Rupture Page 14

“Where were you this morning? You weren’t in the OR, you don’t have a clinic anymore. The only place you need to be is in your lab.”

  Eli knew it was time to shoot straight. Fisher probably already knew anyway.

  “I was downtown.”

  “Downtown? While I was talking to police and trying to cover your ass, you were downtown?”

  As Eli thought of his next response, his beeper went off and he quickly silenced it without looking at the number.

  Fisher continued in a sarcastic romp. “A little sightseeing? Beale Street? Hey, I hear Graceland’s real pretty this time of year. You should check it out.”

  “Not really downtown,” Eli admitted. “I was invited to visit a company.”

  “What company?”

  “RBI.”

  At this, Fisher stood and turned to face the bookcase behind him. Eli’s beeper screeched again and he checked the number. It was the emergency room. With everything else, he had forgotten that he was on trauma call starting at five o’clock. He checked his watch.5:01. Of course.

  “Dr. Fisher, it’s the ER.”

  “Sure, go ahead and answer it. I’m just here for you. I’ve nothing else to do.”

  Eli punched the number into his cell phone and walked to the back of the office, as far as he could get from the heat radiating off Fisher.

  “Dr. Branch, Department of Surgery,” he said with an artificial layer of authority, “returning a page.”

  It was Landers.

  “Dr. Branch, your chief resident wanted me to call you.”

  “Sure, what we got?”

  “Young male in motorcycle crash. No helmet. Sounds bad.”

  “How far out?”

  “Five minutes, maybe less.”

  “All right, get the team ready. I’ll be there.”

  Eli closed his phone. He did not sit down.

  From the shelf, Fisher picked up a crystal globe the size of a softball and slowly turned it in his hands. He continued as though he hadn’t heard a thing. “RBI, huh. In cahoots with the drug companies, are we?”

  “No sir. Just thought there was room for collaboration.” Eli was making this up. He knew of Fisher’s disdain for the pharmaceutical industry and the conflict of interest it could create for an academic department.

  “Our labs aren’t good enough for you?”

  “I’m not sure I have a lab anymore.”

  At this, Fisher swung around and pitched the globe toward Eli. He caught it just before it hit the floor.

  “What you don’t have anymore is a job,” he screamed. “Finish the week and you’re gone.”

  CHAPTER TWENTY-SIX

  GATES MEMORIAL HOSPITAL

  EMERGENCY ROOM

  5:11 P.M.

  The word “bad” grossly underestimated the extent of injuries. Sixteen-year-old male, high speed into a bridge abutment. Witnesses said he flipped airborne and skidded twenty yards on the pavement.

  No helmet.

  The patient was intubated at the scene and transported by helicopter from an exchange off I-55 near the Mississippi border. When Eli arrived in the trauma bay, the surgery residents were lifting the boy off the stretcher. A dozen people filled the trauma room, including the paramedics who were still giving report.

  “The guy did nothing when we got there. A few agonal breaths, didn’t move a thing.”

  Dr. Susan Morris, the chief surgical resident, stood at the head of the table in a yellow protective gown, looking like most of the team, eyes above masks protected by plastic shields. Susan’s tall, athletic build gave a commanding presence in the trauma room. A good chief could direct the resuscitation without much help from an attending surgeon.

  Eli took a position at the foot of the table, a foreman to oversee the work. He tried to prepare himself mentally for the role. As an academic surgeon, he needed to switch quickly from the scientific method, with perfect controls and experimental groups, to complex management of critically ill patients, always taking time to teach students and residents. This time, Eli had to make the necessary adjustment in the shadow of a murder in which he was suspect, and in a hospital from which he had been fired.

  At the head of the table, Susan jammed a Yankaur sucker into the boy’s blood-filled mouth and the suction tubing gurgled. Trauma resuscitations were brief but intense events during which multiple procedures occurred simultaneously. Needles and even scalpels were often wielded by inexperienced team members. The risk of needle sticks and blood exposure to medical personnel was high. And patients with penetrating injuries, especially gunshots and stabbings, were often those who carried infectious blood, such as drug users and gang members.

