Dr. Doug Ross had a reputation around County General. As a pediatrician, he was widely respected for his both clinical skills and his bedside manner, but as a person, he received mixed reviews. He had been referred to as a cowboy, a rebel, and a rogue by his male colleagues, while the female ones tended to call him a womanizer, a philanderer, and a flirt. He found it hard to separate his personal life from his professional practice, especially when he always seemed to be surrounded by attractive women at work. Diane from Risk Management… Linda, the drug sales rep… Holda, the sexy Scandinavian stewardess who had been a patient… and of course, Carol. Beautiful, curly-haired Carol.
His shadow that morning, third-year medical student Harper Tracy, was no exception. With her blonde hair, sparkling brown eyes, and perky breasts, she could have been on the cover of magazines. Instead, she was bent over a teenage boy’s penis, inserting a Foley catheter into his bladder.
“Let me know if you feel any pain, AJ,” Harper told the patient as she finished prepping for the procedure by covering the tip of the catheter in lubricant. “This may feel a little uncomfortable, but it shouldn’t hurt.”
“I can’t feel anything down there anyway,” AJ muttered bitterly. He lay flat on his back, fully immobilized by the rigid cervical collar around his neck and the hard spinal board to which his body had been strapped. The poor kid couldn’t even reach up to wipe away the tears that were streaming down his bright red cheeks.
Doug felt for him. After all, he had been seventeen once - self-conscious, girl-crazy, and seemingly invincible, an adolescent on the cusp of adulthood with his whole future ahead of him. This boy’s world had just been turned upside down, his future plans put in jeopardy, his life possibly changed forever… and if that wasn’t bad enough, he now had to lie there helplessly while this total babe of a med student stuck a tube up his dick. Doug would have been embarrassed, too. But it was necessary - the boy had lost control of his bladder, as evidenced by the urine-soaked clothing they had cut off of him earlier, and claimed he couldn’t feel anything below the waist.
“We’re gonna run some tests to figure out why you can’t feel anything and see if we can fix it,” Doug tried to assure him, blotting his face with a tissue. He remained by the head of the bed while his nurse, Haleh, coached Harper through the procedure. It had been years since Doug had put in a Foley himself; typically, that was something the nurses did. Haleh Adams was one of the most experienced nurses they had working in the ER.
“Now, advance the tip into the meatus,” she was telling Harper, who, despite her looks, was no dumb blonde. In the first few weeks of her ER rotation, Harper had proven herself to be highly capable, a fast and eager learner. “Good,” Haleh praised her. “Keep pushing it in gently, about an inch at a time. There you go. If you meet any resistance, just rotate it slowly right and left until the tissues relax enough to let it pass; don’t try to force it.”
More tears spilled out of AJ’s eyes as he stared miserably at the ceiling. “I know this sucks, kiddo,” Doug said, ruffling his dark hair. “Not the way you wanted to spend the morning, huh? But hey, look on the bright side: I bet this buys you at least a few days off school. Is that where you were headed - school?”
AJ sniffled. “No. I’m not really in school right now; I have a tutor who travels with me instead. I’m part of a band. We’ve been performing all over the country for the past couple years.”
“Really?” replied Doug, raising his eyebrows. “Wow… so you’re already living like a rockstar, out on the road. And to think, when I was seventeen, I was schlepping burgers after school.” He grinned.
A ghost of a smile flickered across AJ’s face. “Eh, it’s not as glamorous as it sounds. Our van’s a piece of shit, and we have to share hotel rooms. There’s five of us in the group, so someone always gets stuck sleeping on the floor - usually me or Nick cause we’re the youngest.” For a few seconds, it seemed like talking about his band had taken his mind off of what had happened to him, but all of a sudden, his expression changed, his brow creasing with worry again. “God, I hope Nick and the other guys are gonna be okay…”
“What’s the name of your band?” Doug asked, trying to distract him again.
“The Backstreet Boys. You probably haven’t heard of us, have you?” AJ looked up at him hopefully, but Doug shook his head.
