by Radclyffe
“Congratulations,” he said, untying Arly’s brown belt. He slipped the black belt around her waist and tied it.
Arly’s arms snapped to her sides and she bowed. “Thank you, Sensei.”
He returned her bow. “Dismissed.”
Arly raced over to Quinn and Honor. “I did it, did you see me?”
“Great job.” Quinn slung her arm around Arly’s shoulders as Honor circled her waist.
“Congratulations, honey,” Honor said.
Arly took a deep breath. “I’m really glad I passed.”
“Never a doubt,” Quinn said.
Arly grinned. “Kino is really tough. I might’ve gotten lucky with that spin kick.”
Quinn laughed. “You know what I always say—”
“Better lucky than good?” Arly shot back.
Honor rolled her eyes. “Luck had nothing to do with it. It’s training.”
“That always helps too.” Quinn’s beeper vibrated, and she frowned. “Huh. I better get this.”
“I thought you weren’t on call tonight?” Honor said.
“I’m not. Probably a mistake, but I ought to check.”
“Go ahead. We’re good here.”
As Arly packed up her gear, Quinn stepped out into the hall and dialed the extension.
“TICU,” a man said.
“Maguire. Someone paged?”
“Oh, right…hold on for a second. Hey, Nalini, I’ve got Dr. Maguire.”
A few seconds passed. “Dr. Maguire, it’s Syd Stevens.”
“Hi, Syd. What’s up?”
“Really sorry to bother you, but Dr. Hassan must be out of beeper range. We’ve been trying to get him. It’s about a post-op patient from today.”
“The girl with the spine fracture?”
“Right.”
Quinn listened, mentally sorting options as Syd gave her a rundown of what had been happening. “So what do you think?”
“I think we have to be sure there isn’t an intra-abdominal bleed. It could be neurogenic shock, but if we’re wrong, and she crashes—”
“Have you called CT?”
“Yes, they can take us now.”
“Do it. I’ll be there in a few minutes.”
“I’ll call you—”
Someone shouted in the background. “She’s crashing.”
“I gotta go,” Syd said and disconnected.
Quinn stuck her head back in the dojo and caught Honor’s eye. “I gotta go.”
* * *
“What happened?” Syd said breathlessly as she raced back to Cindy’s bedside.
“Her pressure dropped out,” Emmett said.
“I can’t get a pulse,” Nalini said, letting the side rail down and opening Cindy’s gown.
“Rapid V-tach,” Emmett said and began chest compression.
“Give an amp of epi.” Syd grabbed the defibrillator paddles. “Charge to one twenty.”
As soon as Nalini had the pads attached to Cindy’s chest, Syd applied the paddles. “Clear!”
She discharged the defibrillator and Cindy’s body jerked. She tried not to think about what the sharp spasm might be doing to her spine. What mattered now was stabilizing her rhythm and getting her blood pressure back to a normal level, or it wouldn’t matter.
Breathlessly, she stared at the monitor. The cardiac rhythm went from the sharp sine waves of ventricular tachycardia to the erratic blips of fibrillation. Cindy’s heart was not beating, just fluttering in her chest, unable to pump blood.
“Charge to two hundred.” Syd re-applied the paddles. “Clear.”
Emmett lifted her hands and waited for the jolt of electricity to pass back and forth between the paddles. Syd watched the EKG. The rapid fluttering disappeared. Flatline.
Her stomach plummeted. “Give her another amp of epi and charge to three hundred.”
She positioned the paddles one last time.
“Clear.”
Syd waited, time suspended, her gaze riveted on the EKG. The alarm continued to sound, signaling the absence of a detectable rhythm. Syd’s heart rate skyrocketed. A second later, a normal beat spiked on the flatline. Then another. And another.
They’d gotten her back.
“Pressure?” Syd asked, her voice hoarse.
“Pressure’s sixty palpable,” Nalini said. “Still can’t get an audible.”
Another TICU nurse appeared in the doorway. “The lab called. Her hemoglobin is seven.”
