“… marked paleness of the skin … cyanosis of lips, nails, fingertips, lobes of the ears …”
“… weak pulse, very rapid … respiration quick and shallow …”
“… blood pressure's so damned low I can't get a reading …”
“Didn't those as**oles treat her for shock?”
“Sure, all the way in.”
“Oxygen, CO-2 mix. And make it fast!”
“Epinephrine?”
“Yeah, prepare it.”
“Epinephrine? But what if she has internal injuries? You can't see a hemorrhage if one's there.”
“Hell, I gotta take a chance.”
Someone put a hand over her face, as if trying to smother her. Lindsey felt something plugging up her nostrils, and for a moment she could not breathe. The curious thing was that she didn't care. Then cool dry air hissed into her nose and seemed to force an expansion of her lungs.
A young blonde, dressed all in white, leaned close, adjusted the inhalator, and smiled winningly. “There you go, honey. Are you getting that?”
The woman was beautiful, ethereal, with a singularly musical voice, backlit by a golden glow.
A heavenly apparition. An angel.
Wheezing, Lindsey said, “My husband is dead.”
“It'll be okay, honey. Just relax, breathe as deeply as you can, everything will be all right.”
“No, he's dead,” Lindsey said. “Dead and gone, gone forever. Don't you lie to me, angels aren't allowed to lie.”
On the other side of the bed, a man in white was swabbing the inside of Lindsey's left elbow with an alcohol-soaked pad. It was icy cold.
To the angel, Lindsey said, “Dead and gone.”
Sadly, the angel nodded. Her blue eyes were filled with love, as an angel's eyes should be. “He's gone, honey. But maybe this time that isn't the end of it.”
Death was always the end. How could death not be the end?
A needle stung Lindsey's left arm.
“This time,” the angel said softly, “there's still a chance. We've got a special program here, a real—”
Another woman burst into the room and interrupted excitedly: “Nyebern's in the hospital!”
A communal sigh of relief, almost a quiet cheer, swept those gathered in the room.
“He was at dinner in Marina Del Rey when they reached him. He must've driven like a bat out of Hell to get back here this fast.”
“You see, dear?” the angel said to Lindsey. “There's a chance. There's still a chance. We'll be praying.”
So what? Lindsey thought bitterly. Praying never works for me. Expect no miracles. The dead stay dead, and the living only wait to join them.
THREE
1
Guided by procedures outlined by Dr. Jonas Nyebern and kept on file in the Resuscitation Medicine Project office, the Orange County General Hospital emergency staff had prepared an operating room to receive the body of Hatchford Benjamin Harrison. They had gone into action the moment the on-site paramedics in the San Bernardino Mountains had reported, by police-band radio, that the victim had drowned in near-freezing water but had suffered only minor injuries in the accident itself, which made him a perfect subject for Nyebern. By the time the air ambulance was touching down in the hospital parking lot, the usual array of operating-room instruments and devices had been augmented with a bypass machine and other equipment required by the resuscitation team.
Treatment would not take place in the regular emergency room. Those facilities offered insufficient space to deal with Harrison in addition to the usual influx of patients. Though Jonas Nyebern was a cardiovascular surgeon and the project team was rich with surgical skills, resuscitation procedures seldom involved surgery. Only the discovery of a severe internal injury would require them to cut Harrison, and their use of an operating room was more a matter of convenience than necessity.
When Jonas entered from the surgical hallway after preparing himself at the scrub sinks, his project team was waiting for him.
Because fate had deprived him of his wife, daughter, and son, leaving him without family, and because an innate shyness had always inhibited him from making friends beyond the boundaries of his profession, these were not merely his colleagues but the only people in the world with whom he felt entirely comfortable and about whom he cared deeply.
Helga Dorner stood by the instrument cabinets to Jonas's left, in the penumbra of the light that fell from the array of halogen bulbs over the operating table. She was a superb circulating nurse with a broad face and sturdy body reminiscent of any of countless steroid-saturated female Soviet track stars, but her eyes and hands were those of the gentlest Raphaelite Madonna. Patients initially feared her, soon respected her, eventually adored her.
With solemnity that was characteristic in moments like this, Helga did not smile but gave Jonas a thumbs-up sign.
Near the bypass machine stood Gina Delilo, a thirty-year-old RN and surgical technician who chose, for whatever reasons, to conceal her extraordinary competence and sense of responsibility behind a pert, cute, ponytailed exterior that made her seem to be an escapee from one of those old Gidget or beach-party movies that had been popular decades ago. Like the others, Gina was dressed in hospital greens and a string-tied cotton cap that concealed her blond hair, but bright-pink ankle socks sprouted above the elastic-edged cloth boots that covered her shoes.
