Do No Harm (2 page)

A nurse's hand appeared seemingly out of thin air, handing Diane another saline bottle.

Carson Donalds ran in, breathing hard, and shot looks around the room with the mixture of anxiety and disorientation typical of a medical student. He ran a hand through his mop of curly blond hair, his eyebrows disappearing under the front line of his bangs. "I heard you have a pretty gnarly alkali burn." He saw Pat's face, then glanced at the body and took a step back. "Fuck. Is that Nancy?"

David's bottle spat air, so he tossed it into the bin, grabbed another, and continued irrigating the eyes. "Dr. Donalds," he said, taking a calm, didactic tone, "why don't we use emetics for alkali ingestions?"

"Because she's paralyzed and tubed and the last thing you want is her barfing up and asphyxiating," Carson said.

"How about if she wasn't tubed? Would we use an emetic then?"

"No. You don't want to reexpose the esophageal tissue to offending agents on the way back up."

"And?"

Carson shook his head.

"Dr. Trace?" David said. He didn't look up from the eye he was spraying, but he sensed Diane's head pivoting.

She switched the saline bottle to her other hand, squinting as a wayward squirt caught her across the brow. "Increasing intraluminal pressure generated by emesis is speculated to increase the risk of perforation when the tissue is markedly weakened. Carson, get your ass over here and give us a hand."

Carson lunged forward and grabbed a saline bottle. Diane nudged him with a shoulder. "What are the three reasons we don't use charcoal to soak up alkali in the stomach?" she asked.

"Four reasons," David said.

Diane grimaced at being corrected but didn't look up.

Pat switched IV bags, then checked Nancy's blood pressure cuff, her face stained with grief and shock. With twenty-three years as an RN under her belt, Pat was the den mother of the ER nurses; that's why she'd followed Nancy in here, probably sending one of the more junior nurses out front to triage. Her crew cut was shot through with sweat.

"I don't know any," Carson confessed.

David raised an eyebrow at Pat. "Pat?"

"Why are you pimping a nurse?" Carson asked, a competitive note finding its way into his voice. Most doctors only fired questions at med students, interns, or residents.

"Because, in general, they've been around longer and know more than arrogant med students."

Pat looked over quickly, her cheeks quivering. "I . . . what . . . ?"

"Would you like to tell Carson here, and Dr. Trace, the four reasons we don't use charcoal to soak up alkali in the stomach?"

Pat managed to regain her focus, which had been David's aim in questioning her. "One, activated charcoal doesn't absorb alkali. Two, it obscures the endoscopic visual field. Three, if the patient is perfed, it would leak right into the mediastinum, and four, it's a vomit risk, and Carson and Diane already pointed out those pitfalls."

"That's right." David glanced around the small room bustling with people. A few faces still looked upset, and a lab tech was holding one of Nancy's limp hands. "We have a damn sharp team here," he said. "Don't worry, and stay focused."

A clerk leaned through the door. "Dr. Jenner's ringing through."

"Aah," David said. "Our ophthalmologist."

The telephone behind David emitted only a half ring before he grabbed it, first handing off his saline bottle to a nurse and pointing. "Keep flushing," he mouthed, pivoting to miss an IV pole a lab tech pulled around.

"Dr. Jenner, just in time. We need you down here, got a bad alkali exposure to the eyes."

"Was the skin around the eyes burnt?" Dr. Jenner's deeply textured voice was low, rolling, authoritative.

"Everything's burnt. The cornea's cloudy white."

"So the endothelium's already not functioning. Are you irrigating?"

"Saline."

"Good. Osmosis advantage."

"I can't find the Morgan lenses."

"Don't worry about it. They're outdated and overrated. Just get the eyes open and keep irrigating copiously. Once the eyes are better cleared, give her a drop of Pred Forte to stop the inflammation and a drop of Cipro for infection. I'm on my way."

Diane glanced up at David as he hung up the phone. He chewed his lower lip. "Pat, can you call GI again, ask what's taking so goddamn long on our consult?"

The radiology tech poked his head into the room, fresh back from the X-ray suite in the rear. "No free air," he said.

That was good--at least the alkali hadn't eaten through the esophagus, allowing air to escape into the body. Yet.

Diane leaned forward over Nancy's body, and she and David brushed foreheads. Her eyes jerked quickly away. "Sorry."

