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Stabbing Back Pains
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I had been expecting Pam to be awake.
I was in her room one morning after mitral valve surgery. They’d gotten her off the ventilator some time in the middle of the night. The nurse was gathering her notes and getting ready to write report, finishing up an 11p-7a shift caring for four patients. I asked her how Pam did during the night.
“Well, she was restless all night, kept twisting and moving around. Seems like she couldn’t get comfortable.” She lightly stroked Pam’s cheek with the back of her hand. “Poor thing.”
This is what she’d just written in her notes:
“Nurse’s note 06:20 Pt more restless and moving constantly in bed. Has received Ativan and Fentanyl… She is reporting stabbing back pains… she has repositioned herself repeatedly…”
The nurse and I were standing on the same side of the bed facing the open door. An unshaven young man in rumpled scrubs walked in and, without looking at us, put his hands under the sheets covering Pam’s upper abdomen. The nurse and I looked at each other.
“Excuse me,” said the nurse.
The intruder paid no attention and kept rooting around under the sheets. I said Hey and he kept going and I said HEY again, loudly and sharply, and that got his attention and he looked up. The nurse and I both said: “Who are you?” He said he was from Cardiology and he was there to check on Pam’s pacemaker. Then he disappeared. The nurse said she’d never seen him before. She shrugged and went out. 
Stabbing back pains… I adjusted the pillow beneath Pam’s head. I slid my hand under her back to smooth out the sheet. I felt something and pulled from beneath her lower back a pair of curved forceps.
∞
A
After turning in the forceps at the nurse’s station, I went to to the airport to pickup Pam’s mother, Jackie, who is a practical person, especially in a pinch. The women in her family would not abide incompetency in a man—husbands specifically. At the time, this did not apply to doctors. She was at the curb with her carry-on bag and got in the car as soon as I pulled up. I was able to report that Pam’s heart surgery had gone well and that she was off the ventilator and in a private room. She was asleep when I left, but most likely Pam would be sitting up in a chair beside the bed when we got there — and she could talk to us.
Jackie listened to me and did not ask questions until I was through, and when her questions were answered she went silent. I was glad that she had come. She had an innate sense of how to manage a crisis. After a few days we could take Pam home and her mother could look after her while I got back to business. Everything was going to be O.K.
We entered Pam’s room with anticipation, smiling. But she was not there. The sight of the empty bed was jarring, but before I could speak a nurse came and said that Pam had been sent back to intensive care, was back on the ventilator, and that they could tell us more when we got there.
Back up to the fifth floor.
The good news from the ICU was that Pam’s temporary pacemaker, the one the mystery man from cardiology had been checking on, was in fine working order. They could tell because when they turned it off, Pam’s heart didn’t work at all and the cardiac monitor showed flat lines. When they plugged it back in, the lines on the monitor resumed the rhythmic blips which normally produce the soothing lub dub, lub dub sounds of a human heart. From now on, of course, any infant that Pam held close would hear the metallic sound of modern high technology. Click click… Click click… Click click… the distinct audio signature of a sturdy St. Jude Medical© Model MEC-102 27mm Mechanical Heart Valve made of pyrolytic carbon and tungsten.
It’s supposed to last forever.
As for why she had landed back in intensive care, extubation can be a hit or miss procedure if you’re not careful. A machine has been doing your breathing for you, and getting your lungs to take responsibility again is sort of like pulling the old table cloth trick. They’ve got to make sure that blood gasses are high enough so that the pump is primed and the lungs will gradually take over from the machine. A patient must be carefully and deliberately weaned off the ventilator. It’s a delicate maneuver that must be performed with care and precision.
Respiratory therapy note:
22:59 Pt was extubated… Was extremely anxious and was extubated per order before mechanic or CPAP gas was up… Acute confusion and anxiety increasing…
02:01 Re-intubation performed by Anesthesia resident…
03:37 ETT position migrated. Cuff above vocal cords. Significant air leak heard. 02 sat decreasing. Ambu bag used for ventilation…
04:59 Bleeding noted on pt. gown in mid ABD area …
So they took her breathing tube out before she was ready, put the tube back in, but it came out again and started leaking so that they had to ventilate her by hand with and Ambu bag, which is sort of like a bellows and she was a bloody mess by the time they had finally snatched her from an early grave.
And as for why her heart was not beating on its own at all anymore, it could be just normal, temporary post-op irritation. Or it could be that the circuit board of her heart had been accidentally blown, fried, toasted; in which case a permanent pacemaker becomes another souvenir from Johns Hopkins, like the St. Jude Mechanical Heart Valve and the attending scar tissue.
For the second time in her two days in the care of Johns Hopkins Medicine, Pam’s life was in free fall. Of course, I didn’t know any of this at the time. I’d been reassuring myself by reading the posters in the hall proclaiming Hopkins to be the best hospital in the land.
