Friday, October 8th
Lucifer — Puissant Lord of Evil, Utmost Originator of All Things Foul, Master of the Netherworlds, Purveyor of Anguish — glanced up from his newspaper to stare thoughtfully over the miles of open office space that made up the central nervous system of Hell. Uncounted thousands of imps and leccubi and damnedsouls sat at uncounted thousands of obsolete, cantankerous computer terminals, alternately typing and swearing. The air conditioning was on the fritz again, and Hell’s computers worked poorly in the resulting heat.
Lucifer’s main office manager, the fallen angel Sertapius, had sent in a request for more computer techs. Unless things improved, he wasn’t going to get them. They were hard to corrupt. They liked their work too much, and happy people didn’t go to Hell. Lucifer had some of his top people working on a way to convince computer techs to get involved in politics — after all, bureaucrats were easy. Hell was up to the tips of its horns in them.
The news was about average — wars, famines, plagues, shootings, hatred, racism, sexism, politically correct fanaticism — in other words, all good. Lucifer flipped to the entertainment section and read Calvin and Hobbes, which he enjoyed when Calvin was being terrible. And then he read his weekend horoscope — he always read his horoscopes. Some of his best future denizens wrote them, and he liked to check out the talent.
LIBRA — Fellow Libran, concerned by issue of fairness — like all born under your sign — intercedes on your behalf. Beginning of new week brings you unimagined opportunities.
Lucifer arched an eyebrow and rubbed thoughtfully at the base of one of the curled ram-horns that sprouted from his forehead. Promises, promises — the horoscopes were always full of them. Of course, where he was, nothing ever came of those promises.
That was the hell of Hell.
Dayne Kuttner was trying to catch up on her charting. She kept one eye on the monitors — rows of green light slid across the black screens in a variety of ugly, irregular patterns. Nobody looked good today, and she waited tensely for the next lethal change.
She glanced at her watch and wrote: “1432. Systems assessment — see previous notes. Changes are as follows — both pupils now fully blown, no reaction to light. Sclerae edematous. Eyes lubricated, padded and taped. Decerebrate posturing noted …” She went through the list, noting every sign that the woman in bed 432-D wasn’t going to be getting better. Mrs. Paulley, seventy-eight years old, had fallen down her stairs at home and fractured her skull. By the time her daughter had found her and gotten an ambulance, the old woman’s brain had undergone irreversible damage caused by the swelling.
Her doctor was a huge believer in heroic measures, however. The old woman, at death’s door, was given infusions to reduce the swelling inside her head, other infusions to regulate her erratic heart, further infusions to control her blood pressure — and then she’d been shipped upstairs to the ICU and Dayne.
And there she’d languished for over a week. When her breathing stopped, Dr. Batskold put her on a ventilator. When her kidneys failed, he had the portable dialysis unit brought in and he’d flushed her blood through a machine.
She was in a coma. She was never going to see anyone again, she was never going to sit up again or laugh again or even breathe on her own again. She was never going to be a human being again, and yet the ICU nurses had orders to treat her as a full code — to take every possible measure to keep her alive, no matter what that measure was.
Dayne had protested this to Dr. Batskold after the first dialysis.
“We’re here to save them, Dayne,” he’d said. It was his perpetual response to Dayne’s protests against what she saw as his excessive heroics. He shook his head and looked over at her — gave her his famous, kindly, grandfatherly smile. “I don’t play to lose, Dayne.”
“It’s my job as this patient’s advocate to suggest that what we are doing to her isn’t in her best interests,” Dayne told him.
Batskold raised an eyebrow. “Did you get a promotion? I didn’t hear.”
“Promotion… to patient advocate. How exciting for you.” He’d looked down at Mrs. Paulley’s chart. “I must see a copy of your new job description.”
“Every nurse is a patient advocate,” Dayne had told him.
He’d finished his orders and slammed the cover shut on the chart. “Then why doesn’t every nurse give me the kind of trouble you give me, Dayne? No. You’re out of line here — overstepping your bounds. It’s my job to decide when we keep on trying. It’s your job to keep on trying. When God is ready for Mrs. Paulley, He’ll take her.”
