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“BP is 72 over 44, pulse ox 89.” Kim called out across the room.
Al-Hashimi nodded, and gestured towards the head of the bed. “Put him on 100% non-rebreather.”
Donnie walked over to place the mask over the patient’s head.
“Call Surgery!” Mohan yelled out. Whitaker scrambled to the phone calling Garcia’s extension by heart, 1121.
When the conversation finished Whitaker sighed and hung up.
He yelled, “Surgery says it’ll be ten minutes!”
“Not good enough!” Mohan snapped back.
“Okay, prep for a needle thoracostomy, Samira.” Al-Hashimi shook her head. They all knew they needed to relieve the pressure and waiting ten minutes would make a critical difference in care. Mohan gestured to Kim and Donnie who prepped the tray and started fitting her gown.
From behind, Ogilvie raised his hand, “Doesn’t he need a chest tube?”
Whitaker shook his head. “Surgery will need to come in and place the chest tube, until then we relieve the pressure from the tension pneumo through the needle decompression.” Joy watched the whole exchange silently, tense but with no investment.
What occurred next happened quickly. Mohan placed the needle in the mid-clavicular line between the 2nd and 3rd intercostal space, aimed the catheter towards the head and advanced to the needle. The hiss of trapped air was audible on release and she quickly placed the one way valve.
“Pulse ox and pressure climbing.” Kim informed, her eyes watching the rising numbers on the monitor.
And with it, the tension in the room lightened..
“Surgery is not gonna be happy about this one,” Ogilvie remarked with a smirk. The pneumothorax should have been caught, the ultrasound was in the system and the patient had been back from imaging for at least twenty minutes.
Mohan shook off the gown and threw them in the bin before signing in to the workstation. “Images were in over half an hour ago,” Mohan shook her head in disbelief.
“Who’s the primary on this?” Al-Hashimi asked no one in particular.
“Oh um, it’s Santos- Dr. Santos,” Whitaker answered.
“Ohh,” Mohan said in understanding. The strain and tightness across her shoulders slackened and she shrugged off and walked towards the door, “I’ll go grab her and fill her in.”
“Uh, yea, she might be in the break room, she was resting from the code on the ten-year old from earlier,” Whitaker nodded solemnly.
“Got it,” she responded.
Mohan left the room and the nurses started clearing the used supplies and bringing in the chest tube tray, knowing they’d need it soon.
“So, how much do you wanna bet Dr. Garcia yells at Dr. Santos?” Ogilvie smirked at Joy.
Whitaker snorted before Ogilvie could even finish the sentence. The two turned to him and gave him a strange look, but continued. “Let’s make it more interesting, let’s bet on nicknames,” Joy smirked.
“I heard her call Javadi a nepo-baby, what’s she gonna call Dr. Santos, gunner wannabe?” Ogilvie’s smile widened.
“Yesterday, I saw Dr. Garcia yell at Dr. Shen so bad he went and forgot about his coffee at the nurses’ station, it was still there in the morning.” Joy shivered at the thought.
“Isn’t Dr. Shen an attending?” Ogilvie asked, and Joy just nodded solemnly. “Okay, so do we bet on if she cries?”
From across the room, Al-Hashimi stood patiently, her hands held behind her back as she waited for the surgeon. She could hear their conversation but chose not to partake, feeling that especially the students needed some harmless outlet to distract from the newer gruesome realities presented before them.
“Listen, I’m gonna save you both some money and tell you that none of that’s gonna happen. Not today anyway,” Whitaker shook his head with a smile on his face.
From the other side, Kim let out a small chuckle and Donnie released an involuntary “Hah!”
Joy looked around to the two nurses and saw their smiling faces then turned back to Whitaker. “Oh yea, what’s the tea?” Joy raised on her eyebrows curiously.
“Right, you guys have never worked with both of them at the same time?”
“No, just separately, but I will say that both experiences have been suboptimal for me,” Ogilvie grimaced, remembering the disimpaction and glass fragment incident.
“Well, you can’t tell either of them this, but-” Whitaker looked at his surroundings, on the lookout for either his roommate or her paramour, “around here, we call it the Trinity Theorem.”
That. That got Al-Hashimi’s attention, and she turned her gaze to the young student doctors and intern’s direction.
“The Trinity Theorem?” Joy scrunched her face.
“Trinity, yea, that’s Santos’ first name,” Whitaker nodded. “It makes more sense when you know the theorem.”
Al-Hashimi decided to stop eavesdropping and walked over in their direction, and the three froze. “No, please, continue. I’ll admit, I’m also curious about this Theorem,” she smiled at them. Whitaker was caught off-guard, but it wasn’t the biggest secret. The whole ED knew and even contributed to it. Well, everyone except for the two women in question.
Whitaker nodded his head, “Uh yea, sure, so basically it’s something the rest of the Pitt came up with, just, you know, don’t ever tell Santos and Dr. Garcia,” he trailed off.
