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Knolls Community Hospital, settled within the autumn-dusted elegance of a Knolls residential section, gave new arrivals the impression of serenity with its pink granite two-story structure and thick evergreen landscaping. The emergency and outpatient areas formed a wing jutting out from the building westward, looking like an arm reaching out to welcome patients in. Two hundred fifty health-care personnel, food service and housekeeping providers and office workers earned their living here. They gave quality care to up to sixty patients on the floor. Family physicians' offices clustered close, circling the main structure in a large section of acreage. The hospital administrator, Mrs. Estelle Pinkley, ruled with the firm hand of a hardheaded, hard-nosed grandmother, whom almost everyone in the county knew and loved.
Dr. Lukas Bower, the unwilling temporary director of Knolls Emergency Department, depended on Mrs. Pinkley to help him handle staff and make executive decisions. In the meantime he took every opportunity to convince her that he was a doctor, not an administrator. If the future of Knolls Community Hospital depended on his interdepartmental skills, the jobs of two hundred fifty people stood in the shadow of death.
Today, however, the third Monday in September, Lukas gave even less thought than usual to paperwork and verbal sparring. The ambulance radio had just blared out the news of a bad accident involving a car and a tour group down on the square. At least five people, including the driver of the car, were being brought in, several of them serious.
Lukas released the switch that had sent his voice over the radio to the paramedic on scene and turned with growing restlessness to locate his staff. Judy, the slender secretary with short salt-and-pepper hair, sat at the computer and spoke on the telephone to a patient who had been treated and released last night.
Lukas picked up his own phone at his workstation at the large oblong central E.R. control counter and dialed Surgery. He told the nurse to keep a surgery suite open until he knew for sure if it would be needed. He hung up and turned around to find Lauren McCaffrey, RN, stepping back into the E.R. from an early lunch break. Good. He needed her.
Lauren stopped to joke with one of the housekeepers, peered over Judy's shoulder to see what was on the computer screen, then glanced over at Lukas. She caught sight of his expression, and her characteristic smile disappeared.
"What's up, Dr. Bower?" She hurriedly stashed her purse beneath the desk and tied her long blond hair back into the ponytail she wore for work.
"Accident coming in," he said. "Several injuries. Apparently a group of pedestrians took on a car with a drunk driver."
She nodded. "Why does stuff like this always happen at lunchtime? I'll go make sure the trauma rooms are ready, and I'll break out the gear for the staff."
"Thanks, Lauren. Has Claudia gone to lunch?"
"Yes, but she may be back in the break room. I think she brought her lunch today." Lauren shook her head as she turned and walked toward the trauma rooms. "Mrs. Pink-ley's a smart lady," she called over her shoulder. "I bet she knew double nursing coverage would increase business."
Lukas looked over to find the secretary off the phone. "Judy, would you please call upstairs for an extra nurse, and then contact Dr. Richmond. She's medical backup for today, and I need her."
"You sure?" Judy asked, peering at him over her reading glasses. "I talked to her secretary a few minutes ago, and they're up to their eyeballs in walk-ins over there at the clinic."
"Tell her I'm sorry, but it looks like we have some bad ones coming in." He turned toward the trauma rooms to make sure Lauren had all the gear the staff would need.
He knew Mercy Richmond's practice was doing well, and he was glad for her. She had worked hard for it, she was a caring doctor and she deserved a break after long years of struggle. He hated to overwhelm her today. A busy Monday could keep her occupied long after clinic hours were over.
Times like this were why Lukas needed to hire more help, and he needed to do it as soon as possible. The growth of this progressive Ozark town of ten thousand would be reflected in the use of the hospital. They had to be prepared, and like it or not, the E.R. was his responsibility. The problem was, he'd never hired anyone before. Thanks to Mrs. Pinkley's erroneous faith in him, he was jumping into the directorship with both feet. He might drown.
So far Lukas was the first and only full-time physician in this department. The family practice docs affiliated with the hospital picked up hours on nights and weekends, but they were getting tired of the extra load, especially as the opportunities dwindled for sleep during night shifts. Lukas knew that firsthand, because when someone didn't come in, he usually got stuck with the extra shift. Last night was a case in point, and today was a bad day to be sleep deprived.
