Chapter 3: Return of Spontaneous Circulation
He had said it at five in the morning under the overhang of the ambulance bay, his hand at the collar of his own jacket and the kid's pulse knocking against his knuckles. Then he had taken his hand back and gone inside.
Whitaker had come in a minute behind him. They had changed into clean scrubs in the locker room with their backs to each other and not said a word, and at seven they had taken sign-out from the night team like two men who'd slept.
By then the snow had turned to rain, and the rain was freezing wherever it landed.
The call came at 7:26. Robby took it at the desk with Dana at his elbow, and he knew from the EMS command doctor's voice before he got to the numbers.
"Parkway East, outbound, just past the tunnel. A city bus went sideways on the ice and took out everything behind it. They're still counting cars. Twelve at least. We're estimating twenty-five to thirty patients, multiple criticals. The other trauma centers are splitting the head injuries. You're getting everything else we can't sort in the field."
"Understood. We're open." Robby hung up. Dana was already reaching for the overhead.
He'd done this before. He'd done it the day of PittFest, with a festival's worth of gunshot wounds coming through those doors, and for a moment, standing at the desk with the phone still warm in his hand, the department went thin and far away and the floor under his clogs was slick with something that wasn't there. He put both hands flat on the counter. The laminate was cold. He counted the screws along the edge of the desk until there were four of them and they were real.
"Rob," Dana said.
"I'm fine. Call it."
She called it. The overhead said the words the hospital used for this, and the department turned over like an engine. He gave the orders without having to think about them; he'd written half the plan himself. Discharge everybody who could walk. Hold the night team. Move the waiting room into the cafeteria. Collins in Trauma One, Mohan in Two, King and McKay running the yellows in the hallway with every nurse Dana could steal from upstairs.
"Santos, you're on airways. Whitaker—"
Whitaker stood at the edge of the group in fresh scrubs and Robby's fleece, which he'd pulled back on over them. He looked up.
"You're with me," Robby said. "Ambulance bay. Triage."
Dana's eyebrows went up and stayed there. Robby didn't look at her.
The bay was a sheet of ice. Somebody from facilities was throwing rock salt across it by the bucket, and it crunched under the tires of the first rig as it slid in sideways and stopped a foot from the wall. Robby stood under the overhang with a stack of triage tags and a Sharpie. Whitaker stood next to him with another stack. The doors kept opening.
You didn't treat at the door. You sorted. Walking and talking went green, to the hallway. Breathing faster than thirty, no radial pulse, unable to follow a command: any one of them meant red, straight back. Somewhere in between was yellow. Thirty seconds a patient, if you were good, and Robby was good. A bus passenger with a broken wrist, green. A man whose scalp laceration had bled all down his shirt, green. A teenage girl with her thigh bent wrong under the blanket, yellow, until he felt for her pulse again and made it red. The bus driver, gray and sweating, one hand pressed hard to his left ribs: red.
The fifth rig had a woman in it.
She was maybe thirty-five. She was breathing the way people breathe once the brain has stopped asking them to, long ragged pulls with nothing in between. Part of her skull was the wrong shape under the dressing, and both pupils were wide and black and didn't move when Robby put his light in them. The medic didn't say anything. He didn't have to.
Robby wrote on the tag, tore it, and tied it around her wrist. Black. In a mass casualty you did not spend a room and four pairs of hands and six units of blood on someone you could not save, not with three behind her you could.
As he pulled the knot tight, her coat pocket started to ring.
It was the ringtone a phone came with out of the box, a bright little marimba tune, playing into the cold. Robby's hands stopped on the tag.
"Robby," Whitaker said quietly, beside him.
"Take her to the quiet room. Somebody stays with her." His voice sounded normal. He heard it sound normal. "Next."
The next rig was already backing in. The man on the stretcher was making a wet, drowning sound, his face pushed in on one side where it had met a steering wheel, blood bubbling at his lips with every breath.
"Airway," Robby said. "Whitaker, take him. Find Santos. Go."
Whitaker went. Robby turned back to the doors and the next stretcher, and behind him in the corridor, getting farther away, the phone was still ringing.
Santos met him at the door of the ortho room with the video laryngoscope already in her hand.
"Face?"
"Steering wheel. He's drowning."
They got him over onto the bed. Up close it was worse. The middle of the man's face had come loose from the rest of it; his upper jaw shifted under Whitaker's fingers when he touched it, and blood poured from his nose and mouth faster than the suction could pull it away. His sat was eighty-one.
"If we sit him up, he'll drain—"
"C-collar," Santos said. "We can't." She went in with the blade. Whitaker held the suction in the corner of the man's mouth and watched the screen, and the screen showed red. Nothing but red, and the bright edge of the blade moving through it.
