"An Equitable Trade"
Chapter Twelve
In the back of the ambulance already en route to Rampart…
Dixie attached a heart monitor to their collapse victim's heaving chest.
A staccato of electronic beeps immediately filled the compartment.
Roy watched wordlessly as a complete lab draw was made and all warranted drugs were administered. 'Circling the drain...' That was the grim term emergency medical personnel used to describe patients in Johnny's condition. The two of them had even found themselves using it, on occasion. The paramedic quickly shoved the morbid phrase out of his mind, but couldn't seem to shake the gut-wrenching feeling that, no matter what medical treatment he received now, his partner was just gonna keep getting closer and closer to that damn 'drain'.
Johnny's injuries were not life-threatening and his blood loss was not all that severe. The real killer would be Cryptic Shock—a direct consequence of 'untimely' medical treatment.
Roy continued watching as Brackett gave their patient a complete assessment.
Airway:
Brackett checked the position of the trachea and palpated the posterior thorax.
The patient's airway was both open and intact.
Breathing:
Kel auscultated the fireman's lungs.
Relatively clear.
Circulation:
The doctor palpated the patient's abdomen.
No rigidity.
The leg wound seemed to be seeping.
Neurological evaluation:
Kel did the math in his head and winced.
Johnny scored a mere 6 on the Glasgow Coma Scale.
On the up side:
The wide open 100% oxygen treatment was increasing the efficiency of their shock patient's diminished supply of hemoglobin.
On the down side:
The wide open saline solution was diluting those remaining red blood cells. The seeping wound was an indication that the blood's clotting factors were also being diluted.
Top priority:
CS, and whether or not it could be reversed.
Items of lesser concern—at the moment:
the untreated penetrating wound, with the potential for sepsis.
the threat of inhalation pneumonia
and the crushing injury to the patient's right pelvic region,
with a potential for nerve and arterial damage.
Two things were certain:
One, it was a miracle Johnny was still alive.
And two, it would require another miracle to keep him that way.
The sirens cut out, signaling their arrival at Rampart.
Benjamin Tyler, one of the ER docs currently on duty, met them at the doors. "We're set up for him in Three!"
The gurney was unlocked and unloaded and it, and the assembled medical team, disappeared into the building, with the gurney's occupant's partner in tow.
Once again, the gallant doctor helped the RN step down onto the pavement. He saw the corked glass vials in Dixie's hands and barked out, "U+Es/Chem7, FBC, Glucose, type and cross-match!"
Dixie nodded and suddenly realized something. "Remember that school bus roll over last week?"
Kel nodded.
"Hank's whole crew stopped by, right after their shift, and gave blood. I'll see if his is still available."
'That would certainly qualify as a minor miracle,' the physician silently realized and headed for Treatment Three.
Inside Treatment Three, following a flurry of activity…
Their collapse victim had been intubated.
40,000 units of antibiotics were currently being administered, via a piggyback IV.
Amazingly enough, the patient's donated blood was still in the hospital's bank, so John was transfused with a unit of his own whole blood and two units of plasma.
A pulse oximeter was attached to the fireman's right index finger. The new-fangled instrument would use light readings to provide valuable information about arterial oxygen content and tissue perfusion.
A Foley catheter was inserted, so urine output and fluid input could be monitored.
Another sample was drawn and sent to the lab for arterial blood gases analysis.
The penetrating wound to his right thigh was thoroughly cleaned.
"Clean it again," Brackett abruptly ordered.
RN Tammy Tiernan looked up at the physician in disbelief. "I've flushed it twice already, doctor."
Dixie saw Kel's eyes narrowing and quickly intervened. "The solution to pollution is—?"
"—Dilution," Miss Tiernan meekly replied and resignedly sighed. "I'll flush it again."
Once everyone was satisfied that the wound had been thoroughly cleansed, two drainage tubes were inserted and sutured in place.
Openings to the wound would remain open, to allow drainage and, hopefully, prevent sepsis—blood poisoning—from developing.
Finally, a dressing was applied.
"His blood work is back," Tyler proclaimed as he came barging into the room.
Kel latched onto the lab report and perused it.
'Metabolic acidosis with lactate acidemia and negative base excess,' he silently summarized.
