Warning Signs

by C. J. Lyons

  “Sure. How about if I bring them over to your place?” Nora would have liked nothing more than to have somewhere to go tonight.

  After moving out of the town house she and Seth had shared, Nora had jumped at an opportunity to exchange some light nursing care for room and board, and she’d moved into the top floor of a house owned by a lawyer with MS. Despite her wheelchair, Mickey Cohen, the lawyer, was mostly self-sufficient—in fact, she needed so little help that Nora felt guilty for not paying rent—but she was wise enough to realize that having someone around was a good idea. And Nora found that having someone to talk to, eat with, just be there in the house had helped her avoid facing the emptiness of life without Seth. But now Mickey was out of town with her sister on a two-week cruise, leaving the house and Nora’s nights vacant. “Unless you and Trey have plans?”

  “Nothing special. Yeah, tonight works.” Lydia opened the door and Nora followed her out.

  “We still need to talk about Deon Grey,” she reminded Lydia.

  “I’ve got it covered,” Lydia said without looking back. Her shoulder blades hunched together defensively, and Nora knew better than to pursue the subject.

  While Lydia went to the med command phone, Nora tapped Jason, the desk clerk. “Page Tommy Z for me. We need him in the ER to evaluate a child for placement. Thanks.”

  Nora didn’t know what Lydia had against asking for help. Didn’t matter. Sooner or later she’d come to see the value of having friends and co-workers watching her back.

  EIGHT

  Thursday, 10:38 A.M.

  AMANDA TREATED HERSELF TO AN ELEVATOR ride up to the PICU on the fourth floor. Not because she was tired or thought the elevator would be faster than the stairs. Rather, sandwiched in the corner between a man pushing an IV pole with one hand and fumbling his cigarettes back into his pants pocket with the other and a couple obviously on their way up to OB, it gave her a few minutes to feverishly search through her pocket guides.

  None of them mentioned hypothermia as a treatment for hypoxia, but the newest guide had been published last year (which meant it was actually written at least two to three years ago). Forget about a protocol for a seven-month-old.

  Her vision swam as the elevator lurched to a stop and she elbowed her way out. She was so very much in over her head, like walking through a marsh only to find the ground shifting beneath her and sucking her down. The kind of muddy marsh where alligators liked to hide in wait for their prey—that was Jim Lazarov with all those shiny teeth of his. World-class alligator on the prowl.

  Good thing she knew a thing or two about alligators. If only she knew what in the hell she had to offer a little baby trying hard not to die.

  The doors to the pediatric ICU swished open, discharging a smell reminiscent of her great-aunt Nellie’s attic. Not dirty or moldy, but stale. As if even the air didn’t dare move too much in fear of disturbing the children who lay within. There was a chemical aftertaste to the scent as well, a hint of alcohol and iodine, biting against the back of her throat.

  Amanda stepped inside, and the doors slid shut again. Nurses and doctors hustled and bustled, no one running but no one moving slowly either. Neon lights of monitors cast strange glows on the reflective surfaces surrounding the children—all of whom appeared much too small for their beds. Parents slumped in rocking chairs, wearing the haunted expression of the sleepless and hopeful.

  It was a place where miracles occur—and where those same miracles could fail, come crashing down to earth with shattering speed.

  Avoiding anyone’s eyes, especially any parents’, Amanda walked to the nurses’ station and retrieved her new patient’s chart. Alice Kazmierko. Alice in Wonderland.

  An alarm sounded across the room—muted compared to the noise in the ER, but loud enough to bring several people running. They gathered around a child, but not a baby, so at least she knew it wasn’t her patient causing the panic. She took Alice’s chart into the dictation room behind the nurses’ station and began to read.

  She hadn’t gotten far when her pager bleeped. The medical ICU. She dialed the number, hoping Tracey Parker hadn’t taken a turn for the worse. “Amanda Mason, someone paged.”

  “Tracey Parker’s boyfriend is here and he’d like to talk to someone about her,” the clerk answered.

  Damn. Jim must have given the ICU Amanda’s pager number. Like she needed more to take care of. She glanced at her watch. She was due at Dr. Nelson’s in twenty minutes. “Right. Where’s he at?”

