PROLOGUE

IT HAD STARTED WITH A SORE THROAT.

Nattie Serwanga remembered the exact moment. She had been having dinner with her husband, Eli, when some green beans hurt her going down. At the time, the two of them were talking about whether Nadine would be a better choice to name their daughter than Kolette. The discomfort was the beginning of a cold, she thought. Nothing more.

But despite treatment from the doctors in the clinic, the sore throat had gotten progressively worse. Now, nine days after that first scratchy pain, Nattie knew she was sick—really sick. The pounding headache told her so. So did the chills and the sweats and the fiery swelling in her throat that the antibiotics had done nothing to help. And beginning at three this morning, there was the cough.

Across the raised glass counter, the kids from the hospital day-care center were lined up for lunch. Chicken nuggets and spaghetti. Pudding for dessert.

Hi, Nattie Smattie. . . . Me first, Nattie. Me first. . . . Ugh, not spanetti again.

Winking at an adorable four-year-old named Harold, Nattie forced a few drops of saliva past the burning in her throat and filled his plate. A moment later, without enough warning even to raise her hand, she was jolted by a vicious, racking cough—the worst yet. Droplets of her saliva sprayed over the contents of the trays in front of her. She stumbled back but caught herself before she actually fell. Each hack drove a six-inch spike into her brain.

Damn, she muttered, regaining her equilibrium. She was tough—tough as nails, one of her sisters liked to say. But this infection was tough, too. Instinctively, she slid her hands beneath her apron and pressed them against her womb. For a few horrible, empty seconds, there was nothing. Then she felt a sharp jab on her right side echoed immediately by one on the left. Despite the headache and the cough and the hot coals in her throat, Nattie Serwanga smiled.

At forty, married seven years, she had begun to believe it was her sad destiny to remain childless. Eli, who came from a family of ten children, desperately wanted kids. He had all but given up, though, and had begun talking about taking in foster children or even adopting. Then the miracle.

Nattie, are you okay?

Supervisor Peggy Souza eyed her with concern. Nattie’s smile this time was forced. A piercing ache had materialized between her shoulder blades.

I’m . . . I’m fine, she managed. It’s just a cold that doesn’t want to dry up. I been to my obstetrician—twice.

He give you something?

First penicillin, then something stronger.

She decided to leave out the part about sending her to an infections specialist if she wasn’t better soon, or all the questions about the trip she and Eli had just taken to see his family in Sierra Leone.

You wanna go home?

Nattie gestured to the crowd on the other side of the counter. A number of nurses and doctors were now lined up behind the kids.

After the rush, maybe.

The trip to Africa had used up the last of her vacation. She had been saving up her sick days to use in conjunction with maternity leave. With any luck she would be able to work until the last week and then take almost three months off. There was no way she could leave work just now.

Well, I tell you what, Peggy said. Why don’t you wear one of these surgical masks until you’re ready to leave? That was some nasty coughin’ you were doin’.

Nattie turned so that Peggy couldn’t see her fumbling with the strings of the mask.

What in God’s name is happening to me?

The next ten minutes were a blur of pain and poorly suppressed coughing. Still, Nattie managed to finish serving the children and even to make a dent in the staff, each of whom, she knew, had almost no time at all for lunch. Now, in addition to the unremitting pain, she was experiencing spasms and fullness in her rectum.

Please God, take care of my baby. Don’t let anything happen to her.

Nattie? . . . Nattie!

Huh? Oh, sorry, Peggy. My mind just wandered.

You were just standing there starin’ off into space. I think you need to stop for the day an’ . . . Nattie, look over here at me.

What?

Your eyes. They’re all spotted with blood.

What are you talking about?

The white part of your eyes. There’s, like, patches of blood all over them. Nattie, you’d better get to a doctor right now.

A sudden, strangulating tightness in her rectum made it impossible for Nattie to speak. Panicked, she nodded, then hurried as best she could to the rest room. The masked face staring back at her from the mirror looked monstrous. From under her paper hair-covering, clumps of her ebony hair were plastered to the perspiration on her forehead. Below that, the whites of her dull, almost lifeless eyes were nearly obliterated by splashes of bright crimson. She untied the top strings of her mask and let it flop over onto her chest. The inner surface of the mask, spattered with blood, looked like some obscene piece of modern art.

Another spasm from below—a white-hot spear thrusting up inside her.

