Deadly Errors

by Allen Wyler

  He heard, “What the … ahhh Jesus Christ, someone barfed.”

  On his side, knees against his chest, Larry Childs struggled to roll onto his stomach when something kicked his leg. A white hot ember glowed in the back of his mouth above his tongue, stealing his breath.

  “What the hell …” that voice said. “Oh, Blessed Virgin Mary, Larry, s’that you? What’s wrong?”

  Mr. Jorgenson was kneeling over him now trying to turn him onto his back. But Larry wouldn’t let him. He didn’t want his boss to see his hand and send him home or to the doctor. This job—the only real job he’d been able to land in his 21 years—was just too important to him. Reliability and dependability had been drummed into him during the vocational rehab sessions. No, he wouldn’t let Jorgenson send him home.

  “I … just need to get to the men’s room … wash up.”

  The stench of frying vomit and the burning in his sinus sent another ripple of bile racing up his esophagus. But there was nothing much to come this time. The headache kept squeezing in from both temples as if a vice was being cranked slowly closed. Both eyes felt ready to pop from his skull.

  Again he tried rolling onto his stomach, but Jorgenson kept trying to turn him onto his back. The really bad thing was the headache was much more intense lying down on the floor—worse than during past two days as it grew to the point he couldn’t sleep flat without it becoming intolerable. So each night he had waited until his parents went to bed before sneaking downstairs to sleep upright in Pop’s La-Z-Boy recliner.

  Out of the mental haze he heard, “Frank, call Larry’s mother. The number’s on the Rolodex on my desk.”

  Larry struggled to push up, to tell him no. She’d only take him home and that would ruin everything. Doctor Fraser at Voc Rehab had warned him …

  MAYNARD MEDICAL CENTER

  “DOCTOR MATHEWS.”

  Tyler turned from the patient he was examining. “Yes, Teresa?”

  “Phone call for you. I’ll put it through to your office.”

  He cast the clinic nurse a questioning look. The only reason to interrupt him during a patient visit would be a call from another doctor. In such cases she always mentioned the physician’s name.

  She nodded toward the hall, suggesting she’d provide an explanation out there. He told the patient he would be right back and exited the room. Before he could ask, she said, “It’s your ex-wife.”

  “Nancy?” His heart accelerated. How long since she walked out on him? Ten months, ten days, he knew. Was this it? Had she unleashed her pit bull lawyer? His stomach knotted.

  “Is there another one I don’t know about?” When he didn’t respond immediately, she added softly, “Yes, Nancy. That’s why I thought you might want to take it.” Her eyes twinkled against her flawless brown Filipino skin.

  A strange brew of hope and dread infused his chest, causing him to freeze.

  She shot him a questioning look. “Is there a problem? I thought you’d be overjoyed, the way you still mope around here, pining away about her.”

  “I mope and pine?” trying to make it light.

  She gave him a playful slap on the arm. “You’re changing the subject. Is there a problem?”

  He started walking. “Are you always this nosey?”

  Teresa laughed.

  Sitting in his small office, hand wavering over the phone, he thought, This can only be bad news. It’s finally over. He palm-wiped his face, sucked a deep breath, and picked up the phone. “Hello, Nancy?”

  “Hi, Tyler.” Her voice sounded upbeat and friendly. A good sign?

  “What’s up?” trying to sound casual, trying to mask the dread in his voice. He visualized the day he’d met her at UCLA—a molecular biology grad student hunched over a microscope. At the time he was a chronically fatigued first year neurosurgical resident.

  “I’m in Seattle now, working at the Fred Hutch.” She laughed. “Mom’s ecstatic, says that by leaving the academic womb, I’m finally acting like a grown up and putting my degree to good use.”

  Tyler rubbed his temple. “This a consulting thing or what?”

  She exhaled audibly. “No. It’s permanent. I mean, like any grant it’s for as long as the money holds out. Oh heck, I’m not very good at this, at making myself vulnerable, but … I was wondering … if we, you know, you and me … if we might still have … damn it, Tyler, let me just say it. I miss you. I have since the day I left you. Do you think we might try … I mean, are you seeing someone?”

