Frost Bite
Hedge Mage and Medicine Book 1
SA Magnusson
Copyright © 2018 by SA Magnusson
Cover art by Rebecca Frank
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Contents
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Author’s Note
Also by SA Magnusson
1
In the Emergency Room—the ER—you get used to different noises. There’s the sound of monitors beeping, intravenous pumps beeping their alerts, the occasional siren from an ambulance pulling into one of the bays, patients shouting or crying—maybe even screaming.
Then, there are sometimes families doing the same, the nurses running in between, frantic, consoling them both. And it all combines to create the steady rhythm of the ER, a sound I’d become far too accustomed to during my emergency medicine residency. Despite that, the sudden alert for a ‘Code Blue’ was the one that always caught my attention.
Running toward the trauma bay, I was the first physician there. That was unusual.
The nurse working on the patient, an older, heavyset redheaded woman by the name of Joan, looked up when I entered. “What do we have?” I asked, grabbing my shoulder length black hair and tucking it out of the way.
“Dr. Stone,” she said, barely hiding the disappointment in her eyes. “Older man brought in by ambulance. Found unresponsive on the street. Hypothermia most likely.”
I stepped up to the bed and began my assessment, making a point of showing Joan I was competent. It was one of the ongoing struggles I had as someone who’d trained there and now worked as a fellow—though, even during a fellowship, I also served as an attending physician.
The older man had probably once been handsome, with graying hair and a distinguished chin. His body was cold already, his fingertips incredibly so, and although he had a rhythm on the heart monitor, his radial pulse was weak. He was well-dressed, wearing a nice suit that had been torn away for the heart monitor pads to be placed. Even his nails were manicured.
How could a guy like this have ended up hypothermic?
I glanced away when a noise in the room caught my attention. Two other nurses—a younger man named Josh, and Carrie, a nurse with several years’ ER experience—entered. And right away, they looked to Joan rather than to me for guidance.
It was difficult not to be too annoyed by that. It wasn’t that I was incompetent—I wasn’t—it was just that I wasn’t the doctor they wanted here. They all preferred Dr. Michaels, the trauma fellow, but she wasn’t the one there now. And I was.
“We need to focus on re-warming. Warm saline. Warm blankets. Call the lab, and—”
His monitor flatlined while I was talking.
“Shit,” I whispered. I’d kept my fingers on his radial pulse, but grabbed for a carotid pulse too, finding it absent. The Advanced Cardiac Life Support algorithm for asystole—pretty much a flatline, a cardiac arrest displaying no discernible electrical activity on the monitor—flashed into my mind, though it really didn’t need to. I’d been in hundreds of similar situations over the last few years, enough of them that the algorithm jumped to mind easily. The only problem was that every situation was at least a little different. An algorithm was a guidance, nothing more than that, but in situations like this, having that guidance was helpful.
Joan didn’t give me a chance to react, beginning CPR right away. She jammed her fists over the patient’s sternum, pumping down rapidly, and I didn’t need to count or even track the pace to know she was doing it at just the right frequency. Whenever I performed CPR, I always went back to the Bee Gees’ song, Staying Alive; it was how my first instructor had taught me, so the words rolled through my head unintentionally whenever CPR was carried out, by me or anyone else.
Now Carrie was in the midst of it, too, grabbing for the ambu bag and beginning to breathe for the man while Joan continued her compressions.
“Josh. Why don’t you go for the warming blankets and saline?” I said.
“That’s not the algorithm, Dr. Stone,” Joan cut in, her gaze piercing through me. “For asystole, you need to—”
“I know what the algorithm says,” I answered. “And we’ll make sure to get epinephrine into him, but if this is hypothermia, we have to correct the underlying cause.” I held her gaze, unflinching, and she said nothing while continuing her compressions. “Can somebody get the epi off the crash cart?”
I glanced at the clock, looking at our time. The algorithm suggested compressions and medication administration every so many minutes, and in somebody with hypothermia, we had just a little bit more leeway. Some cardiac patients we actively cooled in order to protect their hearts; it was the same thing we’d begun to do with stroke victims, seeing higher survival rates for both. Now, if we could just warm this guy up, there was a chance we could save him, but I had to get the others to work with me rather than against me.
The heart monitor continued to beep, a reminder of the patient’s lack of rhythm.
As much as I wanted to shut it off, it was helpful to have it as background noise, if only because it would help us know when the patient regained his rhythm.
One of the nurses administered the epinephrine, and I glanced at the clock. We could do it every three minutes. One of the anesthesiology residents strolled in, and I looked over at him.
“Hypothermia. Asystole. Down for unknown period of time,” I said to him.
