I would like to dedicate this book to my parents,
Patric and Paula, who always supported me in my writing
Night had fallen over the desert like a black curtain of Spanish lace. Razor wire topped the electrified fence surrounding the isolated hospital for the criminally insane. A guard tower was manned and equipped with motion-detecting surveillance cameras and a reciprocating array of searchlights. The front entrance to the facility housed a sleepy guard who was watching old movies on a tiny television. A waxing gibbous moon cast a spangled patina of shadows across the dingy floor through barred windows.
It was early morning, a few hours before sunrise, and most of the patients were sound asleep, albeit not soundlessly. Their collective stertor could be mistaken for a chorus of swine at mealtime. The orderly was napping as usual. There wasn't much for him to do. No medications needed to be handed out. The orderly was a man of large build wearing a wrinkled, stained, white uniform. His size eleven shoes had been doffed and lay on the floor. He reclined with his feet reposed cross-legged on top of the metal office desk. A crumpled pack of Marlboro cigarettes lay on the desk alongside a three quarters empty bottle of cream soda and an overflowing ashtray. There was no smoking allowed in the lockdown ward, but the orderly chose to ignore this rule and would often stand by his office window and exhale the smoke to the outside. The orderly kept a noisy desktop air purifier going constantly to rid the air of any lingering stale smoke smell. Most of his coworkers knew of his bad habit but chose not to report it. Besides, it would be difficult to find a replacement to work this ungodly night shift in this ungodly place.
The patients in the lockdown ward were all hardened criminals, murderers, and serial rapists. They were here at the behest of the courts, either awaiting trial or placed here until their mental status changed enough for them to be housed outside the locked ward with the rest of the loonies being treated by the State of California. The patients inside the lockdown ward were either a danger to society or considered a danger to themselves. If not mentally ill, some would be sentenced for consecutive life sentences in a maximum-security prison, most likely confined in solitaire. Instead, they were imprisoned here in a minimally secure hospital. They were subdued, not with chains and restraints, but rather with psychotropic cocktails designed to keep them docile and compliant.
The orderly was the only one working in the lockdown ward at night and the armed security guards only phoned in to check rather than come down here in person. He would hide the ashtray and its evidence in his locker before the shift change.
Dr. Jonathan Anderson lay wide-awake on his decade's-old bed, the mattress ticking of which was as stiff as canvas and smelled of musty, stale urine from past incontinent patients. Anderson arose and crept from his bed, stalking silently, hugging the wall, avoiding the security cam. The only illumination for the dimly lit ward came from a white and green EXIT sign over the locked, double doors located at one end. Upon reaching the sliding glass door separating the night orderly from the patients, he paused a moment in the shadows in order to peer inside.
Noiselessly, so as not to awaken the orderly, Anderson slid the glass door open. Out of the corner of his eye he detected a movement in the darkened ward. One of the patients was sitting erect on a nearby bed watching him with mute, moronic curiosity. Anderson smiled amiably; shrugged, and waved casually as if to say, "don't worry." The demented patient grinned maniacally in response and continued to stare and watch Anderson's every move with deranged eyes that reminded him of those googly eyes used in stuffed toys.
Anderson moved slowly behind the sleeping orderly until he could just reach out to touch him. Then, like a professional wrestler, he used his strong right arm to clamp a sleeper hold around the orderly's throat. The man's eyelids flapped open, and his florid face took on a look of surprise. There was a slight, muffled struggle, but within seconds Anderson had cut blood supply to the brain by effectively compressing the carotid arteries on either side of the man's burly neck. He was careful not to tighten his grip too hard for fear of crushing the larynx. Soon the man's arms and legs stopped flailing. He slumped further and further into his seat until he fell off the edge of the chair onto the floor in a heap. Anderson relaxed his grip but could still feel the man's pulse. The orderly was alive and would most likely sleep for a while, but when he awoke he might experience a slight headache and sore neck.
Anderson had no reason to kill this man. For the most part, he had been treated well by the orderly, as by the rest of the staff over the course of his confinement. They all were treated with dignity and compassion. Maybe not with the respect due a physician of Anderson's stature, but this could be forgiven under the circumstances. The orderlies probably didn't have a clue as to the former careers of these prison patients. All of the patients had equal standing in here. There was no deference given according to their prior status or position in life. Anderson himself rarely spoke and appeared to be in a psychotropic-induced catatonic state most of the time. The patient's charts contained only his medical history and current treatment plans.
The psychiatrists, ultimately in charge of these patients, rarely visited the lockdown ward. They preferred to meet their patients handcuffed or restrained in a private treatment room just outside the lockdown doors. The psychiatrists would know much about each patient's former life but were bound by professional ethics not to share this with the orderlies or anyone for that matter.
Anderson checked the orderly's pockets. He found car keys, a wad of bills, and a butane lighter. He carefully laid each item on the desk. Then, with some effort, he managed to remove the man's uniform and change into it. Anderson had to gulp air through his mouth as the smell from the body odor assaulted his nostrils. The orderly did not give much importance to personal hygiene and was not a frequent bather, evidently. It was not a perfect fit; the sleeves were a little short, and he was not able to fasten the collar button, but it would do on casual inspection. The prison staff picture I.D. card attached to his breast pocket was old and outdated. The picture was hazy, and Anderson suspected it had gone into the wash along with the shirt on more than one occasion.
