Death Rounds

by Peter Clement

  Janet’s eyes widened even further with panic as they pushed her down and grasped her head between their hands.

  “I’m here, Janet; this will help you,” I reassured, trying vainly to sound calm. Inside I didn’t know if I could do what I had in mind. Fear of failure was constantly present in any race to win back an airway or recapture a heartbeat, but the terror of losing Janet jangled my thinking, unsteadied my hands, and corroded my nerve.

  Atropine would reopen her airway by blocking the neuronal pathway that was keeping the larynx in spasm, but the IV route took time. A resident handed me the syringe that I requested, the inch-long needle glinting under the ceiling lights. I squirted out a few ccs of saline, snapped open the brown vials, and drew the atropine up into the cylinder. Then I grabbed an alcohol swab from the night-stand and, to the gasps of the residents, ran it over the front of Janet’s larynx. I was going to inject directly into her neck. I’d never treated laryngospasm this way before, but I’d put needles into the trachea to freeze it for intubations of head trauma cases and I’d shoved atropine down endotracheal tubes during cardiac arrests. I couldn’t think of anything that would work faster.

  “Janet, if you can hear me, close your eyes, love!” I commanded, my voice shaking as I located the landmarks of the cricothyroid membrane—the thin “window” covering the opening where access to her windpipe would be easiest—and brought the needle point up, pressing it against the overlying skin. She seemed to stare at it and increased her efforts to break free. “Hold her,” I yelled.

  They steadied her movements, and I shoved the tip of the needle hard enough to penetrate her skin, pulling gently back on the plunger as I advanced the point. A tiny stream of bubbles flowed up into the cylinder indicating I was through to her airway. I angled the needle toward her larynx, pushed the plunger as hard as I could, and yanked out the emptied syringe.

  Ten seconds passed. Her movements grew feebler and her eyes, still open, fluttered up under her lids.

  From the resuscitation cart I grabbed a black rubber ventilating mask, connected it to an oxygen outlet, and pressed it to her face. I squeezed the attached bag in an attempt to force air down her lungs, but there was resistance against my hand. It meant her larynx was still closed.

  Another ten seconds passed. Her eyes were nearly shut, her skin was blue, her limbs were starting to jerk.

  “Get ready to sedate and paralyze her,” I ordered, but my own voice sounded far away while my panic continued to mount If she seized, her teeth would clamp together and her body would start heaving with convulsions so powerful that we’d break her bones if we tried to hold her down. We’d only be able to intubate her after the drugs or the severe lack of oxygen broke off the pulsing muscle contractions. That might take more than a minute, enough time to put her into cardiac arrest.

  I squeezed the bag once more. Again the resistance remained so firm I couldn’t budge my fingers. Then I felt a release, the bag responded to the pressure of my hand, and I saw Janet’s chest rise. I squeezed again and again, each time pushing oxygen more and more easily through her opened airway and into her lungs. Over and over I ventilated her, watching her skin quickly turn back from blue toward pink. Soon she was stirring, moaning, and shoving the mask away as she rapidly resumed breathing for herself. She coughed repeatedly, but didn’t expectorate much. When I listened to her chest, she was wheezing, but the sounds were distributed uniformly, probably from the infection, and there was equal air entry into the bases of both right and left lungs. It would take an X ray to be sure, but I didn’t think she’d aspirated.

  When she finally stopped choking enough to speak, she looked at me incredulously and croaked, “You put a bloody needle in my neck!”

  Tears came to my eyes as I laughed to keep from crying. “And you scared me half to death,” I said, leaning over and putting my arms around her.

  The residents shuffled nervously and the nurse looked on disapprovingly. I ignored them all. They’d account to me later, I swore, but I didn’t give a damn for anything at that moment except to feel Janet against me. Yet I was also thinking like a physician. Her breathing was still labored, presumably from her developing pneumonia. While I held her, I reflexively checked the IV, making sure her movements hadn’t dislodged it. I noted the label on the overhead bag read Erythmmycin. I was resetting its flow rate with one hand when I saw Cam standing at the door watching us all.

