Every emergency department had a Maureen Sawyer, RN. Edging out of what could be called middle aged, overweight, her hair pulled shamelessly back in the sloppy bun of a 21 year old and her stethoscope always slightly tangled in the librarian chain from which her reading glasses hung. Thirty years of cortisol and incredulity were very honestly the only things keeping her coming back for more, and she had committed a long time ago that she would do the job until she was shot or her back went out on her, and she'd been lucky so far. Her tough frame was wrapped in a pair of the darkest grey scrubs she could find because every other color was a f*cking nuisance to clean and it was just close enough to dress code to count. Tonight, she was working charge, which she liked because it meant her back got a break from its usual torture.
Andre Somers, who had not yet worked near enough years to push the dress code envelope and respected that limitation, was wearing the much lighter set of grey scrubs that had come with the job, City South Emergency Department emblazoned across the front breast pocket. A year out of orientation, he'd gotten close enough to Maureen's good side that she only ever gave him patients he would have killed for in nursing school.
But what he would have killed for a lot of the time in nursing school was the chance to use a code algorithm. Now ATLS trained and with Maureen working charge, the novelty had mostly worn off. He saw her waddle over, her hands on her lower back like she was eight months pregnant. She sat in the office swivel chair next to his and smiled over at him like she knew he wasn't going to like what she had to say.
"Squad's on the phone, they want to give a special someone report." She said as a greeting. Andre bit his tongue to keep from snorting.
"And you think buttering me up's gonna make me jump all over that?" He asked. Maureen shrugged. "Alright, sell it to me."
"No time." Maureen said. "They'll be here in ten. Tonight this ED is a strictly voluntold-run organization."
"You gotta get yourself a new joke book, Maureen. The one you've been using is gettin' old."
"Been using the same one for the last thirty years and no one's complained yet, kid." Maureen countered, a smile on her face.
"That's only cause they scared of you, Maureen." Maureen hauled herself up.
"Oh, the guy they're bringing in- he's a hazmat. I put the gear in trauma 2 already."
"Not the guy who fell in the overchlorinated pool again, is it?" Andre asked, scooting his office chair over to the desk with the squad phone on it as Maureen sidled back to the charge office.
"White phosphorus. Be careful." She answered.
"The hell is that?"
"No clue. Google it." Maureen called over her shoulder.
"Ever helpful, Maureen" Andre shook his head as he picked up the squad phone and cancelled the hold. He sandwiched the phone between his shoulder and ear while pounding the esc button on the computer keyboard in front of him.
"Andre Somers, RN- City South ED." He started, typing "white phosphorus" into the search bar. Luckily, the hospital internet was not acting up today. "What've you got for me this fine evening, squad?" He asked.
"This is Cody Mason, paramedic on squad 0-2 incoming. ETA eight minutes. We're bringing in Derek Morgan, 43-year-old African American male, picked up seven minutes ago with blunt force trauma to abdomen, partial and full-thickness chemical burns to upper torso, and a knife-related puncture wound to his right hand. Had a three-minute run of v-fib on scene, converted to sinus brady with 2X360J. We've got pads and telemetry on him. He's in and out of consciousness, A+Ox1 when he's conscious. RR of 12 satting at 93% on 8 liters non-rebreather, pulse 48 and rising, blood pressure's 95/48, temp 39. Pale bordering on cyanotic for some reason. We've got an 18 in the right AC running normal saline wide open. Unable to determine allergies, medical history or current medications but law enforcement at the scene stated they found a torture kit with white phosphorus salve. We recommend hazmat contact precautions." The medic rattled the figures off.
"That's what my charge said, already covered." Andre said, taking a last few seconds to scribble the remaining lines of report onto a yellow legal pad. He repeated the important stuff back to the medic, who confirmed it as correct. "Fantastic. Bring him into trauma 2 when you get here." Andre ripped the hasty report off the pad and shoved it into his pocket.
"Will do, Somers." He hung up the phone. With now only 4 minutes to the squad's ETA, he paged the on-call trauma doc and respiratory tech to trauma 2 and scoured Medscape's meagre information on white phosphorus exposure. There wasn't much there but if they'd wanted him to know more about it they would have taught about it in nursing school or given him more than four minutes to brief himself. He felt like a clinical student rapidly memorizing MOIs and side effects before getting grilled at medpass- a certainly familiar but unpleasant experience. With two minutes to go he shook his head. The Medscape article would have to be enough.
