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Chapter 7


Dr. Peter Benton, third-year surgical resident, was both respected and feared by his colleagues at County General. Talented, ambitious, and hard-working, he took his career seriously - perhaps a bit too seriously. His job was important, no doubt; whether he was in the emergency room or the operating room, he often dealt with matters of life and death. But despite the demands of their work, the other doctors managed to laugh or at least smile once in a while. John Carter wished Benton would lighten up just a little. It would make working under him so much more pleasant.

John - or just “Carter,” as he had come to be called - had been assigned to Dr. Benton for his first clinical rotation of medical school in the County General ER. Now a fourth-year med student, Carter was back at County and working with Benton once again as he completed his highly-coveted surgical sub-internship. He’d gotten off to a rough start this rotation, but after surviving a disastrous first day, during which he had arrived two hours late and fainted in the middle of a trauma, he finally felt like he was back on track. It was hard to tell with Benton, who wasn’t big on giving feedback. Carter had come to accept the fact that he would never get accolades from his mentor. Anytime he made it through a full day without getting chewed out for one mistake or another, he considered it an accomplishment.

Carter was off to a good start that day. He had made it to the hospital on time for morning rounds and answered most of his resident’s questions right for once. Having just helped rule out a ruptured appendix in a woman with acute abdominal pain (correct diagnosis: a bad case of constipation), he and Benton were about to head back upstairs to the OR when they heard a voice shouting, “Dr. Benton, wait!”

Both men turned around to see Harper Tracy running up the hallway toward them. Carter couldn’t help but smile at the sight of the pretty blonde med student, whom he’d had a crush on ever since he had met her on her first day at County.

“Dr. Benton,” Harper said breathlessly. “Dr. Ross needs you in Trauma 2 right now for an unstable kid.”

“We’re on our way,” replied Benton without hesitation. “C’mon, Carter.”

Carter couldn’t believe his good luck. First he had gotten out of having to disimpact the constipated patient - which was exactly the kind of procedure Benton would have expected him to do during his ER rotation - and now, he was on his way to what promised to be a more interesting case. His heart bounded in his chest as he and Benton hurried after Harper to the trauma room, where doctors Ross and Lewis were hovered over a teenage boy with blond hair.

Nurse Carol Hathaway quickly brought them up to speed. “Nick Carter, fifteen, restrained backseat passenger in the MVA on the bridge. He was stable at the scene - no visible injuries, complaints, or LOC - but he collapsed and lost consciousness about an hour after he was brought in.”

Ross joined them in the corner of the room. “He’s showing all the signs of hypovolemic shock secondary to an abdominal bleed,” he said in hushed tones, so the kid couldn’t hear him. “He’s tachy and hypotensive, and his belly’s distended and tender with rebound pain and guarding upon examination. Labs aren’t back yet, but bedside ultrasound showed free fluid in the abdomen.”

Benton nodded. “Sounds like you’ve already made a diagnosis.” Nevertheless, he pulled on a pair of gloves as he approached the bed to examine the patient himself. “Hi, I’m Dr. Benton,” he introduced himself briefly before he began poking and prodding at the boy’s belly.

Carter hadn’t realized the patient was conscious, but when he heard the poor kid cry out, he hurried to the head of the bed. “Hi,” he said, giving the boy a sympathetic smile as he bent over him. “Your last name’s Carter?”

The boy nodded, his blue eyes appearing bleary and unfocused behind the fog of pain.

“What a coincidence - mine, too!” He gestured to the blue name badge pinned above the breast pocket of his white coat. “John Carter.”

A weak smile crossed the kid’s pale face. “Nick.”

Carter nodded. “Nice to meet you, Nick,” he said with a grin. “We’re gonna take great care of you.”

“You’re right; he’s gonna need surgery,” he heard Benton tell Ross. “Notify the OR; tell them to book a room for an emergency ex-lap.”

“Surgery?” Nick repeated, his eyes widening. “Right now?”

