Patient One (6 page)

“It’s impossible to say,” David replied. “If we’re lucky, it’ll hold until the gastroenterologist gets here.”

“My stomach feels like it’s frozen,” Merrill complained.

“That’ll pass, Mr. President,” David assured him.

Merrill turned on his side and spat a mouthful of pink saliva into the basin.

“Do you know I had an uncle who bled to death this way? They said something was wrong with his blood.”

David’s eyebrows went up instantly. “Did he have a coagulation defect?”

Merrill nodded and looked over to Warren. “What was the name of that strange disease he had?”

“Von Willebrand’s disease,” Warren replied.

“Jesus Christ! You’re a bleeder!” David blurted without thinking. “You’ve got an inherited defect.”

“No, he doesn’t,” Warren disagreed immediately. “The President’s father, who was a senator and the brother of the man with von Willebrand’s disease, had no bleeding tendency. And the President has never shown any propensity to bleed. But to be on the safe side, the President was evaluated with a bleeding time and Factor VIII level. Both tests were within normal levels, excluding the diagnosis of von Willebrand’s disease.”

David asked the President, “Have you ever had major surgery or a tooth extracted?”

“I had a molar extraction years ago.”

“How much blood did you lose?”

“It took almost a week for the bleeding to finally stop,” Merrill recalled, then glanced over to his personal physician. “And, Will, the fact of the matter was that Father had the same bleeding disease as my uncle. They kept it quiet because it could have been politically damaging to him. He, too, once had presidential aspirations.”

“And you knew you had the disease, as well?” Warren asked incredulously.

Merrill shook his head. “My blood tests were always negative. I thought the disease had skipped over my generation.”

David gave the President a skeptical look. With Merrill’s family history and his prolonged bleeding after a simple dental extraction, he must have known he had the disease and, like his father before him, was hiding it for political purposes. But then again, people believed what they wanted to believe. Maybe Merrill was actually convinced he didn’t have the disease. After all, this was his first major hemorrhage.

Finally David said, “Mr. President, von Willebrand’s disease is an inherited disorder of coagulation characterized by a prolonged bleeding time and a low level of a protein in the blood called Factor VIII, which is essential for clot formation. But these abnormalities can vary in a given patient, with the tests being normal one week and abnormal the next. So, even with normal tests you can still have the disorder, Mr. President. And this would explain why you’re bleeding so much.”

“Jesus Christ!” Merrill groaned sourly. “Am I going to just lie here and bleed?”

“No, sir,” David answered at once. “The bleeding responds to injections of fresh plasma and to concentrates containing high levels of Factor VIII.”

“Then inject me with them,” Merrill said.

David hesitated, now in over his head. He sounded impressive, but his knowledge of von Willebrand’s disease was limited to the single case he’d heard discussed at a Grand Rounds conference. He could define the disease, but treating it could be a tricky matter.

“Mr. President, I have no experience in the use of concentrates, which is the preferred treatment for this disorder. That requires a specialist in blood diseases. So what I’d like to do is give you fresh frozen plasma, which will stabilize your bleeding, and call in a hematologist to advise us on how to administer the Factor VIII–rich concentrates.”

“Do it,” Merrill directed.

David turned quickly to Warren. “If he starts bleeding again, lavage his stomach with more ice water.”

Warren was about to ask what to do if the bleeding didn’t stop, but David had already dashed out of the room. Warren sighed heavily to himself. He was out of his depth and knew it.
The President was a GI bleeder with a coagulation defect!
It was a rare, complex condition, and the President would need specialists in both hematology and gastroenterology to survive another major bleed. And even they might not be able to save him. The President suddenly gagged, and more stingy clots oozed from his nose. Warren could only hope it didn’t signal the start of another bleeding episode.

David sped down the corridor, passing a cluster of Secret Service agents and two big, burly Russian security guards. All the doors were closed, but David could hear the occupants throwing up. The smell of vomit was everywhere.

At the nurses’ station, David called over to the clerk. “Where’s Carolyn?”

“In the treatment room.”

