Jake was paralyzed.
“Douglas, are you coming down or what?”
The ER doctor repeated himself three times before Jake said quietly, “Yeah, I’ll be right there.”
Without saying another word, Jake turned and headed out of the ICU. He kept flipping through pages as he walked, noting several pages with numbers that he hadn’t recognize or bothered to call back. He noticed now that all but one was the same number. Jake thought to himself, Bill Thomas.
Jake looked through the ER windows at the guy sitting on a gurney. He had black hair, was unshaven, and wore torn pants. He looked like he had been repeatedly run over by a truck. Before Jake approached the patient, he stopped by a desk to call the unknown number that appeared the most on his pager.
A deep male voice answered, “Hello.”
“Thomas, is this you?” asked Jake.
“No, you dumb shit. It’s Snow White! Don’t you ever
answer your shit ass pages? What kind of neglect is that from a nice doctor?”
“Listen, I can answer that, but if I spend the next ten minutes explaining myself to you, this guy over here will probably die. So maybe we’ll discuss it later. I have not seen him yet, I mean formally, but I am looking at him right now, and he looks like
shit.”
“Alright, alright. This is what we need to do, Douglas. Conduct your surgery, and get the specimen. Walk it over to pathology yourself. A lab person is there 24 hours a day. I’ll be down the hall between the operating rooms and pathology. Deliver the specimen to me, and I will place your package in your locker.”
“But- my lock?”
“Jake, I have that covered, but don’t take all the gifts home at once. It will be too obvious, sparking too many questions. You must not tell anyone about this, and don’t try to contact me. You should have no worries or questions. I will leave all that you need in your locker. I’ll see you in a bit.”
The phone clicked. Jake slowly put the receiver in the cradle.
He slowly walked to the man on the gurney and picked up his chart, moving as if in slow motion. Jake looked up at the man as if he were a familiar face but realized he didn’t know anything about him except there was something in his belly that needed to come out.
The stench from the man was horrendous. He had the smell of body odor combined with vomit. His clothes were in shambles, and his face was unshaven and drawn out like somebody who was extremely dehydrated. Jake noticed the IV tubing and saw an empty bag of LR that was disconnected. He saw the present bag almost empty as well.
Jake reached out his hand and slowly but quietly introduced himself. “Hi. I’m Dr. Douglas. I was told you have some belly pain.”
The man nodded in pain and shook his hand. “I’m Ziamuddin.”
Jake slowly but carefully felt the man’s abdomen. Indeed it
was tight as a drum and exquisitely tender throughout. The man moved about squirming beneath the exam. Jake leaned over and said, “I think you need to have surgery to see what is going on inside. I’ll give you some antibiotics and Morphine right now. That should make you feel much better.”
The man nodded again.
Jake slowly backed away from the man, maintaining eye contact. He continued to walk backward until he bumped into the nurse’s desk.
“Dr. Douglas, are you okay?” one of the nurses asked. “It looks as if you have had a tough long day. Maybe we should get one of the other surgeons to take a look at that man for you. I don’t think you are in any shape to do surgery tonight.”
“Uh, that’s okay, Margret. I’ll be okay. Maybe I’ll get a bite to eat while you all call in the OR crew. That should make me feel better.”
“That sounds like a good idea,” the nurse agreed.
All the while Jake could not stop looking at the man.
Steve and Roger burst into the ER to see what the excitement was all about. “Jake!” they shouted.
“What?!”
“We thought you might have an appy or something,” Steve said. “Maybe after I do the History and Physical on him, could Roger and I scrub on the case?”
Jake turned around slowly and looked Steve right in the eyes. “Carmichael, I’ll do the H and P. Why don’t you get Mr.
Conrad all straightened out?”
Steve was adamant. “Come on, Jake. It has been over a month since I started, and I’m probably the only intern that has not done an appy yet, not to mention that I haven’t scrubbed for, I don’t know, a couple of weeks or so.”
