Terry’s Works, a self-serving website featuring Terry Riley’s creative works

Arrowpoint

Chapter 1 (draft)

Sammy

A rooster tail of red dust chased after Thomas Featherstone’s Chevy pickup as it tore across the desert floor. Thomas knew the capabilities of his truck and the limitations of the roadway. He had driven that rutted, gravel road from the time he was 14. He knew every turn, rise, drop and camber of the two-mile stretch from the Tanawaquee Pueblo to New Mexico State Highway 611. Nevertheless, at nearly twice the posted speed limit of 30 miles per hour, Thomas was barely able to avoid drifting into the ditches that bordered the corrugated roadway. 

Next to Thomas in the sweltering cab lay Sammy, his 8-year-old son. Sammy’s face was swollen and expressionless. His breathing was shallow. His arms were tightly wrapped around his head, and a weak moan accompanied each exhaled breath. Most frightening to Thomas was that he had no clue as to the reason for Sammy’s agony and even worse, no way of easing it. Thomas was scared, but resolute in getting Sammy to the Arrowpoint Medical Center as fast as he could.

Desiccated air whipping through the truck’s open windows did little to alleviate the oppressive heat of the mid-June afternoon. Perspiration gathered under Thomas’ chin then dripped on to his T-shirt. When he dared, Thomas released his iron-like grip on the shuddering steering wheel to stroke Sammy’s head, comforting his son… and himself. “Hold on son. We’re going to get you some help. You’re going to be okay. I promise. It’s going to be okay. Just hold on. Please, please, please just hold on.” 

Thomas continued to speak to Sammy nonstop, repeating short phrases of fatherly assurance over and over as he covered the distance to the state highway in two minutes. He glanced up and down the highway as he approached its intersection. Seeing no cars on the road for a half-mile in either direction, he blew through the stop sign at the junction. He cut the steering wheel sharply to the left, fishtailing onto the highway and accelerated toward the Regional Medical Center, nine miles away. At 85 miles per hour, Thomas was pushing both his truck and himself to their thresholds.

After four high-speed minutes, Thomas could see the Medical Center. He cut his speed to 50, still well over the posted speed limit. Another half-mile, a hard left turn, 300 feet up a slight incline, and Thomas came to an abrupt stop under a porte-cochere marked with a large sign of bright red letters: EMERGENCY. 

Thomas shifted the pick-up into “Park,” set the brake and killed the engine. He pried his sweat-soaked shirt from the truck’s seat back and slipped out from behind the wheel. He hurried around behind the truck to the passenger door. Sammy’s arms had fallen away from his head, and his limp limbs swung freely as Thomas collected him into his arms.

Holding him much like a rugby player would secure a ball, Thomas carried Sammy the short distance to the glass doors that were also marked ACUTE MEDICAL UNIT. Thomas used his elbow to mash the large, square, metal button labeled PRESS TO OPEN. The doors responded quickly and swung wide.

Brooklyn Tararro was the AMU Intake Nurse on-duty. She was alone behind the admissions desk in the reception area. Not uncharacteristic for a quite mid-week, mid-afternoon day, she was perusing a two-month-old copy of People magazine. When the exterior doors opened and she felt the air pressure in the room drop, Brooklyn was on her feet and on her way to greet Thomas even before the doors had fully extended. Seeing Sammy’s sagging body swaying in Thomas’ arms, she gestured toward the open doorway marked “AMU1” and instructed, “Take him into that room.” 

Thomas’s arms were trembling, but he was able to comply. He entered the examining room and laid Sammy onto a gurney as gently as he could. Sammy was pale, limp and unresponsive. Thomas was pale, limp and apprehensive. 

Brooklyn grabbed the phone on her desk, pressed the number 7 button twice and spoke calmly into the receiver to summon the AMU Physician/Nurse team on call that afternoon. “Dr. Nightridge and Nurse Royce to the AMU, STAT. Dr. Nightridge and Nurse Royce to the AMU, STAT.” (Because there were no standardized hospital codes in the U.S., Arrowpoint Regional Medical Center used plain-language announcements over its public address system.) Brooklyn placed the phone receiver back on its cradle, snatched up her stethoscope and within seconds had joined Thomas in the examining room.

