Lee felt as if a sledgehammer had bludgeoned his chest. He struggled up each step, moving as quickly as his rubbery legs would allow. Eventually, he returned to the bright lights and harsh glare of the medical floor. The antiseptic odors acted like smelling salts, bringing him more fully back to his senses. He rushed toward Susie’s room, battling for balance. Orderlies, visitors—basically, anyone not confined to a bed—lurked in the hallway, listening to Susie’s primal screams.
The scene inside Susie’s room was utter chaos. On her bed, the girl thrashed about wildly. Not only had she pulled out the leads to her monitors, she had managed to rip out her IV as well. Blood spurted from the open vein, splattering the floor and spraying the white hospital sheets crimson. Nurses moved quickly to get the bleeding under control.
A nurse heroically managed to reattach Susie’s IV, but the floor was now slick with blood. The room warmed with the heat of many bodies. Nurses gathered around Susie’s bedside, fighting what appeared to be a losing effort to keep her limbs contained. She wanted out of her bed, out of this hospital, and was willing to do anything to break away from those attempting to hold her down.
“Let me go!” she screamed. “They’re crawling all over my legs!”
She unleashed a bloodcurdling yell.
Surveying the room, he noticed no white lab coats present. Everyone here was a nurse. As if to put an exclamation mark on his observation, the nurse in blue scrubs, the one Lee had almost knocked over, cried out, “Dammit, page Dr. Rajit again. We need him here, STAT!”
Lee stepped forward.
“I’m a doctor at the MDC,” he announced. “I’ll take over until Dr. Rajit arrives.”
One of the nurses recognized Lee and nodded vigorously, encouraging him to take charge. Susie’s agitation was intensifying—a funnel cloud forming into a tornado.
“Get them off me! Get them off! I hate spiders!”
Susie shrieked while violently brushing her arms and legs, as if arachnids actually were crawling on her limbs.
“Susie, sweetheart, you need to calm down. There’s nothing on you.”
The nurse, a dark-haired, stout woman, had managed to pin Susie’s arms to her sides using significant force. Susie fought hard to free herself, and when that failed, tried to get one leg over the bed rail so she could climb out.
“They’re biting!” She yelled as if in extreme pain, staring at her legs with horror in her eyes. She was seeing something though nothing was there.
What are these hallucinations all about? Lee wondered. He knew it was not a symptom of CO poisoning. Could it be a bizarre reaction to a medication? Or did the repairman do something to cause her delusions?
“They’re all over me,” Susie whimpered, her body convulsing as she bucked and writhed in an effort to rid herself of these imaginary creatures.
“What’s been her status?” Lee asked. Basically, he wanted to know what had happened during his footrace with the repairman.
“This! This has been her status!” The nurse holding Susie’s arms sounded exasperated. “We’ve tried reasoning with her, but she’s completely delirious.”
Crazed is more like it, thought Lee. He had seen The Exorcist plenty of times, and the way Susie flailed and contorted was terrifyingly reminiscent of the film.
“They’re in my ears! I feel them crawling in my ears! Biting me!”
Susie’s bloodcurdling scream caused several nurses to jump.
“No, nothing is biting you, sweetheart.” The stout nurse did her best to sound reassuring.
No good. If anything, Susie’s paroxysms intensified. Sweat glistened against her pale skin. She was warm to the touch, probably febrile, but no one could get a temp on her just yet.
“We need to restrain her, right now,” Lee said.
He spoke in a commanding voice, but tried not to sound overly aggressive. He had to keep everyone calm. Or maybe he was trying to keep himself calm. A flutter of nervousness came and went. He’d been a resident the last time he triaged a patient in crisis. On a daily basis Lee dealt with sore throats, fussy kids, odd ailments; not what appeared to be delirium tremors on steroids.
Lee joined three other nurses in holding down each of Susie’s limbs, while another nurse lashed restraints onto the metal bed frame. Susie resisted with the strength of a wrestler escaping a pin. She arched her back, bucked her hips, and swiveled violently from side to side, all while groaning and shrieking incoherently. With Lee’s help, the team won the battle and got her secured. Thick fabric straps, impossible to rip, bound her wrists and ankles.
