Cogan got one more reading on her vital signs—her blood pressure and pulse were holding steady—then he went to the other side of the room, where Kim had put the X-rays up on the light box and was looking at her chest X-ray. He was looking at her lungs. White was air. Black was nothing, emptiness, a non-functioning lung.
They were looking at white.
“No pneumothorax,” Kim said, informing Cogan of what he, too, saw: neither lung had collapsed. “But she’s got rib fractures. Left ribs 9-11. That’s why she’s having trouble breathing.”
Rib fractures were extremely painful. They turned grown men into babies.
“I think that’s it,” the younger doctor went on after a moment, looking at her neck and pelvic X-rays. “C-spine is clear and her pelvic films are normal.”
“Doctor,” Wexford said, her voice more urgent than it had previously been. “Her blood pressure is falling. She’s getting more tachycardic.”
Both surgeons turned around and looked at the machines. She was 80 systolic. Her heart rate was up to 170. Her hemoglobin down to 12.
Kim looked at him, his face tense. They both were thinking the same thing.
“Do you want me to do a wash?” Kim asked.
“I’d better do it,” Cogan said.
He went back over to the patient and asked a nurse for a peritoneal lavage tray. “Quickly, please,” he said. His voice remained calm but the whole team immediately went on alert, for everybody knew that Cogan, unlike some surgeons, made such demands only when the situation truly called for it.
A “wash” was short for a peritoneal lavage, a procedure in which a saline solution is injected into the peritoneum, the membrane lining the abdominal cavity, then aspirated back into the syringe. If the saline solution comes back bloody, it means there is blood where there shouldn’t be.
Cogan made an incision in the girl’s belly button, then carefully pushed a narrow piece of plastic tubing into the hole he’d made. Next, he attached the tubing to a syringe filled with saline solution and, with his thumb, slowly squeezed the plunger on the syringe, gradually pushing the saline solution into the girl. When the syringe was almost empty, he carefully began to pull up on the plunger, aspirating the fluid back into the syringe.
What came back was a deep red.
“Grossly bloody,” he said, handing the syringe to a nurse. Then, after a brief pause, he said “OK, ladies and gentlemen. I think she’s got splenic rupture. Hang more fluid, cross her for six units, and let’s get her to the OR stat.”
With that order, the whole team began to focus its efforts on transferring the girl, along with her IVs, from the fixed gurney she was lying on to one that had wheels and was mobile.
“Kristen,” Cogan said to the girl, taking her hand. “You’re doing good, but we’re going to take you upstairs so we can take a look at what’s going on inside you if we have to. Do you know where your parents are? We need to get their consent if we have to operate. Is there a number where we can reach them?”
He knew she probably wouldn’t be able to answer him, but the rules said he had to at least make an attempt to contact the parents of a minor before he operated on her.
Her eyes were vacant. She looked at him, then closed them.
“OK, let’s go,” Wexford said loudly. “Head or feet, Dr. Kim?”
Kim took the feet at the front end of the gurney and pulled, while Pam pushed from the back where the girl’s head was. The team’s job was finished. The girl was officially Cogan’s patient.
2/ WHY TODAY?
March 31, 2007—4:25 p.m.
STANDING BY THE VISITOR’S DUGOUT, DETECTIVE HANK MADDEN wipes his brow in the late Saturday afternoon sun. It’s hot, too hot for March, and Madden’s head is throbbing—from the heat and from the fresh-cut grass of the outfield. His allergies have been wreaking havoc on him all week, but that hasn’t kept him away from the newly refurbished La Entrada Middle School field in Menlo Park where his son is pitching in his team’s opening game of the Alpine/West Menlo Little League.
The batter steps back into the batter’s box. The kid thinks he’s Barry Bonds. Same stance. Same cool cockiness. It makes Madden smile because there’s his son, standing on the mound just like Greg Maddux. He knows that Henry, whom the other boys call Chico because of the hint of his mother’s Hispanic features, is imitating Maddux. All he can talk about when he’s