All in all, it wasn’t a bad night for walking. Houston in August can be brutal, but there had been showers earlier that took the bite out of summer heat. The evening was cool and moist and the greenery smelled fresh. As he walked across the forty acres of the Houston Medical Center, Matt marveled at the number and sizes of hospitals gathered here. The number of inpatients in these hospitals at any one time probably exceeded the population of more than ninety percent of the cities in Texas.
As he threaded his way along dark, winding sidewalks, Matt glanced up at giant, skeletonlike structures hovering over the buildings. Outlined against the night sky like huge, mutant praying mantises, the construction cranes were symptomatic of the never-ending construction going on at the medical center.
His scrotum tightened and the hair on the back of his neck stirred as he covered the last hundred yards to the Taub. He wanted to run from the darkness of the path to the safety of the lights; that would be unprofessional, not to mention cowardly. His legs didn’t care. They pushed him faster and faster until when he finally reached the hospital entrance he was walking like an Olympic racewalker.
Ben Taub is a charity hospital serving Houston and Harris County. Most of the patients, and people who bring them to the hospital, are poor. Assorted thugs and lowlifes hang around the entrance and parking lot of the hospital.
In spite of his fear, luck was with him and Matt made it to the emergency room without being mugged. He figured that was because it was Friday. Even though it was barely eight-thirty in the evening, ambulances were already having to wait in line to unload their cargos of human bodies torn apart as a result of alcohol and drugs bought with payday checks.
Emergency room staffs are superstitious, he knew, and spread a lot of wives’ tales about things that cause an increase in the damage people do to one another. Some are far-fetched, such as a full moon causing more obstetrical deliveries and lunacy. Others are more scientific, such as the heat during the Dog Days of summer causing more murders, and Fridays having the highest ratio of ER visits. Matt’s father, recently retired from the Houston Police Department after thirty years, told him on more than one occasion that the graph for homicides and violent crimes almost exactly matched the charts for temperature.
Paramedics were unloading an ambulance as Matt climbed the steps to the double doors of the loading dock at the emergency entrance. He leaned back against a wall and watched as medics struggled with a stretcher holding a huge black man who was moaning, cussing everyone around him. There were two IVs going, one in his right arm and another in his right leg. This usually meant the patient had lost a lot of blood—a fact confirmed by a scarlet-stained sheet covering the upper half of his body.
One of the attendants reached over as their stretcher raced through the doors to ring a trauma bell hanging by the entrance.
Like a shot of adrenaline to a failing heart, the tolling of the bell galvanized the ER staff into action. Before paramedics even got their patient on a table in Trauma Room One, the chief surgical resident, head of the trauma team, was at his side peeling back his blood-soaked sheet, examining his wound. The paramedic informed a resident the man had been drinking all afternoon at a local pub, and when he went home he tried to enter through a bedroom window to avoid a scene. His wife thought he was a burglar and unloaded on him with a shotgun, blowing his left arm almost completely off. The bet was even money among officers on the scene, someone said, whether she actually knew it was her husband or really thought he was a burglar.
Matt left his medical bag at the front desk and strolled into the trauma room, trying to stay out of the way and observe how the team functioned, part of his job as associate professor of emergency medicine. Besides his teaching duties, which were relatively minimal, he had the job of periodically visiting three major ERs in the medical center and evaluating and occasionally giving advice to the house staff that manned them. A few of the residents resented someone only a couple of years older giving them advice, but most liked Matt and knew he was only trying to help.
Right then, the team was functioning like a ballet troupe. Every member knew their job.
While the chief surgical resident examined and probed the wound, a nurse attached a blood pressure cuff to the patient’s right leg, well out of the way in case his heart stopped and his chest had to be cracked on the table. Another nurse stripped the patient’s clothes off with a pair of bandage scissors until he was completely naked. A recording nurse was standing in a corner, writing down the medication and lab and X-ray orders the surgical resident was calling out as he examined the wound. Matt listened to see if he missed anything.
