Michael Palmer - Fatal

In the hospital, the anesthesiologists were the royalty of intubation, having honed their skills hundreds of times in the operating room. During one of his residency electives, Matt had chosen anesthesia and "tubed" dozens of cases under their guidance. Over the years that followed, he had multiple reasons to be grateful for every one of those opportunities. The main rule he had learned was that if the caregiver performing the procedure wasn't absolutely comfortable, physically and mentally, the chances of a failed intubation were greatly increased. The most common disasters were intubating the esophagus instead of the trachea, thereby filling the stomach with air; tearing the tissues of the throat and causing bleeding, which made subsequent attempts that much more difficult; damaging the vocal cords by forcing the tube down without adequate visualization; and finally, inserting the tube too deeply and occluding one of the two main bronchial tubes.

Matt now did what had been taught to him and what subsequently he had taught to many students and paramedics — he took an extra few seconds to position his new patient and compose himself before proceeding. With the woman on her back on the stretcher, he tilted her head slightly downward, straightening her neck. Gary Lydon knelt beside him to hold her head steady in that position. Physically settled on one knee, and as confident as he could be given the circumstances, Matt slid a curved, lighted laryngoscope blade along the woman's tongue and pulled the blade straight up toward her chin. All he could see was lake water, welling up from her lungs. Trouble — maybe big trouble. In the ER there would have been suction to clear her airway. Not here. A blind thrust with the semi-rigid tube was possible, but treacherous. Doing so had to be a last resort.

Easy, now, easy.

The woman's color remained poor. Brain cells were being compromised every second. Soon, they would begin to die.

Come on, Rutledge. Stay cool and don't panic. You can do this… You… can… do… this.

Matt took a deep, calming breath, grasped the handle of the scope tighter, and pulled the blade upward another eighth of an inch. The move nudged the victim's tongue out of the way even more and lifted her epiglottis — the flap that protected the lungs from aspirating food or drink. The slight adjustment caused the pool of water to recede just enough to expose the two silvery half-moons of her vocal cords.

Yes!

Matt smoothly slid the tube between the cords.

"We're in," he said, trying for some matter-of-factness but missing badly.

There was audible relief from both EMTs and the police.

"Nice going," one of them said.

Matt used a large syringe to blow up the balloon fixed around the end of the tube, sealing it in place and preventing air from escaping around it. Kirsten Langham quickly attached the black latex bag to the tube and connected it to oxygen. In seconds, the mottled duskiness of the woman's complexion began to improve. She was almost certainly going to make it. How much of her brain would make it, too, remained to be seen.

Matt handled the breathing bag as the troupe awkwardly retraced their steps, pushing the stretcher along the path back to the ambulance. While the woman was being lifted into the back, Matt took the two teens aside.

"You guys did one heck of a job. In all likelihood, you saved this woman's life."

"Lucky we was there," one of them said.

"I'll say. You're Harris?"

"I'm Michael. He's Harris."

"Got it. Two things. First, tell me again. You were fishing and she fell into the water right in front of you."

"Yes."

"And sank?"

"She might of stayed on the top for a second or two," Michael said, "but otherwise that's the way it happened. I got down ta her, but I couldn't get a grip afore I ran out of breath. Then we did it together an' brought her up by the hair."

Two minutes, minimum, Matt estimated again. Four maximum, depending on when they started breathing for her and how well they did it.

"And you did mouth-to-mouth?"

"Harris did. I screamed for help."

"Harris, did you hold her nose closed?"

"I did, sir. And I tipped her head back, too."

"Where did you learn how to do mouth-to-mouth?"

"They taught us in Health, sir. We used a dummy to practice."

"Well, we sure are glad you were paying attention in that class," Matt said. "Now, about those gunshots."

"They weren't shots," Michael said. "They were too soft. They were branches cracking, probably. Maybe a car backfirin' out ta the road."

"Were, too, gunshots," Harris insisted. "Michael, I'm telling you, pistols don't sound the same as backfirin'. There were two shots, maybe three."

"Ready," Gary called out from the rear of the ambulance. "Kirsten's going to bag her with you. I'll drive."

"You guys did great," Matt said again. "Lots of people, doctors included, sometimes think they saved someone's life, when the truth is, they might not have. Take it from me, you two really did it."

He jumped into the ambulance and waved to the boys as Gary closed the door. Then he took a seat on the bench opposite from the EMT and, for the first time, took a careful look at the woman who had come so close to dying beneath Niles Ledge.

She was still unconscious. The swelling above her left eye was pronounced and beginning to discolor. But to Matt's touch, there was no evidence for a depressed skull fracture beneath the bruise. The linear gouge above her right temple certainly could have been from a gunshot. There were also scratches on her cheeks and chin, similar to those Matt had sustained just half a day ago. It wasn't a stretch to imagine her terrified, charging through the dense woods with someone shooting at her.

He separated her eyelids and used his penlight to check her pupils' response to light again. This time the results were different.

"Pupils are both reacting," he announced to the EMT.

"Great," Kirsten said. "Her oxygen sat is ninety-seven."

"Decent enough. I can't say why, but she just doesn't seem that deep to me."

"I know what you mean. She's sort of begun chewing on the tube a little."

Matt brushed her sodden hair from her forehead. Her face, distorted some by the breathing tube, still had a peaceful, gentle quality to it — pale, unlined brow… high cheekbones… wide, almond-shaped eyes. He lifted her limp hand and set it on his. Her fingers were long and slender, nails cut short. If there was polish on them, it was clear. There was a gold claddagh friendship ring — two hands supporting a heart — on her right fourth finger, and a single gold bangle on her left wrist. No other jewelry. Her palms were soft without a hint of callus, but there was a fullness to the muscles. Matt imagined the hands playing piano or writing or throwing clay pots — something manual and artistic.

Come on, you, he urged silently, wake up!

The mobile MRI facility that served the region was currently in its two-month rotation at Hastings Hospital, twenty-five miles away. Montgomery County, though, did have a CT scanner, which for blunt head trauma was nearly as definitive. Matt radioed ahead and asked that the room be reserved in one hour. He also asked the nursing supervisor to call the Belinda Police Department and request that an officer come down to the ER to begin investigation of a possible shooting, and also to try and determine the identity of their patient. He wondered as he rang off whether or not the powers at BC amp;C had filed any complaint with the police against him.

Patient saved, doctor arrested.

The sort of news a small town loves.

The ER crew was waiting for them as they backed into the ambulance bay. For the next fifteen minutes, Matt was a secondary player. The nurses and respiratory technologist became the major caregivers while the phlebotomist from the lab and the tech from radiology spearheaded the gathering of diagnostic information. Their comatose Jane Doe was lifted from the stretcher to an ER bed, stripped down, and covered in a johnny and a sheet. Her IV and monitor lines were quickly transferred to hospital equipment. A catheter was placed in her bladder to keep close track of hydration and urinary output, and she was hooked up to a ventilator. Next, a portable chest X ray and skull film were taken.