Foreign Threat

by Mitchell Goldstein

  First, the blood pressure would need to be corrected with fluids. He would give the patient a bolus of IV fluid, probably Lactated Ringers, probably 500 milliliters. No, maybe that would be too much, maybe only 250. Whatever the amount, it would probably help his urine output as well. Steve thought about the rash as he slammed his car door shut. What could be causing the rash?

  He was pondering this thought when an arm reached around his shoulders, “Good morning, Steve.”

  “SHIT!” he screamed.

  “Sorry, I didn’t mean to scare the shit out of you,” said a friendly voice. Dennis Burrows felt bad that he had scared his friend but still managed to get a few chuckles from the moment.

  “Very funny,” said Steve. “Next time why don’t you bring the defibrillator with you so that when I have a coronary, you can just shock me out of Vfib right then and there!”

  “I’m so sorry, but I didn’t think you would get so spooked. Next time I’ll just wave hello from across the parking lot.”

  Steve nodded but continued, “I can’t help it. Today is my first call day, so I am a bit on edge.”

  Dennis knew exactly what Steve was talking about. “Oh, it’s your turn tonight. My first call was two days ago, and it actually wasn’t too bad. I got a bunch of calls from post ops and then one ER consult.”

  “Wow, that was really sweet! You lucked out. We’ll just

  have to wait and see how tonight goes.”

  “Alright, I hope your call day goes smooth. Maybe I’ll see you later. Good luck!”

  “Thanks, I’ll need it. See ya later,” replied Steve.

  The two of them entered the hospital together, but once inside, they quickly went different directions. Steve wanted to make sure that he was able to pre-round on all of the post-op surgical patients. He ran up the stairs to the locker room and dropped his stuff off. Since he was on call, he thought it would be a good idea to just change into scrubs now rather than wait until some drunk in the ER lost his stomach on him.

  After changing, he dashed to the ICU so he could go over the sickest patients on the service. As he was going over the vital signs of the last patient, Jake and Sally walked into the ICU. Steve saw the two of them together and for a split second, he thought they were becoming a hot item. This type of thing happened all the time in the hospital and especially during residency. He had even heard of a staff surgeon having an affair with one of the younger female residents while his wife was being treated for breast cancer. Certainly long hours in the hospital and time spent away from loved ones could lead to encounters such as this, but that relationship never sat well with him. Not that any encounter outside of the marriage was appropriate, but to cheat on your wife while she was being treated for cancer was pathetic.

  The fact that Jake and Sally walked in together probably meant nothing, but Steve was grossed out by the thought that any woman could stand to be with Jake Douglas if she didn’t have to be. The more Steve thought about it, he figured they probably happened to ride the elevator together.

  “Good morning, Carmichael. So this is the big day, huh? I just hope you don’t bug me all night with sorry ass little things

  that should be taken care of by the intern,” squawked Jake.

  “I won’t bug you if you let me do an appendectomy,” joked Steve.

  “What is it with all you interns? You come out of medical school expecting to do appys your first day out. Well, I’ll tell you when I was an intern, we had to show our dedication to the chief before we ever saw the inside of an operating room let alone performed any surgery. And Carmichael, this is only your first day on call! Let’s see how you do first before we have you cutting up people,” said Jake.

  Steve thought to himself, Dedication? Doesn’t working alongside Jake Douglas show dedication?!

  The ICU rounds went as usual: short and sweet. Jake never wasted any time with nonsense. He would get the vitals and talk to the patient. Dr. Douglas would quickly complete the pertinent physical exam, review the labs, and make a management plan for the day. There were only three ICU surgical patients for Dr. Douglas’s service today, so the rounds in the unit went exceptionally quick. Steve made sure that he paid special attention to everything that morning since all the phone calls would be directed to him throughout the day. For that matter, it would last all night. The floor rounds went just as quick, and Steve made mental notes on each patient so that when he got phone calls about the patients, he would be able to respond with some recollection of their status.

