Two hours after midnight, sirens tore through the cinder-block walls, shattering the momentary calm. There was the screech of rubber tires against pavement--the ambulances careening to a stop in the receiving circle--and the steady wail was joined by the shouts of paramedics as they unloaded their cargo. A second later, the double doors crashed open, and the vast room seemed to buckle inward, as a torrent of stretchers streamed across the tiled floor.
"Here we go!" someone shouted, and suddenly the emergency room came alive. Bleary-eyed doctors in white coats and pale-blue scrubs leapt forward, shouting for chem trays and surgical consults. Triage nurses in pink uniforms swirled between the stretchers, trailing IV wires and portable crash carts. At first glance, the room seemed gripped by chaos, but in reality, it was a highly controlled, intricate performance. The nurses and doctors played off one another like professional athletes, acting out their roles in kinetic bursts of harmony.
Huddled in a corner near the back of the ER, Brad Alger watched the unfolding spectacle with wide eyes. Although he had been on duty for less than twenty minutes, his scrubs were already thick with sweat. Red splotches covered the sleeves of his white doctor's coat, and his high-top Nikes had turned a strange, nearly violet color. His platinum-blond hair rose from his head in unruly locks, like a miniature sunburst. There were heavy bags under his glassy blue eyes, and he looked as though he hadn't slept in months.
He rubbed a damp sleeve across his forehead, then quickly stepped aside as a disheveled nurse pushed a crash cart up against the wall next to him.
"Christ," Alger coughed, his voice pitching upward, "it's knee deep in here. I thought the first salvo was bad--but this is crazy. How many ambulances did they say were coming?"
"Twenty-two," the nurse answered, tossing a pair of blood-spattered gloves toward the floor. "Maybe more. At first, they thought there were only nine cars involved in the accident. Now they say it was more like thirteen."
Alger whistled. "Thirteen cars. At two in the morning."
"This your first Friday night?"
She had spiky dark hair and kind eyes. Alger guessed she was thirty, maybe thirty-five. He felt like a kid next to her, and he tried to take the fearful edge out of his voice. "My internship started on Sunday."
The nurse offered a sympathetic smile. "Welcome to New York."
She grabbed a clean pair of gloves from the crash cart and moved back into the fray. For the thousandth time in less than a week, Alger wondered what the hell he was doing there. A month ago, he had been a fourth-year medical student in Cincinnati, Ohio. His biggest worries had been his school loan payments and Kelly Pierce, his most recent ex. He had done a rotation in emergency back in Cincinnati--but he had never imagined anything like this.
The evening had started innocently enough. A few cardios, a handful of recent entrants into the knife-and-gun club, a half dozen respiratory gomers sneaking cigarettes under their oxygen masks. And then the call had come over the emergency room's intercom system. There had been a multicar accident on the FDR Drive; at least ten critical, another two dozen in bad shape. All available doctors had been summoned down from the hospital's other departments, and the emergency room had been put on full trauma-alert.
Alger had made the mistake of asking Duke Baker--the gargantuan, short-tempered chief resident--what that meant in English. The Duke had nearly busted a capillary berating him; the only English spoken in the Duke's emergency room took the form of four-letter words. Trauma-alert meant you tried not to kill anyone before dawn--and in the process, kept the fuck out of Duke Baker's way.
"Brad! Over here!"
Alger felt his pulse rocket as he caught sight of Dennis Crow. Tall, thin, with a shock of dark hair and freckles covering every inch of exposed skin. Crow was one of the four interns who had started with Alger, and the only one who seemed even more out of place. Born on a farm, trained at the University of Wisconsin--and completely in over his head at the big-city ER. In other words, he had the Duke's footprints all over his freckled ass.
At the moment, Crow was standing between two paramedics, at the head of a stretcher on the other side of the ER. The two paramedics were struggling with a convulsing patient as Crow worked an endo tube down the man's throat. Although both paramedics were big and burly, they were having a hell of a time keeping the patient still. One was fighting to get a Velcro restraint around the man's shoulders, while the other was using his weight against the patient's wrists.
Alger grabbed a pair of sterile latex gloves from the cart next to him and rushed forward. As he navigated across the room, he signaled for a crash cart, a portable EKG machine, and a chem tray. He reached Crow and the stretcher seconds ahead of the equipment and a nurse. He watched as Maria Gomez began pasting the circular electrodes from the EKG monitor across the patient's chest. She was a big woman, with thick folds of fat hanging from around her arms and neck--but her motions were fluid and practiced. Still, her brown eyes showed a spark of concern. Crow and Alger were both interns with less than a week of experience. No nurse in her right mind wanted to stand around and watch two kids playing doctor.
