The ER team was ready and waiting by the bedside when EMS rolled through the ambulance bay doors. One medic walked at the foot of the stretcher; another walked at the head, squeezing the ambu-bag attached to the ET tube every five or six seconds. A third followed with his computer in hand, standing by to give report.
They lined the stretcher up with the ER cot, and various team members began unclipping safety belts and preparing to lift and transfer the patient. The room was silent save for the voice of the reporting medic.
“This is Jason. He’s a 21-year-old male with a history of depression and multiple suicide attempts. Jason was found by his mother in the garage of their home approximately 30 minutes ago. He was unresponsive, cold to touch, and found lying in a pool of his own vomit. He was last seen by his mother eight hours ago; there was an argument and she believed he had left the house.”
The lead ER nurse took advantage of the pause in report to move the patient off the paramedic’s stretcher. “We’re lifting on three – one – two – three -”
The young man lay absolutely still on the cot as the team cut away all his clothing, hooked him up to the heart monitor, pulse oximeter, blood pressure cuff, drew blood from his IV lines, continued breathing for him with gentle, even breaths from the bag. I stood just outside the room, out of everyone’s way, readied as a runner if someone needed supplies.
“We have a 7.5 tube, 19 at the teeth. We have bilateral AC 16-gauge IVs, and he’s had a 500cc bolus of normal saline en route.” The medic finished his report, and closed his laptop with a gentle snap.
The ER resident listened to the patient’s chest and lungs, and then pulled one side of the stethoscope out of his ear. “Did you find any pill bottles or alcohol near him?”
The medic shook his head. “Nothing out in the open, and we didn’t feel we could delay transport to dig through the garage.” He shrugged. “Police are on scene, maybe they’ll find something.”
The resident nodded, and spoke to the nurses. “All right, guys, I’ll need pretty much everything — labs, foley, u-tox, EKG, chest –”
“What did he take?” came a quiet, serious voice from the corner of the room. The attending physician stood there, his eyes on his resident, his hand on the arm of the medic to prevent him from leaving just yet.
Everyone in the room went still. The resident froze in place, his eyes darting quickly to his patient, then back to his attending. He was a first year, less than six months into his rotation. I liked working with him and generally trusted his judgement, but he was still very, very new. I could see the gears in his head turning frantically, trying to figure out what he’d missed.
“Ah, well, obviously we need to consider a medication overdose — maybe an anti-depressant or anti-anxiety med — maybe he combined it with alcohol –”
The attending physician, a tall, lean, serious man who smiled rarely and intimidated me thoroughly, turned his gaze to the medic, effectively cutting off the resident’s stuttered ramblings.
“When you arrived on scene, prior to any of your interventions, was the patient hyper- or hypotensive?”
The medic blinked in surprise, but knew his patient. “Slightly hypertensive, actually.”
“And when you arrived on scene, prior to intubation, was he breathing fast or slow?”
The medic paused for just a moment, taking his mind back into that garage, to the sprawled figure lying on the concrete, ghostly under the bare bulb hanging from the ceiling. “Fast. Very fast.”
The attending physician looked over and stared at Jason, lying on the bed. “He drank antifreeze. He has ethylene glycol poisoning. We need to call for immediate dialysis.”
~ ~ ~
I had continued to renew my contract at this particular teaching hospital for a number of reasons. I loved the staff — they were a smart, mouthy, hard-working, no-bullshit group of trauma nurses, techs, and RTs. It was the largest ER I’d ever worked in — more than 100 beds divided amongst adult and pediatric trauma, psych and observation units. And with my marriage slowly and inexorably crumbling into ruins around me, I wanted nothing more than to lose myself in my work, to forget the world outside the ER doors.
I ended up working there for a full year. And in those twelve months, I never once took a lunch break. I have never been so busy, nor so gratefully lost in it, as I was there.
And at that astonishing moment, in that jaw-dropping second after the attending physician correctly diagnosed Jason’s overdose with only two questions, I realized that I was about to get very busy indeed. There were only three rooms in the ER set up to accommodate a dialysis machine, and they were all in my assignment. Jason was about to become my patient.
~ ~ ~
The problem with drinking antifreeze – of which the primary ingredient is ethylene glycol – is not the antifreeze itself, per se. In the early stages after ingestion the patient may simply appear to be drunk, as ethylene glycol has similar effects on the nervous system as its close cousin ethanol, the primary alcohol of beer, wine, and liquor.
But when the body starts to metabolize ethylene glycol it eventually produces glycolic acid, and this will eventually tip the body over into a metabolic acidosis. Most of the organs in the body depend on a relatively neutral pH, and the excess acid is extremely dangerous. There are other steps in this metabolic cascade which continue to wreak havoc on the body, and the end result, if not treated, is kidney failure and brain death.
The medics found Jason unconscious but breathing, which ruled out a narcotics overdose. Had Jason taken a handful of pain pills, the respiratory depression caused by opiates would have shut down his drive to breathe, and Jason’s mother would have found him dead. The medics also found him with a relatively normal blood pressure, rather than the low blood pressure we frequently see in our deeply drunk – and therefore sedated – patients. Finally, the medic noted that Jason’s breathing was shallow and quick. In a final effort to balance the acidosis in his body, Jason’s lungs were trying their best to rapidly blow off carbon dioxide – an acid formed during normal gas exchange in the lungs – thereby raising the body’s pH.
