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  For Leila, Asher, and Xander

  PROLOGUE

  Isabel Wilcox had run track in high school. She had taken gold in regionals for the hundred-yard dash. Still, she had never run faster than she was running right now. It should have been cause for celebration, if not for the fact that she was running for her life.

  Isabel should have stayed home that night. She should have been happy with her score for the day. She had cleared five grand since breakfast, but she was unable to resist the easy money. Then things went south. She was grabbed from behind, a bag thrown over her head, and she was stuffed into the backseat of a car.

  But now she was free. And she was fast. And she was sprinting through the woods.

  Tears rolled down her face, leaving tracks of mascara on her cheeks. Her neck was marred with her own blood. “Oh my God, help me!”

  The response that rang back was the report of a rifle. She felt its slug graze her open jaw before its sound reached her ears. The searing pain sent her careening into the trunk of a cedar. The skin of her forehead ripped off like a piece of bark on the centuries-old tree.

  The head wound opened a faucet over her right eye, pouring blood. She lay back into the cushion of fallen leaves, applying pressure to the gash and wiping the red that pooled around her eyes. Her ears rang from the gunshot and her out-of-breath sobs were muffled now, sounding as though she were crying underwater.

  Isabel tried to compose herself. Catch her breath. Control the bleeding. But there was so much blood. She remembered when she was fourteen, babysitting for Michael Squitteiri, and the time he fell off the monkey bars, splitting open his eyebrow. She had been surprised that so much blood could spill from such a small body. She remembered the paramedic soothing her, explaining that the face has more capillaries than any other part of the body. Like a spiderweb of blood vessels just under the skin. It’s why we turn red when we blush.

  She looked up at the tops of the trees, swaying in the breeze. Serene. Lovely. She thought about closing her eyes. Allowing the flow of blood to carry her peacefully to sleep.

  But then she heard footsteps in the distance. She was not ready to die. Not now. Not like this. She caught her breath, ready to run again.

  Isabel stood and sprinted off. She couldn’t be sure that she was running toward help, just that she was running away from the sound of her attacker.

  A few yards later, Isabel’s foot came down hard on a fallen branch and her ankle twisted painfully in her high-heeled suede ankle boot. Shit. She took a few hobbling steps before regaining her balance and forging ahead. Each lungful of air scraped painfully, her heart pounded like it was going to explode, and her muscles screamed in protest. How long had she been running since escaping the car? Five minutes? Ten? Something shrieked in the branches above her; something else rustled in a nearby thicket.

  She’d give anything for Brad to be here now. She’d never brush him off again. She’d return his calls, and cut him in his full share. Or, no, forget Brad. If someone, anyone, would show up and rescue her, she’d give up all of it. No more drugs, no more fake IDs, no more—

  There was a loud clang, and her foot fell into a hole, pitching her forward, face-first onto the ground. Her palms skidded over scratchy foliage and her jaw bounced off a log, but even worse was the excruciating pain that suddenly shot up her leg, like it was being crushed by a huge boulder. She tried to jerk it free, but it was held fast. Blinking dirt out of her eyes, she twisted her body and was horrified to see that her foot was caught in what looked like giant metal teeth. They’d sliced the suede of her boot, piercing through the delicate skin of her feet.

  Isabel’s voice was hoarse from screaming. She could feel her energy slipping away, along with what looked like a gallon of blood soaking her jeans and the ground below. She wrapped her hands around the trap but it was no use—she could barely reach the heavy springs, much less release them, and trying made the pain even worse.

  More blood drained from her body, saturating the ground around her. She was getting dizzy. Her brain tried to reckon with the agonizing pain . . . tried to latch on to a happy memory. Her first kiss with Jeffrey Lampman in seventh grade after show choir. Pledging Theta Pi and doing tequila shots, licking the salt off Lauren Swick’s neck. But nothing worked; she couldn’t trick away the burn. And there was so much blood.

  A branch snapped behind her. She whipped her head around.

