“Tension pneumothorax!” Michael blurted.
“My thoughts exactly,” Lynn cried. “If so, it is a real emergency. His left lung must be collapsed, and with every breath, the right is being compressed. He needs an X-ray, but there’s no time.”
“He needs a needle thoracotomy on the left!” Michael shouted. “And he needs it now!”
In a panic, the two students regarded each other across the body of the patient. For a second they hesitated, even though they were frantic. Neither had ever seen a needle thoracotomy performed, much less done one. They’d read about it, but to go from book learning to actual performance was a giant step.
“How soon do you think the ER doctor might get in here?” Lynn demanded anxiously.
“I don’t know,” Michael said. Perspiration appeared on his forehead.
“Mr. Weston,” Lynn yelled as she gave the man’s shoulder a shake. The patient didn’t respond. Instead he collapsed supine onto the gurney, no longer supporting himself on his elbows. “Mr. Weston,” she called louder, with a more significant shake to his shoulder. Nothing. The patient was no longer responding.
“We can’t wait,” Lynn said.
“I agree,” Michael replied. The two of them rushed over to a crash cart that had all sorts of emergency equipment. They grabbed a large syringe, a sixteen-gauge intravenous cannula, and a handful of antiseptic pledgets. Then they rushed back to the patient.
“My memory is that it is supposed to be done in the second intercostal space between the second and third rib.”
“You do it!” Lynn yelled, thrusting the cannula into Michael’s hands. “How the hell do you remember such details?”
“I don’t know,” Michael retorted as he quickly snapped on a pair of sterile gloves. He then tore open the sterile wrapping on the cannula. It had a needle stylus to facilitate insertion.
“What if it is hemothorax and there is blood in there instead of air?” Lynn questioned anxiously. “Would we be making it worse?”
“I don’t know,” Michael admitted. “We’re in uncharted territory here. But we got to do something or he’s going to check out.”
Lynn tore open several alcohol pledgets and rapidly swabbed a wide area below the patient’s left collarbone. Michael positioned the tip of the cannula with its needle stylus over what he thought was the correct position. He’d located it by palpating the area and feeling the bony landmarks. Still he hesitated. It was a daunting task to blindly plunge a needle into someone’s chest, especially the left side, where the heart was.
“Do it!” Lynn snapped. She knew that she and Michael were an example of the blind leading the blind, but the needle thoracotomy had to be done, and it had to be done immediately. The patient’s color had deteriorated despite the oxygen.
Gritting his teeth, Michael pushed the catheter through the skin and advanced it until he felt the needle tip hit the rib. He then angled it upward slightly, and pushed again. He could actually feel a pop after advancing the needle another centimeter or so.
“I think I’m in,” Michael said.
“Great,” Lynn said. “Take out the stylus!”
Michael pulled out the stylus. Nothing!
“I guess I have to advance it a bit more,” Michael said. “I must not be in the pleural space yet.”
“That, or we have made the wrong diagnosis,” Lynn said.
“Now, that’s a happy thought,” Michael added sarcastically. He reinserted the stylus and then pushed deeper into the patient’s chest. He felt a second pop. This time when he removed the needle, both he and Lynn could hear a rush of air come out through the needle like a balloon being deflated.
Lynn and Michael’s eyes met. Both allowed a tentative smile. Over the next few minutes their smiles broadened as the patient’s breathing and heart rate improved, as did his color. He also slowly returned to consciousness. Lynn and Michael had to hold his hands to keep him from reaching up and touching the cannula sticking out of his chest while they waited.
“Maybe we should do a residency as a single person,” Michael said. “I think we make a good team.”
Lynn smiled weakly. “Maybe so,” she agreed, pushing away the thought that she wished she were heading up to Boston with Michael.
Just then a blood-spattered ER doctor by the name of Hank Cotter and a nurse rushed in. They went directly to the patient, crowding Lynn and Michael to the side. While the nurse took Clark’s blood pressure, Hank listened to the man’s chest. He saw the needle thoracotomy.
“Did you guys do this?” he questioned.
“We did,” both Lynn and Michael said in unison.
“Collectively we decided it was a tension pneumothorax,” Lynn explained.
“We thought we had to do something, as the patient was going downhill fast,” Michael added. “We didn’t think it could wait.”
“And you guys are medical students?” Hank asked. “I’m impressed. Have either of you rotated through the ER?”
Both Lynn and Michael shook their heads.
“I’m even more impressed,” Hank said. “Good pickup.” Then, turning to a nurse who had just entered, he said: “Let’s get a portable chest film stat and bring in a pack for inserting a chest tube.”
Hank turned back to Lynn and Michael. “Now, I’m going to have you guys insert a chest tube. Are you up for it?”
BOOK 2
19
Tuesday, April 7, 9:38 A.M.
Lynn had been the one to insert the chest tube using local anesthetic. Michael had watched. It was far easier than when they had inserted the needle thoracotomy, because Hank, a third-year emergency medicine resident, had been the instructor and stayed with them through the procedure. It went without a hitch and both Lynn and Michael felt reasonably confident they were much better equipped to handle the emergency care of chest trauma cases in the future.
After Clark Weston had been stabilized, Lynn and Michael went back out into the ER proper to see if they could lend a hand with any other patients. To their surprise, what they found was that the emergency situation was essentially over. While they had been seeing to Clark Weston’s needs, the rest of the patients from the accident had been taken to the MUSC Medical Center while the ones that had arrived at Mason-Dixon had all been seen and were in the process of being treated.
While they were still at the ER desk, checking if there was anything else they could do to help, Lynn caught sight of Dr. Sandra Wykoff, who had also responded to the call to come to the ER. Impulsively running over, Lynn caught up with the woman as she was about to leave. Controlling her emotions, Lynn quickly reintroduced herself and again asked about getting together. Graciously the doctor agreed but said, “It has to be now since I’m about to begin a case. Will that work for you?”
“Absolutely,” Lynn said.
“Then come up to the anesthesia office on the second floor, next to surgical pathology. I’ll meet you there but don’t dawdle.”
“I’ll come right away,” Lynn assured her.
Rejoining Michael, Lynn snapped under her breath: “See the woman I was just talking with? That’s Wykoff, the anesthesiologist who screwed up with Carl.” She motioned with her head in the woman’s direction.
Michael watched Wykoff disappear before turning to Lynn. “Come on, sis, we’ve been over this. Be cool! For the tenth time, you don’t know there was any screwup.”
Lynn gave a short, mirthless laugh. “We’ll see,” she said. “The important thing is that she’s willing to see me now. Are you interested?”
“Since we missed the derm lecture, I guess I don’t have any excuse, and somebody has to keep you in line. But we’re going to go via the cafeteria so you and I get a few calories. I’m about out of gas and you’ve been on empty for hours.”