“Apparent shotgun wound to left upper extremity, traumatic amputation. Ambulance tourniquet in place, brachial artery severed, but bleeding controlled. Call OR, we’re gonna need a vascular surgeon and team, including heart-lung bypass. Gimme a stat SMA-7, CBC, C and S, type and cross four units whole blood to start. X-ray chest and left shoulder. . .”
While he was rattling off orders, a lab tech stuck an eighteen-gauge needle in the patient’s right femoral artery, at the groin, and withdrew six tubes of blood to run the tests the resident was ordering. Another tech wheeled in a portable X-ray unit and was loading cassettes with film for studies the doctor wanted.
A second-year medical student was attaching metal clips to a protruding end of the brachial artery, the big one that supplied the entire arm, and various nerve fibers he could find in the shredded meat of the stump of the arm. Another student, probably third year, was poking and probing and listening to various other parts of the man’s body, looking for other injuries. It wasn’t unheard of for a patient to come in with an obvious major trauma and have it fixed, only to die from another hidden injury that was missed in the excitement.
The people of Trauma Team One swarmed over the body like worker ants in a disturbed ant bed, each with his specific job to do. Voices cried out orders for medicine and tests, observations of vital signs and blood pressure and the normal findings.
The med student called out his findings as he examined the patient. “Heart regular sinus rhythm, no murmurs, gallops, or rubs . . . lungs clear, abdomen soft, bowel sounds active.” From the cacophony of sound, all the members of the team managed to hear only what they needed to do their jobs, bringing order out of seeming chaos.
The entire process, from the time the bell rang until the patient was on the way to the operating room, took less than ten minutes. As the elevator doors closed behind the gurney with the patient on it, the team went from fast-forward to slow motion and seemed to wilt like flowers in the summer sun as their adrenaline ceased to flow. They stood in various poses, the resident leaning against a wall with one hand, rubbing his face with the other, the nurses walking slowly toward the big coffee urn in the staff room down the hall, the medical students jabbering to each other excitedly about the gory mess the shotgun had made of the man’s arm.
Matt walked to the center of the hall and stood there, slowly clapping his hands, a big smile on his face.
Jeff Strickland, the surgery resident, looked up, smiling tiredly in recognition. “Hey, Dr. Carter. What’s happening?”
The nurses looked once over their shoulders, waved and said, “Hi, Dr. Matt,” then continued toward the lifeblood of the ER staff—coffee.
The medical students became hushed and tried to look professional and grown up, managing only to look younger than they could imagine. “Good evening, Dr. Carter,” they said almost in unison.
Matt waved and walked toward Strickland. He put his arm around the exhausted resident’s shoulders and guided him toward the coffeepot. “Looked good in there, Jeff.”
“Thanks, Matt. The team is really starting to come together.”
“Looks like about”—Matt glanced at his watch—“nine minutes, forty-five seconds. Not bad, not bad at all.”
Strickland shook his head, eyes on the floor as he walked. “We could do better. The X-ray tech is a little slow, and the students always get f
aster after a couple a weeks on the service.”
Matt could feel the tightness in his shoulders. “How long you been on?” he asked.
“What time is it?”
“Eight forty-two P.M.”
Strickland thought for a minute, then smiled ironically. “What day, Thursday or Friday?”
Matt laughed. “Friday.”
“Then it’s goin’ on thirty-three hours.”
Matt shook his shoulder. “Hey, no problem then, you’re on the downslope.”
The surgical residents worked thirty-six hours on, twelve hours off one week, and thirty-six on, eight off the alternate week. Strickland only had three more hours to go until he was off duty for twelve whole hours. In that time, he would reacquaint himself with his wife, tell his kids hello, then try to sleep before his next thirty-six-hour shift.
As the two doctors entered the small break room where the coffee was kept, it looked like a haven for insomniacs. The entire staff of the ER wore surgical scrub suits to work. Scrubs looked like pajamas, V-necked cotton one-piece tops and baggy, string-belted pants dyed a solid sky-blue color. The nurses’ hairdos were limp and straggly and the men all had two-day beard growths and dark shadows under their eyes. Looking at the bedraggled crew, Matt was reminded of our medical forefathers’ wisdom in decreeing that no one over the age of twenty-five could enter medical school—any one older than that couldn’t survive the rigors of training.
