My sincere apologies for the length of time between postings. Life has been incredibly hectic here lately (in a good way though, thankfully). Hopefully things have settled down now and I can concentrate on the story. Cathy.
Chapter 56
"We've got a female, late thirties, early forties, transmediastinal gunshot wound," the emergency room physican said, as they wheeled Cecilia into the examining room of the ER. "Penetration to zone one, single bullet through and through." He quickly assessed her vitals. "Let's get her intubated now people, she's in respiratory distress." He spoke calmly but with urgency.
"Her blood pressure is sixty over forty," one of the nurses was saying, "pulse is weak and thready. There was cardiac inactivity at the scene, and paramedics administered CPR."
"There's an active, external hemmorhage," Dr. Van Dyke observed stonily. "I've got to get this bleeding slowed, or she's going to exsanguinate. Get an IV in." He reached into the wound cavity with his gloved fingers, feeling around. "We may be looking at arterial vascular injury," he noted, continuing to apply direct pressure.
"Someone page Dr. Kasey," he ordered, referring to the hospital's cardiothoracic surgeon. "We're going to have to get her into the OR. Get a room prepped."
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The clear glass doors to the hospital's emergency entrance slid back, and Jim raced to the reception desk, where the triage nurse was taking the temperature of a patient who was filling out her insurance information. His eyes were wild, his features pale.
Fontaine had managed to keep close behind the ambulance, following in Detective O'Reilly's car. Unconsciously, Brass had kept his right foot jammed to the passenger side floor, as though he was pressing down on the gas pedal, urging the vehicle to top speed. He had watched the coloured lights spinning an all too familiar show, and listened to the strident screech of the ambulance's siren, as it weaved through traffic up ahead. All the while he had imagined Cecilia's inert form, strapped to the gurney, while the attendents worked to keep her alive.
"Where's the woman they just brought in?" Jim demanded. "Gunshot victim."
The triage nurse looked up at him uncertainly. There had been an ambulance bring an emergency transport through the side door just moments ago. Before she could reply, the detective was dashing down the corridor, Fontaine hurrying behind.
Brass was stopped at the end of the hall by an orderly who inserted his body between the detective and the doors to the examination room, where there was a flurry of activity within. "Sir, you can't go in there."
Jim looked beyond the other man and though he couldn't see the face of the patient, just the white sheet covering the lower extremities, he knew that it was Cecilia. There was a fair-haired doctor standing over the bed, his white-coated back to the door.
Jim could hear the urgency in the voices within, though he couldn't make out what they were saying. He watched the physician's blood stained, latex gloves flash into view as the man worked to assess and assist his patient. Critical. Jim had heard the paramedics and ambulance attendents make the pronouncement as they had hurried to wheel Cecilia away from Sturney's house.
He had failed her. It should be him, Brass knew, undergoing emergency ministrations. His life in limbo. He was Sturney's final target. He had miscalculated, going off alone to find the killer, falling for Sturney's simple ruse and putting his gun in the hands of a madman. If Jim had only been smart enough to understand Sturney's motivation, if he had only thought before reacting, he might have kept Cecilia safe even still. But Jim had made her a target, through his love and the blinding fear that had gripped him when Sturney had first pointed the Magnum at Cecilia. He had told the killer the best way to destroy him. By hurting her. And Sturney had acted on the knowledge.
Fontaine's hand descended on the detective's shoulder. "I'm sure they'll let us know something when they can," he spoke quietly. "Let's go find a place to sit down."
"I'm not leaving her," Brass replied stubbornly, moving again to push past the orderly, dropping his left shoulder and preparing to barrel his way into the room. He had to be with Cecilia. To hold her hand. To tell her to fight. To let her know how very much he loved and needed her.
The orderly looked past the detective at the taller man, his eyes imploring him for help, even as he spread his feet and secured his stance. "The best thing you can do is give them room and let them help her," he advised.
Seeming not to have heard him, and shrugging off the FBI agent's grasp, Brass heaved forward and the doors swung open into the room. He was immediately struck by the grave, thin-lipped mouths, the shadowed gazes and the intensity of those who worked on Cecilia.
The doctor looked up, frowning. "Get him out of here!" he snapped.