Flanking the operating table were Dr. Ken Nakamura and Dr. Kari Dovell, two hospital-staff physicians with successful local private practices. Ken was a rare double threat, holding advanced degrees in internal medicine and neurology. Daily experience with the fragility of human physiology drove some doctors to drink and caused others to harden their hearts until they were emotionally isolated from their patients; Ken's healthier defense was a sense of humor that was sometimes twisted but always psychologically healing. Kari, a first-rate specialist in pediatric medicine, was four inches taller than Ken's five-feet-seven, reed-thin where he was slightly pudgy, but she was as quick to laugh as the internist. Sometimes, though, a profound sadness in her eyes troubled Jonas and led him to believe that a cyst of loneliness lay so deep within her that friendship could never provide a scalpel long or sharp enough to excise it.
Jonas looked at each of his four colleagues in turn, but none of them spoke. The windowless room was eerily quiet.
For the most part the team had a curiously passive air, as if disinterested in what was about to happen. But their eyes gave them away, for they were the eyes of astronauts who were standing in the exit bay of an orbiting shuttle on the brink of a space walk: aglow with excitement, wonder, a sense of adventure—and a little fear.
Other hospitals had emergency-room staffs skilled enough at resuscitation medicine to give a patient a fighting chance at recovery, but Orange County General was one of only three centers in all of southern California that could boast a separately funded, cutting-edge project aimed at maximizing the success of reanimation procedures. Harrison was the project's forty-fifth patient in the fourteen months since it had been established, but the manner of his death made him the most interesting. Drowning. Followed by rapidly induced hypothermia. Drowning meant relatively little physical damage, and the chill factor dramatically slowed the rate at which postmortem cell deterioration took place.
More often than not, Jonas and his team had treated victims of catastrophic stroke, cardiac arrest, asphyxiation due to tracheal obstruction, or drug overdose. Those patients usually had suffered at least some irreversible brain damage prior to or at the moment of death, before coming under the care of the Resuscitation Project, compromising their chances of being brought back in perfect condition. And of those who had died from violent trauma of one kind or another, some had been too severely injured to be saved even after being resuscitated. Others had been resuscitated and stabilized, only to succumb to secondary infections that swiftly developed into toxic shock. Three had been dead so long that, once resuscitated, brain damage was either too severe to allow them to regain consciousness or, if they were conscious, too extensive to allow them to lead anything like a normal life.
With sudden anguish and a twinge of guilt, Jonas thought of his failures, of life incompletely restored, of patients in whose eyes he had seen the tortured awareness of their own pathetic condition.…
“This time will be different.” Kari Dovell's voice was soft, only a whisper, but it shattered Jonas's reverie.
Jonas nodded. He felt considerable affection for these people. For their sake more than his own, he wanted the team to have a major, unqualified success.
“Let's do it,” he said.
Even as he spoke, the double doors to the operating room crashed open, and two surgical orderlies rushed in with the dead man on a gurney. Swiftly and skillfully, they transferred the body onto the slightly tilted operating table, treating it with more care and respect than they might have shown a corpse in other circumstances, and then exited.
The team went to work even as the orderlies were heading out of the room. With speed and economy of movement, they scissored the remaining clothes off the dead man, leaving him na*ed on his back, and attached to him the leads of an electrocardiograph, an electroencephalograph, and a skin-patch digital-readout thermometer.
Seconds were golden. Minutes were beyond price. The longer the man remained dead, the less chance they had of bringing him back with any degree of success whatsoever.
Kari Dovell adjusted the controls of the EKG, sharpening the contrast. For the benefit of the tape recording that was being made of the entire procedure, she repeated what all of them could see: “Flat line. No heartbeat.”
“No alpha, no beta,” Ken Nakamura added, confirming the absence of all electrical activity in the patient's brain.
Having wrapped the pressure cuff of a sphygmomanometer around the patient's right arm, Helga reported the reading they expected: “No measurable blood pressure.”
Gina stood beside Jonas, monitoring the digital-readout thermometer. “Body temperature's forty-six degrees.”
“So low!” Kari said, her green eyes widening with surprise as she stared down at the cadaver. “And he must've warmed up at least ten degrees since they pulled him out of that stream. We keep it cool in here, but not that cool.”
The thermostat was set at sixty-four degrees to balance the comfort of the resuscitation team against the need to prevent the victim from warming too fast.
