The approaching siren ricocheted off tall buildings. Red ambulance lights pulsed the nocturnal Seattle fog outside Harbor ER where the charge nurse and I waited, ready for the challenge of an unconscious young addict with a chest stab wound. Trauma codes occurred several times a day at the University of Washington teaching hospital. Outside in cool air for a few minutes relieved my exhaustion. Only seven hours to go before sleep, and six months to go before the end of ER medical training.
Back doors flung open in a cloud of diesel exhaust before the vehicle came to a stop. A young paramedic pumped on the stabbing victim’s chest with one hand and moved the stretcher toward us. “Dr. McKay, the stab wound is in the left chest. First Responders started CPR.”
His partner clamped the mask tighter and squeezed a bag pushing in oxygen. “We didn’t delay transport to place a tube or line. She was just around the corner on James.”
Inside a large trauma bay with bright lights and equipment everywhere, I gave the gathered trauma team a rapid overview. “She’s in hemorrhagic shock from a single stab wound in the left chest. Her only chance for survival is to crack her chest and stop the bleeding.”
The team washed over the young victim in a wave of yellow gowns and gloved hands. We slid her to the ER bed where nurses connected monitors and readied bags of saline for IVs.
“Get her on a ventilator, two large-bore IVs, labs, high volume fluid, and pump in O negative blood.” I looked around. “Where’s Warren? Page him stat.”
Annie’s scissors chomped through ragged blue jeans. Another nurse ripped open the victim’s T-shirt and peeled back her clothing.
The thin adolescent body of an intravenous drug user lay before us, mutilated by needled-tracked veins, a clitoral ring, and tarnished rings through pubescent nipples. A wad of Vaseline gauze sealed the half-inch stab wound. Blood oozed around the edge of the dressing.
An adrenalin-junkie paramedic calmly searched for an intravenous lifeline for fluids and blood. Like him, I had learned to internalize stress and remain calm under dire circumstances.
A practiced ER behavior.
Don’t cry when babies die.
No emotions. Do your job.
I examined the patient while talking to staff and ran the trauma code like Jackson Hunter, our brilliant director, had drilled into me over the past two and a half years. I spoke his words. “Be careful. Protect yourselves. Anyone not assigned here, please leave.”
Anesthesiology resident Dr. Milt Flora rushed into the room and elbowed his way toward the head of the bed. “Get me a goddamned tube.”
I pointed at the ventilator. “You’re late. We already placed the ET tube.” Milt glared. His attitude made me want to tube him just to stop his insults.
Milt detested taking orders, especially from women. His surly behavior tonight reminded me of Annie’s comment after one of his fits during a prior code. She said, “What do you expect, Kelly? His father is a cop and his mother a psychiatrist. The poor guy was probably potty-trained at gunpoint.”
Annie, a striking black woman who had worked at Harbor for years, took charge of nursing issues. The medics helped us stabilize patients by adding another layer of expertise to our rapid ER interventions until they had to rush off on another call. Paramedic Nate grabbed a gown and gloves. “What do you want me to do Doc?”
“Start a peripheral line if you can find a vein while I place a large-bore line in her internal jugular.”
His fingers searched the patient’s arms for an intravenous site. “She’s hard-core. Needle tracks everywhere. Her veins feel like ropes.” His initial grim expression flashed to a smile. “She’d have trouble using this one.” He scrubbed the skin over a pristine vein on her upper arm with an alcohol wipe and eased in an intracath needle and short plastic tube. Blood flashed back.
RNs connected blood and saline via rapid infusers into the medic’s line and the line I placed in the victim’s neck. “Pump in six units of blood and get six more of O negative while we’re waiting for type-specific units.”
Annie opened a surgical tray and placed it on a stand next to me on the patient’s left side.
Milt smirked from the head of the table. He monitored the patient’s airway, oxygen status and fluids. “What are you, McKay, a one-man show? Where’s your surgeon?”
My redhead temper flared. I clenched my teeth to stop words I might regret. I would have preferred doing a vasectomy on Milt without anesthetic, but the asshole did have a point. “Where the hell is Dr. Warren? Page him again!”
