Therapeutic Window
Page 19
It was seven-thirty when I left the hotel. The sidewalk was already a sea of faces, briefcases and suits. Traffic flowed in stop-start fashion, frustrated by sequential red lights. Normally I would have been uplifted by the big city dynamism. Today though, I was Boatwood’s messenger boy. A sea of conference delegates awaited my delivery. It occurred to me that it was only two weeks before that I was in a similar state of agony leading up to my exam. Past traumas quickly lose their significance. I would have given anything to be transported back in time, if it merely meant sitting a written exam paper. I looked in envy at the patrons of early morning cafes, curled up with their hot croissant and Sydney Morning Herald. So what was I worried about?A stuttering, ineffective performance - with incorrectly packed slides, followed by penetrating questions from the floor. Someone pointing out that the presentation was selective submission of data. That someone would have to be Gibbs or Green – or both. Above all, the death of Mr Hart hung over the whole thing like a big dark cloud. In the audience were Boatwood antagonists, Green and Gibbs – ready to strike. Boatwood had played it all down. They weren’t presenting a major series. It was merely a primer – to show the way for the future.
The conference centre was imposing. In the main corridor, I sat on a bench seat, swallowing and yawning. Filing past me were hundreds of earnest looking delegates, clutching giveaway conference satchels. I was the third speaker of the session. My predecessor on the podium was the typical power dressed, booming voiced, sycophant, I had seen many times before at such events. The zealot had of course given impassioned thanks to the organising committee for inviting him. Similarly, it was a great honour for him to be in the beautiful city. And, he was completely humbled, by the elegant presentation of the previous speaker.
I was humbled as well – by nausea and a dry mouth – almost retching in the penultimate moments. Once I had ascended the stage though, and activated the first slide, and it was the correct one, I felt more relaxed. The slide, a pretty picture of Dunedin city and Otago Harbour, was my prop to enable me to get my voice activated – to get a flow going. I gave a short history of the use of PEEP. The upper value for its application I noted, had settled at around 30 cmH20, after it had become apparent that higher values seriously impeded the blood’s return to the heart. The modern push to higher and higher settings, had arisen because clinicians realised they could counter the negative effect on the circulation in other ways, for example with fluid and catecholamine infusions. Additionally, it was thought the failing heart might actually benefit from hyperPEEP, via the induced afterload reduction. Boatwood’s pilot study was small. The results nevertheless achieved statistical significance, when one looked at the improvement in arterial oxygen of the study group compared to the control animals. Much larger American studies, were going on in Baltimore and Utah. However this data of Boatwoods, was the first presentation of any successful HyperPEEP data.
As the applause died down, people were queuing up behind microphones in the aisles. My heart sank. I had been hoping for a quick exit. The early questions, Iwas able to fend off relatively easily. Gibbs however, had made his way to the centre aisle. In the dull lighting, he stood erect, face set. “Do you believe there is enough evidence from animal experiments, to allow the application of hyperPEEP to humans?” The voice that sounded like a sneer, reverberated about the walls of the lecture theatre.
My mind looped in turmoil. Gibbs knew damn well that Boatwood had already carried out one such application. If I chose to ignore that fact, then I could be rudely exposed by Gibbs, and in turn sink Boatwood into controversy. I also knew that time was running out, and the chairman would be soon forced to close the debate. I cleared my throat. “Codes of ethics, vary from country to country. This variation is due to differences in cultural and ethnic make up of those countries. What is acceptable in one country may be unacceptable in another.” I paused, uncertain where to go next. Gibbs made a move to speak again. I had to recommence quickly, to not allow Gibbs any air time. “Medico-legal history,” I barked, “medico-legal history is important, when considering this issue. In the USA where legal action is commonplace, the release of drugs for use in humans can be much delayed when compared to their release date in Australia or New Zealand. Therefore the answer to your question, is that human application of HyperPEEP could be ethical, given the right balance of completed animal research, and a liberal governing body.”
Gibbs rode in rapaciously. “Specifically Dr Davenport, in your country, is the application of HyperPEEP ethical, given the current state of animal research in this area?”
