Silent Pledge

by Hannah Alexander

  “Yeah, I know, sounds funny coming from me, but what could it hurt?” he said at last. “I mean, what’ve you got to lose?”

  Buck sighed and closed his eyes. “Nothing, Clarence. We’ve got nothing to lose. Go for it.” He bowed his head.

  Kendra turned and stared at her husband for a long moment. Clarence watched her. For a few seconds some of the pain left her eyes.

  Then Clarence bowed his head, like Ivy always did. “God, first of all I need to say that we’re praying this in the name of Jesus, just so I don’t forget at the end.” He didn’t understand all that yet because he’d never tried that hard to listen, but he knew Ivy always said these words to end her prayers. “And then I want to ask You to give Buck and Kendra some of the love I think You’ve been showing me lately. And then I want You to stay with Kendra after Buck and I leave, because I think she’s going to need You worse than anybody. And that’s all I can think of to say right now.” He raised his head and looked at them. “Guess that oughta do it.”

  Chapter Six

  Lukas was drifting to sleep in the call room early Sunday morning when he heard the blare of a siren. He opened his eyes to the sight of orange and red flames racing across the wall, and he sat up with a shout.

  And then he realized that the flicker was from an ambulance outside. Its lights penetrated the window blinds in fiery streaks of color. Lukas pushed his blanket back and got out of bed. Sometimes he still had nightmares about the explosions in October, of following Buck Oppenheimer through the collapsing E.R. and fighting the inferno that nearly engulfed them.

  The telephone rang. He reached over, felt for his glasses on the desktop and picked up the receiver.

  “Dr. Bower, this is Tex,” came the voice over the phone. She sounded irritated, but with Tex’s deep voice it was hard to tell. “Quinn and Sandra are bringing somebody in. Of course they didn’t radio us, so I don’t know what’s going on. I tell you, that man should not be wearing a uniform. Want to join us?”

  “I’m on my way.” Lukas grabbed his stethoscope from the desk and rubbed at the lenses of his glasses with the hem of his scrubs as he squinted his way out of the call room.

  When he reached the E.R. he saw Quinn and Sandra wheeling a slightly overweight, unresponsive young woman into the E.R. from the ambulance bay while Tex held the door and helped push. Quinn was doing chest compressions and an IV had been established, with a needle and tubing connected to her left arm. The patient had been intubated, and an ambu bag was attached to the tube, which Sandra squeezed rhythmically to help the woman breathe. Sandra was pushing the cot with her free hand. The woman had been stripped to the waist. The odor of sour milk lingered around her.

  Lukas rushed toward them. “Carmen,” he called to the secretary over his shoulder, “call a code and launch a chopper.”

  Carmen swiveled in her chair and stared at him blankly. “What?”

  Lukas shook his head. “Get me a nurse down here from the floor. Tell her we’ve got a code. Then call our airlift service and get them here.” He grabbed the end of the gurney and helped Sandra and Tex push it inside. “What’s the rhythm?”

  “V-fib,” Quinn said. “I’d just intubated her on scene, and then she crashed.” His words came fast, almost as if he were trying to convince Lukas he’d done everything right. “She was unresponsive, and she had inhalers in her pajama pocket. Had to be asthma—”

  “How many times have you shocked?” Lukas asked.

  “Three with one dose of epi.”

  “What?” came an irritable voice from the doorway.

  Lukas turned to find Tex already in the trauma room, snapping the plastic lock from the tool chest-shaped crash cart beside the exam bed. “That’s not current ACLS guidelines,” she muttered.

  On the count of three, they transferred the patient from the gurney to the bed, and Tex immediately replaced the leads to the hospital monitor on the woman’s bare chest. The v-fib rhythm continued, with the line racing across the monitor screen above the bed in an irregular steak knife-edge pattern. The monitor emitted a high, continuous beep.

  “Well, you got your intubation this time, Dr. Bower,” Quinn muttered. “Hope you’re happy, because it’s not doing her any good.”

  Lukas ignored the comment. “What drugs have you given?”

  “I just finished the first dose of epinephrine as we pulled in.”