“It’s pretty simple, at the base of it, there’s a Core Tenet, and then three operating principles.”
He explained that the core tenet was the foundation of the theorem, and that it was supported by three principles that were tried, true and measured objectively.
“It’s basically guaranteed that you'll see all three principles in action,” he spoke confidently and shrugged.
As he completed explaining the tenet and principles, Santos walked through the glass doors in a frenzy.
“Shit, Dr. Al-Hashimi, I’m sorry, I was so focused on Betty from before I-”
“Dr. Santos, it’s fine, we were able to handle it in your absence,” she smiled kindly at the younger woman. Al-Hashimi took a closer look at the younger doctor who took her place at the patient’s bedside. Al-Hashimi couldn’t quite reconcile the younger woman in front of her with the Theorems that Whitaker had brought up.
Both Joy and Ogilvie also studied Santos given the recent revelation from the intern, trying to match the image up in their mind. Ogilvie let out a pessimistic snort at the thought.
“That’s an interesting conjecture you mentioned Dr. Whitaker, I'm curious to see how well that theorem stands,” she smiled at him from across the room.
The Trinity Theorem - Core Tenet
Trinity Santos’ presence during a Yolanda Garcia surgery consultation correlates to improved outcomes for all participants. This is due in part to three operating principles.
Or in Whitaker’s words:
“If Trinity is around when Garcia comes down, everything is a lot easier. There's three main reasons:”
Just then, a force of nature burst through the doors, Yolanda Garcia had landed.
“What’s up, party people?” She called boastfully, her head was tilted down towards the chart in her hands displaying the ultrasound results. “I heard you guys fucked up and need me to save you, again,” she said the last words with a raised edge.
The three observers to the theorem weren’t at all surprised at Garcia’s attitude. This was exactly how they’d expected the surgeon to act after the patient oversight.
“Next, she’ll talk about how we wasted surgery’s time and resources,” Ogilvie whispered quietly to Joy beside him.
“Uh yes, Cormac Martins. 37 year-old male, brought in with minor chest pain and difficulty breathing. We ran an EFAST and ruled him negative for a pneumo but had him stay for imaging, POC ultrasound and a CT,” Santos called out.
Garcia’s head bolted up from the chart and towards the direction of the speaker. “Okay, and then after that,” she prompted Trinity.
“His BP crashed, Dr. Mohan and Dr. Al-Hashimi saw the tension pneumo on the ultrasound, and after finding out you were going to take some more time, they did an emergency needle thoracostomy.” She finished.
The observers watched Garcia carefully, her expression was neutral but they could all already hear the typical admonishments from the surgeon.
His ultrasound results came in 30 minutes ago, why wasn’t it read?!
His BP would’ve been trending down for at least 15 minutes before the crash, why wasn’t anyone watching him?!
Congrats, you’ve just given him a free trip to minor surgery and a lifetime of bills!
“Okay,” Garcia said softly. “So what’s next?”
Santos nodded. “Chest tube, then potentially intubation after so we don’t have positive pressure during the pneumo.”
Garcia smiled.
Ogilvie coughed at the sight. Joy’s jaw was sweeping the floor. And even Al-Hashimi appeared taken aback. Whitaker meanwhile, had his arms crossed tightly as always and watched what was the typical occurrence between the two.
“I knew you wouldn’t forget again,” she spoke softly to Trinity. So softly, both Ogilvie and Joy had to lean in to catch the words. “Like you said, that’s how we learn,” Santos sent a small smile back. The quiet conversation the two appeared to be having with only each other set the others to look around the room to see if they were going crazy. Ogilvie and Joy made eye contact with disbelieving expressions, nothing was said but the sentiment was clear.
Is this really happening?
Operating Principle 1:
For the duration of Santos’ presence, Garcia’s vocal volume is decreased by a mean of 6 decibels. A direct address to Santos produces as much as a 10 decibel reduction.
“Garcia gets like really quiet around Trinity, they practically whisper their conversations, so there’s no yelling involved”
Ad Dictum Dennis Whitaker
“Okay, let’s get started,” Garcia pulled the chest tube tray. “Dr. Al-Hashimi, we’re all good here if you had any other pressing patients,” Garcia nodded at her.
Al-Hashimi snapped out of the trance she was in. The sight before her was truly shocking and she wanted to continue exploring this theorem. “Nothing pressing at the moment, I’ll observe,” she smiled at the surgeon.
Garcia shrugged and turned to the intern at the foot of the bed instead.
“Hey White Chocolate, do you expect your med students to watch from all the way over there?” she gestured to the two.
Whitaker shook his head at the nickname. “Joy, Ogilvie” he called and gestured towards the side where the surgeon was prepping the site. They quickly shuffled over to see the wound site had been draped and covered in betadine.
