Life Support (4 page)

"I don't know. A few months ago, I guess."

Toby absorbed that information in silence. If Daniel Slotkin resided in Boston, then he lived less than twenty miles away. Certainly not a distance that would explain such infrequent contact between father and son.

As though sensing her unspoken question, Daniel Slotkin added, "My father leads a very busy life. Golf. Daily poker at the country club.

It's not always easy for us to get together."

"He was mentally sharp a few months ago?"

"Let's put it this way. The last time I saw my father, he gave me a lecture on investment strategies. Everything from stock options to the price of soybeans. It went over my head."

"Is he on any medications?"

"Not that I know of."

"Do you know the name of his doctor?"

"He goes to a specialist in that private clinic at Brant Hill, where he lives. I think the doctor's name is Wallenberg. Look, just how confused is my father?"

"The police found him on a park bench. He'd taken off his clothes."

There was a long silence. "Jesus."

"I can't find any injuries. Since you say there's no history of dementia, there must be something acute going on. Maybe a small stroke. Or a metabolic problem."

"Metabolic?"

"An abnormal blood sugar, for instance. Or a low sodium level. They can both cause confusion."

She heard the man exhale deeply, a sound of weariness. And maybe frustration. It was five in the morning. To be awakened at such an hour, to face such a crisis, would exhaust anyone.

"It would be helpful if you came in," said Toby. "He might find a familiar face comforting."

The man was silent.

"Mr. Slotkin?"

He sighed. "I guess I'll have to."

"If there's someone else in the family who can do it�"

"No, there's no one else. Anyway, he'll expect me to show up. To make sure everything's done right."

As Toby hung up, Daniel Slotkin's last words struck her as faintly threatening, To make sure everything's done rig*t. And why wouldn't she do everything right?

She picked up the telephone and left a message with the Brant Hill Clinic answering service, telling them their patient Harry Slotkin was in the ER, confused and disoriented. Then she punched in the beeper for the Springer Hospital X-ray tech.

A moment later, the tech called back from home, his voice groggy with sleep. "This is Vince. You beeped me?"

"This is Dr. Harper in the ER. We need you to come in and do a STAT CT head scan."

"What's the patient's name?"

"Harry Slotkin. Seventy-two-year-old man with new-onset confusion."

"Right. I'll be there in ten minutes."

Toby hung up and stared at her notes. What have I overlooked? she wondered. What else s*auld I be searching for? She reviewed all the possible causes of new-onset dementia. Strokes. Tumors. Intracranial bleeds. Infections.

She glanced again at the vital signs. Maudeen had recorded an oral temperature of 37.9 degrees centigrade. Not quite a fever, but not quite normal, either. Harry would need a spinal tap�but not until the CT scan was done. If there was a mass in his skull, a spinal tap could lead to a catastrophic shift in pressure on the brain.

The wall of a siren made her glance up.

"Now what?" said Maudeen.

Toby shot to her feet and was already waiting at the ER entrance when the ambulance pulled up with a loud whoop. The vehicle's rear door flew open.

"We got a code in progress!" the driver yelled.

Everyone scrambled to unload the stretcher. Toby caught a quick glimpse of an obese woman, her face pale and limp-jawed. An ET tube was already taped in place.

"We lost her pressure enroute�thought we'd better stop here instead of going on to Hahnemann�"

"What's the history?" snapped Toby.

"Found on the floor. Had an MI six weeks ago. Husband says she's on Digoxin�" They rushed the patient through the ER doors, the driver pumping clumsily on the chest as the stretcher careened up the hall and swerved into the trauma room. Val hit the light switch. Overhead lamps flooded on, blindingly bright.

"Okay, you all got a grip? She's a big one. Watch that IV! One, two, three, move!" yelled Maudeen.

In one smooth transfer, four pairs of hands slid the patient off the ambulance stretcher and onto the treatment table. No one had to be told what to do. Despite the seeming confusion of a Code Blue, there was order in chaos. The driver resumed chest compressions. The other EMT continued bagging the lungs, pumping in oxygen. Maudeen and Val scrambled around the table untangling IV lines and connecting EKG wires to the cardiac monitor.

"We've got sinus rhythm," said Toby, glancing at the screen. "Stop compressions for a second."

The driver stopped pumping on the chest.

