“Less secretions, eh?”
Another bit of good news. When Shirley arrived at the ICU, her chest x-ray showed substantial infiltrate clogging her lungs.
Amber said, “The respiratory therapist titrated down her oxygen and now she’s only on forty-five percent. When I left yesterday she was on sixty.”
Julie went to the Medi-Vac unit mounted on the wall and inserted a catheter down the tube. She engaged the suction, producing a whirring sound, and up came a soupy, yellowish, highly viscous, putrid-smelling liquid. It was less than Julie had expected.
“Looks like Shirley really is getting better,” Julie said. “Maybe today you can give her a wake-up and lighten the propofol.”
Amber acted disappointed. “Shirley can be a handful. I’m really going to miss the milk of amnesia,” she said.
Julie smiled at the long-running ICU joke; the milky white drug had the same color and consistency as the popular over-the-counter laxative. A sleeping patient makes no trouble, said the adage on the floor. But staying on the ventilator long term increased the likelihood of going from sleeping to dead. The breathing tube keeping Shirley alive was also a gateway for getting bacteria into the lungs. Ventilator-associated pneumonia was a real risk. For people already seriously ill, it could be a death sentence.
“Let me know how Shirley is doing when she’s awake. Maybe we can reduce the ventilator further, and if that goes well, we’ll move on with a spontaneous breathing trial.”
If Shirley were able to breathe for two hours under her own power, Julie would consider taking her off the ventilator.
“I’ll get her awake right away,” Amber said.
“Good,” Julie answered.
So far the day was off to a banner start.
A raven-haired nurse named Lisa, dressed in floral scrubs, poked her head into Shirley’s cubicle.
“Dr. Devereux, I need some help. It’s the quarterback. I’m worried. We’re cranking vasopressors, but his BP is unstable and trending down.”
Julie darted out of the room and Lisa fell into step behind her. ICU nurses were not only compassionate, but were some of the best trained in the field. They seldom worried over nothing.
CHAPTER 3
The quarterback in question was Max Hartsock, a six-foot-five, two-hundred-twenty-pound star of the Boston College Eagles football team. Max was in the ICU with kidney failure and on dialysis following an exceptionally nasty MRSA infection. Instead of running plays, he lay on his back, spread-eagled, with a damp sheet covering his barrel chest.
Max’s dark skin was an ashy shade. A thin layer of sweat glistened over muscles bloated with fluid. His numerous tattoos were stretched out and badly misshapen.
Tubes were inserted in all parts of his body. Most of the tubes put medicine into him, but a red one carried Max’s blood to the dialysis machine, which was on and turning in a circular motion, removing waste products and essentially doing the work his kidneys could not. A different red tube put the cleaned blood back in.
A native of Dorchester, Max Hartsock was something of a legend, a local boy from a tough neighborhood who overcame adversity to become a Division I football standout.
Trevor’s dad, who like Julie was a BC alumni, was still slightly obsessed with BC football, and Julie had fond memories of going to the games as a family. Paul’s devotion to the team had rubbed off on Trevor. Her son, a soccer player and self-proclaimed ESPN addict, had plastered his bedroom walls with various Boston sports paraphernalia. In deference to his parents’ alma mater, Trevor designated a special section of wall exclusively for BC football’s annual team poster, which this year featured Max Hartsock front and center.
Julie came to Max’s bedside. “How are you feeling?”
“Like I just got sacked by the entire Florida Gators football team.” Max’s voice came out thick and raspy.
“That good, huh?”
“What’s wrong with me, Doc?”
“Well, a lot. The MRSA infection caused your body to go into shock, which then shut down your kidneys. And now, for some reason, your blood pressure isn’t stable.”
She checked the carotid pulses on either side of Max’s muscled neck. They were regular, but a little thready. Lisa’s concern had been valid. Julie sensed a crisis might be looming and, paradoxically, she relaxed. Maintaining a level head was essential for making smart decisions.