Dayne would have mentioned that God had been trying to take Mrs. Paulley for over a week, but it wouldn’t have done any good. Batskold’s response to that was invariably, “He isn’t trying hard enough then, is he?”
The conversation, days later, still ran through her head. She kept writing, angry. Sooner or later someone would review one of Batskold’s charts and question his treatment of people who had no hope. They would look at the costs he was running up for families who would never be able to pay off the hundreds of thousands of dollars their bill would run; they’d look at the pain he was causing to those same people, by letting them hope for miracles that weren’t going to happen; and someday, someone in authority would do something.
In the meantime, Dayne could do nothing more than she was already doing. Write down everything, question questionable orders… get written up by Batskold.
Out of the corner of her eye, she caught a change in the flickering pattern of light that scrolled across the monitor. The reading was Mrs. Paulley’s, and it was bad. A run of PVCs — premature ventricular contractions. The ventricles of Mrs. Paulley’s heart were pumping irregularly, a sign that could indicate they were going to quit pumping altogether at any time.
Dayne put the chart down and headed into the glass-walled room in front of her desk. She had certain things she could do without notifying Dr. Batskold, and she did them. She increased the amount of the cardiac medication that was running into Mrs. Paulley’s veins, she brought in the crash cart, with its heart defibrillator and drawers full of emergency medications, and she checked to make sure Mrs. Paulley’s IV’s were still putting their medication into her bloodstream where it needed to be, and that they hadn’t worked loose to pour it into her flesh, or into the bed. She checked to make sure the ventilator was working correctly, and that the tube carrying oxygen into the old woman’s lungs was clear. She slipped a blood pressure cuff around the old woman’s arm and checked her pressure — it had dropped.
Dayne looked at the over-bed monitor. She was starting to get regular runs of those same PVC’s. She waved at the ward secretary. “Stacy! Page Dr. Batskold up here. I need him to take a look at this.” Stacy nodded and got on the phone.
Dayne increased the dose of the cardiac medication again, and looked at the old lady lying in the bed, tiny, frail, pale and bruised, with bandages around her head and bandages over her eyes, with a huge white plastic tube shoved down her throat and Teflon catheters shoved into the veins of her neck. The ventilator hissed and chugged, forcing her chest up and down, the IVs clicked and beeped, the monitor ticked overhead.
Dayne walked over to the side of the bed and took the old woman’s hand. Sometimes she sang to her comatose patients while she worked on them — hearing was supposed to be the last sense to go, and she wanted them to know someone was there, someone who still remembered they were human — but she didn’t feel much like singing at that moment. Instead, she just talked.
“It’s a pretty October day out there, Mrs. Paulley. The leaves are starting to turn, and the sky is so blue you’d think it was in a painting instead of real. Out your window I can see a mother and two little boys sitting on the bench over by the pond. They’re feeding the ducks and a couple of Canada geese — throwing bread to them. The littlest boy is sitting on his mother’s lap because one of the geese came right up to him and it was as big as he is.”
She was watching the monitor — no improvement. She let go of the old lady’s rigid hand and pulled a pre-filled syringe of the cardiac drug out of the cart. She injected it into the IV, wrote down the time she’d given the drug and the amount she gave on a paper towel, and watched for any change in that thin green line.
She said, “Your daughter called to tell me she and your two grandchildren would be stopping by this evening. You have a very nice family. They love you very much.”
The ventilator hissed, the IV’s dripped and beeped, and Mrs. Paulley’s cardiac rhythm got worse. Dayne put the blood pressure cuff on automatic and set it to do a check every minute, then lowered the head of the bed until it was flat.
“Stacy,” she yelled, “get the nursing supervisor and the respiratory therapist up here stat, and change Dr. Batskold’s page to stat, too. She’s going to code on me!”
Mary Deiner ran into the room. She was one of the other three RN’s in the unit; her patients were bad, too, but the ICU nurses helped with each other’s codes. “What do you want me to do?”
“Defibrillate when we need it. Push drugs. I’ll do CPR.”
Mary nodded, and warmed up the defibrillator. The high-pitched whine of that machine joined the rest of the machine noises in the cramped room.
Stacy came in and grabbed the code log. “Should I start it now?”