Carter nodded again. “The accident caused some bleeding inside your belly. We need to repair it before it gets worse. Unfortunately, that requires an operation called a laparotomy,” he explained. “I know that sounds scary, but you’re in good hands. Dr. Benton here is one of our best surgeons. He’s gonna fix you right up and get you feeling better.”

“Where are the parents?” Benton wanted to know.

“Nick, honey, is your family here in Chicago?” asked Carol.

Nick shook his head, tears welling in his eyes. “They’re back home in Tampa with my little brother and sisters,” he replied miserably.

“Who’s responsible for you when you’re out on the road?”

“I dunno… I guess Denise? AJ’s mom.”

“Denise McLean?” asked Dr. Ross, as he hung up the phone. Nick nodded. “She’s the mother of my other patient,” the pediatrician told the others. “I’ll go talk to her and see if she can help us reach his folks.”

Upon hearing that, Carter’s heart went out to the kid. He hadn’t realized he was so far from home, but could relate to having parents who always seemed to be someplace else. “It’s gonna be okay, Nick,” he tried to reassure him, as he helped roll the boy’s bed out of the room. “I’ll be right here with you the whole time. Isn’t that right, Dr. Benton?” Across the gurney, he caught his mentor’s eye and raised his brows, begging for silent permission to scrub in for the surgery. Benton stared at him for a second, seeming to consider his request, then gave a brief nod. Carter couldn’t help but grin. His day just kept getting better and better.

In the scrub room, they were joined by Dr. Angela Hicks, the surgical attending who would be overseeing Nick’s operation. “Care to catch me up to speed?” she asked, as she worked the antibacterial scrub solution into a thick lather to begin the lengthy process of washing and decontaminating her hands.

“Patient is a fifteen-year-old male who sustained a seatbelt injury in an MVA this morning,” Benton began in his usual, matter-of-fact manner, as he meticulously scrubbed each finger with a brush. “His condition was initially stable, but decompensated in the ER.”

“His name’s Nick,” Carter added, using a nail pick to clean beneath his fingernails, “and he’s pretty scared. From what I understood, he’s from out of town; his parents are in Florida.”

Benton gave his student a long look before continuing, as if he hadn’t spoken, “Upon examination, the belly was distended, rigid, and tender with decreased bowel sounds, and the abdominal ultrasound showed free fluid in the left upper quadrant.”

“Did you get a CT scan?” Hicks wanted to know.

“No. I wasn’t comfortable waiting for a CT with as unstable as the patient’s pressure was,” Benton answered coolly. Carter paused his scrubbing, waiting to hear if his mentor was about to be reprimanded for this decision, but Dr. Hicks simply nodded.

“Hence the need for an emergency ex-lap,” she concurred. “Mr. Carter, what kind of injuries should we be looking for based on the ultrasound findings?”

Caught off-guard by the question, Carter’s mind began to race, trying to remember which organs were located in the left upper quadrant. “Um… something involving the spleen?”

To his relief, Hicks gave another nod. “A splenic laceration is the most likely cause of blood in the upper left quadrant, but it’s not the only possibility. We’ll also need to carefully examine the left kidney, along with the diaphragm, bowel, bladder, and surrounding anatomy, as blood from an isolated injury to one of those areas tends to collect in the upper left quadrant.”

“Sounds like a plan,” said Carter, trying to sound confident as he continued to scrub. Based on his previous experiences in the OR, he would probably be doing more observing than actual assisting, but if he continued on the surgical path, there would come a day when he had to know all this stuff himself. It was a lot to remember.

When he was fully gowned up and sterile, he followed Hicks and Benton into the operating room, where their patient was prepped, but still awake.

“Hi, Nick,” Carter said when he saw that the boy’s blue eyes were open. He smiled automatically before he remembered he was wearing a surgical mask over his mouth and nose.