He left the man sitting there bent over, wearing only his underwear. His head rested on the desk. He was drooling and apparently sleeping, but at least he was still breathing. Anderson looked around for a moment and then he hid his patient pajamas in one of the orderly's desk drawers. There were no identifying marks on them, all of his fellow prisoners wore them, and one size fit all. He didn't think he would ever need them again.
Moving more quickly now, and not trying to be as quiet, he crossed the ward to the bed of the new patient who had been brought in last evening. Anderson had been waiting a long time for someone like this to be admitted. What he did next was a callous gesture, as if Anderson was merely putting a sick animal out of its misery. Anderson removed the man's pillow from under his head and without hesitation or further thought he placed the pillow over his unfortunate victim's face. This time there was hardly a struggle due to the strong sedative that they had administered to the prisoner earlier upon his admission to the lockdown ward this evening.
The guards had brought the new prisoner in shackled hand and foot, with blood still spattered on his clothes. The unmistakable acrid smell of gunfire added to the mélange. They cleaned him up, replaced his bloodied cloths with patient pajamas, and sedated him with a strong enough tranquilizer to keep him quiet until morning for his scheduled arraignment. After a short duration, Anderson removed the pillow to find the hapless patient cured forever of his suicide tendencies and schizophrenia. The man wore no expression of shock or fear, only peace. His eyes were open, and Anderson took his thumbs and closed them.
Anderson didn't feel remorse for this killing and gave it no more thought than if he had to perform an act of euthanasia for one of his former terminal patients. It reminded him how he frequently had to perform euthanasia on a lab animal he had used in his research. Ultimately, he was merely fulfilling the man's dying wish to put an end to his own mental suffering.
Anderson had overheard the guards talking about how a few short hours earlier this man had been out of work due to the recession and the downsizing of the company. He had worked as an air traffic controller for twenty-some years. Unemployed for over a year, he was forced to work a survival job as a short order cook, just to feed his family and keep on the utilities. Unable to pay the house payments with his menial job and unable to get help from anyone, he lost his house to the bank in foreclosure. He and his family were soon to be evicted. His wife might have been able to work, but she was disabled and due to some bureaucratic error, she was not eligible for disability insurance or worker's compensation. Without insurance her medical bills were piling up along with all of the others. Going from a six-figure salary to minimum wage was humiliating enough. And watching his family disintegrate before his eyes with the prospect of moving them to a homeless center must have finally pushed him over the edge.
He killed his own wife and kids with a shotgun while they slept. He would have committed suicide had he not run out of shotgun shells. The neighbors heard the gunshots and called 911. The police found him bug-eyed and hysterical, with the muzzle of the shotgun stuffed inside his mouth so far it was making him choke as he repeatedly pulled the trigger.
Now Anderson had only to exchange armbands with the dead man and he was halfway there. Hefting the dead weight and heaving the body over his shoulder was the hardest part. He was out of shape from inactivity over the past three years. He struggled with the burden as he crossed the short distance to his bed, upon which he deposited the inert body. He switched the labeled false teeth cups at the bedside table with his and with disgust pocketed the patient's choppers. It was not a perfect fit, but he had little difficulty stuffing his own pair of false teeth into the dead man's slack-jawed mouth. He hoped this would also help with the misidentification of the victim. They must think the dead man lying here was Dr. Jonathan Anderson.
Emptying the orderly's ashtray into the desk trashcan, he took the lighter and ignited the paper. Some part of him regretted this act as it may incriminate the orderly in the cause of the fire, but that might be explained away in light of the fact the orderly had been overcome by one of the patients. It would have to be determined if the assault occurred before or after the fire began. The flames caught the greasy drapes first, and the fire licked hungrily at the flakey dry walls, which soon exploded in sheets of flame. He took some burning drape embers and lit the dead man's bed on fire. He could not afford to leave a corpse with fingers that could be printed or DNA which could be matched. The bed burst into flame as the old blankets were made of highly flammable burlap-like material. It soon resembled a funeral pyre.
Some of the other beds burst into flame as the blazing curtain ashes wafted into the air and came to rest on burlap. All of the patients were awake now, and were huddled together near the door. Their voices were a collective mewling like animals trapped in a burning barn. Almost immediately there was smoke everywhere. The smoke detector began blaring, awakening all the remaining patients, whose babble added to the cacophony. Some panicked and screamed when they saw the flames, but most were heavily sedated from a nighttime concoction of psychotropic sedatives. Those just stood and watched with helpless fascination as the room transformed itself into a burning inferno. The smoke and fire and the insanity made Anderson think this must be what the last circle of Hell might look like. The smoke became thick; everyone began coughing and gasping for breath.