“Sorry, can’t say that I have. What kind of music do you do?”
“Pop and R&B. It’s okay; we haven’t really hit it big yet. We just got a record deal last year. We’ve mostly performed at schools, malls, theme parks, places like that, but right now we’re doing a radio tour to promote our first single we just released.”
Doug raised his eyebrows again, impressed that he had a bona fide recording artist in front of him, even if it was one he’d never heard of. “Yeah? Well, congratulations on the record deal. What’s your song called?”
“‘We’ve Got It Goin’ On.’”
He nodded, cracking a smile. “I bet you do.”
“Wait a second…” At the foot of the bed, Harper suddenly looked up. She had been quiet during their conversation, focusing on her procedure, but apparently she had been listening. “Is that the song that starts ‘Everybody, groove to the music. Everybody jam…’?”
Doug and Haleh both looked at the med student in surprise as she started singing, one hand still firmly grasping the patient’s penis while the other threaded the catheter through his urethra.
AJ’s eyes widened. “Yeah!” he gasped. “That’s it!”
“I’ve heard that song at the club at least a couple of times!” Harper exclaimed. “That’s you?!” She suddenly looked down, the smile fading from her face when she remembered what she was in the middle of doing to the seventeen-year-old singer. Her cheeks turned bright pink, as if she had suddenly realized she might have said too much.
AJ was blushing furiously, too, but he answered, “Yeah… that’s me and the Boys.”
“Wow… well, it’s a great song. Really catchy,” replied Harper before she bent over again and got back to work. Watching with amusement, Doug and Haleh exchanged a grin. The poor girl was clearly flustered, but she finished the procedure without any complications. “I’ve got some urine return,” she told Haleh, showing her the amber-colored fluid flowing through the tube. Doug was relieved to see that it looked clear - no sign of blood, which could indicate internal injuries.
“Good. That means you’re in,” said Haleh, nodding with satisfaction as she inspected the site. “Use the syringe to inflate the balloon with ten CCs of sterile water.” Once the catheter was in place, she showed Harper how to secure the tubing to the patient’s leg and hang the collection bag on the side of the bed.
Doug cleared his throat. “Now that that’s taken care of, kiddo, we’re gonna do a test to assess your level of feeling and function in different parts of your body. This will help us figure out exactly where you’re hurt and how to help you. Okay?”
“Okay,” AJ said, sounding nervous. “Can my mom come back in yet?”
“Eh, it’s probably best she stays in the hall until after this test,” answered Doug, who’d had Haleh escort the hysterical Mrs. McLean to chairs before they put in the Foley. No teenage boy wanted his mom around to witness that particular procedure, just as no doctor preferred to have his patient’s family members present during an ASIA Exam. It was too hard to watch - and too tempting not to cheat. “You look like a tough guy. You’ve got this, right?”
AJ put on a brave face, but Doug could see the fear in his dark brown eyes.
The pediatrician turned to Harper. “Ever seen an ASIA Exam done before?” he asked her. ASIA stood for the American Spinal Injury Association, which had developed the standards for assessing spinal cord damage.
The med student shook her head. “Not on a real patient. Just practice ones in class.”
“No problem. Mark thought this would be a good opportunity for you to observe one. Watch me and record the findings on this form,” Doug replied, handing her a clipboard with a diagram of the body, divided into key sensory points and labeled with the spinal nerve that controlled each part of it. By documenting the sensation and motor function the patient had in each area, they could classify the level and type of injury.
“Sounds good,” Harper said with confidence, taking a pen out of the pocket of her lab coat.
Doug pulled a cotton swab out of a container on the counter and showed it to their patient, explaining, “All I’m gonna do for this first part of the test is touch you in a few different places with a cotton swab and have you tell me if it feels normal or not normal. This is what it should feel like.” He brushed the tip of the cotton swab across the boy’s forehead, an area where he should have normal sensation. “Do you feel that?”
“Yeah.”
