Angels on the Night Shift (2 page)

She pressed the adhesive electrodes onto his chest, checked the monitor for good contact, then reached for some nasal prongs and plastic tubing.

“O2?” she asked, looking up at me.

Ernest seemed a little short of breath, and I nodded to her. “Three liters a minute.” His color wasn’t good, and he kept a hand pressed against his sternal area. “And let’s get a line started.”

I was about to ask for his blood pressure, when Lori said, “88 over 60 in triage. I’ll check it again now.”

The door opened and Jeff Ryan walked in. He was the nurse assigned to cardiac this morning, and he went quickly over to where Lori stood.

“What do you need?” he asked.

She handed him the oxygen setup and said, “If you’ll get this going, I’ll work on his IV. And we need to repeat his blood pressure.”

I stepped to the other side of the stretcher and began asking Mr. Shays about his chest pain. Glancing over at the counter behind him, I noticed his short-sleeved shirt, tossed there by Lori. An open pack of Marlboros had partly slipped out of the breast pocket.

“I was fine when I got up this morning, Doctor,” he was telling me. “Getting ready to go to work, when all of a sudden my chest started hurting. Never had anything like it in my life. It was terrible. Sharp pain, like I was tearing apart. Right here,” he said, pointing to his breastbone. “After a couple of minutes, it seemed to ease off. But I felt weak, and knew I needed to get to the hospital.”

Lori was behind me, getting a bag of normal saline from one of the shelves on the wall. I heard the sound of glass hitting the counter and jerked my head around. Two glass vials had fallen, apparently as she’d been sliding the bag toward her. She picked up one, which was cracked open and empty. The other one was empty as well. She held up the first one to the light and studied the label.

I noticed a puzzled look on her face and asked, “What is it?”

“It’s Vistaril,” she answered. “But I don’t know what it’s doing up here. Why would—”

“70 over 50,” Jeff called out with an edge in his voice.

I turned back to the stretcher and said to Lori, “Let’s get that line going.”

She tossed the vials into a nearby trash can, grabbed her IV supplies, and quickly turned to Mr. Shays.

“I’m right here.”

One of our techs hurried into the room, pushing our EKG machine.

“Can I get in there and get this done?” she asked, looking over at Jeff.

“Yeah,” he answered, checking the patient’s BP again.

He inflated the cuff and slowly released it, listening carefully.

“Still 70 over 50.”

“Are you having any pain now?” I asked Ernest.

“No pain, Doctor. I just feel weak, and a little light-headed.”

“Do you want this wide open?” Lori asked me, having started the IV and now adjusting the flow rate.”

“And my legs are gettin’ numb,” Shays added, looking up at me.

I looked over at the monitor. His heart rate was in the 80s and regular. Then I glanced down at the EKG that was printing and just starting to be spit out from the machine. It looked normal, with no evidence of any acute injury.

“I can barely feel them,” Ernest said again, rubbing the tops of his thighs.

He was remaining calm, which was more than I could say about myself. He was in trouble and I was beginning to fear the worst.

“We need a portable chest X-ray stat,” I directed Jeff, looking over at him and seeing his worried brow furrowed. He was feeling for a femoral pulse and nodded his head. “Faint, but I can feel it,” he told me. “And I’ll get Amy on that X-ray,” he added, stepping toward the doorway.

“Wide open on those fluids,” I told Lori. “And we need to get lab in here now. The routine stuff, but we’re going to need to type and cross for some blood too.”

She glanced at me, a question in her eyes.

“Is it my heart, Dr. Lesslie?” Ernest asked me. “Am I going to die?”

I stopped what I was doing and looked down into Mr. Shays’s eyes. He was afraid, and I needed to be honest with him. If I was right, it wasn’t his heart, but he was in real trouble.

“Ernest—” I began, but was interrupted by the appearance of the portable X-ray machine in the doorway. The radiology tech was deftly guiding the cumbersome motorized equipment to the edge of the stretcher.

“Ready for this?” she asked, already beginning to swing the arm and tube over Mr. Shays’s chest.

“Yeah,” I answered, stepping back out of her way. “We need that as fast as you can.”

The chest X-ray would probably give me my diagnosis, and I still needed to answer Ernest’s question. But that would have to wait.

