They carefully slipped the backboard under him and lifted him onto a gurney, covering him with a blanket and placing an oxygen mask over his mouth and nose. The gauze bandage taped over the gash on his forehead was already soaked with blood.
“Hey,” said the medic, “we’re close enough to the ED we could just hike the stretcher up the rise and wheel him there.”
“The sidewalk’s rough. It’ll be easier to drive around.”
* * *
Two minutes later, siren screaming, they pulled up to the ambulance bay doors, having had time to give only the briefest of radio reports to the ED staff.
“They’ll be pissed we didn’t call earlier.”
“They’re always pissed. You can’t win. I hope Dr. Forester’s working.”
XVI
The Good News First
The EMS radio crackled to life in the ED.
“This is Canterbury Seven with an elderly man, fall from a height, positive loss of consciousness, hemorrhage from a head laceration, tenderness of the left chest. Possible rib fractures. Unknown other injuries. BP 105 over 55, pulse 118, respirations 25 and erratic, Glasgow 12, over.”
The medic sounded anxious. Darcy didn’t like it when they sounded anxious. She’d be going on vacation in a couple of weeks, thanks to Jack Forester and Gail. An extra week of paid vacation! Though the thought had been enough to rejuvenate her, she didn’t want to see any more blood today.
Fat chance.
“Copy that,” she responded. “What’s your ETA?”
Nothing—they’d cut off the radio. They were at the damn doors already. Jesus Christ. A gurney flew through the ambulance entrance on a wave of cold air. Darcy jogged out from behind the counter.
“Take him to the trauma bay—and give us a little warning next time.”
The medic winked as he passed.
“Darcy, you’re looking good tonight.”
“Eat your heart out.”
* * *
The surgical intern, Dr. Steve Brasio, had just sewn up the thumb of a woman who’d cut herself slicing tomatoes. Peeling off his gloves, he headed for the charting station to write up the case but stopped when he saw two blue-jacketed medics wheel in a stretcher with a patient on a backboard wearing a neck collar. There were bloody bandages on his head.
Brasio’s mind and body tensed. Trauma. The Chairman of Surgery, Dr. Hansen, said he wanted surgical interns to get involved in every major trauma case that rolled through the doors when they were doing their ER rotations. Brasio grabbed a fresh pair of gloves from a dispenser on the counter and dashed after the stretcher.
This was only the second day of a six-week emergency medicine rotation for Brasio, a twenty-seven-year-old former college hockey player who’d graduated from Tufts Medical School just five months before. Until now, things had been routine. He’d sewn up lacerations, evaluated belly pains and treated a few burns, but nothing major. He had been well aware, however, that one day something awful was going to roll in the door and test his mettle. It might be somebody with an arm cut off, or a throat slashed, or a bullet wound to the chest. Fortunately, there was always an ER attending on duty to back him up.
With that in mind, he took a deep cleansing breath—he and his pregnant wife were going through Lamaze classes—and strode into the trauma suite. Two nurses had beaten him in and were preparing to move the new patient onto the trauma gurney.
“What happened?” he asked.
Nobody seemed to hear. He repeated the question, louder, and one of the medics looked over at him.
“Doc, this guy apparently fell off the footbridge, about twenty-five feet,” he said. “Nobody saw it, but that’s what we think happened.”
Brasio was still hovering about ten feet away.
“I see,” he said.
“I bet he jumped,” said one of the nurses. “The railing’s too high to just fall over.”
Brasio edged closer. It was obvious the man had a head injury—tufts of bloodstained white hair peeked over the top of the thick orange neck brace. On the count of three, the medics and nurses lifted the backboard and transferred the man onto the trauma gurney. As they did, a blood clot slid out from under the man’s head and plopped onto the linoleum.
It might be a good idea to get the attending in here—Brasio wasn’t quite sure where to start.
He strode back out into the hallway, but there was no sign of Dr. Atwood at the charting station. He checked the cross corridor, and still no sign of him. A nurse passed by, but when he asked her if she knew Dr. Atwood’s whereabouts, she rolled her eyes and laughed. Should he go look for Atwood himself? No, that would waste precious time, and he hadn’t even examined the patient yet.
