By Allen Wyler
Astor + Blue Editions, LLC Copyright © 2012 Allen Wyler
All rights reserved.
Seattle, Washington Trauma Room Three, Maynard Medical Center Emergency Department
"Is this how you found him?" Robin Beck, the doctor on call, asked the paramedic as she quickly ran the back of her fingers over Tyrell Washington's skin. Warm, dry. No fever, no clamminess. Black male. Age estimated in the mid-sixties. Half open eyes going no where. Findings that immediately funneled the diagnosis into the neurologic bin.
"Exactly as is. Unresponsive, pupils mid position and roving, normal sinus rhythm. Vital signs within normal limits. They're charted on the intake sheet." Breathing hard, the paramedic pulled the white plastic fracture board from under the patient, unofficially consummating the transfer of medical responsibility from Medic One to Maynard Medical Center's Emergency Department.
"History?" Beck glanced at the heart monitor as the nurse pasted the last pad to the man's chest. Heart rate a bit too fast. Was his coma cardiac in origin?
A respiratory therapist poked his head through the door. "You call for respiratory therapy?"
She held up a "hold-on" palm to the paramedic, and told the RT, "We're going to have to intubate this man. Hang in here with me 'til anesthesia gets here."
The tech nodded. "You called them yet?"
"Haven't had time. It's your job now." Without waiting for an answer she rose up on tip toes and called over the paramedic's head to a second nurse plugging a fresh line into a plastic IV bag, "Glenda, get on the horn to imaging and tell them we need a STAT CT scan." Better order it now. The scan's status would be the first question out of the neurologist's mouth when asked to see the patient. Nervously fingering the bell of her stethoscope, she turned to the paramedic. "I need some history. What have you got?"
"Nada." He shook his head. "Zilch. Wife's hysterical, can't give us much more than she found him like this." He nodded at the patient. "And, yeah, he's been a patient here before."
A phlebotomist jogged into the room, gripping the handle of a square metal basket filled with glass tube Vacutainers with different colored rubber stopper, sheathed needles, and alcohol sponges. "You call for some labs?"
"Affirmative. I want a standard admission draw including a tox screen." A screen blood test for coma producing drugs. Then to the paramedic, "Did the wife call 911 immediately?"
He shrugged, pushed their van stretcher over so his partner standing just outside the door could remove it from the cramped room. "Far as I know." He paused a beat. "You need me for anything else?"
"That's it? Can't you give me something else to work with?" She figured that under these circumstances a hysterical wife was of little help in giving her the information needed to start formulating a list of possible diagnoses.
His eyes flashed irritation. "This was a scoop and scoot. Alright? Now, if you don't need me for anything else ..."
She waved him off. "Yeah, yeah, thanks." She wasn't going to get anything more from him now. At least knowing the patient had been treated here before was some help.
She turned toward the monitor. Blood pressure and pulse stable. For the moment.
She called over to the lead nurse. "We got to get some history on him. I'm going to take a look at his medical records."
At the work station, Beck typed Tyrell Washington's social security number into the electronic medical record database. A moment later the "front page" appeared on the screen. Quickly, she scanned it for any illness he might have that could cause his present coma. And found it. Tyrell must be diabetic. His medication list showed daily injections of a combination of regular and long-lasting insulin. Odds were he was now suffering a ketogenic crisis caused by lack of insulin.
Armed with this information, Robin Beck hurried to the admitting desk where Mrs. Washington was updating insurance information with a clerk.
"Mrs. Washington, I'm Doctor Beck ... has your husband received any insulin today?"
Brow wrinkled, the wife's questioning eyes met her. "No. Why?"
Suspicions confirmed, Beck said, "Thank you, Mrs. Washington. I'll be right back to talk to you further." Already calculating Tyrell's insulin dose, Beck hurried back to Trauma Room 3.
"I want 15 units of NPH insulin and I want it now." Let him start metabolizing glucose for an hour before titrating his blood sugar into an ideal level. For now she'd hold off calling for a neurology consult until assessing Washington's response to treatment.
"Mama, what's happened to Papa?"
Erma Washington stopped wringing her hands and rocking back and forth on the threadbare waiting room chair. Serena, her oldest daughter, crouched directly in front of her. She'd called Serena—the most responsible of her three children—immediately after hanging up the phone with 911.
"I don't know, baby ... I just don't know." Her mind seemed blank, wiped out by the horror of what life would be like without Tyrell.
Her daughter reached out and took hold of both her hands. "Have the doctors told you anything yet?"
"No baby, nothing."
"No, wait ..." Amazed that she'd completely forgotten. "A lady doctor came, asked had Papa been given insulin today."
"Insulin? Why'd she ask such a thing, Mama? Papa doesn't take insulin!"
* * *
"Doctor beck, come quick. Room Three's convulsing."
