Second Opinion (4 page)

CHAPTER 6

Thea felt herself go cold.

Her father's heart was in ventricular fibrillation. The powerful cardiac muscle was quivering impotently within his lion's chest like so many strands of spaghetti, unable to generate a heartbeat in any organized fashion. The colored monitor readings overhead were recording the disaster.

Pulse 0… Mean arterial pressure 0…

Selene had run off to page Scott Hartnett. The ICU intensivist was heading across campus from the cafeteria.

The biological clock of brain death had begun ticking the instant Petros's heart had stopped.

Thea's own heart felt like an expanding balloon, her stomach a pit of molten acid.

Calcium… potassium… Perhaps it was an abnormality of one or the other of those, she thought desperately. Or maybe some drug toxicity. Or maybe tamponade.

'Tracy,' she heard her voice say with no great authority, 'please call a Code Blue.'

To one side of the cubicle, Niko stood, his arms folded, his face stone.

'Code Blue Medical ICU… Code Blue Medical ICU…' the overhead page operator's voice droned from speakers outside the unit. 'Code Blue Medical ICU.'

Tracy raced in with the crash cart and immediately reached up and hit the button that started the red sweep-second hand on the code clock set high on the wall over the door. The time started at zero, but Thea knew fifteen seconds or more had already elapsed. Every one of those seconds diminished the likelihood of a successful resuscitation and increased the evolving brain damage. The point of no return in any cardiac arrest was felt to be four minutes. No blood pressure beyond four minutes, unless deep body cooling had occurred from exposure or drowning, and brain damage would be irreversible. The only way to extend the four minutes was through effective CPR.

Seconds later, the hospital CEO and nursing supervisor were there, along with one of the other ICU nurses. Amy Musgrave took up the Code Blue clipboard that was hanging by the door and began recording the event.

'I've got this, Susie,' she said to the nurse. 'You help Tracy. Where's the intensivist?'

'On his way from the caf.'

The first technician arrived pushing her EKG, and began hooking Petros to the leads of his machine. Inhalation was next, then the evening nursing supervisor, who saw Musgrave handling what would have been her role had the chief not been there, and backed out of the rapidly filling cubicle.

Thea glanced at the door, her mind unwilling to grasp that this was her show. The code clock was nearing thirty seconds. She was off to a terrible start.

Do something!
her mind screamed.
This is jour father. Do something!

She had taken, and of course passed with top marks, any number of advanced cardiac life support courses. She had instant total recall of the step-by-step problem-solving algorithms related to cardiac arrest.

Rhythm: ventricular tachycardia
… Institute basic life support including chest thump… Give amiodarone 300 mg IV and prepare to defibrillate at 200 joules…

All she needed to do was compensate for the wave of anxiety that seemed to be smothering her. Over her years of training, she had participated in a number of codes, but almost always, she had deferred control to one of the other docs. In Africa, more than a few of her patients had died, but a cardiac resuscitation was seldom successful when nothing could be done about the underlying condition that had caused it. And with the populations she was caring for, there was no shortage of lethal underlying conditions.

Suddenly, she was at the bedside, delivering a sharp blow to Petros's sternum with the side of her fist, and beginning chest compressions over the same spot.

'Niko, you outweigh me by seventy-five pounds,' she said over her shoulder. 'You should be doing this, not me.'

There was no response from her brother.

'Oh, Niko,' she groaned.

A burly resident entered the cubicle.

'What do you need?' he asked

'Some good, strong compressions,'Thea said, stifling the white-hot burn she was feeling toward her brother.

The resident moved in and began what Thea felt was adequate pumping, rhythmically squeezing Petros's heart between the underside of his breastbone and his spine. She set two fingers on her father's groin and felt a soft-but-definite jet of blood with each compression. Not great, but good enough provided it did not take too long to reverse the fibrillation.

The code clock swept past forty seconds.

'Two hundred joules,' Tracy said.

'Amiodarone in,' the other nurse reported.

Thea took the paddles of the defibrillator, placed one to the left of Petros's sternum and the other lower and farther to the left. Then she glanced back at her brother, who hadn't moved.

'Two hundred joules! Everybody clear!' she called out.

