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  Emma glanced at Mike Griggs, who was hovering nearby, listening to the conversation. As ISS commander, his primary goal was to keep the station up and running, and he was firmly opposed to abandoning her. He joined the conversation.

  “Cutler, this is Griggs. If my crew evacuates, we lose experiments. That’s months of work down the drain. A shuttle rescue makes the most sense. If Kenichi needs to get home, then you folks come pick him up. Let the rest of us stay here and do our jobs.”

  “Can a rescue wait that long?” asked Todd.

  “How soon can you get that bird up here?” said Griggs.

  “We have to talk logistics. Launch windows—”

  “Just tell us how long.”

  Cutler paused. “Flight Director Ellis is standing by. Go ahead, Flight.”

  What had started as a closed and confidential loop between two physicians was now open to the flight director. They heard Woody Ellis say, “Thirty-six hours. That’s the earliest possible launch.”

  A lot could change in thirty-six hours, Emma thought. An ulcer could perforate or hemorrhage. Pancreatitis could lead to shock and circulatory collapse.

  Or Kenichi could recover completely, the victim of nothing worse than a severe intestinal infection.

  “Dr. Watson’s the one examining the patient,” Ellis said. “We’re relying on her judgment here. What’s the clinical call?”

  Emma thought about it. “He doesn’t have an acute surgical abdomen—not at the moment. But things could go bad fast.”

  “So you’re not sure.”

  “No, I’m not.”

  “The instant you give us the word, we’ll still need twenty-four hours for fueling.”

  A whole day’s lag between a call for rescue, and the actual launch, plus additional time for rendezvous. If Kenichi suddenly took a turn for the worse, could she keep him alive that long? The situation had turned nerve-racking. She was a physician, not a fortune-teller. She had no X rays at her disposal, no operating room. The physical exam and blood tests were abnormal but nonspecific. If she chose to delay rescue, Kenichi might die. If she called for help too soon, millions of dollars would be wasted on an unnecessary launch.

  A wrong decision either way would end her career with NASA.

  This was the tightrope Jack had warned her about. I screw up, and the whole world knows. They’re waiting to see if I’ve got the right stuff.

  She looked down at the printout of Kenichi’s blood tests. Nothing she saw there justified hitting the panic button. Not yet.

  She said, “Flight, I’m going to keep him on IVs and start NG suction. Right now his vital signs are looking stable. I just wish I knew what was going on in his belly.”

  “So in your opinion, emergency shuttle launch is not yet indicated?”

  She released a deep breath. “No. Not yet.”

  “We will nevertheless be poised and ready to light Discovery’s candle, should it be necessary.”

  “I appreciate that. I’ll get back to you later with a medical update.” She signed off and looked at Griggs. “I hope I’m making the right call.”

  “Just cure him, okay?”

  She went to check on Kenichi. Because he would need attention throughout the night, she’d moved him out of the hab module and into the U.S. lab, so the rest of the crew would not have their sleep disturbed. He was zipped into a restraint bag. An infusion pump fed a steady flow of saline solution into his intravenous line. He was awake and obviously in discomfort.

  Luther and Diana, who’d been watching the patient, both looked relieved to see Emma. “He vomited again,” said Diana.

  Emma anchored her feet to hold her position and slipped the stethoscope on her ears. Gently she placed the diaphragm on Kenichi’s abdomen. Still no bowel sounds. His digestive tract had shut down, and fluid would begin to accumulate in his stomach. That fluid needed to be drained.

  “Kenichi,” she said, “I’m going to insert a tube into your stomach. It will help the pain, and maybe stop the vomiting.”

  “What—what tube?”

  “A nasogastric tube.” She opened the ALSP medical kit. Inside was a broad array of supplies and drugs, a collection as complete as a modern ambulance’s. In the drawer marked “Airway” were various tubes, suction devices, collection bags, and a laryngoscope. She tore open the packet containing the long nasogastric tube. It was thin and coiled, made of flexible plastic, with a perforated tip.

  Kenichi’s bloodred eyes widened.

