Book Design By Amanda Dewey

This is a work of fiction. Names, characters, places, and incidents either are the product of the author's imagination or are used fictitiously, and any resemblance to actual persons, living or dead, businesses, companies, events, or locales is entirely coincidental.

While the author has made every effort to provide accurate telephone numbers and Internet addresses at the time of publication, neither the publisher nor the author assumes any responsibility for errors, or for changes that occur after publication. Further, the publisher does not have any control over and does not assume any responsibility for author or third-party websites or their content.

ACKNOWLEDGEMENTS

As usual in writing my fact-based novels, I've had to rely on friends and acquaintances to answer my innumerable pesky questions. It was especially important for Crisis, since the story line bridges medicine and law.

Although I thank everyone who was graciously willing to help, those whom I would particularly like to cite are (in alphabetical order): John W. Bresnahan, investigator,

Division of Professional Licensure, Commonwealth of Massachusetts Jean R. Cook,

psychologist

Joe Cox, J.D., LL.M.,

tax and estate-planning attorney

Rose Doherty,

academician

Mark Flomenbaum, M.D., Ph.D.,

Chief Medical Examiner, Commonwealth of Massachusetts

Peter C. Knight, J.D.,

malpractice attorney

Angelo MacDonald, J.D.,

criminal law attorney, former prosecutor

Gerald D. McLellan, ID.,

family law attorney, former judge

Charles Wetli, M.D.,

Chief Medical Examiner, Suffolk County, New York

Dedication

This book is dedicated to the contemporary medical

professionalism as promulgated by the Physician

Charter, in hope that it takes root and flourishes …

Make way, Hippocrates!

The laws of conscience, which we say are born of nature, are born of custom.

— MONTAIGNE

Prologue

SEPTEMBER 8, 2005

Contents - Next

Autumn is a glorious season, despite its frequent use as a metaphor for approaching death and dying. Nowhere is its invigorating ambience and riotous color more apparent than in the northeastern United States. Even in early September the hot, hazy, humid days of the New England summer are progressively replaced by crystalline days with cool, clear, dry air and azure skies. September 8, 2005, was a case in point. Not a cloud marred the translucent sky from Maine to New Jersey, and within the macadam maze of downtown Boston and the concrete grid of New York City, the temperature was a comfortable seventy-seven degrees Fahrenheit.

As the day drew to a close, two doctors coincidently and reluctantly fumbled to pull their ringing cell phones from their belt clips in their respective cities. Neither was happy about the intrusion. Each was fearful that the melodic ring would herald a crisis that would require their professional attention and presence. An inopportune interruption, as both individuals were anticipating interesting personal evening activities.

Unfortunately, the doctors' intuitions were correct, since both calls were to give credence to autumn's metaphorical reputation. The call in Boston concerned someone about to die with the acute onset of chest pain, profound weakness, and difficulty breathing, while the one in New York was about someone recently but clearly already dead. Both situations were emergencies for the respective physicians, necessitating that they put their private plans on hold. What the doctors didn't know was that one of the calls would initiate a sequence of events that would seriously impact them

both, put both in jeopardy, and turn them into bitter enemies, and the other call would ultimately put a different spin on the first!

Boston, Massachusetts

7:10 p.m.

Dr. Craig Bowman let his arms dangle at his sides for a moment to relieve his aching forearm muscles. He had been standing in front of the mirror that was attached to the backside of the closet door, struggling to tie a black formal bow tie. He'd worn a tuxedo at most a half a dozen times in his life, the first time at his high-school prom and the last time when he got married, and on all of those previous occasions, he'd been satisfied to snap on a pre-tied model that came with the rented tux. But now, in his reincarnation of himself, he wanted the genuine article. He'd bought himself a brand-new tuxedo and wasn't about to settle for a fake tie. The trouble was, he really didn't know how to tie it and had been embarrassed to ask the salesclerk. At the time, he hadn't been worried since he figured it would somehow be similar to tying his shoes.

Sadly, it was proving to be a lot different, and he had been attempting to tie the blasted thing for a good ten minutes. Luckily, Leona, his new and dynamite secretary-cum-file clerk and even newer companion, had been preoccupied with her makeup in the bathroom. Worst case, he'd have to ask her if she knew how to do it. Craig really didn't want to do that. They hadn't been seeing each other socially that long, and Craig preferred that she maintain her apparent belief in his sophistication, fearing he'd otherwise never hear the end of it. Leona had what his matronly receptionist-secretary and his nurse called a "mouth." Tactfulness wasn't her strong suit.

