by Jaime Maddox
Ward had camped in the boardroom, fearing the interruptions she’d face in the physicians’ lounge and the ER, and so she wouldn’t have to move when the meeting began. She took her place at the computer and logged in. She had three more hours before the room started to get noisy, giving her about fifteen minutes to review each chart. Some would be easy to get through. Reviewing massive brain hemorrhages and dissecting aneurysms and other catastrophic illnesses didn’t require much time. She would make sure the basics had been done—patients were seen promptly, proper tests were ordered and the results documented correctly. Other disease processes weren’t so straightforward, and she might need to spend more time going through them. There are always questions when someone dies, and Ward had to ask them. Was time wasted? Were the proper medications given and the proper tests ordered? Were mistakes made, such as giving the wrong medication or putting a breathing tube into the stomach? Was the doctor successful in his or her attempt to insert the tube or the IV? Was the correct diagnosis made?
Ward took her list, a pen, and some sheets of notepaper and got to work. The first patient on the list was a ninety-year-old man who’d developed indigestion after eating his nursing-home hash on the morning of April Fools’ Day. His heart rate and blood pressure were tanking by the time he got to the hospital, and he’d suffered a cardiac arrest within minutes of arrival. Everything conceivable was done, but nothing helped. After reviewing the chart, Ward decided that his care had been first rate and appropriate. She moved on to chart number two. A week later, a teenager was brought in, also near death. He’d hit a telephone pole and suffered massive facial and head trauma, so much so that the paramedics were unable to secure his airway with a breathing tube through the pools of blood and broken facial bones. Anticipating trouble after the medic’s radio report, the ER doctor had paged the surgeon, who was waiting in the ER when the patient arrived. In spite of the emergency airway the surgeon inserted into his trachea, the patient coded and couldn’t be revived.
Not much could be done to force oxygen through his bloody airway, and Ward sensed his care had gone above and beyond the standard.
The final patient seen in April was another heart-attack victim, and this one was completely unresponsive to every medication and maneuver the medics and the ER team had given him. Ward couldn’t find a single fault in the patient’s care.
She logged into the next chart and checked the time. She’d spent forty-five minutes on the three patients who’d died during the month of April. Right on schedule. Fortunately, the May cases were straightforward as well. She made it through most of June and couldn’t avoid it any longer. It was time to look at the eight-year-old’s chart.
Her name was Hailey, and Ward was unable to shake her sadness as she finished reading the notes that documented her final minutes of life on earth. A car had hit her when she’d run into the street, fracturing her femur. The medics had successfully inserted an IV and given fluids, but the IV had shifted at some point and stopped running. Her heart rate was fast and her blood pressure was low—a complication of the massive blood loss associated with femur fractures—necessitating another IV. The ER doctor had successfully inserted an IV into her subclavian vein, but within seconds of that maneuver, Hailey had coded. An extended course of CPR was unsuccessful, and after more than an hour of trying, the code was called.
On autopsy, a significant amount of air was found in her heart, a fatal complication of insertion of the subclavian catheter.
Ward leaned forward onto the computer table, rubbing both temples. It was hard to argue this case. Unlike the eight charts she’d reviewed before this one, where she could place no clear-cut blame, Hailey’s death could be directly attributed to the insertion of the line. No line, she lives. Line placed, she dies. Did that mean the doctor was at fault in her death for failing to check the line? Or was the nurse at fault for failing to purge air from the IV tubing? Was a venous air embolus an acceptable complication of IV insertion? Ward wasn’t sure. She knew it happened, but did that mean it was okay? She’d have to research that a little more. She also needed to decide if the line was really necessary in the first place. If the risk of a procedure is death, the procedure better damn well be a lifesaver. Yes, her blood pressure had been low, but had they tried other IV sites before jumping to the subclavian vein? If not, that would be the first recommendation she made to the board.
Picking up the phone, she dialed the ER. Shayna had been the nurse taking care of Hailey, and Ward had seen her earlier. Perhaps she’d have a minute to talk and share her take on the events.
