by JA Schneider
Levine followed after her.
“Why sure,” said Mackey heartily, turning back to Tricia. “Always glad to help.”
“Why the scowl?” David Levine asked.
“Who’s scowling?” Jill said, aware of the brittle tone in her voice.
“You are. Come on, what’s the matter?”
Jill had made the mistake of marching up the hall in the wrong direction, only to find herself blocked by the double swinging doors which led to the delivery area. There remained only one refuge: a walk-in linen closet. Levine had followed after her and now stood, leaning on the jamb, his tall, broad-shouldered frame blocking the exit.
She kept her back to him, pawing furiously through a pile of sheets pretending to look for something. She felt his eyes on her.
Abruptly he said, “I’m sorry I yelled.”
She hadn’t expected that. She stopped, stared at a stack of white towels, then slowly turned. He saw with surprise that her eyes were tearing, her cameo-perfect face blotchy. Quite a contrast to the way she had looked eleven days ago on the first day of internship. The new bunch had arrived on the floor looking like awkward schoolchildren, except for Jill Raney. She looked confident and relaxed – not surprising since she was already an old hand around here. Coming from the med school, she had already spent her fourth year in clerkship on the hospital floors, caring clinically for patients and generally getting to know her way around. Her clerkship – like all of them – had been a rotating one, but David had seen enough of her, darting in and out, to decide that she was a babe. Once, the week before internship began, he had shown the group around the OB floor. Their glances had met, she smiled at him, and he was thrilled.
Now he leaned with his arms folded and watched her, disappointed. She wasn’t smiling anymore.
Her slender hands clenched. “Oh, you didn’t yell,” Jill said in a faintly supercilious voice. “All you did was make a complete ass of me in an ordinary voice. ‘No comments allowed from the munchkins,’” she mimicked angrily. “Everyone thought it was just hilarious – including the patient!”
He dared a smile. “They say it’s the best medicine.”
“Well, I call it lousy medicine!” She made a swipe with her hand and sent packages of gauze flying. “Hollins wasn’t like the other cases. She needed Pentothal, not five lousy milligrams of Valium. How can you do an amniocentesis on someone who’s practically jumping off the table?”
Another resident would have decapitated her for mouthing off like that.
Levine unfolded his arms and straightened. “Well, we did it, didn’t we? The less medication the better for the baby. All Hollins needed was a few minutes to calm down, and Procaine’s a great painkiller.” He held up his finger. “Now you, kiddo – ”
“Don’t call me kiddo!”
“ – spoke out of turn.” He let some anger rise. “You scared the patient. Interns are supposed to observe and keep their mouths shut and do what they’re told!”
His face colored as he stepped closer to her. She took a step backward, her eyes glaring with fury.
“Flaunty egotist,” she hissed.
“Bratty sorehead,” he returned.
Then she burst into tears.
Levine blinked at her. Would he have been this absurdly nice if he weren’t already attracted?
“Aw, come on.” Awkwardly, he reached out to her and she yanked away, turned her back again and found herself quelling sobs before a pile of toilet paper.
Damn, he was glad no one was seeing this. Drunks in a bar were easier to deal with than a crying woman! But here he was, confronted by a delicate, rather brilliant and thoroughly annoying young woman, and he was at a loss.
Time for a different tack.
“Okay, Dr. Raney. Tantrum’s over. I know all about your impressive scholastic background, and starting from square one again must be hard on your vanity.” Her back was still turned. She was sniffling quietly. He went on in a lower voice.
“You’re going to find that putting an M.D. after your name doesn’t make you a doctor. That takes longer. And if you can’t manage a little give and take around here, you’re not going to make it. Med school’s just a sandbox compared to what’s ahead. Got that?”
A long moment passed. She turned her head toward him. Her face unpinched a little, she looked at him with those achingly vulnerable green eyes, and then looked away.
He heard his name being paged. Well…they could wait thirty seconds.
“Jill.” He bent his head, tried to look into her face. “Hey, you’re assigned to me. You and the others. I said I’m sorry. Do you think we can work together?”
She shrugged and gave a weak nod.
“I’m sorry too,” she said in a low stifled voice. Her head dropped down. “I’m an insecure, overcompensating jerk.”
