Chapter 17 — Air Ambulance

_July 6, 1989, McKinley, Ohio_

{psc} "What do you need, Doctor Casper?" I asked as Mary, Tom, and I entered Trauma 2.

"Doctor Wilson is in Trauma 3 for a chest tube and central line, so I need you to put those red scrubs to use and confirm my MVA needs an ex-lap for splenic rupture."

"Indications?"

"Abdominal pain, epigastric tenderness, Kehr's sign, tachy, hypotensive, strained respiration requiring intubation. The patient consented before intubation."

"Tom, ultrasound, please," I said.

"Be right back!"

"Mary, Kehr's sign?"

"Acute pain in the shoulder, usually resulting from blood in the peritoneal cavity in a supine patient with their legs elevated. Left shoulder referred pain is a sign of splenic injury."

"Differential?"

"Diaphragmatic injury, kidney stones, and, in a female patient, ruptured ectopic pregnancy."

"Very good. You perform the ultrasound."

"Uh…"

"You can do it," I said. "We'll all see the image."

Tom returned with the ultrasound unit and I walked Mary through the procedure.

"What do you see?" I asked.

"I have no idea what I'm looking at," she said.

"This," I said, pointing, "is his spleen, right below his left lung and to the left of his liver. And this," I pointed again, "is free fluid around the spleen, indicating bleeding. We could do a peritoneal lavage to prove it's blood, but I think that's wasting time. Mary, call up and say we have a surgical case — ex-lap for probable splenic fracture. Tom, we need an orderly."

"Thanks, Mike," Ghost said, handing me the chart.

I made my notes, signed it, and handed it back.

"Somebody call for a surgeon?" Doctor Mary Wilson asked, coming into the room.

"Mike did the consult," Ghost said. "You were busy with the driver."

"Then I'm going up because they'll need two teams."

And if she was going up, that meant my students and I couldn't scrub in, as I'd be the only surgical Resident available.

Twenty minutes later, Mary, Tom, and I were back in the ED.

"I thought we might get to scrub in," Mary said.

"Once Doctor Wilson said there were two surgeries, and she was going to scrub in, I knew that couldn't happen."

"Doctor Mike?" Nurse Tiffany, who was at the triage desk, called out. "Walk in chest pain."

Which meant they had to be seen immediately, with only someone transported by EMS having priority. I looked at the board and saw Trauma 4 was free.

"Tom and Mary, wheelchair, and bring the patient to Trauma 4. GO!"

I went to the nurses' station and asked for a nurse, and Billie followed me to Trauma 4.

"What's your name, sir?" I asked, as my students brought him in.

"Mike Meyer," he grunted.

"Let's help him onto the table," I said. "Mary — EKG, monitor; Tom — IV saline and start a chart; Billie — nasal canula, CBC, Chem-20, ABG, and stat cardiac enzymes."

We got Mr. Meyer onto the bed and I performed the primary exam while the others executed their tasks.

"How old are you, Mr. Meyer?" I asked after auscultating his heart and lungs.

"Forty-nine," he grunted.

"Do you smoke?"

"No."

"IV is in!" Tom announced.

"Do you consume alcohol?"

"A couple beers after work with the guys most days."

"When did the pain start?" I asked.

“About an hour ago, I guess.”

"BP 190/120," Mary reported. "Tachy at 125; PO₂ 92%; EKG shows arrhythmia."

"What do you see?"

"The T-wave doesn't look right."

I looked up and saw she was correct.

"Inverted T-wave. Call for a cardiologist, please. Tom, get the blood to the lab."

"Right away!" Mary replied.

"On it!" Tom declared.

"What's that mean?" Mr. Meyer asked.

"That your heart has been damaged in some way. Just try to relax, please. We're calling for a cardiologist and we'll give you some medicine to help. Billie, 250mg ASA IV push and sub-lingual nitroglycerin tab."

"250mg AGA IV push; sub-lingual nitro," Billie repeated.

The nitroglycerin brought down his blood pressure slightly and helped with the pain. About four minutes later, Doctor Shore from Cardiology arrived with a Third Year I didn't know.

"Shore, Cardiology. What do we have?"

"Hi, Pat," I said. "Mike Meyer; forty-nine; presented with chest pains; hypertensive; tachy; inverted T-waves on the monitor; murmur on auscultation. Administered ASA and nitro. Recommend cardiac echo."

