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One broken wrist. One UTI. One nausea and vomiting that turned out to be a flu. One bead stuck in a kid's ear.
And it was already noon.
Not bad for the Pitt, Santos thought. Was this one of those much-fabled days when everything would go as it should and they would leave at the end of their shift?
If it continued like this, she might even be willing to believe it in a few hours’ time.
She moved to the hub, and, as she raised her eyes to the screen above to choose a new case, she announced loudly, “The next one is mine!”
No one reacted. Nurses passed her by. Whitaker disappeared inside a patient room. Javadi continued working at her computer. Kwon was staring at her phone, leaning against the counter.
For a moment, there was an eerie silence in the Pitt.
Then, the door to the ED burst open, and two EMTs rolled in a stretcher with a patient.
“Male, age 76,” one of them began explaining, “Poor general condition. Fever, 101.1 at the moment, started last night. Difficulty breathing, SpO2 86% with 10L of oxygen via non-rebreather mask. BP 98/63. Pulse 112.”
“Dammit!” Santos cursed under her breath.
“Take him to North 6,” Dana called from somewhere down the hallway, and the EMTs hurried to do so.
“He is mine!” Santos announced, holding her right hand up, as if there were hordes of doctors running to dispute her claim.
There were not.
As the EMTs and their nurses were moving the patient from the stretcher to the bed in North 6, Santos turned to Kwon. If this was what she suspected it was, a walking encyclopedia would prove rather helpful.
“Well, Joy, you are here to learn, aren't you?” Santos asked her, and the girl gazed up at her with distrust. “I have just the case for you!” Santos told her, gesturing toward North 6. “Fever, sweating, difficulty breathing, hypotension. What is not to like?”
Kwon clearly did not find the case as exciting as she was trying to make it seem, but she did pull away from the counter with a sigh and followed Santos into North 6.
“Name?” Santos asked as the two of them entered the room.
“John Myers,” one of the EMTs answered. “His wife is just outside.”
She followed his gaze to the door where a short, white-haired lady was peering inside, gripping her purse tightly.
Santos returned her attention to the patient, who was now placed securely on the bed. The monitor showed his SpO2 at 85%, and his BP at 95/60 mmHg.
“Raise his oxygen to 15L,” she told Kwon, who hurried to do so. “Perlah, prepare to draw blood for CBC, CMP, a lactate, CRP, procalcitonin, and two blood cultures. Once you have the line, hang a liter of normal saline and administer 1000 mg of acetaminophen.”
The nurse nodded and left the room.
SpO2 was now 87%. Santos approached the patient.
“Mr. Myers, can you hear me?”
No answer. She could barely make out his features beneath his mask. Santos reached to shake his shoulder. “Mr. Myers!”
The patient now opened his eyes and looked around, disoriented.
“Do you know where you are?” Santos asked. SpO2 was now 90%.
The patient muttered something that she could not make out. She turned back to Kwon. “We need his medical record. Speak with his wife. Search the system. In the meantime, I will do the physical exam.”
“Lung squamous cell carcinoma, diagnosed in February 2025,” Kwon was reciting dutifully, like the good med student she was. “Stage IV through multiple liver metastases. Treated at Westbridge Hospital. Received carboplatin, paclitaxel, pembrolizumab in the first line, then progressed after a year. Currently, receiving second-line treatment with docetaxel and ramucirumab. The last cycle was seven days ago.”
“Well, now we know why this poor man is in septic shock,” Santos remarked, rubbing her eyes. She turned to their nurse. “All right, Perlah, start antibiotics—meropenem, 1 g every 8 hours, vancomycin, 1 g every 12 hours.”
Perlah nodded and left the room. The patient was maintaining his BP at around 90/60 and his SpO2 at 90%. For now. Those antibiotics would need to work fast.
“All right, Joy. Why is this patient desaturating?”
“Well, the obvious reason is the pulmonary infection we already suspect,” Kwon answered readily. “Considering that he also presents with sepsis, the pneumonia must be rather severe, impairing his pulmonary function.”
Santos nodded. “Anything else?”
“PE. Oncologic patients have a high risk of DVT and PE. Even more, ramucirumab shares a class with the more common bevacizumab, and both are known for raising the risk of cardiovascular events.”
Santos stared at Kwon for a moment. “Oncology will love you. Another cause?”
The girl hesitated, and Santos stopped her before she could reach for some rare disease or secondary effect. “Half of his left lung is gone. Replaced by the tumor. It's a wonder he can barely breathe as it is.”
She hoped it was pneumonia or PE. Those they could treat. The cancer, not so much.
“Either way,” Santos concluded, gazing at the patient before them. “He needs a CTA chest now. We need to rule out PE, and knowing more about his lungs will do us no harm.”
