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Franklin Guiles was a happy man. Everything was in order, the world lay in wait. Except for one nagging problem he could not figure out, nearly everything else in his life was plum and, like the caressing rev of motors, finely tuned and running well.
In the last few days he had consulted Pathology, whom he generally thought were idiots, Cardiovascular Medicine, and Pulmonology. Moreover, he had ordered every imaginable scan and culture available, but just could not get to the root of why Zach was so ill.
Hospital rounds were completed by 0800, later than he would have liked, but he'd been held up by the flirtatious ward secretary Tom on the 8th floor. Poor kid, he thought. He still doesn't get it.
He returned to the ICU and Zach's bedside where his nurse, Andrew, was bathing the troublesome patient. Dr. Guiles took a seat in the corner and stared at the monitors, a vague inquiry hovering on his next breath. He felt comfortable brain-storming in Andrew's presence, as they were about the same age and each felt a great deal of respect for the other. During Guiles' residency Andrew had been one of the few constants in his Intensive Care rotations. He was bright and cheerful, had boundless energy, and was intelligent beyond the obvious. In addition, he possessed an intense passion for his work, and enjoyed the intimacy of the one-on-one patient care that the ICU setting offered.
Andrew juggled the venous and arterial catheters with grace and precision, all the time humming to Zach in rhythm with the ventilator. Zach's eyes remained closed, but it was believed he could still hear much of what was happening around him. Both men's training and most of the available literature supported the concept that, despite the Glasgow coma scale rating, most patients remembered and reacted to conversations. Hence, content of bedside dialogue was circumspect and the environment kept quiet.
"Lung CT negative, MRI negative, all tissue and blood cultures negative," Dr. Guiles reviewed. There was no need to look back through the chart, he had it memorized by now.
"Cerebral angiogram negative, stereotactic ring scan negative, patient afebrile... vital signs within normal limits..."
"Well," Andrew interrupted, "his temperature has been going up and down in the last 24 hours. It hasn't spiked, so I didn't say much. Probably just some early atelectasis. But, Doc, his blood gases have taken a turn again, although I can't really put my finger on it."
"What do you mean?" asked Guiles.
"Well," said Andrew, "when I draw the sample it just looks dark, even though the numbers come back OK. I even sent two samples once, just to see if it was lab error. They were identical."
"Hmmm," he mumbled, "I thought we had addressed that problem. It's back?"
Andrew turned back to the bed and finished his morning care. Guiles sat back and studied the young man and his style, sincerity, and his passion for the work. He watched the focus and intensity in Andrew's face as he tenderly made Zach comfortable for another long day in the hospital, the strange room, and the unfamiliar bed. Andrew double-checked the propofol drip and cleared the moisture from the ventilator tubing. He then leaned over and whispered quietly into Zach's ear.
"You really do enjoy the job, don't you, Drew," he said. Dr. Guiles noticed a diamond ring on Andrew's right hand he had not seen before. "And it pays well, yes?"
"I'm sorry Doc," Andrew replied. "I was somewhere else."
"That's OK," he said. "Keep me posted, alright? I'll be back this afternoon.
Burnham Hospital lay in the middle of a Kansas plain that was slowly evolving from farmland to urban sprawl. The campus had been there for so long, and was still running in the black, that no private or government agency dared to touch it. Its reputation was impeccable, especially for academics and teaching. The residency programs drew ten-fold the applicants it could accommodate, and nurses waited more than a year to sign on.
The small Midwest city had been steadily growing with population influx and slowly incorporating its suburbs, welcoming alternative lifestyles and becoming far more tolerant and accepting than the remote, peripheral towns that dotted the plains. Nightlife flourished, especially around the university and downtown, where a fresh infusion of youth was now evident year round. Old businesses and clubs breathed new life and catered to a blend of eager adolescents and contemporary young adults. The gentrified sprawl stretched to older neighborhoods where solvent singles and couples of all strata snatched up homes to remodel. Zach had likewise migrated to the growing metropolis, having discovered a freedom in the city he had heretofore not known in his hometown. He had a good-paying job, was back in school, and enjoyed a new circle of friends. One by one, the stifling and oppressive mores of his rural upbringing were shed like scales from an old snake.
