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>> Liner Notes <<

Dempsy - out. Tilden - defeated! Houdini -dead. Discordant Wozzeck - croaked Deiner muttie ist tot!. Bleeding from the ears as art. Europe's gray wreckage spawned fearful apparitions - robotic Metropolis - cold, aloof. So many omens - warnings. Ends without rebirth. 1926 writhed in decline. The New World was now nibbling on the same poison that killed the old one, power. Few over many. Some of the people all of the time. Lineage. If you didn't have it? You came here, and maybe you found the North Ward, if all you spoke was Italian. But hope's light was dim, school out of reach, uncertainty as comfort. And behold! The new god - one radiating vacuum. Sweat shop temples offering children up to product. Shoulders pressed in procession. Flesh in lock step to vats of steaming acid dye. Women, men, children. Self determination, voice, free will - not here, genuflected before choicelessness. A theocracy of currency. Faith means don't ask questions - high preists taking their tribute, anything that could be taken. Whatever it is, that obscure ever iterating force which inflicted Attila on the ancients, now spewed robber barons. Tailored suits. Progress! Expropriation beats a steady drum. You need the stick, power - and a permit. Politicians swaggered in silken robes loomed by children, poisoned of purple, deafened to the racket of the mills. Through this wall of steam and noise came Jazz Man - and Momma. From the docks, festering garbage nurtured toxic vapors of humanity and an orphan of the nil, child of killer chaos and hellish intuition - Nino - the last man you never heard coming. One promise, death. One purpose, family. One tear, Zora.

Recall, in eddies, fed on exhaustion. Flashes. Blurs. Hand-me-down stories of long ago in snippets of inconsistency spun as odd fallen leaves on vortices trapped at the edge of the mind stream, stuck, not wanting to go away. And somehow, they belonged. Doctor Macaluso, motionless in the sullen dim, not allowing sleep though not committed to quickness, conjured these fleeting visions. Shadows of realization, Nino, Jazz Man, the burning scar - reflections - of the pool welling over and drowning children - they were his. The cast of shadow emanated from him. In that slow heavy ebb which pressed him deeper than sleep, he entered the cave of the beast. It was time to set it free. Come. I know who you are, he said with his eyes. Death's aged child, in the flowing robes of darkness, bowed before him, offering an out held sleeve of stark bones. "I have been watching over you." The doctor whispered, "I know. May I embrace you?”

>> Your Wallet? <<

The night smelled of pine, creosote and wood chips. "Excuse me, are you doctor Wagner?" a simple enough question, but alone in an unlit parking lot, not what he wanted to hear unexpectedly from behind. Tightening his grasp on a grossly overstuffed portfolio which he was carrying, awful possibilities occurred to him for the very first time. Did someone from the meeting follow him out? A guarded slow half turn with a strained nod allowed that he had heard the question without committing a specific answer, "Sir?" "Aren't you forgetting something, doctor?" The doctor's free right hand began groping through his trench coat but his left arm remained tightly encircled around his documents. Beeper. Pen. Keys. Wallet? Wallet! "Oh goodness. My wallet." With embarrassment, the doctor turned toward his smiling savior, who was holding forth that missing item. "I can't imagine how I.." That was caught short by a sharp constriction suddenly around his neck from behind. Half spit and half words now choked in appeal for reason as the fellow with the wallet stepped back and observed with a detached frown. The attacker, despite his advantage of a successful surprise leap from darkness, seemed unable to finesse his misbehaving deadly wire off the doctor's collar and so, "sclhhhstttttop gak-kkkkkkkhelp kcchelchhlpp kchhhh.. chellschtop,.. " continued on. The far off labor of a train came and went as this spasmodic gurgling continued steadily on. But night sounds and gurgles of despiration were increasingly lost to the struggling grunts and ever more straining curses emanating from the assailant whose sickening work was not being made any easier by the doctor's wild flailing which bashed the thug repeatedly face-long into the car mirror. "Shit! Plfft. Cut that out, damn it! Owww. " His

own grimace of ineptitude intensified by cutting finger pain from a poorly handled garrat, this vile man was getting redder in the face than his victim. His left eye was like a boxer's with a badly managed cut. Through all of this this, the smug wallet bearer just nodded with snorting half laughs of condescending disapproval until - over the continuing gurgling rasping protest - he heard a clear, "OK, Mick. You do it." And so Mick did, telling his accomplice to stick to computers. "Putz... Now, the girl. Lose this guy. Follow me in his car."

>> OR 1 <<

He called them his younger years. His surgical training could only be described as brutally sadistic. But, he wasn't that same person anymore, not that young resident. Maybe responsibility and savvy make up for lost vigor. Maybe not. Two straight days of unremitting emergency now had him sagging, shaken even, when the phone rang. Christ,what now? He wanted to throw a hammer at the damn thing. It rang again. And again. Oh God, he dreaded as everyone else went still. Silence in an operating room is a wallpaper of regular beeps, pfoooshes, and clicks. Absence of these sounds isn't silence, but vacuum. Beep beep beep. Regularity, a steady hold of the child's beating heart. The soprano tenor in each chirping tone reassuring that arterial oxygen levels are high - the brain is safe. An unhurried soothing respirator hiss rising to a crescendo dropping in an abrupt pfooosh clicked off by a back flow valve, sssssssssssush click sssssssssssush click sssssssssssush click sssssssssssush click. That is as quiet as any surgeon would have it. Only an hour before, those beeps had become groveling baratone groans, the respirator dead silent - yanked off line as anesthesiologists frenzied obstructing bloody ooze from a young girl's lungs. In a tumble of professional instinct and experience, the comforting wallpaper of unprovoking chirps had been reestablished. Sounds were once again comforting. Lulling. Reassuring - until that damned phone. Damn! Marcus Macaluso's mental plea of a Not for you was quickly dashed, though in an unexpected way, the worst way possible, an unappreciated way. It's that triage thing. In theory, emergency goes first. Survival trumps convenience, age, status, or anything else. But, ass holes who didn't get it? Macaluso, even on good

