The Grantville Gazette - Vol 3 Part 22

2.

"May I join you, Beulah? If it won't disturb you," Werner asked quietly. At her nod, Werner sat on a bench next to her in Leahy's conservatory. "This is a lovely spot. I can see why you start your mornings here.Especially lately."

"It's been especially comforting this last week. The memorial service yesterday was pretty intense. We'regoing to miss them. At least Mary Pat got to go toMagdeburg to be withSharon for a while. Given the unrest there, having a trauma nurse on the spot might not be a bad thing. She'll be back in another week or two if things settle down there. I hear she and Philip had organized a trauma rotation for a couple of the students."

Werner gracefully accepted the change in topic. She clearly didn't want to talk too much about what had happened. He understood taking refuge in work. While he hated to push at a time like this, the needs and responsibilities that had brought him to Grantville still existed. "So I am given to understand. Philip and the students are very excited about it. We have spent a considerable amount of time in the library reading basic texts and sharing the texts we brought with us with Hayes and Stoner. I have had some very interesting conversations with Stoner. When he can be spared from his work here, and before he leaves forItaly , I should very much like to have him visit me inJena and look over our gardens there."

"I'm sure he'd be happy to see them. You've done a great job with them."

"Thank you. As we have been reading in the library, the complexity of public health measures that are taken to prevent the spread of illness are of particular interest, especially as it will be spring soon. I was wondering if it would be possible to have a lecture given to the students and faculty on public health and the prevention of communicablediseases? I understand you have some expertise in this area."

If she was at all unhappy or angry about being in essence asked to give a lecture to the group fromJena after what happened last time, Werner saw no sign of it. Then again, she was an experienced faculty member. The circ.u.mstances were different and one incident out of a long career wasn't going to stop her.

He doubted much of anything would stop this woman once she set her mind to something, and he both needed and wanted to have a better relationship with her and the other medical personnel in Grantville.

But particularly with her. She was very highly regarded and involved in some way in every aspect of medical care here. It was Beulah who was the liaison with the program at the high school, who had been the Director of Nursing, who consulted with the Sanitation Committee, and on and on. While they had been here less than a month, her central role in the small medical community was clear. He and the other faculty would make sure the students stayed in line this time.

Not that he thought it would be really necessary. Kunz had had a severe talking to for some of the more rigid students. Being left behind with Grantville's treasures before them had weighed more heavily than some of the views currently being shaken. He rather thought Kunz had been surprised to find himself as an advocate for Beulah and the Grantvillers, however reluctant he had been to do it. Werner thought that the students had responded very well to the lead the faculty had taken. They had all had their eyes opened to another way of practicing, a highly effective way at that. He didn't know what they would take from the Grantville way of doing things in the long run. But, in the short run, all of them were very curious and being very observant.And polite about it, too.

"Makes sense.I'd be happy to give the lecture myself if you'd like. I'd want to pull some materials so they have a few of the basic science concepts down before I gave the lecture. We could set it for say, two weeks from today?"

"I was hoping you would agree to do it. Two weeks from today then."

3.

Beulah paused in the ER exam room door that evening to watch Ernst, one of theJena students, with Fritz as his a.s.sistant st.i.tch up a small shin laceration. The patient was an up-time youngster of about eight, whose mother was watching carefully. Beulah didn't see any extra anxiety because a down-timer was working on her son. Fritz was translating Ernst's comments when he needed help with English. Nice bedside manner, rea.s.suring and calm.A little gentle teasing to set the little one and his mom at ease and distract him. She noticed with a tiny smile that he was being very, very careful of his sterile technique.

Beulah slipped away unseen by the group in the small room. She didn't want them to feel she wasn't confident in them. The scene heartened her. This was what they were working toward. The child would have had to wait until James or one of the RNs was free to do the suturing otherwise. He'd have been in pain and the normal inflammatory response to injury would have made the wound more difficult to close.

Since James was in surgery and the only RN available to cover the ER was with another patient, that wait might have been an hour or more.

They would make this work. It had taken no time at all for Phillip and two of his students to start spending every spare moment in the ER.Phillip the adrenaline junkie. Who'd have thought it?

Chapter Seven.

October, 1633

1.

"What happened?" Phillip asked as he hurried into Leahy's Emergency. Two of his students, Ernst and Heinrich, trailed closely after him as he more or less trotted beside Mary Pat. She'd grabbed them out of the Grand Rounds they'd been having on the Surgery Ward. Phillip, Ernst and Heinrich were doing a trauma and surgery mini-rotation. They spent every spare minute they could in the ER.

