by SA Magnusson
Heat Stroke
Hedge Mage and Medicine Book 3
SA Magnusson
Copyright © 2018 by SA Magnusson
Cover art by Covers by Christian
All rights reserved.
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Contents
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Author’s Note
Also by SA Magnusson
1
There were times when it was peaceful working in the ER. Most of the time, however, the ER was a place of chaos, a place where screams would often be mixed with prayers or with shouts for assistance. And it was a place where monitors would beep endlessly. It was the kind of place that had an ongoing hum of activity, which could either be peaceful or chaotic. The peaceful shifts tended to be earlier in the day, before people were awake, though not always. There were times when the activity of the day became hectic, almost.
Today was one such day.
It was late August, and by this time in the summer, the heat should have been settling down, and yet it had been sweltering, leaving us busy with countless heat-related illnesses. Too often, people would spend time outside, working in the heat and humidity, forgetting to drink enough. Occasionally, we got those same people coming in on the overnights, and yet those tended to be the ones who had been drinking the wrong kind of rehydrating liquids.
I rubbed my weary eyes, staring at the computer screen, hesitating to look away and see what else came into the ER. I wasn’t supposed to be the one seeing the patients first, not now I was a full attending. It went against my natural instincts, though. It was difficult to sit back and let others do the work I was fully capable of doing, and yet I knew I needed to. It wasn’t so much for my benefit as for both the students and residents I worked with.
Staying at the nurses’ station, out and visible, was my one concession. At least here, I was a part of the flow of the emergency room, even if I was allowing the interns and residents to take first crack at patient care.
“Dr. Stone?”
I looked up, twisting the bracelet that connected me to magic, half expecting it to be one of the nurses. We were in August now, which meant not only was I new to my attending physician, but the interns were all brand new too, and the upper-level residents were still barely removed from their former places as the prior intern set.
“What is it?” I looked up to see it was Dr. Edwards, one of the new interns we’d taken on. He was young, the same way I had been young when I’d graduated medical school and gone into my residency, and as far as I could tell, he was hard-working and bright, no different to most of the residents we took. For the most part, Hennepin General Medical Center was competitive enough that we only took incredibly bright students.
“Can I run a case by you?”
“Of course. You don’t have to ask permission to run a case by me.”
“I’m sorry. I just didn’t want to be a bother to you.”
I smiled and looked up at him, waiting. A moment passed, then another, and when he said nothing, I cleared my throat. “This is the part where you present the patient you wanted to ask me about.”
“Oh. That’s right. Well, it’s not too exciting. A 30-year-old man. He came in with chest pain. It seems to be reproducible on exam.”
I nodded. At that age, a cardiac etiology would be pretty unlikely, though I had seen stranger things than a 30-year-old with heart problems. I wondered how thorough he had been with his evaluation. If he stuck to the differential diagnosis that included only musculoskeletal causes, then there were a few different things he could miss.
“Anything worrisome about him?”
Dr. Edwards frowned, his brow furrowing as he held out his phone. There was a time when having an intern looking at a phone this way would have been offensive, but nowadays it was not uncommon. He was able to access all of the labs he needed by looking at his smartphone and it was just as quick as sitting down at a computer.
“His vital signs were completely normal. Blood pressure, heart rate, pulse oxygenation. Like I said, the physical exam is pretty unremarkable other than reproducible chest pain.”
“What’s your plan?” I asked.
When I had been an upper-level resident, it had been hard for me to get used to the fact that I needed to let the students do the work, to work through the process and to come up with their own plans. All of that involved them taking the next step in their own training, the same way I had once taken the next step in mine. If I didn’t let them, I slowed their development. At the same time, I had to be careful to put patient care first. I couldn’t let them make a mistake which could lead to someone else ending up in danger because of an error on their part. As I was now the attending, the buck stopped with me, as the saying went. I was even more acutely aware of my responsibility than I had been when working as a fellow.
“Probably no more than giving him a couple of Tylenol and sending him on his way. If it’s costochondritis, then he can ice it, take some non-steroidal anti-inflammatory drugs, and check back with us if he’s not getting better.”
I flipped over to the patient he referred to and glanced at the chart briefly. There hadn’t been much of a workup started yet, which was surprising. Someone coming into the emergency room with chest pain was going to get at least a chest x-ray, an EKG, and a basic set of labs, regardless of their age.
As I waited for the EKG image to load, I glanced back up at Dr. Edwards. “Is there anything different you would like to obtain?”
“Different? How so?”
“To make sure you felt comfortable with him discharging.”
