by P A Vasey
The larger of the two sidled over; his companion hung back but kept his eyes on the patient on the trolley.
“What’s your name?” I said.
“Bob. Bob Westwood.” He reached out for a shake but I was snapping on gloves and hands in a silent ‘don’t touch’ kind of way. He moved a bit closer to the trolley, peering at the figure under the blanket. I coughed and he shifted his gaze back to me. “Yeah, so it was early. One-ish I reckon. Me and my brother here were driving down the highway when this guy appeared directly in front of us, just walking down the centreline, cool, as you like. Carrying no lights, nothin’. We wuz goin’ fifty-sixty or so but I braked hard, and pulled the wheel over to the left, tried to cross into the opposite lane. Didn’t make it.”
“So was it a glancing hit, maybe just the edge of the truck?”
He shook his head. “Here’s the weird thing. I swear I saw him raise a hand towards us and suddenly the brake wouldn’t work and the steering wheel kinda became disconnected from the wheels. Hit him full on. He bounced off the hood, cartwheeled into the windscreen, shot over the roof and back down the road like a rag doll. We zigzagged down the highway for fifty yards or so before the brakes came back on. I killed the engine and my brother and I just kinda stared at each other in shock.”
I imagined the truck’s engine idling, smoke settling as they turned the ignition off and the sounds of the desert starting to impose. Frogs and crickets chattering in a nearby water hole. A not-so-distant coyote howling plaintively just above the sound of wind through the bushes and the scouring of wind-borne sand across the road.
You know the sort of thing.
I blinked to clear the image and turned to Jeff who was continuing to bag the patient, squeezing the rubber balloon, pushing oxygenated air into the patient’s lungs.
“Do we have a name?”
“No name, no ID,” he said.
I dismissed Bob with a wave and he wandered back over to the reception to join his brother. I turned back to the trolley and pulled my stethoscope out of my pocket.
“What’s his status?”
The other paramedic, a balding younger guy I hadn’t met before, looked up, shook his head. “Not sure. Can’t get a reading on his oxygen sats, but he isn’t cyanosed. Auto-reader gave a figure of sixty-six per cent on six litres oxygen, but that can’t be right so we’ve disconnected it. I can’t find a pulse, and he’s got no blood pressure. He doesn’t appear to be spontaneously breathing.”
“So he’s dead then?” I said.
“Theoretically yes, but he keeps moving. Look…”
He nodded at Jeff who stopped his ventilatory efforts with the mask and removed it. The patient twisted his neck, as if stretching and yawning.
I frowned. “Clearly not dead.”
“I know, right?” said Jeff. “I’ve been bagging him at twenty per minute without any spontaneous respiratory effort. Yet he still shows signs of life.”
“Maybe it’s all instinct,” I mused softly to myself, “and he’s brain dead.”
The other paramedic shrugged. “He’s got a temperature. A smoking forty-two degrees.”
I put my hand on the patient’s forehead, expecting to feel the heat of a fevered brow. I recoiled and looked at the paramedic. “Really? He feels cold. Clammy, even.”
“Weird, isn’t it? And there’s more. I can’t get a response to pain stimuli. I got his GCS at 3; all 1 for EMV; his pupils are really, really big, but they’re equal and they don’t react to light stimulus.”
“That’s not good,” I said, quietly.
All 1 for EMV meant the lowest score for eye, motor or verbal response; evidence pointing towards coma and possible brainstem damage. I hooked him up to a cardiac monitor, applying sticky pads to his feet, arms and chest. I switched on the machine, and watched as the lines appeared. Flat. No cardiac electrical activity.
“We’ve struggled to get intravenous access,” said Jeff at the head of the gurney. He pointed to the IV running into the forearm. “I don’t even think that’s in a vein. His skin’s so tough, I couldn’t get no back-flow of blood.”
