“You’ve met Nolan Bridges, I think.”
“The family practitioner from Fort Mill?” she asked.
I nodded, and she said, “Yes, he’s come through the ER a couple of times. Nice guy.”
“Yeah, he’s a nice guy,” I agreed. “Not long after we moved to Rock Hill, I saw a fifty- or sixty-year-old man in the ER—came in with cough and some congestion. I can’t remember his name, but he looked fine. No fever, no chest pain, no shortness of breath, just a cough for a couple of days. Sounded straightforward to me.”
“Bronchitis,” Liz opined.
“That’s what I thought,” I said. “And I gave him an antibiotic and something for his cough and told him to follow up with his family doctor if he wasn’t better in a few days. That was Dr. Bridges, and he saw him a week or so later, no better with his cough. Still no fever, just the congestion. And the cough was keeping him awake at night. Bridges saw him and gave him a different antibiotic. This time he was wheezing a little, so he gave him an inhaler too.”
“That all sounds reasonable,” Liz said. “But I don’t see the connection with Sammy Hodges. How does that—”
“Just hold on,” I stopped her. “Bridges saw him two or three more times in the office with the same complaints and kept changing things around. Put him on some steroids, and that seemed to help a little. But the cough never went away. Then one night he showed up in the ER. I remembered him from a couple of weeks earlier, and he told me what had been going on. He was wheezing that night, and seemed a little short of breath. Still no fever or chest pain, and he looked okay. I was about to treat him again for a persistent bronchitis, but something just didn’t seem right. I got a chest X-ray, and guess what?”
“Pneumonia!” Liz exclaimed, satisfied that she had solved this case.
“No, it wasn’t pneumonia,” I told her, my eyes searching hers for another response.
“Not pneumonia?” she responded, frustrated. “Well, what was it?” she asked, giving up.
“This man had early heart failure,” I said. “And he’d had it for a couple of weeks. I didn’t pick up on it when he first came to the ER, and then Bridges made the assumption that I knew what I was talking about.”
“That’s a big assumption,” she chuckled. “But this wasn’t a straightforward presentation of heart failure.”
“Doesn’t matter,” I said. “The point here is that a string of assumptions—his assuming my diagnosis was correct, and then my assuming his diagnosis was correct, and then his assuming my diagnosis was correct…”
“Okay, okay—I get it!” she laughed. “Never make assumptions!”
“That is the point,” I agreed. “But you can see how subtle this can be. It’s an easy trap to fall into, especially in the ER. The safest thing to do is always step back, take a look at things, and don’t be lazy. Sometimes the toughest course is the right one. No, that’s not true. Usually the toughest course is the right one.”
Liz was thinking about this last statement, and I was about to tell her about Miles Sudderth, when I looked up again at the clock. It was 7:45 and she needed to get out of here and get some sleep. I told her just that, and she was soon up and on her way home.
“And next time,” I called out to her, “We’ll talk about why you shouldn’t believe everything you see or everything a patient tells you.”
As she walked through the ambulance entrance, the orthopedist on call passed her on his way in to see Sammy Hodges.
I was still sitting at the back counter wondering when Amy Connors would make it to work, and I found myself thinking about Miles Sudderth again. That had been a close one.
It had happened a long time ago, just a year or so after I had finished my residency. Jack Frazier, a friend of mine who was two years behind me in the emergency medicine training program was moonlighting in a small ER, not far from here. It was a fall weekend afternoon, and I remember the day as being perfect. Because it was a “football Saturday” the afternoon hours in the ER were typically quiet. That would probably change in the evening.
Sometime around 3 p.m., Jack called me.
“Robert, I’m over here at Divine Savior and I’ve got a fifty-two-year-old man I need to send your way.”
Divine Savior was a small hospital, its doors long closed now, and it had a minimal capacity for handling emergencies. Fortunately, most people in the area bypassed it on their way to Rock Hill General, but every once in a while they would get some really sick or injured patients.
