Shiloh County Medical Center - Emergency Department

[T. Murdoch]

*I quickly pop out of the back and start pulling out the stretcher, unloading the cop. I get him inside and we're directed to Trauma 1. As doctors and nurses start filling the room, I begin to give report as Erika, Callahan, and the nurses move the patient over to the ER bed, and the doctors start to assess him.*

[Z. Russo]

*I park in the spots reserved for police cars and walk into the ER. I walk in and see the reception desk, The clerk is in a wheelchair.*

'Hi my name is captain Russo I'm with the sheriffs department. I'm here to check up on my deputy that's been shot.'

'The Law enforcement staging area is at the conference room at the end of the hall. Hes in surgery now but they've been giving updates as soon as they come in'

'Thank you, I should have another one of my guys coming in soon just direct him to the back please.'

'Sure thing sir'

[J. Patterson]

* after stopping to let Ajax out aswell as feeding and getting him fresh water i pull my truck into the police reserved area by 400, parking my truck and cracking the window for ajax even though the trucks climate control will kick on as needed i exit 230 straightening my uniform as best my class D allows and walk into the ER after getting checked in i grt directed to a conference room spotting the captain i give him a nod then move to sit down*

’ hey cap,any updates on him?’

Edited June 25, 2020 by Vanguard

[Z. Russo]

’Hey cap,any updates on him?’

*I hear before I get a chance to sit down.*

'I just got here. Nothing aside from hes in surgery'

[J. Patterson]

* hearing zachs reply i sigh i hadent thought i was that close to his ass  but maybe getting checked in was slow or something* ‘ guess its just a waiting game, i hope he makes it’

[Z. Russo]

"Guess its just a waiting game, i hope he makes it'

*Its late, I'm tired. I want to make sure hes ok and go home. I sit in this hard plastic chair as I rest my head in my hands with this floroscent light making a sickly glow that offends all senses.*

'Don't fucking talk like that.'

*I look up and say, Making it very clear that I don't want to hear this*

[J. Patterson]

*i nod as the cap kinda bites my head off knowing i probably shouldent of even said what i said i dont even know the guys injuries but im intimately familiar with the weapon and round that hit him 7.62x39 was a nasty nasty bullet that i saw to many squadmates in the sandbox die  or get injured from* ‘ my apologies’ * i reply lowering my head into my hands and opt to say an unspoken prayer while i wait*

Edited June 25, 2020 by Vanguard

[Z. Russo]

 ‘My apologies’

'If it was you who got hit you wouldn't want us asking that would you?'

*I say in a hushed monotone voice, *

[A. Blackburn]

*Entering the hospital after stopping of at Mike's I walk up the receptionists with two cups coffee and a couple of burgers in a doggie bag.  Getting directed to a conference room I nod and head on over there.  Upon my entrance into the room I see the Captain and Patterson in here.  Figured Russo would be in here.  Guess I should've figured Patterson would be in here as well.  Putting down the bag of food on the conference table I walk on over to Russo who is sitting down.*

'Next of kin is being notified now.  Coffee?'

*Taking a sip from the coffee that's mine I extend my hand with the other cup for Russo.*

[Z. Russo]

'Next of kin is being notified now.  Coffee?'

*I hear as I turn around and see Blackburn with a togo order and coffee from Mikes.*

'Thank you. Who was his next of kin, His parents or is  he married?'

*I say realizing I didn't really know the guy, Grabbing the coffee I put in some cream and sugar.*

[A. Blackburn]

'Parents and siblings'

*As Russo takes the coffee I head back to the conference table.  Setting down my cup of coffee I open up the to-go bag.  Reaching in I pull out a foil wrapped burger as I take a seat at the table. Unwrapping the burger, a bacon cheeseburger, I take a bite.*

[Dr. C. Grant]

---- Some time earlier ----

*I stand in the trauma bay by the head of the empty bed. Face mask, gloves, gown, and goggles on. A mass of gowned and masked people slowly start to accumulate in the room. The surgery resident stands off to the middle-left side of the empty bed, staking his claim for the prime piece of real estate.

'Who's the trauma attending today?' I ask the surgical resident.

'Dr. Semenov' he replies not too enthusiastically. 'She's on her way. She was just scrubbing out of another surgery.'