Kwon nodded, leaving to inform the nurses. Al-Hashimi entered the following moment, gazing at the patient with narrowed eyes.
“What do we have here, Dr Santos?”
Santos presented the case as her attending nodded along.
“All right, I want to see the bloodwork and the CT results when they are done,” Al-Hashimi told her. “We will also need to place an Oncology consult.”
“Will do!” Santos answered.
“Continue monitoring him until then. His condition might worsen at any moment.”
Santos nodded, and her attending left the room, hurrying toward another emergency.
Well, if this was not one of her best interactions with Al-Hashimi. Who knew septic patients brought out the best in her?
The patient’s vitals were stable. He had received his first dose of antibiotics. The normal saline was running. They were waiting on his kidney function to send him to the CTA chest.
There was nothing she could do now but wait.
Santos moved to the door, then took a deep breath before exiting into the hallway. She knew what awaited her. It was her least favorite part in cases such as this.
The old lady appeared next to her as soon as she stepped into the hallway.
“Will my husband be all right?”
Santos tried to express the optimism she was not feeling. “We are doing everything we can for him, Mrs. Myers. Your husband suffers from what we suspect is a severe case of pneumonia. Unfortunately, it appears that the bacteria has passed into his bloodstream, which is the reason for his poor condition. Because of the chemotherapy he had received recently, your husband is greatly vulnerable to such pathogens.”
The old lady was nodding, listening attentively.
“We have drawn blood to confirm our suspicions,” Santos continued. “We will perform a CT to rule out other causes for his current condition as soon as we are certain his kidneys are functional. We have already started antibiotics and rehydration. If we succeed in treating the infection, his condition should improve significantly.”
“Will you?” the lady asked as soon as Santos stopped talking. “Will you succeed in treating his infection? Will he get better?”
These were the questions Santos had feared, but which always came.
“I cannot say for certain, Mrs. Myers,” Santos responded, choosing her words carefully. “Your husband's condition is critical at the moment. It all depends on the following hours. For now, he is stable. But I cannot promise you he will not get worse.”
A sob escaped Mrs. Myers, and she brought both hands to her mouth. “Oh, John… Ever since we received this diagnosis, I had hoped… I always understood this could happen, but seeing him like this… He was—is such a good man. Smoking was his only vice.”
Santos remained silent, finding no words to soothe this poor woman's pain.
“I must call the children,” Mrs. Myers continued. “They are both in California. They will not arrive in time, but… They need to know.”
“You can go inside if you wish, Mrs. Myers,” Santos offered, gesturing toward North 6. “Only make sure you put a mask and gown on before entering. You can watch over him until they take him to the CT.”
Drawn out of her musings, it took a moment for Mrs. Myers to respond. “I… Yes, of course! Thank you! For everything you are doing.”
Once she helped Mrs. Myers put her protection on and saw her enter her husband's room, Santos turned to see Kwon a few feet away, one of the hospital’s tablets in her hand.
“We have the bloodwork.”
“Great!” Santos answered, moving to the hub while Kwon followed close behind. “Hit me.”
“Hemoglobin 9.2. Platelets 110,000. Leukocytes 900.”
“Here it comes,” Santos muttered with a sigh.
“Neutrophils 50.”
“Febrile neutropenia. Just as we suspected.”
Kwon nodded, then continued. “Procalcitonin 30.68. It's quite impressive,” she commented, gazing back at Santos.
Having reached the hub, Santos leaned against the counter. “I’ve seen worse. We need these antibiotics to do their work fast, or we will lose him. eGFR?”
“35.”
“It’s as good as we are going to get. Send him to the CTA chest now.”
The girl hurried to do as she said, and Santos took the opportunity to sit down.
It would be some time before the CT results arrived. Maybe she should start charting. Oncology would love her for it.
“Red is for artery. Blue is for vein.”
Subconsciously, Santos turned her head toward the sound of the voice as she returned from her short bathroom break, and saw McKay inside the room to her left, performing a Doppler ultrasound on an elderly patient. The probe was on the underside of the patient's knee, so Santos guessed she was searching for a DVT.
But this was not why her eyes widened. What shocked her were McKay’s words.
Santos shook her head and continued on her way. It was none of her business.
But what if Al-Hashimi was the one who had passed by?
Suppressing a sound of frustration, Santos decided to talk to McKay about it once she caught her alone.
Why did she always care so much when she had nothing to gain from it?
“Red flows toward the probe. Blue flows away from the probe,” Santos said when McKay approached, stopping her charting. “It doesn't sound as nice as your version, but a Doppler is not an anatomy book.”
“What?” McKay asked, her brow furrowed as she gazed down at Santos.
“I heard you while you were doing the Doppler in Central 10,” Santos answered simply, meeting McKay’s eyes.
