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Chapter One He had taken great pains to prepare for his new role. After all, a medical residency at the famed Johns Hopkins Hospital was something sought by many but found by few. He was one of the lucky ones and wanted to look good. A crisp blue button-down shirt and striped tie were nicely framed by his short white coat. A new I.D card hung from his breast pocket, showcasing his thick light brown hair and warm smile. With his black doctor’s bag in hand, he was ready to go. After straightening his jacket and taking a deep breath, he briskly walked down the hall to the emergency room. As he approached, the electronic double doors quickly swung open to greet him. In the massive waiting room, the soft glow of the hallway was replaced by the blinding glare of fluorescent lights. Their pale gray hue lent an appearance of an aging photograph. Patient families and friends were sprawled across long rows of uncomfortable chairs. Some were sleeping. Others aimlessly stared at the wall-mounted TVs. Nearly everyone had spent most of the night there. No one seemed to mind. They were accustomed to the slow-moving wheels of emergency medicine. In the East Baltimore ghetto, there were few alternatives. For generations, a seemingly endless stream of the sick and suffering had sought refuge at this castle on the hill. Some were legitimately sick. Others were simply lost, with no other place to go. This day would be no different. Eventually, they would all be seen. For some, the problems were relatively minor and easily addressed. For others, the stakes would be much higher, with no room for error. A dozing security guard and receptionist manned the desk at the entrance to the inner sanctum where patients are cared for. Summing his most professional demeanor, he confidently approached. “Hi, I’m Dr. Hank Baldwin and I’m here to start my rotation in the medical ER.” Barely looking up, the receptionist muttered, “Really? With that starched white suit on, I thought you were selling ice cream. Head on back down the hall. You’ll find them.” Shaking her head, the receptionist returned to her paperwork with an obvious indifference to his presence. This was not exactly the warm welcome he’d hoped for. Nonetheless and now with an obvious spring in his step, Hank strode down the hall where the emergency room team was beginning to assemble for morning rounds. As he approached, the significance of this tepid welcome soon became apparent. Everyone was wearing blue surgical scrubs. The receptionist was right. In his starched white coat and pants, Hank looked more like he was heading to a Halloween party than going to work in a busy inner-city emergency room. It would not be a great first impression. The awkwardness of the situation was quickly defused by Dr. Vince Jenkins. Jenkins was well known throughout the hospital as a great doctor and a strong patient advocate. Growing up in East Baltimore, Jenkins had escaped from the perils of inner-city life with a basketball scholarship to the University of Maryland. Not quite good enough for the NBA, he opted to go to medical school at Duke. His only career goal was to return to work in the hood where he had grown up. And so, he did. Jenkins was now an attending physician in emergency medicine at the Johns Hopkins Hospital. For the next twelve hours, the emergency room would be his ship to sail. “Hank, welcome aboard!” Jenkins bellowed, beaming a megawatt smile that was amplified by his dark skin and shaved head. “We were just getting ready to walk around and review the hold-over patients from last night.” In a quick aside, he introduced Hank to the rest of the team. Peter Chen was a senior resident in emergency medicine. He greeted Hank with a quick handshake and a cool hello. There was an intense rivalry between the emergency medicine and those know it all internal medicine residents. Mollie Etheridge was the senior nurse on duty. Caramel skinned and slightly overweight, she had a well-deserved reputation as a force to be reckoned with. Over the past twenty years, she had seen an army of young residents pass through her emergency room. At times, her no-nonsense demeanor could effectively belie her considerable experience and boundless empathy for the patients and staff. Immediately sensing Hank’s discomfort, she was quick to put him at ease. “Dr. Baldwin, it’s nice to meet you. You remind me of Dr. Jenkins on his first day as a resident.” She then cocked her head and looked at Jenkins. “He wore these silly white buck shoes to work. You would think he was planning to go out dancing somewhere. Mind you, those nice little ditties stayed clean for about fifteen minutes.” Everyone laughed. Jenkins took it all in stride, soon quipping that he’d always needed to rely more on good looks than on skill. Putting her hands on her hips and turning to Hank, she said, “Maybe tomorrow you’ll come back like you’re dressed ready to do some work.” Hank blushed but stayed silent. Cheryl Bradley was the junior nurse. Probably in her early twenties, she had been with the department for a year and said little other than hello. There were a few others present on walk rounds: nurse’s aides, orderlies, respiratory therapists, and X-ray technicians. They all seemed nice enough. Today, they would work together to efficiently care for the scores of patients that had come to them for