"I can't see anything." Santos pulled out, swore, went back in. "I can't see a goddamn thing. It's all blood."
"Seventy-six," the nurse said.
Whitaker fitted the bag-valve mask over the man's face and squeezed. Air hissed out around the broken bones and went nowhere. The chest didn't rise. He tried again with both hands sealing the mask and the nurse squeezing the bag, and it still didn't rise, and the number on the monitor said seventy, then sixty-eight.
"Can't intubate," Whitaker said. "Can't oxygenate. He needs a cric."
Santos looked at the door. Through its window the hallway was a jam of stretchers, and somewhere at the far end of it Robby was tying tags onto people's wrists.
"There's no time to get him," Whitaker said.
"Then do it." Santos tore the cric kit open and slapped the scalpel into his palm. "Do it, Huckleberry. I've got the bougie."
He did it the way the book said, because his hands didn't know any other way. Left hand on the larynx, thumb and middle finger walking down from the hard ridge of the thyroid cartilage to the small soft dip below it, where the airway came closest to the skin. A vertical cut, four centimeters, and the blood welled up dark and immediate, so that he lost the landmarks and had to find them again with a finger in the wound. There. The membrane, giving slightly under his fingertip.
He turned the scalpel crosswise and pushed it through. Air hissed out around the blade, wet.
"I'm in."
He rotated the blade so the sharp edge faced the man's feet, and Santos slid the bougie down along it and into the hole. Whitaker felt the tip click faintly as it ran over the rings of the trachea, and then hold up deep, where it should.
"Six-oh tube."
The tube went over the bougie and down. Cuff up. Bougie out. The nurse hooked up the bag and squeezed, and the man's chest rose, and the little plastic detector on the tube went from purple to yellow on the first breath.
"Color change," Santos said. "Holy shit."
Sixty-eight. Seventy-four. Eighty-five. The number climbed for half a minute and stopped at ninety-four, and only then did Whitaker notice that his right hand had started to shake, the one still holding the scalpel.
Santos took it out of his fingers and dropped it in the sharps. "Huckleberry," she said. "You just cricked a guy."
"Yeah."
"Robby needs to know you just cricked a guy."
But Robby wasn't at the doors when Whitaker went looking. Collins had triage now, tagging the last of the rigs. Robby wasn't in One or Two or at the board, though his name was on half of it. Dana, on the phone at the desk with her hand over the receiver, shook her head when Whitaker asked.
He found him in the decontamination room off the ambulance bay, which nobody used except to store cots for flu season. The light was off. Robby was sitting on the tile with his back against the wall and his knees drawn up, breathing too fast and too high, as if the air only went down as far as his collarbones.
Whitaker shut the door behind him. He crouched a little way off, the way you came up on a spooked animal, low and slow and from the side, and didn't touch him yet.
"Robby."
Robby's eyes came up. They didn't land.
"The bus driver's in the OR," Whitaker said. "Collins says it's his spleen. They took him straight up. The girl with the femur, Mel's got her. Pressure's holding, ortho's coming down. The scalp lac's getting stapled. Your guy with the face has an airway. He's going up with the facial team." He paused. "I cricked him. Santos and me."
Robby's chest was still going too fast, but his eyes had found Whitaker's face. "You cricked him." His voice sounded scraped raw.
"Sat's ninety-four."
"Good." A breath, deeper. "That's good."
"The woman with the phone," Whitaker said. "Dana answered it. It was her sister. Dana's in the family room with her now."
Robby shut his eyes. His hands were on his knees, and they were shaking, a fine, fast tremor that went all the way up into his forearms.
Whitaker reached out and took the right one. He held it for a second. Then he turned it over and pressed it flat to the middle of his own chest, under the open fleece, over his sternum, and held it there with both of his.
"It's going pretty fast," he said. "Count it anyway."
Robby's fingers spread a little against the cotton. His lips moved. Whitaker could feel the count in the pressure of his palm, and he breathed slowly on purpose, in and out, letting his own heart come down under Robby's hand. After a while Robby's breathing came down with it.
They stayed like that until the overhead said Robby's name. Dr. Robinavitch to Trauma One. Dr. Robinavitch, Trauma One.
Robby took his hand back. He wiped his face with both palms, hard, and got up off the floor in one motion, like a much younger man. At the door he stopped with his hand on the push bar.
"Whitaker."
"Yeah."
"Good cric," Robby said, and went out into the noise.
The ice kept coming down into the evening. By the time the last of the Parkway patients had gone upstairs or gone home, the buses had stopped altogether, and the city sat under a skin of glass that snapped limbs off the trees and dropped them across the streets.