Outweighing him by at least 40 pounds, Brooklyn was able to push Thomas out of her way to get better access to Sammy. “Give me some space here, Thomas,” she commanded. Thomas initially resisted Brooklyn’s intrusion, but then moved into a corner of the room where he slumped against the walls. Thomas looked like a slowly deflating tube-man, one of those rubbery advertising mannequins that could be found on the lots of used car dealerships. 

With Thomas out of the way, Brooklyn began her diagnostics. “Sammy, can you hear me?” She did not need to repeat the question because it was clear that the boy was comatose. Brooklyn plugged the tips of her stethoscope into her ears, raised Sammy’s T-shirt up to his armpits, and methodically slid the instrument’s diaphragm over his small chest. She paused the movement of the stethoscope from time to time as she listened to Sammy’s breathing and heartbeat. Processing what she heard, Brooklyn slipped a blood pressure cuff over Sammy’s right arm and checked his pressure and pulse. Using a ballpoint pen, she recorded Sammy’s BP and RH values on the back of her hand. 

Next, Brooklyn removed a small flashlight from the chest pocket of her smock, clicked it on with the thumb of her right hand and used the fingers of he her left hand to lift Sammy’s right eyelid. She examined the sclera then alternately directed the light beam into, then way from, Sammy’s pupil. She gauged the eye’s response then repeated the process on his left eye. Finally, Brooklyn removed a tympanic thermometer from its docking station on the wall and inserted it into the child’s right ear, waited to hear a beep, then noted Sammy’s body temperature and added it to the other numbers inked on her hand. 

With a cursory examination of Sammy complete, Brooklyn turned to the computer terminal mounted on a rolling cart and transferred the information from the back of her hand, plus a comment that Sammy had had a nosebleed, into the Medical Center’s database. In anticipation of the arrival of Dr. Nightridge, she attached a saline solution bag to an I.V. pole, moved it into a position near Sammy’s shoulder and stepped to the medical cabinet to gather together a few drugs that were her best guesses as to what Dr. Nightridge would likely request—sodium nitroprusside, Cleviprex, Nitropress. She set the drugs on the counter. 

With preparations in order, she took hold of Sammy’s hand and gently rubbed his arm. She turned to Thomas. “Okay. So what happened?”

“I don’t know. He just... ah....” Thomas was exhausted, mentally depleted, torpid.

“Thomas, tell me what happened to Sammy.” She was not asking.

“Like I said, I don’t know. He just came into the house and sort of collapsed.”

 “When did this happen?”

Thomas rubbed his forehead with his thumb and forefinger as though he was trying to summon up an answer. “I don’t know. Maybe half an hour ago. I got him into my truck and brought him here as fast as I could.”

“Okay, did you notice if he—” 

A loud whoosh accompanied Dr. Nightridge and Nurse Royce as they barged through the corridor doors into the AMU. The two were dressed in the bright yellow scrubs that announced them as the AMU day-shift team. Had the situation been different, one could smile at the pair’s vivid yellow appearance as they rushed into the examining room. Dr. Susan Nightridge was on the tall side, slender and willowy. Nurse Roland Royce III, at six feet, seven inches in height and weighing north of 325 pounds, was… well, imposing. Indeed, Rolls—that’s how everyone except his mother referred to him—may well have been the largest RN in North America. Side-by-side, the doctor and nurse reminded Brooklyn of the ON/OFF symbols—I/O—stenciled on the rocker switches of the printer next to her computer.

Still breathing heavily, Susan and Rolls moved next to the patient. Susan immediately recognized the boy. She knew the Featherstone family. Susan grew up within a block of the Featherstone’s home. And, like many in the community, the Featherstones had made occasional visits to the Medical Center. In the prior week, Sammy’s grandmother had shown up for her regularly scheduled, hypertension treatment assessment. And Sammy had recently been in the AMU for a few stitches to his forehead following a minor skateboarding accident. Presented before Susan at that moment, however, was no minor medical situation.