days, had no patience for them. "Triage! I assert triage," is all that he had actually said. It was his face, though. Jesus, he could look scary, and that might be trumped up to a charge of being threatening. Even so, bumping a cosmetic surgeon to another operating room, a loss of an hour in turn over, just shouldn't matter. Life and limb, not some babe's sulky pouty lips and tight buns. If you are a cosmetic surgeon, tough shit. That's just the way it is. You're too damn overpaid anyway. There's gotta be some downside to being lavished with up front money for unnecessary low skill surgery. Christ, every real surgeon knows that those guys have no useful surgical talent. Macaluso didn't endear himself to the bottom line people with his candid snarling opinions. Anyway, you didn't get the tirade unless you prodded him. Don't want to hear it? Then stay away. Fatigue can make anybody a bit crusty. And Macaluso? Well. OK, so put yourself into his shoes. What would you do or say when a huffy administrator, who knows nothing of what has been going on, and doesn't seem to care, calls you right in the middle of a great reversal of a near disaster, demanding an immediate meeting, right now, in his office to discuss what he is going to have to do with you because you, he was told, behaved disparagingly - even menacingly - to a colleague, a cosmetic surgeon, who was "merely asserting his own practice interests." Sometimes, you know, you can listen to stuff like that and it rolls right off. But today? After all this? With what could have happened not having happened because everything was done well and fast? No. Not today. Today, you are putting together a child's bloodied crushed limbs while other surgeons repair liver lacerations and ruptured intestines. You are also helping the real plastic surgeons - the ones who are trying to avert a life of prolonged depression, one of avoiding mirrors. This is the second child of three. There's still one more to go, from that accident on Route 48. That third kid is

being stabilized in the next operating room. Doctor Ivory is there right now seeing to it that her neck injury does not evolve into quadriplegia as others handle her injured airway and chest. The word is that there are multiple leg and arm injuries in her case as well. That means you. That's what you do. Oh, and two lesser urgencies are also waiting in the emergency room for your attention which, by the way, has been drifting steadily. Somehow numbed fatigue lulls in the steady heart sounds as practiced hands keep on, working on their own even as the mind drifts into havens. There's a whole room full of tools and equipment seeking out change, ready to announce anything amiss in shrill blasts. Shit does happen here and operating room people know how to boogie when it does. They even expect it. Listen to their conversation. They exclaim if everything actually goes well. Everything going well is not anticipated. Operating rooms do not attract optimums. If shit isn't happening here, shit that happens somewhere else is brought here - on wheels, on wings, or carried in arms of despair. Worst case scenarios are regularly practiced and somehow reality finds a way to top the imagination of the best of them. Chaos, like the cosmos itself, is boundless. Chaos never generates anger, no matter how badly it behaves. The O.R. team is steeled to the challenges which chaos tosses their way. It is what they do. But obnoxious demanding phone calls from posturing power climbers? Break for an immediate meeting, right now, in his office to discuss what he is going to have to do with you? Hmmmm.

Take a moment. Think this through. What do you say? Forget the blood. Put that suture down. Have a cookie and some milk while you carefully consider all the many ramifications of each word you might utter. OK? Got your answer? And will your reply always be the same? Always? Even when chaos has you by the nuts? Nurses know. They just know. For sure they knew doctor Marcus Macaluso. "Here, Mac." Nurse Sutherland, circulating back-up between the two active trauma rooms, slipped a root beer barrel candy into his surgical mask. "Fading?" She returned to the phone, which she had interrupted and put on hold. He sighed, "Mmmmm. Shthanksh. Schluuup. Gesh sho." Well? What do you do? Do you stop surgery to listen to that blowhard? Afterall, he sounded quite adamant. How's this? Offer several possible meeting times, referring him to your secretary? Or do you, as Sutherland just knew was coming, and remember you have been in surgery for 30 continuous hours and will probably not be done for some time yet - do you tell him to go to the morgue and chew on the dead? Gee. Tough choice. Grovel to an unctuous low life who really can't do squat to you because he isn't worth snot - or - let him know what you think? Now, if you find this hard, if you are having a problem with this hypothetical, maybe you ought to go away - now. Just go. Go tell babbling fools how their points are all well taken. Go buy some controlling stocks - or something else comfortably base. You don't really want to know any more about our doctor friend who was in a race to keep up with realities thrust before him and not inclined to make apologies for his own stretched emotional resources. Sutherland was no dummy. She couldn't get to that root beer candy fast enough nor did she gently drop it in into his mask as much as pull his head around and shove it