David hurried on, deciding to order two units of fresh frozen plasma. That should hold the President for now, assuming the diagnosis of von Willebrand’s disease was correct. It was, he told himself. It had to be. There was no other explanation for that much bleeding in a simple case of food poisoning.
Damn it! A coagulation defect! I should have thought of that early on, because I’ve seen it before. I’ve seen patients in the ER bleeding like hell from minor wounds because they had a coagulation deficiency that was either inherited or caused by blood-thinning drugs like Coumadin. And I almost missed the diagnosis in the President of the United States. Jesus Christ! Get your head out of your ass, and think!

He entered the treatment room and found Carolyn rummaging through a drawer. She cursed under her breath.

“What are you looking for?” David asked.

“Pliers,” Carolyn replied. “Kate broke off the key in the narcotics cabinet. Those Secret Service agents must have removed all the tools.”

“That can wait,” David said urgently. “We’ve got to clear this room except for the bare essentials.”

“Why?”

“Because they’re going to do the President’s endoscopy in here. They don’t trust any other place in the hospital.”

“Those guys don’t take any chances, do they?”

“Not when it comes to the President,” David said, and walked over to the phone on the wall. “Has the blood bank sent up those units yet?”

Carolyn shook her head. “They’re having trouble finding a match for the President.”

“Damn it!” David groused and rubbed at his forehead, as he tried to think through the predicament. No matched blood was available, and none would be any time soon. Plasma alone wouldn’t help the President’s worsening anemia. “We may have to use O negative blood in him.”

“Is it that bad?” Carolyn asked.

David nodded. “At the rate he’s going, the President could bleed out on us.”

“Oh, Jesus,” Carolyn breathed in a whisper.

David rapidly dialed the number of the blood bank and spoke to the technician in pressing tones. “I need that blood up here now! … I don’t care! … Get it up here!” David’s jaw tightened, a vein on his temple bulged. “Put the director of the blood bank on!”

While he waited, David glanced over to Carolyn and said, “And to complicate matters, the President probably has a coagulation defect.”

“This is getting worse by the minute.”

“Tell me about it.”

Carolyn watched David pace around the phone, pleased that he was there tonight rather than the other attending physician, Oliver Sims, who was brilliant but slow and hesitant. In contrast, David was sharp and quick and decisive, and at his best in emergency situations. Like now. She tried to pry her eyes away from him, but couldn’t. Her gaze kept coming back to his uneven good looks that she found so captivating. She wondered if Sol Simcha was right about David watching her. If David was really interested, he was doing a good job of hiding it.

“I don’t give a damn who he’s talking to,” David yelled into the phone. “If the director is not on this line in sixty seconds, I’m coming down to get the blood myself.”

He listened intently, then added, “You just wasted five seconds. You’ve got fifty-five left.”

David’s eyes narrowed. “Now you’ve got fifty.” He cursed under his breath and looked over to Carolyn. “Can you believe this?”

“They’ve only got the night crew on,” Carolyn said. “I suspect they’re overwhelmed.”

“We’re all overwhelmed,” David grumbled. “We’ve got a bleeding President up here, and they can’t shift it into high gear.”

A large fly suddenly buzzed by Carolyn. She tried to swat it out of the air with her hand, but missed. “Damn flies!”

“You’ve got flies up here?” David asked, surprised.

Carolyn nodded. “A large colony somehow found their way up to the Pavilion and, even with pest control, we can’t seem to get rid of them.”

David brought his attention back to the phone. He pressed it to his ear and said, “Dr. Nelson, listen closely because I’m only going to go through this once. This is David Ballineau on the Beaumont Pavilion. I need two units of O negative blood and two units of fresh frozen plasma, and I need them now … No! Not twenty minutes! Now! … Then warm them quicker and have them up here within ten minutes or we’re going to have a dead President on our hands … Good! Ten minutes then.”

David hung up and growled, “I wonder what else is going to go wrong.”

“Will they be able to eventually find a match for the President?” Carolyn asked.

“Probably. But in his case, eventually may be too late.” David quickly glanced around the treatment room, then pointed to pieces of furniture that wouldn’t be needed. “Let’s move the supply cabinet and the metal stools into the hall, and the small table has to go too.”

