Recently, I have been working with a writer who has a medical background. When I read her hospital scenes I find that I become completely immersed in the drama; I feel that I’m there. She uses professional jargon and terminology with skill, providing enough context so that the reader has a good idea of what is going on, without her having to stop the flow to explain.
I asked Joan if she would mind contributing a scene so I could show you what I mean. Happily, she agreed… so here’s a scene showing how an anaesthetist in a new environment (working as a locum) copes with a tricky situation. Note how the scene moves the story forward by giving him some insight into his troubled relationship with Ryan, the son of the woman he is seeing.
When you read it, think about how you might use some of your own technical/professional knowledge or skills in a scene in your own book.
The patient looked like Ryan. Just a little smaller, if that was possible.
Dakota patted the OR bed, and addressed the little guy. “Come on over here, Logan. This is where all the action takes place.”
Working locums was a bit like driving an exotic car in a foreign country, he realized. He could keep things safe, but since each little piece of equipment –and every bell and whistle on the anesthesia machine – was in an unfamiliar spot, he had to be super vigilant. How the hell had Lee done it all these years?
He had to stifle a grin as Logan wiggled from the transfer bed to the OR bed, taking great care to stay covered with his blankets. “Do I have to take my clothes off?” the child asked with as much poise as a scared, vulnerable kid entering puberty could muster.
He decided to not point out that Logan’s only ‘clothes’ was a flimsy hospital gown.
“Patients ask that all the time,” he lied. “The answer is: never, really. With some operations, patients are naked, but your hernia surgery isn’t one of them.” He and the circulator began applying monitors. “After you’re asleep, we’ll pull your gown up a little. Then we’ll put paper drapes over the bottom of your torso and legs. There’ll be just, like, a four inch square of belly showing when the surgeon comes in, and all during the surgery. We want you as covered as possible, so you don’t lose heat. The drugs to keep you asleep work better if you’re at a normal temperature.”
For children, he knew, the fear of pain was just part of the emotional trauma. Separation from parents, body image issues, and inability to communicate all added to the stress. Still, he’d always prided himself on his finesse with pediatric clients. When he’d worked at St E’s, the staff had frequently requested that he give anesthesia to their own kids.
How had he failed so spectacularly in communicating with Ryan?
He wiped a streak of glue-like material inside a child size anesthesia mask. Bubble-gum scent. Then, tried to forget what had been at St E’s. And what had been with Grace, and Ryan. And what might have been.
Focus, he commanded himself. He took a few extra seconds to re-check crucial safety elements: IV was running well…Logan had no allergies, no family history of anesthesia complications… suction worked well …it all checked out.
The induction went smoothly. After his patient was asleep, he eased a laryngyl mask into the child’s airway, then turned on the ventilator and anesthetic gasses. With any luck, he wouldn’t have to chemically paralyze this kid, and later reverse those paralytic drugs with other drugs. In this case, less was better.
He looked up as the surgeon came into the room. “I’m going to try to get away with no muscle relaxants, so just tell me if he moves, and I’ll take care of it.”
“Okay. It’s hard to hit a moving target, but God knows it wouldn’t be the first time.” He seemed like a congenial old fellow.
When the circulator started scrubbing Logan’s abdomen with Betadine solution, he heard the beat of the pulse-ox accelerate. Why? Was the child’s anesthetic too light? Did he need to deepen it?
He looked at the readings for exhaled gases, and the index for brain activity. The kid had plenty of anesthetic on board; maybe he was just a little dehydrated. The heart had probably gained speed trying to keep up a decent cardiac output – trying to compensate – as the anesthetic lowered the blood pressure.
He opened up the thumb-drive on the IV line, allowing a bolus of fluid to enter the patient’s circulatory system. That should help.
“Everything all-right, Dakota?” The circulator kept scrubbing the abdomen, but looked directly at him. Evidently concern had shown on his face – or she wouldn’t have asked.
