“Marci, Ken, Jean, Paula, Gary and Beverly.” She touched his arm. “We have a woman with a laceration in H, it’s only level four, but she keeps getting bounced back. She’s been here for almost three hours.”
“Probably lost her Christmas cheer by now.”
“She’s been surprisingly patient, but I feel bad for her. I’ve cleaned up the cut and put on a temporary bandage, but she needs sutures.”
“Do you have her chart?”
“Right here.” She handed him a clipboard. “She cut herself slicing the Christmas ham.”
He examined the chart. “How big is it?”
“The ham?”
He looked up and a smile rose on his lips. “The laceration.”
Kelly blushed. “Sorry. About two and a half centimeters.”
“Let’s go see her.”
The woman was twenty-something, dressed in black, tight, low-slung jeans and a long-sleeved pink T-shirt. She had darkly lined eyes and spiky, brunet hair. She was sitting upright on the examination table, holding a gauze pad around her finger. The blood had stained through the bandage and she glanced up nervously as he entered. He greeted her with a warm smile. “I’m Dr. Cook. I’m sorry you’ve had to wait so long.”
“It’s okay. It’s really busy.”
He walked to her side. “I understand you decided to serve your finger for dinner.”
She slightly smiled. “I was cutting a ham and the knife slipped.”
“How long ago was that?”
“About three hours ago. I came as soon as it happened.”
“Let’s take a look.” He gently pulled back the bandage. The laceration was about an inch long and looked like it went clear to the bone.
“You’re pretty brave. I’d probably be howling about now. Before I give you an anesthetic, I need to see if you have nerve or tendon damage. I want you to extend your finger like this.” He held his forefinger out in demonstration. She obeyed.
“Now hold it stiff, don’t let me bend it.” He pushed down on the top of her finger, which she successfully resisted.
“That’s good. Keep holding it out and I’ll check blood flow.”
He squeezed the end of her finger until it was white, then released. It quickly turned pink again. “Blood supply is good. Just one more test.”
He took the paper clip from her chart and bent it out so its two ends were extended. “Close your eyes.” He touched her finger with the two prongs. “How many points do you feel?”
“Two.”
He moved it down her finger.
“And now?”
“Two.”
“Good. You can open your eyes.”
She examined the paper clip. “That’s pretty high-tech equipment you’ve got there.”
He smiled. “Nothing but the best for my patients. Kelly, get me three cc’s of two percent plain Xylocaine.”
Kelly had already prepared for the shot. “Here you go.”
“Thank you.” He took the syringe and turned back to the young woman. “You missed all the vital stuff. So all I need to do is sew you up and send you home. Let me have you lay your hand down, palm up. I’m going to give you a digital block to numb your finger.”
She turned away as he slid the needle into the palm of her hand. She said, “I feel so dumb. I work at a floral shop and cut flowers all day and I’ve never had an accident.”
“Accidents happen. Dumb are those who do it on purpose.” He took the needle out. “Just one more.”
She bit her lower lip as he slid the needle back into her palm. She asked, “Do you see many suicides?”
He nodded. “Especially this time of the year.” He stood, breaking the needle off into a disposal pack. “It will take a few minutes for that to numb. I’m sorry to make you wait again, but I’ll be back in just ten minutes. Promise.”
“Thank you.”
He walked back to the charting room and wrote down the details of his visit, then scanned the screen for his next patient. Another nurse, Ken, was inside the room. Paul asked him, “Have you seen Mrs. Schiffman in G?”
“About ten minutes ago.”
“Let’s go see her.” He grabbed a chart and walked to the fourth door. A blond woman in her mid-thirties lay on her back. She was wearing a hospital gown and her foot was elevated about five inches off the bed. Her husband, a red-faced, barrel-chested man with a beard and a large belly sat next to her reading Car and Driver. He looked up as Paul and Ken entered, his face screwed up with annoyance. “It’s about time someone came. Doctors think their time’s more valuable than everyone else’s.”