And so the cycle of growth prospered, as did wealth, a palpable detachment from reality, and the inevitable waves of vice.
Zach had been admitted four days prior after clubbing late into the night. A girlfriend had called an ambulance when he was found on the dance floor confused and agitated. En route, he had suffered a seizure and respiratory arrest and, on arrival to the hospital, was deeply cyanotic and slipped in and out of consciousness.
Dr. Guiles was the intensivist on call that night and assumed care of Zach once he had been intubated and stabilized. The Emergency Doc had briefed him, but not to Guiles' satisfaction. He had left the service transfer with an ignorant "dunno" in summing up the admission. The one thing Dr. Guiles had found peculiar was the patient's blood gas which, on paper, was out of range and did not make sense for the clinical picture. Zach had likely not aspirated, his lungs were clear, he had not been drinking, and all blood studies ruled out recreational drug use. Yet, here he was, clearly acidotic with a pH of 7.30, PaCO2 of 39, PaO2 of 70, HCO3 of 18, and a saturation of 90%. His blood pressure was down and his heart rate were over 100; odd for a young and otherwise healthy man.
The ER had ruled out a cardiac infarct as, even with sustained tachyardia, his EKG had shown no specific changes, and the VQ scan indicated he wasn't shunting nor had he suffered a pulmonary embolus. He was transferred to the ICU whereupon, the next morning, Andrew noticed Zach's name on the chart and eagerly assumed his care.
Andrew was completing his other morning duties when the fire alarm sounded overhead, accompanied by the ridiculous, ear-splitting dings and flashes of god-forsaken hospital strobe lights. On the street behind the complex an ambulance siren wailed incessantly. In the next room Zach's body tensed as he began to fight the ventilator. In an instant, the blood pressure in his pulmonary circulation reached crisis as the ambient corridor noise was compounded by the multiple alarms on his monitors.
Inside his brain the machine guns blazed in time with the disco and subwoofer base and, layered with orgasmic screams from the dance floor, the club walls vibrated. His head ached and his thick, chocolate-brown blood burst through the microarterioles in his body's mucous membranes, forming fresh pettechiae on pink exposed skin, slowly congealing into red and blue wounds. The base of his skull racked with the sounds, earth-shale shifted, and the sea floor moved and crashed, making his head pound more and more.
Andrew's experience allowed him to discern the distinct tones through the wall as the building temporarily plunged into animated darkness. The generator kicked in as the emergency lights glared. He ran into Zach's room to find the patient in tonus and his PA catheter readings breaching the limits of sustainability.
"Call a Code!" he said above the fray, and the charge nurse responded in an instant with the available team. Overhead the operator repeated, "Code 99, ICU Room 6 Code 99..." Dr. Guiles arrived with the pharmacist, asked for a benzo, and quickly handed it to Andrew to calm the patient.
"What the...?" he asked. "I've never seen his pulmonary pressures this high!"
"Dr. Guiles," the charge nurse said, "look at this!"
Rivulets of bright red ooze seeped down from Zach's nose and pooled onto the bed sheets.
"Good God," Dr. Guiles stepped closer to assess the trembling mass of youth, deteriorating before his eyes.
"DIC?" he shouted over the waning alarms, "What triggered this?"
Slowly, the patient calmed as the numbers began to return to normal, and the oozing stopped. Guiles watched for a few minutes then pensively sighed as he folded his arms.
"When he's been calm for a bit, get a blood gas and serum lactate, OK?"
"Will do," said Andrew.
"Christ..." Guiles said and turned away. He paced the small ICU room, checked the monitors once again, then returned his eyes to Zach. Andrew was injecting something into the central line, something in a syringe other than the one Guiles had given him.
"What's that, Drew?" he asked.
"Flush to follow the Versed," he said. "New policy." He quickly tossed the syringe and left the room.
