Lethal Practice

Lethal Practice

Peter Clement

Chapter 1

“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, calm 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 team.

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 jolt 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 massage 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 job changes from resuscitator to traffic cop.

The first through the door was James Todd. As always, his clothes were disheveled 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 a 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.”

I accompanied him and the nurses for the short elevator ride up to ICU. It was Sunday evening, and only a resident would be there. Sometimes the resident had enough experience to handle a difficult case until a staff supervisor could be called in from home, but I wanted to make sure. Though my patient was making it out of the ER, the real trick now was for him to get out of the hospital alive.

At first, after the stark glare of emergency, the shadowy darkness of intensive care made it hard to see. A hushed place even in the daytime, the ICU at night is a gallery of backlit souls, each hooked into a wall of blinking red and amber lights and bound in a tangle of tubes and wires. The curtains that divide the cubicles hang like shrouds. Now and then a soft beep gets the attention of the nurses. The monitors at their dimly lit station flicker in fluorescent green and show a dozen jagged lines furiously writing the fate of each fragile heart.

While I huddled with the young resident, the nurses quickly signed over to their counterparts and returned downstairs. It took me five minutes, however, to explain the case to the increasingly nervous trainee spending his first night on duty in the ICU. By then I needed a stretch, so I decided to walk back down the three floors to the ER.

As I headed for the staircase, I noticed that the hallways glistened from a fresh mopping, then spotted a deserted mop and pail near the door of the doctors’ lounge. I glanced at my watch; it was only seven
P
.
M
. Less than three hours on the job, I thought, and already one of the housekeepers was occupying an overstaffed leather chair in the sanctum forbidden her during the regular day hours. Each to her own perks.

Around the corner, I literally ran into our esteemed chief executive officer and two-hundred-pound resident souse, Everett Kingsly. He grunted with surprise and let me know in one breath what he’d been drinking. He normally had a well-groomed mane of white hair, but now it had become tangled and tufted into peaks like whipped meringue. His white beard, full more from neglect than by design, stuck out in wiry bristles that made me itch. Overall, he looked as if he’d been caught in a windstorm.

“Dr. Garnet!” He said my name as if he were identifying an out-of-place signpost.

“Evening, Mr. Kingsly,” I replied, quickly steadying him, then stepping aside—considerably aside. He had that aroma of alcohol-soaked sweat that inevitably gives secret vodka drinkers away.

“Yeah,” he answered after what seemed like a lot of thought.

“Can I help you?” I asked.

He gave me a hurt look and gazed off into the space behind me. He appeared to take a reading on the next wall extinguisher, then lurched toward it. He was hanging on to this latest handhold, surveying the next leg of his journey, when I left him. I was feeling guilty for not helping him at the moment, but I had to get back to emergency. I did a quickstep to security and told the guards on duty where they could pick Kingsly up.

“Christ, someone should do something about that guy,” I heard one of the guards say as I turned to head for the stairs. “It’s the second time this month.”

“Somebody said he tried to paw Agnes from housekeeping last week.”

“Kingsly’s an alcoholic. Why don’t they—” The stairwell door swung closed behind me, cutting off their conversation. That guard was right though. While the rest of the world had given up the three-martini lunch, Kingsly had become increasingly devoted to it. Over the last year he’d deteriorated. Some days he was a dead loss after lunch in terms of hospital business—but a menace to reasonably attractive women of any age who dared to go near him. This weekend he must have been drinking at home and come into the hospital... for what? To grope some woman on staff?

I felt another twinge of guilt at my increasing impatience with Kingsly. Eight years ago he’d been a vigorous administrator and an enthusiastic supporter of making me the new chief of emergency. “New blood! New ideas, that’s what the place needs,” I remember him declaring shortly after my appointment. It was pathetic he’d become such a liability to the hospital now, but someone definitely should have done something about his drinking months ago—and, since no one else had done so, I suspected the others he worked with were as shamefully preoccupied with their own problems as I was.