Monday, June 14, Greenbeck Dermatology

Jake

Monday morning hits me like a sledgehammer.

The weekend is now just a memory, replaced by the trappings of another hectic workday at Greenbeck Derm. Superficially, the landscape of my world may look the same, but I sense everything has shifted, and not in a good way.

The day is off to an ominous start.

Without my permission, Nina and Al have cancelled all my scheduled patients, replacing them with back-to-back Replacidin study volunteers. All except for my nine o’clock.

That slot belongs to Roy Caulder, who’s here to treat his sweaty pits.

After the car incident last week, I flagged his chart to keep him from scheduling another appointment with me. Only one person has the authority to override this order.

“Goddamn it,” I hiss, slamming the keyboard when I see Nina’s initials on the computer screen. “I swear that woman’s trying to torture me.”

Erin rolls her eyes in agreement.

“Well I’m not seeing him. Tell Nina she can do the damn treatment herself!”

“I’m sorry, doc.” Erin nibbles on her lower lip. “But I already brought Mr. Caulder in. Should I tell him you’re not available?”

“No…” My shoulders slump as the full weight of the last forty-eight hours hits me. How can I possibly face this asshole now? “Sorry Erin… I didn’t mean to snap at you. This is my problem. I’ll deal with it.”

Roy Caulder greets me with a smug grin. He looks so relaxed, reclining in the exam chair, that I’m almost lulled into a false sense of security.

Until I see the dark flicker in his color-mismatched eyes.

He knows something.

“It’s called heterochromia.”

“Excuse me?”

“The color discrepancy in my eyes… there’s a name for the condition.”

“Yes, I know.”

“Of course you do.” He shows his teeth in a predator’s grin. “You’re a doctor, so I’m sure you also know it’s a rare condition, one that’s actually turned out to be quite useful in my line of work.”

“How so?”

“It helps me to read people. For instance, some can’t help but stare. Those are the easiest ones to figure out. No game. No social skills. You can read them like an open book. Then there’s the exact opposite, the ones who pretend not to notice. Most still give you some sign they’re aware, like looking away for a moment or fidgeting. But then there are those rare people who don’t even blink. Those are the actors. The real pros.”

His eyes fix on mine. “What’s really interesting about you, doc, is that you didn’t blink the first time we met, but now… you’re kinda staring.”

“Yes, well that’s probably because I’m very pressed for time this morning.”

“Of course.” Caulder tips his head. “How inconsiderate of me. I should be thanking you for squeezing me into your busy schedule.”

I force my lips into a smile. “That’s not necessary. I’m just glad we could accommodate you.” My eyes move to the syringes of Botox lined up neatly on the tray next to him. “Are you ready?”

Caulder pulls off his suspenders with a loud snap, then starts unbuttoning his shirt, uncovering a smooth, muscular torso. It’s the kind of smoothness that could only come from regular waxing or laser hair removal. I picture that unnaturally sleek skin rubbing against Briana’s – Kristy’s – body and feel the bile rise in my throat.

“So anyway,” I say, forcing that disturbing image from my mind. “The procedure’s simple. First, I paint your skin with iodine. Then, I brush on a light coat of corn starch. When the iodine and starch mix with sweat, the color turns black. That’s where we concentrate our injections.”

Caulder peaks his eyebrows. “What’s with the needles? Why can’t you just rub the Botox in?”

“Because it won’t absorb into the sweat glands that way. Don’t worry, the injections shouldn't hurt much. If you want, we can pre-treat the area with numbing cream.”

“That’s okay.” He folds his right arm behind his neck, exposing an armpit. Even there, he's virtually hairless. “Bree says you’re quite gentle, so I’ll trust you. Besides, if you hurt me… well, then I’ll just have to hurt you back.”

Despite his choirboy smile, the words still make me shudder.

I paint on the iodine and starch, then reach for the first syringe, thinking of Kristy’s bruised belly as I repeatedly puncture his skin and inject.

Puncture and inject. Puncture and inject.

Wishing with each stab that I’d used a bigger needle.

Roy Caulder’s treatment only takes five minutes to complete, but before I can run off to confront Nina, my first study patient arrives.

“Welcome back.” I smile, putting on my best cheerleader face. “Are you excited?”

Jean Clark gives me a nervous nod, looking anything but excited. Terrified would be a more fitting description. From the way she’s gripping the chair armrests, you’d think she’s a flight-phobic person on the runway bracing for take-off.

“The procedure is easy,” I say, patting her white-knuckled hand. “You’ll see. It just takes a few seconds, and you probably won’t even feel anything.”

