room to room in search of Faye, heard the EMT’s radio crackle with questions from the Knox Hospital ER.
“How much blood loss?” It was McNally’s voice on the radio.
“Her clothes are saturated,” answered the EMT “At least six stab wounds to the chest. We’ve got sinus tach at one-sixty BP palpable at fifty. One IV in. We can’t get a second line started.”
“Breathing?”
“No. She’s tubed and we’re bagging her. Dr. Effiot’s here with us.”
“Gordon,” Claire called out. “She needs immediate thoracotomy! Get a surgeon there, and let’s just move her!”
“We’ll be waiting for you.”
Though it took only seconds to transfer the girl into the ambulance, Claire felt as if everything were moving in excruciatingly slow motion. She saw it all through a cloud of panic: the heartbreakingly small body being strapped into the stretcher, the tangle of EKG wires and IV line, the tense faces of the EMTs as they ran the girl down the porch steps and slid her into the ambulance.
Claire and one of the EMTs climbed in beside the girl and the door slammed shut.
She knelt beside the stretcher, bagging the lungs and fighting to keep her balance as they bumped down the Braxton driveway, then swung onto the main road.
On the cardiac monitor, the girl’s heart rhythm stumbled. Two premature ventricular beats. Then three more.
“PVCs,” said the EMT
“Go ahead with the lidocaine.”
The EMT had just started to inject the drug when the ambulance hit a pothole. He sprawled backwards, his arm snagging the IV line. The catheter slid out of the girl’s vein, sending a spray of Ringer’s lactate into Claire’s face.
“Shit, I’ve lost the line!” he said.
An alarm beeped on the monitor. Claire glanced up to see a string of PVCs skipping across the screen. At once she began cardiac compressions. “Hurry with that second line!”
Already he was ripping open a package, pulling out a fresh catheter. He tied a tourniquet on Kitty’s arm and slapped the flesh a few times, trying to get a vein to plump up. “I can’t find one! She’s lost too much blood.”
The girl was in shock. Her veins had collapsed.
The alarm squealed. Ventricular tachycardia was racing across the screen.
In panic, Claire gave Kitty’s chest a sharp thump. Nothing changed. She heard the whine of the defibrillator. The EMT had already punched the charge button and was slapping contact pads on Kitty’s chest. Claire pulled away as he positioned the paddles and discharged the current.
On the monitor, the tracing shot up, then slid back to a rapid sinus tachycardia. Both Claire and the EMT released loud sighs of relief.
“That rhythm’s not going to hold,” said Claire. “We need the IV.”
Fighting to keep his balance in the swaying ambulance, he wound the tourniquet around the opposite arm and again searched for a vein. “I can’t find one.”
“Not even the antecubital?”
“It’s already blown. We lost it trying to get the IV started earlier.”
She glanced up at the monitor. PVCs were beginning to march across the screen again. They were still miles away from the ER, and the girl’s rhythm was deteriorating. They had to get an IV in her now.
“Take over CPR,” she said. “I’ll start a subclavian line.” They scrambled to switch positions.
Claire’s heart was hammering as she crouched beside Kitty’s chest and stared down at the collarbone. It had been years since she’d inserted a child’s central venous line. She would have to insert a needle under the clavicle, angling the tip toward the large subclavian vein, while running the danger of puncturing the lung. Her hands were already trembling; in the swaying ambulance, they would be even less steady The girl is in shock, and dying. I have no choice.
She opened the central venous line kit, swabbed the skin with Beta-dine, and snapped on sterile gloves. Then she took a shaky breath. “Hold compressions,” she said. She placed the tip of the needle beneath the collarbone and pierced the skin. With steady pressure she advanced the needle, the whole time gently applying suction to the attached syringe.
Dark blood suddenly flashed back.
“I’m in the vein.”
The alarm squealed. “Hurry! She’s in V. tach!” said the EMT
Lord, don’t send us over a pothole. Not now.
Holding the needle absolutely still, she removed the syringe and threaded the J wire through the hollow needle, into the subclavian vein. Her guide wire was in position; the most delicate part of the procedure was over. Moving swiftly now, she slid the catheter into place, withdrew the wire, and connected the IV tubing.
“Good show, doc!”
“Lidocaine’s going in. Ringer’s at wide open.” Claire glanced at the monitor.
Still in V. tach. She reached for the paddles, and was just placing them on Kitty’s chest when the EMT said, “Wait.”
She looked at the monitor. The lidocaine was taking effect; the V. tach had stopped.
The abrupt lurch of the braking ambulance alerted them to their arrival. Claire braced herself as the vehicle swung around and backed up into the ER bay.
The door swung open and suddenly McNally and his staff were there, half a dozen pairs of hands reaching to pull the stretcher out of the vehicle.
They had only a bare-bones surgical team waiting in the trauma room, but it was the best McNally could round up on such short notice: an anesthetist, two obstetrical nurses, and Dr. Byrne, a general surgeon.
At once Byrne moved into action. With a scalpel, he slashed the skin above Kitty’s rib and with almost savage force shoved in a plastic chest tube. Blood gushed through the tube and poured into the glass reservoir. He took one look at the rapidly accumulating blood and said, “We have to crack the chest.”
They had no time for the ritual hand scrub. While McNally performed a cutdown on the girl’s arm for another IV line, and a unit of O-neg blood pumped in, Claire slipped into a surgical gown, thrust her hands into sterile gloves, and took her place across from Byrne. She could see from his white face that he was scared.
He was not a thoracic surgeon, and clearly he knew he was in over his head. But Kitty was dying, and there was no one else to turn to.
“Hail Mary, full of grace,” he muttered, and started up the sternal saw.
Wincing at the whine of the saw, Claire squinted against the spray of bone dust, into the widening gap of Kitty’s chest cavity. All she could see was blood, glistening like red satin under the lights. A massive hemothorax. As Byrne positioned the retractors, widening the gap, Claire suctioned, temporarily clearing the cavity “Where’s it coming from?” muttered Byrne. “The heart looks undamaged.”
And so small, thought Claire with sudden anguish. This child is so very small…
“We’ve got to clear away this blood.”
As Claire suctioned deeper, a tiny spurt suddenly appeared from the lacerated lung, pumping out an arc of blood.
“I see it,” he said, and snapped on a clamp.
Another spurt appeared, fresh blood swirling bright red into the darker pool.
“That’s two,” he said with a tense note of triumph, clamping off the second bleeder.
“I’m hearing a BP!” said a nurse. “Systolic’s seventy!” “Hanging the second unit of 0-neg.”
“There,” said Claire, and Byrne clamped off the third telltale spurt. Claire suctioned again. For a moment they watched the open chest, waiting in dread for the blood to reaccumulate. Everyone in the room fell silent. The seconds ticked by.
Then Byrne glanced across at her. “You know that Hail Mary I just said?”
“Yes?”
“It seems to be working.”
Pete Sparks was waiting for her when Claire finally emerged from the trauma room. Her clothes were
