Fiction: Pressure

By Holden Michaels

Do you know what pressure is? In physics it’s defined as force divided by area. For me, the area was a small pediatric Emergency Department. The undeniable force at play was a legally dead 5-year-old that I was tasked to save. Now that’s pressure.

I was just a baby doctor. Sounds a bit cheeky but it was dually true. I was a pediatric resident, so I saw a lot of babies, and additionally I was an intern, so like many of my patients, I was in my infancy. Yeah, I had an MD, and yeah, I had graduated from med school, but I couldn’t practice on my own.

My shift had started Saturday afternoon, but it was now edging close to 3am Sunday morning. Most 26-year-olds this time of night would be stumbling out of a bar on drunken legs and falling into an uber. God, I missed those nights. Instead, I was in the ED, dealing with hypochondriac parents and screaming toddlers, because I had decided to languish my 20s in favor of medical training.

Have you ever tried looking into the ears of a wailing two-year-old? Imagine taking a peek through a screen the size of your fingernail and seeing an image that is even smaller, and said image is constantly bouncing in and out of your view because the dang kiddo is bobbing his head like he’s at a 90’s grunge concert. That was my Saturday night.

I had seen about 20 patients during that shift and let me tell you, ya girl was tired. I had removed a Lego from a 5-year old’s ear because he ‘wanted to hear’ what the Lego man had to say. I’d done a debridement) for 2nd degree burns on a 7-year-olds boy’s leg. He had been gifted the burns by his sister's easy bake oven. Dad was the least concerned about his son’s permanent scars and more worried about the fact that his boy liked to play with ‘girl’s toys’. El oh el. On top of that I had seen about a dozen headaches, stomachaches, and fevers; normal bodily responses to being sick, but some parents interpret them as the inevitable signs of death.

Additionally, I was suffering from sensory overload. I was tired of hearing the sound of sneakers squeaking against stainless floors, and my nostrils had been incinerated by the perpetual scent of hand sanitizer and bleach. I couldn’t hear my own thoughts because they were constantly interrupted by the beeps and blips from all the various machines and monitors.

My shift was set to end at 4am. I had been 15 minutes away from the last hour of my shift, also known as the glorious ‘screen o’clock’. See what they don’t tell you about being a doctor is that you spend more time typing like a novelist than you actually do seeing patients. The last hour of our shift is dedicated to charting our patient’s notes on a computer. ‘If it aint documented, it didn’t happen’ is the phrase that got beaten into our heads.

We had to document everything the parents said, all of our physical exam findings, and then painstakingly write down the entire treatment course. Imagine doing that for over 20 people in a row. The charts tend to stack up like fickle Jenga pieces, so ‘screen o’clock’ is reserved for finishing them. All I had to do was make it to 3am, and I would not have to see any more patients!

I was mad tired. My eyelids felt like anvils, and I had more bags under my eyes than a serial traveler. Of course, my Attending noticed this and began a pimping session.

Pimping is when an Attending or Senior resident decides your life is not hard enough and they start lobbing medical questions at you that range from routine to obscure until you get one wrong or your brain melts from exhaustion.

“Keisha,” he said sharply, jolting me out of my daze, “how much Motrin should you give a 3-year-old with fever.”

I snapped out of comfort mode and prepared for his rapid-fire line of questioning. He was starting off with an easy one.

“10 milligrams per kilogram Q-6 hours PRN,” I said confidently. God, I sounded like a robot.

That was softball question, so of course he didn’t give me my flowers for getting it right. Instead, he upped his artillery.

“When does the American Academy of Pediatrics recommend screening for hypertension?”

“I believe 3 years old,” I said with a little hesitance.

“You believe, or you know?”

“I know,” I lied.

He granted me the smallest smile to signal his approval. Alright girl, get ready, I thought to myself, the third one is always a trip.

“4-month-old male has fever without an obvious source. What is his sepsis work up?” I subconsciously sighed in relief. I knew this one!

“You would get blood cultures, chest XR, and a CRP,” I said without hesitation.

“We’re sorry that’s incorrect,” he said in a terrible game show host accent. “You were close Doc, but you forgot to ask if the kid was circumcised. If they’re uncut, get a urinalysis and urine culture as well.”