"Thanks, Mike. Mr. Meyer, I'm Doctor Shore from Cardiology."

He proceeded to listen to Mr. Meyer's heart and reviewed the EKG.

"I'll take him on my service," Doctor Shore said. "Mr. Meyer, we're going to take you upstairs and perform an echocardiogram — an ultrasound of your heart — to get a better idea of what's going on. Mike, enzymes?"

"Ordered stat. We should have them momentarily."

"Kyle," he said to his student, "call for an orderly. Mike, I'll need him on a portable monitor."

"Tom," I said. "Switch to a portable monitor and escort Mr. Meyer upstairs."

"Will do."

I updated and signed the chart, then said, "Mr. Meyer, you're in very good hands. Mary, with me, please."

We left Doctor Shore, Tom, Kyle, and Billie with the patient.

"Mike," Angela called out. "Arm lac in Exam 6. Doctor Varma asked if your student could suture."

"Absolutely," I said. "Mary, this is all yours. I'll watch. Remember, identify yourself as a Sub-Intern and me as your supervisor."

"Got it!"

The arm lac was clearly a simple repair, so once Mary had explained what she was going to do, I left the exam room and saw Tom walking down the corridor from the elevators.

"Trouble?" I asked.

"V-fib in the elevator, but he cardioverted immediately. How did you know?"

"You were gone too long for a simple transport," I said.

"Mike?" Nicki, the clerk called out, "EMS two minutes out with a burn victim. It's a bad one. Doctor Casper needs your help."

"OK. Tom, let's go. Mary is suturing."

We gowned and gloved and hurried to the ambulance bay. I looked across the driveway and saw the slowly rising building that would be our new trauma center, but the paramedics arrived just a few seconds later, and I cleared my mind to focus on the patient who was about to be unloaded.

"Mike, if this is as bad as it sounds," Ghost said, "we'll stabilize, then you'll take him to the burn center in Columbus."

"I haven't made all my flights," I said. "I'm one short."

"The number of flights is advisory only," he said. "Josh will sign off, I'm sure. The problem is that if one of the senior Residents or Attendings go, we'll have to call someone in and we're short-staffed because Loretta is on leave until tomorrow and Boyd and Fitzgerald are out sick."

"OK. I'll leave you Mary even though she'll have a fit. She can do suturing and other basic procedures for which Tom hasn't yet been trained."

"Helicopter?" Tom asked nervously.

"Yes."

"They come off the assembly line with the single mission of killing all their occupants!"

"I can take Doctor Varma's third year," I said.

"No, I'll go."

The EMS squad pulled up, and the paramedic jumped out.

"Bad one, Doc!” he said as he moved to the back of the squad and opened the door. “John Doe, mid-to-late twenties, with third-degree burns on his arms and most of his torso; smoke inhalation; BP 90 palp; tachy at 130; PO₂ 90% on ten liters by mask with no cyanosis; morphine administered; IV saline."

That amount of burn coverage meant, based on the rough calculations, about 50% and his chances of survival were around 60%, though with smoke inhalation, that number was likely generous.

"Mike, have them warm up the chopper. Tell Mary I need her, and the sutures will have to wait. Get ready to go, because as soon as I evaluate him and get another IV into him, he's going to Columbus."

"Right away, Doc! Tom, come with me."

My first stop was at the clerk's station, where I asked Nicki to call for the helicopter, which she did. Next, I went to Exam 6 and asked Mary to step out.

"Doctor Casper needs you in Trauma 3 to help with a burn victim. Tom and I are going to take him to Columbus by chopper as soon as he's stabilized. I'll let your patient know you'll be back in a few minutes.

"Not to be a bitch…"

"I know, but we're short-handed and no disrespect to Tom, but you can be much more useful here, rather than babysitting the patient on the helicopter. Go!"

"Yes, Doctor."

She left, and I went into the exam room and informed the patient that we had a serious emergency case and that Mary would be back shortly. We left the room and Nicki signaled me.

"Fifteen minutes," she said. "The crew is on their way to the pad."

"Thanks!"

I took Tom to the locker where I gave him the same basic instructions I'd once been given, and I put on a red flight surgeon jacket while Tom donned a blue trainee jacket. We grabbed our helmets, but didn't put them on, then headed to Trauma 3.

The patient had been intubated and now had two large-bore IVs for fluid replacement. The burns made an EKG impossible, and the pulse oximeter was on his ring finger, rather than index finger, due to burns. And the room smelled of charred flesh, which caused my stomach to turn.

