October 24, 1997
On nights that she took STEMI call but still got a decent amount of sleep, Dr. Monica Quartermaine attempted to swim before making early morning CCU and ICU rounds. Because she was technically still on call and because time mattered where myocardial perfusion was concerned on those mornings right before she got into the pool, she placed a call to the PCGH ED to ensure they didn't have any active potential STEMI patients in the department or enroute via EMS. It was a practice that had served her and her patients well over the years. So, standing on the indoor pool deck of the Port Charles Fitness Club at four AM, when the night charge nurse, Mary Scanlon informed her that they didn't have any potential patients she almost hung up the phone before she heard the rest of her sentence. Apparently, Dr. Carmichael had been unable to reach her colleague taking non-STEMI cardiology call and was wondering if he could speak with her. "Umm, sure," she mumbled. She couldn't exactly say no, could she?
"Dr. Quartermaine, thank you so much for speaking with me. I guess something must be wrong with Dr. Devlin's pager," Port Charles General Hospital Emergency Medicine Attending, Dr. Richard Carmichael said.
Monica took a deep breath and tried to extend some grace. She had heard that Dr. Devlin's daughter was missing, and she was sure he was struggling with that. She couldn't even imagine! However, she knew that Dr. Rothstein and Dr. Ford had offered to trade calls with Dr. Devlin, and he had declined probably because he knew that at least Dr. Ford would insist on the call being paid back. "I'm sorry about the miscommunication. We will certainly address that at the departmental level but how can I help you now?"
"So, Katherine Bell is in Trauma 6. Apparently, she had acute onset of chest pain and respiratory distress. EKG showed sinus tachycardia but no ischemia. CK-MB was 5.6 but Troponin is negative."
"If you haven't also obtained a CMP, Mg, total CK, and serum toxicology can you add on those tests. How high is her heart rate? Is she hypoxic at all? What is her blood pressure?"
"Umm, EMS insisted that saturations were lower 90s and they brought her in on oxygen, so I went ahead and scanned her chest. No Pulmonary Embolus and no dissection. She is 100% on 2L/min now. Blood pressure is 170/100 and her heart rate is 100. Honestly, maybe it is good that Dr. Devlin didn't call back because I'm sure he would scream at me to admit to medicine."
"Well presuming that the total CK is elevated so the CK-MB index is normal then I still think she needs a chest pain workup but that can be done by any of our very competent internists. My bigger concern would be how high the total CK will be. I just did an echo during her last admission and the ejection fraction on that was normal so you can probably bolus her aggressively with Lactated Ringers while you're waiting for your total CK," Monica said. Then she silently prayed that whichever internist was up for the next unassigned admission was not one who was prone to consult cardiology on every patient with chest pain.
"Thanks! I'm going to get a two-hour troponin and CK-MB along with the total CK so maybe I'll just call you when those are back."
"Sure, also can you check with Neurosurgery and see if they are comfortable with anticoagulation in case it looks like she really is having a Non-STEMI Heart attack. She had a subdural hematoma during her last admission," Monica said.
"Thanks again!" Dr. Carmichael said good naturedly.
Monica hung up her cell phone, adjusted her swimming cap, and then launched herself into the pool. She was definitely going to need a vigorous swim to prepare herself for another encounter with Katherine Bell.
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As she lay on her gurney moaning and panting in the PCGH Emergency Department, Katherine Bell was a bit overwhelmed by how unwell she felt. She hadn't been able to explain it to the doctor well partly because honestly it was hard to get more than a few words out at a time. But beyond that she just had hard time even putting her thoughts together. Everything hurt, but especially her chest. It was almost as if there was a heavy weight on it that was preventing her from breathing or even moving. As if that wasn't bad enough the room was spinning and she felt overheated, sweaty, nauseated and so unsteady like she was going to pass out. Perhaps passing out would be preferable then she wouldn't have to struggle so much just to take a breath.
"Is that better?" Nikolas Cassadine asked as he laid a cold washcloth over her forehead.
Everything seemed surreal. Katherine somehow knew she was meant to say yes and let Nikolas feel like he was doing something, but the stupid washcloth was like a drop in the ocean. "Everything hurts…" was all she could manage.
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Dr. Alyssa Doyle exhaled to release some frustration as she exited Lucy Coe-Stanton's room in the 4 West ICU. She understood that it wasn't fun to have a 103-degree fever and she knew that physiologically that probably did yield generalized muscle pain. She could extend sympathy but since she had already started appropriate IV antibiotics; managed to get her blood pressure to 100/70 albeit with 0.6mcg/kg/min of a Norepinephrine Drip; and assured that her oxygenation levels were fine there wasn't much more she had to offer. She had tried to explain that diplomatically to her nurse and then made an eighth trip to the bedside just to be sure she wasn't missing anything. She wasn't!
"So, I just re-explained to the patient that I am sorry she feels so horrible and I completely believe she does but right now the fact that her blood pressure is appropriate with vasopressor support and she is on appropriate broad-spectrum antibiotics is essentially the limits of modern medicine. We will know more when the cultures come back and can adjust the antibiotics then if needed. I'm not sure what else I can say," Dr. Doyle told the nurse who had been essentially hammer paging her most of the night.
Lynette Marsh RN just laughed. "You do realize you're talking about Lucy Coe, right?" she asked.
"Yes, the patient in 4220 who you have been paging me about all night!" Dr. Doyle said.