“I don’t know. He doesn’t have any real red flags. He does smoke a pack a day, but he’s only been doing that for the last five or six years. From what he tells me, there’s not much in the way of a family history, either.”
I glanced back at the image, frowning as I did. “Are you sure you don’t want to get anything more?”
“Why?”
I quickly tapped over to the orders section of the record, entering a few stat labs, and got to my feet. “Why don’t we go see this patient together.”
“Dr. Stone?”
“Did you look at the EKG?”
Dr. Edwards frowned. “I think so.”
I started off down the hall, making my way to the emergency room where the patient would be found. I knew better than to get upset with Dr. Edwards. He was new, and all of this was more than he’d ever dealt with before. I understood the challenges which came from that, much like I understood that there was plenty he had yet to learn. He was only asked to see a few patients per shift, but of those patients, he was expected to work them up as thoroughly as possible, to the best of
his ability. In this case, I suspected he hadn’t even bothered to look at the EKG. If he had taken more than a cursory glance at it, he would’ve seen that even the computer interpretation of the tracing suggested there was something more to be concerned about.
Pausing at the door, I knocked before heading in. The man lying there was covered in sweat, which at this time of year was not terribly surprising. He had his shirt off, heart monitor stickers stuck to each shoulder and on his belly, and he lay with his eyes closed. There was something about him suggesting he was uncomfortable.
“Mr.…”
“Johnson,” Dr. Edwards said.
“Mr. Johnson. I’m Dr. Stone. I’m one of the attendings here at Hennepin General. Dr. Edwards was telling me about your chest pain.”
The man blinked open one eye, looking over at me. “It’s still there, Doc.”
We hadn’t even managed to get him pain-free yet? More than anything, that bothered me. One of the first tenets of working up chest pain in the emergency room was getting the necessary information, but then also treating it. If there was any question it might be cardiac, nitroglycerin was the first-line therapy. I understood it was hard to believe a 30-year-old could come in with cardiac chest pain, and the likelihood was pretty low that this was the case—but at the same time, I had to at least consider it, which meant Dr. Edwards had to at least consider it too.
“How long has it been there?”
“The better part of an hour,” Mr. Johnson said.
“What were you doing when it started?”
“I’ve been working outside,” he started, and the door opened letting lab join us. The lab technician glanced from me to the intern before heading to the bed and checking the patient’s ID bracelet.
“We’re just going to draw a little blood to see if there’s anything to be concerned about,” I said. “You were working outside?”
“Yeah. I work in construction. They’ve been long days.”
“And hot, too, I imagine.”
“You wouldn’t believe it,” he said.
“Have you been staying hydrated?”
“I’ve got my jug of water with me all the time. I know better than to get dehydrated.”
He motioned to the corner, and my gaze looked in that direction before realizing what he was indicating. There was a jug resting there. It was beaten, the lettering on it faded, but it was fairly sizable. If he had been staying on top of drinking from it, then it still might be possible for him to get dehydrated, but it would be far less likely.
“What other symptoms have you noticed?” I asked.
“Just the pain.”
“Is it stabbing, crushing, or does it feel like—"
“It feels like I can’t take a deep breath. It’s almost like there’s someone sitting on me.”
I nodded, pulling my stethoscope off from around my neck, lowering it to his chest and auscultating it, listening carefully. “Have you been feeling short of breath?”
“Only since it started.”
“Any nausea?”
“Not really.”
“Headaches?”
“Not so much.”
“How about arm pain?”
“I work in construction. I always have a little bit of shoulder pain.”
“Is one side worse than the other?” I asked.
“Sure. I’m left-handed, so that side always throbs a little bit more.” He made a fist, flexing his arm as if to show me that it was more sore than the other side.
“What about pain in your jaw or your back?”
“I don’t know. It’s hard to tell.”
“Once we get the results from these labs, we’ll come back and talk to about what our plan is going to be. In the meantime, Dr. Edwards here is going to do everything in his power to get you comfortable.”
The man closed his eyes, and I tapped on Dr. Edwards’ shoulder as I headed out of the room.
Outside of the door, I waited for Dr. Edwards to join me. “Is there anything you would like to order at this point?”
“I guess I would check some electrolytes, especially if he’s been outside all day, and maybe a blood count?”
I wasn’t used to our interns failing me like this, or maybe it was more that I had tended to avoid them, especially lately. More often than not, I had been working on my own, especially ever since I had become a fellow. There hadn’t been any reason to work with students, and I tended to spend more of my time with the upper-level residents. Occasionally, I would interact with interns, but after what had happened with Gillespie, I didn’t want to be spending time around them.
