Authors: Lewis Perdue
Relief arced through me in a great electrifying wave when I realized the blood on Jasmine's white silk blouse had come from someone else.
Jasmine didn't see me at first, as I studied her holding the hand of a woman with a severe head wound lying on the gurney From all the blood on Jasmine's blouse, it appeared to me she had cradled the wounded woman's head in her lap. My ears picked up the strong, calm tones of Jasmine's voice as she tried to reassure the woman on the gurney The woman blinked her eyes and looked to Jasmine for strength.
More police and EMTs came through the double doors bringing more casualties. One casualty had both hands cuffed to the gurney and his feet bound with shackles. The echoes of too many excited voices jammed the corridor. I followed Claiborne and Tyrone Freedman as they headed for one of the young men dripping blood onto the floor. I pressed the thumb and middle finger of my right hand to his neck and found no pulse.
"Quiet!" Clifford Scarborough's deep, authoritative voice resonated in the corridor. "Heads up, people!" Talking ceased as if a switch had been flipped. A sucking chest wound filled the brief acoustic vacuum with ragged wet noises; the woman next to Jasmine groaned quietly.
Scarborough looked around and asked for a triage roll call along with an injury assessment from each of the medical personnel surrounding the wounded. The presentations were quick, concise, professional, and, sadly, reflected the extensive practice all the medical personnel had, even those not formally assigned to the emergency room. I did not remember Greenwood as being a dangerous place and wondered when it had become so.
There were seven cases in all. When it came time, Tyrone Freedman spoke for our patient. When Jasmine's eyes met mine, her jaw dropped and her gaze widened. I offered her my best smile.
Scarborough and the triage nurse then directed patients and trauma teams into treatment bays.
"Dr. Stone," Scarborough called. "I'd like very much if you'd take a look at the head wound in C-2."
I doubted "Good Samaritan" laws would protect me for treating this woman. I had no license to practice medicine in the state of Mississippi and knew the trial lawyers who had the entire country by the gonads would surely sue the hell out of me for the slightest and most irrelevant of provocations regardless of whether I was volunteering to save this woman's life or not.
But a life was in the balance here. I'd worry about the lawyers later.
"Yessir," I said.
Scarborough gave me a smile, then turned to a rotund woman with short brown hair. "Helen, please find another nurse and assist Dr. Stone."
"Right away." Helen pulled another woman over and wheeled the gurney into the treatment area. When a policeman tried to pry Jasmine away, the woman on the gurney launched into terrified hysterics. Scarborough shook his head at the cop, then nodded at Jasmine.
"Don't worry," Jasmine said as she bent over the woman's head. "I won't leave you." The wounded woman calmed immediately. "And don't you worry. The best brain surgeon on the planet is going to take care of you." Jasmine turned her head toward me and smiled.
Scarborough glanced at Jasmine, then gave me a questioning look. I shrugged as we all made our way into the treatment area proper. "What happened?" I asked Jasmine as we made our way into the treatment bay.
"Lashonna—" She looked down at the woman on the gurney. "Lashonna's my paralegal, my right hand, my right arm. She's my main contact with Talmadge's lawyer. The guy won't talk to anyone else." Jasmine stopped and fixed my eyes with hers. "We're sunk without her. Anyway, she was outside the office taking a cigarette break with the others when the shooting started." Jasmine's voice carried a case-hardened toughness.
" …felt like a hammer," said Lashonna. Her voice slurred more than just moments before, and her gaze flickered like a bad television signal.
"Then I fell… hit head." She closed her eyes. I bent over and saw that above and to the right of her eye was a pronounced depression roughly shaped like an inverse pyramid.
"Did she hit her head on the corner of something?" I asked.
"Uh-huh. Brick planter."
"Nuts." I gently opened each of Lashonna's eyelids in turn and found her right pupil more dilated than the left.
"Okay, folks, let's get her relaxed and intubated," I said as I bent over Lashonna's head and moved her long hair around to get a look at her wounds. "Helen, what do you think about her weight?" The woman looked surprised to have someone ask her opinion.
"About fifty kilos."
I nodded. "What do you think about giving her about five milligrams of pancuronium for the endotrach and two milligrams of morphine sulfate in her IV?"
Helen smiled. "I'd say you were right on."
"Then let's do it."
