Chapter Four
“First, Mrs. Pickett, I think it’s important that you’re aware of the worst-case scenarios that we’re dealing with here,” said Dr. Kelly Ralston in the ICU waiting room.
“Please, call me Marybeth.”
“All right, Marybeth, I don’t believe in sugarcoating anything, and I want you to be fully informed so you can make the best decisions in regard to your husband and his medical care.”
“That doesn’t sound good.”
“Then we can talk about the best-case scenarios.”
Marybeth had just returned from the women’s restroom down the hall, where she’d wanted to be alone for a few minutes.
The helicopter ride had been stressful, and she’d spent the entire flight watching the monitors attached to Joe that displayed his heartbeat and oxygen levels, all the time praying that he continued to breathe.
Joe had not regained consciousness, although she thought for a moment that she felt a squeeze from his hand, whether involuntary or not.
Inside the restroom, she’d tamed her windblown hair from the helicopter blade wash after landing on the roof a half hour before.
Then she wept uncontrollably over the sink.
Her sobs were so violent and racking for a few minutes that her legs felt weak.
She’d been scared to look up and see her face in the mirror.
Finally, the emotions ebbed and she was able to dry her tears and clean off the streaks of mascara that had coursed down her cheeks.
Dr. Ralston, the head neurosurgeon at St. John’s Hospital in Billings and the primary reason Joe was flown there, was waiting for her when she emerged.
Dr. Ralston was in her midfifties and she was petite and thin-boned, with raven-black hair and striking azure eyes.
She wore green scrubs, and a pair of readers hung from a chain around her neck.
Her demeanor was direct and all business. Marybeth instantly liked her.
“Let’s sit,” the doctor said.
When they were settled on opposite ends of an uncomfortable metal-framed couch, Ralston leaned forward and placed her small hand on Marybeth’s and looked into her eyes.
“There are a few things you need to know because medicine is all about percentages,” she said. “The first and most critical is that gunshot wounds to the head are fatal about seventy to ninety percent of the time without emergency room trauma care.” She let that sink in before continuing.
“For victims who survive the initial trauma, about fifty percent die in the emergency room. Those are not good numbers, but they’re accurate numbers.
There are so many victims of gun violence in the United States and so many emergency room studies out there that I can tell you this with absolute statistical certainty.
Our numbers here at St. John’s aren’t much better. ”
Marybeth felt as though icicles were being stabbed into her chest, and she took a ragged breath and held it.
“I don’t want to give you false hope,” Dr. Ralston said. “I don’t do that to the loved ones of those who suffer traumatic brain injury. But…”
The word hung there until Marybeth repeated it. “But?”
“We may have some factors working for us.”
“Which are?” Marybeth asked.
“He’s not dead, for one thing. He’s alive.
He had very good care on the ground, and that probably saved his life for the time being.
They put immediate pressure on the wound and stopped the bleeding.
They also addressed a bullet wound to his left shoulder.
I couldn’t help but notice bullet wound scars on his body already.
It looks like he’s lived an…adventurous life. ”
Marybeth nodded. “He’s a Wyoming game warden.”
“Are numerous bullet wounds common for game wardens?”
“Not really,” Marybeth said. “Joe’s special.”
Then she let out her breath and asked, “How bad is the damage to his brain?”
Dr. Ralston leaned back and her hand slipped away from Marybeth’s, but not in a way that was dismissive.
She said, “It’s too early to tell a lot of things.
There are so many variables to consider at this point.
We’re doing a CT scan of his head now to determine the extent of the damage.
We don’t yet know what his level of consciousness is, and that will be determined by something we call the Glasgow Coma Scale.
And we don’t yet know the degree of his brain stem neurological function.
“Like I said, there are so many variables, like the location of the bullet entry, the areas of the brain damaged by the trajectory, what kind of bullet is in there, where it’s lodged, et cetera.”
“When will you know all of this?”
“Soon. When the CT scan is complete, I’ll leave you and go do a full diagnosis.”
Marybeth said, “You said bullet entry, but not exit. Are you saying it’s still in there?”
“That’s exactly what I’m saying,” Dr. Ralston said.
“That can be a good thing. It matters that there aren’t two wounds.
Often, the exit wound causes much more damage than the entry because often the bullet expands on impact and mushrooms in shape, so the exit is much bigger.
