Critical Judgment (1996) (18 page)

“Keep the saline running at five hundred. Routine labs and clotting studies. Type and cross-match for five units. Have X ray do a shoot-through and lateral of her neck. Clear those films with me before you do anything else. Then we’ll do portables of her chest and leg before we send her over for real films. Catheterize her bladder. Be sure ortho is on the way in, and be sure to check those foot pulses every minute.”

“Yes, Doctor.”

“Anything else anyone can think of? Good. Keep me posted.”

One down. Abby changed gloves and hurried over to the second woman, Katherine McNamara, who had already had her clothes cut away, and was covered with a sheet. Her head was swathed in gauze, which was becoming bloody over her right eye. Like Rebecca Mason, her neck was in a hard cervical collar, and her head was secured to the body-length fracture board. The nurse, whom Abby recognized from the floor, gave a quick report. Lacerations on her back that no one had gotten a good look at because of the need to protect her neck, and a deep gash on her forehead. Otherwise nothing obvious.

Abby knew that from here on she had to prioritize the treatment of each case relative to the others. This was triage, the ongoing process of evaluating multiple patients with illness or injuries to ensure that sicker patients would be seen first. The idea was to get the maximum benefit from the personnel and facilities available. But in disasters such as this one, another wrinkle was added. Treatment had to be given first to those who needed it to survive, and not to those who had no chance regardless of the efforts of the caregivers. If that situation did arise, the call would be hers.

Abby’s assessment of Katherine McNamara put her on a lower priority level than the first. No triage problems
so far. Of the two Rebecca Mason would go to X ray first and would be cross-matched for blood first. Mary Wilder hurried over just as Abby was finishing issuing orders.

“They’re four minutes out with the next one, a forty-one-year-old male. Priority one. Barely conscious, hypotensive, multiple trauma.”

“Another tennis player?”

Mary shook her head.

“No, this one’s the driver. The one responsible for all this.”

“Put him in the trauma room,” Abby said. “And, Mary?”

“Yes.”

“Let’s all do our best to stay as objective and professional as possible.”

The older woman’s glare quickly softened.

“I’ll try,” she said. “But I know both of these women, and I know the one who’s still out there, too.”

“What have they reported about her?”

“Her name’s Peggy Wheaton. Multiple trauma. She’s unconscious. Her husband, Gary, is the president of the Patience Savings Bank. They have three kids.”

Despite Abby’s plea the nurse failed to mask the judgment in her voice.

“Get together the team assigned to this man. Then have another one ready when Peggy Wheaton arrives.”

She stood on her tiptoes and scanned the ER, which was in barely controlled chaos. Several police officers were there now, along with the paramedics, technicians, nurses, and even two people from housekeeping—one of the downsides of calling a disaster drill. Abby motioned one of the policemen over and asked him to be sure that anyone not essential to the care of the patients be sent to the waiting room. Then, across the ER, she spotted the first doctor to arrive, a competent young pediatrician named Susan Torrance.

“Tell me what to do,” Torrance said.

“Become an orthopedist.”

“I wish.”

“Any problem suturing?”

“None.”

Sirens again. The first priority one. Abby directed Susan Torrance to do a detailed examination of Katherine McNamara but to be sure neck films had been cleared by Abby or a radiologist before moving the woman.

Abby gloved again and headed out to the ambulance bay.

“Where are all the doctors?” she asked Mary Wilder.

Everyone, whether on call or not, was part of the telephone pyramid and was expected to drop whatever he or she was doing and get into the hospital.

“I think a lot of them are away on vacation or at meetings. The telephone system breaks down some when too many people aren’t home. They’ll be in, though. I promise. Meanwhile, you’re doing just fine.”

Abby managed a tense smile.

“Thanks,” she said.

“Here they come.”

With another police cruiser whooping along ahead of it, the ambulance swung onto the long drive up to the ER. Abby moistened her lips and rhythmically tightened, then loosened, her fists. Priority-one trauma. At St. John’s, since her residency, she had always been a relatively small part of the team evaluating and treating such patients. During her residency she had trained in all aspects of trauma technique, usually working on anesthetized sheep. And at one time or another she had performed many of the techniques on patients. But after she had joined the faculty, there had always been residents about, anxious to hone their skills, and staff surgeons available to oversee and teach them. Now it was just Abby.

