“02 SAT’s maintaining on a non-rebreather mask,” the same nurse called out.
“Thank you,” Dr. Gerber replied. “Dr. Benton, have you seen this? Both jugular veins are slightly distended.”
Julie’s effort had fixed the problem only temporarily. Those veins were still symptomatic.
“Dr. Julie Devereux performed a pericardial tap in the back of the ambulance on the way here. That’s what I heard, anyway.”
Drs. Gerber and Benton stopped their exam to lock gazes with the nurse who supplied that information.
“Is that true?” Dr. Gerber asked. He sounded incredulous.
Julie took this as her cue, and she stepped into view. “Yes, I did. James, can I be of help? Please. I’m here.”
Dr. Gerber took one look at the blood caked onto Julie’s face and clothes and his expression conveyed his deep compassion.
“Not yet, Julie,” he said. “We’ll get you some scrubs, though.”
“They’re coming,” said Julie.
“Just hang back a moment. Nurse, let’s get an IV of seven milligrams lidocaine in him with epinephrine, please. Buffer that with a milliliter of sodium bicarbonate.” Dr. Gerber’s voice held no edge.
Julie exchanged glances with an X-ray tech waiting outside the curtain with a portable unit. He would be called to the stage soon enough.
“BP measures eighty-five palp,” a nurse called out.
“I’m okay with that,” Dr. Gerber answered quickly.
Normally, this would be more concerning, but Julie understood Dr. Gerber’s logic. Low blood pressure helped to lessen the bleeding, and the more blood they could keep in Sam’s body, the better.
Dr. Gerber continued his primary survey, concentrating several seconds on Sam’s abdominal area. Dr. Benton leaned over Sam to listen for any speech. The surgical resident, a spitfire Indian woman named Dr. Riya Kapoor, diminutive in stature only, listened intently with her stethoscope and announced in a clear voice, “Equal breath sounds.”
“We have some slight bruising surrounding the umbilicus,” Dr. Gerber noted. “Let’s get two units of plasma from the blood bank, O-neg of course. And tell them to keep it coming. And grab some splints, please. Need them for both arms and the left leg.”
The ER tech took off at sprinter’s pace to fetch the blood and splints.
“Oh two SAT’s ninety-three percent on a non-rebreather.”
“Fine. Fine.”
The phlebotomist got Dr. Gerber’s attention. “Trauma panel is set and ready … CBC, CHEM-7, coagulation profile, and tox screen. We’ll also type and screen for blood transfusion and liver function. Any other special orders?”
“No, that’s good,” Dr. Gerber said. “We’re going to finish this survey quick and get him to the OR.”
“Agreed,” Dr. Benton said. “With the blunt chest trauma and blood in the pericardium, I’m concerned about aortic injury.”
Dr. Gerber’s focus shifted from the abdominal area to a soft-tissue assessment. Dr. Kapoor conducted a neurovascular exam of Sam’s open leg fracture, which would eventually require surgery.
“Left leg bleeding has slowed,” Dr. Kapoor announced. “Maybe minimal arterial damage.”
“Even so, I’d like to start him on cefazolin, two grams IV, right away. We’ve got infection risk with that open fracture, after all,” Dr. Gerber said. “Can we get pulses?”
“I’ll do it,” Dr. Kapoor said. The head nurse left the trauma room in a hurry to get the medicine Dr. Gerber had ordered. The ER tech returned with the splints. The scene was similar to the kinetic choreography at the accident site, only with a larger ensemble.
“Let’s get the FAST exam done,” Dr. Benton said. “Arthur, can you please set up the ultrasound?”
The ER tech ran to the corner of the room and wheeled the ultrasound machine over to the exam table. He got the machine powered on while a nurse set to the task of splinting Sam’s many fractures.
“Radial pulse is ninety-eight, weak and thready, equal on both sides,” Dr. Kapoor announced. “Carotid and femoral same. Nineties. Weak and thready. Equal on both sides.”
The scribe recorded all this information into the computer as it was presented.
“Finish the neuro check, please,” Dr. Benton said to Dr. Kapoor.