A chestnut-haired nurse called out, "Jim!" then moved around her colleagues and towards the door. She grabbed the detective's right arm firmly with both hands, turning him, and exiting the room. Once outside again, though still clutching him, she assessed his wan features and the anxiety that furrowed his brow. His dark eyes were clouded with worry, and she could smell the fear that oozed from his pores. "Is she a cop?" the nurse asked sympathetically.
Brass just stared at Megan Joyce, seeming not to recognize her for a moment. Then her voice jolted him back to reality. He and Megan had gotten to know one another over the years, when Jim had accompanied a suspect or victim to the ER where Megan was on rotation. Conversations had lead to coffee in the hospital's cafeteria, and they had even gone on a couple of casual dates, to dinner or a movie, before realizing that they didn't have much in common outside of the occasional cross-over of their professions.
It had been more than a year and a half since they had last gone out together as a couple, though they would still have coffee and chat once in a while, when their jobs brought them together. Megan was a good nurse, devoted to her job and her patients. Jim looked at her now, and shook his head in answer to her question.
If the gunshot victim wasn't a fellow cop, clearly she was someone that the detective knew personally. Megan Joyce had never seen Jim Brass looking so devestated. "Someone close to you?" she queried, trying to keep her voice low and soothing, and to keep the detective distracted and out of the way. The next few minutes could be critical, and while she knew her nursing skills might be needed inside the room, she believed that keeping Jim out and letting her colleagues do their jobs, might help the patient even more.
Brass nodded, his throat tight. "She can't die," he whispered hoarsely.
Megan squeezed his arm. "They'll do everything they can," she assured him. "Dr. Van Dyke is one of the best. But he can't be distracted right now, do you understand?" She looked past the detective and called for another nurse, standing down the hall at the nurse's station, to take her place in the exam room.
Brass nodded again, looking defeated, his craggy features crestfallen.
When she felt sure that the detective wasn't going to try to interfere anymore, the nurse let go of his arm, and patted his shoulder sympathetically. "She has a gunshot wound to the upper chest, and there's a hemmorhage that is concerning," Megan Joyce explained. "Dr. Van Dyke suspects arterial vascular damage. They're monitoring her vitals, and they've called in a cardiothoracic surgeon, Dr. Eileen Kasey. Someone will keep you updated, when they're able. What you can do for her now Jim, is pray."
Pray? Jim couldn't remember the last time he had lowered his head to commune with a higher power. He didn't even know if he believed in prayer anymore. Or in God. What kind of difference then, he wondered dully, would his supplications make?
Then a crisis erupted in the room beyond.
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"Doctor, the patient is flatlining," a young, dark-haired nurse informed him
Van Dyke gritted his teeth. "I'm going to have to do an emergency thoracotomy, or we're going to lose her." It was preferable to wait for a specialist, but the physician knew there was no time, if there was going to be any chance of saving the patient's life.
A silver-haired nurse hurried for the implements that would be needed for the procedure, wheeling the cart with the thoracotomy pack next to the bed.
"There's no time for full asepsis," the doctor continued, referring to the practice of fully preparing the skin and surgically draping the patient. The older nurse began a rapid application of skin preparation across Cecilia's upper chest. "Scalpel and forceps!" he called, extending his right hand for the tools.
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Jim heard the shouts in the room beyond, and watched as people scurried about, calling orders and getting equipment. Something had happened. From where he stood, he could see the heart monitor above the bed, and the air in his lungs seemed to freeze as he stared at the thin, unbroken line. Noooo!
Art Fontaine was questioning his wisdom in bringing the detective to the hospital. He had thought it the compassionate, merciful thing to do. He had seen how distraught Brass was, and he knew that Cecilia Laval was in critical condition. Fontaine had figured that had their positions been reversed, he would want to be near the woman he loved. That the waiting and wondering would drive him crazy. But how merciful was it really, to allow Jim Brass to stand helplessly in the hallway just a few feet away, and watch Cecilia die?
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Van Dyke quickly made bilateral cuts in the fifth intercostal space in the mid-axillary line, breaching intercostal muscles and pariatal pleura. Deftly he connected them with a deep incision. A gloved hand reached around with a wad of gauze to absorb the blood that welled from the crimson lines he had carved.
