Amanda’s blood pressure on the cardiac monitor had dropped to 96. We reflexively turned back to where we could see Amanda through the edge of the exam curtain. She sat bolt-upright, her breaths coming in shallow panicky gasps. No wonder the poor kid can’t lie down; that feeling of drowning was real.
Immediate Treatment
“Karen.” Dr. Benner’s voice was sharp and focused. Gone was the laid-back, you’ve got a stain on your tie repartee. He clicked out a series of orders. “Turn her O2 up to 6 L/minute. Switch her IV to normal saline, and let’s give this young lady a liter of normal saline wide open over the next 15 minutes. Start another wide-bore IV in the opposite arm. We don’t want to get caught without IV access if a line infiltrates. Get Maine Medical Center Emergency Department on the phone. Turn around the Buxton ambulance that left five minutes ago. It’s too late to call in the ultrasound tech to verify there’s a big effusion around the heart. We need a transfer, now.” He shot me an uncertain, questioning look. “How much Solu-Medrol was that?”
“A gram of Solu-Medrol,” I repeated.
“Make that a gram of Solu-Medrol. Send Tom up to the pharmacy. I know we don’t have that much down here. STAT. Let’s get that Solu-Medrol infused before the transfer …”
Additional Lab Results
The lab tech was hovering, unsure who to give the remaining lab results to. I took the sheet from her, and the results were a splash of red, critically abnormal numbers. Okay, concentrate.
Off to one side, I reviewed where we stood in Amanda’s work-up and treatment, aware that in another half hour, another team of physicians was going to evaluate Amanda, and I wanted to ensure we weren’t overlooking any critical data that required immediate attention. The diagnosis of systemic lupus erythematosus was firm, even without the immunologic lab, which would drift back over the next several days. She had the classic malar rash, oral ulcers, patchy alopecia, pericarditis and arthritis involving the knees and small joints of the hands.
Scanning the lab numbers, I noted she was in kidney failure. Poor kid.
I parted the curtain and, taking Amanda’s parents aside, reviewed the diagnosis of lupus with them, and why we needed to transfer her across town to Maine Medical Center. “Sometimes, the fluid around the heart has to be drained, and a larger hospital can give Amanda the specialty care she needs.”