The muffled pop of electricity jerked Petros's restrained arms upward. Then just as quickly, they dropped back to the bed.

'Sinus rhythm,' Musgrave called out excitedly. 'Nice going, Doctor.'

'I've got a pulse,' Thea said.

The normal rhythm lasted only twenty or thirty seconds before deteriorating, once again, to ventricular fibrillation.

'Resume compressions, please,' Thea said to the resident. 'One milligram of epinephrine IV, please, Tracy. Prepare to shock at three hundred.'

'Three hundred,' the ICU nurse said, setting the defibrillator.

'Three hundred,' Thea said, now totally immersed in the resuscitation and in replaying the algorithms in her mind. 'Ready, clear!'

Again the odd pop; again the marionette-like jerk of Petros's arms; again the short-lived appearance of a normal rhythm before the reversion to fibrillation.

Thea felt the tension building once again. The sweeping second hand on the code clock passed two and a half minutes. On the bed, Petros lay rather serenely, his eyelids taped down, the ventilator supplying oxygenated, humidified air with a steady, repetitive whoosh. They would continue until there was no effective heartbeat and no hope of getting one, but unless something was done to deal with whatever was keeping the normal rhythm from rapidly deteriorating, the conclusion of this affair was foregone.

'Resume compressions, please. Could someone send for the ultrasound tech and bring me the kit for doing a pericardial tap?' Thea asked.

She wondered if her voice sounded as strained to everyone else as it did to her. She also wondered what people thought of Petros Sperelakis's cardiac-surgeon son, who remained a statue outside the crowd around the bedside.

/
can't let him go like this,
she was thinking.
I have to f
ind the answer.

Thea pressed her fingers into her father's groin once more. The pulse being generated by the resident was significantly less forceful.

Where was the intensivist?

'Are you getting tired?' she asked the resident.

'A little.'

Niko, what are you doing? Help us!

'Just give me one more good minute,' she said.

'You've got it.'

The compressions intensified and the resulting pulse became sharper. Three and a quarter minutes.

'Pericardiocentesis tray is ready, Doctor. Gloves are right here. Six and a half okay?'

'Perfect.'

Don't die like this, Dad
… Don't die like this.

Was it worth waiting for the ultrasound to demonstrate that there was or wasn't fluid pressing in around the heart? Absolutely not. Even with adequate CPR, there was ongoing brain cell death by the second. The pericardial tap had to be done now. The problem was that except for working on a cadaver in medical school, she had never done one. The anatomy presented no problem, but the technique might.

In her mind, Thea opened the instruction pages she had once studied in a syllabus on procedures and techniques. Then she gloved and put the special cardiac needle together. Did she go up under the sternum, or down between the ribs? Did it make any difference? Under, she decided. The syllabus she had memorized ten years ago said
under
.

Where's Ultrasound, dammit?

Her mouth dry, but her focus sharp, Thea snapped an alligator clip to the near end of the long cardiac needle, and attached one of the EKG leads to it. When the tip of the needle hit the heart muscle, there might be a noticeable change in the fibrillation tracing. Then she could withdraw the needle just a little and be in the space between the pericardial membrane and the heart muscle. Otherwise, the best she could hope for was getting fluid before hitting the heart. It all seemed perfectly logical—at least on paper it did.

'All right, let's try shocking him one more time at three hundred and sixty,' she said, with surprising determination and force, 'then we'll go for the tap.'

This time the shock produced no return at all to a normal rhythm—only a change in the ventricular tachycardia from a rough, sawtooth-like pattern to a form of V-tach where the irregular spikes were smaller. Petros's heart was giving out. Thea ignored the fear and anxiety that continued clawing at her, and prepared to perform a pericardiocentesis for the first time on a living patient, driving a thick four-inch needle up under the tip of her father's breastbone and into his heart, hoping to avoid piercing the left lobe of his liver along the way.

'You need to have the catheter ready, sis,' Niko said suddenly.

'I have it right here. You want to do this or not?'

'It isn't going to make any difference.'

'Then you have nothing to worry about, Niko.'

'That jungle certainly toughened you up.'

'This day has toughened me up more than all those years in the jungle ever did. Yes or no?'