"Chopper will be ready in about ten minutes," I said, fighting the nausea.

"Full-thickness burns over his arms and torso," Doctor Casper said. "Tom, get Doctor Taylor please. Drag him in here if you have to."

"Yes, Doctor," Tom replied.

He left and returned with Doctor Taylor about a minute later.

"What do we have, Ghost?"

"Male; late-twenties; 50% full-thickness burns; hypotensive and tachy; IV Ringers with dobutamine; intubated; minimal urine in the bag; he needs to go to the burn unit in Columbus as soon as surgery does an escharotomy. The chopper is warming up and I plan to send Mike and Tom. You'll need to formally sign off for Mike to fly solo. He's done three and has the signoffs for those in his book."

"Mike, let me have your procedure book, please," Doctor Taylor said.

I pulled it from my back pocket and handed it to him. He wrote on a blank page, signed it, and handed it back.

"You're cleared. I'll update the hospital records. Ghost, I think he should take a nurse as well. Kellie can go with them; she's a certified flight nurse from her Navy service. I'll let her know. She'll bring the drug box."

"What do we have?" Doctor Lindsay asked, coming into the room.

"Hi, Shelly," Ghost said. "50% full-thickness burns with pulmonary compromise. He needs an escharotomy."

"OK. Mike, put a gown over that flight jacket and assist, please."

Nurse Billie helped me into a gown, and put a mask on me, and I stepped up to the table with Doctor Lindsay, who had been helped into her gown and mask by Nurse Jenny.

"Have you seen one of these?" she asked.

"No."

"We incise the burn skin down to the subcutaneous fat and into healthy skin lengthwise, if possible. The goal is to relieve the constriction of his chest and allow for better respiration. When you cut, you need to take care to avoid nerves and veins. Watch and one of us will supervise you performing this in the future."

She made the necessary incisions, which only increased my nauseated feeling. I'd always heard severe burns were the worst, and now I was sure of it, and not just for the patient, but for the surgeon and other medical staff. The smell, combined with the sights and sounds of crackling flesh as she cut, was enough to induce nausea into anyone.

"Billie," Doctor Lindsay said, once she'd completed the procedure, "antimicrobial dressing, please. Vancomycin, 100mg IV push then drip at 10mg/min."

"Vancomycin, 100mg IV push, drip at 10mg/min; antimicrobial dressing,” Nurse Billie repeated.

She and Jenny quickly and efficiently set up the IV and dressed the escharotomy.

"50%?" Mary asked quietly.

"It's a rough calculation — 9% for each arm, 36% for the torso, 9% for head and neck, 18% for each legs, and 1% for genitalia."

"Thanks."

"PO₂ now 93%," Ghost said. "A slight improvement. Mike, your key number is his BP. Keep the fluids flowing, and keep the dobutamine drip going. The fluids and dobutamine should keep his pressure up. Increase the dobutamine if you see the pressure drop. If you need help, they'll patch you through the radio to us or the burn center."

"OK," I said. "Let's go."

Ten minutes later, Tom, Kellie, and I were buckled in and the patient was loaded on the helicopter.

"Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University," I heard in my helmet as the helicopter lifted off.

"Relax, Tom," I said, seeing his knuckles whiten as he gripped the armrest to his left.

"First time on a helicopter?" Kellie asked him.

"Yeah," he said. "You were in the Navy?"

"I was a nurse aboard the carrier _Nimitz_ for six years. I flew on dozens of SAR missions."

"Ever jump into the water?" I asked.

"No, we had divers who were trained as corpsmen for that. My job was to assist the flight surgeon, as I'm doing now."

"Fishing pilots out of the water?"

"Mostly, yes. Occasionally over land, but mostly at sea. Rescue choppers take off before air operations, and I flew those, too, but mostly that was simply sitting waiting for something that rarely happened — a catapult problem or engine problem that dropped a Tomcat into the water."

"Get a BP for me, please," I said. "You'll need to use the ankle given the burns on his arms and the dressing."

She took the measurements and reported them as 110/80, which I adjusted, as ankle systolic pressure was anywhere from ten to twenty percent higher than brachial pressure. That meant his brachial pressure would be somewhere around 100/70, which was much better than when he'd first come in.

"No changes to the IV," I said. "Sats look as good as we could hope for."

