Oh shit, thought Ken. He remembered her now and realized his blunder. He had violated a cardinal rule of medicine: Never, under any circumstances, ask a patient such as Dorothy Lubriani how they are feeling.
“But my asthma’s doing pretty well—only a touch of wheezing. Dr. Jefferies says the new regimen he has me on—you know, alternating the three inhalers—has been shown in recent clinical studies to be most effective.”
Ken looked around the holding area for moral support. Mike was several litters away but was too engrossed starting an IV on his patient. He didn’t look to be in a joking mood anyway. Ken returned his attention to Dorothy who had paused to take a breath. “That’s great,” he said and fought hard to keep a straight face.
“Thank God she’s asleep!” Ken said to himself as the Diprivan finally hit. He noted that Dorothy had taken a relatively large dose, probably owing to her frequent reliance on painkillers.
“Cripes, Ken. What took you so long?” asked Babs Honeywell, the circulating nurse. “I thought you’d never get her to sleep.”
“Me either,” said Ken.
“Thank God, it’s a general,” said Sandy McCoombs, the scrub nurse as she noisily made last-minute rearrangements of her instruments.
“Yeah, she’s some piece of work,” muttered Ken as he proceeded with the anesthetic. He knew the intravenous Diprivan would wear off in about five minutes, and in order to keep Dorothy anesthetized, he would need to quickly administer a gaseous anesthetic agent. He dialed in the Forane vaporizer to two percent. To provide muscle relaxation, he also administered Atracurium intravenously, which would temporarily paralyze his patient.
“What’s wrong with you today, Ken?” asked Babs, good-naturedly. “Cat got your tongue?”
“I’m out of it today, Babs. Ryan was up half the night with croup. After we finally got him settled, I was too keyed up to sleep.”
“How old is he now?”
“Ten months.” Ken scanned his monitors—everything looked good—sat down, and started to fill out his anesthetic record.
“They’re so cute, then,” Babs said. “Well, if I see you nodding off, I’ll bonk you one.”
Ken looked up. “Yeah, you do that,” he said. He broke off eye contact again and busied himself with his record, hopefully signaling an end to the conversation.
The surgeon, Dr. Bruce Watkins, came through the door, his hands dripping wet and held high. “Hi, Babs, Sandy.” They proceeded to gown and glove him. “Morning, Ken.”
“Hi, Dr. Watkins.” Ken still didn’t feel comfortable calling the older surgeons by their first names, even though he had worked with them for three years now.
“What do you think of my patient, Mrs. Lubriani?” Watkins asked.
“She sure can talk a blue streak,” Ken said. Looks like everyone’s in a talkative mood this morning, he thought glumly.
“Ah, you noticed. Any trouble putting her to sleep? She’s got a slew of medical problems.”
“No, not really. Once you take her brain out of the picture, she’s really quite healthy.”
“You’re probably right, Ken. I’m not sure how diseased her gallbag’s gonna be, but she’s been hounding me for six months now to take it out.”
“I can imagine.” Ken didn’t want to be rude, but he hoped Watkins would pick up on his disinterested tone soon.
“She’s got the symptoms down pat—she was a nurse you know—but her papida scan doesn’t show much.”
“Well, we’ll see,” Ken said. “She’s awful big, though.”
“You know what they say: female, fat, and forty—think gallbladder,” Watkins said and cracked up at his own wit.
Ken yawned under his mask.
Dorothy regained consciousness slowly. She felt very peaceful and relaxed. She wasn’t quite sure where she was but didn’t let that concern her. She was probably home in bed making a late morning of it. She could open her eyes if she wanted. Naw, just savor the floating sensation. Bits of a faraway conversation drifted by her ears. She chose to ignore them. Then one word, a name, penetrated her stupor—Dr. Watkins—her surgeon. That’s right! This was the special day she had waited so many months for. She was supposed to have her gallbladder out today. She also heard her name and the beeping of some monitor.
Oh, of course, silly. You’ve already had your surgery and you’re in the recovery room. I remember seeing that nice Dr. Danowski and drifting off to sleep. Wow! That was fast. And no pain. Isn’t modern medicine wonderful? I knew laparoscopic procedures were less painful, but this is fantastic!
