For Peter

My forever love, my inspiration.

Man has made many machines,

Complex and cunning,

But which of them indeed rivals

The workings of his heart?

Pablo Casals

PROLOGUE

The human heart is a highly sophisticated pump. Protected by the ribs, it lies deep in the chest cavity. Though scientists have created prototypes, successful replication has failed.

The adult heart is roughly the size of a man’s fist and weighs about a pound. It pulses an average of one hundred thousand times a day, over two billion beats in a normal lifetime. In one minute, this magnificent muscle pumps about five liters of blood. The heart sustains life in two ways. First, it siphons oxygen-rich blood from the lungs, circulating it to the brain, kidneys, and other vital organs and tissues of the body. Then it recycles waste products, like carbon dioxide, back to the lungs for exhalation. The work performed by a heart over a lifetime is comparable to a single man lifting thirty tons to the peak of Mount Everest.

Heart performance is a delicate, synergistic balance of anatomic and physiologic factors. Fluid and electrolyte balance provide the electrical conductivity necessary for the heart to beat. Hypothalamic cells affect the rise and fall of blood pressure, stimulating an increase or decrease in cardiac output. The complex and elegant interfaces that occur at the cellular and organ level are unknown and taken for granted, not even given a thought by the average healthy person.

The heart is a living paradox—strong yet fragile. Subtle changes within this system can trigger a cascade of events that, if unrecognized, will kill.

Death Without Cause

Pamela Triolo

F I R S T   E D I T I O N

HARDCOVER ISBN: 978-1-939288-09-7

eBook ISBN: 978-1-939288-10-3

PAPERBACK ISBN: 978-1-939288-06-6

Library of Congress Control Number: 2013931497

ALL RIGHTS RESERVED

©2013 Pamela Triolo

No part of this publication may be translated, reproduced or transmitted in any form without prior permission in writing from the publisher. Publisher and editor are not liable for any typographical errors, content mistakes, inaccuracies, or omissions related to the information in this book.

This is a work of fiction. Names, characters, places, and incidents either are the product of the author’s imagination or are used fictitiously, and any resemblance to actual persons, living or dead, businesses, companies, events, or locales is entirely coindicental.

Published by Post Oak, An Imprint of Wyatt-MacKenzie

postoak@wyattmackenzie.com

CHAPTER 1

TEXAS MEDICAL CENTER, HOUSTON

Early October

Santos Rosa raced up the stairwell on the tail of his long white coat. Her heart pounded and her mind raced. One more to go … we’re almost there … will we make it in time?

“Patrick, you’re a maniac, wait up!” Patrick Sullivan’s long legs took the stairs two at a time and he burst through the door and ran down the hall toward the polished brass entrance of the VIP unit—the unit that housed headliners from rock stars to international royalty. She caught up with him as he punched in the security code. The doors flew open. Santos and Patrick, experienced CCU RNs, rushed in side by side. She looked up and down the hallway. Every sense was on full alert, fueled by the adrenaline of anticipation. She spotted a staff member who pointed down the hall to the left. On reflex, she reached into her pocket, grabbed her stethoscope, laced it around her neck, and ran.

“Code Blue, Jones 6 … Code Blue, Jones 6,” the overhead paging system repeated.

Santos and Patrick were rotating on the code team. She looked up at Patrick and saw concern etched on his face. Who was it this time? The lavishly furnished unit had hosted a string of who’s who for decades. The crash cart was next to the door, drawers open and supplies littering the floor. Staff spilled out the doorway, waiting to assist.

Entering the hallway of the spacious suite, she wove through the crowd of residents, medical staff, pharmacists, and nurses in search of the patient. Before she could see what was going on, she could smell it—sweat and blood. What she saw was shocking. Sheets of shiny, wine-red blood cascaded off the bed and dripped onto the floor. The tile floor was stamped with bloody footprints. The woman on the bed, a well-known and respected public figure, was still, her skin as pale as her hair. Dr. Richard Whiting, CCU medical director, was doing CPR, and the bed rocked with the force of his chest compressions.

“More plasma!”

“Coming!”