“Hi, Ward, how’s it going?” Shayna asked in greeting.
“Great. I need a little help, though. I’m reviewing cases for the M & M meeting, and you took care of one of the patients. Hailey Conrad. Can I ask you a few questions?”
Shayna gave a deep sigh and was silent for a moment. “That was the most fuckin’ awful code I’ve ever been on,” she said a few seconds later.
“I can imagine,” Ward said softly, beating down her own little ghosts.
“We gave her blood, fluids, all the right meds. Nothing worked. We tried for like an hour, and we never even got a blip on the monitor. Once she coded, it was a like a fuse got tripped. Nothing.”
“I could see that from the chart, Shayna. You did all you could.”
Shayna sniffled. The cocky young nurse, with spiky hair and tattoos on her tattoos, was really a softy at heart. “Thanks.”
“Can I ask you a question?” Ward asked.
“Sure.”
“Why did Dr. Hawk put in the central line? Was there no other access?”
“Huh! That’s what I told him! I’m great at IVs, and he practically pulled the needle out of my hand so he could put in that subclavian. It was like he had an agenda, ya know? Do doctors have to do a certain number of procedures on kids to keep your licenses? ’Cuz that’s what it seemed like to me. Nothing was going to stop him from putting in that line. He got the kit out, opened his own gloves, even pulled out the bag of fluid and hung it himself.”
“So you didn’t prime the tubing for him?”
“No. He was on a mission, and he did it all himself. As a matter of fact, when I tried to help, he glared at me. Told me to check on the transfer, since we were going to have to send her out to have the fracture repaired. Our orthopedics wouldn’t even come in to see her.”
“Did he seem like he knew what he was doing?” Ward asked. Injecting air was a rookie mistake or one made in haste. Clearly, he wasn’t in a hurry if he was gathering the equipment and priming the IV tubing by himself.
“Oh, yes. His technique was flawless. He gowned up and had the sterile gloves on in seconds, found the vein on the first try. He bragged that he was an expert on IV insertion. Said he was the one they called when no one else could get the line in.”
“So, he wasn’t a rookie,” Ward murmured, almost to herself.
“No, definitely not.”
It wasn’t a rookie mistake. And he wasn’t in a hurry. So what the hell had happened to little Hailey? Her conversation with Shayna didn’t tell her why it happened, but it clarified one thing for Ward. The source of the air embolus was the doctor, and no one else.
“I appreciate your help, Shay.” Ward disconnected the phone and stood again, going through her familiar stretching routine. She hadn’t finished by the time the first arrivals began walking through the door for the Morbidity and Mortality Committee Meeting. Damn, she thought. She still had two charts to review. Hailey’s had taken so much time she hadn’t had a chance to finish the others. Glancing at her watch, she contemplated sneaking back to the ER. A half hour remained before the start of the meeting, and if she hurried, she could finish those two charts and be done with it. She hadn’t counted on the early birds.
“Joe McGee,” a man said and held out his hand, interrupting Ward’s thoughts. He was short and morbidly obese, with thinning hair and pale skin. His smile was warm, though, and his greeting friendly. “I’m the pathol
ogist. Thanks for helping out with these chart reviews. It’s always beneficial when you can have the opinion of a neutral expert, and you certainly qualify.”
“I’m not so sure about that.”
“On the neutral or the expert?”
“Yes,” she said, and he laughed as he turned and waddled away.
“I have to agree with you!”
Turning slightly from Dr. McGee, Ward caught the glare of Dr. Marc Pierce, one of the hospital’s three radiologists. She hadn’t noticed him as she’d focused on the pathologist. Ward had met Pierce only once, in the lounge, and he’d seemed cordial enough. Likewise, whenever she’d spoken to him on the phone about imaging studies, he’d been professional and receptive to her questions. Now, though, he seemed quite confrontational.
Ward looked around. No one else in the room. “Are you talking to me?”
“Damn right I am, and as soon as the rest of the group gets here I’m going to propose removing you from this committee. I’d say sleeping with the hospital CEO is a conflict of interest, wouldn’t you?”
