Harmful Intent

by Robin Cook

  The ectopic beats were increasing in frequency. Why would the heart rate increase and why the irregular rhythm? If the anesthetic dose did go intravenously, why wasn’t the blood pressure falling? Jeffrey had no immediate answers to these questions, but his medical sixth sense, born of years of experience, set off alarm bells in his mind. Something abnormal was occurring. Something Jeffrey was at a loss to explain, much less understand.

  “I don’t feel good,” Patty said, turning her head to talk out of the side of the mask.

  Jeffrey looked down into Patty’s face. He could see it was again clouded with fear. “What’s the matter?” he asked, puzzled by these rapid events. He touched her shoulder.

  “I feel funny,” Patty said.

  “How do you mean, funny?” Jeffrey’s eyes went back to the monitors. There was always the fear of allergy to the local anesthetic, although developing allergy in the two hours since the first dose seemed a rather farfetched notion. He noticed the blood pressure had risen slightly.

  “Ahhhhh!” Patty cried.

  Jeffrey’s eyes shot to her face. Patty’s features were twisted in a horrible grimace.

  “What is it, Patty?” Jeffrey demanded.

  “I feel a pain in my stomach,” Patty managed hoarsely through clenched teeth. “It’s high up, under my ribs. It’s different from the labor pain. Please . . .” Her voice trailed off.

  Patty began to writhe on the table, drawing up her legs. Sheila reappeared along with a muscular male nurse who lent a hand in attempting to restrain her.

  The blood pressure that had risen slightly now began to fall. “I want a wedge under her right side,” Jeffrey yelled as he got ephedrine from the drawer and prepared it for injection. Mentally he calculated how far he’d let the blood pressure drop before he’d inject the pressor agent. He still had no idea of what was happening, and he preferred not to act before he knew exactly what he was up against.

  A gurgling sound brought his attention back to Patty’s face. He pulled off her oxygen mask. To his surprise and horror she was salivating like a mad dog. At the same time she was lacrimating profusely; tears were streaming down her face. A wet cough suggested that she was also forming increasing amounts of tracheo-bronchial secretions.

  Jeffrey remained the ultimate professional. He had been trained to deal with this type of emergency situation. His mind raced ahead, taking in all the information, making hypotheses, then ruling them out. Meanwhile, he dealt with the life-threatening symptoms. First he suctioned Patty’s nasopharynx, then he injected atropine intravenously, followed by ephedrine. He suctioned Patty again, then injected a second dose of the atropine. The secretions slowed, the blood pressure plateaued, the oxygenation stayed normal, but Jeffrey still did not know the cause. All he could think of was an allergic reaction to the Marcaine. He watched the EKG, hoping that the atropine might have a positive effect on the irregular heartbeats. But they remained irregular. In fact, they became even more irregular as Patty’s pulse quickened. Jeffrey prepared a 4 mg dose of propranolol, but before he could inject it, he noticed the muscle fasciculations that distorted Patty’s features in a series of seemingly uncontrolled twists and spasms. The fasciculations rapidly spread to other muscles until her body became wracked by clonic jerks.

  “Hold her, Trent!” Sheila cried to the male nurse. “Get her legs!”

  Jeffrey injected the propranolol as the EKG began to register further bizarre changes, intimating there was diffuse involvement of the heart’s electrical conduction system.

  Patty spewed up green bile which Jeffrey quickly suctioned away. He glanced at the oximeter readout. That was still holding. Then the fetal monitor alarm began to go off; the baby’s heart was slowing. Before anyone could react, Patty suffered a grand mal seizure. Her limbs flailed madly in all directions, then her back arched in awkward hyperextension.

  “What the hell is going on?” Simarian shouted as he came flying through the door.

  “The Marcaine,” Jeffrey shouted. “She’s having some sort of overwhelming reaction.” Jeffrey didn’t have time to elaborate as he drew up 75 mg of succinylcholine.

  “Jesus Christ!” Simarian yelled, coming around the table to help hold Patty down.

  Jeffrey injected the succinylcholine as well as an additional dose of diazepam. He was thankful that his compulsiveness had made him change the IV to a more secure one. The audio portion of the oximeter readout began to fall in pitch as Patty’s oxygenation decreased. Jeffrey again cleared her airway and tried to bag her with the 100% oxygen.