“No pressure, no pressure! We’re losing her,” shouted the anesthesia resident monitoring blood pressure, oxygen saturation, and cardiac rhythm. The attending anesthesiologist, OR mask still hanging around her neck, bagged the patient forcing in oxygen. Every heart in the room pounded rapidly. Every heart but the one they had come to save.

“Come on, people,” Whiting shouted. “We can’t lose her!”

Whiting briefly looked up, and his eyes locked on the newcomers. His ruggedly handsome face was wet with the sweat of exertion, and his long gray ponytail had come loose. Hair was plastered to his face and neck. Deep green eyes, ringed by dark circles of exhaustion, reflected his worry and sadness.

“Patrick, get your butt over here. Take over for me.”

Patrick quickly navigated around the equipment and people and smoothly transitioned chest compressions, relieving Whiting.

“Santos, take a look at the record with me.” Whiting headed over and stood by her side, looking down at her. Everyone towered over her. “How could we let this happen?” On the portable computer, she swiftly pulled up the EHR, reading over the electronic health record for clues.

“She was here for a knee replacement, a simple knee replacement. We should have put her in CCU as a precaution,” Whiting commented while scanning. His eyes darted back and forth between the patient and the record.

“Labs look normal, her INR looks normal. She was getting routine enoxaparin injections and Coumadin by mouth,” Santos reported.

“That can’t be right. That INR cannot be right. It’s too low … it’s normal. She’s hemorrhaging! We need to recheck it now … where’s that Vitamin K? Move it people!” he shouted.

“Injecting now. More plasma on the way.”

Santos read from the record, “She has a history of some internal hemorrhoids, some pretty serious bleeding episodes. Admitted to the ER twice for rectal bleeding. She’s on beta-blockers and Coumadin for atrial fib. Looks like her INR fluctuated quite a bit.” Her heart was sinking with worry, and she stopped, looked at him, and waited for his response.

Whiting raked his hand through his wet hair, looked down, and muttered under his breath, “What a mess! God help us.”

Three long seconds passed.

Decision made, Whiting turned around.

“Call him,” Whiting said quietly to the tall man standing nearby, telltale corkscrew wire threaded into his ear. The man’s tailored black suit and tie stood out in stark contrast to the sea of blood-splattered white coats and rumpled, faded blue and pink scrubs. His face was a mask of emotion, but the eyes were alert, constantly scanning the area. “He needs to be here. Be sure that someone is with him when he hears. This could kill him.”

The man nodded, lifted his hand toward his face and softly spoke a few code words into the radio. Then he returned to watching the unit, the flow of clinicians coming and going, and occasionally his eyes would rest on the still figure of the woman on the bed.

Outside the circle of the code, a tall man in a pristine white lab coat carrying a collection of tubes and vacutainers passed by the open door of the room. He looked at the organized chaos, but kept his distance. Then he stopped, turned around, and shuffled out of the unit as quietly as he had come.

CHAPTER 2

Two Months Earlier … August

He could not breathe.

The weight crushed his chest. He struggled in agony to draw in just one lifesaving breath, but his ribs felt squeezed in a vise. He tried to inhale again … break loose … nothing … he was paralyzed. Fully alert, his brain supercharged with the adrenaline of fear, he knew he was suffocating. Within moments, he saw black and white dots swirling. Losing his grip on consciousness, he plunged into the abyss.

He shot up in bed, gasping for air, drinking in deep breaths of cool air. His heart hammered, threatening to explode in his chest. Blood pounded up his carotids and throbbed into his jaw. The sheets were wet and cold with the sweat of his fear.

Fresh memories flooded back as if it had been yesterday, when in fact it was nearly thirty years ago: suffocating, then waking up intubated, alert yet unable to move a muscle, eyes fixed on the cracked and peeling ceiling in the Cyprus hospital, alive only because a machine breathed for him. Tears burned his eyes, tears that he would never weep, and he swallowed hard, choking back the bitter taste of bile.

He had suffered the humbling, grueling, and never-ending journey of rehab as he struggled to strengthen wasted muscles. The attack of Guillain-Barre forced him to regain the stamina to walk, to rediscover the dexterity to eat, and to rebuild the neural pathways that had forgotten how to do the simple things in life—hold a fork, brush his teeth. The humiliation of going from decorated military pilot to helpless baby as others washed him, fed him, and cleaned up after him was still raw.

