Authors: Daniel Palmer
Instead, Julie knelt beside the man she could hardly wait to marry, the man who made her heart swell with his kindness, and tried to comfort him as best she could. The helmet had safeguarded his head and face, but blood escaped from a grisly four-inch gash that had opened on Sam’s chin. His beard, flecked with debris, looked red.
The panic that had gripped Julie in those first terrifying moments gave way to a gut-wrenching awareness. This was happening. This was real. This
had
happened.
A circle of bystanders had formed around Julie and Sam, watching the gruesome scene with grave expressions. The spectators were visibly shaken. Some were crying. Some looked away as Sam emerged from the initial shock enough to feel the first pangs of real pain. He groaned and his mouth contorted into an agonized grimace.
“Sam, can you hear me? Can you say anything? Baby, please, say something if you can.”
Sam’s lips trembled. “It hurts,” he wheezed. “Oh God, this hurts. This hurts so much.”
Tears streamed down Julie’s face. “I’m sorry. Help is on the way. Wiggle your fingers if you can. Just a little wiggle.”
Nothing.
Off in the distance, Julie heard the first wail of sirens on fast approach. She saw the flashing lights, and soon the first responders were on the scene. She counted three police cars, two fire trucks, and two ambulances.
Julie stood, waving frantically. She got the attention of the lead ambulance driver, who made a hard stop not more than ten feet away. Two paramedics, dressed in blue uniforms with EMT badges sewn into the pockets of their shirts, latex gloves already donned, burst from the vehicle and raced to Sam’s side.
“I’m Dr. Julie Devereux,” Julie said in a breathless voice. “I work in critical care at White Memorial Hospital.” Julie got the names of the two EMTs. Bill was a thin man in his midtwenties with shaggy brown hair and deep-set eyes. Ashley, in her late thirties, was athletically built, with broad shoulders, strong legs, and muscular arms.
“Did you see the accident?” Bill asked.
Julie nodded. “Yes, we were riding together. The victim is my fiancé, Sam Talbot.” Julie had to look away until she steadied herself.
“His airway is clear,” she said, trying to find some authority in her voice. Julie did not hear any crackling, grating sounds of crepitus, indicating air had not penetrated the soft tissue. “No crepitus, but I’m fairly certain he has a flail chest on the left ribs seven, eight, and nine. Both carotid and radial pulses are present, but weak. I don’t think there’s bleeding in the abdomen, but I’m worried about hemorrhagic shock. I’m also concerned his jugular veins are distended. I checked for a pneumothorax, but he has good breath sounds.”
Bill and Ashley crouched next to Sam.
“Is his airway still clear?” Bill asked.
Ashley checked. “Yeah, he’s got a good airway. He’s breathing on his own.”
A firefighter wearing a brown turnout coat and pants with sewn-in yellow bands approached.
“Need any help?”
“Yeah, we need the backboard and a cot, please,” Ashley said. “Bill, can you take a look at his lower extremities? I need to get his helmet off to make sure he has a really good airway. Dr. Devereux, are you in a position to assist?”
Julie did not respond. Her focus had been entirely on Sam, who moaned and made a low gurgling sound.
“Dr. Devereux, can you assist?” Ashley asked again.
This time the question hit Julie like a slap.
Get with it!
“Yes, of course I can,” Julie said.
Ashley gave a nod and took her position in front of Sam’s head. Once there, she undid the strap to Sam’s helmet. Bill brought out strong scissors, capable of cutting through the leather of Sam’s motorcycle pants.
“Okay, straps off,” Ashley said. “I got c-spine.”
Ashley was stabilizing Sam’s cervical spine with a hand behind the head supporting the base of the skull, while her other hand held Sam’s chin firmly.
Julie got directly behind Sam and slowly, methodically, began to pull the helmet off Sam’s head. To do so, she maneuvered the helmet up and down, pulling with gentle force, careful not to catch the sides on his ears or snag his nose with the chinstrap. Ashley kept tension in her arms so that Sam’s head would not drop.
The moment the helmet came off, Sam let go with a deep, guttural noise that tore at Julie’s heart. She looked down and got her first good look at her fiancé’s face. It was the only part of him not horribly injured, though his grayish coloring was most unsettling. Julie’s chest grew tight. Ashley moved her hands up higher on Sam’s head to continue to support the c-spine.
“We got an open fracture in the left lower leg,” Bill announced.
Julie cringed.