The police officers, two of them, hurried in first.

“He’s under arrest for attempted murder, Doc,” one
of them said. “Just keep us posted with what’s going on.”

“Exactly what happened?”

“He hauled himself off the road at a high rate of speed, drove up a little hill, and crashed through a fence onto the tennis court. Slammed through these poor girls like a bowling ball, then slammed into the steel light stanchion. Crazy idiot was wearing a Marine uniform. He’s no more a Marine than I am.”

“Was he conscious? I mean, did he pass out at the wheel with his foot jammed on the accelerator?”

“Hell, no. Two people heard him yellin’ and singin’ before he hit the fence.”

“Okay. Thank you. Mary, here we go.”

The litter was raced out of the ambulance, right past Abby and into the ER. She hurried in behind it. All she had seen was a man, covered with blood and glass fragments. He was moaning and struggling against the restraints that held him to the fracture board. His neck was in a soft cervical collar, not the sort of rigid collar that had been secured on the first two victims. Had the rescue squad run out of rigid collars? Or had someone already placed a value on the man’s survival?

The fracture board was lifted onto the hospital gurney. Abby stood back for a few seconds as the nurses cut away what clothes they could. Then she took a towel to brush away glass and moved to the bedside.

“Pressure’s seventy,” a nurse said.

“Wet a towel and hand it to me, please,” Abby said. She swept aside some of the glass stuck to the blood on the man’s face and caught in the corners of his eyelids. When time permitted, they would use inverted loops of tape to remove the fragments. Right now there was more important business at hand. “Open that IV wide and get me set up to put in an internal jugular line.”

“Right away.”

“My eye,” the man moaned. “There’s something in my eye.”

“Well get to it, sir. Just try to hold still.”

Abby began her primary assessment. His respirations were shallow and grunting. There was a gauze pad taped to his chest, beneath his right nipple. Abby removed it, revealing a jagged gash. There was no air movement in his right lung.

“Get me a chest tube setup, please,” Abby said, pressing the gauze back over the wound.

The lung had been punctured and had collapsed. Each time the man breathed, air was going straight through the bronchial tubes and into the right chest cavity. The increasing pressure from that side was making it impossible for the left lung to get enough air. That mounting pressure had to be released, and the right lung had to be reexpanded.

Abby wiped off the blood from the man’s face to assess his color. There were a number of scrapes and shallow cuts, but nothing that would compromise his upper airway.

“Help me,” he moaned. “Please help me.”

Abby stared down at him.

“Mary, I know this man,” she said suddenly. “I saw him at the Colstar picnic. His name is Willie Cardoza.”

“T
hey’re two minutes out with Peggy,” Mary Wilder said as she wheeled in a cart with the equipment to insert a chest tube into Willie Cardoza. “Still no change. Vital signs are stable. She’s breathing on her own, but she’s not conscious.”

“Okay. Get everyone ready. Right now I’ve got to get this line in, then the chest tube. I’m very concerned about this man.”

Mary’s expression left no doubt which patient
she
was concerned about.

Cardoza’s condition was deteriorating. In addition to the collapsed lung, he almost certainly was bleeding internally. His blood pressure was barely discernible, and his consciousness was fading. Abby found no fracture in a lateral X ray of his neck, and removed the soft collar. Several other views in addition to the lateral would have been more reassuring, but there simply wasn’t time. She numbed up a spot just to one side of his larynx. In trauma victims large-bore IV lines were critical for the rapid infusion of fluid and blood. Like most ER physicians, Abby was highly skilled at getting them in, either by way of the “blind” subclavian stick she had used to insert the pacemaker in Hazel Cookman, or by a “blind”
stick into the internal jugular vein, which she was preparing to do now.

“Any more doctors?” she asked.

“Dr. Cohen just got here,” Mary said. “The two in the OR will be done in ten minutes.”

Les Cohen, an older GP, would be better than nothing, but just barely.