Craig shot a quick glance in Leona's direction. The door to the bathroom was ajar, and she was doing her eyes, but all he could see was a side view of her curvaceous twenty-three-year-old derriere covered with a lustrous pink silk crepe. She was on her tiptoes, leaning over the sink to get closer to the mirror. A fleeting, self-satisfied smile passed over Craig's face as he thought

of them walking down the aisle of Symphony Hall that evening, which was why they were getting decked out in their finery. Compensating for being a

"mouth," Leona was a "looker," especially in the low-cut dress that they had recently bought at Neiman Marcus. He was sure she was going to turn some heads and that he'd be dodging some envious looks from fellow forty-five-year-old men. Craig realized such feelings were rather juvenile, to say the least, but he'd not felt them since that first time he'd worn a tuxedo, and he was going to enjoy it.

Craig's smile faltered when the question occurred to him whether any of his and his wife's friends might be there in the audience. His goal certainly wasn't to humiliate anyone or hurt anyone's feelings. Yet he doubted he'd see any acquaintances, because he and his wife had never gone to the symphony, nor had any of their few friends, who were mostly overworked physicians like himself. Taking advantage of the city's cultural life hadn't been part of their particular suburban lifestyle, thanks to the hours a typical practice of medicine demanded.

Craig had been separated from Alexis now for six months, so it wasn't unreasonable to have a companion. He didn't think it was an age issue. As long as he was with an adult woman of a reasonable, post-college age, it shouldn't matter. After all, being seen out and about with a date was going to happen sooner or later, as active as he'd become. In addition to regular attendance at the symphony, he'd become a regular at a new gym, as well as at the theater, the ballet, and a number of other activities and social gatherings that normal educated people participated in in a world-class city.

Since Alexis had consistently refused to go along with his new persona right from its inception, he now felt he was justified to accompany whomever he wanted. He wasn't going to be held back from becoming the person he aspired to be. He'd even joined the Museum of Fine Arts and was looking forward to exhibition openings, despite never having ever been to one. He'd had to sacrifice enjoying such cultural activities during the arduous and isolating effort of becoming a doctor — particularly, becoming the best doctor he could be — which meant that for ten years of his adult life, he was absent from the hospital only to sleep. And then once he'd finished his specialty training in internal medicine and hung out his

proverbial shingle, he'd had even less time for personal pursuits of any kind, including, unfortunately, much family life. He'd become the archetypal, intellectually provincial workaholic with no time for anyone but his patients. But all that was changing, and regrets and guilt, particularly about family issues, had to be put on hold. The new Dr. Craig Bowman had left behind the lockstep, hurried, unfulfilling, and uncultured workaday life. He knew that some people might call his situation a midlife crisis, but he had a different name for it. He called it a rebirth or, more accurately, an awakening.

Over the previous year, Craig had become committed to — even obsessed with — transforming himself into a more interesting, hap-pier, well-rounded, better person and, because of it, a better doctor. On the desk of his in-town apartment was a pile of catalogues from various local universities, including Harvard. He intended to take classes in humanities: maybe one or two a semester to make up for lost time. And best of all, thanks to his makeover, he'd been able to return to his beloved research, which had completely fallen by the wayside once he'd started practice. What had started out in medical school as a remunerative job doing scut work for a professor studying sodium channels in muscle and nerve cells had turned into a passion when he was elevated to the level of a fellow researcher.

Craig had even co-authored several scientific papers to great acclaim while he'd been a medical student and then resident. Now he was back at the bench, able to spend two afternoons a week in the lab, and he loved it.

Leona called him a Renaissance man, and although he knew the description was premature, he thought that with a couple of years of effort, he might come close.

The origin of Craig's metamorphosis had been rather sudden and had taken him by complete surprise. Just over a year previously, and quite serendipitously, his professional life and practice had changed dramatically with the double benefit of significantly raising his income as well as his job satisfaction. All at once it had become possible for him truly to practice the kind of medicine he'd learned in medical school, where patients' needs eclipsed the arcane rules of their insurance coverage. Suddenly, Craig could spend an hour with someone if the patient's situation required it.

