by Gary Birken
Morgan was the first to reply. “Thanks for coming. I appreciate your forbearance.”
Todd rubbed his chubby hands together. “Let the games begin.”
“When did you first notice the clots?” she asked him.
“After the grafts had been sewn in and we were re-warming.”
“Tell me specifically how that’s done.”
“We simply bring the temperature up on the circulating blood. If we can’t get the patient’s temp back to at least ninety-seven degrees, it’s hard to get their heart started again.”
“And I assume Mr. Wallace’s temp was coming up okay.”
“It was.”
“Fine. What do you do next?”
“Nothing. Once the heart is warm, it generally starts beating on its own. After that, if everything looks good, we take the patient off bypass.”
“How long does the whole process take?”
“About twenty-five minutes.”
Morgan walked back over to the table. “Okay. Let’s concentrate on what happened from the time you started the re-warming process until the pump clotted off. What exactly were you doing?”
“I was checking the circuit and talking to the medical student.”
“Who was the first to notice there was a problem?”
“Dr. McBride. He saw clots in the pericardial well and let me know. When I checked the circuit, I had the same thing.”
“What did you do?”
“I started changing the circuit tubing as fast as I could.”
“What was Dr. McBride doing?”
“You mean besides having a heart attack of his own?”
“C’mon, Todd,” Robin interjected. “We need straight answers or we’ll never get through this.”
“Sorry. There really wasn’t too much he could do other than squeeze the heart and hope we could get the whole circuit changed.”
Morgan studied the medication flow sheet. “Exactly what time does your record show that you started re-warming?”
Todd looked down at his own record and then ran his finger down the left margin. “At nine forty-five.”
“I want to concentrate on something we kind of glossed over the first two times. What was Dr. Quintana doing while you were re-warming?”
“Checking vital signs and giving whatever meds are required.”
“From what I can tell, the only drug Mr. Wallace received once re-warming was started was nitroglycerine. The infusion began at nine forty-eight.”
“That sounds right. The nitroglycerine drip decreases the amount of work the heart has to do and helps recovery. Anesthesia routinely gives it when we start re-warming.”
“Did you give any meds?” she asked.
“Nope.”
“The nitroglycerine drip? Do you know when the pharmacy sent it over?” she inquired, picking up the five-hundred cc bag of saline that contained the nitroglycerine in solution.
“It wasn’t sent over by the pharmacy.”
She looked up. “What do you mean?”
“Dr. Quintana made the drip himself.”
“Why?”
“It’s routine. All of the anesthesiologists make up their own drips. They feel it’s safer.”
“When do they do that?” Morgan asked.
“It’s usually when they’re setting up for the case.”
“Could the medical student have accidentally done anything to the pump that might have caused it to clot off?”
“Not a chance,” Todd insisted. “It’s a firm policy that students aren’t permitted to do anything except observe.”
“Was that the first time she’d worked with you?”
“No. She’d been with me for a couple of weeks,” he answered with a puzzled look on his face.
Morgan put the IV bag down. “According to the record the first clots were noted at nine fifty. That would have been five minutes after the re-warming process was started, and about two minutes after the nitroglycerine drip was hung.”
“That sounds about right.”
“Assuming this wasn’t some kind of pump malfunction, what else could have caused the problem?” Morgan asked.
“The only other possibility would be that the heparin wore off and Mr. Wallace started making clots again.”
“But I thought you monitor the patient’s state of anticoagulation during the pump run and give as much heparin as necessary to prevent clot formation.”
“We do.”
“And?”
“Mr. Wallace had an ACT at nine thirty-five that showed he was very adequately anticoagulated. There’s no way his blood could have made a clot. He did not require any additional heparin.”
“But that was fifteen minutes before the clots were first noted. Could the heparin have worn off that quickly?” she asked.
“Not a chance.”
“But normally you don’t wait for the heparin to wear off before you come off of bypass,” Morgan said.
“No. When the patient’s ready to come off, we give protamine, which immediately reverses and neutralizes the heparin.”
“Which would mean the patient would be able to make clots again.”
“Instantly,” Todd said.
Morgan raised her eyes from the IV bag and looked squarely at Todd. “So if it wasn’t a pump problem and Mr. Wallace had plenty of heparin on board—what the hell happened?”
Throwing his arms up in the air, he said, “It’s kind of like I’ve been saying all along. There is no explanation.”
Morgan reached for the two bottles of protamine and held them up.
Todd shook his finger at her. “No way. I know what you’re thinking and you can forget it.”
“Really?’ Morgan answered.
“The protamine was the first thing Dr. McBride and Dr. Quintana checked.” Todd walked over and pointed to the bottles in Morgan’s hand. “These were the only two bottles in the room, and as you can plainly see their metal seals are unbroken. There’s no way the patient accidentally got any protamine.”
“How can you be so sure?” Morgan calmly asked.
“With all due respect, Dr. Connolly. I just told you the vials were never touched. You can see for yourself the seals are unbroken.”
“I guess we still don’t know—”
“I don’t know why the pump clotted off, but it wasn’t because Mr. Wallace mistakenly got a premature dose of protamine.” Todd crossed his arms. “I don’t want to appear arrogant, but we do this every day, which makes us incapable of making a mistake of the magnitude your suggesting.”
