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Yeah. Don’t hit the heart…
She looked steady enough now. Whatever had her fighting panic, it came and went in waves.
Enzo backed up enough to make room but stayed close enough to keep the stethoscope in place to listen while the monitor was hooked up.
This might have been a bad call. She seemed competent except for those nerves. Her nerves triggered his. If she ended up doing more damage… Maybe they should just move him now and hope he lasted another five minutes, or however long it took to get to the hospital.
With her arms steadied and braced, she waited patiently the long seconds it took for the electrodes and wires to be placed.
He listened hard, holding his breath to cut out as much sound as possible. His own pulse sounded in his ears louder than what he was hoping to listen for…
Closing his eyes helped, cutting down the external stimuli. Without vision in the way, he could hear the heartbeat faintly in the background. Fast. Very fast. And with an abnormal rhythm.
This heart didn’t just inch toward failure, it galloped. The man would never make it to WMS.
What kind of fibrillation—atrial? Ventricular? He opened his eyes and craned his neck to see the green line denoting the rhythm tracing across the black screen of the monitor.
The line swung wildly in an undulating wave that told him nothing.
Check the leads.
Okay, check the placement of the electrodes.
He grabbed an extra electrode and placed it beside the one that looked somewhat off-center, then reattached the lead. The line settled into the regular, horizontal position, allowing him to really see the points.
Ventricular fibrillation. And tachycardia. He listened again, with his eyes following the line. The sounds were almost too faint for him to hear—something that backed up her diagnosis: there had to be a massive amount of fluid compressing the heart. “He’s in V-tach.”
“Thought he might be. His time is running out.” She breathed in. When all hands were still, she breathed out slowly as she pushed the needle into the man’s chest.
She could’ve done this a thousand times. Smooth and slow enough to be cautious but quick enough to feel the texture of the different tissues she penetrated. Her eyes had taken on that out-of-focus quality that came with pinning all your attention on feeling your way to a site unseen. He’d seen that look on the real pros so many times—an amazing ability to visualize the path through and the imagination to picture the diagnosed problem. It almost felt like sorcery.
As she drew back the plunger, bright, arterial crimson began to fill the clear tube. As pressure was siphoned off, the heartbeats became a little louder, a little more distinct.
She withdrew the full syringe and looked at him, those eyes dark with fear… not the exhilaration he’d expected. But, then, he’d never been in this situation, either. Exhilaration was hard to come by. Something entirely more primitive took its place.
“No change?” So hopeful.
“Still in V-tach.” Enzo listened a few more seconds to give him time to convert. He tried counting beats but found it impossible and shook his head. “No change.” He gave the heart a few more seconds, listening again, then shook his head, “Clearer, but still distant-sounding and out of rhythm. Drawing off the fluid wasn’t enough to convert him to normal sinus.”
She paused another few seconds, pinned by those soulful eyes. Dr. Ootaka, his mentor, counseled distance. Emotions clouded reactions. Enzo had never had reason to doubt this mantra, though right now he couldn’t claim to have that distance. He wanted to give the hope her eyes begged him for.
Hoping wouldn’t get the job done. “I’ve never dealt with this. How did they do it at your old hospital?”
“The only one I saw treated was done in the hospital and they used imaging equipment to verify the diagnosis and location of the fluid before they aspirated.” She answered quickly, her focus returning, and her voice firmed as she spoke. One word led to the next, and she focused on the EMT. “I need another hypo. Bring two, just in case.”
She’d only seen it done once. Ugh. At least she didn’t look it. Move past it. Enzo gestured to the defibrillator and she followed his gaze.
“Not yet. He’s already banged up enough. Let’s give him one more chance to convert. Honestly, it’s not electrical, it’s the pressure in his chest. I doubt cardioversion would do any good for him unless his heart stops entirely.”
She rose on her knees and shouted toward the back of the medic, “Bring epi if you have it! Enzo, start the cuff again. I want the pressure before and after each draw.” With a fresh alcohol prep she swabbed the area where she’d just gone in, readying the chest for another puncture.
Long, torturous seconds passed and the other medic arrived. As soon as the pressure was displayed, she pushed through with the second needle.
