Lie Still (3 page)

Angry with myself, I jerked the tube out too fast. “Ventilate, please,” I said. Roger reattached the mask and pumped oxygen, probably pushing chunks of dinner farther down the respiratory tree.

I grabbed at the laryngoscope and knocked it to the floor, where the blade and handle separated with a mocking clang.

“Keep breathing, please,” I said, bending to get my tools off the floor. I reunited blade and handle and looked at the ceiling, biting my lip.

I sucked out Henry’s mouth one more time and slid the blade in so deep I knew my first view would be esophagus.

I slowly backed out the blade until the voice box suddenly fell into view. I finessed it open with the tip of the blade and saw the by-God vocal cords. They’re distinct when they show up. “Well, hot damn,” I mumbled. I slid in the tracheal tube. Again the string quartet routine. This time the chest rose instead of the stomach.

Though Patty was listening to the chest again, the Doctor’s Rule is to disbelieve until you hear it yourself.

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“Where’s my stethoscope?” I asked, scanning the growing clutter of syringes and wrappers and alcohol pads surrounding the boy.

“Around your neck, Doc,” Roger said, smiling. “That’s always where they are.”

Henry had definite wheezes and new gurgling noises that made the picture ominous. Roger taped the tube to Henry’s face while Patty did the breathing.

“More epi, please,” I said.

“Do you want another dose of atropine?” someone asked.

“No. He’s blocked out for the next four hours at least.”

I asked Vickie to stick the big artery in his groin for a blood gas. Shock plays hell with acid-base balance. She managed to find a vessel on the first pass. It was darker than spoiled claret, but at least it wasn’t black.

An elfen blonde making notes on a clipboard, leaning back on the counter, blurted, “It’s been twenty-three minutes.” It’s about now in a code when the team begins to back down, hoping the Guy-in-Charge isn’t one of those who thinks he can cheat death if he works everyone to exhaustion. I’m usually one of the first to pronounce the dead dead, but they usually hit the door dead, not sassy like Henry had been.

“You want to try shocking him?” Patty asked.

Vickie said, “Live better electrically.”

“He’s in asystole,” I said. “No point.”

“Maybe it’s fine v-fib,” Patty said. That’s the excuse for getting out the electricity when there’s nothing else to do.

“Well, if you want to, we can,” I said.

“I just thought it was the only thing we hadn’t tried.” Sub-text:
Nothing’s working means he’s dead. We got work to do
elsewhere.

I checked his pupils with a light—both were dilated open and paralyzed. In this setting it didn’t mean anything definite, but it looked bad. Robin paused her chest compressions two beats’ worth and looked at me with what I took to be a plea. Like everyone else, she and I were exasperated, but we had, by virtue of Henry having shown up on our watch with 14

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an apparently functional heart, the most at stake in his resuscitation. Our eyes locked for a second before she went back to staring into the ether.

I said, “There’s no reason for this kid to be dying.”

I knew they were all thinking,
Even if heart starts, brain
still dead.
The books say even the best chest compressions achieve only 20 percent of normal blood flow. However, I had seen a patient open his eyes and look at me during CPR.

He nodded to a question. Ten minutes later he died. You don’t forget that.

“Anybody got any ideas?” I said. “Am I missing anything?” Before you let go it’s always best to be sure no one on your team is silently thinking you’ve forgotten something.

“Anyone object to stopping?” There was verbal silence.

Robin spoke. “Maybe one more round of drugs.”

“Sure,” I said. “Epi. And give some bicarb.” I nodded at Vickie and Patty.

One of the gallery spoke: “American Heart Association doesn’t recommend bicarb.”

I nodded. “Yeah, I know. And I know why. And I want it anyway.”

“Want to try high-dose epi?” Patty asked.

“High dose?” I said, obviously seeking guidance.

“It’s kind of new. One of the other docs told me about it.

I guess it’s still controversial, but apparently sometimes it works when nothing else does.”

“Okay,” I said. “How much?”

“Well, like six or eight milligrams at a time in an adult.”

“Okay. Give him four,” I said. “And two amps of the bicarb. Sometimes it helps the epi work.”

