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Tuesday, April 7, 7:20
A.M.

E
xcuse me,” Lynn said as she came up to Dr. Erikson. She extended Morrison’s chart. “Thank you for calling our attention to this case. It is very similar to Vandermeer’s, and we should be following it for sure.”

The hematologist glanced up briefly.

“Should I put Morrison’s chart back in the rack or do you want it here with you?” Lynn asked.

Dr. Erikson pointed toward the desk next to her. “Here is fine,” she said distractedly without looking back up at Lynn.

“I hate to trouble you,” Lynn said, “but we would like to take another quick glance at Vandermeer’s. There’s something we missed.”

Dr. Erikson’s head popped up, and she regarded Lynn with icy blue eyes, and her nostrils flared. For a moment Lynn thought the woman was going to angrily deny her access to the chart. But then her expression softened.

“If it is a bother, we can come back later,” Lynn added quickly. Although she had not noticed it before, now that her attention had been drawn to the woman’s face, Lynn thought that the doctor did
not look well. The paleness of her skin was striking, almost translucent, and her cheeks looked hollow. Beneath her eyes were purplish, dark circles. “I just thought you might be finished with it.”

“It’s not a bother,” Dr. Erikson said. She separated Carl’s chart from those in front of her and extended it toward Lynn, asking: “What year medical students are you two?”

“We’re fourth-year,” Lynn said. Her pulse quickened in anticipation of possible trouble. Now that she was close to the hematologist, she could see that the woman wasn’t exactly overweight, as she had thought earlier. It was more that her abdomen was distended, as if she might be four or five months pregnant, which seemed inappropriate, considering her age.

“And you are on a rotation in anesthesia?”

Lynn nodded. “The specialties are our final rotation before graduation.” She hoped Dr. Erikson would assume anesthesia was considered a specialty at Mason-Dixon, even though it wasn’t: just ophthalmology, ENT, and dermatology.

“Have you come to any conclusions why these patients have suffered comas?” Dr. Erikson asked.

“No, we haven’t,” Lynn said. She was nonplussed, wishing she had not gotten herself into conversation. “Have you any ideas?”

“Of course not,” Dr. Erikson snapped. “I’m a hematologist, not an anesthesiologist.”

Lynn wanted to leave but felt caught as Dr. Erikson was still holding on to Carl’s chart and staring at her with unblinking intensity. After a moment of strained silence the hematologist asked another question: “Do you have any hunches as to what might have happened?”

“Not so far,” Lynn said.

“If you come up with any particular ideas, let me know!” Dr. Erikson said. It was more of an order than a request. Finally she let go of Carl’s chart.

Relieved, Lynn said, “We’ll be happy to let you know if something occurs to us.”

“I’ll be counting on it,” Dr. Erikson said. Then she pulled a professional card from one of her pockets and handed it to Lynn. “Here are my contacts. Let me know right away if you come to any conclusion.”

“Thank you,” Lynn said, taking the card and glancing at it. She smiled uncomfortably and was about to flee back to Michael when Dr. Erikson added, “Do you have any questions for me?”

Despite her fatigue, Lynn tried to come up with a question. She desperately wanted to leave but thought it best to play the medical-student role and keep the conversation academic rather than take the risk of having it turn to what she and Michael were really doing: namely, violating rules and looking at unauthorized charts. “Well . . . ,” she began, “in your consult note in Morrison’s chart you mentioned a possible monoclonal gammopathy. Do you think that was caused by her having had anesthesia?”

“Absolutely not!” Dr. Erikson said with a dismissive chuckle, as if it were the most ridiculous idea she had heard in a long time. “There is no way anesthesia could cause a gammopathy. The patient had to have had the condition prior to her surgery. It just hadn’t been recognized. With an asymptomatic gammopathy, the only way it can be discovered is by a serum electrophoresis, a test she never had had until I ordered one because of her unexplained fever.”