“Yeah, I think so.” He looked at the monitors again. The CO2 was up. Why? A bad feeling began to creep into his mind. “CO2’s sixty.”
The surgeon stopped drying his hands on a surgical towel, and looked at Dakota, then at the monitors.
“I’m giving him good tidal volumes. Sat’s 100%.” He pointed to the numbers on the anesthesia machine display, then looked at his patient. “And, chest is rising and falling well with each breath. So, he’s not building up CO2 from lack of ventilation.”
He suspected, though. Malignant Hyperthermia. The name said it all. Traveling high temperatures. On rare occasions, an anesthetic agent triggered a sharp escalation of the patient’s metabolism, causing extreme temperatures – which traveled wild. If his suspicions were correct, the child could burn to death from the inside out. If true, his best hope was a drug called Dantrolene.
If it was MH, and even if they treated the condition perfectly, he knew, there was still a 10% chance the child was going to die.
The pulse rate continued to climb. 140’s…150’s…shit. The circulator had joined the scrub tech and surgeon in standing still and staring helplessly at the monitors.
He reached forward to try to move the child’s jaw. It was almost impossible. In that moment, the reality of the situation hit him as surely as if a semi – one that had previously been swerving – had now crossed the center line and was veering straight at him.
“I’m calling it. We’ve got a MH crisis, here.” He looked at the surgeon. “Break scrub. Call the Malignant Hyperthermia hotline. Get ‘em on speaker phone. The number’s on the red sticker on the phone.” He quickly shut off the anesthesia gasses, and switched to 100% oxygen.
Thankfully, the doctor seemed familiar with the idea. They’d undoubtedly done MH drills once a year.
“Are you sure? Is his temp up?” The scrub tech tried to reason; tried to be logical.
“No – but that’s a late sign. And yeah, I’m pretty sure.” He’d only seen it one other time, back in training. But the signs were there: male child, exposed to anesthesia gasses, vital sign acceleration…jaw rigid, muscles tight.
The scrub tech tried to reason, again. “But he’s had surgery before – an appy just last year.”
“Doesn’t matter.” He knew his voice was getting terse, but dammit. They had to stop the terrible cascade of events.
Thankfully, the circulator had the presence of mind to face the reality of the situation. “I’ll get the MH cart,” she said, and ran out of the room.
“I’ve got ‘em on the line!” the surgeon announced.
“Hello? Hello? Can you hear me?” came a voice over the speaker. “I’m Doctor Reddy from the MH crisis center. Can you hear me? Can you tell me what’s going on?”
“Just give me one second, Dr. Reddy. Please stay on the line.” He needed to do several things at once, and found himself simply pointing directly to each member of the OR team to assign duties. He hadn’t worked with these people enough, and right now he couldn’t remember their names.
“Get lab up here.” he pointed at the scrub tech first.
The circulator wheeled the MH cart into the OR, then met his glance.
“Thanks,” he said. “ Now, get every hand on deck. Pull doctors and nurses from the ER and the floors. We need lots of people to mix Dantrolene.”
“It’s in here,” she said as she pointed to the cart, then ran from the room to do as he’d ordered. Thank God, she seemed to know her stuff.
Without the medicine, he knew, there was a 90% chance the child would die. But if they could just get it going in time, there was a 90% chance he’d live. But they’d need to mix the Dantrolene powder in water first – a very labor intensive project. And there were lots of other things that needed to be done, as well.
Finally, he looked at the scrub tech. “We need ice water. Lots of it. We’ve got to cool him down.”
She nodded sharply, and left.
He called to the speaker phone, “Dr. Reddy, are you still there?”
“Yes, I need to speak to the anesthesia provider.”
“That’s me. People call me Dakota. Dakota Kohler. I’m a CRNA working locums in a one-man shop in rural South Dakota.”
“Okay, Dakota. Whatcha got?”
