by Allen Wyler
As Tyler pulled the Mayo stand next to the gurney, Rowley said, “I am personally going to see that this is brought up to the Medical Executive committee. You’re doing this without an operative consent.”
Brown called over, “Hey, good point. His wife’s out in the waiting room. I’ll go get one from her.”
“Thanks.” Tyler slipped on a mask and sterile gloves, opened the sterile layer of the pack and draped off the prepped area with four blue sterile towels, which he clipped together at the corners of the opening.
He waved a syringe at a nurse. “Need some Xylocaine with epinephrine.”
The nurse held out a vial. Tyler punctured the protective membrane with a needle and withdrew 5 ccs which he injected in the skin where he intended to drill. He stabbed a small scalpel blade through the wheal and for the next thirty seconds pressed a small cotton sponge over the wound to stop the bleeding. Next he selected a small drill bit from a choice of three and tightened it into the chuck of a stainless steel hand drill. Carefully, he slipped the drill through the stab wound and hit skull.
He jutted his chin toward Torres’s head, told the nurse, “Need some help here. Give me some counter pressure.”
Gently at first he drilled, feeling the tip bite into bone. Ninety percent of this technique was feel, he knew. Now that he could appreciate the force against the bit he turned it a little faster. A few turns and the bit advanced, dropped through the outer bone layer into the thin marrow space. It “caught” again as it started cutting into the inner bone layer. He drilled slowly now, waiting to feel the final slight catch as the tip penetrated the skull and pushed up against the dura. There! He felt it.
Not wanting to drive bone flecks into the underlying brain he withdrew the drill and wiped the bloody tip clean with a fresh sponge. In the background he could hear another Rowley rant. Fuck him, he thought and concentrated on sliding the drill bit back through the scalp wound on into the skull hole. He gently tapped the drill point against the dura, feeling the tough membrane give way ever so slightly. With a quick twist, the drill point shredded the dura, giving him a path to pass a needle.
Brown entered the room waving a piece of paper. “Got it. You can shut up now Roland.”
Tyler replaced the drill on the tray and sorted through the long biopsy needles. He picked a long round tipped one with a single side port and a core filled with a removable stylet, which he tested to make sure removed easily.
For a moment Tyler studied Torres’s head, imagining the underlying anatomy in three dimensions, a process he excelled at. His drilled hole was directly above the left ear, placing him above the mastoid sinus, which he believed would be the nidus the infection had spread up from, probably spreading along the veins that drained the brain. If so, if he passed the needle slightly downwards toward the base of the skull, chances were he’d hit the abscess.
Big if, he realized, as Rowley’s threats echoed in his mind.
He glanced up. Rowley glared back at him. “You’ve done it now, Mathews. You better pray you’re right otherwise I’ll have the executive committee strip your privileges from you.”
Suddenly his confidence vanished. Other diagnostic possibilities began to flood his brain, none of them very likely, but neither was a brain abscess—statistically speaking. C’mon, pal, what else can it be?
Holding the needle between thumb and forefinger, bracing the side of his hand against Torres’s scalp, Tyler gently slid the needle into the hole. Probing, layer by layer, he worked the needle tip down to the dura. Next the tip entered soft mushy brain with a feel obviously much different than normal tissue.
“Feels too mushy,” he muttered to no one in particular, trying to buoy his confidence.
Means nothing except it’s abnormal, he decided. Could still represent a stroke, just like Rowley claims it is.
Slowly, gently, he pushed the needle deeper, the tip of in index finger transmitting subtle, tactile messages to his brain.
“There! It hit resistance.”
He probed again. Clearly resistance. An abscess capsule maybe? Or even tumor. His finger tip tapped the needle a little deeper, breaking through the resistance into another mushy area.
Left hand holding the needle perfectly still, his right hand pulled out the stylus. Green, foul smelling puss poured out. Relief surged through his body. He glanced at Rowley who turned away muttering.
