Patient One: A Novel Page 3

  Carolyn placed the phone down and turned to her mother. “Mom, I’ve got to go back to the hospital. But Dolly will be here soon to stay with you. Okay?”

  The woman continued to stare ahead with a blank expression.

  “I love you,” Carolyn whispered and kissed her mother’s forehead.

  Her mother showed no response.

  “I have to go upstairs and change,” Carolyn said and hurried to the door. Halfway there, she stopped abruptly. Behind her, her mother was making some sort of sound. Carolyn spun around. Her mother had her lips pursed and was sending Carolyn kisses. There even seemed to be a hint of a smile on the woman’s face. Then, in an instant, the expression disappeared and the woman went back to staring into nothingness.

  “Oh, Mom!” Carolyn whispered, her tears welling up as she ran for the stairs.

  Four

  The emergency room at University Hospital was in turmoil. Doctors and nurses were racing back and forth in the corridors, clearly overwhelmed by the influx of sick people. And more were coming through the front entrance. The noise they made was deafening, with shouts and yells and cries for help mixed in with moans and groans and the sounds of individuals retching. Every room was taken, every bed and gurney occupied by nauseated patients. Even the space on the floor was filled with elegantly dressed people throwing up into handheld basins. The overcrowding was made worse by the Secret Service, which had closed off an entire section of the ER for the President of the United States. Two agents were hurriedly placing waist-high wooden barricades across a corridor to discourage the curious.

  Aaron Wells pointed to the barricade, saying, “I want another row of those things about ten feet back, and line them up so you can knock over one without knocking over all the others.” He waited for the additional barricades to be put in position, then added, “And I want two agents behind each row. Nobody in, nobody out, without my say-so.”

  Wells quickly surveyed the interior of the ER again, looking for weak spots. The two examining rooms in the middle of the section, which held the President and the First Lady, had no windows or exits except for their closed doors, and those were being guarded by a pair of agents. There was no staircase or fire escape to be concerned with. At the end of the corridor was an elevator on hold, its door open and guarded by two more agents. Secure enough, Wells told himself, but he was still worried about the mass of sick people, which could provide cover for an attack on the President. If the crowd, for any reason, suddenly rushed the barricades, they would rapidly overrun the agents guarding the President. Or terrorists could jump out of the crowd with automatic weapons or grenades, and kill everybody in the section.

  “The crowd!” Wells grumbled to himself. “The goddamn crowd!” He couldn’t throw them into the street, and there was no way to check them all out. The President was in a dangerous position and had to be moved.

  Wells saw Agent Dan Morris, the second in command, coming through the barricade and waved him over. In a low voice he asked, “Did you locate the President’s daughter?”

  Morris shook his head. “We’re still looking.”

  “Look harder,” Wells urged. The first thing on the President’s mind would be the well-being of the First Lady and their daughter. “Did you check the hotel?”

  “She’s not there,” Morris said. “And she’s not here. I’ve got men posted at the entrance to all the ERs in the vicinity. As soon as she and her date are found, they’ll be brought here.”

  “What about Suslev and his wife?”

  “They’re in another part of the ER, with their own security.”

  “Are they as exposed as we are?”

  “More so.”

  “Shit!”

  “Yeah.”

  Morris asked, “What caused all this? Food poisoning?”

  Wells shrugged. “I guess.”

  Morris moved in closer and quietly inquired, “How’s Liberty?”

  “Not good.”

  A middle-aged man just beyond the barricades began retching loudly, then threw up a stream of brownish liquid. The vomit gushed from his mouth, like a projectile. The patients around him ducked and brought up their arms to cover themselves from the spray. A few were so ill they barely moved. The stench of vomit filled the air and made the patients nearby even more nauseated. Wells looked away and over to a set of swinging doors that led to the outer waiting area. It was another weak point. He considered having an agent circulate beyond the doors, but decided against it. All the agent would see was a swarm of people throwing up over each other.

  Wells cursed to himself. He wished the President had taken the Secret Service’s advice and had his meeting with the Russian leader in Washington, where everything could be tightly controlled. But Liberty insisted on having the official dinner in Los Angeles. It was a gesture of goodwill to the President of Russia, who would later fly to San Francisco, where world leaders were gathering for a celebration of the United Nations Charter. To hold the official dinner in Los Angeles, with its generous political donors, would be convenient for everyone, the President had said. It would also be much more dangerous, the Secret Service had argued. But the President had insisted. And the end result was a nightmare in the making, Wells thought grimly. Nothing in the ER was under control. Everything was in a maddening state of flux, and this left the President vulnerable. Very vulnerable.

  “Aaron,” an agent by the barricade called out, “the ER doc wants to talk with you.”

  Wells signaled the young resident over and asked, “What?”

  “We’re having trouble finding a ward we can empty out,” the resident answered.

  “Don’t tell me your problems. Just get it done.” Wells was a big man, with broad shoulders and a square jaw. His balding blond hair had been shaved off down to the skin, leaving his steely gray eyes as the most prominent feature of his face. He gave the resident a hard stare, then said, “And do it now.”

