LITMIR.BIZ

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to catch her breath, grind her teeth. Every shouted word was lancing a hot arrow into her chest and abdomen.

      “Stop!” He did, still heaving with racking coughs. She forced more directions out. “Just one more step and you’ll hit the edge of the sidewalk—yes, you’re there. It’s high, more than a foot. Yes, yes—now four of your paces and you’ll come off it. No—watch it!” He stumbled off the sidewalk and fright forced the air out of her. He straightened, his body language hesitant and anxious as she gasped for oxygen, fighting against the mounting pain. She failed in both but still shouted, “It’s all clear to where I’m standing. Just follow my voice.”

      In twenty seconds he’d stumbled to her and she took some of the woman’s weight off him, directing him until they had her on the stretcher. She harnessed her in, then turned to him.

      His face was drenched in tears, his nostrils flaring convulsively, his eyes spasmed shut as tears gushed down his cheeks and off his hard jaw. Every inhalation shrieked in, and came out in frightening barks of abrasive coughing. She pushed him through the doorway leading to the driver’s compartment and shoved him down in the passenger seat.

      Rushing back to the patient compartment, she snatched a look at the mayhem outside. The man Armando had roused had stumbled out of danger. The other casualty, whom he’d managed to drag aside, hadn’t. She had to rush to him.

      She kneeled by their casualty, prying off the rebreather mask Armando had placed on her face. It would protect her against the tear gas.

      Armando’s labored words carried to her, and a jolt of horror paralyzed her in mid-motion. “He’s…dead. Rubber bullet…through the…eye.”

      She knew so-called ‘safe’ rubber bullets could cause considerable damage, according to the distance they were fired from and the area of the body they hit. She hadn’t known they could kill.

      Now she knew.

      Urgency bubbled over inside her. Help those you can.

      She reached for Armando, shook him. “Keys, Salazar.”

      He only pointed to his right back pocket, almost coughing his lungs out again. Moving his convulsing, massive body was almost impossible. She was pummeling him in frustration by the time she had him supine over both driver and passenger seats. Now to fish the keys out. Her fingers felt like wet spaghetti and his jeans—were they painted on or what?

       Get those keys. No time to think where you’re shoving your hands.

      At last she succeeded. Too late. The mob’s sentinels had reached them. One pulled the driver’s door open, jumped in, shouting in Spanish at her. A blind need to protect surged inside her, blanking out the pain. She leapt over Armando, rammed the man back, snatched the door from him, slammed it shut and central-locked the van.

      Time slowed. Her mind raced. Everything was suddenly in pinpoint focus, one thing filling her awareness.

       Get Armando and the woman out of here.

      In a vacuum of calm, she shoved Armando back in his seat, jumped into the driver’s seat, fired the engine and put the van in motion, showing the mob who were now battering it with their fists and ramming it with their bodies that she wasn’t about to let them stop her or enter it, yet still managing to give them enough time to move out of her way.

      It was street after street of that. Suspended in reaction, she drove on and on until her path cleared. Then she floored the pedal. Armando’s choking curses rose as his unrestrained body bounced off hers then slammed against the door with every violent pitch. Strange—her mind didn’t register that she was driving roughly. Then his harsh wheeze filtered to her above the screaming engine noise. “Stop. Far enough…”

      How he knew that with his eyes closed, she didn’t know. She had no idea where they were. All around were the rolling plains of the magnificent pampas, only a few cars on the horizon of the near-deserted road.

      She slowed down, pulled up off the road, eyes flying to the clock.

      Unbelievable.

      Only thirty-five minutes. From the moment her cab had refused to go any further when the riot alert had broken out, leaving her to reach her destination on foot, and she had gotten mixed up in all that.

      She turned to Armando. His coughing was abating, but his lips were blue with oxygen deprivation and his eyes were still spasmed, tears still pouring.

      “Water…in…the back…”

      She understood. To counteract the effects of tear-gas after removal from exposure, eyes, nose and mouth had to be copiously irrigated with water or saline. In seconds she returned with four bottles. He made an urgent gesture demanding she hand them over.

      “Shouldn’t you be breathing easier by now? Maybe a bronchodilator…”

      He twisted a bottle open, choked, “See to…our casualty…”

      He was right. Simple triage made their casualty the priority. She left him rinsing his eyes and went to the unconscious woman.

      Laura snatched a look at the woman as she turned on the suction/aspiration and wall-mounted oxygen outlets, snapped on gloves and chanted under her breath, “A, B, C, D, E.”

      As a surgeon, she usually didn’t get to handle the ABCDs of emergency resuscitation, but they’d been so deeply ingrained in her during her early training, they were second nature. Mentally ticking off the procedures, she simultaneously and seamlessly implemented them.

      Thrust jaw above hard collar to overcome upper airway obstruction. Suction excess secretions in trachea. Gather equipment for intubation. Ventilate with one hundred per cent oxygen. Assemble laryngoscope, lubricate cuffed endotracheal tube, cut tape, ready clamp, syringe, flexible introducer and forceps. No need for induction anesthesia since the patient was already unconscious. No gag reflex. No need for local either.

      In seconds she had the woman intubated, the tube connected to the bag-valve combination and was ventilating with oxygen. She looked at the chest. No improvement in air entry. She reassessed her measures, made sure the ET tube was in place in the trachea. It was. Airway secure but breathing not any better; shallow, strident 55 prm.

      Exposing her patient’s chest, she saw the tell-tale paradoxical movement of her ribs, a segment moving in while the rest moved out with breathing. Flail chest—ribs broken in a row and moving independently of the rest of the chest wall.

      Stethoscope already drawn, she gave the chest a listen. Normal breath sounds on the right side, none on the left. On percussion, stony dullness at the base of the lung. Hemothorax. But the trachea was deviated. Probably hemopneumothorax—both blood and air gathering around the left lung, collapsing it and interfering with the right lung and heart function. Fatal if the building air and blood weren’t evacuated—fast.

      She picked an angiocath to perform a needle thoracostomy, slipping it between the ribs and into the pleural space. She heard the distinctive rush of air in relief, then placed a one-way valve on the end of the angiocath to prevent air re-entry. Immediately, there was an improvement in air entry, if not in breath rate.

      Check circulation. Pulse 180—ectopics all over the place. Blood pressure 80 over 50—hemothorax must be massive. Going into shock.

      She exposed the woman’s arms, snapped tourniquets on both and inserted two wide-bore 14-gauge IV cannulae. The woman moaned in protest around her tube.

      “Sorry I had to prick both arms!” She released the tourniquets, hung two Ringer lactate solution bags from the IV holder, connected their tubing to the lines in the arms, set the drip to maximum, then swooped for tube thoracostomy instruments to drain off the blood. First, local anesthesia.

      “This sting you’ll thank me for,” she said soothingly as she injected the local anesthetic and disinfected the area until it took effect.

      “I doubt she…understands a word of English—if she can hear you at all…”

      Laura

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