How to mend a broken heart.

Posted on Fri Oct 12th, 2018 @ 2:43pm by Lieutenant JG Siobahn Fallon & Major Hailey Weston

Mission: https://wellington.pegasusfleet.site/index.php/sim/missions/id/5
Location: Trauma 2

Siobahn followed Hailey out of main sickbay, silent for the first moment, simply contemplating over the situation before she started speaking. "How bad is the aortic puncture? Has any medical history been taken at all?" There was a slight waver to her voice as she spoke, clearly from nerves. "Blood type? Anything that we should be made aware of?"

Hailey smiled slightly at the questions as the two of them followed the two nurses quickly towards the operating room, completely unaware of the red splash that adorned her uniform jacket, "No medical history, as far as I'm aware, she's unconscious, last name of Setine. When in doubt, we're going to use O-negative blood, universal and all." She noticed Eries give a direction, then leave the room while the male nurse kept the pressure on the wound, "How bad is it? Bad. That kid that was holding the pressure on her kept her alive." She reached for the white surgical jacket on the wall and slipped it on, "We'll know more shortly... Can you check her eyes, see how reactive they are, breathing, pulse rate?" She also decided this would be a teaching moment.

Retrieving a small light from her pocket, Siobahn walked around the bed, moving behind Hailey toward the head of the bio bed, her gaze falling to the face of their patient for the first time. Gasping with recognition, Siobahn felt the light fall from her fingers, hitting the deck with a thunk, all colour draining from her face as she took a step backward. "Is this some kind of sick joke?" she asked, her voice shaking as she looked across at Hailey.

Hailey glanced up briefly, then for another couple seconds before her voice came out, gentle but with the firmness of command, “This isn’t a joke, Doctor Fallon,” she glanced at the face, it was familiar but she couldn’t place it, “That woman there is in a really bad way and it’s our job to make sure she comes out of it alive. Put whatever you feel for her out of your head, because that can only hurt the situation.” She ran a sterilizer over her hands twice each, “Evaluate her eyes, we need to know if they’re fully reactive, sluggish or not at all, please.”

Swallowing back a wave of nausea and blinking back tears, Siobahn leaned down, picking up the light and moving back to the bio bed again. "It's Renee," she murmured quietly, referring to the woman who had basically become her closest friend aboard the ship, excluding Hailey. She gulped again, putting one hand on Renee's clammy face. "Her body temperature is lower than I would have expected," she commented quietly. "Her optical reflexes are extremely sluggish and her pupils are enlarged." she pocketed the light quickly. "Her heart rate is incredibly low, and her blood pressure is dropping." Siobahn glanced up, her eyes widening again. "I think she's going into shock...." without waiting for Hailey to respond, she turned to the nurse standing next to her. "Replicate warm blankets and cover any part of her body that doesn't need to be exposed for surgery. Cover her lower body and the top of her head and increase the ambient temperature in the room to ninety eight degrees." She looked across to Hailey, still trying to remain composed. "Slightly warmed IV saline and a blood transfusion will help but surgery will need to be quick. Renee is AB Negative. I know. If she needs plasma and blood she is going to need type specific."

Even while Siobahn was talking, as soon as Hailey heard the eye reaction and then the additional heart rate and blood pressure, she'd grabbed a pair of surgical scissors and ran them down the uniform front, cutting it away completely, "We're going to need three units, push one into her and drip the other two." Her movements were very quick, but with extreme confidence. She removed the bandage again and this time instead of a spurt of blood, it was just dribbling out. "Margo, scalpel." Her hand reached out and the female nurse that had come in after Eries had left handed her the scalpel, "I'm sorry, Doctor, I was going to let you be the primary hands in the field, but this needs to be done a bit quicker than I'd anticipated." She positioned the scalpel over where the heart lay, "We are going to be relieving the pressure by slicing into the pericardial sac, which if I'm right, is applying pressure to the heart. This should help the heart rate and blood pressure, but we are going to need blood in her quickly." She cut deep and precisely between a pair of ribs and the sternum, not having time to do a proper cracking of the chest. Blood sprayed from the new wound as it sought to equalize the pressure between the outside and the inside. The slight smile on Hailey's face belied the carnage, but it had been what she'd expected to have happen.

Siobahn cringed slightly, not from the action, but more so from the fact that this was her friend that was literally bleeding out in front of her. Instead she tried to turn her mind to something useful, like calculating the optimum rate for a full platelet transfusion for Renee. "Run the transfusion at 300ml per hour," she ordered. When the nurse beside her hesitated, Siobahn turned toward her. "Do it!" she ordered sharply before turning back to Hailey as she took a cloth and used it to cover the new wound, just long enough to stop it from spraying. "Her blood pressure is still dropping," she said quietly.

