Anaphylaxis Read online

  Anaphylaxis

  Medicine and Magic Book 5

  SA Magnusson

  Copyright © 2018 by SA Magnusson

  Cover art by Rebecca Frank

  All rights reserved.

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  Contents

  Chapter 1

  Chapter 2

  Chapter 3

  Chapter 4

  Chapter 5

  Chapter 6

  Chapter 7

  Chapter 8

  Chapter 9

  Chapter 10

  Chapter 11

  Chapter 12

  Chapter 13

  Chapter 14

  Chapter 15

  Chapter 16

  Chapter 17

  Chapter 18

  Chapter 19

  Chapter 20

  Author’s Note

  Also by SA Magnusson

  1

  As I stared at the computer monitor, my mind taking in the slew of orders the intern had entered, I debated whether I should cancel them or let the intern take the blame for over evaluating the patient. It was a complete evaluation, and probably the same thing I would’ve done two years ago, but now that I was in my third year of residency, I had learned to be a little more discerning in the nature of my evaluations.

  “What is it, Kate?”

  I glanced up as my friend Jen came down the hall toward me. She had her hair pulled back in a ponytail and her white coat buttoned all the way up, covering her scrubs. A stethoscope dangled around her neck like jewelry.

  “Syncope.”

  Jen chuckled. “That’s easy enough to evaluate. Why is it that you look like you want to throw something?”

  “Is that what I look like?”

  “You’re staring at the screen as if you want to throw something. Maybe the computer. Hell, I wouldn’t blame you. This morning, I couldn’t get my orders to go through the way I needed. I kept getting those stupid stop signs that forced me to open up different sections of them and—”

  “Dr. Michaels?”

  I glanced over at the door to Room 7. Dr. Stefan, a dark-haired man with thick glasses, poked his head out, glancing from me to Jen. I could tell he was debating which of us he would go to with his question. It was early enough in the year that he hadn’t decided which of us he favored. And it was early enough that he didn’t want to risk irritating either of us.

  I smiled to myself, considering excusing myself and letting Jen take over, but she caught my attention and shook her head. “I’m working in Room Three. I’ve got a fourth-year gunner who thinks that he knows everything about suturing.”

  “Be kind to him. You were once that fourth-year gunner,” I said.

  “I was never like that. I had other ways of getting what I wanted,” Jen said, making her way down the hallway.

  I laughed to myself as I turned my attention back to Dr. Stefan. “What’s your question?”

  “I was just wondering if you were going to take a moment to evaluate the patient before I present him to Dr. Locks.”

  Locks was on? When had he gotten here?

  I hadn’t paid as much attention to which attendings were on today, mostly because now that I was a third-year resident, it didn’t matter quite as much. I didn’t need to present my cases to them one by one. I could bundle them once the patient was fully evaluated, as long as there wasn’t anything too odd about them. That was one advantage of reaching this point in my training. The other was that most of my time was spent in the ER rather than on some other rotation, like surgery.

  I glanced back at the computer, thinking that maybe it would be better if the intern completed this workup along with Dr. Locks. I could imagine Locks loving how extensive this evaluation was. It fit right up his CYA alley.

  But doing that would do a disservice to the intern. He had to learn, and I knew the kind of things Locks intended to teach.

  “Tell me about the patient,” I said.

  Dr. Stefan stepped out into the hall, pulling the door closed behind him. At least he had a sense of privacy. Too often, the interns overlooked the fact that patients could hear us talking, and they needed to believe that their doctor was competent. Part of that involved not knowing just how little their doctor actually knew when they were little more than interns.

  “He’s a fifty-five-year-old machinist at a local shop. He was working when he started to get lightheaded and passed out. His coworkers said he was out for a few minutes before he came around.”

  “Do you have any physical exam findings that are worrisome?”

  I’d already looked through the chart and had seen the nurse’s notes. I trusted the nursing evaluation, especially Patty’s. She was thorough, sometimes to a fault. She would have ensured that the patient was fully evaluated prior to letting the intern work him up. His vital signs were stable, including his blood pressure and heart rate; nothing there that raised any alarm bells. Patty’s notes told me more than Stefan’s brief presentation had, though. He’d been working non-stop for about ten hours in hot conditions and a face shield. I already knew what he needed.

  “His exam was normal.”

  I arched a brow at him. “Is that what you intend to tell Locks?”

  Stefan licked his lips and swallowed. “How much information do the attendings like?”

  I smiled tightly. I could be the type of third-year resident that I had when I was a new intern, a bitch like Dr. Kelly, who had made it sound as if the attendings wanted a complete evaluation with every single patient, including a detailed report about their findings. I remember that first presentation that I had made to Dr. Smith and the way he’d sat there patiently the entire time until I was finished. Only then had he asked the only question that mattered: What did I think?

