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Old 06-12-2017, 07:52 AM   #178
Icelander
 
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Default Knife Work that Needs Doing

When Dr. Anderson arrived at the Manhanock medical center, Dr. McKinney had already decided that surgical debridement was urgently necessary to reduce the chances of life-threatening infection and sepsis in the cases of Russell Tucker and Frederick Pierce. Both have massive third degree burns leading to significant necrotic tissue and their injuries are further complicated by the introduction of tissue debris, such as fibers from clothing and protective wear.

Arthur Reilly, a psychiatric nurse at Manhanock, had previous experience as an ER nurse and along with another nurse, Justin Foreman, has suited up to provide assistance. Dr. McKinney clearly wants to wait for the EMTs from the Coast Guard to arrive, but has reluctantly determined that Tucker has already demonstrated indicators of severe systemic toxicity and waiting any longer is highly likely to result in his death.

Dr. McKinney: “Dr. Anderson, orderlies James and Gilbert here claim that you provided effective emergency assistance to wounded people earlier tonight. Do feel qualified to assist in surgical debridement?”
Dr. Anderson: “I am board-certified as a general practitioner, in addition to psychiatry and paediatric sleep medicine. I have some surgical experience, but I do not claim to be certified in either emergency medicine or critical care surgery. If it is your considered medical opinion that the patient requires immediate emergency surgery and on the understanding that I assume absolutely no liability and all responsibility lies with the medical insurers for the Manhanock Asylum for the Criminally Insane, I am willing to act as surgeon’s assistant for any procedure you recommend.”
McKinney: “Thank you, Dr. Anderson. It is so understood. Due to his extensive experience in surgical settings, Nurse Reilly has agreed to serve as our surgical technician. Nurse Foreman acts as circulator nurse and I, eh… I will have to serve as both anaesthesia provider and surgeon.”

As far as Dr. Anderson sees, the operating theatre has been professionally scrubbed and prepared. As he finishes his own pre-operation hygienic routine and puts on surgical scrubs, he can tell that Dr. McKinney, despite his clear nervousness at having to function as lead surgeon, seems competent as an anaesthetist. Even with the complications of repeated doses of morphine having been used for acute pain management by Tucker’s fellow guards, Dr. McKinney has achieved general anaesthesia with excellent vitals and respiration.

His hands are steady when he starts an incision on Tucker’s chest, peeling away strands of para-aramid fused with the necrotic flesh. Dr. McKinney moves his Watson knife slowly and carefully, allowing Dr. Anderson plenty of time for haemostatic measures and removing the excised tissue. He is so careful, in fact, that at this rate, the procedure will take all night. After some thirty minutes of agonisingly slow surgery, it is evident to all present that Dr. Anderson’s motor control is considerably finer than that of Dr. McKinney.

Dr. McKinney: “Uh… Dr. Anderson, I hesitate to ask, but would you be willing to take over the knife? Younger hands, do you see?”
Dr. Anderson: “As long as it is still understood that I am working under your direction and assume no liability, I am willing to wield the knife.”
McKinney: "Of course. Thank you, doctor.”

As soon as he has taken over the surgeon’s role, Dr. Anderson greatly increases the pace of the debridement. The rest of the surgical team watch in awe as he cuts away necrotic tissue and foreign debris with confident assurance and amazing dexterity. There is no wasted motion and no hesitation.

In a few moments, Dr. Anderson finishes the worst of Tucker’s charred chest and moves on to burns on the left side of the torso. After only slightly more than an hour, all debris visible to the naked eye, along with all major concentrations of necrotic tissue, have been removed from Russell Tucker’s unconscious body. As the surgical team scrubs down, they notice a man clad in some sort of rescue swimmer rig from the Coast Guard standing outside the operating room.

Dr. Anderson: “Can we help you?”
CPO Morgan: “I’m Chief Petty Officer Liam Morgan. I’m an aviation survival technician, US Coast Guard. That means I’m a qualified EMT. I’ve got three other men here with emergency medical training. Our warrant officer is a reservist who is a surgical PA at Maine Medical Center in civilian life. We wanted to know if we should try to get authorisation to move your two burn victims ashore for surgery.”
Anderson: “You should check with Dr. McKinney here. He is the chief of general medicine at Manhanock.”
Dr. McKinney: “Eh, yes. Thank you, Dr. Anderson. I think there is no need to move Tucker, here. It’s touch and go for him, still, but moving him is probably the greater risk at this point. As for Pierce, we should probably look at him again to evaluate whether we should operate here, send him ashore or wait for specialists to arrive here.”
Morgan: “Do you have the capability to operate here?”

