Title: There Were Days (3/16)
Author: Still Waters
Fandom: Star Trek TOS
Disclaimer: Not mine. Just playing, with love and respect to those who brought these characters to life.
Summary: McCoy is critically injured and Christine Chapel does what she does best. A character study of Leonard McCoy and a look into the world of the Enterprise medical team.
Notes: Thank you all for the wonderful reviews and feedback as I explore this world! This has moved from a 2 part to a 3 part to a "now I have no idea how many" part story. Every time I think I'm done, I end up with the sickbay staff grabbing my hands and telling me more. Again, I am writing this as I am planning the final stages of a 2500 mile move across the country, so please excuse any glaring errors. Medical notes are at the end of the chapter.
"He's got 1,000 units rinhepin on board for the a-fib," Christine yelled over the screaming alarms as M'Benga desperately tried to divide his attention between the operating table and his crashing colleague. "What do you want?"
"O2 sat's 70s and dropping," Mara shouted, reaching up to silence the shrieking oxygen alarm. The flashing red of a critical reading and the cyanotic tinge to McCoy's face were enough. Christine quickly nodded her thanks.
"Push another 2,000 now and start a drip at 1,000 an hour," M'Benga ordered, "and get OR 2 prepped now." He strode back to Lt. Commander Kelly.
Christine grabbed the hypo and administered the rinhepin. "2,000 units rinhepin in," she confirmed. She looked up, searching for more staff. "Mike," she shouted over the still-screaming mini-vent alarm. "Get OR 2 prepped. Zan, stay with Tenzin."
Mara slammed the 'alarm silence' button on the mini-vent, disconnected the mask tubing, attached an ambu-bag and began manually pumping air into McCoy's lungs. "I've got him," Mara said. "Go get the drip."
Christine spun, sprinting for the intravenous cabinet. Shaking her head to clear the last of the echoing alarms, she grabbed a bag of rinhepin and IV supplies and sprinted back to McCoy's side and a new cacophony of voices.
"I'm all right," she heard Tenzin insisting, pulling himself further up in bed. "Go help the nurses," he pleaded with Zan, who, bless him, stubbornly refused to leave the man's side.
"You may not be as sick as Dr. McCoy, but Nurse Chapel still wants you monitored," Zan repeated firmly.
"Nurse Chapel!" Tenzin shouted across the empty beds. The blond head bobbed up briefly from securing the IV catheter. "I'm fine. Please tell Zan to help you guys," he pleaded, wide eyes on the doctor's still form.
Christine whipped around from priming the tubing at the sound of her name being called again. Elise, the OR nurse assisting M'Benga, poked her head out of surgery. "Give him to me, Chris," she nodded at Zan. "I'm having M'Benga wake Kelly up now. I can finish recovery with another set of hands and M'Benga can scrub again."
Christine nodded. "Zan, go help Elise in OR 1," she ordered, hooking up the tubing and setting the pump for the prescribed dose and rate. "But," she stopped him mid-sprint, "I want you to hook Tenzin's monitor readings into the second screen in OR 2," she added. She fixed Tenzin with a firm look. "I know you feel fine and you probably are," she said, "but if ANYTHING feels weird, you call us."
"Yes ma'am!" Tenzin nearly saluted.
"Okay," Christine agreed. "Zan, go. Elise, he's all yours."
"Sat's still in the 70s," Mara reported, double-checking that the oxygen was as high as it would go.
"No response to the extra 2,000," Christine shouted to M'Benga as he rushed to discard his surgical scrubs and wash his hands. "Drip's started at 1,000 an hour," she reported. "What next?"
"You have the location scan?" M'Benga asked, scrubbing his hands furiously.
Mara nodded, changing her hands on the ambu-bag while waving away Christine's silent offer to switch positions. "On the scanner next to the anticoag kit," she confirmed.
"Prep another 2,000 units for direct delivery and hook in the anatomical relay," M'Benga ordered.