He lived in a prison not of his making. They had let him down, crippled him for life, and robbed him of his hopes and dreams. The people who had taken an oath to protect and cure had destroyed the man he was, the man he had hoped to be. He had lost everything: his career, the woman he loved, and any chance of ever becoming a father. Bastards!

He had chosen the path of anger for years, and anger had carved deep lines in his forehead and the downward creases of his mouth, sculpting his face into a mask of bitterness, his mouth a sneer. Nearly succumbing to the depression of self-pity, he stopped himself before drowning in the black hole of despair. He breathed more evenly now, his heart slowed, and he looked around at the tranquility and order of his bedroom and remembered. Today would be different.

After the usual slow struggle of shaving and showering, he limped into his kitchen, a crutch supporting his weak right leg. His hand tremors decreased a bit when he poured thick black coffee into a heavy white stoneware mug. Juggling the mug in his left hand, he headed over to the kitchen table, spilling some of its contents on the floor. Sighing, he put the mug on the table, went back to the counter, pulled off a length of paper towels, and mopped up the small mess.

He had no close friends and lived alone. His house was meticulous in its order, a clue to his military past. There was not a speck of dust on the minimalist space; magazines and books were stacked on the coffee table, corners matching and titles in alphabetical order. The white dishes on the open shelves were arranged with such symmetrical precision that even Martha Stewart would approve. His shrine of a computer alcove held the latest high-tech gadgets, with cords neatly wrapped and everything in place.

These days, everything seemed to tick him off. His anger, simmering for decades, had moved closer to the surface after his new supervisor had recently moved him with other MTs—medical technologists—to remote, windowless cubicles away from the general bustle of the hospital laboratory. Instead of covering all functional areas of the lab, the redesign clustered MTs into work groups: chemistry, hematology, stat lab, etc. His new assignment was chemistry, not his favorite. His preference was the stat lab, where the sense of urgency and variety kept him pumped. The stat lab was the epicenter of medical decisions, and the techs who worked there were adrenaline junkies.

He doubted the suits had any idea that the real source of power in health care was the laboratory. Physicians, nurses, pharmacists depended on lab results to provide crucial pieces of the clinical puzzle. Unlike forensic experts who searched for answers after death, health care clinicians searched for real-time biological clues—clues vital to discovering the cause of illness. Lab tests revealed secrets and told truths. Lab results could bring patients incredible joy and unspeakable sorrow.

With the local TV news on in the background, he ate a simple breakfast of instant oatmeal, his head buried in The Houston Chronicle. He glanced up and a rare smiled played on his lips. If I did it right, would I read about this in the papers? Anonymously, of course—this would be a perfect crime. His Google and other Internet searches had yielded long-ago references to his heroism. Now he was just another vet lost in the mainstream of life. Maybe finally, he would get some recognition for his IQ of one-fifty-five and the precision of his planning. He was about to begin a deadly game where he would write the rules, others would unwittingly play, and he alone would know the score.

CHAPTER 3

Late August

In the early morning darkness, Santos rode The Woodlands Express into Houston, drinking in the relative quiet of the dim interior. She was dark and striking, a petite young woman of twenty-five with streaks of natural russet in her thick, mahogany hair. Her hair swung shoulder length, framing an olive-skinned oval face with hazel-rimmed brown eyes. Her eyes appeared to change color depending on her emotions, from warm coffee to black that could shoot sparks of amber when angry. Right now, they were clear and bright, sparkling with anticipation.

Named for the day she was born, Dia de los Santos, All Saints Day, Santos was a first-generation Texan. Her family had emigrated from Mexico some thirty years ago, and she was the youngest of seven and the first to be born in the United States. Though not the first in her family to graduate from college, she was the first nurse, and that achievement was the pride and joy of her parents. Her cultural background had turned out to be a career boon as well: bilingual in Spanish and English, she was much sought-after for her ability to translate for families who came from around the world for care.

