Her first thought was that she had to get up. It must be morning. She wasn't sure what she had to do, but she was certain she was late. She started to roll out of bed, only to find that she couldn't move. She was strapped down. And the room was moving—rocking from side to side, bumping up and down. What was going on?
"Just take it easy, miss. Lie back."
The unfamiliar voice didn't reassure her. Just the opposite. She was in some sort of narrow room, and the sound of a siren seemed to be all around her. Where was she? And why couldn't she move? She opened her eyes but the light was dim. Everything was fuzzy, with halos and colored spots making it almost impossible to see anything clearly.
She heard a man's voice, the words faint and echoing as though issuing from a tunnel. "Easy there."
She tried to turn her head but met resistance. A wave of pain drove her back against the bed. What was going on?
"Don't struggle. We have you secured to a stretcher. Your neck's in a collar, in case you hurt it when you fell back on the concrete. Just relax and we'll have you in the Emergency Room in just a few minutes."
She strained to move, but when she flexed her right wrist she felt a sharp prick.
"You have an IV in your arm. Just lie back. We'll be at the hospital soon."
Why was he saying that? What was going on? Another effort to turn her head intensified pain that she thought couldn't get any worse. Her stomach began to churn. She lay back, closed her eyes, and took a deep breath.
"Can you tell us what happened to you?"
The voice was nearer. She opened her eyes, squinted, saw a man bending over her. He was wearing blue coveralls with some type of emblem on the chest. The nameplate over his breast pocket read "Tom."
"Tom." Her voice was raspy. She swallowed and tried again."What happened? Where am I?"
"Hold on. Let me check your vital signs again."
She felt something squeeze her arm to the point of pain, heard a mechanical whir. She bit her lip from the discomfort before the pressure was released with a low hiss. Tom nodded and made a notation on a clipboard he pulled from somewhere behind him. "Okay. Here's what I know. You apparently fell in the parking lot of Metro Labs. Looks like you hit the back of your head. Lost consciousness. One of the technicians stepped outside for a smoke, saw you, and called it in. We just picked you up, and we're headed to the Emergency Room."
"Hey, Tom." A metallic voice came through a speaker above her head. "Baylor's ER says they're swamped. If she's stable, I'm detouring to Parkland."
"Affirmative," Tom replied. "Let's do it."
She squeezed her eyes shut and tried to concentrate. Her head felt as though an air hose was inflating it to three times its normal size. The pain increased with every beat of her heart. When the wail of the siren dipped, she was conscious of a constant roaring in her head. The ambulance—at least, she figured she was in an ambulance—rocked and swayed, bringing with it more nausea. She swallowed hard and willed her stomach to be calm.
Think. Why had she been at that lab—the name had already flown from her thoughts—and why did she fall? As her thoughts went around like a carnival ride, going in a circle with no progress, a more important question intruded. Who was she? AMBULANCE COMING IN, DR. FELL. FEMALE, FOUND UNCONSCIOUS IN A parking lot. Vital signs are stable. The EMT says she's starting to wake up."
Dr. Will Fell looked up long enough from the wound he was suturing to nod at the nurse. Then he bowed over his work, careful to give the same attention to this last stitch as he had to the first one. He could still hear Dr. McIntyre's voice."Resist the temptation to hurry when you're about through. Don't think about the next patient. Think about this one. Every patient should get your full attention until you're finished. That's the only way to practice medicine."
He snipped the ends of the suture and motioned for the aide to apply a bandage. "See that he gets a tetanus shot, wound care instructions, and a follow-up appointment for suture removal in a week to ten days."
Will looked down at the man on the table, a middle-aged Mexican laborer who'd come in with a nasty laceration of his arm from an industrial accident. The man spoke little English, and Will's Spanish was rough, but they'd communicated well enough.
"¿Alguna pregunta? "
The man shook his head. No, no questions. Will figured as much. If the man had any, he probably wouldn't ask them. Keep your head down. Don't call attention to yourself. This was the lesson learned early on. Even if you had your green card, stay away from anyone in authority. Will looked at the technician."Be sure he understands, would you?"
"No problem." The aide reached into a cabinet behind her and pulled out a sheet that contained wound care instructions in both English and Spanish.
Now he could shift his attention to the next patient. As Will stepped into the hall, he began running through a mental checklist of the causes for unconsciousness. Start with the broad categories: traumatic, toxic, metabolic, neurologic, infectious, vascular. Then again, once you broke them down into individual conditions, the number was staggering. In medical school, Will had once competed with several other students to list as many specific causes as possible for unconsciousness. Will had won with two hundred seventy-two.
Well, if she's already regaining consciousness, his job was a bit easier. He'd definitely look for a head injury, probably check some blood chemistries, a toxicology screen, maybe schedule an EEG to see if this was a seizure. Then, like any good diagnostician, he'd see where his findings took him. That's something else Dr. McIntyre instilled in all her residents. For a surgeon, she had a lot of internist in her—always looking deeper into the problem, taking pride in her diagnostic ability. Look closely; don't rush to judgment. He liked what he'd heard her say once. "You're not a technician. You're a doctor. So be a good one. Anyone can learn to cut. A good clinician knows why and when."
Well, Dr. McIntyre, let's see how much I learned from you. Will tapped lightly on the door of Trauma Room Two and pushed through the door. The EMTs were just unloading the patient onto a gurney and giving their report to the nurse. Will took the clipboard from the lead EMT and studied the scribbled notes.
