Four of the six gurneys in the thirty-by-thirty room were occupied, and mixed teams of residents, interns, rotators, all talking at once, were establishing airways, getting in lines, seeking to stabilize the trauma victims. Normally the trauma team of ER physicians, surgical residents, radiologists, and anesthetists responded to the gunshots, stabbings, and car accidents—the so-called Code Yellows—but when logjams developed, support came in from the adjacent departments. The Willowbrook was a teaching hospital, so there were always enough hands in an emergency despite the lack of funds, but things could get pretty noisy at times.
Ford took in a red-faced patrolman who was standing in one corner, a paper cup in his hands, his tired eyes fixed on the gurney where his wounded colleague lay in a pair of inflated medical antishock trousers—or MAST pants.
“Where’s the homeboy?” asked Ford.
Mary Draper led him across to one of the noisiest groups, people parting as they saw Ford come through. There was a flurry of good mornings but no let up in activity. The patient had been anesthetized, and a fourth-year surgical resident was cutting through the cricothyroid membrane, seeking to establish an airway without going through the nose or mouth. At the same time this was happening, another resident was cutting off the young man’s pants, running the shears up one leg, then the other, cutting through underwear, belt, everything. The pants unpeeled like a banana skin, revealing pieces of lint in the man’s pubic hair. Ford noticed the relative absence of blood—a few splashes on what looked like brand-new Nikes, that was all. What was it with these kids and footwear?
“He took a nine-millimeter shell in the throat?”
Draper nodded, pointing to the entrance wound on the right side of the neck.
“Looks like the missile came out through the left jaw.”
The anesthetized patient began to gag as a tracheostomy tube was inserted into the incision and the cuff inflated. It sounded as if he were trying to clear his throat, but it went on for several seconds. Then it stopped. Ford’s eyes flicked up at the ECG monitor. He was doing okay. Two of the team stepped back, shoulders relaxing, coming down off the buzz of action.
“Nice intubation,” somebody said.
“Looks like the bullet missed the major vessels,” Ford observed.
There was a sharp ripping sound of stripped adhesive tape. They were taping the young man’s head to the backboard.
“Blood pressure was okay, so I guess he’s not bleeding too bad. Just the one missile?”
“So far as we can see.”
Mary Draper was punching in numbers for the operating room. There were three ORs at Willowbrook, located directly above the Emergency Department on the second floor, right next to the Intensive Care Unit.
Melvyn Hershy, the doctor who had performed the cricothyroidotomy, came around the gurney as Mary Draper slipped into her ultracool, I-cannot-be-fazed telephone manner—“Hello, Janet. I have a customer for you. Black male in his mid twenties…”
“Glock,” said Hershy. “According to a bystander it was a young lady pulled the trigger. Track goes in through the sternocleidomastoid, through the base of the tongue and out through the left mandible. Must have missed the carotid and the jugular by a whisker.”
Ford looked at the young man, who was now breathing through the tube.
“And he’s got a hell of a throat infection,” said Hershy, almost to himself.
“A what?”
“A throat infection. Saw it when I was taking a look inside. Strep throat.”
“Well, I guess that’s the least of his problems now,” said Ford.
Hershy smiled.
“You get held up?” he asked mildly.
“There was some trouble on the freeway.”
The other man was shaking his head now, looking back at the patient.
“I’m not surprised.”
“Oh?”
Hershy looked back at Ford, confused for a moment.
“Didn’t you catch the news this morning?”
“No.”
Hershy shook his head again.
“It was a hell of a night. Big Shootout in Crenshaw. Fertilizer truck flipped over on the Pomona Freeway. About one o’clock the Mother started sending cases over to us. There was a kid—little girl with appendicitis—got referred to us in the early hours. Appendix ruptured in the ambulance. Kid went into shock, died.”
“Jesus.”
“Yeah, well, anyway there was media all over the place. Somehow they found out about the girl. Story was all over the networks by dawn. ‘Hospital turns away dying black kid’ kind of thing.”
Ford shook his head.
“So they start burning ambulances.”