Appropriately, it had become his decision. In one fell swoop, he'd been freed of the dual scourge of falling reimbursements and rising costs that had forced him to squeeze more and more patients into his busy day. To get paid, he no longer had to fight with insurance personnel who were often medically ignorant. He'd even started making house calls when it was in the patient's best interest, an action that had been unthinkable in his former life.

The change had been a dream come true. When the offer had unexpectedly come over the transom, he'd told his would-be benefactor and now partner that he'd have to think about it. How could he have been so stupid not to agree on the spot? What if he had missed the opportunity to grab the brass ring? Everything was better, save for the family problem, but the root of that issue was how submerged he'd been from day one in his former professional situation. Ultimately, it had been his fault, which he freely admitted. He had let the exigencies of current medical practice dictate and limit his life. But now he certainly wasn't drowning, so maybe the family difficulties could be resolved in the future, given enough time. Maybe Alexis could be convinced how much better all their lives could be.

Meanwhile, he resolved to enjoy bettering himself. For the first time in his life, Craig had free time and money in the bank.

With an end of the bow tie in each hand, Craig was about to try tying it again when his cell phone rang. His face fell. He glanced at his watch. It was ten after seven. The symphony was to start at eight thirty. His eyes switched to the caller ID. The name was Stanhope.

"Damn!" Craig blurted with emphasis. He flipped open his phone, put it to his ear, and said hello.

"Doctor Bowman!" a refined voice said. "I'm calling about Patience. She's worse. In fact, this time I think she's really sick."

"What seems to be the problem, Jordan?" Craig asked as he turned to glance back into the bathroom. Leona had heard the phone and was looking at him.

He mouthed the name Stanhope, and Leona nodded. She knew what that meant, and Craig could tell from her expression that she had the same fear

he had — namely, that their evening was now in jeopardy. If they arrived at the symphony too late, they'd have to wait for the intermission to sit down, which meant forgoing the fun and excitement of the entrance, which both had been keenly anticipating.

"I don't know," Jordan said. "She appears unnaturally weak. She doesn't even seem to be able to sit up."

"Besides weakness, what are her symptoms?"

"I think we should call an ambulance and go to the hospital. She's greatly perturbed, and she's got me concerned."

"Jordan, if you are concerned, then I am, too," Craig said soothingly. "What are her symptoms? I mean, I was just there at your home this morning dealing with her usual medley of complaints. Is it something different or what?" Patience Stanhope was one of less than a half-dozen patients that Craig labeled "problem patients," but she was the worst of the group. Every doctor had had them, in every kind of practice, and found them tedious at best and maddening at worst. They were the patients who persisted day in and day out with a litany of complaints that were, for the most part, completely psychosomatic or totally phantom and that could rarely be helped by any therapy, including alternative medicine. Craig had tried everything with such patients, to no avail. They were generally depressed, demanding, frustrating, and time-consuming, and now with the Internet, quite creative with their professed symptoms and desire for lengthy conversations and hand-holding. In his previous practice, after ascertaining their hypochondriasis beyond a reasonable doubt, Craig would arrange to see them as infrequently as possible, mostly by shunting them off to the nurse practitioner or to the nurse or, rarely, to a subspecialist if he could get them to go, particularly to see a psychiatrist. But in Craig's current practice setup, he was limited in his ability to resort to such ruses, meaning the

"problem patients" were the only bugbears of his new practice.

Representing only three percent of his patient base, as reported by the accountant, they consumed more than fifteen percent of his time. Patience

was the prime example. He had been seeing her at least once a week over the last eight months and, more often than not, in the evening or at night.

As Craig frequently quipped to his staff, she was trying his patience. The comment never failed to get a laugh.

"This is far different," Jordan said. "It's entirely dissimilar to her complaints last evening and morning."

"How so?" Craig asked. "Can you give me some specifics?" He wanted to be as certain as possible about what was going on with Patience, forcing himself to remember that hypochondriacs occasionally actually got sick.

The problem with dealing with such patients was that they lowered one's index of suspicion. It was like the allegory of the shepherd boy crying wolf.

"The pain is in a different location."