  The resident wasn’t accustomed to being intimidated, but the agent’s glare caused him to look away. “Maybe we could clear out the special unit.”

  “What’s that?” Wells asked.

  “It’s a restricted ward that’s used for patients receiving experimental drugs,” the resident replied. “But it may not be possible to evacuate—”

  “Just do it!” Wells cut him off. “I don’t care how you do it. Just do it!”

  The door to the trauma room holding the President opened, and his personal physician, William Warren, stepped out. There was blood on his hands and on the sleeves of his coat. Glancing over to Wells, he immediately sensed the agent’s worry. “The President is stable.”

  Wells breathed a sigh of relief inwardly. Thank sweet Jesus in heaven above! he thought, but said only, “Good.”

  “Do we have a ward cleared for the President?” Warren asked.

  “Not yet,” Wells replied unhappily.

  “What’s the holdup?”

  Wells gestured with his thumb to the young resident. “He’s a little slow following orders.”

  “Well, let’s see if we can speed him up,” Warren said in a neutral tone, but his temper was rising. He turned to the resident. “I want you to listen carefully because I’m only going to say this once. We need a safe ward for the President and we need it now. If necessary I can have a fleet of ambulances outside this hospital in a half-hour with a doctor in each one. We’ll pick a floor and have the chief of service meet us there. Then we’ll roll out the patients and put them in ambulances which will take them to other hospitals. And we’ll end up with a safe ward for President Merrill. So the choice is as follows—either you do it or we’ll do it for you.”

  The resident swallowed nervously. “But, sir, I can’t just …”

  “Let’s get those ambulances,” Warren instructed Wells. “Twenty-five should do.”

  “What abou
t the doctors?” Wells asked.

  “Get a list of all the physicians who live within a ten-mile radius of the hospital and have the police …”

  “Aaron,” an agent at the first row of barricades yelled out, “there’s another doctor who wants to see you.”

  The resident peered over and said hurriedly, “That’s the director of the emergency room. Maybe he can do what you want.”

  “An ER specialist isn’t going to be of much help,” Warren groused.

  “He’s also a senior staff member at the medical center,” the resident informed him. “When he gives an order, people jump.”

  Warren briefly studied the doctor by the barricades. “So he has a lot of pull, eh?”

  “And a lot of push,” the resident added. “He runs a tight ship down here, and knows how to move patients out. Nobody stays for long.”

  Warren looked over to Wells and nodded. “Let’s see what he has to say.”

  Wells waved the doctor in and watched him approach, keeping his eyes on the new arrival’s hands and making sure they were always in sight. “Are you in charge of any of the wards?”

  The doctor shook his head. “Just the ER.”

  Wells groaned to himself. Shit! This guy isn’t going to be any help. “Who’s in charge of the beds?”

  “No one person,” the doctor replied. “Each specialty controls its own ward.”

  Shit! Wells thought again.

  Warren stepped forward and introduced himself. “I’m William Warren, the President’s physician.”

  “And I’m David Ballineau, the staff physician on call tonight.” He was tall and lean, in his mid-forties, with an angular face, close-cropped salt-and-pepper hair, and pale blue eyes that seemed to be fixed in place. His clean-cut good looks were marred by a jagged scar across his chin. “The nurse notified me that you need a special area for the President.”

  “I need more than an area,” Warren told him. “I need an entire ward cleared so that the President can be protected. Can you help us with that?”

  “I can certainly try,” David said. “But first, I have to know the President’s diagnosis.”

  “That’s not your concern,” Wells blurted out.

  “Yes, it is,” David answered, standing up to the powerfully built agent. “We have special wards for specific illnesses. If he has just food poisoning, he can go to a general medicine ward. If he’s had a myocardial infarction on top of it, he’ll need to be in the ICU.”

  “He has straightforward food poisoning,” Warren said. “He’s got nausea and vomiting, and is throwing up some blood.”

  David looked at Warren oddly. “People with garden-variety food poisoning don’t throw up blood. Never. You’d better look for another diagnosis.”

  Warren hesitated. He did not want to discuss the President’s medical history with anyone, not even with another doctor—who might turn out to be loose-tongued. But he knew there was no getting around this conversation, if they were to make the necessary arrangements for protecting the President. Warren took David’s arm and guided him away from the Secret Service agent.

  “What I say to you goes no further than this hospital corridor. Understood?”

  “Understood,” David replied.

  “The President has acid reflux disease with moderately severe esophagitis,” Warren described, keeping his voice low. “I believe his esophageal mucosa is already thinned out, and the toxins from the food poisoning must have eroded through it. That’s why he’s bleeding.”

  David nodded slowly. That combination could be responsible for the bleeding. But bacterial toxins rarely caused upper gastrointestinal hemorrhaging, even under extreme circumstances. In all likelihood, there was another reason for the President to be vomiting blood. “How much blood has he lost?”

  “Enough to drop his hematocrit to 40 percent.”

