Excerpt from Critical Care

Chapter One

Don’t die, little girl.

Dr. Logan Caldwell pressed the heel of his hand against Amy Hester’s chest, taking over
heart compressions in a last attempt to save the child ’s life. Her small sternum hollowed and
recoiled under his palm at a rate of one hundred times per minute, the best he could do to mimic
her natural heartbeat. A respiratory therapist forced air into her lungs. Don’t die. Logan glanced
up at the ER resuscitation clock, ticking on without mercy. Twenty-seven minutes since they’d
begun the code. No heartbeat. Not once. Time to quit, but--he turned to his charge nurse, Erin
Quinn, very aware of the insistent wail of sirens in the distance. “Last dose of epi?”

“Three minutes ago.”

“Give another.”

Logan halted compressions, his motionless hand easily spanning the width of the twoyear
old’s chest. He watched until satisfied with the proficiency of the therapist’s ventilations,
then turned back to the cardiac monitor and frowned. Asystole--flat line. Flogging this young
heart with atropine and then repeated doses of epinephrine wasn’t going to do it. A pacemaker,
pointless. She’d been deprived of oxygen far too long before rescue. Logan pushed his palm into
Amy’s sternum again and gritted his teeth against images of a terrified little girl hiding in a toy
cupboard as her daycare burned; and a frantic search in a suffocating clo ud of smoke, amid the
chaos of two dozen other burned and panicking children.

“Epi’s on board, Logan,” Erin reported, sweeping an errant strand of coppery of hair
away from her face. She pressed two fingers against the child’s arm to locate the brachial pulse
and then raised her gaze to his. “You’re generating a good pulse with compressions, but . . .”

But she’s dead. With reluctance, Logan lifted his hand from the child’s chest. He studied
the monitor display and then nodded at the blond nurse standing beside the crash cart. “Run me
rhythm strips in three leads, Sarah.” He drew in a slow breath of air still acrid with the residue of
smoke. Then glanced down at Amy Hester, her cheeks unnaturally rosy from the effects of
carbon monoxide and glossy brown curls splayed against the starched hospital linen. Dainty
purple flower earrings. Blue eyes, glazed and half- lidded, tiny chin, and lips--pink as a
Valentine cupid--pursed around the rigid breathing tube, as if it were a straw in a snack time
juice box. Picture perfect . . . and gone.

He signaled for the ventilations to stop, then checked the code clock again. “Time of
death: nine-forty-seven.”

There was a long stretch of silence and Logan used it to make his exit, turning his back to
avoid another glance at the child on the gurney . . . and the expressions on the faces of his team.
No good came from dwelling on tragedy. He knew that too well. Best to move on with what he
had to do. He’d almost reached the doorway when Erin caught his arm.

“We’ve put Amy’s parents and grandmother in the Quiet Room the way you asked,” she
confirmed, her green eyes conveying empathy for him as well. “And I can send Sarah with you,
if--”

“No. I’ll handle it myself,” Logan said cutting her off. His tone was brusquer than he’d
intended, but he just wanted this over with. “We need Sarah here.” His lips tensed at a child’s
shrill cry in the trauma room beyond, followed by the squawk of the base station radio
announcing an ambulance. “There are at least five more kids coming in from the propane
explosion. We’ll need extra staff to do more than pass out boxes of Kleenex. I want nurses who
know what they’re doing. Get them for me.”

***

Why am I here?

Claire Avery winced as a child’s painful cry echoed up the Sierra Mercy emergency
department corridor and blended with the wail of sirens. Almost an hour after the Little Nugget
Day Care explosion, ambulances still raced in. Fire. Burns. Like my brother. No, please, I can’t
be part of this again.

She leaned against the cool corridor wall, her mouth dry and thoughts stuttering. Being
called to the ER was a mistake. Had to be. The message to meet the director of nursing didn’t
make sense. Claire hadn’t done critical care nursing since Kevin’s death. Couldn’t. She wiped a
clammy palm on her freshly pressed lab coat and stepped away from the wall to peer at the ER.
Then jumped, heart pounding, at the thud of heavy footfalls directly behind her.

She whirled to catch a glimpse of a man barreling toward her with his gaze on the
ambulance entrance some dozen yards away. He looked a few years older than she was, maybe
thirty-five, tall and wide shouldered with curly dark hair, and faded blue scrubs. He leveled a
forbidding scowl at Claire like a weapon, and slowed to a jog before stopping a few paces from
her.

“What are you doing?” he asked, grabbing his stethoscope before it could slide from his
neck.

“I’m . . . waiting,” Claire explained, awkwardly defensive. “I was paged to the ER.”

“Good. Then don’t just stand there holding up the wall. Let’s go. The charge nurse will
show you where to start.”

Start? “But I—” she choked, her confusion complete.

