Miracle Cure (37 page)

The resident cleared gravel from his throat.

“Mr. Paul Wilansky,” he began, “is a fifty-five-year-old married accountant who—”

“I’m going to need the condensed version,” Brian said, continuing his examination.

At that moment, Carolyn Jessup entered the room, breathing hard. She was dressed identically to Brian—scrubs, sneakers, and a knee-length coat.

“I was just finishing a case when the clerk here called down looking for help,” she explained. “The elevator took forever.”

“I’m glad you’re here,” Brian said. “Go ahead, Mark. Hurry, please.”

“He had a semi-elective quadruple bypass done by Dr. Randa two and a half days ago. No complications. Moved here to the step-down unit last night. Scheduled for discharge the day after tomorrow. He was fine. Then suddenly, his pulse started going up and he complained about feeling light-headed and nauseous. A few minutes later he lost consciousness.”

“How long ago?”

“Five minutes,” a nurse responded, indicating the code clock on the wall over the bed.

Brian slipped on a rubber glove, worked his hand between the man’s legs and under his scrotum, and did a rapid rectal exam. Then he smeared a bit of stool on a chemically impregnated card and added a drop of developer to test for blood.

“Negative,” he said to Jessup.

Sudden intestinal hemorrhage was moved well down the list of possibilities, although a massively bleeding stomach ulcer could still cause this kind of shock before the blood had time to reach the man’s rectum.

“Just in case this is
upper
GI bleeding,” Jessup said to one of the nurses, “please slip a nasogastric tube down into his stomach.”

“Still no pressure,” the nurse at the bedside called out.

“Dopamine’s up and wide open,” the third nurse said.

Brian scanned Wilansky’s EKG, then passed it over to Jessup.

“Some strain, some old damage, nothing new,” she said.

“Agreed.”

With no obvious acute damage on the cardiogram, a heart attack, highly unlikely in view of the recent bypass surgery, seemed more unlikely still.

“Mark, do you want us to run this code until the surgeons get here?” Brian asked.

“Sure. I mean, please, go ahead.”

“I think we’ve got to start pumping until we get this thing sorted out. He’s got to be bleeding someplace.”

Jessup checked the patient’s carotids and listened to his chest.

“I would think so, Brian,” she said, totally calm, totally focused. “Nothing else makes sense. When were his pacemaker wires taken out?”

The wires!
Brian thought.
Of course
.

The pacer wires, inserted routinely during bypass surgery, were at one time removed as late as five or six days postoperatively. But in the era of managed care and shorter hospitalizations, two to three days had become the norm. Removing the wires that early was fine, Brian had often said sardonically, unless, of course, the patient subsequently needed them.

“The wires?” Lewellen replied. “Oh, Dr. Randa left orders to have them removed. I pulled them about an hour ago.”

“Bingo,” Brian said, nodding his appreciation of Carolyn’s assessment.

“We’ll see soon enough,” she said coolly.

Brian and she were standing elbow-to-elbow, functioning perfectly in tandem, each backing up the other,
making certain no possibilities or actions were being overlooked.

“Mark,” Brian said, “I think you’d better start pumping on this man’s chest right now. Is anesthesia coming? If not, we need to intubate him.”

“Can you do that?” Carolyn asked Brian.

“I can do that.”

The resident moved to the bedside and began doing closed-chest compressions. The mottling of Paul Wilansky’s skin had given way now to a deep violet. With no blood pressure, he was on the edge, the very edge. And most disturbing was that there was no abnormal heartbeat rhythm for them to correct.

“Anesthesia is tied up in the OR,” the nurse said.

“Miss—” Brian read the head nurse’s name tag, “—Dixon, we think that while the pacemaker wires were being removed, one may have gotten tangled around the branch of a vein graft. If that’s the case, and this man is bleeding rapidly from a torn graft into his chest, we’re going to need an operating room and a bypass pump on standby for your surgeons. In the meantime, I need a seven-point-five endotracheal tube and a laryngoscope. Be sure to check the balloon on the tube for leaks.”

Brian pressed his fingers down on the patient’s groin, trying to feel if Mark Lewellen’s closed-chest compressions were pushing blood around forcefully enough to generate a pulse in the femoral artery.