"Scissors!" The physician inserted the first two fingers of his left hand into the incision, holding the lung aside, and then began to cut towards the sternum, through all the layers of the intercostal muscles and pleura. He did the same on the other side of the chest, until there was only a sternal bridge between the two anterolateral thoracotomies.
"Gigli saw," he requested, and someone was passing him the serrated wire that he would use to cut through the hard bone of the sternum.
The intern who had come to assist passed the large forceps under the sternum, while Van Dyke slipped the wire into the incision. The intern clamped one end of the Gigli saw, and then the doctor quickly pulled the other back underneath the sternum. Once the handles were connected, Van Dyke began to cut through the sternum from the inside out, using long, smooth strokes.
"Retractors, please," he asked next. The doctor could feel the perspiration begin to bead his forehead. Even though he knew he was capable of doing the procedure, he couldn't deny the anxiety he was feeling.
Working quietly, they placed the two self-retaining retractors in position, opening them fully to expose Cecilia's chest cavity and to gain access to all areas. Using forceps to tent the pericardiam, and then requesting the scissors again, Van Dyke made a large midline longitudinal incision, careful not to damage the phrenic nerves, running through the lateral walls of the pericardial sac. Those crucial nerves provided motor innervation to the diaphragm, and were responsible for the act of breathing. He knew that if he made the incision too short, however, he would limit his access to the heart.
Van Dyke began evacuating the blood and clotting that surrounded the heart, then began to search for the source of the bleeding. He was not surprised to see that the left subclavian artery had sustained damage, just past the aortic arch, likely from bone fragment that had been decimated by the bullet's passage.
One of three scenarios could happen now, and the physician held his breath. He expelled it thankfully against his mask when the heart began to beat spontaneously accompanied by a return of cardiac output. This was what he had hoped for. If the heart had failed to restart following the thoracotomy, if it had remained in asystole, he would have had to work manually, massaging the heart to get it restarted. Even if it had begun to pump weakly, he would have had to wait to stabilize the patient first before continuing. Now Van Dyke could ligate the artery, tying it off until the patient could be moved to an OR.
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Jim realized that he had lost his ability to gauge time. He couldn't have said accurately whether the emergency procedures taking place in the small room had been going on for hours or only minutes. He had pressed his forehead against the cool glass and stared uncomprehendingly at the activity within.
The silence and lack of motion in the hall outside was glaring in juxtaposition. Brass could feel Megan Joyce's palm, soft against his shoulder, even as the strange sense of disassociation washed over him. He imagined that he was inside the exam room, hovering in the air above Cecilia's pale, prone form, while skilled hands moved over her. Jim almost thought he could smell the overpowering, coppery scent of her rich, crimson blood, which stained not only the physician's hands now, but the sleeves of his white coat as well.
So much blood.
He concentrated on the monitor, willing that flat, blue line to once again register activity. Please, Jim thought plaintively, though it fell short of an actual prayer.
When it began to move again, slowly at first, Cecilia's pulse weak but undeniably there, he closed his eyes and sagged against the wall.
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Dr. Kasey strode into the room then, looking with clinical interest at the woman's cracked chest and exposed heart and lungs. "Good work, Doctor," she complimented behind the green mask, as Van Dyke finished up.
"I need the patient anaesthesized pronto," Van Dyke said tiredly. If the thoracotomy had been successful, the woman could begin to regain consciousness at any time and they needed to get her under. He felt as though he had just run the Boston marathon and was relieved that the surgeon had arrived.
As could often be expected, the return of circulation was accompanied by bleeding from the internal mammary and intercostal vessels. The emergency room physician observed for a moment, then reached in to clamp at two sites with artery forceps.
"She's all yours doctor," Van Dyke nodded to the specialist. He had managed to keep the patient from bleeding out on the table, but her ordeal was far from over, and there were no guarantees that she would survive the OR, let alone the night.
"All right then, let's get her up to the theatre for definitive repair," Dr. Kasey suggested briskly.
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Jim sat on one of the wooden pews, alone in the hospital's chapel. His head rested on his forearms, crossed over the back of the pew in front. When he was growing up, the Brass family never attended church services except on religious holidays. When they did, it was at a Presbyterian church, the denomination his mother had been raised in.
