This is the final entry into the Time collection of short stories. Dr. Dayo first appeared in Scarcity as a cardiac transplant surgeon who was faced with a difficult situation regarding one of his patients. I threw a challenging patient at him in this story as well. I hope you enjoy it.
Six Hours with Dayo
The stars were out but the lights of Baltimore drown out all but the brightest from his gaze. Despite this flaw it was still one of his favorite views and he took it in alone from the roof of the hospital as he had done before on countless occasions. He leaned the overworked lawn chair back as far as he dared and placed his feet up on the parapet. The chair protested with a loud squeal and he froze until it decided it would hold his weight. A search of his pockets produced a cigar and he soon had it clipped and lit with one of his last wooden matches. He made a mental note to buy some more as he puffed on the Montecito, working the glow on its end into a healthy orange. It was a nice interruption to what had so far been a boring night of on-call duty.
Since he was alone he practiced. The art of blowing smoke rings was one he had yet to master. His attempts were drawn out and over his feet only to be sucked down and out of sight by the downdraft created by the buildings edge. He gave himself a success rate of one for three, he worked on it some more.
The silence was shattered by two aircraft, one he identified as a jet passing overhead. He named its destination by its course; Andrews air force base. He shrugged it off as he listened for the second aircraft. Helicopters were not unusual here in Baltimore, but if this one was flying into Johns Hopkins it might change his otherwise boring evening.
The sound faded in and out until suddenly becoming louder as the helicopter circled the building before landing. Just as the pilot killed the engines his pager vibrated. The chair protested again as he twisted in its grip to read the small screen. ER-STAT it read. He took one last puff before quickly stubbing out the cigar on the tar roof. He launched himself from the chair and made it to the stairs in time for the first overhead page. He heard his own name twice before the elevator arrived.
“Coming, mother,” he told the elderly female voice.
He entered the empty car and quickly punched buttons. Thankfully there were no stops on the way down and Dayo bolted out the opening doors as soon as they cracked open, only to run square into a man as big as himself waiting. They instinctively grabbed one another to keep themselves upright and did an awkward dance.
“I’m sorry,” Dayo apologized.
“No problem,” the man replied. Dayo spun and speed walked in the direction of the ER. He got a few feet before hearing a shouted question from the man he had run into.
Dayo rounded an intersection and was joined by the pilot of the helicopter who had lagged behind the medical crew to secure his bird.
“What did you bring in?” Dayo asked without slowing down.
The man had a look of bewilderment on his face as he tried to come up with the words to describe what the doctor was asking. He scrambled to keep up.
“Seems this Amish guy was helping to build a barn with a bunch of his buddies. Somehow he got knocked off the frame and fell about a story or so. He was holding an axe when he fell and…well, he landed on it. It’s not pretty doc. Guy’s a tough one though. No phones there of course so he laid there for at least an hour before we got there.”
“Well, they threw the fastest kid on the fastest horse and sent him down the road to find the nearest phone. A few miles I guess. Nobody home so he smashed a window to get in, only then does he find out that the people have no phone at the house. Only cell phones. Well the wife comes home and freaks out over the strange kid in her house but he finally gets through to her what’s happening and we get the call. The woman gives the kid a ride back to the barn and then relays directions. Of course it’s dark by this time and we only found them because she put her flashers on. I found a field with a few cows in it close by and managed to land without chopping any up. Unbelievable.”
“Okay, but what about the injury? Where’s he cut?”
“Not really a cut…I’m not sure what you’d call it, you’ll have to see it for yourself.”
Dayo gave up as they were at the ER doors. He swiped his card and slapped the button to open them and they were immediately assaulted by the noise and confusion that was normal to an inner city Emergency Room. Dayo worked his bulky frame through the throng until he got to the charge desk. He saw a nurse he knew typing furiously into a computer without the aid of a chair.
“Becca, where they at?”
She glanced up to see who it was and then back to her computer screen as she answered.
“Trauma one, you’re gonna love it.”
Dayo frowned at that but wasted no time. He spun on a heel and drove back through the crowd until he got to the trauma room. There was a group of techs from various departments waiting outside along with a few curious nurses.