Nick blinked, and the cloud of sleepiness in his eyes cleared momentarily when he recognized the face behind the mask. “Hi, Dr. Carter,” he replied faintly. Beneath the bright fluorescent light, his own face looked ghostly white.

In spite of the concern he felt for his patient, Carter couldn’t help but smile at being called “Doctor.” He didn’t bother to correct him. “How are you feeling?” he asked instead.

“C-cold.” Lying unclothed on the hard surgical table, the poor kid was shivering violently beneath the thin sheet that covered him. They always kept the air in the OR cool, but Carter suspected the combination of shock and nerves were contributing to his body’s reaction.

Carter gave a sympathetic nod. “It’s chilly in here, I know.” Looking around, he spotted the scrub nurse, Shirley. “Can we get him a blanket or something?” he asked her.

“We’re about to put him under,” the anesthesiologist, Dr. Babcock, answered brusquely before the nurse could. “He’ll be fine.”

Carter frowned beneath his mask. He wished he could hold the boy’s hand or brush back his hair, anything to bring him some comfort while he was still conscious, but he knew he couldn’t touch him while he was sterile. If he contaminated his gloves, he would have to go back into the scrub room and start the sterilization process all over again. Then he would miss the beginning of the surgery, and Benton would be annoyed with him. So he held back, hoping he could comfort the kid with words instead. “Hang in there, Nick,” he said. “We’re gonna give you some medicine to make you fall asleep. In a few minutes, you won’t feel a thing.”

Nick nodded, his Adam’s apple bobbing in his throat as he swallowed hard. “What if I don’t wake up?” he asked in a whisper, fear flickering in his blue eyes.

“Don’t you worry about that,” Carter tried to reassure him. “We’ll get you through this, Nick. You’re gonna be just fine.” In the back of his mind, he knew he shouldn’t make any promises - no procedure was without risks, and emergency surgeries such as this could be especially perilous - but now wasn’t the time to talk about potential complications. He wanted his young patient to feel as calm as possible in his last moments of consciousness.

“All right, Mr. Carter,” said Dr. Babcock. Carter looked up instinctively, only to realize he was talking to Nick, not him. “You’re gonna feel yourself getting sleepy now.” As he spoke, the anesthesiologist pushed down the plunger on the syringe in his hand, slowly dispensing a dose of sedative into Nick’s IV line. “I want you to slowly count backwards from ten for me. I doubt you’ll make it to one. When you wake up, it’ll all be over.”

Nick nodded, taking a deep breath before he began to count. “Ten… nine…” On seven, his speech started to slur, and by four, his eyelids were drooping. His tongue tried to form the word “three,” but failed, his mouth falling open as he faded into unconsciousness.

“He’s out. Get ready to intubate,” Babcock told the respiratory therapist, as he prepared to administer the paralytic.

Carter took a step back, giving the respiratory therapist room to insert a breathing tube. “What should I do, Dr. Benton?” he asked his mentor, hoping to be assigned an interesting task this time. He was tired of just watching, but knew better than to complain. Benton could be vindictive; he had once punished Carter for being late by forcing him to hold up a patient’s heavy arm for the duration of an operation, even though the OR had a perfectly good pulley system that could have served the same purpose.

“You can suction for me,” said Benton, as he took his place on one side of the table, across from Dr. Hicks.

Carter was delighted. Being responsible for sucking the excess blood and fluids out of the surgical field would put him right in the center of all the action. Besides, it looked like fun.

The nurses finished creating a sterile field by pulling back the sheet to expose the patient’s body, placing blue surgical drapes around his abdomen, and painting his bare skin with antiseptic.

“Ten blade, please, Shirley,” said Benton, and the scrub nurse promptly handed him the scalpel. “I’ll begin by making an upper midline incision.” He ran the blade smoothly down the center of Nick’s torso from the bottom of his sternum to just above his navel. As he deepened the incision, dissecting through layers of subcutaneous fat to reach the lining of the abdominal cavity, he continued to narrate each step of the procedure for both his student’s benefit and his boss’s approval. “Now I’ll enter the peritoneum...”

