The Sixth Sense (Brier Hospital Series Book 3)

by Lawrence Gold

  For Jim, the logic was simple: Do something to improve her lung function so she no longer required the ventilator; move Connie to a long-term respiratory support unit or to home with the appropriate equipment and training, or finally, get her a heart-lung transplant.

  The RCU staff met repeatedly about Connie and had recently introduced a new structured multidisciplinary program to try to get her off the ventilator. The players in the new program reacted with enthusiasm to the studies on this new approach that showed a 50 percent success rate.

  Connie did not share their enthusiasm. She submitted to part of their efforts and actively blocked others.

  “She’s depressed,” said Alan Morris, the pulmonary consultant.

  Jim McDonald put down Connie’s chart. “Maybe she’s just taking control of what little she has left to decide for herself.”

  When they pushed Connie’s support by adding tube feedings to the intravenous nutritional solutions, she gained weight. The staff carefully adjusted the ventilator to allow Connie’s own muscles to help her breathe. In spite of her objections, they kept Connie out of bed for extended periods. On paper, she looked better, emotionally, she was worse.

  Take me off this fucking machine, she wrote with a shaking hand. I want to die. It’s my right to die. Tears streamed down her face.

  Connie rejected everyone’s attempt to reason with her. Passive, at first, she now attacked nurses, technicians, and even her physicians. She tried several times to free her arms so she could pull out the breathing tube. She fought the physical restraints to exhaustion. Psychiatric evaluation was useless and any attempt to deal with her psychopathology, whatever it was, by drugs, they rejected for fear they would further compromise her breathing. Finally, she fell into a catatonic state and refused to respond to any question or follow orders.

  “We’re plain out of tricks,” Jim said to the Rinaldis. “It makes me sick to see that we’ve come so far to only to fail because we can’t deal with Connie’s depression. We can try antidepressants, but that will take weeks and there’s no certainty that they’ll work under these circumstances.”

  “You must try something,” Joseph said.

  Jim sat with Connie’s parents. “Connie’s situation bothers me. She’s entitled to her emotions and she may or may not be rational in her decision to stop treatment. I’m not sure what I’d do if I were in her situation.” He hesitated a moment, and then continued, “Let me talk with the psychiatrists again. Maybe we can come up with something.”

  The RCU was quiet but for five ventilators whirring and clicking. Rarely synchronous, the sounds sometimes fell into a pattern until one or another patient sighed or stirred, upsetting the rhythm.

  Patricia Coleman, an experienced RCU nurse, had three patients tonight. Two were early in their clinical courses and required lots of attention. The third was Connie, who remained awake, with eyes open, but still refused to or couldn’t react.

  Patricia had become so involved with the two sicker patients that she had to remind herself several times to record Connie’s vital signs. At four a.m., she broke away and approached Connie’s bed. Something was wrong. She couldn’t hear the distinct sounds of Connie’s ventilator. When she pulled the curtains around the bed, she was shocked. Connie’s hands were free and she was grasping the tracheal tube in her fist. The ventilator sat in silence.

  “My God,” she screamed, then pushed the Code Blue button, and then flipped on the bright overhead lights. In seconds, two other RCU nurses joined her and moments later, the respiratory therapy tech and the ER physician appeared.

  “What happened?” the ER doc cried.

  “I don’t know. She must have freed herself somehow, removed the tracheal tube, and switched off the ventilator.” Patricia fumbled with the plastic packaging for a new tracheal tube, but before she could insert it, the ER physician held her back.

  “Wait a minute. She’s breathing on her own. Let’s get her on oxygen and get a set of blood gases.”

  When Patricia tried to insert a suction catheter into the tracheotomy to insure it was clear of mucous, Connie sat upright, pushed the nurse back, raised her right hand like a crossing guard, and mouthed the word, STOP!

  Later, with Tina, Joe, and Connie crying at the bedside, Jim McDonald watched in awe as Connie activated the speaking valve on her tracheotomy. She pulled Jim McDonald close and said in a voice somewhere between a whisper and a croak, “Don’t know if I should kiss you or kill you.”

  Jim turned to Jack Byrnes. “The more I practice medicine, the less I know.”

