Checks and Balances
Chapter 7
Every bump in the road jarred Roy's nerves. He kept checking the needle in Johnny's chest to be sure it hadn't moved. Roy felt like he should be making fists with his hands to stop them from trembling. Something was nagging in the back of his mind, but he couldn't place what was bothering him. He felt wholly culpable for Johnny's situation. Why had he ignored so many things?
Johnny seemed to be short of breath several times throughout the evening. He had never even touched Mike's fried chicken. He had that short dry cough. Roy suddenly remembered something else. He picked up Johnny's hand and it felt cool, almost cold to the touch. He had noticed that earlier when they went on that last call to the museum. He mixed up the IV bags and missed the turn. Johnny was showing signs of confusion. Then in the dorm room Johnny was moving so slowly and he was obviously in pain. He even admitted to feeling lousy.
These were all symptoms Roy should have paid attention to. He should have put them together; he should have realized that something was very, very wrong! When they found Johnny lying on the floor, looking for all intents and purposes like he was dead, Roy felt the weight of all of these symptoms crash down on him like a boulder. He checked the needle again. Roy had never performed a thoracostomy before and hoped he never would need to again. He had to admit that he must have done it correctly because Johnny's color looked better. Before, he was almost grey with blue tinged lips. Now his color, although pale as a sheet, was no longer grey and the cyanosis had abated somewhat.
Roy listened to Johnny's lungs again and was rewarded with breath sounds, even though they were a bit labored and rattly. Once again Roy felt an uneasy sensation tickling the back of his consciousness, as though there was something else that he was overlooking. Shaking his head he took a new set of vitals and picked up the biophone.
"Rampart, this is squad 51."
Dr. Brackett's voice came on right away. "We read you, 51."
"Vitals remain stable, but his breathing is labored and I am hearing crackles bilaterally," Roy reported.
As Roy called in the update, he looked over at his partner and no longer saw the fogging of the mask that accompanied breathing. Roy quickly listened to Johnny's chest. "Rampart, the patient has gone into respiratory arrest again."
"51, is the esophageal airway still intact?"
"That's affirmative."
"Force ventilations at 15 liters O2."
Roy had already replaced the regular oxygen mask with the respirator mask as he responded. "10-4, Rampart."
"What's your ETA, 51?"
Roy called up to the driver. "Hey, how long before we hit Rampart?"
"About five minutes," came the reply.
"Too long! Floor it, Hal." Roy heard the engine rev up and felt the increased speed of the vehicle. "Rampart, our ETA is less than 5 minutes."
"10-4, 51. We're set up to receive you in Treatment 1."
Roy was still ventilating Johnny when they arrived at Rampart. He was again terrified that he had done something wrong with the thoracostomy, which had in turn caused Johnny to fall into respiratory arrest a second time. As they wheeled the gurney into treatment room 1, Roy was never so glad to see Dr. Brackett and Dixie McCall in his life. He maintained ventilations as the staff moved Johnny to the exam table and pulled him up to the top so that Dr. Brackett could allow his head to fall back off the end - facilitating the removal the esophageal airway and insertion of an endotracheal tube.
"Let's get him stabilized, people. One hundred percent O2 until I see a blood gas. Connie, set those leads up for a cardiac rhythm and get me an EKG. Somebody get me a portable chest x-ray, STAT." Brackett directed the frenzy with preternatural calm, his hands working quickly to secure the ET tube in place while his eyes and ears took in all necessary information at once. "Dix, stabilize that needle in his chest. I don't want it moving until I have a chance to see what we're up against."
Roy hooked the IV on the pole, and then stepped back to the corner as the rest of the ER staff worked around the exam table.
Dr. Brackett finished inserting the ET tube and looked up at Roy, "How long was he in respiratory arrest the first time?"
Roy had to stop and think about that for a minute. "I'm not sure. Maybe two or three minutes before we could force some air into the left lung, longer for the right, not until after the thoracostomy."
Brackett did some calculations in his head and mumbled to himself as he adjusted the settings on the respirator. "That could be as much as 6 or 7 minutes. I'll have to review the call recording."
Once Johnny was on the respirator and the lab draw was done, Dr. Brackett moved him to a better position on the table to inspect Roy's handy work.
"Nicely done, excellent placement, Roy. You saved his life with this. I couldn't have done it better myself."
Roy seriously doubted that and felt that Brackett was trying to give him a false sense of security, but that did not fit with the normally straight forward doctor who had all the subtlety of a sledge hammer. Dr. Brackett stepped aside to allow the portable x-ray unit that had been standing by to get in so that a chest x-ray could be taken.
"I want that film STAT, Jerry."
Roy, Dixie and Dr. Brackett stepped outside the exam room so that the x-ray could be done. Roy moved nervously from foot to foot. "So,if I did the thoracostomy correctly, why did he go into respiratory arrest again?"
Dr. Brackett placed his hand on Roy's shoulder. "There are a number of reasons, but the most likely answer is bronchial spasm. Think about it, Roy. Johnny started out with a partially collapsed lung that got increasingly worse as the evening progressed. It was getting harder and harder for him to breath."
That sensation of something being off screamed at Roy and he felt the hair on the back of his neck stand on end.