She reflected on the past two weeks and smiled at the memories of her vacation in Telluride. The drive up through Texas, New Mexico, and then the winding mountain roads of Colorado had allowed her to decompress. She loved to travel and explore. The spectacular mountain peaks, crisp mountain air, and the wonderful aromas of cedar mulch and juniper trees had made for a welcome escape from the oppressive heat of the southern summer. The dry heat, nearly cloudless mornings, and afternoon cooling showers were lovely. She had happily slept with the windows open at night while temperatures dropped into the forties. The public transportation system was amazing. Gondolas connected Mountain Village with the village of Telluride. The only one of its kind in the US, the ride down to Telluride showcased a spectacular view of the valleys. When the gondolas got close to the tree line, they nearly grazed the foliage, and then soared high into the sky. The ride was so quiet that she could hear the sounds of birds and the distant laughter of families.

Refreshed, she was ready for the never-ending challenge of work.

As the bus drove down Montrose under the arched canopy of gigantic live oaks, she could see the lights from the sprawling Texas Medical Center, the largest medical center in the world. The brightly lit twin needles of St. Luke’s Towers stood out in relief against the backdrop of night. The TMC, composed of over fifty organizations employing some one hundred thousand faculty and other staff, covered an area about the size of the Chicago Loop. Created as a nonprofit mecca for health care over sixty years ago, it now included a cluster of nationally known Magnet hospitals recognized for the high caliber of their nurses. Riding in and seeing the exciting complex still gave her a thrill. With six million patient visits a year, the TMC had been her first choice for work and education. Yet, until 2011 when US Representative Gabby Giffords had come for rehabilitation from a traumatic brain injury, few people outside of Houston seemed to know of its existence.

The bus pulled up to the Holcomb stop, and her mind jolted back to the present. She stood up with the rest of the early risers to move off the bus. After good-byes to some of her regular riding friends, she briskly walked the short distance to work. The air was cool and breezy, heralding the onset of fall, the much-awaited respite from the scorching and humid heat of summer. The route took her along outdoor paths bordered by huge mounds of colorful vincas and petunias, then inside to air-conditioned skywalks that connected most of the buildings.

As she walked, she noticed people eating in restaurants, new seasonal clothes in some of the shops, and a sale in the jewelry store. She was constantly amazed by the buzz of activity even this early in the morning as patients and students from all over the world came for health care or education.

Three years out of college, Santos had quickly earned the title and role of clinical mentor in the thirty-bed CCU. She felt privileged to work at Medical Center Hospital, where the nursing beacon burned bright and there was a waiting list for employment. Nursing was her mission and her passion. She had chosen nursing as a career because she knew it would challenge her intellectually. Naïve going in, she had discovered that it tested her in every way, stretching her to grow. She knew that every day she could make a difference in people’s lives.

She moved purposely through the maze of corridors, smiling and exchanging greetings with colleagues from Food and Nutrition Services, Housekeeping, and Pharmacy. At 6:30 a.m., the halls were already crowded and bustling with people and equipment. The thousands of employees in the 450-bed academic tertiary hospital made it more like a small town. Staff considered their coworkers part of their family, generally spending more time at work than they did with their families at home. Teamwork was one of the reasons staff stayed and the patients received some of the best care in the city.

She guided a lost couple to the east wing pre-op area, walking and talking with them to allay the husband’s obvious fears about his wife’s imminent surgery. Then she swiped her badge through the electronic time-and-attendance recorder, avoided the slow elevator bank, and walked up the two flights of stairs, jostling the backpack on her back and the casserole in her arms.

Approaching the entrance to the CCU, she punched the red button on the wall with her right elbow. The double doors swung open, revealing a sea of patients organized in circular pods around the centralized workstation. The noise and bright lights of the unit assaulted her senses. Having been away for two weeks, she stopped and looked with fresh eyes at what new patients and families saw every day. It struck her how the cavernous architecture and tile floor amplified the noise—the constant beeping of IV pumps and heart monitors as well as the whooshing rhythm of the ventilators. The unit was alive with movement and energy. Change of shift. The unit was crowded with doctors in long, white coats, accompanied by exhausted medical students in their distinctive short white jackets. At least ten clinicians stood clustered around the workstation. She headed toward the conference room wondering as usual how patients could ever rest and heal amidst the cacophony.