Max had an arterial line in for continuous blood pressure monitoring. Julie glanced at the digital readout: ninety-five systolic, lower than it should have been with all the vasopressors in his bloodstream. He was also running a fever, 102 according to the readout on the monitoring system. He had almost every hookup the ICU had to offer, but nothing could explain why his BP was not stable.
“He’s had a heparin infusion?” Julie asked Lisa.
“A few hours ago,” Lisa said.
Julie gave a nod. This was standard practice for preventing thrombosis during intermittent dialysis.
“I’m already at the max dose of Levophed, thirty micrograms,” Lisa said, as if reading Julie’s thoughts.
“Well, his BP should be higher. Give him fluids while we’re sorting this out.”
“Is that your son?” Max asked Julie in a raspy voice.
Julie spun her head toward the door.
“Trevor, what are you doing here?” she said in a sharp tone. “You’re supposed to wait for me in my office.”
“I needed a charger.”
“Read a book,” she said with a scowl.
Trevor gave Max an awkward wave.
“Yes, that’s my son, Trevor,” Julie said. “He’s actually a very big fan of yours. But he shouldn’t be here.” To Trevor, Julie said, “Should you?”
“That’s okay, Doc, I don’t mind.” It took effort, but Max waved Trevor into the room.
At the same time, Lisa went to the door and yelled into the hall, “Hey, can someone help me?”
A second nurse soon arrived. “What do you need?”
“A liter of saline,” Lisa said. “No, make it two.”
“You’re a BC football fan, eh?” Max said to Trevor.
“Yeah. Big time.”
“Ever go to the games?” Max’s voice came out just above a whisper and Trevor had to lean in close to hear.
“Yeah,” Trevor said. “Saw you play against Syracuse with my dad. Three hundred twenty-five yards passing, three TDs, and no picks. Awesome game.”
Max managed a half smile. “Kid, you know my stats better than me.”
Trevor blushed. “I doubt it.”
“Your mom’s taking good care of me. You being cool with her?”
“Yeah, pretty cool.”
Julie set a damp cloth against Max’s forehead to soak up some of the perspiration. The saline arrived and a nurse went to work getting the bag hooked up. After scanning his body head to toe, Julie double-checked Max’s lines and glanced at the screen of the dialysis machine. She kept an even keel as she ran through her list, conducting a rapid-fire differential diagnosis in her mind.
Two-port line for the dialysis catheter seems okay … no signs of bleeding there … dialysis machine says the blood flow is appropriate … no blockages … lines don’t appear to be stuck against a blood vessel wall …
In the middle of her exam, Max’s BP crashed.
“BP is down to seventy-five!” the monitoring tech called, talking only about the systolic reading, a common practice during an emergency.
A loud beeping startled Trevor. For a few seconds nobody moved, no sound other than the incessant churning from the dialysis machine as it cleaned Max’s blood. Trevor moved back a few steps as Max let out a soft moan.
Julie felt her pulse quicken.
“Trevor, please wait in my office.” There was no room for negotiation. Trevor departed with haste.
We’re giving him fluid, max vasopressors, lowered dialysis, and he’s still shitting the bed …
A monitoring nurse out in the hall yelled, “Hey, is anybody see
ing this? The BP in room fifteen is dropping like crazy.”
Lisa yelled back, “Yeah, we’re seeing it!”
“When was he last fine?” Julie asked Lisa. “Was he okay after the line went in?”
“Yeah, he was fine then,” Lisa said. “Then the nurse turned on the dialysis and he got worse, so she turned down the flow, thinking that would help.”
Max took several short, sharp breaths that barely moved air, and let out another moan. Julie eyeballed the monitor, taking in the oxygen saturation reading, and saw it was within the normal range. She reviewed Max’s heart rhythm as measured by the telemetry and noted an increased heart rate that often accompanied episodes of low blood pressure. The rhythm in his pulse gave no indication of any cardiac trouble. The usual culprits appeared not to be at play here.
What the hell is going on?