help. These casual introductions all came to a screeching halt when a voice over the intercom blared: “Patient to the cardiac room!” Suddenly, the electronic double doors to this inner sanctum swung open. A few seconds later two male attendants were hustling a gurney, bearing a lifeless body, into the cardiac room. The cardiac room was a large area in the center of the medical section of the cavernous Emergency Department. It was always ready for any type of medical emergency. At its center stood an impressive operating table, on which the patient would lie during any resuscitative effort. Large circular surgical lights, suspended from the ceiling, bathed the area with a bright white light. Multiple IV bags had been previously prepared and hung like vines from the ceiling. Along one wall stood a series of sterile tables. Green cotton sheets concealed the variety of medical instruments that might be needed in any emergency. Another wall was covered with rows of blue plastic bins containing all types of medications and supplies. Everything was right there and within each reach of the medical team that stood ready to do their job. This, after all, was the John Hopkins Hospital emergency room. It would be hard for someone to die here. “He was just dumped off at the front door by a couple of guys in a car!” the panicked security guard shouted. “They just dropped him on the pavement and sped off! I think he’s dead.” A hysterical attendant yelled. The attendants were quickly moved aside. On the count of three, Jenkins, Chen, Mollie, and Cheryl carefully lifted the lifeless body off the gurney, transferring him to the operating table in the center of the room. Under bright surgical lights, the emaciated body of a young black man was easy to see. He was perhaps, in his early twenties. A dirty T-shirt was stained with what looked to be fresh vomit. The front of his torn and dirty jeans appeared to be soaked, through and through, with urine. This picture of urban indigence was starkly juxtaposed with the thick gold chain hanging around his neck and the new Nike’s adorning sockless feet. He didn’t move at all. The attendants were correct. He looked dead. The eyes were fixed open, staring straight at the ceiling. His mouth gaped, revealing a pale parched tongue and some residual vomit. Standing at the head of the table, Jenkins quickly inserted a curved plastic airway into the patient’s mouth. This would help keep the tongue out of the way during ventilation. He then placed an oxygen mask over the patient’s face and with one hand, firmly held the mask down against his chin, creating an airtight seal. With the other hand, he rhythmically squeezed the attached ambu bag. With each squeeze of the bag, the patient’s thin chest rhythmically moved up and down. Using specially designed scissors, Cheryl carefully cut off the dirty T-shirt and attached EKG electrodes to his chest. Mollie began taking vital signs, while Chen systematically examined the patient. Hank silently stood to the side, in awe of their coordinated efficiency. The room remained silent except for the hi pitched beat of the EKG monitor and a periodic swoosh from the ambu bag. The gravity of the situation hung in the air. “Talk to me, people,” Jenkins calmly said as he continued to ventilate the patient. “BP 70 over palp, pulse 130, spontaneous respirations 8 and shallow. Pulse Ox 88 percent on 100 percent O2. Non-responsive to deep pain. The rhythm looks like sinus tach,” Mollie calmly noted. “Heart sounds are clear; breath sounds present bilaterally but distant. The belly is soft. No signs of trauma,” echoed Chen. After placing a tourniquet on a heavily tattooed arm, Mollie said, “I can’t find anything here.” “Same thing on this side,” echoed Cheryl, carefully feeling the patient’s arm for a hidden vein. Hank just stood by, taking it all in. The pace was fast, but the actions were deliberate. Everyone, except him it seemed, had a role. Jenkins then turned to Hank, saying, “Dr. Baldwin, can you put in a central venous line?” The necessary equipment had been previously prepared, covered and placed on a nearby table. In medical school, Hank had performed this procedure only a handful of times. Nonetheless, he was confident that he could insert a large bore IV line through the femoral vein without much difficulty. Moving to the foot of the table, Hank began to lower the patient’s soaked jeans. After exposing the groin, he let out an audible gasp. Eyebrows raised; his face went blank. Inside the pants, the patient’s entire crotch was packed with melting ice cubes. “Hank, we don’t use femoral lines here. It’s too easy to inadvertently nick the femoral artery. You will need to go subclavian,” Jenkins said, matter of factly. Hank said nothing, covering the ice packed groin with a towel and redirecting his attention toward the patient’s upper chest. Hidden beneath the clavicle, the subclavian vein could neither be seen nor felt. Inserting a large both catheter here was fraught with danger and required an entirely different set of skills. With Mollie’s assistance, Hank cleansed the area around the left shoulder and neck with an iodine solution. Next, with a set of sterile towels, he draped the area, forming a small triangular opening between the towels. Hank suddenly stopped and stared at the sterile field he had just created. The enormity of the task suddenly hit him. He was now