Chapter Seven
“C ode Blue, ED room two,” blared overhead on repeat as Lee speed-walked from the inpatient wing toward the ED, joining several staff heading in the same direction. What the heck? Bruce had been stable and getting ready to be admitted for observation at the upcoming seven p.m. shift change. His lab results were reassuring.
Maybe someone had hit the code button by mistake or accidentally pulled the alert cord in the ED restroom? Wouldn’t be the first time that had happened.
Or had another patient recently arrived and coded? Could be. Lee hadn’t looked at the census in the past fifteen minutes. If EMS was coming in hot or if it was a John Doe, the patient might not have been added to the patient list. She fingered her cell phone, ready to pull up the ACLS algorithm. In a critical situation, even the best-drilled protocols flew out the window. Good to have her peripheral brain backup.
She tallied her resources as she hurried down the hallway. Six forty p.m. on a Friday. Drs. Burmeister and Moore as well as one of the physician assistants were all off today. The remaining PA had finished up their clinic schedule a few hours ago. The nurse anesthetist or CRNA took hospital call from home. Lee peeked out of a window. Windblown snow swirled beneath parking lot lights. The CRNA wouldn’t arrive quickly enough.
Swiping her badge to enter the ED, Lee paused. A radiology tech rumbled the portable x-ray machine to a stop outside of room two. In the hallway, a rolling phlebotomy cart with a lab tech standing ready next to it waited in the hallway. The ED HUC stood at the trauma bay door with a laptop computer on a stand, acting as scribe, and moved so Lee could enter the room.
Lee stumbled on her own footstep.
It was Bruce.
Lee pulled in a lungful of air. Time slowed down.
Monitors beeped all over the place, ringing out three quick high beeps and two lower, loud beeps, over and over. Insistent sounds of impending death. Not good. Tense, low voices filled the room.
ABC. Airway, breathing, circulation. She could do this. She could run this code.
One of the ED nurses, Clyde, did a limbo move to duck under oxygen tubing on the wall and step over cords to start bag-mask ventilation from the head of the bed. He pressed Bruce’s jaw up against the mask to create a tight airway seal despite Bruce’s beard hair. Bruce’s chest rose with each squeeze of the green ambu bag.
An ED nurse, Amberlyn, stood on a footstool, performing CPR compressions. The day shift charge nurse for the inpatient unit ran in wearing the Lucas compression device backpack. She set it on the counter and began unpacking it.
Lee took another big breath and positioned herself at the foot of the bed, gripping the footboard for support. An attending physician would be helpful right about now. She quickly scanned the team around her. No luck. Not a cardiologist, ER doctor, or critical care specialist in sight, either. Damn it. She was the attending physician.
The sight of Bruce’s pale face and lax body shot adrenaline through her, driving her to panic. Driving her to rush through the steps.
No. The words of Dr. Tyanna Ross, one of her OB fellowship attendings, floated up from several years ago when Lee was elbow-deep in emergency C-sections and high-risk deliveries. Slow is steady. Steady is smooth. Smooth is fast.
“Update.” Lee projected her voice to stay calm but carry over the incessant and loud telemetry alarms.
Deirdre glanced up from where she knelt, placing a second IV line and drawing several tubes of blood. Keeping her eyes on her work, she said, “Chest pain started a few minutes ago along with increasing O2 requirement. Initial troponin level was normal. We were waiting on the four-hour repeat troponin before admitting him. Amberlyn”—she nodded toward the nurse doing vigorous compressions, her long, dark hair floating in front of her face—“was about to call you, but then Bruce said he felt ‘something wrong in my chest.’ He lost consciousness. Telemetry went from sinus to sinus tach, and about thirty seconds ago, it rolled straight over to V-fib.” A quaver roughened her words.
She handed off the multiple vials to the lab tech, who hurried out of the room. Then she taped the IV in place with a deft flick of her wrist and stood.
Lee stared at the monitor that displayed small irregular waves. It beeped with alerts but emitted no sounds of regular heartbeats. Ventricular fibrillation—an unstable heart rhythm incompatible with survival. “Pulse?”
Clyde pressed on Bruce’s neck. “Not palpable.”
“Let’s shock.”
“Got it.” Deirdre retrieved pads from the top drawer of the rolling CPR cart and slapped them on Bruce’s hairy chest as Amberlyn restarted compressions.
