myotonic jerks.
Raj took a step back, shocked by what he was observing. Although he’d been cautioned, the reaction had been more rapid and more disconcerting than he’d expected. He watched for another beat as the patient tried to sit up but immediately collapsed back like a freezer bag full of fluid. With a sense of revulsion, Raj turned and fled. The problem was, he didn’t get far. As he yanked open the door to the corridor, he literally ran into a white-coated figure who’d just raised his hand to push open the door that because of Raj was no longer there.
Raj grabbed the man in a bear hug to keep from knocking him over as his inertia carried them out into the corridor. “I’m so sorry,” the befuddled nurse blurted. The collision had been so unexpected, and making it even worse, he recognized the man. It was Dr. Nirav Krishna, David Lucas’s surgeon, on late rounds before heading home.
“My God, man,” Dr. Krishna snapped. “What the bloody devil is the rush?”
For a brief moment of utter panic, Raj tried to think of something to say. Realizing there was no way out, he told the truth. “It’s an emergency. Mr. Lucas is having an emergency.”
Without saying anything, Dr. Krishna pushed by Raj and dashed into the room. Coming to the bedside, he saw David Lucas’s beginning cyanosis. Out of the corner of his eye he saw from the monitor the heart was beating relatively normally. It was then that he realized the patient was not breathing. He did not see any fasciculation, because they had already stopped.
“Get the emergency cart!” Dr. Krishna yelled. He yanked out the nasogastric tube and threw it to the side. Grabbing the bed control, he began to lower the head. Seeing Raj glued to his spot, he again yelled for him to get the crash cart. They were going to have to resuscitate.
Raj recovered from his paralysis but not his terror. He raced from the room and ran headlong down the corridor toward the nurses’ station, where the emergency cart was stored. As he ran he tried to think of what he should do. He couldn’t think of anything other than to help. The surgeon had gotten a good look at him, and if he just disappeared, he’d surely be implicated.
Reaching the central station, Raj blurted out to the two nurses sitting at the desk that there was a code in room 304. Without stopping, Raj threw open the door to the storeroom where the crash cart was kept, grabbed it, backed out with it in tow, and then raced back down to David Lucas’s room, making an enormous racket in the process. When he got there, the lights had been turned up. Dr. Krishna was doing mouth-to-mouth, and to Raj’s added horror, Mr. Lucas didn’t look so bad; his cyanosis had faded to a large extent.
“Ambu bag!” Dr. Krishna shouted. One of the floor nurses who’d raced after Raj grabbed it from the cart and tossed it to the doctor. Dr. Krishna repositioned the patient’s head, applied the bag, and began respiring the victim. Now the chest was moving even better than it was with the mouth-to-mouth. “Oxygen!” Dr. Krishna barked. The other floor nurse got the cylinder over to the head of the bed, and between Dr. Krishna’s compressions, she connected it to the breathing bag. Within seconds Mr. Lucas’s color improved dramatically; it was now actually pink.
As these activities progressed, Raj had an opportunity to appreciate just what kind of disaster he was in. He didn’t even know for certain whether it would be better if the patient died or was saved. Nor did he know if it would be better for him to slink away or stay, and the uncertainty kept him riveted in place.
At that point the evening house doctor, Dr. Sarla Dayal, arrived at a run. She crowded in at the head of the bed, and Dr. Krishna gave her a rapid summary of what had happened.
“When I got here he was definitely cyanotic,” Dr. Krishna said, “and the cardiac monitor looked reasonable, but it’s only one lead. The problem was, he’d stopped breathing.”
“You think it was a stroke?” Dr. Dayal questioned. “Maybe a heart attack precipitated a stroke of some sort. The patient has a history of occlusive cardiovascular disease.”
“Could be,” Dr. Krishna agreed. “It does look now like the cardiac monitor is telling us something. The rhythm is certainly slowing.”
Dr. Dayal placed a hand on the patient’s chest. “The heart rate is slowing and feels rather faint.”
“It’s probably the patient’s obesity.”
“The patient also feels really hot. Take a feel. I’ll breathe for a while.”
