Bottom line: until the bleeding stopped, nothing they gave me was going to stop the bleeding.
What we have here is a Catch-22 of life-threatening proportions.
Now what? Was I supposed to just lie here and be nothing more than a conduit for gallons of blood, FFP, Ringer’s lactate, platelet packs, antibiotics, and whatever else they chose to pour into my PICC line? None of it was doing me any good; it was just passing through, waving bye-bye on its way to the big jugs on the floor. See ya later, alligator.
I wished I could ask all these questions, but I couldn’t talk with an endotracheal tube in place, and I couldn’t write notes with my hands restrained. I couldn’t even ask for a pad and pencil in sign language.
Maybe when Hal came, he could ask the questions for me. Only, how was I going to tell him what they were?
I was at this point more frightened than I’d been in Ruthie’s crawl space. At least then I’d had some hope that I’d be rescued, taken to the hospital, and treated, and then everything would be all right.
But it didn’t sound like everything was going to be all right. In fact, it sounded pretty damn hopeless. I knew that this state of affairs couldn’t continue indefinitely. Eventually I’d develop pneumonia or adult respiratory distress syndrome or sepsis—and finally, multiorgan failure.
Poor Hal. How was he going to deal with watching me slowly deteriorate day by day? Seeing my life’s blood running out through tubes into those jugs on the floor, with no end in sight? How would he handle the hopelessness of knowing that no matter what anybody did, he would eventually lose me? It would be like having terminal cancer.
How would I handle seeing the pain in his eyes, the tears, and the despair—and my inability to comfort him? If I was unable to hold him, unable to even talk to him—this man I loved with all my heart—how was I going to even tell him how much I loved him? How could I say good-bye to him? I was going to die, and I wouldn’t see him again until he died too, because I did believe in an afterlife where I would eventually be reunited with all my loved ones.
But Hal was Jewish and didn’t believe in an afterlife, so he didn’t even have that comfort. He couldn’t know that he would be with me again someday. And at the utter hopelessness of that thought, tears came to my eyes, ran down my face, and I began to sob—not an easy thing to do with an endotracheal tube in place. I gasped and fought the ventilator, pulling at my restraints, and an alarm started beeping. My chest and belly were killing me, but I couldn’t stop.
June rushed back in. She looked at my face and gasped, “Dr. Day, Toni, what’s wrong? Are you in pain? What hurts?” As if I could tell her. What hurts? Everything. My chest, my belly, my throat from the fucking ET tube, my nose from the fucking NG tube, and my breaking heart. All I could do was cry and struggle against my restraints, and all she could do was check to make sure that all the tubes were in place, that I hadn’t managed to pull anything out, and that my restraints were secure but not too tight. She checked my incision and replaced the dressing. She checked to make sure my Foley catheter was properly taped to my leg and not under any tension and that it was draining properly. She checked to make sure I hadn’t soiled myself. Then she injected something into the PICC line.
“There now,” she said solicitously, “that should feel better soon, and then you can just take a nice nap.” She patted my arm and left.
Obviously Jeff or George or somebody had left orders for sedation in case the patient threw a tantrum. Time out. Bedtime for Bonzo.
Sunday, December 28
Chapter 36
Surgeons must be very careful
When they take the knife
Underneath their fine incisions
Stirs the culprit … life!
—Emily Dickinson
I awoke to see Hal and Mum standing at my bedside.
They were deep in conversation and didn’t notice at first that I was awake.
“Fiona,” Hal was saying, “she’s asleep. She can’t hear you.”
“I was just making conversation, Hal, dear,” Mum replied. “Just because her eyes are closed doesn’t mean she can’t hear me.”
“Well, she can’t answer you,” Hal countered, “so it’s not a conversation. Whoever heard of a one-way conversation? It’s a monologue, is what it is.”