McKay’s frown deepened for a moment, then her eyes widened as she understood. “That's not… I was not saying… In the window I had at the time…” She trailed off, shaking her head. “I was trying to simplify for the patient so she could understand more easily.”
“Why bother?” Santos asked, and McKay looked back at her in shock. “They don't understand, nor do they care what we do. They simply wish to get better. You don't need to speedrun med school with them. You only need to tell them when to take their pills, and they will be happy.”
“It’s the patient’s right to understand what is wrong with them,” McKay pushed back with a frown.
Santos leaned back into her chair. “All right. So you give this easy, nice, and wrong explanation about the colors on the Doppler. Best-case scenario, the patient understands nothing and forgets everything by the time the next day rolls around. You have wasted your breath and time. Worse, you meet someone who actually knows how the Doppler effect works, and they think you are an idiot and will no longer trust you with their care. Worst-case scenario, Al-Hashimi hears you and chews you out. It's always a lose-lose scenario. So why bother explaining anything?”
McKay shook her head and walked away.
Indeed. Why did she even bother?
“Male, age 40, fell off his roof while working. Suspected calcaneal fracture. Pain responded to 4 mg of morphine.”
Santos raised her head as she heard the EMT speaking and saw Whitaker follow the patient's stretcher before they all vanished from her sight.
She turned to Mel. “Do you ever wonder if we would be facing the opioid crisis of today if we did not give morphine to every patient that walks—or is pushed—through this door?”
Mel gazed at her in confusion. “Well, while it is known that morphine is highly addictive even in small doses, in the case of patients with intense pain—”
“Mel.”
“—euphoria does not manifest—”
“Mel!” Santos repeated, fixing her with a hard gaze.
“What?” Mel asked, growing even more confused.
“It was a rhetorical question,” Santos said, returning to her charting.
“Oh, right,” Mel said, returning to her own work. “Of course.”
Santos checked the results of the CTA chest once again. Nothing yet.
At least her patient was still stable.
“We have the CT results,” Santos declared victoriously, and Kwon approached.
“Is it a PE?” the girl asked.
Santos’s eyes flew over the words on the screen before her. “No, no PE,” she muttered, a word catching her attention and making her heart drop. “Pneumonia, yes, the whole lower lobe of the left lung is consolidated.”
“We expected this, didn't we?” Kwon remarked.
Santos nodded. “Yes. But we did not expect lymphangitic carcinomatosis.”
It took a moment for Kwon to understand. “That is why he is desaturating!”
Santos nodded. “It’s certainly one of the reasons. And there is nothing we can do about this. Even if we treat the sepsis, we cannot fix his lungs.”
“So he won't have long either way,” Kwon concluded, her expression darkening.
“Go show Al-Hashimi the results and catch her up on the case. I will place a consult for Oncology.”
Kwon did as asked while Santos turned to gaze at North 6, where Mrs. Myers was sitting by her husband's side, holding his hand while he gasped weakly.
She hated cases like this.
“Santos, can you take the patient in South 19?” Dana called out to her as she moved by the hub.
“Ask Whitaker,” Santos answered. “I’m waiting on Oncology for my lung cancer patient. Also, he might crash at any moment.”
Dana simply nodded, leaving to search for Whitaker.
Santos tapped her fingers against the counter, gazing at her patient and his wife while she waited. Why was it taking so long?
“I’m here for an oncologic patient,” she heard a man’s voice from behind. “Do you know where I can find his doctor?”
She turned and saw Dr. Rausch, the tall, grumpy oncologist she knew so well, at the counter, his question posed to Princess.
She hurried to approach him. “It's my patient, Dr. Rausch! I called you down here.”
“All right,” Dr. Rausch answered. “I hope it's not another breast cancer patient with a stomach ache, like last week. You ED doctors often seem to forget that a patient can have diseases that do not relate to their cancer.”
Santos forced a false smile that did nothing to hide her sarcasm. “I’m pretty certain this one is yours, Dr. Rausch.”
The doctor nodded. “Let's hear it.”
“Lung squamous cell carcinoma stage IV, currently receiving docetaxel and ramucirumab at Westbridge. The last cycle was seven days ago. The patient presents with poor general condition, fever, difficulty breathing, coughing, hypotension, respiratory failure. We suspected febrile neutropenia and pneumonia. We started meropenem and vancomycin. The bloodwork confirmed the neutropenia and infection. We performed a CTA chest to rule out PE. There is no PE, but we did see lymphangitic carcinomatosis. Currently stable on 15L of oxygen.”
Dr. Rausch nodded, showing no sign of surprise. “You chose the antibiotics well. Let's see him.”
Santos asked Mrs. Myers to wait outside as Dr. Rausch did his own clinical exam. The patient’s BP was 87/59. His SpO2 was 88%.