“There is no governing body that sets limits to the amount of airway pressure delivered to the patients. Individual clinicians have to decide what is reasonable and what is not, based on the potential therapeutic gain of the treatment, against the possible deleterious effects of that same treatment.”
Gibbs had more to say. “You’re just side-stepping the question . . .”
The chairman jumped in to the argument. “Thank you . . . I’m sorry, time is up and I’ll have to interrupt at this point. The question of when it is appropriate to apply the results of animal studies to humans, is an interesting one, and important to all of us. I ask you to thank Dr Davenport for his presentation here this morning.”
As the scattered applause broke out, I bolted for the side-door. I had no inclination to argue the toss about Boatwood’s research ethic with any incensed zealot who might try and accost me. After all I was merely the messenger boy. The main attraction was holed up in Dunedin, preparing to defend himself against a sententious lynch mob at home.
I had barely gotten out of the building however, when I was halted in my tracks.
“Hey . . . stop right there.” Gibb’s voice was like a gunshot. He marched up to me, his face crimson and his eyes hard and penetrating. He grasped the lapels of my shirt.
“You . . . You fool,” he spat. “You think you can bypass me . . . Why are you supporting that maverick? . . . You are making as ass of yourself?”
I didn’t move a muscle. Gibb’s had nearly lost all decorum. I looked around and noted people watching us. Gibbs followed my gaze and thought better of his actions. He released my shirt and stepped back. His voice became more even.
“Boatwood killed that patient, and you know it. Yet you stand up here, in Sydney, in front of Australasia, and make out that hyperPEEP is the greatest thing in the world.”
“I’m an innocent bystander here,” I said. “I’m just doing what I was asked to do by the head of department. If you’ve got a problem, take it up with him, or someone else appropriate . . . Just leave me out of it.” I turned and walked away from Gibbs, into a crowd of tourists milling around some quay-side shops.
Gibbs strode along behind me for a short distance. “When I’m the professor, you’ll be dancing to a different tune. Mark my words.”
I carried on, threading my way through the crowd. When I sensed he’d stopped and turned back I turned around to look. It was a relief to be free of him.
Back in Dunedin, Remington had organised a midweek dinner at Palms. At the last minute Eleanor pulled out of attending. It was all too much for her to cope with. It was the inebriation, the verbal jousting and the leaden cloak of her own conservatism. After a heated exchange I clattered down the steps to the car. The metal door handle was freezing in my grasp. In the rear vision mirror, a plume of exhaust billowed with ignition. The icy grip of winter had fully engulfed the city. Through a windscreen of splintered ice, the city lights resonated like stars in a fractured cosmos. As I negotiated through the streets, I reflected on my recent visit to Palms Cafe. Then, I had revelled in the embryonic stages of what appeared to be new and consequential relationships. Now I carried the wounds of the fracture with Melanie. My sluggish approach to two ethical dilemmas had driven a wedge between us. It was a grim time – the penetrating cold complemented the mental torture of all the struggles – my marriage, Melanie, Isobel the exams and Boatwood’s experiments.
In the rest
aurant we talked about the impending oral exams.
So it’s all next weekend, is it?” Arnold’s new girlfriend asked. She wore a black and yellow striped sweater. Naturally, she became known as ‘Bumblebee.’
“I’ve got to go to Auckland for mine. How about you Remington?”
“Christchurch.”
Insults increased in length and ferocity, as the evening progressed. A potent combination of alcohol, provocative spirits and stress electrified the conversation. Marion was looking at us sideways, as she waited on other tables. Her face was a mixture of stoicism, annoyance and pity. Whenever she took our orders, she was assailed by an onslaught of wicked barbs and double entendre. She kept looking at me, I assume trying to place me – as if I was some trouble-maker from the past. And I, seeking escape from all the crises, entered the therapeutic window for alcohol at maximum speed. Toxicity grabbed at me like an undulating fever. I came to say something, but it was gone. My friends’ faces wobbled, then rotated about me.
“Davenport’s losing it,” Remington announced, in a loud voice.
I pretended to loll my head back in uncontrolled extension, which rocked my chair over backwards. The resulting smash, reverberated around the room. The table erupted in laughter and Marion came running.