Alger pushed the thought away. He wasn't playing doctor--he was a doctor. He focused his attention on the patient in front of him.
Caucasian, maybe twenty-four, twenty-five years old. Tall, muscular, with chiseled, boxy features and glazed, bright blue eyes. A blond crew cut, military style. His shirt had already been cut away by the paramedics, and there was a tattoo on his upper right shoulder, some sort of dragon with red flames coming out of its mouth. No visible signs of trauma, none of the marks of injury that Alger would have expected from a car-crash victim.
He watched as Crow finally got the intubation tube past the man's epiglottis and into his throat. The man's chest swelled beneath the EKG electrodes, and Crow quickly attached an air tube to the top of the endo tube. As the patient's breathing resumed, he settled back against the stretcher, his eyelids rolling shut. Alger turned toward the paramedics. "What have we got?"
The larger of the two answered as he finished fastening the Velcro restraint around the patient's chest. "Found him collapsed, unconscious, in the breakdown lane, maybe twenty feet from the site of the crash. No contusions, no visible signs of trauma. He convulsed twice in the ambulance--and just a few minutes ago he went into respiratory distress."
The paramedic stepped back from the stretcher. "No ID, no wallet. Doesn't respond to any stimulus at all. He was conscious for a few minutes in the wagon--but we couldn't get him to answer any questions."
"Start him on any meds?"
The paramedic shook his head. "His pulse and BP seemed fine. Like I said, his breathing didn't go down until a few minutes ago."
"What about the EKG?"
"You'll be the first to see it. It was a real grab and dash at the scene. We had another in the same ambulance, in much worse shape. We're not even sure this one was involved in the accident--he might have been a bystander. Certainly doesn't look like he was thrown through a car windshield, or anything like that." He paused. "Okay, you guys got it from here?"
There was obvious hesitation in the paramedic's eyes. Alger felt his face flush red. He couldn't help how young he looked. He nodded, his expression bold. The paramedic turned and headed back toward the double doors. His partner gave Alger a tiny nod, then followed. It was up to the two interns, now. Alger tossed a glance toward the Duke, huddled over a patient on the other side of the ER, then gritted his teeth. He was fresh--but he could handle this.
"All right, let's start with the basics. Airway, Breathing, Cardio."
He knew he sounded like an idiot to the experienced nurse, but he had to begin with what he knew--and that meant the ABCs of medicine. He watched the man's chest rise and fall, and knew that Crow had done a good job with the intubation. Then he turned toward the EKG--the cardiac monitor--and focused his eyes on the small screen on top of the waist-high steel cart.
"Holy shit," he whispered.
Crow followed his gaze, his eyes widening. The screen was covered with frantic green lines. "He's all over the place! It looks like his heart's doing cartwheels! Is that V-fib?"
Alger stared at the screen, then shook his head. The man wasn't in arrest yet--but he was certainly close. Alger had never seen anything like it before. One second, the monitor showed an elevated cadence--and the next second a prolonged skip. One second he seemed to be in normal, sinus rhythm--and the next second he was bouncing through a combination of arrhythmias. Alger had no doubt that if the paramedics had seen such a bizarre EKG reading in the ambulance, they would never have handed this patient over to two interns. They would have brought him straight to the chief resident.
Alger turned back to the patient. The man looked calm, still unconscious, but there were visible spasms beneath his skin. His muscles seemed to vibrate in concert with the readings on the screen. No doubt about it, something weird was going on. "Jesus, this isn't good. What's his BP?"
Maria Gomez looked up from the blood-pressure gauge strapped around the man's right arm. "Two-twenty over one-twenty."
The nurse looked at the gauge again. She shrugged, her face slightly pale. "Two-twenty over one-twenty."
Alger coughed, his stomach churning. Two-twenty over one-twenty was extremely high. Along with the erratic heartbeat, it was a dangerous sign. The man's circulatory system was completely out of whack, and his heart was enormously overstimulated.
"An acute MI?" Crow tried. "Maybe a pulmonary embolism?"
Alger shook his head. The EKG didn't look like an MI or an embolism. Alger rubbed sweat out of his eyes. Stay calm. Stay focused. It was a mystery--but that was the thrill of the ER, wasn't it? Solving the mysteries? "Okay, we need a blood workup, a Chem 7--"
"His BP's rising!" Gomez blurted. "Two-fifty over one-fifty!"