“I see,” Lynn said, trying to think up another question. “Are you doing a hematology consult on Carl Vandermeer?”

“Why do you ask?” Dr. Erikson said.

“Because you have his chart and you did a consult on Scarlett Morrison.”

“The answer is no,” Dr. Erikson said. “I am only seeing the patient as a courtesy since the nursing staff has told me the patient has had a temperature elevation, like Scarlett Morrison, with no apparent signs of infection.”

“Do you think that her fever is due to her gammopathy?”

“Now, that is an excellent question,” Dr. Erikson said.

Lynn breathed a sigh of relief. Now she knew she could break off the conversation without leaving behind an irritated attending who otherwise might be tempted to ask questions and blow their cover.

“An immune response can indeed cause a temperature elevation,” Dr. Erikson said in a didactic monotone. “There is no way to know for sure, but since an infection has been ruled out, I think it is safe to say the elevated temperature is due to her gammopathy.”

“Is something stimulating her immune system and keeping her temperature elevated?”

“I would have to assume there was. Perhaps it’s the stress of what happened to her. But I really don’t know.”

“Is there any treatment for her gammopathy?”

“It is not necessary to treat it unless the elevated protein interrupts kidney function or if the gammopathy progresses to a blood cancer.”

“You mean like multiple myeloma.”

“Exactly. Multiple myeloma, lymphoma, or chronic lymphocytic leukemia.”

“Since Vandermeer has an elevated temperature and no immediate signs of infection, do you think he has a gammopathy?”

Dr. Erikson didn’t answer immediately, and Lynn feared the volatile woman was getting irritated all over again as her eyes had narrowed and her nostrils flared. Lynn berated herself for not leaving when she had the opportunity.

“Vandermeer’s infectious disease workup has just begun,” Dr. Erikson finally snapped. “We’ll just have to see.”

“Thank you for taking the time to talk with me,” Lynn said, and quickly returned to her seat. As she put Carl’s chart down on the desktop, she made eye contact with Michael, who was looking bored.

“Now, that was shooting some real shit,” Michael said, keeping his voice low.

“I’m sorry,” Lynn said with an equally low voice. “I couldn’t get away.”

“Yeah, sure.”

“I’m serious. First she held on to the chart like she did with you and grilled me. She wanted to know what year we were. I thought for sure she was going to question our supposed anesthesia rotation. Luckily she didn’t. One thing for sure, she’s a bit weird.”

“Really? Lay it on me!”

“It’s hard to explain. For a moment it seemed to me she was acting pissed we were here, looking at these charts, which made me fear for the worst. But then her attitude changed. At least I think it changed. Actually my mind is not working at full power as tired as I am, so maybe I’m making all this up. But let me ask you: does she look healthy to you?”

“It didn’t occur to me one way or the other,” Michael said. He started to turn to look over at Dr. Erikson, who was only about a dozen feet away, but Lynn restrained him.

“Don’t look!” Lynn ordered in a forced whisper. “Be cool! I’m telling you she’s weird and could be trouble. Trust me! Let’s not give her any more reason to question us. I really thought she was going to demand to know what we are doing here, looking at these charts. Luckily she didn’t. And tell me this: did you notice her abdomen is distended, almost like she is pregnant?”

“Really?” Michael said, raising his eyebrows. He started to turn to look at the doctor again, but for the second time Lynn stopped him.

“I’m telling you, don’t look!” Lynn snapped.

“I can’t imagine she is pregnant,” Michael said. “She’s no spring chicken.”

“I can’t imagine she is, either,” Lynn said. “Of course, with what’s happening in IVF, it’s not out of the question. My guess is that she has some kind of liver or kidney disease.”

“I suppose it is possible,” Michael said. He was growing bored with the whole situation. He was also starved.

“The strangest thing she said was that she wants to hear if you and I come to any conclusions to explain why Carl and Morrison didn’t wake up from their anesthesia.”

“I hope you didn’t say that you think someone fucked up.”