“Make a hole,” Dayo ordered.
He sidestepped through the parting sea of people and entered the room. The first thing he saw was the trauma surgeon, Dr. Balzano, standing arms crossed over the man on the gurney in front of him, a puzzled frown on his face. Dayo’s own eyes popped when he saw the patient for himself.
A man of about fifty lay on the bed with what appeared to be a piece of raw leather clenched in his teeth. He sported a six-inch beard with no moustache that immediately identified him as a member of the Amish community. His bare frame showed the lean sinewy build of a man who was no stranger to hard physical labor. The nurses in attendance were removing the last of his pants with trauma shears. The man calmly reached up and pulled the leather from his mouth. The teeth marks were deep. His voice, while possessing a edge, was calm.
“Spare the boots if you can please.”
The leather was quickly replaced and again clenched down on hard. The man was obviously in a great deal of pain, but was handling it well.
The source of the pain was evident. The blade of an axe was secured to his upper thigh with what looked like ordinary duct tape. The axe blade was clean and shiny, the edge covered with layers of cloth surgical tape to prevent it from cutting anyone.
The three foot handle was buried deep within the man’s body.
“What the hell happened?” Dayo asked.
Dr. Balzano snapped a picture with his phone and just shook his head before pointing to the flight medic who had brought him in. The man told the story again.
“Seems Mr. Yoder here was helping to build a barn today. They were swinging a beam into place and he got knocked off his perch. About a twenty-foot fall. Unfortunately he was holding the axe between his legs when it happened. It stayed with him all the way down and he landed clean on top of it. From what I’ve been able to check so far the blunt end of the handle tore through his scrotum and entered his groin before traveling up toward his left shoulder there where you see it bulging the skin out. I think it just kind of shoved everything aside as it went. Lucky for him it seems to have chosen the outside path when it got to his ribs. At least two of them are broken there at the bottom and the clavicle may be up at the top. But his pressure is good and his lungs are clear. The people there say he was awake the whole time and there’s no head injury that I can see. Minimal blood loss. He laid there for over an hour until we got there. Evidently they had no phone close by and had to send somebody…”
“Yeah, I got that part already.” Dayo cut him off. “What have you done so far?”
“Some fentanyl for the pain but he didn’t want too much. He’s been making do with the leather there. A pair of IV’s. Other than that, we just got ready.”
Dayo looked him over again and frowned. “Duct tape?”
The medic frowned back. “It was there when we got there, I didn’t see any reason to change it.”
“That was the right call,” Balzano broke in. “Does he have any family coming?”
“The village elders are on the way in with his wife.”
Balzano nodded in approval as he was familiar with the Amish community. While they lived a simple life of their own choosing they did not have any qualms about using modern medicine. If one member of a village was injured, the whole town supported them. The trauma surgeon had developed a great respect for them over the years, they were excellent patients. He stepped up to the head of the bed so the man could see him.
“Mr. Yoder, I’m Dr. Balzano, I’m the trauma surgeon working tonight and I’m going to be taking care of you. Can you tell me if you’re having any trouble breathing?”
The man calmly reached up and removed the leather as he had before and answered the doctors question.
The surgeon smiled at that. The short answer spoke volumes to him. He donned his stethoscope and listened to the man’s chest before moving to his abdomen.
“He sounds good. Give him another fifty of fentanyl and watch his respirations. Did we draw all the labs I ordered? Type and cross him? Alright then, let’s get him to CT, I want to see what’s going on in there.”
Both surgeons watched as the man was packaged up and wheeled out of the room. Balzano tugged on Dayo’s sleeve and they stayed behind until the room was empty.
“How the hell do you want to do this?” Dayo asked.
“I’m not sure, never seen anything like this before in my entire career. You?”
“Not even close.”
“Okay, I guess we just make it up as we go along. Glad you’re here, I’ll defiantly need the extra hands.”
“No problem, I wasn’t really doing anything when you called.”
They walked out and headed for CT. Becca gave Dayo an I-told-you-so look as they marched by the desk. He nodded back with a smile. She had been right.
