Robin Cook - Foreign Body

Luckily, he was able to slip unseen into the room, but then he stopped just inside the door. He heard hushed conversation. Mr. David Lucas was not alone!

Confused about whether to stay or flee, Raj froze. A second later a wave of relief spread over him. It wasn’t a visitor; it was the TV. With a surge of confidence, Raj walked farther into the room, rounding the outer wall of the bathroom, affording him a view of the strikingly obese patient propped up in the hospital bed. The patient was asleep. A nasogastric tube issued forth from one nostril and was connected to suction. About a half-cup of yellowish, blood-tinged fluid could be seen in the collecting bottle. A cardiac monitor on the wall behind Mr. Lucas played out a regular rhythm. All in all, the entire scene looked identical to how it had looked when Raj had left for the day a little after three that afternoon.

Raj reached into the pocket of his white nurse’s trousers and pulled out the syringe he’d prepared back at the bungalow. In contrast to Veena and Samira, he’d not had to go to the empty operating room to get the succinylcholine, and for that he was pleased. He knew he had Samira to thank, and had already done so.

After checking the syringe to be certain none of the fluid had leaked out, a distinct possibility, since he had actually overfilled the 10 cc syringe, Raj was ready to go. He’d overfilled the syringe on purpose, thinking that the last thing he wanted to do was not give enough.

Returning to the door, Raj gave one last look up and down the corridor. There was one nurse walking toward him, but she turned into a room and disappeared. Sensing the time was never going to be better, he returned to the bedside. Carefully picking up the IV line without pulling on it, he took the cap off the needle with his teeth, and then gently poked the needle through the IV port. There was no need to worry about sterile technique.

Thus prepared, Raj paused for another moment, listening if there were any telltale sounds from the hall that he could hear over that of the lowered TV. There weren’t, so he used both hands to discharge the entire contents of the syringe into the IV line in a large bolus. Having not stoppered the upper part of the IV line beforehand, the first thing he noticed was a rapid rise in the level of fluid in the millepore chamber. But that effect was overshadowed by the patient’s response. As Samira had warned, there were almost instantaneous fasciculations of the facial muscles combined with David Lucas’s eyes shooting open. He also started to cry out as his extremities began a series of myotonic jerks.

Raj took a step back, shocked by what he was observing. Although he’d been cautioned, the reaction had been more rapid and more disconcerting than he’d expected. He watched for another beat as the patient tried to sit up but immediately collapsed back like a freezer bag full of fluid. With a sense of revulsion, Raj turned and fled. The problem was, he didn’t get far. As he yanked open the door to the corridor, he literally ran into a white-coated figure who’d just raised his hand to push open the door that because of Raj was no longer there.

Raj grabbed the man in a bear hug to keep from knocking him over as his inertia carried them out into the corridor. “I’m so sorry,” the befuddled nurse blurted. The collision had been so unexpected, and making it even worse, he recognized the man. It was Dr. Nirav Krishna, David Lucas’s surgeon, on late rounds before heading home.

“My God, man,” Dr. Krishna snapped. “What the bloody devil is the rush?”

For a brief moment of utter panic, Raj tried to think of something to say. Realizing there was no way out, he told the truth. “It’s an emergency. Mr. Lucas is having an emergency.”

Without saying anything, Dr. Krishna pushed by Raj and dashed into the room. Coming to the bedside, he saw David Lucas’s beginning cyanosis. Out of the corner of his eye he saw from the monitor the heart was beating relatively normally. It was then that he realized the patient was not breathing. He did not see any fasciculation, because they had already stopped.

“Get the emergency cart!” Dr. Krishna yelled. He yanked out the nasogastric tube and threw it to the side. Grabbing the bed control, he began to lower the head. Seeing Raj glued to his spot, he again yelled for him to get the crash cart. They were going to have to resuscitate.

Raj recovered from his paralysis but not his terror. He raced from the room and ran headlong down the corridor toward the nurses’ station, where the emergency cart was stored. As he ran he tried to think of what he should do. He couldn’t think of anything other than to help. The surgeon had gotten a good look at him, and if he just disappeared, he’d surely be implicated.

Reaching the central station, Raj blurted out to the two nurses sitting at the desk that there was a code in room 304. Without stopping, Raj threw open the door to the storeroom where the crash cart was kept, grabbed it, backed out with it in tow, and then raced back down to David Lucas’s room, making an enormous racket in the process. When he got there, the lights had been turned up. Dr. Krishna was doing mouth-to-mouth, and to Raj’s added horror, Mr. Lucas didn’t look so bad; his cyanosis had faded to a large extent.

“Ambu bag!” Dr. Krishna shouted. One of the floor nurses who’d raced after Raj grabbed it from the cart and tossed it to the doctor. Dr. Krishna repositioned the patient’s head, applied the bag, and began respiring the victim. Now the chest was moving even better than it was with the mouth-to-mouth. “Oxygen!” Dr. Krishna barked. The other floor nurse got the cylinder over to the head of the bed, and between Dr. Krishna’s compressions, she connected it to the breathing bag. Within seconds Mr. Lucas’s color improved dramatically; it was now actually pink.

As these activities progressed, Raj had an opportunity to appreciate just what kind of disaster he was in. He didn’t even know for certain whether it would be better if the patient died or was saved. Nor did he know if it would be better for him to slink away or stay, and the uncertainty kept him riveted in place.

At that point the evening house doctor, Dr. Sarla Dayal, arrived at a run. She crowded in at the head of the bed, and Dr. Krishna gave her a rapid summary of what had happened.

“When I got here he was definitely cyanotic,” Dr. Krishna said, “and the cardiac monitor looked reasonable, but it’s only one lead. The problem was, he’d stopped breathing.”

“You think it was a stroke?” Dr. Dayal questioned. “Maybe a heart attack precipitated a stroke of some sort. The patient has a history of occlusive cardiovascular disease.”

“Could be,” Dr. Krishna agreed. “It does look now like the cardiac monitor is telling us something. The rhythm is certainly slowing.”

Dr. Dayal placed a hand on the patient’s chest. “The heart rate is slowing and feels rather faint.”

“It’s probably the patient’s obesity.”

“The patient also feels really hot. Take a feel. I’ll breathe for a while.”

Dr. Krishna turned the ambu bag over to the house doctor and felt David Lucas’s chest. “I agree with you.” He looked over to one of the floor nurses. “Let’s get a temperature!” The nurse nodded and got the patient’s thermometer.

“Do we have a cardiologist on call?” Dr. Krishna asked.

“We certainly do,” Dr. Dayal said. She called over to the other floor nurse to give Dr. Ashok Mishra a call and ask him to come in immediately. “Tell him it’s an emergency,” she added.

“I don’t like that the heart rate keeps slowing,” Dr. Krishna said, watching the monitor. “Let’s get a stat potassium level.”

The floor nurse who was not on the phone drew some blood and rushed it off to the lab herself.