The Second Opinion, page 4
“The name Sperelakis is worth millions in referrals,” Niko added. “They asked us if we thought you’d agree to take over Petros’s practice, and all we could tell them was to ask you, but that you were a great doctor. We had no idea they’d charge in and bring it up right after you’ve stepped off the plane.”
“You know I’d never succeed in this setting, Niko.”
“I’m not so sure,” Selene said. “You’ve managed to succeed in almost anything you’ve ever done. Please don’t be angry with us, baby. We’ve got enough to deal with right here.”
Thea looked over through the forest of tubes. Petros, his raccoon eyes and battered face making him a grotesquerie of the powerful man who had ruled their home, was lying peacefully on his back, being attended to by a tall, young unit nurse named Tracy. Vernice, the nurse who had volunteered to help with his bed care, was gone.
His splinted hands were restrained to the sides of the bed against the remote chance that he might suddenly wake up and pull out his arterial line or IVs or his tracheotomy tube. The top bedsheet had been pulled aside, exposing him and revealing his penis and urinary catheter. One indignity piled on the next.
High on the wall, the monitor protruded on a mobile arm, displaying various param eters as continuous tracings and numbers in different colors. Blood pressure and mean arterial pressure were red; heart rate yellow. Central venous pressure, indicating the volume of blood returning to the heart, was blue. Oxygen saturation, core body temperature, respiratory rate, and spinal fluid pressure were being continuously recorded as well. Many times over her years in medicine, Thea had seen overwhelmed, impotent, often bored visitors to patients in the ICU staring up at the monitor screen as if it were televising some sort of sporting event.
Almost subconsciously, she herself scanned the screen, making a mental note of the various tracings. Details, always details. Three of the tracings resonated to a mild extent—a drop of five in the mean blood pressure, the appearance of occasional extra heartbeats (one or two every minute), and also what seemed like a slight change in certain portions of the individual heartbeat tracings. The observations were not enough to trigger any alarms, and also not the sort of thing neurotypicals were likely to pick up on. They were just . . . there.
“Okay,” she said to the twins. “I’m sorry to have gone off at you like that. You’re right. We do have our hands full.”
The extra beats were of little concern to her, and in many instances, at a rate of only one or two a minute, were the result of stress, mucus in a bronchial tube, or even a stimulant such as caffeine. In fact, Petros was on some IV theophylline, a bronchial tube dilator for wheezing that often stimulated heart muscle irritability. But Thea felt certain that the subtle changes in what was known as the PQRST complexes of Petros’s cardiogram were new from when she first arrived in the unit.
“. . . starting with the health care proxy Father left,” Selene was saying.
The news startled Thea’s focus away from the monitor.
“He left a proxy?” she asked, surprised that no one had mentioned it before now. “What does it say? Who did he appoint to administer it?”
“Actually,” Selene replied, sweeping a wisp of errant hair back into place, “it doesn’t say much. It turns over all decisions regarding his treatment to the four of us.”
“The four of us?” Now Thea was incredulous. “Did he leave a living will?”
Selene shook her head.
“None that anyone’s been able to find. His secretary had the proxy in a file with our names on it. We have the power to decide if heroic measures should be instituted or continued, but only if we four are in agreement.”
“Including Dimitri?”
“Including Dimitri.”
Selene’s expression and tone made it clear what she thought about including their oldest sibling.
“Petros Sperelakis, the master of control,” Thea said.
“Right to the grave,” Niko added. “There’s a copy of the proxy in his record. We’ve already signed off on it.”
“Did Dimitri sign?”
“Not yet. I don’t think he’s even been here more than once. The proxy doesn’t really say anything other than we four must concur on any action.”
“In that case I’ll be happy to sign.”
“But you’re not certain what you want to do about instituting heroic measures?”
“Niko, look at him. We’ve already instituted heroic measures.”