Arterial blood gases, PH and PCO2, levels all pointed to inadequate perfusion. No urine output and unconsciousness were also indicative of poor end-organ perfusion, not to mention cellular hypoxia.
Hopefully, the next report would show some improvement.
Treatment Three, ten minutes later…
John's latest labs revealed what both doctors already suspected.
Lactic acid levels remained elevated, 4 mmol/L.
In spite of their best efforts, tissue hypoxaemia remained unresolved. Microcirculation was being irreparably damaged.
Kel glanced up at John's heart monitor.
Tachycardia in the presence of normalized pressures was yet another sign of cryptic compensated shock.
Just stabilizing someone's BP or heartrate was no guarantee of survival.
Their CS patient was stably unstable, and still at a ridiculously high risk of death.
"I need some air." The frustrated physician locked gazes with John Gage's partner. "Care to join me?"
The paramedic's reply must have been in the affirmative because he immediately began heading for the door.
Kel caught up with him out in the hall and the two of them began strolling toward the ER's exit. "Ben didn't wake us until he heard you guys called out. So we managed to get a few hours of sleep. What about you? Were you able to get any sleep?"
Roy shook his head. "Just about five hours of mandatory 'rest'."
They reached the end of the hall.
Instead of turning toward the exit/entrance, Brackett stepped up to the ER's public waiting room. The doctor just stood there in the wide doorway, staring.
A wooden crate was occupying a large portion of the already crowded space and blocking access to the ER's Admitting desk.
The doctor stepped up to said desk and demanded, "Donna, what is this crate doing here? Besides obstructing Admissions..."
Donna pointed to the crate in question, "That is our new hyperbaric oxygen chamber. It wasn't supposed to arrive for another six months, but a hospital in Riverside cancelled their order, so we ended up with theirs. Seems it was delivered to the wrong door and the wrong floor. Guess this was as 'out of the way' as they could get it."
Something suddenly occurred to Kel and his look of annoyance quickly transformed to one of jubilance. "Wrong! It was delivered to the right door and the right floor! Donna, get Respiratory Medicine on the line. Tell the Hyperbaric Oxygen therapist to report here—on the double!"
Donna hesitated. "I don't think his shift starts until eight."
"I don't care! Just get him to the hospital and this crate up to ICU! Roy, come with me!"
The paramedic did as directed. Roy had no idea where the doctor was headed or what he was up to. He was just relieved to see the physician's haggard face filled with a look other than hopelessness.
Twenty minutes later, up in ICU Room 604...
Doctor Tyler had gotten wind of what his colleague was up to. "What are you doing with the hospital's hyperbaric chamber?"
"That isn't just a hyperbaric chamber, Ben," Kel calmly corrected. "You happen to be looking at a bona fide miracle!"
"Kel, hyperbaric treatment is contraindicated in these cases."
"Treatment protocol for CS is 'oxygen as required'. Well, he happens to require more than he is currently receiving."
"CS patients only qualify for hyperbaric oxygen therapy when they are unable to receive blood products for religious or medical reasons. HBOT is known to decrease heart rate, a-and it has the potential to decrease cardiac output. It can also cause a loss of hypoxic drive to breathe. It could trigger respiratory arrest."
"So? If he gets the treatment, he could die. If he doesn't get the treatment, he WILL die! Even without all the lab results to back me, Johnny's altered level of consciousness is proof enough that his vital organs aren't being sufficiently perfused. You know as well as I do that patients with an oxygen debt greater than 9 seldom, if ever, recover. Well, he's already at 9!"
"Kel, we're not just talking 'hospital reprimand', here. You could be brought before the Ethics Board you could lose your medical license."
Kel swung an arm in the horizontal paramedic's direction. "That young man risks everything to save others—and does so on a regular basis. It's time someone risked a little to save him. This isn't debatable, Ben. I've already signed the treatment order."
Upon hearing that, Tyler promptly took his leave.
Tyler returned ten minutes later, with the signed medical order. "Take a look."
"I don't have to take a look. I know what it is. I signed it. Remember?"
Ben held the paper up in front of his stubborn colleague's face and forced him to 'take a look'.
Kel's jaw dropped. He wasn't the only one who had signed the order for treatment. Every physician working the hospital's graveyard shift had also signed it. Ben Tyler's was the first signature below his. He shoved the paper out of his line of vision and directed his dazed, amazed gaze at his fellow doctor.
