Leaving Tonight
#14 of Love Letters - The Whole Story
All the great things happen at night, it seems.
Leaving Tonight
*
Hello, people! Speckle is back, and Daniel is...Daniel. *smiles* Hope you like it!
*
_ _
"Speckle?"
The voice was familiar, but not the most welcome one at this moment.
"Yeah?" I mumbled.
"Ambulance is pulling up soon with an end stage brain cancer," Whitney spoke from somewhere at the lit orifice that was the door into the corridor, "ETA is five minutes out."
I squeezed my eyes shut firmly.
"And it's just me?"
"Doctor Parker is putting a chest tube on an MVA victim. We need you."
"Thanks," I breathed. "Just let me...get my stethoscope."
"They're pulling up in five," Whitney said.
"Thanks."
She slammed the door shut and left me in the darkness for a few more moments.
Just think of the night pay.
_ _
The night pay was going to pay for the loan I'd needed to cover the costs of this training, I reminded myself, as I turned on the small lamp above the bed. My stethoscope was hanging from the lamp, which meant I had to give it another stare while reaching for the tool of my trade. It felt as cruel as the wakeup call to possibly attempt to do life-saving procedures on someone who was already beyond help.
I straightened up the lapels of my white coat while I stepped into the corridor, quiet for now, with only two homeless bums sleeping off the day's ethyl alcohol intake. I remembered not to breathe through my nose while past them, and a huge yawn covered the rest of my respiratory system from it.
I reached the admin desk in a moment and leaned onto it for one final breather before the show would begin.
"Tina, any news about the incoming brain cancer?" I asked.
The surprisingly alert-looking coyote shook her head.
"Haven't called up since the last check-up, but I've pulled up the old charts of the patient for you, they're on the computer," she said,
"Thank you," I said. "Is trauma one ready?"
"All is set," she said.
"Thanks."
Grayson appeared from the medical storage, paws full of supplies.
"What's that?" I asked. "Is that for the incoming?"
The wolf shook his head.
"Logan's in and doing a DPL on the MVA guy. The kit in the trauma room was expired."
"Oh, okay, good luck then," I said.
The wolf managed a quick nod before he hurried into the trauma room again, protective gown waving about him. I thought about putting one on myself, but the reported history of the patient didn't really indicate there was going to be a lot of bodily fluids spewing out of him. I did snap on gloves and took a few steadying breaths. This might get ugly.
They were just pulling up. Whitney stood next to me, a somber expression on her muzzle.
The doors slid open.
"Robert Stuart, aged 61, end stage brain tumor. Has been responsive until today, but tonight he was discovered unconscious and unresponsive by the wife who phoned 9-1-1!"
There was a wolf lying on the gurney, covered in a red ambulance blanket. His eyes were open, but even from afar, I could see that there was very little going on behind them. An oxygen mask covered his muzzle and tubes curled all over the bed, while a beeping defib monitor showed the zigzag of a pulse.
"Okay, let's take him to trauma one," I told the paramedics pushing the gurney.
"WHERE IS HE?" a voice yelled down the corridor.
"That's the wife."
A middle-aged wolfess appeared, clutching some sort of a small bag in her paws.
"I FORGOT HIS MEDICINES!"
"BP is 140 over 125, pulse is 50, respiratory rate, 15 to 40 and shallow, pulse ox is 93 on the mask. Pupils are equal but sluggish, and GCS has been 5 on site and onwards, there's no verbal response or spontaneous eye opening. The patient is DNR."
"Let's get him onto the bed," I told calmly, "let's hook up the O2 and the monitor, keep the fluids going and let's re-assess the GCS and stand by with any other measures for now."
"Doctor, he doesn't want to end up in tubes!" the wolfess yelped from the door.
Whitney looked at me questioningly. I gave her a nod.
"Keep him comfortable," I told him as I stepped over towards the doors. "Mrs. Stuart?"