  A man dressed all in camo came jogging into the clearing and stopped short. His face was covered by an orange knit mask with holes for the eyes and mouth. Was he here to help? Or was he the one who had taken her? He stared down at her for a full beat before dropping his rifle on the ground and kneeling in the brush next to her, pulling off his gloves and reaching for her wrist, feeling for a pulse.

  He thinks I’m dead, Isabel realized, and though she tried with all her might to convince him otherwise, she could barely move her lips.

  “Help me,” she moaned, although it came out more like “Hemmie,” so soft she wasn’t sure he’d heard her.

  The man leaned into the spring, grunting with the effort of prying it open. Her leg still hurt, but thankfully it was beginning to go numb. It was almost as though Isabel was watching from a distance as the trap finally sprang open, revealing the bloody mess of severed skin and muscle and tendon showing through the torn suede and denim.

  Her liberator sat her up, ready to lift her onto his shoulders when—

  Pfft. Something zinged past her ear. And, suddenly, the hunter’s hold on her relaxed. A moment later, he crumpled down beside her. Isabel screamed again, but all that came out was a hoarse shriek. She felt something at her back—a boot?—and for a moment it rested there, lightly, almost gently, and then it gave her an enormous shove and she tumbled forward. There was no time to throw her hands up to protect her face as it slammed down hard in the center of the reopened trap. In the split second it took to fall, she saw the jaws of the reopened trap rushing up to meet her.

  The last sound she heard was the screech of metal on metal as the teeth clamped through her neck.

  And then the pain was gone.

  ONE

  “Hey,” a voice murmured, so close to her ear that Dr. Kimberly Patterson could feel warm breath tickle the hairs on the back of her neck. “Upsy-daisy. I think you’re going to want to see this one for yourself.”

  “Don’t wanna,” Kim mumbled into the drool-dampened spot on the cheap mattress. She was curled up on the lower bunk in the darkened residents’ sleep room of the Jarvis Regional Hospital. “Make the other resident do it.”

  “She’s not on call tonight. You are. And I already let you sleep an extra eleven minutes.”

  “Just one more minute.” Kim rolled away from the voice so that she was facing the wall that was painted a shade reminiscent of the lunch trays at St. Katherine’s School for Girls, where years ago she had graduated forty-ninth out of a class of fifty.

  “Come on, Kim,” the voice said, more firmly this time. It belonged to her boss, Dr. Kyle Berman. “You’re on at three, which is in four minutes. Get up.”

  “Eat me.”

  “God, I wish. But between your schedule and mine, our next day off together isn’t until— Hey. Hey, seriously, didn’t we talk about this?”

  Kim had managed to sit
up in the bed, the thin, scratchy sheets sliding off her bare shoulders. “About what?”

  “About having consideration for others in the common sleeping space.”

  “But it gets so damn hot in here.”

  “And yet, somehow, every other resident manages to keep their clothes on.”

  “My clothes are on. My pants, anyway.” Kim blinked the sleep from her eyes as she dug through the sheets and came up with a scrub shirt. The shirt was a much-laundered, faded green one that she had inherited from Ethan Kuhn, along with the apartment he no longer needed when he quit his residency to weave seagrass baskets in Ketchikan. “Besides, I read the whole welcome packet when I started here, and there wasn’t anything in there about sleeping room regulations.”

  “Yeah, because most people don’t need it spelled out for them, that you need to keep more on than just your . . .” Kyle pushed his glasses higher on his nose with one hand and gestured at her while looking the other way.

  “Bra. You can say ‘bra,’ Kyle. It’s not a dirty word, I promise.”

  “Come on, Kim, you know the review board is looking for any reason to come down hard on you. Do you have to bend every single rule in the place?”

  “Mmm, you know how I love it when you get all bossy,” Kim said, but the mention of the review board was enough to propel her out of bed. At twenty-nine, she was eager to finish her residency and open her own practice. She yawned as she stepped into her rubber clogs. “Do I have sleep breath? Do you have a mint?”