Niko worked his way through the bedside crowd and confidently pulled on a pair of latex gloves.

'You were doing well, Thea,' he said.

Thea glanced up at the code clock. Four minutes.

'Keep pumping until Dr. Sperelakis asks you to stop,' she told the resident. 'So far, you and you alone have saved this patient with your excellent CPR.'

In the hands of a skilled cardiac surgeon, the pericardiocentesis took just seconds. The return of a striking amount of blood-tinged serum from beneath the pericardial membrane was diagnostic.

'Well, I'll be,' Niko said. 'You got me, sis. You got me good. Resume pumping, Tim, until I get this catheter sewn in place to keep the drainage going… Great. Now, let's try once more at three hundred and sixty joules. Ready… and… clear!'

CHAPTER 7

Wagner's 'Ride of the Valkyries' exploded through four suspended mega-speakers the moment Thea opened the door and stepped into the subdued light of the carriage house. The structure, large enough for half a dozen carriages at least, featured dark paneling, post-and-beam construction, and an expansive loft. Throughout her childhood, Thea had usually been frightened to enter the place, perhaps responding to the sensory defensiveness that had influenced so much of her life—in the case of the carriage house, an aversion to the dim lighting and dark corners, as well as to the broad staircase leading up to the unknown gloom of the loft.

Later, as it became more and more the domain of her older brother, she allowed him to coax her inside for mock dragon battles and role-playing games. In her best school years, Thea still had few close friends, just a couple of them of her gender. Dimitri did better in that regard, often hosting the 'Nerd Squad'—a gang of boys and an occasional girl who closed themselves in the carriage house, playing countless hours of computer games and intricate role-playing adventures such as Dungeons and Dragons. By the time Thea reached her mid-teens, many of her brother's Nerd Squad had graduated from MIT or Harvard or other top colleges, usually in computer technology, engineering, or some obscure area of science. Dimitri, however, possibly the brightest of the bunch, had graduated from no place, but instead, after a brief try at a local college, had receded deeper and deeper into the isolation and recesses of the carriage house.

'Dimitri, shut that off! Shut that off or I'm leaving!'

The powerful music, famous in part as the accompaniment of helicopter bombing runs in the movie
Apocalypse Now,
continued unabated. Thea pressed her palms against her ears. She had gained some control over her reaction to loud noises and other elements of her sensory defensiveness, but certainly nothing like total mastery. Smiling in spite of herself at how little time it had taken for her brother to reestablish his outlandishness, she stood by the ornately carved oak door and called out one more time.

After what had just transpired in the hospital, between her and her buttoned-down siblings, it was impossible not to measure them against Dimitri, who had always been something of a hero to her.

'Dimit—'

The music stopped mid-note. Dimitri materialized at the head of the stairs, then slid down the banister, vaulting over the end cap with practiced ease to land just two feet away from her.

'Dimitri, you child.'

They embraced briefly and awkwardly. Even after many hours of social role-playing improv games during various group sessions, Thea was still more reserved than many when it came to hugging—although much less so with her patients than with her friends and family.

Two of the three boyfriends she had had in her life were neuro-atypicals, and weren't excessively touchy. The third, Rick, neurotypical and her first true lover, told her over and over that she was the smartest, sexiest, most beautiful woman he had ever known. They stayed together for more than six months in college, sharing what Thea felt was an appropriately passionate love life. Then, with little warning, Rick drifted on to a woman who was, in his words, less physically inhibited. As she did with most of the emotionally charged situations in her life, Thea intellectualized his decision, and after seeing him together with his new girl, Thea decided he was right. She was still the most beautiful woman he had ever met.

'Welcome home, little sister.'

'Thanks. You look good.'

In fact, despite his perpetual dark stubble, he did. Thea remembered dense shadows under his eyes and persistent blinking, from stress or fatigue, or meds if he was taking any. Now there was less tension. In fact, there was almost a calmness to him. He looked more than ever like Petros—certainly more than Niko did—dark, swarthy, and classically Greek, with a spare physique that featured none of the soft prosperity that Niko's did.

