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  “I would,” Beane said, “but the dude just got up and left.”

  Will raced to the front door. A mean wind was sweeping through the blackness. There were a few patrons shambling toward him, but John Cooper was gone. Impotent with the situation and peeved at himself for possibly frightening the man off, Will was still on the staircase, peering down the street, when his cell phone went off. The display showed an ER number.

  “Damn.”

  “Will, it’s Lydia,” the surgical resident said. “Rescue just called from an alley downtown. They’re working on a guy a couple of kids found there, beaten up pretty bad. Mid-forties, robbery probably. No ID, no BP to speak of. He’s frozen, but they assure me he’s still alive.”

  “ETA?”

  “Ten minutes.”

  There was no sense in trying to find out the location of the alley, even though it might have been nearby. In the field, the paramedics and EMTs were better and faster than he could ever be.

  “I’ll be there,” he said, sensing the familiar adrenaline rush and accelerated thinking that accompanied a possible surgical emergency. “Have the CT scan people ready to do his head. Call someone in if there’s no one there right now. Two lines in, large bore, cath his bladder, get bloods off including a stat alcohol and drugs of abuse panel, type and cross-match for six units and have them be ready to do more. As soon as the bloods are off, give him a jolt of glucose. Don’t bother waiting for the sugar result before you do that. Just in case, alert anesthesia and the OR that something may be brewing.”

  “Got it.”

  “Oh, and, Lydia, if he’s as cold as the rescue people say he is, please have the nurses get a warming blanket ready and heat up some Ringer’s lactate solution.”

  Of all the Tuesdays he had taken call while volunteering at the Hearth, this was the first time he was faced with an emergency that demanded his immediate return to the hospital, ready to race up to the OR. He went back inside, looked over at the kids, and, as he was doing for the emergency at FGH, sorted through a dozen different courses of action at the same time. Finally, knowing there was no other way, he swallowed his pride and frustration, and called Maxine.

  Lydia Goldman spotted Will and the twins approaching down the hallway and raced to meet them. A third-year resident, she had never handled emergencies calmly, and Will was pleased to have learned some weeks ago that she had been accepted into a plastic-surgery program in Kansas.

  “This is real trouble, Dr. Grant. His core temperature is fifty-two. He’s been beaten to a pulp. BP isn’t readable. I’m getting set to put in an arterial line.”

  “Deep breath,” Will said, “now slow exhale. Kids, this is Lydia. Lydia, Dan and Jessica. The guy’s alive, right?”

  “Yes, but—”

  “Hold it for a second. Jess and Dan, I’m really sorry about having to cut off the night so early. Mom will meet you over there in the waiting room. I’ve got to get to work helping Lydia with her patient.”

  “Can we watch?” Jess asked.

  “Yuck,” Dan said.

  “Another time, I promise. I’ll see you both on Saturday. I love youse guys.”

  “Da-ad.”

  “I know, I know.”

  Will kissed each of them on the forehead, then followed Lydia into the ER. The unconscious, middle-aged man had been stripped and placed on a large warming pad. Two nurses were adjusting his IV lines and monitoring equipment. He had been beaten badly about the head, face, and chest, with some fresh bruising on his abdomen as well.

  “Order some neck films, Lydia, just in case.”

  “Oh, my, I’m really sorry I didn’t do that.”

  The woman, a knowledgeable-enough resident in spite of her lack of cool, flushed at having made an oversight. Will paused to settle her down.

  “Lydia, we do this as a team so that together we might think of everything, okay? Self-flagellation does nothing to improve our focus.”

  “O-okay. I’ll be right back.”

  She raced off to get spine X-rays ordered.

  “Arterial line,” Will called after her, already examining the patient as he approached the bedside.

  No extremity fractures . . . pupils slightly dilated, not reactive to light . . . probable orbital fracture on the right . . . chest appears intact, moving air poorly with grunting respirations . . .

  “Julie,” he called to one of the nurses, “please call anesthesia down here to put a tube in this man.”

  Abdomen somewhat distended, dull to percussion . . . fluid? . . . blood? . . .

