She looked dead. Her flesh was mottled purple and white from not enough oxygen and loss of circulation. But as I stepped up to the stretcher where she was lying, I could hear her breathing--gurgling noises, each ending with a whimper--and I could see the muscles between her ribs suck in and out as she struggled for air. Her skin felt warm despite its ghastly appearance and had a sour acrid smell, the aroma of sweat saturated with lactic acid. Brown fingertips betrayed years of smoking. At the touch of my hands she half opened her eyes and stared about her with quick darting movements. Her pupils were wide with terror, dilated by the flood of adrenaline mat goes with dying, and her gray hair splayed out wild and tangled over the pillow. The worst was when those black eyes glared at me. Even in her agony, gasping and unable to move or speak, her expression seemed to say. You sent me home.
I smothered a rising wave of alarm and guilt as I placed two fingers at the right side of her neck. "Pressure?" I asked, trying to sound in control. I could barely palpate a pulse in her carotid artery.
"Eighty over zip. Doctor," replied the nurse who was at the patient's head. She was applying a translucent green oxygen mask and attaching the tube to a hissing wall outlet. "I just took it. And the pulse is one-twenty and irregular." She'd already wired the woman to a cardiac monitor. The erratic beeping accompanying the rapid squiggle on the screen above me was far from reassuring. "I think it's atrial fib," she added, as she watched me study the tracing. She was right.
When I didn't reply, she asked, "Aren't you going to cardiovert it?"
Her tone made it clear she thought I should try to shock the heart back into a normal rhythm. I shook my head. "It may be the result of the shock and not the cause." I forced myself to concentrate to keep thinking this through.
Two other nurses trying to start IVs in the woman's arms crouched at opposite sides of the table. Bags of saline had been suspended in readiness from overhead poles. "Got it," announced Susanne Roberts at my elbow. She was the head nurse and, like me, a twenty-year veteran of these desperate struggles. Without waiting for instructions, she reached up and adjusted the valve in the clear tubing that dangled from one of the bags of fluid. She then stepped around the foot of the bed and came to the aid of her much younger colleague, who'd just muttered, "Damn!"
The nurse at the head of the table reached past me to clip an oxygen monitor to the tip of one of the patient's fingers. Yet another machine began beeping behind me. "02 sat's only eighty percent," she commented grimly, meaning the blood oxygen level was dangerously low.
"The first person free," I said, "get me a twelve-lead cardiogram, and I want a portable chest stat. Get someone else in here to draw bloods and catheterize her."
"Routine bloods are drawn and gone. Dr. Garnet," Susanne informed me as she started the second IV, "and X ray's been called." Then she nudged her flustered helper and quipped, "Even if he is chief of ER, I hope he knows enough to want blood cultures because I ordered them as well."
This time I barely managed a curt nod as I quickly slipped my stethoscope into my ears and listened to the woman's heart sounds. Susanne gave me a puzzled little glance.
Normally I welcomed her sassy wisecracks and joined in the fun. It was how we kept the rookies relaxed.
I moved the stethoscope to the lower right side of the woman's chest. Barely any air moved in her lungs. What little flow there was wheezed and crackled as it passed through--what? Fluid? Pus? Both? A listen on the left revealed more of the same. She was in warm shock, probably caused by sepsis--an overwhelming infection spread into the blood stream--with pneumonia being the most likely primary source. Yet I continued to check elsewhere. Stepping around the tangle of ECG wires Susanne was hooking up, I palpated the abdomen and examined the lower extremities. Nothing. But when I moved back up to the patient's head and flexed her neck, checking for stiffness and evidence of meningitis, her eyes still followed me and I had to endure that stare again. Look at what you've done to me!
I shuddered but kept myself focused on treating her. "Okay, everyone, this is an infectious case, septic shock, probably from overwhelming pneumonia of some kind, and isolation is in force." We were already wearing masks and gloves as a general precaution. Isolation meant donning surgical gowns for additional protection against bodily fluids and discarding all this protective gear in a bin at the door whenever we left the room. Such measures were intended to protect us and the other patients in the rest of the hospital. Hopefully. The circus I was about to create wasn't conducive to the confinement of deadly microbes.
People were running in, fumbling with back ties on their half-done-up masks and gowns.
I kept giving orders. "Keep the IVs open, raise her legs, but give me vitals every few minutes. We don't want to overload her. And get me an inhalation therapist fast. We need to intubate this lady and help her breathe now!"
But my words sounded hollow. When I turned to speak specifically to Susanne, I found it hard to look her in the eye. "When whoever you called to take blood cultures gets down here, have him culture and Gram-stain everything else as well--sputum, urine, CSF, even stool--and repeat the blood cultures again in thirty minutes if we get that far." While talking, I was already struggling into a green OR gown I'd gotten from one of the racks where we kept gear for dirty cases. "Get one of our residents to do the LP," I added, praying that no one would see through my phony show of calm.
The lab tech arrived with a basket of tubes and swabs.