Tyler shrugged. "Somebody had to play devil's advocate."
Kel couldn't help but chuckle. "Thanks, Ben. John Gage obviously has a lot of friends at Rampart."
Tyler couldn't believe what he'd just heard.
Only one signature on the treatment order was saving the paramedic's life. The other signatures on the order had been added to save Kel's career.
"He can't possibly be that clueless," Ben said in an aside to Dixie.
The RN arched an eyebrow. "Wanna bet?"
Roy heard the sound of wheels rolling across floor tiles and looked up in time to watch Eleanor come banging, backwards, into the ICU lounge. "Are you supposed to be out of bed?"
"If they didn't want me to go A.W.O.L., they shouldn't have left this contraption in my room."
Several seconds passed and no attempt was made to wheel her back to her hospital bed prison.
"That'll teach 'em," Roy played right along, and even managed a fleeting smile.
Eleanor gave her co-conspirator a grateful grin. "John said the two of us would hit it off," she fondly recalled and rolled her escape 'contraption' right up in front of the forlorn looking fireman. "That partner of yours is a remarkable young man."
The paramedic's smile made another brief appearance. "Took me all of five minutes to figure that out. We met when he came into headquarters, to have some questions answered about the paramedic program. This job is rewarding, but it takes a toll—both physically and emotionally. For a paramedic partnership to work, you have to find someone who is as dedicated to saving lives as you are. After five minutes of listening to him talk, I knew I didn't need to look any further. I'd met my match."
E.J. placed her right hand over Roy's and gave it a comforting squeeze. "John's partner is a pretty remarkable young man, as well."
"I don't know ab—"
"—Okay, Roy, where were—," Brackett caught sight of the woman in the wheelchair and cut his interrupting comment short. "Are you supposed to be out of bed?"
Eleanor found the tall, dark-haired doctor in the doorway a tad more intimidating.
"If you don't want your patients going A.W.O.L.," Roy parroted, "you shouldn't leave these contraptions in their rooms."
The physician fought back a grin.
"You were saying…" Eleanor urged the no longer 'gruff' looking guy.
"I was about to explain to Roy, here, how hyperbaric oxygen therapy works."
"Splendid! Now you can explain it to the both of us."
"Very well." Brackett turned one of the chairs at the nearest table around, dropped exhaustedly down onto it and began, "Hyperbaric oxygen therapy, or HBOT, is breathing 100% oxygen while under increased atmospheric pressure. Hyperbaric treatment has been around since the 1600s.
The patient is placed in the chamber in a reverse Trendelenburg—a reclining position. The windowed chamber is then sealed and pressurized with 100% oxygen. All patient care is rendered from outside of the chamber. All medical equipment remains outside the chamber. Only the patient's intravenous line will penetrate through the hull.
Patients in late Stage II CS, Cryptic Shock, have lost significant oxygen carrying capacity in the blood. The major oxygen carrier in human blood is hemoglobin, transporting 1.34 mL of oxygen per gram. The Central Nervous System and cardiovascular system are the two most oxygen-sensitive systems in the human body. Whether organs fail, or not, depends on the level of ischemic damage and on the different organs physiological reserve in terms of hemodynamics and metabolic capacity. It is crucial to recovery that any oxygen deficit be reversed A.S.A.P.
Most oxygen carried in the blood is bound to hemoglobin, which is 97% saturated at standard pressure. Some oxygen, however, is carried in solution, and this portion is increased under hyperbaric conditions. Because the oxygen is in solution, it can reach areas where red blood cells may not be able to pass and can also provide tissue oxygenation and increased plasma oxygen content and microvascular blood flow.
By increasing the atmospheric pressure in the chamber, more oxygen can be dissolved into the plasma than there would be at surface pressure. So, when a patient is given 100% oxygen under pressure, hemoglobin is saturated, but the blood is also hyperoxygenated by dissolving oxygen within the plasma.
HBOT is administered at 2-3 ATA, Atmospheres absolute, for periods of up to four hours per treatment. As many as 3-4 treatment sessions per day may be necessary. Treatments continue until the patient no longer demonstrates end stage organ failure, or no longer has a calculated oxygen debt. Any questions?"
