Lie Still (45 page)

I was breathing heavily. The woman next to me laid a hand on my arm and smiled.

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“What the hell is this?” I whispered.

“That was a cap gun,” she said.

“I hope so.”

“He’s demonstrating how the speed—or slowness—of neural transmission can limit one’s actions.”

“What?” I mumbled, still trying to regain full consciousness.

She shifted around to better lean into my ear. “He had the woman put the gun in his back and told her to pull the trigger as soon as he moved. Then he turned back to face her, fast as he could, and knocked the gun away from his back with his elbow. He says anybody with normal coordination can knock the gun away before the gunman can mentally process the sensory data of what’s happening and send the neural message to the forearm to pull the trigger. Even, as he said, ‘an old man.’ ”

“Every time?”

“So he says. Said he learned it from a karate master.”

“Why, I guess this was practical,” I said. “Any other hot tips I missed?”

“Go back to sleep,” she whispered.

“Was I snoring?”

“Well, deep breathing anyway.”

“Just kick me next time.”

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H E N RY RO J E L I O , DAY S I X ( C O N T I N U E D )
I did not go back to sleep in the lecture, though, nor even relax. I was troubled by something vague. It wasn’t Dr.

Weigand, even with a handgun. And it wasn’t The Longhorn’s dinner
plato
. Something in my dream.

The lights came up, signaling the end of Dr. Weigand’s lecture. The applause was long; I suspect the faculty were impressed that anyone could make any part of neurophysi-ology entertaining. I joined, at its toil, the small rabble around the dais. Those ahead of me were anxious to shake hands with the eminence from Chicago. I only wanted Dr.

Hebert but he was entrenched beside his guest.

As I waited my mind worked. I’d been dreaming about Robin in a lab coat. Odd. And then I remembered: the bubble. The bubble from the TB syringe. The dose of medication had come from the syringe and
then
the bubble. It didn’t work that way. When you drew up a solution you tapped the bubble to the top and then expelled the air. Sometimes a little of the air stayed in the hub of the needle so that a bubble preceded the drug, but not the other way around. Not if you did it right.

I half closed my eyes in concentration. When Gordon and LIE STILL

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I had given the dog in the physiology lab the sample from the syringe, a bubble had come out of the needle. Of that I was certain. But that was not the first injection from that syringe. The first had been into Henry’s forearm. And then a bubble.

“Holy shit,” I mumbled to myself.

TB syringes were of such small diameter that an air bubble could easily occupy the entire lumen and act as an im-permeable barrier between two different solutions, one on each side, both in the same syringe without intermixing.

Surface tension in the fluid columns. Elementary physics.

It would have been so easy to do. First draw up about eight tenths of a cc of epinephrine, then a tiny air bubble, then highly concentrated succinylcholine. Give the kid the muscle relaxant, squeeze out the air, and all that’s left is the epi. She just hadn’t squeezed out all of the air. Some was hidden in the metal needle hub. She probably had just stopped the plunger at the 0.8 mark and not even looked.

She was anxious.

I
was anxious. I looked up to see Dr. Hebert with an amused smile, watching me talk to myself. He motioned for me to come closer. “Ishmail! Damnit. Someday you’re gonna be invitin’ me to these things, I hope.” He turned to Professor Weigand. “This here is one of our—he
was
one of our better residents. He pissed off the wrong damn female.

We gettin’ him back, though.” As I shook Dr. Weigand’s hand I realized I did not need to talk to Dr. Hebert anymore.

If the bubble separator worked, the contents of the syringe would be epi and only epi. Whatever had preceded it in the barrel of the syringe was long gone—into Henry.

Dr. Hebert said, “Ain’t we, boah?”

I said, “Absolutely, sir. All my appeals are locked and loaded.”

“Shit, son, fire at will.”

I was dying to test my theory. I said, “I am, sir, I am.”

Dr. Hebert said, “You needin’ something again? How’d that project work out with Alphonse?”

“Fine. He was very helpful.” I looked at the two men 342

DAVID FARRIS

blankly. “I just wanted to say how much I enjoyed your lecture, Dr. Weigand.”

Dr. Hebert gave me a cocked look. He said, “Ishmail. You nevah had no brown nose befoah. What kind of trouble you into?”

