The peritoneal membrane bulged out, tight with blood.
“It’s about to get messy,” she warned, her blade poised to penetrate. Though she was braced for the gush, that first piercing of the membrane released such an explosive spout she felt a flash of panic. Blood spilled onto the drapes and streamed to the floor. It splattered her gown, its warmth like that of a copper-scented bath soaking through her sleeves. And still it continued to flow out in a satiny river.
She thrust in retractors, widening the wound’s gap and exposing the field. Littman inserted the suction catheter. Blood gurgled into the tubing. A stream of bright red splashed into the glass reservoir.
“More laparotomy pads!” Catherine yelled over the scream of suction. She had stuffed half a dozen of the absorptive pads into the wound and watched as they magically turned red. Within seconds they were saturated. She pulled them out and inserted fresh ones, packing them into all four quadrants.
A nurse said, “I’m seeing PVC’s on the monitor!”
“Shit, I’ve already sucked two liters into the reservoir,” said Littman.
Catherine glanced up and saw that bags of O neg blood and fresh frozen plasma were rapidly dripping into the IV’s. It was like pouring blood into a sieve. In through the veins, out through the wound. They could not keep up. She could not clamp vessels that were submerged in a lake of blood; she could not operate blind.
She pulled out the lap pads, heavy and dripping, and stuffed in more. For a few precious seconds she made out the landmarks. The blood was oozing from the liver, but there was no obvious point of injury. It seemed to be leaking from the entire surface of the organ.
“I’m losing his pressure!” a nurse called out.
“Clamp!” said Catherine, and the instrument was instantly slapped in her hand. “I’m going to try a Pringle maneuver. Barrows, pack in more pads!”
Startled into action, the medical student reached toward the tray and knocked over the stack of laparotomy pads. He watched in horror as they tumbled off.
A nurse ripped open a fresh packet. “They go in the patient, not on the floor,” she snapped. And her gaze met Catherine’s, the same thought mirrored in both women’s eyes.
That one’s going to be a doctor?
“Where do I put them?” Barrows asked.
“Just clear the field. I can’t see with all the blood!”
She gave him a few seconds to sponge the wound; then she reached in and tore apart the lesser omentum. Guiding the clamp from the left side, she identified the hepatic pedicle, through which the liver’s artery and portal vein coursed. It was only a temporary solution, but if she could cut off the blood flow at that point, she might control the hemorrhage. It would buy them precious time to stabilize the pressure, to pump more blood and plasma into his circulation.
She squeezed the clamp shut, closing off the vessels in the pedicle.
To her dismay, the blood continued to ooze out, unabated.
“Are you sure you got the pedicle?” said Littman.
“I know I got it. And I know it’s not coming from the retroperitoneum.”
“Maybe the hepatic vein?”
She grabbed two lap pads from the tray. This next maneuver was a last resort. Placing the lap pads on the liver’s surface, she squeezed the organ between her gloved hands.
“What’s she doing?” asked Barrows.
“Hepatic compression,” said Littman. “Sometimes it can close off the edges of hidden lacerations. Hold off exsanguination.”
Every muscle in her shoulders and arms went taut as she strained to maintain the pressure, to squeeze back the flood.
“It’s still pooling,” said Littman. “This isn’t working.”
She stared into the wound and saw the steady reaccumulation of blood. Where the hell is he bleeding from? she thought. And suddenly noticed there was blood oozing steadily from other sites as well. Not just the liver, but also the abdominal wall, the mesentery. The incised edges of skin.
She glanced at the patient’s left arm, which poked out from beneath the sterile drapes. The gauze dressing over the IV site was soaked with blood.
“I want six units of platelets and fresh frozen plasma STAT,” she ordered. “And start a heparin infusion. Ten thousand units IV bolus, then a thousand units an hour.”
“Heparin?” said Barrows in bewilderment. “But he’s bleeding out—”
“This is DIC,” said Catherine. “He needs anticoagulation.”