“V-fib. Shockable rhythm,” Lee confirmed once more, sweat prickling between her breasts. The likely cause of Bruce’s collapse was cardiac, but she had to think through all reasons for the arrest. Pulmonary embolism, sepsis, cardiac tamponade, pneumothorax, electrolyte disturbances.
“Charge to one hundred twenty joules.” Lee stepped away from the bed. “I’m clear.” She scanned the room as Deirdre moved away from the metal railing.
Clyde lifted the ambu bag away from Bruce.
“You’re clear.” Lee checked once more as Amberlyn raised her hands and stepped back. “Everyone’s clear. Shock.”
Deirdre pushed the button, and Bruce’s body jumped.
Lee studied the cardiac monitor pattern for ten seconds. “Still V-fib. Continue compressions and let’s give one milligram of epi.” Lee turned to the HUC. “Please tell me when it’s been three minutes, and we will repeat the epi dose.”
Deirdre grabbed the brown medication box from the CPR cart, opened it, flicked the caps off the vial and syringe at the same time with both thumbs, shoved the vial into the syringe, then injected epi through the IV port.
Lee’s response to stressful situations was objective and measured—going to pieces could wait for later. She pulled up the ACLS algorithm on her phone. “Continue compressions for two minutes.” She confirmed that a bag of IV fluid ran at a wide-open rate. Unlikely to be volume depletion, but that was an easy diagnosis to treat, and the fluids might improve blood pressure.
Deirdre and another staff member slid a hard plastic piece under Bruce’s back as Amberlyn continued her CPR efforts. In less than a minute, they had the Lucas automatic compression device set up and chunking out high quality, regular chest compressions. Panting, Amberlyn wiped sweat from her forehead, stepped away from the bed, and tucked the stepstool into the corner of the room.
Lee had less than two minutes to think during each CPR cycle. What came next? It had been several years since her training, and even then, the residents had in-house critical care, hospitalist, or emergency department docs to supervise codes. Lee had paid close attention and kept up her certifications, but Lordie, this situation stretched well beyond her comfort zone.
She squeezed her grip on the plastic footboard. “All right. Let’s get an advanced airway. You up for it, Clyde?”
He eyeshot her a wide-eyed expression and gave a curt shake of his head. “Out of my scope of license. What about the CRNA?”
No one answered. Lee’s palms got sweaty. The CRNA hadn’t arrived yet. Criminelly. How long had it been since she had intubated an adult? Stiffening her spine, Lee covertly scrolled on her ACLS steps so she could select endotracheal tube and laryngoscope blade sizes without floundering.
She would have to do this herself. Okay, then.
“Anyone want some help?” a familiar low voice carried through the murmurs, telemetry beeps, and relentless grinding chunks of the pistoning Lucas device. Maverick filled the doorway, beanie and coat on, paramedic kit over his shoulder. Louise hovered next to him, dark brown eyebrows raised.
“Yes!” Lee and Deirdre said in unison. No idea how Maverick and Louise managed to be here, but in Lee’s universe, the more qualified help she had, the better.
Maverick flashed a quick grin, looked down at Bruce, then shook his head. “For the record, he was fine when Louise and I dropped him off.”
Deirdre glared daggers at her brother.
He raised his hands. “ Oof . Tough crowd.” He set the paramedic bag on the floor and opened it, shrugged out of his coat and hat, snapped on gloves, then unwrapped one end of the endotracheal tube sterile packaging and laid it next to Bruce’s head on the bed. He pulled out a laryngoscope blade and snapped it open on the handle, making the blade’s bright light shine. “Move that way for a second, Clyde.”
“Two minutes,” the HUC spoke up.
“Stop compressions,” Lee said, studying the monitor for a few seconds. “V-fib. Charge to one hundred fifty joules.”
Deirdre pressed the button to charge the defibrillator, the high-pitched whine of the machine ratcheting up the stress level in the room.
“I’m clear. You’re clear. Everyone’s clear,” Lee said. She double-checked that the metal laryngoscope Maverick held in his hand didn’t touch the bed. “Shock.”
Deirdre pressed the button, and Bruce’s body jumped again.
After another few seconds, the monitors resumed the loud, wild alarms. “V-fib.” Lee stared at the monitor. Damn it. “Pulse?”
Clyde checked. “Not palpable.” He continued bag-mask ventilation.
Her mind spun. Focus on the ACLS steps . “Resume compressions.”
Amberlyn restarted the Lucas, and the device’s thick chunking provided strange percussion to the high-pitched beeps from the telemetry machine.
