"h.e.l.lO, DR. HELVELIUS."
"Odin, do you have an a.n.a.lysis of the vascular pattern for us?"
"I DO, DR. HELVELIUS. THERE ARE SIX ARTERIAL FEEDERS, AND EIGHT MAJOR VENOUS EFFLUENTS. ONE OF THE SMALL VEINS HAS UNDERGONE SPONTANEOUS OCCLUSION SINCE THE LAST SURGERY. OTHERWISE, THE PATTERN IS THE SAME."
"Thank you, Odin."
"I RECOMMEND LEAVING THE LARGEST VEIN OPEN UNTIL LAST. IT CONNECTS DIRECTLY WITH THE SINUS RECTUS."
"Afraid I"ll have to overrule you on that, Odin."
"IT WILL PROVIDE THE HIGHEST POSSIBLE FLOW RATE, AND MAINTAIN THE LOWEST POSSIBLE PRESSURE WITHIN THE AVM. THIS MINIMIZES THE RISK OF A CATASTROPHIC BURST HEMORRHAGE."
"Yes, but it"s too short. Tethered like that, I won"t be able to manipulate the AVM. I need a little room to work with, Odin."
"YES, I SEE. MAY I SUGGEST AN ALTERNATIVE?"
Helvelius looked at Kevin"s monitor, where a longer but slightly narrower vein was highlighted in yellow.
"Yes, Odin, my thoughts exactly."
Jamie was lying facedown, his head enclosed in the chrome-plated cage of the modified Budde halo ring retractor. The crown, where the AVM was, had been elevated a little above the rest of his body. Inside the metal ring was a small circle of freshly shaved, iodine-painted scalp, bordered by sterile blue paper drape.
"Let"s go in," said Helvelius. Esther, his favorite scrub nurse, slapped a #10 scalpel into his hand, and with a single swerving motion, he cut through Jamie"s scalp, tracing the thin, U-shaped scar left from the last surgery. Ali held the incision open with a small retractor as Helvelius gently peeled the skin away from the glistening white skull underneath, working through the sticky patches with the blunt end of the scalpel. She watched as he used a bone chisel to pry away a coaster-sized disk of skull-the same skull flap he had cut out at Jamie"s first operation. Only a few judicious taps with the chisel were necessary now to free up the flap. Once loose, it swung open like a clamsh.e.l.l. Ali was satisfied to see that it was still connected to its blood supply through a flap of the parchmentlike dura mater that lined its inward face.
"Okay," said Helvelius. "Start thiopental."
"Giving two hundred milligrams now," said the anesthetist.
"t.i.trate it until we get burst suppression on the electroencephalogram."
Helvelius took a step back from the operating table and looked at the tiny red light of the TV camera. "Uh, thiopental is the notorious "truth serum,"" he explained. "We"re giving it to Jamie because it decreases the blood flow to the brain, and relaxes the pressure inside the AVM. It also slows down the activity of the brain itself, which will protect it in the event that there is any temporary cutoff of oxygen. We don"t expect that to happen, but it pays to be prepared."
"We"re there," said the anesthetist.
At a nod from Helvelius, Ali slipped a pair of retractors into the groove between the two halves of the brain and gently pulled them apart. Deep inside the brain, she now saw the wrinkled, purplish, softly pulsating ma.s.s of the AVM. She felt a little anxious. After two operations, more than half of the ma.s.s had been removed, and there had been no mishaps. But both she and Helvelius knew that the most difficult, knotty part of the tumor was what faced them now. If this phase of the operation went wrong, there would be no need for SIPNI.
But she was an experienced surgeon. There was no need for anxiety. The AVM was merely a delicate puzzle box, requiring a steady hand and the utmost of patience for its solution. It had a solution. It was nothing to fear. And with that insight, she returned to the calm, focused, Zen-like state of mind she always strove for-the sense of order she craved more than anything else in the world.
