Do No Harm
Gregg Hurwitz
Gregg Hurwitz
Do No Harm
Chapter 1
Face white and blistering, eyelids swollen nearly shut, hair falling from the front of her scalp in thin clusters, the nurse stumbled blindly through the UCLA Medical Center Emergency Room doors, both hands waving in front of her. Her cries came from deep in her chest, rapid animal sounds that twisted into raspy moans by the time they left her mouth. A half-moon darkened the V of her scrub-top collar, and the skin along her clavicle had whitened and softened.
She tried to say something, but it came out a guttural bark.
A Hispanic gardener leapt up from his seat before the lobby's check-in windows, cradling the bloody bandage wrapping his hand and knocking over his chair. He circled wide as the nurse advanced, as if afraid of attack or contamination. A mother holding her five-year-old stepped through a set of swinging doors, shrieked, and beelined to the safety of the waiting room. The guard at the security desk rose to a half crouch above his chair.
A blister burst near the woman's temple, sending a run of viscous fluid over the mottled landscape of her cheek. Open sores spotted her lips, and when she spread her mouth to scream, her Cupid's bow split, spilling blood down her chin. She groped her way along the wall, her shoulders racking with sobs, her mouth working on air.
An expression of horror frozen on her face, Pat Atkins circled her desk in the small triage room, knocking over her first cup of morning coffee, and ran into the lobby toward the woman.
The woman retched, sending a thin spray of grayish vomit across the vivid white wall. She lunged forward, her shin striking the overturned chair, and tumbled over, breaking her fall with the heels of her hands.
Pat sprinted over, shouting at the security guard, "Tell them to get Trauma Twelve ready!"
She reached for a pulse as the nurse rolled onto her back, sputtering and gurgling, leaving a hank of hair on the clean tile floor. When Pat saw the nurse's ID badge, she inhaled sharply, running a hand over her bristling gray hair.
"Jesus God," she said. "Nancy, is that you?"
The swollen head nodded, the whitish raw skin glistening. "Dr. Spier," she rasped. "Get Dr. Spier."
Nearly knocking over a radiology resident with an armful of charts, David Spier sprinted into the Central Work Area bridging the two parallel hallways of exam rooms that composed his division. He pointed at an intern and snapped his fingers. "Carson's supposed to stitch up a leg in Seven. Go keep an eye so he doesn't duck out-you know how he is with sutures. And I need a urine on Mitchell in Eight."
He stepped across the CWA, patting his best resident on the shoulder. "Diane-let's move."
Diane handed off the phone to a nurse and pivoted, her shoulder-length straight blond hair whipping around so the nurse had to lean back out of its way. Grabbing the pen from behind her ear, Diane slid it into the pocket on her faded blue resident scrubs. David rested a hand on her shoulder blade, guiding her into Hallway One. They both shuffle-stepped back as the gurney swept past them and banked a hard left into the trauma room. They followed behind, David resting his hands on the back of the gurney. The nurses folded in on the patient's writhing body, a wave of dark blue scrubs. Pat leaned over, slid a pair of trauma shears up the moist scrub top, threw the material to the sides.
"What do we have?" David asked.
A nurse with shiny black hair glanced up. "Caucasian female, probably midtwenties, some vomiting, erythematous blisters on face and upper chest, eyes are opaque, moderate respiratory distress. Appears to be some kind of chemical burn." She reached down and untwisted the ID badge from the mound of fabric. Her face blanched. "It's Nancy Jenkins."
The news rippled visibly through the nurses and lab techs. Though they were accustomed to operating under duress, having a colleague and friend wheeled into the ER in this state was beyond even their experience.
David glanced at Nancy's blistering face, her pretty blond hair lying in loose strands on the gurney, and felt a chill wash down his chest to his gut. He recalled when they had wheeled his wife in here two years ago, the night of his forty-first birthday, but he caught himself quickly, checking his thoughts. Instinctively, his physician's calm spread through him, protective and impersonal.
He quick-stepped around the gurney so he could examine Nancy's face. Her eyelids and lips were badly burnt. If the caustic agent dripping from her had gotten into her eyes and down her throat, they were dealing with a whole new host of problems.
