Oxygen

by Carol Wiley Cassella

  I remind myself that for all her experience in the legalities of medicine, she isn’t a doctor. “I’m not sure. I gave her a narcotic, fentanyl, and that might have kept it from going up.”

  She raises her eyebrows and waits. I add, “In the whole picture? It probably doesn’t mean anything at all.” Despite this blind alley, it is a relief to finally admit this fraction of doubt in a protected space. “Regardless, the autopsy should confirm anaphylaxis, if I’m right about that.”

  She nods and takes a sip out of her own teacup; her lipstick stays perfect. “Let’s hope so. Keep in mind that whether you did everything right or not, First Lutheran has a vested interest in keeping this quiet, which means settling even if that implies some error. The degree of your error or competence primarily impacts the dollar amount of that settlement.”

  “When do you expect the autopsy results to be back?”

  “Weeks, usually. We’ll go forward on the presumption that they don’t indicate any act of negligence.”

  Negligence. It’s the first time anyone’s spoken that word to me out loud. I’ve said it to myself. I even looked it up: “failure to exercise the care that a reasonably prudent person would exercise in like circumstances.”

  “Ms. Jansen hasn’t actually sued me, though, has she?”

  “No,” she states with a finality that makes me almost relax. Then she continues. “But I expect she will. And if she does, she won’t sue just you, she’ll sue the hospital and everyone in that operating room. And if she sues this will get into the newspapers and cost us that much more.”

  “I understand,” I say, not really sure I understand at all.

  “This needs to be quick.” She is back to all business, her fingers locked across her thin waist. A diamond on her left ring finger sprays flecks of light across my file. “I’m sure you know what a claim like this will do to your database, but we can’t risk a trial. First Lutheran can’t risk it and neither can you. If we settle we at least have some control over the costs. Remember, your policy has a cap. There’s really no winning this, it’s purely a matter of how much we pay her.”

  “What would happen if a settlement went above my cap?”

  Her eyebrows dart upward for a second, and I realize how naive my question must sound.

  “Well, anything above your cap would have to come out of your own assets.”

  Will Hanover is on call tonight. Well after eight o’clock I go back to the hospital and knock on the call room door, hoping he isn’t still in the operating rooms. I hear the bed springs squeak under the pitiful excuse for a mattress we all rotate using.

  “Hi, Will. I’m sorry, were you trying to rest?”

  He runs a hand over his hair and scratches his scalp. “Not at all. I was reading the paper. We’re starting an ex lap in an hour or so—waiting for the patient’s son to get here.”

  “Who’s the surgeon?” I ask.

  “Marconi. Poor lady is eighty-six with an ischemic bowel.”

  “Do you need any help setting up?”

  He laughs. “So you dressed up in your nice clothes and came back to the hospital to help me set up my operating room?” He shakes his head. “How did your meeting go today?”

  I shrug and shove my hands into my coat pockets. “OK. I guess. How did you hear?”

  “Joe. Want a cup of coffee?”

  At a corner table in the cafeteria, I finally ask, and Will tells me the details of a lawsuit he went through in his first year of practice at a hospital in Portland. “It was a bilateral carotid in an obese woman. Not the best surgeon; I was fresh out of residency. I wanted to leave her intubated at the end and the surgeon insisted I pull out the tube. I was right, and he was wrong, but I didn’t stand my ground.”

  He pulled out her breathing tube in the recovery room after she was fully awake, but she thrashed and her blood pressure skyrocketed. The carotid sutures ruptured and she bled into the tissues of her neck, closing off her airway. He couldn’t get the breathing tube back in.

  “She died?” I ask.

  “Worse. She was vegetative for eight years before she died. I wanted to settle but it got too contentious. The family’s lawyer pitted the hospital and me and the surgeon against each other so it went to trial. The award went way past my malpractice coverage. I didn’t have much money at the time, but I lost what I had.”

  “Oh God, Will. I’m so sorry.”