  “Hold on a second.” A sudden dizziness forced him to lean back in the chair next to his desk, the small office cramped with filing cabinet, book cases, one wall choked with framed diplomas, and both his California and Washington state licenses.

  He rubbed his lips and tried to calm his voice before uttering another word. “No. I’m not seeing anyone.”

  “Then can we meet for dinner, say next week?”

  Tyler’s heart leapt with joy. Then his beeper started ringing. “Hold on a second.” He recognized the phone number for the Emergency Department. The digits 911 after the message signaled an emergency. “Yes, I’d love to but I just got beeped … an emergency. Got something to write with?”

  “Yes.”

  He gave her his apartment phone number. “If I don’t answer, leave your telephone number. I’ll get back soon as I have a chance.” On second thought, might as well write it down now. He glanced around his cluttered desk and found a ballpoint advertising a new antibiotic. “What’s your number?”

  She recited it. He scribbled it on a Post-It.

  “I really want to see you again, Tyler.”

  His throat constricted, his eyes misted. “Me too, Nancy. Gotta run. Bye.” Reluctantly he hit the disconnect button and dialed the ED.

  “Doctor Mathews answering. What’ve you got?”

  “Thanks for getting back to me right away. Remember a patient, Larry Childs?”

  Tyler’s heart sank. “What? He have a seizure?”

  “No. Worse than that. Looks like he’s herniating.”

  “Herniating? People with epilepsy don’t herniate, they seize.”

  “That’s all well and good, but that’s sure as hell what it looks like from this end. Guy’s left pupil’s blown, both disks show four plus papilledema and he’s Cheyne stoking.” Papilledema. A bad sign meaning the nerves at the back of the eyes were full of fluid from elevated pressure inside the skull.

  “Cheyne stoking?” An abnormal breathing pattern. “Damn.” Obviously, something other than his epilepsy was causing the problem. A subarachnoid hemorrhage? “Ordered an MRI yet?”

  “Scanner’s full with another emergency. He’s on his way to CT as we speak.”

  “I’ll be right down.”

  “MAN! NOW THAT’S what I call ugly,” whispered the CT technician so the nurse from the Emergency Department on the other side of the lead impregnated glass couldn’t hear. The tech was an overweight, thirtyish woman with a duck’s ass haircut and a white polo shirt cut sleeveless to showcase tattooed barbed-wire encircling linebacker biceps. Tyler liked her because she could whip out three top quality scans in the time most techs took for two.

  Tyler stood in the scanner control room watching “slices” of Larry Childs’s brain appear as infinite shades of gray and black on a finger smudged 21-inch monitor. The air was stale from poor ventilation and smelled vaguely of electronics.

  Tyler mentally ticked through several possible causes for Larry’s problem. The entire left side of the kid’s brain was swollen, flattening the surface against the inside of the skull and obliterating the normal convolutions that characterize human cortex. Even more alarming was that the swollen left brain was compressing the normal right side and in the process had twisted the brain stem causing Larry’s coma.

  Tyler leaned out of the control room doorway, and said to the nurse, “I want 25 grams of Mannitol and ten milligrams of Decadron pushed STAT.”

  She cast a hesitant glance at her patient while untying the le
ad shield. “You’ll watch him?”

  “Of course, now go!”

  Tyler stepped down one step into the room that housed the GE-built scanner and accepted the lead-impregnated shield from her. Since the scan was over, he draped it on the wall holder over two similar protectors, then moved next to the table as the sliding gantry withdrew Larry Childs’s head from the huge cream-colored donut. Thin, gaunt, Larry’s pale white skin blended with the sheet covering him.

  Larry’s breathing was becoming more labored. Before the CT tech could leave the control room phone, Tyler yelled to her, “Page anesthesia and respiratory therapy, STAT. He needs to be intubated.”

  She flashed a thumbs up.

  Tyler pulled a penlight from his white coat to shine in Larry’s pupils. The right one was normal size and reactive. As billed, the left was dilated and non-reactive. Not bothering to test the corneal reflexes, Tyler tapped his reflex hammer against Larry’s biceps and patella tendons. The right-sided reflexes were distinctly more brisk than the left. All findings consistent with the CT picture of swollen brain pushing on the delicate brain stem regions controlling consciousness.

