Wear a little death, smear on a little flesh, dab on a bit of blood: foolproof insect repellant. `Course it's not exactly the next hoola hoop, is it? Bit hard to bottle. And how would you market miasma?
I am alone, stone cold alone, catching a cup of coffee and a breather in the dark humid mist of the night.
It occurs to me that the snazzy pattern may be keeping the mosquitoes at bay.
I look at my scrubs, chin down to take in my chest, legs lifted to study the deposits there. Even in the dark, the pattern is unmistakable: polka-dotted with blood, and, courtesy of the seasonably steamy night, matted to my skin like sweat-based paper maché. Good thing OSHA doesn't use late Friday night for unannounced inspections.
I sit on the hood of my rust-eaten `76 Aspen wagon, outside the ER. My moribund car is parked beside Harrison Jeffries' gleaming, hunter green, 12 cylinder, one-grand-a-tune-up BMW 850ci. I glance at the BMW; the night turns a shade darker, and a degree or two hotter.
My plan is to force Dr. Jeffries to repent.
I listen to a mental playback:
Jeffries says, This is the top for you, Barnes. You know the Peter Principle, right? Any higher and you've graduated to incompetence. You're a trauma man, and a damn good one. Leave it at that.
I can match you, I reply.
You can match me? You can match me? Jesus.
Give me a chance to prove it.
You'd just embarrass yourself, Barnes. Rest where you are. A generalist mopping up the blood.
I freeze, squint, and turn my ear toward what I take to be the distant wail of yet another arrival, which is what my plan calls for, but there is only, in the background, the metronomic melody of crickets. Their energy, in this suffocating heat, strikes me as superhuman. I take an abortive sip of the caffeinated acid the nurses called coffee, and slosh the liquid onto the blacktop beside one of my hubcapless wheels, where it hisses into steam. Super human? Do crickets experience our trauma? If they do, there sure as hell aren't any sleep-deprived residents waiting around to patch them back together. In that regard, human animals are singularly stupid --- stupid enough to spend four years in that inferno of mechanical memorization called med school, at a six figure cost that mortgages half a life away, only to graduate to enslavement under senior surgeons who pocket 5 to 10K a pop for sliding a scalpel over iodine-tanned flesh when they feel like it. And except for slavedriving workaholics like Harrison Jeffries, they never feel like it during daylight on Wednesdays and Saturdays, when they take calls by cellular phone while serenely moving a little white ball over manicured grass.
I listen again for the tell-tale banshee 
nothing, which is a bit of a problem: it is
a good plan, but it does require some trauma. And of the right sort, no less.
In the distance, the lights of I-565, shrouded in the viscous
haze that descends nightly in these steamy parts, glow. As drivers zoom through
Huntsville, they are greeted in both directions by a mammoth billboard: Harrison
Jeffries, touched up to perfection, looks down with huge, benevolent eyes,
smiling. HUNTSVILLE MEDICAL CENTER: THE PRIDE OF `BAMA shines above his head in an unintended halo. The cinereous hair upon the
gigantic head is a good deal more plausible than it's real-life counterpart.
I sit here, on the hood of my Aspen, my dead battery beneath me and Jeffries'
immaculate 12 cylinders beside me. I'll need a jump start to get home again 
On a whim, I pull out my penlight, shine it into the cabin of Jeffries' BMW, and internally muse: Leather, mahogany, probably got a phone, a fax, a concert stereo, but of course no jumper ca-- What's that?
And this is where it starts.
I put down my coffee cup and hop off the hood for a closer look. Aim the little flashlight onto the rear seat of the BMW.
The rhythm of my respiration changes.
Skulls? Children's 
skulls?
I don't much like the faces looking back at me. The beam from my flashlight turns them strangely animate, three motionless ghouls from the darkest parts, the deepest fears, of my psyche.
The calm I used to know when I was beating toward my father's dream spreads through me.
They're not human. It's the bone structure of a primate; probably rhesus. This comes as a bit of a surprise: as far as I know, Jeffries isn't doing any monkey work. Yet this trio has had surgery. I illuminate a perfect circle in each cranium, about the size of a small button.
