Death Flight

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Death Flight Page 12

by Melissa Yi


  Let him do it, Hope. Show him you have faith in him.

  Gideon barked in response. I'd lost track of him, but he sounded like he was immediately behind Herc.

  "Keep the dog away," I warned. The last thing we needed was canine intervention while Tucker had a knife in his hand.

  First, Tucker explored the larger wound with his dominant index finger. The wound was almost exactly where we'd make the incision for the chest tube, so it was possible that he could use part of the wound itself for the tube. Not recommended, but neither is a butter knife instead of a scalpel.

  "How deep is it?" I burst out.

  "Deep, but the wound is at an angle." He wiggled his index finger. "I can't get my finger in. Can't tell how deep it is."

  Maybe I could get my finger in the wound. Sometimes small fingers are an advantage, like during a vaginal hysterectomy.

  No, Hope. Let him run the show.

  Tucker placed the knife less than a centimetre away, at the anterior axillary line. That means the line if you drew straight down from the front fold of the armpit. He was going to cut laterally, away from the midline. That made sense to me. Move away from the sternum, or breast bone. More room to explore.

  "Light, please," I snapped. He was casting a shadow on his own work because of the airplane's crappy overhead light. "Does anyone have a flashlight on their phone?"

  Three people immediately flashed their LED's, blinding me, but better than fumbling in the shadows. "Thank you," I said, and I leaned forward, resting my hands well away from his work site, but drawing the edges of skin away from each other. By increasing the tension on the skin, I was making it easier to cut with the butter knife. "Try to shine your lights over Dr. Tucker's left shoulder."

  More lights beamed over us, kind of like a concert, only much creepier.

  Tucker sawed back and forth with the almost-invisible teeth of the butter knife, pressing hard enough to divide the epidermis, the top layer of skin, as well as the dermis, the fatty layer underneath. It was only another two centimetres, but I knew from my limited chest tube experience that you'll need room to explore within the chest cavity, so you can't be squeamish and make too small a hole. Then your finger won't fit, or it gets stuck.

  Tucker made a face. "I need a Kelly."

  I nodded. It's not safe to stick the knife into the chest wall. He could accidentally go too deep and stab the heart himself. The scalpel is a tool to cut the skin, but you want to stop and separate the muscle fibres with Kelly forceps, or safer yet, your fingers. The first and only time I did a chest tube with the pigtail catheter, I slowly and methodically used the Kelly to separate the three muscle layers of the chest wall until the surgery resident told me, "Go ahead, Hope. You aren't going to hurt anyone."

  Now I said to Tucker, "Do you want me to try and find a pair of scissors?" I dreaded the answer, except then I'd be doing something.

  He shook his head. "I can do it. Just slowly, that's all."

  "I've got one," said Pascale, displaying a small, bronze pair of scissors with a handle made to look like a stork's body. Its beaks formed the two-inch blades. My mom had a pair like that for sewing, but I was astonished to see them on an airplane. Who knew they were allowed by the TSA? It could even have been the weapon used on Mr. Money, although this one already looked clean even before I rinsed it with the last of the brandy.

  Pascale held up another brandy bottle for me, anticipating my next question.

  I smiled and handed her the knife. The handle still felt warm from Tucker's skin, even through my gloves.

  "You want help?" called Compton.

  Gideon barked. Every time someone yelled, he barked, adding to the chaos.

  "No. Be quiet," I said. Tucker had started the most difficult part, trying to cut through the parietal pleura, the lining inside the chest wall, without piercing the lung or the heart. The scissors were slightly safer than the knife, because he had his thumb on the dull edge of the blade to control it, but he could slip. Some people make a hole and then use their fingers to rip the muscle apart to widen it, but either way, this was risky business.

  Mr. Money was still breathing. For now.

  I held my own breath and kept the tube in my hands, the hockey stick hook side facing toward me, ready for Tucker's signal.

  When Tucker broke through the last layer of the chest wall, it hissed as if he'd opened a pop can.

  The air literally blew my hair back from my face like a hair dryer.

  My face, neck, and clothes were sprayed with something wet.

  I would have sworn, but I didn't want to open my mouth.