Christine put the hypo within easy reach of her right hand while setting the medical scanner to overlay McCoy's anatomy with the previous two-dimensional scan result. "You want a pre-op coag profile?" she offered.
M'Benga strode to Christine's side and grabbed the proffered scanner, adjusting the display until he was sure of the clot location and local landmarks. At his nod, Christine passed the hypo across her body, her eyes never leaving the monitors. "2,000 units rinhepin," she stated.
M'Benga gave the scanner one last check before plunging the hypo directly into the clot's location. "2,000 units rinhepin in," he confirmed, switching to a localized perfusion scan. "Maintain the drip and get me that coag profile now, please."
"You okay, Mara?" Christine asked the other nurse. They didn't bag patients very often anymore and even with frequent practice, hand cramps were quick to develop.
"Fine," Mara acknowledged, switching the bag from her hands to under her arm. "I'd be better if he'd do this himself though."
Christine welcomed the quick laugh. "Yeah," she said softly as she began drawing blood.
"I'd be happy with a sat over 80," M'Benga mumbled quietly, glaring at the scanner as if he could will the procedure to work.
"You want a VBG too?" Christine asked, looking nervously at the monitor.
"Might as well…" M'Benga trailed off, squinting hard at the scanner. "There! It's dissolving! Mara, keep getting that oxygen into him. Christine, run the VBG, but set me up for an ABG as well, please."
Mara pumped the ambu-bag with renewed vigor. "That's it Dr. McCoy," she encouraged, "take it in. Now, bring that sat up."
Christine blew out a breath and turned to an unusually subdued James Kirk, who had taken up residence in a corner far enough out of the way, but close enough to see and hear everything going on. "The clot is breaking up. His oxygen level should improve soon," she explained as she carried the blood tubes over to the analyzer, set the machine and returned to M'Benga's side with the ABG kit.
"Sat's 83% and rising," Mara smiled. "It's about time," she chided McCoy.
M'Benga nodded. "Keep bagging him until he's over 90% again, then put him back on the previous vent settings." He turned to Christine. "We'll draw the ABG once he reaches that point." He glanced at the monitor, then back to Christine. "You said he was bradycardic a-fib in Engineering? How low again?"
"Started in the 30s, came up to 40s briefly, then went back to 30s despite half a milligram of atropine." She followed his eyes to the monitor. "And of course now he's tachy from the stress of the PE," she sighed heavily. "Just what a damaged heart needs," she grumbled. "Dammit Leonard, why do you have to act like such a critical patient?!"
M'Benga took the outburst in stride. While his own medical approach tended to be much calmer and often more polite than McCoy's, he found he drew a certain amount of strength from the other doctor's shouting, bouncing, and general passion in his pursuit of his craft. McCoy's sheer energy inspired him to step outside his comfort zone and, he had to admit, he missed that presence. He very much appreciated Christine stepping into that role right now. M'Benga brought his attention back to the monitor. "You gave cordarone during the resuscitation?" he asked.
Christine nodded. "150 of cordarone during the RSR setting, then 30 milligrams of demcorzen after the second shock, once the a-fib presented," she confirmed.
"We'll try the demcorzen again," M'Benga decided. "It may control the rate if nothing else and I need that heart rate down. If the rhythm doesn't break, we can cardiovert down the road….." he trailed off as two sets of eyes looked up, mirroring his own concern. He cleared his throat. "But for now, start a demcorzen drip. Bolus 100 milligrams, then continue at 60 milligrams an hour. Once we get a sense of the damage and get in there with the cardiac tissue regenerator, that alone may give his heart the strength to break the rhythm."
"Sat's up to 95%," Mara took the opportunity to interject. "Switching back to previous vent settings now." She unhooked the ambu-bag, reattached the ventilator tubing and reset the machine. "You got the monitors Chris? I'll grab the drip," she nodded toward the intravenous cabinet.
"Got them," Christine waved her on.
