Chapter 13 Bradycardia

23:40. Heart rate 38.

The number was glowing green on the monitor above resus bay three when I came through the doors, and the name on the whiteboard beside it, in a triage nurse's quick black capitals, was CALLOWAY, E.

My pager had gone off on the sixth floor while I was writing up a post-op note. ED resus, 85M, brady 30s, known cardiac, your pt per Okafor. I'd taken the stairs. Six floors, two at a time, my stethoscope bouncing on my chest. Felix would have counted them. I knew the number anyway, because Pippa had announced it on my first day: ninety-two, counting the broken one.

The bay was crowded and too bright, and it smelled of alcohol wipes and wet coats. An emergency resident, a respiratory therapist, two nurses, a paramedic finishing his handover by the curtain. In the middle of it, on the gurney, under a white blanket, was Edmund.

He was gray. Not the gray of the ballroom floor, the gray of a heart that has stopped, but a duller color, waxy, the gray of a man who has been sinking slowly for days. His mouth hung open. His chest barely moved.

"Respiratory rate eight," the resident said, seeing my badge. "Sats eighty-eight on room air, ninety-four on the mask. Pressure ninety over fifty. Rate's been between thirty-five and forty since the ambulance picked him up. His nurse says he wouldn't wake for his ten o'clock meds."

"Who's his nurse?"

The resident pointed with his chin. Ursula Blythe was standing in the corner of the bay in her navy cardigan, her hands folded in front of her, her face composed.

I went to the head of the gurney.

"Edmund." I put my hand on his shoulder and squeezed, hard. "Edmund, it's Margot. Open your eyes."

Nothing. Then, slowly, the lids lifted. Halfway. Underneath, the eyes were swimming and unfocused. They drifted toward my voice, slid past it, and jerked back. Slid and jerked. A slow, coarse nystagmus, worse than Monday. Much worse.

I took out my penlight. His pupils were small, but they reacted, sluggishly, closing down when the light hit them and drifting open again when it moved away. I lifted his left arm off the blanket and let it go. It dropped and lay where it fell.

He made a sound: no word in it, none of the broken anger from the consult room, only a long slurred exhalation that went nowhere.

I knew what this was. I'd known since Monday. But I'd been at the ballroom too, and I'd learned the hard way what happens when everyone in the room knows what something is before anyone checks.

"Send a digoxin level," I said. "Now, please. Urgent. And a full panel, a gas, glucose, and a benzodiazepine screen."

The resident blinked. "Digoxin? He's on a tiny dose, it's in the—"

"I know what's in the chart. Send it anyway."

---

I hummed while we worked. I always do.

The respiratory therapist and I lifted his jaw and got a good seal with the bag and mask and breathed for him, slow, one breath every five seconds on top of his own feeble ones.

The gas came back with his carbon dioxide high and his oxygen low: a man who'd been breathing too shallowly for too long. As we pushed air into him, the number on the monitor began to climb. Forty. Forty-four. Forty-nine. His color came up a shade.

"Pacing pads on, please," I said. "Just in case. Atropine drawn up. Hold his metoprolol and his digoxin tonight."

The pads went on, cold on his chest. Nobody needed them. By midnight his rate was in the mid-fifties and holding.

The digoxin level came back at twelve-fifteen. Normal. Right in the middle of the therapeutic range, exactly where it ought to be.

I read the number twice. Then I made myself breathe out, and admitted to myself that I'd been afraid it would be high. That somebody had done it again.

Somebody hadn't. Not with digoxin.

"So what is it?" said the resident.

"Pull up his medication administration record for the last week, please. The one his home nurse keeps. Ms. Blythe, I think you brought it with you."

Ursula handed over a clipboard without a word.

I went down the columns with my finger. Lorazepam 1 mg, three times daily, scheduled. Every dose given and initialed. Below it, Lorazepam 0.5 mg PRN agitation. Monday, two doses. Tuesday, three. Wednesday, four. Thursday, four. Today, four, the last at six in the evening. Every one initialed U.B. in the same small, neat hand.

Four extra doses a day, on top of the scheduled ones, for an eighty-five-year-old man with a damaged brain. I didn't need the screen to come back. I could see it lying on the gurney in front of me.

"He's oversedated," I said. "He's had close to double his usual benzodiazepine load every day for a week. His breathing's dropped, his oxygen's dropped, and his heart's slowed down to cope."

"Flumazenil?" said the resident. It's the reversal drug. Every junior reaches for it.

"No." I said it gently. "Not in a man who's been on lorazepam every day for five years. Reverse it all at once and you'll throw him into withdrawal, and he'll seize on this gurney. We support his breathing until it wears off. And we stop the extra doses. All of them. Tonight."

I wrote it as I said it, standing at the computer in the corner. Discontinue all PRN lorazepam. No additional benzodiazepines. Continue baseline dose, then supervised inpatient taper, reduction schedule to follow. Seizure precautions. Continuous monitoring. Hold digoxin and metoprolol overnight, review in the morning.

Behind me, Ursula said, "No."

---

I turned around.

She hadn't moved from her corner. Her face was still composed, but her hands had come unfolded.