in. "Fading?" You couldn't see her lips as that question was pointedly asserted. But the eyes, they spoke. He read them. They said to ignore the fool, she'd handle it. Do the kid. And that's what he did as she revived the phone and relayed that the child presently being put back together had been hit by the governor's car - a total fabrication. The other party's back pedaling was hilarious. "Slik, Southie. He'll find out, though," Macaluso drooled around his root beer barrel. "So sue me," she laughed hanging on to the anesthesiologist's shoulder. The night passed quickly. Macaluso didn't linger to the thanksgivings of shocked families. Such effusive gratitude is self directed. They were really saying thank you for affirmation of their desperate and hysterical assumption that the children were now once again intact, all as before. Magic. No end harm. Risk Management - lawyers - would have you out there destroying families with immediate comprehensive absolute worst case prospects, possibility stripped of optimism. It's better to dodge families than tread on hope. Hope heals. As bloody floors were mopped, as intensivists were taking notes from anesthesiologists and resetting monitors and reorganizing the spaghetti of arterial, venous, central and crash lines, as the orchestration of beeping sensors changed pitch and tempo to announce battery units kicking in for transport, and as eyelids suddenly lost the support which came from urgency - he left. He didn't revel in the rush that succeeding in emergency delivers. He had just about enough time to hustle through morning rounds and catch a bite of breakfast in a quick pass through the cafeteria before beginning this next new long day of elective reconstructive surgery. Macaluso wasn't quite sure what it was he had just eaten, some kind of soft bun with red stuff in the center. There was something particularly unappetizing about buns

individually shrink wrapped in plastic. Whose stupid idea was that? Guaranteed freshness? Who they kidding? Sogginess! Soggy clammy mystery fruit center buns. But in the greater scheme of lesser things, food was fuel, nothing more. Coffee was important. Just get me through this day, he prayed mentally. Yeah, right. Anyway, his prayer was to the coffee. He knew that around here God doesn't deal in caffeine.

>> Signs <<

It wasn't that things went suddenly bad no matter how it seemed. There were warnings, or at the very least - oddities. Doctor Wagner, the Lucious W. Wagner, MD, running off with his secretary? Him? The prude of prudes? Hardliner of harliners? Hypocrites' personal archangel? The very thought was juicy. People just wanted to swallow that hook. And besides, she did have legs up to her neck and great knockers. And her? What did a young chippie see in that crusading old fart? Money. Yeah, he had some. But enough for a really hot babe to trade in her goods? And, where'd they go? Where could they go? Did that gel? It did if you wanted it to and forced the incongruities to just melt away into think-fog. Sure there were all sorts of papers scattered about which indicated a hot and sordid relationship. But why was that kind of shit so easy to find when the really important stuff, the stuff Wagner was known for, was nowhere to be found? Took it with him? A man succumbs to pussy and takes along key legal documents for his plunge. Doesn't anybody think? No. Sorry, the correct answer is no. No. They don't. Not if the facts aren't biting them on their own asses. Weird shit could have, should have, served as omens. See? The problem with portents is that you have to be cued in, primed, receptive. Involved. Even then, you have to be instructed in the fine points to even notice them. Now, right there, that's a big drawback, along with ambiguity. So let's say, for instance, when you, Pharaoh, hot shot decision maker for the worlds first great power, are suddenly up to your dufuss head dress in frogs, do you call a French chef? Really. What the hell do you make of a frog plague? Uh oh, frogs. One bitchin load of them. Does that do anything for you? Do frogs everywhere EVER mean

that there's a new God in town and He's disappointed with you? Is that an obvious connection? OK, maybe frog outbreaks way back then, were like tornados in Oklahoma today? Would that help interpretation? Hey, maybe even if they were named the way we name hurricanes? Frog plague Alhammed, frog plague Barbiehottenpantz through Kendollmnesta? Was it like that, you think? Nnnn-no. Probably not. But if that were so, supposin, you just know that some long dead and gone geek had criteria. That part never changes. There's always somebody with criteria. Not technically a plague, more a tropical swarm building up from a throng toward a besetting. Geeks do that, drawing vertical lines through fog. And we listen. "Hey! I got frogs up my ass here! This is a plague, I tell you!" No. Just a regional press. But when you think about frogs, not as frogs, but rather as slimy green jumpy swamp things - does that EVER scream a specific warning at you? Ribbit let my people ribbit go ribbit let my people ribbit go. OK Pharaoh, maybe you - not being totally conversant in frog speak - let the wrong people go. Maybe you released a couple of necromancers who had been disturbing everybody's sleep with loud incantations under the moon. You know, swap one annoying noise for another annoying noise. It would be really easy to miss the leaping symbolization - freedom of a multitude green with envy. To this day, this is still a very valued lesson. Ignore the words. Follow the feet. More bull shit comes through human lips than from steer recta. But even to a black belt augur, or whatever trinket of clothing denotes magus sooth distinction, frame of mind

matters. It isn't just signs alone. We need to render ourselves receptive, primed, looking to change. But there isn't much space between hopeful receptivity and delirium. Having everything you do blow up in your face can do one helluva rendering job. But be careful, dissatisfaction at the extreme promotes fantasy. Maybe that dove is just a pigeon. Look closer. Confused? Add to that, burnout. Fatigue complicates everything. It blurs. You fail to notice, let alone interpret. Heed, even obvious signs - like frogs dropping out of clouds? What time is it? Fuck the frogs. Or the reverse, reading everything into nothing. So divination has passed in our time to hunch and savvy. Unless a frog can recite in fluent sentences and deliver a signed affidavit, it's just a friggin frog. Today, we sanction and affirm the curious with science while still deferring to our intuition for survival. Funny, huh? We cling to our instincts but espouse science, the religion which has cast intuition into hell. Fortunately, for the bleeding, surgeons use science the same way they use soap. It's important, but they don't worship it. Well, ok, some of the crummy ones do. But more often than otherwise, it is quick intuition, sharpened by science, which brings surgical artists through tempests of churning trauma. Signs? Oh yeah, Macaluso had them. Signs matter. But so does dullness - and pressured distraction. There was even more of that.