I check the consent form, asking if she has any questions as I pull on my gloves.

She gasps, squirming away from my hands. “Those aren’t latex, are they?”

“No,” I reassure her. “It’s in the chart that you’re latex allergic, so these gloves are latex-free.”

“But what about the syringe?”

“No latex there either. We’ve got it covered, so you can relax, Jean. You’re in good hands.”

I pick up her chart, reading through her long list of supposed allergies. “So, it looks like you’re also allergic to peanuts, soy, penicillin, Keflex, erythromycin, tetracyclines, aspirin, ibuprofen, morphine, red dye, Zoloft, Wellbutrin, Neurontin, Lipitor, Benadryl, and prednisone?”

Erin and I exchange a knowing look, and she scribbles a message on my prescription pad: “I’M SURPRISED SHE DIDN’T LIST OXYGEN.”

She has a point. It will be hard to figure out which of these allergies, if any, are real.

“Benadryl and prednisone?” I ask. “Are you sure about those last two? Most people don’t have true allergies to these drugs. In fact, we use them to treat allergic reactions. I don’t think I’ve ever seen anyone who’s allergic to both.”

“Well I am. I had a very bad reaction to Benadryl once. My heart wouldn’t stop racing. And prednisone!” She presses a hand to her chest. “That poison should be taken off the market!”

“Sure,” I agree. “It makes some people feel jittery.”

“Well it almost killed me.”

“I see.” I exhale slowly. Why the hell do I always get these people? “And what happens when you’re exposed to latex?”

She scowls. “Latex gloves give me a terrible rash.”

“But did you ever get short of breath, wheeze, or break out in hives after wearing them?”

“No. They just irritate my skin. It’s an absolutely dreadful allergy.”

“All right,” I say, putting a question mark on the chart next to the latex allergy. “That sounds more like a contact dermatitis, which isn’t as serious. All the same, we’ll be using no latex materials in this procedure.” I flash Jean a reassuring smile. “Just to be safe. Now, shall we get started?”

Mrs. Clark sighs, looking like she’s bracing for a traumatic event.

“Of course, it’s completely voluntary,” I remind her. “You can change your mind at any time.”

“No, no.” She flaps her hands a few times to calm herself. “I suppose we should just get it over with.”

“Okay then. Just lean back and relax.”

I check the Replacidin vial’s label and lot number, then hold it up to the light, examining the bottom of the glass. Usually, there’s a rim of light gray powder containing the dehydrated drug, but Erin must have already mixed in some sterile saline. I give her a nod, silently thanking her for saving me the time as I draw the liquid into the syringe.

The procedure takes less than a minute. When it’s over, Mrs. Clark looks up at me expectantly, like she’s still waiting for the injections to begin.

“That’s it,” I say, pressing an ice pack to her forehead. My eyes wander to Erin, and I don’t need to ask her to take over. Judging from her expression, she knows exactly where I’m headed.

Nina’s office door is closed and her blinds are drawn, but that doesn’t stop me from barging in.  When she pretends not to notice me, I clear my throat loudly enough to interrupt her phone conversation.

“Just one moment,” she announces sourly, showing me her palm. “Listen, Bianca darling… I’m afraid we’ll have to continue this conversation later. Yes I know. It’s been ages.”

She lets out a trill of laughter, simultaneously eviscerating me with her eyes. “Absolutely! You’re right! It’s criminal. Let’s not make it so long next time, okay? Ciao.”

After ending the call, she peers at me through a ridiculously oversized pair of white-framed designer glasses. You’d think from her expression that I was a homeless person who had wandered in off the street.

“What? We don’t knock anymore?”

“Why did you slip Roy Caulder into my schedule this morning?” I demand.

Nina leans back in her chair, lips pursed like she's just licked a bitter stamp. “I don’t think I appreciate your tone, Jake. And I certainly don’t appreciate having my personal space violated.”

“Well, I don’t appreciate having my professional space violated. I deliberately blocked Roy Caulder from my schedule. Why did you override me?”

“Here at Greenbeck Dermatology, we don’t ban our patients from getting appointments.”

“I see. So that must be why your husband only sees patients who pay cash.”

That hits home. Nina removes her ridiculous glasses to give me her best Medusa stare. “Once again, I don’t appreciate your unprofessional tone. Besides, I really don’t see why you’re getting so… agitated. Mr. Caulder requested a cosmetic appointment. You had an opening this morning, so I gave it to him. Given your billing deficiencies, you should be thanking me.”