His loft looked like the communications center for a portion of NASA. There were five monitors, two of them large flat screens. Both displayed video games in progress. In front of several of them were game consoles—Xbox, PS2, Wü, and a couple that Thea suspected her brother might have built himself. In addition, there were oscilloscopes and screens related to several other computers. To one side of the space, in front of shelves of Star Wars models, memorabilia, and games, was a broad worktable, strewn with ongoing projects and partially dissected hard drives. The area spoke to her of isolation and solitude, and would have saddened her greatly except for the word at the hospital that, some years before, Dimitri had actually participated on a team working on the development of a complex system of electronic medical records.

'So,' Dimitri said, 'how's the man?'

'He died, but I resuscitated him,' Thea said matter-of-factly.

It was much easier for her to speak with her older brother than with either of the twins. With them she was constantly monitoring herself to gauge whether she was being too blunt or insulting, or whether she was overlooking some social nuance. She didn't always pick up gaffes before they happened, but she knew she was still, and always would be, a work in progress.

'Uh-oh. How did that sit with you-know-who and you-know-who-two?'

'How does it sit with you?'
^v

Dimitri propped his bare feet on the counter beneath the monitor screens.

'You're the doctor. Is he ever going to wake up, Doctor?'

'I don't believe so, but I really can't predict at this point.'

'And what will he be like if he does? Animal, mineral, or vegetable?'

'Sometimes people make it pretty far back from these sorts of things.'

'Sounds like another way of saying vegetable. I've been in to see him once. Sure didn't look to me like he's coming back.'

'So you think I should have just let him go back there? No resuscitation?'

'I think you're a doctor. You gotta do what you gotta do. But I also know that the twins are doctors, too. And I know they've been waiting for you to come home so we all can sign a paper telling the doctors at the hospital not to do what you just did.'

'You were going to sign that?'

'Actually, I told Niko and Selene that if you signed, I'd sign. Us against them, just like the old days.'

Thea tilted her chair back and set her feet up next to her brother's.

'It's not time yet.'

'There's a lot of money at stake, I would guess. That's got to be of interest to the Twinkies.'

'They're both surgeons, Dimitri. They have plenty of money.'

'Suit yourself. You want to see this great new Mario game? I have a friend online who is just the ultimate artist. I think he's from Japan someplace. He can take any video game, like
Super Mario World,
and make it X-rated. Just imagine what the princess is doing in that other castle? See, I help him with the technical end. He chips in the artwork. The guy's a genius. You should see what he did with
Pac-Man.
Ms. Pac-Man can't keep her snapper off him.'

Thea grinned. The abrupt subject change was Dimitri's way of saying that talk about their father and the twins had gone on as long as he could handle. For Dimitri, as for her, in fact, life was all about keeping stress down to a manageable level. Chaos, uncertainty, unexpected changes, difficult social situations, and confusing topics were some of the enemies. The difference between the two of them was that she initially had their mother and now Dr. Carpenter as advocates and guides, and Dimitri had never really had anyone.

As far as Thea knew, her brother's diagnosis had never been established, although she suspected that whatever had placed him squarely among the neuroatypicals fell somewhere on the autism spectrum, quite possibly some variant of Asperger syndrome or Asperger's combined with some other condition.

'Another time, Dimitri. I'm going to head back to the hospital. I'm sort of reverse jet-lagged right now.'

'If you see the lights on up here, I'm up. Just ignore my alarm system and come on in.'

She wondered as she stood to leave what, if any, impact the death of their father would have on him. She glanced over at his sleeping area: a rumpled double bed, armoire, hot plate, and apartment-sized refrigerator. Over the time she was here, she resolved to spend more time with him, possibly outside of his lair, and to get more of a sense of his survival skills. He didn't seem particularly miserable at this juncture of his life, but he didn't seem especially joyful either.

'Okay, maybe I'll see you later or in the morning,' she said. 'I might just stay in the family room at the hospital tonight.'

'It might not have been an accident,' Dimitri replied, continuing to shoot at an advancing horde of demons, each one of whom exploded in green blood when hit.

'What?'

'The man's accident. It might not have been one. Someone might have hit him on purpose.'

'Why would you say that?'

Dimitri remained focused on the demons.

