Authors: Daniel Palmer
“I still don’t see why you couldn’t have left me at home like I wanted. I would have been fine on my own. Better than being stuck in your office all day.”
Julie shook her head in frustration. “Getting suspended two days for fighting isn’t exactly how to earn trust,” she said in a matter-of-fact tone.
“Well, he started it,” Trevor shot back.
Julie sighed. Trevor always had an answer for everything.
“How come I can’t just stay with Dad?”
“Because your father isn’t home. Believe me. I called.”
“Where is he?”
“In New Hampshire, collecting scrap metal for his next sculpture.”
Trevor seemed to think this was cool. His dad was cool. Of course he would think that. His dad thought homework was a waste of time and sugared cereal was a four-course meal.
“Dad let me weld the last time I was there.” Trevor made this seem like an off-the-cuff remark when he knew he had tossed a barb that would sting.
“He did what?” Julie arched one of her delicate eyebrows and tried to block all sorts of horrible images from her mind. She had seen enough third-degree burns in her career to have some stern words with her ex-husband before this day was over. Paul had good intentions, but when it came to good judgment, he could be worse than Trevor.
“If it sells, I’m going to get a cut,” Trevor announced with pride.
“Well, before you pick out a new iPad with your earnings, ask your father how many sculptures he’s sold in the last few years.”
Trevor looked away because he knew the answer was zero. Paul was quite talented, and his art fairly inventive, but he was not particularly ambitious or motivated. He did not make much money from his sculptures. Julie accepted that, as long as he paid the court-ordered child support. Paul could do this because of a substantial inheritance from a grandmother, one that allowed him to lead an artist’s life. Paul paid his share of the child support on time and with no grumblings, but still Julie wished he’d be a stronger role model for his son.
Sam Talbot would never replace Paul as a father—nor would he ever try—but with his kindness, maturity, and stability, Sam was sure to be important in Trevor’s life. As a high school history teacher, Sam was not exactly rolling in the dough, but the way he loved her and the way she loved him made Julie feel like the richest woman in the world.
Julie set a hand on Trevor’s delicate shoulder. Her son might have been obstinate, disrespectful at times, a little mouthy, but he was still her pride and joy.
“Look, kiddo, you’re here for the day,” Julie said, “so do your homework and try to make the best of it. And I hope you brought a good book, because you’re not going to be glued to your electronics all day.”
Julie tugged on her white lab coat so it fit better over her beige blouse. Everything fit better since she’d lost the weight gained during the divorce. She told people it was diet and exercise, but really the weight came off after she jettisoned the stress. For that, Julie had motorcycles to thank—a Honda Rebel 250, to be precise, which Sam, an avid rider, had bought for her as an engagement gift. Julie was looking forward to their upcoming ride to the Berkshires, and showing Sam the new hip-hugging leather pants she’d bought online from Cycle Gear. But the weekend was several days away, which meant plenty of time for Julie to work, look after Trevor, and feel like she was shortchanging both.
Since her separation from Paul, Julie had come to know a lot of single, career-oriented mothers who tried to be all and do all. Her advice to them, whenever asked: go ride a motorcycle. The moms might not lose the worry and doubt, she explained, but they’d have a blast forgetting some of their troubles for a while.
Julie’s first patient of the day was Shirley Mitchell, a seventy-seven-year-old woman with a nasty case of pneumonia to go along with the initial stages of peripheral artery disease. Despite her illness, Shirley had a fairly decent quality of life. This could not be said for many of Julie’s critically ill patients in the thirty-three-bed unit, who sometimes endured debilitating and costly treatments in order to squeeze out only a few more months of life.
Julie was an advocate for death with dignity. She wrote papers and frequently spoke at conferences with the goal of bringing about policy change. Self-determination was a fundamental right, and the courts were beginning to agree. It was coming to health care whether the providers liked it or not. High-profile cases like that of Brittany Maynard, the twenty-nine-year-old woman dying of brain cancer who ended her suffering on her own terms, would continue to be a force for change. Death with dignity laws did not, as some critics said, kill people who did not wish to die. Julie could produce thirty years of data as proof.
