Hannah Alexander - Silent Pledge

L ukas was drifting to sleep in the call room early Sunday morning when he heard the blare of a siren. He opened his eyes to the sight of orange and red flames racing across the wall, and he sat up with a shout.

And then he realized that the flicker was from an ambulance outside. Its lights penetrated the window blinds in fiery streaks of color. Lukas pushed his blanket back and got out of bed. Sometimes he still had nightmares about the explosions in October, of following Buck Oppenheimer through the collapsing E.R. and fighting the inferno that nearly engulfed them.

The telephone rang. He reached over, felt for his glasses on the desktop and picked up the receiver.

“Dr. Bower, this is Tex,” came the voice over the phone. She sounded irritated, but with Tex’s deep voice it was hard to tell. “Quinn and Sandra are bringing somebody in. Of course they didn’t radio us, so I don’t know what’s going on. I tell you, that man should not be wearing a uniform. Want to join us?”

“I’m on my way.” Lukas grabbed his stethoscope from the desk and rubbed at the lenses of his glasses with the hem of his scrubs as he squinted his way out of the call room.

When he reached the E.R. he saw Quinn and Sandra wheeling a slightly overweight, unresponsive young woman into the E.R. from the ambulance bay while Tex held the door and helped push. Quinn was doing chest compressions and an IV had been established, with a needle and tubing connected to her left arm. The patient had been intubated, and an ambu bag was attached to the tube, which Sandra squeezed rhythmically to help the woman breathe. Sandra was pushing the cot with her free hand. The woman had been stripped to the waist. The odor of sour milk lingered around her.

Lukas rushed toward them. “Carmen,” he called to the secretary over his shoulder, “call a code and launch a chopper.”

Carmen swiveled in her chair and stared at him blankly. “What?”

Lukas shook his head. “Get me a nurse down here from the floor. Tell her we’ve got a code. Then call our airlift service and get them here.” He grabbed the end of the gurney and helped Sandra and Tex push it inside. “What’s the rhythm?”

“V-fib,” Quinn said. “I’d just intubated her on scene, and then she crashed.” His words came fast, almost as if he were trying to convince Lukas he’d done everything right. “She was unresponsive, and she had inhalers in her pajama pocket. Had to be asthma—”

“How many times have you shocked?” Lukas asked.

“Three with one dose of epi.”

“What?” came an irritable voice from the doorway.

Lukas turned to find Tex already in the trauma room, snapping the plastic lock from the tool chest-shaped crash cart beside the exam bed. “That’s not current ACLS guidelines,” she muttered.

On the count of three, they transferred the patient from the gurney to the bed, and Tex immediately replaced the leads to the hospital monitor on the woman’s bare chest. The v-fib rhythm continued, with the line racing across the monitor screen above the bed in an irregular steak knife-edge pattern. The monitor emitted a high, continuous beep.

“Well, you got your intubation this time, Dr. Bower,” Quinn muttered. “Hope you’re happy, because it’s not doing her any good.”

Lukas ignored the comment. “What drugs have you given?”

“I just finished the first dose of epinephrine as we pulled in.”

“Then we’ll have to shock again quickly. Stop compressions but keep bagging.” Lukas positioned his stethoscope on the woman’s chest, listened, frowned. “I don’t hear good breath sounds.”

“So? She was obviously in broncho spasm,” Quinn snapped. “She had inhalers, remember? Or weren’t you listening?”

“And you just took that for granted?” Tex’s voice rose like mercury in a hot room. If she saw Quinn’s flush of anger or glare of growing resentment, she didn’t acknowledge it. “Did you even check the placement of the tube when you did the procedure?”

“What good would it do if she was in broncho spasm?” Quinn’s lips thinned and whitened.

Lukas raised his hand for silence and repositioned the stethoscope over the belly. Now he heard breath sounds, and he felt a chill of foreboding. “It’s in the wrong place. The tube’s in the esophagus instead of the trachea.” The oxygen was flowing straight into her stomach. She wasn’t getting any oxygen. “We have to reintubate.” He turned to the others. “Sandra, stop bagging and take over the compressions. Hurry! Tex, get me a syringe, then get the suction ready.”

Tex moved quickly. “It’s one thing to miss placing the tube correctly, Quinn,” she said as she worked. “That’s happened to all of us. But to leave it there…unforgivable! You might as well have placed a pillow over her face and suffocated her! Why didn’t you check?”

Quinn’s jaw jutted forward. “I told you she had inhalers. If you hadn’t made such a big deal about that old man’s tube earlier, I wouldn’t have even wasted my time on this one.” He took a step backward, then pivoted and stalked out of the room.

“No!” Lukas shouted after him. “Quinn! You don’t walk out on a code!”

“Just let him go, Dr. Bower,” Sandra said, her soft voice growing softer as she worked hard to continue chest compressions. “He won’t listen to anybody. I tried to get him to check his work, but he was in too big of a hurry. If I can’t get another partner I might as well quit. This is stupid.”

As soon as Tex handed Lukas the syringe, he attached it to the tiny balloon at the mouth end of the endotracheal tube and deflated the air from the gear that kept it in place. He pulled the tube out of the patient’s mouth and checked the monitor to make sure the rhythm was still v-fib.

“It’s time for another shock. Sandra, bag her again.”

Sandra stood at the head of the bed and placed the bag valve mask over the patient’s face. Tex charged the defibrillator to 360 joules and handed the paddles to Lukas.

“Clear,” he called, and made sure everyone was out of touch with the bed, then pressed the paddles to the patient’s chest. The body jerked into an arch with the sizzle of electric current, then fell back onto the bed. Everyone looked at the monitor. The rhythm had changed.

“All right!” Tex exclaimed. The v-fib had stopped, and now the blip danced across the screen with more powerful strokes.

Lukas pressed his fingers against the woman’s throat, feeling for the carotid artery, and the hope that had flared within him died painfully. There was nothing. “Oh, no. Pulseless electrical activity.” This was worse! They couldn’t break this new rhythm with a shock. What was happening here?

“Sandra, bag her again,” he said.

The nurse from upstairs came rushing into the room, and Lukas gestured to her. “You’re just in time. I want you to do chest compressions.” What could be causing this? “Let’s intubate now, Tex. And let’s get some fluids in.” What would cause respiratory arrest and pulseless electrical activity in such a young woman?

“Dr. Bower,” Sandra said softly, “the bra we cut off her was a nursing bra.” She indicated the young woman. “She’s been nursing. She was all alone outside the apartment building.”

Lukas felt as if he were on a treadmill going twenty miles an hour. He had to keep up. “Carmen, contact the police,” he called toward the secretary as he worked. “They need to check the area for a baby!” He had to focus. If the woman was recently pregnant…severe respiratory distress…pulseless electrical activity…He caught his breath.

“Oh, no, Dr. Bower,” Tex groaned. “That sounds like massive pulmonary embolism.” Lukas nodded. A blood clot in the lung was deadly.