Doctor Jack Harris breathed into his cupped hands. The heating in the ER wasn't good enough to overcome the frequent bursts of cold, damp air through the automatic doors, a cold that that cut right through him. He'd only been on this ER rotation for three nights, but the freak winter weather made it feel more like Nova Scotia than the remote coastal town of Duvall, Louisiana. His white coat and scrubs were no match for the brisk wind that froze sheets of ice on the ambulance ramp. Jack rubbed his eyes and took the X-ray films from their sleeve. The small hospital was leaking money so fast that it was just a matter of time before it closed, and the administration had issued new budget cuts that bordered on the absurd. They had taken away the view box in the private dictation room, so he had to get his first look at the films in front of the patient, something he dreaded, since it robbed him of the chance to compose himself if the news was bad. He eased past the curtains around ER Bay 3, snapped the X-rays onto the view box, then looked at the girl. "Is it getting numb yet?" "So what do you care?" She shivered in her wet clothes. He draped a blanket around her shoulders. She'd turned down their offer to change into some dry scrubs. "Why shouldn't I care?" "It's none of your business, that's why." She straightened her back, all attitude. The ER chart said that Shannon Wills was only sixteen, too young to have taken that kind of blow to her face and arm. Jack had already set her broken wrist in a cast. The bruising and cuts looked like someone had wrenched her arm before it broke. He had a feeling that she hadn't fallen down some stairs, the story she'd told the triage nurse. She jerked away when Jack tried to gently examine the laceration over her cheekbone. Overlying the cut were small marks, the kind knuckles might make. He ran his hand through his thick black hair, something he'd done since childhood whenever he was worried. He was only 28 himself, but he just wasn't sure how to reach her. She seemed to be in way over her head. One poorly chosen word, and she'd run. "Your cheekbone isn't broken, but the swelling's bad, and you'll have a nasty bruise. Might take a few weeks for the discoloration to go away." "Weeks?" She strained to see her reflection in the glass cabinet door above the counter. "Am I going to have a scar?" "I don't think so. I can close the skin with some Steri-Strips." "It hurts." "I know, and I'm sorry. You might need something for pain, but I'll have to give the prescription to your parents." "I don't need any pain medicine. Just fix me up, and I'll go." "Is there anyone here with you?" She nervously ransacked her purse, removing her lipstick, then some paper. "I've got money." Jack heard the harsh signal from the emergency radio at the nursing desk. The triage nurse would answer it, but it would be only a matter of moments before she'd call him. "What we talk about is confidential. I'm worried about you. Maybe I can help." "I don't need your help. The bone's not broken. Just fix it so I don't have a scar." The nurse pulled the curtain ajar. "Doctor Harris, there's a call for you." "Ambulance?" "It's the police." He could sense the young girl tensing up, but before he could say anything, the nurse said, "One of the officer's been shot. They're bringing him in a squad car." Jack squeezed the girl's hand. "I'll be right back." He walked the long hall to the nurse's desk. South Bay Hospital had been built just after World War II, hadn't been upgraded in thirty years, and it showed. The University had pulled most of the training programs for residents last year, but they still supplied ER residents, claiming they'd benefit from the experience of working in a rural facility. But everyone knew it was just a way of keeping referrals coming to the main campus in New Orleans, forty-five miles away. The area had been booming when Jack worked the off-shore oil rigs before college, but times had changed. The administration had recently ordered every other ceiling light shut off as a cost-cutting measure, creating an odd mix of chrome and shadows in the ER that did little to inspire Jack, or the patients. Some of the overpasses had begun to ice, a rarity this far south, bringing the stream of patients to a near standstill. The ailments he'd seen so far had been a drunk with a sprained ankle, an old man with a kidney stone, and a nursing home patient with pneumonia who had to be admitted. Simple enough, and what he'd grown to expect, since the paramedics routed serious cases to University Hospital. As he walked to the desk, he was keenly aware of how utterly unprepared this place was for a major emergency. The nurse said, "Both policemen at the same place-must have been something