Beulah had inst.i.tuted Grand Rounds as a teaching tool. The rounds gave them a chance to review cases with Beulah who did hands on teaching and explanations of actual patient conditions and their treatments for small groups of students. Much as Phillip and the other two students appreciated the floor time, they'd fallen in love with trauma and any opportunity to get in on something that got Mary Pat moving that quickly was to be pounced on with speed. Beulah had waved them on with a "Catch up in a few minutes.

Go on."

"Just got a call from the ambulance.We've got a couple of casualties coming in; they're about ten minutes out now. I left Mara prepping before I came to get you and grabbed some supplies from the OR on the way. The report the EMTs called in is that there was an accident at one of the farms. The loft in a barn gave way and the two men getting hay for the cows went down with it. One of the men is in pretty goodshape. b.u.mps, bruises, stable vital signs. He's got a possible concussion but also has a scalp laceration that's bleeding even through the pressure dressing."

As they arrived in the ER, she directed them to the side-by-side exam rooms where Mara was prepping IV fluids and setting out linen bandages. Mara worked quite a bit in the ER because she got calmer and calmer the more desperate the situation. She was sharp as the proverbial tack to boot. Mary Pat appreciated her abilities but the fact that Mara's thick drawl also got slower during a crisis drove her nuts sometimes. Mara looked up at them and waved Ernst over to a cabinet. "Great. Our master of the suture is here. Going to put all the suture practice you've had to use today Ernst. Can you get your stuff ready?"

As Ernst headed over to the supply cabinet, Philip and Heinrich looked at Mary Pat, who continued her report. "The one we're most concerned about, Harmon Manning, wasn't so lucky. Evidently, he fell directly onto the concrete floor rather than the hay, and some equipment stored in the loft fell on his chest.Looks like he's got crushing chest injuries as well as a broken arm and collarbone.May have some spinal cord injuries. They're bringing them all in on back boards just in case.Mara, any new info?"

"Vitals are going downhill on Manning. Carotid pulse is palpable, rhythm sinus tach with a rate of one-sixty, up from one-forties." Seeming to remember who else was in theroom, she glanced up and then went on. "They don't have much time with someone that far out and that seriously injured. So they don't spend a lot of time on blood pressure taking. Instead, as a general rule of thumb if you have a carotid pulse, you have a systolic-ah that's the top number on the blood pressure-of at least sixty. Sixty is the minimum amount necessary to for the brain to be perfused, although it isn't optimal. Sinus tachycardia means that the heart rhythm is regular but too fast."

"Can you two start setting up the splints and chest tube trays?" Mary Pat headed for the oxygen cylinder set up near the wall. They didn't have oxygen piped through the walls the way an up-time hospital would have but at least they could make it and refill the cylinders from the nursing home. With the curtains open between the ER "rooms" they could all talk freely. The rooms were large so they could handle lots of people and equipment if needed. Philip, Heinrich and Ernst had spent a fair amount of time here and they'd been shown where things were located and some of the basics during the last few weeks. "A pulse at the femoral artery should indicate a pressure of at least seventy, radial at the wrist at least eighty. That they're looking at a carotid pulse and that his heart rate is that rapid is a probable indication of being in shock. The shock could be from hypovolemia, that is, too much blood loss or from cardiogenic shock from injury to the heart. That is that the heart has been hurt too badly to function well."

Mara laid out toweling and said "Okay everybody, get scrubbed up. They should be here any minute.

The last report indicated that his respiratory status was bad.Supraclavicular retractions, respiratory rate is almost forty and he's cyanotic. They've been able to cut away his clothes in the ambulance to get a better look at him. They've got a flail segment. Sounds like a big one."

Philip looked from one to the other. "And the significance of that is...?"

Mary Pat looked back at them and scrubbed her hands harder. "With a flail segment, a contiguous group of ribs are broken. The person can't breathe normally because the rib cage doesn't move in a unified fashion. When the person breathes in, the flail segment sinks instead of expanding and vice versa.

There isn't enough negative pressure to fill the lungs with air sufficiently if the segment is big enough. That means we're probably dealing with a pneumothorax, maybe a hemopneumothorax, which is blood as well as air building up in the chest cavity."

"Ah, like Viet." "Worse than Viet this time, I think. Heinrich, I'd like you to handle the ambu bagging please. You'll be monitoring his respiratory status. You've done it before. You may be at it a while this time."

James came in through the double swinging doors from the OR. He pulled off the surgical gown he was wearing, dumped it in a linen bag and began scrubbing his hands. While Mara briefed him quickly, Mary Pat looked around to make sure that everything was ready and got a final report from the ambulance crew. Their patient sounded unstable as all h.e.l.l. Mary Pat felt the adrenaline pumping through her system, sharpening her mind and slowing everything down with an odd crystalline clarity. They were lucky to have this much prep time but every minute that their critical patient was in the field was a minute too long.

Beulah came in and caught the report while she joined James at the sink to scrub.