  “Could we hurry, please? Graver called us down to the ER. They have a patient who came in missing a finger. He’s telling them he ate it.”

  “You should have opened with that. Now that is interesting,” Kim said, running her fingers through her long, tangled hair and following him to the door. “Thanks for cutting me in on this.”

  “My pleasure,” Kyle muttered sarcastically.

  * * *

  “NICE OF YOU TWO to take time out of your busy day to visit us.” Dr. Miranda Graver, the Jarvis Regional Hospital’s chief of staff, was waiting for Kim and Kyle in the hall outside the nurses’ station, the only place in the ER that afforded even a little privacy. “And I see you took note that the invitation specified ‘creative formal,’ Dr. Patterson. Rest assured that your effort is not lost on me.”

  Kim looked down at her shirt and winced. Before decamping downcountry, Ethan had washed some of his clothes along with rags he’d dipped in paint thinner, and the result looked like a cat had thrown up on it. “I’ll try to do better,” she promised.

  “I seem to have heard that before.” Dr. Graver’s stare could freeze water. “Okay, here’s what we’re working with: severed fifth digit, clean bilateral cut right below the distal phalanx on both hands. Left side’s an old injury, healed up pretty well. Right side’s infected with significant discharge, swelling, and tissue deterioration. The patient keeps changing his story when asked what happened, but he told Jennings that he cut it off on purpose . . . and ate it.”

  “That’s a new one for me,” Kyle admitted.

  “Let me talk to him,” Kim suggested. The fact that Graver had been called downstairs for this case made it a perfect opportunity to score some much-needed points with the woman who had the power to make or break Kim’s medical career.

  “As far as I’m concerned, he’s all yours,” Graver said, and after a brief hesitation, Berman nodded. “But, please, Dr. Patterson, do keep our little hospital’s policies in mind this time.”

  Kim kept her expression neutral as the chief of staff stalked back toward the elevators in her perfectly tailored and pressed navy suit. Graver sidestepped a patient whose two front teeth were missing—his mouth bleeding profusely. At first, because of his clattering footsteps, Kim thought he was wearing high heels, but then she realized the clicking sound came from the ice skates he wore. Alaskan emergency rooms treated even more hockey-related injuries than you might expect.

  But patients who ate their own fingers . . . not so much.

  “I’ll come in with you,” Kyle offered when the chief was out of earshot.

  “No, let me go in alone,” Kim said. “Teaming up on this kid isn’t going to help.”

  “Kim, the review board specifically recommended supervisory oversight for all your patient interactions,” Kyle said. “And since I’m your supervisor—”

  “Technically, it was only a recommendation,” Kim pointed out. “Plus, nothing was put in writing.”

  She ducked around a passing cart and into the examination room before he could answer, praying he wouldn’t follow. As fragile as her situation with the review board was, she couldn’t give her patients the attention they deserved with Kyle breathing down her neck. He was only thirty-three, but sometimes Kyle’s seriousness made him feel much older. She needed to be able to bond with this kid.

  Sitting on the side of the bed staring at his phone was a lean, scraggly-haired teenager. Sure enough, he was missing the tip of the pinkie finger on his left hand. Kim could see that the stub had healed well, the skin shiny and pink at the end. His other hand, the fifth digit freshly bandaged, rested beside him on the bed, and an IV line trailed from that arm. A quick glance at the boy’s chart showed that the wound had been drained and cleaned and a course of intravenous antibiotics had been started.

  Kim dropped into the chair next to the bed and put her feet up on the bed rail. “Good decision, going for the pinkie finger,” she observed. “You can do without it for like ninety-five percent of everyday tasks. Plus, there’s a whole theory that the human fifth digit is evolving into a vestigial appendage. You know, like a dew claw on a dog?”

  The boy looked up from his phone long enough to give her a withering glare. “Fuck off.”

  “Ah. Uh-huh. Right. You think I’m patronizing you.”

  A shrug.