I climb back atop my Aspen, recline with my back against a spiderweb-cracked windshield that needs to be replaced. Take a deep breath. Start to try to reason out the presence of the skulls.
I hit a series of dead ends.
What time is it, anyway? I look to my wrist: my watch is gone --- I remember that my Timex has been drowned by blood from a chainshaw-opened artery, my first case of the night. John Cameron Swazy apparently never tested watches by submerging them in a 14 gram hemoglobin solution.
I look up at the sky and half-try to remember Boy Scout lessons about telling time from the heavens. The stars are still out, and the haze of heat has woven them together into a dome of shimmering lace. The `Bama bullet, as the natives call the sun, has not yet begun to send a flame over the horizon. This is but the seventh inning stretch; plenty of time left for further gore and death.
I move my cup up for a sip --- then remember that I tossed the liquid moments before. An interesting system, this. They want me to make split-second, life-and-death decisions in the ER, but they don't allow me enough sleep to recall whether or not my coffee-cup is filled. I have a passion for logic, and hence wonder why the hell I've become a doctor. I've taken an unlikely journey from the Diamond to the Hippocratic oath, all for what? Maybe I should have remained in the limbo in between: crippled, poor, bored, married --- but damn well-rested.
A voice speaks through the pager on my belt. Lauren.
``County rescue's barreling in. It's Harold."
I hold the speak button down: ``They have what I need?"
``Sam, you're not going to go through with that, are you?"
``What do they have? Head?"
``It's suicide. Jeffries'll just penalize you. It won't convince him of anything. Besides, no, Harold isn't talking head trauma."
I look toward the ER. Lauren stands on the spotlit breezeway, a starlet on the stage of a nightmare that now, with intermission ending, is about to resume. She can't see me, but I can see her; I look for a while in silence out from my solitude, and am again struck afresh by the improbability of a woman like that in a place like this. She is that cliché incarnate.
I hop off the pliant hood, which groans in relief, and walk out of the darkness toward the medical complex, a towering behemoth of cold, hard, futuristic lines conceived of by none other than Harrison Jeffries. When Lauren makes out my approaching silhouette, she smiles, and draws in and lets out a deep breath of relief so intense it borders, perhaps, on the erotic.
Lauren Louise Thorsen is a wildly improbable woman. She is just on the petite side, with a perfectly proportioned frame that transforms a polyester uniform into high fashion. She has long, luxuriant auburn hair that seems to catch and trap light, but in my presence she always wears it restrained by pins and clips; I've never seen it any other way. Lauren is also smarter than most of the doctors here, valedictorian of her class at Duke's School of Nursing. Just last night a first-year resident, called to read the EKG on a man whose heart was nearly jumping out of his chest, shook his head in defeat, and phoned the senior cardiologist at home. The cardiologist, an urbane Southener who as a rule abhors scatological language, informed the resident that his brain is a heaping pile of shit, not because he couldn't diagnose the tape, but because instead of consulting Lauren, he'd called at 3 a.m. The cardiologist zapped off the videophone without diagnosing the faxed tape. The resident sheepishly called Lauren. She said, in less than a heartbeat after scanning the tape, ``Rapid a-fib," and prescribed a stiff shot of verapamil, which did the trick in 44 seconds.
Lauren is also affianced --- to a monster truck driver, the Dixie Dragon on the circuit, a long-haired, muscle-bound, growling, tattooed terror --- who turned out, in person, to be a fellow graduate of Duke and Lauren's longtime suitor, a sane, articulate entrepreneur, from whom, as best as I can tell, she intends to squeeze two-kids-and-a-dog domestic bliss. That's the thing about Lauren: she wants commitment. I don't even have it in my soul anymore to give.
We are inside now. Before handing me the receiver, Lauren cups the mouthpiece, whispers, ``Breakfast when we get off?"
``Where?"
I think I see --- maybe --- mischievous light in her eyes. ``Where do you suggest?"