I would have to answer to Dr. Hunter if I didn’t follow protocol and opened the teenager’s chest without a surgeon to assist. But, the patient would lose her chance for survival if I didn’t act quickly. I’d have hell to pay either way. “Stop chest compressions. Check vital signs.”
Milt announced, “We made a little progress. Weak carotid pulse. Heart rate 130. She’s had five units of packed red cells and four liters of saline.”
My gut hurt and hands shook as I pulled on sterile gloves. “Okay. Let’s open.”
Annie removed the Vaseline gauze and scrubbed the victim’s chest with iodine solution. Each ventilator breath spewed red droplets from the stab wound. The blood mixed with the smelly brown liquid, forming glistening copper streaks in an abstract mosaic on the white and purple mottled skin.
Annie handed a male med student sterile gloves. “You’re Dr. McKay’s assistant.”
His eyes glistened as if she had handed a kid a bag of chocolates.
We draped and clipped sterile sheets over the patient, covering all but the left chest.
I handed my assistant the suction and poised the scalpel at the point of incision. “Get ready. We’ll have torrential bleeding when I open.”
Milt’s eyes squinted at me above his mask. “I have two units up and two more ready to hang. You should wait for help.”
“There’s no time. Somebody page a surgeon, anyone!”
One swift strike along the rib interspace below the stab wound, beneath the breast, extending from sternum to underarm, opened her chest. A geyser of blood shot over my unprotected arms and sloshed my blue scrub top.
I had warned everyone else, but I had failed to wear a protective gown myself—a critical oversight in my rush to help an addict likely to carry a blood-borne dreaded disease. I couldn’t take the time to put on a gown with her chest open.
The clear plastic suction hose turned crimson and filled a canister.
Milt scrambled to hang more blood.
I slid rib spreaders into the incision and spun the crank to separate the blades, opening the chest wide. The student suctioned more blood.
Someone pushed in beside me.
I couldn’t look away from what I was doing to see who it was, but I hoped it was Brett Warren. When I heard the voice, I cringed.
Mona Maddox, another senior ER resident, peered into the chest. Her harsh personality always raised my blood pressure. “Kelly, I’ll help you. What’s the history?” She dived into a gown and gloves.
I gave her a mini history while I suctioned, trying to clear the blood inside the chest to expose the bleeding site while Mona’s shrill voice twisted the emotions of those near her, much like Milt’s voice did. Having both of them on this team added to the chaos. Her first demand to Annie was, “Scalpel!”
Annie cautiously passed a scalpel to her.
Mona elbowed me. “I’m going to extend the incision a little to give us more visibility.”
I adjusted the rib spreader and felt a sudden sharp pain. I jerked back my hand.
A slice through my glove across the back of my hand ran red. I felt blood pooling inside my glove. “Dammit, Mona, you cut me. This is an addict!”
Blood dripped off my gloved fingertips to the floor.
Mona snarled, “I told you I was extending the wound. It’s your fault for getting in the way.”
She pushed me with her ample hip. “Get a new glove and give me some damn help.”
The horror of my cut awash with an addict’s blood sent fear to my core. A major blood contamination from an addict. HIV? Hepatitis C? I flexed my fingers to be sure the tendons were intact and could still grip an instrument.
The worried eyes of the team watched an RN remove my bloody glove and slosh iodine over the laceration. They understood that prolonged contact between the addict’s blood and my open wound increased the risk of blood-borne disease.
Annie held open a fresh sterile glove. I plunged in my hand. She offered a second as a double barrier.
Milt screamed, “We’re losing ground! Her pressure’s 60! Set up the reinfuser! More blood, stat!” A nurse moved to the head of the table to help him pump fluids into the patient, and she hung another unit of packed red blood cells.
Mona grabbed a suction from the med student’s hand and pulled off the angled metal handle to provide a larger opening for removing the blood. She thrust the tube deep in the chest.
Profuse bleeding made it impossible to see the cut vessel. I scooped out blood with my hands, soaking my shirt and pant legs. Warm liquid and clots slithered off the gurney onto the floor, squishing inside my shoes.
“We can’t see!” Mona yelled. “Somebody adjust the damn light.”