Robby's car spent every winter on the fourth level of the staff garage, an old gray Volvo he kept there for the days the weather turned in the middle of a shift. He started it and sat with the fan roaring cold air at the windshield, which was fogged on the inside and glazed on the outside. Whitaker got in on the passenger side, looked at the dashboard, and then looked at him.
"This was here last night," he said.
"Yes."
"You said you weren't riding home in the snow."
"I wasn't riding." Robby kept his eyes on the windshield. "I didn't say anything about driving."
Whitaker was quiet. Robby could feel him putting it together: the call room, the top bunk, the man who'd lain awake over his head all night with car keys in his pocket.
"You stayed," Whitaker said.
"You'd just done forty minutes of compressions on a nineteen-year-old. I wasn't going to leave you alone in a call room." That was true, as far as it went. They both heard where it stopped.
The fog began to pull back from the bottom of the glass in two small ovals.
"I sent an email this morning," Robby said. "At six. To the program."
Whitaker turned his head.
"I've taken myself off your evaluations. Procedure sign-offs, the committee in the spring, all of it. Collins and the other attendings will do it. I told them it was a conflict and that I'd rather not say what kind, and they'll let me get away with that for a while." He watched the ovals grow. "It doesn't fix anything. I'm still the attending on every shift you work. I still decide who goes into Trauma One. An email doesn't change who I am in that building."
"I know."
"I'm telling you so you know I did it."
"Okay." Whitaker was quiet for a moment. "Then you can't use that one anymore."
Robby laughed. It surprised him, how it came out of him, rough and short, like something knocked loose. "It's not the only reason."
"I know. You're fifty. You've been doing this since I was in kindergarten." Whitaker's voice had gone gentle. "You were on the floor of the decon room this morning."
"Yes."
"You let me see that."
"I didn't let you do anything. You found me."
"You didn't send me away."
"I couldn't have sent you anywhere. I couldn't stand up."
"You stood up," Whitaker said.
The heater had finally started to mean it. Warm air came up around their feet and the fog went back from the glass in a slow tide, until there was nothing to see through it but a concrete pillar with a 4 stenciled on it in yellow paint.
Robby made himself look at him. All of him, the way he'd spent three weeks refusing to: twenty-eight years old, a farm in his hands and a cric on his record from twelve hours ago, sitting in a cold car at nine at night because he wouldn't be moved down a hall. Melted ice in his hair. His face very serious.
"This is a bad idea," Robby said.
"I know."
"I mean it. It's the worst idea I've had in a long time, and I've had some."
"I know you mean it." Whitaker leaned across the console. He stopped with an inch left between them, close enough that Robby could feel his breath, and waited there. "So tell me no."
Robby had said no to a lot of things in his life. To himself, mostly. He'd had plenty of practice.
He put his hand on the back of Whitaker's neck, where it had rested in the room with the boy and the sock: the same hold, warm skin and the short hair at the nape. Whitaker's eyes closed. Robby closed the inch.
It was slow at first, almost careful, Whitaker's mouth cold and then not, tasting of the bad coffee from the third floor. Then Whitaker made a small sound against him, and his hand came up and fisted in the front of Robby's scrubs, and it stopped being careful. Robby held on to the back of his neck and kissed him like a man who'd been thinking about it for twenty-one days, and longer, since a chest tube in Trauma One, since some hour in September he couldn't have named. The heater roared. Whitaker's knee knocked the gearshift and neither of them paid it any attention.
He was the one who stopped. He had to be. He pulled back just far enough to breathe, and their foreheads stayed together, and Whitaker's hand stayed knotted in his shirt.
"We can't do this here," Robby said.
Whitaker's eyes opened, very close and very clear. "Then where?"
Headlights swung around the ramp from the level above, white and sudden, and filled the windshield.
Robby didn't let go fast enough. The car came down the ramp slowly, the way everyone was driving tonight, a green Honda with a crumpled rear fender that he would have known anywhere, and as it drew level with the Volvo it slowed to almost nothing. For two long seconds Dana Evans looked through the glass at the two of them. Then the Honda went on down the ramp, its taillights turned the corner, and the garage was yellow and quiet again.
Whitaker had gone still under his hand. "Was that—"
"Yes."
Thirty seconds later Robby's phone buzzed in the cup holder. He picked it up.
6:30 tomorrow. You're buying the coffee and you're doing the talking.
"Is it bad?" Whitaker said.
Robby looked at the message a while longer. Then he put the phone face down on the dash. His other hand was still on the back of Whitaker's neck, and he left it there. The glass had cleared all the way to the edges.
"Tell me where you live," he said, and put the car in reverse.