The Code

By Ann Dominguez

Dr. Kate Deming has spent four brutal years working in a Chicago ER, swinging back and forth from tragedy at work to guilt for what she’s missing at home. The prescription is a new job that will allow more time with her growing daughters: an eight-year-old pirate wannabe planning to run away to the high seas, and a twelve-year old expert in eye-rolling and sarcasm who is the star of her middle school’s new code breaking team.

When a sophisticated ransomware attack paralyzes the hospital’s electronic medical record, the hospital pinpoints Kate’s computer as the electronic gateway. She thinks it’s a misdiagnosis until the FBI raids their apartment and arrests her husband, whose home tech support now appears all but benign. Meanwhile, her daughter’s classmate overdoses to get away from a sextortion scheme that her daughter knows too much about. Can Kate crack the code before another child gets hurt?

• Language: English
• Publisher: Ann Dominguez
• Release date: Oct 7, 2022
• ISBN: 9780997029703

Ann Dominguez

Ann Dominguez lives in Colorado with her husband and children. Her writing has appeared in JAMA and Medical Economics. She was a contributor to Let Us Keep the Feast, published by Doulos Press. Online, her work can be found at The Well, Venn Magazine, and HuffPost, and http://anndominguezbooks.wordpress.com.When she’s not writing, parenting or doctoring, she enjoys reading and running. She hopes someday to finish a cup of tea before it gets cold.

Book preview

ONE

Sweat oozed down my wrist into the blue nitrile glove. I’d been gripping the metal scope in my hand for a hundred and twenty heartbeats, but it was still icy cold. The patient’s mouth smelled like vomit and decay, and the trembling of my arm rattled the blade against his teeth. My goggles started to steam up, and I slowed my breathing and waited for the glottis to line up between the pale pillars of his vocal cords.

Do you want me to get an attending? Shaniqua asked.

Not yet. I can get it. I hoped I could get it, but right now I couldn’t see a thing around his enormous, cobbled tongue. I rocked the blade forward half a degree, and one of his incisors gave slightly. Abruptly I tipped the blade back toward me and hauled straight up.

Heart rate forty-two, Shaniqua said, as if I couldn’t hear the beep of the monitor slowing behind me. In this case, forty-two was not the perfect number. For someone so emaciated, his head still weighed a ton. His tongue was everywhere. Why couldn’t I see anything?

For starters, I didn’t have a Glide Scope. When I started residency, we’d done all our intubations with the Mac blade, but one of the video scopes was out for repair, anesthesia had borrowed the second two weeks ago, and Amina was using the other. Also, I’d been working for nine hours, almost half of one doing chest compressions, and my arms were quivering like strawberry Jell-O. Third, and most critically, I’d just promised his mother we would do everything we could.

I still couldn’t see the glottis. I pulled the blade out and dropped it on the Mayo stand with a clatter. Shaniqua handed me the bag-valve ventilator, and I started giving rescue breaths. I listened for the beep of his heart rate to pick up. I wanted it above sixty before I tried again. Is it time for more naloxone yet? I asked.

Naloxone, Shaniqua repeated and pushed it into the IV.

His heart rate came up with the breaths, or the naloxone, and I tried to steady my own breathing. What was I going to do when I was on my own and couldn’t phone a friend? In ten months, I’d be the attending physician—the only one who could save the life in my hands. As if I’d conjured her, Dr. Mindy Schwartz came in, her hand patting her empty breast pocket once, presumably for the Dutch courage a pack of cigarettes had once afforded her. I stood up, but she waved me down and took a spot at my shoulder, like a good angel.

Nineteen-year-old, overdose on—

I recognize him, she said. How can I help?

I can’t see anything. His tongue is everywhere.

She glanced up at the monitor, where his heart rate beeped at seventy beats per minute and his oxygen was one hundred percent. She took over bagging his breaths and hitched her chin at the laryngoscope blade I’d put down.

I started again from the beginning. Sniffer position, his chin pinched in my right fingers, blade in my left hand. The light popped on as I clicked the blade into position at ninety degrees, and I slid it between his teeth.