Awww…
Impulsively he reached out and pulled off her surgical scrub cap. He had wanted to do that since he chased her into this place. Her long, dark hair fell to her shoulders and framed the high cheekbones, the beautiful face. He held his breath.
A harried-looking Sam MacIntyre poked his head around the door. “David, page. Want me to take it for you?”
Wrenched back to reality. “No, I’ll answer,” David said, handing Jill back her scrub cap. “But do something else? Tell the interns to take the Hollins specimens up to Pathology.”
Sam turned and looked down the hallway. “Looks like they’ve already left for Pathology. And took the lab rack with them, it appears.” He snorted laughter and looked back in. “Can you beat that? The pups are getting housebroken - oh, sorry, Jill.”
He gave her a sheepish grin.
She surprised him with a faint smile.
Sam left and David turned back to her. She was stuffing her hair back into her surgical cap.
“The page,” he started, and his cell phone beeped. He answered and listened intently. Then stiffened; repocketed the phone.
“The others have left the floor,” he said. “Something just came in to Emergency, and they can’t handle it. Woody said it’s an obstetrical nightmare.”
Jill was beside him. “Stairs or elevator?”
“Stairs are faster. All set?”
He turned and hurried out. She followed.
They ran down the hall and past the nurses’ station. At the far end they pulled open a steel door, and pounded down five flights of stairs as if somebody’s life depended on it.
3
Rounding the last landing, they rushed down the wide E.R. waiting area. The place was bedlam. Outpatients milled and watched them curiously. The paging system was louder down here to override the noise. “Dr. Levine. Calling Dr. Levine. Emergency Room, please.”
Every chair lining the periphery was filled; children cried; ailing or injured people and their relatives formed a check-in line that stretched from the main entrance to the long reception desk. Clerks and nurses at the desk looked harried. Phones rang, while tall stacks of patient charts threatened to topple. To one side, an anxious group argued with an exasperated doctor. Rap music boomed from a knot of kids watching a man near them bent over double.
Jill stopped and did a double take. The man was about ten feet away from her. Bright veins mapped his nose and cheeks; his clothes were tattered and he was having a coughing fit. Suddenly he clutched his ribs and began to vomit blood. “Shee-it,” yelled one of the rap kids, rescuing his Xbox. Two policemen at the entrance stood by impassively. They were here for somebody else.
“David!” she cried. Levine turned, followed her gaze, and gestured to two orderlies who were fast approaching with a gurney. “We’ve got a hot one too.”
They rushed under the E.R. arch and down the busy corridor. Doctors and nurses whisked past in both directions, and Jill recognized another new intern carrying wet X-rays. Levine wove rapidly ahead. Trying to catch up, Jill collided with a rolling green laundry basket full of bloody sheets, turned to excuse herself to the orderly pushing it, and was rammed by a lab tec
hnician wheeling a table filled with test tube racks. She felt dizzy. Heard Levine ahead, calling to her; then he disappeared around the corner.
She ran.
Passing a trio of cops, she raced under a second arch and through the busy, large gray room. She caught up as David reached a far cubicle on the right. The only thing separating the cubicle from the pandemonium outside was a flimsy nylon curtain. He flung it aside.
Inside four people crowded around the bed. Two nurses were on the left, one adjusting a blood pressure cuff, the other tearing open a package of tubing. On the right two young doctors in scrub suits worked near the head of the bed. The taller one, Jim Holloway, was nervously eyeing a fetal cardiac monitor. The other, Woody Greenberg, was fussing with the position of the disk electrodes on the patient’s chest. Both were first year residents. Both looked overwhelmed.
Woody glanced up at Levine as they entered.
“Omigod, David, what do you make of this? We’ve never seen it!” He stumbled over his words. To Jill, the already wiry young man looked as if he’d just sweated off five more pounds.
David hurried around the bed as one of the nurses moved in front of Jill. She craned; the nurse moved on, and Jill stared.
On the bed lay a young woman, about eight months pregnant, bleeding profusely from her nose, mouth and ears. Her still face and closed eyelids were grayish-blue. Her arms and torso were covered by spreading areas of black and blue, as if she’d been beaten and was still getting beaten. Blanketing her skin was a sheen of sweat.