Julie slipped her stethoscope into her ears. She listened carefully for the telltale rubbing sound that signals when renal failure causes fluid to build up in the sac around the heart, essentially squeezing the life out. She heard the fast lub-dub of Max’s heart racing to send blood to his vital organs.
“Did you get a chest X-ray?” she asked Lisa.
“Yeah, we did the X-ray,” Lisa said. “But it hasn’t been read yet.”
“Dammit,” Julie said. “Well, get someone to read it, will you?”
Setting the diaphragm of the stethoscope on Max’s back, Julie gave a careful listen to the chest posteriorly. Next, she put it near the armpit, and then to the front of the chest, hearing bilaterally symmetrical breath sounds. Even with those normal sounds, Julie could not rule out the possibility that the insertion of his central venous catheter might have caused a pneumothorax. If air were leaking into the space between the lungs and the chest, it would explain Max’s hypotension. She needed those X-rays pronto.
Lisa soon returned, while Julie continued to listen with her stethoscope. A second nurse and a monitoring tech also entered the cramped quarters.
“We got a rush on the read,” Lisa said. “I’m trying to pull it up on the computers, but the system is down for maintenance.”
“Damn computers,” Julie muttered.
“They said it won’t be long before the system is back online,” Lisa said. “We can try to get it from the backup.”
“No, by then the main system will be back. Did he ever spike a fever?” Julie asked.
“It’s been gradual,” Lisa said.
A series of alarms sounded louder than any previous alerts. The BP monitor rang loudest and grew in volume as Max’s blood pressure sank lower, to sixty-two.
“Should I call a code?” Lisa asked.
Julie had been thinking the same herself.
She needed that damn radiological read.
Julie’s composure began to fracture. The code blue seemed a likely course of action. She shot Lisa a fierce look.
“Get someone to call down to radiology and tell them we need that reading now! Fix whatever they have to fix, but get me that read! Lisa, tell me again, what dose of Levo is he on?”
“Thirty micrograms,” Lisa answered.
“Are you sure that’s the right stuff?” Julie asked.
Lisa looked at the bag and nodded.
“We’ve already given fluid,” Julie said as the calm returned to her voice. “Let’s get a second vasopressor going. This time use vasopressin.”
You are not going to die, young man. No way!
Max was groaning incoherently and sweating profusely. Lisa got the new medicine hooked up while the second nurse left the room to call radiology. She returned a few moments later.
“The system is back online. Radiology said no pneumothorax,” the nurse said, glancing at her note. “‘New dialysis catheter in place adjacent to previously seen subclavian line.’”
This struck Julie as odd. Typically the catheter for the vasopressors and the one for the dialysis would have been positioned opposite each other. There was a computer in Max’s room, and this time Julie was able to pull up his X-rays and read them for herself. The frontal X-ray showed that the lines were in fact overlapped, easy for her to see.
“BP is fifty-nine!” the tech reported. The alarms were really going.
Julie looked at Lisa. “Why did the radiologist put the dialysis line on the same side as the subclavian line for the vasopressors?” she asked.
Lisa thought before answering. “Max had a broken collarbone that ripped the subclavian vein, so that’s why they switched to the right. They capped the port and he was fine.”
A thought tingled. “Fine until when?” Julie asked, an edge to her voice.
“Um, for a while after we started the dialysis. I don’t know exactly how long.”
Julie studied those lines on the X-ray once more. It was uncommon but not unprecedented for the two catheters to be on the same side of the body. In optimal placement the catheter tips would be right next to each other, but on Max’s X-ray Julie observed a noticeable gap between them.
The image called up a memory of a time she ran out of gasoline while on a long ride with Sam. To get her bike started, Sam had to siphon the gas from his tank into hers using a tube he carried in a satchel for just such emergencies. The siphon did not function at all until Sam got the tube positioned properly, but once he did, the suction it generated was impressive.
Max was fine for a while after we started the dialysis … after …
Julie felt a surge of excitement. She had never encountered something like this, but those cath lines might be positioned in such a way to create a siphon inside Max’s body. If that were the case, the blood filled with the vasopressors needed to keep Max’s blood pressure up during dialysis was being siphoned into the very machine that was purifying his blood, removing all traces of the medication he needed.
