"BP is dropping," the nurse calls out. "Fifty over thirty. Heart rate is 140."
"Fluid bolus!" I order. "Hang the blood!"
"Dr. O'Connell."
Maxwell is at my side. He’s looking at the monitor, then at the patient’s distended neck veins.
"Look at the EKG," Maxwell says, pointing a gloved finger. "Electrical alternans. And the pulse pressure is narrowing. It’s not just a hemothorax."
I look. He’s right. The heart tracing is swinging high and low.
"Tamponade," I curse. "The sack around the heart is full of blood. It’s strangling the heart."
"He needs a pericardial window," Maxwell says. "We need to get him to the OR. Now."
"We can't move him," I say, checking the abdominal distension. "His belly is rigid. He’s got internal bleeding in the abdomen too. Liver or spleen. If we put him in the elevator, he codes before we hit the second floor."
"He will codehereif we don't relieve the pressure on the heart," Maxwell argues. "We need a sterile environment. We need bypass capability."
"Look at him, York! He’s dead in two minutes!"
The monitor screams. A flat, high-pitched tone.
"Code Blue!" Mama yells. "Starting compressions!"
"No!" Maxwell shouts, grabbing the intern's hands before she can push on the chest. "If it’s a tamponade, compressions won't help! The heart can't fill! You’ll just crush it!"
We are standing over a dying man. The noise of the ER fades into the background. It’s just me, Maxwell, and a flatline.
Maxwell looks at me. For the first time, I see a crack in the ice. He’s brilliant, but he needs his tools. He needs his castle.
"We have to open him," I say.
Maxwell’s eyes widen. "Here? In the Trauma Bay? It’s septic. The infection risk?—"
"Infection kills him next week," I snarl, grabbing a bottle of Betadine. "The tamponade kills him right now."
I don't wait for his permission. I pour the iodine over the man’s chest, soaking the grey skin in orange.
"Scalpel!" I roar.
Indira slaps it into my hand.
"What are you doing?" Maxwell demands, though he’s not moving to stop me.
"Clamshell thoracotomy," I say. "I’m cracking the chest."
I slash the blade across the chest, from the sternum to the armpit. I do the same on the other side. It’s brutal. It’s violent. It’s the kind of medicine that gives civilized doctors nightmares.
"Rib spreader!"
I jam the metal retractor into the wound and crank it open. The ribs crack—a sickeningcrunchthat makes Indira gag.
There it is. The heart. It’s not beating. The pericardial sac is tight, purple, and bulging with trapped blood.
"He’s yours, Max!" I step back, blood dripping from my forearms. "Fix the heart! I’ve got the belly!"
Maxwell hesitates for exactly one second. He looks at the blood on his pristine coat. He looks at the non-sterile ceiling tiles. Then, he steps into the mud.
