Ambulance coming in,Dr. Fell. Female, found unconscious in a parking lot. Vital signs are stable. The EMT says she's starting to wake up."
Dr. Will Fell looked up long enough from the wound he was suturing to nod at the nurse. Then he bowed over his work, careful to give the same attention to this last stitch as he had to the first one. He could still hear Dr. McIntyre's voice."Resist the temptation to hurry when you're about through. Don't think about the next patient. Think about this one. Every patient should get your full attention until you're finished. That's the only way to practice medicine."
He snipped the ends of the suture and motioned for the aide to apply a bandage. "See that he gets a tetanus shot, wound care instructions, and a follow-up appointment for suture removal in a week to ten days."
Will looked down at the man on the table, a middle-aged Mexican laborer who'd come in with a nasty laceration of his arm from an industrial accident. The man spoke little English, and Will's Spanish was rough, but they'd communicated well enough.
"?Alguna pregunta? "
The man shook his head. No, no questions. Will figured as much. If the man had any, he probably wouldn't ask them. Keep your head down. Don't call attention to yourself. This was the lesson learned early on. Even if you had your green card, stay away from anyone in authority. Will looked at the technician."Be sure he understands, would you?"
"No problem." The aide reached into a cabinet behind her and pulled out a sheet that contained wound care instructions in both English and Spanish.
Now he could shift his attention to the next patient. As Will stepped into the hall, he began running through a mental checklist of the causes for unconsciousness. Start with the broad categories: traumatic, toxic, metabolic, neurologic, infectious, vascular. Then again, once you broke them down into individual conditions, the number was staggering. In medical school, Will had once competed with several other students to list as many specific causes as possible for unconsciousness. Will had won with two hundred seventy-two.
Well, if she's already regaining consciousness, his job was a bit easier. He'd definitely look for a head injury, probably check some blood chemistries, a toxicology screen, maybe schedule an EEG to see if this was a seizure. Then, like any good diagnostician, he'd see where his findings took him. That's something else Dr. McIntyre instilled in all her residents. For a surgeon, she had a lot of internist in her-always looking deeper into the problem, taking pride in her diagnostic ability. Look closely; don't rush to judgment. He liked what he'd heard her say once. "You're not a technician. You're a doctor. So be a good one. Anyone can learn to cut. A good clinician knows why and when."
Well, Dr. McIntyre, let's see how much I learned from you. Will tapped lightly on the door of Trauma Room Two and pushed through the door. The EMTs were just unloading the patient onto a gurney and giving their report to the nurse. Will took the clipboard from the lead EMT and studied the scribbled notes.
Jane Doe. No ID on her, no purse or wallet at the scene. Vital signs stable. Neuro exam not remarkable-take that with a grain of salt, since a neurological evaluation done in a moving ambulance might not be accurate. The note said there was no odor of alcohol, none of the sweet smell of diabetic ketoacidosis on her breath. Swelling in the occipital region, bruising at the point of the chin, so there was probably some trauma involved. If she'd fallen, that explained the injury to the back of the skull, but why the bruising on the chin? Had she been in a fight? He'd definitely want a CT of the skull.
"Okay, Doc. She's all yours." The EMT turned back to the patient. "Good luck, lady. You're in good hands."
"Thank you," she said.
Will's head snapped up at the sound of that quiet voice. He covered the distance to the gurney in five quick steps, stopping short to look down at the disheveled form of his mentor, Dr. Anna McIntyre. She smiled weakly and said, "Are you a doctor? Can you help me?"
The man looking down at her seemed so young. Was he a doctor? Or was he a nurse or a technician, even an orderly? Had she made a terrible gaffe by calling him "doctor?" No matter. He had a kind face and she sensed somehow that he cared. Maybe he could help.
"Dr. McIntyre?"
Was the young man speaking to another doctor in the room? That name sounded so familiar. Even the room looked familiar. Why? What was going on?
"Please, can you help me?" she said again.
The man leaned over her. He was wearing what looked like gray pajamas, covered by a white coat with words embroidered over the breast pocket. She squinted. Will Fell, M.D.
"Dr. McIntyre? Don't you know who I am?"
"I'm sorry. Should I? I mean, I can't even recall my own name, so I guess it's okay that I don't know yours."
