Ch. 15 – The ABCs of Saving a Life

Derrick had learned some trauma protocols from Tony, and he would have to put his knowledge into practice now, or get shot dead by a gangster, most likely.

There were three wounds of note, besides some scrapes and small cuts: gunshot wounds in the abdomen, calf, and head. The patient’s head was swelling and bloody, but otherwise intact, so the bullet must have glanced off it.

“His abdomen is the killer. Jesus. It’s a big exit wound,” Tony said. There was a large hole in the patient’s abdomen that was visibly spurting blood, now that that they removed the amateur dressing. “We need to close this right away. Clean the area and apply pressure. How much hemostatic dressing do we have left?”

They had been short on hemostatic dressing—gauze coated with a special agent that encouraged blood clotting—for weeks, but there were still sealed packs in the cabinet under the cart.

Derrick opened the pack and stuffed the dressing on the abdominal wound, and then, keeping pressure on it, grunted as he slipped a compression wrap underneath the man’s body, and then fastened it tightly around his abdomen. “The dressing’s packed, and I’ve started the pressure on the abdomen.”

“Good.” Tony was standing at the patient’s head, leaning over, ear to his mouth. “What’s his name?” Tony shouted. “I thought he was breathing fine . . .”

The White Leopard in the corner jumped out of his chair. “He’ll respond to Ah Jun—what’s wrong—?”

“Be quiet, please, unless I ask you something,” Tony said, in his hospital voice. It was calm and immovable, even dismissive, as if he hadn’t been held up at gunpoint a few minutes ago. “Derrick, something’s off with his chest movement. I’m going to get the cervical collar, go through the ABCs with him.” Tony jogged off to the storage closet, kicking aside some boxes to clear a path.

Airway, Breathing, Circulation, Disability, Exposure: or ABCDE for short. A sequence of checks in the order of importance to the patient’s survival. Managing the ABCs was the first step in treating a trauma care patient. After all, if a patient wasn’t breathing, then it didn’t matter which type of antibiotics you prescribed for them; they’d be dead.

Derrick kept pressure on the man’s abdomen as he moved closer to the patient’s head. Derrick said in Chinese.

The elderly man called Ah Jun groaned and coughed, gargling, before managing a faint

“Patient can feel pain,” Derrick shouted, so Tony could hear him.

The patient parted his lips, and then Derrick gently opened his mouth the rest of the way.

There weren’t any solid objects in the man’s mouth, but there was a pool of blood coming from a cut inside his cheek. Shit. “I’m putting another compression bandage around his abdomen, but I need my hands free to drain fluid build-up in his mouth.” Hopefully it’s enough to stop the bleeding, but we’ll have to keep checking on the abdomen. If he keeps bleeding, we’ll have to keep manually applying pressure. Derrick tugged the man to one side of the all-too-narrrow operating table so that he could roll him onto his side without pushing him off and onto the floor.

Tony came back with the cervical collar. “Wait, put this on him first before you roll him over. He was probably struck in the head with a bullet, so the cervical spine’s at risk.” The rigid collar, lined with gel at the contact points to be supportive without greatly increasing intra-cranial pressure, would open and then fit between the head and shoulders, and make it safer to move the patient without damaging his cervical spine—those seven important vertebrae of the neck: a potentially fatal outcome. Tony helped Derrick get the collar on to the patient before they rolled him onto his non-injured side, draining the blood out of his mouth, and letting it leak onto the table and floor.

“How is he?” Tony asked.

“He has a cut on the inside of his mouth, I saw the weird chest movement too; maybe draining the blood out of his mouth will help.”

“Okay, good. Apply pressure with gauze to the cut for fifteen minutes. I’ll keep looking at his airway in the meantime.”

Derrick nodded and get a new clean roll of gauze out. He moved to the side of the table while Tony took position at the patient’s head again, and bent down, putting his cheek near the patient’s mouth to feel for breathing. Derrick tried to flatten his hand to the side of the man’s mouth to get it out of Tony’s way. His wrist began to strain from applying constant pressure, and it was quickly getting sweaty near the table as Derrick and Tony tried to hold their positions.

“I feel breath, but it’s weak. No abnormal sounds now that the blood’s been drained. Hm, actually, I’ll hold the gauze. Can you get me some oxygen, Derrick?”