"It's all right." Hailey said just as quietly, reaching up and triggering the display for the surgical bed, smearing the panel with blood, then snagged an additional IV line and expertly inserting it into the crook of the elbow, speaking at the male nurse, "Eric, squeeze a unit of whole blood, add saline to the drip." Then she pointed up at the display that had performed a full scan, "We've got a big piece of shrapnel right there, it's still in the artery.." She reached to the instrument tray and grabbed the laser scalpel that was used when they needed to get into the chest cavity, "Doctor, we're going to open her up completely, but very carefully. If that piece of metal moves too much, it'll rip the aorta wide open." She ran the scalpel down the center of the patient's chest then also to each sides before grabbing the extractors to allow them to actually see into the cavity, "We need suction, there's a lot of blood in here. There's something else going on besides that shrapnel, there's too much.."

Siobahn paused for a moment, squeezing her eyes closed and sucking in a sharp, deep breath. Was she really going to do this? "Renee has implants," she finally said quietly. "Some subdural, some subcutaneous, and some intravenous. Would that be affecting things?" She looked across at Hailey, silently willing the other woman not to ask questions but just to accept the fortitude it was that Siobahn had been involved in this procedure.

Hands pausing for a few moments, Hailey considered, "Are any of them in the chest or abdominal area that you know of?"

Siobahn closed her eyes for a moment, trying to recall the implants Renee had talked about. "I can't remember... I know she has one optical, and I think two in her hand... I can't remember any others."

The senior doctor paused for all of two seconds, then continued on her movements, "Eric, I need that cavity cleared of blood absolutely right now." Her hands kept wiping away the area around the heart, then clamped off the artery leading to the breakage, "Forceps." She said to Margo, then handed them over to Siobahn, "Doctor, I'm going to hold this open right here, I need you to very, very carefully extract that shrapnel. After that, start looking for other bleed points from the bottom up, try to at least find the general area of it, then probe deeper." She reached out and grabbed a patch of essentially synthetic sterile flesh about three layers thick, it wouldn't hold the area for long, but she only needed a few minutes of veinous integrity for the moment and it would suffice.

Nodding slowly, Siobahn took the forceps and followed the instructions as they were given, carefully maneuvering the first piece of shrapnel out and dropping it on the tray beside her. "There's extensive damage to the artery surrounding the area," she said quietly. "The shrapnel mangled everything... hang on..." She paused, handing the forceps back to Margo to hold. "I think there's something else here... it's small... really small..."

Hailey took a look at the shrapnel, then at the damaged site and nodded, making a mental note as she carefully wrapped her temporary 'bandage' around the ragged artery, then slowly released the clamp, watching for leakage and seeing none, changed her focus to where Siobahn was inspecting, "Blood pressure?"

Margo, who had set down the forceps and picked another set up in preparation, looked up, "Still low, but holding.. Pulse is rapid."

The Major nodded, "I have about an hour before I have to go back to that... What is that?" She spotted what Siobahn had, but couldn't ID it. "Could that be one of the implants you were talking about?"

Siobahn shook her head again. "No, it's not like any of her implants I've ever seen, it doesn't even look technological... Do we know what exploded to cause the damage?"

Hailey actually barked a brief laugh, "You know as much as I do." She took the forceps from Margo and slowly reached in, took a firm grasp of whatever it was and gently eased it out. A rush of blood followed it, then began to peter out, "Can you stitch that up, Doctor? I don't think it's anything critical, this just kept it active." She looked at the object, then placed it in a separate pan.

With a nod, Siobahn ran the stitches quickly and easily before pausing to assess the wounds again, looking for anything that they might be missing.

"That's it." Hailey murmured, "I'm seeing a pair of small cuts, but I'm not worried about those. We can get some antibiotic foam inserted in there to prevent infection, but those'll heal better on their own than if we mess around with them. All right, Doctor Fallon, let's take a look at the heart, why don't we?" She brought their attention back up, "Do a scan of the aortal damage and tell me what you see." Now came the tricky part, but there was some time at least and it was time to do a bit of teaching.

Scanning as instructed, Siobahn shook her head slightly. "The aorta itself sustained serious damage, but it also looks like the left ventricle has also been damaged, which would be what is lowering her blood pressure and affecting her oxygen saturations?" Siobahn paused and looked across at Hailey, uncertainly. "The pericardium has also been damaged, probably by the shrapnel, and from the uneven beat of the heart I'd guess it's probable that she's also sustained nerve damage."