He turned and gave orders to the woman beside him. Some of the words made a vague sort of sense, but the memories they triggered seemed as disconnected as the pieces of a jigsaw puzzle just dumped from the box. And when she tried to put them together, all it did was make her headache worse.
The doctor turned back to her. "I'm going to examine you. Just try to relax. First of all, follow my finger with your eyes." As the examination went on, there were times when she seemed to know instinctively what was coming next. Most of the time she was right. What could that mean?
The doctor shoved his stethoscope-she wondered how she knew that was what it was called-into the pocket of his white coat. "We're going to take a bit of blood for some lab work. Then the nurse here is going to take you to X-ray for some studies of your head. After that, I'll be back to talk with you some more."
"But you haven't answered my question. Can you help me?"
"Of course," he said. But she could see the doubt in his eyes.
The voice on the phone was neutral, the greeting brisk. "Dr. Simpson."
"Sir, this is Will Fell. I'm a surgery resident in the Parkland ER."
"Yes, I know. You're the Pit Boss. What do you need?"
Will guessed that when you were the chief of a busy neurosurgical service you didn't spend much time in social niceties or idle chitchat. He swallowed hard, more nervous than he'd ever been while presenting at Grand Rounds. "Sir, I need you down here. We-"
"Whatever this is, why can't one of the neurosurgery residents handle it?"
"Dr. Simpson, I think I need a faculty presence. Dr. Anna McIntyre was just brought in to the ER. She apparently sustained some head trauma and lost consciousness. She's awake now, but she's amnesic-not just for the event, it's global amnesia. She's getting a CT of the head right now. I did a neuro exam, and I think it's normal, but-"
"I'm on my way. Meet me in radiology."
Twenty minutes later, Will sat beside Mike Simpson, chairman of the Department of Neurosurgery, watching the man study the images on the computer screen in front of them.
"What do you see?" Simpson asked.
Will squinted, wondering what he'd missed. To him, this was a normal CT of the head. No midline shift, no masses, nothing. What had Simpson seen that he hadn't? "Sorry, sir. It all looks normal to me."
Simpson nodded. "Right. Now why did you get this scan?"
Oh, boy. Will steeled himself for the chewing out that was coming. Every test, especially one with a hefty price tag, required justification. "Well, she had physical evidence of trauma to the head. I wanted to rule out a subdural hematoma. That's a surgical emergency."
"But did she have neurologic signs?"
Will felt drops of sweat coursing between his shoulder blades. "Uh, well, I wasn't sure."
"You're a second-year resident. You've probably done hundreds of neuro exams. What did you think about this one?"
Will squared his shoulders. "I thought it was normal. But this is a faculty member and I thought-"
"You wanted to be sure. And that was a good decision. But did you think her neurologic exam was normal?"
"Uh… yes, sir."
"Deep tendon reflexes brisk and equal. Pupils reactive to light. No papilledema. Sensation intact. So she was neurologically intact?" Simpson turned from the computer screen and fixed him with cold gray eyes. "But she had amnesia. That's abnormal. It's not a physical sign, but recall that one of the elements-the first element-of a good neurologic is whether the patient is oriented to time, place, and person. She isn't, so her neurologic is abnormal. Never mind her pupillary reactions and deep tendon reflexes. So you were right. You had to get the CT." The faintest hint of a smile flickered on Simpson's lips."Fell, you're a good doctor. Dr. McIntyre told me once she had high expectations for you. When you know you're right, don't back down. But remember one thing. In our profession, good isn't enough. We have to be perfect."
Will nodded. "So you agree she has no evidence of a subdural?"
"Just a concussion."
"And the amnesia? Should I get a psychiatry consult?"
Simpson shook his head. "Transient global amnesia. A rare consequence of head trauma, especially if there's significant associated psychological stress. I'm betting that within the next few hours she'll start remembering things. By tomorrow, maybe the next day, she should be fine."
"Will all her memory come back?"
Simpson shrugged. "Most of it. Generally these patients don't remember anything about the precipitating event. Other than that, yes, it all comes back to them."
"Do you want her hospitalized for observation?"
"Admit her to my private service with the diagnosis of head injury, rule out subdural hematoma. Neuro signs every hour. You know the drill. Get an MRI of the head tomorrow to make sure she isn't developing anything else. I'll see her before I leave this evening. If anything comes up before then, page me."