It was 94%, and given his smoke inhalation combined with the circumferential burns, I doubted we could get it higher until his lungs recovered.

"Mike, can I ask why they didn't send an Attending?" Tom inquired.

"It's only required for cardiac cases," I replied. "And despite hypotension and tachycardia, the patient doesn't appear to have any compromise of heart function. In effect, we're acting as paramedics, and both Kellie and I have more training than they receive. Both pilots are paramedics as well, and you've had two years of med school. Given the limited ability to do procedures in the chopper, it doesn't make much difference. And I can radio in if something happens that concerns me."

"I wonder what happened?"

"One thing you'll learn in the Emergency Department is that you will likely never know much about what happened before or after you see a patient. Our job is assessment and then stabilization or treatment. After that, we admit or discharge them. Either way, what happens after they leave the ED is opaque in most cases. That was the most difficult thing for me to adapt to."

"Five minutes out," came over the headset.

I listened as the co-pilot spoke to the controllers and, as predicted, just under five minutes later, the helicopter touched down on the helipad. As usual, the rotors continued to turn as the local staff rushed out, ducking, and the co-pilot opened the door.

I carefully jumped out, took off my helmet, and moved directly to the doctor, who had arrived with two nurses, an orderly, and a medical student. I put my ear near his mouth and my mouth near his ear so we could converse over the noise of the helicopter engines and blades.

"Jones, burn specialist,” he said loudly.

"Loucks, trauma surgeon; John Doe; late twenties; 50% full-thickness burns to arms and torso; escharotomy; IV Ringers; dobutamine and vancomycin; ankle BP 110/80; pulse 100; PO₂ 94% on vent; minimal urine production."

I handed him a copy of the chart, he signed my form for our chart, and they moved the patient from the helicopter. As soon as the patient was clear, I got back into the helicopter and the co-pilot shut the door. He climbed in, checked with the controller by radio, then announced our departure. As was my usual practice, as soon as the helicopter left the ground, I leaned back and closed my eyes.

I wasn't sure how long I slept, but I was jolted awake when a klaxon sounded and the helicopter shuddered. The nose of the helicopter dipped, and I felt my stomach move as it did on rollercoasters.

"Engine failure!" I heard over the headset. "Emergency landing! Hang on!"

"Oh, God!" Tom moaned in distress. “No!”

"We have two engines," Kellie said calmly. "They'll put us down on a road or other flat surface."

She was WAY too calm in my mind. Sure, I slept on the return flights, but this was different. I did the only thing I could — prayed the Jesus Prayer. About thirty seconds later, we made a rough landing, and the co-pilot ordered us out of the chopper. Tom needed no encouragement, throwing open the door and bolting out. I quickly followed him, but Kellie simply calmly exited the passenger compartment.

I immediately surveyed where we were, and saw we'd landed on a baseball field, in the shallow outfield, just past second base. I turned and saw a bit of smoke coming from one of the two engine compartments, VERY happy the helicopter had _two_ engines. The pilot and co-pilot both had extinguishers in hand, but weren't using them.

Tom, still moving, stumbled, and collapsed onto the ground. Kellie quickly moved to him. She checked his pulse, then had him lie down.

"180!" she announced.

My heart was racing, too, but probably around 130. Kellie, on the other hand, was cool as ice.

"Let's see if it resolves," I said. "Tom, just try to breathe normally."

"How are you, Doctor?" Kellie asked.

"Well, I managed to avoid soiling my underwear, so there's that."

After about a minute, Tom sat up and seemed to be doing better, with his pulse down to about 130. The pilot came over to us.

"I called it in. We're about six miles from the hospital. They'll send someone for you; we'll stay with the bird until the maintenance crew arrives."

"Will you fly it out?"

"No way. They'll put her on a flatbed and take her back to the barn."

About fifteen minutes later, a van arrived to take Tom, Kellie, and me back to the hospital. Kellie and I helped Tom into the van, we all buckled in, and the co-pilot closed the door of the van.

"Tom," I said when the van pulled away, "when we get back, take a thirty-minute break in the on-call room."

"Thanks," he said.

"Come see me after your rest period, and we'll evaluate."

"I will."

"How many mechanical failures did you experience, Kellie?"

"Four, but as with this, the pilot simply managed it and set the helicopter down on the deck. We had one really hard landing, worse than the one we just had, and that helicopter was salvaged for parts because it wasn't worth fixing. The others were back in the air within a day or two."

