Chapter One

Mrs. X

             Nobody had to tell me what had happened to the woman on the ER gurney.  I knew.  A thunderbolt of a headache had struck her out of the blue, leading to frightening dizziness and vomiting before her lights went out, maybe for good.

            She was beautiful—or had been, an hour or so ago—hardly out of her twenties, with fine, translucent skin stretched over delicate cheekbones, her hair a gleaming blond.  She had a Scandinavian look about her, as though she should be a Mrs. Lundquist or a Mrs. Svensson—Cristina, maybe.  Tonight she would be Cristina Svensson.  Some part of me needed a name.

            The nameless happened into emergency rooms almost nightly everywhere—temporary Xs stamped on their wrist bands, even Ys and Zs on busy nights in the big cities, along with seven- or eight-digit admission numbers.

            We had our share of Xs: people unconscious from car accidents most often, but also growing numbers of the homeless and drug pushers, plus teenagers on the lam.  But this woman, Christina, was different.  She had a home, and people who cared about her—a husband, possibly even children, who depended on her.  She had that look about her.  I didn’t need a name to know that.

            Her cotton hospital gown bulged over a swollen belly that promised new life, a life all too soon to be struggling for existence, with its mother now powerless to shift for either of them.  She wore a tiny diamond on her left hand.

            An explosion of blood had taken place between her frontal and temporal lobes, splashing back and forth and collecting at the base of her brain.  It came from her carotid artery.  The CT was textbook typical.

            An endotracheal tube curled from her throat.  A larger, more flexible length of tubing connected the endo-tube to the ventilator behind her head.  It hissed and puffed at intervals, pumping oxygen into her lungs.   

            “What was she like before you paralyzed her?”  I knew Garrison had given her something. 

            “Pretty much as she is now,” he said.  “Comatose.”  He wore a stiff white coat and a red bow tie, a clip-on job. 

            “All the way out?  Not moving anything?  Not even a hand, or a leg?”

            “Nothing.”

            Her scan almost promised she would be paralyzed on the left side, but I wished I could have seen her myself when she arrived.  Even the slightest flicker in her right hand would prove she had a fighting chance.

            “No posturing?”  That kind of stiffening of her arms and legs would have pointed to a big time injury high in her brainstem.   Her extremities were limp now.

            “No.”

            I bit my lip.  I was going to the limit for this woman, but knowing, really knowing we had a chance seemed to make a difference.   Knowing surgery wasn’t just a preamble to an autopsy was a huge plus.  I’d had my share of Chinese fire drills.

            “Looks like you saved her life, Hal.”

            “For a while anyway.”  He gave me a sour look.  He knew the score.  ER docs did what they had to, and fast.  Garrison had been around.  No doubt his intubating her, and getting her on the respirator, had bought her some time.  But it didn’t look good for Mrs. X.  I could only hope he had overlooked the barest twitch of a finger.

            “But she was trying to breathe?  Right?”

            “Barely.”

            With a thumb and forefinger I lifted her eyelids and studied her pupils, begging them to constrict in the overhead light.  The one on the right was fully dilated and stone still, but the other one quivered a little.  Did I imagine it?

            “Does the left pupil react?”  The nurses had examined them earlier.  It was part of the routine.

            “No, sir.”  It was Spurgeon Green, a nurse whose ass I’d pulled out of the fire a couple of weeks ago.

            I slid the left eyelid back to half-mast, then raised it again, quickly, searching for the barest flicker of a change.  There.  There it was!  Maybe I was deluding myself.  I was dying to see a reaction.

            “What’s her BP?”

            “One-twenty over eighty.  Pulse is ninety.” A woman’s voice.  Another nurse.  She seemed anxious, almost frightened.  I’d never seen her before.  She had flaming red hair.  

            That much was good.  Sometimes the blood pressure shoots sky-high with a hemorrhage, the heart pumping like mad to fill up the coronaries and keep a constant blood flow to the brain.  But high blood pressure could cause more bleeding too.  Even a trickle now could kill Mrs. X, or Cristina Lundquist, or whoever she was.

            “She needs an angiogram, Hal, right away, then the OR.  She’s got an aneurysm.”  I made it sound as final as I knew how.

            “You’re kidding.” Garrison’s thin grin seemed more challenging than questioning. 

            The red-headed nurse glanced at Garrison, then back at me.

            “Not quite,” I muttered, forcing a smile.  “I didn’t get out of bed tonight to regale you guys with jokes.”

            “But . . .”  His shoulders wilted, and his head tilted forward, his gaze skipping back and forth across the floor, as though he might be able to find his thought rolling around at his feet, like change that might have fallen though a hole in his pocket.

            I waited.  Garrison wouldn’t pop off on the first idea in his head. 

            “This woman’s a goner,” he stammered finally, like he had a sure way of knowing.   “She’s brain dead.”

            “Not if she’s trying to breathe.”

            “She only sucked in a gasp or two.”

            “Sounds alive to me.  Plus, her left pupil’s reactive.”  Why be equivocal about it? 

            “You amaze me, Ravenel.”  Garrison was smiling, clearly challenging me now.

            “That’s nice.”  What else could I say?

            “Come on, Grant.  You guys thrive on playing God, but this one’s way beyond anything you can do.  Don’t do something you’ll wish you hadn’t.”

            Like surgeons, ER doctors are action people, used to cutting through unimportant information quickly, making decisions in a hurry, then sticking to them, never looking back until they’re proved to be so wrong there’s nothing left to do.  They are also like surgeons in that they are rarely dangerous until they’ve gained a little experience, get too sure of themselves.