The nurses injected the drugs. The chest was bellowed up with the breathing bag and compressed down by Robin’s weight in alternating synchrony. We all stared silently at the EKG monitor. At first nothing happened. In fact, it probably took a full minute, but the needle made a sudden jump up in the middle of its regular CPR-induced bounces. We all saw it, but all knew it could as likely have been from sunspots as Henry’s heart. Then it did it again. And again. “Hold compressions,” I said.

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Robin wiped the hair from her eyes and leaned over to join us watching the EKG. The needle jerked upward, then retreated back to midline with a lazy floating motion. In the next fifteen seconds, the jerks upward began to come more rapidly and the floaty motions downward began to sharpen, to look more like the inverse of the twitches upward, and these “beats” sped up to about one per second.

“Jesus Christ, I think it’s beating,” I said quietly. Louder:

“Stop compressions a sec.”

The waveforms, at first only an evil approximation of an EKG, lost, beat by beat, their aberrant slopes and plateaus.

An army of upright and familiar-looking spikes marched across the screen like soldiers to the rescue. Just as slowly I began to smile. In the next few minutes the stagnant venous blood, with its overload of epinephrine, was accelerated back into action. Henry’s pulse hit 180, and he developed a real blood pressure.

The faces of the staff showed a mix of relief and surprise.

While they set up drug infusions Patty made a speech out of a medical cliché: “Geez, it’s good to have the heart of a thirteen-year-old.”

Vickie said, “Yeah, but Henry will find a way to make us pay for this. You know he will,” she laughed.

Sometimes after a full arrest you get a honeymoon recovery; the heart will beat like crazy for twenty minutes, then rapidly degenerate and finally quit forever—the last cardiac gasp. I hovered over Henry’s monitor, expecting the worst.

Watching the hypnotic march of the EKG, I mentally replayed the first half of my encounter with Henry, looking for clues. When he’d been checked into the ER, Robin had written on his clipboard only “asthma” in big quotes. She’d found normal temperature and blood pressure, though his heart rate and breathing were both a little fast.

When I’d gone in to talk to him, he was alone, sitting on a gurney, bare to the waist. “Hi, Henry, I’m Dr. Malcolm.” I squatted a bit to get to his eye level.

He squinted at me. “You’re new here,” he said.

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“Well, I’ve been here off and on for a couple of months,”

I said. “How’s your breathing?”

“Like always.” His voice was low and croaking—froglike.

“Like always when you come in here, you mean?”

“Uh-huh. I don’t come in unless it’s bad. Or I’m having a seizure.”

“No, of course you wouldn’t.” I warmed the business end of my stethoscope between my palms. “Who’s your favorite Diamondback?” I gently laid it on his back.

“My what?”

“Your favorite baseball player. The D-Backs? You don’t like baseball?”

“No. It’s boring.”

His heart was fast, and he was wheezing and struggling a bit to move air. But for scrawniness, the rest of the exam—

the belly, the throat, and reflexes—was all normal. “What sports do you like?”

He said, “None.”

“Okay, Henry, let me see about getting you some medicine.”

“Wanna see my penis?” he asked, reaching for his pants.

I am not often speechless, but that did it. “It’s crooked.”

A good doctor would never ignore a symptom. Though I figured I would probably regret it, I went along. “Is it bothering you?” I said. Maybe it was infected or something. Infections can set off asthmatics.

“Here,” he grunted, pushing his pants and briefs off his bony little hips. “Look at it.”

I was indeed regretting this. I found some gloves and began an orderly genital exam. He had very scant early pubic hair. His testicles were normal, but there was a mildly contracted surgical scar on the underside of the shaft.

“Looks like you had a hypospadias repair,” I said, suddenly remembering I should have had a nurse “chaperone”

present for any genital exam.

“Is that where—that thing you said—does that mean the piss comes out the bottom?” He was pointing to his scar.

“Yes, if you mean the bottom side of the penis,” I said.

“The opening of the urethra—the hole the pee comes out—

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is on the underside of your penis when you’re born. It was probably fixed when you were a baby.”

“It was,” he said. “Now it’s crooked.”

“Well, not too much,” I said, straightening it and letting it fall back. Time to change the subject. “It looks like you’re working pretty hard to breathe, Henry. I think we better get you a respiratory treatment.”

