Face to Face (12 page)

"Med Five en route with a three-year-old." She remembered the dispatcher's impassionate voice sounding over her trauma radio. "ETA two minutes."

The little girl was tiny for three, and so pale, Cassie had to resist the urge to smear her fingertip against her cheek to see if it was white makeup. One medic forced oxygen into her lungs through a tube inserted into her trachea while the other steered the gurney. 

"Heart rate's still good but we couldn't get a BP even by palp. Color's a little better since we tubed her."

This was better? We're in deep shit, Cassie thought, as she helped push the gurney around the corner into the resuscitation bay where her team waited. 

"What's the story?" she asked as they moved the patient across to the ER's bed.

"Mother said she'd been vomiting for two days and complaining of belly pain. She called grandmother for advice this morning when she couldn't wake Mary, that's the girl, up. Grandmother came over, took one look at her and called 911. When we arrived she was unresponsive to deep pain, so we scooped and ran, tubed her on the way in."

She leaned over her tiny patient, listening to her lung sounds. The nurses were working around little Mary, cutting her clothes off, trying for an IV. 

"Jesus Christ!" The exclamation came from one of the paramedics as Mary's nightgown fell open. Linda, the nurse who had cut it off, took a step backwards. 

There was silence in the room for a few heartbeats as they looked at the now naked child. A multitude of bruises covered her body. Her abdomen was grotesquely distended, giving the preschooler the appearance of some kind of obscene pregnancy. 

The paramedic, a seasoned Lieutenant, raised his fists, ready to bolt the room. "That sonofabitch."

Cassie stopped him. She needed all the help she could get. So did Mary.

"Get me peds surg stat and have an OR ready," Cassie commanded. "I want trauma labs drawn and two lines. In the meantime get me two units of Oneg on the warmer. Let's get an NG and Foley in her. What's her rhythm on the monitor?"

"Sinus tach, still no blood pressure even with Dynamap."

"She's hard to bag," the respiratory tech spoke up.

Cassie listened once more to her breath sounds. "No pneumo. It's the belly distention. I'm going to relieve the pressure with a paracentesis."

She grabbed some Betadine and prepped the little girl's belly, trying to focus on her task and ignore the reality of the torture this child had endured. Not only from the beatings but also from the severe pain of a perforated bowel. 

Linda worked beside her, trying to place a Foley catheter into Mary's bladder before Cassie stuck a needle into the belly to relieve the pressure. The nurse dropped the Foley and had to open a new kit.

"What's the problem?" Cassie asked as she drew on sterile gloves. "We don't have time to waste here."

"Look for yourself." The nurse had gone a pale shade of green and her hands were trembling. Cassie didn't want to know what made a seasoned ER nurse react like that, but it was her job to know. 

She bent over and looked. Mary had suffered more than just a beating. 

"Christ," she sighed. "Okay, Linda, you're doing fine." Cassie talked her nurse through the procedure in a level voice but she really wanted to scream in frustration. Who could do this to a child? Out of the corner of her eye she saw one of the paramedics retch and turn to the scrub sink, hands over his mouth.

Linda's eyes watered with tears but her hands were steady. "I don't want to hurt her," she whispered.

"It's okay. She's not feeling anything." Linda was able to thread the Foley catheter and Cassie turned back to the belly. She prepped the abdomen and inserted a catheter to relieve the pressure. As soon as it entered the peritoneal cavity there was a rush of air, like a balloon releasing.

"I can bag better now," respiratory said.

"I lost her pulse!"

"Start chest compressions and keep pushing the fluid. Where's that blood?" 

"It just got here."

"I want it in as fast it can go. Give her two of epi." Cassie went to the head of the bed and reassessed her patient. No signs of pneumothorax or tamponade; her heart had probably stopped because of the shock and blood loss, which they were working to correct. Thirty long seconds passed.

"Stop compressions for a pulse check," she commanded as she felt the carotid. She took a deep breath. It was faint but there was definitely a pulse. "I've got one. Where's the surgeon? She needs to be up in the OR."

"He's on his way." 

Cassie looked at the clock, she'd been working on the girl for less than ten minutes but it seemed an eternity. 

