This is from the thirtieth chapter from my best-selling book,Bryson City Tales. I hope that you’ll enjoy going back to Bryson City with me each week, and that if you do, you’ll be sure to invite your friends and family to join us.
THE SHOWDOWN (PART 2)
I was making my evening rounds. The days were getting longer and the trees were beginning to bud. The gray days were a little brighter and the spring flowers were starting to poke up through the dirt. Nevertheless, my and Rick’s mood was still as somber as the winter skies had been that year.
The nursery had three newborns who were doing well—as were our other patients in the hospital. I was sitting at the nurses’ station when Maxine Wilson, the evening charge nurse, came over and sat by me.
“Dr. Larimore, we’ve got a problem.”
“There’s a three-year-old in the ICU I think is dying.”
She had my attention. “What’s going on?”
“Dr. Mathieson admitted the little one, Amber, last night.
She’s had terrible diarrhea and was real dehydrated. He couldn’t start an IV, so he started cleisis.”
“Cleisis? What is that?”
“Basically it’s an old, old technique. He just places a butterfly needle under the skin of the thigh and runs IV fluids into the subcutaneous tissues.”
“Why would anyone want to do that?”
“The older doctors only use the technique if they can’t get an IV started. This child’s veins are so collapsed from the dehydration that we can’t get an IV going.”
I knew that Mathieson would be livid if he knew Maxine was telling me all this. She was putting her job at risk.
“What can we do?” I asked.
“Can you do a cutdown?”
She was referring to the technique where a doctor will numb the skin over a large vein and then carefully cut through the skin, dissect the vein, and insert a small plastic tube for an IV access—which could save the life of the patient.
“I can, but won’t Dr. Mathieson go nuts?”
“Normally he would. But he’s out of town. He and Mrs. Mathieson have gone over to Asheville and left instructions that if there’s any trouble with his patients, Dr. Bacon is to be called— not you. But we can’t get Dr. Bacon to answer. So, according to policy, I’ve got to come to you.”
“Let’s look at the kid.”
We walked into the ward. The young couple sitting alongside the child was obviously anxious and pensive. Maxine introduced me to them. I found out that they owned a small business downtown.
I turned my attention to the child, whose breathing was labored and whose pulse was weak and thready. My own pulse quickened. This child was sick—real sick. Her eyes were sunken, her mucous membranes dry and parched. Lungs clear, abdomen soft and concave. Then I saw the thigh—it was bloated and edematous, with a butterfly needle taped to the inside of the upper thigh and connected to IV fluids. Fortunately the pulse in the foot was normal.
“Max, get me a cutdown tray, stat. Also, have the lab prepare for some stat lab work.”
I turned to the parents. “Mom and Dad, I’m Dr. Larimore. Your child is, as you well know, very ill. I suspect that she’s septic—there’s a germ growing in her system that is making her very sick. With your permission, I’d like to numb the skin over her ankle and make a small incision. Through that incision I’ll try to place a small plastic tube into a vein that will then allow us to give her antibiotics and fluids. Is that OK?”
“I’ll also need to do a spinal tap to be sure that she doesn’t have meningitis—an infection around the brain and spinal cord. I’ll need to take just a teaspoon of fluid that I’ll draw from her back. I’ll numb the skin so she’ll feel no pain, and I’ll draw it from the lower back so the needle can’t damage any of her nerves. Is that OK?”
They nodded again.
“I’ll have Mrs. Wilson get you to sign the permission forms, and then if you’ll wait in the waiting room, I’ll come get you as soon as we’re done.”
With tears streaking down their cheeks, they turned to leave. Immediately I empathized with them. I remembered Barb and I shedding tears when we handed six-month-old Kate over to the neurologist for her CT scan—the scan that would confirm a diagnosis of cerebral palsy. I remember how alone and frightened we felt as we waited in the waiting room. If we had only known then what we know now about the power and peace that prayer can bring!
“Folks,” I called after them, “before you leave, would you mind if I prayed for your daughter?” I had no idea how they’d respond. I didn’t even know if they believed in prayer, but I knew I did—and I knew that their child needed it, as did I. They looked at each other with wonder. Then the dad spoke. “We’d appreciate that, Doctor.”