Robin bolted across the hall to Washington's room. The man's limbs were locked in extension, pressing the stretcher side rails out, jaws clamped shut, saliva bubbling out between upper front teeth. From across the room he heard the raspy stridor of a compromised airway. Luckily, the nurses had left the center restraining strap pulled snugly across his belly. A pool of sickening acid settled in Beck's stomach. She'd missed something. Either that or she completely miscalculated the insulin dose.
She yelled to the closest nurse: "Ten milligrams Valium. Now," then muttered, "Shit, where's respiratory when you needed them?" To a nurse just entering the room, she yelled, "Get some nasal oxygen on him." She looked at the suction to assure herself it was hooked up and functional. All she needed now was for the patient to vomit and aspirate. The best thing, she knew, was to turn a seizing patient on his side so fluids would run from the mouth instead of down the trachea into the lungs. But with his arms rigidly straight this would be impossible.
The cardiac monitor alarm rang with a slicing shrill.
Beck saw a flat green line streak across the screen and yelled, "Get a crash cart in here!" She slapped the red "Code 199" wall button, scrambling the medical center cardiac arrest team from whatever parts of the hospital they were presently working.
Oh Christ, not again, thought Gail Walker. Two migraines already this month and the spots in her vision that signaled her typical onset were dancing again. She believed they were triggered by the recessed fluorescent ceiling lighting throughout the Intensive Care Unit. She'd considered requesting a transfer to another nursing service but loved the action of this surgical intensive care. There were other ICUs in Maynard Medical Center, of course. Neonatology and cardiac, for example. But she hated seeing newborns and preemies in heated incubators, with four to five tubes sticking out of their wrinkled little bodies. The cardiac care unit depressed her, reminding her of her own mortality and the incremental age each day checked off of her life. From the fanny pack around her waist she withdrew and then dry-swallowed a pill. Catch those suckers soon enough, chances were you could abort them.
The centrifuge beside her stopped. She removed the small capillary tube and placed it against a chart. The deathly pale 32-year-old real estate broker—one of Doctor Golden's stomach bleeders—now had a hematocrit of 18. Too low. Not unexpected. Especially since a half-hour ago he had discharged a large amount of foul-smelling black tar into a bedpan.
From the little ICU lab she stepped into the nurses station and found a free computer terminal. On the wall above her left shoulder hung the white board—in spread sheet form at—listing each room, each row stating the patient's name, admitting physician, and assigned nurse. She double checked the patient's orders on the electronic medical record. Just as she thought: she was to give him two units of packed red blood cells if his hematocrit dropped below 20.
With another few key strokes she ordered the two units of red blood cells from the blood bank and marveled at how much more efficient this sort of task had become since MMC had installed the new Med-InDx Computerized Information System—or CIS, as the IT techies called it. The electronic medical record, or EMR, was just one component of the entire CIS system.
Ten minutes later two clear plastic bags of red blood cells arrived on the unit. With a scanner similar to those used by grocery clerks, she verified the bags as those typed and crossed matched for her patient. Before the advent of the Med-InDx CIS, this job would have required another nurse to cross validate the blood. Now the task could be done in a fraction of the time with absolute accuracy. God bless technology.
She entered the room and asked, "How you feeling? Still short of breath?"
The pale man turned his head to her. "Man oh man, it seems like it's getting worse."
"That's because you're anemic." She held up the bags of red blood cells for him to see. "Once I get these into you you'll be feeling much better."
With both bags of packed cells dripping into the patient's IV, Walker checked on another patient—a post-op open heart who'd probably thrown a blood clot to his brain during a coronary artery bypass operation to unclog three Big Mac encrusted arteries—where she ran through an NIH stroke assessment and recorded it into the chart.
An alarm from a cardiac monitor shrieked.
She glanced at the row of nursing station slave monitors, did a double take. What the hell? Her patient. Golden's GI bleeder. Shit, what happened?
She raced around the corner of the desk to join the flock of nurses and doctors funneling into the room.
January, the following year
"It's been the shift from hell. I'm outta here."
William Thornton threw a mock salute to the nurse he was replacing. "Have a good one."
Walking past sliding glass doors to a string of patient rooms in the MMC Cardiac Care unit, Thornton began mentally organizing the next sixty minutes of his ten-hour shift. He stopped outside room 233. As an RN he had responsibility for three CCU patients instead of two—a thin staffing pattern brought about by the nursing shortage. A staffing pattern the administration deemed acceptable because of using nursing assistants as extenders. A practice Thornton knew the nurses' union intended to make a hot issue during the next round of contract negotiations.
Might as well start by making rounds on the patients, he decided. Tablet computer in hand, he entered room 233.
"Hello, Mr. Barker, I'm Bill Thornton." He reached out to feel the 55-year-old man's pulse, an unnecessary move since he could read it off the monitor, but one he knew personalized the contact. "How are you feeling?"
