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Akutagawa followed his attending’s cues: if the man shrugged his coat off and stood by the door, then Akutagawa got the hint it was time to go. He rose slowly, logged out of the computer twice for good measure, then followed him out of the dictation room.
“Questions?”
Akutagawa knew he mentioned it during their briefing, but he asked again. “What type of airways can EMS place in the field?”
“Oropharyngeal most often. They have their own set of standing orders to follow, it differs slightly from agency to agency.”
Akutagawa hurried behind his brisk footsteps, muttering an inattentive “Sorry” after turning the corner too quickly and the squeal of someone’s shoes scuffing the vinyl flooring rang out.
“Remember your patient in 43?”
Room 43, Akutagawa wondered. No, he hadn’t seen a patient on that end of the unit since he started. That was almost two weeks ago. He tried to place their face—
“She didn’t meet the criteria for an OPA. An NPA was used instead.”
“Right,” Akutagawa agreed blindly. There were different indications for different airway securement devices, a baby could have known this.
The next words came playfully. “Criteria such as…”
“Consciousness.”
“Correct. Her gag reflex was still intact. It wouldn’t have been pretty if she vomited on us.” The man grinned, “Akutagawa-kun doesn’t like to get his sleeves dirty.”
Akutagawa flushed. It was cold in the hospital, he preferred longer shirts and he preferred to keep them clean. Though, he didn’t think he was that obvious about it.
“I’ll have you meet the students, then we’ll get started.”
“Med students?” Akutagawa asked cautiously. He wouldn’t be far off from their positions if they were—just a single degree conferring his title separated them.
“High school, actually. We partnered with the local school district. They occasionally send some of their students during a period of their day here to expose them to…well, this.”
Their pace finally slowed as they approached the trauma bay.
“Smile. Don’t let them know you’re forced to work overtime.”
Akutagawa held his sigh. Dazai Osamu was brilliant, an excellent physician with office walls made of framed certifications because even in his free time he couldn’t be swayed to do something that wasn’t related to work. Akutagawa was incredibly fortunate, really, for matching at a well-established institution and working with an attending doctor as involved as Dazai was. He never missed a chance to take advantage of any situation good or bad. But—
“—This is Akutagawa-sensei.” Dazai whispered behind a cupped hand to the small group of uncomfortable teenagers all wearing collared shirts and khakis crowding the hallway, “Be careful, he’ll poke you with a scalpel if you get too close.”
“Dazai-sensei,” Akutagawa warned. Dazai could be a handful to keep up with.
“I’m only joking,” Dazai laughed. He straightened his posture and took inventory of the trauma room: A scribe had set up near the door behind a computer, an X-ray and ECG machine were turned on and in standby with the techs, the pharmacist was nearby, a critical care nurse was grabbing supplies. Things were coming in order. Dazai’s attention turned back to the students. “You will all be in the room with us. It will look chaotic, it won’t be. Just be mindful of where you’re standing. Someone will more than likely tell you to move if they want you to move.”
The students shuffled themselves into a corner, stood still, and remained quiet. Akutagawa laughed to himself at the sight of it. He was like that before, not too long ago, still kind of was like that. Though, if he ever wanted to be a physician worth anything, he had to step up. Dazai had been carting Akutagawa around every and any opportunity to do something he hadn’t before because even Dazai understood that.
“Akutagawa-sensei, do you need report?”
Akutagawa stumbled back at the voice that demanded from behind him. A petite woman stared at him squarely. He thought she might have been the charge nurse who initially informed Dazai about the incoming patient but he couldn’t remember her name. Akutagawa glanced at Dazai in the middle of the room who watched him.
“No, thank you. I received it.”
The woman quickly moved on. Dazai nodded then spoke loud enough for the entire team among their bustling to hear. “Alright, everyone. We have a patient who is being brought in via ambulance, their ETA is 5 minutes. Patient is a 32 year old male who was found unresponsive on the ground by a family member in their house. EMS was called immediately by the patient’s wife. Our goal as of now is to get him into CT as fast as we can and safely.”
Akutagawa returned to Dazai’s side. “What little information we have to go off of.”
“As is the nature of the ED.” Dazai shrugged. “Do you feel comfortable intubating?”
“Perhaps after one more demonstration.”
Dazai laughed. “Adjust the vent, okay?”
“RT may not be happy with me.”
“Ranpo-kun can be territorial.” He thought for a second. “Then just tell me which settings you would use.”
