All hell broke loose then. The Casualty doors were held wide open. The trolleys were brought, one after the other. Manik was working on the first casualty before they entered the resuscitation room. (Resuscitation is the process of correcting physiological disorders such as lack of breathing or heartbeat.) Nandani just had time to register mass of frothy blood around the girl's face before her own patient was taken on the second trolley. The paramedic accompanying gave her a quick breakdown of the findings.

"Motorbike accident," he said. "The patient was unconscious at the scene, he has not regained consciousness. His left leg has been splinted. It is deformed, looks like a fracture in the femur bone. We don't know about spinal injuries, but it is possible. We have put a backboard to support his spine. We removed his helmet because we needed to put an airway." Nandani nodded and said, "Thank you."

While the paramedic had been talking, Nandani checked the patient's airway and found that he was breathing but it was labored. She was concerned about his chest. She ordered the nurse to get his clothes off. 

Manik from the other side of the room ordered the X-ray technician to put him on a sliding plate trolley, and then the patient was gently shifted, taking care of his head and neck. His clothes were cut away to reveal his injuries.

"If he lives he'll complain like mad about this," the nurse working along with Nandani said with a grin, as she cut open the expensive leather gear the man was wearing.

"Let's just hope he lives to complain," Nandani muttered. She then ran her expert eye over him, so as not to miss anything.

As the paramedic staff had said, the patient's femur bone just above the knee was distorted. His right wrist also looked strange. But it was his chest that Nandani was concerned about. The left side was not inflating properly, and when she pressed down gently she could feel the crepitations (sound) of the bone ends scraping together.

She informed Manik, "I think he has got a punctured lung, as his lower ribs have shifted to the left."

Manik advised her, "Watch him for shock, his spleen might have gone too," Manik then swore as his patient had severe convulsions. He ordered, "Damn it. I need to get an airway sorted."

Nandani then concentrated on her patient. His pupils were equal and reactive to light, which she was grateful for, but he did not respond at all to voice, and only slightly to pain. She recorded everything on a neurological chart because of the suspected head injury. She was more concerned about his chest and abdomen.

She put in two chest drains, one for air and one for blood, and asked the nurse for his status, while she watched the drain. There was a steady ooze of blood from the lower chest drain. She was glad she did it before it was too late.

The nurse informed, "Pulse one-twenty, blood pressure seventy over thirty and falling (Suggestive of shock.)

"Damn. Let's get an I.V line and put in some fluids. Is X-ray coming?" she asked.

The door opened then and the radiographer came in. He asked Nandani to move, while the patient was been X-rayed. Nandani refused to move and continued putting an I.V line into his left arm.

"You are a young woman, you shouldn't do that," the radiographer scolded her gently. (X-ray harms the uterus, particularly during childbearing age.) 

"Don't worry about me, I am fine," Nandani said, as she withdrew some blood from the IV line, for cross-matching. "Can we have the chest results quickly, please?"

"Sure," the radiographer replied.

They then infused, 'Haemaccele,' a plasma expander in very rapidly, till they waited for his cross-matching report. His blood pressure increased a little, and they inserted another line into his damaged right arm.

"I don't want to use his legs because of the femur injury," she said to Manik, "And the neck vein I want to avoid until we are sure he does not have a head injury. So I have used his right arm, is that okay?"

"You have got no choice," Manik said. "Can you cope, Nandani?"

"Yes, I think so," she replied.

"Get four units of blood into him stat, use O negative while you wait for cross-match," Manik advised Nandani.

Her patient's pulse was very thready (weak) although they had boosted his blood volume. She wondered where he was losing the blood? It was in the thigh, or in the abdomen? She was sure it could be a ruptured spleen. 

Manik advised, "Treat as if he is bleeding from the spleen. There should be a general surgeon on his way down. If he is not here in five minutes or if the boy's condition worsens, I will insert a needle and check. Meantime you catheterize (urinary catheter) him, anyway he will have to go to the Theatre. Does he have any ID?"

The nurse lifted her head from the catheter that she had started inserting. "Yes. The police are contacting his relatives now."

Just then a tall man came in. He called out, "Manik, is their query abdomen for me?"

"Oh, hi Steven. Yeah, Nandani's got it. She'll fill you in with the details" Manik replied.

Nandani said "Hi," to the Surgeon. "I think his spleen has probably punctured. Also, his ribs have penetrated his left lung downwards, he also has a possible head injury. He has a right wrist and left femur fracture too."

Dr. Steven nodded. He asked, "Can I have a trocar?"

He scrubbed quickly while they prepared the abdomen for his incision, then Nandani watched as he carefully pushed the trocar into the abdomen and pressed gently. Blood gushed out rapidly from the hole.

"Damn. You are right, Dr. Nandani." He then asked for the head and spinal X-rays, which were put up on the light boy by the radiographer. "That looks okay. So the abdominal bleeding is of primary importance. Once I finish with his spleen, I will ask the Ortopaedician to take care of his, wrist and femur. How stable is he?"

Nandani replied, "Not bad now. I think he is improving a bit, though his pressure is still a little low."

"Okay. Can you send him up to the theatre, please? I'll go and scrub myself meantime" Dr. Steven instructed. While leaving he asked Manik, "What is your patient?"

Manik said, "Smashed lower jaw, deep cut on the tongue, I am suturing it now to stop the bleeding. She is also in a coma, and has leg fractures."

Dr. Steven snorted and left the room.

Nandani's patient's parents arrived then. She warned them about his condition, the breathing tube, the chest drains. They were shocked and upset, but thankful that he was alive. They were also informed about the girl accompanying him on the bike, who had extensive facial injuries and would need plastic surgery, provided she survived the head injury.

The boy's parents were distressed by her condition. They knew that they were both seeing each other.

Manik asked them, "Do you know where the police might find her parents?"

They replied, "Yeah."

Manik said, "Sister has some forms for you to sign first, then you could go talk to the police."

With shaking hands, they signed the consent form for the surgical treatment of their son's various injuries. After which the patient was shifted to the theatre.

 Manik's patient had fragments of her fractured lower jaw that had penetrated her mouth and tongue. Manik was unable to put an airway, so he had to do a tracheostomy (hole in the throat, to allow a person to breathe). He had also sutured the cut on the tongue, which stopped the profuse bleeding. 

Nandani then went over to Manik. She asked if she could help.

He grinned tiredly. "No. Not really. You could finish off that patient you abandoned. I'll finish here in a minute. The patient will then be shifted to the ICU. I will come with you if you hang on."

Manik was still working. Nandani asked, "How is her head injury?"

"Not good. She is still comatose. She has multiple fractures in both legs and one arm. She has a nasty cut on her leg too. She will need a Tetanus shot."

After finishing, Manik praised her and said, "You did a great job with that lad, by the way. Well done."

Manik's eyes glowed with appreciation, and Nandani felt as if the sun had come out from behind the clouds.

She returned his smile, and her confidence increased. "Thanks," she murmured. She then went towards the door to attend to her patient with a lacerated wound, she left an hour back.

Manik reminded her, "Change your coat before you go there."

She looked down at her coat full of bloodstains and said, "I see what you mean."

Manik's patient was sent over to the ICU, in the meantime, Nandani changed her coat. Smilingly they left for the patient.

But they found out that some other doctor had taken care of Nandani's patient, so they went into the staffroom. Manik put a fresh pot of coffee brewing. Then just as the coffee-machine beeped, they heard a siren again.

Manik looked at her and raised a brow expressively and said, "We have another emergency. You stay here and have coffee if you like. I will handle it."

Nandani got to her feet. She said, we will both go and deal with it, and then we will both have coffee."