The man waggled his hand and launched into a clipped summary.
Luke listened while looking over the doctor’s shoulder, taking in the scene. Susan, syringe in hand, stabbed the patient’s right arm repeatedly, a hint of frustration playing on her face. The other nurse tapped the patient’s left foot, searching for a vein. Megan was hunched over the table, her back to Luke, moving her stethoscope across the boy’s chest.
“Any unusual rashes?” Luke asked. He was hoping he wouldn’t have to call in his father, who, as the head of Infectious Diseases, was the go-to person for tropical diseases. The man already worked too many hours.
The transport physician shook his head while continuing his report.
Luke cut him off in mid-sentence with a “Thanks” and walked into the room, taking a position well behind Megan. From ten feet away, nothing jumped out at him other than the boy’s wasted form and a crude tattoo on the left side of his chest. It was dark blue, about an inch across, and shaped like a crescent moon.
Only Susan, who was facing Luke, seemed to notice his presence.
“Patient’s moving air well,” Megan said, her tone a swirl of confusion. “A few faint wheezes, but otherwise his lungs are clear.”
The respiratory therapist’s eyebrows angled downward, her expression bemused.
Apparently, everyone shared the same question. What would normally have been good news was anything but. Despite good airflow into his lungs, their patient was oxygen starved.
Susan showed Luke a peevish frown while fingering the stethoscope around her neck.
Luke waved her off. There was no reason to usurp Megan’s role as team leader — at least not yet.
“Is the blood gas ready?” Megan asked the therapist.
“Just drew it. Have it in a moment.”
The blood gas results would give them far more information about the patient’s lungs. It would reveal if the patient’s body was retaining carbon dioxide, and if so, whether his blood was becoming dangerously acidic.
But it wouldn’t tell them why.
Luke hoped that Megan didn’t spend too much time thinking about the unknowns, questions for which she didn’t have answers. She needed to focus on what she knew and could act upon.
“Someone call X-ray again,” Megan said, “and while you’re at it, call Admitting and tell ’em to get an ICU bed ready.”
“Megan, we’re not having any luck getting an IV started,” Susan said, her eyes aimed at Luke. “His perfusion’s poor. He’s clamping down.”
The boy’s body was doing exactly what it was designed to do, diverting blood flow from the muscles and skin to more vital organs. Come on, Megan, it’s time to move on this.
Susan shot another frustrated glance at Luke.
Luke held out a palm.
The nurse rolled her eyes, shook her head.
A half second later the acoustic rhythm of the heart monitor broke its stride and played a few erratic beats. Luke’s eyes went to the electrical tracing and jagged lines. The boy’s heart was racing at 180 beats per minute, and his blood pressure was dangerously low.
Megan said, “Get me a central line setup, and pull an endotracheal tube in case we need to intubate him.”
Placing a central line into one of the larger, deeper blood vessels would allow them to deliver substantial amounts of fluids quickly. Luke wondered how many times Megan had done the procedure, if ever.
The respiratory therapist handed a strip of paper to Megan. “Here’s your blood gas,” she said. “We’re going nowhere fast. O-2 sat is hovering in the low seventies and his CO-2 is climbing. I’m switching to an Ambu bag.”
The therapist ripped off the patient’s oxygen mask and replaced it with a thicker one attached to the Ambu bag, alternately compressing and releasing the rubber oxygen reservoir.
They were now breathing for Josue.
Luke glanced at the boy’s face when the therapist removed the oxygen mask. The fear that had been there a minute ago was gone. He had a glazed, stuporous look. He no longer felt anything.
Whoosh. The doors swung open. Five sets of eyes turned in unison.
A high-pitched whir invaded the room when the X-ray technician guided the motor-driven X-ray machine into the room. Luke held out an outstretched arm, signaling the tech to stay put for the moment.
“Blood pressure’s dropping,” Susan announced. “And his pulse is thready.”
“Someone get McKenna,” Megan shouted. “Drag him in here if you have to.”
“Right here.” Luke stepped up beside her.
Megan’s eyes showed a blend of puzzlement and irritation. “How long—”
“Let’s divide and conquer,” he said while stepping over to the surgical tray. “Go ahead and intubate the patient. I’ll put in the central line.”
Megan said, “I was about to—”
“You comfortable intubating the patient?” Luke asked. His gaze had settled on the instrument tray, but he could feel Megan’s stare.
After a moment, she said, “Yeah…sure.”
Luke quickly scrubbed the boy’s upper thigh, found the femoral vein, injected an anesthetic, made a quick stab, and inserted the line.
Megan said, “As soon as Dr. McKenna has that line secured, give the patient a normal saline bolus, as fast as it’ll run. Call out the blood pressure every minute until it’s back above ninety.”
Luke glanced at the boy’s face. He’d slipped into unconsciousness. They had no time to give the drugs normally used to sedate and anesthetize a patient undergoing intubation. He hoped Megan realized that.
Holding the laryngoscope in her left hand, Megan called out, “Ready.”
The therapist removed the Ambu bag from the patient’s face and stood back.
Megan inserted the laryngoscope into the boy’s mouth, taking a deep breath as she did so. “Hand me the tube.”
The therapist passed it to her, and Megan immediately slipped the endotracheal tube down the patient’s throat.
The respiratory therapist connected the Ambu bag to the end of the tube and began squeezing and releasing it with her left hand, her movements practiced and rhythmic.
Megan ran her stethoscope over both sides of the boy’s chest.
“Tube’s in position,” she said, exhaling heavily. “Let’s hyperventilate him for a few minutes.” Then she called out antibiotics to be given stat.
Susan glanced at Luke for confirmation of the antibiotics order, and he returned a subtle nod, which he hoped Megan didn’t notice.
Megan said to the X-ray technician, “We’re ready now.” She waved her arm in a circle as if directing the man through a busy intersection.
The tech sauntered over to the table with his film casings, displaying the same energy and enthusiasm as someone standing in line at the post office. He said, “By the way, folks, there was a beat-down slugfest at the other end of the hall. Some guy got into it with one of our docs. I heard maybe one of ’em’s dead.”
“No one’s dead,” Luke said. “Let’s focus on our work here.”
Megan glanced at him, or more specifically, the tear in his lapel.
Dr. Henry Barnesdale, chairman of University Children’s medical staff, sat at the antique burled-walnut desk that dominated one end of his cavernous office and stared at a list of E.R. patients on his computer screen.
Patient number 134—Josue Chaca — stared back at him.
“He’s in the E.R.,” Barnesdale said into the phone. “What do you want me to do?”
“Nothing,” the Zenavax CEO said.
“But—”
“I said leave it alone.” A heavy breath came through the phone. “But in the future, stay away from my test sites. It’s a big world out there. Your hospital can find another place to do its charity work.”
Barnesdale’s oblong shadow jiggered on the far wall of his office, swimming in a pale green halo of light seeping from the banker’s lamp on the credenza behind him. He was usually the one wielding the power, and didn’t like playing serf to this man. He couldn’t help it that the boy and his mother had marched fifty miles through mountainous terrain to reach the hospital’s clinic. But he wasn’t about to say that to the Zenavax CEO.