She and the other nurse moved swiftly to sedate Lashonna.
While they prepared the anesthetics, I examined Lashonna and located a long, horizontal scalp laceration running through the hairline over her left eye and disappearing into a small, almost invisible hole above her ear. I felt Lashonna relax beneath my probing fingers as the drugs worked quickly. Jasmine stepped out of the way and stood with her back to the wall.
Helen announced that Lashonna's heart rate and blood pressure were steady; her breathing was steady. She was stable. For now.
When I looked up, Tyrone stood there with an endotracheal tube. "I came to watch the master work his magic," Tyrone said. "We called the other guy about a minute ago."
"I don't think you'll find any magic, but I'm happy to have help." I stepped back to let him do the work, "The gunshot was tangential and appears to have penetrated the cranial cavity. There is no exit wound."
Tyrone expertly worked the plastic airway tube into the woman's throat.
"Nice," I said quietly to him, then louder, "We'll need a CT to determine the extent of the projectile's damage, but I think the immediate issue is this parietotemporal injury." I looked at Tyrone, then pointed to the indentation in the woman's forehead. "Since her arrival, the patient has deteriorated from a group one prognosis to group two, which lowers her survival rate from about ninety percent to maybe sixty-six percent. I think her condition is clearly indicative of significant mesencephalic compression, likely from herniation of the ipsilateral uncus of the temporal lobe through the tentorium."
I looked at Tyrone. "Is there an OR ready?"
"All of them. Standard procedure for a big trauma call like this."
"Cool." I looked over at Helen. "Can we get a quick CT on the way to the OR?"
"Sure we can," Helen said. "I'll get her prepped and up there in a jiffy." She nodded toward the other nurse and set about shaving the area around Lashonna's wounds and painting everything with Betadine. The ominous wounds stood out.
I pointed at the slug's entry wound, then looked at Tyrone. "The problem with a tangential wound penetrating the cranium is that a slug with enough momentum will follow the interior wall of the cranial cavity, orbiting around inside, doing more damage as it goes."
Tyrone made a tsking sound as Helen unlocked the gurney wheels and pushed it toward the doors.
"Yeah." Tyrone and I followed the gurney. "But as bad as that is, I suspect the blunt trauma will be the one to watch."
"Brad?"
I turned toward Jasmine. Is she going to make it?"
I hesitated. "I'll do my best. I'll know better after we get the CT." Jasmine nodded slowly as moisture gathered in her eyes.
I scurried to catch up with the gurney and followed it from CT scan to OR, where we first set about reversing the pyramidal depression above her eye.
"Okay, this is good," I said as I pulled the broken pieces of her cranium back from the wound. "See here: the dura is intact, and since the CT didn't show a significant herniation, we'll leave the skull pieces folded out and give the brain room to expand. Nothing more we can do for this wound but pray."
"Pray," Tyrone said. "That's a pretty odd thing for a surgeon to say."
I shrugged, then bent over to look closely at the bullet wound. I put my finger on the hole, then traced it back.
"Now, according to the CT, the slug'll be about here." I rested my index finger on Lashonna's shaved head. "Right here, a couple of centimeters down. We'll need to open her up along the entire path and debride the damaged tissue."
With Tyrone's assistance, I performed a circumferential craniotomy,
which exposed a large, oval portion of Lashonna's brain along the bullets trajectory.
"To start with, remove all the debris you can find here"—I traced a gloved finger along the slug's trajectory—"pulpified brain tissue, bone fragments, clots, and other crap." I looked over at Helen. "I need to irrigate the missile track with saline, something that'll sustain a moderate pressure."
"Will a squeeze bottle do?"
I nodded as I bent over and began to clean up the wound with a pair of forceps. When nurse Helen returned with the plastic squeeze bottle, I showed Tyrone how to use it to rinse out tissue as I debrided it.
"We want to debride all the necrotic tissue as well as about a half centimeter of healthy tissue around it. A bullet can contuse a substantial area around the path, and while it may look normal to us now, it could deteriorate and leave us with a problem on our hands later."
We worked methodically toward the slug.
"It's awesome" Tyrone said as he looked down at the surface of the brain beneath our hands. The blood vessels pulsed. "I mean ... this is her, what makes her who she is."
I nodded and tried to suppress a smile.
"Do you still feel that? That ... awe?"