After what seemed like an eternity, the locked-from-the-outside double doors burst open, letting in two orderlies and a rush of oxygen, which in turn caused the room to implode with flame. The two orderlies quickly stripped blankets from the beds and vainly began to beat at the flames. They tried to smother Anderson's burning bed, but their efforts and the added oxygen only seemed to fan the flames. One of the orderlies grabbed a fire extinguisher from the wall, pitifully inadequate for the size of the blaze, and the fire seemed to grow stronger when splashed with the foamy retardant.
They noticed the orderly still slumped over his desk and rushed to his side, nudging him and yelling for him to wake up. They must have thought it strange he was sleeping at his desk in his tighty whities, but there were more pressing matters. Someone had pulled the building's fire alarm and the blaring sound and flashing lights added to the dissonance. No one noticed the silent hulking form dressed in a white orderly's uniform emerge from his hiding place and steal off into the dimly lit, smoke-filled corridor now that the entrance door was left ajar. Most of the patients followed him down the hallway still gibbering and whining like animals. To anyone who saw them, it would appear they were being evacuated to safety.
Surprisingly, Anderson met with no more locked doors or human resistance as the staff was fewer on the late shift. When Anderson reached the hospital entrance, he ran smack into an orderly who was rushing toward the sound of the alarm.
"There's a fire on ward seven," Anderson yelled, pointing down the hall. "I'll get help," he blurted, as the other man ran off in the direction of the fire. If he had failed to recognize Anderson as not being one of the staff, it could be excused due to the smoke and mayhem.
When Anderson reached the employee parking lot of the hospital, he was relieved to find there were only a few cars left. He went frantically to each one in turn, pressing the remote alarm disable button on the key fob he had secured from the unconscious orderly. Shortly he found a vehicle blinking its lights and chirping in response to the silent radio signal. It was a four-wheel drive Chevy 3/4-ton pickup with a 350cc engine and a large roll bar. It had oversized tires, which made it look like one of those monster trucks he'd seen advertised on TV that could effortlessly climb over a stack of boulders. Before touching anything in the fast-food-wrapper-littered truck, he put on the latex gloves he had pocketed earlier. He had to struggle to hoist himself up to get into the driver's seat, which was a good three feet off the pavement. The truck sounded like a Panzer tank revving its diesel engine as he backed it quickly into the deserted parking lot. There was a case or more of empty beer cans rolling around in the truck bed, which made it sound like a trailer park burglar alarm. He ducked his head low and pulled on a San Diego Padre Baseball cap he found lying on the truck's seat as he approached the gate. He did not wish to be identified by the security camera.
The unarmed gate guard waved his arms frantically and just managed to leap out of the way as the truck sped up and struck the locked electrified gate. Sparks fanned into the air, but the gate provided little resistance for the raging steel. He rammed his foot on the accelerator and he savagely twisted the wheel while viscously jamming the four-on-the-floor gear shifter. It had one of the custom handles on it in the shape of a leering skull. When gripped his fingers slid into the exposed eye sockets, and his thumb found the toothy mouth of the skull.
He swept onto the highway in a billowing cloud of dust, leaving the crippled, gutted hospital barracks behind. Smoke billowed from windows and flames licked at the untreated wood shingled rooftops. The State's mental hospital was situated in a group of buildings that were over 50 years old. The State had recently taken over an abandoned military base. The locked Ward housing the criminally insane was formerly a single story men's barracks, which had been built around the time of the Korean War, and it wasn't yet retrofitted with automatic sprinklers.
Anderson could hear keening and mewling sobs from the patients who were now huddled together in the parking lot. He noticed the orderly now revived and standing there in his underwear apparently yelling, cursing and gesturing to whoever would hear that someone was stealing his truck. Anderson hoped the vehicle theft would not seem important to the approaching fire and rescue personnel who would undoubtedly soon be joined by the local police. Putting out the fire and getting everyone to another safe facility would take precedence. Sorting out how the fire started and getting an accurate head count might take awhile, giving him more time and distance before an escaped prisoner search would begin.
The truck was lit up like a redneck Christmas tree, with running lights all around and six frog-eye headlights perched on top of the roll bar. Reaching the freeway frontage road, he made a hard right, crossing over the eight lanes, and headed toward the coast at speeds reaching well over 100 miles an hour. He let out a depraved laugh as he glanced into the rear view mirror at the carnage he had caused. He was elated, more alive than he had since his incarceration three years ago.
His carefully crafted plan was working perfectly. By the time investigators discovered it was he that had escaped and not the homicidal patient they had just admitted, he would be well on his way to Greece. Besides, for a while they would be searching for the wrong escaped prisoner. Initially, they would think that he, Dr. Jonathan Anderson, had died in the fire. It would take an autopsy to reveal the fact the dead prisoner in his bed had no soot in his lungs or a scorched larynx. This in itself would not prove it was murder but would rule out the fire and smoke as the cause of death. After all, he had already been smothered by his pillow a few minutes before the fire started. This would be hard to prove, as there would be no evidence as the smothering pillow would have burned along with the rest of the bedding. He hoped the corpse he left would be burned to a crisp. He knew from watching CSI, and television reality cop shows that identifying bodies burned in a fire were initially done by dental records, hence the need for leaving his own set of false teeth inside the dead man's mouth.