Dr. Semenov...oh Dr. Semenov...she's always amusing to watch, although she can be a bit abrasive. She's a relic of a bygone era. Born and raised in the Soviet Block...and still acts like she's there...cold as a Siberian Snow Storm.

Wait...*I look around*...

'Where's the ultrasound?' I ask out loud. 

*No answer*

'Can we get the ultrasound cart in here please?' I ask out loud.

'I'll get it' someone says from amongst the crowd.

*The room suddenly bustles to life as the paramedics bring in the patient and start to rattle off their report.*

Once moved over, everyone gets to work. Nurses finish stripping him down, the surgical resident starts evaluating the abdomen and legs. I start at the head.

'Hey there, I'm Dr. Grant, what's your name?' I ask as I start looking him over.

'...Ricky...' he struggles let out softly.

'Ricky, we're going to take good care of you. Can you tell me where you're hurting right now?' I ask. 

I lift up his right arm and take a look at the wound. I see a tourniquet is in place. 

'...everywhere...' he replies to me.

'We've got an entry and exit wound right proximal humorous.' I say out loud for it to be documented.

'BP 80 over 53' someone shouts.

'How's the bleeding on that?' the surgical resident asks.

'It's got a tourniquet, its controlled.' I reply before quickly changing direction.

'We need another line in him somewhere. Right arm's no good, and we got one in the left already.' I say as I pull out my stethoscope to listen to his heart and lungs.

'What about an EJ?' one of the nurses asks.

'Sure try it.' I say distracted. 'Can someone get me the IO kit please.'

'I need labs, type and cross, and 4 units of O neg blood, right now.' the resident rattles off as he checks out the right thigh gunshot wound.

'Heart and lungs are clear. Good, even chest rise.' I say hurriedly putting my stethoscope away

'Lets flip him over to check his back side' the resident says. '1...2...3..' 

*The patient is rolled over onto his side. He lets out a moan in pain.*

'I got one exit wound lateral to L2 on the right...can I get a dressing please?' the resident says while running his hand down the patient's back.

*A dressing is placed and the patient is rolled back onto his back*

'I got the ultrasound' a tech announces as she rolls in the ultrasound cart.

*The surgical resident stops what he's doing and grabs the ultrasound cart and rolls it over to the patient's side and starts his FAST exam.*

*One of the ER residents comes walking into the room.*

'Need any help?' he asks as he dons a pair of gloves .

'Yeah. Get me an IO.' as I make my way back to the patient's head.

*I start checking his head, eyes, ears, mouth, and neck.*

'...don't let me die...' he lets out, struggling to talk and in obvious pain.

'We're doing everything we can. We aren't going to let you go. We're taking good care of you.' I say to him.

'Ear, nose, throat clear. Eyes equal and reactive. Neck non-tender.' I say out loud. 

'What we Have here?' a rushed and slightly out-of-breath thickly accented Russian voice fills the room.

*Dr. Semenov enters the room....all 5 feet 3 inches of her commanding presence. Her dirty blond hair hidden underneath her surgical cap adorned with matryoshka dolls, and her light blue eyes and dark pupils look like they could peer directly through your soul. Her skin is light yet weathered. She's....well come to think of it...I'm not exactly sure how old she is...perhaps in her early 50s or late late 40s.

The surgical resident gives his report and findings. As she peaks at the ultrasound machine.

'Why are you wasting time with ultrasound?' she asks him angrily. 'He has penetrating abdominal wound, he's getting surgery regardless. This is time waste.' she says as she takes ultrasound from him.

I look away out of embarrassment. See....Cold as a Siberian Snow Storm.

The IO goes in, and even an EJ is placed. We now have lots of fluids and blood running. 

'Blood pressure's coming up...96/65' someone say out loud.

*The patient lets out a groan as Dr. Semenov sticks a gloved finger deep into the gunshot wound to explore it. She finishes and has the patient rolled on to his side again so she can see the exit wound. Once done he's rolled back down.*

Dr. Semenov looks up and sees the arm and leg wounds. 'Are those controlled? Get those wrapped. We call vascular and ortho they take look in OR, yes?'