I looped my stethoscope around my neck, and pulled the sheet down to get a good look at the patient. He was tall, with his feet hanging over the edge of the gurney. A head taller than most people I would consider tall. He didn’t look lanky though, as there was bulk to him, in all the right places. He had a full head of blue-black hair, cut short and GI-like. He had strong arched brows and thick eyelashes and his face was chiselled with cut cheekbones and an aquiline nose. He was striking up close, but his pale skin and thin lips made me hesitate in calling him handsome.
“Doc,” said Jeff, bringing me back to earth. “What do you make of the wetsuit?”
I saw that the paramedics had cut open his clothes to gain IV access, but I hadn’t registered what he’d been wearing. I took a second to re-appraise this fact. “What was he doing wearing this in the desert?”
The second paramedic shook his head and grinned. “Fancy dress party?”
I gave him flat eyes. “Right.”
He shrugged. “Why not? Maybe from the Base, out on pass, at a wild party? Coulda got drunk, and his buddies left him behind as a prank. You know those guys can party.”
He smiled knowingly at me and I felt my cheeks burning.
Small town.
I pulled some scissors out of the top pocket of my scrubs, and started cutting away the rest of the wetsuit. I carefully peeled away the neoprene top and started my examination. I worked methodically over his upper body, feeling for abnormalities, swellings and deformations consistent with fracturing or internal bleeding. Everything seemed structurally normal. I once again noted that he was toned with very well defined musculature but interestingly he had no body hair. I tried to pull up a section of his forearm skin between my fingers, but nothing moved. It felt like leather. Or rubber. Anything but what normal skin should feel like.
“So… no signs of bruising over abdomen and chest wall,” I was talking to myself. “Upper limbs appear intact.” I stood back, hands on the side of the trolley and give a perplexed look. “Skin coloration definitely a little pale and waxy. The skin tone is tight, very tight …”
Jeff was standing back, watching, chin in hand. I looked up and caught his eye. He raised his eyebrows and blew out his cheeks.
“Doc, there’s not a bruise or a scratch anywhere. I can’t see any blemishes either, can you? No moles, birthmarks, nothing.”
I nodded slowly, and pushed the earpieces of my stethoscope into place and listened to the man’s chest. I could just hear a faint low noise, which I took to be heart sounds, very slow. I then placed the stethoscope on the abdomen, held it there for half a minute, then moved it around and listened again. I looked up at the paramedics, worried, and placed a hand on the abdominal wall. It was solid, like a board.
“I can’t hear any bowel sounds,” I said. “I suppose the impact might’ve produced a traumatic ileus, shutting down his bowels.”
Or he could simply be bleeding out.
I pulled a pair of scissors from my pocket, and eased them between the skin and the wetsuit. I started cutting, expecting a tough job because of the thick rubber but the scissors sliced through the material like paper. Methodically I cut lines from the ankles to waist, and removed the leggings.
“Must be the cheapest wetsuit in the world,” cracked the other paramedic.
I ignored him and ran my hands over the patient’s legs, checking for broken bones. Everything looked structurally intact. There was no sign of injury to his legs or pelvis. I looked up, brow furrowed.
“There’re no cuts or bleeding. Isn’t that a little strange?”
They both nodded in agreement.
I stood back. “He must be one tough son of a bitch.”
“I’ll tell you something else,” said Jeff. “When we lifted him onto the stretcher, he weighed almost nothing. Like a child. Can’t be more than ninety pounds.”
I looked up sharply.
“That doesn’t fit. Look how tall he is. And he certainly isn’t emaciated.”
“I guess. Maybe he has hollow bones,” he said with a smile.
I gave him a sarcastic half smile back. The nurses were hanging around the bay so I decided to get them busy.
“Hayley, try and get some basic blood work off please. Can we get a full haematology profile, random chemistry including magnesium and glucose, blood gases, oh and a toxicology and alcohol screen? Carlie, you call the radiologist in, lets get a CAT series of his head, neck, chest and abdomen. I also need him catheterised to culture his urine. And culture his blood as well.”