She opened the paw bag and pulled out a brown envelope.
"He's got a DNR and I've got a durable power of attorney in case he becomes unable to make decisions for himself and this is it, isn't it?"
"I'm Speckle Augustine, I'm a physician assistant here at the emergency room," I told her," we are doing everything we can for your husband."
"He doesn't want to be kept alive," she told me in a wavering voice, "I...I don't want him to..."
"I understand that if that is his wish, we will do what his wishes are, ma'am," I said, "may I see that?"
"Y-yes," she said as she handed over the envelope," I've got his drugs here too..."
She pulled out a Ziploc baggie from the same handbag, full of pill bottles.
"It's all he's on and there's the list the home hospice care nurse wrote down for me," she spoke breathlessly, "God, I wanted him to be comfortable and at home but then he was unconscious and I panicked and I wasn't sure if he was alright and - "
I touched her arm, gently, and smiled, as softly as I could.
"We are doing everything we can for him to be as comfortable as possible, ma'am."
"BP is 135 over 125, Speckle, pulse is 45," Whitney said from by the bed, "sounds like Cheyne-Stokes breathing."
"Ma'am, you should probably wait outside while we assess your husband's condition," I told the wolf.
She shook her head firmly.
"If he dies now, I want him to know that I'm here," she said, "let me stay. I'll be here, out of the way."
"It may be distressing for you to witness some of the procedures and examinations," I told her, "it is for your - "
"I've watched him die for a year, I'm not going to be shocked by anything anymore," she replied sharply. "Now go and help him."
"Want me to get mannitol ready?" Whitney asked.
I took out my penlight from my pocket and shook my head to Whitney.
"Probably not applicable in this case," I said, "would you check the drug list from this bag?"
I gave her the bag and moved myself over to the unconscious wolf. I had to pry his eyes opened with my fingertips to shine my lamp onto them.
"Pupils are...sluggish, and the right one is slightly dilated," I said, "Doll eyes..."
The eyes remained staring up onto the wall.
"Looks like possible brainstem involvement," I said, "GCS...eyes are 1...Mister Stuart?"
Silence.
"Verbal is one..."
I pressed my paw over the wolf's chest and rubbed. The old man's floppy arms. Attempted to rise up from the gurney.
"Motor response is three, and poor."
"He was moaning and I wasn't sure if he was in pain and I just had to call the ambulance," the old wolf lady spoke somewhere behind me.
"He appears to be deeply unconscious, Mrs. Stuart, I don't think there is any discomfort."
"Okay...this says...Dilantin, dexamethasone, Benadryl and Valium."
"Quite the cocktail," I said, "we may have to check the phenytoin and dexamethasone levels. Whitney, can you draw the bloods?"
"Right away."
"Is your husband on any other medication?" I asked the wolfess.
"No, no, the home hospice care nurse comes every day to give him his injections," she said.
"Alright, thank you," I said.
I picked up the ophthalmoscope and moved over to the patient again.
"Papilledema on the right side...definitely increased ICP."
"He's maxed out on steroids, we know it's the end," the wolfess said. "Just don't let him suffer, please."
"We won't," I said. "I'll just have to consult with my colleague, I will be right back, and the nurse will be with you all the time."
I didn't really like going out, but I didn't have a choice, as I went across the corridor and into the rather more urgent and staffed trauma two.
"Doctor Parker?"
The Golden Labrador looked at me through the face shield covering his muzzle.
"What is it?"
"I've got an end stage brain cancer with DNR, brought here because he's no longer conscious nor reacts to stimuli, GCS is five and depressed from baseline, and vitals are indicating the Cushing's reflex, BP is high and pulse is slow at 45. There's right-sided papilledema and decorticate flexion."
"Curved Kelly!" the dog told to Grace, standing next to him. The nurse slapped an instrument to the dog's bloodied, glowed paw.
"They don't want any heroic measures," I said.
