ADRENALINE: New 2013 edition (25 page)

Moments later, the respiratory therapist, a heavyset man in his twenties, waltzed in, seemingly without a care in the world and asked, “Is this the patient who needs the breathing treatment?”

“Yes, it is!” Mike shouted. Bonehead! How many other patients do you see here being bagged with a sat in the 60s? “Hurry and hook it up, please,” Mike said, barely controlling his fury.

“How much epi?” said the therapist, unfazed.

“Point three cc’s in three cc’s normal saline!” Mike thought it was an asinine question because the adult dose was always the same. “Hurry, damn it!” Mike roared. “Can’t you see he’s dying!”

“No need to yell.” The therapist methodically hooked up the nebulizer. Steam hissed out from the mask in a large plume. He strapped it tightly to Mr. Tompkins’ face.

After several minutes of breathing the racemic epinephrine, the result was almost miraculous. Mr. Tompkins’s breathing eased dramatically, and his O2 sat climbed into the 90s.

God, that was close
. Mike allowed himself a couple of deep breaths as well. “How’s that, Mr. Tompkins?” he asked.

“Better. Thank you,” said Mr. Tompkins in a relieved voice.

“Feel better now, doc?” the respiratory therapist said and smirked. He packed up his bag and left the room shaking his head and muttering, “Dying—yeah right.”

“Hey, I don’t hear that noise anymore,” Rusty said.

“Yeah. That was inspiratory stridor,” said Mike. “We were dealing with a partial laryngospasm, but I’m not really clear why yet.”

“What’s rasimic epi?” Rusty asked.

“Racemic epi. It shrinks down swollen laryngeal structures allowing him to breathe easier. I think we saved him from being re-intubated and spending the night on a blower.”
And saved me from another man’s death
.

Peg Vargas returned to the bedside and shot Mike a “You-got-lucky-this-time” glare and moved on down the line to tend to more pressing matters.

CHAPTER TWENTY-ONE

“Wow, that was some fancy piece of diagnosis back there,” Rusty said and meant it; he was not engaging in any med student/attending brown-nosing. They were back in the anesthesia control office taking a breather while waiting for the next case to go. He flipped the top on his Pepsi and took a long swig. He admired Dr. Carlucci’s quick thinking; he wondered if he would ever have the skill and nerve to deal with similar situations. “How exactly does that epinephrine work?” Rusty asked. “I’ve never heard of it.”

Dr. Carlucci smiled and took a large gulp of his Coke. “Epinephrine is another name for adrenaline. It’s a powerful vasoconstrictor.”

Dr. Carlucci continued to smile, and Rusty realized he hadn’t seen him this happy since he’d met him. “What’s the racemic mean?”

“That’s an organic chemistry term. Surely, you remember your O-chem, Rusty. You’re a lot closer to it than I am.”

“Well . . .” Rusty felt himself blush. Here we go again.

“It refers to a compound that’s optically active,” said Dr. Carlucci.

“Huh?” What the hell does that mean?”

“Actually, it means a fifty-fifty mixture of two mirror image molecules.” Dr. Carlucci put his hands together fingertip to fingertip to demonstrate. “You know, it’s like a spider doing push-ups on a mirror,” he said and laughed as his hands pumped up and down.

“What’s the point?” Rusty asked, baffled.

“In the body, epinephrine is produced by the adrenal gland. Only the levo-isomer, or left-hand molecule, is actually made. The dextro-isomer, or right-hand molecule, isn’t made because it’s physiologically inert. A racemic mixture contains 50% L-isomer and 50% D-isomer.”

Rusty struggled to follow the explanation. “But you said the D-isomer is inactive as far as the body’s concerned, so why put it in the mix?”

“Good question. When the compound is synthesized in the laboratory, both forms are produced in equal quantity owing to some physical chemistry property that I really don’t remember. It would be very expensive to extract the L-isomer, since chemically the two molecules function identically. Only in a complex biological system, such as an animal or human with stereo-specific receptors and enzymes is there any difference. So they just don’t bother.”