"Get me GI and ophtho consults," he said. "And someone contact the tox center. Let's get the offending agent ID'd."
Pat glanced up from her post behind Nancy's head. "Some nasal flaring here, and she's stridorous." She chewed her lip. "Hurry with that monitor."
"Find me some pH strips," Diane called out. "And let's get saline bottles in here stat."
A clerk ran from the room. Two nurses dashed in, pulling on latex gloves and snapping them at the wrists.
"Was it an explosion?" someone asked.
"Doubt it," Pat said. "Nancy walked in herself-it must've happened right outside. Security's already contacted the police."
"She's working hard," David said, glancing at the skin sucking tight against her ribs and around her neck. "Supraclavicular and substernal retractions. Let's get ready to tube her."
Nancy tried to sit up, but Pat restrained her. Nancy's breath came in great heaves. "Dr. Spier," she said. Her voice was thick and rough, tangling in the swell of her throat.
David leaned over Nancy's face. The skin around the blisters was whitening, contrasting sharply with the red bulges. She appeared to be trying to go on speaking.
His hands fluttered near her jaw, ready to check her airway. "I'm right here, Nancy. We're gonna get you taken care of. Can you tell us what substance we're dealing with?"
IVs being hung, pulse ox sliding on the finger, scrubs cut free from her legs and tossed into a trash bin. Cardiac leads plunking down across her chest like bullet holes.
Nancy coughed, contorting on the gurney.
"Heart rate's one forty," someone said. "O-two saturation's low nineties and dropping."
David leaned closer. "Nancy, can you tell us?"
The green line on the EKG monitor showed tachycardia, the peaks and valleys getting mashed closer and closer. Her arm rose, a hand pawing limply at air.
No more time. He pulled her jaw open and peered down her throat. Ulceration of the oropharynx, subacute airway compromise from edema. Whatever had gone down her throat had irritated the tissue, causing massive swelling. He needed to secure an airway quickly before her throat closed off.
David tilted her head back to give her throat maximum patency. "Push twenty mgs of etomidate and one hundred of rocuronium," he said, his voice ringing sharp and clear even to his own ears. The drugs would sedate and completely paralyze Nancy. She'd be unable even to breathe unless they could get a tube down in her to do it for her. "Laryngoscope," he said.
The L-shaped tool slapped the latex covering his palm. Positioning it in his left hand, he then slid the blade down along her tongue, using the small attached light to guide it past the epiglottis. The laryngeal swelling was bad, even worse than he'd noticed at first glance. He couldn't see the vocal cords between which to guide the endotracheal tube.
He glanced up at Diane, who was performing the Sellick maneuver, applying pressure to the cricoid membrane beneath Nancy's larynx, trying to bring the vocal cords into view for him. It wasn't working.
"Someone get on the horn to anesthesia and see how long it'll take to get a fiberoptic scope down here," David barked. If the swelling got too bad, he could look through the thinner scope and maneuver down the trachea.
He repositioned Nancy's head and tried again, but st
ill couldn't make out the vocal cords behind the swelling.
"Crich her?" Diane asked.
David shook his head. "Not yet. Before we cut, I'll try to tube her blind and see if we get lucky." Though the swelling prevented him from eyeing the anatomical landmarks, he began pushing the endotracheal tube, tracing a path along the underside of the laryngoscope blade down Nancy's throat. He pulled the laryngoscope from Nancy's mouth. The clear ET tube remained, protruding a few inches from the line of her teeth. David removed the metal stylet that ran down its length and inflated the cuff at the other end, which was buried somewhere in Nancy's throat. He popped the end-tidal carbon dioxide monitor on the end of the tube, then attached the oxygen bag valve atop the monitor.
Diane pulled her stethoscope from across her shoulders, cleared her hair with a head jerk, and positioned the plugs in her ears. She listened over the lungs, then switched to the stomach, as David pumped the bag with his hand. "I'm getting a gurgle," she said.
The ET tube had wound up in the esophagus rather than the trachea, the usual result of tubing someone blind. Diane was picking up stomach noises rather than movement through the lungs. The monitor reading showed high carbon dioxide-Nancy still wasn't breathing.
