"I need a good lateral of his neck right away.
Have them shoot a chest and pelvis as well. June, I don't think he needs a tube yet, but he might. He looks like hell. What's his pressure?"
June Feldman tried to find out with a cuff and Doppler electronic stethoscope, then shook her head.
"As soon as bloods are off to the lab, get an arterial line in him.
Then a catheter," Eric ordered.
Feldman set to work cannulating the man's radial artery, while a second resident numbed a spot near his navel and thrust a tube into the abdominal cavity.
A flush of saline through the tube showed no evidence of internal bleeding.
Eric nodded. The test had ruled out a ruptured spleen or liver, and had made an aortic tear less likely.
The possibility of pericardial tamponade as the cause of Russell Cowley's shock had just increased severalfold.
Tern Dillard rushed into the room.
"How's he doing?" she asked breathlessly.
"No better, no worse," Eric said. "He's tamponading."
"You sure?"
"Not yet, but almost. And if it's true, hold on to your hat.
'You're going to get to see something no one has ever seen-not even me.
That is, providing goddam Subarsky gets down here in time."
"Well, I hope whatever it is happens quickly," Tern said, "because we just got a call on the Batphone.
Boston Rescue is on the way in with another Priority One-a man found in an alley in the North End. No pulse, no respiration. They're doing CPR."
"A drift diver?" Eric asked, his concentration still focused on the residents and technicians.
The term referred to the derelicts pulled from snowdrifts throughout the Boston winter. Most of the time they were well beyond salvation.
"I think so," Terrf said. "The rescue people refuse to incriminate themselves over the radio, but they did say there was a nearly empty bottle of Thunderbird in the man's coat pocket."
"Is he warm?"
"I have my doubts. Rescue made it sound like they were only working on him because their protocol demands: it."
"E.K.G?"
"Essentially straight-line, with an occasional agonal beat."
"Pupils?"
"Dilated and fixed."
"Lord. Tern, isn't there someone else around to work on him?
This is big stuff going on here. This guy's the president of a company, a trustee of this hospital, and he's got treatable injuries.
I don't want him shortchanged while I go through the motions with a wino who probably died hours ago."
Tern's eyes narrowed.
"You're the only senior person around," she said coolly. "If you need help, Dr. Kaiser is next door doing walk-ins." "tell him to take charge of the diver. If this guy needs his pericardium drained, I'm going to do it.
"En'c, come on," she said. "Gary Kaiser's been here a year and a half, and he gets flustered taking care of strep throats. I think his father must have endowed a building or something. There's no other explanation for his getting an internship here."
"well, just tell him it's time to be a goddam doctor.
That's what he came here to be. Anyhow, it sounds like this diver's going to be just another D.O.A. Tern, for chrissakes, don't make that face. Okay, look, I'll be over to help him as soon as- Wait, there's Subarsky.
If things go the way I hope, we may be done before the diver arrives."
Dave Subarsky lumbered into the room, hauling a cart laden with complex machinery. Subarsky had a PhD. in biochemistry from M.I.T but at six foot two or three, with a full beard and massive gut, he looked more like a professional wrestler. He and Eric had grown up just a few doors from each other in Watertown. And although they had entered grammar school the same year, by the time Eric graduated from high school, Subarsky was in his third year of college. It was an unexpected perk of Eric's residency appointment to find his old friend doing independent research in one of White Memorial's labs.
"Ye, David," Eric called out. "You have the right dye? Great.
Run into your boss at all? No? Perfect.
Okay, then, set up right there. We're going to go for it.
June, is that arterial line in yet?"
"Right now," she answered. "One more second and… Voila!"
A low, rapid wave-tracing appeared on the oscilloscope beneath Russell Cowley's E.K.G pattern. Next to it were the numbers 50 and 0.
Systolic and diastolic pressures. Cowley himself had lost consciousness, but his respiration remained steady and reasonably effective. The violet in his face, however, had deepened.
"Call the O.R. and have them mobilize the cardiac surgical team," Eric said. "If this doesn't work, we'll try a needle. But they'd best be ready to open this man's chest." "Okay, David, this is it. Everybody listen up. This is Dave Subarsky. He's a biologist from M.I.T and this is a new kind of laser he's helped develop.
We're going to use it to open a window in this man's pericardium and drain the blood out from around his heart and into his chest cavity, where it will simply get absorbed."
"Is it dangerous?" one of the nurses asked.
"Not in David's hands. It was developed for vascula work, but I got the idea to adapt it for pericardiocentesis- I have total confidence in our ability to do this. We-Dave and I-have been doing animal work with it for months, mostly at three or four in the morning-"
Dave Subarsky, adjusting the dials on the machine, smiled behind his beard.
As soon as it received F.D.A approval for general use, the combination X-ray and coaxial, flash-lamp, pumped-dye lasers would, Eric hoped, become known as the Subarsky/Najarian laser.
First, though, the technique had to work.
"I want you all to know," Eric went on, "that this procedure is virtually noninvasive-far safer and more accurate than the needle approach you're all familiar with. In that lower machine, there, we are using a dye specific for the protein in the pericardium. 'This upper component is an X-ray laser beam that will carry the dye laser beam through the intervening structures, right to the pericardium."
"What should we expect to see?" the same nurse asked.
"well, for starters, a drop in his CVP, and something a little more effective than a systolic pressure of fifty," Eric replied, barely masking his growing irritation with the woman. "Now, if you'd all just move back." "a-I," Tern Dillard hurried into the room.
"Eric, the other Priority One is in Six. Gary Kaiser's working on him."
"What's his temp?"
"Ninety-six two."
"E.K.G?"
"Straight-line with a rare agonal beat." god."
"Tell Kaiser to pronounce the guy if that's all he's-" "Yes, but-"
"Is the cardiac team on standby for this man?"
"Eric, we just lost his pressure," June Feldman said. "Do you want me to start CPR?" the wave formation on the oscinoscope was a straight line. The systolic and diastolic readouts both showed zero. The heart rate began to slow.
Cowley's respiration grew shallow.
"Damn," Eric whispered. "Okay, everyone, this is it. Tern, you'll just have to tell Kaiser to do his best.
Then call the cardiac people and get them down here.
We may have to open his chest right here. Also, get some blood.
They should have him typed by now. Tell them to forget the cross-match on two units and get them over. June, keep a finger on his carotid.
Ready, David?"
"Ready.
"Go for it."
Dave Subarsky hit one switch, then another. A faint blue beam shot from the upper laser, followed almost instantly by a red one from the lower.
The beams intersected at a spot just above Russen Cowley's lowest left rib, and disappeared into his chest.
For five seconds, ten, there was nothing.
Eric shifted nervously and moved forward with the cardiac needle.
"More power?" he asked.
"I don't think so, Doc," Subarsky replied.