  Will set his hands on either side of the man’s abdominal wall and felt the muscles beneath them tighten. Even comatose there was some reaction from John Doe. Light pressure had caused enough pain to break through his depressed consciousness.

  “It’s in here,” he said to no one in particular. “I’d bet the ranch on it. Listen, everyone, as soon as we have cervical spines and a CT scan of his head, we’re going up to the OR. Someone alert them. Lydia, you’ll assist, so go scrub as soon as you can. Tell them we’re going to explore this fellow’s abdomen.”

  “Do you want antibiotics?” she asked.

  Will glanced up at her and pumped his fist just enough for her to see.

  “Way to go,” he said. “Order whatever you think would be best.”

  “Julie, two grams of Mefoxin IV, please,” Lydia said.

  In minutes, the broad-spectrum antibiotic was in, and the anesthesiologist had placed a breathing tube down John Doe’s trachea. Next he inserted a third intravenous line via a “blind stick” into the internal jugular vein.

  “Temp’s seventy-two,” a nurse announced. “BP is still in the twenties.”

  Will glanced down at the man’s abdomen, which was more distended than even a short while ago.

  “Let’s get him over to X-ray right now,” he said. “We’re running out of time.”

  This was medicine the way it was meant to be, Will thought, vigorously scrubbing his hands with a hexachlorophene-impregnated brush. A patient in big trouble, a surgeon and his team prepared to act. No forms to fill out; no panel to go through.

  He wished things with Maxine had worked out differently and that he didn’t spend so much of what little free time he had alone. He wished he had the kids more and the money and time for a memorable vacation with them. He longed to spend more time in the gym. But one thing he never wanted to change was the rush of this moment, focusing years of training and experience into the awesome responsibilities of being a surgeon.

  Using his knee, he shoved the lever to the right, shutting off the water. Then, hands up, palms facing in, he backed into the OR, accepted a towel from the nurse, and dried his hands. Finally, he slipped into a sterile gown, allowed it to be tied, and thrust his hands into a pair of size 71⁄2 gloves. Time for battle.

  John Doe was stretched out on the table, covered with drapes that exposed only his abdomen, swabbed in russet antiseptic. Will could see and feel that the area had become even more distended. Just before he had entered the operating suite, he had received the blood-alcohol report—negative. That result, coupled with the negative head CT, strongly suggested overwhelming infection or massive blood loss into the abdomen as the cause of the profound shock and coma.

  “Ready, Ramon?” he asked the anesthesiologist, who peered over the drape separating his work space from Will’s and nodded. “Ready, everyone? Lydia? Okay, number-ten blade, please, Jennifer.”

  One by one Will sliced through three of the four layers of John Doe’s abdomen.

  “Suction ready,” he called out just as the fourth layer, the thin peritoneal membrane, parted beneath his blade. Under pressure, volumes of foul-smelling brown liquid spewed out of the abdominal cavity, a good deal of it overwhelming the suction and flowing down onto the floor. Will stepped back just in time to keep from irreparably soiling his trademark OR footwear—red Converse Chuck Taylor high-top sneakers.

  “Whew!” the circulating nurse exclaimed. “Deodorizer?”


  “Why not. And a pile of lap sponges, Jen, and more suction.”

  The circulator placed two drops of deodorizer on every person’s mask. One by one, Will inspected each organ—large and small bowel, kidneys, pancreas, liver, spleen, stomach, and gallbladder, even though the source of the problem was already quite apparent. Scar tissue from chronic inflammation caused by gallstones had shut off the blood supply to the large intestine, causing a foot-long section of it to become gangrenous and finally to split, spilling feces into John Doe’s abdominal cavity. Septic shock was the result.

  “Lydia?” he asked. “Where to from here?”

  The resident’s eyes were red from the onslaught of the fetid spillage. Will suspected that at least a corner of her brain was imagining life as a plastic surgeon—bowel contents versus Botox. No contest.

  “Isolate the diseased intestine, staple it off with a GIA stapler,” she said, “then control bleeding, irrigate the abdominal cavity clear with warm saline, and then go after the gallbladder first.”

