“BP is tanking! Seventy over forty. We’re losing the radial pulse. Fluids wide open. Squeeze the bags!”
“Where the hell is the surgeon?”
Sterling tried to turn his head, but his body felt like it was made of lead. He recognized the voice shouting orders. It was Sarah.
They burst through a set of double doors into a trauma bay. The air was colder here. He was lifted, rough hands grabbing the sheet under him, and transferred onto a hard trauma table.
“Trauma team to Bay One,” the PA system announced overhead.
A young resident in a white coat rushed over, looking at the monitors. “What do we have? I thought this was a hip consult.”
“Retroperitoneal bleed,” Sarah’s voice cut through the noise. She was at the head of the bed, managing the airway. “Patient is post-op combat injury. Twenty years. Shrapnel migration. He’s hypovolemic. He needs blood, not saline. O-neg. Two units. Stat.”
The resident hesitated, looking at Sarah. “Nurse, we need a CT scan to confirm before we—”
“Look at his belly!” Sarah shouted, grabbing the resident’s hand and forcing it onto Sterling’s distended abdomen. “He’s rigid as a board. If you send him to CT, he dies in the elevator. This is a blowout. You need to clamp the aorta or get him to the OR now.”
“I can’t open him up down here without an attending,” the resident panicked. “Dr. Halloway is still scrubbing out.”
“Then get another attending!” Sarah yelled.
Sterling’s eyes fluttered. He felt cold. So incredibly cold. It felt just like Garmsir. Just like the ditch where he had bled for three hours waiting for the bird.
This is it, he thought. Taken out by a piece of metal twenty years late. In a waiting room in San Diego.
He felt a hand grip his shoulder. A strong, warm hand.
“Mike! Stay with me!” Sarah was leaning over him. She wasn’t looking at the monitors. She was looking right at him. “Do not fade on me, Marine. You did not survive Fallujah to die on my shift.”
“Sarah,” he gasped. “The map…”
“Forget the map. Focus on my voice.”
The monitor began to scream a steady, high-pitched tone.
“V-fib! He’s coding!” the resident yelled. “Charging paddles!”
“No!” Sarah shoved the resident aside. “He has no pressure. There’s nothing to pump. It’s PEA—Pulseless Electrical Activity—from hypovolemia. Start compressions. Push Epi.”
Sarah climbed onto a step stool instantly. She laced her fingers together, positioned herself over Sterling’s massive chest, and began to pump.
One, two, three, four.
“Come on, Mike!” she grunted with the effort. “Fight!”
Sterling floated. He was in a gray hallway. At the end of the hall, he saw faces. He saw Gunny Miller. He saw the boys from 3/5 who hadn’t come home. They were waiting, smoking cigarettes, leaning against a HESCO barrier.
“Not yet, sir,” Miller seemed to say. “She’s not done with you.”
Thump, thump, thump. The force of Sarah’s compressions was brutal. She was cracking ribs. She didn’t care. She was manually forcing his heart to circulate the little blood he had left.
“I need that blood!” Sarah screamed at the nurses running into the room. “Squeeze it in! Pressure bag! Blood is hanging!”
“Dr. Halloway is two minutes out!”
“We don’t have two minutes!” Sarah stopped compressions to check the pulse. Nothing. She looked at the resident. “REBOA. Do we have a REBOA kit?”
The REBOA—Resuscitative Endovascular Balloon Occlusion of the Aorta—was a specialized device. A balloon was threaded up the femoral artery to plug the aorta from the inside, stopping the bleeding below the chest and keeping the blood in the brain and heart. It was advanced, it was risky, and it was usually done by a surgeon.
“I’ve never done one,” the resident admitted, his face pale.
Sarah looked at the crash cart. She looked at the dying Marine on the table. She made a choice that could end her career. A choice that could send her to prison if she failed.
“Open the kit,” she ordered.
“Nurse Jenkins, you can’t…”
“I was FRSS certified in vascular access under fire,” she snapped. “I’ve done three of these in a ditch in Ramadi. Open the damn kit or get out of my way.”
The room went silent. The authority radiating off her was absolute. It was the Angel of Jolan surfacing. The resident opened the kit.
Sarah moved with terrifying speed. She grabbed the ultrasound probe with her left hand, the access needle with her right.
“Compressions, hold,” she barked.
She scanned the right femoral artery. The good leg. Found it. She stuck the needle. Flash of blood. She threaded the wire.
“Catheter.”
The resident handed it to her. She slid the long, slender tube up Sterling’s artery, guiding it blindly by feel and landmarks, visualizing the anatomy in her head. She had to get the balloon high enough to block the blood flow to the hips, but not so high it stopped flow to the kidneys.
“Deploying balloon,” she said calmly. She inflated the device inside Sterling’s aorta.
Everyone stared at the monitor. For ten agonizing seconds, nothing happened. The line remained flat. Then a blip. Then another. The blood pressure, which had been non-existent, suddenly registered.
