Foreign Threat

by Mitchell Goldstein

  No sooner did Steve make it through the doors than Jake appeared out of nowhere. They almost collided as Steve was on his way out to meet the victim on the ambulance. “Glad you could join us, Dr. Douglas. I thought maybe you were going to skip town on us at this crucial moment.”

  Jake smiled as if he had cracked a joke to himself, “Now, now, Dr. Carmichael. I would never let you sink on your own, though I know without a doubt that you would be able to handle most anything that would come into the ER.”

  They continued out to the rig. On the gurney was a person lying limp on the backboard, moaning but not moving. The person’s face, shirt, and pants were covered with blood. One shoe was missing, and the remaining one was covered with blood and glass.

  Steve noticed the lack of IV tubing and fluid. “Hey, why don’t you guys have any fluid running?”

  “You gotta be kidding, rookie!” one of the paramedics said with a condescending tone. “We just scoop and run with these babies. You big doctors can fix them all up here.” The two paramedics laughed as they took the gurney out of the ambulance. The condescending paramedic continued talking to Steve. “Alright, rookie. We have a very nice but unfortunate woman who was minding her own business driving some place when some asshole T-boned her. Probably some drunk shithead. He probably doesn’t even know what happen. We just scooped her up and ran. She has just been moaning since we got her into the rig. She has a thready pulse, and her systolic was never more than the 90s. Her breathing is almost absent.” He saluted. “Good luck, boys and girls.”

  Steve looked up. He hadn’t realized that they were already in the trauma cell. Some people thought of it as the stabilizing room, but that’s what the surgery interns referred to as the trauma room. Since the surgery interns got dumped on so much, especially during the traumas, they perceive the trauma experience as a life sentence without parole.

  “One, two, three, and go,” said a charge nurse.

  Everyone took a hold of the backboard and lifted the unfortunate patient to a center table. The hustle of a trauma code started.

  “Ok, Carmichael,” said Jake. “What is the first thing we need to do in this situation?”

  Steve didn’t hesitate. “Primary survey,” he shouted as the noise level continued to escalate.

  “Go on, Dr. Carmichael.”

  “The first thing is airway, and then breathing.”

  “So what about it?” asked Jake.

  “Well, her breaths are pretty shallow.”

  “Pretty shallow?” shouted Jake, “She is barely breathing, Carmichael! My cat snores louder than that. What should we do?”

  “She needs to be intubated.”

  “Then let’s rock, or you are going to lose her, not that she has much of a chance,” Jake bellowed pessimistically.

  “Get me a 71/2 tube and the rapid sequence intubation kit, and give ten of succnicoline and-”

  “Steve!” shouted Jake. “She is about to arrest. I don’t think she will give a flying shit if you stick that tube into her trachea. She may, in fact, appreciate that you are saving her life. Let’s go!”

  Steve grabbed the laryngoscope and began to slide the narrow plastic tube into the patient’s airway. He stopped for a moment just before forcing the tube down into the lung. “Hey, ma’am, can you move your legs for me? Can you move your arms for me?” He could see her attempting to move. She did make a slight motion with both her arms, but her legs never moved. “Alright, let’s be careful. She may have a cervical injury. Jake, stabilize her head!”

  “Good going, Carmichael. Way to plan ahead. It’s nice to know what kind of neuro status she may have prior to paralyzing her.”

  Steve continued to intubate her. “Suction!” he shouted.

  Her face and hair were covered with blood. The scent of dried blood was like the smell of a drunk after puking a pint of liquor. Steve tried to ignore it the best he could. He and Jake were careful so as not to move the head around too much just in case there was a cervical neck fracture. However, blood was obstructing her vocal cords. The suction was used to help clear the blood in order to help provide a clearer view of the cords, thus enabling the tube to glide in the correct spot between the two vocal cords instead of sliding down into the esophagus.

  After Steve placed the tube and felt he was in the correct place, the respiratory therapist gave a few breaths with the ambu bag. The CO2 monitor read about forty-two, which was normal and confirmed that indeed the breathing tube was in the airway.

  “Nice going, Carmichael. What’s next?”