Left to right, she said in my ear.

I swept the tongue to the left and just like that, the glottis appeared like the mouth of Indiana Jones’s cave. Someone slapped the endotracheal tube into my right palm, and I slid it easily between the vocal cords. I tugged the stylus out of the tube and withdrew the blade. Mindy attached the end-tidal CO2 monitor and the bag-valve apparatus to the top of the tube. I watched his chest rise and fall. The CO2 monitor turned purple. I put my stethoscope in my ears and listened on both sides of his chest. Right and left filled with the reassuring whoosh of air.

I stepped back, and the finely choreographed dance of respiratory tech, nurse and X-ray tech began. Wordlessly they worked around one another to attach the ventilator, tape the tube in place, sweep away all the detritus from the intubation, and slide the X-ray plate under his back. I gave the respiratory tech the ventilator settings, and Mindy and I stepped out of the room for the X-ray.

Now that it was done and he was safe for now, embarrassment replaced my relief. I can’t believe I forgot it was left to right, I said, stripping off my yellow plastic gown and gloves. I kept going straight and then couldn’t see anything around his tongue.

She took a squirt of soap and waited her turn for the water. We’ve all done it, she said. We’re so used to the Glide Scopes. Like the EMR. Can you imagine what would happen if we had to go back to paper charts?

Or dumb phones.

Cameras with film, she said.

I dried my hands and tried to remember putting film in a camera. A roll of twenty-four photos had always included at least six blurry shots and two of my finger.

Do you want me to talk to his mom, or—

I’ll do it, I said. The tech was wheeling the portable X-ray out of the room as smoothly as Snoopy’s Zamboni, and Shaniqua was piggybacking a bag of naloxone on his IV drip. His mom was waiting in the small family conference room down the hall and popped up out of her chair the moment I opened the door.

Is he…

Stable, I said, thinking of all the false promises implied in that word. He’s going to be fine. He’s going to make it out of this. He’s going to be the same person when he wakes up. He’s going to get clean.

Can I see him?

She followed me past rooms full of broken arms and sprained ankles, all of which would heal with time, to her son’s room and pushed aside the curtain. Shaniqua had placed a chair by his right hand so that her back would be to the clear glass doors. A semblance of privacy, if that could exist in the emergency room. She sat down and took his flaccid hand in hers. I grabbed the wheelie stool from the corner and sat across from her. Why is the IV in his neck? she asked, between mechanical breaths.

He’s used up all his other veins. His arms, hands, feet, abdomen, legs and scalp were scarred down with old needle tracks. Now that we’d accessed his external jugular, he probably would, too. The next time he came in, he’d have a stroke or an abscess from shooting heroin into his heart.

She swallowed hard. The clock above the door said five-twenty. Conversations like this were like talking to my children about where babies came from—they went better when I answered only their questions—but my shift was over in twenty minutes. Dan and the girls were no doubt packing the car for vacation as I sat here, and I still had to finish three notes before I could leave the hospital. I wiped my hands on my scrubs and wiggled my toes inside my sweaty socks. Was she waiting for me to say something?

I don’t think I can do this again, she said, voice cracking.

Still not quite a question. I wondered which part she meant—telling his father he’d overdosed again, the miserable hospital stay, or the desperate search for the unicorn of a rehab bed?

The last time, Drew was on five south for almost a week while we waited for a bed to open up, and then left against medical advice the day he was supposed to be discharged. She smoothed the white cotton blanket, and we listened to the hiss of the ventilator behind his head. The smell of bleach from his sheets was almost strong enough to cover the smell of his rotting toes. You just never think this is what your life will be like, you know? When they’re little, you think your biggest problem is bedtime, or that they put their shoes on the wrong feet.

We both looked down toward his feet. I thought about the slipper Shaniqua’d had to cut off his swollen foot in our search for a vein. I hadn’t noticed if it was a right or left.

Of course bad things happen—you can’t pick up your phone without seeing some horrible headline—but you don’t think it will be your kid. Your family. You think it happens to somebody else. Her eyes were so shadowed she looked like a lemur. What would happen if I walked away this time?

