Authors: Neil McMahon
Monks said to him, “You’re in charge until one of us says different. Leah?”
She went into a rapid rundown of the incoming situation. Vernon set down the clipboard, his startled blue eyes widening further.
“The critical’s got trouble breathing and low blood pressure,” she said. “Gained twelve points with MAST suit inflation.” She stopped talking. Vernon’s gaze moved to Monks. Monks stared back impassively, arms folded.
Vernon was on rotation, had been in the ER
just two months, and had some experience handling trauma, but never anything like this. Monks could see the realization starting in his face that he was going to be literally holding a life in his hands with minutes or even seconds to save it, that a slip or hesitation could make the difference.
Monks said, “You don’t have to do this.”
Vernon’s shoulders shifted toward the wide glass double doors, where in approximately seven minutes an ambulance would arrive to unload its bloody cargo.
“I’ll do it.”
“Good. Think out loud.”
“I see two immediate problems.” Vernon spoke hesitantly, with the care of a schoolboy at the state spelling bee. “The critical’s losing blood fast. Maybe a clipped artery.”
“In his chest? Belly?”
“I’m guessing belly. If he had a chest cavity full of blood, there’d be other signs.”
“Second problem?”
“His breathing. Sounds like a lung’s been hit.”
Monks allowed him a nod. The MAST suit, Military Anti-Shock Trousers, compressed bleeding vessels and maximized circulation. The suit’s inflation had increased blood pressure, which probably meant a damaged artery; if it was in the chest, there would have been other signs, from hacking up great bloody gouts to immediate death.
“What about the other guy, the thigh wound?”
“He’s not critical. We make him comfortable and get to him later.”
“Go on.”
“You did a lot of this, didn’t you?” Vernon said. “Gunfire.” He pulled nervously on his large fingers.
Monks understood the unspoken plea for help and relented another notch. Guessing at the damage was one thing. Knowing where to start was another.
“I’d assume the blood loss is stabilized and worry instead about his breathing,” Monks said. “Ever done a chest rube?”
“Once, in dog lab.”
“Same procedure, Vernon,” Monks said kindly. “The stakes are higher. Mrs. Horvitz is waiting for orders. I’ll meet you in the trauma room in three minutes.”
Monks stayed long enough to hear Vernon’s hurried instructions to Leah—bring in lab and X-ray, alert the OR, full cart in the trauma room with all personnel standing by. Then Monks walked through the ER, the kind of one-minute scan that told him without conscious thought most of what was going on: which cubicles were open and closed, patients’ appearances, positions of the nurses, whether clipboards on the desk had blank charts or lab results and EKGs. His ears picked up a bedside pump measuring medication into an IV, a child’s cry, the hiss of an automatic blood pressure cuff. The room was stirring in an
imperceptibly different way now. Staff were moving with the kind of hushed speed used around patients who were already scared and about to be a lot more so.
Monks stepped into the trauma room. The cart was already there, brought by a nurse who was young and relatively new to the unit: Jackie, he recalled. It took him a moment to supply the last name: Lukas. She was lean-faced, with sandy-hair pulled back in a ponytail; not pretty, but attractive in an athletic sort of way. She smiled nervously and murmured a greeting. He had worked directly with her only a few times, and not in crisis. There was no telling how she would hold up. With Vernon, that made two unknowns. Monks decided to make sure Leah Horvitz was nearby when the action started.
He glanced over the can’s equipment and adjusted the overhead light as he spoke.
“Lay out a suture set and a couple of chest rubes, thirty-three French. Gowns, goggles, two pair of gloves apiece. Seven and a half for me. Dr. Dickhaut’s are probably bigger.” He noted that she moved quickly and without questions, a good sign.
Vernon entered, and all three stepped into plastic barrier gowns, mandatory trauma apparel in the age of AIDS. Monks caught Vernon’s eye and held up a second pair of gloves. The trick was one a nervous resident might or might not remember. The outer pair could be stripped off
after the exterior body examination, leaving the inner gloves sterile for going in without pausing to reglove. It could save as much as twenty seconds. He stepped to the door and looked at the clock. It was 8:58. The ambulance was a minute late.
Then he caught the rumble of an approaching vehicle and backup beeper, quickly growing louder. As many times as he had heard it, it still brought a rush. There was no other sound quite like it.
