by Robin Cook
“He’s OK now,” said Dr. Goodman.
“Good. OK, Penny, feed me those chromic sutures and I’ll get this joint closed,” said Colbert.
The resident made fine headway, closing the joint capsule and then the subcutaneous tissues. There was no conversation. Mary Abruzzi sat down in the corner and turned on a small transistor radio. Very faint rock music trickled through the room. Dr. Goodman started the final notations on the anesthesia record.
“Skin sutures,” said Dr. Colbert, straightening up from his crouch over the knee.
There was the familiar slapping sound as the needle holder was thrust into his open hand. Mary Abruzzi changed her worn-out gum for a new stick by lifting the lower part of her mask.
At first it was only one premature ventricular contraction followed by a compensatory pause. Dr. Goodman’s eyes looked up at the monitor. The resident asked for more suture. Dr. Goodman increased the oxygen flow to wash out the nitrous oxide. Then there were two more abnormal ectopic heartbeats and the heart rate increased to about 90 per minute. The change in the audible rhythm caught the attention of the scrub nurse, who looked at Dr. Goodman. Satisfied that he was aware, she went back to supplying the resident with skin sutures, slapping a loaded needle holder in his hand every time he reached up.
Dr. Goodman stopped the oxygen, thinking that maybe the myocardium or heart muscle was particularly sensitive to the high oxygen levels that were obviously in the blood. Later he admitted that this might have been a mistake as well. He began to use compressed air for aerating Berman’s lungs. Berman was still not breathing on his own.
In quick succession there were several back-to-back runs of the strange premature-type heartbeats, which made Dr. Goodman’s own heart jump in his chest from fright. He knew all too well that such runs of premature ventricular contractions often were the immediate harbinger of cardiac arrest. Dr. Goodman’s hands visibly trembled as he inflated the blood pressure cuff. Blood pressure was 80/55; it had fallen for no apparent reason. Dr. Goodman looked up at the monitor as the premature beats began to increase in frequency. The beeping sound became faster and faster, screaming its urgent information into Dr. Goodman’s brain. His eyes swept over the anesthesia machine, the carbon dioxide canister. His mind raced for an answer. He could feel his bowels loosen and he had to clamp down voluntarily with the muscles of his anus. Terror spread through him. Something was wrong. The premature beats were increasing to the point that normal beats were being crowded out as the electronic blip on the monitor began to trace a senseless pattern.
“What the hell’s going on?” yelled Dr. Colbert, looking up from his suturing job.
Dr. Goodman didn’t answer. His trembling hands searched for a syringe. “Lidocaine,” he yelled to the circulating nurse. He tried to pull the plastic cap from the end of the needle but it would not come off. “Christ,” he yelled and flung the syringe against the wall in utter frustration. He tore the cellophane cover from another syringe and managed to get the cap off the needle. Mary Abruzzi tried to hold the lidocaine bottle for him but his trembling hands made it impossible. He snatched the bottle from her and thrust in the needle.
“Holy shit, this guy’s going to arrest,” said Dr. Colbert in disbelief. He was staring at the monitor. The needle holder was still in his right hand; a pair of fine-tooth forceps were in his left hand.
Dr. Goodman filled the syringe with the lidocaine, dropping the bottle in the process so that it shattered on the tile floor. Struggling with his trembling he tried to insert the needle into the I.V. line and succeeded only in jabbing his own index finger, bringing a drop of blood. Glen Campbell whined in the background from the transistor.
Before Dr. Goodman could get the lidocaine into the I.V. line, the monitor abruptly returned to its steady, pre-crisis rhythm. In utter disbelief Dr. Goodman looked at the electronic blip moving through its familiar and normal pattern. Then he grasped the ventilating bag and inflated Berman’s lungs. Blood pressure read 100/60 and the pulse slowed evenly to about seventy per minute. Perspiration coalesced on Dr. Goodman’s forehead and dripped off the bridge of his nose onto the anesthesia record. His own heart rate was over one hundred per minute. Dr. Goodman decided that clinical anesthesia was not always dull.
“What in God’s name was all that about?” asked Dr. Colbert.