*The team finishes off all of it's assessments and prepares to take him directly into surgery.*

'Are we ready?' Dr. Semenov asks. 'Let's go.' she says hurriedly as the patient is wheeled away and up to surgery. Into the ER and out to surgery, in less than 10 minutes.

*I take my gloves, gown, mask, and goggles off and throw them into the trash and make my way to wash my hands.*

 

---- Present ----

*I lean back in my chair.*

'Hey Julie. Any luck on getting a hold of Mr OReilly's family?' I ask the clerk with my arms folded behind my head.

'Yeah. They're in one of the family waiting rooms. #1, I think.' She tells me. 'And his cop buddies are in the conference room.'

'Wonderful' I say.

*I see Dr. Semenov walk past. I jump up from my seat and try to catch up to her. She walk amazingly fast for being so short.*

'Dr. Semenov...' I say to get her attention.

She stops for a moment and looks back, allowing me to catch up.

'Dr. Grant?' she replies.

'How's Mr. O'Reilly?'

'He will live. He's lucky to be alive.' she says in her thick accent as she continues to walk.

'I had to take out about 4 inches of bowel, but considering he was shot with high caliber bullet...he's lucky. It missed vena cava and renal artery.' she tells me.

'Wow. So good new then?'

'Yes. It appears so. two millimeter higher and he would have died in the street.'

'Lucky guy' I say back to her in amazement.

'Yes....listen...I talk to family already...they're up with patient in ICU. I hear he has colleague down here, do you know where?' she asks.

'Uh, yeah, this way.' I say as I take the lead and show her to the conference room.

*I knock on the door and enter the conference room with Dr. Semenov behind me.*

'Hi there. I'm Dr Grant, this is Dr. Semenov. Are you here for Mr. O'Reilly?' I ask as we start to shake hands with the people in the room.

I get a confirmation.

'Excellent.' Dr. Semenov says. 'I am surgeon who took care of him....he came in with three gunshot wounds, one to right upper arm, one to right upper leg, and one to right abdomen. He was very sick on arrival and...uhhh...we took him to surgery immediately. He lost a lot of blood, but we were able to replace. His arm and leg wound were easily dealt with, but as you know abdomen contains lots of delicate organs. All I can say is he is lucky. Bullet went in the front and out the back and missed all major blood vessels. I had to do some repairs, but I expect him to make full recovery. He's young.'

*I can feel a giant sense of relief in the room*

'I have already talked to family and they're in surgical ICU with him. If you want, you can visit, but please just give a little time to get him settled in. He is still sedated and intubated and will be until tomorrow.' she says and then pauses.

Edited June 26, 2020 by Chris07

[Z. Russo]

*A Short blonde Woman in scrubs walks into the room,*

'I am surgeon who took care of him....he came in with three gunshot wounds, one to right upper arm, one to right upper leg, and one to right abdomen. He was very sick on arrival and...uhhh...we took him to surgery immediately. He lost a lot of blood, but we were able to replace. His arm and leg wound were easily dealt with, but as you know abdomen contains lots of delicate organs. All I can say is he is lucky. Bullet went in the front and out the back and missed all major blood vessels. I had to do some repairs, but I expect him to make full recovery. He's young. I have already talked to family and they're in surgical ICU with him. If you want, you can visit, but please just give a little time to get him settled in. He is still sedated and intubated and will be until tomorrow.'

*Despite here thick eastern European accent she gets her point across. In a hushed tone I say to Blackburn and Patterson*

'Lets let the family be there now. I'm going to assign a detail to him and the family, Patterson I want you to stick around until I can get a permanent liaison assigned.'

*I stand up and we make our way to the ICU. The charge nurse sees us coming.*

'He's sedated right now. Dr. Semenov really wants friends and family only right now.'

'I understand, I actually would like to speak to his family if possible. We'll be brief'

'Just please make it quick. Hes in bed 6.'

'Of course, Thank you.'