  “The artery we need to tie off to get the gallbladder out?”

  “Cystic.”

  “Excellent. Go ahead and locate it. You sure you want to go into plastics?” Will could tell from her eyes that she was missing the glint in his. “Don’t bother answering that,” he said.

  He guided her through the removal of the gallbladder and then did the colon removal and colostomy himself. If by a miracle Mr. Doe survived this ordeal, the colostomy could be reversed some time in the future. With heavy bacterial contamination, it was best to leave the skin incision packed with dressings rather than to suture it closed. The scar would be impressive, but that, too, could be revised down the line. At the moment, it was life versus death, with death holding most of the high cards.

  Finally, it was done. A procedure fraught with potentially fatal pitfalls had just been completed quickly and virtually without a hitch, and every person working in OR 3 at that moment felt part of it.

  “Great job, Will,” the anesthesiologist called out as he lowered the drape. “You can take out my gangrenous intestine anytime.”

  Several nurses and Lydia echoed the praise.

  John Doe still remained teetering on the edge of death and was facing a multitude of potentially lethal complications if he managed to survive the hours immediately post-op. But Will felt exhilarated. The hundreds of decisions he had dealt with, instinctively or after deliberation, were holding up.

  He helped transfer the man to a recovery-room bed and watched approvingly as the nurses reconnected the myriad of fluid and monitoring lines.

  Maxine, the exhausting hours at work, the alimony and support payments, the periods of loneliness, the truncated time with the twins, the pressures from managed care—as long as practicing medicine could deliver as it had tonight, he would somehow find the strength to deal with the rest.

  CHAPTER 3

  At five in the morning Serenity Lane was dark and still. Posed in front of the vast picture window over the kitchen counter, Cyrill Davenport carefully fork-split a Thomas’ English muffin and set the toaster oven for precisely two-point-five. Davenport was nothing if not precise—obsessive, he knew some at the company called him, but he didn’t care. He was the president and chairman of the board of the Unity Comprehensive Health HMO, and they weren’t. He could see little through the darkness beyond the window but had no trouble envisioning his yard—nearly two rolling acres of grass, gardens, walkways, majestic boulders, and ten varieties of mature trees. Not bad for someone who had to wheedle a scholarship just to attend a small state school. Now the student center at that school bore his name—his and Gloria’s.

  It had been a mistake to include her name on the building, he thought now. He unwrapped a soft pat of custom-prepared butter, sliced it precisely in two, and spread each piece in concentric circles beginning at the center of the muffin halves. If he had donated a detox to the school, Gloria’s name should definitely have been on it—but otherwise, most resoundingly not. The Cyrill Davenport Student Center—that’s how it should have been. He poured eight ounces of the chilled orange juice he had squeezed the previous evening into a Waterford goblet and sipped it down as he finished the muffin. No matter, he acknowledged. Gloria gave great parties, kept a magnificent house, and handled the help impeccably. So what if she was too sloshed most of the time to be much of a wife?

  Davenport pulled on his overcoat and set his dishes in the sink. This day was to be a most significant one for Unity Comprehensive Health. Depson-Hayes, one of the largest electronics-manufacturing corporations in the Northeast, was on the verge of shifting its total coverage package to Unity. By mid-morning, the announcement would be made, and the seven different HMOs that had been covering the D-H employees—including several who had been pressuring Unity to join in their merger—would be shit out of luck.

  It had taken statistics and promises—a boatload of each—to convince the health people at D-H that care would not suffer despite a striking reduction in the premiums they and their employees would have to pay. Now it would be up to Davenport’s lieutenants to see to it that Unity’s hospitals and physicians made good on those promises. Davenport knew he was asking the impossible, but this was one instance, like horseshoes and hand grenades, where close would be good enough. There could be problems and complaints from the D-H policyholders, even serious ones—just not too many of them. Fortunately, although he would never broadcast the fact, both the state and federal governments had taken significant steps backward when it came to holding HMOs responsible for medical catastrophes incurred by their insured. Clearly, the powers that be understood that the HMOs and other health insurers were merely trying to make the system work by keeping costs in line. If the physicians and hospitals in the old fee-for-service system hadn’t lost sight of that goal, fee-for-service would still be the standard of care in the land.

