Critical Judgment (1996) (54 page)

“I’d be happy to.”

He glanced back at Jack, who was resting comfortably, then took a step forward. The head nurse continued to block the doorway. She motioned Brian to a spot in the hall, out of earshot of both Jack and the staff.

“Before you go in there,” she said in a stern half-whisper, “I want you to know that I insisted Sherry Gordon tell me who you are and at what hospital you are working. She told me you had lost your license.”

“So?”

“And when I pushed her for an explanation, she told me why.”

Brian’s reaction to the woman had blossomed from a kernel of wariness into full-blown mistrust. He pulled himself up to his full height plus half an inch or so.

“Get to the point,” he said.

“I don’t want anyone without a valid license practicing medicine on any patient on my emergency ward.”

“Frankly, I don’t see where sharing my experience and ideas is practicing medicine.”

Carole Benoit’s eyes were hard.

“I’ll be in there watching,” she said.

Brian stepped back into the room to reassure Jack that he’d be nearby and would be right back. Then he flexed a bit of tension from his neck and headed over to room 4.

It had been ten years since Brian and Phil Gianatasio had been medical residents together at Eastern Mass Medical Center. They had worked well together during those
two years. Phil seemed at ease with Brian’s flamboyance and self-confidence, and Brian appreciated that Phil, more steady and meticulous than brilliant, always worked within his limitations and was never afraid to ask for help. After residency, Brian had won a cardiac fellowship at one of the finest hospitals in Chicago, and Phil had temporized his future by enlisting in the service—the army, Brian thought. At first they had exchanged a few letters and calls. But gradually their connection weakened, then vanished.

Phil greeted him from the far side of the gurney. Phil had always been overweight, but since residency he must have gained twenty pounds. His dark hair was yielding to an expanding bald spot on top and was longer in the back than Brian remembered. But one thing that hadn’t changed a bit was the warmth and kindness in his face. At this moment, though, Phil looked worried. It was not difficult to see why.

On the gurney, unconscious and clearly toxic, was a disheveled woman with graying red hair, in her late sixties or early seventies. Her grunting respirations were barely moving air, and the paleness around her eyes and mouth was a frightening contrast to the crimson of the rest of her face. Also in the room were Ethan Prince, Sherry and another nurse, the anesthesiologist, and, over in a corner, an older man with a rumpled suit and a stethoscope protruding from his jacket pocket. The woman’s private physician, Brian guessed. It was just a snap judgment, but the man seemed ill at ease and out of his element in the face of a crisis. Just inside the doorway, observing more than participating, stood Carole Benoit.

Monitor pattern … cardiac rate … puke oximeter reading … complexion … fingernail bed coloring … cooling blanket
 … By the time Brian had gone from the doorway to the bedside, his mind had processed a hundred bits of information. He breathed in the action and the urgency.

“Brian, you’re a sight for sore eyes,” Phil said. “Like one of those gods in Greek tragedy who pop out of the wall of the theater just when they’re needed.”

“Hey, careful. I’m through doing the god thing. It ended up causing me nothing but trouble. What’s the scoop here?”

“Well, Mrs. Violet Corcoran here is a sixty-eight-year-old patient of Dr. Dixon’s. That’s Fred Dixon right there. Fred, Brian Holbrook.” Brian and the older doctor exchanged nods. “As far as Fred knows, she’s never been really sick before this week.”

Something in Phil’s tone suggested that merely having Dixon as one’s physician carried with it certain health risks. But the man
had
come in to see his patient on a Sunday afternoon, and in Brian’s mind that negated a certain amount of clinical incompetence.

“He was treating her with some erythro for an upper respiratory infection,” Phil went on. “A couple of hours ago her husband called in that she wasn’t looking so good. Her temp’s one-oh-four. Pulse one-forty. She’s got a pretty dense left lower lobe pneumonia. BP was one-sixty. Now it’s down to one hundred.”

“Septic shock?”

“Probably. But look what she’s doing.”

Phil indicated the cardiac monitor screen, which now showed a heart rhythm pattern Brian was almost certain was sustained ventricular tachycardia. V. tach of this sort was very unstable in most situations and was often a precursor of full-blown cardiac arrest.

“I read v. tach,” Brian said.

“We all agree. She’s been in and out of it since she arrived. Short bursts at first. Now more prolonged.”

“Treatment?”

