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Eyes Wide
by Tamarak
"Eyes Wide"
House had just been walking by, pondering how to get out of clinic duty the rest of the afternoon. The ducklings had all gone running off to answer a big MVA, truck jackknifed on the interstate, massive pile-up, so he'd decided to loosen up his leg by walking around for a while. He was sure Cuddy'd be helping in the ER, too, so she wouldn't notice his absence from the clinic for at least another hour. So, there he was, walking his leg loose, away from his usual haunts, when a code alarm went off, in post-op, a few feet from him as he was passing. Hospital policy required medical personnel to respond, but he wanted to keep going. He hated codes. He didn't used to mind them; at one point, he'd even enjoyed the challenge. But now they took too much energy, put too much stress on his leg if he had to put aside the cane, too many people around bumping into him, too much touching people. He glanced in, just in time to see the nurse jump back and the patient lurch on the table beneath a doctor. Correction. Crap. Short coat. Med student. What the hell was a med student running a code for? The nurse seemed to be trying to say something, but the med student was having nothing of it.
He stepped into the room and looked at the patient. Going gray from pink, female, mid-forties looking, bruises on her face, left arm set, probably with a pin, surgical bandage on her abdomen, bruised chest exposed with two bright red burns from the paddles. No central line, but she had a BP/O2 sat probe on her right index finger. And her hands were bruised from some sort of fight. Obviously, she'd lost.
The med student yelled "clear." Yelled! He was panicked. No good yelling. No point in such a small room, anyway. He was almost as gray as the patient.
"Wait," House interrupted. The student stopped, turned around. He looked relieved to see someone else in the room. "You have more time than you think. You just called the code?"
Now House looked at the monitor. Tachycardia, BP high and rising. She was making pressure, so why'd the med student shock her? Her blood sat was low. Well, yeah, that breathing thing, after all.
The med student blithered, "Yes..."
"So, we've got plenty of time." Plenty if you measure in seconds. The key is to slow time down, observe, think, put things together. Figure out why the patient's body is doing what it's doing.
"A.B.C.," House said, as much for his own benefit as the student's. "Airway. Breathing. Circulation." No good starting the heart if the patient weren't breathing. And this one isn't. He moved to her head. No movement. Eyes wide open, pupils blown, fixed. Crap. Not good. She was losing color, getting grayer. House leaned his cane against the head of the bed. He felt time slowing down for him as he focused.
"She's still making pressure, but not for long." He looked at the nurse, young, but not panicked. She'd be steadier than the student. "Let's start an airway." The nurse had a kit ready, handed him the laryngoscope, put the stylet into the tube. She also jotted some notes on the front of her scrubs. Good, House thought, at least she knows her job.
"Just down from surgery? What's she on? What was the surgery for?"
The med student pulled himself together; history, he could do that, "Atropine... her BP was next to nothing, now it's through the roof. And Nimbex, 10 mg, IV, to sedate her before the Atropine."
"And Ringers, grav drip," the nurse added in.
House nodded; surgeons love Ringer's. He opened the patient's mouth. No movement, no resistance. Where was respiratory? Why hadn't the surgical resident answered the code yet?
He spoke to the patient, "I'm Dr. House. We're going to put a tube in your throat to help you breathe." It was training, old training which he rarely bothered with these days, communication, in case she wasn't under too deeply. If she was, just a few wasted words. If her dilated eyes meant anything significant, it was all a waste anyway.
The student continued, "Broken arm, set with a pin. And exploratory on the abdomen. She took a pretty good beating. Home invasion rape, from what the cops said."
House used one hand to pass the laryngoscope into the patient's mouth and leaned over so he could see the cords; with his other hand, he added a bit of cricoid pressure to move the trachea and close the esophagus. He slipped the tube in and down, gently, then pulled the stylet back out. The nurse handed him the bag; he inflated it slightly, then let it go. The CO2 indicator turned yellow. CO2. Good, he'd gotten the trachea. He moved the tube to the 22 cm marker, inflated the cuff, and held the patient's jaw there while he started bagging, trying to keep the rhythm steady, not push too much air in, nor too little. He could feel his own heart racing. A few seconds had passed, but time was running slowly for House now.
There'd been a series of home invasion rapes over the past couple months in the area, but House didn't remember hearing about any victims needing hospitalization for injuries. This one must have fought, and lost.
"Bradycardia? And now she's Tachy?"
