Bellevue

Chapter 20

Wednesday, July 3, 10:45 p.m.

Mitt’s phone jolted him out of a dead, dreamless sleep, and he bolted upright. For a brief moment he was disoriented, but he quickly acclimatized to his surroundings. With a bit of a struggle, he got his strident phone out of his jacket pocket, and before he connected the incoming call, he checked the time. It was a quarter to eleven, meaning he’d gotten a bit more than three hours of uninterrupted sleep, more than he had expected but not nearly enough. It took him a moment to even focus on the phone.

When he’d come back to the on-call area just after seven, he’d gone directly into his room, purposefully avoiding going into the lounge area to join other on-call residents who were sitting around socializing. Following Dr. Singleton’s advice, he wanted to try to maximize sleep opportunities early in the evening. Again, like Monday night, once he was in his room, he didn’t shower or do anything else that might have given him a second wind. All he did was stretch out on the bed in his scrubs and white coat and attempted to think about nothing. Apparently it had worked like a charm.

“Hello?” he said, hoping the call might be some minor issue such as a dosage question or the need for a sleep-medication order, both of which he was becoming progressively adept at handling over the phone. But it wasn’t to be. The caller sounded hurried, even frantic. “Is this Dr. Fuller?” she questioned.

“It is,” Mitt responded, throwing his feet onto the floor. His flight-or-fight reaction had now been fully awakened by the sound of the urgency in the woman’s voice.

“I’m calling about Latonya Walker. She is your patient, is she not?”

“She is,” Mitt said, feeling an added jolt. “What’s the problem?”

“She’s had an arrest,” the nurse barked. “The crash team is here on Fifteen West, but I thought you’d want to know.”

“Good grief,” Mitt said. In the next instant he was holding a dead phone. Pocketing it and leaping to his feet, he had to momentarily put his hand against the wall to steady himself to weather a fleeting spell of dizziness. He then shoved his feet into his loafers, quickly exited the room, ran through the now-empty lounge area, and headed out into the elevator lobby.

After his early dinner, Mitt had made it a point to visit all six nurses’ stations on floors fifteen, sixteen, and seventeen, saying hello specifically to the head nurses but other nurses as well. His goal was to generally make his presence known in an attempt to head off having to deal with pesky issues like laxative requests later. All the surgical inpatient floors had been exceptionally busy, presumably due to the holiday the following day. Not only were there lots of visitors but also plenty of residents and attendings making rounds. But most important, he’d confirmed that there were no looming clinical problems. During his meet-and-greet, he’d run into Dr. Madison Baker, who was rounding on her own patients. She gave him the excellent news that from her perspective things were looking good for the night. She said the sickies she’d worried about Monday night had all dramatically improved.

During his walk-around Mitt had also made a point of stopping in to see the two ward patients he had, Diego Ortiz and Latonya Walker. Both had been doing fine, particularly Ms. Walker, who had eaten a decent meal and didn’t seem to have much pain. Her drain showed almost no drainage and her incision looked fine beneath the paper tape. As well as she’d been doing, a cardiac arrest now seemed hard to believe. As far as he could remember, she’d had no personal or family history of any cardiac issues whatsoever.

Mitt hit the elevator call button multiple times despite knowing full well that it wouldn’t bring the car any faster. Now that he was on his way, his sleep-deprived brain had cleared considerably, bringing with it a definite case of the jitters. The idea that another one of his assigned patients, who had been doing well, was now struggling for her life was an issue he didn’t even want to contemplate. Although he was realistic about not being needed with the crash team on-site, he felt a responsibility to be present. And there was a slight possibility he could help because he’d had a bit of experience with cardiac arrests as a medical student. He’d participated in a handful during his third-year internal medicine rotation and had made it a point to read the most recent medical literature on the subject.

“Where the hell is the goddamned elevator?” Mitt growled under his breath while slapping an open palm against the nearest elevator door and mentally cursing whoever it was who had come up with the idea of siting a hospital in a high-rise. As he stood there waiting, he marveled that it was Latonya Walker who was in trouble. Earlier, he’d worried that there was a good chance he might be called on an emergency with Elena Aguilar, considering how precarious her clinical state was. He’d even forced himself back to the ICU to check on her before heading to the on-call room, in a kind of superstitious hope that making the effort might forestall it from happening.

