Harbordale General Hospital
Spokane, Washington
Working in the ICU was the only job Lori Case had had since graduating nursing school. After fifteen years, she was a battle-hardened veteran who was completely unflappable. For the past two days, she had been taking care of Lizette Bordene, Harbordale General’s fourth patient admitted with GNS. Lizette was the assistant manager of a small clothing boutique and the mother of two. Until a few days ago, she had never been seriously ill in her life.
Lori returned from her break to find Lizette’s mother exactly where she’d left her, sitting forward in a small plastic chair at the foot of the bed.
“Why don’t you go home and get some rest?” Lori suggested. “I’ll call you if there are any changes.”
“I’m…I’m not sure. Maybe I should—”
Lori put her hand on Gail Bordene’s shoulder. “Go ahead. She’ll be fine. You need some rest.”
Gail reluctantly came to her feet. With an empty stare, she looked at her daughter. After a few seconds, she removed her purse from the back of the chair.
“I’ll be back in a few hours. You have my cell phone number.”
“It’s written on the board and it’s in my phone book,” Lori assured Gail as she walked her to the door with her arm around her shoulders.
For the next two hours, Lizette’s condition was stable. Lori had resigned herself to another long but uneventful shift. But all of that abruptly changed when, without any warning, Lizette’s blood pressure went into an uncontrolled free fall.
The room instantly reverberated with a cacophony of alarms and alerts. Lori’s eyes flashed to the cardiac monitor. In addition to a dangerously low blood pressure, her pulse was erratic. As a reflex more than anything else, Lori smacked the Code Blue button on the wall summoning the rapid response team. She had barely gotten back to the bedside when Dr. Stephen Arrani and two nurses charged through the door. Lori held Arrani in higher regard than most of the other doctors she worked with because he was knowledgeable and decisive, which were skills that seemed to be lost on many of the newer physicians.
“What’s going on?” he asked, snatching the stethoscope that lay draped across his shoulders.
“She’s crashing,” Lori told him, checking the IV tubing. “Her pressure suddenly took a dive for no reason. It’s down to sixty, and her cardiac rhythm’s all over the place.”
“Looks ventricular. What was her last potassium level?” he asked, cranking up the oxygen to one hundred percent as he snugged the mask around Maggie’s nose and mouth.
“I drew one a couple of hours ago. It was normal.”
By this time, a respiratory therapist and a pharmacist had dashed into the room and had taken up their assigned positions for a Code Blue.
“Looks like she’s in V-tach,” Arrani said. “Give her a dose of lidocaine.”
“I’ve already drawn it up,” the pharmacist said, handing the syringe to Lori who immediately injected it into the IV port. Silence settled over the room as everyone’s eyes locked on the monitor waiting to see if the medication would correct the irregular heart rhythm.
“She’s still in V-tach,” Arrani announced, his voice building in intensity.
“Her pressure’s down to thirty,” Lori said.
“Start chest compressions,” Arrani ordered. “And get a ventilator set up. She’s going to need it.”
Lori was all too familiar with the razor-sharp pinch in the pit of her stomach she was now feeling. As a seasoned ICU nurse, she had taken care of countless patients who had taken an unexpected turn for the worse, but it was something she had never gotten used to.
“She’s not breathing. We need to tube her right now,” Arrani said, craning his neck in the direction of the door. “Who’s here from anesthesia?” Carrie Sherman, the nurse anesthetist on call, moved to the head of the bed. “Are any of the obstetricians in house?” he asked.
“I saw Dr. Crossman up on labor and delivery about twenty minutes ago,” Carrie answered. “He was just finishing up a delivery. He’s probably still here.”
“Tell the unit secretary to find him stat. If we can’t get her heart rhythm back to normal and her blood pressure up in the next five minutes, she’s going to need a crash C-section.”
While Arrani continued to shout out orders, Lori carefully slid a metal scope in Lizette’s mouth. The highly practiced maneuver brought her vocal cords into clear view. She reached for a curved plastic tube and eased it between the cords and down into her windpipe. As soon as she had it securely taped into place, she connected it to the ventilator. Lizette was now completely dependent on the machine for every breath of air that filled her lungs.
“Her pressure’s still thirty,” Arrani called out. “We’re losing her. Where the hell’s Crossman?” He turned back to Lori. “Give her an amp of epinephrine and keep going with the chest compressions.”
Arrani’s words were still suspended in air when Jim Crossman burst into the room with his chief resident in tow. Crossman was one of only three obstetricians on staff who agreed to cover the trauma center. After responding to dozens of critically injured pregnant women who were the victims of serious car accidents, gunshot wounds and stabbings, he was no stranger to performing a crash C-section to save the baby of a dying mother.
“Somebody talk to me,” Crossman said, making his way to the bed.
“She’s a thirty-year-old with GNS,” Arrani answered between quick breaths.
“How far along is she?”
“Twenty-nine weeks.”
“What happened?”
“She went into V-tach and her blood pressure dropped.” He shook his head. “I’m trying, but I can’t get it back up.” His eyes shifted to the cardiac monitor. “She’s going to arrest.”
“How long has her blood pressure been that low?” Crossman asked.
“Four minutes.”
“Any chance you can reverse all this in the next minute or so?”
“I doubt it.”
“Keep up the chest compressions,” he ordered. “If we don’t keep Mom’s heart pumping, the baby doesn’t have a chance.”
At that same moment, two nurses from the operating room with a huge metal box of sterile instruments came through the door.
“I think we should get her ready and move her to the operating room,” Arrani said.
“The operating room is two floors away,” Crossman reminded him. “From what I’m looking at, she wouldn’t survive a change of socks at the moment, let alone a trip to the OR. We’re doing the section right here.” He stole a quick glance around the room. “I need everybody who doesn’t absolutely need to be here to get the hell out right now. What do you say, Carrie? Can I start?”
“Go. She’s not going to move.”
By this time, his scrub nurse, Kate, had carved a path to the front of the room and had set up two sterile trays of instruments.
“We’re ready,” she told him.
“Somebody call the neonatal ICU,” he said, slipping on his sterile gown and gloves. “Dr. Armbrister’s on call. Tell her to get her butt down here right now.”
The stalwart look on his face left no room for misinterpretation. His decision to proceed with the emergency C-section was not up for discussion. “Don’t stop for me,” he told Dr. Arrani. “The sooner you get her heart rhythm fixed, the better chance she and the baby have of surviving.”
He then reached his hand behind him. Kate handed him a sterile metal basin filled to the top with iodine prep solution. There was no time for the usual neat application of a coat or two. Crossman tossed the entire contents of the basin across Lizette’s abdomen. And then, except for the rhythmic snap of the backboard with each compression of her chest, the room again became silent.