The student looked confused.
"Analgesic?"
"Nimbex, I just said," the student answered.
"15 mg Morphine." House looked at the nurse, who nodded and responded quickly. "IV, fast." The pressure of standing on his leg suddenly nauseated him.
He kept bagging, one hand holding the patient's jaw. He looked down at her, hazel irises barely visible around dilated pupils. Probably the Atropine. He hoped so, because if not, bad news. Her eyes were fixed. No blinking, no movement. She was looking, but she wasn't looking at anything. He wished he hadn't left his office, hell, his bed that day. He felt sick.
The med student protested, "She's a junky, you can't give her Morphine." He pointed to a line of light colored scars on the inside of her right arm. Impressive, House thought. Observant student. At least he'd noticed. He hadn't caught it all, but he'd noticed. The scars were small, clean.
House nodded to the nurse, who was hesitating at the IV. "Give her the Morphine. What's her name?"
The med student hesitated, but the nurse spoke up, "Katherine Reynolds."
"Ms. Reynolds, this is Dr. House again. We're going to give you some different medicine for the pain." He kept his voice even. The patient was pinking up at least. He noticed the pain in his leg again and wished he could reach down for a Vicodin. He wished he could have some of the Morphine, actually. He glanced at the monitor long enough to see the blood sat was slightly better.
He watched the nurse start injecting the Morphine into the IV tube, spoke quietly near the patient's ear. "Ms. Reynolds, we're giving you the medicine now. It should help pretty fast." He wondered what she was thinking, something between terror and worse. His leg spiked pain. He kept bagging evenly, counting.
House glanced up at the student, who looked confused, asking "Patient left or right handed?"
He looked back at the patient's face again before speaking to the student, "It's winter, so no watch line. But look at the second finger on each hand. Where's the writing callous?"
The student looked at the patient's hands. "Right hand," he said, sounding half guessing.
Another nurse came in, brought the ventilator over. House straightened painfully as she connected the tubes, attaching them to the ventilator and releasing him from the burden of bagging. He picked up his cane again. He watched the first nurse push the Morphine slowly into the IV tube, and began to explain to the med student, "So, she's right handed, and has a series of nice, tiny, well-healed needle scars on her right arm. The problem is, it's really hard to inject yourself with your left hand if you're right handed. So, someone else did it. But no pitting from infections, so someone's been careful with those needles." He stopped for a beat, giving the student a chance to get it while he found his cane again.
"Nice vein, too. Same one, repeatedly. And they look like years of scars. Junkies don't get years of scars looking that neat. Feel the scar tissue on the vein." House watched the monitor; before, when he'd had his hand on the patient's throat, he'd felt her pulse, but now he depended on the monitor. The heart rate was going down, BP too. A minute in and the Morphine was doing its work. Blood sat was fine, now. The crisis was over. He looked at the EKG; the heart rate was still fast, but the QRS was normal, no damage visible that way. He backed away from the patient a bit, giving the nurses room to work.
The student felt the scar tissue, but still wasn't making a connection. He'd calmed down, though. He was starting to think, and he'd pinked up, now, too.
House gave the punch line. "Blood donor, probably. Use the same vein all the time, clean needles, no infection. Makes a line of scars like that. If so, means she's fairly clean on general health, too." A good story was like a joke; you built up, and then got the pay off. Not a great punch line here, but it would make sense of what the student was seeing. It didn't really have to be right, either; that's the beauty of a good story. It doesn't have to be the truth in any way; it just has to make enough sense of the situation. He didn't really care if the patient were a Morphine addict; he'd have given her Morphine even if he were sure of it. But he couldn't tell the student that.
Finally a resident showed up. The heart rate was fast, but not badly so, and the BP was dropping into normal range. The resident looked bored. House felt time moving back to normal speed. He gave his orders, "Get a central line started, and get radiology in here to check the tube and the line. When you get the line checked, start a Morphine drip at 100 mg an hour, then titrate. And start Mannitol until you can get neuro in here to do an assessment." More residents showed up, and another nurse. House moved further away from the patient, glad to be free of physical contact, and turned back to the med student. The residents took over the work, starting the line, doing the chart work. They had it under control now. "And treat the burns with a topical antibiotic."
Teaching time now. He looked at the student and nodded him away from the patient; they moved to the far end of the admittedly small room.