"Okay, that's a start," Craig said. He shrugged for Leona's benefit and motioned for her to hurry. If the current problem was what he thought, he wanted to take Leona along on the house call. "How is the pain different?"

"The pain this morning was in her rectum and the lower part of her belly."

"I remember!" Craig said. How could he forget? Bloating, gas, and problems with elimination described in disgustingly exquisite detail were the usual complaints. "Where is it now?"

"She says it's in her chest. She's never complained of pain in her chest before."

"That's not quite true, Jordan. Last month there were several episodes of chest pain. That's why I gave her a stress test."

"You're right! I forgot about that. I can't keep up with all her symptoms."

You and me both, Craig wanted to say, but he held his tongue.

"I think she should go to the hospital," Jordan repeated. "I believe she's having some difficulty breathing and even talking. Earlier, she managed to tell me she had a headache and was sick to her stomach."

"Nausea is one of her common afflictions," Craig interjected. "So is the headache."

"But this time she threw up a little. She also said she felt like she was floating in the air and kind of numb."

"Those are new ones!"

"I'm telling you, this is altogether different."

"Is the pain visceral and crushing, or is it sharp and intermittent like a cramp? "I can't say."

"Could you ask her? It may be important."

"Okay, hold the line!"

Craig could hear Jordan drop the receiver. Leona came out of the bathroom.

She was ready. To Craig, she looked like she belonged on the cover of a magazine. He indicated as much by giving her a thumbs-up. She smiled and mouthed: "What's happening?"

Craig shrugged, keeping the cell phone pressed to his ear but twisting it away from his mouth. "Looks like I'm going to have to make a house call."

Leona nodded, then questioned: "Are you having trouble with your tie?"

Craig reluctantly nodded.

"Let's see what I can do," Leona suggested.

Craig raised his chin to give her more room to work as Jordan came back on the line. "She says the pain is terrible. She says it's all of those words you

used."

Craig nodded. That sounded like the Patience he was all too familiar with.

No help there. "Does the pain radiate anywhere, like to her arm or neck or any other place?"

"Oh my word! I don't know. Should I ask her?"

"Please," Craig replied.

After a few deft maneuvers, Leona pulled on the looped ends of the bow tie and tightened the knot she had made. After a minor adjustment, she stepped back. "Not bad, even if I say so myself," she declared.

Craig looked at himself in the mirror and had to agree. She had made it look easy.

Jordan's voice came over the phone. "She says it's just in her chest. Are you thinking she's experiencing a heart attack, doctor?"

"It has to be ruled out, Jordan," Craig said. "Remember, I told you she had some mild changes on her stress test, which is why I advised more investigation of her cardiac status, even though she was not inclined."

"I do remember now that you mention it. But whatever the current affliction, I believe it's progressing. I believe she even appears rather blue."

"Okay, Jordan, I'll be right there. But one other quick question: Did she take any of those antidepressant pills I left this morning?"

"Is that important?"

"It could be. Although it doesn't sound like she is having a drug reaction, we have to keep it in mind. It was a new medication for her. That's why I told her not to start until tonight when she went to bed, just in case they made her dizzy or anything."

"I have no idea if she did or not. She has a lot of medication she got from Dr. Cohen."

Craig nodded. He knew very well that Patience's medicine cabinet looked like a miniature pharmacy. Dr. Ethan Cohen was a much more liberal prescriber of medication than Craig, and he had originally been Patience's physician. It had been Dr. Cohen who had offered Craig the opportunity to join his practice, but he was currently Craig's partner more in theory than in fact. The man was having his own health issues and was on an extended leave that might end up being permanent. Craig had inherited his entire current roster of problem patients from his absent partner. To Craig's delight, none of his problem patients from his previous practice had decided to pay the required fee to switch to the new practice.

"Listen, Jordan," Craig said. "I'm on my way, but make an effort to find the small vial of sample pills I gave Patience this morning so we can count them."

"I will give it my best effort," Jordan said.

Craig flipped his phone shut. He looked at Leona. "I've definitely got to make a house call. Do you mind coming with me? If it turns out to be a false alarm, we can go directly to the concert and still make the entree.

Their house is not that far from Symphony Hall."

"Fine by me," Leona said cheerfully.

While pulling on his tuxedo jacket, Craig went quickly to his front closet.