  The day in the OR was scheduled to be very busy for Dr. Douglas and his team. Consequently, when the team finished with rounds, they ran off to the operating rooms and left Steve with the patients. All of the patients. Steve counted the list of names. Eighteen patients! That would be no big deal if there was another body to help manage them, but everyone else had gone to the OR, even the medical students.

  Steve found his way to the cafeteria to grab a cup of coffee and collect his thoughts. He wanted to organize his morning in order to get all the scut work done. As he sat down with his coffee, he heard a friendly voice.

  “Well, good morning, stranger.”

  Steve looked over to the next table and saw Erica having breakfast by herself. “Hey, how ya doing? I’ve been meaning to talk to you this week, but the time…well, the time just slipped away from me.”

  Erica laughed, “Yeah, that’s what they all say. At least you surgeons do. They never have any time to themselves once they start their careers. But that’s ok, you just miss out on life. But hey, there is life after death, so when you do unexpectedly pass up on this life, you can enjoy that life, unless of course you provide surgical services for the dead too.”

  Steve looked at her in a confused sort of way, and they both laughed.

  “So what do you have there?” asked Erica.

  “Oh, this is my patient list with all the things I need to get done today before Dr. Douglas gets out of the OR. I just have eighteen patients with four discharges to complete, three NGs to take out, two chest tubes to remove, two IVs to place, and a bunch of labs to review. Then I need to-”

  Before Steve could continue, they heard an all too familiar sound, the sound that most medical students love and most residents grow to despise. That sound would only be that of a pleasant little box clipped to the waistband on your pants or scrubs. That magnificent music could only be that of a pager.

  Steve jumped straight up into the air as his beeper went off

  for the first time. “Shit!” he screamed.

  Erica just giggled.

  “I guess I wasn’t ready for the first page of the day.” Steve nervously hurried over to the phone as if he were keeping whoever paged him waiting too long. There were four phones in the cafeteria so that residents and doctors could get their pages while eating. After all, why should one enjoy a meal when they could be paged constantly?

  Erica watched the very innocent and green intern answer the page. He tried to write some info down on a piece of paper with the phone balanced between his shoulder and right ear. He looked very serious as he listened to the call. Erica tried not to

  laugh when he came back to his table.

  “Well, let’s add two admissions and a consult to that list of chores to do for the day,” Steve griped.

  “Don’t complain, Dr. Carmichael,” said Erica. “If you stay busy like this, think of how fast your call day will go. You’ll never be bored, and you’ll probably learn a lot, which is really why you and I are both here anyway.”

  “Yeah, you’re probably right,” acknowledged Steve. “But it would be nice to sit down and have a cup of coffee before all the shit hits the fan.”

  “Shit hits the fan?” exclaimed Erica. “If you think one page equals shit hitting the fan, you better hang on tight for a long and bumpy ride!” She rolled her eyes. “Or you could change to Internal Medicine where we start each and every day with a cup of coffee.”

  Steve smiled back at Erica. As he got up, his pager we
nt off again. “Shit!” He looked at the pager but didn’t recognize the number. “2004?”

  “Ah, you might want to get that one right away. That’s the ICU,” Erica calmly suggested.

  Steve rushed to one of the phones with a frightened look

  on his face. As he quickly dialed the number, Erica walked by and grabbed him. She gently but firmly shook his arm and said, “Chill out, Carmichael, if you freak out like this all day long, you will be on anti-acid medication by the end of the night. If they really wanted you, I mean really wanted you for a serious problem, they would have overhead paged you. So just relax.

  They probably need TPN orders or something like that.”

  Steve nodded his head as he put the receiver to his ear. “Hello, this is Dr. Carmichael. Were you looking for me?”

  Erica stared at Steve and silently lipped, “Hello?” She just shook her head and said, “Let’s meet for dinner down here tonight.”

  Steve again nodded yes and then listened to the voice on the

  other end. “Hi, Dr. Carmichael. This is Nina Rogers, and I am the nurse taking care of Bed 4. Could we please have a TPN order?” Steve looked at Erica as she walked out of the cafeteria. He smiled.

