Tuesday, 10 December 2013

Heart's A Mess: Chapter Twenty Three Part I

Three Years Later. 

"Stop." The command came out, barely a whisper. Desperate, devastated and disbelieving all at once.
This was a conversation that she had prayed would never transpire. She had stared out the wall of windows for the past hour, the voices filtering in and out in muted waves. Sunlight trickled through the porous expanse of grey cloud hovering above the city, an occasional light shower painting the windows with liquid murals; dozens of droplets eddied upon the glass. Here, on the twentieth floor, Khushi felt that if she just stretched her fingers, just enough, just past the glass, she could reach the cloud.

"Khushi we need an answer." Danes pressed her, his demeanour tired and grave.

She stood beside the windows, staring straight ahead. Dread seeped under her skin, taking her nerves hostage. Slowly but surely it's creepers climbed up the cable like bundles, clawing their way up her throat, till finally its long bony extensions wrapped around her windpipe. She struggled to breathe; gasping, every breath short and sharp. There was an overwhelming need to purge her stomach of its contents as nausea staked its claim, constricting her chest. This wasn't supposed to be happening.

Not like this.

Not so soon.

"Dr. Gupta your presence here is simply a gesture of good will. We will proceed as we see fit."

Khushi felt empty inside. How long had she been fighting this? Life seemed nothing but a continuous struggle to scavenge time. Every month she had come into this boardroom with steely resolve; Arnav was not going to be placed into hospice. She had fought, debated, cajoled, convinced and begged for the board to look into new avenues: clinical trials, experimental drugs, holistic treatment.


But now, after this morning, she felt her strength leaving her. It was time to surrender to the inevitable and move forward with as much dignity as possible. She had been Arnav's shield this long and she wasn't going to stop now. Taking a deep breath, she squared her shoulders and addressed the clinical co-ordinator in a fractured voice.

"Actually it's Dr. Riazada now."

The severe woman blanched momentarily and answered in haste. "Regardless, we are here to make a decision that is in the best interest of the patient." 

"I'm sure we can all agree that Khushi has Mr. Raizada's best interest at heart." Oliver interjected politely yet forcibly.

The woman grit her teeth. "Her interests, whatever they maybe, are clouding her judgement. The LVAD has been sustaining him thus far but the incident this morning cannot be ignored. Correlations between ventricular arryhthmia and morbidity in CHF patients are still unclear."

"My position as a wife has not miraculously made me an incompetent doctor." Khushi bit back. "I beg you to remember that I am one of the youngest fellows on this board and remind you to address me with due regard."

The board held it breath as the tense atmosphere turned hostile. To the world Khushi looked worn. Frayed at the edges. Unravelling at the seams. And honestly no one knew how much longer she could keep it together. There was only so much a person could take. Today the entire transplant team was present, putting forward their professional assessment of the patient: transplant surgeons, transplant physicians, surgical nurses, psychologists, social workers, financial advisors and the two transplant co-ordinators.

"I think what we all need is some perspective." Timothy, the procurement co-oridnator, tried to diffuse the situation. "We are here to assess and rank the deteriorating health of the patient. We have a patient who is in chronic heart failure with Mitral valve insufficiency and a history of Rheumatic heart disease. 12 months ago he was inserted with a ventricular assist device that markedly improved his worsening symptoms. Leaving aside the episode of sudden cardiac arrest this morning we predict that the LVAD will continue to support him in the short to medium term."

Dr. Parker added to the assessment. "The sooner we can advise UNOS the better it is. This morning's episode will put him in a better position if there is a viable heart. Ambulatory care is no longer a viable option."

Hannah, the clinical co-ordinator, snorted. "Why are we pussy footing around? Anyone?"

"I would ask you to remain professional Ms. Rodriguez and watch your language." Danes, the most senior member on team flexed his authority.