“Bill, I need a blanket under Sam’s head right away. Please, quickly.”
Bill stopped cutting and did as he was instructed.
“Dr. Devereux, can you continue to take c-spine?” Ashley asked.
Ashley sounded so calm, so composed, the way Julie was accustomed to being.
“Of course,” Julie said, keeping her hands to the sides of Sam’s head.
With careful, practiced movements, Ashley unzipped Sam’s jacket and took scissors from a belt pouch to cut open his shirt.
“Trachea is midline, and those neck veins do look slightly engorged,” Ashley said.
“Slightly? Check again,” Julie said. “It’s more than that.”
Those veins were a symptom of something, but of what?
“Yeah, I agree,” said Ashley. “How’s your breathing, Sam?”
Sam groaned and made another noise that sounded barely human.
“Let’s get oxygen on him,” Ashley ordered. “I’m going to get two IV Lactated Ringer’s going.”
Sam needed a lot more than the fluid and electrolyte replenishment. Looking down at the pant leg Bill had cut away, Julie saw where the bone had sheared through the skin. It was a hideous, jagged cut, crisscrossed with strands of frayed muscle and ringed by clumps of fatty tissue. The bone poked out from the middle of a five-inch gash in the leg. It was barely a speck of white adrift in a sea of blood. The Lactated Ringer’s infusion would replenish electrolytes, but contained no antimicrobial agents. With such an open wound, Sam’s risk of infection had markedly increased.
Ashley set her hands on Sam’s bare chest, an area of his body spared major cuts and abrasions thanks to his protective gear. Along with providing oxygen flow and bleeding control, stabilizing any chest wall defect was a first priority.
Julie thought back to the accident. Had Sam hit the pickup’s side mirror? Did the motorcycle land on top of him? A crushing impact of either type could be devastating. Ashley listened with her stethoscope, and Julie resisted the urge to rip the instrument from her ears to give a listen for herself.
Time was of the essence. It had been five minutes or so since Ashley and crew had arrived on the scene. In five more minutes, they should be in transit. If Ashley or Bill detected any major issue in Sam’s ABCCs, it would be a load-and-go situation for certain.
“Can you tell me where you are hurting?” Ashley asked.
No response.
“Sam, can you wiggle your toes at all?”
Sam groaned incoherently.
Bill dressed the leg wound while Ashley got the portable oxygen unit running and the mask secured in place. All of the essential equipment was bagged and at the ready, saving valuable time that might have been wasted running back and forth to the ambulance.
Once the IVs were hooked up, Ashley undid the snaps of Sam’s pants and palpated his abdomen.
“Abdomen is soft. We need to get a c-collar on him, then we need to log roll.”
“What about those jugular veins?” Julie asked. “I’m really concerned.”
“Then the sooner we get him to the hospital, the better,” Ashley said.
Not just any hospital,
Julie thought.
Ashley got the plastic, bivalved shell secured in place around Sam’s neck while Julie continued to hold his head still. The entire process took less than a minute.
“Okay, are we ready to log roll?” Ashley asked.
Bill, having dressed the leg wound as best he could, nodded and took up position by Sam’s lower extremities. Ashley reached across Sam’s body so that she could get enough leverage to roll him onto his side.
“On my call, on three,” Ashley said. “One … two … three.”
Ashley and Bill pulled Sam onto his side, while Julie twisted her body to continue to support his head. As he rolled, Sam let out another loud groan. A firefighter tilted the cot and Ashley quickly inspected Sam’s posterior from head to toe before the backboard was brought up flush against his body.
“Lower on my count,” Ashley said. “One … two … three. Now we slide on three.”
Together they slid Sam onto the board. Ashley conducted another examination of the pelvis and lower extremities before the anti-shock garments, padded liners that could be inflated to protect the body during transport, were secured in place. Ashley removed Sam’s socks and shoes while Bill thoroughly assessed Sam’s body using inspection and palpation techniques. They checked his distal pulses once more as two firefighters secured the backboard straps around Sam at three points.
Everyone stayed in constant motion, and every action had a purpose, like a choreographed dance rehearsed thousands of times. Julie’s only job was to hold Sam’s head perfectly still until the blocks were put into place. It was the best job for her: her hands on him, touching him, comforting him.
“Sam, can you wiggle your toes or fingers for me?” Ashley asked.
He made no movement at all. Panic set in as Julie contemplated the extent of Sam’s injuries.