M'Benga verified that the clot had indeed dissolved and that the pulmonary vessels were clear. He handed the scanner to Christine, who checked that the radial and ulnar arteries were both perfusing adequately before disinfecting both sites on McCoy's wrist. M'Benga pulled on sterile gloves, palpated the radial artery and made the stick. While Christine held pressure on the puncture site, Mara returned with the demcorzen drip and began piggybacking it into the rinhepin line. She set the bolus rate, took the new blood tube from M'Benga and moved to the lab.
"What now?" Kirk asked quietly from the corner as sickbay began to quiet down.
"Now we finally get a look at what's going on," M'Benga stated, taking up the scanner again and beginning his assessment.
Christine pulled the gauze from McCoy's wrist to check the site. "Shit!" she hissed, slapping the gauze back down and glaring at McCoy. "You just had to make us do an arterial stick on your rinhepinized ass, didn't you?" she muttered.
"I take it Dr. McCoy is somewhat anticoagulated?" M'Benga allowed himself a chuckle.
"Not ridiculously," Christine said, "but enough that I could use a pressure bag," she directed back toward Mara.
Mara closed the analyzer lid and grabbed the previous VBG and coag profile results. "I got it," she assured Christine, heading for the supply cabinet. She returned to Christine's side, lightly taped the dressing in place, and set the pressure bag over the site before turning to the IV pump and switching over the demcorzen rate. "100 milligram bolus demcorzen in," Mara stated, "setting hourly rate of 60 milligrams now."
Hands finally free, Christine motioned at the lab results. "How bad?" she asked.
"Crappy," Mara shrugged, "but better than you'd expect for a man who was dead for six minutes and just spent the last few satting in the 70s." She handed the PADD over as M'Benga blew out a breath. Three sets of eyes whirled on him.
"How bad?" Christine repeated, this time directing her attention to M'Benga while waving Kirk over for the discussion.
M'Benga closed his eyes and handed her the scanner as he began rattling off the details. "Second degree burns to both hands, rapid atrial fibrillation, generalized ileus…..and massive cardiac and cerebral cell death with several completely infarcted areas," he practically whispered the final words.
Mara gasped. Christine clenched the PADD hard. It was Kirk who finally spoke. "Heart and brain damage?" he choked. He moved to McCoy's face and rested a hand against the pale man's cheek. "Oh, Bones," he whispered. He looked back at M'Benga. "What do we do?" he asked.
"There isn't much we can do Captain," M'Benga said softly. "The damage is extensive, even to modern medicine."
Christine felt something stir deep in her gut. She desperately tried to push back the threatening tears, but let go and let them fall as she realized they weren't tears of despair. They were tears of rage and that rage was fueling her inner Leonard McCoy. "No," she demanded, bolting up from her chair.
M'Benga looked up at her pityingly. "Christine…" he began.
"No!" Christine shouted, stamping her foot. "I know what his wishes are, but we have to try first." She looked at McCoy, a fond smile playing across her tear-streaked face. "You didn't see him with that tribble, Geoff," she said softly. "Hell, he turned PTSD treatment on its head….. on a whim. Who else would have thought a tribble could ground someone in the midst of a flashback?" She turned back to M'Benga. "He wouldn't give up on us until his gut and his brain were completely exhausted. Then he'd go raid someone else's. He deserves nothing less."
Kirk's eyes flashed his support, all traces of previous grief melting away. The natural refusal to back down that made him Captain of the finest ship in the fleet took over.
"And if our guts and our brains aren't enough?" M'Benga asked quietly.
"Then we do the EEG and if it says to let him go, we let him go," Christine said simply.
"Time to get to work, Doctor," Captain Kirk said to his current CMO.
M'Benga sighed. "All right, give me that PADD and start talking. Let's start with what we can fix most easily."
"About damn time," Christine grinned, bouncing on her toes as she reviewed the scan.
Kirk tried not to stare. She was practically channeling Bones right now and he couldn't help but grin himself. This was going to work. It had to. "Burns," he offered the group.
