COUNTERBLOOD

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Chapter One

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The Ruby Emergency Department of the Vino Heritage Medical Center was a state-of-the-art facility thanks to a generous donation from the town of Manhattan. Open for just a year and a half now, the forty-thousand-square-foot complex was built specifically for the nasty stuff. There were twelve treatment bays, six on each half of the building. Emergency patients were admitted through the A or B track, and they stay with whichever team had been assigned to them in the beginning until they were released, admitted or sent to the morgue.

Running down the center of the facility was what the medical staff called "the passage"—short for the passage to Heaven or Hell. The passage was strictly for trauma admits, who were either flown in from a rescue-copter on the rooftop, or bused in by an ambulance. Anyone who came by helicopter tended to be more of the hard-core type. The copters went out at about a hundred and fifty mile radius around Manhattan, and even once shipped in some people who were involved in an unfortunate shark attack in the middle of the ocean. For those types of patients, there was a large elevator that came out right at the end of the passage. It was big enough to fit two gurneys and ten medical personnel at one time.

The trauma facility also had six open patient bays, each with X-ray and ultrasound equipment, oxygen feeds, medical supplies and plenty of space to move around. The operational hub was smack in the middle of the trauma facility, a conclave of humming computers and personnel that was, tragically, always busy. At any given hour there were at least one admitting physician, four residents and six nurses standing in the area, with typically two or three patients in-house.

Manhattan was a big city, with a lot of gang violence, drug-related shootings and car accidents, among many other things. Plus, with over six millions residents in the city, there was an endless variation of human miscalculation—nail guns going off into a man's stomach because he wanted to fix the button on his jeans; and arrow through a cranium because someone wanted to show off their aiming skills; a stay-at-home-dad figured it would be helpful for his wife to come home to a home-cooked meal and ends up frying himself and one of his kids.

Yui Komori lived in the passage, and many would say that she owned it. As chief of the Trauma Division, she was administratively responsible for everything that went down in those six bays. She was also trained as both an ED attending and a trauma surgeon, so she was hands-on. On a day-to-day basis, she made calls about who needed to go up one floor to the ORs, and a lot of times she scrubbed in to do the needle-and-thread stuff, too.

The ambulance had called about ten minutes ago, saying that they had a gunshot victim incoming for her. She'd been reviewing the charts of two more patients currently being treated, and finally decided to put them down. She looked over the shoulders of a few residents and nurses in the operational hub as they worked.

Every member of the trauma team was handpicked by Yui, and when recruiting, she didn't necessarily go for the Ivy Leaguer types, although she had graduated from Harvard herself. What she looked for were the qualities of a good soldier—someone with smarts, stamina and the ability to mentally detach from a situation. That was the most important quality. She knew better than anyone that you had to be able to stay tight in a crisis.

But that didn't mean that compassion wasn't mission-critical in everything that they did there. In fact, many people would argue with her about that, but she believed it to be true above anything else. If there was anything she couldn't forget about, it was the compassion she had for her patients and their loved ones. Being humble and sympathetic was very important to Yui, and she made sure that all members of her team had it.

Generally, though, most patients didn't need hand-holding or reassurance. They tended to be either drugged up or so shocked from spurting blood or a detached body part in a freezer bag that they didn't really notice any compassion. But what they did need were levelheaded people on the medical and business ends of the paddle.

The families and loved ones, however, needed kindness and sympathy always, and reassurance when that was possible. Lives were either destroyed or resurrected every single day in the passage, and it wasn't just the people who stopped breathing or started again. The waiting rooms were always filled with people who were affected as well—husbands, wives, parents, children.

Yui knew exactly what it was like to lose someone who was a part of you, and as she went about her clinical work she was very aware of the human side of all the medicine and technology in the facility. She made sure all her people were on the same page as her regarding that—you needed the battlefield mentality and the bedside manners. She also believed that it was important to take time to hold someone's hand or offer a shoulder to cry on, because in a second, the roles could be reversed. Tragedy didn't discriminate. Everyone was subject to the whims of fate. And as far as she was concerned, everyone was equal. Everyone was loved by someone, somewhere, even in ways you don't expect. And always doing her best to save every life was critical.

Jun, one of the nurses, came up to her as she continued waiting for her gunshot victim. "Dr. Chiharu just called out sick, Dr. Komori," she said.

"Did he get that flu that was going around?"

"Yes, but he got Dr. Izanami to cover."

"Bless Chiharu's heart. She need anything?"

Jun smiled. "She said her husband was thrilled to have her home when he was awake for once. He was making her chicken soup last I heard."

"Good. She needed some time off anyway."

"Yeah. She said she was going to ask him to watch some girly movies with her."

