CHAPTER 15
Elena
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The outgoing night nurse, Priya, twelve-hour shift, hair coming down at the temples, met her at the end of the cot with the flowsheet already turned to the current page.
The boy in the bed had red-blond hair fanned across the pillow and a freckled bridge to his nose.
His name, from the whiteboard, was Sam Alden.
Seven years old. Post-op day three from an open splenectomy after a bicycle accident had put him on the pavement of the West Side Highway path with a ruptured spleen.
“Mother?”
“Family alcove. She’s been up since three.”
“Discharge?”
“Planned for Monday. He was on room air by midnight.”
Elena thanked her. She read the flowsheet once. She read it again.
The numbers ran in her head the way they always did—a small ladder, a stair the child was climbing.
Heart rate 96 to 112 was sixteen beats over six hours.
Temperature had climbed four-tenths in two hours.
The mean arterial pressure (she did the arithmetic with a pencil on the corner of the sheet) was down four points since three in the morning. Small drop. Enough to note.
She washed her hands at the bedside sink, foam to elbow, twenty seconds by count.
The back of her fingers went to the boy’s forehead.
Hot, not radiant. She lifted his hand and pressed his nailbed until the pink went white and then let go.
Cap refill was a hair over two seconds. She did it on the other hand to be certain.
A hair over two seconds. His skin was slightly clammy at the palm and along the collarbone where the neckline of his gown had shifted.
She smoothed the gown flat, checked the wound dressing over his left upper quadrant—dry, edges clean, no strike-through—and set the sheet back down without a wrinkle.
She was twenty-nine. She had been a PICU nurse for six years. She recognized the pattern.
Sam opened his eyes when she took his pulse. Pale lashes, blue underneath.
“Hey there,” she said. “I’m Elena. I’m your nurse today.”
“Where’s Priya.”
“Priya went home to sleep. I’m going to be with you until night.”
He closed his eyes again.
Adam Cole came through at seven-forty, coffee in hand, hair damp from his shower, the sandy fringe he never quite tamed already falling into his eyes. He was married, mid-forties, kind. He had two children of his own. He had been kind to Elena from her first week.
He read the flowsheet at the end of the bed. He put the back of his own hand to the boy’s forehead the way she had. He looked at her.
“Fever,” he said.
“His MAP is off four points since three. Cap refill is over two.”
“Post-op fever, Rossi. Day three. Viral is my read.”
She kept her voice level. “I would like a lactate, blood cultures times two, urinalysis with culture, procalcitonin, repeat CBC with diff, and broad-spectrum on standby.”
Cole looked at her for a long second. He set his coffee down on the counter.
“That is a big workup for a viral fever.”
“It is a small workup for post-splenectomy sepsis, Dr. Cole. His spleen came out three days ago. He has lost his best filter for encapsulated organisms.”
He stayed silent for a beat. She let the silence do its work. She had learned in her first year that arguing with an attending after you had said the thing was how you lost the thing. She had said the thing.
He looked at the flowsheet again. He looked at the boy. He put a finger to Sam’s wrist and took the pulse himself, watched his watch through the count. He looked at the temperature line, at the MAP column, at the cap-refill note in her careful hand.
Ninety seconds, by her watch clipped upside down on her scrub top.
“Okay,” he said. “Order it. Ceftriaxone and vanc empiric while the cultures cook.”
“Okay.”
She kept her face at its working set. She wrote the orders through the terminal at the huddle station, called down to the lab, spiked the piggyback of ceftriaxone from the med room herself because the pharmacy tech ran slow on Sundays.
She hung the vancomycin on a syringe pump at the right rate for a seven-year-old—she double-checked the weight-based math and had a second nurse double-check it after her.
She drew the blood cultures out of both arms, aerobic and anaerobic each side, and labeled them by hand before she left the bedside because mis-labeled cultures killed children.
She sent the urine on a straight-cath because Sam did not have a Foley and she was not going to guess.
Then she went to the family alcove.
Mrs. Alden was in the chair by the window. Fair, red-eyed, the same freckles across her nose that her boy had, a hospital blanket around her shoulders. She stood when she saw Elena.
“I’m Elena, Sam’s day nurse. Can I sit with you a minute.”
The woman nodded. She sat back down. Elena took the chair next to her, not across.
“We are treating for an infection while we wait for the labs. He is stable. I will be with him.”
“Is he going to be all right.”
Elena held her gaze on the mother’s.
“I think so. I will not lie to you if that changes.”
Mrs. Alden closed her eyes. A tear came out from under one eyelid and she did not brush it away.
“Thank you,” she said.
“I’ll come back when the first labs are in.”
Elena went back to bed 3. She checked the vancomycin pump, running to rate, the flow indicator ticking green, and looked at the monitor above the head of the bed.
Heart rate 114. Respiratory rate 24. Sat 97 on room air.
She adjusted the pulse-ox probe on his index finger, because the tape had loosened a little where his palm was damp.
The labs came back in a shorter window than she expected.
The point-of-care lactate posted first on the terminal—2.
8 mmol/L. The procalcitonin came back elevated forty minutes later.
Elena wrote the numbers on a paper towel out of habit, walked them over to Cole at the huddle station, and set the paper towel on the desk in front of him.
His face changed shape. That was the phrase she used privately for it—his face changed shape. The tired came out of it. Something else replaced the tired.
“Bolus,” he said. “20 mL/kg, normal saline, over thirty. Call peds ID for me. Bump him up the acuity list.”
