Mercy

CHAPTER 10

The siren’s persistent wail rattled Julie’s nerves and made it impossible to concentrate. Ashley, more accustomed to the noise, appeared unfazed by the racket as she conducted a thorough secondary trauma survey on Sam.

Julie had ridden in the back of ambulances before, but only as part of her training. She did not remember them being so claustrophobic. She found the constant jostling unnerving.

To put an exclamation mark on that thought, the ambulance lurched forward. Julie, occupied with Sam’s heart rate and pulse oximeter readouts, tumbled to the floor.

“Are you all right?” Ashley asked.

Julie quickly got back to her feet. Her gaze went to the heart rate monitor, which showed a jump from 97 to 125 in less than a minute.

“What’s going on with that?” Ashley said, and began to reassess Sam anew.

Sam’s heart rate continued to tick upward: 125, 130, 145…

Julie had a gut feeling it had everything to do with those distended jugular veins. Through one of the windows between the hard plastic struts that made up the cervical collar, Julie could see those veins were even more grotesquely engorged than before. Blood filled them from Sam’s sternum to his jawline. It was a clear sign of impaired blood return to the heart.

His breath sounds were still solid, though, and the pulse oximeter read 96 percent, which was in line with the ten liters of oxygen flowing into Sam’s face mask.

Julie recalled all of the anatomy she knew about the heart. It was an ingenious circulatory system that regulated blood flow from areas of high pressure, with less space for the blood to flow, to areas of low pressure, which included the body’s veins. In a healthy person those jugular veins should be flat, with no noticeable bulge.

The bulge on Sam’s neck was a clear indication that the whole system was in disarray. If pressure built up in the heart’s right atrium, the first chamber to receive blood returning from the body, blood could begin to back up into the veins leading to it. That included those jugular veins, which drained the head and arms.

Julie centered her thoughts.

“His heart rate is still climbing,” Ashley announced. “One fifty-five. His pulse is thready. I’m really worried he’s going to arrest.” Her calm exterior seemed to be fraying.

“It’s those veins,” Julie said, softly, almost to herself. “Something is causing the pressure to increase in his circulatory system. It’s not building from inside the heart, but from outside of it.”

The ambulance shimmied and shook. Its siren screamed. All of it combined to make it difficult for Julie to focus on a differential diagnosis. She fought the distractions, churning through the limited possibilities. Topping the list was a tension pneumothorax, common in chest trauma. A collapsed lung, pushing against the heart, could squeeze the vessels and the heart itself toward the opposite side of the chest. If enough air pressure built, blood could not enter the heart and it would back up into Sam’s veins. But those breath sounds simply did not support the theory. What then?

“Dr. Devereux, heart rate is at one hundred sixty-five. BP down from one hundred to eighty-five.”

Blood pressure dropping, heart rate going up. What’s the damn cause, here?

“He’s going to arrest any second!” Ashley’s voice betrayed her fear.

Julie looked down at Sam and saw that his lips, ears, and nose had begun to turn an alarming shade of blue. She tried to get a carotid pulse, but checking was near impossible with the collar around Sam’s neck.

“Can you get a pulse here?” Julie spat out the words.

Even Ashley, more experienced working around the c-collar, was hampered. It did not help matters that the ambulance swung violently from left to right as it zoomed around slower-moving traffic.

“Careful, Bill!” Ashley barked. “We’re in crisis here.”

Sam’s readouts continued to go wild. His heart rate was nearing 200 and his blood pressure was down to eighty over sixty.

“I can’t get a pulse,” Ashley yelled. “We’ve got to start CPR now! He’s in PEA.” Pulseless electrical activity. Sam’s heart was not pumping blood, but it still had a rhythm observable on the electrocardiogram. Julie knew she had only a minute or so before asystole ensued-what most people would call flatline.

Something held Julie back. A feeling, same as the one she’d had with the BC quarterback, Max Hartsock. Something simply was not right, and CPR was going to be a potentially tragic waste of time.

“Heart rate at two oh one and no pulse!” Ashley called out. “Forty milligrams vasopressin, ready to go.”

Sweat dotted Julie’s forehead. Heat rose through her body. The ambulance was cramped, cacophonous, and the constant movement kept her off-kilter.

Think… get your head around this… what could it be?

“Dr. Devereux! We need to code him. NOW!”

The accelerated beeping and increased volume of Sam’s many monitors had reached a fevered pitch. Julie did not react impulsively. Her brain worked lightning-fast to weigh the probability of one condition over another.

What about a sternal fracture? Julie thought. It was an uncommon injury, but one linked to trauma. The breastbone sat in front of the heart and great vessels. A hard enough blow to the chest could push the bone into the thoracic cavity, blocking blood flow to the heart from the head and arms. If that were the case, there was nothing Julie could do from the back of an ambulance.

A voice whispered in the back of Julie’s mind, telling her to focus on CPR and get Sam to the hospital.

But something-instinct, experience, fear-told her to wait.

Two paths. Did he need CPR or something else? Choose wrong, and he could die.

“Heart rate two oh five. He still has no pulse. We’re going to lose him, Dr. Devereux, if we don’t start CPR now!”

Julie looked down at Sam’s lifeless face. The serenity of his expression unsettled her to the core. He looked so at peace, almost unbroken, except for those veins. Those damn veins.

And that’s when Julie knew the answer.

“I need a needle, stat!”

