Jay's pain had been increasing all night. His nurse had even called Dr. Morelock for a higher dose of pain meds, which he agreed to.
He rushed to the bathroom per usual, the urge hitting him suddenly. However this time it was just blood, bright red blood. He was shocked for a second not knowing what to do. Afraid to flush it he called the nurse with the help button in the bathroom. She came in quickly, "Jay you okay?"
"Ummm I think it's all blood, and a lot of it." She looked into the toilet. "Yeah I think so, let's get you back to bed and I'll call Dr. Morelock."
Hailey heard the commotion and woke up as the nurse was getting him settled. "What happened?"
"I just shit straight blood," he said casually as if it was normal. Well that got her attention. "Don't worry the nurse is calling Morelock."
The nurse returned, "He ordered some blood work to make sure your hemoglobin isn't dropping As long as that's okay, he said he will see you first thing tomorrow morning," She got his blood work and asked him if he needed anything before leaving.
"Do you want me to call Will."
"Not yet."
His blood work was okay and the rest of the night was seemingly uneventful. So when Dr. Morelock came in that morning, he was alarmed by Jay's condition. He was clammy and pale, acting very out of it. He arrived right after shift change so the day nurse hadn't been in yet and Hailey was still sleeping. He looked out in to the hall and asked "Can someone find his nurse, it's urgent." He gently called Hailey's name. She was startled by his presence, looking at him a bit confused. "Hailey, It's about to get a little busy in here, you know how we talked about doing the surgery before it became an emergency. Well that time is now."
The nurse rushed in, "Sorry I just got here, the night nurse said he was fine besides the large bloody bowel movement."
"I know, just get me a new set of vitals, they were fine at four am."
"BP and HR are stable, but umm his temp is 103.8, do you want a rectal?"
"No, will you page colorectal, Dr. Patel please."
"Of course," she responded before leaving the room.
Dr. Morelock continued assessing Jay. He got him to wake up but was he clearly out of it. "Jay, how we doing," he said with a bit more force than normal.
"My stomach," he said before grabbing his abdomen tightly. "Fuck I feel like shit," Jay said, practically slurring his words.
"You have a really high fever, Hailey why don't you see where Will is at."
"Yeah, um yeah, okay." She was still kind of stunned, not sure how things escalated so quickly. Will finally picked up the phone after several rings, she was starting to worry he wouldn't answer. "So-"
She interrupted him, "Are you at work, You need to come up here. Jay is really sick, like really sick. Dr. Morelock is here and he had the nurse page the surgeon from yesterday."
"Hailey, what do you mean he's really sick, what's happening," he asked as he started looking for someone to cover his patients.
"He has a really high fever, he's sweaty and is pretty out of it."
"I'll be right there."
Will and Dr. Patel arrived at the same time. This time she had several residents in tow.
She quickly took control of the room. "What are his vitals?" The nurse rattled them off. "Alright let's get a liter of LR going, give it over an hour. Get me another IV if you can. How were his morning labs."
"Let me check, they weren't back yet during shift change."
"CRP is up, White count doubled."
"Alright," she looked to one of the residents. "Go order zosyn for him, put it in STAT please. Renal function okay?"
"Yes," the nurse responded as she prepared the LR infusion. Another nurse had come in to help and was preparing to insert the IV. Jay hadn't moved while she looked for a good vein and prepped the site, but he protested weakly when she inserted the needle. Gently trying to move her hand away.
Will stepped forward, "Jay, I need you to stay still, she's just putting in another IV okay."
Dr. Patel was on other side of the bed, busy assessing Jay. She gently palpated his abdomen and he groaned, not able to stay still he attempted to move away from her touch with little success. "Abdomen is firm and distended. When was his last known well time."
"Four am," the nurse responded as she attached the infusion to the newly placed IV.
Dr. Patel walked over to Hailey and Will, motioning for Hailey to sit. She did as directed, the shock starting to wear off. "It's an emergency now, we need to do the colectomy. I could do a CT to confirm, but I'm confident he's perforated and sepsis is starting to set in."
Hailey just nodded. "We went over the risks and potential complications yesterday, do you have any questions?" Hailey shook her head no, while Will stayed silent. "Jay is too out of it to legally consent right now, so I'm gonna need you to sign these consent forms. This first one is for the surgery and the one underneath is a consent for blood if he were to need it during surgery."
