No One Can Know

by Lucy Kerr

  “Who’s on OB?” he asked as he scrubbed in.

  I didn’t look up from the IV bags I was hanging, two liters of saline ready to go in the minute our patient was on the table. “Garima. Alejandro paged her and called in Dr. Solano for the consult.”

  Even though emergency room staff is trained to work on any patient who comes through our doors, obstetrics and neonatology is a highly specialized field. We all felt better calling in an expert, and there was nobody I’d rather have on the job than Garima Karundhi, a high-school friend and star of the maternal-fetal medicine department at Stillwater. Even Costello was happy to hand over an OB case to her.

  “Blood bank’s sending up the O neg?” He pulled on a yellow gown, gloves, goggles—the usual assortment of protective equipment.

  “Five units on its way.” I laid out a series of test tubes and began labeling them for the variety of blood samples we would need to run.

  He peered over my shoulder at the neat rows of supplies, no doubt looking for a mistake that wasn’t there. I took his silence as approval and slipped into my own gear. Esme appeared in the doorway with the infant warmer and switched it on while a tech from radiology parked the portable CT scanner outside the door.

  “Where the hell is Flight for Life?” Costello demanded as we headed for the ambulance bay. “We should be sending her to Peoria.”

  Esme jerked a thumb at the storm outside. “You want them to fly in that?”

  Through the automatic doors, we could see the trees tossing about, the cornstalks in an adjacent field nearly flattened. The lights in the parking lot were blurred behind a curtain of rain. No wonder the helicopter team couldn’t transport our patient—this weather would have endangered the entire crew.

  Costello cursed under his breath, rolling his shoulders like a prize fighter warming up. “Okay, people. Our job is to stabilize her. We work fast, we work hard, we leave the baby to the OB department. I want Mom ready to go out on a chopper the minute we get a break.”

  Lightning crackled across the sky, and I shivered as if the wind had snuck inside. I had a feeling we wouldn’t be catching many breaks tonight.

  Esme’s words came back to me. Careful what you wish for. I hadn’t, of course. Nurses didn’t wish for patients any more than firefighters wished for flames. But people would get sick, cars would crash, accidents would happen. When they did, I liked knowing I had the skills to make it better. To save a life. To dig in and make a difference.

  There was no sign yet of the ambulance, no lights strobing across the cornfields or sirens audible amid the sounds of the storm, and the silence grew awkward as we waited.

  “Did you get your apartment squared away?” Esme asked in a blatant attempt to ease the mood. This would be the first major trauma we’d dealt with since I’d started at Stillwater Gen, and like any team, we were all on edge wondering how I’d fit in.

  “Finally, yeah.” I’d left Chicago for Stillwater with only a few hours’ notice, assuming my trip would last a few days at most. Now that a few days had turned into a months-long commitment, it hadn’t made sense to let my city apartment sit empty. “A friend of a friend is going through a bad breakup, so she’s subletting it. I moved my stuff into the store over the weekend.”

  Technically, I’d shoved everything into the office above my family’s hardware store, to my sister Charlie’s chagrin. There’d been no room at the family home and no sense in unpacking when I’d be leaving again soon.

  “You’re serious?” Costello asked. Hard to tell if it was disbelief or horror coloring his voice. Probably both. “You’re really going to stick around?”

  “I signed a contract, remember? Three months.”

  Three months—that’s what I’d promised Grace Fisher, the hospital president. Time enough to help my sister get the family hardware store back on its feet; time enough for my newest niece, born prematurely, to come home from the hospital. Time enough to mend fences with all the people I’d left behind twelve years ago. I hoped so, anyway, and shoved away the whisper that said three months might not be enough time, after all.

  “Doesn’t mean you’ll stick.” He shrugged, not taking his eyes from the horizon. “Not from what I’ve heard.”

  “There.” Esme pointed toward the road, where the blurred lights of the ambulance were finally visible. My pulse kicked up reflexively at the sight, my heartbeat drumming in my ears. My muscles tightened like a runner at the beginning of a race—all adrenaline and hyperawareness as if waiting for the starting gun.

