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Chapter 5

One of Susan Lewis’s strengths was the ability to stay calm in a crisis. It was a skill she had developed during her childhood, having grown up as the most stable member of her dysfunctional family, and so far, it had served her well in her career in emergency medicine. Battles between life and death were fought on a daily basis within the walls of County General’s emergency room, and as a third-year resident, Susan often found herself on the frontlines. Every day she went to work, she was faced with some kind of critical illness or catastrophic injury, which she was expected to treat. On a typical day, she did so without batting an eye or breaking a sweat. Nothing much fazed her anymore.

In a way, she supposed she had become desensitized to the tougher parts of her job - not only the blood and gore and other bodily fluids, but the feelings that went along with watching people in pain. It wasn’t that she no longer had empathy for her patients and their families, many of whom she met on one of the worst days of their lives. It was just that she had learned to compartmentalize, to keep her emotions contained so she could fulfill her duties with the cool logic expected of an ER doctor.

Some days it was easier than others. Looking down at the distraught man lying on the gurney in front of her, it was hard not to feel bad for him. Tears flowed freely from his green eyes while she tended to his leg wound. It was a gruesome injury; his tibia bone had broken clear through the skin of his lower leg, which was covered in blood. “I’m sorry, Mr. Richardson,” Susan apologized as she irrigated the wound with saline, washing away debris and bacteria that could cause an infection. “I know this hurts.”

“It’s not just that,” her patient replied, shaking his head. “I’m worried about my friends… and my cousin.”

“Your cousin was in the crash with you?” she asked, continuing the conversation while she worked. If she could keep him talking, she might be able to take his mind off the pain until enough time had passed to give him more morphine.

“Yeah… his name’s Brian. Brian Littrell. Do you know if he’s been brought in yet?”

“I’m not sure, but I can find out for you when I finish here,” Susan promised him. “The radiology department should be ready for you soon. I’ll ask about your friends while you’re getting X-rays done.”

“Thanks,” he replied gratefully.

The phone in the room rang, and Connie, the nurse who was assisting Susan, hurried to answer it. She spoke softly for a brief minute, then came back to the foot of the bed. “That was ortho. We’re gonna be waiting awhile on that consult; the orthopod who’s supposed to be on call is stuck in traffic.” She rolled her eyes.

Susan nodded, pausing to press her fingers lightly against her patient’s ankle. She frowned in concentration as she felt for a pulse in his posterior tibial artery, wanting to make sure his circulation hadn’t been compromised by the injury before she answered Connie. Once she was satisfied that blood was still flowing through the patient’s foot, she replied, “That’s okay. He’s got good foot pulses, so I’m not too worried right now. We’re still waiting on Radiology anyway.”

“Orthopod?” her patient asked, raising one of his prominent eyebrows. “Sounds like some sort of prehistoric animal.”

“It does, doesn’t it?” said Susan with a smile, as she went back to irrigating his open fracture. “But it’s just short for ‘orthopedic surgeon.’ We called for one to come take a look at your leg.”

He grimaced. “I’m gonna need surgery?”

Her eyes followed the stream of blood and irrigation solution as it flowed down his shin and dripped into the collection container she had set on the floor in front of her. Below the fracture site, his leg was bent at an unnatural angle, the foot and ankle turned sharply to the left. Glancing up, she gave him a sympathetic nod. “Unfortunately, yes. You almost certainly will.”

“Great,” he groaned, dragging his hand down the front of his face. He had to be close to her in age, maybe a few years younger. For all she knew, it was his first time facing major surgery.

“You’re going to be okay, Mr. Richardson,” she tried to reassure him. The break was a bad one, but she had seen worse. At least his leg seemed salvageable.

“Please… call me Kevin,” he replied, the corner of his mouth twitching into a tiny smile.

Susan nodded. “Of course… Kevin.”

“How long of a recovery am I looking at here, Dr. Lewis?”

“Susan,” she said before she could help herself, smiling back at him. “Since we’re using first names now… mine’s Susan.” Out of the corner of her eye, she saw Connie raise her eyebrows. It wasn’t like Susan to flirt with a patient - but then, it wasn’t often that a patient who looked like Tom Cruise came into County’s ER. Feeling herself blush, Susan quickly continued, “As far as your recovery time goes, that’s really a question for the orthopedic specialist... but if I had to give an estimate, I’d say you can expect to be back on your feet in four to six months.”

“Six months?” Kevin repeated. “Damn… that’s a long time to be laid up.”

“It may not take that long. Let’s wait and see what the orthopedic surgeon has to say before you worry.” Lowering her head, she went back to work. “What do you do for a living, Kevin?” she asked, as she finished irrigating his leg.

“I’m an entertainer,” he answered. “I’m part of a male pop vocal group with four other guys. They were in the van with me…”

Glancing up again, Susan saw fresh tears welling in Kevin’s eyes as his thoughts went back to his friends. “Male pop vocal group?” she repeated, hoping to distract him from worrying about them. “Like a barbershop quartet?”

“Sort of… we do sing a capella sometimes, but we also dance.” Kevin paused, then added, “Picture New Kids on the Block, but with better voices.”

Susan laughed. “New Kids on the Block, huh? There’s a name I haven’t heard in a while.” She wiped away the excess fluid from around his wound. “What’s your group called?”