Akutagawa sighed. He recited the mechanical ventilator settings word for word as it was outlined in the hospital’s policies.
The clock ticked as everyone waited with their feet tapping and fingers fidgeting. All preparations were in place and the room was as controlled as could be. Of course it was, Dazai was leading. The only thing left was for the patient to arrive.
Akutagawa had been making decent progress as an intern. As a rule, he was only allowed to see nine patients maximum each day. He did stay behind to chart after hours, but he completed it every time. The chief resident, Kunikida-sensei, was always around to answer his questions—of which he had many, and the nursing staff would overlook his blatant shortcomings whenever he asked them what medications he should be ordering. His progress was coming along fair enough, though not as fast as he would have liked. But, what he truly felt wholly unprepared for, hence Dazai’s presence, was the inbound Code Blue.
Light poured into the hallway as the ambulance entrance opened, Akutagawa saw the red and white of the vehicle parked in the background. He heard the squeaking of springs and rubber soles as a flurry of his team members moved to the door to help EMS through.
“Our patient is coming in. Everyone, please quiet down,” Dazai voiced, putting gloves on.
Akutagawa counted three EMT’s as they came into the room, gurney between their hands, their calmness and composure unbefitting for the tangle of wires and cords strewn across the patient’s lower half and the patient’s ongoing bag-mask ventilation. The nature of emergency medicine, Akutagawa repeated Dazai’s words.
The gurney was immediately lined up next to the bed. Akutagawa reached over to grab the slide sheet, his grip on it tight for a patient of this size. Another stood side by side with him ready to pull on the sheet that was already stretched taut. Akutagawa counted out, “One, two, three.” He pulled on the sheet expecting to meet resistance—he was never that strong to begin with—and he did. But, without a hitch, someone had managed to squeeze in next to him. Their hands grabbed onto the sheet much more firmly than Akutagawa ever could and practically hauled the patient from the gurney to the bed by themself.
Akutagawa looked to see that it was one of the EMT’s. Actually, a paramedic judging by his dark uniform. He was smaller than Akutagawa was, and his orange hair was the brightest color in the room that it was surprising. Even Dazai took notice as Akutagawa saw his gaze linger on the man’s striking appearance.
Akutagawa looked for shears to cut the patient’s shirt off, and, as luck would have it, the paramedic spoke, satisfying Akutagawa’s curiosity.
“Is everyone ready?” the man waited expectantly.
Dazai obliged, “Please.”
“This is Matsuo Ryota, a 32 year old male who was found down in his home at 0930 this morning by his wife who called EMS. EMS arrived at approximately 0938. Patient was found on the kitchen floor, unresponsive. His wife reported a history of alcohol withdrawal, unknown when last drink was. The patient was bradypneic and oxygen was 75%. GCS 2-1-4. We intubated him with a 90 millimeter oropharyngeal airway adjunct and began bag-mask ventilation and activated a code blue. During transport, he experienced one episode of seizure activity lasting no more than 30 seconds. Last vitals were taken at 0952, BP was 148/98, pulse 110, temp 99.1, respirations 12, O2 99% via BVM. ECG shows a prolonged QT interval, a copy of that is here—” he held up a sheet of paper. Dazai motioned that he wanted it.
Every person in the room knew their role and worked efficiently as the man spoke. Bagging was handed off from EMT to staff, vitals were retaken, leads placed, larger IV placement and catheter insertion was in progress. Akutagawa was amazed at how they operated as if it was routine.
The paramedic was collected as he continued. “Blood glucose is 60. He has a 22 gauge IV on his left arm. We administered 10 milligrams of IV diazepam at 0945. Do you have any questions?”
“Did you give any paralytics for intubation?”
“We did not give any paralytics.”
“Thank you.” Dazai put down the ECG strip and got to work. The EMT’s cleared out of the room, and the one redheaded paramedic stopped by the scribe taking notes to tell her something before he made his way out.
“Do we have a weight on him?” Dazai asked.
“Weight is 99.7 kilos,” someone yelled back.
“Prepare IV rocuronium 0.6 milligrams.” Dazai took over bagging at the head of the bed and began calling orders. “Akutagawa-sensei, set up a size four blade laryngoscope and nine millimeter ET tube.”
“Laryngoscope and ET tube coming.” Akutagawa turned to the airway cart that was already near Dazai. He scanned the labels, hoping the correct supplies were the ones his eyes happened to fall upon first. Just what he needed, thankfully, was right at the top—Ranpo had anticipated exactly what they would use.