  “I’ll be as gentle as I can,” she said. “You can help it go faster by taking a sip of water when I ask you to. I’m going to insert this end into your nostril. The tube will go down the back of your throat, and when you swallow the water, the tube will pass into your stomach. The only uncomfortable part will be right at the beginning, when I first slip it in. After it’s in place, it should hardly bother you at all.”

  “How long does it stay inside?”

  “A day, at least. Until your intestines start working again.” She added, gently, “It really is necessary, Kenichi.”

  He sighed and nodded.

  Emma glanced at Luther, who was looking more and more horrified by the idea of this tube. “He’ll need water to sip. Could you get some?” Then she looked at Diana, who was floating nearby. As usual, Diana looked unperturbed, coolly detached from the crisis. “I need NG suction set up.”

  Diana automatically reached into the ALSP kit for the suction device and collection bag.

  Emma uncoiled the NG tube. First she dipped the tip in lubricant gel, to ease its passage through the nasopharynx. Then she handed Kenichi the pouch of water, which Luther had filled.

  She gave Kenichi’s arm a reassuring squeeze. Though dread was plain to see in his eyes, he returned a nod of consent.

  The perforated end of the tube glistened with lubricant. She inserted the tip into his right nostril and gently advanced it deeper, into his nasopharynx. He gagged, eyes watering, and began to cough in protest as the tube slid down the back of his throat. She threaded it deeper. He was twitching now, fighting the overwhelming instinct to thrust her away, to yank the tube out of his nose.

  “Swallow some water,” she urged.

  He wheezed and with a trembling hand brought the straw to his lips.

  “Swallow, Kenichi,” she said.

  When a bolus of water is passed from the throat into the esophagus, the epiglottis reflexively closes over the opening to the trachea, preventing any leakage into the lungs. It would also direct an NG tube down the correct passageway. The instant she saw him begin to swallow, she swiftly advanced the tube, threading it past the throat and down the esophagus, until it slid in far enough for the tip to be in the stomach.

  “All done,” she said, taping the tube to his nose. “You did fine.”

  “Suction’s ready,” said Diana.

  Emma connected the NG tube to the suction device. They heard a few gurgles, then fluid suddenly appeared in the tube, flowing out of Kenichi’s stomach, into the drainage bag. It was a bilious green; no blood, Emma noted with relief. Perhaps this was all the treatment he needed—bowel rest, NG suction, and intravenous fluids. If he did indeed have pancreatitis, this therapy alone would carry him through the next few days, until the shuttle arrived.

  “My head—it hurts,” said Kenichi, closing his eyes.

  “I’ll give you something for the pain,” said Emma.

  “So what do you think? Crisis averted?” It was Griggs speaking. He had watched the procedure from the hatchway, and even though the tube was now inserted, Griggs hung back, as though repulsed by the mere sight of illness. He did not even look at the patient, but kept his gaze focused on Emma.

  “We’ll have to see,” she said.

  “What do I tell Houston?”

  “I just got the tube in. It’s too early.”

  “They need to know soon.”

  “Well, I don’t know!” she snapped. Then, swallowing her temper, she said more calmly, “Can we discuss this in the hab?�
�� She left Luther to stay with the patient and headed through the hatchway.

  In the hab module, she and Griggs were joined by Nicolai. They gathered around the galley table as though sharing a meal. What they were sharing, instead, were their frustrations over an uncertain situation.

  “You’re the M.D.,” said Griggs. “Can’t you make a decision?”

  “I’m still trying to stabilize him,” said Emma. “Right now I don’t know what I’m dealing with. It could resolve in another day or two. Or it could suddenly get worse.”

  “And you can’t tell us which is going to happen.”

  “Without an X ray, without an OR, I can’t see what’s going on inside him. I can’t predict what his condition will be tomorrow.”

  “Great.”

  “I do think he should go home. I’d like the launch moved up as soon as possible.”

  “What about a CRV evac?” asked Nicolai.

  “A controlled shuttle ride is always better for transporting a sick patient,” said Emma. A CRV return was a rough ride, and depending on weather conditions on earth, they might not be able to touch down in the best possible location for medical transport.

  “Forget CRV evac,” said Griggs flatly. “We’re not abandoning this station.”

