Ventilate with one hundred per cent oxygen. Assemble laryngoscope, lubricate cuffed endotracheal tube, cut tape, ready clamp, syringe, flexible introducer and forceps. No need for induction anesthesia since the patient was already unconscious. No gag reflex. No need for local either.
In seconds she had the woman intubated, the tube connected to the bag-valve combination and was ventilating with oxygen. She looked at the chest. No improvement in air entry. She reassessed her measures, made sure the ET tube was in place in the trachea. It was. Airway secure but breathing not any better; shallow, strident 55 prm.
Exposing her patient’s chest, she saw the tell-tale paradoxical movement of her ribs, a segment moving in while the rest moved out with breathing. Flail chest—ribs broken in a row and moving independently of the rest of the chest wall.
Stethoscope already drawn, she gave the chest a listen. Normal breath sounds on the right side, none on the left. On percussion, stony dullness at the base of the lung. Hemothorax. But the trachea was deviated. Probably hemopneumothorax—both blood and air gathering around the left lung, collapsing it and interfering with the right lung and heart function. Fatal if the building air and blood weren’t evacuated—fast.
She picked an angiocath to perform a needle thoracostomy, slipping it between the ribs and into the pleural space. She heard the distinctive rush of air in relief, then placed a one-way valve on the end of the angiocath to prevent air re-entry. Immediately, there was an improvement in air entry, if not in breath rate.
Check circulation. Pulse 180—ectopics all over the place. Blood pressure 80 over 50—hemothorax must be massive. Going into shock.
She exposed the woman’s arms, snapped tourniquets on both and inserted two wide-bore 14-gauge IV cannulae. The woman moaned in protest around her tube.
“Sorry I had to prick both arms!” She released the tourniquets, hung two Ringer lactate solution bags from the IV holder, connected their tubing to the lines in the arms, set the drip to maximum, then swooped for tube thoracostomy instruments to drain off the blood. First, local anesthesia.
“This sting you’ll thank me for,” she said soothingly as she injected the local anesthetic and disinfected the area until it took effect.
“I doubt she…understands a word of English—if she can hear you at all…”
Laura started. Armando—she’d forgotten he was here.
“She’ll understand my tone, that I’m taking care of her!” She snapped her eyes back to the instrument compartment and extracted a 38-French large-bore chest tube, explaining why she needed it. She looked him over as he came to crouch beside her. “So you’re better now?”
“Better than you. Move—I’m doing this.”
She protested but he’d already snapped on gloves and was taking the scalpel and tube out of her hands. He wasn’t breathing much easier, but she was sweating. Not the stuffy sweat expected with the heatwave that was ending March, Argentina’s last summer month, but the cold, sick sweat of depletion. Bright pain had settled in her right side. Gray mist had crept up over the rest of her a couple of times back there. He was probably in better condition than her. She made way for him.
Flopping into the attendant’s seat, she watched him recline the cot so that their restrained patient lay in a 50-degree reverse Trendlenburg position with her legs down. Both that and the incision between the ribs in the mid-axillary sixth intercostal space made for best drainage of blood. In deft, sure moves, he punctured the intercostal muscles and pleura with a curved hemostat clamp, advanced and secured the track with his finger and inserted the tube into the pleural cavity. Blood gushed out, just as she’d predicted. He secured the tube with a suture and tape and connected it to an underwater-seal bottle, attaching it to the suctioning device.
She busied herself with a secondary assessment of the woman’s vital signs. Breathing down to 24 and blood pressure up to 110 over 70. Measures working. She told him. He nodded. “Let’s look her over,” he said.
Apart from a multitude of bruises, a quick exam for dysfunction and a full exposure didn’t reveal further significant injuries. Eyeing the bottle for the collected blood, Armando frowned. It was over 900 ccs.
“A lot,” she said.
He gave a slight shrug. “But it has almost stopped coming. She’ll be OK. Load me 10 mg diazepam while I decompress her stomach.”
“But her GCS is 5—6 at best!” Centrally depressant drugs were contra-indicated when consciousness was compromised and scoring on the Glasgow coma scale measuring responsiveness and alertness was below 8. “How can you consider sedating her?”
“I believe she lost consciousness with respiratory distress and shock, not from a head injury. If you hadn’t noticed, she’s lightened up.”
“What if she has? Why not just let her wake up, extubate her and put her on positive pressure ventilation with a face mask?”
“She’s a cervical spine injury suspect. If we need to operate further, and it turns out she does have a cervical injury, this ET is our one safe chance of having one in. I want it left in.”
Laura mulled this over, watching his every move as he slipped in the nasogastric tube and emptied the woman’s stomach. Incisive, ultra-efficient.
And right.
Damn him.
In seconds, she’d slipped the diazepam into the woman’s drip, hooked her to the cardiac monitor and raised her head. She found him watching her in turn, something like surprise in his bloodshot eyes.
He shook his head, made a strange, wheezy sound—an incredulous laugh? “Good work!”
He was surprised, double damn him! How dared he be surprised?
But really, why should she be surprised? She should be used to his opinion of her medical competence, of her worth in general, by now.
Still biting her tongue, she watched as he checked their patient one last time, then rummaged for a syringe, loaded it with an ampule diluted with saline and injected himself subcutaneously.
“Ventolin,” he rasped, then muttered something else under his strident breath.
So he did need a bronchodilator and… What had he said?
It sounded too much like Laura Loca to her. Crazy Laura.
“What did you say?”
“So you heard me, huh?” His shrug was careless as he crossed to the driver’s compartment, throwing a calm “Good” over his shoulder.
In seconds he was revving the engine loudly and putting the van in gear, forcing her to scramble to the passenger seat.
“I’m crazy? I’m not the one driving a car fifteen minutes after being zapped with tear gas.”
“One of us has to and apart from my eyes stinging like hell and my skin and lungs feeling about to combust, I’m in a far better condition than you—Laura Loca!”
“You’re saying it again!”
“Don’t mention it. What
