An excerpt from South Eight.
There is little similarity between the stillness of the archer, or of Arkin’s former self on the rifle range, with the organized chaos of a dozen nurses and respiratory therapists and lab technicians pouring into Room 326 of the PCU. And yet there is something of it within him, a stillness descending within the cloud of voices, a fold within the rush of time and movement. He sees: the sleeping man in the other bed awaken with a start as CNA’s unlock his bed and sweep it and him out into the hallway; the lab tech setting out her tubes for the expected orders for blood draws; a nurse beginning a log of events, jotting down the code’s start time; another nurse clamping the Ambubag to the patient’s face as the respiratory therapist begins ventilating; the Lifepac illuminating with its ECG trace. “Hold atropine,” he hears himself say, seeing the coarse and irregular waves of ventricular fibrillation. “Let’s shock him, 120 joules,” his voice sounds a little high, a little above his normal register, and far away, like Judy’s when she says, “Charging.” And then as the Lifepak’s tone whines upward toward full charge: “Clear,” and the assembled dozen or so people back away from the bed as Judy touches the ‘shock’ button on the Lifepak and the electrical charge flashes back and forth in a millisecond between the two pads on the man’s torso, traversing the heart as the body spasms and heaves and the ECG trace changes not at all, and Judy says, drily redundant, “Shock delivered,” followed by his own voice, pitched lower but just as distant as he says, “switch to 200 joules,” and “give one milligram epi,” and someone answers “epi going in.”
***
And in just this state of, if not mere reverie, not true dream, Arkin suddenly revises his sense of his sniper self, his error of self-esteem, for Arkin sees now that in Afghanistan it was not so much that he knew who had to die — anymore that he knows now that this patient in room 326 is about to do so (for the moment Arkin has forgotten his name): it’s that he knew whom he and Kelly were about to kill, which is anything but a subtle distinction when you are the one pointing out targets to the man next to you, who can put a high velocity NATO round through a can of tuna at eight hundred yards. Anymore than predicting the success of this resuscitation — and this thought propagates a wave of sudden near panic on the surface of his reflection — is a subtle art when you are the one in the room giving orders that will or won’t revive someone. Arkin has never actually killed a patient, that he knows, although he also knows it likely that he has done so. Along the line, of the thousands he has treated, first as a resident and now as an attending, he has surely made the fatal error or missed the crucial fact, and either managed to deny the catastrophe-level doubt such a miss would create (as opposed to routine doubt in which he marinates continuously), or more likely managed to block the self-scrutiny that would reveal it.
***
And seven minutes into the code, Arkin is sure this patient will not survive. He has ordered three shocks with two minutes of chest compressions between. He has given two doses of epinephrine, now orders amiodarone, “300 milligrams,” which Judy dutifully repeats, adding “pushing amio” as she injects it into the patient’s saline lock. Nurses are taking turns doing the best they can with chest compressions given the man’s bulk. One of the smaller ones has climbed up onto the bed, kneeling beside his body in order to push directly down on the chest. There has been no change in his rhythm on the Lifepac, beyond what appears to be a slow degeneration of the original coarse fibrillation into a finer waveform. The next step in the process will be asystole, or “flat line” as classic episodic TV would have it, although Arkin has never heard anyone use that term, that he can recall. He struggles also to recall the “H’s and T’s,” the acronym for the causes of cardiac arrest, but can remember only the first two, hypovolemia and hypoxia, neither of which applies in this case, he thinks. The man is hypervolemic if anything, still overloaded with fluid from his heart failure; and the respiratory therapist and the nurse managing the Ambubag clamped to the man’s face are getting good “chest rise” with each squeeze of the bag by the RT, so at least for now there’s pure oxygen flowing to his lungs and presumably, with good chest compressions, to his brain. But what the third or fourth “H” is, much less any of the “T’s,” Arkin cannot recall just now. Instead he feels the fine sweat, not only of panic but of impending humiliation, begin to form on his brow just as a nurse runs into the room to announce blood gas and lab results: “He has a pH of 7.15 and a potassium level of 7.2.”
This is almost miraculous news, not least because the lab has never resulted chemistry so quickly, but also because it reminds Arkin of two more “H’s,” hyperkalemia (high potassium) and hydrogen ion, or elevated acid level. And equally miraculously, Arkin emerges from his dream state into the realization they can be treated the same way: “Bicarb …” and Arkin steadies his voice, in which he’d heard a momentary vibrato of nervousness (unacceptable) or possibly excitement (less so), forcing him to repeat: “Bicarb, give one amp, get a second amp ready.”
And just that quickly, as quickly as the cardiac arrest algorithm has come into focus, Arkin himself focuses more sharply still, can see more of the larger picture: how obesity and the resulting poor respiratory effort, along with pulmonary edema from the heart failure, plus bradycardia and poor perfusion of the kidneys, had caused the acidosis, along with a likely overdosing of potassium to offset aggressive diuresis — whatever — and as all that falls into place for him, and the 50 mili-equivalents of bicarbonate have drained into the patient’s vein, Judy announces, far too coolly, “We have a rhythm.”
Larry Atlas is a nurse practitioner and author of South Eight.
Image credit: Shutterstock.com
