by Robin Cook
“It’s not too early for a little fun, is it?” asked Doris, pressing herself against Thomas and sensing his arousal.
“God, no,” said Thomas, pulling her down onto the couch and yanking off her clothes in an ecstasy of excitement and relief at his own response. As he plunged into her he comforted himself that the problem that he’d experienced the night before was Cassi’s, not his. It never occurred to him that he had yet to take a Percodan that day.
The nurses in the surgical intensive care unit knew that problems, particularly serious problems, had an uncanny way of propagating themselves. The night had begun badly with the eleven-thirty arrest of an eleven-year-old girl who’d been operated on that day for a ruptured spleen. Luckily things had worked out well, and the child’s heart had begun beating again almost immediately. The nurses had been amazed at the number of doctors who had responded to the code. For a time there had been so many doctors that they’d been falling over each other.
“I wonder why there are so many attendings in the house?” asked Andrea Bryant, the night supervisor. “It’s the first time I’ve seen Dr. Sherman here on a Saturday night since he was a resident.”
“Must be a lot of emergency cases in the OR,” said the other RN, Trudy Bodanowitz.
“That can’t be it,” said Andrea. “I spoke to the night supervisor there and she said that there were only two: an emergency cardiac case and a fractured hip.”
“Beats me,” said Trudy, looking at her watch. It was just after midnight. “Do you want to take first break tonight?”
The girls were sitting at the central desk finishing the paperwork engendered by the arrest. Neither was assigned to specific patients but rather manned the central station and performed the necessary administrative functions.
“I’m not sure either of us is going to get a break,” said Andrea, looking around the large U-shaped desk. “This place is a mess. There’s nothing like having an arrest right after shift change to spoil routine.”
The nurses’ station in the ICU rivaled the flight deck of a Boeing 747 for complicated electronic equipment. Facing the women were banks of TV screens giving constant read-outs on all the patients in the unit. Most were set within certain limits so that alarms would go off if the values strayed too far from normal. While the women were speaking, one of the EKG tracings was changing. As crucial minutes passed, the previously regular tracing began to look more and more erratic. Finally, the alarm went off.
“Oh shit,” said Trudy as she looked up at the beeping oscilloscope screen. She stood up and gave the unit a slap with her hand, hoping that an electrical malfunction was the cause of the alarm. She saw the abnormal EKG pattern and switched to another lead, still hoping the problem was mechanical.
“Who is it?” asked Andrea, checking for any evidence of frantic activities on the part of the nursing staff.
“Harwick,” said Trudy.
Andrea’s gaze quickly switched over to the bed of Dr. Ballantine’s OR disaster. There was no nurse in attendance, which was not unusual. Mr. Harwick had been exceptionally stable over the last weeks.
“Call the surgical resident,” said Trudy. Mr. Harwick’s EKG was deteriorating even as Trudy watched. “Look at this, he’s going to arrest.”
She pointed to the screen where Mr. Harwick’s EKG was showing typical changes before it either stopped or degenerated to ventricular fibrillation.
“Should I call a code?” asked Andrea.
The two women looked at each other.
“Dr. Ballantine specifically said ‘no code,’ ” said Trudy.
“I know,” said Andrea.
“It always gives me an awful feeling,” said Trudy, looking back at the EKG. “I wish they wouldn’t put us in this position. It’s not fair.”
While Trudy watched, the EKG line flattened out with just an occasional blip. Mr. Harwick had died.
“Call the resident,” said Trudy angrily. She walked around the end of the ICU desk and approached Mr. Harwick’s bed. The respirator was still inflating and deflating his lungs, giving him the appearance of life.
“Certainly doesn’t make you excited about having surgery,” said Andrea, hanging up the phone.
“I wonder what went wrong. He was so stable,” said Trudy.
Trudy reached out and flipped off the respirator. The hissing sound stopped. Mr. Harwick’s chest fell and was still.
Andrea reached over and turned off the IV. “It’s probably just as well. Now the family can adjust and then go on with their lives.”
Five
Two weeks had passed since Thomas learned of Cassi’s visit to his mother. While they had only fought briefly, the tension had been unbearable. Even Thomas had noted his increased dependency on Percodan, but he had to take something to allay his anxiety.
As he ran down the hall late for the monthly death conference, he felt his pulse race.
The meeting had already begun, and the chief surgical resident was presenting the first case, a trauma victim who had expired shortly after admission to the ER. The resident and intern had failed to notice warning signs that the sac covering the heart had been damaged and was filling with blood. Since no attending had been involved, the doctors happily raked the house staff over the coals.
If the case had belonged to one of the private staff men, the discussion would have progressed very differently. The same points would have been made, but the physician would have been reassured that the diagnosis of hemopericardium was difficult and he’d done the best he could.
Thomas had realized early in the game that the monthly death conference served more to relieve guilt than to punish, unless the offender was a resident. Lay people might have thought the death conference served as a kind of watchdog, but unfortunately such was not the case, as Thomas cynically observed. And the next case proved his point.
