Abby paused and glanced around at the circle of faces. Had she screwed up already? She couldn't be sure. She took a breath and continued. 'Vital signs were blood pressure of ninety over sixty and pulse of a hundred. She was already intubated. She had no spontaneous respirations. Her rate was fully supported by mechanical ventilation at twenty-five breaths per minute.'
'Why was a rate of twenty-five selected?'
'To keep her hyperventilated.'
'Why?'
'To lower her blood carbon dioxide. That would minimize brain edema.'
'Go on.'
'Head exam, as I mentioned, revealed both depressed and compound skull fractures of the left parietal and temporal bones. Severe swelling and lacerations of the face made it difficult to evaluate facial fractures. Her pupils were midposition and unreactive. Her nose and throat-' 'Oculocephalic
'reflexes?'
'I didn't test them.'
'You didn't?'
'No, sir. I didn't want to manipulate the neck. I was concerned about possible spinal dislocation.'
She saw, by his slight nod, that her answer had been acceptable.
She described the physical findings. The normal breath sounds. The unremarkable heart. The benign abdomen. Dr. Wettig did not interrupt. By the time she'd finished describing the neurologic findings, she was feeling more self-assured. Almost cocky. And why shouldn't she? She knew what the hell she'd been doing.
'So what was your impression?' asked Dr. Wettig. 'Before you saw any x-ray results?'
'Based on the midposition and unreactive pupils,' said Abby, 'I felt there was probable midbrain compression. Most likely from an acute subdural or epidural haematoma.' She paused, and added with a quiet note of confidence, 'The CT scan confirmed it. A large left-sided subdural with severe midline shift. Neurosurgery was called in. They performed an emergency evacuation of the clot.'
'So you're saying your initial impression was absolutely correct, Dr. DiMatteo?'
Abby nodded.
'Let's take a look at how things are this morning,' said Dr. Wettig, moving to the bedside. He shone a penlight into the patient's eyes. 'Pupils unresponsive,' he said. He pressed a knuckle, hard, against the breastbone. She remained flaccid, unmoving. 'No response to pain. Extensor or otherwise.'
All the other residents had edged forward, but Abby remained at the foot of the bed, her gaze focused on the patient's bandaged head. WhileWettig continued his exam, tapping on tendons with a rubber hammer, flexing elbows and knees, Abby felt her attention drift away on a tide of fatigue. She kept staring at the woman's head, recently shorn of hair. The hair had been a thick brown, she remembered, clotted with blood and glass. There had been glass ground into the clothes as well. In the ER, Abby had helped cut away the blouse. It was a blue and white silk with a Donna Karan label. That last detail was what seemed to linger inAbby's memory. Not the blood nor the broken bones nor the shattered face. It was that label. Donna Karan. A brand she herself had once purchased. She thought of how, sometime, somewhere, this woman must once have stood in a shop, flipping through blouses, listening to the hangers squeak as they slid across the rack…
Dr. Wetrig straightened and looked at the SICU nurse. 'When was the haematoma drained?'
'She came out of Recovery about 4 a.m.'
'Six hours ago?'
'Yes, that would make it six hours.'
Wetrig turned to Abby. 'Then why has nothing changed?' Abby stirred from her daze and saw that everyone was watching her. She looked down at the patient. Watched the chest rise and fall, rise and fall with every wheeze of the ventilator bellows.
'There… may be some post-op swelling,' she said, and glanced at the monitor. 'The intracranial pressure is slightly elevated at twenty millimetres.'
'Do you think that's high enough to cause pupillary changes?'
'No. But-'
'Did you examine her immediately post-op?'
'No, sir. Her care was transferred to Neurosurgery service. I spoke to their resident after surgery, and he told me-'
'I'm not asking the neurosurgery resident. I'm asking you, Dr. DiMatteo. You diagnosed a subdural haematoma. It's been evacuated. So why are her pupils still midposition and unreactive six hours post-op?'
Abby hesitated. The General watched her. So did everyone else. The humiliating silence was punctuated only by the whoosh of the ventilator.
Dr. Wettig glanced imperiously at the circle of residents. 'Is there anyone here who can help Dr. DiMatteo answer the question?'
Abby's spine straightened. '! 'I can answer the question myself,' she said.
Dr. Wettig turned to her, his eyebrow raised. 'Yes?'
'The… pupillary changes — the extensor posturing of the limbs — they were high midbrain signs. Last night I assumed it was because of the subdural haematoma, pressing downwards on the midbrain. But since the patient hasn't improved, I… I guess that indicates I was mistaken.'
'You guess?'
She let out a breath. 'I was mistaken.'
'What's your diagnosis now?'
'A midbrain haemorrhage. It could be due to shearing forces. Or residual damage from the subdural haematoma. The changes might not show up yet on CT scan.'
Dr. Wettig regarded her for a moment, his expression unreadable. Then he returned to the other residents. 'A midbrain haemorrhage is a reasonable assumption. With a combined Glasgow Coma Scale of three…' He glanced at Abby '… and a half,' he amended, 'the prognosis is nil. The patient has no spontaneous respirations, no spontaneous movements, and she appears to have lost all brainstem reflexes. At the moment, I have no suggestions other than life support. And consideration of organ harvest.' He gave Abby a curt nod. Then he moved on to the next patient.
One of the other residents gave Abby's arm a squeeze. 'Hey, DiMatteo,' he whispered. 'Flying colours.'
Wearily Abby nodded. 'Thanks.'
Chief surgical resident Dr. Vivian Chao was a legend among the other residents at Bayside Hospital. As the story went, two days into her very first rotation as an intern, her fellow intern suffered a psychotic break and had to be carted off, sobbing uncontrollably, to the loony ward. Vivian was forced to pick up the slack. For twenty-nine straight days, she was the one and only orthopaedic resident on duty, around the clock. She moved her belongings into the call room and promptly lost five pounds on an unrelenting diet of cafeteria food. For twenty-nine straight days, she did not step out of the hospital front doors. On the thirtieth day her rotation ended, and she walked out to her car, only to discover that it had been towed away a week before. The parking lot attendant had assumed it was abandoned.
Four days into the next rotation, vascular surgery, Vivian's fellow intern was struck by a city bus and hospitalized with a broken pelvis. Again, someone had to take up the slack.
Vivian Chao moved right back into the hospital call room.
In the eyes of the other residents, she had thus achieved honorary manhood, a lofty status which was later acknowledged at the yearly awards dinner when she was presented with a boxed pair of steel balls.
When Abby first heard the Vivian Chao stories, she'd had a hard time reconciling that steel-balls reputation with what she saw: a laconic Chinese woman who was so petite she had to stand on a footstool to operate. ThoughVivian seldom spoke during attending rounds, she could always be found standing fearlessly at the very front of the group, wearing an expression of cool dispassion.
It was with her usual air of detachment that Vivian approached Abby in the SICU that afternoon. By then Abby was moving through a sea of exhaustion, every step a struggle, every decision an act of pure will. She didn't even notice Vivian was standing beside her until the other woman said, 'I hear you admitted an AB positive head trauma.'