“That’s a reasonable place to start. And it’s good you got the chest x-ray and EKG—” I said it even though I knew the nurses had most likely been the ones to have put in those orders rather than Dr. Edwards. He might have co-signed them, but the origin had come from nursing. “But I’d like to get a cardiac panel, along with a D-dimer,” I said.
“You’re worried about a PE?”
A pulmonary embolism, or PE, would be one potential cause for this guy’s symptoms, but if that were the case, I would have expected a slightly different history out of him. I hadn’t taken much in the way of a history in terms of whether he’d traveled a lot or had any recent surgeries or any family history of blood clotting, but these were things I hoped Dr. Edwards would go back in and pursue.
“I think we need to be inclusive with our differential diagnosis. The nature of his pain is at least suspicious, even if he doesn’t fit any of our typical age categories.” And given the way he looked, and as fit as he appeared, it would be surprising for him to fit that profile. But that was why we were in the emergency room; we couldn’t afford to miss anything. “Which is why I want to check a troponin, and maybe give him some nitroglycerin and some fluids while we’re at it.”
Dr. Edwards glanced toward the door, and it was almost as if I could see the wheels spinning in his head.
“Think you can manage from here?”
“I’ll take care of it, Dr. Stone. Thanks.”
“Thanks?”
“For not making a big deal that I didn’t order what I should have.”
I glanced at him askew for a moment. “We all have to learn, Dr. Edwards.”
“I know, and some attendings are a little better than others at letting us do that.”
I wasn’t about to argue with him, having gone through something similar myself, so I understood what it was like to have an attending who didn’t make you feel like a complete idiot when you didn’t order the tests they thought were necessary.
I left Dr. Edwards, heading back to the nurses’ station, and took a seat. The computer at this station had become something of a workplace for me, and thankfully, most nurses avoided using it when I was on. It allowed me to survey the inside of the emergency room more easily. While sitting there, I pulled open the patient’s record, seeing if there was anything more about Mr. Johnson I could uncover. We didn’t have a lot of information in his record about his family history, but the nurse who had done his intake—an older lady by the name of Joan who tended to be thorough—had documented well. There had been no travel or trauma according to her records, and no family history of heart disease. Interestingly, she commented on him drinking a number of energy drinks.
If I’d had a better connection to magic, it would have been possible for me to use it to diagnose and not need all these tests. Unfortunately, even though I now carried two charms with me—the bracelet Kate had given me and a necklace connecting me to Barden’s magic, something he strongly felt I needed to have—I still couldn’t do such magic.
I looked up, noting that Kim, a middle-aged blonde-haired nurse I knew reasonably well, had taken a seat near me. “Have you seen Joan?”
“Not for a while.”
“If you see her, let her know I have a question for her about one of her patients.”
“Happy to do that, Dr. Stone. Is there something I can help with?”
I shook my he
ad, clicking through Mr. Johnson’s notes a little bit more, searching for anything to help me determine what risk factors he had for not only an abnormal EKG, but symptoms which were at least suggestive of a cardiac cause.
“Not so much. It’s more that he made a comment in this guy’s chart about his energy drink consumption.”
“Oh. That guy. Yeah, Joan was talking about it. The guy drinks something like ten of those things a day. I think the caffeine in those would kill me.”
I frowned to myself. How much caffeine would be in an energy drink like that? It was worth investigating, if only because the nature of Mr. Johnson’s symptoms was such that I couldn’t help but think there was something more than we’d uncovered.
“Maybe you don’t need to get Joan for me, then.”
“No?”
“I just needed to know how many drinks this guy was taking a day.”
Kim chuckled, turning her attention to the computer. “Do you think it’s important?”
“You never know.”
On a whim, I decided to pull up a search to see how much caffeine would be found in one. Obviously, he wasn’t drinking only water as he had claimed, and it might be that I wouldn’t be able to figure out how much caffeine was in one anyway, but it was possible I could find a comparison among all of them. At least I could get a sense for average amounts.
Though people liked to think otherwise, caffeine was a drug, and while a little bit could be beneficial—and I was known to have a cup of coffee in the morning to wake up, just like anyone else—too much could be dangerous. As a stimulant, it could cause the heart to beat more rapidly, but also could cause the vessels to constrict. Vascular constriction was one potential cause for a heart attack. It was possible caffeine—especially excessive caffeine use—along with his smoking history and perhaps dehydration would be enough to trigger a real event.