From the top shelf, he got his black bag and snapped it open. It had been a gift from his mother when he'd graduated from medical school. At the time it had meant a mountain to Craig because he had an idea of how long his mom had to have squirreled money away without his father knowing to afford it. It was a sizable, old-fashioned doctor's bag made of black leather with brass hardware. In his former practice, Craig had never used it since he didn't make house calls. But over the last year he'd used it a lot.

Craig tossed a bunch of supplies he thought he might need into the bag, including a bedside assay kit for myocardial infarction or heart attack biomarkers. Science had advanced since he'd been a resident. Back then it could take days to get the results back from the lab. Now he could do it at the bedside. The assay wasn't quantitative, but that didn't matter. It was proof of the diagnosis that was important. Also from the top shelf he pulled down his portable ECG machine, which he handed to Leona.

When Craig had formally separated from Alexis, he had found an apartment on Beacon Hill in the center of Boston. It was a fourth-floor walk-up duplex on Revere Street with good sunlight, a deck, and a view over the Charles River to Cambridge. The Hill was central to the city and fulfilled Craig's needs superbly, especially since he could walk to several good restaurants and the theater district. The only minor inconvenience was the parking problem. He had to rent a space in a garage on Charles Street, a five-minute walk away.

"What are the chances we can get away in time for the concert?" Leona asked when they were on their way in Craig's new Porsche, speeding westward on Storrow Drive.

Craig had to raise his voice against the whine of the engine. "Jordan seems to think this might be legit. That's what scares me. Living with Patience, he knows her better than anybody."

"How can he live with her? She's such a pain in the ass, and he seems like quite a refined gentleman." Leona had observed the Stanhopes in the office on a couple of occasions.

"I imagine there are benefits. I have a sense she is the one with the money, but who knows. People's private lives are never what they seem, including my own, until recently." He gave Leona's thigh a squeeze.

"I don't know how you have such patience with such people," Leona marveled. "No pun intended."

"It's a struggle, and between you and me, I can't stand them. Luckily, they are a distinct minority. I was trained to take care of sick people.

Hypochondriacs to me are the same as malingerers. If I had wanted to be a psychiatrist, I would have studied psychiatry."

"When we get there, should I wait in the car?"

"It's up to you," Craig said. "I don't know how long I'll be. Sometimes she corners me for an hour. I think you should come in. It would be boring to sit in the car."

"It will be interesting to see how they live."

"Hardly the average couple."

The Stanhopes lived in a massive, three-story, Georgian-style brick house on a sizable wooded lot near the Chestnut Hill Country Club in an upscale area of Brighton, Massachusetts. Craig entered the circular drive and pulled up to the front of the building. He knew the route all too well. Jordan had the door open as they mounted the three steps. Craig had the black bag; Leona carried the ECG machine.

"She is upstairs in her bedroom," Jordan said quickly. He was a tall, meticulous man dressed in a dark green velvet smoking jacket. If he marveled at Craig and Leona's formal attire, he didn't let on. He held out a small plastic vial and dropped it in Craig's hand before turning on his heel.

It was the free sample bottle of Zoloft Craig had given Patience that morning. Craig could see immediately that one of the six pills was missing.

Obviously, she had started the medication earlier than Craig had suggested.

He pocketed the vial and started after Jordan. "Do you mind if my secretary comes along?" Craig called out. "She can possibly lend me a hand." Leona had demonstrated a few times in the office her willingness to help out.

Craig had been impressed by her initiative and commitment from the start, long before he thought of asking her to a social event. He was equally impressed that she was taking night courses at Bunker Hill Community

College in Charlestown, with the idea of eventually getting some sort of medical degree as a technician or nurse. For him, it added to her appeal.

"Not at all," Jordan responded over his shoulder, waving for them to follow.

He had started up the main staircase that skirted the Palladian window above the front door.

"Separate bedrooms," Leona whispered to Craig as they hurried after Jordan. "It kind of defeats the purpose. I thought that was only in old movies."

Craig didn't respond. They quickly descended a long carpeted hallway and entered the feminine master suite upholstered in a square mile of blue silk.

Patience, her eyelids heavy, was lying in a king-size bed, semi-propped up with overstuffed pillows. A servant in a demure French maid's outfit straightened up. She had been holding a moist cloth against Patience's forehead.