The moment the elevator arrived, he jumped into the empty car, pressing the 15 button almost a dozen times. He wracked his brain, trying to imagine what could have caused Latonya Walker to have a cardiac arrest. The only possibility that came to his mind was her obesity, since he knew that there was a direct correlation between being overweight and heart disease. Yet why would it happen now, when she’d not shown any signs suggesting that she was developing a problem? Could it have been merely from having had anesthesia, even if there hadn’t been any problems whatsoever during her procedure? Mitt had no idea, especially since he knew next to nothing about anesthesia other than it was a medical specialty in its own right.

As the elevator door finally opened on fifteen, Mitt charged out and turned toward the west rooms. But he didn’t get far beyond the elevator lobby when he came to an abrupt halt. About twenty feet down the nighttime-darkened hallway stood the blond girl, arms akimbo, seemingly laughing at him soundlessly. Thankfully there wasn’t any accompanying terrible odor.

Mitt closed his eyes tightly for a moment, hoping the hallucination would vanish like it had that afternoon in the operating room when he’d momentarily averted his gaze. But it didn’t work on this occasion. When he looked back, she was still there and still silently giggling, giving Mitt the sense that she was making fun of him. Then the girl stopped laughing, and when she did, she raised her arm and extended her hand, which was gripping the same stainless-steel, pencil-like instrument he’d seen before.

Overcoming his shock, Mitt started forward, intent on getting to Latonya Walker’s cardiac arrest despite this distraction set up by his overactive imagination. The hallucination’s response to his approach was seemingly glee, as her smile broadened. And similar to the previous night, as Mitt neared she again disappeared into the surgical conference room. It had happened so quickly — one minute there, the next minute gone — that Mitt wasn’t even certain if the door had been opened or if the girl simply passed through it.

Mere seconds later, Mitt himself was abreast of the door, and despite his being on an emergency call, he thrust it open, lunged in, and flipped on the lights all in one continuous motion. His thought was that the bright, fluorescent light would dispel the hallucination, as it had the night before. But on this occasion, it didn’t. Instead, he saw not only the blond girl but the horde of apparently surgerized people who had been behind her in the operating room. As close as they were, Mitt could see they were in all manner of period dress and undress and varying levels of cleanliness and filth, some carrying their missing limbs or organs. And to add to the horror, swirling around their feet and climbing up their legs were hundreds if not thousands of rats. Then, on top of the almost incomprehensibly repulsive scene, the cacosmia returned with a vengeance, making Mitt stagger back from both the stench as well as the sight.

As the young girl and the crowd surged forward, Mitt leaped back out of the room, noisily yanking the door shut behind him. Terrified that the blond girl, the mob, and the seething mass of rats would in the next instant pass through the door and come at him, he flattened up against the opposite wall, preparing to defend himself as best he could.

But then nothing happened. A few seconds passed. To his left down the hall, he heard someone shout a question, although he couldn’t make out what it was. A moment later he heard someone else respond, again unintelligibly. But the reassuring sounds of normal people doing normal things meant he was in the real world and not an imaginary one.

Building up his courage, Mitt took a step back across the hallway to the door and grasped the knob. He waited for a moment, listening, sure that there was no way the horde could be silent — although now he couldn’t remember if he’d heard anything when he’d confronted them or not. It had all taken place so quickly.

When Mitt didn’t hear anything from the room beyond, he pushed open the door suddenly while anticipating he might have to close it in a flash. But he didn’t have to. The room was empty of people and rats and spotlessly clean despite what he’d seen just a few moments earlier. And the stench had also mercifully evaporated.

Quickly, Mitt leaned back out of the room, pulling the door closed behind him. He took a deep breath to fortify himself. He couldn’t believe what his imagination was apparently capable of doing. It boggled him. At the same time, he knew he didn’t have time to ponder the issue.

With renewed urgency, Mitt rushed the rest of the way down the hallway from the elevator lobby to the corridor that ran along the west-facing patient rooms. Latonya Walker’s room was a six-bed ward to the left, and as Mitt turned the corner, he saw a small group of nurses and residents clustered at its doorway. As quickly as he could, he joined this group.

“How’s it going?” Mitt asked the first nurse who turned in his direction. Despite being stressed from his most recent hallucinatory experience, he tried to act normal.

“I don’t think they are having much luck,” the woman responded. “But it’s not been going on for that long.”

Mitt nodded. He pushed into the room. Latonya Walker’s bed was the first one on the left, near the door to the en suite lavatory. The privacy curtain was drawn shut, leaving about four feet of space between the curtain and the bed. The crash cart was on the bed’s right side with the curtain partially draped around it.