Finally a question. I expect he’ll wake up tonight or tomorrow morning.

But you don’t know.

Not yet. There was nothing outstanding on his head CT.

What does that mean?

No new changes. No stroke, no infection. I think this is all from the heroin. The naloxone drip should overcome it, and then we’ll extubate him.

And then he’ll need a rehab bed.

Yes. Please don’t ask me how long that will take.

How long will that take?

I don’t know.

She nodded. She knew more about how that worked—or didn’t work—than I did. Nobody went from the ER to rehab. His chart showed six previous overdoses followed by rehab stays, as well as the three times he left before they got him a bed. How many times had she been through this with him in other hospitals, other ERs? How many times had she resuscitated him with a naloxone injection at home without ever bringing him in? I thought of my mother who had walked this road with my dad before there was naloxone, before opiate crisis was a household phrase, back when no one talked about addiction, and wondered why she hadn’t walked away. Where would Drew go if he didn’t live with you?

She shook her head slightly. The street. He’s run out of friends with couches.

His father—

No.

The clock said five-fifty. Through the glass behind her, my replacement gave me a nod and badged into the computer terminal at the desk.

What am I legally required to do? Her voice shook, but she held my gaze.

I—I don’t know. Certainly she had met any reasonable standard.

I know I’m his next of kin and have to make decisions for him if he can’t speak for himself, but at some point… I mean, he’s an adult. At some point, doesn’t he have to…

When does he turn twenty-six?

You mean because he won’t be able to be on my insurance anymore.

Also not a question.

Yes.

December. She nodded, three bobs of her chin in the time it took her son’s chest to fall, and then she took a shuddering breath at the same time as the vent filled his lungs again. It reminded me of the deep breath you take with your child when they’ve just stopped sobbing. All right. She fumbled in her purse and took out her phone.

I pulled the glass door seven-eighths of the way shut, rubbed an aliquot of hand sanitizer in and made for my corner of the workstation. I shrugged on my fleece and opened my laptop, which came to life with a quiet whirr. As IT had prepped for next week’s update, our computers had gotten slower and slower. Instead of waiting, I went to grab a cup of coffee. When I came back, the HEROs graphic was still circling. A minute later, it switched to the blue screen of death. And not just my computer. Over the carnival of hospital noises—monitors, distant crying and residents complaining about how busy it was—floated a collective groan, and then a silence, like the deflating of a balloon. The mobile computers the nurses rolled around and the desktop terminals had gone dark as well. Seriously? someone behind me said. Seriously?

Everyone reached to turn their terminals off and back on, but the blue screen persisted.

After a few minutes, a white box appeared. YOUR SYSTEM HAS BEEN LOCKED BY 8LAXP0T, it announced. YOU HAVE 168 HOURS TO PAY 60 BITCOIN TO UNLOCK YOUR SYSTEM, OR ALL RECORDS WILL BE ENCRYPTED PERMANENTLY.

I glanced across the unit. All the terminals flashed the same message, iterated forty times as if we were at Best Buy. A minute later, disbelief erupted, followed by swearing. I saw four people pick up phones, presumably to call IT. I was so close to getting out of here. Dan probably had the girls in the car already. But I couldn’t leave until my notes were done, and with no computer, there was no way to do my notes.

Is it REvil?

What’s REvil?

That Russian hack.

It says it’s eight L-A-X pot.

That’s a zero, not an O.

How much is sixty bitcoin in dollars? someone asked.

No one seemed to know. Nobody knew how much data it was, either. I remembered a random factoid Dan had spouted once, that an MRI might take thirty megabytes of storage, but extrapolating from that statistic to a sum of all the scans, reports, notes, orders and vitals for more than two hundred thousand patients in our system for the seven years we’d been using HEROs would require a quantum computer.

Should we reboot? Ryan asked. Or unplug them? He had the lean body of a distance runner and ran a hand through his hair in a good imitation of Ryan Reynolds. Or Gosling. I could never keep them straight.

These are just terminals, I said. There’s no data stored in any of these.

