GWOT Infirm Moment
Sep. 29th, 2018 08:11 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
drewkittyGWOT Infirm Moment
(immediately after Dirty Mercs)
Once we had verified by long range CCTV and sniper-observer teams that our guests had in fact left the area, and were not for example motivated to make a U-turn and attack the site, I proceeded to the next location where my presence was needed.
The infirmary.
Note that I did not say the clinic, or the hospital, or the trauma center. Or especially not the psychiatric ward or the rape crisis unit.
Today, our infirmary would have to serve all five purposes simultaneously. Again.
The properly marked patient care board posted prominently in front told the story, in order of severity.
Flail Chest, Head Injury
Head Injury, Broken Jaw
Head Injury
GSW right leg, Broken Jaw
Amputation
Broken Jaw, 261
261 foreign object
261
Slash Wounds
All medical staff were present and working, busily. Six of the eight wounded were triaged Immediate, as in their injuries were considered potentially life threatening without immediate stabilization and treatment. Only the last two were considered Delayed. Both were in "chairs," the waiting area. A stretcher bearer sat with each. One stared blankly at the ceiling. The other rocked slightly under the reddish rolls of gauze tightly wrapped around both her upper arms.
I walked into Trauma 1. The vet surgeon looked up to order whoever it was out, saw me and barked, "Glove up asshole!"
I therefore gloved up from the boxes mounted on the wall, above the sign saying "INFIRMARY PERSONNEL ONLY THIS MEANS YOU."
"Go next door," she ordered her assistant, who perforce disappeared into Trauma 2. I took over what her assistant had been doing -- keeping the flowing oxygen mask on the convulsing man's face. His hands and legs were already strapped to the stretcher.
"Status epilepticus, at least fifteen minutes down," she snapped at me. "Any bright ideas?"
He had been stripped. His rib cage was purple and black where he had been kicked repeatedly, with big heavy boots. His trachea was visibly distended to one side. But the blood and clear fluid leaking from his nose and ears, and the heavy bruising around his eyes and under the base of his ears on either side told the worse story.
Fractured skull. This patient was not immediate. This patient, given our capabilities and available levels of care, was expectant.
As in expected to die.
Shortly.
But not quite yet.
The over the counter pulse oximeter we had stolen from a pharmacy on his finger read 85. Small mercies.
"Blood pressure?"
"180 over 40, five ago."
Heart at work over heart at rest. The brain injury was affecting him neurologically. The heart was desperately pushing the blood into the damaged brain, which had no way to get rid of it.
"Meds on board?"
"One morphine Syrette." And probably wasted. Enough morphine to put him down would stop his breathing. "Twenty-four drops of sativa sublingual. No effect."
His bruised brain was pushing against the bones of his skull, crushing it. In a modern, state of the art trauma center, he would be the focus of an entire patient care team - drugs to paralyze him, drugs to encourage circulation, drugs to throw off excess body fluids.
"Diezapam, rectal," I asserted.
"Out." I had used the last injectable dose on a bus passenger, whom I had later murdered.
"Versed? Ativan?"
"Out."
"Ether?"
"Out."
"Nitrous oxide?"
"Out."
This was not the time to discuss how low our emergency drug stocks had been depleted.
This was the time for utterly desperate measures.
"Amyl nitrite."
"What?"
"Poppers, doctor. A drug of abuse that also lowers blood pressure."
"Do it." I went to the phone and called the extension labeled Pharmacy, on speakerphone.
"Amyl nitrite, two doses, STAT" I ordered.
The pharmacy tech - who was as much a pharmacist as I was an emergency physician - ran in with the doses. Little bottles of video tape cleaner. We didn't have a nebulizer. So the only solution was to soak a piece of cloth, and put it over the patient's nose.
So I did, for a good half minute.
We took vitals again. Pulse 130. BP 160 over 70. Not good but a lot better.
He stopped seizing.
Immediately I checked his pulse. Good and strong.
I strapped the O2 mask over his head.
In a real hospital, the next step would be labs and imaging. We had neither, with one exception.
"Ultrasound?" I asked.
"Our set can't do transcranial," she cursed.
I took out a pen light and did a careful, thorough examination of his head, starting at the top, and including looking in his mouth.