“I’m going to step out into the hallway,” I told him, patting his arm. “When she’s finished, I’ll be back in.”

As I opened the door to leave, I was met by Amy Connors.

“Mr. Shays’s wife and son just got here,” she told me. “They’re out in the waiting room and want to know if they can come back.”

I closed the door behind me and we stepped into the triage hallway.

“Let them know we’re getting a few things done, but they can come back in a couple of minutes,” I said. “Give me a chance to look at that X-ray and then I can let them know more about what’s going on.”

A few minutes later, standing in front of the view box, I had my answer. Ernest Shays’s chest X-ray was clearly abnormal, with a markedly widened mediastinum. This was the central part of his chest, which contained his heart, but also his major blood vessel—the aorta. It was enlarged, much bigger than it should be. The tearing feeling he had experienced was this big vessel ripping apart—dissecting. Like the rings of an onion, the inner lining was separating from the outside of the vessel, and the ripping was making its way through his chest and down into his abdomen, shearing off any blood vessels in its way. That’s why his legs were getting numb. The arteries that supplied those limbs were no longer carrying blood to them.

His blood pressure had responded to the IV fluids we were giving him, providing a narrow but closing window to save his life. And his pain had gotten better after the initial dissection had started, after the ripping had begun its work. After that initial tearing sensation, most patients seemed to have a lessening of their pain. But that was a false sense of improvement. Things were going to get worse.

As I walked back to cardiac, I glanced over at Amy.

“Get me the thoracic surgeon on call,” I said. “Tell him I need him right now. And you can let Mr. Shays’s family come back. I want to talk with them.”

Jeff was standing at the head of the stretcher, adjusting Ernest’s IV tubing.

“Pressure’s up to 90 over 60,” he told me. And he says he’s starting to feel his legs again. Do we need to do anything else?”

Prompted by the comment, Ernest moved his legs from side to side, patting his thighs. “I’m feeling better, Doctor,” he said hopefully. His face was still pale, and the fear remained in his eyes. “What did you find out from the X-ray?”

The door opened and Amy ushered in a middle-aged woman and a young man who looked to be in his twenties, Mr. Shays’s wife and son. They immediately stepped over to his side, his wife caressing his damp forehead and gently grasping his hand.

Then anxiously she looked up into my face.

“I’m Ernest’s wife,” she nervously told me. “And this is our son, Julius. Please tell us what’s wrong with him. Is he going to be okay?”

I could see she was trying mightily to maintain her composure, but her lips were trembling as she said this. She could see how pale he was, and feel the clammy coolness of his brow beneath her hand.

Taking a deep breath, I began to explain what was causing Ernest’s chest pain. His aorta was dissecting, and if he was going to live, it had to be repaired—and quickly. That “window” was now counted in moments, not hours.

“Is he going to—” Mrs. Shays began, interrupted by the door of cardiac bursting open.

Jason Evans, one of our thoracic surgeons, rushed into the room, dressed in surgical scrubs and still wearing a sweat-stained surgeon’s cap. He must have just come out of the operating room.

“Robert,” he stated with unusual animation. “I looked at the chest X-ray hanging on the view box. If that’s his,” nodding at Ernest Shays, “we need to get him to the OR right now.”

“It’s his,” I confirmed. “And we’ve called the OR supervisor and let her know what’s coming.”

“Have you crossed him for some blood?” he asked, stepping over to the side of the stretcher and putting his hand on Ernest’s shoulder.

“Eight units,” Jeff told him.

“Good,” Jason nodded. “But we’re going to need more.”

He quickly introduced himself to Ernest and then to his wife and son. As quickly as he could, he explained what needed to be done, and then he was gone.

The room erupted with activity. A nurse from the OR hurried in, while Lori helped Jeff make the necessary preparations to get our patient over to surgery. Another lab tech came in with several units of cross-matched blood. And all the while, Ernest lay on his stretcher, calmly holding his wife’s hand and curiously surveying the hectic activity surrounding him.

Then he was wheeled out into the hallway toward the OR, and he was gone.

I stood in the middle of the now strangely silent and almost empty room, the floor littered with bits of cardiac monitor strips and discarded wrappers and pieces of equipment.

