#my ribs and back hurt so much and the swelling is just so. protrusive on my ribs. its so GROSS...

[isa-ah]

barking yelling etc

[fanficsandfluff]

Hannibal: A Little Less Different

This fic can also be found on my AO3, where it was first posted, here.

As much as I adore all the art that’s out there for Hannigram, I really don’t feel comfortable writing for them. So instead I chose my other OTP, Will and Beverly! I seriously love their dynamic. So, enjoy!

Pairing: Will & Beverly (platonic)

Words: 2075

~~~~

It wasn't so much shame as it was embarrassment that Will Graham felt while sitting at FBI headquarters mere yards away from the morgue. Or was he closer than that? Yardage didn't matter. A probe was gently stuck into his right ear, bringing Will back to this present moment momentarily. It was an uncomfortable sensation. This physical reminded him of why he doesn't like doctors. Why take the physical at FBI headquarters, one might ask?

Will got hurt on their last catch. It was no one's fault, Will tried to reassure. There was a fleeting moment of uncertainty where Will experienced time-lapse, and he fell into a ditch. That was the first instance. While facing off with the killer, he was thrown into the corner of a mantle. Scathed but alive, that's what Jack called it. As much as Will demanded he be given leave to go home and heal, Jack wanted to make sure there was nothing more seriously wrong with him. It was his leg and back right behind his ribs that were the main sources of pain. Typical injuries and soreness, in Will's head. But Jack gave him that look and, well, here we are now.

"Lie down for me, please."

Beverly's calm voice resonated in Will's head as he obeyed her instruction. He'd just gone through the vitals checks, passing each with flying colors, he was sure. Will shivered when his bare back touched the icy metal table. Now he felt like he belonged in the morgue. A very corpse-like feeling encompassed him as the metal chilled his skin and likewise, he warmed the metal.

"Will."

Will's eyes focused on Beverly. She clearly had just said something to him and had gotten no response.

"I said loosen up a bit."

"The table's cold."

Beverly smirked, "I saw you shiver. Relax."

"In this position, am I wrong to have a fear that you'll start cutting into me?"

"Your only fear right now should be not listening to my instructions."

Will smiled. He was put at ease. Beverly rested her hands on Will's belly and started pressing around. Will could feel her cold hands through her latex gloves, but that wasn't his only thought as he sharply inhaled and grunted. Beverly paused and looked at Will's face. Having not worked as frequently with living subjects, she feared she was being too rough. She was checking for injury, after all, so maybe she hit a sore spot. She proceeded with slightly gentler touches. But again, Will tensed.

"You can let me know if I'm hurting you," she rested her hands on the table as she looked down upon Will's pale upper body.

"No, you're not hurting me. I'm sorry. Continue."

Beverly massaged just under Will's ribs and that one got him to shoot up from his prone position, arms coming forward to protect. Beverly stared with an agape mouth and was about to send him to the hospital for intense organ displacement when she heard a small titter.

New shivers coursed through Will's upper body and he made shy eye-contact with Beverly, "I'm ticklish," he admitted.

Beverly's look of utter alarm placated to a kind of smugness when Will came clean.

"Well, better that than injury. Lay down, I need to finish up," she let Will lay down once more before she continued. No organ swelling or odd lumps, though she did get him to giggle. When she felt just behind his right set of ribs, he winced from pain this time. Assessment with that finished, Beverly then rolled up Will Graham's pant leg and brushed her fingers around his leg. Swelling under his kneecap.

The crime scene investigator lifted Will's leg and rotated his ankle, "Does this hurt?"

Will responded, "It's uncomfortable."

Beverly finished her physical examination and peeled off her gloves after instructing Will to get dressed.

"Am I dying?"

"Not this time," she responded with her usual wit. Will liked that he could talk to Beverly like this. The jabs, the morbid humor. They bounced off each other well.

"Bruised ribs, swollen knee, and twisted ankle. Nothing a little R&R in bed can't fix," she gave her analysis to Will, "I don't know how well you're gonna adhere to my prescription."

"I'll do my best."

"I think I'm going to have to check up on you."

"Well, aren't I the special patient."

Beverly grinned, "Goodbye, Will."

"Goodbye."