The anesthesia resident pushed dark-rimmed glasses up on his nose, running a hand through his hair, and glancing at the monitor. “Need me to intubate, or not?”
“For hypothermia, we might be working on him for a while.” When the man didn’t do anything, I shook my head. “That’s a yes.”
He shrugged and headed toward the crash cart to begin gathering supplies.
“You need someone to swap out for you, Joan?”
She shook her head. I couldn’t tell if she was getting tired or not, and when it came to Joan, it was possible she’d be able to continue her compressions without letting up.
Josh had returned with warm saline, hooking it up and beginning to flood it into our patient. Warming blankets were placed around the patient’s legs and upper body, though they left his torso open for Joan to continue her compressions. The anesthesiologist began to intubate, which left me watching the heart monitor, ensuring everyone else was doing their jobs as they were supposed to. At the same time, I wanted to know more about what happened to this man.
“Do we know anything about him?” I asked.
“He was brought in like this. They attempted to warm him, but they found him near the river,” Josh said.
The river, in this case, meant the Mississippi, and at this time of the year in Minneapolis, it would be icy
cold. “So, did he fall in?”
I glanced at the clock. It had only been two minutes. The monitor remained showing asystole, which meant that medications and treating anything reversible were all we had. Considering the only reversible cause I had at this point was the hypothermia, that was the primary focus, but that didn’t mean it could be my only one.
“EMS didn’t say anything about pulling him out of the river.”
And he didn’t look as if he’d been sopping wet. His clothing was dry. Maybe he’d been drinking too much the night before and passed out?
Another minute passed.
“Give him another milligram of epinephrine,” I said. I glanced at Joan. “You need to switch.”
“I’m okay.”
“Switch, Joan.”
One of the other nurses that had joined us—a dark-haired nurse named Riley with a pixie cut—took over for Joan. I ignored Joan glaring at me; I could deal with that, especially as the entire purpose of us being there was to save the patient, not to have her ego managed.
“Epi’s in,” Josh said.
I watched the heart monitor. It felt like all we could do was wait. In this case, if he didn’t regain his rhythm, there might not be much else we could do for the guy. And with hypothermia, I wasn’t about to abandon the resuscitation effort until we’d gotten his temperature up; so, he remained in asystole.
While staring at the monitor, something changed.
No longer did it seem to be in asystole. Now, it looked to be a fine ventricular fibrillation.
“We have a shockable rhythm,” I said. I ignored the way Joan peered at the monitor, almost as if she intended to second-guess me. “Why don’t we charge to 200 joules?”
While we were preparing, I checked the placement of the defibrillator pads. In order to do so, I had to move his shirt off to the side, and when I did, something caught my attention.
It was a marking, something like a tattoo, but I’d seen a shape like that before.
I frowned, staring hard at it. Had I seen it even two years ago, I might not have recognized the importance of a marking like that, but in that time, I’d come to realize the world was not as I’d once believed. Creatures I’d once thought were nothing more than mystical existed in our world. Not only were there mages, people with the power to cast powerful spells, but there were shapeshifters and vampires, and perhaps a dozen other different creatures the movies made out to be real.
My best friend had magic in her, too. It was because of her that I knew it existed, and while I had no magic of my own, I’d gone with her a few times when she’d run off to battle within her world.
And this marking was a symbol. Not just any symbol. A magical symbol.
Who was this guy, then?
Furthermore, having a marking like that, meaning that he had some connection to the magical world, made it more likely that what had happened to him was not quite as simple as I’d been hoping. More likely than not, it would have something to do with his connection to that magical world.
And I wouldn’t have any answers unless we managed to save him.
And so, we had to; things were that simple.
The steady whine of the defibrillator charging up added to the noise within the room. It was one more thing there that demanded attention, and when it was fully charged, Riley stepped back.
“I’m clear. Everyone clear. Shocking.” I pressed the discharge button, and the patient convulsed as the electrical charge jolted through him.
I reached for him and checked for a pulse. Still nothing.
Looking at the monitor, it still appeared to be in a fibrillation pattern.
“Let’s charge to 200 joules again.” The steady whine of the defibrillator built once more. “And grab amiodarone. We’re going to give a three hundred milligram bolus.”
When the defibrillator had charged, Riley stepped back.
“I’m clear. Everyone clear. Shocking.”
After pressing the discharge button this time, the patient convulsed again as the electrical charge hit him, shocking through his body afresh.
I glanced at the monitor as Riley returned to CPR.
The heart rhythm changed; now, it had become a sinus bradycardia—a slow heart rate, but a normal kind. Checking for a carotid pulse, it was there but faint.
“Let’s give half a milligram of atropine,” I said. Riley glanced over at me and I shook my head. “And keep up CPR until we have him back.”