“Down from ten earlier.” Syd glanced at Emmett across Cindy’s still body. “She’s got to be bleeding. She’s too unstable to take down to CT. We need to get her to the OR.”
“I’ll let them know you’re coming,” Emmett said and sprinted out.
Syd helped Nalini get Cindy ready for transport. She couldn’t leave her side now in case she arrested again. Once they reached the OR, the surgical team guided the bed in and Syd went to scrub. Quinn arrived just as she finished scrubbing.
“What’s the status?” Quinn grabbed a mask and tied it around her neck.
“We can barely keep her pressure up. We cardioverted her three times in the TICU. I didn’t think we could risk having her crash in CT.” Through the windows above the scrub sink, Syd watched Emmett and the OR team transfer Cindy to the table.
“What’s your plan?”
“An open abdominal tap. If we find blood, we can convert to a laparotomy.”
“Got enough help?”
“I can assist Emmett if—”
Quinn shook her head. “Why don’t you start. Emmett can assist, and I’ll just put my head in when you know what’s going on.”
“Right.” Syd finished scrubbing, backed through the door and spun around as the scrub nurse held out a towel. She dried her hands. “Go scrub, Emmett.”
Quinn followed her in. “Go ahead, Emmett. I’ll get her prepped.”
Emmett didn’t hesitate. “Thanks.”
Syd took a deep breath, slid her arms into a sterile gown, waited while the scrub nurse held up her first glove, and pushed her hand into it. By the time the second glove was in place, Quinn had the abdomen prepped and Emmett had returned. A minute later, Cindy’s face was obscured by the green sterile drapes. Only the rectangular patch of her abdomen was visible.
Syd stepped up to the table, held out her hand, and said, “Scalpel.”
Chapter Nineteen
Scalpel in hand, Syd looked across the table into Emmett’s eyes. Emmett looked back, her gaze warm and steady. Quinn was in the lounge if they needed her, but here at the table there were only the two of them. Sometimes all they had were seconds to act, mere heartbeats in time to make a save or lose a patient. Here everything hinged on trust as much as skill. More, sometimes. Here, trust gave you the courage to be more than you thought possible.
“Ready?” Syd murmured.
“We’re good.”
Syd had time for a fleeting thought before she lowered the blade. Here in this moment, they were good.
She made a two-inch incision starting right below the navel and moving downward. Emmett sponged the blood away and Syd switched to the cautery to divide the underlying fat and muscle tissue until she reached the thin covering of the abdominal contents. Emmett had the short right-angle retractors ready and inserted them into the incision, pulling them apart to give Syd enough room to safely divide the last barriers. Once she’d breached the peritoneal cavity where all the vital organs were contained, she planned to insert a scope to determine if there was any bleeding, even a small amount.
“Scissors,” she said and held out her hand. The handle slapped her palm, she slipped her fingers around it, and she snipped the filmy fascia. Instantly, bright red blood welled up into the wound. Her stomach tightened.
“We’ve got free blood,” she said evenly.
“Pressure’s dropping,” the anesthesiologist announced.
Emmett asked him, “Are you hanging blood?”
“Second unit,” he replied.
Syd said, “Better c
all for two more. She was only seven to start and she’s actively bleeding. And someone call Dr. Maguire.”
“I’m here,” Quinn said from the corner of the room.
Syd hadn’t noticed her come in. Without looking up, she said, “We’re going to need to extend the incision and get a good look around.”
“Sounds like a plan.” Quinn pulled a stool over near the wall and sat down. “Go ahead, let me know what you find.”
Emmett said, “Can we get another suction up here.”
“Knife.” Syd started several inches above the navel, curved around it, and cut down all the way to the lower abdomen. Once she’d entered the abdomen, Emmett placed the self-retaining retractors and cranked them open. Instantly, the intestines ballooned into the field, moist and pink and healthy looking. A sheen of blood covered everything.
“Moist lap pads,” Syd said.