It also might mean that the velocity of the bullet wasn’t as high-powered as it could have been from, say, a hunting rifle.
But it all depends on where the bullet traveled through the brain before it stopped. Or where it is located right now.”
“Will he recover?” Marybeth asked. “Will he be able to use his mind if he does?”
“I can’t answer either one of those questions with any certainty,” Dr. Ralston said.
Marybeth looked away, trying not to cry again.
“For now,” the doctor said, “with your permission, we’d like to induce a medical coma.
The purpose of the procedure is threefold: to allow your husband to rest, to reduce his blood pressure, and to hopefully stave off excess swelling of the brain caused by the trauma.
In effect, we’ll be tricking his body not to rush blood to his brain to try and heal it too quickly.
In order for us to do this, you’ll have to sign off on some paperwork that gives me permission to proceed with an emergency hemicraniectomy and an external ventricular drain. ”
“A medically induced coma?” Marybeth said. “I’m familiar with it.”
She didn’t feel the need to recount how April, their middle daughter, had once been put into a coma after she was seriously injured.
Dr. Ralston said, “You don’t have to sign off on it. I’m not intending to apply pressure on you. Some family members don’t agree, and that’s okay. They prefer to let nature take its course.”
“If it was your husband, what would you do?”
“If it was my husband,” Dr. Ralston said with a mischievous grin, “I might let nature take its course. But since it’s your husband and you obviously want to give him the best chance to survive, I’d sign the papers.”
Then: “I shouldn’t have said that. I’m in the midst of a nasty divorce.”
“I’m sorry to hear that,” Marybeth said.
“If you agree, we’ll have the anesthesiologist administer propofol,” Dr. Ralston said. “No drug is ever one hundred percent safe or foolproof, but we use that drug every day in the operating room.”
“How long will he be in a coma?”
“Again, we don’t know yet. It could be hours, days, or weeks.
I’ve read of instances where the coma was kept up for six months.
It’ll depend on whether the swelling recedes and how much the metabolism of his brain has been altered.
If the brain heals and the swelling goes down, we can reduce or even halt the propofol. ”
“I’ll sign the form,” Marybeth said.
Dr. Ralston acknowledged her decision with a curt nod. Then she stood up and said, “I need to get back to the OR now. The CT scan should be done. I’ll keep you updated.”
“Thank you.”
Dr. Ralston’s expression softened when she said, “There’s a list of hotels at the nurses’ station. You should find a nice one and book a room. It may be a few days, if you can do that.”
“I’ll worry about that later,” Marybeth said.
After Dr. Ralston departed, Marybeth retrieved her phone from her purse. There were dozens of texts from friends, her staff, and most of all from her daughters. They all wanted to know what was happening.
She tried to summarize what Dr. Ralston had told her without putting too much spin on it either way.
She first sent a quick text to her staff saying Joe was injured but alive and that she wouldn’t be back in the office right away.
Then she began to create a text message to send to their daughters.
It took her a few moments to gather her thoughts and put them into words.
TO: Sheridan, April, Lucy
Your dad is alive. He was shot twice, once in the head. We’re at St. John’s Hospital in Billings and I just spoke with the surgeon. They don’t know how severe the damage is yet, but they should know soon. I’ll keep you updated on what I hear. I trust the doctor.
Pray for him, as I will.
I love you,
Mom
Marybeth reread the message before sending it and she made two changes. She replaced I love you with We love you. And she added and Dad to her sign-off.
It was important, she thought, that their daughters knew they were still communicating to them as a team, even if Joe was unaware of it at the moment.
Then she pressed Send.
—
She was shocked a few minutes later to see middle daughter April pushing through the double doors into the waiting room. As she entered, April held her phone out in front of her at eye level.
“Well, thank God he’s okay,” April said. “It was killing me not to know.”
“He’s not okay yet,” Marybeth said, rising to greet her. “But he’s alive.”
“I told him a while back to quit getting shot,” April said, her nostrils flaring. “I wish for once that he’d listen to me.”
“We all do,” Marybeth responded. She embraced her daughter and April hugged back. April wasn’t an immediate hugger like her two sisters were.
“Where is he now?” April asked when they separated.
“In the OR. They’re inducing a coma to prevent swelling in his brain.”