Thursday, July 4, 2:02 a.m.
Like an exquisite torture, Mitt’s phone again rang seemingly the moment he’d fallen asleep. And on this occasion, it was particularly loud, as he’d put his phone on the bedside table instead of leaving it in his white jacket pocket. With the jacket draped over the reading chair and out of reach, he’d purposefully taken out the phone to have it within his reach. His hope was that if he was called yet again that night, he might be able to handle the issue remaining recumbent, without even getting to his feet. The downside was that it took a moment of frantic fumbling in the dark to find the damn thing and bring it up to his ear. By then his pulse was up over a hundred beats per minute.
“Yes?” Mitt managed scratchily but urgently. He could feel his pulse hammering away in his temples.
“Dr. Fuller, this is Sheila Ferguson. Your patient, Mr. Diego Ortiz, is acting strangely.”
“Oh?” Mitt questioned. Half expecting something significantly worse, his flight-or-fight reaction mellowed a few degrees. “Acting strangely” was a far cry from being informed his patient was having an arrest, like he’d been told about Latonya Walker and Elena Aguilar. “What exactly do you mean by ‘acting strangely’?”
“He’s agitated, speaking Spanish a million miles a minute, and waking up all his suite-mates. One of the nurses who speaks Spanish says he’s not making any sense, which is strange because he’d been so calm all afternoon and evening according to the report when I came on duty. And he’s been asleep the whole time I’ve been here.”
“Are you suggesting we give him something like a tranquilizer or just double down on his sleep medication?” Mitt asked. He was trying to think of something specific to offer. The last thing he wanted to do was go to the fifteenth floor just because someone was anxious. “Or do you have something else in mind?”
“I think you need to come and see him,” Sheila said. “My intuition tells me that his sudden change in attitude is worrisome. It’s bizarre in my experience, and I don’t like it.”
“What about his incision?” Mitt asked. He was still fighting against the need to pay a visit to the patient in person. Mr. Ortiz’s dressing was just a piece of paper tape, so any developing problems like bleeding or swelling would be immediately apparent.
“The incision looks fine. I don’t think you understand. The man is beside himself. You need to come!” With that final comment, the nurse disconnected the line.
Reaching over in the darkness, Mitt turned on the bedside lamp. Then, for a minute filled with a slew of barely audible curse words, he lay back against the pillow and lamented his fate, wondering why he hadn’t been attracted to a future in finance, following in his father’s footsteps, where you could at least sleep through the night. But then, recognizing the inevitability of the situation, he put his feet over the side of the bed, sat up, and slipped on his loafers. Getting to his feet, he waited a few beats for his circulation to catch up to the changing demands. When it did, he picked up his white jacket and slipped it on.
As he walked through the on-call lounge, he didn’t rush. It sounded to Mitt more like a behavioral problem than a medical problem, which the nurses should have been able to handle. At the same time, he did recognize that Diego Ortiz was his only living patient and that he should be inordinately thankful he wasn’t being called for a cardiac arrest or some other medical emergency. In comparison, handling a behavioral issue should be relatively easy.
When Mitt arrived at the elevator lobby, he found himself speculating whether or not he would be seeing a hallucination in the elevator. The thought made him smile ironically at his nonchalance, and he wondered if it was because he’d become numb from lack of sleep, or because the increasing frequency was just making him expect one. Whatever the reason, when the elevator arrived and the door slid open to reveal an empty car, he merely shrugged and boarded without giving it much thought.
He felt the same way when the elevator discharged him on the fifteenth floor, wondering if he’d have to endure the bad smell or see the blond girl in the darkened hallway on the way to the west side of the building. As it happened, he didn’t smell or see anything, but he did hear his patient screaming in Spanish while still in the hallway and not even abreast of the nurses’ station.