“What on earth are you doing,” she said, her mouth set. A figure rose from the adjacent table. Amid the shouting and hilarity, he was an abrupt apparition in our presence. Tall, bespectacled, blue cardigan and square jawed, he stood beside Marion.
“Now excuse me,” he announced. “We’ve just about had . . .”
“Look at this boy!” Remington shouted, pointing at the intruder. “Where’d you get that nice blue cardigan sir?”
“And an excellent square jaw,” Arnold chimed in.
The man was outraged. He took a step forward and berated us. Who did we think we were? He’d been in hundreds of restaurants, all around the world and never had to put up with such a racket.
“You’re well travelled then?” Remington asked.
“I’ve had enough of you,” Square-jaw hissed, coming forward to grab the xray doctor by the lapels.
I rose uncertainly to my feet. “Come on now old chap. Where’s your sense of humour?”
Alana smiled up at the man. “Look, we’re very sorry to cause you offence. They’re in the middle of exams. They’re a bit wound up.”
Square-jaw absorbed the information and released Remington. “Exams eh?” he said, rubbing his hands together. “So what are you studying lads?” His ruddy face, twisted into a bridge-building smile.
“He’s studying rocket science,” Remington said, pointing at me. “And I’m doing anology.”
“Anology?” Square-jaw looked puzzled.
“Yeah. It’s the study of arse-holes. That’s why we came here. We thought we might see one.”
There was a pregnant pause, as Square-jaw’s face transformed. His pupils dilated and his mouth dropped open. His decorum completely unhinged, he lunged at Remington, who hastily beat a retreat around the back of the circular table. Bumblebee jumped to her feet, effectively blocking Square-jaw’s progress with her ample frame. The enraged red-neck, thought better of manhandling a woman. Instead he unleashed a plethora of insults banging the table between himself and Remington with closed fists. The crockery jumped, spilling sauces and food onto the cloth.
Marion enraged, thumped the table as well. “You’re out of here. All of you. This whole table. I want you out. I’ll get the police otherwise. I’m not putting up with this.”
Patrons from the other room came through, attracted by the fracas. They stood and watched as Alana, in a bid to win a reprieve, followed the fuming governess to the foyer. At the same time Square-jaw stood with legs apart and arms folded to deliver a stuttering discourse on how one should conduct oneself in a public place. Remington clearly thought better of further character baiting, since he remained silent through the whole monologue. When Square-jaw had finished, he stood for a few seconds, hands on hips, glowering. Then he smacked his hands together and retired to his table. With the fun seemingly over, the spectators faded away. The restaurant buzzed with accelerant conversation.
Alana came back. “We can stay, but she’s really pissed off.”
“Where’s Eleanor?” Arnold asked, noticing the empty chair.
In my inebriated state, I absorbed the news of our reprieve with indifference. I could have been anywhere.
In the uneasy peace that had pervaded the room, Arnold lit up a cigarette. Through half shut eyes, I watched it glowing between the benign one’s lips. The smoke rushed out, decelerated and billowed into a mushroom cloud. It rolled over towards me, entering and lighting up an inscribed olfactory memory.
“Ah . . . Cannabis,” I said.
“Let’s hope Square-jaw isn’t familiar with the smell,” Arnold said, holding fingers and cigarette aloft. Square-jaw wasn’t but the chef was. This time we were out. Dessert was off. We had to pay up and go. “I know you’re just in high spirits,” Marion said, as she received the cheques and credit cards. “But we survive on reputation. I can’t have you turning this place into a Turkish smoke shop. I feel I’ve given you every chance.”
Alana, in the Henry Kissinger role, rolled out the platitudes. On the street, Remington said, “That was a great spiel Pixie. You probably saved us from a lifetime ban.”
“Yeah, you were excellent Alana,” Arnold said.
“Nevertheless, I feel there is unfinished business in there,” Remington said, gazing back in through the plate glass.
“Square-jaw,” Arnold said quietly.
“Oh no,” Alana said hurriedly. “No you’re not. Definitely not.” She tugged at her partner’s arm. “You’re not students now.”