Dr. Ballantine was mounting the podium to present Herbert Harwick. When he finished, an obese pathology resident quickly ran down the results of the autopsy, including slides of the individual’s brain, of which little remained.
Mr. Harwick’s death was then discussed but with no mention that his trauma in the OR was the possible result of Dr. Ballantine’s inept surgery. The general feeling among the attendings was, “There but for the grace of God go I,” which was true to an extent. What made Thomas sick was that no one remembered that six months previously Ballantine had presented a similar case. Air embolism was a feared complication that at times occurred no matter what one did, but the fact that it occurred so often and at an increasing frequency to Ballantine was always ignored.
Equally amazing, as far as Thomas was concerned, was that nothing was said about Harwick’s actual death in the ICU. As far as Thomas knew, the patient had been stable for an extended period of time before the sudden arrest. Thomas looked at the members of the audience and puzzled why they remained silent. It reconfirmed for him that bureaucracy and its committee method of dealing with problems was no way to run an organization.
“If there’s no further discussion,” said Ballantine, “I think we should move on to the next case. Unfortunately I’m still in the dock.” He smiled thinly. “The patient’s name is Bruce Wilkinson. He is a forty-two-year-old white male who had suffered a heart attack and who had shown focally compromised coronary circulation, suggesting he was a good candidate for a triple bypass procedure.”
Thomas straightened up in his chair. He remembered Wilkinson very clearly, particularly the night he’d attempted to resuscitate him. He could still see the surrealistic scene in his mind’s eye.
Ballantine droned on, presenting the case with much too much detail. The chin of the surgeon sitting next to Thomas slumped onto his chest and his deep, regular breathing could be heard as far away as the podium. Finally Ballantine got to the end and said, “Mr. Wilkinson did extremely well postoperatively until the night of the fourth postoperative day. At that time he died.”
Ballantine looked up from his papers. His face, in contrast to its ex
pression when they were discussing the previous case, had assumed a defiant expression as if to say, “Try to find a mistake here.”
A slight, well-dressed pathology resident got up from the first row and stepped behind the podium. He adjusted the small microphone nervously and bent over, thinking he had to speak directly into it. A high-pitched, irritating electronic sound resulted, and he backed away with apology.
Thomas recognized the man. It was Robert Seibert, Cassi’s friend.
As soon as Robert began his presentation of the pathology, all evidence of his nervousness disappeared. He was a good speaker, especially when compared with Ballantine, and he had organized his material so that only the significant points were mentioned. He showed a series of slides and pointed out that, although the patient had been described as having been deeply and grossly cyanotic at the time of death, there was no airway obstruction. He next presented a photomicrograph that showed that there was no alveolar problem in the lungs. Another series of slides showed there were no pulmonary emboli. Another series of photomicrographs was presented that showed there was no evidence that there had been a rise in left or right atrial pressure prior to death. The final series of pictures indicated that the bypasses were skillfully sutured in place and that there was no sign of recent myocardial infarction or heart attack.
The lights came back on.
“All this shows…” said Robert, pausing as if for effect, “that there was no cause of death in this case.”
The audience responded with surprise. Such a statement was completely unexpected. There were even a few laughs as well as a comment from one of the orthopedic men who asked if this had been one of those cases that had awakened in the morgue. That inspired more laughter. Robert smiled.
“Must have been a stroke,” said someone behind Thomas.
“That is a good suggestion,” said Robert. “A stroke that shut down the breathing while the heart pumped the unoxygenated blood. That would cause deep cyanosis. But that would mean a brain-stem lesion. We went over the brain millimeter by millimeter and found nothing.”
The audience was now silent.
Robert waited for more comments, but there were none. Then he leaned forward and spoke into the microphone: “With permission I’d like to present another slide.”
Cleverly he’d caught the imagination of the gathering.
Thomas had an idea of what was coming.
Robert switched off the lights, then switched on the projector. The slide showed a compilation of seventeen cases, containing comparable data on age, sex, and points of medical history.
“I’ve been interested in cases such as Mr. Wilkinson for some time,” said Robert. “This slide is to show that his is not an isolated case. I have found four similar cases myself over the last year and a half. When I went back in the files, I found thirteen others. If you’ll notice, they have all had cardiac surgery. In each circumstance, no specific cause of death was found. I’ve labeled this syndrome sudden surgical death, or SSD.”
The lights came back on.
Ballantine’s face had turned bright red. “What do you think you are doing?” he spat at Robert.
Under different circumstances Thomas might have felt sorry for Robert. His unexpected presentation did not fit within the rather narrow protocol for a death conference.
Glancing around the room, Thomas saw many angry faces. It was an old story. Doctors did not like to have their expertise questioned. And they were reluctant to police their own.
“This is a death conference, not a Grand Rounds,” Ballantine was saying. “We’re not here for a lecture.”
“In discussing the case of Mr. Wilkinson, I thought it would be enlightening…”
“You thought,” repeated Dr. Ballantine sarcastically. “Well, for your information you’re here as a consult. Did you have something specific to say when you presented this list of supposed sudden surgical deaths?”
“No,” admitted Robert.
