Foreign Body

by Robin Cook

  The footsteps were rapidly descending; Raj had to decide! He was in a panic. He heard the more hollow sound as the approaching individual reached the landing. In an even greater panic, Raj opened the door to the third floor only enough to step through and then used his hip to push it closed. Not realizing he’d been holding his breath, Raj allowed himself to breathe as he glanced up and down the corridor. Behind him, in the stairwell, he could hear the now muffled steps descending toward the third-floor landing. For fear whomever it was might try to exit on the third floor, Raj pushed off the stairwell door and headed for his patient’s room. He’d been forced into action. It had been like standing at the edge of a pool afraid of the water and then being pushed in. Raj did not look back until he’d reached David Lucas’s door. Just ahead, two nurses emerged from the next patient room, in deep conversation about the individual’s care. Luckily, they immediately turned toward the central desk. Had they looked in the opposite direction, they would have locked eyes with Raj a mere ten feet away, and he would have had some serious explaining to do.

  Luckily, he was able to slip unseen into the room, but then he stopped just inside the door. He heard hushed conversation. Mr. David Lucas was not alone!

  Confused about whether to stay or flee, Raj froze. A second later a wave of relief spread over him. It wasn’t a visitor; it was the TV. With a surge of confidence, Raj walked farther into the room, rounding the outer wall of the bathroom, affording him a view of the strikingly obese patient propped up in the hospital bed. The patient was asleep. A nasogastric tube issued forth from one nostril and was connected to suction. About a half-cup of yellowish, blood-tinged fluid could be seen in the collecting bottle. A cardiac monitor on the wall behind Mr. Lucas played out a regular rhythm. All in all, the entire scene looked identical to how it had looked when Raj had left for the day a little after three that afternoon.

  Raj reached into the pocket of his white nurse’s trousers and pulled out the syringe he’d prepared back at the bungalow. In contrast to Veena and Samira, he’d not had to go to the empty operating room to get the succinylcholine, and for that he was pleased. He knew he had Samira to thank, and had already done so.

  After checking the syringe to be certain none of the fluid had leaked out, a distinct possibility, since he had actually overfilled the 10 cc syringe, Raj was ready to go. He’d overfilled the syringe on purpose, thinking that the last thing he wanted to do was not give enough.

  Returning to the door, Raj gave one last look up and down the corridor. There was one nurse walking toward him, but she turned into a room and disappeared. Sensing the time was never going to be better, he returned to the bedside. Carefully picking up the IV line without pulling on it, he took the cap off the needle with his teeth, and then gently poked the needle through the IV port. There was no need to worry about sterile technique.

  Thus prepared, Raj paused for another moment, listening if there were any telltale sounds from the hall that he could hear over that of the lowered TV. There weren’t, so he used both hands to discharge the entire contents of the syringe into the IV line in a large bolus. Having not stoppered the upper part of the IV line beforehand, the first thing he noticed was a rapid rise in the level of fluid in the millepore chamber. But that effect was overshadowed by the patient’s response. As Samira had warned, there were almost instantaneous fasciculations of the facial muscles combined with David Lucas’s eyes shooting open. He also started to cry out as his extremities began a series of myotonic jerks.

  Raj took a step back, shocked by what he was observing. Although he’d been cautioned, the reaction had been more rapid and more disconcerting than he’d expected. He watched for another beat as the patient tried to sit up but immediately collapsed back like a freezer bag full of fluid. With a sense of revulsion, Raj turned and fled. The problem was, he didn’t get far. As he yanked open the door to the corridor, he literally ran into a white-coated figure who’d just raised his hand to push open the door that because of Raj was no longer there.

  Raj grabbed the man in a bear hug to keep from knocking him over as his inertia carried them out into the corridor. “I’m so sorry,” the befuddled nurse blurted. The collision had been so unexpected, and making it even worse, he recognized the man. It was Dr. Nirav Krishna, David Lucas’s surgeon, on late rounds before heading home.

  “My God, man,” Dr. Krishna snapped. “What the bloody devil is the rush?”

