by Atul Kumar
Any resemblance to actual persons, living or dead, or to actual events or locales is entirely coincidental.
Seven Patients
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Copyright © 2012 Atul Kumar. All rights reserved, including the right to reproduce this book, or portions thereof, in any form. No part of this text may be reproduced, transmitted, downloaded, decompiled, reverse engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical without the express written permission of the author. The scanning, uploading, and distribution of this book via the Internet or via any other means without the permission of the publisher is illegal and punishable by law. Please purchase only authorized electronic editions and do not participate in or encourage electronic piracy of copyrighted materials.
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Version 2012.05.21
To Neeta Varshney.
“The art of medicine consists in amusing the patient while nature cures the disease.”
François-Marie Arouet (aka—Voltaire)
Seven Patients
Table of Contents
Chapter One: Shaken
Chapter Two: Two Enter, One Leaves
Chapter Three: Pancreatic Scare
Chapter Four: Myiasis
Chapter Five: High Five
Chapter Six: Holey Man
Appendix 1: Acronyms
Appendix 2: Definitions
Chapter One: Shaken
We were just about to start our team dinner at 11 p.m. when everyone’s pager simultaneously went off. There was no need to check the message because the overhead intercom blared, “CODE BLUE, ER, ETA 2 min; CODE BLUE, ER, ETA 2 min.”
Scarfing down whatever morsels of food we could stuff into our mouths, we all ran to the ER and took our positions near the large trauma doors … awaiting whatever disaster was headed our way.
The atmosphere was one of tense anxiety, with everyone ready to leap to action but with nothing yet to do. Masks were donned and gloves snapped on as all ER personnel made their way towards the trauma doors; leaving the 20 ER patients who were in various states of agony and distress temporarily ignored.
All attention was focused on the two humongous double doors leading to the ambulance docking bay. The immediate team was two senior physicians, two residents, two interns, a respiratory therapist, a pharmacist, three nurses, and me, the omnipresent token medical student—harbinger of just enough knowledge to be dangerous.
After 20 seconds of uncertain stares and unnoticed tics, a faint siren was heard, getting louder and louder—there would be no Doppler effect with this ambulance as it would stop just a few yards from where I stood.
As the siren was reaching an almost unbearable crescendo it suddenly died, tires screeched, gears crunched, and there was that moment of deafening silence before the trauma doors ferociously flung open. A team of paramedics rushed in and Dr. Peters began to get debriefed. The patient was surrounded by medical personnel so quickly that I never even got a glance.
“Cyanotic and apneic on arrival, unresponsive to pain, unable to intubate in the field, naso-tracheal tube placed without complication, responded to positive ventilation, heart rate 180 and weak at first, now strong, poor breath sounds on the right, normal on the left. No IV access. C-collar placed. Pupils dilated and unreactive. Initially flaccid, and unfortunately that hasn’t changed much,” the lead medic expelled in a single breath en route from the door to trauma bay #2, a total distance of about 20 feet.
All the while Dr. Peters made no comment and looked only at her patient, nodding once at the end of his report, a nod only found in the medical world, indicating he did a superb job and his superiors would be notified of his efforts. Understanding they were relieved, the medics quickly peeled off to complete their paperwork at the central work station.
“Get me an IV kit, hook up the EKG leads, and get CT ready STAT,” barked Dr. Peters, with a confidence that comes only with years of experience and having seen everything before, at least twice. “Also call the OR and give them a heads up. You,” pointing to one of the senior residents, “take off the remaining clothes and do a complete primary assessment while she scribes.”
Having something to do, the crowd dispersed, each with their own specific task. I was finally able to nudge my way in and get a look at our focus of attention for this evening. It was strange—despite the number of people, the room seemed vacuous. Instead of the normal array of large life-sustaining machinery, everything was miniature. Four physicians and a respiratory therapist were huddled around a gurney. As I drew nearer I realized it wasn’t a gurney at all; it was a crib.
Our patient was a mere ten pounds and barely two feet in size. This was a pediatric code!
No wonder the commotion was more intense than normal, children, and especially infants, always put medical personnel on edge. I’m not entirely sure why. I used to think it’s because nobody wants to see a child sick, but I think the real reason is that pediatric care is so highly litigious that everything is scrutinized.
In an effort to make myself useful I quickly looked around the room. I must have repeated this gesture several times because a nurse came up to me and recommended perhaps I stand on a stool and observe instead of spinning around like a dreidel in everyone’s way.
Withdrawn, I slouched down, found a stool, and silently took up position in the corner of the room and out of the way, the omnipresent but seldom noticed medical student. At least this time I had a nice bird’s eye view.
“I got IV access, left foot,” announced one of the residents.
“Leads in place, normal rhythm with tachycardia,” announced another.