~~~~

It turns out Will didn't listen very well, after all. Two days passed and he was keeping up with his day to day activities, concordant with his sleeplessness. He walked the dogs, worked on flies, thought about death and destruction and loneliness and mental illness... all of Will Graham's greatest hits.

He was rightly a little surprised when a knock came on his door on a sunny winter morning. He expected Alana, or Jack, or even Hannibal. They frequently checked on him; and it was always a worrisome house call. They'd be concerned about him or if it was Jack, he'd be picking him up to consult on the newest grisly murder. No one ever checked up just... cuz.

"Hey," it was Beverly who greeted Will when he opened his door for her.

"Oh," he sounded surprised because he truthfully was, "Hi," he looked past Beverly, thinking there was someone else with her.

"Can I come in?"

"I need house calls now?"

Beverly and Will exchanged small smiles. He stepped aside to let her in. She stepped inside and placed a hot coffee on his desk, "I didn't know how you liked it. I deduced no sugar, dash of milk."

"You would be almost correct. I like one sugar packet," he lifted up the coffee in his hand and took a sip.

Beverly groaned and snapped her finger, "Ugh! So close. I figured someone unstable might not want sugar."

"As in not want joy?"

"As in don't overanalyze coffee preferences."

Will smiled at that. Beverly walked around his home, taking a look at the bits and bobs of the place that made it home. She leaned down and pet a few of the dogs that brushed against her boots.

After Will took one more sip of the steaming, bitter coffee, "Can I ask why you're here?"

"We haven't had a new case since the last one, and no one's heard or seen from you since. I figured you needed something to think about."

"You figured I needed someone to talk to."

"That too," Beverly took a seat on the ottoman of a sofa chair. Winston came over and rested his chin on her lap.

"You're not a dog person."

"You can tell?" Beverly rested a gloved hand on Winston's head and gently pet it, "I always believed dogs gravitated towards people who they knew were uncomfortable around them."

Will smiled and he took a seat in the chair adjacent to Beverly, "To torture them?"

"To tease, or to convert."

"Is Winston converting you?"

Beverly set her coffee down on the floor carefully and removed her gloves. Once she did, she gave Winston a full petting and scratching. Will looked on.

"Thank you for the coffee."

"You're welcome," Beverly tucked some hair behind her ears after Winston trotted away from her to go to his dog bed, seeming proud and accomplished, "You haven't been relaxing very much, have you?"

"I'm doing the best I can."

"I don't want to be your nurse, I really don't... but if Jack needs you back in the field, he's gonna want Will Graham at 100%."

"That sounds like an impossibility. Will Graham has never performed at 100%."

Beverly watched how Will's eyes looked nowhere towards her. They didn't seem to focus on anything.

"Will you let me take another look at you?"

"You think you missed something?"

"No, I just want to do a little checkup. See how things are healing."

Will took another big gulp from his coffee and he walked over to his bed and sat at the edge of it. Beverly followed him and sat beside him.

"This doesn't seem like protocol."

Beverly looked at Will's face, his striking jawline. He was right. It wasn't. She cared about his wellbeing, physical and mental. If she could pay him a visit under the guise of medical work, then so be it.

She slipped her hand under Will's sweater to find the tender spot at the back of his ribs. The second her fingers made contact with the skin, Will gasped and he flinched.

"Your fingers are very cold."

Beverly grinned, "Being inside your icebox of a home isn't exactly helping," she teasingly traced her nails towards the front of Will's ribs and gave them a scratch. The consultant forced out a sputtering breath.

"I will repeat myself. This doesn't seem like protocol."

Beverly couldn't not smile now. She had Will here, in the safety of his own home, his dogs all around him, and now she was present. She needed to act on this, she may never get another opportunity to do so. Will froze, as did Beverly's hand. She kept her hand just barely touching Will's ribs, still under his thick sweater. It was just this extra pause of anticipation that bubbled up in Will's chest and he giggled sporadically when Beverly dug in. Will wiggled like a worm on a hook, unable to escape Beverly's hand.

"You're not a very good patient," Beverly teased and she introduced her other hand in the mix, all ten nails scratching and digging against Will's soft, tense skin. Will threw his head back as a louder laugh ripped through his lungs and he fell back onto the bed. It was very cute, Beverly couldn't lie.