Dorothy Lubriani figured it was time to wake up and perhaps see about some additional pain medicine, just in case. She tried to open her eyes and found she couldn’t.
That’s strange. She noticed that she wasn’t breathing normally. In fact, the air was being pushed into her lungs instead of her sucking it in. Very strange.
Fear began to creep into her sodden brain. What was going on? Was something wrong? Since she couldn’t see anything, she focused on listening.
“—female, fat, and forty—think gallbladder.”
That’s Dr. Watkins, she thought. Hey, who’s fat!?
Dorothy had had enough of this little game. It was time to stop playing possum—time to get up and go. Only when she tried, she found she couldn’t move a muscle.
That’s weird, Ken wondered to himself. His patient’s heart rate had just shot up from the 70’s to over 120, and her blood pressure had increased to 190/110. Normally, heart rate and BP jumped on incision, but they hadn’t touched the patient yet. Watkins was still BS-ing with the nurses, and they were in slow gear hooking up all the video equipment necessary for laparoscopic surgery.
She seems light. Ken quickly dialed the Forane to three percent, a very high setting he rarely used, while he reviewed his anesthetic. He knew he had given her plenty of Fentanyl and already had the Forane on a hefty amount. She can’t be light on three percent Forane on top of the Fentanyl and Diprivan. Maybe she really does have a bona fide medical problem after all—untreated hypertension. If so, the only way to bring down the pressure and pulse was with an antihypertensive. Ken drew up some Labetalol and gave it, hoping to control the pressure before incision.
“Okay to go, Ken?” Watkins asked as he grasped the scalpel in his gloved hand.
“Uh, yeah, sure,” Ken replied, feeling uneasy. He knew Watkins wouldn’t really wait for an answer. The question was more of a formality designed to denote incision time, rather than actually ask permission. Ken drew up more Labetalol and watched his monitors closely.
“Okay to go, Ken?”
Whoa—wait just a minute here! What’s going on? Why can’t I move?
Dorothy’s questions were all answered when she felt the searing pain just below her umbilicus as the scalpel blade bit in.
She screamed, but no noise came forth. Her mouth didn’t even twitch.
Stop! Stop! You can’t do this! I’m awake, damn it! She thrashed as hard as she could, but she might as well have been a statue. The pain intensified. Tears came to her eyes.
C’mon, Dorothy. Fly right. Ken wanted to stabilize his case and veg out a little. He wasn’t in the mood to tackle any big diagnostic dilemmas or emergencies this morning. He gave several more large doses of Labetalol before he got the pressure under control.
He sat down and started to draw up his drugs for the next case, but uneasiness still tugged at the edges of his mind. Ken had been doing anesthesia long enough to know that many patients didn’t follow the textbooks. However, he also knew it was generally not a good idea to ignore his sixth sense. More often than not, there was something he had overlooked. He reviewed his anesthetic once again. Nothing amiss. She just runs high, that’s all.
Oh, sweet Jesus! Don’t let them do this! The pain was becoming unbearable. Please, dear God, just let me die. Help me! Help me! Dorothy continued to sob.
God, it’s only 8:30, thought Ken. I’m wasted already. Gonna be a long day. Ken yawned for the hundredth t
ime. His mind drifted and he imagined himself sitting in his easy chair at home watching TV with his wife, Lynn. The baby was asleep upstairs and all was so peaceful.
In his daydream, his black Labrador came over to him and pawed at his arm. “Leave me alone, Trooper,” he mumbled. Ken snapped awake at the sound of his own voice. Something was wrong!
He sat bolt upright and shook his head to clear it. He scanned his monitors once again and went through a mental checklist, forcing himself to look carefully at each one.
Was she getting enough oxygen?
O2 Sat - 99%
FiO2 - 0.52
Yes. Oxygen saturation was excellent and inspired oxygen concentration was a normal 52%.
Was the tube in?
