Harmful Intent

by Robin Cook

  “Really?” Patty asked.

  “If we didn’t have so many happy customers, do you think so many women would be coming back a second, a third, or even fourth time?”

  Patty smiled wanly.

  Jeffrey spent another quarter hour with her, questioning her about her health and allergies. He sympathized with her when she told him her husband was out of town on a business trip. Her familiarity with epidural anesthesia surprised him. She confided that not only had she read about it, her sister had had it for her two deliveries. Jeffrey explained why he wouldn’t be giving her the epidural immediately. When he told her that she could get some Demerol in the meantime if she wanted it, Patty relaxed. Before leaving her, Jeffrey reminded her that any drugs she got, the baby got. Then he told her again there was no reason to worry; she was in good hands.

  Coming out of Patty’s labor room and suffering through another intestinal cramp, Jeffrey realized he would have to take more drastic steps against his own symptoms if he was to get through Patty’s delivery. Despite the paregoric, he was feeling progressively worse.

  Passing back through the connecting doors to the OR suite, Jeffrey returned to the anesthesia alcove next to the OR, where he’d spent most of the day. The room was empty and probably wouldn’t be used again until the following morning.

  Glancing up and down the OR corridor to make sure the coast was clear, Jeffrey pulled the drape closed. Although he’d finally acknowledged being sick, he wasn’t about to admit it to anyone else.

  From the drawer of his Narcomed III anesthesia machine, Jeffrey got out a small-gauge intravenous scalp needle and an infusion setup. He pulled a bottle of Ringer’s Lactate IV fluid down from the shelf and snapped off the cover over the rubber port. With a decisive shove, he pushed the IV tubing into the bottle and hung the bottle up on the IV stand over the anesthesia machine. He ran fluid through the tubing until it was free of air bubbles, then he closed the plastic stopcock.

  Jeffrey had only started IVs on himself a couple of times, but he was practiced enough in the procedure to be adept. Using his teeth to hold one end of the tourniquet, he secured it around his bicep and watched as his veins began to distend.

  What Jeffrey had in mind was a trick that he’d learned as a resident. Back then, he and his colleagues, especially the surgical residents, refused to take any sick time for fear they’d lose the competitive edge. If they got the flu or symptoms like the ones Jeffrey was now experiencing, they would simply take time out to run in a liter of IV fluid. The results were almost guaranteed, suggesting most flu symptoms were due to dehydration. With a liter of Ringer’s Lactate coursing through your veins, it was hard not to feel better. It had been ages since Jeffrey had last resorted to an IV. He only hoped the efficacy would be as strong as it had been when he’d been a resident. Now forty-two, he found it hard to believe that last time he had been almost twenty years younger.

  Jeffrey was about to push the needle in when the curtain to the alcove was pulled aside. Jeffrey looked up into the surprised face of Regina Vinson, one of the evening nurses.

  “Oh!” Regina exclaimed. “Excuse me.”

  “No problem,” Jeffrey started to say, but Regina was gone as quickly as she had appeared. As long as she’d inadvertently caught him in the act, Jeffrey had half a mind to ask her to lend a hand by attaching the IV to the scalp needle once he got it into the vein. Reaching out, he pulled back the curtain in hopes of catching her, but Regina was already far down the crowded hall. He let the curtain fall back into place. He was just as well off without her.

  Once the IV tubing was attached, he opened the stopcock. Almost at once he felt the cool sensation of the fluid as it flowed rapidly into the arm. By the time most of the bottle had run in, Jeffrey’s upper arm was cool to the touch. After he pulled out the IV needle, he put an alcohol swab over the site and bent his elbow to hold it in place. He disposed of the IV paraphernalia in the wastebasket, then stood up. He waited for a moment to see how he felt. The light-headedness and headache were totally gone. So was the nausea. Pleased with the speedy results, Jeffrey pulled open the curtain and headed back to the locker room. Only his colon still troubled him.

  The evening shift had now taken over and the day shift was in the process of leaving. The locker room was full of cheerful people. Most of the showers were occupied. First Jeffrey used the toilet. Then he got out his paregoric and took another hefty swig. He shuddered at the taste and wondered what made it so bitter. He tossed the now empty bottle into the wastebasket. Then he took a second shower and put on another set of clean scrub clothes.

