No matter. It provided her with the perfect opportunity to remove the device, destroy the evidence, and orchestrate Nick’s demise in the process. This hadn’t been part of the original plan, but as a physician, Elizabeth had become adept at improvising.
“It’s good to see you back at work, Dr. Gravel,” said one of her nurses, Suzanne, as they prepared Nick for the procedure. “How’s your brother doing?”
“Not well,” Elizabeth lied. “Patrick still has his good days now and then, but the bad days are definitely becoming the norm. His heart has started to fail, but he doesn’t want another transplant. He went through hell with the first one, but I keep trying to convince him his life is worth it. He doesn’t want to listen. He’s depressed, which I think is partly due to the fact that he doesn’t feel well. It’s been rough, watching his health decline.” She heaved a dramatic sigh, secretly enjoying the looks of sympathy her colleagues were giving her.
“That sounds horrible,” said Suzanne, shaking her head. “I’m so sorry. If there’s anything I can do…”
“Thank you,” Elizabeth replied, pulling on a pair of surgical gloves over her freshly scrubbed hands. “Prayers are always appreciated. I’d rather not be reminded of Patrick right now, though. I need to focus on the patient.”
“Oh, of course. Sorry for asking,” Suzanne apologized, blushing. As she bent over Nick’s body, swabbing the left side of his chest with betadine, she added, “I can’t believe we’re about to operate on a Backstreet Boy. My daughter would die if she knew. She was such a big fan back in the day.”
Elizabeth smiled. “I know what you mean. I always liked their music myself.” She helped Suzanne unfold a sterile drape over the surgical field. “Hopefully he’ll be back to making more of it soon. Ten blade, please.”
“I hope so,” Suzanne agreed, handing her a scalpel. “He sure looks like he’s been through a lot. I heard someone say this ICD was implanted by the same person who abducted him. Is that true? Because if so, that is absolutely insane!”
“I have no idea,” Elizabeth lied again, as she ran the scalpel right over the original incision underneath Nick’s collarbone, “but I don’t think we should be spreading rumors like that around the hospital. Let’s do our part to protect Mr. Carter’s privacy and leave the rest for the police to figure out.”
Suzanne nodded, using a gauze pad to wipe away the blood and pus that oozed out of the incision. “You’re right. Sorry.”
“No need to apologize,” said Elizabeth, as she peeled back a thick flap of skin to expose the device pocket she had created in Nick’s chest well less than three weeks earlier. Dissecting down to the pulse generator was the easy part, as not enough time had passed for a significant amount of scar tissue to develop around it. Pulling out the lead that she had threaded through his subclavian vein into the right ventricle of his heart would be more difficult.
She inserted a stylet into the lead and advanced it to the tip, locking it into place. The stiff wire would make it easier for her to maneuver the lead later. The X-ray technician helped her position the fluoroscope so she could visualize the pertinent parts of Nick’s vascular system on a screen as she placed a sheath over the lead.
Suddenly, an alarm sounded on the heart monitor. “He’s throwing PVCs,” observed the anesthesiologist who was monitoring Nick’s vital signs during the procedure.
Elizabeth nodded. “I’m in the right ventricle,” she replied, studying the screen. “They should stop as I start to extract the lead.” Using the sheath to provide countertraction, she slowly pulled back the lead, rotating it left and right to break up the fibrous bands that had formed around it. The fluoroscope allowed her to watch its progress as it retreated from Nick’s right ventricle, through his tricuspid valve, and into the right atrium. “So,” she said casually, as the end of the lead entered the superior vena cava, “what’s everyone doing for Thanksgiving next week?”
Out of the corner of her eye, she saw the other members of her team exchange glances, taken by surprise. None of them had ever heard her make small talk during a procedure before; normally, the cardiologist was all business and rarely participated in such conversations, let alone initiated them. Of course, Elizabeth had counted on this. As she pretended to listen to each of them describe their plans or lament having to work on a holiday, she paid attention to where they were looking. While they were all sufficiently distracted, she gave the lead a sharp but subtle tug. One twitch of the wrist was all it took to tear the second largest vein in Nick’s body.
Elizabeth saw the dark blood leaking into the space around his heart on the fluoroscopy screen, but she proceeded as if nothing had happened, her eyes fixed on the length of lead in her hand. She didn’t look up again until she heard another alarm go off, as Nick’s already low blood pressure began to fall.
***
“Waiting is the worst,” groaned AJ, as the guys sat around the waiting room with Lauren, Leighanne, and Baylee. Detective Overton had stepped out to take a call.
“You’re preaching to the choir,” Kevin agreed.
The cardiologist had told them the procedure to remove Nick’s ICD could take anywhere from two to six hours, which Howie thought was quite a wide range. He worried there was a higher risk of complications than she had let on to Lauren. Why else would she have allowed for such a large window of time?
“Anyone need anything?” he asked, as he looked around at the others. “More coffee? Or how ‘bout some breakfast, maybe?”