  Jack smiled. “We have to deal with surprising success and fortuitous failure, except we’re unaccustomed to the successes, and find them more shocking. Success challenges the most dearly held conceit…our certainty.”

  Chapter Thirty-Two

  Lois and I enjoyed San Francisco’s gourmet restaurants. Although we earned more than a decent living, something about paying two hundred dollars or more for a dinner and wine felt obscene and left us guilt-ridden. In recent years, when we went to the city for dinner, we opted instead for ethnic dining, Chinese, Italian, Mexican, etc.

  To keep in touch with the trendy foods and wines, we had FallFest, held each September in San Francisco.

  “My nose is crying out to me, sweetie,” I said, as I put down the ‘What’s Going On’ section of the San Francisco Chronicle. “It’s FallFest time, and it’s saying, take me to the Embarcadero Center this weekend.”

  “You’re on,” Lois said, patting her flat belly. “I’m not eating after Thursday.”

  The Embarcadero Center with its five office towers, restaurants, upscale shopping plazas, and theaters, sprawled over five blocks of San Francisco’s prime commercial district and hosted FallFest.

  As we drove over the San Francisco-Oakland Bay Bridge toward the city, the morning fog evaporated into the light of the midday sun. My nose savored the bay’s briny aromas. When we reached the midpoint at Yerba Buena Island, my nose registered the pungent aroma of roasting beans at the Hills Brother’s coffee plant under the San Francisco anchorage. Traffic intensified as we approached the Embarcadero Center.

  Lois studied the traffic. “I hope they’re not all going to FallFest.”

  “I don’t think so. Although weekend traffic in the Bay Area is ne’er impossible, nothing is going to keep us away from all that gourmet food and wine.”

  We worked our way through the Embarcadero Center canyons in the shadows of high-rise office buildings looming overhead. Soon, we found signs for FallFest parking that pointed us into an underground garage.

  Brightly decorated signage directed us up into Justin Herman Plaza. As we ascended, I sampled much of the fare trapped in the elevator’s air. My mouth watered and my stomach cramped with hunger. When the elevator doors parted, the refined aromas of San Francisco’s creative culinary chefs—of genius—inundated me.

  Hungry gourmands snacked through the open space. Green linen-covered tables for tasters had colorful protective umbrellas. Sampling altars stood at the plaza’s periphery. The cream of the city’s gourmet restaurants, specialty food preparers, wineries, and chocolatiers displayed their tasty treats. Chefs stood tall behind their restaurant displays wearing executive chef coats embroidered with their names and a variety of headgear, including the traditional white chef hat, the chef’s toque, and a few malcontents were wearing chefs’ colored baseball caps.

  We ate through the selected appetizers, sampling wines and a few microbrewery local beers. These were the best the city had to offer. Their aromas were incredible—their tastes even better.

  We stopped next at Ritchie’s, and upscale continental restaurant. Ritchie himself was having a fine time with the tasters who were enjoying the chef as much as the food. Ritchie wore a chef’s white baseball cap with three Habanero peppers embroidered on the bill, green, orange, and red. Tasters sampled small pieces of grilled lamb chops with Jalapeno pepper jelly.

  “Give it a try,” Richie said as we approached his tab
le.

  “It’s not too hot, is it?” Lois asked.

  “No, you’ll love it.”

  Tentatively, Lois took a bite, and smiled.

  I stuck the toothpick into the meat, lifted it to my mouth, enjoying the flavor before it hit my tongue.

  The taste exploded in my mouth. “Ritchie, this is special. Serrano peppers, right?”

  Ritchie looked at me strangely. “Right. You must have a world-class sense of taste to make that distinction.”

  “We love Serranos, but can’t find them in the Bay Area. Where do you get them?”

  “I have friends in San Carlos, Mexico. They come up with them or arrange for someone to bring them out. They’re worth the effort, aren’t they?”

  “You should bottle this jelly, Richie. We’d buy it for sure.” I licked my fingers. “I love the apricot and the pear you added. It really adds pungency to the jelly.”

  “That’s amazing,” he said. “I’d better be careful what I serve around you.”

  Our conversation drew onlookers. “If everything you serve is as good as that dish, we’re customers for life.”