“We need some culture tubes,” he called to Brown. “Anaerobic and aerobic. And I want a STAT gram stain, culture and sensitivities, and …” so relieved, his mind went blank. “Shit, just give me the whole enchilada.”
He selected a glass syringe from the sterile tray, attached it to the needle and slowly aspirated a full 10 ccs of pus. He handed the gunk-filled syringe to Brown and picked up another. Again he filled it. A total of 20 ccs withdrawn. That should make a huge difference, he thought.
Torres began to groan and tried to move his head. “Hold on, Jose.” Tyler pulled the needle from his brain, having withdrawn enough pus to decompress the life threatening pressure.
With a butterfly Band-Aid Tyler closed the small stab wound, then stripped off his gloves. Off in one corner Rowley chewed his lower lip. Tyler caught his eye for a moment and held it before turning to Brown and saying, “I’ll go put a note in the chart.”
Just then his beeper went off.
“This is Doctor Mathews. Did someone page me?” Tyler sat in front of a computer terminal in the Emergency Department work area, his left shoulder wedging the phone against his ear while he held up his beeper and rechecked the displayed number. It wasn’t familiar but the prefix could very well be within the medical center exchange.
“Doctor Mathews, thanks for calling back so promptly. This is Lieutenant Campbell, Maynard Security. Could we meet outside your locker in the dressing room.” It was not a question.
16
A FIST GRIPPED Tyler’s intestines and twisted. A cold feeling of déjà vu swept through him like an arctic gust. “My locker?” He flashed on California.
“Yes sir.”
He glanced around the area in panic, instinct urging him to get out of the hospital. “Why would you want to meet me at my locker?”
“I don’t want to go into it over the phone.” This said with a sharp edge of impatience. “If you please, just meet me at your locker in, say, two or three minutes.”
“Sorry, I’m busy in the Emergency Department at the moment.”
“You know what, I’m a very busy person too, so I don’t exactly have a world of time to dick around with you about this. Let me put it to you this way. That locker of yours will be opened in three minutes with or without you standing there to witness it. After that, closing it will be your problem. Understand?”
The line went dead.
Tyler quickly terminated the connection to Torres’s chart and told the nurse he’d be back in a few minutes. He chose a side stairwell to climb from A Level to the second floor, taking stairs two at a time. As he walked the block-long hall from the south to the north end of the building, a nauseating premonition churned his gut. Another set up. He was certain of it. Someone knew exactly what happened in California and was copying it.
The question was, who?
He would need a lawyer, of course. A criminal defense lawyer. And a good one. But how to find one?
He rounded the corner to the short hall that ended at automatic double doors serving the operating rooms. On his right, the women’s locker room. To his left, the men’s locker room. An officer in a black MMC security uniform stood outside the door waiting. Presumably Lieutenant Campbell. Doctor Jean Anderson, Director of Medical Affairs, stood next to him wearing a dour expression and a pale violet Armani suit with a blue silk scarf around her neck. Both went well with her short cropped silver hair.
She said, “Sorry to have to do this Tyler, but …”
“Your lack of sincerity is deeply touching, Jean.”
Campbell said to her, “I’ll go in first, make sure everybody’
s ready to receive a female visitor.”
With Campbell gone, Tyler asked her, “What’s this all about, Jean?”
She hesitated a second. “Someone swiped some narcotics from the anesthesia pharmacy.”
“And an anonymous tip just happened to finger me, huh? How convenient.”
She adjusted the gold lady Rolex on her wrist. “Sarcasm isn’t going to get win you any brownie points on this one Tyler, so stow it. Besides, you’re in more trouble than just this. The Quality Assurance committee has been asked to review a recent surgical mortality. Larry Childs?”
He started to defend himself when Campbell’s head popped out from behind the door. “Coast is clear.”
Heart pounding, fingers tingling, Tyler led them to his locker. He picked up the combination lock, missed the first number and started over again. This time the lock clicked. He opened the narrow metal door and stepped aside without even looking, knowing exactly what they’d find.
Campbell stepped up to the locker. “My oh my, what do we have here?”