*I approach the family. His mother sitting next to the bed with her hand on his arm. Her eyes still puffy from crying.*

'Hello, I'm Captain Zachary Russo with the Shiloh County Sheriff's department. I'm Richard's commanding officer. this is Lieutenant Andrew Blackburn and Sergeant Jason Patterson. As you know Richard's actions were undoubtedly heroic. I would also like to inform you that the officers on scene returned fire and struck and killed the man who did this to your son. I would also like to place a 24 hour a day detail where one of the deputies will maintain a watch over Richard until he's home and act as the liaison between your family and the sheriff's department. If you guys need food, coffee, a ride or literally anything the sheriff's department will be more then willing to be there. As of right now Sergeant Patterson will be filling that role but he should have relief coming in the next hour or so.'

*His father steps up and extends his hand to our group.*

'Thank you guys'

*We shake hands. I pull out my business card and write my personal cell number on the back.*

'This is my personal phone number as well as my department phone number, If there are any issues don't hesitate to give me a call about anything'

[A. Breslin]

"Medic 5 calling in a burn notification. I have a patient in her mid 20s unresponsive Hr of 112  BP of 84/44, spo2 of 79 , gcs 3, RR of 4. Intubation was a failure were getting a king tube now IO is in place ETA is 6 minutes."

[Dr. C. Grant]

*I'm dictating a note, holding the dragon USB mic to my face.*

'..Patient discharged to home, period...Patient set up with appointment for endocrinology at resident clinic in 3 days for further workup of her thyroid nodule...period...patient advised that thyroid nodule must be worked up to rule out malignancy and she stated understanding...period.'

A nurse comes walking into Resus.

"Medic 5 has a burn with a compromised airway that's 6 minutes out." she announces to some other nurses.

I look across the room having overheard the announcement.

'Where you putting them?' I ask.

'Probably in 7' the charge nurse replies.

'Page out a trauma alert, and get a cric kit.' I say as I get up.

*I head over to the room and start grabbing some supplies.*

I break the seal on the crash cart and start rummaging through it for some supplies.

*The room is bustling as everyone is getting set up*

 

Edited August 15, 2020 by Chris07

[Dr. J. Thompson]

*I stroll into the room behind Dr Grant and get out a cric tray from the cabinet. I set it on a tray near the head of the bed and get out a BVM, getting ready for the patient.*

'Sounds like a bad one.'

[Dr. C. Grant]

'We'll see.' I say.

*I stand around waiting for our patient to arrive*

'Have you done a cric before?' I ask casually.

*Someone wheels in the video laryngoscope into the room. I walk over and wheel it over to the head of the bed*

Edited August 15, 2020 by Chris07

[Dr. J. Thompson]

'On mannequins. And a couple times on cadavers. Not live, though. Wonder why EMS hasn't done it yet.'

*I pop open the cric tray and look over all the equipment before nodding satisfactorily. We were ready to go as soon as they walked in with the patient.*

[A. Breslin]

*i feel the ambulance back up into the bay. Despite the king tube and the IO her vitals are still shit.*

'Shes about to code, Callahan hurry the fuck up.'

*I hear the cab door close. As I look at the monitor I see the rhythm change into V-Tach.*

'Fucking great.'

*The back doors open and we pull the stretcher out. I get on side rails of the stretcher and start doing compressions as Doug and Callahan roll us into the ER.*

"This is the note, They just coded in the bay, No chance to shock."

*I say as I ride the stretcher into the Resus room. Giving report*

"Approximately 25 year old female received  flash fire to the face, Possible basilur skull fracture unresponsive up arrive coded upon arrival. Veins are shit so we got an IO in the tib plate unable to intubate so we have an LMA in place. Monitors showing V-Tach"

*I step off and unbuckle the pt.*

'Ready to move on you'

[Dr. C. Grant]

'On mannequins. And a couple times on cadavers. Not live, though. Wonder why EMS hasn't done it yet.'

'I don't know, they can't do surgical crics...so we'll see.' I pause.

'Just remember, Cricoid cartilage below and thyroid cartilage above and find that soft depression of the cricothyroid membrane...make lateral incision and don't be shy. Make the incision, blunt dissect the underlying structures away until you can get into the trachea...then just pass the bougie in the kit through the hole to guide your tube and dilate the tracheal incision. Advance until you feel it clicking against the tracheal rings and then fish the ET tube over the bougie and into the trachea...inflate the ciff and you're done...Just make sure you verbalize everything you do as you do it.' I say.

'We'll check the airway with the laryngoscope first to see if it's even necessary.' I say.  

