Friday, February 8, 2013

Insurance

(list of medical terminology specific to this chapter is included below)

     Acutely aware of her growing impatience, Sarah pushed 40 milligrams of intravenous succinylcholine, observing as Minerva, now deeply anesthetized, defasciculated into flaccid paralysis. After positioning a rubber bite block between Minerva's pristine incisors, Sarah cupped her left hand gently around the plastic face mask covering her patient's mouth and nose, her right hand rapidly and rhythmically squeezing a distended green breathing bag that delivered oxygen from the anesthesia machine through a corrugated circuit, hyperventilating Minerva's lungs to optimize her seizure threshold before the "shock." Another day in ECT paradise. Glancing at her end-tidal CO2 waveform, Sarah alerted the busily chattering psychiatric team, "We're ready to treat." The procedure nurse applied a round probe loaded with conductive gel to the crown of Minerva's head, and Sarah manually occluded her jaw as the amperage began to flow. "Hmm, 100 milliCoulombs and we're still sub-threshold," Dr. Stevens, the chief of psychiatry, remarked with disappointment upon seeing no motor or EEG evidence of a seizure. "I'll kick it up another notch. You ready, Dr. Livingston?" "Yes, ready. We need to work quickly, though," replied Sarah, having already resumed aggressive hyperventilation. "The Brevital's gonna wear off soon." Let's speed things up here, guys, we've still got fifteen cases to go!

     The morning had started off like cold molasses, a slow-motion rodeo of the demented and down-trodden, each case sadder than the last. Sarah didn't get too involved with these patients, but Minerva's situation had impressed her because they were exactly the same age. So were their sons. She'd caught a glimpse of Tyler on Peter's iPhone as she was scribbling down Minerva's pre-op assessment. "What a cutie!" she'd responded automatically, trying to sound enthusiastic. Her throat tightened with regret as bittersweet thoughts of her own son flooded her consciousness. Fighting back the same tears she'd already cried too many times, Sarah returned to her paperwork. I've gotta keep myself together in that courtroom today. 

     In less than an hour, she'd be attending the final custody hearing in her long, drawn out divorce. Two years ago, her husband, Carter, blind-sided her with the news that he'd filed for divorce as well as sole physical custody of their son, Dylan. It literally came out of nowhere, hitting her like a ton of bricks. Carter had lost his job in pharmaceutical sales when the economy collapsed, so he played house-husband while she went back to working full-time with her old anesthesia group, taking extra call to cover their expenses. Dylan was only three then. Transitioning from being a stay-at-home mom to working 60 hours a week was tough on all of them, especially Dylan--he'd always been such a mama's boy. She recalled a recent conversation she'd had with her girlfriend, Viv, an ENT surgeon/divorcée. "Medicine is insidious--it'll suck the life right out of ya," Viv philosophized. "Under the guise of altruism, that deeply ingrained sense of responsibility we learned as medical students holds us hostage somewhere between our unachievable ideals and incomparable standard of living." This immediately called to mind the two million dollar life insurance policy that had been mandated in the terms of Sarah's divorce. "Ain't that the truth?" Sarah quipped. "I just mailed off a $2500 insurance premium check. Hell, I'm worth more dead than alive!" Rolling her eyes while slicing her throat with her index finger, she'd added, "If only it weren't for that two year exclusion on suicide." Hearing herself say this made Sarah flinch; it sounded so cynical. Although she and Viv shared a commiserating "been there, done that" laugh, the truth was that Sarah had seriously contemplated ending her life. But, that was normal under circumstances like hers, right? Surely she was just disillusioned, having forgotten what it was like to hold Play-Doh, instead of life, in her hands.

     Long story short, Carter was going to get Dylan, their mountain cottage, and half of her 401K, as well as a small fortune in child support and alimony. This was the thanks she got for supporting him all those years. Once Dylan started school, Carter had nothing but time on his hands, time to devise an airtight defense which portrayed her as cold and chronically unavailable, "an absentee mother and unfaithful wife, who is married to her work," according to the original complaint. She never would have asked Carter for a divorce. Sure, neither of them was happy, but wasn't that just marriage-with-kids in general? Doesn't everyone's sex drive suffer when life becomes a monotonous routine? Mediation had failed, and because of the custody dispute, the case went before a judge. During the divorce proceedings, she was dumb-founded at the judge's obvious sympathy for Carter, but her attorney insisted there was no recourse. "It's the luck of the draw, Sarah," he'd told her defeatedly upon learning Judge Dixon was appointed to their case. "I wish judges could be hand-picked because you've gotten stuck with a real lemon." To make matters worse, Carter was starting a job on the West coast next month, and Dylan could hardly wait. "Daddy's gonna teach me how to surf and ski, Mommy!" He wasn't quite grasping the distance that would soon be separating them. Sarah chastised herself for feeling irritated by the unfiltered ignorance contained within Dylan's childish innocence, and for wishing that he loved her the most.

