Karma

By Twist Ranger

Book Two in the Redwood County Medical Mystery Series. “Sickest quickest” is Dr. Fiona Tyler’s mantra. Fiona is the Emergency Department chief at rural Redwood County hospital. This Saturday night, sickest includes the loopy patient playing with the entrails spilling out of his belly. Most people wouldn’t be quite so happy about crocheting their intestines into doilies. Who is spilling the guts in Redwood County? Bart Hargraves, the local police detective, nominates Fiona’s boyfriend Gary, but Gary is confined in the state facility for mentally disordered forensic offenders at Atascadero.

When a call comes in about a woman whose husband whupped her upside the head with a chainsaw, Fiona is dragged off to the scene by Bart and ends up crawling around on the lady’s kitchen floor trying to pump fluids in faster than they’re squirting out. A trauma surgeon is able to repair the massive neck wound, but a judge releases the abusive husband.

The next patient claims a cop popped up outside his window and shot him. He had a mobile methamphetamine lab in his van. He said this way he combined production and distribution in one operation.

Fiona’s friend Clary Sage Walker arrives at the ED with the freshly-battered woman who suffered the chain saw injury. The husband is then brought in to the ED with fatal stab injuries. Clary’s fingerprints are found underneath some of the blood smears when the police process the crime scene after the abuser’s death.

The police detective keeps trying to interest Fiona in the eviscerated patient. Fiona consults Gary, who has some insight into disordered minds, both his own and those of his fellow inmates. Gary has a theory that the perpetrator is building an insanity defense as a fall-back plan in case he’s apprehended, but isn’t really mentally ill. On the other hand, haruspicy was practiced by the perfectly rational Greeks and Romans and derived from the Etruscans and Babylonia, and who is to say this grisly method of divination doesn’t work? Fiona is afraid if he goes too much further down this path her boyfriend will never be released.

The mobile methamphetamine van explodes in the hospital parking lot, sets the woods on fire and sends the ED into disaster mode.

Clary is followed by a person she says does not have pleasant intentions, he radiates violence. His aura is shot through with darkness. Clary takes Fiona to Panther Beach, and if she doesn’t want to sit there and confront the pursuer with the dark aura, she has to follow her friend through the rocks. They crash through a rocky passage pursued by a shooter and land on the tiny sand spit of Hole in the Wall Beach. The tide’s coming in, they can’t get out, and the beach is underwater at high tide.

• Language: English
• Publisher: Twist Ranger
• Release date: Mar 31, 2016
• ISBN: 9781310060373

Twist Ranger

Twist Ranger is like a lively and elegant wine: bright, rich, rounded with an energetic red fruit top note and purple forest ending.

Book preview

The patient was giggling. Dr. Fiona Tyler didn’t usually see happy patients in the Redwood County hospital Emergency Department, especially when they had their intestines dangling from their belly in a gory mess. It wasn’t that the patient was unaware of the problem. No, he was fully focused on the slimy, greasy jumble of guts. This guy was fondling his intestines with the level of intensity most people give to fondling their genitals. He had both hands entwined in the slippery mass of entrails and was trying to pull more loops of small intestine out of the vertical incision in his abdomen. He stank of blood and guts.

Stop that! The paramedic who brought him in tugged on the patient’s hands. Bobby, you’re making it worse.

Fiona took a half step backwards as a freed loop of gut flung muck across the treatment room. Scene safety, there was a potential for fluid contamination. She went through the rest of the mental litany: airway, the patient was making sounds, if not coherent speech, score one for a patent airway. Breathing: not even hard. Circulation: the viscera was nicely vascularized and Fiona could see abundant dark blood in the capillaries.

Vital signs? Fiona asked. Surgeon on-call, OR team, full set of labs, toxicology screen, psychiatrist, she added.

You’re not kidding, the paramedic muttered.

The charge nurse, Maria, had gowned and gloved. Maria pulled a transparent plastic shield and mask over her face and approached the giggling patient carefully.

What’s your name? she asked the patient.

The patient held a tube of intestine in each bloodied hand and tried to form loops, pull one loop through the other. He hummed and chirped happily.

