Doing Harm (38 page)

The doors close. The elevator lurches upward.

Exactly one floor.

And then it stops.

The doors roll slowly open. Two young nurses get in, oblivious to my presence, loudly gossiping about a colleague, like girls between classes in a high-school hallway. One of them, heavyset and ponderously munching on an Oreo, pushes the
5
key.

Are you kidding me? They can’t take the stairs for just one fucking floor?

I rock back and forth on the balls of my feet and savagely consider telling the heavyset one that a little stair climbing might do her some good. But I hold my tongue.

After depositing the gossip girls on the fifth floor, the elevator continues to the tenth without further incident, and I’m out the doors and sprinting toward the patient-care area, looking for room 1014. I hear shouting, but don’t see anyone else.

The panels next to the doors flash by: 1010, 1011, 1012, 1013 …

Finally, 1014.

The door is closed.

That’s strange.

I fling it open, my heart in my throat, expecting the worst …

*   *   *

… and find Mr. Schultz fast asleep, the room as still and quiet as a tomb.

What the hell?

Mr. Schultz, jolted awake by the sound of the swinging door crashing against the wall, picks his head up off the pillow and squints at me, his squat bulk framed by the block of bright light cast across his bed by the wide-open door.

“What the
hell?
” he shouts raspily.

I ignore him, stick my head back out the doorway, and quickly scan the rest of the corridor. At the very end of the hall, several doctors and nurses are leaving the room of another patient. One of the nurses is pushing a crash cart full of medications and a defibrillator. They all look varying degrees of pissed.

“What’s going on down there?” I ask a passing nurse, pointing at the clutch of people, who are mumbling angrily to one another, some yawning and rubbing their eyes.

“False alarm,” he replies. “Somebody called a code on a patient who wasn’t coding.”

“No shit.”

He grins. “Yeah, no shit.” He stops when he realizes what room I’m coming out of. “Was there something you needed, Doc? I’m taking care of Mr. Schultz tonight. Is he okay?”

“Couldn’t be better,” I say distractedly. I should be relieved, but instead I’m completely unnerved. My mind spins feverishly, like a hamster on its wheel. What’s going on? Could I have been wrong about the ICD? Why would GG ignore an opportunity like this to murder Mr. Schultz? The setup was so perfect.

Perfect.

A little too perfect, maybe?

I watch as the code team, called to a code that wasn’t really a code, disperses.

I think about GG’s involvement in Mr. Schultz’s transfer earlier this evening, and the mysterious page to the cardiac floor for which nobody took responsibility.

Is it possible that I’ve been tricked? Could it be that Mr. Schultz was a feint? That he was never GG’s intended target to begin with? Was GG trying to draw my attention away from someone else?

“Doc?” The nurse is still standing there, waiting for me to answer.

But then, if Mr. Schultz wasn’t her target, who is? We only have a few patients in the hospital right now other than Mr. Schultz. None of them is particularly vulnerable.

Unless—

Could it possibly be—

Oh
no
.

It couldn’t be.

Oh, shit
.

Not her. Please not her
.

“Yeah,” I tell the nurse. My left arm is tingling. I ignore it. “Run a twelve-lead EKG and page the cardiology tech to come and interrogate the ICD. And don’t let anyone else in the room.”

I’m sprinting back the way I came before he has a chance to tell me that cardiology techs aren’t usually available in the middle of the night. This time, I ignore the elevators and find the nearest stairwell, retracing my path, taking the stairs two at a time. It’s all downhill, but it’s seven flights, and I’m in horrible shape, so I’m panting and clutching my side as I tear through the back door of the SICU, past a couple of startled nurses, and into Mrs. Samuelson’s room …

*   *   *

… to discover to my horror that she’s sitting straight up in bed, pale as a ghost, clutching her chest with both hands, gasping for breath. The warning alarms on her vital-signs monitors are going haywire. Instead of charging boldly across the screen, tracing the sharp peaks and valleys of a normal cardiac rhythm, her heart produces a feeble, wavy line that lurches from one side of the heart monitor to the other.