  When he walked out into the surgical lounge he almost felt human. He intended to sit down for a half hour or so and read the paper but before he had a chance his beeper went off. He recognized the number. It was delivery.

  “Mrs. Owen is asking for you,” Monica Carver told him when he phoned.

  “How is she doing?” Jeffrey asked.

  “Just fine,” Monica said. “She’s a little apprehensive, but she hasn’t even asked for analgesia even though her contractions are now coming frequently. She’s somewhere between five and six centimeters.”

  “Perfect,” Jeffrey said. He was pleased. “I’ll be right over.”

  En route to the delivery area, Jeffrey stopped at the anesthesia office to glance at the big board to see about the evening assignments. As he expected, everyone was busy with ongoing cases. He took a piece of chalk and wrote that whenever someone was free he or she should come over to delivery and relieve him.

  When Jeffrey arrived in labor room fifteen, Patty was in the middle of a contraction. An experienced LPN was with her and the two women were functioning like a practiced team. Beads of sweat dotted Patty’s brow. Her eyes were shut tightly, and she was gripping the nurse’s hands with both of hers. Strapped to her abdomen was the rubber monitor keeping track of the progress of the labor as well as the fetal heartbeat.

  “Ah, my white knight in blue,” Patty said as the pain abated and she opened her eyes to see Jeffrey standing at the foot of the bed. She smiled.

  “How about that epidural?” Jeffrey suggested.

  “How about it!” Patty echoed.

  All the equipment Jeffrey needed was on a cart he had wheeled in with him upon his return. After putting a blood pressure cuff in place, Jeffrey removed the rubber monitor from Patty’s abdomen and helped position her on her side. With gloved hands he prepped her back with an antiseptic solution.

  “First I’m going to give you the local anesthetic we talked about,” Jeffrey said as he prepared the injection. He made a small weal with the tiny needle midline in Patty’s lower back. She was so relieved to be getting it, she didn’t even flinch.

  Next, he took a Touhey needle from the epidural tray and made sure the stylet was in place. Then, using both hands, he pushed the needle into Patty’s back, advancing it slowly but deliberately until he was certain he had reached the ligamentous covering of the spinal canal. Withdrawing the stylet, he attached an empty glass syringe. Jeffrey put slight pressure on the syringe’s plunger. Feeling resistance, he expertly returned to advancing the needle. Suddenly the resistance on the plunger disappeared. Jeffrey was pleased: he knew he was in the epidural space.

  “Are you okay?” Jeffrey asked as he used a glass syringe to draw up a test dose of 2 cc’s of sterile water containing a tiny amount of epinephrine.

  “Are you finished?” Patty asked.

  “Not quite,” Jeffrey said. “Just a few minutes more.” He injected the test dose and immediately tested Patty’s blood pressure and pulse. There was no change. If the needle had been in a blood vessel, Patty’s heart rate would have increased immediately in response to the epinephrine.

  Only then did Jeffrey seize the small epidural catheter. With practiced care, he threaded it up the Touhey needle.

  “I feel something funny in my leg,” Patty said nervously.

  Jeffrey stopped pushing the catheter. It was only in about one centimeter beyond the tip of
the needle. He asked Patty about the sensation, then explained that it was common for the epidural catheter to touch peripheral nerves as they traversed the epidural space. That could account for what she was feeling. When the paresthesia subsided, Jeffrey gingerly advanced the catheter another one and a half centimeters. Patty didn’t complain.

  Finally, Jeffrey pulled the Touhey needle out, leaving the small plastic catheter in place. Then he prepared a second test dose of 2 cc’s of .25% spinal-grade Marcaine with epinephrine. After injecting this second dose, he monitored Patty’s blood pressure and her sense of touch on her lower extremities. When there were no changes even after several minutes, Jeffrey was absolutely sure that his catheter was in the proper place. Finally, he injected the therapeutic dose of anesthetic: 5 cc’s of .25% Marcaine. Then he capped off the catheter.

  “That’s all there is to that,” Jeffrey said as he put a sterile bandage over the puncture site. “But I want you to stay on your side for a while.”

  “But I don’t feel anything,” Patty complained.

