Deadly Errors

by Allen Wyler

  “Radiation necrosis sometimes subsides if you get the initial portion—the site the radiation targeted—totally removed. That’s the reason I’m going after this temporal lobe. If I can remove it, then sit on him with steroids for a couple of days, he might just have a chance.”

  “Always the optimist, aren’t you, my friend. Anyway, that’s good to know.”

  Tyler turned to the scrub nurse. “Surgicel.” A thin mesh-like material used to help control bleeding.

  She handed him a folded towel with half-inch squares of the silver colored mesh. He picked up several squares with forceps and laid them individually over areas of oozing brain surface. Blood seeped through each one without slowing.

  Michelle asked, “Did I hear you correctly when you said this poor boy has never had any prior radiation?”

  “More Surgicel.” Then, to Michelle, “Look, Shellie can we talk about that later, right now I have a problem. I can’t get any hemostasis.”

  “Oh dear.”

  A hushed conversation between the scrub and circulating nurses stopped abruptly, leaving the steady piping of the heart monitor and the plodding whoosh of the respirator the only room noises. Both nurses looked at him with alarm. He ignored them.

  Tyler covered the oozing area with more squares of Surgicel, then layered this area with several white cotton strips, each about two inches by a half inch, over them. He held these in place with his fingers as a roto-rooter ground away at his stomach lining. Maybe I should’ve asked for help. Christ, maybe I should’ve listened to Bill.

  “Shit,” he muttered. Tightness enclosed his heart. His hands started tingling and he realized he was hyperventilating, his facemask now soggy against his lips.

  After thirty seconds he let up the pressure on the cotton strips, hoping they would stick against the Surgicel as a sign of clotting. They didn’t. They fell away as more blood started oozing again from the raw, crumbling brain.

  “How much blood we have on hand?” he asked Michelle.

  “Didn’t type and cross him, I’m afraid.”

  “Oh, great!” Tyler said to the scrub nurse, “Irrigation.”

  She handed him a blue rubber bulb, like you would use to baste a turkey. Gently, he squirted sterile saline over the brain surface, washing away the useless Surgicel.

  “Load me up again, but this time cut them postage stamp size.” He rolled his neck, working out the kinks. “Sponge.”

  Tyler held a sopping wet cotton sponge against the raw edge of the cavity as the scrub nurse cut more squares of the blood-clotting agent.

  “Whatcha going to do?” Michelle asked.

  He didn’t know, but he sure as hell wasn’t going to say that with both nurses listening. “We’re going to get it controlled.”

  “But, how?”

  He shot him a look. “Goddamnit, Shellie …”

  The scrub nurse held out a folded blue surgical towel, the squares of Surgicel aligned in neat parallel rows. One by one he placed them over the oozing brain. Once the entire lemon-sized cavity was lined this way, he packed it with snugly with cotton sponges, then backed away from the operating table, both nurses avoiding eye contact.

  He said, “Five minutes by the clock. Starting now.” He glanced up at the round face clock over the gleaming stainless steel autoclave and decided to give it every second of the five minutes to clot. Not one second less.

  Michelle sidled up next to him as close as possible without contaminating his sterile surgical gown and whispered, “Thought about just closing him up and getting the hell out of there?”

  Tyler looked at her. “You mean before we get the bleeding stopped?”

  “Seems to me like that might not happen. Besides, you plan on staying here all night?”

  “Jesus Christ, Michelle, it’d kill him,” he whispered while drilling her a look.

  “Seems to me he’s a dead man either way you cut it,” Michelle snipped. “You wouldn’t be the first to bail out on a hopeless case. I’ve seen a few of your esteemed partners fold the tent and load the camel on lesser problems than this one.”

  When Tyler didn’t answer she added, “Like the Nike ads used to say … just do it.”

  4

  “SLICK … VERY SLICK. Where did you learn that one?”

  Tyler glanced up. Michelle was peering over the drape at him. “Surgery 101. Apply pressure, wait, and try to strike a bargain with God.” He made no attempt to hide the huge relief from his voice. He used saline to irrigate the cavity where the tip of Larry Childs’s temporal lobe had been. He stopped irrigating and waited for the bubbles to clear. The water remained free of blood this time. “Time to play hockey.”