There were four residents obviously in charge of the resuscitation, and Mitt assumed they were the on-call cardiac unit. Teaching hospitals, like Bellevue, all had standing, highly trained resuscitation teams available 24/7. It was a service that was too important to be left to chance. Currently the team was three woman and one man, all dressed in full whites, and they were busily engaged. A female resident was at the head of the bed using an Ambu bag to respire the patient, another was up on her knees on the bed doing closed-chest cardiac massage, while the lone male was operating the defibrillator. The final resident, who was obviously the most senior and in charge, was watching the blip of the cardiac monitor as it traced a flat line across the screen. She appeared frustrated and confused, slowly shaking her head with her lips pressed tightly together.

Mitt quickly saw someone whom he recognized: Madison Baker. She was intently watching the monitor over the senior medical resident’s shoulder. Relieved to see his surgical backup was already there, meaning he wouldn’t have to call her if he was asked to do something he wasn’t capable of, which was just about anything at all, he moved over behind her. “Hello, Madison,” Mitt said to get her attention.

Madison turned around upon hearing her name. “Mitt,” she said, acting surprised. “What are you doing here? I was hoping you were in never-never land.”

“I was but I got a call saying my patient had an arrest. I got here as soon as I could.” Mitt was aware of being less than truthful, but hallucinations were the last thing he’d be willing to admit to Madison.

“Oh, for goodness’ sake,” Madison complained. “I told the nurses specifically not to call you because I was already here. Well, I was not exactly here in this room, just a couple of doors down with one of my patients. The nurse who’d been assigned to Ms. Walker ran in and got me. It’s a strange story. She said the patient had been perfectly stable all evening, even ate a full liquid diet, and had only been using her PRN IV analgesic sparingly. The next thing she knew, the patient had no heartbeat. None. Zero. It’s weird. And the resuscitation team can’t figure it out, either. They’ve tried multiple shocks and even an external pacer and can’t get any electrical response. I know you scrubbed on the case this morning. Was there any problem with the anesthesia that you remember? Anything at all?”

“No,” Mitt said. “The anesthesia went perfectly fine. It was the earlier case where there was a problem with anesthesia.”

“Oh, yeah, I heard about that one. She’s in the ICU, correct?”

“Correct. The name is Elena Aguilar.”

“I looked in on her earlier in the evening. That’s another weird situation. I understand she never started breathing after her succinylcholine was stopped.”

“Unfortunately, that’s true. And then later on, she even stopped fighting the ventilator.”

“What did the anesthesiologist think was going on?”

“I asked but didn’t really get an answer. Later it was discovered her electrolytes were abnormal, and she started having cardiac issues as well.”

“You mean the electrolytes became abnormal while she was in the PACU?”

“Apparently. That’s what the nurse suggested to Dr. Singleton and me.”

“Somebody mustn’t have been watching the IV,” Madison hypothesized with a disapproving shake of her head. “That’s even stranger, because the PACU nurses are a terrific bunch and extraordinarily competent.”

“I got the impression the PACU nurse herself was confused.”

“Well, enough about Aguilar. What’s the story with this patient? I haven’t had an opportunity to check the EHR. Any personal history of cardiac issues that might explain this episode?”

“There wasn’t,” Mitt said. “None at all. No family history, either.”

At that moment a nurse pushed by Mitt and Madison, forcing them to step out of the way. The nurse handed the medical resident in charge of the resuscitation a slip of paper.

“Holy shit!” the medical resident exclaimed the second she glanced at what the nurse had handed her. “The freakin’ potassium’s 14.95! I’ve never heard of that. That’s impossible! My God! No wonder there’s no electrical activity.” She then barked a series of orders to the male resident to prepare bicarbonate, calcium gluconate, hypertonic glucose, and insulin, all of which she immediately began to administer as soon as it was available. While she was busy doing so, she asked Madison over her shoulder if the patient had a history of kidney failure, adrenal insufficiency, diabetes, or HIV, all of which can be associated with high blood potassium.

Madison looked at Mitt, and Mitt responded with a definitive no.

“This is ridiculous,” the resident complained to no one in particular. “A 14.95 potassium level has to be a world’s record, and if we don’t get it down ASAP, there’s no chance of success here.” She then turned to the nurse who’d handed her the slip of paper. “Call the medical resident on call and say we need emergency dialysis stat!” Then she turned to Madison. “Since you surgery guys are here, can we get you to insert a tunneled dialysis catheter for us? I’m sure you’re better at it than we are.”

“That’s to be debated,” Madison said. “But sure. We’re happy to help.”