  For a brief moment of utter panic, Raj tried to think of something to say. Realizing there was no way out, he told the truth. “It’s an emergency. Mr. Lucas is having an emergency.”

  Without saying anything, Dr. Krishna pushed by Raj and dashed into the room. Coming to the bedside, he saw David Lucas’s beginning cyanosis. Out of the corner of his eye he saw from the monitor the heart was beating relatively normally. It was then that he realized the patient was not breathing. He did not see any fasciculation, because they had already stopped.

  “Get the emergency cart!” Dr. Krishna yelled. He yanked out the nasogastric tube and threw it to the side. Grabbing the bed control, he began to lower the head. Seeing Raj glued to his spot, he again yelled for him to get the crash cart. They were going to have to resuscitate.

  Raj recovered from his paralysis but not his terror. He raced from the room and ran headlong down the corridor toward the nurses’ station, where the emergency cart was stored. As he ran he tried to think of what he should do. He couldn’t think of anything other than to help. The surgeon had gotten a good look at him, and if he just disappeared, he’d surely be implicated.

  Reaching the central station, Raj blurted out to the two nurses sitting at the desk that there was a code in room 304. Without stopping, Raj threw open the door to the storeroom where the crash cart was kept, grabbed it, backed out with it in tow, and then raced back down to David Lucas’s room, making an enormous racket in the process. When he got there, the lights had been turned up. Dr. Krishna was doing mouth-to-mouth, and to Raj’s added horror, Mr. Lucas didn’t look so bad; his cyanosis had faded to a large extent.

  “Ambu bag!” Dr. Krishna shouted. One of the floor nurses who’d raced after Raj grabbed it from the cart and tossed it to the doctor. Dr. Krishna repositioned the patient’s head, applied the bag, and began respiring the victim. Now the chest was moving even better than it was with the mouth-to-mouth. “Oxygen!” Dr. Krishna barked. The other floor nurse got the cylinder over to the head of the bed, and between Dr. Krishna’s compressions, she connected it to the breathing bag. Within seconds Mr. Lucas’s color improved dramatically; it was now actually pink.

  As these activities progressed, Raj had an opportunity to appreciate just what kind of disaster he was in. He didn’t even know for certain whether it would be better if the patient died or was saved. Nor did he know if it would be better for him to slink away or stay, and the uncertainty kept him riveted in place.

  At that point the evening house doctor, Dr. Sarla Dayal, arrived at a run. She crowded in at the head of the bed, and Dr. Krishna gave her a rapid summary of what had happened.

  “When I got here he was definitely cyanotic,” Dr. Krishna said, “and the cardiac monitor looked reasonable, but it’s only one lead. The problem was, he’d stopped breathing.”

  “You think it was a stroke?” Dr. Dayal questioned. “Maybe a heart attack precipitated a stroke of some sort. The patient has a history of occlusive cardiovascular disease.”

  “Could be,” Dr. Krishna agreed. “It does look now like the cardiac monitor is telling us something. The rhythm is certainly slowing.”

  Dr. Dayal placed a hand on the patient’s chest. “The heart rate is slowing and feels rather faint.”

  “It’s probably the patient’s obesity.”

  “The patient also feels really hot. Take a feel. I’ll breathe for a while.”

  Dr. Krishna turned the ambu bag over to the house doctor and felt David Lucas’s chest. “I agree with you.” He looked over to one of the floor nurses. “Let’s get a tempera
ture!” The nurse nodded and got the patient’s thermometer.

  “Do we have a cardiologist on call?” Dr. Krishna asked.

  “We certainly do,” Dr. Dayal said. She called over to the other floor nurse to give Dr. Ashok Mishra a call and ask him to come in immediately. “Tell him it’s an emergency,” she added.

  “I don’t like that the heart rate keeps slowing,” Dr. Krishna said, watching the monitor. “Let’s get a stat potassium level.”

  The floor nurse who was not on the phone drew some blood and rushed it off to the lab herself.

  To stay out of the way, Raj had slowly backed away until he’d hit up against the wall. He was thankful that people were so involved in the resuscitation activity that he was being virtually ignored. He again began to think about slipping out, although the specter of drawing attention to himself made him stay put.

