Chapter 1: Primary Survey
The flight crew had decompressed his chest somewhere over Murrysville, and the farmer was still worried about his cows.
"Four o'clock," he said into the mask. Each word came out on its own short breath. "Somebody's got to do the four o'clock."
"Gary Kostelnik, sixty-one." The flight nurse kept pace with the gurney as it came off the helipad elevator, one hand steadying the bag of blood that swung from the pole. "Tractor rolled on a hillside and pinned him under the fender. Neighbor found him after about forty minutes. Left chest was tight and he was satting seventy-eight in the field, so we needled him at the second intercostal and got a good rush of air. Flail segment on the left, you'll see it. Pelvis is unstable, binder's on. He's been eighty over fifty since we lifted. Two units in, third one hanging."
"Thanks. Good work." Robby had his gloves on before they cleared the doors of Trauma One. "On my count. One, two, three."
They slid him across. Gary Kostelnik was a big man gone the color of putty, and when his barn coat came away under the shears, his left chest moved the wrong way: a palm-sized section of it sank in when the rest of him tried to breathe. There was mud in the creases of his neck. The room filled with the smell of diesel and wet hay.
"Collins, airway. Mohan, eFAST, start with the chest. I want a second large-bore line and the blood bank on the phone." Robby leaned over the man's face so he'd be the thing Gary saw. "Mr. Kostelnik. I'm Dr. Robinavitch. You're at PTMC in Pittsburgh, and we've got you."
"Cows," Gary said.
"I hear you."
Somebody heard him better. Whitaker had come in with the line kit and ended up at the head of the bed, and Gary's hand, black under the nails, found his wrist and closed on it.
"What do you run?" Whitaker asked him. "Holsteins?"
"Sixty head."
"The neighbor who found you. What's his name?"
"Dale."
"Then Dale's milking tonight. A man who drives out to check on you is a man who'll milk for you." Whitaker's voice had dropped into something slower than his usual, a voice for a nervous animal in a stall. "They'll be loud about it being late. They'll get over it."
Gary's eyes went over his face. "You farm?"
"Grew up on one."
"Then you know."
"I know," Whitaker said, and left his wrist where it was.
Dennis Whitaker was twenty-eight years old and five months into his intern year. He still apologized to IV poles when he bumped into them. In a trauma bay, though, he went quiet in a way Robby had learned to trust, and right now that quiet was keeping a frightened dairyman's eyes on his face while Collins laid out the airway tray.
"No sliding on the left," Mohan said, the probe tucked under Gary's arm. "Right side's sliding. Morison's pouch is clean, splenorenal's clean. Nothing in the pelvis I can see past the binder."
"Sat's eighty-three," Collins said. "He's tiring, Robby."
"I know. Ketamine and rocuronium, weight-based. Call him a hundred and ten kilos." Robby bent close again. "Gary. We're going to put you to sleep and breathe for you for a while. You'll wake up with a tube in your throat. Don't fight it."
"The four o'clock—"
"I'll call Dale," Whitaker said. "I'll call him myself."
Gary let go of his wrist. The ketamine went in, then the paralytic, and the big chest went still under Collins's hands while she slid the blade in and found the cords on the first pass.
"Tube's in. Good color change."
"Left chest tube." Robby looked across the bed at the two interns. Santos had already stepped forward. "Who's done one?"
"Three," said Santos.
"Two," said Whitaker. "One was a cadaver."
Robby told himself it was about numbers. Santos had three, Whitaker had one living patient, and the residency office counted procedures the way the blood bank counted units.
"Whitaker."
Santos looked at Robby as if he were a consultant who'd left her on hold for forty minutes. Whitaker didn't see it. He was already gowning, and when he turned back with the chlorhexidine he'd gone into the quiet again.
He did it by the book. Gary's arm up and back over his head. Two fingers walking down the ribs to the fifth intercostal space, just in front of the mid-axillary line, Whitaker's lips moving a little as he counted. Lidocaine into the skin, then deeper, down to the bone. A three-centimeter cut along the top of the sixth rib, and then the curved Kelly clamp in his right hand, pushing through fat and muscle in short, spreading strokes.
Robby stood at his shoulder. He could see the sweat starting under the edge of Whitaker's cap, and the pulse in the side of his neck, and the angle of the clamp.
For half a second the angle looked low.