“Tell me about him,” I said, taking my pen in hand and sliding a pad of paper in front of me.
“I think it’s going to be straightforward,” he began. “His name is Miles Sudderth, and he started having chest pain about an hour ago. He only lives a half mile from the hospital, so he came here instead of driving over to Rock Hill. Blood pressure’s a little high—160/110—and he takes medicine for that. No diabetes, but he used to smoke.”
I heard him talking to someone in the background and then he continued.
“His EKG is abnormal—looks like an acute anterior MI, with big changes in those leads. But like I said, his pressure’s not low, and he doesn’t seem to be in any distress right now. Still with some chest pain, but we’re giving him some nitro for that now, and then some morphine. His chest X-ray looks good to me, but there’s no radiologist over here to show it to.”
So far, it did sound straightforward. Jack was a good resident and was always on top of things. I had no reason to believe that anything he was telling me wasn’t accurate.
We talked a little more and then made arrangements for Sudderth’s transfer to Rock Hill General.
“We’ll be expecting him,” I told Jack. “What do you think, maybe twenty minutes?”
“That’s sounds about right,” he answered. “And give me a call when you get a chance and let me know how he’s doing. He’s a nice guy, and his whole family is here with him. I’m working a ‘24,’ so you’ll know where to find me.”
Betty Caldwell was the nurse working with me, and I called her over and told her what was coming in.
“I’ll give Pete Jenkins a call and let him know too,” I told her.
Jenkins was the first cardiologist to come to Rock Hill, and that had only been about six months earlier. He was well-trained, energetic, and determined that Rock Hill General would be on the cutting edge when it came to hearts and community hospitals. I was glad to have him available.
“And Betty,” I added. “Get the TPA ready in cardiac. It sounds like we might be using it.”
These were the early days of the “clot-busters,” those medications used to dissolve blood clots that formed in the vessels of the heart, causing heart attacks. TPA was one of the early ones, and we had it stocked in the ER, ready for use. These drugs were capable of saving peoples’ lives, but they could be dangerous as well.
I called Pete Jenkins and told him what was going on.
“If it looks like an acute MI, get the TPA started as fast as you can,” he responded. “I’ll be right in.”
As I hung up the phone, Miles Sudderth came through the ambulance entrance on his stretcher. I introduced myself to him as he passed the nurses’ station, and took his chart and X-ray folder from one of the paramedics.
“Over here,” Betty called out from the doorway of cardiac.
I opened Sudderth’s folder and spread out his paperwork on the countertop. A quick look at his EKG confirmed what Jack had told me. The pattern was classic for an acute heart attack. I quickly scanned the rest of his record, but found nothing significant. Then I picked up his X-ray folder, took out the single film, and walked over to the view box.
It looked fine. His lungs were clear, and his heart shape and size were normal. I peered closer at the X-ray, searching for a subtle partially collapsed lung. I didn’t want to miss that.
Nothing. Everything on his chest film looked good.
When I walked into cardiac, Sudderth had already been moved over to our stretcher, and his
IV line and oxygen tubing were being adjusted.
“How do you feel?” I asked him. “Are you still having any chest pain?”
I glanced over at his monitor—his heart rate was 82, nice and regular.
“150 over 100,” Betty told me, taking her stethoscope out of her ears and putting it down on the counter behind me.
“I’m still having some pain, Dr. Lesslie,” he told me. “Not as bad as when I first got to Divine Savior, but it’s still there.”
He was pointing to the middle of his chest and was moving a little on the stretcher, trying to get comfortable.
The two paramedics from EMS were packing up their equipment, getting ready to leave.
“I think Dr. Frazier gave him another 5 of morphine right before we left,” one of them said. “That’s a total of 15 he’s had.”
“Thanks,” I said as the men rolled their stretcher out of the room. That was a pretty good dose of morphine, and along with the nitroglycerin, he should be having some relief. This was even more reason to get the TPA going and try to open up his coronary vessels.