  “Dr. Mishra will be in as soon as he can,” the nurse yelled out while hanging up the phone. “He’s finishing up with another emergency.”

  “That’s not good,” Dr. Krishna said. “I have a bad feeling. With this progressive bradycardia, it might be over by then. This heart is definitely having trouble. It looks to my untrained eye as if the QRS interval is widening.”

  “The patient definitely has a fever,” the nurse blurted, staring at the thermometer in disbelief.

  “What is it?” Dr. Krishna demanded.

  “It’s over one hundred and nine.”

  “Shit!” Dr. Krishna shouted. “That’s hyperpyrexia. Get ice!”

  The floor nurse ran out of the room.

  “You must be right, Dr. Dayal,” Dr. Krishna moaned. “We must be dealing with a heart attack and a stroke.”

  The nurse who’d dashed up to the lab returned on the run. She was out of breath but managed to say, “The emergency potassium level is nine-point-one milliequivalents per liter. The tech says he’s never seen it that high, so he’s going to repeat it.”

  “Yikes!” Dr. Krishna exclaimed. “I’ve never seen a potassium level like that. Let’s give some calcium gluconate: ten milliliters of a ten percent solution. Draw it up. We’ll give it over a couple of minutes. Plus, I want twenty units of regular insulin. And do we have cation-exchange resin available? If so, get it.”

  The floor nurse came back with ice. Dr. Krishna dumped it over the patient, and a lot clattered to the floor. The nurse then ran back out to try to get the resin while the other began to draw up the medication.

  “Damn!” Dr. Krishna shouted as the blip on the monitor flat-lined. “We lost the heartbeat.” He climbed up on the bed and began closed-chest massage.

  The CPR attempt went on for another twenty minutes, but despite the medication, the ice, the cation-exchange resin, and a lot of effort, a heartbeat was not regained. “I think we are going to have to give up,” Dr. Krishna said finally. “It’s intuitive what we are doing is not working. And I’m afraid rigor mortis is setting in already, probably from the patient’s hyperthermia. It’s time to stop.” He let up from compressing the chest. Although Dr. Dayal had offered to relieve him ten minutes earlier, he’d refused. “It’s my patient,” he’d explained.

  After thanking the two floor nurses for their help and Dr. Dayal for hers, Dr. Krishna pulled down the sleeves of his white coat from where he’d pushed them up at the outset of the resuscitation attempt, and started for the door. “I’ll do the paperwork,” he called over his shoulder as the others began to pick up the debris, put the room in order, and prepare the body. “As per that e-mail directive that came out just today from admin about reporting deaths immediately, I’ll also call CEO Khajan Chawdhry to give him the bad news.”

  “Thank you, Dr. Krishna,” the two nurses echoed.

  “I’ll do the phoning to Khajan, if you’d like,” Dr. Dayal offered.

  “I think I should do it,” Dr. Krishna rejoined. “He was my patient, and I should take whatever heat this is going to create. With those deaths over at the Queen Victoria garnering international media attention, this episode is going to be looked upon as very inconvenient, to say the least. I’m sure there’ll be great pressure to keep it under wraps and dispose of it promptly. It’s too bad, because under more normal circumstances, I’d actually like to learn the physiological sequence of events, starting with the patient’s history of obstructive heart disease, right up to the hyperpyrexia and the massively elevated potassium level.”

  “I doubt we’ll ever know,” Dr. Dayal said. “I agree with you about the admin wanting to keep this quiet. But if Khajan wants to talk to me, tell him I’m here at the hospital and can be paged.”

  Dr. Krishna waved over his shoulder to indicate he’d heard. He was about to turn down the short corridor to the room’s door to the hall when his eyes passed over Raj. Reflexively they snapped back to the statue-like nurse. “My gosh, son, I forgot all about you. Come with me!” Dr. Krishna waved for Raj to follow, then preceded him out the door.

  Vainly hoping he would have continued to be ignored as if he were invisible, Raj reluctantly followed the surgeon. Once again, his heart was racing. He had no idea of what to expect, but it was going to be bad.

