Chapter One First, Do No Harm
Chapter One
First, Do No Harm
The blood reached Renji before the patient did.
It streaked the gloves of the paramedic braced over the trolley, soaked through the pressure dressings wrapped around the young man's abdomen and ran in narrow red threads down the metal frame.
One wheel rattled as the emergency team pushed through the double doors, the sound almost lost beneath the overlapping voices filling the trauma bay.
"Twenty-six-year-old male," the paramedic called. "Motorcycle versus delivery truck. Helmeted, thrown approximately fifteen metres. Hypotensive throughout transport. Suspected pelvic fracture, abdominal trauma and left-sided chest injury."
Renji stepped alongside the trolley without breaking stride.
"Blood pressure?"
"Seventy-eight over forty-two."
"Heart rate?"
"One forty-six."
"GCS dropped from thirteen to nine en route."
The patient's face was grey beneath smears of road dirt, his eyes fluttering without focusing, his breathing shallow and uneven behind the oxygen mask. Renji placed two fingers against the side of his neck. The pulse beneath them was fast and thready, already fading.
"Move him across on three," Renji said. "One, two, three."
The trauma team transferred the patient onto the bed. Renji did not raise his voice. He never needed to.
Around him, the room organised itself. Scissors cut through torn leather and blood-soaked clothing. Leads were attached. A nurse called out oxygen saturation. Someone prepared rapid-sequence intubation drugs while another pushed the ultrasound machine into position.
"Akiko, airway."
"Already on it."
Akiko Sasaki appeared at Renji's shoulder, dark hair tucked beneath a surgical cap patterned with tiny yellow ducks.
The absurdity of it had caused several junior doctors to underestimate her over the years.
None had made the mistake twice. She tilted the patient's head, cleared the blood gathering at the corner of his mouth and had the airway trolley open before the anaesthetic registrar's hands were even on the tube.
"Aoi," Renji said, "activate massive transfusion protocol."
Aoi Nakamura was already at the phone.
"Done."
"Call theatre. Tell them we're coming."
"General or vascular?"
"Yes."
Aoi gave him a brief look. Renji did not look up from the ultrasound probe.
There was free fluid around the liver — a great deal of it.
He moved the probe lower, then pressed briefly against the iliac wings.
The pelvis gave, unstable beneath even gentle pressure.
The patient's oxygen saturation continued falling despite assisted ventilation.
"Absent breath sounds on the left," Akiko said.
"Chest drain."
A tray appeared. Renji cleaned the skin quickly, made the incision and pushed through muscle with a curved clamp. The moment he entered the pleural space, blood poured over his gloves and splashed onto the floor.
"Massive haemothorax," he said. "Record the output."
"Eight hundred millilitres immediately," Aoi called. "Still draining."
The monitor alarm changed pitch.
"Pressure sixty systolic."
"First unit going in."
The tube was secured. Akiko listened over both lungs.
"Tube's good."
Renji looked at the young man's face. Twenty-six, the paramedic had said.
A faded festival wristband circled his right wrist, a silver ring hung from a cord beneath his torn shirt, and someone had written a phone number in black ink across the back of his hand — small evidence of a life that had existed normally an hour ago.
Perhaps he had complained about work that morning, left dishes in his sink, or had someone waiting for him to answer a message.
"Renji."
Akiko's voice drew his attention back to the monitor. The heart rhythm was deteriorating.
"Prepare for thoracotomy," he said.
One of the junior doctors froze — only for a second, but Renji saw it.
"Doctor Yamada."
The young doctor looked at him.
"Open the thoracotomy tray."
"Yes, Doctor."
There was no time to reassure him. The patient's heart stopped.
"Pulseless," Aoi announced.
"Start compressions."
Hands moved into position. The trauma bay narrowed around Renji until there was nothing beyond the patient, the failing rhythm and the next necessary action.
He had always found a strange kind of peace there — not in suffering, never that, but in the clarity of crisis.
A body did not care about politics, wealth, status or pride; it did not lie about what it needed.
It asked only that someone understand it quickly enough to keep it alive.
Renji cut through skin and muscle between the ribs.
"Rib spreader."
Metal opened the chest. The heart lay pale and motionless inside.
Renji reached into the cavity and wrapped one hand around it.
For a moment the room seemed to fall silent — not truly silent; the alarms still sounded, compressions had stopped, blood continued dripping onto the floor, and people breathed behind their masks waiting for instruction — but Renji heard something beneath all of it: a faint rhythm, not in the heart itself but deeper, a pattern lingering through tissue and blood.