Picking up his speed, Mitt hurried the rest of the way down to Mr. Ortiz’s room. Inside, all the overhead lights were on. Mr. Ortiz’s bed was next to the window with the curtain pulled out. All five of the other beds were occupied and all the patients were awake and wide-eyed, with their covers pulled up around their necks. There were two nurses trying to deal with Mr. Ortiz, who was sitting cross-legged in the middle of his bed and loudly carrying on in Spanish. At that moment the nurses were trying to take his blood pressure, but he was resisting. He was totally naked with his short dark hair spiked up wildly like a cartoon character who’d stuck his fingers into an electrical outlet. Another woman dressed in a white coat over a dark pants suit was near the head of the bed. Mitt later learned she was a Spanish translator who’d been called to assist. Her expression was one of confused alarm.
Already wondering what the hell he was going to do as the supposed “savior” doctor, Mitt approached the foot of Mr. Ortiz’s bed, rapidly taking in the scene. The patient’s body was flushed a bright crimson, and he was sweating profusely as if he’d just run a marathon. Even more alarming, his bloodshot eyes were bulging like they were going to pop out of his head. His IV was still in place, running into his left arm.
“My God!” Mitt croaked under his breath. As green as he was, he knew instantly this was no simple behavioral problem and that once again he was in way over his head. Aware that the patient had had thyroid surgery, Mitt surmised he was seeing something he’d only read about, namely acute thyrotoxicosis, or worse yet, a thyroid storm, which could be fatal. “Somebody please get Dr. Baker here stat!” Mitt yelled as he pushed up alongside the bed so that he could slap his hand against the patient’s forehead. Mr. Ortiz fought back, but Mitt persisted, and when he got his hand against the man’s forehead, his fears were corroborated in spades. The man was burning up.
“Tell Dr. Baker we’ve got a patient in thyroid storm!” Mitt yelled after the nurse who’d broken away to call her. At that moment, Mr. Ortiz suddenly stilled with a confused expression, but then blew out his cheeks before exploding with a bout of projectile vomiting. The episode was so forceful that most of the vomitus cleared the foot of the bed and sprayed out onto the floor.
“Good Lord,” Sheila Ferguson, the other nurse, exclaimed. She’d just managed to dodge the icky deluge.
As if vomiting had exhausted him, Mr. Ortiz’s eyes suddenly rolled back as much as they were able, and he collapsed onto the bed unconscious.
“What’s the blood pressure?” Mitt demanded. Sheila already had a blood pressure cuff partially around the man’s right arm and a stethoscope in her ears, as she’d been struggling to take his blood pressure even before Mitt arrived.
While Sheila repositioned the blood pressure cuff and blew it up, Mitt felt the man’s pulse at the wrist and quickly guessed it was galloping along somewhere between 150 and 200 beats a minute. Concerned at the tachycardia, he looked across at Sheila as she removed the stethoscope’s earpieces. “It’s way up there,” she said urgently. “It’s in the neighborhood of 180 over 135!”
“Holy shit,” Mitt murmured with alarm. Despite being a newbie, he intuitively knew that kind of blood pressure and pulse had to be cardiotoxic and unsustainable. With a sense of desperation, he looked back down at the patient, trying to come up with something he might do before Madison arrived. Although he knew he was in way, way over his head, he was sure there had to be something that could start to reverse the process. Then his mind latched onto an idea that he knew had to be important: Try to get the man’s body temperature down. The sky-high body temperature had to be feeding both his pulse and his blood pressure and turning his body into a kind of pressure cooker.
“How can we cool him?” Mitt demanded frantically. “He’s burning up.”
“We have ice,” Sheila said.
“Get it!” Mitt yelled. “Get as much as you can.”
Sheila disappeared, leaving Mitt alone with Mr. Ortiz, who was like a piece of glowing charcoal, cooking all his internal organs. Seeing the stethoscope that Sheila had dropped on the bed after taking the blood pressure, Mitt reached across, put the earpieces in his ears, and listened to Mr. Ortiz’s chest. The man was breathing fast and shallowly, and Mitt heard all sorts of additional sounds that he knew he wasn’t supposed to hear, all of which made sense if the man was not long for this world. He was frying his lungs, as well as his kidneys, liver, and brain.
Sheila was back in a flash along with a number of other nurses. Word traveled quickly around the ward that an unusual problem had developed, and everyone was curious and willing to help if they could. Sheila had brought back a bucket of ice as well as a bunch of towels. Soon everyone was putting ice cubes onto towels, folding them up, and then placing them all over Mr. Ortiz’s body. One of the nurses thought to bring a remote thermometer. When she used it, everyone was both shocked and horrified. It registered 111 degrees.