"Dr. Bower, I have a call for you," yelled Judy from the central desk.
When he turned to look at her, she pointed toward his workstation and motioned for him to pick up his phone. He groaned. It was probably Dorothy Wild again. She got a power rush as director of the quality assurance program, and she flaunted it at every opportunity. Once, she had even gone so far as to coordinate a disaster drill just to test Lukas. This time she was probably calling to complain because he hadn't okayed the stack of charts she'd given him last week. Or maybe Medical Records was calling to scream at him because he hadn't written a diagnosis on a patient before ordering lab tests.
Medicare and Medicaid and health plans were making it harder to practice medicine with the good of the patient in mind instead of the glorified buck. Health-care providers often found themselves in a Catch-22 situation. Doctors and hospitals were under increasing pressure to eliminate "unnecessary" tests, yet were provided no protection from litigation if omission of one of these "unnecessary" tests resulted in a missed diagnosis. It was crazy. And medical costs were still on the rise. If Lukas were in charge of the insurance programs, he wasn't sure what he would do about it.
He picked up the receiver. "Yes." His voice was clipped as he imagined Dorothy Wild on the other end of the line.
"Doctor?" It was an unfamiliar woman's voice, shaky with tears, and Lukas immediately regretted his curt tone. "You've got to help us. Our little boy just swallowed some stuff, and I don't know how much" her words tumbled over themselves, threatening to spiral out of control "and we don't know what to do, and we're too far away to"
"Hold it, wait, calm down." Lukas kept his own voice soft. He glanced toward the entrance to see if the ambulance had arrived yet. The bay was still clear. He turned back. "What did your little boy swallow?"
He heard the muffled sound of a hand over the receiver, heard the woman's panicky voice, and then the sound cleared as the hand was removed.
A man's voice, high-pitched with near panic, as well, came across the line. "Hello? This is Craig Chapman. My wife's not doing too well right now." He stopped and took a breath. "I was winterizing the car out in the garage, and our three-year-old drank some of the antifreeze while my back was turned. It was dripping from his chin when I caught him."
Some of Mr. Chapman's tension transferred itself to Lukas. This could be bad. "Do you have any idea about how much he swallowed?"
"No. I hadn't used the stuff for a few months, and I didn't pay any attention. I tried to get him to throw it up, but nothing worked."
"Where do you live?" Lukas asked.
"We're out by Old Well. You're the closest hospital."
Lukas grimaced. Old Well was almost an hour's drive into the hills over rocky dirt roads.
"What can we do?" Mr. Chapman asked, panic once more filling his voice. "Will this stuff hurt him?"
"It depends on how much he drank, Mr. Chapman. I need you and your wife to stay calm so we can discuss this and help your son as quickly as possible." Old Well what was it Lukas remembered about that place? "Do you have any liquor in the house?"
"No, we don't drink."
"How about your neighbors? Are you close to a liquor store?"
"We don't know our neighbors around here yet. We just moved in from Kansas." The man's voice grew tighter and higher. "Tell me what to do!"
"Do you have any cooking extracts? Any vanilla?" If there was enough, vanilla extract could save the child's eyesight due to the high percentage of alcohol. It could even save his life.
He heard the man put the phone down and ask his wife, heard her frantic reply and a small clatter of bottles, and then suddenly remembered who else lived near Old Well. Yes!
Chapman came back on the line. "We've got half of a little bottle of vanilla, Doctor. Is that enough? Will that help?"
"Give it to him, but you'll need more."
"He's not showing any symptoms yet. He isn't acting sick."
"The symptoms won't show up for twelve to twenty-four hours." And then it would be too late. "Mr. Chapman, do you know Emmet and Ruby Taylor? They live out in the hills near you at the edge of Mark Twain National Forest, about two miles from the cemetery by the church at Old Well." He should know. Ruby Taylor had almost died of lead poisoning from her still a few months ago. The still had been destroyed since then, but Lukas knew Ruby. "Take your son over to their place. Tell them I sent you, and ask for a bottle of their best. They'll have liquor somewhere." He prayed that the Taylors were there. They usually were, with their teenage boys and dairy farm, pigs and chickens and rusted-out tireless cars sitting in the front yard.