Looking up from the dead man to Jonas, Kari said, “Cold is good, okay, we want him cold, but not too damned cold. What if his tissues froze and he sustained massive cerebral-cell damage?”
Examining the dead man's toes and then his fingers, Jonas was almost embarrassed to hear himself say, “There's no indication of vesicles—”
“That doesn't prove anything,” Kari said.
Jonas knew that what she said was true. They all knew it. There would not have been time for vesicles to form in the dead flesh of frost-bitten fingertips and toes before the man, himself, had died. But, damn it, Jonas did not want to give up before they had even started.
He said, “Still, there's no sign of necrotic tissue—”
“Because the entire patient is necrotic,” Kari said, unwilling to let go of it. Sometimes she seemed as ungainly as a spindly-legged bird that, although a master of the air, was out of its element on the land. But at other times, like now, she used her height to advantage, casting an intimidating shadow, looking down at an adversary with a hard gaze that seemed to say better-listen-to-me-or-I-might-peck-your-eyes-out-mister. Jonas was two inches taller than Kari, so she couldn't actually look down at him, but few women were that close to being able to give him even a level-eyed stare, and the effect was the same as if he had been five-feet-two.
Jonas looked at Ken, seeking support.
The neurologist was having none of it. “In fact the body temperature could have fallen below freezing after death, then warmed up on the trip here, and there'd be no way for us to tell. You know that, Jonas. The only thing we can say for sure about this guy is that he's deader than Elvis has ever been.”
“If he's only forty-six degrees now … ,” Kari said.
Every cell in the human body is composed primarily of water.
The percentage of water differs from blood cells to bone cells, from skin cells to liver cells, but there is always more water than anything else. And when water freezes, it expands. Put a bottle of soda in the freezer to quick-chill it, leave it too long, and you're left with just the exploded contents bristling with shattered glass. Frozen water bursts the walls of brain cells—all body cells—in a similar fashion.
No one on the team wanted to revive Harrison from death if they were assured of bringing back something dramatically less than a whole person. No good physician, regardless of his passion to heal, wanted to battle and defeat death only to wind up with a conscious patient suffering from massive brain damage or one who could be sustained “alive” only in a deep coma with the aid of machines.
Jonas knew that his own greatest weakness as a physician was the extremity of his hatred for death. It was an anger he carried at all times. At moments like this the anger could swell into a quiet fury that affected his judgment. Every patient's death was a personal affront to him. He tended to err on the side of optimism, proceeding with a resuscitation that could have more tragic consequences if it succeeded than if it failed.
The other four members of the team understood his weakness, too. They watched him expectantly.
If the operating room had been tomb-still before, it was now as silent as the vacuum of any lonely place between the stars where God, if He existed, passed judgment on His helpless creations.
Jonas was acutely aware of the precious seconds ticking past.
The patient had been in the operating room less than two minutes. But two minutes could make all the difference.
On the table, Harrison was as dead as any man had ever been. His skin was an unhealthy shade of gray, lips and fingernails and toenails a cyanotic blue, lips slightly parted in an eternal exhalation. His flesh was utterly devoid of the tension of life.
However, aside from the two-inch-long shallow gash on the right side of his forehead, an abrasion on his left jaw, and abrasions on the palms of his hands, he was apparently uninjured. He had been in excellent physical condition for a man of thirty-eight, carrying no more than five extra pounds, with straight bones and well-defined musculature. No matter what might have happened to his brain cells, he looked like a perfect candidate for resuscitation.
A decade ago, a physician in Jonas's position would have been guided by the Five-Minute Limit, which then had been acknowledged as the maximum length of time the human brain could go without blood-borne oxygen and suffer no diminution of mental faculties. During the past decade, however, as resuscitation medicine had become an exciting new field, the Five-Minute Limit had been exceeded so often that it was eventually disregarded. With new drugs that acted as free-radical scavengers, machines that could cool and heat blood, massive doses of epinephrine, and other tools, doctors could step well past the Five-Minute Limit and snatch some patients back from deeper regions of death. And hypothermia—extreme cooling of the brain which blocked the swift and ruinous chemical changes in cells following death—could extend the length of time a patient might lie dead yet be successfully revived. Twenty minutes was common. Thirty was not hopeless. Cases of triumphant resuscitation at forty and fifty minutes were on record. In 1988, a two-year-old girl in Utah, plucked from an icy river, was brought back to life without any apparent brain damage after being dead at least sixty-six minutes, and only last year a twenty-year-old woman in Pennsylvania had been revived with all faculties intact seventy minutes after death.