I glare at her, my cheeks burning. "You created that opening by canceling my other appointments! I checked the computer. And in case you’re wondering, I blocked Mr. Caulder from my schedule for a reason, Nina. The man’s not mentally stable. I’m not comfortable seeing him!”

“I see,” she mutters under her breath. “So he’s the one who’s not mentally stable.”

“Listen,” I snap. “It’s really quite simple. I won’t see Roy Caulder again. If you try to force him or any other patient into my schedule in the future, then they won’t be seen… not by me at least. And if you have a problem with that, then may I suggest you get your own damn medical degree and see him yourself!”

Nina jumps up from her seat, lips puckering with a come-back, but before she can speak, the door bursts open.

It’s Erin, eyes wide with panic.

“Doctor Goodwin!” she blurts. “There’s a problem with one of your patients. You need to come now!”

Nina’s fuming, saying something about us needing to have a serious conversation about my future at Greenbeck Dermatology, but the words barely register. I’m already pushing past her desk, focused on Erin’s alarmed expression as we race toward the clinical area.

“Mrs. Clark?” I ask breathlessly.

She nods, eyes urging me to move faster.

“Vasovagal?”

“I don’t know. She looks…”

Like she’s dying.

That’s the first thought that crosses my mind when I enter the room. Jean Clark looks pale and terrified, like she’s being mauled to death by a wild animal.

“Jean? Can you hear me? It’s Doctor Goodwin!”

She rolls dazed eyes toward me. “Wh-what’s happening to me?”

“You might be having a reaction to the procedure,” I say, reaching for her wrist. Cold, clammy skin. I feel for her pulse, finding only a weak twitch beneath my fingertips.

I pivot to Erin. “Let’s get some vitals and hook up the EKG. We need IV access, so call for back-up.”

“H-Help meeee!” Jean Clark pleads, sputtering to get the words out. Her skin now looks ashen, bloodless.

I tilt the exam chair to angle her head downward.

“Looks like you’re having a vasovagal reaction,” I say, as much to reassure myself as my patient. “That’s a fainting spell that can happen right after a procedure. It passes quickly. The position you’re in now helps the blood rush back to your brain.” I find her hand and give it a reassuring squeeze. “Do you feel nauseous? Like you’re about to throw up?”

She nods, gulping in shallow breaths as Erin inflates the blood pressure cuff around her arm.

Is this anaphylaxis? A life-threatening allergic reaction to the study drug or one of its preservatives would explain the sudden difficulty breathing. But then why aren’t her lips swollen?

I grab a stethoscope from the nearest drawer and press it to her throat.

No wheezing to suggest a swollen, obstructed airway. Just rapid, shallow breathing.

Like a fish gasping on the dock.

“Just try to take slow, deep breaths.”

“I…” She rasps out a cough. “I can’t!”

“Blood pressure is 160 over 100,” Erin calls out in an anxious voice. “Pulse, 124. At least!”

What the hell’s happening? Skin pallor. Racing heart. High blood pressure. Labored breathing.

Too many possibilities race through my mind. A panic attack. Myocardial infarction. Cardiac arrhythmia. Pulmonary embolism caused by a blood clot lodged in the vessels of her lungs.

“Erin, we need that IV access!”

“Got it!”

By now, three med techs have joined us, but they’re just standing in the doorway, looking like a family of startled deer.

“Dora!” I bark to the nearest one. “Call EMS, then get Doctors Greenbeck and Markum in here!”

“Doctor Greenbeck’s not in the office,” she sputters.

“Then get Doctor Markum! Now!”

As if to underscore the urgency of the moment, Jean Clark starts wailing like a banshee, sending all three med techs fleeing into the hallway.

Erin eyes me with desperation. “Anaphylaxis?”

I shake my head. “Blood pressure’s too high.”

“Should we use the reversal agent?”

“I’m not sure,” I admit under my breath.

Up until this point, I haven’t even considered the possibility of Replacidin toxicity. It just doesn’t happen.

“Jean, do you hear me?” I grip her hand again, desperate to break through her hysteria. “This is very important. I need to know what you’re feeling.”

She coughs and sputters, grabbing her throat. “Can’t breathe! Ch-chest… Oh, God! It huuurts!”

“MI?” Erin asks.

“Don’t know,” I grunt, thinking it’s time to assume the worst. During internship, I saw enough dying patients to recognize the feeling I’m getting now.

“I need that EKG hooked up. All 12 leads. And where the hell’s the crash cart?”

“In the utility room… next door.”

“I’ll be right back!”

When I return with the cart, Erin has already clipped the leads into place.

“Sinus tach,” I say, feeling my own heart rate slow as the first tracings come through. “No obvious ST elevations here. No flipped T waves either.”