Dr. Guiles walked to the bedside and placed one hand on Zach's shoulder. He then steadied himself with his other hand on the cold, steel ventilator that had kept the young man barely alive, and closed his eyes to think. His feet hurt and his mind reeled with fragmented information. A wave of odd, sweet scent momentarily passed by. The noise that had shattered the morning had now abated, and he began to feel the rhythm of the mechanical respirations - in and out, in and out - humming life, as a semblance of quiet slowly returned to his frustrated soul.
Zach intermittently chewed on the endotracheal tube and the reddish-blue flush had all but drained from his face. His vitals slowly drifted down and returned to just above baseline. Feeling Dr. Guiles' hand on his shoulder, he began to relax and, almost imperceptibly, turned his head toward the good doctor.
That afternoon Dr. Guiles sat in his office and contemplated his dilemma, barely noticing a colleague knock and enter.
"May I come in?"
"Of course, John. I'm sorry, I didn't hear you."
Dr. Hill sat across from Guiles and watched him for a moment before he spoke.
"Looks like you've got the world on your back, Franklin. What's going on?"
"I've got this patient in the ICU and I cannot make heads or tails of it. For the life of me it just does not fit any clinical picture I have ever run across."
"Actually," Hill continued, "that's why I'm here." The young man has been here nearly five days and we still haven't a working diagnosis. You've considered pneumocystis?"
"That's the first thing I thought of, but all the cultures are negative, and I don't want to treat him with something that would potentially bottom out his pressure when there is no obvious benefit and nothing to support its use."
"Yes, I imagine you have been your usual thorough self," Hill said. "No one can fault you for that."
He paused, "Franklin, have you thought about thinking beyond the obvious?"
"Step back from the picture for a while and see what comes to you," Hill said. "Do you know much about his life or lifestyle? Who his friends are? Where he came from?"
Franklin sat for a moment and then spoke.
"John, you know this hospital better than anyone. I, uh... I, um..." he hesitated, "I want to inquire about someone on staff, but want to do it discreetly.
"Personally, or professionally?" asked Hill.
"Maybe a little of both."
Carol Ashton was a formidable woman; revered, respected and, by some, feared. She had begun at Burnham over two decades prior and had risen to the position of Director of Nursing through a solid clinical foundation and a drive that was unstoppable. Performance expectations of her staff were known to be among the highest.
Her office door was open to anyone, anytime, and the hospital was her life. One needn't go through multiple administrative layers to see her and, despite her authority, she remained a compassionate force at the heart of the care she advocated.
Dr. Guiles came to her office that afternoon and knocked.
"It's Carol, please. Do come in."
Guiles sat down across from her dark mahogany desk. As she finished some paperwork, he noticed that she was wearing a comfortable suit, her hair done well. Her face was calm. The walls were adorned not with accolades and honors, but with tasteful art and photos of her staff. There wasn't a scintilla of arrogance about her and he quickly and easily relaxed in her presence.
"I've met you, Franklin," she began. "On Grand Rounds. And your reputation precedes you."
"Thank you," he said. "That's very kind."
"John Hill said you may be coming by. What can I do for you?"
"I would like to inquire about one of your ICU nurses, Andrew..."
She put her hand up and looked at the open door. "Let's go for a walk," she said. "I need a smoke."
Miss Ashton put on her lab coat as they walked toward the elevator and outside. Guiles noticed that the elegant touch of formality made her look taller. The grounds that greeted them were well-kept and the pedestrian pathway led them through a small garden. The fall colors were changing as the early afternoon sun lightly caressed the landscape. Guiles remembered why he enjoyed it here so much.
"It's better out here," she said as she lit a cigarette. "Meet my personal trainer."
As Franklin did not smoke he stood back a little, folding his arms against the early autumn chill, and faced her. He felt he could trust this woman, and knew that his words would be kept confidential. She certainly did not get this far by deceit.
"Before you begin, let me say this," Miss Ashton interrupted, taking another long and pensive drag on her cigarette.
