The Grind: Chapter 17
📊 Global Attending Consensus
The team voted to: Hayley delegates Bed 2's cardioversion entirely to Daniel, while she and Mitch aggressively push Clevidipine and Fentanyl on Bed 3 to break the sympathetic surge before attempting CT transport.
"Sync and shock, Farmboy. Do not press that button unless the sync flag is active!" Hayley barks, instantly pivoting away from the electrical burn in Bed 2. She and Mitch descend on the screaming 65-year-old in Bed 3. The man's aorta is actively unzipping, his arterial line reading a catastrophic 210/110. "Donna, hit him with a hundred mics of Fentanyl to break the sympathetic drive," Mitch orders, grabbing the Clevidipine emulsion. "Starting Clevidipine at two milligrams an hour. We need his systolic under one-twenty yesterday." The opioid sledgehammer hits, silencing the patient's agonizing screams. As the calcium channel blocker rapidly dilates his arterioles, the monitor's red waveform steadily drops: 180, 150, and finally settling at a beautiful 115/65. "He's packaged. I'm taking him to the doughnut of death," Mitch announces, unlocking Bed 3 and physically rolling the temporized dissection out the double doors toward CT.
Across the trauma pod, Daniel stands entirely alone at Bed 2. The lineman's V-Tach is a lethal, wide-complex blur at 210 beats per minute. Daniel’s massive Nebraska hands hover over the defibrillator. He forces himself to breathe, pressing the 'Sync' button. White markers immediately appear above each R-wave on the monitor. "Charging to two-hundred joules!" Daniel shouts, his voice cracking slightly. "Clear!" He hits the shock button. The lineman's body violently jolts against the restraints. The monitor flatlines for one agonizing, endless second before a jagged, but narrow, sinus tachycardia appears. Heart rate 110. Blood pressure 95/60. Daniel exhales a breath he didn't know he was holding and carefully hangs a 150mg Amiodarone drip to infuse over ten minutes. "Nice work, Nebraska," Donna mutters, sweeping up the shattered safety glass near Bed 1 as the vascular team arrives to whisk the temporized cathinone overdose up to the OR.
With Beds 1 and 3 suddenly empty, a rare, fleeting wind-off settles over the pod. Hayley leans heavily against the nurses' station, sipping a lukewarm coffee Lupe silently slid across the desk. "Two empty beds. That's practically a vacation in this hellhole," Hayley says dryly. Daniel is gingerly rubbing the bruised collarbone he sustained from the psych patient's headbutt. "Does hospital security cover chiropractic bills?" he asks, wincing. "Only if you can prove the patient had good form," Donna deadpans. The quiet is instantly shattered by a psychiatric patient in the hallway violently screaming at a vending machine, a stark reminder of the 85 patients still overflowing the waiting room.
The EMS radio shrieks, cutting the banter dead. "Medic 9. Priority One. Twenty-five-year-old male, impaled by a wrought-iron fence post through the right upper quadrant. We had to use the jaws of life to cut the fence. Two feet of iron pipe protruding anteriorly and posteriorly. Awake, but the pipe is physically pulsating." The ambulance doors blow open. The patient is ghost-pale and hyperventilating. The heavy, rusted iron post is wedged deep in his abdomen, and with every single beat of his heart, the metal visibly ticks like a metronome. Dr. Elena Garza steps into the bay, takes one look at the massive pipe, and shakes her head. "He won't fit in the CT scanner with two feet of iron sticking out of him. And I am not doing a blind ex-lap without knowing if that pipe is the only thing plugging his vena cava." The metal ticks again. The trauma bay is deadlocked.
Across the trauma pod, Daniel stands entirely alone at Bed 2. The lineman's V-Tach is a lethal, wide-complex blur at 210 beats per minute. Daniel’s massive Nebraska hands hover over the defibrillator. He forces himself to breathe, pressing the 'Sync' button. White markers immediately appear above each R-wave on the monitor. "Charging to two-hundred joules!" Daniel shouts, his voice cracking slightly. "Clear!" He hits the shock button. The lineman's body violently jolts against the restraints. The monitor flatlines for one agonizing, endless second before a jagged, but narrow, sinus tachycardia appears. Heart rate 110. Blood pressure 95/60. Daniel exhales a breath he didn't know he was holding and carefully hangs a 150mg Amiodarone drip to infuse over ten minutes. "Nice work, Nebraska," Donna mutters, sweeping up the shattered safety glass near Bed 1 as the vascular team arrives to whisk the temporized cathinone overdose up to the OR.
With Beds 1 and 3 suddenly empty, a rare, fleeting wind-off settles over the pod. Hayley leans heavily against the nurses' station, sipping a lukewarm coffee Lupe silently slid across the desk. "Two empty beds. That's practically a vacation in this hellhole," Hayley says dryly. Daniel is gingerly rubbing the bruised collarbone he sustained from the psych patient's headbutt. "Does hospital security cover chiropractic bills?" he asks, wincing. "Only if you can prove the patient had good form," Donna deadpans. The quiet is instantly shattered by a psychiatric patient in the hallway violently screaming at a vending machine, a stark reminder of the 85 patients still overflowing the waiting room.
The EMS radio shrieks, cutting the banter dead. "Medic 9. Priority One. Twenty-five-year-old male, impaled by a wrought-iron fence post through the right upper quadrant. We had to use the jaws of life to cut the fence. Two feet of iron pipe protruding anteriorly and posteriorly. Awake, but the pipe is physically pulsating." The ambulance doors blow open. The patient is ghost-pale and hyperventilating. The heavy, rusted iron post is wedged deep in his abdomen, and with every single beat of his heart, the metal visibly ticks like a metronome. Dr. Elena Garza steps into the bay, takes one look at the massive pipe, and shakes her head. "He won't fit in the CT scanner with two feet of iron sticking out of him. And I am not doing a blind ex-lap without knowing if that pipe is the only thing plugging his vena cava." The metal ticks again. The trauma bay is deadlocked.
What are your orders, Doctor?
Call the heavy rescue fire squad to use a reciprocating saw to cut the pipe down in the trauma bay so he fits in the CT scanner, accepting the massive risk that the intense vibrations will shear his aorta.
Execute Option 1Hayley aggressively fights Garza, demanding they bypass the CT scanner and take him straight to the OR for a blind exploratory laparotomy, risking uncontrollable hemorrhage once the pipe is removed without a roadmap.
Execute Option 2Hayley and Daniel deploy a Zone 1 REBOA in the ER to proactively clamp the descending aorta before anyone touches the pipe, buying Garza a bloodless field but starting a strict 30-minute ischemic clock.
Execute Option 3