by Robin Cook
Michael flew back into the room, panting from exertion. “I couldn’t find anyone free. The only person I found was an ER doc two doors down struggling with a dislocated shoulder. He promised he’d be here as soon as he got the arm back in the joint. How is the patient doing?”
“He’s getting oxygen, which should help some,” Lynn shot back. “But he is in trouble. But I think I know what is going on.”
“Clue me in!” Michael demanded.
“Listen to his chest! See what you think. But do it quickly.”
Michael struggled to get his stethoscope in his ears. While he listened first to the left side, then to the right, and then back to the left, he kept his eyes on Lynn, who was taking the man’s pulse. “There’s no breath sounds in the left side,” Michael said.
“Try percussion!” Lynn said. “But do it fast. His heart rate is up to one hundred twenty. That can’t be good.” Lynn could feel her own pulse in her temples beating almost as rapidly.
Michael quickly did as Lynn suggested. The hyper-resonance on the left was immediately apparent, and he said as much.
“Does that ring any bells to you?” Lynn said. “Especially since he has dilated neck veins.” She pointed.
“Tension pneumothorax!” Michael blurted.
“My thoughts exactly,” Lynn cried. “If so, it is a real emergency. His left lung must be collapsed, and with every breath, the right is being compressed. He needs an X-ray, but there’s no time.”
“He needs a needle thoracotomy on the left!” Michael shouted. “And he needs it now!”
In a panic, the two students regarded each other across the body of the patient. For a second they hesitated, even though they were frantic. Neither had ever seen a needle thoracotomy performed, much less done one. They’d read about it, but to go from book learning to actual performance was a giant step.
“How soon do you think the ER doctor might get in here?” Lynn demanded anxiously.
“I don’t know,” Michael said. Perspiration appeared on his forehead.
“Mr. Weston,” Lynn yelled as she gave the man’s shoulder a shake. The patient didn’t respond. Instead he collapsed supine onto the gurney, no longer supporting himself on his elbows. “Mr. Weston,” she called louder, with a more significant shake to his shoulder. Nothing. The patient was no longer responding.
“We can’t wait,” Lynn said.
“I agree,” Michael replied. The two of them rushed over to a crash cart that had all sorts of emergency equipment. They grabbed a large syringe, a sixteen-gauge intravenous cannula, and a handful of antiseptic pledgets. Then they rushed back to the patient.
“My memory is that it is supposed to be done in the second intercostal space between the second and third rib.”
“You do it!” Lynn yelled, thrusting the cannula into Michael’s hands. “How the hell do you remember such details?”
“I don’t know,” Michael retorted as he quickly snapped on a pair of sterile gloves. He then tore open the sterile wrapping on the cannula. It had a needle stylus to facilitate insertion.
“What if it is hemothorax and there is blood in there instead of air?” Lynn questioned anxiously. “Would we be making it worse?”
“I don’t know,” Michael admitted. “We’re in uncharted territory here. But we got to do something or he’s going to check out.”
Lynn tore open several alcohol pledgets and rapidly swabbed a wide area below the patient’s left collarbone. Michael positioned the tip of the cannula with its needle stylus over what he thought was the correct position. He’d located it by palpating the area and feeling the bony landmarks. Still he hesitated. It was a daunting task to blindly plunge a needle into someone’s chest, especially the left side, where the heart was.
“Do it!” Lynn snapped. She knew that she and Michael were an example of the blind leading the blind, but the needle thoracotomy had to be done, and it had to be done immediately. The patient’s color had deteriorated despite the oxygen.
Gritting his teeth, Michael pushed the catheter through the skin and advanced it until he felt the needle tip hit the rib. He then angled it upward slightly, and pushed again. He could actually feel a pop after advancing the needle another centimeter or so.
“I think I’m in,” Michael said.
“Great,” Lynn said. “Take out the stylus!”
Michael pulled out the stylus. Nothing!