  Eli gave an affirmative nod to Landers, who held a syringe with a large-bore needle for femoral artery puncture. Just don’t stick yourself again. Eli watched as Landers submerged the syringe into the patient’s groin with immediate return of pulsatile flow into the chamber.

  “Tube’s in place,” the chief resident confirmed as she withdrew the laryngeal blade. She flicked a penlight across each pupil. “Fixed and dilated.”

  The respiratory therapist rhythmically squeezed air into the patient’s lungs.

  “Hyperventilate with forty breaths per minute,” Susan told the therapist.

  Eli hoped that Susan Morris represented the quality of all the residents in the program. She appeared in command of the situation.

  Eighteen-gauge IVs were placed in both arms and heated fluid was infused under pressure. A digital clock on the wall recorded elapsed time since arrival.

  Two minutes forty-five seconds.

  A male nurse slid trauma shears up the leg of the boy’s jeans and through the crotch and easily separated the zipper. The sheers could cut a quarter in half. One snip later, the underwear was off and a stench filled the room.

  “No rectal tone,” the third-year resident announced as he withdrew a gloved finger smeared with stool.

  Everyone in the room knew that this was a bad sign; loss of sphincter tone was indicative of neurologic devastation.

  “His belly blew up like a toad in route,” the head paramedic said, continuing his report. A Foley catheter was threaded into his penis and returned bloody urine.

  The boy was tall and slender, maybe 140 pounds. His left collarbone was broken and trying to poke through the skin at the base of the protective C-collar around his neck. An oozing raw swath across his chest looked as if it had been buffed with a sander. But below his ribs, his abdomen jutted out like a plump watermelon.

  “And it’s not air,” Susan said as she percussed the abdomen with a dull thump by tapping her fingers along the distended surface.

  The trauma nurse knocked the stethoscope from her ears and ripped open the Velcro blood pressure cuff.

  “Pressure’s sixty-five.”

  “Ringer’s Lactate wide open,” Susan said. “Two liters almost in.”

  Eli looked at the charge nurse, held up two fingers, and mouthed “O negative.”

  The patient had telltale signs of hypotensive shock, both low blood pressure and rapid heart rate. His pulse was 148, an expected compensatory response in a healthy youngster who could sustain a supraphysiologic heart rate to make up for a vastly diminished blood volume.

  Eli felt Landers brush against his coat.

  The teachable moment.

  “Why is he in shock, Landers?”

  “Blood loss, sir,” Landers said immediately. “Hypotensive shock.”

  “Good,” Eli said. “Where is his blood loss?”

  Landers pointed to the boy’s abdomen. “It’s in his belly, Dr. Branch.”

  Eli knew that in minutes they would be in the patient’s abdomen through an emergent laparotomy. Likely a fractured spleen. Maybe his liver. The only way to maintain his blood pressure until they were in the OR would be by replacing lost blood with universal donor O negative. They could not afford waiting for results from the type and cross testing and would have to risk transfusing nontype-specific blood.

  Eve
n if they could repair his abdominal injuries, the extent of brain damage would determine the patient’s outcome, what function he could hope for, if his life would be confined to a bed. A head CT scan was needed to assess for intracranial blood, but the boy was too unstable and would likely bleed out in the scanner before he ever got to the OR.

  Susan pushed a portable ultrasound machine to the gurney as a nurse squirted blobs of lubricating gel into the patient’s navel. As Susan moved the probe over the upper abdomen, she called out the results from snowy shadows on the screen.

  “Blood all around his liver and spleen,” she said so the entire room could hear.

  Eli was watching his chief resident. If Susan didn’t make the call to go to the OR, he would have to tell her. They made eye contact and Susan raised her index finger and pointed at the ceiling. Eli nodded.

  “Okay people, we’re taking him up to the OR. Pack it up. Respiratory, you bag him on the way. Landers, go get an elevator.”

