Gregg Hurwitz - Do No Harm

FACE white and blistering, eyelids swollen nearly shut, hair falling from the front of her scalp in thin clusters, the nurse stumbled blindly through the UCLA Medical Center Emergency Room doors, both hands waving in front of her. Her cries came from deep in her chest, rapid animal sounds that twisted into raspy moans by the time they left her mouth. A half-moon darkened the V of her scrub-top collar, and the skin along her clavicle had whitened and softened.

She tried to say something, but it came out a guttural bark.

A Hispanic gardener leapt up from his seat before the lobby's check-in windows, cradling the bloody bandage wrapping his hand and knocking over his chair. He circled wide as the nurse advanced, as if afraid of attack or contamination. A mother holding her five-year-old stepped through a set of swinging doors, shrieked, and beelined to the safety of the waiting room. The guard at the security desk rose to a half crouch above his chair.

A blister burst near the woman's temple, sending a run of viscous fluid over the mottled landscape of her cheek. Open sores spotted her lips, and when she spread her mouth to scream, her Cupid's bow split, spilling blood down her chin. She groped her way along the wall, her shoulders racking with sobs, her mouth working on air.

An expression of horror frozen on her face, Pat Atkins circled her desk in the small triage room, knocking over her first cup of morning coffee, and ran into the lobby toward the woman.

The woman retched, sending a thin spray of grayish vomit across the vivid white wall. She lunged forward, her shin striking the overturned chair, and tumbled over, breaking her fall with the heels of her hands.

Pat sprinted over, shouting at the security guard, "Tell them to get Trauma Twelve ready!"

She reached for a pulse as the nurse rolled onto her back, sputtering and gurgling, leaving a hank of hair on the clean tile floor. When Pat saw the nurse's ID badge, she inhaled sharply, running a hand over her bristling gray hair.

"Jesus God," she said. "Nancy, is that you?"

The swollen head nodded, the whitish raw skin glistening. "Dr. Spier," she rasped. "Get Dr. Spier."

Nearly knocking over a radiology resident with an armful of charts, David Spier sprinted into the Central Work Area bridging the two parallel hallways of exam rooms that composed his division. He pointed at an intern and snapped his fingers. "Carson's supposed to stitch up a leg in Seven. Go keep an eye so he doesn't duck out-you know how he is with sutures. And I need a urine on Mitchell in Eight."

He stepped across the CWA, patting his best resident on the shoulder. "Diane-let's move."

Diane handed off the phone to a nurse and pivoted, her shoulder-length straight blond hair whipping around so the nurse had to lean back out of its way. Grabbing the pen from behind her ear, Diane slid it into the pocket on her faded blue resident scrubs. David rested a hand on her shoulder blade, guiding her into Hallway One. They both shuffle-stepped back as the gurney swept past them and banked a hard left into the trauma room. They followed behind, David resting his hands on the back of the gurney. The nurses folded in on the patient's writhing body, a wave of dark blue scrubs. Pat leaned over, slid a pair of trauma shears up the moist scrub top, threw the material to the sides.

"What do we have?" David asked.

A nurse with shiny black hair glanced up. "Caucasian female, probably midtwenties, some vomiting, erythematous blisters on face and upper chest, eyes are opaque, moderate respiratory distress. Appears to be some kind of chemical burn." She reached down and untwisted the ID badge from the mound of fabric. Her face blanched. "It's Nancy Jenkins."

The news rippled visibly through the nurses and lab techs. Though they were accustomed to operating under duress, having a colleague and friend wheeled into the ER in this state was beyond even their experience.

David glanced at Nancy's blistering face, her pretty blond hair lying in loose strands on the gurney, and felt a chill wash down his chest to his gut. He recalled when they had wheeled his wife in here two years ago, the night of his forty-first birthday, but he caught himself quickly, checking his thoughts. Instinctively, his physician's calm spread through him, protective and impersonal.

He quick-stepped around the gurney so he could examine Nancy's face. Her eyelids and lips were badly burnt. If the caustic agent dripping from her had gotten into her eyes and down her throat, they were dealing with a whole new host of problems.

"Get me GI and ophtho consults," he said. "And someone contact the tox center. Let's get the offending agent ID'd."

Pat glanced up from her post behind Nancy's head. "Some nasal flaring here, and she's stridorous." She chewed her lip. "Hurry with that monitor."

"Find me some pH strips," Diane called out. "And let's get saline bottles in here stat."

A clerk ran from the room. Two nurses dashed in, pulling on latex gloves and snapping them at the wrists.

"Was it an explosion?" someone asked.

"Doubt it," Pat said. "Nancy walked in herself-it must've happened right outside. Security's already contacted the police."

"She's working hard," David said, glancing at the skin sucking tight against her ribs and around her neck. "Supraclavicular and substernal retractions. Let's get ready to tube her."

Nancy tried to sit up, but Pat restrained her. Nancy's breath came in great heaves. "Dr. Spier," she said. Her voice was thick and rough, tangling in the swell of her throat.

David leaned over Nancy's face. The skin around the blisters was whitening, contrasting sharply with the red bulges. She appeared to be trying to go on speaking.

His hands fluttered near her jaw, ready to check her airway. "I'm right here, Nancy. We're gonna get you taken care of. Can you tell us what substance we're dealing with?"

IVs being hung, pulse ox sliding on the finger, scrubs cut free from her legs and tossed into a trash bin. Cardiac leads plunking down across her chest like bullet holes.

Nancy coughed, contorting on the gurney.

"Heart rate's one forty," someone said. "O-two saturation's low nineties and dropping."

David leaned closer. "Nancy, can you tell us?"

The green line on the EKG monitor showed tachycardia, the peaks and valleys getting mashed closer and closer. Her arm rose, a hand pawing limply at air.

No more time. He pulled her jaw open and peered down her throat. Ulceration of the oropharynx, subacute airway compromise from edema. Whatever had gone down her throat had irritated the tissue, causing massive swelling. He needed to secure an airway quickly before her throat closed off.

David tilted her head back to give her throat maximum patency. "Push twenty mgs of etomidate and one hundred of rocuronium," he said, his voice ringing sharp and clear even to his own ears. The drugs would sedate and completely paralyze Nancy. She'd be unable even to breathe unless they could get a tube down in her to do it for her. "Laryngoscope," he said.

The L-shaped tool slapped the latex covering his palm. Positioning it in his left hand, he then slid the blade down along her tongue, using the small attached light to guide it past the epiglottis. The laryngeal swelling was bad, even worse than he'd noticed at first glance. He couldn't see the vocal cords between which to guide the endotracheal tube.

He glanced up at Diane, who was performing the Sellick maneuver, applying pressure to the cricoid membrane beneath Nancy's larynx, trying to bring the vocal cords into view for him. It wasn't working.

"Someone get on the horn to anesthesia and see how long it'll take to get a fiberoptic scope down here," David barked. If the swelling got too bad, he could look through the thinner scope and maneuver down the trachea.