I frantically tried to think of what I had done to be on Virginia’s bad pad. That was somewhere that no one, at least no thinking person, wanted to be. Virginia had been the head nurse in the ER for a lot of years, and she commanded the respect of everyone in and out of the department. Her training was that of a military nurse, and that demeanor and bearing had not been softened by her years in the “civilian sector.” If you crossed the line somehow, you were going to hear about it.
Unable to come up with anything I might have done recently, I took a deep breath and headed over to her office.
“Close the door, if you would,” she instructed me from behind her desk. She was drumming her fingers on its clean and ordered surface, impatiently waiting for me to do as I was told and to have a seat in front of her.
Dutifully complying, I sat down and asked, “What is it, Virginia? Is there a problem in the department?”
“No, not a problem,” she answered, looking me squarely in the eyes. “I just want to be sure that we don’t have one develop.”
I nodded my head, wondering where this was going. Maybe I had done something. Then I remembered last weekend. That must be it! I had somehow figured out how to put the hospital paging system on hold, then told one of our new secretaries there was a call for her on that line. When she picked up the phone and pushed the button, she would be speaking throughout the entire hospital. It had worked better than I had hoped, with the young woman insistently asking, “Hello! This is Miss Jones! Who is this? I know you’re there! Who is this?”
Lori Davidson had come to her rescue and hung up the receiver, pointing an accusing finger at me. Miss Jones fortunately never figured out what had happened.
That must be it. Someone had talked.
“Virginia, I—”
“Tell me what you think about Darren Adler,” she interrupted.
“Excuse me?” I stammered, having been prepared to fall on my sword and plead mea culpa.
“Tell me what you think about Darren,” she repeated.
Incredibly, I was off the hook. I slumped a little in the chair and took a deep breath. Then I quickly collected myself and focused on her question.
Darren Adler was one of our new nurses. Actually, he wasn’t exactly new, since we had known him as a paramedic for eight years before he decided to go to nursing school. His goal had been to get his degree, spend some time upstairs in the ICU and CCU, and then come to the ER. He had done just that and had begun working with us two months ago.
“I think Darren is fitting in with the staff,” I told her. “And he’s doing a good job. Why? Is there a problem?”
I glanced down at her desktop and for the first time noticed the personnel file. On its label I was able to make out Darren’s name and date of hire.
“No, not a problem,” she answered, pursing her lips and peering intently at me over her black horn-rimmed glasses. It was always difficult to meet and hold her gaze, and I found myself feeling the uncomfortable need to break off. But I didn’t and instead focused my eyes on her seemingly permanent bright-red lipstick.
“Not yet, anyway,” she continued.
“What do you mean?” I asked, becoming curious. Darren had always been a solid paramedic, and he was now proving himself to be a good ER nurse. What kind of trouble could he have gotten himself into?
“You know he came from the ICU,” she said, nodding her head and not waiting for a response. “According to Brenda Slater, he did a good job for her. Dependable, focused on his patients, good charting.”
She paused for a moment and I waited. Brenda Slater was the ICU charge nurse, and had been from the time I had first come to Rock Hill. We had had a few run-ins over the years, always about getting our admitted patients upstairs in a timely manner. But we had always been able to work things out. She was strong-willed, as was Darren, and I was beginning to understand Virginia’s concerns. She and Brenda were close friends.
“There was never any specific problem that I know of,” she went on. “But Brenda has some concerns about his attitude and his respect for authority. Maybe it was all those years with the EMS. He does seem at times to be doing his own thing. And that might get him crossways with me. We don’t have the time for that down here.”
She was studying me now, and I continued to look squarely into her eyes.
“I understand what you’re saying, Virginia,” I told her. “That’s the last thing we need, for Darren to lock horns with you. But I’m sure that’s not going to happen. This is where he wants to be, and he’s worked hard to get here.”
“I think so too,” she mused. Then without thinking, she reached up and adjusted the small, starched white nursing cap that was bobby-pinned to her dyed-black hair.