            “Why did you call me, then, if you’re so sure?”  I had to calm down.  I didn’t need somebody running off to administration again, or to the nursing office, spouting off nonsense about me blowing my top in the ER.

            “Well, only you can make it official.  You’re the neurosurgeon.”

            I paused a few seconds to let what he’d said echo back to him.

            “So you want me to write your opinion on this woman’s chart and sign my name to it.  Is that it?”

            His face darkened.  “Hell, Ravenel, I don’t care what you write on her chart.  Do whatever you like.  Everybody knows you’re superman.  Let’s see if you can raise the dead.”

            My neck tensed a little as I rotated my bad shoulder forward a few degrees.  It had been sore since my morning case.  “All I know is, Hal,” I said finally, “if I were in this woman’s shoes, I’d want somebody busting his butt to give me a chance.  If I’m wasting my time, it’s my time to waste.”

            “She’s carrying a perfectly viable infant, Grant,” Garrison said.  “Please don’t do something dumb, something that puts the baby in jeopardy.”  He seemed sincere enough, but . . .  I took a deep breath.

            “Has OB seen her?”

            “Yes.  Greta Sauls.  She wants to section her right away.  She’s got an OR standing by.”

            “I don’t have a problem with that, after the aneurysm’s clipped.”

            “But—”

            “But what?  Do they think the fetus is in danger?”

            “Not yet.  The heart sounds are fine, hardly more than one-forty a minute.”

            “They shouldn’t mind waiting a few hours then, until the mother’s safe.”

            “The pediatricians are standing with them.  Tim Finney was here a few minutes ago.  He’s nervous about the baby.”

            So?  Finney was always nervous about something.

            “Tim wants us to start some fluids IV, and epinephrine, boost her BP a little.”

            “Why?”

            “To perfuse the placenta, the way we do when kidneys are to be transplanted.”

            “Don’t do it.  That’s a terrible idea.”  I wouldn’t be a part of causing a rebleed, and a death.

            He gave me a hard look, one that twisted finally into a nasty grin. 

            My shoulder began to ache a little more, like it always did when I felt stress coming on.  Stress.  Maybe the shoulder-aching was part of a primitive response, like nature getting a guy set to punch somebody.  Yeah, right.  What happened to my shoulder so long ago had kept me from even waving at anybody.   

            “Are you trying to find out who she is?” 

            “We’re working on it,” Garrison snapped. 

            “We need her husband.” 

            “Why?  I can’t believe you’re looking for somebody to console.”

            “Come on, Hal.  If we’ve gotta choose between her and the baby, we need his help.”  I could make surgical decisions, but I wasn’t into moral judgments for folks I didn’t know.

            “You’d listen to him?   Is that it?  Just not Tim and me.”

            “Come on, Hal.  I’m not going to let you, Sauls, and a pediatrician make this call for me.  You don’t want to bring another orphan into the world without going all-out for its mother, do you?”

            Garrison’s jaw muscles rippled his face.  

            “How’d she get here anyway?”

            “Catawba CountyRescue.  They say she collapsed in a 7-Eleven.  No purse, no driver’s license.  The attendant called 911.” 

            “There must be a registration card in her car,” I said.

            “Right.  They didn’t take the time to check that out.  The police are out there now.”

            “We can do an angiogram while we’re waiting.”

            Garrison would come around.  He didn’t have the balls to be responsible for a neurosurgical patient, mine, against my judgment, even with Sauls and Finney holding his hand.  

            “Keep an eye on the BP, Spurgeon,” I told Green as I turned to leave.  “Don’t let it go higher than one-twenty.  Use Nipride if you have to.”

            “But, the pediatricians—” Green was pale.

            “Tim wants a pressure of one-forty, Grant,” Garrison said.  “We’re going to start an epinephrine drip.  Greta agrees.” 

            “Don’t do it.  Unless you want to kill this woman,” I snapped.   “I’ll call Greta.  Explain it to her.”

            Garrison shrugged, cocking his head to one side.  Green looked at him, then back at me. 

            “How much Nipride do I give her?”  Green wanted specific directions.  This was a controversy he could avoid.

            “As much as it takes,” I said.  “Her BP might hold at one-twenty without anything, or it may take more than you can imagine.  Mix up a drip of one hundred milligrams in a half-liter of saline.  Check her BP every ten minutes, and use as much Nipride as you have to.”

            “But giving her too much could—”

            “Hypertension, or a rebleed, can kill her a lot faster than Nipride,” I said slowly.  Did I have to draw him a picture?  Just do it, damn it, I wanted to scream.

            “But what will Nipride do to the baby?”  Green had been around.  Just having a doctor’s order was nowhere near enough for him.  I respected him for that, but we needed to get moving.

            “Hopefully we won’t have to use enough to make any difference,” I said.  “Use what you need to, and chart what you give her.”

            “Would you write that order for me?”

            I felt another stab in my shoulder.  This was getting crazy.  We had a woman dying in front of us, and he’s worried about his skinny butt.  The chart might save Green, but who was going to save this woman?  I stared at him in disbelief.

            “I’ll get the Nipride, Spurgeon,” the red-head said, heading for the medications cabinet.  I breathed a sigh of relief.  Making me walk the paperwork line didn’t make sense.  Not tonight.  But the red-head got it.  She would write my verbal order.

            “Okay, Smitty,” Green said finally.

            Garrison crossed his arms and glared at me, his jaw muscles dancing up and down his face.  He would be in Hanes’s office early in the morning, complaining about me bullying my way around the ER again.  Screw him!  Screw Hanes too.