  I wasn’t going to be like that. I needed to be better, though there were times—and some of the interns, especially the cocky bastards that we got because of the prestige of our training program—when I wondered if I really wanted to be better.

  “You’ll get to realize that each attending is a little bit different. Locks prefers to prove to you how much he knows, so you have to give him that opportunity. Share with him your assessment, be thorough, but be prepared for letting him have the chance to tell you how much he knows.”

  And it wasn’t that Locks was dumb. Far from it. He was just lazy. It made for a strangely beneficial situation where he allowed the residents to have the necessary freedom to practice, but where he also had the knowledge needed to teach.

  “I’ve ordered a CT, a panel of labs, and an EKG. Is there anything else I should do?”

  My gaze flickered back to the computer. The obvious answer was dehydration in someone like this, though working up someone in the ER was about more than finding the obvious answer. We had to be prepared for what some called the zebras, the strange things that would often only present in the ER, even if common things presented commonly.

  “Why don’t you check orthostatic blood pressure?”

  “Will that tell us anything the labs and EKG won’t?”

  I stared at him a moment, debating whether I should say something smartassy or not. Probably not. “It doesn’t cost him anything and it can suggest a possible etiology for his symptoms.”

  “But everything is normal so far.”

  �
��Exactly. And I suspect you’ll find that everything remains normal when you put him through all the expensive tests you’re about to do. With his age, I think an EKG makes sense. You can check the lab panel, but I doubt we’ll find much there. The CT is more to make you feel better, but is unlikely to provide any answers. But the yield on checking whether his blood pressure drops when you change positions…”

  I was leading him more than anyone had ever taken the time to lead me. Stefan had to be smart. We didn’t take any residents who weren’t smart, which made his obstinance all the more frustrating. He should be better than this.

  “You think it’s dehydration?”

  I nodded. “Just ask Patty to check his blood pressure for you. When you present to Locks, you’ll look even better.”

  That might not be entirely true. Locks was all about the thorough evaluation, especially when it came to something like this. Hell, I wouldn’t be surprised if he sent the guy out with a heart monitor and an order for a stress test.

  “Thanks,” he said, relief in his voice.

  He left to find Patty and I shook my head. He’d been a resident for the better part of a month and still had that attitude? Some were quicker to make the transition than others, putting into practice the knowledge gained in medical school. Maybe Stefan wasn’t going to be one of those.

  Stepping into the room, I let out a surge of magic, feeling for any significant injury to the man. Using it in this way guided my medical knowledge. Probably too much, if I were honest with myself. I had begun to rely upon what I could glean from my magical connection, using that to help guide the tests I ordered. Doing so could be very cost effective, especially as it only took a little bit of my magical connection in order for me to do so. Most things could still be handled and healed naturally, though there were more and more times when I had begun to use a touch of magic to speed along the process.

  As I had suspected, there wasn’t anything seriously off with him, and certainly nothing that required my magical abilities to ensure he recovered. All he really needed was a liter of fluids and he’d be back on his feet, feeling better. Considering Patty had already started the fluids before I’d even come in, he was well on the way.

  “I’m Dr. Michaels,” I started, but cut off as the low-pitched sound of an ambulance siren reached my ears.

  As it always did, my heart fluttered briefly in excitement. There was the possibility of something interesting with each ambulance, a challenge that I savored. Now that I had begun to use my magic, no longer fighting it quite as much as I once had, I didn’t feel the same challenge that I had when I first began residency. There was still the thrill, but it was different now.

  “There was another doctor in here a little bit ago,” the man said without looking up. He was a solidly built man, thick with a mixture of muscle and a heavy layer of fat. Sweat beaded on his balding head.

  “That was Dr. Stefan. I’m working with him.”

  “Are you his trainee? Like in the TV shows?”

  I grunted. “Actually, I’m—”

  The chill along my spine warned of a different kind of danger. Death.

  In the ER, it wasn’t uncommon to feel the coming of death. It was a part of the job, and it was one thing that I had initially disliked about it. Now that I knew I had a connection to death that somehow strengthened me, I hated it more than before. There was temptation within that power. A promise of more power, if only I would be willing to reach out for it. Most of the time, I managed to push it away, save the patient, and prevent the cold chill from growing stronger—to prevent me from growing stronger.

  This was already potent.

  “You’re going to have to excuse me,” I said and turned to hurry from the room.

  As I raced from the room, I thought I heard him shouting after me, but I ignored it.

  It wasn’t difficult to find where the ambulance had gone.

  Trauma Room 2 had the glass doors open and nurses streamed in and out. One of the interns, a Dr. Gelman, stood outside the room as if unwilling to head in. Ignoring him, I hurried into the room and took a chance to survey what was taking place.

