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  “Yes, this is my first night here,” Eli said, hoping to speed up the process. “Why don’t you tell me—”

  Norman interrupted. “What kind of doctor is he?”

  Confused by Norman’s odd questions in third person, Eli noticed that Janice was thoroughly amused. She leaned forward with both hands on the bed, a stethoscope dangling from her shoulders like a necklace framing full-chested blue scrubs.

  “You’re lucky, Norman. Dr. Branch is a surgeon.”

  Norman spoke directly to Eli. “A surgeon. Oh my. I need a surgeon, yes I do. You do specialize in surgery of the neuroconnective tissue, don’t you?”

  Janice covered a silent laugh with her hand.

  Eli looked at his patient. It was middle of the night, the place was quiet, deserted practically, yet Norman was somewhat charming in an odd sort of way.

  “Yes. In fact, I’m a neuroconnective specialist.”

  “Well goody,” Norman said, “because it feels like the top of my head is crawling off.”

  “Let me take a look,” Eli said, reaching to remove the wool cap with his right hand. He held his left close to his side in a splint.

  Norman pulled back. “What’s wrong with your hand?”

  Eli raised his arm and examined the splint as though for the first time. The scar down his forearm peeked through the support, the flesh still red and angry. He’d wondered how patients would react to his injury. Now he knew. Eli decided there was no reason to hide the truth.

  “I was on the wrong end of a knife fight.” He noticed that the nurse perked up, listening intently.

  “A knife fight? Like in a bar?”

  “No, not exactly. In the operating room. A scalpel, actually.”

  Norman thought about this. “So that’s why you’re here, taking ER call,” he said. “You can’t operate anymore.”

  Eli nodded. “Severed most of the tendons.” He raised his hand and watched a flicker movement of his fingertips. “With rehab, I’m getting a little back.”

  Norman grimaced. “I’m sorry, doc.”

  Eli squeezed Norman’s knee, then reached to remove his cap. “Let’s take care of you, shall we?”

  But Norman pulled away again.

  Eli looked to Janice for assistance.

  “He’s never let us take it off before,” she said.

  Norman confirmed this. “I never take my cap off in public.”

  Eli’s first impulse was to say, How the hell do you expect me to help you? He hesitated, calculated his words. “You’re going to have to trust me.” Eli reached for Norman’s toboggan.

  The edge of the cap was stuck as though sealed to his forehead. When Eli broke the seal, a tiny white flake, like a piece of skin, fell out and stuck to the bed sheet. Janice stepped back.

  But rather than stick there, the white flake began to move, then wiggled to a crawl along the linen’s surface.

  “It’s a maggot!” Janice’s voice held both clinical objectivity and a touch of horror.

  Eli peeled the cap back and slung it to the corner, a shower of white larvae following in its wake.

  A heaped up landscape of ulcerated skin and crevices covered the top of Norman’s head and bored down to the bone of his skull, each pocket teaming with maggots.

  “I need my cap back,” Norman said, as though unaware of the brood living with him.

  “We’ll give it back to you,” Eli said, “after we clean you up a bit.”

  Norman volunteered more information. “I haven’t shampooed in a while.”

  “Yes,” Eli confirmed. “I know.”

  Janice continued to stare at the man’s head. She couldn’t seem to turn away.

  Eli had encountered maggots once before. He knew some compromised patients, the sick, the homeless, the demented, were prey to the insects, especially in the midst of a hot summer. As a medical student, ten years earlier, Eli had treated a diabetic patient a full month after she scalded her insensate foot in bath water. The wound had not healed and maggots had burrowed a crevice between her toes.

  “Will you have to operate?” Norman asked, hopeful.

  Eli considered the options. Hundreds of maggots had taken residence in Norman’s scalp. Too many to remove, one by one. Most of them happily burrowed in little maggot caves. He would need to blast them out, somehow.

  “Yes, we will need to operate.” Eli inspected the man’s head again. “Using a very special piece of equipment.” He turned to his nurse. “Janice, in the staff bathroom, on the bottom shelf, I noticed a WaterPik machine. Could you get that for me?”