Although Thomas preferred to stay silent at such meetings, he had to ask a question: “Excuse me, Robert,” he called. “Did all the seventeen cases have deep cyanosis?”
Robert could not have been more eager to field a question from the audience. “No,” he said into the microphone. “Only five of the cases.”
“That means that the physiologic cause of death was not the same in all these cases.”
“That’s true,” said Robert. “Six had convulsions prior to death.”
“That was probably air embolism,” said another surgeon.
“I don’t think so,” said Robert. “First of all, the convulsions occurred three or more days after surgery. It would be hard to explain that kind of delay. Also when the brains were autopsied, no air was found.”
“Could have been absorbed,” said someone else.
“If there had been enough air to cause sudden convulsions and death,” said Robert, “then there should have been enough to see.”
“What about the surgeons?” called the man behind Thomas. “Were any more heavily represented than others?”
“Eight of the cases,” said Robert, “belonged to Dr. George Sherman.”
A buzz of conversation broke out in the back of the room. George rose furiously to his feet as Ballantine nudged Robert from the podium.
“If there are no further comments…” said Ballantine.
George spoke out: “I think Dr. Kingsley’s comment was particularly cogent. By pointing out that there were different mechanisms of death in these cases, he indicated that there was no reason to try and relate the cases.” George looked over at Thomas.
“Exactly,” said Thomas. He would have preferred to let George sink or swim on his own, but he felt obligated to respond. “It occurred to me that Robert had correlated the cases because of some similarity he saw in their deaths, but that didn’t seem to be the case.”
“The basis of the correlation,” said Robert, “was that the deaths, particularly over the last several years, occurred when the patients were apparently doing well, and there was no anatomic or physiologic cause.”
“Correction,” said George. “No cause was found by the department of pathology.”
“It’s the same thing,” said Robert.
“Not quite,” said George. “Maybe another pathology department would have found the causes. I think it’s more of a reflection on you and your colleagues than anything else. And intimating that there is something irregular about a series of operative tragedies on such a basis is irresponsible.”
“Hear, hear,” shouted an orthopedic surgeon who began to clap. Robert quickly stepped down from the podium. There was an air of tension in the room.
“The next death conference will be one month from today, January seventh,” said Ballantine, switching off the microphone and gathering his papers. He walked off the stage and over to Thomas.
“You seemed to know that kid,” he said. “Who the hell is he?”
“His name is Robert Seibert,” said Thomas. “He’s a second-year pathology resident.”
“I’m going to have the kid’s balls in Formalin. Who does the little turd think he is, coming up here and putting himself up as our Socratic gadfly?”
Over Ballantine’s shoulder, Thomas could see George making his way over to them. He was just as provoked as Ballantine.
“I got his name,” said George menacingly, as if he were revealing a secret.
“We already know it,” said Ballantine. “He’s only in his second year.”
“Wonderful,” said George. “Not only do we have to put up with philosophers, but also smart-ass pathology residents.”
“I heard there was a death this month in one of the cath rooms in radiology,” said Thomas. “How come it wasn’t presented?”
“Oh, you mean Sam Stevens,” said George nervously, watching Robert leave the room. “Since the death occurred during the catheterization, the medical boys wanted to present it at their death conference.”
While Thomas watched Dr. B
allantine and George fume, he wondered what they’d say if he told them that Cassi had been involved with the so-called SSD study. For everyone’s sake he hoped they wouldn’t find out. He also hoped that Cassi had had sense enough not to continue her association with Robert. All it could do was cause trouble.
In a totally dark examination room, Cassi was lying flat on her back and could not have been more uncomfortable. She wasn’t in pain but close to it as she was forced to keep her eye still while Dr. Martin Obermeyer, chief of ophthalmology, shined an intensely bright light into her left eye. Worse than the discomfort was her fear of what the doctor would say. Cassi knew she’d been less than responsible about her eye problem. Desperately she hoped that Dr. Obermeyer would make some reassuring comment as he examined her. But he remained ominously quiet.
Without so much as a word, he shifted the light into her good eye. The beam came from an apparatus that the doctor wore around his head, similar to a miner’s light, but more intricate. Although the light seemed bright in her left eye, when it shifted to the good eye the intensity was so great it was difficult for Cassi to believe it did not cause damage in and of itself.
“Please, Cassi,” said Dr. Obermeyer, lifting the light beam and peering at her beneath the eyepieces of the instruments. “Please hold your eye still.” He pressed down with a small metal stylus.
Irritative tears welled up, and Cassi could feel them spill over and run down the side of her face. She wondered how much longer she could stand it. Involuntarily she gripped the sheet covering the examining table. Just at the moment she thought she could no longer remain still, the light disappeared, but even after Dr. Obermeyer turned on the overhead lights, she could not see well. The doctor was a blur to her as he sat down at his desk to write.
It concerned her that he was being so reticent. Obviously he was annoyed at her.
“Can I sit up?” asked Cassi hesitatingly.
“I don’t know why you ask my opinion,” said Dr. Obermeyer, “when you don’t follow any of my other suggestions.” The ophthalmologist didn’t bother turning around as he spoke.