Bruce Wilkinson went from dead asleep to full awake with such suddenness that he felt overwhelmed with a sense of fear, like a child awakening from a nightmare. He had no idea what had awakened him but guessed it was some noise or movement. He wondered if something had touched him. He stayed still, holding his breath, and stared straight ahead, listening. At first he was disoriented, but as his mind took in his limited field of vision, he remembered he was in the Boston Memorial Hospital: in room 1832 to be exact. At about the same instant that he realized where he was, Bruce perceived that it was the middle of the night. The hospital was clothed in a heavy stillness.
On his current admission for cardiac bypass surgery, Bruce had been in the hospital for over a week. But a month or so before he’d spent three weeks several floors down, recovering from his unexpected heart attack. As a consequence Bruce had become accustomed to the hospital routine. Such things as the squeak of the nurse’s medication cart as it was pushed up the hall, or the distant sounds of an arriving ambulance, or even the hospital page calling a doctor’s name had become reassuring phenomena. In fact, Bruce could often tell merely by listening to these familiar sounds what time of day it was without looking at his watch. They all signified that help for any medical emergency was close at hand.
Bruce had never worried much about his health even though he was a victim of multiple sclerosis. The problem with his vision that had brought him to the doctor five years ago had cleared, and Bruce had made a conscious effort to forget the diagnosis because hospitals and doctors tended to frighten him. Then, out of the blue, came the heart attack with its attendant hospitalization and the current major surgery. His doctors assured him that the heart problem was not related to the multiple sclerosis, but that disclaimer had done little to buoy his sagging courage.
Now, as Bruce awoke in the middle of the night and heard none of the usual reassuring hospital sounds, the hospital seemed like an ominous and lonely place, evoking fear rather than hope. The silence was intimidating, providing no immediate explanation for his sudden wakefulness. Bruce felt himself inexplicably paralyzed by a sensation of acute terror.
As the seconds passed, Bruce’s mouth became dry, exactly as it had been after his preop medication five days earlier. He attributed this to fear, as he continued to lie perfectly still like a wary animal, his senses straining for any disturbance. He’d done the same thing as a boy after awakening in the night from bad dreams. If he didn’t move, perhaps the monsters would not see him. Lying on his back, he couldn’t see much of the room, especially since the only illumination came from a small floor-level night-light behind his bed. All he could see was the indistinct juncture of ceiling and wall. Silhouetted against it was the magnified shadow of his IV pole, bottle, and tubing. The bottle seemed to be swaying slightly.
Trying to dismiss his fears, Bruce began monitoring his internal messages. The big question loomed in his mind: Am I all right? Having been rudely betrayed by his body by the heart attack, he wondered if some new catastrophe had awakened him. Could his stitches have split? That had been one of his fears immediately after the operation. Could the bypass have come loose?
Bruce could feel his pulse in his temples, and, despite a clamminess to his palms and a somewhat disagreeable sensation in his head that he associated with fever, he felt okay. At least there was no pain, particularly not the crushing, searing pressure that had come with the initial heart attack.
Tentatively Bruce took a breath. There was no stabbing knifelike pain although it seemed to take extra effort to inflate his lungs.
In the semidarkness, a throaty, phlegm-laden cough reverberated within the confines of the room. Bruce felt a new surge of fright, but he quickly realized that it was just his roommate. Perhaps Mr. Hauptman’s coughing had been the sound that had awakened him, Bruce thought, feeling a modicum of relief. The old man coughed anew, then noisily turned over in his sleep.
Bruce entertained the idea of calling a nurse to check Mr. Hauptman, more for the opportunity for Bruce to speak to someone than because he thought there was a real problem. The truth of the matter was that Mr. Hauptman coughed like that all the time.
The disagreeable feverish sensation became more intense and began to spread. Bruce could feel it in his chest like a hot liquid. The concern that something had gone wrong on the “inside” reasserted itself.
Bruce tried to turn to locate the nurse’s call button that was looped through the side rails of the bed. His eyes moved, but his head felt heavy. Out of the corner of his eye he saw quick, staccato movement. Looking up he could see his IV bottle. The movement he’d seen was coming from the rapid running of his IV. The drops in the micropore chamber were falling in quick succession, and the night-light glinted off the liquid with an explosive sparkle.
That was strange! Bruce knew that his IV was only being maintained for emergencies and was supposed to run as slowly as possible. It should not be running quickly. Bruce could remember having checked it as he always did before turning out his reading light.
He tried to reach out and find the nurse’s call button. But he couldn’t move. It was as if his right arm had not gotten the command. He tried again with the same result.
Bruce felt his terror become panic. Now he was certain something terrible was happening to him! He was surrounded by the best medical care but unable to reach it. He had to get help. He had to get help instantly. It was like a nightmare from which he could not awaken.