Mary Draper put down the phone.
“They’re ready in OR-three, Dr. Ford.”
Ford refocused on the job at hand.
“Do we know this kid’s name?”
“The ‘Shark’ is what he said to the paramedics. Or ‘Sharky.’ “
Ford looked at Hershy and smiled.
“My first fish of the day.”
From the other side of the room there was a sudden spike in the noise. It was always bad in the critical room when more than one gurney was occupied, but when things started to go wrong the shouting took on an edge, a jagged sharpness. Ford turned away from Hershy and entered a new group.
“Pulse going over one-twenty. Tachycardia!”
“Get these fucking pants off him.”
“Systolic blood pressure dropping. We’re down to ninety.”
The patrolman was jerked hard as the deflated MAST pants were pulled away, revealing dark blue polyester pants soaked in blood. The patrolman started fumbling at his oxygen mask and was immediately restrained.
“For Christ’s sake, hold him!”
Ford stepped forward, gently pushing a nurse to one side.
“Cut off the uniform. Tourniquet the left thigh. Dr. Ozal, get a line into the distal saphenous vein. I want three liters of volume resuscitation.”
The shouting moderated to status-updating level as Peter Ozal, a third-year surgical resident, performed the ankle cutdown required to access the saphenous vein. Ford watched Ozal’s nimble hands as he incised the exposed vessel.
“Okay,” said Ford, taking a deep breath, making an effort to keep the anger out of his voice. “Here we have a perfect example of why MAST pants create as many problems as they solve. Dr. Ozal, your opinion?”
Ozal frowned with concentration, inserting sterile intravenous tubing four inches into the big leg vein.
“Well, I guess you could say their strength is also their weakness,” he said out of the side of his mouth.
Ford smiled. He liked Ozal, but he tended to be a little taciturn.
“You could,” he said. “But what would that mean?”
“Well, the MAST pants work by increasing peripheral resistance in the lower half of the body, allowing more blood to get to the upper trunk and head. But the problem is that when you deflate the trousers too rapidly”—Ozal shot a glance across to a diminutive Asian nurse who was trying to avoid his eye by staring at the monitors—“you can get profound hypotension. Patient’s blood pressure drops through the floor.”
“Exactly. Another problem is you can’t see exactly what’s going on. Without the MAST pants, we can see clearly”—he pointed to the wound on the patrolman’s left thigh—“where the missile entered the leg.” Ford looked around at the circle of young faces. “Remember, patients will die of hypoxia before they bleed to death, but in fact, after central nervous system injury, the commonest cause of death is exsanguination.”
Ford checked the monitors and stood back from the gurney.
“Is he going to be okay?”
There was a momentary pause in the babble of talk as Ford turned to see the other patrolman, still holding his paper cup. He gestured with it towards the man on the gurney.
“He’s goin’ to be awright, right?”
Ford took in the weary face of a stocky man
in his late forties. Broken veins high on each cheekbone gave the man the appearance of good health, but underneath the threadlike capillaries the skin was sallow and open-pored. There was a smear of dirt across his forehead. He looked as though he’d had a rough night.
“Yes, I believe he is. We’ll get him up to the operating room, take that bullet out of his leg.”
Ford started to move away, but the patrolman followed.
“Hey, Doctor…” They had left the critical room and were out in the corridor now, the patrolman keeping close. Ford noticed the bloody Reeboks still on the floor where Gloria must have left them. He bent to pick them up. “Doctor, there’s something I wanted to ask you.”
The man sounded hostile, and Ford prepared himself for whatever was coming. He turned, the bloody shoes in his right hand.
“Go ahead.”
“I wanted to ask you…”—he had to draw a breath, he was so angry—“why it is you’ll care for a … for a scumbag gangster before an officer gunned down in the line of duty.”
Ford raised a warning finger.
“Well, first of all, I don’t know that the young man with the neck wound is a gangster,” he said. “I don’t know that he wasn’t an innocent bystander.”
The patrolman pressed a hand against his mouth, bottling up the hot feeling that threatened to overwhelm him. Ford noticed bitten nails—abrasions and grime on the knuckles.