Reminded of his latent maturity, Remington shrugged off his clamouring desire to paste a dessert all over Square-jaw’s face. We lolled along the street towards the mid-city bars. Driving was out of the question, since everyone was soused. We came upon a phone box. I excused myself and went inside. I fumbled for the required coins. I dialled the number, 580330. Rikki’s voice came into the earpiece – slightly puzzled, but polite. Although it was a fifty-fifty shot, I was shocked at the sound of his voice. I banged the receiver down and stood pensively in the sudden silence, feeling ridiculous and annoyed. Melanie was probably in bed with Rikki. The thought made me angry. Jealousy was always great punisher.
“Who were you ringing – the Whitehouse?” Remington asked, when I caught the other three up.
“No, no, my girlfriend.”
“Naturally,” Remington said.
Monday, I felt down – sullen and negative. The drunken weekend, ached in my bones. The ominous spectre of examination defeat, loomed at the week’s end. But mostly I hurt. I hadn’t spoken to Melanie for three weeks. Her absence deflated me.
In front of me, the automated Xray viewing box clanked and whirred. Remington, who directed the device with a remote control, was acting the big know-all. His face was flushed with blood, the lips pouted and full. His voice boomed out at an excessive volume. Beside him the radiology professor, a bald pate, but with thick slabs of hair over his ears, looked over the throng of intensivists with bemusement. Behind his heavy glasses, the eyes were magnified and distorted, like a pair of poached eggs. We were all there to discuss Xrays, taken during the previous few weeks in ICU. The intent of the session, usually took second place to a battle of egos. Gibbs harried the radiologists like a virulent fox terrier.
“That’s oedema fluid, not consolidation,” he spat at one point.
“Impossible to tell the difference,” Heavy-glasses retorted, in a southern English accent.
“Bollocks,” Gibbs said, his top lip raised.
Nigel cleared his throat. “I think we should respect our radiology colleagues’ opinions here. They don’t have the clinical information that we have, to fit the whole puzzle together.”
I noted Nigel’s diplomacy with silent amusement. Remington looked ov
er and raised his eyes, seemingly oblivious to the fact that he had just been furnishing his own ego, a few minutes before. To get on in this medical battlefield, I reasoned, you had to bloat yourself up with self confidence. He who shouted loudest and longest, had the most satisfaction at the end of the day. However today wasn’t going to be my day for ego projection. I was too dispirited for that. I remained silent.
“Mr Lionel Hart,” Remington announced, as the next Xray screen shuddered into place. My heart beat raced and there was a pregnant pause before Boatwood spoke.
“You give the history Davenport,” he said.
I straightened up in his chair - apprehensive in the limelight. A dozen pairs of eyes were focusing on me. I shifted in my seat and closed his eyes. “This sixty two year old man was admitted to ICU, after nephrectomy. His operation had been complicated by a large blood loss, low blood pressure and subsequent blood transfusion. On admission he was hemodynamically stable, but it was decided to ventilate him overnight to allow body temperature, electrolyte status and acid base balance to be optimised. However that evening, his lung function deteriorated, and by morning, he was on seventy percent oxygen and five centimetres of PEEP.”
“Just stop there will you Gerry,” Boatwood interrupted. “Can we look at the chest xray for that morning.”
Remington began outlining features of the film, with a laser pointer.
“There is patchy opacification over both lung fields, but it’s not dramatic. The heart size is normal though – so we can assume this is noncardiogenic pulmonary oedema or bronchopneumonia.”
Gibbs grunted, his nostrils flaring. “There’s no way it’s bronchopneumonia.”
“You can say that now, with hindsight,” Heavy-glasses said. “Radiologically though, we can’t tell the difference at this stage.”
“Well maybe you can’t,” Gibbs said.
“Lets go on with the history,” Boatwood said hurriedly. “Gerry?”
“Over the next thirty-six hours, his lung function gradually deteriorated, requiring higher oxygen concentrations and more PEEP. On the evening of the third day, his inspired oxygen concentration was so high, that we feared the onset of oxygen toxicity.”
“How much oxygen is toxic to the lungs?” Heavy-glasses enquired.