  He was wearing protective gear, but his eyes above his mask were dilated and dark with rage, exactly as I’d seen them earlier this morning. For a second I thought it was the sight of me again that was making him furious, but he swung that fierce gaze toward the residents, “What the hell have you been doing to Dr. Graceton!” he screamed at them.

  The bunch of them seemed to flinch, but one in particular averted his eyes and tried to edge behind the others. Cam must have seen the movement as well, because he immediately singled him out. “You! Tell me what happened or I’ll suspend the lot of you and make sure you never set foot in this hospital again.”

  The young man froze, and the others moved away, leaving him standing alone in front of Cam. His face reddened above his mask all the way to the upper tips of his ears.

  “Well?” demanded Cam, towering over him.

  “I thought we could do a simple aspirate with a small catheter,” he began to explain, sounding plaintive. “I did it all the time on patients in recovery during my anesthesia rotation—”

  “Those patients are already sedated and intubated!” roared Cam. “What the hell made you think you could do the same to an alert patient?”

  “None of us had experience with midazolam to put her to sleep, and I figured without her intubated we shouldn’t freeze her gag reflex—”

  “Jesus Christ, lord save us from what you call thinking. And the rest of you did nothing to stop this genius from nearly killing Dr. Graceton?” he yelled, turning to the others. “How dare any of you stand by and not attend to a patient’s pain before an invasive procedure—any invasive procedure at all—you understand me! You damn well don’t hurt patients. I’ve half a mind to put tubes down your throats and let you experience what you just put Dr. Graceton through. Disgraceful! The lot of you are on probation as far as I’m concerned.”

  Now all the residents flushed crimson above their masks. Some grew wide-eyed while others glared furiously at the one who’d performed the suction.

  “You don’t go near a patient of mine without discussing it with me first,” continued Cam, his voice lower, but his tone as hard and unforgiving as ever, “and you don’t write an order without it being countersigned immediately by a staff person. In forty-eight hours you bozos will present what you did here today to a special grand rounds on laryngospasm in front of all your colleagues in our residency program. Now get out of my sight!”

  They filed out of the room without looking at each other. Some were so dazed they had to be reminded to remove their gowns and masks at the door while the others flung their clothing into the disposal bin and stomped off. The nurse quietly tried to follow them, but Cam wasn’t finished with her either.

  “Hold it,” he told her brusquely. “You’ve got some explaining to do as well. What were you thinking of, letting those clowns proceed the way they did? They were obviously in over their heads. Who even ordered a tracheal aspirate?”

  She stopped moving toward the door and turned to face him. I only now took a real look at her. She was dark-haired with a few strands of gray, tall, and as far as I could tell rather slim looking, but whatever physical attributes she had hidden under her costume, I’d already decided that her disposition was nasty. A name tag over her left breast told me we should call her Miss Brown. “It’s your own policy. Dr. Mackie,” she replied in a sweet singsong tone that sounded belligerent

  Cam exploded, “Doing tracheal aspirates on unmedicated patients is not my—”

  “Getting proper sputum samples is, especially since we’ve had so much trouble with infected personnel latel
y. I saw a note in her chart saying the sputum sample they got in ER was scanty.”

  It was Cam’s turn to go beet red. “Legionella, as you should know better than anyone. Miss Brown, doesn’t produce much sputum.” His voice vibrated with the same barely controlled anger I’d heard him direct at me this morning. “My guidelines for getting proper sputum samples are meant to be applied with clinical judgment.”

  “I’m only a nurse. Dr. Mackie. It’s not up to me to know which rules you want used and when—”

  I felt Janet lift her head off my chest. “That’s a crock. Cam. I told her that Harold Miller had taken samples in ER and that the scanty sputum was to be expected. She refused to listen.” Even weakened by what she’d been through, Janet’s tone had the scalpel-sharp bite she saved for unpleasant truths.

