OUT OF THE MAINSTREAM

17-CAS

CASUALTIES.

HEADLESS WOMAN PUB,

WASHINGTON DC, 2am

Skinner’s decision was obviously final. It was pointless to argue and Scully was too exhausted to even try. She finally handed him the gun and walked out of the bar. In the glare of the headlights and the garish wash of flashing blue and red from the emergency lamps she made her way through the throng of patrons and bystanders to where the ambulance was parked.

The EMTs were busy working on Pendrall as Scully climbed on board. They had inserted the pharyngeal airway, resecured the oxygen mask, and were now hooking him up the ECG. She glanced up to inspect the IV infusion bags and noted with approval that they’d piggybacked normal saline and sodium bicarb. As she watched, the EMTs double checked the straps and made sure the stretcher was properly locked. One of the men turned to her. "You’re riding with us?" She nodded. "Okay," he said and moved forward to the driver’s seat while his partner closed the doors and then returned to his position beside the stretcher. Scully took a seat.

As they moved off, the driver radioed in: "Despatch, this is Georgetown Two Zero en route. We have a white male, late twenties with a gun shot wound to his right lung. Vital signs to follow."

"Copy, Two Zero. An ER team is standing by. What’s your ETA?"

"Ten minutes."

The second paramedic took the vital signs and recorded them onto his note pad. Scully saw that his name - ‘D. Crocker’ was neatly stencilled across his instrument pouch.

"Dave," the driver called over his shoulder, "talk to me, buddy. Give me the numbers!"

Crocker rattled off the vital signs to his partner, who he called Ken, and the information was relayed to despatch. Crocker had left the BP cuff in place and again checked the blood pressure reading. He frowned, his short-cropped moustache curling a little as he did so. He looked over at Scully, saw for the first time her blood splattered face and the red-stained handkerchief clutched tightly in her hand. She hadn’t indicated to either of them that she was injured at all. "You okay?" he asked her.

"I’m fine." She dismissed the question. "How’s he doing? The BP’s down." She had seen the reading and was aware of the implications. Crocker regarded her with a query. "I’m a doctor," she informed him. He crouched beside her.

"To be honest, not good. He’s still losing blood. Pulse is weak and thready."

Concerned, Scully borrowed the EMT’s stethoscope to listen for herself, and plainly dissatisfied, shook her head. She took Pendrall’s pulse, checked his pupils, felt his face. His heart was racing, his skin was cold and clammy to the touch, and his pallor had turned greyish. He seemed to be slipping in and out of consciousness, not a good sign. Scully already knew Pendrall was in shock but he wasn’t stabilising; he was getting worse.

"We’ve got sinus tachi and the blood pressure is dropping fact," she warned. "He’s in and out. We need to ventilate."

Crocker understood and replaced the oxygen mask with an ambu bag. He pumped the bag measuredly, knowing he would need to do so at a regular rate to assist Pendrall’s respiration, but there were other concerns. "He’s showing signs of peripheral shutdown," he told her.

Scully frowned. These were classic signs of internal haemorrhage. "We’ve got to get a volume expander into him." she explained as she reached for a new cannula from an adjacent tray. "Have you got any plasma?" It was a hopeful question. She wasn’t certain how well equipped these vehicles were. Crocker casually put her in the picture.

"This is the gunshot capital of America, Doc. Fresh frozen coming right up." He swung on his heels to the refrigerator directly behind him.

Scully looked askance at the man, taken by the matter of fact explanation and realised this was commonplace for him. The EMTs were indeed on the front line, facing this level of trauma every day. She wondered how they coped, then understood that she, too, was on a high just trying to deal with this one situation. Even so, her tone was moderate and business-like. "Okay, hang a unit. I’ll get a second line in."

Crocker let her take control, trusting in her obvious ability and very glad of her help. He selected a bag of FFP, readied it and hung it onto one of the fixed roof hooks. Scully got the second line in and inserted the giving-set he handed to her into the indwelling cannula. Crocker carefully checked the drip flow as Scully pumped the set to increase the rate of plasma into the vein. She returned the stethoscope to her ears with her other hand to listen and studied the ECG monitor closely. Her face clearly displayed her worried concern. "He’s weakening," she intone after a while, her voice husky and edged as she pulled the stethoscope to her neck. "We need to intubate now."

The crash kit was already open and Crocker took out the endo-tracheal tube. Scully placed her hand under Pendrall’s neck and pulled to tilt his head back a little so Crocker could withdraw the pharyngeal airway from Pendrall’s mouth in order to guide the ET tube into position down his throat. He did so with practised skill. "Okay, that’s got it," he said and quickly clipped on the ambu bag to resume ventilation. Scully checked the blood pressure and pulse again. Their procedures weren’t working. A pained look flashed across her face.