“Betty, how close are we with the TPA?” I asked her.
“Just about ready,” she answered, with her back to me. She was standing at the counter, preparing the medication. It was a simple white powder that had to be mixed with saline, and it was expensive—more than two thousand dollars a dose.
Just don’t drop it! I thought.
In another minute or so, she had the TPA ready to be infused through one of Sudderth’s IVs. I explained to him what we were going to do, what we wanted to see happen, and what he might feel. I also told him there was some risk involved, and that a small number of people had hemorrhages in their heads from the medication. He didn’t fall into any of the high-risk groups, but it was still a possibility.
“Is this the best thing for me, Dr. Lesslie?” he asked me, still rubbing the middle of his chest. “I mean, if you were me lying here, would you take the TPA?”
That question always made me stop and think. After all, that should be one of the things that guide our actions. Would I take the same treatments that I offer my patients?
“Mr. Sudderth, this is exactly what I would do,” I told him confidently. “And I would do it right now.”
He nodded his head slowly and looked away.
“Okay then—let’s do it,” he said quietly.
“Dr. Lesslie,” Betty said from the other side of the stretcher. “Would you check this for me?”
She was taking his blood pressure again, this time in his right arm.
A little impatiently, I walked around the bed to where she stood.
“I just checked his pressure and it’s 180 over 110 in this arm,” she informed me. “Would you see what you get? That’s a lot higher than in his left.”
I quickly felt the pulse in his right wrist and then compared it to his left. They seemed about the same, and his hands were warm. But sometimes you can’t detect subtle changes, even not-so-subtle ones. I needed to check the blood pressure in both arms.
Betty was right. His BP on the right side was 180/112. I quickly stepped to the other side of the stretcher and checked his left arm. 140/96. Something was wrong.
The door opened and Pete Jenkins walked into the room.
“Hey, Robert,” he greeted me, then nodded his head at Mr. Sudderth. “I looked at the EKG out on the counter, and I agree with you. He’s having an MI. And if that’s his chest X-ray on the view box, it looks okay. Have you started the TPA yet?”
Betty had walked over to the IV stand and was getting ready to start the infusion.
“Hold on!” I told her, holding up my hand. “Pete, we’ve got a problem here. I’m not sure this is an MI,” I told him. “There’s a difference in the pressures between his arms, and I think we need an echocardiogram, stat.”
Pete walked over to the stretcher and checked the pulses in Sudderth’s wrists, and then his legs. He had a puzzled look on his face, having felt the same warm extremities I had.
“What are the differences?” he asked, picking up Betty’s clipboard and scanning it for the patient’s vital signs. “Wow!” he exclaimed when he saw the measurements.
We had an echocardiogram done in the room, and Pete studied its screen, pointing out to me the source of Miles Sudderth’s chest pain.
It wasn’t a heart attack after all, at least not the type we were getting ready to treat. He had a dissection of his aorta. The layers of the biggest blood vessel in his body were coming apart and separating. But instead of extending away from his heart and down into his chest, the dissection had traveled back toward his heart. As it had reached the blood vessels that feed the heart muscle, it had sheared them off, effectively blocking them just like a blood clot would have.
But his problem wasn’t a blood clot, and had we given him the TPA, he could easily have bled out and died.
“We’re not going to be giving him the TPA,” Pete told Betty.
Then he looked down at our patient and said, “Mr. Sudderth, you’re going to need surgery, and soon.”
That had been a close one—too close. And it was a lesson I had never forgotten.
I stood up and stretched, looked around the department, and then walked over to the other side of the nurses’ station. Standing in front of Susan Everett, I asked her, “Any word from our missing secretary?”
“I’m comin’ as fast as I can!”
It was Amy Connors, hurrying up the hallway from the staff lounge.
“I got here as quick as I could,” she said, walking around the counter and waiting for Susan to get up out of her chair. “Wouldn’t you know it? A brand-new truck, and the battery’s dead.”
