Chapter 39: It Never Happened

July 13, 1990, McKinley, Ohio

"Mike, we need both you and Mary," Doctor Williams said just after my dinner break.

"What's up?" I asked.

"MVA with six victims. A Flight for Life helicopter was dispatched to the scene. They'll be bringing two patients here. I need you to take Doctor Jefferson, her students, your students, and two nurses to the helipad to receive them. We'll reserve Trauma 1 and Trauma 2 for you. Mary and her students will assist us with the ones transported by ambulance. Doctor Caton will man triage with her students."

"And the hits just keep on coming," I sighed. "We'll get up there right away."

"Thanks, Mike. I've also called for Residents from Medicine to assist."

I assembled the team, and the eight of us took the elevator to the roof, waiting inside the shelter of the elevator room until the helicopter approached. I checked the windsock, then turned to scan the sky to the northeast, as they would try to land into the wind if at all possible.

"Leticia, I have no idea what kinds of injuries we're going to see, so this isn't a matter of taking the first or second patient, but of what they need. I suspect both will be surgical, given they're being brought in by Flight for Life. You and your students, and nurse Amy will take one, Al, Molly, nurse Peggy, and I will take the other. When you get downstairs, if you need help, send your student to find an Attending or more senior Resident.

"I'll approach first and signal for either you or my team. Remember to crouch low when we approach the helicopter because we cannot wait for the blades to stop spinning. One of the flight paramedics will open the door and help us get the patient onto a gurney. As soon as your patient is on the gurney, head for the elevator. I may tell you I need to go first, but either way, start your assessment as soon as you're in the shelter or on the elevator."

"Got it," Leticia said.

I saw the flashing lights that indicated the approaching helicopter and warned everyone to be ready. Ninety seconds later, the skids on the helicopter settled on the roof, and I quickly made my way to the door of the helicopter, crouching low. It opened just as I reached it. The paramedic put his mouth close to my ear.

"Patient one, severe head injuries, blood loss, and injuries to extremities; patient two, blood loss, and crush injuries. Both intubated; both have a unit of plasma and saline."

"Who's closest to the door?"

"Patient two!"

I waved for Leticia, and she and her team rushed over, pushing a gurney and crouching low. Between the two flight paramedics and the medical staff, we got the patient onto the gurney, and Leticia and her team made for the elevator, with one flight paramedic giving her vitals and injuries as they moved, with one of Leticia's students bagging the patient.

I waved for Al, Molly, and Peggy, who crouched and pushed a gurney to the helicopter. We quickly moved the patient to the gurney and rushed for the shelter, with Molly bagging the patient who had been disconnected from the helicopter ventilator.

"Maribeth Finlon," the paramedic yelled. "Seventeen; unbelted MVA; head struck the windshield; intubated; backboard and cervical collar; severe laceration to the right leg with pressure bandage applied; abdomen rigid; PVCs and SVT on the monitor; pulse 130 and thready; BP 70/30; PO₂ 93% on vent; likely under the influence of alcohol, marijuana, or both."

I said a silent 'Lord have mercy', then began giving orders. Leticia had taken the elevator, which meant we had about a minute to wait for it to return. We had some supplies in the emergency kit Peggy had brought with us, so we could get started.

"Kelly, instant ABG, plus tox screen, CBC, and Chem-20. Al, connect the portable EKG to the existing pads; Molly, keep bagging. As soon as we get downstairs, Molly, hook up the vent; Al, Foley catheter and urine dip."

I began my assessment as the others followed my instructions, and I started with auscultation. I didn't like what I heard, nor what had been reported on the monitor, and wondered if Ms. Finlon would even make it downstairs.

"Peggy, forget everything I said. Cardiac needle on a syringe. Forget the alligator clip, I have to do this completely blind."

"Doctor..." she began to caution.

"She'll code before we can get her into a trauma room! Do it!"

