“Let’s go Rusty!” Mike said, jumping to his feet. He felt his heart slam into action; STAT pages always had that affect.
“PACU? What’s that?” Rusty asked, his body visibly tensing.
“Follow me,” said Mike, breaking into a run. “It’s the recovery room—post anesthesia care unit or some bullshit like that.”
“Oh.”
STAT pages to the recovery room were rare. The recovery room nurses at Mercy were generally experienced, so when STAT calls were made, they tended to be legitimate. Mike was slightly out of breath when the pair got there. He noticed Rusty was breathing fine.
The PACU was a large narrow room with twelve bays, complete with monitors and oxygen setups, for surgical patients to shake off the effects of general or spinal anesthesia. “Bay” was a nice term for a space on the floor to park the litter. There were no cubicles or walls. Slidable partitioning curtains hung from the ceiling giving one the illusion of privacy, but these were used only to hide the prison patients and their shotgun-toting guards from the public.
“Doctor Carlucci!” yelled a stocky fireplug of a woman, identified by her nameplate as Peg Vargas, R.N. She was clearly upset. “My patient’s having a hard time catching his breath—it’s getting worse!” She quickly motioned them over to the struggling man’s litter.
Peg Vargas had over fifteen years experience in the recovery room. Perhaps because of this, she felt entitled to be brusque, although Mike would’ve called it rude. He got along well with most of the recovery room nurses, but Peg Vargas wasn’t one of them. Interestingly, Mike watched her calm down right before his eyes. She had just fulfilled her primary nursing responsibility and had summoned help. Now it was out of her hands and up to the doctor to do something. She could relax and play her favorite game of armchair anesthesiologist.
“Who is he?” asked Mike, as he scanned the patient and his monitors. Most troubling was the pulse oximeter reading of 82%. Rusty looked back and forth between the patient, Mike, and the nurse. His eyes were wide, and his hands twitched about. Mike gave Rusty credit for appreciating the gravity of the situation.
“Mr. Tompkins, seventy-five,” Peg answered sharply. “He had a radical prostatectomy. Dr. Marshall brought him in about half an hour ago.” She was no longer flustered at all.
“How long has his sat been in the 80s?” Mike fired back, stalling to get his bearings. Oxygen saturations below 90% were considered dangerous. The patient was obviously struggling to breathe, and Mike knew he’d have to do something quickly. Oddly, he reflected that he was the only one who truly felt the pressure of the situation. Although Rusty most likely realized how serious it was, they all expected Mike to know what to do. Just once, he thought, he’d like to see Peg Vargas in his position; see her snooty, know-it-all facade crumble in a panic.
“It’s been falling just in the last couple of minutes—that’s why I called,” Peg said somewhat defensively.
“He was OK when he came in?” Mike asked. Jesus, he looks dusky.
“Yeah, he seemed fine.” Peg had no trouble returning his glare.
Mike wondered how he went from fine to respiratory distress in minutes. He doubted she had kept a close enough eye on him, but now wasn’t the time to cast aspersions. “Put him on a hundred percent rebreather,” he ordered.
She just stood there for a moment, looking at him. Was she questioning his judgement? Or perhaps she didn’t trust him after Mr. Rakovic’s death in the OR. He knew they all talked about how he had cracked under the pressure behind his back. “I’ll have to get it,” she finally said and wheeled from the bedside.
“What do you think’s wrong with him, Dr. Carlucci?”
Mike put up his hand to shush Rusty. “Hang on Rusty.”
Mike knew he didn’t have the luxury of time to expound upon medical diagnostic theory at the moment; the situation demanded immediate action. He was acutely aware that he didn’t have a working diagnosis yet. He turned to the patient. “Mr. Tompkins, how’s your breathing?”
“Not—so—good,” the patient managed to get out, in a cross between a whisper and a gasp.
Good question, Mike. Now that we got that clear, can we move on to make a diagnosis? Mr. Tompkins was sitting bolt upright on his litter and laboring mightily to breathe. He was a tall, gaunt man with white, patchy stubble adorning his hollow cheeks. Mike whipped out his stethoscope and listened to his chest. He didn’t hear much air moving. The oxygen sat had fallen to 80%.