  Davenport flicked off the kitchen and hall lights and slipped out the door into the garage. As he was shutting the door behind him, he swore he heard Gloria’s prizewinning snoring emanating from the master suite, upstairs and at the far end of the house.

  The broad garage door was closed, and Gloria’s neat little white BMW roadster was in its customary spot, but his Cadillac Seville was missing. Suddenly nonplussed and anxious, Davenport hit the button on the wall beside him. As the automatic door glided upward, he sighed with relief. The silver Caddy, an absolute joy from the day six months ago when he decided to make the switch from his Lincoln, was parked a dozen or so yards down the drive, right by the walk to the front door.

  Curious.

  Davenport distinctly remembered driving into the garage last night when he returned from work, and also closing the electronic door behind him. Only Gloria, their garage-door service company, and their attorney knew the keypad password. Not even their groundskeeper, Julio, had it.

  Davenport glanced at his Rolex. Almost five-thirty. He had a mountain of work to get done before the others arrived and this most significant of days got under way. It had to have been Gloria, he decided as he stepped out onto the drive and shut the garage door behind him. She obviously ran out of booze late last night and in a moment of clarity decided to take the heavier, safer car to get restocked. Davenport grimaced at the image of her fumbling with the keypad in the Caddy, then finally giving up, leaving the car where it was and entering the house up the front walk instead. The notion of her driving sloshed, which she was even before he went to sleep, produced a knot in his throat. Gloria was capable of doing damage that not even their ten-million-dollar umbrella liability policy could cover. He wondered how the neighbors would feel having some homeless, crippled accident victim take over Sycamore Hill.

  With images of another trip to rehab suddenly occupying his mind, Davenport slipped the key into the ignition and turned it. The Caddy purred to life. He put the car in reverse, checked over his right shoulder, and gently depressed the accelerator. The journey to Unity Comprehensive Health lasted just four feet. Cyrill Davenp
ort heard the explosion a nanosecond before he and the Cadillac were blown to bits. All twenty-three windows on the south side of 3 Serenity Lane shattered.

  In the second-floor master suite, Gloria Davenport, her blood-alcohol level still three times legally intoxicated, opened her eyes a slit and tried to make sense of the noise she had just heard and the chilly air she was feeling. Then she pulled the covers over her head and sank back to sleep.

  CHAPTER 4

  The jangling phone slammed into Patty’s dream like a wrecking ball, shattering a scene in which she was flying, arms outstretched, over the houses and buildings of Pittsfield, her hometown. In the dream, a recurring one since childhood, she would put her head down, sprint ahead, and leap, only to fall heavily to the ground. Again and again she would repeat the maneuver until at last, after numerous tumbles and bruises, she would hover just a bit before the painful fall. Finally, after increasing periods just above the ground, pulling through the air like a frog through water, she would suddenly gain altitude and fly. It was a glorious experience when she made it to the clouds, but thanks to the disrupted, bizarre sleep patterns associated with her job, the occasions when her soaring reached such an altitude were few and far between.

  “’lo?”

  “Patty Moriarity?”

  “Yes?”

  The LED on her bedside clock read 6:00, not that early, but she had been riveted to the computer screen in her office until nearly two, researching serial killers.

  “Sorry to have woken you.”

  “No, no, I was just getting up.”

  The woman chuckled.

  “I always say that, too. Patty, it’s Kristine Zurowski from the academy. Remember me?”

  “Of course.” Patty instantly conjured up the image of a pleasant, dark-haired woman, who, like herself, was in her early thirties. The similarities between the two of them hardly ended there. Kristine was also intelligent, extremely intense, and as committed as Patty to making it to detective in the state police. The two of them each finished close to the top of their class, and, within a shorter time than any of the other graduates, Patty had made detective. Not long after that, she heard that Kristine had, too. “Everything all right with you?”