ADRENALINE: New 2013 edition (24 page)

“Hold on, let me check.” He heard muffled talk in the background. “She didn’t show up for work today,” came the reply.

“You mean called off sick?”

“Well, not exactly. She just didn’t show up.”

“Hmmm—thanks.” What the hell does that mean?

CHAPTER TWENTY

“Sorry, it took me so long, Doctor Carlucci,” Rusty said. “I had to make an important phone call.”

Mike studied him for a second. Rusty was grinning as usual, and his red hair stuck out around his ears in contrast to his blue surgical cap. He looked excited about something. “I still took a couple of wrong turns on the way back, though,” he said.

“No problem, Rusty,” Mike said. He liked Rusty; he helped take his mind off his own problems. “Look, maybe I can help you with the layout. Basically, the OR complex is arranged in a cross shape. Here, I’ll show you.” He drew a diagram on his scrub pants. “The control office, where we are now, is the nerve center of the department. It’s here at the center of the cross.” He pointed to the appropriate place on his pants. “The anesthesia on-call room, where we had out little discussion over bagels this morning, is at one end. The recovery room is at the other end. The OR’s are here.” He slid his finger down the long part of the cross.

“Thanks,” said Rusty. “That helps.”

“Here, have a seat.” Mike gestured to one of the other four chairs in the room. “I just started reviewing our next patient’s chart. He’s the one sawing wood out there.” They both paused to listen. Loud snoring could easily be heard coming from the holding area across the hall.

“Yeah, I noticed him on the way in,” Rusty said. “He must’ve had some good pre-op medication. What was it?”

“Midazolam.”

Rusty reached for one of his pocket pharmacology handbooks and started to page through it. “What kind of drug is it?”

“Midazolam is in a class of potent tranquilizer, anxiolytic drugs in the benzodiazepine family of Valium fame.”

“Geez, I guess I don’t need this,” Rusty said and put the book back. “You’re a walking encyclopedia.”

“Wake him up and ask him how sleepy he is.”

A bewildered look appeared on Rusty’s face that Mike found amusing.

“OK, you’re the boss,” Rusty said and dutifully got up and walked out. Moments later he returned smiling. “It’s weird.” Rusty leaned his tall frame against the doorway. “The patient says he’s relaxed, but not sleepy. Then he closed his eyes and started snoring again.”

“That’s exactly what I wanted you to see,” Mike said. Midazolam is incredibly insidious in its effect. Many patients deny feeling any effect whatsoever, even though they are obviously impaired—slurred speech, loss of short term memory, and marked drowsiness.”

“That’s pretty cool.”

Mike frowned. “It’s also dangerous in the wrong hands.” Mike lowered his voice. “Maybe you’ve heard of “Easy-Lay?” It’s a date-rape drug with a chemical structure similar to Midazolam.”

“Oh,” Rusty said, erasing his smile. He hesitated for a moment and asked, “What’s up with Doctor Landry today?”

“What do you mean?” Mike replied and went back to studying his patient’s EKG.

“He seemed kinda upset.” Rusty shuffled his sneakers on the floor and looked at them intently. “I just saw him in the locker room getting ready to leave. It’s only four o’clock. Why is he going home so early?”

“He’s pre-call,” Mike answered. “He’s on call tomorrow.”

“Oh—didn’t you think he was upset?” Rusty asked, looking up directly at Mike.

Mike was surprised that Rusty had picked up on the tension between them this morning. Although, on second thought, maybe it wasn’t that hard. “He must have his reasons.” Mike quickly broke eye contact and resumed reading his patient’s chart. He hoped Rusty would let it drop.

“Don’t you know?” Rusty pressed. “I thought you guys were buddies.”

Mike paused from reading the lab values, sighed, and met Rusty’s gaze. His initial irritation quickly subsided when he saw that Rusty’s concern was sincere; Rusty wasn’t just being a meddlesome, pain-in-the-butt kid. A rare quality in a med student. He decided to answer him. “I’m not so sure—”

A loud, electronic screech, followed by the blaring of the OR-wide intercom interrupted him. “Anesthesia! STAT! PACU!”

“Let’s go Rusty!” Mike said, jumping to his feet. He felt his heart slam into action; STAT pages always had that affect.