  Steve asked loudly, “Who has the pressure?”

  A small voice was sounded from the corner where a nurse was documenting everything. “86 over 40, and her pulse is 125.”

  Steve continued, “Let’s get two bags of LR hanging wide open. This lady is in shock! Let’s get some trauma labs drawn including an ABG. Where is X-ray? We need a C Spine Chest and Pelvic X-ray.” He glanced at Jake.

  “Doing good, Carmichael. I think we should get four units typed and crossed and start giving universal donor blood. I agree that she is in shock, and she no doubt is bleeding aggressively somewhere, maybe her pelvis or chest. Let’s start using blood as volume. Steve, what about the Primary Survey? Where are we?”

  “We are getting ready to expose and look for any external injuries and neuro deficits.”

  “Good,” said Jake, “but you missed something major.”

  Steve focused on his actions thus far. He could not think of what Jake had in mind. “I’m not sure what you are-”

  Jake interrupted him. “You got this lady intubated with good CO2 levels, but we have not listened to her.”

  While Steve and Jake were carrying on their conversation, the x-ray tech was taking pictures. Neither doctor paid attention to the fact that they both were unprotected from the x-rays without lead aprons.

  Steve acknowledged the breathing issue. He pulled a stethoscope off a nurse and listened to the patient’s chest wall.

  “Shit. I don’t hear anything!” Steve shouted frantically.

  “I gathered as much.” Jake smiled. “The left side of her chest is not moving with inspiration. She may have a tension pneumo. That might even be why she has a low BP and is tachyardic. Let’s get a chest tube in and see what that does to her vitals. How are you with chest tubes, Carmichael?

  Have you done any yet?”

  Steve thought about lying but knew that risked killing her. “I have assisted on a few, but I have not yet had the chance to do one solo.”

  “You assist in surgery, Carmichael, but you have either put a tube in or not.”

  Steve replied honestly, “Not.”

  “Alright, Steve. Let’s get going. Someone get the chest tube tray and get the chest tube reservoir set up, NOW! Steve, get

  your gloves on and rock!”

  Steve didn’t wait. His gloves and gown were on in a few seconds, and Jake handed him the materials he needed. Steve knew the patient’s injuries were serious and life threatening. He almost felt that Jake should put the tube in quickly and then they could continue to assess her, but he didn’t have the chance to voice his thoughts. It was time to place the tube.

  “What size tube do you want, Carmichael?”

  Steve responded without hesitation. “A 40-French so we can evacuate both air and blood that maybe in the plerual space.”

  “Perfect, Steve. So here is your tube.” Jake pulled a chest tube from the drawer and opened a 40-French tube.

  Steve was motionless as the tube was opened for him. He realized that Jake was not gloving up. He was on his own for this one.

  “Aren’t you gloving for this?” he asked, just to be sure.

  “I told you before, rookie, no assisting for chest tubes. Get a move on it, or this lady is going to code!”

  Steve took the tube and turned toward the patient. He stared for a long moment before he began painting her left chest with betadine. His heart was racing, and he could feel every beat. As he reached for the ste
rile towels to drape the patient, he could see his hand shake uncontrollably. He knew that it was just the adrenaline running through his body. He grabbed a syringe in order to draw some Lidocaine to numb the skin before making the incision.

  “What are you doing, Carmichael? She is about to code! Believe me, she won’t feel the knife. She is somewhere between here and heaven, so let’s move!” shouted Jake.

  Steve took a 15-blade knife, and at the nipple level in the mid axillary line, he made a 2cm incision. He then dissected the

  tissue and muscle above the rib.

  Jake was correct: she did not so much as flinch with these maneuvers.

  As Steve continued with the chest tube, Jake managed the trauma code. He walked over to the x-ray view box and looked at the chest x-ray as the tech was putting it up. “Shit, Carmichael, you better hurry up. There is a total collapse of the left lung. Move, move, move!” Jake looked over his shoulder at Steve who was slowly dissecting the muscle off the top aspect of the rib. “Come on, Steve. Just pop the damn clamp through the muscle superior to the rib!”