Nigel entered the debate. “It depends how long the exposure time is Geoffrey. Anything over sixty to seventy percent for many days is likely to damage lung tissue. If you’re up to one hundred percent oxygen, then considerable damage can occur, quite rapidly.”
Nigel turned and nodded at Gerry. The latter cleared his throat. “The lungs were
drowning in fluid by this time. Even with eighty percent oxygen and twenty of PEEP, there was a falling oxygen tension in the blood. We decided to increase the PEEP rather than risk oxygen damage to the lungs. Prof decided to jump up to seventy of PEEP at this point.”
A portentous few seconds passed, before Boatwood spoke. “Let’s see the chest Xray from that morning.”
Remington flashed his pointer over the black and white film. “You can see here, that both lung fields are considerably affected by fluid accumulation. The left base has collapsed and really there’s not alot of normal aerated lung remaining.”
“Do we have any films taken, while this patient was subject to seventy centimetres of PEEP?” Gibbs barked from the background.
“No, there wasn’t time when the crisis occurred,” Boatwood replied curtly.
“Yes, well there’d be bugger all blood to see in those lungs. It would have been all squeezed out by the enormous pressure.”
“No. On the contrary Trevor,” Boatwood said. “With the help of an adrenaline infusion, we had a normal blood pressure and urine output for several hours.”
Gibbs raised his voice. “The fact remains, the patient died shortly after the application of a therapy, that should never have been tried in the first place. Christ, you still had plenty of room to move in the therapeutic window for PEEP. But no, straight up to seventy! It’s irresponsible.”
Boatwood’s countenance suddenly looked irked. “The circulation crashed several hours after the PEEP was taken up to seventy,” he said. “It crashed dramatically over a few minutes. If you analyse it, there is no obvious cause and effect.”
“Well how do you explain this,” Gibbs roared “I’ve seen the acid-base data. You had a pH of six point nine just before death. So do you think, maybe his tissues were a bit short of oxygenated blood for a few hours? . . . Eh?”
Boatwood was on his feet. “You listen here Gibbs,” he said raising a finger. “We had a normal blood pressure and oxygen saturation up to a few minutes before death. So his tissues were receiving plenty of oxygen. Therefore the acid build up, was from a failure to use the oxygen. Something had poisoned the tissues.”
In his peripheral vision, Gerry saw Nigel Green leap up. His face had become a rare shade of puce. “Poisoned . . . Yes . . . Poisoned,” he shouted. “That’s just it, isn’t it. Here we have a patient dying an unknown death, from an untried therapy. God knows what toxins are released from lungs, subject to your controversial hyperPEEP. You don’t know, I don’t know . . . None of us know. But we know it poisoned the tissues – via the cytochrome system presumably. And you Prof, the head of this department, should have known better.” Green was shaking, his face pinched.
Heavy-glasses rose off his stool. He stood with arms outstretched, palms facing downward. “Come now gentlemen,” he implored. “This is an interesting debate, but we have come to discuss the radiology of the patients. So I suggest we do just that. Let’s move on to the next patient.”
Remington activated the viewing box. “Mr Miller,” he announced.”
When the day’s work was over, I ambled out into the drizzle with a heavy heart. The evening of frantic study ahead had little appeal. It was unseasonably warm. My car was parked in London Street, quite a steep climb. I jay walked across the glistening damp tarseal, stopping in the middle to look down over the neon pattern below. Curtains of descending rain drifted down in slow motion, vanishing into the shadows between buildings. Turning back, I paused to allow a car coming down the hill, to pass by. I watched the oncoming headlights, two yellow moons, warily least the driver hadn’t spotted me in the dark. I was surprised, when the lights abruptly flooded onto full beam. Puzzled, I took a step backward, lifting a hand to shield my dazzled eyes. The car changed direction. It was a subtle shift in angle. I was transfixed momentarily, inert in the face of this driver, intent on mowing me down. I flung myself away – a headlong dive onto black greasy tarmac. I hit hard but painlessly, flexing my legs away from the danger, and rolling onto my back as I slowed to a stop. My eyes followed the red tail lights as they ran the stoplight at the intersection below.