EtCO2 - 35 mmHg
FiCO2 - 0 mmHg
Again, yes. He had normal readouts showing the presence of carbon dioxide in the exhaled gases and no rebreathing of CO2.
BP-170/95
P-76
All still OK, except for a mildly elevated BP. He couldn’t find anything wrong with any of the other monitors. Ken was baffled.
He turned to examine his patient. One of the casualties of the hi-tech explosion in anesthesia, he knew, was that recent grads focused almost wholly on their computer screens instead of their patients. For the most part, this worked out well. After all, modern advances in monitoring had largely accounted for the increases in anesthetic safety. But Ken also understood there was a danger to this approach.
He looked at Dorothy’s face. Her color was good, the tube looked fine—no kinks, disconnects, or secretions. Then he saw something about her eyes, which he had taped shut at the beginning of the case. Wait—she’s tearing. That’s odd.
Tearing could be a sign of lightness, but he thought he had ruled that out early on when he had turned the Forane to the max. He quickly pulled the tape off one eye and opened the lid. What he saw froze him and a sickly fear gripped him.
Holy shit! Her right pupil was hugely dilated. Ken’s adrenals squeezed hard, and he felt the rush of adrenaline slam his tired brain into overdrive. He ripped the tape off the left eye. It’s blown, too! Damn it, she’s stroked!
Ken suddenly felt ill with crushing guilt; the gut-wrenching sensation spread like wildfire through his body before the analytical part of his mind had a chance to respond. His breathing became labored. No reason to stroke, though, he finally reasoned. He grabbed the flash-light out of his drawer and clicked it on. He opened Dorothy’s right eyelid and held the light about two inches from her eye. He moved it off to the side and quickly brought it back to shine in her eye.
The flood of light came crashing through Dorothy’s right eye and then left eye. She stopped sobbing for a minute. That was Dr. Danowski I saw—why, he looked like he had just seen a ghost. Darkness again. Help me, Dr. Danowski! Help me, Dr. Danowski!
A bright light shone directly into her right eye. It was so intense, it hurt. This must be the light they talk about. I’m dying. I’m heading for the light.
“Oh, thank God,” Ken sighed with relief. Dorothy’s pupils had contracted briskly to the light, indicating her brain was still functioning. There was no stroke. The conclusion was inescapable. She’s light! How did I miss it? She’s light, possibly even awake!
“Everything OK up there, Ken?” Watkins asked.
“Yeah, fine,” Ken lied, his voice a bit shaky. He didn’t want to upset Watkins, who had a nasty reputation for turning ugly if all didn’t suit him.
“Makes me nervous when I hear my gas-man praying,” Watkins said, breaking up again.
Ken injected large doses of Fentanyl, Versed and Diprivan into Dorothy’s intravenous line while he tried to figure out what had gone wrong. He whispered in Dorothy’s ear, “Everything’s OK, Dorothy. You’re all right.”
Dorothy sensed herself being carried away again into oblivion. The awful pain was finally going away. God’s answering my prayers and taking me. As she lost consciousness for the second time that morning, Dorothy thought she could hear the Almighty telling her: “Everything’s OK, Dorothy.”
Ken checked his infrared agent monitor again. It was reading -
Just what he had dialed in. That should have been plenty to keep her asleep. What went wrong? Computer glitch? Monitor malfunction? Broken vaporizer? Sudden instinct propelled him to action before he fully comprehended what he was doing.
Ken tore the rubber breathing bag from the circuit and sniffed the contents. Almost three percent Forane should be easy to smell.
What the—that’s not Forane! It’s Suprane!
In a flash, it all made sense. Two-point-nine percent Suprane isn’t enough to keep anyone asleep. Eight to ten percent Suprane were the typical concentrations used. Poor Dorothy had been light all along, probably even awake.
But, how could it’ve happened? he wondered sickly. And, how much would she remember?
CHAPTER SEVEN
Maybe now, I’ll get some answers, Rusty thought as he waited in the hallway for Dr. Landry to come out of the locker room. The two had hooked up this morning and done several cases in the outpatient surgery wing, a stand-alone unit separate from the main hospital OR. Rusty’s investigation of his past had amazingly led him to Mercy Hospital, but here the trail went cold. Ever since his days at the orphanage, he had wondered about his parents. Who were they? Why did they put him there? What had really happened to them?
