Post, surgical scrub, Dr. Alan Quartermaine backed his way into OR 6 with a sense of dread. He reached for the towel that the scrub nurse handed him and then diverted his eyes towards the sterile mayo stand where she had opened a gown and few pairs of size 8 gloves for him. "I'm good," he said. He would dress himself because it was quite clear Dr. Meadows needed all hands, on deck.
Moments later, dressed in his full surgical regalia, as his residency mentor Dr. Steven Lansing would have called it. Alan stepped up to the table and took in his niece by marriage's open abdomen full of blood. Unfortunately, his concerns about DIC had not been overstated. "What have we given blood product wise?" he asked.
"4 FFP and cryopreciptate are in. This is the fifth unit of packed cells, and we have another on the way," Dr. Meadows said.
"Was the placenta completely abrupted?" Alan asked.
"Probably 90%, your nephew can thank whichever of your SICU nurses called us so quickly. The baby came out a little stunned, but he was screaming by the time the NICU team took him," Dr. Meadows said.
"So, I'm guessing the HELLP Syndrome, and the abruption threw her into DIC and now the hemorrhage is just adding fuel to that fire. Raj, can you give 1g Tranexamic Acid if you haven't already. What do you have the Pitocin Drip running at?"
"We have not given TXA, but I will. The Pit is at 500 units/hr," Dr. Rajeswami said.
"Thank you, let me know when that is in," Alan said. He turned to the circulating nurse. "We're going to need another 4 units of cryoprecipitate now and tell bloodbank to just pull a rapid transfusion protocol and send the cooler to the OR. I'm also going to need ten packs of gel foam. Let's start with five on the field," he instructed.
The circulating nurse looked terrified. She gulped audibly and then croaked, "Of course, Dr. Quartermaine."
Alan took a deep breath and turned to Dr. Meadows. "I'm going to partially undersew the uterus and then we're going to pack with gel foam overlay with a Blakemore Tube, and I'll finish that closure. If that gives us any degree of hemostasis, then we can try packing more gel foam and gauze and leave an open abdomen. If that doesn't work and IR doesn't see anything they can embolize then I guess it's your call about hysterectomy," he said.
"Normally with this much blood loss we would just do the hysterectomy but in Carly's case I'm afraid that she may completely bleed out if we try. That's why I paged trauma on call," Dr. Meadows said.
Alan didn't disagree with her concerns. The sad reality of medicine was that sometimes despite appropriate care patients still died and he was afraid that they might be at a point where no matter what anyone did, Carly would never have the chance to hold the child she had fought so hard to bring into the world.
"The TXA is in Alan. I'm just about to start the 6th unit of packed cells and I'll give the cryo as soon as they send it and then do you want labs?" the anesthesiologist asked.
"Yes, thanks, and unless a miracle occurs I would redose that TXA in 30 minutes," Alan said. Then he took a deep breath, silently prayed that his great nephew would not grow up without his mother, reached for the needle driver loaded with absorbable suture, and started to close the uterine incision.
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Rachel Berlin rolled her eyes as PCGH Child Life Specialist, Chari Nomen navigated her wheelchair into the playroom on the fourth-floor pediatrics unit. She wasn't sure whether it was more humiliating to be attending a Halloween Party with literal toddlers or to arrive there in a wheelchair. Both were beyond pathetic!
"Ok, here we are," Chari Nomen said way too cheerfully.
Rachel rolled her eyes again. "Thanks, I can take it from here," she said.
Chari smiled brightly. "Oh, it's ok I don't mind being your personal chauffeur. Remember that Dr. Hardy said it was important that you not overexert," she said.
"How would I overexert in a wheelchair?" Rachel asked. She rolled her eyes again and shook her head.
"Why don't we focus on what you can do rather than your current restrictions. Now, come on why don't we start at the facepainting station or perhaps a balloon animal," Chari suggested.
Rachel rolled her eyes again and crossed her arms in front of her. But apparently Chari wasn't deterred because she felt her chair moving forward towards a table with long sausage balloons and balloon animals. A girl with long brown hair and brown eyes was sat on a stool beside the table. She looked up and smiled warmly. "Hi, I'm Emily Quartermaine," she said.
Rachel was mildly curious if she was Dr. Quartermaine's daughter decided not to ask. She was debating asking for a flamingo when the guy she blackmailed into bringing her magazines appeared carrying a pack of balloons.
"I know you!" Rachel said.
