PROLOGUE: Fifteen Years Ago
The man staggered out of the garage, coughing violently, a dark form cradled in his arms. Smoke was everywhere and flames spewed from the first floor windows, lighting up the summer night sky. Red-hot embers danced and swirled skyward like millions of drunken fireflies. The sirens were close now. He stumbled toward his wife at the end of the driveway. “I got him,” he rasped. “Poor thing. I found him curled in a ball under the laundry room sink.” The man laid the trembling chocolate Labrador retriever on the cool asphalt and knelt to smooth his fur. “I think he’ll be alright, Marie.”
His wife did not respond—her body was rigid.
The man stood up to comfort her. She remained frozen, her mouth worked but no words came out. Her eyes were wide with panic. The man whipped his head around. “Where’s David?”
Still no response, but she began to shake. He faced her, hands clamped on her shoulders. “Marie, where is he?” he shouted through smoke-filled lungs. “Where’s David?”
“He went after you to look for Brownie,” she managed to get out before dissolving into sobs. “He moved too fast—I couldn’t stop him.” She pointed in the general direction of the garage, her arm swaying wildly.
He ran back into the garage. The metal door to the house radiated heat. He touched its surface and yanked his hand away; it was much hotter than it had been five minutes ago. He didn’t have time for this safety drill. Ignoring how the knob burnt into the palm of his hand, he twisted it and pushed.
Flames burst out of the doorway, growling like some alien beast. The heat and flame bowled him backwards and he lost his footing and went down hard, hitting his back on his John Deere tractor. The hair on his right forearm was singed off. “David,” he yelled from the cement floor. “Come on out! I got Brownie!” No reply other than the roaring of the flames and the crackling of the wood that used to be the frame of his house.
Scrambling to his feet, he ran back out and around to the front of the house. He heard the fire trucks rumbling up the street, sirens blaring so loud it was hard to think. Flashing red lights played on the trees in the front yard, casting strange shadows, lending a sense of unreality to the scene. The flames were spreading quickly to the second floor.
He approached the front door, knowing that it was locked—Marie was a stickler for these things. He shoved his hand under the thick bristly WELCOME doormat for the key, struck by the absurdity as he unlocked the door and opened it. Welcome to hell, maybe.
Again a wall of flame greeted him. This time he was ready; he took two steps back, careful not to fall down. “David!” he yelled. “I have Brownie!”
He paused to listen and thought he heard a faint scream. But from where? He was about to back away when he heard a peculiar, musical sound coming from the living room. Was that David playing the piano? Again, the unreality of the situation washed over him and for a split second he questioned his sanity. Then, just as quickly, he realized the piano wires were twanging randomly as the flames set them free.
He ran around to the back of the house, his feet slipping on the dew-slicked grass, and peered in the kitchen window. The flames were not as intense here, but smoke was everywhere. He thought he could make out some movement through the smoke. Please God, protect him. Save my boy.
He tried the handle—for once it wasn’t burning hot, but it was locked and he didn’t have the key. He kicked at the door, aiming high, near the lock. Something cracked, but the door held. Backing up several steps, he ran toward the door and sprang forward, hitting the door squarely with both feet. The frame splintered and the door crashed inward. He fell backwards onto the flagstone patio, smacking his right elbow. Smoke billowed out of the ruined doorway, but no flames. He pushed to his feet and started forward.
Someone tackled him from behind, knocking the wind out of him and sending him back to the ground. “I can’t let you go in there,” a deep voice of authority warned. He rolled over and looked up at a large firefighter standing over him. The air tanks strapped to his back and the face mask below his helmet made him resemble a cross between a spaceman and a sumo wrestler.
Painfully, he sucked air back into his lungs and pleaded hoarsely while climbing to his feet, “My boy’s in there!”
Another fireman, smaller than the first, ran over and helped restrain him. The big one said, “Take it easy! If you go in there, you’ll never come out alive.”
“But my boy…” His voice trailed off into an agonized groan. He strained harder against them.
The firefighter put a hand on his shoulder and fixed him with kind blue eyes. “We have equipment. We’ll go in and get him.” Blue Eyes turned and shouted, “Bill, bring the hose and gear around back here!”
He stopped struggling. As the arms holding him relaxed their grip, he broke free and ran toward the doorway, ignoring their cries of “Shit!” and “Don’t be a fool!”
He ran into the house, his sneakers crunching on broken glass. “David—it’s Dad,” he called out. “I’m in the kitchen.” Coughing spasms prevented him from saying anything else. The black smoke was so thick he couldn’t see a thing. Breathing was a nightmare. He dropped to all fours, cutting his hands on the glass. Here he could breathe in little gasps and see his bloodied hands on the vinyl brick flooring.
“I’m coming for you, son,” he yelled, his voice already raspy from the smoke. More coughing fits. Again, he thought he could hear faint cries coming from upstairs, but he couldn’t be sure because the roar of the flames was so loud.