>> OR 2 <<

Last night drudged seamlessly into today. Scheduled surgery begins promptly at seven twenty A.M. so at seven, in the staging area, an odd mix of prepared patients converged on the last checkpoint before heading into the surgical zone. It didn't say Abandon all hope ye who enter here, instead No street clothes beyond this point. Didn't matter. It had the same feel. In the temporary checkpoint stations, which were just parallel parking spots marked with lines on the floor, other surgeons were telling drop jawed adult patients about possible complications of hemorrhage, stroke, paralysis, respiratory compromise, and unforseeable untoward reactions to medications and anesthetic agents. The parents of Dr. Macaluso's patient just stroked their youngster's hair and reassured as each verbalized potential disaster directed at some poor soul in a nearby stretcher, was overheard, "That’s OK honey, we've already done that one. It's somebody else's turn. To that backdrop of monition our doctor suddenly appeared straight away pressing his lips to Henrietta's cheek with a big kiss and a hidden glance at the youngster's feeding tube which punctuated the left upper corner of her abdomen. It was properly capped. "Hey! You ready for a tune up? Huh? Are ya?" The little doll beamed twinkling eyes. Macaluso then quickly reminded mother of the game plan. To the uninitiated it sounded rather complex. Some parents melt at this point, knowing, just knowing, that every single thing that could go wrong was indeed going to go wrong. When did anything ever go right with this child? No prayer had ever been answered. His "I am here for you," was oddly comforting. Was that egotism? Perhaps, to them, a sign?

Macaluso learned, long ago, that diversion worked better than assurance and probability. "I WANT YOU TO REMEMBER THE PLIGHT OF BATHSHEBA! NOW THINK OF THAT! Please. Be still and let me do my work," he repremanded a nearby pair of accompanying visitors whose misgivings were unsettling others. Later in the day, an entire waiting room would erupt in the singular question, what WAS the plight of Bathsheba? " Beats me, he would tell them, but Henrietta is in recovery doing fine and demanding her promised presents. Bathsheba would probably never cross this family's mind again. But right now he stepped mom through Henrietta's proposed surgery. Muscles had to be lengthened here and there. The left dislocated hip would be opened and emptied of obstructive fat and fibrous ingrowth. A stretched out and thickened ligament also had to be removed to make space. At the lower pole of the socket a spanning ligament needed to be divided to enlarge socket capacity otherwise the ball of the hip, having grown relatively larger would not seat. The stretched out hip capsule had to be reshaped. "How do you do that, doctor?" "Ahhh, just a nip here and a tuck there. Simplicity patterns." His hand gestures were comical to Henrietta so he reprised them with a funny face of wild eyes to her laughter. He then went on about chisels and a high speed turbine driven side cutting drill that a dentist from hell might use. The left pelvis would be divided in a sweeping curve just above the hip so as to swivel the lower half delivering the hip socket into a more horizontal position. Carefully shaped and interlocking bone graft harvested from another part of her pelvis would lock in this new orientation. Pins drilled across these bones would reinforce the pieces. "Her cast will go from here to here," he swept his

hand from her mid chest to her toes. "Four weeks," anticipated the inevitable question. "Through a trap door in the bottom," headed off the next inevitable. "Shannon has taken you through all the support services?" "Yes." "OK." He described ileus, the refex stoppage of intestinal function which follows entry into the abdominal cavity. Several days of intravenous feeding would be needed until digestive functions resumed. The anesthesiologist had already gone over the generalities and had set up medication plans. Macaluso quickly scanned those entries on the worksheet. Morphine and Valium dosages and schedules of administration were established by cross checking the calculated values based on the child's weight against the actual sensitivity to similar anesthesia agents as tested during the course of the procedures. During surgery, nearly nothing of any of this was discussed. It was, after all, routine. What did they talk about? "Here. I got it. So, Kathy, how's your cooking course going? Pull this over." "Let me.. mmm, OK. We're going to smoke, next. How's that?"

"Perfect- and steady. Smoke what? Fish?" "Fish, turkey, ham. All sorts of things." "Why? That's popular?" "No. But it's something to know." "Hmmm. Like glazing?" "Did that."

"I know. When do you get to make real food? Move this way. Yeah like that. Take this away." The x-ray tech slid the large C-shaped fluoroscopic frame which embraced the table out of the way. "Looks nice. Real food? Like what?" "Mmmm.. s'been so long... like, like, shrink wrapped soggy breakfast buns rendered suitable for tube feeding. OK, Gerry. It's a wrap. Tell Lou we're using the small hand table for the next case. No x-ray. Next one is lead free." A chorus of praise the Lord followed. No matter how interesting or uplifting surgery is, dressed in lead you are miserable. There were things to do in change over. Actually quite a few, but it was much like a rushed stage change in the theatre with all tasks performed simultaneously, hopefully without anybody tripping over anybody else. As red bagged wet drapes were dragged away along with balled up inside out rubber gloves, the mops were right on their trail cleaning the floor. Satellite lamps were wiped down. Set-up tables were swapped. Instruments had already been counted even before the final sutures were trimmed. Now they were sorted for cleansing and second inventory. A few items needed sharpening and got set aside. Supplies for the next case were recounted and logged in as checked against procedure cards. The overhead lights were repositioned for upper extremity work as bipolar electrocautery ground wires were quickly strung beneath the hand table. Hoses were pulled off the anesthesia machine and the internal lines purged. The CO2 absorption canister was checked as were backup oxygen and inhalant gas tanks. Syringes for five emergency drugs were lined up on the anesthesia table with

