WARNING SIGNS excerpt
Amanda Mason raced down Pittsburgh’s Angels of Mercy Medical Center’s east stairwell, the echoing sound of her clattering heels reminiscent of rain tap dancing on a tin roof, taking her home to rocking chairs, sweet tea, and her mother’s veranda.
Her pager screeched, obliterating the illusion. The pulse-jarring noise propelled her into an instant state of alertness. Worse than Pavlov’s dogs, Amanda thought, hating the gut-twisting adrenalin surge that hit her stronger than any caffeine jolt.
She silenced the pager and clutched the stethoscope jostling around her neck, barely catching herself as she rounded the landing. Her coat pockets bristled with notebooks, index cards, and neurology manuals. The books were heavy enough to swing the coat like a pendulum, throwing her off balance as she dashed down the stairs to the ER.
The ER, which would not stop paging her. She quieted the beeper again. “I’m coming, I’m coming,” she said aloud, startling the janitor mopping the landing below her.
He glanced up, but didn’t bother to move out of her way once he caught sight of the short lab coat marking her as a mere medical student, or “scut-monkey” in hospital parlance. The lowest of the low, actually paying for the privilege of running labs, starting IVs, jabbing poor unsuspecting patients for blood, and stroking attending physicians’ egos.
Amanda skidded across the wet floor, grabbing the door handle to stop herself before she slammed into the concrete wall. Her short heels were comfortable but not designed for galloping down stairs in response to a summons from the ER for a stat neurology consultation.
A lady never rushes. Her mother’s oft-repeated instruction returned to her. Amanda took a breath, smoothed her lab jacket, and straightened her stethoscope. She closed her eyes for a moment, trying to recapture the serenity she’d felt out on the river, rowing in the predawn mist that huddled over the Allegheny.
Then she calmly strode through the door—with three older brothers to keep up with, her mother had never been successful in getting her to glide like a proper lady—and entered the vortex of humanity that was Angels of Mercy’s Emergency Department.
“What are you doing here?” Nora Halloran, the ER day-shift charge nurse greeted Amanda, glancing up at the clock.
“You called for a neurology consult?” Amanda tried to sound confident, as if a fourth-year medical student could actually contribute something useful. She still broke out in palpitations every time she remembered that this time next year she’d be a real life, full-fledged doctor. How could one person ever hope to learn everything she needed to know in such a short time?
“Not me, I’m not on the clock yet.” Nora’s hazel eyes gleamed as she took in Amanda’s dress and heels.
“You aren’t either—not until seven. Trying to impress someone special?”
“Please.” Amanda’s Southern accent drew the word out into two syllables. She straightened her posture, tucked an errant strand of blond hair behind her ear and attempted to look calm, cool, professional. “No, I have a doctor’s appointment later, is all.”
“Pretty nice dress for a doctor’s appointment,” Nora continued. “Who’s the doctor, George Clooney?”
Amanda smiled at the compliment. She’d chosen the blue linen dress to match her eyes, and she felt good wearing it. After spending her last rotation mainly in the OR, stressed out and sleep-deprived, wearing scrubs and blood-splattered Reeboks, she had rejoiced in the opportunity to dress like a real person again, pulling all her favorite girl clothes from her closet.
“No, it’s Dr. Nelson. Last time I saw him, I was working the ER, hadn’t slept in two days or had a chance to shower. I wanted him to see that I know how to take care of myself.” Another reason why she’d gotten up before dawn and headed over to the boathouse on River Avenue. She’d neglected her rowing—or any exercise—for several months, and she was determined to put herself and her health ahead of her studies for once.
The door to the resuscitation room banged open. A dark-haired woman craned her head out, her gaze sweeping across the ER, looking for trouble. Dr. Lydia Fiore, the youngest and newest ER attending, gave Amanda an abrupt nod. An alarm blared and she vanished back into the room.
“Guess I know who paged me,” Amanda said, leaving Nora for the resuscitation room, her heels clacking against the linoleum with an authority she didn’t feel.
