CHAPTER 32
CRICOTHYROTOMY
The men rolled Robert onto his back. Blood poured over his face. The wound ran from below one eye, through his nose and ended below his chin, causing him to gurgle in pain. Other men turned helplessly to Nick, who stiffened for a moment until instinct jumpstarted his brain. ABCs…airway, breathing, circulation. Crap. All three compromised. Robert struggled to move air through his damaged airway while blood streamed from the gash.
Airway. Nick grabbed Robert and rolled him onto his side. The wound and flowing blood were blocking his airway. He started yelling as if he were back in the emergency room and his staff would understand. “Light! I need light. Get me a shirt or rags. I’ve got to stop this bleeding!”
He clamped his hand over Robert’s chin to try to close the wound while allowing some air movement through Robert’s mouth.
The villagers stood around Nick and his patient, understanding nothing and staring wide-eyed and frozen.
Breath. Robert gasped a few short breaths. Yes, it was helping, but barely. Finally, someone shined a flashlight beam on Robert, illuminating the wound. It was ugly. The sharp steel had cut into the sinus cavity, the upper palate, tongue, and cleanly through the mandible. Blood oozed down Robert’s throat, further compromising the airway. He needed intubation, a tube inserted down his throat to save him. Impossible. Nick didn’t have a laryngoscope or an endotracheal tube to insert for an airway.
Circulation. Nick jerked Robert’s upper body off the stairs and positioned his face lower than his chest. He couldn’t stop the blood, but at least he could keep it from running down his windpipe and drowning his lungs. Someone else pushed a white towel in front of Nick’s face. He grabbed it and wrapped it around Robert’s jaw and face, keeping a space for air to move. The cloth saturated quickly but stemmed the tide of blood. It was a knife-edge balance—too much pressure and he would stop breathing, not enough and the blood would soak through.
“My God, help us!” Nick screamed. This was why he hated medicine. He cursed his helplessness. Supporting Robert’s head and neck with both hands, he looked up to the eyes of the men around him and saw blank stares. He recognized one teenage boy that knew English. “A tube. I need a tube.” He let go with one bloody hand and made a small okay sign. “It has to be about this big,” indicating a half an inch. “Like a rubber tube…and a knife. I need a sharp pocket knife.”
The boy translated the needs and men fled to search.
Cricothyrotomy. It was the only way to save his friend. If Robert was to survive, Nick had to establish an airway. He would cut a slit in the throat and insert a tube directly into the trachea. It was tricky at best and fraught with complications: slicing through the vocal cords or creating uncontrollable bleeding. He had never done one, never even seen one.
The EMTs would talk about cricothyrotomies, the ER docs hated them, and only a handful that had attempted one either wore the merit badge with pride or didn’t want to talk about the disaster that followed—watching the patient die in agonizing suffocation.
“More light!” Nick yelled. He had to see what he was doing. The only possible way to do the cric was to roll Robert onto his back, giving Nick a fraction of time before Robert was smothered by his blood.
More flashlight beams illuminated the patient, followed by a small pocket knife and the best gift of all—a water bottle with a large plastic straw. The water container advertised a chicken restaurant. Nick was never so thankful for fried chicken.
“Pull the straw out!”
The boy did what he was told. If Nick could carefully cut through the skin below the Adam’s apple, the cricothyroid membrane, and into the trachea, the plastic tube would be perfect. It could have been a few millimeters bigger in diameter, but it was ribbed and sturdy enough not to collapse.
“Open the blade.” Nick nodded toward the pocket knife. What he wouldn’t do for some alcohol right now—this was not going to be sterile or pretty. He had one chance. The man holding the knife opened the blade.
“Oh great!” Nick cursed loudly. It was rusted.
He swallowed his disappointment and went into action.
“When I roll him over, shine as much light as you can on his neck. Then hand me the knife, another towel, and the tube. We have one shot at this,” he yelled.
The boy interpreted, and Nick waited to make sure they understood.