Mara stepped up. "Easy – a round or two with the dermal regenerator and plenty of ROM while he's out. His hands will be good as new by the time he wakes up. A-fib," she threw out the next task.
"He's got the demcorzen drip for rate control and possible chemical conversion," Christine reiterated, "and rinhepin on board for anticoagulation so hopefully we won't have a repeat of the clot incident. Where do you want his coags?" she directed the conversation to M'Benga.
"His HSNR is 1.5 as of these labs," M'Benga nodded at the PADD in his lap. "Normally I'd want it over 2 for a-fib, especially since he's already thrown a clot, but I also don't want him bleeding out during surgery. We'll keep the rinhepin as it is and maintain continuous perfusion scans. Make sure surgery is stocked with torpramine in case we have a hemorrhage issue."
"What about sending him into surgery with the dysrhythmia?" Mara asked.
"I wouldn't if I had a choice, but I've done it before," M'Benga said, "and we really don't have the time to wait. His heart is so damaged that it probably won't even think of converting until it's stronger, so we continue what we've been doing and take care of the root issue."
"The ileus will resolve once his body gets used to actually perfusing again," Christine decided, "and we're just going to have to deal with it again after surgery as a normal post-op issue anyway, so let's move on. Cardiac," she stated, moving into the real challenges.
"There's no way we can correct that kind of damage transcutaneously," Mara shook her head. "We need to get in there."
"Direct regeneration?" Christine asked. "We haven't done that in awhile," she turned to M'Benga.
He blew out a breath in agreement. "True, but I think we have a chance. Direct regeneration will allow us to both re-perfuse salvageable areas as well as stimulate new cell growth at the same time. I don't like the idea of opening him up in this weak of a state and with the rinhepin infusion, but we'll just have to manage. "
"Okay, so how do we fix his brain?" Kirk jumped in, encouraged by the plan so far.
Mara sighed. "When I was stationed on Omega II, the native people brought us two of their miners, who had been trapped in a cave-in. The men suffered severe head injuries, but the chief physician, Dr. Leurer, had worked with Dr. Kerebus from Starfleet Neurology. Dr. Kerebus was launching his study on direct cerebral regeneration at that time, and as a last-ditch effort, Dr. Leurer contacted him and tried the procedure on the miners. It worked well for brainstem injury, but was completely ineffective anywhere else. The natives didn't believe what the EEG showed them and thought that since the men were breathing on their own, they were fine. They took them home where they eventually died from complications due to prolonged immobility. They never woke up."
Kirk shuddered.
"Dr. Kerebus," M'Benga thought out loud. "I remember reading the subsequent reviews of that study. He felt that they were so close, that it should work."
"Wasn't it something about the oxygenation?" Mara's forehead creased with concentration.
Christine bolted from her seat. "Tri-ox!" she shouted. "I can't believe I didn't think of it earlier," she chastised herself out loud. "Kerebus and a student of his published an article last month in Annals of Neurological Research. Kerebus was sure that the original study failed due to insufficient oxygenation during the process. His student suggested using tri-ox to supplement direct regeneration. It was only a case study, but the results were incredible – 94% improvement. Leonard and I were discussing how that last 6% could be made up!"
Even M'Benga sat upright. "Of course!" he recalled the article. "They used a tri-ox mist over the regeneration sites. The conclusions were the longer the tri-ox supplementation, the better, but the surgeon was limited in how long he could keep the brain exposed."
"That's where Leonard insisted there should be a way to prolong that time," Christine said excitedly. "He suggested a shunt placement, to allow continuation of tri-ox therapy once the skull was closed and the patient in recovery."
"Placing a shunt in the brain?" M'Benga's eyes widened. "The last time I saw that done was in the history books."
"Which means it just might work," Christine insisted. "We contact Dr. Kerebus, get his ideas and go from there."