Flashing lights moved in to sweep the room, pulsing reds and blues from the ambulance and squad cars. Personnel crowded through the door. Alarmed patients edged away, staring. Monks walked back to Vernon, who was standing still and pale, and gripped his upper arm hard.
“‘Gird up now thy loins like a man,’ “Monks said, “‘for I will demand of thee.’”
The critical came in fast on a gurney wheeled by paramedics, looking like a captured creature out of a science fiction movie: strapped with nylon webbing to a backboard, head taped down and neck pinned by a cervical collar, shirt ripped off his blood-soaked torso, the bright orange MAST pants ballooning around his body. Bags of saline fluid hooked to the gurneys rack dripped through IVs into each arm. He was moving feebly, blood bubbling between his lips. Vernon strode beside him, leaning over, fingers examining head and mouth.
“I’m a
doctor,
you understand me? You’re in a hospital, you’ve been
shot.”
The boy mumbled something. He was slight, olive-skinned, perhaps sixteen, with eyes like a scared fawn’s. Monks felt his professional insulation slipping.
The next gurney was trundling in now, flanked by three blue-uniformed SFPD cops. This boy was older, also strapped down, but struggling and panting. A field dressing covered his left leg from hip to knee. The bandage was blood-crusted, but with no sign of an open major vessel.
Monks called, “Five milligrams morphine, IV,” to a waiting nurse, dien pointed the gurney to the next cubicle.
“We’re gonna take
care
of you. Can you breathe, does it hurt?” Vernon was yelling now, leaning close to the first boy. No words came from the mouth: only a raspy unintelligible sound of forced air.
Vernon said, “Airway first.”
“Blood loss?”
“No exit wounds and no pumping bleeders. His heart’s probably not hit. We’ve got to trust the MAST suit and IVs.”
“Keep moving and keep talking.”
Vernon thrust his fingers into the open mouth, probing the upper throat. Sweat glistened on his forehead above his goggles.
“Airway’s clear. Let’s move him.”
The paramedics lifted the backboard onto the
trauma room’s stainless steel table. Vernon’s fingers traveled over the bloodcaked rib cage, searching for entrance wounds. They paused at a small hole above the right nipple. His hand went flat and moved around the chest, fingers of the other hand tapping its back.
“Right side’s hyperresonant. Percussion dullness of the heart has shifted left.”
“Check his larynx.”
Vernon’s fingers moved over it. When he looked up again, the respect in his eyes was evident.
“Displaced left,” he said. “I’d say we’ve got a tension pneumo.”
Monks had been reasonably sure of that from the paramedics’ description. He had seen a number of them, some from nine-millimeter rounds. Air escaped from a punctured lung and got trapped in the chest cavity, the wound sealed off by the pleural membrane. Pressure held that lung collapsed and useless, while the other functioned with difficulty.
“Proceed.”
Jackie said, “Anesthetic?” She was hanging right in there, Monks noted approvingly, hip to hip with Vernon.
Vernon hesitated, then said, “No time.”
Monks nodded once more, and Jackie took the chest tube from its sterile wrapping: eighteen inches of plastic one-half inch in diameter, to be pushed through an incision in the rib cage deep into the lung.
A commotion was rising outside, shouting voices coming closer. A blue uniform moved by fast. Monks stepped to the door. A small crowd had formed near the Nurses’ Station, the police facing off several young Hispanic men wearing baggy pants and baseball caps turned backward. Limbs flailed in hot gestures, and words flew in staccato street Spanish. He got a brief unsettling flash of being back in Saigon, surrounded by small intense people whose language and intentions he could not understand, except that they might at any second erupt into violence.
A clerk was talking rapidly on the phone, probably to security. Monks glanced back into the trauma room. Vernon was washing the boy’s chest with sterile prep solution. It would not be long now, and without anesthesia this was going to get loud. Monks strode to the nearest cop, a burly man with a deeply lined face and organ-grinder mustache. The cop’s name tag read SALVATORE. He nodded curtly to Monks, his angry gaze staying on one of the young men.
“Says he’s the kid’s brother,” Salvatore said.
“There’s a conference room off the main lobby,” Monks said. “Have them wait there, and tell them somebody will come talk to them in a few minutes.”
The brother’s glare shifted to Monks, and he postured, one shoulder thrust forward and other fist clenched. His hair was bristly on top and
slicked back on the sides, falling to his shoulders. He was not much over five feet tall.
