by Radclyffe
“That’s Flann’s doing. She got them to upgrade the brand of coffee and change out the urns every couple of hours. One of the perks of a small place like this. You won’t be a cog in a wheel here.”
“I’m glad.” Maybe this place would be the community she’d lost. “I think I’ll like—”
“Hey, Archer. Seven ten and you’re still lounging over coffee. No wonder you jumped ship.”
Mari stared up at the woman in navy scrubs and a wrinkled, shapeless green cover gown, rather like a giant cloak, standing beside the table. A surgical mask dangled around her neck and her disheveled mop of dark hair still showed the imprint of a surgical cap. Her face was all edges and long lines, attractive, Mari supposed, if you liked the dark, edgy type. She preferred Glenn’s cooler, classic contours…and stopped herself before that thought went any further. Glenn was very good-looking, and the swift changes that came over her face—from light to dark, cool to warm—along with the fleeting hints at whatever she kept so close were fascinating. Mari had never looked at a woman and thought fascinating in her life, which ought to be caution enough. Glenn had secrets, just as she had, that was all. She felt a flush rise in her neck when she realized the newcomer was studying her with unapologetic frankness. She lifted her chin, refusing to be embarrassed by the scrutiny.
“Actually,” Glenn said with that faint hint of a drawl, “we’re in the midst of orientation.”
“Ah. Fresh boots?” Grinning, the woman held her free hand out to Mari and sipped from the cup of coffee she held in the other. “Flannery Rivers. Welcome aboard.”
Mari smiled and took her hand. The long fingers that closed over hers were firm and smooth and certain. “Mari Mateo, and my boots are already well broken in.”
“Good to hear. Glenn will probably need all the help she can get.”
“Thanks,” Glenn said good-naturedly. “How’s the patient from last night?”
“Just saw her. Temp’s down and the leg looks good. Nice work.”
“Thanks,” Glenn said quietly.
Flann pulled a chair over from an adjacent table and settled in between Mari and Glenn at their small table. “How many more recruits do you have coming?”
“One more new staff and four students.”
Flann laughed. “It’ll be a hell of a day down there.”
“We’ll handle it.” Glenn smiled. “Dr. Remy has put together an amazing program in an incredibly short time.”
“You helped,” Flann said.
“I followed orders,” Glenn said.
“Well, Abby is very efficient when she wants something done.” Flann glanced at Mari. “Dr. Remy managed to seduce Glenn away from the OR in record time.” She shook her head. “First she takes my job, then she takes my right hand. It’s a damn good thing I love her.”
“Um…” Mari was at a complete loss and sent a helpless look in Glenn’s direction.
Glenn laughed. “Dr. Rivers is chief of surgery, Mari, and for a while she wore another hat—heading up the ER too. Until Dr. Remy came along.”
Flann sighed. “Yeah. Then Abby decided that Glenn belonged in the ER full-time, and she took her too.”
“It seems that Dr. Remy has very good judgment,” Mari said.
Flann grinned. “She has to, she’s going to marry me.”
“Oh.” Mari laughed. Flannery Rivers might like to tease, but her fondness for Glenn was obvious, and the way her eyes sparkled every time she said Abigail Remy’s name told exactly how she felt about her. Flann reminded her a little bit of her oldest brother Hector, always high on life, playful and charming, when he wasn’t being downright annoying. A swift shock of sadness and unexpected longing shot through her. She caught her breath and forced a smile. “Congratulations.”
“Thanks. I’m hoping Glenn gets bored fast and comes back where she belongs.” Flann stood. “But in the meantime, good luck.” Her voice had gone from teasing to sincere, and the warmth with which she looked at Glenn gave Mari some idea of the depth of the friendship between the two. She was glad. Glenn seemed so very alone.
“Don’t get into too much trouble without me,” Glenn said.
Flann squeezed Glenn’s shoulder. “Wouldn’t think of it. Don’t forget to tell Mari and the rest of your new boots about the barbecue.”
“Right,” Glenn said, pulling her phone from her pocket as Flann walked off. She glanced down and then at Mari. “Incoming. You ready to go to work?”
