by Olivia Gates
But she was tired—and more. What was she feeling, thinking? Was she wondering what she was doing here? Cursing herself for being so stupid? Was it too much for her already? She wasn’t made to weather places like this, even temporarily. That damned vulnerability was becoming a part of her and it intensified her impact on him to the point of pain. But it also gave him hope. Hope she’d break soon, leave sooner.
He wanted her gone. He told himself that. He’d told her that. He’d told her not to come near him again. And she was heeding his gruff warnings. She’d pulled out of his arms the moment she’d steadied herself. No lingering this time, no soft glances and touches leaving him flailing, gasping for air and control. He’d put her in her place all right.
Now he squirmed. Oh, it had been easy to play righteous when she’d sought him out. As easy as when he’d walked away from her that first time. Easy as a single crippling blow to the spine. It felt even worse when she’d pulled away just now. Could this be how she’d felt when he’d pushed her away?
What’s so bad about showing you how I feel?
Nothing, he wanted to roar. Show me. Everything. Let me pull you back into my arms, soothe you until that injured look leaves your eyes, stroke you until wildness replaces it…
“We’re all set, Javier!”
Esteban’s call jerked him around to find everyone had converged on their convoy of four Jeeps and was ready to go back to the camp.
A wan Savannah went with the women, even when he invited her to ride with him, ignoring his outstretched hand and his concern.
That was what he’d wanted, wasn’t it? El idiota!
Alonso, Luis and Miguel jumped into his Jeep and called out to him, forcing him to turn and take his place behind the wheel. His heart almost uprooted itself when he found Savannah walking back towards them.
“Got one more place? The ladies have two patients with them that Elvira wants to check right away.”
He jumped out, held the door open for her, tried to meet her eyes. She wouldn’t let him.
After a few minutes of thick silence, Alonso exclaimed, “Man, that was even worse than I thought. And that’s saying too much.”
Luis huffed a despondent sigh. “Those areas aren’t called the ‘misery belt’ for no reason, Alonso.”
“I just can’t believe how close they are to Bogotá!” Alonso’s voice rose, giving vent to his shock. “How come no one there knows what it’s like here? Or is everyone just looking the other way?”
“Steady, Alonso.” Javier soothed him, his eyes fixed on Savannah’s grave expression in the rearview mirror. “The horror you’re experiencing is natural. You’ve been briefed about the upheaval displacement causes, but no briefing could have prepared you for witnessing these extremes of despair. But we’re here, amigo, hopefully the first of many to come, and we’ll do all we can to put things right.”
Alonso was only more infuriated. “The only way to put things right is for those people to return to the lands and homes they’ve been driven out of. We’re just going to be painkillers, placebos, leaving no lasting effect behind.”
“You’re wrong, Alonso.” Savannah’s serene assertion hushed Alonso, jerked Javier’s eyes to her when he needed them on the dusty, rocky road. “One of the most important things those people need is hope, the knowledge that they’re not forsaken. We may not lift their oppression or cure all their ills, but we will cure a few, and that is something. A big thing to them. A lasting thing. Don’t start out by doubting our value here, or you’ll give them less than your best, what they deserve of you. We can’t change it all, but when can we ever? Just remember what you’re in control of: your commitment and abilities. These people need those far more than any patient you’ve ever had. Let’s be satisfied with doing the best job we can.”
Savannah could have kicked herself.
She turned on her back on her thin mattress, the hard ground poking into her, adding to the distress of her every screeching muscle. And she’d thought she was fit. Fit enough for a grueling aerobics class, sure, but not for a day out there in real life. She turned on her side and faced the other shapeless wall of her tent and exhaled again.
But why kick herself? Sooner or later someone was bound to do it for her. Javier most likely.
How self-righteous she must have sounded! The guys had fallen silent all the way back to the camp because they could have only sneered at her, or burst out laughing at her naïveté and presumption.