“PACU? What’s that?” Rusty asked, his body visibly tensing.

“Follow me,” said Mike, breaking into a run. “It’s the recovery room—post anesthesia care unit or some bullshit like that.”

“Oh.”

STAT pages to the recovery room were rare. The recovery room nurses at Mercy were generally experienced, so when STAT calls were made, they tended to be legitimate. Mike was slightly out of breath when the pair got there. He noticed Rusty was breathing fine.

The PACU was a large narrow room with twelve bays, complete with monitors and oxygen setups, for surgical patients to shake off the effects of general or spinal anesthesia. “Bay” was
a nice term for a space on the floor to park the litter. There were no cubicles or walls. Slidable partitioning curtains hung from the ceiling giving one the illusion of privacy, but these were used only to hide the prison patients and their shotgun-toting guards from the public.

“Doctor Carlucci!” yelled a stocky fireplug of a woman, identified by her nameplate as Peg Vargas, R.N. She was clearly upset. “My patient’s having a hard time catching his breath—it’s getting worse!” She quickly motioned them over to the struggling man’s litter.

Peg Vargas had over fifteen years experience in the recovery room. Perhaps because of this, she felt entitled to be brusque, although Mike would’ve called it rude. He got along well with most of the recovery room nurses, but Peg Vargas wasn’t one of them. Interestingly, Mike watched her calm down right before his eyes. She had just fulfilled her primary nursing responsibility and had summoned help. Now it was out of her hands and up to the doctor to do something. She could relax and play her favorite game of armchair anesthesiologist.

“Who is he?” asked Mike, as he scanned the patient and his monitors. Most troubling was the pulse oximeter reading of 82%. Rusty looked back and forth between the patient, Mike, and the nurse. His eyes were wide, and his hands twitched about. Mike gave Rusty credit for appreciating the gravity of the situation.

“Mr. Tompkins, seventy-five,” Peg answered sharply. “He had a radical prostatectomy. Dr. Marshall brought him in about half an hour ago.” She was no longer flustered at all.

“How long has his sat been in the 80s?” Mike fired back, stalling to get his bearings. Oxygen saturations below 90% were considered dangerous. The patient was obviously struggling to breathe, and Mike knew he’d have to do something quickly. Oddly, he reflected that he was the only one who truly felt the pressure of the situation. Although Rusty most likely realized how serious it was, they all expected Mike to know what to do. Just
once, he thought, he’d like to see Peg Vargas in his position; see her snooty, know-it-all facade crumble in a panic.

“It’s been falling just in the last couple of minutes—that’s why I called,” Peg said somewhat defensively.

“He was OK when he came in?” Mike asked. Jesus, he looks dusky.

“Yeah, he seemed fine.” Peg had no trouble returning his glare.

Mike wondered how he went from fine to respiratory distress in minutes. He doubted she had kept a close enough eye on him, but now wasn’t the time to cast aspersions. “Put him on a hundred percent rebreather,” he ordered.

She just stood there for a moment, looking at him. Was she questioning his judgement? Or perhaps she didn’t trust him after Mr. Rakovic’s death in the OR. He knew they all talked about how he had cracked under the pressure behind his back. “I’ll have to get it,” she finally said and wheeled from the bedside.

“What do you think’s wrong with him, Dr. Carlucci?”

Mike put up his hand to shush Rusty. “Hang on Rusty.”

Mike knew he didn’t have the luxury of time to expound upon medical diagnostic theory at the moment; the situation demanded immediate action. He was acutely aware that he didn’t have a working diagnosis yet. He turned to the patient. “Mr. Tompkins, how’s your breathing?”

“Not—so—good,” the patient managed to get out, in a cross between a whisper and a gasp.

Good question, Mike. Now that we got that clear, can we move on to make a diagnosis?
Mr. Tompkins was sitting bolt upright on his litter and laboring mightily to breathe. He was a tall, gaunt man with white, patchy stubble adorning his hollow cheeks. Mike whipped out his stethoscope and listened to his chest. He didn’t hear much air moving. The oxygen sat had fallen to 80%.