  “That’s the idea,” Jeffrey said with a smile.

  “You’re sure it’s working?”

  “Just wait until your next contraction,” Jeffrey said with confidence.

  Jeffrey conferred with the LPN to let her know how frequently he wanted Patty’s blood pressure taken. Then he helped her put the labor monitor back in place. He remained in the labor room through Patty’s next contraction, using the time to complete his habitually meticulous anesthesia record. Patty felt reassured. The discomfort she had been experiencing was much improved, and she thanked Jeffrey effusively.

  After telling Monica Carver and the LPN where he would be, Jeffrey went into one of the darkened empty labor rooms to lie down. He was feeling better, but certainly not normal. Closing his eyes for what he thought would be just a few minutes and soothed by the sound of rain against the window, he surprised himself by falling fast asleep. He was dimly aware of the door being opened and closed several times as different people checked on him, but no one disturbed him until Monica came in and gently shook his shoulder.

  “We’ve got a problem,” Monica said.

  Jeffrey swung his legs over the side of the bed and rubbed his eyes. “What’s wrong?”

  “Simarian has decided to do a Caesarean on Patty Owen.”

  “So soon?” Jeffrey asked. He glanced at his watch. He blinked several times. The room seemed dimmer than before. Checking his watch, he was surprised to see that he’d been asleep for an hour and a half.

  “The baby is an occiput posterior and hasn’t been progressing,” Monica explained. “But the main problem is that the baby’s heart has been slow to return to a normal rate after each contraction.”

  “Time to do a Caesarean,” Jeffrey agreed as he got unsteadily to his feet. He waited a beat until his mild dizziness cleared.

  “Are you all right?” Monica questioned.

  “Just fine,” Jeffrey said. He sat down on a chair to slip on his OR shoes. “What’s the time frame?”

  “Simarian will be here in twenty minutes or so,” Monica said, studying Jeffrey’s face.

  “Is something wrong?” Jeffrey asked. He ran his fingers through his hair in fear it was standing on end.

  “You look pale,” Monica said. “Maybe it’s the lack of light in here.” Outside it was raining even harder.

  “How’s Patty doing?” Jeffrey asked, heading for the bathroom.

  “She’s apprehensive,” Monica said from the door. “Painwise, she’s fine, but you might consider giving her some kind of tranquilizer just to keep her calm.”

  Jeffrey nodded as he turned on the light in the bathroom. He wasn’t wild about the idea of giving Patty a tranquilizer, but given the circumstances, he’d consider it. “Make sure she’s on oxygen,” he told Monica. “I’ll be out in a second.”

  “She’s on oxygen,” Monica called over her shoulder as she left the room.

  Jeffrey examined himself in the mirror. He did look pale. Then he noticed something else. His pupils were so contracted, they looked like twin pencil points. They were as small as he’d ever seen them. No wonder he’d had trouble seeing his watch in the other room.

  Jeffrey splashed his face with cold water, then dried it roughly. At least that woke him up. He looked at his pupils again. They were still miotic. He took a deep breath and promised himself that as soon as he got through this delivery, he would make tracks for home and put himself to bed. After adjusting his hair with his fingernails, he headed for labor room fifteen.

  Monica had been right. Patty was embarrassed, scared, and nervous about the upcoming Caesarean. She was taking the failure of the labor personally. Tears came to her eyes when she again voiced anger at her husband’s absence. Jeffrey felt sorry for her and made a big effort at reassuring her that everything would be fine and that she certainly wasn’t at fault. He also gave her 5 mg of diazepam IV, which he thought would have minimal effect if any on the unborn child. It had a rapid calming effect on Patty.

  “I’ll be asleep during the Caesarean?” Patty asked.

  “You’ll be very comfortable,” Jeffrey replied, skirting the question. “One of the big benefits of continuous epidural anesthesia is that I can extend it now that we need a higher level, without disturbing Patty junior.”

  “It’s a boy,” Patty said. “His name is Mark.” She smiled weakly. Her lids had become a little droopy. The tranquilizer was clearly taking effect.

  The transfer from the delivery area to the OR suite was accomplished without incident. Jeffrey kept Patty on oxygen by mask during the short trip.