  “What?” Janice did not move but she did avert her eyes from Norman’s head. “You can’t be serious.”

  “Yes,” Eli said, confidently, as though he had requested a state-of-the-art surgical instrument.

  A minute later, Janice returned. Her eyebrows drawn in skepticism, she showed him the WaterPik, the unit in one hand, the pencil-sized applicator in the other.

  “I had forgotten we had this. Is this what you want?”

  “Perfect,” Eli said. He took the small machine and Janice plugged it into a wall socket.

  Norman’s sagging posture grew erect.

  Eli gave a test spray into the sink. A single shot of water hit the stainless steel with a ping. He reached over and turned the pressure to high.

  A slight grin developed on Eli’s face—a kid with a new toy.

  “You’re sick,” Janice whispered.

  Norman heard her. “Nurse, leave my surgeon alone. He’s trying to concentrate.”

  Janice rolled her eyes and watched a stronger stream of water splatter the sink.

  “There,” Eli said, pleased with his calibration.

  Janice placed a surgical mask over her mouth and was applying protective eyewear, like a hygienist about to clean teeth. She offered a mask and eyewear to Eli, but he waved her off. After ten years of general surgical practice, he’d had much worse splatter in his face.

  Like a good patient, Norman bowed his head to present the operative site. The first shot was dead aim at the base of the largest cavity. The whole maggot colony blasted away and scattered across the floor.

  Next, he aimed the applicator at a group of superficial maggots that seemed almost too easy. He smiled at Janice with complete satisfaction and thought he heard her gag.

  What kind of doctor had he become? From a rising academic surgeon to a small time ER doc shooting maggots with a WaterPik.

  One patient at a time, Eli told himself. Besides, what else did he have to do? No other patients had come to the ER. Hours remained in his shift.

  After several more rounds, the maggot refuse began to pile up. Problem was, the maggots weren’t actually dead. After being momentarily stunned, they’d begun to wiggle and crawl and look for a new home to eat. Janice called the night-shift housekeeping crew, a single-man unit consisting of Benjamin, the longest-standing employee from the time the hospital was built in the mid-seventies.

  Eli heard Benjamin’s mop bucket banging the wall as he approached. This was followed by the stomp of a boot. After a moment’s silence, Eli heard, “Damnation to hell. How’d these maggots get in here?”

  Benjamin knocked open the door with his foot and stood holding his mop like a shotgun. “After thirty-four years, thought I’d seen everything. Now we got maggots crawling under the door.” He looked at Eli, bent over Tobogganhead’s scalp like a neurosurgeon teasing brain. “What will these new doctors think up next?” He began stomping the crawlies again.

  For the next fifteen minutes, Eli kept blasting away at the open pocks in Norman’s scalp while Janice tried to stay out of the fray. He knew that removing the maggots was only a start. The whole top of his scalp was most likely a cancer, a neglected carcinoma turned happy maggot home. The lesion went all the way down to the skull and would need radical excision, skin grafting, maybe even plastic surgery to swing a flap from the shoulder for coverage.

  Norman “Tobbaganhead” Felts would be in the hospital for days, possi
bly weeks. And it didn’t take a social worker to figure out that he was a flight risk. Eli suspected that Norman would be hard to convince that the top of his head was eaten up with cancer. Once the “crawling” went away, so would Norman.

  Between Eli’s WaterPik blasts and Benjamin’s stomps and mutters, the only other sounds came from outside the room—car tires squealing, followed by a series of escalating shouts.

  “Which room is he in?” one of the nurses yelled from the hallway.

  Eli knew this couldn’t be good.

  “Dr. Branch, we need you out here. Now!”

  Janice opened the door. “We’re almost finished.” They all wanted to complete the maggot procedure, no matter what the emergency.

  A nurse stood in the doorway, eyes wide. “They just dropped him off. Blood’s everywhere. He may already be dead.”

  Eli listened as he finished the procedure on Norman’s head. Calmly, he told Norman, “I have to see another patient now, but I want you to stay right here until I get back.”

  Norman had reached up with one hand and was barely touching the raw surface of his scalp.