The two surgeons stood behind the tech as the images slowly scrolled their way onto the screen. They took mental notes and frowned at things that were out of place. The tech struggled to concentrate as the two men crowded him in what was normally an empty room.
“Clavical looks intact, just rotated out of place.”
“The ribs are fractured…here…and here. Looks like the handle just scraped across the rest. Lungs are clear, for now anyway, those ribs could decide to puncture something every time we move him. I should have left him on the board.”
“I don’t like how these structures here are bunched up, especially the spleen, we could have something tamponauded off in there and never know it.”
They watched and made further notes until the entire axe handle had been scanned.
Balzano spoke first; “The way I see it we have two choices; open him up from handle to blade and pull the whole thing at once, or open him at intervals as we retract the handle out the same way it went in and just repair things as we go.”
Dayo frowned while he considered their options. He had assumed they would be doing the first option, but the man’s lungs were clear and so far he had tolerated the injury well, showing no signs of shock or other complications. Item two may be worth a shot. If they were successful the man’s recovery would be shorter, if something went wrong they could always switch to an open procedure.
“If you want to try option two I’m up for it. Your patient.” Dayo answered.
Balzano nodded as he reviewed another image. It was his patient and his decision, but it helped knowing Dayo agreed with his call.
“Option two then. Let’s get him upstairs and prepped.”
He walked around the wall and stepped out into the hall where the transport team waited.
“Take him upstairs guys. Rita, we’ll be taking it out the way it went in, but be ready to switch to an open just in case. He’s got two broken ribs on the lower left so handle him gently, I don’t want them poking any more holes in him.”
With a nod and a unspoken “Okay” Rita pulled out her cell phone to call the surgical unit. Balzano didn’t bother to listen, with Rita there he knew everything would be just as he wanted when they arrived. He turned back into the room to find Dayo still studying the images. The tech was making copies for them to take up with them, along with a few extra to show off to his coworkers.
Balzano looked through the window and watched the team prepare to move the patient off the CT scanner and onto the transport gurney. The shiny axe blade gleamed in the bright light.
“What are we going to cut that blade off with?”
Dayo smiled. “I know a guy.”
Joe stood outside the doorway of the operating room with the same bewildered look he had on his face the last time he had been summoned there. This time the instructions were just as strange though. Instead of a timing light he now held a simple wood saw in his hands. He watched the nurses and techs race around the room and position various machines and other items. Tray after tray of shiny objects landed next to the black operating table. All seven overhead lights came on. He spotted the by-pass machine he had fought with a few months ago and was pleased to see it staying in its designated parking place. Obviously something was happening, he just didn’t know what. He searched for a familiar face to question but it was hard to recognize them behind their surgical masks. He wondered how they worked for hours wearing them, his had only been on for the last few minutes and it was already driving him nuts. The booties on his feet barely covered his work boots, he had to be careful as they were slippery.
A voice from behind him made him jump.
“Joe, you made it.”
He turned to see a pair of doctors approaching with a team of people pushing a patient on a gurney behind them. The one in front he knew, the other he had seen before but had never talked to.
“Dr. Dayo? You call for me?”
“That’s right. I need your help with something. Only take a minute, take a look.”
The team stopped the bed in front of him and Dayo flipped the sheet back. Joe’s mouth fell open as he took in the sight. The team smiled behind their masks at his reaction.
“I need you to cut the head off of this axe for me. Get as close to the blade as you can and try not shake it too much. Its touching some important stuff.”
Joe quickly recovered and examined the job at hand.
“Uhh…okay, anything else?”
Balzano spoke up. “Try not to cut the patient either.”
Joe just nodded. “Right, I’ll need some help holding it.”
Three pair of hands reached out and held the axe still while another held the patients equipment out of the way. Joe cut the tape lose and pulled it away first with his pocket knife. He then tried the saw at a couple different angles before selecting to cut from under the axe, away from the patients leg. The surgeons nodded in approval but said nothing.
“Okay, here we go.”
