“This has to be the same problem that they had in the OR,” said Bellows, watching the premature contractions increase in frequency until the rhythm dissolved into fibrillation. “You’re up again, Reid ole boy. Let’s go, team.”
By 1:15 Nancy Greenly had been defibrillated twenty-one times. After each shock a relatively normal rhythm would return only to disintegrate into fibrillation after a short duration. At 1:16 the ICU phone rang. It was answered by the ward clerk, who took the information. It was the lab calling with the stat electrolyte values. Everything was normal except the potassium level. It was very low, only 2.8 milliequivalents per liter.
The ward clerk handed the results to one of the nurses, who showed them to Bellows.
“My God! 2.8. How in Christ’s name did that happen? At least we have an answer. OK, let’s get some potassium in her. Put 80 milliequivalents into that I.V. bottle and speed it up to 200 cc per hour.”
Nancy Greenly responded to this command by immediately lapsing back into fibrillation for the twenty-second time. Reid started compression while Bellows readied the paddles. The potassium was added to the I.V.
Susan was totally absorbed by the whole resuscitation procedure. In fact, her concentration had been so great that she had almost missed hearing her name crackle out of the page system speaker near the main desk. The page system had been intermittently active throughout the entire cardiac arrest procedure by calling out the names of physicians followed by an extension number. But the sound had blended and merged with the general background noise, and Susan had been oblivious to it. At least until her own name floated out into the room along with the extension 381.
Somewhat reluctantly Susan left her place by the wall and used the phone at the main desk to answer her page.
381 turned out to be the extension of the recovery room and Susan was quite surprised to be paged from there. She gave her name as Susan Wheeler, not Dr. Susan Wheeler, and said that she had been paged. The clerk told her to hold the line. He returned immediately.
“There’s an arterial blood gas to be drawn on a patient up here.”
“Blood gas?”
“Right. Oxygen, carbon dioxide, and acid levels. And we need it stat.”
“How did you get my name?” asked Susan, twisting the cord on the phone. She hoped it was by some sort of mistake that she had been called.
“I just do as I’m told. Your name is on the chart. Remember it’s stat.”
The line went dead. The clerk had hung up before Susan could respond again. Actually she had little else to say. She replaced the receiver and walked back to Nancy Greenly’s bedside. Bellows was repositioning the paddles again. The shock swept through the patient’s body, the arms ineffectually flopping across the chest. It seemed both dramatic and pitiful at the same time. The monitor showed a normal rhythm.
“She’s got a good pulse,” said Cartwright at the groin.
“I think she’s holding her sinus rhythm better now that some of the potassium has gotten into her system,” said Bellows, his eyes glued to the monitor screen.
“Dr. Bellows,” said Susan during the lull in the action. “I got a call to draw an arterial blood gas on a patient in the recovery room.”
“Enjoy yourself,” said Bellows, distracted. He turned to Shergood.
“Where in heaven’s name are those medical residents? God, when you need them they lie low. But just try to take someone to surgery and they hang around like a group of vultures, canceling your case because of a borderline serum porcelain.”
Cartwright and Reid forced a laugh for political reasons.
“You don’t understand, Dr. Bellows,” continued Susan. “I’ve never drawn an arterial blood gas. I’ve never seen one drawn.”
Bellows turned from the monitor to Susan. “Jesus Christ, as if I don’t have enough to worry about. It’s just like getting venous blood only you get it out of an artery. What the hell did you learn during the first two years of medical school?”
Susan felt a defensive surge; her face reddened.
“Don’t answer that,” added Bellows quickly. “Cartwright, head over with Susan and ...”
“I’ve got that thyroidectomy you put me on with Dr. Jacobs in five minutes,” interrupted Cartwright, looking at his watch.
“Shit,” said Bellows. “OK, Dr. Wheeler, I’ll head over with you and show you how to do an arterial stick but not until things are reasonably quiet here. Things are looking a little better; I’ve got to admit that.” Bellows turned to Reid. “Send up another blood sample for a repeat potassium.
Let’s see how we are doing. Maybe we are out of the woods.”
While she was waiting, Susan thought about Bellows’s last comment. He had used the pronoun we rather than saying that Nancy Greenly was out of the woods. It fit the pattern and she pondered about depersonalization. It also reminded her of Stark. He didn’t seem to care for Bellows’s pronouns either.
Monday, February 23, 1:35 P.M.
“Some days are like this,” said Bellows, holding the door open for Susan as they left the ICU. “Lunch can be considered a luxury. Even a nice ...”
Bellows paused as they walked down the corridor. They were both eyeing the floor. Bellows was searching for a word. Then he changed his incompleted sentence. “On occasion it is even hard to find, time to relieve oneself.”
“You meant to say ‘a nice shit,’ didn’t you?”
Bellows glanced at Susan. She looked up at him with a slight smile. “You don’t have to act differently on my account,” said Susan.
Bellows continued to study her face, which she carefully kept as neutral as possible. They walked in silence past the holding area for surgery.
“As I mentioned before, an arterial stick is just about the same as a venous stick,” said Bellows, changing the subject. He sensed the unnerving effect Susan had on him and he sought to regain the upper hand. “You isolate the artery, either the brachial, radial, or femoral, it really doesn’t matter which, with your middle and index fingers, like this
...” Bellows held up his left hand and extended his middle and index fingers and pretended to palpate an artery in the air. “Once you have the artery between the fingers, you can feel the pulse. Then simply guide the needle in by feel. The best method is to let arterial pressure fill the syringe. In that way you can avoid air bubbles, which tend to distort the values.”
Bellows backed into the recovery room door, still gesturing the technique of the arterial stick. “Two important points: you have to use a heparinized syringe to keep the blood from clotting, and you have to keep pressure over the site for five minutes after the stick. The patient can get a frightful hematoma from an arterial stick if the pressure part is forgotten.”
To Susan the recovery room seemed superficially similar to the ICU
except that it was brighter, noisier, and more crowded. There were about fifteen to twenty spaces designated for beds. Each space had a complement of equipment built into the wall, including monitors, gas lines, and suction lines. Most of the spaces were occupied by high beds with the side rails pulled up. In each bed was a patient with fresh bandages over some part of his body. Bottles of intravenous fluid were clustered on the tops of poles, like some hideous fruit on leafless trees.
New patients were arriving, others leaving, causing mini-traffic jams of moving beds. Conversation flowed freely from those who worked there and felt at home in the environment. There was even some occasional laughter. But there were also some groans, and a baby was wailing an unheeded lament in a crib by the nurses’ station. Some of the beds had groups of doctors and nurses busily engaged in adjusting the hundreds of lines, valves, and tubes. Some of the doctors were dressed in wrinkled scrub suits, stained with all sorts of secretions, although blood was the most prevalent. Others wore long white coats starched painfully stiff. It was a busy place, a crossroad filled with patients, charts, motion, and talk.
Bellows was anxious to dispense with the task ahead and approached the main desk, which was strategically placed in the center of the large room. In response to his inquiry he was handed a tray with a heparinized syringe and directed to one of the recovery room beds to the left, opposite the door through which they had entered.