Yanking his head off the pillow, Bruce screamed for a nurse. His voice surprised him with its weakness. He’d intended to yell but instead he whispered. At the same time he became aware that his head felt tremendously heavy, requiring all his strength to keep it off the pillow. The exertion caused a trembling that rattled the bed.
With a barely audible sigh, Bruce collapsed back onto his pillow, compounding his panic. Trying again to call out, he heard an incomprehensible hiss almost devoid of vocalization. Whatever was wrong with him was rapidly worsening. He felt as if an invisible lead blanket was settling over him, pressing him flat against the bed. His attempts to breathe were pitiful, uncoordinated heaves of his chest. With utter terror Bruce comprehended he was being suffocated.
Somehow he organized his thoughts enough to remember again the nurse’s call button. With horrendous effort he lifted his arm from the bed, and in an uncoordinated, spastic fashion pulled it across his chest. It was as if he were immersed in some viscous liquid. His fingers brushed the rails, and he grasped vainly for the button. It wasn’t there. With the last vestiges of strength, he heaved himself onto his left side, rolling over and thudding up against the rail. His face pressed heavily against the cold steel, occluding the view from his right eye, but he did not have the strength to move. With his left eye he saw the emergency button. It was on the floor, curled on itself like a snake.
Panic and desperation filled Bruce’s consciousness, but the oppressive weight on his body increased, precluding all movement. In his terror he guessed that something had happened to his heart; perhaps all the stitches had burst. The sense of being smothered intensified as Bruce’s brain screamed for life-giving oxygen. Yet Bruce was totally paralyzed, able only to grunt in agony as he desperately tried to breathe. Yet through all of this, Bruce’s senses were sharp, his mind painfully clear. He knew he was dying. There was a ringing in his ears, a sense of revolving, nausea. Then blackness . . .
Pamela Breckenridge had been working from eleven to seven for over a year. It wasn’t a popular shift, but she liked it. She felt it gave her more freedom. During the summer she’d go to the beach by day and sleep in the evenings. In the winter she slept days. Her body had no problem making the adjustment as long as she slept at least seven hours. And as far as her work was concerned, she preferred night duty. There was less hassle. Days sometimes made a nurse feel like a traffic cop, trying to get patients to and from their numerous X rays, EKGs, lab tests, and surgeries. Besides, Pamela liked the responsibility of being alone.
Tonight as she walked down the empty, darkened corridor all she heard were a few murmurs, the hiss of a respirator, and her own footsteps. It was 3:45. No doctors were immediately on hand, nor even other RNs for that matter. Pamela worked with two LPNs, both skilled veterans of the ward. The three of them had learned to deal with any number of potential catastrophes.
Passing room 1832, Pamela stopped. During report that evening, the charge nurse going off the shift had mentioned that Bruce Wilkinson’s IV was probably low enough to think about hanging a new bottle of D5W before morning. Pamela hesitated. It was probably a job she should delegate, but since she was right outside the room and no stickler for protocol, she decided to do it herself.
A wet cough rattled a greeting in the dimly lit room, making Pamela want to clear her own throat. Silently she slipped alongside Wilkinson’s bed. The level of the bottle was low, and she was startled to see the IV running at a very rapid rate. A fresh bottle of D5W was on the nightstand. As she changed the IV and adjusted its rate, she felt something hard under her foot. She looked down and saw the call button. It was only as she bent to retrieve it that she looked at the patient, noticing his face pressed up against the side rail. Something was wrong. Gently she eased Bruce onto his back. Instead of the expected resistance, Bruce flopped over like a rag doll, his right hand coming to rest in a totally unnatural position. She bent closer. The patient was not breathing!
With trained efficiency, Pamela pressed the call button, switched on the bedside light, and pulled the bed away from the wall. Under the harsh fluorescent light, she saw that Bruce’s skin was a deep grayish blue like a fine Chinese porcelain, suggesting that he had choked on something and had asphyxiated himself. Immediately Pamela bent over, pulled Bruce’s chin back with her left hand, covered his nose with her right hand, and forcefully blew into his mouth. Expecting an airway obstruction, Pamela was surprised when Bruce’s chest rose effortlessly. Obviously if he had choked on something, it was no longer in his trachea.
She felt Bruce’s wrist for a pulse: nothing. She tried for a carotid pulse: nothing. Taking the pillow from beneath Bruce’s head, she struck his chest with the palm of her hand. Then she bent over and reinflated the lungs.
