The sun was up by the time the call came in to County General’s emergency department, but it was pitch black inside the exam room where Dr. Mark Greene was sound asleep. The door burst open suddenly, flooding the small room with fluorescent light from the hallway.
Mark stirred slightly at the sound of his name, but kept right on snoring.
The shout startled him awake. “What is it?” he mumbled, without opening his eyes.
“We’ve got a major trauma coming in,” replied nurse Lydia Wright from the doorway. “MVA involving a van.”
Mark lifted his head, squinting into the bright light. “How many?”
“At least four on the way, but there may be more. We’re gonna need all hands on deck.”
“What’s their ETA?” he asked, checking his wristwatch. The numbers blurred before his eyes.
“Five minutes out.”
Mark reached for his glasses and slipped them onto the bridge of his nose. “All right,” he sighed, untangling his stethoscope from the oxygen line over his head as he sat up. “I’ll be right there.”
So much for trying to catch a few winks before the second half of his double shift began, he thought with regret as he staggered down the hall, stretching his arms over his head to work out the kinks in his back. Such was the life of an emergency room physician. Even as an attending, he was still perpetually exhausted.
He had thought, naively, that having a tenured position at the hospital would make his life easier, not harder. What he hadn’t counted on was the added responsibility that came with the job - all the administrative duties, the extra meetings, the paperwork. And it didn’t help that he had to commute between Chicago and Milwaukee several times a week just to see his wife and daughter. No wonder he was tired.
Several of his colleagues were already waiting in the ambulance bay, gowned up and ready for the slew of trauma patients to arrive. “Oh, Mark, there you are,” commented the new chief resident, Kerry Weaver, shifting her weight on her crutch. “We were beginning to wonder if you’d ever wake up.”
Mark forced a smile. “I’m up,” he said shortly. Behind Kerry’s back, Dr. Susan Lewis rolled her eyes, while pediatrician Doug Ross caught his eye and winked. They were Mark’s closest friends among the ER staff, and he knew it had been a struggle for them both to adjust to working with the authoritative Weaver. Her appointment as chief resident hadn’t been his idea, but since he had been the one to approve it, he got all the blame.
“What I’m wondering is why it’s so damn cold out here!” said Susan, hugging herself to keep warm as she bounced up and down on the balls of her feet. “This feels more like winter than fall.”
“Actually, Susan, the autumnal equinox isn’t until tomorrow, so technically it’s still summer,” put in Kerry matter-of-factly.
Doug snickered. “Welcome to the Midwest, where you can enjoy all four seasons in a single day.”
Susan groaned. “I should have done my residency in the desert.”
“We’ll all warm up soon enough,” said Mark, as the distant sound of sirens grew steadily louder. “They’re almost here.”
As an ER doctor, this was what he lived for. When the first of four ambulances rounded the corner, red and blue lights flashing eerily through the fog, Mark was in his element. “What have we got?” he asked, as paramedic Doris Pickman jumped out of the back to begin unloading her patient.
“Kevin Richardson, twenty-three, open tib-fib fracture following a single-vehicle MVA: van versus guardrail,” rattled off Doris. “Mr. Richardson was awake and responsive on scene, with no other obvious injuries. He’s slightly tachy at 110; otherwise, vitals are normal. We gave him ten of morphine in the field.”
“Why don’t you take him, Susan? Trauma 2’s open,” said Kerry, her eyes already surveying the second ambulance to arrive. As soon as the rig skidded to a stop, the driver jumped out and raced around the back, opening the doors to reveal two paramedics performing CPR on the patient inside. “I’ll get this next one.”
Mark braced himself, half-expecting Susan to complain about Kerry assigning her the less interesting patient and taking the more critical one for herself. But when Susan saw the morbidly obese, middle-aged man being lowered - with difficulty - out of the back of the ambulance, she just smiled. “Sure, Kerry,” she said, turning to her patient, who even Mark had to admit fit the description of “tall, dark, and handsome” to a T. “Hi, Mr. Richardson, I’m Dr. Lewis,” he heard her say as she helped roll the young man with the broken leg inside. “We’re going to take good care of you.”
Mark couldn’t help but chuckle to himself as he and Doug hurried to help the paramedics unload the big guy. “Lou Pearlman, forty-one, front seat passenger, found unresponsive at the scene,” panted one of the medics, struggling with the weight of the man wedged between the safety rails of the stretcher. “Initial rhythm was V-tach. We tried to cardiovert him, but lost his pulse in the ambulance.” As soon as they got the gurney’s wheels onto the ground, she began bagging the patient again while her partner resumed chest compressions.
