by Harry Kraus
“What did Dr. Overby do?”
“He immediately lifted her onto a stretcher so we could lower her head. He took a syringe and tried to pull air back out of the IV, because he feared that she had been able to suck air back into her venous system, causing an outflow blockage within the heart itself.”
“What do you think happened?”
“I think she had a very low blood pressure from losing so much blood into her abdomen from her liver injury. So her central venous pressure was very low because of the bleeding, and therefore when her central line became disconnected, she sucked too much air into her central veins and died from a massive air embolism.”
“Would she be alive if you had seen the IV become disconnected?”
Claire begin to sob. “I—I—”
Walter Andrews cleared his throat. He had been silent up until that point other than his greeting. “Claire, it’s okay.” He cast a fatherly glance at the attorney. “Easy, Peter.” He reached over and laid his hand against Claire’s arm. “We don’t have an exact answer to his question, so it’s unfair to ask it of you. The patient’s liver injury appeared severe, and in the presence of so much blood in the abdomen, and with her hypotension before the scan, we assume she was still actively bleeding. All of these facts together make it highly likely that she would have died anyway.”
“Am I going to lose my job?”
Dr. Andrews shook his head. “Of course not. This is an unfortunate event for your first month, but you will be forced to learn a lesson that all of us eventually learn. We do make mistakes because we’re human. And patients suffer because we aren’t perfect.”
“Is Mr. Jones going to sue?”
Wanda spoke up. “We don’t know. Other than the threat he made to you yesterday, did he say anything on the night his daughter came in?”
Claire sighed. “He was upset from the moment he met me. He saw that I was a woman, and assumed I wasn’t even a doctor. Then, when we were going to the scanner, he asked Dr. Roberts if he was going along. Dr. Roberts assured him that his daughter was in good hands. Then, at the scanner, he wanted to go in with his child, but the technician wouldn’t let him.” She winced, remembering her words. “I tried to comfort them. I told the parents that Sierra would be fine.” She looked up at Dr. Andrews. He was frowning, not appearing angry, just sad. “I’ll know better than to make such assurances in the future.”
Mr. Ondrachek stood up, signaling an end to the meeting. “If you get any further threats from this man, please let us know. And do not speak to anyone about this case. It would be best if you didn’t mention it at all. Right now that’s only a recommendation. If he sues, it will become a legal necessity.” He nodded seriously. “And one more thing. If there’s a memorial or funeral service for this girl, and I’m sure there will be, please don’t show up. We’ve had residents in the past who have felt bad about deaths they’d caused, and they show up at the memorials in an attempt to show respect. But let me assure you, that’s a bad idea. The attorneys for the other side will read that as remorse, presumed evidence of guilt. In addition, since the father has made a threat, showing up at a memorial service might result in some unpleasant fireworks.” He raised his eyebrows. “Any questions?”
“No,” Claire responded.
None for you. Only the ones I’ll ask myself over and over. Would Sierra Jones still be alive if it wasn’t for me?
By evening, Claire felt like a walking zombie. She’d been in the hospital, except for thirty minutes when she picked up her clothes, for sixty hours. She was in desperate need of sleep and a shower.
She trudged toward the hospital lobby, taking mental inventory. She’d arrived at six A.M. on July 31, enthusiastic, self-confident, and ready for her last night of trauma call. She was leaving on August 2, six P.M., defeated, threatened by a lawsuit, full of self-doubt, and confused about her feelings for Brett Daniels. She’d not had one spare minute to give to an anxiety over her family or the looming possibility of Huntington’s disease. She smiled, nearly giddy from lack of sleep. The one advantage to being so busy with my internship is I don’t have any time to worry about my dysfunctional family.
She was unlocking her car door when she saw Dr. Overby wave. He lumbered across the parking lot and wiped the sweat from his forehead. “I’m glad I caught you. I wanted to warn you about Friday. I had to post Sierra Jones’s case for discussion for Friday’s M and M conference.”