  “Then we’ll have to shock again quickly. Stop compressions but keep bagging.” Lukas positioned his stethoscope on the woman’s chest, listened, frowned. “I don’t hear good breath sounds.”

  “So? She was obviously in broncho spasm,” Quinn snapped. “She had inhalers, remember? Or weren’t you listening?”

  “And you just took that for granted?” Tex’s voice rose like mercury in a hot room. If she saw Quinn’s flush of anger or glare of growing resentment, she didn’t acknowledge it. “Did you even check the placement of the tube when you did the procedure?”

  “What good would it do if she was in broncho spasm?” Quinn’s lips thinned and whitened.

  Lukas raised his hand for silence and repositioned the stethoscope over the belly. Now he heard breath sounds, and he felt a chill of foreboding. “It’s in the wrong place. The tube’s in the esophagus instead of the trachea.” The oxygen was flowing straight into her stomach. She wasn’t getting any oxygen. “We have to reintubate.” He turned to the others. “Sandra, stop bagging and take over the compressions. Hurry! Tex, get me a syringe, then get the suction ready.”

  Tex moved quickly. “It’s one thing to miss placing the tube correctly, Quinn,” she said as she worked. “That’s happened to all of us. But to leave it there…unforgivable! You might as well have placed a pillow over her face and suffocated her! Why didn’t you check?”

  Quinn’s jaw jutted forward. “I told you she had inhalers. If you hadn’t made such a big deal about that old man’s tube earlier, I wouldn’t have even wasted my time on this one.” He took a step backward, then pivoted and stalked out of the room.

  “No!” Lukas shouted after him. “Quinn! You don’t walk out on a code!”

  “Just let him go, Dr. Bower,” Sandra said, her soft voice growing softer as she worked hard to continue chest compressions. “He won’t listen to anybody. I tried to get him to check his work, but he was in too big of a hurry. If I can’t get another partner I might as well quit. This is stupid.”

  As soon as Tex handed Lukas the syringe, he attached it to the tiny balloon at the mouth end of the endotracheal tube and deflated the air from the gear that kept it in place. He pulled the tube out of the patient’s mouth and checked the monitor to make sure the rhythm was still v-fib.

  “It’s time for another shock. Sandra, bag her again.”

  Sandra stood at the head of the bed and placed the bag valve mask over the patient’s face. Tex charged the defibrillator to 360 joules and handed the paddles to Lukas.

  “Clear,” he called, and made sure everyone was out of touch with the bed, then pressed the paddles to the patient’s chest. The body jerked into an arch with the sizzle of electric current, then fell back onto the bed. Everyone looked at the monitor. The rhythm had changed.

  “All right!” Tex exclaimed. The v-fib had stopped, and now the blip danced across the screen with more powerful strokes.

  Lukas pressed his fingers against the woman’s throat, feeling for the carotid artery, and the hope that had flared within him died painfully. There was nothing. “Oh, no. Pulseless electrical activity.” This was worse! They couldn’t break this new rhythm with a shock. What was happening here?

  “Sandra, bag her again,” he said.

  The nurse from upstairs came rushing into the room, and Lukas gestured to her. “You’re just in time. I want you to do chest compressions.” What could be causing this? “Let’s intubate now, Tex. And let’s get some fluids in.” What would cause respiratory arrest and pulseless electrical activity in such a young woman?

  “Dr. Bower,” Sandra said softly, �
�the bra we cut off her was a nursing bra.” She indicated the young woman. “She’s been nursing. She was all alone outside the apartment building.”

  Lukas felt as if he were on a treadmill going twenty miles an hour. He had to keep up. “Carmen, contact the police,” he called toward the secretary as he worked. “They need to check the area for a baby!” He had to focus. If the woman was recently pregnant…severe respiratory distress…pulseless electrical activity…He caught his breath.

  “Oh, no, Dr. Bower,” Tex groaned. “That sounds like massive pulmonary embolism.” Lukas nodded. A blood clot in the lung was deadly.

  Quinn came rushing back into the room, puffing from exertion and wiping his eyes with the back of his hand. “I’m sorry, Dr. Bower. That won’t happen again. I mean it. I’m sorry. I was just so—”

  “Can it, Quinn,” Tex snapped. “We don’t have time tonight for your theatrics.”

