The Patient

by Michael Palmer

  “Please page Emily DelGreco and get her down here right away” was Jessie’s first order.

  The neurosurgical resident on duty, Steven Santee, was in the ER when she arrived, preparing a stretcher for their case in one of the available trauma rooms. He wasn’t the sharpest of his group of residents, and certainly was not the one she would have chosen to assist her on this case, but he was a damn hard worker.

  “Don’t bother, Steve,” she said. “We’re going right from the door to CT. Just keep bugging the lab. I want ten units of O-negative blood in the OR when we arrive. We’ll use them until we get the kid cross-matched. It’ll be your job to draw blood on him unless the rescue people did it when they started his lines.”

  “They’re two minutes out,” Larry Miller called down the hall. “Emily said she’ll meet you in the OR and will have everything ready when you get there. Anesthesia’s on the way there, too. So are the nursing supervisor, a scrub nurse, and a circulating nurse. Do you want me to come with you?”

  “With Emily meeting us, we may be okay. But then again, I may need another pair of hands.”

  “Will I do?”

  Jessie hadn’t noticed that Alex had come into the ER. Now, she sized up the situation.

  “You don’t mind being a gofer for blood and instruments?”

  “Hardly. You sure it’s okay for me to help in the OR?”

  “Hey, I’m the surgeon. It’s okay if I say so. And you won’t faint on me?”

  “We already discussed that, remember?”

  “Well, then, stick around. As soon as the kid gets here, we’re going to CT. You be the motor for his stretcher. Steve and I will do the evaluation. Emily will make sure the OR’s got everything we need, and do what she can with the lab.”

  Santee, Larry Miller, Emily, and now Alex. A ragtag medical army if ever there was one—especially poised to battle such potent foes. But at least, as far as Jessie knew, there were no expanding egos on the team. Each of them would do whatever she needed—no questions asked, no improvising.

  Jessie felt energized, but she had dealt with enough gunshots to be frightened as well.

  “They’re on the drive,” Larry Miller called out.

  “Steve,” Jessie said, “take a minute and get what history you can from the rescue squad, especially the caliber of that bullet. Alex, Larry, we get the stretcher and go. I want this kid in the OR within eight minutes.”

  At that instant, the doors to the ER glided open and the battle began in earnest.

  “Drive-by shooting,” an EMT said breathlessly, handing over their paperwork. “We assume it was a handgun. The poor kid was just in the wrong place at the wrong time.”

  “Thanks,” Jessie called out, as Alex took over at the rear of the litter. “You can pick up your stretcher at CT. Just have someone follow us.”

  There was a CT scanner that served the ER alone. In fifteen seconds, Jackie Robinson Terrell was on the table. Jessie’s heart ached as she looked down at the naked child, spattered all over with his own blood. His body was as perfect as most eight-year-olds’—not an ounce of excess fat, muscles just beginning to become defined. His smooth, chocolate skin was unscarred. But the pressure dressing on his head was soaked through with crimson.

  The entry wound, just behind the child’s left ear, was in a bad spot, but it could have been even worse. An inch to the right, and it would have shattered the torcular—the bony ridge at the base of the skull that protected the confluence of the straight and sagittal sinuses, the largest blood-filled cavities in the brain. Had the torcular been hit that way, Jackie Terrell would still be on the sidewalk, covered from head to toe with a sheet, lying in a pool of his own blood. Now, at least, he had a chance.

  “Poor little guy,” Jessie murmured as she checked his pupils for size and responsiveness to light. “Poor baby. Larry, could you please go back to the ER and see where this child’s parents are. If you find them in the next minute, bring them here. Otherwise, explain what’s happening and bring them to the Surgical Eight waiting room. Then go save us an elevator in the Surgical Tower.” She turned to Lydia Stewart, the radiologist. “Stew, give me just five cuts through the hemispheres and two through the posterior fossa, please. As soon as you’re done, we’re out of here, so please hurry.”

  “What do you think?” Alex asked.

  Jessie shook her head.