With a quick glance at Patience and without saying a word, Craig rushed over to the woman, dropped the bag on the bed next to her, and felt for a pulse. He snapped open the bag and pulled out his blood-pressure cuff and stethoscope. As he wrapped the cuff around Patience's right arm, he barked to Jordan: "Call an ambulance!"

With only a slight elevation of his eyebrows to indicate he had heard, Jordan went to the nightstand phone and dialed 911. He gave the servant woman a wave of dismissal.

"Good Lord!" Craig murmured as he tore off the cuff. He snapped the pillows from behind Patience's body and her torso fell back onto the bed like a rag doll. He yanked down the covers and pulled open her negligee, then listened briefly to her thorax with his stethoscope before motioning to Leona to give him the ECG machine. Jordan could be heard speaking with the 911 operator. Craig fumbled to unsnarl the ECG leads and quickly attached them with a bit of conducting jelly.

"Is she going to be all right?" Leona asked in a whisper.

"Who the hell knows," Craig answered. "She's cyanotic, for Christ's sake."

"What's cyanotic?"

"There's not enough oxygen in her blood. I don't know if it's because her heart isn't pumping enough or she's not breathing enough. It's one or the other or both."

Craig concentrated on the ECG machine as it spewed out a tracing. There were only little blips, widely spaced. Craig tore off the output strip and took a quick, closer glance at it before jamming it into his jacket pocket. He then snapped the leads off Patience's extremities.

Jordan hung up the phone. "The ambulance is on its way."

Craig merely nodded as he rapidly rummaged in his bag and pulled out an Ambu breathing bag. He placed the mask over Patience's nose and mouth and compressed the bag. Her chest rose easily suggesting good ventilation.

"Could you do this?" Craig asked Leona as he continued to ventilate Patience.

"I guess so," Leona said hesitantly. She squeezed between Craig and the headboard and took over the assisted breathing.

Craig showed her how to maintain a seal and keep Patience's head back. He then glanced at Patience's pupils. They were widely dilated and unreactive.

It wasn't a good sign. With the stethoscope, he checked Patience's breath sounds. She was being aerated well.

Back in his black bag, Craig pulled out the assay kit for testing for the biomarkers associated with a heart attack. He tore open the box and pulled out one of the plastic devices. He used a small, heparinized syringe to get some blood from a major vein, shook it, and then put six drops into the sample area. He then held the device under the light.

"Well, that's positive," he said after a moment. He then haphazardly tossed everything back into his bag. "What is positive?" Jordan asked.

"Her blood is positive for myoglobin and troponin," Craig said. "In layman's terms, it means she's had a heart attack." With his stethoscope, Craig ascertained that Leona was ventilating Patience appropriately.

"So your initial impression was correct," Jordan commented.

"Hardly," Craig said. "I'm afraid I have to say, she is in a very bad situation."

"I was trying to communicate as much on the phone," Jordan said stiffly.

"But at the moment, I was referring to the heart attack."

"She is worse off than you led me to believe," Craig said as he got out some epinephrine and atropine, along with a small bottle of intravenous fluid.

"I beg your pardon. I was quite clear she was progressively getting worse."

"You said she was having a little trouble breathing. Actually, she was hardly breathing at all when we got here. You could have let me know that. You said you believed she was rather blue, whereas I find her totally cyanotic."

Craig deftly started an intravenous infusion. He taped the needle in place and gave the epinephrine and atropine. He hung the small IV bottle from the lampshade with a small S hook he had made for that specific purpose.

"I was doing the best I could to communicate to you, doctor."

"I appreciate that," Craig said, holding up his hands in a conciliatory gesture. "I'm sorry. I don't mean to be critical. I'm just concerned about your wife. What we need to do now is get her to the hospital as quickly as we can. She needs to be ventilated with oxygen, and she needs a cardiac pacer.

On top of that, I'm certain she is acidotic and must be treated for it."

The undulating sound of the approaching ambulance could be heard in the distance. Jordan left to go downstairs to let in the emergency technicians

and direct them up to Patience's room.

"Is she going to make it?" Leona asked as she continued compressing the Ambu bag. "She doesn't look quite as blue to me."

"You're doing a great job with that breathing bag," Craig responded. "But I'm not optimistic, since her pupils haven't come down, and she's so flaccid.

