Critical Judgment (1996)

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Critical Judgment (1996) Page 42

by Michael Palmer

Monitor pattern ... cardiac rate ... puke oximeter reading ... complexion ... fingernail bed coloring ... cooling blanket ... By the time Brian had gone from the doorway to the bedside, his mind had processed a hundred bits of information. He breathed in the action and the urgency.

  "Brian, you're a sight for sore eyes," Phil said. "Like one of those gods in Greek tragedy who pop out of the wall of the theater just when they're needed."

  "Hey, careful. I'm through doing the god thing. It ended up causing me nothing but trouble. What's the scoop here?"

  "Well, Mrs. Violet Corcoran here is a sixty-eight-year-old patient of Dr. Dixon's. That's Fred Dixon right there. Fred, Brian Holbrook." Brian and the older doctor exchanged nods. "As far as Fred knows, she's never been really sick before this week."

  Something in Phil's tone suggested that merely having Dixon as one's physician carried with it certain health risks. But the man had come in to see his patient on a Sunday afternoon, and in Brian's mind that negated a certain amount of clinical incompetence.

  "He was treating her with some erythro for an upper respiratory infection," Phil went on. "A couple of hours ago her husband called in that she wasn't looking so good. Her temp's one-oh-four. Pulse one-forty. She's got a pretty dense left lower lobe pneumonia. BP was one-sixty. Now it's down to one hundred."

  "Septic shock?"

  "Probably. But look what she's doing."

  Phil indicated the cardiac monitor screen, which now showed a heart rhythm pattern Brian was almost certain was sustained ventricular tachycardia. V. tach of this sort was very unstable in most situations and was often a precursor of full-blown cardiac arrest.

  "I read v. tach," Brian said.

  "We all agree. She's been in and out of it since she arrived. Short bursts at first. Now more prolonged."

  "Treatment?"

  "We're working our way through the pharmacy. So far we've tried Xylocaine, bretylium, and Pronestyl, and we're about to give her a hit of digitalis. Nothing's touched it."

  "She's going too fast to try and guide her out of it with a pacemaker."

  "Exactly."

  Brian motioned toward Phil's stethoscope.

  "May I?"

  Carole Benoit had seen and heard enough.

  "Dr. Gianatasio," she cut in, "I'm sorry to have to remind you, but Dr. Holbrook has no license to be treating or touching our patients."

  For a few seconds there was no movement in the room, no sound save for the soft gurgle of the oxygen bottle. Then Gianatasio slipped his stethoscope from his neck, rounded the gurney, and handed it to the head nurse.

  "Okay, then, Ms. Benoit," he said without rancor, "suppose you evaluate this woman and give us your considered opinion."

  Benoit's face grew pinched and flushed. She pushed the proffered instrument back at Phil and moved away.

  "Suit yourself," she said. "But I'm holding you responsible for whatever happens."

  "I'll take my chances. Brian, if you don't come up with something we haven't tried, I'm going to have Sule here intubate her and we'll take a crack at shocking her out of this."

  Brian took Phil's Littmann stethoscope and moved to the bedside.

  "I don't think zapping her with a lightning bolt is going to make any difference," he said. "Not unless we figure out the underlying reason she's in that rhythm and do something about it."

  "It could be just massive infection in a woman with some preexisting heart disease."

  "Maybe."

  "Whatever it is, be quick, Brian. She's in it again."

  Brian first scanned Violet Corcoran, head to feet. There was something about her, something that reminded him of a case he had seen somewhere in his training. Where? What was it? He felt over her heart, then her neck, then the arterial pulses at her elbow, wrist, and groin. Finally, he slipped the earpieces of Gianatasio's Littmann into place and worked the diaphragm side of the stethoscope over her heart, chest, and neck. Next he repeated the exam using the bell side.

  "Sule, go ahead and intubate her," Phil said. "Then we've got to try shocking her. Damn, this is getting out of hand fast."

  Brian didn't respond. He was completely immersed in a sound--a sound coming from the front of Violet's neck. And suddenly he remembered. To his left, the anesthesiologist had slipped in an endotracheal breathing tube so smoothly that Brian had not even realized she was doing it.

  "We'll try two hundred joules once, then go right to three-fifty," Phil ordered.

  "Wait!" Brian said, indicating a spot on Violet's neck. "Phil, listen to this."

  The easily heard humming sound, Brian was nearly certain, was a bruit--the noise of turbulence caused in this case, he believed, by blood rushing through a markedly overactive thyroid gland.

  "Pressure's dropping," Sherry Gordon said. "Ninety."

  Phil listened for a few seconds.

  "I heard that sound when I first examined her, but I thought it was a murmur transmitted up from her heart."

  "I don't."

  "Thyroid?"

  "I'm almost sure of it. I've only seen one case of thyroid storm in my life, but this looks just like it. High temp, wild pulse, coma, increasing stretches of v. tach."

  Gianatasio listened to the sound again.

  "Could be," he said excitedly. "Dammit all, it just could be. Fred, does this lady have any history of hyperthyroidism?"

  Fred Dixon flipped through his office notes and lab reports.

  "Eighty," Sherry called out.

  "Well," Dixon said, his voice a bit shaky, "I noted a slightly elevated thyroid level at the time of her physical a year ago. But people her age get underactive thyroids, not overactive, and besides, I didn't think--"

  "Brian, where do we go from here?" Phil cut in.

  "Call an endocrinologist. But I would say, in the meantime, massive doses of steroids, high doses of IV propranolol to block the effect of the hormone on her heart, and then some sort of specific chemical blockade of thyroid hormone production as well. The endocrinologist or a book can tell us what and how much."

  "Let's go with it," Gianatasio said. "Ms. Benoit, find out who's on for endocrine and get 'em down here or on the phone as quickly as possible. If it's the phone, put Dr. Holbrook on. Then get over to the residents' lounge, please, and get me Harrison's Principles of Internal Medicine and the fattest endocrinology textbook you can find. If there's none at least two inches thick, go to the library. The rest of you, listen up, please. We're sailing into some uncharted waters...."

  ABOUT THE AUTHOR

  MICHAEL PALMER, M.D., is the author of Miracle Cure, Critical Judgment, Silent Treatment, Natural Causes, Extreme Measures, Flashback, Side Effects, and The Sisterhood. His books have been translated into thirty languages. He trained in internal medicine at Boston City and Massachusetts General Hospitals, spent twenty years as a full-time practitioner of internal and emergency medicine, and is now an associate director of the Massachusetts Medical Society's physician health program.

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