Morgan smiled at him courteously, thinking to herself that it was Todd’s overconfident attitude that frequently set the stage for tragic medical mistakes.
Morgan said, “About six months ago a relatively healthy woman ran out of her blood pressure medication. She couldn’t find an open pharmacy so she went to her local emergency room because she was starting to feel a little light-headed from her pressure going up.”
Todd said, “Are you trying to make a point or did this really—?”
“Really happen? The hospital’s right here in Miami. May I finish, please?”
“Sorry.”
Morgan went on, “The doctor prescribed eight milligrams of the blood pressure med to be given intravenously. The nurse misread the order and thought he wanted eight hundred milligrams. She then proceeded to go to nine different locations in the hospital in order to gather up the twenty-six vials of the medication necessary to prepare the dose. At no time did it cross her mind that this was a little out of the ordinary. She then tried to put this massive overdose in a liter bag of saline, but because it wouldn’t fit she hooked a second liter bag onto the first. When she finished preparing this lethal injection, she then opened up the IV and walked away to attend to another patient.”
“And the end of the story is that the patient died,” Todd said.
“Yes, she did. But the reason I’m telling you this is because there were no systems in place to prevent this catastrophe.
The machines that dispensed the drug weren’t computer linked so they couldn’t block her from taking twenty-six vials of the same medication within thirty minutes. None of her colleagues checked the dose. Nobody was suspicious about this strange-looking double IV bag she jury-rigged. What I’m trying to say is that the culture of safety in that hospital was inadequate to prevent an overworked and fatigued nurse from making a fatal mistake.”
Todd shrugged. “I understand that people die of medical errors. I just think the whole thing is way overstated.”
“Really? Do you know how many patients in this country were injured or died last year because of medication errors?”
Todd rolled his eyes. “I’d be guessing. Maybe a few thousand.”
Morgan walked across the room, stopping a few feet in front of Todd. “Try one-point-five million—so don’t tell me we’re incapable of making a medication error. The only thing we’re incapable of is losing our arrogance. Maybe when we do, we’ll cut down on medical mistakes and have a safer environment for our patients.”
During the uncomfortable silence that ensued, Morgan replaced the medications in the carton box. She then closed the lid but left the IV bag containing the nitroglycerine on the table.
“I guess we’ll just have to keep trying to figure out what went wrong.” Without making eye contact, she added, “Thanks, Todd. I appreciate your help.”
Todd started for the door. Before he stepped into the hall he said, “You might as well give up, Dr. Connolly. We’re never going to figure out what went wrong.”
“He seems a little annoyed,” Morgan told Robin.
“This case has generated a lot of speculation and innuendo. If it was a pump problem, Todd’s ultimately responsible. He’s understandably defensive.”
“It would help if we’d stop blaming people and start blaming our antiquated systems,” Morgan stated, picking up the nitroglycerine drip. “Do you mind if I borrow this?”
“Borrow it?” Robin asked with vaulted eyebrows.
“Let’s just say it’s official business of the Patient Safety Committee. I’ll bring it back as soon as I can.”
Robin looked at Morgan as if she were proposing homicide. “I’m going to recheck these boxes in forty-eight hours. I kind of like this job. Try not to get me fired.”
“Your job is safe. Thanks for your help.”
Morgan was rapidly becoming convinced that everybody involved in the Tony Wallace case was as pessimistic as Todd was regarding the chances of ever figuring out what had caused the pump catastrophe. The strange irony was that as long as they remained convinced his death had been nothing more than an unfortunate medical error, they were probably right.
Morgan left the operating room and headed straight for Dade Presbyterian’s laboratory. She glanced down at the nitroglycerine drip she held in her hand. She knew it was a long shot, but she still held out hope that very shortly, she would have indisputable proof that Tony Wallace’s death was not the result of some bizarre or unavoidable medical error.
CHAPTER 28
With the nitroglycerine drip in hand, Morgan strolled into Dade Presbyterian’s main laboratory.
Surrounded by a flurry of activity, she spotted Dr. John Ackerman tinkering with a sophisticated-looking piece of laboratory equipment. Ackerman had been the director of Laboratory Services at Dade Presbyterian for the past ten years. Good-natured at heart, he was, at times, annoyingly glib and especially masterful at making a long story longer. His sappy sense of humor frequently sent even his closest friends scurrying for cover. But in spite of his minor peculiarities, he was an instinctive pathologist with an encyclopedic fund of medical knowledge.
“John?” Morgan asked, walking up behind him.
He glanced over his shoulder, massaged his scaly forehead with his fingertips, and then smiled.
“Well, well. Dr. Morgan Connolly. It’s not often I get paid a visit from our chief of Emergency Medicine. What can I do for you?”
She shook his extended hand, noticing his new crop of hair plugs, which did little to improve his appearance.
“I’m actually here in my capacity as a member of the Patient Safety Committee.”
He came to attention and saluted. “In that case I’ll be especially cooperative. Have a seat.”
“I have a couple of questions about one of our Code Fifteen cases.”
“What’s the patient’s name?”
