Critical Judgement

"Three hundred joules, please...Keep pumping..."

Abby Dolan tightened her grip on the defibrillator paddles as she passed them against the front and left side of the man's massive chest. He was in persistent cardiac arrest despite two electrical shocks and medication. His face and upper torso were mottled violet, reflecting inadequate circulation despite the ongoing CPR. Clearly, time was their enemy.

"Ready," said the nurse handling the defibrillator console.

"Okay everyone, clear!"

Abby pressed her thumb down on the square plastic button set in the handle of the right-hand paddle. Instantly, there was a muffled pop and an audible, visible spark from two spots where the paddles and skin did not make perfect contact. The man's body -- 250 pounds at least -- stiffened and arched. His arms snapped upward like whips. Then, just as rapidly, he was still.

"Pump, please," Abby said, checking the monitor screen.

The paramedic, up on a stool for leverage, wiped the contact gel off the man's chest with a towel, set the heel of his hand over the base of the sternum and resumed his rhythmic compressions. For several seconds there was a slashing up-and-down movement of the tracing on the monitor. But Abby knew from ten years of ER work and countless code ninety-nines that the pattern was artifact, not related to any effective electrical activity of the heart.

She glanced up at the code clock started by the charge nurse at the moment of the man's arrival in room three. Nine minutes. So far nothing. Abby had been working in the Patience Regional Hospital for over two weeks now, at once dreading and eagerly awaiting her first code. She had been busy, at times very busy, over those weeks. But no codes. Now it was happening. And "The Professor," as she knew some of the staff were facetiously calling her, was losing.

She looked back at the paramedic who was doing the cardiac compressions. Too mechanical. He was well trained, but he was using the technique he had learned on the CPR mannequin, Resusi-Annie. This was a 250-pound bull of a man. Abby pressed her fingertips into Tracy's groin, searching for the femoral-artery pulse that the paramedic should have been generating. Nothing.

"Harder, Tom," she said. "Much harder. You're not moving enough blood."

"But --"

"Please, I know you feel right with what you're doing, but you've got to do it harder. A little faster, too. That's better. That's it. Good. That's it."

In addition to Abby, there were three nurses, a respiratory therapist, and the paramedic in the room. At St. John's there would often be that many physicians at a cardiac arrest. If the patient didn't make it, at least they all knew that everything that needed to be thought of had been.

"Are those labs back?"

"Three or four minutes, they say."

Abby knew that three or four minutes often meant five or ten. Bill Tracy didn't have that kind of time. She looked down at the dark, stretch-scar-like markings over his lower abdomen, and the fullness of his face. Then she reached under his shoulder and placed her hand palm up at the base of his neck. There was a prominence there, a definite fullness. Over her decade as a physician, she had seen only five or six cases of Cushing's syndrome, but this man certainly seemed like a candidate. The syndrome was caused by a small, benign brain tumor that chemically told the body to produce an excess amount of the hormone cortisol. The tumor itself wasn't usually fatal, but the high sodium, low potassium, and other derangements caused by the cortisol often were.

Abby rapidly processed the possibilities. Without lab results, especially a potassium level, she was running blindfolded. If Tracy had low potassium from Cushing's, none of their resuscitative efforts would work until the abnormality was corrected. If he didn't have Cushing's, if his potassium was normal and she gave him more of the electrolyte intravenously, he would be as good as dead.

"Get ready for another shock," she said, struggling to keep panic out of her voice. "Three hundred joules again. Tom, keep pumping, please. As hard as you can." Just go ahead and shock him, the voice in her head insisted. Do it!

"Mary, I want him to get some potassium right now," she suddenly heard herself saying. "Ten milliequivalents IV."

"But I've never..."

"Please," Abby ordered sharply. "I don't have time to debate this." She quickly filled a syringe. For a moment Abby thought the woman was going to tell her to inject it herself. But no.

"Your potassium's in, Doctor," she said coolly.

"Thank you."

First the paramedic, now the nurse. How many more people would she offend before the code was over? She checked the clock. Almost twelve minutes, plus a few to get Tracy in from the ambulance. Too long for him still to be in ventricular fibrillation. She took the defibrillator paddles, accepted some contact gel from the nurse, and rubbed the two circular steel heads together to spread it out. A negative outcome and controversy -- the last results she would have wanted from her first code in Patience. But then, she would never have been in Patience in the first place if Josh hadn't --

"Okay, stop pumping, please. Everyone clear!"

Forty-five seconds since the potassium. Now fifty. There was no more time. Abby hit the button. Again the muted pop, the single spasmodic contraction of every muscle in Bill Tracy's body, the faint odor of searing skin. And, again, the tracing showed only artifact.

"Resume pumping," Abby said, no longer trying to mask her dejection. No. No, wait. The artifact had largely cleared. There was a rhythm on the monitor -- slow, but regular. Abby felt her own heart skip some beats. "Check for a pulse, please."

"Go, baby," someone murmured. "Go..."

"I've got a pulse," the nurse called out as she pressed down over the femoral artery. Purposely looking away from the monitor screen to remain as objective as possible, she reported what she was feeling in her fingertips. "Now............... now............... now......... now......... now......... now..........now."

The pulse she was chanting correlated perfectly with the monitor pattern. The heartbeats were speeding up; the electrocardiogram complexes were becoming narrower, healthier.

A successful code was everyone's victory. But more often than not, Abby knew, the failures were left to the Doc.

Bill Tracy's horrible, violet mottling rapidly and markedly improved. Tissue throughout his body was getting blood for the first time in fifteen minutes. No CPR, however well performed, could ever measure up to the real thing, Abby was thinking. Now all that mattered was getting him stabilized and praying that his brain had not been part of the tissue too deprived of circulation during that fifteen minutes.

Abby checked the monitor. The encouraging pattern was holding, although Bill Tracy was still unconscious. She lifted his eyelids. Midsize pupils, no wandering eye movements -- both good signs.

At that moment the lab tech arrived.

"His potassium's only one point eight," he announced. "Checked and rechecked. One point eight."

For the first time since the rescue-squad call had come in from the golf course, Abby Dolan smiled.

"Not anymore," she said.