Anderson had no next of kin who could be called in to identify the body, that is should there be any recognizable remains. And testimony from the witnesses to his deeds by inmates of the mental ward would be unreliable due to their sedated state of insanity. He had been careful to avoid having his face recorded by the security cameras. Painstakingly he had searched out the location of each one long before his escape. The guard he left behind sleeping on his desk would have been rescued, but would not have been able to identify his assailant, as Anderson had made sure to keep his face behind him during their short struggle. The switching of the armbands and bed assignments would also help in his ruse. There was enough of a resemblance of baldness, body build and facial features to throw off suspicion as well in case he was picked up on a security camera. He remembered the dead patient's dentures in his pocket he had taken from the labeled cup of water beside his bed and planned to throw them from the truck's window when he was sure he was far enough away. Leaving his pair of dentures behind was necessary to facilitate the misidentification and the loss of which was a minor problem, as he knew where his spare set was located. His gums felt raw where he had been unconsciously clenching his jaw in concentration.
He just needed to get to his safety deposit box in the city of Harborside. The bank would open by ten. The bank officer would not recognize him, as he had never actually been there. The account had been opened for him by his accomplices under the name of his new identity. There he would find his passport, a visa, a few thousand dollars of getaway cash, plane tickets to Athens, and other necessities to facilitate his escape. First he would have to ditch this truck than walk a few blocks to where he had left his car in storage. The vehicle storage facility had a keypad lock on the gate of which he had previously memorized the code. The keys to his Mercedes would be found in a magnetic hide-a-key box stashed under the rear bumper by the license plate. There would also be a change of clothes and a packed suitcase inside the trunk. He also would find a wallet with a fake driver's license and credit cards in the glove box.
All of these preparations were surreptitiously made for him by a private investigator he had hired earlier. He had been recommended by his lawyer. The P.I. was known for his discretion and absolute loyalty and was not above doing dirty deeds and keeping secrets for a hefty retainer. He had made several calls lately to the detective, spelling out the details. He had used an untraceable and disposable cell phone secretly brought to him during a visit by his lawyer.
The bulk of his wealth had been placed in an offshore numbered bank account by his well-paid lawyer. It was totally untraceable, and the money thoroughly laundered. He planned to live out the rest of his days on the Mediterranean in relative comfort and anonymity due to his new identity, also set up by the private detective. Upon arrival in Greece, he would find more documents to support his new identity in the house purchased months ago, also prepared for him by his lawyer. Henceforth, he would be known as Theodore Manassas; the name given to a prematurely born infant who had died a few hours after his mother had also died due to complications of childbirth in a Greek hospital shortly after being born almost 59 years ago. The caretaker who was looking after his new house was expecting him, and only knew he was retiring soon in America and planned to relocate to Greece. He would be an expatriate with dual citizenship. Having been raised in Greece, he could blend in easily, and he knew the language and the area well. No relative who knew the former Jonathan Anderson as a youngster was alive to recognize him. He had never attended school in Greece, as his parents moved him to America at an early age.
If his plan were discovered and the detectives somehow found his whereabouts in Greece, he had an exit strategy set which would get him to Brazil where the extradition laws were in his favor, as long as he was able to keep the local government lubricated from his extensive monetary resources.
He hoped that the remains of his surrogate from the mental hospital would be cremated with no funeral, as had been Anderson's expressed wishes in his will. His lawyer would handle these stipulations, and there should be no resistance from the authorities who would be more than happy not to be bothered with his body's disposition. His remaining assets, properties, and bank accounts would be liquidated and dispersed to satisfy creditors, and the rest donated to local charities. These arrangements had also been made long ago with the help of his lawyer, who he trusted explicitly and who would never give him up due to their long relationship and a hefty retainer. Anderson would burn any old forms of I.D. he brought with him to Greece. He even had an appointment scheduled with a shady plastic surgeon that would change his fingerprints and he was even thinking of altering his appearance. A facelift, nose job, and hair implants should do the trick. He would grow a mustache and maybe even a beard. Dr. Jonathan Anderson would soon be no more.
He slowed his speed as he approached an access ramp to the coast highway. He just hoped there wouldn't be any highway patrol on this deserted stretch at this time of night. He needed to ditch this truck as soon as possible. It stuck out like a Rose Parade float, and he needed to be invisible.
* * *
Highway 101 was devoid of traffic on the lonely stretch between San Jose and San Francisco, save for an occasional semi-truck and the lone northbound station wagon. In a few hours, however, early morning traffic would begin clogging the major artery that fed and joined northern California with its southern counterpart like cholesterol plaques in an atherosclerotic vessel.
The occupants of the late-model Buick station wagon were two children and two adults. The children, Laura, seven, and Jimmy, just turned five, were asleep huddled on a worn-out mattress laid over the folded-down back seat amidst an amalgam of household items, toys and clothing. A man, in his thirties, was sleeping in the front seat, his head lolling against the passenger door as he snored softly. The driver looked haggard and drawn; her eyes heavy from lack of sleep. Her husband Jerry had insisted they drive straight through from Dallas to San Francisco, some two thousand miles without stopping except for the necessary but infrequent "pit stops."