She signed them quickly. "The pre-op nurses will come get him shortly, we need to do this now."
Hailey just said, "okay."
The nurse came back in with the antibiotic, hanging it quickly before they came to take him down.
Will went back over to Jay. "Hey buddy, can you wake up for me." Jay opened his yes slightly. "What," murmured. "They're gonna take you down for surgery in a few minutes. They need to do the colectomy now, you're too sick."
"I don't feel good," Jay responded, almost child like. "I know we'll get you taken care of," Will said softly to him as he squeezed his hand.
Hailey was now on the other side of the bed, holding his hand. She didn't know what else to do, she felt so out of her element in this moment. The OR staff arrived, quickly whisking him away, before they left Hailey leaned down, kissing Jay's forehead. "I love you," she waited for the "I love you too," but it never came. Soon he was gone.
Dr. Morelock was outside, methodically looking through Jay's chart, looking for something he missed. He hadn't expected him to deteriorate so quickly. With the bloody bowel movement overnight he was concerned but certainly didn't think he'd be calling Dr. Patel upon his arrival.
He walked back into the room. Hailey was crying, while Will was trying to comfort her. "I'm sorry guys, I thought we had more time, I should have pushed harder."
"So did we, but it wouldn't have mattered. Jay was never going to consent to that surgery yesterday if he didn't have to. He wasn't ready," Will simply stated. Will shook his hand, "Thank you for everything."
Dr. Morelock, "you're welcome I'll come check on you both later."
Hailey didn't remember walking down to the surgical waiting room. Goodwin had agreed to find someone to cover Will's shift. They sat together in silence.
After a while Hailey finally spoke, "Fuck I should call Voight," she hesitated, "What do I even tell him?"
"Hailey, I can call him."
"Please," and she handed him her phone.
He answered quickly, "Voight."
"Hi this is Will Halstead, Hailey wanted me to call you with an update."
"He's not getting better is he?"
"No, he's in surgery right now. They're removing his colon and placing an ostomy. We were hoping it would be a scheduled surgery in a few days, but it quickly turned into an emergency this morning. It's a big surgery so he'll be out of work for several months probably."
"Should we come down there?"
"Umm, I think maybe just Kim. Hailey's really overwhelmed right now."
"I'll send her your way when she gets here. Let us know if we can do anything else."
Kim arrived just as one of the residents came out to give them an update. "The colon's out, ostomy is placed. She's just really washing him out now, as suspected he perforated. He's relatively stable, blood pressure is little low, so the anaesthesiologist is watching that closely. He should be done in about an hour roughly."
Kim went straight to Hailey giving her a hug. They both sat down. "What happened?"
"He just hasn't been getting better. They had the surgeon come in yesterday to talk about the colectomy and getting an ostomy, but he needed some time. The surgeon thought it could wait a few days, but she warned him there was a risk of it becoming an emergency if he waited too long. We all thought he had more time, but this morning he woke up with a crazy high fever and was really out of it, so they decided it was an emergency."
"How long has he been back there?"
"Two hours maybe, you'd have to ask Will, this morning was crazy."
Kim sat with Hailey, chatting about nothing, trying to distract her.
Dr. Patel greeted them after an hour and a half. "He did well, relatively speaking. We removed the colon, rectum is still in place and placed the ostomy. It's on his right side, stoma is nice and pink, no bleeding. I'm sure the resident told you he perforated, so we washed him out thoroughly. Therefore he has an additional drain. NG tube is in. Blood pressure has been a bit labile, so anaesthesia placed a central line. Right now he's on a small amount of levophed, a drug we used to keep his blood pressure up. I also added another antibiotic. Because of his blood pressure he'll be in the ICU at least into tomorrow. He's getting settled in the ICU as we speak, if you want to walk up there someone will come get you from the waiting room once he's ready for visitors. I'm sure you know the way Will."
"Thanks Dr. Patel," replied Will. Hailey added, "Yes, thank you so much."
"I'll be by to check on him this afternoon okay."
Only two people were allowed in ICU, so Hailey sent Kim back to the precinct, thanking her for coming down. Hailey was eager to finally see Jay. Looking at him though, she was afraid to touch him. He had so many tubes and was attached to so much stuff. Will explained everything to her before he started checking things over for himself. He had oxygen on, the NG tube was in his nose, she could see what she assumed was the central line in his neck, he still had both IVs in his arm, plus the urinary catheter was hanging at the end of the bed. He had a blood pressure cuff on, going off every 15 minutes. A pulse oximeter was on his finger and per Will the Foley catheter has a probe in it measuring his temperature continuously. She knows there's more underneath his gown, but isn't ready to think about it. She can't remember him having this many things attached to him even when he was shot a couple years ago.
