April was clearly excited about her father’s birthday. She had good reason to be. Just six months ago, she wasn’t sure there would be another birthday to celebrate. Bob Lehman had undergone emergency coronary artery bypass grafting just before the Fourth of July.
He had been at the office when he developed crushing chest pain and was rushed to the local community hospital, Our Lady of Mercy. April had taken the call at home and had raced to the emergency room just in time to see her father being wheeled to the cardiac catheterization lab. She remembered her father’s ashen complexion and perspiration-soaked gown. But these were nothing compared to the thinly veiled look of terror in his eyes. She kissed him and gave him a quick hug in spite of the tangle of EKG leads, IV tubing, arterial line, and oxygen hoses crisscrossing his body. She told him she loved him and would see him shortly, when this was all taken care of. Oh please, God, pull him through. I swear I’ll do anything.
The emergency room physician had told her they would try to dissolve the offending clot with a new drug called “tissue plasminogen activator,” or “tpa” for short, but they also needed to obtain some pictures of the blood vessels feeding the heart—the all important coronary arteries. Unfortunately, they only had about four hours before the damage to the heart muscle became irreversible. A myocardial infarction would be the result. This translated into death of a portion of the heart muscle and could be fatal.
April remembered the agonizing wait while her father was in the cath lab. When one of the interns came out and told her he was being rushed to the OR for emergency bypass surgery, she was beside herself with fear and dread. Only last year she had watched her mother die in this hospital; it was a horrible, suffering death as only metastatic cancer can provide. Now she was to lose her father. She quickly made more promises to God, not holding back anything.
Her father survived his surgery and actually did quite well. He had only one minor complication—an incisional hernia that was scheduled to be repaired the following day as an outpatient. He appeared to thoroughly enjoy his birthday, and April marveled that he spared little energy worrying about the upcoming surgery. She only wished she could be so relaxed.
It was late Sunday night, and Rusty Cramer knew he should’ve been in bed. Instead, he pored over his computer screen. He had finally received the e-mail he had been waiting all weekend for. He read it and reread it. Rusty shut down his computer and ran his fingers through his hair. Things were coming together. He got up from his chair, paced around the room for a few minutes, and then made his decision. He would skip the Visiting Professor lecture series tomorrow. Perhaps Wednesday, he would take a trip to Philadelphia. He had more business to attend to.
CHAPTER FOURTEEN
It was 11:45 a.m. Monday morning, and Melissa Draybeck was dutifully setting up for a noontime lap choley in OR#2. She was a conscientious OR scrub nurse with considerable experience built up over twenty years of service to Mercy Hospital. Melissa prided herself on her rigid, sterile technique and extensive knowledge of surgeons’ operative techniques including the vast array of surgical instruments involved. This was no mean feat, considering virtually every surgeon had a rather large laundry list of likes and dislikes for everything under the sun, including which gown to put on (Gore-Tex or regular), which gloves (latex, rubber, non-allergenic, orthopedic, Vaseline wipe before gloving), which surgical instruments, which OR room, which OR table, which suture, which dressings, etc. And of course, each surgeon believed his technique was the only logical choice and therefore expected the nurses to anticipate his needs or there would be hell to pay.
Thank God most ORs, in an effort to pander to the surgeons and preserve the sanity of their staff, made up a card for each surgeon and his individual operations. A general surgeon might have ten cards—one for his laparoscopic cholecystectomy, one for his bowel resection, one for his herniorrhaphy, etc. This gave the poor scrub nurse some degree of protection from the wrath of God when the demanded instrument was not immediately on hand. Melissa knew how the conversation went:
“I’ll need a thirty-degree scope for this part.”
“We’ll get you one in a minute, Doctor. We just have to run down the hall and get it from Central.”
“What! You don’t have it in the room? Damn it! I always use a thirty-degree scope. That’s gotta be on my card. I never have this problem at Poly.”
“Let me see, Doctor. Sorry, it’s not on your card. Would you like us to add that?”
“Yes of course, damn it! I don’t ever want to have to wait for that again. I could’ve sworn I’ve told you to add that before.”