A few minutes later and to Mitt’s utter relief, Madison showed up. “Do you really think it’s a thyroid storm?” she demanded, out of breath, while pushing in against Mr. Ortiz’s bed across from Mitt.
“It has to be,” Mitt said. He described what he found when he first arrived. “The guy’s literally burning up. Even with the ice packs, his remote temperature was over 110 a minute or two ago!”
“Whoa,” Madison commented. “Yikes! That’s not good. Anyway, I took your word about the diagnosis and immediately called for an emergency Internal Medicine consult. They should be here momentarily. I’ve never handled a thyroid storm. Have you?”
“Are you joking?” Mitt asked. He looked across at Madison to see if she was being serious.
“No, I’m not joking. I’m impressed you made the diagnosis and so quickly.”
“When I saw him sweating and felt his temperature, I knew there weren’t too many medical explanations for what was going on. Besides, he’d had thyroid surgery today, which I suppose is a giveaway. But then again, his past history is of hypothyroidism rather than hyperthyroidism, which is what a thyroid storm is. Well, to be honest, I can’t explain it, but here we are. What are we going to do?”
“We’re waiting for the medical guys,” Madison said. “Handling a case of thyroid storm is out of my league. I’m assuming all is okay on the surgery end?”
“See for yourself,” Mitt said. He lifted the ice-filled towel draped over Mr. Ortiz’s neck to reveal the paper tape covering the incision.
“Well, at least that appears to be fine. What’s his blood pressure?”
As soon as Madison asked the question, Sheila nudged her out of the way and retook the blood pressure. As she was busy doing that, Mitt felt the pulse. Another nurse lifted an ice pack and again used the remote thermometer.
“His pulse is still way up there around 150,” Mitt said.
“Blood pressure about the same,” Sheila said. “I’m getting about 170 over 130.”
“Temperature still reads 108 despite the ice packs,” the nurse with the thermometer said.
“Good grief,” Madison said. “That’s not good. Such numbers are incompatible with life, at least in my book.”
At that moment a team of three on-call medical residents came rushing into the room out of breath. There were two males and one female, all dressed in whites. Many of the nurses who’d grouped around the bedside gave way to the newcomers.
“I’m Dr. Deion Phillips, senior medical resident on call,” the lead resident said breathlessly as he pressed in against the bed. He was a strapping young Black man with imposing but restrained dreadlocks. “I’ve been told you have a case of thyroid storm. Is that true?”
“That’s what we believe,” Madison said. “He’d had a thyroidectomy this morning.”
“Any idea of the BP, pulse, and temp?” the medical resident asked hurriedly as his eyes took in the entire scene, particularly noting the patient’s dramatically flushed color, his copious perspiration, and the vomit on the floor. He snatched up Mr. Ortiz’s wrist to feel the pulse.
Madison rattled off the results. “We’d just taken them before you arrived.”
Dr. Phillips whistled in appreciation at hearing the numbers. “Whoa, this is one sick dude.” Quickly pulling his stethoscope from around his neck, he listened briefly to Mr. Ortiz’s chest, first his heart for a couple of beats and then his lung fields for several breaths. “Shit, man!” he said, straightening up. “This does look like a thyroid storm! Amazing! He’s already got serious pulmonary edema! No wonder he’s breathing so rapidly. Not good! Let’s get an O2 monitor on him and get an idea of his saturation. I bet it’s in the toilet.” He then turned to his compatriots, and in keeping with Bellevue being a teaching hospital, he asked them what they thought the guy needed and needed stat.
“Methylprednisolone, metoprolol, methimazole, and propranolol,” the two more junior residents rattled off in unison.
“Right on!” Dr. Phillips said, flashing them a thumbs-up. Then he turned to Sheila Ferguson. “Do you have these meds here on the floor?”
“I’m sure we do,” Sheila said. She immediately left to head down to the floor’s pharmacy room.