“I didn’t.”

“Thank the Lord.”

“I said we didn’t have any idea.”

“That’s God’s truth. You’re learning, girl.”

“She made me promise that if we did come up with something, we’d let her know. She even gave me her card.” Lynn showed the card to Michael, who merely shrugged. “You don’t find all this a bit odd?” Lynn questioned. “Why would she be interested in what a couple of medical students might dream up? As an attending she could go to anybody in anesthesia, from the department head on down.”

“Okay, it is strange,” Michael admitted. “Are you happy now?”

Lynn closed her eyes for a moment, as if she needed to reboot. When she opened them again she said: “The last question I asked was if Carl might have a gammopathy like Morrison to explain his fever. Her response was to look mad.”

“Now, that is odd. What did she say?”

“She said his infectious-disease workup had just begun, so we’d just have to wait and see. But she said it as if she was irritated I had asked.”

“Okay, you’ve made your point. She’s weird. Now, how about we make tracks for the cafeteria.”

“Let me look at Carl’s chart quickly.” Lynn opened the chart to the progress note section. There was nothing from Erikson, although when she turned to the orders page, there was a request for a serum electrophoresis, on Dr. Erikson’s order. Lynn looked off into the distance, as if thinking.

“Okay, are we finished?” Michael asked. “Come on! Let’s get out of here.”

“Just let me look at Carl’s blood work,” Lynn said, turning back
to the lab section. “Okay,” she said after a moment. “His white count is eleven thousand. Some people may not consider that elevated, but I think it is. The key fact is that his lymphocytes are also elevated, at almost five thousand, which argues against an infection.”

“That’s great. Now can we go to breakfast?”

“All right, but let me return this chart.”

“Don’t get in another conversation,” Michael cautioned.

“Not on your life. I’m going to give the chart to Peter.”

Their departure was just in time. As they were leaving the central circular desk, all the nurses had finished their rounds and were filing in. Gwen Murphy, the head nurse, eyed the students but didn’t say anything, although she paused for a second to stare. Very little that happened in the neuro ICU went unnoticed during her shift.

Just before Lynn went through the heavy double doors leading out into the sixth-floor hallway, she stopped and hazarded another glance over at Carl. A nurse was at his side, adjusting something. Carl appeared as peaceful as he had earlier. The only discernible movement was from the flexing and extension of his operated leg.

Lynn shuddered. She knew all too well that his tranquillity was in sharp contrast to the mayhem that had occurred in his brain. The MRI and the CT scan had confirmed her worst fears, and the stark reality of his status gave her a new surge of energy and purpose. At the moment she didn’t care that part of her motivation might have stemmed from guilt of possibly equating his bleak future with academic freedom for her. Her intuition, which had always served her well in the past, was sending alarms that something was amiss in this whole affair. She sensed that the hospital was going to be content to let the issue die a natural death, but she was not going to allow it. She would find out what had happened. She owed as much to Carl and future patients.

“Come on!” Michael urged. “Now I’m in as much need of calories as you, and the dermatology lecture isn’t going to wait for us.”

“I’m coming,” Lynn said.

As they started down the hallway, the hospital PA system crackled to life, and like everyone else in the hospital, they stopped to listen. In the old days hospital PA systems provided a constant background of doctors being paged, but that was no longer the case, with smartphones and computer tablets. The Mason-Dixon Medical Center had a hospital-wide PA system, but it was only for disasters. So when the system came on, everyone in the hospital, even in the operating rooms, stopped to listen.

“All available medical personnel! There has been a serious head-on collision on the interstate near our campus involving a bus and a tractor-trailer. As the closest medical center, we will shortly be receiving the most seriously injured. Anyone who can, please proceed immediately to the ER! Operating room personnel, free up as many operating rooms as possible. Thank you!”

Lynn and Michael exchanged a hurried glance. “What do you think?” Michael asked. “Does that include us medical students?”