I shrug. She says, ``Well, how about an Egg McMuffin?"
``Perfect," I say, my eyes flickering involuntarily to the receiver.
She hands it to me and walks off to ready the reception for Huntsville's latest tragedy.
I put the receiver to my ear.
The EMTs are indeed on the line, screeching home at full bore, and singing the standard tune for my waiting team: Hazy, hot and humid in the heart of Dixie, Friday evening, payday, enough moisture in the air to slick the roads; driver found pinned against the wheel of the car, his GTO's ``three deuce" carburetor lodged in the trunk of an oak. No passengers, no witnesses. The EMTs estimate 90 mph before impact.
``Head trauma?" I ask, hoping.
``Don't look like it," Harold says.
``Give me the specs." There is no point in hiding the weariness in my voice.
``Beau Madison, thirty-two yeah old, white, cawpulent male." Harold has recently learned what `corpulent' means, and now he uses the term proudly whenever a victim is overweight. Last week he called an angina-plagued, half-ton, miniskirted, circus-performing fat lady cawpulent. He knows that his own body habitus is the biological equivalent of jello, and he likes to think of it as merely corpulent. ``Respiration: 30," Harold continues, ``gettin' labored. Pulse 140, blood pressure 98 over 50. Peripheral pulses present but weak. He's reportin' grade nine slash ten thoracic pain. Compromised movement of the chest wall, `specially on the left. Tenderness to palpation over the entire chest. No evidence of neck involvement. No external bleedin', `cept some tiny lacerations of the nose and lips."
``You got a collar, backboard, oxygen?" I mutter, depressed that I am already deducing the nature of Beau's internal trauma, which doesn't fit my plan for flooring Jeffries. Questioning the application of standard EMT protocol is the epitome of disrespect; the conversation grinds to a halt. I hear squealing tires in the background as I wait for Harold's silent protest to pass. Harold's sidekick --- Tony, a rapier-thin chain smoker --- is a maniacal driver who relishes turning the van into a centrifuge. One night last month the ambulance itself was responsible for a good deal of trauma on I-565.
``We ain't Boy Scouts and we're movin'," Harold testily declares. He then informs me that this time there is a twist: no apparent alcohol or drugs involved. In fact, only a few minutes after Harold and Tony reached the scene, Beau became talkative: when they peeked into the gnarled cabin of the muscle-car, expecting the worst, there he was, locked in a vice created by the steering wheel and collapsed roof, moaning a remarkably distinct and doleful litany of apologies.
``He kept sayin' he was sorreh, so sorreh."
``Sorry?"
``Yep."
``Who was he addressing?"
``Beats me, boss."
Harold goes on to report that when Beau heard his saviors, he brushed a film of blood from his eyes with the nonchalance of a butler dusting a tea set, and turned suddenly lucid. He officiously walked the EMTs through neutralization of the smoking wires of the ignition system, through the jaws of life, and through proper handling of a possible spinal injury.
``We're bringin' y'all a reeeal charactuh," Harold chuckles.
``Just bring me a living character." A click in response tells me that Beau's condition is deteriorating. Harold specializes in DOAs.
The hospital's AC is still out; streamers on the vents hang down, dead. My trauma team, fully prepped on the basis of my deduction, wait in heat that draws sweat through pores like water through a colander. Finally we detect the distant siren. Thirty seconds after that, at 3:42 a.m., the ambulance skids up as if in extreme pain, and Harold, riding his normal adrenal high, propels Beau Madison into the ER atop a wheeled stretcher with the all the care of a bowler.
Madison sports a mountainous beer-belly and grips a blood-stained ``STP" baseball cap which he manages to miraculously tip in my direction.
I am ready. Almost three years of a surgical residency in a place that admits 1000 badly injured a year makes it easier to remember the trauma drill than to remember tossing coffee in the parking lot.
``Mah babih," Beau rasps. ``Mah babih." His beard is long, unruly, blonde-red. It holds countless droplets of blood which shine like tiny crystals under ER illumination. The man's body odor is overwhelming.
