Deadly Errors

by Allen Wyler

  “I’ll be right back with a consent form, Mrs. Childs. I’ll need you to sign it.”

  “TEEING UP A case this late in the day?”

  Tyler pulled on his scrub shirt. He recognized Bill Leung’s tenor voice without turning. Bill, a senior partner in their group, occupied the locker flanking his.

  “Long as you’re here, might as well give me your opinion on something.” Tyler cinched the pulls on the scrub pants then tied a bow, which he tucked inside the pants—a long-ingrained habit to prevent dangling ties from contaminating a sterile field. Finished dressing, Tyler reached into the narrow locker and came away with a white and brown MRI envelope.

  “Here,” he said, handing it to his partner. At 57 Bill still looked like a Marine drill sergeant. Lanky, not an ounce of extra fat. From running every day, Tyler thought. Compulsive about it.

  Also clad in green scrubs, Bill held up a rectangular oak box the size of a small jewelry case. Loupes. Magnifying eyeglasses worn by most neurosurgeons. “Let me get rid of these first.” His partner spun the combination lock to his locker. A triangle of sweat darkened the midline of Bill’s scrub shirt by at least two shades.

  “Tough case?”

  Uttering a sigh weighted down with cynical fatigue, the veteran surgeon opened the gray metal door. “Aren’t they all?” After setting the mitered wood box on the single shelf he turned, hand extended. “Let me see those pictures.”

  Tyler passed over the envelope and followed Bill into the adjoining tiled shower/toilet area. Without a backlit viewbox available the best place to examine the images would be against one of the frosted windows. Bill quickly sorted the films, zeroing in on the most telling. With his left hand pinning it flat against the window, he slipped on a pair of half-height reading glasses and leaned forward, chin up, to examine the images.

  Bill gave a slow whistle with a headshake. Removing the film from the window, he turned expectant eyes on Tyler. “Herpes?”

  “That your first choice?”

  Bill peered over the top of his tortoise shell glasses at Tyler before stealing another glance at the film. “Could be anything, I guess … Glioblastoma, infection, you name it. All I see is a shit-load of edema …” tapping the film with an index finger, “no well-defined mass … yeah, herpes is the first thing comes to mind. Why? You going to tell me it’s CPC material?” Clinical Pathologic Correlation is a weekly conference at which difficult to diagnose cases are discussed.

  Tyler recited Larry Childs’s history.

  Bill slipped the film back into the envelope. “Well there you go. Seems to me like your patient has a bad case of radiation necrosis.” He paused. “Not that any case of radiation necrosis isn’t bad, mind you, it’s just that this looks really bad.” Envelope now intact, he handed it back to Tyler.

  “I was afraid you were going to say that.” They headed back to their lockers. Tyler needed to slip on his shoes and grab his own set of loupes before heading for the operating room.

  Bill pulled the sweat-stained scrub shirt over his head, balled it up and threw a double pump jumper toward a linen hamper. “Word of advice?”

  Tyler watched the shirt miss and fall to a green clump on the floor. Tyler bent down, pulled a pair of air cushioned Nikes from the locker floor, then dropped his butt onto a wood stool. “What?” Tyler suspected he was going to advise not operating and wondered how much of his partner’s surgical conservatism came from wisdom and how much came from plain old grind-it-out fatigue of years in the OR.

  “I wouldn’t do anything more than needle biopsy that Mother of All Edema.” Leung was sending him that dead-eye Chinese look Tyler found difficult to evaluate.

  “I was planning on taking out his temporal lobe.” He started tying the laces.

  Bill slipped off his pants and this time tried a hook shot. Missed again. “That, my friend, is a huge mistake.”

  “Why so?” He jerked the knot tight and turned to the other shoe.

  Bill’s face turned even more serious. “Kid’s temporal lobe isn’t your biggest problem here. Hell, with that scan the kid’s probably a goner anyway. The problem is you can bet your bippie that family will have some sleezeball lawyer licking his chops before the sun sets. You operate that kid and he’ll have you in the knee-chest position so fast it’ll make your head spin. And he won’t provide you the courtesy of using KY jelly, either.”

  Tyler sighed. “Point noted, but that’s the risk we all take when we schedule cases.”