Yui laughed. "You sure that won't make her sicker? Oh, listen, I wanted to do grand rounds on the Haru case. There was nothing else we could have done for him, but I think we need to go over the death anyway."

"I actually had a feeling you'd want to do that. I set it up for you the day before yesterday." Yui gave the nurse's hand a little squeeze.

"You're great. Thanks."

"No, I just know our boss, is all." Jun smiled. "You never let them go without checking and rechecking in case something could have been done differently."

And Jun was right. Yui could remember every name of every patient that died over the past year and a half under her care. The deceased catalog was all in her mind, and it was a reminded every time she went in to save someone. Sometimes, at night when she couldn't sleep, the names and faces would run through her head until she thought she would go mad. She hated failing like that—having someone's life in her hands and not being able to save them was her least favorite fear.

On the other hand, it was the ultimate motivator to be better and better every day, and right now, she'd be damned if this gunshot victim was going on that list.

Yui went over to one of the monitors and called up the information on her incoming patient. Just from a glance she knew that this one was going to be a battle. She was looking at a stab wound as well as a bullet in his chest cavity. And given where he'd been found, she was willing to bet that he was either a drug dealer doing business in the wrong territory or a big buyer who'd gotten the shaft. Either way, she thought it was unlikely that he had health insurance, not that it mattered to her. Ruby ED accepted all patients, regardless of their ability to pay. She wouldn't have agree to work anywhere with lesser standards.

About a minute and a half later, the double doors at the front of the passage swung open and the crisis team came in in a rush and a loud chatter. Mr. Ayato Sagamaki was strapped to a gurney, a tall, athletically-built man in what looked to be some kind of a uniform. He was younger than Yui was expecting. The paramedic at his head was bagging him, while another one held the equipment down and pulled.

"Bay three," Yui told the EMTs, rushing over. "Where are we?"

The guy bagging said, "Two large-bore IVs in with lactated ringers. BP is sixty over forty and falling. Heart rate is in the one-forties. Respiration is forty. Orally intubated. V-fibbed on the way over. Shocked him at two hundred joules. No response. Sinus tachycardia in the one-forties."

In bay three, the medics stopped the gurney and braked it while the passage's staff coalesced. One nurse took a seat at a small table to start recording everything. Two others were on standby to give the supplies at Yui's direction, and a fourth got ready to cut off the patient's clothes. A pair of residents hovered to watch or help as needed.

"I got the wallet," the paramedic said, handing it over to the nurse with the pair a scissors.

"Ayato Sagamaki, age… I think this ID is fabricated. The birth date says he's over a hundred years old. The picture is blurry, but… it could be him, assuming he dyed his hair purple after it was taken."

She handed the wallet over tot he colleague who was taking notes and then started to remove the patient's clothes. The shirt was easy, but she needed the scissors to cut the pants down the side and peel them off.

"I'll see if he's in the system," the other woman reported as she logged onto a computer. "Found him—wait, this isn't right, either… Must be an error. No, the name and address is the same, the age is still wrong, though."

Yui cursed under her breath. "Are we still having problems with the new electronics record system? We can't trust the information on there right now. I need a blood type and a chest X-ray asap."

While blood was being drawn, Yui did her best to analyze the situation. Her preliminary exam didn't reveal much—the gunshot wound was a tidy hole with only a rivulet of blood coming out. The knife wound was much the same—there wasn't much externally. She hoped his intestines hadn't been nicked with the blade.

She glanced down the rest of his body, noticing his pale, flawless skin. If he was involved in some drug business, he must have been quite new at it with no visible scars or marks. Not even a single tattoo. And he couldn't have been over thirty.

"Let me see the X-ray. And I want an ultrasound on his heart—"

To her left, the nurse who had been removing his clothes yelped and jumped back. The side of her hand was bleeding and she was holding it against her chest.

"I just went to check his teeth for minerals and… he bit me. His teeth felt like knives..."

For a split second everyone froze.

"Back in the game!" Yui clipped. "You, get out of here and get your hand treated. I want someone on that ultrasound, pronto! Where's the X-ray?"

Her commands snapped the staff back into attention as the nurse left the room, still holding her hand. One of the residents followed her to help.

The chest X-ray came out relatively fine, but for some reason the ultrasound of the heart was in poor quality. Both, however showed exactly what Yui had been expecting—pericardial tamponade from a right ventricular gunshot wound—Blood had leaked into the pericardial sack and was compressing the patient's heart, compromising it's function and causing it to pump poorly.

"We need an ultrasound of his abdomen for that knife wound while I buy us some time with his heart." Yui figured that the knife could be more serious than the gunshot if the blade had hit anything traumatic. "And as soon as that's done, I want both machines check. Some of these chest images have an echo."