“C’mon Peg! I need that mask!” Mike shouted in the direction she had headed. He was oh-so-thankful he had dosed up this morning. The Fentanyl was the only thing standing between himself and decompensation. Be cool. Gotta think. God knew he couldn’t handle another catastrophe.
“Rusty, hear that noise?” Mike asked. Mr. Tompkins was making a faint squeaking noise as he struggled to suck air in; breathing out seemed to be OK.
Rusty leaned in close to the patient, and a puzzled look came over him. “Yeah,” he said unconvincingly.
“It’s all upper airway—the chest is clear,” Mike said as much to himself as anybody. He needed to make a diagnosis—his patient was heading south quickly. The scene was horribly reminiscent of Mr. Rakovic’s case. Please, no V-tach. He shot an accusatory glance at the EKG monitor. It was OK for now, but he knew time was running out.
“Do you need a chest x-ray?” Rusty asked, interrupting his thoughts.
“No time.”
“Are you going to intubate him?” Rusty asked excitedly.
“Not sure yet.”
The sat monitor beeped loudly as the alarms announced the sat had dipped below 80%. It continued to fall: 79, 78, 77.
“Here, hook up that Ambu bag to the oxygen,” Mike said. He handed a long green tube to Rusty and motioned to an oxygen nipple outlet on the wall. He turned to the patient and said, “I’m going to help you breathe, Mr. Tompkins.”
Mike grasped Mr. Tompkins’s bony shoulders and pulled him back down to the bed. 76, 75, 74.
“I . . . can’t . . . breathe . . . Need . . . to . . . sit . . . up.”
Mr. Tompkins tried feebly to get up, but Mike held him down. He began to manually assist Mr. Tompkins’s breathing with the Ambu bag. It was difficult to get a good mask seal on his face; his lips caved in because he had no teeth, and his skin was oily. 73, 72, 71.
Mike knew it wasn’t pleasant to have someone force air into your lungs, but it beats suffocation. “Relax and don’t fight me,” Mike said. “Everything’s going to be all right.” A faraway corner of his brain registered that this last expression was generally reserved for when things were far from all right. “Rusty, go get some intubation stuff—tube, laryngoscope—hurry!” Mike said without looking up. He saw some fog in the mask and knew he was getting some air in, but it didn’t seem like enough. Shit! Running out of time!
Just then, Peg came back with the rebreather mask. She stared at the sat monitor a little too long, as if to say: “What did you do to my patient?”
“Never mind the mask now!” Mike barked at her. “We’re beyond that.” He concentrated all his effort on mask ventilating the old man.
“What’s wrong with him?” Peg demanded. “Can’t you do something?”
He stopped ventilating for a second to glare at her. “Can’t you see I’m trying.” He had trouble thinking with her badgering him.
70, 69, 68.
Mr. Tompkins began to thrash about. His face continued to turn deepening shades of blue. Mike felt bad for the man and tried to reassure him. “You’re going to be fine, Mr. Tompkins. You’re going to be just fine.” But again, he couldn’t help thinking: hospital lingo for you’re in deep shit.
Even with Mike’s skilled hand on the Ambu bag, the oximeter continued to plummet. Mike saw the horror of airway hunger, one of the most dreadful of all human sensations, grip Mr. Tompkins. Panic glazed his eyes, and his thrashing intensified.
64, 63, 62.
The pulse ox continued to make its horrible, low-pitched b
eeps. If he had a free hand, he’d turn the damned thing off. Peg just stood there staring at him. “Peg, turn the alarm off!” Where was Rusty? What was taking him so long? Mike could almost feel Mr. Tompkins’s life slipping away between his fingers. He glanced again at the EKG monitor. The rhythm had begun to become irregular. Oh shit! Not again!
“Do something!” Peg shouted at him.
Suddenly a bit of inspiration flashed through his mind. “Get respiratory here STAT with a racemic epi treatment!” Mike had made his diagnosis; he only prayed it was right and not too late.
Peg flung the mask down and headed for the phone.
Just then, Rusty ran back up to the bedside, breathing hard now, his hands full of intubation equipment. He looked scared to death as he fumbled with the laryngoscope and tube, trying to get them ready. The heavy metal laryngoscope fell on the floor making a loud racket. Before he could do or say anything further, Mike held up his finger. “Wait, Rusty. I have an idea.”