Dr. Krishna turned the ambu bag over to the house doctor and felt David Lucas’s chest. “I agree with you.” He looked over to one of the floor nurses. “Let’s get a temperature!” The nurse nodded and got the patient’s thermometer.
“Do we have a cardiologist on call?” Dr. Krishna asked.
“We certainly do,” Dr. Dayal said. She called over to the other floor nurse to give Dr. Ashok Mishra a call and ask him to come in immediately. “Tell him it’s an emergency,” she added.
“I don’t like that the heart rate keeps slowing,” Dr. Krishna said, watching the monitor. “Let’s get a stat potassium level.”
The floor nurse who was not on the phone drew some blood and rushed it off to the lab herself.
To stay out of the way, Raj had slowly backed away until he’d hit up against the wall. He was thankful that people were so involved in the resuscitation activity that he was being virtually ignored. He again began to think about slipping out, although the specter of drawing attention to himself made him stay put.
“Dr. Mishra will be in as soon as he can,” the nurse yelled out while hanging up the phone. “He’s finishing up with another emergency.”
“That’s not good,” Dr. Krishna said. “I have a bad feeling. With this progressive bradycardia, it might be over by then. This heart is definitely having trouble. It looks to my untrained eye as if the QRS interval is widening.”
“The patient definitely has a fever,” the nurse blurted, staring at the thermometer in disbelief.
“What is it?” Dr. Krishna demanded.
“It’s over one hundred and nine.”
“Shit!” Dr. Krishna shouted. “That’s hyperpyrexia. Get ice!”
The floor nurse ran out of the room.
“You must be right, Dr. Dayal,” Dr. Krishna moaned. “We must be dealing with a heart attack and a stroke.”
The nurse who’d dashed up to the lab returned on the run. She was out of breath but managed to say, “The emergency potassium level is nine-point-one milliequivalents per liter. The tech says he’s never seen it that high, so he’s going to repeat it.”
“Yikes!” Dr. Krishna exclaimed. “I’ve never seen a potassium level like that. Let’s give some calcium gluconate: ten milliliters of a ten percent solution. Draw it up. We’ll give it over a couple of minutes. Plus, I want twenty units of regular insulin. And do we have cation-exchange resin available? If so, get it.”
The floor nurse came back with ice. Dr. Krishna dumped it over the patient, and a lot clattered to the floor. The nurse then ran back out to try to get the resin while the other began to draw up the medication.
“Damn!” Dr. Krishna shouted as the blip on the monitor flat-lined. “We lost the heartbeat.” He climbed up on the bed and began closed-chest massage.
The CPR attempt went on for another twenty minutes, but despite the medication, the ice, the cation- exchange resin, and a lot of effort, a heartbeat was not regained. “I think we are going to have to give up,” Dr. Krishna said finally. “It’s intuitive what we are doing is not working. And I’m afraid rigor mortis is setting in already, probably from the patient’s hyperthermia. It’s time to stop.” He let up from compressing the chest. Although Dr. Dayal had offered to relieve him ten minutes earlier, he’d refused. “It’s my patient,” he’d explained.
After thanking the two floor nurses for their help and Dr. Dayal for hers, Dr. Krishna pulled down the sleeves of his white coat from where he’d pushed them up at the outset of the resuscitation attempt, and started for the door. “I’ll do the paperwork,” he called over his shoulder as the others began to pick up the debris, put the room in order, and prepare the body. “As per that e-mail directive that came out just today from admin about reporting deaths immediately, I’ll also call CEO Khajan Chawdhry to give him the bad news.”
“Thank you, Dr. Krishna,” the two nurses echoed.
“I’ll do the phoning to Khajan, if you’d like,” Dr. Dayal offered.
“I think I should do it,” Dr. Krishna rejoined. “He was my patient, and I should take whatever heat this is going to create. With those deaths over at the Queen Victoria garnering international media attention, this episode is going to be looked upon as very inconvenient, to say the least. I’m sure there’ll be great pressure to keep it under wraps and dispose of it promptly. It’s too bad, because under more normal circumstances, I’d actually like to learn the physiological sequence of events, starting with the patient’s history of obstructive heart disease, right up to the