  Steve looked up at Jake and back at the clamp.

  “Steve, let’s go! This should only take a second. She is about to crash and burn.”

  Steve took the clamp, felt the rib, and pushed gently to the top of the rib. Then he pushed hard, but nothing happened. He leaned into it with his force of his body and felt finally a pop. He carefully spread the clamp. The entire room heard the loud rush of air as the tension was released.

  Everyone shouted to congratulate Steve on his first chest tube.

  “Good going, Carmichael,” said Jake. “Let’s see what her BP jumps up to. Who’s got the BP responsibilities tonight?”

  One of the nurses alongside the patient was taking a manual BP. “100 over 50, doctor.”

  “Okay, Steve, what else can we do for this lady? Her pressure is still sagging. I don’t think the tension pnemo is her only problem. What do you think, pal?”

  Steve tried to provide the right answer. “She probably has

  some serious internal bleeding going on. Maybe we should do a DPL to see if there is free blood.”

  “No doubt, Carmichael. While we get the DPL kit, what

  next? Is there anything else we can do to get that pressure up?”

  Steve had a thousand questions whirring through his mind. What about the pressure? What about the peritoneal lavage they were about to set in motion? What kind of neuro trauma had she suffered that she is not responding to barely any stimuli? The list of concerns continued. “Well, she needs volume, and if the blood is not here yet, then I would just pour in Lactated Ringers.”

  “Good,” said Jake. “How are we doing for blood?”

  “Dr. Douglas, blood is on the way from the blood bank, but we have a problem, sir.”

  “What now?” he demanded.

  “We can’t get another line in her. She must be so volume depleted that all her veins are flat.”

  Jake faced Steve again. “Alright, Carmichael. We only have one line. What the hell do you want to do next? Don’t just think, Carmichael! She doesn’t have the time. What is next?”

  Steve took charge and shouted, “Someone grab me a central line kit pronto!” He stepped up to the patient’s left side to start on that side for central line placement. With his bloody gloves, he tore the woman’s blouse on the left side of her chest in order to do a sterile prep and drape of the shoulder and neck. Steve was so aggressive that he tore the entire sleeve off.

  Jake gasped.

  Steve was set on autopilot and took an extra moment with the other OR crewmembers to register disbelief. The room became quiet for what appeared to be an eternity but lasted only a few short seconds.

  One of the nurses was busy calculating the chest tube suction when she realized the slight pause in the high-energy activity. As she glanced at the bare left arm, she cried, “Oh my

  God. It can’t be! Oh shit, it just can’t be!”

  On the patient’s upper arm was a tattoo of a pink and white dove. It was the most recent tattoo that Karla in the OR had painted on her left arm.

  “Give me a wet towel, now!” yelled Jake.

  As the doctor began to wash off the blood from the woman’s face, the OR nurse began to scream. “Oh, shit, it just can’t be. Not again, damn it!” She dropped the chest tube device and left the room sobbing.

  “Alright people, let’s keep it together. This looks like our patient is Karla, but let’s keep it going. We have to. We have to for Karla. Steve, keep that idea of the central line going. Let’s prep, and I’ll give you a hand with this central line. On second thought, why don’t you let me put this line in?

  I’ll promise you the next one.”

  Steve was relieved. “That sounds like an excellent idea.” He quickly backed up.

  Jake moved up to Karla’s left side and started to place a central line in her subclavian vein.

  A voice from the foot of the bed announced a dramatic

  change in the vital signs. “Oh shit, her pulse is beginning to drop. Oh shit, there she goes. Doctor, she is down to the thirties.”

  “Alright, alright,” Jake replied. “Go ahead and give her-”

  “Doctor, she just went into Vtach. Oh shit, make that Vfib!”

  Jake shouted, “Steve, go ahead and start chest compressions.” He looked at another nurse to rattle off more orders. “Let’s give a hundred of Lido and charge at 200. Where the hell is the blood? Damn it!” He ordered a third nurse to go check on the blood. “CLEAR!” Jake shouted. He waited a second to allow people helping around the bed to drop what they were doing and step back from the table.