“You good to intubate, Maverick?”
“Almost, Doc.” He crouched, then picked up the laryngoscope.
“Three minutes, doctor,” the HUC called out.
“Push another milligram of epi.” Lee glanced at her phone. “Also, mark it so I remember to give three hundred milligrams of amiodarone IV in two minutes.”
“Epi is in,” Deirdre announced. “Pulling up three hundred milligrams of amiodarone to have ready.”
The Lucas machine continued chugging away. Lee’s clenched jaw ached as she scooted around the bed, standing near Bruce’s chest and ready to take additional action if needed.
Maverick’s broad shoulders rose and fell once, twice. Then he braced his legs wide, bent down, and slid in the laryngoscope blade to move Bruce’s tongue out of the way and lift the jaw. The only sound in the room was erratic, blaring alarms and the chunk-chunk beat.
Without taking his eyes off the blade, he said, “Louise, cric pressure.”
Louise pressed her gloved thumb and index finger down on Bruce’s cricoid cartilage, making the larynx structures easier to see and access during intubation. With her other hand, Louise held the sterile packaging as Maverick grasped the endotracheal tube. Once the tube was inserted, Louise removed the metal stylus inside the ET, or endotracheal, tube while Maverick held the ET tube in place. They performed the procedure without saying a word. Perfect teamwork.
With the ambu bag attached and Mav providing ventilation, Lee listened with her stethoscope over Bruce’s chest. Bilateral breath sounds, equal chest rise visible. “ET tube placement looks good.” She exhaled along with several other staff members in the room.
“It’s been two minutes, Doc,” the HUC said.
“Give amiodarone three hundred milligrams.” She paused as Deirdre gave the medication. “Any test results yet?”
The HUC punched an extension into the portable phone, mumbled, then shook her head. “Labs are still in process.”
CPR continued. Maverick gave Lee a tight smile as he inserted the CO2 detector for a few breaths, nodded, removed it, then reconnected the ET tube to the ambu bag that Clyde squeezed. Then he secured the endotracheal tube in place with tape.
Lee checked the monitor for the hundredth time. Damn, damn, damn. Time slowed. Her focus sharpened as she processed every detail around her. As Lee fought to stay calm, her words became slower and more deliberate, syllables drawn out. Those extra milliseconds gave her space to think.
To plan a few steps ahead. “Hold compressions.” She peered at the monitor. Still in V-fib. “Let’s go ahead and shock at two hundred joules, please.” Lee crossed her fingers and tossed up a silent prayer.
She was running out of options to save Bruce’s life. The longer he had CPR without return of spontaneous circulation, the less likely he was to survive.
Lee’s mind raced. Her stomach tensed.
Deirdre charged the unit. “Come on, Bruce,” she murmured, a shimmer in her eyes.
Maverick peered at his sister, one brow raised.
Everyone got clear on Lee’s command.
Please work. A bead of sweat rolled down Lee’s temple. Her dry mouth formed the word.
“Shock.”
Deirdre hit the button. Bruce’s body jumped.
One second.
Two.
Three.
Lee’s gaze landed on the suddenly silent telemetry monitor, back to Bruce with the ET tube and IV lines, and then to Maverick. He gave her a reassuring nod, then resumed ventilating with the ambu bag. Amberlyn’s finger hovered over the switch to restart compressions.
Then, regular beeps filled the room. Lee blinked. What? She pressed the back of her forearm to her damp brow and squinted.
Someone in the room muttered, “Whoa.”
Telemetry read—oxygen saturation 95 percent, pulse sinus rhythm at ninety beats per minute.
“Oh my gosh,” Lee said, her ears ringing. “Check for a pulse.”
Clyde pressed his fingers against Bruce’s neck. “Palpable and steady.”
“Wahoo!” Amberlyn gave a gentle whoop.
Happy murmurs added to hers in the strangely quiet room. Only the regular, softer beeps of the monitor and the soft whoosh of the ambu bag filled the space now.
“Everyone agree?” Lee gripped the railing of the bed and leaned forward, scared to take her eyes off the monitor.
She doubted herself for a split second. Then she glanced over at Maverick.
He gave her a sheepish grin. “Hey, I’m just a paramedic, not a fancy doctor, but it looks like normal sinus rhythm to me. Ow.” Maverick winced as Deirdre—carefully, since he was still providing ventilation—punched him in the arm. “What?”
Lee palpated Bruce’s carotid and felt the regular pulse. His chest rose and fell.
