“How many times have you shocked?” Lukas asked.
“Three with one dose of epi.”
“What?” came an irritable voice from the doorway.
Lukas turned to find Tex already in the trauma room, snapping the plastic lock from the tool chest-shaped crash cart beside the exam bed. “That’s not current ACLS guidelines,” she muttered.
On the count of three, they transferred the patient from the gurney to the bed, and Tex immediately replaced the leads to the hospital monitor on the woman’s bare chest. The v-fib rhythm continued, with the line racing across the monitor screen above the bed in an irregular steak knife-edge pattern. The monitor emitted a high, continuous beep.
“Well, you got your intubation this time, Dr. Bower,” Quinn muttered. “Hope you’re happy, because it’s not doing her any good.”
Lukas ignored the comment. “What drugs have you given?”
“I just finished the first dose of epinephrine as we pulled in.”
“Then we’ll have to shock again quickly. Stop compressions but keep bagging.” Lukas positioned his stethoscope on the woman’s chest, listened, frowned. “I don’t hear good breath sounds.”
“So? She was obviously in broncho spasm,” Quinn snapped. “She had inhalers, remember? Or weren’t you listening?”
“And you just took that for granted?” Tex’s voice rose like mercury in a hot room. If she saw Quinn’s flush of anger or glare of growing resentment, she didn’t acknowledge it. “Did you even check the placement of the tube when you did the procedure?”
“What good would it do if she was in broncho spasm?” Quinn’s lips thinned and whitened.
Lukas raised his hand for silence and repositioned the stethoscope over the belly. Now he heard breath sounds, and he felt a chill of foreboding. “It’s in the wrong place. The tube’s in the esophagus instead of the trachea.” The oxygen was flowing straight into her stomach. She wasn’t getting any oxygen. “We have to reintubate.” He turned to the others. “Sandra, stop bagging and take over the compressions. Hurry! Tex, get me a syringe, then get the suction ready.”
Tex moved quickly. “It’s one thing to miss placing the tube correctly, Quinn,” she said as she worked. “That’s happened to all of us. But to leave it there…unforgivable! You might as well have placed a pillow over her face and suffocated her! Why didn’t you check?”
Quinn’s jaw jutted forward. “I told you she had inhalers. If you hadn’t made such a big deal about that old man’s tube earlier, I wouldn’t have even wasted my time on this one.” He took a step backward, then pivoted and stalked out of the room.
“No!” Lukas shouted after him. “Quinn! You don’t walk out on a code!”
“Just let him go, Dr. Bower,” Sandra said, her soft voice growing softer as she worked hard to continue chest compressions. “He won’t listen to anybody. I tried to get him to check his work, but he was in too big of a hurry. If I can’t get another partner I might as well quit. This is stupid.”
As soon as Tex handed Lukas the syringe, he attached it to the tiny balloon at the mouth end of the endotracheal tube and deflated the air from the gear that kept it in place. He pulled the tube out of the patient’s mouth and checked the monitor to make sure the rhythm was still v-fib.
“It’s time for another shock. Sandra, bag her again.”
Sandra stood at the head of the bed and placed the bag valve mask over the patient’s face. Tex charged the defibrillator to 360 joules and handed the paddles to Lukas.
“Clear,” he called, and made sure everyone was out of touch with the bed, then pressed the paddles to the patient’s chest. The body jerked into an arch with the sizzle of electric current, then fell back onto the bed. Everyone looked at the monitor. The rhythm had changed.
“All right!” Tex exclaimed. The v-fib had stopped, and now the blip danced across the screen with more powerful strokes.
Lukas pressed his fingers against the woman’s throat, feeling for the carotid artery, and the hope that had flared within him died painfully. There was nothing. “Oh, no. Pulseless electrical activity.” This was worse! They couldn’t break this new rhythm with a shock. What was happening here?
“Sandra, bag her again,” he said.
The nurse from upstairs came rushing into the room, and Lukas gestured to her. “You’re just in time. I want you to do chest compressions.” What could be causing this? “Let’s intubate now, Tex. And let’s get some fluids in.” What would cause respiratory arrest and pulseless electrical activity in such a young woman?
“Dr. Bower,” Sandra said softly, “the bra we cut off her was a nursing bra.” She indicated the young woman. “She’s been nursing. She was all alone outside the apartment building.”
Lukas felt as if he were on a treadmill going twenty miles an hour. He had to keep up. “Carmen, contact the police,” he called toward the secretary as he worked. “They need to check the area for a baby!” He had to focus. If the woman was recently pregnant…severe respiratory distress…pulseless electrical activity…He caught his breath.
“Oh, no, Dr. Bower,” Tex groaned. “That sounds like massive pulmonary embolism.” Lukas nodded. A blood clot in the lung was deadly.
Quinn came rushing back into the room, puffing from exertion and wiping his eyes with the back of his hand. “I’m sorry, Dr. Bower. That won’t happen again. I mean it. I’m sorry. I was just so—”
“Can it, Quinn,” Tex snapped. “We don’t have time tonight for your theatrics.”
Lukas ignored the interruption. “Let’s get her set up for a pacer, and get me dopamine.” Now he knew what to do. But was there time?
Marla drifted in a dark fog, for a few moments far from the pain and cold and terror. But the drifting didn’t last. Her baby…Jerod! She could hear echoes of his cries, and she couldn’t get to him. He needed changing. He would have to be fed again soon, and there was no one to help him.
And then another voice reached her from some distant place…. “We’ve got a pulse….” Marla’s chest hurt again, and somebody was pushing her, hard. Her throat hurt. She felt the pressure in her ribs and heard more people talking around her…. “We’ve got a blood pressure, Dr…” She felt something hard pinch her arm…. “The helicopter’s landing, Dr….”
Something brushed across her shoulder, and light beamed past her closed lids. But she couldn’t open her eyes. She felt the rise and fall of her chest, and the continued sharp pain under her ribs, as if someone was stabbing her from the inside out.
The pain was too much. Even with the echoes in her memory of Jerod’s cries, she couldn’t force past that barrier of pain. She tried to form words on her lips, but something was in her way. She couldn’t speak. Jesus, take care of Jerod. He’s so little and helpless.
She could almost hear her baby’s cries again, wished she were back in the cold, grungy room with wet diapers and neighbors banging on the wall for silence.
And then, as if from somewhere besides the room where she lay, a strong, familiar voice reached her, a voice different from the ones that shot around her with businesslike efficiency. This one was unhurried, calm, even joyful. “It’s time to come home, Marla. I’ll be here with you.”
The sound of the voice permeated her and gave her a feeling of warmth, and she wondered if she were in a coma. But that voice… Dad? She thought the word and heard her own voice, though her mouth did not move.
“Remember the verses I read for you so often when Mom died? ‘The righteous perish, and no one ponders it in his heart—devout men are taken away,