premeasured doses of resuscitation medications, the Hail Mary Meds. Hopefully they would not need to be given. That was all routine which went on as the doctor hurried through his own between case chores. That included speaking to the next child's parents after first talking to the last child's parents. There was dictation, a detailed account of what was just done, mask change, briefing the control desk of any new needs or changes in time estimates. The next youngster had a spastic arm which involuntarily poised the hand at shoulder level and flexed sharply at the wrist. This stemmed from an intrauterine stroke caused by a placental separation. Belatedly, at seven years, the hand was showing improved prospects of function, but limited by the ability of the forearm and elbow to deliver it away from the shoulder. Simple enough. Muscles were detached, rotated and moved back to alter leverage and constraint. Others were restrung to new locations to promote the desired wrist extension and thumb release. After the hand, wrist, forearm, and elbow procedures were finished and the long cast was split to allow for swelling, a trip to recovery was accompanied by a litany of questions from the anesthesiologist about the upcoming case. This was typical. Shannon had already arranged most of the follow up details and was reviewing the immediate post operative rehabilitation orders. There were six more children on the schedule waiting for surgery. That adrenaline which flows through a surgeons veins was kicking in as was the fifth cup of coffee. Macaluso was still at full speed. A long day passed in this manner. Only Macaluso and Kathy, a fee for service surgical nurse assistant, stayed the full span. For them, there were no pauses in the flow. Otherwise, nurses swapped in and out for their lunches and for their breaks. Anesthesiologists gave each other eating and bathroom spells. But for the surgeon and his assistant, Saltine crackers and coffee from the common area off

the dressing rooms, where the face masks were boxed, was as close as they got to food on such days. His only sitting moments were taken up in rapid fire robotic dictations of surgical detail of the just completed procedure rammed into which ever of the several telephone transcription devices were free. Saltine crackers stuffed into the mouth do wonders for rapid speech and operative reports. Kathy was telling the parents what that high speed word burst that just came from the doctor really meant. " No. That's good. That's what we want. Con-tain-ment is good." Containment does sound a bit like contaminant. The next mother was already dressed in a paper suit to allow her to accompany her child into the operating suite. It took just moments and the next child was asleep and mother guided out of the operating room. Kathy's cooking class discussion picked up again as if it were a tape recording placed on hold and someone pressed play. "I'm not into buns," drew a laugh. Soon, hands were moving to subtle gestures. This is how the day went, hectic but controlled by interlocking and layered routines. It was in this pace, this blur, that totally unaware, his very first summons to recall what seemed to be an irrelevant and lapsed past began. It was with an innocent sounding, though unusual, message piped into the operating room. A sign? You bet. Even so, in the final details of his last of eight surgeries, he was still energetically into his art with little else on his mind than just finishing - that and meeting his wife Mina at the nearby Irish Pub where the corned beef stands up to the beer. A surgeon's life is fragmented and dispersed through his duties. So there are OR protocols for everything, including social. All he had to do was ask one of the nurses to relay a few words to Mina. With his operative equipment set-up cards, they also had a

card with telephone numbers including her place of work and a list of canned messages that could be left. Make a sprint. Mina knew what that meant. Sprint was the pub. Trot was Italian. Bolt was Mexican. Dash was Sushi. The nurses supplied arrival times. They were better at it. Then there was the rain message. Rain was, well, rain - not going to make it - go ahead and eat without me - again -more to do. Mina claimed to have become an inhabitant of a rain forest. His mind was on finishing, but his hands were all business, not losing even a second. Surgeons use hand gestures as often as not for their operating needs. It's a right brain thing. Speech doesn't get in the way. Small talk does not matter. The left brain needs something to do while the right brain is doing all the work. To the uninitiated, it is hard to figure how he could even think with the radio so loud, occasionally shouting, "Here, hold this. Give me the Haney needle holder. No. Back hand. Yeah, better, OK, OK, there! Buh-buh-buh-baaaaaad!" The left brain would occasionally have to clarify a right brain hand gesture. At least it had something to do besides listen to rock and roll. Into his work, he was way beyond thought, in its usual sense. Monitor beeps were mentally muted, getting notice only if they changed. "Buh-buh-buh-baaaaaad. Bad to da bo-wone." Right now George Thorogood had at least half of his attention. It was impossible for him to not reflexly chime in, even though a child's body parts and future were literally in his hands, trusted to his every move. With moves that seemed to be on auto pilot, this was play. There was a devilish smile unseen beneath his mask. "Buh buh buh baaaaad," Dr. Macaluso echoed, pulling the longest hamstring muscle through a new tunnel he fashioned in the thigh before anchoring it for it's new work. Multiple other muscles were already relocated.

There were length and tension readjustments to be performed before closure and final cast application, but the hardest parts were completed. "Kathy? Yo. Kathy, forget that stuff. Grab a suture and start closing these while I tidy up here." The anesthesiologist had turned off the radio anticipating lightening the patient. The goal was having the child breathing solo and nearly awake by the time the body cast was finished but not actively moving before the cast was hard. A stethoscope taped directly to the chest had one ear-piece for the lungs and the other for the heart. It wasn't wise to trust everything to electronics of which there was plenty. "O - sixty five." holding out a down turned palm expectantly, "Then, get the zero chromics, followed by two's, and five-o poly for top closure..." a twisting finger gesture conveyed how the hand off was to be positioned. Mandy, the circulating nurse, waited for a lighter moment, while they were finishing the details of the legs of the cast, "Hey Mac, nice spica, you should do that for a living. You have a congress lady waiting on your bod." "A what? What? Here hold this. What? Who? Who wants my bod?" Mandy repeated, in a mocking way, "A con-gressss lady is here to meet with youuuu. Ooo ooo ooo. You planning to run for office, Mac?" laughing.