  Patty’s seizure movements slowed as succinylcholine-induced paralysis took effect. Jeffrey slipped in an endotracheal tube, checked its position, and ventilated her well with the oxygen. The sound of the oximeter immediately returned to its higher pitch. But the fetal monitor was still sending out its alarm. The baby’s heart had slowed and was not speeding back up.

  “We gotta get the baby!” Simarian yelled. He grabbed sterile gloves from one of the side tables and yanked them on.

  Jeffrey was still watching the blood pressure, which had started to fall again. He gave Patty another dose of ephedrine. The blood pressure started back up. He glanced at the EKG; it had not improved with the propranolol. Then to Jeffrey’s horror, just as he was watching, the EKG disintegrated into senseless fibrillation. Patty’s heart had stopped beating.

  “She’s arresting!” Jeffrey shouted. The blood pressure fell to zero. Both the EKG and the oximeter alarms began shrieking stridently.

  “My God!” Simarian yelled. He had been hastily draping the patient. He moved up to the table and started external cardiac massage by compressing Patty’s chest. Sheila put out the word to the OR desk. Help was on its way.

  The crash cart arrived along with additional OR nurses. With lightning speed, they prepared the defibrillator. A nurse anesthetist also arrived. She went directly to Jeffrey’s side.

  The oxygen content of Patty’s blood went up slightly. “Countershock her!” Jeffrey ordered.

  Simarian took the defibrillator paddles from one of the nurses. He applied them to Patty’s bare chest. Everyone stepped back from the OR table. Simarian pressed the button. Since Patty was paralyzed with the succinylcholine, there was no apparent effect from the electric current except on the EKG screen. The fibrillation disappeared, but when the phosphorescent blip returned, it did not show a normal heartbeat. Instead, it traced a completely flat line with only a few minor squiggles.

  “Restart massage!” Jeffrey ordered. He stared at the EKG. He couldn’t believe there was no electrical activity. The muscular male nurse took over from Simarian and started compressing Patty’s chest with good result.

  The fetal monitor was still sounding. The child’s heart rate was too slow. “We gotta get the baby!” Simarian snapped again. He changed his gloves and hastily took additional drapes from the scrub nurse. He positioned them as best he could despite the cardiac massage. He grabbed a knife from the instrument table and went to work. Using a generous vertical incision, he sliced Patty’s lower abdomen open. With the reduced blood pressure there was very little bleeding. A pediatrician arrived on the scene and prepared to take the baby.

  Jeffrey’s attention stayed with Patty. He suctioned her and was surprised at the amount of secretions even after the two doses of atropine. Checking Patty’s pupils, he was pleased they were not dilated. In fact, he was surprised to find them pinpoint. With oxygenation remaining up, Jeffrey decided to hold off introducing any more drugs into Patty’s system until after the baby was delivered. Briefly, he explained what had happened to the nurse anesthetist.

  “You think it’s a reaction to the Marcaine?” she asked.

  “That’s all I can think of,” Jeffrey admitted.

  In the next minute a silent, blue, flaccid baby was pulled from Patty’s abdomen. After the cord was severed, the child was quickly handed to the waiting pediatrician. He rushed the newborn to the infant care unit, where the baby was surrounded by his own resuscitation team. The nur
se anesthetist joined that group.

  “I don’t like this flat EKG,” Jeffrey said to himself as he injected a bolus of epinephrine. He watched the EKG. No response. He then tried another dose of atropine. Nothing. Exasperated, he drew an arterial blood sample and sent it off to the lab for a stat reading.

  Ted Overstreet, one of the cardiac surgeons who had recently finished a bypass case, came in and stood next to Jeffrey. After Jeffrey explained the situation, Overstreet suggested opening her up.

  The nurse anesthetist came back to report that the baby was not in good shape. “The Apgar is only three,” she said. “He’s breathing and his heart is beating, but not well. And his muscle tone is not good. In fact, it’s weird.”

  “How so?” Jeffrey asked, fighting a wave of depression.

  “His left leg moves okay, but not his right. The right one is completely flaccid. With his arms it’s just the opposite.”

