Shadow Watch

He nodded.

“We’d better check in with him,” he said. “Got a feeling he’s going to want us back in San Jose right away.” The doctors knew they had their job cut out the moment he was brought into the emergency room.

It would have been clear even to an untrained observer that he was in terrible shape; clear from his near- comatose state; clear from all the blood that had soaked from the gaping hole in his belly through his clothing, the thin blankets covering him, and the uniforms of the technicians who had delivered him on the stretcher; clear from the blue cast of his skin and the weak, irregular rhythm of his breath.

To the expert eye, these physiological signs pointed toward specific life-threatening complications that would have to be assessed and treated without losing an instant. The severe hemorrhaging alone would have led them to evaluate him for shock, but his lividity left scant doubt of its onset, and the blood pressure cuffs placed on his arm as his stretcher was rolled in had given systolic and diastolic readings of zero over less than zero, indicating a near-cessation of his circulatory processes. His thready breathing also suggested that a tension pneumothorax — in laymen’s terms, an air pocket between the lungs and their surrounding tissues developing as a result of shock — was putting pressure on the lungs and causing them to fully or partially collapse.

The condition would lead to respiratory failure and certain death unless relieved by external means.

Managing a medical crisis requires a constantly unfolding and frequently accelerating series of prioritizations. In this case the priority was to stabilize his vital functions even before the injuries to his internal organs could be determined by Xrays and exploratory abdominal surgery. Only then would it be known with certainty how many times he’d been shot, or what path the bullet, bullets, or bullet fragments had taken.

With the clock ticking, the surgeon in charge at once began giving directions to his assistants in a rapid and assertive manner.

“I want MASTs…”

This being an acronym for medical shock trousers, which could be slipped onto the patient and inflated with air to force blood up from his lower extremities to his heart and brain.

“… seven units of packed RBCs…”

Shorthand for red blood cells, the hemoglobin-rich component of blood that provides life-giving oxygen to body tissues. In a typical situation requiring transfusion, the patients’s serum is cross-matched for compatibility with a sample of the blood product to be administered, but because he was an employee of UpLink, this man’s type was already on file on the doctors’ computer database, eliminating that step and conserving precious minutes.

“… a big line…”

A wide intravenous catheter used to get the RBCs into his system by quick, massive transfusion.

“… and a needle aspirator in him stat!”

The needle aspirator being a large syringe used to drain the air out of the pneumothorax, inflate the lungs, and restore normal breathing; stat, medical jargon for I need it done five seconds ago, a word derived and abbreviated from the original Latin statim, meaning immediately.

While the image of medical professionals working in conditions of ordered, clockwork sterility is a common one, nothing will dispel it faster than a glimpse inside a trauma room, where the battle to save lives is a close, tense, chaotic, messy, sweaty affair. Jabbing a 14-gauge big-bore needle into the chest of a powerfully built two- hundred-pound man, clenching the attached syringe in your fist and unsuccessfully attempting to insert it between hard slabs of pectoral muscle once, twice, and again before finally making a clean entry, then drawing out the plunger and getting a rush of warm, moist air in your face as the pocket that had formed around the lungs decompressed, was nobody’s idea of a picnic — as the young doctor who had been hastily summoned on duty tonight, and who was now toiling away over Rollie Thibodeau here in the ISS facility’s critical-care unit, trying to prevent him from dying before he made it onto an operating table, would have attested if he’d had the time. But he was too busy following the instructions called out by the chief physician, himself standing over the patient, working to get the big line and saline IVs connected to him in a hurry.

With the syringe in place and the air suctioned from the pneumothorax, it was essential to prevent its recurrence and keep the patient breathing. This meant going ahead with a full closed-tube thorascostomy.

The first step was to create an airtight seal around the tube. Barely registering the frantic activity around him, the young doctor lifted a scalpel from an instrument tray and sliced into the flesh between the ribs, making a horizontal incision. Then he took a Kelly clamp off the tray and pushed it into the incision, holding it by the shaft, expanding it to spread the soft tissue and create a tunnel for his finger. Blood splashed up around the clamp as he removed it from the opening and pressed his gloved finger between the lips of the cut, going in as deep as his knuckle, carefully feeling for the lung and diaphragm. After assuring himself that he had penetrated through to the intrapleural area — the space between the lungs and ribs where the air pocket had formed — he asked a scrub nurse for the chest tube and carefully guided it into the opening.

He paused, studied the patient, and exhaled a sigh of relief. The patient’s breathing was stronger and more regular, his skin color vastly improved. A water collection system at the opposite end of the chest tube would keep the air draining from the patient’s chest while insuring that no air was drawn back into it. To complete the procedure, the young doctor would suture the skin around the tube to preserve the seal.

A very long night still lay ahead, but Thibodeau would have something like a fighting chance as the doctors hustled him into the OR, opened him up, and got a look at the extent of the damage that had been done inside him.

SIX

CHAPARE REGION WESTERN BOLIVIA APRIL 18, 2001

A look of quiet gratification on his face, Harlan DeVane watched the line of three flatbed trucks roll along the hardpack at the eastern border of his ranch as they approached the airstrip and the waiting Beech Bonanza in a cloud of dust. Now, before midday, the sun was a firebrand hanging above the battered old camiones and the wide, flat pasture closer by, where he could see his cattle, prime heifers imported from Argentina, grazing indolently in the heat. There was no wind, and the ash and smoke from the forest fires seemed an inert smear above the horizon. Once the afternoon breezes stirred, however, it would rise and spread into a blanketing gray haze, dimming the sun so that one could look directly up into it with the unprotected eye. It was a price of development that DeVane found regrettable, but he was a man who dealt with realities as they presented themselves. The loggers bulldozed new roads, and the opportunistic peasant farmers and ranchers who came here to settle followed along those roads, and because the soil was quickly depleted in the Amazon basin — good for no more than three years’ growing of crops — they would clear previously untouched tracts of forest as their fields dried up and grew fallow. The cycle was implacable yet unavoidable. Nothing in life came free of charge, and most often you paid as you went.

“It appears the plane soon will be on its way, Harlan,” Rojas said, taking a sip of his chilled guapuru.

DeVane looked at him from under the brim of his white Panama hat. His skin was tightly stretched over his cheeks and almost colorless. His eyes were a frozen shade of blue set deep in their sockets. He wore a white double-breasted suit that had been custom-tailored from some lightweight fabric, probably in Europe. The collar points of his blue silk shirt were neatly buttoned down under blue-and-yellow pinstriped suspenders. Unbothered by the torrid weather, he seemed to occupy his own still pocket of space, putting Rojas in mind of the lion-fish that floated in the waters of the Carribean — so illusively delicate in appearance, so serenely poisonous.

“And you, Francisco?” he said, speaking Portuguese although Rojas was proficient in English. “Will you be leaving with it? Or can I assume you’ve made other arrangements?”

“You know it is my habit let the perico fly on separately,” Rojas said. “As a precaution.”

DeVane was inwardly amused by his choice of words. The cocaine made you manic and talkative. Like a parrot, perico in Spanish. It was a term of low slang he might have expected from some street-level dealer in San Borja, not a Brazilian police official of considerable rank. But Rojas was of a type. A gutless, corrupt, lazy little south-of-the-equator bureaucrat trying to affect the manner of an outlaw. Light a firecracker outside his office window and he would hide quailing under his desk.