Death Rounds (30 page)

The isolation rooms in ICU were identical to the glass coffins at St. Paul’s—elevated, situated against an end wall, and brightly lit compared to the subdued lighting throughout the rest of the unit. They also appeared small and claustrophobic, and as I approached the only chamber that was occupied, I felt my stomach knot. Through the windows I could see the backs of half a dozen residents wearing protective gear crowded around the bed, blocking my view of Janet. But nearing the door, I could hear her well enough. “Please stop, stop it,” she sobbed, then her plea exploded into a retching cry followed by gagging, coughing, and the rasp of stridor—the rattling wheeze of indrawn breath through an obstructed windpipe. The sound sent a chill through me. Something must have blocked her upper airway.

One of the residents uttered, “Christ! Get some atropine.”

“What’s happened?” I demanded from the doorway, frantically grabbing a gown from a pile on a cart and reaching for a mask. But as I pulled them on none of the residents answered me. Instead they started barking out panicky orders to each other and remained bent over the bed where I heard Janet continue to cough and struggle for breath.

“Turn her on her side!”

“Suction her!”

“It’s laryngeal spasm. She needs atropine!”

‘Tell me what’s going on!” I shouted as I strode into the room still pulling on a pair of surgical gloves.

A nurse turned from the bed and tried to block my way. “Sir, you aren’t allowed in here right now,” she snapped at me, placing the flat of her hands on my chest and pushing.

I brushed them off. “Like hell I’m not,” I snarled, shoving by her. “I’m Dr. Garnet, her husband.”

“You are not a doctor here!” she cried out in a shrill voice.

Ignoring her, I slid between the residents and saw Janet lying on her side, her face practically purple, and her entire upper trunk and neck straining to draw a breath. A thin plastic suction catheter dripping with saliva and vomit lay hissing on the covers in front of her. Scattered across the bed were unused culture bottles, swabs, and slides. My alarm rocketed. These dolts must have been trying to suction her trachea for a sputum sample. The muscles in her larynx and vocal cords had responded by locking into a protracted spasm and cutting off her airway. She might even have aspirated vomit into her lungs.

Fighting back my own panic, I reached for her neck. It was bulging with strands of tendons and webs of muscles as she struggled to gasp in a breath. I managed to palpate the pulse of her carotid artery, but I could count two seconds between each beat beneath my fingers.

Through clenched teeth I ordered the nurse who’d tried to bar my way, “Get me two milligrams of IV atropine stat!”

She simply stood there.

“Move, you idiot!” I screamed at her, beside myself with fright.

She flinched, then turned toward a set of open shelves at the head of the bed where there were labeled trays of different drugs in single-dose vials.

Janet’s eyes were bulging at me. I didn’t know if she could see, but she grabbed at the front of my gown while her entire body bucked rhythmically in her continuing struggle to draw a breath. I clasped her hands to my chest. They were cold and slippery with sweat. “Janet, it’s Earl. I’m going to give you something to restore your airway. Just a few seconds more and you’ll be breathing.”

The nurse slapped two small brown vials down onto a nightstand and glared at me over the top of her mask.

Fuck you, I thought, turning for help to the residents instead. “Get me a ten-cc syringe and twenty-two needle filled with normal saline,” I snapped at the young man on my right To the woman beside him I added, “You get the crash cart ready and prepare to intubate, in case what I’m going to try here doesn’t work.” I spun around to face their colleague on my left, “You draw up ten milligrams of midazolam and a hundred milligrams of succinocholine. We may yet have to sedate and paralyze her.” They jumped to obey. After the mess they’d made, it obviously mattered little to
them
who I was, as long as I saved their patient and their asses.

More hideous rasping noises continued to come from Janet’s throat—the sound of air sucked through an opening in the vocal cords no bigger than a slit We probably had another thirty seconds before she’d start to seize. Cardiac arrest would follow. Right now she was still conscious and in agony.

“Hold her firmly and keep her head steady,” I told the three remaining residents, “but don’t hurt her, you hear me!”

“Yes, sir,” they mumbled in unison under their masks.

Janet’s eyes widened even further with panic as they pushed her down and grasped her head between their hands.

