Lee raced through the double doors to the emergency room, fully anticipating its atmosphere of everyday chaos and confusion. Doctors and nurses hurried about, but the intense commotion coming from bay 6 told him where his patient would be found. Two men dressed in dark suits with short haircuts—FBI, had to be—waved Lee over and pointed to that bay.
“He’s in there,” one of the agents said.
Lee rushed in, throwing back the curtain, and found himself looking down at Yoshi, lying flat on an emergency room bed surrounded by six nurses, gloved and gowned for isolation, scurrying about adjusting lines and monitor leads, drawing labs and calling for a stat portable chest x-ray and a head CT. Two ER doctors in scrubs barked orders.
Dressed in his trademark black, Yoshi lay unresponsive on a hospital gurney. A sickly bluish cyanosis signaled oxygen in his blood was dangerously diminished and presaged imminent death. Traces of blood dribbled from his nose, over his lower lip, and down his chin.
His long, white hair was helter-skelter and caked with blood, spittle, and vomit. Lee saw that he was bleeding from below, too, as one of the nurses inserted a rectal tube to help get some control over what appeared to be unstoppable choleric diarrhea.
“I can’t get him to stop bleeding,” another nurse said while she kept constant pressure on an intravenous access site.
The FBI had identified the type of mushrooms found on Yoshi’s kitchen floor. Lee was hardly an expert on mushroom toxicity, but it was obvious this was no accidental ingestion. Yoshi, who had studied mycology, had to know what the Amanita phalloides, the death cap, would do to him.
Quick as that thought came, another followed. What if it wasn’t deliberate? What if someone forced Yoshi to eat them?
These questions would have to wait. Right now, Lee was dealing with a dying man.
An FBI agent showed up, flashed a badge to the triage team. “This is a matter of national security,” the agent announced. “Dr. Blackwood is taking over. Everyone please stay here to assist him.”
The two ER docs showed no interest in defending their turf. As if someone had pinned a sheriff’s star to his chest, Lee was officially put in charge.
“BP is sixty over palp,” said a nurse, taking the measurement by palpating with her fingertips.
“Pulse one forty-eight by monitor. I can’t even feel a carotid pulse.”
“Call vascular surgery to see if they can help us with a central line,” Lee said. “Right now, D-five normal saline at two hundred an hour. Wide open. What’s his potassium? Let’s get him intubated. Blood gases?”
The rhythm of the ER took practice to perfect, and Lee was surprised how easily, how naturally the orders came to him. Triaging Susie had apparently woken something inside him.
“We’re just getting his labs back,” a nurse in blue scrubs said. “Potassium is high at six point two. BUN is fifty. Creatinine two point nine. Both elevated. Sodium is low at one twenty-eight. Bicarb is low at eighteen. His blood gases show a pH of seven point two eight, pCO2 of thirty-six and a pO2 of sixty-four on room air.”
Renal failure and metabolic acidosis, Lee concluded. Not good.
“What about liver function?” he asked.
Those labs indicated sudden, acute liver failure.
All markers pointed to hepatorenal syndrome, a rapid deterioration in kidney and liver function.
No, not good at all.
Yoshi’s nonstop bleeding meant that his dying liver had run out of clotting factors. Nothing to do now except pull out all the stops and hope.
“Get him typed and crossed for transfusion,” Lee said. “Let’s try and stop that bleeding. Vitamin K ten milligrams and prothrombin complex concentrate five thousand units. Fresh frozen plasma at fifteen milliliters per kilogram.”
The nurses ran about with schooled efficiency, preparing IVs and calculating infusion drip rates, stat calling labs and pharmacy, continuously monitoring leads, vitals, intake and output, and charting nonstop.
“Drop a large-bore nasogastric tube and start him on activated charcoal fifty grams every four. That should help to keep any poison that’s still in his stomach from getting absorbed,” Lee said. “Also get him on penicillin G, ten million units,” he added. “See if it competes with the toxin.”
“He’s going to need dialysis,” the ER doc said.
“Call in renal, gastroenterology, and hematology consults,” Lee answered. “He’s probably got cerebral edema from acute liver failure. He’s going to need a CT scan once we get him stable—”
If …
“And a neuro consult,” Lee continued. “Let’s get him tubed. Can’t wait for anesthesia. Get me a seven-oh endotracheal tube and a blade. Suction out his airway!”
Yoshi’s organs were vanishing. He was bleeding out.
In the background he heard someone yell, “I can’t get a blood pressure! He’s flatline on the monitor!”
Lee called out, “Put the pads on him and start CPR. One milligram of epinephrine and two amps of bicarb.”
Though it had been years since he had last intubated a patient, Lee’s instincts and experience paid off, and he slid the endotracheal tube smoothly into Yoshi’s trachea.
“Compressions at ten per minute. Give him forty units of vasopressin.”
Lee took over giving compressions. His arms ached. Sweat dripped into his eyes. He kept pumping. His back started to hurt. He thought about Cam and the secrets Yoshi would take to the grave. He kept pumping. He thought about his promise to the president. He kept pumping.
“Still flatline,” a nurse said after ten minutes. “No shockable rhythm.”
Lee checked Yoshi’s pupils. Fixed and dilated. No spontaneous respirations. No response to painful stimulations. No brain stem reflexes. No pulse. No blood pressure.
Dead.