Jake stared at Steve for a few seconds before reluctantly
giving in. “Alright. Go get Mr. Conrad tucked in and tell Agusta to give us a call if there is a problem. Have Roger sit up there with him until you get out. And Carmichael, you might want to sweet talk Agusta into not calling Rosberg in right now.”
“Oh, yeah. Fine. Fine. Fine. I’ll take care of it. Thanks, Jake!”
As Steve ran off to the ICU, Jake turned around and started to write a History and Physical on Ziamuddin. He glanced up to find Margret, the charge nurse in the ER.
“Margret!” he yelled.
“Yes, Dr. Douglas. What can I do for you?”
“I need to take this man down to the OR immediately. Make sure that the OR crew has been called in and that they know it is for a stat procedure. Then they won’t dilly-dally. And give the patient another liter of Lactated Ringers, three grams of Unasyn and four of Morphine in his IV. Thanks.”
Jake tried to write the preoperative notes and history but discovered that his hand was shaking and his heart was pounding. He wasn’t sure what he was going to find, but there was no way to back out of it now. Even if he tried to give the case to someone else, the man on the gurney wouldn’t tolerate a transfer to another facility. Jake had to do it, or the guy was going to die.
Chapter 23
Jake burst down the corridor of the OR toward the Path department. He was trying to move slowly in order not to attract too much attention but at the same time move quickly to get rid of whatever this thing was. He was in such deep concentration trying to stabilize the mass that he almost sped right past his contact.
Bill Thomas interrupted his concentration. “Where are you going in such a rush?”
Jake looked up franticly at the man and stared at him. “Uh, here you go, Mr. Thomas. Here is your prize as requested. But I have just one question-”
“I put the money in your locker. You are now a man without debt.”
“That’s great,” replied Jake, “but that was not what I am concerned about. You see, I inadvertently slipped my finger through whatever this is. And since it happened, I’ve wondered if it might be dangerous shit. Could this be true?”
Now it was time for Bill Thomas to panic. He couldn’t believe what he just heard. This would probably change everything. He wasn’t even sure if his contact would even pick the package up after this.
Thomas grabbed Jake’s shoulders and jerked him back and forth. “Did anyone else see you do this? Does anyone else know that you put a hole in this thing?”
Jake already felt a little better. If it were truly dangerous, there was no chance in hell Thomas would jolt it around like he was doing. “Hey, hey, settle down,” he said with a sigh of relief. “I never even took my finger out of the hole. It’s still in this piece of shit here.” He lifted the package up with his left hand. “Here is my little old finger stuck in this piece of shit. No one saw, and no one had a clue. So let’s relax a bit.”
Thomas wasn’t as satisfied and kept jerking Jake around. This issue could jeopardize the entire project. As he reacted, he realized that Jake had no clue what this meant; the more attention Thomas created, the more trouble he might make. With that thought, he stopped jostling the other man. He was about to thank him for his duty when they both heard the overhead speaker.
“Dr. Jake Douglas, Dr. Jake Douglas, stat to the OR. Dr. Jake Douglas, Dr. Jake Douglas, stat to the Operating Room.”
Jake thought out loud, “Shit. I bet
that poor guy is totally septic and bottoming out his blood pressure.” He glared at Thomas. “Well, it has been a real fuckin’ pleasure working with you, and I hope our paths don’t ever meet again. See ya.” The doctor turned and ran to the OR, leaving his contact holding the specimen in the container with white powder spilled in the bottom of the basin.
Chapter 24
Jake barreled through the OR doors. He found Steve doing CPR and Karla running the crash cart over to the table. A.J. too was moving about quickly.
“What the hell is going on?” shouted Jake.
A.J. replied, “It is the damnedest thing, but about a minute after you left, this kid’s blood pressure shot through the roof. His BP was 245 over 125. That is just nutty. I mean, I thought the guy would code but maybe from a hypovolemic or septic component. I initially gave him more inhalational anesthetic thinking that he was waking up, but that didn’t help in the least. Now I have an Esmolol drip going, but he just went into Vtach, and his blood pressure just came crashing down. We can’t get good femoral pulses, so we started CPR. I have given two boluses of Lido without any change. I’m not sure what the hell is going on, Jake, but you better get a hold of Rosberg before this patient crumbles. And he is about there now!”
