Royal Pains

by D P Lyle

  “That’s it,” I said. “You should feel better in a minute.”

  Jesus seemed to breathe freely for the first time. “Is better already.”

  Divya and I rolled him onto his back again. He winced and grabbed his belly with both hands. Sweat trickled into one eye, causing him to blink. He swiped it away with the back of one hand. His breathing became more labored.

  I listened to his lungs again, still clear, still inflated and working well. One concern in any rib fracture is a pneumothorax caused by the broken rib puncturing and collapsing the lung. That wasn’t the situation here.

  I moved to his abdomen, which I could now examine more easily. As I pressed my fingers into the left-upper quadrant, he moaned. I could now feel a mass in the area.

  “I think he’s ruptured his spleen.”

  Divya checked his blood pressure. “I’m getting eighty over fifty. Pulse is one thirty.”

  I looked up toward Ellie and Jackie. Sam had joined them. “Sam, call nine-one-one.”

  Sam turned and hurried inside.

  “No hospital,” Jesus said.

  “Jesus, we don’t have any choice. I think you’ve ruptured your spleen and you’re bleeding into your abdomen. If we don’t get you to the hospital and get it fixed, you’ll bleed to death.”

  His level of consciousness was dropping. His head rolled from side to side and he murmured, “No hospital.”

  Divya started an IV. “I’ve got a liter of lactated Ringer’s.”

  “Run it wide open,” I said.

  My cell phone buzzed. I answered. It was Nathan Zimmer. He sounded distressed. He spoke rapidly, telling me he was having chest pain and was short of breath.

  “Calm down, Mr. Zimmer. I want you to call nine-one-one.”

  When it rains, it definitely does pour.

  Divya looked at me with a raised eyebrow.

  “I’m not going to call the paramedics,” Nathan said. “I want you to come over here and tell me what’s wrong.”

  “I’ll be glad to do that, but I think you should call now. And I want you to chew an aspirin.”

  “I’ll take the aspirin, but I’m not calling the medics.”

  I heard sirens in the distance. I looked down at Jesus. He was awake again and his breathing was less labored.

  “Hold on just a second, Mr. Zimmer.” I muffled the phone against my chest. “Check his blood pressure again.”

  Divya did. “Better. It’s ninety-five over sixty.”

  I heard commotion up on the patio and turned. The medics had arrived and were carrying a stretcher toward us.

  I pressed the phone to my ear again. “Okay, Mr. Zimmer. I’m on the way.”

  “Hurry up.” He disconnected the call.

  “What was that?” Divya asked.

  “Nathan Zimmer. Having chest pain. He’s refusing to call the medics, so I’ll have to go see him.”

  “I’m not surprised. He probably thinks he can’t be away from his phone and computer long enough to go get medical help. And he’s probably smoking right now.”

  I told the medics that Jesus had a couple broken ribs and probably a ruptured spleen. They placed an oxygen mask over his face, hooked him up to a cardiac monitor, and loaded him on the stretcher.

  “No hospital,” Jesus said. “They’ll send me back to Mexico.”

  “Jesus, right now no one cares whether you’re here legally or illegally. Understand? You don’t have a choice.” He started to say something, but I stopped him. “If we don’t get you to the hospital and get this taken care of right now, you’re going to die. Understand?”

  He nodded.

  “Let’s roll,” I said.

  Chapter 23

  While accelerating, braking, and sliding through turns as if she were in the Monaco Grand Prix, Divya brought me up to date on Nathan Zimmer’s history. During a lull in the story, I made the mistake of suggesting she might want to slow down. Actually what I said was, “Are you trying to kill us?”

  “No. I’m merely responding to an emergency call.” She jumped on the accelerator a little more forcibly.

  “Try to avoid trees.”

  She frowned at me. “You sound like Evan.”

  Ouch. I shut up and held on.

  By the time we reached Nathan’s house, smoke drifted from the brakes and heat waves danced above the hood. I stepped out on wobbly legs.

  “Next time I’ll drive, Dale.”