“I’m not getting anything,” Brian said.

“The heart’s empty,” Carolyn said. “We need more volume. Use a large syringe to push in the Ringer’s lactate. Dr. Lewellen, can you do your cardiac compressions any harder?”

“I think I’ve already torn apart the wires that were holding his sternum together.”

The resident was unable to keep the panic from his voice.

“That’s okay,” Brian said reassuringly. “The surgeons can fix those.”

They can’t fix dead
, he wanted to add but didn’t.

Like Jessup, he appreciated that the patient lying there had little chance of making it. And like the resident, he was feeling enormous tension. The trick was not letting that anxiety show too much, or more importantly, not letting it get in the way of thinking clearly. Whatever had to be done they would do. Having Carolyn Jessup working alongside him was like bringing a ship through treacherous waters with the help of a seasoned pilot.

Brian knelt at the head of the bed. He had moonlighted in various ERs for most of his medical career, and despite the eighteen-month layoff, intubating a critically ill patient was still second nature. He shifted Wilansky’s tongue aside with the lighted blade of the laryngoscope and then smoothly slipped the clear polystyrene breathing tube in place through his vocal cords.

“Nice shot,” Jessup said.

Brian attached the end of the tube to a breathing bag and began rapid, one-a-second ventilations to try and replace built-up carbon dioxide in the accountant’s lungs with oxygen.

Jessup checked Wilansky’s neck and groin for pulses and then shook her head. Still none.

Brian could tell what Carolyn was thinking. He was thinking the same thing. Wilansky was in EMD—electromechanical dissociation—the gravest of all cardiac emergencies. The cardiogram pattern said that the natural pacemaker and nerves in his heart were appropriately delivering electrical impulses to the muscle, but the muscle wasn’t responding with a contraction forceful enough to circulate blood. The explanation had to be that much of
the man’s blood was in his abdomen or chest cavity. They had to buy some time until the underlying problem, which Brian assumed was a torn graft, could be corrected. And Lewellen’s external compressions, though technically well performed, weren’t doing the trick.

They had done almost everything they could do to save this man … 
almost
everything.

“Have you ever done open massage?” he asked her.

She sighed deeply and shook her head. “Maybe way back in the old days when we were just switching over to closed-chest compressions. You?”

“Just once,” Brian replied, “but it was a few years ago. A gunshot wound I treated in the ER. Gang fight. Opening the guy’s chest went well enough, so did sewing up the two bullet holes in his heart.”

“And?”

“He never made it to the OR.”

“Well, Brian, maybe this man will.”

Shit
.

Brian wasn’t certain whether he had spoken the word or just thought it. The way they saw it, there was simply no option left other than to open the man’s chest where he lay, clamp the bleeding bypass graft, continue massive fluid-volume replacement, and squeeze the heart manually until the surgeons could get him to the OR and onto a heart-lung bypass machine. The chance of Paul Wilansky surviving the chest crack would be slightly more than zero—especially with a nonsurgeon performing it. But without control of the bleeding site and manual compressions of the heart, the EMD would soon degenerate into lethal ventricular fibrillation.

Brian thought about saying that he wasn’t up to trying the procedure, that Carolyn’s overall experience as a cardiologist more than offset his single, unsuccessful case. Instead, he checked the man’s pupils, which were not
especially dilated, and bit the bullet. Maybe there was still time.

Brian’s mouth was desert-dry. Every muscle was tensed. Thoughts of Leon and the incident in the BHI subbasement were forced to the back of his mind.

“Miss Dixon, get set to open his chest, please,” he heard himself saying.

“Right away.”

“Chest set’s ready,” the nurse called out.

Brian slipped on a mask and gloves and picked up a scalpel. Then, suddenly, there was commotion and loud voices from the hall. Moments later, Laj Randa stormed into the room. His small black eyes were those of a hawk about to strike.

Randa quickly took in the scene surrounding his patient. Mark Lewellen was still pumping on Wilansky’s chest, but Randa ignored him. He turned to Brian.

“Why are you up here on my service?” he asked.

