TRALI (LU in Healthcare)
Part 1
It’s time for more boys to meet Fable! And I wanna expose y’all to ECMO because it’s my favorite thing ever ☺️
Legend yelped as he rounded the corner at the nurse’s station and immediately got splashed in the face by a squirt of saline. Spluttering, he heard a handful of people laughing and saw Warriors smirking, flush in hand, while Wild and Hyrule cackled.
“And now we’re even,” Wars remarked, leaning against the desk and tossing the flush.
It was still worth kicking Warriors’ chair out before he could sit in it.
“Well, if you’re done, some of us are trying to do our jobs,” Legend huffed mildly, wiping his face and moving to a computer. He was curious if his patient’s lab results were back.
Warriors barked out a laugh. “Checking on your favorite patient for the eighth time and seeing where they’re at in their Harry Potter marathon is not doing your job.”
“They’re watching Harry Potter?” Another nurse asked. “Okay but what movie are they on?”
“Fourth.”
“Oooo, wait that’s my favorite!”
“Dude, first one’s the best.”
As a heated debate broke out at the nurse’s station, Warriors noticed a page get blasted to the red team, reading out Alpha Trauma Alert, MVC, 38 YOF, ETA 18 minutes.
“Well, you enjoy your date with your lovely patient, I have actual work to do,” Warriors noted with a smirk as he headed towards the trauma bays.
Legend glanced at the page as he opened the lab results on one of his patients. “I can give you a hand, I just have to discharge one of mine and then I’m free for a bit.”
He almost tripped over his words as he saw his patient’s potassium was through the roof, and he felt his own heart skip a beat. “Uh… well, yeah. I can help.”
He was going to be temporizing someone for sure, but his other two patients were fairly straightforward. One needed stitches for a cut after a fall, the other had a migraine and was resting after some pain medicine.
Twilight also was in motion, getting ready for the trauma by checking the carts and stuffing his pockets full of IV supplies. Hyrule gave a little salute to Wars with a good luck with that, and headed back to the ambulance bay.
It had been a fairly uneventful evening, so they all supposed it was time for some chaos.
The trauma bay slowly came to life as more people trickled in. Warriors and Twilight made sure the place was supplied while Wars checked on his other patient. Time arrived with a resident, as well as the emergency physician. Wind and his preceptor came next, getting airway supplies ready. The more information came in, the more people arrived.
MVC, rollover with ejection. The patient was the driver, her passenger had been thrown from the vehicle and was declared dead on scene. The other vehicle involved had caught fire, and the one patient from that was being flown to a burn center. The crew transporting her was fighting just to keep her alive. They’d given TXA, Ancef, about a liter of LR, and ketamine.
"Does this squad have an RSI protocol?" Time asked the emergency physician.
"I don't think so," the physician replied. "Very few medics can RSI in our area. Protocol committee and OMD didn't deem it necessary since they're so close to multiple hospitals."
Legend popped in, gowning up with everyone else as they got an update the ambulance was arriving. He had his trauma shears at the ready, though the ambulance crew should have already exposed everything.
A moment later the patient rolled in, with two frazzled looking providers at either end of the stretcher. The patient was lethargic, a nonrebreather over her face, and had two IVs already started with one giving a fluid bolus. Everyone paused collectively, remaining silent so the advanced EMT could give a report while everyone listened. Warriors scribbled down notes quickly while Legend helped unbuckle the patient from the stretcher so they could transfer her to the bed as soon as the provider was finished talking. They quickly slid the patient over, getting the bloody stretcher out of the way. The residents did a head to toe assessment while Legend got vitals and Twilight got labs from the established IVs.
The woman's vitals weren't great. Heart rate high, blood pressure low, and she was white as a sheet. The abdominal ultrasound showed blood. Warriors and the emergency physician coordinated to get a cooler of blood products while Legend packed the patient up for a quick trip to CT.
They hadn't expected her to code in CT.
It was a shockable rhythm, indicative alongside the context that this was a hypovolemic arrest. One shock and some compressions alongside squeezing some blood into her brought her back, and they made a hasty return to the ED.
And then stayed there and dumped blood product after blood product in her. A chest tube was placed. An OR was prepped. But they had to just get her stable enough for surgery, and that was proving to be a problem.
"She has to have a liver lac," Warriors grumbled as he grabbed the next cooler, ready to check off blood with Legend. Blood products had to be reviewed by two nurses to ensure the patient was getting the product specifically chosen for them, and with "fast blood," they had to check an entire cooler to make the process faster.
"Okay, ready?" he asked Legend, grabbing the patient's arm bad that he'd taped to the door to help expedite things.
"Ready."
"I have Stellia Blue, date of birth 4/12/1988, MRN 45947651."
"Stellia Blue, date of birth 4/12/88, MRN 45947651," Legend confirmed on the sheet attached to the bag of red blood cells in his hands. Then he handed the bag to Warriors while still reviewing the paper.
"I've got packed RBCs, O negative, unit #1829 24 5869 division 00 D, expires 12th of May 2026."