“I haven’t the slightest idea,” said Dr. Goodman. “But finish up. I want to wake this guy up.”
“Maybe it’s something wrong with the monitor,” said Mary Abruzzi, trying to be optimistic.
The resident finished the skin sutures. For a few minutes Dr. Goodman had them hold off deflating the tourniquet. When they did, the heart rate increased slightly but then returned to normal.
The resident started to cast Berman’s leg. Dr. Goodman continued to aerate the patient while he kept one eye on the monitor. The rate stayed normal. Dr. Goodman tried to record the events on the anesthesia record in between compressions of the ventilating bag. When the cast was completed, Dr. Goodman waited to see if Berman would breathe on his own. There was no breathing effort at all, and Dr. Goodman took over again. He looked at the clock. It was 12:45. He wondered if he should give an antagonist for the fentanyl to try to curtail the respiratory depressant effect it was apparently causing. At the same time he wanted to keep the medication that he gave to Berman to a minimum. His own clammy skin reminded him vividly that Berman was no routine case.
Dr. Goodman wondered if Berman was getting light despite the fact that he was not breathing. He decided to test the lid reflex to find out. There was no response. Instead of stroking the lid, Dr. Goodman lifted the lid and he noted something very strange. Usually the fentanyl, like other strong narcotics, produced very small pupils. Berman’s pupils were enormous. The black area almost filled the clear cornea. Dr. Goodman reached for a penlight and directed the beam into Berman’s eye. A ruby red reflex flashed back but the pupil did not budge.
In total disbelief, Dr. Goodman did it again, then again. He did it once more before his own eyes looked up at nothing. Dr. Goodman said two words out loud . . . “Good God!”
Monday
February 23
12:34 P.M.
For Susan Wheeler and the other four medical students, the charge down the hall to the elevator fitted perfectly their preconceptions of the excitement of clinical medicine. There was something horribly dramatic about the headlong rush. Startled patients sitting there casually leafing through old New Yorker magazines while waiting to see their doctors reacted to the stampeding group by drawing their legs and feet more closely to their chairs. They stared at the running figures who clutched at pens, penlights, stethoscopes, and other paraphernalia to keep them from flying from their pockets.
As the group came abreast of, then passed, each patient, the patient’s head swung around to watch the group recede down the corridor. Each assumed that a group of doctors had been called on an emergency, and it was reassuring for the patients to see how earnestly the doctors responded; the Memorial was a great hospital.
At the elevator there was momentary confusion and delay. Bellows repeatedly pushed the “down” button as if manhandling the plastic object would bring the elevator more quickly. The floor indicator above each elevator door suggested that the elevators were taking their own sweet time, slowly rising from floor to floor, obviously discharging and taking on passengers in the usual slow motion. For such emergencies there was a phone next to the elevators. Bellows snatched it off its cradle and dialed the operator. But the operator didn’t answer. It usually took the operators at the Memorial about five minutes to answer a house phone.
“Fucking elevators,” said Bellows striking the button for the tenth time. His eyes darted from the exit sign over the stairwell back to the floor indicator above the elevator. “The stairs,” said Bellows with decision.
In rapid succession the group entered the stairwell and began the long twisting plunge from the tenth floor to the second floor. The journey seemed interminable. T
aking two or three steps at a time, constantly turning to the left, the group began to spread out a bit. They passed the sixth floor, then the fifth. At the fourth floor the whole group slowed to a cautious walk in the dark because of the missing lightbulb. Then down again at the previous pace.
Fairweather began to slow and Susan passed him on the inside.
“I don’t know what the hell we are running for,” panted Fairweather as Susan passed.
Susan managed to brush her hair from her face, hooking it behind her right ear. “As long as Bellows et al. are in the lead, I don’t mind running. I want to see what goes on but I don’t want to be the first one on the scene.”
Fairweather assumed a comfortable walk and was quickly left behind. Susan was nearing the third floor landing when she heard Bellows pound on the locked door on two. He yelled at the top of his lungs for someone to open the door, and his voice carried up the stairwell, reverberating strangely, taking on a warbling quality. As Susan rounded the final landing, the door on two was opened. Niles kept the door open for her and she entered the hall. The constant turning to the left in the stairwell made Susan feel a bit dizzy, but she did not stop. Following the others, she ran directly into the ICU.