He bolted into the trauma room.
“Hey, intern,” one of the nurses yelled. “Help us get him undressed.”
“Sure, right, okay,” said Brasio, trying to recall all he’d learned in the Advanced Trauma Life Support course he’d taken back in July with the other interns.
Patients with major trauma need to be exposed so you won’t overlook serious injuries.
“Right, we need to expose him. Let’s get him exposed.”
Heart pounding, he took out his bandage scissors and began helping the nurse cut away the man’s clothing.
Begin your evaluation with the ABCs.
A: Assess the integrity of the airway. Is there massive facial trauma? Is there blood or foreign material in the mouth?
No, not from what he would see.
B: Note how the patient is breathing—look for rise of the chest wall, listen for noises.
Yes, the chest was rising regularly, and the breathing wasn’t noisy.
C: Check for circulation. What’s the blood pressure, and does he have a good pulse?
Brasio reached for the old man’s wrist. He felt a strong, fast pulse.
“What’s his blood pressure?” he asked the nurse.
“One-ten over fifty-eight.”
Okay, so that was the ABCs. Now what?
Then perform a quick secondary survey from head to toe, looking for things that need immediate attention like hemorrhages. Examine the chest, abdomen and pelvis for signs of internal bleeding. And—Jesus Christ, the neck—don’t forget the patient’s neck. Head trauma always carries the possibility of a neck injury—so obtain a lateral c-spine film early on.
Brasio had heard stories about people with broken necks having their cords severed by careless interns who moved their heads before getting an x-ray.
“Let’s get a neck x-ray stat!” he ordered.
“Already called for it, Dr. Sherlock,” said the nurse, a tiny brunette whose name was Bridgett.
The medics found this humorous.
“Okay, then, I need to check his chest and belly,” said Brasio, blushing.
“Be my guest,” said Bridgett, who had wrapped a rubber tourniquet around Gavin’s arm and was stabbing a vein with a huge IV needle.
The other nurse was hooking him up to the cardiac monitor.
“Don’t you want chest and pelvis x-rays, too?” she suggested.
It’s always wise in patients with significant trauma to obtain routine chest and pelvis films so as not to miss potentially life-threatening injuries.
“Definitely—let’s order them.”
“Already done,” said Bridgett. “How fast do you want the IVs going?”
Brasio hesitated.
“How about wide open,” she said. “His pressure’s a little low.”
“Yes, wide open,” he agreed. “Good idea. Wide-open lactated Ringers.” Brasio leaned over the man’s face. “Sir, can you hear me?” he yelled.
The man’s eyelids fluttered.
“How are you feeling?”
“What happened to me?”
“You fell, sir,” Brasio told him. “Listen, you’re going to be okay, we’re going to take care of you. What’s your name?”
The man didn’t respond.
“We don’t know either,” said the medic. “He called
himself Dean.”
“Is your name Dean?” Brasio asked.
“Jim.”
“Jim? Jim who?”
“Jim Gavin. What happened?”
At that moment, Brasio heard Bridgett gasp. He looked at her, afraid he’d stepped on her foot.
“Oh, my God, I recognize him now,” she said. “This is Dr. Gavin, our old dean.”
“Holy Mother of God, you’re right, Bridge,” Darcy cried. “It’s Dr. Gavin.”
Every muscle in Brasio’s back seemed to tense. He looked toward the door.
“Somebody, please go find Dr. Atwood,” he commanded.
“Good idea,” Darcy said as she punched the intercom button that connected the trauma suite to the charting station. “Kathy,” she yelled. “Find Dr. Atwood and send him into trauma, STAT.”
“You’re going to be okay, Dr. Gavin,” Bridgett assured him. “You had a little fall.”
“Ah,” Gavin murmured. “Thank you.”
“Dr. Gavin,” said Brasio, “could you squeeze my fingers, please? Good. Now wiggle your toes. Good. Where all do you hurt?”