Nikolas Cassadine looked a little flustered but then he seemed to regain his countenance. "Miss Berlin, it is a pleasure to see you again. Have you met my friend, Emily Quartermaine?" he asked.
"Only just now. How about a Flamingo? Could you make that?" Rachel asked.
"You're in luck, I can. One of my friends in Boston was a huge Flamingo fan," Emily said. She picked up a long pink balloon and started twisting it to form the body.
Rachel watched Emily work, and watched Nikolas watch Emily. She wondered if Sarah knew how close Nikolas had become with one of his fellow teen volunteers. Apparently, sometimes people did get what they deserved.
"Here," Emily said as she extended a pink flamingo with a black nose tip.
Rachel was genuinely impressed. "Thanks! This is actually pretty cool," she said. "So, how did you and Nikolas meet?" she asked.
Emily seemed a little taken aback. She glanced at Nikolas and then met Rachel's eyes again. "My parents are both physicians, so my sister Allison and I have been volunteering here for a few years," she said.
"Come on Rachel, why don't we check out some other stations," Chari suggested. But she also pushed the wheelchair away before Rachel had a chance to respond.
Rachel seethed internally. She hated it when people treated her like a child. It was one of many reasons she hated her mother!
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Amy Elizabeth Morgan laid more mini pumpkin buckets full of makeup on the table and then turned back to her administrative assistant turned friend, Danielle Ashley. "These really turned out so cute! Like I said before, you seriously should consider event planning," she said.
"Maybe…" Danielle said wistfully.
Amy internally debated whether she wanted to probe further. Sometimes she just wanted to be left alone so if that was Danielle's position, she wanted to respect it. On the other hand, she knew Danielle was going through a lot. "Is there anything you want to talk about?" she finally asked.
"I guess I was just a little thrown to see Dominique's memorial plaque outside the infant and toddler unit. Maybe I shouldn't have been, I know both Scott and Lucy mentioned that Dominique left an endowment to the hospital in her will," Danielle said.
"Yeah," Amy said. "I can see how that would be a lot to take in right now," she added.
Danielle just silently nodded.
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Melissa McKee Murdoch glanced at the clock. In another ten minutes, it would be seven o'clock. It looked like her shift would end before her patient returned from the OR. Was she meant to give report? Technically her patient spent a larger portion of her shift in the OR than in the SICU and theoretically the OR team should give report. So, did that mean she could just leave? Despite Amy's snide comments that it must be nice to have only one patient and then no patients she was exhausted. In the morning she literally had not had a chance to sit much less take a break. After Carly had departed with Dr. Meadows and the OR team around noon, she had looked around the chaos left behind and started cleaning and reorganizing.
Sixty minutes later she had finished that and completed the post-transfusion paperwork to send the used blood bags back to blood bank. Her charge nurse had taken pity on her and suggested she could take that back down to blood bank and go get lunch. But when she returned from lunch, there really wasn't anything more to do except focus on just how long Carly had been in the OR. That was more than a little ominous.
"I would say we could give report bedside, but we seem to be missing the bed," Mitch Harris quipped when he stepped into the room.
"Excuse me," Melissa said.
"Guess who got pulled from ER to SICU this evening, yeah, you're looking at him," Mitch said.
Melissa nodded. "Ok, so, I would try to give report, but my patient has been in the OR all but the first almost five hours of my twelve-hour shift so…"
"So basically, you're almost as clueless as Amy but with an actual legitimate reason?" Mitch asked.
Melissa wasn't sure if she was supposed to be offended by the comment. She would generally rebuke anyone who tried to lump her in with Amy Vining, but she was almost past a point of caring. Perhaps Mitch sensed that, or maybe her silence just made him uncomfortable.
"I'm sorry, I'm military and I generally work in the ED, so I have quite the gallows humor. Please don't be offended, or at least please don't report me because I have a lot of weekend plans in November and can't possibly make it to any of the professionalism remediation workshops," Mitch said.
She had heard that Amy Vining had also been required to attend some kind of professionalism training but had presumed that was just a joke. Apparently, it was a real thing, or maybe it was. "The hospital actually holds professionalism courses?" she asked.
"Technically courses are only available on a need-to-know basis. So, if you don't know they exist, then the powers that be think you're conducting yourself with at least a minimum of professional decorum, at least when they're watching," Mitch said.
Melissa laughed. "No offense, but that's a pretty low bar," she said.
"You could say that. Dr. Quartermaine said that I'm a bit of an acquired taste," Mitch said.
"Did Alan say this before or after he sent you to professionalism training?" Melissa asked.
