Page 7 of Night Shift

“I thought we were starting at point five milligrams per kilogram?” Brian said with uncertainty in his voice.

My frustration threatened to boil over, but Sam’s calming touch on my arm refocused me.

“The patient is in respiratory arrest right now, so we need to focus up,” she said with assertiveness.

Adrenaline coursed through my veins as I barked orders. “Brian, get that physostigmine ready. Kat, open that ambulatory bag and start breathing for the patient. Oxygen, now!” I demanded. Sam quickly adjusted the simple face mask, setting the oxygen flow to two liters per minute. The capnography monitor beeped ominously, indicating the absence of carbon dioxide exhalation—a clear sign of respiratory arrest.

Was this situation somehow my fault? I did not fuck up my procedures. Structure. Routine. Safe patient outcome. Maybe I’d let Sam distract me? I should have confirmed the dosage one last time before moving forward. Fuck!

Kat’s hands moved deftly. “I’ve got the bag valve mask ready,” she announced as she removed the simple face mask.

“Start bagging him, Kat,” I instructed. She nodded, expertly fitting the mask over Mr. Stewart’s face and beginning the manual ventilation. His chest rose and fell with each of her compressions on the bag.

I glanced at the cardiac leads. Mr. Stewart’s heart rate was elevated, hovering around one hundred ten beats per minute, a natural response to the hypoxia.

Brian looked at me, awaiting instructions.

“Administer the physostigmine, twenty-eight micrograms per kilogram,” I said. “We need to stabilize him.” I turned to Sam. “What’s his oxygen saturation?”

She swiftly checked the monitor. “Ninety-two percent and dropping.”

Soon, the physostigmine started to take effect. After several more compressions of the BVM, the capnography monitor showed signs of improvement.

“Replace the BVM with the simple face mask, with oxygen flow set to two liters per minute,” I instructed. “Let’s see if he’s able to breathe on his own and his vitals return to normal.”

A few seconds later, Mr. Stewart drew in a ragged breath and then exhaled. His breathing gradually normalized.

After a few minutes, everyone’s nerves settled. I needed a new plan, fast. “Brian, prepare a combination of midazolam and ketamine—point oh five milligrams per kilogram of midazolam and point two milligrams per kilogram of ketamine, max twenty milligrams,” I directed.

Brian repeated the dosages back to me for confirmation and then set to work. This time, we were all on the same page.

As he administered the sedative mix, I kept my eyes glued to the monitors. Mr. Stewart’s heart rate stabilized, dropping to a more normal eighty bpm. His oxygen saturation climbed back up, reaching ninety-seven percent. I let out a breath I hadn’t realized I was holding.

“Respiratory rate?” I asked.

“Steady at twelve breaths per minute,” Sam reported.

The new cocktail of sedatives had been effective. Mr. Stewart’s body relaxed, his face losing the strained expression of unconscious distress. Now that the crisis had been averted, we were ready to proceed with the task at hand.

“Let’s reduce this fracture,” I said. With gentle but firm hands, Jake stabilized his arm while I applied traction and manipulated the broken bone, aligning it as precisely as I could. The tech, already prepped, began the splinting process.

“Keep monitoring his vitals,” I reminded Sam and Kat. They nodded, closely watching the screens displaying Mr. Stewart’s heart rate, blood pressure, and oxygen levels.

I stepped back to assess our work and Mr. Stewart’s condition. His vitals had stabilized, and the reduction appeared successful.

“Let’s get radiology’s mobile unit in for a post-reduction X-ray,” I instructed. “We need to confirm the alignment.”

“Understood, Dr. Thorin,” Sam replied, already in the process of meticulously documenting our intervention in the patient chart.

“And let’s keep him on observation for a while,” I added. “I want to be sure there are no further complications.”

As the tension in the room ebbed, I took a moment to reflect. The situation had been precarious, a reminder of the thin line between life and death we trod in emergency medicine. But thanks to the quick thinking and expertise of our team, we had navigated through the crisis successfully.

Mr. Stewart would recover; I was confident about that. But this case, like so many others, would stay with me, a constant reminder of the responsibility we bore and the lives that hung in the balance.

A short time later, when Mr. Stewart came to, I leaned in and said, “You did great. In a few minutes, radiology is going to come back in with their mobile unit and take another picture of your arm. If everything looks good, we’re going to get you out of here in a couple of hours. You will need to follow up with an orthopedic surgeon, so I’ll get the referral set up for you. It’s important that you carefully follow all the instructions they give you at discharge. Sound good?”

“Sounds good, Dr. Thorin. I’m glad nothing bad happened to me when I was out,” he replied.

---