He crawled across the foyer to the base of the stairway and began ascending the stairs on all fours. The heat ratcheted up the higher he climbed, and the smoke thickened. Coughs wracked his chest. He wouldn’t be able to breathe much longer. If he turned around now, he could probably make it out the way he had come, to the cool, fresh air outside. He groped for the gold cross dangling from his neck and squeezed it hard, saying a quick prayer. Then he heard his boy crying—no imagining this time—a horrible, high-pitched keening that pierced his very soul. He climbed upward.
Halfway up the staircase, he paused and lifted his sweat-soaked t-shirt to cover his mouth and nose. He took several deep breaths through it, then held the last one and clambered to the top of the stairs. Although the smoke made his eyes burn as if someone had poured acid in them, he forced himself to look down the hallway.
What he saw filled him with a sickening dread. Midway along, a hellish inferno blocked the hallway. The heat pouring off the flames was roasting him alive. He put one hand up to shield his eyes, clenched his jaw, and advanced. As he got closer, he noticed that the wall of flame wasn’t quite as dense as he had first thought. There was a spot clear of flames at the end of the hallway, near David’s room.
His air hunger was becoming unbearable and his surroundings swirled in his dimming vision. He ran toward the flames, but tripped on some unseen debris and went down hard, forcing the last bit of air out of him. Reflexively, he sucked in a lungful of thick, burning smoke, then coughed painfully. His lungs felt like they were being ripped to shreds; soon the bloody remnants would spill out of his mouth. No air was getting in.
The hallway dimmed again. He wasn’t going to make it. As his consciousness flickered, he glimpsed his boy through the smoke and flame at the end of the hallway. David was reaching out to him, crying, “Dad, I’m here! Help me!”
Friday, September 1, 3:30 p.m.
“I want you to curl into a ball and arch your back like a mad cat at Halloween,” Dr. Luke Daulton said. “Or a shrimp. Here, look at me.” Luke bent over, demonstrating the proper position so he could administer the spinal anesthetic. He had a healthy respect for large obstetrical patients. Perhaps aversion was a better term, and maybe it wasn’t so healthy.
“But you don’t have a belly like I do,” whined Shirley. She tried to lean forward, but only succeeded in bending her neck—her back remained ramrod straight.
Luke sighed and smiled under his mask. He had forgotten how much he disliked OB anesthesia—taking care of two patients at once was always tricky. He turned and winked at Teri, the anesthesia tech assigned to help him, trying to display more confidence than he felt as he snapped on his sterile gloves.
The Delivery Room was a busy place and everyone was in close quarters. To his left, two scrub nurses in sterile OR attire counted their surgical instruments, creating quite a racket as they banged them down on the metal trays. Across the room, a neonatologist and neonatal nurse practitioner were readying their pediatric resuscitation equipment. The large radiant warmer above the baby bassinet let out loud screeches intermittently and had to be repeatedly silenced. Two circulating nurses were talking and busily filling out paperwork. Luke could see the obstetrician through a window, scrubbing his hands at the scrub sink.
“That’s Dr. Seidle,” Teri said, nodding toward the window. She leaned in close and whispered, “He’s pretty cranky for a young guy. Ever since he got sued last year for a bad baby, he’s never been the same. He yells a lot—especially when the shit hits the fan.”
“Great,” Luke said, thinking he knew the type well. He made a mental note to try to keep shit away from the fan today.
Luke searched the faces of the obstetrical team assembled around him, looking for a sympathetic face; he found none. They eyed him curiously, undoubtedly because he was new, but there was no discernible warmth, either. He wouldn’t get the benefit of the doubt around here. Plain and simple: this was a test and he was on trial.
There was also an edgy undercurrent present—a kind of dangerous electricity, a palpable tension. Everyone in the Delivery Room chuckled and talked nonchalantly, but they all knew that things could go horribly wrong in this place. People could die and careers could be ruined in a matter of minutes.
Luke shook his head to dispel these thoughts. Such negativity—Dad would’ve scolded him, if he were around.
“Teri, can you help Shirley lean forward?” Luke asked.
“Sure, Dr. Daulton.” Teri stepped up on a footstool for better leverage. Luke was happy to have at least one ally in the room.
Shirley attempted to lean forward again, but this time managed to arch her back exactly the opposite way to what he had just demonstrated.
“That’s better,” Luke said with resignation. Time to punt on proper positioning. “Okay, a little bee sting,” he said, the words making him smile as they always did. They brought to mind his medical student days five or six years ago, when an old man told him what large bees they had around these parts. He numbed her skin with a local anesthetic.
“Ouch!” Shirley cried. “Sonuva…”
“That’s the worst part,” Luke soothed. He felt himself relax a little; he had done this procedure countless times. “Try not to move. A little pressure now.” Luke advanced the delicate spinal needle, roughly the diameter of a human hair, hoping to hit pay dirt—the CSF, or cerebrospinal fluid that bathes the brain and spinal cord. He kept checking as he advanced. No fluid.