For the love of God, I screamed, but of course no sound came out. Why are the two of you carrying on this stupid, pointless conversation about having a conversation, when I’m lying here dying and I can’t even tell you or say good-bye or how I love the both of you more than life itself—which seems ironic since life itself is what’s at stake here?
Of course my agitation caused the monitor to go crazy and make much more interesting lines and patterns than before, while every alarm in the place went off.
A nurse, whose name I knew was Leslie, tore the curtain aside. “What’s going on in here?”
“I don’t know,” Hal said, shrugging. “All of a sudden she just started struggling and …”
Jeff Sorensen materialized behind him. “How’s our patient doing?”
Hal turned to look at him. “She seems upset.”
“Well, let’s check.” Jeff moved in closer and Hal moved aside. Jeff lifted up my gown to check my incision, and apparently Hal and Mum were seeing it and my belly for the first time, because they both stared at it as if a snake had just crawled out and stuck out its tongue at them.
“What the hell happened here?” Hal demanded. “Is all that hemorrhage from surgery?”
Jeff stopped in the middle of removing my dressing and stared at Hal. “No, it’s not from surgery. It looked like this when she came in. It’s actually a little better today.” He went back to the dressing. “Looks pretty good. Nice and pink, no sign of infection. Awful lot of drainage, though. Looks like it hasn’t stopped bleeding. Better put a thicker pad on it next time, Les.”
“Yes, Doctor.”
“How’s the hemoglobin this morning?”
“Eight-point-three, Doctor.”
Jeff straightened up and stared at her. “That’s less than it was last night! And after—how many units of blood since then?”
“Four, Doctor, and two fresh frozen plasma and ten platelet packs. And by the way, her platelet count is only twenty-five thousand.”
Jeff ripped off his latex gloves and clutched his forehead. “Jesus. I don’t get it. I don’t get it! We’ve poured in, what, ten, no, fourteen units of blood, twenty platelet packs, at least ten units of fresh frozen plasma, and where’s it going?”
Hal backed up and looked down at the floor. “Into those bottles, I’m thinking.”
“I’m sorry, Doctor,” Mum said, “I’m sure I don’t mean to interfere, but you do realize that my daughter can hear everything you’ve said, don’t you? Look at her face! She’s scared to death, and with good reason. Could we possibly discuss this elsewhere?”
Jeff glanced at me. I opened my eyes wide and glared at him so fiercely that I’m sure the whites showed all the way around. I rattled my bed rails and tried to make a writing motion with my right hand, the one that wasn’t bandaged. He gave me a slightly panicked look and then vanished around the curtain after Mum and Hal.
He was replaced almost immediately by George Marshall, who jerked a thumb in the general direction of where Mum and Hal and Jeff had gone and looked at me. “What’s the hoo-hah all about?”
Was he expecting me to tell him? How? I rattled the bed rails again and tried to convey to him that I wanted a pencil and paper to write on. I couldn’t very well talk with a fucking ET tube in my mouth.
Leslie spoke up. “Dr. Sorensen’s upset because the bleeding hasn’t stopped or even slowed down. She’s had fourteen units of blood, twenty platelet packs, and ten of FFP, and her hemoglobin is eight-point-three and platelets twenty-five thousand.”
I rattl
ed the bed rails again. Leslie put her hand over mine to still it, but I wasn’t having any. I had something to say, goddamnit, and I couldn’t get it across to anybody. I rattled the rail harder. I tried to vocalize. The ventilator didn’t like it. The monitors reacted and alarms went off again.
“Toni, stop it,” George snapped. “You’re not doing yourself any good doing that.”
I opened my eyes wide and looked at my right hand, then back at George and back at my hand. I rattled just the right bed rail this time. Leslie removed her hand and looked hard at my fingers.
“Doctor Marshall?”
George looked up from my chart with annoyance. “What, Leslie?”
“I think she’s trying to tell us something. I think she wants to write something.”
George looked at my hand and then my face. “Is that what you want, Toni? To write something?”
I nodded as much as I could with the damn tube in my way.