“The Backstreet Boys,” he replied, somewhat grudgingly. Susan could see why - it was a pretty corny name.

“Ah, I see,” she said, smiling. “So you’re, like, from the street behind the block where the New Kids lived?”

Kevin groaned. “Something like that.” He lay his head back and looked up at the ceiling. “It’s gonna be hard to perform with my leg like this…”

Susan winced and shook her head. “Yeah, I definitely wouldn’t recommend doing that.” She wrapped his shin with a fresh sterile dressing soaked in saline, wanting to keep it covered until the consulting surgeon arrived to examine it. “How does that feel?” she asked when she finished.

“All right, I guess,” Kevin replied with a shrug. “I don’t feel much, thank God.”

“You can thank the morphine for that,” said Susan with a wry smile. “Let one of us know if the pain starts to get worse again, okay?” She rose from her stool and stripped off her gloves. “I’m going to go see what I can find out about your friends,” she added, as she walked across the room to wash her hands. “Connie will stay here with you while we wait for someone to take you to Radiology.”

“Sounds good,” said Kevin gratefully, his green eyes following her to the door. “Thanks, Susan.”

“You’re welcome, Kevin,” Susan replied and left the room with a smile on her face. It quickly faded when she saw the body being wheeled out of Trauma 1, where Kerry Weaver had just pronounced her patient’s death. “Please tell me that wasn’t the same guy from the MVA,” she begged Mark, who was hunched over the desk across from Curtain Area 2, catching up on his paperwork.

“I would, but I’d be lying,” he said, giving her a grim look as the sheet-covered gurney rolled past. “How’s your guy?”

Susan sighed. “Stable, but worried about his friends. I promised I’d find out how they’re doing for him.”

“I sent one off to Radiology for a head CT a little while ago,” replied Mark, standing up with his clipboard in hand. “He may have a mild TBI, but he was conscious and talking. Should be okay.”

“That’s good,” Susan said with a nod. She walked alongside him as they headed toward the admit desk down the hall. “Have you heard anything on the others? There were at least five.”

“Doug’s with one of them - kid with a suspected spinal cord injury,” said Mark, making Susan cringe. “I don’t know about anyone else.”

As if on cue, they suddenly heard the desk clerk call, “Dr. Greene!”

“What’s up, Jerry?” Mark asked, as they hurried ahead to the admit desk, which was always a hub of activity.

“Carol Hathaway just called. She’s with Unit Forty-Seven, bringing in two more patients from that MVA on the bridge. One’s stable, but the other’s in full arrest after being pulled out of the river. They’re ten minutes out.”

“Oh god,” said Susan, her heart sinking as she thought of Kevin. Unbeknownst to him, he had already lost one of his friends. Now it looked like he was about to lose another.

“You wanna run this one, Susan?” Mark offered.

Steeling herself, Susan nodded. “Sure. Let’s get a trauma room ready. I want some heated saline on hand in case he’s hypothermic. It’s freezing out there this morning; I can’t imagine the water’s much warmer.”

“What’s open, Jerry?” asked Mark.

“Both trauma rooms are already being used,” replied the clerk with an apologetic shrug. “Try Curtain 1.”

Susan shook her head, knowing they would need the more advanced equipment available in a trauma room. “They just took the dead guy out of Trauma 1. We’ve got ten minutes. Let’s go!”

They rushed back to Trauma 1, where the nurses and custodial staff were still cleaning up after the last patient. “We’re gonna need this room,” Mark told them. “We’ve got another cardiac arrest coming in.”

As the team scrambled to get the room ready, nurse Lily Jarvik popped her head through the door. “Dr. Lewis? They’re pulling up with your patient now.”

Susan rushed after her to the ambulance bay, where paramedics Shepard and Melendez were already unloading a stretcher from the back of their rig. She recognized the dark, curly hair of ER nurse manager Carol Hathaway, who had climbed atop the stretcher, straddling the patient so she could continue performing high-quality chest compressions during transport.

“Twenty-year-old male in asystolic arrest after being submerged in the river for approximately twenty minutes following an MVA on the bridge,” rattled off Shep as they rolled the stretcher inside. “We’ve already given three rounds of epi, but there’s been no response.”

“Take him to Trauma 1,” Susan told the paramedics, helping guide the gurney. The boy lying on it looked lifeless and gray. “What’s his name?” she wanted to know.

“Brian,” said Carol breathlessly, as she pumped the boy’s chest. “Brian Littrell.”

Susan felt her heart sink further when she recognized the name of the cousin her last patient had been so worried about. Judging by what she had just heard, he was likely a goner, but she was bound and determined to try her best to bring him back.

Once inside the trauma room, Carol climbed off the stretcher, as Susan coordinated the patient’s transfer. “On my count: one, two, three!” Her team slid the backboard onto the awaiting gurney in one swift, smooth move. “Lily, take over compressions, please,” she ordered, as Carol hooked him up to the hospital’s cardiac monitoring equipment. Immediately, the monitor let out a loud wail as it registered a flatline.

In the midst of the commotion, Susan heard a small voice say, “Can you save him?” She turned and saw a teenage boy standing in the doorway, watching with wide, scared eyes. He was wrapped in a blanket, and his wet, blond hair was plastered to his head.