``Clothes first. Lauren, hold the head while I take off the collar. Frank, check the IV's, get the warm Ringer's running full blast and get the routine bloods with a femoral blood gas. What's the BP?"
``70 over nothin' just before we rolled in," Harold reports.
I remove the front of the cervical spine-protecting hard collar and place my second and middle fingers on the trachea just above the breast bone: deviated to the right. Dried blood, pieces of shattered glass, and innumerable small abrasions and lacerations almost obscure the blue columns just under the skin, extending on both sides of the neck from the collar bone to the jaw.
I nestle my stethoscope between two folds of fat on Beau's hairy chest. The hollow left thoracic cavity is soundless. Elementary deduction: a tension pneumothorax on the left, busy pushing Beau's heart a crucifying two inches to the right.
``Fourteen gage intracath," I bark. Frank hands me the needle, the size of a Parker refill. Without even an alcohol wipe I thrust it quickly into Beau's left upper chest. Whooosh. The escaping air spatters droplets of blood on the floor tiles six feet away.
``BP 100 over 60, pulse 110, respirations 20!" Frank announces, as perky as always. I figure he could have been the quintessential Big League bat boy.
``How do you feel now?" I ask.
``Ah installed a nitrous oxide injector. Pressure gauge, micro switch, shit, ah even
threw in a pretty little remote bottle valve. But the first time ah kicked it in at
eight hundred fifty p.s.i., she took off like a bat outta hell, and
" Madison
manages to lift his large head for a view over his breasts and gestures with his chin
at the hole in his chest. But the muscles in his thick
neck give out and his
boulder of a head falls back with a bang.
``You're lucky to be alive," I say. ``If you want to stay that way I suggest you talk a little less. Frankie, chest tube tray. Beau, does this hurt?" I firmly press on the back of Madison's neck.
``The only damn thing that hurts" --- Beau rolls his eyes down and tries to lift his head again, this time in a vain --- ``is where you stabbed me." Truculence: good sign.
I put the collar back on. Then I listen to the thump thumps of Beau's heart and note the contusions and abrasions over his left chest, finger his scalp and face, press on his abdomen, compress his hips, check his urethral meatus for blood, place a gloved finger in his rectum, and manipulate his upper and lower extremities. Then I return to a closer study of the victim's scalp, hoping.
The skin over Beau's right ear is 
can it be? Yes: the skin is definitely sponge-like. Possibly, just possibly, an underlying skull fracture, near the artery that
supplies the parchment-like sack surrounding the brain. Maybe this is my chance
after all. There doesn't seem to be any neuro deficit, however. At least not at the
moment.
I peer into Madison's eyes. They are bright and alert --- but behind them flickers a rising, elemental fear. Right about now, I figure, Beau's hypothalmus, the part of the human brain inherited intact from the lower mammals, is firing off enough information to fry a supercomputer.
I decide to knock off the easy stuff before returning to the possible head trauma, the ammunition I need.
Tears begin gathering in Madison's eyes. They well up, then gently trickle from the corners of Beau's bloodshot orbs, streaking his crow's feet. He suddenly looks a good deal older, his full fifty years.
I place a hand on Madison's massive shoulder, above a number of dramatic tattoos clearly visible against the man's pallid skin. A menacing cobra, ready to pounce, crouches along his bicep; a sultry, impossibly endowed woman vamps down his shoulder. Beau's lids rise, revealing pale blue, bloodshot eyes that are nonetheless startlingly lucid. Madison speaks again:
``You and me, doc, we're in the same boat. It's all a matter uh mechanics, isn't
it? Somewhere along the line ah did somethin' wrong." Madison sniffs. ``Maybe
the ratio was off. Maybe there was a defective valve. Ah'd nurtured her from
birth, ya know. And in the twinklin' of an eye she's sheet metal. Sure glad ya
didn't make the same kinda mistake on me. Whad`ya have to do? Stick a tube in
and suck out some blood? That it?" Madison's voice dies down to a whisper;
his eyes start to lose their astonishing light. ``Used to love checkin' mah goat's 
oil.