“But what?” He glanced toward sounds at the ambulance bay and then back at her.

Claire cleared her throat. “I don’t know why I’m here.”

He shook his head, his low groan sounding far too much like a smothered curse. “If that
question’s existential, I don’t have time for it. But if you’re here to work, follow me. Erin Quinn
will tell you everything you need to know.” He pointed toward a crew of paramedics racing
through the ambulance doors with a stretcher. A toddler, his tiny terrified face raw and blistered
behind an oxygen mask, sat bolt upright beneath a layer of blue sterile sheets. “See that boy?
That’s why I’m here. So either help me or get out of the way.” He turned and began jogging.

Speechless, Claire stared at the man’s retreating back and the nightmarish scene beyond:
burned child, hustling medics, a flurry of scrubs, and a hysterically screaming parent. Help or get
out of the way? What was she supposed to do with that ultimatum? And what gave this rude man
the right to issue it?

Then, with a rush of relief, Claire spotted the Jamaican nursing director striding toward her.
This awful mistake was about to be cleared up.

“I’m sorry for the delay,” Merlene Hibbert said, her molasses-rich voice breathless. “As you
can imagine there have been many things to attend to.” She slid her tortoiseshell glasses low on
her nose, squinting down the corridor. “I see you already met our Dr. Caldwell.”

Claire’s eyes widened. Logan Caldwell? Sierra Mercy Hospital’s ER director?

Merlene sighed. “I’d planned to introduce you myself. I hope he wasn’t . . . difficult.”

“No, not exactly,” she hedged, refusing to imagine a reason she’d need an introduction. “But
I think there’s been a mistake. He thought I’d been sent down here to work in the ER.” Tell me
he’s mistaken.

“Of course. A natural mistake. He’s expecting two more agency nurses.”

Claire’s knees nearly buckled with relief. “Thank goodness. They need help. I can see that
from here.” She glanced at the ER where patients spilled over onto hallway gurneys. A nurse’s
aide held a sobbing woma n in her arms, her face etched with fatigue. Styrofoam coffee cups,
discarded cardboard splints, and scraps of cut-away clothing littered the floor. All the while, the
distant cries of that poor child continued relentlessly.

“Yes, they do.” Merlene agreed. “And that’s exactly why I called you.”

“But I’ve been at Sierra Mercy only a few months, and my hours are promised to the
education department—to train the students, write policies, and demonstrate new equipment.”
Claire floundered ahead as if grasping for a life preserver. “I’ve interviewed to replace Renee
Baxter as clinical educator. And I haven’t done any critical care nursing in two years, so working
in the ER would be out of the—”

“That’s not why you’re here,” Merlene said, cutting her off. Her dark eyes pinned Claire like
a butterfly specimen on corkboard. “I need you to assess my staff to see how they’re coping
emotionally. I don’t have to tell you this has been one miserable morning.” She studied Claire’s
face and then raised her brows. “You listed that in your résumé. That you’ve been recently
trained in Critical Incident Stress Management?”

CISM? Oh no. She’d forgotten. Why on earth had she included that? “Yes, I’m certified, but
. . .” How could she explain? Merlene had no clue that Claire’s entire future—maybe even her
sanity—depended on never setting foot in an ER again. It was the only answer to the single
prayer she’d clung to since her firefighter brother’s death in a Sacramento trauma room two
years ago. Being helpless to save him left her with crippling doubts, sleep-stealing nightmares,
and . . . Heal my heart. Move me forward. She’d prayed it every day and mapped her future out
meticulously. The move to Placerville, a new hospital, new career path, no going back.
Everything depended on her plan.

Claire brushed away a long strand of her dark hair and forced herself to stand tall, squaring
her shoulders. “I understand what you’re asking. But you should know that I haven’t done any
disaster counseling beyond classroom practice. I’m familiar with the principles, but . . .” What
could she possibly offer these people? “Wouldn’t the chaplain be a better choice?”

“He’s going to be delayed for several hours. Erin Quinn’s my strongest charge nurse, so if
she tells me her ER team is at risk I believe it. They received six children from that explosion at
the day care. Four are in serious condition, and a two-year-old died.” Merlene touched the amber
and silver cross resting at the neckline of her uniform. She continued, frowning. “Dr. Caldwell’s
working them ragged. An agency nurse threatened to walk out. Security’s got their hands full
with the media. . . . You’re all I can offer them right now.”

Me? Claire’s heart pounded in her throat. With every fiber of her being, she wanted to sprint
into the northern California sunshine. Fill her lungs with mountain air, cleanse away the
suffocating scents of fear, pain, and death; keep on running and not look back. It would be so
easy. Except that these were fellow nurses in that ER; she’d walked in their shoes. More than
most people, Claire understood the awful toll this work could take. The staff needed help. How
could she refuse? She took a breath and let it out slowly. “Okay. I’ll do it.”