"You know," she began, "I love these kids. I see such potential in their abilities and I believe in them. In turn, they know what I want and deliver the best care. Our reviews speak to that. That's what it's all about.
"I don't care about their personal lives," she continued, "as long as it doesn't interfere with their job. I want them to have a life outside the hospital."
She crushed the unfinished butt under her shoe and sighed, looking out past the trees.
"Andrew is a special young man to me. I knew his mother. I know he has problems but, damnit, he produces. He works hard, and he plays hard, but he's never let me down.
"He is always the first to take an extra shift and, God knows, not everyone is as devoted as that."
"You say you knew his mother," Guiles asked, "What happened there?"
Forcing back a trespass of memories Miss Ashton put her hands in her pockets and stared at the ground. An eternity passed before she spoke. Guiles' pager interrupted the silence and he shut it off. The Director didn't notice it.
"Andrew's father had a history of substance abuse and, as a result, was quite self-destructive." She paused. "He was also quite violent toward Patricia."
"Short story is, one night he beat her so badly she died of head wounds. I went to the ER when I heard she had been admitted, but she was gone. Poor thing didn't have a prayer."
"And Andrew?" Guiles asked.
"He was away at school when it happened. He came back to an empty house, no mother, and watched as his father was incarcerated. That's quite a burden for a young man.
"And the father?"
"Hung himself awaiting trial."
"For all that, however," she offered, "he has come out of it a remarkable young man."
"Yes, it seems he's held up pretty well."
The sun was beginning to drop below the fine clouds on the horizon. Carol shivered and shuffled her feet. Dr. Guiles was quite taken aback by this as, for all the time he had known Drew, he hadn't a clue about his tormented past. He gestured for them to walk back to the warmth of the building's underbelly, and Carol followed.
"Look, Franklin," she offered, "I don't pretend to understand all of this, especially when there is a generation gap. I loved his mother like I would a sister, but I also knew she couldn't fully accept his being... you know... as he is.
"He never really had the chance to... what do they call it? Come out to her. After he joined here I had him in my office several times just to see if he was alright, and he assured me he was. I didn't want to pry.
"He came back here to work, made a circle of friends, and seemed content to let the past be just that."
"I am son to my father, but not to his ways."
"William Shakespeare," said Guiles. "Henry the V."
"Oh," Carol said, and smiled as she watched the evening shadows silhouette and embrace the Doctor's handsome profile.
They entered the building and welcomed the visceral warmth from the long and dimly lit basement corridors.
"It's Friday, Dr. Guiles." Carol offered, extending her hand. "Go home and get some rest."
"Thanks, I will, right after rounds. You?"
"Nah," she said, "I've got some major Pharmacy discrepancies to address. Seems someone has been pilfering IV nitroglycerine, though God knows why."
Guiles stopped and said, "Oh, Carol, one more thing."
"Is it policy to flush the central line each time a med is given?"
"Hmmm, no. Not unless the patient is coding or is on fluid restriction. Why do you ask?"
"No reason, just wondering. Thanks."
Dr. Guiles slowly walked back to the ICU and, as he entered, he saw Andrew heading out the door in street clothes.
"Goin' out tonight, Doc?"
"Nah, I'm too old for that." He certainly felt old today. "You?"
"You bet!" Drew said with a grin. "I'm meeting some friends for dinner and then to dance the night away. I'll see you Monday."
"Uh, Andrew," Guiles stammered a bit and motioned him closer, "I know things have changed, but... you are careful, aren't you?"
"More than you know," he said and winked, "More than you'll ever know."
Franklin Guiles drove home in a heavy, fatigued daze. He had turned the car radio off and listened instead to the soothing, steady drone of the purring engine as it led him out and away from work. Distractions aside, his mind wandered uninhibited and free, and a watery, warm calm allowed him to slowly segue into the alpha state he sorely needed, nearly falling asleep at the wheel. Arriving home, he unlocked the door to his house and was greeted by the cold, stale air and the distant, impersonal beep of his answering machine. He opened the refrigerator and lamented his palpable absence of domesticity.
