Death Flight

by Melissa Yi

  "A cystoscopy, which is a camera? Or a scan?"

  "I don't know." She played with the rings on her fingers. She seemed to have shrunk and aged about 20 years.

  "Okay, it doesn't matter. Did anyone find the list of medications?"

  Mrs. Yarborough said, "It's on his phone, and I don't have his password. He's—paranoid, I'm afraid."

  Join the club. Out loud, I said, "Let's lie him down in case he's anoxic." Even in first class, the seats don't lean all the way back, and we needed as much oxygenated blood as possible flowing to his poor brain. Since we hardly had any room, Tucker and I tried to lie him down sideways, using his wife's aisle seat as a pillow. The purse on the seat made a plasticky and rattly sound that I recognized over the rumble of the engine.

  "Hey! You've got his medications in there," I said.

  Mrs. Yarborough stared at me.

  "In your purse. You thought you packed them. I heard some pills in there. I know it sounds funny, but I've got good ears." I reached for the purse.

  She picked it up first, unzipped it, and lifted out a white plastic bag. "I was sure I packed them."

  Maybe she was losing her memory, too. I stayed cheery. "Good thing you brought 'em. A list is better, but we can catalogue these." It would be a lot faster than quizzing her about his prostate cancer history.

  Linda said, "I'll make the list. Could I have the bag?" She grabbed it in one hand and slipped out her phone with the other, ready to make notes.

  I hesitated. I'm a control freak. I wanted to go over those medications myself. On the other hand, it was a relatively unskilled task. I had to focus my brain cells on stopping his seizures.

  Tucker waved his hands to get my attention. "Cations next. Sodium, calcium, magnesium."

  We both paused to contemplate that. I said, "That could be it. But how are we supposed to test that on an airplane?" I turned to Linda and Pascale. "Can we do a blood test on him?"

  "You want a blood sugar monitor? We have one," said Linda.

  "No, not his blood sugar. We already did that. I want his sodium, ionized calcium, and magnesium levels. Can you ask the flight doctor?"

  Linda wavered. "I'll ask. Pascale, can you make the medication list with the doctor?"

  "Yes, ma'am." Pascale accepted the white plastic bag. This was a messy code. That was the problem with not enough skilled people. At a hospital, I yell, "I need a meds list!" and someone gets one, either locating a pharmacy slip in the wallet, calling a drugstore, or requesting a fax from the government. Similarly, I say, "CBC, lytes, BUN, creatinine ... " and someone is obtaining them before I close my mouth.

  Right now, we were on an airplane with nothing. Just me and Tucker, one dead man, one seizing man, and a killer lurking among us.

  32

  The white plastic bag crunched as Pascale pulled a full bottle out of it, oblivious to my frustration. "This is—Tradjenta?"

  "Right. It's a diabetic medication." It was better to have a task to ground me. Maybe I was a working dog, too. I took the bottle and wrote the name down in a little notebook that Pascale had handed me, along with a pen. The Americans seemed to have added an extra d to Trajenta, but it was recognizable. "Five milligrams. Okay. Let's separate the ones we've already done." I pushed the Tradjenta in the closest seat pocket.

  Pascale stared at the next bottle for a blank second. I passed the notebook over to her and said, "Look. I'll call out the names, and you write, okay? You probably have better handwriting than me."

  While I grouped the medication bottles together by type, Tucker said, "D. Drugs. I've got another mnemonic for that. CRAP. Cocaine, Rum—or some other alcohol—Amphetamines, PCP."

  "Where can I get some of those?" called a man’s voice. I smiled as I clumped together Mr. Yarborough's drugs for diabetes, angina, high blood pressure, high cholesterol, reflux, depression, dementia, all filled two days ago, and—pay dirt on the last bottle. "Tucker, he's on Apixaban."

  Tucker stopped in the middle of his monologue. "Two point five mill?"

  "No, five." I frowned at my own words. He was on the higher dose, and at a higher risk of bleeding, especially if his kidneys crumped.

  "What is it?" said Pascale.

  "He may be bleeding in his head, and that's why he's seizing. This is a blood thinner." I turned to Mrs. Yarborough. "Did he fall and hit his head?”

  She shook her head. "I don't think so, unless he hit it in the bathroom without me.”