When Nick rolled Robert onto his back, his breathing stopped and the timer on Robert’s life started. Nick pushed Robert’s chin up and away, stretching his neck, tenting the trachea and hoping the old man’s Adam’s apple was easy to feel…it wasn’t.
There, I think that’s it. Maybe.
Robert was drowning in his blood and started to flail his arms. The men held him down.
If Nick didn’t do it now, all was lost. He grabbed for the knife, and his hand shook violently. Adrenaline surged through his body and brain. His heart beat in his ears, blocking out the cries of everyone around him. He wished he was back in an operating room with a diamond-sharp scalpel. He pressed the knife edge to the skin and drew back, trying to carefully make a longitudinal incision. He lifted the knife away. Not even a scratch.
“It’s dull.” He shot a glance at the boy. “You got me a frickin’ dull knife?” he yelled. “Aaaagh,” he screamed, trying to stop his hands from shaking.
He ran his thumb over the knife. It couldn’t have been duller. The tip, try the tip, his brain screamed.
He felt again for the thyroid cartilage and plunged the tip of the blade through the skin into the trachea. A rush of air bubbled the blood. He held the handle of the rusted knife in his fist and withdrew it hard and fast, slicing the skin and windpipe, hoping it was enough.
It was.
He grabbed the tube the boy handed to him and thrust it into the trachea, worrying whether it would fit, believing it would follow the trachea down and not up, praying it didn’t collapse.
It worked. Robert gasped a deep breath. And then another and another. Coughing around the tube, sending blood splattering. It was a marvelous sight.
* * *
Nick made sure Robert was not moved an inch until the villagers found a ball of string so he could secure the tube in place. He lassoed the twine around the tube and tied it tight around Robert’s neck, adding a second strand for good measure. If the tube was dislodged or knocked out of place, their heroics would be wasted. It was a lucky insertion to begin with, and that kind of luck happens only once.
With an airway established, Nick stuffed Robert’s mouth with rags and stopped the bleeding. ABCs restored. Robert was alive and for a moment he had even opened his eyes.
The boy who spoke English had found the sat phone and brought it to Nick, who wiped his hands on a towel and tried to remember Dr. Amy’s instructions. Fortunately, she had programmed her number on speed dial. Nick hit the series of keys.
“Hello,” the New Zealand doctor’s voice crackled through the phone.
“Amy, this is Nick. We’re in trouble.”
“Nick…what…call,” the phone sputtered.
“Amy…help,” Nick yelled. It was all he could think to say before the phone squawked a series of beeps that ended the call.
“Damn,” he yelled.
He looked at the phone and tried again, but there was no connection.
He set the phone down and was about to tell the men to help him carry Robert to the longhouse when the phone rang.
“Nick, this is Amy. I’m calling you back from the plane’s satellite phone.”
“Amy, we’re in a whole pile of dung here. We need you or Wright or someone to come get us, now!” Nick screamed. “There has been an attack on the longhouse, and Robert’s injured. I had to cric him,” he added, trying to catch his breath.
“Did you say cric…like cricothyrotomy?”
“Yeah, one and the same. He’s stable for now, but we need to get him to care.”
There was silence and Nick cursed loudly, thinking they had l
ost the call again.
“Nick, sorry…I am still here. Criminy, I have no bloody idea what to do. I’m at thirty thousand feet on my way to Singapore with the family.”
“Well, then call Wright and have him jump in his frickin’ whirlybird and come get us.”
“Nick, let me call you right back.”
The phone clicked off.
The realization that he was in the middle of nowhere and was not going anywhere quick collided with Nick’s desire to provide proper care for Robert. He wanted to scream or run, but he’d already screamed, and there was nowhere to run. Panic was about to overtake him when a hand grabbed his arm…it was Robert’s. Startled, Nick turned to his patient. Robert’s eyes were open, and he was trying to talk around the tube and the mouthful of dressings.