  The OR had been advised as to the decision to do a Caesarean. By the time Patty was transferred, the room was almost set up for the procedure. The scrub nurse, already scrubbed, was busy laying out the instruments. The circulating nurse helped guide the gurney into the room and transfer Patty to the OR table. Patty still had the fetal monitor on, which was left in place for the time being.

  Jeffrey wasn’t as familiar with the evening personnel, and he hadn’t met the circulating nurse before. Her name tag read: Sheila Dodenhoff.

  “I’m going to need some .5% Marcaine,” Jeffrey told Sheila as he changed Patty from portable bottle oxygen to oxygen delivered through his Narcomed III anesthesia machine. He then reapplied the blood pressure cuff to Patty’s left arm.

  “Coming up,” Sheila said cheerfully.

  Jeffrey worked quickly but deliberately. He checked off every procedure in his anesthesia record once it had been performed. In sharp contrast to most other doctors, Jeffrey prided himself on his exquisitely legible handwriting.

  After hooking up the EKG leads, he attached the pulse oximeter to Patty’s left index finger. He was replacing Patty’s IV with a more secure intracath when Sheila returned.

  “Here you go,” she said, handing Jeffrey a 30 cc glass vial of .5% Marcaine. Jeffrey took the drug and, as he always did, checked the label. He set the vial on top of his anesthesia machine. From the drawer, he took out a 2 cc ampule of spinal grade .5% Marcaine with epinephrine and drew it up into a syringe. Maneuvering Patty onto her right side, Jeffrey injected the 2 cc’s into the epidural catheter.

  “How’s everything going?” a booming voice called out from the door.

  Jeffrey turned to see Dr. Simarian holding a mask to his face while he held open the door.

  “We’ll be ready in a minute,” Jeffrey said.

  “How’s the little one’s ticker?” he asked.

  “At the moment, fine,” Jeffrey answered.

  “I’ll scrub up and we’ll get this show on the road.”

  The door swung shut. Jeffrey gave Patty’s shoulder a squeeze while he studied the EKG and the blood pressure readout. “You okay?” he asked her, moving the oxygen mask to the side.

  “I think so,” she said.

  “I want you to tell me whatever you feel. Understand?” Jeffrey said. “Do your feet feel normal?”

  Patty nodded. Jeffrey went around and
tested her sensation. Coming back to the head of the table and checking the monitors again, he was sure that the epidural catheter had not moved and had not penetrated either the spinal canal or one of the pregnancy-dilated veins of Bateson.

  Satisfied that all was in order, Jeffrey picked up the vial of Marcaine Sheila had brought him. Using his thumb, he snapped off the top of the sealed glass container. Once again he checked the label, then drew up 12 cc’s. He wanted anesthesia to extend at least to T6, and preferably to T4. As he put the Marcaine down, his eyes caught Sheila’s. She was standing off to the left, staring at Jeffrey.

  “Is something wrong?” Jeffrey asked.

  Sheila held his gaze for a beat, then spun on her heels and left the OR without speaking. Jeffrey turned to catch the eye of the scrub nurse, but she was still busy setting up. Jeffrey shrugged. Something was going on that he didn’t know about.

  Returning to Patty’s side, he injected the Marcaine. Then he capped off the epidural catheter and returned to the head of the table. After putting down the syringe, he noted the time and the exact amount of the injection in the record. A slight quickening of the beep of the pulse brought his eyes up to the EKG monitor. If there was to be any change in the heart rate, Jeffrey expected a slight slowing from progressive sympathetic blockade. Instead, there was the opposite. Patty’s pulse was speeding up. It was the first sign of the impending disaster.

  Jeffrey’s initial reaction was more of curiosity than concern. His analytical mind groped for a logical explanation for what he was witnessing. He glanced at the blood pressure readout and then the oximeter LED. They were all fine. He looked back at the EKG. The pulse was still quickening, and even more disturbing, there was an ectopic, irregular heartbeat. Under the circumstances, that was not a good sign.

  Jeffrey swallowed hard as fear clutched at his throat. It had only been seconds since he’d injected the Marcaine. Could it have gone intravenous despite the test dose result? Jeffrey had had one other adverse reaction to local anesthetic in his professional career. The incident had been harrowing.