“I guess I have to advance it a bit more,” Michael said. “I must not be in the pleural space yet.”
“That, or we have made the wrong diagnosis,” Lynn said.
“Now, that’s a happy thought,” Michael added sarcastically. He reinserted the stylus and then pushed deeper into the patient’s chest. He felt a second pop. This time when he removed the needle, both he and Lynn could hear a rush of air come out through the needle like a balloon being deflated.
Lynn and Michael’s eyes met. Both allowed a tentative smile. Over the next few minutes their smiles broadened as the patient’s breathing and heart rate improved, as did his color. He also slowly returned to consciousness. Lynn and Michael had to hold his hands to keep him from reaching up and touching the cannula sticking out of his chest while they waited.
“Maybe we should do a residency as a single person,” Michael said. “I think we make a good team.”
Lynn smiled weakly. “Maybe so,” she agreed, pushing away the thought that she wished she were heading up to Boston with Michael.
Just then a blood-spattered ER doctor by the name of Hank Cotter and a nurse rushed in. They went directly to the patient, crowding Lynn and Michael to the side. While the nurse took Clark’s blood pressure, Hank listened to the man’s chest. He saw the needle thoracotomy.
“Did you guys do this?” he questioned.
“We did,” both Lynn and Michael said in unison.
“Collectively we decided it was a tension pneumothorax,” Lynn explained.
“We thought we had to do something, as the patient was going downhill fast,” Michael added. “We didn’t think it could wait.”
“And you guys are medical students?” Hank asked. “I’m impressed. Have either of you rotated through the ER?”
Both Lynn and Michael shook their heads.
“I’m even more impressed,” Hank said. “Good pickup.” Then, turning to a nurse who had just entered, he said: “Let’s get a portable chest film stat and bring in a pack for inserting a chest tube.”
Hank turned back to Lynn and Michael. “Now, I’m going to have you guys insert a chest tube. Are you up for it?”
BOOK 2
19.
Tuesday, April 7, 9:38 A.M.
Lynn had been the one to insert the chest tube using local anesthetic. Michael had watched. It was far easier than when they had inserted the needle thoracotomy, because Hank, a third-year emergency medicine resident, had been the instructor and stayed with them through the procedure. It went without a hitch and both Lynn and Michael felt reasonably confident they were much better equipped to handle the emergency care of chest trauma cases in the future.
After Clark Weston had been stabilized, Lynn and Michael went back out into the ER proper to see if they could lend a hand with any other patients. To their surprise, what they found was that the emergency situation was essentially over. While they had been seeing to Clark Weston’s needs, the rest of the patients from the accident had been taken to the MUSC Medical Center while the ones that had arrived at Mason-Dixon had all been seen and were in the process of being treated.
While they were still at the ER desk, checking if there was anything else they could do to help, Lynn caught sight of Dr. Sandra Wykoff, who had also responded to the call to come to the ER. Impulsively running over, Lynn caught up with the woman as she was about to leave. Controlling her emotions, Lynn quickly reintroduced herself and again asked about getting together. Graciously t
he doctor agreed but said, “It has to be now since I’m about to begin a case. Will that work for you?”
“Absolutely,” Lynn said.
“Then come up to the anesthesia office on the second floor, next to surgical pathology. I’ll meet you there but don’t dawdle.”
“I’ll come right away,” Lynn assured her.
Rejoining Michael, Lynn snapped under her breath: “See the woman I was just talking with? That’s Wykoff, the anesthesiologist who screwed up with Carl.” She motioned with her head in the woman’s direction.
Michael watched Wykoff disappear before turning to Lynn. “Come on, sis, we’ve been over this. Be cool! For the tenth time, you don’t know there was any screwup.”
Lynn gave a short, mirthless laugh. “We’ll see,” she said. “The important thing is that she’s willing to see me now. Are you interested?”
