Oath of Office

“Okay if I go in there, Officer?”

“Sorry to give you a hard time,” the cop said. “It looks like you have a boxer’s knuckle, there. I’m not used to seeing doctors with boxer’s knuckles.”

“I work in a really tough ER,” Lou replied.

Sara Turnbull was a crackerjack nurse-as smart and intuitive as she was compassionate. There was a time when Lou could have added passionate to her list of attributes, but those times were long past. The last he had heard from her was a get-well card forwarded to him in rehab.

“How long have you been working here?” Lou asked as they joined the crowd milling in the gleaming ICU.

“Just four months. My husband’s a nurse on med/surg. We have a one-year-old son. It’s not Eisenhower, but it’s a decent-enough place-at least it was. This is a mess, Lou. An absolute mess. I’m charge nurse today, and I can’t follow some of the things that are happening.”

“Like someone blindly jamming a hemostat into a patient’s brain, fishing for a bullet?”

“Exactly. That’s Dr. Prichap. As far as I know, he’s a decent-enough neurosurgeon, but I’ve never seen anyone do that.”

“It may be a while before you see anyone do it again,” Lou said. “What else?”

“Dr. Meacham is going downhill fast, but no one seems all that alarmed. Do you know him?”

“For a few years. We’ve actually gotten to know one another pretty well. This came right out of the blue. I can’t believe he did it.”

“He’s over there in three. Dr. Schwartz, the intensivist, has been in and out, but mostly it’s been Dr. Prichap. It looks as if things have quieted down now. Prichap may have given up hunting for the bullet.”

“I hope so,” Lou said, almost to himself.

Lou followed Sara into the cubicle, which was crowded to near overflowing with nurses, radiology, lab, and respiratory techs, what appeared to be a resident, and a short, copper-skinned man-probably from India. ANTHAR S. PRICHAP, M.D. was stitched in blue over the breast pocket of his lab coat. Although he wore scrubs beneath his white coat, it appeared that he had performed surgery just as he was. Next to Prichap was a tray with bloody sponges and instruments piled on it.

No bullet.

On the bed, barely visible in the crowd, was John Meacham. His trachea had been intubated through his mouth, and he was being ventilated mechanically by a state-of-the-art machine that occupied most of the space the crush of bodies did not. A tall man-six feet or so-Meacham looked lost, almost diminutive. He appeared to be unconscious. His eyes were taped shut, and his head had been shaved on the right side. The bullet hole, just above his right ear, seemed to have been widened. On the wall view-box were anterior-posterior and lateral skull films showing a deeply embedded slug, fragmented into one small and two larger pieces, none of which were easily accessible to the entrance wound itself.

Dr. Schwartz, the hospital-employed intensivist, was apparently off with other patients. Why hang around for a plain old everyday gunshot wound to the head?

Lou introduced himself to Prichap, and received an uninterested nod in return. No handshake. Then, without a word, the neurosurgeon drifted into the background as Lou conducted a quick visual scan of Meacham. What he saw immediately disturbed him. There were two intravenous lines-one inserted in the elbow crux of Meacham’s left arm, and the other at the wrist of the right. The line at the elbow was barely running, despite a blood pressure reading on the monitor screen that demanded fluids and pressor medications-eighty over forty. Surrounding the spot where the catheter had been inserted was a large swelling. The line was infiltrated, and rather than pouring life-supporting fluid into the circulatory system, it was pooling fluid in the tissues.

Careless, dangerous medicine.

“Sara, that needs to be replaced,” he said, pointedly ignoring Prichap, who, at that moment, was looking rather pleased with himself for whatever reason.

The Sara Turnbull he remembered would never have allowed a critically traumatized patient to have only one working IV. Perhaps in the chaos, she simply had not noticed. In seconds, she was taking down the dressing and preparing to replace the IV line-this time at the wrist.

Lou glanced up again at the perilously low blood pressure reading, which had dropped from a systolic of eighty to seventy-four. Unless the cause could be identified and reversed, John Meacham was heading out. Quickly, Lou began mentally ticking through the possibilities. It took only a few seconds to connect with the right one.

Stunned at what he was seeing, Lou worked his stethoscope into place and listened to Meacham’s chest. There were no breath sounds on the right side. The exam was not really necessary. All the information he needed was visible in the distension of the jugular veins along the sides of the man’s neck, the slight bowing of the trachea toward the left, the persistently low oxygen saturation, and the asymmetrical hyperexpansion of the right chest.

A tension pneumothorax-collapse of the right lung due to a tear, probably caused by excess pressure from the ventilator. Air was being forced by the vent through the ruptured lung and into the chest cavity. The midline structures including the heart, esophagus, aorta, and other great vessels were being pushed to the left. The absence of breath sounds on the right merely confirmed the diagnosis.

Lou noted that the vent pressure was dangerously high and turned it down. From beside the machine, the respiratory tech-a tall, pencil-necked man in his late twenties-stood smiling at him blandly.

Did you do this on purpose? Lou wanted to shout. Did you?

“Everyone, please, listen to me,” he called out, louder than he’d intended. The commotion immediately stopped. “I’m Dr. Lou Welcome from the ER at Eisenhower Memorial. This man has a rapidly expanding tension pneumothorax. We need to dart his chest immediately to get the air out of there. Then we’ll get a chest tube in. I need an IV angiocath in a number sixteen or fourteen needle. Quickly, please.”

Missing from the emergency, except in himself, was any sense of tension and urgency. Lou wondered if anyone in the room really cared whether John Meacham made it or not. It would not be hard to understand if they didn’t, even though, as Sara had said, it should never be a caregiver’s role to pass judgment on any patient.

This was as bad as it could get.… Poor bastard.… Poor victims.

What in the hell happened?

A large-bore needle with a plastic catheter running through it was brought on an instrument tray, along with latex gloves, a large syringe, surgical sponges, some surgical snaps, and several culture tubes.

Blood pressure, seventy over thirty. Oxygen saturation, 60 percent. Color worsening.

Moving rapidly, Lou gloved and swabbed some Betadine antiseptic below Meacham’s collarbone on the right side. Then he set the plastic catheter aside and attached the needle to a 20 cc syringe. His movements were careful and considered, but almost automatic, like a boxer throwing a right-left-right combination.

To Lou’s left, behind the crowd, he could see the neurosurgeon, Prichap, gazing almost placidly out the glass wall of the cubicle. No apparent concern, no offer to help out.

The needle thrust was where the right second rib space was intersected by an imaginary line between the middle of the collarbone and the nipple. Gripping the syringe tightly, Lou forced the needle against the top of the third rib, and then drove it to the hilt, over the bone and into Meacham’s chest. The jet of air, under great force, actually blew the plunger out of the syringe. Lou twisted the syringe from the hub of the needle, set it on the tray, slid the catheter into Meacham’s chest, then quickly sutured it to the skin. Air continued to hiss out as the collapsed lung struggled to reexpand.

Blood pressure, eighty over fifty. Color slightly improved. O₂ sat, seventy-two.

“Chest tube kit, please,” Lou said firmly.

“Here you go, Doctor,” Turnbull said, replacing the used steel tray with a fresh one and opening the setup used to insert a much larger tube.

Lou glanced over and realized that the blown IV had been replaced by one that was running smoothly. The emergency was beginning to feel more normal. Despite some improvement, however, Meacham was still in big trouble. In case he was not in a coma, Lou anesthetized an area of skin over the fifth rib, two inches below the catheter. Then, using a scalpel, he opened a slit through skin and muscle, grasped the end of the chest tube with a heavy clamp, and drove it into the space between the still-deflated lung and the inside of the chest wall. Given the