“We’re almost doctors,” Lynn shot back. “Let’s go!”

They ran down the hallway, effectively dodging nurses, orderlies, ambulatory patients, and food carts to the elevators, but instead of waiting for one, they ducked into the stairwell. As they thundered down the metal steps, they found themselves in a swelling bevy of stampeding doctors and nurses, with more joining at each floor.

Tuesday, April 7, 7:52
A.M.

T
he ER was a madhouse. A continuous stream of injured patients was being frantically wheeled in and distributed to various exam rooms. The trauma rooms had already been filled. Several of the senior ER physicians were doing quick triage out on the receiving dock, as patients were unloaded from ambulances. The more seriously injured were immediately handed off to waiting groups of doctors and nurses who started assessment and treatment even before the gurney got into an exam room. Those patients with relatively minor injuries were rolled off to the side to wait their turn.

Neither Lynn nor Michael had much experience with emergency medicine other than a brief didactic exposure in lectures and a short tour of the department during third-year surgery, and they didn’t know any of the emergency room personnel. Although the house officers they arrived with had a general idea of what to do, Lynn and Michael had no clue. Lacking any specific destination, they ran up to the front desk. At first no one paid them any attention. What
they didn’t realize was with white coats over scrubs, the nursing staff took them for residents, not medical students.

“Can we help?” Lynn asked one of the harried nurses who seemed in charge, as she was directing traffic more than anyone else, hollering orders to various people. She was standing just behind the chest-high counter of the ER check-in desk along with a roiling crowd of almost twenty people. Everyone was busy with phones and paperwork, some abruptly racing off to one of the rooms while others arrived. Over the babel of voices the sounds of sirens could be heard, as more ambulances pulled up outside.

At first the nurse whom Lynn had addressed just looked at her but didn’t respond. Her eyes were distantly focused, suggesting her mind was processing too many things at once. As Lynn repeated her question, the woman recovered from her mini-trance. She reached out and snapped up a clipboard from a pile in front of her. She handed it to Lynn, saying, “Take care of this case! Exam room twenty-two. Male with a mild breathing difficulty. Blunt-force chest trauma.”

Before Lynn could respond, the charge nurse yelled to a colleague across the room to bring down several more portable X-ray machines from X-ray and to get them into the trauma rooms. Then she turned to another nurse behind her and told her to check on what was happening in Trauma Room 1 to see if the patient was ready to be sent up to surgery.

Lynn read the patient’s name: Clark Weston. It was scrawled in longhand on the ER admission form, along with a chief complaint: breathing difficulty, blunt trauma. Lynn noticed the blood pressure was normal although the heart rate was a bit high, at 100 beats a minute. A scribbled note said:
mild dyspnea but good color. Sternal contusion but no point tenderness over individual ribs. No lacerations. Extremities normal. No broken bones.
That was it. There was nothing else. After a quick glance to see if she could again get the head
nurse’s attention—which she decided was unlikely, as she had momentarily disappeared—Lynn looked at Michael, who she knew had read what was on the clipboard over her shoulder. “What do you think?” she asked. “Can we handle it?”

“Let’s do it,” Michael said. Both realized that the head nurse had no idea they were medical students. Both were wearing lanyards with their ID cards around their necks, but one had to look at them closely to see that there was no
MD
after their names.

Despite the chaos and no one to ask for directions, they found Exam Room 22 without much difficulty. The door was closed. Lynn went in first, and Michael followed right behind her, pulling the door closed behind him. The room was an island of tranquillity in the middle of a storm.

Alone in the room, Clark Weston was supine on a gurney but propped up on both elbows, struggling to breathe with shallow, rapid respirations. He was a middle-aged blond man, mildly overweight, and fully dressed in a suit jacket, white shirt, tie, and dark slacks. The tie was loosened. The shirt was open and pushed to the side, revealing a pale, expanded chest with obvious central bruising. Both medical students immediately noticed the man’s color was not good, contrary to what was noted on the admission form. His skin had a bluish cast, as did his lips. His expression was one of desperation. Concentrating on trying to breathe, he couldn’t talk. It was obvious he thought he was about to die.