"We have to save money Margaret, and freeway motels can be so expensive." Jerry would explain prudently.
Margaret, in her mid-twenties, was nearing the peak of her sleep-deprived endurance level. She could only manage a fretful doze while her husband took his turn at the wheel, a phobic trait acquired in childhood when she had been asleep in the back seat and her parents had crashed their family car head-on into another, leaving her an orphan at the age of twelve. She was never able to forget the terror of awakening to the sound of her mother screaming and the centrifugal force inside the car as it spun and flipped crazily off into oblivion. She still suffered from nightmares, screaming herself awake some nights. She glanced in the rear view and saw the children were restless but asleep.
Luckily, Jerry could sleep through almost anything. Listening to him snore she had to grin at the thought. He probably could even sleep through an earthquake. Shuddering, the image brought her back to reality with a rush.
"They say that San Francisco is due for another big one soon," she muttered under her breath.
She was not sold on the idea of moving out here anyway. With all the freaks, the Goths and degenerates, she thought. All she knew about California came from MTV and movies.
Having been raised on a farm in a small dairy community south of Dallas, she had led a sheltered, cocoon like existence that was difficult to emerge from. She was more than a little apprehensive about living and raising children in this new environment. This trip was the first time she'd ventured more than a day's drive from home. She was already homesick and missed her friends and family.
Jerry, her second husband and the father of Jimmy, had only just recently graduated from night school, and had earned a certificate in computer programming. Lured by the promise of lucrative job opportunities in California in the burgeoning field of software development, he decided to join the mass exodus of technicians from all over the country who were lining up for the jobs. It was a modern gold rush phenomenon. Someone had told him that for every trained computer programmer, there were ten jobs available in portentous-sounding places like Silicon Valley, which offered comparatively staggering salaries. With stars in his eyes, he had begged and pleaded, using every stratagem at his disposal, until he had finally been able to persuade his wife to pull up stakes, leave her elementary-school teaching position, and make this big move.
Margaret opened her blouse a little. Perspiration made her feel drenched to the bone. The air was heavy and sticky. The dank humidity sucked most of the breathable air from the atmosphere, leaving a vacuum like that found in a huge bell jar.
She stuck her face from the window in a futile attempt to refresh herself with the breeze. Instead, a blast of air sucked at her as if she'd opened the door to a long-ago sealed sarcophagus. A thick blanket of marine mist shrouded the freeway surface, obscuring the center divider and making visibility poor. They had been following the California coastline for miles but now were leaning inland to the east and would be in agricultural territory soon. Already homesick, she missed the smell of cattle and freshly plowed earth.
Their headlights lanced through the darkness. The mist separated, allowing the car to move forward and then closing behind it as if blocking all retreat. The road bumps, "Bott's Dots," alerted her if she accidentally drifted too far to the right or left. The monotonous highway, with its bright reflectors and the lack of variety of visual stimulation, had its predictable hypnotic effect. The eerie, lurid glow from the amber sodium streetlights cast an otherworldly spell over the gloomy, desolate surroundings. Moths and beetles circled languidly, Icarus-like, and dove into their artificial replica of the sun again and again before dropping to earth exhausted, scorched, or dead. There were no signs of life save for an occasional desert coyote whose silvery half-dollar-size eyes mirrored her headlights from the clipped hedges along the road amidst the freeway variety ice plant. An occasional rabbit ran across the road only to stop halfway and freeze in the headlights. She would never understand why animals did that, as if they suddenly became hypnotized or blinded. She had lost count of the road kill she had seen.
She peered in her rearview mirror again and saw that Laura and Jimmy were each coiled around their blankets. Jimmy was clutching his teddy bear; thumb stuck securely in his mouth. He is softly snoring. 'Like father like son,' she thought with a grin. Laura was hugging the Raggedy Ann doll she had got from "Shanty Clauth." She had a slight speech impediment. The doctor said it was caused by her enlarged tonsils, which were due to come out as soon as their new health insurance kicked in. She might have to have a speech pathologist work with her afterwards. Her moist blonde curls were matted to her scalp; play makeup was smeared on her face, and her little terry cloth nightdress was all wrinkled and pulled up around her chest.
She feared for her children. They would suffer most from the move. They would miss their "Papa and Nana." Jerry's parents had proved invaluable when she had returned to her teaching job after giving birth both times. They just lived down the street and were always willing to help. That was one of the advantages of living and raising children in a small town.
They would make new friends and acclimate to their new surroundings in time. At least one of her children was preschool aged. She wondered how long before they would lose their Southern accents. It is as if they are moving to a foreign country. She would have to brush up on her Spanish. California schools have a disproportionate mix of races and cultures, and she might even have to teach her classes in English and Spanish.
Margaret returned her gaze to the front. Straining her eyes through the pallid mists, she could barely make out red and blue lights blinking far off in the distance. It sent a shiver of apprehension down her spine. Her arms and legs had goose flesh. As she drew nearer, she slowed even more and dimly noted with mounting curiosity that all the southbound lanes were sealed off, apparently by a police roadblock. Margaret could just make out the "Smokey the Bear" hats on the State Troopers as they signaled with their glow stick flashlights.