Mrs. Shays and her son stood next to me, staring at the floor and not knowing what to say or what to do.

Without raising her eyes, Mrs. Shays quietly whispered, “Dr. Lesslie, is Ernest going to live? Will we see him again?”

I looked at her and then over at her son.

“Dr. Evans is a good surgeon,” I told her. “Your husband is in good hands.”

Her head remained bowed for a few more seconds. Then she looked up and in a calm voice said, “He’s in the Lord’s hands.”

I looked more closely at this woman. Her face now radiated peace and a sure knowledge of what she had just said.

“Yes, he’s in the Lord’s hands,” I repeated.

6:55 p.m
. Elizabeth Kennick walked through the ambulance entrance, an overnight bag slung over her shoulder. She was the 7p to 7a doctor—my relief. As usual, her long blonde hair, light-blue eyes, and warm, self-assured smile caused most of the male heads in the department to turn in her direction.

She was used to the attention, and without seeming to notice it, she walked over to where I stood and plopped her bag on the floor beside me.

“Anything exciting to tell me about, Robert?” she asked, glancing over to the patient ID board. It was almost completely filled in, with only a few empty beds in the department. Typical for this time of day.

I was finishing up some prescriptions for the asthmatic truck driver in room 4.

“Nope,” I answered. Then sliding the chart down the counter to Jeff Ryan, “This should just about do it for me, so there’s nothing to turn over.”

“Good,” she replied, her voice animated with anticipation. “Looks like we’re going to have a busy evening.”

I had first met Elizabeth—Liz, as she preferred—when she was a fourth-year medical student rotating through the emergency department of Charlotte Memorial Hospital. I was serving as chief resident, and found her to be quick, eager, and a good Password partner at three in the morning. Nobody could beat us. Her parents were both physicians, internal-medicine specialists in Asheville, and she had finished summa cum laude at Chapel Hill.

After med school, she had completed an emergency-medicine residency in Atlanta, and then we had talked her into joining us in Rock Hill. After only three months, she had fit right in and was one of the “family.”

“I guess no Password tonight,” I quipped, then turned and headed down the hallway to our office. Liz grabbed her bag and followed me.

We were just outside the ortho room, about to turn the corner, when Jason Evans almost ran into me.

“Whoa, Robert!” he exclaimed, stopping just in front of me. “Glad I caught you. I wanted to give you an update on the guy with the thoracic dissection.”

“Mr. Shays,” I said. “Yeah, how is he doing? We haven’t heard anything.”

He stood silent for a moment, shaking his head. It was then I noticed the blood spattered on his pant legs and surgical shoe covers. His scrub top was drenched with sweat, plastered against his body.

“We just finished in the OR,” he said, glancing over at Liz and then back to me. “That was a really close one. It took us forever to get enough exposure to find out where he was bleeding, and then to put things back together. But he’s heading up to the ICU shortly, and he’s stable, for the moment. He’s not out of the woods, but he’s got a reasonably good chance of surviving this.”

Relieved, I nodded my head, then asked, “Is his family still in the surgical waiting room?”

“Just left them,” Evans replied. He glanced down at his wristwatch. “Gotta get going. Got several people to see upstairs. Just wanted to let you know about your patient.” Then he turned and was gone.

“You had a dissection today?” Liz asked, wide-eyed and excited. “And did he say
thoracic
? I’ve never seen one. How did he present? Was it straightforward or…You know, according to the textbooks, only 25 percent of them present with classic symptoms, and only 50 percent survive an operation. In fact, most don’t make it to the OR.”

She paused just long enough for me to wonder which question I was supposed to answer.

“Wow! You were right, Robert,” she exclaimed. “You told me I’d see it all if I came to Rock Hill!”

She paused again, and I had just enough time to say, “I need to go check on Mrs. Shays before I head home. And you’d better get out to the department and keep things moving.”

Heading toward the surgical waiting room, I heard our office door open behind me and Liz call out, “I want to hear all about that case in the morning!”

I shook my head, marveling at her enthusiasm and trying to remember if I had been that way when I first started out. Taking a deep breath, I walked down the hall toward the surgery waiting room.