Dr. Madison Toms was the trauma surgeon on call. She was not a lazy person- you couldn't do that and get away with anything in the medical field, let alone the military base where she'd spent her residency- but she had moved to City South for the express purpose of getting a reprieve from the constant blood, guts and bone fragments that had plagued the staff at City North. She'd thought about changing her specialty entirely for a split second some time last November. Proper ER docs got regular schedules like the nurses did and no call shifts. But that sounded like starting over. At fifteen years into the work, residency was still somewhat fresh in her mind and she wasn't rearing for that level of repeat performance. So City South, Level-2 Trauma Center, was the next best thing. Sometimes she even got to sleep on call shifts here.
Maybe not tonight. It was nearing two AM after a moderately severe motor vehicle accident and set of two closed forearm fractures. She'd been aggressively lying in bed in the call room for a full two minutes now, having finished her notes on the cases just a few moments before that, when Andre's page came in. Trauma Bay 2. With a grunt she hoped no one else had heard, she pulled herself out of her sleeping bag and upright.
The City South Emergency Department consisted of two long rows of rooms sandwiching what looked like an office space for charting and computer work. At the far end near the ambulance entrance, four trauma bays- larger rooms packed with medical equipment and their own crash carts- were inset into the side of the adjacent hallway. Andre approached with the fast, confident step of someone who knew a lot more about phosphorus exposure than the Medscape article he'd just skimmed. As promised, the contact precautions cart was already outside trauma 2. He silently thanked Maureen for the head start as he donned the slightly thicker, chemo-resistant version of the trauma gown, gloves and mask.
Becca Grayling had picked the wrong moment to visit the supply closet. She saw Andre getting suited up for an incoming trauma too late to dodge out of the way.
"Beeeeeex." He called out. "You ever seen phosphorus burns?" They probably weren't anything more exciting than regular burns, Andre thought, but it was the marketing that counted when recruiting help in a trauma. Becca stopped pretending to ignore him, seeing an opportunity. She slipped the four IV start kits she'd just collected out of her pocket and waved them in front of her.
"I'll make you a deal- the second your guy goes to the unit, I've got a SFV in 12 who needs a 14-guage IV until they can get the central line in her." Becca said.
"Are we dealing now, Bex?" Andre asked. "I thought us emergency nurses had to stick together. Help each other out of the goodness of our hearts?"
"Andre I been working this ED for 6 years, it sucked all that out around week 3."
"But you'll help?"
"If you put my IV in."
"Awesome possum." Andre smiled.
"You're getting the better end of this deal, she's seriously SFV." Becca warned, already wrapping herself in a gown from the cart.
"I'll make it happen."
Madison Toms rounded the corner. "Okay, what are we dealing with?" She asked tiredly.
"Hey Dr. Toms." Andre greeted. "Squad's bringing in a hazmat related to white phosphorus burns, blunt force abd trauma and a stab wound to right hand. 43 year old African American male. Went into vfib on scene but they shocked him twice and he's coming in sinus brady. Systolic's in the 90's, satting at 93% on 8 liters. I've got RRT paged as well."
"Why are we getting him?" Dr. Toms asked, pulling her own gown on as Becca began organizing vials for lab and doing checks on the crash cart and other equipment. "He sounds like a City North case."
"No clue, they're taking a while to get here so it could have been remote." Andre speculated. "Could have just been the closest. Anyway, what do you know about white phosphorus?"
"Very little." Dr. Toms admitted. She'd been on a military base, so they'd been trained, but that had been nearly a decade ago and her experience was still lacking. "It's used in munitions. Combusts in air." She paused, looking around the room. "Why don't you soak a couple of ABD pads in saline, just so we can keep him wet until we can get it out of the burns."
"I'm on it." Andre said. He pulled a basin out of one of the storage units on the walls and filled it with saline from a bottle before emptying a few packages of the bandages into it.
While he was doing that the blue scrubbed respiratory tech pushed a computer into the room. "Hey Dr. Toms." Rachel Sweeny greeted, an echo of Andre's greeting earlier. Rachel looked like she'd been pulled out of something unpleasant and was very excited to be anywhere else.
"Alright, squad will be arriving any second so our goals right now are to get survey and labs done and get him to radiology as soon as safe. We need to rule out significant abdominal trauma but he's a hazmat so unless he looks like he's bleeding out our priority is decontamination. I'll be heading that after survey. Rachel I want ABGs on him and standby in case we need an airway, Andre get a second IV somewhere above his left AC…"
"What you want running in it?" Andre asked.