"Me? Yeah, right. Who is it?" "Congresswoman Woodrow."

She could have said "A plague of frogs." Really, what's the difference? How could any of them have known that hell was bursting at the seams and about to vent?

>> Getting Better <<

Shadows in the stark lighting accentuated railroad track stitching coarsely spanning the left upper aspect of his purple bloated face, where a swollen orbit consumed a battered eye. Still bending over his toil, he slowly forced a right gaze toward his preceptor, hoping to catch approval. "That was better, huh?" Spittle leaked through the damaged lip. Dulled in strangled pale skin, a sprawl of long graceful legs were lifeless at his feet. Awkward reversals of stilled posture only accentuated her supple beauty. Better? Than what? Mick didn't want to encourage this."Pfshuh .. you know I drugged her." "Look, Mick!" Her gracile lifeless arm, lifted, was let drop,"She's dead! What more do I..." But that word tentacle was cleaved to a stub by Mick's razor glare. Deadly radiating lines furrowing a tensioned face said, Shut up. You ass hole. Just shut up. Mick was a steel spring trap, always set precariously, ready to snap - and this new guy was tap dancing on his trip. Not the first one to do that, though. One for mistakes and another for talking too much, Mick had already strangled two prior partners. Mick wasn't fickle. Fact is, he didn't get to pick them. Not long in people skills, he didn't feel inclined to suffer them either. You could pack a corpse with the ice that was hanging in the the air. This lacerated lavender faced moron with a dangling wire still wrapped on one hand, took to pulling at the seat of his pants looking for a distraction, anything. Links on his watch band, "Yeah, but I got the hang of this, right?" "I.. I, don't think I would quite put it..."

studied, as if they held some deep mystery, eventually made it clear that there would be no further slavering comments. With that silence established, Mick walked away, not betraying his distraction. He sensed something wasn't right. Was it what that drooling ass hole was so pleased about? What he, himself, had done? Or, not done? So far that creep had accomplished nothing worthwhile. It wasn't he who kidnapped the woman, goaded every ounce of information from her - though nothing useful. The photographer. Really. Who else has connections to get dead men photographed with drugged women? The swizzle stick. That Mona Lisa smile was Mick's idea. An unconscious woman or the look of great sex? You can't use just any old drugs! In this business, you gotta know lots of shit. Sharing, teaching? That was just plain dangerous. And for what? What did this guy do except get his face tenderized on a car door mirror? Nothing. Even this very simple killing, Mick thought, who propped her, picked out the garotte? Hell, he even cushioned the chair. That damn fool couldn't afford to hack up the other eye. What an ass hole. That was probably it. The unease. But the girl. Mick was annoyed by his choices. She had been appealing, lovely and innocent. Except for dollars, picking between that girl and this damaged dork would have been no contest. Nothing they did to her yielded anything to help him dislike her. If only there had been some juicy gossip on the esteemed Dr. Wagner. That was his first choice. It just wasn't there. Still, a good discrediting, no matter what it takes, is better than a mysterious disappearance. So this, Wagner, a sexy looking secretary, and planted photos - public carnality would do the rest. If you were careful. It gets harder and harder to doctor evidence. You need professionals with the right tools to fool them. You need savvy. And the technology keeps changing. How can you

be running all over the place stalking people and at the same time keeping up on everything that's happening in forensics? Or computers? But, in fact, this was his business. What he did. Why was he uneasy? Some damaged moron exaulting in an unresisted killing, without struggle, without danger, without anything to deflect even beastly reconsideration, that was annoying. Mick didn't care who was making these assignments, it was only computer skills keeping this goon alive. Night courses could fix that. After all, he learned the old stuff with no sweat. He could learn the new. "Didn't mean to bug ya, Mick." "Mmmm, yeah. Lose the body. I've got shit to study." A guy's gotta keep up.

>> Coming Storm <<

In a room of raised eyebrows, congresswoman? Macaluso just shrugged... mmm, Woodrow... whoever the hell that was, thinking Christ it never ends. Then, "Oh, let me guess, another fund raiser." He mused that doctor Wang might get to reprise his last soprano performance of Lovely to Look At, which broke the room into song - Ruvree ter rook at, derightfur ter seeeee.... That was good for a minute's yuk. Wang had this deep baritone Cambridge scholastic inflection as his trade mark, making it all the funnier. Gerry Yount, the anesthesiologist, suggested that more than likely they'll do the coersion table in the lobby deal. "They'll get fifteen so called volunteers together - for eight friggin hours - twisting arms to raise as much money as the volunteers would have paid to not be there." Yount's arm twist reference brought out a chorus of Shannon. "Yeah, I'll bet... well... no," Marcus wasn't so sure, "I dunno. I think she would'a told me. Nnn-no. She would have said something." There was a pause of OR silence capped by his throaty grumble, "nnnnnn You think, another late night?" There was a taint of hope struggling for life in that expression of dread minimized as a question. Kathy didn't want to be a killjoy, trying to discretely eyeball the circulator about calling Mina for a rain check. Macaluso stopped that with a wagging finger - no. Maybe it's just a cloud, he thought. Yeah. Right. There are clouds and then there are CLOUDS. "Doctor Macaluso," the wall announced in clipped walkie-talkie static. Button three on the intercom telephone was flashing. "please pick up on line three." "Ohhhhh. Jesus."

