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PROLOGUE TODAY University of Pittsburg Medical Center (UPMC) Walking down the hospital corridor, lost in the swirl of my own thoughts, it was the sight of him that brought the glow in my core. He smiled that warm smile that always seemed reserved for me as he opened the door to the stairwell and beckoned to me to join him. As if with one mind, I knew he wanted me to join him on rounds. We were two people with one sense of experience, sharing the stories of our patients. His white coat was so crisp and clean it seemed to act as its own source of light. The coat emitted an ethereal glow as he headed up the steps to the transplant ICU. To be part of his world and share in the devotion he had to his practice was what I thought I wanted. To know this man and understand what inner and outer passions commanded his soul was a dream I held in my most inner lockbox. Suddenly there was a beeping sound. A fire alarm? A code? Code Blue? Code Red? Reluctantly I snapped myself out of my sleep. It was that darn beeper. So much for my lovely, romantic, impossible dreams. Slowly I sat up on the narrow bed that the call room provided, my whole body screaming as I fought the stiffness that age and overwork created. *** My name is Dr. Casey J. Cook. I put people to sleep so that they could endure surgical procedures. My primary goals were amnesia and analgesia. Basically, I pushed drugs through veins and gases through the lungs to keep the patient from feeling pain during the procedure or remembering it afterward. Along with sleep and comfort, it was my duty to make certain that the really sick patients lived through the surgery. If the blood pressure went up too far, I would give drugs that brought it back down. If it dropped too much, I would give other drugs or fluid replacement to bring it up. It was an elaborate balancing act. While working a complex set of situations, symptoms and possible outcomes clicked away in the brain. One wrong substitution for one wrong variable could invite disaster. Through my residency and subsequent fellowship here at the University of Pittsburg Medical Center (UPMC), I had gradually segued from general anesthesiology to hepatic anesthesiology – or specializing in surgeries of the liver. It took another year of training after residency, but to me, it was worth it. It meant I got to work with the best surgeons on the sickest patients. I became involved in the work on the anesthesia side of the drapes and would remain so throughout most of the case. We were tuned in to the work with the surgeons at certain landmarks through the case. Sometimes it seemed like our work was independent but at all times it had some common relationship. Our goal of providing an optimal outcome for the recipient was the same. It was just that our approach was from a slightly different angle. It was here at UPMC that the discipline of hepatic anesthesia was born. Building on the early works of doctors such as Kang, Aggarwal and Sassano, Dr. Thomas Starzl had performed the first successful liver transplants. Collectively known as the “Pittsburgh Group,” each of these doctors had lent his own particular genius to make this groundbreaking procedure possible. There had been previous attempts in other hospitals, but none had reached the level of success of UPMC. I came to the university in the mid-nineties, more than ten years after the first hepatic transplantation was performed. It was still an exciting space—perfect for the adrenaline junkie that I had always been. I felt that after taking care of these patients, I could offer the best of care to anyone who ended up in my operating room. They were often as sick as anyone could be, yet through the work of our surgical team, they could survive the ordeal of getting another person’s liver. I gave myself a moment to recover from the dream, then swung my legs over the edge of the bed and slipped my feet into a pair of soft, white, leather clogs. These clogs allowed me to stay on my feet for the long hours in the OR. Dressing up or changing clothes before I answered the page was not necessary, as I was already dressed in my favorite scrubs. The older ones were best, and these in particular were like a second skin—thin and soft—unlike the new ones that were stiff and scratchy. There was an endless supply of scrubs at the hospital; no matter how often you changed after a long nap or a bloody surgery, there was always more, a reminder that we were all married to our jobs. They were also an equalizing force – worn by every staff member, be it under the long white coats of the doctors, the short white coats of the medical students or the colorful smocks the nurses tended to wear. The scrubs were one of the few things that placed us on a common ground. I went to the mirror on the wall in the small lavatory adjacent to the call room. Years ago my sorority sisters had told me I