Though just five feet, she felt taller as she walked with confidence into the conference room bearing gifts. A cluster of nurses, both men and women, were finishing work and chatting. Everyone looked up with smiles when they saw her. Not only was she new energy back from vacation, but she had brought a casserole of breakfast tortillas to feed the forever-hungry crew of nurses and residents who rarely got off the unit to eat. She unzipped the red-quilted insulated cover and lifted the lid from the still warm dish. The aroma of scrambled eggs, sautéed onions, green peppers, potatoes, and sausage filled the room. The conversation shifted from patients to food.

“How do you stay tiny when you cook like this?” asked Emma with a Southern drawl and a roll of her eyes as she opened a foil wrapper and bit into a soft, warm breakfast tortilla. She sighed deeply with pleasure. “Mmmmmm … your Mamma taught you well.”

Emma Perrine, RN, had been Santos’s mentor since she started on the unit. A beautiful woman with skin the color of creamy milk chocolate, Emma’s dark eyes were warm with compassion and deep with the wisdom of experience. At forty, Emma was an expert practitioner who was also the mother of three active teenagers. Like Santos, Emma was multilingual, fluent in both French and Creole. Her body, graced with generous curves, was testimony to her love of food and her reputation as a fabulous cook. Santos smiled as she watched Emma eat, remembering the story of her friend’s delight when nurses went from white uniforms to comfortable scrubs with elastic waists.

Cody Patterson, the RN administrator on duty, stopped in while on rounds.

“For once, I’m in the right place at the right time.” He sat down at the table and quickly reached for one of the rapidly vanishing tortillas. “There’s nothing in the world like homemade breakfast tortillas! Santos, you’re the best! Why don’t we do this more often?”

Santos shook her head, then smiled and pointed her finger. “Cody, your turn next time.”

“Hey, now that we have you back, when is your Abuela going to make tamales again?” Patrick Sullivan smiled, winked at her, and then leaned over to pluck a tortilla from the casserole. Five years her senior, he was tall, with a strong athletic build and youthful good looks. He was one of the best and brightest nurses on the unit; in fact, in the entire hospital. Well-known for his consistent performance, great interpersonal skills, and strong clinical diagnostic aptitude, Patrick was constantly encouraged to move into management. Yet he had told Santos that the real place to make a difference was in patient care. He was consistently in demand as a mentor for seasoned nurses as well as students and new staff. His energy was boundless, he always had some new project going, and he had just finished his graduate degree. He was on Santos’s case to get started on hers.

Santos smiled at Patrick then frowned. She looked around the room with concern at the crowd that had gathered, counting heads and tortillas. Would the supply of food hold out? These people were her work family. This was a real treat, and she only hoped it would go around.

Patrick ate with relish, attracting another envious comment from Emma. With the chiseled jaw and lean look of a marathon runner, he was able to consume tons of calories and never gain an ounce. Santos watched him finish his first tortilla in three big bites and reach for another. She felt warm all over thinking about Patrick and smiled at his obvious pleasure. She had tremendous respect for him; she could always count on him for great clinical advice or help. Besides, he was so cute with his blond buzz and those few freckles.

“Abuelita hasn’t been feeling well recently. I really need to go and see her.”

“Abuelita” was Santos’s special name for her grandmother. Wishing for tamales was one thing. Making them was another. Tamales were an ancient food, dating back to the pre-Columbian era, and a holiday favorite of her family. The preparation of this labor-intensive comfort food began with soaking dried corn husks for hours, braising beef or other filling, creating the sauce, preparing chilies and grinding them to powder, and making masa, a cornmeal dough. The multistep process took hours and many hardworking hands. Santos’s job in the production line was lining the corn husks with masa.

“I’ll be sure to bring some in when the family gets together again over the holidays. Ya’ll come! We can always use an extra set of hands.”

“I heard that the cooking school in The Woodlands had tamale classes,” Emma piped up. “Bet they can’t compete with your family recipe, but that would be fun to do as a group sometime.”

“Let’s do cooking school before I start classes next semester,” Santos replied. She had just registered for her first course at the University of Texas Health Science Center School of Nursing. She was excited not only about the challenge of graduate work, but also about meeting new people from other hospitals. She loved learning, was always hungry for new information.

The quick conversation around school and food abruptly ended with the departure of the night shift and the need to get to patients. Santos sat down, logged in, and began to review the electronic records of her patients. She had much to review, as all the names were completely new. Pausing in her work, she looked over her shoulder at the casserole of tamales, thinking she should put the leftovers in the refrigerator. Too late—devoured.