Moments later, I surveyed my palms under the weak inside light of the Triumph. Streaks of bloodied tissue underlay broken skin. I dug out specks of gravel with a fingernail, grimacing at each shot of pain. I was strangely calm despite the incident. The driver had lined me up, there was no doubt about that. But I felt sure the car had pulled out of the attack at the last minute. I hadn’t seen that. I had been diving through the night air at the time. Rather, I sensed that the car had pulled away. Who? Maybe it was a bunch of hooligans, out to give me a fright. I hadn’t seen the form of the car. But the throaty roar, as it crossed the intersection to get away, had a familiar sound to it – Volkswagen. I knew I had one black mark against me that might be bothering someone. My former attachment to Melanie – someone could be upset about that.
That night I phoned Junot. He was a bit clipped with me – still smarting over Isobel’s fall from grace and my role in it. I feigned a bit of interest in what he was doing before getting to the point of my call. “Oh by the way, what sort of car does Rikki East drive?” I asked.
“A Volkswagen,” he said. “Why?”
“Oh nothing important . . . Would Rikki know a guy called Drummond at the hospital?”
“Brother in law,” Junot said.
“You’re the main man I hear,” he said, in a gauche Australian accent.
Whittle, the chairman, opened up the proceedings, outlining the purpose of the evening. During the day they had heard Boatwood’s version of events. Now it was time to listen to his registrar, who had been in the ICU the night Mr Hart had died. “Once again,” said Whittle, beneath coarse luxuriant eyebrows. “Let me say, that we are here, to safeguard the rights of patients, and protect them from harm. In particular, in this case, we are considering the ethical aspects of an innovative procedure. We are looking for a direct link between the use of hyperPEEP and the demise of the patient. However this isn’t the critical ethical issue. The more relevant issue to consider is this. Did the decision to apply hyperPEEP, have a sound scientific basis? It would appear the use of hyperPEEP on Mr Hart, had followed limited experimentation with animals. Was the clinical application of the new therapy to a sick patient justifiable? Or should there have been more animal study, perhaps across a wider range of species.”
Whittle asked me, to detail the two swine studies, I had been involved with. I explained how the control and experimental groups of pigs had been given oleic acid to induce lung injury. “Respiratory management in the control group was low level PEEP, and a constant inspired oxygen level. The experimental group was managed in similar fashion, except that the PEEP level was higher by a magnitude of seven times. This level of PEEP is termed hyperPEEP”
“What was your expectation of results for the two groups?” Delany asked.
“We measured arterial oxygen levels, as the indicator of PEEP and HyperPEEP efficacy. We expected higher arterial oxygen levels in the hyperPEEP group based on a previous American study using rabbits, subjected to 40 cmH2O PEEP.
“Gerry, I’d be grateful if you could explain how hyperPEEP improves oxygen transfer from the lungs to the blood,” Faulks said. “Alot of these folks wouldn’t recognise PEEP if it came and bit them on the backside.”
The social worker shook her head, while the do-gooder maintained a perpetual frown.
I carried on. “In disease states, blood passing through collapsed non aerated areas of the lung, will not pick up any oxygen. This volume of blood, joins up with oxygenated blood from healthy areas of lung and is pumped by the heart out into the body. The poorly oxygenated portion of blood causes an overall reduction in the measured arterial oxygen level. The idea of PEEP, is to get a better distribution of gases, to all parts of the lung, particularly those with high blood flow. By applying this baseline positive pressure – termed PEEP – throughout the breathing cycle, collapsed areas of lung are expanded, thereby improving the total area of aerated lung tissue exposed to blood.”
I paused in my delivery. The unidentified do-gooder appeared puzzled. However Faulks was happy with this explanation, and urged me to continue with the chain of events.
I explained that the first time we had attempted the experiment, things happened beyond our control due to a lack of supervision. “When I returned to the laboratory at two in the morning, the pigs had been unseen for some eight hours. So we had no idea what caused many of the experiment group to be wiped out.”
Whittle winced at my choice of words. “Yes, but whatever it was, it selectively caused rupture of a lung, in all the HyperPEEP animals. There was no problem with the control group, receiving the ten centimetres of PEEP.”