Woody’s piping voice gave David the case’s rundown. The young woman’s name was Maria Moran; she was twenty-eight; she had collapsed uptown and been brought in bleeding from every orifice. Her blood pressure was down to 70/40, her pulse was 140 and “thready” – too rapid and barely discernible.
“And look at the nails.” Holloway grimly lifted a gray bruised hand by the wrist. A wedding ring glinted feebly.
“Cyanotic,” Levine said tightly. To one of the nurses, “Nan, I’ll need sterile gloves and an OB pack.” And to the two younger doctors: “Okay, what’s been done so far?”
“Started an I. V.,” Woody piped rapid-fire. His hair of sandy corkscrews was darkened by perspiration. “Drew blood for hemoglobin and hematocrit, ordered a type and cross match, sent off the SMA-12 blood chemistries and ordered a complete blood count…” He stopped, winded.
“Also ordered a bleeding and clotting workup,” said Holloway, his eyes glued to the patient. “I’m not even sure why we ordered it, except that at the rate she’s dropping…”
There was a snapping sound as the nurse helped David on with his surgical gloves. She looked at him and shook her head. “She was pink when they brought her in. Honest, pink. I never saw anything like this.”
Frowning, Levine bent and his gloved hands felt the woman’s abdomen. “Uterus is as hard as a rock.” No one spoke. Sixty seconds passed while his experienced fingers pressed gently, here, there. The huge, knotted contraction did not even begin to let up. Levine’s eyes became troubled. He understood.
Woody Greenberg had brushed by Jill and was now peering anxiously outside the curtains. “Ginny’s supposed to be back from hematology,” he said. “Jeez, what’s taking her…”
“Forget it,” said Levine.
They all looked at him.
“Abruptio placentae,” he said softly. Jill’s lips parted. The disorder he had named was to most a word found only in textbooks. It was rare. It was the most bizarre of obstetrical mishaps, and it was bad.
With his left hand still on the patient’s abdomen, Levine reached up with his right hand and pressed a red button. “Hematology!” he called. “Ginny Tata, are you there?”
An electronic babble of voices answered him.
“Ginny, don’t wait for the chemistries,” he said. “Run to the blood bank and get eight units of fibrinogen stat! Also two units of whole blood and two units of packed red cells. Got that?”
There was a crackling, high-pitched response and David switched off.
For seconds he stood, staring at the hanging I.V. bottle. Then he bent and began helping the second nurse remove blood clots from the patient’s nostrils.
Jill stood frozen at the foot of the bed. Futilely she clutched her stethoscope, knowing there was nothing she could do except watch as Levine managed the case.
“Before anything,” he was saying, “you have to get the blood pressure out of shock level. Then we can take her up to the O. R. and do a Caesarean.” To the second nurse he said, “Cathy, give her eighty milligrams of Aramine.” And, glancing over at Holloway: “How’s the fetal heartbeat?”
“One-sixty and rising,” said Holloway, watching the fetal monitor positioned next to the maternal monitor.
“That’s starting to sound like trouble, isn’t it?” Levine said.
“Yep,” Holloway said tightly.
Jill had trouble finding her voice. “If you stabilize her do you have to do a Caesarean?”
“If is a big word,” said Woody Greenberg.
Levine said nothing as he watched Cathy administer the Aramine. Jill knew he was trying to elevate the blood pressure. She could hear his rapid breathing. “Nan,” he said. “We’re going to need two lines open. Start another I.V. in the left antecubital. When the blood arrives push it in as fast as you can. And on the other side start the fibrinogen, right into the tubing, okay?”
“Got it.”
The nurse named Cathy opened a fresh box of cotton swabs. Jill glanced into the bin where she’d been throwing the blood-soaked swabs. It was almost full.
“Dammit, where’s Ginny?” David said to no one. Jill helped the nurse named Nan hook up another bottle of 5 percent dextrose in saline, then heard Levine’s voice again, sounding solemn.
