Dr. Catherine Cordell sprinted down the hospital corridor, the soles of her running shoes squeaking on the linoleum, and pushed through the double doors into the emergency room.
A nurse called out: “They’re in Trauma Two, Dr. Cordell!”
“I’m there,” said Catherine, moving like a guided missile straight for Trauma Two.
Half a dozen faces flashed her looks of relief as she stepped into the room. In one glance she took stock of the situation, saw jumbled instruments glittering on a tray, the IV poles with bags of Ringer’s lactate hanging like heavy fruit on steel-rod trees, blood-streaked gauze and torn packaging scattered across the floor. A rapid sinus rhythm twitched across the cardiac monitor—the electrical pattern of a heart racing to stay ahead of Death.
“What’ve we got?” she asked as personnel moved aside to let her pass.
Ron Littman, the senior surgical resident, gave her a rapid-fire report. “John Doe Pedestrian, hit-and-run. Rolled into the E.R. unconscious. Pupils are equal and reactive, lungs are clear, but the abdomen’s distended. No bowel sounds. BP’s down to sixty over zip. I did a paracentesis. He’s got blood in his belly. We’ve got a central line in, Ringer’s lactate wide open, but we can’t keep his pressure up.”
“O neg and fresh frozen on the way?”
“Should be here any minute.”
The man on the table was stripped naked, every intimate detail mercilessly exposed to her gaze. He appeared to be in his sixties, already intubated and on a ventilator. Toneless muscles sagged in folds on gaunt limbs, and his ribs stood out like arching blades. A preexisting chronic illness, she thought; cancer would be her first guess. The right arm and hip were abraded and bloody from scraping across pavement. On his right lower chest a bruise formed a purple continent on the white parchment of skin. There were no penetrating wounds.
She slipped on her stethoscope to verify what the resident had just told her. She heard no sounds in the belly. Not a growl, not a tinkle. The silence of traumatized bowel. Moving the stethoscope diaphragm to the chest, she listened for breath sounds, confirming that the endotracheal tube was properly placed and that both lungs were being ventilated. The heart battered like a fist against the chest wall. Her exam took only a matter of seconds, yet she felt as though she were moving in slow motion, that around her the room full of personnel stood frozen in time, awaiting her next action.
A nurse called out: “I’m barely getting the systolic at fifty!”
Time sprang ahead at a frightening pace.
“Get me a gown and gloves,” said Catherine. “Open the laparotomy tray.”
“What about taking him to the O.R.?” said Littman.
“All rooms are in use. We can’t wait.” Someone tossed her a paper cap. Swiftly she tucked in her shoulder-length red hair and tied on a mask. A scrub nurse was already holding out a sterile surgical gown. Catherine slipped her arms into the sleeves and thrust her hands into gloves. She had no time to scrub, no time to hesitate. She was in charge, and John Doe was crashing on her.
Sterile drapes were whisked onto the patient’s chest and pelvis. She grabbed hemostats from the tray and swiftly clamped the drapes in place, squeezing the steel teeth with a satisfying snap, snap.
“Where’s that blood?” she called out.
“I’m checking with the lab now,” said a nurse.
“Ron, you’re first assist,” Catherine said to Littman. She glanced around the room and focused on a pasty-faced young man standing by the door. His nametag read: Jeremy Barrows, Medical Student. “You,” she said. “You’re second assist!”
Panic flashed in the young man’s eyes. “But—I’m only in my second year. I’m just here to—”
“Can we get another surgical resident in here?”
Littman shook his head. “Everyone’s spread thin. They’ve got a head injury in Trauma One and a code down the hall.”
“Okay.” She looked back at the student. “Barrows, you’re it. Nurse, get him a gown and gloves.”
“What do I have to do? Because I don’t really know—”
“Look, you want to be a doctor? Then glove up!”
He flushed bright red and turned to don a gown. The boy was scared, but in many ways Catherine preferred an anxious student like Barrows to an arrogant one. She’d seen too many patients killed by a doctor’s overconfidence.