Lauren shook her head. “No thanks, Howie. I’m not hungry, and the last thing I right now need is more caffeine.” She offered a humorless laugh. “My nerves are shot already. That just might send me over the edge.”
“I know the feeling,” Leighanne agreed, giving Lauren’s leg a squeeze. Howie didn’t know which of them had it worse - Lauren, whose husband might not make it, or Leighanne, whose husband was still missing. He was worried about both of his brothers, but at least his wife was safe at home.
“I could eat,” said Baylee out of the blue, surprising them all.
AJ chuckled. “Thatta boy. C’mon, I’ll take you down to the cafeteria. I could use another cup of coffee myself - or a cigarette.”
“Stick with the coffee,” said Kevin.
“Especially around my son,” added Leighanne, giving AJ a look.
“Yeah, yeah, I know… secondhand smoke kills.” AJ rolled his eyes and grinned at Baylee behind his mother’s back as they both stood up to leave. But before they could get out of the room, Detective Overton came barreling back in, nearly knocking Baylee down.
“Where do you think you’re going?” she demanded.
Baylee looked like a deer in headlights. “Uh… to get food?”
“Not right now, you’re not. You’re going to want to hear what I have to say first.” She paused, her formidable expression relaxing into a rare smile. “It’s good news, I promise.”
Howie’s heart lifted with hope as he looked up at the detective.
“Your dad’s been found,” she told Baylee. “Alive.”
The waiting room erupted with cheers as everyone reacted at once. AJ grabbed Baylee by the shoulders, jumping up and down like he was still just a kid himself, while Lauren hugged Leighanne, who wept with happiness. “Thank God,” Kevin kept repeating, as tears of relief rolled down his cheeks. “Thank God.”
“Is he okay?” Howie was the first one to ask, wanting to know more details before he celebrated with the rest of the group. He couldn’t forget how bad off Nick had been when he was brought into the emergency room; the image of his little brother lying lifelessly on the stretcher, receiving CPR from a machine, would haunt him for the rest of his life. “Alive” didn’t mean “all right.”
“Brian is reported to be conscious and communicating,” Detective Overton assured them. Holding up her phone, she added, “That was one of our deputies. He was out on patrol duty when he spotted the red Honda Civic registered to Danielle Henault - same license plate number and everything. He pulled it over, but didn’t find Danielle or her husband behind the wheel. It was a different man. While he was questioning the driver, Deputy Martinez heard banging sounds coming from the back. He did a search of the car and discovered Brian in the trunk.
“Oh my goodness!” Leighanne gasped, looking horrified. “Poor Husband…”
“But he’s gonna be okay?” Kevin asked again, his brow creasing with concern.
The detective nodded. “Martinez said Brian will need medical attention, but doesn’t appear to have any life-threatening injuries. Another officer is bringing him to the hospital now.”
Leighanne jumped up from her chair. “Let’s go downstairs,” she said, grabbing Baylee by the hand. “I want to be there when he gets here.”
“Wait a second, Mom,” protested Baylee, pulling his hand out of hers. He turned back to the detective. “What happened with the driver? Did they arrest him?”
Detective Overton nodded. “The driver’s in custody. Deputy Martinez is taking him straight to the station for questioning.”
“Was it the same guy from the airport?” Baylee asked. The detective seemed hesitant to provide any more details, but Baylee continued to press her for information, looking remarkably like Brian as his nostrils flared with anger. “Come on, please… I wanna know who did this to my dad!”
“According to the deputy, it does appear to be the same man we saw on the airport surveillance footage,” Detective Overton confirmed. “His name is Patrick Gravel. His family used to run a funeral home here in Key West. That’s where Brian said he and Nick had been held hostage for the past few weeks.”
“Gravel?” Kevin repeated, frowning.
Howie’s mind raced. He knew without asking what Kevin was thinking: that name sounded familiar to him, too. And then it clicked: “Gravel… as in Doctor Gravel?” he asked. “The cardiologist?”
Lauren’s head suddenly snapped up, her eyes growing huge as she looked at Howie in horror. “Oh god!” she cried. “Nick!”
***
In the cath lab, Nick’s condition was rapidly deteriorating.
“His pressure’s dropping, seventy over thirty,” the anesthesiologist alerted Elizabeth. “Heart rate is tachy at one-ten.”
“There’s blood in the pericardium,” said the X-ray tech, pointing out the effusion on the screen.
“Damn,” Elizabeth swore, shaking her head. “Something must have nicked the vein.”
The nurse palpated Nick’s wrist. “I can barely feel a pulse!”
Elizabeth slipped her stethoscope into her ears and auscultated Nick’s chest as she studied the fluoroscopy screen. The accumulation of blood was compressing his heart, preventing it from beating properly. “Diminished heart sounds. He has cardiac tamponade,” she diagnosed. “Suzanne, set up for pericardiocentesis.”
“Should we notify the cardiothoracic surgeon on call?” asked the anesthesiologist.
“Not yet. Let’s drain the blood from his pericardium first and see if he stabilizes,” said Elizabeth. “Then we’ll be able to better assess the damage and decide if it warrants surgical repair.”