"Here, your congressional elevatedness. Maybe it's the president." The receiver was held at full arms reach toward him so that he could lean his ear into it and not breach sterility. Teasing references to Bond, James Bond and M were being flipped his way. In a furrowed squint, nodding the phone away, "Wrong government. Put it on speaker. " He wasn't James Bond. He had no Miss Moneypenny and certainly no secrets. Yount was, nevertheless, still off on a train of Bond speak, instructing how his anesthesia machine was, in reality a Porsche equipped for underwater stealth, until that unmistakable voice clicked in over the wall speaker. Even the respirator hung in expectation, Yount's hand muffling the escape hiss. "Oh God!" as surety sucked from doctor Macaluso's eyes with the first syllable - Mar... It was unmistakable, Shannon, in a tone, way too familiar, drawing out his name, all sugary-like. -cus. Doom. "Oh this ain't good. This ain't... ohhhhhhh... ok... what?" Resignation was kicking the shit out of hope. Word was that there was a problem at "Neemah", that is NEMH, Northeast Mercy Hospital. Don't show N E Mercy is how docs at County teased their NEMH colleagues. Neemah had as good a reputation as County, NENH being the other trauma center serving the huge contiguous urban population, but more to the west. The two hospitals had two understandings. The first was that Neemah wouldn't poke fun at County's uninspiring name and County would not point out that they were more north and more east than Mercy. Even the Mercy staff couldn't bear that they were named as being

northeast of Bethdale, an absolute shit hole calling itself a hospital in a town of the same name, a town of whore and warehouses. The second understanding was that when shit hit the fan, shit was shared. Nothing important should EVER be allowed to leak into Bethdale. It just wasn't right. They couldn't do anything about Bethdale, which had some magical political favor. But ethics were ethics - no sick or injured should ever be allowed to go there. No how, no way. Everybody respected that. Transfers between the two facilities were all reviewed by a committee every month, no matter what. That was important as hospital to hospital travel was the weakest link, the one with the least direct hospital control requiring the most vigilance. You had to be proactive about delay and insufficient life support in transit and dog every step before the step was taken. That a sick patient might sit around unnoticed after transfer was another P4FU, as it was called. That potential for foul up also had to be preempted. Shannon's message was, at its core, simply to be ready. A very difficult case taken to Mercy would likely be bounced. Mercy was, Shannon described, up to their asses in bad stuff. The two main Neemah trauma surgeons wouldn't be free for at least three hours, optimistically, optimistically a medical term for "not gonna happen." The third line lateral shift doctor, Dr. Mesner, a straight shooter with good hands was the one who had called, as Shannon went on, "..and I quote him, Mac, This one's beyond me. The kid also has other neurologic disabilities, giant axonal neuropathy, your kind of kid, even so, it's a mess." Yount and two nurses were now harmonizing rain as Macaluso went quiet thinking about kinky copper colored hair and ataxia. He could have amazed everybody by describing her before she arrived but instead guttural noises were emanating. These

noises were from some deep place, not groaning, exactly. It was more of a of low throat resonance which meant this was indeed looking to be a long day with another long evening, second full night in a row. Translation, seventy two straight hours of speed. He had done this many times, and knew the potential, Not at my best. Not at my best. Fatigue. Every slows and drags. And what do you do when something unforseen and beyond your power delays a case? Curl up on an OR table, sleep, and hope nobody takes your spleen out. Given the choice, though, between spleen and sleep? Shit, he thought, give'em the spleen, I can operate without it. His mind dance finally bowed to resolution. There were no choices here. "Shannon, expedite it," he blurted, "Track every step... the transport... no limo's, get Interservice over there... mmm... everything. Have the peds residents set up whatever is needed, meet'em at the door. Call Rashaad, I think he's around. Oh, Shannon, find out more. Get the details. Difficult is one thing. Emergency is another. Let's be ready.... ." There were a few additional procedural possibilities and preferences quickly discussed before the phone was cradled. The forecast of rain went out to Mina. Five silent, even somber, minutes later Shannon called back. The details, a high fall with a shattered elbow in more fragments than they could count with wicked displacement. Not bleeding, skin badly stretched but not breached, yet. "THEY said yet," she quickly added before he could ask whose yet that was. Finger tips were pink. The victim, a girl ten years old, was crying so badly that it was impossible to know what specific sensory function in her hand was intact or absent. "T'sall I got, Mac." That was plenty. His grimace was not hidden by the mask.