“Well, Les, go get her a notepad and a pen,” George said, “and we’ll see what this is all about.”
I relaxed back onto my pillows with a sigh of relief, and the ventilator didn’t like that either. Leslie disappeared and came back with a notepad and a pen. She untied the restraint on my right wrist and gave me the pen. “Here, Dr. Day, can you hold this? I’ll hold the pad for you.”
I flexed my fingers and took the pen. With great difficulty, I wrote, as legibly as I could, “cell saver?”
Leslie held the pad out to George. “Cell saver?” he said, puzzled. “I’m sure they used it in surgery, but …”
At that point Jeff, Mum, and Hal came back in. “We did,” Jeff said. “We’d have gone through twice the blood if we hadn’t. What’s this all about?”
I reached out for the pad. George gave it back to me. While Leslie held it for me, I wrote, “chest tube wash out Lovenox give back RBC.”
Jeff looked at the pad and then at me. “You want us to run your chest tube drainage through the cell saver and wash your red cells and give them back to you, and you think that’ll wash the Lovenox out of your blood?”
I wrote, “yes.”
Hal looked over Jeff’s shoulder. “Would that work?”
George shrugged. “It might be worth a try. What do you think, Jeff?”
“It’d help if we had some idea how much Lovenox she got,” Jeff said. “The cell saver can wash about five hundred cc’s at a time, but it’s gonna take a while to wash her whole blood volume. Maybe plasmapheresis would be faster.”
“Why don’t you ask her?” Mum suggested.
I wrote, “50x.”
“What’s that?” asked George.
“She says she got fifty doses,” Hal said.
“Jesus,” Jeff said. “No wonder she’s still bleeding. She’s basically gotten an exchange transfusion already, but her anti-Xa is still sky-high. We can’t just keep running bank blood through her. But we don’t have the wherewithal to do plasmapheresis here. She’d have to go to Boise or Salt Lake for that, and she’s not stable enough to transfer, except by Life-Flight.”
I wrote, “ask BB or RC”.
“BB?” Mum asked. “RC? What are those?”
“Blood Bank and Red Cross,” Hal said. “Doesn’t the Red Cross have a mobile donor setup in a van that they use to go to smaller towns? Maybe they have a plasmapheresis unit.”
“Well,” Jeff said, rubbing his hands together, “let’s ask the blood bank. Maybe they can get the Red Cross to let us use it.”
They left, talking animatedly.
I was elated. Maybe now things would begin to turn around. Maybe they’d turn around in time to keep me from bleeding into my brain, because that was the only thing that hadn’t bled yet, which was—you should pardon the expression—a bloody miracle.
Hal leaned over and kissed me on the cheek. “Gotta go, sweetie. Love you.”
Mum kissed my other cheek. “We’re going to go and let your doctors get on with it, kitten. We’ll be back later.”
Leslie retied my restraint. “Looks like I’ve got my work cut out for me,” she told me, and she too vanished. I heard her talking to the patient in the next cubicle. I figured I may as well go back to sleep, since there wasn’t anything else to do, and that was a mistake.
I dreamed that I was back in Ruthie’s crawl space, where she chased me around with a butane lighter and a large knife, threatening to cut my wrists and my throat. She came closer and closer and finally caught up with me behind the furnace, where she pulled the hoses loose and wound them around me, immobilizing me. She plunged the knife into both of my wrists, pinning them to the ground, and then held the knife to my throat, while I screamed and struggled futilely until everything faded to black.
I didn’t know how she managed to have the knife in two places at once, but it was a dream, and as such, didn’t have to make sense.
“June, give me a hand here. She’s gonna pull everything out if she keeps this up. Hey! Toni! Wake up! You’re having a bad dream!”
I opened my eyes. Oh, thank God. That was bloody awful. I never thought I’d be so glad to find myself in a hospital bed—although, in the dream I could move my arms and talk, and now I couldn’t. I guess you can’t have everything.