  She lifted her bag from the backseat. “Dale? Who’s Dale?”

  “Earnhardt. Famous NASCAR driver. Died when he plowed into a wall.”

  “In case you didn’t notice, I hit no walls.” She slung her bag over her shoulder. “Or trees.”

  “Sometimes luck is on your side.”

  “Maybe I’m a better driver than Dale.”

  I had no comeback for that.

  Todd, Nathan’s assistant, led us through the house and out to the patio. On the way he told us that Nathan seemed worse than he had been just a few minutes earlier. More pain and very short of breath. He had tried to convince Nathan to let him call 911, but he had refused, saying it was just indigestion from the chilaquiles he had had for breakfast. Todd argued, but Nathan, “the most stubborn man I’ve ever known,” said he’d wait until I arrived.

  Todd’s diagnosis?

  “I think he’s having a heart attack. My father had three of them before he died, so I’ve seen them before.”

  Todd pushed through a large glass door that opened to the patio. We followed. Nathan reclined on a lounge chair, cigarette hanging from his mouth. Sweat slicked his face, his shirt damp from perspiration. An open laptop and a cell phone sat on the patio next to him.

  “What did I tell you?” Divya said, indicating the cigarette.

  “It’s about time,” Nathan said. “I could’ve died waiting for you.”

  I yanked the cigarette from his mouth, dropped it on the patio, and crushed it with my shoe. “I’m Dr. Lawson. Do you think smoking right now is a smart move?”

  “I was nervous. Smoking calms me down.” He laid a clenched fist on his chest. “Didn’t help this darn pain much, though.”

  “Gee, I wonder why not.”

  Divya inserted an IV and hooked up a bag of halfnormal saline. I dragged a chair over and she hung the bag from its back. She then began attaching EKG leads, beginning with his ankles and wrists.

  “Did you take the aspirin like I said?” I asked.

  “That didn’t help either.” He looked at Divya. “And those bloody patches and that gum don’t help at all. I’ve tried both and they just make me want a cigarette more.”

  Divya had finished hooking up the limb leads and now unbuttoned his shirt so she could position the EKG’s precordial leads. Three nicotine patches decorated his chest.

  “What are these?” I asked.

  “Ask her. She told me to use them.”

  I now noticed that he had gum in his mouth. “Wait a minute. You put on the patches AND you’re chewing gum?”

  He nodded.

  “And smoking,” Divya said.

  Nathan looked at her. “I told you the patches weren’t working.”

  I peeled off the nicotine patches and had him spit out the gum.

  Divya now had his shirt completely undone, revealing two more patches on his abdomen. She removed those.

  “I figured the more the better,” he said. “Isn’t that how it usually works?”

  “That’s not how this works. Nicotine is dangerous. Particularly in someone who could have coronary disease.”

  “I never had that before.”

  “Not that you knew of, anyway,” I said.

  Nicotine does several nasty things, like constricting, or narrowing, arteries, including the coronary arteries, which supply blood to the heart. If someone already has atherosclerotic narrowing of these vessels, any further constriction can reduce the blood supply to the heart muscle and result in tissue damage and death. This is what happens in a heart attack. In medical terms a myoca
rdial infarction, or MI. By any name it can be deadly.

  Divya finished the EKG tracing and handed the strip to me. It showed that Nathan was indeed in the midst of an acute MI, one that appeared to involve the front, or anterior, wall. Not the best place. MIs in this area tend to do the most damage and are the most life threatening.

  “How is the pain now?”

  “Worse than when I called you but better than it was ten minutes ago.”

  “You’re having a heart attack. We’ve got to get you to the hospital.” I looked at Todd. “Call the paramedics right now.”

  He glanced at Nathan as if awaiting permission.

  “Now,” I said.

  Todd flipped open his cell phone.

  Divya retrieved a spray bottle of nitroglycerin from her bag. “Open wide.” Nathan did and she pumped two quick sprays into his mouth. “Close your mouth and let it absorb.”

  “When did this start?” I asked. “The pain?”