     After depositing Minerva in the recovery room, Sarah gave report and washed her hands. "It's normal for this lady to wake up crying," she'd informed the nurse. "Try not to give her any Ativan if you can help it." Sarah didn't need any complications today. One of her partners was coming to relieve her in just a few minutes so she could appear in court, and she was trying to lighten his load as much as possible, insuring future favors she eventually hoped to return. Upon exiting the ECT lab, she noticed it was raining again. Having forgotten a raincoat or umbrella, Sarah dashed out to her car, shielding her hair from the rain with her purse. Even though she felt herself becoming increasingly more unglued, she was determined to at least look composed. Fuck 'em. In six years, Dylan can make up his own mind about which one of us he'd rather live with.

     It was 10:15 when Sarah pulled out of the parking lot, giving her ample time to deal with any weather-induced traffic she might encounter. Court didn't start until 11:00, so she'd be able to grab a coffee to go. There was a coffee shop along the way, in the strip mall just past the public elementary school. This route had become a regular detour for her on court days, and despite the fact that Dylan attended private school across town, she still imagined him among the kids she saw, playing kickball or waiting for their buses to arrive. Lost in pleasant thoughts of the days when she heard "Mommy" a thousand times, when all of Dylan's hurts could be healed by her kisses, she barely noticed her phone ringing. Fumbling for her phone, she was simultaneously distracted by the sight of a young boy, scaling the outstretched limb of a massive tree 50 yards in front of her. For a split second, she watched in horror as the child lost his balance, attempting to recover what appeared to be a lunch box dangling from a branch just beyond his reach. Veering spontaneously off the rain-slicked street to avoid possible collision with the faltering child, she barreled into a huge oak tree. Startled to find herself now hovering above the tree tops, she observed as the boy righted himself, grasping his lunchbox and the gnarled limb resolutely with both hands, hanging on for dear life twelve feet off the ground. Vaguely bothered by the fact that he didn't seem to hear her, she kept screaming at him. "Hold on tight, baby! Don't let go!" Below her, amidst the gathering crowd and the flurry of emergency vehicles screeching onto the scene, a lifeless woman slumped over the steering wheel of a crumpled sedan that was wrapped inextricably around an oak tree, the pre-existing condition under which she'd desperately stashed syringes and several vials of propofol and rocuronium inside her glove box no longer an obstacle to her insurance.

Part I: The Appointment
Part II: Amplitude
Part III: Redemption


Terminology
ECT: electroconvulsive therapy (shock therapy), used to treat severe refractory depression
Flaccid: lacking in tone; limp
Succhinylcholine: a short-acting, depolarizing paralytic agent which paralyzes skeletal muscle.
Defasciculation: the prevention of muscle twitches
Hyperventilation: rapid breathing that lowers the blood's CO2 level as well as seizure threshold
End-tidal CO2: expired CO2, a measurement of ventilation
milliCoulombs: a unit of electric charge in amps/second
EEG: electroencephalogram. A wavelike recording of the brain's electrical activity
Brevital: methohexital, a short acting barbiturate used to induce general anesthesia
Ativan: a benzodiazepine, like Valium or Xanax, used to produce sedation and treat anxiety
Propofol: an IV anesthetic, used to induce deep sedation and general anesthesia (aka "the Michael Jackson drug")
Rocuronium: a rapid onset, non-depolarizing paralytic agent, used to paralyze skeletal muscles during general anesthesia.






18 comments:

  1. A true picture of like Kris and how even tho we are living it those around us are living theirs as well. There are always distractions around which reminds us all all fragile the lives around us really are. More often than not, being dead is worth more than being alive, strange that we consider that an option. Fantastic conclusion. Cannot wait until we get the next story!

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    1. Thanks, Steven! In researching this story, I learned that many life insurance policies contain a two-year exclusion on suicide...what a strange concept life insurance is in the first place! Being worth more dead than alive is a pretty common joke among doctors, especially those who are going through a divorce or being sued.