Jason had been alone in a cold garage, dying from his overdose, for as long as eight hours. We didn’t have time to test his blood for ethylene glycol, or to calculate his serum osmolality, or check his urine for calcium oxalate crystals. Immediate dialysis would protect his kidneys, correct his acidosis, and give him his best – and maybe only – chance of survival.
~ ~ ~
The resident placed his first emergent femoral dialysis catheter right there in the ER, and the dialysis nurse wheeled the huge machines into my corner room. The first team of nurses transferred Jason into my room, connected him to the monitors, reported off, and headed back to their side of the ER.
I stood on Jason’s right side and recorded his vitals, adjusted the monitor settings, checked his ventilator limits, and adjusted the IV pump running the propofol drip into his vein. We didn’t know if he had suffered any brain damage, but we wanted to ensure that he would stay sedated and calm, and not reach up and tear at his dialysis catheter or endotracheal tube.
The dialysis nurse stood on the left side, and connected Jason to the machines. They roared to life in a whirlwind of spinning wheels and flashing lights, and Jason’s blood shot through the tubing and into the dialysate.
And then — as is often the way in our line of work, once the chaos is over — we waited.
~ ~ ~
I checked on my other patients, and rotated through Jason’s room every twenty minutes or so. The dialysis nurse sat patiently on his left, in front of her machines, working on her charting. I saw the social worker escort a middle-aged woman to Jason’s bedside, and assumed it was his mother. A few moments later, the resident followed them in, and closed the door.
He emerged ten minutes later, and walked over to where I was sitting at the desk. He leaned one hand on the desktop, and suddenly brought his other hand to his eyes, covering his face. He shook very slightly, and then was still again.
“What is it?” I said quietly, not wanting to attract the attention of the other nurses. I hooked my foot around his ankle, and rolled my chair right up next to him. I put my hand on his arm. “Dime,” I said in Spanish, keeping up a habit we had of tossing Spanish phrases back and forth to one another. Talk to me. Tell me.
“I just told his mother that it’s bad. Really bad.” Two huge tears rolled down his face, and he rushed to wipe them away. “His labs are shit, he was just down so long –” He paused again, and drew a deep breath. “He’s only 21. Jesus Christ.”
He squeezed my hand quickly, and then walked away without another word. He headed towards the back hallways, the convoluted twists and turns beyond radiology, where the lights were kept low, and nobody was nearby.
I let him go.
~ ~ ~
Jason woke up, suddenly and violently, an hour later.
It was just by luck that I was in his room at the time, recording vitals, checking his IV drip, talking quietly with his mother. He wrenched his arms against his wrist restraints, pulling his shoulders up off the bed; he tried to draw his knees up, catching his ankles fast against the soft restraints I’d tied there as well. He ground his teeth against his breathing tube, and the ventilator began to alarm. His eyes were open and wild, confused, terrified.
It was startling, distressing, and wonderful, for in that instant, I knew he was going to survive.
“Jason, RELAX!” cried the dialysis nurse, and leaned heavily on his knees, holding his legs still, trying to protect the dialysis catheter and lines snaking out from his groin.
I placed one hand on his shoulder, and shoved him back flat onto the bed. “Jason, it’s ok, you’re at the hospital, man. You’re safe, you’re all right.” With my other hand I quickly changed the programming on his IV pump, shooting him full of an enormous bolus of the propofol. I should have been watching him more carefully — the dialysis was getting rid of the metabolites of the antifreeze, but it was getting rid of the propofol, too.
His mother scrambled to her feet from her chair, and grabbed her son’s hand. “It’s ok, baby. I’m here. Jason, I’m here with you. I love you, Jason. I love you so much.”
The propofol hit his system, and his eyes rolled back in his head, and he sank back against the mattress. His mother continued to stroke his hand, murmuring quietly to him. I silenced the vent, and tightened his restraints. I pulled his mother’s chair up next to the bed, and she sat down again, maintaining her connection to her son.
We all sat there silently for a few moments, listening to the soft exhalations of the vent, the quiet hum of the dialysis, the sounds forming the quiet tapping of a ‘delete’ key for the past ten hours of Jason’s life.
“He hates himself so much,” said his mother, quietly. Tears began to roll down her cheeks. “He feels like dying is his only option. We’ve done this so many times.”
I glanced down at Jason, now still and peaceful. I gently brushed his hair away from his face. He looked very young, almost childlike.
“How can I possibly express to him how much he is loved?” she continued, her voice steady despite her tears. “He is loved. SO much. By so many people.”
She glanced up at me. “But if love can’t fix it, what will? What can I do if love isn’t enough?”
~ ~ ~
I finished my shift and stepped out of the ER into the cold of an early winter morning. The sun was just peering over the lake, and the sky was a brilliant mass of orange and red and gold, as though the world were made of fire. I took a deep breath of the frigid air.
What can I do if love isn’t enough?
If love can’t fix it, what will?
I had been asking myself those questions for months. I wanted an answer as desperately as she did.
I had nothing I could offer to either of us.
I turned my car toward the inferno on the horizon, and slowly drove home.