  “Maybe an hour ago. It started in my jaw. I thought I had a toothache or something like that. But then it moved down to my neck and chest, like it is now.” He opened and closed his left fist a couple of times. “Even my arm feels heavy and numb.”

  “What did you think this was?” I asked. I always ask this question. Particularly of men who are great deniers. I’ve heard some outlandish diagnoses. Everything from insect stings to allergies to sleeping on the wrong side to cold air from a nearby window air conditioner to bad chili. Nathan fit the last category.

  “I had chilaquiles for breakfast. I thought that was it.”

  “Really? That’s your story?”

  He sighed. “Okay. You win. I thought it might be my heart.”

  “You sure this has been going on for less than an hour?”

  “About that. It sort of comes and goes. Not really gone, more like it would get better and then worse. Back and forth.”

  “That’s because there’s a clot sitting in your artery that’s getting bigger and smaller. As the clot grows larger, it blocks the artery more completely and the pain increases. Then the body starts destroying it, and as it gets smaller, the pain lessens.”

  “Heparin. Ten thousand units,” Divya said. She injected the drug into the IV line’s side port.

  “What’s that?” Nathan asked.

  “A blood thinner. Helps reverse the clotting.”

  “Why did it clot in the first place?”

  “A plaque, a cholesterol plaque, in your artery cracked. The body doesn’t know the difference between a cracked plaque and a gunshot wound. All it sees is a breach in the system. And just like there’s no screen doors on a submarine, the body knows to patch up any breach. So it forms a clot to seal the crack. Unfortunately, the clot can grow large enough to block the artery and cause a heart attack.”

  “That doesn’t make sense.”

  I smiled. “The body also makes certain enzymes that destroy the clots and that’s why the clot gets bigger and smaller.”

  “Sounds like a screwy system to me. Like the body can’t decide what to do.”

  “It’s actually very elegant. And necessary. If you cut your finger, the blood in that area clots, which is a good thing. Keeps you from bleeding to death from a minor injury. But what’s to keep this process from spreading through the entire system and clotting all the blood?”

  “Those enzyme things?”

  “Exactly.”

  He thought about that for a minute and then said, “It is clever.”

  “I can’t take credit for it. I didn’t invent it.”

  “No wonder medical school takes so long.”

  “Yes, it does.”

  “I’m glad you didn’t cut classes the day they talked about heart attacks.”

  I laughed. “I was definitely there on heart attack day.”

  Todd had walked away to call the paramedics and now came back toward us. He snapped his phone closed. “They’re about twenty minutes away.”

  “Any reason he can’t get tPA?” I asked Divya.

  “No history of severe hypertension or of a previous stroke. His blood pressure right now is one thirty over seventy.”

  “You’ve never had ulcers or nosebleeds or problems with bleeding during surgery?” I asked Nathan.

  “Don’t know about surgery, since I’ve never had any, but no to everything else.”

  “How much do you weigh?”

  “Why?”

  “So we can give you the right dose of this medication.”

  “What medication?”

  “Remember that clot we talked about? This drug breaks it up.”

  “I had a business associate once who got that and bled like crazy.”

  “That can happen. It can also abort this heart attack you’re having.” I sat down on the edge of the lounge chair next to him. “Listen to me. This heart attack. It’s a big one. We have to get you to the hospital so a cardiologist can open the artery up. But every minute that goes by, more damage is being done. That’s damage that can’t be reversed. This drug will save heart muscle and that’s the name of the game. How well you do down the road depends on what we do right now.”

  “You aren’t much for sugarcoating, are you?”

  “Not in a situation like this. I know you’re scared, but just let us do what we need to do and everything should work out fine.”

  “I’m not scared. I just don’t have time for all this.”

  “There’s never a good time for a heart attack,” Divya said.

  Divya drew up the tPA, tissue plasminogen activator, a clot-busting drug, and handed me the syringe. I inserted the needle into the IV line.

  “Here goes.” I pressed the plunger.

  “Will I feel anything?”

