He first measured the intraocular pressure and examined the insides of the eyes for injuries. The eyes were also windows to the brain—changes in the optic disc supplied reliable information about any rise in intracranial pressure.
Dante pulled back on a sharp inhalation. “OK. First good news I’ve seen so far. Amazing, too. The eyes themselves are intact.”
Gulnar heard Emilio’s exhalation a few inches away from her ear. So he, too, had been holding his breath.
Dante raised his eyebrows at her. “Now I’d really like those X-rays.”
Gulnar swung to the senior ICU nurse, who hurried out herself this time, came back in a couple of minutes handed Dante the films with a grim face. He thanked her in Azernian, made sure he caught the nurse’s eyes, gave her a soothing smile. Gulnar’s heart swelled.
How considerate he was. How tender. Oh, Dante. Still here, but already lost to her.
She clamped down on the tide of agony as he shook his head, looking at the X-rays. “Without 3-D X-rays or even CTs to visualize whole structure of the face and skull from all sides and in perspective, there’s no way to see the injury in detail. But I guess this will have to do. When was this taken?”
“After surgery.”
“Hmm. Emilio, Gulnar, come over here.” Gulnar darted to his side. Emilio’s surprise that Dante had included him made his movements slower. They both ended up hovering on either side of Dante. “Tell me what you see.”
What she didn’t see chilled her. She had no solid arguments, no clinical evidence to back up her belief. It was instinct. And no one had agreed with it. If Dante didn’t either, her mind would be set at rest. She prayed he wouldn’t. She exhaled. “Nothing much. But judgements based on plain X-rays tend to under-diagnose the extent of injury. Dr. Moya was adamantly against doing anything about the facial fractures. He said we could always have delayed reconstruction when Dimitri is out of danger.”
“But that’s not your verdict, hmm?” Dante probed.
“No!”
Dante released her eyes, pored over the X-rays again. And again both she and Emilio looked over his shoulders. “Here—where you can’t see it, but from my manual exam—is a pulverization of the naso-orbito-ethmoid bones constituting the whole mid-face. I thought that the frontal bone had been spared. It was only on palpation that I found out the posterior table of the frontal bone is also pulverized.”
“But how can the posterior table be fractured without the anterior one?”
Gulnar couldn’t blame Emilio for being skeptical. The frontal bone, making up the forehead, was made up of two layers, an outer one and an inner one. The inner one almost never fractured if the outer one remained intact.
Dante shrugged. “It happens. Rarely, but it does. And this misleading intactness probably accounts for your doctor’s optimistic outlook. I wouldn’t fault him too much. As you said, X-rays aren’t useful in showing damage to the posterior table.”
“So this is why he has a normal fundus,” Gulnar exclaimed. “There is no rise in intracranial pressure because he’s been leaking cerebrospinal fluid though the fracture all the time!”
Dante’s lips twisted. “And the reason for his deterioration is neither shock nor direct trauma to the brain, but a spreading infection. If he weren’t sedated, he would have shown all signs of meningo-encephalitis.”
“Oh, Dimitri!” Of course. His brain was exposed to the elements through the fracture. But in that case… “Oh, God, Dante, he’s been on massive post-operative corticosteroids—they can suppress immunity and promote infection!”
Dante glared at Emilio. “You didn’t mention corticosteroids!”
Emilio glared back. “You’re the surgeon. You should know what goes on post-operative medication orders!”
“Well, you can strike them out at once!”
Emilio strode to the ICU nurse, relayed the new orders, anger clenching his every muscle.
Gulnar interrupted their sparring, still thinking, all the pieces falling into place. “So there was no cerebrospinal fluid leaking from his nose because he’d been on his back, with his head extended backwards!”
Dante came to stand beside Gulnar, his eyes sweeping her with appreciation, respect. Yes, but there was more. Regret. Sadness.
He nodded. “Another misleading lack of evidence. You were absolutely right to suspect the worst, to get me here. It was uncanny how you felt his danger against all evidence.”
She held herself rigid, swallowed a barbed lump of agitation and longing. “But why aren’t the antibiotics doing their job now?”
“Not even broad-spectrum antibiotics are good at crossing the blood-brain barrier, at least not at the concentration needed to treat such an acute and severe infection. And, anyway, the area has very poor blood supply right now. Not much antibiotic-loaded blood is making its way there.”
Everything made perfect sense, the explanation to her instinctive diagnosis. “Do you think there is a dural tear, too?” If the frontal bone was fractured, it might have torn the outer brain covering attached to it as well.
“Very likely.”