It had been a few minutes. I put the rag back over his nose for ten seconds.
Pulse ox stabilized at 90. Not good, not horrible.
"Subdural hemotoma. Do you concur?"
"Yes. Did you see the mechanism?"
"Reported by a witness, rifle stock to the right upper side of the head. Not the temple."
Or he would have died twenty minutes ago.
"Do we trephane?" I asked.
"Crainectomy," she corrected. "And we're almost out of antibiotics."
Drilling holes in his head to relieve the pressure was straight out of caveman times. And doing it without a medical degree was inviting the American Medical Association to burn us at the stake.
But we had done worse. And burning at the stake was nothing compared to a Homeland interrogation.
"Meow," I said deliberately. "Or perhaps woof."
She blinked and reached across for a sterilized instrument tray. I reached under for a power drill.
We were doing surgery. She had applied her touchstone for doing medical procedures on people.
"If this were an oversized dog or cat, what would I do?"
I shaved a flap of hair on the opposite side of the skull while she washed her hands carefully. I put the sterilized narrow drill bit into the clean but microbiologically dirty power drill.
She did the deed. Twice I put the rag back over his nose for half a minute.
His breathing steadied as blood trickled from the hole. The vitals we took every ten minutes improved.
She put a band-aid with a fold of gauze over the hole, and a larger transparent sterile cover over that.
"Stabilized, move to intensive," she snapped at the door. "Next!"
What "intensive" meant in our context was a half-trained nurse's assistant who would continuously watch the person and take vitals, getting assistance from someone more qualified if anything strange happened.
It was better than nothing.
###
The best we could do for a broken jaw was to wire it into a position where the patient could breath but the broken bones could heal.
Our dirty merc visitors had been fond of breaking jaws. One with rifle butt, one with fist, and one with an expandable baton suddenly deployed.
The problem was a notable lack of painkillers. Sativa helped but it mostly made the wits wander. So applying the wire and padding and tightening same was an exercise in tedium for the staff and in agony for the recipient.
###
Three forcible rapes that required treatment. We were still in disaster operating mode; so one was waiting in chairs - the triage nurse had looked at her vayjay and determined that she was badly bruised but not bleeding.
The case coded on the chart "261 foreign object" was in front of me, with her legs in our one stirrup setup. The vet surgeon was taking the smallest stitches she could manage while I held the most powerful portable light we had.
She was bleeding. And not just from her labia. We'd already transfused her twice, but if we couldn't get the internal bleeding to stop, she would die. Slowly but just as certainly as if shot or stabbed.
Packing was right out. What we needed was a powerful vasoconstrictor. But we didn't have oxytocin or misoprostol. We'd had a little - all from my Bakersfield run - but had used it postpartum on deliveries.
So we had one other trick up our sleeve - careful but painful external uterine massage, administered by our one nurse with midwife experience.
The surgeon took her last stitch. A slow trickle of blood still oozed out.
"Unstable, move to intensive," the surgeon ordered, and hesitated. "One more transfusion. Minimize movement."
It would be touch and go. Would clots form and hold? Only then would the question of infection arise.
The instrument had been a baseball bat. I doubted her assailant had sterilized it.
###
Worst was the amputation. Not physically. Four fingers of the right hand had been cut off, with a large butcher knife. The stumps had been hastily bandaged at scene, then debrided and cleaned and carefully bandaged at infirmary.
But there would be no reattachment, even if a full surgical team capable of the task and the complex melange of necessary drugs were present.
Her attacker had eaten them. In front of me. Under conditions where I had no choice but to keep telling the sniper who had the attacker in sights to check fire.
But I had to check on each patient. She was a patient. So I had to check on her.
I had to face my handiwork. Every one of these people was hurt because of decisions I had made.
I wouldn't have had to visit anyone if I had made the other decision. Because my sightless eyes would have stared endlessly at the sky, just another body in a pile of bodies made by people who spent their careers making piles of bodies out of armed, trained soldiers. Not wannabes and security guards stiffened by a couple vets.
"I know you're very busy," she said. "I want you to know something. He cut off my fingers for trying to take the money back, the money he paid me and then stole from me. He has the money.
"I still have another hand. I want to kill him with it."
I nodded.