"Beulah," James began, "I'd like you and Heinrich to take the possible concussion. Evaluate him and get him patched up as much as you can. Give a shout if you think he's got an intracranical bleed cooking in there or anything else you think I ought to look at. The rest of us will work on the patient with the flail segment."

Two things happened as James finished speaking. The outer doors opened with the ambulance crew bringing in the stretcher with their critical patient while the LPN and nurse's aide stationed outside to wait for the ambulance helped get the second patient out. Another aide came rushing in carrying two gla.s.s bottles of blood from the blood bank. Mara had ordered them as Mary Pat had gone out earlier.

From the looks of Harmon Manning they were going to need both of them, and then some.

2.

Phillip didn't like the way the man looked as the EMTs wheeled him in. There wasn't a great deal of bleeding apparent, but the man's skin was a grayish blue color he'd recently learned to call cyanotic. Each rapid breath was a labored, pain-filled gasp. Philip knew what death looked like and this was death before him. He exchanged glances with Ernst and Heinrich who both looked grave but still optimistic.

Phillip, who had seen far more death than they, wasn't so confident. They had seen amazing things in Grantville these last weeks, true.

Ernst and Beulah headed for the second patient while Mary Pat, Mara and one of the EMTs helped move him over onto the ER gurney since it was wider. Phillip managed the IV and oxygen tubing as James leaned over to expose his chest, stethoscope in hand. Phillip had been reading about "breath sounds" and he'd been able to actually hear an asthmatic child's wheeze just that morning on rounds. He didn't think James would be happy with whateverbreath sounds he heard out of this patient.

He could hear Beulah talking with the second patient, hear his slurred speech and concern about his friend. Beulah was talking quietly with him behind the drawn curtain and rea.s.suring him that his friend was being treated. Phillip had moved a tray of instruments and gotten out of the way as the others settled Harmon and began the examination. Mara's face was the only one he had a good view of and something in her face made him edge closer to the gurney, trying to see what had occasioned that sad compa.s.sionate look.

As he got closer, he could see the look on James' face as well. James was very carefully touching-ah,palpating, the word was palpating-their patient's chest. Phillip frowned. He thought that normally, one listened to the chest first in an a.s.sessment. That was what the book had said. He remembered the pa.s.sage clearly. As James lightly touched his chest on the right front side, Phillip could hear a crackling kind of sound.

"What is that noise?His ribs?"

"Crepitus," answered Mary Pat. "That means that the ribs have probably punctured the lung and air is being forced into the skin by the building pressure. See how the area is swollen too? James is trying to get a sense of how big the flail is. An X-ray would tell us more but the patient doesn't have that kind of time."

"About twelve by sixteen centimeters."James reported grimly. He turned toChester , the EMT. "Is the family on the way?"

"Won't be here for at least an hour."

Phillip felt it again, just as he had with Viet all those months ago. It was clear that Mara, Mary Pat andChester knew what to make of James' question. He didn't and neither did Heinrich who was carefully using the ambu bag to help the patient breathe. Beulah stepped softly to Phillip's side. He could hear the LPN working with Ernst as they st.i.tched up the bleeding laceration on the patient in the next bay.

"Want me to get some morphine?" she asked quietly.

James looked up at her and nodded."Yeah. Let's make him as comfortable as we can."

Phillip walked with Beulah to the medicine cabinet at the nurse's station in the center of the room. "He is not going to live, is he?"

"No. The flail is too large and the bones are pulverized under his skin. I watched as Mary Pat took his blood pressure. I could tell she didn't get a very good pulse and when I saw the mercury pulse the first time in the gla.s.s, it was only around fifty. His heart rate is becoming not just rapid, but erratic. We'd rush him into surgery at this point if we could,giving him more blood and IV fluids to keep his pressure up as much as possible. We'd also put in at least one chest tube and so on. But we don't have any ventilators.

Ventilators are machines that can breathe for the patient when the patient can't manage. With a flail chest, we'd need to do that so the bones could knit together while the machine breathed for him. We can't splint the ribs when they're broken that badly because we could drive a piece of bone into his lung. Plus, unlike limbs, which can be immobilized by casts or splints to heal, the ribs will move multiple times each minute with every breath. It would take too much strength for him to do that himself for a few weeks. With a small flail, we'd give it a try but this is just too large. The other injuries he has might kill him as well but if we can't keep him breathing, it's a moot point."

She finished drawing the morphine into a syringe and headed back to the patient. "All we can do ismake him comfortable. We don't have a vent to breathe for him for weeks after the surgery. We also don't have any of the substance that could help glue the bones together. Even though we know he won't make it, we could try to keep him alive until his family gets here so they could say goodbye." She handed the syringe to Mara. "There's ten mg in the syringe. I thought you could s.p.a.ce it out as needed."