“I want to get them to CT in four minutes. Can we get a chest X-ray ready, please?” It was Dazai’s voice calling out again, the sound of it causing Akutagawa’s heart to thump in his chest and echo in his ears.
“Rocuronium 0.6 milligrams prepared.”
“Let’s give rocuronium.”
How does anyone work under such pressure? Akutagawa’s hands still listened to him despite their slight tremble. He attached the blade to the laryngoscope—his first time doing it properly as he wasn’t familiar with this brand of equipment, a small win for him—switched it on, made sure the camera screen and light worked, and held it out for Dazai.
Dazai swiftly eyed the supply tray to determine if it was to his liking before he stopped ventilating—it was. He switched with Akutagawa: Dazai took the laryngoscope and Akutagawa grabbed the bag valve mask.
Dazai kept the patient’s head tilted back to keep their airway open. His eyes stayed on the task at hand—removing the existing airway—even as he communicated, “What are current vitals and rhythm check, please.” He then slid the long curved blade smoothly down the throat of the patient.
Akutagawa watched as engrossed as he could while Dazai worked, trying to absorb every tip and nuance from an exceptional teacher. Intubation was supposed to occur rapidly. When Akutagawa practiced in school, he would take two minutes just to get the tip of the blade placed in the correct area and another minute to second guess the amount of pressure he was supposed to apply. Three minutes was triple the amount of recommended time to complete an entire intubation attempt. Akutagawa took note of his watch then held the endotracheal tube and an empty syringe ready for when Dazai needed it.
“Students, come closer so you can see.” Dazai wagged his fingers and tilted the small video screen toward the group of high schoolers all tiptoeing forward and craning their necks. “I’m sliding the blade into the mouth and adjusting it until I can see the glottic opening which is right there.” He kept one hand on the laryngoscope and the other reached for the endotracheal tube. Akutagawa passed the tube to Dazai who was nimble with his fingers, feeding it down the patient’s mouth and into their trachea like it was nothing. He then used the empty syringe to inflate air into the cuff that kept the tube in place, and Ranpo hooked the tube up to the ventilator.
Akutagawa checked his watch. 44 seconds.
The X-ray machine was rolled up to the patient’s bed at Dazai’s request. The students looked on attentively though confused as Dazai pointed out the anatomical structures on the chest X-ray that confirmed he placed the tube correctly.
That should do it.
Dazai peeked at the monitor. “Oxygen looks good. I say we send him to CT, is everyone comfortable with that?”
Agreement resounded throughout the room.
“Excellent. Go ahead.”
It was after the patient was whisked down the hall in the hands of a few nurses did Akutagawa’s shoulder’s slump. He listened to Dazai praising everyone’s work in the background as he took a moment to lean back against the counter, only then comprehending the heat he felt behind his neck and down his back. He was sweating and hadn’t realized it. The gloves stuck to his skin as he peeled them off. All things considered, even despite the minor role he played, Akutagawa thought that went much better than the last code he was in. Though it would take a lot of work to get to Dazai’s level—the gap in their abilities was on full display and abundantly clear.
He watched as Dazai approached the scribe and asked if there was anything he missed.
The scribe stopped shuffling the papers in front of her, she looked genuinely thrown by his inquiry. “No, Dazai-sensei.”
Dazai gestured casually, “I only wanted to check. I thought I saw the paramedic might have left you some information on the way out.”
“Ah, yes,” she remembered, “the wife is on her way. She might have some more information on what led up to this.”
“Wonderful. Thank you, Yosano-san.”
Akutagawa tailed Dazai out of the room.
“Let’s see if we can talk to the wife.”
Akutagawa agreed, though he was just a bit surprised that Dazai caught the paramedic’s interaction with the woman named Yosano. Very little escaped Dazai's notice.
Outside, it looked like the EMT’s hadn’t left yet. One of the younger men stood by the wall and chatted with a nurse, and the one with the bright hair was filling out some paperwork near the nurses’ station.
Dazai made a beeline toward the nurses’ station. Therefore, Akutagawa did as well. The man looked up at the sight of two people approaching him. Dazai greeted him then introduced himself and Akutagawa. “I don’t think we’ve met yet.”
The man put his pen down and it rolled a short bit on his papers before it stopped. Akutagawa noticed it was a blue pen, one that matched the color of his eyes that he really couldn’t believe were real because no one in Yokohama had an appearance quite—
He was trailing off.