  Next to me, Costello was practically vibrating with eagerness, and the animosity between us fell away. Wordlessly, we tracked the ambulance’s approach, knowing it was impossible to predict what awaited us when the doors slid open. It didn’t stop me from running down a checklist in my mind, going over the steps we’d take as soon as the gurney rolled in. We’d need to get a monitor on her. Cut off her clothing, slap on the leads as best we could, push IV fluids, and start a ventilator, if necessary. Get a fetal monitor on her too, but the obstetrical team would handle anything related to the baby. In this moment, the mother was my only concern.

  Someone brushed against my arm—Garima, mouth set in a grim line, arms wrapped around herself as if she was cold. Behind her stood a nurse I’d seen on the neonatal unit, her teddy-bear-printed scrubs lending an incongruously cheerful note. I nodded a greeting and Garima returned it, but neither of us spoke as the lights grew closer, and the sirens grew louder, and the wait twisted into awful, excruciating tension …

  And then the ambulance was there, back doors swinging open, paramedics scrambling out, lifting down the gurney, shouting vitals and patient history as Costello barked orders and Garima demanded answers.

  The victim was battered and bleeding, her face swollen beyond recognition. One of the paramedics was methodically pumping air into her lungs.

  Pent-up adrenaline sizzled through my limbs. I dove into the fray, anticipation replaced by movement and instinct and speed.

  In an instant, our Tuesday ER came alive, and so did I.

  *

  We burst into Trauma One, a storm of noise and motion. “One-two-three,” the paramedics chanted, and our patient was on the table, the merciless overhead lamps revealing the full extent of the damage, along with her very advanced pregnancy. We swapped monitors and started fluids and oxygen, every move designed to steal a few more seconds in which to save her.

  “Head looks bad,” Esme warned.

  “Heart’s no prize either,” Costello replied, but he glanced over, grimacing when he saw the shattered portion of her skull. “Get the collar off her; let’s see what we’re dealing with.”

  I glanced at the monitor, not liking the pattern of peaks and valleys. “She’s in V-tach.”

  “What do you think, Jess? Thirty-six, thirty-seven weeks?” Garima asked her nurse as she ducked around me to hook up the fetal monitor. “Not quite full-term, anyway.”

  Trauma’s a cross between a ballet and a battle—we all knew the moves, and any fears we’d had about teamwork evaporated as I took my place in the well-choreographed pattern. Esme assisted Costello directly, handing him instruments as he surveyed the damage to our patient’s skull, while I took over artificial respiration from the paramedic.

  Beside me, Garima’s nurse—Jess—made a noise of distress and pressed a fist against her mouth. I followed her gaze to the silver bracelet glinting at the patient’s wrist. Two painstakingly rendered bears dangled from the heavy links: one the size of a dime and the other a corn kernel.

  Mama bear and baby bear.

  My stomach twisted, but there was no time for sentiment. I kept going, my arms already aching from the compressions as the anesthesiologist began preparing to intubate the patient, letting a machine take over her breathing.

  “Patient went over the embankment near Sutherland Road,” the paramedic said. “She must’ve been there for at least half an hour before we arrived.”

  Costello scowled as he drew back the patient’
s eyelid and shined a penlight at her pupils. “Left side’s blown,” he said. “Where’s the damn trauma team? Where’s my neuro consult?”

  In the Venn diagram of medicine, emergency and trauma overlap, but they’re not the same thing. ER doctors are there to stabilize anyone who comes in the door. They’re the first line of defense. Trauma teams are more specialized, working to save the most grievously injured patients. In a large hospital like Chicago Memorial, we’d had multiple trauma teams on-site around the clock. At Stillwater Gen, we didn’t have the need, or the budget, for that kind of specialized support. Instead, we kept a team on call, ready to come in at a moment’s notice.

  “Roads are terrible,” one of the paramedics said. “Unless they’re driving a Humvee, you’re on your own for a while.”

  “She doesn’t have a while,” Costello snarled and barked orders at everyone in sight.

  I watched the monitors and called out numbers as the anesthesiologist performed the intubation, and the harsh rhythm of the ventilator joined the cacophony.