  He stirs his coffee and takes a minute to answer. “The money’s not the hard part. The hard part is convincing yourself that you should ever be allowed to take care of people again. The hospital, the insurance company—they all fixate on the dollars. But you’re the one who tries to go to sleep every night with that patient’s face floating over your head.” The cafeteria is almost deserted; it smells of bleach and detergent and overheated coffee. The janitor begins vacuuming our section and we’re quiet until he leaves.

  “This lady, she had nine kids, eleven grandkids—every time I went by the ICU in the days after it happened, her room was filled with people. Wouldn’t even consider turning off the ventilator. All praying and waving a Bible over her, waiting for her to wake up.”

  He looks up at me and folds his hands in his lap. “I shouldn’t say that, should I? I don’t mean to offend anyone by it.”

  I shake my head. “I was raised Catholic but we dropped it all when I was a teenager. So how did you get through it?”

  “Youth. Jenny, my wife, was great—we had to sell our house. Phil Scoble gave me this job, which I was very grateful for at the time. And I’ve never gone against my own medical instincts again. If there’s any good outcome, it’s that.” He sits back in his chair. “So on to you. Was this your attorney today?”

  “No. My malpractice claims manager. She wants to settle it as quickly as she can—the mother hasn’t sued me, but everyone’s expecting that.”

  He nods. “Well. Yours ought to be more straightforward. I know you can’t talk about it—I sure remember that part—but it doesn’t sound like you made any mistakes. It’s remarkable how many months these things can drag on, though. Lawyers bill by the hour.”

  I wish I could smile at this. “Phil’s been supportive. Even Frank.”

  He nods again, more pensively. “Phil’s a decent guy. Just…” He stops.

  “Just what?”

  He flinches for an instant. “Nothing. Personal philosophy. Always remember they’ll sacrifice the soldier before they’ll lose the war.” His pager goes off and he has to leave for the operating room. The coffee feels like it’s burning right through my stomach.

  The following morning I’m called before the hospital’s Internal Quality Control panel to present Jolene’s case. Someone pours juice for me; I pick up my glass and a quake of tremors spirals across the surface. In voices tempered with sympathy, a panel of strangers in white coats convert my chart notes and dictated description of the catastrophe into a series of checked boxes on a standardized intraoperative death report. The chairman, a doctor who retired from First Lutheran before I went to college, shakes my hand as we leave the room. “This is all formality, Dr. Heaton. The doctors against the lawyers.” He drops his voice to a whisper. “My daughter is a pediatrician. Got sued for giving a kid his measles vaccination. She walked away from her practice afterward. It’s like everybody’s forgotten how to make an honest living.”

  That evening, after my last patient is in the recovery room, I meet with the Physician Committee for Mortality and Morbidity. This time I sit at the end of a table filled with my own colleagues and friends—Sandy, Will, Peter Janovich, Sean Marconi—surgeons, anesthesiologists and internists assigned to objectively analyze my role in Jolene’s death. Phil presides over the hearing. Finally I’m allowed to discuss the details of the case with other doctors—people who can understand all the possible consequences and rationale for the drugs and CPR I gave Jolene. With the record of her surgery and anesthetic in front of me, and the notes I composed after her death, I explain every incremental change in
her status and the intervention I chose to correct it. I keep looking across at Phil, trying to interpret each nod or sigh or pause. Slowing the events down like this, removing the panic, it’s clear to me—to everyone here—that I missed nothing, that I responded appropriately and promptly to every alarming number as it flashed on my monitor. No one points any damning fingers or flags my personnel file with condemnations. Phil concludes by commending my quick recognition of the crisis, my cool allegiance to emergency protocols, my stoic return to work, how appropriately I am putting remorse into its proper professional perspective. There can be nothing to fault, except that Jolene still died.

  Will stops me on the way out. “That went pretty well, don’t you think?”

  I lean against the wall and hug the copies of Jolene’s notes against my chest. “Better than I’d expected.”

  “So maybe there won’t be any lawsuit. Phil told me nobody’s filed anything.”

  He looks so hopeful, it’s hard not to be inspired. “Well, if this committee didn’t flay me alive, maybe the lawyers won’t smell enough money to come running, huh?”