In sharp contrast to the former dimness of the room, it was now brightly illuminated with stark fluorescent light that provided a shimmering aura to objects within the room. The white vinyl floor added to this effect. In the corner the three ICU nurses were engaged in giving closed chest massage to Nancy Greenly. Bellows, Cartwright, Reid, and the medical students crowded around the bed.
“Hold up,” said Bellows watching the cardiac monitor. The nurse giving the closed chest massage straightened up from her efforts. She was kneeling on the edge of the bed on the right side of Nancy Greenly. The monitor pattern was wildly erratic.
“She’s been fibrillating for four minutes,” said Shergood watching the monitor. “We started the massage within ten seconds.”
Bellows moved rapidly over to the right of Nancy Greenly and while watching the monitor, he thumped the patient’s sternum with his fist. Susan winced at the dull sound of the blow. The monitor’s pattern did not alter. Bellows began closed chest massage.
“Cartwright, feel for a pulse in the groin,” said Bellows without taking his eyes from the monitor. “Charge the defibrillator to 400 joules.” The last command was directed to anyone. One of the ICU nurses carried it out.
Susan and the other students backed up against the wall, acutely aware that they were mere observers, and although they wanted to, they could not help in the frantic activity occurring before them.
“You’ve got a good pulse going,” said Cartwright with his hand pressed in Nancy Greenly’s groin.
“Was there any warning for this or did it drop out of the blue?” said Bellows with some difficulty between compressions of the chest. He nodded his head toward the monitor.
“Very little warning,” answered Shergood. “She began to have a suggestion of increased excitability of her heart by having a few premature ventricular beats and a suggestion of a mild atrioventricular conduction defect which we picked up on the recorder.” Shergood held up a strip of EKG paper for Bellows to see. “Then she had a sudden run of extra systoles, and wham . . . fibrillation.”
“What has she got so far?” asked Bellows.
“Nothing,” said Shergood.
“OK,” said Bellows. “Push an amp of bicarbonate and draw up 10 cc of a 1:1000 epinephrine in a syringe with a cardiac needle.”
One of the ICU nurses injected the bicarbonate; another prepared the epinephrine.
“Somebody draw blood for stat electrolytes and calcium,” said Bellows, letting Reid take over the massage. Bellows felt the femoral pulse under Cartwright’s hand and was satisfied.
“From what Billings said at the complication conference on this case, the same thing is happening here that happened in the OR to cause all her troubles in the first place,” said Bellows thoughtfully. He took the 10 cc syringe with the epinephrine from the nurse, holding it up to let the last traces of air escape.
“Not quite,” said Reid between compressions. “She never fibrillated in the OR.”
“She didn’t fibrillate but she did have premature ventricular contractions. Obviously she had an excitable heart then as now. All right, hold up!” Bellows moved along Nancy Greenly’s left side, brandishing the syringe with the cardiac needle. Reid straightened up from his resuscitative efforts so that Bellows could feel along Nancy Greenly’s sternum for the landmark called the angle of Louis. Using that as a guide, he located the fourth interspace between the ribs.
The needle on Bellows’s syringe was three and a half inches long and a sparkle of reflected light danced off its stainless steel shaft. Decisively Bellows pushed it into the girl’s chest, all the way to the hilt. When the plunger was pulled back, dark red blood swirled up into the clear epinephrine solution.
“Right on,” said Bellows as he rapidly injected the epinephrine directly into the heart.
Susan’s skin crawled with the vivid thought of the long needle tearing its way down into Nancy Greenly’s chest and spearing the quivering mass of cardiac muscle. Susan could almost feel the coldness of the needle in her own heart.
“Go to it,” said Bellows to Reid as he stepped back from the bed. Reid immediately recommenced his cardiac massage. Cartwright nodded, indicating that there was a strong femoral pulse. “Stark is going to be pissed when he hears about this,” continued Bellows, eyeing the monitor, “especially right after his lecture on vigilance in these cases. Shit, I really don’t deserve this kind of headache. If she croaks, my ass is grass.”