Oh, what the hell! She believed every word she’d said. When faced with a disaster of such magnitude, trying to process it as a lump could lead to insanity or irreversible depression at the very least. It was best to focus on details, on what could be done.
It was also better to sleep now, to recharge for the first day of real work tomorrow…
Suddenly her every hair root prickled. She shot up into a sitting position and listened. Nothing. Just the camp’s noises. But this sustained electric charge prodding her—it had to mean something!
She twisted up to her knees and scrambled for her pants. In five seconds she was out of her tent. Their guards were by the fire, deep in conversation, their backs to her.
They didn’t hear anything, so maybe…No! She just knew something was wrong. Alert Javier!
Two dozen stealthy footsteps carried her to his tent. She didn’t call out, just pushed aside the tent’s flap and rushed inside.
Everything slowed down as her eyes fell on his naked back, watched him swinging around, his face aggression incarnate, a growl rumbling from his chest, a knife launching from his hand.
Her heart stopped as their eyes clashed, horror leaping in his. His hand jerked at the last second, adjusting the trajectory of the knife. It hit the tent wall just beside her head, went through the tough fabric with one single, sickening ripping sound. Then she was yanked against him and crushed to his flesh.
“Madre de Dios—madre de Dios, Savannah!” He pressed her harder, pushing her face into his chest, his lips grinding in her hair, his words a ragged litany of horror. “I could have killed you!”
“I’m sorry…”
She was suddenly free, pushed away from him by the thrust of his rage and shock. “Sorry? Sorry? You don’t do that, Savannah! You don’t sneak up on someone like that in our situation. I expected you to be a gunman, I expected a bullet, and was ready to do anything in return.”
“Just listen—”
“You call out, you make your presence known! Por Dios, do you know what I thought in the few seconds as I felt you sneak outside my tent? That a band of mercenaries had slaughtered you all in silence, that I didn’t hear your cry for help, that you didn’t get the chance to cry out, or even worse—”
“Javier, listen!” Her shout stopped his tirade. He stood there, towering over her, breathing hard, sweating in the cold night. “I think something’s wrong, not sure what. I was coming to warn you…”
She felt it again, listened for it. His confused look moved away from her, shifting around, concentrating, listening but not hearing anything.
Then it was suddenly unmistakable. They both heard it now. Shouts, far away—but coming nearer. She’d been right. Something was wrong!
In seconds he’d dressed and they were rushing outside, found their three guards on their feet, weapons ready. They saw approaching torches.
“That’s not an attack.” Javier corroborated her own belief. “They’re shouting for help. Esteban, get the van. We’ll meet them halfway.”
Before he jumped into the van, Javier turned to her. “Expand the MSU and get the OR ready, Savannah. I have a bad feeling we’ll be needing it.”
CHAPTER FIVE
“HOW bad is it?”
Javier snatched the oxygen mask Savannah was extending to him, fitted it on their patient’s face, his deepening scowl answering her whispered question.
She’d run out to meet him as soon as she’d seen the van kicking up dust in the moonlight, the torches following it in the distance. Now, in the dim
light of the campfire and the open MSU, she finally saw their casualty, an unconscious Afro-Colombian man of around fifty.
She jumped back into the MSU, checked the crash cart and the emergency stretcher with Caridad, snapped on gloves, and stood holding another pair for Javier to put on as soon as he came in.
It took only a minute for the practiced team of men to lift their casualty inside, every care taken in transporting the critically injured man.
As soon as the man was secure on the emergency stretcher, Javier swung around to the hovering Alonso. “We need to intubate. No rapid sequence anesthesia since he’s already deeply unconscious. Get on it.”
Alonso ran to the preoperative area and Javier turned to the rest of them. “Elvira, Miguel, Luis, Nikki, see to the other casualty.”
The four rushed to receive that other casualty who was being elevated on the emergency stretcher lift. She was conscious, crying—and pregnant. Savannah didn’t get a chance to see anything more as her four colleagues closed in on their patient.
