Night Shift

Chapter 31

Wednesday, December 8, 5:49 p.m.

Ronnie was feeling chipper and whistling under his breath as he emerged from the Emergency Department’s doctors’ lounge dressed in a fresh white doctor’s coat over scrubs. He was a bit early, but he didn’t think it mattered. He walked out into the main waiting area and surveyed the scene. It was moderately busy, as was normally the case at that time of day. A handful of triage nurses and clerks stood behind the main desk and a half dozen or so patients were lined up waiting to check in. Respecting the taped markers on the floor, they were maintaining the social distancing required by the Covid-19 pandemic.

As he approached the main desk, Ronnie scanned the personnel, looking for Dr. Carol Sidoti. She wasn’t to be seen, so he approached one of the clerks and inquired after her.

“I’m not sure where Dr. Sidoti is,” the clerk said. “She’s either in the back or in her office.”

Of those two suggestions, the closest was the emergency-physician supervisor’s hole-in-the-wall cubby next to the security office. Ronnie rapped on the door in passing, thinking that at that rather busy time, the supervisor would undoubtedly be in the thick of things in the acute care center of the ED. He was surprised to hear Dr. Sidoti call out, “Come in.” Ronnie was already several steps away and had to return. Leaning inside while holding the door ajar, he found the svelte, wiry woman at the built-in desk using a hospital monitor.

“Hey, Ronnie!” Carol said. “You’re early. Don’t you have a life?”

Ronnie laughed. “The MMH is my life,” he said.

“I know what you mean,” Carol agreed. “Especially during this damn pandemic. It’s going to be touch-and-go whether we’ll be able to recover our lives when it is over.”

“How’s the evening looking?” Ronnie questioned. “Anything cooking surgery-wise that I should know about? And how’s the bed situation?” Frequently the night nursing supervisor had to find beds for the ED if the hospital was near capacity. On occasion it was Ronnie’s most difficult job. He could have called the bed manager, but Ronnie preferred to hear it directly from the ED, who more often than not due to the pandemic had patients lined up in the halls waiting for in-patient beds and or Covid PCR results.

“No problem bed-wise, at least currently. And as far as surgery is concerned, we’ve got nothing cooking at the moment. But, and this might be a big but, I just got a heads-up from an ambulance paramedic that a serious bicycle accident is on its way in.”

“Oh?” Ronnie questioned. He experienced a minor jolt, realizing that the serious bike accident could very well be Jack Stapleton, and if it was, it meant the man might unfortunately still be alive. Ronnie had expected to run over Jack like he had the bike instead of catapulting him up into the air, but as hard as Jack had hit the windshield, Ronnie had been relatively confident that a fatal outcome had been achieved anyway. Inwardly Ronnie groaned. At the same time, he realized he should be thankful the ambulance was headed to the MMH ED. If by some miracle Jack had survived the collision, having Jack as a patient meant Ronnie could finish the job if need be, pretty much at his convenience. “How serious is the case, did you get an idea?”

“Very serious, from the sound of it,” Carol said. “Vital signs are okay, but the patient is unconscious with a head injury. On top of that, there’s a compound right lower leg fracture and a probable hip fracture.”

“Well, that certainly sounds like surgery is in the cards. I’ll check the ortho beds when I get upstairs.”

“My guess is that you should check on the neuro beds. On the other hand, with that much general trauma, he’ll probably end up in the surgical intensive care unit.”

“Agreed,” Ronnie said. “So, it’s a male?”

“I believe the paramedic said he, and most of the serious bike accidents we see are male, but I’m not one hundred percent sure.”

“Did they mention where the accident occurred?”

“Yes, they did. It was at the corner of First Avenue and Eighty-Third. Why do you ask?”

“Just curious,” Ronnie said. He nodded. Obviously from the location alone, the incoming patient had to be Jack Stapleton! And recalling the sound of him hitting his windshield, Ronnie was impressed the man was still alive. It was as if he were a cat with nine lives.

“Let me finish here,” Carol said, gesturing toward the monitor in front of her.

“Of course,” Ronnie said. “Sorry! I’ll hang around and check out this patient to have a better idea of what his needs are going to be.”

“Be my guest,” Carol said.

Ronnie wandered back into the interior of the ED and poked his head into the nearest trauma 1 bay. It was dark and deceptively quiet with all its high-tech equipment at the ready. He knew the scene would be changing dramatically and soon, and indeed he didn’t have long to wait. At the moment he was surveying the room, he became aware of the distant undulations of an ambulance siren. As he listened, it slowly gained volume.