The glut of incoming staff and overnighters wanting to go home made the work station feel like a junior high passing period. A few of the nurses were still delivering medications, while the doctors had all been trying to finish their charting. Peggy scanned her ID on the pharmacy’s medication dispensing machine, but nothing happened. She repeated the process twice more before entering her code manually, but it had a blank, blue screen, too. Of course it was connected to HEROs. A surgery resident I recognized swore and headed back toward the hall that led to the ORs. Our most senior clerk, Miss Washington, stood up. She was the texture and color of a raisin and barely taller standing than sitting, but her height belied her power. She was our collective memory. The resilience of analog. I’ll go find some clipboards, she said. You can use the white board in the break room to make a census.

In the years before the patient privacy craze, the ER had kept track of patients and staff on a large white dry erase board, leading to a citation for violating HIPAA. The board had been banished to the break room and was used to write kudos to each other—which were supposed to make up for the pay cut we’d had to take last year—and requests to switch shifts. There were more schedule change requests than kudos. Mindy, Ryan and I cobbled together a census of the unit before Miss Washington came back from whichever subbasement had the clipboards. In the meantime, no one had been able to open the electronic medication dispensary. The X-ray tech was back with the portable machine, but her tablet with all the X-ray orders had gone blank. The telemetry and vital sign monitors over the patients’ heads were flashing the same harsh message as the computers, only the 168 had started to count down and was now at 167 hours and thirty-seven minutes.

A pharmacy technician came running into the unit with a rolling cart of medications. He screeched to a halt when we saw us huddled around the census board. So it’s not just us, he said, wiping his forehead on his shoulder until his neck cracked. Has anyone called IT?

Five minutes later, Mindy sent nurses and residents two-by-two like Ark animals to figure out who still needed scans and meds. Three IT techs finally arrived, all wearing Hawaiian shirts, neon badges that said SUPERHEROs, and panicked looks. I knew the woman from the last two weeks of mandatory trainings, during which she’d clapped her hands like a SeaWorld marine biologist and repeated over and over how great the update as going to be. It’s going to be like getting a whole new addition to your house, she’d promised. Today she looked like an Orca trainer who’d run out of fish. We’ll have this sorted out as soon as we can.

Which is never, the blond SuperHERO grumbled. You can’t unlock—

The taller one nudged him harder than necessary. Where did it start? he asked.

Hands gestured in every direction. How could we tell where it started? Are we the only floor this has happened to? I asked. Pharmacy said—

No, Blond Hawaiian said, swiping his badge in front of a terminal. It’s all over the hospital. Even some of the remote sites. He bent under the counter and unplugged the terminal. Next he’d probably slap the side of the monitor. Percussive therapy, Dan called it.

I didn’t have time to tell him that wouldn’t work. Peggy was at my side with a stack of clipboards. She handed me half, and we started at room seventeen, making notes as we went. Can the lab tube us results? Or should we send a runner down every fifteen minutes?

Maybe they can fax the results, she said.

They wouldn’t be able to, because last year IT had replaced all the fax machines with scanners working through the web interface. And there’s pharmacy and blood bank, I said.

What about the monitors? she asked. How are we going to keep track of vitals?

Manually, obviously, but I had no idea what to do about telemetry. We’d have to put a nurse in every room. How were we going to find enough staff for that?

My shift should have ended five minutes earlier, but I hadn’t finished my charts or given sign-out. I was about to text Dan not to pick me up yet when a Code Blue alert sounded from room eighteen. I looked automatically at the monitor, but it only flashed its dire warning. 167:21. I grabbed the defibrillator, and Shaniqua followed with the crash cart. I introduced myself to the patient, who was unresponsive, and donned a pair of gloves. The room was too quiet without any of the normal hospital sounds. Not even the patient’s labored breathing.

Whose patient is this? I asked.

Mine, Ryan said, crashing into the room like Cramer. He was fine five minutes ago.