"Beverly! B-Bev-- wahahait!" Will giggled away. He wasn't trying to shove at her attacking hands, nor really try to protect himself. It seemed all he was managing to do was wrap his arms loosely around his middle. Beverly was still able to access every curve and protrusion on Will's torso.

Beverly tried squeezing instead, and she latched onto both of Will's sides, allowing her thumbs to do most of the work digging into ticklish muscle. Will spasmed and he rolled side to side, his elbows pressing into his sides more now to try and lessen the sensation.

Will Graham's laugh was nothing like Beverly imagined. She didn't imagine it much, mind you, but she did think about it more than once. His laugh was deep and steady. Nothing she did really changed its pitch. Beverly scritched her hands to Will's belly and that's the first time Will reacted strongly to her tickling. He grabbed her wrists with his hands and tried pushing them out from under his shirt.

"Noho more, please," he giggled, face flushed red.

"You don't want a repeat physical?"

"More than anything, no."

Beverly shot her hands onto Will's belly again, even with him holding on, and she poked and clawed at anything she could. Will belted out more laughter. He snorted when Beverly scratched a nail around his bellybutton. When Will was snorting more than actually laughing, Beverly felt she betrayed him enough. She relinquished her ticklish hold on his bare skin and slipped her hands out from under his sweater. Will was panting on his bed, the tip of his nose having turned red from the fit of laughter.

"Is... Is it bad if I say I never want you as my doctor again?"

Beverly chuckled and she tucked hair that fell in her face behind her ear, "You're a pretty fun patient, I might have to recommend that we keep seeing each other."

Will smiled without provocation now and he sat up, "I really don't want to know how you're so good at that."

"Eldest child. Had a lot of practice."

Will looked at Beverly and his lips were quirked upwards. He had a friend in Beverly. It warmed his heart, almost more than the tickling warmed his body.

"Thank you for bringing me company. Just... don't tell anyone about... all of this."

Beverly smiled and she nudged Will's shoulder with her own playfully, "Wouldn't dream of it. Being ticklish definitely conflicts with your whole unstable, outsider persona."

"How so?"

Beverly considered it, "It makes you a little less different."

Will appreciated that statement. They sat in silence for a few extra seconds. One of the dogs jumped up onto the bed and made itself comfortable.

"I think I should take a look at that ankle now."

[kk095]

Last Ride

Here's my latest story! @defibresuslover247 gave me the idea and @eyesfixedanddilated gave me a few pointers along the way. I hope everyone enjoys!

****

Brooke was a 22 year old with a full, busty figure, dirty blonde hair, and blue eyes. She was a southern girl, born and raised in eastern Tennessee. She was always a bit of a tomboy and enjoyed outdoor activities like hunting, fishing, and riding ATV's.

The night of the incident started off normally. Brooke’s older brother Mike had received a nice tax return that year and decided to splurge a little bit by purchasing a new ATV. Since he knew his younger sister was into riding ATV's, he invited her to try it out with him.

The two siblings went out into a vacant 20 acre lot on the outskirts of town. This particular plot of land had plenty of hills and open areas, so a lot of ATV enthusiasts in the area enjoyed riding there. When the 2 of them got there, Mike parked his blue Ford F150 along a dirt path about 50 yards or so from the road. Mike got the ATV out from the small trailer attached to the back of his truck and the riding began.

For the first hour or so, the 2 siblings were having fun in the outdoors. They were zipping up and down the hills, through the dirt paths, and had a few beers along the way. But as time went on, the drinking and lack of light once the sun set took its toll. While Brooke was riding the ATV by herself, she went was riding downhill at a high rate of speed, losing track of her speed. Her chest hits the handlebars before she goes flying off the vehicle. She lands hard on the ground, striking her head and left side of her face. While tumbling down the hill, the ATV rolls violently down the hill, stomping right over Brooke’s right femur before continuing on down. Brooke screamed at the top of her lungs, feeling her right femur snap like a twig and slightly protruding through her jeans. Brooke’s wild trip down the hill came to an abrupt stop when her left arm and ribcage smashed into the side of a tree.