Walking a short distance farther down the hallway, Ronnie gazed out at the ED’s empty concrete receiving bay, which didn’t stay empty long. With its siren trailing off, an ambulance soon burst into view, and after making a rapid three-point turn, it backed up to the dock. Before it came to a complete stop, its rear doors swung open and two paramedics piled out onto the platform. Silently and without a second’s hesitation, they pulled out a gurney with a patient strapped into it, raised it up, and then came bursting through the swinging doors with one pushing and the other pulling. As the gurney came abreast of Ronnie, he looked down at the face of the patient. It was, as he’d fully expected, Jack Stapleton. The man was easy to recognize despite a large abrasion on the right side of his face below his closed eyes. Most of his clothes had been cut off. Around his neck was a high cervical collar, and enclosing his right leg was an inflatable cast. At the foot of the gurney was Jack’s lime green bicycle helmet with its right side partially crushed in.

The paramedics rapidly wheeled the gurney down the hallway and into the same trauma room Ronnie had just been viewing. Ronnie followed. Already the lights were on and several nurses in protective gear were waiting. In a well-orchestrated series of movements, Jack was unbuckled and transferred onto the examination table in the center of the room. Carol Sidoti and several other doctors swept in and began their evaluation as Jack was connected to an ECG machine, a blood pressure cuff, and an oximeter. At the same time, one of the paramedics gave a running explanation of all that had been done at the scene and en route while the other paramedic handed over Jack’s wallet to one of the ED social workers, who set off to make sure the police had notified the next of kin. Clearly, permission was going to be needed for the necessary emergency surgery.

To make himself useful, Ronnie got a large-bore catheter and started an intravenous line on the side opposite the IV the paramedics had started in the field. Everyone in the ED knew Ronnie and were fully aware of the specialized battlefield medic training he’d gotten in the navy, so no one was surprised when he pitched in to help. He wanted a particularly good IV line as he was already thinking ahead to how he was going to make sure that Jack didn’t survive his hospitalization. Knowing he’d need something that acted rapidly and with great surety, he had already decided on using potassium chloride intravenously, and he planned on using it that very night no matter whether Jack ended up on the ortho floor, the neuro floor, or the SICU.

Ronnie had used potassium chloride to great success on a number of occasions, as it caused a rapid cardiac arrest that couldn’t be reversed unless treated almost immediately with a heavy dose of a very specific neutralizing drug called sodium bicarbonate, but that almost never happened because hyperkalemia, meaning too much potassium, was never suspected unless the patient had chronic kidney disease or a specific endocrine disorder called Addison’s disease. Interestingly, Ronnie had used potassium chloride on the case five months earlier, when he’d inadvertently barked out the order for sodium bicarbonate when the newbie residents were at a loss about what to do. It ended up saving the patient, at least until the next night, when Ronnie rectified the situation with an overdose of another surefire agent that the patient had been prescribed: digitalis.

By the time Ronnie had the IV going and it had been determined the patient was stable, it was time for preliminary X-rays of the skull, right hip, and right lower leg. At that point, everyone momentarily crowded out of the room save for the X-ray technician. As Ronnie had walked out of the room, he took the bike helmet to look at it more closely, believing with mixed emotions it was what had kept Jack alive. One of the paramedics, seeing Ronnie with the helmet, approached.

“We had to bring that helmet along,” he told Ronnie. “If there was ever an argument for wearing one of those blasted things, this was it. He must have landed on his head, with the way it is broken there on the right side.”

“That’s what it looks like,” Ronnie agreed. Under his breath he cursed the freaking thing since it alone was most likely responsible for forcing him to have to finish the job in the hospital. Jack Stapleton, unfortunately, whose injury stemmed from an accident, would have to be considered a medical examiner case, and Ronnie couldn’t do anything about it. On the positive side, from a forensic viewpoint, potassium chloride was a perfect agent as it couldn’t be detected, so he wasn’t overly concerned. The only potential problem that Ronnie would have to solve was that the lethal effects of injecting potassium chloride intravenously were almost immediate, meaning the timing and the circumstances had to be taken into careful consideration. Ronnie was aware of this reality all too well, as he’d had more than enough experience in dealing with it. What was going to make it a bit more of a challenge was that Jack would undoubtedly end up in the surgical intensive care unit, where nursing supervision of each patient was significantly more than it was in a private room.