  A younger patient, female and covered with blood, lay on her back, moaning. Two nurses—a younger male nurse named Thomas and good old Joan—tried to start an IV on either arm, but neither seemed to be having much luck. A third, Val, worked at cutting away the woman’s clothes with her trauma shears. My gaze was drawn to her swollen belly and the chill along my spine took on a different meaning.

  The woman was pregnant.

  “What happened?” I asked, jumping into action. My mind already began to buzz with the possibilities. The blood on her suggested an accident, but I didn’t see any visible injuries. Assault? That would mean different mechanisms and possibly a different workup.

  Val glanced over her shoulder and relief swept across her face. “Michaels. I’m glad it’s you. She was in an accident. Slipped on stairs. Went down a flight and landed on her side.”

  “And the blood?”

  “EMS thinks its fetal.”

  Shit.

  “How far along is she?”

  “Thirty-seven weeks,” the woman said between moans. “It’s too early…”

  I stepped up alongside the cot and briefly squeezed her hand. “I’m Dr. Michaels. We’re going to take good care of you here. Thirty-seven weeks is just fine to deliver if it comes to that.” I would have asked why they’d brought her here rather than to OB, but if they were concerned about trauma, we could evaluate her faster than they could.

  She screamed.

  “What hurts?” I asked.

  “My back. My stomach. Everything.”

  I glanced over at Val. “We need to get her on a fetal monitor. And I need the ultrasound. And have someone call OB.” If we had to deliver her down here, I wasn’t going to do that myself. I’d delivered a few babies, but none by choice. It was better for everyone involved if she made it up to OB.

  Val nodded and raced out of the room. The other two nurses finally managed to get their IV started and began pushing in fluids.

  I quickly scanned for any signs of external injury, but there were none. I didn’t want to roll her without help, but would need to look at her back. Grabbing my stethoscope, I leaned down to listen to her heart and then lungs, but everything was relatively normal. Thomas had placed a blood pressure cuff and it began to cycle as I stepped back, waiting.

  When the reading came back low, I wasn’t surprised.

  She’d lost blood somewhere. Likely vaginally, which meant the baby could be in danger. We needed that fetal monitor.

  Val returned, pushing the ultrasound cart and dragging the fetal monitor. Her eyes were tight and she bit her lower lip. “OB was called, but they’re really busy up on the floor. They’re sending someone down, but I don’t know how long—”

  The woman screamed again.

  I grabbed the ultrasound and began running the probe over her belly. First I needed to know that the baby was alive. Then I could begin to look for whatever else had happened to her.

  Finding the baby’s heartbeat wasn’t that difficult. It was there, beating steadily, but slower than it should. My mind raced through what a normal fetal heart rate should be, and the baby—at 110 beats in a minute—didn’t seem quite right.

  Was it the baby I’d felt dying?

  Letting magic trickle out, I sent an inquiry into the woman. The power flowed slowly, carefully, washing through both mother and baby. I had to be careful that I didn’t push too much out. There was a danger, especially as my magic tended to be destructive. I’d begun to gain some control over it, but it was still more destructive than not and I didn’t want to do anything that might harm either of my patients.

  The emptiness I’d come to associate with death was there.

  It was everywhere.

  We were going to lose not one, but two patients if I did nothing.

  “What is that?” Val asked.

  She leaned over my shoulder an
d I looked up at the ultrasound screen. “Blood. Lots of it,” I said.

  “Why would she be bleeding like that?”

  There were plenty of reasons, but only one that seemed likely, given the images.

  Shit.

  “Dr. Michaels?” Val asked.

  “Uterine rupture,” I whispered. I looked up at the woman. Her face was pale and I suspected we were lucky she’d come in when she had. The baby still had a pulse, but for how much longer? “Someone get OB down here STAT!”

  My heart hammered. The idea of losing a patient was never easy, but losing a baby? Sadly, I’d been through it before and it was always traumatic. Usually something respiratory went wrong when they were really little.

  As I stared at this woman, I made a decision. I wasn’t going to lose them.

  “Have you ever had a C-section before?” I asked the woman.

  She shook her head, moaning.

  That was the most common cause, though even that was pretty rare. Maybe the trauma of the fall really had been enough to have caused this.

  Glancing over at Val, I said, “Call trauma. General surgery. Whoever might be available.”

  She ran from the room without questioning.

  I placed my hands on the patient’s stomach, letting magic work out from me. Knowing it was a rupture meant that I should be able to fix it. All I had to do was wrap the magic around the injury, seal in the sense of emptiness, and I would be able to save her.

  Only, the surge of cold along my spine suggested I didn’t have the time I thought would be needed for that.

  Magic wasn’t going to be enough.

  I didn’t know enough medicine. Not the kind that would help.

  The blood pressure cycled again. As it did, the fetal heart monitor began to beep, the alert set to warn me that the heart rate was dangerously low.