The two practical nurses raced into the room at the same time. Pamela said one word, “code,” and they went into action like a crack drill team. Rose quickly had the emergency paged over the loudspeaker while Trudy got the sturdy two-by-three-foot board used for support under a patient during cardiac massage. As soon as Bruce was settled on the board, Rose climbed onto the bed and began to compress his chest. After every fourth compression Pamela reinflated Bruce’s lungs. Meanwhile, Trudy ran for the emergency crash cart and EKG machine.
Four minutes later when the medical resident, Jerry Donovan, arrived, Pamela, Rose, and Trudy had the EKG machine hooked up and running. Unfortunately it traced a flat, monotonous line. On the positive side, Bruce’s color had improved slightly from its former grayish blue.
Jerry saw the flat EKG indicating no electrical activity, and, like Pamela, he hit the patient on the chest. No response. He checked the pupils: widely dilated and fixed. Behind Jerry was an intern named Peter Matheson, who climbed up on the bed and relieved Trudy. A disheveled medical student with long hair stood by the door.
“How long has this been going on?” asked Jerry.
“It’s been five minutes since I found him,” replied Pamela. “But I have no idea when he arrested. He wasn’t on the monitor. His skin was dark blue.”
Jerry nodded. For a split second he debated continuing resuscitation. He suspected the patient was already brain dead. But he still hadn’t come to terms with denying treatment. It was easier to go ahead.
“I want two amps of bicarbonate and some epinephrine,” barked Jerry as he took an endotracheal tube from the crash cart. Stepping behind the bed, he let Pamela inflate the lungs once more. Then he inserted the laryngoscope, an endotracheal tube, and attached an ambu bag, which he connected to the wall oxygen source. Resting his stethoscope on the patient’s chest and telling Peter to hold up for a second, he compressed the ambu bag. Bruce’s chest rose immediately.
“At least his airway is clear,” said Jerry, as much to himself as anyone.
The bicarbonate and epinephrine were given.
“Let’s give him calcium chloride,” said Jerry, watching Bruce’s face slowly turn a normal pink.
“How much?” asked Trudy, standing behind the crash cart.
“Five ccs of a ten-percent solution.” Turning back to Pamela he said, “What’s the patient in for?”
“Bypass surgery,” said Pamela. Rose had brought down the chart and Pamela flipped it open. “He’s four days postop. He’s been doing well.”
“Was doing well,” corrected Jerry. Bruce’s color looked almost normal but the pupils stayed widely dilated and the EKG ran out a flat line.
“Must have had a massive heart attack,” said Jerry. “Maybe a pulmonary embolus. Did you say he was blue when you found him?”
“Dark blue,” Pamela affirmed.
Jerry shook his head. Neither diagnosis should have produced deep cyanosis. His thoughts were interrupted by the arrival of a surgical resident, groggy with sleep.
Jerry outlined what he was doing. As he spoke, he held up a syringe of epinephrine to get rid of the air bubbles, then pushed it into Bruce’s chest, perpendicular to the skin. There was an audible snap as the needle broke through some fascia. The only other sound was the EKG machine spewing out paper with the straight line. When Jerry pulled back on the plunger, blood entered the syringe. Confident he was in the heart, Jerry injected. He motioned for Peter to recommence compressing the chest and for Rose to reinflate the lungs.
Still there was no cardiac activity. As Jerry opened the outer cover of the sterile packaging holding a transvenous pacemaker electrode, he wished he had never begun the charade. Intuitively he knew the patient was too far gone. But now he had started, he had to finish.
“I’m going to need a fourteen-gauge intercath,” said Jerry. With betadine on a cotton sponge, he began to prepare the entry site on the left side of Bruce’s neck.
“Would you like me to do that?” asked the surgical resident, speaking for the first time.
“I think we have it under control,” said Jerry, trying to project more confidence than he felt.
Pamela began helping him on with a pair of surgical gloves. They were just about to drape the patient when a figure appeared at the doorway and pushed past the medical student. Jerry’s attention was drawn by the surgical resident’s response: the ass-kisser did everything but salute. Even the nurses had perceptively straightened up as Thomas Kingsley, the hospital’s most noted cardiac surgeon, strode into the room.
He was dressed in scrub clothes, obviously having come directly from the OR. He approached the bed and softly laid a hand on Bruce’s forearm as if through the mere touch he could divine the problem.
“What are you doing?” he asked Jerry.
“I’m passing a transvenous pacemaker,” said Jerry, shocked and impressed by Dr. Kingsley’s presence. Staff members usually did not respond to cardiac arrests, especially in the middle of the night.
“Looks like total cardiac standstill,” said Dr. Kingsley, running a portion of the voluminous EKG tape through his hands. “No evidence of any type of AV block. The chance of a transvenous pacemaker being successful is infinitesimally small. I think you’re wasting your time.” Dr. Kingsley then felt for a pulse at Bruce’s groin. Glancing up at Peter, who was perspiring by this time, Dr. Kingsley said, “Pulse is strong. You must be doing a good job.” Turning to Pamela he said: “Size eights, please.”
