LIFELINES Excerpt
July first, the most dangerous day of the year.
Transition Day, the day newly graduated medical students arrive to begin their internships, freshly scrubbed, wearing long white lab coats instead of their short student jackets. And absolutely no smarter than they were on June 30th.
Dr. Lydia Fiore knew all about the dangers of Transition Day. People died on Transition Day.
Yet, here she was, starting her new job as an attending physician at Angels of Mercy's ER. On today, of all days, the most dangerous day of the year.
Attending physician. As in: attending to the needs of all the patients and their loved ones and the staff and the residents and the medical students and, if there's time, catch up on charting, quality assurance, research, lecture preparation, public relations, committee meetings, continuing medical education, and oh yeah, don't forget to be nice to the volunteers and auxiliary members while you're making those life and death decisions.
An air-conditioned breeze escaped through the ER's open doors, bringing with it the familiar sounds of urban trauma. Footsteps clattering, a baby crying, voices colliding.
A siren's call to Lydia. Her toes curled in anticipation, eager to push off from a high cliff. Ready or not, this was her new life.
"Fourteen-year-old male found in full arrest at Schenley Park," a medic called out as they rushed a sandy-haired teen strapped to their stretcher down the hall. The second medic rode on top of the gurney, straddling the boy, performing chest compressions amidst the remains of a Buckcherry t-shirt that had been cut away to allow placement of EKG electrodes.
They quickly arrived in the critical care room. Lydia helped her team transfer the teenager to the ER's bed. A hum of contentment mixed with adrenalin sparked an electrical tingle that radiated throughout her body. She loved it when a resuscitation flowed almost effortlessly, as if it was choreographed.
"His friends said he was fine, then suddenly got a frightened look on his face, jumped up, ran about twenty yards and collapsed. One of them began CPR at the scene. We found him in v-fib, shocked him without results, one round of epi, shocked again and loaded with lidocaine." The medic's tone was grim, with good reason. The prognosis of an arrest unresponsive to epinephrine and defibrillation was worse than poor.
Ain't no cure for death, Lydia thought, remembering the words of her first ER charge nurse back in LA where she'd done her internship.
"Drug use? Any past history?" She glided her hands over the now naked teen's body, searching for any trauma or other reason for his sudden collapse. Her vision tunneled to center on her patient, her focus drowning out all sounds except the information her team provided. In the zone.
"Friends said no, but we saw a couple empty cans of beer. They said he's healthy."
"Shock him at 360," she ordered, "then load him with amiodarone."
"He'll be due for another round of epi," The medics hauled their stretcher out of the room, freeing up space for Lydia's team to work. They returned to stand in the corner, watching. Wondering about the new doc in town, no doubt.
Lydia backed away from the bed to gain a better perspective—the big picture. A nurse delivered the shock to the electrode pads. The dancing green lines that represented the electrical activity in his heart spiked erratically before finally resolving themselves into a regular pattern.
"V-tach. Do we have a pulse?" she asked.
"No pulse."
Lydia bounced on her toes, doubt breaching her defenses, releasing a stream of nervous sweat trickling down the back of her neck. Ventricular tachycardia was theoretically better than ventricular fibrillation, but no pulse was still dead.
She sped through the possible causes of arrest. For a healthy fourteen-year-old, drugs like cocaine or crystal meth were high on the list. Until the tox screen came back there was little she could do except run the cardiac arrest protocol. Much as ER docs loved guidelines and protocols, Lydia knew they were really a mask to hide the real truth about medicine on the front lines–doctors pretty much made it up as they went along.
Except Lydia was running out of ideas. And time. "How long has he been down?"
The medic answered. "Coming up on seven minutes."
She squeezed one hand tight into a fist, then released it as if flinging away pessimistic thoughts. Damn it, she hated losing. Even worse, losing a kid.
"Hang a amiodarone drip, defibrillate again at 360 and give another epi."
After the jolt of electricity finished arcing through her patient, she performed a complete reassessment. When in doubt, start from the ABC's: airway, breathing, circulation. She needed to find something to treat. The boy had been without oxygen for too long; if she was going to get him back it had to be now.
The odds were against her and her patient. Full arrest in the field, not responding to electricity or meds—Lydia had better odds winning the lottery without buying a ticket.
"He's back in v-fib."
She was losing him. Lydia leaned forward to listen to his breath sounds again. Then, stopped, sniffing. What was that, Pine Sol? No, it smelled more like a new car. Around the tape of the endotracheal tube, beneath his nose and around his mouth, a red rash like prickly heat mottled his skin.
"Hold that epi," she told the nurse preparing to push the stimulant into the IV. "Get me propranolol, one milligram."
The room quieted.
"Dr. Fiore, I don't think that's what you want," the nurse said in a tone implying that Lydia was clearly out of her league.
Lydia straightened, met the charge nurse's gaze across the table, the patient between them. Everyone was silent, watching to see who drew first blood.
The nurse stepped closer, laid one hand on the patient's arm as if protecting him from Lydia.
"Do as I say. Give him the propranolol."
"That's not AHA protocol, Dr. Fiore," A nurse didn't out-trump a physician, especially not an attending physician, yet everyone in this tight-knit team clearly deferred to the her authority. "American Heart Association has set guidelines for a pulseless arrest."
Pittsburgh charge nurses were no different than LA's. They truly believed in protocols–just like they lived for paperwork, preferably done in triplicate.
Lydia grabbed the vial of propranolol from the crash cart and filled a syringe with the proper dose. "We don't have time to argue."
"Epinephrine is the drug of choice–" the nurse protested.
"If you give him that epi, he's dead."