  Michelle laughed. “Watch it, Tyler. You’ll ruin your image.”

  Tyler held out his hand to the scrub nurse. “Load me up with dural silks and keep them coming as fast as you can.” Then to the anesthesiologist, “What image is that?”

  “Doctor Dour. Surgeon Serious. The man who doesn’t joke around in the OR.”

  Suture accepted, Tyler began the first stitch. I haven’t always been like that, he mused. It wasn’t like that when I was with Nancy.

  TWENTY MINUTES LATER Tyler leaned over to inspect Larry Childs in the recovery room. The area was populated with only a few stragglers from end-of-the-schedule cases. “He’s not waking up. You given him anything since the OR?” After helping to load Larry Childs onto a recovery room stretcher, he’d ducked into the dressing room to dictate an op note. Now, standing over his patient, he tried again to evoke a response by pinching the skin over his chest. Nothing.

  Michelle Lawrence, sitting at a stainless steel counter between two patient bays glanced up from the computer terminal she was typing on. “Give him anything? Heavens no. I ran him the last hour on just nitrous and oxygen.” She began playing with the mask still hanging around her neck.

  “Good.” Tyler preferred his patients awake soon as possible after the end of the case so he could examine their brain function. Tyler continued to examine Larry in more detail.

  The endotracheal tube was out and the kid was breathing on his own, so at least that much was okay. Tyler gently opened Larry’s eyelids. The left pupil remained dilated, the eye deviated to the left. No worse than pre-op but still a sign of damage to the third cranial nerve—probably from the shift of the temporal lobe before he decompressed it. The right eye also appeared to be the same as pre-op. Tyler rocked Larry’s head side to side. The left eye didn’t move, but the right did. Next, he pulled the cotton tip of a Q-tip into a wisp, which he used to gently brush each cornea. Both eye lids blinked a weak response. Larry’s respirations, however, were Cheyne Stokes. Abnormal, signifying a poor connection between the brainstem and cortex.

  “Doctor Mathews?”

  The RN assigned to Larry drifted over from her other patient. She wore a blue scrub suit with a gray hospital-issue stethoscope draped around her neck.

  “Yes?”

  “The family’s been increasingly inquiring about Larry’s condition for the last hour. They seem quite anxious. When can I tell them you’ll be down to talk to them?”

  He’d become familiar with the various family members during discussions leading up to Larry’s enrollment in the radiation trial. He didn’t want to deal with Larry’s antagonistic sister right now.

  “I’ll call down and talk to them. I don’t want to go face to face with his sister until I have a better idea how soon it’ll be before Larry wakes up.”

  She seemed to accept this but wasn’t happy with his plan.

  Tyler glanced at the anesthesiologist. “Hey Shellie, you interested in grabbing a bite before the cafeteria closes?”

  The anesthesiologist checked her Swiss Army watch. “Sure. I have enough time. There’s a potential C-section cooking upstairs, but if we go now …” She slipped off the stool.

  An idea hit. “Hold on a sec. Want to check something first.” He took the stool Michelle just vacated and logged onto the medical record system. He called up La
rry Childs’s chart and moused the radiation therapy tab. A smaller window opened. Tyler blinked, moved in for a closer look. He realized a patina of sweat now coated his body in spite of the chill. An urge to vomit battled his self-control.

  “Holy shit, Mathews, you okay?” Michelle reached out, grabbed his shoulder to steady him.

  A tingling floated over his skin, his equilibrium faltered. He inhaled deeply and planted both palms squarely on the stainless steel counter for support.

  He found his mouth too dry to speak so cleared his throat and swallowed. “Ah, can you tell me what the screen says?”

  “Which one? The dialog box?”

  He nodded, the dizziness starting to clear enough to release one hand from the counter.