“Is this the other patient you were bringing in?” she asked Carol, tipping her head toward the boy.

Carol nodded. “His name’s Nick. He was still in the van with Brian when it went into the water. He was able to free himself, but couldn’t get his friend out,” she filled them in quietly. “I’ll take care of him.” She walked over to the younger boy and put a comforting arm around his shoulders. In the background, Susan could hear her saying, “Come with me now, Nick. We need to let a doctor take a look at you.”

“No, please,” Nick protested, shaking his head wildly. “I wanna stay with Brian!”

The nurse hesitated, looking from Nick back to Brian. Susan could see the sympathy in her eyes. “Did anyone examine him in the field?” she asked Carol.

Carol nodded. “I did. Normal vitals, no obvious signs of injury.”

“Then let him stay,” Susan decided. In an undertone, she added, “That way, he gets to say goodbye, and this poor kid won’t have to die alone.” She met Mark’s eyes across the gurney, and he gave her a grim nod of approval.

Tightening her arm around Nick, Carol slowly brought him closer to the foot of Brian’s bed. “You need to stand back here so we have room to work,” she explained. “We’re going to do everything we can to help Brian.” Nick nodded, watching the flurry of activity around his friend with a look of horror on his face.

“Good luck, Hathaway,” Susan heard Shep say to Carol as he and Melendez cleared out of the crowded trauma room. She couldn’t help but notice how close Carol seemed to be getting with the paramedic these days and made a mental note to ask her about it when they weren’t in the middle of a code.

Mark cleared his throat. “He needs an advanced airway, Susan. Want me to intubate?”

“No, I will,” said Susan, snapping on a pair of sterile gloves. She moved to the head of the gurney, where Lydia had set up an intubation tray. “Laryngoscope, please.” She held out her gloved hand, and the nurse placed the tool neatly into it.

“What are you doing to him?” Nick asked, his voice shaking.

“Dr. Lewis is putting a tube down Brian’s windpipe to help him breathe,” Carol told him in her usual calm tone.

Susan could tell it was going to be a tricky intubation. She couldn’t tilt the patient’s head back or lift his chin because of the rigid cervical collar wrapped around his neck, yet she didn’t dare remove the collar until his spine could be cleared. If he had broken any vertebrae in the accident, moving him the wrong way could result in permanent paralysis. It was a risk she wasn’t willing to take.

Instead, she pried his jaws apart and bent down, trying to find the best angle to visualize the back of his throat. White foam bubbled up from his esophagus each time Lily pushed down on his chest, filling his mouth and obstructing Susan’s view. “I need suction!” she demanded. “I can’t see a damn thing.”

Lydia stuck the suction wand into the patient’s mouth and sucked up as much of the foamy liquid as she could to clear his airway before Susan tried again.

“That’s better - thanks.” She inserted the blade of the laryngoscope, using it to push his tongue to the left, out of her line of sight, and lift the epiglottis. “Number eight ET tube,” she requested once she could see his vocal cords. Carefully, she advanced the tube into the opening between them. “Okay, I’m in. Bag him.”

As Lydia went back to ventilating Brian with an Ambu bag, Susan slipped her stethoscope into her ears so she could listen to his lungs. “Good chest rise and bilateral breath sounds,” she observed, confirming her placement of the tube. “Keep bagging. It’s been about two minutes - Mark, take over compressions for Lily, please. Carol, can you get a core temp?”

“Ninety-three degrees,” Carol called out after a minute, as Mark continued CPR.

“That’s only mildly hypothermic,” Susan noted, not sure whether this was a good or bad sign for her patient’s prognosis. In her head, she could hear her medical school professors reciting the old adage, “Nobody is dead until they’re warm and dead,” as they stressed the importance of continuing resuscitation efforts in pulseless hypothermic patients until their body temperature had been brought back up to at least thirty degrees Celsius - eighty-six degrees Fahrenheit. But Brian’s temperature, while still several degrees below normal, was already above the threshold for declaring someone “warm and dead.” He wasn’t a popsicle, but he might be a vegetable if she did manage to bring him back - a possibility that was looking less and less likely with each passing minute.

“Do you want warming blankets?” offered Carol. “Heated saline?”

After a moment’s hesitation, Susan nodded. “Yeah. Let’s run in a liter and switch him over to heated, humidified O2 - see if it helps.”

“Ahem.” It was hard not to notice Kerry Weaver clearing her throat. Fighting the urge to roll her eyes, Susan turned her head and saw the new chief resident standing in the doorway. “I’m sorry to interrupt,” said Kerry as she walked into the trauma room, “but I couldn’t help overhearing. Susan, you may not have read the study published last year on the positive effects of mild hypothermia after cardiac arrest in canines.”

“Canines,” Susan repeated, raising her eyebrows.

Kerry nodded. “The results were quite promising,” she continued conversationally. “The dogs in whom mild hypothermia was induced immediately after cardiac arrest had improved cerebral outcome compared to the control group.”

“Well, in that case, hopefully my patient will be back to shaking paws and fetching sticks real soon,” Susan replied sarcastically, flashing Kerry a close-lipped smile.

Kerry gave her a pointed look. “Hypothermia helps protect the brain from hypoxic injury. It may be better to keep your patient in a state of mild hypothermia until his heart is beating again.”