Ward was momentarily stunned. It wasn’t like she and Abby were hiding their relationship or that they needed to, but still—were they ready to be out? Too late for that question, she realized. More germane, did her relationship with Abby in some way conflict with the interest of the committee, as he suggested?
Joe McGee’s eyes bulged, and Ward wondered if it was homophobia, surprise at the information, or shock at Pierce’s gall.
Deciding to ignore the gossip and address the potential problem, Ward looked at Pierce. “In what way does my relationship with Abby affect this committee?”
He laughed. “She’s the administrator, and she has an agenda!”
“And what would that be, Dr. Pierce?”
Ward wasn’t sure who was more surprised by Abby’s question, her or Marc Pierce. She knew who was the most relieved, though, and was grateful to have Abby in her corner. The fire in her eyes and the steel in her posture told her Abby was poised to do battle.
Pierce’s chin shot up and he looked down his nose at Abby, puffing out his chest as he did so. “To control this medical staff like we’re your puppets. Ever since you came here, you’ve been using this committee to pull the staff apart, to position us against each other, making us place blame for patient deaths on each other’s shoulders. United we stand, and divided…well, you get to be in charge, then, don’t you?”
Abby calmly walked to the head of the long wooden table in the center of the room and, dismissing her detractor, placed her briefcase on the table and sat down. When she did, she met his glare. Her posture had softened, but the fire remained in her eyes. “You are most welcome to share your thoughts and opinions, Dr. Pierce, but perhaps you should practice before a mirror first. It would give you an idea of how idiotic you sound.”
A man from the kitchen walked in at that moment, pushing a laden cart. Food was always a good way to attract committee members, and suddenly Ward’s growling stomach reminded her lunch had been long ago. Abby had promised her the spread would be worth her wait, and as she spied each plate being uncovered, she had to agree. There were the customary salads, of course, but also colossal shrimp in a white wine sauce, salmon with a dill dressing, and beef tips in gravy. Mixed veggies and red potatoes rounded out the dinner menu, and on a separate table, Ward glimpsed crème brûlée with a strawberry garnish.
As happy as she was for the food, she was more thrilled that the confrontation with Marc Pierce had ended. Sure, the respite would be temporary, but it gave both her and Abby an opportunity to form a battle plan, and with the element of surprise gone, Pierce was in for a fight. Personally, Ward didn’t really care much about the committee. A few hours of her time would be wasted if she was dismissed, but in the end, it didn’t really matter. To Abby, though, this was a huge moment. How would she defend herself and her relationship with Ward to the committee? Abby’s words and actions at this meeting could have serious repercussions in her future as CEO.
When the dinner plates were cleared and while the coffee was being poured, Abby called the meeting to order and didn’t waste any time addressing the matter. “Dr. Pierce made some comments this evening about my interest in this committee. I’d like to address them. A committee such as this is vital and necessary to the quality of care provided at a hospital. It is our job to make sure our professional staff is giving the most appropriate medications and using the most current protocols in caring for our patients. If someone is behind the times, it is our job to point it out to them and to educate the rest of the staff as well. It is not about pointing fingers or blame. It is about improvement. It is what modern institutions such as ours do. It is also a requirement of our malpractice insurance policy to conduct such reviews.”
“The malpractice requires it?”
The question came from Ham Jarrod, a young internist just out of residency. How did he get roped into this committee?
His question echoed around the room in a variety of forms. Really? Wow? Get out! and You’ve gotta be kiddin’ me came from the ten members of the committee. Any who might have questioned Abby’s personal motives seemed to resolve the issues on their own, as no one mentioned it, and Marc Pierce sat in stunned silence, his crème brûlée untouched before him.
“That is correct, Dr. Jarrod. Insurance companies reward good behavior and penalize bad behavior. In our case, the findings and recommendations of this committee are submitted along with a ton of other data required when our policy is reviewed.”
“Why are we with this company if they make us jump through so many hoops?” Joe McGee asked.
