“Nikki, did Karen bring his family up?”

“They're across the hall. I have some lab results, doc.”

“Okay, shoot.”

“His PTT is 70 seconds. His blood gas shows a PO2 of 73, PCO2 of 64, and a pH of 6.2.”

David shook his head and grimaced. With the exception of the PTT, the numbers were all bad—very bad.

“Jenny, his PTT’s good. Keep the heparin as is. He’s still acidotic, pH down to 6.2. Push another amp of bicarb. Marsha, send another blood gas. We have to see if his numbers improved after intubation.”

"Right away, Doctor B.”

The large, double wide utility doors to the lab swung open as a bypass pump tech, pushing an intra-aortic balloon pump with one hand, and carrying tubes, cords and other pump paraphenalia in the other, hurried into  the lab. “Dr. Barnett, I’ll have things ready to go in a couple of minutes.”

“Thanks. I have to talk to the family. We’ll insert the balloon as soon as I get back.”

“Sounds good.”

“Doug, his PCO2 is up to 64. You’ll have to increase your rate. And he’s very hypoxic. You sure he’s gettin’ a hundred percent oxygen?”

“Yeah. Tubing’s hooked up, max O2 running.”

“Marsha, you and Jenny keep a close eye on him. Titrate the Isuprel to keep a pressure of eighty or higher. Watch his rhythm. If he starts throwin’ any PVC’s, I want you to bolus him with a hundred of Lidocaine. Push it slowly, it could drop his pressure. I’ll be back in a minute.”

David removed his blood stained gown and lead apron. After wiping sweat from his face and hair, he entered the conference room. Carlo was sitting next to Laura at a table. He glowered at Barnett with an angry sneer. David turned to face Laura.

“Doctor, please tell me what’s happening. Is Michael okay?”

“Mrs. Conti, I’m very sorry, but your husband isn’t doing well. He has severe narrowings in all three of his coronary arteries and his heart muscle has been extensively damaged by this heart attack. I hate to say this, but you need to know; I don’t think he’s going to survive.”

Carlo shot up from his chair and screamed. “You son of a bitch! Who the fuck do you think you are to tell me my son’s gonna die? You screwed up, didn’t you? Where the hell were you when we needed you?”

David winced, turned away from the old man and took a seat next to Laura. Carlo sat, glaring at the doctor. Laura Conti was crying.

“Oh, my God. I can’t believe it. My poor Michael.”

“I’m sorry, Mrs. Conti. I don’t know what’s going on here, but your husband has extremely severe arterial disease—much more than would be expected in someone his age. It really doesn’t make any sense. I’m concerned that he may have a genetic problem.”

Carlo shouted. “He doesn’t have a genetic problem you asshole. You’re the problem."

Leaning across the table, Carlo grabbed Barnett by both wrists. David yanked free. "Mr. Conti, if you continue to assault me I'll be forced to have  security intervene."

Laura reached out, touching her father-in-law on the hand."Please stop. Just stop!"  She shook her head with disgust, cried a bit more, then took a moment to compose herself. “Doctor, please excuse his behavior. He’s really distraught. I hope you can understand.”

David was silent as he stepped to the conference room phone and dialed the lab.

“Cath lab, this is Nikki.”

He spoke in a low voice, nearly a whisper. “Nikki, please clean the room as best you can. Place a clean drape over Mr. Conti. I'm going to have his wife and father come in to see him. This may be their last chance."

"Will do, Dr. B."

“Thanks.” David returned to the table. "Mr. Conti, Mrs. Conti, I think you should see Michael now. His condition remains critical, but he's stable at the moment. I believe he'd like to talk with both of you. My nurse, Nikki will be here in a moment to escort you to Michael's side. Please, It's difficult to say this, but I must tell you that this may be the last time you see him alive. Be prepared to say what's important.You don't want lingering regrets. I strongly suspect Michael knows this is the end."

Carlo stood and walked out of the room. David took the opportunity to talk privately with Laura Conti.