“Tony Wallace.”
“The clotted cardiac bypass pump?”
“That’s the one.”
“I’m all ears.”
“Would you happen to know if there’s any specific test or assay available that can detect the presence of protamine in an IV solution?”
His answer was immediate. “To my knowledge, there’s no assay for protamine either in the blood or an IV solution.”
“Are you sure?” Morgan asked, feeling whatever glimmer of hope she had fading.
“I’m quite certain there’s no specific test commercially available.”
“Well,” she said with a short sigh. “I appreciate the information.”
“You seem disappointed,” he said. He then pointed at the IV bag. “What do you have there?”
“It’s a nitroglycerine drip. I was hoping you could tell me if there was any protamine in here, but I guess I was wasting—”
“Wasting your time? I don’t think so.”
Morgan’s eyes narrowed. “John, didn’t you just tell me that you couldn’t—”
He held up a finger. “You asked me if there was any test available that would directly measure protamine in solution, and I told you there wasn’t,” he answered, taking the IV bag from her and studying it from every conceivable angle. “Sometimes there are mysterious ways of figuring things out without the help of some multibillion-dollar drug company.”
Fighting to stay patient and indulge John’s unusual sense of humor, Morgan pressed her palms together. Before she spoke, she raised them to her face as if she were praying. “John, I just need to know if, by any means available to you, you can tell me if there’s protamine in this IV solution.”
“Absolutely. It’s not a problem.”
Morgan took a step closer. “How?”
“By indirect means.”
“Would you mind explaining that to me?”
“All we have to do is find a willing volunteer, draw a tube of blood from that brave individual, and then add some heparin to it.”
“I’m listening. Go on.”
“You would agree the heparin will anticoagulate the blood. It won’t be able to make any clots.”
“I agree.”
“We can even prove it’s anticoagulated the same way the cardiac surgeons do before they put a patient on bypass by doing an ACT test on it.”
“Then what?”she asked.
“Once we’ve proven the ACT is abnormally high,” he said, tapping the IV bag, “we simply add a little of this IV solution you’ve brought to the blood-heparin mixture and do the ACT test again.” He paused briefly. “Do you see?”
Morgan’s look of bewilderment quickly faded and became frozen as a smile. “If there’s protamine in the bag, then the ACT test should neutralize the heparin and the second ACT should return to normal.”
“Bingo. But if there’s nothing in here except nitroglycerine, then—”
“Then the ACT should remain high because the heparin won’t be neutralized or reversed.”
“You got it,” he said, pointing right at her.
“When can we try this?” Morgan asked.
He smiled annoyingly. “As soon as you roll up your sleeve.”
Morgan frowned. She hated being stuck with needles. She looked at Ackerman, who was still smirking. After a few seconds, she blew out a long breath and rolled up her sleeve.
CHAPTER 29
Even before the tech slid the needle into Morgan’s vein, she cringed with anticipation.
“Your jaw muscles are tighter than a banjo string,” Ackerman sa
id. “If I had known it was going to be this traumatic for you, I would have volunteered myself.”
Before Morgan could answer, she felt the hot pinch of the needle penetrating her skin.
“We’re almost done, Dr. Connolly,” the tech said, exchanging an amused look with Ackerman. As soon as he had filled the red-top tube with ten cc’s of Morgan’s blood, he handed it to Ackerman.
“I’ll get started on this. As soon as you’ve recovered from your little ordeal, you can join me over there by that little blue ACT machine.”
By the time the tech had made sure there was no bleeding from the puncture site and had placed a Band-Aid on Morgan’s arm, Ackerman was already adding the heparin to the tube of Morgan’s blood. He flipped the tube over several times to make sure the drug was well mixed. He then removed a small amount and introduced it into the ACT machine. It took only about thirty seconds for the result to appear on the digital display. It read six hundred fifty.
“Okay,” he said to Morgan. “The normal ACT should be about a hundred so we’ve successfully anticoagulated your blood. You wouldn’t be able to make a clot now if your life depended on it.”
Next, Ackerman reached for the IV bag containing the nitroglycerine drip. Using a small needle and syringe he removed five cc’s of the solution and injected it into the tube that contained Morgan’s blood and the heparin. Once he had thoroughly mixed the contents, he held it up in the air and tapped the tube several times.
“What are you looking for?” she asked.
He gave a light shrug. “I don’t know, but in every old doctor movie I’ve ever seen on TV, the brilliant pathologist always holds the tube up, studies it intently, and then taps it a few times.”
Morgan rolled her eyes but said nothing. She watched as Ackerman withdrew a small amount of blood from the tube and introduced it into the ACT machine. Morgan stood with her arms crossed staring at the blank digital display.
When the number ninety flashed up, her eyes remained locked on the display. Finally, she looked over at him. He was now stone-faced.
“No doubt about it,” he said. “There has to be protamine in the nitroglycerine drip.”
“The question is, how did it get there?” Morgan asked in just above a whisper. “John,” she began slowly, “I’m not sure what I’m going to do with this information yet, but it’s absolutely imperative that you don’t discuss this with anybody. I’m sure I don’t have to tell you that is an extremely delicate matter.”
