Indication for Procedure: This 35-year-old, previously healthy and active ambulance physician presents with marked dyspnea, tachypnea, and hypotension with a blood pressure of 70/40 and heart rate of 160.
An emergency chest X-ray demonstrates a large right-sided pleural effusion coincident with an entry wound just lateral to the spine in the fifth inter space and medial to the posterior axillary line.
The entry wound measures only 1.5 cm. The patient displayed a decorative dagger, which the ambulance attendant had removed at his direction after the patient was stabbed. This event occurred approximately 27 minutes prior to the initiation of the procedure.
Description of Procedure: IV access was obtained and light general anesthesia was administered and deepened as tolerated after ongoing fluid resuscitation. Orotracheal intubation was performed and the patient was placed in the full lateral position. The chest was rapidly prepared with Betadine and a fifth inter-space incision was made anterior to the entry wound.
Several liters of clotted blood were removed rapidly and minimal ventilation was performed in order to rapidly assess the mechanism of injury. Irrigation was used to remove the deeper lying thrombus. The lung parenchyma was essentially spared. Attention was then turned to the hilum.
Inspection of the anterior vessels showed no evidence of pulmonary or bronchial artery injury.
The lung was then reflected medially and an area of posterior thrombus was identified well behind the phrenic nerve.
This area was suspicious for a pulmonary vein injury and was approached as carefully as possible.
A large defect was seen in the right superior pulmonary vein continuing from the pleural space into the pericardium. The pericardium was lacerated inferior to the venous laceration.
Once the defect was visualized, a light 4–0 silk suture line was begun to close the defect. Unfortunately, several minutes were needed to find the suture and while the chest was flooded with irrigation the patient arrested.
An arterial air embolus was suspected. Open chest cardiac massage was begun and the defect was closed with good hemostasis. The pericardium was then widely opened and no further injuries were seen.
Continued resuscitation was performed for another 30 minutes. Despite these measures, the heart continued to fibrillate and a proper rhythm could not be established.
The patient was pronounced dead in the operating room at 5:53 a.m.
The retractor was removed and the incision was closed with interrupted suture.
Kogan’s objective here was to create record, to show who killed his friend and to document the extent of injuries.
If you are a homicide detective, you want notes these good, but you rarely get them.
* * *
Kogan felt pride every time he walked through the entrance of Pervaya Gradskaya. The hospital was built in 1832 at a time of Russia’s great imperial ambitions. It was a grand place with massive columns, a cupola, and two small bell towers rising incongruently but charmingly from the sides of the portico at the main entrance.
Kogan often noted that the building looked even more impressive than Johns Hopkins Hospital in the city of Baltimore, state of Maryland. He chose Hopkins as a benchmark because it’s such a storied place, especially for surgeons.
On February 23, seven days after his friend died on the operating table, Kogan was summoned to the hospital’s Special Department.
Kogan’s strategy in dealing with the Special Department was the same as his strategy in dealing with fellow doctors, nurses, and janitorial staff: listen well, tell the truth, show respect.
The director’s office was small, carved up in more than a century of reorganizations. It looked like a small sliver of a ballroom. The walls were green; a tilted portrait of Stalin looked down at the visitor’s chair. The ceiling was impossibly high, and the lone, uncovered window took up the entire side of the room, giving the hospital’s most ominous department the feel of a glass palace.
The man running the Special Department was rumored to be a colonel of national security. Most people in that rank will not give you their last names. This man was different. He used only his last name: Zaytsev.
Zaytsev didn’t get up when Kogan walked in. When Kogan extended his hand, Zaytsev’s hand remained on the massive, prerevolutionary walnut desk.
Zaytsev drilled Kogan with his wide blue eyes. The two men were about the same age, early fifties, except Zaytsev was pudgy and looked officious in a blue gabardine suit and even a tie. Kogan was in his white coat. He would be returning to work, God willing.
“I will not play games, Sasha,” Zaytsev began. “We have a problem here at Pervaya Gradskaya.”
Kogan knew that when men like Zaytsev promised to refrain from playing games, they were, in fact, starting a game.
The doctor cringed a little after being addressed by his first name. This man wasn’t a friend, and decorum in medicine was important. Such were his manners; everything about Zaytsev was backward.
Zaytsev pointed to a chair, and Kogan settled in.
“A young doctor here, Arkady Kaplan, now deceased, was conducting religious propaganda with an ambulance driver. He said Jesus Christ was a Yid doctor. Were you aware of this?”
“No,” said Kogan.
This was no surprise. They got to Spartak after the stabbing, and with his friend dead, he had no reason to protect Kaplan.
Kogan had no idea precisely what was said in that ambulance, but it had to have been funny. He smiled. Arkashka would have wanted him to.
“What can you tell me about him, Sasha?”
“Nothing to tell, Comrade Zaytsev. I thought he was a talented young doctor. I met him before he enrolled in the medical institute. It was in Stalingrad. He was a medic. I was hoping he would get additional training and become a surgeon.”
“Stalingrad. Medic. Interesting … When he was evacuating the wounded, do you believe he got close to German positions?”
“I presume. This is one of the dangers of the job, being in no-man’s-land.”
“Do you believe that he may have come very close, close enough to get recruited by the Germans?”
“Why would that happen? And how? He was Jewish, by nationality, as you should be able to see in the dossier.”
“Exactly! Who would suspect him? Next question: do you believe Kaplan had the skills required to operate a radio?”
“I don’t know. What makes you ask?”
“I am not at liberty to discuss. The investigation is ongoing. Have you known this man outside work?”
“Well, yes, he was a frequent guest at my apartment.”
“Did he speak German?”
“Yes.”
“Do you?”
“Yes. You know from my dossier, I studied in Berlin.”
“I wanted to hear that from you, man to man. The professors you had in Berlin; were they German?”
“Some were. I ask that you familiarize yourself with my dossier, Comrade Zaytsev. I studied in Germany in 1926 through the end of 1928. I was sent there by the Commissariat for Health. It was official business.”
“And your professors, where are they now?”
“Some died in the war, some in the concentration camps; one practices in London, another, I believe, in America.”
“Where in America?”
“Boston.”
“Where in Boston?”
“Harvard University.”
“Are you in touch with them?”
“No. Not at all.”
“It says in the dossier you have relatives abroad…”
“Yes, I do. My parents left Odessa in 1918, just as I was joining the Red Army.”
“Are they living?”
“I don’t believe they are. Though I have never been informed of their deaths.”