  “Anesthesia’s tied up in the cardiac ICU.” The imaging tech stood beside him now.

  “God, every time you need an anesthesiologist …” He shook his head and recalculated the need to intubate Larry. “Respiratory therapy?”

  “On the way.”

  At that moment the nurse returned with a syringe, a vial and an IV bag. “Here’s the Decadron,” she gasped between breaths. “Give that. I’ll push the Mannitol.”

  “Wait a second.” Tyler held up his hand. “We need to cath him first.” Giving a powerful diuretic like Mannitol without a urinary catheter in place could burst the bladder.

  “I’ll do it,” the tech offered.

  The ED nurse’s brow furrowed, “You certified to do that?”

  “Fuckin’ A.” She thrust a thumb at her own chest. “Served as a navy corpsmen before this gig.”

  Tyler cut off the ED nurse: “We don’t have time for any territorial pissing matches.” To the CT tech he said, “Grab a Foley set and get to work.” To the nurse, “If there’s a problem, I’ll deal with it later.”

  She shot him a withering glare before jerking a blood pressure cuff from the wall holder.

  “Stow it. We don’t have the time,” he shot back.

  From the small glass vial, Tyler drew into a syringe ten milligrams of a steroid to combat brain inflammation. He injected the drug into Larry’s IV line as a respiratory therapist—a Japanese woman, no taller than five feet—jogged into the room. “What’s up?”

  She looked no more than 21 to Tyler. “We need to tube this patient now. You have an intubation tray ready?”

  “You bet, but anesthesia’s tied up for ten minutes or so. Can it wait?”

  Tyler glanced at Larry again. His right arm muscles were tightening into rigid extension, signaling his brain function was deteriorating. “No we can’t.”

  “Well then—”

  “I’ll do it,” Tyler interrupted. “Just get the tray.”

  Soon as the words flew from his mouth a feeling of panic shouldered aside his confident reply. Unlike the well-lit operating room where a few anesthesiologists allowed him to practice this skill, this area had poor lighting and he was wedged awkwardly between the scanner and the wall.

  “All done.” The CT tech pulled the white sheet over Larry’s exposed genitals. Pale yellow urine flowed down the plastic tube toward the collection bag.

  The nurse gently pushed Tyler aside as she wheeled a stretcher next to the scanner. She asked the group, “Ready to transfer him onto the stretcher?”

  Using a plastic transfer board to bridge the gap between the scanner gantry and stretcher, they used the draw sheet under Larry to pull him onto the stretcher.

  A moment later, the respiratory tech rushed in carrying a tray wrapped in a blue surgical sheet sealed with strips of autoclave-sensitive tape. She asked Tyler, “Where do you want this?”

  Tyler sucked a deep breath, glanced around and nodded at a stainless steel Mayo stand against the wall. “Over there.”

  She placed the package on the stand and expertly unwrapped it, keeping the contents sterile.

  Just then Childs’s respirations stopped.

  “Shit.” Tyler’s gut knotted.

  The respiratory therapist shot him a nervous look. “You sure you can do this? I could put some O-2 on him until anesthesia gets here.” She didn’t sound convinced this was such a good solution.

  Tyler glanced at the opened tray and back to Larry Childs. “We can’t wait.”

  3

  WITH DELIBERATELY UNHURRIED movements Tyler snapped a medium curved blade onto the laryngoscope handle. Start to rush, you make mistakes, he reminded himself. After checking to see if the light at the end of the blade worked, he pulled the chrome Mayo stand to the head of the stretcher. He told the respiratory tech who was struggling to keep Larry’s lungs full of oxygen by using a face mask and an AMBU bag, “Open me a seven point five.” Then to the nurse, “Suction ready?”

  “Yes.”

  He sucked a deep breath, trying to quell the anxiety making his hand tremble. One shot’s all you get, pal … Aggravate the vocal cords into spasm and the resulting lack of oxygen will cause Larry’s brain to crush the brain stem.