  This was not helpful. I raised my eyes to Tucker. "We can't reverse the anticoagulation right now."

  "No? No Andexxa or PCC on board?" he said, which was a joke, but I couldn't laugh. We couldn't check Mr. Yarborough's calcium. We couldn't drain a brain bleed. We couldn't correct an ischemic stroke. I felt so helpless. I always secretly worried that I'd be useless in a zombie apocalypse, with precious few antibiotics and no imaging, and that was exactly our situation now. My shoulders slumped. "Does anyone have Ativan or Valium?" I called.

  Linda returned from the cockpit, already shaking her head. "We don't allow other passengers to share their items."

  "Even though it's an emergency?" I said.

  She shook her head again, but she looked troubled. "I'll have to get permission from Avian Air."

  "Status epilepticus causes brain damage! Neurons die, he could choke, he could have a heart attack—" I said.

  Mrs. Yarborough moaned from the aisle. She'd been pushed so far back behind the flight attendants, she was close to Trina, who leaned away from the aisle.

  "I'm sorry. I'll have to ask first," said Linda. "I just wanted to tell you that the flight doctor said we can't test for anything except glucose on board. Everything else, we must land the plane."

  "And when is that?" said Tucker.

  "About 30 minutes," she said.

  The pilot had estimated half an hour about fifteen minutes ago. It felt like we'd never get off. I tamped down my panic.

  "These are for you," said Linda, showing me two bottles. "I accidentally walked away with them when I started cataloguing the medication."

  "Hey! Those are Seroquel and Clonazepam." The latter is in the same family as Ativan, although it has a longer half-life. As in, it would take twice as long to clear Clonazepam out of his system compared to Ativan. That would be dangerous if we overdosed him and he stopped breathing.

  On the upside, he'd also stop seizing, and we could intubate him to protect his airway. It wouldn't stop the electric activity in his brain, but it would make me feel better.

  I popped open the bottle and counted ten Clonazepam pills.

  "He might be having a withdrawal seizure from the Clonazepam," Tucker pointed out.

  "All the more reason to give it to him. Now." I eyeballed Mr. Yarborough, who was still shaking and rattling, although not rolling, and still mostly sitting up. "I usually give it IV." Clearly, the blue pill was not an intravenous form. We could crush it and try to dissolve it in something, but would probably end up giving him Streptococcus instead if we tried to inject it.

  Tucker shook his head, and I bit my lip. "We could try under the tongue."

  Ativan is great under the tongue. It's one of the only drugs we give SL, or sublingual (along with nitroglycerine, which was another one of his bottles). But Clonazepam looked pretty small, and he only had the 0.5 mg tablets. According to the bottle label, he took these twice a day. He might choke on it. Even if we crushed it, he might choke on the spit. Maybe if we mixed it in applesauce and painted it on the inside of his cheek again?

  "I can push it rectally," said Tucker.

  "Thanks, man."

  Tucker raised his eyebrows in a You owe me way, but I smiled and said, "Everyone, please stand back and give Dr. Tucker some privacy." I might even have said priv-a-cy, with a short i, the way the British do, to give him extra decorum.

  "What are you doing?" said Mrs. Yarborough.

  "I need access," I huffed. Even in business class, there's not much leg room to roll over a sizeable old man who's convulsing on a sw
ooping airplane.

  "Stop!" She thundered toward us.

  "We're giving medication to stop the seizures. Please, Mrs. Yarborough," said Tucker in his most charming way.

  "Stop touching him!" She grabbed Tucker's arm.

  I had only barely started to unbuckle his leather belt. "It's because he might choke on the pill, even if we crush it. This way is safe."

  "No! He—wouldn't want this! He's DNR!"

  I hesitated. "Mrs. Yarborough, that means no heroic measures. But this isn't a heroic measure. We're only putting a pill or two up his back end. It won't hurt." Especially if we found some lube.

  "I said NO," she hollered, flinging her arms wide open, nearly clipping me in the head.

  I ducked. "Someone take her out of here. Pascale!" We've done mock codes before where someone pretends to be an obstructing mother. It's impossible to run a code that way. You have to get someone to take charge of the mom and yank her out of your way.