Dayne was running in a second bolus dose of the cardiac drug. “Not yet. She still has a viable rhythm.” She shook her head. “No — go ahead and write these down.” She handed the ward secretary the paper towel with the blood pressure and the two boluses of cardiac drugs noted, as well as the changes in the titration of the IV drips.
The blood pressure monitor showed that Mrs. Paulley’s pressure had dropped. Her heart was failing fast in spite of everything Dayne tried.
“Increase the dose on her Nipride for me, Mary.” The machine that ran the blood pressure medicine was closer to Mary than to Dayne.
Dayne studied the monitor. The wide, slashing V’s of the irregular ventricular beats still ran across the screen in clumps. Then all the normal beats vanished. The monitor showed nothing but a broad band of up-and-down slashes — its alarm went off at the desk with a scream. The blood pressure monitor alarmed at the same instant.
The old woman’s heart was no longer moving blood through her lungs into her brain or other vital organs. She had no blood pressure and no pulse.
“Shock her,” Dayne said to Mary. “Start at a hundred joules.” That was a low amount of electricity, but the old woman was nothing but bones.
The supervisor and the respiratory therapist ran in as Mary pulled Mrs. Paulley’s gown up and put the cold metal paddles on her chest. “Clear!” Mary yelled, and everyone stood away from the bed. There was a ‘whump’ as the paddles discharged their electricity, then Dayne felt for a pulse at the woman’s neck while she watched the monitor. The line that crawled across the screen was ragged and smaller, with no sign of a rhythm. Dayne found no pulse. “Nothing. She’s in V-fib now. Give her a dose of epi, and if that doesn’t work, we’re going to shock her at two hundred.”
Mary injected a drug that sometimes caused the heart to restart. It didn’t work this time, though, and she warmed up the paddles to a higher voltage. “Clear!” she yelled, and again everyone stood back.
“Why are we doing this, Dayne?” the supervisor asked. “She’s decerebrate.”
“Her pupils are blown, too,” Dayne said. “But she’s Batskold’s. He made her a full code — we’re to do everything we can.”
“Speak of the devil,” the respiratory therapist said, as the doctor walked into the room.
“Where are we on this?” he asked.
Dayne gave him a quick rundown of all the steps she’d taken, ending with the summation that the old woman had not responded to anything.
“Shock at three hundred joules,” he told Mary.
The paddles ‘whumped’ again, and the room filled with the unmistakable odor of burned flesh. The old woman’s heart rhythm remained absent.
Dayne climbed onto the edge of the bed, locked her hands together with her fingers raised and her right hand over her left, and began pressing into Mrs. Paulley’s sternum with the heel of her left hand. “One-one-thousand, two-one-thousand, three ….”
Everyone in the room heard the crunch as Mrs. Paulley’s sternum cracked and her ribs broke. Dayne shuddered. Dr. Batskold said, “Keep going. If she lives, we can heal the ribs. We can’t do anything for her if she’s dead.”
Dayne kept on compressing, forcing blood through the old woman’s body. The ribs crunched beneath her hands with every push — a sound and a sensation she would relive in her nightmares. Meanwhile, Dr. Batskold pumped his patient full of drugs, tested the amount of oxygen in her blood, tinkered with the titrations of the drips he’d put her on…
“There! You see?” he suddenly yelled. “We have a rhythm! Stop CPR!”
Dayne pulled back and automatically felt for a pulse. A thready one slipped beneath her fingers — but it was definitely there. Poor old woman.
“We won!” Dr. Batskold said, and grinned cheerfully around the room. “Good work, everyone. Okay — Dayne, standard orders. Let’s get a chest x-ray and hourly ABG’s and …” He rattled off a long list of orders, which Dayne wrote on the chart.
“Code status?” Dayne asked when he’d finished.
“Oh, definitely let’s keep her a full code. Definitely. We don’t concede defeat until we have to.” He turned and, whistling, walked to the nurses’ station to begin charting the annals of another of his victories over death.
“We won?” the nursing supervisor asked with a lift of her eyebrow. She stared at the comatose body in the bed.
“Oh, yeah,” Dayne said softly. “Dr. Bastard always plays to win.”