Matt picked up a Styrofoam cup and poured coffee from a blackened, ancient-appearing pot. He shook his head, swearing to himself he could see the liquid eating away parts of the Styrofoam. Strickland flopped into an empty chair, letting his head fall back over the edge of the seat. Within thirty seconds, he was snoring.
Tentatively, Matt sipped the coffee. It was primo hospital coffee—hot, black, and loaded with caffeine. It kicked his heart rate up ten beats and started a fine tremor in his hands. He carefully poured the remainder down the sink, hoping the pipes could survive it. One of the nurses, he thought her name was Sally, looked up at him through eyes the color of a sunset and said, “Hey, Matt. A couple of us are going clog dancing after work. Wanna come?”
He smiled at the gallows humor, knowing she would be lucky to get undressed before she crashed after her twelve-hour shift was over. “Naw, get one of the med students. Those guys never sleep.” He waggled his eyebrows at her. “And they just love nurses.”
Just then the trauma bell rang again, bringing Strickland immediately awake. He was out the door and running down the hall before Matt could put his empty cup down. He followed, looking at his watch. It was a slow night for a Friday. It had been all of twenty minutes since the bell had last rung. As he walked down the hall, the bell rang again. One of the nurses looked back over her shoulder and shouted, “Trauma Team Two, heads up, it’s a twofer!”
The second trauma team assembled from various other ER rooms where they had been busy with minor cases—suturing, pumping out stomachs, setting broken bones.
Matt entered Trauma Room two. He had already observed Strickland, now he wanted to watch the other surgical resident, Bob Mathis, work. He was a year behind Strickland, but Matt suspected he was going to be just as good. The paramedics were wheeling in two teenage Hispanics, shot in a drive-by in Houston’s fifth ward. The gangs waged war there every bit as brutal and deadly as the Serbs and Muslims had waged in Bosnia, and with similar results.
As Mathis took charge, Matt saw that his team was a little fresher than Strickland’s since they were on second call and hadn’t had as many major traumas to deal with. Everything was going by the book when the bell rang again. Mathis looked up from the patient’s body, his hands covered with blood and mucus, and raised his eyebrows at Matt. “No problem,” Matt said. “I’ll take it.”
The Taub only has two major trauma rooms, so Matt waved the paramedics pushing a stretcher down the hall toward a regular room as he shrugged out of his white clinic jacket, wishing he’d had time to change into scrubs. He was probably going to get messy on this one.
He had one of his surgical gloves on and was in the process of putting on a second when they pushed the stretcher into the room. He didn’t like the look of the girl lying there. Her eyes were closed and her head flopped loosely with the motion of the gurney. Her color was about the same as the sheet covering her. Matt’s mind automatically clicked into high gear, an adrenaline-charged state that all ER docs come to love. Thoughts are generated with lightninglike speed, and perceptions are heightened to a point where the conscious mind recedes and lets the subconscious run the show. Time seems to slow and every minute detail of a patient’s condition is noted without conscious volition and stored for later use. While the mind is busy cataloging, storing, and thinking of things needed, the hands seem to be controlled by some other part of the body, probably the brain stem. They go on about their business without waiting for conscious orders—poking, probing, feeling, and evaluating almost before the patient is quiet on the table.
Matt didn’t notice which nurses helped him with the patient; his eyes never left her body. As he bent over to examine her, he was struck with a sudden and almost overpowering queasiness. A strange, musky smell rose off her body, causing a feeling of dread to crawl up Matt’s spine and make him shiver. He had a sudden urge to look over his shoulder and see what menacing creature was standing there, watching him. Taking a deep breath and swallowing hard he began his examination of the woman.
She was naked under the sheet, with heavy theatrical makeup on her face and long, fake eyelashes on her lids. One came off and stuck to his glove as he raised her eyelid and looked for a narrowing of her pupil in response to light. He thought it constricted slightly, but that may have been wishful thinking. Running his gaze down her body, he noted her obvious injuries: She had a four-centimeter gash in her throat, over the right carotid artery, and bloodstains down the sides of her neck but no current bleeding. Part of her hair on either side of her head was uprooted and partially pulled out, her scalp peeled back, as if someone had held his hands in her hair while she struggled, ripping it out by the roots. Her left nipple was bitten almost off, hanging by a slender thread of tissue. Bad sign, he thought, that it isn’t bleeding either. Her labia were macerated and torn, and scarlet stains ran down her buttocks over her thighs.
