Scarcity (Jack Randall #3) (38 page)

He turned his head to Jessica. She held Cody on her lap and the boy stayed quiet. He gave them both a reassuring nod, but it failed to lessen the fear in her eyes. But she was strong, and she was keeping her fear under control. He hoped she would instinctively duck when the time came, but seeing the amount of room she had to deal with in the small space, there wasn’t a lot she could do. With Cody on her lap, he knew her first instinct would be to shield him from the gunfire, with her own body if necessary. Something he refused to picture.

He returned his gaze to Manuel. The sweat was growing on his forehead, it wouldn’t be long. Jimmy squirmed in his seat as if to seek a more comfortable position. Manuel watched every move.

Some more people walked past on the dock speaking loudly, and they all listened intently. Five people Jimmy counted, and something else he couldn’t quite place. He followed the noise until it faded away toward the parking lot. Manuel reached for the sweat in his eyes.

The silence was shattered by furious barking in the form of Sam at the open hatch. Jimmy jumped at the noise, and as Manuel’s attention moved to the dog the gun automatically followed. Before he could correct himself, Jimmy had his hands under the table and around the .38. Yanking it free he stood to make it easier to bring up. Manuel saw the motion, but before Jimmy could pull the trigger, he had the gun aimed back at Jessica and Cody.

“Don’t do it!” he yelled at Jimmy.

Jimmy stopped himself from pulling the last bit of trigger just in time. His aim however didn’t waiver.

“Don’t do it,” Manuel said again. “You’ll kill us both!”

Jimmy exhaled. Manuel was right. The situation had changed, but Jessica and Cody were just as dead if he shot him. Something he had also taught his protégé.

“Shut the dog up.”

Jimmy grit his teeth.

“Do it!”

“Jess, call Sam.”

Jessica swallowed twice before she could get the words out. The dog obeyed on the second command and scampered down the steps to sit beside them on the seat. He continued to growl at Manuel, instinct telling him who the enemy was.

Jimmy and Manuel just stared at each other across the small room. The lapping of the waves against the side of the boat filled the silence.

Organ Transplant Study Finds
Wide Disparity Among Institutions
October 14, 1999—New York Times
 

—THIRTY—

“Y
ou’ve got to be kidding me!” Dr. Jacobs exclaimed.

“What is it?” Tony quietly asked.

“A septal defect. Looks like it’s high up in the ventricles, too. It’s letting blood pass from the left to the right on each contraction,” Stephanie explained.

“Do we fix it now or later?”

Dr. Fong answered that one.

“Right now. Let’s get her back on bypass.”

His tone revealed his current feelings. Dr. Jacobs was just getting started.

“How the hell does a heart with a VSD get through the system? Somebody screwed up!”

“It doesn’t matter right now, let’s just get it fixed.”

“I want somebody’s ass for this! Who’s the Lifelink rep, that blond woman? What’s her name?”

“Later, John. Can you tilt her a little my way please?”

Dr. Jacobs cooled off and returned to the task at hand, but not without some words only he could hear from behind the curtain. Dr. Fong agreed with him 100%, but he had to keep his cool. There would be some phone calls and paperwork later. That, he was sure of. But right now they still had a teenage girl on the table in front of them.

He pushed the why out of his mind and concentrated on the current flaw in the donor heart. It had a hole in the wall of muscle separating the left and right ventricles. Its previous owner had no doubt gotten winded after a prolonged exertion, yet the problem, most likely something he’d been born with, had never been detected, or just simply never been addressed. Nevertheless, it was here now, and it was time to correct it.

“Pericardium?” Stephanie asked.

“We’ve got some core matrix in supply,” Kye spoke up.

“I’d rather use that,” Dr. Fong informed her as they worked to reestablish bypass. The cardioplegia was reintroduced and the heart once again stopped beating. Kye scrambled to re-supply Raina as they changed from closing the chest and back to another open procedure.

“Refresh me? What’s the plan?”

Dr. Fong spoke while his hands moved around the catheters.

“I’ll make a transverse incision here just below the pulmonary artery. It’s best if you split the muscle fibers rather than going longitudinally. There’s less chance of damaging a coronary artery. Then we just have to see how big a hole we’re dealing with. If it’s small, we can just suture it, but it almost always needs a patch. There’s some tricky stitching to avoid the Bundle of His and again on the cephalad edge so you don’t damage the aortic valve. But other than that it’s just patching a hole. The new core matrix is great. Stem cell coated, it’ll grow a new wall to fill the gap. When we’re done with the patch we just close with some 4.0 and restart her again.”

Kye burst through the door back into the operating room.

“I got your matrix!”

“Good. Tony, we ready?”

He watched as Kye dropped the matrix in his sterile field. “We’re ready.”

“Okay . . . let’s do this. Knife.”

•      •      •

Dr. Dayo watched from his seat at the OR computer desk while Jennifer deftly ran the heavy sternal wires through Oscar’s rib cage. She twisted the wires around one another, passing the heavy Kochler clamps from hand to hand with a practiced dexterity. She paused to cut away some stray tissue with the Bovi scalpel, and the smoke curled up and around her gloved hands. Once the offending item was cut away, she began tugging the wires tighter, drawing the severed sternum back together. Oscar rocked on the narrow table as she increased the effort. Soon the gap was closed and the twisting of the wires began again, the violence of her action in sharp contrast to the previous activity inside the chest cavity.

His gaze moved from the actions of his PA to the monitor screen over her head as Dr. Dryer fired up the cardiac echo machine. Placed in Oscar’s esophagus just prior to surgery, it provided a view of the newly installed heart as it worked in its new residence. The anesthesiologist adjusted a medication drip with his free hand and the heart responded with an increase in its efforts. Dayo followed his gaze as it switched to another screen.

