Compromised, page 28
part #1 of MetroGen Forbidden Love Duets Series
The tech finished cutting off the man’s white shirt and black blazer with the insignia of CCFD. The charge nurse had his information up on the computer. “Works at the fire department. History of appendectomy, several broken bones, not in our system because he moved here from Manhattan. Social history says he was a 9/11 first responder and is married with three kids.”
Angela didn’t like the way the heart rate was flirting with a rate of 120 as they put her lead apron and then the sterile gown on. “Guess I’d better get to this now since he’s died twice.”
Technically, the attending was supposed to be in the room. However, they also needed to meet the ninety-minute to cath window, and time was tissue.
“Russell Taggert, 63, presumed STEMI based on EKG and cardiac arrest. We’ll begin on the left side.” She threaded the catheters through his right radial artery and reached the aorta easily. She hit the dye and found the left side coronary arteries remarkably clean. The mild stenosis in the basal branch of his left anterior descending coronary artery didn’t explain his cardiac symptoms. Anterior septal wall MIs were rare in isolation.
Then his heart rate started to climb again.
“We have sinus tachycardia,” her nurse warned her. “Still climbing, over 200. Pulse ox still 93 percent.”
“He’s going into v-fib,” Angela called out. “Get me 1 mg of epi and slap the defib pads under the drape.”
The tech did as commanded, placing the pads around the cardiac telemetry monitors Taggert already had in place.
“Epi is in,” the nurse announced. “No change in rhythm.”
“Hit him with 200 joules,” Angela ordered, lifting her hands away from the sterile field. “I’m clear. Everyone clear?”
“Clear,” the nurse confirmed, and their defib’s whine reached a crescendo before delivering the shock.
The heart snapped back into sinus rhythm. The ease at which they got him back again should have been reassuring. However, he had three strikes against him now.
She redirected the cath to the right side of the heart.
Damn. No blockage on the right either.
Angela cleared her mind. The patient wasn’t having an anterior septal heart attack. This wasn’t an anatomic variation if the right coronary arteries were clear. Which meant a different condition was causing his arrests.
Pulse ox wasn’t reliable when the heart wasn’t beating correctly to judge oxygen content in the blood. His cardiac electrolytes were normal, and his blood gas was nonspecific.
He did have tachycardia.
“Show me the pictures of the right coronary arteries again.”
Her tech displayed the images on the computerized screen and played the insertion of dye in real time. “Clean as a whistle.”
“Play it again,” This time Angela ignored the dye and focused on the motion of the heart itself.
“Still clear.”
“The right ventricle is overstretched and not contracting enough.”
“I don’t understand,” the tech said.
“We’re pulling out of the right side. Prepare for a pulmonary artery angiography, and I need a Flowtriever suction catheter from the vascular lab. Call the ICU and tell them to prep clot busters and the ECMO perfusion team. Find me the cardiothoracic surgeon on call.”
“The ECMO team?” the tech asked.
Before Angela could explain, Mr. Taggert’s heart rate sped again and went into v-tach.
“Epi 1 mg again,” Angela ordered. “He has a pulmonary embolism blocking the blood flow to his lungs. He’s supposed to get the pulmonary angiogram in CT, but he’ll never make it. We’re doing a suction embolectomy here. Start compressions.”
The CRNA began compressions, leaving the patient on the ventilator. The sterile field was screwed right now.
“Hit him with 360,” Angela commanded, and the CRNA got out of the way.
The 360 did it, this time.
Angela went to the right groin and poured the closest bottle of beta-dine on his femoral vein. In a perfect world, they’d have done extensive prep and shaving of the area to minimize infection.
However, who gave a crap about infection when the patient was dead?
The tech brought her over the requested instruments on a tray and a new set of gloves.
“Have you ever done this before?” he asked.
“A few times during residency. In the animal lab,” Angela said, threading the femoral vein. She expected to find at least one of the pulmonary arteries fully blocked. He’d have died in the field if both were compromised, though it was likely the clot grew with every heartbeat.