A bright beam swung around and aimed directly into the red cavern. I pushed a soft gray lung out of the way and felt the staccato hammering of the patient’s heart. In the depths of the chest, a small area of rhythmic bursts burbled up like water from an artesian well. I blindly squeezed the submerged vessel with my left hand.
Mona pushed against me. “Let me see.” She pressed on my lacerated hand.
I gasped with pain. “Mona, move your head. You’re in my way.” I held out my injured hand to Annie. “Vascular clamp!”
A clamp slapped my hand. “Mona, suction by my left hand so I can see what I’m clamping.”
She suctioned but blocked my view again. I nudged her with my hip. “I can’t get a clamp around the vessel if I can’t see it. Give me some room.”
Mona held out her hand. “I see a gusher. Clamp! Give me a clamp!”
An operating room tech who had just arrived to help passed Mona a long vascular clamp.
I held firm, compressing the bleeding vessel.
Mona struggled inside the chest, suctioning. She clicked the clamp closed.
I loosened my hold.
Blood spurted. She had missed.
I squeezed again, stopping the flow. I would have done better without her. I held out my hand for another long vascular clamp.
Milt barked orders to two nurses helping him pump in blood.
Still controlling a bleeding site with my left hand, Mona took the suction to clear the area.
I clamped. The bleeding stopped. I took a deep breath and let go.
The bleeding stopped, but not because I had clamped the vessel. Her heart quivered against my hand.
No rhythmic contractions.
I squeezed an empty heart. We’d lost. “Stop resuscitation. She bled out.” My eyes went to the wall clock. “Time of death, zero-zero-thirty.”
A blood-soaked pant leg clung to my skin like a hand.
The phantom grip of the dead girl.
In my mind, her voice cried out, “Doc, don’t stop. Help me.”
I stepped away from the bed. My foot slipped on the bloody floor, sending me off balance. I grabbed Mona’s arm to keep from falling. Perspiration moistened my forehead. Rivulets of sweat joined the red stains soaking my scrub shirt.
The wordless trauma team removed gloves and long-sleeved gowns in slow motion as they backed away from the grisly scene. Eyes drifted to my scrub top stuck to my skin like I was in a wet T-shirt contest. Milt met my eyes and then fixated on my breasts.
The cardiac monitor displayed the undulating, useless electrical rhythm of the teenager’s fibrillating heart.
Milt turned off the ventilator and IV pumps.
The monitor screen went dark.
The oxygen flow stopped.
My voice sounded loud in the silent room. “Thanks for your help. We didn’t get to her in time.”
Milt’s final statement before the door closed behind him, “What we needed was a real surgeon.”
The rest of the staff filed out, leaving me with Mona, Annie, and the body.
Mona disconnected bloody suction tubing from a canister. She stared at the dead girl while slowly coiling the tube like a lasso.
Her presence was worse than no help. I tried to sound grateful, hiding the anger I felt. “Thanks for the help.”
“You really blew it, getting that laceration, Kelly. I’ll stitch it for you.” Mona threw the coil into a metal bucket with a loud clang like an exclamation point at the end of her statement. “Milt’s an ass. Besides, I knew we couldn’t save her. I wouldn’t have tried if I’d been in charge.” She removed her gloves and gown. “Get your baseline labs drawn and start HIV prophylaxis tonight. That loser’s blood could kill you.”
“I haven’t forgotten and won’t forget you did this to me.” I walked to the sink and removed my gloves to clean the wound. “I’ll have someone else stitch it.”
Mona scowled and walked out.
Exposed white extensor tendons lay like fat spaghetti within the three-inch cut across the back of my hand. The cut didn’t worry me. A nick in one of the tendons required no repair, but the blood exposure mandated immediate drugs. Contaminated needle sticks are low risk for disease transmission, but a large wound with blood contact upped my chances of developing a fatal disease.
My life as an ER doctor would be over if I contracted HIV or hepatitis C. I didn’t want to think about it.
The cold water ran red. I scrubbed the wound with a surgical prep sponge. It hurt like hell until I injected anesthetic to dull the pain.
Annie irrigated the bleeding wound with two liters of sterile saline and compressed a wad of gauze over the surface with an elastic wrap. “Do you want me to order a stat HIV and hepatitis panel on the patient’s blood?”
