Night Zero (Book 1): Night Zero

by Horner, Rob

  There were three providers on duty, one physician and two nurse practitioners. James, a new NP with less than six months’ experience since passing his national certification exam, currently staffed Fast Track, a job that put him in the triage room with the nurse, where he examined and treated the less-serious patients, often before they even completed the triage process. Coughs, colds, sore throats, mild sprains and Get-Out-Of-Work for a day stomach aches comprised the majority of cases seen in any emergency department, with a healthy dose of urinary tract infections, sexually transmitted diseases, and unintentional pregnancies thrown in for good measure. Having a provider in the front who was able to diagnose and treat these minor maladies kept the staff in the back from being bogged down with lower-acuity patients. This allowed the waiting room to keep moving and kept beds available for the patients with chest pain, hip fractures, sudden changes in mental status, pneumonia, or abdominal pain not explained by a problem with the urine. It wasn’t uncommon for Fast Track to see more patients in twelve hours during flu season than the rest of the emergency department did in twenty-four. The patients appreciated the service as well, since it dropped typical wait times down from several hours to less than thirty minutes.

  At five o’clock James was sitting at his computer terminal, chatting amiably with the triage nurse, Tiffany, the two sharing guesses on the daily crossword puzzle in the current issue of the Gazette. They knew nothing of the incoming ambulance carrying two patients, one of them behind the wheel.

  The second nurse practitioner, an experienced provider of eight years named Tina Maltis, stood gathered with a handful of nurses and technicians, watching the ambulance pull into the driveway, ready to spring into action the moment the patient was delivered. Having shared the details of the radio transmission from the ambulance driver with the attending doctor, she would manage the aggressive patient, while the doctor cared for the driver. In most cases, the NP would be charged with caring for someone who required a task like suturing, but Dr. Patel loved to sew, and disliked dealing with potential psychiatric patients, most of whom he felt could be better helped by getting their parents in the room and showing the cowards how and when to spank their children.

  In addition to the three providers, five nurses, two CNAs, and a unit secretary, the emergency department currently held three patients.

  Randy Sprugg was an eighty-six-year old veteran of the Korean conflict who regaled everyone, nurse, doctor, and family members alike, with tales of the things he had seen and done on the battlefield. He was also over six feet tall and close to two hundred pounds. What he’d lost in mental faculty he’d maintained in physical strength, and anytime the nursing home sent him to the hospital was a trial and a tribulation for the ED staff. Dementia, as it progresses, is an evil thing, stealing more than just memories, often leaving nothing but a shell that eventually forgets to eat or use the bathroom. Even at eighty-six, Randy was stronger than half of the staff. Yet he lived his life in an adult brief, needing to be cleaned regularly, which contributed to the development of the occasional urinary tract infection, something which exacerbated dementia like giving an upper to a bipolar person already in a manic phase.

  The emergency department had few resources to manage a patient like Randy. They couldn’t restrain or sedate him unnecessarily. All they could do was place him in a room near the nurses’ station (room 16, in this case), and post one of the CNAs in a chair outside his door, there to watch him in case he tried to get out of bed. Unsteady on his feet at the best of times and dizzier than normal with his infection, he was at a heightened risk of falling. Randy wasn’t cognizant enough to understand there was an IV in place delivering antibiotics and fluids that would hopefully return him to his mental baseline and allow the ED to transport him back to his long-term care facility. He might try to pull it out or, more likely, wouldn’t even realize it was there and accidentally pull it out just trying to walk away from the bed.

  Room Nine held a young, pregnant woman complaining of abdominal pain and vaginal bleeding. Though her urine was clear of any blood, protocol dictated that an ultrasound be performed to determine the status of her baby. Amy Cumberland knew the protocols, having already delivered three children, and knew what to say to get an ultrasound much sooner than her Medicaid-sponsored OB/GYN would permit. The ultrasound technicians weren’t supposed to disclose details like the sex of the baby, but they often did, and it was the reason Amy had come to the ED that day. She was only twelve weeks pregnant, give or take, and determined not to bring another boy into the world.