She, and others who thought like her, wanted to take government out of the equation and let the patient and the patient’s doctor come to a decision on what was best. The option to have an option was what Julie fought for, not some death mandate, as her opponents feared.
Her activism, of course, was controversial among her colleagues who viewed her stance as anathema to their profession.
It violates the Hippocratic oath to do no harm. It demeans the value of human life. It will lead to abuse or reduce palliative care options.
All valid arguments, but Julie believed that even those most vocal in their opposition had at some point wrestled with doubt while helping to keep alive a supremely sick patient who wished only to die.
Sometimes dead is better.
Shirley’s nurse was Amber, a petite twenty-six-year-old blonde who one day—not quite yet—might turn Trevor’s head. For now, Trevor seemed oblivious to Amber’s beauty and was content to wave hello from the doorway after Julie made introductions.
“Trevor, you know where my office is. Why don’t you go there now and wait. I’ll come get you for lunch.”
Trevor gave a nearly imperceptible head nod, and away he went.
Somehow Amber had managed to turn Shirley onto her side, not a simple feat given this particular patient’s size, and was applying moisturizer to the backside of her body. ICU nurses were some of the most compassionate Julie had ever worked with. They did an incredible amount of work, almost always with a smile regardless of the unpleasantness of the task.
Shirley was not aware of Amber. She was sleeping soundly, thanks to the propofol, and breathing normally through the endotracheal tube inserted down her throat.
“How was her night?” Julie asked. Since this was the morning shift, Julie would get Amber’s take on what the night nurse had relayed.
“I heard it went pretty well,” Amber said in a cheery voice. “Fever is down to a hundred and one. WBC is fifteen thousand.”
“Fifteen thousand for the white blood count,” Julie repeated, sounding pleased. “That’s approaching normal.”
“And there’s less secretion in her endotracheal tube,” Amber added.
“Less secretions, eh?”
Another bit of good news. When Shirley arrived at the ICU, her chest x-ray showed substantial infiltrate clogging her lungs.
Amber said, “The respiratory therapist titrated down her oxygen and now she’s only on forty-five percent. When I left yesterday she was on sixty.”
Julie went to the Medi-Vac unit mounted on the wall and inserted a catheter down the tube. She engaged the suction, producing a whirring sound, and up came a soupy, yellowish, highly viscous, putrid-smelling liquid. It was less than Julie had expected.
“Looks like Shirley really is getting better,” Julie said. “Maybe today you can give her a wake-up and lighten the propofol.”
Amber acted disappointed. “Shirley can be a handful. I’m really going to miss the milk of amnesia,” she said.
Julie smiled at the long-running ICU joke; the milky white drug had the same color and consistency as the popular over-the-counter laxative. A sleeping patient makes no trouble, said the adage on the floor. But staying on the ventilator long term increased the likelihood of going from sleeping to dead. The breathing tube keeping Shirley alive was also a gateway for getting bacteria into the lungs. Ventilator-associated pneumonia was a real risk. For people already seriously ill, it could be a death sentence.
“Let me know how Shirley is doing when she’s awake. Maybe we can reduce the ventilator further, and if that goes well, we’ll move on with a spontaneous breathing trial.”
If Shirley were able to breathe for two hours under her own power, Julie would consider taking her off the ventilator.
“I’ll get her awake right away,” Amber said.
“Good,” Julie answered.
So far the day was off to a banner start.
A raven-haired nurse named Lisa, dressed in floral scrubs, poked her head into Shirley’s cubicle.
“Dr. Devereux, I need some help. It’s the quarterback. I’m worried. We’re cranking vasopressors, but his BP is unstable and trending down.”
Julie darted out of the room and Lisa fell into step behind her. ICU nurses were not only compassionate, but were some of the best trained in the field. They seldom worried over nothing.
The quarterback in question was Max Hartsock, a six-foot-five, two-hundred-twenty-pound star of the Boston College Eagles football team. Max was in the ICU with kidney failure and on dialysis following an exceptionally nasty MRSA infection. Instead of running plays, he lay on his back, spread-eagled, with a damp sheet covering his barrel chest.
Max’s dark skin was an ashy shade. A thin layer of sweat glistened over muscles bloated with fluid. His numerous tattoos were stretched out and badly misshapen.