“Be careful that you don’t cut too deep and injure the intraperitoneal contents,” Dr. Hicks warned, keeping a watchful eye on her resident as he made a small and shallow incision in the thin membrane surrounding the abdominal organs. Immediately, blood began to bubble up through the opening, as a foul smell filled the operating room.

“Damn,” Benton swore. “Suction!”

Carter’s stomach churned as he swept the suction wand over the incision to suck up the blood. It seemed to be coming out as quickly as he could clear it away. “Did you nick an artery?” he asked, his heartbeat accelerating.

“No, Carter, I didn’t nick anything,” Benton replied defensively, as he cut a wider opening to get a better look at the organs within. “His belly’s full of blood.”

“Probably a perfed bowel. Janet, hang another four units of type specific on the rapid infuser,” Hicks said to the circulating nurse. “We don’t want him bleeding out.”

“Turn up the suction,” Benton snapped at Carter, as the nurse hurried to transfuse more blood. “I can’t see a damn thing in here. Lap pads, please.”

Carter did his best to keep up with the suctioning while Hicks helped Benton pack the patient’s abdominal cavity with absorbent gauze pads so they could locate the source of the bleeding. All of a sudden, a torrent of bright red blood spurted out of the opening, spattering the front of Carter’s surgical gown.

“We got a pumper!” cried Benton, as Carter instinctively jumped back out of the way. “Carter - suction!”

Swallowing hard, the med student forced himself to take a step forward. He fought against his nausea as he stuck the suction wand back into the boy’s belly, trying to clear away as much of the blood as he could so the surgeons could see where it was coming from.

In the background, he could hear one of the monitors issue a high-pitched alarm. “His pressure’s crashing,” the anesthesiologist warned them.

Benton shook his head, looking down in dismay. “He’s losing blood faster than we can give it to him.” Carter’s heart sank as he watched Nick’s abdominal cavity refill with blood, despite his best efforts to keep up with the suctioning.

“He must have blown a clot,” said Hicks. “Could be a mesenteric rupture. Cross-clamp the aorta.”

Carter knew this was a risky move; it meant cutting off circulation to the lower half of the kid’s body, which could result in dead tissue and permanent damage. But it was a necessary risk: if they didn’t take drastic measures to stop the flow of blood, Nick would hemorrhage to death before the two surgeons could repair the tear in his artery. Either way, they were in a race against time now.

“He’s bradying down,” said Babcock, as Nick’s heart rate dropped.

“I need more suction!” barked Benton as he bent over the operating table, his blood-soaked hands buried in the boy’s abdomen.

“I’m trying, but it’s turned up as high as it will go!” Carter insisted, making another sweep with the suction wand.

“We’ve lost his pulse!” Babcock cried, as the beeping of the cardiac monitor slowed. “He’s in PEA.” Another alarm sounded, and suddenly, the separate blips were replaced by one long, continuous whine. Carter glanced up to see the waveform flatline as Nick’s heart stopped. “No, asystole.”

“Aorta’s clamped. Carter, start CPR,” Benton ordered, catching his student off-guard.

“But I’m sterile,” Carter started to protest, holding up his gloved hands.

“That doesn’t matter anymore. If we don’t keep his heart pumping, the kid’s dead anyway. He needs external cardiac massage - now!”

Carter hesitated only a second before he handed the suction wand to Dr. Hicks and scrambled up onto the footstool the circulating nurse had placed next to the operating table. He bent over Nick’s body, positioned his hands between the boy’s nipples, and began chest compressions.

“Run in two more liters of type-specific,” Dr. Hicks said over the loud rattle of the suction system. “We need to get his blood volume back up before we can restore a heartbeat.” Carter marveled over how she managed to remain so calm and collected while a kid was dying on the operating table right in front of her. He supposed that was what made her such a successful and well-respected surgeon. His own mind was racing, but he tried to concentrate on the rhythm of his compressions and block out the rest.

