The little girl was running around the room, screeching happily, and when she saw me she hid under the bed. I could see her peering at me from between the legs of the gurney as I stood with her chart in my hand. Her father shook his head, grinned, and looked at his wife. "I told you there's nothing wrong with her."
I looked down at the chart. On it the triage nurse had written, in bold black letters, "Two-year-old acting weird."
"I'm Dr. Huyler," I said. "What can I do for you?"
"Nothing," the man said, and his wife hushed him.
"She's not acting right," she said. She wore an African print dress, and I found myself staring at the intricate pattern of swirling reds and browns. Her hair was cornrowed, a bead at the end of each strand.
"They're Medicaid," the triage nurse had whispered pointedly in my ear. The implication was clear; they wanted something for free: Tylenol, a work excuse. But it was 10 o'clock on a Friday night.
"What has she been doing?"
"It's kind of hard to explain. She just isn't acting herself. I noticed it right away. But she's been fine ever since we got here."
"Can you be more specific?" I could feel myself getting impatient. There were half a dozen patients waiting, the ER was full. I wondered why they hadn't called their regular pediatrician.
"Well," she said, thinking. "You know how people look when they're staring into a mirror? Kind of blank?" I nodded. "She's like that. Only there isn't a mirror. There's nothing there."
The child's vital signs were completely normal. Her mother coaxed her out from under the bed and held her wriggling in her arms as I listened to her heart and lungs, looked into her ears.
I'm uneasy with children. I must have been a cold, white form to her, large, bending down with my stethoscope and light. I could see nothing wrong with her. She looked impeccably cared for, without any sign of the abuse I had been vaguely and secretly considering. I always do. It's been drummed into us.
"Does she have any medical problems at all?"
"No," he father said, anticipating my questions. "She's always been healthy. She's had all her shots. She's growing like she should, and she can talk a little, only now she won't 'cause she's shy." He wagged a finger, and she giggled, hiding her face with the bottle her mother had given her.
"Has she had any recent stress, something that might have upset her?" They looked at each other.
"I don't think so."
"Is there any history of seizures in the family?"
Her mother thought for while. "I think my brother might have seizures," she said finally, "but I haven't seen him in a long time."
"And right now she's acting normally?"
"She's fine," her father said to his wife. "Come on, let's go. If she does it again we'll come back. It's past her bedtime."
I considered what I'd heard. A vague history of blank spells; it could mean anything, from a rare type of seizure to the vagaries of the 2-year-old mind. She could see her pediatrician on Monday, I thought. She was a completely normal child.
On my way out the door, though, I turned around. "Is there any chance she might have gotten into someone's medications? Does anyone in the family take medications regularly?"
"Well, she stays with my mother when we're at work. She takes medicines."
"What kind of medicine does she take?"
"I'm not sure. Something for her blood pressure and a sugar pill."
Oral hypoglycemics--sugar pills--are among the most dangerous of overdoses. They can drop blood sugar profoundly, cause brain damage, seizures, coma. Designed for adult diabetics, they are long-lasting, and one pill could kill a small child, even many hours later.
"Let's check her blood sugar," I said, "just to be sure. And please call your mother, find out exactly what she takes."
From the doctor's station I could hear the child shrieking as the nurse drew her blood. Her mother spoke into the phone a few feet away.
"My mother takes glipizide," she said, handing me a piece of paper where she'd written it down. "She ran out of her blood pressure medicine two weeks ago."
A sugar pill.
The nurse came out of the room with a syringe full of blood. The child's mother and I watched as she eased a single drop from the tip of the needle onto the portable blood-sugar machine she held in her hand. It digested the blood for a few seconds, then displayed the number on the screen. Forty-two.
"Is that low?" her mother asked.
"It's about half of what it should be," I replied, stunned. "she must have taken one of your mother's sugar pills."
"My mother is legally blind. She probably dropped one and didn't notice."
"We need to keep her in the hospital for at least a day and give her sugar intravenously." I said it quietly, half to myself.
"Will she be all right?" She was afraid, staring at me.
"She'll be fine." And suddenly I began to shake. "But I'm very glad you brought her in. You may have saved her life."
"My husband wanted to put her to bed," she said softly, looking off down the hall.
It was suddenly clear. Sometime that afternoon the girl had taken the pill, and by the time her parents came home she was showing the effects of low blood sugar: the staring spells, the blank look.
"What did you do when you saw she was acting weird?"
"We gave her a bottle," the father said, standing with us now. "And then we gave her a sucker."
They had given her sugar. When she arrived in the ER her blood sugar had risen enough for her to look and act herself, but it wouldn't have lasted long. Later that night, when the whole family was asleep, it would have fallen again, and she might never have waken up.
As I watched the girl skip and jump around us, the pain of the needle forgotten already, I felt sick, cold and damp, terrified by what I had almost missed. One question, an afterthought. That was all it had been.