When we arrived back at the hospital, the news had spread, and Ghost came to talk to me while we took off our gear.

"Tom is going to take a break," I said. "His pulse skyrocketed."

"How are you?"

"Fine. My pulse went up from the adrenaline hit, but it resolved quickly. Kellie, on the other hand, has ice water in her veins!"

"Eight years in the Navy, six on a carrier will do that," Ghost observed.

"Kellie, when did you get out?" I asked.

"In May. I flew home, had my interview here the next day, and started a week later."

"Your work wife wants you to call her," Ghost said to me. "Then go see Josh."

I chuckled, "Thanks."

"Work wife?" Tom asked.

"Doctor Clarissa Saunders," I replied. "We did undergrad and medical school together, and now are doing our Residencies together. Eventually, we'll be Attendings in the same hospital."

"THIS hospital!" Ghost corrected.

"Who knows what will happen in seven or eight years?" I replied. "I have a long way to go."

I made sure Tom went to rest, then went to the lounge to get some juice and call Clarissa.

"I can't leave you alone for two seconds, Petrovich!" she said.

"It's been hours since I've seen you, Lissa! And, as Nurse Kellie said, the helicopter has two engines."

"What happened?"

"Flying machine break; alarm sound; land hard; Ogg not know more!"

Clarissa laughed, "The crew didn't say?"

"No. Just 'engine failure' and I saw some black smoke from one engine compartment after we’d landed."

"You might want to call Kris, because it'll probably hit the news."

"No reporters showed up, and I doubt my name will be attached to it. Not to mention no blood or gore and nobody died, and the chopper isn't obviously damaged, so the Press won't care too much. Tom had a bit of an anxiety attack, and I had the expected adrenaline rush, but our nurse, who is ex-Navy, was cool as a cucumber. I don't think her heart rate went up a point! She served on the _Nimitz_ as a flight nurse."

"Let me guess — you were sleeping."

"That is what I do on the flights back. The engine alarm woke me up."

"Call Kris. If she finds out some other way, it won't go well."

"You're right."

"I usually am!"

"Uh-huh," I replied flatly. "Snacks at 11:00pm if I'm free?"

"Call me when you are."

We ended the call, and I dialed the house, surprised when Lyudmila answered.

"You're not my wife!" I declared.

"Is that a good thing or a bad thing?" she teased.

"Oh, no you don't! You French girls are troublemakers!"

"Yes, we are! Kris is putting Rachel to bed. Is there a message, or do you need to speak to her?"

"I should probably speak to her," I said.

"Let me take over for her. Rachel won't mind her «tante préférée» stepping in!"

She set the phone down, and about a minute later, Kris was on the line.

"Mike? Is something wrong?"

"No, but I didn't want you to worry. I was on an air ambulance flight that made an emergency landing on a baseball field on the way back from Columbus. Everyone is safe, but I know TV can blow things out of proportion, so I wanted to call."

"What happened?"

"All I know is what the co-pilot said — one of the two engines failed. My mechanical abilities are near zero, and I don't know anything more than the basics about engines."

"How did you get back?"

"They sent a van to pick us up."

"Why were you on the flight?"

"A patient with third-degree burns over more than fifty percent of his body. We're not equipped to treat a patient with those kinds of injuries, so we stabilized him, performed emergency life-saving procedures, and then loaded him onto the air ambulance to take him to the burn center in Columbus."

"What happened to him?"

"I have no idea. The paramedics didn't say, and he obviously couldn't talk because he was unconscious and intubated. I'm sure it'll be on the 11:00pm news."

"And I'll be in bed. Lyudmila is staying, so I don't have to take her home, and that's why Rachel was up late. I'll read about it in the _Columbus Dispatch_ or _McKinley Times_ in the morning."

"OK. I need to go."

"What's the answer?"

"To?"

"If it's a good thing or a bad thing that Lyudmila isn't your wife!"

"There is no way I am answering that question! In the immortal words of Admiral Ackbar — _It's a trap_!"

Kris laughed, "A very wise man! See you tomorrow evening. Remember, Rachel won't be in daycare."

"I remember. See you!"

We said 'goodbye' and I hung up, then went to see Doctor Taylor.

"Are you OK?" he asked. "You can take some time if you need it."

"What? And get no end of grief from Kellie Martin?"

Doctor Taylor nodded, "I spoke to her. She's one cool customer."

