sudden, all the surgical cases who could pay-those with insurance, or on Medicaid-were going to this Mainwaring. I've heard some of the rumors myself and, let me tell you, they are vicious. Drinking, doing unnecessary internal exams on women, taking powerful drugs because of a small stroke…'
'Is there truth to any of them? ' Zack asked. During the summer between his sophomore and junior years at Yale Med, he had worked as an extern at the then Davis Regional Hospital, and Beaulieu had gone out of his way to bring him into the operating room and to nurture his growing interest in surgery. It was a concern he had never forgotten. The Judge shook his head. 'According to Guy, there have been no specific complaints from anyone. Just rumors. He says that about eighty percent of his work now is charity stuff at Clarion County, and that he hasn't operated on a non-French-Canadian patient at Ultramed for almost a year.
He says the whole thing is a conspiracy to get back at him because he was so opposed to the sale of the hospital to Ultramed in the first place.'
'That's ridiculous, ' Frank said. 'Mainwaring's getting the cases because he's good and he works like hell. It's as simple as that. You know, Judge, I don't think it's fair for you to take Beaulieu's side in this thing.'
Clayton Iverson slammed his hand down on the table. 'Don't you ever dare tell me what's fair, young man! ' he snapped. 'The provisional phase in our contract with Ultramed still has a month to run. I convinced the board of trustees to sell out to them in the first place, and by God, the three weeks until our meeting and vote is more than enough time for me to convince them to exercise our option and buy the damn place back.'
He breathe deeply and calmed himself. Zack glanced over at Frank. Though he was staring at their father impassively, his hands were clenched and his knuckles were bone-white. 'And let me make this clear, ' the Judge went on, 'I haven't taken anyone's side. As a matter of fact, Frank, I resented his implications that you were in any way involved with his problems, and I told him so. He apologized and backed off some, but he's hurt, and he's angry.
I promised him I'd speak to you-both of you-about it… ask you to keep your eyes and ears open. I feel we owe it to him. You were too young to remember, Frank, but that man all but saved your life when your appendix burst.'
Frank's fists relaxed a bit, though Zack could tell that he was still smarting from the Judge's threat. Personality clashes, power plays, and political machinations were, he knew all too well, as omnipresent and as integral a part of hospital life as IVS and bedpans. But he sensed something more to all of this-something virulent. 'Annie!'
Cinnie Iverson's cry was followed instantly by the crash of dishes. With reflexes born of years of crisis, Zack was on his feet and headed toward the kitchen as Frank and the Judge were just beginning to react. Annie Doucette was on the floor. Her back and neck were arched, and her limbs were flailing uncontrollably in a grand mal seizure. As Zack knelt beside the woman, he felt the change sweep over him.
Early on, he had heard about the phenomenon from other, older docs, but did not undergo it himself until midway through his second year of residency, when he witnessed the cardiac arrest of a patient. In that moment, his world suddenly began to move in slow motion. His voice lowered and his words became more measured, he sensed his pulse rate drop and all his senses heighten. It was unlike anything he had ever experienced in similar emergencies. Movements became automatic, observations and orders instinctive. Dozens of facts and variables were processed instantly and simultaneously. Later, with the patient successfully resuscitated and stabilized, he would learn from the nurses that he had acted quickly, decisively, and calmly. It was only after hearing their account of his performance that he realized fully what he had done. The change had been part of him ever since. 'Mom, call an ambulance, please, ' he said as he rolled Annie to one side to prevent her from aspirating her own stomach contents, should she vomit. His fingertips were already at the side of her neck, feeling for a carotid pulse. As the change intensified, all sense of the woman as a friend, a loved one, a patient, yielded to the objectivity of assessment. If it became necessary, in any way, to hurt in order to heal, then hurt he would. 'Frank, my medical bag is in a large carton at the back of the van. Could you get it, please? ' Please. Thank you. The use of these words during a crisis kept everybody calmer, including, he suspected, himself. Stroke, heart attack with arrhythmia, epilepsy, sudden internal hemorrhage causing shock, hypoglycemia, simple faint mimicking a grand mal seizure, the most likely diagnostic possibilities flowed through his mind, each accompanied by an algorithm of required observations and reactions. Annie's color was beginning to mottle. Her back remained arched and her arms and legs continued to spasm. Her jaw was clenched far too tightly to slip any buffer between her teeth. Again and again, Zack's fingertips probed up and down along the side of her windpipe, searching for a pulse. She had had chest pain at the table. Zack felt certain of that now. Heart attack with an irregular, ineffective beat or complete cardiac standstill moved ahead of all other possibilities in his mind. 'Judge, are you okay to come down here and help? Good. I'm going to put her over on her back. If she starts to vomit, please flip her back on her side, regardless of what I'm doing. Lisette, check the time, please, and keep an eye on it.'