The nurse taking care of him retuned with an armful of stuff. She could see the apprehension on Hailey's face.
"Hey, I know it's a lot, but he's under there I promise."
"Has he woken up at all," Hailey asked.
"Not really, he grunted when we moved him over to the ICU bed, clearly didn't appreciate the movement. He opened his eyes briefly but not for long. When someone comes to the ICU after surgery, they come here directly, skipping recovery, so the anesthesia is still very much in his system. I'm gonna set up his PCA so he won't be too uncomfortable when he wakes up. He'll get a continuous dose of dilaudid every hour and then can press it when he needs it. While he's still coming out of anesthesia I can give him some IV push doses until he's more with it like they would do back in recovery. Does he usually tolerate anesthesia well?"
"No," Will answered, "it always makes him really nauseous."
"When I'm done here I'll bring him in some zofran to try to get ahead of it."
She finished setting up the PCA and left the button next to Jay's right hand for when he wakes up. Bringing back the zofran, she administered it through an open port on his central line. "Zofran is in." She lowered her voice, now talking directly to Jay. "Alright Jay, I'm going to lift your gown up and check all your drains."
She gently pulled his gown up, the bulb drains were already filling up so she emptied them, making sure to measure each one. Hailey was watching over her shoulder. "You can come look, it's okay." Hailey shook her head no so the nurse continued. "She washed him out pretty extensively from what I understand, so I would expect a lot of output over the next couple days," She looked at his stoma, it was nice and pink like it should be. "Stoma looks good, good blood flow. Dr Patel makes the prettiest stomas, if that's even a thing." The large dressing covering his incision looked dry. She began palpating his belly to make sure it was soft. "Belly's nice and soft." As she was finishing Jay grimaced a little.
"Mr. Halstead, can you wake up for me?"
"Call him Jay," Hailey interjected.
"Jay, wake up for me please," he grimaced again, moving slightly before settling back down.
"He needs more time, it's still early. I'll give him a small dose of dilaudid, I don't want him to get behind on pain control" Hailey maneuvered next to Jay grabbing his hand when the nurse left.
Jay felt the nurse pushing on his belly. He heard murmuring in the background. When the nurse found a tender spot he could not hold back a groan. A hand grabbed his and he heard the nurse call his name. "Mr. Halstead," then "Jay," but his eyes were so heavy, he couldn't quite open them. The pain was becoming too intense, but it was a different pain now, Jay tried to remember why, but couldn't. He moved slightly and then froze, that was a bad idea he thought to himself. He heard more murmuring until the lingering anesthesia pulled him back under.
Anna came back with the dilaudid, after administering it she busied herself with a few more tasks in the room. She measured his urinary output and adjusted one of the medications. "His blood pressure has been solid since he's gotten here. I'm gonna start slowly weaning down the medication we're using to keep it up. He's all set for now, press the call button on his bed if you need anything."
"Thanks," Will said softly. He was standing on the other side of the room, leaning against the wall. He had been quiet, satisfied after he checked everything over, watching the nurse work.
It was another hour before Jay attempted to resurface again. The pain was more intense the second time around, he could feel all the uncomfortable tubes and wires on him. He squirmed slightly. Hailey felt the small movement, "Jay, Jay are you awake?" It took him a few tries, but he managed to open his eyes half way. He tried talking, desperately trying to tell them how much he was hurting, all he could muster was a quiet, "ow."
Will rushed over to the bed, placing the PCA button in Jay's hand. "Can you push the button for me Jay?" Jay tried but he was still too out of it. He clumsily tried again, "it's okay, we'll get you something for pain." Will pressed the call bell. His eyes slipped close before the nurse arrived.
"Hey, what can I do for ya."
Will spoke up, "he opened his eyes for a second, he looked like he was in pain, managed to say 'ow.' I tried to get him to push the button but he was still pretty out of it. Could you give him another dose maybe?"
"Yeah, absolutely." She went to grab it and returned, "Sounds like next time he might fully break through.
"Yeah I think so," Will responded.
Jay could hear the people talking. He felt the rush from the dilaudid, sending him back under.