Sixty over forty. Then eighty over fifty. By plugging the leak, she had forced the remaining blood back to his heart and brain.
“Sinus rhythm,” the resident breathed, looking at Sarah with awe. “We have a pulse.”
Sarah didn’t celebrate. She slumped slightly, sweat dripping from her nose onto her mask. “He’s stable. Get him to the OR. Halloway can fix the tear now that he’s not bleeding out.”
The doors burst open. Dr. Halloway, a tall man with silver hair, rushed in, still tying his surgical mask. He looked at the scene: the crash cart, the blood on the floor, the REBOA catheter sticking out of Sterling’s leg, and Sarah standing there, chest heaving.
“Status?” Halloway demanded.
“Ruptured iliac from shrapnel migration,” the resident reported, his voice shaking. “He coded. Nurse Jenkins… she placed a REBOA. She brought him back.”
Halloway stopped. He looked at the device. He looked at Sarah. He knew Sarah was a good nurse, but he had no idea she even knew what a REBOA was, let alone how to place one in a coding patient.
“You placed this, Sarah?” Halloway asked.
“He was dead, Doctor,” Sarah said, her voice trembling now that the adrenaline was fading. “I didn’t have a choice.”
Halloway checked the monitor. “Placement looks perfect. You saved his life.”
He turned to the team. “Let’s move OR One is ready. We have a window. Let’s not waste it.”
As they wheeled Sterling out, Halloway paused and put a hand on Sarah’s shoulder. “We need to talk about this later,” he said seriously. “But good work, Lieutenant.”
He used her old rank. He knew.
Sarah stood alone in the empty trauma bay. Her hands were covered in Sterling’s blood. She walked over to the sink, turned on the water, and rolled up her sleeves. The water ran red as she scrubbed. She looked at the tattoo on her arm, the map of Fallujah.
“Not today,” she whispered to the skull and spade. “You don’t get him today.”
The Intensive Care Unit at Balboa was a hushed cathedral of technology, a stark contrast to the chaotic noise of the trauma bay. Lieutenant Colonel Mike Sterling woke to the rhythmic whoosh-click of a ventilator, though the tube had already been removed.
His throat felt like he’d swallowed broken glass, and his left side was a heavy, numb block of ice. He blinked, his eyes adjusting to the dim light. A figure was standing at the foot of his bed, reviewing a chart.
It wasn’t Sarah. It was Dr. Halloway.
“Welcome back to the land of the living, Colonel,” Halloway said, his voice low. He looked tired. “You gave us quite a scare.”
Sterling tried to speak, coughed, and accepted the ice chips Halloway offered. “The hip?” he rasped.
“Repaired,” Halloway said. “We removed the shrapnel. It had jagged edges; looked like a piece of an old Soviet artillery shell. It sliced your common iliac artery. You bled out about two liters into your retroperitoneal space. Frankly, Mike, you should be dead.”
Sterling’s memory was a fragmented haze. He remembered the pain. He remembered the waiting room. He remembered Sarah.
“The nurse,” Sterling whispered. “Sarah. She… she was there.”
Halloway’s expression tightened. He closed the chart and pulled a chair close to the bed.
“That’s what we need to talk about. Sarah Jenkins saved your life. There is no ambiguity there. You coded. Your heart stopped. She performed a REBOA procedure. She inserted a balloon into your aorta to stop the bleeding so we could get you to surgery.”
“So? She did her job,” Sterling said, confused by the doctor’s grim tone.
“She did my job, Mike,” Halloway corrected him. “The REBOA is a surgical procedure. It is not within the scope of practice for a civilian nurse at this facility. She isn’t credentialed for it. She didn’t wait for an attending. In the eyes of the hospital administration, she performed an unauthorized, invasive surgery on a high-ranking officer.”
Sterling tried to sit up, but the pain forced him back. “She saved me. If she waited, I’d be in a box. I know that.”
“You know that. But the Hospital Director, Stephen Caldwell, sees it differently. He sees a massive liability lawsuit waiting to happen. If she had perforated your aorta, if you had died, the hospital would have been sued into oblivion for letting a nurse ‘play surgeon’.”
Sterling felt a surge of the old combat rage. “Where is she?”
“She’s been placed on immediate administrative leave,” Halloway sighed. “Pending a review board hearing tomorrow morning. They’re going to fire her, Mike. And they might report her to the State Board of Nursing to have her license stripped. They’re calling it gross negligence and ‘cowboy medicine’.”
“Cowboy medicine?” Sterling growled. “She’s a combat veteran. She learned that in the dirt.”
“Caldwell doesn’t care about what happened in Fallujah. He cares about protocol. And right now, Sarah is standing alone.”
Sterling looked at the IV lines running into his arm. He looked at the window where the San Diego sun was trying to break through the fog. He remembered the tattoo. So Others May Live. She had lived her creed, and now they were crucifying her for it.