  “Paul, we’ve got a placental abruption,” Garima called over the noise.

  He ignored her and kept talking to Esme, who caught my eyes and gave the barest of grimaces. Placental abruption meant bleeding that could put both mother and baby in jeopardy.

  “Got a name!” cried one of the paramedics, who’d been going through a blood-spattered tote bag. He held up a driver’s license. “Katherine Tibbs, age thirty-six, blood type A positive.”

  “Katherine,” I said, adjusting the IV flow, keeping an eye on her sat levels, “you’re at the hospital. We’re doing everything we can to help you and your baby. Hang on, okay?”

  Garima spoke again, louder this time. “I need to get the baby out.” She turned to her nurse, who was breathing too quickly for my liking. “Jess, get the C-section tray.”

  “Not yet,” Costello snapped. “I need to get the cerebral edema under control. Vargas, push forty mil of furosemide and point-two diazepam. I don’t want her seizing.”

  “We have two patients,” Garima said. “If we wait too long, we’ll lose the baby.”

  He didn’t even spare her a glance, too focused on examining Katherine’s skull fracture. “Save the spaceship, save the astronaut.”

  Jess gasped, sweat beading along her upper lip. “She’s not—”

  Costello wasn’t being cruel or glib. He was doing what all emergency responders do in a crisis—separating the personal from the medical, which gave him the distance he needed to work. But Jess, who had probably never encountered this degree of trauma in the neonatal unit, wouldn’t see it that way.

  “Keeping mom alive gives baby the best chance,” I said, trying to reassure her.

  “But she’s …” Jess swayed and bobbled the tray of scalpels, nearly scattering them across the floor.

  That was all it took for Garima to make the call. “Switch it up,” she ordered. “Jess, you’re recording. You”—she pointed to the nurse who’d been taking detailed notes of everything that happened—“take over ventilation. Frankie, with me.”

  “Don’t move my staff,” Costello began but changed his mind when he spotted Jess’s slack features. “Fine. Go, Stapleton.”

  I swapped places, warning Garima, “I don’t have a lot of OB experience.”

  “You’re about to get some,” she replied with a glance at the monitor. “Baby’s heart rate is dropping.”

  “So’s Mom’s pressure,” Costello muttered as he and Esme worked feverishly. “Let me get her stabilized, do a head CT to find the bleed. There might be …”

  “Paul”—something in Garima’s voice made the room go quiet—“we don’t have to lose them both. It doesn’t have to be that kind of night.”

  I watched him closely, saw the muscle in his jaw jump, saw the second his hands stilled.

  “You’ve assisted with a C-section before,” Garima said, turning to me.

  I swallowed. “A few.”

  “Good enough.” She checked with the anesthesiologist, then said with a voice tighter than piano wire, “Number ten scalpel. Retractor. Let’s go.”

  If I wanted to, I could look back in the chart and see how quickly the procedure actually took. But no report could ever capture the strange duality of those minutes—Garima’s movements swift, calm, and precise as everything around us was falling apart. The scent of blood and rain and mud mingling with disinfectant. The sound of the monitors shrieking while Costello and Esme worked to stabilize Katherine. Garima’s murmured directions and my desperate attempt to follow them.

  But what I remember most of all was the sense of urgency twined with a sense of inevitability—that we were working to save a life at the very instant one was being lost.

  The monitors flatlined, a piercing shriek that nearly made me flinch. “Charge the paddles,” Costello said to Esme. “Shock her the second they’re clear.”

  Garima ignored him. “Here we go,” she said softly. “Here we go, little boy. I’ve got you.”

  Her gloved hands cradled the infant securely, and the room stilled for an instant.

  A cry. A mew, really, faint and pitiful and barely audible amid the chaos, but it was enough.

  “Frankie, cut the cord,” she ordered.

  I did, and she stepped away, turning toward the infant warmer and hooking the baby to a tiny cannula, boosting his oxygen. Behind me, Costello shouted, “Shock her. Two hundred joules.”

  The defibrillator whined and chirped. “Clear,” Esme called.