“Twelve year old male. No family history of MH. Induction of anesthesia complete. Surgery not started. Heart rate in 170’s, now, up from 80’s pre-op. Jaw’s tight. Damn tight. CO2’s…” he looked at the monitor. Fuck. “Seventy-two and climbing. The only thing on board right now is 100% O2.”
“Did you use any triggering agents?”
“Okay. You’ve got Dantrolene?
“Yes. They’re – the staff is mixing it, now.” He looked over to see that the circulator had commandeered nurses from the hall just outside the OR. Damn, she was quick. She was firing orders at them – getting multiple vials of the powder diluted and into syringes for injection.
“How many bottles do you have?”
“Hey!” He tried to remember the circulator’s name, but couldn’t. “How many bottles do we-“
“That might not be enough,” boomed Dr. Reddy’s voice. Call local hospitals. Get every bottle you can get your hands on. Have them send it by state trooper, ambulance, helicopter – whatever they’ve got that’s fastest.
“I’ll take this one!” The surgeon raised his hand as he ran from the room. The doctor had just gone through the door when Dakota saw an ice machine – the whole damned machine – being shoved through the doorway by the scrub tech and a man he suspected was from maintenance. Behind the large silver box came two lab technicians with plastic totes full of equipment.
“Dr. Reddy, lab personnel’s here. Could you please talk to them – tell them which tests we need? We’re mixing Dantrolene, I’m going to start giving it, and I’m starting another IV line.” Even as he spoke, he turned Logan’s head to the side and slipped an 18 gauge needle into the external jugular.
When the circulator handed him the first syringe of medicine, he pushed the plunger with one hand, twisted to look behind him, and rustled through a cart of supplies. He needed to find tubes…gastric…urinary…shit! He’d checked the anesthesia supply cart before the surgery – now to just remember where the needles in the haystack were located.
He’d do what he had to do, dammit. Push ice down this kid’s throat, shove it up his rectum, bathe him in it, if need be. He wasn’t giving up. As he adjusted ventilator settings – he had to get the CO2 down – he noticed the lab techs drawing multiple vials of blood from Logan’s arms.
They all worked frantically for what seemed like an eternity. Finally, finally…the CO2 started to drop, along with the heart rate. He knew they weren’t out of the woods. He’d undoubtedly be up all night manning this kid’s Dantrolene infusion, electrolytes and vital signs, but things were looking up.
When he had just a second to regroup, he looked at his patient’s face. Hell, if he didn’t look like Ryan. And then it hit him: Grace would want to be here, if it were one of the boys. She’d be frantic. Mother bear frantic.
“Hey, guys,” he said. “Now that we’ve got the labs drawn, Dantrolene going, and everything, anybody got any objections to bringing this kid’s mom and dad into the OR?”
It just made sense. Give the parents the opportunity to hold their child’s hand – maybe for the last time . Let them see how hard the staff was working to salvage their loved one.
He was met with several blank faces. “We’d do it for a code, and we’ve got things under control, now.”
A couple seconds of silence – shocked disbelief, really – was followed by Dr. Reddy’s voice over the speaker. “It’s probably a good idea. Sounds like this patient will make it, but still-”
“Yeah,” the surgeon motioned to the scrub tech. “Ask them to come in here.”
It was 2:00 A.M., and he’d been at the boy’s side for nineteen hours straight. When Logan started grousing about being thirsty, Dakota thought he might cry with joy.
The hell of it was, there was no-one to call who’d really understand. Well, there was Lee, of course, but it wasn’t her.
For the first time in his career, he understood why so many anesthesia providers became drug addicts. Why they stole pain medications from their patients and shot up. The rates were staggering.
Not that he’d do it. But for the first time, he actually empathized.
And for the first time in his career, he thought: just quit. He had enough money in the bank – he could switch careers. Teach, or something. Why continue to go through this kind of stress, alone?
Copyright Joan Potter, 2013.