David pulled the endotracheal tube from Nancy's mouth; it swayed beneath his fist like a bloody snake.
"Her O-two sat's dropping… " Pat said, a note of panic creeping into her voice.
Nancy's flesh was going from white to blue.
"Is the fiberoptic scope here?" David asked.
A clerk leaned into the room. "Not yet, but anesthesia said it's on the-"
David reached for a scalpel, fingering beneath Nancy's larynx for the cricothyroid membrane with his other hand. He cut lengthwise along the membrane, opening up a surgical airway in her throat. Diane had the three-pronged retractor in his hand immediately; he slid it into the cut and it opened like a tripod, spreading the hole. Feeding a 4.0 ET tube into the hole, David plugged the other end into a ventilator hose. The ventilator breathed for her, pushing air through the tube into her lungs.
Her chest started rising and falling, and her oxygen saturation climbed slowly back up past ninety. Airway secured. Now he'd have to identify the offending agent.
He glanced up at the nurses. They were moving a little slower than usual, still shell-shocked. A lot of looks to Nancy's face.
"I know this is hard," David said, gently yet firmly, "but right now we're just dealing with an injured body, like any other body. Have you drawn blood?"
Pat nodded.
"Send off a CBC, a chem panel, type and screen, and get a rectal. Does someone have my pH strips?"
The black-haired nurse slid a gloved hand between Nancy's limp legs.
Someone handed David a yellow pH strip and he laid it across Nancy's cheek. It dampened quickly, but did not change. He threw it aside. "Not an acid," he announced. Pat was ready with the red strips; he laid one on Nancy's forehead and one just beneath her eye. Almost immediately, they turned a glaring blue.
David cursed under his breath. A base. Probably Drano. Acids are nasty, but they attack tissue in such a way that the skin scars quickly, usually protecting healthy underlying tissue. Alkali, on the other hand, produces a liquefaction necrosis, saponifying fats, dissolving proteins, penetrating ever deeper into the tissues. Unlike acid, it keeps burning and burning, turning flesh to liquid. Same way it opens clogged drains.
Diane glanced at the blue pH strip and immediately began dousing Nancy's face with saline.
"Follow her lead," David said. "Irrigate the hell out of her." He raised one of Nancy's lids with a thumb and stared at the white cloudy eyeball. Corneal opacification. More bad news. He picked up a little 250-cc saline bottle and flushed the eye. "Someone find me some Morgan lenses." Each of the hard Morgan lens contacts connected to a tube that could continually flush the eyes with saline. As they were seldom needed, he hadn't used Morgan lenses for about ten years.
The blistering lips and swollen throat indicated that the alkali had gone down Nancy's throat. If it had burned through her esophagus, letting air escape into her chest cavity, he would have to get her to the OR immediately. If it hadn't fully penetrated, then the alkali remained on the esophageal walls, eating through additional tissue, and there was very little they could do about it.
He slid an X-ray cassette, encased in a dull silver case, beneath Nancy's body. "Everyone in leads!" Everyone present threw on lead aprons as Diane positioned the X-ray unit over Nancy's body and threw the switch. Quickly, they repeated the procedure until they'd completed serial chest and abdominal films. A lab tech slid the final cassettes out from beneath Nancy and handed them off to the radiology tech, who scurried from the room.
"Check for free subdiaphragmatic air, mediastinal emphysema, and examine lung parenchyma for signs of aspiration," David yelled after the tech. "Did he hear me? Someone make sure he heard."
Several nurses and lab techs were spraying down down Nancy's face with saline bottles. Water and runoff drenched the gurney sheets.
"Should I get ready to drop an NG tube to lavage the stomach?" Diane asked. "Dilute the alkali?"
"No, it's contraindicated," David said. "It can cause retching or vomiting, and the alkali could migrate back up the tube, reexposing tissue. Plus, you could drop the thing right through a weakened esophagus wall into the mediastinum. Getting her stomach pumped isn't worth the risk of boxing her."
A nurse's hand appeared seemingly out of thin air, handing Diane another saline bottle.
