Робин Кук - The Year of the Intern

“Can you hold the head still?” I asked one of the nurses. She tried, but couldn’t really. Between bounces, I slid the laryngoscope through his mouth and down into his throat. The epiglottis alternated in and out of view. Advancing the tip farther, I pulled up, and the ’scope clanked against his teeth. Nothing. I couldn’t orient myself in the red folds of mucus membrane. Quickly taking out the ’scope, I blew in a few more breaths between compressions. The ER intern was getting nice sternal excursions; the breastbone was moving in and out about two inches, undoubtedly forcing blood through the heart quite well. I tried with the laryngoscope again, down to the epiglottis, tip of the ’scope up, then in farther, and down. There, I saw the cords for a second.

“The endoctracheal tube.” A nurse handed it to me. I didn’t take my eyes away from his throat. “Push on his larynx.” I motioned to the neck. The nurse pushed. “Harder.” Then I saw the cords again and pushed in the tube. “The Ambu bag.” I hooked up the Ambu breathing bag and watched his chest as I compressed it. Instead of the chest rising, the stomach bulged a little. “Damn! Missed it.” I pulled the tube out, put my mouth over the patient’s again, and blew, twice more. Then the laryngoscope again. I had to get it this time. “Push again on his larynx.” I pulled up very strongly, and then I could see the cords between each chest compression. “Hold it. Okay, stop the compression.” The ER intern interrupted his rhythm for a second while I slid in the tube; then he immediately recommenced the massage. With the Ambu bag attached and compressed, the chest rose nicely. The ER nurse had put in the needle leads for the EKG, and we had a blip on the oscilloscope. It wasn’t grounded very well.

“Put the EKG on lead two,” the ER intern said. That was better. I was compressing the Ambu when a nurse-anesthetist arrived. She took over the Ambu.

“Medicut.” The nurse gave me a catheter, and I put a piece of rubber very tightly around his left upper arm. Medicuts can be tricky, especially when you’re in a hurry, but they’re much faster than cutdowns, because you put the medicut into the vein by just pushing it through the skin rather than making an incision as with the cutdown. I pushed the medicut into the patient’s arm and advanced it until I thought I was in the vein; fortunately blood came back into the syringe — but that was only half the battle. I pushed the plastic catheter forward on the needle, hoping it would remain within the lumen of the vein. Then, by wiggling the needle back and forth, I attempted to advance the catheter still farther into the vein. When I pulled out the needle, some dark brownish-red blood flowed through the catheter over his arm and onto the bed. A nurse was still struggling with the plastic tubing from the IV bottle. I just let the blood flow; it didn’t make any difference. After securing the end of the tubing to the catheter, I could see the blood disappear from the catheter, running back into the vein as the IV started up. Snapping off the rubber tourniquet, I watched the drip, and opened it all the way until it was running fine. “Tape.” I secured the catheter to the arm. The EKG still showed rapid but coarse fibrillation. “Epinephrine,” I barked. I thought a heart stimulant might smooth out the fibrillation, before we tried to change it electrically to a regular heartbeat.

“How about directly into the heart?” The ER intern suggested.

“Let’s try just IV first.” I wasn’t very confident of that intracardiac method. The nurse gave me a syringe and said it was 1:1,000 diluted to 10 cc. I injected it rapidly into the new IV site through a small length of rubber tubing, being careful to compress the distal plastic tubing to keep the epinephrine from going back into the IV bottle. “Bicarbonate,” I said to the nurse, holding out my free hand. The nurse gave me a syringe, saying it held 44 milliequivalents. “How are you doing with the pumping?” I asked the ER intern.

“I’m fine,” he answered.

I injected the bicarbonate into the same IV site — and pricked my finger in the process by putting the needle all the way through the little rubber section. Sucking my index finger, I watched the EKG. Slowly it began to show stronger fibrillation.

“How about defibrillating now?” the ER intern suggested. The defibrillator was all charged up. A nurse held the paddles, with a smear of conductant on each one. Stopping his pumping, the ER intern took the paddles, placing one over the heart and one to the side of the chest. “Away from the bed!” The nurse-anesthetist let go of the Ambu. Wham! The patient jumped, his arms fluttered, and the EKG blip was gone. When it came back, it was just about the same. A medical resident arrived breathlessly and quickly got oriented.

“Hang up a 5-per-cent bicarbonate on the IV and give me some xylocaine.” The nurse gave the medical resident 50 mg. of xylocaine. He handed it to me, and I injected it. We defibrillated him again. In fact, we tried about four times before the fibrillation disappeared. But instead of a normal cardiac rhythm taking over, all evidence of activity in the heart disappeared, as the electronic blip on the EKG screen became perfectly flat.

“Damn! Asystole,” said the resident, watching the blip.

Epinephrine, isuprel, atropine, pacemaker: we tried all the stuff we had. Meanwhile, the man’s pupils came down to about normal size from the widely dilated state they’d been in when we first started. At least that meant that oxygen was getting to his brain, that our cardiac massage was effective.

Another intern arrived, taking over the massage part so the ER intern could go back to his primary duty, poor fellow. Then I took a turn at the massage. “How about calcium?” the other intern suggested. The resident injected some calcium. I asked for another nasogastric tube, but didn’t get to put it down until the intern could relieve me at the massage. There wasn’t much in his stomach except some gas, and that was probably just what I had pushed in there earlier by mistake, through the misplaced endotracheal tube. I told the resident that this patient was the one whose EKG I had called him about earlier. I also told him that the portable X ray of the chest was generally clear.

Looking behind me, I was surprised to see the Supercharger standing there quietly watching our feverish activity. I guess the nurses had called him. He didn’t say a word. The resident injected the heart several times with intracardiac epinephrine. Still we couldn’t break the asystole, and we were running out of options. Pumping and breathing, pumping and breathing, for fifteen minutes more we watched the machine trace a straight line across the oscilloscope.

“All right, that’s enough. Stop now.” It was the Supercharger finally speaking, after standing by in silence for almost thirty minutes. His words surprised us and failed to penetrate our routine, so that we didn’t stop right away, but kept on pumping and breathing as if he hadn’t said anything.

“That’s enough,” he repeated. The nurse-anesthetist compressing the Ambu was the first to stop. Then the intern, who happened to be massaging at the time. All of us were tired by then, thinking about getting back to bed, and conscious of the fact that we might have stopped earlier if the man’s pupils hadn’t reduced so well. Constriction of the pupils is one of the signs of revival; that had kept us going. But clearly this time it had been a false sign. So we stopped, and the man was dead. The Supercharger walked out and disappeared down the corridor toward the nurses’ station, where he did the paper-work chores and called the relatives. The nurses unhooked the EKG machine, while I got out a large intracardiac needle.