But we'll know better when we get her over to Newton Memorial Hospital, get some blood work, get her on a respirator and a pacer. Would you mind driving my car? I want to ride in the ambulance in case she arrests. If she needs CPR, I want to do the chest compressions."

The EMTs were an efficient team. It was a man and a woman who obviously had worked together for some time, since they anticipated each other's moves. They swiftly moved Patience to a gurney, brought her downstairs, and loaded her into the ambulance. Within just a few minutes of their arrival at the Stanhope residence, they were back on the road.

Recognizing a true emergency, they had the siren screaming and the woman drove accordingly. En route, the male EMT phoned ahead to Newton Memorial to advise them of what to expect.

Patience's heart was still beating, but barely, when they arrived. A staff cardiologist whom Craig knew well had been summoned, and she met them on the unloading dock. Patience was rolled inside with dispatch, and an entire team began to work on her. Craig told the cardiologist what he could, including the results of the biomarker assay confirming the diagnosis of myocardial infarction, or heart attack.

As Craig had anticipated, Patience was first put on a respirator with one hundred percent oxygen followed by an external pacemaker. Unfortunately, it was quickly confirmed that she then had the problem of PEA, or pulseless electrical activity, meaning the pacemaker was creating an image on the electrocardiogram but the heart was not responding with any beats. One of the residents climbed up onto the table to start chest compressions. Blood work came back and the blood gases were not bad, but the acid level was close to the highest the cardiologist had ever seen.

Craig and the cardiologist looked at each other. Both knew from experience that PEA had a dismal outcome with a hospital inpatient, even when caught quickly. The situation with Patience was far worse, since she had come in by ambulance.

After several hours of attempting all possible efforts to get the heart to respond, the cardiologist took Craig aside. Craig was dressed in his formal shirt, complete with bow tie still in place. Blood spatter adorned the upper part of his right arm, and his tuxedo jacket hung on a spare IV pole against the wall.

"It must have been extensive cardiac muscle damage," the cardiologist said.

"It's the only way to explain all the conduction abnormalities and the PEA.

Things might well have been different if we had been able to start on her a bit sooner. From your description of the time course, I imagine the size of the initial infarct significantly grew."

Craig nodded. He looked back at the team that was still doing cardiopulmonary resuscitation on Patience's slim frame. Ironically, her color had returned to near normal with the oxygen and the chest compressions. Unfortunately, they had run out of things to try.

"Did she have a history of cardiovascular disease?"

"She had an equivocal stress test a few months ago," Craig said. "It was suggestive of a mild problem, but the patient refused any follow-up studies."

"To her detriment," the cardiologist said. "Unfortunately, her pupils have never come down, suggesting anoxic brain damage. With that in mind, what do you want to do? It's your call."

Craig took in a deep breath and let it out noisily as a reflection of his discouragement. "I think we should stop."

"I agree one hundred percent," the cardiologist said. She gave Craig's shoulder a reassuring squeeze, then walked back to the table to tell the team

it was over.

Craig got his tuxedo jacket and walked over to the ER desk to sign the paperwork indicating the patient was deceased and that the cause was cardiac arrest following myocardial infarction. Then he went out into the emergency room waiting area. Leona was seated among the sick, the injured, and their families. She was flipping through an old magazine.

Dressed as she was, she appeared to Craig like a nugget of gold among nondescript gravel. Her eyes rose up as he approached. He could tell she read his expression.

"No luck?" she said.

Craig shook his head. He scanned the waiting area. "Where is Jordan Stanhope?"

"He left over an hour ago."

"Really? Why? What did he say?"

"He said he preferred to be at home, where he would await your call. He said something about hospitals depressing him."

Craig gave a short laugh. "I guess that's consistent. I always thought of him as a rather cold, odd duck who was just going through the motions with his wife."

Leona tossed aside the magazine and followed Craig out into the night. He thought about saying something philosophical about life to Leona but changed his mind. He didn't think she'd understand, and he was worried he wouldn't be able to explain it. Neither spoke until they got to the car.

"Do you want me to drive?" Leona asked.

Craig shook his head, opened the passenger door for Leona, then walked around and climbed in behind the wheel. He didn't start the car

immediately. "We obviously missed the concert," he said, staring out through the windshield.