Surgeons, Rivals...Lovers

“He was hit chest first,” she said, taking the blood pressure again. “As in he landed with his chest on the front top edge of the grille of the car. Then bounced off. I’ve seen this before in another crash. Three big symptoms, Beck’s Triad. Muffled and faint heartbeat. Distended neck veins. A narrow difference in the blood pressure readings… One, two, three.” She pointed as she counted, chest, neck and the cuff. “There’s barely anything between the systolic and diastolic.”

The cuff beeped again, the new results darkening the screen. Pulse one sixty-two. Pressure eighty over sixty-five.

Damn. She really was right. He was either bleeding out or something else was filling his chest.

The sound of sirens close by caught his attention. They were only a couple of blocks from the hospital, and the sound came from the right direction. Closer than Dispatch, and coming toward them now. Lucky.

They’d have a defibrillator, and other tools…

He could hear her little cuff running again, beneath the blessedly loud siren of the ambulance as it rolled to a stop just ahead in the intersection. “You.” He jabbed a finger at a woman in a power suit who still stood nearby, watching, “Meet the ambulance. Tell them we need a huge syringe.” He placed the stethoscope on the patient’s chest again, doing what little he could do to monitor the situation as help arrived.

Before the suited woman even got to the ambulance, the medics came running with a bag of tools, defibrillator and a large hypodermic syringe they slapped into his hand. His order had done the trick.

“Have you aspirated a pericardium before?” Enzo asked, looking at Kimberlyn. He hadn’t. Normally he’d like to try, but she’d made the diagnosis. Even if it weren’t a professional courtesy, he wanted to see her perform so he could gauge her skill level. It was the best way to ascertain if she was simply another trauma resident or an actual threat to his fellowship.

Whether she had ever done it before or not, the small brunette crammed her hands into the gloves presented by the medic and indicated an area on the right side of the man’s chest, “I can do it. Swab around and between the fourth and fifth ribs.” She joined him on the patient’s right side.

He ripped into the alcohol prep and broke the canister within the squeegee to disinfect the area.

“Tell me if his heart starts sounding louder or if there’s any other change.”

Would chest compressions even work if the pericardium was full of fluid? It’d be like trying to squeeze a water balloon inside a larger, overfilled balloon…

Even with the stethoscope buds in his ears, he could hear the tremor in her voice. Still scared. Was she steady enough to perform the aspiration?

“I will.” He listened and directed the EMT, never taking his eyes off Kimberlyn, “Get him wired up and on the monitor.”

Cardioversion was possible now at least.

With the extra-large hypodermic in hand, she braced one elbow on her knee for support and explained. “I’m going from the right side because the heart juts to the left, and I don’t want to hit it.”

Yeah. Don’t hit the heart…

She looked steady enough now. Whatever had her fighting panic, it came and went in waves.

Enzo backed up enough to make room but stayed close enough to keep the stethoscope in place to listen while the monitor was hooked up.

This might have been a bad call. She seemed competent except for those nerves. Her nerves triggered his. If she ended up doing more damage… Maybe they should just move him now and hope he lasted another five minutes, or however long it took to get to the hospital.

With her arms steadied and braced, she waited patiently the long seconds it took for the electrodes and wires to be placed.

He listened hard, holding his breath to cut out as much sound as possible. His own pulse sounded in his ears louder than what he was hoping to listen for…

Closing his eyes helped, cutting down the external stimuli. Without vision in the way, he could hear the heartbeat faintly in the background. Fast. Very fast. And with an abnormal rhythm.

This heart didn’t just inch toward failure, it galloped. The man would never make it to WMS.

What kind of fibrillation—atrial? Ventricular? He opened his eyes and craned his neck to see the green line denoting the rhythm tracing across the black screen of the monitor.

The line swung wildly in an undulating wave that told him nothing.

Check the leads.

Okay, check the placement of the electrodes.

He grabbed an extra electrode and placed it beside the one that looked somewhat off-center, then reattached the lead. The line settled into the regular, horizontal position, allowing him to really see the points.