The nurses started moving, jolted into action. I got out my phone and took a quick picture of the patient, pulling the oxygen mask down for a better view. The plastic covers on the ER main doors slapped, and my colleague for the morning shift Clem Reynolds pushed through wearing Nike running gear and holding a Starbucks cup. He had a fringe of grey-white hair around his balding, mottled scalp but his face was free of lines and his eyes sparkled with youthful vigour. He took in the situation with a glance, and went straight to the opposite side of the couch, checking the patient out.
“Interesting start to the day?” he said, with a twinkle in his eye.
Clem was an ex-military surgeon in his early 60s who did ER work in his spare time from being Indian Springs’ only general practitioner. He was well liked and respected locally, and I’d appreciated the support and collegiality he’d offered to me when I arrived. I had stayed with Clem and his wife for two months while I was getting my act together and finding my feet. I can’t imagine how hard I must have been to live with, but Clem never complained.
I gestured to the man on the trolley. “Do you recognise him? Maybe one of the GI Joes from the Base?”
Reynolds was gently turning the man’s head side to side. “Never seen this guy before. Where was he found?”
“He was taking a stroll down the middle of the I-95 just a few miles east of Mercury. Those guys hit him.” I pointed to Westwood and his brother, who were watching proceedings, wide-eyed.
“We tried to avoid him, but …” Westwood stuttered.
“You guys still here?” I said. “You need to check in over there”.
When they had shuffled away I turned to Reynolds. “Better get the police to talk with them. Something’s not right. The paramedics said the hood was all bashed in from the impact. This guy shows no obvious sign of injury.”
Reynolds nodded, and then leaned over the patient and put his mouth close to his ear. “Hello, can you hear me? You’re in a hospital. Can you hear me?”
There was no reply, so he placed a knuckle over the man’s sternum and dug it in back and forward with a twisting movement. The man stirred, his neck arching backwards and upwards.
Jeff looked up, “that’s an improvement.”
Suddenly, the man’s eyes flickered open, and the cardiac monitor came to life. Red and yellow lines started spasming and jerking across the screen before settling into a nice steady rhythm of eighty beats per minute. The oxygen saturation reading flicked to ninety-nine per cent. I stared unbelievingly at the monitor. All the parameters were now normalising. The automatic blood pressure cuff was activating and flashed up a healthy 120/65 reading.
“What can I say, I’m a good doctor,” said Reynolds, a wry smile creasing his features.
I fished in my white coat pocket and brought out an ophthalmoscope. I pulled down the patient’s right eyelid and shone the ophthalmoscope’s light at the pupil. There was no light reaction, the pupil staying large and fixed. I leaned closer, winding the focus wheel down on the scope and attempted to bring the retina at the back of the eye into view. The optic disc came into focus and I could see numerous grey/black lines arcing concentrically away from where the optic nerve should be. I was about to examine the edges of the retina when there was a brief pulse of phosphorescent light that spun counter-clockwise along the lines, disappearing into the edge of the disc.
I straightened. “That’s … that’s very interesting.”
Clem looked up. “What?”
I turned the ophthalmoscope around in my hand as if I had never seen one before. I looked up at Clem and held it out to him. “Take a look.”
He took the scope and leaned down to examine the man’s other eye. After a minute or so looked up, disbelief etched on his face. “Is that … electricity?”
He moved around to the left side of the trolley, and examined the other eye in the same deliberate way. He then handed the ophthalmoscope back to me, stood back, and wiped his mouth with the back of his hand. “Unusual pigmentation of the retina, don’t you think?”
“I don’t know what to think. I’ve never seen anything like that,” I said.
I hadn’t. It was so abnormal it made no sense at all.
Jeff had put the oxygen mask back over the patient’s mouth, and re-started bagging him. He looked up at me, and then over at Reynolds. “Are you guys going to do anything to help this guy?”
Clem was jolted out of his daze. “Yes, absolutely. Kate, whatever that was, it’ll have to wait. You said his abdomen’s rigid and there aren’t any bowel sounds. He must have some internal injury so maybe he’s bleeding internally. Do you think we should prep him for emergency surgery?”
I laid a hand on the prostrate figure’s abdomen and nodded absently. I looked into the man’s face. “Sure, but let’s get some scans first.”