“Good.” Relief flooded into Merlene’s eyes. She handed Claire a dog-eared sheaf of papers.
“Here’s our hospital policy for staff support interventions. Probably nothing new there.” She
gestured toward her office a few yards away. “Why don’t you sit down and review it for a few
minutes before you go in? You can report to me later after I make my rounds.”

Before Claire could respond, the ambulance bay doors slammed open at the far end of the
corridor. There was an answering thunder of footsteps, rubber-soled shoes squeaking across the
faded vinyl flooring.

Logan Caldwell reappeared, shoving past a clutch of reporters to direct incoming
paramedics. He raked his fingers through his hair and bellowed orders. “Faster! Get that stretcher
moving. Give me something to work with, guys. And you—yeah, you buddy—get the camera
out of my face! Who let you in here?” The ER director whirled, stethoscope swinging across his
broad chest, to shout at a tall, red-haired nurse who’d appeared at the entrance to the ER. “Where
are those extra nurses, Erin? Call the evening crew in early; a double shift won’t kill anyone.
We’re working a disaster case here. Get me some decent staff!”

Decent? Claire gritted her teeth. Though she still hadn’t officially met him, there was no
doubt in her mind that Logan Caldwell deserved his notorious reputation. Dr. McSnarly, the
nickname fit like a surgical glove. Thank heaven she didn’t have to actually work with him—the
man looked like he ate chaos for breakfast.

Claire turned to Merlene. “I’ll do the best I can,” she said, then drew a self-protective line.
“But only for today. Just until the chaplain comes.”

“Of course. Very short-term.” Merlene began walking away and then stopped to glance over
her shoulder. “Oh, a word of caution: Dr. Caldwell hates the idea of counseling. I’d watch my
back if I were you.”

***

Claire hesitated outside the doors to the emergency department. She’d reviewed the
summary of steps for an initial critical stress intervention and was as ready as she’d ever be.
Considering she’d never done any peer counseling before. I’m a fraud. Why am I here?

She shut her eyes for a moment, hearing the din of the department beyond. It had been
stupid to put the CISM training on her résumé. She’d taken the course last fall and participated
reluctantly in the mock crisis situations, mostly because it would look impressive on her
application for the clinical educator position. But afterward Claire knew that she could never
volunteer as a peer counselor. Never. It felt too personal, too painful.

Healing the Healers, they called it, the basis for the work of vo lunteer teams that waded into
horror zones after events like 9/11, the killer tsunami, and the devastating aftermath of Hurricane
Katrina. And a Sacramento, California, trauma room after a warehouse fire that killed seven
firefighters.

Claire fought the memories. Yes, the counseling teams made sure that caregivers took care
of themselves too, assessing them for burnout and signs of post-traumatic stress. Like difficulty
making decisions, sleeplessness, nightmares, and relationship failures. Claire knew the
symptoms only too well. She’d struggled with most of them herself these past two years, exactly
the reason she’d run away from that Sacramento hospital—after refusing its offer of stress
counseling—and never looked back.

But here she was at another ER door, peeking inside through a narrow panel of bulletproof
glass. And now she was responsible for helping these people deal with everything she was trying
so hard to forget, and expected to offer the kind of counseling she’d never accepted herself.
Beyond ironic—impossible and completely at odds with her plan.

Claire raised her palm and pushed the door inward.

Heal my heart and move me forward. She’d prayed it every single day.

So why was her life slamming into reverse?

The essence of Sierra Mercy ER hit Claire’s senses like an assault. Sounds: anxious chatter,
a burst from the overhead PA speakers, beeping of electronic monitors, inconsolable crying, and
painful screams. Smells: nervous perspiration, stale coffee, surgical soap, bandaging adhesive,
the scorched scent of sterile surgical packs—and of burned hair and flesh.

No, no. Claire’s stomach lurched as she clutched her briefcase like a shield and scanned the
crowded room for the charge nurse. The redhead. Find Erin Quinn. Concentrate on that.

She took a slow breath and walked farther into the room, searching among the eddy of staff
in multicolored scrubs—technicians, nurses, and registration clerks. She forced herself to note
the glassed-in Code Room, a small central nurses’ station and its large dry-erase assignment
board, the semicircular arrangement of curtained exam cubicles with wall-mounted equipment at
the head of each gurney, and huge surgical exam lights overhead.

Claire tried to avoid the anxious faces of the family members huddled close to the tiny
victims. Because she knew intimately how much they were suffering. No, much worse than that.
I feel it. I still feel it.

