Mercy

CHAPTER 11

Julie was a spectacle, a true sight to behold, on her march through the hospital waiting area to the ER trauma room. A boy in his basketball jersey, his wrist encased in a bag of ice, huddled close to his mother as Julie passed. A woman with a hacking cough stopped long enough to fix Julie with an open-mouthed stare. Another woman, baby clutched to her chest, turned away, but not before Julie caught her eye. How she must have appeared to them! Blood splatter across her face, in her hair, soiling her clothes. What had happened to this poor woman? Whatever scenarios they conjured, surely they were thankful for their own conditions over Julie’s.

Inside the ER, Julie drew more shocked looks from nurses and doctors who knew one of their own had been involved in a terrible accident. A nurse dressed in blue surgical scrubs, her long blond hair locked in a tight ponytail, came rushing over.

“Dr. Devereux, I heard. I’m so very sorry. Can I get you anything? I’ll grab you some scrubs to wear. You need something to drink. Some water?”

Julie nodded numbly. She did not know this nurse by name, but recognized her face.

“Where is he?” Julie asked. Her voice came out as a rasp, barely audible. Physically her body was inside the ER, but her thoughts were still on that bloodstained road, still in the ambulance.

“He’s in trauma room two over there,” the nurse said, pointing.

Julie handed the young woman her phone. “Please call my ex-husband, Paul Devereux. Tell him what happened. His number is in my contacts. Tell him where I am.”

The nurse took the phone and nodded. “Yes, of course. I’ll be right back with some clothes.”

Julie approached the trauma room with trepidation, heart pounding, arms dangling limp at her sides. The space, twice the size of a typical ER suite, was crowded with people from the rapidly assembled trauma team. She noted, with a huge sigh of relief, that Dr. Wendy Benton was among them. Dr. Benton, a highly skilled trauma surgeon, conducted her primary survey while the phlebotomist scoured Sam’s body for areas undamaged by impact so she could draw blood for labs. Had Sam not worn his helmet, the only people attending to him would be down in the hospital morgue.

At the foot of Sam’s bed stood Dr. James Gerber, a slender ER doc with silver hair whom many nurses considered to be among the very best of the staff. His voice was calm but commanding, bringing order to the chaos. The triage team worked independently yet functioned essentially as a single organism, with Dr. Gerber taking in all the information while he performed his own exam.

Sam had been transferred to a hospital bed, where he remained lashed to that board. The cervical collar and cushioned blocks were both still in place. From the head of the bed, a nurse, her identity concealed beneath a surgical mask and head covering, spoke in a loud, clear voice.

“Sam, can you hear me? Give my hand a squeeze. Can you wiggle your toes?”

The nurses had already dressed Sam’s palms in light gauze and were busy applying topical hemostatic agents using oxidized cellulose sponges to clean and sterilize some of the lesser cuts. Nearby, an intubation tray was prepped and ready with a complete set of endotracheal tubes, laryngoscope, and Magill forceps. Sam would be intubated before they moved him either to radiology for a CAT scan or to the OR for surgery. Two liters of normal saline hung from an IV tree and provided Sam with vital electrolytes as well as a source of water for hydration. EKG leads connected to the cardiac and hemodynamic monitors showed real-time vitals for his blood pressure, heart rate, rhythm, and oxygen saturation levels.

“02 SAT’s ninety-four percent on a non-rebreather,” a nurse called out to the medical scribe, who entered that information into a portable computer. “HR is one ten. Occasional PVC. BP measures ninety palp.”

The numbers were not horrible, and certainly a lot better since Julie had drained Sam’s blood from the pericardial sac. A respiratory therapist pulled aside Sam’s oxygen mask to check his airway for soft-tissue laxity, tongue blockage, or potential hematoma from a swollen blood vessel. Julie knew the process, as she’d done it countless times herself.

“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.