looked like Claudia Schiffer. At the moment I neither looked nor felt like anything resembling a super model. A few lines in the face and a hair in need of a trim. How I looked was often the least of my worries, however, for there was always something more pressing. Deep down, I guess I thought it didn’t matter to anyone what I looked like. At least, not anymore. I washed my face and tucked my long, thick, layered hair under my OR cap, then applied a light coating of face powder I always carried with me. It didn’t work miracles, but it did hide a few evils, thank goodness! Gone was a girl that hoped for a bit of romance. The need for that sort of validation had long ago disappeared. When the hope for romance leaves, so does a particular attention toward appearance. Romance had been replaced by the steady drive to get the sickest of patients through the ordeal of their OR experience. I often wondered if my work had pushed the need for romance aside or had merely filled a void left by my unsatisfied urges, but there was no time to ponder that paradox now. My services were needed. There was another case to follow. I dialed the number on the pager screen. “Dr. Cook here.” “Yes, Good evening, Doctor. This is Elaine Marsh, the nurse in charge in OR 6. We have a match. An organ is being harvested and both it and the recipient will be in the facility within a couple of hours.” “Who’s the recipient?” “Marion Johnston.” “Great. On my way.” With that, we hung up. I had been waiting for this action. I was always waiting for it, even when I slept. Now that it was here I needed to review the patient’s file and meet with him before he was brought to the pre-op holding area. As I left my room and started down the hall toward the Operating Room, the memory of the dream crept back into my brain. Why do I keep dreaming of HIM? There had been other romantic interests, quickly faded and forgotten, why did this particular person keep entering my mind? My dreams? Perhaps it was because it was a relationship that had held so much promise, then fizzled before it started. Dr. Eduardo Montesi. I said his name in my head to somehow make him real and place the experience in a realm separate from dreams and fantasies. I still was not certain how things got so horribly confused. All I knew was that by the time I finally realized the handsome Eduardo Montesi might actually desire me, it was too late. This, coupled with the twisted deception of others that could have easily ruined my career, destroyed anything that might have been. To this day, the thought of that time still brought a sick, scary feeling to my otherwise case—hardened soul. There were many times in our lives when we were confronted with seemingly insignificant decisions. Should I go to dinner with him or not? Should I take the highway or the back roads? Should I approach the person I’m interested in or wait and see if he makes the first move? At the time they are made, many decisions seem to have no consequence, as unimportant as deciding whether to have bacon or sausage. The outcome is but a lone mark on our personal timeline, but as you grow older and – hopefully - wiser, you look back and see that every decision creates a ripple effect. Every action is an essential part of the weave in the fabric of life. Who should get this vital organ? Which life should I save? And finally, how can I get through this and save my own hide? It was thoughts like these that held the frontline in my brain. While many of the other women I came in contact with were thinking about makeup or buying new carpet, I was, more often than not, thinking about keeping a patient alive. At times it seems as though no matter how carefully we weigh things, how carefully we plan toward an outcome, it was the other path we should have taken. At other times, we are forced to a detour that is not of our choosing or desire. This was how it was during my and Eduardo’s time. After a seemingly simple gesture to help a friend of a friend, I found myself sucked into a vortex that quite possibly cost me my chance at love and nearly my life as well. Careers were jeopardized and nothing seemed to happen as it should. It was like driving a vehicle that had lost its breaks. You have some control, but mostly the outcome depended on many factors that would have their way – weather, traffic and so on. It didn’t seem possible that the person I was today was the same person who had been drawn into an activity that was not only illegal, but possibly unethical and immoral. And it wasn’t. That’s only what it may have looked like. All this made me weary and sad. I longed for the feel of Eduardo’s arm against mine. Our secret ritual. At the end of a case, we would stand on the same side of the patient’s bed so as to gently lift him or her off the OR table and onto a bed for the trip to the ICU. Our arms would touch or even cross as we performed the only slow dance we would ever