Always made sure it was right on the full line, not a hair below, not a hair above.
Yeah, you and me, you and 
me, doc, we
" His voice dies but his lips keep
moving wordlessly. His lids draw down with a disturbing finality.
I say, ``Okay, Lauren, let's do it."
I pull on sterile gloves as Lauren washes Beau's left chest with iodine, a semblance of sterility so belated it is absurd. She configures the chest tube suction apparatus in seconds.
A soft, mellow, unfocused ``Shiiiit" is Beau's response to the 2 inch lidocaine injection into the skin beneath his left pectoralis. Some subconscious part of Beau's brain fires out a command for his body to roll away from the pain, but it's like a sparrow telling a Brachiosaurus to move aside: Madison is slowly but surely turning into an immovable slab.
``Okay, hold on, Beau." I know that Mr. Madison needs a helluva lot more than ``okay anesthesia," but pain control has dropped by the wayside.
I make a two inch cut where the lidocaine was injected, and with a few more firmly stated OK's shove a curved clamp on top of a rib into the chest, a probing finger after that, and then the 32 French chest tube. Non-clotting blood gushes out, further coloring my scrubs. 300 cc's of bloody fluid streak through the chest tube and into the suction container. Then the flow slows to a trickle. A slow bubbling of air from the chest tube follows. This indicates that the leak of air from the left lung isn't large.
While I attack the chest, Frank slides a tube via Beau's penis into his bladder, and Lauren repeats, ``Swallow, swallow," as she passes a tube from Beau's nose down to his stomach. Beau's consciousness crystallizes into one diamond-sharp point of utter and absolute pain.
Frank proudly announces, ``BP 120 over 70, pulse 100, respirations 18."
It's 3:57 a.m.
Besides me, Sam, Lauren, Frank, and Harold, there is no one else in the Trauma Room, which seems miles away from the drying out drunks, the kids with ear aches, the ``maybe it's appendicitis" crowd only 20 feet away in the ER's foyer. Harold's driver, Tony, doesn't like watching the action and is outside having smokes.
Time to make my move. I don't call Sandbloom, the senior resident. Instead I announce: ``CT scan."
Lauren looks up. ``CT? What about C-spine, chest and lavage?"
``Lauren. Come on. Cross your fingers. Beau here may be my ticket."
Lauren doesn't answer. She isn't irritated; just silent, focussed, trying to stay on my placid plane. She told me once of her fantasy about charting the depths of my serenity under fire: Inject me with radioactive glucose, array the PET sensors around my head, have me sit in the chair while she flashes snapshots of horrors we've both seen wheeled in. She suspects that the scan will show my amygdala to be as calm and clear as the blue, blue sky of a cloudless Spring morn. She's wrong.
``CT," I repeat. ``Come on. I'll handle Sandbloom when we get there."
Sandbloom is the senior general surgery resident on the Trauma Service. The 200 yards to the CT scanner, which for some reason the architects failed to take into account, always feels like rock-climbing with a backpack of lead: the stretcher, EKG monitor, IV poles, oxygen, chart, Pleurevac, endotracheal intubation equipment --- all of it has to be pushed. I lead, back to Beau, Lauren at the head, Frank and Harold on the left and right. Harold isn't supposed to be here, but as long as he doesn't get a call, he's going to watch this performance to the end.
At 100 yards Beau's chest freezes.
I jump to his head.
``Beau?" I open the closed eyelids. ``He's blowing his right pupil. He does have an epidural. Give me the laryngoscope and the number 8 endotracheal tube. We don't have suction. Here goes."
I take the silver, L-shaped, lighted throat probe from Lauren, pass it into the
right side of Beau's mouth, push the floppy tongue to the left, and sneak up on
the epiglottis, the firm midline flap protecting the airway from foreign invaders.
Beau gags violently: his throat is a sea of turbulent froth. I can't make out the epiglottis.
But in my mind's eye I have a perfect view of Beau's epidural, the root cause of the
descending blackness: a deadly sphere of expanding, brain-compressing blood.