As a child, Jim had enjoyed the smells of wood polish, and candles, and the sounds of the choir. He had accepted, without thinking about it too deeply, that there was God who had created man and the universe, and Jesus, who had died so he could go to heaven one day. But the words of the biblical passages were just words to him, a story not much different than any of the ones his mother would read to him at bedtime.
When he had gotten older, and was in his teens, he had resisted accompanying her even for those few days a year; because he was trying to assert his independence, because church wasn't cool, and because he had come to understand that he no longer blithely accepted a religious perspective of the world. By the time he was an adult, and had come face to face with some of the horrors life had to offer, Jim had decided that faith was just a nice coping mechanism for those who found comfort in it.
Sitting here now though, knowing Cecilia was in surgery, her life in danger, Jim wanted to believe. He wanted to think that somewhere there was an omnipotent being who would not only hear his prayers, but who had the power to answer them. To believe that as bleak as things might look, there would be a miracle. Surely, if anyone was deserving of divine intervention, Cecilia was.
Dr. Van Dyke had washed up and changed and then come out of the exam room to speak with him, while Cecilia had been taken up the OR, under the care now of Dr. Kasey. He had explained the emergency thoracotomy to Jim, who had only understood bits and pieces, but who had nodded as though he was absorbing all of the details.
Dr. Van Dyke had been sympathetic but no nonsense. Cecilia had suffered penetrating neck trauma as a result of the gunshot wound. He had told Jim and Agent Fontaine that vascular trauma was usually present in twenty-five percent of penetrating neck injuries. In some studies, mortality rates approached fifty percent. Jim had clung to those numbers. Fifty-fifty. That didn't sound as bad as he might have imagined. There was a good chance that Cecilia would pull through. She was in good health otherwise, and had received prompt medical attention.
The physician had continued though, and each new bit of information had eroded Jim's hopes. Injuries to the great vessels and pulmonary hila had a somewhat higher mortality rate. And when cardiac arrest occured at the scene, as had happened in Cecilia's case, the chances of survival decreased again. The reality was that she had suffered significant injury to vital structures of the neck, as clinically manifested by the active external hemorrhage from the wound site. The hemorrhage had been a result of arterial vascular injury.
Pointing to his own chest, the physician had told the two men that the subclavian artery was a major artery, located below the clavicle, or collarbone, supplying blood to the head and arms. The left sulbclavian artery, the portion affected in Cecilia's case, extended directly from the arch of the aorta.
Jim had tried to keep up with the explanations and the medical terms. Even more telling than the physician's words though had been the truth in the man's blue-green eyes. It was a very real possibility that despite his heroic intervention, Cecilia might die.
Dr. Van Dyke had explained that in few other regions of the body were there so many vital structures located in so small a volume. What it came down to was that penetrating injuries of the subclavian artery were associated with high morbidity and mortality. Unstable vital signs upon presentation, and wounds resulting from gunshot injuries, greatly increased mortality.
Dr. Van Dyke admitted that the preferred course of action would have been to move Cecilia immediately to an operating theatre where optimal surgical expertise and facilities would increase the chances of success. However, because she had been in cardiac arrest, they had been unable to wait, and an emergency thoracotomy had been his only recourse.
The thoracotomy had extended her life long enough that the cardiothoracic surgeon could now seek to repair the damaged artery. It had given her a chance to survive long enough to be brought to surgery. But that was all. Dr. Van Dyke had excused himself then, promising that Dr. Kasey would speak with them later, following surgery.
Fontaine had brought the wound on the back of the detective's head to Megan Joyce's attention, and she had insisted on having Jim seen by one of the interns. The doctor had informed him that the detective's loss of consciousness following the blow indicated a concussion, and suggested an x-ray, but Jim had shrugged dismissively. He had eventually acquiesced to allowing the man to wash the area and administer several stitches under the nurse's watchful eye.
Brass and Fontaine had retreated to a waiting room, to sit watch until Cecilia was out of the OR. Fontaine had tried to occupy the detective's mind by asking about what had occured at Sturney's, beginning with how Brass had discovered the serial killer's identity. But Jim was both unwilling to be distracted and unable to focus on retelling the events that had preceded the shooting.
Finally, Jim had expressed a desire to find the chapel, and Fontaine had remained in the waiting room, allowing him his privacy.