big." "Better call the chopper." A list of things to do ran through his head. If the officer had taken a bad hit, the best Jack could offer was to stabilize him well enough to survive the flight to the University. Jack picked up the maroon phone. "Doctor Harris, here." "Doc, he shot Bobby in the chest. He's not breathing so good." A siren blared out through the static on the line. "Is he conscious?" "Been out about five minutes, but he's still got a pulse." "How far away are you." "Couple of minutes, maybe less." "Can you elevate his legs?" "It's only me, doc, and I'm driving." "Just do the best you can. We'll be ready." Jack hung up and gave orders to the nurse as they cleared the trauma bay. "Get four units of O-negative blood, stat. We'll also need a chest tube, a thoracotomy tray, a central line set up, and a couple of liters of normal saline." The nurse pulled sterilized surgical packs and the other supplies while the unit clerk went to the blood bank. Jack had no sooner finished scrubbing his hands than he heard the siren outside. The glass doors opened, bringing a burst of cold. A policeman ran in, grabbed a gurney, and rushed it out to the parked car. In seconds, he returned with the injured officer. Blood trailed behind them. Jack quickly gowned, gloved, then put on a mask with a clear shield that protected his eyes. Jack said to the nursing aide, "Get some pressure on that chest wound." The officer's entire shirt was saturated with blood. Jack cut the shirt away and quickly realized that both lungs had taken a bullet. The worst was on the left, where blood was oozing fast around the aide's fingers. The nurse handed Jack a stethoscope. There were faint breath sounds on the right, but none on the left. Jack moved to the head of the gurney, saying, "We've got to intubate him." The nurse passed him the scope, and Jack inserted the curved blade into the man's larynx, then slid the hollow plastic endotracheal tube in place. After securing the ET tube, he looked at the officer who'd pushed the gurney, and said, "Bag him at 16 per minute." He listened again, but still heard no breath sounds on the left. Although he considered the possibility that he might have slid the ET tube too deep, sending it into the right bronchial tree alone, a quick check of the markers on the ET tube convinced him otherwise. The reason that there were no breath sounds on the left was because the officer had a pneumothorax. Jack shook his head, and quickly swabbed Betadyne solution over the outer aspect of the man's left chest. The nurse had understood, and was already opening the pack for the chest tube. Jack changed to sterile gloves, and she handed him the heavy gauge tube, through which he slid a metal rod until its beveled tip extended just beyond the tube's edge. There was no time to numb the skin, so he made a quick incision between two ribs. The officer's body jerked away, but Jack and the others were able to hold him down. He then wedged some large forceps into the hole, spreading a path. Jack positioned the sharp rod tip and forced it through the intercostal muscles, in spite of the man's writhing. Removing the rod, he pushed the flexible chest tube into the thoracic cavity, then quickly sewed a series of purse string sutures around it, closing any possible air leak and securing the tube in place. The nurse hooked it up to the water bottle on the floor, then connected the suction tubing to the bottle. Jack listened again, and was now able to detect breath sounds in each lung. He stood back to assess the damage from the bullet wounds. They involved the clavicle area on both sides, so he decided against trying a central IV line in the chest. Instead he worked the man's pants down to the knees, then cut the underwear. Jack wiped Betadyne over the crease at the top of the man's leg, and now, with the pneumothorax corrected, there was time to numb the region with Xylocaine. He then inserted a needle into the femoral vein, slowly aspirating with a syringe until he got a back-rush of dark venous blood. Steadying his hand, he removed the syringe, and threaded a flexible wire through the hollow needle into the femoral vein. Next, he cut a small opening into the skin, then threaded the central IV catheter into the vessel. After securing it with two sutures, he held the end toward the nurse, who connected the normal saline IV fluid, then hung the first bag of blood into a second port of the catheter. The aide holding pressure said, "Doctor, we've got a new problem." Blood was flowing from the crude pressure bandage in the chest, but the left sleeve had finally fallen away, exposing another entry wound in the man's forearm, with blood flowing nonstop. Jack said, "Get me an arterial clamp." He tried to quickly