Hailey took a look at the readings on the left ventricle very closely for a few seconds, then nodded, "Good catch and I do think I agree. I think the damage to the ventricle is causing all of the problems, including the uneven heartbeat, but I think we can put that on the back burner for the moment. The pericardium will be an easy fix, so that's not a worry. So let's worry about the aorta." Hailey smiled as she used some sterile water to wash the site clear, "Doctor Fallon, why can't we just regenerate the aortal artery and call it a day?" She did feel like being a teacher today and well, there was nothing Siobahn could do as a mistake that she couldn't fix in this lovely room.

"It wouldn't be strong enough to withstand the constant changes in the blood pressure, especially so close to the ventricle," Siobahn answered quietly. "Any regenerated tissue would be more likely to burst under the pressure until it's fully healed. The risks would go up every time she undertook any kind of physical activity, even just walking, and if it burst she would likely bleed out before anyone even realised what was going on." She sucked in a sharp breath and shook her head quickly. It still felt so surreal that she was standing there talking about her friend in such a clinical manner.

“Excellent. So what we are going to do is take about five inches from the posterior tibial vein, which we can regenerate immediately without a detrimental effect, and use that as a reinforcement sheath on the outside of a regenerating artery. As the artery regenerates, it will absorb the tissue without worrying about a tissue rejection, since it’s her own, and she can resume reduced but standard duties as she recovers.” A reassuring smile to Siobahn, “And you are going to perform the transplant, Doctor Fallon.” She stepped down once and cut away the bottom of the trousers.

"I can't, I have no idea what I'm doing!" Siobahn protested. "I'm not a surgeon!"

“All the best reason to learn, then. You did have a year of surgical in the Academy, didn’t you?” Hailey asked.

Siobahn shook her head quickly. "I only did 3 months..." She hesitated for a moment before explaining. "I was three months into surgical when my family died, I took time off after and then did alternate extra credit work to make up the grade difference."

Hailey nodded somberly, “Them you really do need the experience. While it probably won’t be a major part of your duties, you need to know how to do surgery and hands on experience is the best teacher. Don’t worry, I’m right here to help you and to answer any question. Also, we have this lovely surgical suite, so if anything goes wrong, I’m not in my normal conditions out in the field to try to keep her together. Barring stabbing her in the brain, there really isn’t anything you can do right now that I can’t fix, I promise.”

"Okay," Siobahn said quietly. "I can do this..." She drew in a deep breath and nodded, almost as though she were reassuring herself. "Where do we start?"

Hailey gestured towards the heart, “You are going to need to put her heart into arrest so we can handle the artery, so work with Margo to get the bypass affixed to the right area while Eric and I excise the portion of the vein you are going to need.”

"Margo, start with two iv infusions, one with lidocaine and one with adenosine," Siobahn said, her voice sounding surprisingly calm, something she definitely did not feel. "We'll run both simultaneously. We'll also need a hypospray of each. Set the IV infusion rate initially at 5cc and we'll do a 5cc push to actually stop her heart." As Margo stepped away to get the drugs ready, Siobahn reached down and brushed a stray blonde curl from Renee's face. "I'm sorry," she whispered softly.

Down near the ankle, Hailey motioned Eric to the other side of the operating table and expertly began to open the site, quickly laying the area open and clamping off the blood flow and cutting the posterior tibial vein out in the precise length that would be needed. "All right Eric, go ahead and begin the regeneration of this one, then gradually release the clamps and allow the bloodflow to normalize." He nodded at her and she brought the tube up to the primary site on a sterile tray, "Whenever you're ready, Doctor."

Taking a deep breath, Siobahn nodded slowly and deliberately. "Alright, let's get this done."

LATER:

The surgery had been completed, and at least so far appeared to be successful. Blood loss had been contained and blood flow through the aorta was holding steady, though Renee was still heavily sedated to allow her body more time to heal. It would be a good twelve hours at least before they would even consider dialing back on the sedation. Even though there was a perfectly competent team of nurses who were able to monitor Renee's condition closely, Siobahn had made the decision to remain with her herself, watching the machines that recorded her vitals. At least for the moment, there was no place more important for her to be.

OFF:

Major Hailey Weston
Marine CO/Second Officer
USS Wellington

Ensign Siobahn Fallon
Medical Officer
USS Wellington