M and M, the morbidity and mortality conference, was the weekly critique of all that went wrong from the week before. It was supposed to be a learning experience. For most residents it was a definite Maalox moment, as they had to be thick-skinned and prepared for questions. The chief residents were responsible to list all unexpected outcomes, complications, and deaths on their respective services. To not list a complication was risking discovery by Dr. Rogers and expulsion from the pyramid.
“Oh.” She was too tired to care.
“You’re going to have to present the case, Claire. I’ll be there. I won’t let you drown, but you’re going to have to take whatever the attendings dish out. You should read up on air embolism and liver trauma. They are likely to ask you questions.”
She opened her car door and threw in her call bag.
She knew the reputation of some of the attendings for chewing up the residents when they made mistakes. “Will it get ugly?”
“Probably not. Just don’t make excuses. That just invites their attack. If you say, ‘I screwed up,’ it’s more likely they won’t be too excitable. The harshest comments usually come from other attendings who have specific bones to pick with the attending responsible for your case. So for you, that’s good. Hardly anyone dislikes Dr. Andrews.”
That seemed like little consolation. It had been bad enough going over the details for Mr. Ondrachek. Now she was going to have to confess her sins to the entire surgery department.
“Thanks for the warning.”
“Sure.”
With that, he turned and walked away. Claire sat in her car and began to cry.
Chapter Twenty-One
Once home, Claire forced herself to eat a nutritious meal, a microwave dinner. She consumed it in large bites, standing at the kitchen counter, knowing it would be faster that way, and less likely that she’d fall prey to the sleep which crouched ready to assault her at any moment. She dressed for bed and thought about returning a call from John, but decided she didn’t have the mental energy to explain what she’d been through in the last few days. I’ll just have to call him Friday night.
She slept the sleep of the dead, a motionless coma, aware of nothing until her alarm resurrected her at five. She rose and stared at her open closet and again promised herself that she’d go shopping soon.
She selected her only other skirt, a khaki material that fell just above the knee. She put on a white shirt with fine blue stripes, then sniffed the armpits of the white one she’d hung on the bedpost the night before. This will have to do. She hung it on a hanger, threw a pair of clean undies in her call bag, and headed for the Mecca.
Morning rounds with Dr. Rosenthal, the CT fellow, did not go well. Martin had given orders for Hespan on Dr. Lewis’s patients, when he preferred crystalloid. He had transfused Dr. Blanton’s patient with a hematocrit of twenty-seven, when Dr. Blanton preferred no transfusion for his patients until the hematocrit was below twenty-five. With each error, Dr. Rosenthal cleared his throat and appeared to be clenching his teeth.
Claire stepped back and stayed quiet as she observed Dr. Rosenthal’s face reddening. Martin hadn’t called the fellow when an open-heart patient had slipped into atrial fibrillation, a clear departure from accepted protocol. “When in doubt, Dr. Holcroft, it’s always better to call.” The CT fellow’s face was within six inches of Martin’s. “Do you understand?”
“Yes, sir, but the patient didn’t have a drop in blood pressure and it was only an hour until rounds, so I thought I’d wait and—”
“Your job is to do what the
attendings want. Your job is not to act on your own. Do you understand?”
Martin huffed. “Yes, sir.”
Dr. Rosenthal backed away, then gave the nurse the appropriate drug orders to treat the dysrhythmia that Martin had ignored.
Claire followed along, herding the medical students to the next patient. Martin’s shoulders drooped and he looked at Claire and rolled his eyes behind Rosenthal’s back. Martin just wasn’t getting it. Internship was more about keeping the residents above you happy than about learning to be a great surgeon. And keeping the higher-ups happy was more about following stupid rules than being an independent thinker. Claire suppressed a smile as she thought about the wisdom of the O-man and his third rule of internship survival. “If you don’t know, ask.”
After rounds, Claire cornered Stephanie Dickson, who was just completing sign-out to the nurse coming on for day shift. She kept her voice low, her tone that of a conspiring comrade. “What’s the deal with Dr. Holcroft? Didn’t you help him with the protocols?”
