Intensive Therapy Part 18

34.

Jonas looked expectantly at Jennie, while Pete and Beth Bodenheim, hosting Thanksgiving at their Old Greenwich, Connecticut, home, sat contentedly at the head and foot of the table. A pair of college-aged girls served coffee and souffles. Beth Bodenheim had just delivered a light-hearted tribute to life in the locker room with Pete and their two sons, and it was Jennie's turn to reflect on what she was thankful for.

Jennie paused thoughtfully. She put her hands on her children's shoulders. "I give thanks every day for my husband and children. Without them, I would not be the woman you see today. Gracie, your kindness has always delighted me. Gil, I marvel at your solidity and self-discipline. Before you two, I never appreciated how much of a privilege it is to be a mother. Raising you has been a chance to grow up all over again. Seeing the world through your eyes as you've developed has been an amazing journey. The little things: the way Gracie changes the pictures on her wall to mirror the coming and going of the seasons; the sensitivity Gil shows by lowering the volume of his ba.s.s when Dad comes home, even when he's working on a new song; how he always calls home when he knows we might worry about him. While other children are sullen and self-consumed, Gracie and Gil never take their families and friends for granted. You've made me into a kinder, more forgiving person. I never think about what I don't have or what I didn't get when I was growing up. You're such a joy. I want you to know how much I wanted you both. I give thanks for you every day."

I try so hard to feel like she does, Jonas thought, wondering if it had to do with his children being adopted. Why don't I?

Jonas's cell phone began vibrating. He excused himself to answer it. The call originated from area code 215. Jonas had given his number to only one person in that area code, Victoria Schone-Braun, but it was not her calling.

He meandered into a corner of the Bodenheim's family room, and said, "This is Dr. Speller. Can I help you?"

A frantic man's voice exclaimed, "Dr. Speller, I'm so glad it's you. My wife said to call you. I know it's a holiday, but it may be a matter of life and death."

Jonas's throat tightened. "You're Martin, aren't you? Victoria's husband? What's happened?"

"It's unbelievable. Victoria's in the ambulance with our son Gregory. They're taking him to Children's Hospital. I think he's dea ..."

"Oh my G.o.d, no," Jonas cried loudly enough to hush everyone. He retreated into Pete's den and closed the door. "What happened? What's Gregory's condition?" Someone knocked tentatively on the door. Jonas said, "Don't go away, Martin. I'm at dinner."

It was Jennie at the door. She said, "My G.o.d, Jonas. Your face is the same color as your shirt. What's happened?"

"My patient's family just suffered a catastrophe. The child of someone I saw on Monday is in critical condition. I have to figure out what to do. Tell everyone I'll be back in as soon as I can."

Jennie squeezed his hand. "It'll be all right."

He tried to believe her.

Martin said, "I'm so sorry to disturb your holiday."

Jonas ran his hands through his hair, preparing himself for a very long night. "It's okay. Tell me what happened to Gregory."

"It's his head. We both saw the fall. He slipped down our cement steps and cracked his skull against the pavement. I'm no doctor, but I think he's hurt very badly. He's out cold. When the EMTs got him into the ambulance, they said that his breathing was irregular and his heart rate was slowing down. They also said his left pupil was much larger than the right."

Oh no, thought Jonas, who knew that bleeding inside the skull causes downward pressure on the base of the brain-the part called the brain stem-which regulates breathing, blood pressure, and heart rate. Brain stem compression traps the nerve that controls dilation and contraction of the pupils, which would account for what the EMTs said about Gregory's eyes.

Martin continued, "I don't know what it's like where you are, but we've just had a slush storm, and everything turned to ice when the temperature turned bitter."

Jonas looked around. Everywhere, he saw pictures of Pete, Beth, and their children. He said, "Did this have to do with Melinda?"

"Yes. On the way home from Thanksgiving at my parents', she got out of control with Gregory and attacked him like a maniac. We barely got home in one piece. Our front steps were solid ice. When Melinda charged after Gregory, he fell down and slammed his head. Then Melinda ran away. The police are looking for her now. G.o.d knows what she'll do if she thinks her brother's dea-" Jonas shuddered. "Melinda knows how close Victoria is to Gregory. If he dies ... she knows her mother will never forgive her. Melinda could do something desperate."