“Is she on any new medications?” Lee asked.
“No,” a nurse replied, as she worked to reapply the leads for the telemetry monitors.
“Has her blood sugar been stable?”
“Stable,” another nurse said. “But she’s anuric.”
Indeed, the bag used for collecting and measuring urine output through the Foley catheter that had been inserted into Susie’s bladder was empty.
“Forty milligrams furosemide. Increase the IV to one fifty cc’s per hour. D-five normal. How about renal function?”
“BUN thirty-six, creatinine two point eight,” a nurse said.
“K?” Lee said, meaning potassium.
“Five point one.”
Borderline, but likely on its way up too, thought Lee. Any higher could mean a potential fatal cardiac arrhythmia. Trouble. But what was doing all this?
Susie grunted and groaned, then violently rolled her head from side to side.
“Please, please, they’re in my hair, they’re crawling toward my eyes—please—” Her voice had softened to a whimper.
“Haloperidol five milligrams,” Lee ordered, hoping that would stop the hallucinations. “Got those leads back on?”
“Almost there,” a nurse replied, her voice a bit breathless.
The monitor showed Susie’s heart racing at 160 beats per minute. There were frequent premature beats, PVCs. Her BP was 176 over 112, way too high, but not high enough to worry about an imminent brain hemorrhage.
“Labetalol twenty milligrams,” Lee called out. “Then start a drip at two per minute. Get a twelve-lead ECG.”
They had to get her BP down.
“Temp’s one oh two point four,” shouted one of the nurses.
“Get me a tox screen, and blood cultures. And a stat thyroid panel. Repeat her chemistries and CBC. Let’s check blood gases.”
Lee paused to review the cardiogram. Brief runs of ventricular tachycardia. The T-waves were inverted in the inferior leads, worrisome for myocardial ischemia, a heart attack. In a nineteen-year-old? He felt baffled.
Why was this girl acutely delirious? He needed answers, but those would have to wait.
Susie’s bucking and thrashing had finally begun to subside. She gazed unblinking at the overhead fluorescent lighting. The haloperidol and restraints were doing the job.
At that moment, a team of doctors burst into her cubicle. The one of Indian descent, who a nurse identified as Dr. Rajit, glared at Lee.
“Who are you?”
He did not sound pleased.
“Dr. Lee Blackwood, I’m with the MDC. I was here to speak with Susie when she crashed.”
Dr. Rajit’s eyes widened, his body tensing as he readied for a confrontation. “Speak with her? What on earth for?”
The answer would have to wait. Susie’s back arched as her limbs stiffened. She moaned loudly, a strange wounded noise that escaped her pale lips just before her face turned crimson. She started to tremble, imperceptibly at first, and then with larger synchronous jerks. The restraints kept her from hitting herself.
“She’s seizing!”
“Get anesthesia in here! We’ve got to intubate!” Dr. Rajit yelled the order, sending the nurse closest to the door scrambling for the phone.
Turning Susie’s head to one side, Lee prevented her from aspirating the foaming saliva into her lungs. Could anything more go wrong?
“Two milligrams lorazepam IV and load her with fosphenytoin IV. What’s her weight?” Lee asked.
“Forty-nine kilos,” a nurse replied.
“Okay. Eight hundred milligrams phenytoin equivalents at one hundred per minute. Now!”
Dr. Rajit nodded at Lee. He would have ordered the same.
Susie’s seizure subsided quickly, but in a matter of minutes she was yelling out again, pulling at her restraints, talking about spiders.
“Let’s get her sedated,” Lee said. “Start her on a ketamine drip. Labs back yet?”
Suddenly, Dr. Rajit seemed blindsided by Lee’s orders. “Dammit, this is my patient!” he growled at Lee. “And who ordered labs?”
“Dr. Blackwood did,” a nurse said.
