Lethal Practice

Lethal Practice

"I'm going to die, aren't I, Doc?"

Christ, they always seemed to know.

"No, sir," I lied. "Your lungs are filling with fluid. We're going to give you medication to clear them out."

Openmouthed and gasping beneath the oxygen mask, the patient was frantic for air. All the muscles in his chest and abdomen heaved with every attempt to breathe, but each breath was shallow and ended with an ominous gurgle. His skin felt clammy and had turned the color of a dead fish's belly. I guessed he was about fifty, though he looked almost twice that age now.

We were in the resuscitation room, a large, tiled chamber, cold, full of echoes, harsh light, and harsher verdicts. Crouched over the patient's left arm, Susanne Roberts, head nurse, was struggling to find a vein and get in an IV.

"Damn," she muttered.

"Get Ventolin and eighty milligrams of Lasix. I'll try to get a line in his right arm." I was already reaching for a tourniquet as Susanne moved fast to follow my order. The patient's skin was slippery cold. I moved my fingers to his neck and found a pulse. It was very faint and rapid, but at the wrist, there was nothing. Shock. "And dopamine!" I yelled after Susanne. She and I had run this race together a lot of times during the fifteen years she'd worked in the ER and, like familiar sex, she'd know exactly what I wanted.

The patient's respirations were getting faster, the gurgling louder. He was literally drowning in his own fluids. An IV, the drugs, and intubation might empty the lungs in time but, then again, might not.

I tourniqueted his right arm but got no bulge at the vein site. I'd have to make a blind try. I anointed the chosen spot with alcohol and went in. Still nothing.

His chest was heaving harder now. He could no longer utter syllables. I advanced the IV. Blood started to come back up the catheter. I was in, but he was looking bluer. The cardiac monitor showed extra beats.

Susanne was back at my side with the drugs.

"I got a line," I said. "Give me the IV." She passed me the clear tubing that dangled from overhead sacks of fluid. I shoved the tip through the blood running from the end of my needle catheter and opened the line. The skin bulged with overflow from a broken vein.

Shit. When it goes wrong, it really goes wrong.

His eyes began to roll.

"Call ICU stat, please, and inhalation therapy." I spoke in that phony, clam tone we use when we're losing it. I've always wondered if it fools anyone.

Susanne hit the phones, and I abandoned trying for an IV, reaching instead for the intubation tray. The man's lungs were filling up much faster than I'd expected. Bloody foam started bubbling out of his mouth. Too late for medication. My only hope of saving him now was to pass a tube down his airway and blow the fluid back out of his lungs with pressurized oxygen. Susanne finished her terse conversation, then started hooking up the tubes and equipment we'd use.

The overhead PA screeched, "ICU and inhalation therapy, stat! Emergency department!"

Now the whole hospital knew we were in trouble.

So did the patient. He dropped his head, seized, and quit breathing.

"Call ninety-nine!" I yelled. The code would bring the cardiac arrest tetam.

The heart monitor showed the jagged dance of ventricular fibrillation. Susanne was shoving a board under the patient's shoulders as I grabbed for the paddles, then set the machine for two hundred joules. Susanne slapped some lubricant on the man's chest and turned back to the phones.

The current hit him with a loud thwack, arched him, but left the heart dead. I shocked him again. The holt hit, but still no response. I tried a third time. Nothing.

The inhalationist arrived.

"Move in!" I commanded.

She was already at the man's head, pulling off the clear mask and tubing we'd applied earlier. She plopped a black ventilating mask on his face and attached it to a rubber bag that she squeezed to give him a few puffs of oxygen. Next she reached for a laryngoscope, flicked it open like a switchblade, and went into his mouth. Foam and vomit spilled out. She grabbed a suction catheter and probed through the mess in the back of his throat. Noisily it sucked the debris clear. After reopening his airway with the blade, she smoothly slid a long, curved tube into his trachea.

"Got it," she reported matter-of-factly.

After she hooked up the bag and began forcing air into the guy's lungs, more bloody foam came bubbling up at her with each puff. The oxygen was pushing out what had clogged his breathing. She grinned cockily. "Having a good day, Dr. Garnet?"

"Smartass," I said, smiling.

Susanne was pumping his chest. The ventilation and cardiac message began to pink him up a bit, but the monitor looked like the stock market ticker on Black Tuesday. We still didn't have an IV line.

I heard the crackling of the PA.

"Ninety-nine, emergency! Ninety-nine, emergency!" the anonymous voice called, requesting help for us again.

As much as I may need it, I hate it when help arrives. Everyone in the hospital with nothing better to do shows up. They all come thundering in, and my hob changes from resuscitator to traffic cop.

The first through the door was James Todd. As always, his clothes were dishevelled and the expression on his face was intense. A lot of the interns adopted that overworked and earnest appearance because they hoped it would compensate for what they didn't know. Just looking at one of them made me feel exhausted. Todd was buckling up his belt as he came toward me. He'd probably heard the call in the can.

"Dr. Todd, good to see you. Can you get me a central line?"

Todd had a reputation for magic hands. Under the clavicle is a major vein that passes to the heart. I knew he'd have a needle in it with no trouble. With a quick nod, he started gloving up while I hoped he'd washed after finishing at the toilet.

As I waited, I broke open a few ampules of diluted epinephrine and poured them into the endotracheal tube. The inhalationist resumed bagging. Normally this would have forced the epinephrine all the way down to the small air sacs in the lungs and through their walls into the bloodstream. But in this man fluid was pouring back from the bloodstream into these very sacs; the way was blocked. I had Todd, Susanne, and the inhalationist stand clear while I shocked him again. Just as I feared, it didn't work.

Two medical students rushed in, and I got them busy drawing blood gas. The noise level was rising. A third came in and I stationed her at the door, telling her not to let anyone else get by, but almost before the words were out of my mouth, the priest, a regular in the ER from nearby Blessed Trinity Church, darted under her arm.

"Is he Catholic, Earl?" the priest asked, trotting with me back to the patient. When I merely shrugged, the priest reached over my shoulder, touched the patient, and started muttering the last rites. Real confidence boost, that one. "Ready," Todd said. He had his line.

At my order, Susanne broke open another ampule of epinephrine and injected the contents through our IV. I recharged the paddles, placed them, and fired. The patient arched as before, but this time the scribbled line on the cardiac monitor untangled itself and formed the steady, organized pattern of a functioning heart. I put my fingers to his neck; there was a pulse again.

"Could I have a blood pressure reading, please?"

Susanne pumped up the cuff on the patient's left arm and listened with her stethoscope while slowly deflating the bulb. "Ninety over sixty."

Everyone relaxed a bit. Still a long way to go.

I ordered some small Xylocaine boluses, one to use immediately and another in ten minutes to prevent any more defective rhythms. Susanne hung up a drip without my even asking. The BP rose to 110/70.

The room was quiet except for the rush of air with each squeeze of the respirator bag and the welcome steady beep from the monitor. It's always like this at the end of an arrest, whatever the outcome. I broke the spell. "Get this patient up to ICU before he crashes again."

For the last twenty years it's been my job to take patients like this and try to make them better. Trouble is, I'm no St. Jude, and whether they are routine problems, potential miracles, or already lost causes, they all come through the door together. We do triage to sort out those people who have seconds from those who have hours. I'm forever behind, it's always catch-up, and in a chaotic profession of desperate moves with precise skills, the fear of failure never leaves. By the time I get to them, they inevitably have the same unspoken prayer in their eyes, "It's come to this, and you're all I got, Doc. Please be good."