This is bad. Oh, this is bad.

She hobbled into the stall. Her clothes were drenched with sweat. A viselike cramp in her lower belly was followed immediately by explosive diarrhea. Heavy drops of perspiration fell from her forehead.

Eli . . . oh, honey, I’m so sick. . . .

Nattie struggled to her feet. Behind her, in the bowl, was a hideous mix of stool and curdled blood. More blood. All she could think of was the baby. She tried again to feel the kicking in her womb, but she was shaking so hard, she couldn’t tell. Eli would know what to do, she thought. He was always the calm one. She fumbled in her pocket for some change to call him at work. Nothing. The phone in Peggy’s office. She could call him from there.

Lurching from side to side, unbalanced by her pregnancy, Nattie braced herself against the wall and moved ahead. Sweat was pouring down her now, stinging her eyes and dripping off her nose. Twice she was stopped by rib-snapping salvos of coughing. Her hand and the wall beyond it were speckled with crimson.

Nattie? . . . Nattie, just lie down! Right there. I’ll call the ER. Jesus, look at her!

Peggy’s voice seemed to be echoing through a long tunnel.

My baby . . .

Nattie sank to one knee as pain exploded in her head. A white light bathed the inside of her eyes. She felt her bowels and bladder give way at the moment her neck jerked back. She knew she was falling, but there was nothing she could do about it.

She’s having a seizure! Call the ER!

Peggy’s words were the last thing Nattie heard before a darkness mercifully washed away the pain.

          CHAPTER 1

Belinda, West Virginia

MATT, THIS IS LAURA IN THE ER. . . . MATT?"

Yeah.

Matt, you’re still asleep.

I’m not.

You are. I can tell.

Time zit?

Two-thirty. Matt, please turn on a light and wake up. There’s been an accident at the mine.

Matt Rutledge groaned. Friggin’ mine, he muttered.

Dr. Butler has activated the disaster protocol. Team B is it tonight. Matt, are you awake?

I’m awake, I’m awake, he pronounced hoarsely, fumbling with the switch on his bedside lamp. Nine times seven is fifty-six. The Miami basketball team is the Heat. The fifth president—

Okay, okay. I believe you.

From college, through medical school and residency, and now into his life as an internist, it had always been a chore for Matt to shut his mind down enough to fall asleep—but not nearly the challenge of subsequently waking up. Laura Williams knew this trait of his as well as any nurse, having worked with him in the ER of Montgomery County Regional Hospital for two years before his decision to switch over to private practice. She and all the other nurses had adopted the policy that Dr. Matthew Rutledge wasn’t definitely awake until he could prove it beyond a reasonable doubt.

Light on? Feet on the floor?

I’m up, I’m up. Hold on for a second. Matt tossed the receiver onto the bed and pulled on a pair of worn jeans, a can aerosols now T-shirt, and a light sweater. Was it a cave-in? he asked, tucking the receiver beneath one ear. He sensed a tightening in his gut at even saying the words.

I think so. Ambulances are out there, but no one’s been brought in here yet. The man from the mine just got here, though. He says he thinks ten or twelve are injured.

Man from the mine? Matt pulled on a pair of gym socks. Two toes—the little one and the fourth—poked through a hole in the left one. He briefly considered a replacement, then pushed the toes back in and went for his boots instead.

He called himself the safety officer, something like that, Laura said.

Tall, black hair with a white streak up the front? Sort of like a giant skunk, Matt wanted to add, but didn’t.

Exactly.

That would be Blaine LeBlanc. He’s a very important person in Mineville. Just ask him. Laura, thanks. I’m up and dressed and on my way.

Great. The first rescue unit won’t be here for a little while, so drive slowly.

I know. I know. Motorcycle equals donorcycle. He pulled on his boots. I won’t go over five, I promise. The rest of the team on their way in?

All except Dr. Crook. So far he hasn’t answered his phone or his pager.

Please let it stay that way, Matt thought. Robert (Don’t ever call me Bob) Crook was a carriage trade cardiologist. One of the senior medical citizens in the multispecialty Belinda Medical Group, he had been the most vocal in opposition to Matt’s move from the ER into their practice. Ultimately, though, those who thought a well-liked, Belinda-born-and-raised, Harvard-trained internist and ER specialist might just help fill the desperate need for a primary care doc won out over Crook, whose main objection (spoken) was that Matt was an arrogant weirdo who didn’t dress or look like a doctor, and (unspoken) that he had once turned down his daughter’s invitation to the prom.