“Oh,” said Rusty woodenly. Then he added with more life, “Wow, I’m impressed. How do you know all that?”

“I was a chem major in college.” Suddenly, a strange look came into Dr. Carlucci’s eyes and his smile vanished.

“Where’d you do your under—”

“Jesus!” Dr. Carlucci shouted and jumped out of his chair, propelling the wheeled thing backward to crash against the wall.

Rusty startled, almost spilling his Pepsi. “What is it?” he called to Dr. Carlucci’s back. He was puzzled—he had never thought organic chemistry was that exciting. He had to run to follow him out the door.

“Tell Raskin to start my next case with a nurse,” Dr. Carlucci called from halfway down the hall. “I’ll be in the library.”

Minutes later, Rusty walked into the hospital library. He was surprised to see how small it was compared to the sprawling layout he was used to at the medical center. An elderly lady with a volunteer button manned the front desk. He quickly spotted Dr. Carlucci at one of the carrels paging through some big reference books. Otherwise the room appeared to be empty, but he couldn’t see behind all of the bookshelves. Rusty flashed the old lady a smile and made his way over to Dr. Carlucci.

Dr. Carlucci looked up, the strange light still burning in his eyes. “It’s the perfect murder, Rusty!” he whispered vigorously.

“What are you talking about?” asked Rusty.

Dr. Carlucci immediately grabbed Rusty’s shoulders and squeezed hard. “Don’t you see?” he asked and a look of such anguish crossed his face that Rusty was shocked. Before he could answer that he didn’t have a clue, Dr. Carlucci continued. “Maybe I didn’t kill him. Maybe I didn’t.”

Rusty wriggled free and backed up a step. “Kill who?” he managed to get out. He was worried that Dr. Carlucci had gone off the deep end.

“Sorry, Rusty,” Dr. Carlucci said. He seemed to get a grip on himself and relax a bit. The anguished look was gone. “Let me back up some. Let’s say someone slips epinephrine into one of your syringes—it wouldn’t take much—only a milligram or so. You push the doctored syringe, pardon the expression, into a patient, and blammo, the pressure goes ballistic, and the heart goes haywire—V-tach, V-fib, you name it.”

“Wow! But wait a minute, I thought you
gave
epinephrine at codes to save people, not kill them.”

“Epinephrine, or adrenaline, is a strange drug, Rusty. A milligram of it is life-saving to someone in cardiac arrest or anaphylactic shock, but give that same milligram to you or I, and you’d likely kill us.”

“Be-zarre!” Rusty exclaimed a bit too loud. The librarian, who had been staring at them all along, cast them a fresh look of disapproval.

“But getting back to murder.” Dr. Carlucci paused and quickly glanced around the room. “The beauty of it is, epinephrine’s a natural compound. That means, A, it’s already supposed to be there and B, it’s quickly degraded by natural enzymes. It would be virtually undetectable, and even if it was, you couldn’t separate it from normal levels.”

“Amazing. So you’re saying someone sabotaged your and Doctor Landry’s syringes—added epi to them?”

“Yes, and both our patients had coronary histories—mix that with high dose epi, and it’s a sure-fire recipe for disaster.”

“Yeah, the perfect murder, all right,” Rusty said. He couldn’t believe he was hearing this.

“Unless . . .” Dr. Carlucci stared off into space.

“What?” Rusty asked anxiously.

“Maybe there is a way—”

“But, you said there’s no way to detect it, didn’t you?”

Dr. Carlucci began to furiously flip the pages of one of the large reference books he had piled up helter-skelter on the table. “Look! Right here!” he practically shouted. He stabbed his finger repeatedly at the page.

“The B t1/2 is the half life elimination time of a drug from the body. The physiologically active L-isomer is degraded on the
order of minutes, but the D-isomer is relatively inert and relies on the much slower hepatic conjugation and renal elimination pathway for the body to clear it.”

“What’re you saying?”

“Doug’s patient from yesterday, Mister what’s-his-name, is still in the SICU. He probably still has some D-isomer in his blood!”