"I'll try to see that you get the chance."
(immediately after Dirty Mercs)
Once we had verified by long range CCTV and sniper-observer teams that our guests had in fact left the area, and were not for example motivated to make a U-turn and attack the site, I proceeded to the next location where my presence was needed.
The infirmary.
Note that I did not say the clinic, or the hospital, or the trauma center. Or especially not the psychiatric ward or the rape crisis unit.
Today, our infirmary would have to serve all five purposes simultaneously. Again.
The properly marked patient care board posted prominently in front told the story, in order of severity.
Flail Chest, Head Injury
Head Injury, Broken Jaw
Head Injury
GSW right leg, Broken Jaw
Amputation
Broken Jaw, 261
261 foreign object
261
Slash Wounds
All medical staff were present and working, busily. Six of the eight wounded were triaged Immediate, as in their injuries were considered potentially life threatening without immediate stabilization and treatment. Only the last two were considered Delayed. Both were in "chairs," the waiting area. A stretcher bearer sat with each. One stared blankly at the ceiling. The other rocked slightly under the reddish rolls of gauze tightly wrapped around both her upper arms.
I walked into Trauma 1. The vet surgeon looked up to order whoever it was out, saw me and barked, "Glove up asshole!"
I therefore gloved up from the boxes mounted on the wall, above the sign saying "INFIRMARY PERSONNEL ONLY THIS MEANS YOU."
"Go next door," she ordered her assistant, who perforce disappeared into Trauma 2. I took over what her assistant had been doing -- keeping the flowing oxygen mask on the convulsing man's face. His hands and legs were already strapped to the stretcher.
"Status epilepticus, at least fifteen minutes down," she snapped at me. "Any bright ideas?"
He had been stripped. His rib cage was purple and black where he had been kicked repeatedly, with big heavy boots. His trachea was visibly distended to one side. But the blood and clear fluid leaking from his nose and ears, and the heavy bruising around his eyes and under the base of his ears on either side told the worse story.
Fractured skull. This patient was not immediate. This patient, given our capabilities and available levels of care, was expectant.
As in expected to die.
Shortly.
But not quite yet.
The over the counter pulse oximeter we had stolen from a pharmacy on his finger read 85. Small mercies.
"Blood pressure?"
"180 over 40, five ago."
Heart at work over heart at rest. The brain injury was affecting him neurologically. The heart was desperately pushing the blood into the damaged brain, which had no way to get rid of it.
"Meds on board?"
"One morphine Syrette." And probably wasted. Enough morphine to put him down would stop his breathing. "Twenty-four drops of sativa sublingual. No effect."
His bruised brain was pushing against the bones of his skull, crushing it. In a modern, state of the art trauma center, he would be the focus of an entire patient care team - drugs to paralyze him, drugs to encourage circulation, drugs to throw off excess body fluids.
"Diezapam, rectal," I asserted.
"Out." I had used the last injectable dose on a bus passenger, whom I had later murdered.
"Versed? Ativan?"
"Out."
"Ether?"
"Out."
"Nitrous oxide?"
"Out."
This was not the time to discuss how low our emergency drug stocks had been depleted.
This was the time for utterly desperate measures.
"Amyl nitrite."
"What?"
"Poppers, doctor. A drug of abuse that also lowers blood pressure."
"Do it." I went to the phone and called the extension labeled Pharmacy, on speakerphone.
"Amyl nitrite, two doses, STAT" I ordered.
The pharmacy tech - who was as much a pharmacist as I was an emergency physician - ran in with the doses. Little bottles of video tape cleaner. We didn't have a nebulizer. So the only solution was to soak a piece of cloth, and put it over the patient's nose.
So I did, for a good half minute.
We took vitals again. Pulse 130. BP 160 over 70. Not good but a lot better.
He stopped seizing.
Immediately I checked his pulse. Good and strong.
I strapped the O2 mask over his head.
In a real hospital, the next step would be labs and imaging. We had neither, with one exception.
"Ultrasound?" I asked.
"Our set can't do transcranial," she cursed.
I took out a pen light and did a careful, thorough examination of his head, starting at the top, and including looking in his mouth.
It had been a few minutes. I put the rag back over his nose for ten seconds.