She shook her head and wondered what had led her to this tough job. She remembered a time when she had had different plans for her life. As a young woman, newly graduated from nursing school, she had envisioned herself married with children someday, but the proper relationship never materialized for reasons she cared not to examine too closely. She knew she was no beauty, but it was more than this. Although she continued to date sporadically, deep down she knew she was not marriage material. She was so set in her ways that she couldn’t imagine giving up her relaxed, if somewhat dull, free, if somewhat lonely, lifestyle for some man. Or more correctly she believed, for some man who would be interested in her. She had long since given up on the idea, and now appreciated the freedom of no children or husband. Melissa’s life was reasonably simple, and she was reasonably content with it, although she might have defined content as resigned.
She realized what gave her life meaning was her job. At work, she could put her lonely existence of making rent and cooking meals for one on hold and participate first hand in real-life drama more exciting than any of the soaps she watched. Although many of the physicians, especially surgeons, fell into the love-to-hate category, she would never characterize them as boring. Flamboyant, rude, obnoxious, egomaniacs, prima donnas, greedy maybe, but not boring. On some deeper level, Melissa was vaguely aware that she came to work each day not solely for a paycheck, but to fill a void in her life.
Halfway through her suture count, she noticed she was missing some 3-0 Vicryl on a P-3 cutting needle. She knew Dr. Alfonse was a stickler about these things and would whine unmercifully if she didn’t have it. She started across the hall toward OR#1 where a large supply cabinet of suture material was located. Halfway across the hall, she noticed that the lights were out in OR#1. She didn’t give it much thought, as it wasn’t that unusual. She simply assumed they must’ve broken for lunch and turned the lights off when they left.
As she approached the door, she stopped and hesitated a moment. Through the small window in the heavy wooden door, some motion caught her eye. She thought she could make out a shadowy figure at the opposite end of the room where the anesthesia equipment was. The shape seemed to be moving quickly towards the other door at the far end of the room. Strange, she thought, that someone would be in there working in the dark.
She shook her head briefly to dispel the growing fear, pushed the door open, and entered the room. As she turned and groped for the light switch, she distinctly heard the creaking of the far door as it closed. The lights blazed on and bathed the room in bright white, hospital-approved light. The room was empty.
Melissa walked over to the suture cabinet, opened the doors and retrieved her missing suture. She had the unmistakable sensation that someone was watching her through the window in the far door. The window shade was pulled down, so she couldn’t see, but she was convinced someone was on the other side. It gave her an acute condition of “cutis anserina” or goose bumps. She considered for a moment walking over and opening the door, but she couldn’t summon the proper courage. All she could manage was a long stare. Soon she turned around and rapidly exited the room with her precious suture in hand.
CHAPTER FIFTEEN
Doug hated Mondays, especially those following a call weekend. Only halfway through the day and he already felt bushed. He summoned some additional energy and went to meet his noontime patient. There were seven pati
ents awaiting surgery crammed into the small holding area. The scene frequently reminded Doug of a busy stockyard where the patients were the cattle. He squeezed in between two of the litters to get to his patient. Doug extended his hand to the big man lying on the litter in front of him.
“Mr. Lehman, Hi I’m Doctor Landry. I’ll be helping you go off to sleep today, so we can fix your hernia.”
“Hello, Doctor Landry. Nice to meet you.” Bob Lehman grasped Doug’s hand and pumped his arm hard with a grip somewhere between firm and crushing.
“How are you doing today?” Doug asked, extricating his hand quickly to avoid injury.
“Just fine,” Mr. Lehman replied. “That shot really helped me relax. I’m kinda hungry, though.”
Doug glanced at his watch—12:05 p.m. “Yeah, I agree—that’s the worst part. So, nothing to eat or drink after midnight, right?”
“Not a thing. And let me tell you, just between you and me.” Mr. Lehman lowered his voice conspiratorially and Doug leaned closer. “I don’t miss many meals.” Mr. Lehman patted his ample midsection and grinned. “I’d settle for a cup of coffee right now. It doesn’t help when they wheel you right past that coffee machine over there.” He pointed across the hallway to the surgeon’s lounge. “Smells great.”