  The monitor beeped once, then flatlined again.

  “Again,” Costello said. “I want to see a sinus rhythm, people.”

  Esme repeated the clear, voice filled with dread, but the monitor droned on.

  “Stapleton, get over here.” He turned back to the woman on the table, his expression fierce. “Come on, Katherine. Don’t you want to meet your son? Stapleton, epinephrine syringe, one mil. Vargas, go again.”

  Garima waved me off, and I readied the syringe, waiting as Esme shocked her again.

  I held out the syringe but kept my fingers wrapped around it as Costello reached out expectantly. His gaze snapped to mine.

  “Doctor Costello.” I didn’t say any more. Just stood across from him, over the body of a woman who was already gone, and held my breath.

  He froze, then stepped back from the table, his hands in the air like a man at gunpoint. Someone turned off the monitor.

  “Time of death, ten oh-two,” he said tonelessly, the infant’s cries filling the air.

  Two

  We’d walked up to death, battled it, and lost. In the aftermath, our routine tasks—from cleaning the body to completing paperwork—took on the feeling of a ritual, giving us a bridge back to the living.

  “Rough case for Costello,” Esme said in the sudden quiet of the trauma room.

  “He’s fine,” I replied, methodically inventorying all the supplies we’d used. Gauze, IV bags, sponges, clamps. Everything needed to be recorded before we discarded it, as if we were tallying our failure.

  Not a total failure. Four floors up, there was a child in the NICU who wouldn’t have survived without us. We might not have saved the spaceship, but we’d made sure the astronaut landed. Tonight, that would have to be enough.

  “It’s not the first time he’s lost a patient. Not the first time for any of us.”

  “Except that NICU nurse, maybe.” Esme shook her head in dismay. “If I didn’t know better, I’d have said she was a rookie.”

  Jess and Garima had left shortly after Costello called time. The baby was in shock, but the placental abruption hadn’t cost him too much blood. Dr. Solano had arrived mere minutes after the delivery and insisted on transferring the baby to the neonatal intensive care unit, where they’d run a battery of specialized tests and had a team trained to care for tiny patients.

  Jess had trailed behind Garima, pale and trembling as she wheeled the isolette out. I’d half expected Dr. Solano to take over for her.

  “I’v
e seen Jess working in the NICU. She never struck me as the freezing type,” I said.

  Esme shrugged. “Maybe it’s the first time she’s ever scrubbed in on that kind of trauma. Guessing it’ll be her last, though. Costello’s not likely to let her back in the ER unless she’s a patient.”

  “Probably not.” I glanced at the figure on the bed. We’d covered Katherine Tibbs with a sheet, but the image of her blood-streaked bracelet lodged below the surface of my thoughts like a splinter. “Why did you say it was rough for Costello? I would have thought nothing fazed him.”

  She glanced around as if making sure nobody would overhear. “The mom angle,” she said softly. “I think it hits home for him. Stirs things up that he tries to stuff down, you know?”

  I paused in the middle of gathering spare surgical clamps. “His wife.”

  Costello and his teenage daughter, Meg, had moved here several years ago, following the death of his wife. I didn’t know the circumstances, and I hadn’t felt any desire to find out, though it was likely common knowledge. Everything in Stillwater was, after all. But sympathy was the last thing he’d want, whether it was to his face or murmured in the hallway.

  “He’ll be fine,” I repeated as Alejandro knocked on the doorframe, shifting an ice pack from hand to hand. “Did I leave that on the counter? It’s for the shoulder in Exam Three.”

  In the rush to care for Katherine Tibbs, I’d forgotten all about the unsettling Mr. Mueller. “Can you take it to him? I’ll be in to clean him up as soon as I finish here.”

  “No can do,” Alejandro said with a frown. “He’s gone.”

  My skin went hot, then cold. “Gone as in dead?”

  He shook his head. “Nope. Just gone. Took off while we were working on this lady, I think.”

  I groaned. “You’re kidding me. I lost him? You’re sure? Maybe he wandered off into another room.”

  Alejandro gave me a pitying look. “You really think we have that many places for a full-grown man to hide?”