  A second later Michelle gave a slow whistle. “Oh dear… . Two hundred. That’s—”

  Tyler grabbed her arm, whispered, “Hold it ‘till we get down stairs.” With a shaking hand he withdrew a pocket computer from his coat then fumbled with pulling the stylus free. Slowly, deliberately he worked through the screen to where he kept notes on research patients. He scrolled through the record to the entry he’d made when Nick Barber determined Larry Childs’s radiation dose. The number jumped out at him: 10 Gr.

  He handed it to Michelle. “Check it out.”

  She accepted the computer but kept staring at him. “Hey, you want to lay down or something?”

  “Look at it, damnit.”

  Michelle handed it back with a nod, her face drained of color. “You’re right. Let’s discuss this downstairs. You up to walking now?”

  “IF THAT ISN’T radiation necrosis then what the hell could it possibly be?” Michelle dragged the end of a French fry through red catsup mounded at the end of the oval plate. Her short precisely manicured fingernails were coated with clear lacquer.

  Michelle waved the fry. “What I’m saying is that I don’t buy this business about herpes or a wildly malignant glioblastoma. Holy shit, the brain’s necrotic and he apparently received enough radiation to melt an aircraft carrier. What more is there to say?”

  Tyler had also chosen the fish and chips. He took a bite of cod. It tasted like cardboard. He pushed his plate away and forced a swallow. “I know. It’s logical, isn’t it. Just hard to accept.”

  “Okay then. The kid’s got a case of radiation necrosis. That’s the easy part. The next question is how the hell could that kind of overdose happen? Way you describe the protocol, it’s impossible. Besides, you showed me your palm computer. I’m no radiation therapist, but that dose is more like what I’d expect.”

  The chill in Tyler’s gut intensified. “It has to be radiation necrosis. Can’t be anything else.” He looked at her. “Jesus, I couldn’t have made a mistake like that and typed it in wrong.”

  She frowned at him. “For Pete sake, stop this mea culpa routine. You don’t make those kinds of errors. We both know how tight assed compulsive you are about things like this. I don’t for one minute believe you allowed that crazy a dose to blow right past you. No way, no how. Besides, the computer would’ve caught it and asked you to verify.”

  “Then what else could’ve caused it?”

  “What about dear old U Pitt? Don’t tell me they don’t have a license to screw up once in a while just like the rest of us mortals.” She popped another fry into her mouth.

  “Sure, but the dosage value is double checked by the radiation therapists before being sent. And,” he remembered at the last minute, “the value has to be within safe ranges parameters or the U Pitt computer chokes and won’t allow the data transfer. And, like you just said, it’s the same with our computer. If it isn’t a reasonable value, we won’t accept it. “It’s a one-shot deal, you know, the zap. And believe me, that protocol’s bullet proof too. Had to be for NIH and the local IRB,” referring to the institutional review board that oversees human experimentation, “to sign off on it. No,” he shook his head thinking about it, “there’s no way in hell that kind of dosage mistake could’ve happened.”

  Michelle coated another fry. “Get real, Doctor Pollyanna. I’ve seen the bumper sticker … Shinola happen. It’s Murphy’s basic rule, the one all the other Murphy’s rules derive from: if something can go wrong, it will.”

  He mentally ran the protocol again, searching for a way to go wrong. “But the way this is set up, something can’t go wrong.”

  The anesthesiologist sat back with a smirk. “And how, dear boy, can that be? Something can always go wrong. Believe me, I know.”

  Intuitively, he knew Michelle was probably right. He just couldn’t see how. “Okay, let’s walk through this again. The patient’s MRI is sent to the Principle Investigator at University of Pittsburgh with the targeted area overlaid on the images. The PI’s radiation boys determine the dosage, it’s double checked, then sent back here electronically where it goes into the patient’s chart automatically. It’s only after I double-check the dose that Larry’s given treatment. It’s all done by computer. No chance for human error.”

  “Right. No chance of human error. But what about computer error?”

  He considered this suggestion a moment. “I dunno … the protocol is supposed to be infallible.”

  Michelle threw up both hands. “Okay, okay, you made your point. The protocol is inviolate. But what about someone else? Couldn’t someone else change it?”

  “Impossible. Only the treating physician can do that. That’s me. And I can guarantee you I didn’t.”