My cubicle was full of people. June was holding my legs down. George and Jeff were each holding down a shoulder. When they saw that I was awake and no longer struggling, they let up on the pressure. George and Jeff looked at each other across my body. “So what do you think?” Jeff asked.
“About what?” George returned.
“This is the third time in twenty-four hours that she’s had an episode like this. Do you think we need to paralyze her?” I knew that they were talking about giving me a shot of succinylcholine or something so that I wouldn’t fight the ventilator, but I wasn’t having any truck with that. Paralyze me? I don’t fucking think so!
So I shook my head vigorously from side to side in an emphatic negative and tried to yell, “No!” which put me once again at odds with the vent and resulted in yet another cacophony of alarms.
“Oh for God’s sake,” Jeff yelled. “Toni, stop it. You’re not doing yourself any good, struggling like this.”
George pulled at his moustache. “I think she’s trying to tell us she doesn’t want to be paralyzed.”
Jack Allen put his head around the curtain. “Hey, do you guys mind? All this noise is disturbing the other patients.”
“Sorry,” George said. “We were discussing whether or not we should paralyze Toni to keep her from fighting the vent, and she objected rather violently.”
Jack looked at my face for the first time and recognized me with a start. Then he checked the pulse oximeter. “How much O2 you got her on?”
“Forty percent,” Jeff said. “Why?”
“Well,” Jack said, “this looks pretty good. How bad do you think she needs to be on the vent?”
Jeff sighed impatiently. “She had a thoracotomy day before yesterday. She’s got three broken ribs, and one of them tore her lung up pretty bad. She’s still bleeding from her chest and her stomach. What do you think?” He didn’t really sound as if he were asking for Jack’s opinion, but he got it anyway.
Jack said, “Can I try something?” and not waiting for an answer, he turned the ventilator off. “Toni? Can you take a breath for me?”
I did so. It hurt, but no more than before. I took another. And another. Jack said, “What’s the pulse oximeter say now?”
“Ninety percent,” George said.
“And that’s on room air,” Jack said. “Look. She’s breathing just fine on her own. Toni? Are you getting enough air?”
I nodded.
“How about it, guys? We let her breathe on her own for about, say, twenty minutes? June, keep checking that pulse oximeter. If she drops below eighty-seven
, get Respiratory to hook up a bypass at forty percent. Then, if she can keep her pO2 above ninety, we can take that tube out and use a nasal cannula. Would you like that, Toni?”
This time I nodded as vigorously as I had previously shaken my head. Had I possessed a tail, I would have wagged it.
“You know,” Jack said, “she’s had that tube in for nearly two days, and after three days she’d have to have a tracheostomy so the tube won’t wear holes in her larynx.”
George pulled at his moustache some more. It seemed to help him think. “Well, you’re the pulmonary guy,” he conceded. “If you think she can do without the tube, who am I to argue? Seems to me, the sooner we get that out, the better.”
“Okay with me,” Jeff said.
Okay with me too. Last thing I need is another scar. Assuming I survive long enough, that is.
“I’ll write the orders,” Jack said and disappeared around the curtain.
“Toni, in case you haven’t noticed,” Jeff said, “you’re having plasmapheresis as we speak. Actually, it’s more like a plasma exchange. That’s why you’ve got lines in both wrists, so we’re a little concerned that you don’t struggle. Okay?”
I looked around. Sure enough, there was another machine next to my bed. A familiar figure sat in a chair next to it, checking the lines and bags hanging from it. She smiled at me. “Do you remember me, Dr. Day?” she asked. “I’m Sherry McKinstry. I used to be a nurse anesthetist here. Now I’m a trained perfusionist for the American Red Cross in Boise. I do plateletpheresis and make fresh frozen plasma.”
I nodded. I did remember her. Years before, a patient had died on the operating table, and I’d done the autopsy. The findings had absolved Sherry from any wrongdoing.
Too Much Blood Page 29