“Holy shit… BROOKE?!” Mike shouted from the top of the hill after watching the event unfold in horror. “Brooke?! BROOKE?! You ok?!” Mike yells as he starts to run down the hill. At the bottom of the hill, Brooke was screaming out in agonizing pain. She could see a bone fragment penetrating through her jeans on her right thigh, and her left arm was badly broken. She felt a bit dizzy, and could the stinging from open cuts and blood on the left side of her face. Her left humerus, which broke the fall into the tree at the bottom of the hill, was swollen and had some obvious deformities. Brooke tried to get up, but she obviously couldn’t. She sat on the ground squirming and crying, begging her brother to help.

When Mike got to the bottom of the hill, he was taken aback by his sister’s injuries. He stood lorna deer in headlights for a few seconds before whipping out his cell phone to call 911. The call was transcribed as the following:

911 dispatcher: 911, what is your emergency?

Mike: I need an ambulance! My sister’s hurt real bad!

911 dispatcher: Sir, please remain calm. Can you tell me the location of your emergency?

Mike: we’re on that vacant lot off of highway 501 with all the hills and paths! You gotta hurry, I think she’s hurt bad!

911 dispatcher: alright sir, police and EMS are en route. Can you tell me what happened?

Mike: She flipped off the ATV and rolled down the hill. There’s a bone sticking out of her leg!

Due to the extent of her injuries, the 911 dispatcher instructed Mike to refrain from first aid and just stay with his sister to keep her calm. Since the vacant lot was outside of town, it was going to take the ambulance at least 10-15 minutes to arrive on scene. But with the amount of pain Brooke was experiencing, those 10-15 minutes would feel like an eternity.

When EMS arrived on scene, they found Brooke screaming and crying in agony and Mike panicking, feeling semi responsible since this was all his idea. The medics instructed Mike to step away and give them space to examine Brooke.

The medics noted a few injuries immediately: open right femur fracture, left humerus fracture, facial+head lacerations, and some bumps on her head. The medics placed a c-collar since a spinal cord injury was within the realm of possibilities. The medics then removed Brooke’s socks, shoes, and snipped off her jeans so they can reset the open femur fracture. Brooke winced in pain while the 2 medics wiggled the pants off after making a few cuts with trauma shears. Next, the medics reduced the open femur fracture, which cause Brooke to scream loudly in pain for a second. Once the bone was below the skin and somewhat in its ’s normal place, the laceration from the bone protrusion was bandaged up and the area was splinted off. The next order of business was to focus on the humerus injury. There was obvious swelling and deformity, consistent with a displaced oblique fracture within the humerus. The upper left arm was also reset and splinted, causing Brooke a great deal of pain. After the arm was treated, the medics quickly bandaged up some of the head lacerations and abrasions and began setting up 2 large bore IVs. After IV access was obtained, normal saline was hung, but the medics refrained from administering pain medications since alcohol was smelled on Brooke’s breath, and there were beer cans scattered across the ground just up the hill. Brooke’s top was then cut off, sparing her black bra and matching underwear. A 5 lead ECG with a portable heart monitor was set up to obtain readings for her vital signs. On scene, Brooke’s vitals were: BP 87/49, Pulse 121, o2 saturation 94%. Brooke was placed onto a backboard and taken over to a gurney, and taken into an ambulance.

Mike begged and pleaded with EMS to ride in the ambulance with them, but they told him he couldn’t. “THAT’S MY FUCKIN SISTER! LET ME IN!” Mike shouted belligerently. One of the cops on scene offered a compromise: since he had too much to drink, they’d drive him to the hospital.

During the first part of transport, Brooke was a little short of breath, so an o2 mask with high flow oxygen was placed. The medic in the back of the ambulance lowered their stethoscope onto the girl’s chest and listened to her heart and lungs. “heart sounds good, but we’ve got diminished breath sounds on the left. Might be a tension pneumo.” The medic announced to the driver afterwards. The medic also noted that there was swelling and bruising on the side of her chest along her left ribcage, consistent with possible rib fractures or dislocation.