“Sam, we’re going to lift you now.” Whether he heard her or not, Ashley was going to give Sam the play-by-play. “You won’t fall, because you’re strapped in,” she said. “Okay, on my count of three we lift him onto the cot. Everyone got a good grip?”
Bill, Julie, and two firefighters nodded in unison. On three they lifted Sam onto a rolling stretcher. Additional straps were quickly secured around him.
As soon as Sam was loaded into the back of the ambulance, Julie pulled Ashley aside.
“I want to ride in the back with you,” she announced. “You’re going to need two people looking out for him during transport, anyway. And please—let’s bring him to White Memorial.”
Ashley did not look pleased with either request. “I have a third EMT who will ride with us. I’m sorry, but that’s our policy. And White Memorial is simply too far away.”
Julie’s eyes welled. White was smaller than some other Boston hospitals, but the trauma team was unsurpassed.
“Ashley, I’m begging you. It’s where he needs to be. We don’t have time to debate it. Please, just do it. You know it’s the right thing to do, and you know I can help.”
Bill had climbed into the back of the ambulance so he could assess and reassess Sam’s condition. He was looking for deformities, contusions, abrasions, and penetrating punctures, and constantly monitoring Sam’s vital signs.
“Hey, Ashley,” Bill called out. “I’m really worried about these distended jugular veins. This isn’t right. Yeah, it’s, uh … it’s not good at all.”
Ashley shot Julie a nervous glance.
“Climb in, Dr. Devereux,” Ashley said. “White Memorial, here we come.”
The dead can speak. It just takes time and patience to learn their language. Dr. Lucy Abruzzo had spent her career studying this language, and as White Memorial’s chief of pathology, she spoke it better than anyone on staff. These days, bureaucracy and administrative duties took precedence over the lab work that had fed her passion for years. Lucy’s personality was better suited to working with tissue samples and cadavers than to managing budgets, personalities, and cost structures. But hospital CEO Roman Janowski was not somebody you turned down twice.
As a manager, she remained somewhat of an enigma. A detached personality, someone a bit aloof, she was well suited to the autopsy table, but around a conference room table that personality could be off-putting. Lucy was an infrequent contributor to any pre-meeting banter. Most jokes and pop culture references were lost on her, as someone who did not own a television. Away from the lab, Lucy read nonfiction compulsively, ran for distance, loved chess, and enjoyed cooking, but only when following a recipe. Improvisation was for wilderness medicine.
It was common for Lucy to be so overscheduled with meetings that she never had time for any actual pathology. Weekends were different, though. Lucy used Sundays to catch up on paperwork and assist in the lab. Someone was always here doing something.
The moment Lucy set foot in the lab, a powerful scent hit her nostrils. Someone was testing stool samples, probably looking for a toxin. The pathology lab was always full of unusual smells, and Lucy found them all oddly pleasing. Dr. Becca Stinson, a fresh-faced second-year pathology resident, waved Lucy over to her workstation.
Some cases Lucy’s team managed were difficult to crack, while others were more straightforward. The pathology of the human body could be like the mystery novels Lucy once favored. Bodies had unreliable narrators, red herrings, good guys and villains, and answers that could be proved beyond a reasonable doubt using the right tools and investigative logic. The case Becca was working was evidently a tough one to solve.
Lucy pushed her shoulder-length brown hair away from her narrow face and put on her tortoiseshell glasses so she could read the case file Dr. Stinson handed her. It looked straightforward.
Becca, who trained at a CrossFit gym and discussed it incessantly, had about four inches and twenty pounds (all muscle) on Lucy, whose arms and neck were thin from years of running. Though she was petite, Lucy probably could have held her own in the CrossFit arena. Years of cutting ribs and sawing bones had built up a lot of strength in those delicate arms.
Lucy studied the file intently for several quiet moments, her focus unwavering, the noxious odor no longer even registering.
The doctor’s report was succinct, just the way Lucy liked it.
The patient, Cliff Anderson, seventy-seven, has experienced progressive cognitive decline and increased incidents of lethargy, depression, and memory troubles. The patient has presented with decreased motor function, as exhibited by multiple recent falls at home. Physical and neurological examinations were both unremarkable. CT and MRI scans of the head did not reveal significant acute pathology and the EEG was negative for seizure-like activity. Cerebral angiography also negative for abnormalities. Temporal artery biopsy ordered to rule out temporal arteritis.