LITMIR.BIZ

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hadn’t had a cardiac tamponade patient in his four years of residency, but she sounded certain and had the look of someone with first-hand knowledge.

      Something had to be blocking the sound of the heart. If anything, the man was underweight, nothing else made sense besides a wall of fluid muffling the sounds.

      Sam Napier, his best friend in the residency program, had warned him that one of the many women in Sam’s House of Gorgeous Roommates had a cousin transferring in to chase Enzo’s fellowship. He’d expected… well, someone sunnier in disposition and appearance. A duplicate of Caren’s golden-blond curls, dimpled cheeks and the too-cheerful smiles that made it hard for him to be around her before at least two cups of coffee. Not this soft-spoken, dark-haired creature with the delicate features and soulful brown eyes.

      “He was hit chest first,” she said, taking the blood pressure again. “As in he landed with his chest on the front top edge of the grille of the car. Then bounced off. I’ve seen this before in another crash. Three big symptoms, Beck’s Triad. Muffled and faint heartbeat. Distended neck veins. A narrow difference in the blood pressure readings… One, two, three.” She pointed as she counted, chest, neck and the cuff. “There’s barely anything between the systolic and diastolic.”

      The cuff beeped again, the new results darkening the screen. Pulse one sixty-two. Pressure eighty over sixty-five.

      Damn. She really was right. He was either bleeding out or something else was filling his chest.

      The sound of sirens close by caught his attention. They were only a couple of blocks from the hospital, and the sound came from the right direction. Closer than Dispatch, and coming toward them now. Lucky.

      They’d have a defibrillator, and other tools…

      He could hear her little cuff running again, beneath the blessedly loud siren of the ambulance as it rolled to a stop just ahead in the intersection. “You.” He jabbed a finger at a woman in a power suit who still stood nearby, watching, “Meet the ambulance. Tell them we need a huge syringe.” He placed the stethoscope on the patient’s chest again, doing what little he could do to monitor the situation as help arrived.

      Before the suited woman even got to the ambulance, the medics came running with a bag of tools, defibrillator and a large hypodermic syringe they slapped into his hand. His order had done the trick.

      “Have you aspirated a pericardium before?” Enzo asked, looking at Kimberlyn. He hadn’t. Normally he’d like to try, but she’d made the diagnosis. Even if it weren’t a professional courtesy, he wanted to see her perform so he could gauge her skill level. It was the best way to ascertain if she was simply another trauma resident or an actual threat to his fellowship.

      Whether she had ever done it before or not, the small brunette crammed her hands into the gloves presented by the medic and indicated an area on the right side of the man’s chest, “I can do it. Swab around and between the fourth and fifth ribs.” She joined him on the patient’s right side.

      He ripped into the alcohol prep and broke the canister within the squeegee to disinfect the area.

      “Tell me if his heart starts sounding louder or if there’s any other change.”

      Would chest compressions even work if the pericardium was full of fluid? It’d be like trying to squeeze a water balloon inside a larger, overfilled balloon…

      Even with the stethoscope buds in his ears, he could hear the tremor in her voice. Still scared. Was she steady enough to perform the aspiration?

      “I will.” He listened and directed the EMT, never taking his eyes off Kimberlyn, “Get him wired up and on the monitor.”

      Cardioversion was possible now at least.

      With the extra-large hypodermic in hand, she braced one elbow on her knee for support and explained. “I’m going from the right side because the heart juts to the left, and I don’t want to hit it.”

      Yeah. Don’t hit the heart…

      She looked steady enough now. Whatever had her fighting panic, it came and went in waves.

      Enzo backed up enough to make room but stayed close enough to keep the stethoscope in place to listen while the monitor was hooked up.

      This might have been a bad call. She seemed competent except for those nerves. Her nerves triggered his. If she ended up doing more damage… Maybe they should just move him now and hope he lasted another five minutes, or however long it took to get to the hospital.

      With her arms steadied and braced, she waited patiently the long seconds it took for the electrodes and wires to be placed.

      He listened hard, holding his breath to cut out as much sound as possible. His own pulse sounded in his ears louder than what he was hoping to listen for…

      Closing his eyes helped, cutting down the external stimuli. Without vision in the way, he could hear the heartbeat faintly in the background. Fast. Very fast. And with an abnormal rhythm.

      This heart didn’t just inch toward failure, it galloped. The man would never make it to WMS.

      What kind of fibrillation—atrial? Ventricular? He opened his eyes and craned his neck to see the green line denoting the rhythm tracing across the black screen of the monitor.

      The line swung wildly in an undulating wave that told him nothing.

      Check the leads.

      Okay, check the placement of the electrodes.

      He grabbed an extra electrode and placed it beside the one that looked somewhat off-center, then reattached the lead. The line settled into the regular, horizontal position, allowing him to really see the points.

      Ventricular fibrillation. And tachycardia. He listened again, with his eyes following the line. The sounds were almost too faint for him to hear—something that backed up her diagnosis: there had to be a massive amount of fluid compressing the heart. “He’s in V-tach.”

      “Thought he might be. His time is running out.” She breathed in. When all hands were still, she breathed out slowly as she pushed the needle into the man’s chest.

      She could’ve done this a thousand times. Smooth and slow enough to be cautious but quick enough to feel the texture of the different tissues she penetrated. Her eyes had taken on that out-of-focus quality that came with pinning all your attention on feeling your way to a site unseen. He’d seen that look on the real pros so many times—an amazing ability to visualize the path through and the imagination to picture the diagnosed problem. It almost felt like sorcery.

      As she drew back the plunger, bright, arterial crimson began to fill the clear tube. As pressure was siphoned off, the heartbeats became a little louder, a little more distinct.

      She withdrew the full syringe and looked at him, those eyes dark with fear… not the exhilaration he’d expected. But, then, he’d never been in this situation, either. Exhilaration was hard to come by. Something entirely more primitive took its place.

      “No change?” So hopeful.

      “Still in V-tach.” Enzo listened a few more seconds to give him time to convert. He tried counting beats but found it impossible and shook his head. “No change.” He gave the heart a few more seconds, listening again, then shook his head, “Clearer, but still distant-sounding and out of rhythm. Drawing off the fluid wasn’t enough to convert him to normal sinus.”

      She paused another few seconds, pinned by those soulful eyes. Dr. Ootaka, his mentor, counseled distance. Emotions clouded reactions. Enzo had never had reason to doubt this mantra, though right now he couldn’t claim to have that distance. He wanted to give the hope her eyes begged him for.

      Hoping wouldn’t get the job done. “I’ve never dealt with this. How did they do it at your old hospital?”

      “The only one I saw treated was done in the hospital and they used imaging equipment to verify the diagnosis and location

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