“We’re a little busy,” Paul said, then turned to the woman who was clearly embarrassed by her husband’s temper. “Hi, I’m Dr. Cook. How did you hurt yourself?”
“I was carrying my boy out to the curb when I slipped on some ice. I think it’s broken.”
He examined her leg. An enormous bruise blackened her ankle, which was swollen to almost twice its normal size. He felt around it, pressing in spots. “Does that hurt?”
“Yes.”
“And here?”
“Ow! Yes.”
“Sorry.” He turned to Ken. “Let’s get a complete set of X-rays on this.” He said to the woman. “I’m guessing that you have a type A fracture of the fibula. In English that means you’ve broken your leg. But we’ll need X-rays to be sure. Have they given you anything for the pain?”
“No.”
“Are you allergic to anything?”
“Valium.”
He lifted the chart and wrote on it. “Ken, let’s give her ten milligrams of morphine with fifty milligrams of Phenergan IM.” He touched her arm. “I’ll see you when I get the X-rays back.”
“Hey! You’re not leaving?” the man said.
“There’s nothing I can do until I see the pictures. But Ken will take good care of your wife for now.”
The woman flushed but said nothing. The man grumbled as they walked out.
“Sweet guy,” Paul said. “Let me know when the pics are up.”
“You got it.”
“And take this, please.” He handed the chart to Ken, then walked back to room H. The young woman smiled as he entered.
“I told you I’d be back. Are you numb?”
She nodded. “As a brick.”
He smiled at her choice of words. “Good. The miracle of Xylocaine—greatest discovery since the bikini.” He took a suture pack from the cupboard. “Let’s sew you up and get you out of here.” He sat down next to her and pulled on some latex gloves. “All right, lay your hand on this.” He guided her hand over to a padded armrest. “Just relax. First I’m going to apply a small tourniquet. Fingers tend to bleed a lot and that makes it hard for me to see.” He rolled a small rubber ring down her finger. “You’ll feel some pressure, a little tugging, but you shouldn’t feel any pain.” He hooked the needle through the flap of flesh. She jerked.
He looked up. “Did you feel that?”
“Sorry. I’m just a little jumpy.”
“Try to hold still.”
“Sorry.”
He hooked the needle through the opposite flesh and tied the first stitch.
“How many stitches will this take?”
“Six or seven.” He sensed her anxiety. “You’re a florist?”
“Yes.”
“Where do you work?”
“Hyde Floral. It’s just a few miles from here, on Ninth.”
“Across from the Honda dealership.”
“Right.”
“I’ve bought your flowers before.”
“Cool. Your next order’s on me.”
“Thank you. What’s your name?”
“Lily Rose.”
He looked up. “Really?”
“I know. It was my grandmother’s name. Lillian Rose. I get razzed about it every day at work. I guess I’m in the wrong line of work.”
“Or the right one.” He pulled a thread up and tied it. “It’s nice to meet you, Lily. Though next time we’ll meet
at your place.”
“No argument here.”
“Whom were you cooking for?”
“My family. We get together once a year to remind ourselves why we stay away from each other the rest of the year. If you’re off soon, you’re welcome to join us.”
He smiled. “Tempting.”
“It would make my mother’s Christmas. She’s always wanted me to bring home a doctor. And a handsome one at that.”
Paul smiled. “Thank you.”
Just then Kelly stepped into the room. “Doctor, paramedics are in transit. We have a child with respiratory distress.”
He continued suturing. “Where’s Doctor Garrity?”
“We had a code blue on the floor. A woman went into arrest while delivering a baby.”
“What’s the ETA?”
“About two minutes.”
“Is the child still conscious?”
“Yes.”
“What’s his oxygen saturation?”
“It’s dropping. It was eighty-eight percent at the house, now it’s down to eighty-two.”
Paul frowned. “What happened?”
“Possible aspiration of an unknown object. The parents and the paramedics tried the Heimlich, but it didn’t help.”
“Tell the paramedics to get an IV going but don’t delay transport.”
“I’ll call.”