The north and southbound lanes were separated by a deep canal. As she passed, she curiously craned her neck to look back over her left shoulder, wondering what might be happening.
When she again turned to face forward, she caught her breath in fear. During her last conscious seconds on earth, her only thought was, Oh my God! There's an airplane; it's trying to land on the freeway! It's going to crash… She screamed in horror as she realized it was headed straight for their car. Jerry awakened by her scream, squinted his eyes at the bright light.
A large, black, amorphous shape is descending toward them. Glaring lights shone inexorably, momentarily blinding them. She helplessly slams on the brakes and instinctively covers her face with her arms. Their car fishtailed and came to a stop, but it is too late. Her screams are drowned out by the deafening sound of metal rending metal.
Time is reduced to an almost trance like slow motion. Her senses are awakened to the point that she is acutely aware of every detail as it happens. What Margaret thought was an airplane is actually a four-wheel drive pickup truck with six halogen lights setting frog-eyed on top of the roll bar. To avoid the roadblock and the pursuing police escort, it left the road on the other side of the freeway at a high rate of speed, veering down the incline of the divider canal and then accelerating up the opposite ramp. It become airborne for the next hundred feet in a high arcing parabola before descending onto the hood and roof of the unfortunate station wagon. The truck's driver, the lone occupant, is catapulted through the windshield, which disintegrates, sending a shower of glass splinters to the pavement.
The weight of the vehicle smashing down on the hood of the station wagon blew out all four tires sideways from below. The truck's cowcatcher grill caused the top of the car to squash down and then shear off backwards, cart wheeling, exploding more glass shards into the air. Their vehicle was bounced into the ditch, and they were engulfed by a cloud of dust and smoke. The occupants of the car were thrown around like rag dolls.
Margaret witnessed out of the corner of her eye Jerry's head very nearly decapitated as he was pitched forward by the momentum only to meet the intractable solid bulk of the scrunched-down metal. Margaret's body was compressed as if trapped inside a giant trash compactor. The steering column speared her chest, and the steering wheel became bent into a sculpture. Her thighs were ground and crushed by the weight of the dashboard. The pain was excruciating, and she was overcome by sudden dizziness. She wanted to scream, but all that came out was a strangled gurgling sound. Mercifully, she lost consciousness.
The two children were miraculously spared serious injury, in spite of not wearing seat belts. They were cushioned by their blankets and pillows against the soft backing of the front seat. They became lodged in the floorboard space. The flying objects, toys, and snacks caused their only injuries as they were hurled at them from behind like missiles. When the vehicles finally came to a rest the children whimpered in terror. They called out for "Mommy," but heard no response.
The night air was still for a few moments as everything settled into a vortex, like the eye of a hurricane. Nothing moved, and only a fathomless, abysmal, echo permeated the silence. Then there began a mournful wailing as sirens competed for dominance, drawing nearer from the distance.
The sleepy emergency room was startled into action by the emergency base station's two-way radio. The shrill squawk had filled the air, awakening the male receptionist who had been dozing at his typewriter, and bringing a gaggle of nurses and orderlies rushing in from all over.
"This is Engine 29. How do you read?" a terse voice had crackled.
"You're 10-2. Go ahead," a sleepy nurse had answered into the microphone on the receiving room desk.
"Roger! We are in route to your facility with five victims of a head-on collision on 101," the paramedic gasped over the loudspeaker to the waiting ears of the huddled ER staff. One of them was furiously writing down every word in a spiral notebook like a court reporter.
"We have one male victim who appears to be in his early fifties. He has a severe head injury, and several abrasions, and lacerations about the head and face. He is unresponsive, but is vitals are stable, with a BP of 140 over 80 and a pulse of 90; respirations are 20. We have an IV started with Ringers Lactate.
Next is a young female, ah . . . about twenty-five, with a probable flail chest injury and possible bilateral femur fractures. Her lower extremities have been splinted with Harris traction. Her BP is 60 over 20 and respirations are wet and fast at about 40; her pulse is weak and variable, averaging around 90. She is in a Mast Suit to prevent shock, and we have an IV with Normal Saline running at full bore.
We have a young male, in his late twenties, with multiple compound fractures involving all four extremities. He has no discernible life signs and is cyanotic, and his pupils are fixed and dilated. He has an obvious head injury, and there appears to be cerebral spinal fluid draining from his mouth, ears, and nose. CPR is in progress. An IV was attempted but unsuccessful due to collapsed veins.
There are two children; one male approximately six years of age and one female, age ten. Both have multiple abrasions and small lacerations. They are conscious but are being treated for shock and possible concussion injury. They are ambulatory and stable. The rescue vehicle will transport them. We will be arriving in three ambulances. Our ETA is about fifteen minutes. Over."
"This is KKXL base station, 10-4. Over," the nurse said into the microphone and released the talk trigger.