“Hang on, Nick,” he chanted, as he pumped the patient’s chest. Sweat poured from his brow, and his breath came in short bursts behind his mask. He could already feel his arms getting tired, but he pushed through the fatigue. Against his better judgment, he had all but promised this poor boy he was going to be fine, and he was determined to fulfill that promise.

“Looks like you were right, Dr. Hicks,” he heard Benton say in the background. “There’s a small laceration in his superior mesenteric artery.” This was the vessel that supplied blood to the lower gastrointestinal tract, Carter recalled from his anatomy classes.

“Tie it off so we can unclamp the aorta before we begin the repair,” Hicks advised. “Remember, time is tissue.”

“The rapid infuser’s finished, Dr. Hicks,” said the nurse who was handling the transfusion. “Do you want any drugs or more blood?”

Dr. Hicks looked up at the clock. “How long has he been down?”

“Almost two minutes.”

“Let’s try an amp of epi,” said the attending. “Will someone please take over CPR for Mr. Carter?”

“No, I’m okay,” Carter replied breathlessly, as he kept pumping. “I can go another round.” The muscles in his arms and back were screaming for a break from the constant pushing motion in a bent over position, but he wasn’t ready to stop.

“Suit yourself,” she replied. “Let us know when you get too tired to maintain high-quality compressions, and one of us will trade places with you.”

Carter nodded, hoping their patient’s heart would be beating again before he got too tired to continue. He was just a kid… a kid who had been awake and talking only half an hour ago. Carter could still see the look in his eyes when he had asked, “What if I don’t wake up?”

“Don’t you worry about that,” he heard his own casual, almost cavalier response. “We’ll get you through this, Nick. You’re gonna be just fine.”

“C’mon, Nick,” he murmured, his breath catching in his throat. “Stay with us.” He went on massaging the boy’s heart, while Hicks and Benton worked frantically to restore blood flow to his bowels.

After what felt like forever, he heard the circulating nurse say, “It’s been two minutes since the last epi. Let’s pause for a pulse check.”

Carter straightened up, his arms burning, his lower back aching, and looked automatically at the cardiac monitor. To his relief, he saw the line rise and fall… then rise again - a near perfect waveform.

“We have a beat,” Babcock announced triumphantly. “Looks like a normal sinus rhythm.”

“I feel a faint radial pulse,” the nurse confirmed as she palpated Nick’s wrist. “BP is ninety over sixty-five and rising.”

“Nice save, everyone,” said Dr. Hicks. Her brown eyes crinkled at the corners as she looked around the operating room, acknowledging each member of the surgical team. “We got him back. Now we just need to maintain his pressure and preserve as much of his bowel as we can - right, Dr. Benton?”

“Mm-hm,” replied Benton without bothering to look up, his hands still busy inside Nick’s belly.

Carter stepped down from the footstool on shaky legs and let out his breath in a long sigh. He felt like he had just finished a marathon, yet the surgery was far from over. “You think he’s gonna pull through?” he asked, looking over his mentor’s shoulder.

“I can’t make any promises,” muttered Benton. He didn’t sound overly optimistic, but then, he wasn’t exactly known for his upbeat personality. Perhaps he realized this because, after a moment, he added, “But I think he probably will, thanks to you.”

Carter blinked in surprise. “Me?”

Benton glanced up. “You kept his blood pumping, didn’t you? And you didn’t panic or pass out this time - that’s progress. Good work, Carter.”

Taken aback by this rare compliment, Carter hardly knew how to respond. “Thanks,” he finally managed to say. Behind his mask, he couldn’t help but smile.

***

Chapter End Notes:
Full disclosure - I made this chapter much more dramatic than it was originally planned to be, solely so that I could find a way to work in my favorite line of ER trauma scene dialogue: “We got a pumper!”  LOL Sorry, Nick.