Lou was about to suggest that the two of them return to a single file, when there was a sound from his right. Cap lurched past him somewhat awkwardly. A glance at the ground showed that he had slipped on a nearly invisible, flat, wet rock. Initially, Lou was surprised and even a bit amused. But then the situation registered. Cap’s arms were extended, waving wildly, sweeping the air for balance. There was a glint of panic in his eyes. Clearly, the man was in trouble. Big trouble.
Trying to stop short, Lou skidded and stumbled, but managed to stay on his feet. Cap, who had incomparable footwork and balance in the ring, was out of control, twisting in what seemed like slow motion, and staring down at the drop beneath him. Lou pivoted and reached out. His fingers caught hold of Cap’s backpack strap. But his grip was poor. Cap’s upper body was already over the edge, and his weight tore the strap free. He twisted and reached back, clawing for Lou’s outstretched hand. At the last possible moment, their palms met and their fingers locked.
Please hold … please! Cap’s eyes pleaded.
His fingers closed on Lou’s, but it was a tease, not a grip. In an instant, gravity snatched his hands away. He pawed at the air like a novice backstroker. Then he slammed against the cliff face, and was gone. Stunned beyond understanding, Lou sank to his knees. For a moment, there was only silence. Then he heard a cry and the snap of branches breaking, followed by more silence. Lou crawled closer to the edge, hardly aware that the muddy ground was falling away from beneath his knees. Shaking viciously, nearly unable to stand, he pushed to his feet. Finally, almost inaudibly at first, then a bit louder, he heard Cap cry out.
Lou’s heart stopped. Then it began hammering.
“Cap, it’s me! I’m here! I’m coming! I’m coming for you! Hang on, brother! Hang on!”
He raced to his right, as close to the crumbling precipice as he dared, peering over for a way down. It took twenty-five feet or so before he saw a slope he felt he could handle. On his belly, clawing to maintain contact with the dirt and stones, grabbing at roots and bushes, he worked his way down, pausing to listen for Cap’s voice, and each time believing he was hearing it.
Five feet … ten …
In the ER, Lou prided himself on staying cool even when faced with the most dire medical emergencies, or the most horrible crunches. Now he felt frantic and utterly out of control.
Five more feet … another five.
His slide loosened rocks, mud, and pebbles that rained down on him, getting in his mouth, and eyes. From his right, he felt certain he could hear Cap’s groans.
“Hang on, buddy! I’m almost there!”
Breathe in … breathe out. For God’s sake, Welcome, get it together. Whatever has happened over there, he needs you. The best friend you’ve ever had needs you!
The steep drop had begun to lessen. Lou stopped himself and peered through the trees. Nothing. The sounds were close, though. Very close. He pushed to his feet and thrashed to the right. A dozen more feet and he spotted Cap, spread-eagle on his back on a fairly level piece of rocky ground. He was continuing to moan, but was otherwise motionless. There was blood smeared across his face and shaved scalp from a cut across his forehead.
Then, as Lou hurried across the last ten feet, it registered that Cap’s right leg was bent at an odd angle. It took a moment to make sense of what he was seeing. When he did, his stomach instantly knotted. Protruding from a gash at the midpoint of Cap’s thigh, was a jagged, bloodied spear of white bone—the fractured mid-shaft of Cap’s femur.
CHAPTER 8
It is the obligation of the family, not the government, to provide for those who cannot provide for themselves.
—LANCASTER R. HILL, 100 Neighbors, SAWYER RIVER BOOKS, 1939, P. 167
For Lou, filthy and soaked, the scene was surreal.
Cap was moaning piteously. The jagged mid-shaft of his right femur, surrounded by spaghetti-like strands of muscle, protruded garishly from a four-inch gash—easily the worst compound fracture Lou had ever seen. A tree? A boulder? Whatever caused the break really didn’t matter. The femur was perhaps the strongest bone in the body, and the force that shattered it had to have been enormous. The leg, itself, was shortened and rotated.