“And as for the circumstances in which these people are shot, I can’t say that that enters into the equation. The neck wound might have been life threatening. You would be surprised how quickly you can lose a patient wounded in that area, so close to the spine, and major blood vessels. I made a decision based on my experience.”
This was too much for the policeman.
“But I just watched my partner nearly … nearly bleed to death, goddammit!”
Ford waved away a concerned-looking Melvyn Hershy. He could handle this on his own.
“It may have looked like that to you. In fact he was momentarily hypovolemic due to a procedural … due to a moment’s clumsiness. But they got a line into his leg and he’ll be fine now.”
The patrolman took a step closer, so that Ford could smell his rank breath.
“Do you know what I think, Doctor?”
Ford stared into the man’s bloodshot eyes. You didn’t need to be telepathic.
“I think that in a … in a war you have to make up your mind whose side you’re on.”
Ten minutes later Ford was scrubbing up, preparing to go into the OR. He watched the hot water run over his hands and arms, then pushed the faucet lever with his elbow. He kept seeing the scared faces of the people in their cars, looking out at the burning ambulance. He knew exactly what they had been thinking: a couple of hours earlier, and it could have been me. Night after night the TV pumped out stories of rape, murder, drive-by shootings, recreational killings, riots, but it wasn’t until you smelled the smoke, saw the blood on the sidewalk that it came to you what a violent city LA really was.
“What’s up, Doc?”
Ford turned and saw Conrad Allen, a senior surgeon specializing in cardiothoracic injuries. Allen was gloved up and ready to go, an unconscious Mexican with a bullet lodged in his colon waiting for him in OR1. Ford shrugged, taking in his old friend’s face. Allen had a rich caramel complexion flecked with dark freckles that went right up into his short frizzy hair. His playful, relaxed demeanor belied the dedicated professional and superb surgeon that he was: decisive, cautious, quick when necessary, qualities he kept steel-hard and blade-sharp right through to the end of a twelve-hour shift. He was one of the few people in Trauma Ford felt he could rely on one hundred percent.
“A police officer just told me I had to decide whose side I was on.”
Allen’s smile crimped the skin around his intelligent brown eyes.
“The good guys or the bad guys, right?”
“I think he had in mind the good guys or the black guys.”
“Riiight.” Allen dragged out the monosyllable, still smiling “I thought maybe it was Loulou Patoulou put a dent in your morning.”
“You’ve seen her?”
“She was going in to see Haynes.”
Dr. Lucy Patou (Loulou Patoulou, the Culture Vulture or simply the Vulture) had been the control of infection officer for the Willowbrook since 1990. She had been brought in to tackle what the county considered to be elevated mortality levels due to nosocomial infection—infections caught by patients inside the hospital and to a degree encouraged by hospital conditions.
The year Dr. Patou joined the Willowbrook, there had been an outbreak of Staphylococcus aureus on the neonatal ward in which four infants had been infected, one fatally. The staph bacteria in question proved resistant to treatment with penicillins, but had responded to high doses of cephalosporin. Despite this, Dr. Patou had instituted a draconian regime that included stripping out all organic material—curtains, sheets, rubber fittings on equipment such as ventilators and trolleys—and scrubbing down of the whole ward with disinfectant. The staff didn’t know what had hit them.
Patou’s background was in pediatrics, where infection was one of the principal enemies of the clinician. In Ford’s view she tended to apply the pediatrician’s perspective to every other aspect of hospital care, and it was this that so often put her in conflict with the Trauma Unit, where sterility was frequently sacrificed to speed of intervention.
Five years at the Willowbrook had taught Patou to stay away from Trauma and the unedifying spectacle of dirty people coming into the hospital with dirty wounds. Unfortunately that just meant that the frequent clinician versus infection officer spats were staged in the Intensive Care Unit, where Dr. Patou was forever asking for items to be cultured (hence the nickname) in order to see what bugs might be getting established. IV lines were removed and replaced, mattresses taken away and, on some occasions, without explanation, incinerated. Even respirators were taken out of commission in order to be stripped down, cultured, and then put back together again. In the opinion of some of the Trauma staff, Dr. Patou would have preferred it if the Willowbrook could be run without the patients. It would have been so much cleaner.