"How are you doing on the eyes there, Carson?" David asked.

Carson nodded. "Okay. But I think she's gonna need a corneal transplant." He leaned over, examining the other eye. "Two."

"We're going to apply some Cipro and Pred Forte drops. Can you get them ready?"

A uniformed UCLA Police Department officer strolled in; David was immediately irritated by his casual gait. The cop cleared his throat. "I have some questions I need to--"

"This patient is unconscious and can't answer questions."

"Well, I'll need to take a--"

"Not right now," David said. "Out, please. Out."

The cop shot him a good glare before retreating.

The nurses and techs continued to irrigate Nancy's flesh, lined on both sides of her body like feeding pups.

"Good, good," David said. "We're gonna keep irrigating her for hours."

Pat looked up, a little moist-eyed, and nodded. "We'll be here."

The wall phone rang, and a tech grabbed it, then held it out to David. "Dr. Woods."

David shot a latex glove into the trash bin and fisted the phone. "What took you?"

"I was in on a--"

"We have an alkali burn, some ingestion. No free air on the film."

"Ulceration of oropharynx?"

"Yes. And acute laryngeal swelling. We had to crich her."

"We like to have them swallow a little water, push the alkali down the esophagus into the stomach. Greater area, protective acids." Dr. Woods's voice was slow and droning. It reflected his personality.

"The swelling was already acute, and I didn't want to run the risk of her vomiting it back up," David said, a note of impatience creeping into his voice.

"Smart . . . smart. Unfortunately, there's little you can do to mitigate esophageal damage. Liquefaction necrosis happens almost instantaneously."

"Yes," David said. "I know."

"Fever? Whites are normal?"

"No. Yes."

"I'm going to need to get down there and take a look."

"In the meantime?" David waited through what seemed an eternity.

"One-fifty of Zantac IV stat to reduce the stomach acid. That should prevent stress bleeding and ulcerations as well."

"We'll see you shortly."

"Okay. Very we--"

David set the phone down on the cradle and relayed the order. He glanced at the monitor, admired the healthy baseline rhythm. Blood pressure 160 over 100. Respiratory rate at eighteen. Pulse 120. Oxygen saturation 99 percent.

He pulled a deep breath into his lungs and exhaled loudly. It took a conscious effort to relax his muscles and let his shoulders sink. Diane leaned forward over Nancy's face, continuing to irrigate her eyes. A wisp of hair arced across her cheek, finding the corner of her mouth.

An intern skidded on the floor, accidentally sliding past the door. She hooked the frame with a hand as she leaned in. "Golf cart versus Buick. Two forty-three-year-old males with penetrating head wounds. ETA two minutes. We're prepping Procedure Two."

David shot his other latex glove at the trash bin and headed for the door.

"YOU let me the fuck back there or I'll mop the floor with that ratty head of yours."

The police officer's gloved hand was inches from Carson's nose, pointing, as David approached them. Carson stepped back and glanced at the floor. He did not look pleased at the prospect of his prize locks being used to clean the tile of Hallway Two.

"Excuse me, officer," David said, pulling Carson farther back with a hand on his shoulder. "I'm Dr. Spier, chief of the ER Division. What can we--"

"You'd better step back," the officer said, the words coming in a low hiss through his teeth. Though he was cleanly shaven, incipient stubble dotted his face. It was only a little after 10 A.M., David thought. That's a lot of testosterone.

The cop's shoulders were broad, made broader by the dark, dark blue LAPD uniform that stood out in the stark white hall like a stroke of paint. His hair was neatly groomed, flicked to one side in a clean part. Though he looked younger than thirty, the hard flat sheen of his eyes bore witness that they'd already seen much beyond the purview of civilian eyes. His eyebrows, sharp strokes above his supraorbital arch, lent his face a sharp, focused cast.

David glanced quickly behind him for a white security uniform, but saw only pink and blue scrubs. He wasn't sure how helpful a security officer would have been in the face of a belligerent cop anyway.

David spread his arms slightly, his hands splayed, palms out. "You seem agitated," he said. "I'm sorry."

The cop took a deep breath and David eyed the name tag above the pocket line on his right breast. Jenkins. Nancy's brother?

David looked up and caught Jenkins's hard stare. "I'm sorry," he repeated.

