Chapter 1: CRASH CART! NOW!

August 26, 1987, McKinley, Ohio

“CRASH CART! NOW!” Doctor Lindsay commanded.

She quickly put an oxygen mask on Elizaveta and turned the dial to its maximum setting. A nurse hit the red ‘crash’ button on the wall and seconds later a nurse rushed in, wheeling a crash cart before her. Doctor Forsberg sprinted into the room and moved to Elizaveta’s side, followed by Doctor Strong. I suddenly felt weak and my head spun, causing me to stumble.

Clarissa and Father Nicholas caught me and supported me while Doctors Lindsay and Forsberg evaluated my wife, the mother of our child.

“V-fib!” Doctor Forsberg declared as Doctor Strong rushed into the room.

“Lord have mercy,” Father Nicholas said quietly.

“Charge to 200!” Doctor Strong commanded.

The defibrillator whirred as the capacitors charged, and Doctor Forsberg tore off Elizaveta’s gown and put pads on her chest.

“Clear!” Doctor Strong commanded.

Doctor Forsberg removed the oxygen mask, then stepped back. Doctor Strong pressed the paddles against the pads and pressed the buttons, causing Elizaveta’s body to convulse. A few seconds later, I saw a strong beat on the monitor, then another, then a third.

“Normal sinus rhythm,” Doctor Strong said. “What happened?”

Doctor Forsberg put the oxygen mask back on Elizaveta’s face, and Doctor Lindsay began an assessment using her stethoscope.

“Elizaveta was talking to Mike,” Clarissa said. “She said she didn’t feel well, went pale, then lost consciousness. That’s when the monitor showed irregular electrical activity then V-fib.”

“Post C-section?” Doctor Strong asked.

“Yes,” Clarissa replied. “By Doctor Kendall and Doctor Forsberg. I observed. No obvious complications, minimal bleeding, no placental problems, and a healthy baby.”

“Well, something caused an otherwise healthy eighteen-year-old young woman to crash! Doctor Forsberg, any trouble during her pregnancy?”

“None,” Doctor Forsberg replied.

“Reason for the C-section?”

“Elizaveta called saying she was having what sounded like short runs of V-tach, so I told her to come in. Her blood pressure was normal when she arrived and we put her on a monitor. She had a run of V-tach while I was examining her, and the baby seemed to be in a bit of distress.

“I suspected Elizaveta was experiencing postural orthostatic tachycardia syndrome, and because she was a week past term and the baby appeared to be in a bit of distress with late decels not associated with contractions, I determined a C-section was the best course of action and had Doctor Kendall paged.”

“Nulliparous and primigravida before delivery?”

“Yes, she’s now G1, T1, P0, A0, L1.”

I had to think back to what that meant. GTPAL was the mnemonic for Gravidity, Term, Premature, Abortion, Living with reference to the number of times pregnant, the number of babies carried past thirty-seven weeks, the number of premature births, the number of abortions, and the number of living children.

“She went into labor naturally?”

“She did.”

“Amniotic fluid levels when she arrived?” Doctor Strong asked.

“Low, typical of post-term pregnancy, but within the acceptable range. That cost one point on the biophysical profile which was 9 with everything else being perfect.”

“Placenta?”

“Sent to pathology, but grossly normal with no tears or other injuries, and no excess bleeding. Good cord perfusion.”

“The baby?”

“Good initial and five-minute Apgar scores. Glucose stick test was in the normal range, as was bilirubin. She’s well formed, properly developed, and in the nursery.”

“Doctor Lindsay?” Doctor Strong inquired, “Your findings?”

“Moderate edema in both lungs identified by crackles and a third heart sound. BP is low at 90/50, pulse is tachy at 110, resps are shallow at 17. Unknown why she has not regained consciousness.”

Doctor Strong moved to the side of the bed and used his stethoscope to listen to Elizaveta’s heart and lungs.

“Pericardial knock,” Doctor Strong said. “Doctor Forsberg, were there any signs of heart trouble during her pregnancy?”

“None at all until she reported the ‘racing’ or ‘fluttering’ when she called me. Mild peripheral edema, typical of pregnancy, but no identifiable circulatory problems, with strong distal pulses and good heart sounds.”

