Cutter's Trial

by Allen Wyler

  “Shit!” Alex shouldered Stein aside. “Lap pad, soaked!”

  Chuck rammed the sodden cotton into his hand. Alex pushed it against the dura, hoping to stop the hemorrhage and prevent the sinus from sucking air. “What the hell did you do?”

  “I … wanted a bit more exposure. Just a snip.”

  “I said stop. What didn’t you understand about that one fucking word?” Alex immediately regretted his tone. “Sorry.”

  His mind started racing. His gentle pressure on the lap pad was keeping the bleeding minimized but not controlled. He paused to collect his thoughts. It was crucial to glimpse the damage so he could decide the best way to repair it. “Bob, we have a major problem here.”

  “I can see that,” Cole replied, peering over the sterile drapes.

  Alex began thinking out loud, talking to no one in particular. “We need to look at the damage. Steve, how much did you cut?”

  “Jeez, I don’t know. I put the tips of the Metzenbaum in and snipped … Wasn’t much, couldn’t been more than a couple millimeters.”

  Bullshit. From the ooze seeping around the lap pad, Stein had clearly entered the sinus in the upper right-hand corner of the craniotomy. The question now was how much had been opened. Regardless of how much pressure he applied—and he couldn’t apply much because he was pressing against brain—the bleeding continued, forcing him to do something quickly to control it before the patient bled too much.

  “Okay, I’m going to pull back the corner to get a look. Steve, I want you ready with a large-bore Sachs sucker.”

  He waited for Chuck and Steve to change to a larger sucker, capable of handling the amount of bleeding.

  “Ready?”

  Steve put the sucker tip into place next to where Alex would pull back the lap pad.

  “Have another soggy lap pad ready, Chuck. Okay, here I go.” He tossed the soaked pad blindly behind him then reached for a replacement. Blood gushed at him with such force he couldn’t see the origin. “Fuck!” He pressed the fresh pad into place.

  “Bob, we’ve got some serious trouble here.” He fought to keep gut-wrenching fear from his voice. If he showed the slightest panic, everyone would panic.

  “What do we do?” Stein asked.

  “Shhh! Let me think!”

  Basics. Always default to basics. Knowing there were fundamental rules, surgical principles to follow, gave him a sliver of hope. Don’t deviate from the basic rudiments. Control bleeding and maintain an airway. He ran a mental checklist of the things he needed. “Bob, how much blood we have on hand?”

  “Two units.”

  “Run out a couple red tops for four more immediate units, then have them set up another four for standby … just in case. We’re getting some major blood loss here.”

  “I’m drawing them as you speak,” Cole said.

  “And turn off the music.”

  In the next instant all you could hear were the monitors and mechanicals. Alex bet everyone could probably hear his heart hammering his sternum.

  Blood’s taken care of, airway’s under control. What next?

  “Bob. Raise and level the table.”

  “What do—”

  “Silence!” Alex cut Stein off again but this time didn’t bother to worry about his tone. Several seconds ticked past as he thought and rethought his limited options. He was sweating profusely as drops slithered down his chest.

  “Okay, here’s the deal,” he explained to no one in particular. “We’re in the sinus. That much is clear. The question is how much is cut and how can we control it.” All of this was rhetorical, he knew, but it felt better to talk through it out loud. “I need a visual to know that.”

  “Chuck, load up a big wad of Surgicel plus a wad of thrombin-soaked Gelfoam.” Both were agents used to help blood clot. “When you have those ready, let me know and I’ll try to take another look. Steve, be ready with two Sachs suckers down here. Soon as I pull the lap pad, get in and clear out as much of the field as possible.” He wished for more experienced hands to help him but couldn’t afford the time to muster another assistant into the room. He flashed on Reynolds’s advice of having seniors with him. Too late for that.

  “Want me to bust out Fullager?” the circulator asked, referring to the chief resident. “He’s just next door.”

  “Thanks, but we don’t have time.” He glanced up and saw Chuck pouring thrombin into a stainless steel bowl, soaking big squares of Gelfoam. Two big wads of Surgicel, a silver mesh, were balled up and ready to go. “Tell me when you’re ready.”