Enzo watched another rush of bright red fill the tube. It looked thinner and more translucent than it had before. “It’s part serum, or he’s filling with more serum than blood now.”
“Good. The pressure might stop his heart still, but maybe it’s not an aortic dissection. Buys us some time.”
If it was only a small cut in the aorta rather than a hole through it, they had a chance of getting him stabilized and to the hospital before he crashed.
He concentrated on what he was hearing—the monitor couldn’t tell him how loud the heartbeats sounded so the stethoscope was still needed. It was easier to look at the monitor—or even the dark, eggplant-like bruise on the man’s chest—than at her worried face. He could tell from her complexion that she was normally a warm tan, but today she looked pale and fragile. Not a great look for a trauma surgeon. Even a trauma resident.
With the second round of pressure relief, the speed of the man’s heart slowly decreased and the rhythm began to convert to something closer to normal. First, a few normal beats amid the pre-ventricular contractions. Then louder. Then steadier.
“It’s working.” He pressed the button on the cuff again and then leaned back to place the stethoscope in her ears, holding the chest piece over the heart again. He let her listen as she was the one performing the procedure.
After a few seconds she nodded. “I don’t want to go again, I might hit the heart. The less fluid that’s in there, the closer the pericardium is to the heart, the less balloonish padding to protect it.” And they didn’t have the luxury of imaging equipment here to see how thick that fluid balloon was.
“Agreed.” Enzo checked the cuff again. “One hundred and forty-three over eighty-one.” The tension that had held him stiff and hard in the preceding moments left in one rushing wave, so swift his shoulders slouched forward briefly.
Without thinking, his nearest hand landed on the back of her neck to lightly squeeze as he directed her gaze to the cuff. Her skin felt hot beneath the ponytail she wore, and his palm prickled where it touched her.
“Blood circulating again,” she whispered, her breathless smile hitting him square in the chest. Shared relief. Before he could think it through, he pulled her into his arms for a hug. She sagged against him, her hands fisting in the back of his scrubs.
Apples. Her hair smelled faintly of apples, and something earthier. Clean. Sweet.
The comfort was fleeting as within seconds she’d stiffened. Her hands released the material of his shirt, reminding him it wasn’t the time to be hugging this stranger with the soft womanly curves, or smelling her fruity hair.
He let go and put a little distance between them. What was worse, looking overly familiar or overly emotional?
Color had returned to her face and was focused on her cheeks now. He’d definitely crossed some line.
Right. “Get a line in him, and we’ll ride with you.” He redirected his thoughts to the paramedics, who really didn’t need to be told what to do except that they’d come to a scene with two surgeons running things.
Kimberlyn left the cuff in place but went about gathering the contents of her bag as if the contact had never happened. He reached for his cell again.
Ootaka answered on the first ring. “Dr. Ootaka, there was an accident a few blocks from the hospital. Assisting with a cardiac tamponade. Thought you might want a heads-up to meet the ambulance.”
The conversation was brief. A neck brace and helmet removal later, they lifted the man onto a backboard, then the stretcher, and trotted for the ambulance.
“He’s on call today?” She climbed into the ambulance after the stretcher had been rolled in.
Enzo nodded, keeping his hands off her even though his natural instinct was to help her into the ambulance. “He’s going to meet us.” He stashed his phone and jerked his head in the direction of the hospital. “I’m running. Keep our patient alive. It’s only a little way to the hospital.”
Some physical exertion would help. So would avoiding any enclosed spaces with her. Good for all concerned. Or good for him, which was the important bit. And she wouldn’t have to worry that he was about to hug her again. What the devil had that been about? He was happy about the patient, but still—weird.
Probably some kind of natural instinct in the wake of all that fear and hope warring on her face roused his protective instincts. Unfortunately.
He closed the doors, banged once to let them know it was safe to drive and then took off at a run for a nearby alley. Three blocks by vehicle, one on foot.
After her showing up on the scene, even if Ootaka would’ve been put off by the emotion, he still would’ve been impressed by the woman’s knowledge. Which was okay, so long as Ootaka remained most impressed with him. Enzo hadn’t fought his way through school and years of residency to lose it at the eleventh hour to a little scared Southern nobody…
If his luck held, Ootaka would meet him at the ambulance bay and he’d have a couple of minutes to speak with him before the ambulance—and his shiny new competition—caught up.