From time to time I think about her. I imagine her playing in parks, jumping on the couch, shrieking in the bathtub. I imagine her head teeming with small thoughts, and the motion of her hands, her eyes, alive in the world, going out into it, entering it, decade after decade ahead.
A Difference of Opinion
"I don't think any of us here seriously expect this man to survive," the attending physician said every morning when we doctors in training reached Room 6 on the intensive care unit (ICU). We expected the remark. Then the presentation would begin, and it was always the same.
"This is ICU day 28 for Mr. Johnson, a 26-year-old cowboy with pneumonia, sepsis, respiratory failure, renal failure and anemia." A detailed analysis of each problem, in descending order of severity, then ensued. He was growing steadily worse. The ventilator had been at maximum settings for weeks, supplying the man's ruined lungs with just enough oxygen to ensure another identical presentation the next morning.
"This is ICU day 29 for Mr. Johnson. . . . I don't think any of us here seriously expect this man to survive," and we would move on, halfway through rounds and already worn out.
Mr. Johnson was a bull rider, thrown at a local rodeo, who had broken several ribs. He'd gotten up, dusted himself off, gone home, and over a few days he had developed pneumonia in his injured lung. His family brought him in nearly unconscious, with both lungs full of pus, and over the ensuing weeks his other organs also failed: liver, kidneys, intestines. He lay drowning in his own fluid, the fever unrelenting, his family gathering and staring at him. Over the past few days they had stopped coming, consigning him, it seemed, to his fate alone.
One night, more than a month into his stay, I was on call when his blood pressure began dropping yet again. The intern and I stood looking at him, swollen like a toad on the ventilator. He always tormented us like this.
"Give him some more fluids," I said. "And let's go up on his dopamine." The nurse sighed; she'd heard all this before.
Listening to the ragged sounds of his lungs, I thought something had changed. His left lung sounded a bit quieter than it had the night before, an ominous sign. "All right," I said, resigned. "Let's get a chest X-ray."
The chest X-ray had not changed much. Looking hard, though, the radiology resident thought he saw a slight difference on the left. "Could be a pneumo," he said, "though I'm not sure. Let's get a CAT scan."
He referred to the possibility that air was leaking out of a hole in the lung, collapsing it. The treatment for this is minor surgery, done at the bedside. You cut into the chest between two ribs, insert a finger into the chest cavity, and push the lung out of the way. Then you slide a long plastic tube between the lung and the chest wall. When suction is applied through the tube, air and blood rush out, allowing the lung to re-expand. Mr. Johnson had been the victim of this procedure so often that his chest was a mass of wounds that refused to heal and oozed blood-tinged fluid into the bedding.
The intern and I looked at each other, shaking our heads. This meant hours of work, wheeling him with his ventilator and multiple IV drips down to the CAT scanner, waiting for the scan to be read, then putting in the chest tube and getting X-rays to make sure we'd done it right. Any chance of sleeping that night vanished. It was already early morning, and we were tired.
"Looks like a pneumo, all right," the radiologist said, pointing to the dark mass of air visible on the CAT scan. "A pretty big one. I'm surprised we didn't see it better on the X-ray."
Mr. Johnson's lung, by the time I finally cut down to it through the deep, soggy tissues of his chest wall, felt exactly like a piece of cork. It was stiff, as if already embalmed. "You've got to check this out," I said to the intern. "Put on some gloves and feel this thing."
For a few moments he felt around with his finger, then withdrew it, covered with blood, and held it instinctively up in the air. "Feels like a piece of meat," he said.
The next morning we were reprimanded. "I think we should seriously consider the ethics of performing such aggressive procedures in this man," the attending physician began. "I should have been called. It's high time, in fact, that we considered withdrawing support altogether."
There was a long silence. "He's a young guy," I protested. "And we've done it before. And it helped." This was only marginally true. His blood pressure had come up slightly, but it was hard to know why.
About this time another attending came on the service, and for the next few weeks he alternated call nights with his colleague. He had different views. "This is a young man," he would say, when we reached room 6. "This is exactly the kind of patient we should be most aggressive with."
A bizarre dynamic developed. On even days we did almost nothing, checked no lab work, stopped antibiotics and tube feeds, and nodded solemnly as the attending shook his head and said things like, "The most important thing we can do now is keep this man comfortable."
On odd days it was the full-court press. We worked to undo the previous inactivity, checking arterial blood gases, blood cultures, and X-rays, adding antibiotics and fluids, tinkering with the ventilator. We nodded solemnly as the attending said things like, "This man deserves everything we can give him."