Doctor Lewis jolted awake at the din of the base station alarm and sprang from his cot. He often slept in his surgical greens in order to save time. They were wrinkled but otherwise clean. His bare feet found his pair of blood stained tennis shoes that the washing machine couldn't remove, and he threw on a freshly pressed white lab coat to trudge out into the garish fluorescent lights of the ER. Blinking his eyes against the glare, he watched his scrambling ER staff rushing about in preparation for the incoming accident victims. He glanced at the large clock on the wall by the receptionist desk and noted the time at 3:15 in the morning. His heart beat rapidly with anticipation and adrenaline was surging through his stocky five foot nine inch frame. He listened to the reedy voice over the two-way and thought, Why now? This is my last night on ER duty after three uneventful months of treating people with the flu, sewing up small lacerations and splinting fractured extremities.
Most of the time during the day shift, there were plenty of other doctors around to share the responsibility if something serious came in. During the graveyard shift, there was only one doctor to handle any ER cases and "in-house emergencies." The twenty-four hour shifts, every other night were especially fatiguing, but he was getting used to the pace by now.
Mark Lewis, in his penultimate year of a two-year residency at Harborside Memorial Hospital, was gaining confidence and eager to put into practice all he had learned in theory. After ten rigorous years of pre-med, med school, and now internship, he was about to choose a specialty, and fulfill still another two-year residency. Yet nothing he had seen so far had prepared him for the carnage he now faced as the ambulance screeched to a halt outside the ER entrance. His mostly untested ragtag trauma team mobilized into action.
"Give me the paddles," Mark demanded desperately. A nurse handed him two Teflon-coated electrodes, which resembled bicycle handgrips with flat metal plates attached. The assembled staff was all dressed in yellow protective gowns, masks, and face shields.
"Charge it up to 400 watts-per-second," he ordered.
The defibrillating device made a high-pitched whine followed immediately by a low, guttural sound, indicating that its capacitor was fully charged.
"All right, everyone. Clear," he shouted. After making sure he wasn't touching the patient or the gurney himself with his body, he simultaneously pressed the two red buttons on top of each handle while holding the lubricated plates against the patient's left chest. There was a dull Whump.
The gurney shook as if possessed by a demon and the unconscious young woman jerked into the air spasmodically. The lights flickered. A quick glance at the cardiac monitor revealed a change from the previously erratic green line to a steady series of small waves registered by an audible "beep" like a metronome.
"We have a weak sinus rhythm," the intern exhaled, more than a little relieved, not realizing he had been holding his own breath. "What's her pressure now?" He said handing the paddles to a nurse.
"I still can't get a BP, Doctor Lewis," a pretty, freckle-faced nurse reported frantically. She had a clipboard on which she had been writing a succession of descending blood pressure readings.
"Get the Doppler, Stat," he ordered, "and somebody pump up the Mast-Suit. She's undoubtedly in shock from trauma and loss of blood."
Dr. Lewis quickly placed a cold, stethoscope to the patient's chest and listened to the ominous, gurgling death rattle of agonal respiration. In his mind, he could picture the blood-filled bronchi.
"She has rales bilaterally and decreased breath sounds," he announced ominously. "Set up for bilateral chest tube insertions. Meanwhile, I'll attempt to intubate her."
Dr. Lewis gently extended the comatose woman's head, lifting up on her lower jaw with one hand while pushing on her forehead with the other. The woman's mouth hung open grotesquely; a mixture of grease, dirt, and blood was caked on her lips, teeth, and even her tongue. A nurse handed him a thick tube with a gob of lubricant dripping from the tip. With practiced movements, he used the blade of a metal laryngoscope to place the breathing tube past the vocal chords. Leaning in and bending an ear to the opening he listened for the reassuring breath sounds.
A robust respiratory tech attached an ambu bag to the tube and began to bellow air into the woman's oxygen starved lungs. "Got it in on the first try, eh doc?"
Dr. Lewis ignored the innuendo and asked in frustration, "What's keeping X-ray?" He was used to being hassled by the support staff due to his intern status. It was a paradox being a M.D., yet not fully experienced in treating real live patients.
As the moan of an approaching portable X-ray machine drew near, he shouted, "We need a chest X-ray and cross table cervical spine."
"Doctor Lewis! Her abdomen has increased markedly in size since she was brought in," a nurse informed him.
"Set up for peritoneal lavage," Dr. Lewis ordered, anticipating a ruptured spleen or liver causing a bleed into the peritoneal cavity. "Have the lab get over here and draw a type and cross match. We need to get some blood going in fast. Also, somebody draw a blood gas."
Doctor Lewis stalked up and down from patient to patient, shouting orders to the staff like a ship's captain in the heat of battle. The nurses and EMT's rushed about setting up for procedures. One nurse was attempting to place an intracatheter into a small bulging blue vein in the patient's wrist. On the opposite wrist, another nurse attempted to draw a blood gas sample from the pulsating radial artery.
A nurse glanced up from between the young female patient's thighs. She had just inserted a urethral catheter and announced, "There's blood in her urine, Dr. Lewis."
Mark's swarthy complexion drained of color as he realized the full extent of the injuries sustained by this young mother of two children. He was attempting to place a central line into the subclavian vein of her upper chest and was having difficulty due to her low blood pressure and shock that was causing the collapse of most of her blood vessels. An X-ray tech brought a chest film for Mark to see, and he raised it up so the kettle drum-shaped spotlight could illuminate the white and black shadows on the film.