  Pascale tried to tug Mrs. Yarborough behind the seats, but she stood her ground. "No! You're assaulting him! I'm the one who speaks for him! You can't strip him naked in front of an airplane! He would rather die!"

  Tucker and I both paused. Consent was a tricky issue. Mr. Yarborough was unconscious, so his wife had to speak for him. "Do you have your DNR papers?" asked Tucker.

  "Of course." She rummaged in her black bag and lifted out her iPad. "I hope it works. If not, I have it on my phone. I can text it to you."

  The tablet screen worked, displaying a neon pink form different from the one we had in Canada, but easy to understand. She had ticked off both the boxes "Do not attempt resuscitation" and "Comfort-focused treatment."

  I let go of Mr. Yarborough's pants.

  She was calmer now that we'd backed off of his buttocks. "And doesn't he have his bracelet?"

  "What bracelet?" I had a bad feeling about this.

  "His DNR/POLST bracelet."

  I understood DNR, for Do Not Resuscitate, but not the second one. She said, "POLST. The Physician's Order for Life Sustaining Treatment. That's the form I showed you."

  Sure enough, when I glanced at her screen, the heading was POLST. Although the name suggested it meant you had to sustain life at all cost, or that's the way my emergency-trained mind worked, she had signed not to do that.

  "There's no bracelet," said Tucker, who had pushed up both of Harold's sleeves.

  "Well, that's strange. It's not supposed to fall off," she said. "Maybe he pulled it off at some point."

  I was more concerned with the fact that he was still staring into space and tweaking his arms, with an occasional leg twitch. "How long has he been down? Forty-five minutes?"

  She looked at her watch, and Basso Profundo said, "That's what she estimated."

  "You want me to time him?" asked Compton, who was squashed beside him, but looked reasonably happy.

  "Yes, please, Compton. You'll be our time keeper." I turned to Mrs. Yarborough. "Are you telling me that you refuse rectal medication, but you'd accept oral? Even if he chokes on it and gets pneumonia?" I said, enunciating and looking her in the eye as I spoke. "Pneumonia is treatable, if we—when we manage to land. But status epilepticus—"

  She bit her lip. "I don't know what to think." She crossed her arms. "I don't want him to suffer."

  "Then let us help him!" Could I give him medication without her consent? Otherwise, I had nothing for Mr. Yarborough. Unlike Meredith Grey, I wasn't about to drill a hole in his skull. I couldn't reverse any bleeding or usher more blood flow through his cerebral arteries. But we had medication right in our hands that could help him.

  "We could also try to give saline," said Tucker. "If he's hyponatremic, maybe it'll bring him back up to normal, and uremia can cause seizures."

  I eyeballed the DNR sheet. Mrs. Yarborough hadn't ticked off the middle box for IV. "Can we still give IV fluids?" I asked her.

  She covered her mouth. Probably she could feel everyone's eyes boring into us, the way I did. "I don't know what to think."

  Think fast, I thought. It was what my classmates used to say, usually before whipping a ball at my head.

  "It's hard, eh?" said Tucker. "You love him. You don't want him to suffer. But I assure you that an intravenous isn't suffering. He won't choke on an IV. And if he wakes up a little, we can try the Clonazepam."

  After a long moment, she nodded.

  "I'll start a second IV." Tucker was careful and respectful as he tightened a tourniquet around Harold's left arm and swabbed the inside of his left elbow, looking for a second vein.

  I smiled as I held the arm in place. It's more common to put IV's in the hand, because people want to bend their arms, but Tucker was thinking like an ER doctor: put as big a needle as close to the heart as possible, so we could get the drugs in ASAP. The only disadvantage was that Mr. Yarborough might dislodge the needle, but that was true of anyone anywhere.

  When Tucker got a flash of blood up the angiocatheter, I grabbed the normal saline. The smooth bag was heavy in my hands. If we thought hyponatremia was causing his seizures, we should be using hypertonic saline instead. But we had no idea of his sodium level.

  "What about CPM?" I whispered to Tucker as he attached the saline. If you correct the sodium too fast, you can end up with Central Pontine Myelinolysis. They might look fine at first, but then end up confused and unable to walk a few days later. You need your pons. You need your whole brainstem.

  "We'll go slowly," he said.