She and Emmett quickly used the ten-by-ten cotton pads to cover the bowel, and with one hand, Syd pushed it off to the side so she could get a look at the other organs. The liver filled the right upper quadrant, glistening bluish-red and undamaged. Blood continued to pool in the deeper recesses, obscuring her view of the stomach and spleen.
“Can you give me a little more exposure in the left upper quadrant,” she said.
“Hold on,” Emmett said, repositioning her retractor and leaning back a little to open up the space where Syd needed to see.
Syd gently lifted the bowel to check the stomach and vessels entering from the aorta that lay along the spine. The stomach and spleen all looked good, but fresh blood dribbled down the left side of the abdomen and pooled in the pelvis. When she scooped out the last of the small bowel she saw it. Blood seeped out of the fan-like sheath where the small bowel attached to the posterior abdominal wall.
“She’s got a tear in the mesentery right where the superior mesenteric artery comes in,” Syd said, just barely able to visualize the area of damage. “Emmett, can you get a hand under the bowel and take some of the pressure off?”
The last thing she wanted to do was convert a partial tear in an artery or vein into a total one. The big vessels that nourished the entire small bowel came directly off the aorta—if they were disrupted, the hemorrhage could lead to rapid exsanguination.
Emmett gently slipped her hand beneath the intestines. “You’ll need to open that up to see what’s bleeding.”
“I know,” Syd said. And when she did, she wouldn’t have much time to control the bleeding. “Dr. Maguire? I might have to clamp the superior mesenteric.”
If she did, the entire blood supply to the small bowel would be interrupted. If the bowel died, so did Cindy.
Quinn ambled around the foot of the table and stood behind Emmett, one hand on Emmett’s shoulder as she leaned over to peer into the wound. “Yep. Looks like you’ve got an expanding hematoma down there. Something sure is bleeding. Better look and see.”
“She’s going to need more blood,” Syd said.
The anesthesiologist replied, “Hanging another one now.”
“Satinsky,” Syd said, holding out a hand for the noncrushing vascular clamp. She’d done bowel resections before—lots of them for tumors and infections. She’d repaired arteries and veins too. At Franklin, they saw hundreds of patients with diabetic vascular disease who needed bypasses to help blood flow to their legs. She’d done all the parts, but she’d never done this. Emmett was a good assistant and Quinn continued to observe. If she got into trouble, Quinn would be right there. Knowing that settled her nerves. She knew what she was supposed to do, and knowing that she was the one in charge, the one expected to do it, gave her the confidence.
“Emmett, can you open up the mesentery.”
“Scissors,” Emmett said.
Syd readied the clamp in one hand and the suction in the other. Emmett incised the tissue surrounding the vascular bundle. A gush of blood poured into the field.
“One of the vessels must be torn,” Syd said, her breath coming a little faster. Passing the suction to Emmett, she squeezed the vessels between the fingers of her left hand, manually cleared away the fat encasing them with a sweep of her thumb, and slid the clamp around the artery and vein with her other hand.
“The vessels are clamped,” Syd said. The bleeding stopped. The bowel turned a dusky blue. The countdown clock in her head started ticking.
“Can you see the tear?” Quinn asked.
“Not yet,” Syd said. “Emmett, sponge below my fingers.”
Emmett muttered, “There it is.”
“I see it,” Syd said. “A partial avulsion of the vein. I think we can get a suture in it without narrowing it too much.”
“Give it a shot,” Quinn said.
They had one shot. If the suture didn’t hold, the repair would be ten times harder and would take too long. Syd looked up for the first time. “You’ve got a better angle, Emmett. Go ahead.”
Emmett nodded. “Five-oh Prolene on a vascular needle.”
The scrub tech passed Emmett the vascular forceps and suture.
“Scissors,” Syd said.
Emmett inserted a figure of eight suture and tied it down. Syd cut the suture and released the clamp.
The artery pulsed.
The vein filled up.
The bowel turned a healthy shade of pink.
Syd smiled.
“I’ll be in the lounge,” Quinn said and walked away.
“Let’s run the bowel one more time,” Syd said, “then we’ll irrigate and close.”