“He dies, man, you going
with
him, motherfucker!”
Monks leaned close to his face.
“Your brother can’t breathe and his belly’s full of blood. You want to come help?”
He watched the eyes turn uncertain and saw through to the truth of it: this was a kid, too, and scared.
But a kid who had likely been pan of the incident, who might have pulled a trigger himself, who could threaten death with chilling ease. Monks’s own anger and fear bristled as he wheeled and stalked back.
He stepped into the trauma room in time to see Vernon making a scalpel incision low on the right armpit. With a quick glance at Monks, Vernon set aside the scalpel, chose a Kelly clamp, and eased it into the slit, twisting downward. Monks gripped his wrist, stopping him. An artery and nerve ran beneath each rib, vulnerable to the clamp’s sharp jaws.
“On
top
of the rib. The artery.”
Vernon closed his eyes in despair.
“Shake it off,” Monks said fiercely, fingers digging into Vernon’s wrist. “Come on, he’s dying.” Vernon inhaled, readjusted the clamp, then stopped again. His face was almost white. Monks counted, one, two, and just as he was about to
shove in and take over, Vernon found his nerve and thrust the clamp through the pleura.
The hiss of escaping air was drowned by the boy’s cry, a feeble shriek like the rending of rusted metal. His limbs thrashed against the webbing while Jackie held him down,—but he was breathing again. Vernon, still ashen-faced but now firm, probed the incision with his finger, then slowly introduced the tube into the heaving chest cavity in an obscene parody of sword-swallowing-It would be sewed into place and taped airtight, then attached to a water-seal mechanism to suck out the excess air and allow the lung to expand fully.
Monks glanced up and saw Charlie Kolb, a wiry man with the grim look trauma surgeons developed, standing at the door.
“The OR’s here,” Monks said to Vernon. “Blood pressure’s holding and he’s breathing. Get that tube hooked up and we’ll call him stable for now.”
Kolb was a compendium of nervous gestures, pulling at his ears and lips, running his hand over his thin hair as Monks briefed him. There remained the matter of at least three liters of lost blood, much of it probably sloshing around inside the belly. But the real danger would come with the MAST suit’s deflation; whatever damaged blood vessels it was compressing would open again rapidly.
“We’ll go into his belly now if you want,” Monks said. “Your call.”
“Let’s get him upstairs. We’ll try to clamp him off.”
Monks watched with a mixture of letdown and relief as the process of transfer began; the ER’s responsibility was ending, the OR’s beginning. Surgery was better equipped to handle it, but both of them understood that this was a bad situation for surprises.
The burly cop, Salvatore, was standing outside the next cubicle. One of his partners had moved to the ER entrance and stood with radio in hand, watching the parking lot.
“We think you just got cruised,” Salvatore said. “A car came around, bunch of kids; took off when they saw the units. Maybe the other gang, coming by to clean up.”
Automatic weaponfire in the ER, Monks thought. Their little hospital was growing up.
“Any idea who or what?”
Salvatore shrugged. “Turf war. The others were Asians. The way they do it now, they leave their wounded and take off; they know we’ll bring them to the hospital. Then both sides say it was a drive-by.” He nodded at the second boy, King strapped to his backboard. “We know these guys, they’re homeboys. The other kid’s an Esposito, with the mouthy brother. This one’s Vasquez, Rafael. Rafael ain’t talking, he’s a tough guy. Got to protect his good buddies that left him bleeding cm the sidewalk.”
This boy looked older, muscular but slack and
silent now from the morphine, or perhaps because the reality of the situation was starting to break through to him.
“Right, tough guy?” Salvatore said. “How old are you? I want to know, is it gonna be juvie hall or Q?”
The lips moved, a reflexive mutter Monks understood without hearing:
chinga tu madre.
Salvatore grimaced. “Truth is, he’ll be out in a few months. Big reputation and a scar to brag on.”
“Give me a minute with him,” Monks said, and stepped to the bedside. “The pain coming back?” Rafael Vasquez said nothing, but Monks saw the answer in the glazed defiance of his eyes.
“How’s he doin’, man?” Rafael’s head gestured in the direction of the next room.
“He’s not doing too well, Rafael,” Monks said quietly. “Tell me something. I’m a doctor, not a cop. I won’t rat you off. I just want to understand. What happened that was worth this?”