"We’re losing him," she said desperately. "BP is sixty over twenty, pulse is barely discernible… " her voice trailed off and she wrenched off the stethoscope rather savagely. "He’s going into Vee Eff," she called out. "Defib!"

Ventricular fibrillation and Crocker instantly crabbed forward to the storage cabinets where the defibrillator was kept. He prepped the machine and applied the contact gel. Scully took the paddles from his outstretched hands. "Two hundred watt seconds!" she ordered, and Crocker dialled it up. Like the sound of a very loud photographic flash pack building power the piercing hum grew until the unit finally indicated it was ready. Green light. "Charged."

Scully placed the paddles onto Pendrall’s bare chest. "Clear!" Crocker backed away. Scully hit the contacts and Pandrall arched against the straps. They got two beeps, then a third and fourth, clearly out of rhythm. Suddenly a single high tone.

"Flat line!" Crocker called and turned to his partner. "Ken, tell them we’ve got a code red, cardiac arrest!"

The siren went on. Scully dragged the crash kit to her. "I’ll give him an amp of epi I.V." She prepared the syringe and injected the ampoule of epinephrine into Pendrall’s I.V. line, then recapped it and tossed the empty back into the kit. "Beginning C.P.R." she explained and stood up. Scully struggled out of her overcoat, threw it onto the seat and leaned over Penrdall to start cardiac pulmonary resuscitation. She flattened the heels of her palms over his sternum and pushed down with elbows and wrists: pressure, release, pressure, release -

"One, two, three, four, five," she counted off and after ‘five’ Crocker pumped the bag. They continued like this for some time. The shrill note seemed terribly loud. "He’s not responding," Crocker spoke quickly. Scully knew it already.

"I’ll give him another amp of epi, this time intracardial, and we’ll go again," she called, clearly desperate and breathless from her exertions. This time she stabbed the needle directly into the heart. They resumed C.P.R. as soon as she withdrew and carried on their co-ordinated effort for what seemed like an eternity. Still nothing and Pendrall’s pallor had turned deathly white. Scully refused to give up.

"Come on, Pendrall, don’t you dare die on me!" she growled under her breath. "Come back, damn it!" It was almost as if he had obeyed her. Colour returned to his cheeks. The beeps resumed and Scully was finally rewarded. "We’ve got a rhythm." Her smile was tight nevertheless. A glance at the readout gave her a rush of heightened motivation. "We’re back to Vee Eff. Defib! Three twenty!"

Crocker reset, dialled it up and then continued respiration while the charge built. On the green light the called: "Charged!"

Scully again placed the paddles into position. "Clear!" Crocker let go of the bag and leaned back. Again Scully hit the contacts and Pendrall’s body arched against the straps. The beeps increased.

"Veetach," Crocker intoned, watching the monitor. Ventricular tachycardia - fast, irregular. "Go up to four hundred?"

"No. Again, three twenty."

He checked. "Charged!"

"Clear!" She hit Pendrall once more. Crocker read it aloud. "Sinus tachi, Doc." The cardiac output, although regular, was still fast. Scully dropped the paddles, picked up the stethoscope and checked his blood pressure, aware that the internal haemorrhage was complicating matters. "We’re up. One hundred over sixty. It’ll do." She studied the ECG, and listened intently to his heart, but pleased as she was at the restoration of Pendrall’s heart beat she knew they weren’t out of the woods yet. "What’s the ETA now?"

"Can’t be more than a couple of minutes," he told her, speaking loudly above the siren.

"He’s bleeding through his dressing. He needs another pressure bandage." Suddenly Pendrall began to cough up frothy bright pink sputum into the mask. Aware of the danger Crocker worked efficiently using suction to clear the airway. Pendrall, however, continued to experience difficulties. Crocker didn’t like what he saw and turned to his partner. "Ken, we’ve got a severe internal haemorrhage. Get us there, buddy!"

Scully watched her patient closely. Pendrall’s eyes opened abruptly - he looked frightened. She took his hand to reassure him; his grip was shaky and very weak. Scully leaned closer to touch his face. "Stay with me, Pendrall. Don’t go to sleep," her tone was calming. He seemed to recognise her. "We’re almost at the hospital. Okay? Not long now." She thought she saw him nod as his eyes latched onto hers and she felt him squeeze her hand but his grip remained weak. She had to move a little as Crocker crowded in to attend to the dressing. The siren went off. Scully had to let go of Pendrall’s hand in order to tap his chest with her fingers. It was a dull tone, a definite decreased percussion note to the right chest wall. She suspected a lacerated pulmonary artery, and knew she had to get a drainage tube in and that surgery was needed, but this wasn’t the ideal place. With the vibration and sway of the vehicle it was difficult enough just to stand.