CHAPTER TWO
ENZO MET DR. TAKEO OOTAKA at the ambulance bay doors. Normally, sprinting a block would do very little to his heart rate. Not today. Today he was winded by the time he jogged through the automatic doors. Winded and annoyed. Off his game.
The older Japanese surgeon stood waiting, leaving Enzo no time to work out his problem. He barely had time for a good breath. Ootaka stared past Enzo to the empty ambulance bay, a look that demanded answers.
During the past four years, and especially the past year when he’d largely been Ootaka’s primary assistant, he’d become used to anticipating Ootaka’s questions from his expression alone. So he answered, “I ran ahead. It was faster on foot and I wanted a better chance to brief you.”
And it’s hot, he wanted to say. Hot and muggy, which no doubt contributed to his elevated pulse and respirations.
He took another deep, cleansing breath and launched in, giving the pertinent details even as he heard the sirens drawing closer to the building. “Massive bruising, likely fractured sternum, probably some ribs, too, but structure mostly intact.”
From where the ambulance bay was located, he could see the vehicle turning into the parking lot. If he wanted to ask, it was now or never.
“I expect that there will be a need for surgery.” He waited only long enough for the usually taciturn surgeon to nod, and added, “I’d really like to stay with the patient and assist you.”
Underhanded? No. Smart.
She’d been the one ahead of the curve with the diagnosis and field aspirations. While he wouldn’t ever claim the spot of underdog, or let himself be relegated there, winners made their own fate. Preemptive maneuvers. Offense, not simply defense.
Besides, Davis had to learn sometime that the laid-back Southern lifestyle wouldn’t fly in the city—something she clearly needed to work on, in addition to learning some leadership qualities. Let that be her second New York lesson: if you want something, you have to fight for it. Everyone wanted something, so chances were if you wanted something, then someone else wanted to take it away from you.
And that was enough justifying. What in the world was wrong with him?
He blew out a steady breath as his vitals came back under control.
“Let’s see what we have, then.” Ootaka finally spoke as the ambulance rolled to a stop, triggering the automatic doors. They moved off to one side to clear the route for the stretcher.
Ootaka stood with his hands at his sides, placid and waiting attentively. No indication anything was amiss.
Never in his entire career so far had Enzo ever felt this rattled in front of his mentor.
Only one person in the hospital had ever been able to rattle him, and they had an unspoken agreement of avoidance.
Even while watching his fellow residents fall out of the grizzled surgeon’s favor, Enzo had always been the one in control and confident in his abilities. He knew Ootaka’s rules. He understood the detached perfectionism that made up nearly the entirety of his operating-room demeanor. His professionalism, steadfast confidence and resolve were perfection in Enzo’s eyes. Ootaka was precisely the kind of surgeon Enzo wanted to be. The best. Second to none after Ootaka retired. There could be no better place to learn that than Ootaka’s OR.
Tension rolled over his shoulders and down his arms. Not like Ootaka’s relaxed stance. In the reflection of the glass doors he could see his own arms… hanging at his sides, but stiff, ready for a fight. He rolled his hands at the wrist and settled. Shaking his arms out would only look even more affected.
He couldn’t avoid Davis as he did Lyons. Did he even want to? He took an inventory of his goals. Staying on top would mean a better understanding of whether she truly was a threat or just another future ex-contender. Having a good understanding of his obstacles was the only way to overcome them. It was the not knowing that had him rattled. Once he had figured out the situation, there wouldn’t be any weird emotional responses to taint Ootaka’s opinion of him.
Whatever it took. Even if it meant angering a new colleague when she figured out he’d outmaneuvered her. But what did that matter to him? Another fact for her to get used to. She would’ve had to anticipate the sharp learning curve to come into the program this late in the game, and there was zero chance of her assisting on her first day anyway.
Ootaka never trusted one of his patients to anyone with untested skills. In that light, his request wasn’t anything more than a formality when you got down to it. Asking first just showed initiative, a good practice. He wouldn’t feel guilty about it.
