by Barbara Ebel
Wilbur nodded before she even finished.
“Strange,” she said. “I’m familiar with the patients who died on our service since our team began. I could even get some of their charts if needed. But could you get their anesthesia records?”
“Yes, but why?”
“I’m not sure. But I think we owe it to them to dig deeper. You and I can walk through their cases side-by-side: anesthesia and surgery. I just think there’s something amiss like burnt toast in a bag of bagels.
Wilbur shrugged. “Okay, I’m in. Nothing like a little espionage … as if anesthesia isn’t exciting enough already.”
Chapter 19
After rounds the next morning, Robby brought the team back to the office. It didn’t escape Annabel’s eyes that he looked especially more vibrant and professionally dressed. She wondered why because, after all, it was just another on-call day. Was he that in love with his specialty to be so chipper about the next twenty-four or thirty hours living in the hospital?
“I am leaving now and will be gone for the weekend,” Robby announced, slipping off his white coat. “Dr. Mack and Dr. Wallace are in charge of the team and will be in close contact with Dr. Pittman. On purpose, we have no elective surgeries scheduled for today although the team will still be taking admissions and emergency operations. I was satisfied with the status of our patients and the only discharge will be Mrs. Watkins. She’s doing fine from yesterday’s thyroidectomy.”
“That’s because only senior staff were in the OR,” Marlin said. He passed it off with a chuckle but no one laughed.
“Save the editorial,” Robby said to him. Marlin squirmed against the door as their chief resident continued in a stern manner. “Any OR cases today will have a student present. This is a teaching hospital.”
“We’ll see to it,” Brandy said.
With parting glances, everyone got up and headed to their duties. Annabel dawdled with her overnight bag while Robby took a few items out of his lab pockets and hung the coat on a hook behind the door.
“Dr. Burk,” she said, “I hope you don’t mind my mentioning this but I heard you were served legal papers regarding Mr. Simmons’ death. I am really sorry to hear that.”
“Yes, it’s true. A first for me but, in our medical careers, it’s bound to happen.”
They were standing close and he looked into her eyes; Annabel gulped at the nearness of his body while his engaging brown eyes stayed on her. “Again, I believe I had nothing to do with that sponge.”
“That may be true.” A smile crept across his face while he still didn’t move. “We did have a little discussion in the cafeteria one day about Global M.D.s. That’s where I’m going right now. To Tallahassee for an interview with them.”
“That’s fantastic! I bet you have nothing to worry about,” she said. “You would be such an asset to a program like that.”
Their eyes continued to hold. Annabel knew he had never paid her this much attention and she felt a flash of longing for him.
“Thank you,” he said softly. Without warning, he swiped the hair alongside her face and goose bumps went down her arms.
“You’re welcome,” she said. “And good luck.”
Robby nodded. “Likewise. And I expect you to live up to your potential on the surgery final as well as your clinical score. Is that a deal?”
Annabel flushed. “Deal.”
Robby made a left out the doorway and disappeared down the hallway as she tried to catch her breath. His behavior had stunned her. Had he developed a personal interest in her? That would be unlikely but, for now, she had enjoyed the attention. In any case, he was her chief resident, he’d be finished with this program within months, and he had a fiancée.
-----
During the day, Annabel and Wilbur Gill both made successful efforts to gather a few patients’ charts that she had selected. Since they were both on call, they had to wait until Wilbur had his dinner break and hopefully Annabel would also be free. That way, they could sit down with the records and brainstorm together any details of the patients’ treatment or care that raised a similar red flag.
Right after Dr. Mack and Dr. Wallace had late-day rounds with the team, the students were told to go eat before the night had the potential to erupt with admissions.
Bob began walking towards the elevator with Da’wan and Ginny. “Aren’t you coming with us?” he asked Annabel.
“No, I may have to skip right now,” she said. “Can you pick up a sandwich and put it in the fridge for me?”
Bob scrutinized her. “Sure,” he said and glanced back at her as they left.
Annabel grabbed the patient data she’d collected and hurried to the anesthesia department next to the OR. Wilbur had texted her that he’d just been sprung from his case by a colleague.
As she opened the door to go in, Marlin Mack came out of the elevator and saw where she went. But she didn’t notice him as she went straight into the department’s conference room where Wilbur fished through his brown-bag of dinner items.
“I have thirty minutes to eat,” he said. “Come over to this side. I have the anesthesia records lined up.”
“Thanks,” she said. “That’s all? Do you mean to say that all the information on a surgical case gets squeezed onto that one sheet?”
“Usually, unless the case goes on for hours then we start another page. And there’s also the preop evaluation sheets which are in this group,” he said.
Annabel placed her own data corresponding to each patient above each anesthesia record while Wilbur dug a plastic fork into a container of chicken salad.
“Wilbur, I don’t know squat about anesthesia pharmacology but that may be to our benefit. So let me ask you this: How short and how long of an effect can some of the drugs you give last?”
“Nice. You’re thinking like an anesthesiologist. Ultra-short acting … like a drug is almost metabolized by the time I turn off an infusion. Or I can give a drug which allows the patient to practically sleep to Thanksgiving.”