Derrick kept pushing the gauze against the cut until Tony’s fingers took over. The oxygen concentrator was in the closet. He gripped the dull gray device by the handle and wheeled it out of the closet to the sink, filled the reservoir with water, and attached the tube running from the outlet to the mask that would go on the patient’s face. The device was capable of releasing a constant flow of oxygen, concentrated from the oxygen present in the ambient air. By increasing the pressure in the air chamber, the device would cause the ambient nitrogen to adsorb to a bed of zeolite, so that only the oxygen would pass through to the patient.

Wound up tight around the handle with twist ties was the cable that allowed communication between the concentrator and the pulse oximeter that Tony had clipped on the patient’s finger. The oximeter, a small, rectangular monitoring device the size of a fat clothespin, detected the oxygen saturation in the finger’s blood by measuring the amount of light absorbed by the blood, which changed with its oxygen content. The oxygen concentrator and pulse oximeter communicated with each other to maintain blood oxygen levels within a healthy range, without over-oxygenating the patient. Derrick fumbled to undo the ties and plug the cable in, and then brought the concentrator over to the operating table.

Tony was still holding the gauze to stop the bleeding in the patient’s mouth. “Got the oxygen? Good. We can’t put the mask on until we stop putting pressure on his mouth wound, but we have it ready. I’ll keep holding the gauze, can you do a jaw thrust?”

“Just the jaw thrust?”

“Yes, remember, we don’t wanna fuck this guy’s cervical spine.”

The triple airway maneuver was an effective way to open up a patient’s airway: tilting the head back, lifting the chin, and pulling the jaw forward. But pulling the jaw forward was the only one that didn’t involve moving the cervical spine.

Derrick put his fingers on the bony parts of the patient’s jaw and lifted it up and forward, while keeping the man’s mouth open with his thumbs to make sure air could flow. It was usually painful for the patient, but that helped keep them alert and conscious. The man coughed and started breathing more deeply.

“How’s it look, Tony?”

“Chest movement seems fine now, but he’s breathing fast. We’ll just have to let the blood ooze from his mouth wound for now, let’s get the mask on.” Tony took the gauze, stained red, out of the patient’s mouth and fitted the oxygen mask on.

“Okay, airway’s done; let’s move to Breathing. Pulse oximeter reads oxygen saturation of 88%. That’s low, but it’s misleading and probably even lower, since he’s lost a lot of blood. Nothing abnormal on the neck, and the trachea appears central. Where are the scissors? Ah, fuck it. Exposing the chest.”

Tony put his bulky arms to work—he had some brawn under all that fat—and ripped the upper part of the patient’s shirt off. He placed his hand at different positions on the chest and rapped it with his knuckles. The sound was bright and resonant, as opposed to dull. “Percussion’s normal, so no fluid build-up in the lungs or chest cavity. Good, so the gunshot wound to his abdomen is probably confined there, and didn’t break through his diaphragm. I was worried the diaphragm had been compromised, what with that weird chest movement from earlier. We need him on an IV. Start him on the oxygen-carrying blood substitute, and ramp it up slowly, to stay in hypotension. If his blood pressure spikes too suddenly we’ll break his blood clots, and he can’t afford to lose more blood.”

“Okay.” Derrick ran over to the corner of the room, where they kept their medical IV pole. It was a rusty and creaky thing, and it stopped and started a few times as he dragged it across the tiled floor.

“Hurry the fuck up! Didn’t you hear your boss?” the White Leopard in the corner shouted.

Derrick blinked some sweat out of his eyes and glared at the man. So what if he didn’t hurry up? In fact, what if he slowed down? Why was Derrick running ragged in the operating room, saving members of the gang that killed his parents?

Derrick and Tony might be shot for failing to save the man, but then again, they might be shot if they succeeded. Maybe the man was wanted, like Tony thought, and the Leopards had to keep his presence a secret. Killing all witnesses was the easiest way to do that. That was the sort of lazy and cruel solution the White Leopards were known for; it was baked into the gang’s DNA.

Tony wouldn’t like it, but what if Derrick took a few more seconds here to bring the medical IV pole over, and few more seconds there to grab the bag of oxygen-carrying blood substitute. Would it kill the old Leopard on the operating table? Wouldn’t that gangster have deserved it? Wouldn’t all these gangsters deserve a painful death?