"Good morning, Will." Anna pulled the covers up to her chin. It wasn't so much a matter of modesty. Goodness knows that had gone out the window along with her clothes when the nurses replaced them with a hospital gown. And she dreaded looking in a mirror. One of the ICU night nurses had taken pity on her and scared up a hairbrush and lipstick, but Anna still felt-and probably looked, she guessed-like a Halloween leftover.
"Morning, Dr. McIntyre." Will was freshly shaved, his scrub suit and white coat were clean and unwrinkled, but the dark circles under his eyes told a different story.
"Will, you were in here offand on all night. Weren't you supposed to go offduty last evening?"
Will suddenly found her chart very interesting. He didn't look up as he said, "Well, I decided to hang around here last night."
"There was no need for that. Dr. Simpson came by last evening. He brought the on-call neurosurgery resident with him and briefed him on my case. You should have gone home for some rest."
"Oh, I snatched a few naps in the call room. No big deal."
Anna decided not to pursue a subject that was obviously an embarrassment to Will. Instead, she asked, "So, what's the plan?" She grinned. "I mean, I think I know what the plan should be, but I still have some holes in my memory right now."
Will seemed on firmer footing now, talking about something clinical. "Your neuro signs are stable, so we-I mean, Dr. Simpson-will let up on the frequency of checking those. You're scheduled for an MRI this afternoon. If things go well, we can get rid of that IV this evening and start letting you eat and move around."
"And how long before Mike lets me go home?"
"Maybe another day or two. And I'm pretty sure he'll want you on limited activity for a week or so."
Something that had been gnawing at the back of Anna's mind began to burrow forward into her conscious thoughts. She had gone to that laboratory for a reason. All the pieces of the puzzle hadn't put themselves together in her addled brain, but she had the sense that she needed to get back to whatever she was doing. Soon.
Will hesitated for a moment before reaching down and touching her hand, carefully avoiding the IV snaking into the vein just above her wrist. "I've got to go back on duty in the ER, but if you need anything, just have the nurses page me."
"Thanks, Will."
Anna appreciated Will's obvious concern for her. She was independent enough to think she didn't need his help, but it was nice to know it was there. Then she realized that there were a couple of men in her life who'd already shown her that they cared. And she should probably contact both of them.
That led to another thought. Her cell phone. Where was it? The answer came back quickly, and with it another set of problems reared its head. Her cell phone was in her purse. And her purse? The last she'd seen of it, a derelict was tugging it away from her. Purse. Cell phone. Wallet. Identification. Cash. Credit cards. All gone. And her car? What were the chances it was still parked where she had left it? There was so much to deal with. But not now. Not yet. Instead, she closed her eyes and began to do the only thing she felt well enough to do. She prayed.
Nick Valentine frowned at the ringing phone. What now? He wasn't on call, so this couldn't be a frozen section or an autopsy. He was current on all his dictation, not just the pathology reports-he was scrupulous in keeping current with those-but even the academic and administrative material. The long-delayed curriculum vitae was on Dr. Wetherington's desk, putting an end to almost daily phone calls asking for that piece of material. No, Nick's desk was clean, and his conscience was clear. So why couldn't he have a moment's peace to finish this journal article he'd been trying to read for the past month?
"Dr. Valentine." Nick noticed that he hadn't been completely successful in keeping the annoyance out of his tone, and a glimmer of guilt flitted across his mind.
"Nick?" The voice was a little weak but he recognized it immediately.
"Anna! Where are you? Are you all right? I've been trying to reach you since noon yesterday."
"It's sort of a long story. Right now I'm at University Hospital. They've just moved me out of the ICU and into a room. If you want to come by, I'll-"
"I'm on my way. What room?"
Nick rushed down the warren of corridors from his office at the medical school to the University Hospital, his mind churning. ICU? What had happened? Was Anna going to be okay? He arrived at the elevators but decided they were too slow. He took the stairs two at a time. He paused at the door to her room long enough to slow his breathing, wondering if his pounding heart was a consequence of the stairs or a signal of the emotion he felt. He tapped on the door.
"Come in."
The response was faint, the voice almost unrecognizable. Nick opened the door. What he saw brought the same feeling as his first- and last-roller-coaster ride. His stomach dropped, his pulse raced, and he wanted to turn back the clock and start over. Anna lay with eyes half-closed, lifting her hand a few inches in greeting before letting it fall back on the covers. The bruise on her jaw was a palette of green and blue, a stark contrast with the pallor of her skin. Her red hair was tousled, and her green eyes had none of their usual snap and sparkle.