The doctor turned back to her. “How much does he weigh?”
Santos moved to the patient bed, pressed the right button, and waited. The number flashed on the side. “141 pounds.”
“Give him Filgrastim 300 mcg before you send him upstairs. We will admit him to Oncology in about half an hour. We need to prepare a room to isolate him.”
Santos nodded. This went more swimmingly than expected. “Thank you, Dr. Rausch.” She hesitated for a moment. “There is not much you can do for him, is there?”
With a sigh, Dr. Rausch shook his head. “I fear not. We will try to treat the pneumonia, but even if we do, his lungs will give out in a few weeks’ time. We will speak with the family and explain his situation to them. We will give him the support he needs, but we cannot perform miracles.”
“Of course,” Santos muttered.
Why did she even bother asking?
“Male, age 28, gunshot wound in his left flank, no exit wound. His blood pressure is falling, 85/54 right now.”
Santos stopped listening to the EMT when she saw Langdon and Whitaker rush toward the stretcher to check the patient’s vitals. They all vanished soon after in Trauma 1.
Of course Langdon and Whitaker got the fun gunshot wound patient whose life depended on their rapid care and skills, who needed risky maneuvers and keen eyes, who got the blood pumping and the adrenaline going, who would walk out of here in a few days’ time with his whole life before him.
Meanwhile, all she had was the lung cancer patient, whose life was already over, even if his body did not realize it yet, for whom there was nothing she could do but pray that his antibiotics would allow him to survive the day, who would most probably never walk out of this building at all.
But Mr. Myers was not all so bad, Santos thought as she hovered outside North 6, waiting on Oncology to admit him upstairs, fearing he might crash before they could.
Mr. Myers was quiet. He never argued with her or demanded explanations or refused the treatment she was trying to give him. Mr. Myers never caused her any trouble of his own volition.
He was not aware enough to do so.
So his body and that damn monitor did it in his stead.
There were times she wished she could have spoken with him—times she wished she could have known him as a person rather than just a dying body.
She saw Al-Hashimi run toward Trauma 1. So she would not be here to see Mr. Myers off when they came to take him, then.
Not long after, Kwon appeared from down the hallway, moving to her side.
“How is our patient?” she asked Santos.
“Still holding on,” Santos answered, looking at the girl with slight surprise. “Oncology is taking its sweet time coming down for him. But why are you here? There is a gunshot patient. Go watch.”
Kwon shrugged. “They stop being interesting after, like, the third one.”
Santos chuckled, shaking her head. “Febrile neutropenia patients stop being interesting after the first one.”
Still, Kwon remained by her side.
So, yes, Mr. Myers might be gasping weakly for air, Santos thought as she moved to glance inside North 6. He might be sweating profusely. The air around him might be stale with that odd smell that was not blood, or pee, or vomit, or sweat but something in between, that odd smell she could not describe, but always felt around dying people.
He might… be getting better?
“Blood pressure 102/61!” she called out loud, unexpected relief flooding her. “Perlah, you can forget about the norepinephrine. He is going to Oncology. He has dodged the ICU!”
The nurse smiled as she passed them on the way to another patient, and Kwon approached her, clearly confused. “What’s so bad about the ICU? Wouldn't he receive better care there than in Oncology?”
“If by better care you mean intubation and vasopressors,” Santos answered, “then yes, he would receive better care there. They would be more than happy to give it to him, and he would spend the last weeks of his life sedated and unconscious. Then, he would die when his heart finally fails. Is that worth it? Oncology might give him less time, but it will be a better time.”
His SpO2 was still 88%. There was a reason she had decided not to begin BiPAP.
Out of the corner of her eye, she saw men approaching with a stretcher.
Finally, Oncology.
Santos was watching Mr. Myers be wheeled away when someone took both of her hands in theirs.
“Thank you, Dr. Santos!” Mrs. Myers told her, smiling weakly. “Thank you for everything you did. Just before they came to take him, John opened his eyes and looked at me. He recognized me, I am certain! I think he will be able to speak with us again soon. So thank you. Thank you for giving us a few more moments together.”
Santos swallowed, pushed down her discomfort, and searched for the right words.
She had not told Mrs. Myers about the lymphangitic carcinomatosis or what it meant. They were all cowards in their own way.
“I only did what I am here to do, Mrs. Myers. There is no need to thank me.”
The old lady's smile grew. “Even so, thank you.”
And with those words, she left to follow the men moving her husband to Oncology.
With a sigh, Santos turned to Kwon, who was gazing after their patient and his wife with an unreadable expression.
Then the girl sighed too and moved to the hub to lean against the counter. “I can't wait to finish this rotation.”
Santos patted her on the back as she passed her. “Let's first finish the day, shall we?”