            I couldn’t get Spurgeon Green out of my head as I pulled on a set of scrubs in the dressing room.  Surely I could count on him.  I didn’t go to bat for a nurse every day.  Green had never acknowledged I’d done anything special for him, but he had to know about it.  I played it back in my mind as I slipped off my shoes and took down the old pair of clogs from the top of my locker.

            “I’ve got to let him go, Doctor,” Patsy Schrock had said, hardly two weeks ago.  She faced me from behind her desk—a big woman, heavy, a washed-out look in her face that matched her hair.  It was short.  She’d given up dying it years ago.   

            “You can’t afford to fire him, Miss Schrock.  He’s the best ER nurse we’ve got, by far.  He’s quick, and has an amazing feel for what’s important.  Plus, he knows how to get things done.  He’s just been on the job a month, but he knows more about what’s really important than any of the others.”

            “But he’s not a graduate of a certified nursing school!  That leaves us with too much exposure.  The hospital can’t afford that kind of risk.”

            “No nursing school?  You gotta be kidding.”

            “He attended field service schools in the Army, one at Tripler in Hawaii, the other at Walter Reed.  That’s it.”

            “But he knows what he needs to know.  No question about that.  Plus, he’s served two tours as a medic in Vietnam.”

            “Well, Doctor, I don’t know that battlefield experience qualifies a nurse to work in this hospital.  Anyway, military institutions are simply not on our approved list.”

            “Says who?” 

            “Mrs. Blackwelder, our policy-compliance officer.  She checks new personnel qualifications against the requirements dictated by administration.”

            I closed my eyes and forced myself to silence.  Administration?  It was the same old story.  MethodistHospital was like a pig in quicksand.  Miss Schrock had kept her job forever and a day by being dedicated to the status quo.  She wasn’t about to start ripples in the water now.  She would not stretch her neck, even if it meant efficiency in the ER.

            “It’s a fine time to fire a nurse like this on that kind of technicality,” I said, trying to sound calm.  “Surely you can do something.”

            “It’s out of my hands.  I don’t interfere with my senior staff, and none of us bend rules.  You can understand that.”  She gave me a look that told me I should stop thinking such thoughts.

            But in the end, somehow, I convinced her.  I’d promised to be personally responsible for Green, and she stipulated he be on probation for a year.  George had backed me up, and even Parker Hanes approved, the idiot who runs the hospital.  Hanes never sided with me about anything.        

            In a way, Hanes was responsible for every constraint any doctor worked under around here.  He had set up the system.  We all had folks watching us, actions we knew we might have to explain someday.  Some of us were more affected by Hanes’s system than others.  With Spurgeon Green it was the nursing service hierarchy.  Hal Garrison and the other ER docs worked according to a protocol devised by the ER committee.  Hanes saw to it that individual doctors weren’t trusted to think for themselves.  The system insured that obedience to a given method or philosophy was established by committee.  But it was Hanes himself that stuck in my backside.  He was dedicated to appearances—especially cozy relationships between doctors and doctors and doctors and nurses—also how to get things done with the hospital spending the least amount of money possible.  It was driving me crazy.

            In the x-ray department I studied the films from the right carotid injection.  I’d paged Greta Sauls a second time, but she had yet to call.   There were twenty x-rays in two lines on the view box, AP and lateral projections.  The aneurysm was best seen on the two-second film.  It was large, and had two lobes, one larger than the other.  The big one projected downward, into the cistern where the third cranial nerve coursed toward the orbit.  They would inject the other carotid to make sure there was no aneurysm on the left.  It happened sometimes.  I didn’t need any surprises tonight.

            From the next room I could hear the radiologist communicate with a technician as he prepared to inject.  “Ready . . . shoot!”  She activated the film-changer the instant he’d emptied his syringe into the IV.  Then came the bang-bang-bang of the changer ratcheting the celluloid beside the woman’s head at two  frames per second at first, then one film per second as dye moved into the venous system.  The first film would be blank, dye appearing first on the second, then spreading throughout the arterial system, finally slowing at the capillary beds and lighting up the cerebral veins.   Only a faint trace of dye would be present after seven seconds or so.

            A tall woman with rimless glasses emerged from the angiogram room.

            “Dr. Ravenel?  I’m Dr. Greta Sauls from OB.” 

            I winced.  I knew who she was, and she knew about me.  What was going on?  She’d been in practice long enough to stop calling herself doctor.  But I could go along with it if it made her feel better.

            “Hello, Dr. Sauls,” I said, mustering a smile.

            Rumor had it she was about to be named chief of obstetrics at CountyGeneral.   None of the locals preferred having their babies at a county hospital, but Sauls was part of CountyGeneral’s plans to change that.  She had been in town only a couple of years, but she had the all the qualifications, as far as I knew anyway.  A Boston fellowship, all the gloss.

            “You find what you’re looking for?”  She glanced at the x-rays and paused at the two-second film.  I was impressed.  She was looking straight at the aneurysm, seeming to size it up, figuring exactly what its relationship was to the anterior choroidal and posterior communicating arteries, something I hadn’t been comfortable with until I was a second year resident, after I’d seen a few operated on.

            “Yeah, she’s got an aneurysm all right,” I said, curious what she would say next.

            “A tough one?” 

            What did she know about aneurysms?  They all were tough, in one way or another.  I paused a few seconds, waiting for her to list the problems I would face.  How could she know?  I didn’t know squat about OB and was relieved she said nothing more.

            “It’s not going to be difficult to get to, but its shape may make things a little tricky.”  What else could I say?  About all the x-rays can tell you is exactly where the aneurysm is.  We had to learn the rest on the wing, in the OR.

            “How long do you think surgery will take?” she asked. 