Faulks raised a finger to the cardiac surgeon. “That’s true Patrick. But what Gerry alluded to before, is the key here. The experiment was unsupervised, and therefore the results were invalid. When they did it properly the next week, the results were clear cut. HyperPEEP improved lung function. No doubt about it.”
The Australian’s assertion was so emphatic, that Whittle seemed disinclined to make further comment on the animal experiments.
Stocker, straightening in his chair, cleared his throat. “It may not be worth debating the failure of the first experiment, but how credible in fact, was the successful second experiment. Was the history of all animal experimentation – in Dunedin, the US, wherever – sufficient to then go on and apply the new therapy to humans? Your sample size was very small. It must have been difficult to obtain statistical significance with such a small study group. What statistical significance was in fact achieved Gerry?”
Stocker, chin up and eyes half closed had been looking at Whittle, but he finished the question by rounding on me. His face betrayed a hint of a smile.
“In terms of improved oxygenation, it was statistically significant. The p-value was less than point one.” I glanced up at Stocker from my papers,
“O.K, you’ve got a good result in terms of oxygenation – but is that enough to go ahead and apply hyperPEEP to Mr Hart? Surely six pigs aren’t enough on which to base such an important decision.”
“Well you have to ask – is there a governing body?” Faulks declared. “If it was a drug therapy we were talking about, then –no problem – you’ve got the FDA and all its equivalents, right around the Western world, lining up with rules and regulations. They have protocols to govern how much research is necessary, before proceeding with the general application of a new drug. But who controls respiratory therapies such as PEEP? The answer is no one. OK, there is the College of Physicians or Intensivists or whatever, who might have recommendations. You’ll note I say recommendations. So here we have this professor who applies an everyday respiratory therapy, the only difference being, that he gives a whole lot more of it. There’s no governing body. There’s no protocol saying you must do this, or you must do that. Therefore what he did was ethical, given the rules and regulations of the day.”
“There was no precedent though,” the lawyer said, squeezing the bridge of his nose. “There was no previous use of the therapy, to give credence to its use on this occasion. And importantly, this committee was not consulted to give its approval.”
“There were hundreds of precedents,” Faulks said, his glasses misting up. “Let’s not forget that Boatwood set out to save Mr Hart’s life. And everyday, right around the world, doctors are stepping outside protocols, in desperation, to save a patients life. Because protocols and accepted practice don’t work every time. So I ask you, when these situations arise, what do you expect these clinicians to do? Walk away? No of course not. We expect them to fight to the end.” Faulks paused in his delivery. He looked at Whittle. “We expect them to be heroic. And that’s why these people are giving supra-maximal doses of adrenaline, that’s why they are doing radical trauma surgery, that’s why they are using high frequency ventilation, that’s why Professor Boatwood gave supra-maximal PEEP to a dying patient in Dunedin. To save his life!”
I felt like applauding the speech. However I managed to contain myself. I knew Faulk’s tirade could be pulled apart, just as easily as it was delivered. However the assertive delivery and those key words, ‘to save his life,’ seemed to keep the committee silent.
Whittle turned to his colleagues, to see if anyone was going to play the antagonist to Faulks. There were no takers. He cleared his throat noisily. “Well, I’m interested finally, in looking at the mode of death. Particularly whether there was a link between the applied hyperPEEP, and the death by circulatory shock. In the animal experiments, death was due to pneumothorax. In the case of patient Hart however, pneumothorax did not occur, but rather, death occurred from myocardial infarction after a period of very low blood pressure. Dr Davenport, since you were present during the last few hours of
the case, it would be appropriate to hear your version of events.”
I turned my mind back to that fateful night. The first image was that of Melanie, lying up against me on the old hospital bedstead .I fought off her image. Instead, I dragged Mr Hart and his respiratory failure, to the forefront of my mind. I told them of the deteriorating blood-gas values for oxygen. I explained the worry of oxygen toxicity, when the amount required by Mr Hart increased to above seventy percent. I outlined Boatwood’s response – dialling the PEEP up to seventy, so that they might reduce the toxic oxygen concentration in the breathing system.
“Didn’t it strike you as odd, that your Professor jumped from thirty centimetres to seventy centimetres, in one motion? I mean, why not increase the dial gradually, in five to ten centimetre bites?” Delany sat back in his chair, ready to savour the answer to his question.
