by Allen Wyler
TYLER MADE IT from the basement cafeteria to the second floor recovery room in record time. Gasping for air, he pulled up alongside a respiratory tech squeezing the black AMBU bag connected to the tube into Larry’s lungs. Larry’s eyelids were wide open, both pupils so large and black only a thin rim of green iris showed.
“Shit,” he murmured. Then, to one of the nurses hovering, “Call CT, tell ’em I want a stat scan.” He bled into that resection, was his first thought.
The nurse glanced up from the computer keyboard. “Figured that’s what you’d ask for. Already called. A transporter’s on the way.”
Tyler grabbed the head of the bed, started pushing. “Don’t have time for that. I’ll take him myself.”
5
ONE BY ONE Tyler watched black and white images fill the oversized GE monitor as he scrolled the CT series once again. Through the lead-impregnated glass window his peripheral vision caught the recovery room nurse, the CT tech, and the respiratory tech transferring Larry’s supine body from the scanner to the recovery room bed. Larry’s body, he mused, already preparing his emotions for the eventuality he saw in the scan.
“Where do you want him to go?”
Tyler glanced up at another recovery room nurse who had entered the room undetected. He knew the guy, an ex-corpsman, if memory served correctly. “Take him up to ICU.” It would be better to have the family see him there than in the recovery room. Besides, the recovery room nurses had finished their shift by now and were closing down the unit until tomorrow morning’s cases started rolling in. “But before you do, I want another look at his pupils. I’ll be out in a minute.”
“Thanks.” The ex-corpsman moved off to help the others.
Tyler returned his gaze to the huge blood clot filling most of the area where Larry’s brain should be. Return to surgery and evacuate the clot? Why? Larry was, by now, brain dead. Beside, getting in and out of Larry’s head a second time without the clot reaccumulating was about as likely as winning the Lotto. No, he had nothing left to offer the poor kid.
Tyler wondered what sort of hopeful dreams the prospect of a life without seizures had spawned in Larry Childs’s imagination. Probably included a raft of trivial daily activities most of us take for granted, he supposed. Conveniences and privileges that allow independence. A driver’s license. Employment. Being able to sit in a theater without fear of soiling himself or having moviegoers goggle in horrified interest at a convulsion. Gone now, all of them.
Suddenly Tyler’s shoulders seemed twenty pounds heavier as the fatigue from operating and the depression of seeing his effort fail seeped through his bones. He thought of the family downstairs—waiting, unaware of this terrible complication, still holding out hope for Larry’s survival.
His beeper started chirping. He called the unfamiliar number.
“Tyler, Michelle. Got hold of that technician for you. I told him what we’re thinking—the hacker and all? He doesn’t believe it. Thinks we’re full of shit. Much as said I’m crazy. Claimed it’s impossible for anyone to penetrate their security. Bottom line is there’s no way he’s coming back tonight to even discuss it. Said he’d meet me tomorrow at the latte stand.”
“Which one?”
“The one in the cafeteria.”
“Thanks.” He almost hung up before realizing he needed more information. “Oh, what time?”
“Seven.”
“You going to be there?”
“Probably not. Depends on whether I’m finishing up a case or not.”
“Got it. What’s his name?”
“Jim Day.”
WEARILY TYLER ROLLED back and pushed out of the task chair. For a moment he stood, hand on the chair back and sucked a deep breath before palm wiping his face. He stepped into the scanner room and over to Larry. For a moment he studied his half-opened eyes. Believing only in the reality his own senses provide, Tyler had no idea what clerics conceptualized when speaking of a person’s soul. He doubted it was some sort of metaphysical energy packet that, at the moment of death, levitated from the lifeless body into Heaven or dropped into the abyss of Hell. What he knew for certain was there came a time in the dying process when an immeasurable sign of life vanished from a person’s pupils. He’d witnessed it too many times to not believe in it. He had never known a patient to survive once that light disappeared. It had vanished from Larry’s eyes sometime within the past few hours.
He told the nurses, “You can take him up now. I’ll go talk with the family.”