  David knitted his brow and did a quick mental calculation. The hematocrit was the ratio of packed red cells to a given volume of plasma, expressed as a percentage. The normal value was 46 to 50 percent. David estimated the President had lost at least 500 ccs of blood.

  “Is he still bleeding?”

  “Not actively,” Warren answered, then corrected himself. “At least, he’s not throwing up red blood any more.”

  “We should scope him as soon as possible,” David recommended.

  Warren hesitated again. The quickest way to make an accurate diagnosis was to pass an endoscope into the President’s stomach and search for the bleeding site. But the procedure required anesthesia, and the President had had a severe allergic reaction to the anesthetic when he was endoscoped a year ago.

  “We’ll hold that for the present.”

  “If he’s still bleeding, now would be the time to check him endoscopically,” David urged.

  “But he may no longer be bleeding.”

  “Let’s pass a nasogastric tube and find out.”

  Warren considered the suggestion carefully before asking, “Are you experienced at that?”

  “I’ve done it easily a hundred times,” David said. “And while we’re doing that we should have him typed and cross-matched for four units of whole blood.”

  “I’ve already ordered two units.”

  “That’s not enough.” David reached for his cell phone and called the blood bank. After speaking briefly, he came back to Warren. “If the President starts gushing blood, we’ll need at least four units to hold him.”

  “That’s not likely,” Warren said.

  “Maybe not,” David said with a shrug. “But if he does, we don’t want to get caught short, do we?”

  “Lord, no,” Warren concurred. This doctor was obviously experienced when it came to acute G.I. bleeding. Excellent! I can use him until the specialists arrive. And they will tell me whether there’s an urgent need to call in an endoscopist or some other expert. But wait a minute! Who were these specialists being called in to treat the President? I don’t know them or how good they really are. This is a teaching hospital after all, and the most senior specialists could be academicians rather than active practitioners. Warren glanced back into the treatment room where the President lay. The cardiac monitors at his bedside showed a steady pulse and blood pressure, with no evidence of new hemorrhaging. “We could have the President helicoptered to Air Force One in fifteen minutes,” Warren said, more to himself than to David, “then zoom like hell back to Washington.”

  “You may not have fifteen minutes,” David cautioned. “If he starts to really spout blood aboard that helicopter, you could have a dead president on your hands. Then you’d be flying his corpse back to Washington on Air Force One.”

  “You’ve got a point,” Warren agreed, and for a moment envisioned what a nightmare that would be. He hurriedly cleared his mind. “Dr. Ballineau, can you quickly get us the ward we require?”

  “The best location for the President would be the Beaumont Pavilion,” David proposed. “It’s a closed-off floor with a single corridor and has a total of fourteen individual suites.”

  “Excellent,” Warren approved immediately and beckoned Wells over, saying, “I think we’ve got a ward for the President.”

  David thought for a long moment before adding, “But I can only give you eleven of the suites.”

  “I need the entire floor.”

  “That’s not possible,” David said firmly. “Three of the patients are too ill to be moved off the floor. I know this for a fact, because I’m the attending physician up there.”

  Warren stared at David, not certain he understood. “They have an emergency room up on this pavilion?”

  David shook his head. “It’s a medicine ward for the rich and famous who have difficult diagnostic or therapeutic problems,” he explained. “All staff members are required to teach on the wards or in the clinics for si
x weeks, and I spend my teaching time on the Beaumont Pavilion rather than down in the ER. It’s a change of pace.”

  “And a little more perspective on the real world of everyday medicine, eh?”

  A lot more perspective, David wanted to say. The Pavilion reminded him why he liked the ER so much. In contrast to the wards that moved along at a snail’s pace and where most of the time was spent talking, the ER was action-packed and hectic, full of excitement and drama.

  Warren tried to read David’s expression, but couldn’t. “Are you having second thoughts about using the Beaumont Pavilion?”

  David shook his head again. “The Pavilion is fine, but those three patients must stay put.”

  “They’ll have to be moved for security’s sake,” Warren insisted.

  “Security won’t be a problem with these three.”

  David described the three critically ill patients, highlighting the important features. The sickest was a movie star in her sixties with cirrhosis, who was drifting in and out of hepatic coma while she waited for a liver transplant. The second patient was a young college student with a lupus-induced pericardial effusion that was gradually impeding her heart’s ability to pump blood. And the final patient was an eighty-year-old man with polymyositis, a rare inflammatory disease involving the large muscles.

  “These people are so weak they can’t get to the bathroom without help,” David concluded.

  “I still don’t like it,” Wells said.

  “If you’re worried about them, you could post agents outside their doors,” David suggested.

  Wells and Warren exchanged glances, a silent message passing between them.

  “Okay,” Wells consented reluctantly, now determining how the eleven suites would be used. The two presidents and their wives would occupy four rooms; four rooms would be needed for the Secretary of State and the Russian Foreign Minister and their wives; and two more would be held open for the President’s daughter and her date. The final suite would be used for operations and communications. He turned to David and asked, “How many non-patient rooms are on the floor?”