“Good. Okay, AJ, I’m gonna have you close your eyes now, and when you feel me touching you with the cotton swab, tell me if it feels normal or not normal. Got it?”
“Got it,” AJ muttered, closing his eyes.
Doug dragged the cotton swab lightly down the side of his face. “C2,” he muttered to Harper, making sure she was looking at the right part of the chart.
“Normal,” said AJ, as expected. If his spinal cord had been injured at that level, he would have been intubated by now, unable to control the muscles in his chest he needed to take a breath. Luckily, his breathing had been normal during Doug’s initial examination.
Doug moved the swab to a spot just above his collarbone. “C3.”
“Normal,” AJ said again.
Doug continued across to his shoulder and then down his right arm to the tips of his fingers. He repeated the same procedure on the left arm. The sensation was normal on both sides, which meant the patient’s cervical nerves were intact. Doug worked his way down the boy’s chest, assessing his thoracic nerves. All was well until he neared AJ’s waist level, at which point the sensation became “not normal” and then absent altogether below the waist.
“Are you still touching me?” asked AJ, frowning, as Doug brushed the cotton swab across the sole of his left foot.
The doctor cleared his throat. “Nope, all done for right now,” he replied. “You can open your eyes.”
AJ looked up at him uncertainly. “How’d I do?”
“You did just as I asked,” said Doug, smiling down at him. “Now, for the next part of the test, I’m going to see if you can feel the difference between a sharp touch and a dull touch. The sharp touch will be a light prick with the pointy end of a safety pin. It’ll feel like this.” Gently, he poked AJ’s forehead with the pin. “The dull touch will be the round end of the safety pin.” He flipped the safety pin around and rubbed the curved bend across AJ’s brow. “Can you tell the difference?”
“Yeah.”
“Good. I’m gonna have you close your eyes again, and this time, I want you to tell me if the touch you feel is sharp or dull. Got it?”
“Got it.”
The pediatrician repeated the procedure, this time alternating between the two ends of the safety pin as he probed each area. The results were what he had expected: AJ had normal sensation above the waist, where he was able to tell the difference between the two types of touches, but below the waist, he couldn’t feel a thing.
Next, Doug unfastened the straps from the spinal board to free AJ’s limbs so he could assess his motor function by asking him to move different muscles or resist when the doctor tried to manipulate his limbs. While AJ had full strength and range of motion in his arms, hands, and fingers, his legs were dead weight in Doug’s hands, limp and lifeless. He couldn’t lift them off the bed, nor prevent Doug from pushing them back down. It broke Doug’s heart to hear him ask, “Am I doing it?” when Doug told him to wiggle his toes. Lying flat on his back, AJ couldn’t even see his feet to tell whether or not they were following the commands his brain was giving them.
“You’re doing great,” Doug assured him, dodging the question. He would wait for the neurology consult he had called to come down and examine AJ before giving him any kind of prognosis. Doug was no neurologist, but based on the findings, he suspected his patient had suffered a spinal cord injury somewhere around the junction between the thoracic and lumbar vertebrae in his lower back. If it was a complete injury, the boy would be a paraplegic - paralyzed from the waist down and likely to be wheelchair-bound for the rest of his life. He didn’t want to be the one to break that kind of devastating news to a seventeen-year-old kid with dreams of stardom.
“Did you get all that down?” he asked Harper quietly, craning his neck to check her notes. She nodded, giving Doug a grim look as she showed him the clipboard she had used to record AJ’s test results. She, too, seemed to understand the implications of what they revealed. Her eyes had lost some of their sparkle; he could see the expression of pity reflected in them as they glanced back at the patient.
“Hey, Doc, you didn’t answer my question,” said AJ, his own eyes flashing accusingly as they shifted to Doug’s face. “Did my toes wiggle or not?”
Doug sighed. “No,” he admitted. “They didn’t.”
“Damn,” AJ groaned, his face crumpling. “Does this mean I’m gonna be a cripple?” Fresh tears filled his eyes as he looked desperately at Doug.