"Normal saline, run it wide open until further notice. His BP isn't exactly toilet quality but I want a buffer to protect his kidneys if we can. And when you start it pull the trauma labs."
"Normal saline, wide open." Andre echoed, hanging three bags on an IV stand over the bed and priming a set of tubing coming from the first.
"Becca, get a twelve lead and get him on five-lead tele with pulse ox and non-invasive BP every 2 minutes."
"Anything else?" Andre asked.
"From there it depends on what we find." Dr. Toms answered.
Just then there was a rattling in the hall and a young, pudgy face came into view around the doorway. "Special delivery for Andre Somers." The medic waved a clipboard in the air.
"Just in time, Cody." Andre said.
"What I specialize in."
"How's the patient?" Dr. Toms asked.
"Conscious. Not sure how. Since last report his BP's holding in the high 80's over high 40's. Pulse has come up to the low 60's with peaked T-waves." Cody reported. Dr. Toms squinted at the portable monitor as the rest of Cody's squad rolled the cot in. "Chemical burns to the midline, significant bruising to abdomen, and he's got a wound on his hand, knife was removed at the scene to remove him from a table."
"Thanks. What's his name?" Dr. Toms asked.
"Derek Morgan." Cody supplied.
"Okay, let's put a stat on those lab orders and add a full electrolyte panel." Dr. Toms said. Andre caught a look at the monitor as well and was about to say something about starting a betting pool on the guy's serum potassium, but thought better of it. They lined the cot up to the ED cart. Andre and Bex took an almost automatic stance on the opposite side, both reaching over to the handles on the backboard underneath their patient. The squad was already in position on the other side.
"Derek, we're going to pull you over onto the cart on three, just try and stay still." Cody said. The man on the cart didn't say anything to that, but weakly pulled his arms in a little tighter. "Okay, on my three. One. Two. Three!"
"Mmmshffgh." It was unclear if it was pain or just the general shifting that had caused their patient to groan, but there was still a lot of work to do, and at the moment, Dr. Toms was just glad the man was hanging in there.
"Not over quite yet, Derek, we're going to have to roll you." She said. She hadn't been expecting a response, but, remarkably, the man brought his head up in a kind of slight nod. "Try not to move, okay, we'll handle that."
"Mmhmm." Morgan agreed, seemingly resigning himself to the next pain he was about to be subjected to. Again on three they rolled him. Another groan and they had him fully on his back on the cart, backboard back in the hands of the medics. Bex swooped in, covering the wounds with the saline bandages. Then she disconnected the squad's monitor leads and pads and replaced them with the hospital's. She attached a blood pressure cuff and wrapped a pulse ox clip around one of his fingers. All this within about thirty seconds.
Andre took the saline bag from the medics and hung it next to its already primed cousins hanging on the IV pole. Then he put in a second IV, drew the labs from it and capped it. He had to admit, he appreciated the fitter crowd. Their veins were extremely helpful.
While Andre had been sticking him in the upper arm, Rachel had pulled the blood gasses from his wrist.
Cody pulled his own gown off as he left the room. He waved the clipboard again through the window. Andre excused himself. "Were you guys covered the whole time?" He asked the medic, removing his gloves and taking the clipboard to sign the handoff sheet.
"We were." Cody confirmed. "Don't have to tell me twice- looks like nasty stuff."
"From what I read, it is." Andre handed the clipboard back. "You boys have a good night."
"Will do."
Cold. There was something hard against his back and he was naked and people were jostling him around like a life-sized doll. Every time they moved him there was a sharp pulling at the torn flesh of his chest. And not even really pain. Just that weird feeling after the stinging dies down on a badly skinned appendage. A dull buzzing numbness that he didn't want to move or touch. His abdomen felt worse, dull but constant pain that he'd ignored earlier but now that the phosphorus on his chest was no longer winning the pain game he was beginning to notice again. Not pleasant.
But then it would go away, fade and he could rest for a second, and then suddenly there would be something cold again and people talking and… Directions. Roll you. He tried to agree but they were already doing it. He held in a yelp of surprise and pain as the numbness breached and he didn't want to breathe.
He fought, desperately, against the urge to lash out. They were helping him, he kept reminding himself. The people who were moving him, shoving things under him and poking him with needles were medical. Good guys. He couldn't hurt them. But he didn't want to be there. He could take a lot of pain, a lot of crap, but he was exhausted and even he had his limits. He stifled something halfway between a groan and a whimper and hoped no one in the room had heard it. His jaw was taught when they rolled him back.