Susan and Rolls scanned the boy for any observable signs of trauma or disease. Between huffs, Susan asked Brooklyn, “What… do we have… here?” 

Susan and Rolls took turns washing their hands and slipping on latex gloves while Brooklyn reported Sammy’s vitals: “Blood pressure 182 over 133, heart rate 108, respiration elevated, temperature 99.2. Father says that the boy came into the house this morning and collapsed. That’s all we know.”

“Okay,” Susan began, “Let’s get his shirt and pants off. I want to check for any lacerations or broken skin.”

Rolls removed Sammy’s shoes and socks and pulled off his pants and underwear. He first smelled then saw indications of diarrhea. He cut away Sammy’s T-shirt, noting residue of vomit. Rolls mentioned these findings to Susan as he put the clothes in a plastic bag and placed it between Sammy’s legs.

Brooklyn grabbed the plastic bag in one hand and Thomas’s arm with the other. “Let’s give them some room here, Thomas. Come with me.”

Only a few months earlier, all the AMU nurses were rotated through Emergency Room Visitor Behavior Management training, an Indian Health Service sponsored workshop in Albuquerque. Over the three-day workshop the attendees learned how to manage the behaviors of those who accompany patients into hospital emergency departments. 

At the time Brooklyn was skeptical of a couple of shrinks flying in from Washington to tell the staff at the Medical Center how to manage peoples’ behaviors in their AMU. But now Brooklyn was about to put into action the number one and two techniques she had learned in that training. 

 [First: Remove the friend/family member from sight of the patient and from the activity surrounding his/her treatment.] Brooklyn led Thomas out of the examination room. [Second: Affirm the decisions and actions taken by the friend/family member to get the patient needed help.] “You did the right thing, Thomas, getting Sammy here as quickly as you did.

Brooklyn could feel the tension in Thomas’ arm begin to abate as she led him back into the waiting area and assisted him into a plastic visitor’s chair. She set Sammy’s bag of clothes on a chair next to him and asked, “Can I get you some water or a soda or some coffee?”

Thomas took a very deep breath. “No. I’m okay, thank you.”

“Okay, but let me know if I can get you anything.” Brooklyn walked the short distance to the reception desk where she retrieved the hand-held, patient-intake computer-tablet.

Returning to Thomas, she moved a chair to a position in front of him and took a seat, again recalling her training. [Position yourself in front of and close to the friend/family member at eye level. Maintain eye contact so that he/she will stay in the moment.] “Thomas, you did the right thing getting Sammy here as fast as you could,” Brooklyn reiterated. “He is in the best hands he can be. [Display confidence in your staff’s capabilities to address the patient’s issue.]Now to help out the doctor, we’re going to need as much information about Sammy as you can give us. For instance, when did you notice Sammy wasn’t feeling well?” [The use of “not feeling well” is more delicate than “feeling sick.”]

Thomas dropped his head. He gazed at the tiles on the floor. His eyes defocused. “Let me think. Okay. You know, last night he did seem quieter than usual. He is an active kid, but uh… last night he really seemed kind of—I don’t know—just quiet.”

“Okay.” Brooklyn made entries to the intake form on the computer tablet then asked, “Anything else you noticed about the way he was behaving that was unusual?” [Talking, and more importantly active listening, comforts the friend/family member. Moreover, the use of open-ended questions requires the friend/family member to concentrate on facts, allowing emotions to subside.]

Thomas blinked, as though to clear his mind. “No, not really.”

Brooklyn continued, “Did Sammy complain about how he was feeling or that he didn’t feel well?”

“No. Not until this morning.”

“What happened this morning that changed?” Brooklyn asked.

“He said that his stomach hurt really bad.”

“Is that when you decided to bring him in to the hospital?”

“I wish it was, but I waited.” Thomas paused, rubbing the palms of his hands against his eyes. “I was thinking that he’d just throw up and then be okay.”

“And did he vomit?”

“Yeah, but he still didn’t feel any better. In fact he started to cry, he hurt so bad. I should have….” Thomas turned away from Brooklyn and wiped his hands down his face.

