“I need this bed turned around.” Dante stood back as his order was carried out. Gulnar stood beside him, horror sweeping her again at the sight of her dynamic young friend lying there like a gutted corpse, with his abdomen wide open and covered in plastic. And his face…
She was used to the worst. She’d had the worst. But when it was someone she cared about…! It was just another reminder not to care, never again.
What about Dante?
No. She could care about Dante. She did. So much—lord, so much. It was safe to care, she told herself, to let herself feel as deeply and as totally as she wanted. Then he’d be gone and she’d never know what happened to him.
Wouldn’t that finish her off? Losing him when he walked away?
She no longer cared what happened to her after he was gone. She wanted whatever she could have.
Dante had taken his position at Dimitri’s head, was giving his nightmarishly distorted face a long, assessing look. She could almost feel his diagnostic mind going into overdrive. Then he exhaled.
Gulnar winced. Please, let it be better than she thought. Let Dante, with his extensive experience, have a different, ameliorating opinion.
His gaze roamed over the rest of the ICU staff then back to her and Emilio, the only two English-speaking people around. “History, status and current measures?”
Emilio picked up the Azernian-written charts, looked at Dante. “He was in the debris for six hours before extrication. He’s been intubated and on bag-valve mask with 100 per cent oxygen since extrication. On the last recording, ten minutes ago, pulse was 128 with irregular ectopics, BP 90 over 60 and oxygen saturation 90 per cent.”
Dante absorbed the facts, started to examine Dimitri’s injuries by extra-gentle palpation, assessing the lacerations, pausing to feel the crackling of bone fragments and the give of undermined structures. “GCS at the scene and all through until he was anesthetized?”
Gulnar looked over the rest of Dimitri’s deficient case file, filled with reports from everyone who’d handled him from the bombing scene onwards. This hospital was totally unused to and unequipped to handle mass casualty situations. It had been chaos, with so much disorganized and missing.
She sifted through the messy notes, not finding any mention of Dimitri’s Glasgow coma score.
She looked at Dante, exasperated. “He was conscious at extrication, so he couldn’t have been much less than fifteen at the scene. When I saw him immediately before surgery, six hours later, he was a six. Dr. Moya said that the debris pressure had stopped blood flow. Once it was lifted, abdominal bleeding increased, and he went into shock. He attributes Dimitri’s deterioration to that.”
And how she wished he was right! His opinion that Dimitri wouldn’t withstand the extended anesthesia of a lengthy reconstructive procedure, while on the surface conservative and pessimistic, was better than hers. Dante met her eyes. Seemed he shared her pessimism!
Her heart plummeted. Dimitri was too precious to lose. A rare and true source of hope around here. He made such a difference, so many people needed him. Like Dante…He just had to live—and live whole! But at the moment it looked he’d either deteriorate and die, or at best live deformed and disabled. The two possibilities skewered through her. Please, please.
Dante concluded his examination, looked at her. “Three walls out of four of both internal orbits are destroyed. Has there been no ophthalmological exam?”
Gulnar leafed through the reports. “Left eye only. Nothing mentioned about the eye’s condition, just that there was no optic nerve cupping. I guess this supports Dr. Moya’s diagnosis that there’s no intracranial injury or rise in pressure.”
Dante’s massive shoulders rose in irritation. “It tells me nothing. For all I know, his right eye is lost, and his left eye is, too, by now. A lot can happen in fourteen hours. It’s a sorry fact in mass casualty situations that seemingly non-life-threatening stuff gets overlooked and that as soon as a casualty looks stable, it’s on to the next unstable one.” Another exhalation. “Let’s take a look at his eyes, and his brain through them.”
A few words from Emilio to the efficient ICU staff brought the instruments Dante would need in seconds. He thanked Emilio, turned to her. “Gulnar, retract the lid for me.”
Her heart blocked her throat, her stomach rebelled. She could take anything, had taken far worse than this, but somehow the idea of handling Dimitri’s delicate, shredded flesh overwhelmed her. Just do it. Go to pieces later.
She took her position at Dimitri’s head and applied extra-gentle, calibrated traction with the lid retractor, prying the swollen lids apart for Dante.