Someone had once told him that you only reached your limits when your brain shoved them in your face so hard you could no longer ignore them. That the trick was learning to push those signals away, saying you aren't done yet to yourself until it stuck. Well that became harder once exhaustion set in and while he didn't want to die, quite the opposite, in fact, he kind of just wanted everything to be over, so he could go home and make dinner and go on with his life.
But then someone was shaking his shoulder so hard the fragile skin on his chest felt like it was tearing. "My name is Dr. Madison Toms, I'm going to be taking care of you right now, can you tell me-" He hadn't even opened his eyes but his hand had reached up to stop her shaking him.
"Derek, Derek it's okay, okay? I'm sorry for hurting you. I won't shake you any more." Dr. Toms said, calmly moving her hand out of the way of Morgan's arm. Andre positioned himself with his hand ready to catch any further attempts to punch her, but she'd been doing this long enough she knew how to duck. "My team and I will be moving you some and I'm going to be pressing on some things and it might hurt, and I need you to tell me about that." She paused. "Can you tell me your name?
"Derek… Morgan"
"That's good, you're doing great. Do you know what day it is?"
"Tuesday."
"Good, good, can you tell me where you are and what happened?" The questioning was exhausting in itself.
"Hospital. Some guys…" Tortured him. He couldn't say it like that. Dr. Toms let her face soften as little.
"Okay." She paused. "Is anything hurting you right now?"
It was becoming hard to speak. He did move his hand inwardly, indicating his abdomen. Andre kept a wary eye on it. "You've got some bruising there, we're going to be taking some pictures of it in a little bit to see if there's any inside damage. How is your chest feeling?"
"Less… than the stomach."
"There's some burns on it. They were made by a chemical that can ignite if it touches air, so we're keeping the burns damp until we can get the chemical out." Dr. Toms said, working her way down Derek's body with her assessment as she talked.
"Its.. safe. Neutralized… the phosphorus." Morgan struggled. Dr. Toms looked at the monitor. The most recent set of vitals had come in and it was dinging a little. Still not the high priority alarm but edging towards that territory. Blood pressure and O2 sats were dropping and pulse was becoming irregular, QRS complexes on the ekg were widening to match the peaked t-waves.
"How?" She demanded, suddenly a lot more intense than a second ago. "Becca, do we have the lab values back yet?" Becca looked up at the monitor.
"Damn, anyone want to take a bet on the K+ before I read it?" Even though the scene was really intense and his patient was heading for a code, Andre had to fight back a snort. "Nevermind, its 8.1. Lab sent a caution that it looked like some of the cells had lysed, but looking at that…" Becca said.
"Right." Dr. Toms confirmed. "Do we have arterial sats?"
"Yeah, 99%" Becca responded.
"Did you use copper sulfate?" Dr. Toms demanded of Morgan.
"In a pesticide…" he trailed off.
"Did you rinse it off after?"
"No… water." He explained weakly.
"Okay, at least we know where to start now. He's got copper sulfate in his system, its causing acute hemolysis and bumping up his potassium. Start a K cocktail. Andre call the blood bank, lets get two units of PRBC on him and see if that brings up his peripheral sats and pressure before we start pressors- type and cross should be in their system already. As soon as his potassium's stable we need to get a CT of his abdomen in case he's bleeding too. While he's there I'll call up to the unit, see if we can't get the PICC team there to get a dialysis catheter in him stat." Dr. Toms ordered.
There wasn't a lot to do as an emergency nurse in a radiology lab. Techs knew their own stuff and things were ordered and completed relatively quickly in the ED.
Andre helped to move Morgan onto the CT bed, and then moved and organized the lines and leads so they didn't interfere with the exam. Then he stepped out while the machine did its work. A few minutes later, he was back on his way to the room for Dr. Toms to debride the burn of the remaining white phosphorus and copper sulfate. Once that was complete, he would be up to the unit. It had certainly been a thrill ride tonight.
Ding! Ding! Ding! Ding! DING! DING! DING! DING! Okay, thrill ride wasn't over yet. "Derek, you with me?" He asked urgently. Morgan didn't respond. Andre looked at the monitor. VFib. Shit.
He pulled the footboard off the bed as he scoured the hallway for a Code Blue button. Seeing none, he resorted to shouting as he threw back Morgan's covers and rolled him onto the footboard and started CPR.