Dr. Phillips stepped up to the head of the bed and checked what the IV bags contained. Only one had fluid remaining and it was saline. Grasping the tubing that snaked down into Mr. Ortiz’s arm, he called out: “Who put in this IV line?”
“Anesthesia did this morning at the beginning of his surgery,” Mitt responded.
“Okay, good,” Dr. Phillips said. “That means we can count on it. Now, let’s get more ice!” He handed off the empty bucket to one of the nurses, who quickly disappeared. At that moment, the patient’s rapid, rather noisy breathing came to a sudden stop. Immediately Dr. Phillips again snatched up Mr. Ortiz’s wrist to feel for a pulse. When he couldn’t feel one, he let go and then tried again. When he still didn’t feel one on the second attempt, he shouted: “Good God! We’ve got an arrest here! Someone call the resuscitation team and let’s start CPR!”
Dr. Phillips himself climbed up onto the bed, kneeled next to Mr. Ortiz, and started the closed-chest massage. He also called out for an Ambu bag, and another nurse ran to get it. Next he questioned loudly if the resuscitation team had been called. One of the nurses responded positively. Dr. Phillips then told one of his fellow medical residents to get a syringe and draw some blood for stat electrolytes.
“Looks like we have been appropriately preempted,” Madison said as she drew Mitt a few steps away from the bed to give everyone who was actively engaged more room. “This is another unique experience for me, and I have to give you credit for appropriately calling this one. Seems your diagnosis of a thyroid storm was right on. I’m impressed. I’m also impressed that you seem to be a magnet for what I’d call rather unique clinical cases, considering this thyroid storm and the aneurysm blowout on Monday night.”
“Maybe I am a magnet,” Mitt admitted. “This case is making me seriously paranoid.”
“What on earth do you mean? How can a case of thyroid storm make you paranoid?”
“It’s simple,” Mitt said, looking back at the frantic activity around Mr. Ortiz. “This is another of my assigned cases. I assisted on his surgery this morning.”
“Okay! A couple of cases of bad luck, but you certainly didn’t have any role in causing the thyroid storm or the abdominal aorta bursting.”
“It makes me paranoid because I’m getting the distinct feeling he’s not going to make it. And if he doesn’t, I’m batting a thousand.”
“Batting a thousand?” Madison questioned, staring directly at Mitt with confusion. “What on earth are you talking about?”
“Maybe you don’t know this yet, but Bianca Perez also had an arrest and died tonight in the ICU. And with Latonya Walker’s earlier arrest, this fellow, Diego Ortiz, is my only living patient after three days of surgery, and I think you’ll admit, he’s on the edge of the precipice.”
Madison’s mouth slowly dropped open as her tired mind came to understand exactly what Mitt was saying. She shook her head in disbelief. “All right, I’m getting your point. That is big-time weird. How many patients are we talking about?”
“So far, six out of seven are dead,” Mitt said. “And this one ain’t looking so good.”
At that moment the resuscitation team came flying into the room, pushing their noisy crash cart, forcing Madison and Mitt to move farther out of the way to give them access. Then after a quick conversation with Dr. Phillips to get the details, they took over the resuscitation from the medical residents. Mitt watched with interest, hoping against hope that such an experienced, first-class team might be successful on this attempt, but in his heart of hearts he knew it wasn’t going to happen. Like it or not, he was going to be forced to deal with a shocking 100 percent mortality statistic.
For a few minutes, both Mitt and Madison silently watched the frantic activity as the resuscitation team determined that the heart was in ventricular fibrillation, and as soon as the defibrillator was set up and charged, it was used, but it wasn’t successful. Before they tried again, they started epinephrine and lidocaine. They also intubated the patient and switched to 100 percent oxygen to improve his respiration, which was critical, as his saturation was below 50 percent.
“Okay,” Madison said, looking back at Mitt to resume their conversation. “I can understand you feeling a little weird and maybe even victimized by chance with what’s happened to the patients you’ve been arbitrarily assigned, but I certainly don’t understand you feeling paranoid and thinking that it is any way your fault. To me that smacks of a bit of megalomania since you happen to be low man on the totem pole.