Everyone looks at Dr. Anderson, who nods slightly.

Dr. McKinney: “It depends on whether anything has changed with the patient, but we ought to have what’s necessary. Dr. Anderson, why don’t you take a look at the other OR and look in on Pierce on the way? I’ll see if we don’t have some tasks for these gentlemen to perform.”
Dr. Anderson: “As you wish. Nurse Reilly should probably check the OR with me.”

After examining Frederick Pierce and the other OR, Dr. Anderson informs Dr. McKinney that there is no reason they cannot perform the debridement of Pierce there. CPO Morgan cannot promise that a helicopter could take Pierce off immediately and odds are that he would not enter surgery at Maine Medical before dawn. This would probably be soon enough to save his life, but prudence would most likely demand amputation of his right hand and possibly the arm at the elbow. The burn damage is extensive and deep enough for infection to be all but guaranteed.

After consultation, Dr. McKinney and Dr. Anderson decide to operate on Pierce. USCG WO Carter Johnson serves as the surgical technician, freeing Nurse Reilly to be the circulator nurse. Dr. McKinney explains to the Coast Guardsmen that even though he’ll be the lead for this procedure, Dr. Anderson will make the incisions, as he has younger hands and a better eye. Dr. Anderson quickly proves the truth of this, going to work with a deft assurance.

Dr. Anderson elects not to amputate Pierce’s hand, but instead manually remove the necrotic tissue, and despite some misgivings, Dr. McKinney concurs in this. Pierce had earlier given verbal consent to any medical procedures that might be necessary to save his life, but he had been in extreme pain and his mental state debatable. There had been no chance to discuss any potential procedures or obtain meaningfully informed consent for drastic measures. In any case, his hand could always be amputated the next day.

As Pierce is not evidencing as acute symptoms of systemic toxicity as Tucker, Dr. Anderson goes slower with his debridement, trying to do minimal damage to nerves, ligaments and muscles. By the time he’s finished, Pierce’s ravaged hand and arm have been carefully cleaned of necrotic tissue and the Coast Guard emergency technicians are looking at Dr. Anderson with expressions of unqualified respect.

WO Johnson: “That’s damn fine knife work, doctor. I won’t say the hand will ever be good as new, but if he gets to keep it at all, it’ll be down to your skill. We couldn’t have done it any better ashore. Are you maybe an orthopaedic surgeon?”
Dr. Anderson: “Psychiatrist, but I have had an eclectic education.”
Johnson: “I’ll say.”
Anderson: “If there are no more patients in immediate danger, I believe I shall ask your leave to take some rest now.”

Everyone hastens to assure Dr. Anderson that he is welcome to retire for the evening. In light of his ordeal, it is unconscionable to expect him to perform any work at all, really. Anderson sets out to find an empty sick room with a bed, but before he retires, decides to check out Benjamin Hewitt and Harold Lamb. Chase Taylor had been afraid he’d killed them or at least caused them some permanent trauma.

Lamb proves to be awake and recuperating. His lower back has a massive bruise and he has shooting pains around the kidneys, but there is no evidence of damage to the spine or internal bleeding. Unfortunately, Lamb seems anxious, emotional and has indicated to the orderlies helping him that he is terrified of being left alone or closing his eyes to go to sleep. Dr. Anderson studies his chart for a while and prescribes him a mild sedative.

Hewitt is unconscious and heavily medicated. He suffered a very ugly multiple fracture of the tibia and patella of his left knee, with extensive fragmentation of the patella. There is every reason to expect that the ligaments of the joint are badly damaged and major reconstructive surgery will be required to provide any chance of using the leg again.

They’d initially worried that Hewitt may have suffered a hairline fracture of the mandible as well, but looking over the X-rays, Dr. Anderson cannot see any break in the jaw bone, just bruising around it. There’s also extensive bruising from the knee kick to the groin, but Hewitt appears to have escaped a testicular rupture or other types of lasting harm to the reproductive organs and there is no significant bleeding.

After having determined that neither of them is likely to die from the injuries Taylor inflicted on them, Dr. Anderson beds down in an empty room in the medical center. He had not been entirely honest with his colleagues. Dr. Anderson had not in fact slept since his coma of the year 2000. It is not rest he craves, but the delirious joys he can find by visiting the dreams of others.
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Za uspiekh nashevo beznadiozhnovo diela!

Last edited by Icelander; 06-13-2017 at 06:59 AM.
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