This is it. My ticket. I'll pull the damn thing off right under Jeffries' uncooperative
nose
``Give me the tube," I command, ``push on his thyroid cartilage."
Frank hands me a clear plastic hose reinforced by a malleable metal rod. Lauren gently steadies the voice box. I close my eyes, visualize Beau's vocal cords, advance the endotracheal tube slowly down. Beau continues to gag convulsively. ``Feels good," Lauren says, as she senses movement under her fingers. I pull out the metal rod and slip the end of the oxygen tube into the endo tube. Soundless breaths. Fog moving back and forth in the tube. Success.
I listen to the lungs as Lauren deftly pushes air in and out with the ambu bag. Not bad. But I can feel it. Beau has arrived at that fundamental fork: Life or Death. All to be decided in a matter of minutes. His right pupil is dilated, the eye deviated wildly to the right.
I prod him: unconscious. Left side paralyzed. Madison is falling into the abyss.
``Forget the CT scan. He goes straight to the OR."
Frank and Harold look at each other; then, jointly, they look at Lauren. She says: ``Jeffries is still on the gunshot. Maybe if you give him some mannitol and get the CT, Jeffries will have time to finish. Why don't you call --- "
``Lor, it's time to piss on protocol. Frank, call the OR and tell them we're coming, and call Sandbloom and tell him I'll meet him in the OR."
Frank frowns. ``Jeffries ain't gonna like --- "
``I don't give a shit what he likes."
Sam and Lauren turn the stretcher around and head for the OR elevator, 25 yards away. The elevator doors open and Hector, the OR supervisor, emerges. Hector loves rules. His hobby is correcting grammatical errors in OR chit chat. More than once he's condemned a solecism during life-and-death surgery. And this time Lauren's legs aren't going to be of any help. Diversion is impossible.
``You cannot take this patient in. You are not a senior resident." Hector's diction is flawless.
``Sandbloom is on his way."
``Allegedly. Until I hear from him, you stay parked. Besides that, we don't have anesthesia."
``She can give anesthesia," I say, cocking my head toward Lauren, whose eyebrows rise.
Hector responds with a snort and a smirk, and his posture in front of the elevator takes on the air of granite.
``Okay," I say. ``You two stay here and watch over him while he dies. I'm gonna place a call to the funeral home, and then his lawyer." I head off down the hall, sweetly whistling a dirge.
``Christ! Alright!" Hector shouts.
Sandbloom meets us at the front desk. ``What is it this time, Barnes?"
``Epidural.``
`` You made the diagnosis? You're supposed to call me for OR trauma."
``Look. Tension pneumo on the left, rib fractures, hypotension, Ringer's running wide open, blown pupil, hemiplegia --- getting pissed because you didn't get called isn't exactly efficient."
``So you're going to do a craniotomy."
``That's right."
``You've cleared this with Jeffries?"
``Not yet. Look, if you're so interested in protocol, then you do lavage while I'm recruiting Jeffries."
``You'd better pull this off, Sam, or you'll be the one doing all the talking to the family, the chief, and the malpractice lawyers."
We wheel Madison into OR 2 with Jeffries working in OR 1 next door.
4:20 a.m.
Kumar, the Indian anesthesiologist working with Jeffries in OR 1, notices the activity in OR 2, leaves the nurse anesthetist with Jeffries' patient and, with mask on and right and left pockets of his scrub jacket overflowing with pens, penlights, stamp cards and crib cards, comes through the swinging doors like an over-the- hill outlaw gunslinger ready for a showdown. Only gunslingers usually don't wear turbans and speak in Indian accents.
``What the hell do you think you're doing, Barnes?" The voice is soft and sing-song.
``I'm getting ready for life-saving surgery."
``You can't just wheel somebody up here. Get the other members of your crew out of here and have them wait at the desk."
