The Surgeon (3 page)

"Why not?"
"What would be the point?"
"The point is that you might've learned something
interesting. Like the fact she left Savannah soon after that
attack. And guess where she's living now?"
Through the hiss of the cell phone, he could hear the
whoosh of his own pulse. "Boston?" he asked softly.
"And you're not gonna believe what she does for a living."

three
D    r. Catherine Cordell sprinted down the hospital
corridor, the soles of her running shoes squeaking on the
linoleum, and pushed through the double doors into the
emergency room.
A nurse called out: "They're in Trauma Two, Dr. Cordell!"
"I'm there," said Catherine, moving like a guided missile
straight for Trauma Two.

Half a dozen faces flashed her looks of relief as she
stepped into the room. In one glance she took stock of the
situation, saw jumbled instruments glittering on a tray, the IV
poles with bags of Ringer's lactate hanging like heavy fruit on
steel-rod trees, blood-streaked gauze and torn packaging
scattered across the floor. A rapid sinus rhythm twitched
across the cardiac monitor--the electrical pattern of a heart
racing to stay ahead of Death.
"What've we got?" she asked as personnel moved aside to
let her pass.
Ron Littman, the senior surgical resident, gave her a rapid-
fire report. "John Doe Pedestrian, hit-and-run. Rolled into the
E.R. unconscious. Pupils are equal and reactive, lungs are
clear, but the abdomen's distended. No bowel sounds. BP's
down to sixty over zip. I did a paracentesis. He's got blood in
his belly. We've got a central line in, Ringer's lactate wide
open, but we can't keep his pressure up."
"O neg and fresh frozen on the way?"
"Should be here any minute."
The man on the table was stripped naked, every intimate
detail mercilessly exposed to her gaze. He appeared to be in
his sixties, already intubated and on a ventilator. Toneless
muscles sagged in folds on gaunt limbs, and his ribs stood
out like arching blades. A preexisting chronic illness, she
thought; cancer would be her first guess. The right arm and hip

were abraded and bloody from scraping across pavement.
On his right lower chest a bruise formed a purple continent on
the white parchment of skin. There were no penetrating
wounds.
She slipped on her stethoscope to verify what the resident
had just told her. She heard no sounds in the belly. Not a
growl, not a tinkle. The silence of traumatized bowel. Moving
the stethoscope diaphragm to the chest, she listened for
breath sounds, confirming that the endotracheal tube was
properly placed and that both lungs were being ventilated. The
heart battered like a fist against the chest wall. Her exam took
only a matter of seconds, yet she felt as though she were
moving in slow motion, that around her the room full of
personnel stood frozen in time, awaiting her next action.
A nurse called out: "I'm barely getting the systolic at fifty!"
Time sprang ahead at a frightening pace.
"Get me a gown and gloves," said Catherine. "Open the
laparotomy tray."
"What about taking him to the O.R.?" said Littman.
"All rooms are in use. We can't wait." Someone tossed her
a paper cap. Swiftly she tucked in her shoulder-length red hair
and tied on a mask. A scrub nurse was already holding out a
sterile surgical gown. Catherine slipped her arms into the
sleeves and thrust her hands into gloves. She had no time to

scrub, no time to hesitate. She was in charge, and John Doe
was crashing on her.
Sterile drapes were whisked onto the patient's chest and
pelvis. She grabbed hemostats from the tray and swiftly
clamped the drapes in place, squeezing the steel teeth with a
satisfying snap, snap.
"Where's that blood?" she called out.
"I'm checking with the lab now," said a nurse.
"Ron, you're first assist," Catherine said to Littman. She
glanced around the room and focused on a pasty-faced young
man standing by the door. His nametag read: Jeremy
Barrows, Medical Student. "You," she said. "You're second
assist!"
Panic flashed in the young man's eyes. "But--I'm only in my
second year. I'm just here to--"
"Can we get another surgical resident in here?"
Littman shook his head. "Everyone's spread thin. They've
got a head injury in Trauma One and a code down the hall."
"Okay." She looked back at the student. "Barrows, you're it.
Nurse, get him a gown and gloves."
"What do I have to do? Because I don't really know--"

"Look, you want to be a doctor? Then glove up!"
He flushed bright red and turned to don a gown. The boy
was scared, but in many ways Catherine preferred an anxious
student like Barrows to an arrogant one. She'd seen too many
patients killed by a doctor's overconfidence.
A voice crackled on the intercom: "Hello, Trauma Two? This
is the lab. I have a hematocrit on John Doe. It's fifteen."
He's bleeding out, thought Catherine. "We need that O neg
now!"
"It's on its way."
Catherine reached for a scalpel. The weight of the handle,
the contour of steel, felt comfortable in her grasp. It was an
extension of her own hand, her own flesh. She took a quick
breath, inhaling the scent of alcohol and glove talc. Then she
pressed the blade to the skin and made her incision, straight
down the center of the abdomen.
The scalpel sketched a bright bloody line on the canvas of
white skin.
"Get the suction and laparotomy pads ready," she said.
"We've got a belly full of blood."
"BP's barely palpable at fifty."