“Not necessarily,” Doug tried to reassure him. “I don’t want you to worry yet. The paralysis may not be permanent. There’s one more part to this test that will tell us whether your injury is complete or incomplete. If it’s incomplete, there’s a better chance you could recover at least some feeling and function below the waist.”
Through the tears, the pediatrician saw a glimmer of hope in his patient’s eye.
Clearing his throat, he went on, “I’ve gotta warn you, though, this part’s not real pleasant. We’re gonna roll you onto your side so I can give you a quick rectal exam.”
AJ snorted, apparently assuming he was joking. When Doug didn’t crack a smile, the kid’s eyes widened. “Wait, you’re gonna what?! Seriously?”
“Seriously. Trust me, it’s not my favorite thing to do either,” he said apologetically, “but it’s necessary. We need to check for something called ‘sacral sparing.’ This test will tell us if any signals sent by your brain are making it all the way to the bottom of your spinal cord, which controls the area around your anus.”
AJ made a face.
“The good news,” Doug continued, “is that we’ll have to get rid of that backboard you’re lying on, so you should be a little more comfortable when this is all done. Okay?”
The kid closed his eyes and sighed. “Do whatever you gotta do, I guess.”
Doug turned to Harper and Haleh, telling them, “Let’s log roll him onto his left side and remove the spinal board.” Working together, the three of them moved AJ’s body into the proper position, taking care to keep his spine in alignment.
“Okay, AJ, I want you to tell me when you feel a sharp or dull touch, just like before,” said Doug, taking out his trusty safety pin again as he sat down on a stool behind his patient. He poked AJ in a few places with both the curved and the pointed side of the pin, but there was no response from the boy.
Knowing he needed to go deeper, Doug snapped on a fresh pair of gloves. “Doing great, kiddo,” he said, as he dipped his index finger into a liberal amount of lubricant. “I’m going to put my gloved finger inside you now, okay? You may feel a little bit of pressure, but you shouldn’t feel any pain.”
“Just get it over with,” AJ groaned.
Carefully, Doug inserted his finger a couple of centimeters. “Can you feel anything?” he asked, as he slowly rotated it clockwise.
“Yeah!” AJ gasped. “Pressure… like you said.”
Doug caught Harper’s eye. Her brows were high on her forehead in a hopeful expression as she observed the exam. “Can you tell which side I’m pushing on?”
“Um… the right?”
“That’s right,” said Doug, shooting Harper a grin. “Very good.” The student offered a relieved smile in return. “Okay, one last thing - I want you to squeeze your sphincter like you’re holding in a bowel movement. Can you do that for me?”
“I’ll try…” AJ said, sounding both doubtful and disgusted by what he had been asked to do. But a few seconds later, Doug felt the muscles tighten around his finger.
“There you go!” he praised his patient. “That’s it!”
“I did it?” asked AJ in disbelief.
“You did it,” Doug confirmed, removing his finger. “You did very well.” He stood up, stripping off his gloves, and went to the sink to wash his hands.
“Good job, honey,” he could hear Haleh reassuring AJ in the background.
When he returned to the bedside, Harper and Haleh helped him roll AJ onto his back again. “So,” said Doug, smiling down at the teenager. “What that test told us is that some signals are still getting through, so the injury to your spinal cord is incomplete. That makes your odds of recovery much higher.”
“So I’ll be able to walk again?” asked AJ hopefully.
Doug hesitated, feeling his smile fade. “I can’t promise that. I’ve called another doctor, one who specializes in spinal cord injuries, to come take a look at you. He’ll be able to give you a better idea of what to expect after he’s had a chance to examine you and do some more tests.”
Suddenly, the door to the exam room burst open. Doug turned his head, surprised to see Carol - beautiful, curly-haired Carol Hathaway - hurrying in. “Doug, I need you!” she cried. “We’ve got a kid crashing in Trauma 1!”
Doug’s heart leapt into his throat, racing with a surge of adrenaline. “Hang out here until Radiology’s ready for him,” he told Haleh. “Harper, bring his mom back to the room and then meet me in Trauma 1.” Then he took off after Carol, watching the way her black curls bounced about her shoulders as she jogged through the hallway.