Lynn ran to one side of the gurney while Michael went to the other. Both felt an instantaneous rush of terror with that sudden realization that this was no mere difficulty breathing, and as neophytes, they were in totally over their heads, facing a patient in extremis.

“I hope you have some idea of what to do,” Michael croaked.

“I was counting on you,” Lynn said.

The patient, hearing this exchange, rolled his eyes before closing them to concentrate on trying to breathe.

“I better get a resident,” Michael blurted, and before Lynn could respond, he bolted from the room, leaving the door ajar.

Left on her own, Lynn dashed over to an oxygen source, turned on the cylinder, and then rushed back to put a nasal cannula around the patient’s head. Placing the bell of her stethoscope on the right side of his chest, she listened. The man was breathing so shallowly and rapidly, she could barely hear any sounds. The competing noise from the ruckus coming in through the open door didn’t help.

At that point Lynn realized how overly expanded the man’s chest was. It was as if he was blown up like a balloon. What did that mean? She tried to think and access her memory banks about what she had been taught in physical diagnosis, but her exhaustion combined with the terror engendered by her feelings of incompetence made it difficult. She vaguely remembered that an expanded chest meant something important, but what? She didn’t know.

Moving the bell of the stethoscope to the left side of the man’s chest, Lynn was surprised to hear almost nothing. At first she thought it was her problem, meaning she was doing something wrong, but then she compared the two sides. It was apparent that she could hear breathing sounds on the right, even if they were bearly discernible, and nothing, or close to nothing, on the left. Suddenly an idea of what was going on began to form in her mind. Taking the stethoscope out of her ears, she tried percussion: placing her left middle finger on the patient’s chest and taping it with the middle finger of her right hand. The resultant sounds between one side and the other were different. The left side was hyper-tympanic, like a drum, compared with what she heard on the right side.

Michael flew back into the room, panting from exertion. “I couldn’t find anyone free. The only person I found was an ER doc two doors down struggling with a dislocated shoulder. He promised he’d be here as soon as he got the arm back in the joint. How is the patient doing?”

“He’s getting oxygen, which should help some,” Lynn shot back. “But he is in trouble. But I think I know what is going on.”

“Clue me in!” Michael demanded.

“Listen to his chest! See what you think. But do it quickly.”

Michael struggled to get his stethoscope in his ears. While he listened first to the left side, then to the right, and then back to the left, he kept his eyes on Lynn, who was taking the man’s pulse. “There’s no breath sounds in the left side,” Michael said.

“Try percussion!” Lynn said. “But do it fast. His heart rate is up to one hundred twenty. That can’t be good.” Lynn could feel her own pulse in her temples beating almost as rapidly.

Michael quickly did as Lynn suggested. The hyper-resonance on the left was immediately apparent, and he said as much.

“Does that ring any bells to you?” Lynn said. “Especially since he has dilated neck veins.” She pointed.

“Tension pneumothorax!” Michael blurted.

“My thoughts exactly,” Lynn cried. “If so, it is a real emergency. His left lung must be collapsed, and with every breath, the right is being compressed. He needs an X-ray, but there’s no time.”

“He needs a needle thoracotomy on the left!” Michael shouted. “And he needs it now!”

In a panic, the two students regarded each other across the body of the patient. For a second they hesitated, even though they were frantic. Neither had ever seen a needle thoracotomy performed, much less done one. They’d read about it, but to go from book learning to actual performance was a giant step.

“How soon do you think the ER doctor might get in here?” Lynn demanded anxiously.

“I don’t know,” Michael said. Perspiration appeared on his forehead.