  “Look, Wallace—” Kim said, glancing at the chart for the boy’s name. “You go by Wally? Wall-man? Wall Dog? Okay, Wally, I know it’s not like you dreamed you’d grow up and become a cannibal when you were a little kid. I know you don’t wake up every day and go, like, Hey, what’s it going to be today? Maybe an earlobe? A nice chunk of thigh filet?”

  No reaction from the kid. Kim plowed on.

  “What you’re dealing with is a compulsion. It feels like you literally can’t stop yourself, right? I get that, I really do. We’ve all got compulsions. Believe me, you do not want to know what I do when I think no one’s watching. And Dr. Berman out there? He’s got both his testicles pierced like twelve times—one of ’em got infected a while back and swelled up like a watermelon, and he had to borrow a knee cart from orthopedics to get around.” She leaned forward and lowered her voice. “I mean, maybe don’t let him know I told you that. All I’m saying is, everybody does weird shit. We just wanna help you figure out how to tone it down a little so you can still type on that thing.”

  Wally glared at his phone bleakly. “Whatever.”

  “What did you use, anyway?” She made a sawing motion with her hands.

  “You know.” He peeked up from under a fringe of long lashes, suddenly looking much younger than his seventeen years.

  “Actually, I don’t. And I’m genuinely curious. This is off the record. It’s just me and you chatting here.”

  He sighed and let his gaze drift back down to the floor. “Table saw, the first time. But my stepdad freaked and locked up his tools, so I had to use a knife.”

  “Ah,” Kim said. “Probably took one out of the kitchen drawer? Same one your mom uses to cut up chicken? That could explain the infection. I’d say first disinfect the knife next time with plain old rubbing alcohol, except I’m kind of hoping there won’t be a next time. Maybe we could try to get you to cut back to just your hangnails or something. What do you think, are you okay with talking to someone about this?”

  He shook his head. “I’m not going to that fat Nazi counselor again.”

  “School counselor?” Kim asked sympathetically. Judging from his cheap sneakers
and the fact that his phone was at least three versions out of date, Wally’s family likely couldn’t afford a private psychiatrist.

  “Yeah.” Wally hung his head lower.

  Autophagia was an extreme example of an impulse-control disorder. Some people experienced excitement or even arousal at the prospect of consuming their own flesh, and the practice was sometimes associated with psychosis or schizophrenia, but Kim was guessing that for the young man huddled on the bed, looking like he wanted to disappear into the floor, the act offered temporary relief from the stress and anxiety that hounded him. What Wally needed, once the infection was under control, was a complete psychiatric evaluation and treatment for what was almost certainly underlying depression and severe anxiety.

  “Tell you what. You let me work out the logistics,” she said. “I’m going to put a special ‘no Nazi’ clause in your paperwork. I’ve got someone in mind. I think you’d like him. Works in a clinic so far across town that you won’t have time to get back to class after—and it’s guaranteed one hundred percent confidential, so you can tell that school counselor to go suck ass and he won’t be able to do a damn thing about it. The clinic will also help your family figure out all the paperwork so insurance will cover it. What do you say?”

  Before Wally could respond, a muffled crash and a series of screams sounded through the exam room doors. “I think that’s for me,” Kim said, smiling wryly. “Gotta run. Listen, I’m going to hook you up with my friend, and I’ll keep tabs on you. Deal?”

  Wallace gave a desultory shrug.

  “Okay, I’m going to take that as a yes. So, ta-ta for now.” Kim backed out of the exam area, flipping him the bird through the curtain at the last moment. “Just giving you a reason to hold on.”

  A ghost of a smile flashed across Wally’s face as he returned the one-finger salute with both hands.

  In the hall, Kim pushed past Kyle, who been eavesdropping along with Dr. Jennings, the emergency room physician who’d admitted Wallace. The screaming grew more distinct closer to the doors separating the exam rooms from the waiting area, and Kim could make out occasional phrases—all of them variations on a theme involving bitch, crazy, and psycho.