Before she went back to the records, her mind skipped ahead to Kimberly’s wedding this weekend. Santos met Kimberly at a seminar on quality improvement. It turned out that Kimberly worked in physical therapy at Medical Center Hospital. They knew many of the same colleagues and quickly found common ground. Over the years, they had forged a relationship that grew into a strong friendship. Kimberly was from the country-club set and Santos’s family—well, no one owned a set of golf clubs or belonged to a country club. She was excited about the evening, but had mixed feelings. So many weddings, and I go alone. It always felt a little awkward and lonely. But she smiled, happy for her friend. Back to the present, Santos squared her shoulders and dug into the patient records.

CHAPTER 4

While Santos was working her first shift in two weeks, keeping up with patients and the constant churn of medical students and residents, he completed a set of blood tests and verified results. Will they ever label these specimens right? The health care system was full of potholes and riddled with mistakes—mistakes that could misdiagnose or kill.

A smile quirked at the edge of his mouth.

His mind worked rapidly while he processed specimens. His conscientious side was energized by the precision required. In spite of the constant repetition, doing it right required discipline. The job was dangerous: it involved constant exposure to blood and body fluids, viruses and bacteria. Measuring the right amount of a specimen, usually blood, diluting as needed, adding the appropriate reagents, and mastering the technology were all a part of successful testing.

A raw sense of power throbbed through him as he analyzed samples. Patients knew their lives were in the hands of doctors and nurses, but did they ever give a thought to the people behind the scenes? He could change lives in an instant, and no one would ever know.

Absorbed in his work, his thoughts rarely strayed from the boundary of the specimen. Analyzing specimens brought him peace and calm. The potent sense of control, knowing that the outcome of his professional work affected people’s lives, combined with the tranquility of the detailed work, had kept him engaged for nearly three decades. Consumed by the process, he was free of his lower-body physical weakness. His hand tremors eased up with voluntary movement, and he felt unencumbered.

The hours flew by, and his subconscious worked through the puzzle of his plan. He would fine-tune each step, yet leave room for improvisation. The plan was a game, an intellectual challenge. It had been percolating under the surface of his psyche for years and was nearly ready to put into play.

He pulled off his latex gloves, heaved himself up out of the chair, and lumbered over to the computer cubicle to review the latest set of lab results for outliers before posting to the patients’ electronic records. As he scanned the lab results, he remembered that tonight he had an appointment at the health club. He worked out three times a week, twice on his own and one night with a trainer who was also a physical therapist. He kept his upper body strong, using free weights at home between the health club workouts. As a result his upper-body strength was formidable, a source of great pride for him.

The weekly check-in with the trainer helped to keep up the flexibility and mobility of his legs, particularly the right one. Even though the workout was often painful, he knew, after years of rehab, that it kept him strong and active.

Returning to the centrifuge, he picked up a fresh specimen. Specimens came into the lab via pneumatic tube or personnel walked them down to the Processor. The Processor would log in the specimen, scan the bar code with the patient’s ID, and run it in the centrifuge where it would stay until picked up and analyzed by the MTs. Then the MT would scan the patient’s bar code pasted on the specimen into the scanner and manually enter the test results, or the computer would analyze and record them. Focus helped the hours fly. He smiled. Soon it would be time for him to launch the game.

CHAPTER 5

Labor Day Weekend

Saturday morning dawned cool and clear, with periwinkle skies. The haze of humidity had lifted, and the passing “cold” front brought relief from the heat, dropping the temperature to a gorgeous eighty degrees. Santos sat on her small sheltered back patio, drinking jasmine tea, her favorite, steeped exactly two minutes. She loved the soothing fragrance of the tea. Wind chimes played softly and melodically in the distance.

Without warning, a wave of melancholy washed over her. Her index finger traced the rim of the fine bone-china cup, one of her late mother’s, and she felt a small chip. Lifting the still warm cup to her cheek, she remembered the times she had watched her mother drink from this very cup. She felt a strong spiritual connection with Marianna, and cherished using her mother’s things, liking wearing her pearls, as it made her feel closer … the sadness blew away, passing just as quickly as it came.