clean the deep gash in the forearm, but the arm jerked erratically. While the nurse helped hold the arm down, Jack injected several regions with Xylocaine, then began to probe the wound with forceps. Although the pumping artery was an obvious target, the complex anatomy made the approach difficult. He had to work carefully around frayed tendons that had been ripped by the bullet, and removed several bone fragments before he could finally get good exposure of the radial artery. He kept his eye on the vessel, and spoke to the nurse. "Clamp." Once he had the delicate tissue isolated, he gently squeezed the handles together, carefully compressing the bleeding end of the artery. "We need an arm board so I can secure this clamp." The nurse sent the clerk to the OR for the needed equipment. In the mean time, Jack palpated the officer's hand down stream from the bullet wound. The skin maintained a decent color and temperature, indicating that blood was still getting there via the ulnar artery on the other side of the forearm. Once the arm board was in place, he wrapped the arm and clamp as best he could, hoping that it would stay secure during the flight. He then motioned for the aide to remove the pressure bandage from the top of the man's chest. Blood flowed again, and bubbled slightly with each breath, which meant there was an air leak that would prevent the chest tube from fully inflating the lung. Jack knew it would take a thoracic surgeon to get to the trouble in the chest. The only thing he could do at this point was to sterilize the area and seal it with a clean pressure bandage. He taped the area as best he could, but he had doubts that it would make a difference. The nurse was able to get another IV in the man's right arm, and a second unit of blood was being infused along with a bag of normal saline by the time the helicopter landed. The flight crew arrived and Jack gave report to the flight doc while the crew helped his nurses inflate a pair of Military Anti-Shock Trousers, designed to progressively shunt blood from the lower extremities to vital organs. Once that was done, they wasted no time in moving the wounded officer. Outside, the police car engine was still running and its blue lights flashed the crew as they crossed the parking lot to the helipad. Jack wondered if the guy would even make it to University Hospital alive. But he knew he'd given the officer a fighting chance, something he didn't have when he'd hit the doors. The rain had stopped, but Jack's skin burned from the raw turbulence of the chopper lifting, the damp February air slicing right to his bones. There was something about the cold that heightened the smell of salt from the Gulf of Mexico. One winter on the oil rigs was enough to last a lifetime. He could still feel the acid burn of salt water on those metal pipes. Ever since, he associated salt air with freezing temperatures no matter how hot it got. Its smell permeated the derricks, the shrimp boats and everything else in this town, and it had an effect on everyone, one way or another. It made some people drink hard, turning their minds to things that most people never contemplate. It just made him feel alone. He'd left the Gulf coast as a teenager when his father moved for work, but returned on his own because he needed money for school, and when the oil market was right, the money flowed with it. When he finally left, he thought it was for good. Now he found himself back where his pain was wide open. And the salt cut as deep as it ever did. Jack walked back into the ER just as the charge nurse came out of the lounge. He checked his watch. "I guess we ought to finish with that young girl before they turn off the rest of the lights." He opened the curtains of the cubicle where he'd last seen her, but she was gone. He looked at the unit clerk and asked, "Where's Miss Wills?" The clerk held up a clipboard. "She left while you were working on that officer." He pulled the curtains back, as if he might find her hiding. "What did she say?" The clerk said, "Didn't say anything. I saw her slip out, but you needed the arm board, so I didn't have time to track her down." Jack ran outside and scanned the dark parking lot, but there was no sign of the girl. He braced against the wind off the Gulf, realizing that in different ways he'd lost each of the last two patients. Shannon Wills was in trouble, and they both knew it, but she didn't have any clue of how to get out. He went back inside, and examined the cubicle again, slowly smoothing the tufts of sheet at the end of the stretcher. There was a clump of debris-a bobby pin, strands of hair, crushed remnants of chocolate, where she'd apparently up-ended her purse on the bed. With them was a folded piece of paper, so thin