by K Carothers
An Eternity in a Moment
© 2018 K. Carothers
All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher, except for the use of brief quotations in a book review.
Printed in the United States of America
Cover Design: Claire Flint Last
Luminare Press
438 Charnelton St., Suite 101
Eugene, OR 97401
www.luminarepress.com
LCCN: 2018960091
ISBN: 978-1-64388-002-0
This book is dedicated to all those who
have ever bravely fought through tragedy,
and to those who have helped them.
Love seeketh not itself to please,
Nor for itself hath any care,
But for another gives its ease,
And builds a Heaven in Hell’s despair.
—William Blake
Chapter
1
“We just lost her pulse!” the paramedic uttered breathlessly, pushing hard and fast on the lifeless young woman’s chest as he knelt straddling her on the stretcher they’d brought her in on. At the same time, another paramedic urgently rolled the stretcher into an open trauma bay in the ER—the epicenter of the barely controlled chaos at Boston General Hospital—as the cries of other wounded patients echoed up and down every hallway.
“Call the OR and tell them we need a surgeon down here now—anyone they can spare,” Dr. Erin Pryce told the nurse standing next to her. She gave the order in the same calm, controlled voice she always used, no matter the situation. And this one couldn’t get much worse.
Erin quickly pulled on a pair of exam gloves, knowing there wasn’t much help to be found. The ER was nearly at overflow capacity, despite all the efforts being made to keep beds open. Teams had been organized to manage the massive surge of walking wounded, and almost every department in the hospital was helping out in some way, but the number of seriously injured victims was staggering. And the trauma surgeons were all in the OR working as fast as they could. So at least for the moment, she was on her own.
There wasn’t an act of terrorism, an insane gunman, or a hurricane that could be blamed for the catastrophe this time. Just fog and drizzle on an especially chilly May morning—which would have been perfectly harmless if everyone had stayed home.
Boston drivers were already well known for being some of the most aggressive, impatient drivers in the country on a good day. And with the dense fog and cold drizzle added to the mix, venturing out onto the roadways during the morning rush hour had become an especially dangerous proposition. But not enough people took heed of the warnings, unwilling to have their usual routines disrupted by the weather. As a result, ambulance crews from Boston EMS had soon been dispatched to accidents all over the city. But it was a crash on the interstate that precipitated the real mess, a disaster of epic proportions between Mother Nature and man.
A bus crash. At the worst possible moment. And in the worst possible place.
The bus, fully loaded with tourists, had spun out of control and flipped over on I-93 nearby, pinning several vehicles under it before bursting into flames. That horrific accident then triggered a massive pileup, the likes of which Boston had never seen before. At last count there were thirty-four people dead, with hundreds of others injured. Medical personnel at the scene were attempting to distribute the patients equally to all the local hospitals, but Boston General was the closest. It was also the best. Today, however, even its world-class resources were being stretched to the breaking point. Not even the Boston Marathon bombing had done that.
“She was an unrestrained driver who got T-boned in the pileup,” the other paramedic said as he hauled the stretcher in, using one hand to intermittently squeeze an oxygen bag attached to the end of the tube they’d inserted into the woman’s airway. “She was ejected from the driver’s side door of her car and had a GCS of 7 when we picked her up—she’d moan once in a while and withdraw from pain. There was no one with her, and we couldn’t find an ID. She had a pressure of 102 over 54 initially, with a pulse in the 120s. We intubated her at the scene and got two large-bore IVs in. She just went into cardiac arrest now.”
The paramedics quickly transferred the woman to the trauma bed, and with CPR momentarily stopped, Erin looked at the heart monitor. A normal-appearing rhythm marched steadily, silently across the screen. She checked for a pulse in the woman’s neck, but felt no movement against her fingertips. She was in PEA—pulseless electrical activity.
“Resume chest compressions, and switch positions with each rhythm check,” Erin instructed the paramedics. Then she told the two nurses with her, “Give one milligram of epinephrine IV push. Run fluids wide open for now, and start TXA per protocol for hemorrhage.”
Erin looked over at the only other person in the room, a young man she didn’t know, who hovered near the doors. And when their gazes met she saw fear, bordering on terror, in his eyes. She glanced at his name tag. Danny O’Boyle, Pathology Assistant. “Call for blood,” she said as gently as circumstances allowed. “Use the red phone on the wall near you. It connects directly to the blood bank. Tell them to activate the massive transfusion protocol. Then I want you to record everything we’re doing.”
Erin turned back to the bed, pulling a stethoscope from the pocket of her white lab coat, and listened to the woman’s chest and stomach while one of the paramedics continued to bag her and the other vigorously performed chest compressions. She heard good air movement in both lungs, and no gurgling sounds over her stomach to indicate the tube had accidentally been put into the esophagus instead of the trachea. It was one less problem, at least. A chest X-ray would still be needed, but they had more pressing matters to deal with at the moment.
“Can I hook her up to a ventilator?” the paramedic giving oxygen asked.