Clumsily, Jim tried to form the words of a prayer in his head, but everything he could come up with seemed so stilted. He finally satisfied himself with closing his eyes and picturing Cecilia vibrant and alive, curled with him on the leather couch, listening to the secrets of his past and the dreams for his future. He could feel her in his arms, hear the dulcet tones of her voice, and held tight the memory of her incredible beauty and kindness. Jim tried to believe that as long as he held her soul this way in his heart, he could hold her body on earth.
He heard the door open, and the soft shuffle of footsteps on the floor. Another man or woman, seeking mercy for their loved one, Brass thought achingly. Then a weight settled on the pew beside him.
Jim opened his eyes, startled to see Gil Grissom. The scientist looked back at him, his blue eyes veiled. Gil didn't say anything initially, and the two men just sat together in the quiet and solitude.
Eventually, Grissom spoke. "I understand Dr. Kasey is one of the best cardiothoracic surgeons in the state." He watched as the detective nodded dully. Gil shifted on the hard, wooden bench. He had been surprised when Agent Fontaine had told him where Brass had gone. Gil hadn't thought that the cop was the religious kind. He knew though, how in times of crisis, people often sought miracles and put their faith in something they might ordinarily have scorned.
Cecilia Laval's condition was critical, Gil knew. As he sat there next to Jim Brass, he fought back feelings of guilt. When they had finally learned what had happened at Sturney's...who it was who had been killed, and who had been seriously injured...relief had flooded over the criminalist. It had been swift and intense, shifting before long to concern for the writer, but his initial reaction had almost been one of gratitude. He was grateful hat it hadn't been either Catherine Willows or Jim Brass who had died at the hands of the serial killer, or whose survival was precarious.
Not that he was not affected to learn that Cecilia had been shot and critically wounded. Gil had come to like and respect the writer during her time at the lab. He could see that Cecilia and Catherine had developed a real friendship. And he had watched the positive changes in the detective as the other man had pursued a romantic relationship with the novelist. Gil understood that Brass was hurting...terribly. He wanted to do something to ease his friend's pain; to comfort him. But he wasn't sure how to do that.
Brass looked ten years older, Gil thought. The lines that etched his face had deepened, and the skin and flesh itself seemed to sag against the underlying bone and muscle. The detective's dark eyes were haunted. With fear. With regret. With guilt. With an undeniable pain that shone in their depths.
That was the problem with loving people, Gil knew. With letting them close to you. It was true, they could bring you inordinate happiness and give your life an added dimension...a meaning that it might otherwise lack. But at what cost? Too often, those you loved would leave you. Suddenly and without warning. Gil had first learned that truth at the age of nine, when his father had laid down on the sofa for a nap, and never woke up again. The sense of loss and desertion had never entirely left him.
In the course of his profession, that truth was hammered home to the scientist again and again. One moment things were wonderful, you were sharing your life with another person, giving and receiving love...and then all of that could change, often inexplicably and in seconds. A brain aneurysm. A motor vehicle accident. A heart attack. Random violence. No one was safe. And then the grieving were left bereft and alone.
How would it affect Jim Brass if Cecilia Laval died? Gil wondered to himself. What would having loved her end up costing the detective, if he were to lose her now? Jim looked...shattered. What would Brass' life be like if Cecilia didn't make it? Would he face a lifetime of regret and self-castigation? How long before he would be able to find happiness and take pleasure from life again?
Even if the detective's life prior to Cecilia hadn't been perfect...even if there had been times when Gil would hear the sarcasm or the flippancy in the other man's voice and wonder if they masked an emptiness or dissatisfaction...Brass had been getting along okay. Maybe there hadn't been any incredible highs, but there certainly hadn't been such an incredible low either. Jim had a full career and he had people he counted as friends. Maybe Jim Brass hadn't been exactly happy before he met Cecilia. But how unhappy would he be in the years to come, if he lost her?
Gil had no words of wisdom. No faith that everything would be all right. He didn't know how to communicate to the detective that Brass' fear and sorrow were shared now, and that his friend's pain was his own. Gil simply sat silently on the pew next to the detective, sharing his vigil. While somewhere in an operating theatre on a floor above them, it wasn't just one life, but two, the criminalist realized glancing sideways at Jim, that hung in the balance.