Critical Judgment (1996) (29 page)

“Yes, Doctor.”

Despite the situation, and in spite of herself, Abby flashed on the nurse’s horrible death in her nightmare.
If you only knew …

“Jill, don’t worry about a line,” Abby said. “Just find some little vein and get the epi in. You can do it. I know you can. Put it in her femoral or external jugular if you have to. Just make sure it’s IV.”

She checked Claire’s jaws, which were, in fact, rigidly closed. Trying to get a breathing tube through her mouth was out of the question. But there was another way—in fact, there were two. One of the techniques, nasotracheal intubation, she could possibly do right there. The other, an emergency tracheotomy, would require the surgical lighting, wall suction, and equipment of the ER. And that meant a risky dash.

“I need a six-oh nasotracheal tube,” she said.

The nasotracheal breathing tube was made to be passed through the nose, down the back of the throat, and between the vocal cords. Because the NT tube was held tightly in place by the long nasal passage, it caused less tissue injury over long periods of assisted ventilation than the more wobbly endotracheal tube, inserted through the patient’s mouth. But the nasal technique was slower to perform, technically more difficult, and damaging to the nose if not done correctly. Usually, when inserting the nasal tube, a lighted laryngoscope blade would be slipped into the patient’s mouth to push the tongue aside and allow the physician to use a long-handled clamp to guide the NT tube downward through the vocal cords. This time, though, because of Claire’s tightly clenched jaws, using the laryngoscope was out of the question. Abby would have to do the insertion blind, by feel—and hearing—alone. It was a technique she had practiced many times but had seldom used in an emergency situation, especially with a patient who was still awake and thrashing about.

She turned away from Claire Buchanan for a moment and added softly, “And somebody please get over to the ER and get us ready for a tracheotomy if I can’t get this in.”

She turned back to the stretcher and set about trying to calm Claire down. She also used the mask and bag to deliver high-flow oxygen along with what little air the woman was managing to get in on her own.

Their worst enemies right now were time and the cramped quarters in which Jill had opted to work. Abby identified the people who were not essential to the moment and asked them to wait outside. Del Marshall she motioned back to a corner, out of the way. The radiologist, who was hardly used to this kind of crisis, readily complied. He was tight-lipped and plaster pale. For a moment Abby worried he was going to pass out. As she watched him move aside and brace himself against the wall, her line of vision connected with Joe Henderson,
who was watching and listening from just outside the doorway. For the briefest moment their eyes met and held. Then, with no other acknowledgment, she turned away.

Claire’s face was horribly swollen now and a mottled crimson. Her lips were like sausages. Her eyelids and the surrounding tissues were so puffed that it was impossible to tell whether her eyes could even open. And to make matters worse, her struggles were weakening.

Come on, Jill
, Abby urged silently.
Get that epi in.… Dammit, come on!

The nurse working the crash cart handed over the nasotracheal tube.

“Did you check the balloon?” Abby asked.

Too often she had seen a breathing tube inserted flawlessly, only to discover that the circumferential balloon used to seal the space between the tube and the inner wall of the trachea was defective. The insertion would have to be repeated with another tube, but this time through vocal cords that were often traumatized and swollen from the initial attempt.

“No, Doctor,” the nurse muttered. “Sorry.”

“Do it, please,” Abby demanded. “And it’s got to be lubricated better.”

Keep upsetting people like Jill and this nurse, and it will be a miracle if you’re not lynched
, she was thinking.

“I’ve got it, Abby!” Jill exclaimed suddenly. “Epi’s in!”

“Way to go. I knew you could do it. Now, please get to work on that subclavian, and take your time. As soon as it’s in, give her some IV steroids—make it forty of Solu-Medrol—and also give her fifty of Benadryl.”

Claire had stopped breathing altogether. In a few more seconds they would have to begin doing CPR. But without a way to get oxygen in, the pulmonary part of the CPR would not be possible. Abby couldn’t remember the last time she had seen an anaphylactic-shock patient die in the emergency ward. The treatment was
usually effective, and at St. John’s there was just too much talent around, including skilled trauma surgeons who could perform a perfect tracheotomy in just a minute or two. But this time the severity of Claire’s allergic reaction, plus Jill’s indecisiveness and poor judgment, had put them in a deep hole.