“What happened?” Gavin asked again.
“You fell.”
“Okay, thank you.”
“What do you remember?”
“I’m not sure,” he said. “Did Captain Peters make it?”
He obviously had a concussion, so there was no point in trying to get any more history. Brasio continued with his examination. Gavin had a big laceration on the left parietal scalp, and Brasio could see the glistening membrane over the cranial bone.
“Let’s order a head CT as soon as possible,” he said. “How are the vitals doing now?”
“I’ve got him on the automatic cuff,” the second nurse said. “You can see up there yourself.”
Brasio looked at the monitor screen mounted on the wall above the patient’s head. It showed a blood pressure of 105 over 50 and a heart rate of 124. The pressure wasn’t all that bad, but his heart rate was higher than it should be. That might mean impending hemorrhagic shock.
Or he was in shock already?”
Brasio felt sweat rolling down his neck. There was obvious bruising to the left side of Gavin’s chest, but his arms, shoulders, legs and hips seemed okay, and his abdomen was soft and didn’t seemed tender. Where might he be hemorrhaging from? Maybe he’d lost enough blood from the scalp laceration to leave him in shock.
“Have we located Dr. Atwood yet?”
Bridgett snorted.
“No, and don’t hold your breath,” she snapped. “We’ll page him again.”
“Sir, tell me where you have pain,” Brasio continued. “Does your neck hurt?”
“Tell Nelson to go to hell.”
Reassess, always assess and reassess. Brasio quickly reviewed the situation. Definite head injury. The x-rays of neck, chest and pelvis would be done shortly, and the labs would soon be back. The guy seemed reasonably stable. Then the head CT. The vital signs—he’d keep a close eye on them. Atwood would show up any minute.
Brasio began to relax. Perhaps he would manage to negotiate this minefield, and what a story he’d have to tell on rounds tomorrow—treating the former dean of the medical center by himself because they couldn’t find the attending!
“Bridgett, could you help me get ready to suture the scalp laceration?” he said. “I don’t want the bleeding to kick up again.”
“Wait,” Bridgett cautioned him. “Take a look at his heart rate.”
Brasio’s eyes shot to the monitor screen. The series of green squiggles representing the heart rate were coming even closer together now; the digital read-out said 140 beats a minute. An alarm went off inside his head.
“His BP is bottoming out,” Bridgett yelled.
Brasio looked. It was now 82 over 39.
“He’s going into shock,” Bridgett said.
“He’s probably bleeding inside,” Darcy added. “We’d better hang some blood.”
“Yes, right, definitely,” Brasio said. “Let’s get two units. And call for help—call the chief resident if they can’t find Dr. Atwood.”
Bridgett punched the intercom button.
“Kathy, page the surgical chief super-STAT.”
Gavin’s skin had gone pale and clammy, and he was breathing in rapid gasps. A wave of pure horror washed over Brasio.
“Pressure’s down to seventy,” said Bridgett.
“Open the IVs wide,” he ordered
The worst thing he could do was panic. Think. What was going on? Why was this guy going down the tubes? Where the hell was the attending? If he were sitting in a classroom right now analyzing this situation, the solution would probably be obvious.
Gavin was losing blood, but his abdomen was soft, so it wasn’t likely a ruptured spleen. But it could be. Or he might he be bleeding into his pelvis? But he wasn’t tender there, either. He could be bleeding inside his skull, but if that were the case he should be unconscious, or so the book said. But the book also said that any internal hemorrhage can give misleading symptoms, or no symptoms at all until it was nearly too late to correct the problem.
Or could it be from something else? What the hell was going on?
“Are you still with us, Dr. Gavin?” he asked.
No response.
“I can’t get any pressure now,” Darcy said. “Oh, shit, look—he’s gone into V tach.”
Gavin’s cardiac tracing looked like a picket fence. Bridgett hit the button again.
“Kathy, call a code in the trauma suite.”
Racing back to the bedside, she elbowed past Brasio and started pumping Gavin’s chest with her palms. Darcy took out the defibrillator pads and began squirting electrode paste on them.