"CODE BLUE! HALLWAY OUTSIDE RADIOLOGY! I REPEAT. CODE BLUE, HALLWAY OUTSIDE RADIOLOGY! Five, six, seven, eight…" He said more quietly, feeling Morgan's chest give unnaturally under his hands with each count.
This was not his first code. There had been a guy in his late 80s who'd been putting off getting advance directives. They'd ripped him apart trying to save him, and had failed. This was different, though. A 43 year old trauma. Not even an MVA or gunshot, though those were certainly sad. But this guy had been tortured. On purpose. And then done everything he could to save himself only to have it end up stopping his heart.
Ten minutes (or five minutes, or even three minutes) could be infinitely longer than he'd realized in nursing school. Someone had heard his shouts and a radiologist and two techs ran out, followed a few seconds later by nurses from the ED and Dr. Toms. The announcement went out over the PA System. "Code Blue. B-building. Radiology. Code Blue. B-building. Radiology." Repeated several times over. The adrenalin was simultaneously thrilling and making him feel sick. Someone had brought a crash cart and was attaching pads to Morgan's chest.
In the end, codes were really just following a pre-programed set of instructions. Dr. Toms had a history with the patient and took control of the situation, ordering everyone back to trauma 2 immediately.
They rolled, Andre riding the cart doing CPR like it was a TV show for the first time in his career. When they arrived back, Bex cracked ampules of epi and vasopressin and amioderone and had them set up neatly on the counter. Maureen scribbled on a code chart off to one side of the room.
Andre completed four full rounds of CPR, during which time Respiratory had gotten another set of ABGs and had him intubated, the oxygen now turned on a hundred percent. Rachel worked ventilations.
"Charging to 360J" Dr. Toms announced, turning the dial on the manual defibrillator to the same setting the AED would have used in the ambulance. "I'm clear, you're clear, everyone's clear!" She called. Andre jumped back at "I'm clear" and took several deep breaths as Morgan's body tensed under the pads. Then he went right back to compressions.
"Morgan, Derek. 43 year old male. Went into v-fib three minutes ago secondary to hyperkalemia. His second episode of v-fib today, the first being at approximately 0145. Evidence of hemolysis secondary to copper sulfate intoxication. He's already had 1,500mL of normal saline bolus, 10 units of regular insulin IV with corresponding dextrose in water to bring down potassium. We're waiting on a second set of labs and results from CT to determine internal bleeding from blunt force abdominal trauma." He called out for those who were new to the party and Maureen, who was writing everything down.
"Got it." Maureen called.
"Give 1 mg of epi." Dr. Toms called. Becca did so. "And then get 90 mEq's of bicarbonate ready."
"Epi in, 90mEq of bicarb coming up." Becca repeated, quickly adding it to her collection on the table. Five rounds of CPR. Andre wasn't out of shape by any means, but he was sweating and out of breath by the time the "I'm clear, you're clear, everyone's clear" call came. He stepped back and again Morgan tensed. Someone tapped him out and took over CPR and he filtered to the back of the room.
"Give the bicarb." Dr. Toms said.
"Given." Becca confirmed. CPR continued for several more counts.
"Rhythm change on the monitor- I'm seeing sinus brady again." Becca alerted the room. Then, a few seconds later: "Getting a blood pressure as well- 75/38." Andre craned to see it, letting out a sigh of relief.
"Acknowledged, continue with CPR four more cycles and we'll check pulse." Everyone in the room was quiet except for the breathing of the nurse still doing compressions, all hoping the tenuous rhythm on the monitor would continue.
"Finished CPR." She said, also stepping back from Morgan.
"Okay, we have a pulse of 58, blood pressure of 80/40 and rising, both maintained without CPR. Lets get him upstairs to the unit, I'll debride when we get there." Dr. Toms closed.
"There's a bed waiting." Maureen confirmed. "Nurses'll be down in a minute." Then she added: "Andre, stick around and have your report ready."
"Will do, Maureen."
Becca had finished cleaning up her medication counter and came over to where the two of them stood, an evil smile on her face. She clapped a hand on his shoulder. "You owe me so many IVs, dude."
"As many as you want, Bex. Did you see how I got to ride on the cart?" Andre poked back.
"Like, you understand I'm calling you in on your days off and demanding that you show up because I have an IV I can't get and its your responsibility."
"Worth it. Thank you, Bex."
"Oh my god you two, get a room" Maureen said, shaking her head as she shuffled back to her office. Then she turned around. "You both did really good today, and tell Dr. Toms that as well if you see her."