Littman was staring at her. “We don’t have the labs yet. How do you know it’s DIC?”
“By the time we get the coag studies, it’ll be too late. We’ve got to move now.” She nodded to the nurse. “Give it.”
The nurse plunged the needle into the IV’s injection port. Heparin was a desperate toss of the dice. If Catherine’s diagnosis was correct, if the patient was suffering from DIC—disseminated intravascular coagulation—then throughout his bloodstream, massive numbers of thrombi were forming like a microscopic hailstorm, consuming all his precious coagulation factors and platelets. Severe trauma, or an underlying cancer or infection, could set off an uncontrolled cascade of thrombus formation. Because DIC used up coagulation factors and platelets, both necessary for blood to clot, the patient would begin to hemorrhage. To halt the DIC, they had to administer heparin, an anticoagulant. It was a strangely paradoxical treatment. It was also a gamble. If Catherine’s diagnosis was wrong, the heparin would make the bleeding worse.
As if things could get any worse. Her back ached and her arms were trembling from the effort to maintain pressure on the liver. A drop of sweat slid down her cheek and soaked into her mask.
Lab was back on the intercom. “Trauma Two, I’ve got STAT results on John Doe.”
“Go ahead,” the nurse said.
“The platelet count’s down to a thousand. Prothrombin time’s way up at thirty, and he’s got fibrin degradation products. Looks like your patient’s got a roaring case of DIC.”
Catherine caught Barrows’s glance of amazement. Medical students are so easy to impress.
“V tach! He’s in V tach!”
Catherine’s gaze shot to the monitor. A whipsawing line traced jagged teeth across the screen. “Any pressure?”
“No. I’ve lost it.”
“Start CPR. Littman, you’re in charge of the code.”
The chaos built like a storm, swirling around her with ever more violence. A courier whooshed in with fresh frozen plasma and platelets. Catherine heard Littman call out orders for cardiac drugs, saw a nurse place her hands on the sternum and begin pumping on the chest, head nodding up and down like a mechanical sipping bird. With every cardiac compression, they were perfusing the brain, keeping it alive. They were also feeding the hemorrhage.
Catherine stared down into the patient’s abdominal cavity. She was still compressing the liver, still holding back the tidal wave of blood. Was she imagining it, or did the blood, which had trickled like glossy ribbons through her fingers, seem to be slowing?
“Let’s shock him,” said Littman. “One hundred joules—”
“No, wait. His rhythm’s back!”
Catherine glanced at the monitor. Sinus tachycardia! The heart was pumping again, but it was also forcing blood into the arteries.
“Are we perfusing?” she called out. “What’s the BP?”
“BP is . . . ninety over forty. Yes! ”
“Rhythm’s stable. Maintaining sinus tach.”
Catherine looked into the open abdomen. The bleeding had slowed to a barely perceptible ooze. She stood cradling the liver in her grasp and listened to the steady beep of the monitor. Music to her ears.
“Folks,” she said. “I think we have a save.”
Catherine stripped off her bloody gown and gloves and followed the gurney bearing John Doe out of Trauma Two. The muscles in her shoulders quivered with fatigue, but it was a good fatigue. The exhaustion of victory. The nurses wheeled the gurney into the elevator, to bring their patient to the Su
rgical Intensive Care Unit. Catherine was about to step onto the elevator as well when she heard someone call out her name.
She turned and saw a man and a woman approaching her. The woman was short and fierce-looking, a coal-eyed brunette with a gaze direct as lasers. She was dressed in a severe blue suit that made her look almost military. She seemed dwarfed by her much taller companion. The man was in his mid-forties, and threads of silver streaked his dark hair. Maturity had carved deeply sober lines into what was still a strikingly handsome face. It was his eyes that Catherine focused on. They were a soft gray, unreadable.
“Dr. Cordell?” he asked.
“Yes.”