She turned back to the little girl, combing her fingers through Mary's blonde curls. It was frustrating to admit, but there was nothing more she could offer the child. Mary needed to be in surgery.

In answer to her prayers, Kurtis Waite, the pediatric surgeon appeared. He must have rushed straight from the OR because he still wore his paper cap and shoe covers. 

"What's the story?" he asked, his eyes taking in the girl and her bruises.

"Three-year-old, found unresponsive, history of vomiting. When she got here she was in sinus tach with no blood pressure, her belly so distended it was interfering with ventilation. We've given her three fluid boluses and she's on her second unit of O-neg."

He nodded. "How's ventilation after you decompressed the belly?"

"Better, but then she arrested. We got her back after the third fluid bolus and a dose of epi."

"Is the OR ready?"

"They said they'll need another ten minutes."

"Fuck that, tell them they have two. C'mon, let's roll." Waite pulled on the stretcher, not waiting for help. Cassie nodded to her nurses and they quickly grabbed the monitor and IV pumps, rushing behind him out the door.

Cassie leaned against the counter in the suddenly quiet critical care room, taking deep breaths in an attempt to calm herself. The paramedic still stood there, as if frozen. 

"I've never seen anything like that," he finally said.

Cassie looked up at him. He was a fifteen-year veteran of the worst the streets of Pittsburgh could offer. She sighed. "Me neither." 

They stood there in silence, mourning Mary's lost innocence, when Cassie's phone rang.

"The family's here. Dr. Waite asked if you could talk to them," the clerk told Cassie.

Cassie could imagine just how colorfully Kurtis Waite made that request. He was an excellent surgeon but with little patience for dealing with situations like this.

"Police and children services notified?"

"They've been called."

"Who all are there?" she asked.

"Gramma, mother, and stepfather."

She went down to the family area. There she saw a middle-aged woman weeping on the sofa, face in her hands. On the other side of the room was a young couple, the woman in her mid-twenties and the man just slightly older. 

"I'm Dr. Hart, I was taking care of Mary while she was here in the ER." Cassie sat on the ottoman near the door so she could make eye contact with them. "Can anyone tell me how Mary got hurt?"

The grandmother looked up, shaking her head. "Is she going to be all right? I want to see her."

"She's in very serious condition and is being operated on right now. There's a chance that she might not live," Cassie said softly. 

The grandmother let out a low moan. "Oh, my baby, my poor baby." 

Cassie looked to the mother and stepfather, both stared at her silently, neither moving to comfort the older woman. 

"You know what happened to Mary, don't you?" she asked in a level voice, not accusing, just stating a fact. 

They looked at each other then nodded.

"I'm sorry," the stepfather whispered. His body seemed to deflate as he slumped down into the chair. "I'm so sorry." He ran his fingers through his beard, covering his mouth as if ashamed of his words.

He was an ordinary appearing man. Slightly overweight. Skin a little sallow, like maybe he spent too much time inside watching football on TV, drinking more beer than was good for him. Like so many ordinary men here in Pittsburgh.

Plain clothes, jeans and a flannel shirt, working man's boots scuffed but with new laces.

Ordinary, hard-working man who'd just admitted to being a monster. 

Cassie concentrated on finding air to breathe as the room felt smaller as the truth the stepfather admitted filled the space between them. 

"It's important I know when this happened and exactly how Mary got hurt. We need to know what kind of injuries to look for," Cassie continued in that same soft voice. Her stomach churned with nausea and she wanted to run from the room and the evil contained there, but she controlled her feelings and forced herself to make eye contact with the mother.

Mary's mother perched on the arm of the chair, an arm around her husband. "It wasn't Ron's fault," she said, her voice high pitched like a school girl's. It made Cassie wonder if she was younger than she appeared. "Mary never listened. He told her not to make a fuss about going to bed. He counted to ten. He warned her..."

"Did this happen last night or the night before?"

Silence for a moment, then Ron spoke up. "Two nights ago. Cindy was trying to get out the door to go to work so I put the kids to bed. Mary kept getting back out of bed, wanting a drink, wanting a story, wanting to watch a video, she just wouldn't listen!"