"Mrs. Conti, I know your father in law has lost loved ones in the past, and I’m sure this is devastating news for him. But I can’t tolerate his belligerence. He must calm down or I'll have him removed by security."  

“I understand. I'll do my best to settle him but it won't be easy. Carlo's had a problem with doctors, even the medical community in general, for many years. He blames doctors for his daughter's death. She was only five, you know. He's been like this for decades--it's an obsession. He actually abhors, really hates physicians. And now, since his wife's death he's worse. He's consumed by loathing and anger and seems to thrive on it. It's all so irrational."

"I empathize with him, having lost his entire family. It's very sad. Doctors are far from perfect, some are simply incompetent, others are just in it for the money. I hope the death of his children and wife weren't due to negligence." 

"I have no idea. Michael never talked about his sister's illness; I don't think he was ever told anything. Carlo never permitted Marie and Michael to see a physician. So I can't blame any doctor, only my father-in-law. Doctor Barnett, You know as much about Michael as anyone, with the exception of that doctor Tamayo, where ever he is."

Laura changed the subject. Doctor, you said something about my husband having a genetic condition. What could that be?”

“Michael may have inherited a predisposition to atherosclerosis, hardening of the arteries. We should discuss that later.I have get back to the lab.”

“What more can you do? Does he need one of those balloon treatments or surgery?”

“Neither of those is possible or indicated at the moment. A balloon angioplasty wouldn’t help, and it would be dangerous. Urgent open heart surgery is out of the question. He wouldn’t live through it. I’m going to put him on a machine; it’s called an aortic balloon pump. It has nothing to do with balloon angioplasty. It’s not a treatment, but may help support his blood pressure. Mrs. Conti, I’m not hopeful. You should be prepared for the worst.”

“I don’t know what I’m going to do without him. Please do all you can.” Her head fell—tears dripping to the floor.

“I’ll do my utmost. I promise. I have to go.”

David literally ran to the cath lab, grabbed his lead from the floor and went to the scrub counter for gloves and a fresh gown. “Marsha, what’s goin’ on?”     

“Jenny says his pupils are still reactive, but he’s barely responsive.”

“Okay. How’s his rhythm and pressure?”

“Systolic BP still hangin’ in at seventy-five to eighty. Jenny had to up the Isuprel drip to fifteen.”

“And his rhythm?”

“He started throwin’ some PVC’s. We gave him lidocaine as you said. It seems to have settled things down.”

“Good, that’s good.” David came to the table in fresh gloves and gown and addressed the pump tech. “I’m sorry, I don’t know you’re name.”

“Jim, Jim Novak.”

“You ready to go?”

“All set.”

The tech had prepared the pump equipment. "Jim, I see you've started an arterial line in the left radial. Nice work."

David stepped to the far side of the table, next to Michael’s left groin. He pondered some of the possible reasons for Michael’s advanced arterial disease. “Marsha, draw some blood from the right femoral. Nikki, send the specimen for a cholesterol fractionation. Have the lab send the results to my office."  
                                                      * * *

A cholesterol or lipid fractionation cannot be run stat. The test would take twenty-four to forty-eight hours. David would later review the results at his office. 
                                                      * * *

Marsha drew the blood and stepped to the opposite side of the table, next to David. "Okay, Marsha, let's do this."

                                                                    * * *

An intra-aortic balloon pump (IABP) is a temporizing device used to support heart contraction and blood pressure in the face of severe left ventricular failure. It may keep a patient alive long enough for the damaged myocardium to heal--many days, or weeks if necessary. However, without definitive treatment, such as coronary bypass or heart transplant, the patient will usually not survive.