Will had convinced Hailey to go take a break and get some food from the cafeteria. She had pulled a chair up to the bed after Jay woke up the first time. Will had settled into the chair in the corner, turning the TV to some random channel to keep them occupied.
He heard Jay softly whisper "Hailey." He walked over to Jay, not convinced he was actually awake. To his surprise Jays stared back at him.
"She's downstairs getting something to eat. She's gonna be pissed you woke up while she was gone. How are you feeling?"
"Hurts, different," he hesitated. "What happened?"
"What do you remember?"
Jay was starting to wake up a bit more, "blood in the toilet."
"Well Dr. Morelock came to see you first thing. You had a really high fever and were pretty out of it, so he paged Dr. Patel. They determined it was an emergency and took you to surgery to remove your colon and give you an ostomy. Your colon perforated so you were starting to go septic."
Jay stared back at him blankly. Will wasn't sure what to make of his reaction or lack there of. Maybe he was just still too out of it. Jay finally responded, "okay."
"You have a PCA in your hand, you can press it for pain relief." He pressed the button, waiting for the relief to wash over him. His energy was waning, Will could see his eyelids getting heavy. "Jay it's okay, go to sleep."
His eyes were about to close when Hailey walked in. She saw that he was awake and rushed to him, grabbing his hand. Tears formed in her eyes. She looked away from Jay for a second, trying to get her emotions under control to no avail. When she looked back at him she noticed that he too was fighting off tears. She ran her fingers through his hair and kissed his forehead.
"I love you, you'll be okay, you can sleep now." His eyes were getting too heavy, finally closing, and he was back asleep.
Anna was in out and checking on them regularly, completing all the frequent task that an ICU patient required. Jay continued to sleep for a while. "It's time for another full assessment so I'm gonna see if he'll wake up for me. He's almost off the pressors now so we're moving in the right direction."
"Jay, can you wake up for me," she asked softly. She could see his eyes start to flutter. "That's it open those eyes for me."
He followed her directions and opened his eyes, giving her a slightly confused look.
"Hi, I'm Anna, I'll be the nurse taking care of you until seven pm. Can you tell me where you are?"
"Med."
"Can you tell me why you're here?"
"I had surgery," he answered quietly.
"Good, are you in any pain right now?" He quickly shook his head yes. "There's a PCA button, next to your hand over there, push it for me okay." He pushed the button, clearly still drowsy, but more with it. "I need to do an assessment real quick." She pulled out her stethoscope, listening to his lungs and heart. She didn't bother listening to his abdomen, knowing it was too early for bowel sounds. Satisfied she moved on.
"I'm gonna move your gown up a bit so I can look at your belly." She noted the look of apprehension on his face. "You don't have to look, I know it's overwhelming right now." She quickly emptied his drains, reassessed his stoma and the dressing on his incision. "I'm gonna press on your belly a little bit," she warned. He grimaced as she moved her hands around, unconsciously trying to move away from her hands. "You can probably have another dose of pain meds now, it's set up so you are receiving a small amount continuously and then you can get a dose as needed every six minutes." He slowly pressed the button and could hear the pump dispensing a dose. She went down to the end of the bed emptying his catheter, before leaving. "All set for now, let me know if you need anything."
As the nurse left, he looked over to Will and Hailey. "Hey."
"How do you feel," Will asked.
"Like I got hit by a truck, what is all this stuff one me." Now that Jay was more awake, Will went more in depth. "So you've got the NG tube in your nose to prevent stomach acid from backing up, you're still on a little bit of oxygen, your blood pressure was low so you're getting some medication to help with that through the large IV in your neck."
Will continued "As far as your belly goes, the ostomy is on your right side and there is three small abdominal drains." Jay paled at the mention of his ostomy. "Since infection was starting to set in, they had to wash you out really well, so that's why you have the extra drain. You also have a urinary catheter."
Jay remained quiet, letting the events of the morning sink in. They sat together, watching tv before Jay fell asleep again. By the afternoon he was stuck in an unfortunate cycle. He'd push the button for pain, fall asleep, then wake up twenty minutes later in severe pain. He'd press the button again and the cycle would repeat itself. He was too weak and uncomfortable to move so he'd just lay there breathing through pain until the dose kicked in.
After a few rounds, Will pressed the call light. Anna came in quickly, "What can I help with?"