  “Thirty seconds.”

  Alex checked his own breathing, forcing himself to take slow, measured breaths instead of hyperventilating as he’d been doing. He mentally orchestrated the exact moves he needed to make once he pulled away the sponge. “Speed kills,” he muttered, an old axiom learned from Baxter. Be careful.

  “Ready when you are,” Chuck said.

  “Okay, listen up everyone. This is the plan. I’m going to pull back the corner of this lap pad while Steve sucks. I figure we have maybe three seconds to look. Chuck, have the Gelfoam ready first.” He held up his bayonet forceps so Chuck could load the tips with the foam. “I’m going to stuff this into the corner, then pack it in place with the Surgicel. Steve, have a cottonoid ready to follow. Soon as I put the Surgicel in place, stuff that cottonoid directly on top of all of it. Then a fresh lap pad.” The old pad was already leaking way too much blood. “Okay, we set?”

  Chuck, Stein, and Cole said they were.

  “On the count of three. One, two, three.”

  Alex threw the blood-soaked pad off to his left, landing with a sodden plop on the floor, while Stein sucked at the torrent of blood filling the field. “Suck!”

  Stein couldn’t begin to keep up with the hemorrhage.

  “Shit! Gelfoam.”

  He quickly stuffed the foam into the approximate location, then repacked the field in the order he’d described, holding just enough pressure to keep the blood from seeping around the pack.

  “What now?” Cole asked.

  Good question.

  “Can’t see the bleeding site well enough. I want to try one more look, but not until I’ve held pressure on it for five minutes by the clock.” He hoped the thrombin-soaked Gelfoam might slow the hemorrhage by that time. “Start the clock. I don’t want us short-changing the time. Bob, raise his head just a bit.”

  “Why do that?” Stein asked. “Doesn’t that increase your risk of air embolism?”

  Alex nodded. “Yes it does, but so far we haven’t been able to see a goddamn thing. I’m hoping to improve enough venous return to slow the bleeding and see the cut. If we have any chance at all of getting the patient out of here, we have to control the bleeding. Forget about going after the tumor at this point.”

  The room remained deathly silent. Everyone realized Alex wasn’t being melodramatic.

  “Everyone know what to do?” Alex asked even though he knew they did. “Okay then, on the count of three. One, two, three.”

  Hands flew. Alex glimpsed the cut sinus. He held out his hand. “Backhanded dural silk. Quickly!” He intended to stitch in a Gelfoam patch, another trick learned from Baxter. If he could just get the stitch in—

  “We’re getting air,” Cole said with urgency.

  “Lap pad.”

  Alex packed the opening as Cole leveled the operating table.

  “She just arrested,” Cole said.

  The pit of Alex’s stomach dropped out. The complication just gained more momentum than they could likely handle, and in that instant he knew the patient was doomed.

  “Get the overhead out,” Alex shouted, kicking off the brake and pushing the heavy table away from the patient just as Chuck jumped off. The sterile field vanished as he dragged drapes over it, but at this point sterility was the least of their concerns. Alex stayed at the patient’s head, holding the blood-soaked pad on the wound in an attempt to staunch more bleeding, which he later realized was fruitless because
the heart was no longer beating.

  With the respirator on full assist, Cole started pumping the chest, the monitors screaming at the flat-line EKG. “Get another anesthesiologist in here!” Cole yelled to the paralyzed, wide-eyed circulator.

  She bolted from the room.

  “Your call,” Cole said to Alex.

  Alex used the bloodied sleeve of his surgical gown to blot away tears. He tried to swallow, but the constriction in his throat kept him from doing that. Cole, the other two anesthesiologists, Chuck, Steve, and the circulator waited in the mess surrounding the operating table: syringes, sponges, debris strewn over the floor. He tried to swallow again and wet his mouth with saliva.

  “Okay.” He glanced at the wall clock. “The official time of death is nine twenty-seven,” he said in a weak, cracking voice.

  He stripped off his gloves, balled up his gown, and threw the wad into the linen hamper. “I’ll go tell the parents.” The patient was a twenty-one-year-old single woman.