Jake could not believe his eyes or ears. He knew that the patient had a good chance of becoming septic since his belly was filled with stool. He just didn’t figure the guy would do the opposite and become hypertensive. Nonetheless, A.J. was right about getting in contact with Dr. Rosberg. Rosberg would not be happy but probably wouldn’t trouble himself to come in for a homeless foreign patient about to die. Instead, he was likely to stay at home and figure out ways to pulverize Jake at the next Morbidity/Mortality Conference.
Jake quickly dialed the memorized phone number and told Dr. Rosberg what had happened. As expected, Dr. Rosberg didn’t feel inclined to come in since the patient sounded as if he was about to die.
Jake asked, “Do you have any ideas about what the mechanism is here? He just is not responding to anything!”
After a moment of silence on the phone, Dr. Rosberg said, “I really don’t know what the hell is going on, Douglas, but I don’t think it was anything you guys did. We don’t know this guy at all, but it sounds like he had a little too much cocaine this afternoon. Does he use, do you know?”
Jake quickly responded, “Not that I am aware of, but then I didn’t really get a good chance to talk to him prior to surgery. He was so sick. I just wanted to get him down here and explore his belly as soon as I could.”
“That was an excellent idea, but maybe there was something more to this story than meets the eye. Oh, well. You and A.J. give it your best, and I’ll talk to you in the morning.”
Jake could not believe how sympathetic Rosberg was, but maybe he had been fast asleep and didn’t realize to whom he was talking. He did refer to him by name, so maybe he’d had a little cocktail and forgotten to be an ass while talking to him. Whatever the reason, it was nice that Jake was not placed on the defensive tonight. Without a doubt, he would be raked over the coals at M&M conference later this week.
After hanging up, he hurried back to the operating table and the patient. “What is his BP now?”
A.J. hollered back, “The last systolic I could get was about 60, but it’s a thready pressure. I’m not sure if this guy can hang on much longer!”
Steve was busy doing chest compressions and thinking how badly he had wanted in on this case. Now he wished he were a million miles away. He thought to himself, Poor case selection. This was his first real case to scrub, and now he and Jake would have to defend their actions at the M/M conference. Fortunately, Steve would not get picked on much as the intern, but still there was the possibility of shark bites from the hungry staff surgeons who enjoyed watching their prey squirm before getting attacked.
Steve tried his best to focus on the moment and saving this guy’s life. His surgical cap was becoming soaked with his sweat. He could barely feel his hands as they were clinched together to do CPR. However, there was no one else to relieve him as A.J. was busy running in meds, Sue was helping A.J., and Karla was monitoring the defibrillator. Steve glanced at Jake who was staring at the monitor. It was if Jake was waiting for the right moment to give up and call the code.
“How long have we been at this?” asked Jake.
“About eight minutes. It was shortly after you left the room that the guy started to get hypertensive and then went into Vtach,” answered A.J.
“That’s it!” yelled Steve as he bounced on the patient’s chest. “I don’t know what caused his high pressure, but once he went into Vtach, he lost his pressure. Let’s treat his Vtach and disregard his Hypertensive episode.”
“That sounds like as good as a plan as any,” said A.J. “Karla, bring the defib unit over, and set us up for 360 joules. Sue, draw up five of Epi, and let’s blast this guy with it.”
Jake grabbed the paddles, and Karla placed the insulation pads on the chest.
“CLEAR!” yelled Jake, and everyone stepped back from the table. With the push of a red button, the doctor sent a strong shock through Ziamuddin’s body.
Everyone looked up at the monitor. Instead of a flat line, there was almost a fine Vfib.
“That’s a start,” cheered A.J.
Jake took the reins. “Go ahead and charge me up, Karla. A.J., blast him with the Epi and then give him another 100 of Lido. CLEAR!” He sent another jolt through the body of the young patient.