Be careful, you’re going to put a finger through one of those … Fiona said. She visualized fecal contamination adding to the problem of ordinary gross contamination from dirt and exposure.

He looks like he’s crocheting. Fiona’s new medical resident, Dr. Maggie Fitzpatrick, was watching with interest from the foot of the stretcher.

Can we get him on the gurney?

Fiona, Maria, Maggie and the paramedic grabbed the corners of the sheet under the patient on the ambulance stretcher and hauled him bodily over onto the ED gurney. The ambulance crew had thoughtfully provided plastic-backed paper chux under his back, so the whole mess came with him, even the parts that had spilled out the sides of the wound.

What did this? Fiona asked. Was there a weapon at the scene?

We didn’t see one. We found him on the embankment by the river, where the homeless people hang out. He was sitting on a park bench with his hands up to the wrists in his innards. There was a trail of blood on the ground so it looked like he walked there. Transients in the area said his name was Bobby. We just picked him up and got out of there.

Fiona nodded. The best prehospital treatment for penetrating trauma was diesel: scoop the patient up, apply diesel fuel to the ambulance engine, and get the patient to definitive care in the hospital.

Maria had the patient’s left hand secured with a gauze wrapping around the wrist and a short leash to the stretcher side rail. When she pulled his right hand away, Bobby’s cheerfulness deserted him and he began to wail. It took three people to get the right wrist wrapped and tied, and he drummed his heels like a two year old having a tantrum.

Get his feet!

The Emergency Department technician, Danny, grabbed both ankles and leaned on them. Danny was a big man, but the patient was bouncing him up and down. Fiona’s hair was in her face because the scrap of bandage she had used to tie it came loose in the melee. Her gloves were smeared so she tossed the hair over her shoulder with a shake of her head.

Get the blood, Fiona told Maggie. I want to use chemical restraint, for his safety and ours, but I want to know what he’s got on board first.

The patient’s eyes focused on Maggie as she approached with a syringe, and he stopped struggling to coo softly at her.

Bobby? I’m going to take some blood out of your arm, Maggie said. Please hold still. That’s good, you’re doing good.

Maggie slipped the needle in and drew back. The patient lay quietly for her.

Okay, visual restraint, Fiona said. Stay in his line of sight, Maggie, he likes you.

You mean my class in animal mesmerism paid off? Maggie whispered. She took the wet washcloth Maria handed her and started cleaning the caked blood off the patient's hands. Good, you're doing good, she repeated.

The trauma surgeon on call was Dr. Boghazkeui. Fiona snapped off her gloves and pitched them in the wastebasket, went to get him on the telephone. She cradled the cell phone between her ear and shoulder while she pulled stockinette bandage from the wall dispenser and used a length to tie her long blonde hair out of the way.

Fiona and the charge nurse were carefully arranging saline-soaked drapes over the patient’s exposed abdominal contents when the trauma surgeon and a police officer showed up in the doorway. There was a moment of confusion before the police gave way to the surgeon, who pushed ahead of him, walked in and instantly flipped the wet coverings off the patient’s belly and onto the floor.

Dr. Boghazkeui didn’t even glance at the patient’s face. He bent forward until his nose was practically touching the loops of intestine.

Size eight, Dr. Boghazkeui said, without looking at anyone. When the assembled staff didn’t understand, he pulled himself to his full height and wheeled on the charge nurse. Size eight sterile gloves, he snapped. Immediately.

The charge nurse’s eyes widened. She blinked.

The medical resident moved to the storage cabinet and got a package of sterile gloves for the surgeon, and snapped the package open. Maggie held the opened package carefully on her palm. The surgeon slid delicate fingers into one glove, stuck a finger in the cuff to align it precisely, then slipped his other hand into the second glove. The wrapping fluttered to the floor. The surgeon poked at the swollen gut tissue. A trickle of blood from the edges of the wound dripped over the edge of the stretcher onto the floor.

Ick, the police detective said.

Maggie bent down to retrieve the paper wrapping from the gloves, which took her out of the patient’s sight. Bobby began to wail and drum his heels again. Danny, the ED technician, stood unmoving against the wall.