I put a finger on the patient’s carotid. Nothing. I ripped the bag-valve-mask device off the wall and connected the oxygen, one of the few parts of the ER that wasn’t connected to HEROs. I handed the BVM to Shaniqua, who began giving the patient breaths, and opened the defibrillator. More nurses arrived and donned gloves.

Why did he come in? I asked Ryan. He was flipping through loose papers that didn’t appear to have much written on them. He shot a frantic look at Peggy and shook his head.

You start compressions, I told him. Peggy, you record. Someone tell me what he’s here for.

Pneumonia, Ryan said. And he was in atrial fibrillation with a rate of one-ninety.

According to the defibrillator, it was ventricular fibrillation now, the chaotic cardiac equivalent of what was happening across the hospital. I need a blood pressure,.

It’s connected to HEROs, the medical student said.

Take it manually, I said. And put on some gloves.

He fumbled into a pair of nitrile gloves too small for him and ripped the cuff off. His hands were shaking so badly, he had trouble getting the stethoscope into his ears.

Fluids? Mike asked, going to the IV pump.

Wide open for now, I said.

Ryan’s panicked compressions weren’t deep enough to do much good. The patient’s rhythm changed to ventricular tachycardia, and the defibrillator told us to clear the bed. Ryan jumped off so fast he knocked into the crash cart and sent it into the wall with a thump.

Make sure the bed is locked, I said. We looked so much like a circus I wondered when the car full of clowns was going to arrive. Epinephrine.

Shaniqua held up the syringe and repeated the order.

At some point between the second and third shocks, the security guard came in. I heard him say, We’ve run out of chairs in the lobby. Do you have any beds you can free up?

Peggy shot him a look. Give us a minute, and we’ll put this guy on the floor for you.

Get the house supervisor, I said. We’re going to have to go on bypass.

Half an hour later, we had the patient whose name I still didn’t know back in a survivable rhythm and on his way to the Cath Lab. Mindy and Amina were in the room with their own Code. Dr. Smith waltzed onto the unit in his crisp white coat and waved his badge at the locked computer. Miss Washington was explaining to the interns and second-year residents how to write their orders on paper. You have to write clearly, she said. And put your pager number under your signature so I can call you if it’s illegible.

Dr. Smith looked up. What is this?

We got hit with ransomware, Blond Hawaiian said from the floor. He had a stack of useless laptops in front of him.

This is unacceptable, Dr. Smith said to Miss Washington, as if she’d caused the outage. Someone call IT.

TWO

When I made it out of the hospital, our car was idling in the no parking zone like a smoker banished one hundred feet from the entrance. Do you want me to drive first? I asked. Dan and I both knew I’d be too tired to drive later.

No, I’m good. He smiled.

I crammed my briefcase into the back between a suitcase and the dog’s crate, though the dog wasn’t in it. She had her back paws between the girls and her front paws on the door. Her long nose pushed past Genie, who was so engrossed in her phone she didn’t even notice. Molly leaned over wagging dog butt to ask me questions I didn’t know the answer to. Which room will I get? Do you think there are fish in the lake? Are they big fish? What time will we get there?

Finally a question I could answer. Three and a half hours. Maybe four. I shut the hatch, slid into my seat and buckled up. I shot a glance at Dan, but he didn’t look mad, or even annoyed that I was more than an hour late. He handed me a McDonald’s bag and pulled away from the curb.

Can I have some of your fries? Molly asked.

You had some already, Dan said.

The car did smell overwhelmingly of fries. And dog.

Peanut ate mine, Molly said.

Not all of them, she didn’t, Genie said without looking up from the phone.

Will the house have a pool?

No, it has a lake. The fries were still warm, though no longer crisp. The salt melted on my tongue, and I tried not to look like they were the best thing I’d put in my mouth in the last month.

Can you swim in the lake?

Yes, sad city girl, you can swim in the lake.

How was your shift? Dan asked.

I shrugged and stuffed down all the horrors I couldn’t unsee and couldn’t share—Drew’s loose teeth, perfectly straight from thousands of dollars of orthodontia but rotting now from meth and heroin. The anal cancer that had festered until its victim couldn’t sit down. The rape kit. The three people I’d declared dead