  Jeffrey shook his head. Obviously the child had been oxygen deprived in utero and was now brain damaged. The realization was crushing, but there was no time to wallow in regret. Just then his chief concern was Patty and how to get her heart started.

  The stat lab work came back. Patty’s pH was 7.28. Under the circumstances, Jeffrey thought, that was pretty good. Next he injected a dose of calcium chloride. Minutes dragged like hours as everyone watched the EKG, waiting for some sign of life, some response to treatment. But the monitor traced a frustratingly flat line.

  The male nurse continued the chest compressions and the ventilator kept Patty’s lungs filled with pure oxygen. Her pupils remained miotic, suggesting her brain was getting enough oxygen, but her heart stayed electrically and mechanically still. Jeffrey repeated all the textbook procedures but to no avail. He even had Patty shocked again with the defibrillator set at 400 joules.

  Once the pediatrician had the newborn stabilized, he had the entire infant care unit vacate the OR along with its attendant clutch of residents and nurses. Little Mark was on his way to the neonatal intensive care unit. Jeffrey watched them go. He felt heartsick. Shaking his head in sorrow, he turned back to Patty. What to do?

  Jeffrey looked up at Ted, who was still standing next to him. He asked Ted what he thought they should do. Jeffrey was desperate.

  “Like I said, I think we should open her up and work on the heart directly. There’s not much to lose at this point.”

  Jeffrey watched the flat EKG for another moment. Then he sighed. “Okay. Let’s try it,” he said reluctantly. He had no other ideas, and he didn’t want to give up. As Ted pointed out, they had nothing to lose. It was worth a try.

  Ted gowned and gloved in less than ten minutes. Once he was prepared, he had the nurse stop compressing the chest so that he could rapidly drape and slice into it. Within seconds he was holding Patty’s naked heart.

  Ted massaged the heart with his gloved hand and even injected epinephrine directly into the left ventricle. When that failed to have an effect, he tried to pace the heart by attaching internal leads to the cardiac wall. That resulted in a complex on the EKG, but the heart itself did not respond.

  Ted recommenced the internal cardiac massage. “No pun intended,” he said after a couple of minutes, “but my heart is no longer in this. I’m afraid the ballgame is over unless you guys have a heart transplant waiting around here. This one is long gone.”

  Jeffrey knew that Ted didn’t mean to sound callous and that his apparently flip attitude was more of a defense mechanism than a true lack of compassion, yet it cut Jeffrey to the quick. He had to restrain himself from lashing out verbally.

  For as much as he’d given up, Ted continued the internal cardiac massage. The only sound in the OR came from the monitor recording the pacemaker’s discharge and the low hum of the pulse oximeter as it responded to Ted’s internal massage.

  Simarian was the one who broke the silence. “I agree,” he said simply. He snapped off his gloves.

  Ted looked across the rapidly erected ether screen at Jeffrey. Jeffrey nodded. Ted stopped massaging the heart and pulled his hand from within Patty’s chest. “Sorry,” he said.

  Jeffrey nodded again. He took a deep breath, then turned the ventilator off. He looked back at the sorry sight of Patty Owen with her abdomen and chest rudely sliced open. It was a terrible sight, one that would stay with Jeffrey for the rest of his life. The floor was littered with drug containers and wrappers.

  Jeffrey felt crushed and numb. This was the nadir of his professional career. He’d witnessed other tragedies, but this was the worst, and most unexpected. His eyes drifted to his anesthesia machine. It too was covered with debris. Beneath the debris was the incomplete anesthesia record. He’d have to bring it up to date. In the fevered attempt to save Patty he’d had no time to do so. He looked for the half-empty vial of Marcaine, feeling an irrational antipathy toward it. Although it seemed unreasonable in light of the test dose results, he couldn’t help but feel an allergic reaction to the drug was the root of this tragedy. He wanted to dash the vial against the wall, just to vent his frustration. Of course he knew he wouldn’t actually throw the vial; he was too controlled for that. But he couldn’t find it among the mess.

  “Sheila,” Jeffrey called to the circulating nurse who was starting the clean-up process, “what happened to the Marcaine vial?”