Susan had trouble comprehending that Bellows had actually said what he did. Once again she was faced with the fact that Bellows and probably the entire crew were not thinking of Nancy Greenly as a person. The patient seemed more like the part of a complicated game, like the relationship between the football and the teams at play. The football was important only as an object to advance the position and advantage of one of the teams. Nancy Greenly had become a technical challenge, a game to be played. The final, ultimate result had become less important than the day-to-day plays and moves and ripostes.
Susan felt a strong surge of ambivalence toward clinical medicine. Her nascent female sensitivities seemed to be a handicap within the mechanistic and tactically oriented atmosphere. She silently longed for the old familiar lecture hall and its abstractions. Reality was too bitter, too cold, too detached.
And yet there was something fascinating and academically satisfying seeing the application of the basic scientific knowledge she had acquired. From physiology experiments with animal hearts, she comprehended the disorganization that the fibrillating heart within Nancy Greenly represented. If only the whole mass could be depolarized to stop all electrical activity, then the intrinsic rhythm could possibly begin again.
Susan strained to watch as Bellows placed the defibrillating paddles on Nancy Greenly’s exposed chest. One of the paddles was held directly over the sternum, the other was placed against the left lateral chest, slightly distorting the left breast with its pale nipple.
“Everyone away from the bed!” ordered Bellows. His right thumb made contact and a powerful electric charge spread through Nancy Greenly’s chest, arcing from one paddle to the other. Her body jerked upward; her arms flopped across her chest with her hands twisting inward. The electronic blip disappeared from the screen, then it returned. It traced a relatively normal pattern.
“She’s got a good pulse,” said Cartwright.
Reid held up on the external massage. The rate held steady for several minutes. Then a premature ventricular contraction appeared. The rate was again steady for several minutes followed by three premature ventricular contractions in a row.
“V tach,” said Shergood confidently. “The heart is still very easily excitable. There has to be something very basic wrong here.”
“If you know what it is, don’t keep it from us,�
� said Bellows. “Meanwhile let’s have some lidocaine, 50 cc.”
One of the nurses drew up the lidocaine and handed it to Bellows. Bellows injected it into the I.V. line. Susan moved so that she could see the monitor screen more clearly.
Despite the lidocaine, the rhythm rapidly deteriorated to senseless fibrillation once more. Bellows swore, Reid started massage, and the nurse recharged the defibrillator.
“What the hell is going on here?” queried Bellows, motioning for another amp of bicarbonate to be given. He didn’t expect an answer; he was posing a purely rhetorical question.
Another dose of epinephrine given by I.V., followed by a second defibrillation attempt, returned the rate to a semblance of normal. But premature contractions returned, despite additional lidocaine.
“This has to be the same problem that they had in the OR,” said Bellows, watching the premature contractions increase in frequency until the rhythm dissolved into fibrillation. “You’re up again, Reid ole boy. Let’s go, team.”
By 1:15 Nancy Greenly had been defibrillated twenty-one times. After each shock a relatively normal rhythm would return only to disintegrate into fibrillation after a short duration. At 1:16 the ICU phone rang. It was answered by the ward clerk, who took the information. It was the lab calling with the stat electrolyte values. Everything was normal except the potassium level. It was very low, only 2.8 milliequivalents per liter.
The ward clerk handed the results to one of the nurses, who showed them to Bellows.
“My God! 2.8. How in Christ’s name did that happen? At least we have an answer. OK, let’s get some potassium in her. Put 80 milliequivalents into that I.V. bottle and speed it up to 200 cc per hour.”
Nancy Greenly responded to this command by immediately lapsing back into fibrillation for the twenty-second time. Reid started compression while Bellows readied the paddles. The potassium was added to the I.V.
Susan was totally absorbed by the whole resuscitation procedure. In fact, her concentration had been so great that she had almost missed hearing her name crackle out of the page system speaker near the main desk. The page system had been intermittently active throughout the entire cardiac arrest procedure by calling out the names of physicians followed by an extension number. But the sound had blended and merged with the general background noise, and Susan had been oblivious to it. At least until her own name floated out into the room along with the extension 381.