Susan hesitated. On one hand, she would do anything to save her patient. On the other hand, she hated to admit that Kerry might be right. “Mark?” she asked, appealing to the attending in the room, whose judgment mattered more than either resident’s.

“Kerry has a good point,” Mark said as he gave compressions, barely glancing up.

“If you say so,” Susan sighed, annoyed at Kerry for constantly correcting her and at Mark for always seeming to side with the esteemed Dr. Weaver. “Cancel the heated saline and O2.”

“What drugs have you administered?” Kerry wanted to know next.

“Nothing yet; I just finished intubating him,” said Susan, feeling defensive.

“Lily, let’s give him one milligram of epinephrine, IV push, and then get blood drawn for labs - I want an AGB, CBC, glucose, lytes, lactate level, and coag panel,” Kerry ordered, pulling on a pair of gloves as she approached the gurney.

Susan bristled. “Excuse me, Kerry, but I’m running this code.”

“So run it,” snapped Kerry. “You need to be able to multitask in order to successfully manage a resuscitation team.”

Susan couldn’t resist rolling her eyes that time. “When was his last epi?” she asked Carol, ignoring Kerry.

Carol looked back at the clock. “It’s been at least five minutes.”

“Okay. Lily, go ahead and give him another amp of epi, then order those labs,” said Susan. “Let’s continue CPR for two more minutes and see how he responds. I’ll trade you places, Mark.” She positioned herself on the side of the gurney opposite the attending and planted her hands firmly over the patient’s sternum the second Mark pulled his away. She pushed hard and fast, imagining it was Dr. Weaver’s face she was pummeling instead of this poor young man’s chest.

“We’re going to need some more epi in here,” said Lily, as she took a tiny glass vial out of the top drawer of the crash cart. “We’re almost out.”

“This is our second cardiac arrest case in a row in this room,” Kerry replied. “I doubt the nurses had time to restock after the last patient before this one was brought in.”

As she bent over Brian’s body, Susan rolled her eyes again. Was Weaver trying to blame her for that, too? “We didn’t have a choice, Kerry,” she said, already breathing hard from the physical effort of performing chest compressions. “We needed the room.”

“I’ll go get some more epi from Trauma 2,” Carol volunteered, ducking through the double doors that separated the two trauma rooms.

“Carol?” Susan heard Kevin say before the doors swung shut again.

“Oh god,” she groaned, looking up from the lifeless body beneath her hands. “The guy in 2 is this one’s cousin.”

“Kevin?” Susan had almost forgotten their friend Nick was still in the room until he spoke for the first time in several minutes. “Is that Kevin next door?”

“Hey, wait-” she started to say, but before anyone could stop him, Nick followed Carol into the other room.

“Kevin!” Susan heard him cry. “Are you okay?!”

“Nick! Thank god you’re all right!” came Kevin’s reply. “I’ve been so worried about y’all. No one will tell me anything.”

She couldn’t hear what Nick said next; the doors had closed again. But when Carol came back in, carrying enough ampules of epinephrine to fill both hands, Susan saw Kevin crane his neck to look through the open doors into the next room. His eyes locked with hers for a brief moment before they lowered to the body on the bed.

“Brian!” Kevin cried. “Oh god, Brian!”

Carol looked back in sympathy as the doors swung shut, cutting him off from his cousin. “They’re related,” she said quietly, as she added the clear vials of medication to the drawer of the crash cart. “I didn’t realize he was right next door.”

“I did,” Susan sighed, shaking her head. “I treated him, too. The poor guy’s tibia is literally sticking out of his shin, and all he cared about was whether his cousin and their friends were okay.”

“That’s exactly how he acted at the scene of the accident, too,” said Carol. “They seem really close.”

Considering this, Susan looked at the large window in the wall separating the two trauma rooms. It had horizontal blinds that could be opened during busy traumas, when staff members might be moving back and forth between multiple patients, but were usually kept closed to protect the patients’ privacy. “Why don’t you open the blinds so he can see what’s going on?”

“And be even more traumatized?” Kerry interjected. She could always be counted upon to express her disapproval.

“Actually, Kerry, studies have shown positive effects of families being present during CPR,” said Susan snarkily, pumping faster. “Or maybe you missed those articles.” She glanced up and saw with satisfaction that Kerry’s face was as red as her hair.

“Watch it, Susan,” said Mark in a warning tone. “You’re hardly giving his heart enough time to fill.”

With a sigh, Susan slowed down her rate of compressions, concentrating on keeping them deep and steady. Mark was right; she had gotten carried away. It wasn’t like her to lose control in the middle of a trauma, but Kerry Weaver seemed to bring out the worst in her. “How long since the last epi?” she asked.

“Almost two minutes,” Lily answered.

“Okay… let’s see if it had any effect.” Susan stopped CPR just long enough to look hopefully at the heart monitor, but the green line running across the black screen remained stubbornly flat. Her face fell. “Still asystole,” she sighed. “Let’s try atropine… one milligram.”

“Susan, why don’t you take a break and go talk to the cousin?” Mark suggested, as Lily administered the medication. “I’ll get back on the chest.”

“Okay,” she reluctantly agreed, removing her hands so Mark could resume compressions from the other side of the gurney. Her arms felt like limp spaghetti as she walked around the foot of the bed and over to Trauma 2.