  Nicolai said, “If he becomes critical—”

  “Emma will just have to keep him alive long enough for Discovery to get here. Hell, this station’s like an orbiting ambulance! She should be able to keep him stable.”

  “What if she cannot?” pressed Nicolai. “A man’s life is worth more than these experiments.”

  “It’s the option of last resort,” said Griggs. “We all jump on the CRV, we’re abandoning months of work.”

  “Look, Griggs,” said Emma. “I don’t want to leave the station any more than you do. I fought like hell to make it up here, and I’m not about to cut my stay short. But if my patient needs instant evac, then it’s my call.”

  “Excuse me, Emma,” said Diana, floating in the hatchway. “I just finished running Kenichi’s last blood tests. I think you should see this.” She handed Emma a computer printout.

  Emma stared at the results: Creatine kinase: 20.6 (normal 0–3.08).

  This illness was more than pancreatitis, more than just a gastrointestinal disturbance. A high CK meant there had been damage to either his muscles or his heart.

  Vomiting is sometimes a symptom of a heart attack.

  She looked at Griggs. “I’ve just made the decision,” she said. “Tell Houston to fire up the shuttle. Kenichi has to get home.”

  August 2

  Jack tightened the jib sheet, his sunburned arms gleaming with sweat as he strained against the crank. With a satisfying whomp the sail went taut, and Sanneke heeled leeward, her bow suddenly slicing faster through the muddy waters of Galveston Bay. He had left the Gulf of Mexico behind him, had sailed around Point Bolivar earlier that afternoon, dodging the ferry from Galveston Island, and was now tacking past the string of refineries on the shores of Texas City as he sailed north toward Clear Lake. Toward home.

  Four days at sea on the Gulf had turned him brown and shaggy. He had informed no one of his plans, had simply stocked up on food and set sail toward open water, beyond sight of land, into nights so black his eyes had been dazzled by the stars. Lying on his back on deck, the Gulf waters gently rocking the hull beneath him, he’d gazed for hours at the night sky. With that field of stars stretching in every direction, as far as he could see, he could almost imagine he was hurtling through space, that each rise of the swells was thrusting him deeper into the coil of another galaxy. He had emptied his mind of everything but the stars and the sea. Then a meteor had streaked by in a brilliant slash of light, and suddenly he’d thought of Emma. He could not put up barricades high enough to keep her out. She was always there, hovering at the edges, waiting to slip into his thoughts when he least expected it. Least wanted it. He had gone rigid, his eyes fixed on that dying streak of the meteor’s trail, and even though nothing else had changed, not the direction of the wind nor the rise and fall of the swells, he had felt suddenly, deeply, alone.

  It was still dark when he’d raised the sails and turned back for home.

  Now, as he motored up the channel into Clear Lake, past rooflines silhouetted against the glare of sunset, he regretted his decision to return home so soon. On the Gulf there had been a constant breeze, but here, the heat hung unstirred and the humidity was stifling.

  He tied up at his slip and stepped onto the dock, his legs unsteady from days at sea. First order of business, he thought, was a cold shower. He’d save the boat cleanup for tonight, when it was cooler. And as for Humphrey, well—another day in the kennel wouldn’t hurt the little hair ball. Lugging his duffel bag, he headed up the dock and was walking past the marina’s small grocery store when his gaze fell on the newsstand. His duffel bag slipped from his grasp and hit the ground. He stared at the banner headline across that morning’s Houston Chronicle:

  “Emergency Shuttle Countdown Begins—Liftoff Tomorrow.”

  What has happened? he thought.

  What has gone wrong?

  With shaking hands he pulled quarters from his pockets, fed the coins into the slot, and grabbed a copy from the stand. Two photos accompanied the news article. One was of Kenichi Hirai, the NASDA astronaut from Japan. The other was of Emma.

  He snatched up the duffel bag and ran for a phone.

  There were three flight surgeons at the meeting—an indication to Jack that the crisis they faced was medical. As he walked into the room, heads turned in surprise. He read the unspoken question in space station flight director Woody Ellis’s eyes: What’s Jack McCallum doing back in the fold?

  Dr. Todd Cutler gave the answer. “Jack helped develop our emergency medical procedures protocol for the station’s first crew. I thought he should join us.”