Harry Lewton strode quickly down the Pike. Over more than a century, Fletcher Memorial Medical Center had grown out of a jumble of buildings of different sizes and architectural styles. The outpatient clinic of the Department of Endocrinology was in the very center of this jumble, where it jutted from the central section of the quarter-mile-long corridor, or the Pike, that ran like Main Street through the long row of buildings. When Harry reached it, the big gla.s.s doors of the lobby had been propped open, and three or four patients were already spread out among the leatherette chairs, waiting for ultrasound exams or capsules of radioactive iodine. The ubiquitous drone of a TV set could be heard.
It was pretty quiet. On his morning rounds, he had noticed that this particular clinic was always dead on Mondays. It was no different today.
He went straight to the receiving desk, a long, high barrier of dark wood and sand-colored fabric panels that separated the patients from the suite of exam rooms in the back. He flashed his hospital ID and introduced himself to a young African-American woman in a white dress and flowered smock. "Did you open the clinic this morning, Tia?" he asked, reading her name from her ID badge.
"Yes, sir. Fifteen minutes ago."
"See anything unusual? Anything that doesn"t belong here?"
"No." She had that skittish look that people did whenever authority showed up without an invitation.
"Any unfamiliar people?"
"No. Just these." She nodded toward the patients. "Is there a problem?"
Harry quelled an impulse to shrug. Although he didn"t want to alarm the girl, he didn"t want to appear too casual, either. "It could be nothing. Why don"t you go back to what you were doing while I have a look around?"
Tia nodded warily, then picked up a plastic watering jug and padded off through the door that led to the exam rooms. She looked back over her shoulder twice before she disappeared.
Harry scanned the room. Okay, what have we got here? There was a woman in her forties, short black hair-dye job-talking on a cell phone. She hadn"t looked at him since he came in, which meant she had nothing to hide. Two gray-haired gals sat together on the other side, one watching TV, the other just sort of staring at the wall. No, make that snoozing. There was one old geezer looking at a magazine. By the way his hand shook, Harry figured he"d have blown himself up directly if he had ever taken to building a bomb. That was it. No master criminals. All right, what else? Objects: women"s purses, all within arm"s reach. Old guy had a tripod cane. No backpacks anywhere. No parcels. Harry could see easily under all those spindly legged chairs. They were clean. Ditto for those little gla.s.s tables with the magazines on them. There weren"t any telltale carpet impressions to suggest that anything had been moved....
Harry heard a shuffling noise behind him, and jerked his head around a trifle quicker than was normal for him. It was just Tia coming back to water the office plants. Don"t get jumpy, Pilgrim. Harry let her pa.s.s. As she did, his eye was drawn to the area behind the receiving desk. He saw a half-dozen computers with their cables tangled like jungle vines on the floor, some low-backed chairs on casters, and a taboret or rolling file with a sliding door with a lock on it. That looked like a possibility. The file had been pulled out, putting it in the way of the receptionist"s chair. It didn"t usually sit there.
Harry was about to approach the taboret for a closer look when, from the far window, Tia called out to him. "This what you"re lookin" for?"
She was standing beside a shoulder-high potted sansevieria, or mother-in-law"s tongue. As Harry stepped closer to her, he could see a plain brown grocery bag tucked between the planter and the wall.
"Don"t touch it!" he shouted. The girl backed off, instinctively sidling toward the cover of the receiving desk.
Harry approached the bag, angling his head to check out every side. Just a bag. No trip wires. No pressure plate hidden under the carpet. When he had reached the window, he leaned forward on his toes, and slowly pulled the bladelike leaves of the plant toward himself so he could look straight down at the bag. The top had not been crimped shut, and he could see inside. By the light of a pocket flashlight, he glimpsed some coils of red and blue wires, and underneath these, a milky-colored block of something like modeling clay.
"Jesus Christ," he said, lurching back, as though he had just stepped on a rattlesnake.
"Is it something bad?" asked Tia. Two of the patients also turned to look in his direction.