When she’d agreed to do this for Merlene, she’d hoped this smaller ER, miles from the
Sacramento trauma center and two years later, would be somehow different, but nothing had
changed. Especially how it made Claire feel, the same way it had in those weeks after Kevin’s
death. Unsure of herself for the first time in her nursing career, she’d been antsy, queasy, and
clammy with doubt. Dreading the wail of approaching sirens and jumping at each squawk of the
emergency radio. No matter how hard she tried, she couldn’t shake the irrational certainty that
the very next ambulance stretcher would be carrying someone she loved, someone she’d be
unable to save, and . . .

A cry in the distance made Claire turn. Her breath caught as the young charge nurse opened
a curtain shielding a gurney. A child, maybe three years old, rested upright in a nest of blue
sterile sheets, tufts of his wispy blond hair blackened at the tips, some missing in spots, reddened
scalp glistening with blisters. One eye had swollen closed, and his nose was skewed a little to
one side by the clear plastic tape securing a bandage to his cheek. The other blue eye blinked
slowly as if mesmerized by the drip chamber of the IV setup taped to his arm. An oxygen
cannula stretched across his puffy, tear-streaked face.

Beside him, a stainless steel basin, bottles of sterile saline, and stacks of gauze squares sat
assembled on a draped table. Burn care: control pain, cool the burn to stop it from going deeper,
monitor for dehydration, and prevent tetanus and infection. All the bases covered. Unless the
burns are horrific and complicated, like Kevin’s. Unless there is profound shock, heart failure,
and . . . No, don’t think of it.

Claire exhaled, watching as Erin Quinn, pressed the button on a blood pressure monitor and
efficiently readjusted the finger probe measuring the child’s lung status. She made a note on a
flow chart and moved back to the bedside as the child stirred and cried out.

“Mommy?”

“Mom’s getting a bandage on her leg, Jamie, remember?” she explained gently, then caught
sight of Claire and acknowledged her with a wave. She called to another nurse across the room.
“Sarah, can you finish the ointment on Jamie’s scalp? watch him for few minutes?” After giving
a brief report to the petite blonde nurse, she crossed to where Claire stood.

“Good, you found me,” Erin said, noting Claire’s name badge and offering a firm
handshake. Strands of coppery hair had escaped from her ponytail, and her blue scrubs were
splotched with snowy white burn ointment. She nodded as Claire glanced once more at the
injured boy. “Second-degree burns. No explosion trauma, otherwise he’d be on a chopper ride to
Sacramento. But Jamie’s got asthma, and the smoke stirred things up. So . . .”

“He needs close observation,” Claire finished. “I understand.”

Erin smiled. “Hey, I really appreciate your coming here. We’ve had a horrible shift, and my
staff are workhorses, but the Hester child was a real heartbreaker. We worked a long time to save
her, but it didn’t happen. And only last weekend we had the first drowning of the season. Junior
high boy fishing on the river. Overall my crew seems to be coping fairly well, but today
might be that last straw, you know? So I have a couple of issues I’d like to discuss with you. I
can spare about ten minutes to fill you in. Will that be enough to get you started?”

“Yes . . . okay.” Claire tried to recall the details of her review. How much could she offer
here? One person couldn’t do more than a brief assessment and let the staff know more
assistance was available. At least she’d found the self- help pamphlets. “But first I should tell you
that I left a message for the hospital social worker because if an actual debriefing is needed, then
a mental health professional is required. That’s policy.” She swallowed, hoping she sounded
more confident than she felt. “The debriefing should be done tomorrow or the next day.”

“What?” Erin shot her a look that clearly implied Claire was the one who needed mental
help. “Tomorrow? I called you here because we need help now. Didn’t Merlene tell you that?”
She pressed her fist to her lips. “Look, I’ve had a lab tech faint, the media’s harassing family
members in the waiting room, and an agency nurse threatened to walk out. Walk out, when I’m
short-staffed already! I’m sorry if I seem testy, but I’m responsible for the quality of nursing care
here. My team needs help, and I’ll do everything it takes to make that happen. Merlene told me
you were a trained peer counselor. Aren’t you?”

She hated herself. Erin Quinn was right. Claire needed to do whatever she could for these
people. Somehow. She reached into her briefcase and grabbed a sheaf of glossy pamphlets. “Yes,
I’ve been trained. And I can start an initial assessment, get things going in the process. I promise
I’ll do as much as I can to help, and . . .” Her voice faltered as heavy footsteps came to a stop
behind her. She fought an unnerving sense of déjà vu and impending doom.

“Help?” A man’s voice, thick with sarcasm, prodded her back like the devil’s pitchfork.

“I’d watch my back if I were you.”

Claire turned, several pamphlets slipping from her fingers.

It was time to officially meet the newest threat to her plan, Dr. Logan Caldwell.

Please watch for the release of CRITICAL CARE in bookstores nationwide June 2009.