Shit. How could his BP be rising? It was already off the map! Alger cursed. Thrill or no thrill--he knew it was time to bring the Duke over. Any second, this patient was going to arrest. Alger was about to call out across the ER when Crow shouted at him. "Now that's V-fib! That's definitely V-fib!"
Alger whirled back toward the EKG screen. The bright green lines had become completely disjointed and frantic, indicating that the man had gone into ventricular fibrillation. His heart was responding to random electrical impulses, and was no longer capable of pumping blood to the rest of his body. In other words, this patient was failing. Fast.
"BP dropping!" Gomez chimed in. "He's crashing!"
Alger leapt for the crash cart, while Crow called the Code. Normally, doctors and nurses would have rushed toward the crashing patient--but tonight there were so many tragedies filling the ER, the Code barely registered. Alger knew that the Duke would make his way over when he realized his two interns were in charge of the dying man--but Alger didn't have time to wait for the chief resident to take over.
He grabbed the defibrillator paddles off the crash cart and slipped them over his hands. He rubbed the conductive fluid over the pads, then scraped them together in a circular motion. He had no choice but to shock the man and pray that his heart resumed a workable rhythm. He had never used the paddles before--but he had watched the procedure a dozen times during medical school.
"Three hundred joules," he declared, trying to keep the emotion out of his voice. He knew three hundred was a high place to start--but this was a big, muscular guy. Probably worked out every day of his life. "Clear!"
Everyone stepped back from the stretcher. Alger pressed the paddles against the man's bare chest and hit the triggers with his thumbs. The man's body spasmed upward, then crashed back down onto the stretcher. Alger turned to the EKG machine.
Still nothing. He turned back toward Gomez, who was now standing by the defibrillator. "Three-sixty. Stat!"
"Jesus," Crow mumbled. "Where the hell is Duke?"
Alger ignored him. There wasn't anything the Duke could do at this point--either they got this guy's heart started again, or he was finished. Gomez upped the voltage, and Alger readied the paddles. "Clear!"
This time, the man arched a full four inches off the stretcher. His neck twisted back and his arms convulsed beneath the Velcro straps.
"Flat line!" Crow yelled. "He's down! Brad--"
"Again!" Alger shouted back. "Clear!"
He shocked the man a third time. The smell of burned flesh filled Alger's nostrils, and he frantically turned back to the EKG machine. Still nothing. He tossed the defibrillator paddles aside and leapt halfway up the stretcher, placing his palms roughly near the center of the man's chest. The muscles of his forearms contracted as he started the most vigorous CPR of his life. The man's chest felt strangely stiff beneath his fingers, his skin rough, almost leathery. He worked in near silence, the minutes ticking by as he tried to coax the man's heart back to life. He ignored the sweat running down his back, the ache in his arms and shoulders. His mind raced through everything that had just happened, searching for some reason why things had gone so drastically wrong. Was there anything he had missed? Was there anything else he could have done? Did he make the right choice when he went for the defibrillator paddles?
"Well?" he asked, desperate, already knowing the answer.
"Still nothing," Crow responded. "He's gone, Brad. You're just pumping beef."
Alger looked at the EKG screen, then back at Crow. He glanced at Gomez, who nodded. He felt his shoulders deflate, his arms going limp. Damn it. It had all happened so fast. He glanced toward the Duke, who was still working on a patient near the front of the room. Either he hadn't heard the Code, or he was handling an emergency of his own.
Alger swallowed, telling himself that he had done everything by the book. The Duke wouldn't have handled the situation any differently. The guy had gone into arrest less than two minutes after he had been wheeled into the ER. The paddles could have saved him--and they certainly didn't kill him. Still, Alger felt awful. A man had just died in front of him. He lifted his hands off the man's bare chest and took a step back from the stretcher. Why the hell had he chosen emergency? He glanced up at the clock over the double doors. "Time of death--three-fifteen."
He peeled off his gloves as Gomez rolled the stretcher toward the elevator at the back of the room. The elevator was a straight shot downstairs to pathology, then onward to the hospital morgue. There would probably be an autopsy, because of the mysterious circumstances behind the man's death, and maybe the pathologist would be able to tell him what had really happened. But it wouldn't make any difference to the man on the stretcher.
Alger's face went slack as he watched Gomez push the corpse away. His eyelids suddenly seemed as if they were filled with lead. He felt Dennis Crow's hand on his shoulder. "We did everything we could. People die, and despite what the Duke might think--sometimes it's not our fault."