Nick stood next to Kevin’s bed now, looking like a lost child as he clung to his hand. “Dr. Lewis… Susan,” said Kevin, looking desperately at her. “That’s my little cousin in there. Please… don’t let him die.”

Susan swallowed hard. “We’re doing everything we can,” she assured him, “but so far, Brian hasn’t responded. I want to prepare you for the possibility that we might not be able to bring him back.”

Kevin shook his head. “You don’t know Brian like I do. He may be small, but he’s the strongest person I know. He’s a survivor,” he insisted, his green eyes swimming with tears. “When he was five, he got real sick with an infection that went into his heart. The doctors told his parents to start planning his funeral because they didn’t think he was gonna make it. At one point, his heart even stopped for thirty seconds… but they brought him back. It was a miracle.”

Susan offered him a sympathetic smile. “It’s been more than thirty minutes this time,” she told Kevin as gently as she could. “Even if we manage to get his heart beating again, his odds of making a meaningful recovery-”

“Don’t count him out yet,” Kevin cut her off. “He can come back from this, too. I know he can.” Next to him, Nick was nodding adamantly, as tears poured down his pale face.

Susan’s heart broke for both boys. “We’re not giving up,” she promised them, watching her colleagues through the window. “We’re gonna keep working on him for as long as we can.” But as she walked back to Brian’s bedside, where the resuscitation effort was still in full swing, she knew there would come a point when she had to call it off, when it simply wasn’t feasible to continue wasting time and resources on a patient with no chance of recovering.

“Any response to atropine?” she asked hopefully, looking around at the rest of her team. They had rotated roles: Kerry was performing CPR now, her crutch propped against the side of the gurney, while Mark ran the code. Lily had taken Lydia’s place at the head of the bed, squeezing the Ambu bag once for every five compressions to keep Brian ventilated. Lydia manned the crash cart, ready to administer more meds at a moment’s notice. Carol acted as recorder, her eyes moving between the clock on the wall and the chart in her hand, where she was making notes.

“Nothing,” said Mark, shaking his head. “Still in asystole.”

“What was his initial rhythm?” Kerry wanted to know.

“He’s been asystolic since he was pulled out of the river, but he had a pulse before that,” answered Carol. “I examined him in the van before it went over the side of the bridge. He’d lost consciousness, but he was breathing.”

Susan caught Carol’s eye and gave her a grateful smile. She could tell the nurse was clinging to that last shred of hope, hellbent on saving their patient, just like she was.

Kerry, on the other hand, seemed ready to call it quits. “And how long has it been since then?” she asked, panting slightly as she pumped his heart.

Carol glanced at the clock again. “Almost fifty minutes,” she admitted. “There’s something else I just thought of, though. When I listened to his chest in the van, I heard a murmur. I was worried he might have an aortic dissection.”

Susan’s eyes widened as she looked down at the patient, considering this possibility. He didn’t appear to have any genetic disorders or other obvious risk factors that would predispose him to such a catastrophic condition, but she supposed it could have been caused by blunt chest trauma or a deceleration injury he had sustained during the crash. “Let’s do a transesophageal echo and check for blood in the chest,” she decided, hoping to rule it out. If Brian’s cardiac arrest had been caused by a ruptured aorta rather than drowning, as they had assumed, then he was already dead.

“I’ll do it,” Mark volunteered, as Lydia raced to set up the ultrasound equipment. The resuscitation efforts continued as Mark inserted the probe into the patient’s esophagus, advancing it downward until it was positioned directly behind the heart. “I don’t see any free fluid in the chest cavity,” he said, squinting through his glasses at the ultrasound screen as he adjusted the angle of the probe. “Aorta’s intact - no sign of injury. The heart’s refilling with blood after each compression, but… it looks enlarged, doesn’t it?” He turned the screen toward Susan so she could see it, too.

She frowned as she studied the screen. “For a man his size? Yeah… it definitely does,” she agreed. “Could be some kind of underlying condition. Should we call for a cardiology consult?”

“Let’s focus on achieving ROSC first,” Mark advised her, pulling out the probe. “No point in wasting anyone’s time hurrying down here for a heart that’s not even beating. Even if he does have an underlying condition, I doubt it’s what caused him to arrest.”

“It could be a contributing factor…”

Mark raised his eyebrows, giving her a look that told her she was reaching. “Susan, he was underwater for, what, twenty minutes? This is a clear case of drowning.”

“But maybe we’re missing something,” Susan said stubbornly, her mind racing. She racked her brain, running through every possible cause she could come up with for refractory cardiac arrest. “Think Hs and Ts: besides hypoxia, hypothermia, and hypovolemia, what else could be keeping his heart from responding to the drugs?”

“Brain death?” suggested Kerry in a sarcastic tone. “Take a look at his pupils, Dr. Lewis. What do you see?”

With a sense of dread, Susan approached the head of the bed. Gently, she used her finger to lift one of the patient’s eyelids. His pupil was so large, she could barely see the blue iris surrounding it, and it didn’t shrink under the fluorescent lights. She knew this was a bad sign, but nevertheless, she pulled her penlight out of the front pocket of her lab coat and flicked it on, shining the narrow beam into the patient’s eye. She observed no response; his pupil remained in the same position. A repeat examination of the other eye revealed the exact same results. “Fixed and dilated,” she admitted, feeling defeated as she lowered the eyelid over his glassy stare.