  “Hopefully, this’ll make the pain better.”

  That’s exactly what happened. By the time the medics arrived, Nathan’s pain and the massively elevated ST segments on his EKG had begun resolving.

  The medics carted him through the house and loaded him into the ambulance. I climbed in back with him. We roared up the drive, Divya on our tail.

  I hoped she didn’t think this was a race.

  Chapter 24

  The emergency department was slammed. That was obvious from the moment we pulled up to the receiving ramp. Two other ambulances sat nearby, one with red lights still pulsing, the other silent, except for the two medics who worked in its open rear doorway, stuffing soiled towels and empty medication boxes into a plastic hazardous-materials bag.

  Inside chaos ruled: nurses and doctors scurrying from one room to another, an X-ray tech maneuvering a portable machine into one of the cubicles, a lab tech drawing blood from a young woman in another, Dr. Andrew Weinberg putting a chest tube in a middle-aged man in the major-trauma room, shouted orders flying from every direction, and the cries of several babies echoing from the packed waiting room.

  It reminded me of my days in the ER. Days when one catastrophe piled on top of another, when time for contemplation was a lost commodity and you had to move on instinct, when the decisions you made and actions you took made a difference right then and there.

  Real medicine. At its purest.

  I missed it.

  Near the nurses’ station, Jill stood like a calm oasis in the middle of the storm and directed traffic.

  “Where do you want Mr. Zimmer?” I asked her.

  “Over here, cubicle six. I saved the last monitored bed we have for him.”

  We rolled Nathan into the cubicle and slid him from the stretcher onto the treatment table. A nurse, whose name tag read SUSAN FOSTER, RN, began swapping the medics’ portable cardiac monitor for the hospital one.

  “I’m putting him on our portable, since he’ll be going directly to the cath lab.” Once she got the electrical cables attached, she adjusted the IV flow rate and then began wrapping a blood pressure cuff around Nathan’s arm. “How are you feeling?” she asked him.

  “Better. The chest pain is almost gone.”

  “We gave him tPA a
t the scene,” I said. “Looks like he reperfused. His pain resolved and the ST elevations have decreased.”

  “That’s what cigarettes will do for you,” Susan said.

  He gave her a quizzical look.

  “I can smell them on you. We ER nurses have pretty good noses.” She smiled. “Especially for things like cigarettes. I bet you get religion after this and put those things down.”

  “Maybe.”

  “That’s usually how it works,” Susan said. “‘Maxwell’s silver hammer’ hits you in the head and you begin to see things a little differently. Sort of a wake-up call. Seen it a million times.”

  Dr. Walter Edelman walked in. He was young, maybe midthirties, and had been on staff for only a couple years but was arguably the best cardiologist. I had met him a few months earlier when I brought in another patient almost identical to Nathan Zimmer. An acute MI, tPA, the whole deal.

  “Hank,” Edelman said. “How’s it going?”

  I wasn’t sure if he was asking about me or about Nathan. I went with the latter. “Much better. Looks like the tPA worked.”

  Edelman introduced himself to Nathan and then said, “The cath lab is waiting. First thing we’ll do is an angiogram to see what we’re dealing with and then maybe put in a stent or two. I’ll explain it on the way, but let’s get you out of this chaos and down to the lab, where it’s much quieter.”

  While the nurse began preparing for the transfer, I told Nathan, “You’re in good hands here. Just do what Dr. Edelman says and everything will work out.”

  “You saying I’m a difficult patient?” he said with a smile.

  “Let’s go with stubborn.”

  “I guess I can’t argue with that.”

  “I’ll check on you later.”

  “Thanks, Doc. I owe you.”

  As I exited the cubicle, I saw Divya come through the double doors and work her way through the chaos.

  “Looks like you guys are having fun today,” Divya said.

  “Big accident over on the highway,” Jill said. “I hear there were six cars involved and two fatalities. We have four of the injured here already and two more on the way.”

  Divya’s cell phone buzzed. She pulled it from her purse and walked away to answer the call.