She noticed my eyes following her movement, and the beginning of a twinkle—
“Don’t you even…” she snapped, quickly putting her hands back on the desk. She was the only nurse in the Western Hemisphere who still wore one of these caps. And whenever I thought I could get away with it, I’d give her a hard time about it.
“Anyway,” she sighed, composing herself. “Just help me with that. Give him a little guidance if he needs it. We don’t want things to get out of joint. He has the potential to be a good one for us.”
“I’ll do what I can,” I said, standing up and pushing the chair back. “Thanks for the heads-up.”
“Just hold on there,” she said, pointing to my chair. “I want you to tell me about the Haskell baby.”
I sat back down, wondering once again how she seemed to know everything that happened in the department. I guess that was her job, but this had occurred more than two weeks ago, and at three in the morning. Darren Adler had been working with me that night. Maybe that’s why she wanted to know.
3:15 a.m. Darren had been out in triage and had suddenly burst through the door, glanced over at the nurses’ station, and said to me, “Got a sick one here. I need your help!”
Then he bolted toward major trauma. In his arms was the listless body of a two-year-old boy. Right behind him was a young woman dressed in jeans and a tie-dyed T-shirt. Her face was bloated from crying and she looked over at me with panic and fear in her eyes.
Amy Connors sat upright in her chair as I quickly headed for trauma.
“This is Tyler Haskell,” Darren told me while carefully putting the boy down on the stretcher. “And that’s his mother, Sherry,” he added.
I nodded in her direction and went around to the other side of the bed.
“What’s going on?” I asked Darren.
The child was breathing, but had a strange, dusky color. He was clearly cyanotic, suffering from a critical lack of oxygen, and his eyes had rolled up into his head. I easily found a femoral pulse and then automatically began to gently palpate his abdomen.
“His mother tells me he’s been sick for a couple of days, but started to get a lot worse tonight,” Darren explained while attaching cardiac electrodes to the boy’s chest. “Blood sugar is normal, but his pulse ox out front was 84. You want some O2?” he asked, already reaching for the oxygen mask.
An oxygen saturation of 84 percent was low, dangerously so. His level should have been above 95. He would need some oxygen, and I would need to find out why he was cyanotic.
“Yeah, put the mask on him,” I instructed Darren. “And we’ll need lab down here and X-ray. And get respiratory therapy—we’ll need a blood gas too.”
“Got it,” Darren answered, moving quickly and efficiently.
I listened to Tyler’s heart and lungs, checking for any unusual chest sounds or a heart murmur. Normal.
“Let’s see if he pinks up a little with the O2,” I said to Darren. Then turning to his mother, “Does he have any medical problems? Has he ever been in the hospital for anything?”
“No…no,” she stammered. “He’s always been real healthy. Never had anything more than an ear infection. Not until a couple of days ago.”
“Has he fallen or hurt himself somehow?” I aske
d her.
“No, nothing like that,” she said, shaking her head emphatically.
“Does he take any medication?” I continued.
“No, nothin’. Just some Tylenol yesterday and today, ’cause of the fever,” she answered, shaking her head. “Is he goin’ to be alright?”
I continued to examine Tyler, carefully rolling him onto his side and looking for any bruises or anything unusual. Everything looked fine. No help there. Then as I moved him back over, he moaned a little and I glanced up at his face.
“How long has this been going on?” I asked her, pointing to the boy’s mouth.
Leaning down over her child she said, “That started right after the fever. He just started gettin’ these blisters and then wouldn’t eat or drink. They must be hurtin’ him a lot.”
“Wow!” Darren softly exclaimed, looking into the back of Tyler’s throat as I gently held his tongue out of the way with a wooden blade. “Look at that!”
In his haste to get him back to the ER, Darren hadn’t looked closely at the boy’s face.
His lips and the entire inside of his mouth were covered with angry, red ulcerations. Some were bleeding, and a few on his lips looked infected. It was almost certainly a viral infection, but maybe the worst I had ever seen.