“Since we missed the derm lecture, I guess I don’t have any excuse, and somebody has to keep you in line. But we’re going to go via the cafeteria so you and I get a few calories. I’m about out of gas and you’ve been on empty for hours.”
“All right, but it’s got to be takeout and fast,” Lynn said. “There is a narrow window of opportunity. She’s about to start a case. She even warned me ‘not to dawdle.’ Can you believe it? I don’t think I have ever heard anybody use the word dawdle.”
“You are certainly looking for ways to fault her,” Michael said. “Dawdle is a perfectly fine word. You catch my meaning, right?”
“I suppose,” Lynn agreed reluctantly.
Lynn was willing to take the risk of going via the cafeteria because she knew what food meant to Michael. She teased him on occasion that he was a growing boy. Taking the time now to get him some food was a way of showing her appreciation that he was willing to come with her to talk to Wykoff. As a realist, she knew she probably needed some protection from herself, and he was the one to provide it. She couldn’t help but feel anger toward the woman and knew that expressing it would certainly be counterproductive.
The visit to the cafeteria was appropriately short. They grabbed a couple of bread rolls and some fruit at the register to eat on the run. As far as Lynn was concerned, there was another reason it was good that they did not stay. In her fragile emotional state, she didn’t want to take the chance of running into anyone who might ask about Carl’s surgery.
Five minutes later when they arrived outside the anesthesia office door, Michael pulled Lynn aside. “Wait a second,” he said. “We have to think what to say if Wykoff asks why we are interested in Carl’s case and how it was we read her note. She’s bound to ask us, and we can’t use the anesthesia story.”
“Obviously,” Lynn said. Because of the detour to the cafeteria, even though it was short, she was particularly impatient to get inside the office. She was afraid of Wykoff being called out at any moment and cutting the meeting short.
“The only thing that comes to mind,” Michael continued, “is to say we are on a neurology rotation, which I suppose is a laugh. It means we use anesthesia for neurology and neurology for anesthesia.”
“I don’t know,” Lynn said hesitantly. She didn’t like the idea and struggled to find another. “I agree she might ask, just like she might be touchy about Carl’s disaster. The problem is that it’s too easy for an attending like Wykoff to find out we’re lying. All it would take is one phone call, and we’d be in deep shit, and all doors for finding out about Carl would slam shut. No, we have to come up with something else so we’re not lying. Why don’t we say we are researching hospital-acquired morbidity? At least it’s true.”
“I’m not sure saying we’re studying hospital-acquired morbidity would be much better,” Michael said. “With the administration, the idea of its own medical students researching something like that will go over like one of Ronald’s bad jokes.”
“Well, I can’t think of anything else,” Lynn said. “I think we’re stuck with the morbidity angle. That is, if she brings it up. Maybe she won’t. Come on! We have to get in there!”
“All right,” Michael said, throwing up his hands. “You’re the boss.”
“Hardly,” Lynn said. Facing the door, she hesitated. Not knowing if they should just go in or not, Lynn knocked, thinking it best to err on the conservative side. The sign on the door just said ANESTHESIA. A voice from inside called for them to come in.
It was a relatively small office without windows. There was no secretary. The space had four modern desks supporting computer terminals to be shared by all the anesthesiologists to handle their paperwork. A large bookshelf ran along the right wall and was filled with anesthesia texts and journals. Dr. Sandra Wykoff was sitting alone at one of the desks. As the students approached, she motioned for them to bring over a couple of the other chairs.
“So . . . ,” Dr. Wykoff said once they were seated, “who, may I ask, are you?” She was looking directly at Michael, and unlike many of the other attendings, she maintained eye contact.
“Another fourth-year medical student,” Michael said. He was impressed that she continued to stare at him.
“And you are researching the Vandermeer case along with Miss Peirce?” Dr. Wykoff’s tone was surprisingly matter-of-fact, neither friendly nor unfriendly.