Brian felt foolish, standing gloved, gowned, and masked, scalpel poised in hand before one of the great surgeons in the world. In spite of towering over Randa, he felt himself shrink before the man’s obvious disapproval. What would have happened, he wondered, if he had cracked Wilansky’s chest and the man had died? Or worse still, if he had cracked Wilansky’s chest, their assessment of the situation had been wrong, and the man had died? Actually, he realized, nothing worse than what was probably going to happen anyway.

“I had the code-call beeper,” he replied with some defiance.

Randa evidently had heard enough from him.

“Carolyn. What’s going on?”

“Sudden shock less than an hour after his wires were pulled,” she said. “He’s essentially in EMD. You can see
what we were getting prepared to do. Dr. Holbrook has some experience with the procedure, so we—”

Randa stopped her with a raised hand. He had heard and seen all he needed to.

“Chest tray,” he ordered. “Quickly, now. Quickly. If Mr. Wilansky appears to need it, give him some IV Demerol.”

He motioned Lewellen away from the bed with a shake of his head and, with a similar movement, ordered one of his cardiac surgical fellows to take the young physician’s place.

Without having to be asked, the nurse helped Randa slip a surgical gown over his street clothes, and stretched open a pair of gloves, into which he thrust his hands. His movements were rapid and smoothly precise.

“Scalpel,” he said. “Have the spreader ready.”

Without another word, the cardiac surgeon sliced through the paper tape and the incision with the same stroke. The sternum had been split down the middle for Wilansky’s surgery, after which the bone had been wired back together. Only the middle one of the three wires had broken during Lewellen’s closed-chest massage. Randa snipped the remaining two while his surgical fellow worked the spreader into place.

“Tamponade,” Randa said, speculating that they would find the heart constricted by hemorrhage.

The gush of blood from the cardiac cavity confirmed his prediction, as well as the diagnosis Carolyn had made. The pacemaker wire had caught on the vein graft and pulled it free of the aorta.

Except for his own commands, Randa worked in absolute silence. In less than a minute, the bleeding was stemmed. He slipped his left hand beneath Paul Wilansky’s heart to cradle it while he performed downward compressions from above with his right. Brian noted,
without surprise, that Randa’s technique was perfect. The two-handed compressions would keep the surgeon from squeezing with one hand and inadvertently perforating the thin right atrial wall with his thumb.

“Good pulse,” Brian risked saying, his fingers pressing down over the femoral artery.

“We need an OR,” Randa said to the nurse, blatantly ignoring Brian.

“They’ll be ready for you by the time you get there,” she replied. “The pump team should be there by now.”

“Who ordered that?”

“Dr. Holbrook. We also have two units on the way and he ordered another six cross-matched.”

Randa continued his rhythmic massage. Then he turned to Mark Lewellen, who looked as if he were trying to melt into the wall.

“You nearly killed this man, Lewellen, by not recognizing EMD and its cause,” he said icily. “You have only these doctors to thank that he’s alive. I want you off my service immediately and I don’t want you back.”

“But—”

“Now!” Randa snapped the word like a whip.

Complete, painful silence accompanied the shattered young resident from the room. Brian managed a glance at Jessup, who looked furious, but she just shrugged and tightened her lips.

“So,” Randa said to his staff, “let’s unhook this man from the monitor and get him down to the OR. My hands are getting tired.”

Without another word, Randa and his entourage quickly maneuvered themselves out the door of the room and down the hall.

Brian, Carolyn, and the two remaining nurses stood silently amid the debris that was the typical aftermath of a Code 99, sharing exhaustion and lingering uncertainty, as
well as dismay over the way Mark Lewellen had been expelled. The twenty minutes just past had been frantic, gut-wrenching, challenging, and up to now at least, triumphant. And during that time, members of the hastily formed team had been bound to one another in a way unique to a crisis in a hospital.

Finally, the nurses thanked the doctors for their help and assured them that their obligation to the surgical service did not extend to helping to clean up the room. Brian followed Jessup to the hallway.

“That was a really great pickup,” he said, “diagnosing a torn bypass graft that quickly.”

“Thank you, Brian. I was going to tell
you
how much confidence I have in you, having seen you in the cath-lab emergency and now here.”

“What a team.”

Brian held out his hand. Almost hesitantly, Jessup took it.

“A team,” she said softly. “Well, I’m late for an appointment.”