“Joy, which intercoastal space are we using for this chest tube?” Garcia asked.
Joy froze. Ogilvie saw her expression and jumped in “It’s the fo-”
“Fourth and Fifth intercostal” Joy interrupted. She glared at Ogilvie, who shrugged with a smile.
Garcia let out a small chuckle at the two.
“Great, ten blade to Joy, please Kim,” Garcia gestured to the woman beside her and Kim nodded.
Both Ogilvie and Joy’s jaws dropped, one in jealousy and the other in disbelief.
Joy quickly put on the fresh gloves Kim had placed in front of her and grabbed the scalpel as directed.
“You want the fifth intercostal space, mid-axillary line. You want an incision big enough to accommodate your index finger, and chest tube, so about 3 centimeters.”
Joy found the appropriate rib, judged the distance and cut the approximate length.
“Great, long kelly next.”
Garcia walked Joy through the next several steps, using the long kelly to apply firm pressure to pass through the parietal pleura, then spread the instrument parallel to the rib. Next was to insert a finger into the thoracic space to confirm thoracostomy then finally to insert the tube itself.
If either of the two students had been paying attention to anything other than the chest tube, they might’ve seen Garcia look up every so often to make eye contact with a certain female doctor who was watching the entire interaction. This, however, did not go unnoticed by the rest of the room, most of whom were well aware, but observer Al-Hashimi’s eyes were darting between the two doctors each time Garcia glanced up.
“Ogilvie, what’s the next step?” Garcia asked as Joy finished the tube insertion.
“Uh you need to secure the tube before attaching a drainage system.”
Garcia nodded, “That’s correct, gloves for Ogilvie.” Kim was already ready with the gloves and passed them to the man who took his place by her side as Joy stepped back.
Joy removed the bloody gloves, willing her hands to stop shaking now that her portion appeared to be complete. She was aware of the possibility of doing procedures but as an MS3 this was beyond what she thought she’d complete. And while she truly couldn’t see herself doing EM long-term she couldn’t help but admit it was a thrill.
Similar to before, Garcia walked him patiently through each step in the procedure, first the incision, then wrap the suture around the chest tube twice and tie, repeat again. Second stitch to close incision, and connect pleuravac to chest tube and remove the long kelly. Review volume output and then apply dressing.
“Lastly, you just need Xeroform and some 4x4’s. Kim can show you,” Garcia gestured towards Kim, who nodded.
Operating Principle 2:
For the duration of Santos’ presence, Garcia exhibits a marked increase in instructional behaviour. This behaviour extends to surrounding staff and not just Santos.
“Next, Garcia will start teaching. Like actual teaching, step by step instructions and questions too. Usually, it’s directed at Trinity, but everyone’s fair game.”
-Dennis Whitaker
Garcia took off her gloves and threw them in the bin, the procedure completed with minimal problems. As Ogilvie was finishing the last of the dressing, Garcia turned to the students, “Good tube placement and neat and clean sutures,” she nodded, satisfied.
The two medical students froze once more, doubtful their ears were correctly hearing the compliment coming out of the surgeon's mouth. “That’s all for me, later odds,” she cheered, letting her gaze fall on one woman in particular in the room and giving her a small smile before turning to walk out.
“Oh, Dr. Ogilvie, Dr. Kwon, good job,” Garcia smiled at them as they turned towards her, the same look of shock on their faces. Whitaker was in the corner trying to hide his soft chuckle, and Donnie and Kim were smiling knowingly. Trinity didn’t appear to think much on it and instead walked straight to the computer to place the required updates to the man’s chart.
Operating Principle 3
For the duration of Santos’ presence, Garcia displays a marked increase in positive reinforcement, and a significant decrease in the use of hostile nicknames.
“Lastly, she gets big on compliments and praises. And so long as she doesn’t really hate you, she stops calling you nicknames. Well, she still calls me by them, but that’s something else-”
Id Est Whitaker, Dennis
Al-Hashimi took some time to process the last few minutes, then walked out to follow the surgeon, leaving just a final glance to the oblivious R2 at the computer.
“Dr. Garcia!” She called out.
Garcia stopped and turned to the attending, pausing to wait for the other woman.
“I wanted to say that you did a good job in there, with the students,” she smiled
Garcia raised an eyebrow in confusion, “Of course, I did. Business as usual, Dr. Al-Hashimi. This is a teaching hospital isn’t it?” Garcia scoffed and smiled.
Al-Hashimi paused, and looked at the other woman strangely for a moment. She studied her face to see if there was any trace of deception, but found none. Garcia was completely genuine in her self-assessment.
It seemed there was a specific reason the “Theorem” should not reach either woman’s ears. They both seemed to be wholly oblivious to the effects of their presence on each other.
Behind them, Mohan snorted as she overheard the conversation. She knew there’d been nothing to worry about as soon as she’d heard Trinity was the primary.