Robby's hand closed over Whitaker's on the Kelly. Two layers of nitrile between them, and he could still feel the tendons on the back of the kid's hand go tight and then go still.
"Over the top," Robby said. "The nerve and the artery run under the rib. Over, always."
"Over the top," Whitaker said, and pushed.
Robby felt it through both their hands: the small give of the pleura. He had felt it a thousand times, under his own hands and under residents' hands like this one, and it still went through his ribs. Air hissed out around the steel, then came a slow, dark rush of blood. Whitaker opened the jaws of the clamp, drew it out, and slid a gloved finger into the hole to sweep for adhesions. Robby's hand had come off his by then. He couldn't have said exactly when.
"Twenty-eight French," Whitaker said, and Dana put the tube in his palm. It went in clean, angled up and back. They clamped it and hooked it to the drainage box and watched the collection chamber fill.
The blood came fast and then slower. Four hundred. Five-fifty. It crawled past six hundred and stalled around six-fifty, while the third unit ran in and the numbers on the monitor began to climb.
"Ninety-four over sixty," Dana said.
"Six-fifty out," said Robby. "If he puts out two hundred an hour for the next few, he goes upstairs. If he doesn't, IR can have the pelvis. Whitaker, sew it in. Mohan, call IR. Santos, take the leg. I don't like the color below the knee. Get me pulses and call ortho."
Everyone moved. Whitaker threaded the suture and anchored the tube with neat square knots, and Robby watched his hands do it, steady as any surgeon's, and then made himself look at the monitor instead.
"That was my tube, Huckleberry," Santos said under her breath as she went past.
"You can have the next one."
"I'm having the next three."
Ruth Kostelnik got there at a quarter past two, still in her muck boots, a pair of reading glasses pushed up into her gray hair as if she'd forgotten them on the way to the truck.
By then her husband was out of interventional radiology, where they'd found the artery bleeding into his pelvis and plugged it with coils, and on his way to the surgical ICU with his chest tube putting out a respectable thirty an hour. Robby had the update ready. He'd given some version of it a few thousand times. He walked into the family room with it and found Whitaker already there.
The kid was perched on the edge of the low vinyl couch, elbows on his knees, both hands around a paper cup of vending machine coffee he wasn't drinking. Ruth sat beside him with another.
"—a tube between the ribs, here," Whitaker was saying, touching his own side. "His lung had collapsed and there was blood around it. The tube lets it drain so the lung can come back up. It looks bad, but it's not the scary part anymore."
"What's the scary part?"
"His pelvis was bleeding. They fixed that about an hour ago. Dr. Robinavitch can tell you more than I can." He'd seen Robby in the doorway. His ears went pink. "He's the attending."
Ruth looked up. She had a farmer's face, weather worked into it. "You're the one in charge."
"For my sins." Robby sat across from her and told her: the coils, the ICU, the ventilator for a day or two at least, the ribs that would heal on their own and hurt like hell while they did it, the leg that ortho was watching for swelling. She listened the way people do when they've decided not to cry in front of strangers. When he finished, she nodded slowly and turned back to Whitaker.
"Did you call Dale?"
"Yes, ma'am. Right after he went up to radiology." Whitaker set his cup down on the carpet. "He's got his two boys over there. They'll do tonight and tomorrow morning and as long as you need. He said to tell you the heifer with the bad foot is fine, and he's not taking any money, and you shouldn't try."
Ruth laughed, one rough, surprised sound, and then she did cry, briefly, into the back of her wrist. Whitaker didn't say anything. He picked up the box of tissues from the side table and held it where she could reach it, and when she'd taken one he set it down again and waited.
Robby found he had nothing to add. That didn't happen to him often.
He was in the corridor when Whitaker came out ten minutes later carrying the empty cups. Whitaker stopped short.
"You called the neighbor," Robby said.
"I said I would."
"You said it to a man we were about to paralyze. He won't remember."
Whitaker frowned, as if the logic didn't hold. "I'd remember."
There were things Robby could have said. About the line between patient and family, about time, about the fourteen other people in his department who needed the intern who was standing here holding two empty cups. He looked at Whitaker's earnest face, still pink at the ears, and said none of them.
"Good tube," he said instead.
The pink went all the way down Whitaker's neck into the collar of his scrubs. Robby watched it go. Then he turned around and walked toward the board, because Dana was standing at the end of the hall with a chart in her hand and her eyebrows up.