  “I don’t know. His pupils are still mid-sized. That’s a good sign. But he’s got no corneal reflex, and he’s losing blood fast. He was probably just playing out there—maybe thinking about what he wanted for his birthday.…”

  She shook her head as if clearing it, then reached over and took two lead aprons from the wall, handing one to Alex.

  “Is this necessary?” he asked.

  “That depends on whether or not you think your gene pool is worth protecting. Listen, when we get to the OR, I want you to put on scrubs and stay on hand. We really are short-staffed and I may need you to run errands.”

  Jessie held Jackie Terrell’s little hand as the CT scanner whirred. Moments later, the radiologist called out that the views were on the screen. The pictures were grim. Fracture lines everywhere, a massive collection of clotting blood, and definite brain destruction. It was as if an egg had been dropped onto concrete from ten feet, but had somehow stayed together.

  “We’re out of here,” she said, motioning Alex to help her lift the boy onto a gurney.

  They hurried through the hospital to the bank of elevators in the Surgical Tower. Larry Miller was there, holding the doors of one car open. Standing back a ways were a dozen or so curious onlookers, anxious to check out the emergency before going about their business. The three of them squeezed into the elevator with the gurney. For eight floors, Jessie’s arm was pressed tightly against Alex’s. As the doors parted, he briefly squeezed her hand.

  “Good luck,” he said.

  “This way, quickly,” she replied, racing to the front of the stretcher. “The men’s dressing room is right over there. Cap, mask, shoe covers, and scrubs.”

  Jessie checked the time as she and Larry Miller exploded into OR-2 with Jackie Terrell. Almost nine minutes. Not a prizewinner, but good enough. Emily was there, scrubbed, gowned, and ready to begin prepping the child’s scalp. The anesthesiologist, Byron Wong, stood by his instruments, set to slip in a breathing tube and connect his other highly sophisticated monitoring equipment. Ten units of uncrossmatched O-negative blood were arranged on a tray by his station. With almost no antibodies to the proteins in type A or type B blood, nor to the Rh factor protein, O-negative blood could be treated to absorb most of what antibodies were there, and then used for emergency transfusions until properly cross-matched blood could be obtained. Not optimum, but then nothing about this case was close to that.

  As Jessie and Wong were transferring the child from the stretcher to the OR table, he suddenly cried out and flailed with his left hand, actually hitting Wong on the shoulder.

  “Jesus,” Jessie said, “he’s moving. We’ve got a chance.”

  Steve Santee poked his head in.

  “Dr. Copeland, Jackie’s mother is in the family room. His father is a bus driver. They’re trying to locate him now.”

  Excuse me, Mr. Terrell, but we wonder if you could drive on over to Eastern Mass Medical. Your eight-year-old son has been shot in the head.…

  The notion made Jessie cringe.

  “Get scrubbed, Steve,” she said. “Emily, after he’s intubated, get two units running. I want him left ear up. Do a quick prep, then stay next to me. Steve’ll work across from us. I’m going to say a word to the boy’s mom and then scrub. I want to make the incision in two minutes. Three tops.”

  “You’ve got it,” Emily said.

  Charlene Terrell, an expansive woman with a gentle face, was wringing her hands. An older woman, who introduced herself as a family friend, sat with an arm around her.

  “We’re going to operate in just a minute,” Jessie said after brief introductions.
“Jackie’s been hurt very badly.”

  “He’s a wonderful boy,” Charlene sobbed. “Please save him. He’s our only child.”

  “I’ll do my best.”

  “Thank you, Doctor. Oh, thank you so much.”

  “One thing. Is he left- or right-handed?”

  “Jackie? Oh, he’s right-handed. You should see him throw a ball. He’s only in third grade, but he already can play with the middle-school kids.”

  “Thank you, Mrs. Terrell.”

  Grim.

  Jessie hurried to the prep room. At this point she had neither the time nor the inclination to go into any of the gunshot-wound details with her patient’s mother. Until the operation was completed, there was nothing she could say that wouldn’t make a very bad situation worse. Right-handed meant that most of the vital speech and movement centers were on the left side, precisely around the bullet’s path. Tamika Bing’s situation, only with right-sided motor deficits as well.