“Chuuya,” the man said. And if Akutagawa’s interest wasn’t piqued enough, the firmness behind Chuuya’s handshake shocked him. He was a smaller man, yet his strength completely surpassed Akutagawa’s own. It had been a full day of griping with his own shortcomings. Akutagawa pouted. And it was still only morning.
“You run a tight ship,” Chuuya observed.
Dazai’s eyes crinkled. “Ah, they’re never this well-behaved. I usually get a few objections and some dropped syringes.”
Akutagawa partially agreed with his statement. Everyone in the team was well-experienced, yes, and this was overall a smoother code, but Dazai had enough clinical acumen to continuously dot his i’s and cross his t’s. On paper he was flawless.
“I am familiar with some of the folks at Yokohama’s fire department, but I don’t know that I’ve seen you around,” Dazai wondered.
“I’ve been moving from area to area. I was actually Fire Captain for the last year while the previous one was on leave. Now that he’s back, I’ve been helping out where I can.” Chuuya ran his hand through his hair with little thought. The orange strands seemed difficult to tame seeing that, despite his effort, the waves fell where they pleased.
Dazai clasped his hands together. “Well, your training speaks for itself. Our agency is always more than happy to work with YFD.”
Chuuya did seem comfortable in his work, he didn’t appear frazzled or stressed, and when faced with Dazai’s zealousness, was nonchalant. Leaning against the counter with his hair lightly tousled, he was perfectly cool.
“That’s good to hear, thanks”
There was a pause before Dazai added, “And your report was excellent.”
“Thank you.”
The silence was deafening.
“Your OPA was placed exactly.”
“Sure.” Chuuya’s tone was noncommittal.
Dazai continued to stand there, his mind either running a mile a minute or a complete vacuum. All the while, Chuuya stared at him, perhaps politely waiting, perhaps mildly amused. For Dazai’s sake, Akutagawa thanked the powers that be that the nurses’ station was unattended to witness this.
Dazai came to himself, abruptly switching to “I wanted to ask you about the patient’s family members.”
“Okay.”
Akutagawa saw it in his smirk, Chuuya was amused.
“Any word from the wife?”
“She went through her home video feed and found the patient had four fully topped-off glasses of wine 36 hours ago.”
Dazai considered that information for a moment. “I see.”
Chuuya tapped his papers with the back of a finger. “I have her contact information but she is already on her way, they have two young kids that she had to take to school first.”
“And her name?”
“Yuna.”
“Yuna,” Dazai repeated. “Okay.”
“Is there anything else?”
Dazai shook his head. “No. Thank you for your help, Chuuya.”
“Anytime, Dazai-sensei,” Chuuya spoke slowly and deliberately. He turned. “Akutagawa-sensei.”
Akutagawa nodded his farewell. Dazai’s lip tightened, then, “Alright, let’s go see how our patient’s doing.” His long legs carried him through the hallways quickly. Akutagawa followed after him.
“Based on his ECG, what would we be concerned about?” Dazai’s strides slowed as he began digging into his front pockets.
“QTc prolongation.”
“Right, he did have that. What are we worried that it could progress to?” He tried his back pockets. “For example, if his heart rate was higher…”
“Oh, Torsades de Pointes.”
“Yes, a polymorphic V-tach—seems I’ve left it in the room.” Dazai pivoted around, unable to find what Akutagawa assumed was the ECG strip Chuuya had given him. “Go ahead, I’ll meet you there.”
A nurse came down the hall with a meal tray balanced in her arms. She stopped at the sight of Dazai. “Dazai-sensei,” she got his attention and he stopped in his tracks. “Your patient in 21. I started the plasma. After 15 minutes, her temp went from 98.5 to 99.7.”
“Was anything else abnormal?” Dazai glanced down the hallway in the direction of the trauma bay.
“No. Her heart rate increased from 80 to 96 but…”
Dazai thought about it, his tone conflicted. “Ah—okay, give me a moment, I’ll check in with you.”
Dazai disappeared. Akutagawa knew it’d be a while before he saw him again. Everyone needed Dazai’s attention.
Akutagawa badged himself out of the unit and into the hospital’s back hallways. He looked around and waved down a young man walking by. “Excuse me, do you know where the CT room is?”
“No, sorry, I’m a volunteer.”
Akutagawa sighed. And it was still only morning.