M'Benga opened his mouth, but closed it abruptly. He wasn't a neurosurgeon. Hell, his specialty was Vulcans, but as there was only one Vulcan on this particular ship, he had to keep his general human surgical experience sharp. General, being the key word. He was worried enough about attempting direct cerebral regeneration, but to perform a variation of a procedure that probably hadn't been done in two hundred years…to insert a device that would give outside access to McCoy's brain to try and improve a process only done once so far…..
M'Benga wanted to say "no." Direct regeneration was a leap enough. He lifted his head, getting ready to speak again and was met with three sets of expectant eyes: Mara, all sweet hope that those two men didn't die in vain; Kirk, wild excitement at the possibility of getting his friend back mixed with a hint of curiosity as to whether he could actually order the current CMO to perform the procedure; and Christine…..radiating rage, brilliance and readiness and the start of a wild smile….and suddenly McCoy was there, in Christine's face and in M'Benga's head. "Come on son," the Southern drawl deepened with his passion, "what's the point of all this fancy equipment if we don't use our God-given brains? Just because something's in the past doesn't mean it's meant to stay there you know. Not every step we've taken has been an improvement." M'Benga remembered sitting with McCoy, listening to those words after the CMO's in-service on CPR and cardio stimulators to the crew. Two days later, Montgomery Scott was walking out of sickbay with a clean bill of health, not three hours after an Engineering crewman, armed with McCoy's CPR demonstration and a well-placed cardio stimulator, pulled him from cardiac arrest.
M'Benga sighed. "All right," he acquiesced. "Get Dr. Kerebus on the line – I need to 'raid his brain' as you put it Christine," he smiled softly. "We're going to need to make sure OR 2 is supplied for all this. You should set up for a central line too – if we're going to start pulling things from the history books, we might as well go big, as Leonard would say. He's going to need a lot of intravenous support once we're through with him."
Christine grinned and rushed to the comm, asking Lt. Roberts in Bridge Communications to contact Dr. Kerebus and connect the call to M'Benga's office. "Oh my God!" she exclaimed as she ended the transmission. "Mara, where's Uhura? Is she okay?" She had completely forgotten about the injured communications officer. The call about her bleeding laceration seemed like another lifetime ago.
Mara laughed. "She's fine, Chris," she assured her. "The laceration responded right away to a dose of coagulant, sealed beautifully and we sent her on her way with a dose of pain meds and antibiotic right before you guys got up here from Engineering."
"Good," Christine sighed, putting a hand out to steady herself on the desk. "Now, you want OR prep or monitoring duty?"
"What I want is for you to get some sleep," Mara said.
"What?" Christine countered.
"Chris, your shift has been over for how long now?" Mara asked, staring pointedly at the time. "You're due back in a few hours as it is for your next one. Go sleep. We can handle things from here."
"But the OR…." Christine began.
"Mike's already done the basics. I'm already updating the equipment list," she waved the PADD in her hand, "and he can read. I'll double check the med stock once Zan gets back out here."
"Elise…."
"….is fine!" Elise called from recovery. "And so is the Lt. Commander. Zan's all yours again."
"Tenzin….."
Mara turned around. "Hey Ensign!" she shouted.
Tenzin looked up and waved.
"You still alive?" Mara teased.
"Feels like it," Tenzin smiled.
"Any pain, difficulty breathing or other concerns?" Mara threw back.
"Not a thing, Nurse," he laughed.
"See?" Mara said. "He's fine."
"What about other casualties from the solar flare?" Christine demanded.
"Tom's on call," Mara reminded her, "I called him in ten minutes ago to triage and treat what are very minor injuries."
"And surgery….?"
"God, you're dull," Mara laughed sympathetically. "I'm still on shift. I'll assist M'Benga in surgery. Chris, if you stay here, you'll either fall flat on your face or you'll make a stupid mistake. You know the rules – leave it here. Go grab a few hours. I'll wake you if anything happens."
Christine sighed. She knew Mara was right. "You'll call me if ANYTHING happens?" she clarified. "If he crashes, I want to know."