  Ellis said, uneasily, “The personal angle makes this complicated.” Emma was what he meant.

  “Every member of that crew is like family to us,” said Todd. “So in a way, it’s all personal.”

  Jack took a seat beside Todd. Sitting at the table were the NSTS deputy director, the ISS mission operations director, flight surgeons, and several program managers. Also present was NASA’s public affairs officer, Gretchen Liu. With the exception of launch days, the news media largely ignored NASA operations. Today, though, journalists from every news agency were crammed into the tiny pressroom in NASA’s Public Information building, awaiting Gretchen’s appearance. What a difference a day made, thought Jack. Public attention was fickle. It demanded explosions, tragedy. Crisis. The miracle of a flawless operation drew no one’s attention.

  Todd passed a sheaf of papers to him, with a note scrawled on top: “Hirai’s labs and clinical findings last 24 hours. Welcome back.”

  Jack flipped through the medical reports while he listened to the meeting. He had a day’s worth of developments to catch up on, and it took him a while to absorb the essentials. Astronaut Kenichi Hirai was seriously ill, his lab findings puzzling to everyone. The shuttle Discovery was poised for a six A.M. EDT launch manned by Kittredge’s crew, along with an astronaut-physician. Countdown was on schedule.

  “Any change in your recommendations?” the NSTS deputy director asked the flight surgeons. “Do you still think Hirai can wait for a shuttle evac?”

  Todd Cutler answered. “We still believe a shuttle evac is the safest option. We aren’t changing our recommendations in that regard. ISS is a fairly well-equipped medical facility, with all the drugs and equipment needed for cardiopulmonary resuscitation.”

  “So you still believe he’s had a heart attack?”

  Todd looked at his fellow flight surgeons. “Frankly,” he admitted, “we’re not entirely certain. There are things that do point to a myocardial infarction—a heart attack, in layman’s terms. Mainly, the rising levels of cardiac enzymes in his blood.”

  “Then why are you still unsure?”

  “The EKG shows only
nonspecific changes—a few T wave inversions. It’s not a classic pattern for an MI. Also, Hirai was thoroughly screened for cardiovascular disease prior to his acceptance in the program. He had no risk factors. Frankly, we’re not sure what’s going on. But we do have to assume he has had a heart attack. Which makes a shuttle evac the best option. It’s a gentler reentry and a controlled landing. Far less stress on the patient than coming home in the CRV. In the meantime, ISS can deal with any arrhythmias he may have.”

  Jack looked up from the lab reports he’d been scanning. “Without the necessary lab equipment, the station can’t fractionate these CK levels. So how can we be sure this enzyme is really from the heart?”

  Everyone’s attention turned to him.

  “What do you mean by ‘fractionate’?” asked Woody Ellis.

  “Creatine kinase is an enzyme that helps muscle cells utilize stored energy. It’s found in both striated and cardiac muscle. When there’s damage to heart cells, say, in a heart attack, the CK levels rise in the blood. That’s why we’re assuming he had a heart attack. But what if it’s not the heart?”

  “What else could it be?”

  “Some other type of muscle damage. Trauma, for instance, or convulsions. Inflammation. In fact, just a simple intramuscular injection can cause the CK to rise. You need to fractionate the CK in order to tell if it’s from heart muscle. The station can’t do that test.”

  “So he may not have had a heart attack at all.”

  “Correct. And here’s another puzzling detail. After acute muscle damage, his CK levels should drop back to normal. But look at the pattern.” Jack flipped through the lab sheets and read off the numbers. “In the last twenty-four hours, his levels have been steadily rising. Which indicates continued damage.”

  “It’s just part of the bigger puzzle,” said Todd. “We’ve got abnormal results all over the board, without any recognizable pattern. Liver enzymes, renal abnormalities, sedimentation rate, white blood cell counts. Some labs go up while others are dropping. It’s as though different organ systems are taking turns being attacked.”

  Jack looked at him. “Attacked?”

  “Just a figure of speech, Jack. I don’t know what process we’re dealing with. I know it’s not lab error. We’ve run controls on the other crew members, and they’re perfectly normal.”