“A ‘neb’?”

“Yes, Henry, a ‘neb.’ ”

“I don’t like those,” he said.

“Well, I’m sorry about that, but the alternative is a shot, and my guess is you’d like that less.”

He grunted and said, “I get those all the time.”

“Let’s try the easier thing first, shall we?”

He grunted again.

Awaiting me at the doctor’s desk were the three and a half volumes of old charts from his dozens of prior visits and admissions. I ordered his inhalation treatment and began reading the highlights from The Book of Henry.

In addition to his hypospadias repair and asthma, he now clearly had “pseudo-seizures.” More of his prior ER visits were for feigned seizures than for asthma. Most of the seizures had been easily debunked by the usual bedside tests. Someone having a generalized seizure—a real one—

is incapable of doing anything purposeful, yet Henry would routinely make small movements to help the nurses get him into a protected position. One time, on hearing that he needed a bite block between his teeth, he opened his mouth.

“Pseudo-seizures syndrome” is a diagnosis both ugly and complex. I pulled a text. What I remember now are things like “complex disorder of behavior,” and “commonly dead of suicide before age thirty.” These patients learn to use fake seizures to get maximal attention. The psychiatric progres-sion is both predictable and extremely refractory to treatment. A few cases had responded to the most intensive psychotherapy—on the order of two to four hours with a therapist every day. No health insurance in the world would 18

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pay for that, nor would the State of Arizona or Maricopa County.

His prior caretakers believed he had been abused as a toddler by his biological father. I mentally laid the psychiatric disorder on an abusive father, despite the lack of any evidence of a connection between the two pathologies. I went to the hallway vending machines for a can of Squirt.

When the neb was finished I listened again. His wheezing was better but not much. Robin told me he asked her for his shot. He told her that was what he always got. I checked his chart. As he said, he had been given sub-Q epi at each of his last two visits for asthma and responded well. I wrote the order. Minutes later the dam broke.

Henry’s cardiac honeymoon was holding up without any more heroics from us. He stayed pink. His pupils stayed big, though, and he wasn’t waking up. Brain in limbo.

Convinced he was going to live at least the next half hour, I decided I could afford to attend to the mundane. I sat at the desk to write my report, but the cut on the back of my hand was bleeding on the page. I found two sterile cotton balls and taped them over the gash. Thus made safe for paperwork, I wrote a two-page chart note headed

“Code—MD Report.” I put down every clinical detail I could remember, from the moment Henry first arrived in the ER until we declared our standoff with death. It lacked only an explanation of the cause.

Henry needed to be in a pediatric ICU. From our faux-oasis outside Phoenix, I had two choices. St. Elizabeth’s was closer, more pleasant, more “moneyed.” But like any fledgling doctor, I chose what I knew, the one on my old turf, University of Arizona, Maricopa Branch. “The ’Copa.”

While Patty called an ambulance for transport, I phoned the Maricopa operator and asked for the Pediatric ICU.

“Who’s the resident ‘on’?” I asked the charge nurse.

“Intern is Michelle Rosenbaum,” she said. “Senior is Mary Ellen Montgomery.” Dr. Montgomery was my housemate and closest friend.

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“Is either one there?”

She found Dr. Rosenbaum. The intern said “Sure” as formal acceptance of transfer. I told her everything I knew about Henry and asked her to have Dr. Montgomery call me back.

My next job was one of the particularly hellish moments of doctoring—facing the family. I would need to tell people I had not previously met that their son had nearly died at my hands and might yet finish the job. Despite my natural desire to hurry through any such discussion, I have learned it is best to go slowly and give information by implication, nursing along the aggrieved until they get it. I leaned on my elbows at the desk for a good three minutes of silence, rubbing my face and rehearsing my words. I remembered the troubled boy I had spoken to—their son. I stood up straight enough to make my mother proud and marched into the waiting room as if I did this every day.

All for naught: The waiting room was empty.

I asked Patty to call Henry’s home. She left a vague message.

So we entered the many stages of waiting. Waiting for the ambulance, waiting for a callback from the family, waiting for Henry to wake up, waiting for an answer. The hardest part of medicine.