*The room bustles to life as the EMS crew enters*

"Approximately 25 year old female received  flash fire to the face, Possible basilur skull fracture unresponsive upon arrival coded upon arrival. Veins are shit so we got an IO in the tib plate unable to intubate so we have an LMA in place. Monitors showing V-Tach"

'Any drugs or shocks?' I ask as I help get the patient prepped for transfer onto our stretcher.

'Ready to move on you' 

'Okay lets move on 3....1...2..3' the patient is moved to the ER stretcher.

'What was her last set of vitals before she coded? GCS? Was she responsive or following commands at any point with you?'  I ask as I feel for a pulse.

"Lets go ahead and re-start compressions and get her hooked up to our monitor. Let me know when she set up for a shock please."

'Dr. Thompson check out her airway, see if she can be intubated or not.' I say as I start to do a quick head to toe on her, dodging nurses as I do so.

'Video laryngoscope is behind you.' I say

 

[A. Breslin]

'Any drugs or shocks?'

'What was her last set of vitals before she coded? GCS? Was she responsive or following commands at any point with you?

'No shocks or drugs, Happened as we were rolling her out. Pulse 110 80s/40s respirations were being assisted GCS of like 3. She was down a few minutes before we got there'

[Dr. C. Grant]

‘Was it an explosion or just a flash of flame to her face? Do we know?’ I ask. ‘Like where did the flame come from? I take it you guys don’t have anything on history?’

 

’Eye brows and nose are singed.’ I say as I reach for the otoscope. I look in her ears and notice a scant amount of clear fluid in her right ear.

’We’re set to charge’ someone says.

”Let’s charge two hundred” I say as I step back and out the otoscope back in its holder.

The defibrillator charges. 
“Alright everyone stand clear.”

I nod to the nurse controlling the monitor. The patient is shocked. 

’Sinus tach. Is there a pulse?’ I ask.

’No’. Someone replies.

’back on compressions please.’

’Hows that airway look John? That’s most likely her problem.’ I ask peaking at the video screen.

Edited August 15, 2020 by Chris07

[Dr. J. Thompson]

*As the patient gets moved to our bed and Dr. Grant begins his head-to-toe, I pick up the Glidescope and turn it on. I slide the blade into the patient's mouth and lift, examining their airway. It looked like shit, honestly. No chance a tube was getting through this swollen, burned mess of an airway. I pull the Glidescope back out and clear the patient as Dr. Grant delivers a shock.*

'Like shit. I'm gonna cric.'

*I grab the tray and take out the iodine swab, preparing the patient's skin. I then take the scalpel and make the incision, then blunt dissect the underlying structures away. I pass in the bougie, then start passing in the tube.*

[Dr. C. Grant]

*I stop what I'm doing and take the laryngoscope and have a look for myself.*

The airway is a swollen mess.

'Yeah. Cric 'em.' I say.

*I wach Thompson as he does the Cric*

'Good. Just a little bit bigger of a hole' I say, coaching him as he does a decent job at doing the cric on his own.

*He passes the ET Tube in*

'Good. Suture it in place.' I say to Thompson.

'Start bagging please.' I say as someone start hooking up a BVM to the trach.

*Before we can even give the patient 2 solid breaths, the monitor goes into V.Fib*

'Stop compressions. Let's go ahead and shock him.' I say standing back.

*The defibrillator charges and a shock is delivered*

Asystole on the monitor. Damn.

'Another round of epi.' I say looking up at the clock.

We've established a good airway now, but perhaps it's too late. Things aren't looking good.

'John, what do you think caused her arrest?' I ask him to see what his thought process is. This is still a teaching hospital after all. Every case is a teaching case.

[Dr. J. Thompson]

*I suture the tube in place and then move out of the way as respiratory takes over bagging the patient, moving to the side with Dr. Grant.*

'Well, hypoxia is the first suspect. Her airway has been closed for quite a little while now and she hasn't been able to move any air. She's also a multitrauma, with unknown internal injuries that are likely severe. She's got a skull fracture, she could have a traumatic cause to the arrest that we need to look for. We need to take another listen to lung sounds and confirm there's no hemo- or pneumothorax and we need to rule out the possibility of tamponade.'