Legend repeated the information on the sheet to confirm they matched, the pair of nurses initialed the paper, and they moved on to the next product. Another nurse popped in to help Legend finish checking the blood so Warriors could hang more on their rapid infuser, as they were burning through bags every couple minutes.
"Will this ever stop?" Twilight asked as he threw away another empty bag.
"Either she dies or she clots," Warriors answered grimly.
"Can we give her something to make her clot?"
"The EMTs already did. That's what TXA is for. What she needs is surgery."
"But she isn't stable enough."
"Not yet."
Twilight signed, frustrated. However, despite how grim it was, the patient's blood pressure finally was starting to stabilize, and her labs were finally showing that some of the blood was actually staying where it belonged. Her abdomen was getting progressively more rigid, though.
And then, just as they were finally getting her packed for surgery, a new challenge arrived.
"Why is her SpO2 in the 80s?" Wind asked. "We've got her on 100% FiO2 on the ventilator!"
Wind tried troubleshooting the matter with his preceptor, discussing perhaps that there might be too much PEEP for a trauma patient, but the last x-ray hadn't shown an issue with either a pneumothorax or hemothorax.
The emergency physician came in to evaluate after Warriors called him over, and the pair was bouncing ideas around with the respiratory therapy team.
"We could've fluid overloaded her," Warriors suggested. "She got somewhere around thirty products."
"So we do need more PEEP?" Wind asked his preceptor quietly as the physician listened to his lungs.
"She does sound wet," Daphnes noted.
The physician ordered another chest x-ray, and as the tech arrived, Warriors noticed another issue.
"She's febrile," he said, staring bemusedly for a moment, and then he cursed under his breath.
This was a transfusion reaction, wasn't it? A lot of the symptoms were masked, between the patient being obtunded and slightly sedated and intubated, not to mention she was already in shock...
The chest x-ray showed profound pulmonary edema, and Warriors gave the physician a grim expression. The monitor continued to alarm low oxygen saturation, despite Daphnes troubleshooting the ventilator.
"Do you think it's TRALI?" he asked the physician.
The doctor sighed heavily. "Maybe. I'll call Dr. Lon."
Time, who had been discussing another patient with a surgical fellow while waiting for this one to stabilize, arrived quickly, listening as the emergency physician gave him the run down.
"Have we done an ECMO consult?" he asked. "They might be helpful."
"Don't you think that's escalating things a little quickly?" the ED doctor asked.
"Are you kidding?" Warriors fired from the room while he struggled with Daphnes to keep the patient adequately oxygenating. "Please escalate it. She still needs surgery, if we can't get her sats under control she'll die in the OR anyway!"
The doctor sighed, and Time raised an eyebrow. "All right, I'll consult them."
Wind helped run multiple arterial blood gases to monitor the patient's oxygenation while Daphnes tried different modes on the ventilator. Warriors eventually was told to paralyze the patient, though he was worried about adequate sedation - too much sedation would mess up her sympathetic response that was currently keeping her alive while she was still actively bleeding, but not enough would make her awake while being paralyzed.
Well. She was obtunded anyway. Maybe another bolus of ketamine would do the trick fine.
Eventually, though, despite their best efforts, the patient was still struggling, and her blood pressure was starting to show it.
"She won't live to surgery if we don't do something," Warriors argued as the ECMO team spoke with the ED physician. Eventually, they decided to cannulate the patient, and more people arrived from the cardiovascular ICU to assist.
Legend sighed as he walked into the room with another cooler of blood products, ready to check it off with Warriors, when he froze.
"Ledge, come on," Warriors called. "Let's check these before we start needing the belmont again."
Warriors traced Legend's gaze to one of the nurses who had arrived with the ECMO team, a woman with blue eyes, blonde hair barely noticeable under a blue scrub cap that matched Legend's. Her eyes matched his too. And her nose. And...
Wait a damn minute.
"Do you two know each other?" Warriors asked, squinting suspiciously at Legend.
His friend's cheeks flushed. The CV ICU nurse rolled her eyes.
"She's... yes. I know her."
"He's my brother," she huffed, walking by, unbothered by the bombshell she'd just dropped. Legend spluttered, and Warriors stared.
"You have a sister and she works here, and you never once thought to mention that?" he nearly yelled, waving a hand.
"Worry about your patient!" Legend grumbled.
"That's her patient now," Warriors reminded him, though he still walked back into the trauma bay to give Legend's sister report. "This conversation is not over."
Legend scowled as he walked away, returning to his own patients, and decided that he should indeed just hide in his favorite one's room and keep watching Harry Potter with her.
Meanwhile, cardiac surgeons started to prep the patient while Wind maneuvered between people and machinery to get to Warriors. "Hey, so what's going on now?"
"Have you not studied ECMO yet in school?" Warriors asked quietly before pausing and looking back at the door. "Hey, wait a second, Ledge get back here! We gotta check off blood!"