“Got it yet?” asked Shirley.
“You’ll be the second to know.”
Teri rolled her eyes at Luke. Even though she had her surgical mask on, Luke could tell she was smiling from the crinkling around her eyes. “Bone?” Teri asked.
“No, it’s a clean shot.”
Finally, Luke had the needle inserted to the hub, three and a half inches in, and still no CSF. “Teri, get me the next one up.” This meant the five-inch needle, the “harpoon.” Luke hated the harpoon because it was long enough to be dangerous. The aorta and the vena cava ran just in front of the spinal column and were easy targets for the big needle.
He checked her landmarks again. They were difficult to palpate, owing to the size of his patient. Teri gave him an encouraging look. The rest of the team stared at him coolly, fidgeting with their instruments or shooting each other glances.
One inch. Two inches. Three. Four. Still no CSF. Luke began to sweat and felt the droplets course down his arms. For the first time, it hit home that there was a real transition to be made here. Two and a half months ago, he was a well-respected, confident senior resident who knew all the ropes at the Hospital of the University of Pennsylvania. Now, after taking the job at Swatara Regional Hospital, he had thrust himself into the real world of private practice.
At four and a half inches, Luke struck white gold. Precious CSF dripped from the hub of his needle after he removed the inner stylet. Releasing a big sigh of relief, he turned to wink at Teri again. He attached the syringe and injected the spinal anesthetic agent and quickly withdrew the needle.
“Okay, Shirley, all done. Gonna lay you flat now.” He grasped her shoulders and pulled her down.
“Wow, my feet are getting warm already,” Shirley said.
“Good, good. You did great sitting there. Hope I didn’t hurt you too much.”
“No, it wasn’t bad. I can’t move my feet, though. Is that normal?”
“Perfectly normal,” he said, although he thought it was a bit fast. “Time to check your level.” He poked her gently in her groin region with a needle. “Can you feel this?”
He worked the testing needle up onto her sizable belly. “This?” Still no response.
When he got up to her mid-chest, she said, “Yeah, I can just barely feel that.”
“Great; you’re going to be very comfortable.” Luke felt relief and a certain degree of satisfaction wash over him. He couldn’t wait to tell Kim about it—the two of them loved to exchange work stories.
Teri nudged him and threw a glance at the blood pressure monitor. It read 90/60, down from 145/80 three minutes ago.
Luke reached around to his anesthesia cart and picked up the ephedrine syringe. He injected some into the intravenous port and ensured the IV was running maximally.
“I feel kinda sick,” Shirley moaned.
“I just gave you some medicine to fix that, Shirley,” he said, and patted her gently on her head. “It’ll work in about a minute.”
Dr. Seidle entered the room from the scrub sink, hands held high. “Everything okay?”
“Fine,” Luke said. “Ready to go. I’m Luke Daulton.”
“Mark Seidle. Nice to meet you.” Seidle gave Luke a quick, penetrating stare, then turned to the nurses who were waiting to gown and glove him. “Your wife goes to our practice, doesn’t she?” Seidle asked over his shoulder.
“Yes, Kim sees Rob Gentry; he’s a great guy.”
“Yes, he is.” Seidle stepped up to the OR table. “Where are you from, Daulton?”
“I trained at Penn,” Luke answered, but quickly wondered if this was what he had meant. “I grew up outside Philly—Media, actually.”
“I see,” Seidle said, losing interest in the conversation. He peeked around the drapes to look at his patient and said, “Okay, Shirley, let’s have this baby.”
The BP monitor beeped and displayed its latest reading: 90/60.
Luke scowled briefly at this lack of response to his first dose of ephedrine. He pumped in another 10 milligrams and began to wonder if his spinal was too high, a distinct possibility in an obese patient.
“I think I’m going to—” Shirley let out a loud belch, then showered her pillow with green vomitus.
“You all right up there?” asked Seidle.
“I just yorked all over the place,” Shirley said. “Where’s my husband?”
Luke groaned inwardly, but said, “You can bring him in now.” Having family present in the OR was always a bad idea.
“Okay to start?” Seidle asked, knife in hand, poised to make incision, not bothering to look up.
“She seems good and numb,” Luke said, “but why don’t you check her.”
Seidle fixed Luke with a hard stare. “I guess we could do that.” He smacked the scalpel down and demanded a hemostat. “Shirley, can you feel this?” he asked as he clamped her skin roughly with the large instrument.
Shirley gave him a puzzled look. “Nope, not a thing.”
“Good. Knife.” The scrub nurse handed Seidle the scalpel back.
Luke tensed—he had one more hurdle to clear. There was no such thing as a guaranteed perfect spinal, especially in an obese patient. The spinal block could sometimes range high or low. Luke stared over the drape as Seidle prepared to make the incision. This was the moment of truth. If the spinal was good, Shirley would be unaware of the incision. If not, she would scream.