Kumar is in my pocket now; this is the way to get his attention. Follow protocol, and Kumar will diddle daddle about getting lines in, looking for an old chart, reading the EKG, anything to delay. Anything that might allow his nurse to do the work instead of him. ``You can run two rooms, Kumar. You know that, I know that. This guy's dying. He's already unconscious, you don't even have to put him to sleep, just give him oxygen."
``You've told Jeffries?"
``Not yet."
Kumar whistles and shakes his head. Were he not Hindu, he would cross himself.
I put on an OR hat and mask and enter OR 1, which is wonderfully cool, air-conditioned by standalone units that only Harrison Jeffries has.
Jeffries, mask and telescopic loops spattered with blood and brain matter, is working with a second year female resident and the only available scrub nurse. He doesn't look up. ``I know damn well what you're trying to pull, Barnes. What do you have?"
``Right-sided epidural, progressing fast, unconscious, hemiplegia, respiratory depression."
``Skull fracture?"
``Right temperoparietal."
``CT scan?"
``Clinical exam."
Jeffries pulls his head back and looks up at me. From behind the black mechanical eyes he seems to be surveying me like a submarine captain with a periscope. ``You're kidding."
``Hardly."
Now Jeffries stands up straight. One gloved hand holds a micro-dissector, the other a micro-tweezer; both are bloodied. Harrison Jeffries is fifty-two years old and dramatically out of shape; he is a full head shorter than my 6'3". I suspect he hasn't been in a fistfight since his scrapping, struggling, clawing days as an undersize something-to-prove dynamo growing up on the streets of Queens. But his net worth exceeds half the assets controlled by his adopted home state of Alabama. And his complexion is so fiercely reddened by overwork and constant concentration, his features so large and blunt, his neck so thick, that he has the menacing air of a former prizefighter.
Jeffries says, ``You don't know a damn thing about the brain."
``I'm learning."
``Digging in without a scan." Jeffries' voice is filled with contempt. ``You don't impress me one little itty bitty fucking bit, you understand that, Barnes? You can forget neuro."
``Relax, Harry."
``Relax, my ass. And it's Harrison. How'd you get up here?"
``Hector? Come on."
``Listen to me good now, Barnes: vanish."
``He's dying."
``I'm nearly done."
I look through the shotgunned skull at brain matter about as neat as masticated small intestine. I say, serenely, ``You need me."
``Like hell. You haven't slept in three days."
``Whose fault is that?"
``I didn't hire you for neuro."
``That's what you keep telling me."
``That's right. I keep telling you your job is to be a damn good sleep-deprived general surgery resident."
``Things change."
``Not in the twinkling of an eye. I'm not your fairy godmother. I can't wave a magic wand and give you what it takes. Which is about a decade of training."
``I have what it takes."
Jeffries looks over into OR 2. ``What's Sandbloom in there for?"
``Protocol," I say, with unveiled sarcasm.
``Jesus. You want to do the head with Sandbloom as assistant?"
``Yup."
``Without CT confirmation? Without - fucking - CT - confirmation?"
``Yup."
This is it. Jeffries can kill it right here. The man's molten core is white-hot with calculation. We stand staring at each other.
Jeffries says, ``Don't put my name on the chart. You blow it, you're back to ex-jock in Hicksville. And even if you pull it off, don't expect a ticket on the neuro express. Expect a demotion."
I return to OR 2, query Sandbloom by raising my eyebrows.
``Clear fluid," he responds.
I nod at Lauren. With help from Harold and Frank, she rolls Beau onto the table, untangles his IV's and other attachments, and continues to hang more salt water.
I notice that Kumar is motionless. The anesthesiologist's cheeks swell under his mask from a hidden smile. ``Notice something missing?" he says in a voice on the brink of laughter. His brown eyes twinkle. ``No scrub nurse, Barnes."
I look at Lauren. She looks back, and then nods slightly and grins. To Kumar, her voice as smooth as silk: ``I would suggest four units of blood, immediately."
Kumar twists his eyes away in defeat and moves. He begins dutifully firing up the anesthesia ventilator and gases. A wave of narcotics and muscle-relaxants rolls through Beau's massive body.