* * *
New Canterbury’s General Surgery residency program was of the pyramid type. Fifteen interns started out each June, and each year their number declined. By the fifth and final year there were only three left—a trio of chief residents who had been tempered in the flames of unrelenting responsibility, continuous evaluation and hundred-and-twenty-hour workweeks. By that fifth year, they were proud and tough—some would have said arrogant as well.
Thirty-year-old Sarah Hopper, the on-duty surgical chief, was in the ICU checking on a subclavian line she’d placed that afternoon when the ER paged. Her first impulse was to run down and take command. Experience had taught her, however, that if she didn’t put up at least a token resistance, she would soon be busy beyond any human’s capacity. So, she strolled to the phone and called the ER desk.
“Hopper here. What’s up?”
“They need you in trauma,” Kathy said.
“I assumed that much. For what?”
“Because there’s a patient dying down here.”
“That doesn’t tell me anything.”
“Listen, all I know is that a very good nurse told me to page you STAT, okay?”
This didn’t sound like the usual bullshit. She felt her heart quicken. The landing craft was grinding against the beach, the ramp swinging down and bullets thwacking metal.
“Okay, but the next time, some more information would be helpful.”
She slammed the phone down and took off at a dead run. You never knew what might be going on down there. Some of the ED docs, like Jack Forester, knew acute trauma management, but others couldn’t manage their way out of a paper bag. They’d call you down to evaluate a fucking hangnail. Nurses, though, tended to know their stuff. Bad sign when a nurse calls uncle.
Down six flights of stairs she dashed, and she wasn’t even out of breath when she hit the ground floor. She bashed through the back door of the ED, hit the trauma room and slammed on the brakes.
There stood one of the new interns with a deer-in-the-headlights look in his eyes and a sheen of sweat on his brow. Nurses and techs of all varieties were milling around, and in the middle of the crowd a tiny nurse stood on a stool doing CPR.
“Out of the way,” she commanded. “Stop the CPR for a minute.”
&nbs
p; Though not much larger than Bridgett, she picked up the nurse by her elbows and set her aside.
“You,” she said, pointing at Brasio. “Tell me what the hell’s going on.”
The room fell silent as the intern described the situation.
“Jesus, this is great,” Hopper said when he’d finished. “You’ve got the Nobel Prize-winning former dean of the medical center falling off a fucking bridge, and you didn’t call me sooner? Where’s the ER attending?”
“Good question,” Bridgett growled.
Hopper knew exactly what the problem was within several seconds, and she started barking orders. Then her eyes bored into the intern.
“Brasio, this patient’s got an obvious tension pneumothorax. Look at how his trachea’s deviated, and he’s got crepitus up and down his left chest. That’s why he’s hypotensive, goddamnit. You should have done a needle decompression of his chest ten minutes ago. CPR is just making it worse. Somebody give me a fourteen-gauge angiocath needle and bring me the chest tube tray and a seven-point-five ET tube so I can intubate him. Quickly, people. Watch close, Brasio.”
In one deft movement, Hopper stabbed the needle high in the front of Gavin’s left chest. As trapped air under pressure escaped through the needle, a hissing sound was audible across the room.
“Step one.”
“I can palpate a pulse now,” Bridgett announced.
“Of course,” Hopper said. “He had no venous return due to buildup of pressure in his chest. He’s probably bleeding inside the chest, too. Have you ordered blood, Brasio?”
“Yes.”
“Good.” Hopper bent over and slipped a tube through Gavin’s mouth into his trachea. “Have you looked at the chest x-ray yet?”
* * *
Steve Brasio said nothing. His vision was blurry from the sweat running into his eyes. The chest x-ray. He’d ordered one, hadn’t he? Had it been done? He wasn’t sure. All he knew was that his career was over. He would be drummed from the program. His family would be disgraced. His wife would leave him out of shame. His child would never know a father.
Hopper swore but didn’t skip a beat. She tore open the chest tube tray and began placing one into Gavin’s chest to keep the lung inflated.
Final Mercy Page 13