  He holds his palm up for a high five and I meet it with a light slap, but then clasp it tight. “Thanks for being in there, Will. It sure helped to look up and see your face.”

  He shoves his hands into his pockets—now I’ve embarrassed him. “Jenny’s picking me up for dinner at Chez Chez. Why don’t you come?”

  “I can’t. I’ve got a hair appointment.”

  He weighs an invisible scale of pleasures. “Dinner out? Haircut? It’d be our treat!”

  I laugh. “Believe it or not, this is a great sign—that I’m relaxing enough to even think about my hair. Maybe next week, though. You and Jenny can come over to my place.”

  James combs my hair back from my face, presses his palms against my temples and turns my head from side to side. “How about some more layering, around the front?”

  He tips my head back into the sink and begins a deep scalp massage that puts me into a near trance. Over the sound of spraying water I listen to the continuing story of his tattoos: an evolving work of animal art that crawls, swims and flies over his arms and torso. “I interviewed an artist from Taos for the dragon scales.”

  “What happened to the guy from Laguna Beach? I thought he was finishing the dragon.” Even my words are slowed down; I wonder if James can read my future through the bumps on my head.

  “We ran into some artistic differences. This guy’s got a better sense of color, anyway. New Mexico sunsets.”

  “Just make sure he uses clean needles.”

  “Of course, doctor!” He exaggerates the title humorously and starts rinsing out the soap. “So what happened to that kid at your hospital?”

  The muscles in my abdomen go rigid. “What kid?”

  “One of the surgical techs is a client and he told me some kid died on the operating table a couple of weeks ago. Makes me glad I don’t have to cut anything that bleeds. I guess you have to get used to that kind of thing in your business.”

  The water is so warm over my face I can’t be sure if I’m crying when I answer him. “Nobody with a heart could get used to that.”

  Driving home, I go over and over the questions I answered for the committees, replaying their supportive comments and reassurances, waiting for them to sink in and make me believe in myself again. In all the medical minutiae I recited, nobody asked me about the hour I’ve never had to document—the hour I spent trying to help Bobbie understand what had happened to her daughter in the operating room. I can close my eyes and see Bobbie’s face going white, watch her slide onto her knees as if something solid inside her were dissolving.

  I never had a chance to tell her I was sorry. The chaplain interrupted us. Sorry feels like such an insignificant word in the irrevocable context of death; such an obvious sentiment—Bobbie may have heard me say it even though I didn’t. But now, absurdly, it feels like some vital conclusion we both needed. As if, if I could only go back in time and tell her how sorry I am, the outcome could change.

  8

  A certified letter from Feinnes, Reames and Peynor, Personal Injury Legal Specialists, arrives at the end of the second week. We are all named: Don, Brad, Mindy, Alicia, the pharmacist, Matt Corchoran, even Joe—everyone who was anywhere near that room during Jolene’s surgery, whether because they’d been randomly assigned to her case or because they’d been compassionate and dedicated enough to come running when I called the code. Caroline Meyers-Yeager assures me this shotgun approach is common. After the first scattered blast Bobbie’s attorneys will quickly focus on the most exposed and lucrative targets—the hospital, the surgeon and me.

  Lawyers seem to rain out of Seattle’s skyscrapers, clustering around First Lutheran’s mahogany conference table so every named soul can be pulled out of the operating rooms in shifts. Boxes of Krispy Kreme doughnuts and vats of coffee are passed around while they interview all of us. Mindy sits next to me, and she keeps squeezing my hand under the table in a maternal way. She answers every question with an emphatically optimistic note, like a mother defending her child before the school board. They hammer Brad for more than two hours about his twenty minutes in that room. He sifts through pages of typewritten notes he made right after the death, blushing and stammering every time he answers a question about my choice of anesthetic technique, drugs or equipment, or the way I managed her resuscitation.