  Brian Wentz, of the nearly-famous Wentz family of Gaffney, was another in a long line of malingerers who spent more time in emergency department waiting rooms than he did at any of the dozen minimum-wage jobs he’d held over the past year, angling for a diagnosis that would net him either a disability claim, a valid worker’s comp complaint, or at least enough pain medication for one good high. Today’s complaint was pain in his right wrist from working on a production line at the local Nestle factory. Normally a Fast Track kind of complaint, he’d dodged that bullet by coming in an ambulance. All he’d gotten so far was a strong dose of ibuprofen, and all Tina was waiting for was a read on the wrist x-ray by the radiologist confirming no acute findings before she sent him home with nothing else. He was in room five.

  In South Carolina, especially in areas like Gaffney, where the manufacture and distribution of methamphetamines produced more income than the remaining mills that once employed 60% of the population, hospital doctors and nurses had Concealed-Carry Permits, and they exercised their God-given right to keep and bear arms. In the staff parking lot outside the emergency department there were two shotguns and two semi-automatic pistols belonging to four of the employees, locked up in their owners’ cars but easily accessible if needed. Others took their license to carry concealed to mean they could break the hospital’s No-Gun-Zone policy. On any given shift, there was at least one handgun buried in a woman’s purse or stashed in someone’s locker.

  In those same areas in South Carolina, whether because the trade demanded it or because the people were unaware that a felony record negated the constitutional right to own a firearm, most of the users and purveyors of methamphetamine also carried concealed weapons. Theirs were neither legal, nor licensed. Of the ninety percent of the population who followed the law and did not do drugs, more than half owned a firearm.

  In most hospitals, the security guards are nothing more than men and women in special uniforms who kept doors locked and tried to look imposing when they stood tall and crossed their arms over their chests. They had no handcuffs, no weapons, and no powers to arrest or detain. They roamed the halls or took turns darkening the doors of psychiatric patients, writing reports and calling each other on their small radios. They responded when needed and went wherever they were requested. It takes a special bravery to walk into a situation where a weapon would be appreciated but is not allowed. Unfortunately, on that Saturday, there were no security personnel stationed in the emergency department.

  Not that it mattered.

  Before the shifts rotated at 7pm, one of those seventeen people would be shot.

  The only thing having a security person available would change is the total number of potential targets.

  Chapter 5

  After eight years in an emergency department as a nurse practitioner, Tina Maltis thought she’d seen everything.

  Found unconscious, too-slow respirations, pupils pinpoint and powdered cocaine visible around the nostrils?

  Check.

  Man coming in face down on a stretcher because he slipped on a bathroom floor while pleasuring himself with a toilet plunger, and all that could be seen of said plunger was the rubber bell peeking out between his butt cheeks?

  Check.

  Cardiac arrest that came in with four broken ribs and a punctured lung because EMS had been pumping on his chest for twenty minutes, vital signs nonexistent, whose heart miraculously started beating again after the doctor
called time of death?

  Check.

  She’d seen horrors and miracles, the best of humanity and the very worst kind of people, like the gunshot victim who was dropped off outside the ambulance doors, just pushed out of a car and left there. Before anyone could get outside and begin attending to him, another car raced up, passengers from both the front and back seats firing handguns to finish the job. She’d seen the kid in kidney failure fading before her eyes, in desperate need of a transplant but without a prayer of reaching the top of the waiting list in time, until his brother came home from Afghanistan, rolled up a sleeve, and demanded to be tested. A week later, both young men walked out of the hospital arm in arm.

  Most patients in the ED didn’t need to be there. That was an absolute truth in every hospital in every state in the country. But it was for those who did need them, the heart attacks and strokes, the broken bones and arterial lacerations, the aneurysms and septic infections, that Tina loved coming to work.