How did Dr. Brackett know that Johnny had a collapsed lung that was steadily growing all evening? How did he seem to know what was happening even before Roy could describe all the symptoms?
Roy was so immersed in his own thoughts that he didn't hear the question that Dr. Brackett asked him until he had to repeat it.
"Roy! What was Johnny doing when he collapsed?" the doctor asked with concern on his face.
"He had gone to bed early and must have woken up in distress. He was trying to get to the day room and managed to pull the in-house alarm before passing out."
"He was sleeping?" Dr. Brackett asked.
"Yeah, like I said, he turned in early. He said he felt lousy, but he wanted to wait until morning to come back in to be checked again. I should have made him come in. This is all my fault."
The look that crossed Dr. Brackett's face made Roy hold his breath for a moment. The man lowered his eyes and looked to the floor. He sighed heavily and placed a hand on Roy's shoulder before lifting his face up and staring Roy straight in the eyes. His voice sounded regretful somehow.
"No, it's not." Dr. Brackett paused for a moment as if weighing what he was going to say next. He glanced over to Dixie whose expression was unreadable. "Roy, while Johnny was up and moving the pneumothorax grew in size gradually, but lying down to sleep was the worst thing he could have done. Not only the fact that he was lying down, but when you sleep you breathe more evenly and deeply. With every breath he took more air became trapped in the plural space causing the pneumothorax to get bigger until the entire lung was compromised."
Roy nodded his understanding of the situation, but he wanted answers to address the feeling that was growing in his gut. "I don't understand how he wound up with a collapsed lung in the first place. His x-ray this afternoon was clear."
Dixie and Dr. Brackett exchanged a serious look, which Roy didn't miss. As he opened his mouth to ask what was going on, the door cracked open a bit. "All set, Doc. I'll personally develop this film and bring it to you in a few minutes."
"Thanks, Jerry," Dr. Brackett said, as he held the door open so that the x-ray tech could maneuver the machine out of the room.
Roy was about to follow the doctor back into the exam room when the HT he had crackled to life.
'Engine 51 to HT 51, what's your status?'
Roy didn't want to leave without answers, but his sense of duty overruled desire. "HT 51 available, but down one man."
'We have a structure fire with people trapped at 14th and Delroy. Paramedic relief has arrived and is 10-8 to Rampart, ETA 3 minutes.'
Roy knew that was it. He would have to leave Johnny in Dr. Brackett's hands. "10-4 Engine 51, en-route to 14th and Delroy."
Roy looked at Dr. Brackett as he turned to enter the treatment room and stopped him with a hand on his shoulder. "Doc, is there something I should know?"
The feeling in Roy's gut was reinforced when Dixie turned away and hurried off to follow the departing x-ray tech. Dr. Brackett nodded his head as if coming to a conclusion.
"There is something I need to discuss with you, Roy, but right now I need to get back to Johnny, and you need to get back to work. After this run come and find me."
Roy stood in the hallway just staring after Dr. Brackett as the door to the treatment room closed. He didn't want to believe that the uneasy feeling that had been steadily growing was valid. He wanted more than anything to believe that he was leaving his partner and best friend in capable hands, but now he questioned that. Did he see guilt written across Dr. Brackett's face? Had Brackett missed something? Feeling confused and numb, Roy turned and walked back out to the ambulance bay, trying to piece things together. By the time he stepped out of the bay doors he saw the squad coming out from the walkway overpass and backing into a space just to the left of the doors. Roy jogged over and opened up the passenger side door to see Tom Dwyer driving.
"Hey, how's Johnny doing?"
"I'm not sure. He's on a respirator and Doc Brackett will need to put in a chest tube."
"The guys didn't tell me much when I got to the station," Dwyer continued, as he pulled out to head toward the call the station had been toned out for. "How did he end up with a collapsed lung?"
Roy shook his head. He knew the answer, but was still confused by the fact that the x-ray had been okay. "He fell off a roof this afternoon. We didn't know that anything was seriously wrong. He was checked out here at Rampart and had a chest x-ray before he was cleared to go back on duty."
A frown clouded the senior paramedic's features. Roy was not one to jump to snap judgments about people, especially people he knew and trusted, but something about all of this was wrong. Dr. Brackett's evasive answers had Roy questioning everything he thought he knew about the doctor. Roy had learned over the years of being a firefighter and paramedic to trust his gut, but he didn't like what his gut was telling him. He was tempted to tell Dwyer about his misgivings, but he didn't have the facts and it wasn't his place to second guess the doctors so he kept silent - for the time being.
TBC
A/N: I am an X-ray technologist by trade. I have no experience with needle throacostomies nor have I ever seen one done, however, I have done quite a lot of research on the condition described in this story and have used the knowledge of the doctors and nurses I work with as well as a goodly amount of medical research to come up with the description of the procedure as it would occur 35 years ago. That is actually the most difficult aspect of writing E! fan fiction. The medical facts need to be dated. Thank you for the reviews and comments. I am currently without my laptop (it is in for repairs) so I have had to try and work from an old (and I do mean old) computer in our den that I have to fight for time on! Thank you for your patience.
I would also like to thank my good friend Dawn. She has been helping me to find better ways to break these chapters up into more reasonable sizes. This chapter was originally somewhere in the neighborhood of 8,000 words. I do tend to over write almost everything!