The first few strokes elicited a groan from the patient and Balzano nodded to a nurse who increased the IV drip rate. Joe didn’t stop, he just kept an even stroke on the small saw and concentrated on not moving the handle too much. Soon he was halfway through and had to stop to allow a tech room to move his hands to a different spot, if the axe handle were to pinch on the blade it could result in a jerk on the handle, something they didn’t want.
When he got close to the edge he sounded a warning. The techs held their faces away as the blade sliced through the last centimeter and popped up. The heavy axe blade fell into the hands of a nurse who set it on a nearby cabinet. Another nurse carefully gather the towel holding the sawdust and deposited it into a trash can. Before Joe had a chance to admire his handiwork they had pulled the sheet back over the man and were wheeling him into the room.
“Thanks Joe, nice work,” Dayo voiced.
“Yeah, uhh…no problem. Say, how did he get that…”
“I’ll have to tell you later. Gotta go.”
Joe watched through the glass window as they swarmed around the patient. The man was soon lost from sight with only his feet showing between two busy bodies. Joe retreated back and turned to leave but his attention was caught by the axe blade sitting on the cabinet, still half covered in tape.
He grabbed it and bounced it in his hand a few times before carrying it out with him. The charge nurse just smiled and waved as he walked past.
His wife was more likely to believe his story if he had the blade to show her.
Balzano stood over the patient stretched out on the table in front of him while Dayo mirrored his image on the other side. Playing to each mans strengths they had decided that Dayo would perform the first few cuts and handle everything above the diaphragm. Once that was clear they would switch sides and Balzano would handle the rest. Dr. Dryer had arrived and now Mr. Yoder was fully sedated, paralyzed and intubated. The ventilator settings were shallow and slightly more rapid than usual so as to lessen the movement of the chest wall. Rita had given her speech and announced them ready.
“Okay, let’s do this. Rita, who’s going to pull?” Balzano asked.
“Oh…okay.” He looked across the table at his colleague. “Whenever you’re ready.”
Dayo checked the time before holding out his hand. “Starting at 22:31.”
Accepting the scalpel he made an incision just over the top of the protruding axe handle. The tenting skin fell away, pulled apart by the pressure of the handle. The head of the handle was soon visible with the aid of a little retraction and the surgeon peered into the opening he had created.
“The tissue is separated fairly clean, just peeled apart as we expected. Clavicle appears intake, I think if we retract the handle a bit it will rotate back into place. The handle appears very smooth actually, obviously been well used. I don’t see any splintering or cracks. I think we can try pulling it.”
“Okay, Rita, pull it out about three inches, just be ready to stop.”
Rita stepped up to the table and wrapped her gloved hands around the freshly sawn wood. She didn’t really wish to be the one to do this, but she was the only logical choice as she was the only one of them that wasn’t scrubbed in and sterile. They had already secured a heavy strap under the man’s armpits and across his shoulders so she wouldn’t pull him down the table, so she planted a hip for leverage, took a deep breath, and applied some muscle to the issue.
The team all watched as the head of the handle slowly retreated into the man’s body while an equal portion emerged from his groin. The clavicle seemed to uncoil under the skin as it turned and found its natural place. A sucking sound emanated from the wound and the pop of moving bones made some cringe. Causing such noises was frowned upon outside of the orthopedic room, but they really had no choice.
“Alright, stop there. How do we look?”
With the techs once again retracting, Dayo opened the cut he had made and examined it anew.
“Looks good, clavicle is back in place, no significant bleeding, nothing left behind. I’m happy.”
“No change. You’re good.”
“Okay, let’s do it again.”
Dayo measured before making another incision below the first. Again the skin split open without retraction due to the pressure being applied. Gleaming white ribs could be seen through the opening and Dayo took his time examining the path that the handle had taken. Again, he saw nothing significant that required his attention. He gave the go ahead for another pull.
Rita rolled her eyes before grabbing the handle once again. She measured the distance. This pull would take her to the bottom of the rib cage. She didn’t like that.
“You want me to pull it past the ribs?”
Balzano immediately saw why she was asking. Those ribs were broken, they knew that already. Having the head of the axe handle resting on just them might be enough to force them deeper, pushing the broken ends into the lungs or some other organ.