I stepped to the top of the bed behind the woman's head and flipped off her oxygen mask. She'd started to cough, and yellow foam was seeping out between her lips. Mercifully her eyes were now closed. "Get whoever's on call for ICU and ID," I said over the rising voices. I grabbed a rigid suction catheter from the wall beside me and opened the valve that activated it. "And tell ID if they don't get here fast, we'll choose their antibiotics for them." Infectious disease consultants, by definition, never liked our choice of treatment, even when we got it right. Today I knew I needed their help.
I put my gloved fingers into the pus streaked with blood flowing from her mouth and scissored open her teeth. Through the thin latex I could feel the debris was thick and warm. How could I have allowed her to get like this? Whatever I thought of her, she was one of our own. With the recriminations, I broke into a sweat.
"Let me culture that gunk before you suction it out," ordered the lab tech who'd just finished drawing off the bloods. He pushed by me, took a sterile cup and gingerly scooped up a glob of the stuff as it rolled out the corner of her mouth. He'd mount a dab of this sample on a glass slide and color it with violet and iodine solutions, the ingredients of a Gram stain. In twenty minutes he' d have it under a microscope and know what was killing her. He then plunged several long Q-Tips into the pool of secretions welling up at the back of her throat. Her whole body bucked as she gagged and choked while he poked about. Small yellow droplets flew onto the front of my glasses. When he withdrew, thick strands of the purulent sputum dripped from the ends of the swabs. These specimens would be plated onto various types of agar in which the organism would be grown to determine what antibiotics, if any, it was sensitive to. "That'll do it," he said, sliding the cultures back in their containers of charcoal growth medium and sticking labels on them.
I stuck the catheter into the woman's mouth. The unsightly debris vanished noisily up the tubing. She still bucked at the stimulation, but less than before. I focused my thoughts enough to verify there was no evidence of tonsillitis or discoloration of her mucous membranes to suggest a toxic shock syndrome. But would she tolerate intubation without sedation? My hesitancy disgusted me.
"I've got it. Earl," said a familiar voice at my side, and Dr. Michael Popovitch reached across me, a laryngoscope in one hand, an orange endotracheal tube in the other. Even if he hadn't spoken, the pepper-and-salt beard sticking out from the corners of his mask and the unmistakable pear-shaped physique under his surgical gown made him instantly recognizable. He was both director of teaching and my associate chief in ER, but more important, he was also my friend.
"Thanks, Michael," I said, moving out of the way.
He slipped the curved steel blade of the scope alongside her tongue, opened her airway to illuminate her vocal cords, and slid the tip of the curved rubber device into the woman's trachea. She immediately heaved and blew out some more of the yellow slime that was clogging her bronchi, then fell quiet. As he started ventilating her, the inhalation therapist ran up and took over. Michael stepped back, then led me by the arm away from the table to where we wouldn't be overheard.
"Earl, what the hell's the story with this lady? And are you okay? Christ, you're pale, you're sweating--" He suddenly looked horrified. "Oh my God! You haven't got chest pain have you?"
I took a breath. "The story with this lady, Michael, is that her name is Phyllis Sanders, she's in her fifties, and she's an OB nurse at University Hospital. Eighteen hours ago she presented here with a slight cough, minimal fever, and a touch of diarrhea. I assured her she only had the flu and sent her home."
The rest of the resuscitation raced on around me. Residents eager to do procedures rushed into the room grabbing needle sets and ripping open packets for central lines. Michael hastily reined them in and orchestrated their frenzy into specific tasks. The beeping sounds from the monitors and the shouted orders for blood gases and LP trays seemed distant.
She needed antibiotics. But I couldn't organize all her symptoms and signs to point to a likely organism and make the choice clear. All that pus suggested a gram-positive coccal infection, probably pneumococcal, but other parts of the pattern didn't fit, nagged at me, hinted at something unlikely and atypical. Or was I just trying to let myself off the hook... make it seem more complicated than it was to justify my screwup?
A sudden stench in the room told me someone had gotten a stool sample. Even though her source of infection was obviously in her lungs, the emergence of drug-resistant infections in many U.S. hospitals made screening her feces for VRE, vancomycin-resistant enterococcus, mandatory and routine.
I wasn't waiting for ID. "Hang up two grams of ceftriaxone in one IV, and one gram of erythromycin in the other," I told Susanne as I saw her get off the phone. I'd cover a mix of possibilities for now.
"ICU is ready for her as soon as you can get her up," she reported as she wrote out my order and handed it to one of the orderlies she'd stationed at the door to act as runners.
We got Phyllis Sanders's pressure to rise a bit, started the antibiotics, and snapped a portable chest X ray before whipping her off to ICU, where they would put her on a respirator. We even managed to slow down her heart with a bit of intravenous digoxin. The X ray confirmed my diagnosis of pneumonia--her entire right lung and part of the left were whited out by the infection--but by then the woman had drifted off into a coma. Her blood results, when I finally got them, were a disaster of falling white counts, rising liver enzymes, and increasing renal failure.