"Looks like both lungs are filled with blood. She has multiple rib fractures," Mark stated matter-of-factly. "The endotracheal tube is down past the carina into the right main-stem bronchus. Pull it back about three centimeters," he snapped to the respiratory technician.
Blood began gurgling into the tube from the lungs, as the technician removed the ambu-bag for a moment so he could pull the stiffened tube out a little, and inserted a vacuum straw to suction the frothy blood.
A young paramedic was standing on a footstool, giving the patient cardiac massage. The patient had a pulse, but it was too weak to sustain life. His two locked arms rhythmically pushed down on his interlaced hands, synchronizing with the forced breathing. His normally pale complexion was now beet red, either from exertion or embarrassment. The patient's exposed perky breasts jiggled with each compression.
"I can feel her ribs cracking every time I press down, Doctor," the young man piped.
They used the defibrillator again, and when the heart began to beat sufficiently on its own, the paramedic was relieved of his CPR efforts.
Mark attempted to feel for the carotid artery on her neck, and felt a spongy, crackling crepitus, like the texture of a beanbag. It was a sign that air was leaking into the loose skin of her chest from a puncture of the lung, most likely caused by a knife-sharp broken rib.
Just then the "on call" general surgeon burst into the trauma unit. He was dressed in a pair of running sweats and a T-shirt with the words "10 K for Breast Cancer" emblazoned across it. He was the local jogging guru, and he and Mark were friends and sometimes ran together. He had been trying to get Mark to commit to the next marathon in San Francisco.
"I came as fast as I could, Mark," he puffed breathlessly, taking in the scene at once with a look of appreciation for the seriousness of the situation.
Mark, more than a little relieved that he had help, rapped, "She has bilateral hemothorax from a flail chest; there is possible internal bleeding into the abdomen, and her femurs are fractured."
Dr. Michaels looked at the chest X-ray while donning a sterile paper gown. A nurse automatically tied it down the back. "Have you done a CT scan?"
"Not yet, she is too unstable," Mark answered.
"First things first. Prep her for bilateral chest tubes," Dr. Michaels ordered. He donned goggles and pulled on a pair of sterile gloves before jumping into the fray. A nurse painted the woman's bare chest an orange color with an antiseptic solution. Mark had already gowned and gloved and was suturing the subclavian vein catheter to her skin, anchoring it, while a nurse hung a bag of blood to the connecting tube.
"Let's start some Dopamine to bring up her blood pressure," Dr. Michaels suggested.
Mark had placed himself on the other side in position to place the left chest tube.
After using sharp scalpels to make identical incisions in the skin between the eleventh and twelfth ribs, they simultaneously stabbed long stillets into her lungs. The blood made a whooshing sound as it drained into two vacuum bottles on either side of the gurney.
"She needs a blood transfusion. We can use the blood in the vacuum bottles for an auto transfusion," Dr. Michaels ordered.
Mark was studying the cardiac monitor and noticed a peculiar waveform. "Her QRS is less than 5 millimeters, and there are a few ectopic beats," he said slowly.
"Right," Dr. Michaels agreed. “And she has pulsus paradoxus. Couple that with the low voltage EKG and the wine bottle shaped heart silhouette on this chest X-ray, and what is your diagnosis doctor?"
"Cardiac Tamponade?" he asked, with some hesitation.
"Go to the head of the class," Dr. Michaels congratulated him. "Evidently this patient has blood pooling in the lining of the heart muscle. Hemopericardium. You don't see this but once or twice in your entire career. Give me a 50cc glass syringe with an 18 gauge spinal needle," he instructed a nurse. He began to palpate the space between the ribs to the left of her sternum. Then, with a sudden movement, he plunged the needle into that location.
"She must have bruised her heart when she was pinned by the steering column." Mark mused. He watched as Dr. Michaels drew 30 ccs of blood into the syringe, relieving the pressure. The heartbeat returned to normal.
Dr. Michaels noted the results of the peritoneal lavage Mark had performed. Blood was filling a vacuum bottle as it was siphoned from the patient's abdominal cavity. "We need to get her to the OR now. I think she's circling the drain, if you get my meaning," Dr. Michaels said.
"The OR crew have been called and are on their way." a matronly white-haired nurse interjected.
"What is their ETA?"
"Twenty minutes give or take."
"We can't wait that long. She won't make it. Come on, Mark. Let's get her in there."
Dr. Michaels was legendary for his flamboyant style. He was not reluctant to attempt the unorthodox if it meant saving a patient's life. He had received invaluable training while serving in a MASH unit as a surgeon during Desert Storm.
Dr. Michaels led a phalanx at the head of the gurney, with Mark at the foot heading down
Publisher: BookRix GmbH & Co. KG
Text: Reggie Ridgway
Images: © yodiyim - Fotolia.com, © Stefan Rajewski - Fotolia.com, © Nick Alexander - Fotolia.com, Coverdesign: Vivian Tan Ai Hua – http://www.facebook.com/aihua.art
Publication Date: 06-04-2014
All Rights Reserved