“Where did they take Nick?” she asked Lydia, who was tending to the patient in Trauma 1 - apparently not the same one she had summoned him for.
“Next door,” the nurse replied, pointing to Trauma 2.
Doug and Carol barrelled through the door that connected the two trauma rooms. Susan Lewis was bent over the teenage boy lying on the bed, examining him while one of the nurses, Lily, started an IV.
“His name’s Nick,” Carol said shakily, as she and Doug hurried over to help. “He was a backseat passenger in that van accident on the bridge. I examined him at the scene; he was alert and oriented with normal vitals and no obvious injuries or complaints, but he just collapsed without warning a few minutes ago while he was watching us work on his friend. I must have missed something...”
“You don’t know that,” said Doug, who was naturally inclined to come to Carol’s defense. They had dated a couple of years earlier, but he had ruined that relationship the same way he seemed to ruin all his relationships. At least Carol didn’t seem to be hurting anymore; the last he’d heard, she had started seeing a paramedic. That was probably why she had been at the accident scene in the first place, he realized: she’d been riding in his ambulance. “He could have just fainted from emotional trauma,” Doug added, forcing himself to forget the paramedic and focus on the patient. His eyes swept over the unconscious kid, noting his pale and diaphoretic skin. “What are his vitals?”
“BP seventy over forty, heart rate one ten, resps twenty-five and shallow,” said Susan, taking her stethoscope out of her ears.
Doug frowned. “On second thought, it sounds more like he’s in shock. He could be bleeding internally. Carol, call Radiology - he needs a head, chest, and abdominal CT, stat. Lily, run in a liter of normal saline, and let’s get a full trauma panel: CBC, lytes, BUN and creatinine, lactate, urinalysis, blood gas, and type and cross.”
“His belly looks distended, Doug,” Susan pointed out, as she peeled the cut flaps of damp fabric from Nick’s oversized t-shirt away from his skin.
Doug noticed a characteristic abrasion across his abdomen, just below the naval. “He’s got a seatbelt sign,” he added, suspecting an intra-abdominal injury.
Replacing her stethoscope, Susan pressed the diaphragm to the upper left quadrant of his abdomen and listened. “Decreased bowel sounds,” she observed, as she slid the stethoscope lower.
Doug snapped on a pair of gloves before he began palpating the boy’s abdomen. It was tight and firm, with a doughy fullness that further supported his diagnosis. “Belly’s rigid. Let’s do a portable ultrasound.” It was the fastest way to confirm the presence of blood or other fluid in the abdomen, besides the more invasive peritoneal lavage.
“I’ll grab the cart from next door,” Susan volunteered, slipping back into Trauma 1.
As Doug continued his examination, pushing his fingers down deeper, the patient started to regain consciousness. Doug felt the boy’s abdominal muscles tense as he moaned and tried to twist away from the doctor’s hands. “Rebound pain and guarding are present.”
Carol hung up the phone and rushed to his bedside. “Hi, Nick,” she said softly, stroking the boy’s blond hair back off his sweaty forehead. “You fainted a few minutes ago in Brian’s room. How are you feeling?”
Nick’s eyelids fluttered. “My stomach hurts,” he mumbled, barely audible.
“I know. Dr. Lewis and Dr. Ross here are going to find out why and get you feeling better.”
Doug cleared his throat. “Actually, I think we’re gonna need a surgical consult for that. Anyone seen Benton around?”
“I’ll page him,” Carol offered, picking up the phone again.
Doug took her place at the head of Nick’s bed. “I’m Dr. Ross,” he said, smiling down at him. “We’re gonna give you some medicine to help with the pain, okay? Lily, let’s start with three of morphine.” As the nurse injected the medication into Nick’s IV, Doug asked his patient, “Does it hurt anywhere else besides your belly?”