  “I realize that. What I’m suggesting is a hacker.”

  Tyler thought about this a moment. “Jesus, Med-InDx’s made a point of absolute security that that possibility didn’t even cross my mind. Huh!” Made sense.

  Michelle smirked again. “Absolute security? Just like Microsoft?”

  “Good point.”

  “So what are you going to do about it?”

  The question triggered a cascade of thoughts. “Shit, Shellie, I just realized … this would classify as a sentinel event. Which means whatever the cause of Larry’s problem, I need to report it to NIH and our administration. First thing in the morning, too.”

  “Oh dear, that probably means JCAHO too.” JCAHO—the body charged with accrediting hospitals.

  Wrong treatment dosage, Tyler mused. Exactly the types of mistakes electronic medical records are supposed eliminate. But how could this one happen?

  “Holy shit!”

  Tyler snapped back out of thought. “What?”

  “I just thought of something. Did you ever know Robin Beck? The ED physician?”

  “No. Why?”

  “Now that I think about it, she had something similar to this happen. Hold on, let me see if I can get my facts straight.” Michelle pressed her fingertips against both temples and closed both eyes. A moment later her eyes popped open. “Okay, I think I got it straight.” She sat back in the booth, hands folded on the table. “She injected a patient with a whopping dose of insulin. The only problem was, the patient wasn’t diabetic. She swears the chart unmistakably showed the patient on a combo of regular and long-lasting insulin.”

  “Jesus. What happened?”

  “Patient died.”

  A finger of nausea stabbed Tyler’s gut. He thought of Larry.

  “Now that I think of it, there was another one too …” Michelle snapped her fingers. “Okay, yeah, yeah … a nurse—what was her name?—gave a GI bleeder a couple units of mismatched blood. Patient ended up having a mondo transfusion reaction and boxed.”

  Tyler smoothed out a napkin, removed a garish purple and blue drug company ballpoint pen from his white coat. “You remember the nurse’s name now?”

  Michelle paused to think a moment. “Gail Walker? Yeah, Gail Walker.”

  Tyler wrote that down. “And the other doctor’s name is Beck? Robin Beck?”

  “Right.”

  “How’d you know about this? You know them personally?”

  “No. Just heard about them.”

  “Where?”

  Miche
lle shrugged. “Doctors’ lounge I guess.”

  Typical, he thought. With no office to tend to or patients to see, when not sleeping a case, most gas passers hang around the lounge drinking coffee and taking the pulse of the medical center. They become the staff ’s CNN. Want to know which hospital administrator is having an affair? Ask your favorite anesthesiologist. Want to know what line items are being cut from the budget next year, ditto.

  “How long ago did these complications happen?”

  “Oh man, you would have to ask that, wouldn’t you. Let’s see.” Michelle’s brow furrowed, accenting penciled eyebrows. “You know what, I can’t honestly remember. Last fall, I think. It’s been a while. I know that much.”

  “Both of those sound exactly like the kind of screw ups EMRs are supposed to prevent.”

  “My point exactly. Which makes a pretty good argument for a hacker diddling the system, doesn’t it?”

  Tyler groaned. The thought of Larry’s brain being irreparably damaged by some pimpled face techno-geek made him almost vomit. “What happened? I mean those cases must’ve been investigated, right?”

  Michelle looked up surprised, as if not having considered this angle before. “You know, I don’t really know. I do know that Beck was slapped with a huge malpractice suit. Ten million’s the word on the street. Other than that …” she shrugged.

  Tyler glanced at his watch. “I’m going to call the Med-InDx tech.”

  Just then Tyler’s beeper began chirping. It displayed the recovery room number followed by 911—meaning an emergency. “Jesus, here we go … the ICU.”

  Michelle waved him away. “Go ahead. Answer it. I’ll call the technician for you. You want to meet tonight, right?”

  Tyler nodded and pushed out of one side of the booth as Michelle did the same.

  When he answered the page a moment later the nurse told him, “Dr. Mathews, you better come quickly. Your patient just blew both pupils and stopped breathing. He’s getting ambued now.”