  I looked at Tucker. He was spattered in blood, too, but he'd commandeered the chest tube out of my hands and was tunnelling it in.

  When he paused, I knew what he wanted. I yanked the coat hanger out so he could move the chest tube deeper without fear of impaling the lung or the heart.

  A woman screamed. It might have been Mrs. Thatcher.

  I was screaming inside, too. Who knew what blood-borne diseases Mr. Money was harbouring under his sleek exterior? I'm more careful than most doctors and nurses when it comes to suiting up. Unlike them, I actually wear the masks with eye protection, even over my glasses, plus a disposable gown, at every code. Another doctor once told me that I looked like I was wearing a condom.

  This time, my glasses might've protected me a little, but Tucker's eyes, nose, and mouth were completely naked, and he'd received the full blast with an open wound on his arm.

  My man was a hero. Now he could be a dead hero.

  It's okay, Hope. HIV is treatable now, and Hep C ... I tried to remember the treatment for Hep C. They've got new antivirals, but my heart cried out. Tucker had barely escaped the OR, and now he might end up back on the treadmill of doctors' visits and blood tests and treatment so harsh that we also use it for chemotherapy.

  If Mr. Money hadn't already been almost dead, I would've killed him.

  After taking stat samples for baseline HIV and hepatitis testing.

  My heart thudded. I gritted my teeth inside my still-closed mouth. We barely had gloves. A plane didn't carry any other personal protective equipment. And Mr. Money hadn't asked us to save his life. Tucker had sailed into the breech because—well, because he lived for that sort of thing. If he wasn't saving lives, he'd be half a man.

  The good news was, if this worked, Mr. Money was saved. We could stop right here.

  Please work.

  Please wake up, you bloody bastard.

  21

  In the movies, Mr. Money would have stayed still for a crucial beat or two, and then taken a deep breath, opened his eyes, and said something sweet (for a rom com) or salty (for a thriller).

  Instead, he lay there, still breathing, but too fast, at about 24 resps per minute. The balloon valve puffed with each breath, so it worked, and I could testify how much air had escaped from the guy's chest based on my new hairdo, but he hadn't improved much. In fact...

  "He looks dead," said some guy.

  "He's still breathing," I said, annoyed, but I took his pulse.

  Gideon growled as I repositioned myself and my fingers.

  "Shh, shh," said Gladys, to no avail. Gideon started barking louder than ever, making it hard to concentrate.

  I shook my head at the pulse, which was faster and weaker. "About 125," I told Tucker. "No, 130."

  I kept my fingers on the pulse. I was afraid we'd lose it at any moment.

  "Look at those neck veins," said Tucker, eyeing the right internal jugular.

  I repositioned my fingers to try and cast less of a shadow. Even through my concussed eyes, Mr. Money's jugular venous pressure was still through the roof.

  We didn't have an ultrasound or cardiac monitor, and I couldn't hear his blood pressure enough to judge a narrow pulse pressure. I nodded anyway and said what we were both thinking: "Tamponade."

  Tucker took a deep breath and replied, "Pericardiocentesis."

  Doing pericardiocentesis is no big deal on your ora
l exams. All you have to say is "I stick a needle into the pericardial sac," the examiner replies, "You drain 30 cc of fluid," and you feel like a hero.

  In real life, on this airplane, we couldn't confirm the diagnosis before sticking a needle within a few millimetres of this man's heart.

  "I'll get a needle. Magda, you put the oxygen on him," I said. This was Mr. Money's last chance. If it didn't work, nothing would. We had to drain the blood that was leaking into the sac around his heart, literally squeezing his heart to death. I told Pascale, "Keep taking his pulse. Tell me as soon as he loses it."

  Her eyes bulged. I probably should have said "If he loses it." Too late.

  I snatched the biggest needle in the kit, but it was still only an inch long. Mr. Money was a stocky guy with a mix of muscle and fat. An inch wasn't going to penetrate his chest wall and pierce the pericardial sac. You have to go through the anterior chest wall at an angle (45 degrees! Toward the left shoulder! Although ER guru Tintinalli suggests you can choose the right shoulder instead!) in order to drain the blood.

