Kadence, a new type of implanted defibrillator, misfires in a patient visiting University Hospital for a routine medical procedure—causing the heart rhythm problem it’s meant to correct. Dr. Kate Downey, an experienced anesthesiologist, resuscitates the patient, but she grows concerned for a loved one who recently received the same device—her beloved Great-Aunt Irm.
When a second device misfires, Kate turns to Nikki Yarborough, her friend and Aunt Irm’s cardiologist. Though Nikki helps protect Kate’s aunt, she is prevented from alerting other patients by the corporate greed of her department chairman. As the inventor of the device and part owner of MDI, the company he formed to commercialize it, he claims that the device misfires are due to a soon-to-be-corrected software bug. Kate learns his claim is false.
The misfires continue as Christian O’Donnell, a friend and lawyer, comes to town to facilitate the sale of MDI. Kate and Nikki are drawn into a race to find the source of the malfunctions, but threats to Nikki and a mysterious murder complicate their progress. Are the seemingly random shocks misfires, or are they attacks?
A jaw-dropping twist causes her to rethink everything she once thought she knew, but Kate will stop at nothing to protect her aunt and the other patients whose life-saving devices could turn on them at any moment.
While the novels in the Kate Downey Medical Mystery Series stand on their own and can be read in any order, the publication sequence is:
“A medical thriller meets domestic suspense meets serial killer terror all rolled into one page-turning extravaganza. You will read Misfire for the plot, but absolutely stay for the characters. I miss them already.” —Lisa Gardner, #1 New York Times best-selling author
“Medical suspense as sharp as it gets. Euliano is off to a good, no, a brilliant start.” —Kathy Reichs, New York Times best-selling author
“You aren’t gonna let me die this time, are ya, Doc?”
So started my Wednesday, with about the worst line any anesthesiologist can hear from a patient in preoperative holding.
“This time?” the nurse said.
“Last time my heart decided to dance a little jig instead of pumpin’ my blood.”
Sitting close beside Mr. Abrams, his wife squeezed her eyes closed. “Abe, tell Dr. Downey the whole story.”
“I read about it in your chart last night,” I said. “Last time they tried to fix your hernia, your heart needed a jump start.” To the nurse I added, “V fib,” a chaotic heart rhythm that usually requires electrical shock to convert back to a normal rhythm. “It happened when they were putting you to sleep and they canceled the case.” Instead of a hernia operation, Mr. Abrams ended up with a very different procedure that day—placement of an automated internal cardioverter defibrillator, or AICD. A device implanted in his chest to detect and treat the problem should it recur.
“Your AICD hasn’t fired, right?” The device had been checked by cardiology the day before.
“Right. Rosie watches it like a hawk huntin’ a rodent.” He nodded to his wife, who slipped her phone under the book in her lap.
“I completely understand,” I said to her, nodding at the hidden phone. “My aunt has the same AICD, and I can’t stop checking the app either.” Maybe a downside of the novel AICD, the Kadence communicated through the patient’s phone to the cloud, where I could view status reports on my beloved Aunt Irm’s heart. “I don’t expect any problems this time, but we’re ready if your heart decides on another jig.”
“Dr. Downey, I need to ask a favor.” Mrs. Abrams didn’t look at me, or at anyone. She gripped her paperback as if it would fly open.
“Call me Kate.”
“Come on, Rosie, let the doc do her job,” Mr. Abrams said.
She ignored him. “Dr. Yarborough is his cardiologist. She said if he could keep his phone during the operation, she would be able to watch his AICD.”
I generally like to honor requests. This one required a caveat. “I’ll make a deal with you. We’ll keep the phone close for Dr. Yarborough as long as you promise not to watch the app.”
Her sparse gray eyebrows drew together.
“During surgery, there’s electrical noise that can confuse the AICD. I don’t know what it might report and I don’t want you frightened.” Sometimes we turn off AICDs during surgery, but this operation was far enough away from the device implanted near his left shoulder that the noise shouldn’t cause a problem. What she might see on the app, though, I couldn’t predict.
She nodded uncertainly.
Eric, the anesthesia resident assigned to work with me on the case, arrived with a small syringe of a sedative. “What do you think about some happy juice?”
“I think my wife needs it more than me,” Mr. Abrams said.
Her lipstick appeared to redden as her face paled.
“Unfortunately, it goes in the IV,” Eric said with a kind smile for her. “We’ll take good care of him.”
“You’ll watch his blood sugar,” she said.
“Yes, ma’am.” Eric unlocked the bed.
“And be careful with his AICD.”
“We will.” He unhooked the IV bag from the ceiling-mounted pole and attached it to one on the stretcher.
Tears dampened her eyes as Mrs. Abrams stood and leaned down to kiss her husband’s cheek.
“I’m gonna be fine, Rosie. Don’t you worry. I’ll be huntin’ by the weekend, and we can try out that new squirrel recipe before our anniversary.”
“We are not serving squirrel stew for our fiftieth anniversary,” she said.
Eric and I exchanged a smile.
“Oh now, you wait and see.” Mr. Abrams patted his wife’s hand.
“What’s squirrel taste like?” Eric pushed the bed from the wall.
“Tastes like chicken.” Mr. Abrams laughed loudly. “No, just kiddin’ with ya . . .” As they turned the corner, the voices faded. I stayed behind to reassure Mrs. Abrams.
“I can’t lose him.” Eyes squeezed shut, a sob escaped.
I wrapped an arm around her ample shoulders and waited. I knew that feeling; had lived that feeling; had lost.