Well, I should be there in ten minutes.

Make it fifteen.

Okay, okay.

And Matt?

Yes?

Nine times seven is sixty-three, not fifty-six.

I knew that.

Matt set the phone down, pulled his dark brown hair back into a ponytail, and secured it with a rubber band. For as long as he and Ginny had known each other, he had worn his hair short—not exactly a crew cut, but almost. And by her decree, she was the only one allowed to barber him. Since her death, he hadn’t done more than trim his sideburns. The stud in his right earlobe had followed a year or so later, and the tattoo on his right deltoid a few months after that. It was a masterful rendering done from a photograph of the white-blossomed hawthorn tree in their yard—Ginny’s favorite.

The five-room log cabin the two of them had designed together was perched on a bluff looking out across the Sutherland Valley at the Allegheny Mountains. Pulling on a denim windbreaker, Matt stepped out onto the broad porch where, toward the end, Ginny had spent most of her time. In fact, only the tattoo artist in Morgantown had kept him from having the porch etched permanently into his arm instead of the hawthorn tree. (I can dig the sentiment, man, but believe me, the aesthetic is just bogus.)

Anytime Matt began doubting his decision to come back to West Virginia—and of late those times were increasingly frequent—he needed only to walk out the front door of the cabin. This was Ginny’s kind of night. There wasn’t a single cloud in the new-moon sky. Directly overhead, the eternal river of the Milky Way shimmered across the blackness. The chilly late-summer air was, as always, tinged with a hint of smoke from the huge coal processing plant adjacent to the mine. Nevertheless, it was still sweet and fragrant with the scents of lavender, linden, wild orchids, wild roses, St. John’s Wort, and hundreds of other kinds of blossoms.

Country roads, take me home, to the place I belong. . . .

Matt looped around the cabin to his one-car garage and fired up his maroon Harley Electraglide. In addition to the hog, he had a 900cc Kawasaki roadster and a 250cc Honda dirt bike, all of which he could pretty much maintain himself. The Harley was his choice for cruising, and the jackrabbit-quick roadster for those days when he wanted to live a bit more on the edge. The Honda, in addition to being a thrill a second in the woods, was invaluable in making house calls to a large portion of his practice, inaccessible by any but the most primitive road.

As he rolled down the gravel drive to State Highway 6, Matt started feeling the first rush of adrenaline at what the next few hours might hold. This accident was hardly the first he had dealt with courtesy of the Belinda mine, although at ten to twelve injured it would be the biggest. Over the years, there had been bruises, gashes, strains, sprains, and fractures too numerous to mention. There had also been a few deaths. But the only other time disaster team B had actually been called in proved to be a farce. An underground train known as a maintrip had derailed deep in the mine. Twenty members of team B had milled around the ER from two until three in the morning before word was received that instead of the thirty to forty casualties originally reported, there were none.

However, this new disaster, Matt sensed, was the real deal.

The six-mile ride to the hospital was along a serpentine road for which the motorcycle seemed expressly created. Matt leaned into the familiar turns with a rhythm that had become second nature. He wondered if this latest disaster was yet another monument to the Belinda Coal and Coke Company’s cutting safety corners wherever possible. Despite the constant pressure for modernization and improved safety that he and a few other brave souls tried to keep on the mine owners, little had changed. BC&C was persistently unwilling to do anything but the barest minimum to ensure the well-being of the miners. It was that way with the massive conglomerate today just as it had been that April night twenty-two years ago when the ceiling of Tunnel C-9—the tunnel cutely nicknamed Peggy Sue—caved in, crushing to death three miners, including shift foreman Matthew Rutledge, Sr.

          CHAPTER 2

THE ER AT THE MODERN, 120-BED MONTGOMERY County Regional Hospital had a patient capacity of twelve, including rooms specially equipped for orthopedics and pediatrics, as well as room 10, the crash suite for major medical or surgical emergencies. Two surgeons and a GP were waiting by the nurses’ station when Matt arrived, but he knew there were at least two or three more clinicians around, plus a radiologist. In addition, almost certainly poised over in the lab, was Hal Sawyer, the chief of pathology and Matt’s uncle. Hal, part mountain man, part community activist, part playboy, all scholar, was Matt’s mother’s brother, his godfather, and the major reason he had decided on a career in medicine. Over the twenty-two years since the cave-in of Tunnel C-9, Hal had been as close to a father as Matt had.