Her body felt boneless, and she exhaled. “Wow. Good job, everyone. Let’s run a post-arrest epinephrine drip at”—she sized him up and did a quick math calculation—“twenty-five micrograms per minute.”
Maverick’s sky-blue gaze at the head of the bed locked on to Lee. Her face tingled. Probably residual reaction due to stark fear for Bruce’s life. For what felt like way too long, she held still and studied Bruce.
Deirdre said, “Okay for me to remove the Lucas?”
“Yes, but… send it with transport?” Lee’s brain whirled while they took away the equipment and reattached EKG leads.
“No need. We have one on the bus.” Maverick cleared his throat. “So…” He drew out the word. “Next steps. We’re thinking transport?” He wasn’t ordering or directing. He worked as a team member, nudging her toward the correct answer.
Heck, yes. Bruce needed to be out of her ED, stat.
Her head bobbed. “He can’t stay in this facility. We don’t have an ICU or ventilator here.” She thought through the unfamiliar resources out loud. “He needs to be in Fairbanks for critical care and cardiology management.”
“Louise, could you call the evening shift EMS crew?” Maverick asked. “We have a transport vent on our rig.” He paused. “Um, did you want a chest x-ray? Sedation during transport?” Throughout his questions, he kept squeezing the green ambu bag, creating steady, even breaths for Bruce.
Damn it. Her knees shook. She needed to focus on post-resuscitation stabilization.
Her thought processes took a while to catch up. “Yes. Absolutely. Portable chest, please.” The radiology tech outside the room acknowledged the request and set up the machine. Lee then turned to Deirdre, who was holding open doors for the tech’s machine. “Do you have Precedex in-house?”
She closed one eye and looked up at the ceiling. “Nope. Go fish. Got a second-choice sedating med?”
Lee’s heart pounded. She checked the ACLS app on her phone. It didn’t hold this answer.
She racked her brain, aware of seconds ticking along with the regular telemetry beeps. “Propofol?” Anything to provide sedation while he was intubated. Once he was evaluated further in Fairbanks, he could then be extubated in a safer setting.
“Bingo!” Deirdre quipped. “Back in a sec.” She hurried to the ED’s Pyxis medication dispenser in the center of the ED.
The radiology tech and Amberlyn slid the film cassette under Bruce’s upper back, with Maverick maintaining the ET tube and airway. The tech squinted at Maverick and the ambu bag, then draped a protective lead apron over his neck and shoulders, covering him to his upper thighs. The whole time, Maverick continued to ventilate Bruce.
Lee and everyone else but the lead-aproned tech and Mav stepped out to avoid radiation exposure while the machine whirred and beeped.
Reentering the room, Lee pulled up the digital image on the portable x-ray machine’s screen. ET tube in proper position. No pneumothorax. Cardiac silhouette was normal. No significant infiltrates in the lungs.
After the portable x-ray machine was trundled away, Deirdre hung the Propofol drip. Sedation was on board.
Lee shifted from foot to foot, every cell in her body wanting Bruce out of this hospital and at the larger Fairbanks facility. Now.
Maverick lifted his chin toward the trauma bay door. “Any day now with that transport vent, Louise. I’m getting carpal tunnel here.”
His partner rolled her eyes and indicated for everyone to move so she could set up the equipment.
Lee gripped the bed railing. Next steps. Think . The on-call CRNA, Thomas, arrived, a perplexed expression crossing his face when he spotted Maverick and Louise and their equipment.
“I missed the party.” He pulled a fur-lined hat with ear flaps off, revealing his close-cropped hair.
“Tom, could you scroll through the telemetry leads for me?” Lee asked.
Because if she knew one truth of medicine, it was that the doctors should never touch the monitors, vent settings, or the IV pumps, else they risked dirty looks or dismemberment by the rest of the healthcare team. Tom turned the dials, cycling through to show the readouts from available leads. It was like reading the EKG without needing to run a formal EKG. A quick way to get big-picture information.
“There.” She pointed. “Tombstone.” Lee used the expression to describe the characteristic EKG appearance in the early phase of an acute heart attack.
Maverick whistled low.
Deirdre winced and patted Bruce’s arm. “Oh, Bruce.” She quietly sniffled and met Maverick’s eyes for a split second.