  “Why, Dr. Graceton,” the woman protested, “you can’t expect to give orders when you’re a patient—”

  “But I can give orders. Miss Brown,” bellowed Cam, “and since you’re so good at following rules, here’s one for you. Until I can haul you into a morbidity review about what you did here, you’re no longer to have anything to do with nursing Dr. Graceton. Come with me, and I’ll arrange it with your supervisor! By the time I’m through with you, you’ll never work in an ICU again!” He stormed from the room, practically ripping his protective clothing off at the door before heading to the nursing desk.

  Brown flashed a murderous look at Janet, then followed after Cam. She flung her own gown, mask, and gloves on the floor beside the designated bin.

  “Jesus Christ” was all I could say. I’d seen bungling before—what the residents had pulled was the sort of near disaster that happened from time to time, unfortunately, in a teaching hospital—but Nurse Brown was outright scary. She deserved everything that Cam had threatened her with, if not outright dismissal. The residents would probably learn from this. What Cam had in mind for them made it unlikely any of them would ever screw up doing tracheal suction again. But I doubted any amount of disciplinary action would ever make Brown into the sort of nurse I’d want near Janet, me, or anyone else.

  Yet seeing Cam once more fly into a rage, even over a serious infraction, I was left feeling ambivalent and uncomfortable about him. He was a chief in this hospital. He knew a public blowup could badly disrupt a critical-care unit and interfere with the staff’s calm and concentration. No one was immune to being angry—I’d also wanted to scream at both Brown and the residents—but his performance only added to my doubts about his tendency to lose control. My first impulse was to transfer Janet away from the bunch of them.

  “Janet, let me get you out of here and to St. Paul’s, where I can assure you no one like Brown or these residents will get near you.”

  “You’d deliver me to the hands of Gary Rossit? No thank you.”

  The recollection of him sitting beside Hurst at Death Rounds and grinning up at me flashed through my mind. “Of course not,” I quickly agreed. “Being around him is totally out of the question. But whoever the Phantom is, you’re vulnerable here. I can get someone else--”

  “Stop it, Earl!” She leaned back out of my arms and looked me in the eye, a stern expression crossing over her face. “Stewart Deloram wasn’t safe at St. Paul’s, and I told you before, running away is not an option.” She took a breath, as if to continue speaking, then seemed to change her mind. She put her head back against my chest. “As for the residents and nurses,” she added, sounding a little softer, “I’m sure Cam will make certain there won’t be any more screwups by them. Besides, it’s my infection that’s got me scared now. Despite Stewart Deloram doing well, I don’t know how bad I’m going to get, and I want Cam taking care of me.”

  I continued to stroke her hair and cradle her against me, glad she couldn’t see the tears that I felt brimming in my eyes. Her straightforward admission of yet another of my fears—that no one knew for certain how ill she might become—nearly made me lose the puny grip I’d managed to keep on my emotions.

  As I clung to Janet, I looked through the glass in the front of her room and watched Cam standing in the nurses’ station with his back to me. The overly tall man was engaged in an animated conversation with Brown and another nurse who I presumed was the supervisor. Whatever I thought Brown deserved, I continued to be troubled by the way he kept waving his hands about while stabbing at the air between them with his index finger. Obviously he was still beside himself with fury. The image of his face at Death Rounds, distorted with rage and inches from my own, wasn’t hard to recall. I’d given him the benefit of the doubt then. It was altogether something else to suddenly have him as Janet’s physician now that she’d been attacked. Even when he was focused on the residents, I’d felt disturbed by being in such close quarters with him.

  Perhaps it was the shock of having had to resuscitate my own wife, perhaps it was having seen my best friend put near death not twelve hours earlier, perhaps it was the frustration of not being able to prove this killer even existed, certainly it involved my instinct to protect those I loved above all else—whatever the blend of reasons, it was a potent fuel for a rush to judgment.

  In a flash any inclination I had to be balanced and fair was gone. Suspicions that I’d tried to keep in check resurfaced with a vengeance and images I’d tried to suppress or explain away flew to mind—Rossit and Hurst glibly chatting before the remains of Phyllis Sanders, the powerful business group ringing Hurst as he manipulated his way through the amalgamation meeting at St. Paul’s, a shadowy figure creeping up on Janet

  “Do you have any idea who might have gotten close enough to infect you?” I asked through clenched teeth trying to keep my voice steady and my stomach down.