"So, what happened?" House moved his cane to his left arm, found his Vicodin bottle, and took two. Then he leaned on his cane with both hands to give his right side a needed break.
The student pulled himself together a bit to answer, "Well, we brought her down from the OR, and everything was fine; then the residents got called down for an MVA. She was fine. We were getting her settled, I had the nurse give her some more Nimbex, and then all of a sudden her BP started dropping like mad, and... I gave her Atropine. And," the student groaned and swore, "I shouldn't have shocked her. She was still making pressure. But I did, and then BOOM, she was tachycardic and her BP shot through the roof. Then you came in."
House nodded. "Ever noticed how the OR is cold as a witch's tit?" He loved a simile. This wasn't a great one, but it had a nice rhythm, and it was good enough. House felt himself relax again. He could teach even if he couldn't stand touching a patient or being touched. He liked language, liked figuring out how bodies work and putting it into language. If you could make up a good enough story out of the situation, the student would be able to picture what was happening. Of course, the real beauty was in the story most people couldn't make sense of, the elegance of the chemical reactions, the intricacy of how Morphine interacts with body chemistry, a-binding in the nervous system, hepatic metabolism, and then renal osmosis.
The med student looked slightly shocked, but said, "Yeah, cold."
"So," House began telling the story, not the one he really wanted to tell, the one about the beauty of chemical interactions, but the one that would help the student understand what had happened, "you take a patient in there, open her gut, look around, expose it to all that cold air, and as her temperature drops, all her blood vessels constrict. Natural reaction; keeps people alive in cold weather."
House glanced at the patient. She'd pinked up to normal color now, but still wasn't moving. Even across the room now, he could see her pinprick pupils showing that the Morphine was working.
House continued, "And then you bring her into a nice warm room, put her in a warm bed, and those same vessels start to dilate. At the same time, her blood's going to the sites of injury, her gut and arm. Remember, blood pressure's got three components, volume, pump, and squeeze. Volume's all the blood in there, pump's the heart, and squeeze is the relative constriction of the vessels. So, the vessels open up, less squeeze, more area for the volume of blood, and at the same time, the body sends blood to injured areas, so her BP drops. The heart tries to make more BP, so it pumps faster, and you see tachycardia. If you know it's coming, and you should," House warned, "you warm her up slowly and push some IV fluids. That makes more volume take up the space the vessels give you and the heart doesn't need to beat faster to make up the pressure."
The student said, "I know this. I just..." He shook his head.
"If you think in terms of seconds, you have a lot more time than you think you do when you call a code. Three minutes, that's 180 seconds. You can do a lot in that time. You want to make sure you do it right, and you do that by thinking about what's happening and why." House paused, and shifted back, starting a new chapter of the story, "Ok, so then you gave her the Nimbex. And Nimbex does?" House waited for the student to make the connection. He raised his eyebrows and watched the student, hoping for a sign he'd learned something in a semester of pharmacology.
Some people thought this was the Socratic Method. Bunch of crap, thought House. Socratic Method my ass. It's 20 questions. He knew the answer, the student knew he knew, and the student would try to think of the answer House wanted, not the real answer, necessarily, or the truth, but the answer House wanted. He liked telling stories better than pretending to play Socrates, but he ended up pretending to play Socrates sometimes just because most people were so much slower at putting two and two together than he was.
The student started uncertainly, "It's a sedative. So, oh, God, that would depress her breathing."
"No and yes. It will depress her breathing, or, in this case, pretty much stop it altogether." House paused for effect, and shifted weight away from his right leg. "But it's not a sedative. It's a paralytic. It has no pain killing, and no sedative effects at all. It just paralyzes you. You can't move, but you're awake under there."
The med student finally put things together, and turned pale. "So, she was awake."
"Yep," House moved back into story mode to explain, "You saw the drop in blood pressure, thought she was going bradycardic, gave her the Atropine. Meanwhile, she was waking up from whatever Anesthesia gave her for the surgery; she couldn't move, but she could feel the pain. First, there was the post-operative pain, not huge, perhaps, but plenty scary, especially if you can't move. So, you had a drop in blood pressure from vessels dilating, and the heart starts to beat faster to keep blood circulating. Add in the post-operative pain, the heart starts going faster. Add fear, and adrenaline, and the heart goes nuts, and blood pressure rises. Enough pain, and the heart begins to go so fast it will kill itself. And her."