"You want me to get my little boy drunk?" Chapman asked, a hint of indignation in his voice, as if it had suddenly dawned on him what Lukas was saying.
"I want you to get enough grain alcohol down him to counteract the effects of the antifreeze," Lukas said. "About three tablespoons of Ruby's stuff ought to do it, but you don't want to overdose him, especially since we don't know how much he's ingested. Mix some orange juice or something with it so he'll drink it. Maybe some sugar will kill the taste. Then get him here as fast as you can."
"Won't the alcohol interfere with the antidote?"
"In this case, the alcohol is the antidote. Mr. Chapman, the effects can kill him if you don't treat." He didn't want to be cruel, but the man needed to be aware of the serious risks. The sound of a siren echoed through the doors, then the reflection of ambulance lights bounced against the bay entrance. "Are you okay with that?"
"Yeah, Doctor. We'll get him there."
"Good. I'll see you then."
Lukas hung up and got up to walk out to the ambulance bay just as the EMT threw open the back doors of the van. He stepped over to the foot of the first cot that was pulled out.
The patient was a female in a nonrebreather mask, fully immobilized on a long spine backboard with head blocks. She had a large bore IV in her right arm, and blood splattered her clothing. Blood also concentrated in a dark, thick stain that had seeped through a bandage over her right lower leg, where her jeans had been cut free, and a Harris long traction splint held firm.
"Is this the worst?" Lukas asked.
"Sure is. She looks pretty bad." The EMT gestured to the other patient, who was still inside the van. "That's her husband in there."
Lukas didn't like the looks of the patient's right foot almost white from lack of circulation. She moaned, but her eyes remained closed.
The paramedic stepped out of the back of the van. Connie was a muscular, seasoned professional with short boy-cut blond hair and a chronically serious expression. "Hi, Dr. Bower. This is Alma Collins, forty-five years old. First re-sponders had to free her from between the car and the concrete balustrade of the courthouse." Her voice remained monotone, a habit she practiced when she worked with patients to keep from alarming them. "She was unconscious on scene, but she's been coming around since we've been en route, and she's in a lot of pain. She has an obvious open tib-fib fracture, badly mangled leg, no pulse on the foot. Vitals initially on scene, heart rate 115, BP 90 over 60, respiratory rate rapid, with slight improvement following a liter bag of normal saline wide open. She's received 700 cc's so far. A lot of bleeding on scene from right lower extremity, but we managed to control it some after we placed the splint."
"What about the other patient?" Lukas gestured toward the cot still in the van.
"That's Arthur Collins, the husband," Connie said. "He has a deep scalp laceration, and it looks like he may have a dislocated or broken right shoulder. He lost a lot of blood from the scalp, but it's been controlled by direct pressure."
Lukas reached forward to check Alma more thoroughly while he continued to talk to Connie. "What else is coming?"
"Two more are on their way in the BLS ambulance, and one's coming in by private car."
Lukas placed his hands over the sides of Alma's hips and gave a gentle but firm squeeze. There was no reaction of pain. Good. He would get a film on it, but if she didn't have a pelvic fracture, it would be a lot easier for her. As Connie continued with the report, Lukas helped her rush the patient through the doors and into the first trauma room, leaving the EMT and E.R. tech to handle Alma's injured husband.
"Judy, get a chopper on standby," he called over his shoulder as he and Connie transferred Alma to the exam bed. "And let Lab know we've got stat blood work for them." He turned to Lauren, who had come in behind them. "Start another IV, and draw blood for a stat trauma panel."
Alma's pupils reacted briskly, and her breathing, though a little fast, was even. Her eyes remained open after he checked them. She moaned again, and Lukas bent toward her. "Mrs. Collins, I'm Dr. Bower, the E.R. physician here." Because Connie's businesslike manner could sometimes make a patient feel cut off from human support, he injected even more tenderness than usual into his own voice. "Can you hear me?"