“It’s time to face the facts. This boy has been dead since before his body was recovered from the water,” Kerry stated bluntly. “We’ve been trying to resuscitate him for over forty minutes now, and nothing has worked. How long are we going to delay the inevitable?”

Susan looked back through the window into Trauma 2, where she could see Kevin and Nick watching. Kevin’s hands were clasped tightly together, as if in prayer, while Nick was anxiously rocking back and forth. She didn’t want to let them down.

“This is my patient and my code. We’re gonna keep going until I say stop,” she snapped. “I promised those guys in there we wouldn’t give up, and I meant it. If you’re not here to help, then get the hell out!”

Kerry looked up, her icy blue eyes piercing Susan’s, and lifted her hands off the patient’s chest. “Fine. You wanna keep flogging him? Be my guest.” She retrieved her crutch, slipping her right arm into its cuff, and stepped back from the bed.

Susan brushed past her, practically pushing the crippled woman aside as she moved in to take over CPR. In the back of her mind, she knew Kerry was probably right about delaying the inevitable, but she wasn’t ready to pronounce his death just yet.

“What are you doing, Susan?” said a low voice after Kerry left. Susan looked up and saw Mark staring at her from the other side of the gurney.

“Trying to save my patient, Mark,” she replied evenly as she bent over the boy’s body. She could feel the muscles in her back and shoulders screaming in protest as her arms pistoned over his sternum, but she fought through the pain. “Got any ideas for me?”


She glanced up again long enough to give Mark a disgruntled look. “I was thinking of something more scientifically-proven. Hey, what about cardiopulmonary bypass? Hasn’t that been shown to work in hypothermia cases?”

He shook his head. “That’s only recommended in patients with much lower core temps, as a way of rapidly rewarming them during resuscitation. He’s above the threshold.”

Susan sighed. “So you’re saying he’s already ‘warm and dead’?”

“Not until you pronounce him.” Mark shrugged. “It’s your call, Susan.”

Susan appreciated his confidence in her, but she could tell he was with Kerry on this one. He was just too polite to say so. “It wouldn’t hurt to try, though, would it?” she persisted. “I mean, at least it would keep his blood circulating better than CPR.”

“But for how long? You can’t leave him on bypass for more than a few hours. Eventually, you have to get his heart beating on its own, or he’s dead either way. Sorry, Susan, but I don’t see the point in putting a patient through an invasive procedure just to delay the inevitable.”

Susan frowned as she realized Mark was echoing Kerry’s earlier words. “Fine. Let’s try another amp of epi then. Lydia?”

“Coming right up,” the nurse replied, retrieving another vial from the cart.

As Lydia injected the drug into Brian’s IV line, Connie poked her head through the doorway connecting them to Trauma 2. “Susan? Radiology’s ready for Mr. Richardson now, but he’s not. He’s refusing to go... begging me to let him stay here with his cousin.”

Susan sighed. “Mark, will you take over compressions so I can go talk to him again, please?”

“Sure, Susan.” Mark may not have agreed with her course of treatment, but he complied with her request, continuing CPR while she went next door, where Kevin and Nick were still watching through the window.

“Kevin,” she said gently, “I know you want to be with Brian, but it’s really important that you get down to Radiology to have X-rays taken before the orthopedic surgeon gets here. If you don’t, it will only delay surgery.”

Kevin shook his head. “I don’t care about that right now,” he muttered without looking at her.

“An open fracture is nothing to mess around with,” she warned him. “The longer we wait to repair it, the higher your risk of complications, like bleeding, infection, or loss of circulation. In a worst-case scenario, we wouldn’t be able to salvage your leg and would have to amputate it below the knee.”

That got his attention - and Nick’s, too. “What?!” the kid cried, his blue eyes bugging out of his head. “No way! Kev, you can’t let it get that bad. Go get your X-rays. I’ll stay with Brian.”

Kevin sniffed and wiped his eyes. “Can you just give me a few more minutes with him? Maybe wheel me in there so I can…” He trailed off, pinching the bridge of his nose as he bowed his head.

Susan understood. He needed closure, a chance to see his cousin up close… touch him… talk to him… and tell him goodbye.

“Okay, but just for five minutes,” she conceded, bending down to unlock the wheels on his gurney.

Connie helped her roll Kevin into the next room, where the rhythm of resuscitation went on. Mark was panting as he pumped Brian’s chest, the gurney rattling beneath their combined weight. Lily was still squeezing the Ambu bag after every five compressions, forcing oxygen into Brian’s lungs. Lydia fiddled with the IV, making sure the medication was flowing into his veins to try and stimulate his heart, while Carol watched the minutes tick away on the clock. “Two minutes since the last epi,” she said quietly, as Connie and Susan parked Kevin’s bed next to Brian’s. Nick hung back in the corner, his arms crossed tightly over his chest as he watched with a look of terror on his tearstained face.

Time was running out. The longer they kept going without any kind of response, the less likely they were to have a good outcome. One more round, Susan told herself. If we can’t get a rhythm in the next five minutes, it’s over.

“Let’s pause for another pulse check,” said Mark breathlessly, straightening up. The back of his scrubs were soaked with sweat.