  A small clicking sound was heard, and Karla’s limp body

  sprung up off the bed a few centimeters. Her arms flailed with the jolt of electricity that flowed through her body, but no solid pulse was noted on the screen. Just evidence of Vfib with a squiggly line for a pulse.

  “Recharge up to 360 joules. Let’s go! Let’s go, people!” Jake shocked her again but nothing changed. The EKG on the monitor just showed a flat line. “Damn it!” shouted Jake. “Alright, let’s get a chest tray NOW. We have to crack her chest. Someone put an NG down.” Jake looked at Steve, “An NG will go into her esophagus and help us delineate the esophagus versus the aorta. Since there is no heartbeat now, the aorta will feel just like a hollow viscous. The NG will help determine which is esophagus and which is the aorta. Then we can clamp the aorta and stop the ongoing internal bleeding that is presumed to be causing her shocky state.”

  Steve listened and took mental notes.

  “Let’s give an amp of epi! Where the hell is the ches tray,

  people?” Jake was shouting orders as fast as people could get them done, but the fact of the matter was that Karla was quickly losing ground. Everyone knew it.

  “Dr. Douglas, are you sure you want to crack her chest?” The voice was familiar to the surgery residents. Agusta, the ICU nurse, was there helping with the trauma code. “I mean, seriously Jake, she has been here for about thirty minutes with barely any perfusion to her organs. Are you really going to improve her life, or are you trying to make yourself feel better about this terrible accident?” Agusta put her hand gently on his shoulder.

  “She is screwed either way, but her only chance for surviving this is to crack her chest and get that aorta clamped.

  Then I can get her to the OR and-”

  One of the other nurses quickly interrupted Jake’s attempts

  at justifying his plans. “Dr. Douglas, she is flat line. She has had one amp of epi and a hundred of lido, not to mention several shocks.”

  Jake looked up at the monitors and saw the flat line. “Try another amp of epi and a milligram of Atropine. Charge me up again to 360.” It was as if Jake was ignoring the pleas of the nurses to let this poor young lady go. “CLEAR!”

  Yet another shock of electricity was delivered through the paddles on Karla’s chest. Her body sprung up as it had before, but the attemp
t was futile. She was still in asystole.

  Jake looked up at the monitor and then down at Karla. He didn’t move for about a minute before glancing at the clock. “Unless someone objects, we’ll call the code at 12:34 A.M.”

  The room was silent. Not one person made a vocal objection. One of the nurses disconnected the Ambu bag and the leads to the monitor. Another nurse took a wet cloth and began washing the blood off Karla’s limp body. Yet another person was finishing her charting. People were slowly picking up their tasks but not saying much.

  Agusta approached one of the police officers who was standing near the trauma cell. “Hey, have any of you nice boys located kin nearby?”

  “We have not made contact with anyone from her home. We will stop by in a few minutes. We are trying to get some information on the vehicle before we tell her family. As it stands, we probably have a drunken guy who seemed to have fled after the accident. His car just reeks of alcohol. And the real bizarre catch to this whole mess is that there are no plates or license for the car. Right now, I don’t even know where the car is from, not to mention who was driving it.”

  Steve was leaning against the counter nearby, listening to the entire conversation and becoming just as confused as

  Agusta.

  “Well,” Agusta blurted out, “if you don’t have the plates or the driver, can’t you get the serial number on the car and trace the records that way?”

  One of the officers answered, “Why, yes, we can, ma’am. The only problem is that the serial number of the vehicle, the engine, and some of the car’s insides are all missing. Very strange indeed. But before we go over to Karla’s home and make contact with her family, we would like to have some more concrete information. Right now, I can’t tell them jack shit.”

  Steve continued to listen to the conversation. Why were the police unable to trace the car that took Karla’s life? He straightened up and headed back to the center of the trauma cell to help clean. As he worked, he played back most of that conversation, trying to piece together some of the missing links. Where was the driver? Was he hurt? How did he manage to leave the scene, and why was the car untraceable? These were some serious questions that needed to be answered. The more Steve thought about it, the happier he was about being a doctor instead of a detective.