Mercy

CHAPTER 18

ONE WEEK LATER…

Julie finished a busy morning in the ICU, plus extra time on the phone with an obstinate agent from an insurance company. Goodness, weren’t they all? This one refused to pay for Xolair because the patient had “asthma-like symptoms,” not pure asthma. It did not seem to matter to her one bit that Julie’s patient had failed standard therapy with prednisone. What mattered was that prednisone cost three dollars a month, and Xolair could run anywhere from five hundred to two grand, depending on the dose prescribed. It irked Julie to no end that someone in a cubicle without an M.D. was reviewing checkboxes to see if all the criteria had been met.

“Has the patient been on a moderate dose of inhaled corticosteroids plus long-acting beta-agonists for three months?”

Come on now, Julie wanted to scream into the phone. The patient is here, right now, and he’s having a hell of a time taking in a good breath, not to mention he’s had four emergency room visits in the last month. Julie knew that Xolair would make a difference. The patient had an immunoglobulin E level through the roof, the exact area Xolair worked on.

“Is the patient’s diurnal variation in peak expiratory flow greater than thirty percent?”

Do you even understand what that means? Julie wanted to say. She controlled herself. This was a game, and she was adept at playing. Her goal was to get the best treatment possible for her patients, while the insurance companies she battled wanted the least expensive/best treatment possible.

Therein lay the conflict: two little words with such an enormous impact. Least expensive. Julie knew she would win the Xolair battle eventually. After all, she had the MD. The game being played was one of attrition. If the insurance companies set up enough roadblocks, enough doctors would give up and settle for second best. It was a profitable strategy for the companies, but Julie was not about to be one who gave up the fight. She was compulsive about getting everything in order before even picking up the phone. The price Julie paid for her effort was a lot of extra time during nights and weekends, gathering her swords and shields for battle.

By one o’clock she was ready to head to the rehab floor, where she would have lunch with Sam. For today’s feast, she had prepared a special meal at home with Trevor’s help: buttermilk fried chicken and homemade coleslaw. The past couple of weeks had been difficult ones for Sam, compounded by a terrible outbreak of hives. But Sam was out of the ICU, and had sort of made good on his promise. He only asked Julie to help him die every other day.

Over the course of many conversations, Sam repeatedly expressed dismay at Julie’s continued commitment to him and to building a life together. For a man used to giving of himself, he now felt like a burden to everyone. Often, Sam asked to be left alone. He confessed that Julie reminded him of all he had lost and would never get back.

Michelle insisted that “let me die” was a phase in the process. Indeed, Julie saw glimmers that proved her right. Sam had begun to sit in a wheelchair for a couple hours at a stretch before exhaustion forced him back into bed. Every day physical and occupational therapists stretched Sam’s body to the absolute limit, and he seemed able to withstand the ordeal. The work kept Sam’s muscles from atrophying completely, but did little to lift his spirits.

Sometimes during her lunch break, or after a shift, when Trevor was with Paul, Julie would climb into bed with Sam. Together they watched documentaries on YouTube detailing different stories of spinal injury and survival. For the most part, Julie found them life-affirming and deeply inspirational. Sam took it all in, and even asked a nurse to gather some information on assistive technologies. He was particularly interested in a computer that would allow him to type with his eyes. That was a positive sign, Julie decided. The speed at which cutting-edge communications technology was being blended with therapeutic and rehabilitative care was nothing short of astounding.

Close to the elevators, Julie picked up the pace and caught one going down. She was eager to play a song for Sam. Along with the cooler of lunch food, Julie had brought the iPod nano loaded with new music. She’d bought Sam the iPod a few weeks ago and downloaded a variety of music files from iTunes. Sam was not yet interested in listening to audiobooks; it took too much focus, he said.

Sometimes Julie would bring the iPod home and refresh it with more songs, organizing them into playlists for easier listening. Well, Trevor did the refreshing and playlist creation. It was his way of doing something nice for Sam. He was also much more adept with technology and was part of a computer programming club at school, The Bytes. Trevor had visions of MIT that did not yet jibe with his study habits, but his innate ability would take him places, Julie believed.

The iPod Trevor managed for Julie had a preponderance of jazz and blues, two of Sam’s favorite genres, and lots of classic rock. Today she had added a song from the band Weezer, a tune that held special significance for both of them.