"So, Mac, what do you think?" Kathy asked busily trimming the cast around the nipples after the youngster in the body cast was transferred from the operating table to the gurney. "I have no idea - what it is going to need, but have the battery oscillating drill up, and the small fragment equipment, the Doppler, it, mmm, it depends on the skin and all that," he shrugged. He knew that Northeast didn't just dump patients. To pursue that would have been an insult. Northeast received more dumps than anybody, a dump being a case that is 'too hard' to do simply because the patient is uninsured. Kathy cut him off. "No, not the phone thing, here, this kid. Will he walk? Will this do it?" "You buh buh buh bet your buh buh buh bones he will! Wait til he gets out of this plaster! Whooooweee! Ba-ba-ba Baaaad." The cast was fiberglass, but old terminology, so ingrained, makes for strong ties to the past. History is in our speech whether or not it is in our consciousness. "You think the Congress lady has anything to do with this kid?" Kathy speculated. "A sponsor? Oooo. Maybe," pausing, then brightening, " Hey! Maybe we'll get paid this time!" to a general groan from everybody, the anesthesiologist's letting fly the middle finger bird suggesting otherwise. To everybody else, this was one twisted sorry ass kid who had even limited prospects for sitting. But doctor Macaluso kept repeating that the young fellow had "control arcs" and that there was enough "expendable remote motor inventory" to work with. "Look. We make him a set of hip extensors by moving some of his thigh knee flexors up one level. Easy. See? We simulate knee extension by ground reaction from the loose ankle tenodesis preserving the tibialis

anterior proprioceptive linkage. We convert the gastrocnemius to a knee flexor bumping it up a level and bingo!" Of course, the response was always something like "Bingo? Bingo what?" Nobody knew what the hell he was talking about, though, even his most ardent critics agreed that he, in some weird way, did. One quote was that where others see dog shit he sees pate'. None of them would ever admit outright that they didn't like his shoes walking that pate' all over this particular institution, questions of cost, limited funds doing more good by performing lesser more practical services for greater numbers of people. People is always short for people-who-can-pay. Macaluso's response was, "Let's see. How much dental floss can we give out if we don't buy a resuscitation machine? Think of all those healthy gums. Nice pink gums. I will smile at you writhing on the floor clutching your wretched low percentage chest. Me with my healthy flossed gums. Maybe I'll floss that foaming ass hole, you call a mouth, as you croak!" "Oh, geez," he wispered, "Our Impervious Leader." Melissa Tawney, a nurse who controlled the operating room's front desk on evening shift, wandered in with a long dangling sheet of paper. The dense two sided agenda of scratched out names paired with estimated times had been heavily worked and reworked. It was the dreaded "add on" sheet. Macaluso’s whisper shifted to a groaned "oh shit" as she twinkled her eyes mockingly over her powder blue face mask. He just knew it was there, and could see it in his mind's eye, her tongue sticking out at him beneath that cool blue cover. It was that kind of look. "I don't want to hear this, Lissa," as she bit back at him, "It's Melissa, to you, bubby!" cheerfully informing the good doctor, as she called him, that this newly declared

case of his coming from Mercy was placed on the tail end of her list, her very very long list. "I don't know... maybe two or three in the morning?" to his pleading question of when, capped by, "if you're lucky." "No good. Lissa. No good. Please. Do me a favor. We still have a full twenty room complement of day crew here, just finishing up. There will be seven empty rooms in about, what would you say, thirty minutes or so?" She corrected that there were already two finished rooms and recited her estimates of closing for the rest. It sounded more exact but wasn't much different from the original assertion of seven empty in thirty minutes. Macaluso reiterated, pressing his foreboding distress, urging, using words like preparedness, alert, vigilance, service, and unfortunately, the lethal word - probable. Probably wasn't the same as absolutely positively. But then, to him, what ever was absolute in medicine? That the expected patient might have an emergency as opposed to being merely a complex problem to resolve, just didn't cut it. "Too fucking bad, doc. You're here on the list.." with a menacing point to the bottom. That meant the middle of the night, many hours away. Macaluso, in turn, just pled his case again, over and over with increasing emphasis and volume. His central theme was the need, the duty, to keep one of the closing room's day team in place until the Mercy child arrives. If it turned out that it wasn't red hot as a true emergency, then the team could go home and the kid put in the cue. But he had hot buttons and nurse Tawney thrilled in pressing them. The hottest two were that nurses get tired at the end of the day and the other - the killer - overtime. Money. Melissa was just too stupid to keep that, the real issue, the only issue, behind the dense curtain of bureaucratic bullshit. Long waits were about relative costs of hiring additional staff with employee

benefits versus paying overtime. Overtime. And overtime was very much a count of how many persons were placed on overtime. It was money. Period. Maybe it was the fatigue. Probably not. He lost it. He wasn't loud but what you would call pressured. His voice transformed from trippingly pliant to rigidly harshly whispered resolute and beyond, as she kept pressing his buttons, until his speech had taken on the quality of a power saw cutting oak. A throat tearing at its work as he enforced his demand, "I am telling you nurse. I am telling you, do you hear me? Telling! One thing! Keep one daytime crew in place until that child arrives. Do not, NOT, DO NOT leave me here frigging naked with an emergency we can't handle! Don't you dare second guess me! One team! If she's OK, they go. If not, we move. Got it? Now get out of my face because you are REALLY pissing me off! One team! No questions. Get!" She got. She got and did one thing. One only. Melissa called a senior administrator, one who was always aloof, into self promotion, decorum, and of course the short term bottom line. It seems that the volatile doctor Macaluso had shouted the F word at her. That was the one thing she did. Keeping one backup room ready would have been two things. She'd teach him. Nobody pushes her around. Meanwhile, and unaware, Mac was mumbling about imagining what would happen to their reputations if an emergency that sped in from a trauma center got trashed while waiting in the elective overflow cue. After all, most of the late cases are not emergencies at all. They're simply cases that need doing sometime in the next week but can't find big enough slots in the day schedule, or those that need a certain consultant to be around whose day schedule is unwieldy, or cases which need specialized already assigned equipment, a certain microscope, a special table, whatever. But real emergencies should not go on the ends of such lists! Damn! How