"Bored. Why the hell can't I have a TV in here?"
Thornton scanned the patient's vital signs. Heart in normal sinus rhythm, blood pressure 144/76, pulse 78. Color good, patient responsive.
"Don't want to get you excited. Not for a day or so." He already knew Barker's story but asked, "Tell me what happened to you?" to test his memory.
"It was the damndest thing, I'm down in my basement workshop—I do wood working you know ... furniture, pretty good stuff too, if I do say so myself—when I get this chest pain." His right hand massaged his left breast. "Just like what they tell you? Ya know, like a fucking elephant stepping on my shoulder. Well hells bells, I knew exactly what it was. Scared the bejesus outta me too. I didn't want to move so I called my wife and she called 911. Doc says two of my arteries were almost completely shut down."
Thornton nodded approval at the story. "But that's all taken care of, right?"
"Except for the fact you're still having some irregular heart beats." An understatement. Barker was still on high-dose IV medications for life-threatening arrhythmias.
With his notebook computer, Thornton logged into the EMR and checked Barker's medication schedule. To his shock he noticed the nurse he just relieved had neglected to give a critical anti-arrhythmic medication. Horrified, he moused the pharmacy tab, double clicked on the medication, then clicked STAT.
"Matter of fact," he said, trying to mask any anxiety from his voice, "you're due for another dose of medication right now. I'm having it sent up right away."
Ten minutes later Thornton returned.
"You're in luck, Mr. Barker," he joked. "The pharmacy still carries this." He held up a syringe of clear colorless fluid, squeezed out a drop of air, and injected the drug into the IV port.
Finished, Thornton dropped the empty syringe in the wall mounted "sharps" container just as the cardiac monitor began shrieking. He turned to see the tracing go flat-line.
January, one week later
For the first time since starting their discussions, second thoughts began eroding Sergio Vericelli's confidence. It wasn't the proposal evoking the toe-nail nervousness that had started creeping up in waves from his feet up to his chest, filling his gut with a tightness. It was the man sitting across the small bistro table from him.
He realized the man had asked a question. "Sorry, I became distracted. You will repeat it?"
A flicker of irritation in the man's penetrating dark eyes broke the emotionless mask he wore so effectively. "How would you like to receive the money? I suggest it be wired to an off-shore account. I assume you have one?"
Sergio studied the man's face for a hint of what disturbed him so. Chiseled, rugged features that he supposed women found handsome. From his perspective the only mar was a shock of white from the widow's peak—a contrasting streak against black hair combed straight back. A flaw Sergio would have taken care of if it were his. Maybe there was nothing sinister there at all, he decided. Maybe his nervousness was nothing more than the muffled voice of his conscience shouting to be heard above the cacophony the hundred thousand dollar offer caused. An additional fifty thousand, if all went as planned.
"No, but I will open one tomorrow."
Sergio realized he'd just moved one step closer to consummating the deal. Did he really want to do this? He thought of childhood stories of men who made pacts with the devil. But this is not the devil, he reminded himself.
Are you very certain of this? Do you know this to be fact?
Sergio Vericelli felt a shiver snake down his vertebrae spine only to be chased away by the thought of what $500,000 would buy.
"Excellent. Then we are agreed?"
Sergio swallowed only to find his mouth dry. "Agreed."
The man with the shock of white hair held out his hand.
A primitive gut-level fear caused Sergio to hesitate a beat before clasping the dry, warm flesh. But the moment the other man's fingers wrapped around his, dreams of further riches smothered those fears.
August, Seattle, Washington, McDonalds Restaurant
Larry Childs wiped sweat from his brow with the back of his forearm and tried to ignore the pounding in his temples. It was hotter than hell behind the grill, the smell of sizzling fry grease cloying, nauseating him more and more. Suddenly, bitter, bilious gastric acid shot up his esophagus. He swallowed what he could but a small residual burned the back of his throat. He remembered the dark olive, vile gunk spewing from his mouth ten minutes ago as he had bent over stained, urine scented porcelain. He gagged again at the mere memory. This time a bolus of stomach juice shot upwards, rushing toward his mouth so fast he knew he wouldn't make it to the john. Eyes wide with fear, right hand clamped against gritted teeth, he frantically scanned the greasy work area for a waste basket.
The warm liquid hit his palate with the force of a home run. Both knees buckled. His vision dimmed. His right hand shot out, connecting with something solid. With his lips and hand forming a tight barrier, the path of least resistance became his nose. The sickly green fluid spewed from both nostrils onto the hot grill. (Continues...)
Excerpted from Dead Errors by Allen Wyler. Copyright © 2012 Allen Wyler. Excerpted by permission of Astor + Blue Editions, LLC.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.