She waved her hands, exasperated. "Look all I am saying is we can pretend that this morning didn't happen till the cows come home but it doesn't change the facts. Sure, the LVAD is doing great and he could have another year or two on it. But he still is on immunosuppressants increasing his risk for infection compounded by the fact that he has a history of Rheumatic Fever. Not to mention LVAD patients are at a high risk of developing infection with a high rate of mortality. So he is three times as likely to develop an infection than any other cardiac patient."

Taking a breath, she sighed. "We don't even know the chance of a repeat episode of v.fib." Scoffing, she continued on sarcastically. "Since everything is so obviously going in this man's favour let's just assume it's skyrocketed."

Matt ground his teeth, frustrated by the lack of empathy on display. "You could say things worked in his favour. Dr. Raizada was with him at the time."

Hannah raised an eyebrow at the territorial show of support for his female colleague. "Sure. But what about next time? Honestly, at this stage, the guy should be dead."

Everyone stilled and reflexively turned to look at the wife of said man. Khushi, it seemed had finally reached her limit as she turned from the window and ran out the room, her vision blurring.


"How long do you think I'll be stuck here this time round?" Arnav whined flopping back onto the bed. 

Khushi rolled her eyes, her back turned to him. Unpacking his night bag, she reached up on her tiptoes to put his shirts on the top shelf and threw a hospital gown blindly in his direction. "The same amount of time you are usually stuck Arnav. Stop asking me galactically stupid questions."

Arnav, in typical fashion, had a quick quip as she wandered in the bathroom. "You know ever since you became a wife you've become so critical. I preferred the old Gupta. Women. You're all the same. You only show your true colours after marriage." Shouting out, he craned his neck, trying to see her response from the ajar door. 

Khushi laughed softly, organising his toiletries. Her heart did a flip. It was little moments like these that she lived for; the witty banter between them. Two years and seven months. That's how long they had been married. Looking at herself in the mirror she swore she looked like a newlywed. Flushed cheeks, a shy smile and wide bright eyes. All it took were few words, a sly glance...a brush of the fingertips. The man could wield her emotions at will.  

Biting down on her lip, to stop a bubble of laughter she yelled back. "You know ever since you became a husba..."

A loud crash drowned her out.

She froze. 

Stumbling over her own feet Khushi ran out to the room. Arnav lay crumpled on the floor, his limbs rigid as he convulsed. His skin was deathly pale almost tinged blue; a superficial laceration on his forehead dripping blood onto the white lino. Her gaze lingered on the toppeled over meal trolley, silver cutlery splayed out on the floor. He must have hit it on his way down. Years of training clicked into gear and she moved with seamless grace. Hitting the button behind the bed Khushi activated the code blue alarm. 

The speaker system echoed around in a dulcet female voice. 

Code Blue. Code Blue. All medical personnel please report to the fifth floor. Code Blue. Code Blue. All medical medical pers.....

By the time she dropped down next to him the seizures had ceased. Her fingers searched for his pulse. 


She screamed out into the hall. "SOMEBODY GET ME A CRASH CART

Delivering three large precordial thumps, she frantically palpated his neck. Finding no pulse she began to resuscitate him. Fingers interlocking with one another she put her entire weight behind the compressions. 

"Come one baby. Come on." Khushi murmured willing him to open his eyes and look at her. Looking down at her hands she noticed just how small they were on his broad chest. How could such small hands possibly revive this giant? Several surgical nurses and an intern ran into the room. She barked out a series of well practised commands. " Jeff get a central line in. Susie take over compressions. Dom page anaesthesia now, I'll try and intubate him in the meantime."

Susie paused, unsure. Khushi looked up as she gloved herself. "What!? What the hell are you waiting for an invitation?"

"We can handle this. Dr. Parker is on his way. You shouldn't be doing this."

Khushi continued the intubation unphased. "Susie, I am currently the most senior member in this room and if you try and get in my way I will gut you. Are we clear?"Shocked at the unusually harsh outburst from her colleague, Susie took a second to gather her wits and resume compressions. Trying to find a clear passageway, she heard several other people entering the room and preparing equipment. Khushi kept mumbling. "You're so cold. So cold."