Seven pairs of eyes turned hopefully to the heart monitor, only to see the same stubbornly flat line continue straight across the screen.

“No pulse,” said Lydia, as she pressed her fingers against the carotid artery in Brian’s neck.

“Still asystole,” sighed Mark, turning to Susan. Time to call it, his eyes were telling her.

Rationally, she knew he was right. The situation seemed hopeless. There was no sign of electrical activity in her patient’s heart; there hadn’t been the entire time they had been working on him. The kid had been clinically dead for close to an hour now, and despite their heroic measures, her team couldn’t bring him back to life. But behind Mark, she could see Kevin and Nick both watching her, and their eyes were begging her to keep trying.

Susan cleared her throat. “Carol, will you take over compressions, please?” she said, prompting the nurse to trade places with Mark. “Lydia, give him one more amp of atropine.”

“Got it,” said Lydia, fetching another vial from the crash cart.

“Can’t you shock him or something?” Kevin asked desperately, as Carol went back to pushing on Brian’s chest, just as she had in the beginning.

Susan shook her head. “A defibrillator only works for certain rhythms. Unfortunately, Brian doesn’t have a rhythm to shock,” she explained as delicately as she could. “We’ve been giving him medications to try to restart his heart, but they haven’t helped. At this point, he’s probably beyond help.”

“No… please,” Kevin pleaded hoarsely, as tears poured from his eyes.

“You can talk to him,” she encouraged. “Let him know you’re here… that he’s not alone.”

Kevin nodded. Clearing his throat, he muttered, “Brian, it’s me, Kev. If you can hear me right now, you gotta hang on, okay? C’mon, cous… come on back to us.”

Please, Frick,” Nick begged, rocking back and forth on the balls of his feet. “Please come back.”

“Atropine is in,” Lydia announced as she pushed down the plunger of the syringe she had plugged into Brian’s IV line.

Better pray it works, thought Susan, swallowing hard. Religion had never played a big role in her life; she preferred to put her faith in science. But if there was ever a time to pray for a miracle, it was now.

The room went quiet as they continued CPR, forcing the medication to circulate through Brian’s system. By now, the nurses just seemed to be going through the motions, pumping his chest and squeezing the Ambu bag with the kind of automaticity that came with experience. Susan could tell none of them truly believed they were going to get their patient back at this point.

She tried her best to prepare the two boys. “We’re going to give the medicine a couple minutes to kick in,” she told Nick and Kevin, “but if it doesn’t work… we’re going to have to let Brian go. He’s been down too long. Do you understand?”

This time, neither one of them protested. Kevin nodded, tears dripping from his chin. Nick said nothing, just stood there hugging himself as his whole body trembled. It seemed that seeing their friend up close had helped the harsh reality of the situation hit home. Based on Brian’s gray pallor, it looked like he was already gone.

“It’s been two minutes,” said Mark, glancing at the clock. “Hold compressions.”

Carol’s hands hovered above Brian’s chest, as they all looked up at the heart monitor again. But this time, Susan noticed a slight variation in the formerly flat line. It was a subtle rise and fall, not very tall and far from anything resembling an organized rhythm - but electrical activity nonetheless, the first sign of life he had shown since being brought in. “That looks like fine V-fib to me,” she gasped, barely able to believe what she was seeing. “Resume compressions. Charge the paddles to two hundred.”

“Charging,” said Lydia, as she fired up the defibrillator on top of the crash cart.

“Stay back. Don’t touch him,” Susan told the two boys, making sure they were a safe distance away from Brian’s bed before she picked up the paddles. She rubbed them together to distribute the liberal amount of conductive gel Lydia had applied.

“Charged to two hundred,” the nurse announced.

“Clear!” Once everyone around the bed had held up their hands, Susan pressed the paddles to Brian’s chest and pushed the button to discharge them. His torso twitched as an electric current zapped across his heart. The line on the cardiac monitor spiked sharply, then bottomed out before reverting back to the same random squiggle as before. “No response,” said Susan, watching the frenetic waves of ventricular fibrillation scribble across the screen. She thought their amplitude looked a little higher, at least. “Continue CPR, and let’s hit him again - three hundred this time.”

“Charged to three hundred.”

“Clear!” Again, Susan applied the paddles, and Brian’s body jerked with the sudden jolt of electricity that surged through it. Again, the rhythm on the monitor remained chaotic, incompatible with life. “Still in V-fib. Crank it up to three-sixty.”

“C’mon, cous…” she could hear Kevin chanting in the background.

“Charged to three-sixty.”

Third time’s the charm, Susan thought hopefully as she raised the paddles once more. “Clear!” Carol halted her compressions. Lily let go of the Ambu bag. Susan lowered the paddles onto Brian’s chest, pushing down firmly as she defibrillated him. His whole body seemed to jump beneath her hands… and then, miraculously, his heart began to beat.

Susan could hardly believe her eyes when she looked up at the monitor and watched the waveform change, the random peaks transforming into a recognizable pattern of P-waves and QRS complexes. “We’ve got a rhythm!” she gasped, her own heart bounding inside her chest. She held her breath as she studied the screen. The green line crept across it, continuing to rise and fall in a series of slow, but steady beats. “Looks like sinus bradycardia. Anyone feel a pulse?”