Matt hadn’t been in the ER more than a minute when a pickup screeched into the ambulance bay bearing the first casualty. He waved off the other docs and accompanied two nurses to the truck. If the miner, muddy from a mix of limestone, coal dust, dirt, and perspiration, was any indication of the carnage in the mine, it was going to be a long night. His bloodied leg, fairly effectively splinted between two boards, had an obvious compound fracture of the femur. A grotesque spike of bone protruded through a tear in his coveralls midway up his thigh.

Matt followed the litter to the ortho room. Out of the corner of his eye he saw mine safety officer Blaine LeBlanc, dressed in pressed chinos and a hundred-dollar shirt, speaking to the driver of the pickup while making notes on a clipboard. Too late for Matt to avoid eye contact, LeBlanc turned toward him. His face was pinched and pallid. Matt flashed on what the humorless mine officer might be thinking.

Oh, no, here we go again. Another goddamn crusade by Dr. Do Little. Well, go ahead and try causing us more trouble, asshole. No one pays any attention to you anyhow. . . .

LeBlanc shook his head derisively, and Matt responded with a cheery thumbs-up. As long as Matt continued his efforts to make BC&C own up to its safety shortcomings and corner-cutting, they would be enemies.

Brian O’Neil, the orthopedist on team B, reached the cast-room door simultaneously with Matt. At six-three, O’Neil was two inches taller than Matt was, and a couple of years older. He had added two or three dozen pounds to the hard-nosed linebacker he had been at WVU, but at forty he was still a hell of an athlete. He was also a top-notch surgeon and Matt’s closest friend on the medical staff.

You first, Matt said. I take enough of a pounding from you under the hoop.

Since when did Gunner Rutledge ever mix it up under the hoop? You’d need a map just to show you where under the hoop is. Get a line in please, Laura. Normal saline. Usual bloods. Type and cross-match for six units. Portable films of his chest and leg. As soon as Dr. Gunner here has finished examining him, give him seventy-five of Demerol and twenty-five of Vistaril I.M.

We’re on it, Laura Williams replied, unflappable as always.

You know, pal, Laura and some of the other nurses were betting that you’d sleep through this one.

They may still be right. Seeing you here on time makes me think I might be dreaming.

Together, they moved to the bedside and assisted the nurse in cutting away the young miner’s clothes. He might have been nineteen or twenty, with reddish hair and wide, feline eyes. His narrow face was etched with pain, but he forced his lips tightly together and took the jostling to his shattered leg without a sound.

I’m Dr. O’Neil, the orthopedist, Brian said. This is Dr. Rutledge. He’s a veterinarian, but he’s a damn fine one. We’re going to take good care of you.

Th-thanks, sir, the young man managed. I’m Fenton. Robby Fenton.

What in the heck happened down there, Robby? O’Neil asked as Matt began a rapid physical assessment.

It was Darryl Teague, sir. He . . . he went berserk. He’s been actin’ a little tetched for a while, but tonight he was operatin’ the C.M. an’ he jes went off. You know what a C.M. is—a continuous miner?

That monster machine that scoops up coal and puts it onto the conveyor belt? Matt said.

Exactly. Twelve ton or more every minute.

You never cease to amaze me, Dr. Rutledge, O’Neil said. No wonder you don’t date even though people tell me you’re the prime catch in the region. You scare all the women away with your vast knowledge.

Don’t pay any attention to him, Robby. He’s lucky he’s a darn good bone doctor, or no one would even talk to him. Go on.

Well, early on in the shift Teague got into a shovin’ match with one of the guys, Alan Riggs. I don’t know what it was about. Teague’s been like that for a while—pickin’ fights, complainin’ that people were out to get him, that sort of thing. Well, a bunch of us broke it up between him and Riggs. Then, a little while later, Teague goes after Riggs with the C.M. He runs right over him, I mean right over him. Then he goes on an’ takes out maybe half a dozen supports. That’s when the roof caved in. How are the rest of the guys?

We don’t know yet, Robby. You’re the first arrival.

Alan’s got to be dead. You shoulda seen it. Blasted Darryl Teague. I don’t usually wish nobody no harm, but I hope he got hurt but good.