“That’s when you decided to bring him in?” 

“Yes.”

Progressively following much of the advice from the Washington psychologists, Brooklyn dug deeper. “Did he complain about anything else? What else did you notice about Sammy than his stomachache and him vomiting? Like did he have a fever or muscle pain or anything you can think of?” 

As much as he could, Thomas tried to recall details of the prior hours, but he was unable to provide any additional information. “Sorry, that’s all I can think of.”

“No. That’s good. There probably wasn’t much else you could have noticed. And what you’ve told me here is very helpful and important. Wait here I’ll be right back.” 

Brooklyn stood and walked to the examining room where she delivered the additional information that she had collected. A few minutes late she returned to the seat in front of Thomas. “Okay Thomas, Dr. Nightridge has things under control.” [Frequent, positive updates reduce friend/family member stress.] Brooklyn said, “Let’s get some basic information about Sammy.” Brooklyn knew the Featherstone family, as she did most of the families on the Tanawaquee Pueblo. She could probably have completed ninety percent of the requisite information on her own. Nevertheless, reading from the screen of her tablet, Brooklyn asked, “Sammy is his first name?”

“Yes, well Samuel.”

“Okay Samuel. Middle name?”

    “Westley.”

“Featherstone.” Brooklyn completed line one of the form. “Date of Birth?”

 “Oh, um… I just can’t remember right now. I mean I know it, but it’s just not coming to me.” Thomas’s ordeal was taking its toll on his recall.

“That’s okay. I can get it from his records here,” Brooklyn said. “And where was he born?”

“Here in Arrowpoint. Well we were living on tribal land, but he was born in this hospital.”

And so the conversation proceeded, businesslike, allowing Thomas to focus on facts, moving him away from his emotions. Gradually his respiration steadied, his heart rate slowed, his vision expanded. He was slowly regaining his composure.

Brooklyn was pleased that Thomas was beginning to calm. She returned her chair to its prior location in the reception area—an indication to Thomas that whatever crisis he may have thought Sammy was facing, it was now under control—and returned to her desk. Although the situation with Sammy was grave, a hint of a smile appeared on Brooklyn’ face as she congratulated herself on successfully employing the lessons of Emergency Room Visitor Behavior Management.

- - -

Away from the reception area, Sammy’s condition was less encouraging. He was in and out of consciousness. One moment he was still, the next moment he would stiffen his whole body for an instant. Then he would appear relaxed, except for mild twitching in his legs. From time to time he would emit a high-pitched screech that momentarily halted Susan’s and Rolls’ tasks. Despite these occasional disruptions, stabilizing measures and diagnostic work on Sammy continued at a brisk but controlled pace. 

Because Sammy was likely dehydrated as a result of vomiting and diarrhea, Rolls, with a nod from Susan, prepared and introduced a saline drip. With that done, Rolls retrieved a blood draw kit from the medical cabinet. 

Meanwhile Susan methodically inspected the anterior portions of Sammy’s head and neck, then his chest, arms, hands, legs and finally his feet. She was looking for evidence of snake, rodent or insect bites. Finding no signs of punctures, Susan said, “Let’s turn him over.”

Being in tune with Susan’s practices, Rolls had moved into position, gently placing his hands under the boy’s thigh and back. “I’m ready.” If it weren’t for being dressed in nurses’ scrubs’ Rolls might have easily been mistaken for an NFL linebacker. He could have easily flipped the 55-pound patient with one hand, but his outsized presences always took a backseat to his gentleness. 

Susan put her hands under Sammy’s shoulders and head and gave the command, “Three, two, one, go!”

The two gently rolled Sammy onto his stomach. Susan continued her inspection, looking for indications of bites or punctures. She found none. “Okay, let’s roll him back,” she instructed.

Sammy began to writhe as the two turned him onto his back again. His screams became louder and even higher-pitched.

Rolls set about inserting a syringe into the small patient’s left forearm to draw a blood sample. At the same time, Susan bent down and placed her face close Sammy’s mouth. Rolls, unfamiliar with this examination practice, asked, “What are you looking for?”