  “Sure, but look at it this way. If it’s herpes the biopsy will show it and you can treat him with Acyclover. If not? Like I said, with a scan like that, he’s screwed blue and tattooed anyway. Best to keep as much distance from this tar baby as possible. Hell, even if it is herpes he looks like a goner. I just can’t see any upside to operating the kid.”

  Loupes and MRI in hand, Tyler kicked the locker door. It slammed shut. He met his partner’s questioning eyes. “Way I see it, if it’s radiation necrosis, there’s nothing I can do to increase or decrease my odds of getting sued. It’s either going to happen or it’s not. But if I don’t take out that kid’s temporal lobe, he’s going to die. It’s that simple.”

  “Tyler, let me put it to you this way: what’re you really going to accomplish by opening up that kid’s head?”

  “Don’t start with me again, Bill. We’ve had this debate before. It’s philosophical, not medical. Boils down to one thing—you and I see risk differently. Isn’t that it?”

  “Humor me and walk through this little exercise just for drill. Okay?”

  Tyler couldn’t be certain if Bill was intending to be fatherly or condescending. He gave his senior partner the benefit of doubt. “Why? I know exactly where this is going and I really don’t want to get into a heated debate minutes before opening this kid’s head.”

  “Way I see it, that’s kid’s brain’s trashed as it is. What the hell difference is it going to make if you’re a little hot under the collar when you crack his coconut?” Leung took a deep breath. “I took a huge gamble hiring you, Tyler—”

  Tyler sliced a hand through the air. “Whoa. Hold it right there. Don’t confuse issues, Bill. I have too much respect for you to tarnish that opinion now. Whether or not I operate this kid’s brain has nothing to do with what happened in the past.”

  “Maybe not directly,” Leung interrupted, “but indirectly it sure as hell does.”

  Tyler double-checked Bill’s face and realized the conversation was about to take a completely different tack. “Mind explaining that?”

  Bill leaned against the row of lockers opposite his own, cheeks and eyes sagging with weariness. “Remember you telling me how come you missed that scholarship to UCLA?”

  Tyler flashed on his high school basketball coach warning him to stop unloading impossible shots with only seconds on the shot clock, that it was ruining his average.

  “Sounds rhetorical to me.” Tyler checked the wall clock. “They should be wheeling my patient into the OR any minute now.”

  “Point being, you didn’t listen to your coach, did you?” He waved a dismissive hand. “Yeah, yeah, I know—another rhetorical question. But, the end result was you didn’t win that basketball scholarship you wanted so much. Which, in turn, changed your whole life. Who knows, you might’ve ended up a point guard in the NBA and never gone to medical school.”

  “Look, Bill—”

  “Don’t worry, you’ll have plenty of time to get that case started. You want to hear me out on this one.” Leung adjusted his lean body against the locker. “You’re not listening to me, Tyler.” He punched Tyler’s shoulder softly. “Hey, think of me as your high school basketball coach giving you advice. Try not to make the same mistake twice.”

  Before he could answer, Leung continued, “What you don’t know is that the Quality Assurance committee is looking at your M and M stats and they don’t look all that terrific, Tyler.” He shrugged.

  “What the hell are you saying? I’m a bad surgeon?”

>   “You know damn well I don’t think that. I know the quality of work you do and the type of Hail Mary cases you elect do. Hell, look at this one,” with a nod at the MRI folder in Tyler’s hand. “But the cubicle grunts on that committee don’t know a craniotomy from a pepperoni. In their eyes all surgery is created equal. If your case morbidity and mortality pops up above the average for gall bladders and hemorrhoidectomies they start crooning the bottom-line anthem.”

  Tyler let out a sarcastic grunt. “Far as I’m concerned the Quality Assurance committee can have any of my cases reviewed by an independent panel. But until they can convince me my decisions are wrong, I’m going to practice the best I can. Now, if you’ll excuse me, I have a case to do.”

  Leung called after him. “Take my advice, Tyler, just pop in a burr hole and needle that gobbler and get the hell out of there. You open that kid’s head and you’ll have a tiger by the tail. All that edematous brain comes oozing out into your lap like The Alien, you’re going to wish you never went in there.”