Sedate this evisceration, Dr. Tyler, the surgeon snapped at Fiona. I’ll start the case in precisely ten minutes.

Dr. Boghazkeui removed his gloves as carefully as he had donned them, then threw them on the floor next to the trash basket. He turned and strutted out of the treatment room.

Chapter Two

Oh, man, is it going to be like this all night? Danny groaned.

What a turd. That was the police detective, Bart Hargraves. Bart mopped sweat from his forehead with a wad of shredding paper napkin he pulled from his pants pocket. Is he always like that?

Fiona sighed.He’s the trauma surgeon.Dr. Bog. Great hands, I understand, but his bedside manner is a little, um, abrasive.

Another one who thinks he’s god, the charge nurse muttered. I’d like to put a trocar right through his supercilious gizzard.

The medical resident was quietly sopping up the blood with the discarded wet drapes. Danny held out a red isolation trash bag and Maggie dropped the drapes in. The patient subsided as her face came back into view.

Fiona glanced at the patient. It probably wasn’t a good idea to ruin the victim’s faith in his trauma surgeon in front of him, but she could appreciate that Dr. Boghazkeui hadn’t made any friends with his high-handed, arrogant, insolent behavior. Fiona was unmoved herself . Just another asshole, god must love them, he made so many of them. She was angry on behalf of her team, however. There was probably no hope that the police could arrest the surgeon on grounds of contempt of hospital staff. Maybe Bart could be suborned into arresting him for speeding in the parking lot, or parking too far away from the curb or something. Presuming the surgeon drove, and didn't just walk on water, like he acted.

Maggie, stay where Bobby can see you while we prep him, Fiona said. Let’s cut the rest of his clothes off and get him in a gown.

Careful! Bart put in. Don’t cut through the part where he got stabbed.

The Emergency Department technician gave Bart a dirty look. We know that, he said irritably. We probably see more victims than you do.

This one's alive, Bart said. I'd take it as a personal favor if you could keep him that way.

Oh, god, it was going to be one of those nights. Dr. Fiona Tyler fanned herself with the cardboard backing from a package of pliofilm. Tempers were flaring and it was physically hot in the Redwood County Hospital Emergency Department, too.

Fiona tugged at the neck of her sweaty surgical green scrubs shirt and tried to hold it away from her lanky body for a moment. It was a Saturday night early in July, probably one of the three days all summer when the weather was sultry, and Fiona was longing for cool fog and the winter rainy season. Cool reason wouldn’t come amiss.

Bobby was packaged for the OR. Let’s get him out of here. Maggie, go with the transport team as far as the sterile area, Fiona said.

Did you want some Versed, Dr. Tyler? the charge nurse asked.

Fiona looked innocent. He’s quiet, she pointed out. She smiled.

"Maggie, you go with the transport team to the doors of the operating suite, but

don’t cross the line to the sterile side."

I’ll call the OR charge nurse to let them know you’re coming, Maria said. I’ll warn her what to expect.

Bobby lay unmoving, watching the medical resident intently, cooing softly to himself. His abdomen was tidily covered with wet drapes.

What’s with this guy, anyway? the police detective said. He had alert blue eyes and a nice smile, but his general appearance was bedraggled. His orange and green striped shirt was darker in patches. His navy blue slacks were drenched. Despite being hung all over with police paraphernalia including belt, gun, nightstick, radio, and cuffs, he was outshone by the other cop who was in uniform and looked a lot neater and drier.

Fiona looked the detective over. Were you chasing him, Bart? You’re sopping wet.

No.

Danny kicked the locks off the gurney wheels and he and Maggie rolled the patient out. Fiona waited for more.

I fell in the river, Bart admitted.

Fiona nodded. When she cursed Barton Hargraves she always tried to give him exotic diseases, yaws or leprosy or botfly infestation. Someone had clearly gotten in ahead of her and cursed Bart with a water geas. Even in the drought season every time Fiona saw the man he was wet somehow.

This is Johnny Page. Bart introduced the uniformed officer. Johnny, this is Dr. Tyler. She’s a, uh, doctor. So, ah, what’s up with the jerk there?