  “Stop showing off,” Lois whispered.

  We made several other stops, relishing the tastes and adding several restaurants to our ‘must go’ list. A small group of tasters, intrigued by my talent, followed. I was into it—putting on a show.

  The cioppino scent brought us to Biago’s Trattoria table where the man himself stood erect, smiling smugly as tasters oohed and aahed as the small cups of cioppino passed through the crowd. I loved cioppino and believed that its quality portends the repertoire of a gourmet Italian chef. When we finally reached the table, Chef Biago ladled the iridescent red mixture into our cups. While I passed my nose over the cioppino, Lois said, “This is good, Arnie. Isn’t it?”

  When I filled the tiny cup with cioppino and brought it to my lips, Chef Biago watched me, stroking his thin black mustache with curiosity. Instantly, I had the full recipe in my mind and said, “Not bad.”

  Biago reddened. “What did you say?”

  I looked back at Biago, and repeated my comment. “Not bad. In fact, it’s pretty good.”

  “Pretty good?” came with increased volume and attracted the attention of nearby tasters.

  This is ridiculous, I thought. Who the hell is this guy?

  I decided to keep my mouth shut, and started to turn away, when Biago grabbed my arm. “I asked you a question. At least give me the courtesy of a response.”

  I looked back at the red-faced chef, still seeing the humor in this odd situation. “You want to fight with me about my taste in cioppino?”

  Biago released my arm, but his anger persisted. “I am a chef…a gourmet chef, with years of experience, and pride in my creations. If you’ve discovered something wrong with my cioppino, I want to know about it.”

  Lois grabbed my arm and started to pull me away. “Don’t Arnie. It won’t do any good.”

  I gently shook Lois’s hand away, turned back to Biago. The crowd around us was solid with interest. “I’m not crazy about your ingredients.”

  Biago smirked and shook his head. “What do you do, Mr.…”

  “It’s Dr. Arnold Roth. I’m a family practitioner, and if it’s okay with you, I know what I like and what I don’t like.”

  “Tell the arrogant prick, Doc,” came a man’s voice from the crowd.

  I signaled with my index finger for Biago to come close. “Next time, use only fresh tomatoes, use less fennel, and for God’s sake, for cioppino, use Greek oregano.”

  “I only use the best ingredients,” shouted Biago. “Stick to your own business, Doctor,” spitting out the last word as a profanity.

  As I leaned toward Biago, I said in a voice loud enough that people could hear, “Your creation is a little better than the cioppino you can find in jars at Nob Hill Foods, but not nearly as good as Chef Bruno Vitale’s cioppino. That’s where you stole…I mean borrowed the recipe, isn’t it?”

  “You son-of-a-bitch,” Biago shouted as he lunged for me. His staff restrained him as he flailed and sputtered.

  I was six inches taller and eighty pounds heavier, so I grabbed him by the smock, lifted him off the ground. “Thank your friends, Biago. You may think you’re having a bad day, but I assure you it was about to get a lot worse.”

  Chapter Thirty-Three

  Like most normal people, I hadn’t paid much attention to the sensory aspects of entering a room. With my probing proboscis, the simple sniff became olfactory Russian roulette. Now, each time I entered, I hesitated for several seconds, my nose poised for the cylinder’s spin and the hammer’s click. For me, ordinary smells had become sensory suicide or sensory salvation.

  When I placed my bet by opening the ICU door this morning, a familiar cocktail of blood, alcohol, antibiotics and antiseptics, bath powder, and tincture of benzoin greeted me. Many people don’t recognize the name, tincture of benzoin, but most of my generation recognized it immediately from childhood as that acrid substance their mothers placed in the bedside steam vaporizer for colds or respiratory infections. Benzoin is a tree gum resin from the Far East that’s been in use for a thousand years as incense. Now, its sticky properties made it useful in securing bandages to patients.

  I was in the unit to see Vee Dent, a forty-year-old patient of Bert Kaplan, a family practitioner. I covered for him while he went on vacation. Bert had admitted Vee three days ago with acute gallbladder inflammation. She had a history of depression and alcoholism and several episodes of inflammation of her pancreas, pancreatitis, a serious and painful disorder. Jack Byrnes consulted on her case when her kidney function declined. That had improved with IV replacement fluids.