Dr. Rutledge, we need you, Laura Williams said from the doorway.

Matt had been so mesmerized by Robby Fenton’s account that he had completely forgotten about the deluge that was about to hit. Now the ER was in beehive mode. Six of the beds were occupied by miners in varying degrees of distress and pain. Technicians, nurses, and physicians were in constant movement, but the chaos seemed organized and nothing looked out of control.

We don’t need your internist skills right now, Laura said, but we sure could use your ER talent. There’s a lac in three. A beauty. I’ve ordered skull films, but they’re going to take a while. He’s low on the triage totem pole.

Matt stopped in the on-call room and quickly changed into scrubs. He was on his way to room 3 when Blaine LeBlanc intercepted him. A New Yorker with a dense accent, LeBlanc was a fit fifty, just an inch or so shorter than Matt, and broader across the shoulders. His thick, jet hair was slicked straight back and held in place with something from a tube. His trademark white stripe, an inch and a half across, glistened beneath the fluorescent overheads.

What did that kid in there tell you? he asked.

Nice of you to inquire after the lad, Blaine. He has a compound fracture of his femur. That’s when the ol’ thighbone is sticking out through the skin. He won’t be pushing coal for you for a while.

Back off, Rutledge. What did he tell you?

Matt met LeBlanc’s icy stare with one of his own. The man was potentially dangerous. Of that, Matt had no doubt. It was possible that before Ginny died, he had held his contempt for LeBlanc and BC&C in better check. But with her gone, he simply didn’t care. A lifelong health nut and nonsmoker, Ginny had no family history of lung cancer. She was only thirty-three when the diagnosis was made, and her tumor was an unusual cell type—the kind of unusual cell type that might, might, have been caused by some sort of toxin.

No one could deny that BC&C’s coal processing plant was awash in carcinogenic chemicals. Whether they were handling and disposing those toxins in a safe, legal manner was another story. Matt had plenty of theories and some hearsay about illegal dumping or storage, but no proof. There was never any proof. Still, he was certain that if there were shortcuts in any aspect of mine safety or toxic waste disposal, the directors of BC&C would choose to take them. It had been that way when his father was killed, and Matt felt certain it remained that way today.

Over the years he had kept up a steady stream of letters to MSHA—the Mine Safety and Health Administration—demanding investigations and spot inspections. Once, two years ago, they had actually responded to his demands by sending a man in. Nothing—absolutely nothing except some minor maintenance log omissions. Now his credibility was at an all-time low. The folks at the agency either refused to return his calls or, when they did, as much as laughed at the notion of acting on his information with another surprise intrusion.

Despite his contempt for Blaine LeBlanc, Matt could see no reason why the safety officer shouldn’t know what had happened in his mine.

Fucking Teague, LeBlanc said when Matt had finished the account. Stupid fucking Teague.

Mickey Shannon, the miner Matt had been sent in to suture, was fifty-four—positively ancient for mine work. In fact, he actually remembered working the coal face with Matt’s father.

Good man . . . Real good man . . . Stayed one of the guys even after they made him a foreman.

A sharp chunk of rock from the tunnel roof had glanced off Mickey’s forehead right below the hairline. Three-quarters of an inch higher would have meant a direct hit on his skull, and his name might have been added to the list of fatal mine casualties kept on the wall of The Grub Pit Bar and Grill. Instead, the rock had peeled a five-inch-wide flap down over the bridge of his nose and across his eyes.

I’m going to put some novocaine in to numb this thing up, Matt said.

Don’t bother, Doc. Just sew me up an’ get on to someone who needs your help more’n I do.

Matt knew from experience that this was no false bravado. Mickey Shannon and the rest of the miners had been dealing with physical punishment and pain nearly every day of their adult lives. Caring for them and folks like them was one of the main reasons he had returned home to do medicine. It was the rugged, scramble for every dollar, help your neighbor even though you hardly ever have time to speak with him type of mountain people who made up much of his practice.

Hey, Matt said, you handle the mining, I’ll handle the doctoring.

If you say so. People round these parts speak real highly of you, Doc. I been thinkin’ lately of gettin’ me a doctor, and you’re the one I ’uz gonna call.

Do that, Matt said, dreading what an X ray of the man’s chest might reveal.