  This guy being brought in by EMS had her excited. Unresponsive was one thing. Physical aggression was another. Both were understandable when drug use was a part of the differential. But the pattern didn’t fit, not as it was reported. Maybe Buck had said it out of order, which would be understandable given he must be trying to talk through a lot of pain. The guy bit off a chunk of his ear! It didn’t make sense otherwise. PCP and bath salts users would be hyper-aggressive with tachycardia and hyperthermia, but once they calmed down to the point of sleeping, that should all be gone. Tina had never heard of an unresponsive patient suddenly attacking someone without some kind of precipitating event, like the administration of Narcan or Romazicon.

  So, she waited outside Trauma Two while Josh, one of the RNs, and Brandon, one of the CNAs, went outside to help Buck and the new guy unload the stretcher from the back of the ambulance. She couldn’t hear what was happening outside, but she could see clearly through the two sets of double doors (both of which required a key card to open). Josh waved Buck away from the stretcher as soon as its wheels were on the ground, indicating with his hands that the large paramedic should go inside with Brandon. The paramedic sported a blood-soaked bandage over his right ear, with a river of crusted blood coating that side of his face.

  “I need to give report,” Buck said, his deep voice resonating, shaking off Brandon’s solicitous attempts to guide him into an exam room.

  Tina followed Lisa, the nurse who would have primary responsibility for the patient, over to Buck.

  “I know you’re a tough guy, Buck,” Lisa said, “but that has to hurt like hell. Can we do this while Brandon gets you set up in room fourteen?”

  “Let’s just get it done,” Buck replied. “Patient is Austin Wallace, 32 years old. The rookie has the ID. License is out of Georgia, but no way to know if he’s a visitor or a transplant. There were no keys on him at the scene.”

  Lisa produced a notepad and began taking notes, writing in a form of shorthand any other ER nurse would understand, but which would be meaningless to a non-medical person.

  “We were called to an unresponsive patient on the ground at the outlet mall. GPD had already secured the scene and verified pulse, respirations, and unresponsiveness. Fire wasn’t available.”

  “Okay.”

  “BP was 132 over 77, tachycardic at 144, O-2 at 99%. His respirations are deep and even but not Kussmaul. He felt hot, but we had no way to check temperature. Pupils pinpoint and roving, at least at first. He didn’t respond to anything we did until I got ready to start an IV. Then he jumped on me like he had a sudden hankering for some dark meat.”

  “Looks like he got some,” Lisa said, drawing a chuckle.

  “Don’t I know it! He bit clean through part of my ear.”

  “All right, Buck. We’ll get him settled and get you taken care of. I’ll see about getting Josh to help out—what’s the new guy’s name?”

  “Aw hell, Lisa. How long you known me? You know I don’t bother with their names until I know they’re going to stick around.”

  “Give me something, Buck. I can’t very go out there yelling, ‘Hey, new guy!’”

  The big paramedic chuckled again. “It’s one of those names that ends with an E sound, like Benny, or Jimmy.”

  Brandon gave an exasperated noise that somehow combined a clicking sound with a sigh. “His name’s Danny.”

  Tina suppressed a smile. At six feet tall with broad shoulders and a face handsome enough for a boy band, Brandon could have just about any young woman he wanted. And probably some of the older ones. But he played for the other team. Or, as the ever-vocal Dr. Osbourne liked to say, “He was sweeter than a gallon of tea with five pounds of sugar dumped in it.” Brandon didn’t hide his sexuality like some men, but wore it openly, walking with a tilt to his hips and a lisp on his lips. He was sweet and considerate, and very good at his job, which meant more in a busy hospital than any other quality.

  “If you say so, B,” Buck responded.

  The clattering of hard plastic wheels over metal runners as the stretcher came through the doors drew Tina’s attention.

  “Go on and get him into fourteen, Brandon,” Lisa said. “Tonya will come help get him checked in.”