Mari stood. “You have no idea.”
Chapter Four
Mari raced at Glenn’s side, threading between the tables on the way to the nearest exit. Most people barely gave them a glance, used to seeing staff race off to an emergency. Glenn didn’t return the way they’d come, and Mari was quickly lost and didn’t bother trying to follow their route. She just focused on keeping up with Glenn as they jogged around corners, through a fire door, and down a concrete stairwell lit by bare bulbs in metal cages.
“You run?” Glenn asked, not the least bit breathless.
“I did,” Mari said, trying valiantly to sound as unstressed as Glenn. Her heart pounded against her ribs, but her wind was holding. Her legs were nearing jelly status, but then, she hadn’t used them much in the last half a year or so. They couldn’t have that much farther to go, could they? “I’m a little bit out of training just lately.”
“You move like a runner.”
Mari was oddly pleased by the comment but barely had time to appreciate it before Glenn pushed through another unmarked gray metal door and delivered them into the center of a tornado. A blast of disorienting noise and a flurry of rushing people sent a surge of panic racing through her. Nothing looked familiar—what was she supposed to do? After a second, Mari’s pulse calmed and she made sense of the controlled chaos in the hallway. She’d seen this before. ER staff pushed gurneys toward the ambulance bay to await the injured, pulled back the curtains on examination cubicles, and opened equipment packs. Lights came on in a big room Mari barely had a chance to glance into as she hurried by, but even a quick look was enough to tell her it was a pretty fully staffed operating room.
“What have we got?” Glenn called to Bruce, the nurse Mari recognized from earlier.
“EMS is five minutes out. Grain silo collapse.”
Glenn’s face set into grim lines. “How many?”
Bruce shook his head. “We’re not entirely sure. First report was three, then another unit called in and they’re bringing two, and we think there might be more. Could be upward of ten.” He grimaced. “Apparently a couple of people went in to try to help and ended up getting trapped themselves.”
“How many people do we have down here?”
“Never enough for this kind of thing,” Abigail Remy said, emerging from the reception area wearing scrubs and a white coat, her expression intense and hyperfocused. “Bruce, call up to the SICU and see if they can spare us a couple of nurses. Then get the respiratory techs down here—every one we have in-house. You’ll be triage.”
“Yes, ma’am,” Bruce said, practically saluting. He spun on his heel and strode away.
Abby turned to Glenn and Mari. “Glenn, I want you to take the criticals, anyone that looks like they need immediate surgical intervention, get them into the trauma bay stat. I’ll call Flann and alert the OR to put a room on standby.”
“Roger.” Glenn leaned toward Mari and lowered her voice. “How are you feeling?”
“Fine,” Mari said. “I’m good.”
She was. Her heart galloped with the adrenaline rush, but she wasn’t nervous and she wasn’t afraid. She also wasn’t alone, and she knew it. If she got something she couldn’t handle, she’d have backup. Glenn was here, looking solid and sure, as if she’d seen and done this kind of thing a hundred times before—because she had. Dr. Remy too. But most of all, Mari trusted her training.
“Good,” Glenn said. “You’ll take anyone who isn’t actively hemorrhaging or in full arrest. Use room one.”
“Okay—you bette
r tell me about grain silos. What can I expect?”
Glenn’s gray-blue eyes darkened to nearly black. “Don’t see much of that in LA?”
“Try never.”
“Depends on what was in the silo, but usually corn or wheat, which generates heat, toxic gases, and a hell of a lot of dust. When the structure collapses or the contents avalanche inside, whoever’s buried will suffocate in seconds or be crushed, but they can also get sucked into the augers and mixers—meaning broken or severed limbs.” She spread her hands. “If it takes more than a minute to extract the ones who are completely submerged, their lungs will be full of dust and even if we intubate, it’s not going to be enough.”
“So blood gases on everyone,” Mari said, trying to formulate a treatment plan on the fly. This was nothing like a multi-vehicle pileup on the interstate, but the principles were always the same. “What else? Injury-wise?”
“Compression syndromes, fractured ribs, open and closed extremity type injuries. The fractures can all wait unless there’s vascular compromise.”
