‘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.
‘Start CPR,’ he instructed Beth.
She worked hard to make her chest compressions as effective as possible, but Luke shook his head as he felt for a carotid pulse moments later.
‘We’re still not getting a pulse.’ He raised his voice. ‘Mike? I’m going to have to go for a thoracotomy here.’
Beth’s jaw dropped but Mike sounded perfectly calm. ‘That’s fine,’ he called back. ‘I’ll come and intubate for you in a second.’
Luke had caught Beth’s astonished expression and his tone suggested he had taken her reaction as a personal criticism. ‘You’ll find a thoracotomy kit in the storeroom, Beth.’
She was pleased to be able to turn away. ‘I know where it is.’
He was a surgeon after all, and maybe Luke had had experience with opening people’s chests. He certainly seemed confident enough, and it was probably the only procedure that was going to save a life here, but it was still horrific to watch him divide Stella’s sternum with a saw in what seemed like only a few minutes later.
It was just as well she’d had theatre experience in the past, Beth decided, handing instruments and wound towels to Luke. It was how they’d met in the first place. Luke had been a surgical registrar and Beth had just been starting work as a theatre nurse. She’d transferred, of course, when their relationship had hit the rocks and the fascination and pressure of working in the emergency department had gone from being a welcome distraction to a real passion.
And here they were again. The bizarre impression of being in a time warp was heightened after Luke took a scalpel and carefully incised the membrane of the pericardium. The rush of blood wasn’t enough to suggest a fatal cardiac injury and there was a collective sigh of relief as the vigorous pumping of Stella’s heart could be actually seen.
Mike had his fingers on the side of Stella’s neck. ‘Great output,’ he said delightedly. ‘Fantastic!’
His voice startled Beth. The feeling that she and Luke had been a single—and isolated—unit had been so strong she had actually forgotten Mike was there in the last few minutes. She had been standing so close to Luke. Their hands had touched more than once when she had handed him instruments, and that closeness—that touch—had wrapped them into a space that had been theirs alone. Luke merely nodded in response to Mike’s delight. ‘We’re not out of the woods quite yet,’ he warned. ‘Let’s cover everything with dressings and sterile drapes and get her up to Theatre to finish.’