He numbed the margins of the huge wound with 1 percent Xylocaine, prepped the area with Betadine, clamped a set of sterile drapes around it, and carefully lifted the flap back in place. There was going to be a scar. There always was when skin had to be sutured. The question was whether to do a meticulous, microscopic closure with tiny sutures that might pull out if tested by Mickey’s going back to work too soon, or a quicker job using thicker suture material, guaranteed to hold under almost any circumstance.

What’s the deal with your qualifying to collect disability? Matt asked.

We get full salary so long’s we have sick time available. Then it’s a month waitin’ period before the disability kicks in. With a doctor’s note sayin’ the problem is work-related, we start collectin’ disability immediately with no loss of sick time. But I’m—

Shhhhhhh.

Matt selected dissolving sutures for a careful, layered closure, and fine, 6-0 nylon for the actual skin. Then he donned magnifying goggles and a new pair of gloves. Mickey’s lined, weathered face showed every day of three decades in the mine. But there was no way he was going to leave the ER with anything but the thinnest of scars from this one.

You’re out for two weeks, Matt said. I’ll give you the note. In fact, make that three weeks. And if you have any kind of a headache, any kind at all, we’ll tack on a few weeks more.

Twenty minutes later, he was halfway done with a closure that would have satisfied a movie star, when Laura Williams, breathless, called to him from the doorway.

Matt, Dr. Easterly needs you right away in the crash suite. You’ll have to finish in here later.

Matt placed some saline-soaked gauze over Shannon’s wound and set the sterile drapes aside. Then he stepped back from the table, flexing some of the tightness from his neck.

Mickey, you hear that? he asked.

Don’t worry about me. Who’s he got to see, miss?

A man named Darryl Teague, Laura replied. Some sort of heavy equipment fell over on him.

Let ’im die! Mickey Shannon snapped.

CONSIDERING THAT EVERY bed in the ER was occupied and most of those patients were being attended to, there was quite a crowd working in room 10. One glance at the overhead monitor told Matt why. Heart rate 140. Blood pressure 80/40. Oxygen saturation only 89 percent. Jon Lee, the nurse working beside the gurney, caught Matt’s eye and made a brief thumbs-down sign. It seemed as if Mickey Shannon’s and Robby Fenton’s prayers were being answered. Somewhere beyond the wall of technicians, nurses, and GP Judy Easterly, Darryl Teague was on the verge of checking out.

What’s up?

Startled, Judy Easterly swung around, then came over to him. Not the most energized or enthusiastic of doctors under any circumstance, she was currently in her seventh or eighth month of pregnancy, and looked as if she would have chosen to be anyplace in the world at that moment other than where she was.

This is the guy who caused all this, she whispered.

I know, Matt whispered back. Is he bleeding somewhere?

Easterly thrust out her gravid belly and arched her back, trying to relieve some tightness somewhere.

Not that I can tell, she replied, still whispering. He drove some piece of heavy equipment over two guys. No one knows why. One of them’s dead. The other’s up in the OR right now, and I don’t think he’s going to make it. After he did that, he knocked down some supports and the roof collapsed. He was trapped beneath a load of rock. The rescue guys said his BP was all right on the way in. I think the triage nurse assigned him to me because he looked pretty good when he got here.

Not anymore. Obvious fractures?

In addition to the usual sources of hidden blood loss—the chest and abdominal cavities—a fractured leg, or even an arm in some cases, could cause enough bleeding into muscle to throw a victim into shock.

None, Easterly said. He’s moving all extremities. Joe Terry was just hanging around waiting for the OR to be ready for his case, so I had him put an arterial line in.

Nicely done.

Matt meant the compliment, although it was also obvious that except for the arterial line, Easterly hadn’t been nearly aggressive enough with a man this hurt. At the moment she seemed close to tears.

You know, she said, if I had known I was going to end up with this sort of crunch in the very guy responsible for the disaster, I would have stayed home.

Listen, Judy, why don’t you go ahead home right now, Matt said. You’ve got things under reasonable control here, and it looks as if you and the kid could use some rest.

Easterly started to protest, then suddenly thanked him.

Bloods are off for the usual labs plus six units, she said rapidly. I ordered a portable of his chest and abdomen. I really appreciate this.

Just name your kid after me, Matt said.

Matthewina, Easterly said. I think she’d like that. Hey, thanks. Good luck.