  “No,” she replied meekly. “I’ve been racking my brains about that. To give me Legionella, whoever it was would have had to make me inhale a contaminated mist or spray, but no one’s been near me and me alone with anything even resembling an aerosol. At other times, when I’m in close quarters with staff members doing procedures, I’m wearing a mask, gloves, and a gown.” She paused and after a few seconds added, “It’s so frustrating, knowing that sometime in the last few days I must have come face to face with the Phantom!” Then she started to cry.

  I was ready to kill whoever had attacked her.

  Turning from the window and nuzzling my head against hers, I asked, “Does Cam always get as mad as he did just now? I’ve never seen even a hint of that kind of temper whenever I met him with you.” Thinking the unthinkable was no longer out of bounds.

  She sighed, then took a few seconds to answer. “Don’t judge him too harshly. He’s fanatical about kindness to patients, the way we all should be, but for him, well, it’s a special cause.”

  I felt a chill run through me.

  “What do you mean a special cause?” I persisted, finding it increasingly hard to keep my voice even.

  “It’s personal, Earl,” she replied, “something he once told me in confidence that he doesn’t like talked about. It’s got nothing to do with the Phantom, trust me.” She was no longer crying, but she still sounded shaky. I don’t think she suspected the impact her words were having on me.

  The chill became a prickle of dampness on my back as I recalled some other words Harold Miller had said at the end of our conversation on my way up here. At the time I was so desperate to see Janet I’d hardly paid attention. Dr. Mackie ‘s a real stickler about not hurting patients.

  I considered very carefully what I was about to say. “Janet, I know that you don’t think I’m good at speculating and that you have a great deal of confidence in Cam, but his behavior this morning at Death Rounds was bizarre.” I paused, waiting for her protest at even a hint of my being about to speak negatively of her friend, but I felt her body stay relaxed against me. Cautiously, I continued, “He was furious that I went into the archives last night and looked through all the old charts of the Phantom’s first victims—”

  “You what!” she exclaimed sharply, pushing herself away from me
again. She immediately began coughing.

  I quickly tried to explain. “Yes, I went through those files, Janet. I had to. After Michael was admitted—”

  “Michael?” she croaked, barely able to find her voice as her coughing spell continued. “What do you mean Michael was admitted?” She was sitting bolt upright now.

  Damn! In all my concern for her I’d forgotten she didn’t know about Michael. I certainly hadn’t wanted to spring the news on her like this. I reached for her hand. The gesture made her look doubly alarmed. “Janet, we admitted Michael last night in septic shock from what I’m sure is Legionella,” I told her, watching her eyes widen. “There’s no sign of staph, but as of this morning he was still unconscious and on a respirator.”

  She uttered a little cry. For the next few seconds all she said was “Oh no” over and over while her horrified expression grew until her blanched face looked like a silent, open-mouthed mask. “But how?” she finally demanded. “Where?” Her voice was high and tremulous. “Any time we got near any organisms in the lab we were in protective gear. Cam and Miller made sure of it. They’re both adamant about that kind of thing, especially now. Oh, why did I get him into this!” she wailed.

  I took her back in my arms and rocked her.

  “What about Donna?” she asked.

  “Shaken but holding up when I left her last night.”

  Between more of her coughing bouts, we sat in silence, hanging onto each other. I wanted only to let her rest and comfort her, but comfort her with what? My thoughts continued to rage with questions about Cam, and I was increasingly convinced she’d be in danger if she stayed here. But without hard evidence I was unlikely to budge her belief in him.

  “Janet, about Cam,” I began again, “you’ve got to listen to me. I swear he’s covering up about the Phantom.” This time I pressed ahead, not wanting to give her the opportunity to interrupt. “Not only is he trying to keep us from drawing attention to the attacks from two years ago, but when I got Williams to instigate a search of the asylum, he seemed most unhappy about that as well. You tell me, if he’s not got something to hide, what’s he afraid we’ll find?”