Jane Doe. No ID on her, no purse or wallet at the scene. Vital signs stable. Neuro exam not remarkable—take that with a grain of salt, since a neurological evaluation done in a moving ambulance might not be accurate. The note said there was no odor of alcohol, none of the sweet smell of diabetic ketoacidosis on her breath. Swelling in the occipital region, bruising at the point of the chin, so there was probably some trauma involved. If she'd fallen, that explained the injury to the back of the skull, but why the bruising on the chin? Had she been in a fight? He'd definitely want a CT of the skull.
"Okay, Doc. She's all yours." The EMT turned back to the patient. "Good luck, lady. You're in good hands."
"Thank you," she said.
Will's head snapped up at the sound of that quiet voice. He covered the distance to the gurney in five quick steps, stopping short to look down at the disheveled form of his mentor, Dr. Anna McIntyre. She smiled weakly and said, "Are you a doctor? Can you help me?"
The man looking down at her seemed so young. Was he a doctor? Or was he a nurse or a technician, even an orderly? Had she made a terrible gaffe by calling him "doctor?" No matter. He had a kind face and she sensed somehow that he cared. Maybe he could help.
Was the young man speaking to another doctor in the room? That name sounded so familiar. Even the room looked familiar. Why? What was going on?
"Please, can you help me?" she said again.
The man leaned over her. He was wearing what looked like gray pajamas, covered by a white coat with words embroidered over the breast pocket. She squinted. Will Fell, M.D.
"Dr. McIntyre? Don't you know who I am?"
"I'm sorry. Should I? I mean, I can't even recall my own name, so I guess it's okay that I don't know yours."
He turned and gave orders to the woman beside him. Some of the words made a vague sort of sense, but the memories they triggered seemed as disconnected as the pieces of a jigsaw puzzle just dumped from the box. And when she tried to put them together, all it did was make her headache worse.
The doctor turned back to her. "I'm going to examine you. Just try to relax. First of all, follow my finger with your eyes." As the examination went on, there were times when she seemed to know instinctively what was coming next. Most of the time she was right. What could that mean?
The doctor shoved his stethoscope—she wondered how she knew that was what it was called—into the pocket of his white coat. "We're going to take a bit of blood for some lab work. Then the nurse here is going to take you to X-ray for some studies of your head. After that, I'll be back to talk with you some more."
"But you haven't answered my question. Can you help me?"
"Of course," he said. But she could see the doubt in his eyes.
The voice on the phone was neutral, the greeting brisk. "Dr. Simpson."
"Sir, this is Will Fell. I'm a surgery resident in the Parkland ER."
"Yes, I know. You're the Pit Boss. What do you need?"
Will guessed that when you were the chief of a busy neurosurgical service you didn't spend much time in social niceties or idle chitchat. He swallowed hard, more nervous than he'd ever been while presenting at Grand Rounds. "Sir, I need you down here. We—"
"Whatever this is, why can't one of the neurosurgery residents handle it?"
"Dr. Simpson, I think I need a faculty presence. Dr. Anna McIntyre was just brought in to the ER. She apparently sustained some head trauma and lost consciousness. She's awake now, but she's amnesic—not just for the event, it's global amnesia. She's getting a CT of the head right now. I did a neuro exam, and I think it's normal, but—" "I'm on my way. Meet me in radiology."
Twenty minutes later, Will sat beside Mike Simpson, chairman of the Department of Neurosurgery, watching the man study the images on the computer screen in front of them.
"What do you see?" Simpson asked.
Will squinted, wondering what he'd missed. To him, this was a normal CT of the head. No midline shift, no masses, nothing. What had Simpson seen that he hadn't? "Sorry, sir. It all looks normal to me."
Simpson nodded. "Right. Now why did you get this scan?"
Oh, boy. Will steeled himself for the chewing out that was coming. Every test, especially one with a hefty price tag, required justification. "Well, she had physical evidence of trauma to the head. I wanted to rule out a subdural hematoma. That's a surgical emergency."
"But did she have neurologic signs?"
Will felt drops of sweat coursing between his shoulder blades. "Uh, well, I wasn't sure."
"You're a second-year resident. You've probably done hundreds of neuro exams. What did you think about this one?"
Will squared his shoulders. "I thought it was normal. But this is a faculty member and I thought—"
"You wanted to be sure. And that was a good decision. But did you think her neurologic exam was normal?"
"Uh . . . yes, sir." "Deep tendon reflexes brisk and equal. Pupils reactive to light. No papilledema. Sensation intact. So she was neurologically intact?" Simpson turned from the computer screen and fixed him with cold gray eyes. "But she had amnesia. That's abnormal. It's not a physical sign, but recall that one of the elements—the first element—of a good neurologic is whether the patient is oriented to time, place, and person. She isn't, so her neurologic is abnormal. Never mind her pupillary reactions and deep tendon reflexes. So you were right. You had to get the CT." The faintest hint of a smile flickered on Simpson's lips."Fell, you're a good doctor. Dr. McIntyre told me once she had high expectations for you. When you know you're right, don't back down. But remember one thing. In our profession, good isn't enough. We have to be perfect."
Will nodded. "So you agree she has no evidence of a subdural?"
"Just a concussion."
"And the amnesia? Should I get a psychiatry consult?"
Simpson shook his head. "Transient global amnesia. A rare consequence of head trauma, especially if there's significant associated psychological stress. I'm betting that within the next few hours she'll start remembering things. By tomorrow, maybe the next day, she should be fine."
"Will all her memory come back?"
Simpson shrugged. "Most of it. Generally these patients don't remember anything about the precipitating event. Other than that, yes, it all comes back to them."
"Do you want her hospitalized for observation?" "Admit her to my private service with the diagnosis of head injury, rule out subdural hematoma. Neuro signs every hour. You know the drill. Get an MRI of the head tomorrow to make sure she isn't developing anything else. I'll see her before I leave this evening. If anything comes up before then, page me."