“Yes,” Michael said. He didn’t elaborate. He wanted this to be Lynn’s ball game. All he was there for was hopefully to keep Lynn out of trouble.
“Why are you two interested in this case in particular?”
Michael noticed that the woman’s gaze had now appropriately shifted to Lynn.
The students exchanged a quick, nervous glance. It was Lynn who spoke up: “We have become aware of the huge problem about hospital-acquired morbidity. We think this case fits that category all too well.”
Dr. Wykoff nodded and paused, as if thinking. Then she said, “Have you read my note in the Vandermeer chart?”
Both Lynn and Michael nodded, afraid of what was coming, namely a question as to why they were looking at the chart and under whose authority. But to their relief it didn’t happen. Instead the doctor asked, “What is it about this case that you want to discuss?”
“What the hell happened?” Lynn blurted out, causing Michael to wince inwardly. “I mean, how could a healthy twenty-nine-year-old man having routine elective knee surgery end up suffering brain death?”
“If you read my note, then you already know that nothing out of the ordinary occurred,” Dr. Wykoff said, seemingly not taking offense. Michael was both surprised and relieved. “The case was entirely normal. I thoroughly checked the anesthesia machine before the case and after. It functioned perfectly in all regards. The sources for all the gases and the gases themselves have all been checked and rechecked. All the drugs and dosages have been checked. I have gone over the case with a fine-tooth comb. So have several other anesthesiologists. Nothing happened that would have contributed to the unfortunate outcome. It had to have been some sort of idiosyncratic reaction.”
“There had to have been a screwup,” Lynn snapped.
Lynn’s tone and words made Michael now visibly wince. Before the doctor had a chance to respond, he said, “We did see in your note and in the anesthesia record that the blood-oxygen saturation suddenly went down.” He deliberately spoke in a measured tone as a counterpoint to Lynn’s outburst. “Do you or anyone else have idea of what made that happen?”
“The oxygen level did go down,” Dr. Wykoff said. “But it only dropped to ninety-two percent, which isn’t that low, and, just as important, it immediately began to rise. Within minutes it was back to near one hundred percent. But to answer your question, I have no idea why it went down. The inspired oxygen concentration and the patient’s tidal volume had not changed.”
Lynn started to speak again but Michael gripped her arm to keep her quiet, saying, “We imagine it must have been a very disturbing case for you.”
“You ha
ve no idea!” Dr. Wykoff said, and paused before adding, “I had never had a serious complication before this case. It is my first.”
“In retrospect, would you have done anything differently?” Michael asked, wanting to keep the conversation going but without being accusatory.
Dr. Wykoff took another moment to continue. “I asked myself the same question. But, no, I wouldn’t have done anything differently. I handled the case the same way that I have handled thousands of others. There were no screwups! I can assure you of that.”
“There had to have been something,” Lynn interjected, despite Michael still gripping her arm. Although her voice wasn’t quite as strident, it was still harsher than Michael thought appropriate. “There had to have been something out of the ordinary that you did even if you didn’t think it could have made any difference.”
Dr. Wykoff silently stared at Lynn long enough to make Michael think Lynn had finally done it. He girded himself for an outburst from the doctor, but it didn’t happen. Instead, to his surprise and relief, Dr. Wykoff said, “There was something, but it was very minor and can’t have been significant. It is not something I did, but something I noticed. It did bother me when it happened.”
“Like what?” Lynn demanded, again with a bit too much emotion.
Michael desperately tried to think of something to say to cover up Lynn’s insensitivity, believing her carping tone was asking for trouble, not only for her but for him, too. The reality was that they had already seriously violated HIPAA by looking at Carl’s and Scarlett’s charts and photographing the anesthesia records, and here Lynn was doing her best to alienate a woman who was being unexpectedly cooperative with a couple of medical students even though struggling emotionally herself. Michael sensed that the woman was deeply troubled by what had happened, which along the lines of “misery loves company” was probably the reason she was willing to talk with them at all.