Standing at the curtain opening, Julie watched Dr. Kapoor peer over Sam’s mangled limbs in search of some body part she could use for the evaluation. She settled on Sam’s big toe and gave it a hard squeeze. Julie bit the knuckle on her thumb. Anxiety seized her and would not let go. It was ironic that with all the advanced machinery hooked up to Sam, all the medicine he received, it was the outcome of this one simple test that would determine so much.
Squeeze the big toe and …
Julie closed her eyes tight and listened.
Please … please …
She prayed for Sam, she prayed to God as so many families of her patients did. She prayed harder than she ever had done before. It was not God who would save Sam; Julie understood this all too well. It was the amazing doctors and nurses who were treating him. Yet in Julie’s heart, she knew that what she really prayed for was a miracle.
Dr. Kapoor spoke up. “No response in any extremity.”
A sob burst from Julie’s lips as the first wave of grief hit like a tsunami. It’s still early, she told herself. It can change.
“Okay, FAST exam now, Riya,” Dr. Benton said.
With the equipment prepped and ready, Dr. Kapoor had the first view up in less than a minute. She kept the probe marker pointed toward Sam’s head to get the clearest picture, and started in the upper quadrant between the seventh and eleventh rib interspace.
Dr. Benton peered at the monitor and put her finger on something that bothered her. “Looks like some free blood in the intraperitoneal space.”
Julie could visualize the black line on the monitor between the liver and kidney that signified the pooling blood.
“And there’s free fluid at the lower tip of the liver,” Dr. Gerber observed.
Dr. Kapoor moved the probe to show the right diaphragm and right pleural space.
“Pericardial sac still has fluid.” She moved the probe quickly onto Sam’s abdomen. “Liver is clear, spleen is fine … seeing some fluid in the pelvis.”
This was the only bit of good news Julie had heard.
“What’s our list of injuries?” Dr. Benton asked.
“Broken radius and ulna each side,” Dr. Gerber said. “Possible fracture of the left olecranon, open fracture left leg.”
Sam had not moved; he had yet to speak.
A nurse leaned over him. “Sam, can you open your eyes?”
Please, open your eyes, Julie begged.
Nothing. No movement at all.
Julie felt the floor give way.
“Glasgow is a six,” a nurse announced.
Dr. Gerber shined a penlight into both of Sam’s eyes. “Pupils equal and reactive,” he said.
The scribe was recording this when the nurse with the long ponytail and Julie’s phone bounded over with a clean pair of scrubs.
“Paul and Trevor are on their way,” she said, handing Julie back her phone. “That was the message.”
“Thank you,” Julie said. She clutched the scrubs in her hands and squeezed hard.
A six, Julie thought. The Glasgow Coma Scale was a simple but effective test of consciousness and nervous system status. Sam needed to be at a thirteen, and he was at a six.
Dr. Gerber put his penlight away and unsheathed a sharp needle from a sterile package. He moved the needle against the heel of Sam’s foot up to the soft part of the pad. Though he was unconscious, Sam’s large toe extended upward, as did the other toes, to a lesser extent. It was Babinski’s sign. The reflex was normal in children up to two years old, but went away with neurological maturity. In an older child or an adult, it was an indication of a spinal injury or brain damage.
Something was very wrong with Sam.
The second survey
began as Dr. Gerber called for the portable X-ray unit. Dr. Kapoor and Dr. Benton reviewed the images from the FAST exam while two nurses rechecked Sam’s vitals.
The X-ray technician inserted a plate underneath Sam’s body and set about placing the films. Silence descended as Julie heard the familiar revving sound of the X-ray machine. The technician worked quickly, moving from several shots of the spine to the pelvis.
Dr. Benton and Dr. Gerber stepped over to view the display. They pulled up the images and studied them intently. Dr. Kapoor looked at the films as well.
“C4 burst fracture!” Dr. Benton called out.
Dr. Gerber’s composure cracked, revealing alarm in his eyes and voice for the first time. He turned to the nurse closest to him. “Two point seven grams IV Solu-Medrol, stat!”