TYLER FOUND LARRY’S family occupying a waiting room corner where the three of them had set up a small camp. A rumpled thermal blanket piled on one end the couch, newspaper sections stacked on the other. Latte cups strewn over a commandeered coffee table, two club chairs liberated from nearby. A priest with basset-hound eyes stood silently to Mrs. Childs’s left. Tyler assumed he was from their parish. This time of evening the large surgery waiting area was deserted except for a middle-aged couple across the room in adjoining chairs, apparently watching CNN Headline News. Tyler suspected they would eavesdrop on this interchange in hopes that any forthcoming bad news might lessen their odds of the same.
A second after eye contact, Leslie Childs, Larry’s older sister and self-appointed family spokesperson and legal counsel, jumped up from the couch but stayed put. The parents’ heads snapped toward him but they remained seated. All three pairs of eyes zeroed in on him. Tyler dropped down on the couch next to Leslie so as to speak directly to her parents, even though he expected her to dominate the conversation.
Knowing no other effective way to broach the subject Tyler began with, “I’m afraid it’s not good news.” He paused for the full impact to register. “Larry’s not waking up. In fact, his condition is worse. He bled into the area I removed.”
Mrs. Childs sobbed, burying her face in both hands. Her husband reached an arm around her shoulders while his other index finger pushed up his bifocals to pinch the bridge of his nose, his head bowed.
“It’s that damned radiation, isn’t it!” Leslie Childs stood pillar straight, fists planted solidly against her narrow hips, flared elbows forming an imaginary barrier beyond which no family member dared to cross. Larry’s parents huddled behind this 5’7” alpha primate in worried silence.
Her outburst came as no surprise. Fully expecting her opening salvo he’d rehearsed a firm, but not too defensive reply. Meeting her eye to eye, he said, “Ms. Childs, I appreciate your concern for your brother, but we’d all be better served if we carry on this discussion on a less antagonistic basis.”
The mother looked up at her daughter. “He’s right, Dear.”
With acetylene torch eyes on Tyler, she forced a smile and dropped into a club chair next to her mother. Mrs. Childs reached over and grasped her hand. The priest began fingering Rosary beads.
Round two coming up, my friend, get ready, bell’s about to clang.
“Here’s what’s happened,” Tyler began. For the father’s benefit he rehashed the CT findings and the explanation given to Mrs. Childs earlier. Then, to all three family members he explained the findings at surgery, how biopsies were submitted to the pathologist, the time needed for a pathologist to make any sense of the tissue, and, finally, Larry’s failure to awaken long after the anesthesia should have worn off and finally the terminal hemorrhage.
When he finished Leslie asked, “All you’ve given us so far is a string of medical mumbo jumbo. What exactly does it mean?”
Fair enough question, Tyler told himself. It was her sanctimonious tone and attitude that grated. Then again, her brother lay dying in the ICU. He took a moment to mentally rephrase his explanation before attempting another pass at it. “I’m afraid your brother’s brain is dead.”
“He’s dead?” Leslie asked without her prior defiance.
“Yes.”
Larry Childs Sr. hugged his wife more closely but she seemed to accept Tyler’s words as a grim anticlimax.
“But his heart is still beating, isn’t it?�
� Leslie asked.
Tyler slipped into words explained many times before. “True.” He paused. “But, the heart isn’t the essence of human life. The brain is. The heart is a symbol of love perhaps, but life can go on if it’s replaced. You can’t say the same for the brain. Once your brain stops working, your spiritual and personal essence stops too, leaving behind only a physical body carrying on a series of metabolic functions.” He braced for a theological rebuttal from the priest but none came.
Leslie nodded, accepting this explanation.
“I have to ask something,” Tyler continued, “that I know will be very difficult for any of you to answer, so if you wish, no answer will be sufficient for me to proceed.”
Leslie offered, “You want to turn off the respirator.”
Again, Leslie’s cooperative tone surprised him. “Yes.”
She thought about this a moment. Then, without conferring with her parents. “That’s what Larry would’ve wanted.”