"I'm barely getting a pulse," said Val.

"Turn up that IV," said Toby. "We got any pressure yet?"

Val glanced up from the arm cuff. "Fifty over zip. Dopamine drip?"

"Go for it. Resume compressions."

The driver crossed his hands over the sternum and began to pump again.

Maudeen scurried to the code cart and pulled out drug ampules and syringes.

Toby slapped her stethoscope on the chest and listened to the right lung field, then the left. She heard distinct breath sounds on both sides. That told her the ET tube was properly positioned and the lungs were filling with air. "Hold compressions," she said and slid the stethoscope over to the heart.

She could barely hear it beating.

Glancing up again at the monitor, she saw a fast sinus rhythm tracing across the screen. The heart's electrical system was intact. Why didn't the woman have a pulse? Either the patient was in shock from blood loss.

Or . . .

Toby focused on the neck, and the answer instantly became apparent to her. The woman's obesity had obscured the fact that her jugular veins were bulging.

"You said she had an MI six weeks ago?" Toby asked.

"Yeah," the driver grunted out as he resumed chest compressions.

"That's what the husband said."

"Any other meds besides Digoxin?"

"There was a big bottle of aspirin on the nightstand. I think she's arthritic."

That's it, thought Toby. "Maudeen, get me a fifty cc syringe and a cardiac needle."

"Gotcha."

"And toss me some gloves and a Betadine wipe!"

The packet flew toward her. Toby caught it in midair and ripped it open. "Stop compressions," she ordered.

The driver stepped back.

Toby gave the skin a quick swab of Betadine, then she pulled on the gloves and reached for the 5Sec syringe. She glanced one last time at the monitor. The rhythm was still a rapid sinus. She took a deep breath.

"Okay. Let's see if this helps . . ." Using the bony protrusion of the xiphoid process as her landmark, she pierced the skin and angled the needle tip straight toward the heart. She could feel her own pulse hammering as she slowly advanced the needle. At the same time she was pulling back on the plunger, exerting gentle negative pressure.

A flash of blood shot into the syringe.

She stopped right where she was. Her hands were absolutely steady. God, let the needle be in the right place. She pulled back on the plunger, gradually suctioning blood into the syringe. Twenty cc's.

Thirty. Thirty-five . . .

"Blood pressure?" she called out, and heard the rapid whi.f>, whi�of the cuff being inflated.

"Yes! I'm getting one!" said Val. "Eighty over fifty!"

"I guess we know what we've got now," said Toby. "We need a surgeon.

Maudeen, get Dr. Carey on the line. Tell him we've got a pericardial tamponade."

"From the MI?" asked the ambulance driver.

"Plus she's on high-dose aspirin, so she's prone to bleeding. She probably ruptured a hole in her myocardium." Surrounded by blood in the closed sac of the pericardium, the heart would be unable to expand.

Unable to pump.

The syringe was full. Toby withdrew the needle.

"Pressure's up to ninety-five," said Val.

Maudeen hung up the wall phone. "Dr. Carey's coming in now. So's his team. He says to keep her stabilized."

"Easier said than done," muttered Toby, her fingers probing for a pulse. She could feel one, but it remained thready. "She's probably reaccumulating. I'll need another syringe and needle pretty quick. Can we get her typed and crossed? And let's get a STAT CBC and Iytes while we're at it."

Maudeen pulled out a fistful of blood tubes. "Eight units?"

"At least. Whole blood if we can get it. And send down some fresh frozen plasma."

"Pressure's falling to eighty-five," said Val.

"Shit. We'll need to do it again."

Toby ripped open a packet with a fresh syringe and tossed the wrapping aside. Already the floor was piling up with the debris of paper and plastic that accumulated during every code. How many times will I have to repeat this? she wondered as she positioned the needle.

Getyour butt over here, Carey. I can t save this woman on my own . . .

Toby wasn't sure Dr. Carey could save the patient either. If the woman had blown a hole in her ventricular wall, then she needed more than just a thoracic surgeon�she needed a full cardiac bypass team. Springer Hospital was a small suburban facility, perfectly capable of dealing with cesareans or simple gallbladder resections, but it was unequipped to deal with major surgery. Ambulance teams transporting serious trauma victims would normally bypass Springer Hospital and head straight for one of the larger medical centers like Brigham or Mass General.