“Good question. The malpractice crisis in Pennsylvania caused quite a few companies to stop doing business here. Our choices are limited. Of those companies large enough to insure us, the requirements are similar. They mandate certain guidelines for us to follow and standards to uphold. I’d be shocked if all insurance companies didn’t have a similar requirement.”
“Damn insurance companies,” someone said, and everyone murmured in agreement.
“Dr. Pierce is concerned because I have a personal relationship with Dr. Thrasher, who has agreed to review the ER cases for April, May, and June. Does anyone else share his concerns?”
No one did.
Way to go, Ward thought as she pulled out her notes. Abby had handled a room full of powerful men with ease, and she sensed they all respected her. When she glanced at Abby she couldn’t help smiling. Abby, though, had already moved on.
“Okay, then. Let’s get to the business of this meeting.” Physicians were present representing every department in the hospital, each of them having reviewed patient deaths and complications according to the standards written for their departments. Since they held this meeting monthly, most had only a few cases to review. One patient had received a medication she was allergic to, but the error seemed to be on the patient’s end, since she’d told the ER, the primary doctor, and the nurse who gave the med that she had no allergies. Another patient had died of sepsis, and the question of transfer was debated. Would the patient have lived if she were sent to a larger hospital with a more experienced team? Who knew? Ward suspected the policy for treating septic patients would soon include an option for early transfer.
They’d made their way around the table, and finally, it was Ward’s turn. She’d purposely sat next to Abby, because it would have looked strange if she didn’t, and besides, she wanted to. That meant she was the last to present her findings, though, and she suspected the committee members were eager to get home. At last glance, the meeting was more than two hours old.
“I’ve reviewed all of the cases except two,” she said. “And I’ll finish those as soon as I can and send all of you a memo about my findings. I found no problems with the care on any of the April and May cases.” Ward listed the names to be sure everyone was clear on her conclusions. She listed the cases from the month of June, explaining her findings. “Hailey Conrad,” Ward said, leaning forward. “
This is a tough call. She died from a venous air embolus, and I don’t know enough about it to say anything at this time.”
“That was Hawk, wasn’t it?” Ham asked.
Ward nodded, and Ham shook his head, a scowl on his face.
“None of us likes to point a finger, but he was bad news.”
Ward looked at him. What did everyone have against Hawk? “Whatta ya mean by that?”
“I can’t explain it. But I’m glad he’s gone. Any chance you can stick around awhile longer? You seem to know what you’re doing.”
Ward blushed, not at the compliment, but at the invitation to stay at Abby’s hospital. The head of pediatrics saved her from answering.
“Hailey was my patient. How long before you can get an answer for us?”
“I’ll have it by tomorrow,” Ward said.
Chapter Twenty-three
Cardiogenic Shock
“Jesus,” Ward whispered as she scanned the pages of yet another scholarly article on venous air embolus. Before taking on this task, she’d known next to nothing about the matter. Now, though, her knowledge was causing a considerable sense of angst. She’d seen the most accomplished and capable physicians whacked in the kneecaps by the hammer of peer review. Sadly, as with malpractice, a bad outcome such as death often causes suggestions for changes that might not be necessary. The challenge is to know when changes need to be made for the sake of safety, rather than for the sake of politics. Typically, Ward could review this case in a matter of an hour. Nothing about Hailey Conrad’s case was simple, though. Should she have been transferred directly to a trauma center? Or a hospital with pediatric critical care? Should a protocol be devised for starting central lines? Or just for central lines in children? Should doctors be prohibited from priming IV tubing, a task normally left to nurses who were more experienced and capable?
“Hmm?” Abby asked.
They were both working, seated on opposite ends of the couch, Ward with her legs propped up on the hassock and Abby sprawled out so her feet rested against Ward’s thigh. In spite of her preoccupation with the case she’d been reviewing, she couldn’t keep from smiling, once again, at the domesticity of the scene. She’d lived with Jess for nearly six years and could count moments like this on one hand. With Abby they were piling up so rapidly she needed to remove her socks and shoes to count toes in addition to fingers.