“No wonder he wasn’t eating,” Darren said.
“We couldn’t get him to take anything at all today,” Sherry volunteered. “And we tried everything.”
“We?” I asked, looking over at the young mother.
“Yeah, me and his father, Jupiter. Jupiter Wells,” she informed us.
The name sounded familiar, and I was trying to place it when Darren spoke.
“Jupiter Wells?” he asked her, repeating the name.
“Yeah, Jupiter,” she answered matter-of-factly. “Do you know him?”
“No. Well, not exactly, but…isn’t he in—”
“He got out last week,” she interrupted him, avoiding his eyes and looking back down at her son. “He’s been real good to Tyler, tryin’ to take care of him and all.”
That’s why the name had sounded familiar. We had seen Jupiter Wells on quite a few occasions in the ER. Bar fights, motorcycle accidents, you name it. And Darren, having been with the EMS, would have seen him more than we had.
Interesting.
I stepped back from the stretcher and quietly stroked my chin, trying to put all of these pieces together. Here was a previously healthy two-year-old boy, with what looked like a viral infection of his mouth and an ominous cyanosis. And he was becoming progressively less responsive. No medications, no history of trauma. And other than his mouth and the bluish discoloration of his entire body, he had a normal exam. There was an answer here, something that should be obvious. But it was eluding me. What was I not seeing?
Darren started an IV while two lab techs came in and drew blood for a battery of tests. Then he did something unusual.
“Excuse me,” he said to one of the techs. “Can I hold one of those tubes?”
He took one of the blood-filled vials and walked over to the corner of the room, directly below one of the bright ceiling lights. Then he held the tube up and studied it, rolling it from side to side between his fingers.
“Is that all you’ll need right now?” one of the techs asked me.
I had ordered every test I could think of and said, “That should do it for now. We’ll call if something changes.”
I was watching Darren, wondering what he was up to, when Sherry Haskell asked me, “What do you think is wrong with Tyler? Is he going to be okay?”
The boy’s color had not improved with high-flow oxygen, and I had examined his heart carefully again, searching for some evidence of a faint murmur or some reason for oxygen not getting into his blood. His lungs were working, and his heart was—
“Doc, come over here a minute.”
It was Darren, and he was still studying the tube of blood, holding it up in the light. I walked over behind him and looked up.
At first, I wasn’t sure what he was talking about. And then I saw it. It was the color of the blood. Instead of being red, it was brownish. Almost like…chocolate! That was it—that was the answer!
The combination of chocolate-colored blood and persistent cyanosis was associated with a type of chemical exposure that altered the iron in the hemoglobin molecule. Technically, the ferrous iron was converted to the ferric form, which bound to oxygen but wouldn’t release it to the body’s tissues. All of the oxygen in the world wouldn’t help. It was called methemoglobinemia, and if the level of the ferric form got too high, you would die of asphyxiation. Tyler would die of asphyxiation. We needed to convert the ferric form back to the ferrous, and fast.
I stepped over to the door, opened it, and called over to Amy Connors.
“Get the pharmacy on the phone and tell them we need some methylene blue—and we need it right now!”
Closing the door behind me, I turned to my nurse. “Darren, have you ever given methylene blue before?”
“Read about it, but never given it,” he answered honestly. “Can’t be too difficult, though. It’s just a liquid, right?” He was already reaching for the drug manual that we kept on one of the shelves in trauma.
“Yeah,” I answered, scratching my head once again. The liquid would be given by IV and would quickly alter Tyler’s hemoglobin, allowing it to carry oxygen normally throughout his body. And it would save his life.
But why was he having this problem? How had this happened? The only cases like this I had ever seen were from some industrial exposure—some kind of dye or other chemical. And the cause was almost always obvious. But I had never heard of it in a small child and couldn’t think of what kind of exposure would have caused this.