Julie’s heart sank. All she wanted to do was collapse, but she was too numb to move.
Dr. Gerber, grim-faced, eyes downcast, emerged from the trauma room and took a single step toward Julie. She could see that he was forming the exact words to say. He didn’t have to say anything: Julie knew the significance of a C4 burst fracture.
CHAPTER 12
The furniture in the modest waiting room on the first floor of the Saunders Building was upholstered in fabric but not very comfortable to sit on. The tissue boxes were equal in number to the dog-eared magazines. Off to the side were small consultation rooms where distraught family members could speak privately with a patient’s surgeon. Sam had been in surgery for six hours. In that time, Julie had seen a number of people go into those rooms and emerge looking utterly destroyed.
What sort of expression will I have? Julie asked herself. No big smiles, certainly; Sam was too badly injured for that. She still hoped for good news, though the odds were not in their favor.
C4 burst fracture! Julie could not stop hearing Dr. Benton’s voice.
The wait was unbearable. No matter how much water she drank, Julie’s throat was persistently dry, her chest drum-tight. The guilt came and went in waves.
If only she had honked in time. If only she had agreed to be home for Trevor an hour later, like Sam had wanted. If only they had taken a different route. If only she had made any number of other choices, they would have been someplace other than behind that Civic. Of course, Sam would tell Julie it was not her fault. He’d tell her that, if only he could.
Julie had showered and changed into scrubs, but felt no better for the effort. She could still smell Sam’s blood in her hair, on her skin, even though all traces had been washed down the drain. The knots in her stomach made it impossible to sip from the second cup of coffee a thoughtful nurse had brought her.
Paul and Trevor were with Julie in the waiting area, and had been there for the past several hours. When they first arrived, Trevor’s baffled expression had made it clear he did not understand why his parents embraced with such emotion. It was understandably strange for him to see his mom and dad being at all affectionate. It would come up later in conversation, and Julie would explain that while she no longer loved Paul as a husband, she regarded him as a friend and appreciated his support at a time of great need.
“Is Sam going to be okay, Mom?” Trevor had asked. His dark eyes were a little watery.
Julie was touched by his emotion. “We’ll see. I don’t know. I’m being honest.”
“Don’t ride motorcycles anymore. Please.”
“I have no plans to,” Julie said.
For the most part, Trevor was quiet now, reading the book he’d gotten from the library before any of this had happened.
“Tell me what I can do for you,” Paul said to Julie. His eyes, brown and clear, brimmed with compassion. He liked Sam, and had encouraged Trevor to embrace him as a stepfather. Sam’s last birthday had fallen on a day when Trevor was with Paul, but Trevor phoned anyway and sang “Happy Birthday.” That had been entirely Paul’s doing.
Julie saw so much of Paul in Trevor. One day, her sweet-faced son would be the spitting image of his father. Paul was a tall, handsome man, with lustrous brown hair that could be unruly but today was pulled into a tight ponytail. He wore a faded brown leather jacket with a black T-shirt underneath, and a worn pair of blue jeans flecked with metallic paint from whatever sculpture he and Trevor had been working on. His craggy face was dappled with the trademark scruff that somehow managed to keep from blossoming into a beard.
“Let me get you something to eat,” Paul said. They sat on adjacent chairs. Her hands were trembling, and Paul had noticed. “You look a little pale.”
“I can’t, Paul. I couldn’t get down a bite.”
“Jell-O, then. It’s not even real food.”
Julie almost managed a laugh. “Okay, Jell-O. Cherry. And maybe an apple.”
Paul stood and put his hand on Julie’s shoulder. “It’s going to be all right,” he said.
Julie swallowed hard, and her face twisted. “I don’t think so.”
“Are they going to arrest whoever caused it?” Trevor asked.
“I honestly don’t know. Why don’t you go with your father and get something from the cafeteria.”
Trevor stood his ground. His sweet nature shone through like a beacon. He wanted to stay by his mother’s side and help guide her through these treacherous waters.
“Go, honey. Go with Dad. Get something to eat. I’ll be fine on my own for a bit.”