"I need to get out more," he chuckled to himself.
He opened a bottle of deep red wine and put on some Strauss. As the haunting sounds of string and soprano richly filled his senses, he sat back and sniffed, then tasted the vintage. A fleeting memory of the odd scent he had witnessed at Zach's bedside momentarily floated back and, just as quickly, disappeared, and he fell into a deep and restless sleep.
Fractionate images blasted through his disinhibited subconscious, pausing for a nanosecond, some surfacing, others flying like rockets to unknown systems. Fleeting photos remained, but none so vivid or clear he could take hold and identify. Dodging branches, on the run, trees falling, bombs, lights from nowhere, salvation replaced by visceral instinct, bullets flying, painful spotlights diving into his liquid vitreous, falling, sucking him into an ominous black void.
Franklin's hands violently flew outward and knocked over his wineglass, which fell to the floor and exploded, abruptly welcoming him into the peace that suddenly followed. The music was off, his bladder hurt, and he mumbled a curse as he walked toward the bathroom and threw some cold water on his face.
He looked into the mirror and thought to himself: What the hell am I missing?
He found a dusty bottle of vodka, took a shot with half a sleeper, and went back to bed, waking several long hours later; calmer, refreshed, and more at peace.
Guiles spent the weekend focused on everything but the case. Instead he spent some time in his modest yard and the late summer chores he had neglected. He made a point of buying groceries and stocking his kitchen, at least enough to represent a semblance of health and self-interest. He took one last bike ride and hung his Centurion upside-down in the garage. By Monday morning he was rested and entered the hospital with few of the nagging entrails that had haunted him last week... all except for one.
He walked into ICU a few minutes early for morning rounds. As he peeked into Zach's room, he noticed another nurse at the bedside. It was before 7, so he thought nothing of it at first but, when Andrew still hadn't arrived by 8, his concern was evident. He walked over to the charge nurse who was preparing for rounds and said,
"I wonder where Andrew is this morning."
"He called in ill. Funny thing is," she said, "his words were slightly slurred and..." she paused.
"...And he sounded as if he had been crying."
Guiles walked back to Zach's room and, in an unprecedented move, suddenly decided to skip ICU rounds. He took Zach's chart into a private office and studied it page by page, beginning with the ambulance and admission records. He went through the pages line by line and the EMT's on-site scribbles:
"12:40 am. Arrived on location from 911 call."
He searched for the address and saw that it was at 345 Fulton St. He hadn't been in that part of town since he was an intern.
"Patient found on floor, diaphoretic, moderately responsive, orthostatic. Difficult to assess due to ambient noise. Transported from Thumpers to Burnham."
"Thumpers," he said, "that's it." He didn't need to read any further.
Thumpers Bar was in an old and seedy part of city. The area had yet to feel the surge of market upswing and crass commercialism. Many believed it was on the "wrong" side of town but it drew a reliable crowd every weekend and the DJs were known to be innovative, the dance floor hot, the clientele sexy, the drinks flowing, and drug use commonplace.
That night Guiles drove to Fulton and walked into this foreign place. He stood back and watched the gyrating, dancing, sweating masses. Good music, he thought, for techno. As he circled the room and leaned in to order a drink, the bartender eyed him, looked him up and down and smiled.
"I'm Jamie. You're new. And cute."
"Evian and lime, please."
"What's with the suit?"
"A little uptight for this place, no?"
"I am looking for someone."
"Aren't we all?" he said, rapping his knuckles on the bar. "Drink's on me."
Guiles turned back to face the kaleidoscope colors of the music and the bodies submerged in synthetic desire, the gyrating spandex, the overpowering presence of pheromones and freedom. The air was thick and stale and redolent with odors sweet and pungent: alcohol, stale urine and something else! He looked around the room and saw bare-chested, tight-jeaned, wild dancing beauties: sharing something, sniffing something. Something in bottles.