Over the following 10 minutes or so, Brooke’s condition changed a bit. Her GCS dropped to 10, and became a bit disoriented. Her systolic BP dropped into the upper 70s, and her heart rate was approaching the 130s. With this in mind, the medics became concerned about a potential head injury. The medics checked her pupils: right pupil was reactive, and the left pupil (injured size) had the early stages of dynamic oval pupil. Essentially, her left pupil had a slight oval, or almond shape. This is typically associated with eye trauma, optic nerve injuries, or brain bleeds originating from the back of the head. Since there wasn’t sufficient evidence of trauma to the eyes/optic nerve, it appeared a head injury was within the realm of possibilities. “Hey, what’s our ETA? GCS dropped to 10 and we’ve got a DOP in the left eye. She needs a head CT ASAP.” The medic in the back of the ambulance called out. “ETA 4 minutes. Hang in there…” the driver replied. The ambulance continued speeding down the road, sirens on full blast while Brooke continued to struggle in the back. She was squirming around and groaning in pain. “Miss, you gotta stay still for me, ok?” the medic said calmly, attempting to reason with brooke. Brooke began crying again while fidgeting around and kicking her healthy leg out. “Miss! You gotta stay calm!” the medic said more sternly, grabbing ahold of Brooke trying to hold her in place. Brooke quickly became inconsolable and demonstrated an altered mental status. “she’s definitely got a brain bleed or something…” the medic thought to themselves. Brooke needed to stay still due to her femur fracture, and because a spinal/neck injury hasn’t been ruled out. Since there was no getting through to Brooke, the medic decided to push a round of rocuronium. This medication is a strong muscle relaxer and paralytic agent, so it’s used as a chemical restraint when patients consume alcohol since alcohol doesn’t mix well with other agents commonly used.

Within 30 to 45 seconds, Brooke was knocked out by the medication. Since she was now unconscious, the medic decided to perform rapid sequence intubation on her for airway management. With a laryngoscope in 1 hand, the medic maneuvered a 7.0 ET tube into the girl’s airway. Once it was at the correct depth and place, the tube was secured with a blue tube holder, and an ambu bag was attached. For the remainder of the ambulance ride, Brooke remained hypotensive and tachycardic, and her GCS was still bouncing between 9 and 10.

Upon arrival at the ER, the medics gave the trauma team a brief rundown of Brooke’s condition as they wheeled her into an available trauma bay. Once in the room, Brooke was transferred onto the table and examination began. She was immediately started on blood transfusions- 1 unit A+ and 1 unit O- with 250 units of rhogam, 1 unit of platelets, and 1 unit of FFP. Multiple specialists were paged for consults, including: orthopedics, neurosurgery, and trauma surgery. While waiting on the specialist to arrive for their respective consultations, initial examination began. A FAST scan was performed first. The chest portion of the exam showed trace pericardial effusion, minor to moderate abdominal bruising but nothing potentially lethal, and the pelvic section came back clean. Multiple x-rays were then ordered: the x-ray of the arm confirmed displaced oblique humerus fracture, which would likely require surgical reduction with rods and pins. The chest x-ray showed 2 broken ribs and 1 dislocated rib on the left side of the thorax, along with bruising and swelling in the intercostal area. The chest x-ray also revealed a left sided tension pneumothorax with pleural effusion, which appeared to be caused from air escaping into the chest cavity, which pinched and pressed up against the lining of the lung. The next x-ray was of the femur fracture. The fracture was quite extensive, which required surgical reduction and many months of physical therapy in order to heal properly. The x-ray of Brooke’s head showed no evidence of a c-spine fracture, but there were some contusions on the skull and there didn’t appear to be any fractures; a head CT was still necessary to get a better understanding of her head injuries.

In the meantime, the trauma team decided to do what they could for her. The first order of business was to deal with the tension pneumothorax on the left side. The treatment for this was placing a chest tube in order to evacuate any air or blood. The procedure started after the area in between her ribs was sterilized. A 1 inch incision was made in the skin, followed by an additional one to cut through any fat and underlying tissue. Once a decent opening was created, a 36fr chest tube was placed into the incision area, and navigated deep into the pleural space. There was a small amount of blood drained from the tube, but a substantial amount of air exited the tube, allowing proper lung expansion once again.

Another concern arose in the coming minutes. The lower half of Brooke’s left leg was a bit discolored and cold. Her dorsalis pedis pulse was weak, so compartment syndrome was a legitimate issue here.

When orthopedics arrived, they wanted to set up pressure monitoring in the thigh to see if compartment syndrome was indeed taking place. But the orthopedic surgeon and neurosurgeon were in a bit of a disagreement. “if we don’t monitor her leg, she could lose it!” the orthopedic surgeon said. “well if we don’t get a head CT, she could die! I’d rather her lose her leg than her life!” the neurosurgeon replied smugly. The trauma surgeon offered a compromise: a fasciotomy in the emergency department. Typically, this is a procedure reserved for the operating room, but this was an emergent situation that required a quick decision. Everyone quickly got on board and the procedure was started in a moment’s notice.

