The Surgeon's Engagement Wish

Luke nodded, acknowledging the information that the woman’s blood pressure had to be very low. He glanced up at the people standing nearby. ‘Can somebody tell us what happened to her?’

‘She got hit in the chest,’ the second woman spat. ‘With a bloody softball bat, that’s what happened.’

‘How long ago?’

But Luke’s query was ignored.

‘And it was that bitch over there that did it. And I’m going to do something about it.’

Fortunately, two more police officers arrived to deal with the woman who was making a new and more frenzied attempt to get free.

‘It must have happened in the car park,’ the first officer told Luke. ‘Probably well over an hour ago.’

‘Thanks.’ Luke slid an arm beneath the woman’s back, the other under her legs, standing up with apparent ease despite the weight of his burden. ‘Let’s go,’ he said to Beth. ‘What’s free?’

‘Resus 2.’ Beth led the way, relieved to move away from the tension in the waiting area, which was now escalating thanks to the screams of their new patient’s friend.

‘Let me go! Where are you taking her? She’s bloody dead, isn’t she?’

Stella wasn’t dead but she wasn’t looking at all well. Mike came into Resus 2 as Luke gently deposited the woman on the bed.

‘What’s happened?’

‘Collapse,’ Luke told him succinctly. ‘Possible blunt chest trauma from a softball bat more than an hour ago.’

Beth slipped an oxygen mask over the woman’s face and turned the flow up to 10 litres a minute, before swiftly turning her attention to pulling open Stella’s shirt. Then she grabbed a pair of shears to cut through the singlet top beneath the shirt.

‘She’s tachycardic,’ Luke told his colleague. ‘And she’s got JVD.’

Beth hadn’t noticed the distension of the jugular veins on the woman’s neck but she recognised the significance of the sign, reaching for the ECG leads as she dropped the shears.

‘Chest-wall contusion,’ she reported.

Stella groaned loudly, swore incoherently and tried to move as Mike put his hands on the obviously bruised area on the left side of her chest.

‘It’s all right,’ he reassured their patient. ‘We’re just checking you out.’ He looked up. ‘Do we know her name?’

‘Stella,’ Beth supplied.

‘I know it hurts, Stella. Hang in there.’ He looked up again. ‘Fractured ribs,’ he said. ‘But she seems to be moving air all right.’

Luke had wrapped a BP cuff just below the tattoo encircling Stella’s upper arm. ‘Hypotensive,’ he noted. ‘Systolic’s barely 80. Let’s get an IV started.’

‘Make it two,’ Mike said. ‘Beth, can you get a line in on your side, please?’

‘Sure.’ Beth stuck the last ECG electrode in place and turned to grab a tourniquet. Mike was watching the screen of the cardiac monitor.

‘Sinus tachycardia,’ he said. ‘And…yes, we’ve got electrical alternans.’

Luke’s grunt sounded almost satisfied as he pulled the cap off a cannula. ‘Thought so. Pericardial tamponade.’

Beth glanced up at the screen, noting the way the spikes of the QRS changed direction every few beats, indicating a change in the cardiac axis. She knew the first line of treatment for an acute pericardial tamponade was a rapid infusion of saline. Bleeding around the heart, trapped by the membrane encasing the organ, was interfering with its ability to pump blood. By increasing the fluid volume of the patient, the output of the heart could be improved.

Pleased to have known to choose a wide-bore cannula without being told, Beth had also gone for easy venous access inside the left elbow. The cannula slid into place and she occluded the vein at the end of the tubing as she withdrew the needle and reached for a luer plug.

Luke was reaching for a luer plug as well. For a split second they caught each other’s gaze and there was a hint of a smile lurking on the surgeon’s face.

‘Snap,’ he murmured. ‘Guess we’ll have to call that one a draw.’

Mike watched them both as they finished attaching giving sets and started the fluids running. ‘Definitely a draw.’ He smiled. ‘Nice work.’ Then his face settled into a frown of concentration as he placed his stethoscope on Stella’s chest.

‘Heart sounds are pretty muffled.’

‘Jugular veins are more distended now.’

‘Stella!’ Mike raised his voice. ‘Open your eyes for me.’

There was no response. Mike pinched her ear lobe but her level of consciousness had dropped enough for the pain to be ignored. ‘GCS is dropping,’ he warned.

‘Beck’s triad.’

Beth wasn’t aware she spoken aloud until she caught Mike’s glance. ‘You know your stuff, don’t you?’ The older consultant sounded impressed. ‘What do we do next, then?’

‘Pericardiocentesis?’ Beth was aware that Luke was watching her. She’d been little more than a student nurse when they had worked together all those years ago. Would he also be impressed at the level of knowledge and the skills she had acquired since then? ‘Removal of as little as 20 mils of blood can improve cardiac output and patient condition considerably, can’t it?’

‘Spot on.’ Mike nodded. ‘You’ll find the kit on the shelf above the IV cannulas.’

Luke drew up the local anaesthetic while Beth swabbed the skin on Stella’s chest. Mike inserted the six-inch, plastic-sheathed needle, aiming towards the base of the heart, and they all watched the monitor screen carefully for ECG changes.

‘QRS complex is widening,’ Luke warned at one point. ‘Draw back a little, Mike.’

Beth held her breath. If it wasn’t blood around Stella’s heart that was causing the problem then their patient was in serious trouble. She relaxed slightly as she saw the needle fill with blood.

‘Here we go.’ Mike drew back on the syringe. ‘Five mils,’ he noted. ‘Ten…fifteen…’

Then the flow stopped. It seemed that enough blood should have been removed to help, but there was no improvement in Stella’s condition. In fact, it got worse. The ECG began to change, with the heart speeding up and missing beats. Stella wasn’t moving or even groaning any longer.

And then Chelsea called out from the adjoining resuscitation area.

‘Mike? He’s bleeding again. I can’t seem to find the right spot to apply manual pressure. Shall I take the bandage off?’

‘Coming.’ Mike glanced up at Luke. ‘Can you manage?’

Luke glanced at Beth. ‘Sure.’

The management of the femoral artery bleed next door was obviously difficult and the rest of the department was still humming. Nobody could be spared to assist in Resus 2 even when Stella’s heart gave up the struggle of trying to pump against constriction.

The electrical stimulus was still there but their patient was pulseless and Luke’s attempt to draw more blood from the pericardium with the needle proved fruitless.