  The patient, Austin, was probably about five-ten, lean, and securely strapped to the stretcher being wheeled into Trauma Two by Josh and Danny. Tina hurried to catch up to them, listening as Josh questioned the EMT, not wanting to interrupt unless they simply forgot to discuss something.

  “Vitals remained stable on the ride,” Danny said. “Last BP was—” He consulted a set of numbers jotted on the back of his left glove. “116 over 72. Pulse is still high at 140, but oxygen has remained stable.”

  “I see a 20 Gauge, left AC,” Josh commented, guiding the stretcher to the left side of the hospital bed.

  “Yeah, I got it on the way in.” He held up a small Ziplok with a red stripe and white letters reading BIO. “Got you a rainbow too.”

  The man’s hair was brown and tousled, lightly speckled with gray, as was the day’s growth of hair on his cheeks and chin, where it wasn’t spattered with dried blood.

  “Is that Buck’s blood?” Josh asked, lowering the rail on the right side of the stretcher.

  “I think so. I don’t remember any blood when we first got there.” Danny shrugged apologetically. “Can’t say for sure though. A lot happened really fast.” He paused, looking as though he had more information but wasn’t sure how to give it. “Buck got…a little crazy when the guy latched onto his ear.”

  “What’s that mean? He punch him?” Josh asked.

  “Yeah, with an 18 Gauge.”

  “Seriously?”

  “All in the left side, five or six times, before I could get a hold of him. Breath sounds were good on the way in, so I don’t think he got a lung.”

  Josh got to work removing the straps that held the patient to the stretcher. “Guy needs a bath,” he said.

  “Don’t you think you should get restraints first?” the EMT asked.

  Before Josh could answer, Tina interrupted, “We can’t restrain him without an order from the doctor. Besides, he looks like he’s passed out.”

  “Yeah, he woke up a little on the ride, said his stomach hurt and asked for someone named Carolyn, then he went back out.”

  “Any further aggressive outbursts?” Josh asked.

  Danny shook his head.

  Josh crossed to the right side of the hospital bed and Lisa went to join him. With Lisa and Josh on one side, and Danny and Tina on the other, they grabbed the sheet under the patient and half-lifted/half-slid him to the hospital bed. As soon as he was clear of the stretcher Tina raised the siderail. Josh and Lisa began hooking him up: attaching sticky electrodes to his chest for the cardiac monitor, securing a fresh blood pressure cuff around his right upper arm, and placing a pulse oximeter on his left index finger.

  “Have you Narcan’d him?” Josh asked.

  “No, his breathing has stayed steady and his O2 is good.”

>   “Good,” Lisa said. “Leave the fun for us.”

  Tina nodded. Narcan was a wonderful drug that temporarily blocked the opioid receptors in the brain, reversing any overt signs of overdose, such as altered mentation and depressed respirations. It didn’t remove whatever drugs the patient took from the body, a common misconception in television dramas, and it only lasted about fifteen minutes, after which the patient would return to their obtunded state. But it was extremely useful in determining whether the patient overdosed on an opioid class drug. Plus, if it was necessary to keep the patient breathing, Narcan could be hung as an IV drip.

  The fun part, as Lisa called it, was the shocking return-from-the-grave moment that many patients experienced as all their opioid-induced high vanished. If they had pain before, it returned full force. If they were unconscious, they came screaming awake, rising off the stretcher like Dracula after someone opens his coffin.

  “You guys need any help with anything else?” Danny asked, backing the stretcher away from the hospital bed.

  “I think we got it, thanks,” Josh answered.

  “Buck’s in room fourteen,” Lisa said gently. “Get your gear cleaned and ready, and then come see us if you need any help with the paperwork.”

  “I’ll give you a hand,” Josh offered. “They haven’t changed the paperwork since I worked there.”

  “Good. I— Thank you,” Danny said. Then, almost as an afterthought, he asked, “You guys gonna check him for everything? You know, since he bit Buck?”

  “Standard panel for a blood contact,” Tina said. “Regular labs for an OD plus hepatitis and HIV.”