Trevor followed his father out of the waiting room just as Dr. Lucy Abruzzo came walking in. Lucy, in her white lab coat, was visibly upset. She moved quickly toward Julie, and the two women embraced long enough for those pent-up tears to fall.
“I’m so sorry. I was down in the lab and didn’t see your text until just now. Julie, what happened?”
The two friends talked together in hushed tones. No particular event had brought Lucy into Julie’s life. They were colleagues at the same hospital who had struck up a conversation one day, and found in each other a dislike for bureaucracy, a love of science, and a passion for medicine. They would eat lunch together whenever possible and sometimes Julie would join Lucy, a seasoned marathoner, for a jog, which always turned out to be a humbling experience.
A prolonged silence followed Julie’s account of the day’s tragic events.
“I’m at a loss for words. I’m so sorry, Julie.”
“What am I going to do?” Julie said, biting at her lip, trying to redirect the pain in her heart to someplace else.
“We won’t know the extent of his injuries until after the surgery.”
“Burst fracture, C4,” Julie reminded her.
Lucy was not going to take the bait. “It’s not a death sentence.”
“A lot of my patients are on the verge of becoming your patients. I know the odds.”
Lucy was too professional to offer false hope, but still did not seem as convinced as Julie.
“We’ve both been around this business long enough to see remarkable recoveries. Sometimes it takes months, years of rehab, but we’ve seen it happen.”
Julie mulled this over. “We don’t see it very often.”
Lucy took Julie’s hand and gave a squeeze. “Just have faith,” she said.
“I know what I would want,” Julie said.
“Don’t get on your soapbox about death with dignity just yet. Sam is still in surgery, and you’re projecting the worst.”
“I’m not projecting, I’m protecting myself,” Julie said.
“I understand completely,” said Lucy. “And if I had any feelings—which according to the other department heads around here, I don’t—I’d be doing the same damn thing.”
The automatic doors opened with a whoosh. Dr. Benton appeared, dressed in a fresh pair of scrubs, her surgical cap still in place. Dr. Riya Kapoor, the surgical resident, was at her heels.
Julie jumped up, closing the distance between them in seconds.
Dr. Benton’s cheerless eyes, glazed from hours of surgery, fixed Julie with a look of compassion.
“Hi, Julie. Let’s go to one of the con
ference rooms.”
The conference room was for long conversations. Julie had been hoping for something that could be said while standing—something like, “He pulled through surgery like a champ.”
“Is he dead?” Julie spat out the words, her voice shaky. The world was turning black.
“No,” Dr. Kapoor said.
Julie motioned for Lucy. They followed the two surgeons into the windowless conference room, which held a small table, a few chairs, and nothing more.
“Sam has stabilized and he’s being taken to the ICU now,” Dr. Benton began.
Julie tried to recall the shift schedule, wanting to know who was on the floor and would be looking after her Sam.
“You know that his injuries are severe. We found the hemopericardium. The cause was a small tear in his aorta. He was placed on bypass, and we repaired it easily in under fifteen minutes.”
So Sam had died, if only for a few minutes. They had placed him on a cardiopulmonary bypass, stopped his heart, and rerouted his blood so they could repair that tear in the aorta.
Julie held her stony expression, knowing the bad news was yet to come.
“He sustained numerous injuries due to the high-speed impact of the crash,” Dr. Benton continued. “Ortho cleaned up the wound from the open fracture. They plan to set it in a day or two, when he is more stable. His wrist and elbow are splinted, and will also need pinning. We’ll try to have two ortho teams in the OR to minimize time spent in surgery.”
That’s not it … there’s something else. I can see it in her eyes.
“He also suffered a pelvic fracture, and is in traction now.” Dr. Benton reached across the table for Julie’s hand.
Oh, no … here it comes … A pit opened in Julie’s stomach.
“The major concern now is that the burst fracture of C4 splintered into the spinal column.”
Julie visualized fragments of bone moving with enough velocity to shear the delicate strands of nerves embedded in the spinal column, the way shrapnel can shred flesh.
“Dr. Weinstein has been involved, and Sam is on the spinal cord trauma protocol.”
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