“Hand me the 3.5 French tube, the 4’s too big for this lil’ guy … and some cricothyroid pressure, gentle there … FUCK, he’s in spasm. Get the fiber optic set here now! CT ready for us yet?” Dr. Peters was starting to get strained. She seldom didn’t get things on the first try, and two failed intubation attempts was not going to set her in a good mood.
The fiber optic intubation set appeared out of nowhere, and the pediatric laryngoscope was so small it looked like a toy. Almost immediately a high resolution image appeared on the LCD monitor. On the screen was a wide field image of the trauma bay, followed by an image of a tongue, a pharynx, and soon, the trachea, a small dark opening leading right to the lungs. Next we saw the clear plastic tube fill in the gap and the picture went snowy as the scope was removed. The endotracheal tube's balloon was inflated and artificial ventilation initiated. Almost instantly the baby went from a bluish hue to a healthy pink color as both lungs began to rhythmically rise and fall with each pump of the tiny ventilator bag, no larger than the size of a small juice box. The whole process took about 10 seconds.
“CT is ready,” hollered a voice from the hallway. As soon as the vital signs were con
firmed to be present and relatively stable, the baby was ushered to the scanner by an entourage of no less than seven highly trained professionals with only one goal: keeping this stranger alive.
I saw them turn the corner and disappear, but not before I saw Dr. Peters shaking her head. The subtle gesture was for her and her alone, but having the bird's eye view, I caught it. She was kicking herself for requiring the video guided scope. Granted it makes intubations much easier, using it is an admission of failing to intubate the “real” way, sans technological assistance. It’s analogous to the pre-GPS days when we had to stop the car and ask for directions. Nobody liked doing it, but sometimes it was just necessary.
As quickly as the trauma bay was populated, it vacated. Only I remained within the empty room. No longer organized and sanitary, instead it was deserted with medical detritus scattered everywhere. Miniature and futuristic looking machines littered the room. Most were still on and emitting various beeps and tones, just without the consistent undulations associated with a beating heart or other functioning organs.
I stepped off my pedestal and directly into a puddle of unknown fluid. It was more viscous than water, but relatively odorless, probably something used to lubricate tubes for intubation. As I started to wipe the goo off my shoes, I heard footsteps enter the room.
“Hey, are you one of the docs that took care of that kid that was just here? I'm Detective Higgs,” boomed a baritone voice from above.
I looked up, and up some more, and there stood not a man, but a mobile mountain. He must have been at least 6 feet, 8 inches tall and 300 pounds. His tan uniform and bullet proof vest couldn't conceal that he spent a considerable amount of time in a gym. The well worn shoulder strap and rapid release holster had definitely seen some action. The confidence in his stance and steadiness of his voice indicated he was secure in his abilities and comfortable in the hospital setting.
“Hi Detective,” I replied while standing on one foot with a gooey towel dripping who knew what in my hand. “I'm not sure that I'm going to be of much help to you. I'm just the medical student. I think the active players in this rescue are still down the hall in radiology.”
He just stood there, taking everything in. I broke the silence, “I know the age of criminals has been decreasing, but the kid here couldn't have been more than five months, way too young to do much more than wet a diaper.”
My attempt at humor was met with more silence.
He scanned the room, presumably looking for somebody else to talk to, but I was the only one in sight. I’m sure merely uttering ‘medical student’ had prompted his complete disinterest. Deciding his time would be better spent elsewhere, he turned and left without another word.
Being a medical student meant I was on the lowest rung of the medical hierarchy, staff and physicians paid more attention to volunteers. The next rung of the ladder was senior medical student, or Sub I (meaning a graduating student, or Sub-Intern), followed by intern (referring to the first year of one’s residency), resident (senior resident generally means that 2 years remain until completion and chief resident refers to the final year of residency, which can vary from 3 to 7 years in length). One can either quit and start a career after residency or continue to train by way of fellowship, another 1 to 3 years of super-specialization. After all training is complete, a physician is known as an ‘attending’ in which they are fully board certified and the top of the totem pole.
After medical school is when the MD degree is bestowed, and one becomes a real ‘doctor’ and is no longer a student. But it’s only after completion of internship that a doctor obtains an actual medical license and drug prescription privileges. But good luck practicing any medicine, which requires board certification; that is only granted after completion of residency or fellowship, depending on which field in medicine.
Given my tremendous immediate responsibilities of wiping goo off my shoe, I decided to follow him. Hell, if the goo could be used to intubate an infant, it wouldn't harm my kicks.
“Excuse me, Detective?” I called out as I chased him down the hallway to the center of the ER—the “command center” as we dubbed it. This was the central hub where all the computers and charts were located. Surrounding it were 12 rooms with clear Plexiglass doors. Off to the side were the two massive trauma bays and a third one that could be opened up if needed. Further down the hall was a similar setup, only smaller with eight rooms and no trauma area.