'I don't think everyone everyplace loved him. Not that often, but sometimes, the man would ask me to come with him on his morning walk. He always went the same route. After he was hit, I drove out to the spot with Niko. It was on a curve right by a three-foot-high stone wall. There was blood and hair on the wall where the man hit it, and he ended up well behind it.'

'A woman walking her dog noticed him, yes?'

'That's what we were told.' bo on.

'Got 'em!' he exclaimed, gesturing to the screen. 'Did you see that shot, lady? Two at once.'

It was hard at moments like this for Thea to believe that her brother might be among the most intelligent beings on the planet, but she had been told by her mother and the twins of testing done by the college he briefly attended, indicating that it was, by some measurements, the case.

'Dimitri, get to the point,' she insisted, an edge of exasperation in her voice.

With no introduction, Dimitri jumped to his feet, marched two screens over, and activated the computer that was there. Instantly an animation appeared showing the road and a stick-figure man walking beside it. The curve was there, and the stone wall, shown in nearly perfect proportions and three-dimensional perspective. Then, in slow motion, the figure became airborne, striking the wall with his head and then flipping over it.

'To knock him in this direction, the car would have to have been coming like this.'

Dimitri pressed a key and the stick figure returned to its original position. Then a green four-door automobile moved into the picture, coming from the right, and struck the figure, sending it tumbling once again, slamming against, then over, the stone wall. Thea saw the point immediately.

'Niko said there were no skid marks and no tire tracks in the dirt,' she said. 'The driver of the car would have had to hit Dad, then make a really sharp left in order to keep from going across that stretch of ground and hitting the wall himself.'

'Exactly. If he was drunk, he wouldn't have been able to do it. If he were sober, he would have had a hundred and twenty feet to see the man before he hit him.'

'Was it dark?'

'Not according to the police.'

'Have you shown anyone this?'

'I told Niko and Selene that I had made it, but they really didn't seem all that interested. The truth is, they're not all that interested in anything I do.'

Dimitri again immersed himself in killing demons. Thea knew he had retreated into the emotional safety of his video games, and for the moment, at least, he was announcing that all consideration of their father's near-fatal accident was over.

For Thea, however, that was not the case. She wandered out of the carriage house and back to Petros's Volvo, immersed in the possibility that the hit-and-run disaster might
not
have been an accident. It was chilling to think that someone could have purposely done such a thing to their father, but at the same time, her finely honed analytical sense was already at work probing the overriding question—why?

'Papa, what is that? The house is shaking. Papa, what's happening? Is this another earthquake?'

Nine-year-old Petros and his father, Konstantine, were in the living room of their modest house on a dusty hillside in the town of Lixouri, prefecture of Kefalonia—an island in the Ionian Sea west of mainland Greece. Konstantine Sperelakis was a teacher of Greek history and literature, and it was said of him that he knew what he knew. It was his absolute belief that Kefalonia, not Ithaca, was the birthplace of Odysseus, and he never passed up the chance to present the evidence to anyone who would listen.

There had been tremors and small earthquakes before— Konstantine had explained that Kefalonia lay on one of the great faults of the world—but something about these tremors was different. In spite of himself, because he knew his father's strict rules, Petros began to cry.

The year of the earthquake—the worst in many decades—was 1949. Sixty years later, lying helpless on his back in the intensive care unit of the Beaumont Clinic in Boston, Petros was reliving that horrible day piece by piece: the sounds, the sights, even the smells. Horrible… fateful. For a brief time, images of the earthquake faded, yielding to the sounds and sensations of another disaster—this one right here in the hospital, and not long ago.

'Clear!'

Thea's voice. Had he arrested? Yes, he had arrested and he was dying… No, he must have been dead. He couldn't focus his thoughts well, but he remembered enough to know he had been resuscitated—just as he remembered the death of his family.

'One milligram of epinephrine IV, please,
Tracy. Prepare to shock at three hundred…'

Thea
…

The tremors were coming closer together. Pieces of the ceiling were beginning to fall.

'Petros, I slapped you
because this is no time for hysteria. If I told you once, I told you a thousand times, no crying! Now go find your mother and your sister and get them out from under this roof before I have to slap you again.'