  The morning was going well for Steve. He calculated TPN orders on all of his patients in the ICU and then made sure they were all taken care of before he moved out to the floor. There he had to take care of the admissions as well as the discharges. It seemed for every person he sent home, there was another one being admitted. Looking up lab information was also important because if someone had low potassium or an elevated bilirubin and he didn’t discover it, then it would be his fault whatever happened to the patient as a consequence of the abnormal lab value.

  Just about lunchtime, he seemed to be nearly caught up when he got two new calls for IVs. He didn’t plan on lunch anyway. He got all the items he needed for placing an IV, including a hep lock, lidocaine, a tourniquet, and of course the IV. He would always bring different size IVs in case he

  couldn’t get a larger size in.

  He could not help himself thinking of the lecture when they all learned about IVs and then placed them into each other. Steve was still upset about that, not that they had to practice on each other, but that it was supposed to be the lecture about appendectomies. All of the interns routinely looked forward to that lecture because they all want to do appendectomies. Steve was no exception. An appendectomy was almost always the first operation interns were allowed to perform. The appendectomy lecture would be the first step to get there.

  After the IVs were successfully placed into the appropriate patients, Steve was about to sit down for a caffeine break when he heard his name overhead. “Dr. Carmichael, stat to the ICU! Dr. Carmichael, stat to the ICU!” Steve instantly felt his heart rate accelerate, adrenaline release throughout his body, and nausea hit his stomach. Before he had a chance to throw up in the cafeteria, he took off for the ICU. He arrived in time to see a large commotion in Mr. Gordon’s room.

  “What is going on?” demanded Steve.

  One of the nurses started to explain, “Gordon’s blood pressure began to drop, and his fever is now 103.2 degrees. His pulse is in the 130s, and his last blood pressure was only 74 over 46.”

  “What was his last hemoglobin?” asked Steve.

  “13.2, after the blood he received yesterday.”

  The young doctor felt frantic. “Did anyone get a hold of Jake yet?”

  “Not yet,” replied one of the nurses. “We haven’t had time.”

  “Shit, shit,” muttered Steve.

  “Dr. Carmichael, what do you want hanging? Any meds you want pushed? Do you need anesthesia? What do you want to do about his blood pressure? What do you want to do about his temp?” The nurses’ stream of questions was endless.

  Steve was in a daze. He felt as if he was in a make-believe story. He didn’t want this to be true. As a medical student, he had witnessed such scenarios with other residents but hadn’t thought it would happen to him so soon in his residency. Steve walked in small circles looking at the monitors, hoping everything would suddenly get better. Maybe if he ignored the situation and all the nurses, this disastrous situation would just disappear. It would become another daydream: you think about the worst-case scenarios and what you would do. When you came up to something that was uncomfortable or hard to handle, then you could jolt your thoughts to something else like what you were going to do Saturday night.

  But this was no dream. Mr. Gordon was crashing.

  “Dr. Carmichael! Dr. Carmichael, what the hell do you want to do? Is there anybody else around? Where is Sally or Tom?” asked Agusta, the veteran ICU nurse.

  “Uh, they are still in the OR.” Steve took a big deep breath in and started belting out orders. “Let’s make sure we have two large bore IVs in and get a central line kit ready for me to put in! Next, give 500 of LR. Just push it in, and if that doesn’t bump his blood pressure, then repeat that bolus. After a liter of LR but still no improvement in his blood pressure, let’s start Dopamine at 5 mics!” He continued dishing out the orders. “Since his temp is sky high, let’s give 1000 of Tylenol. And while we’re on that topic, what antibiotics is he on?” One of the nurses showed him the med list. Steve read the list and then re-read it two more times. “What antibiotics is this guy on?” Steve shouted in a panicked voice.

  The nurse who handed him the meds list looked over the list just as Steve did and then quickly replied, “None! Douglas discontinued them yesterday.”

  “What?!” questioned Steve. He had grown to not really respect the patient management plans devised by Jake, but now he had to deal with consequences for the chief’s poor medical decisions.