Tubes were inserted in all parts of his body. Most of the tubes put medicine into him, but a red one carried Max’s blood to the dialysis machine, which was on and turning in a circular motion, removing waste products and essentially doing the work his kidneys could not. A different red tube put the cleaned blood back in.
A native of Dorchester, Max Hartsock was something of a legend, a local boy from a tough neighborhood who overcame adversity to become a Division I football standout.
Trevor’s dad, who like Julie was a BC alumni, was still slightly obsessed with BC football, and Julie had fond memories of going to the games as a family. Paul’s devotion to the team had rubbed off on Trevor. Her son, a soccer player and self-proclaimed ESPN addict, had plastered his bedroom walls with various Boston sports paraphernalia. In deference to his parents’ alma mater, Trevor designated a special section of wall exclusively for BC football’s annual team poster, which this year featured Max Hartsock front and center.
Julie came to Max’s bedside. “How are you feeling?”
“Like I just got sacked by the entire Florida Gators football team.” Max’s voice came out thick and raspy.
“That good, huh?”
“What’s wrong with me, Doc?”
“Well, a lot. The MRSA infection caused your body to go into shock, which then shut down your kidneys. And now, for some reason, your blood pressure isn’t stable.”
She checked the carotid pulses on either side of Max’s muscled neck. They were regular, but a little thready. Lisa’s concern had been valid. Julie sensed a crisis might be looming and, paradoxically, she relaxed. Maintaining a level head was essential for making smart decisions.
Max had an arterial line in for continuous blood pressure monitoring. Julie glanced at the digital readout: ninety-five systolic, lower than it should have been with all the vasopressors in his bloodstream. He was also running a fever, 102 according to the readout on the monitoring system. He had almost every hookup the ICU had to offer, but nothing could explain why his BP was not stable.
“He’s had a heparin infusion?” Julie asked Lisa.
“A few hours ago,” Lisa said.
Julie gave a nod. This was standard practice for preventing thrombosis during intermittent dialysis.
“I’m already at the max dose of Levophed, thirty micrograms,” Lisa said, as if reading Julie’s thoughts.
“Well, his BP should be higher. Give him fluids while we’re sorting this out.”
“Is that your son?” Max asked Julie in a raspy voice.
Julie spun her head toward the door.
“Trevor, what are you doing here?” she said in a sharp tone. “You’re supposed to wait for me in my office.”
“I needed a charger.”
“Read a book,” she said with a scowl.
Trevor gave Max an awkward wave.
“Yes, that’s my son, Trevor,” Julie said. “He’s actually a very big fan of yours. But he shouldn’t be here.” To Trevor, Julie said, “Should you?”
“That’s okay, Doc, I don’t mind.” It took effort, but Max waved Trevor into the room.
At the same time, Lisa went to the door and yelled into the hall, “Hey, can someone help me?”
A second nurse soon arrived. “What do you need?”
“A liter of saline,” Lisa said. “No, make it two.”
“You’re a BC football fan, eh?” Max said to Trevor.
“Yeah. Big time.”
“Ever go to the games?” Max’s voice came out just above a whisper and Trevor had to lean in close to hear.
“Yeah,” Trevor said. “Saw you play against Syracuse with my dad. Three hundred twenty-five yards passing, three TDs, and no picks. Awesome game.”
Max managed a half smile. “Kid, you know my stats better than me.”
Trevor blushed. “I doubt it.”
“Your mom’s taking good care of me. You being cool with her?”
“Yeah, pretty cool.”
Julie set a damp cloth against Max’s forehead to soak up some of the perspiration. The saline arrived and a nurse went to work getting the bag hooked up. After scanning his body head to toe, Julie double-checked Max’s lines and glanced at the screen of the dialysis machine. She kept an even keel as she ran through her list, conducting a rapid-fire differential diagnosis in her mind.
Two-port line for the dialysis catheter seems okay … no signs of bleeding there … dialysis machine says the blood flow is appropriate … no blockages … lines don’t appear to be stuck against a blood vessel wall …
In the middle of her exam, Max’s BP crashed.
“BP is down to seventy-five!” the monitoring tech called, talking only about the systolic reading, a common practice during an emergency.