The IABP is placed by inserting a large catheter with a narrow, elongated balloon at its tip. The balloon, roughly an inch in diameter and six inches long, is positioned in the thoracic aorta, above the diaphragm and below the aortic arch. The pump’s timing is determined by the heart’s rhythm on EKG. The machine inflates and deflates the balloon in synchrony with heart contractions. Deflation occurs simultaneously with left ventricular contraction, thereby unloading the ventricle, so to speak. Deflation creates a vacuum effect, making it easier for the left ventricle to squeeze and pump blood to the body. Inflation occurs during the ventricle’s relaxation phase, providing increased back pressure to the upper half of the body, forcing more oxygenated blood to the brain and coronary arteries, as well as producing forward pressure down the aorta to vital organs, especially the kidneys.
                                                                       * * *

Jenny prepped the area over her patient's left groin and femoral artery. David inserted a needle into Michael's artery. Blood shot from the tip of the needle, splashing on his chest and arms. He passed a long guide wire, through the needle, into the femoral and half way up the abdominal aorta. The needle was removed over the wire,and the plastic dilator, wide in comparison to that used for coronary catheters, was passed over the wire.

Barnett had to push and rotate the dilator to force it through the tiny puncture site in the skin and femoral. As he removed the dilator, the huge hole made in the arterial wall resulted in a  massive stream of blood shooting from the femoral, over his gown, on his arms and abdomen, and on Marsha's chest and neck.

“Oooh,” exclaimed Marsha, as droplets of blood hit her face.

David turned toward her. “Sorry about that." He tossed a sterile gauze to the end of the table. “Jim, could you please clean her up?”

Novak carefully dabbed the blood off Marsha’s forehead and cheek.

David added, “So sorry, Marsha. My fault."

"It’s okay—just part of the job. I’ve had worse.”

Marsha handed the doctor the catheter, which he advanced over the wire into the dilated opening of the femoral. All went well until the catheter tip encountered narrowings in the aorta. Using fluoroscopy, David could see that Michael’s abdominal aorta was riddled with plaque. He carefully navigated the catheter through tortuous turns in the vessel, finally positioning the balloon just below the aortic arch. After removing the guidewire, he passed the open end of the catheter to Jim Novak, who attached it to a hose coming from the balloon pump, set the timing in synchrony with Michael's electrocardiogram, and turned on the pump. Within seconds, Michael's pressure increased to a range of ninety to ninety-five systolic.

So far so good, thought David. I need to check his ventricular function again. “Nikki, please call for another stat echocardiogram. And I need those lab results.”

“Right away, Doc.”

Marsha sutured the left femoral catheter to the skin surrounding the puncture site. Nikki returned, holding two lab slips. “I’ve got his blood gas and chemistries.”

She held the slips up for David to read. Michael’s blood gas was no better than before. In spite of intubation and multiple doses of IV bicarb, he remained severely hypoxic and acidotic. His chemistry labs showed a high BUN and creatinine, indicating acute kidney failure. Importantly, his renal shut down and metabolic acidosis had caused a life threatening rise in his potassium level. If Michael survived the night, he would need urgent hemodialysis by morning.

There was nothing more David could do. The marginal increase in Michael's blood pressure, was not nearly enough to keep his heart, lungs and kidneys from failing.

                                                                   * * *

Carlo Conti was in his car, ruminating. Despite his son’s impending death, he couldn’t face returning to the hospital. He recalled the horror of holding Cassie’s lifeless body in his arms, and the shock of finding his wife’s pale body lying motionless in bed. The thought of another tragic loss, the death of his son, the end of his family, was too much to comprehend. He couldn’t bear another death. Seeing another body, Michael’s body, would put him over the brink. He feared he would lose control, possibly accost Barnett or tangle with security guards. He had to leave immediately. Carlo slowly drove away, having no idea of where he was going—he just had to leave.

                                                                    * * *

"Nikki, please check his urine output again."

"The Foley bag’s still empty. Just a couple drops of urine, Doc."

Barnett walked to the head of the table. "Mr. Conti, can you open your eyes?"

Michael couldn't speak because of the endotracheal tube. He did manage to slowly open his eyes. He stared at the ceiling without acknowledging Barnett's presence. A young woman rolled the echocardiogram machine into the lab.

"Thanks for coming so quickly. All I need is a quick look at his left ventricular function."

The tech placed the machine at the left side of the table, adjacent to Michael's chest. David pulled the sterile drape from his patient's torso. The technician took a few pictures as Barnett observed the echo screen. Things looked worse as compared to the prior study. Michael's left ventricle was barely moving. His entire heart was enlarged and his mitral valve was leaking severely.