“Right. Airway will be the thing.”
Glenn nodded. “If you need an assist, holler. I’ll be right across the hall.”
Bruce appeared around the corner. “The first bus is here.”
Abby strode confidently into the center of the waiting staff. “All right, everyone, you know what to do. Let’s go to work.”
Mari took a deep breath and hurried into her room, quickly scanning the instruments set out beside the exam table. She pulled on gloves just as a stream of first responders burst into the ER pushing stretchers toward the rooms where Bruce had directed them. Two EMTs angled a stretcher into Mari’s cubicle with a small form nearly dwarfed by oxygen tanks, an EKG monitor, and IV bags. All Mari could make out beneath the tape and O2 bag was a blue-tinged face and a shock of yellow hair.
A heavyset redhead at the front of the stretcher croaked hoarsely, “Juvenile, maybe ten years old, buried in three feet of dust—” He lost his voice for a second, then continued, voice steadier although agony misted his eyes. “The family had already dug him out, and the dad was doing mouth-to-mouth. We intubated in the field.”
“Pulse ox?”
“60.”
Mari’s stomach plummeted. 60 was barely compatible with life and not enough to sustain brain function. She quickly listened to the boy’s small chest and could hear no air moving in the lower two-thirds of his lungs. Thankfully she detected a rapid heartbeat, but that wouldn’t last long if they couldn’t ventilate him. “On a hundred percent O2?”
“That’s what’s running, but it doesn’t seem to be doing much good.”
Mari glanced at Beverly, a middle-aged brunette nurse who’d arrived to help. Her mouth set into a tight line, and Mari didn’t have to ask why. If they did nothing, this child was dead. But no matter what she did, it probably wouldn’t make a difference. Still, her job was to fight, as long as reasonable, and fight she would.
“All right,” Mari said, hoping she sounded confident, since she hadn’t actually heard of what she planned to do being used for anything like this. Although she hadn’t heard of this until ten minutes ago. “Let’s set up a saline lavage, get another pedi tube ready.” She looked up at the two EMTs. “What size do you have in there?”
“Six,” replied the second EMT, a thin young blonde with a silver hoop through the corner of her left eyebrow.
“Who intubated him?”
“I did,” the blonde said.
“Did you see debris in his trachea?”
“I didn’t see anything. It was a blind intubation.”
“All right then, let’s see what we can see.” She ought to clear this treatment with someone before she went much further. “Beverly, can you get Dr. Remy or Glenn for me?”
“Not for a few minutes,” Beverly said. “I saw them both at a resuscitation on my way in here.”
“We don’t have a few minutes,” Mari muttered.
“Let’s not waste any time, then,” Beverly said briskly, as if telling her to do what she needed to do. She stood by with suction and a small-bore catheter connected to a saline bag under pressure.
“Time me.” Mari took a deep breath and slid out the breathing tube, removing the only thing keeping the boy breathing—and alive. She didn’t have long, but then, neither did he. She slid in her laryngoscope and lifted his chin, giving herself a narrow tunnel down which to evaluate his airway. The thin light at the end of the instrument illuminated the back of his throat and the upper part of his trachea. Where she should have seen glistening pink mucosa she saw only thick clumps of dark debris. It looked as if someone had poured concrete into his windpipe. No wonder he couldn’t breathe.
“Let me have the lavage catheter.”
Beverly slid the thin tube into Mari’s hand and she threaded it down into the debris and hopefully into his trachea. “Go ahead, open up the bag and get the suction ready.” Fluid shot into his trachea, completely blocking what remained of his airway. If this didn’t work, he’d drown. The saline mixed with the dust from the grain silo, threatening to glue shut any possible avenues for airflow, and Mari frantically suctioned before the mixture turned into paste.
“Time?”
“Thirty seconds,” Beverly said.
“Another fifteen seconds,” Mari said, the muscles in her shoulders starting to ache.
The curtain twitched back and Abby Remy looked in. “What’s the story?”
“Foreign material in the airway. Some kind of thick, particulate matter—dust, I guess,” Mari said without looking up. “He was tubed on arrival, but not oxygenating. We’re lavaging to clear the trachea and mainstem.”