Tyler heard the clink of glass vials being collected but said nothing. A bonfire erupted in his chest but instinct warned not to say a word at this moment.
Anderson said, “Doctor Mathews, as of now your admitting privileges are suspended pending a hearing with the Medical Executive Board. You have the right to care for any patients still in hospital, but you will not be allowed to admit any new patients. Is this clear?”
FUMING, TYLER SAT in his office and tried to think through his next move. Call Ferguson, tell him what happened and ask for help? Only way Ferguson would help is if Tyler spied for the FBI and that too was an almost certain route to self-destruction—a lesson he learned too well the last time he tried to help the feds. And even if Ferguson agreed to intervene, what could he possibly do or say? Support Tyler’s claim the drugs were planted in his locker? Hardly. Ferguson would never believe him. Not when he held a fistful of Tyler’s forged Ambien prescriptions.
Shit! He reached in his desk drawer for a TUMS.
And what would happen to him now? Sure, he could deny stealing the drugs, but who would believe him? Especially with since graduating a drug rehab program.
He flashed on Nancy. She’d never take him back if she found out. The gut rototiller revved its engine.
You’re really screwed this time, pal.
He noticed the time and realized he’d completely forgotten his interview with Doctor Beck. He picked up the phone and dialed her number. No answer.
For a distraction Tyler turned to the computer and moused the Med-InDx icon. Might as well finish the note on Torres. The chart popped up along with a message notifying him of some preliminary lab results. He clicked the dialog box and found the gram stain findings were back from microbiology. Interested now, he clicked that tab.
And saw:
Gram stain shows numerous white cells, a large degree of necrotic debris, and four plus gram negative rods. Cultures and sensitivities pending.
GRAM NEGATIVE RODS? Tyler vaguely remembered Brown saying something about gram positive cocci, not rods. A completely different type of bacteria. He checked the lab report from Torres’s earlier visit, the one prompting treatment with Ampicillin. Correct. Gram positive cocci were cultured from the original bacterial cultures.
Tyler leaned back and stared at the ceiling, mulling this over. “Huh!” He leaned forward, grabbed the telephone and dialed the Emergency Department and put on hold. A few moments later Brown picked up.
“John, Tyler. Look I was calling about our patient Torres.”
“Nice job, by the way. You ran out on me before I had a chance to thank you.”
“What I’m calling about is, do you remember the results of the original gram stain?”
“I’d have to look to be sure, but I’m almost certain it was gram positive cocci. Why?”
Tyler’s suspicions increased. “It’s now gram negative rods.”
Brown gave a long slow whistle. “Holy Mackerel! No wonder the bug juice didn’t touch him. Jesus. How could I have given him the wrong drug?.”
“Not necessarily. Maybe the abscess came from a different source. Blood borne, maybe.”
“Nice try, Tyler, but I wasn’t born yesterday. I screwed up if it’s gram negative.”
“Don’t be so sure,” he said. “Let’s see what the sensitivities come back as. Even treated otitis can become an abscess it if wants to.” In the background phone noise, Tyler heard Brown’s name paged over the intercom.
“Uh oh, gotta run.”
“Bye.”
Tyler sat back and thought it over again. Brown was a superb ER doc. Not one to make a mistake of that magnitude. He checked the chart again. The original culture clearly documented gram positive cocci, not gram negative rods.
Tyler burnt a copy of Torres’s prior lab results to CD. He knew full well that Khan, or anybody else with system administrator privileges, would be able to document the download if they were monitoring him, but so what? He was on record as having treated the patient in the ED. He had a perfect right to access this chart.
A plan began crystallizing in his mind.
FIVE MINUTES LATER Tyler knocked on Yusef Khan’s open office door. Khan glanced up from a printout on his desk and smiled. “Yes Doctor, what is it I can be doing for you?”
Tyler entered the office. “I believe I’ve found another chart error.”
The man slid off his reading glasses and placed one stem in the corner of his mouth. “Another chart problem? Another one of your so-called hacker problems?” He grinned at Tyler.