“No, they’re all being used, so you’ll have to keep bagging her for now,” Erin responded grimly. The tourist bus crash alone had left dozens of people on ventilators, mostly due to inhalation injuries from the fire. And the shortage of mechanical ventilators meant they’d have to make especially tough decisions about who would get life support—a call she was going to have to make herself in the next few minutes.
Erin draped the stethoscope around her neck and took a penlight out of the breast pocket of her coat, then shined the light into each of the woman’s eyes. They were brown. And both pupils contracted slightly in response to the light, indicating that at least some of her brain was still functioning.
Erin put the penlight away and started examining the woman for obvious signs of trauma, bleeding, anything they could fix immediately to improve her chances of survival, which dropped with each passing minute. There was some swelling and dried blood on her left temple, but no active bleeding. She’d obviously sustained a serious head injury, but that wouldn’t explain such a rapid loss of blood pressure and pulse. Massive internal bleeding was almost certainly to blame.
“We’ve got to get her out of these clothes,” Erin said, grabbing a pair of trauma shears. And with the help of one of the nurses, she cut off what was left of the woman’s thick jacket first. After this morning it wouldn’t be needed anyway, since warm weather was finally expected to settle into the Boston area.
Erin stopped cold when she had the woman’s abdomen exposed, and her green eyes widened in shock. Then there was a flicker of fear. “She’s pregnant…” The words came out barely above a whisper. In all her years of training and practicing medicine, this was the scenario she’d hoped she would never see. T
his was her worst nightmare come true.
Several of the staff present who knew Erin well—at least as well as anyone could, given her extremely reserved nature—looked up at her in surprise, not because the patient was pregnant, but because they’d never once seen Erin waver. She was well known, and well liked, for her even temperament: always calm, capable, and efficient in the face of crisis. Those attributes had gotten her through Harvard Medical School with honors, and had made her, at thirty-two, the youngest ER attending at Boston General.
Erin mentally shook herself. “Page overhead for an obstetrician to ER Trauma Bay 2 STAT,” she told Danny. “Dial 1357 to get on the intercom.” Thankfully, all the other lines of communication in the hospital were holding up fine—despite cell phone networks crashing as a result of the disaster—and the intercom was only being used when absolutely necessary. Experience had taught them well: The ability to manage a catastrophe of any sort was only as good as the quality of communication.
“Should I page someone in particular?” Danny asked.
Erin shook her head as she began palpating the woman’s abdomen. “No. Call for any available obstetrician. Then have Radiology get an ultrasound machine in here immediately.” There was a slight tremor in her hands as she felt for the top of the uterus. It was well above the belly button, which meant the woman was at least twenty-four weeks pregnant and the fetus had a chance of surviving outside the uterus. If it was even still alive.
She looked up at the clock. “Stop CPR for a second. It’s been two minutes. Let’s see what we have for a rhythm.”
The paramedic ceased chest compressions, and they all looked anxiously at the cardiac monitor. They saw what no one wanted to see—a flat line.
“Resume CPR,” Erin ordered. And to one of the nurses, she said, “Repeat one milligram of epinephrine three minutes from the last dose.” She turned to the other nurse, willing away the fear that filled her. She knew what she had to do. There was no time to wait for an obstetrician, no time to wait for an ultrasound. This baby had to come out now. The clock was ticking. “We’re going to do an emergency C-section. Call the NICU and tell them to get a team down here right away. In the meantime, we need to prepare for the baby.”
Erin turned to Danny, who’d just picked up his clipboard after getting off the phone. “Don’t bother recording anymore,” she said. “I want you to stand by the patient instead and push her uterus over to the left. That will improve blood flow to her heart. It’s a very important job. Don’t stop until I tell you to.”
Danny’s eyes widened in shock at her request, the fear in them as bright as ever, and he didn’t move.
He looks like a deer in the headlights, Erin thought. And she’d certainly seen enough of those deer to know, having spent many long years growing up in rural Wisconsin. You could never tell if they would move in time, or if they were truly going to stand right there and get run over. “You’re part of our team now,” she told him calmly. “And we need your help.”
Danny opened his mouth as if to say something, then closed it again. Erin gave him a nod of encouragement, yet he still hesitated. But as she started to turn away, expecting he wasn’t going to move, he did. He put the clipboard down, set his jaw in grim determination, and rushed to do as she said.
Erin didn’t have time to give the moment another thought. She headed over to a cabinet that contained surgical supplies and quickly gathered what she would need for the C-section, placing everything onto a metal surgical tray nearby. Several more staff entered the room just as she was finishing, and she briefly looked up. Help had arrived after all, she was relieved to see. They were two surgical residents she knew well. Nick Olson was in his third year, and Jane Kinney was in her second. Both were already very good surgeons.
“Dr. Jones sent us down from the OR to help,” Nick said. “What’s going on?”
“Have either of you ever done a perimortem C-section?” Erin asked, pushing the surgical tray over to the bed.
There was no immediate response, and she glanced over at them again. They stood frozen, looking at each other in shock. She had her answer. “We have a pregnant trauma patient in asystole with a potentially viable fetus. Jane, I want you to manage CPR with the paramedics. Nick, you assist me with the C-section.” She kept her voice calm, though her heart wasn’t quite cooperating. “I’ll cut.”