enjoy. The hair on my arm would stand up with the electricity of this gesture, as it did today when the memory resurfaced. Here they were again. Those schoolgirl thoughts. I was angry and embarrassed for having them, even as I yearned for romance in my life. I figured this was probably why I’d stayed single - the steady stream of mixed signals radiating from my body. I longed for companionship but wasn’t willing to pay the price of allowing someone to share my life. Over the years, the satisfaction of creating my own life had overshadowed any romantic desires; my choices had made me who I was. It was my dreams that took me to the edge of what might have been, who I might have been. There, in the deep fog of sleep, I would meet him. Eduardo Montesi. And for the life of me I couldn’t figure out what it all meant, why this man in particular continued to haunt me. I forced Eduardo from my mind as I entered the holding area to meet Marion Johnston and prepare him for the procedure. As always before a surgery, I felt the adrenalin building in my body. Then I remembered the date and felt my mood immediately deflate. It was July 2nd, which in a university teaching hospital meant an end and a beginning. Contracts ended, new staff appeared and every medical student and resident moved up one level beyond their competency. Great. I get to work with a bunch of starry-eyed rookies. I quickly reminded myself that I once was one of those starry-eyed rookies who had endured my own numerous fumbles in the OR. Still, my sharp tongue could never resist stinging ambitious surgical residents who would inevitably bring up patients who were not savable. “What’s the matter, light bad downstairs?” I’d say to no one in particular when they came crashing through the OR doors. To me, it seemed pretty obvious that they were pushing a corpse around the hospital but to a young surgery resident, it was seen as the case that might make them a hero. Several of the attending staff surgeons had moved on this year. Dr. Claire McGee went on to a smaller program where she could be chief. If she had stayed here, she may have never enjoyed that status. Dr. Pat Hall left transplantation altogether and took a general surgeon’s position in a rural hospital so she’d have time to enjoy her growing family. I felt myself growing more irritated as I thought about having to work with a surgeon who had not trained in our program. Would they be familiar with the protocols? What surgical techniques did they employ? The good news was that several excellent nurse anesthetists, some of whom had helped train me - were on tonight. Some of them had even become personal friends. My patient was already waiting for me inside the holding area. “Hello Marion. I’m Dr. Casey Cook. I’ll be the anesthesiologist during your surgery.” “Hi, Doc. Nice meeting you,” he said, trying to sound upbeat. “I have to tell you, I’m really nervous.” “No need to be,” I said as I picked up his chart. “Have you ever been under general anesthesia before?” “No, and I hope I’d wake up. I’ve heard bad stories.” I looked him in the eye. “I promise you. You will wake up. This is all very routine. Now, let me hear your heart.” I placed my stethoscope on his chest and started listening. His heartbeat was very rapid. “Wow,” I said, in a joking tone to ease his tension, “You are nervous.” Marion nodded. “Very much, Doctor.” “Don’t worry. Dr. Sharp and I have done this hundreds of times. He’s an excellent surgeon, so just relax, and when you wake up tomorrow you’ll have a brand new liver.” I walked toward the head of the gurney and watched Jeff, one of the technicians, placed the arterial line. The arterial line used monitors to provide a wave form and numeric readout of a patient’s continuous blood pressure in a constant real-time presentation. Debbie, another tech, had placed a wide-bore IV line in his arm that would later be part of a pipeline attached to a high-tech blood infusion pump called the RIS. The RIS had been invented in the early days of transplantation by Dr. Sassano, who, after long, bloody cases had invented an electric pump that could infuse up to a liter-and-a-half of saline, packed red cells and plasma into a patient as needed. By the time Debbie and Jeff were done, Marion looked like a human pin cushion; he was also, however, well-prepped transplant recipient. “I see you’ve met Jeff and Debbie,” I said to Marion. He smiled and nodded, but still looked frightened. “Jeff and Debbie are two of the best technician at UPMC. Does that make you feel better?” I was trying hard to put Marion at ease. “Dr. Cook,” Debbie said, “Pam and Barb are finishing with other cases. They said they would help with another transplant if it materialized.” I nodded. I was expected to handle two cases at once – if necessary. This anesthetist can handle ANYTHING, I thought, my positive mood returning. I reviewed the chart on the clipboard. Marion Johnston was a