“Wow! Your profession wields a lot of power.”
He finished chewing and pushed his finger against the nosepiece of his glasses. “You better believe it. Can’t think of any other group of people who so successfully renders people unconscious and then brings them back. And who also sees to the most important body part for living … an airway.”
She chuckled. “You’re leaving out the heart.”
“But the heart can’t beat unless it gets oxygen which comes from breathing.”
“Everybody makes such a big deal about that diatomic oxygen gas,” she said with a straight face.
“They better. It makes up twenty-one percent of the earth’s atmosphere. But you’re messing with me. I’ll get you back when I’m an attending and you’re maybe an anesthesia resident.”
She laughed and said, “Okay, but let’s get focused on these charts.”
She slipped into a chair and looked at her patient list; it included patients that both the surgery and anesthesia departments had determined had higher than normal morbidity and mortality during the same time frame. They were all accounted for: Mrs. Hardy who had had a cholecystectomy; Mr. Kingman for skin burn grafting; Dolores Vega with a ruptured appendix; and Mr. Simmons due to an inguinal hernia repair complication.
Knowing it would slow her down, Annabel didn’t take notes since they had limited time to sit together. But her first hypothesis she found to be factual; that all four patients had died in the immediate postop period or within twenty-four hours.
As she scanned the anesthesia records more carefully, she said, “They all had general anesthetics and they were all extubated.”
“Correct,” Wilbur said. “And their ages spanned from twenty-five to sixty-five years old. No age discrimination there.”
Annabel nodded. “And one died on the regular ward, one in the burn unit, one in the ICU, and one in the PACU.”
Wilbur frowned. He weeded out each patient’s drug list after surgery. There was n
othing blaringly similar. Although the narcotic pain medication was similar for two of them, the route and dosage was drastically different.
“Nothing suspicious?” Annabel asked after watching him.
“No.” He chugged down orange soda and then tilted his chair back on two legs. “What have you heard about Mr. Simmons’ autopsy results?”
“They are running further analysis on blood work. So, show me what these are on your sheets.” She pointed to handwritten items on the left side.
“That’s what I showed you in the OR. One of the inhalation gases, Isoflurane, has been around a long time. I used it again here,” he said, pointing to another sheet. “But with the gallbladder patient, I used desflurane and I didn’t use any inhalational agent with the sick, ruptured-appendix patient.”
“So no similarities there at all,” Annabel said.
“Correct. We can’t incriminate them. Plus, they’ve withstood the test of time.”
Annabel tapped her fingers on the paperwork while Wilbur unwrapped the cellophane on a jumbo cookie. “Is there any anesthetic that can in and of itself kill someone?”
“That’s a heck of a question, Annabel. An anesthesia provider could kill someone if they overdosed them on a multitude of drugs at our disposal. Take Sufentanil, a potent narcotic which we use mostly for heart surgeries. A couple of vials of that and the patient would succumb to a sleep they wouldn’t wake up from if they weren’t on life support, etc.”
“I can understand that and I don’t know how to really explain myself since I’m not in the field.”
“Which you need to do something about,” he said. “When are you signing up for an anesthesia elective?”
“I want to and I’ll do it when they send out queries about future rotation electives.”
She took his wrapper and dropped it into the can beside her. “And I’m thinking along different lines. Let’s say a patient isn’t intubated and not real sick. And let’s say you give some special IV drug that you use in anesthesia; not an overdose but a regular dose. Is there anything like that that could kill someone if you then left them alone and didn’t support their airway or hemodynamics?”
Wilbur twisted his mouth and thought about it. “Yes, well, I didn’t think about it since it isn’t anything one of us would do.”
“But …?” Annabel waited.
“One of our IV muscle relaxants. The person would become paralyzed and not be able to breathe. Which, by the way, this whole issue with muscle relaxants can be confusing for people who don’t understand the terminology. When lay people think of ‘muscle relaxants,’ they think of a drug that is comforting or sedating, perhaps to ease back pain. But ours are potent agents that paralyze patients and we have the situation under control when using them.”
“I remember I asked you about them in the OR. And you had a little device you were using.”
“A peripheral nerve stimulator. It tells us when the relaxant has worn off well enough to then reverse what’s left of it with another drug.”
“We can’t leave any idea like this unexplored. Where have you marked on your record the muscle relaxant you gave?’ She decided to take out a little notepad from her lab pocket and open it.
Wilbur pointed. “If you are writing this down, I’ll spell it for you. Vecuronium bromide.”
Annabel started searching the records again. “They all received the same thing,” she said as if she’d stumbled onto something.
Wilbur looked at another record. “No. I used a shorter-acting agent for Mr. Simmons’ redo hernia repair. Rocuronium bromide.”
Annabel rubbed her eyes and then ran her hands along her temples. “Two different drugs but they sound similar,” she said, thinking out loud.
“Sure. Lots of drugs fall into their own categories. These two are both aminosteroid non-depolarizing neuromuscular blockers. But if you’re suspicious of them, forget it. They’ve been used for years and they have adequate safety records with the experienced health care providers who use them.”