"I'm afraid you lost me back at the first 'hyperbaric'," E.J. confessed. "I would just like to know, is the shock reversible?"
Brackett suppressed another smile, but then his countenance quickly sobered. "We'll know soon enough. Johnny will either respond to the pressurized oxygen administration…or he won't."
'No news is good news. No news is good news,' Roy kept telling himself as he pulled into the hospital's parking lot the following afternoon. A line from Brackett's lecture also kept playing back in his brain.
'The Central Nervous System and cardiovascular system are the two most oxygen-sensitive systems in the human body.'
It's a good thing he wasn't on duty. The Squad would have been on its umpteenth 'supply run' to Rampart by now.
The paramedic's first stop was Emergency Receiving.
His partner had received a total of twelve HBOT treatments.
Blood work showed signs of remarkable improvement. Still, his buddy remained in 'an altered level of consciousness'.
The paramedic had just stepped off the elevator and onto the sixth floor, when a page came over the hospital's P.A.."Doctor Brackett to ICU…Doctor Brackett to ICU…Room 604."
"It's okay," the ICU nurse assured her patient's panting paramedic partner, as he exploded through the door to 604. "In fact, he seems to be regaining consciousness."
Roy's grim countenance instantly brightened.
That was more than just okay. Heck! That was downright fantastic!
Sure enough! John's lashes fluttered and his lids lifted a little. His vision was all blurry. So he blinked, and kept right on blinking, until the fuzzy form leaning over him finally came into focus.
Roy saw the recognition in his friend's half-open eyes and smiled. "I can't leave you alone for a second."
Johnny was forced to grin.
Roy pressed a straw up to his partner's parched lips.
They parted, and the patient took several long, soothing swallows.
"You weren't supposed to cause any kerfuffles while I was gone. Remember?"
"I didn't cause…any kerfuffles…I joined a kerfuffle…already in progress."
It was Roy's turn to grin.
"Man! I cannot believe we survived tha—" Johnny's face suddenly filled with dread. "WE did survive that…" he all but pleaded.
Roy nodded. "Eleanor is doing just fine."
John's face filled with relief, and then dread again. Had ALL of him survived? His anxious gaze suddenly shifted to the lower half of his body.
"Yes. Your leg is still there," Brackett assured him.
Neither of them had noticed the doctor enter the room.
Kel picked the chart up from the foot of his patient's bed and perused it. "The wound was through and through. Remarkably, muscular and vascular damage was minimal. But, if that rod had penetrated just a fraction of an inch to the left of where it did, we wouldn't be having this conversation right now."
John couldn't seem to keep his vision from blurring, or his eyelids from drooping. "Why am I…so damn drowsy?"
"That would be a side effect of your medication. We've got you on IV antibiotics, to combat infection. How are you doing?"
"You tell me," John countered.
"There is some minor wound infection and we've been monitoring your lungs. Apparently, you inhaled a great deal of dust. What about the leg? How does it feel?"
"I can't really feel the wound. But I must have aggravated some nerves, cuz the pain is pretty…intense."
"We can take care of that." The doctor scribbled something onto his pained patient's chart and then left, to take care of that.
"How'd you guys ever get us outta there?"
Roy proceeded to tell his buddy all about the rescue, being careful to leave out the part where John was practically pulse-less when they finally reached him.
The nurse returned and emptied a hypo into her patient's IV port.
John's already ridiculously heavy eyelids instantly became even weightier. "Considering how…dehydrated I was…did you have any trouble…getting a line in?"
Roy suppressed a shudder. That was certainly an understatement. "Let's just say you were a 'tough stick'…and leave it at that."
"Wanna hear something weird? I keep having this same dream—over and over again. In the dream…I'm being buried alive…and the casket…has this big… window in it."
Roy couldn't keep from grinning.
His practically asleep partner seemed peeved that he had found his nightmare so amusing.
Roy shrugged. "There are good dreams, and there are bad dreams. That is a very good dream."
The look on Johnny's face went from perturbed…to perplexed…to impassive.
As a token of his gratitude, Edward Greenbough wanted to supply his new friends at Fire Station 51 with some practical labor—and life—saving devices. So he had his people contact their people.