            “Two hours, I guess.  Minimum.  Maybe four.”  I wasn’t about being fast.  Getting in a hurry could create real problems.  “Plus, anesthesia will need some time to get their lines in place, their monitoring equipment and whatnot.”

            She paused, seeming to calculate exactly when she could begin her C-section.  “Any chance of me going first?”

            “Too much risk to the mother,” I said softly.

            She shoved her glasses up the bridge of her nose.  “Will you need to take her blood pressure down?”

            She did know something about neurosurgery.

            “I hope not.”  It was an old technique to soften the walls of an aneurysm, but it could reduce blood flow to the brain too.

            “Okay.” 

            I waited, but that was all she was going to say.

            “Any chance of letting her go on to term?” I asked gently.  I wasn’t sure I understood why a C-section had to be done tonight.

            “She’s almost there, Doctor.”  Sauls reddened a little,  maybe wondering if I needed a lecture.  “Do you . . . do you really think she’s got a chance . .  . uh . . . with your surgery?”  She seemed almost embarrassed to confront me openly.  “Afterward, I mean.”

            “She’s got a chance.  Maybe not the best one in the world, though.”

            “I think we’d better press on with a C-section then, as soon as you’re finished.  Women on respirators don’t do well in labor.”  She smiled.  

            It was all I needed to know.  No reason to show any more of my ignorance about delivering babies.  “Sorry about the blood pressure snafu in the ER,” I said as I turned back to the angiogram.

            “Different strokes for different folks, Doctor.”

            What the hell did that mean?  I turned back to face her, but she was gone.  I only shook my head.   Sauls was a force, with a real presence about her—all business, but with a whiff of mystery too.  I liked her style.  Her head was screwed on straight.  And she was beautiful.  She didn’t seem to take much pride in that, but she was pretty all right.

            In another five minutes the remaining films had been developed and hung on the view box.  They were normal—nothing in the anterior communicating artery complex, or on the left carotid or the middle cerebral artery.   I telephoned the front desk in the OR suite to let them know we would be there in fifteen minutes.  They’d had time to set up a room and were probably waiting for me. 

            As I headed back into the angiogram suite, Ivan Andressen was adjusting a padded clamp at Mrs. X’s right groin.  He had removed the catheter and needed to apply steady pressure to her femoral artery in order to avoid bleeding, a process which normally took about ten minutes.  He wasn’t happy I’d insisted on scrapping his idea about studying the vertebral circulation tonight.  We’d been through that a million times in the past.

            “About done, Ivan?”

            “Almost.  Another five minutes.”

            Even if Mrs. X had a second aneurysm arising from the vertebral circulation, it couldn’t have caused the kind of hemorrhage the CT showed.  An aneurysm like that would be a problem for another day, after her baby was born.

            When I checked her pupils again, the left one really did react.  There was no doubt about it.

            “What’s her BP?” I asked the nurse on the other side of the table, the red-head from the ER.  She had just deflated the rubber cuff and was recording a pressure on the ER chart.   

            “One-fifty over eighty,” she said, eyeing me coolly.

            I blinked as her response began to register.  Surely I’d misunderstood her.  “Judas H. Priest!” I snapped when the look on her face indicated that I’d heard her correctly.  My face was immediately hot, and my pulse thudded in my ears.  “What have you been doing, Ms. Smith?”  I couldn’t help glaring at her. 

            She said nothing, simply took a deep breath and finished making a notation in the chart.

            “Ms. Smith, I asked you a question,” I said.  Andressen glanced at me sharply, making me realize that my voice had an edge to it.  I was not going to be accused of storming into some young nurse again, not tonight.  I already had enough on my plate.

            “Sir, I’m doing exactly what I’ve been told to do.”

            “You were to keep the blood pressure at one-twenty or less,” I said calmly.  Good godalmighty, woman!  I had to bite my lip to keep from screaming at her.  It wasn’t her fault she’d had to listen to doctors disagree, but a direct order was a direct order. 

            “No, sir.  I was instructed to keep it at one-fifty or above.”

            She held the chart in front of me, showing me Hal Garrison’s signed order.

            “Dr. Garrison spoke with Dr. Sauls, and they agreed.  Dr. Sauls was here a minute ago to make sure the epinephrine was working.”

            “You’re aware that this is my patient, aren’t you?  That I’m preparing to take her to the OR this very minute, that my instructions were otherwise, aren’t you?”  I kept my voice even, but it was a struggle.

            She looked at me in silence for a few seconds, then said, “You need to speak to Dr. Garrison or Dr. Sauls, sir.  They say this woman has no chance to live, but that the baby does.”

            My face was burning and my shoulder was giving me a fit, but I didn’t say anything.  I only snatched the chart from the nurse and scanned it hurriedly, hardly seeing anything. 

            I glanced at the plastic bags of fluid suspended from the IV stand at the head of the x-ray table—there were two: one, a liter bag of physiological saline plus a smaller one.  The small bag was not covered with tinfoil, mandatory for the light-sensitive Nipride.  They had been giving her epinephrine for nearly an hour and a half!  Only God Himself had kept that aneurysm intact.

            “Dammit,” I snapped, then flung the chart into the wall behind the patient’s head.  The metal cover hit like a rifle shot, and pages fluttered in every direction. I went to the IV pole and disconnected the epinephrine, letting it pour onto the floor, splashing onto the tops of my shoes.

            The nurse scrambled to gather up the papers from the floor as I turned back to Andressen, struggling to make my voice calm.  “Ivan, I hope you’re finished.  I’ve got to get this woman to the OR before some goddamned idiot succeeds in killing her.