"No, I haven't," Wind noted as their friend froze and reluctantly dragged his feet back to the trauma bay.
"ECMO stands for extracorporeal membraneous oxygenation," he explained. "In lay man's terms, it's mini bypass for your lungs and, if needed, your heart too."
"Bypass for your lungs?" Wind repeated, eyes wide. "That's cool."
Legend's sister grabbed a paper towel and clicked her pen, smiling at Warriors. "So what's the sitch?"
"Okay, to start, I am so sorry you're related to him," Warriors said gravely, making her laugh.
"It is tragic, really," she agreed, growing solemn.
Warriors hummed and then continued, "Well, anyway, this one is a 38 year old female, MVC victim, was the driver, unrestrained, rollover crash."
Warriors continued to talk as Legend hovered in the entrance, looking around and then snagging a coworker. "Hey, check this blood with me, will you?"
His coworker glanced into the room, noticing how busy it was, and nodded, grabbing the patient's ID band from the door. By the time Warriors finished report, the CV ICU nurse, who introduced herself as Fable (with a laugh, saying the nickname was a long story but she knew enough about Legend's friends to know there was at least one other person named Zelda), was pushing a small dose of heparin (much to Warriors' alarm, though he was told it was necessary for cannulation), and Wars looked around to find his victim.
Legend had vanished.
"I tried lookin'," Twilight noted. "We'll corner him later. I bet he's in Harry Potter room."
"Well, I'm about to have one less patient, so I'll find him," Warriors promised. "He's never going to hear the end of it."
Several hallways away, Legend crossed his arms as he watched the fifth Harry Potter movie start, skin crawling. He just knew they were talking about him.
Ugh, he grumbled internally. This isn't how I wanted them to find out.
"You seem upset," his patient noted.
"It's fine," Legend said quietly. "Silly things. But we'll re-check your labs in about half an hour to see if the temporizing worked."
"You can stay the half hour if you like," his patient said with a smile.
Legend laughed. "You're sweet. I wish I could, but I have others to check on too. But uh... maybe for a few minutes."
"Oh, you're definitely hiding," she noted.
Legend sighed. "All right, fine, yes. My coworkers just found out about my sister."
"Is that bad?"
"...Not really. Just annoying. It's complicated."
His patient hummed. "Yeah, I get that. Family is hard sometimes."
"I love her," Legend said immediately. "But yes, she's a pain in the ass."
His patient laughed at that. "Buddy, that's just called being a sibling."
Legend snorted. "Yeah, I suppose you're right."
The curtain burst open a moment later, and Warriors was there with a bright smile. "Well hello there! Need any help in here?"
"Ooooh, that's the coworker," Legend's patient whispered. "He's hot."
"He's not worth it," Legend replied immediately.
"But still hot."
Warriors laughed a little, waving a hand. "Not nearly as attractive as you. You're really rocking the hospital gown look."
"I know," the patient replied with a smile.
Before anyone could speak, a code blue alarm sounded, and Legend and Warriors hastily started to move and find the source.
"A sister? You didn't think to tell us you had a sister?" Warriors noted.
"Someone is dying," Legend huffed.
"Dude, we'd be talking about lunch right now and you wouldn't care, you're avoiding the issue. You're so dramatic."
"I am not," Legend snapped.
"Oooh, you found him!" Twilight noted as he dragged the crash cart. "Dude, what the hell."
Legend wished he was the one being coded. At least then he wouldn't have to deal with this absolute disruption of his equilibrium.
The interaction was interrupted as they reached the room in question, helping the primary nurse and the rest of the team as they worked to resuscitate the patient. As soon as they got a pulse back, Legend fled the vicinity, focusing diligently on his own patients.
Warriors, meanwhile, was cleaning up his trauma bay with Twilight. The patient had left for surgery before Wars had gone to harass Legend earlier, and Wind and Time were busy with her now. She would go to the cardiac ICU when everything was done since she was now on the ECMO circuit - all ECMO patients went to that ICU since the nurses there were trained on it.
"Okay, theories as to why Legend didn't tell us, go," Warriors said as he tossed more bloody ABD pads into the red bin.
"She knows all his secrets, duh," Twilight said easily.
"I was going to say it's because she's better at everything than him and he hates that."
"Don't all CV ICU nurses think they're better than everyone?"
"Well, yes, there is that."
Wild popped by, whistling at the mess in the room. "You guys were busy, I see."
"Legend has a sister," Twilight and Warriors immediately said in unison.
Wild blinked, registering this information. "Wait. He--what--was she the patient?!"
"No, no!" Warriors hastily corrected. "Patient's on ECMO now, she was the nurse."
"What's ECMO--"
"Dude, Legend has a sister, focus!"
Wild pulled out his phone. "You're right, I gotta tell everyone."
"Call an emergency meeting at Telma's after work," Warriors added as Twilight laughed.
"He's gonna hate us," Twi noted.
"He loves us," Warriors threw back easily.
Legend did not, in fact, love them as he saw the text pop up on his phone.