At that point things moved into high gear, and in the rush of activity, Mitt was even able to forget about his recent hallucination and his fatigue. With Latonya Walker’s right groin prepped, Madison insisted that Mitt insert the dialysis catheter at her direction while she held back the abdominal adipose tissue with a small retractor. The catheter itself was sizable, containing a double lumen, one for the blood to be taken from the vein to be processed in the dialysis machine and another for the cleansed blood to be returned to the patient’s circulation.

“You remember the inguinal canal anatomy, I presume?” Madison asked in a joking fashion. It was an area of the body all medical students remembered from a popular mnemonic device, NAVEL, meaning nerve, artery, vein, and empty space with lymphatics.

“I do,” Mitt replied. He could feel the pulsating femoral artery and knew that the femoral vein, his target, was immediately adjacent medially. Taking in his breath and holding it, he plunged the pointed catheter tip through the skin, angled upward toward the patient’s head.

“Great,” Madison encouraged. “Now, advance it slowly until you feel it break through the vein wall.”

As a medical student, Mitt had become relatively proficient at drawing blood, and what he was currently doing was similar, just in a unique anatomical location and under far different circumstances. As Madison suggested, he felt the catheter break through an unseen boundary as he advanced the tip. When he drew back on the attached syringe, it filled with blood.

“Perfect,” Madison said. Then after instructing Mitt to thread the catheter up into the vein a short distance and tape it securely to the skin, she called out to the dialysis team that the catheter was good to go.

Mitt enjoyed a rare feeling of accomplishment after he’d stepped back to give the newly arrived on-call medical residents room to attach the catheter to their dialysis machine.

For the next hour and fifteen minutes, the resuscitation team kept up their frantic activities with the person doing the closed-chest massage changing every five to ten minutes. The group of people observing thinned considerably, although Mitt and Madison stayed. After about an hour, the medical resident in charge ordered a repeat potassium level, and when it returned at still over ten, she’d become discouraged, admitting that despite all that had been done, the potassium level remained much too high to expect a return of the heart’s electrical function.

“Okay,” the senior medical resident of the resuscitation team called out. “We gave it our best shot. The key point here is that the patient’s pupils, which were widely dilatated when we first arrived, have never come down. I’m afraid this is a lost cause. Let’s stop.”

As the resuscitation group began to dismantle all their equipment, Mitt and Madison walked back toward the nurses’ station.

“Well, at least that was a good effort,” Madison said. “I was impressed. They pulled out all the stops, but it’s still a mystery to me what the hell could have happened to make the patient’s potassium level go through the roof. I’ve never seen or heard anything like it.”

“It is surprising,” Mitt agreed. Now that the excitement was over, the reality of the situation was sinking in. Another patient he’d been assigned had died under what seemed to be inexplicable circumstances. Latonya Walker had had no history of cardiac disease, and her obesity notwithstanding, there’d been no reason to suspect she’d have cardiac problems despite having undergone general anesthesia and a reasonably extensive operation.

“I’m assuming you’ll handle the paperwork,” Madison said. Her usually crystalline voice had lost some of its sparkle. Like Mitt, she was feeling drained after the excitement and the less-than-optimal result on top of a long day.

“I will,” Mitt responded, although he wasn’t looking forward to it.

“Try to get it done ASAP,” Madison said. “And then get yourself back to the on-call room. Let’s hope that’s all the excitement for tonight.”

“I’ll do my best,” Mitt said. “Thanks for encouraging me to put in the dialysis catheter and then talking me through actually doing it. I appreciate it.”

“You did a superb job and nailed it first try. Bravo!”

When they reached the nurses’ station, Madison said a quick good night before waving and heading down the darkened corridor toward the elevators. For a few beats, Mitt watched her recede, half-wishing that the blond girl would make an appearance ahead of her so that Madison would see her, too. But it wasn’t to be.

Taking a deep breath to give himself a new semi-burst of energy, Mitt went behind the counter. There he was greeted by the head night nurse who, without being asked, handed him the paperwork required for the death. With a sigh of resignation and now armed with the appropriate forms, he took a seat at the counter. He then unclipped a pen from his jacket pocket and got down to work. But as he worked, he couldn’t stop thinking about the blond girl and wondering why the apparition was hounding him and whether he’d have to again confront her and the others on his way back to his on-call room. And the rats: That was something new. All in all, it was one hell of a nerve-wracking situation having his own imagination haunt him, especially considering the stress he was under starting a surgical residency.