  “He’s in the family room.” The clerk hung up before Amanda could ask any more.

  She left Alice’s chart in the dictation station, hoping to return to it in a few minutes. It wasn’t as if she had any answers for Tracey’s boyfriend—and even if she did, she wasn’t sure how much she was allowed to tell him. He wasn’t a relative. And she wasn’t a doctor—what if she told him the wrong thing?

  Her shoulders hunched with additional worry, she walked across the hall to the family waiting area. When her father had his stroke last Christmas, Amanda had spent too many frustrating hours of waiting, crammed into a small room just like this one, with bright shiny holiday decorations all around, thinking about the worst that could happen.

  She paused before entering the waiting room, not sure of exactly what to do. The clerk hadn’t given her Tracey’s boyfriend’s name, and she hadn’t thought to ask. She stepped inside and cleared her throat. A middle-aged couple sitting together on a love seat, holding hands, looked up, their faces tightening at the sight of her white coat.

  “Blackman?” the man said, a weary croak in his voice.

  “No. Sorry. I’m looking for the friends and family of Tracey Parker?”

  The couple shook their heads and looked down. The room was in the shape of an L with a vending area around the corner. Chairs and love seats were scattered about; two TVs hung from opposite corners, dueling soap operas playing across their screens. She turned the corner to the vending machines and was surprised to see a short, stocky man with curly red hair and thickly muscled forearms bending to reach for a cup of coffee.

  “Jared. What are you doing here?” He wore a dark blue hoodie over gray sweatpants with the Allegheny Rowing Association logo adorning both.

  “Amanda. God, I’m glad it’s you. How is she? What happened?” His fingers tightened on the foam cup in his hand as he strode toward her, anxiety radiating off him.

  “Tracey Parker is your girlfriend?” Elise had said Tracey was a long-distance runner; Jared had mentioned his girlfriend training for a marathon.

  Jared nodded, confirming Amanda’s fears. “Her running partners called, said Tracey is here. Said they had to Lifeflight her.” He paused as if waiting for her to fill in the blanks but then changed his mind and rushed on. “They won’t let me see her, tell me anything—no one will tell me anything.”

  In an effort to look professional and knowledgeable, Amanda put her hands behind her back, using the motion to wipe her sweaty palms on her lab coat.

  “Can you get me in to see her? What happened? When can she come home?”

  His questions were making her dizzy, especially as she couldn’t answer any of them. “We’ll know more in a little while,” she said, borrowing a line from Lydia. “In the meantime, can you tell me more about Tracey’s medical history? Does she have any allergies to medication? Has she been sick lately?”

  “Tracey? Sick? No way. She’s about to run a marathon.” He shook his head, appeared stunned at the idea.

  “Does she take any medications?” She reverted to the typical med student litany of thorough history taking, relieved that her questions distracted him from asking about Tracey. “Even vitamins or over-the-counter?”

  Again he started to shake his head, then stopped himself. “Oh. Yeah, she does have some stuff from the health food store. And she sees a doctor here every month. He has her on some kind of special pills.”

  “What kind?”

  “I don’t know—they’re in a big brown bottle, t
he label just has a bunch of numbers and a bar code on it.”

  Sounded like a research protocol. With the medical school and several research labs here at Angels, thousands of Pittsburghers were recruited each year to participate in studies. Even Amanda was on one—the two hundred dollars a month it paid was her food budget. “Do you know which doctor she saw?”

  He shook his head again, noticed the coffee cup in his hand, and turned to toss it away, untouched. “I don’t know—she told me once, I know, I just can’t remember.” He spun around, muscles knotting his forearms as he tensed. “Amanda, tell me, what the hell is going on? What’s wrong with Tracey?”

  “I’m sorry, Jared. We just don’t know very much yet.”

  “Why not? She’s bad off, isn’t she? I mean, she must be if she can’t answer any of this herself.”

  “Right now we have her sedated. We couldn’t find any next of kin.”

  “There isn’t any that I know of. Except maybe a cousin—down in Virginia somewhere near D.C., I think. I can go through her things, take a look.”

