In his dream Jack reached again for Caroline. But she was gone. Jack closed his eyes.
And the dream took him into a deep, still, never-ending darkness.
TEN
Okay, everybody. It's time to put our Humpty Dumpty back together again. He's lost four liters of blood, mostly in the pelvis and hip. If we're going to keep him alive, first thing we've got to do is keep his fluids replenished. We're going to make the switch from the plasma expanders and saline tubes to the large bore. Now! This mother needs some blood and fast. He's leaking all over the fucking place.'
Those were the last words spoken for the next several minutes while the large bore tubes replaced the smaller emergency tubes that had been frantically administered by the guys in the ambulance. Bigger catheters were sutured expertly into the arteries and neck. It was like a circle of serious and flawless quilters doing repair work on a worthless and torn rug. Hands moved nimbly up and down, weaving almost in unison, sealing the lifelines into place. Once the stitching was done, the catheters were hooked up to IV's and soon blood was flowing back into the unmoving body instead of just out.
The room was awash in the blood that had escaped, as were the doctors and nurses flocked around the table. The lead surgeon, Dr. Harold Solomon, shrugged his left shoulder up to wipe a splash of reddish brown from his cheek. He took a long, deep breath, exhaled through his nose as an athlete might, about to expend one last great burst of energy, and spoke quietly, quickly, and emotionlessly to the now still room. He could have been a dock foreman detailing cargo contents and shifts for union members.
'All right. We've got multiple gunshot wounds. One shot took out the right pelvis. Another the right hip. The third got the left knee. In the hip we've got a high-velocity fracture. We're gonna put in a reconstructive plate. Nothing unusual, we've all done it before. The pelvis is potentially life-threatening. We've got a communuted superior rami fracture with extension into the iliac wing. The bullet hit in the midpelvis and, besides shattering the bone, it's screwed up a lot of other things. The most crucial is that the bladder's been ruptured and that's where we've got the massive bleeding. We're going to work there first because, frankly, I don't know if he's gonna survive it, so why waste everything else. For the knee, there's a super condular fracture of the left femur. If he's still around, we'll do a similar type of reconstruction at the hip with plates and screws. All set?'
They were.
The initial surgery took eight hours and forty minutes.
The first step was to build an external fixater for the pelvis. It looked like an old-fashioned toy Erector set, a complex layering of pipes, joints, and hinges. It was a means of both elevating the pelvis – propping it up – and preventing it from splintering completely. Its essential function was to provide enough room for the bladder surgeon to go in and repair the punctured organ. If the external fixater didn't hold, the patient was dead.
The group hovering over the patient were remarkably relaxed and casual. As they worked, a stream of chatter replaced the initial quiet. There were questions about the Redskins front line and the sexual orientation of an orthopedic nurse who was not present for this surgery and there were complaints about the new vending machines in the cafeteria – there was general agreement that the hot whipped mocha concoction tasted like a combination of chalk and urine. This part of the surgical procedure was no different from the way a master carpenter put up shelves. It was done confidently, skillfully, and purely mechanically, with no thought of error. There was no science involved and zero room for interpretation. Once the decisions were made on how to proceed, this was hammer- and-nails stuff, no more emotionally involving than gluing a broken piece of china back together. The pride came from how seamlessly the pieces were restored.
When the external fixater was in place and stable, the bladder surgeon, Dr. Mugg, moved in for his turn. He was not the most popular person in the local medical community. He tended to lecture while he worked – his nickname in the halls was Dr. Smug – and several months ago he'd managed to patent a particular technique of suturing. No other surgeon in the country could now use this method without paying him a substantial royalty on each operation. As a result, Dr. Smug was not only more arrogant than ever, he was driving a new Ferrari and buying a six-bedroom weekend house on the Maryland shore. But his hands moved smoothly and surely, and however much his mouth motored, his eyes never wavered. In just over two and a half hours, Dr. Mugg turned his back on the patient and said, 'It's as good as it gets. It'll take about a week to heal, then we can go back in and do an open reduction and internal fixation. He's one lucky bastard that I was in town.' Without saying anything else, he left the room. The abdomen and bladder were, for the moment, whole and stable.
Now it was time for the orthopedic traumatologist, Dr. Solomon, to step back up to the table and begin to reconstruct the hip.
The bullet had completely reshaped the bone. At first, Dr. Solomon thought it might be necessary to do a replacement, but enough of the original structure around the acetabulum of the hipbone had survived so that a combination of plates and screws would suffice.
The doctor had, before entering medical school, considered becoming an architect. He was a visual person and also tended to concentrate on the way things functioned. So when he looked at an object, his mind would take him below the surface; he concentrated on structure, viewing most things as blueprints. This vaguely Platonic overview – he more often than not saw the way a thing worked rather than the thing itself – not only helped him focus when operating, it kept things on a much more objective basis. It allowed him to disassociate from the human element and concentrate on the structural work at hand. So while he went through the process of repairing this nearly destroyed hip, his eyes did not see the tissue he was slicing through nor the bone he was breaking and remaking. He saw, instead, a precise, neatly drawn architectural plan of the body.
Working from that plan in his mind, he drilled two holes into the head of the femur, inserted two screws, and attached a reconstructive plate that spanned the entire fracture. When the plate was finally in place and immovable, he looked up to see the admiring eyes of his coworkers. The blueprint faded from his mind and the reality intruded. He saw the patient, immobile on the operating table. He wondered when he'd get the details of the shooting, began to imagine the scenario that had led to this kind of destruction, then immediately shook the thoughts out of his head. It was no time to personalize. The left knee still had to be reconstructed.
Although Dr. Solomon had been operating for almost twelve hours that day, there was no hint of exhaustion in his body or his mind. So, with a blueprint of the new area firmly in place, he again began drilling, this time into the expanded distal end of the femur that articulated with the tibia. When that was done, more screws were inserted and another reconstructive plate was attached.
At 6:35 in the morning, the operating team was done.
One nurse had to rush immediately into another surgery – a misaimed bullet in a family feud had passed by the spinal cord of a fourteen-year-old girl. The doctors did not yet know if the cord was bruised or ripped. If bruised, the chances for complete healing were good. If ripped, the girl would never walk again.
One intern made it as far as the first chair he came to in the hospital hallway. There he sat, stretched out, and fell soundly asleep.
Dr. Solomon's first act, when leaving the emergency room, was to head to the cafeteria, put seventy-five cents into the coffee vending machine, get himself a Styrofoam cup of the godawful mocha concoction, then go to sit on the curb outside the side door of the hospital and smoke a cigarette. After fifteen minutes and a second smoke, he stood wearily and headed to his car. By that time he'd already been informed that if the patient lived through the next week – a fifty-fifty chance at best – and the bladder healed properly, Dr. Mugg would, as he'd announced, perform the open reduction and internal fixation of the bladder and then he, Dr. Solomon, would return with the patient to the operating room for a formal plating of the pelvis. That meant, literally, lining him up like a jigsaw puzzle and making sure the skeletal structure was back in the proper place. After that, a balloon would temporarily be placed inside the bladder, the patient would stay several more days in their care, until he was hemodynamically stable, and then he'd be helicoptered back to New York City and the Hospital for Special Surgery, where he would be placed under the care of his own orthopedic surgeon.
Dr. Solomon knew he would never see the patient again after that. Knew he would never find out what his life would become. That didn't particularly bother the doctor. He'd done his job. And if the man lived, the next six to twelve months of his life would be about one thing and one thing only: pain. Harold Solomon was not much interested in pain. He much preferred the contained and docile sterility of the operating room to the prolonged