  Cole came up to him and rested a reassuring hand on his shoulder. “I’ll go with you.”

  Alex felt a flood of relief for having his support. Telling the family was going to be difficult enough. Doing it alone, unbearable.

  “You don’t have to, you know.”

  “I know, but I should be there with you.”

  “Thank you.”

  Alex knocked twice on the door before pushing it open. The mother and father sat side by side in the small room. Styrofoam cups littered the chipped table to the right, and the air smelled of coffee. The mother looked up, saw Alex, and smiled. “That was quick.”

  Alex entered the room, his mind now completely blank, having lost the words so carefully prepared during the trip there. A flash went through the father’s eyes. He knew what was coming.

  “I’m afraid I have bad news,” Alex said, moving to the mother. “Your daughter had a serious complication and her heart stopped. We couldn’t get it started again.” She studied his eyes, processing the unfathomable information as her husband wrapped his arm around her shoulders, hugging her to himself. “I’m so very sorry,” Alex said as she began to cry. Alex knelt in front of her and took her hands in his. “I’m so very sorry.”

  46

  “Fire him,” Lisa said.

  “Who? Stein? No.” Alex waved away the suggestion, his mind endlessly replaying every moment from telling Stein stop opening the dura until he pronounced the patient dead. All the questions reverberating in his brain: What could he have done differently? Wait longer before taking the second look? He kept returning to the bleeding, the volume of it forcing him to act. Could he have worked faster with the stitch? Maybe even …

  “Why not? If I understand it, he did the action that resulted in her death.”

  “He didn’t kill the patient, Sweetie; an air embolism did.” He berated himself for not being more explicit when he told Steve to stop. Was it therefore his fault? It could well have been Alex who cut into the sinus. Well, probably not. He never would’ve have cut that far. How could he live knowing a patient of his died in the operating room from a preventable error?

  “But didn’t you say he caused the air embolism? I don’t understand your logic; you fire a resident for lying, but you don’t fire a resident for a fatal complication? What’s wrong with this picture?”

  Oh, for Christ’s sake. “Can you just drop it? Please? Now isn’t the time, okay?”

  “I’m just asking.”

  “Shit. Those two things aren’t even comparable. Lying repeatedly is a moral issue, a deeply ingrained personality flaw indicative of future ethical problems. What Steve did was a simple mistake in surgical judgment. Every surgeon is going to make that kind of error sooner or later. It’s inevitable. I just hope he learned something from it.” He was certain he had. Steve had been devastated, even offering to resign from the residency. Alex had talked him into staying. At the wet bar Alex poured a weak scotch. “Want a drink?” he asked, hoping to distract her.

  “Sure. But answer my question.”

  “I just did.” He packed two glasses with crushed ice. “It was a mistake anyone could make, even a seasoned surgeon.”

  “Know what I think? I think you can’t be objective about Steve because you two have a history. He’s not like any of your other residents. You picked him for the program. It’s always harder to fire someone you chose.”

  “Lisa, let it go. Please. I don’t care to discuss it. Especially not tonight.” He handed off her drink before heading to his desk. He knew trying to read a journal would be fruitless. Never had he lost a patient in the OR, much less from a preventable error. It’d been a point of pride. Somehow, in spite of knowing the risks of neurosurgery, he’d become … what? Blasé? Believing fatal errors happened only to other surgeons, because he was so careful, so tight-assed that he could sail through a career having none? On the other hand, he’d gone so long with so few complications that the odds were stacked against him. No one could practice the volume he did without stepping on an occasional land mine. He was now paying for letting down his guard. He’d always maintained it was the little things that ended up torpedoing you; he constantly drummed it into the residents’ heads. It’s one thing to have a patient die from a malignant brain tumor, subarachnoid hemorrhage, or head trauma. Those situations carried intrinsically high risks for bad outcomes regardless of any intervention. You felt compassion for those patients but not responsible for their poor outcomes. It was an entirely different matter to have a patient die from surgeon error. Intolerable. If anyone should be punished, it should be him.