Abby tried one last blast of oxygen from the breathing bag. Claire’s neck was as rigid as her jaws. The resistance to proper air flow was intense. On the other side of the litter Jill was moving with agonizing slowness. There was no way Abby could wait for the IV to be established.

She tried to rid her mind of all extraneous thoughts. But some images of Claire Buchanan—snippets of their two encounters—refused to be dispatched.

“…  Are you the nervous type?”

“I don’t think so, except that I’m very claustrophobic.…”

Abby glanced down the long, gleaming MRI cylinder. How in the hell could anyone with true claustrophobia make it in there for the forty-five minutes usually required to complete a study?

Hang in there, Claire.… Please, just a little bit longer.…

Abby felt the icy fingers of panic beginning to take hold.

“…  I
was a damn good dancer, at least for Sioux City.…”

Don’t leave us, Claire.… Don’t leave us now.…

“Okay, everyone, let’s get this tube down. Mrs. Wilder, put your hands on both sides of her rib cage. When I ask you to, give her some rhythmic compressions. That way at least I’ll have a little bit of a target. I’m making one pass. If I don’t get it, we’re going to the ER for a trach. Are we sure there’s no surgeon in the house?”

“The one on call has been paged, but he’s coming in from his office.”

It had been six or seven years since Abby had performed her last emergency tracheotomy. But if she failed
to get the ventilation tube in, there was no other option. If she had to, she would race Claire Buchanan over to the ER, suck up her courage, and do it.

“Jill, hold off until I get this tube in, please. Everyone else, I need perfect silence so I can hear air moving through her cords. Ready, Mrs. Wilder?”

Instantly the room was totally quiet. Abby bent down, her lips next to Claire’s ear.

“Claire, can you hear me?” No response. No movement. “Claire, you’re going to feel a plastic tube inside your nose. It’s to help you breathe.” Still no reaction.

There was no time left for explanations. And no need. Claire Buchanan, though her jaws were still rigidly locked, was on the brink. The two nurses who could backed out of the room to allow more work space. Abby took the lubricated tube in one hand and slid it into Claire’s right nostril. The one-time Rockette barely moved. Next, Abby slipped her free hand beneath the woman’s head and cradled it. The tube caught briefly on one of the nasal ridges, but a little rotating and some gentle pressure freed it and allowed Abby to advance it into the back of Claire’s throat. Step one was done—the easy part.

Abby hunched over now, her ear just above the opening of the tube.

“All right, Mrs. Wilder,” she said into the silence, “compress about once every three seconds.”

Faintly, Abby heard the puff of air. She advanced the tube another half inch. This time she heard nothing. She guessed that she had gone behind the opening of the trachea into the beginning of the esophagus. She withdrew the tube an inch and rotated it slightly to angle the tip more forward.

“Dr. Dolan, I’m not feeling a femoral pulse anymore.”

Abby checked Claire’s carotid pulse. It was still there, but very faint. Time was just about up.

“Hold off on the compressions, Mrs. Wilder,” she
said. “If we have to race to the ER, we’re going to do it without any CPR until we get there. So everyone get ready.”

She was down to it. One more try, ten more seconds, and she would have to make the time-consuming sprint to the ER and perform a tracheotomy under the worst circumstances.

“Quiet, everyone,” she said again, although there was hardly any noise. “Okay, Mrs. Wilder, compressions, please.”

Abby hunched over the tube opening once more.

The nurse squeezed down rhythmically, once, then again. Claire Buchanan’s arms and legs were twitching spasmodically now, purposelessly. Suddenly Abby heard it again, the faint hiss of moving air. She advanced the tube down a quarter of an inch. The sound was louder. Suddenly she encountered resistance again. Was she against the epiglottis, deep in the throat? The bony ridge above the larynx? Or perhaps even the swollen vocal cords themselves?

Abby felt herself beginning to panic once more. This whole thing was a nightmare. An absolute disaster. Should she try forcing the tube down, hoping she was against the vocal cords, or give up and risk the mad dash to the ER for an emergency tracheotomy by a doctor who hadn’t performed one in years? She waited for another wisp of air, and when she heard it, forced the tube down as hard as she dared. If she fractured or tore a crucial structure, with possibly fatal hemorrhage into Claire’s lungs, she would bear the full responsibility.