“Yes, and have them come down a little later and draw a baseline on my blood. I hope they have some of the patient’s blood from the first draw. We gave her so many units, we’d get a dilutional false negative from a later draw even if she was positive for disease.” I slumped on a stool near the ER bed and put on clean gloves for a post-mortem exam. “Taking care of critical patients when I’m this tired is insane.”
“It went well except for Mona. I can’t believe she slashed you in her stupidity. What was she doing here tonight?”
“I think she’s still on a cardiology elective. Must miss the ER.” I looked at the gaping chest incision. “I would have done better without her but I’m not sure we could have saved her even with Warren helping.”
From the opposite side of the bed, Annie looked at the victim’s face. “She was here a couple weeks ago. Medics found her lethargic in a flophouse on Broadway. Beat up. One eye swollen shut. You can still see some discoloration on her face, here.” Annie pointed.
“Do you remember what her drug screen showed?”
“Positive for benzos, narcotics, and meth. The two friends with her that night looked just like her. Hair dyed black. Heads partially shaved. Facial piercings and many earrings.”
“Probably had piercings in other body parts like hers.”
Annie nodded. “Those kids look so much alike, it’s hard to tell boys from girls until you look between their legs.”
I pointed out the vascular anatomy and injury to Annie. “The stab got both the pulmonary artery and the aorta. I guess Mona was right. There is no way we could have saved her based on these injuries.”
“You didn’t know that when you had to make the decision to open her. I’ve only seen a couple of patients saved by ER thoracotomy in the fifteen years I’ve worked here.” Annie turned the flaccid body so I could re-examine the victim’s back. “It would have been nice to have the surgical resident here, but you couldn’t wait. This went fast, like it’s supposed to.” After my exam, Annie turned the body back and purified the death scene with a white sheet.
“I wonder why Brett didn’t show up.”
“Brett’s not the most reliable doc around here. He’s missed codes before and can be a hothead.”
“I hope he’s cool this morning when Hunter burns him in critique for not showing up.”
The disgusting red stains on my pale blue scrubs were drying at the edges. I pulled the sticky part of a pant leg away from my skin and again felt the clinging sensation on my leg. “These scrubs feel gross. I have to shower and find someone to stitch my hand before the anesthetic wears off.”
“I’ll see if Lynn Cabot can do it for you. I’m glad you refused Mona’s offer.” Annie handed me a gown. “Put this on to cover yourself. You can’t walk through the ER looking like you work in a slaughterhouse.”
I tied the gown around me. “Somebody out there didn’t like this unfortunate girl.”
Annie poured hydrogen peroxide over our shoes to clean off some of the blood. “Broadway used to be a nice district with great restaurants, but I wouldn’t go there at night after what we’ve seen recently. This is the second addict homicide I’ve seen in the past two weeks.”
Blood dripped off the bed onto the floor in a gelatinous dinner plate-sized clot. Red footprints tracked the room. Towels, instruments, suction canisters, all red.
Annie handed me a pair of shoe covers to avoid tracking blood into the hallway. “We have to remember to put these on before we meet the ambulances.” She pulled the privacy curtain across the doorway to block the view into the room.
The door clicked shut behind us.
A nurse met us in the hallway. “Dr. McKay, the police are here to talk to you about this patient.”
Annie shook her head. “She has to get cleaned up. I’ll talk to them while she showers. Do we have an open suture bay?”
The nurse raised her eyebrows, eyes focusing on my bandaged hand.
Annie explained about the laceration.
“I’m so sorry, Dr. Mc Kay. I’ll set one up. A med student could suture it for you. Is that okay?”
“Sure. It’ll take me a few minutes to shower.” I walked down the hall, my feet squishing with each step.
Seattle Police Detective Cy Jones caught up to me as I tried to escape. His usual twinkling eyes turned dark when he saw the legs of my scrubs below the gown. “I can see why you’re rushing off.”
“I’m anxious to shower and get this drug-user’s blood washed off.”
“What’s wrong with your hand?”
“Scalpel cut contaminated with her blood.”
“That’s horrible. What if she had HIV?”
“We have good drugs and I’ll start them tonight, but I’m worried. After I shower, we can talk about the victim. It’ll take a few extra minutes to get some stitches.”