He pressed his thumb against the ventricle.
"Internal cardiac massage."
His hand contracted once, twice, again.
"Adrenaline given," Aoi said.
"Cross-clamp."
The instrument was passed to him. Renji worked without looking away. The young man's blood felt cold through the gloves.
"Come on," Akiko whispered.
Renji compressed the heart again. There — a tremor, so slight nobody else would have felt it. He adjusted his grip. The heart twitched against his palm. The monitor produced a disorganised series of spikes.
"We have electrical activity," Aoi said.
"No pulse."
"Continue transfusion."
Renji massaged the heart in a steady rhythm. One of the blood bags emptied; another was connected. The twitch became a contraction, then another — weak, uncoordinated, alive.
"Pulse returning," Aoi said. "Carotid present."
"Pressure?"
"Fifty-eight over thirty."
"Better than zero."
Akiko exhaled. The theatre doors opened and an anaesthetist hurried in, followed by an operating department practitioner.
"Are we moving?"
"We're moving."
Renji kept one hand inside the patient's chest as the bed was unlocked from the floor.
The team pushed through the corridor at speed.
People flattened themselves against the walls to let them pass; a porter pulled a cleaning cart aside; two medical students stared as the open chest crossed their path, then quickly remembered to move.
The lift was waiting — cleared for them before Renji asked.
Inside, Akiko glanced at his hand.
"You realise most surgeons prefer to wait until theatre before holding a patient's heart?"
"Most surgeons lack ambition."
"Most surgeons possess common sense."
"That explains why they rarely achieve anything interesting."
Aoi gave a short laugh from behind the transfusion equipment. The sound eased something in the lift, and Renji felt it happen and allowed it. Fear made people clumsy; a few seconds of levity did not lessen the seriousness of what they were doing.
The doors opened directly onto the surgical floor. They moved again.
Three hours later, Renji stepped away from the operating table.
The patient's abdomen remained open beneath sterile drapes, but the bleeding had slowed to a manageable ooze.
The damaged section of liver had been packed, the ruptured splenic vessels controlled; vascular surgery had repaired the largest pelvic bleed while orthopaedics stabilised what they could.
The young man was not safe — safety was still far away — but he was alive. For now, that had to be enough.
Renji stripped off his outer gloves.
"Leave the packs in place," he said. "Temporary abdominal closure. We'll reassess once his temperature and coagulation improve."
The surgical registrar nodded.
"Take him directly to intensive care. No delays in recovery."
"Yes, Doctor."
Renji looked towards the anaesthetist.
"Call me if his lactate rises again."
"I'll call you if he so much as looks unhappy."
"Good."
Renji stepped back from the table. Only then did he notice the ache across his shoulders. His scrubs clung damply to his back, and there was a tightness behind his eyes that suggested he had been awake longer than was sensible. He could not remember when he had last sat down.
Akiko appeared beside him as they left theatre.
"You need coffee."
"I need the relatives."
"You need both."
"The relatives first."
"They've been told he made it out of surgery."
"They haven't been told what that means."
Akiko pulled off her surgical cap, damp strands of hair clinging to her forehead.
"What it means," she said, "is that you reached into his chest and bullied his heart into restarting."
"The transfusion helped."
"You are physically incapable of accepting praise."
"Praise is rarely clinically useful."
"It can reduce irritability."
"Then you should try praising me more often."
Akiko stared at him.
"That was almost a joke."
"I have no idea what you mean."
"Of course not."
They reached the changing area. Aoi was leaning against the wall outside, holding three paper cups in a cardboard tray, her navy scrubs marked with blood from shoulder to hip. She offered one to Renji.
"Black. No sugar. Unhealthy amount of caffeine."
"Thank you."
"I also found the family."
"Where?"
"Consultation room three. His mother and older sister. Police are trying to contact his partner."
Renji took the coffee but did not drink it.
"What have they been told?"
"Only that surgery is finished."
He nodded. Aoi studied him.
"You have blood on your face."
Renji lifted a hand.
"Other side."
He wiped the wrong cheek. Akiko reached over with a folded gauze pad and removed the mark herself.
"There," she said. "Marginally less alarming."
"I'm a trauma surgeon. Alarm is part of the aesthetic."
"You look exhausted," Aoi said.
"I am exhausted."
The admission surprised both women. Akiko narrowed her eyes.
"Did you just acknowledge a physical limitation?"