Stephanie glanced around the unit. “Of course I helped him. But he’s a pompous jerk. I tried to tell him what the attendings would want, but his Harvard attitude got in the way.” She shrugged. “So I let him swim on his own.”
“Sink on his own is more like it.”
“He didn’t think so.”
Claire put her hand over her mouth and tried not to smile. “He seemed so mild to me.”
“He signed all his orders, ‘Holcroft, MD, PhD.’ You can’t read the Holcroft part, but the initials are all in block letters that a first grader could decipher.”
Claire looked for the cardiac rehab recliner, not seeing it anywhere. “Where did he sleep?”
“He didn’t. He paced the unit like a caged tiger. He made Janice Turlington record vital signs every fifteen minutes on Dr. Lewis’s stable valve patient, so she hid the chair in the storage closet.”
Claire snickered. “You guys are brutal.”
Stephanie pushed a strand of rebellious gray hair behind her ear. “Only when we have to be.”
The intern nodded and picked up a chart to start her daily notes. Boy, it pays to follow the rules.
Claire settled into her new job of “sitting hearts” with little adjustment. As the open-heart cases were finished, she stayed at the bedside, watching the monitors, fascinated by the response of the blood pressure and cardiac output to her interventions. As she dialed up the pressor drips, the blood pressure rose. As she increased the fluids, the cardiac output increased, the response leveling out as the patient’s heart reached optimal volume. This was cardiac physiology in real life, and Claire was in the driver’s seat, loving the ride.
As the night passed, Claire’s anticipation of the Friday morning’s M and M conference grew from anxiety to dread. She’d had little time to prepare, and she knew she would arrive sleep deprived. In between hourly updates on the heart patients, Claire practiced her presentation and hoped for the best.
At five o’clock she stole away from the ICU to an empty call room. If she couldn’t silence the sharks with her knowledge, at least she knew a little mascara couldn’t hurt.
She showered, styled her hair, and applied her lipstick and mascara. “Oh, God,” she prayed. “Please help me not to cry. The last thing I need is to run my mascara in front of the whole surgery department.”
She studied herself in the mirror for a moment. She still had good summer color, although the tan she’d gained from her side trips to the beach was fading fast since she’d begun her indoor CT marathon. As a final step, she put on small pearl earrings, a gift from John, and smiled. She liked what she saw. She might be in need of sleep, but she wouldn’t fail for lack of charm.
After rounds, she dutifully headed for the M and M conference room. She entered, surveying the audience for the best seat. M and M was always crowded. It was a required conference for the residents, but fortunately—perhaps the only thing Claire could find comfort in—it was closed to anyone outside the surgery staff. It was a place to air your dirty laundry in front of your colleagues without the threat that others would overhear.
There were donuts and coffee on a side table. Claire could tell which residents had to present cases. They were seated in the front, looking at their notes, oblivious to the joviality of the rest of the resident staff. No one on the front row was eating. There would be no coffee stains on the coats of the presenters. Claire took her place on the front row and silently noted that no other interns shared her distinction. Great, she mused, Beatrice gets the First Blood award. I wonder what I’ll get for being the first intern crucified in M and M.
The nervous joviality ceased as Dr. Steve Acardi, a third-year resident, presented the first case of a thirty-three-year-old whose laparoscopic gallbladder surgery was complicated by an injury to the intestines. He successfully fended off questions from Dr. Denton, a vascular surgery attending, but got stymied by Dr. Garrison, an old-schooler who still thought laparoscopic surgery was newfangled and dangerous. To the resident’s relief, Dr. Rogers, the GI section chief and chairman of the department, came to his resident’s aid, called Garrison a dinosaur, and told the resident to sit down.