“Yes,” he admitted, studying Khan’s reaction. “Only now I’ve changed my thinking. I don’t think a hacker’s the problem at all. I think the problem’s in the system. A bug in the software.”
The grin vanished from Khan’s face. “A bug in the system? What kind of bug?”
“One that corrupts database fields.”
“This is so?” Khan stiffened and removed the stem from the corner of his mouth. “You have proof of this?”
“Suddenly you’re interested, are you? Sorry to disappoint, but, no, I don’t have proof. I just have an example.” He gave him Torres’s name and chart number, then had him pull the chart up on the monitor. Tyler pointed out the problem with the initial gram stain and the one taken earlier and explained the resultant disastrous abscess from an erroneously treated infection.
“But can not they be different, these two infections?” Khan asked.
“Theoretically, yes. Probabilistically, no.”
“And why are you showing me this?”
Tyler’s turn to grin. Gotcha! “Because, my friend, if anything in that record changes now, you’ll have to believe me. Yes?”
FROM KHAN’S OFFICE Tyler headed straight for Jill Richardson’s office. When he got there her inner office door was closed. He said to her secretary, “I need to speak with Ms. Richardson, it’s important.”
Tony glanced at the wall clock. “She should be finished in another ten minutes if you’d like to wait outside. I’ll fetch you when she’s available.”
After making himself comfortable on a contemporary couch in the administration general waiting area, he pulled out his cellular phone and again dialed Robin Beck’s phone number. After ten rings he hung up. Still no answer.
After about fifteen minutes of cooling his heels, Tony floated forth to announce, “Ms. Richardson will see you now.”
She was leaning toward the computer monitor apparently catching up on email when he entered the office and closed the door.
Jill double clicked the mouse, then turned to him. “So, Doctor Mathews, what can I do for you?”
“I found another patient whose treatment was compromised because of a problem with the EMR.”
Her face turned serious. “Really! Tell me about it.”
Tyler told her how Torres’s bacteria had been erroneously reported as gram-negative rods when they probably really were gram-positive cocci and how this more tha
n likely resulted in an inadequately treated infection becoming a life-threatening brain abscess.
“Couldn’t it be possible that both organisms were present initially and the antibiotics treated one, allowing the other to become the abscess?”
He shook his head. “Nope.”
She sat back, fingers steepled, tapping her lips, and seemed to consider his story. After a moment she said, “What do you plan to do?”
“Do? I’m doing it. I’m reporting this to you as head of Risk Management. And as such I expect you to do something about it. There’s a serious security flaw in the Med-InDx software.” He folded his arms and met her stare. “So, Ms. Richardson, what are you going to do about it?’
She studied her manicure. “I’m not a doctor but I doubt seriously you can prove those results were reported inaccurately.”
“The cultures will prove it.”
She shook her hair, then combed it back in place with her fingertips. “One case doesn’t prove anything.”
“Perhaps. But you and I both know there are other cases, don’t we?”
She didn’t answer.
He decided to push the gambit. “We both know there’s a problem with the medical record. The only way I can prove it is to find some other cases like mine. I want you to give me the names of any other patients who’ve had any complication you believe might have resulted from a record error.”
She cast a puzzled expression. “I’m not sure I understand where you’re coming from. I thought you didn’t have enough data to show there’s a problem. Now you do? On what basis?”
“Why is this sounding like you’re stonewalling? The more you and Khan insist there’s no problem, the more I think there is. All I’m asking is for you to help me do a root cause analysis. Are you telling me you—VP of Risk Management—refuse to investigate a problem that’s a potential risk to patient safety?”
“Are we back to the conspiracy theory now? Hackers and cover ups? Because if you are, I have to tell you I think that’s ridiculous. Yes, of course I know about any major complication that occurs in this medical center. I have to. That’s my job. Be proactive; make sure there’s nothing that’s going to result in adverse medical center exposure. And, if there is, enact the appropriate damage control. If there had been a serious concern about any computer security problems affecting patient safety, I’d know about it. There isn’t.”