  He lifted Larry’s chin, tilting the entire head back toward him and opened the mouth. Laryngoscope in left hand, he slipped the silver blade into the mouth and over the tongue, inserting almost all the curved part before pulling straight up. The pale pink larynx popped into view, both vocal cords glistening in the light. Holding the scope steady, never losing sight of the cords, he held out his right hand. “Tube.”

  And felt the smooth plastic contact his fingers.

  Gently he worked the endotracheal tube over the steel blade and through the opened vocal cords. “Got it.” A paradoxical adrenaline rush hit, making him giddy.

  Stethoscope to her ears, the short respiratory tech listened first to Larry’s left lung and then to his right. “Airway sounds good,” she said with palpable relief.

  Tyler exhaled the deep breath trapped in his lungs since inserting the laryngoscope. He placed a bite block between Larry’s jaws and taped the tube into place.

  As he stripped off his gloves the nurse asked, “His mother’s in his room. You want to talk with her now, or should I tell her you’ll be out later?” Her way of dumping responsibility of breaking the bad news on him rather than the ED physician. Nurses tend to protect their own, he knew. In the ED he was the outsider.

  He glanced at the respiratory tech. She nodded toward the door. “I have him under control until anesthesia arrives.”

  “Which room?”

  “Trauma Six.”

  Tyler sucked a deep breath, stepped out of the cramped scanner room, and stood in the hall wrestling with an explanation Larry’s mother might understand.

  Radiation necrosis. That has to be it.

  He considered this diagnosis more carefully. Four months ago Larry Childs became subject number twelve in a multi-center clinical trial evaluating highly focused radiation as an alternative to traditional surgery to obliterate seizure triggering brain tissue. The one-shot treatment came from the Z-Blade, a third-generation radiation device touted as state of the art.

  A bolt of gut-churning anxiety hit. Did I make a mistake? Did I do this to Larry?

  No, he reminded himself, the system doesn’t allow only one person to determine treatment. He mentally ticked off the steps required. He, Tyler, provided the tissue targeting volume. Then Nick Barber—the study’s Principle Investigator at the University of Pittsburgh—calculated and then electronically transferred the radiation dosage back to Larry Childs’s MMC chart. Only after Tyler confirmed this dose had the Z-Blade accepted it. Even then, the computer was programmed to never accept a dose outside a reasonable range without a cumbersome override entry. This technique was supposed to provide bul
letproof protection from such errors.

  No, he assured himself, it’s something other than radiation necrosis that’s swelling Larry’s brain.

  Despite reassuring himself, he couldn’t shake the nausea twisting his stomach.

  FACE ETCHED WITH deep stress lines, Larry’s mother perched rigidly on the edge of a molded plastic chair, right hand clutching a magazine rolled into a tight baton. She glanced up as he approached, pessimistic fear immediately replacing the glint of recognition that flashed across her eyes. Tears followed in anticipation of Tyler’s words.

  “Is he going to be all right?” she whispered tentatively.

  He hedged. “I don’t know yet Mrs. Childs, I need more information.” He pulled a burnt-orange plastic chair next to hers, reached out, and placed a reassuring hand on her arm. “All I know is the left side of Larry’s brain is swollen and pressing on those deep areas that control his consciousness.”

  “It’s the radiation, isn’t it.” Making it a statement, the fear in her eyes changing to self-incriminating anger. “Lord! I knew he shouldn’t have that radiation.”

  Tyler shook his head. “Whoa, let’s not get ahead of ourselves, Mrs. Childs. We don’t know that.” He caught himself from punctuating the sentence with “yet.”

  The corners of her mouth turned south in an expression that rippled a taste of guilt down Tyler’s throat for not confirming her suspicion. He swallowed. But why speculate on a diagnosis now if not completely certain they weren’t dealing with something totally off the wall? Something like a Herpes infection, for instance.

  “Ma’am, I need to take Larry to surgery to remove that temporal lobe, the one causing the seizures, to relieve the pressure off his brainstem. And I need to do this as soon as I can get an operating room geared up.”

  “He’s going to die, isn’t he.”

  He swallowed again. “Not if I can help it.”

  Her pessimistic eyes said she didn’t believe he could.