Mercy

CHAPTER 41

Julie had just finished her morning cup of coffee when she bumped into Michelle, who was on her way into the ICU. The two women embraced with a bit more intensity than a typical hug between friends.

“Oh my God, Julie,” Michelle said, looking her friend over head to toe. “Are you doing okay? Should you even be here?”

“I’m sorry, I should have called you back. I’m fine, really I am,” Julie said, sounding assured. “It was scary, but it’s over now.”

“Yeah, like all over the news.”

Julie made a half smile. “It’s a little weird, I have to admit, to have my name out there so much. I even got an e-mail from Roman Janowski.”

“The CEO?”

Julie returned a nod. “He was very sweet, very concerned, and didn’t seem at all bothered with my being so prominent these days. But still, you don’t like getting e-mails from the big boss.”

“I’m sure. Say, can you meet for a late lunch? One thirty? I want to catch up.”

“I think so,” Julie said. “What brings you here today?”

Michelle gave a little laugh. “Unfortunately, this is where a lot of my customers hang out.”

It was Julie’s turn to chuckle, though the rest of this conversation would have to wait until lunch. Amber emerged from Shirley Mitchell’s room with a concerned look on her face.

“Dr. Devereux, there’s a problem with Shirley’s central line. Could you take a look, please?”

“Yes, of course. I’ll be right there.”

Julie said a quick good-bye to Michelle and reconfirmed their plan to meet. Perhaps Lucy would be available and could join them. As if on cue, Julie’s phone rang. It was Lucy calling. Julie declined the call and sent it to voice mail. Then Jordan called, and Julie felt a little pang of concern. Why would both of them call in such short intervals? The answer would have to wait. Shirley needed immediate attention.

As Julie predicted, Shirley had not stabilized enough to be weaned off mechanical ventilation. It had been several days since Shirley’s return to the ICU, and her relatives could no longer maintain lengthy bedside vigils. Shirley was alone most of the time, breathing with help, and unaware in her blissful propofol slumber.

“She must have thrashed about and pulled out the line,” Amber said, concern in her voice. In time, the young nurse would realize these things happened. A patient pulling out their central line was not as rare as Kounis syndrome by any stretch, but it was not a common occurrence either, which was what had Amber on edge.

A trickle of blood oozed from a thin gap in the central line where it had detached from the skin. The catheter affixed to Shirley’s jugular vein had been sutured in place, so Shirley’s thrashing must have been considerable in order to dislodge it. It was standard procedure for Julie to put in a new central line. She did so without issue. The line had to be flushed, though, to make sure it was clear.

“Amber, please hand me a saline flush, will you?”

The saline flushes were commonly used items and kept in each ICU room for quick and convenient retrieval. Amber handed Julie a ten-milliliter syringe, though three milliliters of saline would be more than sufficient. Julie undid the wrapping and inspected the site for any redness, swelling, or signs of infection. She scrubbed the catheter hub with an alcohol swab for fifteen seconds, then removed the sterile cap. She inserted the open end of the syringe into a hub on the catheter, followed by a twist to lock it. Next, Julie opened the valve mechanism and slowly injected the proper amount of clear saline into the catheter.

“All set, Amber,” Julie said as she handed the syringe to the nurse for disposal. Julie left Amber to tend to other matters.

Five minutes later, Amber, sounding more anxious than before, called Julie back into the room.

“Dr. Devereux, Shirley Mitchell’s blood pressure just dropped.”

Julie rushed to Shirley’s bedside and immediately noticed a nosebleed so brisk it soaked though several applications of gauze. Alarm bells rattled in Julie’s head when she observed how all of Shirley’s IV sites were oozing. Red rivers snaked down Shirley’s bloated arms and marked her mottled neck. Closing the drape, Julie lifted Shirley’s hospital gown to examine the belly. Signs of bruising appeared as if by magic before her eyes, while pools of blood started to well up from between her thighs. Worry squeezed like a vise around Julie’s chest.

Oh, goodness, no…

“Amber, quick! Call for four more units of blood,” Julie said in a crisp and direct manner. “Draw a set of labs now. I think she is going into DIC.”

The proteins controlling Shirley’s blood clotting had become overactive. It was not unheard of for a patient with a necrotizing skin infection to suffer disseminated intravascular coagulation (DIC) and possibly die because of sepsis, but it was a highly unusual complication. Another nurse came running into the room with a liter of saline to hang as a bolus. Julie stayed calm. She had no intention of announcing Shirley’s time of death.

While Amber prepared to draw her labs, Shirley’s heart rate began to drop precipitously.

“Dr. Devereux, she’s bradying down.”

“Bradying” down was medical speak for a slowing heart rate. Shirley’s had plummeted into the twenties.

“Quick, an amp of epi and call a code blue,” Julie said with force.

Alarms sounded and much commotion followed. A swarm of people burst into the room and took their respective roles in an effort to pull Shirley out of her nosedive. But Shirley’s EKG went flatline, triggering more alarms, more noise, more commotion. Amber and a second nurse took turns performing CPR at a grueling rate of one hundred compressions per minute, while Tammy got the respiratory bag going.

A nurse called out, “Three minutes, another epi, Dr. Devereux?”

“Yes, please.”

Labs were quickly drawn, including a complete blood count, liver enzymes, chemistries, and a full coagulation panel. Two units of packed red blood cells arrived and the nurses hung the bags of medicine and hooked them to the infusion pump.

Come on now… come on…

Shirley continued to be asystole with no cardiac electric activity, no output or blood flow. Julie knew she was running out of time. A nurse delivered that third dose of epi.

“Any pulse?” Julie asked.

Compressions came to an abrupt stop as many hands felt Shirley for a pulse.

Nothing.

“Resume compressions,” Julie said.

No change. Still flatline.

“Is the family here?” Julie asked.

“No, nobody has arrived yet,” a nurse said.

“Okay. Okay, everyone. I’m calling it.”

The mood turned somber. Julie glanced at the clock on the wall.

“Time of death, ten fifteen A.M.,” she announced in a solemn voice.

Grim faces all around. Death was a regular visitor to the ICU, but never a welcome one. Julie left for the break room. She needed to clear her head, decompress, but she could not stop reviewing the case in her head.

Where did things go so horribly wrong?