  Jack sat in his usual place by the nursing station.

  “How’s Vee Dent doing this morning?”

  “Either she has an incredibly low pain threshold or the pancreatitis is rearing its ugly head again.”

  As I examined her, I picked up a familiar aroma, musty and acrid, but I couldn’t quite place it. She was alert and oriented to time, place, and person, and her vital signs were stable.

  “This pain’s killing me, Doc,” she said squeezing my arm. “It’s in my back now, like a knife. I can’t stand it. You’ve got to do something.” She grasped her abdomen with both hands. She’d had an epidural anesthetic, a type of spinal used primarily in obstetrics. They’d used it immediately post op for pain control and removed it last night in anticipation of smooth sailing ahead.

  When I joined Jack, I said, “It’s probably pancreatitis again. Any labs back this morning?”

  He held up the computer printout of today’s lab. “I agree with you, Arnie, and so does the lab. Her tests for pancreatitis are sky high. I’m going to give her Demerol to control the discomfort. She’s going to need potent narcotics for several days to a week.”

  Suddenly, something upset me. I felt anxious, but didn’t know why. I tried to focus my attention by writing my daily chart note as the nurse, Carla Watts, approached Vee with a Demerol-filled syringe. In an instant, it struck me. I shouted, “No! Stop!” I raced to the bedside just as Carla was about to inject Demerol. I grabbed it from her hand and extracted it from the IV line.

  Carla stared at me. “What are you doing? Are you insane?”

  Jack approached. “What’s happening here, Carla…Arnie?”

  “He pulled the syringe right out of my hand, Jack. I was about to inject the Demerol as you prescribed.”

  Jack turned to me, his face full of questions. “Arnie, what’s up?”

  “I think she’s on Nardil, Jack. You can’t give her Demerol.”

  “Nothing on her chart suggests that she’s taking an antidepressant, Arnie.” He turned to the nurse. “Carla, get me the medication history sheet ASAP.”

  Jack stared at me. “What makes you so sure she’s on Nardil?”

  “I just know it,” I said, in a near whisper, avoiding Jack’s eyes.

  Carla studied the chart. “Nothing on the nurses
notes, the admission form, or anywhere regarding Nardil.”

  “Jack, you know what can happen if you give her Demerol and she’s been on Nardil…severe hypertension, seizures, high fevers…it could kill her.”

  Jack gave me a smirk. “Arnie, I’m an intensive care specialist. I know more about the interaction between Demerol and Nardil that you’ll ever know, and I’ve seen its effects up close. I’d never give them together.”

  “You were about to, Jack. Trust me.”

  “Trust you? I need a reason, Arnie. You’re a friend and a good doc, but damn it, I need more.”

  “Let’s talk with Vee.”

  We approached Vee’s bed. She looked up. “You’ve got to help me with this pain. It’s killing me. I can’t stand it!”

  I held Vee’s hand. “We need to ask you a few questions, and then we’ll decide how to deal with your pain.”

  She shook her head in disbelief. “I don’t have time for this shit.” She paused as if taken aback by her own words and then said, “Go ahead, Doc, but make it quick.”

  “When the admitting nurses asked you about your medication, you said nothing about Nardil, is that right.”

  “Yes.”

  “You aren’t taking Nardil?” Jack asked.

  “No, no Nardil.”

  Jack turned to me. “Arnie?”

  “You know the drug Nardil, don’t you?” I asked Amy.

  “Of course, it’s an antidepressant.”

  “Have you ever taken Nardil?” I asked.

  “Of course, but I stopped it three days before coming to the hospital. I was too sick to take it.”

  “But you didn’t say anything about Nardil when you were admitted,” said an anxious Carla Watts.

  “They asked me what I was taking and I told them. Nobody asked me what I’d taken before or when I stopped it.”

  Jack turned red, and then returned to the nursing station. He sat with his head down, and then looked up at me. “I don’t know how you knew, but you probably saved Vee’s life and all our asses. We must stop Nardil two weeks before we can use Demerol safely. We could have killed her!”