Abby felt for landmarks in Cardoza’s neck and found the spots she wanted. She then inserted the large needle, keeping suction on the attached syringe so she would know the instant she was in the vein and could avoid pushing through it. The path was inward and slightly downward, toward the hollow just above his breastbone. After three quarters of an inch, blood shot up into the syringe.
Bull’s-eye!
She detached the syringe, threaded a polystyrene catheter through the needle, and quickly sutured it in place. Central line in. One less thing to worry about.

“What about the other ER docs?” she asked.

“Dr. Bogarsky’s your ER backup. He’s on the way in, but he lives in Millerton. I don’t think they’ve been able to reach the Andersons or Dr. McCabe. Dr. Alvarez is working until eight tonight at the state hospital in Caledonia.”

“How about a surgeon?”

“Dr. Bartholomew’s on. He’ll be here in ten minutes.”

“Tell Dr. Cohen to take over on the lady with the fracture. Have him give her some IV antibiotic. Make it a gram of Unisyn. She’ll be pre-op as soon as orthopedics gets here, but this guy’s almost certainly going to have to go to the OR first.”

“And we don’t know about Peggy yet,” the nurse reminded her.

“Dr. Dolan,” another nurse called from the doorway, “they’re here. They’re wheeling Mrs. Wheaton into the trauma room now.”

“Damn,” Abby muttered. “Pressure, please?”

“Still seventy.”

Cardoza was no longer conscious. His color was poor and his respirations labored. In addition to the chest tube, he needed to have a line placed in the artery at his wrist to monitor his blood pressure continuously, and an irrigation tube inserted into his abdomen to check for internal bleeding. A blood return from that abdominal lavage tube, and he would need to be taken quickly to the OR for exploration.

For Cardoza alone she desperately needed at least one other pair of surgically skilled hands. What she had instead was another priority-one patient to evaluate.

“I’ve got to get this chest tube in before I can leave him,” she said.

“Dr. Dolan,” Mary Wilder said, “it’s Peggy Wheaton. Go ahead in there. We’ll keep an eye on things here.”

Abby felt a spark of irritation.

This is hard enough!
she wanted to scream.
For God’s sake, don’t make it worse!

Quickly, she composed herself.

“Mary,” Abby said evenly, “I’ll be in there as soon as this tube is in. Meanwhile, please send Dr. Torrance in to evaluate her.”

“But she’s a pediatrician.”

“She’s also a doctor,” Abby said, no longer able to cull the impatience from her voice. “Now, I’ve got to get this tube in.”

The nurse glared at her and then stormed off. Abby was aware of an immediate coolness from the staff remaining in the room. But there was nothing she could do. Without the emergency procedure Willie Cardoza would be dead within a few minutes. She was his doctor, not his judge.

Working now in total, icy silence, she made a slit with a scalpel in a spot between two of Cardoza’s ribs. Then she snapped the flexible rubber chest tube tightly into the tip of a heavy hemostat. With all her strength she jammed the tube and hemostat tip through the slit,
worked it beneath a rib, and then popped it through the chest-wall muscle into the empty space where the lung had been. There was a hiss of escaping air as the dangerous pressure was released.

“Hook this up to the suction/drainage system, please,” she said to the two nurses as she sutured the tube in place. “Pressure, please.”

“Eighty, Doctor.” Almost reluctantly, the nurse added, “It’s a little easier to hear.”

Cardoza’s color improved instantly, although it was far from satisfactory. The circulation to his head improved as well. He began moaning once again and making purposeful movements.

“I’ll be needing a setup for an arterial line, and also one for an abdominal lavage. I’m going to check on things in the next room. Then I’ll be back.”

“How’s it going in there, Doc?” asked the policeman standing guard outside the door.

“I don’t think he’s going to escape,” she replied, rushing past him.

The moment she entered the trauma room, she did not like what she saw. Peggy Wheaton lay motionless on the gurney, her eyes closed, her breathing somewhat labored. A solid cervical collar was in place. Her tennis dress had been cut away, revealing an athlete’s body with no hint of having carried and delivered three babies. There was a gauze bandage around her head, with blood soaking through the back left side. Her feet and hands were turned slightly inward. Their variation from normal position was minimal and might have no significance. But Abby sensed it meant serious head injury.