As a resident went to work on the patient's belly with the ultrasound wand, Yui took a twenty-one-gauge spinal needle and plugged it into a fifty-cc syringe. After a nurse Betadined the man's chest, Yui pierced his skin and navigated the bone anatomy, breaching the pericardial sack and drawing out forty ccs of blood to ease the pericardial tamponade. Meanwhile, she gave out orders to prepare OR three upstairs and get the cardiac bypass team on the ready.

She gave the syringe to a nurse for disposal. "Let's see the abdominal."

The machine was definitely misbehaving. The images weren't clear at all. They did, however, show some good news, which Yui confirmed as she palpated the region. No major internal organs seemed to have been hit by anything.

"Okay, his abdomen looks fine. Let's move his upstairs."

n her way out of the passage, she poked her head into the room with the other nurse and looked at the resident. "How's she doing?"

"I don't know what she hit, but whatever it was burned her hand, and she just blacked out."

"Blacked out? And nothing burned her. She was cut by something. She said it was the teeth."

"I don't know what she hit. Our patient's out cold. He wasn't biting anybody, and a simple bite wouldn't have done something like this."

"Well, keep me updated. Take care of her."

"Of course."

Yui caught up with the patient as the staff wheeled him down the passage and into the elevator. One floor up she put on her scrubs while the nurses got him onto her table. At her request, a cardio-thoracic surgical kit and heart/lung bypass machine had been set up for her. The ultrasounds and X-rays had also been put up on a computer screen for her to see while she worked.

With gloves on both hands, held away from herself, she looked over the chest scans again. It was strange, having the images being so subpar—they were very grainy and with that echo, but there was enough to orient herself. The bullet was still inside him, lodged in the muscles in his back, and she was going to leave it there for now. The risks inherent in removing it were greater than leaving it alone for now.

She frowned and leaned closer to the screen. The bullet was interesting, to say the least. It looked like a little round ball, instead of the usual oblong shape she was used to seeing. And she couldn't tell if it was lead or not.

Yui approached the table where the patient was now hooked up to the anesthesia machines. His chest had been prepped, the regions around it draped in surgical cloth. The orange wash of Betadine made him look like he had a bad fake tan.

"No bypass. I don't want to use the time for that. Tell me how much blood we have for him on hand."

One of the nurses spoke up on her left. "The reading on the samples we took came back unidentifiable, but we have seven liters of O."

"His blood didn't type?"

"No, Doctor."

Yui frowned. "Okay, then. Let's do this."

Using a laser scalpel, she made an incision down the patient's chest, then sawed through the sternum and used a rib spreader to pull open the heart's iron bars.

Yui almost lost her breath. "Holy…"

"Shit," someone finished.

"Suction." When there was a pause, she looked up at her assisting nurse. "Suction, now! I don't care what it looks like. I can fix it, but I need a clear shot at the damned thing."

There was a hissing sound as the nurse removed the blood, and Yui got a good look at a physical anomaly she'd never seen before—this man had a six-chambered heart. That "echo" she'd seen in the pictures was actually an extra pair of chambers.

"Pictures!" she called out. "Make it quick, please!"

As photographs were taken she shook her head in disbelief. The Cardiology Department was going to have a field day over this. She'd never seen anything like it before—although the hole that was now torn through the right ventricle was totally familiar. She'd seen a lot of gunshot wounds in her relatively short time in this business.

"Suture," she said when the photographs were all taken.

Her assisting nurse slapped a pair of grips into her open palm, the stainless steel instrument carrying a curved needle with a black thread clipped onto the end. With her left hand, Yui reached in behind the heart, plugged the back end of the hole with her finger and stitched the front impact site closed. Next move was to lift the heart out of its pericardial sac and dot he same underneath.

Total elapsed time was under five minutes. Then she released the spreader, put the rib cage back where it was supposed to be, and used stainless steel wire to close the two halves of the sternum together. Just as she was about to staple him from his diaphragm to his collarbone, the anesthesiologist spoke up and machines started to beep.

"BP is sixty over forty and dropping fast."

Yui called out the heart failure protocol and leaned down to the patient's head. "Don't even think about it," she said softly, "You're not going to die here. Not while I'm taking care of you."

From out of nowhere, and against all medical fact, the man's eyes blinked open and focused on her.

Yui jerked back. God… his eyes were a bright yellow-green, and shined like a full moon on a cloudless, winter night. And for the first time in her life, she was stunned into immobility. In that moment, with their locked stares, it was as if they were linked, body to body, twisted and intertwined, indivisible—

"He's V-fibbing again," the anesthesiologist barked at her.

Yui snapped back to attention.

"You stay with me," she said to the patient. "You hear me? You stay with me."

She could have sworn the man nodded at her before his lids shut. And she got back to work saving his life.