“Yeah, pretty cruel, I know. But you want your surgeon to be awake, right?” Doug paused and glanced at Mr. Lehman’s chart. The only thing that really stood out in his history was his recent bypass procedure. Doug hoped Mr. Lehman’s heart was in as good shape as the rest of him seemed to be. “I’ve read through your chart and everything seems to be in order. Any questions for me?”
“No, let’s get it over with.”
“Left-sided hernia, correct?” Doug asked.
“Right—I mean yes, left.”
Both men chuckled, and Doug wheeled the litter down the hall toward OR#1. Doug instinctively liked the big man although he knew it was a mistake to become too chummy. Always better to keep the relationship professional.
Once inside the room, Mr. Lehman transferred himself from the litter to the OR table with help from the circulating nurse, Sue Hoffman. Doug was impressed that he moved so adroitly for such a big man.
“Just when I got that one warmed up you make me move to this cold bed,” Mr. Lehman complained, although he had a smile on his face. “Not very comfortable either.”
“I’ll get you a warm blanket in a minute,” said Sue Hoffman. “First, we must put this strap on so you don’t fall off this narrow table.” She snugged a six-inch-wide leather strap that meant business around Mr. Lehman’s upper thighs, effectively fixing him to the table. Doug often wondered what patients must think of this strap; it seemed to be a direct descendant from the days of the Inquisition.
“Bed’s kinda small,” Bob Lehman commented as he looked around the room.
“Yep,” Sue said, placing the blanket over him. “Not designed for comfort, are they?”
“I’m gonna be hooking you up to some monitors here, Mr. Lehman,” murmured Doug as he fell into his pre-induction monologue. “Just routine.” He had long ago hit upon what he considered the best combination of phrases to help inform and relax the patient. He knew very well that this was a particularly stressful time for most patients, pre-op medication notwithstanding. He remembered being in this position himself several years ago and literally shaking as he climbed onto the OR table. He also knew his monologue helped to relax himself as well and couldn’t help but notice that he felt strangely on edge.
“I need your right arm out here.” He ripped Velcro and wrapped a blood pressure cuff around Mr. Lehman’s arm, hoping it would fit. “This is a blood pressure cuff. It’s going to pump up and squeeze your arm. It’ll let go in a minute.” He activated the automatic blood pressure machine. “These are sticky EKG patches, so we can monitor your heart.” He placed the first two. “And this last patch goes on your left side, and it’s the coldest of all.”
“Yikes,” said Mr. Lehman. “First you warm me with the blanket, and then you freeze me.”
“Now put your left arm out to this side. I have a little clip that goes on your finger and tells me how well you’re breathing.” Doug placed the pulse oximeter finger sensor.
“It feels like I’m being crucified,” Mr. Lehman remarked, wiggling his outstretched arms.
“Well, it is a Catholic hospital, Bob,” Doug said with mock seriousness, then added quickly, “Just kidding.”
“Thank God it’s not Good Friday,” Mr. Lehman said and laughed.
“Yeah, right,” Doug said as he quickly glanced at the monitors to get some baseline numbers. BP was 145/90, pulse was 78, and O2 sat was 96% on room air. The EKG trace showed normal sinus rhythm. Everything looked good.
“I’m going to give you some medicine to help you relax while we get you set up here.” Doug administered two cc’s of Fentanyl, a potent narcotic used to blunt the patient’s response to pain. He couldn’t help but think of Mike; Fentanyl was the same drug Mike was abusing. He had a vision of Mike sitting in a bathroom stall injecting himself. He forced himself back to Mr. Lehman. “Here’s some oxygen I want you to breathe.” He placed the mask, which was hooked up by plastic hoses to his anesthesia machine, on Mr. Lehman’s face. Doug dialed the oxygen flowmeter to five liters-per-minute. Doug watched the pulse oximeter reading rise from 96% to 100% as Mr. Lehman’s lungs filled with 100% oxygen. “Are you feeling any of that medicine yet?” Doug asked.
“Yes, I believe I am,” came Mr. Lehman’s muffled response from under the mask.
“OK, now it’s time to pick out a pleasant dream. You’ll be going off to sleep in about a minute.”