"Listen, Doctor, I need to know right now where my sister is."

Seventeen years in the ER had left David not unfamiliar with how to deal with hard-ass LAPD cops. He forced a curt smile. "Nancy's in Trauma Twelve. I'll be happy to take you back to see her once I check on her, make sure a visitor won't interfere with the doctors and nurses who are still treating her. I'm sure you don't want to do anything to endanger her."

Jenkins's nostrils flared slightly. David debated asking him to step out through the swinging doors to Admit but decided not to fight that battle.

David backed up and pointed Carson toward the Central Work Area, saying in a low voice, "Get a female nurse over to keep an eye on Mr. Jenkins, please, and ensure he stays put." Jenkins was aggressive and upset--a woman would more likely calm him down, and he probably wouldn't pick a fight with her. "And I heard we've had some press milling around triage. Have security clear them out."

David passed through the CWA, dodging nurses, and ducked into Trauma Room Twelve. Nancy's body lay bare on the gurney, pale except for the red blisters on her face and throat. She was still unconscious, the ventilator pushing air into her lungs. Two nurses continued to irrigate her face and eyes.

A young nurse sat on a chair in the corner, sobbing, her yellow hair falling over her face in thick, yarnlike clumps. She was new to the ER, but David recognized her: one of Nancy's college roommates whom she'd recruited to the Division. In fact, he recognized the faded Aztec-print scrub top that was shaking with her sobs as one of Nancy's.

Pat crouched in front of her, rubbing her upper arm in tight ovals. A lapse in her usual truck-driver toughness.

David pulled a sheet up over Nancy's body, to just below the wounds on her upper chest. Her arm rested atop the sheet, and David noticed the band of pale skin around her ring finger. She'd caused something of a paperwork mess a few months ago when she'd changed back to her maiden name on all employee files.

The younger nurse continued to cry. David crossed to her and leaned over so he could see her name tag. "Jill," he said softly. "I know this is very hard for you, but I'm going to have to ask you to head back to the doctors' lounge. We have some family coming in. Her brother."

Jill stood unsteadily, her thick locks damp and sticking to her wide freckled cheeks. David touched her arm reassuringly. Pat led her out, passing Diane as she entered.

"I see you got someone from head and neck to revise the crich to a formal tracheostomy," David said. "Nice call."

Diane nodded. "Monkey see, monkey do."

A grin touched David's lips. "How flattering."

"We're getting ready to move her to the ICU. Woods is eager to scope her."

"I'm bringing Nancy's brother back to take a look. He's LAPD." David stepped closer to Diane and lowered his voice. "A real hard-on. Brace yourself."

Diane sighed, blowing her bangs up in a puff. Her cheeks were flushed, accenting the icy tint of her green eyes. She beckoned with both hands. "Bring it on."

David went to find Jenkins. It wasn't hard. He hadn't budged. He stood dead center in the hallway, thick arms crossed over his chest, making patients and personnel swerve to go around him. With a small nod, David gestured for him to follow back to the room.

When Jenkins saw his sister's body lying supine on the gurney, some of the protective cruelty washed from his face, and David caught a glimpse of his features unflexed and more softly arrayed. It was easy to forget how young Jenkins was, but in the split second before his veteran's toughness snapped up the slack in his face, David saw the pain striking his youthful core.

Jenkins shuffled forward, lips trembling as he viewed his sister's face. David rested a hand on his shoulder. Jenkins's cheeks colored in twinning ovals, though the rest of his face drained of color. An eerie effect. He raised a fist and coughed into it. "What is this?"

"She sustained a bad alkali exposure to the face," Diane said. "But she will survive."

Nancy's head was still cocked back in the sniffing position, the clear plastic tube running into the hole in her neck. A milky white eye gazed out blankly from between swollen lids.

Jenkins's hands fisted, then relaxed. "Sustained," he muttered. "Why are her . . . why are her eyes all screwed up? Is she blind?"

"I'm afraid she probably is," Diane said. "When she comes to, she'll be able to distinguish light from dark, but that's about it. She'll also have uveitis, which will cause extreme photophobia."

"She'll be sensitive to light," David said. "It'll hurt her eyes." He saw Diane's chin dip ever so slightly and knew she was scolding herself for not speaking to Jenkins in nonmedical terms.