Lee returned a slight shrug before ordering an increased dosage of haloperidol, which seemed to quiet Susie down.
Before anesthesia arrived, the labs came back. A nurse read the results.
“BUN forty-eight, creatinine four point six.”
Lee did a double take. Her creatinine was rising too rapidly, crazily so, from two point eight to four point six. He had never seen anything like this. It made no sense.
“Her blood gases show a metabolic acidosis,” one of the residents intoned. “PH seven point ten.”
“It’s got to be lactic acidosis,” Lee said. “Give her two amps of bicarb in the IV.”
“I’m still confused. Is this your patient, Dr. Blackwood?” Dr. Rajit’s eyes bored into Lee.
“Listen, Dr. Rajit, you’re a resident, right?” Lee made the guess solely based on Rajit’s young-looking face.
“Yes, so?”
“Where’s the intensivist on call?”
“Dr. Sears is in the surgical ICU,” Dr. Rajit said. “I’ve got this.”
“I’m sure you do,” Lee said. “But I’m an attending here at MDC. I’ve got the experience to help you. Let me help. Please. This patient—she’s—she’s very important to me.”
For a moment, Lee was not sure which way Dr. Rajit would go. Was he another Gleason? To his relief, Lee got the consent he wanted.
The anesthesiologist, a silver-haired man with wire-rimmed glasses, stormed into Susie’s room. A female resident pushing the anesthesia cart, along with a nurse anesthetist, came in soon after.
“I’m Dr. Cochran,” said the anesthesiologist. “And what’s happening here?”
Lee summarized the essentials. Dr. Cochran listened while giving Susie 100 percent oxygen through an Ambu breathing mask.
“I’ve given her ketamine, one hundred milligrams,” Lee said.
Dr. Cochran nodded his approval while he extended Susie’s neck to advance the laryngoscope over the back of the tongue and epiglottis. He worked the tube beyond her vocal cords, inflated the cuff to ensure a seal, and listened for breath sounds through his stethoscope.
“Sounds good,” he said. “Let’s get a portable chest to confirm the tube’s placed right.”
And with that, Susie finally appeared to be resting comfortably. All it took was giving her ketamine, getting her anesthetized, and then putting on a ventilator.
Lee noted Susie’s temp was still high, at 101.6. Her blood pressure was also elevated at 160 over 110, and her heart rate still too fast, at 140 beats per minute, with frequent ectopic premature beats.
“Let’s increase the labetalol,” Lee said. “Start her on a drip, fifty milligrams per min. Dr. Rajit, you concur?”
The young resident looked as though he had just leapt from a moving train.
“Yes, yes, of course,” he said.
Blood still had to be cleaned off the floor. The nurses would have to change their clothes, their sneakers, too.
The room was a total mess.
At least Susie’s ECG showed normalization of those inverted T-waves.
“CK-MB and troponin levels normal, Dr. Blackwell.”
“Let’s get another serum creatinine test,” Lee said. A normal jump might be one point per day for someone in kidney distress. Susie’s had gone up more than that in under an hour. Lee had never heard of a patient whose levels had risen so rapidly.
A nurse administered the serum test while Lee kept close watch. A shocked expression came to her face as she read the results.
“Her creatinine level is nine point oh.”
Lee’s mouth fell open.
Impossible.
“We’ve got to get her to the ICU, get her on dialysis STAT! Now! Now!”
Orderlies, nurses, gathered around and rushed Susie out of the room, headed for the elevator to take them to the ICU one floor above. The critical care physicians, with the help of the radiologist, would get her started on dialysis before her creatinine levels shot up to the point of no return.
Lee watched Susie get wheeled away, wondering if her kidney failure could be related to her other symptoms—the ones she and Cam had in common. He desperately wanted those tox screen results. It was certainly a possibility the repairman had injected Susie with something to manifest her delusions; exactly what, he could not say. But he doubted the tox report would explain the sudden and alarming rise of Susie’s creatinine levels.
Nothing in medicine Lee knew of could do that.