“You’re sure about this?” the tech said.
“The EKG lied to us,” Angela said, recognizing the tech wasn’t doubting her diagnosis so much as he was completely unfamiliar with the procedure. “I’m going to hit the right side with dye, and then when we see where the clot is, I’ll use the Flowtriever to suction it out.”
“We don’t have an attending,” the tech said.
“I’d love an attending here. I’d love cardiothoracic surgery to be here for a surgical embolectomy. Too bad all he’s got is me, and this cat doesn’t have nine lives.”
The screen captured her catheter making its way past the right atrium and into the right ventricle. She was about to call for the dye when someone tapped on the observation window.
It was Dr. Marshall and Pegg. “What the hell are you doing?”
“I’m about to do a suction embolectomy. Good of you to join us.”
“We were in a different cath!” Pegg shouted at her.
“Yeah, I did this one solo, and his arteries are clear.”
“You can’t know he has a PE,” Dr. Marshall protested.
“Cath showed the right heart strain, and look. Dye, now.”
The tech hit the dye and, as anticipated, the clot was there.
Except it was much bigger than she’d expected.
“Holy fuck,” Pegg said. “Saddle embolism, how is this guy alive?”
A saddle pulmonary embolism was a clot that blocked both pulmonary arteries. If no blood went to the lungs, those lungs could pass no oxygen into the blood, and the left heart couldn’t pump as it died of oxygen deprivation.
“I’ll be damned,” Dr. Marshall said. “Really gutsy, Perkins.”
“I’m trading out for the Flowtriever now. You coming to do it, sir?” Angela pulled the angiocath back because she’d have to use the Flowtriever, a much larger instrument. They’d need every ounce of power it provided.
“Sure, but I’ve never done a suction embolectomy,” Dr. Marshall said.
“She’s done like six,” the tech helpfully lied.
“Then I’ll be the assist,” Dr. Marshall said.
The Flowtriever took considerably longer to navigate into position. Dr. Marshall gave her encouraging advice as she made her way past the cardiac valves.
“I think I’m in position. Deploying the Flowtriever. You have the manual suction?” she asked Dr. Marshall. The Flowtriever did more than suck up clot. It had ‘baskets’ which caught and pulled the clot backward. It was up to her assistant to use the syringe for the pressure.
“Do you think you’ll get it all?” Marshall said, dropping a good four inches of clotted blood into the towel.
“Doesn’t have to be pretty and doesn’t have to be every bit. Just has to be enough so he doesn’t die.” Angela said. “Moving to the right side.”
“His pulse ox is coming up, and his heart rate is slowing,” the CRNA reported.
“A few more seconds before I’m in position,” Angela concentrated. The patient was unlikely to bleed out here unless she punctured his artery with the catheter.
Which would be bad.
She deployed it again and suctioned out another big hunk of dark, congealed blood.
“Time for dye?” Dr. Marshall suggested.
“Good idea.” Angela nodded for them to hit the dye and waited expectantly.
The whole room breathed a sigh of relief to see the dye get taken up by both arteries, disappearing into the blood vessels of the lungs.
“Damn it, you did,” the tech said.
Finally, letting out the breath she’d been holding for the past thirty minutes, Angela relaxed. “Wow. Cancel the ECMO for now. And let’s get him a bed in the ICU. I drew enough blood here to run some labs and figure out why this happened.”
“He’s thinner than most of our patients. No hardware? No long plane ride, chronic smoker, and recent surgery?” Dr. Marshall referenced Virchows Triad as the traditional causes of pulmonary emboli—immobility, vessel injury, and hypercoagulability.
“He’s a firefighter here in the city. Supervisor, it seems. Don’t think he got enough smoke to count today.” Angela made a few guesses. “Leaning toward malignancy. When he gets to the ICU, make sure they ultrasound his legs. Might have a bunch of other smaller clots.”
A different nurse stuck her head through the door. “Mr. Taggert has… people out here. Sounds important, the Fire Chief. Who’s gonna talk to them?”