~ ~ ~
“…blood pressure was elevated at…uh 180…Patient…endorsed pain of 9 out of 10—“
“Endorsed pain? The patient loves pain?”
Akutagawa clicked the stop button then deleted that last sentence off the computer. He tried again, pressing start. “The patient reported 9 out of 10 pain in the—” he felt around his own stomach— “right lower quadrant.”
Neither one of them bothered to turn the lights on after it got dark. Dazai’s fingers raced across the keyboard as he worked to finish his documentation for the day in the small windows of time he had between his phone pinging with another message. Meanwhile, Akutagawa stared at the ceiling, willing his mind to string the right words together to sound like he was somewhat competent as he spoke into a small remote.
Computer light reflected off Dazai’s glasses. “Good work today.”
The first image that flashed through Akutagawa’s head was when he broke the sterile field during a chest tube insertion just a few hours earlier. Then when a nurse got stern with him for forgetting to put in discharge orders. How timid he felt to involve himself during the code that morning. Even now, as he dictated and Dazai stopped him every other sentence to make a correction. Akutagawa had plenty of objections, but wouldn’t comment on them with Dazai. “Thank you, Sensei.”
“Remind me, you went to Osaka University?”
“That’s right.”
“Many of our colleagues here did as well. I’ve no doubt you’ll be successful.” Dazai shook his head. “Great school.”
“I hope I can make them proud,” Akutagawa lamented. He rested his head on his hand, finding it difficult to be optimistic after a long day.
“You are. Don’t worry.”
He said it so simply, never even ceasing his typing, that Akutagawa turned his head away in embarrassment.
“It is hard,” Dazai continued, “but, you know that.”
“How do you do this?” Akutagawa had to ask. He thought about the awards lining the walls in Dazai’s office, the damn-near entire alphabet of certifications that came after his professional signature. “Accomplish all of this?”
“It might sound vain, but I wanted it. Med school is long enough, why waste more time not getting the things you want out of it?”
“Yeah. Right.” Akutagawa understood Dazai had a go-getter attitude. He never didn’t jump at the chance to do something even if it meant more work and he clearly didn’t doubt his ability.
Akutagawa…could learn a little more from him.
Dazai pushed his chair back to stretch out his legs. A folded sheet of paper fell from his pocket. Akutagawa recognized the small pink printed boxes that were poking out between the folds.
“So you did actually have the strip in your pocket.”
Dazai glanced at where his attention was drawn. “No.”
Akutagawa picked it up. “What’s this?”
“Don’t lose it.” Dazai tucked himself back into the desk as his phone went off with a message. He read it, then furiously typed out a text, the artificial sound of the keyboard couldn’t keep up with tapping of his thumbs.
Akutagawa flipped the paper around to see what was written. He held it up to the computer’s light. 11 digits coped in blue ink. Akutagawa remembered what he saw earlier. “Is this the paramedic’s number?”
“It is not the paramedic’s number.”
“I see.” Akutagawa sat back in his chair and squinted at the screen. “Then you won’t be texting this number after work?”
The phone was carelessly tossed onto the desk. Dazai’s soft but rapid typing filled the room again. “Akutagawa-kun are we here to scandalize me or are we here to chart?”
“I’m not.” Akutagawa slid the paper back to him. “I didn’t imply anything about you and you didn’t go back to ask out the attractive paramedic.”
“Good grief, who taught you to be like this?” Dazai sighed.
Akutagawa let it go. He didn't particularly care what Dazai did or didn’t do, his brain only felt numb from the sheer amount of things he had done that day and welcomed any reprieve. But, he supposed that for as eccentric as Dazai was, he still had his boundaries. Akutagawa leaned back in his chair and picked up the remote. He clicked the button to start dictating.
Dazai stopped typing. “So, you agree?”
Akutagawa hit the pause button. “So, you did ask for his number?”
“I proposed a meeting to discuss a collaboration between YFD and the local school district to run a program much like ours.” Dazai’s expression was neutral.
“A meeting, huh?”
“Yes, on Sunday. Over coffee.”
“Because you don’t want to see him around more?” Akutagawa pressed.
Dazai’s phone pinged again and he reached for it clumsily. He jumped to his feet. “Look at that, one of the poor residents has an emergency.” He shoved his arms through his white coat. “Finish up here, and since you aren’t back tomorrow, try to complete everything. I’ll be looking over it—or Kunikida-sensei will.” Dazai went to close the door behind him but poked his head in one more time before leaving. “Remember, overtime is looked down upon.”
Click!