There was momentary, total resistance. Then, with a soft popping sound, the tube advanced almost an inch. Abby knew she was in. The tip had pushed between the obstructing vocal cords and was now in the lower trachea, just above its split into the main bronchial tubes to Claire’s right and left lungs. There might be some swelling in
those
tubes, but with epinephrine already on
board, the blockage shouldn’t be enough to keep them from ventilating her.

“Ambu bag, please,” she said. “Quickly!”

Mary Wilder passed over the breathing bag. Abby attached it to the top of the tube and began ventilating as fast as she could. There was a tank of oxygen beneath the stretcher. Abby connected it to the breathing bag through a plastic tube.

“I think I feel a femoral pulse,” the nurse called out.

“Excellent. Jill, you’ve got one more shot at that subclavian. Then, in or out, we make tracks for the ER. Take your time. I know you can do it. Just like the epi.”

Jill Anderson, her tears no longer flowing, seemed as if she were about to back off entirely. Then, with a glance at Abby, she located her landmarks and slid the needle in beneath Claire’s collarbone. The blood return was immediate. A perfect shot.

“Yes!” Jill exclaimed unabashedly. “Yes!”

One nurse applauded.

With a good intravenous route established, the steroids, some more epinephrine, and the antihistamine, Benadryl, could be given IV.

In less than a minute Claire began more purposeful movements of her limbs.

“Her pulse is much better now,” the nurse exclaimed.
“Much
better.”

“Great,” Abby said. “Let’s get her the hell out of this box and over to the ER. Mrs. Wilder, would you please lead the charge?”

The graying nurse looked over at Abby with unbridled relief.

“It’s Mary,” she said.

B
y the time Claire Buchanan was transferred from the ER to the ICU, her symptoms had begun to recede. She was groggy, but clearly awake. George Oleander, who had come in immediately to take over her care, expressed gratitude to Abby for her treatment success, but he had no explanation to offer for Claire’s severe allergic reaction. He also made no defense of his insistence not to refer her for a dermatologic consult. Abby wanted to suggest sending off a cadmium-level stat, but given the controversy swirling around her, she decided the suggestion could wait.

Her actual shift in the ER wasn’t scheduled to begin for a few more hours, and she was hardly in the mood to offer to take over early for Jill Anderson. Instead, she decided, she would go up to the unit to check on Claire, then maybe take a walk, and, finally, have dinner at the Peking Pagoda. With all she had been through today, the very least she could do for herself was a PuPu Platter.

Before heading up to the unit Abby went to a pay phone to check in with Sandy Stuart at St. John’s. The toxicologist was at a conference for another two hours, and her secretary had no idea who would have been in charge of a cadmium assay. Abby left her beeper number
and instructions for Sandy to call as soon as she had any information.

The unit was fairly quiet, due in part to Willie Cardoza’s transfer. Abby immediately sensed a change in the attitude of the unit nurses toward her. Two of them made a point of coming over to congratulate her for “the save.” One of them actually muttered something about “that Wheaton thing.” Clearly, the pendulum of hospital opinion was swinging back in her favor. Abby wondered how far it would head in the other direction again if Henderson began leaking the lie that she had not only overestimated the severity of Peggy’s head injuries, but that in her haste to tend to Peggy’s murderer she had completely missed the constrictive hemopericardium that had probably cost the woman her life.

A wave of loneliness washed over her. She glanced at the time and wondered where Lew was. He had been working a fair amount at the state hospital lately because the main-coverage doctor had left without notice. She wondered what would happen to her embryonic relationship with him if she was forced to resign and move out of Patience. She believed something very special might be developing with Lew, but the two of them were hardly far enough along for her to stay in Patience just for him or for him to leave because of her. And, besides, the situation with Josh remained unresolved. Maybe it would be best if she simply ditched them all—Josh, Lew, the hospital, everything—and started over someplace. That notion was not very appealing, especially since leaving would vindicate the slimy methods of Joe Henderson, to say nothing of the heavy-handed approach of Mr. Ski Mask in his red pickup.