Family Practice (3 page)

Thunder crashed, making her jump. Why was it taking so long? Jen had something life-threatening. Bubonic plague.

She lived a few houses from Susan on Walnut Street. A great kid: bright, thoughtful, a lively interest in everything, a touch of hero worship for Susan. Jen had gotten in the habit of dropping in at Susan's when things got too heavy at home. Three weeks ago, she'd come by in a grumpy mood. Mom was planning a weekend away, and Jen would be staying with a babysitter.

“I'm not a baby,” she had groused. “And Mrs. Hoffsteader doesn't like me.”

“I can't believe that,” Susan said. “How could anybody not like you?”

“Mrs. Hoffsteader doesn't like
kids.
”

“Well, what would you think about staying with me?”

Jen's face lit up with her sunshine grin.

“We'll have to ask your mom,” Susan cautioned.

Jen's mother wasn't so thrilled with the idea, nor did she like Susan all that much—Jen's admiration roused some maternal jealousy—but she had, after Jen's pleading, finally agreed.

Susan had arranged her schedule to be off duty the entire weekend. The big plans she and Jen had made didn't include sitting in a doctor's office.

Thunder rumbled. Behind it was a pop. She jerked her head up and listened intently. She caught a puzzled look from Debra. Four, five seconds passed.

A sharp crack. Gunshot. Oh, Jesus.

Grabbing the Smith and Wesson from her shoulder bag, she ran past Debra to the inner door and slammed it open against the wall.

The hallway went straight back, offices on each side. As she dashed down it, a frantic buzzing started up in her mind.

Two doors before the hallway turned off to the right, Jen lay sprawled on the floor. Susan knelt beside her. The girl had fallen forward, partially on her side, one arm flung out beside her head, the other tucked under her body.

No pulse. Breathing in short, agonized rasps. Small blood stain on the blouse, left side of chest.

Beyond Jen, just outside the open office door on the left, Dorothy Barrington lay in a pool of blood. Susan stood and took several steps closer. Chest wound, left side. Shot at close range. Dropped as soon as she'd been hit. Dead almost before she fell, Susan thought.

She heard mewling whimpers and looked up at Debra, whose gaze was fixed on Jen.

“Is there another physician here?”

Debra continued to whimper.

Susan got in her face. “Another doctor!”

Debra tore her glance from Jen and stared at Susan, eyes wide with shock. “Only Dr. Dorothy. She's the only one—” Her eyes rolled up and her knees started to buckle.

Susan caught her, eased her to the floor, and left her propped against the wall.

Using the phone in the empty office across from the one where Dorothy Barrington's body lay, Susan called the police department. “Chief Wren,” she said to Hazel, the dispatcher. “Shooting. Two victims. One fatality. Send an ambulance.” In a voice so tight it didn't even sound like hers, she gave the address. “Round up Parkhurst and Osey.”

“On the way,” Hazel said.

Susan hurried back to Jen. Still making horrifying noises in her struggle for air. Again, Susan could find no pulse. How could she be breathing and have no pulse?

Susan was trained in CPR, but CPR was used on victims with no respiration.

Abruptly, the noises stopped. The silence was even more horrifying.

Hand under neck. Four quick puffs. Check for pulse. Five pushes on chest.

The ambulance screamed up outside. Three paramedics came in at a run. Susan got out of their way. Both victims got attention, but they immediately focused on Jen. Two young males zipped her into trauma trousers, strapped her to a backboard, and hoisted her to a gurney. They raced toward the door, the third rushing alongside rhythmically pushing down on her chest.

The ambulance tore off, siren wailing, and swayed around the corner.

The driver grabbed the radio mike. “Medic One. Brookvale.”

“This is Brookvale. Go ahead.”

“En route. Eleven-year-old girl, gunshot wound left chest, no pulse, CPR in progress. ETA two minutes.”

“I read you, Medic One. Two minutes. We're ready.”

3

D
R.
A
DAM
S
HEFFIELD
hung up the phone and set off for ER at a flat-out run. He had about sixty seconds before the patient arrived to assemble a team and check for needed supplies.

“Set up the thoracic tray,” he told the nurse, then turned to his assistant. “Cutdowns. Don't piss around with IV's. Use the largest tubes you got.”