It had been a gray fall afternoon, much like this one. Sam had lured Julie to his classroom with some excuse about car trouble. When she arrived, the classroom was empty, until one by one a procession of Sam’s students, silent as monks, filtered into the room and took up every available seat. Julie stood at the front of the class with a wary expression, unsure what to make of it all, and not getting any responses from the kids. The lengthy silence broke only when a student in the front row took out a pair of portable speakers and started to play “No One Else” by Weezer, a band Julie had discovered and adored while in medical school. One by one, in synchronized fashion, the kids held up cardboard signs with a letter neatly printed on each.

It took a minute for Julie to realize that the letters spelled out: “Julie I love you. Will you marry me?”

Sam had entered the classroom in a fine suit, holding a beautiful bouquet of white roses. His students had gone crazy, cheering and clapping as Sam went down on one knee to present Julie with a velvet jewel box.

Julie exited the elevator, wondering what impact the song might have on Sam’s mood. Would he snap at her, as he had on several recent occasions? Or would the memory warm him, as it did her?

On the way to Sam’s room, a voice broke out over the loudspeaker that stopped Julie midstride.

“Code blue, room 2206!”

That was Sam’s room. Julie raced down the hallway and turned the corner just in time to see two nurses rush into the room. When Julie got there, one nurse had already started CPR and two others were busy setting up the bedside monitor. The adjustable lamp over Sam’s bed illuminated his face, now disturbingly gray.

The nurses glanced up to see a look of alarm on Julie’s face.

“Quick, tell me what happened!”

“I was just coming in to sit him up and get ready for you to feed him lunch,” one nurse said. “He complained of feeling warm and light-headed. Then his eyes rolled back into his head and he became unresponsive. I couldn’t feel his pulse, so I called the code.”

The rapid response team, pushing various machines and a crash cart, burst into Sam’s room and took up their respective positions. Dr. Hayes, a tall, gangly New Yorker who was a board-certified physical medicine and rehabilitation specialist, rushed to Sam’s bedside.

Julie responded with startling vehemence. “I’ve got this!”

Dr. Hayes retreated a few steps, making room for Julie to take over.

“I’m sorry, Henry. I’m sorry,” Julie said to Dr. Hayes, finding a measure of calm she desperately needed. She directed her attention to a male resident. “Please take over compressions,” she said.

Intubation could wait. There was no lingering animosity. Dr. Hayes understood no one was more qualified to lead the charge to bring Sam back from the precipice of death than an ICU doctor. Julie, however, understood that Sam would want her to do nothing.

She glanced at the IV bags and at the urinary catheter snaking from beneath the sheets. Somewhere within, she wanted to give him the everlasting peace he had begged for. At the same time, she felt an intense need to force life back into the waxy stillness of Sam’s face.

“Okay, okay.” Julie snapped back into herself, feeling the tempest subside as her mind clicked into task mode. “What do we see on the monitor?”

“Ventricular tachycardia at two hundred, no pulse.”

“Charge to two hundred joules,” Julie said.

There was an agonizing silence as a nurse turned the dial on the automated external defibrillator to 200. Another nurse attached two defibrillation pads to the chest to insure that the electricity got delivered to the right place on the heart.

“Draw up forty units of vasopressin,” Julie ordered as she motioned a resident away from the bed. She pressed the charge button and immediately the hum of the machine grew louder, like a mosquito flying closer and closer to an eardrum.

“Step back from the bed,” Julie called out. “Everyone, all clear!”

“All clear,” most everyone repeated, indicating a go-ahead to shock.

“Ready?” Julie said. “Shock!”

Julie pushed the red button on the top of the defibrillator. A metallic thump sounded as two hundred joules of electricity shot through Sam’s chest and into the rest of his body. His paralyzed muscles did not respond to the jolt in the same manner as those of an able-bodied person. His body came off the bed just a little, but without the rigid arch that usually accompanied that much electricity.

“Any pulse?” Julie asked.

“No pulse,” a nurse said. “Monitor looks like v-fib.”

Julie glanced at the monitor and confirmed the read was indeed ventricular fibrillation. The ventricles of Sam’s heart fibrillated, contracting in a rapid, unsynchronized way. The heart pumped little to no blood.

“Is the vasopressin ready? Give it now. Ready, charge to three hundred.” Julie’s voice was firm, but unagitated.

“Charging to three hundred joules,” a nurse announced.

The hum of the machine again increased in volume as the nurse recharged the defibrillator.

“Charging to three hundred, ready.”

“Clear!” Julie called out.

“All clear,” many repeated.

“Okay, shock!”

Julie depressed the red button, repeating the previous jolt. Sam’s body barely moved as a metallic thunk sounded like a distant thunderclap.