"How long?" she asked anxiously, knowing that time was running out.

Crocker looked out the window. "We’re pulling in now."

As soon as the ambulance stopped moving the doors were thrown open and many hands were reaching in to pull the stretcher from the locking clamps. Scully quickly stepped down onto the ramp.

"This man has a haemo-pneumothorax. He needs an intraplural drain immediately," she tried to inform them above the controlled chaos, but she wasn’t even sure they heard her. Scully suddenly found herself superfluous. The well drilled crash team had taken over completely. As she trailed the stretcher through the corridor she heard Crocker call out the vitals and add: "He went into flat line, but the Doc established sinus tachycardia."

One of the doctors nodded. "Okay, but we’ll check on that. Rick, I want an availability on the ORs, stat. He’s bleeding out. Let’s go people!" The extremely busy group of medics burst their way through the double swing doors and into the ER. A nurse turned and gently put a hand on Scully’s arm to stop her forward progress. "Sorry, ER staff only."

"I’m a doctor, I can help."

She wasn’t impressed. "It’s all right. Look, if we need you I’ll come and get you. Okay?"

Scully was angered by the rebuff and hurt by the rejection but before she could protest the nurse was gone. Finally she stepped up to the double swing doors and hesitated, sorely tempted to push her way in there. ER teams had a certain attitude about them. Mostly adrenalin junkies who thrived on the fatigue and stress, they were sometimes irritating, almost provocative. Yet despite this they were a tight-knit unit who did a good, often thankless job. She had to accept the fact that she would only upset the balance and be in the way, so reluctantly she moved slowly away from the doors.

Scully was sitting down on a bench seat in the corridor when Crocker saw her again. She had retrieved her overcoat from the back of the ambulance and it was slung carelessly over one of the armrests. Her face was stern, tired, worried as she waited for news. Crocker and his partner pushed the stretcher against the wall and while Ken went off to replace the supplies they had used, Crocker stepped up to a nearby vending machine, inserted a couple of coins and made his selection.

The cup filled quickly and he carefully removed it from the receptacle without spilling it. Crocker walked over and paused before her. Scully looked up, registered the fact that he was offering her coffee and took the cup with a half smile. "Thank you." She was touched by his thoughtfulness; he even guessed that she preferred it white.

As she brought the cup to her lips to sample the brew, he took the liberty of sitting down beside her. "That habit the British have of giving strong sweet tea to people in shock?" Scully nodded. "Looks like you could use some." She had to smile, but it soon faded. "I’m okay."

"Good, because the tea in that machine tastes like pencil shavings," he warned. She made a face and indicated the cup. "The coffee isn’t much better." He beamed, and added: "No, but it’s strong and hot and it’ll keep you going." He hadn’t failed to notice that she still had blood staining her fingers. He’d seen for himself that the patient had been more than a colleague.

"You know, they’re doing all they can," he told her quietly. "I know these guys. They’re a good team."

Scully nodded silently, and he emphasised the point. "You did all you could." She pursed her lips. Clearly, to her way of thinking, it hadn’t been enough. He understood that she obviously wanted to be alone, and perhaps he was intruding after all. He got to his feet. "Well, I gotta go. Thanks for your help, Doc." She looked up sharply. "Doc", she had never really like the tag very much. "Dana, it’s Dana Scully," she told him matter-of-factly but not harshly. He took that as a cue to formally introduce himself. "Dave Crocker."

She managed a smile. He stood a moment longer, watching as she fingered the rim of the cup. Coffee wasn’t the only thing she needed right now.

"Dr Scully, you gave him a chance he might not have had otherwise. If he gets through this it’ll be because of you."

She continued to stare off into the distance, and he could tell she had been deeply affected by the incident. He’d seen this reaction before, many times. Even the best of them often took it too hard. You could never find the words to make things right. He knew that from experience. It was usually best to let matters lie. "Take care," he said softly and touched her lightly on the shoulder.

She smiled briefly and shot him a quick glance. "And you." Crocker walked away and left her alone with her thoughts.