She inserted a needle through Nick’s chest wall into the sac surrounding his heart and withdrew a syringeful of blood.
“I’m seeing ST elevations on the monitor,” the anesthesiologist warned her. “You might wanna back off; I think you’re making contact with his myocardium.”
That’s the plan, thought Elizabeth, smirking behind her surgical mask, but she pretended to pull the needle back a few millimeters.
Meanwhile, Nick’s blood pressure continued to plummet as more blood poured from his vena cava into the pericardial space, making it harder and harder for his heart to pump. “He’s crashing!” barked the anesthesiologist, as the numbers on the monitor reached critical levels. “I’m calling for surgical back-up right now.”
“I can’t feel a pulse!” Suzanne cried, her fingers clamped over Nick’s radial artery.
Elizabeth looked at the waveform on the wailing heart monitor. It was still showing evidence of electrical activity, but without perfusion, it didn’t matter - Nick would be brain dead from lack of blood flow in a matter of minutes. “He’s in PEA. We can’t wait for the cardiothoracic surgeon; we need to crack his chest now!” she announced, her own heart rate increasing as adrenaline coursed through her body. “Set up a thoracotomy tray.”
As Suzanne readied the surgical equipment, Elizabeth started CPR. She had no intention of saving Nick this time, but she knew it had to appear like she was doing everything in her power to resuscitate him if she was to avoid a malpractice suit. She pumped his chest hard and fast until Suzanne finished preparing for the emergency procedure. Then they traded places, the nurse taking over compressions while Elizabeth picked up her scalpel. A thrill went through her as she made a long incision down the center of Nick’s chest, using a cautery pen to quickly dissect the layers of skin and flesh. Since she had chosen to specialize in electrophysiology, rather than cardiac surgery, she rarely had the privilege of cutting her patients open like this.
“The surgeon’s on her way,” said the anesthesiologist as he hung up the phone on the wall.
“Good. You can assist me until she gets here,” replied Elizabeth, reaching for the sternal saw. With a loud buzzing sound, the blade sliced cleanly through Nick’s breastbone. “Rib spreader,” she requested, and the anesthesiologist handed her a retractor to separate the two halves. As she cranked them apart, widening the opening in his chest cavity, she could see the pericardium bulging from the collection of blood inside. She used the cautery pen to cut the thin membrane open before it could rupture. Blood began to spurt from the small hole, obstructing her view as it filled Nick’s chest. “I need suction!” she shouted. “Hang two units of O-neg before he bleeds out.”
The nurse scrambled to start a transfusion while Elizabeth sucked the excess blood out of Nick’s chest. She pulled back the edges of the pericardium to expose his heart, which was twitching in a feeble sort of way, without enough force to pump the blood that had pooled in its chambers. “Starting internal massage,” she said, as she took the precious organ between her hands and began to squeeze.
All of a sudden, the door burst open. Elizabeth looked up, expecting to see the surgeon. The woman standing in the doorway wore a surgical gown over her gray pantsuit, but she was no doctor.
“Detective Overton, Key West Police Department,” she introduced herself. The mask on her face may have obscured her mouth, but it didn’t hide the fact that she was glaring at Elizabeth. When the two women locked gazes, the intense look of disgust in Detective Overton’s eyes was more than evident. “Dr. Elizabeth Gravel?” she asked.
Elizabeth’s heart dropped into her stomach, but she didn’t let her panic show, maintaining her poker face behind her own mask. “That’s me,” she replied coolly and decided to play dumb. “May I ask what you’re doing in my cath lab?”
“I need you to come with me right now, Dr. Gravel,” the detective said curtly. “I have a few questions to ask you.”
Elizabeth bristled. “Excuse me? I’m in the middle of emergency surgery here!” she exclaimed, nodding towards the table, where her hands were buried inside Nick’s chest. “Surely this can wait?”
“No, it can’t. Step away from the patient,” ordered Detective Overton, her voice rising sharply.
Elizabeth raised her eyebrows. “Are you really sure you want me to do that? I literally have his heart in my hands right now. If I let go, he’ll die.”
“Not if I can help it!” A second woman rushed into the room, fully gowned in sterile garb over her surgical scrubs. Elizabeth recognized Dr. Webber, one of the hospital’s most respected cardiothoracic surgeons. “Go with the detective, Dr. Gravel. I’ve got this,” she said, as she reached into Nick’s open chest from the opposite side of the table.
Elizabeth had no choice but to relinquish her hold on his heart, knowing if she didn’t, she would face disciplinary action anyway for defying a senior doctor. As she reluctantly allowed the detective to escort her out of the cath lab, she could hear Dr. Webber’s voice calling out desperate orders. “There’s a rupture in his superior vena cava! We need to put him on bypass to preserve his brain function while I repair the tear. Come on, people, let’s get those lines placed; we’re losing him!”
It didn’t look good for Nick. Elizabeth suppressed a grim smile as she stripped off her blood-soaked gloves and gown. They’ll never be able to get him back now, she assured herself. It’s too late. He’s already gone.
***