“I’m Detective Thomas Moore. This is Detective Rizzoli. We’re from the homicide unit.” He held up his badge, but it might as well have been dime-store plastic. She scarcely looked at it; her focus was entirely on Moore.
“May we talk to you in private?” he asked.
She glanced at the nurses waiting with John Doe in the elevator. “Go ahead,” she called to them. “Dr. Littman will write the orders.”
Only after the elevator door had closed did she address Detective Moore. “Is this about the hit-and-run that just came in? Because it looks like he’s going to survive.”
“We’re not here about a patient.”
“You did say you’re from Homicide?”
“Yes.” It was the quiet tone of his voice that alarmed her. A gentle warning to prepare herself for bad news.
“Is this—oh god, I hope this isn’t about someone I know.”
“It’s about Andrew Capra. And what happened to you in Savannah.”
For a moment she could not speak. Her legs suddenly felt numb and she reached back toward the wall, as though to catch herself from falling.
“Dr. Cordell?” he said with sudden concern. “Are you all right?”
“I think . . . I think we should talk in my office,” she whispered. Abruptly she turned and walked out of the E.R. She did not look back to see if the detectives were following her; she just kept walking, fleeing toward the safety of her office, in the adjoining clinic building. She heard their footsteps right behind her as she navigated through the sprawling complex that was Pilgrim Medical Center.
What happened to you in Savannah?
She did not want to talk about it. She had hoped never to talk about Savannah to anyone, ever again. But these were police officers, and their questions could not be avoided.
At last they reached a suite with the plaque:
Peter Falco, M.D.
Catherine Cordell, M.D.
General and Vascular Surgery.
She stepped into the front office, and the receptionist looked up with an automatic smile of greeting. It froze half-formed on her lips when she saw Catherine’s ashen face and noticed the two strangers who had followed her in.
“Dr. Cordell? Is something wrong?”
“We’ll be in my office, Helen. Please hold my calls.”
“Your first patient’s coming in at ten. Mr. Tsang, follow-up splenectomy—”
“Cancel it.”
“But he’s driving all the way from Newbury. He’s probably on his way.”
“All right, then have him wait. But please, don’t put any calls through.”
Ignoring Helen’s bewildered look, Catherine headed straight to her office, Moore and Rizzoli following right behind her. Immediately she reached for her white lab coat. It was not hanging on the door hook, where she always kept it. It was only a minor frustration, but added to the turmoil she was already feeling, it was almost more than she could handle. She glanced around the room, searching for the lab coat as though her life depended on it. She spotted it draped over the filing cabinet and felt an irrational sense of relief as she snatched it up and retreated behind her desk. She felt safer there, barricaded behind the gleaming rosewood surface. Safer and in control.
The room was a carefully ordered place, the way everything in her life was carefully ordered. She had little tolerance for sloppiness, and her files were organized in two neat stacks on the desk. Her books were lined up alphabetically by author on the shelves. Her computer hummed softly, the screen saver building geometric patterns on the monitor. She slipped on the lab coat to cover her bloodstained scrub top. The additional layer of uniform felt like another shield of protec- tion, another barrier against the messy and dangerous vagaries of life.
Sitting behind her desk, she watched Moore and Rizzoli glance around the room, no doubt taking the measure of its occupant. Was that automatic for police officers, that quick visual survey, the appraisal of the subject’s personality? It made Catherine feel exposed and vulnerable.
“I realize this is a painful subject for you to revisit,” said Moore as he sat down.
“You have no idea how painful. It’s been two years. Why has this come up now?”
“In relation to two unsolved homicides, here in Boston.”
Catherine frowned. “But I was attacked in Savannah.”
“Yes, we know. There’s a national crime database called VICAP. When we did a search of VICAP, looking for crimes similar to our homicides here, Andrew Capra’s name came up.”
Catherine was silent for a moment, absorbing this information. Building the courage to pose the next logical question. She managed to ask it calmly. “What similarities are we talking about?”