“Yes, pull till you’re clear of the rib cage and then stop.”
“Okay, here goes.”
The handle once again emerged and disappeared at the same time, moving grotesquely under the skin as it traveled through the man’s body. Some more crepitus was heard as she dragged it over the broken ribs, but once clear the motion fell silent and the handle tented the skin less as it was no longer held up by the man’s skeletal framework.
“Uhh, that’s nasty. I can just feel it sliding across all of his ribs.”
Anyone’s reply was cut off by the screaming of an alarm. They all immediately looked at the overhead monitor.
“Systolic pressure is crashing.” Dryer announced.
Dayo looked down to see bright red blood oozing from the last incision he had made.
“From where? The spleen?”
“I don’t know, switching to an open!”
“Rita, get ready to pull that handle again.”
“All of it!”
Rita grabbed the handle and got ready. Balzano accepted a scalpel, stuck his opposite thumb in the notch at the bottom of the sternum and sliced the man’s abdomen open. Blood poured from the opening and Rita’s chest began to ache as she watched him work.
She suddenly realized she had been holding her breath.
Despite its many wonders, the human body also has many flaws in its design. One of these is the spleen. While the spleen performed many functions, none of them were critical to the bodies needs. One could live a long and healthy life minus their spleen.
This was fortunate as the spleen was quite vulnerable to injury and usually impossible to repair. Balzano had once had an instructor describe the spleen as an overripe plum, with its thin skin and soft interior this was a good analogy. If one were to drop a plum onto a hard surface the skin would fracture and split in multiple directions. Due to its vascularity these fractures would then bleed profusely. If one can picture trying to sew such a thing back together they quickly see the folly of such an effort, the patient would bleed out long before the repair could be accomplished. Some of his classmates had actually tried. None had succeeded. The treatment for a ruptured spleen was almost always removal, and quickly.
Balzano’s hands were in constant motion and the techs scrambled to keep up. He soon had the abdomen open and suction tubes worked hard at clearing the blood away.
“Get a hand in here Joey and draw this stomach and bowel down.”
Joey stuck his left hand in and performed the move while also retracting the left margin of the opening upwards. Balzano thought he may have to extend the incision, but Joey’s strength was enough to erase that thought. Dr. Dryer made things easier by tilting the table to the right.
The surgeon’s hands searched for landmarks under the pool of blood and eventually he found what he wanted. A pair of blunt scissors appeared in his hand and he opened a window into the man’s gastrosplenic ligament which allowed him access to the splenic artery, but before he could find it he was interrupted again.
A loud alarm cut through the action on the table. It was one that could not be ignored.
“He’s coding.” Dryer announced, “No pulse.”
“An amp of epi!” Dayo ordered, “Start CPR.”
“Careful, my hand is in here with these ribs!” Balzano voiced.
Dayo looked for a tech to do chest compressions but quickly realized there was no room for them to get in, he began pumping the man’s chest himself.
“Hang two units!”
“Open that IV.”
“You okay?” Dayo asked.
“I’m good, keep going.”
Balzano could feel the broken ribs rubbing against his hand but he had no choice but to continue. He fought the movement of the chest and felt his way along the upper border of the pancreas, breaking some light adhesions as he went in a blind search for the splenic artery. Finding it he froze and called for a scalpel. Another suction catheter joined the one already there and for the first time Balzano could see what he was doing. He quickly incised the peritoneum over the artery, passed a haemostat underneath it and clamped it off.
The bleeding slowed to a trickle. Balzano stuck his hand over the injured area, protecting it from the sharp ribs.
“I clamped the splenic. Bleeding slowed. Let’s get him restarted.”
“One milligram epi going in.” Dryer voiced.
Dayo tilted his head to the screen and examined the waveform. He stopped compressions long enough to see that there was no change. He started anew.
“Pulse is faint.”
“He needs volume, pump up that pressure bag,” Dayo ordered.
Dryer squeezed the bulb and inflated the bag, forcing the blood and saline into the man’s vascular system. He checked the pulse again. The sounds of suction catheters running dry permeated the room.