Bonus: it’d give Ootaka an easy out if Davis came in asking, because she’d definitely want to assist. Helpful, like someone he’d want around for the next two years. As she exited the ambulance, Enzo added, “There was another resident on the scene. The transfer, Davis. She rode in the back with the patient.”
“I wondered why she wasn’t here yet.”
In addition to untested surgeons in his OR, Ootaka also hated tardiness. The man kept an updated list of sins that could get you banned from his OR forever. She probably hadn’t a clue about them. His action now might actually save her career—give her time to learn the rules before she went in blind and violated them. It was a good-guy thing to do. The idea that her competence might come into question because she’d been late saving a life didn’t sit well. He could throw her a bone, let Ootaka know she’d made the call and aspirations.
“She—”
As the first word came out the two EMTs, Davis and the gurney rolled in, the little motor on the wrist cuff whirring to take another reading.
Ootaka cut in, “Who diagnosed the cardiac tamponade?”
“I diagnosed Mr. Elliot’s tamponade, Dr. Ootaka.” She immediately answered the question while still passing through the sliding doors.
All the mousiness he’d glimpsed earlier was gone. That was something at least. She recognized Ootaka on sight, which really shouldn’t surprise him—she’d transferred in for his fellowship if the rumor mill was to be believed. She’d have done some research.
Though Ootaka was hard to miss. He had a kind of forbidding quality to his expression, even when he was in a good mood. Smiles actually involving his mouth were rare. Ninety percent of his expressions were in the eyes.
“The aspirations are what stabilized Mr. Elliot.” He rolled with the name they must’ve discovered on the way. “Brought him back into normal sinus rhythm. He was in V-tach before the serosanguineous fluid was drawn off.”
She still wouldn’t be asked to assist, but she deserved to observe. It’d be the honorable thing to do, help her get a foot into Ootaka’s OR in a way she probably couldn’t unwittingly screw up.
At the scene he’d noted at least three behaviors Ootaka would cut her over: inability to speak with authority; lackluster leadership skills; and visible displays of emotion. From the sidelines she’d be able to get a feel for things without being in the spotlight.
“It had stabilized him, but he’s popping more PVCs than he was, and his blood pressure range is narrowing again,” she added, directing all attention to the patient and the display on his wrist. “One hundred over seventy-five.”
Enzo had gotten used to being the main one to answer questions or brief Ootaka on patients. It was only to make sure that he knew the whole situation that Enzo tacked on, “Pressure had normalized to one hundred and forty-three over eighty-five after the second aspiration.”
“One hundred and forty-three over eighty-one,” Davis corrected.
Right. No more giving her credit. Those four measly points didn’t make any difference to the situation, other than highlighting that he’d made a tiny mistake. Not precisely underhanded but kind of snotty all the same. Apparently she was capable of a modicum of backbone. But squabbling over insignificant details wouldn’t impress Ootaka, so he held his tongue.
Ootaka nodded in the direction of Trauma 1 and led the way. In less than a minute the stretcher was locked into position amid the equipment in the trauma suite, all gloved hands on deck.
“Davis,” Ootaka directed. “Another aspiration.”
Davis? Damn.
A larger hypo than the ones she’d used on scene landed in her hand. A nurse took over the job that Enzo had performed earlier, swabbing the chest.
Again he watched Davis carefully position and guide the needle into the man’s chest, then another flow of bright blood pulled back into the hypodermic. Not so watery as it had been on the second draw.
“For the third draw, it’s a lot thicker than it was even the first time.”
Enzo locked his jaw to keep quiet. Something he never did with the other residents… but this was Davis’s show.
Davis withdrew the needle and concluded, “His chest isn’t simply filling with serum again. There’s bleeding. He’s got a tear somewhere.”
“He does,” Ootaka confirmed. “Going to have to go in. Correct call, DellaToro.”
Of course it was. Enzo stepped forward again. Before Enzo could do more than nod, Ootaka turned to Davis. “Welcome to West Manhattan Saints, Dr. Davis. An OR has been prepped. You’re with me.”
Enzo’s head jerked back as if he’d been slapped.