Jonas had to breathe deeply to keep from vomiting. "G.o.ddammit," he said. "I was afraid something like this would happen. How's Victoria?"

"I think she broke her wrist falling on the ice. She moaned on and on about Gregory, and then she started talking mechanically until the ambulance headed off for Children's Hospital."

"She's overwhelmed."

"What are they going to do at the hospital?" Martin said.

"First they'll secure Gregory's airway by inserting a breathing tube-the EMTs may have done that already-but even if they did, the hospital will want to make sure it's positioned properly. Then they'll try and stabilize his heart rate and blood pressure, and rate the depth of the coma. They'll want a CT scan of his head right away to check for bleeding and a.s.sess the swelling. Swelling is the real enemy in head injuries." Jonas felt confident that practice with head trauma in Philadelphia had kept pace with the latest techniques used in New York.

Martin said, "Excuse me, the police just pulled up. A policewoman is asking about Melinda."

"She'll get frostbite and hypothermia if we don't find her," Jonas said.

Martin said, "Please call Victoria. She begged me to put you in touch with her. Do you have her cell phone number?"

"Yes, I do."

"She may have some life-and-death decisions to make in the next hour. I know it's a holiday, but please do what you can. She trusts you with her life."

Jonas was glad he hadn't had much wine, knowing he needed a clear head. He called Victoria.

"h.e.l.lo, Martin?" her voice resounded after the first ring.

Jonas shot up from the chair. "No, it's Jonas. Martin just called. Have you gotten to the hospital yet?"

"No. The roads are caked with ice. It's taking forever."

"Did they put in a breathing tube yet?"

"Yes. He may have stopped breathing. I can't tell. They also put a brace around his head." Jonas heard Victoria talking to an EMT. She sounded detached, just as Martin had described.

Jonas said, "The brace is just a precaution in case he hurt his neck-that's unlikely, given what Martin described. Gregory's probably hooked up to a heart monitor. It looks like a mini-TV with green blips. Can you see if the blips have a regular rhythm? Do they all look the same?"

"I can't tell."

"Give the EMT your phone."

"What?"

"Just do it, Victoria."

Jonas heard the phone hit something. An angry voice said, "Who's this? We're busy trying to save this boy's life here."

"This is Dr. Jonas Speller. I'm the boy's mother's doctor. Has he stopped breathing?"

"We're not sure. He's intubated and we're bagging him."

"Is his heartbeat steady?"

"It's slowing."

"What about his blood pressure?"

"It's going up and down. We're not sure we're getting an accurate read."

"And his pupils?"

"The left is barely responding."

"Okay. Do you have mannitol?"

"We're just starting to administer it."

"Good. He probably has a bleed that needs to be evacuated. We may have only one chance to save this boy's life, so listen carefully. Children's Hospital has a pediatric neurosurgeon on call. Radio ahead and get him and his team ready. Every second counts. Have him call me on my cell phone the instant you get in touch with him." Jonas gave his number. "When you radio in, do you talk with triage, or do you speak with the ER doctors directly?"

"We've already notified the trauma team."

It's a teaching hospital, Jonas thought. It's a holiday. What if there are only residents and interns on duty tonight? G.o.d help us if we get some arrogant know-it-all who doesn't respect his elders.

Jonas asked the EMTs to have the neurosurgeon call. Then he asked him to hand the phone back to Victoria. He told her, "I'm trying to get the neurosurgeon on the line."

"Neurosurgeon. What do we need a surgeon for?" she asked, terror returning to her voice.

"You're going to have to trust us, Victoria. That's all I can say for now. I have to speak with the doctor, and I'll get back to you the minute I do."

35.

For the next ten minutes, Jonas paced around Pete Bodenheim's den, feeling as though his own son was en route to the hospital. The Connecticut weather had turned frigid, but the ice storm had not advanced that far north. He hoped the turnpike remained pa.s.sable to Philadelphia. In good weather with no traffic, he could be there in two and a half hours. With icy roads, who knew how long it would take? Using Pete's computer, Jonas checked the National Weather Service. No updates had been posted.

