by Jaime Maddox
Edward started his car and pointed it toward New York City. Barring a catastrophe on the highway, he’d be home in a few hours, and then he’d shower, change into club clothes, and head out to one of his favorite bars. With any luck, he’d find a cute young college kid to spend the night with. Boy or girl, it didn’t matter. He was so primed from his day at work, he could fuck anything. And he planned to, many times over the weekend.
On Monday morning, he’d pack his car again and head back the way he’d come. The good people of Carbondale, PA needed an ER doctor, and he was ready to heed the call.
Chapter Nine
Respiratory Arrest
Arriving half an hour early for her shift allowed Ward to ease back into the murky waters of the ER. She’d found that to be a much more pleasant immersion than jumping right in. A locker was waiting for her, along with a stack of institutional-style blue scrubs, which pleased her immensely. They matched her eyes perfectly. After changing and securing her valuables, she walked through another door and into the staff kitchen. It was deserted but well stocked with a traditional coffee brewer as well as a Keurig, a toaster-oven and a microwave, a fridge, and a combination ice-and-water machine. And it was remarkably clean.
She found a corner in the fridge and stored her lunch. Then, after glancing in the mirror to confirm she still looked like a doctor, she took a few deep breaths and went to work.
The department was quiet, and Ward had to search for signs of life. A crew of three—a doctor, a nurse, and a clerk—ran the ER at night, and she found them all in the lobby, watching the news. A tall, unshaven man with black, curly bed head stood and smiled when he saw her, then introduced himself as the ER director.
“Did you bring your boots?” he asked, nodding toward the TV. “More snow tomorrow.”
Ward tried not to cringe when she thought of the boots Jess had given her for Christmas. But they were indeed packed, and she had plenty of cold-weather gear to insure she didn’t freeze on her fifty-yard trek across the parking lot to the hospital from the house where she was staying. “I did,” she said simply.
After they exchanged pleasantries, he introduced her to his colleagues, and she learned she’d be working with them when she covered the night shift the following weekend. At this hospital, the weekend consisted of Saturday and Sunday evenings, and like most places, while the physician staff rotated shifts, the rest of the staff was dedicated to days or nights. Both the nurse and the clerk had young children waiting for them at home, and the few hours of sleep they’d had when the ER was slow was probably all they’d get until they put them to bed that night. Night shifts in a slow ER were a good way for working mothers to go.
The director gave her a little more orientation, made sure all of her passwords were in order, showed her how to use the software for ordering and reading X-rays. “Don’t worry. You can always write the orders on an order sheet and give them to the clerk. And if you’re too slow on the system, you can dictate a note and they’ll scan it in, or you can handwrite the chart and scan that. Just write legibly.” He smiled at his last words.
In the code room, he showed her his favorite toys—a fiber-optic system for intubating and a portable ultrasound to assist with IV access. Ward was familiar with both instruments and was happy to see them. They were like old friends, and she knew they’d have her back. Nothing could get a doctor’s heart rate soaring like a crashing patient who couldn’t breathe and had no IV access, and the equipment he showed her had helped her save more than a few lives.
Voices signaled the arrival of the day-shift team, and introductions were quickly made. An additional nurse was on day shift—the nurse manager, who also wore a few other hats and floated in and out of the department as needed. At nine, when business started to boom, another nurse would start her twelve-hour shift.
“It’s nice to meet you,” the clerk said in a friendly voice, but the nurse, a young androgynous woman with a scowl on her face, wasn’t quite so welcoming. “Hi,” she said, offering a reluctant hand. The grip, though, was powerful, and when Ward met her eyes, she saw a challenge there.
Great, she thought. Just what she needed as she started her new venture—a turf war with a young butch. And several hours later, after the nurse, Erin, had questioned her every order, Ward wondered if she’d made a huge mistake. The next few months would be like medical school again, changing assignments every month, learning new systems and new ways. And new people. There were always battles of wills among the staff: personality differences, cliques, and some downright nasty people to deal with.
Almost ten years had passed since she’d worked anywhere other than home, with the exception of Garden, which truly was an exception. She and Jess were welcomed there, hometown heroes of sorts, and everyone had been friendly. Experience told her that wasn’t the typical case, but she hadn’t even thought about that aspect of the job when she’d signed on the dotted line for the locums job. All that had filled her mind was the thought of Jess, the need to be near her, and the need to work and occupy her time. She’d thought the locum tenens work was ideal, but after only five hours on the job, she was questioning the sanity of that decision.
“I’m not comfortable giving that shot,” Erin told Ward, her arms folded across her chest and her feet spread wide in a challenging stance.
Ward looked up from her computer and met Erin’s icy gaze.
“And why is that?” she asked, leaning back in the chair, giving Erin some space. It sucked to have to deal with this sort of crap, and back in school Ward had just tried to blend in, do her job, not make any trouble. It was different now, though. She was in charge, and that meant she had to stand up to the bullies. She hated it, but she wouldn’t let Erin know that.