  If self-confidence could win a legal case, it’s hard to believe John Donnelly’s ever lost one. He is not an overtly handsome man, but his height, his tan, his graying hair, even the hook of his nose, evoke all the principals and college deans and medical board examiners who have ever unnerved me, and I’m thankful he’s on my side. He conducts my interview in a resonant, assured voice. He guides me through hundreds of questions in practice for my deposition—reiterations of my degrees, my medical experience, my certifications—guides me with the skill of a slalom racer, avoiding the red flags of litigation. I relive those hours of my life a dozen times in a single day, while charts and records are checked and rechecked, notes are scribbled and passed between hospital administrators and insurance executives, and attorneys rhythmically tap their pens through the silence that follows each of my answers.

  I keep wanting to blurt out my own questions: Do any of you see the mistake I’m blind to? Would you trust me to take care of your own child? And, reverberating always, below words, is the germinating concept that the more we lose, the more Bobbie Jansen, who has already lost everything, could gain.

  Phil walks me to my car at the end of the day, filling up silence with complaints about our litigious age. Just before I open my door he becomes more serious. “You look like you haven’t slept all week.”

  I sort through my keys so I don’t have to see his expression, unsure what to say. “It’s hard. I’ll get through it.”

  “Look. Some tragedies are just unavoidable in this job. It’s normal, almost expected, that you’ll begin to doubt yourself, even though you did everything you could to save this kid’s life—absolutely by the book. You can’t let this interrupt your career. You’re one of the best doctors in this department, and I don’t want to lose you.” His jacket is slung over his shoulder and faint rings of perspiration darken the blue fabric under his arm.

  I try to answer him but my throat closes up. The garage is empty, lit by spotlights that pock the vast space in cold white cones. I clutch my sweater tighter, shivering. “Thanks.” It comes out barely audible until I swallow and repeat the word.

  “We can give you some time off if you want. Anything you need.”

  I shake my head vigorously, terrified of idle hours at home. “Oh God. That’s the worst thing you could do right now. Work is the only place I feel sane.”

  “You’re able to concentrate?” he asks, the crease between his brows a black gash.

  “Of course,” I say, holding my breath while I look straight into his eyes. “I wouldn’t be in the OR if I couldn’t.” But I see
on his face that he hears my own doubt.

  Four days later I’m coming home after a night on call, fragile with exhaustion after twenty-four hours of labor epidurals and emergency cesarean sections. A gaunt woman with stringy blond hair and chapped skin rushes at me from the curb beside my building, her cigarette still burning on the pavement. “Are you Dr. Marie Heaton?”

  “Yes, I’m Dr. Heaton, what can I…”

  “I’ve got a subpoena here for you.” She pushes a long white envelope into my hand, jabbing a finger at the black letters of my name, a relieved look on her face, knowing she has earned her pay. She runs back to her car before I can open it, her cigarette still disintegrating on the sidewalk in a graceful twist of smoke. I’ve been expecting this for weeks, but I still feel the affront—like running into a piece of familiar furniture in a dark bedroom.

  In the weeks leading up to my first actual deposition I start coming to work earlier, often arriving before the night cleaning crew has finished—an institutional odor of disinfectant rising like morning fog off stainless steel, the hallways so dim and still they have the aura of a morgue. It becomes the only peaceful part of my day, opening the heavy swinging doors into the dark operating room, the ventilator and pumps and monitors looming in the shadows like mechanical mannequins. I almost hear their robotic voices interrupted by my living presence.

  At home, in the sleepless single digits of the night, I scour textbooks in search of answers. I read about anaphylaxis, an unchecked death spiral of the immune system. I study biochemistry, evolution’s masterwork of elements shot from the first exploding star, cohered into a living being. I rememorize pharmacology, the molecules we manufacture to stall nature’s culling of the ill and aged. I read as much as I can of the ocean of knowledge we have accumulated about our physical bodies since the days of leeches and humors, the ocean of knowledge that encompasses only a fragment of all there is to know about what holds physique and soul in union for the flicker of a lifetime. Knowledge will be my magic wand; knowledge will reclaim my control over the anesthetized patient spread like a crucifix on the operating table.