"Eight's back from CT," she said when he reached her. "Your overdose in eleven is trying to leave AMA, and Gloria wants to talk to you about wait times." Her eyes went past his shoulder, down the hall, and came back. "You look like you need a sandwich."
"I'm fine."
"I didn't ask," Dana said, and handed him the chart.
The roof was the only place in the hospital where nobody could find him by overhead page.
He went up after sign-out, as he did most nights, through the stairwell past the helipad and out into a wind that came straight off the rivers smelling of cold water and exhaust. November had gotten serious. The helipad's edge lights burned blue and amber against the concrete. Past the parapet the city lay folded into its hills, lit along the creases, the rivers black between.
He'd been there five minutes when the stairwell door opened behind him.
"Dana said you'd be up here," Whitaker said. He had two coffees from the machine on three, and he was wearing his scrubs and one thin long-sleeved shirt under them, which in this wind was the same as wearing nothing.
"Dana should mind her own business."
"That's sort of the opposite of her job." Whitaker held out a cup. "I didn't know how you take it. It's black. The machine only really does black."
Robby took it. It was terrible. It was hot, which counted for most things after twelve hours. "You're going to freeze."
"I grew up in barns. This is nothing."
"Barns have walls."
Whitaker's shoulders were up around his ears and his jaw was clenched against chattering. Robby unzipped his fleece, the navy one with PTMC EMERGENCY stitched over the heart, gone shiny at the cuffs, and held it out.
"I'm fine."
"Put the jacket on, Whitaker."
He put it on. It hung loose on him through the shoulders, which surprised Robby; he'd have guessed the farm made Whitaker broader than that. He zipped it to his chin and shoved his hands into the pockets, and his face changed.
"There's stuff in here."
"There's always stuff in there."
Whitaker took things out one at a time and held each one up to the helipad lights. A penlight. Half a roll of antacids. A pen from a drug rep, advertising a blood thinner. Last, a strip of EKG paper folded small and soft as cloth, the creases worn nearly through.
He unfolded it carefully. A row of narrow, even complexes marched across the pink grid.
"Normal sinus," Whitaker said.
"Twelve-year-old at a Little League game, 2014. Took a line drive to the chest and went into V-fib on the pitcher's mound." Robby looked out at the city. "Commotio cordis. One shock in the bay. That's him about ninety seconds later."
Whitaker looked at the strip a moment longer. Then he folded it back along its old creases, exactly, and slid it into the pocket it had come from.
"Mr. Kostelnik's settled in the unit," he said. "Pressures are fine. Thirty an hour from the tube."
"I know. I checked."
"I know you checked. I saw you checking." Whitaker leaned on the parapet beside him, not touching. Robby was fifty years old and signed the kid's procedure log, and he kept his elbows exactly where they were.
"Do you come up here every shift?"
"Most of them."
"To do what?"
Robby considered lying. "Count bridges. There are four hundred and forty-six in the city. You can see nine from here when it's clear."
"Does it help?"
"Some nights."
The wind threw itself across the roof. Down on the Parkway the traffic went on, red one way and white the other. Whitaker drank his coffee. Robby could feel him working up to something, the way he could feel a patient working up to telling him how much they really drank.
"Can I tell you something about the chest tube?"
"If it's that you were nervous, everybody's nervous. I was nervous for about ten years."
"It's not that." Whitaker turned the cup in his hands. "I wasn't going under the rib."
Robby didn't answer.
"I know where the bundle runs. I've known since second year of med school. My clamp wasn't low." He said it without heat, as plainly as he'd told Gary Kostelnik grew up on one. "You put your hand on mine, and I knew I wasn't going under, and I didn't say anything."
Robby ran it back. The clamp, the angle, the half second. He wasn't sure anymore what he'd seen.
"Why not?" he said.
Whitaker looked at him then, straight on, in the blue and amber light. His nose was red with cold. He was wearing Robby's jacket zipped up to the chin.
"Because I didn't want you to move it," he said.
The wind filled the silence. Then Whitaker seemed to hear what he'd said, all of it at once, and he pushed off the parapet.
"Okay. Good night, Dr. Robinavitch," he said, very fast, and crossed the roof to the stairwell, and the door banged shut on its closer behind him.
He'd taken the jacket. Robby let him. He stood at the parapet with the bad coffee going cold in his hand and started on the bridges again, west to east, and lost count at four.