The first falling leaves of the season swirled and danced across the lawn. She reflected back on the week’s events. The slightly detached vacation sense of perspective lingered. Tonight was Kimberly’s long-awaited wedding. Santos had errands to run, groceries to buy, and she desperately needed new shoes. The racing of her mind stopped when a vague feeling of envy surfaced. It seemed as if most of her friends were either married or getting married. Right now, she focused her time on career and school, too busy to think about marriage. Besides, work consumed her and she had little energy to devote to a relationship.

Her cell phone rang. Reality returned.

She took at a look at the caller ID, saw that it was Patrick, and wondered what might be going on with work. Santos always kept her phone close, anxious to be available for work and family. Her brother, Santiago, had teased her about what he had called her “addiction” to communication devices.

“Good morning! You’re up early,” she said, smiling. “What’s up?”

“Lots to do. You know the drill. I’ve already been out—great three-mile run. Thought I’d call and see if you needed a ride to the wedding.”

Patrick was going to the wedding, too?

She exhaled, caught off guard … confused. If she said yes, this would be a date. Their first date. Going to a wedding with someone was a big deal. She really liked Patrick, but they rarely had time to talk outside of work. Twelve-hour shifts did little for your social life. She had no idea how parents with kids juggled nursing shifts, much less how singles found time to date. Logistics rushed through her mind—travel time and the distance between their two homes. Then the more important question: was she ready for this?

She took a deep breath.

“Patrick, it sounds like a good idea, but I have to get some new shoes. I thought I’d come into town a little early, shop, and then head over to the wedding.”

She paused. He was quiet.

She broke the silence. “I’ll see you there? Save a dance for you?”

“I’m going to hold you to that! Sure I can’t pick you up?”

She could hear disappointment in his voice.

“Patrick, I’ll see you there. It’ll be fun. We need to have some fun. Work has been crazy, hasn’t it?”

“Yes, it has. Okay, I hear you. I’ll see you there. Have fun shopping.” Then he hung up.

She sat for a moment, staring at her cell phone, wishing her mother were still alive so she could ask advice. Why did that make me anxious? What do I do? Many women would love to be Patrick’s date for a wedding. Why am I hesitating? She believed in destiny and timing in love, though choice would always play a big part. Now was not the time. Glancing at her watch, she got up and went inside.

CHAPTER 6

That same Saturday morning, he sat glued to the computer engrossed in a web search. Searching for … he was not certain yet. It had to be something that would confuse yet not raise a red flag. It would have to be difficult to diagnose and impossible to trace. It had to be ordinary and every day, yet lethal and quick so they were helpless to stop him. Take them out of control for once.

His head throbbed.

Employee morale in the lab was at an all-time low. Their new manager, a young MHA, wet behind the ears with no clinical experience, had an office in another building. He was just another suit; might have been on another planet, he was so invisible. Obviously, he was a climber, another administrator on his way to the next job who would never learn their names or stop to listen to their issues. Unless you have been in the trenches on the clinical side, you have no idea what it is like.

These days, it seemed as if the only hospital communication, other than reading about something in the newspaper, was from the highly developed staff grapevine, where rumors of another five-percent cut fueled his discontent and paranoia. It would be typical of the bean-counter administration to terminate the most senior people with the highest salaries. The recent knee-jerk boardroom decisions that had reduced supplies and personnel fueled his resentment. Then he thought of the salaries those “suits” made … and his anger nearly blew him off track.

He took several deep breaths to calm himself. Then he refocused on the game plan. He felt like a cat toying with a gecko. He wanted to taunt them and play with death. Come in and out, quickly and quietly, put those arrogant snobs in white coats in their place. Show them real power … the power to kill. They deserved to be humbled. Nothing ever seemed to faze those docs, not even when they let healthy people crash into disability—a disability that would plague them their entire lives. They could walk away; go home in Jaguars to fancy West University or River Oaks. He had seen some of them in the society pages of the paper, partying in Aspen, of all places. They were all smiles, trophy wives dripping with ostentatious bling. Trim pretty boys. Aging icons. Unlike them with the constant rounds of parties and balls they attended, he was always alone … feeling lonely, damaged and incomplete.

