Do No Harm

"Dr. Trace?" David said. He didn't look up from the eye he was spraying, but he sensed Diane's head pivoting.

She switched the saline bottle to her other hand, squinting as a wayward squirt caught her across the brow. "Increasing intraluminal pressure generated by emesis is speculated to increase the risk of perforation when the tissue is markedly weakened. Carson, get your ass over here and give us a hand."

Carson lunged forward and grabbed a saline bottle. Diane nudged him with a shoulder. "What are the three reasons we don't use charcoal to soak up alkali in the stomach?" she asked.

"Four reasons," David said.

Diane grimaced at being corrected but didn't look up.

Pat switched IV bags, then checked Nancy's blood pressure cuff, her face stained with grief and shock. With twenty-three years as an RN under her belt, Pat was the den mother of the ER nurses; that's why she'd followed Nancy in here, probably sending one of the more junior nurses out front to triage. Her crew cut was shot through with sweat.

"I don't know any," Carson confessed.

David raised an eyebrow at Pat. "Pat?"

"Why are you pimping a nurse?" Carson asked, a competitive note finding its way into his voice. Most doctors only fired questions at med students, interns, or residents.

"Because, in general, they've been around longer and know more than arrogant med students."

Pat looked over quickly, her cheeks quivering. "I… what… ?"

"Would you like to tell Carson here, and Dr. Trace, the four reasons we don't use charcoal to soak up alkali in the stomach?"

Pat managed to regain her focus, which had been David's aim in questioning her. "One, activated charcoal doesn't absorb alkali. Two, it obscures the endoscopic visual field. Three, if the patient is perfed, it would leak right into the mediastinum, and four, it's a vomit risk, and Carson and Diane already pointed out those pitfalls."

"That's right." David glanced around the small room bustling with people. A few faces still looked upset, and a lab tech was holding one of Nancy's limp hands. "We have a damn sharp team here," he said. "Don't worry, and stay focused."

A clerk leaned through the door. "Dr. Jenner's ringing through."

"Aah," David said. "Our ophthalmologist."

The telephone behind David emitted only a half ring before he grabbed it, first handing off his saline bottle to a nurse and pointing. "Keep flushing," he mouthed, pivoting to miss an IV pole a lab tech pulled around.

"Dr. Jenner, just in time. We need you down here, got a bad alkali exposure to the eyes."

"Was the skin around the eyes burnt?" Dr. Jenner's deeply textured voice was low, rolling, authoritative.

"Everything's burnt. The cornea's cloudy white."

"So the endothelium's already not functioning. Are you irrigating?"

"Saline."

"Good. Osmosis advantage."

"I can't find the Morgan lenses."

"Don't worry about it. They're outdated and overrated. Just get the eyes open and keep irrigating copiously. Once the eyes are better cleared, give her a drop of Pred Forte to stop the inflammation and a drop of Cipro for infection. I'm on my way."

Diane glanced up at David as he hung up the phone. He chewed his lower lip. "Pat, can you call GI again, ask what's taking so goddamn long on our consult?"

The radiology tech poked his head into the room, fresh back from the X-ray suite in the rear. "No free air," he said.

That was good-at least the alkali hadn't eaten through the esophagus, allowing air to escape into the body. Yet.

Diane leaned forward over Nancy's body, and she and David brushed foreheads. Her eyes jerked quickly away. "Sorry."

"How are you doing on the eyes there, Carson?" David asked.

Carson nodded. "Okay. But I think she's gonna need a corneal transplant." He leaned over, examining the other eye. "Two."

"We're going to apply some Cipro and Pred Forte drops. Can you get them ready?"

A uniformed UCLA Police Department officer strolled in; David was immediately irritated by his casual gait. The cop cleared his throat. "I have some questions I need to-"

"This patient is unconscious and can't answer questions."

"Well, I'll need to take a-"

"Not right now," David said. "Out, please. Out."

The cop shot him a good glare before retreating.

The nurses and techs continued to irrigate Nancy's flesh, lined on both sides of her body like feeding pups.

"Good, good," David said. "We're gonna keep irrigating her for hours."

Pat looked up, a little moist-eyed, and nodded. "We'll be here."

The wall phone rang, and a tech grabbed it, then held it out to David. "Dr. Woods."

David shot a latex glove into the trash bin and fisted the phone. "What took you?"

"I was in on a-"

"We have an alkali burn, some ingestion. No free air on the film."

"Ulceration of oropharynx?"

"Yes. And acute laryngeal swelling. We had to crich her."

"We like to have them swallow a little water, push the alkali down the esophagus into the stomach. Greater area, protective acids." Dr. Woods's voice was slow and droning. It reflected his personality.