When his people informed him that it was against department policy for individual firefighters or fire stations to accept gratuities for services rendered, Edward proceeded to circumvent the policy by giving every Los Angeles County firefighter a short-range radio, and every Los Angeles County fire station central air, an automatic dishwasher, an automatic coffee maker, a microwave, a washer and dryer , new mattresses, a floor scrubber and a 36" color television.
A few days later, John was moved out of ICU and in to a regular room.
Dixie happened to be sitting with him when Roy and Chet dropped by for a visit.
"Sheesh, Gage!" Kelly exclaimed. "If I'd a known you were gonna go getting yourself all shish kabobbed—"
"—Sh-Shish kabobbed?" John cut in, looking amused to no end.
"Yeah. Shish kabobbed. You know, the way you had that rebar rod all skewered through your thigh there," he motioned to the patient's injured right leg. "Anyways, if I'd a' known, I'd a' made you and Eleanor go first."
Dixie's right eyebrow arched in thought. "But then you would have been 'all shish kabobbed.'"
Failing to refute the nurse's logic, Chet quickly changed the subject. "Before I forget…What's a kerfuffle?"
Roy pointed to his partner, who promptly pointed back.
Leaving Kelly more confused than ever.
E.J. entered just then, in a wheelchair that was being pushed by her doting fiancé.
The horizontal fireman's whole face lit up. "Dix, this is the lovely lady who risked her neck to save my life."
"Edward, this is one of the gallant gentlemen who risked their necks to save my life," E.J. quickly countered and pressed something into her rescuer's right palm.
John gazed down at the glistening object in his hand and smiled.
It was one of their chandelier's prisms.
E.J. pulled a matching crystal prism from the front pocket of her blouse. "A habit of mine. I always bring home souvenirs. Little reminders of the amazing places I've been, and the remarkable people I've met."
Gage glanced up at E.J.'s beau. "You, sir, are a lucky man." His gaze returned to E.J.'s gift and his smile graduated into a grin.
It truly was an 'equitable' trade.
The End
EPILOGUE
Six months later…
A package arrived at Station 51. It was addressed to J.R. Gage. The parcel's return address was Passion Press, Inc.
Chet teased that romance novels were one of Gage's guilty pleasures.
The paramedic ripped the package's plain brown wrapper off.
It was, indeed, a romance novel.
A blue-eyed version of J.R., dressed in full turn-outs, and looking incredibly heroic, adorned the book's front cover. In the young fireman's arms was a beautiful figure skater in a skimpy skating costume.
"Fire and Ice" written and illustrated by E.J. Rigby
John flipped the book over and read the blurb on the back:
His whole life was the Fire Service. Her whole life was the Olympics. Until a twist of fate brought the firefighter and the figure skater together in "Fire and Ice"
He opened the paperback. There was a Dedication.
It read:
for J.R. my knight in a drab canvas coat
Below that, was a penned autograph and personal message from the book's author:
With the tenderest of affection,
Eleanor Johanna Rigby
John quickly closed the book and took another, longer look at the voluptuous young lady lying in the heroic fireman's arms.
His wry smile broadened into a wry grin.
Yessiree, Edward was a very lucky man!
Author's Note:
My Father had a really rare blood type, for our area, anyways. AB-, I believe.
As a result, he was occasionally called upon to donate blood.
Fast forward to mid-November 1968.
Another hunter mistook my Dad for a deer and blew most of his upper left arm off.
Of course this happened out in the middle of the middle of nowhere.
By the time they got my Dad to the hospital, the doctors couldn't palpate a pulse.
My Dad's own donated blood was banked at the hospital and the doctor's used it to
save his life. One of the lives he saved turned out to be his very own.
I always wanted to include a scenario like that in one of my fics and this story
gave me the opportunity to do it. Real life IS stranger than fiction, and fiction is,
at times, every bit as odd as real life. :D
Both pulse oximeters and hyperbaric oxygen chambers were in use during the E! timeline.
I have been caring for my 87 yrs. young Mom for the past three weeks. She's been an invalid
ever since she fell and broke her right femur. I don't get much computer time when she's here.
Which is why the final chapter was delayed.
I hope you enjoyed the ending.
Thanks for reading and reviewing!
:) Ross7