thirty-nine-year-old male with a history of alcohol and drug abuse. The hepatitis he got from a dirty needle, coupled with years of alcohol abuse, had destroyed his liver. Without that organ, his body would not be able to cleanse itself or metabolize drugs. He would die. He had to have been clean for two years or the organ would not be wasted on him, and at this point in his sobriety he was on equal ground with any other candidate. Many IV drug abusers had bad vessels and could be hard to start a line on, as the scar tissue left by many unskilled needle sticks made it difficult to place ports necessary for the injection of medication. I was pleased to see that Jeff and Debbie had placed these lines with apparent ease. “Marion, you still nervous?” “Will you be with me during the entire surgery?” “Yes, of course. I’ll be there monitoring you the whole time. Your heart function, rate and rhythm, your blood pressure, respiration, oxygen saturation in the blood, body temperature, brain activity, levels of the anesthetic agents, and your other vitals.” Marion sighed audibly. “Now I feel better.” “Great. Now we need to move you down the hall to the main liver transplant OR and transfer you to the OR table. OR 6 was a large room, lined with green tile except for the stainless steel shelves along one wall. As with other ORs, it was loaded with all the supplies necessary for liver transplants. Once Marion was inside, Debbie and Jeff began the business of placing the remainder of the lines into him. I quickly placed a tube into Marion’s trachea that would allow a gas machine to breathe for him and deliver inhaled anesthesia while the surgery took place. Debbie took the first blood sample. Without these techs, we could not operate on the level we did. They offered us the tools that were essential to our jobs and our research. Throughout the case they would run thromboelsatographs, - or TEGs - that provided us with continuous information on the ability of the patient’s blood to form clots. Patients with liver disease had difficulty forming platelets, which are the mechanism of clotting. Dr. YooGoo Kang, the father of hepatic anesthesia, had developed the protocol for monitoring the real-time clotting of the patient’s blood. A baseline sample told you what condition they were in before the surgery, another told you how good the new liver was functioning and there were others that provided useful information throughout the case. The TEG allowed the anesthesia team to provide the patient with appropriate clotting drugs and necessary blood products throughout the case. This kept the patient from bleeding too much while the RIS helped regulate their blood pressure, and was a significant advancement in liver transplantation. As always when I prepped a patient, I was aware that others were in the OR but unaware of who they were and what they did. I had a vague sense that a nurse and a tech were nearby, opening their supplies, the surgeon was wandering in and out, anxious to begin. Once the labs were done, the RIS and Cell Saver placed, I asked Marion to count backwards. “Ten, nine … eight… seven…” He stopped counting. Marion was asleep and stable. We were ready. As if coming out of a trance, I once again became aware of the usual sounds and smells - the beep of the monitors, the alcohol, betadine and surgical scrub used to prep the patient. The monitors, each with a distinctive beep, carried a lot of information to the trained ears of the anesthesiologist. It would keep me informed on Marion’s status throughout the procedure. Suddenly, there he was. Eduardo. Although I could not see the smile through the mask, I recognized those eyes. The strong build. The familiar warmth that had always been there for me returned front and center. Perhaps, had it not been for what happened all those years ago, we would have made a life together. But there are people out who place professional pride above human needs and Eduardo and I certainly fit the bill. It wasn’t that we wanted love less than anyone else, it was just that he and I focused first and foremost on our work. What we gained in satisfaction and achievement, we lost in social skills, often allowing them to wither and die on the vine. Eduardo wasn’t in this OR now. But his presence certainly was. In my more vulnerable moments I thought of us as two individuals, placed together by kindly angels, only to be pulled apart by jealous demons whose only joy lay in creating destruction and confusion. These demons had caused misunderstandings and placed us in positions that threatened our lives and careers. In actuality, though, the story was not really about me and Eduardo, but about two very sick young women who needed liver transplants; Eduardo and I just got sucked into it. It was a great story, really, with romance, suspense, conflict and more than enough thrills. It was another time –a time when I still believed in love and modern