CHAPTER 8

           It is the obligation of the family, not the government, to provide for those who cannot provide for themselves.

        —LANCASTER R. HILL, 100 Neighbors, SAWYER RIVER BOOKS, 1939, P. 167

For Lou, filthy and soaked, the scene was surreal.

Cap was moaning piteously. The jagged mid-shaft of his right femur, surrounded by spaghetti-like strands of muscle, protruded garishly from a four-inch gash—easily the worst compound fracture Lou had ever seen. A tree? A boulder? Whatever caused the break really didn’t matter. The femur was perhaps the strongest bone in the body, and the force that shattered it had to have been enormous. The leg, itself, was shortened and rotated.

Lou knelt beside the man more responsible for his recovery than anyone else beside himself. The two-inch laceration above his right brow was bleeding briskly, blood pooling in his eye socket and running down the center and side of his face. There were no other obvious injuries. Lou felt sick—nauseous and shaky. But he knew what he had to do.

Process.

At the center of treating multiple people with trauma, or one person with any number of injuries, was process—the step-by-step approach to evaluation, triage, and treatment. That this was his best friend and a virtual saint to all who knew him needed somehow to be put aside. Whatever had to be done to save his life, however dangerous or painful, had to be done.

As Lou checked Cap’s mouth, tongue, and airway, he flashed on a story the man had shared from when he was in his early teens and a group of thugs, all older than he was, kept beating and harassing him. In that neighborhood, there was never any way to avoid them. No place to hide for long. Cap’s solution was, no matter how bad the pummeling, to never let any of them know he was hurt. Before long, they lost interest and left him alone. Cap Duncan was tough then, and he had grown even tougher over the years.

Heart rate one hundred ten. Rib cage and sternum intact to palpation. Carotid, radial, and left femoral pulses all present, although not very strong. The right groin, where the femoral pulse could usually be felt, was already swelling, probably from blood working up from the fracture site.

Airway, breathing, and circulation. All check.

He gingerly worked Cap’s backpack off and opened it on the ground next to his. The man’s muted cries echoed forlornly off the trees, and momentarily reminded Lou of the remoteness of their location.

Stay focused!

Neck seems uninjured.

Just in case, Lou used one of the ACE bandages and an empty backpack to improvise a stabilizing cervical collar.

Time to stop the bleeding.

“Cap, it’s me. It’s Lou. Hang in there, buddy. Hang in. I’m going to press on your forehead. Here, squeeze my hand if you can hear me.… Cap?”

Lou took half the gauze pads to wipe the blood out of Cap’s eye and off much of his face. Then he used the same gauze to apply heavy pressure to the laceration.

“Cap, it’s me. It’s Lou. Squeeze my hand if you can hear me.” Perhaps a flicker. “That’s it, buddy. Squeeze again.”

Lou kept up a steady stream of patter as he maintained pressure with his right hand. With his left, he soaked another gauze square with water from his backpack and wiped Cap’s face clean. Comfort. Every bit of comfort he could produce for the patient and the doctor was a help. He worked some water between Cap’s lips and then squeezed a few drops into his mouth. Cap swallowed. As Lou moved through the process he had mastered over the years of training and ER work, the need to extend his examination and to improvise treatment became increasingly important.

“That’s it, big guy. Hang on. Just hang on.”

The forehead hemorrhage had largely abated. Lou set a square of hi-tech hemostatic bandage over the laceration. There would be time for a dressing later. Another small squeeze of water between Cap’s lips. Again, he swallowed.

Pulses slightly stronger. Abdomen non-tender and flat. Arms and hands intact.

“Cap, it’s me, Lou. Open your eyes if you can. You’re doing better. Better and better and better.”

The leg was truly scary. Obscene to many. To a seasoned ER doc, it was just dangerous. The heavily muscled thigh was capable of holding literally quarts of blood—more than enough for someone to bleed out. The pain and internal bleeding had Cap hovering near shock. Lou had decided not to risk missing something potentially lethal by getting immersed too soon in the most obvious, spectacular injury. Now it was time to get to work on that.

