The stench of iron hung heavy in the air from the blood that spewed from the wounded. Through blank and pallor faces, some stared out into nothingness as shock deadened reality. Others winced and grimaced with each breath they took, and still others cried out in agony, each time dying a thousand deaths.
Hearing the suffering of their countrymen only served to stiffen both doctors’ resolve to save more men. Throughout the day and into the night, the two surgeons worked frantically to save the injured and the dying. As their exhaustion set in, and hysteria and despair overwhelmed them, they searched within themselves for the strength to continue. Eventually, their own bodies and minds began to fail them. They had pushed themselves to the limits of human endurance. With the battle not yet complete, they both knew that tomorrow would bring further death and pain. If they were going to be of service to the young men risking their lives for their country, they both would need some much deserved rest.
With the last flicker of light from the nearly spent oil lamps, the blood soaked surgeons made their way across the other side of the clearing to their two canvas tents. With a quick change of clothing, they laid down on their cots and fell quickly asleep.
TT: Chapter 3
June 8th, 2005
Elanger Hospital was a bustling modern hospital with four branches spread out on each side of the city of Chattanooga; north, south, east, west, and one at the center of the city, accounting for five in total. Regarded as a teaching hospital, they developed and performed the latest cutting-edge medical techniques, producing some of the finest medical staff in the country; although all too often the advancements came as a result of the gang-related violence that erupted within the inner city, many times catching the innocent in its crossfire.
Dr. David Warner burst through the swinging wooden double-doors and headed to the scrub station.
"Ok, what do we have?" he asked as he turned on the water and pulled on the soap dispenser, releasing a large dollop into his hands. Vigorously he scrubbed from his fingertips to his elbows as he listened to his supporting staff inform him of the emergency.
"Doctor, we have a gunshot victim with an entry and exit wound between the seventh and eighth rib, entry through the abdomen. Her belly's distended, must be filling up with blood. Her vitals are low, about eighty-five over sixty. Her Foley output is bright red and she’s hypovolemic from the blood loss. Triage has intubated her and already infused 2 liters of plasma," replied surgical resident Kerry Stadler, as he too scrubbed in for emergency surgery.
"So she's prepped?" Dr. Warner asked.
"Yes, doctor. Prepped and ready," Dr Stadler replied.
"Films?" Dr. Warner asked in abbreviated speech, a function of his occupation.
Before he could receive an answer, surgical nurse Jill Edwards burst through the door. Pulling her mask from her face, she anxiously reported, "Doctors, you'd better hurry. Her vitals are dropping fast. BP is eighty over fifty-five, pulse ox is eighty-five."
Without hesitation, Dr. Warner quickly responded, "Gloves and gown, now! And set up a thoracotomy tray, along with a laporatomy just in case."
Both doctors washed the soap from their hands and arms quickly as the pressure and anxiety of the situation worsened.
“Should we get an ultrasound in here?” Dr. Stadler asked as he started to tie his gown.
“Yes, STAT!” Dr. Warner replied urgently.
As the two doctors quickly donned their attire, Nurse Edwards pulled on her protective mask and rushed back into the OR to prep the ultrasound equipment and set up the thoracotomy tray.
Moving through the double doors, Dr Warner heard the sounds of alarms as the medical equipment coldly reported a patient in crisis. He scanned the various devices as the patient’s levels continued to drop into the danger zone.
As he rushed to the patient’s side, Dr. Warner's eyes widen in disbelief as he realized the age of the tiny victim. "My god, she’s just a baby. How old is she?"
"Eight years," Nurse Edwards replied, her voice sadly exposing what her mask disguised.
“What’s her name?” Dr. Warner asked.
“The chart says Lena Williams,” Nurse Edwards replied.
Shaking his head in disgust, he listened as the cardiac monitor sounded slower beats and become erratic. Immediately, he reacted out of instinct.
“She needs volume NOW. Hang another two on the rapid infuser,” He said, his voice showing the strain as the youth of his patient weighed heavy in his mind.
“BP's seventy over fifty and dropping, pulse ox is eighty-two,” Dr. Stadler informed his mentor and colleague.
“I just lost her pulse,” nurse Edwards cried out as the cardiac monitor sounded the unmistakable tone of ‘flat line’.
“Push an amp of atropine. Charge the paddles to fifty,” Dr. Warner retorted back.
Nurse Edwards quickly wheeled over the defibrillator and programmed the setting to Pediatric, while charging the external paddles to fifty joules. She quickly handed them to Dr. Warner, then injected an amp of atropine into the patient’s IV.
As Dr. Warner prepared paddles, Dr. Stadler scanned the young patient’s belly with ultrasound. Rotating the small metallic wand at various angles, images showed on the monitor, confirming their suspicions of the hidden trauma.
Having applied conductive gel, Dr. Warner placed one of the paddles to the upper right clavicle, and one just below and to the left of the young patient’s left nipple.