  For a brief moment nobody moved, as if they were trying to assimilate the chaos before them. This young man had sustained life-threatening injuries. If he made it, would he have any brain function, any quality of life? It didn’t take long on a trauma service to witness one of these tragedies. A young person is injured, survives, gets a tracheostomy and feeding tube, only to be transferred from the hospital to a rehab facility for weeks, months, maybe forever.

  Above these concerns grew the unnerving sense that comes with namelessness. Who was this boy? Where was his family?

  The chief resident sensed the immobility. “We’ve got to move, people.”

  Eli grabbed the elbow of the charge nurse as she rushed by. “Check his pants.”

  She picked up the crumpled pair of jeans from the corner and removed a thin black wallet. A couple of credit cards, a hundred dollar bill and five twenties, and a driver’s license. The nurse glanced at the boy’s face, then back at the license before handing it to Eli. The handsome, boyish face on the license could not be recognized in the blood-speckled rash of scrapes and cuts, lips swollen and blue.

  With eyes flashing alarm the nurse said, “Do you know who this is?”

  Eli read off the name. “Scott Tynes?” Then he found the date of birth. “He’s sixteen.”

  Everyone in the room stopped and looked at Eli.

  One of the paramedics had lingered at the door to watch the resuscitation.

  “Yeah, this is Roger Tynes son,” he said, as though he had known all along. “Damn, thought you knew that.”

  “As in Tynes Freight and Air?” another nurse asked.

  The paramedic motioned through the glass doors to the loading ramp. “Why do you think the TV crew is swarming?”

  Out in the circular drive, a cameraman focused on a reporter holding a microphone to her face. The trauma team clung to the stretcher like pallbearers, as they rushed Scott Tynes out of the trauma room in a sprint toward the OR elevators.

  As Eli followed, he looked out the glass doors at the reporter and recognized her immediately.

  “Here we go again,” Eli said under his breath.

  “Take two.”

  CHAPTER TWENTY-SEVEN

  TRAUMA ROOM ONE

  5:36 P.M.

  The boy lay naked on the operating room table, arms extended to his side at right angles, as though crucified. Lubricant had been applied to his eyes and they were taped shut. Hidden beneath the tape was the most telling prognostic sign—pupils fixed and dilated.

  The circulating nurse painted his abdomen with deep brown swipes of Betadine, which turned yellow as it dried and desiccated bacteria on the skin. Intravenous lines pumped fluid and blood into veins at the inside bend of both elbows. The anesthesiologist stood poised at the left wrist inserting a radial artery catheter to monitor continually intraoperative blood pressure. Two nurses were stacking units of blood in a cooler, calling out identification numbers as they worked.

  A breathing tube projected from Tynes’s mouth secured with wide swaths of tape that pulled against the boy’s denuded, swollen cheeks. Overhead monitors beeped rapidly. A yellow tube sprouted from his penis and drained red urine into a bag hanging below the table.

  Eli watched a single number, the systolic blood pressure, transduced in real time from the arterial line—sixty-four, then sixty-one, down to fifty-seven.

  The third and fourth units of blood had been transfused. But Eli knew that this blood would circulate through the heart only once before spilling out of damaged organs into the free space of Scott Tynes’s abdomen.

  Already gowned and gloved, Eli stood with folded hands and lowered his head for a moment, eyes closed. Even in the most emergent situation, he made time for this plea, however brief. Then he looked at Landers, who was watching him across the table.

  Eli remembered his first surgical role model when he was an intern. The older man was so skilled in his craft that his movements appeared effortless. He would take charge of a room just by entering it. Yet, he brought a gentle bedside presence to each of his patients. Eli knew that Landers was looking to him for that modeling, whether he wanted to provide it or not. It was a responsibility that Eli found both empowering and intimidating.

  “Okay, that’s enough,” Eli said to the nurse who methodically, and by protocol, painted the cleansing Betadine solution, strip by strip. “Towels.”

  In concert, Eli and Susan draped off the operative field with square blue towels leaving only the protuberant, blood-filled abdomen before them. The anesthesiologist had dropped the table to the lowest level, and yet Tynes’s abdomen ballooned up to the level of Eli’s chest.