Always with the technicalities. He’d been intentionally vague just to ensure I would fail. Residency was ghetto.

He must have felt a tad bit guilty because then he said, “Ok doc, you did good today. I see you’re fighting the internal snooze button. I’ll grab you a cup of joe and once you finish your notes you can head out.”

As my Attending made his way to the 24-hour Starbucks embedded in our cafeteria, I typed away until the pads of my fingers ached. I wanted to get out of there and into my bed. I was the only resident in the ED at the time, the 2nd year had left about two hours ago, and my relief wasn’t due for another half hour. The pace was winding down, it was borderline 3am and the hypochondriacs were too tired to bring their kiddos in.

Behind me was the chatter of bored nurses. They seldom had free time, so they took full advantage of it; by arguing about which male resident in my program had the most rizz. They all agreed it was Marcus with his never patchy, always full beard and permanent smile.

I silently agreed with them. He was one of the few other black residents in my program. As a 3rd year he was practically my boss. He sported a crisp line up that was better than the ‘93 bulls, and he always smelled good. He was probably a fuck boy though and my ass was a professional, so I never tried it.

I started daydreaming about what he looked like under that beard. Did he have dimples under there? Was his jawline sharper than a carefully drawn-out cat-eye liner? However, before my imagination could get too spicy, I heard the words that sank my heart.

“Code Blue, Code Blue, Room 10, Code Blue!” blurted the intercom. All the nurses went silent. There was no more talk about cute residents.

Ten seconds later EMS came sprinting in, bolting towards Room 10. They were pushing a gurney occupied by a 5-year-old black girl. From the brief glimpse I gathered she was motionless with one arm hanging down, banging back and forth against the stretcher.

“Get the crash cart!” yelled one of the nurses.

All eyes fell on me. My Attending was not far, but he might as well have been on Mars. I was the only Doctor in the room, and they were waiting for me to take charge. I stumbled on my actions, just for a few seconds but those seconds dragged on like years. What was I supposed to do? I was just an intern! I hadn’t even sutured a laceration yet let alone handle a code! My heart was running a marathon in my chest. Beads of sweat formed on my head like morning dew.

I broke out of my momentary stall and rushed into Room 10. There were about a dozen people in there: nurses, med techs, EMS, and a few family members including a hysterical woman. That had to be mom.

“I told her a million times she can’t have peanuts!” she cried at one of the nurses.

Remember what I said about pressure? Force over area. That means the smaller the area the bigger the pressure. This room was tiny and filled with people that weren’t helping.

“I need three to four nurses in here tops, everyone else out!” I yelled. It cut through the panic. Bodies started leaving the room. A little less pressure.

Mom remained, unable to take her eyes off her baby. Damn, this woman was young enough to be an older sister. We were probably in the same generation.

“I don’t want no teenager, where the real doctor at?!” she screamed in my face.

I wanted to console her, tell her that Imma pull a Lazarus and bring her daughter back, but I had to focus, at least until the pressure subsided. I pointed at one of the EMS guys. He was a burly fellow that should probably take it easy on the free weights and start hopping on a treadmill to target his beer gut.

“Get her out of here,” I said to him. The words were harsh, but the request was necessary. I was gonna save this girl and if that meant being rude, then oh well. He kindly escorted mom out of the room.

I stared at the girl for just a moment. She looked like me when I was her age. We even had the same hairstyle. She was rocking box braids that I’m sure were way too tight, but her mom probably told her to sit still and stop whining when she braided them, and if she were anything like me, she probably got popped a few times with the comb. Children were often loudmouth denizens that were hopped up on sugar, so seeing one this still and quiet was unsettling.

I checked for her pulse and nearly pulled back my hand when I felt that her skin was glacier cold. There was no pulse, and her chest was not rising. She wasn’t breathing.

I wanted to scream. I wanted to beat feet and run out the room and jump into my bed and pull the covers over my face. I needed to get into a time machine, punch the dial to 5 years ago and talk myself out of taking the MCAT, but I couldn’t.

I pointed to one of the seasoned nurses in the room. She was a middle-aged Jamaican woman and the only one that didn't look like she'd seen a ghost.

