Infection Runs Deep

CHAPTER ONE: DIFFERENTIAL DIAGNOSIS

"Code Blue," I yelled, slamming my finger into a button on the wall. "I need a crash cart!"

A piercing siren wailed throughout the air, the incessant blaring signaling a code blue. My patient had lost his vital signs. Code blue signaled a crash team to assist me in reviving him. Trying to, at least.

I glanced at the monitor. V-fib, ventral fibrillation, a shockable rhythm. The heart's electrical signals were scrambled, but still working to move the heart. A shock of 300 volts should reset the rhythm.

"Charge to 300," I asked the charge nurse. A high pitched whir answered. "Clear." I waited for the other doctors and nurses to remove their hands from the patient. I placed the paddles on the man's chest; one just below his left clavicle and the other on his right ribs. I shocked.

His body jolted up, his limbs tensing. No change. Still V-fib, but his BP was dropping fast. "Push one of epi and charge again."

"Right away, doctor." A nurse twisted a syringe of epinephrine into the patient's IV and pressed down on the plunger, sending pure adrenaline coursing through his blood vessels.

The defibrillator elicited another shriek. "Charging," the charge nurse said.

She gave me a nod and I replaced the paddles on the man's chest. "Clear!" I administered a second shock. "Come on," I whispered, checking the monitor. Still no change.

I handed off the paddles to the charge nurse and reached back my arm, swinging my fist down hard into the center of the man's chest, hoping to reset the AV node and get him into a shockable rhythm.

"Hold CPR," I said, holding up a hand to the nurse, never taking my eyes off the monitor.

I exhaled a sigh of relief. "We have sinus rhythm. BP is stabilizing."

But I didn't know how long he would be stable for. The cause of his crashing was still a mystery. I checked the chart, looking for pre-existing medical conditions and reason for admission. On most cases, I would have already seen the chart, but this wasn't my patient.

Well, not only my patient. As a resident doctor, I wasn't fully in charge of any cases. That was the job of the attending physicians. I controlled a group of interns, first year resident doctors, one of which was responsible for the case. While I did rounds with an attending, the interns prepared the cases to do rounds with me.

Rounds were pretty routine. A resident or intern explained the basics of the case. Patient's medical history, vitals, scheduled procedures, differential diagnoses.

I never rounded on this patient. According to the chart, he was an ER admission in between evening and morning rounds. He was one of my intern's responsibilities. They were supposed to come get me if there was a problem. This was definitely a problem.

My watch face read 3:52 am. I stifled a groan. While I was off at 5:30, all I wanted to do was go home and sleep. Forget going home, I just wanted to find an empty cot and pass out. But, I couldn't. I had to find an intern to monitor this patient, finish some charting, and start a differential diagnosis on this case.

Flipping open the patient's chart to the medical information, I flopped onto the visitors' chairs and scanned through the details.

Bob Sanford

Age: 45

Height: appx. 188 cm

Weight: appx. 86 kg

ORGAN DONOR

Walk-in arrival at 3:37 am

Symptoms: fever, rash, chills, chest pain, muscle spasms, lethargy, confusion