Chapter One

Mrs. X

             Nobody had to tell me what had happened to the woman on the ER gurney.  I knew.  A thunderbolt of a headache had struck her out of the blue, leading to frightening dizziness and vomiting before her lights went out, maybe for good.

            She was beautiful—or had been, an hour or so ago—hardly out of her twenties, with fine, translucent skin stretched over delicate cheekbones, her hair a gleaming blond.  She had a Scandinavian look about her, as though she should be a Mrs. Lundquist or a Mrs. Svensson—Cristina, maybe.  Tonight she would be Cristina Svensson.  Some part of me needed a name.

            The nameless happened into emergency rooms almost nightly everywhere—temporary Xs stamped on their wrist bands, even Ys and Zs on busy nights in the big cities, along with seven- or eight-digit admission numbers.

            We had our share of Xs: people unconscious from car accidents most often, but also growing numbers of the homeless and drug pushers, plus teenagers on the lam.  But this woman, Christina, was different.  She had a home, and people who cared about her—a husband, possibly even children, who depended on her.  She had that look about her.  I didn’t need a name to know that.

            Her cotton hospital gown bulged over a swollen belly that promised new life, a life all too soon to be struggling for existence, with its mother now powerless to shift for either of them.  She wore a tiny diamond on her left hand.

            An explosion of blood had taken place between her frontal and temporal lobes, splashing back and forth and collecting at the base of her brain.  It came from her carotid artery.  The CT was textbook typical.

            An endotracheal tube curled from her throat.  A larger, more flexible length of tubing connected the endo-tube to the ventilator behind her head.  It hissed and puffed at intervals, pumping oxygen into her lungs.   

            “What was she like before you paralyzed her?”  I knew Garrison had given her something. 

            “Pretty much as she is now,” he said.  “Comatose.”  He wore a stiff white coat and a red bow tie, a clip-on job. 

            “All the way out?  Not moving anything?  Not even a hand, or a leg?”

            “Nothing.”

            Her scan almost promised she would be paralyzed on the left side, but I wished I could have seen her myself when she arrived.  Even the slightest flicker in her right hand would prove she had a fighting chance.

            “No posturing?”  That kind of stiffening of her arms and legs would have pointed to a big time injury high in her brainstem.   Her extremities were limp now.

            “No.”

            I bit my lip.  I was going to the limit for this woman, but knowing, really knowing we had a chance seemed to make a difference.   Knowing surgery wasn’t just a preamble to an autopsy was a huge plus.  I’d had my share of Chinese fire drills.

            “Looks like you saved her life, Hal.”

            “For a while anyway.”  He gave me a sour look.  He knew the score.  ER docs did what they had to, and fast.  Garrison had been around.  No doubt his intubating her, and getting her on the respirator, had bought her some time.  But it didn’t look good for Mrs. X.  I could only hope he had overlooked the barest twitch of a finger.

            “But she was trying to breathe?  Right?”

            “Barely.”

            With a thumb and forefinger I lifted her eyelids and studied her pupils, begging them to constrict in the overhead light.  The one on the right was fully dilated and stone still, but the other one quivered a little.  Did I imagine it?

            “Does the left pupil react?”  The nurses had examined them earlier.  It was part of the routine.

            “No, sir.”  It was Spurgeon Green, a nurse whose ass I’d pulled out of the fire a couple of weeks ago.

            I slid the left eyelid back to half-mast, then raised it again, quickly, searching for the barest flicker of a change.  There.  There it was!  Maybe I was deluding myself.  I was dying to see a reaction.

            “What’s her BP?”

            “One-twenty over eighty.  Pulse is ninety.” A woman’s voice.  Another nurse.  She seemed anxious, almost frightened.  I’d never seen her before.  She had flaming red hair.  

            That much was good.  Sometimes the blood pressure shoots sky-high with a hemorrhage, the heart pumping like mad to fill up the coronaries and keep a constant blood flow to the brain.  But high blood pressure could cause more bleeding too.  Even a trickle now could kill Mrs. X, or Cristina Lundquist, or whoever she was.

            “She needs an angiogram, Hal, right away, then the OR.  She’s got an aneurysm.”  I made it sound as final as I knew how.

            “You’re kidding.” Garrison’s thin grin seemed more challenging than questioning. 

            The red-headed nurse glanced at Garrison, then back at me.

            “Not quite,” I muttered, forcing a smile.  “I didn’t get out of bed tonight to regale you guys with jokes.”

            “But . . .”  His shoulders wilted, and his head tilted forward, his gaze skipping back and forth across the floor, as though he might be able to find his thought rolling around at his feet, like change that might have fallen though a hole in his pocket.

            I waited.  Garrison wouldn’t pop off on the first idea in his head. 

            “This woman’s a goner,” he stammered finally, like he had a sure way of knowing.   “She’s brain dead.”

            “Not if she’s trying to breathe.”

            “She only sucked in a gasp or two.”

            “Sounds alive to me.  Plus, her left pupil’s reactive.”  Why be equivocal about it? 

            “You amaze me, Ravenel.”  Garrison was smiling, clearly challenging me now.

            “That’s nice.”  What else could I say?

            “Come on, Grant.  You guys thrive on playing God, but this one’s way beyond anything you can do.  Don’t do something you’ll wish you hadn’t.”

            Like surgeons, ER doctors are action people, used to cutting through unimportant information quickly, making decisions in a hurry, then sticking to them, never looking back until they’re proved to be so wrong there’s nothing left to do.  They are also like surgeons in that they are rarely dangerous until they’ve gained a little experience, get too sure of themselves.