They all looked at the monitor again. After a moment of disbelief, they all cheered. The rhythm showed sinus tach at about 100 beats per minute.
“I can’t believe it!” yelled A.J. “I would never have guessed that he would come back. His pressure is up to 105 over 70. Not bad, kids!”
Jake patted Steve on his back. “Way to go, Carmichael! I have to congratulate you on a job well done. I don’t care what they say about you.” They both laughed as Ziamuddin’s heart rate continued to beat normally.
“Now let’s not get too excited,” said A.J. “We still have to get this guy closed and off the table.”
“Right you are, A.J., my boy,” chuckled Jake. “Let me wash my hands. Then we’ll irrigate, leave a drain, and get out. Karla, let’s put some strong antibiotics in the irrigation. Carmichael, I would advise you just get regowned and gloved. Sue, I guess you and I need to wash up. I’ll wash you if you wash me.”
“Shut up, Jake. This is not the place I was expecting a proposal to take place.”
They all laughed.
Just as Jake and Sue reached the door, A.J. shrieked, “Shit, here we go again, Jake! He’s back in Vtach. Oh shit, make that Vfib. PADDLES, NOW!”
Jake ran back to the table and looked at the monitor.
“Indeed, Watson. That is truly Vfib. Ah, shit. What is his pressure? Karla, charge me up to 360. Let’s go gang!”
Karla was running in all different directions. She dashed to get the machine and, at the same time, threw A.J. another bag of LR. With an extra hand somewhere, she pushed the charge button on the defibrillator.
“CLEAR!” yelled Jake. “Another 100 of Lido and this time, A.J., let’s get a drip going at two a minute. Karla, give him another amp of Epi!”
They knew that in the second round the patient had less chance of surviving. With the stimulation of electrical current that was intended just for his heart, Ziamuddin’s whole body jumped into the air. His arms flopped up and down off the table. It looked as if he was having a short-lived seizure.
After the shock went through the young man’s body, the whole team looked at the monitor with hope for a sinus rhythm. Despite their gallant efforts, the heart rate was still a fine ventricular fibrillation.
“Alright, gang, let’s go through this exercise again. Charge me up, Karla. A.J., let’s roll with another amp of epi. Let’s do it, gang!” Jake shouted.
The crew continued the code for several minutes. Jake delivered shock after shock, and A.J. continued to administer the
medication. Steve did chest compressions between the bolts of electricity, and Karla and Sue were watching intensely, hoping for a miraculous comeback.
After nearly twenty-five minutes, Jake looked up at the monitor and then at A.J. The rhythm on the monitor was flat line and had been for the last ten minutes. A.J. returned Jake’s look and shook his head from side to side. Then he looked down in defeat.
Jake slowly motioned to stop the CPR. “Let’s call it.” He looked up at the monitor one last time and then at the clock. He turned to Karla, “Ten forty-two PM. Cause of death: septic shock.” Jake bowed his head and walked out of the OR without another word.
A.J. started to clean up his mess near the head of the bed. They could still hear the respirator breathing for the young man. Nonetheless, the monitor still displayed a flat line. A.J. continued to arrange his area but leaned over to the on/off switch and regretfully turned the machine off. The room became exceptionally quiet.
Steve recalled how just a few months ago, he was so scared about these codes because he was not sure what to do. Now he was fearful of these codes because many patients rarely survived.
Jake walked back into the room. “Steve, would you mind closing? By the way, you all did a great job. We were just behind the eight ball on this one.”
Jake turned around and was on his way out again when Steve had an idea. “Jake, do you think we should get a tox screen on him? It might show us that this wasn’t Sepsis but maybe drug induced. I mean-”
Jake quickly cut him off. “I don’t think so, Steve. The guy came in with a belly full of pus and septic. We didn’t create the situation, and we did the best we could do. I think you did a great job, Carmichael, but you need to move on from this one. You need to realize this will happen to you sometimes, and there is no simple way to deal with it. You just need to chalk it up to experience and learn from it.”
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