I hesitated. It was a good question. I knew the real answer. Boatwood was quite impetuous by nature. He was well known for his all or none approach to medical practice. He was prone to get ‘a bee in his bonnet’ and push his ideas, no matter what the contrary evidence. That was why he had snapped the dial up to seventy. However, taking Boatwood down, wasn’t on my agenda. “I assume he took the radical step, because the patient’s condition was deteriorating so quickly. It’s as simple as that.”
Delany seemed satisfied with the answer.
“To maintain blood pressure after hyperPEEP application,” Whittle said, “You needed adrenaline, correct?”
“Right.”
“That’s because the high airway pressure, reduced venous blood return to the heart and compressed the heart volume down. These actions reduced the heart’s output.”
“Yes, that’s correct.”
“So during the time period after adrenaline stabilisation of blood pressure, and the eventual blood pressure crash, were there any unusual trends in the measured parameters?”
“No, everything was stable for two hours.”
“Describe then, the likely cause of the sudden decline in blood pressure,” Whittle ordered.
“Well, because heart attack was confirmed by post mortem lab tests and autopsy, the most likely scenario is that the heart was having to work harder than it normally would – probably because of hyperPEEP induced reduced filling pressure. Alternatively there has been speculation that the human heart, subjected to hours of hyperPEEP, might release a vasodilating peptide such as atrial naturetic peptide in massive quantities. But since we can’t measure that peptide, that is just speculation.”
Faulks cleared his throat to enter the fray. “What we are here to ask is – did applied hyperPEEP cause the collapse of the circulation? I say, no way – not directly anyway. The evidence doesn’t stack up. He applied the therapy and the BP was supportable for 2 hours. So we can only speculate on a hyperPEEP contribution to the heart attack. Boatwood says sepsis. O.K let him tell the coroner that. It’s good enough. Good enough to close the case. Good enough to save a valid treatment modality from the agents of mediocrity.” He sucked his breath in and surveyed the ethic’s committee.
The social worker, a middle aged woman with a plump face, sat up stiffly. “Let us not forget that the health service is there for the consumer, not for the convenience of doctors and other staff.”
There was a brief silence after her comment. Nobody came forward to support her so she sat back again. Faulks had brow beaten the committee.
When it was over I followed Faulks into a lift intent on finding out where he was coming from. “Good work mate,” Faulks said, with a wide smile. “That’s a good days work. Where do we get a beer round here?”
That made it easy and I took him to the Robbie Burns bar. HyperPEEP quickly became the focus of our attention without much effort by myself. “I thought it was bloody stupid what he did actually,” Faulks said.
“Yes,” I said. “It did seem rather over the top at the time.”
“But I didn’t want this case to become a precedent. Clinicians the world over would be hamstrung whenever they put themselves out on a limb. But Delany was right. It would have been more logical to rack up the PEEP in a stepwise fashion and watch for side effects along the way . . . But the main thing was that there was no clear direct link between the hyperPEEP and the cardiovascular collapse. That will save Boatwood’s skin when the the coroner gets to grips with it. Boatwood’s actions will be criticized in our report. He jumped in too early with his innovative therapy. But you won’t be able to say his therapy killed the patient. So a censure from the ethic’s committee is all that will happen. But Boatwood will shrug that off, with barely a thought.”
We drank in companionable silence for a minute before I piped up. “That was a very earnest speech you gave about saving lives,” I said,
Faulks roared with laughter. “That was so much bullshit. But I wanted to seal the thing up pretty quickly. I’ve always quite liked old Boatwood. He’s terribly self centred of course. But when he’s not too busy sitting in the ivory tower, he’s really quite good natured and helpful. So I didn’t want to see him go down. With Gibbs and Green ready to pounce, it is a slightly unsavoury situation.”
Driving home I reflected on what Faulks had said – that part of his motivation for supporting Boatwood was because he liked him. It was exactly how I had felt. I’d instinctively looked at ways of supporting Boatwood because I liked him. And that had been the first nail in the coffin with regard to my relationship with Melanie.
Chapter 10