Nick scanned the monitors recording Anna's vital signs, and he relaxed a bit when he saw the values. He covered the distance to the bed in three long strides. "I've been so worried about you."
"I'm sorry. I guess-" She swallowed with visible effort."Could I have a sip of water?"
Nick wondered if it was okay to let her drink. She still had an IV in, but there was a Styrofoam pitcher of water on the bedside table, and a flexible straw sat in a half-full glass beside it. He held the water for her, supporting her head with his other hand. She managed three small sips.
"Thanks," she said. "You must be wondering why I didn't call sooner."
"That's not important. I'm just glad you're okay. At least, if they've moved you out of ICU, I guess you are. What happened? What can I do?" Nick had to stop the questions from pouring out. It appeared that Anna was all right now. That was all that mattered.
"I couldn't call you," she said. "I didn't even know my own name for a while."
He sank into the chair at her bedside and covered her hand with his. He felt her flinch and pulled back. "Sorry."
"No, that's okay. Actually, it's nice. Just watch the IV."
He took her hand once more, this time more gently. "I think you'd better tell me about it."
It took a while for Anna to relate the story. Several times she paused, apparently searching to recapture events. "My memory's coming back now," she concluded. "I don't remember exactly how I got hit on the head, but we've sort of pieced together that I was mugged. And there are still a few areas that are sort of fuzzy around the edges."
"So you're going to be okay?"
"Mike Simpson says I'll be fine, although he wants me to take it easy for at least the next week." She grimaced. "I think I'm probably going to push that, though. As soon as he turns me loose, I want to pick up where I left off… if I can figure out exactly where that was."
A shadow passed across Anna's face and she turned her head away. She freed her hand from Nick's and wiped a tear from the corner of her eye.
"What's the matter?" he asked.
"I just thought of all the things I have to do. The mugger got my purse, with my phone, my wallet, driver's license and credit cards, everything. I can't do anything until I take care of that."
"Let me help," Nick said. "I can-"
There was a light tap on the door and it swung open. Nick turned to see a heavy-set black woman, a sweater thrown over her dark blue scrub suit, tiptoe into the room. "Dr. McIntyre?"
Anna looked puzzled for a moment. Then Nick saw her expression change, and she said, "Miss… Miss Brown? Have I got it right?"
"That's right, Rhonda Brown. You've got a good memory for names and faces."
"Not recently, but that seems to be getting better." Anna indicated Nick. "This is Dr. Nick Valentine."
Nick exchanged handshakes with the woman and offered her his chair.
"Can't stay. I sneaked away from the lab and whenever I'm gone, everything turns to- Well, it gets bad. Got to get back and keep things running." She hesitated, and Nick could tell she was nervous about something. "Look, you need to know something. I'm the one who called the medics. I sneaked out for a smoke just in time to see a wino struggling to get your purse away from you. He decked you, I screamed, and he dropped your purse and ran. I stuck my head in the door and yelled for the receptionist to put down her magazine and call for an ambulance. Then I went back outside to wait with you until the paramedics rolled up. That's when I decided to disappear. Didn't want to be involved, you know?"
"Thank you for calling for help," Anna said.
"Well, that was the least I could do. I kept thinking about that story I learned in Sunday school. You know, the Good Samaritan? All I could think of was 'They passed by on the other side.' I couldn't do that."
"I'm glad you gave me the chance to thank you in person," Anna said. "I know it was hard for you to come."
"You don't know the half of it." Rhonda reached into the shopping bag that dangled from her hand and pulled out a purse. "I didn't trust that gang that's always hanging around in the parking lot. So I grabbed this before they could snatch it and run. Everything's still there: your cell phone, credit cards, driver's license, cash. I even scooped up your car keys and put them in here." She held out the purse.
Anna took it with trembling fingers. "You don't know how much this means to me. Thank you."
Rhonda shrugged. "At first, I figured the money in this would buy me a new pair of Reeboks, with enough left over for lunches next week. But that's the other half of that Good Samaritan story. That guy not only helped out the man who'd been robbed. He paid the innkeeper to take care of him. Besides, I don't need new sneakers, and I'm on a diet."