“There is one more unpleasant issue I need to bring up.” Another pause. “I would think you’d want to know for certain that it was the radiation that caused his problems. I want you to allow me to order an autopsy.”
“HE’S THE PRIEST who baptized and confirmed Larry,” Mrs. Childs whispered to Tyler as she walked into Larry’s ICU room. “I think it’s only right that he gives my son last rites.” Mr. Childs, Leslie, and the priest followed.
Tyler pulled the sliding glass door closed but didn’t approach the bedside so as to not intrude on the family’s private grief. For a long moment he heard only the heart monitor, the respirator, and sniffling. At the head of the bed, the three family members to either side, the priest pulled a long, embroidered sash from around his neck, kissed it, and began uttering words Tyler recognized as Latin.
SILENCE AGAIN ENCASED the room. Tyler cleared his throat softly and said, “I’ll show you where the waiting room is.”
A few minutes later when he returned to Larry a nurse was already turning down the IV drip. She glanced at him. “Time?”
Tyler nodded, wrapped his fingers around the corrugated plastic hose from the respirator, his other hand gripping the endotracheal tube. He paused to reflect once again on what he was about to do. Once disconnected, air could no longer be pumped into Larry’s lungs, causing his heart to stumble and die. Is there a God? Is he watching? What would he do in my position?
He pulled apart the tubes and thumbed off the respirator power switch. Over the past hour he’d allowed Larry’s CO2 blood level to rise to a normal value, just on the off chance some brainstem functions were still there and he’d been wrong and Larry would resume breathing.
For three minutes Larry made no attempt to breath. Shortly after that Larry’s heartbeat began to slow until it finally stuttered, fought for a minute, then became silent.
THE MAN PICKED up the telephone on the third ring. “What!” His voice carried an alcohol slur and a hint of irritation that said he didn’t appreciate being disturbed at night.
The caller said, “We may have a problem.”
“At nine o’clock at night we may have a problem? Can’t it wait until morning? I’m busy.”
The caller wanted to tell the pompous egotistical sonofabitch to shut the fuck up and listen for once. “There’s been a complication. A patient received a radiation overdose.”
“So? That’s life, shit happens.”
“For Christ’s sake, listen up a second. This is different. We got us a doctor running around claiming hackers cracked our system.”
“Well in that case, there’s no problem. No way no how can we have a security breach. You should know that.”
The caller’s irritation rose. For a smart sonofabitch, the man wasn’t very smart. “That’s not the point. She’s got a wild hair up her ass about it, to the point she wants us to start an investigation. She says she’ll have to report this to JCAHO.”
He heard no flip reply this time, just a pause. Finally, “Who’s the doctor? We know anything about him?”
“It’s a her. I looked her up. She’s an anesthesiologist by the name of Michelle Lawrence.”
“Well? So what’s the problem? Just have to make sure nothing comes of it.”
TYLER FLUFFED HIS pillow and settled back onto his left side, the cool cotton pillowcase refreshing against his facial stubble. He listened to rhythmic rap music thumps crescendo then fade as an unseen car passed four stories below. Even with his apartment windows closed, the vibrations easily reached his ears. Amazing. He wondered what those thundering decibels of sound energy must be doing to the delicate nerve endings in the driver’s cochlea? Nothing good, he decided, and imagined an entire generation of prematurely deaf—but hip—citizens. Any hearing aide stocks to invest in long-term? Assuming, of course, he ever got out of debt from the student loans his tough-love, pull-yourself-up-by-your bootstraps father forced him to accumulate. Which wasn’t completely fair, he admitted. Alimony from divorcing his first, alcoholic wife had been a killer on his financial resources.
He sucked a deep breath and tried to weigh what to do in the morning about Larry Childs’s death. Certainly report it to risk management and the clinical trial principal investigator, Nick Barber. But JCAHO was a different matter. Having been once burned, he couldn’t afford to get involved in something having any potential for severe blowback on his job. What if the root cause analysis pointed a finger at him? Would he be fired? His stomach turned sour. It reminded him of what happened in California. Jesus, look how that turned out.