“He’s showing a little S-T elevation in the V-leads. But the heart seems to like the higher pressure.”

“Elevation getting any worse?” Dayo asked.

“No . . . better actually.”

“Air bubble.”

“Maybe.”

Dayo rose from the chair and walked to the screen to examine it a little closer. The deviation Dr. Dryer spoke of could indicate a possible heart attack, but it was fading rapidly. He was glad to see it as it justified his next order.

“Let’s keep his pressure here for now. Once he’s settled in upstairs go ahead and let it come up.”

“Okay.”

Dr. Dryer extracted the echo sensor and began helping his tech clean and stow the equipment. Dayo turned and watched Jen as she placed the last few sutures. Raina and Paula began pulling off the drapes and scrubbing the stray blood away that had found its way under them. Dayo took one look as Oscar’s face reappeared before turning away. Brian was still stewing over his malfunctioning bypass machine with their new team member. Dayo quickly determined that he was the only one in the room with nothing to do, so he decided to leave while he could.

“I’ll meet you upstairs, John.”

“Okay.”

With a firm tug, he tore off his face mask before pushing his way out the door. Paula was reaching for the phone as he left.

•      •      •

Dr. Fong frowned at Tessa’s new heart as Stephanie worked to take her off bypass for the second time. The additional line of suture running across the right atrium was just one more insult to a heart that had been through enough for one day. It had already suffered the brain death of its original owner, an act that basically told the remaining organs to line up and get ready to die. Add to that the actions of the Mexican surgeon, who flooded it with cardioplesia before slicing it free of the chest and placing it on a machine for a three thousand mile journey. On arrival, he himself had greeted it by dropping it into a bucket of near freezing water before carving it up for implantation. They had subjected it to two cycles of warming and cooling now with the septal defect repair. If the heart woke up at all he would be surprised.

But wake up it did. This time they needed the paddles as Stephanie’s magic finger no longer seemed to be working. After a stutter or two, the heart fell into a somewhat regular rhythm.

They all breathed a quick sigh of relief and gazed up at the overhead monitor. They saw the signature double P-wave of the heart transplant rhythm, and nice, narrow, and peaked R waves, but the rest of the EKG was not what they hoped for.

“The right ventricle’s balking,” Fong observed.

“Did you expect that?”

“It doesn’t surprise me. This heart’s been through a lot today.”

Their eyes traveled from Tessa’s new heart to the monitor and back again as they watched the right side of her heart struggle. After a few minutes and no improvement, Dr. Fong made a decision.

“Let’s reestablish bypass and give her a good rest. Say fifteen minutes.”

Working together they quickly had that accomplished. This time there was no cross-clamp on the aorta, so Tessa’s blood was being circulated by both her new heart and the bypass machine at the same time. This gave the organ the least amount of work to perform, and allowed it a chance to get to know its new owner.

“Everybody take a break. Let’s get her numbers the best we can and see what happens after fifteen minutes.”

“You think the RV will step up?” Tony asked.

The surgeon shrugged. “No telling at this point. If it doesn’t, we can try the RVAD.”

Stephanie frowned at that. RVAD stood for right ventricular assist device, and they were seldom used. The chair-sized machine sat in the corner of the room on large caster wheels, and while always present, they avoided its use at all cost. It functioned by intercepting the blood from the vena cava, pumping it around the right atrium and ventricle and directly into the pulmonary artery. This would give Tessa’s struggling heart some much needed help. It was well known that surgeons hated resorting to its use, as it usually only worked to delay the inevitable anywhere from a few days to a few weeks. Dr. Fong referred to it as “the road to nowhere.”

Mike watched as they scrubbed out and filed out of the room to take a break. Only he and Doctor Jacobs remained. He checked his gauges before reaching for his binder. Inside he found a laminated copy of the RVAD connection sequence. He quietly reviewed it while the pumps continued to spin in front of him.

•      •      •

Rico swirled the rapidly melting ice in his drink around while he half-listened to Nestor lecture him about production and material costs. He had never had an interest in that part of the business. Oscar had always taken care of all of that. Rico didn’t have his brother’s gift with numbers, but it was something he would never admit to, especially to these two. He’d been listening to them drone on about this and that for the last hour and he was growing tired quickly. How hard could it be? They paid some peasant farmers double what they would make in a year growing coffee to plant, harvest, and process the drugs. Then they paid the gangs and others to transport it across the borders and into the countries where they had their biggest markets. A few bribes here and a few bullets there, and the money poured in. Simple. Why did these two always want to make it so complicated? Now they were trying to tell him that they had to change things. Why? Everything was working fine. He was thinking about another drink when something Nestor said caught his attention.

“What? What’s the problem now?”

Nestor stopped in mid-sentence before starting over.

“I was saying that we need to use the routes through Mexico less. It gives too much control to the Zeta’s. The longer our product is in their hands, the greater the chances of it being interrupted. The gangs are at war with one another
and
with the army. They are more than willing to inform on each other and let the army do their work for them. Either way, we end up losing product.”

Rico smiled to himself and shook his head. They always called it “product.” Why couldn’t they just call it what it was? Cocaine. They made cocaine and they sold it. Their fancy words just irritated him more.

Pablo spoke up. “It would be better to strengthen our own resources for delivery and move larger shipments.”

“With what, more submarines? Bigger planes? They cost too much, and when they’re caught we lose too much.”

“Not if you look at the numbers and compare them to using the gangs. The product is moved through a much shorter chain of people. Our people.”

Nestor jumped in. “That’s another thing. We can’t have any more men like Angel. He knew too much, and we’re paying for that now. We have to compartmentalize the routes and keep the people involved to a minimum. We lost two of our best tunnels in one day because of him. Because of one man we have too many things to change. I recommend we reduce our shipments for four months and raise the street price everywhere.”