  Sheila stopped what she was doing to glare at Jeffrey. “If you don’t know where you put it, I certainly don’t,” she said angrily.

  Jeffrey nodded and then turned his attention to unhooking Patty from the monitors. He could understand Sheila’s anger. He was angry too. Patty didn’t deserve this kind of fate. What Jeffrey didn’t realize was that Sheila wasn’t angry at fate. She was angry at Jeffrey. In fact, she was furious.

  1

  MONDAY,

  MAY 15, 1989

  11:15 A.M.

  A shaft of golden morning sunlight filtered through a window high on the wall to Jeffrey’s left and knifed down through the courtroom, hitting the paneled wall behind the judge’s bench like a spotlight. Millions of tiny motes of dust sparkled and swirled in the intense beam of light. Ever since the beginning of this trial, Jeffrey had been struck by the theatric quality of the justice system. But this was no TV daytime drama. Jeffrey’s career—his whole life—was on the line.

  Jeffrey closed his eyes and leaned forward at the defendant’s table, cradling his head in his hands. With his elbows splayed on the table, he roughly rubbed his eyes. The tension was about to drive him crazy.

  Taking a deep breath, he opened his eyes, half hoping the scene before him would have magically disappeared and he would wake up from the worst nightmare of his life. But of course it wasn’t a bad dream he was suffering. Jeffrey was involved in his second trial for Patty Owen’s untimely death eight months previously. Just then he was sitting in a courtroom in the center of Boston, waiting to hear the jury deliver his fate on criminal charges.

  Jeffrey glanced over his lawyer’s head to scan the crowd. There was an excited, low-pitched babble of voices, a murmur of expectancy. Jeffrey averted his gaze, knowing that all the talk centered on him. He wished he could hide. He felt utterly humiliated by the public spectacle so rapidly unfolding. His entire life had unraveled and disintegrated. His career was going down the drain. He felt overwhelmed, yet oddly numb.

  Jeffrey sighed. Randolph Bingham, his lawyer, had urged him to appear calm and controlled. Easier said than done, especially now. After all the heartache, anxiety, and sleepless nights, it was now down to the wire. The jury had reached its decision. The verdict was on its way.

  Jeffrey studied Randolph’s aristocratic profile. The man had become a father to him through these last eight harrowing months, even though he was only five years Jeffrey’s senior. Sometimes Jeffrey had felt almost love for the man, other times something more akin to rage and hatred. But he’d always had confidence in his lawyer’s skills, at least until this point.

  Glancing at the prosecuting team, Jeffrey studied the district attorney. He had pa
rticular antipathy for this man, who seemed to have seized on the case as a vehicle for advancing his political career. Jeffrey could appreciate the man’s native intelligence though he’d grown to despise him during the course of the four-day trial. But now, watching as the D.A. conversed animatedly with an assistant, Jeffrey realized he felt oddly devoid of emotion toward the man. For him, the whole business had been a job, no more, no less.

  Jeffrey’s eyes strayed beyond the district attorney toward the empty jury box. During the trial the realization that these twelve strangers held his fate in their hands had paralyzed Jeffrey. Never before had he experienced such vulnerability. Up until this episode, Jeffrey had been living under the delusion that his fate was largely in his own hands. This trial showed him just how mistaken he was.

  The jury had been deliberating for two anxious days and—for Jeffrey—two sleepless nights. Now they were waiting for the jury to return to the courtroom. Jeffrey again wondered if two days of deliberation was a good sign or a bad. Randolph, in his irritatingly conservative manner, would not speculate. Jeffrey felt the man could have lied just to give him a few hours of relative peace.

  Despite his good intentions to refrain from fidgeting, Jeffrey began to stroke his mustache. When he realized what he was doing, he folded his hands and set them on the table in front of him.

  He glanced over his left shoulder and caught sight of Carol, his soon to be ex-wife. Her head was down. She was reading. Jeffrey turned his gaze back to the judge’s empty bench. He could have been irritated that she was relaxed enough to be able to read at this moment, but he wasn’t. Instead, Jeffrey felt thankful that she was there and that she’d shown as much support as she had. After all, even before this legal nightmare had started, the two of them had come to the mutual conclusion that they had grown apart.