            “Why did you call me, then, if you’re so sure?”  I had to calm down.  I didn’t need somebody running off to administration again, or to the nursing office, spouting off nonsense about me blowing my top in the ER.

            “Well, only you can make it official.  You’re the neurosurgeon.”

            I paused a few seconds to let what he’d said echo back to him.

            “So you want me to write your opinion on this woman’s chart and sign my name to it.  Is that it?”

            His face darkened.  “Hell, Ravenel, I don’t care what you write on her chart.  Do whatever you like.  Everybody knows you’re superman.  Let’s see if you can raise the dead.”

            My neck tensed a little as I rotated my bad shoulder forward a few degrees.  It had been sore since my morning case.  “All I know is, Hal,” I said finally, “if I were in this woman’s shoes, I’d want somebody busting his butt to give me a chance.  If I’m wasting my time, it’s my time to waste.”

            “She’s carrying a perfectly viable infant, Grant,” Garrison said.  “Please don’t do something dumb, something that puts the baby in jeopardy.”  He seemed sincere enough, but . . .  I took a deep breath.

            “Has OB seen her?”

            “Yes.  Greta Sauls.  She wants to section her right away.  She’s got an OR standing by.”

            “I don’t have a problem with that, after the aneurysm’s clipped.”

            “But—”

            “But what?  Do they think the fetus is in danger?”

            “Not yet.  The heart sounds are fine, hardly more than one-forty a minute.”

            “They shouldn’t mind waiting a few hours then, until the mother’s safe.”

            “The pediatricians are standing with them.  Tim Finney was here a few minutes ago.  He’s nervous about the baby.”

            So?  Finney was always nervous about something.

            “Tim wants us to start some fluids IV, and epinephrine, boost her BP a little.”

            “Why?”

            “To perfuse the placenta, the way we do when kidneys are to be transplanted.”

            “Don’t do it.  That’s a terrible idea.”  I wouldn’t be a part of causing a rebleed, and a death.

            He gave me a hard look, one that twisted finally into a nasty grin. 

            My shoulder began to ache a little more, like it always did when I felt stress coming on.  Stress.  Maybe the shoulder-aching was part of a primitive response, like nature getting a guy set to punch somebody.  Yeah, right.  What happened to my shoulder so long ago had kept me from even waving at anybody.   

            “Are you trying to find out who she is?” 

            “We’re working on it,” Garrison snapped. 

            “We need her husband.” 

            “Why?  I can’t believe you’re looking for somebody to console.”

            “Come on, Hal.  If we’ve gotta choose between her and the baby, we need his help.”  I could make surgical decisions, but I wasn’t into moral judgments for folks I didn’t know.

            “You’d listen to him?   Is that it?  Just not Tim and me.”

            “Come on, Hal.  I’m not going to let you, Sauls, and a pediatrician make this call for me.  You don’t want to bring another orphan into the world without going all-out for its mother, do you?”

            Garrison’s jaw muscles rippled his face.  

            “How’d she get here anyway?”

            “Catawba CountyRescue.  They say she collapsed in a 7-Eleven.  No purse, no driver’s license.  The attendant called 911.” 

            “There must be a registration card in her car,” I said.

            “Right.  They didn’t take the time to check that out.  The police are out there now.”

            “We can do an angiogram while we’re waiting.”

            Garrison would come around.  He didn’t have the balls to be responsible for a neurosurgical patient, mine, against my judgment, even with Sauls and Finney holding his hand.  

            “Keep an eye on the BP, Spurgeon,” I told Green as I turned to leave.  “Don’t let it go higher than one-twenty.  Use Nipride if you have to.”

            “But, the pediatricians—” Green was pale.

            “Tim wants a pressure of one-forty, Grant,” Garrison said.  “We’re going to start an epinephrine drip.  Greta agrees.” 

            “Don’t do it.  Unless you want to kill this woman,” I snapped.   “I’ll call Greta.  Explain it to her.”

            Garrison shrugged, cocking his head to one side.  Green looked at him, then back at me. 

            “How much Nipride do I give her?”  Green wanted specific directions.  This was a controversy he could avoid.

            “As much as it takes,” I said.  “Her BP might hold at one-twenty without anything, or it may take more than you can imagine.  Mix up a drip of one hundred milligrams in a half-liter of saline.  Check her BP every ten minutes, and use as much Nipride as you have to.”

            “But giving her too much could—”

            “Hypertension, or a rebleed, can kill her a lot faster than Nipride,” I said slowly.  Did I have to draw him a picture?  Just do it, damn it, I wanted to scream.

            “But what will Nipride do to the baby?”  Green had been around.  Just having a doctor’s order was nowhere near enough for him.  I respected him for that, but we needed to get moving.

            “Hopefully we won’t have to use enough to make any difference,” I said.  “Use what you need to, and chart what you give her.”

            “Would you write that order for me?”

            I felt another stab in my shoulder.  This was getting crazy.  We had a woman dying in front of us, and he’s worried about his skinny butt.  The chart might save Green, but who was going to save this woman?  I stared at him in disbelief.

            “I’ll get the Nipride, Spurgeon,” the red-head said, heading for the medications cabinet.  I breathed a sigh of relief.  Making me walk the paperwork line didn’t make sense.  Not tonight.  But the red-head got it.  She would write my verbal order.

            “Okay, Smitty,” Green said finally.

            Garrison crossed his arms and glared at me, his jaw muscles dancing up and down his face.  He would be in Hanes’s office early in the morning, complaining about me bullying my way around the ER again.  Screw him!  Screw Hanes too.