“It causes bleeding, and people have died because of it. The pharmacy issued a warning about it, and I’m not going to risk my license because some hotshot doctor from Philadelphia comes in and starts ordering me around. You don’t give a shit about the patients. You just want to collect a paycheck. You’ll be gone at the end of the month, but I’ll still be here, and I’ll have to face the families of whoever dies.”
Ward was speechless. She’d encountered challenges in her career, but never the open hostility Erin displayed. As tired as she was of Erin’s attitude, and as much as she would have liked telling her off, this wasn’t the time for a fight. “Wow, Erin. I’m going to have to think about that and get back to you. I’m not in the habit of killing my patients, and I feel comfortable with this medication, so if you just give me the vial and the syringe, I’ll draw it up and push it myself.”
Seconds later, the requested supplies were placed on the desk before her. “Thanks,” Ward said, trying to maintain some appearance of professionalism. She picked up the bag and headed into the exam room where a thirty-five-year-old man with a history of kidney stones was moaning and rolling around on the stretcher.
“I have some medication for you, Joe. It’s going to take a few minutes to work, but then you’ll feel better.” Ward popped the plastic tamper-resistant lid from the vial and drew up the appropriate dosage into the syringe, then slowly injected it into the port on his IV tubing.
“Aren’t you going to get a CT scan?” Erin asked from the doorway.
“That’s an excellent question, Erin,” she said, then directed the answer toward her patient. “We know you’ve had kidney stones in the past, and the pain you’re having now seems like a kidney stone, so why should we expose your body to all that radiation? We don’t need a CT scan now, but if your pain doesn’t go away with medication, or you develop a fever, or it doesn’t resolve in about a week, then we should. Most stones will pass on their own, though, if we give them a chance.”
“What if it doesn’t pass?” the man’s wife asked.
“The urologist can fish it out or break it up with ultrasound. Do you understand about the CT scan?”
“It makes sense to me. We know it’s a kidney stone. It just seems like all the doctors want to get a sca
n before they even give him any medication. It’s expensive and we have a high deductible, so it really sucks. And he has to wait a long time for his medicine.”
“Controlling costs is important, and so is controlling radiation exposure.” Ward turned her attention back to her patient. He wasn’t quite so pale and didn’t seem as anxious. “How’re you feeling? Any better?”
He nodded his head. “A little.”
“Good. Let’s give the medication a little more time to work, and then if you need more, I’ll give you another shot.”
“An ambulance is here, we need you,” Erin said as she rushed past the room.
Ward followed her to the large trauma room, which was really a multi-purpose room to take care of all critically ill patients—trauma and medical, adult and pediatric. Much of the equipment used was the same, and in a small hospital like this, it made no sense to have separate areas to treat the sickest patients.
One look at this one told Ward she was in trouble. A woman in her sixties was seated upright on the stretcher, arching her back and her head with each labored breath she took. A plastic mask and bag delivering high-dose oxygen was fastened around her head, but she held it tightly against her mouth, trying to get more air.
However, she couldn’t. The bag was doing its job, but the woman’s lungs weren’t. The only thing that would help her was to force air into her lungs, either with a tube or a mask, and Ward sensed the woman would need the tube.
Ward looked at Erin and ordered the medications she would need to sedate the patient. Then she turned to the nurse manager, who’d arrived with a host of others when the cry for help had been announced over the hospital’s intercom. “Bag her!”
“You’re going to sedate her?” Erin asked. “What if you can’t get the tube in?”
“I’ll get the tube in!”
“What if you can’t? Then she won’t be able to breathe on her own and she’ll die.”
“If I can’t get the tube in, we’ll bag her. The meds are short acting and they won’t hurt her.”
“I don’t feel comfortable with this,” Erin said.
Ward was losing patience. She didn’t have time to debate or educate the argumentative nurse. “Just give me the meds. I’ll do the rest.”
With a clenched jaw, Erin drew the meds and handed them to her. She pushed them into the IV port and watched the patient’s face. The nurse was assisting her breathing with a large Ambu bag attached to the mask across her face, and, as a result, the oxygen levels were climbing, her skin color turning more pink than blue. After a few seconds, when it seemed the woman’s face relaxed and she was sufficiently sedated, and her oxygen level more stable, Ward stepped behind her, opened her mouth, and used the laryngoscope to get a visual on her vocal cords. Without taking her eye off the target, she reached for a breathing tube and easily slid it into her trachea.
“It’s in,” Ward said after watching the tube pass through the vocal cords. Before moving, she used a syringe to inflate the air bladder that would hold it in place.
The respiratory therapist placed a small plastic sensor on the end of the tube, and the color change confirmed Ward’s observation. It was detecting carbon dioxide from the lungs. If the tube had been in the stomach—the only other place it could go—the sensor wouldn’t have changed colors.
The nurse secured the tube with a foam dressing, and the respiratory therapist connected the tubing to the ventilator that would breathe for the patient for the next few days.
After issuing orders to the lab, the X-ray tech, and the respiratory therapist, she turned again to Erin. “Can you get an EKG, or don’t you feel comfortable with that?”
Erin’s face turned red, but she didn’t comment and immediately began attaching the EKG leads. A minute later, she handed Ward the sheet of thermographic paper that had recorded the electrical blueprint of the patient’s heartbeat. The electrical signals were elevated from the baseline in places and depressed in others. In this situation, this could mean only one, very bad, thing.