The student interrupted, voice horrified, "And that's when I shocked her. 70 Joules on the biphasic machine... Oh, god, I can't imagine how that felt."
House could. He dropped his head, tired, "I wouldn't ask her." He took a deep breath. Nasty to think that being raped probably wasn't the worst part of her day. The only useful thing to do at this point was make sure the student learned something from what he'd done. Now that the student could tell the story, he'd understand the way the body worked a bit better. He wouldn't really need House to tell him more. But House wasn't ready to stop yet. He hesitated, glanced at the patient again. Everything moving back to normal, apparently. Foreman walked in, looked surprised to see him, and went to assess the patient.
"Don't be afraid to medicate for pain. Even were she a junkie, she's going to die faster from the pain than from the Morphine we're giving her. And we can wean a patient from Morphine when we have to. It's not fun, but we can do it a lot more easily than we can get someone a new heart."
The student nodded, now horror had fully replaced panic and he'd lost focus again. House needed to bring him back, help him process and learn from the experience. He started a new story, one that would help the student think ahead next time, "Now, we gave the patient Morphine, her heart rate and BP came down. What else do we need to think about?"
The student looked up at him and started to think out loud, processing. "Well, you got an airway, Morphine, she started to get some color. Fluids?"
"She's going to need some fluids. You want a resident to start a central line so you can get whatever you want in fast. But first you need to figure out where her ICP is, and keep it down. So start Mannitol and get a neuro consult. If she got beat up, she could have some bruising. If she does, and she's had a really high bp, you can get brain swelling. You don't know until you get a bolt in there or neuro clears her. Mannitol will dry her out a bit, help prevent swelling."
House edged left slightly to where he could watch Foreman work. The patient was moving a little now, responding to Foreman's orders, though hesitantly. Her eyes followed Foreman's hand as he moved it in front of her. House winced when Foreman squeezed her right pinky against a pen and asked her if it hurt. She tried to move her hand away, and she had tears in her eyes. Her mentation looked good so far, which meant the Atropine had dilated her pupils. That was something, at least. If things worked out, she'd recover, not too much the worse for her experience in here. And maybe the med student wouldn't be raked over the coals. House wouldn't mind raking the charge resident a bit, but he didn't much like surgeons anyway. Anyway, this particular student would never under medicate for pain. House found that satisfying. It might be a valuable mistake if it taught the student to take care of pain well.
The original nurse had written up the chart, and handed it to House for his signature on his orders. He signed, and handed the chart back to her with a nod of appreciation. It was all he could muster to acknowledge that she'd done a good job.
He turned back to the student. "Last thing. If you shock someone, check for burns, and treat them. You don't want an infection biting you in the butt." He turned and hobbled off, feeling as if he'd been beaten up himself. He'd have had a less miserable time in the clinic.
-* - * -
It had taken almost a week for the surgical attending to get in touch with him about the code. Not surprisingly, they'd agreed. The med student had potential, and would learn from the experience. It was a teaching hospital, and they'd done some teaching. The MVA was a pretty unique situation; the ER had needed all the help they could get from the residents. And the hospital code system had worked the way it was supposed to: a senior doctor had stepped in, run the code, and the patient was recovering. She'd be little the worse for wear. No need to write up a disciplinary report or involve the administration. House was glad not to have to write a useless report, and doubly glad not to have to waste his time with the disciplinary committee. It had been a remarkably quick, painless conversation.
-*-*-
House looked up at the sound of knocking on his door to see an orderly with a woman in a standard issue robe. He didn't recognize her, but he recognized the tightness around her eyes, a tautness of skin. He signaled the orderly to wait, and looked back down at the computer screen for a moment to save his GraveDigger fan fic. When he looked up, he saw the orderly pat the woman on the shoulder lightly, and walk away. The woman's reaction, not pained, but expecting pain, struck him. He picked up his cane from where he'd left it hooked on his desk and got up, limping to the door.
He opened the door and stood in it, leaning against the glass, making sure the woman in the wheel chair would need to move back, and making sure she wouldn't have room to start rolling into the room. She reached down, awkwardly, and rolled herself backwards a few inches. House raised his eyebrows and waited, watching her.
"Dr. House?" the woman asked, or not. It wasn't quite a question, and she was sitting in front of a door with his name painted across it. He waited.
"I'm Kate Reynolds," she began quietly. "You," she hesitated and started again. "There was," she stopped again, frowned, and started again. "You gave me some Morphine."