"That's enough. Thanks again."

The technician left.

Barnett returned to the table at Michael's right groin. The monitor showed a heart rate climbing to the one-thirty, one-forty range. In spite of the aortic pump, his blood pressure had fallen back to eighty millimeters of mercury. As David watched the monitor, Michael's cardiac rhythm changed. He threw two separate, aberrant  beats--PVC’s, followed by a couplet, followed by a triplet, and finally, a sustained run of ventricular tachycardia, a potentially fatal arrhythmia.

Michael’s blood pressure dropped precipitously: seventy, sixty-five, fifty, forty. "Jenny, get the paddles."

Jenny grabbed the electrocardioverter and quickly rolled it to the head of the table. She smeared conductive gel over Michael's lower left chest heart and his right clavicle. "Turn it to maximum Joules, asynchronous."

"Okay, got it."

"Shock him.”

“Clear!” Jenny depressed the buttons on each paddle. The machine clicked. The patient's upper body lurched from the table.

Michael was barely aware of the electricity coursing through his chest. He was alive, but his brain was suffering the effects of hypoxia, decreased oxygen. He was having a wonderful dream about Laura. His imaginings overwhelmed him with love for his wife. His mother appeared. She was sitting by his side, patting his forehead—telling him what a smart boy he was. Abruptly, his dream changed. He was pointing a gun at his father. “I hate you, Dad. You’ve ruined my life. I’m gonna kill you.”

Carlo, with his back turned, spoke in a deep, inhuman voice. "You aren't going to kill me. You can't kill me. I'm killing you!" 

Michael felt weak, worthless and terrified. He let out an earsplitting scream as his father turned to face him. Carlo had become a grotesgue, gargoyle like creature with an evil, unholy appearance. This thing  stared at Michael with a wide, toothy grin followed by a roar of laughter. "A frail wimp like you thinks he can kill me? You're a coward.You're couldn't kill anything!"   
 
Michael raised the gun and squeezed the trigger. The creature disappeared, leaving Carlo behind, lying on the ground, dead. Michael began to cry. His dream was over.

The cardioversion worked. Michael’s heart rhythm returned to a sinus tachycardia and his pressure improved. Jenny heard her patient moan over the ET tube. “Mr. Conti, are you awake?”

He didn’t respond. She took a closer look, stunned by what she saw. Michael had tiny tears rolling down his cheeks. He moaned again.

Marsha yelled, “He’s in V-tach again!”

Barnett reacted. “Jenny, push an amp of epi, an amp of bicarb and another bolus of lido, one-hundred milligrams. I’ll take the paddles.”

He shocked Michael again. “Marsha, what’s his rhythm?”

“It didn’t work. He’s still in V-tach.”

Michael’s blood pressure crashed again. David watched as his patient’s rhythm deteriorated further—ventricular tachycardia progressed to ventricular fibrillation. “V-fib,” yelled Marsha. David quickly stepped back to the head of the bed and delivered another cardioversion shock. “Click—thump.”

His patient's body barely moved this time. Michael's chest and back muscles were dying, no longer able to contract. He remained in V-fib for a few seconds and abruptly went flat line.

“Dr. Barnett, he’s flat line.”

Michael Conti was watching from somewhere high above. He could see his body on the cath table below with Dr. Barnett and the nurses working furiously to save his life. Though knowing he was dying, he felt wonderful—enveloped by a warm yellow glow. He had an exquisite taste in his mouth. Captivating sounds, unlike man made music, beautiful sounds, came out of nowhere. He saw Laura sitting at a table, sobbing. He took comfort in knowing she would some day feel as he did at that moment.

Jenny yelled out, “Doctor B., should I start chest compressions?”

David thought it over. CPR was pointless. There was no reason to extend this any further. “No, Jenny, we’re going to stop. Doug, you can stop bagging him.”