  “Okay, Norman?”

  “Sure, doc. Whatever you say.”

  Eli ripped off his gloves and dashed into the hallway. The ward clerk and medical technician were standing outside the trauma resuscitation room, wringing their hands.

  If the squealing car was connected to this new patient, and Eli was sure it was, the injury was most likely penetrating, a gunshot wound or stabbing.

  And life-threatening.

  He stepped into the trauma room and saw a young white male lying lifeless on the gurney. His left arm had fallen off the side and hung at a right angle to his body. The nurse had his right arm extended on an arm board attempting to start an IV.

  “He’s got a thready pulse, shallow respirations,” she said, then blew out a pent-up breath. “I can’t get this damn IV started, his vessels are clamped down.”

  Eli had faced this situation many times. As a chief surgical resident at Vanderbilt University Medical Center, he had directed trauma resuscitations on countless patients—car and motorcycle crashes, knifing victims, gunshots. But at Vanderbilt, he had the luxury of a Level One Trauma Center with specially trained nurses, a blood bank, and the ability to operate in the emergency room.

  It was obvious to Eli why the young man’s veins weren’t cooperating. He had a bullet hole in the dead center of his chest. Strands of a long, gold chain necklace entered the wound. Rhythmically, the chain would catch taut, then release, as if keeping time with his heart.

  What had been the boy’s white tank top was now dark red. With each shallow breath, a frothy plume of blood blew out of the hole. Given the location of the entrance wound, the bullet had likely hit the heart.

  If the boy was to survive, Eli immediately knew what had to happen.

  CHAPTER THREE

  The algorithm was as easy as a child’s nursery rhyme.

  A-B-C-D-E-F.

  Control the Airway. Breathe for the patient. Re-expand the Circulation. Assess for neurological Disability. Finally, cut away all the clothes and Expose any other injuries. If you didn’t make it to one of these steps, then came F—Fatality.

  Earlier that evening, when he arrived for his shift, Eli had passed through the small trauma room to assess the equipment—rudimentary at best. The ward clerk reminded him that they had not used the trauma room in over a year. That his zealous Boy Scout preparation was unnecessary. He could still hear her instruction.

  Look, doc, traumas go to the medical center. Ambulances don’t stop here. They ain’t that crazy.

  She had not considered what was all too real now. The drive-by delivery. A gang member shot. His buddies running from the police, scared shitless.

  Eli’s next actions took all of ninety seconds. He tilted the patient’s head back, inserted a laryngeal blade over his tongue, and jammed a #8 endotracheal tube past the boy’s vocal cords. He saw brief condensation of exhaled air on the Silastic tubing, hooked an ambu bag to the tube, and with his strong hand, pumped five quick breaths, each blowing a bloody spray from the hole in the boy’s chest.

  He gave the bag to a medical technician student, the name Brian stamped on his badge, to continue squeezing breaths into the patient’s lungs. Janice, who’d gladly followed Eli from the maggot room, was struggling with the peripheral IV. So Eli doused Betadine on the boy’s left shoulder, inserted a large bore needle beneath his collar bone, and pulled dark blood from the subclavian vein. He could do this procedure mostly with his right hand, using his injured left to balance the instruments. He threaded a wire, then passed a long central line catheter over it. Through the catheter, Janice infused a bag of Ringer’s lactate, a balanced salt solution to treat his profound shock.

  Eli checked the monitor for vital signs. The boy’s heart was beating at twice normal speed, trying to compensate for a hypotensive pressure of fifty. His pupils reacted to light so at least his head wasn’t dead—yet. Using a pair of trauma shears, Eli cut away the boy’s shirt to reveal a single entrance wound.

  “Help me roll him.”

  In tandem, Eli and Janice rolled the boy on his side so Eli could examine his back. Just as he expected. The bullet had exited through what was now a gaping wound, taking a piece of shoulder blade with it. As they rolled him back, Eli marveled that the boy was still alive.

  “All right everyone.” Eli nearly had to shout to get the emergency room team’s attention. “If there’s any chance he’ll survive, we have to get this boy to the trauma center. Call an ambulance and get the on-call trauma surgeon on the line.”