Ventricular fibrillation. And tachycardia. He listened again, with his eyes following the line. The sounds were almost too faint for him to hear—something that backed up her diagnosis: there had to be a massive amount of fluid compressing the heart. “He’s in V-tach.”

“Thought he might be. His time is running out.” She breathed in. When all hands were still, she breathed out slowly as she pushed the needle into the man’s chest.

She could’ve done this a thousand times. Smooth and slow enough to be cautious but quick enough to feel the texture of the different tissues she penetrated. Her eyes had taken on that out-of-focus quality that came with pinning all your attention on feeling your way to a site unseen. He’d seen that look on the real pros so many times—an amazing ability to visualize the path through and the imagination to picture the diagnosed problem. It almost felt like sorcery.

As she drew back the plunger, bright, arterial crimson began to fill the clear tube. As pressure was siphoned off, the heartbeats became a little louder, a little more distinct.

She withdrew the full syringe and looked at him, those eyes dark with fear… not the exhilaration he’d expected. But, then, he’d never been in this situation, either. Exhilaration was hard to come by. Something entirely more primitive took its place.

“No change?” So hopeful.

“Still in V-tach.” Enzo listened a few more seconds to give him time to convert. He tried counting beats but found it impossible and shook his head. “No change.” He gave the heart a few more seconds, listening again, then shook his head, “Clearer, but still distant-sounding and out of rhythm. Drawing off the fluid wasn’t enough to convert him to normal sinus.”

She paused another few seconds, pinned by those soulful eyes. Dr. Ootaka, his mentor, counseled distance. Emotions clouded reactions. Enzo had never had reason to doubt this mantra, though right now he couldn’t claim to have that distance. He wanted to give the hope her eyes begged him for.

Hoping wouldn’t get the job done. “I’ve never dealt with this. How did they do it at your old hospital?”

“The only one I saw treated was done in the hospital and they used imaging equipment to verify the diagnosis and location of the fluid before they aspirated.” She answered quickly, her focus returning, and her voice firmed as she spoke. One word led to the next, and she focused on the EMT. “I need another hypo. Bring two, just in case.”

She’d only seen it done once. Ugh. At least she didn’t look it. Move past it. Enzo gestured to the defibrillator and she followed his gaze.

“Not yet. He’s already banged up enough. Let’s give him one more chance to convert. Honestly, it’s not electrical, it’s the pressure in his chest. I doubt cardioversion would do any good for him unless his heart stops entirely.”

She rose on her knees and shouted toward the back of the medic, “Bring epi if you have it! Enzo, start the cuff again. I want the pressure before and after each draw.” With a fresh alcohol prep she swabbed the area where she’d just gone in, readying the chest for another puncture.

Long, torturous seconds passed and the other medic arrived. As soon as the pressure was displayed, she pushed through with the second needle.

Enzo watched another rush of bright red fill the tube. It looked thinner and more translucent than it had before. “It’s part serum, or he’s filling with more serum than blood now.”

“Good. The pressure might stop his heart still, but maybe it’s not an aortic dissection. Buys us some time.”

If it was only a small cut in the aorta rather than a hole through it, they had a chance of getting him stabilized and to the hospital before he crashed.

He concentrated on what he was hearing—the monitor couldn’t tell him how loud the heartbeats sounded so the stethoscope was still needed. It was easier to look at the monitor—or even the dark, eggplant-like bruise on the man’s chest—than at her worried face. He could tell from her complexion that she was normally a warm tan, but today she looked pale and fragile. Not a great look for a trauma surgeon. Even a trauma resident.

With the second round of pressure relief, the speed of the man’s heart slowly decreased and the rhythm began to convert to something closer to normal. First, a few normal beats amid the pre-ventricular contractions. Then louder. Then steadier.

“It’s working.” He pressed the button on the cuff again and then leaned back to place the stethoscope in her ears, holding the chest piece over the heart again. He let her listen as she was the one performing the procedure.

After a few seconds she nodded. “I don’t want to go again, I might hit the heart. The less fluid that’s in there, the closer the pericardium is to the heart, the less balloonish padding to protect it.” And they didn’t have the luxury of imaging equipment here to see how thick that fluid balloon was.