He glanced back the way he’d come, wondering if he could possibly climb back up the cliff face to the trail. No chance. Besides, leaving Cap alone was something he could only bring himself to do after all other options had evaporated. For a half minute, while he collected his thoughts about the leg, he tried hollering for help. His cries were instantly swallowed by the dense forest. What about the river? If he could get Cap down there, perhaps he could fashion some sort of raft. But the woods were still shrouded in mist, and he could not even see the river from where they were.

Focus, Welcome. Focus!

The bleeding from the mid-shaft was continuing, and, if anything, seemed to be worsening. Lou checked for pulses behind each ankle and on the top of each foot. Left side, no problem. Right side, none. The femoral artery had almost certainly been torn. Big trouble.

It was then Lou realized Cap’s groans had stopped entirely. Again he went through the process—the A, B, Cs.

Pulse rate one fifteen. Pulse strength down from four to three on a ten scale.

“Come on, pal! Stay with me. Stay with me.”

Time was becoming even more of an enemy. He had to put on a tourniquet near the groin. Cap was still moving air effectively. His pupils were midsize and equal. Was there hemorrhage between his skull and brain? It didn’t look like it, but if there was, Lou knew there was little he could do about it. It had to be first things first. He had to continue to stem the blood loss.

“Cap, it’s Lou. I’m here.”

The moaning began again—barely audible, then louder. Lou got to work on the fractured leg.

“Cap, you’re bleeding badly,” he said, uncertain if his words were registering. “I’m going to have to apply a tourniquet to stop the bleeding. It’s going to hurt. I need you to brace yourself. I’ve got to move your leg.”

From within his pack he removed the nylon rope and his Spyderco knife. He measured off an arm’s length of cord and was readying to cut it off when something made him stop.

Again, the process. He had to remain focused, but at the same time stay cognizant of what might lie ahead.

If things went as he hoped, the rope and the other ACE bandages would be needed intact for something else entirely—getting out. Setting the cord aside, he pulled off his sodden shirt and, using the knife, cut and tore off two strips. Next, as gingerly as he could manage, he knotted them together, slid them around Cap’s thigh inches below the groin, and tied the ends tightly at the skin.

At the first movement of his leg, Cap screamed. Then he screamed again, and thrashed his head from side to side as much as the makeshift collar would allow.

Lou hated the way his friend came to, but was ecstatic that he had. The odds of pulling things off and saving his life had just improved. For one thing, the man was light—awake or at least responsive to deep pain. For another, the cervical spine was almost certainly intact. If Lou needed the ACE bandage for what he had in mind, he would use it. He took what remained of his shirt, and blotted the perspiration that had suddenly materialized on Cap’s face and bald pate.

“Sorry to hurt you, pal. Your leg is broken, and I have to stabilize it. Do you understand?”

Silence.

“Cap, can you hear me?”

Suddenly a faint nod, followed by a coarse whisper.

“I … hear you.”

Yes!

“Squeeze my hand, big guy. That’s it. That’s it. Now the other hand … Perfect. Cap, try to just lie still and concentrate on your breathing. Deeply, now. In and out. I’ll explain everything in a few minutes. For now, I need to tighten this thing on your thigh. It’s gonna hurt.”

“Go … for … it.”

The hemorrhaging was starting to slow, but only marginally. The tourniquet, arterial spasm, or diminishing volume? It was impossible to tell. He had to add torque. Lou crawled in an arc until he found a hefty stick, two feet or so long. He slipped it under the makeshift tourniquet and slowly rotated it clockwise. Cap cried out, but he didn’t scream. Instead he grabbed a fistful of soil and squeezed it tightly.

“Fuck,” he groaned. “… Oh, fuck.”

His breathing remained steady.

After two full turns, the bleeding was reduced to a slow ooze. Lou used the hi-tech, hemostatic bandage to finish the job.

“Cap, stay with me. Stay strong.”

From his pack, Lou retrieved his cell phone, not at all surprised to see there was no signal.

“Help!” he hollered. “Someone please help!”

It felt as if his voice had traveled only a few feet through the heavy air.

Another check of Cap’s pulses. Still palpable, but down to a two.

Lou sat back and wrapped his arms around his knees.

Either he figured out something to do, and soon, or Cap was going to die.

It was as simple as that.