“OK. Let’s get a CBC, Chem-20, ABG, and start her on IV antibiotics as a precaution. I’ll want to do an ultrasound as well. I’ll stay with her until we can move her to the ICU. Someone page Doctor Kendall, please. And page Neuro as well, given we don’t know why she’s not conscious.”

The nurses sprang into action, with one drawing blood, one going to the phone, and the other leaving to get the ultrasound.

“You OK, Petrovich?” Clarissa asked. “You look pale.”

“No,” I replied weakly. “I’m not OK.”

“Let’s get Mike into a bed,” Doctor Strong advised.

“I don’t need a bed,” I protested. “Just sitting down will be fine. Worry about Elizaveta, not me!”

“Deacon Michael,” Father Nicholas counseled, “you need to be healthy for Elizaveta. Let your doctors check you out.”

“Do it, Petrovich,” Clarissa commanded.

“Doctor Lindsay,” Doctor Strong said, “please take Mike to a bed, perform a physical, then report back.”

“Let’s go, Mike,” Doctor Lindsay said coming over to me.

“I’ll stay with Elizaveta,” Father Nicholas said. “I have my chrism, so I’ll anoint her, and if anything happens, I’ll come to see you.”

I thought about resisting, but simply didn’t have the energy. I let Clarissa guide me out of the room, and down the hall to an empty exam room. I got onto the bed and Doctor Lindsay checked my blood pressure and pulse, then listened to my heart and lungs, and checked my distal pulses.

“Your BP and pulse are elevated, which I’ll chalk up to adrenaline,” Doctor Lindsay said. “When’s the last time you ate or had something to drink?”

“Dinner last night, then a large coffee on the way here.”

“Caffeine plus adrenaline,” Doctor Lindsay said. “That would explain it, along with interrupted sleep.”

“Can I go back to my wife, please?”

“Let me check with Doctor Strong,” she replied.

“Ask Doctor Forsberg,” I requested. “She’s an Attending.”

Doctor Lindsay nodded, “She is, but she’ll listen to the surgical and cardiology Residents because she’s an expert in female anatomy.”

“So is Petrovich!” Clarissa tittered.

“Lissa,” I sighed.

“I was going to add ‘not in cardiology or surgery’,” Doctor Lindsay said with a smirk. “This is clearly a case for Cardiology at the moment. And I do get the impression you know your way around female anatomy.”

“I had the required courses,” I replied flatly.

“Uh-huh,” Doctor Lindsay said. “I’ll be right back.”

She left, leaving Clarissa and me alone.

“Lizochka is in good hands, Petrovich,” Clarissa said. “She’s young and strong.”

“Which didn’t prevent her from going into V-fib!” I shot back.

“Mike,” Clarissa said gently, “Do you trust Doctor Strong, Doctor Forsberg, and Doctor Lindsay?”

“Yes,” I admitted grudgingly, knowing what was coming next.

“Then trust they’ll figure this out and that you’ll take your wife and daughter home in a few days.”

“Nothing at all went wrong in the surgery?”

“It was textbook. Elizaveta’s vitals were great the whole time, and your daughter announced her presence with authority as any Russian woman would!”

Doctor Lindsay came back into the room just then and said, “Doctor Forsberg would like you to rest for fifteen minutes. They’re moving Elizaveta to the ICU so she can have continuous monitoring and nursing care while Doctor Strong, Doctor Kendall, and Doctor Forsberg try to determine a diagnosis. It’ll take about ten minutes to get her settled, so you’ll be able to see her then.”

“How’s her heart?” I asked.

“Sinus rhythm but with occasional runs of SVT, which seems to be what happened before her friends brought her in.”

“Tamponade?” I asked.

Doctor Lindsay shook her head, “No, but she almost certainly has excess fluid in her pericardium. The ultrasound will tell us more, and they’ll check for cardiomyopathy as well.”

“Clarissa said the C-section was textbook.”

“It was. Doctor Kendall and Doctor Forsberg were there, and I did the procedure from incision to closure, and I literally followed the textbook steps because everything was perfect except for your daughter’s irregular heart rate, which resolved immediately after I handed her to the nurse.”

“Any idea of the cause of Elizaveta’s arrhythmia?”

“I can only speculate, but chorioamnionitis is a distinct possibility, and is likely part of why Doctor Strong ordered IV antibiotics. The other would be post-op infection, such as endometritis, but it’s awfully soon for those symptoms.”

“What about Rachel?” I asked.