“Mostly anesthesia?”
“Correct. We use them because they facilitate gaining a good view and access to the vocal cords to put in the endotracheal tube, they provide the skeletal muscle relaxation useful for the surgeon to operate, and - of course - they make mechanical ventilation easier both in the OR, the units, or wherever.
He took a bite while Annabel kept thinking of questions.
“Refresh my memory how they work,” she asked.
“Their mechanism of action is due to their competition for the cholinergic receptors at the motor end plate of skeletal muscle.” Wilbur wiped his mouth and smiled. “I just love pharmacology and what I do, and I’m only a resident. It’s going to be double the fun when I’m out on my own.”
“Sounds like it. I have a long way to go and I don’t know if I’ll make it.”
Wilbur rose and pushed back his chair. “Just take it a day at a time. Now, I better get back to my case. I’ll have these sheets with me if either of us can think of anything else that needs looking at.”
“Yes. Good idea. I still feel adamant that, since both departments only see the cases from their own perspective, these patient deaths should be looked at in a joint fashion.”
Wilbur nodded. “So you’ve said. You’re a pest, aren’t you?”
“Not that I’m aware of. But there’s a first time for everything.”
-----
Robby and Faye settled into their hotel room off of I-10 after a direct flight to Tallahassee. Robby rummaged through his suitcase for a fresh shirt while Faye turned on the TV and leaned against a pillow on the bed.
“Sorry you’re not invited to the dinner interview,” he said.
“Yes, it’s too bad,” she responded. “But we’ll have tomorrow to roam around and relax.” After muting the sound, she continued. “Just bring me back something later. I’m not hungry now after our big airport lunch.”
He buttoned a crisp off-white shirt and put on a tie while Faye watched from the side and scowled. She had agreed to come so they could do something together and she could have a breather from her own clinical duties. But, above all else, she hoped his bright idea to give a year to Global M.D.s would blow up in his face.
The probability of matching a surgical position with his own desire of working in southern Africa was a long shot. Faye understood they interviewed most doctors who expressed interest and then kept a list to feed off of in the future as ‘jobs’ became available. But her plan was to get married this year and for them both to get a McMansion and start living like real doctors … those who would finally earn a substantial income after sweating through the scrimpy years. She watched him as he finished giving his hair a comb-through and turned to her.
“The restaurant we’re meeting at looks to be halfway between here and the capital buildings, so I’m figuring about a fifteen-minute drive without traffic. How do I look?”
“Fine,” she said. “Just be skeptical of promises that sound too good to be true.”
“I don’t think they sugar-coat their positions. This is pure philanthropy.” He walked over to the bed and gave her a kiss. “See you later.”
Robby’s drive in the compact rental car brought him to a small parking lot by a dim-looking building. But inside was another matter. Small, intimate, and elegantly furnished, he appreciated the solo pianist playing in the corner. As he began speaking to the manager, a man waved him over to a wooden table where he and a woman both stood.
“Dr. Burk, nice to meet you,” the woman said. “I’m Sheila, one of the personnel recruitment officers, and this is Dr. Yackel.”
Robby relaxed with a fine wine and a light appetizer as they both explained that airfare, housing, food, and light expenses would be covered if he worked for them for the usual twelve months.
After they all ordered the special of the night and they discussed Robby’s educational and training background, he again expressed his geographical interest where he’d like to do surgery.
Sheila glanced at Dr. Yackel and nodded. The elder man picked up his wine glass.
“We’d love for you to come on board,” Dr. Yackel said. “I go over to Africa every other year for four months to help break in new recruits. Would you like to come with me when you graduate as chief resident?”
Robby’s pleasure registered on his face. “Absolutely.”
As the waitress put down their dishes of mahi-mahi, they all raised their glasses for a toast. “You’ve found your destiny for next year,” Sheila said.
By the time Robby tasted his entrée, he realized that more than likely that destiny would not include getting married.
Chapter 20
When Robby and the people from Global M.D.s finished dinner, he ordered the same entree to bring back to Faye. After all, the good news deserved a fine meal for her as well; he also had the server pack up their dessert special.
Still watching TV, Faye hadn’t moved much from the bed. Her fellowship rarely allowed her time to relax and this getaway with Robby was allowing her to do so. But she quickly grabbed the remote and turned the volume down when he came in.
“Wait until you see the dinner I brought back for you,” he said with a huge grin.
“I’m hungry, so I can’t wait,” she said, motioning for the bag.
He came around to the desktop, wiggled out the Styrofoam container with the entrée, and handed it to her.
“Well?” she said while taking the contents and plastic utensils.
“I was promised exactly what I hoped for,” he said, his eyes growing wide along with his smile.
“And you’re really going to do that when you finish?”
“Absolutely. I’m honored to be included.”
“Honored? Obviously we don’t see eye-to-eye about this whole issue,” she said and got up.
“It appears so. And I’m sorry about that.”
“You know, it’s one thing if we have a different opinion about a minor issue, but this is major. And secondly, have you no consideration for the fact that we are technically planning a wedding?”