She turned back to Philip and motioned him back from the bed. "We can't use the supplies to buy him an extra hour and give them a chance to say goodbye. We only have so many chest tubes. That blood was scheduled to be used this afternoon in surgery. We don't have all the resources we once did. Eventhen, we never had endless resources anywhere I worked.Which means making tough choices sometimes. "

Everyone who remained was oddly hushed, their movements and aspect subdued, Philip thought. They continued to do small tasks for their patient and to clear away material, used or not. There was an air of sadness and frustration in his Grantville colleagues. He was familiar with the feeling of losing a patient.

How much more difficult must it be to lose one that you might have saved, that you had the knowledge to save.

3.

"For G.o.d's sake, Mary Pat, did you have to come armed?" Beulah hissed the aside as she looked out into the lecture room on the third floor of Leahy. They were using the future medical library for a lecture on the history of public health and infection control for theJena students. A lecture Beulah was giving.

d.a.m.ned if she was going to let anyone else face them after her experience last time inJena .

Mary Pat tenderly patted the Berretta 9mm pistol her oldest brother had given her and tried very hard to look innocent. Beulah didn't think she looked at all repentant and the sparkle in those green eyes was far from innocent. "I'm on duty. So of course I'm in my Basic Dress Uniform and carrying a side arm. Do you really think I'd shoot one of these med students for getting out of line?"

"Idon't think you'd do it but they might. This is serious overkill here. Not that I don't appreciate the sentiment but even I'm more subtle than that." She looked at Mary Pat out of the corner of her eye. "That smile would rea.s.sure me and our audience a little more if it had fewer teeth in it."

"I'm on duty. I wouldn't go around shooting unarmed civilians for no good reason." She pursed her lips thoughtfully. "Like say, oh, disorderly conduct."

"We have cops to handle that. I don't buy the just happened to turn up here of all places while on duty line Lieutenant."

"Didn't think you would but it got your mind off the lecture didn't it? I'll be on my way, Officer Flanagan, always at your service."

Beulah laughed and shook her head at her. She was so relieved to see Mary Pat teasingagain, she'd forgive her just about anything."Brat. Okay, okay, it worked. Besides, I think they've already got your point. The lecture's about to start, now scoot. You're scaring my students."

Besides, she thought, I've got to be in the right mood to pull this off.These were not stupid people.

In fact, some of those in that room, like Werner, had first rate minds. They also wouldn't be strangers to some of the political maneuvering she was about to try. Ah, well. Misdirection and cooptation were tried and true strategies. She just had to make sure she approached it properly so that she gave them an "invisible war" that they would be fascinated enough by not to look too closely to see what other invisible war they might be fighting.And to think I've given James such a hard time of late. Maybe I should start hanging around Mike and Balthazar more often myself.

4.

"Good morning. For those of you I haven't already met, I'm Beulah MacDonald. Today, I'll be giving a lecture introducing some of the developments in public health as we use it in Grantville. The readings I a.s.signed should have provided you a basis for understanding terms and concepts I'll be using. I know you've all had to learn a lot of information about statistics quickly."

In fact, that had nearly led to an interdisciplinary wrangle. There was only one basic statistics book at the high school. She knew that the students would need that content to understand simple concepts in public health, particularly in epidemiology. The medical students and faculty fromJena had set up a roster to share the book and essentially taken over the high school library for the duration. Those not studying the statistics book had been studying other material until it was their turn. Copies were being made as quickly as possible when the book wasn't actively in use. Basic statistics had lots of applications.

One of theJena delegates was a high-ranking math faculty member. Seeing clear evidence that the math part of the university quadrivium would be needed by future nurses and doctors, he wanted the book for the math faculty and students. He was genuinely interested in the concepts and quite ready to stake a claim to the text. The school librarian had found him some other texts on probability theory to hold him off for a time, but who had the priority need for the text had been a bit sticky for a moment. The librarian was both amused and appalled. She was thrilled to have people wanting to get to a textbook but the arguing over it was a different matter. Beulah gathered that the argument had gotten quite heated. That was perhaps the most blatant conflict over up-timer books among the Jenaites but not the only one. It made Beulah a little uneasy. There were more faculty and students coming fromJena . This was getting out of control. Each group had some reason attached (not always peripherally) to why they needed access to information or books or specialists to help get the new health sciences program up and running.

They seemed to have started an avalanche. Or a train wreck.

She had had the Grantville high school math teachers tutoring the students in the evenings, whenever one had a break between cla.s.ses and at lunch so the group fromJena had at least a little information about statistics. Math students had joined the med school group. Fortunately, there were only a few math students here.So far at least. She'd also given them quite a bit to read in terms of foundations of public health. According to James, the med students and faculty had spent a late night at the Gardens with their notes cramming before this morning's lecture. She hoped they weren't too hung over.