“Listen! You are obviously doing your best, and from my vantage point, you are doing extremely well. If anyone is guilty of setting you up, it would have to be Dr. Van Dyke because she’s the one assigning the cases, but that’s an absurd notion. So, for goodness’ sake, ease up on yourself! I know the first days of residency are hard until you get the swing of things, but I can assure you that you are almost there. All of us have gone through what you are going through, namely a period of questioning our capacity to handle what is a very difficult job, especially when first starting out. Believe me, it’s going to get better. In fact, it is going to get a lot better a lot quicker than you imagine from where you are standing right now. Trust me!”
“Thank you for the pep talk,” Mitt said sincerely.
“You’re welcome,” Madison said emphatically. “With that said, what do you have in mind to do at the moment?”
Mitt looked at her questioningly. “What do you mean?”
“I mean, are you going to hang here while the medical guys and the resuscitation people try to handle this problem, which, like you said, is probably doomed to failure with a body temperature of 111 degrees? Me, I’m going to head back to the on-call room and get some shut-eye. Selfishly enough, I have a beach barbecue scheduled out on Long Island tomorrow, and I’d prefer not to be a zombie. Maybe you should do the same, meaning go get some sleep. They can always call you back to do the paperwork if need be. If perchance the medical people are successful, which I sincerely doubt, they’ll be responsible for following the case and undoubtedly transferring the patient to the medical ICU.”
For a moment, Mitt studied Madison’s face. Her apparent insouciance in the face of Ortiz’s real-time life-or-death struggle surprised him, and he wondered if after a single year he might develop the same nonchalance. From his present perspective, it seemed like a rather large transition. “I’m going to hang,” he said finally, borrowing her particular word choice.
“Suit yourself,” Madison said. “But do me a favor and skip any more ridiculous paranoid ideation. Deal?”
“I’ll try,” Mitt said.
“That’s all I ask,” Madison responded. She gave Mitt’s shoulder a reassuring squeeze before heading for the hallway.
Mitt watched her leave before turning his attention back to the resuscitation attempt. Building up his courage, he advanced to the foot of the bed, avoiding the vomit on the floor. After multiple bouts of ventricular fibrillation and defibrillation, the resuscitation team was now dealing with no cardiac electrical activity at all. The monitor was monotonously tracing a straight line and nothing seemed to be working. Mitt wasn’t surprised.
A few minutes later, the clearly frustrated resuscitation team leader happened to cast a distracted glance in Mitt’s direction and then did a double take. “Hey,” she said, staring directly into his face. “You look familiar. Haven’t I seen you on several unsuccessful cases tonight?”
“You have,” Mitt admitted. “One on this same floor and another in the ICU. I’m a first-year surgical resident, and unfortunately I assisted on all three of these patients’ surgeries.”
“Whoa!” she voiced. “All three? Well, thank you for thinking of us. We appreciate the business, but maybe it would be best if you slowed down a tad. Either that or at least provide us with a case that we can cheer about. The amount of cardiopulmonary failure involved with this one didn’t give us much to work with. Without doubt it’s the worst case of thyroid storm I’ve ever seen. Of course, that’s not saying much since it is only my second case, but it’s so much worse than the first to seem like a completely different physiological phenomenon.”
“It was totally unexpected,” Mitt said. “Especially since the patient’s history was hypothyroid not hyper.”
“I guess he’d been saving up,” she said, attempting a bit of dry humor. Then turning back to the group, she called out: “That’s it, guys! Hold up on everything. We’re done here, and we need to move on!” She handed the defibrillator paddles she’d been holding back to the resident manning the machine.
Once again ignored, Mitt stepped away from the bed and watched the resuscitation team and the three on-call medical resident consults work together to start packing up the crash cart and other paraphernalia and clear the debris they’d caused. As they worked, there was a fair amount of general camaraderie and even joking despite the presence of the recently deceased. It surprised Mitt to a degree, just as Madison’s indifference had, and he wondered again if he was destined to respond similarly when he became more acclimated to being a resident. At the moment, it seemed doubtful, but what did he know.