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  2. Well written, Kris. However, I find the lack of paragraph separation a but hard on the eyes.

    Death and the immediate after life have fascinated me for ages. I loved the final scenes.

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    1. I think I fixed the paragraphs, Robert. Thanks for your comment. Re: death and immediate afterlife, I'm also quite fascinated with it .

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  3. A fascinating read Kris, that I can relate to on several levels. A close schoolmate of mine became an anesthesiologist and ending up taking his own life over a failed romance. Also I have read extensively on near death and beyond experiences. After all, our knowledge of the imponderable lies in this evidence. It makes the task of the skeptics so much harder the further we go.

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    1. Neil, that is so sad to hear about. Unfortunately, it's not an uncommon story because the access to powerful hypnotics and opioids is right there. Like you, I am also fascinated by NDEs; in fact, one of my old colleagues "died" at work, was resuscitated, and told me of his NDE. I intend to write about it at some point. He's not a religious person, and for some reason, that made his story seem even more credible. I don't think it's an impossibility that there are different planes of consciousness, and the things I've witnessed in trauma cases reinforce that.

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  4. Once again, Kris, I love that combination of the emotion of everyday life experience with the seemingly cold and clinical language of science. It makes Sarah's problems and eventual fate all the more chilling and detached at the same time. Sarah is at one and the same time a specimen seen from the outside and a living, breathing, hurting human being.

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    1. Thanks, NP. What I loved about this story is the irony that Sarah, the "sickest" of them all, was helping treat Minerva's refractory depression with ECT. In my medical training, I learned that doctors don't get to be sick. In fact, I've never called in sick to work. Especially in residency, denying our human needs is an unspoken expectation. Crazy!

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  5. What a conclusion, Kris, well done! Reading your description of the ECT procedure gave me chills because my late mother had ECT three times in her life, and I remembered how she’d talk about it. All the rich details and medical terminology you included added to the authenticity. I think the addition of Sarah really enriched the storyline. The way the lives of Sarah and Tyler came together was dramatic and fateful, what an interesting twist! I re-read the last paragraph twice, it was that engrossing. The way you described the scene with Sarah’s spirit hovering, calling out to Tyler, looking down on her lifeless body in the sedan was captivating, so well written. I’ve often pondered the question of what happens at the moment of death. Does one’s spirit hover briefly before moving on, or is there nothingness? I've really enjoyed your story and hope you keep writing! :)

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    1. I'm so glad you enjoyed it, Madilyn. I had such fun writing this story. ECT has come a long way, and is much more kinder and gentler than in days gone by. My mom was a psychiatric nurse during the 50s, and she told me some real horror stories about having to restrain unanesthetized patients during the procedure. Sounds so barbaric. I'm learning that quite a few of us share an interest in what happens at the moment of death. No one really knows, so who's to say?

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  6. Hullo Kris,
    Just went back through the complete story, & you have come around to a great finish.

    Probably 2-comments-
    1/ Agree with Robert re: size of paragraphs. Smaller paragraphs make for easier reading I think. (Although some probably believe they disrupts continuity.) Just a thought.
    2/ I have trouble with the longer medical terms - even with your definitions @ the end). Not sure what you do there, as they may give extra legitimacy.
    Anyway,
    great job...I too have a fascination with that stuff.
    Cheers,
    ic


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    1. Thanks so much for your feedback, Ian! I don't know that there's a way to get around the medical terms; as you said, I think they contribute to the story's authenticity. I will have to experiment with breaking up paragraphs and making them more "feng shui." :-)

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  7. Wow! What a read. Too bad it ended so unhappily. I wanted a Hollywood ending! But reality can be brutal, as you've illustrated so eloquently. Excellent story, my dear.

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  8. Excellent story, Helen. Have you considered the possibility of publishing in the future? If not, you really should! Also, thanks for the vocabulary key, it is very helpful for us non medical types :-)

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  9. Awesome! And your descriptions are always so vivid. "Slow motion rodeo" ...I can see it unfolding right in front of me. Wonderful, wonderful job.

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  10. Very intriguing story! I was hoping for a fairy tail ending, but this ending made me have visions of what might transpire if there was ever a sequel. It would keep me coming back for more. Great job!

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  11. Interesting story. Like watching a movie but better.

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  12. I arrived late. I didn't realize you wrote fiction. Just wanted to say howdy, and I am going to the beginning of the story now.

    Take care, and keep writing. You are great!

    Darin

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