  MICHELLE LAWRENCE, THE anesthesiologist, asked, “Any landmines I should know about?” They were standing next to the heavy steel operating table in the warm glare of two sets of parabolic, high intensity spot lights, a scrub and two circulating nurses scurrying around still opening and arranging instruments. Tyler absentmindedly focused one of the lights more directly on Larry’s shaved head, said, “ICP’s elevated.” Meaning intracranial pressure. “How much, I have no clue, but he’s got four-plus papilledema so that tells us something. Plus, his scan looks like the monster that ate Chicago.”

  Tyler turned to a wall-mounted X-ray viewbox, slapped the edge of a film up underneath the clips, securing it. “Right here, for example.” Tyler tapped one particularly ugly spot on the MRI to emphasize the point.

  Michelle emitted a cynical snort. A little over six months ago Mike Lawrence’s sex change operation created one of the most unattractive, overweight, middle-aged females Tyler ever laid eyes on. Although estrogen therapy suppressed such male physical attributes as facial hair, it certainly hadn’t bestowed Michelle with the grace genetically created females learn from infancy. To make matters worse, rumor had it she underwent surgery to become a lesbian. Go figure, Tyler thought, while watching her return to the anesthesia cart with the broad shouldered swagger of an NFL linebacker. “Lawrence of A Labia” the other anesthesiologists jokingly called her behind her back.

  Tyler double-checked Childs’s positioning on the operating table. Head held solidly in a three-pin clamp bolted securely to the table, chin pointing toward his right shoulder which was propped up with a towel roll to prevent undue neck strain. Childs’s freshly shaven scalp glistened in the high-intensity light.

  For one last moment Tyler surveyed the OR, mentally going through his pre-flight checklist before exiting to scrub. The chilly air raised goose bumps on his exposed skin. His brain already had submerged the white noise of the nurses’ preparatory sponge counts and the rhythmic respirator wheezes into a subliminal zone, giving him full concentration on the task. Satisfied, he turned and pushed through the heavy swinging doors into the hall.

  MINUTES LATER HE returned. The scrub nurse held open a sky-blue paper scrub gown like a matador for him. Next, he pushed his hands into a pair of gloves as the circulating nurse tied the back of the gown. He handed off the final tie to the scrub nurse to hold while he did a 360, wrapping it around his waist. This he knotted, finalizing the ritual.

  With a sterile felt-tip pen he drew a large question mark incision starting mid forehead and ending just in front of the ear. All of the head except for the proposed operative field was draped with four blue surgical towels and then covered with a sticky Saran Wrap-like plastic barrier. A larger blue paper drape shrouded Larry’s entire body. Next, Tyler injected local anesthetic along the proposed incision.

  “Ready?”

  The scrub nurse and Michelle answered, “Yes,” in unison.

  Tyler held out his hand. “Number 10 Bard Parker.” She handed him the scalpel.

  Even without an assistant Tyler worked swiftly, placing clamps along the skin edge to stop bleeding.

  The circulating nurse asked, “Want me to see if I can find you an assistant?”

  Considering the time of day and being an emergency, he hadn’t thought to request one. “That’s okay. I’ll be alright.”

  Michelle said, “If anyone can muddle through a craniotomy, it’s Tyler. But you better get moving, his pulse is starting to drop.” Meaning the pressure in the brain was increasing.

  An anxious fluttering awoke in Tyler’s chest. He remembered Bill Leung’s warning to not open Childs’s head. “Can you hyperventilate him any more?”

  “He’s maxed.”

  “More Mannitol?”

  “He’s so dry right now, he’s pissing dust.”

  “Shit!”

  He peeled back the scalp and the jaw muscle, exposing white skull.

  He held out his hand. “Perforator.”

  The scrub nurse handed him an air-powered instrument. He drilled two nickel-size holes through the bone, exposing the tough brain-protecting membrane, the dura.

  He handed it back to her. “Change it over to the craniotome.” A side cutting saw.

  This he used to connect the two holes with two arcing cuts, forming a circular piece of skull that he carefully removed from the dura.

  He ran his fingertip over the rock hard membrane, muttered, “Shit.”

  “What?” Michelle peered over the barrier—a blue paper sheet clipped to an IV pole and the patient—isolating surgeon from anesthesiologist.

  “This is worse than I expected.”