An interesting approach, thought House, remembering where he'd seen the woman before. No more bruises now, just that tightness around the eyes, fear, tension. Now he also noticed a stiffness in her posture as well. He waited, fidgeting with his index finger on his cane, feeling the texture of the lacquered wood.
The woman continued, "They're checking me out this afternoon. But, I wanted to ask you about the Morphine. There was pain..." She stopped again, and started. "I'm, I don't know, but the pain... I remember your name, and the Morphine."
She thinks I know, House thought. Because of the Morphine, because I made her pain stop for a time, she thinks I know. She wants me to tell her that she'll forget the pain, that nothing will ever hurt that much. She wants me to make sense of it for her. He felt his mouth work, wanting a Vicodin. He could enjoy the irony, but bitterly. I only know the pain, not any way to make sense of it. They all think I know things, just about anything. And I can't figure out the one thing I most want to make sense of.
The thing was, House considered, his pain, bad as it was, had never sent his heart into dangerous territory, never threatened to kill him. Hers had. She could probably tell him a thing or two about pain, if she knew, really knew, what the Morphine would have helped her forget about that day. And House knew that.
House looked at her, and shook his head, before responding slowly, "I don't think I can help you."
He stood in the doorway a moment, looking down at her, saw defeat in her posture. She frowned, nodded once, and started to back the wheelchair clumsily. She looked up at him again, unsatisfied, the skin on her face paler now, tighter. House turned, closed the door behind him, and limped to his desk without bothering to look back.
-*-*-
The local network affiliate interrupted Entertainment Tonight for the second time in two nights. House reached out in his leather chair to twist the blinds a bit tighter, to block the evening sun from his eyes. Even the sun seemed to hurt these days, too hot, too intense, putting him at odds with the three layers of clothes that made his public body armor. Now, alone at home, with no one around to touch him or bump him, he wore only his t-shirt and jeans.
Last night, the news had broken in to raise the alarm after a liquor store robbery had gone terribly wrong. He'd switched channels, choosing the Soap channel instead. He didn't have any illusions that he was going to stop a liquor store robber.
Tonight, though, the robbery was apparently in progress, with news cameras zooming in through the windows of the gas station convenience store to show the shadowed outline of a person apparently holding a gun on someone behind the candy racks. A darker shadow spread over the floor below. Something about the way the gunman held the gun struck House, a stiffness in the shadows.
The station cut to show a grainy security video from the liquor store the night before, with a voice over explaining the victim's injuries; shot in each knee, the groin, the gut, and finally the chest, he'd died on the scene. House tensed; that had to hurt. The video only showed the gunman, dressed in black pants, black leather jacket, then, for an instant, a woman's face, with taut skin drawn around the eyes. House frowned, trying to remember where he'd seen that face before. She moved stiffly, carefully. The video ended when the victim--the guy behind the counter, 20 something, white, well-muscled, in jeans and a t-shirt--and the woman moved out of camera view.
The station cut back to show the scene on the ground, a ring of police cars, lights flashing in the evening sun. The voiceover explained that the police had thought the shooting the night before was a robbery gone wrong, but investigators were now saying that the woman had been a regular customer at the store, and was known to the other employees. So she'd apparently been staking the scene out for months. The police were still uncertain about motive. They were trying to make a connection between the liquor store and the convenience store, but so far had no leads.
The camera shot cut back to zoom through the window again, just in time for House to watch the shadowed woman raise her gun to her head. The television blipped black for a moment, then on again, showing feet and legs on the ground, the rest of the body hidden behind the candy rack, and a dark flow spreading downward across the floor.
The next cut showed police rushing into the store; House found the remote and switched to the Soap channel. He reached for his coat jacket, found the Vicodin, and took two. The police would try to make sense of it, tell a story that fit what they found so that the public would understand what had driven this woman to kill two men and herself. House knew their story wouldn't really make sense of it at all.
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Legal Disclaimer: The authors published here make no claims on the ownership of Dr. Gregory House and the other fictional residents of Princeton-Plainsboro Teaching Hospital. Like the television show House (and quite possibly Dr. Wilson's pocket protector), they are the property of Fox Television, David Shore and undoubtedly other individuals of whom I am only peripherally aware. The fan fiction authors published here receive no monetary benefit from their work and intend no copyright infringement nor slight to the actual owners. We love the characters and we love the show, otherwise we wouldn't be here.
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