Richard Mabry: Diagnosis Death

"I'm sorry, but I'm paying as much as I can each month. There's nothing more I can do right now." The insistent tones of her pager cut through the conversational buzz and clatter of the hospital staff cafeteria. Elena checked the display. Emergency Room. Stat.

"I have to go." She flipped her cell phone closed and hurried toward the door, shoving her tray onto the conveyer belt without breaking stride.

Elena slammed through the swinging doors of the ER, looked around, and saw a pair of EMTs wheeling a stretcher into treatment room two. She and the head ER nurse arrived at the door right behind them, trailed by a nurse's aide.

"Sixty-eight-year-old male found unresponsive by his wife." The EMT grunted out the words as he and his partner shifted the patient from their stretcher onto a hospital gurney. "Comatose. BP 168 over 90, pulse 56, respirations 12 and irregular. He's on Cardizem, Lipitor

…"

Elena listened with one ear, her mind already focused on the problem at hand. She ran her hands over the man's scalp, moving aside the silvery gray hair, looking for bruises and lacerations, finding none.

As she bent to check his eyes, she sniffed the man's breath for the smell of alcohol or the fruity odor that signaled diabetic coma. So far, so good.

Elena flexed the man's head forward. No neck stiffness. She looked for blood in the ear canals. Good, no sign of a basilar skull fracture.

When she thumbed back his eyelids, her pulse quickened. The right pupil was significantly larger than the left. Elena pulled a penlight from the breast pocket of her white coat and shined it into the man's eyes. The right pupil remained unchanged, the left contracted sluggishly.

"Hand me the ophthalmoscope," she said.

Elena used the instrument to look through the pupils to the back of the man's eyeballs. Sure enough, the nerve head of the right optic nerve was already bulging.

"Blown pupil on the right." she said. "Get the neurosurgeon on call down here stat. This patient's had an intracranial hemorrhage." The aide turned and hurried out. "Hang a gram of Mannitol IV. Run the oxygen at high flow. Did you get blood for labs?"

"Did it while you were checking him." The nurse patted her uniform pocket, and Elena heard the muted clink of glass.

"As soon as you get the Mannitol going, send those to the lab for a stat CBC and metabolic profile. When you get a chance, put in a Foley catheter. And he's going to need an MRI, so put radiology on standby."

The aide hurried back in. The nurse paused long enough to hand her the blood samples and whisper instructions. "I'm on it," the aide said, and scurried away.

Elena registered the faint bluish tint to the patient's lips. She checked his fingertips and saw the same coloration creeping into the nail beds. The man's respirations were now weak and shallow. He needed more oxygen.

"Give me the laryngoscope and a tube."

The nurse placed an L-shaped instrument in Elena's left hand, slapped a curved plastic endotracheal tube into her right. Elena pried the man's jaws open with the tip of the laryngoscope and slid the flat end down his tongue. A light at the tip of the instrument showed the opening between the vocal cords, barely visible in a sea of pooled saliva. Elena gritted her teeth and slid the plastic tube downward along the laryngoscope. When the tube disappeared through the cords into the airway, she breathed again. Made it through another intubation. Quickly, Elena inflated the soft rubber cuff that provided an airtight seal around the tube. The nurse hooked the patient to the respirator and looked at Elena with raised eyebrows.

"Set it at sixteen," Elena said. Soon the rhythmic sound of the respirator was accompanied by a regular rise and fall in the patient's chest. She watched for half a dozen cycles before nodding. "There, he's starting to pink up."

Elena ran down a mental checklist. What had she missed? ABC. Airway, Breathing, Circulation: the mantra for handling emergencies, one of the first lessons learned by any doctor. The first two were taken care of. The man's heartbeat was strong, but she'd better check for cardiac damage. "Let's hook him up to the EKG."

A few moments later she scanned the tracing. No abnormalities. Good.

Anything else? As a resident physician at Southwestern Medical Center, Elena was part of a top-notch medical team. Chances were that if she forgot something, someone else would remedy the omission. But when she was out on her own in private practice, it would be totally up to her. That time would be here soon. Better get ready.

Elena looked at the clock on the wall. Sometimes in an emergency, time seemed to slow down. At other times it seemed to be rocket-powered. This was one of those times when the minutes fled by. Where was the neurosurgeon?

At Southwestern there were three separate hospitals on the campus-four if you counted Children's Medical Center. Chances were that the doctor this patient needed had to travel from Zale Hospital, on the far south end of the campus, to where Elena waited with the patient at St. Paul Hospital, at the far north end of the campus. Whether the neurosurgeon came by car or on the campus shuttle, surely he should have been here by now.

Another glance at the clock. Another five minutes gone. Left unchecked, blood from the intracranial hemorrhage would force the brain down against the bony ring at the base of the skull, compromising the vital centers, shutting down the impulses that kept the heart beating, the lungs inflating. Without surgery to relieve that pressure, the man would die. Where was the neurosurgeon?

"Who's on neuro call?" she asked the nurse.

"Dr. Clark."

"And you paged him stat?"

The aide was back now, hovering behind Elena, awaiting instructions. "I asked the ward clerk to do that." She hesitated. "Do you want me to check?"

"Yes, please." Elena hesitated a beat. "First, get me the tray for an emergency trephine. If he doesn't show soon, I may have to-"

"Okay, I'm here. What's so important?" Dr. James Clark strode into the room and stopped at the foot of the gurney. He stared at Elena, and the look on his face said, "This had better be good."

"Elderly male, hypertensive and probably atherosclerotic, found unresponsive by his wife. Right pupil dilated and fixed, left sluggish to react, definite papilledema. Vitals compatible with Cushing's triad. I've alerted radiology for a stat MRI."

Clark grunted and picked up the ophthalmoscope from the table where Elena had laid it. He checked the patient's eyes, then traded that instrument for a reflex hammer and did a bit of tapping. He ran his thumbnail along the soles of the man's bare feet, frowning when the toes fanned and extended upward.

"Okay, you're probably right." He turned to the ER nurse. "Send him for the MRI. Call the OR and tell them to set up for an emergency craniotomy. I want Dr. Miller for anesthesia. If he's doing another case, have him get someone else to take over. And page the chief neuro resident to help me. Make sure the patient's taken directly from radiology to surgery, along with his films. I'll be up there changing."

He disappeared in a wave of self-importance, without so much as a "good pick-up" or even "please."

"I'll go to radiology with the patient," Elena said. "I'll stay there and take him to the OR myself."

"Dr. Gardner," the nurse said. "You don't have to do that."

Elena didn't answer, just released the brakes on the gurney and started pushing it out the door. Clark might think his MD degree conferred immunity from any of the menial tasks involved in patient care, but Elena had a different point of view. She intended to see to it that this patient got the best possible care. There'd be no delays in his treatment. She knew all too well that delays could be deadly.