I start shaving the head.
Sandbloom scrubs, participating both because being in the OR protects him from bullshit middle-of-the-night medical consults, and because he has a ringside seat at a fight too good to miss. He figures I'm a 50 to 1 underdog. His calculation is exceedingly charitable.
``Spectators will have to suit up," I say. Now that the OR is under my control, proper protocol does seem to matter a bit. I exchange glances with Harold, Frank and Lauren. Harold and Frank nod, and turn to leave. I look again at Lauren, and wink. I call after the duo: ``Try to keep the ER quiet for a while, okay boys?"
I drape Beau's hairless, brown-stained scalp. Then I run my fingers over his soft skin, sounding out the region overlying the presumed skull fracture. I find it, and there is little doubt. Blood is accumulating just under the skull, with nowhere to go. Soon the pressure will be enough to squeeze Beau's cortex into mush.
``Knife," I command. Lauren slaps the tool into my outstretched palm.
I make the scalp incision without delay and, by force of will, without even a shiver of doubt. The incision extends from just in front of the ear, curved back, then up and across to the forehead --- a red question mark. With a vigorous pull of the galea toward the surface, I control the torrent of blood shooting from Beau's scalp and hand the clamps to Sandbloom. Then I cut through the temporalis muscle.
And now I can see the fracture, crossing transversely the tempero-parietal region, right in the home of the middle meningeal artery. When I was a kid this was called the soft spot, where a hard blow was supposed to kill. How many times had a 90 mile per hour fastball streaked toward this vulnerable spot on my own head? The ball half way there, and time stops; my stomach flutters, the pitch rockets in, I hit the deck, and the bullet grazes off my helmet with a smack --- injury averted. The soft spot: sometimes old wives' tales aren't so crazy.
I decide to begin the craniectomy at the temporal region, hoping to immediately find blood under pressure. I pull the drill into position, line it up. From this point on I'm in explored territory for me, and there's no turning back.
I kick the drill on.
The automatic trephine whirs and drills, smokes hot, and stops, as designed, just at the inner table of the skull. Clean bore.
Using a rongeur, I begin picking out the remaining circle of brittle bone 
and
it leaps out at me: a deadly little monster, a blob of blood and clot oozing through
the drill hole like jelly through the side of a suddenly compressed peanut butter
and jelly sandwich.
``Lucky son of a bitch," Sandbloom whispers. He is hoping this is my swan song.
I suck the blob from the sac surrounding the brain. That gives a clearer view. Now where the hell's the leak?
Before I find it, the blood is back, ruining my view.
I clear again, look again. Be there for me now, where, where, blood's back, okay, clear.
I apply suction again.
In the background someone murmurs a low, and falling, BP.
Okay, come on baby, where are you? Vessel, yes, clear the space, dura,
dura, vessel, clear 
come on now.
The blood is back all over again. I apply suction for the fourth time.
I'm losing.
Okay, now where are you, you little --- there!
In an instant, I pinpoint the spot, squeeze the cauterizing forceps, and burn the bleeding artery.
The leak is plugged.
Sandbloom is forced to nod. Lauren breathes for the first time in two minutes.
I expect the underlying brain to be only minimally injured, but am obliged to burr more holes, cut out a piece of skull, open the dura and look: the cortex, the gyri. The convoluted conglomeration of cells separated by serpiginous fissures that hold the answers. Consciousness, memory, talent, motor function, coordination, emotion, psyche, everything we call being alive. This is where Beau really resides.
And Beau looks good. Stay away from hot rods and he might just hit old age.
I look up. Jeffries stands beside me. ``Well?" I prod.
Jeffries shrugs a predictable ``So what?" and says, ``That was nothing more than trauma surgery. And you're part of the trauma team, right? A trauma team member guilty of insubordination. A general surgery resident who's going to be good little boy from now on and stay in the ER."
Jeffries turns and walks away. My thoughts about the skulls trail him.
Lauren's eyes, though empathetic, say a gentle ``I told you so." In a voice muffled by her mask: ``McDonald's?"