  Lukas ignored the interruption. “Let’s get her set up for a pacer, and get me dopamine.” Now he knew what to do. But was there time?

  Marla drifted in a dark fog, for a few moments far from the pain and cold and terror. But the drifting didn’t last. Her baby…Jerod! She could hear echoes of his cries, and she couldn’t get to him. He needed changing. He would have to be fed again soon, and there was no one to help him.

  And then another voice reached her from some distant place…. “We’ve got a pulse….” Marla’s chest hurt again, and somebody was pushing her, hard. Her throat hurt. She felt the pressure in her ribs and heard more people talking around her…. “We’ve got a blood pressure, Dr…” She felt something hard pinch her arm…. “The helicopter’s landing, Dr….”

  Something brushed across her shoulder, and light beamed past her closed lids. But she couldn’t open her eyes. She felt the rise and fall of her chest, and the continued sharp pain under her ribs, as if someone was stabbing her from the inside out.

  The pain was too much. Even with the echoes in her memory of Jerod’s cries, she couldn’t force past that barrier of pain. She tried to form words on her lips, but something was in her way. She couldn’t speak. Jesus, take care of Jerod. He’s so little and helpless.

  She could almost hear her baby’s cries again, wished she were back in the cold, grungy room with wet diapers and neighbors banging on the wall for silence.

  And then, as if from somewhere besides the room where she lay, a strong, familiar voice reached her, a voice different from the ones that shot around her with businesslike efficiency. This one was unhurried, calm, even joyful. “It’s time to come home, Marla. I’ll be here with you.”

  The sound of the voice permeated her and gave her a feeling of warmth, and she wondered if she were in a coma. But that voice…Dad? She thought the word and heard her own voice, though her mouth did not move.

  “Remember the verses I read for you so often when Mom died? ‘The righteous perish, and no one ponders it in his heart—devout men are taken away, and no one understands that the righteous are taken away to be spared from evil.’”

  You mean I’m dying? she asked.

  “‘Those who walk uprightly enter into peace—they find rest as they lie in death.’”

  But, Dad, I’m not righteous, she said sadly. Look what I’ve done.

  “Your righteousness has been purchased. It’s time to come home.”

  But my baby…

  “Dr. Bower, I’ve lost the pulse,” came a brisk voice from nearby.

  The wall of pain slipped down and pulled away. Marla felt as if a blanket of comfort were being wrapped around her. She could see again. Her father was holding out his hand.

  “No blood pressure,” came another voice, this one receding, growing fainter. “Doctor, we’ve got asystole…flat line!”

  But the alarm in the fading voices did not disturb her. Dad spoke again. “I have some people for you to meet.” And he took her in his arms and led her home.

  Lukas called the code long after they lost the pulse and the rhythm flattened, battling his own sense of horror and pain as he’d battled to keep death from taking this young mother. He called time of death for the record, then took a deep breath and willed himself to be composed.

  Sandra sniffed with silent tears as she gathered the trash that had collected on the floor. Tex muttered under her breath as she disconnected the monitor from the leads. She paused and glanced at Quinn, her green cat’s eyes narrowed with angry disgust. She shook her head and resumed her work.

  “What’s your problem, Texas, can’t take the pressure?” Quinn reached over to remove the equipment from the body of the deceased. “No wonder you couldn’t handle your resident training.”

  “No!” Lukas reached out to stop Quinn’s movements. “Don’t touch anything on her.”

  Quinn raised his hands in an exaggerated show of obedience. “Hey, Doc, lighten up. I’m just trying to help out. After all, she was alive until we brought her to you.”

  Sandra gasped and looked over at her partner.

  Tex shoved some trash into a biohazard container and straightened to tower over the man. “Breathing into her belly all the way here was what killed her. We might have saved her if you’d given her a chance in the first place, but no, you didn’t even bother to check.”

  “Tex.” Lukas was too tired and grief-stricken to break up any more fights on this shift. “Quinn, everything has to stay in place in case the coroner wants to have an autopsy performed. Tex, will you go call him?” Maybe that would get her away from Quinn long enough to get her temper under control. To see that she did so, he walked out with her.