Pulse ox stabilized at 90. Not good, not horrible.
"Subdural hemotoma. Do you concur?"
"Yes. Did you see the mechanism?"
"Reported by a witness, rifle stock to the right upper side of the head. Not the temple."
Or he would have died twenty minutes ago.
"Do we trephane?" I asked.
"Crainectomy," she corrected. "And we're almost out of antibiotics."
Drilling holes in his head to relieve the pressure was straight out of caveman times. And doing it without a medical degree was inviting the American Medical Association to burn us at the stake.
But we had done worse. And burning at the stake was nothing compared to a Homeland interrogation.
"Meow," I said deliberately. "Or perhaps woof."
She blinked and reached across for a sterilized instrument tray. I reached under for a power drill.
We were doing surgery. She had applied her touchstone for doing medical procedures on people.
"If this were an oversized dog or cat, what would I do?"
I shaved a flap of hair on the opposite side of the skull while she washed her hands carefully. I put the sterilized narrow drill bit into the clean but microbiologically dirty power drill.
She did the deed. Twice I put the rag back over his nose for half a minute.
His breathing steadied as blood trickled from the hole. The vitals we took every ten minutes improved.
She put a band-aid with a fold of gauze over the hole, and a larger transparent sterile cover over that.
"Stabilized, move to intensive," she snapped at the door. "Next!"
What "intensive" meant in our context was a half-trained nurse's assistant who would continuously watch the person and take vitals, getting assistance from someone more qualified if anything strange happened.
It was better than nothing.
###
The best we could do for a broken jaw was to wire it into a position where the patient could breath but the broken bones could heal.
Our dirty merc visitors had been fond of breaking jaws. One with rifle butt, one with fist, and one with an expandable baton suddenly deployed.
The problem was a notable lack of painkillers. Sativa helped but it mostly made the wits wander. So applying the wire and padding and tightening same was an exercise in tedium for the staff and in agony for the recipient.
###
Three forcible rapes that required treatment. We were still in disaster operating mode; so one was waiting in chairs - the triage nurse had looked at her vayjay and determined that she was badly bruised but not bleeding.
The case coded on the chart "261 foreign object" was in front of me, with her legs in our one stirrup setup. The vet surgeon was taking the smallest stitches she could manage while I held the most powerful portable light we had.
She was bleeding. And not just from her labia. We'd already transfused her twice, but if we couldn't get the internal bleeding to stop, she would die. Slowly but just as certainly as if shot or stabbed.
Packing was right out. What we needed was a powerful vasoconstrictor. But we didn't have oxytocin or misoprostol. We'd had a little - all from my Bakersfield run - but had used it postpartum on deliveries.
So we had one other trick up our sleeve - careful but painful external uterine massage, administered by our one nurse with midwife experience.
The surgeon took her last stitch. A slow trickle of blood still oozed out.
"Unstable, move to intensive," the surgeon ordered, and hesitated. "One more transfusion. Minimize movement."
It would be touch and go. Would clots form and hold? Only then would the question of infection arise.
The instrument had been a baseball bat. I doubted her assailant had sterilized it.
###
Worst was the amputation. Not physically. Four fingers of the right hand had been cut off, with a large butcher knife. The stumps had been hastily bandaged at scene, then debrided and cleaned and carefully bandaged at infirmary.
But there would be no reattachment, even if a full surgical team capable of the task and the complex melange of necessary drugs were present.
Her attacker had eaten them. In front of me. Under conditions where I had no choice but to keep telling the sniper who had the attacker in sights to check fire.
But I had to check on each patient. She was a patient. So I had to check on her.
I had to face my handiwork. Every one of these people was hurt because of decisions I had made.
I wouldn't have had to visit anyone if I had made the other decision. Because my sightless eyes would have stared endlessly at the sky, just another body in a pile of bodies made by people who spent their careers making piles of bodies out of armed, trained soldiers. Not wannabes and security guards stiffened by a couple vets.
"I know you're very busy," she said. "I want you to know something. He cut off my fingers for trying to take the money back, the money he paid me and then stole from me. He has the money.
"I still have another hand. I want to kill him with it."
I nodded.
"I'll try to see that you get the chance."
no subject
Date: 2018-10-07 12:29 am (UTC)