  Out in the hall, Dr. Krishna had waited for him. “Sorry to have ignored you, young man,” the surgeon said. “I’ve been seriously preoccupied, but now I recognize you. I saw you this morning when I stopped down here to check on Lucas. You’re the day nurse, if I’m not mistaken. What was your name again?”

  “Raj Khatwani,” Raj hesitantly said.

  “Oh, yes, Raj! My, you have long hours.”

  “I’m not working. I get off after three.”

  “You’re still here at the hospital and you certainly look like you are working, uniform and all.”

  “I came back to the hospital to use the library. I wanted to learn about the surgery you did on Mr. Lucas. Obesity surgery was not included in our nursing-school curricula.”

  “That’s very impressive! You remind me of myself when I was a student your age! Self-motivation is key to success in medicine. Come, walk with me down to the central desk.”

  The two men began walking, with Raj having trouble resisting the temptation to flee. He knew that the longer he stayed and the more he said, the more apt he was to incriminate himself. He could even feel the succinylcholine syringe in his pants pocket, pressing against his thigh.

  “Did your research result in any questions I might answer for you?”

  Desperately, Raj tried to think up a question he could ask to make it seem believable that he’d truly been studying. “Umm . . .” he voiced. “How do you know how small to make the stomach?”

  “Good question,” Dr. Krishna said, switching to a professional mien as he answered it with the help of elaborate hand gestures. He caught Raj’s eyes longingly taking in the stairwell door, which they were passing. The surgeon stopped, interrupting himself. “I’m sorry,” he said. “Do you have to be someplace?”

  “I do have to get home,” Raj said.

  “Don’t let me hold you up,” Dr. Krishna said. “But I do have a question. How was it you were in Mr. Lucas’s room just when he suffered his terminal event?”

  Raj’s mind desperately raced for an explanation. Making the tension even worse, he knew that every moment he hesitated, the less convincing he would be. “After the reading I’d done, I had some questions for the patient. But the second I got into his room, I knew there was something seriously wrong.”

  “Was he conscious?”

  “I don’t know. He was writhing around as if in pain.”

  “That was probably the heart attack. It’s what usually kills these overweight patients. Well, you almost saved the day. Thank you.”

  “You’re welcome,” Raj said with a gulp, almost giving himself away. He couldn’t believe he was being thanked.

  “I have some good journal articles on obesity surgery I can loan you if you’d like.”

  “That would be terrific,” Raj managed.

  After a quick shake of hands, the two men parte
d, Raj disappearing into the stairwell and Dr. Krishna heading for the central desk to fill out the death certificate and call the care manager and Khajan Chawdhry.

  Once inside the stairwell, Raj had to pause. His heart was beating at such a rate that he felt mildly dizzy. Squatting down on his haunches for twenty or so seconds relieved the dizziness, and after wiping the cold sweat from his forehead he stood back up, holding on to the handrail. Relieved, he took a few steps down, and when he sensed he was back to normal, he let himself run down the rest of the stairs to the lobby floor.

  Pleased that the lobby was as deserted as it was, Raj half ran across the room to the main exit door and left the building. Outside, he forced himself to slow to a rapid walk, finding it difficult not to give in to his panic and bolt. He felt like a bank robber exiting a bank with all the cash and every eye on him. At any moment he half expected to hear a shrill whistle and a shouted command to stop.

  Reaching the still-crowded street, Raj hailed an auto rickshaw, and it wasn’t until the Aesculapian Medical Center faded from view out the small rear window that he could begin to relax. Facing forward in a near trance, Raj terrorized himself by rehashing the whole unfortunate episode. He was afraid to tell the others, but he was more afraid not to tell them, unsure of what the ultimate fallout was going to be.

  After passing through the front door of the bungalow, Raj stopped to listen. He could feel the vibration of the large sub-woofer of the video system pumping out the bass in the formal living room, so he headed in that direction. He found Cal, Durell, Petra, and Santana, along with Veena, Samira, and two other nurses, watching a taut action DVD. Durell was enthusiastically into it and cheering on the protagonists, who were facing insurmountable odds.

  Raj went up behind Cal, and after a moment’s hesitation gently shook his shoulder.