Betadine was squirted on the right thigh and the bandage was removed from the splinted compound fracture. A scalpel was used to make 2 deep, long incisions in the thigh. Once the skin was incised, the underlying fat and tissue was cut out so proper bloodflow and blood drainage could take place. Her right calf and right foot immediately became a more normal complexion, and the dorsalis pedis pulse was stronger than it was just a minute or two ago. The freshly opened area was then irrigated with saline and prophylactic antibiotics to decrease the chance of infection, and the wound was somewhat closed with the shoelace suturing technique.

After the fasciotomy, Brooke’s blood pressure began to take a rapid nosedive. Vasopressors were pushed in an attempt to increase BP to a more stable level, and more blood products were hung. While trying to maintain BP, the young woman began to have a tonic-clonic seizure on the ER table. Brooke jerked and flopped erratically, biting down on the ET tube and grunting every few seconds. Her toes clenched up, wrinkling the soles of her size 8.5 feet. To combat the seizure, the trauma team acted quickly by injecting 1 dose of lorazepam intravenously in order to stop the convulsions. It was my like the tv shows where the medicine take immediate effect. In reality, it takes about 45 seconds for the meds to kick in. In those 45 seconds or so, Brooke’s twitchy, spasmodic movements slowed down incrementally until she finally settled down and stopped seizing.

After the seizure was controlled, Brooke was covered up and transported to radiology for a head CT. The GCS drop, altered mental status, DOP, and seizure were all associated with a brain bleed. Once in the CT scanner room, Brooke was transferred into the table and hooked up to a portable ventilator since nobody could be in the room with her during the scan. Prior to the scan, she was given another dose of vasopressors to keep her blood pressure semi stable since she was hypotensive. Pupil reactivity was checked before the scan as well- left pupil was sluggish and still oval shaped, and the right pupil was constricted.

The head CT took about 8 minute to complete. The results of the scan were interpreted quickly: there was a subdural hematoma in the left temporal lobe. The size of the bleed was definitely noteworthy, so the neurosurgeon wanted to drill a burr hole to alleviate the pressure in the cranium and then monitor Brooke with an intracranial pressure monitor to see if an additional surgery would be warranted.

Once the plan was made, Brooke was once again whisked away and back to the trauma bay for a quick burr hole and ICP monitor insertion. The procedure quickly commenced upon return to the ER. A portion of Brooke’s hair was shaved off on the left side and the pasty white skin was sterilized with a small amount of betadine. The neurosurgeon took a surgical drill and drilled 2 holes. The first one was made in the left temporal area to alleviate pressure and create immediate blood drainage. Thick, gooey blood oozed out of the small, circular hole in her skull after it was drilled. The coagulated blood was suctioned out, allowing proper release of the fresh blood from the active bleed. The 2nd hole was drilled in the left parietal area. The purpose of this 2nd hole was for insertion of an ICP monitor and to allow room for additional draining in the event the bleed worsened. After hole #2 was drilled, the ICP monitor was inserted and set up by the neurosurgeon, and a few small drainage tubes were inserted to help drain additional blood in an attempt to restore normal pressure within the skull. The next step of Brooke’s treatment was to take her to the OR for surgical reduction of both her femur fracture and humerus fracture.

Up in the OR, Brooke was hooked up 5o a ventilator and prepped for surgery. The anesthesiologist had some concerns about her blood pressure before surgery, so it was advised that trauma surgery would sit in on the surgery, and have neurosurgery on standby. With her BP still low, a repeat echocardiogram showed that the trace pericardial effusion had worsened in the past little while. Before the surgery started, the trauma surgeon performed an infrasternal pericardiocentesis. The quick procedure drained a decent amount of blood and slightly improved Brooke’s vitals, buying the surgical team enough time to work on the orthopedic injuries.