“I’ll have a cup of coffee ready. You look like you need one.”
“I do. Annie said she’d go into the room with you now if you want to get started.”
Mona sat in the locker room sipping coffee and reading People magazine.
I stripped off clothing as soon as I entered. “I was surprised to see you here tonight. Aren’t you on an elective?”
“It’s my last night on cardiology. I have to come back to this stinking place in the morning.” Mona tossed her magazine onto a table. “I’m leaving now to get some sleep. I came in to use the library when I heard the stat page for Brett.”
“I wonder where he is.”
Mona watched me remove my bloody shoes and toss them in the trash. “I saw him in the library. Maybe he fell asleep.”
I looked down at the red stains on my skin. “It’s been a long, ugly day.”
“It’ll be better when we start working twelves on January first instead of twenty-four-hour shifts.” The door closed behind her.
I threw my underwear in the garbage.
Warm swirls of antibacterial soap mixed with red-tinged water rushed down the drain. My legs and feet returned to pale freckled skin. I shampooed my hair. My tense muscles relaxed. I wanted to stay in the shower for an hour.
The numb area and bandage on my hand reminded me of the possible consequences I faced. I removed the glove I’d used to protect the wound from the shower and donned fresh scrubs. Scratchy seams against my bare skin increased my desire to be home in bed wearing soft PJs, but I had hours more to work. I rushed back, dreading the thought of discussing my dire situation with Dr. Jackson after morning report and, even worse, of having to fight off some incurable disease.
The med student added more anesthetic, irrigated my wound, and closed the edges in record time. In the dictation room, Cy looked up with his characteristic smile that had brightened some of my darkest ER shifts. “Hey, Kelly, that was a fast shower and change. I like that curly wet hairdo.” He handed me coffee. “I’ll microwave it if it’s too cold.”
“Thanks. It’s okay. I’ve learned to like it cold.”
“The medical examiner will be happy to see you didn’t cut through the stab wound. It’ll help him identify the type of blade.”
“I know that’s standard procedure in possible homicides. Are you finished with your investigation here?”
“Yeah. You can send the body to the morgue for the medical examiner. The ME will want all tubes left in place since it’s a homicide. We also bagged her hands to preserve potential evidence. Did you see any defensive wounds?”
“None. Only the stab wound, needle-tracked arms, and an old facial bruise.”
Cy took a few notes. “Did the medics say if she talked to them?”
“She was unresponsive and never regained consciousness. Cracking her chest was her only chance, but we couldn’t save her.”
“You can’t save ’em all, Kelly.”
“I know, but we try. Her stab wound hit two major vessels.”
He eyed my bandaged hand. “I’m worried about your cut.”
“Me, too. I hope she’s clean.”
Annie entered the room carrying a packet of pills. “Kelly, take these, the sooner the better.” She thrust them at me. “We keep one dose on hand in the ER for major blood exposures. I think you’re the first one in months.”
I accepted the pills and swallowed them with lukewarm coffee. “That’s an ignominious honor. Thanks.”
“This is the second druggie death from a chest wound I’ve seen in ER in the past couple weeks.” Annie addressed Detective Jones, “Aren’t you investigating the other one, too?”
“Yes, and there’s a third. All are female teens from the Broadway District.”
Annie’s parting words were, “Good luck finding the guy.”
I swished and swallowed the dregs of my coffee to rid my mouth of the pill taste. Cy listened while I dictated. He took a few notes. I ended the dictation after a spiel of medical information, description of physical findings, and interventions.
Cy sat back in his chair. “You do talk fast. I don’t even think that fast.”
“If I didn’t, I’d spend even more time in this damned cubicle.”
The detective checked his notes. “What injuries did you find from the stab?”
“The knife penetrated both the pulmonary artery and the aorta.”
“The ME called me a few days ago. Injuries in the first two homicides were similar. If this makes three, we may have a serial killer.”
Cy’s comment left me chilled. “Who would do this to an unfortunate group of young women?”
“Trauma code, ER. Trauma code, ER.” An overhead page sounded, and my beeper fired off. Seconds later, other ER staff pagers sounded. We met at the desk for a radio report from the flight team. A male RN arriving with me said, “I love working with you, Dr. McKay. You’re a disaster magnet. We haven’t had time to clean up the mess from the last one and here we are again.”