Javier’s commands wrenched her focus back to him. “Savannah, assess circulation while I ready CT. Alonso, let’s be prepared for the possibility of simultaneous procedures. After you intubate, go ready two anesthesia stations.”
Alonso nodded as he finished assembling his laryngoscope, dragged up the crash cart with his intubation instruments on top and positioned himself at their patient’s head. “Neck injury?”
Javier exhaled. “Highly probable. We’ve been as careful as we can since we got him, but with the way he’d been carried here, any cervical injury must have been exacerbated. Collar him after intubation anyway. Go for 9 millimeter cuffed endotracheal tube but don’t inflate the cuff too much. Caridad, align the neck for Alonso during intubation.”
Savannah’s question stopped him again as he turned to the diagnostic stations. “Did you get history of the method of trauma?”
Javier’s somber eyes momentarily moved to their patient, then back to her. “Severe blunt head injury. He’s been kicked there, over and over, and left for dead.”
A cold fist unfurled in Savannah’s chest at Javier’s grim account. After the shake-up of her incident with him, the confirmation of how real and omnipresent danger and violence were was just another blow to her endurance.
Get busy. See to your patient.
And she did, zooming through the routine of taking the man’s blood pressure and hooking him to a pulse oximeter to monitor his pulse and blood oxygen saturations. Alonso finished the intubation and Caridad started positive pressure ventilation with one hundred per cent oxygen now the man was unable to breathe on his own.
With their patient’s airway secured and ventilation taken care of, it was the turn of circulation. She announced her circulatory assessment as she started preparing the measures to correct the deficits she’d found. “BP 75 over 50, pulse 70, hypotensive and bradycardic.”
Lowered blood pressure and heart rate in brain injury were ominous signs. Javier didn’t hear her as he readied the CT scanning machine with Emmanuel, their technician. Caridad did and turned to her with a whispered question as Savannah gained peripheral venous access. “Aren’t you going to measure intracranial pressure, too?”
Savannah shook her head. “Hypotension is far more serious than a rise in intracranial pressure right now.”
Caridad shot her a quickly subdued skeptical look. “I thought the reverse, that intracranial pressure had to be monitored and kept below 20 millimeters Hg.”
Savannah injected a 250 cc saline bolus into the venous line in the man’s arm, starting blood volume expansion to correct his hypotension. “Decrease of cerebral perfusion pressure—that’s the difference between arterial blood pressure and intracranial pressure—is the culprit behind deterioration and long-term poor prognosis. That’s why oxygenation and keeping his BP over 90 millimeters Hg are the most important things to guard against compounding secondary brain injuries.”
Caridad nodded, absorbing the new information, and followed Savannah’s directions to switch saline delivery to a continuous drip. Javier was concluding his preparations and looking across at them. Savannah wasn’t ready for the look in his eyes. Was that approval? It was!
Her legs quivered and her heart bobbed up and down with his slow nod. When he spoke he just said, “Caridad, give me BP, pulse and oxygen saturation readings every five minutes. Assess neurological status, Savannah. I’ll check on the other patient.”
So he was entrusting their patient to her judgment!
Savannah watched him rush past her to the other team and jumped back to her task. A twinge of embarrassment shot through her at her eagerness, at feeling the adrenaline pumping in her veins as she watched her measures working, as she glided her hands over the man and translated his reflexes into possible diagnoses and counteractive methods.
It hadn’t always been like that. Before that night in the woods, before Javier, she’d been reluctant about the whole medicine thing, just going through the motions. She’d always possessed a natural aptitude for information-gathering and cross-referencing, but had never had any desire to put them to use. Then everything had started to come into focus, and she’d been infused with a new energy and an unknown delight in performing and getting results. At the time she’d thought her spurt of enthusiasm had only been a reaction—to her ordeal, to being near Javier—and that it would fizzle out again in time.