“Yes, Dr. Pryce,” Nick said in a voice that lacked its usual confidence.
Erin tossed her stethoscope onto a nearby counter and took off her lab coat, then hastily donned a sterile surgical gown, gloves, and mask. Nick did the the same, and they moved to opposite sides of the patient, with Nick standing next to Danny, who continued to push the uterus over to the left while the paramedics performed CPR.
“Should we do chest compressions during surgery?” one of them asked Jane.
“I—I think so,” she said, looking uncertainly at Erin.
“Yes, we need to keep as much blood flowing to the placenta as possible until I get the baby out,” Erin told them as she picked up a scalpel and handed Nick a pair of surgical retractors. “And delivering the baby might improve the mother’s response to CPR. It’s her only chance at this point.”
Erin looked at Danny. “You can stop pushing now.” Then she took a deep breath, and casting any doubts aside, quickly made a vertical incision from the pubic bone up to the belly button. She cut through all the layers of tissue, with Nick pulling the fat and muscle apart to help. She reached the abdominal cavity, and blood immediately poured out of the hemorrhaging patient.
“We need suction!” Nick ordered as he grabbed a stack of laparotomy pads—sterile surgical pads used to staunch the flow of blood—and urgently packed them into the woman’s abdomen.
“I can see the uterus well enough,” Erin said. “Just keep the bladder out of the way for now so I don’t cut it.”
Nick used a retractor to shield the thin sack overlying the lower part of the uterus, and Erin made another incision just above it, doing her best not to cut the fetus underneath. Amniotic fluid gushed out as she opened it up, mixing with the blood. She grabbed a pair of bandage scissors, slid several fingers into the incision to lift the uterine wall, and extended the cut upward. Then she threw the scissors aside and plunged her hands in, pulling the baby up out of the massive pool of blood and fluid.
It was a boy. And he appeared to be nearly full term. But he was blue and unmoving, as lifeless as his mother. Erin hastily suctioned his mouth and nose, then clamped and cut the umbilical cord. “You and Jane keep working on the mother,” she told Nick. “I’ll take the baby.”
She ripped her mask off, intending to carry the infant over to the makeshift bed the nurses had set up. But as she turned, the obstetrician who’d responded to their page rushed into the room, and they came face to face. Dr. Peter Pryce—her ex-husband.
He stopped short, his brown eyes widening in horror at the sight of her standing there with the lifeless baby in her bloodied arms.
“Help Nick and Jane,” Erin said briskly, and went over to lay the infant down.
One of the nurses was waiting with towels in hand, and they quickly dried him off. That usually provided enough stimulation to get most babies to breathe on their own if they weren’t already. But he didn’t respond.
“Go ahead and start positive-pressure ventilations,” Erin instructed, then reached over and grabbed her stethoscope. She put the ends of the headset into her ears and placed the diaphragm on the baby’s chest to listen for a heartbeat, holding her breath. And it was like music to her ears when she heard the soft, steady rhythm of his heart. She looked at the clock and counted for six seconds. “I’m getting a heart rate of 70,” she said. For a newborn it needed to be faster—a lot faster.
The nurse had covered the infant’s mouth and nose with an oxygen mask, and was now gently pushing on the bag attached to it, squeezing just enough for his tiny chest to
rise slightly. Erin listened to his lungs, making sure oxygen was getting into both equally, and at the same time watched for improvement in his color, hoping to see movement in that limp body. He didn’t appear to have sustained any obvious trauma. His mother had kept him safe within her womb.
“Come on now,” she whispered, willing him to respond. They would have to begin chest compressions if he didn’t improve within the next thirty seconds. But when she finished listening to him there was still no change. He was as blue and lifeless as before.
Erin set her stethoscope down, telling the nurse, “I’ll get an IO line in. Let me know when it’s been thirty seconds.” The baby was going to need an IV, which would normally be placed in an arm, or sometimes through the umbilical cord in a newborn. But the best option at the moment was to put a line in through the bone in his leg instead, using an intraosseous drill with a needle attached to it. The rich supply of veins in the bone marrow would allow fluid and medication to get into his bloodstream quickly, and an IO line could usually be placed faster than a standard IV or an umbilical line. So she hurried back over to the cabinet and began pulling out the equipment she would need: the IO drill, a needle, syringe, tubing—
All thoughts of the procedure fled when she heard a faint cry. She turned to look at the baby, and saw he was moving his head a little now, weakly protesting the oxygen mask that covered his face. She came back over to the bed, and as she watched, the dusky blue of his skin rapidly faded away and a healthy pink color took its place. He let out another cry, stronger this time, and started flailing his arms and legs in a more vehement objection to his current treatment.
Erin felt her chest tighten with emotion at the sight. But it was with bittersweet joy she watched him come to life. “You can take the mask off now and keep it close to his face,” she softly told the nurse. Then she picked up her stethoscope and checked his heart rate again. It was 130 this time, exactly where it needed to be.