Man the guy could move! I had to jog to catch up to him, and he wasn't even walking fast. “Is there something I can help you with? I pretty much saw everything that happened.”
He pondered the offer and replied, “Yeah, who's in charge today? Can you go get them for me? I'll be in the lounge.”
Great, the only thing medical students are good for—getting stuff. Oh well, I had nothing better going on. “Sure, it's Dr. Peters. I'll find her for you. What do I tell her you want to talk about?”
“Peters, huh? Don't worry about it then. She's one of the few who'll find me when she has a chance. She knows where I'll be.” He sauntered off into the physicians’ lounge.
Figuring I probably shouldn't follow; I snuck into the lounge anyway, before the door closed behind him and locked me out. The detective must be a higher-up to have access to the coveted lounge. Only chief residents and attending physicians have the clearance required to enter.
In reality it's nothing more than a few padded chairs and tables, LCD televisions, a handful of computers, and a kitchen, but it provides a respite from the bustling ER. Not to mention free food—not the generic shrink-wrapped sandwiches and no-name colas. The kitchen is stocked with everything from double-shot Starbucks and Rockstar energy drinks to catered hot food from local restaurants.
The detective grabbed a Diet Coke from the fridge and took a seat in the back corner, like he'd done this a number of times before. Before he could grab the nearest magazine, I walked over and tried to start up a conversation. It couldn’t hurt to have an ally in the police world.
“Detective Higgs, right?” He looked up, but said nothing. “Hi, I'm Rajen. Just started my third year of medical school here. I don't have much experience, but every time I've seen law enforcement in the ER it's usually restraining somebody with either a psychiatric or drug problem, or escorting the loser of a bar fight. Pediatric law enforcement is a new one for me. What brings you by today?”
“Well, I figure since you already saw the kid, it's not a huge secret. Did you see the couple of teens my partner had cuffed in the holding area?” I nodded, negative. “Well, those are supposedly the parents, if you can call ‘em that. Don't even know if they’re out of high school yet. It’s just like that ‘Baby Shaker’ game people used to play on their phones before it was banned, only in real life.”
“You mean the parents did this to her? It could’ve been an accident, right?”
“It wasn’t no accident, that’s for sure. I bet the parents did it, and more likely than not, on purpose. They just didn’t anticipate getting caught. Everyone thinks they’re smart enough to get away. I bet the kid will have perfectly round cigarette burns all over her arms (of course the parents are going to claim it’s from rashes that she scratched), and then there will be numerous broken bones in various stages of healing (the parents will know nothing about those). The kicker is, and I’ll bet you 10:1 on this, the story will be that the kid fell from a crib or table or something when nobody was around and they just found her down. They’ll try to blame a nanny or something, but will provide no contact information or name of the alleged caregiver.”
He took a break to take a pull from his Diet Coke, emptying the seemingly tiny can in his giant paw. He crumbled the can and slammed it into the garbage can with force. “It eats me alive that people do this to innocent little children …”
Just then Dr. Peters walked in. “Evening, Detective. I take it you’re here for the shake-n-bake I just escorted to the OR?” The grisly way medical professionals refer to Shaken Baby Syndrome. Sh
e nodded in my direction, with a hint of recognition, but clearly not recalling my name.
“Yeah, how’d you guess? Parents keep getting younger. Figure the Mom is still in her teens and your guess is as good as mine on who the Pop is. One thing’s for sure, it’s not the dude with her now. He could give a rat’s ass about the kid. Baby got the usual findings?”
“I think so, I definitely saw the characteristic cigarette burns and the CT showed a subdural hematoma which was compressing the brain and causing a significant midline shift. There were several bruises that I’m sure correspond to underlying broken bones. The neurosurgeon is on his way over to drain the hematoma now. I’d give her a 30% chance of making it, and if she does, she’ll be just like the CP’ers and FLK’s.”
“CP’ers?” I tentatively asked as I introduced myself to the famed Dr. Peters, the number two in the university ER hierarchy and on the famed hospital board of directors. She could easily make or break a neophyte medical student’s career.
“Ah, yes, you just started today, didn’t you? I remember your application. You did very well, pleasure to meet you.” She shook my hand as she poured herself a coffee, black. “Sorry your first major ER case has to be such a sad one. CP’ers is just more dark medical jargon; it’s how we refer to kids with cerebral palsy, the ones who are institutionalized with self-destructive behaviors. You’ve undoubtedly seen them in public, wearing helmets and goggles ‘cause they bang their heads and poke their eyes out. Some can talk, most just drool. They’re a huge burden on the family and society.”
Higgs got up and cracked his knuckles, startling me. I thought firecrackers just went off. He moved towards us with a glint in his eyes; something was about to happen. “Hey Doc,” he whispered in an almost conspiratorial tone, “you up for a game of ‘good cop, bad doc’ like we used to play before you had kids and got soft?”