he could almost see through it. It was a copy of a cover sheet of a medical chart listing in faded print the name, address, phone number, and insurance of Donald Wills. Jack took the form, thinking that the information was probably about the girl's father. At the front desk he flipped through the paperwork on Shannon Wills, and wasn't surprised to note that she'd given a different address and phone number to the admitting clerk, but the insurance numbers were the same. He was about to call her father when his attention was drawn to the other officer sitting on a stool in the trauma bay. Jack had assumed he'd gone with his partner in the ambulance. The man was quiet, almost shell-shocked. He had dark hair with a military cut, and there was still a red impression where his hat had creased his forehead. The tile around him looked like the walls of a slaughter house. His uniform was saturated in deep swaths of his friend's blood. Jack said, "I'm sorry about your partner." He stood. "Will he make it?" "It's going to be close." The officer suddenly seemed to lose his balance, hitting a chrome tray with his flailing arm, then falling back onto the stool. Only the wall prevented him from crashing to the floor. Only then did Jack realize that a hole had been ripped in the uniform near the center of the blood stains on his left upper thigh. Jack ran to him. "Damn it, why didn't you say anything?" He turned and called for the nurse to help him get the officer onto a stretcher. Seeing Jack reach for the scissors, the man held up a hand. "Don't do that." "What's your name?" "Sergeant Gillis. Sam Gillis." "Well, Sergeant Gillis, somehow I've got to look at that thigh wound." The policeman grimaced as he inched out of the dark blue trousers. Jack positioned the surgical light, then put on gloves, sterilized the area, and injected the wound. After it was numb, he gently lifted a bloody flap of skin that was barely tethered. "The bullet tore across your leg at a shallow angle. You were lucky it didn't get your femoral artery. A few inches over and your love life would be history." The nurse had connected an automatic blood pressure cuff, which registered 102/50 with a heart rate of 128. Jack worried about significant blood loss. He said, "Let get a CBC, and Type and Cross him for one unit, just in case." Gillis propped up on his elbows. "I don't need anybody's blood. This thing ain't that bad." "You can pump a couple of liters of blood into your thigh before you know it. The Type and Cross is just for safety." "If I need blood, you call my old lady or my brother. They can donate." "Relax. I promise you won't get any blood without your permission. I think I can get the bullet out and patch you up." "How old are you?" "Twenty-eight." "You sure you're a real doctor?" Jack smiled. "Emory Med School, and I finished there in Internal Medicine before I decided to do a residency in Emergency Medicine. I've technically got only a few months before I'm through." "So you're not really through?" "Actually I finished three years ago. This ER residency is extra." "Just wanted to know, that's all." "If I couldn't handle this bullet wound, I'd send you to New Orleans. If it makes you feel any better, when this place sent people to the University to be sewn up over the last year, they were sending them to someone like me." The officer looked him over, then lay back. "Just watch what you're cutting down there." Jack cleansed the area more thoroughly, then draped a series of sterile towels so that the wound was the only area left uncovered. It didn't take long to clean out the wound and close all the exposed layers. "You're damn lucky." He covered it with a sterile dressing. Jack removed his gloves. "When did you last have a tetanus booster?" "Two months ago. Damn teenager on angel dust bit me in the hand." "We're going to give you a couple of antibiotic shots, and I want you to take some by mouth for ten days. The sutures come out in a week." "When can I work?" "Better take some time at home. It ripped some muscle. Walking won't be too easy for at least a couple of weeks. Let it heal and you shouldn't have any trouble." "We're too short handed. I need to get back to the scene tonight." "Not so fast. I don't even have the results of your blood work yet." "You can go with me. Truth is, we need you anyway." "I don't get it." "Homicide. He was trying to kill Bobby when I got there." "I'm not a coroner." "Man, we've never had a coroner. Old Doc Saban would come out whenever a death looked suspicious and they needed someone 'pronounced' on site. And we need some impartial eyes on this one." "Doctor Saban's still the head of the ER. Call him." "That's going to be a problem." "What do you mean?" "Doc Saban's the one we killed."