“OK, Doc. I’m on the beach in Bermuda,” Mr. Lehman said smiling. “On my honeymoon.”
Doug thought of Aruba and his own honeymoon. He and Laura had been so happy. Where in God’s name had they gone wrong? Just yesterday, Laura had tried to make up to him. He hadn’t realized it at the time; he had been too busy projecting coldness. By the time he figured it out, the fragile moment had passed. Perhaps his encounter with Jenny had blinded him to Laura’s intentions?
Mr. Lehman’s voice brought him back to the present. “I’m in your hands, Doc.”
Doug hated it when they reminded him of that. He turned around to get the necessary induction drugs. About twelve syringes filled with the basic anesthetic meds of his trade lay at the ready on top of his anesthesia cart. He reflected briefly on the fact that here before him was a deadly arsenal of drugs. Each syringe was potentially lethal if given in the wrong amount, wrong combination, or wrong order.
Doug shook his head to break this destructive line of thought and hooked the Diprivan syringe to the IV set and injected the entire contents. “OK. Here we go. You’re going to drift off to sleep in about thirty seconds.”
All twenty cc’s of the thick, white emulsion snaked through the IV tubing toward Mr. Lehman’s hand, where it buried itself in a vein. Doug could feel his own heartbeat quicken and his senses snap into focus as he pushed the Diprivan. Whenever he induced a patient, he was keenly aware of taking several irreversible steps—the first being the administration of the induction agent.
Very quickly Mr. Lehman’s jaw sagged, his eyes closed, and he stopped breathing. Doug checked for the absence of a lid reflex by gently touching his eyelids to assure himself that Mr. Lehman was unconscious. He then grasped the mask with his left hand, tightly applied it to Mr. Lehman’s face to effect a seal, and squeezed the breathing bag on the anesthesia machine. He gave Mr. Lehman a couple of quick breaths by forcing air into his lungs. After checking to make sure he could ventilate his patient, Doug moved on to the next irreversible step—this one bigger than the last.
He injected 160 milligrams of Succinylcholine, a muscle relaxant that temporarily produces a muscular paralysis necessary for intubation. A strange wave of muscle rippling traveled through Mr. Lehman’s body as the Succinylcholine exerted its effect and rendered his muscles completely flaccid.
Doug took his laryngoscope, a barbaric-looking metal device with a bright light on one end, in his left hand and opened Mr. Lehman’s mouth with his right. He slid the laryngoscope blade in and hunted for the glottis, which is the opening to the trachea. The laryngoscopy triggered a strong déjà vu. Doug imagined he could feel Jenny pressed up against him, and he could even smell her perfume. He suppressed the memory angrily and glanced around to see if anyone had noticed his hesitation. Sue was busy filling out her paperwork, and the scrub nurse was counting her instruments.
He refocused on Mr. Lehman’s vocal cords, which were asleep on the job, paralyzed by the Succinylcholine. With his right hand, Doug carefully inserted the endotracheal tube through the opening between the vocal cords and pushed it several inches down into the trachea. He removed the laryngoscope blade from Mr. Lehman’s mouth, inflated the cuff at the end of the endo tube, and hooked it up to his breathing circuit. As he squeezed the bag, Doug watched Mr. Lehman’s chest rise and fall. He quickly listened to both sides of Mr. Lehman’s chest with his stethoscope to check for equal breath sounds. Hearing good sounds bilaterally, Doug flipped on the ventilator and dialed in two-percent Isoflurane gas and some nitrous oxide. This would keep Mr. Lehman asleep as the Diprivan wore off.
Doug barely had time to tape the endotracheal tube in place before all hell broke loose. Doug heard the EKG monitor alarm sing out first, and he snapped his head to look at it.
“V-tach! Shit!” he mumbled to himself. “Where the hell did that come from?” He paused for an instant and then said loudly, “Sue, get some help in here stat and bring the crash cart! Got trouble!”
Doug rarely called for help. He had confidence in his abilities to solve most problems, but he recognized true emergencies when he saw them and knew calling for help early was sometimes key; the first five minutes of a crisis were critical. The malpractice records were replete with stories of bad outcomes related to delayed diagnosis and treatment of emergency situations.
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