Max managed a half smile. “Kid, you know my stats better than me.”
Trevor blushed. “I doubt it.”
“Your mom’s taking good care of me. You being cool with her?”
“Yeah, pretty cool.”
Julie set a damp cloth against Max’s forehead to soak up some of the perspiration. The saline arrived and a nurse went to work getting the bag hooked up. After scanning his body head to toe, Julie double-checked Max’s lines and glanced at the screen of the dialysis machine. She kept an even keel as she ran through her list, conducting a rapid-fire differential diagnosis in her mind.
Two-port line for the dialysis catheter seems okay… no signs of bleeding there… dialysis machine says the blood flow is appropriate… no blockages… lines don’t appear to be stuck against a blood vessel wall…
In the middle of her exam, Max’s BP crashed.
“BP is down to seventy-five!” the monitoring tech called, talking only about the systolic reading, a common practice during an emergency.
A loud beeping startled Trevor. For a few seconds nobody moved, no sound other than the incessant churning from the dialysis machine as it cleaned Max’s blood. Trevor moved back a few steps as Max let out a soft moan.
Julie felt her pulse quicken.
“Trevor, please wait in my office.” There was no room for negotiation. Trevor departed with haste.
We’re giving him fluid, max vasopressors, lowered dialysis, and he’s still shitting the bed…
A monitoring nurse out in the hall yelled, “Hey, is anybody seeing this? The BP in room fifteen is dropping like crazy.”
Lisa yelled back, “Yeah, we’re seeing it!”
“When was he last fine?” Julie asked Lisa. “Was he okay after the line went in?”
“Yeah, he was fine then,” Lisa said. “Then the nurse turned on the dialysis and he got worse, so she turned down the flow, thinking that would help.”
Max took several short, sharp breaths that barely moved air, and let out another moan. Julie eyeballed the monitor, taking in the oxygen saturation reading, and saw it was within the normal range. She reviewed Max’s heart rhythm as measured by the telemetry and noted an increased heart rate that often accompanied episodes of low blood pressure. The rhythm in his pulse gave no indication of any cardiac trouble. The usual culprits appeared not to be at play here.
What the hell is going on?
Julie slipped her stethoscope into her ears. She listened carefully for the telltale rubbing sound that signals when renal failure causes fluid to build up in the sac around the heart, essentially squeezing the life out. She heard the fast lub-dub of Max’s heart racing to send blood to his vital organs.
“Did you get a chest X-ray?” she asked Lisa.
“Yeah, we did the X-ray,” Lisa said. “But it hasn’t been read yet.”
“Dammit,” Julie said. “Well, get someone to read it, will you?”
Setting the diaphragm of the stethoscope on Max’s back, Julie gave a careful listen to the chest posteriorly. Next, she put it near the armpit, and then to the front of the chest, hearing bilaterally symmetrical breath sounds. Even with those normal sounds, Julie could not rule out the possibility that the insertion of his central venous catheter might have caused a pneumothorax. If air were leaking into the space between the lungs and the chest, it would explain Max’s hypotension. She needed those X-rays pronto.
Lisa soon returned, while Julie continued to listen with her stethoscope. A second nurse and a monitoring tech also entered the cramped quarters.
“We got a rush on the read,” Lisa said. “I’m trying to pull it up on the computers, but the system is down for maintenance.”
“Damn computers,” Julie muttered.
“They said it won’t be long before the system is back online,” Lisa said. “We can try to get it from the backup.”
“No, by then the main system will be back. Did he ever spike a fever?” Julie asked.
“It’s been gradual,” Lisa said.
A series of alarms sounded louder than any previous alerts. The BP monitor rang loudest and grew in volume as Max’s blood pressure sank lower, to sixty-two.
“Should I call a code?” Lisa asked.
Julie had been thinking the same herself.
She needed that damn radiological read.
Julie’s composure began to fracture. The code blue seemed a likely course of action. She shot Lisa a fierce look.
“Get someone to call down to radiology and tell them we need that reading now! Fix whatever they have to fix, but get me that read! Lisa, tell me again, what dose of Levo is he on?”
“Thirty micrograms,” Lisa answered.
“Are you sure that’s the right stuff?” Julie asked.
Lisa looked at the bag and nodded.
“We’ve already given fluid,” Julie said as the calm returned to her voice. “Let’s get a second vasopressor going. This time use vasopressin.”
You are not going to die, young man. No way!
Max was groaning incoherently and sweating profusely. Lisa got the new medicine hooked up while the second nurse left the room to call radiology. She returned a few moments later.
“The system is back online. Radiology said no pneumothorax,” the nurse said, glancing at her note. “‘New dialysis catheter in place adjacent to previously seen subclavian line.’”
This struck Julie as odd. Typically the catheter for the vasopressors and the one for the dialysis would have been positioned opposite each other. There was a computer in Max’s room, and this time Julie was able to pull up his X-rays and read them for herself. The frontal X-ray showed that the lines were in fact overlapped, easy for her to see.
“BP is fifty-nine!” the tech reported. The alarms were really going.
Julie looked at Lisa. “Why did the radiologist put the dialysis line on the same side as the subclavian line for the vasopressors?” she asked.
Lisa thought before answering. “Max had a broken collarbone that ripped the subclavian vein, so that’s why they switched to the right. They capped the port and he was fine.”
A thought tingled. “Fine until when?” Julie asked, an edge to her voice.
“Um, for a while after we started the dialysis. I don’t know exactly how long.”
Julie studied those lines on the X-ray once more. It was uncommon but not unprecedented for the two catheters to be on the same side of the body. In optimal placement the catheter tips would be right next to each other, but on Max’s X-ray Julie observed a noticeable gap between them.
The image called up a memory of a time she ran out of gasoline while on a long ride with Sam. To get her bike started, Sam had to siphon the gas from his tank into hers using a tube he carried in a satchel for just such emergencies. The siphon did not function at all until Sam got the tube positioned properly, but once he did, the suction it generated was impressive.
Max was fine for a while after we started the dialysis… after…
Julie felt a surge of excitement. She had never encountered something like this, but those cath lines might be positioned in such a way to create a siphon inside Max’s body. If that were the case, the blood filled with the vasopressors needed to keep Max’s blood pressure up during dialysis was being siphoned into the very machine that was purifying his blood, removing all traces of the medication he needed.
“Shut off the dialysis!” Julie barked. “Shut it off right now! This is not the time to be dialyzing our patient. That can wait!”
“BP is fifty-five!” the tech called out.
Max’s eyes rolled back into his head and his mouth fell open as he became unconscious. All sorts of alarms continued to sound, and several more nurses and two residents rushed into the room.
With the push of a few buttons, Lisa shut down the machine. Almost immediately, Max’s blood pressure spiked to seventy. Then seventy-five.