This went on for over a week, until my tenure in the intensive care unit came to an end and I rotated back to the emergency room, leaving my nightly struggles with Mr. Johnson behind. I was glad; he had unfailingly robbed me of sleep, and I had come to dread him. I knew him intimately, had examined him dozens of times, turned him over to look at his back, put my gloved finger in his mouth and into the interior of his chest cavity, and I had never once exchanged a single word with him. He was gone from the waking world, as nearly dead as a human being can be, lying at the edge but never quite crossing over, his body, his animal self just strong, or not strong, enough. I had hoped many times he would die.
About six months later I was walking down the long hall back to the ER from the cafeteria. It was mid-afternoon, a slow day. The door to the pulmonary clinic was open as I passed. A few patients sat in plastic chairs, waiting for their appointments. In one corner, leaning casually against the wall, a man stood reading a newspaper. The paper obscured his face, but as he turned the page I saw it, and I stopped immediately. I felt a strong and sudden force. It took me a few seconds; I knew the man, I knew his face was significant, but I didn't know why. Then I realized, disbelieving.
"Mr. Johnson?" I asked tentatively, stepping in through the clinic door.
He looked up at me from his newspaper.
"Are you Mr. Johnson?" I asked, beginning to feel foolish.
"Yes, he said, looking at me suspiciously. "Do I know you?"
The Bee Sting
The nurse came up to me. "The guy in Four wants antibiotics for his sore throat. Can I give him something?"
I glanced at his chart. He had a cold, that was all, and it was busy. "I haven't even seen him yet," I said.
The nurse rolled her eyes. "He's just going to keep bugging me."
The ER was full, it was the middle of the night, and I was feeling sorry for myself.
The waiting room was full of children. Coughs, runny noses, fevers, keeping their parents up until they'd had enough. I'd seen the look so many times--the worn-out mother, the whimpering child whom I would simply send home again. See your pediatrician in the morning. Give him some Tylenol and lots of juice.
Nothing bad was happening, it was all stuff I could bang out in my sleep. Penicillin for the ears. Cough drops and fluids. If he gets worse bring him back.
After a while you come to rely, more than anything else, on first sight. You walk into the room and you think, sick or not sick. Not sick goes home as fast as possible. Sick, you watch. You draw blood, you order X-rays, you give them fluids. You are careful, because a little bell went off when you walked into the room and saw them. The nurses do it, too, and when they say, "I don't like how this kid looks," you really pay attention if you're smart. It's something you either learn or you don't. Sometimes I think I've learned it. Sometimes not.
The man in Four was not sick. He had a cold and couldn't sleep. It was 2 in the morning, he shouldn't have been there, and the waiting room looked like a schoolyard. The nurse came up to me again. "The guy in Four wants something for his throat. He keeps bugging me."
"I'll be there in a minute. Tell him to wait."
The man lying on the bed looked perfectly healthy. He was in his early thirties, fat, with curly black hair, a runny nose, and small rectangular eyeglasses. On the off chance that he had strep throat, I knew that I would give him an antibiotic. But it was a virus.
"You have a sore throat?"
"Yes, it's terrible. I can't sleep. I'm congested. I've had it for a week." His throat was red, his tonsils angry and swollen, lit up by my penlight.
"Are you allergic to any medications?"
"I think I'm allergic to penicillin. You should ask my mom."
"Are you allergic to Keflex?"
"I don't think so. Ask my mom. She's outside somewhere."
"I'm asking you."
"Whatever," he said. "Just give me something for my throat."
"Okay," I said to the nurse as I left the room. "Give him some Keflex now, and get him out of here." He could fill the rest of the prescription in the morning. Even if he were allergic to penicillin, the risk of a reaction to Keflex was slight--less than 10 percent. The charts were piling up in the rack.
Thirty minutes later, as I bent over another child with an earache, holding her head with one hand and the otoscope with the other, as she struggled and cried, they came and got me.
"The patient in Four is in respiratory distress."
He sat bolt upright on the bed, wheezing, fighting for air, his fingers and toes darkening, with that look on his face, and I knew right away that I was in for it. There was no one to call, no one to turn to. I was the only doctor in the hospital. "Page X-ray and respiratory therapy stat. Give him a milligram of epinephrine sub-Q now. Susan, start a line." He was blue, his eyes wide open and reaching.
"We can't get a line, he's a hard stick."
Commands started flowing out of my mouth, without conscious thought. You and you, work on IVs. You, give him another milligram of epinephrine sub-Q. You, get me a central line kit now. You, put him on a hundred percent face mask with an albuterol nebulizer. All of the nurses were there by then.
When people die of bee stings, this is what kills them. Anaphylaxis, the immune system set off like a bomb, and no one knows exactly why. It's rare; I had never seen a case. The whole body swells into hives, the throat constricts, the lungs spasm and close, the blood pressure falls, and it's over in a few minutes.
I knew what I had to do: get a tube down his throat before it swelled shut, and force the oxygen into him. And then I had to give him drugs, epinephrine, Solu-Medrol, Benadryl, albuterol, dopamine. Even then it would be a near thing. But we still had to start an IV.