Pamela produced the gloves without delay. Dr. Kingsley pulled them on and asked for the crash cart scalpel.
“Could you pull off the dressing?” said Dr. Kingsley to Peter. To Pamela he said he needed some sterile heavy dressing scissors.
Peter glanced at Jerry for confirmation, then paused in his massage, and pulled off the tangle of adhesive and gauze over the patient’s sternum. Dr. Kingsley stepped up to the bed and fingered the scalpel. Without further delay he buried the tip of the knife in the top of the healing wound and decisively drew it down to the base. There was an audible snap as he cut each of the translucent blue nylon sutures. Peter slid off the bed to get out of the way.
“Scissors,” said Dr. Kingsley calmly as his audience watched in shocked silence. This was the kind of scene they’d read about but had never seen.
Dr. Kingsley snipped through the wire sutures holding the split sternum together. Then he pushed both hands into the wound and forcibly pulled the sternum apart. There was a sharp cracking noise. Jerry Donovan tried to glance into Bruce’s chest but Dr. Kingsley had obscured the view. The one thing Jerry could tell was that there was no bleeding whatsoever.
Dr. Kingsley eased his hand, fingers first, into Bruce’s chest and cupped the apex of the heart. Rhythmically he began to compress it, nodding to Rose when she should inflate the lungs. “Check the pulse now,” said Dr. Kingsley.
Peter dutifully stepped forward. “Strong,” he said.
“I’d like some epinephrine, please,” said Dr. Kingsley. “But it doesn’t look good. I think this patient arrested some time ago.”
Jerry Donovan thought about saying he had the same impression but decided against it.
“Call the EEG lab,” said Dr. Kingsley, continuing to massage the heart. “Let’s see if there’s any brain activity at all.”
Trudy went to the phone.
Dr. Kingsley injected the epinephrine but could see that there was no effect on the EKG. “Whose patient is this?” he asked.
“Dr. Ballantine’s,” said Pamela.
Bending over, Dr. Kingsley peered into the wound. Jerry guessed he was assessing the surgical repair. It was common hospital knowledge that on a scale of one to ten, as far as operative technique was concerned, Kingsley was a ten, and Ballantine, despite the fact that he was chief of the cardiac surgery department, was about a three.
Dr. Kingsley abruptly looked up and stared at the medical student as if he’d seen him for the first time. “How can you tell at the moment this isn’t a case of an AV block, Doctor?”
All color drained from the student’s face. “I don’t know,” he managed finally.
“Safe answer,” smiled Dr. Kingsley. “I wish I had had the courage to admit not knowing something when I was a medical student.” Turning to Jerry he asked: “What are his pupils doing?”
Jerry moved over and lifted Bruce’s eyelids. “Haven’t budged.”
“Run in another amp of bicarbonate,” ordered Dr. Kingsley. “I assume you gave some calcium.”
Jerry nodded.
For the next few minutes there was silence as Dr. Kingsley massaged the heart. Then a technician appeared at the doorway with an ancient EEG machine.
“I just want to know if there’s any electrical activity in the brain,” said Dr. Kingsley. The technician attached the scalp electrodes and turned on the machine. The brain wave tracings were flat, just like the EKG.
“Unfortunately, that’s that,” said Dr. Kingsley as he withdrew his hand from Bruce’s chest and stripped off his gloves. “I think someone better call Dr. Ballantine. Thank you for your help.” He strode from the room.
For a moment no one spoke or moved. The EEG technician was first. Self-consciously he said he’d better get back to the lab. He unhooked his paraphernalia and left.
“I’ve never seen anything like that,” said Peter, staring at Bruce’s gaping chest.
“Me neither,” agreed Jerry. “Kinda takes your breath away.”
Both men stepped up to the bed and peered into the wound.
Jerry cleared his throat. “I don’t know what you need more, competence or self-confidence, to cut into someone like that.”
“Both,” said Pamela, pulling the plug on the EKG machine. “How about you fellows giving us some room to get this place in order. By the way, one thing I forgot to mention. When I found Mr. Wilkinson, his IV was running rapidly. It should have been barely open.” Pamela shrugged. “I don’t know if it was important or not but I thought I’d let you know.”
“Thanks,” said Jerry absently. He wasn’t listening. Daintily he stuck his index finger into the wound and touched Bruce’s heart. “People say Dr. Kingsley is an arrogant son of a bitch, but there is one thing I know for sure. If I needed a bypass tomorrow, he is the one I’d have do it.”
“Amen,” said Pamela, pushing her way between Jerry and the bed to begin preparation of the body.