Lily pressed her fingers to the side of Brian’s neck. “He’s got a faint carotid pulse.”

“Weak radial pulse is present, too,” Lydia confirmed, raising her eyebrows as she palpated the artery inside his wrist.

Susan exhaled a sigh of relief. “Okay,” she said, her mind racing as she tried to gather her thoughts. “We have a perfusing rhythm, so we’ve achieved ROSC. Great job, everyone. Lydia, let’s give him one more milligram of atropine to see if we can get his heart beating a little faster. We don’t want him to start bradying down again. Lily, keep bagging him until we can call for a vent. Carol, can you get a BP?”

As her team buzzed around Brian’s bed, carrying out her orders, Susan turned to his two friends. “Thank you, Dr. Lewis… Susan,” said Kevin, as tears streamed down his face. “Thank you so much for saving him.”

Susan flashed him a grim smile. “Brian’s not out of the woods yet,” she warned him. “We still need to stabilize him and run some tests to determine how much damage was done. His heart’s beating again, but his brain was deprived of oxygen for a long time while he was underwater. We don’t know what kind of condition he’ll be in when he wakes up. If he wakes up.”

“But he’s alive,” Kevin murmured, smiling back through his tears. “That’s all that matters right now.” Behind him, Nick was nodding, his body still trembling beneath the blanket draped around his shoulders.

Susan nodded, too, but in the back of her mind, she couldn’t help but think, Sure, he’s alive… unless he’s brain dead. Had she actually saved his life, she wondered, or only prolonged his death? She wouldn’t know until the test results came back. Even if he did turn out to have some brain activity, it could take days or weeks to get a clear picture of his prognosis. He might regain consciousness and make a miraculous recovery, but in reality, it was more likely he would remain comatose or in a persistent vegetative state. All they could do now was stabilize him here in the ER and admit him to the ICU, where they would take a “wait and see” approach.

In the midst of the post-resuscitation rush, Chuny came bursting into the trauma room. “Mark!” the nurse cried. “They need you in CT; your patient’s crashing!”

Mark heaved a sigh as he stripped off his gloves. “Great,” he groaned, running a hand over his receding hairline. “I’ll be right behind you, Chuny.” But before he hurried out after her, he turned back to Susan and smiled. “Nice save, Susan.”

“Thanks. Good luck!” she called, as he raced on to resuscitate the next patient.

Connie raised her eyebrows at Susan. “Can I take Mr. Richardson to Radiology now?”

“Yes - please! And no ifs, ands, or buts about it,” she added sternly to Kevin, who consented with a nod.

“Thanks again for taking such great care of me and my cousin,” he told her, as Connie rolled his gurney out of the room.

“Just doing my job,” Susan replied with a shrug, though she felt a smile tugging at the corners of her lips. She turned back to Brian, who was looking a little better. Some color had come back into his ashen complexion. “Can I get a set of vitals?” she asked the nurses.

“He’s back in normal sinus rhythm - heart rate sixty-two. Slightly hypotensive with a BP of eighty-five over fifty. Sats are at ninety-eight percent, and his core temp is up to ninety-five degrees,” Carol reported.

Susan nodded, satisfied with those numbers for now. “Good.” She slipped her stethoscope into her ears and bent over Brian’s chest to listen. His heart was beating steadily, though she noticed the faint murmur Carol had mentioned auscultating earlier, an abnormal whooshing noise that accompanied each contraction. She was more concerned about the water in his lungs; she could hear wet crackles as they filled with air from the Ambu bag that was forcing him to breathe. “Call Respiratory to bring a ventilator and then Radiology for chest films. I want a C-spine and head CT, too,” she told Carol.

Then she moved to the head of the bed, lifting Brian’s eyelids to check his pupils again. They both looked slightly less dilated than the last time she had checked, but they still didn’t contract when she shone her penlight into his eyes. It wasn’t a positive sign, but she hoped they would become more reactive with time.

Satisfied that he was stable for now, she turned back to his friend Nick. “Would you like to come closer?” she started to ask, but the words stalled on her tongue when she saw how white his face had become, beads of sweat glistening on his forehead. “Nick, are you o-?”

Before she could finish her second question, the boy’s knees buckled, his body slumping toward the floor in a dead faint. Susan dove and managed to catch him, or at least cushion his fall before his head hit the hard tile. “A little help here!” she called, as she lowered his upper body down until he was lying flat.

“Oh my god - Nick!” cried Carol, her eyes widening as she hung up the phone. “What happened??”

“I don’t know; he just collapsed.” Susan reached for her stethoscope again and slid it down the front of Nick’s damp t-shirt. She was relieved to hear both heart and breath sounds, though both gave her cause for concern. “He’s diaphoretic with rapid, shallow resps, and his heart’s racing. He could be in shock.”

Carol had dropped to her knees next to Nick, a blood pressure cuff in her hand. She wrapped it quickly around the boy’s upper arm and inflated it, auscultating his brachial artery with her stethoscope as she slowly let the air out. “He’s barely registering a BP,” she said in alarm.

“His pulse is weak and thready,” Susan replied as she palpated his carotid artery, feeling a faint flutter beneath her fingertips. “Find Ross. Tell him we’ve got a crashing kid in here and need his help right now!”