The locker room door opened and Dr. Landry stepped out, interrupting further thoughts. “C’mon, Rusty,” Dr. Landry said. “I’ll buy you lunch.”
“Sure, you’re on!” Rusty replied. He was always eager to humor his attendings—they were, of course, responsible for his all-important evaluations. Rusty knew he was quite adept at adapting himself to please people. In fact, he had dubbed himself, “Plastic-man,” not really having a shape of his own but able to take any form the other person wanted to see. A true shape-shifter, just like on Star Trek. He had gotten along very well with Dr. Danowski yesterday and figured it would be even easier with Dr. Landry. This skill had served him well through college and the rigors of medical school. He viewed life as an endless series of cranky attendings to be hoodwinked in order to achieve his goals.
But he had to admit that Mercy felt very different from the Med Center. There was a feeling of freedom here to be away from the Med Center’s stiff professors, endless rounds, boring case presentations and countless students. He was getting a taste of medicine on the front lines with real-life doctors. Plus, he was getting one-on-one training, something that just didn’t happen at the Med Center.
“OK, follow me,” Dr. Landry said. “We’ll head down to the coffee shop. The cafeteria will be too crowded this time of day.” He led Rusty back down the OR hallway and out through the imposing automatic doors guarding the entrance. Outside of the OR, they went to the elevator and Dr. Landry pushed the down button. He turned to Rusty and said, “You did a nice job with that intubation.”
Rusty was puzzled because he knew he had struggled to put the breathing tube in. He glanced at Dr. Landry’s face to see if he was putting him on, but saw only sincerity. One of the benefits of being Plastic-man ironically enough, was that Rusty was a rather good judge of honesty. “Thanks for being patient with me, Doctor Landry. That’s the first one I ever got in.”
“Good for you,” Dr. Landry said, smiling broadly. He patted Rusty on the back and said, “We’ll make an anesthesiologist out of you yet.”
Rusty laughed and returned the smile, although he was still locked in his kiss-ass med student/attending mode. The bell sounded and the door slid open revealing a crowded elevator. Dr. Landry and Rusty squeezed on and conversation halted while the elevator descended one floor to the lobby level. Rusty stole several glances at Dr. Landry and reflected that he held the key to an extremely valuable learning experience; a good mentor was hard to find. There was no telling how many procedures Dr. Landry might let him try.
Rusty exited the elevator and came face-to-face with a huge wooden
crucifix, handcarved and beautifully painted, mounted on the marble wall facing the elevators. Dr. Landry steered them through the busy hospital lobby toward the little coffee shop. Rusty hadn’t been on the first floor much and took in his surroundings, trying to get his bearings.
The lobby was an interesting cross between a Roman Catholic chapel and a greenhouse. Numerous large potted plants, hanging ferns, and tasteful flower arrangements were crammed into every nook and cranny, competing for space with religious statues. Large portraits of the Virgin Mary, Baby Jesus, and the Pope adorned the walls. There was also a dignified looking nun Rusty didn’t recognize. He paused to look at her picture.
“That’s the hospital administrator. The coffee shop’s right down here,” Dr. Landry said gesturing forward.
“I’m not used to working in a hospital that seems like it’s half church. Doesn’t it, uh, bother you?” Rusty instantly regretted his choice of words.
“No, Rusty,” Dr. Landry said and chuckled. “I’ve been here so long, I barely notice it.”
Rusty felt relieved; he certainly didn’t want to offend Dr. Landry.
“Actually,” Dr. Landry continued, “come to think of it, I like working here. The sisters do a nice job running the hospital. They have a reputation for being, uh, thrifty, but in today’s competitive market this works well. Also, I think the patients appreciate the religious atmosphere.”
“It just seems funny to have a nun for a CEO,” Rusty observed, fixated on the business end of things. “Can she really hold her own with the HMO corporate sharks?”
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