“We’re working our way through the pharmacy. So far we’ve tried Xylocaine, bretylium, and Pronestyl, and we’re about to give her a hit of digitalis. Nothing’s touched it.”

“She’s going too fast to try and guide her out of it with a pacemaker.”

“Exactly.”

Brian motioned toward Phil’s stethoscope.

“May I?”

Carole Benoit had seen and heard enough.

“Dr. Gianatasio,” she cut in, “I’m sorry to have to remind you, but Dr. Holbrook has no license to be treating
or touching
our patients.”

For a few seconds there was no movement in the room, no sound save for the soft gurgle of the oxygen bottle. Then Gianatasio slipped his stethoscope from his neck, rounded the gurney, and handed it to the head nurse.

“Okay, then, Ms. Benoit,” he said without rancor, “suppose you evaluate this woman and give us
your
considered opinion.”

Benoit’s face grew pinched and flushed. She pushed the proffered instrument back at Phil and moved away.

“Suit yourself,” she said. “But I’m holding you responsible for whatever happens.”

“I’ll take my chances. Brian, if you don’t come up with something we haven’t tried, I’m going to have Sule here intubate her and we’ll take a crack at shocking her out of this.”

Brian took Phil’s Littmann stethoscope and moved to the bedside.

“I don’t think zapping her with a lightning bolt is going to make any difference,” he said. “Not unless we figure out the underlying reason she’s
in
that rhythm and do something about
it.”

“It could be just massive infection in a woman with some preexisting heart disease.”

“Maybe.”

“Whatever it is, be quick, Brian. She’s in it again.”

Brian first scanned Violet Corcoran, head to feet. There was something about her, something that reminded him of
a case he had seen somewhere in his training.
Where? What was it?
He felt over her heart, then her neck, then the arterial pulses at her elbow, wrist, and groin. Finally, he slipped the earpieces of Gianatasio’s Littmann into place and worked the diaphragm side of the stethoscope over her heart, chest, and neck. Next he repeated the exam using the bell side.

“Sule, go ahead and intubate her,” Phil said. “Then we’ve got to try shocking her. Damn, this is getting out of hand fast.”

Brian didn’t respond. He was completely immersed in a sound—a sound coming from the front of Violet’s neck. And suddenly he remembered. To his left, the anesthesiologist had slipped in an endotracheal breathing tube so smoothly that Brian had not even realized she was doing it.

“We’ll try two hundred joules once, then go right to three-fifty,” Phil ordered.

“Wait!” Brian said, indicating a spot on Violet’s neck. “Phil, listen to this.”

The easily heard humming sound, Brian was nearly certain, was a bruit—the noise of turbulence caused in this case, he believed, by blood rushing through a markedly overactive thyroid gland.

“Pressure’s dropping,” Sherry Gordon said. “Ninety.”

Phil listened for a few seconds.

“I heard that sound when I first examined her, but I thought it was a murmur transmitted up from her heart.”

“I don’t.”

“Thyroid?”

“I’m almost sure of it. I’ve only seen one case of thyroid storm in my life, but this looks just like it. High temp, wild pulse, coma, increasing stretches of v. tach.”

Gianatasio listened to the sound again.

“Could be,” he said excitedly. “Dammit all, it just could be. Fred, does this lady have any history of hyperthyroidism?”

Fred Dixon flipped through his office notes and lab reports.

“Eighty,” Sherry called out.

“Well,” Dixon said, his voice a bit shaky, “I noted a slightly elevated thyroid level at the time of her physical a year ago. But people her age get
underactive
thyroids, not overactive, and besides, I didn’t think—”

“Brian, where do we go from here?” Phil cut in.

“Call an endocrinologist. But I would say, in the meantime, massive doses of steroids, high doses of IV propranolol to block the effect of the hormone on her heart, and then some sort of specific chemical blockade of thyroid hormone production as well. The endocrinologist or a book can tell us what and how much.”

“Let’s go with it,” Gianatasio said. “Ms. Benoit, find out who’s on for endocrine and get ‘em down here or on the phone as quickly as possible. If it’s the phone, put Dr. Holbrook on. Then get over to the residents’ lounge, please, and get me Harrison’s
Principles of Internal Medicine
and the fattest endocrinology textbook you can find. If there’s none at least two inches thick, go to the library. The rest of you, listen up, please. We’re sailing into some uncharted waters.…”

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