Lou knelt beside the man more responsible for his recovery than anyone else beside himself. The two-inch laceration above his right brow was bleeding briskly, blood pooling in his eye socket and running down the center and side of his face. There were no other obvious injuries. Lou felt sick—nauseous and shaky. But he knew what he had to do.
Process.
At the center of treating multiple people with trauma, or one person with any number of injuries, was process—the step-by-step approach to evaluation, triage, and treatment. That this was his best friend and a virtual saint to all who knew him needed somehow to be put aside. Whatever had to be done to save his life, however dangerous or painful, had to be done.
As Lou checked Cap’s mouth, tongue, and airway, he flashed on a story the man had shared from when he was in his early teens and a group of thugs, all older than he was, kept beating and harassing him. In that neighborhood, there was never any way to avoid them. No place to hide for long. Cap’s solution was, no matter how bad the pummeling, to never let any of them know he was hurt. Before long, they lost interest and left him alone. Cap Duncan was tough then, and he had grown even tougher over the years.
Heart rate one hundred ten. Rib cage and sternum intact to palpation. Carotid, radial, and left femoral pulses all present, although not very strong. The right groin, where the femoral pulse could usually be felt, was already swelling, probably from blood working up from the fracture site.
Airway, breathing, and circulation. All check.
He gingerly worked Cap’s backpack off and opened it on the ground next to his. The man’s muted cries echoed forlornly off the trees, and momentarily reminded Lou of the remoteness of their location.
Stay focused!
Neck seems uninjured.
Just in case, Lou used one of the ACE bandages and an empty backpack to improvise a stabilizing cervical collar.
Time to stop the bleeding.
“Cap, it’s me. It’s Lou. Hang in there, buddy. Hang in. I’m going to press on your forehead. Here, squeeze my hand if you can hear me.… Cap?”
Lou took half the gauze pads to wipe the blood out of Cap’s eye and off much of his face. Then he used the same gauze to apply heavy pressure to the laceration.
“Cap, it’s me. It’s Lou. Squeeze my hand if you can hear me.” Perhaps a flicker. “That’s it, buddy. Squeeze again.”
Lou kept up a steady stream of patter as he maintained pressure with his right hand. With his left, he soaked another gauze square with water from his backpack and wiped Cap’s face clean. Comfort. Every bit of comfort he could produce for the patient and the doctor was a help. He worked some water between Cap’s lips and then squeezed a few drops into his mouth. Cap swallowed. As Lou moved through the process he had mastered over the years of training and ER work, the need to extend his examination and to improvise treatment became increasingly important.
“That’s it, big guy. Hang on. Just hang on.”
The forehead hemorrhage had largely abated. Lou set a square of hi-tech hemostatic bandage over the laceration. There would be time for a dressing later. Another small squeeze of water between Cap’s lips. Again, he swallowed.
Pulses slightly stronger. Abdomen non-tender and flat. Arms and hands intact.
“Cap, it’s me, Lou. Open your eyes if you can. You’re doing better. Better and better and better.”
The leg was truly scary. Obscene to many. To a seasoned ER doc, it was just dangerous. The heavily muscled thigh was capable of holding literally quarts of blood—more than enough for someone to bleed out. The pain and internal bleeding had Cap hovering near shock. Lou had decided not to risk missing something potentially lethal by getting immersed too soon in the most obvious, spectacular injury. Now it was time to get to work on that.
He glanced
back the way he’d come, wondering if he could possibly climb back up the cliff face to the trail. No chance. Besides, leaving Cap alone was something he could only bring himself to do after all other options had evaporated. For a half minute, while he collected his thoughts about the leg, he tried hollering for help. His cries were instantly swallowed by the dense forest. What about the river? If he could get Cap down there, perhaps he could fashion some sort of raft. But the woods were still shrouded in mist, and he could not even see the river from where they were.
Focus, Welcome. Focus!
The bleeding from the mid-shaft was continuing, and, if anything, seemed to be worsening. Lou checked for pulses behind each ankle and on the top of each foot. Left side, no problem. Right side, none. The femoral artery had almost certainly been torn. Big trouble.