  Not reassuring. Tucker had cut open another man's chest an hour ago. His determination to save Mr. Yarborough's life might make him even more reckless. I'd have to keep an eye on the fluids. And how were we ever going to solve the stabbing?

  It's Ooooooooh. Kay, Hope, I told myself. You can't solve everything. It's not your fault people are killing each other and going into status epilepticus.

  One at a time. That's what nurses tell me in the ER when I feel defeated by the stack of charts.

  Tucker was ready to hook up the saline IV now, so we did.

  Mr. Yarborough seemed to slow down his movements for a second. I shot Tucker a look: Is that possible? Maybe because of vagal stimulation from the IV?

  He shrugged. My guess was as good as his.

  Then Harold started seizing again, and everyone sighed.

  "I'll crush the Clonazepam," I said. "Could I have a spoon? Maybe two spoons." Nurses do most of the crushing, so I was improvising, but it sounded right to me. Pascale handed them to me post haste. I grabbed two little blue pills and used the spoons to crush them together.

  My hands shook. Not cool, but having people stare at me made them shake even more.

  "We could put them in applesauce and put them in his cheek pouch," said Tucker.

  "We don't have any applesauce," said Pascale.

  Sure. Why would you? It's not a high demand item. An airplane isn't a day care. I tried to think of something else pureed that they might carry. "Do you have really thick Clamato juice?"

  Tucker laughed. "Try some yogurt. Or honey."

  "Right. Sure."

  Linda spun off to grab some.

  Please work. Please stop these seizures so we save this guy's brain and figure out who the killer is.

  "We might be able to stick a wad between his gums and his lips," said Tucker.

  He had a lot of good ideas. I loved how creative he was as I tried to scrape all the pill bits together in the middle of the spoon. "How is that different from a cheek pouch?"

  "Easier to administer. Not as many blood vessels, but maybe he'd be less likely to choke on it."

  "Maybe." I felt more helpless than with Mr. Money. I'd rather crack open a chest than argue with a near-widow about whether or not we were allowed to give a medication that might choke him.

  Fortunately, Linda slapped a packet of honey in Tucker's hands. He tore off the foil, and I dumped the pill powder in the middle before he swirled it around with a spoon. "Ready?"

  "Ready. You want to try the gum-lips method?"
he said.

  "Whatever works. And doesn't get us bitten."

  "Done!" said Tucker, and I scooped up some honey on an index finger while Tucker pulled Harold's lower lip out. Harold clamped his gums together, so it was much easier to honey up the inside of his lower lip than reach inside the cavern of his mouth. The honey was sticky, though, with a particular love for my glove, so that took longer than I wanted. I ended up using a spoon to scrape off the honey into his gum-lip crevice while the plane tried out "the floss" dance moves.

  "It'll help for hypoglycemia, too," said Tucker, and I nodded.

  He squeezed the IV bag. "We've done everything we can," he said, more quietly, and I understood his pain. We were at our limit. If this didn't work, we'd have to roll Mr. Yarborough into recovery position and wait for the plane to land.

  The hardest part of a code is standing and waiting with no direction and no clear idea if anything is going to work.

  "Now what?" said Mrs. Yarborough. "What's going on? Harold?"

  "Now, we wait," said Tucker.

  She grabbed her husband’s face. "Harold. Oh, Harold!"

  "Nguh," he seemed to say, his head twitching in her hands.

  She laid his head back on the seat, gently enough, before she wrung her hands. "I can't believe it!"

  "Give the medication a few minutes to work, and then we can try the rectal option," I said. I swear, people think drugs are like magic wands, because TV doesn't show Procainamide infusing over an hour.

  "No," she said, but with less force than before.

  "Seizures are a sign that the brain's not working properly," said Tucker. "The electrical system has short-circuited. Over time, brain cells die, and people stop breathing—"

  "So breathe for him!"

  "We can," said Tucker, "but that means putting a tube down his throat, and you showed us a paper that you don't want that."

  Her fingers tangled in her own hair, and she started yanking so hard that it distorted her eyes. "I don't know what to do!"

  "Let us give the rectal medication," said Tucker. "If he gets too much and falls asleep, we can always support his breathing. We can treat his pneumonia once we land and get him to a hospital. But right now, he's seizing, and it's hurting him."