“I’m here, Janet; this will help you,” I reassured, trying vainly to sound calm. Inside I didn’t know if I could do what I had in mind. Fear of failure was constantly present in any race to win back an airway or recapture a heartbeat, but the terror of losing Janet jangled my thinking, unsteadied my hands, and corroded my nerve.

Atropine would reopen her airway by blocking the neuronal pathway that was keeping the larynx in spasm, but the IV route took time. A resident handed me the syringe that I requested, the inch-long needle glinting under the ceiling lights. I squirted out a few ccs of saline, snapped open the brown vials, and drew the atropine up into the cylinder. Then I grabbed an alcohol swab from the night-stand and, to the gasps of the residents, ran it over the front of Janet’s larynx. I was going to inject directly into her neck. I’d never treated laryngospasm this way before, but I’d put needles into the trachea to freeze it for intubations of head trauma cases and I’d shoved atropine down endotracheal tubes during cardiac arrests. I couldn’t think of anything that would work faster.

“Janet, if you can hear me, close your eyes, love!” I commanded, my voice shaking as I located the landmarks of the cricothyroid membrane—the thin “window” covering the opening where access to her windpipe would be easiest—and brought the needle point up, pressing it against the overlying skin. She seemed to stare at it and increased her efforts to break free. “Hold her,” I yelled.

They steadied her movements, and I shoved the tip of the needle hard enough to penetrate her skin, pulling gently back on the plunger as I advanced the point. A tiny stream of bubbles flowed up into the cylinder indicating I was through to her airway. I angled the needle toward her larynx, pushed the plunger as hard as I could, and yanked out the emptied syringe.

Ten seconds passed. Her movements grew feebler and her eyes, still open, fluttered up under her lids.

From the resuscitation cart I grabbed a black rubber ventilating mask, connected it to an oxygen outlet, and pressed it to her face. I squeezed the attached bag in an attempt to force air down her lungs, but there was resistance against my hand. It meant her larynx was still closed.

Another ten seconds passed. Her eyes were nearly shut, her skin was blue, her limbs were starting to jerk.

“Get ready to sedate and paralyze her,” I ordered, but my own voice sounded far away while my panic continued to mount If she seized, her teeth would clamp together and her body would start heaving with convulsions so powerful that we’d break her bones if we tried to hold her down. We’d only be able to intubate her after the drugs or the severe lack of oxygen broke off the pulsing muscle contractions. That might take more than a minute, enough time to put her into cardiac arrest.

I squeezed the bag once more. Again the resistance remained so firm I couldn’t budge my fingers. Then I felt a release, the bag responded to the pressure of my hand, and I saw Janet’s chest rise. I squeezed again and again, each time pushing oxygen more and more easily through her opened airway and into her lungs. Over and over I ventilated her, watching her skin quickly turn back from blue toward pink. Soon she was stirring, moaning, and shoving the mask away as she rapidly resumed breathing for herself. She coughed repeatedly, but didn’t expectorate much. When I listened to her chest, she was wheezing, but the sounds were distributed uniformly, probably from the infection, and there was equal air entry into the bases of both right and left lungs. It would take an X ray to be sure, but I didn’t think she’d aspirated.

When she finally stopped choking enough to speak, she looked at me incredulously and croaked, “You put a bloody needle in my neck!”

Tears came to my eyes as I laughed to keep from crying. “And you scared me half to death,” I said, leaning over and putting my arms around her.

The residents shuffled nervously and the nurse looked on disapprovingly. I ignored them all. They’d account to me later, I swore, but I didn’t give a damn for anything at that moment except to feel Janet against me. Yet I was also thinking like a physician. Her breathing was still labored, presumably from her developing pneumonia. While I held her, I reflexively checked the IV, making sure her movements hadn’t dislodged it. I noted the label on the overhead bag read
Erythmmycin.
I was resetting its flow rate with one hand when I saw Cam standing at the door watching us all.

He was wearing protective gear, but his eyes above his mask were dilated and dark with rage, exactly as I’d seen them earlier this morning. For a second I thought it was the sight of me again that was making him furious, but he swung that fierce gaze toward the residents, “What the hell have you been doing to Dr. Graceton!” he screamed at them.