Moments later, the respiratory therapist, a heavyset man in his twenties, waltzed in, seemingly without a care in the world and asked, “Is this the patient who needs the breathing treatment?”
“Yes, it is!” Mike shouted. Bonehead! How many other patients do you see here being bagged with a sat in the 60s? “Hurry and hook it up, please,” Mike said, barely controlling his fury.
“How much epi?” said the therapist, unfazed.
“Point three cc’s in three cc’s normal saline!” Mike thought it was an asinine question because the adult dose was always the same. “Hurry, damn it!” Mike roared. “Can’t you see he’s dying!”
“No need to yell.” The therapist methodically hooked up the nebulizer. Steam hissed out from the mask in a large plume. He strapped it tightly to Mr. Tompkins’ face.
After several minutes of breathing the racemic epinephrine, the result was almost miraculous. Mr. Tompkins’s breathing eased dramatically, and his O2 sat climbed into the 90s.
God, that was close. Mike allowed himself a couple of deep breaths as well. “How’s that, Mr. Tompkins?” he asked.
“Better. Thank you,” said Mr. Tompkins in a relieved voice.
“Feel better now, doc?” the respiratory therapist said and smirked. He packed up his bag and left the room shaking his head and muttering, “Dying—yeah right.”
“Hey, I don’t hear that noise anymore,” Rusty said.
“Yeah. That was inspiratory stridor,” said Mike. “We were dealing with a partial laryngospasm, but I’m not really clear why yet.”
“What’s rasimic epi?” Rusty asked.
“Racemic epi. It shrinks down swollen laryngeal structures allowing him to breathe easier. I think we saved him from being re-intubated and spending the night on a blower.” And saved me from another man’s death.
Peg Vargas returned to the bedside and shot Mike a “You-got-lucky-this-time” glare and moved on down the line to tend to more pressing matters.
CHAPTER TWENTY-ONE
“Wow, that was some fancy piece of diagnosis back there,” Rusty said and meant it; he was not engaging in any med student/attending brown-nosing. They were back in the anesthesia control office taking a breather while waiting for the next case to go. He flipped the top on his Pepsi and took a long swig. He admired Dr. Carlucci’s quick thinking; he wondered if he would ever have the skill and nerve to deal with similar situations. “How exactly does that epinephrine work?” Rusty asked. “I’ve never heard of it.”
Dr. Carlucci smiled and took a large gulp of his Coke. “Epinephrine is another name for adrenaline. It’s a powerful vasoconstrictor.”
Dr. Carlucci continued to smile, and Rusty realized he hadn’t seen him this happy since he’d met him. “What’s the racemic mean?”
“That’s an organic chemistry term. Surely, you remember your O-chem, Rusty. You’re a lot closer to it than I am.”
“Well . . .” Rusty felt himself blush. Here we go again.
“It refers to a compound that’s optically active,” said Dr. Carlucci.
“Huh?” What the hell does that mean?”
“Actually, it means a fifty-fifty mixture of two mirror image molecules.” Dr. Carlucci put his hands together fingertip to fingertip to demonstrate. “You know, it’s like a spider doing push-ups on a mirror,” he said and laughed as his hands pumped up and down.
“What’s the point?” Rusty asked, baffled.
“In the body, epinephrine is produced by the adrenal gland. Only the levo-isomer, or left-hand molecule, is actually made. The dextro-isomer, or right-hand molecule, isn’t made because it’s physiologically inert. A racemic mixture contains 50% L-isomer and 50% D-isomer.”
Rusty struggled to follow the explanation. “But you said the D-isomer is inactive as far as the body’s concerned, so why put it in the mix?”
“Good question. When the compound is synthesized in the laboratory, both forms are produced in equal quantity owing to some physical chemistry property that I really don’t remember. It would be very expensive to extract the L-isomer, since chemically the two molecules function identically. Only in a complex biological system, such as an animal or human with stereo-specific receptors and enzymes is there any difference. So they just don’t bother.”
“Oh,” said Rusty woodenly. Then he added with more life, “Wow, I’m impressed. How do you know all that?”
“I was a chem major in college.” Suddenly, a strange look came into Dr. Carlucci’s eyes and his smile vanished.
“Where’d you do your under—”
“Jesus!” Dr. Carlucci shouted and jumped out of his chair, propelling the wheeled thing backward to crash against the wall.