“Shit,” Ward said. “She’s having an MI.” The director had given her a set of instructions on how to handle such emergencies as heart attacks, like this one, that were better treated at larger hospitals with staff cardiologists, cardiac cath labs, and heart surgeons.
The clerk, Petra, was waiting in the doorway for instructions. “I need the hospital in Scranton on the phone for a transfer,” Ward informed her.
She turned to Erin and, instead of giving any further orders, simply asked for the meds she needed. As an ER doc, she was quite capable of administering them herself, and she couldn’t use her energy arguing with Erin. The patient needed her full attention.
“Cardiology on the phone for you,” Petra said a few minutes later.
Ward took the proffered portable phone and shared the information with the cardiologist in Scranton. After agreeing to accept the patient for admission, she asked Ward how long it would take for the transfer. Ward wasn’t sure.
“How long to get to Scranton?” Ward asked the nurse, Jim.
“By the time the ambulance gets here, and they get her loaded, I’d say fifty minutes.”
Ward stared at him, confused. Wasn’t the ambulance already there? It couldn’t have been more than ten minutes since they dropped the patient off. Didn’t they have paperwork to complete, supplies to replenish? They’d brought in a patient from a minor car accident early on in the shift, and Ward would swear they’d hung around for an hour, gossiping with Petra. Even though the delay bothered her, she didn’t question him. She was sure he knew the routine better than she. “Fifty minutes,” Ward informed the cardiologist.
After disconnecting the phone, she went to the patient’s bedside and studied her vital signs. Oxygen level perfect. Heart rate slow and steady. Blood pressure holding. All she needed now was a balloon or a stent to open up a blocked artery in her heart, and she’d be fine. Ward had administered a clot-busting drug, and she asked for another EKG to see if it was making any difference.
“Where’d the ambulance go?” she asked Jim as he handed her the paper.
“Back to the station.”
Ward glanced at the EKG. No change from the prior. “Why?”
“What do you mean?” he asked, his expression guarded.
“They brought the patient in. They knew she was having an MI and would need a transfer to Scranton. Why did they leave at such a crucial time? Time is muscle,” Ward said, quoting one of the early advertising promotions that tried to illustrate the need to act quickly in treating heart attacks.
Jim shrugged. “I guess they had something to do.”
Ward intended to ask them, but when the crew returned, they went straight to work preparing the patient for transfer, and before she knew it they were on their way. As the stretcher disappeared from view, she walked across the hall to check on her other patient.
“How’s the pain?” she asked Joe.
“Gone,” he said.
Ward smiled. Nothing felt better than making someone feel better. A long list of medications would help make sure the pain didn’t return and would allow him to treat further episodes at home. That would save him time and money, and give him faster relief during his next attack. Ward discussed the plan with both Joe and his wife, then excused herself to prepare the discharge instructions.
When Ward finished, no more patients were waiting, so she headed across the department to the break room. She’d snacked on an apple earlier, but she was starting to feel a little hungry. If she didn’t eat when she had the chance, she might not get to. Her peanut-butter sandwich was too cold from the fridge, but it still tasted great. Better still was the quiet and solitude of the room. She was tired of locking horns with Erin and would be happy when the shift ended at seven.
On cue, the break room door opened and Erin stepped inside. She procured a Keurig cup from the cupboard, and after she prepared her coffee to her liking, she leaned against the counter and sipped it, studying Ward.
Ward ignored her and tried not to hurry through her brief respite just to escape this nasty young woman. What was her problem, anyway?
Erin interrupted her thoughts. “They can charge twice,” she said.
“Huh?”
“The ambulance. If they leave and come back, they can charge for two calls instead of one. That’s why they left.”
Ward felt her head drop a few degrees, but her eyes never left Erin’s. The nurse was serious. How awful! In cases like this one, time truly was crucial. A few extra minutes might not seem like much, but they could mean the difference between life and death. One minute a patient was stable and the next in cardiac arrest. What kind of callous disregard for human life would dictate a policy that had trained personnel leave a sick patient’s bedside only so they could charge extra?
“Does the administration know this?”
Erin shrugged. “It is what it is. The ambulance has to make money to stay in business.”
Taking another bite of her sandwich, Ward reflected on Erin’s words. Did the greater good trump the rights of the individual? If the ambulance company went bankrupt, then no one would have access to essential medical services, and many people would die. Yet, by skirting the rules like they were, they put every patient’s life on the line.
“You did a good job with that tube,” Erin said, yet Ward sensed a big “but” coming.
“Thanks,” she said cautiously.
“And you were right about the pain medication.”
Ward nodded and studied Erin for a moment. She leaned against the counter, shoulders shrugged and head hung, looking defeated. Why? She chose her words carefully.
“These are basic things ER docs should be able to do. Manage pain and manage airways.”
“Well, they should, but that doesn’t mean they do.”
Ward sensed Erin needed to vent about something, and if they were going to spend the month together, it was better to get it out now. “Did you have a bad experience with another doc?”