The phone rang and Susan picked it up. She listened for a moment, then handed it to Amy.
“It’s for you,” she told her. “Walter Stevens.”
14
Caught in the Web
A my looked up at me. There was a cold resolution in her eyes, and I nodded my head, understanding her need to get this over with.
Susan reached under the desk, grabbed her purse, and stood up.
“It’s all yours,” she told Amy, oblivious to the emotional turmoil surrounding her.
“Do you want me to stay over tonight?” Amy asked her. “I really appreciate you hanging around for me.”
“No, don’t worry about that,” Susan answered, smiling. “You’ve done it for me enough times. And probably will again.”
She walked around the counter and down the hallway, leaving me alone with Amy.
“Any advice?” she asked me.
“Just what Virginia always tells me,” I answered. “Let him do the talking. If you wait long enough, he’ll show all his cards and then you can respond. You don’t need to tell him much of anything ’cause he doesn’t have much of anything. And try to keep your cool.”
Once again, we were a lot alike, and I knew this last request would be difficult for her.
“I’ll do my best,” she said, moving around the counter and stepping over in front of room 5. “I’ll be back as fast as I can. And if you hear a Code Blue, well…it won’t be me needin’ CPR.”
I chuckled at this, knowing she was right, but a little worried because she was right. As she disappeared down the hall, Virginia stepped out of her office and over to the nurses’ station.
“Is she going to be okay?” she asked, nodding her head in the direction of the now empty corridor, but not really expecting an answer.
“This whole thing makes me sick,” I told her. “I just wish one of us could be there with her. Stevens can be overbearing, as you well know.”
“I’m just glad her husband didn’t come with her,” Virginia mused. “I actually had that thought as I was driving in this morning. Now that would be fireworks! But I don’t think she said anything to him, because knowing Charlie, he wouldn’t let her be doing this on her own if he knew about it. And then there would be trouble.”
Jeff Ryan walked out of triage, leading
a middle-aged man dressed in the garb of one of the city’s utility workers. He was holding a bloody bandage to his right eyebrow, and the two of them headed toward minor trauma.
“Looks like you’ve got work to do,” Virginia said, turning and walking back to her office.
Forty-five minutes later, Amy returned to the ER. I was standing at the nurses’ station, talking with one of our surgeons about a ten-year-old in room 4 with a probable hot appendix. He would be heading to the OR shortly, and when I saw Amy coming up the hallway, I cut short my conversation. I could tell she was upset.
“Thanks, Robert,” the surgeon said to me. “I’ll let you know what we find.”
He walked back over to room 4 as Amy passed behind him and over to her chair. Instead of sitting down, she reached under the counter and grabbed her book bag. Her face was flushed and she hadn’t looked at me yet.
“Amy,” I said tentatively. There was no response, and I repeated myself. “Amy?”
She raised her hand to silence me, and still wouldn’t meet my eyes. Without saying a word, she stepped around the counter and headed for the ambulance entrance.
“Amy,” I said again, trying to stop her or at least get her attention. She didn’t answer and kept walking toward the exit.
Virginia Granger stepped out of the medicine room and saw Amy disappear through the automatic doors. The look on her face changed quickly from one of questioning to one of determination. She gestured with her head, indicating I was to follow Amy. I did, with Virginia right behind me.
Amy was walking quickly, almost running, and we were having trouble keeping up with her.
“Amy!” I called out. “Hold on a minute!”
She kept right on walking and didn’t turn around.
“Amy, I need to talk with you!”
It was Virginia, and I had never heard this tone in her voice. She wasn’t ordering her, or directing her secretary to do something. She was pleading with her to stop.
Amy did. And with her back still to us, she dropped her head to her chest. We caught up with her and she slowly turned around to face us.
“Amy, tell us what happened,” the head nurse asked, coming up beside her. “What’s the matter?”
Angels on the Night Shift Page 14