Rusty startled, almost spilling his Pepsi. “What is it?” he called to Dr. Carlucci’s back. He was puzzled—he had never thought organic chemistry was that exciting. He had to run to follow him out the door.
“Tell Raskin to start my next case with a nurse,” Dr. Carlucci called from halfway down the hall. “I’ll be in the library.”
Minutes later, Rusty walked into the hospital library. He was surprised to see how small it was compared to the sprawling layout he was used to at the medical center. An elderly lady with a volunteer button manned the front desk. He quickly spotted Dr. Carlucci at one of the carrels paging through some big reference books. Otherwise the room appeared to be empty, but he couldn’t see behind all of the bookshelves. Rusty flashed the old lady a smile and made his way over to Dr. Carlucci.
Dr. Carlucci looked up, the strange light still burning in his eyes. “It’s the perfect murder, Rusty!” he whispered vigorously.
“What are you talking about?” asked Rusty.
Dr. Carlucci immediately grabbed Rusty’s shoulders and squeezed hard. “Don’t you see?” he asked and a look of such anguish crossed his face that Rusty was shocked. Before he could answer that he didn’t have a clue, Dr. Carlucci continued. “Maybe I didn’t kill him. Maybe I didn’t.”
Rusty wriggled free and backed up a step. “Kill who?” he managed to get out. He was worried that Dr. Carlucci had gone off the deep end.
“Sorry, Rusty,” Dr. Carlucci said. He seemed to get a grip on himself and relax a bit. The anguished look was gone. “Let me back up some. Let’s say someone slips epinephrine into one of your syringes—it wouldn’t take much—only a milligram or so. You push the doctored syringe, pardon the expression, into a patient, and blammo, the pressure goes ballistic, and the heart goes haywire—V-tach, V-fib, you name it.”
“Wow! But wait a minute, I thought you gave epinephrine at codes to save people, not kill them.”
“Epinephrine, or adrenaline, is a strange drug, Rusty. A milligram of it is life-saving to someone in cardiac arrest or anaphylactic shock, but give that same milligram to you or I, and you’d likely kill us.”
“Be-zarre!” Rusty exclaimed a bit too loud. The librarian, who had been staring at them all along, cast them a fresh look of disapproval.
“But getting back to murder.” Dr. Carlucci
paused and quickly glanced around the room. “The beauty of it is, epinephrine’s a natural compound. That means, A, it’s already supposed to be there and B, it’s quickly degraded by natural enzymes. It would be virtually undetectable, and even if it was, you couldn’t separate it from normal levels.”
“Amazing. So you’re saying someone sabotaged your and Doctor Landry’s syringes—added epi to them?”
“Yes, and both our patients had coronary histories—mix that with high dose epi, and it’s a sure-fire recipe for disaster.”
“Yeah, the perfect murder, all right,” Rusty said. He couldn’t believe he was hearing this.
“Unless . . .” Dr. Carlucci stared off into space.
“What?” Rusty asked anxiously.
“Maybe there is a way—”
“But, you said there’s no way to detect it, didn’t you?”
Dr. Carlucci began to furiously flip the pages of one of the large reference books he had piled up helter-skelter on the table. “Look! Right here!” he practically shouted. He stabbed his finger repeatedly at the page.
“The B t1/2 is the half life elimination time of a drug from the body. The physiologically active L-isomer is degraded on the order of minutes, but the D-isomer is relatively inert and relies on the much slower hepatic conjugation and renal elimination pathway for the body to clear it.”
“What’re you saying?”
“Doug’s patient from yesterday, Mister what’s-his-name, is still in the SICU. He probably still has some D-isomer in his blood!”
“Holy batshit! Let’s go!”
“How long will it take the lab to run the analysis?” Rusty asked, referring to their newly acquired blood specimen. They were sitting in the doctor’s charting area in the SICU. Dr. Carlucci had two blood tubes in his hand and was writing orders in Mr. Lehman’s chart.
“I’m not sure,” he answered, frowning. “Come to think of it, they’ll probably have to send it out to a more sophisticated lab. Might take a week.”
“That long,” Rusty said. “What should we do in the meantime? Shouldn’t we call Doctor Landry?”
ADRENALINE: New 2013 edition Page 17