“How long has he been down?” Kerry asked.
Mark watched the man’s pale, flabby belly bounce with the force of each compression. Poor fat guy didn’t look like he had much of a chance. “You sure you got this, Kerry?”
“I think I’ve got it covered, Mark, thanks. There are supposed to be at least a couple more coming,” said Kerry, limping alongside the gurney as fast as her crutch could carry her. “Let’s take him to Trauma 1.”
Mark and Doug looked at each other. “And then there were two,” said Doug, smirking.
Mark glanced at his watch. “We expecting any pedes cases?”
Doug nodded. “At least one, maybe two teenagers.”
It didn’t take long for the last two ambulances to arrive. “AJ McLean, seventeen, possible spinal cord injury with loss of sensation in the lower extremities,” said one of the paramedics who unloaded the next patient.
“This one’s all yours, Doug,” Mark told the pediatrician. “If you see Harper, have her assist - it’d be a good opportunity for her to learn how to do an ASIA Exam.”
“Will do,” replied Doug as he took the teen inside.
Mark turned his attention to the other ambulance, where the paramedics were unloading yet another young man. “Howie Dorough, twenty-two, suffered facial trauma from striking the window glass. Complains of head and neck pain, but alert and oriented on the scene, no reported LOC. Gave him five of morphine for the pain and started him on supplemental O2, 15 liters per minute. GCS 15, heart rate 92, BP 130/90, resps 20, pulse ox 98,” one of the medics relayed on the way in. The patient’s vital signs were all within the normal range, but that didn’t mean much to Mark, who knew how quickly head injury victims could decompensate. He wasn’t going to take any chances.
“What’s open, Chuny?” he asked one of the nurses, who was waiting for him just inside.
“Exam 8,” Chuny replied, grabbing one side of the gurney. Together, they wheeled the patient into the empty exam room where Mark had been enjoying his nap ten minutes earlier. He looked longingly at the bed before they transferred the accident victim onto it.
“I’m Dr. Greene,” Mark introduced himself, leaning over the young, olive-skinned man to take a closer look at his injuries. “How are you doing, Mr. Dorough?”
“O-okay, I guess,” he answered shakily, as the nurses began cutting off his clothes. “You can call me Howie.”
Mark offered him a reassuring smile, noting a nasty scalp laceration on his forehead and bruising around his swollen right eye. But before he could assess the patient’s head trauma, he had to start with the basic ABCs: airway, breathing, and circulation. “We’re going to take good care of you, Howie,” he promised, as he slipped his stethoscope into his ears. “Any chest pain or trouble breathing” he asked, pressing the diaphragm of his scope to the man’s chest to listen to his heart and lungs.
Mark nodded. Everything sounded as it should. “Good breath sounds bilaterally and normal heart tones,” he reported. With a gloved finger, he gently pried up the patient’s puffy eyelid and shone his penlight into Howie’s eyes to observe their response. “Pupils equal, round, and reactive,” he added to Chuny, who made a note on the man’s chart. “Are you having any trouble seeing? Any blurred or double vision?” he asked Howie.
Mark frowned. “How many fingers am I holding up?” he asked, raising his index finger.
“Good. Follow my finger without turning your head.” He moved his finger slowly back and forth in front of Howie’s face, watching the way his eyes tracked it. Satisfied that there was no injury to the eye itself, Mark moved on with the rest of his examination. “Any numbness or tingling?” he asked, as he palpated the bony structures in the patient’s face.
Howie winced as Mark pressed against his zygomatic bone, just beneath the eye socket. “No, it just hurts.”
“Sorry,” said Mark. He felt along both sides of Howie’s mandible, making sure it was intact. “Open your mouth please.” He looked inside the man’s mouth for broken teeth, but didn’t see any signs of trauma. “Good. You can close now.” He watched the jaws as they shut; they seemed to be properly aligned. “Do you have pain or numbness anywhere else?”
Howie started to shake his head, but the cervical collar around his neck prevented him from moving it. “No,” he whispered. “How long do I have to wear this thing?”
“Just until we make sure you haven’t injured your spine,” Mark replied. “Do you have any numbness or tingling in your arms or legs?”
“My arms are sort of tingly feeling,” Howie admitted, grimacing.