"The alarm went off, the co-pilot called out 'Engine failure' and she just calmly said the helicopter had two engines."

"The Navy trains them right. She said Tom had an anxiety attack."

"Me, too! I nearly soiled my underwear, but Kellie was so calm that I didn't freak out. I sent Tom to rest for thirty minutes."

"Wise. Other than that, Doctor Loucks, how was the flight?"

I chuckled, "Nice play on Mrs. Lincoln and the play! No troubles at all. The patient's vitals were constant the whole way and an entire team was waiting for us on the pad when we arrived. I slept from the time we lifted off until I was rudely awakened by the klaxon. Where's my student?"

"Helping Naveen with walk-ins, but I don't know which room she's in. You OK with another trip when necessary?"

"If Kellie can do it, I can do it!" declared.

"Can't let a girl beat you?" Doctor Taylor asked with a grin.

"You don't know Russian women, do you?" I asked. "Or French women. Or Doctor Saunders."

He laughed, "No, but I have two daughters, eight and six, and I am not looking forward to the next ten years!"

"I think my dad would commiserate with you about my little sister."

"You'll get yours in about fifteen years!"

"I can wait, thanks!"

Nurse Angela came to the door of the Attending's office.

"No rest for the weary! Multiple MVA coming in. Trauma 2 and 4 are open. Four minutes out."

"Let's go, Mike!" Doctor Taylor said. "Angela, send us three nurses and see if Mary is free."

"Will do!" she said.

Fortunately, the accident wasn't serious, and both patients were transported as a precaution. After exams, both were discharged with what a news report would call 'bumps and bruises', with instructions to see their personal physicians. It was a testimony to the effectiveness of seatbelts that they had no serious injuries.

"Don't sit down," Nicki said as I left the trauma room. "EMS two minutes out with motorcycle accident. Doctor Casper is in the ambulance bay and wants your help."

"OK. Mary, let's go."

"Doctor Mike?" Tom called out, coming from the on-call room.

"How are you, Tom?"

"OK, I think. My hands a shaking a bit, but I feel better."

"Go home. I'll clear it with Doctor Taylor. Get a good night's sleep, and take tomorrow off. I promise this won't count against you in any way."

"Thank you."

He left and Mary and I hurried to the ambulance bay, arriving just as the EMS squad pulled in. As soon as the paramedic reported the vitals, I was sure it was a hopeless cause, but that didn't mean we wouldn't try.

"Traci, call for a neuro consult!" Ghost ordered as we rushed the patient to Trauma 1.

My assignment was intubation, and I considered allowing Mary to do it, but decided I needed to do at least _some_ procedures. I did that, then did a neuro check while Ghost examined other injuries.

"CSF in the right ear," I announced. "Right pupil blown, left sluggish. He's going to need mannitol. Mary, check his pockets for his license, and see if he's an organ donor."

"Mind if I finish my exam?" Ghost asked.

"Sorry."

Given the patient wasn't breathing on his own, had cerebrospinal fluid in his ear, had a blown pupil, and had no response to the Babinski, and arrhythmia, the odds of him recovering were almost infinitesimal.

"Cohen, Neuro," Doctor Rebekah Cohen said, coming into the room, with her Fourth Year student Al Temple.

"Mike?" Ghost prompted.

I gave the report, and she nodded, then repeated the tests I'd done, and reached the same conclusion.

"Skull series, then an EEG," she said. "Mannitol, stabilize, then send him to Radiology."

"He's an organ donor," Mary announced.

"OK." Doctor Cohen said. "Is there a family member here?"

"We don't know," Ghost said. "Mike, see if someone is here. Mary, call Radiology for an emergency skull series."

I left the room and went to the admit desk and asked if Mr. Jackson had anyone waiting for him, and was directed to a young woman who was about my age.

"Ms. Jackson?" I asked.

"Yes! How is Mark?"

"We're evaluating him now," I said. "There are two doctors besides me with him and I came out to let you know we're going to take x-rays and run some tests, but his injuries are quite severe."

"Will he die?" she asked, a hitch in her breath.

"It's too early to say anything just yet. Someone will come speak with you, soon. I just wanted to make sure you knew we were taking care of him."

"Thank you, Doctor."

I returned to the Trauma room and let Doctor Cohen know.

"OK. Once the skull series is done and he's upstairs, have your student bring her up to Neuro and we'll take it from there."