Paul looked up at Lily. “I’ll have to leave when the child arrives. I don’t think I’m going to finish this in time. Will you be okay?”
“Yeah.” She was quiet for a moment. “When I was a teenager, I was babysitting a neighbor kid when she choked on a cinnamon bear. She finally coughed it out, but it scared me to death.”
Paul tied off another suture. “Choking always scares me.”
Just then Ken entered the room. “Dr. Cook, we’ve got a cardiac arrest in transit.”
Paul groaned. “When it rains, it pours. What’s the ETA?”
“Five minutes.”
“Status?”
“Paramedics are performing CPR. A forty-two-year-old male who was out shoveling snow when he collapsed.”
Kelly stepped in behind Ken. “Doctor, the ambulance with the child is here.”
He set down the needle, lifted the scissors and snipped the tourniquet. He looked up at Lily. “I’ll be back.”
“Good luck.”
He said to Kelly, “Wrap her with some gauze, then come help me.” He walked out into the hall as the paramedics brought in the child. He was a small boy of three or four. His face was bluish and his eyes were open and wild and a large paramedic struggled to hold him as he flailed wildly, the end of the IV tube whipping with his motion.
“What’s our oxygen saturation?” Paul asked.
“Seventy-nine.”
“Give him to me.” Paul put his arms around the boy and began the Heimlich. Nothing.
“Get him on the table. Get him monitored.”
Just then a woman burst through triage into the E.R. screaming “Where’s my boy?”
The triage nurse had unsuccessfully tried to grab her arm as she passed and she was now following her. “Ma’am, we need you to stay out in the lobby.”
“Where’s my boy? I’m not leaving my boy.”
Kelly arrived. “Dr. Cook, the boy’s mother…”
“Let her back.”
Kelly shouted down the hall, “This way, ma’am.”
The woman ran to where they had gathered around her son. She grew even more panicked at the sight of him. “Do something…please!”
Paul asked, “Do you know what he swallowed?”
“No. He was just playing under the tree.”
“Were there small ornaments?”
“I don’t know. Just take it out! Take it out! He can’t breathe!”
Paul turned to Kelly. “We’ve got to sedate him. Give me one milligram of Versed.”
She injected it into the IV but the boy continued to fight against the men holding him.
“Saturation dropping,” Kelly said.
“The Versed’s not enough. What’s his saturation?”
“Seventy-five.”
“Great,” he said caustically, “I’ve got to find out what he swallowed.” He turned to the mother. “How much does he weigh?”
“Uh, uh, thirty pounds.”
Paul did the math in his head. One milligram per kilogram. “Kelly, get me fifteen milligrams Succs.”
Just then the sliding doors opened and a frigid gust of wind flooded the hall. Two paramedics in thick boots tramped inside pushing a stretcher with a man strapped to it. Marci walked up, her antlers gone. “Doctor, paramedics are here with the cardiac arrest.”
“Where’s Garrity?”
“Still on the floor.”
“You’re going to have to help me, Marci. What room’s open?”
“D. Delta.”
“Take him there and keep the CPR going. What’s his rhythm?”
“V-tach.”
“Have the paramedics shocked him?”
“Two hundred, three hundred and three hundred sixty joules.”
“Give him a milligram of epinephrine, wait one minute and if he’s still in V-fib, shock again with three hundred and sixty joules. Kelly, where’s the Succs?”
“It’s ready.”
“Saturation’s fallen to seventy,” Ken said.
“Get me the intubation kit.”
“Right here.”
“Okay, guys, let’s do this. Give him the Succs, Kell.”
Kelly pushed the syringe. Within moments the boy went completely limp. The woman screamed, “You killed him! You killed my boy!”
“He’s not dead, ma’am. Medic, please take Mom to the family waiting room.”
“I brought him in alive! He was alive! I love you, Stevie.”
“He’s still alive, ma’am,” Paul said, “He’s going to be all right.”
The paramedic took the woman by the arm. “I need you to come with me, ma’am.”
“I love you, Stevie. Mommy loves you,” she sobbed as she was led away.