“Holy batshit! Let’s go!”

“How long will it take the lab to run the analysis?” Rusty asked, referring to their newly acquired blood specimen. They were sitting in the doctor’s charting area in the SICU. Dr. Carlucci had two blood tubes in his hand and was writing orders in Mr. Lehman’s chart.

“I’m not sure,” he answered, frowning. “Come to think of it, they’ll probably have to send it out to a more sophisticated lab. Might take a week.”

“That long,” Rusty said. “What should we do in the meantime? Shouldn’t we call Doctor Landry?”

“I’ll call Doug tonight if I get the chance—I’m late-man and all. Otherwise, we’ll talk to him tomorrow.”

A blond nurse glided around the corner. “Did I hear you mention Doctor Landry?” she asked. “Is this about his patient?”

Rusty was surprised by her sudden appearance. He looked at Dr. Carlucci, who had a worried look on his face. He looked back at the nurse. God, she was gorgeous. Her nametag read, Jenny Stuart, R.N. What should they say?

“Just some routine bloodwork,” Dr. Carlucci said and smiled nervously.

She looked skeptical. “I didn’t see any ordered.”

“I’m ordering it now,” Dr. Carlucci said.

She appeared satisfied and then lightened her tone. “Doctor Landry made quite the save, I hear,” she said, eyes sparkling. Rusty noticed she had a killer body too and couldn’t help but stare. Her perfume drifted over to him, and he thought it was quite nice.

“Yes, he did,” Dr. Carlucci replied evenly. He played with his pen and looked hurt.

“Doctor Landry—miracle worker,” she said and sighed. Dr. Carlucci frowned at this but she didn’t seem to notice. “Is it true they call him the Iceman?” she asked.

Dr. Carlucci hesitated a second. He put his pen back in his pocket and looked up at her. “Yes, and his wife and kids think the name’s a riot.”

She didn’t say anything but made an irritated face back at him.

Dr. Carlucci stood up to leave and said, “We’ll take the specimen to the lab ourselves. C’mon, Rusty.”

“Tell Doctor Landry I said ‘hi,’ if you see him,” she said.

Rusty would’ve preferred to stay a while longer and watch Jenny Stuart, but he obediently got up and followed Dr. Carlucci out of the SICU. He glanced back in time to see her pivot lightly on her feet and return to her work; the rear view was equally rewarding.

The two men walked down the corridor toward the lab in silence. Finally, Rusty’s curiosity got the better of him. “Did you hear the way she said ‘Doctor Landry’?”

“Hard to miss,” responded Dr. Carlucci.

“What’s up with that?” Rusty prodded further.

Dr. Carlucci stopped walking and looked at Rusty. “Look, Rusty, let’s not add to the rumor mill. Anyway, Doug’s too smart to get mixed up with the likes of her.”

They continued walking. Rusty decided to drop it. He didn’t really think Dr. Landry seemed like the fooling around type—he was too nice—but you never knew. Besides, thought Rusty, he’d seen pictures of Mrs. Landry. She was quite attractive. Up ahead, Rusty saw the sign for the lab.

“Are you here tomorrow?” Dr. Carlucci asked.

“Actually, no. I gotta take care of some, uh, stuff.” Rusty knew he had plans of his own tomorrow.

“Don’t tell anyone else about this, OK?” Dr. Carlucci stopped several yards from the lab drop-off window and said softly, “We really don’t know who, if anybody, is behind this.”

A chill went through Rusty. “This could be dangerous, couldn’t it?”

“Well, if my theory proves correct, we’re dealing with a pretty nasty individual.”

Dr. Carlucci had a talent for understatement, Rusty thought. Seemed like an attempt at cold-blooded murder. Rusty got another chill and felt both nervous and excited. “Shouldn’t we go to the police?”

“I don’t think so,” Dr. Carlucci said. “All we have here is some guesswork on my part, and I’m starting to have some second thoughts. Maybe Doug’s right—maybe this sabotage thing is crazy.” The fiery light had left his eyes. “If the sample tests positive, that’s a different story.”