“Robert, it’s okay,” Nick said. “No, don’t try to talk. I put a tube in your throat to help you breathe.” He put a reassuring hand on Robert’s chest.
Robert pleaded with his eyes.
“Are you in pain?” Nick asked.
Robert shook his head and tried to speak again.
“Robert, please hold still. You don’t want to dislodge your tube or start the bleeding again.”
Robert nodded slightly, squeezed Nick’s hand, and lifted it to his own forehead. He put his other hand over his heart and patted his chest like Nick had seen him do when he prayed. Nick thought he understood what Robert was asking.
“You want me to pray for you?”
Robert’s lacerated mouth lifted at the corners, and he nodded.
Nick’s chest heaved with emotion, and his shoulders quaked. “Oh, God…oh, God.” No further words came. His mind was empty. Only the words of Chang filled his head: “Sometimes emptying precedes filling.”
Sure enough, as those words swirled in Nick’s consciousness, a prayer filled his mind and heart. It was the one he had prayed as a child with his mother after his friend drowned. He closed his eyes and prayed out loud.
“Our Father, who art in heaven,
hallowed be thy name,
thy kingdom come,
thy will be done,
on earth as it is in heaven.
Give us this day our daily bread.
And forgive us our trespasses
as we forgive those who
trespass against us.
And lead us not into temptation,
but deliver us from evil.
For thine is the kingdom,
and the power and the glory
for ever and ever…Amen.”
Nick opened his eyes to see Robert’s eyes tearing as he squeezed Nick’s hands hard. Nick couldn’t remember ever praying with such intensity. All these years, never understanding its power.
The sat phone buzzed at Nick’s knee, and he grabbed it and answered. “Yes?”
“Nick, I wish I had good news,” Amy said. “Even if we could turn back, there is obviously nowhere to land near you. I have tried Wright several times, and, strangely, his phone is off—it normally never is. I have talked with Boxler, and she was her usual unhelpful self. Nick, I’m so sorry. The best thing I can recommend is that you get Robert to the research center and I will have someone meet you there. I’m sorry.”
“Amy…that’s not acceptable. What other options do you have?” Nick yelled. He was about to curse at her, when two of the men interrupted him, trying to tell him something. He looked to the boy to translate.
“They are trying to…” the boy began. He turned to the men to ask more questions, then back to Nick. “The man that attacked us is from the abandoned longhouse. A human can’t kill the devil, so the attacker had to be a man, and they recognized him when a woman cleaned his face. They said his name was Rajang…Rajang Bok.”
Nick ignored the boy’s words and turned his attention to Amy.
But before he could speak, Amy, who had overheard the boy, gasped, “Rajang Bok? I spoke with Rajang at that longhouse three weeks ago. He was very distraught. He is one of the witch doctors I told you about. He’d lost his connection with the spirit world and was beside himself. He was on the medication, and I told him to stop it.”
Nick shook his head. “Look, Amy,” he insisted, “we need to take care of the living right here. Help me out. What are you going to do about this mess?”
“I’m sorry, Nick. Please tell the men to get you downriver.”
CHAPTER 33
REGRET
Regret and shame, typically fueled by tequila and bad decisions, hadn’t flooded Maggie’s spirit since her college-day shenanigans before she’d met John.
She rolled over in bed, pulling a pillow over her head. At least this time she was alone. What was I thinking? She’d kissed him back. It was one thing to let him kiss her, but she’d kissed him back. She tightened her grip on the pillow and listened to her stomach gurgle with regret.
After the kiss they returned to the airport in Hong Kong and flew back to Calcutta, where they were chauffeured to their hotel. This extravagant life was exhausting. The worst part of the long night was that Maggie knew she’d hurt Wright’s feelings. After she’d kissed him, he held her tighter and tried kissing her again, only to receive her firm no. It was her heart that stopped her, though her mind and body were willing.
