The Sara Turnbull he remembered would never have allowed a critically traumatized patient to have only one working IV. Perhaps in the chaos, she simply had not noticed. In seconds, she was taking down the dressing and preparing to replace the IV line—this time at the wrist.

Lou glanced up again at the perilously low blood pressure reading, which had dropped from a systolic of eighty to seventy-four. Unless the cause could be identified and reversed, John Meacham was heading out. Quickly, Lou began mentally ticking through the possibilities. It took only a few seconds to connect with the right one.

Stunned at what he was seeing, Lou worked his stethoscope into place and listened to Meacham’s chest. There were no breath sounds on the right side. The exam was not really necessary. All the information he needed was visible in the distension of the jugular veins along the sides of the man’s neck, the slight bowing of the trachea toward the left, the persistently low oxygen saturation, and the asymmetrical hyperexpansion of the right chest.

A tension pneumothorax—collapse of the right lung due to a tear, probably caused by excess pressure from the ventilator. Air was being forced by the vent through the ruptured lung and into the chest cavity. The midline structures including the heart, esophagus, aorta, and other great vessels were being pushed to the left. The absence of breath sounds on the right merely confirmed the diagnosis.

Lou noted that the vent pressure was dangerously high and turned it down. From beside the machine, the respiratory tech—a tall, pencil-necked man in his late twenties—stood smiling at him blandly.

Did you do this on purpose? Lou wanted to shout. Did you?

“Everyone, please, listen to me,” he called out, louder than he’d intended. The commotion immediately stopped. “I’m Dr. Lou Welcome from the ER at Eisenhower Memorial. This man has a rapidly expanding tension pneumothorax. We need to dart his chest immediately to get the air out of there. Then we’ll get a chest tube in. I need an IV angiocath in a number sixteen or fourteen needle. Quickly, please.”

Missing from the emergency, except in himself, was any sense of tension and urgency. Lou wondered if anyone in the room really cared whether John Meacham made it or not. It would not be hard to understand if they didn’t, even though, as Sara had said, it should never be a caregiver’s role to pass judgment on any patient.

This was as bad as it could get.… Poor bastard.… Poor victims.

What in the hell happened?

A large-bore needle with a plastic catheter running through it was brought on an instrument tray, along with latex gloves, a large syringe, surgical sponges, some surgical snaps, and several culture tubes.

Blood pressure, seventy over thirty. Oxygen saturation, 60 percent. Color worsening.

Moving rapidly, Lou gloved and swabbed some Betadine antiseptic below Meacham’s collarbone on the right side. Then he set the plastic catheter aside and attached the needle to a 20 cc syringe. His movements were careful and considered, but almost automatic, like a boxer throwing a right-left-right combination.