Dr. Marshall waved her away. “Go, I’ll work on the transfer. You did the hard part. Good job, Perkins.”
She hung up her lead apron but didn’t bother removing her mask or scrub cap. Mr. Taggert was having a bad day. With his bad luck of the day, he’d probably code, and she’d be forced to crack his chest in an elevator or some other ridiculousness.
Best ward off the bad luck.
She might have been wrong, and Mr. Taggert was the luckiest bastard on the planet. How many guys have a sudden cardiac arrest with an anesthesiologist nearby? Getting CPR, cardiac drugs, and intubation in the field probably saved his life.
And then she saved his life. In front of her Chief.
Sometimes being a rockstar was awesome.
Her mood changed when she remembered the city wide emergency.
Usually she wouldn’t share much HIPPA, but certain rules could be suspended if it was a matter of other people’s lives.
She headed out into the hallway and met the Fire Chief.
He was a foot taller than her, eyes bright blue, and emanated a manner of intensity one could find overwhelming. His aide behind him was positively cowed.
Still, the Fire Chief did seem vaguely familiar. Had she met him in the past?
“I’m Dr. Perkins. How can I help you?”
“I’m Fire Chief Noah Baker. I need an update on Russell Taggert’s clinical condition. We’re in the middle of a possible domestic terrorism incident, and he’s the lead investigator as Fire Marshal. Did he survive his heart attack?”
“Yes, but he didn’t have a heart attack,” Angela stopped him.
“He didn’t? Was he attacked? In an explosion? Poisoned?” the Fire Chief fired off.
“It’s been a weird day,” the aide added.
If they hadn’t been dead serious, she’d have had doubts about their sanity. “No, he’d be in trauma surgery if those things happened. He had a pulmonary embolism. It’s a blood clot in the arteries to his lung. It looked like a heart attack but wasn’t. He died on the table several times. We’re moving him to the ICU right now.”
“Any chance this could have been a deliberate act?” the Chief asked.
Stranger and stranger. “No, it’s not possible to deliberately give someone a pulmonary embolism. However, we don’t have a cause yet.”
“And?”
“Pulmonary embolisms are caused by a combination of not moving around in the setting of higher-than-normal clotting situations, like surgery or cancer. His chart said he was at Ground Zero. His risk of cancer is higher than average.”
The Chief sighed, “Any way I can speak to him?”
She snorted since he was asking the impossible, “He’s unconscious and under sedation, and I don’t know if he’s going to stabilize.”
“What are you saying?”
“I’m saying that fifteen minutes ago he was dead, and we were damned lucky to get him back. We’ll be even more lucky if he survives the night and a miracle if he’s intact!” She might have been a little tough on him, but she didn’t need another person questioning her skills. Pegg had been obnoxious enough.
“I deserved that.” The Chief scrubbed a hand across his face, and Angela realized what she had assumed to be shadows from the lights was actually soot. “I’m sorry. My people are dying. We had to evacuate headquarters. Marshal Taggert is my most experienced investigator and head of our arson task force. No one else has the information he did… does.”
He sounded so lost, so Angela patted his elbow and made an obvious suggestion. “No one else has the information? Copies? Our doctors are on a call schedule, and after sign out, we use the medical chart to fill in the blanks.”
“Actually, someone else does have the information,” the Chief said.
“The police?” the aide suggested.
“Yes and no. There is a police section in the task force, but I bet Reyes had every breathing officer on the street two hours ago.”
“So, not the police?” the aide asked.
“No, let’s get moving.” The Chief pivoted back out and didn’t even bother to say goodbye to her. She had her job, he had his.
Chapter 51
After seeing Angela off, Michael couldn’t get into a deep sleep. He woke up around noon, dreaming about fire. Taussig was asleep, so he tried to rest. If he started scrolling through his phone, he’d get no rest.
When he woke up around three, he swore he smelled smoke. It wasn’t his imagination because the acrid scent was in the air. Taussig didn’t like going outside, and Michael wondered what was burning.