The kiss was more than pleasant, his lips warm and soft. He seduced her with those hazel-green eyes. But the passion halted there. Her heart wasn’t leaping out of her chest. The earth didn’t move. There were no sparks, no fireworks. To tell the truth, it was kind of mechanical and Wright kind of robotic.
Back in her hotel room, she closed her eyes and buried her face in the pillow, where she imagined Nick smiling at her. Oh, God. Nick. What am going to tell him? Am I going to tell him? And what would she say to Wright when she saw him this morning? They planned on meeting for breakfast at eight and going to see his grandmother.
She sat up in bed. Her room was dark. No light showed through cracks in the window shades, and the digital clock on the nightstand read three thirty. She’d gone to bed at midnight and didn’t sleep at all. She fell back onto the feather pillow. In three and a half hours she’d have to pull herself together, and she knew she was going to look as terrible as she felt.
Maggie stared at the dark ceiling. Wright had said her reluctance was perfectly okay, but his body language betrayed his frustration. The color of his eyes changed, and she noticed the shadow of defeat. When they arrived at the hotel, he said he would be patient and didn’t even try to kiss her good night.
Maggie was startled by a loud knock at the door. She sat up straight and wrapped the blanket around her.
BAM, BAM, BAM! The knock was relentless. Then she heard a familiar voice.
She sprang from the bed and put her ear to the door.
“Maggie, it’s Wright.”
“Wright?” she replied behind the closed door. She was not about to open the door in her pajamas.
“Maggie, there’s been an incident!” he yelled.
She grabbed the door handle and pulled, forgetting the security chain was in place. When the door refused to open more than an inch, Maggie peered through the crack to see Wright, fully dressed and asked, “Wright, what is it?”
“There has been an attack on Robert’s longhouse. I’ll be downstairs waiting in the car. We’re leaving immediately.” Without another word, he turned on his heels and left Maggie in shock.
* * *
Maggie’s head spun as the Bentley raced down the empty streets. She held onto a leather strap hanging by the door when the car squealed around a corner.
“Damn it!” Wright cursed. “I never turn off my phone.” He glowered at her, suggesting it was all her fault. “I only turned it on because I couldn’t sleep.” He accentuated his scowl with a frown directed at her.
“Wright…I’m so sorry.” She stumbled over the apology.
“When I turned it on, there was a phone full of urgent messages from Leah and Amy. A crazed man attacked the community, tried to burn the place down, and Robe
rt was nearly mortally wounded.”
Maggie looked out the window at the dark landscape. Was all this her fault? “I am so, so sorry…was anyone else hurt?”
“No.”
She glanced at him, and his countenance darkened.
“Your friend is okay.”
After a minute, his look softened, and he stretched his chin forward. “Dr. Hart saved Robert’s life. But if we don’t get to the research center, this will be all for naught.”
* * *
As the Bentley wheeled up to the jet, Wright answered his phone on the first ring. It was Leah.
“Tell me some good news,” he told her.
“You’re not on speakerphone, are you?” Leah asked cryptically.
“No.” He covered the phone with his other hand and turned away from Maggie.
“The threat has been eliminated.”
That was indeed good news, but not what Maggie would want to hear. Wright shot a stony glance at her. She was staring at him, anxiously awaiting the news. He said nothing. He would have to act.
Anger burned in his stomach as he remembered the last of the many messages left on his voice mail by the frantic Dr. Amy. “The crazed man was one of our patients, Wright. Do you believe me now or do you need more blood on your hands?” she had screamed.
How dare she talk to him like that, even if she was upset? No one talked to him like that. His knuckles tightened around the handset, and he put it back to his mouth.
“When?”
“The good doctor’s plane dropped off the radar as she headed back to Borneo,” Leah said without emotion. “I just got the call from authorities. It was a fatal event.”
A twenty-million-dollar-jet event, he wanted to say. That was the benefit of having insurance. Knowing there were more jets where that came from buoyed his spirit. But this wasn’t the time to show relief. He had to play the grieving employer. He put his hand to his forehead and sighed. “Oh, my God.”
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