"Will do."

"He's not stable enough to move yet," Ghost announced. "And I'm not sure we can do anything about that arrhythmia."

"ICP," Doctor Cohen said. "Mike, could you assist with an emergency craniectomy?"

"I could," I replied. "Here?"

"If we don't relieve that pressure, he's going to herniate and we'll lose him. We might anyway. Al, call Neuro for a nurse and a craniectomy tray, stat. Let's prep."

We washed our hands and put on fresh gloves while the nurses draped the patient. When the nurse arrived from neuro, the tray was opened and set up.

"I'll make the incision in the scalp," Doctor Cohen said. "I'll have you retract the scalp and clip it, and control any bleeders. I'll cut the skull with the saw, separate the dura, then make an incision to allow fluid to drain. We're going to remove a six centimeter section of skull."

"OK," I replied.

My part of the procedure was simple, as it basically involved pulling back the section of scalp she'd loosened, clipping it back with a surgical instrument, then using two hemostats to stop bleeding, while the neuro nurse carefully applied suction. Doctor Cohen, an experienced surgeon, but new to Neuro, cut out the section of bone, and put it in a basin.

"Herniation, Doctor!" the neuro nurse declared as the brain visibly swelled through the skull flap.

"Mannitol, IV push!" Doctor Cohen ordered and her nurse picked up a pre-loaded syringe and injected it into the IV.

"V-fib!" Ghost announced. "Paddles to me!"

Two rounds of shocks and a dose of epinephrine resolved the V-fib, but the patient still had arrhythmia.

"Al, call upstairs and ask for Doctor Baker to come down immediately, please."

He went to make the call and five minutes later, Doctor Baker came into the room. Doctor Cohen reviewed the case with him and he performed his exam, shaking his head.

"I don't think we're going to save this one," he said. "You can't move him and it wouldn't matter if you could. At this point, if the swelling resolves, he might make it. If not…is a next of kin here?"

"His wife is in the waiting room," I said.

"Rebekah, let's go talk to her," Doctor Baker said. "Ghost, with us. Mike stay here and monitor the patient."

"Yes, Doctor," I replied.

They left, along with Al, leaving Mary, me, and two nurses in the room.

"Is there anything more we can do?" Mary asked.

I shook my head, "I already said a prayer, and at this point, that's all that was left to do. The brain swelling isn't reducing after two doses of mannitol, and he's likely to suffer cardiac arrest at any moment. That V-fib before was the harbinger. Some time in the next ten minutes, most likely, he'll have another bout of V-fib which will lead to asystole, if not immediately, then shortly after. There is nothing we can do to stop that."

"You were sure when you did the neuro exam."

I nodded, "So was Doctor Casper, but he was correct to ask me to wait until he'd finished his full exam. A blown pupil, CSF in the ear, and no response to a Babinski all indicate serious neurological compromise. And then when the brain flap was created, the brain swelled significantly. A helmet might have saved his life."

"Why would anyone ride a motorcycle without a helmet?"

I shrugged, "It's a free country, which means we're free to do foolish things like smoke, drink to excess, ride motorcycles without helmets, and get on helicopters!"

"I was pissed right up until they called in that you'd made an emergency landing. After that, not so much."

"If we weren't short-handed, I'd have taken you, but they needed you here."

"I heard Tom was freaked out."

"He was. I sent him home to get a good night's sleep."

The monitor blared, and I reached over and pressed the silence button.

"V-tach," I said. "Run of eight."

"I thought you said V-fib," Mary observed.

"I did. V-tach in short runs isn't life-threatening, but it's an indication of trouble. Any drugs I could give him at this point would likely be counterproductive. Is there any urine in the bag?"

She checked and held it up, "Pink."

"Internal bleeding, too," I said. "Too many things wrong and not much we can do about it."

"I feel helpless," Mary said.

I nodded, "Me, too. But in the end, we're not gods, the red scrubs I'm wearing notwithstanding."

She laughed softly, "You aren't a…"

"Prick?" I prompted.

"I was going to say 'a-hole' like most surgeons."

"Because I'm not a surgeon and don't have the right mentality for it. I'll be a _competent_ general surgeon, but my main role will be emergency procedures. I live for the adrenaline rush."

"Including helicopter accidents?"

"That one was over the top even for me."

The monitor blared again, and I hit the silence button.

"Run of ten," I said. "It won't be long now."

The three doctors came back into the room.