Rage coiled in his gut like a serpent ready to strike; contempt energized him, sharpened his senses, and intensified his efforts. He obsessively searched through laboratory sites, E-Medicine.com, and other sites looking for something that would morph the spark of an idea into a flame of action. What laboratory test is routine, ordinary, done every day that if not done right could be life-threatening? He went through the screens he knew by heart: hemoglobin and hematocrit, platelet counts, differential screens, electrophoresis tests, reticulocyte counts, blood chemistry.

He thought back on his organic and biochemistry background and pulled out an old textbook, opening it to a well-worn section. As his finger traced down the page, his hand stopped at a bold heading. All of a sudden, it was clear. He sat back in his chair and smiled the smug smile of success. Revenge was sweet.

CHAPTER 7

Santos arrived at the cathedral that evening thirty minutes before the ceremony. She quickly found a parking place and followed others into the nearly empty church. She had chosen to wear a black, raw-silk sleeveless sheath that skimmed her curves and showed off the remnants of her vacation tan. She carried a small, black-beaded clutch, and a black wool shawl, essential for survival in chilly, air-conditioned Houston. She was anxious to snag a seat on the aisle so she could shoot great pictures of the bride.

She entered the church and was swept away by the heady scent of tropical flowers and beeswax. Dozens of white arrangements of roses, gardenias, and calla lilies were strategically placed on the altar. The heat of the evening intensified the perfume of the flowers. At the end of each aisle were tall glass hurricane lamps, circled by greenery, and tied with huge satin bows. The lamps softly glowed with white tapers. The candlelit aisle marked the journey to a new life for a committed couple whose story had begun on a blind date three years earlier.

She paused in the vestibule of the church, feeling a bit unsure in such a grand setting. This was a lot more formal than the weddings she usually attended. She looked around to see if she saw anyone she knew.

“Santos, are you ready?” She turned around to see one of Kimberly’s much younger brothers. He looked smart and grown-up in his black tux with white boutonniere roses. He held out his right arm, and she gratefully accepted. “I don’t have to ask ‘bride’s side or groom’s’ with you, do I?” he smiled. “You look great tonight, Santos. Different from your usual jeans and T-shirts.”

“Thank you, Andy. You don’t look so bad yourself.”

Andy guided her to a perfect spot on the aisle in the middle of the church. Santos knelt down in the quiet of the church to offer a prayer for the couple. Then she slid back in the pew to watch the parade of fashionistas. She was not disappointed. The church filled quickly with young and old, all well-dressed for a Houston evening wedding. She was pleased that she had carefully chosen her clothes for the evening. Better to be overdressed than under, her mother had always said. Marianna had felt it was a sign of respect to dress for the occasion. The church was overflowing with the multicultural community, men in their dark evening suits and sophisticated women wearing everything from black cocktail dresses to glittering St. John knit suits.

“Hi there….”

She was so busy watching the parade of well-dressed family and friends that she did not see Patrick slip into the pew on her left side.

“Hi yourself … where did you come from?”

“Andy told me you were here.”

She smiled up at him. “You clean up nicely.” He looked handsome in a dark, tailored suit, white shirt with silver cuff links and a blue tie. His face had a healthy glow from the sun.

He sat down next to her and gave her a long look. Then he reached over and gently took her hand … she turned to look at him. Patrick’s blue eyes turned deep sapphire with warmth.

“Santos, you look beautiful tonight.”

His words touched her soul and rekindled a fire long asleep. Her breath caught in her throat. At a loss for words, she looked away from his eyes, and touched the cuff link on his wrist, rubbing the fine polished metal with her thumb. Her heart fluttered … she felt warm all over. Am I blushing? Something shifted inside of her. It had been a very long time since someone had told her she was beautiful. After a few moments, she found her voice.

“Thank you, Patrick … thank you … you are very sweet.”

The people in the pews next to them began to whisper and look toward the back of the church. She squeezed and released his hand, then checked her watch. It was time. The congregation rose to attention when the organist at the huge, three-keyboard pipe organ began to play the wedding classic Clarke’s “Trumpet Voluntary,” heavy on the bass pedals. The pipes thundered, and the church vibrated from floor to rafters as the glorious music filled the church.