“Clear,” Dr. Warner called out.
Dr. Stadler broke off his examination just as Dr Warner depressed the buttons on the paddles, delivering a charge to the heart as well as other nearby organs.
The patient’s body convulsed from the current coursing through her. Her chest heaved and expanded, then fell and contracted back onto the table. The three medical personnel focused on the cardiac monitor for signs of activity. They held their breath in vain: the monitor continued to report a single monotone sound of flat line.
“Still in V-fib,” Dr. Stadler cried out. Desperation could be heard as he spoke.
“Fifty again,” Dr. Warner called out once more. He replaced the paddles in the previous locations and delivered a second charge. Again the tiny patient's body convulsed. As the three waited for the electrical shock to dissipate and reset the heart, the cardiac monitor registered a single ‘beep’, then another and still another as the young patient's heart began to return to its singular function, pumping life's blood once again through her tiny body.
“Sinus tach,” Dr. Stadler cried out in relief.
Dr. Warner roughly placed paddles back on tray. “Ultrasound?” he asked Dr. Stadler, who had now resumed his examination, nervous sweat beading up on his brow.
“Belly's full of blood. Looks like some major hemorrhaging where the bullet hit the spleen, pancreas and kidney. Eighth rib is broken too.” replied the Dr. Stadler, now regaining his composure.
“OK, eight blade,” Dr. Warner requested.
Instantly, Nurse Edwards handed him a scalpel from the tray of stainless steel instruments, butt end first, taking care not to slice her own hand as she pulled away.
Even with years of experience, the thought of slicing into the poor little girl that lay in front of him felt offensive. Dr. Warner strengthened his resolve and made his incision, cutting through the various layers of tissue as blood flowed freely from the opening. Immediately the unmistakable stench of blood and fecal matter wafted through their protective masks.
He finished the incision and called, “Clamp.”
Nurse Edwards placed the clamp in his hand. Dr Warner positioned the clamp, holding open the incision as he tried to examine the damage through the draining blood.
“Suction,” Dr. Warner called out.
Dr. Stadler inserted the probe into the incision and began to suck out the excess blood.
“Careful; watch the trauma. Work around the transverse colon. Clean out as much of that fecal matter as possible,” Dr. Warner cautioned as Dr. Stadler worked.
“Got it,” Dr. Stadler replied, carefully sucking up the blood and debris from the abdominal cavity.
With a better view, Dr. Warner could now see the damaged organs more clearly. It was apparent the spleen, pancreas and colon, as well as the left kidney had some form of trauma.
“I need a 4-0 prolene and an R.B.-1 needle, now. Anyone know the caliber of bullet?” Dr Warner asked, as Nurse Edwards handed him the needle and suture.
“Doesn't look small, that's all I know,” replied Dr. Stadler, still suctioning the colon.
“Looks like about a .22,” Dr. Warner informed. “Small entry wound, but heavy internal trauma from the shockwave as it passed through at the high velocity.”
“Shockwave?” asked Nurse Edwards.
While Dr. Warner worked to repair the damaged spleen, Dr. Stadler answered Nurse Edward's question.
“As a bullet travels, it pushes the air out of the way, creating a field of turbulent air around the bullet. That air around the bullet, the shockwave, has almost as much destructive force as the bullet itself: so instead of a quarter of an inch bullet causing damage, you have to add the inch of shockwave to the problem too,” Dr. Stadler said.
“Awful, just awful,” Nurse Edwards replied sadly.
“Stats!” Dr. Warner called out as he quickly worked.
“BP seventy-five over fifty, pulse ox eighty,” replied Nurse Edwards
“She's bleeding everywhere,” Dr. Warner complained. He turned to Dr. Stadler and instructed him to repair the transverse colon. “Looks like we have a small puncture in the transverse colon. Can you repair it while I attend to the spleen?”
“I'm on it. Eight blade with suction, and a 4-0 and an R.B.-1 standing by,” Dr. Stadler rattled off in quick succession to Nurse Edwards.
Like a gentle father teaching his son, Dr. Warner delicately cautioned Dr. Stadler, “One thing at a time,” he said, then added, “Work frantically in control.”
“Gotcha,” Dr. Stadler replied, slightly embarrassed by his over zealousness.
As they both worked frantically to repair the damaged organs, the flow of blood went on nearly unabated. Nurse Edwards kept a careful eye trained on the monitors as well as the doctors, anticipating their needs before their requests.
“Doctors, BP is dropping again, sixty-five over forty-eight. Pulse ox is very low: seventy-seven,” Nurse Edwards announced.
“Dammit, where is she bleeding from?” Dr. Warner asked rhetorically.
“We're working the areas now, Dr. Warner,” Dr. Stadler replied.
“No, no, with this much blood loss there has to be a much larger source, like the vena cava or the aorta,” Dr. Warner speculated.
“We're nowhere near those areas. The bullet exited out her back, through the kidneys,” Dr. Stadler replied.