“I’m seeing some arrhythmias here,” the anesthesiologist said, a new tension in his voice that hadn’t been there before.
Syd looked over the ether screen at the monitors, saw several irregular heartbeats.
“She had a run of V-tach earlier,” Syd said.
“I know. I’ve had her on a lidocaine drip but she’s breaking through. You might want to hurry things up.”
“All right,” Syd said, pouring warm saline into the abdominal cavity. “We’ll need fifteen minutes at least.”
The OR door swung open and Kos Hassan hurried in. “I just got my page a few minutes ago,” he said, breathing as if he’d been running. He probably had. “Quinn said she was bleeding. What’s going on?”
Syd filled him in as he stepped close behind her.
“Looks like you’ve got things under control,” he said.
“She’s not bleeding now but she’s still unstable,” Syd muttered, suctioning out the last of the irrigation solution. It was clear. There was no other indication of bleeding.
“Sponge count,” she said.
The circulating nurse started the count, and when they had determined all the sponges were out of the abdomen, Syd began the closure.
“V-tach!” the anesthesiologist called.
Syd continued suturing. Her job now was to get the patient off the table.
“I’ve lost her pressure,” the anesthesiologist said sharply.
“Emmett,” Syd said.
“Got it.” Emmett passed her retractors to the scrub nurse, pushed the drapes up toward Cindy’s head to get to her chest, and started closed cardiac compressions. The field was suddenly bloodless. Cindy’s blood pressure was too low to perfuse her tissues.
“V-fib,” the anesthesiologist said. “Pushing epi.”
“Paddles,” Emmett said.
A second later, Emmett called clear, and Syd stepped back from the table, along with everyone else.
“Nothing,” the anesthesiologist said.
“Charge to two hundred.” Emmett shocked her again, and on the third time, her heartbeat returned.
“She’s still hypotensive,” the anesthesiologist said, “but I’ve got a rhythm.”
“Skin staples,” Syd said, needing to get the incision closed as quickly as possible.
Twelve minutes later Kos helped Syd and the anesthesiologist push Cindy’s bed back into the ICU. Emmett stopped at the nurses’ station to take care of her post-op orders.
“I’m
sorry you couldn’t get me,” Kos said while the ICU team got Cindy settled.
“I didn’t think we could wait,” Syd said, “and Dr. Maguire knew the patient.”
“You made the right decision. All the way down the line.”
Kos stood opposite Syd on the other side of Cindy’s bed. Cindy lay motionless, the ventilator breathing for her through the endotracheal tube, her heart supported by infusions of antiarrhythmics and pressors, her legs encased in compression sleeves to prevent clotting and possible embolus. Her vital signs were stable, but that wasn’t what worried Syd now.
“What do you think those hypotensive episodes did to her spinal cord injury?” she asked.
“There’s a good chance she’s lost whatever slim chance she had to recover function. And considering the two episodes of prolonged cardiac arrest…” He shook his head.
Syd didn’t need it spelled out—prolonged decreased blood flow might have destroyed brain function too. Cindy might never wake up. “Should I get the EEG tonight?”
“Let’s give her until early morning so we’re sure the effects of the anesthesia have worn off.” Kos said. “And, Syd…”
“Yes, sir?”
“You did everything exactly as you should have.”
“If I’d gotten another abdominal CT, we might’ve picked up the bleed before her pressure bottomed out.”
“You had no reason to repeat it. The first one didn’t show anything. These things happen with injuries like this.”
“I know, but if I just—”
“Believe me, if I thought you’d missed something, I’d let you know.”
“Thank you,” she said, appreciative but unconvinced. “I’ll be here the rest of the night to keep an eye on her.”
“Call me if you need me. And get the EEG first thing in the morning.”
“I will.”
After Kos left, Syd double-checked that everything looked stable and joined Emmett at the nurses’ station.
“What a case, huh?” Emmett said, putting Cindy’s chart aside.
“I’m glad you came back with me,” Syd said. “That was hairy.”