  “Ten blade,” Eli instructed, and the scrub nurse presented the scalpel to Eli, handle first.

  To everyone’s surprise, Eli motioned for the scalpel to go to Landers. “Cut him.”

  With eyes wide, Landers looked at Eli and hesitated as though to give him time to reconsider. “That old man’s blood tests are back,” he said, referring to Gaston.

  Eli couldn’t ignore this, although the timing was awful. “And?”

  “He was HIV-positive.”

  Eli tried to hide his surprise. “I’m sorry, Landers. Have you started the pills?”

  “Yeah, triple therapy.”

  Eli nodded and placed one finger on Tynes’s sternum, another on the boy’s pubis. He looked at Landers. “Can you do this?”

  Landers took the knife.

  “Into the deep sub-Q,” Eli instructed the intern. “From here to here.”

  Landers placed the scalpel against the skin just below the breastbone and cut a straight line with a gentle curve around the belly button. Rather than spurting bright red, the subcutaneous bleeders oozed a dark mixture of deoxygenated blood. Landers handed the knife back to the scrub nurse.

  As soon as the scalpel was out of his hands, Susan nudged him toward the foot of the table. “Don’t get carried away, big guy. You’re holding a retractor from here out.”

  Imagining a compressed abdominal clot that had kept the boy from bleeding to death, Eli told the anesthesiologist, “I suspect he has some degree of tamponade. When we release the dam, he’ll bottom out.”

  As he said this, Susan incised the tough fascial lining that held the pressurized abdominal contents. The thin peritoneal lining bulged with a purple dome and then erupted, blowing partially congealed blood up and over the sides of the abdomen like oil from a newly tapped well.

  The scrub nurse was ready with a large basin and Eli and Susan used cupped hands and lap pads to evacuate the blood. In the center, fresh arterial blood mixed and swirled with darker heme to form a deeply toned mosaic.

  “Get me some more blood!” the anesthesiologist yelled.

  Eli glanced at the monitor. The pressure of fifty-seven had been replaced with a big, red zero.

  “Pack him,” Eli said.

  One by one, Eli and Susan submerged thick absorbent towels into the abdomen like a load of clothes into a washing machine.

  “Damage control,” Eli said
, referring to a series of maneuvers to control bleeding by packing towels around the lacerated organs, resuscitating the patient in the ICU, and returning to the OR twenty-four to forty-eight hours later to remove the packs and repair the injuries.

  A good plan if the patient survives the first few hours.

  After packing the cavity with towels, many of which had to be replaced as they floated out on hemorrhagic waves, Eli and Susan pressed hard against the abdominal wall as if packing overstuffed luggage, paradoxically recreating the tamponade they had so effectively released.

  It worked. At least temporarily. Scott Tynes’s blood pressure increased to fifty-one. Still life-threateningly low, but at least his heart had started pumping again.

  “Let me catch up,” the anesthesiologist demanded as he hung another unit of blood along with components to replace diluted clotting factors.

  Eli looked at Susan. Both were breathing hard as if they had held their breath for the last five minutes.

  “You know his brain is squash,” Susan said. She was referring to her neuro exam when the patient arrived. On the Glascow coma score, any number less than eight predicted a negligible chance at recovery. “He had no eye opening, no verbal response, but he withdrew to pain,” she said. “That makes his Glascow a six.”

  It was tempting to become fatalistic in this situation, saving a body only to support a devastated brain. But even the best set of predictors could be wrong.Especially in this sixteen-year-old with a full life ahead. It was times like this that Eli had to believe that hovering above their tired, blood-stained hands, an infinite force held the destiny of Scott Tynes. And it was Eli’s responsibility to keep the team moving toward that destiny, whatever it might be.

  “We’re going to take out his spleen, pack his liver, and get him to the ICU,” Eli told Susan. “You with me?”

  To pull off an operative feat like this, Eli needed unflappable cooperation from the entire team. He conversed briefly with the anesthesiologist about the plan, then glanced at Landers. It was during a very similar life-or-death trauma case that Eli had decided, as a medical student, to become a surgeon.