“The manner in which the women were immobilized and controlled. The type of cutting instrument used. The . . .” Moore paused, struggling to phrase his words with the most delicacy possible. “The choice of mutilation,” he finished quietly.
Catherine gripped the desk with both hands, fighting to contain a sudden surge of nausea. Her gaze dropped to the files stacked so neatly in front of her. She spotted a streak of blue ink staining the sleeve of her lab coat. No matter how much you try to maintain order in your life, no matter how careful you are to guard against mistakes, against imperfections, there is always some smudge, some flaw, lurking out of sight. Waiting to surprise you.
“Tell me about them,” she said. “The two women.”
“We’re not at liberty to reveal very much.”
“What can you tell me?”
“No more than what was reported in Sunday’s Globe.”
It took a few seconds for her to process what he had just said. She stiffened in disbelief. “These Boston murders—they’re recent?”
“The last one was early Friday.”
“So this has nothing to do with Andrew Capra! Nothing to do with me.”
“There are striking similarities.”
“Then they’re purely coincidental. They have to be. I thought you were talking about old crimes. Something Capra did years ago. Not last week.” Abruptly she shoved back her chair. “I don’t see how I can help you.”
“Dr. Cordell, this killer knows details that were never released to the public. He has information about Capra’s attacks that no one outside the Savannah investigation knows.”
“Then maybe you should look at those people. The ones who do know.”
“You’re one of them, Dr. Cordell.”
“In case you’ve forgotten, I was a victim.”
“Have you spoken in detail about your case to anyone?”
“Just the Savannah police.”
“You haven’t discussed it at length with your friends?”
“No.”
“Family?”
“No.”
“There must be someone you’ve confided in.”
“I don’t talk about it. I never talk about it.”
He fixed her with a disbelieving gaze. “Never?”
She looked away. “Never,” she whispered.
There was a long silence. Then Moore asked, gently, “Have you ever heard of the name Elena Ortiz?”
“No.”
“Diana Sterling?”
“No. Are they the women . . .”
“Yes. They’re the victims.”
She swallowed hard. “I don’t know thei
r names.”
“You didn’t know about these murders?”
“I make it a point to avoid reading about anything tragic. It’s just something I can’t deal with.” She released a weary sigh. “You have to understand, I see so many terrible things in the emergency room. When I get home, at the end of the day, I want peace. I want to feel safe. What happens in the world—all the violence—I don’t need to read about it.”
Moore reached into his jacket and produced two photographs, which he slid across the desk to her. “Do you recognize either of these women?”
Catherine stared at the faces. The one on the left had dark eyes and a laugh on her lips, the wind in her hair. The other was an ethereal blonde, her gaze dreamy and distant.
“The dark-haired one is Elena Ortiz,” said Moore. “The other is Diana Sterling. Diana was murdered a year ago. Do these faces look at all familiar?”
She shook her head.
“Diana Sterling lived in the Back Bay, only half a mile from your residence. Elena Ortiz’s apartment is just two blocks south of this hospital. You may very well have seen them. Are you absolutely sure you don’t recognize either woman?”
“I’ve never seen them before.” She held out the photos to Moore and suddenly saw that her hand was trembling. Surely he noticed it as he took back the photos, as his fingers brushed hers. She thought he must notice a great deal; a policeman would. She’d been so focused on her own turmoil that she had scarcely registered much about this man. He’d been quiet and gentle, and she had not felt in any way threatened. Only now did she realize he’d been studying her closely, waiting for a glimpse of the inner Catherine Cordell. Not the accomplished trauma surgeon, not the cool and elegant redhead, but the woman beneath the surface.
Detective Rizzoli spoke now, and unlike Moore, she made no effort to soften her questions. She simply wanted answers, and she didn’t waste any time going after them. “When did you move here, Dr. Cordell?”
“I left Savannah a month after I was attacked,” said Catherine, matching Rizzoli’s businesslike tone.
“Why did you choose Boston?”