Out of the corner of her eye, Thea saw an increase in the frequency of the VPBs (ventricular premature beats) from one or two a minute to four or five. Something was irritating the electrically charged cardiac muscle, possibly the theophylline, she was thinking, although a number of other possibilities began marching through her mind. She glanced about for the intensivist—the specialist in critical care medicine—but he didn’t seem to be in the ICU.
“I see what you mean,” Niko was saying, “but that still doesn’t answer the question of what to do if—”
“Tracy,” Thea cut in, “what’s up with these extra beats?”
“I just saw them, too, Thea,” the nurse said.
“His pressure’s dropped as well.”
“He’s been having some VPBs all day, but this is more. I’ve been here with him all afternoon. I can page the intensivist. He’s at dinner.”
“I think it’s okay if he’s not going to be too long, but do what you’re comfortable with.”
“What’s happening?” Selene asked.
“There are some very small changes in his monitor—widening of the QRS complexes and also some subtle changes in the QT interval and the PR interval.”
“You are too much.”
“I’m not sure I agree with you about the changes, sis,” Niko said.
“Well, Niko, you’re the cardiac surgeon, but I have the tendency to notice such things. Something could be off with his electrolytes, maybe his calcium. He’s on theophylline, which can contribute to that, and also a diuretic that can do the same thing. Is he on any kind of antacids?”
“He’s been getting ranitidine IV,” Tracy said. “Dr. Kessel likes to use it in patients on steroids.”
Thea felt a tension materialize in her throat. Something was definitely wrong.
“Well, I think you should order a full twelve- lead EKG,” she said to the nurse. “Also, I would stop the theophylline for the time being and send off a tube to the lab for electrolytes—sodium, potassium, CO2, and chloride—as well as for free or ionized calcium, what ever they call the test here; just not total calcium.”
“Right away,” the nurse said. “I am going to page Dr. Kessel. It’s a hike from the cafeteria to here.”
“Fine. Selene, perhaps it’s worth paging Dr. Hartnett as well. He’s Dad’s primary care doctor.”
“What do you think is going on?” Niko asked.
“I don’t know, but something’s different than it was earlier today. I’m almost certain of it.”
“What ever it is, don’t you think we should just let it happen?”
“What?” Thea was incredulous.
“Look at him, Thea. He’s a vegetable. Existing like this is nothing he ever would have wanted.”
“Then why didn’t he say so? He took the time to write a proxy. He could have written a living will.”
“Honey, he was always so busy and so distracted,” Selene said. “He probably meant to and just never got around to it. We need to just let him go. We’ve all encountered enough patients with severe head injuries to know where this is going. This isn’t the man who was our father, Thea. It never will be again. Why torture him?”
“It’s too soon,” Thea said.
The twins glared at her.
“If he could speak,” Selene said, an edge to her voice, “he’d scream at us to just let him go. This may be the chance to do it.”
“You know the man, sis,” Niko said, “and you know where this is headed. Be reasonable.”
“Niko, I don’t know where this is headed. I agree that the odds favor a poor outcome, but we only have one father and he only has one life. Is there any reason we can’t see this through for a little while longer?”
“Let me think,” Niko said. “For starters, he could be in terrible pain. We have no way of knowing that. For seconds, a great life is grinding to a halt in total humiliation. Catheters and bed baths for a man known around the world for his brilliance and caring. For thirds, the worst thing that could happen is something truly terrible. We could succeed in keeping him alive. One of the greatest medical minds of our times reduced to being lashed to a chair in the hall, soiling himself, drooling on himself, incapable of speaking, and unable even to hold his head up straight. It would be a hell of a lot easier for everyone if we just choose to throw our lot in with benign neglect—with choosing not to intervene. That way we don’t have to plug in the morphine drip and take an active hand in his end.”
“It’s only been eight days. There’s something going on here, Niko. Right now. Whatever it is could very possibly be reversible. We need to try and figure out what that is and treat it. We don’t have enough information to make the decisions you’re asking us to make.”