“Her glucose was fine, and she had no jaundice. I’m sure Doctor Forsberg and the neonatal Resident will run a full spectrum to rule out any infection.”

Father Nicholas entered the room and said, “They’re moving her to ICU. Doctor Strong said her vitals are good, but she’s still having occasional bouts of whatever it was that causes her heart to race.”

“Runs of SVT,” Clarissa replied. “That’s SupraVentricular Tachycardia. In Elizaveta’s case, it’s paroxysmal supraventricular tachycardia, which basically means she has intermittent episodes of a racing heart with abrupt onset and termination.”

“What causes that?” he asked.

Clarissa looked to Doctor Lindsay.

“Stress would be the main one,” Doctor Lindsay said, “unless she’s been smoking, drinking, or ingesting large amounts of caffeine.”

“None of the above,” I added.

“How are you doing, Mike?” Father Nicholas inquired.

“I want to go see her, but I’m being held prisoner until they get her settled in the ICU.”

“Chill, Petrovich!” Clarissa ordered.

“That’s good advice,” Father Nicholas observed. “I’m going to call His Grace and let him know.”

“You can use the phone in the Residents’ office,” Doctor Lindsay offered. “Clarissa can show you where that is.”

Clarissa and Father Nicholas left, leaving me with Doctor Lindsay.

“Babysitting duty to make sure I stay in this bed for exactly nine hundred seconds, and not one second less?” I asked.

“Doctor Forsberg did instruct me to ensure you rested for fifteen minutes.”

“To keep me out of the way.”

“Medical students with family members as patients tend to try to ‘help’.”

“Did you see me do anything except move out of the way?” I asked. “Or see me freak out? Or anything like that?”

“No. But you’re going to follow Doctor Forsberg’s instructions because otherwise, she or Doctor Strong might ban you from the ICU, which you know they can do.”

“And med students, as with patients, should be treated by how they present, not determined by baseless assumptions contrary to fact!”

“Give it a rest, Mike,” Doctor Lindsay counseled. “Resting here while they transition Elizaveta to the ICU makes sense, and you’d know that if you weren’t thinking like a doctor and instead were thinking the way the husband of a patient should think.”

“I can’t stop thinking like a doctor,” I protested.

Doctor Lindsay smiled, “Quod erat demonstrandum.”

I realized further protests would not help, as I’d just proved the point Doctor Lindsay was trying to make.

“How is your OB/GYN rotation going?” she asked.

“Really well, I think. It was something of an oddity for them because of the Preceptorships. Normally new Third Years are totally clueless and I had at least a partial clue, which caused conflict when I asked to be able to do more than stand around watching. Doctor Cooper and one of her Residents, Doctor Kelly, decided I knew more than the average med student and have allowed me to participate.”

“I take it that caused some drama?”

“It did, but I’ve shown my ability to do basic procedures and exams, so it’s kind of died down. The OB/GYN Chief at Good Samaritan is something of a dinosaur, but fortunately, all my interactions are with female Residents, and my Attending who is female.”

“You don’t think men can be OB/GYNs?”

“I think quite a few men who were trained in the 50s and 60s are not well suited to deal with modern obstetrics and gynecology. Let’s just say that as familiar as I am with female anatomy, not having it does not provide me with a good perspective!”

Doctor Lindsay laughed, “An interesting perspective.”

“One which keeps me alive,” I replied.

“Your wife is a feisty one, and being young, strong, and determined are all indicators of a positive outcome. Just hang in there, Mike.”

“That would be easier if I knew what was wrong.”

“And we’ll figure it out.”

Father Nicholas and Clarissa returned and he let me know the bishop was going to have someone drive him to McKinley as soon as possible.

“Can I go see Elizaveta now, please?” I asked, looking at my watch.

“Yes,” Doctor Lindsay said. “But ICU is limited access, as you know. It’s up to the Attending and Resident if you can stay beyond the usual five minutes. Father Nicholas, as chaplain, you can visit, but again, with whatever rules the Attending and Resident set. And Mike, don’t fight it, because you’re not even assigned to Moore Memorial Hospital at this point.”

“I’ll behave,” I replied.

“That’ll be a first!” Clarissa teased.

“I’ll deal with you later!” I said trying to sound cross.

“I need to go back to OB,” she said. “Page me if anything changes, please, or if you need me.”