Somewhere in the chaos Khushi registered Danes voice booming. "Let's get him on to the body board and up on the bed. Parker monitor his vitals. Can someone tell me WHY is he not hooked up to the ECG yet?"

The heart monitor came to life and started beeping incessantly. Parker yelled out. "His sats are dropping. We're at 95." Paper spilled over from the ECG machine and Matt ran the strip in his hands analysing the electrical waveforms. "He's in V.FIB"

Danes looked to find Khushi struggling to find a clear passageway, her hands shaking as she mumbled to herself. He cursed. Addressing the anaesthesia fellow he quietly asked..."Take over intubation from Dr. Raizada."

Emmanuel tried to pry the laryngoscope and tracheal tube from her hands. She pulled back violently. "I've GOT it!"

"Step back from the patient Dr.Raizada." Danes ordered.

"No." Khushi continued to try and put the tube down the trachea. "Damn it! It keeps getting stuck." she cursed.

"Dr. Raizada you are harming the patient's wellbeing. STEP BACK."

Khushi ignored him and continued to peer down the laryngoscope. Danes nodded to the two security guards at the door. With as much gentility as they could manage, they pulled her back from Arnav.  She looked up in shock. "What....what are you doing? LET ME GO! I said... LET ME GO!" They continued to drag her from the room as the doctors and nurses focussed on reviving the patient. Oliver tried not to look as his mentee screamed in desperation. "NOOOO! NO! LET ME IN!" Khushi banged against the glass. "I NEED TO BE THERE! LET ME IN!" She sobbed and wailed, begging to be let back in.

Her screams pierced the heart of everyone in the room. It was not easy witnessing her pain. Khushi pressed her face and hands against the glass windows of the room looking in from the hallway; her chest wracking from sobs she no longer noticed. Every statistic and paper she had ever read came back to her and she imagined the worst possible scenarios. The odds were not in their favour. 

"Sat's are stable." Parker called out. Emmanuel had managed to intubate him in seconds and stood compressing a large blue bag on the end of the tube. 

"How long since we began compressions?" Danes asked.

Susie looked at the wall clock. "Six minutes."

Danes watched the amplitude of the heart's waveform decrease with every passing minute. "Charge to 200J. Shock him."

Parker yelled out "CLEAR!" Pressing the button he delivered the electric charge to the heart. Khushi watched as Arnav's lifeless body raised a few cm from the bed and landed back down with a thud. She watched as her peers delivered cycle after cycle of CPR followed by electric shocks. She watched as the love of her life slipped away from her with every passing minute. Then without warning the small amplitude waves ceased all together. 

"We have asystole. He's in cardiac arrest!" Parker yelled out to Danes.

"Push another round of epi and atropine."

Suddenly it dawned on Khushi, as she stood pressed up against the glass, that Arnav was dead. From that moment Arnav was quite literally dead. He was gone. In a panicked frenzy she began to bang at the glass screaming. "WAKE UP! WAKE UP! YOU PROMISED ME CHILDREN YOU BASTARD. WAKE UP!"

Emmanuel pushed in the extra epinephrine. Everyone watched as Susie continued compressions. They could only wait now. 

Questions of science, science and progress
Do not speak as loud as my heart

Tell me you love me, come back and haunt me
Oh and I rush to the start
Running in circles, chasing our tails
Coming back as we are

Nobody said it was easy
Oh it's such a shame for us to part
Nobody said it was easy
No one ever said it would be so hard

Thirty seconds later Matt held his hands in his head. "We have normal sinus rhythm."

Author's Note.

Hey guys! As usual let me know what you think. I really appreciate your feedback. It's going to be heart wrenching from here on. There will be some happy moments. Only two more updates then the epilogue. I will tell you that NOBODY has actually guessed the ending. A couple of people have come really close. Only half right though. 

So hold on tight. 

I really would appreciate if you could take out two minutes to view this video. It was what inspired me to become a doctor and the scene form 22.42 to 26.00 minutes will show you what really happens in a situation like Arnav's. I tried to portray it the best I could.