“Any pulse?” Julie asked. A feeling of dread hit so hard it was as if someone had put the paddles on her own chest.

“No pulse, Dr. Devereux,” a nurse announced. “He’s still in v-fib on the monitor.”

With alarm, Julie observed the jagged peaks and valleys of Sam’s telemetry readout. Ventricular rate two hundred beats a minute, atrial contractions not discernable, P waves notably absent. Grim as it appeared, Julie knew Sam still had a shockable rhythm. There was still a chance he could come back to her.

Julie began to order medications to be given through Sam’s intravenous lines. Epinephrine to help increase cardiac output, amiodarone to keep the heart beating normally, bicarbonate to counteract the lactic acid buildup, and even glucose, in case for some reason Sam’s blood sugar had dropped too low. This was followed closely by a 360-joule countershock.

“Yes! We got something,” a nurse announced with jubilation. “Monitor shows wide rhythm at forty-five. I can feel the femoral pulse, though it is weak and thready.”

Julie held in a breath and watched the monitor, half expecting the readout to return to v-fib status at any moment. For the time being, it appeared to hold steady.

“Great job!” Julie said, feeling her own pulse decelerate. But how much of his oxygen-deprived brain would reawaken? “Okay, let’s get IVF bolus five hundred milliliters of normal saline. And hang dopamine. Henry, please tube him now.”

Julie appraised the assembled team, working side by side, each person focused on a specific task. She had been through this scenario hundreds of times before, but never with so much at stake.

“Dr. Devereux, we lost his pulse!”

Julie gave the nurse a horrified look. “What do we have now on the monitor?” Her composure was slipping.

“Slow and wide rhythm in the twenties. PEA.”

Julie’s heart sank. Pulseless electrical activity-no pulse whatsoever. Every inch they had gained in this fight they had just lost.

“Start CPR!” Julie snapped. “Give him more epi, one milligram.”

Everything was done as Julie ordered, and with haste.

“Any pulse?”

“Sorry, Dr. Devereux, no.”

The cardiogram still showed that slow and wide rhythm. Julie’s body became damp with sweat.

“Let’s use an escalating dose of epi,” Julie said with force. “Three-milligram IV push. NOW!”

Chaos and pandemonium erupted.

“Hang an epi drip!” one nurse shouted. “Someone mix it, stat!”

The resident doing compressions had tired. Dr. Hayes took his place.

“Call cardiology,” Dr. Hayes said. “Tell them to come fast. Get echo here! We need echo!”

“Epinephrine, three milligrams in now, Dr. Devereux,” said a nurse. “We still don’t have a pulse.”

Julie tried to ignore the cold tickle of fear running down the back of her neck.

“Continue CPR,” she said. “Give two amps of bicarbonate. Continue CPR. Come on!”

Cardiology arrived. The crowded room heated up as more bodies crammed into the tight space, like canned sardines. The new contingent included Dr. Carrie Bryant from neurosurgery, a recent addition to the White Memorial staff.

“Keep up the compressions,” Julie said. “We can still get a pulse. He just needs more drugs. More epi-please, do it now!”

From the corner of her eye, Julie caught an exchange of nervous glances. The sense of urgency was receding.

Dr. Bryant approached Sam and lifted his lids to shine her penlight into his eyes. She stroked his cornea with a piece of cotton, then applied slight pressure to Sam’s forehead and nose. Her expression without optimism, Carrie stepped away from Sam’s bed and groped Julie’s arm.

“His pupils are fixed and dilated,” Carrie said, looking Julie right in the eyes. “I’m so sorry, but he’s gone.”

Dr. Hayes came forward. “Julie, let me call it,” he said.

The only response Julie could muster was a nod. Carrie gave Julie an embrace.

“That’s it,” Dr. Hayes said, glancing at his watch. “Thank you, everybody, for your efforts. Time of death is one thirty-five.”

Defeated, Julie bowed her head and let her arms fall to her sides. The equipment was put away, the tube removed from Sam’s throat, and the room quickly cleared. Julie resisted the urge to pump on Sam’s chest herself.

Carrie said from the doorway, “You did everything you could, and you did everything right.” With that, she was gone.

Julie stayed behind, too numb to cry, too emotionally drained to do anything but gaze at Sam’s lifeless body. In one intense wave of emotion, the impact of what had just happened hit her full force. Her love was really gone.

He looked at peace. This brought Julie a measure of comfort. In the stillness of the moment, a thought struck Julie with force.

Sam’s heart and lungs had been functioning fine. What caused him to suffer a sudden cardiac arrest?