            I couldn’t get Spurgeon Green out of my head as I pulled on a set of scrubs in the dressing room.  Surely I could count on him.  I didn’t go to bat for a nurse every day.  Green had never acknowledged I’d done anything special for him, but he had to know about it.  I played it back in my mind as I slipped off my shoes and took down the old pair of clogs from the top of my locker.

            “I’ve got to let him go, Doctor,” Patsy Schrock had said, hardly two weeks ago.  She faced me from behind her desk—a big woman, heavy, a washed-out look in her face that matched her hair.  It was short.  She’d given up dying it years ago.   

            “You can’t afford to fire him, Miss Schrock.  He’s the best ER nurse we’ve got, by far.  He’s quick, and has an amazing feel for what’s important.  Plus, he knows how to get things done.  He’s just been on the job a month, but he knows more about what’s really important than any of the others.”

            “But he’s not a graduate of a certified nursing school!  That leaves us with too much exposure.  The hospital can’t afford that kind of risk.”

            “No nursing school?  You gotta be kidding.”

            “He attended field service schools in the Army, one at Tripler in Hawaii, the other at Walter Reed.  That’s it.”

            “But he knows what he needs to know.  No question about that.  Plus, he’s served two tours as a medic in Vietnam.”

            “Well, Doctor, I don’t know that battlefield experience qualifies a nurse to work in this hospital.  Anyway, military institutions are simply not on our approved list.”

            “Says who?” 

            “Mrs. Blackwelder, our policy-compliance officer.  She checks new personnel qualifications against the requirements dictated by administration.”

            I closed my eyes and forced myself to silence.  Administration?  It was the same old story.  MethodistHospital was like a pig in quicksand.  Miss Schrock had kept her job forever and a day by being dedicated to the status quo.  She wasn’t about to start ripples in the water now.  She would not stretch her neck, even if it meant efficiency in the ER.

            “It’s a fine time to fire a nurse like this on that kind of technicality,” I said, trying to sound calm.  “Surely you can do something.”

            “It’s out of my hands.  I don’t interfere with my senior staff, and none of us bend rules.  You can understand that.”  She gave me a look that told me I should stop thinking such thoughts.

            But in the end, somehow, I convinced her.  I’d promised to be personally responsible for Green, and she stipulated he be on probation for a year.  George had backed me up, and even Parker Hanes approved, the idiot who runs the hospital.  Hanes never sided with me about anything.        

            In a way, Hanes was responsible for every constraint any doctor worked under around here.  He had set up the system.  We all had folks watching us, actions we knew we might have to explain someday.  Some of us were more affected by Hanes’s system than others.  With Spurgeon Green it was the nursing service hierarchy.  Hal Garrison and the other ER docs worked according to a protocol devised by the ER committee.  Hanes saw to it that individual doctors weren’t trusted to think for themselves.  The system insured that obedience to a given method or philosophy was established by committee.  But it was Hanes himself that stuck in my backside.  He was dedicated to appearances—especially cozy relationships between doctors and doctors and doctors and nurses—also how to get things done with the hospital spending the least amount of money possible.  It was driving me crazy.

            In the x-ray department I studied the films from the right carotid injection.  I’d paged Greta Sauls a second time, but she had yet to call.   There were twenty x-rays in two lines on the view box, AP and lateral projections.  The aneurysm was best seen on the two-second film.  It was large, and had two lobes, one larger than the other.  The big one projected downward, into the cistern where the third cranial nerve coursed toward the orbit.  They would inject the other carotid to make sure there was no aneurysm on the left.  It happened sometimes.  I didn’t need any surprises tonight.

            From the next room I could hear the radiologist communicate with a technician as he prepared to inject.  “Ready . . . shoot!”  She activated the film-changer the instant he’d emptied his syringe into the IV.  Then came the bang-bang-bang of the changer ratcheting the celluloid beside the woman’s head at two  frames per second at first, then one film per second as dye moved into the venous system.  The first film would be blank, dye appearing first on the second, then spreading throughout the arterial system, finally slowing at the capillary beds and lighting up the cerebral veins.   Only a faint trace of dye would be present after seven seconds or so.

            A tall woman with rimless glasses emerged from the angiogram room.

            “Dr. Ravenel?  I’m Dr. Greta Sauls from OB.” 

            I winced.  I knew who she was, and she knew about me.  What was going on?  She’d been in practice long enough to stop calling herself doctor.  But I could go along with it if it made her feel better.

            “Hello, Dr. Sauls,” I said, mustering a smile.

            Rumor had it she was about to be named chief of obstetrics at CountyGeneral.   None of the locals preferred having their babies at a county hospital, but Sauls was part of CountyGeneral’s plans to change that.  She had been in town only a couple of years, but she had the all the qualifications, as far as I knew anyway.  A Boston fellowship, all the gloss.

            “You find what you’re looking for?”  She glanced at the x-rays and paused at the two-second film.  I was impressed.  She was looking straight at the aneurysm, seeming to size it up, figuring exactly what its relationship was to the anterior choroidal and posterior communicating arteries, something I hadn’t been comfortable with until I was a second year resident, after I’d seen a few operated on.

            “Yeah, she’s got an aneurysm all right,” I said, curious what she would say next.

            “A tough one?” 

            What did she know about aneurysms?  They all were tough, in one way or another.  I paused a few seconds, waiting for her to list the problems I would face.  How could she know?  I didn’t know squat about OB and was relieved she said nothing more.

            “It’s not going to be difficult to get to, but its shape may make things a little tricky.”  What else could I say?  About all the x-rays can tell you is exactly where the aneurysm is.  We had to learn the rest on the wing, in the OR.

            “How long do you think surgery will take?” she asked. 