Time seemed to drag like a sea anchor. Restlessly Scully got to her feet and began to pace the short stretch of highly polished floor between the bench and the swing doors. Once, at the doors she stopped to try and discern the muffled shouting above the clamour of already raised voices, only to hear the unmistakable sound of the defibrillator recharging. Moments later she saw movement behind the glass, curtains tossed aside, figures in blue, green and white rushing about hurriedly, finally the laden gurney being hauled out, a shock of blonde hair as they pushed the gurney around to head to the OR. Scully couldn’t help the cold, clinical observation that Pendrall was slipping and that they were fighting a losing battle.

The waiting was bad enough. Not doing anything to help was even worse. She felt strangely isolated in the crowded corridor. Despite her qualifications Scully felt out of place here. She had spent so little time attending to the living that all her ‘bedside manner’ had been geared to tend to the dead. The field of her expertise was the autopsy, not surgery. In one week Crocker had more hands-on experience in the relief of human suffering than she did in a year. The dead never complained.

Scully returned to the bench seat. The coffee had gone cold. It didn’t matter. The doors opened, she looked up. A surgeon in green scrubs was pointed in her direction by the nurse Scully had encountered earlier, and he walked purposely toward her. "You’re from the FBI?"

Scully got to her feet and showed him her ID. "Special Agent Dana Scully."

"Dr Robertson. I’m sorry to have to inform you your man didn’t make it." Scully heard the words, each one a painful barb, fired as a bolt. The doctor continued. "He died in surgery from severe blood loss following a pulmonary haemorrhage. That’s a -"

"I know what it is," she spoke out of a fog.

"I’m sorry. We did all we could."

She nodded. "Can I see him?’

Dr Robertson consented and turned to lead the way. They took an elevator one floor up. Scully walked into the OR slowly. Two nurses were cleaning up, behind them the body was covered by a sheet. Dr Robertson eased the sheet back a little and the surgical staff respectfully withdrew. Scully stood beside the operating table.

Would it have made any difference if she had been there? Unencumbered by the airway, Pendrall’s face looked serene and relaxed in death. She drew the sheet further back and cast a professional eye over his torso. They had indeed done all they could. There was a large red mark over the centre of his chest and several needle puncture wounds. When an electrical charge had failed to bring him back they had cracked the chest in order to reach the heart to attempt internal heart massage. There was a neat incision along the midline through the sternum. The incision, still seeping, had been closed. A drainage tube had obviously been inserted, now removed and the wound closed. Several cannulas remained, still taped.

Could she have done any more? Probably not, but the unanswered question would remain to haunt her.

He’d always been there, dependable, ever-willing, youthful and vibrant. Pendrall had reminded her of how things had once been, solid cases, not shadows and phantoms. The real work: scientific investigation, lab work, analysis, experimentation, observation. A link to what it was really all about. Scully touched his cheek tenderly. He was still warm and this upset her even more.

Only an hour ago in the pub he’d insisted on buying her a birthday drink. He had been happy, a little drunk and boisterous, enjoying life. Now, he was gone. She had been aware of his awkward infatuation - the boyish crush - she had never encouraged or acknowledged it. Maybe she should have. A single tear threatened to escape her raw eyes.

"I’m sorry, Pendrall. Forgive me."

Finally she pulled the sheet up to cover his face, yet still she lingered. After a time she moved back from the table, turned and walked away.

As she strode out of the OR Scully couldn’t define her feelings, couldn’t quite accept even now what had happened and made her own way back down to the ‘Emergency’ area burdened by fatigue and grief. She picked up her coat from the seat and while slipping it on tried to focus and think about the things she needed do. However she felt there were procedures to follow, tasks to be done. At the reception desk she asked to use the phone. Just as she picked it up Skinner walked in. flashed his badge at an administrator who challenged him and made his way towards her.

"Any word on Pendrall?" he asked before she could speak. Scully put the phone down gently and cleared her throat, certain her voice would fail her and betray her feelings. "He died ten minutes ago, sir." She had to quickly blink back the tears stinging her left eye.

Skinner’s own eyes narrowed and the muscles of his jaw stood out like a tight rope. He stepped back and ran a knuckle over his top lip, obviously disquieted by the news. Scully walked passed him, out into the empty ambulance bay, a little unwilling to share her sorrow at least for now. It was raining. That was appropriate; she could dampen her tears in the rain. In the glare of the bright ‘Emergency’ light, she turned her head up to allow the fine cold drops to bathe her flushed face. Skinner followed her out and they stood together in the drizzle for a little while, until she half turned to him to acknowledge his unobtrusive support.

"He was a good man." Skinner felt he needed to say something.

She nodded without comment. Scully knew he would be concerned and dismayed by the growing casualty list, but how could she tell him that the list was far longer than he could possibly know. They were all casualties.

--end of file--

C L Goodwin 1998