Paul inserted the laryngoscope into the boy’s mouth and lifted his jaw, exposing the vocal cords.
Marci walked back into the room, “Doctor, we need you, the patient just vomited and the paramedics can’t get him intubated.”
“I can’t leave, suck out the vomitus and bag him until I can get there. Kelly, get me the…” Kelly handed him the forceps before he could finish. He reached down the child’s throat. There was a spot of color among the vocal cords. “There it is.”
“Doctor,” Ken said, “Saturation’s at sixty-eight.” Just then the heart monitor started beeping. “He’s bradycardic,” Ken said.
“What’s the rate?”
“Thirty.”
“Ken, start CPR. Kelly, two-tenths milligram of atropine IV and get a six ET tube.” He clamped the forceps on the object and slowly worked it out of the vocal cords. It was a small toy soldier. He dropped the toy and forceps on the bed tray. “Ken, where are we?”
“Nothing.”
“Tube, Kelly.”
She handed him a narrow, plastic tube. He passed it between the boy’s vocal cords, then stopped to listen. “Breath sounds, end tidal CO2 are good. Kell, hyperventilate him.”
“Doctor,” Ken said, “he’s in V-fib!”
Paul felt for a pulse. “I’m going to shock him, Ken, the pads.”
Ken pulled the boy’s shirt up and stuck pads to his chest, clipping wires on with alligator clamps. “Ready.”
“Charge to twenty joules, all clear.” The tiny body jerked.
They all looked to the monitor. Nothing.
“Charge to forty joules, all clear.” Another jump.
“Saturation’s up to ninety, Doctor,” Kelly said.
“We’ve got oxygen, if we can just get this heart beating.”
“Still nothing,” Ken said.
“Ken, CPR. Kelly, epi two-tenths milligram IV.”
Ken began massaging the bo
y’s chest. Paul stared at the monitor, “Come on, come on.”
“Come on,” Kelly echoed.
Paul turned back, “Forty joules. Again. Clear.”
Marci was again standing at the door. “Doctor, what do you want to do with your patient in D? We can’t intubate him, we’ve shocked him six times, three doses of epinephrine and we’re up to a hundred and fifty milligrams of lidocaine.”
A bead of sweat rolled down Paul’s temple to his jaw. “Are there any other docs in the hospital who can help us?”
“We’ve paged overhead but no one’s responded. We’ve called Dr. Mabey at home, but he can’t get here for twenty minutes.”
“This will be over in twenty minutes. Ken, continue CPR. I’m going to D for thirty seconds.”
He ran the forty feet to D. Inside the room a slightly overweight man lay on his back, his shirt cut off of him. There were two paramedics; one of them was pumping on the man’s chest while the other watched. Camille, the respiratory therapist, was holding a mask over the man’s face and compressing a large bag to force oxygen into his lungs. Paul quickly scanned the cardiac arrest record trying to analyze what had been done and what still could be done. All looked to him, their eyes revealing their helplessness.
“Marci, give him another milligram of epi, wait a minute and then, if there’s no change in rhythm, shock him again with three hundred sixty joules. Set me up for an intubation. I’ll be right back.”
Paul ran back to the other room. The boy’s face was an ugly blue. “Where are we?”
“Still in V-fib,” Ken said.
“Shock him with another three hundred joules.”
Kelly looked at him. “Three hundred?”
“I mean forty.” They exchanged glances. “Forty. Clear.”
The body jumped.
The monitor stopped beeping. “We’ve got rhythm,” Ken said.
Paul grabbed the boy’s wrist. “We’ve got a pulse. Kell, call Primary Children’s, we’re going to need a pediatric ICU, let’s see if they can get a helicopter through this storm.”
“Saturation up to ninety-five percent,” Kelly said.
The color was slowly returning to the boy’s face. Paul exhaled in relief. “Good job, guys, good job. Stay with him, I’m going back to D.”
Paul ran back to the other room. The team was still working on the man but visibly distressed. Marci looked up: “We can’t get his heart beating, and we still can’t get him intubated.”