“I’m seeing if I get an odor of bitter almonds.”

“Almonds?”

“Yeah. It’s an indication of cyanide poisoning,” Susan explained.

“Cyanide poisoning. I thought that—”

Susan held up a finger indicting that she needed a moment to sniff for the odor. She took three deep breaths near Sammy’s mouth, then closed her eyes to concentrate on the feedback from her olfactory receptors. Perceiving only a faint odor of bile, she stood and announced, “Good. I got nothing.”

“That’s good,” Rolls confirmed as he flicked the vial drawing blood from Sammy’s arm with his substantial finger. “Doc, I thought that cyanide poisoning was a thing of the past. I knew that cyanide had been used in the old mines around here to process gold and silver, but I thought that those mines have been abandoned for probably a hundred years.”

“Yes they have, but like you said, they’ve been abandoned, not closed, not sealed off, not really safeguarded, so we still get occasional cases.”

“Dr. Nightridge, every day I’m learning more about all the kinds of things we have to look for here.”

Susan asked, with rhetorical suggestion, “That’s a good thing, right?” and moved to the computer terminal to enter her findings into the patient’s chart. 

“You bet. A very good thing.” Rolls finished collecting the blood sample, marked the syringe and began completing the form for laboratory analyses.

Susan gently lifted Sammy’s left hand, turning it so she could inspect his fingernails. Then she did the same thing on his other hand, inviting Rolls to watch. “See here on his fingernails? The white lines?”

Rolls leaned over next to Susan, his bulk excluding any space between them. “Yeah.” Rolls took every opportunity to learn.

“Those could be caused by any number of things. It’s called leukonychia striata. Most likely a result of some kind of trauma to the fingers, often from accidents, not unusual for a kid. But they could also indicate heavy metal poisoning, like from lead.”

“I think I know where you’re going with this, Doc. Maybe the paint from some of those old buildings on the pueblo.”

“You got it. So let’s add testing for lead to that blood analysis, Rolls.”

Rolls returned to the small medical counter where he added the instruction to the blood analysis request form.

“In fact, you know what, Rolls? Have the lab test for arsenic too.”

Rolls raised one eyebrow. (He could do that.) “Okay, Dr. Nightridge. Lead, I get. And now I understand about cyanide too. But arsenic? This is turning out to be a real education for me here.”

“Well,” Susan began, “maybe it’s because I took that continuing education course on poisons last year in Tucson. That’s where I got updated on cyanide poisoning. I learned that groundwater arsenic levels in Arizona are some of the highest in the nation. The presenters spent probably too much time on the topic for most of the attendees, but for me, it really rang a bell because we draw water from some of the same aquifers that run under Arizona.”

“So it could be Cyanide?”

“I don’t know. It could be a lot of things, but right now, it’s about eliminating as many causes as possible.” Susan’s attention turned back to Sammy’s vital indicators. “Now let’s get Sammy some relief from his pain, and get his heart rate down… and do something about that blood pressure.” 

Susan instructed Rolls to sedate Sammy by introducing Pentobarbital into his IV drip. At the same time, she began a diluted infusion of Nitropress to bring down his blood pressure. 

- - -

Thomas’s sympathetic nervous system was returning to a state of normal activity; his anxiety was easing. He took his mobile phone from his pocket and said to Brooklyn, “I have to call Marilyn.”

“Okay,” Brooklyn stood and walked toward Thomas, “but why don’t you let me speak with her first to tell her the situation, then you can talk to her.” Knowing Thomas’ wife, Brooklyn suspected that a whole lot of behavior management techniques would be called upon when Marilyn got on the phone.

“Okay.” 

“Where is she?” asked Brooklyn.

“At work. At Montoya Insurance.”

“Okay, dial her number, then I’ll talk to her.”

Thomas punched a couple of spots on his phone then automatically lifted the phone to his ear. But before he was connected, Brooklyn took the phone from his hand. Thomas did not object.

Marilyn answered, “Montoya Insurance, Marilyn speaking. How may I help you?”