The bunch of them seemed to flinch, but one in particular averted his eyes and tried to edge behind the others. Cam must have seen the movement as well, because he immediately singled him out. “You! Tell me what happened or I’ll suspend the lot of you and make sure you never set foot in this hospital again.”

The young man froze, and the others moved away, leaving him standing alone in front of Cam. His face reddened above his mask all the way to the upper tips of his ears.

“Well?” demanded Cam, towering over him.

“I thought we could do a simple aspirate with a small catheter,” he began to explain, sounding plaintive. “I did it all the time on patients in recovery during my anesthesia rotation—”

“Those patients are already sedated and intubated!” roared Cam. “What the hell made you think you could do the same to an alert patient?”

“None of us had experience with midazolam to put her to sleep, and I figured without her intubated we shouldn’t freeze her gag reflex—”

“Jesus Christ, lord save us from what you call thinking. And the rest of you did nothing to stop this genius from nearly killing Dr. Graceton?” he yelled, turning to the others. “How dare any of you stand by and not attend to a patient’s pain before an invasive procedure—any invasive procedure at all—you understand me! You damn well don’t hurt patients. I’ve half a mind to put tubes down your throats and let you experience what you just put Dr. Graceton through. Disgraceful! The lot of you are on probation as far as I’m concerned.”

Now all the residents flushed crimson above their masks. Some grew wide-eyed while others glared furiously at the one who’d performed the suction.

“You don’t go near a patient of mine without discussing it with me first,” continued Cam, his voice lower, but his tone as hard and unforgiving as ever, “and you don’t write an order without it being countersigned immediately by a staff person. In forty-eight hours you bozos will present what you did here today to a special grand rounds on laryngospasm in front of all your colleagues in our residency program. Now get out of my sight!”

They filed out of the room without looking at each other. Some were so dazed they had to be reminded to remove their gowns and masks at the door while the others flung their clothing into the disposal bin and stomped off. The nurse quietly tried to follow them, but Cam wasn’t finished with her either.

“Hold it,” he told her brusquely. “You’ve got some explaining to do as well. What were you thinking of, letting those clowns proceed the way they did? They were obviously in over their heads. Who even ordered a tracheal aspirate?”

She stopped moving toward the door and turned to face him. I only now took a real look at her. She was dark-haired with a few strands of gray, tall, and as far as I could tell rather slim looking, but whatever physical attributes she had hidden under her costume, I’d already decided that her disposition was nasty. A name tag over her left breast told me we should call her Miss Brown. “It’s your own policy. Dr. Mackie,” she replied in a sweet singsong tone that sounded belligerent

Cam exploded, “Doing tracheal aspirates on unmedicated patients is not my—”

“Getting proper sputum samples is, especially since we’ve had so much trouble with infected personnel lately. I saw a note in her chart saying the sputum sample they got in ER was scanty.”

It was Cam’s turn to go beet red.
“Legionella,
as you should know better than anyone. Miss Brown, doesn’t produce much sputum.” His voice vibrated with the same barely controlled anger I’d heard him direct at me this morning. “My guidelines for getting proper sputum samples are meant to be applied with clinical judgment.”

“I’m only a nurse. Dr. Mackie. It’s not up to me to know which rules you want used and when—”

I felt Janet lift her head off my chest. “That’s a crock. Cam. I told her that Harold Miller had taken samples in ER and that the scanty sputum was to be expected. She refused to listen.” Even weakened by what she’d been through, Janet’s tone had the scalpel-sharp bite she saved for unpleasant truths.

“Why, Dr. Graceton,” the woman protested, “you can’t expect to give orders when you’re a patient—”

“But I can give orders. Miss Brown,” bellowed Cam, “and since you’re so good at following rules, here’s one for you. Until I can haul you into a morbidity review about what you did here, you’re no longer to have anything to do with nursing Dr. Graceton. Come with me, and I’ll arrange it with your supervisor! By the time I’m through with you, you’ll never work in an ICU again!” He stormed from the room, practically ripping his protective clothing off at the door before heading to the nursing desk.

Brown flashed a murderous look at Janet, then followed after Cam. She flung her own gown, mask, and gloves on the floor beside the designated bin.