“You, start compressions.”

“Got it doc,” she said without a hint of protest. Nothing beats a good nurse.

I drew my attention to the other two in the room. There were less eyes on me now, and that meant less pressure. I could still hear mom screaming in the adjacent room. I blocked it out.

“You,” I said to the second nurse, “get some leads on her now!”

She was green compared to the Caribbean nurse. It was likely her first code. Welcome to the club, I thought to myself. She frantically placed the leads on the girl’s chest with anxious hands while the senior nurse continued compressions.

The elder nurses’ CPR form was impeccable. She went deep into the girl’s chest with each thrust. She was keeping a steady pace. The kiddo’s chest wall would ache like a bitch if she ever came to, no doubt, but this was not the time to be delicate. I could tell that the older nurse was getting tired. She’d been doing compressions for about thirty seconds which, if you’re doing it at the right pace and right rhythm, it would feel like an intense workout.

“Switch,” I said automatically. They abided.

The nurse who had placed the leads took over. She hesitated before laying her hands on the girl’s diaphragm.

“Too low, go just above the xiphoid,” I said. She corrected her form.

During the switch I rechecked the pulse. Nothing. Shit. I can’t let this little girl die. Through the glass partition I saw that mom was on the floor now, begging to the sky for someone to help.

“Hit her with epi, 1 milligram,” I said.

Epinephrine, also known as adrenaline, is the ‘life juice.’ It can restart the heart and open up vessels to allow blood to the brain.

“IV?” asked the elder nurse.

Shit. I had three options. I could do IV (intravenous), which would inject epinephrine right into her veins. This is the superior delivery, but it takes time. You had to get ‘access’, or in other words, had to find a good vein, pierce that vein, then deliver the drug. This could take 5 minutes, which was time we could not afford. Every minute the patient had without a heartbeat, 10,000 brain cells died.

Option 2 was IM (intramuscular). This was the quickest method, just stick a shot in her arm and voila medication is in. The only problem is that muscles are dense. It won’t absorb as much as venous access. There was no way to know if it would be enough. The girl was legally dead. In other words, I could do no harm if I overshot, but if I undershot, I would seal her fate.

I was gonna have to go with option 3.

“No,” I answered, “IO.”

The elder nurse gave me a blank look. I read her thoughts. She was thinking, this young fool is playing doctor and has no clue what she’s doing. Maybe she was right, but I didn’t have time to explain my reasoning. We had to act.

“Do it!” I snapped. I didn’t want to give her a chance to protest.

IO means intraosseous. Osseous is a fancy word for bone. So, what is option 3? Option 3 is drilling through bone, usually the tibia aka shin bone, and delivering the epi into the marrow. It’s quick, efficient, but incredibly painful. You could miss a vein when doing a needle stick, but it was virtually impossible to miss bone!

She grabbed the drill from the crash cart while muttering something under her breath and drilled a tiny hole through the girl’s right shin bone. If the little one ever came out of this, she might have a permanent limp, but she would be alive. Once the drill was deep enough, the nurses pushed a syringe containing 1 milligram of epi through the hole.

Mom saw the entire barbaric procedure. We must’ve appeared to her as wanton mechanics who were treating her child like a piece of machinery. She banged her first against the glass.

“What are you doing to her!” she yelled.

Each scream that belched out of her tore at my heart, but I ignored it. She was going to throw out her voice if she continued. I had to push on.

I rechecked the pulse. Still nothing. Damn, I would have to wait another 3 minutes before I could deliver more epi, anything sooner would be ineffective. That would be another 30,000 brain cells down the drain. Granted she had billions to spare, but I still didn’t like those numbers.

The younger nurse was breathing heavily. She was doing compressions, but her rate was too rapid, and her depth was too shallow. She was not applying enough…

“Pressure,” I said to her, “You need to apply more pressure.”

I scooted her out of the way. I didn’t even recognize myself at that moment. I’d never been confrontational. Hell, I was non-religious, but I once talked to a Jehovah’s witness for two hours straight because I was too afraid to tell them to get the fuck off of my doorstep. But that had been civilian Keisha. I was in savior mode, and I had to make moves to bring this girl back. I had to stop the screams of her mother, I had to make sure her little brother would have someone to teach him how to be nice to girls, and most of all I had to be able to sleep tonight.