Once the atropine was in, I watched the heart monitor, and it didn’t take long for his heart rate to increase from the low thirties up into the sixties. I checked his carotid pulse and found it had returned. Moving to check a radial pulse, that had also come back.
“We have a pulse,” I said.
Riley took a step back, wiping her arm over her forehead.
I glanced up at the time. How long had he been down? We’d had two cycles of epinephrine, then gone through a fibrillation pattern followed by bradycardia. Probably no more than ten minutes, all told, though that didn’t count the time he’d been down before he even came into the ER. It was possible he’d been unconscious during that time but with restricted blood flow, making it entirely possible he’d end up with some brain damage following all this. We called it anoxic encephalopathy—and depending on how long he had suffered from it, it was potentially irreversible.
Then again, if this guy had magic in him, he could surprise us. I’d seen how those with magical abilities were able to come back from injuries that shouldn’t be possible to come back from, and so he might still restore himself.
“Still want the amiodarone?” Josh asked.
I wasn’t entirely sure what the right strategy was. “It’s probably not a bad idea.”
Pulling the shirt aside, I stared at the marking there once again. If there weren’t so many people around, I’d have been tempted to pull out my phone and take a picture of it, but I wouldn’t be able to justify that very easily. I could argue I was taking a picture for his records, but even that didn’t fit. The only time that we ever photographed anything, happened when we were concerned about wounds and rashes.
I scanned the inside of the room before my gaze settled on one of the interns. “Dr. Gillespie, why don’t you take over?”
He shrugged. Matt Gillespie was a little older than our usual residents. Most of the time, we got residents straight from medical school, and most of them went to medical school directly after undergraduate training, meaning they were in their mid-twenties when they came to work with us. Matt was a little older, though, having served in the military for a few years first. He didn’t talk about it much, though there were rumors he’d served in the Middle East.
“Anything to do other than get him warmed up?” he asked.
“Keep an eye on his rhythm. If he begins to have any fibrillation, we may need to continue to dose him with amiodarone. Run whatever tests you think are necessary to see if there might be another underlying cause for him ending up here.” Well, I knew what I’d order, but that wasn’t what a new ER intern needed; he needed an opportunity to practice what he was learning. The patient was stable, so it would be unlikely he’d miss anything too crucial, but even if he took too long, I’d make sure he ordered all the right tests. With the electronic medical record, it was easy enough to do from afar.
“Got it, boss.”
I shook my head. “Not boss.”
“No? Would you have me call you something else?”
I eyed him for a moment. There was no denying Matt was an attractive man. He had a square jaw and broad shoulders, and I never knew if it was a matter of the scrubs not fitting quite right or him just filling them out just right, but he was easy on the eyes. “How about Dr. Stone?”
He flashed a smile. “Dr. Stone it is, then.”
I shook my head, heading out of the trauma bay and over to the nurses’ station to document everything. Taking a seat, I grabbed a scrap of paper and scratched the symbols I’d seen onto the page. I could ask Kate
later if they meant anything, and seeing as how she was in fellowship here, it wouldn’t be a privacy violation to share with her that the man had come in. Besides, ER docs always liked to share cases with each other, especially the strange ones.
“What are you doing there?”
I glanced up to see Brad Roberts leaning on the counter, his gaze drifting around the ER. We’d been residents together, and he’d finished his fellowship right as I was starting mine, staying on at Hennepin General Medical Center as an attending physician. As much as I hated to admit it, he was more hands-on than I would’ve expected.
His gaze lingered on one of the younger nurses. Riley, I noticed. Maybe he was a little bit too hands-on there, too.
“Just a tattoo I saw on a patient,” I said as he eyed what I was drawing.
“Yeah? Thinking about getting one?” Brad looked down at me, his eyes dropping to my breasts before coming back up to my eyes.
I glared at him a moment, but he ignored it. “No, but since I don’t know what happened to him, I figured that anything I can learn about what might’ve happened to him is helpful.”
“Helpful? That’s what we have interns for, Jen. You don’t need to go digging about for information. The sooner you get used to that, the easier it will be when you become an attending.”
“Who says I’m going to be an attending with residents? Some of us actually don’t mind seeing patients, Brad.”
“You’re doing a fellowship. You’re going to end up in academics.”
I shot him a look, ignoring the comment. He didn’t know, anyway. It was something I didn’t share with too many; I’d taken on an ultrasound fellowship, wanting to get more skilled with the techniques, but it also served an additional purpose of giving me more time before I had to make a decision about my long-term career. I didn’t know what I wanted to do or what type of facility I wanted to practice in. Although I enjoyed the complexity of emergency medicine, there were parts of it I didn’t love.
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