All of us stuck him with needles until his arms were a mass of puncture wounds, oozing dark blue blood onto the sheets, and finally a nurse slid one in.
"Give him 100 milligrams of succinylcholine IV push."
Succinylcholine is similar to curare. It paralyzes you completely, and this is why the monkeys of South America, hit with a poison dart, fall out of their trees and die. They are awake and alert, but they can't breathe.
There was no choice. He could breathe a little on his own, but not enough. He writhed and fought us on the gurney, he snatched the oxygen from his face, he had lost the ability to reason, and I knew that I could never get the tube down him the way he was. So I paralyzed him.
Even as I gave the order I knew I might not be able to pass the tube into his lungs; his lips and eyes were already swelling. If I couldn't, I had one other chance: last-ditch surgery, a scalpel into the trachea, which I had never done.
The drugs flowed, and he was a still figure, blue, like a body. A sense of resignation settled over me as I put the blade into his mouth, lifted his tongue and jaw. But there they were, like a vision, I could see them, as white as paper, the triangle of the vocal cords, and in a second the tube was in.
Oxygen flowed under pressure. Imperceptible, at first, the change in color, and then it was real, and the blue eased from his face, flowing out of his chest and belly, then out of his arms, the way water dries.
But his blood pressure started to fall.
Open his fluids wide. More epinephrine, start a drip. Get another IV. BP 80/53, heart rate 160.
His mother waited in the consultation room. I walked in and sat down, and for the first time there I was the one shaking, I was the one sick and damp with sweat.
"Mrs. Lopez, I'm very sorry. Your son had a reaction to one of the medicines we gave him. He stopped breathing for a while. He's in critical condition, and I'm sending him by ambulance to the big hospital downtown where they can deal with problems like this." I said it in a rush, barely looking at her.
"This is because of a medicine you gave him?"
I nodded. "He's had a terrible allergic reaction. I was able to bring him back, but I don't know what's going to happen. He might still die."
She looked across the room. "My only son," she said, her lips tightening. "What have you done to my son?"
I sent him, blood pressure next to nothing, by ambulance to the ICU downtown, where the pulmonologists and other specialists waited, and I stared at the empty cubicle, the trash on the floor from the frenzy of the past minutes, a smear of blood, a piece of IV tubing, alcohol pads, and there in the corner, his glasses, their tiny square lenses shining under the fluorescent lights.
The waiting room was still full of children. I had to see them. I had to go in, to look in their ears and listen, but he filled me completely. I was gone, I was somewhere else.
"Say that again?"
"He started coughing yesterday, and then the fever started. You know, we've been waiting a really long time. Is it always this slow?"
I kept running to the phone.
That morning, at home in my bed, I could not sleep, and I was exhausted. His still figure on the gurney, blue, his open eyes--back and forth and back again. Less then 10 percent. By early afternoon I could stand it no longer, and I called again.
"This is Dr. Huyler. I'm calling about Mr. Lopez. He was admitted early this morning, and I'd like to find out how he's doing."
"I'm sorry, sir, we no longer have a patient here by that name."
"Can you tell me what happened to him?"
"Hold on, I'll get the nurse."
Then the silence of waiting, the seconds streaming past, and at last the nurse's voice. "Yes, Doctor. He was transferred to the subacute unit an hour ago. They're going to take him off the ventilator this evening." I had never wanted anything so much.
The days passed, a first, a second, and by the third day I knew it would be all right. But I had to do one more thing.
His room was on the fifth floor overlooking the city, and the sun lit up the mountains in the distance. It was early in the morning when I entered the room, and I heard his voice. He was standing up, talking on the telephone, the swells of his pale white back falling out of the open hospital gown. He heard me enter, and turned.
It took him a little while. At first, I saw the question on his face, and as it slowly gave way to recognition I realized that he was afraid of me.
"Mom, I have to go," he said hurriedly into the phone. "That doctor's here."
"You," he said, then paused. A long silence, and I stood there until he broke it.
"This never should have happened," he said, gathering himself, pointing at me with a thick finger. I heard the anger in his voice, and as I looked at him, nodding as he accused me, humbling myself with an act of will, I felt suddenly large and powerful, somehow proprietary. He had nearly died, and I had brought him back from the edge, I had caught his hand just as he fell into the empty spaces and held him there. His anger sustained me: it meant he was undamaged, it meant that he was safe, nearly home again.
"I'm sorry this happened, Mr. Lopez."
"Easy for you to say," he said, his eyes glittering.
He was so alive.
Frank Huyler is an emergency physician in Albuquerque. This article is excerpted from his book "The Blood of Strangers: Stories From Emergency Medicine" (University of California Press). Copyright 1999; reprinted by permission.