The orthopedic surgeon began with the humerus fracture. The original plan was to hold the bone in place with some plates and screws, but once the doctor got in there, they noticed damage to the proximal head of the humerus. When there’s damage to that portion of the bone, they have to replace it with a titanium joint that’s held in place with screws. Essentially, it’s like a hip replacement in your arm. It’s not a common situation, but it happens every so often, and the surgical team was prepared for that curveball. Part 2 of the orthopedic surgery was the femur repair. A long, thin metal rod was inserted into the femur after the medullary cavity of the bone was essentially scooped out. With the rod in place, the fractured portions of the bone were lined up and then held in place with small plates with titanium screws. Overall, the orthopedic portion of Brooke’s treatment went well, but since she was hemodynamically unstable and required monitoring for a head injury, she was sent off to the ICU for monitoring.

Brooke’s first few hours in the ICU were uneventful, but changes started to occur overnight. Around 3am, her blood pressure began to drop once again, along with an alternating QRS complex on the EKG. The ICU nurses decided to page a rapid response since the changes were concerning. When the trauma surgeon arrived, they pushed a round of vasopressors and hung 1 unit of FFP since there may be some residual bleeding and damage. The doctor’s next order was a repeat echocardiogram to monitor the progression of the pericardial effusion. The echo showed that Brooke was experiencing cardiac tamponade, so once again, an infrasternal pericardiocentesis was the way to go. The needle aspirated a combination of both clotted blood and fresh blood, but cardiovascular function slightly improved after the procedure. Brooke’s pupils were checked afterwards; they were sluggish but reactive, and the dynamic oval pupil was slowly going away. The ICP monitor was showing normalizing pressure in the skull, so it appeared the head injury was on a slow and steady course towards healing. The main concern was the chest injury at that point.

Approximately an hour later, Brooke began to struggle once again. Her blood pressure was still low and her chest tube output decreased. Upon further investigation, it was discovered that there was a blood clot lodged inside of her chest tube. Treatment for this is disconnecting the drainage portion of the chest tube and suctioning the lumen of the tube out until normal output returns. But when the tube drainage is disconnected in trauma patients (because a larger chest tube is required), you run the risk of re-aggravating the tension pneumothorax, so this has to be done rather quickly so excess air doesn’t get into the tube or the patient’s chest cavity.

With the trauma surgeon supervising, the drainage portion of the chest tube was disconnected. A suction tube was placed into the chest tube and the chunk of clotted blood about the size of a pea was slurped out, allowing normal flow and drainage to occur once again. But even after the chest tube was reconnected, Brooke’s blood pressure was still low. A 3rd echocardiogram was ordered, showing a sizable tamponade in the lateral portion of the pericardium. With this continuing to occur, and getting worse, the trauma surgeon decided to page cardiothoracic surgery and immediately take Brooke up to the OR for an exploratory thoracotomy and pericardial window.

While wheeling Brooke out of the ICU, her blood pressure suddenly became dangerously low. “shit, she’s gonna code. We need to get her up there ASAP!” the trauma surgeon blurted out with urgency. The ICU team wheeled Brooke through the corridors at full speed and into an available elevator. No more than a second after the elevator doors shut, Brooke became pulseless. The heart monitors showed pulseless electrical activity, so ACLS protocol promptly began. One nurse began pumping away at Brooke’s bare chest. The 22 year old's chest sunk deeply from the strength of each individual compression. Her chubby body and large, natural breast jiggled around a bit while another nurse injected epinephrine and atropine into one of the IV sites.

A nurse got on top of the gurney and began straddling the young woman, delivering strong, repetitive compressions. A few moments later, the elevator doors swung open and Brooke was wheeled out and into the main hallway of the OR floor. “whoa, what happened?” one of the nurses at the main nurses station asked, surprised to see an active code out in the open.

The team continued wheeling Brooke through the hall, compressions ongoing. Once in the correct operating room, the code was paused for a moment in order to transfer the woman onto the OR table. The monitors chirped loudly while Brooke’s limp body was transferred onto the table. Once on the table, CPR was restarted by one of the surgical nurses. “oh boy… what a mess. We’re gonna have to open her up ASAP. Get me a thoracotomy tray…” the head surgeon called out as they walked into the room. Since the heart monitors still showed PEA, CPR just went on. Redness and bruising started to form on the center of her chest in between both breasts due to all the hard compressions she was receiving. There was a popping sound that occurred during each individual compression since a few of her ribs became fractured or dislocated. The nurse that delivered compressions could feel Brooke’s cold, clammy skin through her gloves while everyone else in the room was scurrying around and barking orders at each other in what seemed like a moment of organized chaos.