Lee ran through her cardiac anatomy. There was likely an occlusion somewhere along the watershed of the left coronary artery. Hopefully, Bruce would remain stable until he reached Fairbanks where the cardiac cath lab could open the blockage. Unfortunately, her patient needed the cath lab now. LifeMed helicopter or fixed-wing couldn’t fly in this weather. Even if the ambulance could safely speed, he wouldn’t receive intervention for at least three hours. Time was heart muscle, as they said.
The HUC’s portable phone rang. After a moment, she turned to Lee. “Lab’s calling with a critical result. Troponin is now elevated at 0.15.”
Troponin. A marker of heart damage. The levels rose as more heart tissue was starved of oxygen.
No surprise. “Got that number for Fairbanks?” she asked the HUC.
Lee grabbed a seat in the central work area of the ED to call. Ten minutes of discussion included tips by a helpful critical care doc along with the on-call cardiologist in a three-way conversation. They walked through the plan for Lee to administer the clot-busting medication TPA. It would be the first time she’d done that by herself.
Here she was, truly practicing full-scope rural medicine at the end of the world. Completely on her own.
Only, she wasn’t alone. Nurses and techs had come running to help with the code. The whole team made this work.
Lee waved Deirdre and Amberlyn over. “We need to give TPA and then send him on to Fairbanks.”
Deirdre tapped her lip as the three of them walked back into the trauma bay together. “Amberlyn, if you can get the protocol checklist, I’ll pull the TPA.”
The way Deirdre remained calm was impressive. Lee quivered inside like a southern rattlebox seed pod in the fall.
“I’m assuming they want us to drip and ship?” Deirdre was saying.
Aka administering the dose while Bruce was en route to the heart center.
“Yes,” Lee said.
“Not a problem, Dee,” Maverick said, securing the transport vent tubing. “The dream team of Hilda and Moose know what to do.” He lifted his chin at the two new medics who arrived.
Louise and Maverick huddled with their colleagues to give a report, their voices murmuring medical shorthand that Lee only half heard.
Lee stared at Bruce, now connected to the transport ventilator Tom was monitoring, the hisses and whooshes syncopating various beeps. Gently patting Bruce’s sheet-covered leg, she sighed. She had to talk with his wife. Aggie was waiting in the family room outside the ED. One of the environmental services staff who was a friend of Aggie’s had apparently dropped what they were doing to keep her company.
Another huge sigh escaped Lee as she smiled at the team around her. “Whew. Anyone else want to pass out, or is that just me?”
Everyone raised their hand, and she got a few grim laughs. Someone suggested going for drinks.
If only. Lee’s call continued until Monday morning.
“Okay,” she said to the team members still present. “Last time I’ll ask. Anything else that we’ve missed? Anything else we need to do before transport? TPA’s started along with the other drips, and he’s tolerating them well. Weather issues?” she asked Maverick and Louise, who stepped back as the newly arrived medics prepped their equipment.
The new medic, presumably Hilda, shook her head. A beanie covered her hair, but some red strands escaped at the nape. “Every day is an iffy weather day in Yukon Valley. Don’t worry. Moose here will get us to Fairbanks.”
If the petite paramedic didn’t look like anything like a Hilda, her tall, thin partner who Lee judged to be around fifty didn’t look like a typical Moose.
Hilda continued, “I have zero desire to deal with another cardiac arrest on the bus ride.” She and Moose worked with the rest of the team to move Bruce to the EMS gurney. They quickly secured him, and Hilda tapped the TPA IV bag and crossed herself before patting the gurney handles. “Let’s boogie, Moosey.”
Her partner shook his head as they exited. Louise followed behind them with a backward glance at Maverick.
Lee spun in a slow circle in the silent and still trauma bay, her ears ringing. Wads of packaging, plastic needle caps, IV luer lock caps and stopcocks, and a small puddle of saline fluid littered the floor.
A full-body shudder ran through her. She’d taken care of what needed to be done. Barely.
The team had performed amazingly well, despite not having any specialized staff available. Wow.
Training was one thing. Real world practice without any safety net was something else entirely. Lee had never truly experienced something like this situation before. Never known the terror of being the very last line of defense between life and death. In every way, this situation was as different from her practice in Georgia as it could be. Foreign. Cold. Uncomfortable, like leaning backward over a cliff while trusting a safety rope to hold. She swallowed against a hard lump in her throat.
No time to process. Lee needed to talk with Aggie.
Maverick stepped in the room, zipped his medic bag, and stood, hefting the bag over a shoulder.
“Hey.” His low voice warmed her as he squeezed her upper arm. “You did good today, Doc.”