“You saw her?” asked Ford. “You didn’t speak to her?”
“No sir.”
Ford let out a sigh. He had been anticipating some acerbic message or other. Then he noticed Allen’s expression.
“What?”
“I didn’t speak to her. Lady spoke to me, though. Gave me that beady eye just as she was going in to Russell and said, ‘Tell Dr. Ford I’m onto him.’ “
“Oh, Lord.”
Allen looked at Ford’s upraised hands inquisitively, as though searching for dirt.
“You better be sure you’re clean because she’s gonna be culturing your ass.”
Ford watched Allen’s receding back and reflected on the potential calamity of having Lucy Patou onto him. Their relationship, fragile from the very start, had taken a turn for the worse at the beginning of the year when he had published an article in The California Medical Review. The article had focused on some unusual infections afflicting abdominal-wound patients at the Willowbrook where the principal pathogen had been Enterococcus faecalis, part of a community of anaerobic bacteria found in the lower digestive tract. Despite treatment with a broad range of antibiotics, including vancomycin, the infections had proved impossible to check. Over a ten-week period, four intensive-care patients had succumbed to blood poisoning and died.
That abdominal wounds should become infected was not in itself unusual. Whenever the bowel was punctured, whether by blade or bullet, the risk of contamination was great. Below the stomach, the digestive tract was heavily populated with bacteria. In fact more bacteria lived on a single square inch of the human intestine than there were humans on the planet. Indeed, there were more bacteria in the human body than there were human cells. As long as the bacteria stayed in the intestine, they could, for their own purposes, assist in the breaking do
wn of fats, sugars, proteins, and unwanted chemical waste. That was the deal that had been struck between bacteria and primates over millions of years of evolution. In a sense, the intestinal bacteria did the jobs that nobody else in the body wanted to do, and for that service they were tolerated. But when they got outside the circumscribed confines of the bowel, they became dangerous. That was why abdominal-wound patients were immediately given broad-spectrum antibiotics as a prophylactic.
What had worried Ford about these particular cases—what had pushed him to write the article—was firstly the inexorable progress of the infections, the inability of the ICU team to stop them, and secondly the compressed incidence of cases, there having been four of them in a matter of weeks.
A few days after the article was published, Ford had been summoned to the medical director’s office. Though Russell Haynes himself had not seemed unduly bothered by what he called Ford’s “disregard for the niceties,” it had become clear that Lucy Patou had lodged a complaint. Ford, as a representative of the hospital, had publicly spoken of a matter and of a domain that, properly speaking, was hers to monitor and, if she felt like it, to comment upon.
There had followed an awkward meeting in which Patou had sought to put Ford in his place. She had drawn his attention to a string of resistant Enterococcus cases at St.
Thomas Hospital in New Jersey in 1994. The cases Ford had encountered, she said, were nothing new. More to the point, the fact that the cases were multiple was not necessarily indicative of a general spread of resistant bacteria among the community at large, as Ford seemed to be suggesting in his article. In fact, the resistant bacteria in New Jersey were proven to have been passed from patient to patient within the Intensive Care Unit via contaminated equipment. In other words, true to form, Lucy Patou was pointing the finger at ward procedure and hygiene. And this despite the fact that thorough investigation at the Willowbrook had revealed no evidence of Enterococcus contamination in the Intensive Care Unit.
Thinking it over now, pushing his hands into the latex gloves, Ford began to understand what Patou had meant when she said she was onto him. She knew all about his invitation to speak at the conference organized by the National Institutes of Health. Indeed, Ford had more or less agreed, under duress, to go through his speech with her prior to the conference. She wanted to be sure that he at least qualified his remarks with some of the doubts she had expressed. Now she suspected him of going back on their agreement and of deliberately avoiding her. Of course she assumed that the speech must be written by now.
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