“Thea, we understand where you’re coming from,” Selene said, “but we’ve been here with him every day. You haven’t.”
“That’s exactly the point, Selene. I just got here. I need more time with him before we . . . before we let him go. Can’t you understand? Niko, look. Look at his neck veins. I think they’re becoming distended. Do you think the chest trauma could have caused bleeding around his heart?”
“Tamponade?” Niko said, with no more than a glance at their father’s neck veins. Distension of them was one of the first signs that blood or other fluid was accumulating and causing life- threatening pressure to build up between the pericardial membrane and the heart muscle itself. “After eight days? Doubtful. Almost impossible. Besides, I don’t think there’s any distension at all.”
“But look,” Thea said. “His blood pressure’s dropped and his venous pressure has gone up and he’s having those extra beats. It could be tamponade.”
“Or too much calcium or too little potassium or a drug reaction or an internal hemorrhage, or just an old man’s old heart giving up. Thea, be reasonable.”
At that instant, with no increased warning whatsoever, one of the errant premature beats fired off precisely on the ascending portion of the following T-wave, and Petros Sperelakis’s heart stopped.
CHAPTER 6
Thea felt herself go cold.
Her father’s heart was in ventricular fibrillation. The powerful cardiac muscle was quivering impotently within his lion’s chest like so many strands of spaghetti, unable to generate a heartbeat in any organized fashion. The colored monitor readings overhead were recording the disaster.
Pulse 0 . . . Mean arterial pressure 0 . . .
Selene had run off to page Scott Hartnett. The ICU intensivist was heading across campus from the cafeteria.
The biological clock of brain death had begun ticking the instant Petros’s heart had stopped.
Thea’s own heart felt like an expanding balloon, her stomach a pit of molten acid.
Calcium . . . potassium . . . Perhaps it was an abnormality of one or the other of those, she thought desperately. Or maybe some drug toxicity. Or maybe tamponade.
“Tracy,” she heard her voice say with no great authority, “please call a Code Blue.”
To one side of the cubicle, Niko stood, his arms folded, his face stone.
“Code Blue Medical ICU . . . Code Blue Medical ICU . . . ,” the overhead page operator’s voice droned from speakers outside the unit. “Code Blue Medical ICU.”
Tracy raced in with the crash cart and immediately reached up and hit the button that started the red sweep- second hand on the code clock set high on the wall over the door. The time started at zero, but Thea knew fifteen seconds or more had already elapsed. Every one of those seconds diminished the likelihood of a successful resuscitation and increased the evolving brain damage. The point of no return in any cardiac arrest was felt to be four minutes. No blood pressure beyond four minutes, unless deep body cooling had occurred from exposure or drowning, and brain damage would be irreversible. The only way to extend the four minutes was through effective CPR.
Seconds later, the hospital CEO and nursing supervisor were there, along with one of the other ICU nurses. Amy Musgrave took up the Code Blue clipboard that was hanging by the door and began recording the event.
“I’ve got this, Susie,” she said to the nurse. “You help Tracy. Where’s the intensivist?”
“On his way from the caf.”
The first technician arrived pushing her EKG, and began hooking Petros to the leads of his machine. Inhalation was next, then the evening nursing supervisor, who saw Musgrave handling what would have been her role had the chief not been there, and backed out of the rapidly filling cubicle.
Thea glanced at the door, her mind unwilling to grasp that this was her show. The code clock was nearing thirty seconds. She was off to a terrible start.
Do something! her mind screamed. This is your father. Do something!
She had taken, and of course passed with top marks, any number of advanced cardiac life support courses. She had instant total recall of the step-by-step problem- solving algorithms related to cardiac arrest.
Rhythm: ventricular tachycardia . . . Institute basic life support including chest thump . . . Give amiodarone 300 mg IV and prepare to defibrillate at 200 joules . . .
