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“I, um …” She fiddles with her hands, tapping one thumb over the other nervously. “Thank you for yesterday, for what you did.”
I freeze for a moment. I’d bet my life Richard didn’t mention my name or my threat, so her guess at what I did, while 100% right, is a shot in the dark.
Grabbing my thermos from the desk, I bring the mug to my lips, pausing for a long, leisurely sip. “Whatever are you talking about, firecracker?”
She smiles wide at the new nickname and my heart roars. “Never mind.” She shakes her head. “Just know that I appreciate what you may or may not have done yesterday.”
I nod, glancing at the computer screen in front of her and recognizing the patient’s name. It’s a young girl who was admitted yesterday for diabetic ketoacidosis. She was managed by one of the other doctors previously but transferred to my care this morning. The report I received from the night shift seemed fairly straightforward. I haven’t dug deep into her chart yet. “What’s going on here?”
She rolls her chair a beat away from me to get a better view of the screen. “Have you had time to review the overnight labs?”
“I know her labs are out of control,” I say, rubbing my palm roughly on the side of my face, scratching my three-day-old scruff,“but she’s only been on the insulin infusion for abouttwenty hours. It’ll take days for everything to get back within normal limits.”
“I know that, but shouldn’t we be seeing some sort of improvement in most of her electrolytes? Plus, her anion gap—”
“Is going to be high. She’s in DKA,” I interrupt before thinking. I'm not sure why she's questioning a seemingly routine case. I haven't had time to see the patient yet, or review labs, but I’ve breezed through enough to know all necessary orders were in. Now it's just a waiting game to see when her glucose improves.
Lainey flinches, just a hair, before turning to pin me with that olive gaze of hers as she leans back in the chair.
“If you had let me finish, Dr. Ryan, I would have said that her anion gap continues to climb, and her glucose hasn’t plateaued yet. She’s on hour twenty-two of a continuous insulin infusion, plus as-needed dosing with meals. Piggyback doses of pFotassium are given almost every four hours, shouldn’t we see an improvement? Something seems off.”
I roll my chair closer to her, reaching over to grab the computer mouse from her, feeling more and more like an asshole the further I scroll.
Well, shit. She’s right.
Even with the insulin infusion and replacing potassium, her chloride and anion gap continue to climb. Her glucose levels haven’t seen much improvement. I rack my brain to think of other causes for the problem besides DKA. Lainey watches the side of my face as I think.
“You’re right. We should have seen some improvement by now,” I finally respond. I lean back in my chair and take a long, hard look at her. I’m impressed. I knew she was smart. I knew she thought more about her work than she needed to, but I didn’t honestly expect her to find something I missed. Something that the night shift doctor also missed.
“So,” her voice is softer as she speaks, and I wonder why that seems to be the case every time she stands up for herself, “what do you think is going on?”
“I want you to figure it out with me.”
A red flush crosses her cheeks. “Okay.”
“What does the anion gap measure?”
“Acid-base level in blood, which is why it’s usually high with DKA because of the excessive ketoacids.”
“Yup, and DKA is an excessive production of keto acids at the expense of what?”
She furrows her brow as she thinks, and I momentarily forget what we are talking about. I study her eyes, that dark green color that continues to stun me no matter how many times I look at them. Today they’re a soft olive. Muted like this when she’s tired or thinking. Some days they are a sparkly emerald, like that night at the bar when we first met.
My favorite is when they are a forest green. Rich, vibrant, when she’s teasing me or blushing under my stare. Match that with her chestnut brown hair, sprinkling of freckles across her nose, and a smile that would stop any man in his tracks. She’sbreathtaking. Add in her brains and her fire, her soft demeanor, and all my defenses are gone.
“Um, bicarbonate?” she asks, snapping me out of my daydream.
“Correct. How is her renal function?”
She scans her very detailed written notes. “Output is good, and creatinine and BUN are normal.”
“Like you said, we’d normally see an improvement in blood sugar levels by now. It’s possible that with the acidity in her blood, she’s developed hyperchloremia.”
“Along with DKA? Or was it a misdiagnosis?”
“They can go hand in hand. Hyperchloremic acidosis can be a complication of DKA due to the type of fluids given. It makes themetabolic acidosis difficult to reverse, which is why her anion gap continues to increase. So, if that’s what we think it is, how do we go about treating it?”
She thinks, biting her lower lip. I grip the arms of the chair to keep myself from reaching up and pulling it out from her pearly teeth.