  “Thanks, we’d appreciate it. When you go home, would you collect her vitamins and medicines and bring them in? All of them?”

  “Sure. No problem.” His mouth twisted. “Do you think I can see her? I really need to see her.”

  Amanda patted his arm. No one had ever told her how hard this was when you knew the patient or their family. “You wait here, Jared, and I’ll see what I can do. It will take a while.”

  She left him feeding more quarters into the coffee machine and returned to the PICU and her other patient. As she pulled up Alice Kazmierko’s ER summary on the computer, she opened the baby’s chart across her lap. Because of the need to document verbal orders and events such as resuscitations, the ICUs and ER were the only areas of the hospital that still had paper charts in addition to the electronic medical record.

  Even though the Institute of Medicine touted the EMR as the solution to many patient care problems such as medication errors, Amanda still thought there had to be a better way. Unlike most other twenty-five-year-olds, she wasn’t completely enamored with technology, still believed in talking face-to-face with actual people, and had a niggling feeling that despite all the safeguards, trusting a machine with patients’ lives was a mistake.

  “That our new patient?” Lucas’s voice startled her, and she fumbled the chart.

  “No. Our patient is a seven-month-old baby girl, not a chart,” she snapped, irritated that he’d seen her clumsiness. Next thing you knew, he’d be ordering an MRI on her.

  He leaned against the doorjamb, a chuckle escaping him at her insubordinate answer, making her flush with embarrassment. She buried her face in the chart, flipping through the ICU orders.

  “Alice Kazmierko,” she began again in a neutral and hopefully more professional tone, “is a seven-month-old, previously healthy girl suffering traumatic asphyxia after prolonged entrapment and extrication from her car seat in a T-bone collision. Patient with no other injuries, unresponsive at the scene, hypothermia protocol begun in ER—”

  “Really?” he interrupted her, sliding the chart from her hand and lowering himself into the chair beside hers. Their legs brushed. Lucas didn’t seem to notice; he was concentrating on the chart. But Amanda did notice, immediately swiveling away, then cursing herself for noticing.

  Why did Lucas always make her feel like a clumsy schoolgirl with a crush on her teacher? She smoothed the fabric of her dress, tugging it lower and crossing her ankles like a lady.

  “Lydia Fiore began the cooling process down in the ER,” Lucas said. “Leave it to her—that’s a pretty bold move.” He snapped the chart shut and looked up at Amanda. “You did a neonatal rotation, right?”

  “In the spring.”

  “Tell me about neonatal hypoxia.” He leaned back in his seat, legs crossed, gaze unwavering, focused on her as if they had all the time in the world.

  Amanda stole a glance at the clock. They didn’t—well, she didn’t. She had to be at the clinic by eleven, not to mention checking on Tracey Parker; getting the pathology results on their patient from last month, Becky Sanborn; and finishing her note on Alice. It’d be nice if somewhere in there she had time to eat, drink, or pee.

  “For a variety of causes, both intrautero and during the delivery process, neonates can suffer hypoxic events, leading to decreased cerebral blood flow. Once blood flow is reestablished, more harm can be done with secondary swelling and inflammation, adding to the damage. For this reason, selected cerebral hypothermia was developed in the hopes of slowing the inflammation and subsequent damage. Studies—”

  The sound of a car horn blaring out a rebel call blasted through the tiny space. Amanda jumped, almost falling off the rolling chair, but Lucas steadied her.

  “I think that’s coming from your pocket.” He grinned as the sound repeated.

  “My roommate, she reprogrammed my ringtones,” she said sheepishly, grabbing her cell phone. She opened it to glance at the readout and see who Gina had assigned the General Lee’s horn sound to. Adam. Her oldest brother. Great, Mama was pulling out the big guns.

  “Go ahead,” Lucas said, typing on the computer, reading through Lydia Fiore’s dictation of Alice’s resuscitation.

  Amanda hesitated, tempted to just turn the phone off, but the annoying ringtone began again and the easiest way to shut it up was to take the call. “What?”