“On it.”
She hung the bolus, primed the line, and set the pump to run over thirty minutes as ordered.
She called down to infectious disease. The peds ID attending—a woman in her fifties whose name Elena did not need to write down because she had worked with her at a Bronx hospital in her second year—was in the building and came upstairs in eight minutes.
They looked at the flowsheet together at the side of the bed and said very little.
Elena had already put the culture bottles on the courier queue and posted the peds ID consult to the chart; the attending only had to sign it.
By noon Sam’s heart rate had come down to 104.
His lips were less dusky. Elena took his temperature at one and it was 38.
0°C, and at three it was 37.8°C. She turned him onto his right side at eleven and back at two, gentle at the incision, hand under his flank to spare the sutures.
She kept a running tally of fluid in, fluid out, and antibiotic times on the paper flowsheet at the bedside because she liked the paper record better than the terminal on days when the numbers were moving.
She let his mother come to the bedside at half past three and hold his hand while he slept.
She showed Mrs. Alden how to read the number on the monitor that mattered, and how to ignore the ones that did not.
She showed her the little bar that meant the antibiotic was infusing on time, and where to find the nurse call so she did not have to leave the chair.
At six the culture bottles rang out on the lab’s board.
Elena caught the flag on her terminal before the call came up: gram-positive cocci in pairs, presumptive Streptococcus pneumoniae.
The classic post-splenectomy organism, the one every peds ICU nurse learned to fear in the first days after the spleen came out.
The peds ID attending confirmed the read on paper and adjusted the plan; ceftriaxone stayed, vancomycin came off once the sensitivities firmed up.
Sam woke at six-fifteen and asked for water.
She gave it to him in a paper cup with a bendable straw.
She wet a washcloth with cold tap water at the med-room sink, folded it, and laid it across his forehead.
She kept her palm on his forehead for a long minute after, because that was what a person did for a boy who had almost gone somewhere he was not coming back from.
Cole found her at the med cart at six-forty. She was drawing up the next dose of ceftriaxone and checking her math against the label. He came up beside her and did not make a thing of it. She had known Adam Cole for a month; she knew he did not make things.
“You caught that forty minutes earlier than I would have.”
She finished the draw without pausing, capped the syringe, and labeled it in her own hand.
“I had the trend in front of me.”
“You had the trend and the read. That is not the same thing. Good work, Rossi.”
He tapped the counter once with the flat of his hand and walked back to his workstation. He wasted no time there. He made no speech of it. Elena finished the draw. She took the syringe to bed 3, spiked it into the piggyback line, and watched the pump start.
Then she went to the med room and washed her hands.
She refilled the Purell reservoir because it was down to the last inch and the day shift always left it for the next shift.
She wiped the counter with a chlorhexidine wipe because someone had spilled saline on it and had not blotted it.
She put the empty vancomycin bag in the sharps-adjacent bin and the used culture-bottle sleeves in the biohazard, and she stacked the paper flowsheet under a clean chart cover so the ink would not smudge before the night nurse got to it.
Then she stood at the window of the family alcove for twenty seconds—a small window, wire mesh in the glass, a view over the roof of the North Tower to the river—and watched a line of geese cross the sky in a wobble of Vs that never quite settled.
Her mind ran clear of anything in particular. Her hands were shaking a little; she flexed them twice and the tremor slid out of them by the second flex, though a small residual thrum stayed in the tendons at her wrists for a minute after.
Sasha met her at nine in the sixth-floor family lobby with his coat over his arm and a bottle of water in his hand for her. He asked her nothing about the shift.
“Home?” he said.
“Home.”
The Range Rover was warm and smelled faintly of leather and of the cedar in the air freshener he preferred.
Sasha drove without music. Elena sat in the back with her forehead against the cool window and watched the city slide by in a low, wet blur—Sunday-evening lights, the FDR gone slack, the river with the lamps of the bridges laid across it.
Nikolai had known before she got in the car; she could tell because Sasha did not ask a single question about the day.
He handed the water bottle back over the seat at a red light on 63rd and she uncapped it and drank half of it in one long pull.
Her throat had been dry for hours and she had not noticed until then.
The penthouse was warm. She hung her coat, set her bag by the door, and went to the kitchen because the counter was where she always went first. Hunger had left her. So had everything else, exactly.
She sat on the stool she liked at the end of the island. The nurse’s watch was still clipped upside down on her scrub top; she unclipped it and set it on the marble face-up, the little hand at the ten.
The kitchen smelled of stock and celery and butter. Nikolai came out of the pantry with a bowl in his hands.
He set it in front of her. Beef broth with soft egg noodles, a scatter of parsley, the bowl white and plain from her mother’s plain-white set.
He set a spoon beside it. He put a piece of bread on a small plate at her elbow.
He sat down on the stool at her right. The steam off the broth carried the smell of bay leaf and long-simmered marrow, and the parsley had been chopped fresh enough that the counter beyond the bowl still held a small green stain from the knife.
He kept his eyes off her for a moment. His gaze settled on the bowl.
“You saved a child today.”
She picked up the spoon. The broth was hot and clean and salted right.
“That is what I am for.”
He tore a small piece of bread and set it on the edge of her plate.
“Eat the bread too.”
“Bossy.”
“Correct.”
The corner of her mouth moved. She ate the bread.
He set his palm against her cheek the way she had set hers against the child’s forehead six hours before, and neither of them said anything else.