I walked to the girl’s bedside, and her parents stood across the bed from me. I bowed my head. “Dear Lord. Little Amber is so sick. I pray that you might guide my hands as I work. Grant me wisdom as I choose her therapy. Cause her to respond well. I pray that you’d give her mom and dad peace and that you’d bring their daughter home safely to them. Amen.”
I looked up. The mother was softly crying, the dad looked devastated. Maxine was standing by the door, and, to my shock, Dr. Bacon was standing next to her. As the parents turned to leave, the mother began to sob. Her husband gently placed his arm around her shoulders and walked her down the hall.
Harold Bacon, looking rather stern, stepped into the room. He took one look at the child, and his face visibly changed. “Walt, what’s going on?” he asked.
“Dr. Bacon, Max called me to see this young lady when she couldn’t reach you. I think she’s septic, and she’s obviously severely dehydrated. The cleisis that Dr. Mathieson began isn’t working and she needs IV antibiotics. I had the parents sign for a cutdown and a spinal tap. I’d be glad to have you take over if you’d prefer. I know you’re covering for Dr. Mathieson.”
“Son, this girl looks bad sick. Bad. I think we’ll be losing her if’n we don’t act mighty fast. I’ve told Mathieson to stop doing that blasted cleisis.”
I stood there, not sure what he was telling me to do. A moment later, he did.
“Go ahead, son. If you don’t mind, I’ll assist you.”
I nodded gratefully. “Max, let’s get her bladder catheterized, and get me an ABG kit, stat—with extra syringes. I’ll need blood culture vials also.” I pulled up Amber’s gown and located the very weak pulse of her left femoral artery. Maxine returned with the kit. I unsheathed the needle and plunged it into the girl’s groin. She didn’t move. When the needle pierced the femoral artery, the blood began to fill the syringe—but much slower than normal. “Her blood pressure must be low,” I commented more to myself than anyone else.
“Not very red, is it?” observed Dr. Bacon. “Max, let’s get O2 started. Forty percent, humidified, via ventimask.”
“Yes, sir. I’ll call the RT.”
I withdrew the syringe. I had drawn extra blood that I now inserted into the lab tubes and blood culture broth. The rest would be for the arterial blood gases that would measure her blood oxygen, CO2 , and acidity. I handed the tubes to the lab tech who had joined us in the room. “Austin, I need the ABG, CBC, and SMA-7 results stat. OK?”
“Yes, sir,” he responded, scurrying off to the lab as Maxine placed the oxygen mask on the child’s face and started the O2 . Almost immediately Amber’s color improved. “Her respirations are better,” commented Dr. Bacon. “That’s good.”
Amen! I thought. I pulled her legs apart and inserted a catheter into her bladder. Only a small amount of dark, concentrated urine appeared. “Max, blow up the catheter balloon and then let’s roll her over for the spinal.”
Maxine expertly secured the urinary catheter and then rolled the child on her side, folding her into a fetal position. Dr. Bacon was opening the spinal kit atop a bedside tray. I found the anatomic marks that guided me to the L4-L5 interspace and marked it with my fingernail—making a small indention in the skin. Once again, Amber offered no resistance. I gloved and then prepped and draped her lower back. I raised a bleb of lidocaine just under the skin where I had made the indentation. The spinal needle passed easily into the spinal canal and the clear fluid began to drip out of the end.
“Harold, I’m not going to take the time to measure opening and closing pressure. The way this is dripping so slowly, I don’t suspect high pressure and I don’t think we have the time to wait.”
“I agree, son,” he nodded. “It does look pretty clear.”
“Yeah,” I agreed. “I’m sure glad it’s not milky or cloudy”— either of which could have indicated a severe case of meningitis. I let about a teaspoon of the fluid drip into each of three sterile plastic collection tubes, then removed the needle and placed a Band-Aid over the puncture wound.
Dr. Bacon actually smiled at me. “You’re doing good, son. Two down and one to go.” I appreciated his encouragement and affirmation, but the fact was that we were still in pretty deep weeds, and the hardest procedure was yet to come.