  “Dr. Carmichael, his pressure is down to the 60s, and hat bolus of LR is in!” a frantic nurse exclaimed.

  Steve thought for a second. He remembered from a Morbidity/Mortality conference one resident whispering to another as a third resident was getting chewed alive by the staff for a bad choice he had made. The guy had whispered, “If you’re going down, drag as many people with you as you can.” The other resident leaned over and whispered in reply, “Never go swimming in shark infested water alone.” They both had laughed as the conference continued.

  Steve did not want to face the M/M conference by himself to explain why a fresh one-week-old intern was taking care of a complicated surgical patient that was crashing, and crashing bad, without the help of any senior residents. He shouted, “Let’s go ahead and start that Dopamine at 5 mics, and Agusta, call the OR and let me talk to Jake, now!” The ICU was in a blur of constant motion. The nurses were great, trained to go autopilot when situations like these developed. In fact, Steve was sure these ICU nurses could handle this crash better than most interns. It didn’t take much time to realize that they had much more experience than most interns just coming out of med school. Steve might be able to recite the biochemical Cori cycle and those nurses probably didn’t even have a clue as to what the hell it was, but the Cori cycle was not going to save the patient’s life at this particular moment.

  As Agusta walked over with the phone, a nurse reported that the blood pressure was back up to 104 over 65. “Here is the king prick for you,” said Agusta, handing the phone to Steve.

  “Jake? Yeah, hi, this Steve, and we have a small problem over here with Mr. Gordon.” Steve was very careful to select his words to not incriminate Jake. He continued, “Uh, it seems that his blood pressure dropped with a sharp elevation in his temp. It looks as though he may be crashing from septic shock.”

  “Oh, great!” exclaimed Jake. “Just give him a lot of fluids, and I’ll be there in about fifteen minutes.” With that, the other end hung up.

  Fifteen minutes? thought Steve. That was a great deal of time where a lot could go wrong, and Steve didn’t trust Jake’s decision thought process anyway. As he scratched his head and thought what would be politically correct, a nurse came running and screamed his BP was back down to 72 over 48 and his pulse was
135. “Shit, alright, let’s get ready for a swan ganz catheter, and Agusta, call Dr. Rosberg and tell him that we are crashing and Jake is busy in the OR. Hey, you!” Steve called out to anyone who would listen, but specifically to a nurse near the bedside. “Let’s hang a liter of Hespan and push it in!”

  Agusta had been around the ICU scene for a long time, and she had seen her share of green interns. Through what she was able to observe thus far, however, she was quite impressed with young Dr. Carmichael. She knew he was placed in a horrible situation, made worse by having to work with Jake Douglas. She would have no hesitation relaying that to Dr. Rosberg.

  As Steve was scrubbing the right clavicular area, he could hear the conversation between Agusta and Rosberg. “He is doing the best under the circumstances. It seems that Douglas stood him up and left him in this mess by himself. I think Mr. Gordon needs a little help from senior staff…all right…uh-huh…ok…great. That sounds just perfect. We’ll see you soon.”

  Agusta placed the phone down and said to Steve, “He will be down in just a second. Just hang on tight!”

  Steve smiled to himself, but not for long as he continued to try to save Mr. Gordon. Steve took a large needle and inserted it into the skin just under the right clavicle. The needle was long and connected to a syringe. All of a sudden, he noticed the syringe fill with blood. He thought to himself, “Great, that was easy!” But as he continued to look at the syringe, he realized that the syringe was filling too quickly with pretty red blood. He figured that he was in an artery instead of a vein, but just in case, he disconnected the syringe from the needle itself to see if there was any bleeding. Sure enough, he saw an episodic arterial pumping of blood and quickly removed the needle from the lifeless body of Mr. Gordon. “SHIT!” Steve shouted in frustration. Nonetheless, he went at it again and this time found a nice normal return of darker blood for the subclavian vein. He placed the guide wire and floated the Swan without a hitch.