            “Two hours, I guess.  Minimum.  Maybe four.”  I wasn’t about being fast.  Getting in a hurry could create real problems.  “Plus, anesthesia will need some time to get their lines in place, their monitoring equipment and whatnot.”

            She paused, seeming to calculate exactly when she could begin her C-section.  “Any chance of me going first?”

            “Too much risk to the mother,” I said softly.

            She shoved her glasses up the bridge of her nose.  “Will you need to take her blood pressure down?”

            She did know something about neurosurgery.

            “I hope not.”  It was an old technique to soften the walls of an aneurysm, but it could reduce blood flow to the brain too.

            “Okay.” 

            I waited, but that was all she was going to say.

            “Any chance of letting her go on to term?” I asked gently.  I wasn’t sure I understood why a C-section had to be done tonight.

            “She’s almost there, Doctor.”  Sauls reddened a little,  maybe wondering if I needed a lecture.  “Do you . . . do you really think she’s got a chance . .  . uh . . . with your surgery?”  She seemed almost embarrassed to confront me openly.  “Afterward, I mean.”

            “She’s got a chance.  Maybe not the best one in the world, though.”

            “I think we’d better press on with a C-section then, as soon as you’re finished.  Women on respirators don’t do well in labor.”  She smiled.  

            It was all I needed to know.  No reason to show any more of my ignorance about delivering babies.  “Sorry about the blood pressure snafu in the ER,” I said as I turned back to the angiogram.

            “Different strokes for different folks, Doctor.”

            What the hell did that mean?  I turned back to face her, but she was gone.  I only shook my head.   Sauls was a force, with a real presence about her—all business, but with a whiff of mystery too.  I liked her style.  Her head was screwed on straight.  And she was beautiful.  She didn’t seem to take much pride in that, but she was pretty all right.

            In another five minutes the remaining films had been developed and hung on the view box.  They were normal—nothing in the anterior communicating artery complex, or on the left carotid or the middle cerebral artery.   I telephoned the front desk in the OR suite to let them know we would be there in fifteen minutes.  They’d had time to set up a room and were probably waiting for me. 

            As I headed back into the angiogram suite, Ivan Andressen was adjusting a padded clamp at Mrs. X’s right groin.  He had removed the catheter and needed to apply steady pressure to her femoral artery in order to avoid bleeding, a process which normally took about ten minutes.  He wasn’t happy I’d insisted on scrapping his idea about studying the vertebral circulation tonight.  We’d been through that a million times in the past.

            “About done, Ivan?”

            “Almost.  Another five minutes.”

            Even if Mrs. X had a second aneurysm arising from the vertebral circulation, it couldn’t have caused the kind of hemorrhage the CT showed.  An aneurysm like that would be a problem for another day, after her baby was born.

            When I checked her pupils again, the left one really did react.  There was no doubt about it.

            “What’s her BP?” I asked the nurse on the other side of the table, the red-head from the ER.  She had just deflated the rubber cuff and was recording a pressure on the ER chart.   

            “One-fifty over eighty,” she said, eyeing me coolly.

            I blinked as her response began to register.  Surely I’d misunderstood her.  “Judas H. Priest!” I snapped when the look on her face indicated that I’d heard her correctly.  My face was immediately hot, and my pulse thudded in my ears.  “What have you been doing, Ms. Smith?”  I couldn’t help glaring at her. 

            She said nothing, simply took a deep breath and finished making a notation in the chart.

            “Ms. Smith, I asked you a question,” I said.  Andressen glanced at me sharply, making me realize that my voice had an edge to it.  I was not going to be accused of storming into some young nurse again, not tonight.  I already had enough on my plate.

            “Sir, I’m doing exactly what I’ve been told to do.”

            “You were to keep the blood pressure at one-twenty or less,” I said calmly.  Good godalmighty, woman!  I had to bite my lip to keep from screaming at her.  It wasn’t her fault she’d had to listen to doctors disagree, but a direct order was a direct order. 

            “No, sir.  I was instructed to keep it at one-fifty or above.”

            She held the chart in front of me, showing me Hal Garrison’s signed order.

            “Dr. Garrison spoke with Dr. Sauls, and they agreed.  Dr. Sauls was here a minute ago to make sure the epinephrine was working.”

            “You’re aware that this is my patient, aren’t you?  That I’m preparing to take her to the OR this very minute, that my instructions were otherwise, aren’t you?”  I kept my voice even, but it was a struggle.

            She looked at me in silence for a few seconds, then said, “You need to speak to Dr. Garrison or Dr. Sauls, sir.  They say this woman has no chance to live, but that the baby does.”

            My face was burning and my shoulder was giving me a fit, but I didn’t say anything.  I only snatched the chart from the nurse and scanned it hurriedly, hardly seeing anything. 

            I glanced at the plastic bags of fluid suspended from the IV stand at the head of the x-ray table—there were two: one, a liter bag of physiological saline plus a smaller one.  The small bag was not covered with tinfoil, mandatory for the light-sensitive Nipride.  They had been giving her epinephrine for nearly an hour and a half!  Only God Himself had kept that aneurysm intact.

            “Dammit,” I snapped, then flung the chart into the wall behind the patient’s head.  The metal cover hit like a rifle shot, and pages fluttered in every direction. I went to the IV pole and disconnected the epinephrine, letting it pour onto the floor, splashing onto the tops of my shoes.

            The nurse scrambled to gather up the papers from the floor as I turned back to Andressen, struggling to make my voice calm.  “Ivan, I hope you’re finished.  I’ve got to get this woman to the OR before some goddamned idiot succeeds in killing her.