  "It'll work if I go through the hole," said Tucker. He meant that normally you're penetrating the chest wall with the needle, but since he'd made an incision already, he didn't have to go as deep. He could sink the needle right up to the hub, and it might be long enough.

  Or it might not.

  We had to try. I attached the needle to the biggest syringe we had, a 20 cc, and said a quick prayer before I offered it to Tucker. Then I poured brandy over the incision as a final attempt at sterility. It would sting if he were conscious, but he wasn't conscious, so booya on that.

  I took turns pouring brandy over each of my hands and gave the bottle to Magda, who'd fitted the ridiculous yellow cup-like oxygen mask over his mouth. Pascale licked her lips and dug her fingers harder into Mr. Money's neck. I recognized that movement.

  "She's losing the pulse. Try it!" I called at Tucker as he braced his right hand against Mr. Money's chest and turned the business end of the syringe toward the incision.

  Mr. Money rolled slightly on his left side.

  "Hold him still!" I yelled at the flight attendants, Herc, and Compton. "He can't move, or else we'll stab him."

  "Should we be doing this?" a woman squeaked.

  Tucker said, "It's his only chance," and the plane quieted down. Even the bing-bing-bings of the alarm and Gideon's barking stilled for a crucial second as Tucker stuck the needle in through the hole.

  Mr. Money spasmed.

  "Hold still!" I shouted, and three pairs of arms shot out to grab him. We were down a few sets of arms because of the manual phone lights. I said, "The light isn't as important now. Just hold him down so he doesn't move."

  "But don't get in my way," said Tucker. "I'm angling the needle toward the left shoulder." We all watched him advance the syringe.

  He moved the needle in. Not yet up to the hilt, he advanced in little jabs, half a centimetre a time.

  The airplane punted to the left, and the needle sank extra deep. Not terrible, but a few more millimetres for sure.

  Tucker froze.

  I sucked my breath in through my teeth.

  Everyone seemed to gasp. Most of the passengers were too far away to watch the needle, but they'd read our body language.

  Medicine is not performance art. My man had testicles of titanium, trying to save Mr. Money's life in front of a planeload of people.

  He's dead, I wanted to tell Tucker. That was what a preceptor, Dr. Dupuis, told me when I worried about running my first code. He's basically dead. If his heart hasn't already stopped, it's going to. We have nothing to lose. This is his last chance. Keep going.

  Tucker might have read it in my eyes or in my body language. He withdrew the plunger on the syringe as he advanced another millimetre. It sounds like a small thing, but it's hard to advance the syringe and pull back on the plunger at the same time unless you use both hands.

  I'd been taught to attach an electrode to the needle, to watch for ST heart wave changes on the cardiac monitor, but of course, there was no cardiac monitor and no electrode. Only Tucker's hands.

  Even so, I stood by, ready in case he needed me to hold the needle or syringe steady while he drained the pericardial sac.

  As he drew up the plunger, a bead of blood followed its path.

  I gasped. Holy crap. Tamponade. And we were—he was—draining it.

  Pericardiocentesis.

  It sounded like a word of prayer now.

  Slowly, he withdrew one cc of dark red blood.

  You are a god among men.

  I laughed in relief, and Tucker's hand twitched.

  He kept pulling, but no more blood followed.

  One cc of blood wasn't enough to stop the heart, especially one as stubborn as Mr. Money's.

  I held my breath.

  Pleasepleasepleasepleaseplease.

  He adjusted the needle, experimenting with the depth and the angle. A bubble of air entered the blood.

  "I'm sorry," Pascale quavered, "but I think—"

  "You've lost the pulse?" I should have positioned myself at the head, but now I was at the foot of Mr. Money's body, and I couldn't reach across Tucker's field. "Someone else double check it, but for God's sake, hold him down. I'll do his femoral." I reached for the guy's right groin and mashed two fingers into the fold of his thigh, searching for a pulse.

  Linda and Magda both reached for his neck.

  "Not at the same time," I shouted. "You’ll stimulate the vagal nerve and make him faint."

  They gaped at me.

  Less information, Hope.

  "Forget it. I can't feel a femoral," I told Tucker, and yelled, "Start CPR. Who knows CPR?"

