Mercy (8 page)

Sweat dotted Julie’s forehead. Heat rose through her body. The ambulance was cramped, cacophonous, and the constant movement kept her off-kilter.

Think … get your head around this … what could it be?

“Dr. Devereux! We need to code him. NOW!”

The accelerated beeping and increased volume of Sam’s many monitors had reached a fevered pitch. Julie did not react impulsively. Her brain worked lightning-fast to weigh the probability of one condition over another.

What about a sternal fracture?
Julie thought. It was an uncommon injury, but one linked to trauma. The breastbone sat in front of the heart and great vessels. A hard enough blow to the chest could push the bone into the thoracic cavity, blocking blood flow to the heart from the head and arms. If that were the case, there was nothing Julie could do from the back of an ambulance.

A voice whispered in the back of Julie’s mind, telling her to focus on CPR and get Sam to the hospital.

But something—instinct, experience, fear—told her to wait.

Two paths. Did he need CPR or something else? Choose wrong, and he could die.

“Heart rate two oh five. He still has no pulse. We’re going to lose him, Dr. Devereux, if we don’t start CPR now!”

Julie looked down at Sam’s lifeless face. The serenity of his expression unsettled her to the core. He looked so at peace, almost unbroken, except for those veins. Those damn veins.

And that’s when Julie knew the answer.

“I need a needle, stat!”

“A needle? What for?”

“Just get it, dammit!” Julie barked out the words.

“What size?” Ashley asked.

Julie’s brown eyes flared like embers from a fire. “The biggest one you got.”

There was some fumbling before Ashley procured a forty-five-millimeter long, fifteen-gauge needle capable of piercing bone. She handed it to Julie. The IO needle, used in intraosseous infusions, was typically inserted into the shinbone. The needle’s large bore allowed for huge volumes of intravenous fluids to be pumped into a patient through the rich network of vessels in the marrow space. But this was not about getting fluid in. It was about getting it out.

“Heart rate is still two oh five,” Ashley announced.

Julie tightened her jaw and nodded that she understood.

If Julie did not do what had to be done, right here, right now, Sam would die before they reached the hospital.

She set the needle against the skin below Sam’s ribs, just to the right of the little key-shaped bone that hung off the bottom of the sternum. Julie did not waste time cleaning the area with Betadine or isopropyl alcohol. If Sam got an infection, at least he would be alive to endure it.

Ashley looked deeply troubled. “Dr. Devereux, what exactly are you doing?”

The constant motion of the ambulance made it difficult to hold the needle in the proper place. The screech of the siren pounded at Julie’s eardrums.

“He’s bleeding into the pericardial sac surrounding the heart,” Julie said. “It’s compressing his atrium and backing the blood up into his veins.”

Being an experienced paramedic, Ashley understood right away what Julie planned to do.

“You’re going to perform a pericardial tap? Here? Now?”

“He’s got cardiac tamponade. If I don’t do it, he’ll die.”

There was no real test for cardiac tamponade, though echocardiography had improved the diagnosis considerably. A process of elimination and a gut feeling had brought Julie to this moment.

The needle trembled ever so slightly in Julie’s typically steady hand. Fear was foreign to her when it came to performing life-saving medical procedures, but Ashley was right to be concerned. In terms of risky maneuvers, this one, under these conditions, ranked near to the top. Sam should be in the ICU. He should be given more oxygen, plasma volume expansion with an infusion of blood or dextran. To do this properly, Julie should take between twenty minutes and an hour. Now, she had but seconds.

Most of the color had drained from Ashley’s face. “We’re not authorized to perform this procedure,” she said.

“Yeah, well, I am.”

The needle was attached to a plastic grip that fit comfortably in Julie’s hand. Julie’s fingertips rested at the tip of the needle, increasing her dexterity and control. She inhaled deeply and exhaled through her nose.

You can do this … for Sam … you can do this …

Julie twisted the needle back and forth and pushed hard enough to puncture the skin. A trickle of blood oozed out from tiny gaps around the circumference of the needle. Julie took in another readying breath and visualized the anatomy. If she didn’t get this right, the needle could puncture the heart or liver, or collapse a lung.

“Bill, pull to the side of the road!” Ashley called out.

“No! Keep driving! I’ve got this.”

“What do you want me to do?” asked Bill, who took his orders from Ashley.

Ashley locked eyes with Julie. “Keep going,” Ashley said.

In one quick thrust, Julie drove the needle up toward Sam’s left shoulder. But that was only step one.

“I need a syringe. Again, the biggest you’ve got.”

The syringe Ashley handed her—twenty milliliters, not quite the size Julie wanted—screwed onto the plastic grip. Julie released a flange, and built-up pressure in Sam’s pericardium pushed blood into the syringe at a rate much higher than Julie anticipated.

“I need another syringe, stat!” Julie yelled.

Blood quickly filled the syringe, but more was coming. Pressure steadily built up inside the syringe, and Ashley reached for a replacement. Too slow. With a popping noise, the plunger damming the blood shot from the syringe barrel like a bullet from a gun. A jet of dark blood exploded in a horizontal geyser that covered Julie’s face in red. Blood splattered on her clothes, her neck, face, and hair.

Ashley gasped in horror as Julie reached for the flange to shut off the blood flow. With the back of her hand, Julie smeared more of Sam’s blood across her face as she wiped her eyes clear. The coppery, metallic taste soiled her mouth and turned her stomach.

“Blood pressure is rising and I have a good pulse,” Ashley said, her voice calm in spite of all the blood. “Heart rate is coming down, too.”

“I need another syringe,” Julie said, breathless. A trickle of blood dripped off her chin and left dots on the floor by her feet.

“Heart rate is one oh six, one hundred … goodness, it’s down to ninety.”

Julie got the second syringe in place. This time, as she opened the flange to allow blood flow again, she kept her hand on the plunger to control the pressure. Blood filled the second syringe as well, but at a normal rate.

Julie used a towel to wipe some blood off her face. The ambulance smelled like a slaughterhouse as it rocketed through the darkening night.

Soon they reached White Memorial. The ambulance came to a hard stop and Ashley pushed the back doors open. The team waiting to receive Sam gasped at the ghoulish sight within. Sam’s blood had splattered the walls, floor, and equipment, and it covered Julie like a gory second skin.

“I did a pericardiocentesis en route,” Julie said to one of the doctors on the scene.

The doctor grimaced and returned a sympathetic look.

“The OR is prepped,” the doctor said. “We’re moving him to trauma first. We’ll take good care of him.”

Sam was wheeled through the emergency doors and whisked down a hallway, out of sight. Julie, alone, stood for a moment at the back of the ambulance. Then she sank to her knees and began to sob.

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?”