His phone rang. "This is Dr. Speller," he said.

"This is Dr. Anna Breckenridge, pediatric neurosurgery fellow at Children's Hospital. I was told to call this number." She sounded neither irritated nor arrogant.

Jonas said, "Who's your attending?"

"Dr. Liddle, La.r.s.en Liddle. Please, who am I speaking with?"

La.r.s.en Liddle. Just like Stan Amernick had mentioned to Jonas years ago. What a small world Philadelphia was.

"I'm sorry, Dr. Breckenridge. I should have introduced myself. My name is Dr. Jonas Speller, and I'm Professor of Clinical Psychiatry and Neurology at Mount Sinai Medical School in New York. One of my patient's children-her ten-year-old son-is coming your way any minute. He's had a horrible closed-head injury; his left pupil is blown and his vitals are deteriorating."

"How do you know that?"

"I just got off the phone with the EMTs in the ambulance."

"Are there any other injuries?"

"Not that we know of. The boy's mother is with him. She's been a patient of mine for years. Gregory, that's the boy's name, is intubated. I hope you don't mind my asking, but what's your protocol for severe head trauma?"

"We use the standard trauma life support protocol. The trauma team will be ready the moment he arrives. They'll examine him for internal injuries and make sure he didn't break any bones. While they're stabilizing his vital signs, I'll examine his cranial nerves and use the Glasgow Coma Scale to a.s.sess his neurological status."

"Excellent."

"Did the EMTs say anything about the boy's blood pressure?"

"They were having trouble measuring it. Why?"

"Low blood pressure in the field is a bad sign."

"I'll make sure they stay on top of it," Jonas said. "Is there anything else I should tell them?"

"See if they can administer mannitol."

"They already started."

"That's good," Dr. Breckenridge said. "Once the boy gets here, the trauma team will X-ray his cervical spine. Then we'll go straight to CT, where we'll look for a bleed, determine the extent of the swelling, and see if there's any midline shift or hydrocephalus."

Jonas held his breath. His palms felt clammy. "Do you do craniectomies? Hemi craniectomies, I mean?"

"Yes, if we have to."

"Good. What do you do with the skull?"

"We used to implant it in the patient's abdomen. Now we put it in a freezer, so there's no need for another incision."

"Good. That's what we do here, too. Mount Sinai gets all the bicycle, skateboard, and rollerblade accidents from Riverside and Central Parks. Plus the motorcyclists who're too macho to wear helmets. I hoped you weren't still relying solely on mannitol, or hyperventilation, or cold perfusion."

"We do give mannitol or hypertonic saline acutely, which is why I want the EMTs to start now. But the definitive treatment is to remove the blood, if the swelling is severe enough, we leave the bone flap off. We try and avoid hyperventilation. We gave up on cooling a while ago."

"Do you do a CT scan on every patient, even when their vitals are deteriorating?"

"It only takes a few minutes. From what you're saying, most likely there's blood on the same side as the blown pupil. But since we're not sure, we should know how much and where. If there's no bleed, we can put in an ICP to monitor the pressure. But from what you said, it sounds like we'll have to open the skull."

"That makes sense. You're going to have a tough time getting the mother to consent to the procedure. That's where I come in. Let me handle Gregory's mother. You've done this operation before, Dr. Breckenridge? I mean you, personally."

"I've a.s.sisted at several in the last year. Children's Hospital is the regional trauma center, so we get head injuries from all over the Tri-State Area. As soon as I get off the line, I'll call Dr. Liddle and tell him what's happening. From what I hear, the roads are bad. I don't know how soon he'll be able to get here, but I don't want to wait. This would be my first unsupervised as the chief surgeon, but I've opened the skull innumerable times for brain tumors, aneurisms, and vascular malformations."

Jonas had no time to quibble about her qualifications. Gregory would be in her hands. Dr. Liddle would get there as soon as he could, but no one could say when.

"I know you'll do just fine, Dr. Breckenridge," Jonas said. "Gregory's fortunate to be in such good hands. I know you'll take good care of him."

"I will, I promise. Thanks for the heads up and the vote of confidence."