"Then what happened?"

"I put her back in bed and told her if she didn't stay put, I would spank her. I went back downstairs, said goodbye to Cin. After that I heard Mary up out of bed again. I grabbed her and carried her back to her bed, and she just started to cry and scream and I lost it—" He shook his head. "I don't know, I just hit her, I wanted her to stop crying, that's all."

"Ronald, be quiet."

Cassie turned to the grandmother in surprise. The older woman stood, holding her hands up above her waist like a conductor calling for attention. "Cindy, tell him to be quiet before he gets us all in trouble." The grandmother stepped between Cassie and the couple. "Doctor, we want to know when we can see Mary, will you please go check?" 

Cassie stared at the woman but she held her ground, arms folded across her chest.

Without a word, Cassie left. Her heart thumped so hard she felt it in her throat, blocking her as she tried to swallow. Those people, what they'd done…She shoved her emotions aside. She still had work to do and wouldn't be any good to anyone, including Mary, if she gave into her anger.

She stopped at the nurses' station to call up to the OR and tell Kurtis Waite the injuries occurred two days ago. She was surprised when the surgeon came to the phone himself.

"How's she doing?" she asked, dreading his answer. Only one explanation for him to be available.

"She just died," he said, confirming her fears. "There was a belly full of blood and several feet of dead gut festering in there. There was nothing I could do." 

The phone was suddenly her only grasp on reality as she broke out in a cold sweat. "Thanks, Kurtis," she whispered. "I'll tell the family."

She retraced her steps back to the family room, not certain if she could contain the fury growing in her. For the first time in her career, she found herself utterly depleted of compassion for the loved ones of a patient. She didn't want to talk to these people again, didn't want to be in the same room as them, breathe the same air.

There were two police officers and a caseworker from Children and Youth now with the family. Ronald and Cindy held hands, both with stubborn sullen looks on their faces as the grandmother yelled at the police to leave them alone, they did nothing wrong, no one had known Mary was sick. Then she saw Cassie and her expression changed from righteous indignation into hopefulness.

"How's Mary, Doctor? How's our little girl? Is she going to be all right?"

Cassie stood with one hand on the door, ready to escape as soon as possible. It was difficult to watch, these ordinary monsters and their performance.

"Mary just died. There was nothing we could do to save her. Her injuries were too severe," Cassie said, her voice sounding flat and distant.

The police officers exchanged glances; this now was a homicide case. Cassie turned her back and walked away. She ignored the grandmother's shouts of malpractice and threats to sue them all. 

Cassie felt dirty. Like she needed to wash herself clean of all this. 

She'd headed back past the nurses' station, grateful the board looked under control, when an angry woman strode out of one of the rooms.

"Nurse, will you find me a doctor?" she demanded. "My son has a sore throat and cough and we've been waiting for over an hour! You tell the doctor he's sick and needs to be seen right now!"

It took every ounce of will power for Cassie to turn and face the woman without lashing out. She looked past the woman to where her teenaged son sat playing a handheld video game, looking anything but ill. 

"We just had a very serious trauma, ma'am," she replied as politely as she could. "Your son will be taken care of as soon as possible."

The woman huffed and stood in the doorway, a scowl on her face. "I'm never coming back to this hospital again."

Cassie ducked into the utility closet and leaned against a shelf, rubbing her eyes with her hands, trying to erase what they had seen today. After a few minutes of the quiet darkness, she took a deep breath, then blew it out.

She remembered looking down at her watch. Five hours left on her shift.

Now Cassie stared out Lisa's streaky window at the city lights, her sandwich long forgotten. Lisa looked up from her note taking, licked some grease from her fingers.

"So you took no part in the evidence collection? The rape kit was done in the OR?"

There was a long pause before Cassie could pull her mind back to the present. She felt as if Mary was in the room with them; patiently waiting for the grownups to finally get it right, bring her the justice she deserved.

"Kurtis did it after he declared her," she finally answered. "I remember there was another trauma alert—roll over MVA. He came down to help, but he would have left the kit with a nurse to guard it. He knows the routine."