Before Matt could even respond, she was gone. It was just as well. She clearly had other things on her mind and was already hovering between not-much-help and downright dangerous. He glanced again at the monitor and moved into Easterly’s spot at the bedside, across from Jon Lee. Then he stopped short, staring down in disbelief at the man whose insane rage had just killed one and possibly two co-workers. Darryl Teague’s face was covered with fleshy lumps, at least twenty of them, some pea-sized, but some quite a bit larger, and one, just in front of his left ear, approximating a walnut. Almost certainly they were neurofibromas—bundles of nerve tissue mixed with spindly fibrous cells. Cause: unknown. Cure: none known. Darryl Teague was well on his way to becoming an Elephant Man.

Even more startling to Matt was that Teague was the second case of such a condition he had seen in the past four or five months.

Laura, Dr. Hal Sawyer is part of our disaster team. Could you please call him in the lab and ask if he can come over as soon as possible.

You’ve got it.

Matt quickly turned his attention to the miner. Teague was conscious and still breathing on his own, but his skin was mottled and his lips were a grayish purple.

Jon, anything ordered for his pressure?

Nothing yet, Doctor. Lee’s tone made it quite clear that he was grateful for the change in medical command.

Hang some dopamine, standard drip. Run it wide open until we see what happens. Get a catheter in him and keep his volume up.

Laura Williams returned. Dr. Sawyer will be over shortly, she said.

Matt peered up at the EKG monitor. The size of the beats on the tracing appeared much smaller than normal. He filed the information away for the moment and began an efficient exam. Teague’s heart sounds were muffled and distant. There was tenderness in the center of his sternum—enough tenderness to cause the semi-comatose man to cry out when the spot was pressed. His belly was soft and not the least bit tender. His lungs were clear. Legs, arms, unremarkable. Skull and scalp also normal, except that there were a dozen or more neurofibromas hidden beneath Teague’s long, strawlike, dirty blond hair.

In short, there was no evidence for bleeding anywhere. So why was Teague in shock?

The likely answer at the moment centered around trauma to the miner’s breastbone, and beneath it, his heart.

Laura, where’s Dr. Crook? he asked.

On his way in. Turns out his beeper was accidentally shut off, and his phone wasn’t working. The Sandersonville police went out to his place and woke him up.

Sandersonville was twenty minutes from the hospital and Crook was hardly the sort who would simply jump into a pair of sweats and race on in—especially when there was no definite indication in any of the victims that a cardiologist would be needed.

Dr. Rutledge?

Lee gestured at the monitor—70/30.

Prepare to intubate him, Jon. Anesthesia around?

In the OR.

Radiology?

Same. She’s doing some sort of procedure with Dr. Terry.

Inwardly Matt groaned. He had intubated dozens of patients, many of them critical, so that was no problem. But his ability to interpret an ultrasound was average at best. In a life-and-death situation like this one, he would want a radiologist’s opinion.

No problem, he said. Get me a seven-point-five tube, please. Laura, could we talk out there?

The nurse looked at him curiously.

Of course, she said.

Jon, just shout if you need me.

Matt walked Laura to the nurses’ station. She was a straight-laced grandmother in her early fifties, traditional in her approach to medicine, and a damn fine nurse. She was never comfortable with Matt’s open style, manner, and dress, and she had said so on several occasions. Still, over the years, they had managed to co-exist with few problems. Now, he knew, he was about to put their mutual respect to the test.

The commotion in the ER seemed to have leveled off, and the moaning from the injured miners was much less.

How’s he doing? Blaine LeBlanc asked as they passed.

Later, Matt said.

You talk to me before you do anything heroic, you hear? That . . . that weirdo killed one and maybe two of my men.

Sure, Dr. God, Matt said. I’ll be certain to consult with you.

He turned his back on LeBlanc and spoke softly to the nurse. From what he could discern, blood was building up between the lining of Teague’s heart and the heart muscle itself. The resultant constriction of the heart muscle was keeping it from filling properly between each beat.

Laura, this guy’s got a pericardial tamponade.

How do you know?

That’s what it’s got to be. We need to stick a needle into it and drain the blood.

Can’t we wait for Dr. Crook?

Unless we can be sure he’s going to be here in the next five minutes, the answer is no.

What about some tests? An ultrasound?

Radiology is in the OR. I don’t trust the tech or me to read one with certainty. Besides, I don’t think we have time. This kid is going out.

Maybe that’s for the best, Laura said.

Now, don’t let us get started on that, Matt said. Please get me a pericardial drainage kit.