In a kind of daze, Mitt left the patient room and walked back to the nurses’ station, where he requested and was given the appropriate death papers to fill out. Since he was having so much practice with the forms, it took him no time at all to get started, at least compared to his first experience. While he was working, he also made it a point to avoid thinking about his patient-mortality track record as Madison had recommended. Besides, he reasoned, he’d have plenty of time to mull it over during the upcoming holiday that was now just a few hours away.
Some forty minutes later Mitt had finished the forms and was about to head back to his on-call room when it popped into his mind to return to Diego Ortiz’s room one more time to try to come to peace with the situation and deal with the residual feelings of guilt and responsibility that were hounding him despite Madison’s lecture. As he headed back in that direction, he wondered if he was doing the right thing or just being masochistic. There was no way to know.
Entering the six-bedded room, he appreciated that it was now dark and peaceful, with Ortiz’s suite-mates asleep after all the excitement. The curtain at Ortiz’s bed was still pulled out and the reading light was still turned on. Mitt walked up along the bed’s left side, looking down at Ortiz’s sheet-covered corpse. He wasn’t surprised the body was still there. He suspected its removal had to be held up until the death was cleared by the medical examiner.
Although he meant to lift the edge of the sheet to allow him to look directly at Diego Ortiz’s face, his attention was drawn to the IV tubing that snaked out from beneath the sheet. What he was looking at was a second IV line joining the main one. He then looked up at the top of the IV pole where the IV source bags were hung, and as he did so, he recalled the anesthesiologist’s description of having added a micro drip setup to allow a constant, slow infusion of synthetic thyroid hormone not only during the operation but also for days afterward until it was certain the patient could take the necessary medication by mouth.
“What the hell?” Mitt questioned softly as he looked at the micro drip’s source. It was completely empty. To be absolutely certain, he even reached up and felt the empty plastic container. There was no doubt. That meant the patient had gotten many days’ worth of thyroxine all at once, perhaps enough to cause a severe thyroid storm.
Suddenly Mitt was no longer tired as he stared off into the middle distance trying to reconcile what he’d just learned. How could this have happened? Was it a mechanical issue, meaning the micro drip malfunctioned, or had someone purposefully turned up the rate of flow? If so, was it done on purpose or by accident?
Mitt shook his head slowly, wondering what he should do—if anything—and whether he should mention what he’d learned to anyone. Madison was the first person who came to mind, but he certainly wasn’t going to call at that moment and wake her up. Maybe there was a simple explanation for what he’d found that was just eluding him at the moment. Maybe one of the nurses mistakenly turned on the micro drip full blast when they turned off the main IV after Mr. Ortiz’s death. Mitt shrugged. Maybe a lot of things, but it was something he would definitely need to think about, and at that time in the morning after such a busy day he wasn’t at his rational best by any stretch of the imagination.
With an obviously false burst of energy, Mitt power walked out of Diego Ortiz’s room. The situation with the micro drip troubled him. As he turned into the night-darkened hallway, passing the nurses on his way to the elevator lobby, the thoughts about the micro drip were chased out of his mind by concern he might again be confronted by the blond girl, and he slowed his pace. The first time he’d seen her had been in similar circumstances of time and place. But to his relief, there was no blond girl, nor a crowd of surgerized people, nor any rats.
Suddenly Mitt found himself wondering if he might have some control over the hallucinations. Was it possible that the mental process of anticipating them could keep them at bay? He didn’t know, but he thought the idea had to have a certain amount of validity since hallucinations were mental phenomena. At least that was how he explained their absence at the moment. Feeling somewhat reassured he wasn’t going to be hounded, he quickened his step.
When he arrived at the elevator lobby, he checked his phone for the time. It was 3:20 in the morning, but as wide awake as he felt, he rashly decided to go to the cafeteria. He felt suddenly more hungry than tired. Besides, the last thing he wanted to do was go back to the on-call room and potentially end up staring at the ceiling in the dark with no answers to any of his current questions, particularly about all his patients dying. In a few hours, he was going to be off duty for the Fourth of July, meaning he could sleep all day if he so desired. On top of that, he’d heard through the hospital grapevine that the nightshift’s “midrats” were some of the best food of the day.