Balzano looked down at the patient. Counting his own there were a total of six hands in his abdomen alone. The veins of Joey’s forearms stood out in his effort to retract the opening so they could all work. He saw that Rita had retracted another six inches of the handle leaving three or four inches still in place in the lower abdomen. Did she fear pulling it past the abdominal aorta? Perhaps. Smart girl. He gave her a nod that said stay put.
Dayo stopped compressions again and they all examined the screen. This time they were treated to a chaotic line marching across it.
“That’s fib”, Dayo announced.
“Charging.” Dryer answered. The capacitor whined in the background.
Balzano frowned. He didn’t want to remove his hands and risk the ribs stabbing something else when the body contracted.
“What?” Dayo asked.
“I want to pack this off. A big one.” Balzano ordered.
Rita dropped the handle and scrambled to comply. She opened it over the patient and it fell right into Balzano’s hand. He shook it out before stuffing it into the opening he had created, taking the place of his protective hand. He withdrew as soon as it was in place and everyone else followed suit.
“Clear,” he announced.
The body on the table shivered violently and then lay still. They ignored it and watched the monitor.
“Still V-fib. Charging!”
Dayo gave a few more compressions while the capacitor charged again.
This time the spike on the screen was followed by a series of smaller ones. They soon fell into a steady rhythm and settle down to a rate of 140.
“Good carotid,” Dryer announced.
“I’ve got a strong femoral,” Rita echoed.
Balzano and Dayo shared a look before they both shook their heads. Everyone took a deep breath. The techs used the pause to get organized while Joey flexed his hands and prepared to once again retract in two directions.
“Okay, let’s get this done. Where the hell was I, Joey?”
“You were about to clamp, cut, and tie his short gastric vessels passing from his spleen to the greater curvature of his stomach.”
“What? I’m going for my first-assist cert,” Joey said
“Well okay then, you can help me,” Balzano replied with a chuckle.
The teams put their heads down and got to work. Dayo and Dryer worked to calm down the patient’s heart and stabilize his blood pressure while Balzano and his new assistant worked to remove the damaged spleen. A small puncture was found into the chest cavity and Dayo installed a chest tube to deal with it before closing the incisions he had made earlier. A tear was discovered in one of the smaller gastric vessels and Joey received an unscheduled class on how to oversew the wall of the stomach with atraumatic sutures. The damaged spleen found its way into a stainless steel tray and was carried away. Eventually the remainder of the axe handle was removed without incident and Balzano was able to sew the man’s groin back together into a complete, if somewhat swollen rendition of its original shape. Before they knew it, two hours had passed.
Balzano stretched while he carefully watched Joey close the patient up. So far he was doing fine and the others tried to perform their clean-up work around him while they watched, most of them jealous and rooting for him at the same time.
“Bigger bites, Joey, otherwise you’re doing fine.”
Joey wisely just nodded and did as he was told. Balzano cranked his neck around to work out the kinks and caught site of Rita across the room.
“Will that fit in the autoclave?” Balzano asked.
Rita looked at the axe handle she had been about to stuff in a biohazard bag. It was covered with blood and bits of fatty tissue and in her eyes the sooner she got rid of it the better. Now she took in the length and mentally measured it.
“I think so; do you think he wants it back?”
“Have them clean it and drop it off at my office.”
Rita rolled her eyes and shared a look with Joey as he finished the last stitch. They had all heard about Balzano’s trophy box. Bizarre was the more polite word for it in their eyes, but if the man wanted it, then he would get it.
Dayo pulled his gown off and wiped the sweat from his forehead before following Balzano out the door.
“I’m going to talk to the family, care to join me?”
“I’ll pass this time. Join me on the roof afterward if you want. I’ve always got an extra.”
“The wife would kill me, but thanks anyway, for the help in there too.”
Ten minutes later Dayo was once again testing the strength of the lawn chair. It creaked and groaned but he managed to ignore it while he took in the view. The moon had advanced across the sky and the city lights had decreased in number but it was still worth his gaze.
The cigar started back up without protest and be puffed on it around a smile of content.
Six Hours with Dr. Dayo, Copyright Randall Wood 2013