effectively peering through a keyhole at a small patch of skin. The usual anatomic landmarks were no longer visible. Through this roughly two-inch window, he would need to puncture the massive vein without hitting anything else. Just a small misdirection of the needle’s tip could position it inside the chest cavity, puncture the lung, and probably kill the patient. “Hank, how’s it going?” Jenkins calmly asked. “Um, just about ready to go,” Hank said in a tone that barely masked is fear. Like a jackhammer inside his chest, Hank’s heart pounded. He fought hard not to shake. He couldn’t mess up on his first day with his first patient. Not now. Not today. If he did, he knew that for the remainder of the month, he would be banished to taking care of colds and sore throats. Tiny beads of sweat began to form on his brow. I can do this, he tried to convince himself. Under Mollie’s watchful eye, Hank slowly and deliberately punctured the skin with a needle as thick as a pipe cleaner. Navigating by touch, he carefully guided it over the first rib and under the left clavicle. With a silent nod from the veteran nurse, he forged forward and felt the needle pop into the hidden venous conduit. He was immediately rewarded by a flash of dark red blood in the chamber of the syringe. “I’m in!” he exclaimed, sounding somewhat surprised. Carefully disengaging the syringe, he passed a long flexible tube through the needle and into the patient’s central venous system. Mollie then connected the tubing to one of the prepositioned hanging bags of saline solution. “Running wide open.” Mollie said confirming the patency of the line. Hank quickly secured the line in place with a suture and Mollie gave him a subtle pat on the back before proceeding to bandage the area. It was delicate work. Hank let out a silent sigh of relief. So far so good. Looking to appear knowledgeable, he volunteered, “Aren’t you going to intubate him now?” Mollie frowned and quickly stepped on his foot, causing him to silently wince. “Cheryl, can you draw up 0.6 milligrams of naloxone and not give it just yet?” Jenkins asked casually. “On the way,” replied Cheryl, running to one of the medication bins that hung on the wall. Hank could not hide the scarlet tide that was now rushing over his body. Naloxone? He thinks this is a drug overdose. How? Mollie then turned to Hank and said, “Help me turn him over on his belly.” What the hell is going on? Hank thought as he helped turn the lifeless body over. With the patient now lying face down, the nurses firmly restrained his wrists and ankles to the table. Lying spread eagle on the operating table, the corpse like patient looked like he was about to be drawn and quartered. The nurses carefully wrapped a long, folded bed sheet under the table and around the patient’s upper torso, firmly securing his body to the table. Hank stood by and gave them a quizzical look. “He’s gonna be wild when he wakes up. If we restrain his arms with him facing up, he may dislocate his shoulders trying to sit up. This way is safer for everyone.” Cheryl said, recognizing Hank’s confusion. “Oxygen sat is down to 60 percent,” Chen casually said. With the patient tied face down, Jenkins had stopped ventilating him. He was no longer breathing. They were running out of time. “Okay, Cheryl, we are good to go,” Jenkins said. With that, Cheryl gave the naloxone through the subclavian IV line that Hank had just established. As if Lazarus were about to rise from the grave, the seemingly dead man let out a primal scream. Shaking violently, he tried to get up and break loose of the restraints. His heart rate skyrocketed. Sweat freely flowed from every pore. Screaming obscenities and fighting to get free, he was now very much alive. It was both a frightening and remarkable sight. The naloxone had replaced the heroin that was circulating through his body. Although alive, he was now abruptly withdrawing from a long-standing drug habit. Within a few seconds of presentation, Jenkins had correctly sized up the situation that Hank had obviously missed. While well-schooled in the science of medicine, Hank was clearly deficient in the practicalities of inner-city emergency care. In restraining the patient face down, the nurses had not only prevented the patient from harming himself, they had also protected the staff from what assuredly would have been a dangerous situation. What at first seemed odd, now made perfect sense. After a few minutes of pandemonium, things began to calm down. The effect of the naloxone would soon wear off, and the heroin would return to its binding sites in the brain. Left unmonitored and without additional treatment, the patient would soon revisit his moribund state. “Cheryl, let’s get him set up for a bed in the ICU.” Jenkins said, slowly removing his gloves. Walking away from the table, he remarked, almost to himself, “This kid may come back someday and not be so lucky. Somehow, we need to do better than this.” The impact on Jenkins was readily apparent to all. He was right, but for now, Hank was mesmerized by what he’d just seen. In a matter of seconds, one drug had completely reversed the effects of another. In doing so, a man had been brought from the verge of death back to life. To Hank, this sudden reversal of fate appeared to be almost miraculous and the beginning of a realization that things were not always what they initially seemed to be.