"Every time I open up a skull."
"It never gets routine?"
"Some people get blasé about the time they start thinking they're God with a scalpel." I shook my head. "But it still gives me chills."
"No lie, man."
We worked silently for a long while. Gutting, trimming, washing, cleaning, as best our human hands could work, and yet at a cellular level, we were a crude, dull, chipped flint blade scraping through.
"How do you know what tissue
not
to take? How do you make sure you don't scrape away something she needs?"
"You don't. Just take all the dead stuff and a little around it. It's all you can do."
He paused to think for a moment. "You might be debriding a memory there, or the ability to do math or make an important decision."
"Right. Only sometimes I wonder if we're debriding the memory or just the ability to access it,"
"What's the difference?"
"No practical difference. That's why I told you there wouldn't be any magic here. We're like a couple of Neanderthals looking at the insides of a supercomputer. We can't directly repair any of the trillions of synapses or rewire any of the live neurons to bypass the ones we had to remove. Even if we magically saw the connections, we're still screwed because all the synapses and neuron patterns are different for everyone, the product of genes, environment, education, experience. There are an infinite number of possible connections among a trillion cells. Only an infinite intellect could possibly know all the infinite permutations and combinations."
"God?"
"I believe so."
"Caveman."
"Uh-huh."
We worked steadily to the end of the bullet track
"I need a pair of bayonet forceps, please."
Helen handed me the tool, and moments later I pulled the slug from Lashonna's brain. "We need to rinse and secure it for the police," I said. Helen held out a stainless steel kidney pan and I dropped it in and gave it a quick squirt from the saline bottle.
"We'll need a clear evidence trail, Helen. Let's make sure it doesn't leave your sight or mine until the police take possession."
We finished the debridement moments later.
"Okay, let's clean this up and cover the wounds with sterile dressings."
"You're going to leave the wounds open?" Tyrone asked.
"The brain is going to swell," I said. "If the tissue can expand out of the openings, there's less chance of intracranial pressure buildup." Tyrone nodded slowly. I looked at Helen.
"If we can't get a chopper, I think she should start to Jackson in an ambulance. One that can maintain a program of controlled hyperventilation to reduce the PaCO
2
to twentyfive to thirty torr. This should give us enough cerebral vasoconstriction to help reduce intracranial pressure. I'd also like you to start mannitol at half a gram per kilo and dexamethasone at point three. Make sure the ambulance crew has diazepam in case she has convulsions. Make up a couple of hypodermics for them ahead of time at point two grams per kilo."
"Right."
"Also, if you have fresh frozen plasma, send it along. It could help with thromboplastin releases."
"I'll check."
"Go ahead and do it now," I said. "We'll finish up while you handle the ambulance and the medications."
She headed for the door
"The bullet?" I asked after her. She stopped. "Why not take it down to the police when you go?"
She nodded, then retrieved the crumbled mass of lead from the pan, dried it out on her scrubs, then tucked it in her pocket.
As she pushed through the stainless-steel OR doors, I looked back down at Lashonna's brain and knew then that the shooting had not merely been another routine drive-by but had been designed to look like it.
I felt old and in desperate need of sleep by the time Tyrone and I finished with Lashonna. What little sleep I had snatched between connecting flights on the red-eye from Los Angeles hadn't done much to erase the deficit I had been running since the sinking of the
Jambalaya.
The wound to my ear was minor, but still it throbbed with every heartbeat, my lower back ached from standing over the operating table, and my feet slogged as if mired in the red, slickery goo of wet Yazoo clay.
Wordlessly, Tyrone and I ditched our gloves, masks, and splatter guards and followed Lashonna's gurney toward the ambulance dock. Outside, heat and humidity smothered us in a steaming blanket. Warm afternoon light painted the street with deep, oblique shadows. We crossed the concrete platform and made for the open doors of an ambulance, where Helen huddled with two EMTs.
Cigarette smoke carried the essence of burning horse manure from the backlit silhouettes of two uniformed police officers and a man in plainclothes to my right. Fear squirmed in my gut. Drive-by shooting investigators or LAPD? My hands turned cold and my heart warmed up for a race.
Jasmine stood upwind from the police, avoiding their smoke. Seeing her cleared my head, shook the mud off my feet, and leavened my fear. She waved at me, then detached herself from the smoking men.