This morning, though, the ambulance had unknowingly delivered a surgical crisis right to Toby's doorstep. And she didn't have the training�or the staff�to save this woman's life.

The second syringe was already filled with blood. Another fifty cc's of it�and it didn't clot.

"Pressure's going down again," said Val. "Eighty�"

"Doc, she's in V-tach!" one of the EMT's cut in.

Toby's gaze shot to the monitor. The rhythm had deteriorated to the jagged pattern of ventricular tachycardia. The heart was using only two of its four chambers now, beating too fast to be efficient.

"Defibrillator pads!" snapped Toby. "We'll go with three hundred joules."

Maudeen hit the charge button on the defibrillator. The needle climbed to three hundred watt-seconds.

Toby slapped two pads on the patient's chest. Coated with gel, the pads ensured electrical contact with the skin. She positioned the paddles.

"Back!" she said, and squeezed the discharge button.

The patient thrashed, all her muscles jerking simultaneously as the current shot through her body.

Toby glanced at the monitor. "Okay, we're back in sinus�"

"No pulse. I've got no pulse," said Val.

"Resume CPR!" said Toby. "Hand me another syringe."

Even as she opened the packet and twisted on the pericardiocentesis needle, Toby knew they were losing the fight. She could suction out liters of blood, but more would accumulate, compressing the heart. Just keep her alive until the surgeon gets here, thought Toby, and the words became her mantra. Keep her alive. Keep her alive . . .

"Back in V-Tach!" said Val.

"Charge to three hundred. Get a lidocaine bolus in�" The wall phone rang. Maudeen answered it. A moment later she called out, "Morty's having trouble crossmatching that blood I sent up!

The patient's B negative!"

Shit. What else can go wrong? Toby slapped the paddles on the chest.

"Everyone back!"

Again the woman's body jerked. Again the rhythm settled back into rapid sinus.

"Getting a pulse," said Val.

"Push that lidocaine now. Where's our fresh frozen plasma?"

"Morty's working on it," said Maudeen.

Toby glanced at the clock. They'd been coding the patient for nearly twenty minutes. It seemed like hours. Surrounded by chaos, with the phone ringing and everyone talking at once, she felt a sudden flash of disorientation. Inside the gloves, her hands were sweating, and the rubber was clammy against her skin. The crisis was spiralling out of her control....

Control was the word Toby lived by. She strove to keep her life in order, her ERin order. Now this code was falling apart under her command, and there was nothing she could do to salvage it. She wasn't trained to crack a chest, to sew up a ruptured ventricle.

She looked at the woman's face. It was mottled, the flabby jowls deepening to purple. Even as she watched, she knew the brain cells were starving. Dying.

The ambulance driver, exhausted from chest compressions, switched places with his fellow EMT. A fresh pair of hands began pumping.

On the monitor, the heart tracing deteriorated to a jaggedly chaotic line. Ventricular fibrillation. A fatal rhythm.

The team responded with the usual strategies. More boluses of antiarrhythmics. Lidocaine. Bretylium. Higher and higher jolts from the paddlles. In desperation Toby withdrew another fifty cc's of blood from the pericardium.

The heart tracing flattened out to a meandering line.

Toby glanced around at the other faces. They all knew it was over.

"All right." Toby released a deep breath, and her voice sounded chillingly calm. "Let's call it. What time?"

"Six-eleven," said Maudeen.

We kept her going forty-five minutes, thought Toby. That's the best we could do. The best anyone could do.

The EMT stepped back. So did everyone else. It was almost a reflex, that physical retreat, those few seconds of respectful silence.

The door banged open and Dr. Carey, the thoracic surgeon, made his usual dramatic entrance. "Where's the tamponade?" he snapped.

"She just expired," said Toby.

"What? Didn't you stabilize her?"

"We tried. We couldn't keep her going."

"Well, how long did you code her?"

"Believe me," said Toby. "It was long enough." She pushed past him and walked out of the room.

At the nurses' desk she sat down to gather her thoughts for a moment before filling out the ER sheet. She could hear Dr. Carey in the trauma room, his voice raised in complaint. They'd dragged him out of bed at five-thirty in the morning, and for what? A patient who couldn't be stabilized? Couldn't they think first before they ruined his night's sleep? Didn't they know he had a full day in the OR coming up?