With the younger nurse out of my way I began the compressions. I never should’ve canceled my gym membership. As I pressed up and down at approximately 100 compressions per minute, my arms felt like they were on my fire. My chest was getting heavier and heavier, and I started panting. I felt the girl’s chest give in a little, a sign that I was applying the right amount of pressure. I had been in the goldilocks zone. If I eased up, she would not get enough blood perfusion, if I went a little deeper, I would crack a rib. Just had to stay here, no matter how exhausting it was.

“Pulse check!” I yelled while gulping for air.

A third nurse placed her index and middle finger on the right side of the girl’s wrist, feeling for a pulse.

“I have a pulse!” she exclaimed and nearly jumped for joy.

I didn’t stop with the compressions, even though I felt like I was about to faint. I was exhausted but that was no excuse, I had to keep going. Just as I thought I was going to give out, I heard a beep coming from the EKG monitor.

I thought my favorite sound in the world was goddess Beyonce tearing it up at the 47th Superbowl halftime show, but that had been replaced with the rhythmic beeps coming from the heart monitor.

I looked up and was relieved to see QRS complexes dance across the screen, as if the heart were celebrating its triumphant return.

“She’s got sinus rhythm,” shouted the older nurse.

There was a collective sigh of relief. The tension was still there but its grip was loosening. I stopped the compressions. My arms might fall off but that was ok, they had done their job.

Just a few moments later my Attending came rushing in. His white coat was painted brown with spilled coffee and his shirt untucked and littered with wrinkles. He was huffing and puffing like an asthmatic.

“Keisha,” he said and then paused to take a breath, “I’m so sorry, the speaker was malfunctioning in the cafe. I ran here as soon as I heard the code, how is she?”

Before I could even respond the Jamaican nurse went up to him and placed a hand on his shoulder.

“Your intern just saved a life, remember that when you write her evaluation,” she says. She was the plug for real.

He looked relieved, not just because the patient was alive, but more importantly because his job wouldn’t be in jeopardy for leaving a resident like me unattended. As I sunk to the floor from exhaustion, I heard a little girl’s voice say, “My chest hurts.”

X

 

A few minutes later I was talking to mom, who couldn’t take her gaze off of her now conscious girl. The woman’s eyelids had become swollen red balls due to excessive crying.

“How many times did I tell you no peanuts!” she said in a cracked voice.

She had a scowl on her face, and of course the little girl was terrified. She thought the mama bear was about to show claws. My mother used to do the same thing, she would always turn up on me after I’d done something crazy, hoping to scare me out of ever doing it again.

The girl looked at me, she was completely oblivious to the fact that she almost crossed over into the great beyond. She pointed at me while dawning the most adorable smile on her face.

“You got braids like me!” she said as she swung them side to side, the beads at the end clapping against one another like a standing ovation.

I felt warm inside, like a freshly baked chocolate chip cookie. I spent the next 5 minutes talking to mom, telling her that her girl was stable, but we would need to admit her to the hospital for observation.

“Will you be watching her?” the mom asked. I realized that this woman trusts me and me alone to protect her daughter. I was not just a doctor to her; I was a healer.

“No,” I said as I tried to hold back my tears. I wanted to wrap this little black girl up in my arms, but I knew I couldn’t. My job stopped at the ED. “But a lot of my colleagues are on the floor tonight. I’ll make sure they take good care of her.”

Mom stared at the ground for a few seconds and then looked back up at me with a slightly embarrassed look on her face.

“Are your colleagues like us?...” she asked. She didn’t have to expand upon what she meant. I got it before she spoke the words. I was probably one of just a handful of black doctors she’d seen in her lifetime.

“Tell you what, I’ll be stalking her chart,” I said.

Mom embraced me like we were long lost lovers. She held me so tightly I could barely breathe. I was showered by the tears coming down her swollen eyes. She was applying a lot of force in this area. A lot of pressure but I did not mind.

Holden Michaels is a first year family medicine resident. When he is not writing up his patient's charts, he is writing short stories. He lives in Atlanta, GA with his cat that serves as his muse.