Abby threaded her way between the EMTs, who hadn’t budged, to the head of the table and looked over Mari’s shoulder. “Lift the laryngoscope a little bit more so I can get a better view.”
Mari took a deep breath and lifted. Now her arm was beginning to shake. Keeping the jaw open and the airway exposed was strenuous, and she hadn’t intubated anyone in almost a year.
“How long on the lavage?” Abby asked.
“Forty-five seconds.”
“O2 sat?” Abby called out.
“58,” the male EMT reported.
Mari’s stomach plummeted. She was going to lose this boy.
“Keep going. You’ve almost got it,” Abby said quietly, her sure, certain tone injecting much-needed strength into Mari’s aching arm. “You want me to take over?”
“No,” Mari said just a bit breathlessly. “He’s almost clear.”
“There you go,” Abby said with a note of victory. “The suction fluid is coming back clear.”
Mari finally breathed. “Turn off the saline and let me have the new ET tube.”
“Here you go. A pedi six,” Beverly said and slipped the curved plastic endotracheal tube into Mari’s outstretched hand.
Never moving her gaze from the small dime-sized opening that led down into the boy’s trachea, Mari slid the tube between his vocal cords and toward his lungs. “Hook us up?”
The ventilator began to hiss, and Mari slid out the laryngoscope and stepped back.
Abby listened to his chest with her stethoscope, nodding as she quickly moved the diaphragm over his chest. “Breath sounds are good. Pulse ox?”
“65,” Beverly said.
“Increase the rate to twenty and decrease the volume. Let’s rapid pulse him.”
The pulmonary tech adjusted the ventilator, and the machine cycled quickly in short, sharp bursts as if it was panting.
“Suction him down the tube, Mari,” Abby murmured.
Quickly, Mari complied, barely able to take her eyes off the pulse oximeter, hardly breathing herself as the numbers began to edge up. 68, 72, 75, 80, 85, 90.
“Holy Jesus,” the big burly EMT muttered. “You got him back.”
“Let’s get a chest X-ray,” Mari said, tempering her elation. A million things could go wrong, and if he’d been without cerebral perfusion for too long, she
might not have saved him after all. Now only time would tell if he would recover. She had to be sure he didn’t have other injuries that could complicate his recovery, and then they would wait.
Abby said, “Draw a full panel of bloods and get him up to the intensive care unit.” Abby squeezed Mari’s shoulder. “Very nice, Ms. Mateo.”
“Thank you.”
As quickly as it had begun, it was over. Beverly drew bloods from the IV line and the two EMTs, who appeared to have no intention of leaving their charge, pushed the stretcher out into the hall. Another stretcher materialized in her cubicle, this one with a young man whose right arm was misshapen and bloodied.
“Hi, I’m Mari Mateo, a PA,” she said, and got back to work.
*
Mari had no idea how much time had passed by the time the last patient left her cubicle for an observation room upstairs. It might’ve been ten minutes, it might’ve been ten hours. All she knew was she’d never felt so exhilarated in her life. She’d splinted fractured limbs, inserted a chest tube under local anesthesia, and treated an acute case of asthma with inhalation agents and intravenous medications, avoiding a dangerous intubation. She’d evaluated more complex cases in one day than she had in a month of training, and she’d managed mostly on her own. She’d been dimly aware of the seething activity around her as she’d worked—once she’d heard the high-pitched wail of someone’s heart breaking, and a moment later Glenn’s low-pitched, melodious cadence calling for a cutdown tray. Dr. Remy popped in and out of her room, checking patient status, reviewing a treatment plan, offering suggestions.
As soon as the transport orderly took her patient, a forty-five-year-old fireman with an impending MI, to the medical intensive care unit and no one brought another patient to replace him, she sagged into the hard plastic visitor’s chair against the wall of her treatment room and stared at the litter-strewn floor. An errant glove someone had tossed toward the trash can and missed, an IV tube dangling from a metal stand, the saline slowly dripping into a clear puddle, bandage wrappers, a plastic cap from a syringe. A war zone.