“No…” Nick looked up anxiously as Susan came back in with the portable ultrasound equipment, which she set up next to his bed. “Is Brian okay?” he asked her.
She flashed him a tight-lipped smile and nodded. “He’s hanging in there.”
“Good…” Upon hearing that, Nick seemed to relax a little, his eyelids drooping as he started to drift off again.
Doug cleared his throat. “Hey, Nick?” he said sharply, causing the boy’s blue eyes to snap back open wide. “Stay with us, buddy.” He wanted to keep the kid conscious and alert, concerned he was on the verge of crashing again. “So, listen: I can tell you were wearing your seatbelt, which was smart - it may have saved your life,” he added, offering his patient another reassuring smile. “But it also might have done some damage. We think you may be bleeding inside your belly, so I’m gonna take some pictures with my magic wand here and see what’s going on in there.” He picked up the ultrasound probe so the kid could see it. “This may feel a little cold.”
Nick flinched as Susan squirted some conductive gel onto his bare skin. Doug tried his best to be gentle as he moved the probe over the boy’s abdomen, applying just enough pressure to get a good picture on the ultrasound monitor.
“He’s got free fluid in the left upper quadrant,” Doug observed, frowning as he pointed out the collection of dark liquid - blood, most likely - filling the space in between the abdominal organs, which appeared white on a normal ultrasound.
“Have you called for a surgical consult?” Susan wanted to know.
“I paged Benton a few minutes ago,” said Carol. “Want me to page him again?”
Before Doug could answer, he saw Harper come in. “Hey, Harper, have you seen Dr. Benton around here?” he asked her.
“He and Carter are with a patient in Exam 2,” the med student replied.
“Good. I want you to go get him; tell him we have a hemodynamically unstable pediatric surgical patient who needs his help right now.” As Harper hurried off to fetch the surgical resident assigned to the ER, Doug turned back to the rest of the team. “In the meantime, let’s transfuse him, try to keep his pressure from bottoming out. Carol, hang four units of O-neg on the rapid infuser.”
While Carol set up for the blood transfusion, Doug took Nick’s hand and gave it a squeeze. “How you doing, kiddo?”
Nick shook his head. “I don’t feel good,” he whispered.
“I know. We’re gonna give you some blood and get you feeling better while we wait for another doctor to come check you out. You hang in there, okay?”
Nick nodded. “Do you know if AJ and Howie are okay?” he asked after a few seconds.
“Well, I haven’t seen a Howie yet, but I just came from AJ’s room,” replied Doug with a grin. “He was telling me all about the group you guys are in.”
“The Backstreet Boys, right?” Susan chimed in. “Kevin told me, too.”
A smile tugged at the corners of Nick’s colorless lips. “Yeah. So AJ’s okay?”
“He’s hurt, but I think he will be,” Doug answered guardedly. He didn’t want to give the kid too much information, but he also didn’t want to give him false hope that his friend would be just fine. AJ’s injuries didn’t appear to be life-threatening, but they could very well be life-altering.
“What about Denise?” Nick wondered. “That’s AJ’s mom.”
“She’s fine. She’s in with him now.”
“And Lou?”
“Lou? Not sure about him,” said Doug, but he saw Susan shake her head a fraction of an inch, a grim look on her face, and he knew: Lou was dead. Better to wait awhile before breaking the bad news, he decided, his eyes darting from Nick’s face to the monitor beside his bed. The kid’s blood pressure was still dangerously low. In his already precarious condition, the last thing he needed was to hear something that might send him over the edge. Instead, Doug tried to change the subject. “So, Nick… you like sports?”
“Yeah… basketball… and football…” Nick’s eyelids fluttered as the light faded from his blue eyes.
“Basketball, huh?” Doug said loudly, bearing down on his hand until the kid blinked, the cloudy look clearing. “Me too. Bulls fan?”
“Sure,” said Nick, a faint smile crossing his face. “Jordan and Pippen are the best.”
“You bet they are,” Doug agreed, grinning back. But behind his easygoing smile, he was worried, wondering, Where the hell is Benton?
***