She can’t speak. She can’t breathe. Her mouth opens and clothes reflexively, over and over again, like a caught fish flopping around on a dock. When she sees me, she reaches out with one hand, her pleading eyes bulging so prominently that they’re practically leaping from their sockets.
Please, I don’t want to die,
they scream silently at me. Her lips are an ugly shade of blue, the dirty shade of a fresh bruise.

Before I can react, she shudders with a horrible rattle that shakes her whole body from head to toe, arches her back and neck, and falls back on the bed, rigid as a wooden board, her eyes rolling up into her head.

For people who’ve never seen a grand mal seizure before, it’s a terrifying sight, with the patient’s arms and legs jerking spasmodically and their whole bodies thrashing around in thoroughly unnatural movements. Even now—having seen a bunch of seizures, knowing scientifically that her problem is caused by a colossal short-circuit of nerve cells in her brain, and remembering that there’s nothing I can do except make sure that she doesn’t hurt herself (that thing about preventing seizing patients from biting their tongues off is complete bullshit urban legend; the last thing I want to do right now is stick anything inside her mouth, least of all my fingers)—watching her flail about like a limp rag doll shaken by a child rattles me to my core.

I run to the head of her bed and cradle her head in my hands to help keep her airway open. Carol and another one of the SICU nurses, alerted by the noise and Mrs. Samuelson’s failing vital signs, join me almost immediately, their faces registering surprise mingled with cool detachment as both of them size up the scene in an instant with their practiced eyes.

“I’ll call the code,” Carol says, and disappears.

The seizure lasts for about ten seconds before she becomes completely, unnaturally, still. At the same moment, the heart rate on the monitor next to her bed falls to zero. I check her pulse, my fingers inching along her neck, seeking the carotid artery. Nothing. No pulse.

Struggling to keep my emotional state from unraveling like a roll of kite string being played out on a windy day, I shift positions and begin CPR, pushing down on Mrs. Samuelson’s frail sternum to keep the blood flowing through her body. The other nurse grabs an Ambu bag and depresses a button that instantly collapses the air mattress underneath Mrs. Samuelson, making it easier for me to push on her sternum. She squeezes past me to the head of the bed, attaches the mask to Mrs. Samuelson’s face, and calmly starts pushing air into her lungs.

“What happened?” she asks.

I describe Mrs. Samuelson’s mysterious symptoms as Carol returns with two of her colleagues. More nurses and doctors arrive shortly thereafter, including the code team (who probably came directly from Mr. Schultz’s room), which is led tonight by one of the more seasoned critical-care fellows. They swarm around Mrs. Samuelson, systematically stripping off her gown, checking her intravenous catheters, and hooking up additional heart and blood-pressure monitors. The anesthesia resident slips an endotracheal tube into Mrs. Samuelson’s throat. The heart monitor still indicates no blood pressure or pulse.

I hand over the job of giving heart compressions to one of the new arrivals and relay my story to the critical-care fellow, Sushil, a rotund, jocular guy who’s been caring for Mrs. Samuelson over the past several weeks.

“Pretty nonspecific symptoms,” he muses. “Any other presenting signs? Anything else that might have precipitated a cardiovascular collapse?”

“No, nothing,” I say. “She was doing great. There’s no good reason why she should have crumpled so suddenly.”

That’s a lie, of course. There’s a very good reason why this has happened, and its name is GG. I’m racking my brain now, running through all of the potential methods she might have used to try to kill Mrs. Samuelson. I have little doubt that this is her doing.

“Hey, Sushil?” the anesthesiology resident calls as he’s attaching the Ambu bag to the endotracheal tube.

“Yeah?”

“There’s a left subclavian central line up here that’s unhooked. And look.” He holds it up for us to see. There’s a small gash in the side of it. “It must have ripped somehow. The line is completely open to air.”

Sushil looks at me sharply.

“Do you think—” he starts.

“Yeah,” I answer, the hair on the back of my neck standing on end. “Definitely. Her presentation is totally consistent with a massive pulmonary air embolus.”

Sushil grimaces. “With that hole in the line being above the level of her thorax, she would have had positive pressure flow of air into the vein. So she never bled, and each inspiration would have sucked air into her subclavin vein.”

I guessed wrong. GG, it seems, decided to go with the air embolus again and not the ICD.

Fuck! How could I have been so stupid? I played right into her hands.