Carson Donalds ran in, breathing hard, and shot looks around the room with the mixture of anxiety and disorientation typical of a medical student. He ran a hand through his mop of curly blond hair, his eyebrows disappearing under the front line of his bangs. "I heard you have a pretty gnarly alkali burn." He saw Pat's face, then glanced at the body and took a step back. "Fuck. Is that Nancy?"
David's bottle spat air, so he tossed it into the bin, grabbed another, and continued irrigating the eyes. "Dr. Donalds," he said, taking a calm, didactic tone, "why don't we use emetics for alkali ingestions?"
"Because she's paralyzed and tubed and the last thing you want is her barfing up and asphyxiating," Carson said.
"How about if she wasn't tubed? Would we use an emetic then?"
"No. You don't want to reexpose the esophageal tissue to offending agents on the way back up."
"And?"
Carson shook his head.
"Dr. Trace?" David said. He didn't look up from the eye he was spraying, but he sensed Diane's head pivoting.
She switched the saline bottle to her other hand, squinting as a wayward squirt caught her across the brow. "Increasing intraluminal pressure generated by emesis is speculated to increase the risk of perforation when the tissue is markedly weakened. Carson, get your ass over here and give us a hand."
Carson lunged forward and grabbed a saline bottle. Diane nudged him with a shoulder. "What are the three reasons we don't use charcoal to soak up alkali in the stomach?" she asked.
"Four reasons," David said.
Diane grimaced at being corrected but didn't look up.
Pat switched IV bags, then checked Nancy's blood pressure cuff, her face stained with grief and shock. With twenty-three years as an RN under her belt, Pat was the den mother of the ER nurses; that's why she'd followed Nancy in here, probably sending one of the more junior nurses out front to triage. Her crew cut was shot through with sweat.
"I don't know any," Carson confessed.
David raised an eyebrow at Pat. "Pat?"
"Why are you pimping a nurse?" Carson asked, a competitive note finding its way into his voice. Most doctors only fired questions at med students, interns, or residents.
"Because, in general, they've been around longer and know more than arrogant med students."
Pat looked over quickly, her cheeks quivering. "I… what…?"
"Would you like to tell Carson here, and Dr. Trace, the four reasons we don't use charcoal to soa
k up alkali in the stomach?"
Pat managed to regain her focus, which had been David's aim in questioning her. "One, activated charcoal doesn't absorb alkali. Two, it obscures the endoscopic visual field. Three, if the patient is perfed, it would leak right into the mediastinum, and four, it's a vomit risk, and Carson and Diane already pointed out those pitfalls."
"That's right." David glanced around the small room bustling with people. A few faces still looked upset, and a lab tech was holding one of Nancy's limp hands. "We have a damn sharp team here," he said. "Don't worry, and stay focused."
A clerk leaned through the door. "Dr. Jenner's ringing through."
"Aah," David said. "Our ophthalmologist."
The telephone behind David emitted only a half ring before he grabbed it, first handing off his saline bottle to a nurse and pointing. "Keep flushing," he mouthed, pivoting to miss an IV pole a lab tech pulled around.
"Dr. Jenner, just in time. We need you down here, got a bad alkali exposure to the eyes."
"Was the skin around the eyes burnt?" Dr. Jenner's deeply textured voice was low, rolling, authoritative.
"Everything's burnt. The cornea's cloudy white."
"So the endothelium's already not functioning. Are you irrigating?"
"Saline."
"Good. Osmosis advantage."
"I can't find the Morgan lenses."
"Don't worry about it. They're outdated and overrated. Just get the eyes open and keep irrigating copiously. Once the eyes are better cleared, give her a drop of Pred Forte to stop the inflammation and a drop of Cipro for infection. I'm on my way."
Diane glanced up at David as he hung up the phone. He chewed his lower lip. "Pat, can you call GI again, ask what's taking so goddamn long on our consult?"
The radiology tech poked his head into the room, fresh back from the X-ray suite in the rear. "No free air," he said.
That was good-at least the alkali hadn't eaten through the esophagus, allowing air to escape into the body. Yet.
Diane leaned forward over Nancy's body, and she and David brushed foreheads. Her eyes jerked quickly away. "Sorry."
Do No Harm Page 1