science could conquer all and that all people were inherently good with happy endings coming to those with patience. Now, I realized that I had been very, very, wrong. Or had I? CHAPTER 1 University of Pittsburg Medical Center (UPMC) Ten years earlier I walked briskly down the OR hallway, thinking about all the pre-op evaluations I had to do that morning. When the second - or third - year senior anesthesia residents were on call, they, along with the help of the first- year junior residents were responsible for doing pre-ops on in-patients and attending any codes in the hospital. Pre-ops were when we went and gathered all the relevant information from the in-house patients such as their medical history, any allergies, what kind of medications they were taking, and so on. This was necessary because all of this could affect our treatment of the patient during the surgical procedure. At this point, the first-year residents were just learning how to navigate the system and getting the routine of pre-ops down. They were hardly ready for taking call independently. Now a third-year resident, I was just beginning to feel confident in my discipline. I had earned that confidence through many long hours, many patients and many painstaking surgeries. Any case that came down the hall, I tried to get involved with. If I wasn’t assigned to it, I helped those who were. Hearts, livers, kidney, pancreas—even traumas. All provided a mental chalk board full of useful information. Coming to the end of the hall, I ducked into the charting room to grab the code bag. It was the anesthesia resident’s responsibility to respond to “codes.” Sometimes the patient was just unstable and needed emergency care, but often they were in a full cardiac or respiratory arrest and needed a full intervention by a skilled team of doctors and nurses. The anesthesia team always monitored the airway or provided breathing assistance when necessary. This same service was expected every time a trauma was coming into the emergency room as well. The code bag provided us with emergency intubation equipment that was necessary if a patient quit breathing. Suddenly, I was startled by a tall figure coming out of one of the operating rooms. His brown hair shimmered from the sunlight, filtering in from the exit door at the other end of the hallway. He glanced at my direction and I was immediately drawn by the warmth in his eyes. They were amber in color, powerful, knowledgeable, and at the same time, mysterious. I found myself staring at them longer than I should have. “Please. I am so sorry to bother you,” he said, almost pleading. “I need some help. I promise it will take only a few minutes.” He spoke softly, with clean sentences and a hint of an accent that I was instantly charmed by but couldn’t place. It might have been Latino Spanish, I thought, but his physical features suggested otherwise. He might have been a Spaniard, Portuguese or even Italian. I knew he thought I was a nurse. Even in this day and age, most people still assumed that men were doctors and women nurses. Rather than correct the mistake and create an embarrassing and time-consuming situation for both of us, I just followed him into the Operating Room. “I’d be delighted to help you, Doctor.” I smiled as I implied respect for my “superior.” “Thank you so very much. I really appreciate it.” Again, those amber eyes. “Not a problem.” Truth was I was actually in a time crunch, but I couldn’t resist the chance to help a good-looking doctor. I didn’t get that chance often. Certainly, not often enough. Inside the OR, I could see that he and another surgeon were going to prepare a donor organ for transplant. The other surgeon was already gowned and seated at a basin placed on a draped steel table. He looked familiar and I recognized him as Dr. Yuji Kinoshita, a transplant fellow who had been around last year. He looked up and nodded a greeting to me, then continued to examine the liver that was submerged in a basin containing crushed ice and a preservative solution. Today he would be showing this “new guy” the art of preparing the donor organ for successful surgical implant. “If you could open this for me, please,” the tall man said, pointing at the packaged sterile gown. While he scrubbed his hands and forearms, I took the gown and unwrap it as he directed. The rest, he didn’t have to tell me, as I was familiar with this routine. After the gown, I opened a pair of sterile gloves, holding the package so I would not touch them directly, and held it out to him. He nodded his thanks, then picked the gloves out and slipped them on before turning around so I could help him with the gown. It was as if we had rehearsed the whole thing, and even at five-eight, I still had to reach up to pull the gown together across his strong shoulders. Yes, he was definitely well over six feet. As I tied the gown around him I found myself enjoying the task. The life of a