I grinned. “None, Dr. Hebert. I just thought of something I need to go do, though. Next time I see you I’ll tell you all about it.”

To find a tuberculin syringe I went directly to the Pediatrics ward, walking into the Procedure Room as if it were my home. Even at that late hour, with a UAMMB name badge dangling on my jacket I would be less than a face in the crowd to any of Maricopa’s legitimate workers. If a nurse came into the Procedure Room, her most likely question would be, “Can I help you find something?” That would be the fastest way to get rid of me.

I ran through nearly a dozen drawers before finding the two basic items I needed: sterile water and a tuberculin syringe. I drew up half a cc of the water from a vial, then drew in a bit of air, then more water. As I moved the plunger back and forth, the bubble moved in unison with the two fluid columns. The bubble and its surface tension were a perfect barrier.

All well and good. But could I make a succinylcholine solution in the concentrated version?

I needed to steal a gram of dry sux. Paging the pharmacist and asking for it would have worked but certainly would have been an invitation for discovery and expulsion. Better to remain a bilge rat.

A back stairway I knew took me all the way down to the basement and landed me five gurney lengths from the doors to the OR suite. I adopted the half-dead mask of a resident and skulked past the main doors to the ones marked “Doctors (Male).” The combination to the locker room came to my hand without conscious thought. It probably hadn’t been changed since the door was installed, and from the look of it, that had preceded my birth. For fun I thought about trying the LIE STILL

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combination to my old locker but rapidly figured the rightful owner, should clothes and wallet be hanging there, would not understand my nostalgic curiosity. I hung my jacket and clothing on the coatrack and got into full surgical garb. I pinned on my name badge in such a way that it would hang with the back side facing out—a common configuration—

and took a rear hallway to the Anesthesia Prep Room, avoiding the control desk.

The Prep Room is actually little more than a supply room. No patient goes there, only anesthesiologists and their aides, usually just to fetch something, rarely to mix some concoction. I turned from cupboard to rack to shelves, mentally practicing my cover story. Eventually I found a six-foot-tall rolling rack of plastic drawers that housed all the anesthesia-related drugs. Each drawer was a different color and covered with printed labels, describing a roughly alphabetic distribution of their unique poisons. I crouched to the “S” drawer.

A male voice behind me said, “Whaddya need, Doc?”

Fortunately I was facing the drugs. I composed myself, turned, and drawled out, “Uh, succinylcholine . . . but in the one-gram thing. You know, to make a drip.”

My helper was a pimple-faced young man with an angular mustache and thin goatee cut to resemble a can opener.

Eager to be the source of knowledge for a bumbling surgery resident, he was all unquestioning help. “Oh, Doc, those are in the fridge, man.” He yanked open the refrigerator behind him, retrieved two plastic squeeze bottles the size of 35-millimeter film cans, and flipped them to me one by one. He said, “Take two. They’re cheap.”

“Yeah. Thanks.”

“Anything else?”

“Well, yes,” I said. “One of the curved blades. What do they call them?”

“MacIntosh.”

“Yeah. A Mac blade.”

“What size?”

I looked blank.

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“How old is the patient?”

“Um, thirty-nine.”

“Adult. Take a three.” He opened a drawer by the sink and handed me a laryngoscope blade.

“Thanks,” I said, and strolled out as if I had real purpose. I took the first turn I could, then a second, ultimately looping back to the rear hallway. En route back to the locker room I slid the blade into one of the scrub sinks where I’d seen the anesthesiologists leave them after use.

I changed back into my clothes and hurried out of the OR suite. I ducked into one of the small “Staff Only” rest-rooms and locked the door. I peeled the protective shrink-wrap off one of the succinylcholine bottles but paused dumbly and stared before twisting off the funnel-shaped cap. I pictured the resident from Gordon’s story who inhaled the contents of just such a squeeze bottle. He ultimately had been able to call for help. I was locked in a bathroom.

Being careful not to squeeze, I pointed it away from me and snapped off the cap. Nothing shocking happened. I pushed the cc of sterile water from the tuberculin syringe into the plastic bottle and swirled it around. The combined water and powder formed a thick white slurry reminiscent of a piña colada sans umbrella. I swirled it longer. The drug still did not dissolve.

