Robin Cook: Godplayer

Pamela Breckenridge had been working from eleven to seven for over a year. It wasn’t a popular shift, but she liked it. She felt it gave her more freedom. During the summer she’d go to the beach by day and sleep in the evenings. In the winter she slept days. Her body had no problem making the adjustment as long as she slept at least seven hours. And as far as her work was concerned, she preferred night duty. There was less hassle. Days sometimes made a nurse feel like a traffic cop, trying to get patients to and from their numerous X rays, EKGs, lab tests, and surgeries. Besides, Pamela liked the responsibility of being alone.

Tonight as she walked down the empty, darkened corridor all she heard were a few murmurs, the hiss of a respirator, and her own footsteps. It was 3:45. No doctors were immediately on hand, nor even other RNs for that matter. Pamela worked with two LPNs, both skilled veterans of the ward. The three of them had learned to deal with any number of potential catastrophes.

Passing room 1832, Pamela stopped. During report that evening, the charge nurse going off the shift had mentioned that Bruce Wilkinson’s IV was probably low enough to think about hanging a new bottle of D5W before morning. Pamela hesitated. It was probably a job she should delegate, but since she was right outside the room and no stickler for protocol, she decided to do it herself.

A wet cough rattled a greeting in the dimly lit room, making Pamela want to clear her own throat. Silently she slipped alongside Wilkinson’s bed. The level of the bottle was low, and she was startled to see the IV running at a very rapid rate. A fresh bottle of D5W was on the nightstand. As she changed the IV and adjusted its rate, she felt something hard under her foot. She looked down and saw the call button. It was only as she bent to retrieve it that she looked at the patient, noticing his face pressed up against the side rail. Something was wrong. Gently she eased Bruce onto his back. Instead of the expected resistance, Bruce flopped over like a rag doll, his right hand coming to rest in a totally unnatural position. She bent closer. The patient was not breathing!

With trained efficiency, Pamela pressed the call button, switched on the bedside light, and pulled the bed away from the wall. Under the harsh fluorescent light, she saw that Bruce’s skin was a deep grayish blue like a fine Chinese porcelain, suggesting that he had choked on something and had asphyxiated himself. Immediately Pamela bent over, pulled Bruce’s chin back with her left hand, covered his nose with her right hand, and forcefully blew into his mouth. Expecting an airway obstruction, Pamela was surprised when Bruce’s chest rose effortlessly. Obviously if he had choked on something, it was no longer in his trachea.

She felt Bruce’s wrist for a pulse: nothing. She tried for a carotid pulse: nothing. Taking the pillow from beneath Bruce’s head, she struck his chest with the palm of her hand. Then she bent over and reinflated the lungs.

The two practical nurses raced into the room at the same time. Pamela said one word, “code,” and they went into action like a crack drill team. Rose quickly had the emergency paged over the loudspeaker while Trudy got the sturdy two-by-three-foot board used for support under a patient during cardiac massage. As soon as Bruce was settled on the board, Rose climbed onto the bed and began to compress his chest. After every fourth compression Pamela reinflated Bruce’s lungs. Meanwhile, Trudy ran for the emergency crash cart and EKG machine.

Four minutes later when the medical resident, Jerry Donovan, arrived, Pamela, Rose, and Trudy had the EKG machine hooked up and running. Unfortunately it traced a flat, monotonous line. On the positive side, Bruce’s color had improved slightly from its former grayish blue.

Jerry saw the flat EKG indicating no electrical activity, and, like Pamela, he hit the patient on the chest. No response. He checked the pupils: widely dilated and fixed. Behind Jerry was an intern named Peter Matheson, who climbed up on the bed and relieved Trudy. A disheveled medical student with long hair stood by the door.

“How long has this been going on?” asked Jerry.

“It’s been five minutes since I found him,” replied Pamela. “But I have no idea when he arrested. He wasn’t on the monitor. His skin was dark blue.”

Jerry nodded. For a split second he debated continuing resuscitation. He suspected the patient was already brain dead. But he still hadn’t come to terms with denying treatment. It was easier to go ahead.

“I want two amps of bicarbonate and some epinephrine,” barked Jerry as he took an endotracheal tube from the crash cart. Stepping behind the bed, he let Pamela inflate the lungs once more. Then he inserted the laryngoscope, an endotracheal tube, and attached an ambu bag, which he connected to the wall oxygen source. Resting his stethoscope on the patient’s chest and telling Peter to hold up for a second, he compressed the ambu bag. Bruce’s chest rose immediately.

“At least his airway is clear,” said Jerry, as much to himself as anyone.

The bicarbonate and epinephrine were given.

“Let’s give him calcium chloride,” said Jerry, watching Bruce’s face slowly turn a normal pink.

“How much?” asked Trudy, standing behind the crash cart.

“Five ccs of a ten-percent solution.” Turning back to Pamela he said, “What’s the patient in for?”

“Bypass surgery,” said Pamela. Rose had brought down the chart and Pamela flipped it open. “He’s four days postop. He’s been doing well.”

“Was doing well,” corrected Jerry. Bruce’s color looked almost normal but the pupils stayed widely dilated and the EKG ran out a flat line.

“Must have had a massive heart attack,” said Jerry. “Maybe a pulmonary embolus. Did you say he was blue when you found him?”

“Dark blue,” Pamela affirmed.

Jerry shook his head. Neither diagnosis should have produced deep cyanosis. His thoughts were interrupted by the arrival of a surgical resident, groggy with sleep.

Jerry outlined what he was doing. As he spoke, he held up a syringe of epinephrine to get rid of the air bubbles, then pushed it into Bruce’s chest, perpendicular to the skin. There was an audible snap as the needle broke through some fascia. The only other sound was the EKG machine spewing out paper with the straight line. When Jerry pulled back on the plunger, blood entered the syringe. Confident he was in the heart, Jerry injected. He motioned for Peter to recommence compressing the chest and for Rose to reinflate the lungs.

Still there was no cardiac activity. As Jerry opened the outer cover of the sterile packaging holding a transvenous pacemaker electrode, he wished he had never begun the charade. Intuitively he knew the patient was too far gone. But now he had started, he had to finish.

“I’m going to need a fourteen-gauge intercath,” said Jerry. With betadine on a cotton sponge, he began to prepare the entry site on the left side of Bruce’s neck.

“Would you like me to do that?” asked the surgical resident, speaking for the first time.

“I think we have it under control,” said Jerry, trying to project more confidence than he felt.

Pamela began helping him on with a pair of surgical gloves. They were just about to drape the patient when a figure appeared at the doorway and pushed past the medical student. Jerry’s attention was drawn by the surgical resident’s response: the ass-kisser did everything but salute. Even the nurses had perceptively straightened up as Thomas Kingsley, the hospital’s most noted cardiac surgeon, strode into the room.

He was dressed in scrub clothes, obviously having come directly from the OR. He approached the bed and softly laid a hand on Bruce’s forearm as if through the mere touch he could divine the problem.