He first measured the intraocular pressure and examined the insides of the eyes for injuries. The eyes were also windows to the brain—changes in the optic disc supplied reliable information about any rise in intracranial pressure.
Dante pulled back on a sharp inhalation. “OK. First good news I’ve seen so far. Amazing, too. The eyes themselves are intact.”
Gulnar heard Emilio’s exhalation a few inches away from her ear. So he, too, had been holding his breath.
Dante raised his eyebrows at her. “Now I’d really like those X-rays.”
Gulnar swung to the senior ICU nurse, who hurried out herself this time, came back in a couple of minutes handed Dante the films with a grim face. He thanked her in Azernian, made sure he caught the nurse’s eyes, gave her a soothing smile. Gulnar’s heart swelled.
How considerate he was. How tender. Oh, Dante. Still here, but already lost to her.
She clamped down on the tide of agony as he shook his head, looking at the X-rays. “Without 3-D X-rays or even CTs to visualize whole structure of the face and skull from all sides and in perspective, there’s no way to see the injury in detail. But I guess this will have to do. When was this taken?”
“After surgery.”
“Hmm. Emilio, Gulnar, come over here.” Gulnar darted to his side. Emilio’s surprise that Dante had included him made his movements slower. They both ended up hovering on either side of Dante. “Tell me what you see.”
What she didn’t see chilled her. She had no solid arguments, no clinical evidence to back up her belief. It was instinct. And no one had agreed with it. If Dante didn’t either, her mind would be set at rest. She prayed he wouldn’t. She exhaled. “Nothing much. But judgements based on plain X-rays tend to under-diagnose the extent of injury. Dr. Moya was adamantly against doing anything about the facial fractures. He said we could always have delayed reconstruction when Dimitri is out of danger.”
“But that’s not your verdict, hmm?” Dante probed.
“No!”
Dante released her eyes, pored over the X-rays again. And again both she and Emilio looked over his shoulders. “Here—where you can’t see it, but from my manual exam—is a pulverization of the naso-orbito-ethmoid bones constituting the whole mid-face. I thought that the frontal bone had been spared. It was only on palpation that I found out the posterior table of the frontal bone is also pulverized.”
“But how can the posterior table be fractured without the anterior one?”
Gulnar couldn’t blame Emilio for being skeptical. The frontal bone, making up the forehead, was made up of two layers, an outer one and an inner one. The inner one almost never fractured if the outer one remained intact.
Dante shrugged. “It happens. Rarely, but it does. And this misleading intactness probably accounts for your doctor’s optimistic outlook. I wouldn’t fault him too much. As you said, X-rays aren’t useful in showing damage to the posterior table.”
“So this is why he has a normal fundus,” Gulnar exclaimed. “There is no rise in intracranial pressure because he’s been leaking cerebrospinal fluid though the fracture all the time!”
Dante’s lips twisted. “And the reason for his deterioration is neither shock nor direct trauma to the brain, but a spreading infection. If he weren’t sedated, he would have shown all signs of meningo-encephalitis.”
“Oh, Dimitri!” Of course. His brain was exposed to the elements through the fracture. But in that case… “Oh, God, Dante, he’s been on massive post-operative corticosteroids—they can suppress immunity and promote infection!”
Dante glared at Emilio. “You didn’t mention corticosteroids!”
Emilio glared back. “You’re the surgeon. You should know what goes on post-operative medication orders!”
“Well, you can strike them out at once!”
Emilio strode to the ICU nurse, relayed the new orders, anger clenching his every muscle.
Gulnar interrupted their sparring, still thinking, all the pieces falling into place. “So there was no cerebrospinal fluid leaking from his nose because he’d been on his back, with his head extended backwards!”
Dante came to stand beside Gulnar, his eyes sweeping her with appreciation, respect. Yes, but there was more. Regret. Sadness.
He nodded. “Another misleading lack of evidence. You were absolutely right to suspect the worst, to get me here. It was uncanny how you felt his danger against all evidence.”
She held herself rigid, swallowed a barbed lump of agitation and longing. “But why aren’t the antibiotics doing their job now?”