"Right, and you do realize that Miss Coe is a drama queen on a good day so obviously she is going to be super drama queen on a bad day," Lynnette said.
Dr. Doyle just shrugged her shoulders. The logic was lost on her but since there were only about ninety minutes left in her nightmare call she decided to just go with it.
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When she entered the hospital a few minutes before five-thirty, Dr. Monica Quartermaine decided she might as well just start in the Emergency Department and see Katherine Bell first. When she made her way into Trauma 6 a few minutes later and saw Katherine laying pale, diaphoretic, and seemingly helpless on a gurney, she realized that might be one of the best choices of her day.
Monica glanced quickly at the monitor which looked like ventricular tachycardia, she quickly palpated and confirmed a pulse and then reached up and hit the button to recycle the blood pressure cuff. She turned to the hovering Prince as she pulled the code cart closer to Katherine's gurney. "Nikolas we're going to take good care of your friend but right now I need you to grab one of the nurses to come in here and go to the waiting room to let us work," she said directly.
Panic seemed to register in Nikolas's dark eyes, but he did exactly that.
"What is the big emergency?" Amy Vining asked as she came into the room.
Monica was sure her eyes must have rolled internally but she just said. "This is unstable ventricular tachycardia, so we need to get ready for synchronized cardioversion. Grab another nurse and then can you draw up 2mg of Versed and 2mg of Morphine?"
Amy groaned but seemed to set to work doing that as Monica exposed Katherine's chest, slid a compression board under her and then placed the pads for cardioversion and defibrillation. "You can give the Morphine as soon as you have it drawn up," she said. Then she turned to Mary Scanlon who had entered the room. "Can you hang a bag of LR and pull up her labs."
Mary Scanlon nodded and started to hang the fluids. "Do you want this as a bolus?"
"Yes, thank you. Amy how are we doing with the medications?"
"Grr hang on, I am giving the Morphine," Amy said as Dr. Carmichael entered the room.
"Do I want to ask what happened?" Dr. Carmichael asked.
"I'm not sure what happened after we spoke but when I walked in she was in sustained ventricular tachycardia with a blood pressure in the 70s. I'm about to perform synchronized cardioversion once all of our drugs are in. Can you pull up her labs?"
"Yeah," Dr. Carmichael said as he logged into the computer. "We had an outside cardiac arrest with CPR in progress come in right after I added on the other labs,33 so I haven't seen them yet," he added.
"Oh, the CK is 150,000 CK-MB is 7.0 Mg is 1.1 yikes!"
"Actually, that explains a lot. Amy, do we have the versed yet?" Monica asked as she switched the defibrillator into synchronized mode and started to charge.
"Yes! Versed!"
"Ok, great!" Monica said. She took a deep breath. "Ok, everyone clear. I'm going to shock on three, one…two…three," she said as she applied the paddles to Katherine's chest. The current jolted through and briefly broke the v-tach but then it recurred.
Monica replaced the paddles and depressed the charge button. She reaffirmed that there was still a pulse. "Ok, we're going to go again," she said as she reached for the paddles. "I am going to shock on three. One….two…three"
Monica applied the paddles again and delivered the shock. The monitor showed a string of sinus beats with some PVCs. She replaced the paddles and again affirmed a pulse. Katherine's color looked a little better. "Ok, lets give 2g of Magnesium Sulfate and 1g of Calcium Gluconate. I can put in a central line if someone gets me a kit."
As Amy rolled her eyes Mary Scanlon deftly passed a line kit to Monica then pulled the calcium gluconate from the code cart and started it.
"Do you want to load Amiodarone?" Dr. Carmichael asked.
"Did the drug screen ever come back?" Monica asked as she was starting to open the central line kit and create a sterile field.
"Not yet, I can check on that. I need to call the ME about that outside arrest as well," Dr. Carmichael said.
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Dr. Monica Quartermaine glanced at the monitor pleased with the 110/70 blood pressure and the 100% saturations as she tied the final suture to anchor in the Subclavian Central Line she had just placed. As she reached for saline to flush the line Dr. Carmichael came back in the room.
"So, the urine drug screen is positive for amphetamines and uhh, thanks a lot for everything earlier," Dr. Carmichael said.
"You don't need to thank me but that explains the rhabdomyolysis and maybe the arrhythmia. She had two 6 beat runs of ventricular tachycardia while I was putting in the line, so I am going to load Amiodarone and start a Bicarbonate Drip. Can you order an ABG? If the ABG is fine, then I guess Cardiology should be primary and I'll take her. Can you also do me a favor and call Nephrology. To an extent there may not be much for them to do right now but they need to be involved in case her kidneys don't survive this," Monica said as she secured a dressing over the line and started to clean up.
"Do you want me to order a chest x-ray too?" Dr. Carmichael asked.
"Yes, that would be helpful. I'll put in the drip orders myself in a few minutes."
As she put all of the sharps in the sharp container, Monica reflected on the seemingly innocuous decision to start in the ED. Sometimes God had a greater plan. After all, Katherine might be mean, immoral and generally annoying but she was still a person and she still deserved appropriate medical care in an emergency.
With that thought, Monica took and released another deep breath. "I'm all done, Amy, can you let me know when they have done the X-ray so I can look at it. I need to get up to the CCU and round there, but I'll pull it up on the PAX," she said.
As expected, Amy Vining just rolled her eyes.