"O neg and fresh frozen plasma's here! I'm hanging it now."
"Someone keep an eye on the rhythm. Let me know what
it's doing," said Catherine.
"Sinus tach. Rate's up to one-fifty."
She sliced through the skin and subcutaneous fat, ignoring
the bleeding from the abdominal wall. She wasted no time
with minor bleeders; the most serious hemorrhage was inside
the abdomen, and it had to be stopped. A ruptured spleen or
liver was the most likely source.
The peritoneal membrane bulged out, tight with blood.
"It's about to get messy," she warned, her blade poised to
penetrate. Though she was braced for the gush, that first
piercing of the membrane released such an explosive spout
she felt a flash of panic. Blood spilled onto the drapes and
streamed to the floor. It splattered her gown, its warmth like
that of a copper-scented bath soaking through her sleeves.
And still it continued to flow out in a satiny river.
She thrust in retractors, widening the wound's gap and
exposing the field. Littman inserted the suction catheter. Blood
gurgled into the tubing. A stream of bright red splashed into
the glass reservoir.
"More laparotomy pads!" Catherine yelled over the scream
of suction. She had stuffed half a dozen of the absorptive

pads into the wound and watched as they magically turned
red. Within seconds they were saturated. She pulled them out
and inserted fresh ones, packing them into all four quadrants.
A nurse said, "I'm seeing PVC's on the monitor!"
"Shit, I've already sucked two liters into the reservoir," said
Littman.
Catherine glanced up and saw that bags of O neg blood
and fresh frozen plasma were rapidly dripping into the IV's. It
was like pouring blood into a sieve. In through the veins, out
through the wound. They could not keep up. She could not
clamp vessels that were submerged in a lake of blood; she
could not operate blind.
She pulled out the lap pads, heavy and dripping, and
stuffed in more. For a few precious seconds she made out the
landmarks. The blood was oozing from the liver, but there was
no obvious point of injury. It seemed to be leaking from the
entire surface of the organ.
"I'm losing his pressure!" a nurse called out.
"Clamp!" said Catherine, and the instrument was instantly
slapped in her hand. "I'm going to try a Pringle maneuver.
Barrows, pack in more pads!"
Startled into action, the medical student reached toward the
tray and knocked over the stack of laparotomy pads. He

watched in horror as they tumbled off.
A nurse ripped open a fresh packet. "They go in the patient,
not on the floor," she snapped. And her gaze met Catherine's,
the same thought mirrored in both women's eyes.
That one's going to be a doctor?
"Where do I put them?" Barrows asked.
"Just clear the field. I can't see with all the blood!"
She gave him a few seconds to sponge the wound; then
she reached in and tore apart the lesser omentum. Guiding
the clamp from the left side, she identified the hepatic pedicle,
through which the liver's artery and portal vein coursed. It was
only a temporary solution, but if she could cut off the blood flow
at that point, she might control the hemorrhage. It would buy
them precious time to stabilize the pressure, to pump more
blood and plasma into his circulation.
She squeezed the clamp shut, closing off the vessels in the
pedicle.
To her dismay, the blood continued to ooze out, unabated.
"Are you sure you got the pedicle?" said Littman.
" I know I got it. And I know it's not coming from the
retroperitoneum."

"Maybe the hepatic vein?"
She grabbed two lap pads from the tray. This next
maneuver was a last resort. Placing the lap pads on the liver's
surface, she squeezed the organ between her gloved hands.
"What's she doing?" asked Barrows.
"Hepatic compression," said Littman. "Sometimes it can
close off the edges of hidden lacerations. Hold off
exsanguination."
Every muscle in her shoulders and arms went taut as she
strained to maintain the pressure, to squeeze back the flood.
"It's still pooling," said Littman. "This isn't working."
She stared into the wound and saw the steady
reaccumulation of blood. Where the hell is he bleeding from?
she thought. And suddenly noticed there was blood oozing
steadily from other sites as well. Not just the liver, but also the
abdominal wall, the mesentery. The incised edges of skin.
She glanced at the patient's left arm, which poked out from
beneath the sterile drapes. The gauze dressing over the IV
site was soaked with blood.
"I want six units of platelets and fresh frozen plasma STAT,"
she ordered. "And start a heparin infusion. Ten thousand units
IV bolus, then a thousand units an hour."