While the surgical techs set up a thoracotomy tray, an OR nurse pushed the next round of intravenous meds since Brooke just crossed the 4 minute mark of the code. The meds didn’t have an immediate effect, but were able to convert Brooke to v-fib after approximately 45 seconds or so. With defib pads already attached to Brooke’s bare chest, they were charged to 200j and a shock was delivered. Brooke’s limp body jolted abruptly on the table in response to the quick dose of electricity. Since no change occurred, CPR resumed for several seconds until the defibrillator pads were recharged.

Seconds later, everyone backed away from the table and a 300j shock was delivered. Brooke’s back arched, forcing her chest up in the air, making her breasts bounce around. Shock #2 failed to convert Brooke from v-fib, so the surgeon took over and made the executive decision to open her chest via a left anterolateral thoracotomy.

Betadine was splashed across the left side of Brooke’s chest in a moment’s notice. With CPR ongoing just inches away, an incision was made in the 5th intercostal space. The cut began just to the left of Brooke’s sternum and extended laterally. The incision continued under her left breast, and ultimately came to a stop a few inches away from her left armpit. The next step was to separate and cut through the underlying tissue in order to create an opening for the rib spreader. This took about 15 or 20 seconds since it was done at a hurried pace. With that out of the way, the finochietto rib spreader was placed in the gaping cut, and the actual opening of the chest began. A cracking sound was heard regularly while the knobs were turned, forcing the 22 year old’s ribs apart.

The OR team was greeted by a rush of blood from the chest cavity upon cracking the chest. Suction was applied to the area and a 2nd chest tube was inserted for additional drainage. With the excess blood out of the way, a pericardiotomy was performed. A quick cut was made into the lining of the heart, which leaked a combination of fresh blood and coagulated blood. The incision in the pericardium was extended to deliver the heart more effectively, and a few small drains were placed into the incised portion of the pericardium for continuous tamponade drainage.

After these critical first few steps, external compressions were swapped out for internal massage. One of the doctors wrapped their hands around Brooke’s heart. They pushed hard and fast in an upwards motion with both their thumbs on the left ventricle in order to force blood through the aorta and out to the body. The doctor could feel Brooke’s heart twitching in their hands as they desperately attempted to reverse the dire situation.

V-fib still persisted after a cycle of internal compressions and another dose of meds, so the internal paddles were called for. The large, spoon shaped paddles were charged to 20j and placed directly against the desperate, spasming organ. After everyone backed away, the first internal shock was delivered. A dull, wet thump was heard, followed by her torso twitching a bit. Her heart fluttered for a second from the direct jolt of electricity, but it quickly returned to its erratic spasming from before. Internal compressions were resumed while a vascular clamp was placed on the descending aorta near the diaphragm. The purpose of this is to temporarily redirect bloodflow back to the heart, brain, and lungs since those organs are most essential. After the large vessel was clamped, the internal paddles were prepped once again, and placed around each side of the young woman’s heart. Shock #2 was a but stronger at 30 joules, causing more noticeable reaction. Brooke’s torso flopped slightly and her toes curled up, wrinkling the soles of her size 7.5 feet. This shock failed to correct the deadly arrhythmia, so resuscitation efforts went on. A cycle of internal massage was performed while the internal paddles were recharged to 40j. After the paddles were good to go, the third internal shock was delivered. The same dull thump as before filled the room for a moment while Brooke’s battered body twitched on the table. The monitors began chirping again, continuing to show v-fib.

The same cycle of internal compressions, shocking and meds continued again…and again…and again, but the OR team just couldn’t get their young patient’s heart to restart. Despite a 26 minute code, Brooke passed away in the OR, with her time of death being called at 5:02am. The monitors were switched off and the ambu bag was detached. Additional equipment such as the EKG electrodes and IVs were removed in the eerily silent OR. Brooke’s naked, battered body laid on the table. Her heart sat motionless in plain sight during the basic postmortem preparations. Eventually, the chest tubes were removed, the ICP monitor was taken out, and the chest was closed up. A cover was placed over Brooke’s body, and a toe tag was placed before sending her off to the hospital morgue, bringing a sad ending to the case.