“I know, but this much blood loss isn't adding up. The bullet missed the renal and spleenic veins and arteries. This can't be from just the organs,” Dr. Warner replied.
The two doctors worked feverishly to repair the damaged and bleeding organs as the patient’s vitals continued to fall. Having repaired the spleen and the transverse colon, the two moved onto the pancreas and left kidney.
“More suction, Kerry,” Dr. Warner instructed Dr. Stadler. He then glanced up and asked Nurse Edwards, “How's our supply?”
“She taking blood faster than we can give it,” she retorted back instantly.
“Hang another two units,” Dr. Warner requested anxiously.
“Dr. Warner, do you see this?” asked Dr. Stadler. “Would you agree that the bullet entered the abdomen, broke the rib and continued through the spleen, pancreas and out the kidney?”
“It appears that way, why?” Dr. Warner asked as he worked on the kidney.
“There seems to be an abrasion heading up into the upper posterior peritoneum,” Dr. Stadler said, as he lifted the pancreas slightly and pointed to an abrasion that angled up toward the middle of the patient’s body instead of down and through it.
“Dammit, you know what that is? That's another entry wound,” Dr. Warner replied. “Eight blade and sternal saw, STAT!” he said to Nurse Edwards.
“Two bullets? But there’s only one entry wound,” Dr. Stadler replied in disbelief.
“I know. Two bullets entered through the same location,” Dr. Warner responded as he accepted the scalpel from Nurse Edwards and began to make a long incision down the patient’s breastbone. “I knew something wasn't right. A .22 caliber can't break a rib, then have enough energy remaining to tear through all these organs. There had to be more than one bullet, and I'm betting it’s also the cause for the massive blood loss,” he explained as he finished his incision.
“What are the odds of that happening? I mean, two bullets with the same entry wound?” Dr. Stadler asked rhetorically, shaking his head now in further disbelief.
“Stenal saw,” Dr. Warner asked next, then added, “I never would have guessed it if I hadn’t seen it with my own eyes.”
Quickly, Nurse Edwards handed Dr. Warner the saw. Placing it at the base of the sternum, he began to cut through the breastbone, the smell of bone and blood penetrating through their masks and into their nostrils. Moments later, he was done.
“Rib spreader,” Dr. Warner requested.
Anticipating his request, Nurse Edwards handed him the instrument immediately. Inserting it directly into the incision, he turned the lever and separated the ribs enough to view the upper chest cavity.
“Probe,” Dr. Warner requested from Nurse Edwards. He then called to Dr. Stadler to begin suctioning the open areas. As he did, Dr. Warner examined the cleaned areas.
“More suction. I need more suction,” Dr. Warner asked with frustration. “Oh man, we have trauma to the inferior vena cava. I need a 4-0 and an R.B.-1, STAT!”
Working feverishly to repair the profuse bleeding, the needle contacted something hard. At first he thought it was a rib fragment, but upon closer inspection Dr. Warner realized it was the second bullet.
“There it is. Forceps,” Dr. Warner requested with an almost frantic tone.
He inserted the forceps into the cavity, gently pushing aside the still-bleeding vena cava and gently extracted the deformed and mangled bullet.
“Wow. The edges are like tiny razor blades. They sliced through the veins on contact,” he announced. “There must be a dozen fissures to repair.”
As he unceremoniously tossed the clamped bullet and forceps into a stainless steel container, he continued to suture the tears to the damaged vein and surrounding organs.
Moments later, Dr. Warner watched as the heart began to slow. Just then, the cardiac monitor sounded. He quickly placed his gloved fingers around the heart and began to squeeze, attempting manual heart compressions even before Nurse Edwards could speak.
“Doctor, she's in PEA,” Nurse Edwards announced.
“Push another amp of Epi and charge the internal paddles to fifteen,” Dr. Warner demanded.
Handing him the paddles, they watch as he inserted them into her chest cavity and placed them on the still heart.
“Clear,” Dr. Warner called out he depressed the button and sent the shock directly into the young patient’s heart. As they listened for signs of life from the cardiac monitor, reality set in. There were none to be heard.
“Charge to twenty. Another 6 milligrams now. Clear!” Dr. Warner frantically called again.
He shocked the heart, sending the current deep within, but to no effect. The cardiac monitor continued to report its menacing tone – flat line.
“Asystole… God dammit.” Dr. Warner shouted out loud.
As he continued with manual compressions he called out once more, “Charge to thirty.”
Inserting the internal paddles again, he delivered a massive jolt to the patient's heart. In horror and sadness, they watched the monitor register no change.
Dr. Warner frantically searched his mind for a solution as he continued manual compressions. Even with his years of education and training,
the damage was too extensive for him to overcome. He pulled his hands from her chest and stood back. With his gloved hands dripping fresh blood onto the floor, he hung his head low.
Tear In Time Page 4