A voice crackled on the intercom: “Hello, Trauma Two? This is the lab. I have a hematocrit on John Doe. It’s fifteen.”
He’s bleeding out, thought Catherine. “We need that O neg now!”
“It’s on its way.”
Catherine reached for a scalpel. The weight of the handle, the contour of steel, felt comfortable in her grasp. It was an extension of her own hand, her own flesh. She took a quick breath, inhaling the scent of alcohol and glove talc. Then she pressed the blade to the skin and made her incision, straight down the center of the abdomen.
The scalpel sketched a bright bloody line on the canvas of white skin.
“Get the suction and laparotomy pads ready,” she said. “We’ve got a belly full of blood.”
“BP’s barely palpable at fifty.”
“O neg and fresh frozen plasma’s here! I’m hanging it now.”
“Someone keep an eye on the rhythm. Let me know what it’s doing,” said Catherine.
“Sinus tach. Rate’s up to one-fifty.”
She sliced through the skin and subcutaneous fat, ignoring the bleeding from the abdominal wall. She wasted no time with minor bleeders; the most serious hemorrhage was inside the abdomen, and it had to be stopped. A ruptured spleen or liver was the most likely source.
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 Surgical 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 protection, 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 their 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?”
“Why not?”
“It’s a long way from the South.”
“My mother grew up in Massachusetts. She brought us to New England every summer. It felt like … I was coming home.”
“So you’ve been here over two years.”
“Yes.”
“Doing what?”
Catherine frowned, perplexed by the question. “Working here at Pilgrim, with Dr. Falco. On Trauma Service.”
“I guess the Globe got it wrong, then.”
“Excuse me?”
“I read the article about you a few weeks ago. The one on women surgeons. Great photo of you, by the way. It said you’ve been working here at Pilgrim for only a year.”
Catherine paused, then said, calmly, “The article was correct. After Savannah, I took some time to …” She cleared her throat. “I didn’t join Dr. Falco’s practice until last July.”
“And what about your first year in Boston?”
“I didn’t work.”
“What did you do?”
“Nothing.” That answer, so flat and final, was all she’d damn well say. She was not going to reveal the humiliating truth of what that first year had been like. The days, stretching into weeks, when she was afraid to emerge from her apartment. The nights when the faintest sound could leave her shaking in panic. The slow and painful journey back into the world, when just riding an elevator, or walking at night to her car, was an act of sheer courage. She’d been ashamed of her vulnerability; she was still ashamed, and her pride would never allow her to reveal it.
She looked at her watch. “I have patients coming in. I really have nothing more to add.”
“Let me re-check my facts here.” Rizzoli opened a small spiral-bound notebook. “A little over two years ago, on the night of June fifteenth, you were attacked in your home by Dr. Andrew Capra. A man you knew. An intern you worked with in the hospital.” She looked up at Catherine.
“You already know the answers.”
“He drugged you, stripped you. Tied you to your bed. Terrorized you.”
“I don’t see the point of—”
“Raped you.” The words, though spoken quietly, had an impact as brutal as a slap.
Catherine said nothing.
“And that’s not all he planned to do,” continued Rizzoli.
Dear god, make her stop.
“He was going to mutilate you in the worst possible way. As he mutilated four other women in Georgia. He cut them open. Destroyed precisely what made them women.”
“That’s enough,” said Moore.
But Rizzoli was relentless. “It could have happened to you, Dr. Cordell.”
Catherine shook her head. “Why are you doing this?”
“Dr. Cordell, there is nothing I want more than to catch this man, and I would think you’d want to help us. You’d want to stop it from happening to other women.”
“This has nothing to do with me! Andrew Capra is dead. He’s been dead for two years.”
“Yes, I’ve read his autopsy report.”
“Well, I can guarantee he’s dead,” Catherine shot back. “Because I’m the one who blew that son of a bitch away.”