“Shut off the dialysis!” Julie barked. “Shut it off right now! This is not the time to be dialyzing our patient. That can wait!”
“BP is fifty-five!” the tech called out.
Max’s eyes rolled back into his head and his mouth fell open as he became unconscious. All sorts of alarms continued to sound, and several more nurses and two residents rushed into the room.
With the push of a few buttons, Lisa shut down the machine. Almost immediately, Max’s blood pressure spiked to seventy. Then seventy-five.
Julie realized she had been holding her breath. She let out a long exhale. Max’s eyes fluttered open, but he was groggy, completely out of it.
“BP is up to ninety,” the tech said.
Julie let herself relax a little only when Max began to move his extremities spontaneously and became somewhat responsive. Lisa set her hands on her hips and struck a pose as if to say that she’d filled her quota of excitement for the day.
“How did you know, Dr. Devereux?” Lisa asked. “Even the radiologist didn’t think of that when he put in those lines.”
“Well, maybe he doesn’t ride motorcycles,” Julie said.
When it was obvious that Max had stabilized, Julie went out into the hallway. To her surprise she found Trevor lurking nearby, with a clear view of the action. He looked at his mother with awe, a look Julie had not seen since her son was six years old. It erased all of her anger over his disobedience.
“That was pretty amazing, Mom. You saved his life, didn’t you?”
Julie just smiled.
CHAPTER 4
Roman Janowski—Romey, to everyone who knew him—sat at his expansive desk fingering the embossed invitation. The black-tie celebration would honor Charles Whitmore as the “Hospital Administrator of the Year.”
Anger and resentment rose in Romey’s throat. Whitmore was a fraud, the exact sort of asshole John Fogerty sang about in “Fortunate Son,” one of Romey’s favorite Creedence Clearwater Revival tracks. Whitmore got the job at Boston General because his family had been at the center of Boston’s illustrious medical history since the 1850s.
Big deal, Charlie, thought Romey as he gazed out his massive office wi
ndows at the green emerald square of the hospital quad five stories below. Daddy got you a job running an internationally renowned medical center with arguably the best medical staff anywhere and a patient service area that includes every millionaire in the world, and so you succeeded. Bully for you!
Romey knew he was the real deal. White Memorial had been a second-rate hospital before he took over. By instituting some unique and unusual methods, he had managed to make the hospital one of the best-run medical facilities in the state.
“Anybody can do a Whipple procedure on a sheik with pancreatic cancer who will die in a year anyway,” Romey had said during a board meeting. “The real trick, the reason you pay me so well, is because I can take the bread and butter of medicine—arthroscopy, gallbladder removal, and pneumonia—and create a margin of fifteen percent. Let the other hospitals battle to attract top doctors who want their egos affiliated with a worldwide organization. I’d rather have enough funds to give bonuses to my physicians so they will do what it takes to improve our bottom line.”
Heads nodded, and no one objected to Romey’s raise—a raise that pushed his salary into seven-figure territory and gave him another seven in bonuses. With that kind of income, Romey could be short and bald, with a noticeable belly and ears like radar dishes, and still attract plenty of leggy blondes, including the two who were his current mistresses. Nancy, his wife of thirty-five years, was willing to accept her husband’s indiscretions in exchange for her cushy lifestyle as long as he had the courtesy not to flaunt the girls in her face. Romey obliged happily. He would do anything to keep Nancy from making good on her longstanding threat to divorce him in the most costly way possible.
Romey folded the invitation in half, then tore it in two. The difference between Romey and Charles Whitmore, Romey knew, was flash and renown. The time had come for Romey to step out of the shadows and build his empire.
He looked at the pile of folders on his coffee table and knew where to begin. Romey slipped on his headset and dialed the direct line for the president of Suburban West Medical Center.
“Allyson Brock’s office,” said the friendly voice on the other end.
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