resident didn’t leave much time for sleep, let alone socializing, so I found the sudden nearness of such a handsome man incredibly exhilarating. Something very simple had quickly become very intimate and I felt my cheeks begin to warm. It was as close to a date as I was going to get for the foreseeable future. He faced me again, bending a bit. “Thank you so much. I really appreciate your help.” This time his brown eyes were closer to mine than before. I felt an instant connection. Unfortunately, this was also my cue to leave. I nodded, then went back to my own business, out the door and down the hall. Halfway down the hall, I ran into my friend Marla. Like myself, Marla was from West Virginia. This created enough of a common ground for us to become friends. I really appreciated having a friend like Marla, because it was hard for me to be myself around my anesthesia colleagues. They only needed to know the professional Casey, not the side of me that was shy, vulnerable and occasionally yearning for the arms of a man. With Marla, I was just another girl from West Virginia. With her I could be full of girl talk and could, for a minute or two, drop the Dr. Cook routine. “Who was that tall surgeon in OR 1 prepping the liver,” I asked. “I’ve never seen him before. He’s gorgeous! And seemed so nice, too!” “Then he can’t be a surgeon,” Marla laughed. “I don’t know who he is, probably one of the new transplant fellows. What were you doing in OR 1 with him?” she said in a silly, suggestive way. “He just asked for me to help him to put his gloves and gown. You know the routine. He is with that surgical fellow, Dr. Kinoshita. They’re doing a backtable.” The backtable is a very important part of the liver transplant. It’s not enough that the organ had been carefully removed from the donor. There were certain other things that have to be done by the surgeons that would optimize the organ’s placement inside the recipient. The liver is prepared for implantation by removing certain unnecessary tissues such as remains of the donor’s diaphragm. After appropriate exposure, the adrenal gland is also removed. All vessels are carefully checked for leakage and prepared to meet the recipient’s anatomy. At all times the liver must remain bathed in the cold University of Wisconsin (UW) solution, which is the gold standard for preserving organs. It was the development of this in the early days of transplantation that allowed the removal of organs in another facility, sometimes some distance from the recipient hospital. The UW contains a precise mixture of potassium, sodium, glucose and other nutrients found to enhance organ viability. These are combined in a precise balance which meets a Ph (acid to base) balance complementary to the human body. All of this is kept cold, iced, in fact, to make ischemic storage, which means the organ is outside the body and not being perfused by blood. All of these developments and activities were as critical as the transplant itself. Without careful management of this, the transplant would not be a success because the transplanted organ would not be viable. In many ways, the liver functions much like a fuel filter in a car, but the replacement of this filter was far more complex. Not only was the surgical technique practiced and immaculate, but the science supporting the procedure reflected many important developments in hematology, biochemistry and histology, to mention just a few that were integral to the procedure. “Hmm,” Marla teased. “I guess we’ll find out sooner or later who he is and where he is from.” “I’m telling you, Marla,” I said, “He is so yummy.” Yummy was our slang for any good-looking male, and I used it now without a hint of exaggeration. So much for being sophisticated and articulate. “I’ve got to check that out. It’s not like we have enough of that around here.” Marla laughed as she hurried down the hall to her OR. Marla might be happily married but that didn’t mean she didn’t enjoy seeing a hot doctor prowling the halls. Like me, admiring the opposite sex was sometimes all that carried us though the long hours. It was universal, sexual energy had an effect, no matter where one worked. The way we balanced life and placed our priorities governed how much this interest was expressed and how much of our life it owned. For me, it was mostly a matter of timing. The right people were never there when I had the time. My first case was a forty-year-old kidney transplant. The surgery had taken four grueling hours, but now the patient was in the recovery room and my relief arrived, just in time for my lunch break. I took the elevator to the cafeteria on the twelfth floor, where I ordered a tuna sandwich and a can of Diet Coke. As I ate, I read the newspaper left by someone on the next table. I was halfway through both when a tray of food was placed down across from me. “I’m sorry, do you mind if I join you?” It was the tall doctor I’d helped