“Are you ready?”
He smiled. “Love it. I’m always ready for more.”
Staff members stood around the desk listening to the flight nurse’s disconcerting radio report. He requested a hot unload for an unconscious young woman with airway problems. She had sustained facial, head, and chest trauma in a T-bone car accident.
A survey of the trauma team concerned me, too. “The chopper’s only two minutes out. General surgery and anesthesia aren’t here yet. Page them again.”
Annie suggested, “Should we alert the OR and ask for neurosurgery to respond?”
I agreed and walked toward the ambulance entrance. The doors gaped, as if sensing my need to disappear into the night and find a warm place to sleep, a different job, a different life. A life where I didn’t face the daily threat of exposure to deadly disease and violence.
I couldn’t help wondering if the choice of a different job might already be out of my hands because of the contaminated wound.
This time, I wore a long-sleeved protective gown, gloves, and shoe covers. The black sky pelted my face with light rain. A wind swirled coastal fog inland, clearing the lights of downtown and sending a chill through my damp hair.
Harbor Medical Center and many other healthcare facilities perched along Seattle’s First Hill had straight routes down Skid Road. Instead of skidding logs as in the early days of the city, many down-and-out homeless people lived in the Skid Road area of Pioneer Square. Noise from the freeway traffic below rose to greet me. A distant siren cut through the din, nearing James Street. A turn up the steep grade could carry them to us. In moments, its urgent tone diminished as it passed by and was absorbed by the night.
Droplets clung to my face like cold beads of sweat. Cigarette smoke rising above a security guard standing out of the rain near the hospital entrance polluted my air. Inside, the trauma team dressed in flowing yellow gowns milled silently near the door, mouths opening and closing in soundless conversation like goldfish in a bowl.
Standing outside for a few minutes allowed me to experience the elements while waiting for the case to arrive. The cold air cleared my brain and beat back the exhaustion from being trapped inside with ailing humanity for so many hours. A short break provided a few moments to reflect on the reported injuries and anticipate rapid interventions we might need to perform on the arriving patient.
Northward across the parking lot, three staff members tensed against the wind and huddled beneath an overhang near the helipad. The pulsing rotor noise materialized from the west, and I watched them twist their heads in unison toward the sound like robots. Our eyes searched the dark sky for flashing lights.
Wind generated by the noisy chopper blasted the waiting workers as the helicopter settled onto the tarmac. The engine noise abated. The older-model Augusta helicopter had no rotor brake, and the patient was too unstable to wait for the blades to stop turning before unloading. The flight crew had asked for a hot unload, so the staff advanced, heads down, as the large blades spun overhead. Fumes carried by rotor wash swept toward me.
The skilled pilot had braved the bad weather, helping the medical team use their battlefield experience to save lives. The flight nurse popped the side door of the helicopter open and peered out. He shielded his face from wet air stirred by the blades and jumped to the ground. The two flight personnel pulled their loaded stretcher onto a wheeled gurney supplied by the ground team. Staff surrounded the patient and wheeled her at a fast jog toward the ER entrance. I advanced to help them and hear their report.
Blood and rain-soaked jumpsuits plastered the bodies of the disheveled former army nurse and ex-LA paramedic. The flight nurse wiped his forehead on a sleeve. “Hi, Dr. McKay. She is critical and the cuff on her ET tube has a leak.”
His paramedic partner held the tube securely and squeezed the bag as we ran. “It was a difficult intubation. She has facial fractures and had a lot of blood in her airway, so we didn’t want to attempt a new tube and chance losing the airway.”
The ER doors parted for the entourage. The trauma team swept forward to help. A gown draped Brett Warren’s tall frame. “Hi, Brett, I guess this one is yours.”
His handsome face tensed. “I guess it is, Kelly. I owe you big time after the last case. Sorry I missed the page.”
I acknowledged his apology, and we turned our attention to the unconscious woman, her face bruised, eyes swollen shut, long brown hair matted with blood. Frothy red fluid sprayed from her mouth with each squeeze of the oxygen bag. She needed a better airway, and fast.