  “Well hello to you too, Baby Girl,” came Adam’s rumble of a voice. If she hadn’t seen the phone number, she would have sworn it was her daddy, they were starting to sound that much alike. “Is that any way to greet your big brother?”

  Adam, the oldest, was seven years older than Amanda and considered himself the boss of all of the Mason children. Boss of the world.

  “I can’t talk now, Adam. I’m with a patient.”

  “It’s an emergency,” he went on without giving her a chance to interrupt. “Mama said you’re not coming home for Andy’s wedding shower.”

  “It’s not Andy’s shower. Andy won’t even be there. He’ll be out hunting with the rest of y’all.”

  “Is that what this is about, Baby Girl? You’re still upset that we won’t take you on our hunting getaway?”

  “I shoot better than any of you, especially Tony.”

  “Hell, Aunt Nellie can outshoot Tony. We only bring him along because he doesn’t whine about cleaning and skinning—”

  “That’s beside the point,” Amanda cut in when she noticed Lucas staring at her, obviously listening with amusement. “I can’t make it home this weekend. Tell Mama I’m sorry. I have to go. Good-bye.”

  “Wait! Don’t you hang up—”

  Amanda flipped the phone shut, hanging up on him. A rush of adrenaline surged through her. She’d just stood up to her oldest brother for the first time in her life. And she’d hung up on him!

  Oh, hell, she’d hung up on Adam … triumph was quickly washed away by guilt and fear. What had she done?

  “Sounds like your family is about as understanding as mine,” Lucas said.

  She shoved the phone back in her pocket, wishing she could hide the flush of embarrassment creeping up her neck.

  Lucas ignored it, tapping his pen against the computer screen. “What do you think about Lydia starting the hypothermia? Was it a mistake? Should she have stuck to conventional trauma protocols?”

  He wanted her opinion? What did she know, she was just a med student. But he seemed truly interested in what she thought. “I worked with Dr. Fiore during my ER rotation. I think she’s an excellent clinician, and she knew that if hypothermia was going to have a protective effect, it’s best to start as soon as possible.”

  His eyes crinkled as he stared at her for a moment longer before nodding. “I agree. It was a gutsy move, but the right one. What are the drawbacks of hypothermia?”

  “You need to monitor the temperature closely, give benzodiazepines to avoid shivering, maintain the caloric intake, avoid acidosis, and watch cardia
c and renal function.”

  “And?”

  She glanced beyond him out the door to the patients in their beds. “And you need to keep the patient sedated and paralyzed, so you lose your neuro exam.”

  “Correct. Making our job that much harder. So what do you recommend?”

  “Initial CT was clear, so I’d continue the hypothermia at least twenty-four hours, do an MRI, and if that shows no signs of any diffuse neuronal damage, I’d let her wake up.” She paused. “Depending on how long blood flow to the brain was compromised, there’s still a significant risk she’ll remain in a persistent vegetative state. Or worse.”

  “Or worse.” He sighed. “Good work. Let’s go find the parents.”

  “The nurses said the cops arrested Dad for DUI, after he assaulted Seth Cochran.”

  “Seth’s all right?”

  “I think.”

  “We’ll try to find Mom, then. She’s probably down in the family room.”

  “I have that appointment—”

  “Right. I don’t know why, of all the research studies out there, you’d sign on with Nelson.” He’d buried his face in the chart, but even in profile, his disdain was obvious. The muscle at the corner of his jaw was practically snapping with tension.

  “Dr. Nelson is helping lots of people with his nutritional supplements—”

  “Dr. Nelson is helping himself get rich.” Lucas jerked his head up and opened his mouth as if ready to say more, but she didn’t give him a chance.

  “You don’t know what you’re talking about. Dr. Nelson doesn’t have to do the studies on his supplements—the FDA doesn’t require them. He does it because he’s a scientist, because he wants to create the best product designed to help the most people—”

  “Who are you, his poster girl?”

  “No.” She pushed out of her chair, stood, straightened her shoulders, and glared down at him. “I happen to be a friend. I was there when he and his wife lost their baby two years ago. Now, if you’ll excuse me, Dr. Stone, I’m late for my appointment.”

  To her surprise, he stood and blocked her way.