“Hold CPR,” Sushil calls to the code team. The resident currently pushing on the sternum pauses. “Is she still in asystole?”

“Yes,” answers one of the nurses, staring at the cardiac monitor over the bead.

“Okay, everyone, for now we’re going to assume she’s got a pulmonary air embolus until we prove otherwise. Let’s place her in left lateral decubitus Trendelenburg.”

Working in concert, and without blinking an eye, the SICU nurses and code team first roll Mrs. Samuelson onto her left side, then tilt the head of her bed downward so that her feet are pointed up in the air and her head is pointed toward the floor. The idea is that, by repositioning her body, we can trap the deadly air in the tip of her heart and away from her lungs. Since she’s now lying mostly on her left side, the team also quickly straps a firm body board behind her back to provide resistance for the now-horizontally-oriented chest compressions.

“And administer another one mg epinephrine,” Sushil says. “Let’s see if we can give her right ventricle some more squeeze.”

“One milligram epinephrine,” the nurse by the cardiac monitor calls back as she injects the medication into one of Mrs. Samuelson’s IVs.

Sushil nods, satisfied, and surveys the room. “Hey, Sheila.” An idle code team resident standing in a corner of the room stirs and looks in our direction. “I need the portable ultrasound for a stat transthoracic echo. Can you go grab it for me? It’s over by the nurses’ station.”

“Got it.” She runs off and soon returns, rolling the ultrasound machine in front of her, a device that resembles a large hat rack on wheels. A large video monitor is perched on top, where the hats would otherwise be.

Sushil turns on the ultrasound machine, punches a few buttons on a keyboard located midway up the hat-rack stand, and unfurls a long cord with a thick plastic tip on one end. It’s the ultrasound transducer—the part of the machine that sends and receives sound waves—and it looks a lot like the handheld, flexible attachment of a vacuum cleaner that you use on hard-to-reach places.

Sushil maneuvers his way between the code-team members working on Mrs. Samuelson. He kneels next to her, squirts a generous amount of a clear-colored material with the consistency of jelly over a spot on her chest (the thick stuff will help transmit the sound waves into and out of Mrs. Samuelson), and places the ultrasound transducer directly over the jelly, ducking regularly to avoid the resident currently administering the chest compressions.

He grunts as he examines the fluttering gray, black, and white images on the video monitor. “Oh shit. See that? That’s her pulmonary artery and right ventricle. Look at all that air in her heart. It’s filling the entire right side. Probably the pulmonary tree, too. Oh
shit.
”

A buzz fills the room, and the atmosphere hums with a subtle new energy.

Pulmonary air embolus.

Definitely not your run-of-the-mill code.

Still staring at the flickering screen, passing the stick back and forth over her chest, Sushil calls, “Ellen! Page the in-house CT surgery attending! Tell him we’ve got a massive pulmonary air embolus here.” His voice remains steady, but there’s an edge to it that wasn’t there a few moments ago, and it cracks on the word
call
. A woman on station near the doorway of the cubicle, who I recognize as the supervising surgery nurse for the night shift, acknowledges him and quickly exits.

“Tell him,” Sushil says more quietly after she’s gone, as if to himself, “that I think we’re going to need some help.” He stands back up, eyes wide, face drawn and pale, for the first time looking truly worried. He gives an order for some more epinephrine before joining me at the foot of the bed.

“Well,” he says. “That confirms the diagnosis. That is one big air embolus. I’ve never seen anything like it. It must be at least two hundred or three hundred cc worth of air sitting in her cardiopulmonary tree. No wonder she’s not responding to CPR. Normally, we’d expect all those chest compressions to push the air bubbles into her smaller pulmonary vessels and dissipate. But—
damn,
that’s a lot of air. You’d almost think somebody had deliberately injected it.”

I chew on my lip and nod, my dread gathering like thunderheads before a storm. “So what do we do now?”

“We’ve got to get that air out of her heart,” he says, absently wiping the gathering sweat from his brow.

“How do we do that?”

“Well, since CPR is failing, we could attempt aspiration of the air. I guess we could float another right-sided central line. Like a Swan-Ganz. Snake it into the right heart and aspirate out the air through that.”