Zack eased the woman onto her back. Her seizure was continuing, though her movements were becoming less violent. Again he checked for pulses, first at her neck, then in each groin. There were none. He delivered a sharp, two-fisted blow to the center of her chest and began rhythmic cardiac compressions as Frank arrived with his medical bag. 'Judge, please fold something up and put it beneath her neck, then lay that chair over and put her feet up on it if you can. That's it. Frank, there are some syringes with needles already attached in the bottom of the bag. I need two. Also, there's a little leather pouch with vials of medicines in it. I'll need Valium and adrenaline. That one may say 'epinephrine' on it. Mom, did you get the ambulance? Good. How long?'
'Five minutes at the most.'
'Frank, can you do CPR?'
'I took the course twice.'
'Good. Take over here, please, while I get some medicine into her to stop her seizing. Don't bother trying mouth-to-mouth until she stops.
Just pump. You're doing fine. Every one's doing fine.' Zack placed his fingertips over the femoral artery. 'A little harder, Frank, please,' he said. 'Time, Lisette?'
'Just over a minute.'
Without bothering with a tourniquet, Zack injected Valium and adrenaline into a vein in the crook of Annie Doucette's arm. In seconds, her seizure stopped. Frank continued pumping as Zack hunched over the woman and administered half a dozen mouth-to-mouth breaths. Moments later, Annie took one on her own. 'Hold it, Frank, please, ' Zack said as he searched, once again, for a cartoid artery pulse. This time he felt one-slow and faint, but definite. He checked in her groin. Both femoral artery pulses were paldable.
I. N Again, the woman took a breath, then another. Come on, Annie, his mind urged. Do it again. Just one more. Just one more. He slipped a blood pressure cuff around her arm and then worked his stethoscope into place with one hand while he returned his other to the side of the woman's neck. 'I hear a pressure, ' he announced softly. 'It ain't much, but for right now, it's enough.'
Annie's breathing was still shallow, but much more regular. Softly, but steadily, she began to moan. Her lips were dusky, but the terrible mottling of her skin had lessened. At that moment, they heard the whoop of the ambulance, and seconds later, strobelike golden lights appeared in the living room window. Zack looked up at his older brother, who knelt across the woman from him. For an instant, he flashed on two young boys kneeling opposite one another in a dusty, vacant lot, shooting marbles. For ten seconds, twenty, neither man moved or spoke. Then Frank reached over and took his hand. 'Welcome to Sterling, ' he said. THE AMBULANCE WAS one of several well equipped vans owned by Ultramed-Davis and operated by the Sterling Fire Department. Zack sat beside Annie in the back, watching the monitor screen as the vehicle jounced down the narrow mountainside road toward the hospital. A young but impressively efficient paramedic knelt next to him, calling out a blood pressure reading every fifteen or twenty seconds. Sterling, New Hampshire, was small in many ways, but Zack could see Ultramed's influence in the emergency team's response. This was big city medicine in the finest sense of the term. Annie was still unconscious, although her breathing seemed less labored and her blood pressure was inching upward. 'Eighty over sixty, ' the paramedic said. 'It's getting a little easier to hear.'
Zack nodded and adjusted the IV which the young man had inserted flawlessly, and even more rapidly than he himself could have done. Frank had stayed behind to tend to the family and contact a cardiologist. They would meet later at the hospital. Zachary felt tense, but he was also charged and exhilarated. When it all came together, when it all worked right, there was no comparable feeling. Come, Watson, Come! The game is afoot. Zack loved the quote, and often wondered if Arthur Conan Doyle, a physician, had transferred the energy of his experience with medical emergencies to his detective hero. After a brief stretch on the highway, the ambulance slowed and turned