It doesn’t look like Jean Clark is having a massive heart attack or life-threatening arrhythmia – not yet, at least.

But then why is her heart rate now pushing 140?

Why does she look like she’s slipping closer to death with each passing second?

My mind races back to one seemingly impossible thought: could the Replacidin be doing this?

I glance at the drawer containing the reversal agent, debating whether or not to give it now. If I make the wrong call and Jean Clark really is having a heart attack, then the injection will slam her with a jolt of epinephrine strong enough to kill her.

“Jean,” I say into her ear. “Do you feel any numbness or tingling in your body?”

Her eyes dart toward mine, head jerking up and down. She points to her lips, then rasps out a single word: “N-n-numb.”

Holy shit! Maybe it is the Replacidin. And even if it isn’t, can I afford to take that chance? Making my decision, I tear through the REST study drawer to find a syringe of reversal agent. Uncap the auto-injector. Jab the needle into the IV port, simultaneously depressing the plunger.

Instead of flowing forward though, the fluid geysers back at me, catching me squarely in the face.

Fuck. Forgot to secure the Luer lock.

Furious with myself, I wipe my face on my sleeve and then grab another syringe. Fasten it correctly this time. Flush the reversal agent through the IV tubing and into my patient’s bloodstream.

Maybe it’s wishful thinking, but she seems to relax, almost instantly.

“Jean? Are you feeling any better?”

Her head lolls forward, as if she’s answering me with a lazy nod, and for a second, I allow myself to feel something approaching relief.

But then I realize she looks too relaxed, like a puppet whose strings have just been cut. Not even her chest wall is moving.

In a state of disbelief, I press my stethoscope to her bird-like chest.

“Goddamn it! She’s not breathing!”

Only seconds to act now.

Start CPR.

Check the airway first.

No obstruction.

Lift chin.

Press ventilation mask over mouth.

Airtight seal.

Squeeze bag.

Check chest wall for motion.

The cardiac monitor blasts out its alarm as her heart rate spikes to 160. The EKG looks like a seismograph tracing of an earthquake.

“What the hell’s going on here?”

Mitch Markum, Al Greenbeck’s junior partner, picks this moment to stroll into the room with his entourage of surgical techs and nurses. Everyone is gowned and gloved, looking like they’ve just stepped out of the OR.

“My study patient’s crashing!” I call out above the blaring alarm. “She’s in respiratory arrest.”

Markum surveys the grim scene. “Where’s EMS?”

“On the way.” I strain to hear the welcome wail of approaching sirens. “We could use some help here.”

“Pressure’s now 80 over palp!” Erin warns, her voice cracking.

Within seconds, the cardiac monitor blares out a new, ear-splitting warning. My eyes shoot to the EKG tracing. See the saw-toothed pattern.

“V Tach,” Markum grumbles, reaching into the crash cart for the defibrillator paddles. “Jesus, Goodwin. You’re losing her!”

Now that we’ve reached this nightmarish point, instinct kicks in, and Markum and I work in silent tandem, going about the bleak routine of trying to reanimate Jean Clark’s limp body. As I start the chest compressions, I’m hyperventilating so badly that my lips start to tingle. I may black out any second now, but that doesn’t matter anymore. I can’t lose this patient.

Somewhere between the first and second attempts at shocking Jean Clark’s quivering heart back to life, Greenwich EMS arrives.

A chaotic jumble of people and equipment now swirls around us. Caught up in what feels like a nightmare, I step aside to watch the paramedics’ well-choreographed dance. The intubation and venting. The rhythmic chest compressions. The futile injection of medications.

Stand Clear!

Jean Clark’s pale chest, now stripped bare, convulses forward, then collapses back into the chair.

The paramedics inject more meds, then dial up the defibrillator. Her chest jerks again, like a kicked mannequin.

Then, as the minutes tick on, the effort becomes more mechanical – a room full of trained professionals, now just going through the motions. No one says the words, but we all know Jean Clark is gone.

Doing nothing looks bad though, so the paramedics get a second wind once they transfer her body onto the stretcher. One guy works the ventilation bag, barking orders while his partners do chest compressions and charge the defibrillator. They whisk my patient’s lifeless body through the hallways of Greenbeck Derm, pausing in the reception area to make one last defibrillation attempt. It’s a staged scene of medi-drama, done for the gawking audience of patients and staff.

As I sprint alongside the stretcher, my eyes brush by one face in the crowd – the only face that seems to be more amused than shocked by this spectacle.

Roy Caulder.

And I could swear, as we push toward the exit, that the bastard is smiling.

***** 

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