Dr. Wong Lee, a chief resident, was next, and presented a vascular case where the distal anastomosis of a femoral-popliteal bypass was accidentally hooked up to the vein instead of the artery. This brought a vigorous outcry from Dr. Denton, who proclaimed Lee to be the victim of a stupidity virus, and warned the audience never to get sick in July at a teaching hospital. Lee sat down humiliated, but breathing. He’d been through this too many times in his six-year stint to be defeated by the hot air of Dr. Denton.
Claire was next, and was thankful that the podium wasn’t transparent. She presented the details of the case without faltering and admitted her mistakes quickly before any of the attending sharks had the chance to smell blood. “I made two critical errors. I didn’t keep in mind how rapidly a pediatric patient can deteriorate.” She looked down. “And I didn’t keep my eyes on my patient at every moment. I was too distracted by my interest in her CT findings. I’d never seen a liver injury so severe, and I was caught up in going over the scan with the radiology resident rather than paying attention to my patient.”
Dr. Stan Fowler stood up. Claire would have been surprised if he hadn’t. As a trauma attending, he was obligated to speak out. She just hoped she’d have the answers to his criticism. But, instead of questioning her, he turned to the audience. “This illustrates a point I’ve made in this conference time and time again. The most dangerous place for an unstable trauma patient is in the radiology department. They don’t have the proper equipment handy in case there is an emergency just like this.”
Dr. McGrath spoke next. “Why did this patient need a CT scan at all? Wouldn’t a portable ultrasound in the ER have been more rapid and given you the same information?”
Claire wasn’t sure what to say. “Well,” she began, just as Dr. Overby interrupted.
“The decision to get a CT scan was mine. An ultrasound would have given us information about free blood in the abdomen and could have shown the liver laceration, but it would never have shown us the additional information about her kidney function and could never have shown us the detail that a CT offers.”
The group argued among themselves, pontificating over the virtues of CT versus ultrasound in the management of acute abdominal trauma. Claire stayed quiet and tried to appear interested, and not just relieved at having the attention off of her.
Dr. Tom Rogers concluded by thanking Claire for bringing the case to discuss, pointing out the necessity of securing all central-line connections with care, and reviewing the steps to manage a patient with possible central venous air embolism.
Claire sat down and took inventory. She’d fielded one question that Dr. Overby answered for her. And she hadn’t cried. Score one for the O-man. She looked over her shoulder and caught his eye. “Thank you,” she mouthed.
He made a barely perceptible nod of acknowl
edgment before looking away.
She relaxed and wished there was an inconspicuous way she could get to the donut table. She was suddenly aware of her famished state and salivated at the aroma of the morning brew.
After waiting through two more presentations and Dr. Rogers’ dismissal, she joined the throng at the refreshment table, listening quietly to Dr. Lee murmuring about the treatment he’d received. She picked up a donut and silently walked out behind him. He leaned toward his junior resident and complained, “If she’d have been a man, they would have taken her to task. But they sat there drooling like they were ready for dessert. I’ve never heard Dr. Rogers thank a resident before. He’d never treat a male resident like that.”
The other resident laughed. “I’ll bet she paid them in advance. Did you see how quickly the O-man took the heat?”
Claire shrank back and paused to let the dispersing crowd go around her, pretending to make a note on her scut list. She took a deep breath and counted to ten, attempting to shrug off their comments. Chauvinist jerks.
Dr. Lee was just jealous. But what did he care? He’d already made it to the top of the pyramid.
She looked up and waited until Dr. Lee disappeared around a corner. I hope I don’t have to work with him anytime soon.
On Friday evening, Claire drove her Toyota up the alley behind Safeway, across Thompson Street, and into her driveway. She paused when she saw the items in the yard next door, the evidences of young children and their play. A wagon, a basketball and a bike, a purple one with training wheels, seemed haphazardly arranged, abandoned by the kids, likely in response to their mother’s call for supper. The only occupant of the yard was a miniature schnauzer named Tiger, who ran up to say hello.
She knelt and scratched him behind his ears, receiving his wet greeting with gratitude while her heart sank. Why did it have to be a purple bicycle? Why not red or blue?