He flashed back to his intern days.
Most hospitals used nitro paste for myocardial ischemia. Multiple codes, confusion, people everywhere - He had once inadvertently rubbed some on his bare fingers and, within minutes, was on his knees, blood rushing to his brain, his heart pounding, his staff laughing, the room spinning, now in contact with the ER floor, his soul questioning his career choice.
Deep within the tombs of his memory, he knew that scent, that rush, that overpowering feeling of dizziness and helplessness.
God, could he have been that naïve?
Guiles turned back to the bar to thank Jamie, but he was already off talking up someone else. He quickly left, walking through the sweaty crowd, oblivious to the cat- calls and gropes from otherwise intelligent men and women, and into the cool and fresh night. He hopped in his car and sped off to the hospital.
He arrived, sought out the night charge nurse, apologized for his appearance and, he was sure, his odor.
"Kathleen, I need to ask a favor."
"Certainly, Dr. G." she said. "Whatcha' need?"
"This needs to be confidential, but I would like to see the personal belongings of the patient in 106."
"Oh, Zach," she said. "Wait here."
As he waited, Guiles thought through the layers of events that had filled the last few days and the unsolved clinical matrix before him.
Zach was here, surviving with numbers that did not make sense, a root problem undiagnosed and ostensibly untreatable. He responded to short term intervention but, every time he seemed to make some progress, he slipped back into an idiopathic hypotensive crisis, with paradoxical bouts of pulmonary hypertension. And the bleeding: why the hell was he bleeding? The ventilator only made things worse and he couldn't be on pressors forever. Something inside Zach's brain held the key - if only Guiles could get inside.
He closed his eyes and replayed everything he had seen:
Sounds bothered Zach, so he heard things, knew things others could only surmise. The Versed calmed him down but what was it that Andrew injected afterward? Versed was in a water-based vehicle, so shouldn't need a flush.
Why was his blood still dark, despite appropriate therapy?
Kathleen returned with Zach's belongings and showed Dr. Guiles a private conference room where he would be undisturbed. If this got out, she may be in trouble as well, but she trusted him.
"Would you like me to stay?" she asked.
"Yes, thanks." he said. "Help me think through this."
He emptied half the contents of the envelope onto the table: A wallet, some keys, loose change, a dark, unlabeled bottle.
Guiles carefully opened the bottle and set it down between them. With no effort, he suddenly got a nose full of a sharp, pungent odor and, within a few seconds, his head hurt. He quickly closed the bottle and closed his eyes until it cleared.
Of course! Amyl Nitrate.
There was a ticket stub, a folded piece of paper, and a man's ring. A diamond ring. The same design Andrew had been wearing.
"Holy Shit!" he said, and called Pharmacy.
He quickly returned all the items to the envelope and handed it to Kathleen.
"This is Dr. Guiles in ICU." His voice was impatient. "Please tube me an amp of methylene blue right away."
"Yes, I'll submit the paperwork later," he shouted, "Please, tube it now!"
It was uncharacteristic for him to raise his voice, but he had no time to waste.
"Kathleen, when this arrives, bring it to me in 106 and stand by. Call Respiratory Therapy and ask them to come as well."
"You got it, Doc."
Guiles returned to Zach's bedside and took his hand. RT arrived and he nodded to them and added, "Say a prayer. If this works, he can be weaned and extubated soon."
Guiles turned off the propofol drip and slowly injected the methylene blue, allowing the IV fluids to run freely, delivering a cool covenant of new hope and freedom into Zach's veins, bringing his dark blood back to life. He then instructed RT to turn off the ventilator. It hissed into silence and the room lay still.
Within a few moments, the young man in the long bed of suffering took a deep breath, opened his eyes and looked directly at Dr. Guiles. He pointed to his endotracheal tube and Guiles carefully removed it and replaced it with an oxygen mask.
Zach relaxed, his blood pressure settled and, as he coughed once, he said, "It was Andrew."
"I know," Dr. Guiles replied. "Let the engines roar."
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