"Then no measures," he replied, "maintain neuro ops and check therapeutic levels for any drugs he's on and keep the patient comfortable."
"Should I try to contact home hospice care to see if they can take him back?"
"Needle driver and 1.0 silk!"
I gave him a moment.
"Doctor?"
"How big is the drop from the baseline?"
"From more or less fully oriented to unconsciousness, no verbal response or pain response."
"Any palliative therapy?"
"Only steroids and Dilantin and Benadryl. High therapeutic doses."
"Petroleum gauze!"
The door behind me swung open.
"Speckle, he's started to rattle, the wife's freaking out," Whitney told me.
"Check the Thora-Seal!"
_ _
"Doctor?" I spoke calmly.
"Since he's DNR, there's no need for any further tests or invasive procedures," Doctor Parker said, "give oxygen, limit IV fluids and maintain therapeutic levels of Dilantin and steroids. And start .5 mg of atropine to help with the rattle."
"Okay."
"I'll sign the chart when I drop by once this one's going upstairs," the Labrador told me.
"Let's go," I told Whitney.
"Speckle!"
I turned to face the doctor again, busy with his chest tube.
"Yes?"
"Remember that you're now treating the family more than the patient, but it's the most important thing you can do."
"I know," I said.
"Looks like 400 cc's out of the right chest!"
_ _
"Damn!"
*
"Robert was a music teacher."
I smiled softly to the wolfess sitting by the bed of the quietly breathing wolf.
"Oh?"
"He'd just turned sixty when he started having headaches and he couldn't play the piano anymore. His right hand just wouldn't cooperate with him. It would...interfere with his Chopin."
I knew that now all I could do was to listen, so I did. I was in no hurry.
"It was two inches across, on the left side of his brain," she said, "it was the...the..."
Her lips moved on their own for a moment, but no voice came out.
"Glioblastoma multiforme?" I guessed.
"That one," she said," they cut it out and we did everything...gamma knife, radiation, the drugs, immunotherapy...and everything went fine for nine months..then it came back and now it's...it's...infiltrating the brainstem."
Infratentatorial lesion, some hysteric part of my brain yelled to me.
"We've been married for 36 years," she said. "We were going to take a cruise in Alaska...for the 36thth anniversary. For the 35th we went to San Francisco."
"Do you like to travel?"
"We always tried to make one trip a year," she said while gazing at the calm face of her husband. lying in bed with his head elevated, tubes in his nose, but otherwise, looking like he was simply asleep. If he wasn't comatose, technically it would be true to say as much.
"Must've been the highlight of the year."
"It always was," she smiled," even the time when we got stomach flu in Kansas."
I smiled sympathethically. The wolf let out a hissing, gargling breath. The wife's ears flattened, briefly.
"Do you think he can hear me?" she asked.
"I've no doubt," I replied. Even my soft voice sounded oddly loud in the quiet, small room. "He may be unconscious, but we don't know which parts of his brain are active at the moment. Even if we...hooked up all those cables onto his head and did an EEG...I doubt even that would tell us the truth about it. I've seen many patients like your husband, and I believe, without doubt, that your husband knows you are here."
I wasn't even lying. Maybe just stretching the truth a little. I couldn't prove it. I was supposed to be a scientist. I wasn't much for God, either, and I wasn't sure whether she was . She hadn't been praying at any point during the night, that much I knew. But one had to have tact in these matters. I couldn't tell her that I didn't believe that he could hear her. I was treating her now, more than the patient, like Doctor Parker had said.
"You are a smart young man," she smiled gently, "you are a little younger than our daughter, I think...I'm not quite sure."
"I am doing my job," I gave her the cowardly answer to these kind of compliments and questions.
"Have you been married for long?" she asked.
My ears perked curiously, as much as they could, in that question. She must've seen my expression, since she gave me a look.
"I saw that you wear a ring on a chain around your neck," she said. "I have seen quite a few medical personnel do that, because you can't wear it on your finger, isn't that right? So, I presume you are married."