  “They’re always worse, Tyler. You suffer from the bane of any good surgeon—optimism.”

  To the scrub nurse Tyler said, “Fifteen blade.” Then to no one he muttered, “When am I going to learn how to stay out of trouble.”

  Blade in hand, he sliced a two-inch incision through the dura, staying low, keeping away from arteries on the brain surface. Gelatinous, white brain tissue oozed from the elliptical opening, slowly at first until Tyler began removing it with a sucker. Once the final membrane broke—encasing cortex—watery brain tissue began spitting out.

  “Give me a specimen cup and some culture swabs. Aerobic and anaerobic. And while you’re at it, some gluteraldehyde for electron microscopy.” That covered infections from bacteria and a virus, he decided. “Oh, and call a pathologist. I want a frozen and viral cultures.” He mentally ran the list he’d just ordered, checking for anything he might’ve forgotten.

  Between collecting the various specimens he sucked at the exuding tissue, purposely not enlarging the incision yet, allowing the internal pressure to push out the damaged, necrotic looking brain like a fetus. This way the pressure would decompress slowly and gently, to minimize any compensatory shift on the brain stem.

  “What’s our game plan, Ace?” Michelle again, eyes wide, the skin above the bridge of her nose conspicuously plucked of fine hairs.

  “For now, just easing the pressure down. After that? Plan to snatch out his temporal tip … give him more room.”

  “Any wild ass guess what diagnosis we might be dealing with?” she asked anxiously.

  “Doubt it’s AIDS or hepatitis related, if that’s your worry.”

  The anesthesiologist let out a little gasp. “Heavens to betsy, no. I never would’ve thought of that.”

  “Could be just about anything. But my money’s on radiation necrosis.” Tyler filled Michelle in on Larry’s history of epilepsy and the clinical trial to destroy seizure-triggering areas of the brain with focused radiation.

  “Doctor Mathews.”

  Tyler looked over at the scrub nurse. She nodded, eyes directed over his shoulder. He turned. A bearded stranger dressed in a green jumpsuit, scrub cap, and mask stood watching him work.

  “You the pathologist?” Tyler asked.

  “Correct. I assume you have a frozen for me?” He spoke with flattened vowels of an Aus
tralian.

  While explaining Larry’s story again, Tyler accepted a specimen cup and a biopsy forceps from the scrub nurse. While talking he slipped the forceps past the dura, blindly into the brain, then closed the tips. This he did several times, removing lima bean size chunks of tissue that he tapped off the end of the forceps into the sterile plastic container. Finished, he capped the cup and handed it off to the pathologist.

  Holding the container up to the operating lights, the pathologist squinted, turned it back and forth, inspecting the small gray chunks of tissue. A moment later he nodded. “Doubt I’ll be able to tell you much more from the frozens than you already suspect, but we’ll see, won’t we.”

  Tyler held out his hand to the scrub nurse. “Scissors.” He began enlarging the opening in the dura in preparation to remove the temporal lobe.

  “But it could be herpes?” Michelle again.

  “It could,” Tyler agreed. He noticed the cut edges of the brain oozing more than before and another jolt of anxiety surged through him.

  As he struggled through distorted dead brain, snippets of recent conversations with Bill Leung and Michelle replayed over and over again like a commercial jingle that becomes an annoying endless loop in the shadows of consciousness: “Tough case?” “Aren’t they all?” and “It’s always worse face to face than what you expect from the MRI.”

  “Yo, Tyler!”

  Without moving his eyes from the surgical field he replied, “What?”

  “Just asked you what his chances are?”

  Tyler straightened up, relieving the cramps in his neck muscles from holding his head in an awkward position for so long. “Depends on the diagnosis. But no matter what, if the rest of this hemisphere looks like the crap I’m pulling out of here, it’s trashed.”

  “But assuming it’s radiation necrosis like you suspect …”

  Tyler started working again, sucking out gray mushy gunk from low in the lobe, trying to find tissue that wouldn’t crumble away and bleed unnecessarily. He decided to keep going until he could define the dura at the base of the brain. At least this would give him a solid landmark from which to judge any further dissection. The tissue bleeding increased, the small vessels just as rotten as the brain, making them almost impossible to coagulate. This was now a major worry. How the hell to stop the bleeding?