She liked Lydia, enjoyed working with her, but the attending’s boundless energy and ability to make diagnoses with minimal information could be a bit overwhelming and intimidating. Even the regular ER staff was polarized by Lydia—either in awe of her apparently magical abilities or scornful, waiting and hoping for her downfall. Lydia didn’t seem to notice or care, instead focusing all her energy on her patients with a self-assuredness Amanda envied.
Pushing open the door to the treatment room, Amanda entered a symphony of chaos. Nurses and lab techs swarmed around a motionless black girl, maybe twenty years old, who lay on the exam table, colored wires leading from her chest to a monitor, two IV lines in place, a respiratory tech adjusting a nonrebreather oxygen mask over her face. Elise Avery, the flight nurse who must have transported the patient in on the hospital’s helicopter, was directing traffic, a scowl on her face.
The only oasis of calm was Dr. Fiore herself, who stood motionless at the head of the bed, one hand resting against the girl’s shoulder as if giving comfort. Except Lydia wasn’t really still. Her gaze was in constant motion, devouring everything in its path, and one foot tapped an impatient staccato that mirrored the beeping of the heart monitor.
Gina Freeman, an emergency medicine resident and Amanda’s roommate, had once compared Lydia to a hand grenade—not much to look at on the outside, but ready to explode when triggered.
“Nineteen-year-old collapsed during a cross-country run this morning, transported in from Millvale,” Lydia told Amanda. “On arrival, she was unresponsive, noted to have hypernatremic dehydration with an elevated sodium of one fifty-one. Vitals were normal, but patient grew increasingly nonresponsive with myoclonic movements of her extremities and eventually exhibited a descending paralysis. I was just getting ready to intubate her, but thought you might want to do a quick exam first.”
“No elevated temp?” Amanda knew heatstroke could cause similar symptoms.
“Not here.” Lydia raised a questioning eyebrow at Elise, the transport nurse.
Elise shook her head, her usual calm, commanding expression clouded by the mystery of why the girl had gone downhill so fast. “None at the scene either.”
Descending paralysis? Amanda had never heard of that—usually paralysis hit one side of the body as in a stroke, or started at the feet and moved up the body as with Guillain-Barré. It didn’t start at the head and work down.
“Normal temp on scene,” Elise continued. “The sodium is coming down nice and slow, so you can’t blame that. Besides, according to her friends, she had the neuro symptoms before she collapsed. Complained of trouble swallowing, uncontrollable muscle tremors, blurred vision.”
Amanda pursed her lips and checked the patient’s reflexes. Nothing. Except the girl did have a normal Babinski reflex, which meant her nerve impulses could make it from the brain to the big toe and back again.She appeared to be sleeping, although her respiratory rate was a little slower than normal.
Amanda stepped back out of Lydia’s way, clutching her stethoscope with uncertainty. If Lydia couldn’t figure it out, what chance did Amanda, a lowly medical student, have? “I think I’d better call my attending.”
“Already paged,” Elise told her.
“Drop an NG,” Lydia ordered. A nurse grabbed the nasogastric tube designed to prevent aspiration. “There’s nothing on exam. I can’t find a reason for this girl to be unresponsive.” Lydia glanced at Elise. “Any past medical history? Drug use? Current meds?”
Elise shook her head. “Friends didn’t know of any. Sorry.” She sounded genuinely regretful that she didn’t have the answers needed to help their patient.
“We’ll have to wait for a tox screen. What else? Tick paralysis? Botulism? Miller Fisher variant?” Lydia muttered, drumming a reflex hammer against her palm in time with her words. She quickly gained control of the situation, completing a head-to-toe assessment of her patient and ordering repeat labs.
Elise moved to one side, leafing through her paperwork as if searching for an answer from her records. If the girl on the gurney in front of them hadn’t been so sick, Amanda might have been pleased to see the transport nurse flustered for once.
Instead, Amanda looked down at their patient and had the sudden image of herself lying there lifeless.
The door banged open and the neurology attending barged into the room, shattering her reverie: Lucas Stone, the one person she’d been hoping to avoid.