What would Dad do in this situation? More to the point, what was the right thing to do?
Another peek at the clock radio. 1:37 AM. The alarm was set for 5:45. Four hours. Enough time to chew an Ambien into a bitter paste and rub it over his gums with the tip of his tongue to speed up absorption to a couple minutes rather than the twenty or so it’d take if swallowed.
No! He had to stop relying on sleepers. For all sorts of reasons, all of which he could recite as easily as the twelve cranial nerves. But the most important reason was the possibility of starting over with Nancy. For a PhD molecular biologist, she had a peculiarly strong prejudice against taking medication she didn’t believe was absolutely critical and life saving. She’d rather suffer through a cold than pop an antihistamine. On the other hand, she’d readily ingest any number of unscientifically proven herbs prescribed by a traditional Chinese naturopath. Got an ache? Chew a weed, but don’t take ibuprofen. A heritage that obviously migrated from Hong Kong to UCLA with her. In San Francisco she occasionally visited Chinese fortunetellers, claiming to not take their forecasts seriously. Tyler didn’t believe it for a second, suspecting she’d rescheduled her entire thesis defense because of one such prediction. Quirky, yes, but one of the little things he loved about her. Almost as much as he appreciated how she cheerfully set aside her studies when his unpredictable schedule allowed for a few unexpected hours together—only to get up an hour or so earlier than usual to make up the time.
Besides, her caution for Western medicine provided a healthy contrast to his willingness to pop medication at the first sign of a cold or an athletic-induced pain, which, now that he thought about it, had probably contributed to his present reliance on sleepers.
But he needed sleep. Besides, he could break the pill in half. That way …
Tyler focused on the clock radio again. 1:39 AM.
Don’t do it.
But I need the sleep.
Sure you do, pal, but when will it stop? You know it has to stop. Especially now. You can’t let Nancy know you’ve developed this little problem.
It isn’t a problem.
No?
Tomorrow night. I’ll stop tomorrow night. I just need some sleep.
Tyler swung his legs out of bed and headed for the bathroom and the amber bottle of white Ambien tablets in the drawer just to the left of the sink.
6
7:04 AM, MAYNARD MEDICAL CENTER CAFETERIA
TYLER HURRIED INTO the crowded cafeter
ia and checked his watch for the fifth time in two minutes. Four minutes late. Not like him. He bee-lined for the latte stand, eyes searching for a likely Jim Day, saw a man the color of bittersweet chocolate and about his age and perhaps two inches shorter standing, latte in hand, with an expression of anticipation. Tyler approached and asked, “You Jim Day?”
The man turned and studied Tyler a moment. “Dr. Lawrence?”
Tyler extended his hand. “No. Actually, Dr. Lawrence called you last night for me. I was busy in the ICU.” He paused, looking for a place to carry on a conversation. “Sorry I’m late. Got delayed on rounds. How about that booth over there.”
Day gave a sarcastic grunt. “No way we’re broaching that subject out here where someone might hear. My office.” He started toward the exit.
TYLER WAITED UNTIL they were seated in the small cramped office before broaching the subject. He got straight to the point by explaining the discrepancy between Larry Childs treatment dosage recorded in his PDA and the one in the EMR. Next, he explained the consequences—a lethal case of radiation necrosis. Not that he had pathological confirmation yet, but there could be no other reasonable explanation.
Day said, “I believe you about your patient … that he has a serious problem and all. That much is obvious. I just can’t believe someone outside the system could change the data field once it had been populated. The only way that field could’ve been changed is someone holding EMR privileges changed it. Even then, they’d have to have superior privileges and that could only be a doctor with direct responsibility for the patient. Even then it’s hard to do, what with all the crosschecks and all. And if they did, there’d be a record of it.”
“I can’t imagine a doctor changing that dose. It just doesn’t make sense. I mean, for what possible reason?” Especially considering Larry Childs was such a low-profile person. “You can check that, can’t you?”