Brooklyn closed her eyes, summoning up the chapter “On the Phone” from the Emergency Room Visitor Behavior Management guide. “Marilyn, this is Brooklyn Tararro. I’m the on-duty nurse here at Arrowpoint Regional Medical Center. I’m here with Thomas. He just brought Sammy into the Medical Center. Apparently Sammy got into something. We don’t know what quite yet, but we want to let you know that he is with Dr. Nightridge and being attended to. Thomas is sitting here in the waiting area right next to me and would like to talk to you.” 

Without waiting for a response, Brooklyn held the phone on her lap and looked directly into Thomas’s eyes. She addressed Thomas with a voice that communicated that he was being given an instruction, not a suggestion, “Take a deep breath.” 

Thomas complied, then cleared his throat. Brooklyn handed the phone back to him. Thomas was calm. He spoke to Marilyn, reassuring her that everything that could be done to help Sammy was being done. They talked about Sammy for a few moments then their conversation turned to logistical family matters: Who will look after Sammy’s seven-year-old sister, Cimarron, when the school bus drops her off in the afternoon? Will Thomas be staying at the Medical Center overnight? Will Thomas’s boss understand that he had a family emergency? How will they explain Sammy’s situation to Thomas’s mother? Should they cancel their trip to visit Marilyn’s sister in Denver? A few other issues were raised and either resolved or put aside for resolution later. 

After about ten minutes, Brooklyn indicated to Thomas that it was time for him to terminate the call. He said goodbye, then looked up at Brooklyn and said, “Marilyn’s decided to go home and take care of Cimarron.”

Relieved, Brooklyn exhaled deeply. Her shoulders lowered, and much of the tension in her neck dissipated. She had not realized how, over the past 20 minutes, the muscles in her body had become taut. Looking down at Thomas, she said, “Thomas there is nothing more you can do here. I’m pretty sure that we will be keeping Sammy here overnight, and you cannot stay. Go home to be with Marilyn and Cimarron and your mother.”

Thomas’s eyes aimlessly searched the linoleum floor of the waiting room. “Yeah.”

Brooklyn ushered Thomas to the door. She knew that he or Marilyn or most likely the both them would return first thing in the morning. As she watched Thomas drive away, Brooklyn again exhaled deeply, then returned to her desk to complete Sammy’s intake information.

- - -

Though still elevated, Sammy’s blood pressure and heart rate had steadied. For longer than a few minutes, he rested quietly in the examining room. Susan considered transferring Sammy to the University hospital in Albuquerque, but after consulting with physicians there, she decided that as long as Sammy was stable, it would best for everyone to keep him at the Medical Center. 

Susan stopped moving for the first time since she was called to report to the AMU. Sammy’s condition was stable, but that could change at any time. Gazing down at the young boy, Susan amalgamated Sammy’s symptoms. And as much as she wanted it to be otherwise, it was becoming apparent: Sammy was suffering a hypertensive emergency. 

- - -

By early evening, Susan, with Rolls’ and Brooklyn’s assistance, moved Sammy to the intensive care section of the AMU. Once he was situated, Susan instructed the AMU staff that if there were any change—any change—in Sammy’s condition, good or bad, to call her immediately. She also left a similar, strongly worded message for the two nurses who would cover the night shift. The staff was well aware that instructions from Dr. Nightridge were not to be unheeded. Susan had a reputation among the staff as a straightforward, no-nonsense, professional, and she expected no less than very high competence from those she oversaw.

Susan returned to her office, and as was not her habit, she ignored her emails, deferred listening to her voice mails, and avoided her text messages. Also unlike her routine, she did not check the daily patient admissions or peruse the daily patient discharges and deaths. She did not scan the recent AMU log or the daily lab tests. And although Tuesdays were the days she generally reviewed the Medical Center’s weekly financial statements, she left those on her desk, untouched. Susan didn’t do any of tasks she would normally do. 

But this day was not normal. Far from it. On a normal day there would not be a child laying in the Medical Center’s AMU and who may not survive through the night. 

- - -

Susan retrieved her keys and handbag then left the Medical Center for the 200-meter walk across the parking lot to the Willow Glen Apartments.