  As she scrubbed, her concentration was almost exclusively on the child and on the surgical approach she was going to take. Almost. One corner of her mind was dominated by a spinning tangle of images—Alex Bishop, Carl Gilbride, Marci Sheprow, Sara Devereau, Tamika Bing, Eastman Tolliver, Orlis Hermann, and the Count, tossing about along with multiple reminders to herself that she wasn’t the one who had pulled the trigger and shot the eight-year-old. Nor was she God. She was simply the one who was on call, and who was doing her best to save the child.

  “You ready?”

  Alex had come up from behind and was standing a few feet away.

  “Ready as I’ll ever be,” she replied. “You can stand behind me to either side. There’s a riser you can step up on to give you a better angle.”

  “I’m praying for the kid,” Alex said.

  Jessie’s eyes locked on his.

  “You keep on doing that,” she said. “I never refuse help.”

  THE APPROACH JESSIE had settled on was pretty standard—a wide scalp flap around the entry wound, drill away as much bone as necessary, and then go for the large collection of congealing blood that the CT scan had located just above and behind Jackie’s ear. Retrieving the bullet and working around the other fracture fragments would come later in the case. The child was anesthetized now, so there would be no more movement, no cries. But the team was driven by what they had seen.

  Quick but careful, Jessie said over and over to herself. Quick but careful.

  “He’s losing a lot of blood,” Emily said. “The rescue squad brought tubes in, so the lab has had a head start with the cross-match.”

  “When do you think we’ll have the blood?”

  “Five minutes, no more.”

  “Hang a couple more units of O-negative, Byron. Alex, could you please call the blood bank and find out how much longer?”

  “Right away.”

  Emily elbowed her friend.

  “Nice helper,” she whispered.

  Jessie glanced up at Steve Santee, who was engrossed in suctioning the persistent bleeding.

  “Behave,” she shot back, her voice shielded by the sound of the aspirator. “That’s it, Steve. Suck right here. We’re doing fine.”

  “They’ll be ready in the blood bank in a minute,” Alex said, returning to his riser.

  “Maddy,” Jessie said to the circulating nurse, “this is Alex Bishop from security. He’s also soon to be a physician’s assistant student at Northeastern. Would you please take him with you to the blood bank and bring us back eight units.”

  Quick but careful.

  Around the bullet hole, the child’s skull was like broken pottery. Jessie removed most of the shards and much of the clot, while Emily and Steve continued aspirating blood, keeping her field clean. The bullet had stopped short of crossing the midline, but had damaged a good deal of brain before it did.

  Jackie? Oh, he’s right-handed. You should see him throw a ball.

  Alex and the circulator returned with the blood, and he again took his place on the riser.

  Jessie forced herself to remember some of the miracles she had seen since entering neurosurgery—the patients who should have died, but instead ended up living quite functional and rewarding lives. Meticulously, she picked off the bleeders, cauterizing them by running electric current through her bipolar forceps. Bit by painstaking bit, the ooze lessened. And as it did, the extent of the damage became clearer.

  “Just keep up with blood loss, Byron,” Jessie said. “It’s still hard to predict, but I will say that I’ve seen worse.”

  “You’re doing an incredible job,” Emily said. “Alex, I hope you have a good view of this, because you’re never going to see a gunshot case handled better.”

  This time Jessie threw the elbow. She knew Emily was saying things just to keep her from getting too tense, but she was beginning to regret having confessed her newly evolving connection with the man.

  “Quit it!” she whispered.

  “A little advertising never hurt,” Emily whispered back.

  The bullet had entered at a slightly upward angle, shattered the inner table of the skull, and ricocheted to a halt just to the left of the midline. Jessie recovered it with ease, then began cleaning away tissue that was clearly damaged beyond healing.