CHAPTER TWO
Indian Springs Hospital and Medical Centre, Nevada
One floor up, and adjacent to the surgical suite, I waited with Clem and the radiologist Pete Navarro for the images from the CT scanner to appear on the monitors. The radiographer was in the scan room next door with the patient, attempting to find a vein to cannulate after Jeff’s needle had tissued soon after arrival in the CT suite. I looked through the leaded glass that separated the reporting room and scanning area, and gave the radiographer a hesitant, questioning thumbs up. Although he was masked, I could see that the expression in his eyes and his body posture indicated that he was still struggling with the IV. Our eyes met, and he replied with a negative downward gesture of his own thumb.
“No-go for intravenous contrast then,” I sighed, looking at Clem. “We’ll need to make do with non-contrast images.”
“Did we get the blood work off?” he said.
“No. We can’t find any veins. Probably all shut down, despite that Bp reading. I’m probably going to have to put a central line in, or do a cut-down.”
Navarro grunted unconcernedly from the centre console chair. He was a fit looking thirty-something ex-airforce corporal with a buzz cut and a non-regulation moustache. I’d heard that medicine had been his second career, and that he’d left the military under a bit of a cloud. He seemed well suited to radiology given his obsessive-compulsive tendencies and poor people skills. Being in a dark room most of your working day looking at x-rays and scans, dictating reports and not needing to speak to actual humans would not have appealed to most people, but he seemed right at home.
“Don’t worry,” he said. “We’ll get all the information we need from the non-contrast scan. I’ll dial the gain up and increase the number and intensity of the slices.” He smiled proudly. “This is pretty cutting edge shit we got here, you know.”
Navarro was both proud and protective of his equipment, and given the almost unlimited budget the US airforce had to work with, he had been able to receive next generation upgrades to the scanning equipment whenever he asked.
“We can also put him through the fMRI machine,” he grinned, “although its a shame he didn’t have his accident next week, ‘cos the new FDG-PET would’ve been ready.”
I raised my eyebrows at Clem, and gave Navarro a blank stare. “Yeah, lucky for him I guess…”
Clem was now perusing the scan pictures that were starting to be downloaded onto the large LED monitors on the desk. I leaned in to watch as he used the mouse to enhance and flick between images. He switc
hed to the quad screen tool and pulled up multiple sequences of brain, chest/abdomen, pelvis, and what was quaintly called the ‘frog view’ by medics in remembrance of animal dissection in student days. He then focussed on the brain, and as the images came into high resolution.
I turned to Navarro. “Well, what am I looking at?”
He shrugged. “Anything particular you’re interested in?”
I leaned over him to get a better look. “Well, he was hit by a truck at high speed. Is there anything broken, signs of internal injury, you know, that sort of thing?”
Navarro pursed his lips and grabbed the mouse out of Clem’s hand to take control of it. He enlarged the images and scrolled backwards and forwards in order to view sections from the front to the rear of the body. There was a faint blurring on the edges of the screen, like an interference pattern, and I pointed this out, but he waved me off.
“Yeah I know, I’m trying to adjust. Something’s not calibrated right.”
A kind of afterimage shimmered into view, an outline of a human body, hollowed out with no internal organs, flickering back and forward between normal anatomical structures like an old cinema reel.
“The contrast must be too high,” he muttered. “The HUD number on bone windows is off the scale.” He started jabbing at the keyboard, making the software algorithms subtly alter the appearance of the tissues, both solid and liquid. I couldn’t see any significant changes manifesting on the screen.
“Speak English?” I said.
Navarro didn’t look up, and continued to flick between dials. “Well, according to this, bone density is ten, maybe twenty times the upper limit of normal. Like concrete.” He adjusted another dial with his mouse and the numbers running up the side of the screen spun downwards. “Oh, that’s better. More like it.”
The images on the monitors stabilised and became recognisable body parts again, sectioned horizontally by the scanner.
Reynolds pointed at the brain images. “What about his head? Any injury? Looks healthy and undamaged to me.”