"I'll call you myself," Mara promised.
Christine walked over the McCoy's bedside. "Be good for Mara," she warned him. She bent down and gently kissed his forehead. She turned to Mara. "Wake me once he's in recovery," she said. She looked down at McCoy one more time. "Even if it's before my shift starts. I want to be there," her voice softened.
"You got it," Mara said gently. "Now get out of here."
Christine smiled and strode out of sickbay. Maybe she'd try some of the meditation Mr. Spock had been trying to teach her. Leonard would love that.
*Medical Notes:
I had a great time working with McCoy's voice in my head as to how to create future technology that would be on the Enterprise while melding it with current knowledge and practice. I tried to be as realistic as possible.
- "O2 sats", "sats" and "satting" all refer to oxygen saturation, which measures the amount of hemoglobin in the red blood cells that is saturated with oxygen molecules. Generally, a healthy person's O2 sat should be ninety-five to one hundred percent.
- "Priming the tubing" refers to setting up an IV drip. After attaching the tubing to the bag, you open the clamp all the way and let the fluid flow through to get rid of any air bubbles before hooking it up to the patient.
- A "coag" profile is a set of blood values used to determine how fast someone is clotting. When a patient is on an anticoagulant (also known as a 'blood thinner'), these levels are monitored frequently to determine whether the level is too high or too low and the medication is adjusted from that point. One value today is the INR (international normalized ratio). My made-up HSNR stands for "homo sapiens normalized ratio" since the Enterprise med staff would be working with several species.
- A VBG is a "venous blood gas." An ABG is an "arterial blood gas." Both measure certain characteristics in the blood that are particularly important to monitor in a patient on a ventilator, such as the pH of the blood, levels of carbon dioxide and oxygen and bicarbonate. An ABG is more accurate in this sense and it requires sticking a needle way down into an artery to get the blood sample.
- "Tachy" is an abbreviation of "tachycardia" (heart rate over 100 beats per minute).
- In the a-fib discussion, "demcorzen" (which is a turned around spelling of Cardizem, a real cardiac drug used today) is used to try to bring down the heart rate when it is too high as well as to try and get the heart to break out of the a-fib and go back to a normal rhythm. Sometimes it works, sometimes it doesn't. I gave the Enterprise crew a break and made the future version free of blood pressure issues. The real Cardizem tends to lower blood pressure, especially when given as a continuous IV drip. "Cardioverting" is using an electric shock to interrupt the heart and get it to reset to a normal rhythm. This is another way of stopping a-fib, but it is only done very early on after the rhythm is discovered as there is a risk for the patient throwing a clot if the rhythm has gone on too long.
- "Christine pulled the gauze from McCoy's wrist to check the site. "Shit!" she hissed, slapping the gauze back down and glaring at McCoy. "You just had to make us do an arterial stick on your rinhepinized ass, didn't you?" she muttered." McCoy is on an anticoagulant so he doesn't clot as well in order to prevent clots from the a-fib. M'Benga just stuck a big needle all the way down into an artery in his wrist. Arteries are high pressure systems. You normally have to hold pressure on an ABG site for five minutes – Chapel is not happy about the implications.
- "Ileus" is a term that generally refers to when the gastrointestinal tract stops moving. This can happen after a long period without blood flow and oxygen and it also tends to be a side effect of general anesthesia. The gut needs to wake up again.
- ""You didn't see him with that tribble, Geoff," she said softly, "hell, he turned PTSD treatment on its head….. on a whim. Who else would have thought a tribble could ground someone in the midst of a flashback?"" The tribble and PTSD incident refers to my story Soul on Fire. McCoy insisted on telling me that story. I have no idea what M'Benga's first name is, but according to Memory Alpha ( /en/wiki/M%27Benga), his name is Geoffrey in two of the novels, so I went with that.
- ROM stands for "range of motion."
- "You know the rules – leave it here." This refers to one of the first things you learn as a nurse (or any medical professional) – leave work at work.