“A needle? What for?”

“Just get it, dammit!” Julie barked out the words.

“What size?” Ashley asked.

Julie’s brown eyes flared like embers from a fire. “The biggest one you got.”

There was some fumbling before Ashley procured a forty-five-millimeter long, fifteen-gauge needle capable of piercing bone. She handed it to Julie. The IO needle, used in intraosseous infusions, was typically inserted into the shinbone. The needle’s large bore allowed for huge volumes of intravenous fluids to be pumped into a patient through the rich network of vessels in the marrow space. But this was not about getting fluid in. It was about getting it out.

“Heart rate is still two oh five,” Ashley announced.

Julie tightened her jaw and nodded that she understood.

If Julie did not do what had to be done, right here, right now, Sam would die before they reached the hospital.

She set the needle against the skin below Sam’s ribs, just to the right of the little key-shaped bone that hung off the bottom of the sternum. Julie did not waste time cleaning the area with Betadine or isopropyl alcohol. If Sam got an infection, at least he would be alive to endure it.

Ashley looked deeply troubled. “Dr. Devereux, what exactly are you doing?”

The constant motion of the ambulance made it difficult to hold the needle in the proper place. The screech of the siren pounded at Julie’s eardrums.

“He’s bleeding into the pericardial sac surrounding the heart,” Julie said. “It’s compressing his atrium and backing the blood up into his veins.”

Being an experienced paramedic, Ashley understood right away what Julie planned to do.

“You’re going to perform a pericardial tap? Here? Now?”

“He’s got cardiac tamponade. If I don’t do it, he’ll die.”

There was no real test for cardiac tamponade, though echocardiography had improved the diagnosis considerably. A process of elimination and a gut feeling had brought Julie to this moment.

The needle trembled ever so slightly in Julie’s typically steady hand. Fear was foreign to her when it came to performing life-saving medical procedures, but Ashley was right to be concerned. In terms of risky maneuvers, this one, under these conditions, ranked near to the top. Sam should be in the ICU. He should be given more oxygen, plasma volume expansion with an infusion of blood or dextran. To do this properly, Julie should take between twenty minutes and an hour. Now, she had but seconds.

Most of the color had drained from Ashley’s face. “We’re not authorized to perform this procedure,” she said.

“Yeah, well, I am.”

The needle was attached to a plastic grip that fit comfortably in Julie’s hand. Julie’s fingertips rested at the tip of the needle, increasing her dexterity and control. She inhaled deeply and exhaled through her nose.

You can do this… for Sam… you can do this…

Julie twisted the needle back and forth and pushed hard enough to puncture the skin. A trickle of blood oozed out from tiny gaps around the circumference of the needle. Julie took in another readying breath and visualized the anatomy. If she didn’t get this right, the needle could puncture the heart or liver, or collapse a lung.

“Bill, pull to the side of the road!” Ashley called out.

“No! Keep driving! I’ve got this.”

“What do you want me to do?” asked Bill, who took his orders from Ashley.

Ashley locked eyes with Julie. “Keep going,” Ashley said.

In one quick thrust, Julie drove the needle up toward Sam’s left shoulder. But that was only step one.

“I need a syringe. Again, the biggest you’ve got.”

The syringe Ashley handed her-twenty milliliters, not quite the size Julie wanted-screwed onto the plastic grip. Julie released a flange, and built-up pressure in Sam’s pericardium pushed blood into the syringe at a rate much higher than Julie anticipated.

“I need another syringe, stat!” Julie yelled.

Blood quickly filled the syringe, but more was coming. Pressure steadily built up inside the syringe, and Ashley reached for a replacement. Too slow. With a popping noise, the plunger damming the blood shot from the syringe barrel like a bullet from a gun. A jet of dark blood exploded in a horizontal geyser that covered Julie’s face in red. Blood splattered on her clothes, her neck, face, and hair.

Ashley gasped in horror as Julie reached for the flange to shut off the blood flow. With the back of her hand, Julie smeared more of Sam’s blood across her face as she wiped her eyes clear. The coppery, metallic taste soiled her mouth and turned her stomach.

“Blood pressure is rising and I have a good pulse,” Ashley said, her voice calm in spite of all the blood. “Heart rate is coming down, too.”

“I need another syringe,” Julie said, breathless. A trickle of blood dripped off her chin and left dots on the floor by her feet.

“Heart rate is one oh six, one hundred… goodness, it’s down to ninety.”

Julie got the second syringe in place. This time, as she opened the flange to allow blood flow again, she kept her hand on the plunger to control the pressure. Blood filled the second syringe as well, but at a normal rate.

Julie used a towel to wipe some blood off her face. The ambulance smelled like a slaughterhouse as it rocketed through the darkening night.

Soon they reached White Memorial. The ambulance came to a hard stop and Ashley pushed the back doors open. The team waiting to receive Sam gasped at the ghoulish sight within. Sam’s blood had splattered the walls, floor, and equipment, and it covered Julie like a gory second skin.

“I did a pericardiocentesis en route,” Julie said to one of the doctors on the scene.

The doctor grimaced and returned a sympathetic look.

“The OR is prepped,” the doctor said. “We’re moving him to trauma first. We’ll take good care of him.”

Sam was wheeled through the emergency doors and whisked down a hallway, out of sight. Julie, alone, stood for a moment at the back of the ambulance. Then she sank to her knees and began to sob.