earlier. His amber eyes were beaming, his smile was relaxed. “No problem,” I said and pushed the paper away. “Thank you for helping me this morning. I’m Eduardo. Eduardo Montesi.” He held out his hand to me. “Casey. Casey Cook.” “So, uh, Dr. Cook…” he began, and I knew the emphasis on the word “doctor” meant he’d noticed my long white coat. He stared at me for a moment, looking a little uncomfortable, perhaps for his earlier mistake. “Please,” I said, giving him my sweetest smile. “Call me Casey.” He smiled. “So, Casey, this is your third year of residency here?” “Yes.” I took a sip of my soda. “How did you find that out?” “Dr. Kinoshita mentioned it to me this morning.” I wondered how the subject had come about but decided not to ask. “And you, Dr. Montesi? I don’t believe I have seen you here before.” “Let’s be fair. I’ll call you Casey, only if you call me Eduardo.” He offered me a dazzling smile. “I started here, I’d say…” He rolled up his eyes to think. “…six months ago. I guess we were just never put in the same case.” “Yeah, I don’t remember seeing you before. Where’d you come from and what brought you at UPMC?” “I’m here for my fellowship in adult and pediatric organ transplantation. Prior to that I was chief resident at Washington University School.” “That’s in St. Louis, right?” “Correct,” he said between bites of his club sandwich. I still could not identify the slight accent. “Montesi. Is that Italian?” “Well, yes. But I’m actually from Argentina.” Well, that explained the accent. I raised an eyebrow at him to let him know I was intrigued. “Many Europeans emigrated to Argentina and Brazil over the years, usually to get away from dictators like Franco or Mussolini.” He sipped some of his soda. “My family came from Italy for that reason, according to my mother. In fact, Buenos Aires has a rather large Italian community.” I nodded, completely fascinated. “There is a fascinating book,” he continued, “called Historia de los Italianos en la Argentina. I’ve been meaning to read it, but with my schedule it’s been impossible.” He paused a moment as if debating whether he should say more, then he shifted gears. “How about you Casey, were you born in the US? I know it seems like a silly question, but from your features – the blue eyes, high cheekbones, blonde hair – you definitely look more European than American.” I was about to answer, but we were interrupted by the rapid beeps of his pager. Darn! Eduardo looked at the display. “I’m sorry, Casey. I’m needed on 10C immediately.” I waved away the apology. “Of course.” He stood and picked up his tray. “I do thank you for sharing your space with me. I hope that we continue our conversation some other time.” I nodded, trying not to be too obvious as I perused his body. My gaze landed on his hands – strong and long-fingered - and saw that they indeed looked as though they belonged to a skilled surgeon. He threw the unfinished sandwich in the garbage can nearby and then pitched the soda can in the recycle bin. I noticed the arms, slender but muscular. Strong arms, the kind that could make you feel safe and secure. As Eduardo exited the cafeteria entrance, I heard a female voice call out, “Hello Dr. Montesi.” Her voice was flirtatious but Eduardo just waved and went on his way. Deidre. That was her name. Deidre McKay. She passed right in front of my table, looking down as if studying me. Something about her stare made me uncomfortable, but I brushed it off, thinking I was just being paranoid. Suddenly I felt embarrassed. Here I was, closing in on my thirties and still shyly watching attractive men as Dr. Eduardo Montesi, just as I had when I was fourteen. Was I available to pursue a career because I’d missed opportunities in love, or was I pursuing a career that pushed love away? Whichever it was, I found myself longing for the arms of this tall, handsome surgeon. *** It wasn’t long before my own pager went off. All it said was “10C” but I knew what it meant. They were calling for the code team to respond. As I gathered my tray and threw everything in the garbage, I heard the overhead page: Code Red-10C. I ran down the steps and in less than a minute, I was approaching 10C. There was a huge commotion, with nurses, technicians, and interns scrambling. I saw a nurse pushing a crash cart, and a tech, a portable X-ray. I recognized Dr. Salomon from the liver team and I rushed to the glassed cubicle, where a patient lying motionless on the bed. I recognized her as Veronica Stern, a woman who’d had a liver transplant six months ago. I had been the resident anesthesiologist during the procedure. Dr. Montesi carefully inserted a fourteen-gauge needle into her abdomen, then threaded a small wire through it. “Lot of excess fluid,” he bellowed. “We need to relieve the pressure!” He then took the needle out and put the catheter with a curved end over the wire. A turbid, very yellow fluid slowly drained from Veronica’s