It was then Lou realized Cap’s groans had stopped entirely. Again he went through the process—the A, B, Cs.
Pulse rate one fifteen. Pulse strength down from four to three on a ten scale.
“Come on, pal! Stay with me. Stay with me.”
Time was becoming even more of an enemy. He had to put on a tourniquet near the groin. Cap was still moving air effectively. His pupils were midsize and equal. Was there hemorrhage between his skull and brain? It didn’t look like it, but if there was, Lou knew there was little he could do about it. It had to be first things first. He had to continue to stem the blood loss.
“Cap, it’s Lou. I’m here.”
The moaning began again—barely audible, then louder. Lou got to work on the fractured leg.
“Cap, you’re bleeding badly,” he said, uncertain if his words were registering. “I’m going to have to apply a tourniquet to stop the bleeding. It’s going to hurt. I need you to brace yourself. I’ve got to move your leg.”
From within his pack he removed the nylon rope and his Spyderco knife. He measured off an arm’s length of cord and was readying to cut it off when something made him stop.
Again, the process. He had to remain focused, but at the same time stay cognizant of what might lie ahead.
If things went as he hoped, the rope and the other ACE bandages would be needed intact for something else entirely—getting out. Setting the cord aside, he pulled off his sodden shirt and, using the knife, cut and tore off two strips. Next, as gingerly as he could manage, he knotted them together, slid them around Cap’s thigh inches below the groin, and tied the ends tightly at the skin.
At the first movement of his leg, Cap screamed. Then he screamed again, and thrashed his head from side to side as much as the makeshift collar would allow.
Lou hated the way his friend came to, but was ecstatic that he had. The odds of pulling things off and saving his life had just improved. For one thing, the man was light—awake or at least responsive to deep pain. For another, the cervical spine was almost certainly intact. If Lou needed the ACE bandage for what he had in mind, he would use it. He took what remained of his shirt, and blotted the perspiration that had suddenly materialized on Cap’s face and bald pate.
“Sorry to hurt you, pal. Your leg is broken, and I have to stabilize it. Do you understand?”
Silence.
“Cap, can you hear me?”
Suddenly a faint nod, followed by a coarse whisper.
“I … hear you.”
Yes!
“Squeeze my hand, big guy. That’s it. That’s it. Now the other hand … Perfect. Cap, try to just lie still and concentrate on your breathing. Deeply, now. In and out. I’ll explain everything in a few minutes. For now, I need to tighten this thing on your thigh. It’s gonna hurt.”
“Go … for … it.”
The hemorrhaging was starting to slow, but only marginally. The tourniquet, arterial spasm, or diminishing volume? It was impossible to tell. He had to add torque. Lou crawled in an arc until he found a hefty stick, two feet or so long. He slipped it under the makeshift tourniquet and slowly rotated it clockwise. Cap cried out, but he didn’t scream. Instead he grabbed a fistful of soil and squeezed it tightly.
“Fuck,” he groaned. “… Oh, fuck.”
His breathing remained steady.
After two full turns, the bleeding was reduced to a slow ooze. Lou used the hi-tech, hemostatic bandage to finish the job.
“Cap, stay with me. Stay strong.”
From his pack, Lou retrieved his cell phone, not at all surprised to see there was no signal.
“Help!” he hollered. “Someone please help!”
It felt as if his voice had traveled only a few feet through the heavy air.
Another check of Cap’s pulses. Still palpable, but down to a two.
Lou sat back and wrapped his arms around his knees.
Either he figured out something to do, and soon, or Cap was going to die.
It was as simple as that.
CHAPTER 9
To place economic security in the hands of the government is quite literally a return to our medieval ancestry where feudal lords took responsibility for the economic survival of the serfs working their estates.