"He doesn't seem to be getting any long lasting relief. He'll press the button, fall asleep and about fifteen, twenty minutes later wake up in severe pain again. Could we adjust the settings, maybe."
"Let me give Dr. Patel a call. Maybe she can increase his basal dose."
Anna came back in a few minutes. "Alright Dr. Patel is planning on coming to see you shortly. She didn't want to change the settings before she assessed you, but did give me an order for a larger dose to hold you over until then."
"Thank you" Jay said, resting his eyes but not fully sleeping.
"I also have your antibiotics." She administered the medications and quietly walked out of the room.
All three of them miraculously fell asleep while waiting for Dr. Patel. She softly knocked in the door, giving them some a few moments to wake up. "Sorry to wake everyone."
"It's fine," Will replied.
"He seems to be doing well overall, I was discussing a few things with Anna out in the hall. She was telling me his urine output has slowed a bit, his drain output is pretty high, so I think he's probably just intravascularly dry. I want to give him a bolus of LR and it should improve. Hopefully with a little more volume we can get him off the pressors as well. I hear he's having some issues with pain control so after I assess him we discuss a plan to help with that going forward."
She went over to begin assessing Jay. "Jay it's Dr. Patel, can you wake up for me."
"Give me a second," he responded, breathing in and out. He pressed the PCA button then opened his eyes.
"How are you feeling Jay?
"Better, but worse, if that makes sense."
"Pretty typical with an emergency colectomy I'm afraid. So this morning when Dr. Morelock went in to see you, you had a very high fever and were fairly disoriented. Your colon had perforated and you were in the beginning stages of septic shock. Luckily, we caught it early. While emergent, I was still able to perform a complete colectomy, we placed an ostomy on your right side and we were able to keep your rectum. Your abdominal cavity was starting to fill with stool from the perforation and your appendix was basically gone. I had to do several extra washouts but I think we're in the clear based on how you're doing. I know you don't feel great, but for major surgery and sepsis you're doing surprisingly well. Because of the extra washouts we had to place an extra drain, so you have a total of three. You're getting IV antibiotics and fluids. Your blood pressure was low during surgery so we've been providing some medication through the central line in your neck to normalise it. I think this is partially due to the sepsis and partially due to dehydration. The drains in your belly are having a lot of output so your body is trying to figure out where all the fluid belongs."
"Today is about pain control and stabilizing your blood pressure so we can get you out of ICU. Tomorrow we need to get you moving to prevent complications and help that ostomy start moving. The small intestine doesn't really like to be touched, so after surgery it can take a while for things to start moving again."
"Anna said you've been having a hard time with pain"
"Yeah I can't really sleep more than twenty minutes at a time without waking from severe pain. I press the button, it gets better, but then I wake up again in another twenty minutes in severe pain.
"Let me do a quick assessment and then we can discuss how to move forward." She pulled out her stethoscope, "Take a few deep breaths for me." He did, but struggled through the, his breath hitching, "I know Jay, push the button. You can breathe normally now." She continued listening to his heart and then gently placed her stethoscope on his abdomen, finding an empty spot between all the drains and his ostomy. He grimaced slightly at the gentle pressure. "Is it okay, if pull up your gown?" He shook his head yes. She assessed the output from each drain, his stoma and the large dressing covering the incision. "Honestly everything looks really good Jay. You're gonna feel me palpating your abdomen okay." He groaned as she gently moved her hands around his belly, gripping the bedrail tight. "Relief is coming, just give the meds a few minutes to work."
'Okay," he whispered eyes closed, hand still gripping the bedrail.
"I think we should go ahead and increase the continuous dose you're getting every hour. I need you to be able to take deep breaths, the last thing we need is pneumonia. Like I said we need you to start moving around tomorrow and we can't do that without proper pain management. I'll order some IV push doses of dilaudid that the nurses can administer as backup. We can always adjust things again. Get some rest okay."
"Thank you," Jay said quietly
The rest of the evening was relatively uneventful compared to the previous 24 hours. Jay seemed more comfortable overall. The pain was still intense, but he was able to get a few stretches of decent rest after they adjusted his PCA settings a second time. The ICU wasn't a place where one could truly rest. The nurse was constantly in the room, emptying drains, looking at his ostomy, checking his incision or recording any new output from the NG tube. Not to mention doing a full assessment every four hours. Both Hailey and Will stayed with him that night. Hailey was grateful for Will's presence.