  Maybe Jackie Robinson Terrell will throw again, she was thinking at the moment the anesthesiologist said, “Everything all right? I’m getting a drop in pressure.”

  “I don’t see—”

  Jessie never finished the sentence. A sudden, continuous gush of dark, venous blood welled into the surgical field from beneath the posterior skull. Jessie’s heart rate rocketed.

  “The occiput was fractured!” she cried out. “The torcular’s torn.” The bone fragments over the network of vital blood vessels had been held together so tightly by the bleeding and swelling around them that the CT scan hadn’t shown the fracture lines. “Byron, pump in every ounce of blood you have and send for more! Steve, let’s get the boy facedown immediately!”

  “But the sterile field—”

  “To hell with the sterile field! This child’s going out!”

  “I need him supine if I’m going to be of any help in keeping his pressure up,” the anesthesiologist said.

  “Byron, he’s got to be prone! If I can’t get at this bleeding, nothing you do matters. Scalpel, please. Scalpel, dammit!”

  Frantically, with no attempt at continued sterility, Jessie cut away the posterior portion of Jackie Terrell’s scalp. The bone over the torcular was split down the middle, and blood was pouring out from the sinuses beneath it.

  “Suck here, Steve! Em, you, too! Byron, we need more blood! Oh, Jesus!”

  “The Doppler monitor on his chest is recording something,” Wong said. “I think it’s air in his heart.”

  Jessie continued packing the bleeding area, but it was like trying to sandbag a waterfall.

  “Pressure?” she asked.

  “Forty. Jessie, there’s definitely air being sucked into his circulatory system. His heart’s filling with it.”

  “Blood! We need volume!” Jessie ordered, unwilling yet to believe what she was hearing. “Put the table in Trendelenburg position. Adjust it until he’s not bleeding out or sucking in air!”

  “Pressure zero,” Wong reported. “The air embolism is huge now. Heart rate is dropping.… Flat line. We’ve got flat line.”

  Jessie fought a few minutes more. Then she stared down at the blood, which continued to well up over her gloves but was now slightly frothy from the air that had been sucked through the damaged sinuses into the child’s circulatory system.

  “That’s it,” she heard her voice say from a million miles away. “There’s no sense in continuing anymore.”

  For a full minute, no one in the operating room moved. Then Jessie shook her head.

  “I’m sorry, everyone,” she said hoarsely. “I’m really sorry. Each of you did a great job.”

  ALONE IN HER office, Jessie stared out her single window at a pair of sw
allows that had settled on her ledge. It had been hell telling Charlene Terrell that her son had died on the operating table—hell trying to explain to her that what ultimately killed her child couldn’t have been anticipated and couldn’t have been fixed.

  One of the things Jessie had come to accept as a neurosurgeon was that many of her patients would never be perfectly, or even reasonably, intact after their surgery. All that was available to those cases and their families was to move the goal markers of their lives—the expectations—and to start over from wherever they could. But this—the inhuman senselessness of Jackie Terrell’s injury, the sudden, unforseeable catastrophe in the OR—this was more pain than she ever wanted from her specialty. Gilbride, Tamika Bing, then Sara, and now this. Maybe it was time to consider moving to the lab for a while. Or maybe it was time simply to realize that she didn’t have the steel plating necessary to make it as a neurosurgeon. Lost in her thoughts, Jessie barely heard the gentle knock on her door.

  “Yes, come in,” she said after clearing her throat.

  Alex Bishop slipped in and closed the door behind him.

  “Hi.”

  “Hi, yourself.”

  “I thought maybe you could use a little cheering up.”

  “A little cheering up might elevate me to miserable.”

  Except for Emily, there was no one in Jessie’s world that she would want visiting her at this moment. Yet Alex Bishop, with his wonderful, troubled eyes, and his gentle voice, was a welcome sight.

  “Your nurse told me there was no way anyone could have predicted that cracked bone when it didn’t show on the CT scan,” he said. “She told me you had saved that kid’s life, but when you removed the clot you also released the pressure that was holding the pieces together, and the crack opened up.”