  But what should he do? Stop operating? Throw away years of training and hard work as penance for one error? After all, air embolism is a well-known complication of intracranial surgery. Isn’t neurosurgery a high-risk practice? Can any surgeon be expected to maintain his volume without a death?

  Two hours later Alex pushed back from the desk and took the empty glass to the sink. Quietly, to not wake Lisa, he slipped into the bathroom to prepare for bed, having resolved nothing.

  Now in bed, he tried to relax, to slip off to sleep. Would God forgive him? If a judgment day did exist, would the good he’d done in a lifetime outweigh the bad? It dawned on him that he thought of God mostly during troubled times—such as now. God. This wasn’t a new thought, yet his stormy weather religion disappointed him. It didn’t seem fair to seek peace of mind only in difficult times. True believers probably thanked God daily for their lives, like Clarence thanking God for a meal. Perhaps. Yet Clarence’s religiosity somehow didn’t ring pure, as if he used it as a prop to garner self-worth or social acceptability.

  Don’t think of Clarence tonight.

  Why am I so skeptical?

  Well, for one, there was the basic Christian assumption— taken to extremes by conservative fundamentalists—that the Bible is the literal word of God. Alex found it inconceivable that translations of documents and verbal histories generated long after the events they purportedly described and chronicled reflected anything more than hearsay or ecumenical propaganda. He remained leery of the Heaven and Hell concept. Or, for that matter, belief in an afterlife of any kind. In spite of these logic road bumps, the phenomenon of life awed him. He found it impossible to wrap his mind around a time-space spectrum that spanned from an atom to a light year, to say nothing of the incomprehensible vastness of the universe. He was left with a myriad of unanswered questions. What exactly was life? Nothing more than a chemical reaction? And what the hell was consciousness? What had his young patient lost today on the operating room table the moment her heart stopped supporting her brain?

  He stared at the barely discernable phone, lit only by the glow of the digital clock. It waited silently two feet from his nose, threatening to ring. He hated the damn thing. Hated how it robbed him of sleep. Hated being held hostage to it. Because the residents knew he preferred to be kept in the loop for problems with his inpatients, he had only himself to blame for the calls. Each call robbed him of an hour or
more of sleep. He’d forgotten how it felt to be completely rested. Did such a state actually exist?

  Alex rolled over.

  Unable to sleep, Alex checked the clock again. 1:08 a.m. Shit! Six and a half hours until his next case. A complicated one at that. He needed to sleep. And that fucking phone sat there waiting for him to drift off before it would ring, as if it was controlled by some evil intent. Alex closed his eyes and waited for the ring. Had he known how fatiguing neurosurgery practice would be, would he have chosen the same career? Good question. Probably.

  He was slowly developing—especially during nights like this—a growing dislike for clinical practice. The harder he tried, the further away research seemed to become. Day after day he removed brain tumors, the majority gliomas, ironically the basis of his research. Would he ever get back on track? Not with his present practice. Not unless he made a major life change. What kind of change, he had no idea.

  The good news, he realized, was he and Lisa didn’t live large like most of his partners. No new cars, no expensive homes, no fancy trips to Europe. Meaning that once he’d built a nest egg, he could bail.

  He squinted at the clock. 2:13. Still no sleep. Goddamn phone.

  “What time you get to sleep?” Lisa asked, setting out a bowl of oatmeal.

  Alex yawned and poured milk over the mush. “Must’ve fallen asleep sometime after two.” The stove clock showed 5:40 a.m. He intended to make fast rounds before heading to the OR.

  “Don’t forget we’re meeting the Canters tonight at your partner’s restaurant.”

  Friday night dinners at the University Club had become an enjoyable ritual for him. Since relocating here, he hadn’t made many friends. Mostly, he didn’t have time, but he hadn’t put much effort into it either, having quickly discovered he shared little common ground with his partners and neighbors. People accepted his practice as a valid excuse that kept them from attending social events. Luckily, Lisa felt the same as he. But Friday evenings with the Canters were different, perhaps because it felt as if they were expats living in a foreign country. Tonight they had reservations at a new Front Street restaurant a clinic partner bought recently as an “investment.” Why a neurosurgeon would invest in a restaurant remained a mystery.