A cutdown was an open door into the circulatory system. Slice through muscle, isolate the biggest vein available and shove a tube in it. Enough cutdowns and, no matter how massive, hemorrhaging can be compensated for.

“We got blood?”

“Two units,” the nurse said. “More coming.”

Two paramedics slammed the gurney through the doors hard enough that it bumped against the table.

“No pulse,” the third paramedic said, never pausing in his rhythmic pressure on the girl's chest. “None.”

The backboard bounced as the patient was half-shoved, half-slid onto the table.

“Stay with CPR,” Adam told the paramedic as he looked at the girl; her chest jerked spasmodically.

From the head of the table, the anesthesiologist slapped two heart monitors onto the exposed chest. The bullet wound was a small hole, dark and puckered, very little blood. Adam glanced at him. “Ready to intubate?”

The anesthesiologist nodded and reached for a laryngoscope. Adam cast a glance over his team. The paramedic continued the pressure on the girl's chest. The assistant was probing the right groin with a scalpel in search of the saphenous vein.

Adam studied the heart monitor; electrical activity moved across it, but no pulse, no regular heartbeat.

A pulse that disappeared so fast meant only one thing; the bullet had penetrated the heart. The membrane around the heart filled with blood and prevented the heart from beating. Cardiac tamponade. Only one thing to do. Cut. Fast.

No time for anesthetic. Didn't matter. The girl was unconscious, for all practical purposes dead.

Adam grabbed a bottle of reddish-brown antiseptic liquid and sloshed it over the girl's chest, clamped gauze pads in a hemostat, and swabbed the liquid around.

The nurse held out a latex glove. Adam jammed his hand in, other hand in the second glove. No time to prep the patient, drape her, or scrub. Aw shit.

If the kid had any chance at all, he had to move. He sloshed around more antiseptic and grabbed a scapel. Leaning into it as hard as he could, he sliced through muscle and gristle between the fifth and sixth ribs.

Not surgery, he thought. More like butchery.

No blood; the kid had no blood pressure.

A lab tech rushed in with two more units of blood. The assistant snatched a unit, attached it to a cutdown, and handed it over to the nurse. “Squeeze,” he ordered.

Adam kept cutting deeper through layers of muscle until he reached the chest cavity. Blood gushed. As he worked the incision wider more dark blood, partially clotted, splashed over the table, soaking into his pants and shoes.

“Jesus,” the assistant said, and hooked up another unit.

Adam stuck three fingers in the incision, couldn't get his hand inside. “Scissors.” He held out a hand, palm up.

The nurse smacked heavy shears in his palm. He started snipping. When he ran into a rib, he wrapped both hands on the shears and gripped down hard, felt the rib snap. He stuck his hand in the incision, let it slip through, and took a breath. Okay.

“When I yell,” he told the paramedic, “stop CPR.”

He squatted, peered in the incision, and saw the pericardium. Dark blue, swollen with blood. Oh boy. He needed to cut into it and let that blood out. And he'd damn well better not cut heart tissue when he did.

“Give me better forceps. With teeth.”

The nurse smacked a hemostat in his waiting palm. He tried to nip the pericardium with the hemostat; it kept slipping free. “Damn it.”

After several frustrating attempts, he felt the teeth grip and hold. Yes. Gently, he tugged the membrane up to create a small pocket and snipped it open. Blood poured out.

All right, kid. This is it. Hang in there for me.

“Now,” he said to the paramedic. “Stop CPR.”

The paramedic stepped back, sweating, breathing hard.

Quickly, Adam extended the cut in the pericardium, stuck his hand through, and curled his fingers around the heart. It quivered.

Yes! Now, let's be very careful here. Slowly and with great care, he tightened his fingers, relaxed them, tightened, relaxed.

The heart made a spontaneous contraction. Yes! All right! Hooray, kid!

He felt blood trickle against his palm and with his fingertips explored the heart's surface. There it is. Hole. Right near the top. He slid his thumb over it and began a fingertip feel toward the back of the heart. Yep. Exit wound. Back of the heart. He moved his middle finger over it. The heart made another beat.

“Pulse!” the anesthesiologist said. “There's a pulse!”

