Lewis Perdue - Perfect killer

"All of them. Standard procedure for a big trauma call like this."

"Cool." I looked over at Helen. "Can we get a quick CT on the way to the OR?"

"Sure we can," Helen said. "I'll get her prepped and up there in a jiffy." She nodded toward the other nurse and set about shaving the area around Lashonna's wounds and painting everything with Betadine. The ominous wounds stood out.

I pointed at the slug's entry wound, then looked at Tyrone. "The problem with a tangential wound penetrating the cranium is that a slug with enough momentum will follow the interior wall of the cranial cavity, orbiting around inside, doing more damage as it goes."

Tyrone made a tsking sound as Helen unlocked the gurney wheels and pushed it toward the doors.

"Yeah." Tyrone and I followed the gurney. "But as bad as that is, I suspect the blunt trauma will be the one to watch."

"Brad?"

I turned toward Jasmine. Is she going to make it?"

I hesitated. "I'll do my best. I'll know better after we get the CT." Jasmine nodded slowly as moisture gathered in her eyes.

I scurried to catch up with the gurney and followed it from CT scan to OR, where we first set about reversing the pyramidal depression above her eye.

"Okay, this is good," I said as I pulled the broken pieces of her cranium back from the wound. "See here: the dura is intact, and since the CT didn't show a significant herniation, we'll leave the skull pieces folded out and give the brain room to expand. Nothing more we can do for this wound but pray."

"Pray," Tyrone said. "That's a pretty odd thing for a surgeon to say."

I shrugged, then bent over to look closely at the bullet wound. I put my finger on the hole, then traced it back.

"Now, according to the CT, the slug'll be about here." I rested my index finger on Lashonna's shaved head. "Right here, a couple of centimeters down. We'll need to open her up along the entire path and debride the damaged tissue."

With Tyrone's assistance, I performed a circumferential craniotomy, which exposed a large, oval portion of Lashonna's brain along the bullets trajectory.

"To start with, remove all the debris you can find here"-I traced a gloved finger along the slug's trajectory-"pulpified brain tissue, bone fragments, clots, and other crap." I looked over at Helen. "I need to irrigate the missile track with saline, something that'll sustain a moderate pressure."

"Will a squeeze bottle do?"

I nodded as I bent over and began to clean up the wound with a pair of forceps. When nurse Helen returned with the plastic squeeze bottle, I showed Tyrone how to use it to rinse out tissue as I debrided it.

"We want to debride all the necrotic tissue as well as about a half centimeter of healthy tissue around it. A bullet can contuse a substantial area around the path, and while it may look normal to us now, it could deteriorate and leave us with a problem on our hands later."

We worked methodically toward the slug.

"It's awesome" Tyrone said as he looked down at the surface of the brain beneath our hands. The blood vessels pulsed. "I mean… this is her, what makes her who she is."

I nodded and tried to suppress a smile.

"Do you still feel that? That… awe?"

"Every time I open up a skull."

"It never gets routine?"

"Some people get blase about the time they start thinking they're God with a scalpel." I shook my head. "But it still gives me chills."

"No lie, man."

We worked silently for a long while. Gutting, trimming, washing, cleaning, as best our human hands could work, and yet at a cellular level, we were a crude, dull, chipped flint blade scraping through.

"How do you know what tissue not to take? How do you make sure you don't scrape away something she needs?"

"You don't. Just take all the dead stuff and a little around it. It's all you can do."

He paused to think for a moment. "You might be debriding a memory there, or the ability to do math or make an important decision."

"Right. Only sometimes I wonder if we're debriding the memory or just the ability to access it,"

"What's the difference?"

"No practical difference. That's why I told you there wouldn't be any magic here. We're like a couple of Neanderthals looking at the insides of a supercomputer. We can't directly repair any of the trillions of synapses or rewire any of the live neurons to bypass the ones we had to remove. Even if we magically saw the connections, we're still screwed because all the synapses and neuron patterns are different for everyone, the product of genes, environment, education, experience. There are an infinite number of possible connections among a trillion cells. Only an infinite intellect could possibly know all the infinite permutations and combinations."

"God?"

"I believe so."

"Caveman."

"Uh-huh."

We worked steadily to the end of the bullet track

"I need a pair of bayonet forceps, please."

Helen handed me the tool, and moments later I pulled the slug from Lashonna's brain. "We need to rinse and secure it for the police," I said. Helen held out a stainless steel kidney pan and I dropped it in and gave it a quick squirt from the saline bottle.

"We'll need a clear evidence trail, Helen. Let's make sure it doesn't leave your sight or mine until the police take possession."

We finished the debridement moments later.

"Okay, let's clean this up and cover the wounds with sterile dressings."

"You're going to leave the wounds open?" Tyrone asked.

"The brain is going to swell," I said. "If the tissue can expand out of the openings, there's less chance of intracranial pressure buildup." Tyrone nodded slowly. I looked at Helen.

"If we can't get a chopper, I think she should start to Jackson in an ambulance. One that can maintain a program of controlled hyperventilation to reduce the PaCO 2 to twentyfive to thirty torr. This should give us enough cerebral vasoconstriction to help reduce intracranial pressure. I'd also like you to start mannitol at half a gram per kilo and dexamethasone at point three. Make sure the ambulance crew has diazepam in case she has convulsions. Make up a couple of hypodermics for them ahead of time at point two grams per kilo."

"Right."

"Also, if you have fresh frozen plasma, send it along. It could help with thromboplastin releases."

"I'll check."

"Go ahead and do it now," I said. "We'll finish up while you handle the ambulance and the medications."

She headed for the door

"The bullet?" I asked after her. She stopped. "Why not take it down to the police when you go?"

She nodded, then retrieved the crumbled mass of lead from the pan, dried it out on her scrubs, then tucked it in her pocket.

As she pushed through the stainless-steel OR doors, I looked back down at Lashonna's brain and knew then that the shooting had not merely been another routine drive-by but had been designed to look like it.

I felt old and in desperate need of sleep by the time Tyrone and I finished with Lashonna. What little sleep I had snatched between connecting flights on the red-eye from Los Angeles hadn't done much to erase the deficit I had been running since the sinking of the Jambalaya. The wound to my ear was minor, but still it throbbed with every heartbeat, my lower back ached from standing over the operating table, and my feet slogged as if mired in the red, slickery goo of wet Yazoo clay.

Wordlessly, Tyrone and I ditched our gloves, masks, and splatter guards and followed Lashonna's gurney toward the ambulance dock. Outside, heat and humidity smothered us in a steaming blanket. Warm afternoon light painted the street with deep, oblique shadows. We crossed the concrete platform and made for the open doors of an ambulance, where Helen huddled with two EMTs.