"Once the inflammation stops," Diane said, "she might be able to have a corneal transplant. If she does, her sight could recover up to ninety percent."

"How long does that take? For the inflammation to stop?"

"Could be weeks, could be months. But we have a top ophthalmologist, Dr. Jenn--"

"What do you do in the meantime?"

"Keep irrigating, for now. We want to minimize the chance of scar tissue causing adhesions between the eyeballs and the eyelids."

"The eyelids," Jenkins repeated dumbly. Some color was returning to his lips, but his eyes retained their glassy sheen.

He reached a hand toward Nancy's forehead; it hovered above the raw, weeping skin. He bit his lip hard, fighting a tremor into submission. "Why's she . . . ?" His finger traced a path around the tube running through her trachea.

"She ingested some alkali, which caused her throat to swell," Diane said. "That's why we had to intubate her. We've already had an excellent gastroenterologist down here--he's going to scope her right now so he can figure out how much damage her esophagus sustained. It may have been badly compromised."

"In which case . . . ?" Jenkins's face was hardening again, the skin drawing tight across his high cheekbones.

"In which case it'll have to be removed and replaced. But let's not get ahead of ourselves."

The two nurses worked industriously with their saline bottles. Nancy's limp body shone with moisture from her scalp to the line of her breasts.

"How about the scars? On her face?"

Diane took a deep breath. "We'll get her into plastics and see about--" The intensity in Jenkins's eyes stopped her midsentence. She looked down, studying the tip of her sneaker that protruded beneath the wide cuff of her scrub pants. "It'll scar," she finally said.

Rage erupted through Jenkins's entire body at once. He turned and backhanded a loose IV pole. The force of his swat sent it flying back into a supplies cabinet, where it cracked the thick glass. One of the nurses emitted a little yelp, and the other dropped her saline bottle, which rolled back and forth on the floor in an oscillating arc.

Just as quickly as it had come, Jenkins's rage dissipated. He stood slightly hunched, shoulders rolled forward, breath hammering through his nostrils.

Diane caught David's eye and mouthed, Security? He shook his head.

Jenkins's breathing evened out. "I'm sorry," he said, to no one in particular.

David calmly walked over, picked up the dropped saline bottle, and handed it back to the nurse with a reassuring nod. Cautiously, the nurses went back to work on Nancy.

"Alkali," Jenkins said. "That's the same as lye, isn't it?"

"Yes," David said.

"I don't understand. I've spilled that stuff on my hand before. Burns a little, but it doesn't . . . " His voice trailed off as he regarded his sister.

"If it's washed off quickly, the damage can be dramatically reduced. But if it's left on, it's terribly corrosive. It's especially harsh on the soft tissue of the throat and eyes." David stepped around into Jenkins's line of sight. "We'll continue to do all that we can."

"Thank you." Jenkins touched a fist to his mouth. "Who's working the case?"

"Two UCLA PD detectives," David said.

"We'll see about that," Jenkins muttered. Lips pursed, he looked down at his younger sister's face, blistered and swollen. A pulse beat in his temple. "Is the fucker in custody?"

"Have they confirmed it was an assault rather than an accident?"

Jenkins's laugh stabbed the air. "I don't think she tripped and fell face first into a vat of Drano." The skin under his eyes was puffy, as though he'd been crying. His hair was mussed up in one spot in the back; it looked all the more sloppy, given the neatness of the rest of his appearance. "Nancy wasn't the kind of girl to have enemies."

"Isn't," David said. "She isn't the kind of girl to have enemies."

"That's right," Jenkins said. "No enemies at all." He smoothed the front of his uniform shirt with his hands. "Just an ex-husband."

"Look," David said. "We don't know--"

"Guess what he does?" Jenkins said, with a crisp little smile.

Diane shook her head.

"A plumber. Fucker totes Drano for a living." He glanced back down at the gelatinous lesions pocking his sister's face, and his grin vanished. "Thank you for your help." He walked so briskly from the room that David felt the breeze across his cheeks.

He and Diane exhaled audibly. One of the nurses shook her head. "He can sure give off some heat," she said.

Diane glanced over at David. "Do you think it was an assault?" she asked.

"I know one thing," David said. He pulled his stethoscope from across his shoulders and repositioned it around his neck. "I'd hate to be her ex-husband right now."