass.”

•      •      •

“So now what?” Jimmy asked.

Manuel waved him silent while he listened to some passing boaters. Once their voices had passed, he relaxed a small degree.

“We sit until the marina is quiet. Then we leave.”

Jimmy nodded. He could fill in the rest by himself. Manuel would keep them here until the marina was quiet and dark before securing the three of them to something solid. Once that was done, he would cast off and sail the boat out into the Gulf. After he was through with them, he would pick a destination to leave the boat, or just sink it and come in to shore using the dinghy. Either way, he was coming back alone. Jimmy had some time to come up with something.

He had secured the cuffs tight enough to function. They were the type he had taught Manuel to use and they worked well. Police riot cuffs. They weren’t just plastic, they had a metal band embedded inside. It prevented the prisoner from chewing through them. But at least his hands were cuffed in front of him. It gave him some options. He felt along the underside of the desk with his knee and located the flare gun. It wasn’t loaded, but the flares were stored with it. It wasn’t a real option. By the time he would have it loaded he would be dead, noise or not. The only hope he had was next to the flare gun—a snub nosed .38 revolver. Jimmy kept the gun handy for whatever may pop up. Stainless steel to survive the humidity, he had never had any use for it until now. Was it loaded? It had been a long time, but Jimmy was sure that it was. He wasn’t in the habit of keeping an empty gun around. An empty gun was as useless as a stick. He felt the Velcro strap that secured it hanging loose, and coughing to cover the noise, rubbed his knee across it. It fell free without a fight. Nothing was holding the gun in the holster now but gravity. He just needed an opportunity to grab it.

“I didn’t see my car in the lot.”

“I left it at the airport.”

“Rico didn’t waste time.”

“He called before I even had it started. Thought he was going to blame me for a second. Was afraid I might have to run, also.”

“You still can.”

“I’m not a runner. They always find you.”

“Not always.”

“
Qué?
Who am I talking to here? Don’t bullshit me, Jimmy, they would hunt me down and you know it. It took Rico one second to decide . . . once he was done cussing you.”

“He won’t last long, you know that.”

Manuel shrugged. “Not my place to decide. I was never cut out to be . . . management.”

“You should call Pablo.”

“Or Nestor? Which one, Jimmy? You have it all figured out, do you? How do you know Nestor doesn’t want to be in charge? What makes you think Pablo isn’t already dead?” Manuel waited, but he got no reply from Jimmy.

“So tell them you didn’t find me. They’ll believe that.”

“And if they don’t?”

Jimmy had no reply for that either. They both knew the answer. Jimmy watched him closely, ignoring the sweat crawling down his back. He examined Manuel, looking for an opening. Like him, he was sweating profusely, and Jimmy was blinking the sweat from his own eyes. Manuel’s head was glistening in the faint light, and Jimmy could see the sweat gathering there. Sooner or later it would be in his eyes and he would have to wipe it away. Would that be enough time? Even if he got the gun up and around for a shot, it didn’t mean Jessica and Cody were safe. Manuel had the hammer back for a reason. It was a lesson Jimmy had taught him. When the human body suffers a gunshot wound it causes the muscles to contract. If he managed to shoot Manuel, his fingers would contract around the gun and cause it to fire, sending the round into Jessica and Cody. The only way to avoid this was to shoot him in the brain stem. It was like flipping a switch. Instead of the muscles contracting, they would instantly go limp. That was the reason police snipers in hostage situations always went for the head shot. It was the only way to keep the hostage alive.

Jimmy would have to get his hands under the table, pull the gun, get it above the table and shoot Manuel in the head across the dimly lit cabin. The first time. The odds of success were slim. But they were all that he had.