“But, Jim, she needs a better blood count to stop the heart attack, which won’t happen unless you get in there and stop the bleeding.”
“Seriously, Julie, this lady is a train wreck. I don’t need the quality safety committee after me when she dies from the colonoscopy. Call interventional radiology, I think Kim is on. She’ll help you.”
Julie picked up the phone and was connected to Dr. Kim Sung in interventional radiology. Arrangements were made and soon enough Shirley was carted off to radiology. After two hours, Julie took a call from Dr. Sung.
“Hey Julie, I tried my best. I coiled a couple of places, but she is oozing everywhere. She’s like a pincushion. Nothing seemed to help. I think you’ve got to get surgery in on this. I have a page for you. Sorry I couldn’t get it done.”
Julie thanked Dr. Sung for her efforts, but had her doubts about the surgery. If GI would not consider a colonoscopy because of Shirley’s cardiac and pulmonary risk factors, it was likely she would get even more pushback from surgical consults.
Only one option remained-Shirley would have to stay in the ICU, get drugged up, get more swollen, and deal with the pain and bleeding as it came and went like the tides. Julie could provide little in the way of meaningful therapy.
Shirley was brought back to the ICU and awake when Julie checked up on her again. Her eyes were open, but dull as if they were covered with film. Her short hair lay matted and without luster. Her lips were two bloodless threads on a starkly sallow face.
“Shirley, how are you holding up?” Julie asked.
“I want to die,” Shirley managed to say in a weak, gravelly voice.
The words hit Julie hard, and of course she thought of Sam.
“Well, we don’t want that to happen,” Julie said.
“I do. The pain is horrible. I want to be with my Bobby. I want to go with him.”
Bobby was Shirley’s husband of fifty years. There were children and grandchildren in the picture, some now in the waiting room, but in this condition Shirley took no joy from them. Everything hurt, and hurt horribly.
Julie locked eyes with Amber, the young nurse who had cared for Shirley the last time. Shirley’s predicament was indeed dire, and Julie believed the sick woman was justified in her wish to end her suffering. All Julie could do now was manage the pain with a little help from Dilaudid.
While conducting her exam, Julie noticed significant erythema on the back of Shirley’s left hand ringing the 18-G IV. It had not been present at the last check. The red inflammation looked similar to Sam’s outbreak of hives, but distinct enough for Julie to know it was not the same condition.
“How long has she had this redness?” Julie asked Amber, a tinge of concern in her voice.
Amber looked at Julie, a little flummoxed. “I just noticed it now,” she said.
Julie called for a stat surgical consult and while waiting, began her procedures. She placed an internal jugular central venous access line and right radial arterial line. Shirley would need aggressive resuscitation for hemorrhagic shock using fluids and pressors. A full panel of lab work was repeated. Results came back fast, and one got Julie’s attention right away. Shirley’s blood gas reading showed her oxygen level was now below sixty millimeters of mercury, which meant respiratory failure. Shirley actually looked worse than her blood gas indicated. She was pale and sweaty, mottled on her arms and legs. Julie called out to the staff: “We need to intubate in here!”
Additional nursing staff charged into Shirley’s room. Tammy, the respiratory therapist, began bagging Shirley with an ambu bag while Julie set up her endotracheal tube. One nurse was drawing up etomidate and another busied herself with the suction tubing.
The intubation went as smoothly as expected given the circumstances. Shirley was heading toward unconsciousness and very little sedation was needed. Her blood pressure, however, tanked, as usually happens after an intubation, and additional boluses were given.
The surgeon, a handsome man with a Harvard pedigree, finally arrived to do his assessment.
It’s about time, Julie thought.
He was immediately distracted by Shirley’s arm.
“Julie, good thing you called. Looks like she has a NSTI infection.”
Necrotizing soft-tissue infections were increasingly more common at hospitals everywhere, for reasons Julie could not quite fathom. Poor woman. Not only did she have hemorrhagic shock, but septic shock as well. One hour later, Shirley was on her way to the OR for emergency debridement, a procedure she was deemed fit enough to survive despite her fragile condition. The timing of Shirley’s departure coincided with the end of Julie’s workday, but she was not headed for home. She had a stop to make first.
MCI Cedar Junction.
LUCY FOUND Dr. Becca Stinson with her eyes pressed against the lens of a microscope. She tapped the young resident on the shoulder, which caused a bit of a scare, but got her attention.
“Becca, do you have a minute?” Lucy asked.
The question was rhetorical. Everyone always had a minute for the boss.
“Yes, of course,” Becca said.
Lucy brought a clipboard that held printouts with the lab order for Sam Talbot’s stains. She handed the clipboard to Becca. “Do you recall doing these stains?”
As part of their training, residents learned the equipment and procedures by doing tests typically handled by the lab techs. For Becca and her peers, processing stains and reviewing path slides was as common a practice as checking e-mail. Equally common were long hours without sunlight. Lucy noticed Becca’s peaked complexion and how her wide eyes had rings around them, a mark of too many hours gazing through a microscope. Lucy brought the paper trail of Sam’s extensive lab tests, hoping a quick review would refresh Becca’s overtaxed memory.
“This is Sam Talbot, Julie Devereux’s husband, right?” Becca said, while leafing through the pages.
“Fiancé,” Lucy corrected. “And yes, that’s right. I was wondering if you remember anything about the stain.”
Becca’s expression went blank. “Like what?”
“Specifically if the eosinophils in the stain showed up pink.”
Becca strained, trying to recall.
“I think that’s right. It was a long time ago, though. I thought I had put something about allergic reaction in my lab report, but it’s not what’s indicated in the report you handed me, so I guess I’m mistaken.”
“Take a look at this, then. It’s the actual slide.”
Lucy went to the digital slide scanner and in no time had the slide of Sam’s heart on the display screen for Becca’s review. It was the same image Lucy had studied in her office after the autopsy and again moments ago. A sea of purple dots covered darker patches to indicate denser tissue morphology. Each slide was like a little painting, and Lucy found the variations, the differing contrasts, and abstract shapes endlessly fascinating. Like paintings, each slide had a story to tell, but the interpretations were seldom subjective. White Memorial used an automated system to apply the H &E stains, the gold standard for this procedure, and the slide on the screen clearly showed elevated neutrophils. The purple coloring was a common occurrence in myocardial infarctions, but also supported Lucy’s takotsubo theory. End of story. If Sam had experienced some sort of allergic reaction, as Julie speculated, the eosinophils in the slide would have stained pink during the chemical reaction, but such was not the case.
“Like I said, it was a while ago and I’ve done a lot of stains since then. So I guess my memory isn’t so great after all.”
Lucy thanked Becca, who did have a memory to rival Lucy’s. But slides were slides, and memories were not always to be trusted.