Harry fought to keep his cool. If you panic, they"ll panic. He was no stranger to explosives-homemade acetone-peroxide b.o.o.by traps had been a fact of life during his days raiding backwoods drug labs in East Texas. Once, at a lecture, he had even held in his hand a few ounces of C4, the high-powered military compound. An instructor had pa.s.sed it around after slamming it against a countertop to show how rough you could get with it and still not set it off without a detonator or an electrical spark. He remembered the stuff well-soft like clay and milky white, like a lump of death in his sweaty little palm. A fingernail-sized piece of it could blow a man so high he wouldn"t have two teeth left together to identify him from dental records. And it looked exactly like what he"d glimpsed inside the bag, except that what he had now was the size of a brick-enough to vaporize the Pike for a hundred feet on either side of him.
Sweet Jesus in Heaven! What kind of sick f.u.c.k would leave this here?
Harry had already made one mistake jumping back from the bag. If there had been a motion sensor in it, he would already be part of the ozone layer. He had to get a grip on himself. Okay, what"s the first thing you need to do? Edging backward, much more carefully now, he turned and looked around the room. Get these people out of here-without setting off a stampede, if you still know how to do that.
He turned to Tia. "Who"s in charge of this clinic?"
"Dr. Saulter."
"Get me Dr. Saulter stat. If there are any patients or staff in that suite of rooms back there, they need to be moved elsewhere as of now. Use the back stairway. Don"t bring them out through here."
He remembered that detonators were often triggered by cell phones, and that any kind of stray electronic emissions-from pagers, phones, microwaves, or scanners-could inadvertently set them off. He turned to the black-haired woman. "Ma"am, I need you to get that cell phone out of here. Don"t turn it off. Don"t touch any b.u.t.ton on it. Just get up and go out and down the corridor. Now!"
Harry stared at the woman imperiously as she got up and reached for her purse. Behind him, he heard the voice of another woman, the one watching TV. "Don"t talk to her that way. She"s not doing anything."
"I need you to leave this waiting room as well, ma"am. All of you need to leave at once. Gather up your things and go to the information desk in the main lobby. Dr. Saulter will have someone call you there."
Wide-eyed, the woman shook her head. "But I have an appointment. I have a lump on my thyroid."
"I"m sorry. You"ll be taken care of at another location. But you must leave now."
Harry tried to spur the patients on with his gaze as they sluggishly hauled themselves out of their chairs and, with no little murmuring, shuffled into the hall. The old man, in particular, couldn"t have moved more slowly if he had tried.
An angry voice drew Harry"s attention toward the exam suite as a man in a white coat and flopping tie came charging out, Tia shyly following at his heels. "What the h.e.l.l"s going on?" he demanded.
Harry brushed aside the challenge and turned to Tia first. "Ma"am, I need you to lock this lobby door from the outside and keep an eye on it until someone can come and rope it off." Only then, after Tia had set an example by swiftly responding to his authority, did he address the man in white. "Dr. Saulter, we have a suspicious object in this lobby. You and I need to make a sweep of whatever rooms you have back there. We need to clear that section of all personnel. Immediately!"
Nostrils flaring with indignation, Dr. Saulter turned with a rude jerk and stalked back toward the exam suite with Harry in tow. As they pa.s.sed through the door, Harry stopped at a wall phone and waved Dr. Saulter on. His heart was pounding. He was trying to solve several problems at once. There were two floors above this one; below it, the ground floor and two bas.e.m.e.nt levels. The whole section had to be evacuated. But how far? What was the bomb"s kill radius? What was its purpose? Don"t let your mind race like this, he warned himself. You have a protocol to deal with these situations. What does it say to do first? He forced himself to remember the bundle of numbers that had to be called. Via landline. No pagers, no cell phones, obviously. Top of the list was 911-the Chicago Police Department Bomb Squad.
The air of Operating Room Three was perfumed with incense for the ear-the unhurried echoes of stone chapels and of cloister-walks polished by the tread of centuries: Oculi omnium in te sperant, Domine, Et tu das illis escam in tempore opportuno.
The words of the chant meant nothing to Richard Helvelius. He was a nonbeliever and not a monk. But he was convinced that the slow, patient rhythms of the music had a positive effect upon his autonomic nervous system. They regularized his heart rate and blood pressure, and gave him a feeling of standing outside of time and place-a very subjective response, admittedly, but one that helped him to concentrate his thoughts.