She put the correct needle on the syringe and handed it to me. I said a brief prayer, then watched the monitor to see if there were any changes. I went solely by feel, and when I was reasonably certain I was in the pericardium, I pulled back the plunger, and the syringe filled with cloudy red fluid.

"Blood in the pericardium!" I declared.

I left the needle in place long enough to listen and hear slightly improved heart sounds, then extracted the needle. The elevator doors opened, and we moved the gurney in and pressed the button for the ground floor. We continued to work on the patient as the elevator moved, and when it reached the ground floor, we rushed the patient into Trauma 2.

Everyone executed the instructions I'd given, and I began evaluating Ms. Finlon's neuro status. What I saw was extremely concerning – a blown pupil with the other one sluggish. I asked Al to perform a Babinski, which he did, and it showed no reaction. There was also blood in the urine bag, and the monitor continued to show arrhythmia.

"Need help, Mike?" Doctor Williams asked.

"I was just about to call for a neuro consult. She needs an ex-lap, but she's unstable, so I can't send her up. I'm about to put in a central line to see if we can get some volume into her and get her BP up."

"What can I do?"

I was tempted to say 'pray', but that wasn't going to change a thing.

"Get someone down from surgery to help Mary because I can't leave this patient."

"I'll make the call," he said.

"Thanks. Molly, call for a stat neuro consult. Peggy, central line kit to me, then two units on the rapid infuser; Al, assist me with the central line!"

We worked together to get the central line inserted, and Ms. Finlon's blood pressure came up to 90/60, but she still showed arrhythmia on the monitor.

"Molly, get the portable ultrasound. I need to see what I'm dealing with!"

She left the room and was back thirty seconds later.

"Both units are being used," she reported.

"Find them! Grab whichever one is done first!"

She acknowledged and left the room. Thirty seconds later, Rebekah Cohen came into the room with a male medical student.

"What do we have, Mike?"

I gave her the status, and she began her exam.

"We need a complete skull series," she said about two minutes later. "I'm reasonably certain she has a skull fracture and swelling. I want to give her mannitol if you think she'll be able to handle it with those cardiac problems."

"If her brain swells, nothing else will matter," I replied. "Order it, and we'll manage any side effects. Al, call for a cardiology consult, please."

He moved to the phone as Molly wheeled in an ultrasound machine. She and I set it up while Peggy administered the mannitol per Doctor Cohen's orders.

"The impact on her chest appears to have caused a BCI," I said. "Peggy, draw for troponin levels; Al, let's switch to a 12-lead."

He retrieved the additional pads and wires, and we worked together to connect them.

"Al, get me a fresh cardiac needle, syringe, alligator clip, and lead."

He did, and I drew a syringe full of bloody effusion from Ms. Finlon's pericardium.

"What do you have, Mike?" Bill Bielski, from Cardiology, asked, coming into the room with Alana Pace.

I reviewed the case for them, then stepped aside so they could examine the patient, including performing an ultrasound.

"Blood leaking from the right ventricle," Doctor Bielski said, pointing to the screen. "She needs immediate surgery."

"She'll never survive the anesthesia," Doctor Cohen observed. "It's obviously your call, Bill, but I don't think we can save this one."

"I'll be damned if I don't try! Alana, stay here with the patient and call anesthesiology. I'm going up to prep!"

He left, and Alana made the call. I was really surprised that an Attending and Resident had come down from cardiology, but I suspected word was out that we'd received six critical victims.

"PVCs!" I called out, seeing them on the monitor. "Run of eight!"

"There's just too much wrong," Rebekah said quietly.

"Yeah," I agreed. "But I can't fault Bill for wanting to try."

"It won't matter," Rebekah said, and I had to agree.

"SVT!" I called out. "Sustained!"

"Lidocaine, IV push!" Alana ordered.

Peggy complied with the order, and about twenty seconds later, the SVTs resolved, but then things became decidedly worse.

"Multifocal PVCs!" I declared, seeing the monitor.

"Nurse, do you have moricizine in the ED?" Doctor Pace asked.