—LANCASTER R. HILL, Climbing the Mountain, SAWYER RIVER BOOKS, 1941, P. 18
Lou estimated they were five miles from the lodge, assuming they had averaged ten minutes per mile over the uneven terrain. The concierge had warned him that cell phone signal strength in the mountains was spotty at best. After failing to get a dial tone, Lou checked the time. He had a new concern. It could take two hours to get back to the lodge and return with help—probably not much less even with an ATV. By that time there could be severe tissue damage caused by the tourniquet. The other potential danger was one he could not shake from his mind—severe shock and cardiac arrest.
Despite what Cap had said right before he stumbled and fell, he was never hot about making this run. Lou had talked him into it. Now there was no way he could allow him to die. The tourniquet had to be loosened as soon as hemorrhaging had clearly been stopped. Somehow, someway, Lou would get the man out of these woods without leaving his side.
“Listen, buddy,” he said, his voice managing to stay even. “This is going to be the tough part.”
“Do … what has … to be … done,” Cap answered, stopping between words to breathe.
With a few decent sips of water, and the bleeding slowed to an ooze, the physical evidence of shock had begun to ebb. As Lou had done with the tourniquet, most of the tools he needed to complete the next phase of the process would have to be improvised. Most medical schools and hospitals, Eisenhower Memorial included, offered a variety of continuing education classes on a regular basis. Six months back, Lou had taken a two-day wilderness emergency medicine course. Ironically, his decision to do so was inspired by his newfound passion for trail running. The class, taught almost exclusively by incredibly competent paramedics and specially trained EMTs, with a few ER docs sprinkled in, was well organized and terrifically informative. With two jobs and a kid, courses and lectures were often triggers for him to catch up on sleep. But fortunately, not that one.
Lou performed a quick, repeat physical. Cap was going to need all of his will and his strength just to survive the pain of what was about to be done to him. The exam offered Lou a whisper of confidence that his friend could endure what lay in store for him without slipping back into shock. Looking over the leg, the ugly bent angle, twisted like a wrung-out dish towel, the bone splintered and frayed at the edges, Lou questioned his own ability to inflict the required amount of pain. But the leg had to be straightened or the chances of saving it were negligible.
No matter how hard he tried to reason away the guilt, it kept gnawing at him. If only he had been less insistent. If only he could have been less exuberant.
If only …
Lou forced those thoughts to the back of his mind. For Cap’s sake, he had to stay in the moment, fully focused and committed to the process.
“I’ve got to straighten out your leg so I can splint it,” Lou heard himself say, his voice actually breaking between words.
Cap’s gaze seemed to sharpen. He eyes locked with Lou’s. There was no trace of doubt or fear on his handsome, bloodied face.
“You do what has to be done, Doc,” he managed.
“Actually, Cap, to do what has to be done, I’m going to need your help.”
Cap brushed the back of his hand across the damp bandage on his forehead.
“Tell me,” he said.
The misty rain had largely let up, but the world was still slippery and cool. To make matters more difficult, bugs had reappeared and were beginning to attack Lou’s face and naked back.
“Straightening and splinting your leg is a two-person production. Unfortunately, you’ve got to be one of those people. I’m going to get a couple of thick branches to be the splint. Then I’m going to tie the rope around your right ankle and loop it around that tree by your foot. When I say push, I’m going to need you to push your left foot against the tree with all your strength.”
“And you’re going to pull the rope.”
It was a statement, not a question.
Lou nodded. “If together we have the strength to do this, we’re going to pull the two segments apart and line them up the way they should be. Then I’ll keep the tension on by wrapping the rope around the tree, and you keep the tension on by pushing. Got it?”
“Sounds like fun.”
“When I get the rope tied around the tree, I’ll use our bandages and maybe your shirt to hold the splint in place. The setup will make sure those sharp bone ends don’t cut anything they haven’t cut already.”
“Got it.”
It sounded straightforward enough, but the truth was, Lou had serious doubts whether or not the two of them could pull it off. They had to overcome the tight spasm of the quadriceps group, the strongest muscle in the body. Just how strong Cap’s quad was would become clear in a few minutes.
Splint ’em where they lie, Lou thought, recalling one of the lessons from the course. Splint ’em where they lie.
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