He was standing back a little from the operating table, holding his bloodstained gloves upright, thinking. It was time to begin the dissection and removal of the AVM from Jamie"s brain. To minimize the chance of bleeding, he had already isolated the major vessels and injected them with fast-hardening glue made of n-butyl-cyanoacrylate. The glue should be hard now. Reaching into the small, circular operating field, he checked each of the veins by clamping it and watching to make sure that the AVM did not swell up. Okay, that one"s safe. Now place the permanent clip. Keep the clip as close to brain tissue as you can. A long stump can rupture....
As he worked, he encountered something soft and purplish, about the size of a walnut. Blood clot. Something was not done right the last time we were in here. There was a little bleeding afterward. Helvelius called for a suction tip and ran it back and forth over the clot, which disappeared in small, jelly-like chunks. Good! Now I have a little more working room. He used that extra room to inspect the veins along the bottom of the AVM, lifting the tumor very gently with a flat retractor blade. I don"t like those veins. Their walls are very thin. If one tears open, it"ll pull back deep into the substance of the brain, and I"ll have to dig deep to stop the bleeding.
Helvelius worked cautiously and deliberately. By the time the CD player had changed to a new disk, he had sealed off all but one last big vein without breaking any of them. That last one he left open to keep dammed-up blood pressure from engorging the AVM. Now it was time to go after the arterial feeders. One by one, he clipped and then cut them, always taking care not to disturb the flow to any branches that fed into normal brain. These arteries were tiny, but blood flowed through them at high pressure. One nick, and you"ll be staring into a well of blood. Helvelius worked slowly, sc.r.a.ping with a fine probe to separate the purple coils of the AVM from the scar tissue that separated the tumor from the brain. His hands moved smoothly and steadily. He enjoyed these fine, controlled movements, like a scribe laboring over an illuminated ma.n.u.script.
Suddenly, the tranquil Gregorian chant was interrupted by the squawk of the overhead speakers. Since the introduction of a wireless paging system, the overhead speakers were rarely used anymore, except for fire drills and the occasional lost patient. Startled by the sound, Dr. Helvelius froze in mid-motion, but the point of his probe did not shift a millimeter. When the interruption was over, he went back to teasing the purplish vessels away from the pinkish-white edge of the brain.
"For Christ"s sake, why do those speakers need to be so loud?" he said. "Can"t we turn them d-down somehow?"
"You say that every time," said Esther, the scrub nurse. "You know there"s no volume switch, Doctor."
"Well, I"ll buy dinner at Spiaggia for anyone who puts a bullet through the d.a.m.ned thing."
Just then, as if to taunt him, the speaker erupted again, seemingly louder than before. "Mr. White, please report to Security. Mr. White, please report to Security."
"Geez, anybody know where this White character is? I"ll bet he"s out grabbing a smoke in the c-courtyard."
"It"s a code, Doctor," said Esther. "There is no Mr. White."
"A code?"
"A security code. Code White."
Out of the corner of his eye, he saw Kevin O"Day sn.i.g.g.e.ring over his keyboard.
"Right. I should know what that is, shouldn"t I?" Every year, the hospital credentialing commission sent its spies out to randomly quiz staff about security procedures, which even department chairs were expected to memorize. Bureaucratic nonsense! Fire, flood, whatever-his response would be the same: to go on operating. What would they expect him to do? Leave a patient with his head cut open so he could run off and spray a fire extinguisher? Of course not. But this announcement was the real thing, not a drill. Not knowing what it meant annoyed him. "Code White. It"s one of those baby things. Stolen baby. Runaway baby. Baby copping a smoke in the courtyard."
"No, it"s not a baby," said Esther. Her eyes flared anxiously above her surgical mask.
"What is it, then?"
At that moment a tiny spray of blood showed that the paper-thin wall of one of the vessels had been breached.
"Bovie, please," said Helvelius.
Esther slapped a white cauterizer into his hand. He lifted the blood vessel with the probe in his left hand, and gently touched the blunt metal tip of the Bovie to the source of the spray. The current came on, and with it a tiny puff of smoke and steam, and a whiff of cooked tissue, not unlike the smell of frying bacon. The bleeding stopped.