The ventilation system overhead switched on noisily and blew cool air down on them. Small black particles floated down as well.

“What the hell is that?” David asked, waving at the dust in front of his face.

“The air filter needs to be changed,” Carolyn told him. “I’ve already called the maintenance people about it twice.” She reached for the phone on the wall. “I’d better call them again.”

“Don’t bother,” David said. “The Secret Service won’t let them come up.”

Carolyn studied the ventilation duct as more particles came down. “I know how to remove the filter, and that’s where most of the dust is.”

“Then let’s get it out.”

“Shouldn’t you get back to the President?”

“His doctor is with him, and until the blood arrives there is not a whole lot I can do for him. And we can’t do the endoscopy in here, with crap flying out of the air duct.”

Carolyn pushed a metal stool over to the countertop. “Hold this for me, David.”

“How are you going to unscrew the duct cover without tools?”

“Trust me,” she said, reaching into her pocket and holding up a nickel. “It’s a broad, flat screwhead, and sometimes a nickel is all you need.”

David grabbed the legs of the stool and watched Carolyn climb up onto the countertop. She stepped over to the sink, then stretched up and used the nickel to unscrew the metal duct. David moved in closer to the countertop to catch her in case she slipped. He glanced up and studied the nurse he’d been attracted to from the first day he saw her. She was slender and shapely, with soft, patrician features and long, brown hair that curled at her shoulders. Not beautiful, he thought, but really pretty. And smart, too.
So why don’t I ask her out? Am I worried it’ll interfere with my duties as an attending physician? Is that it? Or is that just an excuse for not wanting to get involved again? And not wanting to get hurt again?
David shook his head at his stupid daydreaming.
Think about a sick President, not a pretty nurse.
“How’s it going up there?”

“Just about done,” Carolyn said, quickly turning the last screw. “One more—”

A screw fell out and dropped toward the floor. It hit the metal stool beside the counter and bounced up. Effortlessly and without thinking, David caught the screw in midair and gave it back to Carolyn.

“Good hands,” she commented.

“I was born with them,” David said.

“They must have been useful in athletics.”

“And other things.”

“Such as?”

“Such as catching screws.”

Carolyn smiled. There was a lot more to David Ballineau than he let on. He was like a book she wanted to read. Her problem was opening it. She fastened the last screw into the frame, then tossed a round, dirty filter into a nearby trash can. “Want to help me down?”

“Sure.”

“Be careful. My palms are covered with soot.”

David reached up for her waist, which seemed almost small enough for his hands to wrap around. He slowly lowered her until they were face to face. A lock of her long brown hair fell across her temple and cheek. She didn’t bother to tuck it back in place. Instead she just blew at it, and it returned to its original position. Then she smiled to herself as if she had performed some difficult task. David had a nearly irresistible urge to bring her closer, but he forced himself to lower her to the floor.

“Thanks,” Carolyn said.

“No problem,” David replied, now noticing a smudge of dirt on the end of her nose. He reached over and removed it with the tip of his index finger.

“What’s that for?” Carolyn asked, smiling again.

David showed her his finger. “Cleaning service.”

Carolyn smiled wider, wondering what it would feel like to run her hands through his salt-and-pepper hair. For starters. “Send me a bill.”

“First chance I get.”

He watched Carolyn lean over the sink and slowly soap her hands, fingers to palms, as if she was gently massaging them. Everything about her seemed to attract him. Her hair, her long legs, her slender waist, her soft features. But most of all it was her moves that enchanted him. Like the way she blew a strand of hair away from her face and soaped her hands. There was something very sensual about those moves. David continued to stare at her long legs and tight body. He felt himself stir and hastily looked away.
Ask her out to dinner, goddamn it! Just ask!
He cleared his throat and said, “Ah, Carolyn.”

“Yes?” she said, reaching for a paper towel.

“I was wondering if—”

Jarrin Smith appeared at the door of the treatment room and knocked gently. “Dr. Ballineau, the anesthesiologist for the President’s endoscopy is here.”