Mark nodded. “Squeeze my hand,” he requested, picking up Howie’s right hand first, then his left. The grip in both was strong, which assured him that the nerve function was intact. “Wiggle your toes, please.” He watched Howie’s feet move. “Very good. You may have some whiplash, but it doesn’t seem like anything too serious.” Looking at Chuny, he added, “Let’s get a cross-table C-spine, head, and chest CT, orbital films, and a full trauma panel.”
The nurse nodded as she wrote down his orders. “I’ll call Radiology.”
“Thanks.” Mark turned back to his patient. “As soon as Radiology is ready, we’re going to send you for some X-rays and a CAT scan to make sure your head and neck are okay. Once you’re cleared, we’ll be able to take that collar off, okay?”
“Okay… thanks,” Howie said.
“No problem,” Mark replied, now palpating the patient’s abdomen. “Tell me if you feel any pain while I’m pressing on your belly.”
“Okay. Have you heard anything about the others?”
“The others?” Mark asked, as he continued the exam.
“My friends who were with me in the van,” said Howie, starting to sound impatient. “AJ... Nick… Kevin… Brian… Denise… and Lou. Are they okay?”
“Belly is soft and benign - no rebound tenderness or guarding,” Mark reported to Chuny, who wrote down his notes. To Howie, he said, “I’m not sure, but I’ll find out for you as soon as we’re done here.” He tried to keep his face neutral, but he couldn’t help but think about what bad shape the big guy, Kerry’s patient, had been in. He knew not all of Howie’s friends were going to be okay.
“That would be great. Thank you,” Howie said, his impatience giving way to politeness again.
“Of course.” Mark moved to his pelvis, making sure there were no signs of injury there. “So how did the accident happen?” he asked, as he poked and prodded.
“I don’t know… It happened so fast.” Howie swallowed hard. “The fog was really bad. Denise was driving; I don’t think she could see. She must have lost control or hit something… I don’t know. Hey, do you know where she is? She’s AJ’s mom; maybe she knows how he’s doing.”
“I don’t, but I’ll find out,” Mark promised. “Just give me a few more minutes. It doesn’t hurt at all down here, does it?”
“No, no, I feel fine,” Howie insisted. Mark could tell he was starting to get anxious again.
“Tell me about your friends,” he said, trying to keep Howie calm. “Are you all from Chicago?”
“Florida? Wow. My wife and I want to take our daughter down there someday, to Disney World. She’s six,” said Mark. “Were you here on vacation?”
“No, work,” Howie replied. “We’re a vocal harmony group. We’re touring right now, trying to promote our first single. We were supposed to sing on a radio show this morning.”
Mark raised his eyebrows. “Really? Wow. What’s your group called?”
“The Backstreet Boys.” Howie smiled briefly and closed his eyes for a few seconds. When he opened them again, they were full of tears. “Please, do you know anything about the other guys? Are they okay?”
Mark looked up at Chuny, who gave him a significant glance. He could tell she was thinking the same thing he was: asking the same questions over and over again was a sign of brain trauma. It was probably just a concussion, but it could be something worse. “You wanna call Radiology again and put a rush on those scans?” he asked her casually.
Chuny nodded. “I’m on it,” she replied, already reaching for the phone. “Radiology’s ready for him,” she told Mark a few minutes later, when he had finished his exam.
“Perfect.” Mark smiled down at the patient. “Howie, Chuny here is going to take you for those scans now, while I go check on your friends. Sound good?”
Howie offered a grateful smile in return. “Thanks, Doc.”
“Don’t mention it.”
As Chuny wheeled Howie toward the radiology department, Mark wandered down the trauma hallway. He stopped outside Trauma 2, where he could see Susan working on the young man with the broken leg. It looked like she had everything under control, so Mark moved on to Trauma 1.
Inside the trauma room, the efforts to resuscitate the fat man on the table were slowing down. “How long since the last epi?” Kerry asked, as one of the nurses, Malik, continued chest compressions. Mark could tell he was starting to tire; sweat poured down his dark face.
“Two minutes,” Lydia replied. “Do you want to try another dose?”
Kerry hesitated, her eyes on the cardiac monitor. “No. Hold compressions, please.” Malik removed his hands from the man’s flabby chest. Mark watched the monitor flatline.
“Asystole,” said Lydia. “Still no pulse.”
“How long has he been down?” Mark asked, peering over Lydia’s shoulder at the patient’s chart.
“Almost thirty minutes. I’m calling it,” replied Kerry, looking up at the clock on the wall. “Time of death… 6:59.”
Mark sighed. No time to sleep now. His second shift started in one minute.