Michael had tried to be supportive when he'd gotten over his initial surprise at my declaration, assuring me he was certain I'd acted reasonably, but his reassurance hadn't helped. Even when he looked at my notes on her chart from the previous day's visit and said he couldn't see how he'd have acted any differently, I replied, "Given what happened, I should have kept her."
"On what grounds?" he challenged. "A little bit of temperature? Look at the resident's workup. For once we can be thankful about their habit of ordering too many tests. Apart from a slightly elevated white count and a sodium of one-thirty-three, everything else was normal, including the physical exam. Christ, the guy even ordered a chest X ray, which frankly I wouldn't have done. From his note, apparently there wasn't much on that either."
"A bit of COPD from smoking, and a minimal horizontal line in the lower right lung we thought was either old scar tissue or atelectasis," I interjected, precising the report from memory. We were huddled in a quiet corner of the nurses' station, a large central room with huge windows looking out on the rest of the department. I kept watching over Michael's shoulder for ambulances in triage or new patients in the surrounding bed areas, but for the moment the city of Buffalo had given us a breather and ER was quiet. Our residents seemed to be handling whatever few cases the nurses had brought in. "Obviously that little mark was the start of infection and was a lot more significant than we thought," I added, sounding pathetically morose even to myself.
"Bullshit!" Michael said, loud enough for anyone in the station to hear. A young medical student looked up from her computer screen, but no one else paid him any mind. He immediately lowered his voice, but not his intensity. "If a radiologist says that film suggests anything more than what you called it, he's a liar. No one could predict that little mark was brewing into what she had today, certainly not without a previous film to compare it to--which, by the way, makes me wonder why she came here to St. Paul's instead of the staff health service at University Hospital."
"She was on vacation, St. Paul's was closer to her home, and she said she didn't like everybody at work knowing her business anyway," I answered, only giving part of the reason. In fact she had phoned in ahead of time and found out I was on call. "I work with his wife," she'd announced at triage, putting everyone on the defensive. She'd increased the level of discomfort even further by proclaiming, "And my son's the chief technician for the labs at her hospital." By the time she'd done the same routine with the resident who'd initially assessed her--browbeating him into ordering more tests than he might normally have asked for--anyone who went near the woman resented her. I only learned all this from the clerks and nurses after I'd sent her home. But I'd already taken my own dislike to Phyllis Sanders.
"I know Janet, Dr. Garnet," had been her greeting when I'd appeared at her bedside to review her case with the resident.
Dr. Janet Graceton is my wife, an obstetrician at University Hospital. I met people all the time who announced they knew her, had had their children delivered by her, thought the world of her, but this had been different. I felt I'd had my chain yanked.
"I've heard so much about you as well," she'd continued in a high whiny voice. Sitting up in her hospital gown, her arms crossed in front of her chest, her gray hair pulled tightly back into a bun, she'd seemed rigid, held in. She'd forced a smile, but it had looked like a reproach as her forehead frowned while her lips turned up. All the while her eyes seemed to say Are you going to disappoint me too?
I'd resented her immediately and had been particularly repulsed by her attempt to use her acquaintance with Janet to manipulate me.
When she'd told me her son's position and then added, "He's worked with your wife too, you know," I'd barely kept the irritation out of my voice. Go do your wheedling for special treatment in someone else's ER, I'd been thinking while explaining she'd nothing much wrong with her.
"How long did you say she'd been sick?" Michael asked, snapping me back from my thoughts.
"Only a day," I answered, trying to keep my words steady and not sound defensive. "She'd had a slight headache when she woke up that morning, then the temperature and diarrhea."
"It doesn't sound like much to bring a nurse into ER. I wonder if she chose Saint Paul's over her own staff health service because they had her number there and knew she was a malingerer?"
"Maybe," I answered, not admitting that was exactly what I'd suspected as I'd firmly insisted she could go home. "Obviously she wasn't malingering this time."
Michael gave me a smile and clapped his hand warmly on my shoulder. "You made a solid call. Earl, given what was there. Hey! After all your years in the pit, you of all people should know you can't beat yourself up over every disease that turns nasty." He finished signing off his part of today's resuscitation, handed Sanders's chart back to me, and added, "When this case is reviewed, everyone will agree with me." He then strode briskly out of the station and over to where a new ambulance case had been rushed into triage.
He'd meant to support me, but the mention of a case review unleashed once more the sense of dread I'd been trying to control. All unexpected return visits trigger investigations to identify possible slipups. I'd instigated the mandatory checks myself when I'd first become chief over eight years ago. But not all physicians at St. Paul's Hospital had appreciated my setting up an arena where their errors were dissected and laid bare for critical scrutiny. Whenever I had a case on the schedule, more than a few of these doctors turned up hungry to settle old scores. This time they might have a point. As I signed off my own notes, my memory of yesterday's encounter kept playing over and over. Had my resentment toward the woman made me miss something?