This time he turned on the TV and saw there had been a dual arsonist event at a strip mall and the Atlantis distribution warehouse. Various members of police and fire were on TV, giving updates and encouraging non-essential personnel to stay home. Interestingly, they did not have a description of an arsonist, though any suspicious packages or burning material were supposed to be reported.
By five pm, Michael couldn’t stand it anymore. He took Taussig outside one last time and made his way to the hospital. Judging by the mess of the Atlantis warehouse, he couldn’t imagine they weren’t getting slammed with smoke inhalations in the ICU. The banner at the bottom mentioned at least three confirmed fatalities.
The ICU was full, and Raj and Nora were working six charts each. Every room was full and the patients were getting hallway beds with respiratory monitors, similar to what they had in the ER.
Nora spoke in a rapid fashion, “We’re babysitting eight Atlantis employees and four firefighters on the smoke inhalation protocol. We’re supposed to do q 30 min airway checks.”
“Twelve patients. Got it.” Michael took the charts. “I’ll start the transition to night shift now.”
Raj added, “They have several new intubated patients, and we’re not taking care of our regulars today.”
Then Nora dropped her voice. “Two firefighters are not in good shape. One of them was my COPD patient. They don’t think he’s going to make it. His niece is one of the firefighters who had smoke inhalation.”
Michael took over the patients before the night shift arrived and acted as a runner to restock rooms. In situations like these, the medical students were limited because they couldn’t write orders, make med adjustments, or change ventilator settings. They became more helpful pairs of hands, which were better than nothing.
He saw Dr. Varma from afar, the captain of the ship and whirling dervish of activity. Dr. Steadman came through a few times, and did a brief check on each of Michael’s patients, writing for basic burn care.
Somewhere in the unit, a patient coded, but Michael couldn’t leave his patients. Twelve airways were more than a medical student typically handled. Most of them would finish their monitoring over the next few hours and move to regular beds.
Then it came time for Michael to check on one Luna Rodriguez, a firefighter and niece of Mateo Soto. It certainly was the same Mateo Soto he’d met in October back in family medicine.
It was easy to see why Ms. Rodriguez wasn’t in the hallway. Mateo Soto was going down.
A huge Black man and a red-headed woman sat with Luna. A Latina woman in the uniform of Cleveland PD guarded the bed.
Soto’s breathing was labored, and he was on a humidified non-rebreather, the most oxygen they could deliver without removing the ability to speak. Even with the support, his stats barely stayed above 75 percent.
Only one blood gas was written on the board, and its time indicated it was over six hours old.
If Michael hadn’t been convinced before, he was convinced now. When making ventilator adjustments, blood gases were checked around every thirty minutes. The human body kept the blood pH around 7.4, and the rest of the blood gas broke down into oxygen and carbon dioxide, indicating respiratory status and the bicarb buffer. As the respiratory system failed, the carbon dioxide climbed, the oxygen fell, making the blood increasingly acidotic.
Soto’s pH was 7.28/88/105/27. The numbers were not compatible with life. It was only a matter of time now.
They could have pummeled him, intubated him, tried to be more aggressive. It was possible to buy hours at the greatest of cost to the time he had remaining.
The big man next to Ms. Rodriguez wrote something down and handed it to Michael.
We need a priest. A wedding and last rites. Latin. Isadora Reyes and Mateo Soto. - Captain Jacen Williams
Michael bobbed his head in acknowledgment. He hoped his eyes said it would be done.
He went out into the hallway and was able to find Dr. Varma. It took a little time to get her attention.
She had seen which room he exited, so she sighed and beckoned him forward. “Yes, Harper?”
“The Soto family wants a priest. And the emergency affidavit for marriage.”
“A marriage?” She glanced up at the master board of the vitals. “Better be soon.”
“How much time?” Michael asked.
“Less than an hour,” she acknowledged. “We lost the other fire captain ten minutes ago.”
Which explained the code Michael had missed. The next code wouldn’t be for Soto. “Where’s the Chaplain?”