belly. “This should improve her breathing,” he said out loud to no one in particular. The moment was tense while everyone watched Dr. Montesi perform his desperate attempt over the dying patient. He shifted his eyes to Dr. Strickhartz, another surgeon. “We need a pulse reading.” Strichartz did so. Moments later, he shook his head. “We’re losing her.” “The removal of fluid from her abdomen might have caused the sudden blood pressure drop! But we had to do it,” said Montesi. “Let’s look at her heart!” said Dr.Caldwell. I recognized him as someone from cardiac anesthesia. He left but was back in a flash with a STAT echocardiogram. Dr. Montesi looked at the screen as Caldwell was performing the test. “Not good. Not good,” he repeated over and over. “Her heart looks rather empty but fluid is building up in her lungs. Probably a result of the fluid shift in her abdomen. And then into her lungs from portal hypertension.” Things often happened with the sickest of patients that were neither expected nor understood. In many cases, no one had enough experience with the particular scenario. The beep of the monitor was dull and slow. I looked up to see a drifting blood pressure and a low O2 saturation. Veronica wasn’t getting enough oxygen into her blood stream. Her breathing was compromised by the amount of fluid in her lungs. Dr. Montesi glanced at me. “Intubate her, Dr. Cook.” I had been down this road before with Veronica. First, when she had her initial surgery, then through off and on re-intubations over the last six months. She would get well enough to breathe on her own, then crash again. It had been a rough road and it was getting rougher fast. Quickly I pulled an endotracheal tube from my code bag and, with the help of a 3 MAC blade on a lighted laryngoscope, I drove the tube down Veronica’s windpipe and hooked her to a mechanical ventilator. Dr. Montesi and the others scrambled to drain the fluid building from her peritoneum. “Disconnect the PICC line,” he instructed the tech. “I’m afraid it might be contaminated.” Dr. Strichartz bellowed. “Pulse is shallow and thread.” “Let’s get some fluid in her!” Eduardo directed her nurse, “And a unit of albumin!” The nurse went about giving her the albumen and two liters of normal saline through separate lines attached to her arm and pelvic area. Dr. Strickhartz pressed on her carotid. “I got a very slight pulse.” Dr. Montesi glanced at me. “Let’s give some epi to increase her heart rate.” I pushed 1.5 mgs of epinephrine into Veronica’s arm line. An arterial blood sample as well as a few tubes of blood for clotting time measurement and other values had been drawn from her arm and sent to the STAT lab. The nurse showed the results to Eduardo after they flashed up on her screen. “Her hematocrit is in the basement and her clotting times prolonged,” he said, “We need to get some blood products in her. She’s bleeding out!” I quickly reached into a cooler containing a couple united of blood and frozen plasma and proceeded to give them through the line in her groin. Dr. Strickhartz checked her again. “No pulse.” I repeated the dose of epinephrine along with some atropine and calcium that I had grabbed from the crash cart. Dr. Montesi placed his hands on the patient’s chest and began CPR, all the while focused on the monitor screen. “One thousand one, one thousand two, one thousand three...” After a couple minutes he stopped to check her. “No pulse.” With each push on her chest we saw the result on the monitor screen as it affected her pressure. When he stopped – nothing. I pushed another round of drugs and watched the monitor, waiting like everyone else crammed into the cubicle for some sign that what we were doing was working. Nothing. Dr. Montesi did another two-minute cycle of CPR. Again, no pulse. After the third round, we all knew it was over. Veronica was dead. The nurses were in tears as they hugged one another, then wiped the fluid on her body and covered her with a white blanket. This group had cared for Veronica through six months of various surgeries. They knew her well and had comforted her family through all the ups and downs. I watched as Dr. Montesi removed his blue cap and staggered out of the OR. Suddenly, Deidra materialized from nowhere. “I’m so sorry,” she said and gave him a hug. “You did the best you could.” Dr. Montesi continued down the corridor. There was no twinkle in his eyes, his steps were heavy and he was looking down with an aura of defeat. Veronica’s family was waiting for him in a small room next to the nurses’ station. This room- cold and unforgiving with only a circular table and four straight-backed chairs – was the place where bad news was delivered. I saw a few people in there. An older man and woman on their fifties. Young men and women. Perhaps Veronica’s brothers and sisters. I hated to think about the words Dr. Montesi would utter. |
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