“Mr. Weston,” Lynn yelled as she gave the man’s shoulder a shake. The patient didn’t respond. Instead he collapsed supine onto the gurney, no longer supporting himself on his elbows. “Mr. Weston,” she
called louder, with a more significant shake to his shoulder. Nothing. The patient was no longer responding.

“We can’t wait,” Lynn said.

“I agree,” Michael replied. The two of them rushed over to a crash cart that had all sorts of emergency equipment. They grabbed a large syringe, a sixteen-gauge intravenous cannula, and a handful of antiseptic pledgets. Then they rushed back to the patient.

“My memory is that it is supposed to be done in the second intercostal space between the second and third rib.”

“You do it!” Lynn yelled, thrusting the cannula into Michael’s hands. “How the hell do you remember such details?”

“I don’t know,” Michael retorted as he quickly snapped on a pair of sterile gloves. He then tore open the sterile wrapping on the cannula. It had a needle stylus to facilitate insertion.

“What if it is hemothorax and there is blood in there instead of air?” Lynn questioned anxiously. “Would we be making it worse?”

“I don’t know,” Michael admitted. “We’re in uncharted territory here. But we got to do something or he’s going to check out.”

Lynn tore open several alcohol pledgets and rapidly swabbed a wide area below the patient’s left collarbone. Michael positioned the tip of the cannula with its needle stylus over what he thought was the correct position. He’d located it by palpating the area and feeling the bony landmarks. Still he hesitated. It was a daunting task to blindly plunge a needle into someone’s chest, especially the left side, where the heart was.

“Do it!” Lynn snapped. She knew that she and Michael were an example of the blind leading the blind, but the needle thoracotomy had to be done, and it had to be done immediately. The patient’s color had deteriorated despite the oxygen.

Gritting his teeth, Michael pushed the catheter through the skin and advanced it until he felt the needle tip hit the rib. He then angled it upward slightly, and pushed again. He could actually feel a pop after advancing the needle another centimeter or so.

“I think I’m in,” Michael said.

“Great,” Lynn said. “Take out the stylus!”

Michael pulled out the stylus. Nothing!

“I guess I have to advance it a bit more,” Michael said. “I must not be in the pleural space yet.”

“That, or we have made the wrong diagnosis,” Lynn said.

“Now, that’s a happy thought,” Michael added sarcastically. He reinserted the stylus and then pushed deeper into the patient’s chest. He felt a second pop. This time when he removed the needle, both he and Lynn could hear a rush of air come out through the needle like a balloon being deflated.

Lynn and Michael’s eyes met. Both allowed a tentative smile. Over the next few minutes their smiles broadened as the patient’s breathing and heart rate improved, as did his color. He also slowly returned to consciousness. Lynn and Michael had to hold his hands to keep him from reaching up and touching the cannula sticking out of his chest while they waited.

“Maybe we should do a residency as a single person,” Michael said. “I think we make a good team.”

Lynn smiled weakly. “Maybe so,” she agreed, pushing away the thought that she wished she were heading up to Boston with Michael.

Just then a blood-spattered ER doctor by the name of Hank Cotter and a nurse rushed in. They went directly to the patient, crowding Lynn and Michael to the side. While the nurse took Clark’s blood pressure, Hank listened to the man’s chest. He saw the needle thoracotomy.

“Did you guys do this?” he questioned.

“We did,” both Lynn and Michael said in unison.

“Collectively we decided it was a tension pneumothorax,” Lynn explained.

“We thought we had to do something, as the patient was going downhill fast,” Michael added. “We didn’t think it could wait.”

“And you guys are medical students?” Hank asked. “I’m impressed. Have either of you rotated through the ER?”

Both Lynn and Michael shook their heads.

“I’m even more impressed,” Hank said. “Good pickup.” Then, turning to a nurse who had just entered, he said: “Let’s get a portable chest film stat and bring in a pack for inserting a chest tube.”

Hank turned back to Lynn and Michael. “Now, I’m going to have you guys insert a chest tube. Are you up for
it?”