  “That man shouldn’t be allowed to touch patients,” she muttered to him as they left the curtained room.

  Lukas shushed her. Her voice carried past the thin barrier of curtain like the growl of an angry crocodile. Even though he agreed with her, he had to look at both sides. “You know an intubation like that can be difficult. Even the most skilled practitioner could have missed it under those circumstances.”

  “Yeah, but I’d’ve at least checked her breathing. Couldn’t you tell by Quinn’s expression that he hadn’t?” She lowered her voice at last to a hoarse whisper. “I’m going to talk to Sandra later. That girl’s scared of her own shadow, but maybe I can bully her into telling the truth. Quinn’s incompetent. It’s probably because he works too many hours, but that doesn’t excuse his disregard for human life. They need to get rid of him.”

  “And who would they find to replace him?” Lukas asked dryly.

  She grimaced. “Good question. The hospital doesn’t want to pay anything. That’s why we’ve got a bunch of losers here already.”

  “And where does that put you and me?”

  She didn’t even blink. “You’re here to keep busy until the E.R. is rebuilt in Knolls.”

  “And why are you here?” Lukas asked. “You’re no loser. I’ve seen you work. You know your stuff. I couldn’t help picking up on Quinn’s reference. Are you a resident?” He studied her more closely and saw the sudden tightening of her lips, the hooding of her eyes.

  She looked away. “I’m a paramedic right now, Dr. Bower. I’m here because this is home…or it was.” She sighed. “The guy you’re replacing? Dr. Moss? He thought he was coming here for a break from family practice. Ha! Now he’s on suspension here and his license is in question, and it’s not even his fault. You’d better look over you shoulder around here. No telling who’ll try to stab you in the back.” She glared in Quinn’s direction and walked off to use the phone at the nurses’ desk.

  Carmen swiveled in her chair to face Lukas. “Dr. Bower, a friend of mine from the police department just called. They didn’t find any baby, but they called the landlord of the building where the woman was living. He’d gotten complaints from the neighbors for the past two or three days about a baby crying.”

  “Did he say how many people lived in that apartment with her?”

  “Just the woman. Last time he saw her she was pregnant, and that was last week, when he dropped
by to try to get rent payment from her, which he didn’t get. Looks like she was broke, and the room was a mess, like she’d been sick for a while. The baby was obviously a newborn.”

  “Did they give you a name?”

  “Said the woman was Marla Moore. She stayed inside a lot. I guess the landlord’ll have to come down and make identification or something. The police haven’t found any relatives yet.”

  “But the baby,” Lukas said, “what about the baby?”

  Carmen shrugged. “If it’s a newborn, it couldn’t’ve crawled off. Somebody’s got to be taking care of that baby.” The telephone buzzed again, and she turned back to the desk.

  “Hey, Dr. Bower?” came a quiet male voice from behind him.

  Lukas turned to find Quinn standing there, head bowed, arms folded across his chest. “I shouldn’t have given you such a hard time in there. I guess I was pretty nervous.”

  “You don’t walk out on a code, Quinn. We needed you. Where did you go?”

  “I…I’m sorry. I nearly lost my cool for a little bit. I mean, we were fighting for a young mother’s life, and Tex made it sound like I’d really blown it.” He shot a quick glance toward Carmen and Tex, who were both on the telephone at their desks. “What are you going to put on your report?”

  “What do you mean?”

  Quinn shrugged. “I need this job bad, and I can’t afford to lose it. What are you going to say about me?”

  Lukas felt the fresh weight of grief sharpen his tongue. “The truth usually works.” He turned away and left Quinn standing there.

  He went into the call room for a moment. He had reports to fill out, work to do, but he knew from experience that if there were no other patients who needed him, it was best to spend some quiet time after a painful event like this one. If there was any time he needed prayer more…

  And then he realized something. During that whole code, in all the confusion and angry words and difficult decisions, he’d forgotten the most important thing. A habit that he’d developed in his first E.R. rotations years ago was to pray on the run while treating victims of severe illness or trauma. Praying had become second nature for him; he did it without thinking. But this time…this time he’d been caught off guard. He’d allowed his anger at Quinn to divert him from the most important treatment.