Tess Gerritsen: Gravity

The siren cut off with a whoop as the ambulance swung up the ramp and backed up to the dock. Jack yanked open the rear door and got his first glimpse of the patient -- a young woman, head and neck immobilized in a cervical collar, her blond hair matted with blood. As they pulled her out of the ambulance and he got a closer look at her face, Jack felt the sudden chill of recognition.

"Debbie," he said.

She looked up at him, her gaze unfocused, and did not seem to know who he was.

"It's Jack McCallum," he said.

"Oh. Jack." She closed her eyes and groaned. "My head hurts."

He gave her a comforting pat on the shoulder. "We'll take good care of you, sweetheart. Don't worry about a thing." They wheeled her through the ER doors, toward the trauma room.

"You know her?" Anna asked him.

"Her husband's Bill Haning. The astronaut."

"You mean one of the guys up on the space station?" Anna laughed. "Now, there's a long distance phone call."

"It's no problem reaching him, if we have to. JSC can put a call right through."

"You want me to take this patient?" It was a reasonable question to ask.

Doctors usually avoided treating friends and family, you cannot remain objective when the patient in cardiac arrest on the table is someone you know and like. Although he and Debbie had once attended the same social functions, Jack considered her merely an acquaintance, not a friend, and he felt comfortable acting as her physician.

"I'll take her," he said, and followed the gurney into the trauma room.

His mind was already leaping ahead to what needed to be done. Her only visible injury was the scalp laceration, but since she had clearly suffered trauma to her head, he had to rule out fractures of the skull and cervical spine.

As the nurses drew blood for labs and gently pulled off the rest of Debbie's clothing, the ambulance attendant gave Jack a quick history.

"She was about the fifth car in the pileup. Far as we could tell, she got rear-ended, her car spun sideways, and then she got hit again, on the driver's side. Door was caved in."

"Was she awake when you got to her?"

"She was unconscious for a few minutes. Woke up while we were putting in the IV. We got her spine immobilized right away. BP and heart rhythm have been stable. She's one of the lucky ones."

The attendant shook his head. "You should've seen the guy behind her." Jack moved to the gurney to examine the patient. Both of Debbie's pupils reacted to light, and her extraocular movements were normal. She knew her own name and where she was, but could not recall the date. Oriented only times two, he thought. It was enough to admit her, if only for overnight observation.

"Debbie, I'm going to send you for X rays," he said. "We need to make sure you haven't fractured anything." He looked at the nurse. "Stat CT, skull, and C-spine. And ... " He paused, listening.

Another ambulance siren was approaching.

"Get those films done," he ordered, and trotted back outside to the loading dock, where his staff had reassembled.

A second siren, fainter, had joined the first wail. Jack glanced at each other in alarm. Two ambulances on the way?

"It's going to be one of those days," he muttered.

"Trauma room cleared out?" asked Anna.

"Patient's on her way to X-ray." He stepped forward as the first ambulance backed up. The instant it rolled to a stop, he yanked open the door.

It was a man this time, middle-aged and overweight, his skin pale and clammy. Going into shock was Jack's first assessment, he saw no blood, no signs of injury.

"He was one of the fender benders," said the EMT as they wheeled the man into the treatment room. "Got chest pain when we pulled him out of his car. Rhythm's been stable, a little tachycardic, but no PVCS. Systolic's ninety. We gave morphine and nitro at the scene, and oxygen's going at six liters." Every one was right on the ball. While Anna took the history and physical, the nurses hooked up the cardiac leads. An EKG blipped out of the machine. Jack tore off the sheet and focused on the ST elevations in leads V1 and V2.

"Anterior MI," he said to Anna.

She nodded. "I figured he was a tpa special."

A nurse called through the doorway, "The other ambulance is here!" Jack and two nurses ran outside.

A young woman was screaming and writhing on the stretcher.

Jack took one look at her shortened right leg, the foot rotated almost completely sideways, and knew this patient was going straight to surgery. Jack quickly cut away her clothes, to reveal impacted hip fracture, her thigh bone rammed into the socket by the force of her knees hitting the car's dashboard. Just looking her grotesquely deformed leg made him queasy.

"Morphine?" the nurse asked.

He nodded. "Give her as much as she needs. She's in a world of hurt. Type and cross six units. And get an orthopod in here as as -- "

"Dr. McCallum, stat, X-ray. Dr. McCallum, stat, X-ray." Jack glanced up in alarm. Debbie Haning He ran out of the room.

He found Debbie lying on the X-ray table, hovered over by the ER nurse and the technician.

"We'd just finished doing the spine and skull films," said the tech, "and we couldn't wake her up. She doesn't even respond to pain."

"How long's she been out?"

"I don't know. She was lying on the table ten, fifteen minutes before we noticed she wasn't talking to us anymore."

"Did you get the CT scan done?"

"Computer's down. It should be up and running in a few hours." Jack flashed a penlight in Debbie's eyes and felt his stomach go into a sickening free fall. Her left pupil was dilated and unreactive.

"Show me the films," he said.

"C-spine's already up on the light box." Jack swiftly moved into the next room and eyed the X rays clipped to the backlit viewing box. He saw no fractures on the films, her cervical spine was stable. He yanked down the neck and replaced them with the skull X rays. At first glance he saw nothing immediately obvious. Then his gaze focused on an almost imperceptible line tracing across the left temporal bone. It was subtle it looked like a pin scratch on the film. A fracture.

Had the fracture torn the left middle meningeal artery? That would cause bleeding inside her cranium. As the blood accumulated and pressure built up, the brain would be squeezed. It explained rapid deterioration of her mental status and the blown pupil.

The blood had to be drained at once.

"Get her back to ER!" he said.

Within seconds they had Debbie strapped to the gurney and were wheeling her at a run down the hallway. As they swung her into an empty treatment room, he yelled to the clerk, "Page neurosurgery stat! Tell them we have an epidural bleed, and we're prepping for emergency burr holes." He knew what Debbie really needed was the operating room, but her condition was deteriorating so quickly they had no time to wait. The treatment room would have to serve as their OR. They slid her onto the table and attached a tangle of EKG leads to her chest. Her breathing had turned erratic, it was time to intubate.

He had just torn open the package containing the endotracheal tube when a nurse said, "She's stopped breathing!" He slipped the laryngoscope into Debbie's throat. Seconds later, the ET tube was in place and oxygen was being bagged into her lungs.

A nurse plugged in the electric shaver. Debbie's blond hair began to fall to the floor in silky clumps, exposing the scalp.

The clerk poked her head in the room. "Neurosurgeon's stuck in traffic! He can't get here for at least another hour."

"Then get someone else!"

"They're all at Texas Med! They've got all the head injuries." Jesus, we're screwed, thought Jack, looking down at Debbie.

Every minute that went by, the pressure inside her skull was building. Brain cells were dying. If this was my wife, I wouldn't wait.