“Abruptio plancentae,” he said gravely, bending to check some tubing, “is sudden and dramatic. It involves the separation of the placenta from the uterus before the child is born. Usually this is for reasons unknown, and the results are devastating.” He straightened. “What happens is like a dam breaking. The amniotic fluid pours into the maternal circulation, the mother’s veins, reducing the blood fibrinogen level, which in turn causes massive internal hemorrhaging.”
He took a surgical sponge and mopped the bright glistening area stretching from the woman’s nose to her ear. Her hair was matted. The pillow was soaked red.
“Due to blood loss,” he continued, “the patient goes into lightening shock. Diagnosis is hypofibrinogenemia. It happens so fast, that’s what makes it so hard to control…” He stared at the pretty, blue-gray face and inhaled. “The next ninety seconds will tell us if a Caesarean is academic.”
As if by cue they heard a commotion outside and then, with a whisk of the nylon curtain, nurse Ginny Tata burst into the cubicle. “Need my skates,” she huffed, depositing four vials and four red-filled plastic bags on the supply table.
Levine looked over at Greenberg, who had just removed a blood pressure cuff from the patient’s left arm. “B.P.?”
“Plunging,” said Greenberg.
“Doctor…I…” Levine turned toward Nan’s tight voice and said, “Oh Christ.” Jill saw that the nurse had been trying and failing for the last three minutes to insert the new syringe into the vein on the patient’s inner arm. It was no use. The patient was in deep shock; the veins had collapsed and gone too flat to penetrate.
Everyone started talking at once. Woody yelped about the fetal monitor and Holloway and the nurses emoted unintelligibly.
“Jill,” Levine called over his shoulder. “How fast can you do a cutdown?”
A cutdown?
“I’ve never done one.” Her heart started beating hard and she was terrified. “I mean, I’ve memorized it from books and seen it done but I’ve never - ”
“Here’s your gloves.” Cathy stood before her holding up surgical gloves.
Jill pushed her hands into them. She was trembling.
Jerkily, she moved to the patient’s feet. Cathy
hurried a scalpel into her hand while Nan pulled up the sheet to the patient’s knees. David called for eight milligrams of Levophed in a stepped-up attempt to raise the blood pressure. Bending, he supervised the insertion of a nasal oxygen catheter through one of the patient’s nostrils. Turning his head frequently, he watched both the fetal and maternal heartbeats on the two beeping monitor screens.
“Ninety over sixty, with a pulse of one-sixty,” Greenberg said gravely.
“Shit,” Holloway said.
“Fetal distress!” It was Levine’s voice. “Fetal heartbeat’s gone from 160 to 180 and dropped back down to 100.”
God, what now? Jill thought. Caesarean? Here? No, no way. More blood loss would kill the mother instantly. The cutdown was the last chance…
She concentrated. Lowering the scalpel, she held it poised over the patient’s ankle. Then she made a quick incision about an inch wide above the ankle. The skin gaped, like an eye opening wide, revealing a flat, blue vein. She blinked at the cut. The incision was neat, a perfect perpendicular to the vein. She breathed rapidly. Peripherally she heard voices at the head of the bed. Someone was yelling that the patient was fibrillating. She heard a command for Lidocaine – good, they’ll shock her out of it – and tried to concentrate.
Vaguely she was aware of one of the nurses injecting the Lidocaine into the I.V. line, of someone in a scrub suit placing the defibrillating paddles on Maria Moran’s exposed chest.
“Everybody off the bed!” Levine said. Without looking up Jill took a step backward. Levine activated the powerful electrical charge; Maria Moran’s body arched violently; the arms flailed and then flopped forward, across the chest.
A moment passed. Jill heard the electronic blip reappear on the screen. At the “all clear” signal she stepped forward again with her scalpel. Quickly she threaded two silk sutures under the vein, tied the bottom suture and with her left hand exerted traction to pull the vein free. With her right hand holding the tip of the scalpel she nicked the vessel open, then took the polyethylene catheter somebody handed her and began to thread it into the vein and up the leg. I’m doing it! she thought, feeling a thrill of confidence surge through her. Only a few more inches of threading to go and she could hook up the other end of the catheter into the I.V. and they’d have two good I.V. routes going and then they could push blood in faster…