All she needed to do was compensate for the wave of anxiety that seemed to be smothering her. Over her years of training, she had participated in a number of codes, but almost always, she had deferred control to one of the other docs. In Africa, more than a few of her patients had died, but a cardiac resuscitation was seldom successful when nothing could be done about the underlying condition that had caused it. And with the populations she was caring for, there was no shortage of lethal underlying conditions.
Suddenly, she was at the bedside, delivering a sharp blow to Pe-tros’s sternum with the side of her fist, and beginning chest compressions over the same spot.
“Niko, you outweigh me by seventy-fi ve pounds,” she said over her shoulder. “You should be doing this, not me.”
There was no response from her brother.
“Oh, Niko,” she groaned.
A burly resident entered the cubicle.
“What do you need?” he asked
“Some good, strong compressions,” Thea said, stifling the white-hot burn she was feeling toward her brother.
The resident moved in and began what Thea felt was adequate pumping, rhythmically squeezing Petros’s heart between the underside of his breastbone and his spine. She set two fingers on her father’s groin and felt a soft-but-definite jet of blood with each compression. Not great, but good enough provided it did not take too long to reverse the fibrillation.
The code clock swept past forty seconds.
“Two hundred joules,” Tracy said.
“Amiodarone in,” the other nurse reported.
Thea took the paddles of the defibrillator, placed one to the left of Petros’s sternum and the other lower and farther to the left. Then she glanced back at her brother, who hadn’t moved.
“Two hundred joules! Everybody clear!” she called out.
The muffled pop of electricity jerked Petros’s restrained arms upward. Then just as quickly, they dropped back to the bed.
“Sinus rhythm,” Musgrave called out excitedly. “Nice going, Doctor.”
“I’ve got a pulse,” Thea said.
The normal rhythm lasted only twenty or thirty seconds before deteriorating, once again, to ventricular fibrillation.
“Resume compressions, please,” Thea said to the resident. “One milligram of epinephrine IV, please, Tracy. Prepare to shock at three hundred.”
“Three hundred,” the ICU nurse said, setting the defibrillator.
“Three hundred,” Thea said, now totally immersed in the resuscitation and in replaying the algorithms in her mind. “Ready, clear!”
Again the odd pop; again the marionette-like jerk of Petros’s arms; again the short- lived appearance of a normal rhythm before the reversion to fibrillation.
Thea felt the tension building once again. The sweeping second hand on the code clock passed two and a half minutes. On the bed, Petros lay rather serenely, his eyelids taped down, the ventilator supplying oxygenated, humidified air with a steady, repetitive whoosh. They would continue until there was no effective heartbeat and no hope of getting one, but unless something was done to deal with what ever was keeping the normal rhythm from rapidly deteriorating, the conclusion of this affair was foregone.
“Resume compressions, please. Could someone send for the ultrasound tech and bring me the kit for doing a pericardial tap?” Thea asked.
She wondered if her voice sounded as strained to everyone else as it did to her. She also wondered what people thought of Petros Sperelakis’s cardiac- surgeon son, who remained a statue outside the crowd around the bedside.
I can’t let him go like this, she was thinking. I have to find the answer.
Thea pressed her fingers into her father’s groin once more. The pulse being generated by the resident was significantly less forceful.
Where was the intensivist?
“Are you getting tired?” she asked the resident.
“A little.”
Niko, what are you doing? Help us!
“Just give me one more good minute,” she said.
“You’ve got it.”
The compressions intensified and the resulting pulse became sharper. Three and a quarter minutes.
“Pericardiocentesis tray is ready, Doctor. Gloves are right here. Six and a half okay?”
“Perfect.”
Don’t die like this, Dad. . . . Don’t die like this.
Was it worth waiting for the ultrasound to demonstrate that there was or wasn’t fluid pressing in around the heart? Absolutely not. Even with adequate CPR, there was ongoing brain cell death by the second. The pericardial tap had to be done now. The problem was that except for working on a cadaver in medical school, she had never done one. The anatomy presented no problem, but the technique might.