But it hadn’t. In fact, the real change in her had occurred after he’d left her. After that time when she’d realized how worthless she’d thought herself, how pointless she’d believed her existence to be. Then she’d come to thrive on every extreme medicine had to offer, feeling alive and of use at last, until her amused and bemused colleagues had bestowed on her the nickname of “Ambulance Chaser Savannah”.
She completed her tests and called out her assessment to Javier. “His GCS is five. One-three-one.”
Which was very bad news. The GCS, or Glasgow coma scale, quantified the severity of neurological injury. There were four points for eye-opening response, six for best motor responses, and five for best verbal responses. A GCS of 15 was a fully conscious person, while eight down to three indicated a severe head injury and a strong prediction of a poor prognosis.
Javier strode back to them. “Status, Caridad?”
“BP 85 over 60, pulse 80, oxygen saturation 85 per cent.”
Javier’s huff was eloquent. Things weren’t improving enough. “Let’s see what’s keeping our measures from working properly.” Javier pushed the trolley in the CT machine’s direction. In seconds he and Emmanuel had placed their patient in the machine, with both Savannah and Caridad making sure his oxygen and fluid supplies weren’t interrupted. Once he was harnessed on the gliding table, Emmanuel operated the scanner.
“Head and neck only, Emmanuel.” Javier turned to her as they waited for the procedure to begin yielding images for them to review. “So what got three? Motor responses, I hope.”
“Yes. He has abnormal flexion.” She could see why he hoped for motor responses to have scored the highest. Out of the three parameters in trauma, best motor response was the most accurate prognostic indicator. Three out of six wasn’t good, but it was still better than getting a one, no response.
Javier’s words reinforced her opinion. “Three is better than one. But that’s still not good at all, especially after resuscitation.”
“There’s also a unilaterally dilated right pupil with ipsilateral third cranial nerve paralysis.”
Javier grimaced. “Great! These may be the first signs of impending brain herniation!”
Savannah jerked. She hadn’t considered her findings to be anything more than signs of focal injuries in the brain, and not that the brain was swelling and beginning to herniate out of the skull! The consequences of that were catastrophic.
Her own brain felt about to burst with urgency. “Shouldn’t we operate immediately to relieve building pressure?”
In answer to her frantic query Jav
ier just rushed to the crash cart.
She followed him, insisted, “That must take precedence over obtaining CTs!”
He handed her a mannitol bag and a 100 mm syringe. “We have to try other methods of ICP reduction first. Give him a mannitol bolus while I hyperventilate him. I didn’t want to implement either measure before because of their eventual counterproductive side effects, but we’ll use them for a short time, before these develop, only until the CT is over and his ICP is more under control.”
Savannah conceded his rationale. By hyperventilating Torres, they would reduce his blood carbon dioxide content and therefore his brain blood flow and swelling. Mannitol would draw fluids out of his brain tissues by osmosis, also taking down the swelling and reducing the ICP. But both hyperventilation and mannitol reversed their effects on continuation. That was why they had to be administered only as emergency measures and for short periods. Her heart still itched, feeling time ticking past.
Javier was beside her again as he adjusted the rate of oxygen delivery to hyperventilate their patient. Once they’d both finished, he turned those potent eyes on her, reading her doubts and agitation and transmitting his conviction. “CT isn’t a luxury here, Savannah, it’s a vital element of the emergency measures. We must have it, especially if we need to operate. If hematomas are collecting in any layer of his brain, we must know exactly where so we’ll have as precise an approach as possible to evacuate the blood. Anyway, this is an MSCT, a multiple slice CT, 16 slices per second. The whole thing will take minutes and we owe him the chance to respond to our measures before attempting a craniotomy. If he deteriorates he’ll be on table in a heartbeat, so we’re not losing time here.”
Savannah nodded, exhaled. Even in the severest blunt head injuries, there was always hope that non-surgical approaches would stabilize the patient. Twenty years ago, immediate opening of the skull to relieve pressure had been the norm. Now it was left as a last resort. And speaking of last resorts…