“Don't celebrate yet,” Adam said. “I've got my fingers in two holes.” He looked at the clock on the wall. Five minutes had elapsed from the time the kid was brought in until her heart had started beating on its own. Her blood pressure had started to rise, dark blood oozed up in the incision.

He was forced to stoop in an awkward position to keep his thumb and middle finger over the holes in the left ventricle. Already his shoulder ached. He tried to relieve it by moving slightly. Didn't help. Great. He couldn't hold this position for long, and he dared not move either.

Mentally, he pictured the anatomy of the heart. The entrance wound was awful, goddamn close to one of the major blood vessels. He eased his forefinger across the surface of the pulsing muscle, searching for the vein. Christ, if the bullet ripped it, my finger is stopping blood to that area of the heart. The kid, as near as made no difference, would be undergoing a heart attack.

Second attack actually. First one when the bullet ripped into it. A treacherous thought sneaked into his mind. Could she make it?

“Pupils,” he asked the anesthesiologist.

“None. Fixed and dilated.”

Was he going to lose her? He'd lost a patient once. Torn open a chest and felt the heart die, right in his hands.

This sure looked like measuring up to another one. CPR didn't stack up to normal heartbeat. Hell, she could be brain dead already.

What odds for survival? This ain't no super-sterile OR. What we have here is an emergency room, full of bacteria, viruses, old blood, old sepsis, just a few feet away from a door to the big, dirty world.

The heart beat strongly in his hand. He ordered the nurse to give the kid a whopping slug of antibiotics. As long as there's any hope, sweetheart, I'm hanging in there. You've got all I can give you.

Easy enough to say, but the hardest part was still ahead. A beating heart moved all the time. Made suturing a bitch. As soon as he removed a finger to plant a stitch, blood spurted, obscuring anatomical signboards. Heart muscle was delicate; a misplaced suture that tore loose would not bear thinking about.

He asked for pledgets, tiny plugs of felt. Once in place, they soaked up blood, which then formed a clot and closed off bleeding.

Cautiously, he removed a finger, slapped a pledget over the hole, and held it in place while he carefully attached it with running sutures.

The back of the heart was sturdier, but the exit wound was larger, and he was forced to lift the heart and turn it in order to see the hole. If he lifted too high or turned too far, he'd risk pinching a vital blood vessel. That sure as hell wouldn't do the kid any good.

Back aching, he bent over the open chest, carefully dropped a pledget in place, and, working as fast as he dared, managed the sutures.

Finally, he straightened, flexed his shoulder muscles, and glanced at the wall clock. Twenty minutes from the first cut. A lifetime.

He looked down at the heart beating strong and steady. The sutures strained, but by God they held. He grinned at the nurse. She grinned back.

“We can take care of the rest in OR.” He peeled off his gloves and dropped them.

*   *   *

Susan paced outside the emergency-room doors and looked at her watch again. Thirty seconds later than the last time she'd looked. They were still working in there. That must mean something. Oh, God. Jen. Please be alive. Please, God, let her be alive.

In her mind, she saw Jen's inert form being tossed on the gurney and sped to the waiting ambulance. At least they'd moved fast. Jen was alive then.

In California, if a minor child was injured and a parent or guardian wasn't available, the child was automatically made a ward of the state. It was similar in Kansas. Susan had notified Social Rehabilitation Services, and papers had been drawn up.

Lieutenant Ben Parkhurst and Detective Osey Pickett had arrived in the wake of the paramedics. Susan had left them to get on with it and taken herself to the hospital. Since she'd driven to the doctor's office in her little brown Fiat instead of the pickup, she had no police radio, no way to keep in touch. This enhanced her sense of numbness, left her less able to pull in thoughts through her anxiety over Jen.

A muscular man with a pugnacious jaw, in green surgical garb, came out the emergency room door, covered with blood from the waist down. His shoes squished when he walked.

“Dr. Sheffield.” She trotted over to him. “How is she?”

He stopped, turned, and looked at her. “You a relative?”

“Chief Wren. I've not yet been able to reach her mother. What can you tell me?”

“We've patched up the holes in the heart. She's alive, that's about all I can say. We're not done yet, by any means. The bullet tore into her left lung. We're bringing her upstairs to take care of that now.”