One of the pharmacy techs came into the room and handed Darren a clear plastic medication bag filled with a dark-blue liquid. It was actually kind of pretty, and I wondered how Tyler’s mother would react when she watched it course through the IV tubing and into her son’s body. It was perfectly safe, and she would be able to watch as her boy pinked up. That was going to make her happy, and was going to relieve me.
Darren was preparing the methylene blue when he looked over at Sherry. “You said a while ago that Jupiter was ‘trying to take care of’ Tyler. What did you mean by that?”
“He was really bothered by the way Tyler was actin’, with his mouth and all,” she began to explain. “Jupiter kept puttin’ a cold rag on his lips, and tried to get him to take ice chips, but he wouldn’t have none of it. Just kept turnin’ his head away. That’s when Jupiter went into the bathroom and came back with that spray.”
Darren and I both jerked our heads in her direction.
“The spray?” I repeated, surprised by this answer. Maybe this—
“Good Lord!” Sherry exclaimed, pointing down to her son’s arm. The methylene blue had filled the IV tubing and was starting to flow in. I understood her reaction. It was unusual and unexpected, and actually pretty bizarre. But it was necessary and would save her son. I explained all of this to her, and then Darren asked, “What ‘spray’ are you talking about?”
Sherry had relaxed a little, and looked up into Darren’s face.
“It was some spray Jupiter had. He said it was for sore throats.”
Darren and I looked at each other, and then he turned to Sherry again.
“What did it look like—the container, I mean?” he pursued.
She had a puzzled look on her face as she tried to remember.
“It was yellow, I think, with some thin metal tube comin’ out the top. It was bent over, and when Jupiter pushed down on it, the spray would come out the end. Why? Was that somethin’ bad? It seemed to help Tyler, at least for a while, so we kept usin’ it.”
Cetacaine—must be! I thought. That would explain it. Cetacaine was a topical spray we used to numb up someone’s mouth or throat for an oral procedure we might be doing. And it could be used for pain relief. It contained a chemical, benzocaine, t
hat was safe in small amounts. But used in excess, it could cause methemoglobinemia, probably especially so in small children.
“Where did he get the Cetacaine?” Darren asked her.
Sherry blushed and lowered her eyes. It wasn’t critical to know this, but now I was curious. I didn’t think you could get this stuff at the drugstore, and we always tried to keep a handle on it in the ER. I wondered how Jupiter happened to have it in his bathroom.
“Sherry?” Darren prodded gently.
She looked up at me and then at the nurse.
“He…he told me that it was good stuff, that they had used it on him one time in the ER when he had his mouth busted, and that he…he…”
She stopped, and we waited.
“He said that when the doctor and nurse left the room, he put it in his pocket.”
There. She had said it, and now she visibly relaxed.
I shook my head, but wondered why I was surprised. This kind of thing happened all the time in the ER—surgical instruments, sterile gloves, medications, even a thermometer once.
“We’ve been missing a wheelchair…” the nurse whispered in my ear.
“Darren,” I corrected him, chuckling.
Tyler had responded quickly to our treatment. He was much more alert and no longer had that dusky blue color when we sent him upstairs to the pediatric ICU. He would be discharged from the hospital in a few days, completely normal, active, and back to himself.
“What made you check out that blood?” I asked Darren while we stood together in the trauma room.
“I don’t know, Doc. Something just seemed a little odd about all of this. And when I caught a glimpse of one of those vials, I knew something was up. Wasn’t sure what, but it just wasn’t right.”
“Well, I’m sure glad you did,” I told him as we walked back to the nurses’ station. “I was really struggling with that one.”
“Sounds like Darren Adler saved your bacon,” Virginia said, once more peering over her glasses at me.
“I’ll be the first to admit it,” I said, standing up again, this time determined to make it back out to the department.
“I want to keep him down here,” she said again. “I know you like him, but that will make it difficult for you to remain objective. Just keep your eyes open.”
Angels on the Night Shift Page 3