Michael watched from above as he died on the table below. For him, his physical death was inconsequential. He had a euphoric sense of love for everyone: the doctors, nurses, technicians--everyone he had ever known, including his father. He could see Carlo’s car slowly wondering down a narrow road. His father was crying. Michael loved him. All of his father’s ridicule was now meaningless.

Nikki left the lab and returned with a pen light. Barnett checked Michael’s pupils. They were fixed—widely dilated. He listened over his patient’s heart with his stethoscope; no heart sounds."Nikki, record the time of death as ten-forty-eight. Jenny, I’m going back to talk to his wife. Please clean him up before she comes in. Marsha, cover him with a fresh gown. I’ll be back in a few minutes."

Michael Conti, still hovering above, slowly floated away in a blanket of joy and love. He saw his mother walking hand in hand with a young girl. His mother was beautiful. He had never met the little girl, but knew who she was.They were coming to take him home.

Barnett entered the conference room. Laura quickly stood. A look of despondence draped her face. “Mrs. Conti, I’m sorry. Your husband didn’t survive. We had to stop. It was a hopeless situation.”

Expecting the worst, she barely reacted. After a short pause, she asked, “What do we do now?”

“First, I need to talk with your father-in-law. Do you know where he is?”

“I’m not sure. I guess he’s down in the emergency room.”

David called the ER.

“Hello, mercy Hospital emergency.”

“Sherry, it’s Dr. Barnett.”

“Yes, Doctor.”

“Could you please check to see if Michael Conti's father is in the conference room?”

“I saw him leave about a half hour ago. He was headed for the parking lot.”

“Okay, thanks.”

David turned to Laura. “He left awhile ago. The receptionist saw him walking out to his car.”

Laura spoke. “I’m sorry. As you’ve seen, Carlo is out of control. He's so bitter. Actually, I’m glad he’s gone. He’s odd and unpredictable. I can’t imagine what he’d do if he were here right now.”

“I’ll call him later if you’d like.”

“No, I don’t think you should do that. I know he’ll be offensive. I’ll talk to him.”

“Alright, but if there’s a problem don’t hesitate to let me help.”

“Thanks. I will.”

David reviewed Michael’s problem in detail with his wife. They discussed the pros and cons of an autopsy. David, in light of Michael’s severe arterial disease at such a young age, thought it may be best to have an autopsy. However, he had no strong feeling either way. Laura, anticipating Carlo’s reaction, decided against it. Barnett had no objection.

The pair walked to the cath lab for one last visit. David wrote a long note in Michael’s chart. It was eleven-thirty when he left the lab. He had three consults waiting for him, one all the way across town at Toledo Hospital.

Carlo Conti, after wandering around the city of Toledo, eventually, practically by accident, found his way bck to Mercy Hospital. He pulled in the emergency room drive, parked, and sat in his car, staring at the hospital. His cell phone rang.

"It's Laura. I have bad news."

"Of course you do and I don't want to hear it!" He hung up. The demise of his family was the end of everything. His will to live wained as his hatred of doctor's and hospitals surfaced. He was both hopeless and enraged.

Over the past years, Carlo, out of a sense of obligation to Ford Motor, had purchased a new Lincoln Continental on an annual basis. He now sat, transfixed, staring out the windshield of his four-thousand-pound luxury sedan. The Continental was pointed directly at the hospital's emergency room entrance. With mechanical, near robotic motion, he slipped the car in drive. The Lincoln slowly rolled forward. Carlo slammed the accelerator to the floor.

By one a.m., David Barnett had completed his two cardiology consultations at Mercy Hospital. He left the CCU, headed for the ER exit and the doctor's parking lot. The main exit of the emergency room was locked and barricaded. He left via the adjacent ambulance entrance and noticed that the main ER entrance was partially collapsed and cordened off with yellow Police tape. David drove across town to see his third consultation at Toledo hospital.

He arrived home at two-fifteen a.m.; hoping to get a few hours of sleep before starting rounds in the morning. Seconds after he climbed into bed, his cell phone rang. He had an urgent consultation at Toledo Emergency. An elderly woman with an acute MI was in need of attention. He rolled out of bed and got dressed.