Maybe time and heat would help. I drew into the syringe the entire slurry, dropped the capped syringe into the pocket of my jacket, and headed out to find a phone.

If you act like you own the place, most people will assume you do. I put my name badge on my jacket, went straight to the control desk on the surgery ward, picked up the phone, and asked the operator to page Gordon Erickson.

“This is Dr. Erickson.” He sounded half asleep.

“Gordon. Hi. Malcolm Ishmail. Hope I didn’t wake you.”

“Nah. ’Ts okay.”

“You alone?”

“No.”

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“Yeah. Sorry. But this is really critical. Like, saving-a-life critical. I need another consult.”

“Yeah?”

“Succinylcholine. I need a little more info.”

“You gonna kill somebody?”

“No. No way. But if somebody did get a load of sux, what else would you see? I mean, obviously he’d be temporarily paralyzed. But what else? Anything that might show up in a patient’s chart? Side effects?”

He pondered, audibly. Something like “Ehhnnn.” “Well, there’s potassium. Sometimes people get a bump in their K

that might show up in their labs. So you could check that.

But usually it’s pretty mild and you wouldn’t even notice it.

Sometimes, though, you can get a massive rise. People with muscular dystrophy or big, deep burns. Your intended doesn’t have anything like that, does she?”

“No. And I don’t have an ‘intended.’ Anything else?”

“It happens with some other nerve and muscle diseases.

In fact, it’s been reported in a lot of nerve and muscle diseases, but there isn’t a clear pattern.”

“So a bump in his K. What kind of numbers are we talking?”

“Depends. It can be big-time levels—seven, maybe eight.

Nine. It’s known to cause cardiac arrests, presumably from the sudden spike in the potassium.”

“I’ll check it. I know where to look. Anything else? I mean, I hate being desperate, but anything even suggestive.

I’ve got to build a case, and impressions and possibilities seem to be what they go for. You know?”

He made the same “Ehhnnn” sound. “Myoglobin.”

“Huh?”

“Sometimes in the hypercontractile state as the drug is taking effect—you know, like spasms—there’s a shear injury to the sarcomeres—the muscle bundles. If it’s severe enough some of ’em die. They spill proteins—myoglobin—

into the bloodstream.”

“But it would be gone after a couple of days, right?”

“Long gone.”

“I’m sure no one checked a blood myoglobin level.”

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“Yeah, but that’s what I was trying to figure out—something that would have shown up. Myoglobin gets filtered into the urine. If there’s enough of it you get dark urine.”

“Tea colored,” I said, responding to some long-ago lecture I thought I had forgotten.

“Exactly. Just like rhabdomyolysis.”

“Yeah.”

“But even if it’s not that severe, you might get some protein in the urine. If you did a urinalysis.”

“I didn’t order it. But they might have done one anyway.

Urinalysis is still a basic admitting test.”

“Yeah.” A long pause. “I can’t think of much else. And those aren’t much to go with. They’re pretty nonspecific.”

“Yeah,” I said, “there are about fifty causes each of protein in the urine and high potassium. But like I said, any evidence I can use, you know.”

“Yeah.” A pause. “So who do you think got sux that shouldn’t have?”

“It’s just a long shot. I can’t really say, unless I can prove something.”

“Well, good luck.”

“Thanks, Gordon. I owe you.”

Henry’s chart was not to be found at the control desk of the PICU. I went down to his cubicle, again working to look tired and barely interested. His nurse, another woman I didn’t recognize, eyed me. Her nametag said “Jeanie B.” She was resetting the “volume-to-be-infused” on Henry’s IV

pumps. She looked at me only long enough to verify that I was only one of the pseudo-doctors expected to buzz around patients like flies around old meat.

Without looking up a second time, she said, “Are you by any chance from the neurologists?”

“Nope. Just, um, Pedes.”

“Oh,” she said. “I was just wondering because the neurologists apparently were going to do some tests in the morning but they didn’t leave any orders. Like special meds or IVs or anything.”

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“They probably don’t need anything special.”

“Well, that’s what I figured. I didn’t think I’d page them, anyway,” she said.

“How’s he doing?” I asked. Anyone who’s ever been an intern knows the bedside nurse can tell you more in fifteen seconds than the chart will in fifteen minutes.