I turned my attention to the little girl’s ankle. I was thankful for my training at Duke, which gave me the education and experience I needed for these critical cases. I palpated her ankle’s anatomic landmarks and made a mark on the skin above the vein I prayed would be underneath. I prepped and draped the ankle—and then regloved with a new pair of sterile gloves. I anesthetized the skin with lidocaine and then quickly made a two- to three- centimeter incision through the skin. A curved, blunt mosquito clamp allowed me to dissect the subcutaneous tissue. Then, right where it should be, appeared the large vein I was looking for.
“Hallelujah!” exclaimed Dr. Bacon, obviously as relieved as I was.
I exhaled a sigh of relief and felt a tremendous pressure ease off my shoulders. Thank you, Lord! The vein was flat, indicating not much blood flow, but was large enough to receive a catheter that would begin the flow of lifesaving medicine and fluids into Amber’s body. I tied the catheter in place and started to close the wound. By now, Dr. Bacon had gloved and assisted me by snipping the sutures as I tied them off.
“I really should be assisting you, Harold.”
“Nope, Walt,” he reassured me. “This is just fine. Just fine.”
As Maxine dressed the wound, we looked at the lab results.
They were terrible. The white count was low, indicating severe sepsis as her system was running out of infection-fighting warriors. The electrolytes were grossly abnormal. I quickly calculated her fluid needs and wrote orders for frequent vital signs, fluid and electrolyte resuscitation, and large doses of three different IV antibiotics.
As I was starting to jot a brief note in the progress notes, Austin brought us the initial spinal tap results. Dr. Bacon looked them over. “No red cells, no white cells, no bacteria, normal glucose and protein.”
“Good,” I sighed. “No sign of meningitis.”
I turned to Dr. Bacon. “Harold, since you’re covering for Dr. Mathieson and since you know these folks, how ’bout you give them the good news. OK?”
He smiled and looked down at his feet.
“I’ve got to finish the notes and then dictate. Don’t let me keep you.”
He nodded and then proceeded toward the waiting room. I was finishing my dictation when Maxine stuck her head around the corner. “Thank you,” she whispered. “Good job!” She was beaming like a proud mother.
I nodded. She had been a nurse for several decades. She had seen just about everything. Her compliments were given rarely and were sweet indeed for any young physician.
One week later, little Amber skipped from the hospital lobby to her dad’s waiting car. Other than a sore thigh, which was still swollen, she was fine. We never knew the source of the sepsis, but many times we don’t. I was just delighted that she had done so well.
- The Murder (Part 1); (Part 2); (Part 3)
- The Arrival (Part 1); (Part 2)
- The Hemlock Inn (Part 1); (Part 2)
- The Grand Tour (Part 1); (Part 2)
- The Interview (Part 1); (Part 2); (Part 3)
- Settling In (Part 1); (Part 2)
- First-Day Jitters (Part 1); (Part 2)
- Emergency (Part 1); (Part 2)
- The Delivery (Part 1); (Part 2)
- The “Expert” (Part 1); (Part 2)
- The Trial (Part 1); (Part 2)
- Shiitake Sam (Part 1); (Part 2)
- Wet Behind the Ears (Part 1); (Part 2); (Part 3)
- Lessons in Daily Practice (Part 1) — Anal Angina; (Part 2); (Part 3); (Part 4)
- White Lies
- The Epiphany (Part 1); (Part 2)
- Becoming Part of the Team (Part 1); (Part 2)
- Monuments (Part 1); (Part 2)
- My First Home Victory (Part 1); (Part 2)
- Fisher of Men (Part 1); (Part 2)
- Fly-Fishing (Part 1); (Part 2)
- Something Fishy (Part 1); (Part 2)
- A Good Day at the Office
- An Evening to Remember
- Another New Doc Comes to Town
- ‘Twas the Night Before Christmas (Part 1); (Part 2)
- A Surprising Gift
- The New Year (Part 1); (Part 2)
- The Home Birth (Part1); (Part 2); (Part 3)
- The Showdown (Part1); (Part 2); (Part 3)
© Copyright WLL, INC. 2017. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.