Ootaka had invited her to surgery.
A slower step back to get out of the way again and Enzo found himself blinking, as if clearing his vision would do something to clear up what he’d just heard. But nothing had changed. The situation settled like lead in his belly.
Ootaka was definitely impressed with her.
The man told all the first-year residents they couldn’t assist him until he’d seen them in the OR to weigh their ability. They observed, he gave them small tasks, and gradually built up to assisting. Usually other surgeons did much of the initial surgical instruction, Ootaka was next-level surgery. And if you didn’t meet his expectations…
It wasn’t so much that Ootaka made a production of letting the resident know they were no longer welcome—big displays of emotion were the same as big displays of drama—he simply stopped extending invitations. It usually took the resident a few weeks to realize they were no longer welcome or even on his radar. Enzo had even seen the man forget the name of residents once he’d stopped shining attention on them.
Davis wasn’t precisely a first year, but it was her first year at WMS. Ootaka had never seen her perform.
A pericardial aspiration by hypodermic, while tricky, didn’t compare to using a scalpel…
The team wheeled Mr. Elliot out of Trauma 1 and down the fastest hall to the OR, leaving Enzo to find something else to do.
A now-familiar Scottish brogue came from just outside the door. “Kimberlyn got Ootaka already? Caren said she was good.” He looked around the door frame.
“Don’t make me hit you, Sam.” Enzo stepped out, uncrossing his arms to let them hang, feigning the relaxed appearance he’d rather others see. He just couldn’t get his shoulders to loosen up. “What are you doing down here anyway? Aren’t you supposed to be with the babies?”
“I came to make sure Kimberlyn had made it, actually. We were going to walk together today, but I ended up needing to leave early for an errand.”
“Miss Scarlet needs an escort?”
Sam gave a low chuckle. “She really did get under your skin.”
“She’s not under my skin. It was a quick reference to that dark-haired Southern pretty girl thing she’s got going on.” Enzo had lied, and he wasn’t a liar. It was a point of pride that he could be blunt and honest about anything. She’d thrown him off his game for a third time. “It takes more than a strong base of medical knowledge to impress Ootaka. She’s got steady hands, but her leadership is nonexistent. Couldn’t even rally some rubberneckers at the accident to call 911 or to push the vehicle off the patient.”
“Want to grab a pint after your shift? You can find some pretty lass to take your mind off Cricket.”
“Yes,” Enzo answered, because a beer sounded good, as did the idea of finding a pretty lass. Someone more his flavor. Not dark and soulful. Davis probably wrote poetry and wore black all the time when she wasn’t in scrubs. Also not a lass. That sounded entirely too much as if it could fit Davis, and he’d rather have someone real. Overly emotional just didn’t do it for him, either.
Hold on. “Did you call her Cricket?”
“It’s her nickname. Don’t tell her I told you.”
Enzo snorted, but nodded to his friend—Dr. Cricket’s new housemate—and headed off to look at the surgery board. Maybe they’d be in one of the surgeries with an observation gallery so he could at least watch…
A short walk and he stood, looking the whiteboard over. Head of surgical residents Dr. Gareth Langley had taken one of the rooms with a gallery. The name Lyons stood out on the list. He looked only long enough to determine he wouldn’t accidentally walk in on that man’s surgery, then moved on. Ootaka had indeed reserved the last gallery.
If he hurried, he might even avoid accidentally running into Lyons on the way. That had been the other bit of information to stand out on the board: times and approximate duration. His father was the last person he wanted to see today. Or any day. The fact that they frequently shared a hospital made it impossible to avoid him altogether, but Enzo did his best. Always did, and he imagined Lyons did, as well. In four years they’d managed to avoid saying even a single word to one another and that level of avoidance couldn’t happen without two people actively working at it.
He relaxed only when he’d stepped through the door leading up to Ootaka’s gallery.
In his time in the program nearly all of his competition had fallen by the wayside. Winning this fellowship was a marathon, but Davis was here to sprint the last leg. An immediate invitation into Ootaka’s OR definitely meant she had started the sprint and he felt as if he was standing still, which was ridiculous. She couldn’t cover that much distance in one surgery.