At a nod from Helvelius, Ali rinsed the operating field with saline and then suctioned it clean. Helvelius watched for a moment, to make sure that there was no more bleeding, and then handed the cauterizer back to Esther. He switched the probe back into his right hand and prepared to go on with the dissection.
He took a deep breath, clearing his body of tension. "All right. If Code White isn"t a baby, what is it?" he asked in his former bantering tone.
It was Ali who answered. "It"s a bomb," she said. Her voice was solemn, muted-almost a whisper. "A bomb in the hospital."
As if on cue, the CD box was playing the "Dies irae," the Latin hymn for the dead: Confutatis maledictis, Flammis acribus addictis, Voca me c.u.m benedictis.
Apart from that, there was utter silence in Operating Room Three.
8:24 A.M.
Harry Lewton was standing in the Pike with Captain Glenn Avery of the police bomb squad. Like the dozen or so hospital security guards and police officers on the scene, the two men hugged the wall on the side of the Endocrinology Clinic. The double doors of the clinic had been propped wide open to diffuse the force of any blast and to minimize the amount of gla.s.s shrapnel in case a bomb went off. About fifty yards away on either side of the clinic, the fire doors had been closed to seal off the Pike from foot traffic.
Inside the lobby of the clinic a single man, wrapped in a bulky green Kevlar EOD suit and wearing a helmet with a wide, wraparound face shield like a deep-sea diver, knelt near the far window in front of a fan-shaped portable CR 50XP X-ray machine. He had moved the planter to one side, and set the X-ray next to the shopping bag. He carefully slipped the flat twelve-inch digital phosph.o.r.escent detector plate behind the bag, and adjusted the voltage controls of the CR 50XP. Too low a voltage and the image would turn out a murky bunch of shadows. Too high and it would be useless glare. Either way, there could be a loss of a critical detail-a potentially fatal error.
Out in the corridor, the south side fire door opened, and Harry watched a tall, light-skinned African-American man in a dark suit come into the corridor. The stranger coolly scanned the faces along the wall, and without a break in his stride walked straight toward Harry. From one glance Harry took him for a Fed.
"Are you the security director?" he asked in an a.s.sertive baritone.
"Yes, Lewton"s the name. Harry Lewton."
The man flipped open a bifold wallet to show a photo ID and a small metallic shield surmounted by an eagle. "Special Agent Terrell Scopes, with the FBI"s Evidence Response Team. I happened to be in town for a meeting and was notified by local law enforcement that you might have a situation here."
"Glad you could come. I"ve already turned the scene over to Captain Avery and the local bomb squad."
"Has there been a confirmation of the threat?" asked Scopes.
"Any minute, now."
Scopes was agreeably businesslike, but when the door opened again, there appeared a short, slightly built Asian man in the same regulation black suit. Harry felt his shoulders stiffen as he recognized the owlish gla.s.ses, the upthrust jaw, and the mincing step of the newcomer. Aw, Christ! he groused to himself. Not that conceited little p.r.i.c.k! Not in my hospital!
"Gentlemen," said Scopes, "this is my colleague, Raymond Lee, with the FBI"s Critical Incident Response Group."
Lee walked right past Harry without even looking at him, making a beeline for Avery"s blue tunic and bra.s.s bars. "Glenn! Just the man I"d have liked to see here," he said in a thin, nasal voice. "Good to see that Chicago"s sent out its A-team."
"Well, well, Ray!" exclaimed Avery. "We must be in a heap of doo-doo for you to show up." Lee was a good ten inches shorter than Avery, and looked almost diminutive standing beside the Captain"s strapping bench-press bulk. But Harry noticed how Avery, who up until then had been strutting, arms akimbo like a dockside boss, now drew his stance a little narrower as Lee approached.
"Just a courtesy visit," said Lee. "You guys carry on like we"re not here."
"This is the man who found the package," said Avery, pointing to Harry.
Lee craned his neck back toward Harry. Then his jaw dropped like someone had punched him in the solar plexus. "You"re that fellow from Texas, aren"t you?" he muttered. "Lewis."
"Lewton."
Avery, not very observant of the chill between them, chuckled. "You guys know each other?"