Mitch pretended to pout. "The CMO and I aren't exactly on a first name basis, anyway, I was actually referring to Dr. Monica Quartermaine anyway. She likes me because I don't freak if she asks for a trauma cordis in the ED and then just floats her pacemaker through that."
Melissa nodded. "I see," she said.
"But seriously, you can just get out of here if you want to go. I'm sure I'll get some kind of bedside report along with my cooler of doom," Mitch said.
"What?" Melissa asked.
"They activated massive transfusion protocol in the OR, that rarely ends well, but it would be even more rare for it to end in the OR and the patient survive to come back to SICU," Mitch said.
Melissa gulped. "They activated a massive transfusion protocol in the OR?" she asked.
"That's what Mary said," Mitch said.
Mitch sounded far too nonchalant about all of it. Maybe it was an ED thing she just wouldn't understand. Melissa gulped again and then forced herself to release a deep breath. "Who is Mary?" she asked.
Mitch shook his head in disbelief. "Mary Briggs, you know, your nurse manager. Perhaps you should spend more time connecting with her than the Quartermaine Family," he said.
Melissa gulped again. Technically Mary wasn't her nurse manager because she wasn't really a SICU nurse, even if she kept getting pulled to work there. "If you must know, and apparently you must, Mary is no more my nurse manager than she is yours. Like you, I got pulled to work SICU so maybe, Mary should spend more time connecting with her nurses so they won't keep quitting and she won't keep having staffing struggles, and then I won't keep getting pulled to SICU so I won't have to spend all night or day trying to save my husband's best friend's wife's life and then have to go home and pretend everything is fine because HIPAA is a thing even if none of you ED people grasp that concept!" she ranted.
Then because she couldn't quite manage to make eye contact with Mitch after that major loss of control she just turned and fled the room. He had told her she didn't really need to give report, so she was going to take him up on it.
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Oh, Dominique, she is beautiful! Irene Stanton thought as she watched her great niece dance twirl to extend the butterfly wings of her costume while she waited as her younger cousin sunk every single bean bag on the first try.
"That is amazing! You know, I think that must be a new record!" Madeline Richmond exclaimed. Her voice was a mixture condescending praise if that was such a thing.
Dr. Monica Quartermaine seemed to process both pieces of the compliment. She wrapped an arm securely around the shoulders of her youngest daughter. "Thank you for helping with the children's party again this year, Madeline," she said.
Katelyn Quartermaine leaned back against her mother and looked up at her and then said. "Yes, thank you for helping. I love pumpkins!"
Then Dr. Quartermaine navigated away with her daughter and niece in tow and Irene could only look on longingly.
"I am so sorry. I know that must have just been so awkward, but you really handled it well. Between you and me, I just don't understand how she shows her face in public. If my brother did such things well, I would be mortified," Madeline prattled away.
"I suppose that everything happens for a reason," Irene said. Platitudes had their place, especially when she had no idea what Madeline was referring to. She had only figured out that she had been paired with Madeline Richmond who was apparently the wife of Earl Richmond, who had been Mayor of Port Charles from 1990-1994 because Madeline had only mentioned that ad nauseum since they had started manning the bean bag toss game. She still hadn't completely figured out who she was supposed to be. She presumed that Madeline was referring to Scott's recent arrest and she was pretty sure she didn't want to get started on that topic.
"That is really such a great perspective and I think that in the end the truth will really set your family free," Madeline said.
Irene nodded. If only that could be the case!
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Dr. Alan Quartermaine surveyed his work. He had managed to close the uterine incision over a mass of coagulated gel foam and now he was looking at another layer of coagulated gel foam overlaying everything. "I think this is as good as I'm going to do. We'll need to keep a close eye on the hemoglobin and clotting parameters and the nurses will need to measure pressures from the foley because she has a significant risk of abdominal compartment syndrome, but I feel like she has a chance," he said somberly.
"I agree, I'm on call tonight so I'll follow up on everything. Who is on tonight for trauma?" Dr. Meadows asked.
"Dr. Yank Tse Chung, and I'll update him before I leave but you can also just call me with questions. Unless she is grossly hemorrhaging around the packing, I would try not to disturb it for at least twenty-four hours," Alan said.
"I agree, I was planning on trying to delay until Sunday morning and then ideally just do a hysteroscopy and if it looked ok wash out and close skin then," Dr. Meadows said.
"That's what I would do. I really hope it works," Alan said. He did, except that was basically the understatement of at least the month and he was pretty sure Dr. Meadows was well aware of that.