"You can't wear them in the ER, no," I said with a small smile "so many gloves and so much paw washing, it would be difficult to keep it clean, or safe."
Another loud breath. This time she was just looking at me expectantly.
"It's actually an engagement ring," I told her, "we've been engaged for about two years now. Thinking of the right time to...go the full distance."
"My daughter isn't married either," she said, "young furs don't need marriage anymore, do you?"
Isn't it a luxury to be able to choose?
_ _
"It has its...good points," I said, "we're still waiting."
"Got any children?"
"No."
She smiled.
"There is still time," she nodded.
Loud, loud breath.
Now she looked at him again.
"How long can he go on like this?"
I glanced at the immobile wolf, and then looked at her.
"This is the end," I told her quietly. "It is most likely that he will soon stop breathing, with the...with the increased pressure to his brain compressing further structures inside his skull..I'm afraid I cannot put it in more simple terms than that. But basically it means that the growing tumor has reached a critical size and we no longer cannot help him with any medication or surgery."
"And if he was put on a ventilator?"
I swallowed.
"With this level of...depression of consciousness, he would simply stay in a coma for some time longer, without regaining consciousness. And then he would die when his heart stops beating, or possible when we would withdraw the ventilator."
She nodded quietly.
"I know. He didn't want that. I wouldn't want it either. And maybe this isn't bad...at least there's no pain, right?"
"No," I said. "He is just asleep."
My pager beeped. A quick glance put my blood racing.
"I'm afraid I have to go, it is an emergency, "I said. "I'll have a nurse come here to be with you."
She nodded, and brushed a paw over her husband's arm.
"We'll be fine. Thank you."
*
She didn't have to know that the page was Code Blue from Internal Medicine. Since I was the emergency response tonight, that meant racing through the sleeping hospital to find...to find a rather stable angina on a patient with extensive cardiac history. A nitro spray was all that was needed, and a bit of reassurance. I supplied the former, the staff could offer the rest.
I took a quiet walk back to the ED.
"Anything new here?" I asked from Tina.
"Doctor Parker just went into Exam Five," she pointed at the quiet room, "Grayson was asking for him."
I decided not to hurry on this one. It seemed inappropriate. When I entered the room, quietly, Doctor Parker was writing onto a chart, and Mrs. Stuart held her husband's paw. My appearance made her look at me.
"I'm afraid you missed him by a few minutes, Mister Speckle," she said, "he already left."
"Time of death, 06:24," Doctor Parker said.
*
He would be up by now, I thought. There was a particular place...up on the first floor, a balcony opening from the corridor. Perhaps the designers of the building had thought it was a great idea to have some place where the patients could go and take their cigarettes without having to go downstairs. Some naughty staffmembers still did it. The balcony was deserted when I went there.
The phone rang only twice before he answered.
"Morning, handsome!"
_ _
"Hello," I laughed.
"Well this was unexpected! Is something up?"
_ _
I smiled gently, and rubbed my tired muzzle.
"I just wanted to...tell you that I love you," I whispered.
"One of those nights?"
_ _
"Kinda," I said.
"I love you too."
_ _
"I just wanted to tell you because I know I won't see you before tonight so...so this had to do."
"I'm really glad to hear your voice."
_ _
I pressed my paw over my chest, to feel the small, hard ring pressing onto my furs there, under my white coat.
"Me too."
"Aren't you off soon?"
_ _
"Yeah," I said, "just have some paperwork to sign in and then I'll escape before the first walk-in patients come over."
I breathed in some reasonably fresh morning air, and smiled.
"I'll keep the bed warm for you until that."
_ _
I smiled some more.
"As long as it smells like you, I'll be happy."
"I'll promise it will."
_ _
"You're a darling."
"Oh, stop it."
_ _
But I wouldn't. Not yet. Because he didn't have to go yet.
*
Thank you for reading!