  "I do," said Herc, but he was at the leg end, with me, and we needed his strength in case the guy regained spontaneous circulation and tried to rip our heads off.

  In the meantime, the three flight attendants had already put up their hands.

  Of course they knew CPR. What was I thinking?

  "Pascale," I said. She looked the strongest. Magda balked at even touching Mr. Money, and Linda might have to run to the cockpit. "Get in there and do CPR. Magda, get ready to trade off in two minutes."

  Pascale linked her fingers together and extended her arms, but she hesitated. "He's there," she said, pointing to Tucker.

  "Do it from the top end," I said. "Stay out of his way."

  She shied away from the needle and the blood. "I need gloves," she said, and Magda dug in the medical kit for them, while Staci Kelly yelled from the front cabin, "What's happening?" and Mr. Yarborough bellowed back, "Kim?"

  "I'm coming out," said Tucker. "Let her try."

  A newly-gloved Pascale got on her knees and started CPR after Tucker withdrew the needle. I stayed on the femoral pulse and called, "Good compressions." Pascale looked like a black Audrey Hepburn, slim and elegant, but she knew how to get on her knees, lock her arms, and give what for on her compressions.

  "I'll try one last time," said Tucker. "Get me a bowl."

  I shoved the empty brandy bottle at him. He squirted the syringe's cc of blood into the opening.

  "Ew!" I heard someone say, which I ignored as I entrusted the bottle to Linda, who had donned a pair of gloves and a bland expression as she accepted the bottle.

  When I turned back, Tucker had already ordered, “Stop compressions.” He began one last pericardiocentesis, faster this time, more certain.

  He advanced the needle a few millimetres and barely got a few drops of blood. "I need a longer needle!" he shouted.

  "Longer needle!" I barked, in case someone else knew the medical kit better than I did.

  Linda's voice came down hard on both of us. "That's the longest one we've got."

  Tucker swore as he withdrew the needle.

  "Restart CPR!" I called. Magda leapt in this time, also armed with gloves and a pretty good technique.

  Mr. Money was dying.

  He was dying in front of our eyes. All we'd done was prolong the process.
>
  22

  "Fluids!" I shouted. We could compensate temporarily by amping up circulating volume enough to maintain his blood pressure, even if he had too much fluid around his heart.

  Tucker said, "I'm on it."

  He reached in the medical kit and grabbed an IV needle and a bag of fluid. Soon Magda was holding a bag of saline above the patient, trying to squeeze its contents through a 20-gauge needle.

  "Land the plane," said Tucker.

  “The weather system won’t allow it.” Linda's voice was clipped.

  "Land the plane now," said Tucker, and I understood. It was his first code since our hostage taking, and we'd failed. All of us had, but it felt like his failure, because he'd done the procedures, even though I was the trauma team leader.

  Fluids probably wouldn't help, and they might make things worse by diluting the blood and clotting factors and causing more leakage into the pericardial sac, but I was running out of options. We didn't have packed red blood cells to transfuse him, and our needle hadn't worked.

  "Let's run through the H's and T's one last time," I said. We already knew the cause, but you're supposed to follow algorithms and think out loud during codes. "Hypoxia—he has oxygen. Hypothermia—we could get him a blanket, but it's not like he's been out in the ice. Hypovolemia—yes, probably, but we're running normal saline wide open." I left out the fact that the needle was too small. It was the biggest one we had. Tucker could start another IV or two, but the main problem was still the hole in his heart. "Hyper- or hypokalemia—probably not. I can ask his wife if he's a dialysis patient, or on potassium. Hydrogen ions for acidosis—we don't have bicarb."

  "T's." Tucker took over, which seemed appropriate because his name started with T. "Tension pneumothorax—he got the chest tube. Pericardial tamponade—we can't fix him with the equipment we've got." He paused a second to seethe. "Thrombosis, either cardiac or pulmonary—he was stabbed, he didn't have a heart attack, or if he did, it was provoked. And toxins, same. It wouldn't be the primary cause."

  I shook my head. The chance of survival dropped with every minute. Even if his heart started pumping again, his brain wouldn't recover. At some point, you have to stop. "Tucker, we should call it. He's been down for ... " I checked my watch. "Twenty-three minutes."

 

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