You mean the trauma surgeon or the patient?

Start with the patient. Bart grinned, though, as he dug in his pocket for his spiral bound notebook. The notebook came out wadded into a sodden mass. Bart carefully pulled the pages apart to a clean, if damp, part in the middle.

The medics found him on a park bench playing with himself, Fiona said. He appears to have a full-thickness vertical wound with evisceration of the abdominal contents. It looks fresh. The patient was not coherent and gave no history. When we get the labs back I’ll be able to tell you what he was on.

High as a kite, huh?

Flying, Fiona said. Can you tell me, was the wound self-inflicted? Psychiatry will want to know.

No, I don’t think he did that himself, Bart said mildly.

Well, why not? It’s possible. There have been cases in the literature where patients drilled dozens of holes into their brains with power drills and so on. Our Redwood County suicide rate from knife wounds is higher than from gunshot wounds, which is odd but true.

Yuck. Drilled holes in their head? More than once?

Yes.

Bart shook his head. Insane. But this guy, no, unless he finally turned around and did it to himself, he’s just one of a series. Some fruitcake’s been out there unzipping people and spilling their guts.

Fiona frowned. Where are the rest of them? We haven’t been seeing them in the ED.

That’s because they’re dead.

Maggie strode along at the side of the gurney as Danny pushed. Bart Hargraves started to follow them, radio growling softly, police gear dangling from his belt.

What are you doing? Fiona asked him.

Investigating, Bart said. He waved at the patient. He might say something. I'll be back, doc.

Yeah, right. The patient was totally out of touch with reality. Of course, that could describe the police mentality, too, Fiona thought. Maybe they would understand each other just fine. Don't make a special trip on my account, Fiona thought.

Why? she asked.

Bart turned and walked backwards with one hand on the side rail of the stretcher for guidance.

This one's alive, he said patiently. The others were all dead.

Of course they were dead, Fiona thought. Bart investigated homicides. Homicides were dead by definition.

She stood staring at the white board with the charge nurse. The board listed the patients in the treatment rooms and it was nearly full. Parts of it looked like an art object, scribbled and scratched over, crosshatched, stippled with cryptic notations. Kind of like a Jackson Pollack. In the abstract, it was pleasing. The reality wasn't as neat or tightly ordered. Neat and tidy are not prominent characteristics of a working ED.

Fiona tightened the strip of bandage that held her long blonde hair out of the way of bodily fluids or other physiological matter exuded from patients. Getting messy from blood, bile, vomit, fecal matter, and urine was the physician's lot in life; the trick was to contain the damage. Babies were particularly unrestrained in their efforts to share the wealth. Normally she wore the long white lab coat of an attending physician, which gave good protection, but it was just too hot. Fiona was wearing a patient gown with the sleeves rolled up over her scrubs. The perky magenta print clashed with the puke green scrubs.

Redwood County citizens were hanging out on the street corners and bars, milling in throngs on the boardwalk, cruising the streets, looking for trouble or a breath of cool air, whichever came first. Most of the Emergency Department patients would have consumed adult beverages. Redwood County had twice the number of liquor stores and bars as comparable cities its size. They saw the result in the ED. The majority of victims and perpetrators of violent crimes would have alcohol on board. The bars wouldn’t close for hours yet. The Saturday night knife and gun club would show up then.

Fiona glanced at the white board again. All under control. With nothing life-saving to do, she ripped strips of surgical tape off the roll with short, jerky motions. Each strip got a metal paper clip stuck to it. She hung the strips from the frame of the surgical lamp over the unoccupied gurney in room One.

What are those for, Fiona? Maggie asked.

How’d it go?

Maggie grinned. She had a cute snub nose and freckles to go with the mop of red curls, and when she giggled she looked about twelve years old. She looked way too young to be a resident, but they were making them faster now than in Fiona’s day.

"Bobby went batshit when we shoved the stretcher across the line. Dr. Boghazkeui yelled at the scrub nurse to do something about his disgraceful behavior but I’m afraid he meant the patient. How does anybody work with the man? I mean, I know surgeons can be imperious but