"Heparin?" said Barrows in bewilderment. "But he's
bleeding out--"
"This is DIC," said Catherine. "He needs anticoagulation."
Littman was staring at her. "We don't have the labs yet. How
do you know it's DIC?"
"By the time we get the coag studies, it'll be too late. We've
got to move now." She nodded to the nurse. "Give it."
The nurse plunged the needle into the IV's injection port.
Heparin was a desperate toss of the dice. If Catherine's
diagnosis was correct, if the patient was suffering from DIC
--disseminated intravascular coagulation--then throughout
his bloodstream, massive numbers of thrombi were forming
like a microscopic hailstorm, consuming all his precious
coagulation factors and platelets. Severe trauma, or an
underlying cancer or infection, could set off an uncontrolled
cascade of thrombus formation. Because DIC used up
coagulation factors and platelets, both necessary for blood to
clot, the patient would begin to hemorrhage. To halt the DIC,
they had to administer heparin, an anticoagulant. It was a
strangely paradoxical treatment. It was also a gamble. If
Catherine's diagnosis was wrong, the heparin would make
the bleeding worse.
As if things could get any worse. Her back ached and her
arms were trembling from the effort to maintain pressure on

the liver. A drop of sweat slid down her cheek and soaked into
her mask.
Lab was back on the intercom. "Trauma Two, I've got STAT
results on John Doe."
"Go ahead," the nurse said.
"The platelet count's down to a thousand. Prothrombin
time's way up at thirty, and he's got fibrin degradation
products. Looks like your patient's got a roaring case of DIC."
Catherine caught Barrows's glance of amazement. Medical
students are so easy to impress.
"V tach! He's in V tach!"
Catherine's gaze shot to the monitor. A whipsawing line
traced jagged teeth across the screen. "Any pressure?"
"No. I've lost it."
"Start CPR. Littman, you're in charge of the code."
The chaos built like a storm, swirling around her with ever
more violence. A courier whooshed in with fresh frozen
plasma and platelets. Catherine heard Littman call out orders
for cardiac drugs, saw a nurse place her hands on the
sternum and begin pumping on the chest, head nodding up
and down like a mechanical sipping bird. With every cardiac

compression, they were perfusing the brain, keeping it alive.
They were also feeding the hemorrhage.
Catherine stared down into the patient's abdominal cavity.
She was still compressing the liver, still holding back the tidal
wave of blood. Was she imagining it, or did the blood, which
had trickled like glossy ribbons through her fingers, seem to
be slowing?
"Let's shock him," said Littman. "One hundred joules--"
"No, wait. His rhythm's back!"
Catherine glanced at the monitor. Sinus tachycardia! The
heart was pumping again, but it was also forcing blood into
the arteries.
"Are we perfusing?" she called out. "What's the BP?"
"BP is . . . ninety over forty. Yes! "
"Rhythm's stable. Maintaining sinus tach."
Catherine looked into the open abdomen. The bleeding
had slowed to a barely perceptible ooze. She stood cradling
the liver in her grasp and listened to the steady beep of the
monitor. Music to her ears.
"Folks," she said. "I think we have a save."

Catherine stripped off her bloody gown and gloves and
followed the gurney bearing John Doe out of Trauma Two. The
muscles in her shoulders quivered with fatigue, but it was a
good fatigue. The exhaustion of victory. The nurses wheeled
the gurney into the elevator, to bring their patient to the
Surgical Intensive Care Unit. Catherine was about to step
onto the elevator as well when she heard someone call out her
name.
She turned and saw a man and a woman approaching her.
The woman was short and fierce-looking, a coal-eyed
brunette with a gaze direct as lasers. She was dressed in a
severe blue suit that made her look almost military. She
seemed dwarfed by her much taller companion. The man was
in his mid-forties, and threads of silver streaked his dark hair.
Maturity had carved deeply sober lines into what was still a
strikingly handsome face. It was his eyes that Catherine
focused on. They were a soft gray, unreadable.
"Dr. Cordell?" he asked.
"Yes."
"I'm Detective Thomas Moore. This is Detective Rizzoli.
We're from the homicide unit." He held up his badge, but it
might as well have been dime-store plastic. She scarcely
looked at it; her focus was entirely on Moore.