“C’mon Peg! I need that mask!” Mike shouted in the direction she had headed. He was oh-so-thankful he had dosed up this morning. The Fentanyl was the only thing standing between
himself and decompensation.
Be cool. Gotta think
. God knew he couldn’t handle another catastrophe.

“Rusty, hear that noise?” Mike asked. Mr. Tompkins was making a faint squeaking noise as he struggled to suck air in; breathing out seemed to be OK.

Rusty leaned in close to the patient, and a puzzled look came over him. “Yeah,” he said unconvincingly.

“It’s all upper airway—the chest is clear,” Mike said as much to himself as anybody. He needed to make a diagnosis—his patient was heading south quickly. The scene was horribly reminiscent of Mr. Rakovic’s case.
Please, no V-tach
. He shot an accusatory glance at the EKG monitor. It was OK for now, but he knew time was running out.

“Do you need a chest x-ray?” Rusty asked, interrupting his thoughts.

“No time.”

“Are you going to intubate him?” Rusty asked excitedly.

“Not sure yet.”

The sat monitor beeped loudly as the alarms announced the sat had dipped below 80%. It continued to fall: 79, 78, 77.

“Here, hook up that Ambu bag to the oxygen,” Mike said. He handed a long green tube to Rusty and motioned to an oxygen nipple outlet on the wall. He turned to the patient and said, “I’m going to help you breathe, Mr. Tompkins.”

Mike grasped Mr. Tompkins’s bony shoulders and pulled him back down to the bed. 76, 75, 74.

“I . . . can’t . . . breathe . . . Need . . . to . . . sit . . . up.”

Mr. Tompkins tried feebly to get up, but Mike held him down. He began to manually assist Mr. Tompkins’s breathing with the Ambu bag. It was difficult to get a good mask seal on his face; his lips caved in because he had no teeth, and his skin was oily. 73, 72, 71.

Mike knew it wasn’t pleasant to have someone force air into your lungs, but it beats suffocation. “Relax and don’t fight me,” Mike said. “Everything’s going to be all right.” A faraway corner of
his brain registered that this last expression was generally reserved for when things were far from all right. “Rusty, go get some intubation stuff—tube, laryngoscope—hurry!” Mike said without looking up. He saw some fog in the mask and knew he was getting some air in, but it didn’t seem like enough.
Shit! Running out of time!

Just then, Peg came back with the rebreather mask. She stared at the sat monitor a little too long, as if to say: “What did you do to my patient?”

“Never mind the mask now!” Mike barked at her. “We’re beyond that.” He concentrated all his effort on mask ventilating the old man.

“What’s wrong with him?” Peg demanded. “Can’t you do something?”

He stopped ventilating for a second to glare at her. “Can’t you see I’m trying.” He had trouble thinking with her badgering him.

70, 69, 68.

Mr. Tompkins began to thrash about. His face continued to turn deepening shades of blue. Mike felt bad for the man and tried to reassure him. “You’re going to be fine, Mr. Tompkins. You’re going to be just fine.” But again, he couldn’t help thinking: hospital lingo for you’re in deep shit.

Even with Mike’s skilled hand on the Ambu bag, the oximeter continued to plummet. Mike saw the horror of airway hunger, one of the most dreadful of all human sensations, grip Mr. Tompkins. Panic glazed his eyes, and his thrashing intensified.

64, 63, 62.

The pulse ox continued to make its horrible, low-pitched beeps. If he had a free hand, he’d turn the damned thing off. Peg just stood there staring at him. “Peg, turn the alarm off!” Where was Rusty? What was taking him so long? Mike could almost feel Mr. Tompkins’s life slipping away between his fingers. He glanced again at the EKG monitor. The rhythm had begun to become irregular.
Oh shit! Not again!

“Do something!” Peg shouted at him.

Suddenly a bit of inspiration flashed through his mind. “Get respiratory here STAT with a racemic epi treatment!” Mike had made his diagnosis; he only prayed it was right and not too late.

Peg flung the mask down and headed for the phone.

Just then, Rusty ran back up to the bedside, breathing hard now, his hands full of intubation equipment. He looked scared to death as he fumbled with the laryngoscope and tube, trying to get them ready. The heavy metal laryngoscope fell on the floor making a loud racket. Before he could do or say anything further, Mike held up his finger. “Wait, Rusty. I have an idea.”