"With respect, Doctor," she said. "You don't know him. He gets violent without it. He pulls out his lines. He hits. Last year he broke an aide's glasses. Dr. Stroud has managed his agitation for five years, and Mrs. Calloway would never agree to—"

"Mrs. Calloway isn't his proxy."

"Dr. Stroud is his physician."

"Then let's ask him."

She already had her phone out. She'd already called. She held it out on speaker, and from it came the sound of a crowded restaurant, glasses, a burst of laughter, and then Gordon Stroud's voice, thick with irritation and possibly wine.

"Who is this? Ursula? What's going on?"

I told him. Clinically, in order, the way you present a patient on rounds: the rate, the breathing, the gas, the nystagmus, the drug chart. Four extra doses a day.

"Those doses are prescribed," Stroud said. "Within limits. For agitation."

"Then he's been agitated a great deal. Dr. Stroud, he's breathing eight times a minute."

"I forbid it." His voice went up. People at his table must have heard. "Do you hear me? I forbid any change to my patient's regimen. You've been in this country for two weeks. You have no relationship with this family, or rather you have exactly the wrong one. If you touch that drug chart I'll be on the phone to Winston Okafor before you've finished writing."

"Please do," I said. "I'm about to call him myself."

I turned to the resident. "We're admitting him. Cardiac step-down, sixth floor, under my name and Dr. Okafor's. St. Ansel cardiac service." I turned back to the phone. "Dr. Stroud, while he's an inpatient here his medications will be managed by this hospital. You're welcome to visit him."

"You can't do that without the family."

He was right. He knew he was right. That was the only reason he'd said it.

Edmund couldn't consent. Not tonight. To move his care from his own doctor to us, against that doctor's wishes, I needed his health-care proxy to sign.

I knew exactly who his proxy was.

I called Okafor from the nurses' station at twenty past midnight. He answered on the second ring, wide awake.

"Tell me," he said.

I told him. He listened without interrupting. When I'd finished, a clock ticked somewhere in his house, five, six, seven, before he spoke.

"Stroud will call me within the hour," he said. "I'll tell him the patient is under the cardiac service and that I've reviewed your plan and agree with it. Have I reviewed your plan, Dr. Fairley?"

"You have now."

"Good. Then I agree with it." Another pause. "You understand what it looks like. You, of all people, taking that man off his medication against his doctor's orders."

"I understand."

"So do I. Write everything down. Every dose, every time, every name." His voice softened by a degree. "And get the proxy's signature. Without it, I can't protect you."

"He's on his way."

"Ah," said Okafor, who had been in Bramport a long time. "Then good luck."

---

Rhys came through the doors of the emergency department at five to one in a black dinner jacket, his bow tie hanging undone around his neck, rain on his shoulders. He smelled of the cold and of someone else's cigar.

He'd been at some kind of dinner. A charity thing, at the harbor museum. He came straight to the bay without asking anyone where it was and stopped at the foot of the gurney and looked at his grandfather.

Edmund's eyes were closed. The mask hissed over his face. The monitor said fifty-six.

"Where's Delphine?" I said.

"At the opera. Her phone's off." His eyes stayed on the monitor. "Ursula called me."

Ursula, in her corner, said nothing.

I held out the clipboard with the transfer form on it. Consent to admission and transfer of care. He took it and read it, all of it, every line. He read the way other people pray.

While he read, Edmund's left hand moved on the blanket. It crept, an inch at a time, across the white cotton toward the edge of the gurney where I was standing, and the fingers found the hem of my scrub top and closed on it. Weakly. But they closed.

Rhys saw it. His eyes stopped moving down the page.

"Explain," he said.

I gave him four sentences. I'd practiced them on the stairs, between the fifth floor and the fourth.

"He's been given far too much of his sedative this week, and it's slowed his breathing and his heart. He's not in danger this minute because we're breathing for him, but he will be again if it carries on. I want to stop the extra doses and bring the rest down slowly, here, where we can watch him. His own doctor refuses, so I need you."

Rhys raised his eyes from the form, and this time they came to me and stayed.

"You," he said.

"Me."

"You want me to sign him over to you. My grandfather. After everything." His voice was very low and very level. "The last time anyone left him alone with you, he ended up on a ballroom floor."

Behind me, the monitor beeped on. Fifty-five. Fifty-six. The mask hissed. Ursula's shoes shifted on the floor.

I kept my voice at the level of the monitor.

"Tonight I've kept him breathing for an hour and a half. Sign or don't, Rhys. It's your name on the form. But look at the monitor while you think about it. He's breathing eight times a minute on his own while you decide."

He looked at the monitor. He looked at his grandfather's gray face under the mask, and at the thin chest rising and falling, so slowly, so far apart.

His thumb moved once against his bare finger.

He held out his hand. I put my pen in it.

He signed his name across the bottom of the form in one hard black line, the pen nearly going through the paper. Then he held the clipboard out to me, and when I took it, he didn't let go of it right away. His grip on the clipboard was the only part of him that looked unsure.

"If he dies," Rhys said, "it's on you."