Interventions similar to the last trauma code proceeded. The flight nurse handed airway management over to Milt Flora. In one quick move, Milt jerked out the poorly functioning tube and the woman’s blood-spattering respirations stopped.
I took a deep breath and held it, a method I used to help me time a patient without oxygen. If I had to take a breath, she should, too. I looked at the wall clock and watched Milt’s attempts to clear her bloody airway and replace the tube. He swept a broken tooth from her mouth and suctioned again.
She had no respiratory effort.
I had to take another breath.
I watched the heart monitor. Brett said, “Milt, her heart rate is fifty. Get the tube in or she’ll have a cardiac arrest.”
A student at my side asked, “Why the slow heart rate? Shouldn’t it be racing?”
“You’re right.” I watched the sweep of the second hand as I explained. “A slow heart rate is a bad sign under these circumstances. The heart may slow for many reasons, but two common causes are severe brain injury and a heart failing from lack of oxygen. In her case, maybe both.”
“Milt, two minutes without oxygen.” To the student, I said, “Once he gets the tube in, we’ll see if her heart rate picks up.”
Brett and I quickly assessed her injuries.
Milt wedged her mouth open with the scope and suctioned her throat to help visualize her vocal cords for proper tube placement. The flight nurse stabilized the patient’s head to decrease movement and avoid further injury if she had a neck fracture. Milt suctioned again. “I can’t see a thing. There’s too much blood.” His frustration showed as he slammed the scope onto the bed by the patient’s head.
I looked at the clock and took another breath. “Three minutes; three minutes without an airway.” Dr. Hunter’s unmerciful tirades over delayed airway placements disturbed my focus. There’d be hell to pay.
Sweat ran down Milt’s face. He shook his head. Pulled out his misplaced tube and tried again. Brett and I palpated her chest for injury. Checked her heart and belly. Milt prepared for another try.
Brett put on sterile gloves. “This is way too long, Milt. I’m doing a surgical airway.”
The ex-military flight nurse edged closer to Milt. “This was a tough intubation for us in the field. Mind if I give it a try?”
I hoped Milt would accept help from the skilled flight nurse, though in Milt’s eyes, nurses were subordinates.
Airway is first priority. All other interventions are for naught if there’s no oxygen to the brain.
Milt listened to him—after all, it was another male who was offering help. “I’ll give you some cric pressure. Brett, if we don’t get it in this time, go ahead and cut.”
Annie opened the surgical kit and swabbed the patient’s neck. Brett stood ready with scalpel in hand.
Milt pushed down on the patient’s neck to move the trachea into better view to help the RN for this one last try.
Sometimes, in dire situations, teaching opportunities were buried in chaos and the medical students learned from participating or just watching. With Brett in charge of this patient, I had time to give explanations to the two medical students assigned to the team. “Because of unstable face fractures and bleeding into her airway, an oxygen mask is ineffective. The surgical procedure Dr. Warren will use cuts through the cricothyroid membrane, a cric for short. That’s the quickest and least bloody way to enter the trachea and directly place a tube for oxygen delivery.”
Brett watched Milt and the flight nurse struggle. X-ray techs readied film cassettes and waited for a cue from Dr. Warren. He called, “Type and cross six units. Get a blood gas. Chest and pelvis X-rays. Everybody help the techs.” The second Brett’s blade touched the skin, the flight nurse slid a tube in.
Milt inflated the cuff around the tube and squeezed the bag. The patient’s chest rose.
Brett placed the scalpel back on the tray. I listened to the woman’s lungs to be sure the tube was delivering oxygen to both lung fields. “She has equal breath sounds.” I explained to the students, “If it’s in too far, the tube blocks one side and delivers oxygen to only one main bronchus, so you will always want to listen to both sides of a chest after tube placement.”
“Congratulations on getting it in.” Brett told the nurse and then turned to Milt, “You dodged the bullet, but Hunter won’t like our time.”
Milt glared at Brett.
The patient’s heart rate increased after a couple of minutes on 100 percent oxygen.
Brett’s shoulders relaxed. His facial features softened. He didn’t have to cut a hole in the patient’s trachea for an airway, and she was showing some improvement.