"Two runs of V-tach," I said. "Runs of eight and ten. I expect he'll go into V-fib soon, then arrest."

"I'd say that's right," Doctor Baker said. "We did get consent, so I had Al call for the transplant team to stand by."

"Do we try to shock him?" Mary asked.

"Yes," Doctor Casper said. "With no advance directive, we have to try."

Just under ten minutes later, the expected scenario played out, and after five shocks and two doses of epi, the monitor showed asystole.

"Call it, Mike," Ghost said.

"Time of death, 23:51," I said.

"Let's get him up to surgery," Doctor Baker said. "No time to wait for an orderly. Al, grab the gurney."

I filled out the chart while they moved the patient to a gurney, connecting a portable ventilator to keep his lungs perfused with oxygen. Doctor Beker, Doctor Cohen, and Al left with the gurney and Doctor Casper sent Mary to bring his wife to the consultation room.

"Ms. Jackson," I said when she came into the consultation room. "Please have a seat."

"He died, didn't he?" she asked, tears welling up in her eyes.

I nodded, "Yes. We used every skill and every procedure we could, but his injuries were too severe, and he died. With the consent you provided, he's being taken to surgery for organ donation, and you'll be able to see him afterwards. Would you like us to call someone for you? There's a chaplain on call, if you want."

"Our priest at Saint Augustine," she sniffed. "Father Clifton."

"I'll see that he's called," I said. "Mary will take you upstairs and sit with you until your priest comes."

"Thank you," she said.

Ghost and I left the room, and I went to the clerk's desk and asked Nicki to call Father Clifton and ask him to come to the hospital, then Ghost and I went to the lounge to get bottles of juice.

"You jumped the gun a bit," he said. "You were right, but it's important to always finish the exam, no matter how obvious the situation is. It's too easy to start taking shortcuts and making assumptions. And that is the way to kill your first patient."

"Message received loud and clear," I said.

"Just remember, Mike, ninety-five percent of the time the obvious answer is the answer. It's those other five percent that will burn you."

"Doctor Casper?" Nicki said from the door to the lounge, "There's a Sheriff's Deputy here who wants to speak to the pronouncing doctor."

"That's Mike," Ghost said.

"Send him in," I said. "I really do not feel like standing up at the moment."

She left and about fifteen seconds later, Deputy Schmidt came into the lounge.

"Hi, Doc," he said to me.

"Hi, Deputy. You're here about the donorcycle?"

"Yes. I just need a time of death and a summary of his injuries for my report."

"Mind if I ask what happened?"

"He was in the left lane and a car changed lanes without signaling or looking for him. The driver is at the sub-station being questioned. We have two witnesses in a car behind them."

"Reckless operation and negligent homicide?" Doctor Casper asked.

"Most likely, because they can make that stick based on what I've seen."

"Time of death was 23:51. Severe head injuries, which resulted in an irregular heartbeat that we couldn't resolve. He was paralyzed at least from the waist down, and wasn't breathing on his own. He also had internal injuries, but we won't know the extent until we see the surgical report from the transplant team."

"Can you give me a cause of death?"

"Not wearing a helmet," I said. "Beyond that, you'll need to wait for the surgical report or hear from Doctor McKnight."

"What do you think?"

"That I'm not a forensic pathologist or medical examiner," I replied. "All I can say is that we saw his heart stop, which is, in the end, the cause of every death. Which specific injury caused that, I'm not equipped nor prepared to say."

"OK. That's all I need. I heard his wife is here."

"Upstairs with my student, Mary, waiting for a priest. They’re in the surgical waiting room."

"Thanks, Doc."

He left, and I leaned back again, the effects of multiple adrenaline rushes making me feel ready to collapse, despite being only halfway through my shift.

"Go take a nap," Doctor Casper said. "Barring the outbreak of World War III or giant grasshoppers attacking, we won't wake you for two hours."

"If World War III starts, let me sleep. I'd rather the nuke went off and I didn't know about it."

"I hear you on that one. Nice work deflecting Deputy Schmidt."

"It was drummed into my head by Doctor McKnight that he's the only one who can say definitively what happened except in cases of decapitation, which is routinely fatal and obvious."

"You think?" Doctor Casper said, shaking his head. "Go get some sleep."

"Thanks," I said.

I got up, made my way to the on-call room, put on the sleep mask I carried, got into bed, and fell asleep almost instantly.