Michael Palmer: Extreme Measures

The image of the emergency room as a feudal castle under siege had first arisen in Eric's mind during his second year of residency, and had grown in complexity and color over the two years that followed.

The technicians-E.K.G, respiratory, and laboratory-had become the support troops and intelligence agents, gathering information and transporting arms and other gear to the militia, the nurses. The interns and junior residents were the officers-the lieutenants and captains.

And above them all, watching more than doing-waiting for the moment when the encounter with death hung on a single major decision, on one brilliant tactic-stood the lord of the castle, the trauma team leader.

Over the years of his apprenticeship at White Memorial, Eric had driven himself to the limit with thoughts of the day when he would hold that position.

Now, six months into his tenure as one of the two chief residents on the emergency service, he drove himself even harder.

He had grown up in Watertown, not ten miles from the hospital, and was the first in his family even to attend college, let alone graduate school. He had started way at the back of the pack, but after eight years of schooling, every one of them as a full scholarship student, and five more years of the most grueling residency, he was finally beginning to make his mark. And Reed Marshall, the other chief resident, notwithstanding, there were those who now regarded Eric as perhaps the best that White Memorial had ever trained-the best in a hospital that had spawned 150 years of the finest physicians anywhere.

Tern Dillard, the charge nurse on the shift, finished issuing a set of orders to her staff and then spotted Eric.

"We're set for him in Four," she said, crossing to him "I told you we'd get one today," he responded, smiling. "I want the crowd in there kept to a minimum, Tern, okay? Have Dierking get in a CVP line and handle the peritoneal lavage. I don't want the other two yet, and I don't want to have to worry. June Feldman can meet the chopper and do the intubation if necessary. What did they say the guy's pressure was?"

"Seventy."

"Hmmm Eric stroked the mustache he had grown and shaved off half a dozen times in the past three years.

He had no particular desire to have one, but there were times when he felt his authority was compromised by his looking years younger than his age, which on that day was a month shy of thirty-one.

"What are you thinking about?" Tern Dillard asked.

"Your eyes," he said absently.

"I wish."

It would be a surprise, she was thinking, if Eric Najarian ever thought about much of anything except medicine. During her nearly ten years as an E.R. nurse, she had seen all manner of residents come and go-flakes and philosophers; insecure jerks who needed to verbally abuse nurses; brilliant thinkers who came unglued at crunch time; soft-spoken young women to whom she would not hesitate to entrust her life. But this man was one of a kind. When he wasn't working killer shifts in the E.R he was in the library or the lab. If the E.R. was backed up at the end of his shift, he would pitch in and play intern for as many hours as it took to catch up.

As a physician, Reed Marshall was good, very good; but he seldom stepped down from the pedestal of his position-seldom got "dirty." Eric was a barroom brawler. And although Tern knew nurses who had dated Eric, and even slept with him, she knew of none who had been able to compete with medicine as the love in his life.

"why's he in shock?" Eric muttered, asking the question primarily of himself. "A spleen? A river?"

"Aortic tear?" tern ventured.

"Maybe…" His voice drifted off. "It's in his chest," he said suddenly.

"How could you know that?"

"I don't know it. I just feel it. God, I'd love to know what the steering wheel of that car looked like…

"The steering wheel?"

"Listen, I want you to do me a favor. Call Dave Subarsky's lab, extension four-eight-one-one, and see if you can get hold of him.

Ask him to come down here right away, and tell him… Better still, just get him on the phone. I'll talk to him."

He raced off toward the radio. As Tern picked up the phone, she heard him raise the MedEvac helicopter and ask about the accident-particularly about seat belts and the condition of the steering wheel.

She knew from five years of watching him work, that with a Priority One just minutes away from arrival, Eric Najarian was operating in a zone few trauma specialists ever reached.

Within seconds of the MedEvac chopper's touchdown on the roof of the Richter Building, the battle was underway. June Feldman, the junior resident, began her evaluation on the way to the elevator and had her report ready for Eric by the time she and the rescue team exploded through the emergency room doors.

The prize at stake was the life of a man named Russell Cowley, the president of one of the region's larger high-tech firms. Eric's pulse had speeded up a notch at that news, This man's rescue and subsequent resurrection would be the stuff of front-page headlines.

According to the MedEvac crew, Cowley had been speeding north on the interstate, seat belt in place, when the right front tire of his Mercedes 450SL had blown. The car had careened through a snowbank and then the guardrail, sailed nearly fifty yards over an embankment, and then crashed into the base of a tree. The jaws of life had been needed to extricate him from the wreck. The steering wheel, bent almost in half, had pinned him to his seat.

"Cowley… Russell Cowley," one of the residents had mused as they were awaiting the chopper. "I could swear he's a trustee of this place.

In fact, I'm sure of it." Eric had taken in the information without reaction, but the look in his eyes grew even more intense.

With Craig Norrell's abrupt dismissal and subsequent disappearance, the position of associate director of emergency services had suddenly come open. And everyone from the secretaries on up knew that only he and Reed Marshall were in the running for the job.

Now, with the search committee struggling for justification to choose one or the other of them, a trustee had been dropped in his lap.

You don't know it, Mr. Russell Cowley, he was thinking, but there is no way that you're going to die from this. Absolutely none.

The Corporate executive howled in pain as he was transferred to the hospital gurney. Crystals of windshield glass sparkled in his hair.

His face, beneath the smeared blood from several lacerations, was violet. He flailed his good arm and screamed again as a nurse inadvertently jostled his left leg. Gradually he drifted off, moaning softly, The orthopedic resident set about stabilizing the obvious fractures. Eric did a rapid exam and then stepped back. He had found nothing that argued against his notion that the impact of the steering wheel had bruised the man's heart, causing pericardial tamponade.

Blood was collecting between the cardiac muscle and the pericardial membrane that surrounded it. The mounting pressure of that hemorrhage was compromising the filling and pumping power of the heart, and causing progressive shock.

If that was in fact the case, then a pericardiocentesisrainage of the constricting blood-was in order. The standard procedure involved the insertion of an E.K.G-guided needle through the upper abdomen, just past the liver, then through the diaphragm, and finally through the pericardium-a tricky, potentially dangerous maneuver.

Eric had other plans. He glanced toward the 'doorway, wondering what was taking Dave Subarsky so damn long.

"Films first, films first," he said, forcing calm into his voice.

"I need a good lateral of his neck right away.

Have them shoot a chest and pelvis as well. June, I don't think he needs a tube yet, but he might. He looks like hell. What's his pressure?"