He took a penlight out of his pocket and pointed it into the neck wound, seeing edges of the carotid artery lying serrated and torn next to the jugular vein, which also seemed to have been ripped apart.
Holding out his hand, he cried, “Mosquito clamp, stat!” His nurse had already opened a surgical tray and the instrument hit his hand before he said the second word. He snapped the instrument over both the carotid artery and the jugular vein; he’d worry about blood supply to her brain later.
He put the bell of his stethoscope against her chest over her heart and heard a very slow, weak heartbeat. As he leaned closer, his face nearer to hers, she opened her eyes and stared in horror at something only she could see. Matt’s heart jumped and he gasped at the expression of terror on her face. Her lips moved soundlessly as she tried to speak through her ruined throat. He put his ear close to her mouth and heard her rasping whisper, “He was a demon . . . a monster . . . oh God, help. . . .” Matt jerked back and watched her eyes close for the last time.
Stepping quickly back out of the way, he called out his orders: “Stat CBC, type and cross for all we have of her type, two IVs of lactated ringers, run ’em wide open, cardiac monitor and stand by to defibrillate, she’s close!”
While a tech prepared to draw blood and the nurse started IVs, Matt went to the foot of the table and spread the victim’s legs, propping them open by putting the soles of her feet together and letting her knees splay out. He gently put his hand in her vagina to assess the damage. The pelvic sidewalls of her vagina were torn on both sides and he could put his hand all the way up into her abdomen without feeling any resistance. “Jesus,” he muttered to himself, wondering what in the world could cause th
at sort of wound.
The venetech looked up at Matt from his position near the groin. “Hey, Doc, something’s wrong here. I know I’m in the vein but nothing’s comin’ out.”
Matt came over and took the syringe, sliding it gently through her skin, advancing it slowly into her groin area. As he searched for the shrunken vessels, a fine tremor shook his hand and sweat began to bead on his forehead. What the hell is wrong with me? he thought. Even in his internship and residency he had never been bothered by the jitters in the face of trauma.
He wondered briefly if the dying girl’s words could be causing his feeling of dread, of extreme unease. No, she was right, he thought. Whoever did this to her was a monster, a demon. Then why was he so jumpy? He pushed the disturbing thoughts from his mind.
Finally, he felt a slight tug of resistance as his needle pierced a near wall of the femoral artery. As he pulled back on the handle, a few tiny drops of blood appeared in the barrel of the syringe. He withdrew the needle and handed the syringe to a lab tech. “That’s about all we’re going to get. Just do a stat hemoglobin and ’crit for me.” Matt knew from the lack of blood in her vein and the condition of her body she had lost most of her blood volume. The crucial question was, how much?
“Code blue!” shouted a nurse watching the monitor at the foot of the gurney. “She’s flat-lining!”
The monitor tracing showed only an occasional blip, separated by long areas of a straight or flat line. It was the worst sort of arrhythmia. Matt always laughed in movies when the hero doctor shocked a patient with a flat line as if it were supposed to start the heart beating again. Shocking was for fibrillation, irregular uncoordinated beating. For flat-lining, real doctors used adrenaline. “Ten cc’s adrenaline on a cardiac needle,” he said, knowing from the extent of her injuries it was useless but still unwilling to give up until there was absolutely no hope.
The nurse put a syringe with a ten-inch needle in his hand and he quickly felt for the fifth rib next to the breastbone. He inserted the needle about four inches into the chest, at a forty-five-degree upward angle, until he felt it pierce the wall of the heart. He drew back on the syringe handle until blood flowed into the syringe, then pushed ten milliliters of adrenaline directly into her flaccid heart. He began to do closed-chest cardiac massage, hoping to pump enough of the adrenaline into the cardiac muscle to stimulate it to beat. No go. Two short, quick beats and then the heart flat-lined again.
Night Blood Page 3
