Sure enough, Ryan was preparing to intubate his patient, cardiac monitoring was established and kits requested for both pericardiocentesis and chest drainage. Ryan looked determined and confident but less than happy about the challenge he was about to face. And no wonder. From what Hannah could see, the woman’s condition was deteriorating rapidly.
Ominous extra beats were disrupting the line of the ECG trace on the screen of the monitor.
There was time for one more, rapid secondary survey on Brendon before he was taken to the CT suite.
‘Some of these bruises look old,’ she commented.
‘Maybe he plays rugby,’ Jennifer suggested.
‘You reckon his mother does as well?’ Wayne had been helping Ryan’s team in the initial preparation of his patient. ‘She’s covered in bruises as well.’
Hannah eyed the clothing remnants Wayne was putting into a patient property bag. ‘Dressing-gown?’ she queried.
He nodded. ‘I don’t think their trip was planned.’
A police officer was standing well to one side of the now crowded area. ‘Have any relatives been contacted?’ Hannah asked him.
‘We didn’t need to. The car she was driving had just been reported stolen.’ The police officer’s face was grim. ‘By her husband.’
Hannah absorbed the information like a kind of physical blow. Was her patient an innocent young victim caught up in a situation involving domestic violence? Had his mother’s desperate bid to protect him ended in a disaster he might never recover from? Would he even still have a mother?
It seemed unlikely. Ryan was sounding uncharacteristically tense as Brendon’s stretcher was taken through the double doors on the way to CT.
‘We’ve got VF. She’s arrested. Charging to 200 joules. Stand clear!’ He looked up as he recharged the paddles. ‘Hannah, are you free?’
Hannah’s hesitation was only momentary. She had been planning to follow protocol and accompany Brendon but he already had an expert medical escort in the anaesthetic registrar. She knew what Ryan would do if the roles were reversed and she asked for assistance. Hannah turned back.
‘I’m free,’ she said quietly. ‘What do you need?’
‘WE’VE got sinus rhythm.’
Ryan dropped the defibrillator paddles with relief. The same kind of relief he’d noted when Hannah had turned back to help before he’d delivered that last shock. Not that he’d doubted he could count on her in a professional capacity. He could see her pulling on gloves and positioning herself beside the tray containing the pericardiocentesis and chest drain kits as he reached to check his patient’s pulse.
‘Carotid is barely palpable,’ he reported grimly.
‘Systolic pressure is fifty-nine,’ Wayne confirmed.
‘Let’s shut down the IV. Just run it enough to keep the vein open,’ Ryan ordered. ‘There’s been no response to a fluid challenge and if we’re dealing with thoracic haemorrhage it’ll only be making things worse.’
‘Ventricular ectopics starting again.’ Hannah had an eye on the monitor screen. ‘And the systolic pressure is dropping. Down to fifty-five.’
The patient was threatening to arrest again. Ryan reached for a scalpel and Hannah had the forceps ready to hand him a moment later. Then the cannula for the chest drain. In less than a minute, blood was draining freely into the bottle. Too freely. All too soon, the bottle was almost full.
‘Have we got someone from Cardiothoracic on the way?’
‘No.’ Jennifer shook her head at Ryan’s terse query. ‘Sorry. They’re unavailable for fifteen to twenty minutes. They’re tied up in Theatre with a post-bypass complication.’
‘Have we got a thoracotomy kit?’ He could almost hear a collective intake of breath. ‘She’s exsanguinating from a chest injury and about to go into cardiac arrest again. A thoracotomy might be a long shot but it’s the only hope we’ve got.’ Ryan knew the statistics were not on his side but at least they would be doing something other than watching this woman bleed to death.
Hannah nodded once, as though she had gone through the same thought processes and was in agreement with him. ‘Want me to scrub as well?’
‘Yes. Thanks.’
Wayne was sent to find the rarely used sterile kit. Jennifer took over the task of manually ventilating their patient. Ryan scrubbed fast. Ideally he should have the chest opened in less than two minutes. Faster, if there was another cardiac arrest.
‘Have you done this before?’ Hannah squeezed soap into her hands beside him.
‘Yes. You?’
‘Never even seen it.’
‘Know the indications?’
‘Penetrating thoracic injury with traumatic arrest or unresponsive hypotension or blunt injury with unresponsive hypotension or exsanguination from the chest tube. Overall survival is between four and thirty-three per cent but higher for penetrating injury.’
‘We’ve got VF again,’ Jennifer warned. ‘No…it’s asystole.’
Speed was now critical. A flat-line ECG meant that the heart couldn’t be shocked into producing a rhythm again. Chest compressions on someone with blunt trauma were also contraindicated because it could worsen the injury. Opening the chest was the only option with any hope at all now.
It was good that Hannah had never seen the technique. Explaining things as he started this incredibly invasive procedure somehow eased the tension of a desperate measure to save a life.
‘We’ll make bilateral thoracotomies in the fifth intercostal space, mid-axillary line—same as for a chest drain.’ Ryan worked swiftly with a scalpel and then a heavy pair of scissors. ‘I’ll be ready for the Gigli saw in a sec.’
He showed her how to use the serrated wire saw, drawing a handle under the sternum with a pair of forceps and then joining the handles and using smooth, long strokes to cut through the sternum from the inside out.
Hannah was ready with the rib spreaders. For someone who hadn’t done this before, her calmness and ability to follow direction was a huge bonus.
‘You can see why this is called a “clam shell” thoracotomy,’ he said as he spread the ribs away from the anterior incisions. ‘Suction, thanks.’ Ryan sucked out blood and clots from the chest cavity, hoping it would be enough for the heart to start beating again spontaneously.
It wasn’t.
‘Where’s she bleeding from?’
‘Haven’t found it yet.’ Ryan placed both hands around the heart. ‘I’m starting internal cardiac massage. Can you find and compress the aorta against the spine, Hannah? We want to maximise coronary and cerebral perfusion. I’ll clamp it in a minute.’
She was totally out of her depth here. It was a huge relief when back-up from the cardiothoracic surgeons finally arrived. They were impressed with Ryan’s management of the case so far, which was hardly surprising. Hannah wouldn’t have had the confidence or skill to go further than the chest drain insertion.
The thought that Ryan might deserve the consultant’s position more than she did was not a pleasant one.
Edged out as people