“I always need you, Lissa,” I replied.

She smiled and left, then I got out of bed and walked with Father Nicholas and Doctor Lindsay to ICU. We put on masks and gloves as required, and then went to Elizaveta’s bed. The monitor showed sinus rhythm, though her pulse was elevated. I checked the chart and saw her BP was still low.

She had an IV and the chart showed vancomycin, lactated Ringer’s, and vasopressors, or ‘pressers’ as we called them, to try to bring up her blood pressure. It also showed the orders for stat blood work, but I knew the process, and it would be another thirty minutes or so before all the results were back.

The chart also showed the results of the cardiac ultrasound — a small pericardial effusion, which at the moment, did not require treatment, but would be checked every two hours by ultrasound. I was thankful she was breathing on her own and hadn’t needed a vent, though she did have on an oxygen mask.

My goal was to stay with Elizaveta full-time, but that would require permission from the ICU attending, and I’d also have to convince the other Doctors who would, I was positive, demand I get some sleep.

“I’m Ken Jones,” a Resident said. “She’s stable. You’re a med student, right?”

“Mike Loucks,” I replied. “This is our priest, Father Nicholas, who’s a hospital chaplain.”

“OK. I’ll allow you two to visit for ten minutes each hour, which is the most I can do.”

I fought the urge to challenge him because I realized that the Attending, who the board showed was Doctor Roger Murtaugh, would have the final say, and antagonizing the Resident wouldn’t help me win an argument.

“Is Doctor Murtaugh available?”

I could tell by the way Doctor Jones’ mask moved that he was smiling.

“I’m the best you’re going to get. Doctor Murtaugh doesn’t usually grant any exceptions, but he’ll back me on ten minutes an hour. If you go to him, be prepared to have the rules strictly enforced.”

“Listen to him, Deacon,” Father Nicholas counseled.

I sighed because I knew he was right. I wanted to hold my wife’s hand and kiss her, but I knew I’d be immediately kicked out of the ICU if I did that.

“Let’s pray for her, Deacon,” Father Nicholas said.

I nodded and he quietly said the prayers for the sick. As I said ‘Amen’ the monitor beeped and the red light flashed as the EKG showed a run of SVT which lasted about five seconds then disappeared and a normal sinus rhythm resumed.

“Any idea what’s causing the SVTs?” I asked,

“Have you done a cardiology rotation?” Doctor Jones asked.

“Yes. I understand SVTs.”

“It’s likely some sort of stress on her system, but we don’t know what that is just yet. It could simply be a bad reaction to the spinal, or to the surgery. The real concern, obviously, is the V-fib. Doctor Strong is consulting with Doctor Getty about that.”

“Deacon, have you spoken to Elizaveta’s parents?” Father Nicholas inquired.

“No.”

“Let me go call them, and tell Serafima and Alyssa what’s going on.”

“Thank you, Father.”

He left and I stayed with Elizaveta until a nurse reminded me that I only had ten minutes. I leaned down and whispered, “I love you”, then left the ICU. I removed my mask and gloves, then headed to the Maternity waiting room where I found Father Nicholas with Mark, Alyssa, Elias, and Serafima.

“I spoke with Viktor,” Father Nicholas said. “They’re on their way here.”

And my mother-in-law was likely going to have a cow about the fact that she hadn’t been called right away, and despite the fact that I’d been in Cincinnati, she’d take her wrath out on me.

“Yulia is going to be very unhappy with me,” I said to Father Nicholas.

“Let Viktor deal with that, please,” he advised. “Just be polite.”

“It’s my fault, Deacon,” Alyssa said. “I’ll tell Yulia that. She can be angry with me.”

“I’m not sure that will help,” I replied. “But, thank you.”

“You can’t stay with her, Deacon?” Serafima asked.

“Only for ten minutes each hour,” I replied. “Normally the ICU is limited to five minutes a few times a day.”

“Do you need anything?” Mark asked.

“Right now? Just your prayers for Elizaveta.”

“Did you see Rachel?” Alyssa inquired.

“Yes. She’s a cute little thing. They have her in the nursery. If you’ll excuse me, I’m going to call my mom.”

I went to the nurse’s station and asked if I could use the phone in the Resident’s office and was given permission. I walked there and dialed her new number from the small address book I carried in my pocket. I wasn’t surprised when a groggy Stefan answered.