Matt, I don’t like this at all. How many times have you done this procedure?

A few during my residency, Matt lied. I can do it.

Pressure’s not reading, Lee called out. EKG is showing many extra beats.

Please, Matt said, heading back to room 10.

If you’re ordering it, I’ll be right there with the kit.

Remember what I told you, LeBlanc said as Matt passed him.

Matt knelt at the head of Darryl Teague’s bed and skillfully slid a breathing tube down his throat and between his vocal cords. The respiratory tech then hooked the tube to a breathing bag and oxygen, and began to pump. Teague’s chest expanded much more than it had been, but his blood pressure only rose to 50.

Nice intubation, Doctor.

Hal Sawyer stood just inside the doorway. With his dark hair graying at the temples, his carefully trimmed mustache, his gold-rimmed glasses and knee-length lab coat, Uncle Hal looked as professorial as did any medical school dean. In fact, he did have a clinical teaching position at one of the medical schools, but for the most part he stayed pretty close to Belinda, where he was chief of pathology (there was one other full-time pathologist) as well as the Montgomery County medical examiner. Hal was also erudite, well-read, and adventurous. He seldom spoke up at hospital staff meetings, but when he did, people generally listened.

Never married, Hal didn’t seem to lack for company. His latest girlfriend, Heidi, was a pretty, young thing he had met on some sort of rafting trip. The gossipers in Belinda went on about his personal life, but he never seemed to care, just as he didn’t care when the rumors started going around some years ago that he was gay. Hal was very much his own man, and Matt credited him with fostering his own sense of independence.

Hey, Hal, Matt said, thanks for coming over. This is the guy who went berserk in the mine and caused this nightmare. People say he’s been acting paranoid for months. Paranoid insanity coupled with diffuse neurofibromatosis of the face and scalp. Ring any bells?

Just like that cliff diver.

Exactly. His name was Rideout. Teddy Rideout. And where did he work?

As I recall, Hal said, palpating the lumps, he, too, was a miner.

He was most definitely that. BC and C, to be exact.

My, my, Hal said.

Some months ago Matt had been cruising on his Harley down a particularly winding mountain road when Rideout sped past him on the inside, traveling much faster than the road ahead would tolerate. A minute or so later, Matt came upon the shattered guardrail and saw the car lying on its roof several hundred feet below. Rideout lay well beyond resuscitation. His striking facial lumps were identical to Teague’s, and subsequent discussion with his family revealed a history of rapidly progressive paranoia and irrational, aggressive behavior. At the man’s autopsy, Matt wondered out loud to his uncle if Rideout might be toxic from something at the mine.

Hal had promised to run some extra tests, which came back negative. It was Hal’s belief that the man was one of a kind—a very unusual case, but just a single fluke point on the graph of life.

Well, Matt thought now, here’s dot number two.

I’ll see what I can dig up about Mr. Rideout, Hal said. I don’t recall anything unusual in the autopsy except for those neurofibromas, which were only of interest because of their numbers, not their microscopic appearance.

Here’s the kit, Laura said, setting the tray marked PERICARDIOCENTESIS down on the stainless-steel stand.

Any sign of Crook?

He could be here any minute. Are you sure you—

But he’s not here now. This guy’s BP is back down to zero. He’s firing extra beats. I say we go.

Suit yourself, Laura said coolly.

In fact, Matt had attempted pericardial taps a number of times as the last gasp maneuver in cardiac arrest patients who were about to die despite the most heroic resuscitative measures. But never had the procedure located any unsuspected pericardial blood. And never had any of the patients survived.

Need any help? Hal offered.

Will Robert Crook to stroll into the ER right now, Matt said. I just don’t think we can wait.

Beyond Hal, just a few feet outside the door, Matt could see Blaine LeBlanc, watching, waiting.

I’m still not getting any pressure at all, Lee reported. Ventricular extra beats in pairs.

Sometimes you just got to do what you got to do, Matt was thinking.

He attached a four-inch-long, wide-bore cardiac needle to a 20cc syringe and hooked an alligator clamp to the base of it. He would know he was wrong about there being pericardial blood only after he had driven the heavy needle through the tissue-thin pericardial membrane and into the base of Teague’s heart. The electrocardiogram would react immediately to the trauma, and hopefully, he would have time to stop and withdraw the needle before any major damage was done to the cardiac muscle.