“I’m sorry.” She dabbed her eyes with a tissue.
“No need to apologize. Last time scared you. Tell you what, once he’s asleep, I’ll give you a call and let you know it went fine.”
That calmed her. We walked together to the main doors, where I directed her to the waiting room. I turned the opposite direction to not let her husband of fifty years die during a hernia operation. No pressure there.
In the OR, we helped Mr. Abrams move to the operating table. After applying monitors and going through our safety checks, Eric held the clear plastic mask over his face and said, “Pick out a good dream.”
“Oh, I got one.” He winked at me. “I’ll try to behave this time, Doc.”
“I’d appreciate that.” I maintained eye contact and held his hand as I injected the drugs to put him off to sleep. Despite having induced anesthesia thousands of times, I always experience a tense few moments between the time the patient stops breathing and when the breathing tube is confirmed in the windpipe. During those couple of minutes, if we couldn’t breathe for him, there’s a real, if remote, chance the patient could die. Not a failure to save, but, in essence, a kill. Anesthesia is unique in that. We take people who are breathing fine, mess it up, then fix it, so the surgeon can correct the real problem.
When Mr. Abrams’ induction proceeded without incident, I felt an extra sense of relief and was happy to share that with his wife. The operation, too, went well, and an hour later, he awoke from anesthesia, gave a sleepy smile, and said, “How’d it go, Doc?”
“Fine. No more hernia. Are you in any pain?”
He shook his head. “Nope, you done good.”
As Eric gave his transfer-of-care report to the recovery nurse, I helped re-connect the monitors. Mr. Abrams looked great. Whether he’d be hunting squirrel in a few days, I couldn’t say. I headed toward the pre-op area to see our next patient.
I spun back to see Mr. Abrams’ head loll to the side, his eyes closed, his hands on his chest. In two steps I was back at his side. “Mr. Abrams?” I placed two fingers to his neck where his pulse should be while the ECG monitor above showed ventricular fibrillation—a randomly bumpy line—and his pulse oximeter, the sticker on his finger that recorded pulse and oxygen, became a flat line. Cardiac arrest.
What the hell?
I forced the image of his wife saying, “I can’t lose him,” from my mind as I lowered the head of the bed and started chest compressions. “Eric, manage the airway.”
He placed a mask over Mr. Abrams’ nose and mouth and started squeezing the breathing bag. “Why isn’t his AICD firing?”
The overhead monitor flashed and shrieked an alarm.
The fire-engine red crash cart arrived and a nurse snapped off its plastic lock. As she tore open the foil pack of defibrillation pads from the top of the crash cart, the charge nurse assembled medications. A smoothly running team, each member with his or her own tasks.
The overhead alert began, “Anesthesia and Charge Nurse stat to the PACU.” I tuned it out as a crowd in scrubs assembled around us. The anesthesiologist in charge of the recovery room said, “How can I help?”
“Call Nikki Yarborough in cardiology.” As I continued chest compressions, the nurse reached around my arms to place the large defibrillator pads on Mr. Abrams’ chest. I noticed the small scar where his AICD was implanted and silently ordered the damn thing to fire. The charging defibrillator whined with an increasing and eventually teeth-itching pitch.
Seconds before I yelled, “Clear!” the ECG monitor traced a “square wave”—three sides of a bottomless square, up-across-down. I held my breath, though it was only seconds. Normal sinus rhythm followed. His AICD had finally fired, kick-starting his heart back to normal electrical activity.
I stopped chest compressions and placed my fingers on his neck. Strong pulse. “Mr. Abrams?” I grasped his hand and leaned forward. His head turned toward me. “How do you feel?”
He rubbed his sternum with his other hand. “Chest hurts.”
“Like a heart attack, or like someone pounded on it?”
“Pounded.” He opened one eye.
“Sorry about that.”
“No. Thank you.” The corners of his mouth turned up weakly. “You did good.”
“I’ll have cardiology come check out your AICD and figure out why it took so long to fire.”
He nodded. “Can you tell my wife I’m okay?” It struck me his first thought was for his wife, and that I’d told her everything would be fine. Crap. It also struck me she might have peeked at his app.
The recovery room attending waited for me as I stepped away. “Dr. Yarborough’s in a procedure but will come by as soon as she’s done.”
I thanked him and hurried to the waiting room to check on Mrs. Abrams.
She must have followed directions, because I found her in the back corner of the crowded space, the book unopened in her lap. At my approach, she looked up.
“He’s fine.” Always the best lead, but she didn’t smile. I sat beside her and lowered my voice in an attempt at privacy. “After the surgery, he had a rhythm problem like before.”
She gasped and I placed a hand on her arm.
“We did CPR until his Kadence fired and everything is fine now. He’s awake and he asked me to tell you that.”
Tears filled her eyes.
Though I wasn’t supposed to invite her to the recovery room until the nurse was ready, Mrs. Abrams needed to see for herself. I knew what that felt like. “Would you like to see him?”
She nodded and walked with me in silence.
The very understanding nurse lowered one of the stretcher’s side rails, and Mr. Abrams extended an arm to embrace his wife. “Now, Rosie, I told you I’d be fine.” He looked past her shoulder and winked at me, but his eyes shone as well. Such a beautiful couple. I returned to work before we were all bleary eyed.
Excerpt from Misfire by Tammy Euliano.
Copyright © 2023 by Tammy Euliano.
Published with permission. All rights reserved.
When she’s not writing or at the hospital, she enjoys traveling with her family, playing sports, cheering on the Gators, and entertaining her two wonderful dogs.
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