  While the clerk scrambled to make the call, Brian, the med tech student, asked, “What’s this?”

  Eli shouted, “Don’t!” when he saw a bloody gold medallion hanging from the chain necklace the young student pulled from the wound.

  Too late. Blood gushed from the hole in the chest and the boy’s blood pressure dropped to zero. The boy had survived this long because the chunk of gold nugget had plugged the hole in his heart. Now the dam was open. He would be dead long before the ambulance arrived.

  “I’m sorry,” Brian said, horrified. “I didn’t know.”

  “Run in as much fluid as you can,” Eli yelled to Janice. He stuffed a wad of gauze into the boy’s chest wound. Although unlikely to help, any degree of tamponade would be a good thing.

  When Eli pulled his hand back to start chest compressions, the soaked wad shot out of the hole like a Kleenex tossed into Old Faithful.

  “I need a scalpel, rib spreaders, and four 0 pledgeted nylon on a cardiac needle.”

  By the look on Janice’s face, Eli might have just asked for a million dollars, cash.

  “We don’t have all that here. What’re you planning to do?”

  “I’m opening his chest. That’s his only chance.”

  While Eli delivered compressions, Janice returned with a scalpel, the disposable kind with a plastic handle, one that might have been sufficient to lance a boil.

  At least it was sharp.

  Janice pointed at him. “You can’t open his chest with your injured hand.”

  Eli ignored her and nodded to the ward clerk. “Here, do compressions.”

  Wide-eyed, the clerk stared at the patient.

  “Me?”

  “Just press down like I’m doing.”

  They switched places and Eli took the scalpel. The best exposure to the heart would be a median sternotomy, through the breastbone, but he would need a pneumatic bone saw to cut through the sternum. He chose the left chest and incised the skin deeply, just below and lateral to the nipple, following the natural curve of the ribcage all the way back to the gurney. He plunged the knife deep along the top of the fifth rib. Once in the lung cavity, he was greeted with several liters of blood.

  Now he needed that rib spreader. He tried to insert his hands between the ribs but they wouldn’t fit. “Damn,” he said, searching the room for a substitute instrument.


  Benjamin had parked his cart just outside the door. He was watching the procedure.

  “Bring me that two-by-four.”

  The custodian had rigged a short vertical plank on his cart with a sideways hook at the top to keep his mop from falling over. Startled, Benjamin stepped forward.

  “Your cart, the two-by-four sticking up. Bring it to me.”

  Benjamin did as Eli said. He dislodged the plank and shuffled into the room with it.

  Eli took the piece of wood and inserted it sideways between the ribs. Then, in one quick motion, he twisted it at a right angle and wedged the ribs apart. There was a pop and grind as ribs cracked and costochondral junctions tore.

  Eli jammed his right hand through the gaping ribs, all the way to mid-forearm, and grasped the boy’s heart.

  With no blood in the muscular pump, the heart felt deflated like a balloon. He needed light to see into the boy’s chest. An overhead procedure lamp hung from tracks on the ceiling, and he tried to knock the beam into place with his injured hand. But the light fixture was frozen. Without illumination, Eli had to find the problem by feel. His finger happened to slip inside a large hole in the pericardial sac. The bullet had entered the right ventricle and ripped a hole through the muscle. Eli plugged the hole with his finger. He felt the fine tremors of fibrillating cardiac muscle. The electrical impulse was intact but there was no blood in the heart to pump.

  “I need two twenty French Foley catheters. And start charging the defibrillator.”

  Janice peeled plastic off the urinary catheter tubes and handed one to Eli. He inserted the tube through the hole in the boy’s heart and inflated the balloon at the catheter’s tip with fifteen cc’s of water. Then, Eli pulled the tube and balloon back against the hole, effectively sealing it. With his fingers, he located the exit hole in the back of the heart and did an identical maneuver with the second catheter.

  Eli knew this was a long shot. An incredible long shot. At the best of trauma centers, fully manned and stocked and waiting for a victim like this with penetrating cardiac trauma, the majority of patients would die anyway—despite the all-out effort.