Charlatans

by Robin Cook

  “We have one hell of an emergency,” Ava blurted, confirming Noah’s impression. “The patient aspirated a ton of gastric contents and arrested. His bronchi are seriously blocked. He’s not getting enough oxygen and has already arrested once.”

  Noah’s eyes darted from Ava and the other two anesthesiologists to Mason and Andrews and then down at the patient. The patient’s color was getting worse by the second. “There’s no time for bronchoscopy,” Noah snapped. By reflex, his intuitive, can-do surgical personality hijacked his mind. Although he was a mere resident in the presence of a celebrated attending surgeon on a private case, he took control. The first order of business was to sound another alarm even before another cardiac arrest occurred, which he guessed was imminent. Turning and looking through the window toward the main desk and knowing that he could be heard if he made enough of a commotion, he shouted mayday three times followed by: “We need a cardiac surgeon, a perfusionist, and a thoracotomy setup immediately!” Then, with no hesitation whatsoever, he grabbed scissors directly off the sterile instrument tray with a bare hand and proceeded to cut through Bruce’s gown that was bunched up around his neck. He threw the scissors to the side. “Heparinize the patient while there is still a heartbeat!” Noah shouted to the anesthesiologists. “We have to get him on cardiopulmonary bypass.” Still without sterile gloves, as he didn’t want to take the time to put them on, he proceeded to prep Bruce’s chest with antiseptic, frantically sloshing the dark fluid over a wide area and onto the floor.

  Ava and the two other anesthesiologists hesitated for a moment, then fell to work. It was clear to them that Noah was right. The only chance of saving the patient was to get him on the “pump.” More than anything else, he needed oxygen, and he needed it now, since his oxygen saturation was below 40 percent and falling. The bronchoscopy would have to wait.

  Moments later Dawn rushed back into the room along with another nurse carrying the thoracotomy setup and Peter Rangeley, a perfusionist, who would run the pump. Luckily, in this modern hybrid operating room, the equipment was readily available on one of the utility booms suspended from the ceiling. It was up to Peter Rangeley to prime the system with a crystalloid solution and be sure all the air was expunged from the arterial lines.

  Once Noah had the thoracotomy setup available to him after it had been opened by Betsy, he wasted no time, even though a cardiac surgeon had yet to arrive. Still without gloves, Noah took a scalpel from Betsy and made a vertical incision down Bruce’s sternum, cutting directly to the bone to save time. With the blood pressure as low as it was, there was little bleeding. Noah then took the pneumatic sternum saw and proceeded to cut through the sternum from top to bottom. Bits of tissue and blood spattered his chest. As he got close to finishing with the noisy saw, the cardiac alarm went off.

  “He’s in ventricular fibrillation,” Ava shouted.

  “The cardioplegia solution will take care of the fibrillation,” Noah yelled back. “Since he is not breathing, we can’t take the time to defibrillate.” Then, as Noah put in the sternal retractor and began cranking its blades apart, he shouted up at the PA system: “Have you found us a cardiac surgeon?”

  “I’m not sure he is completely heparinized with his heart fibrillating,” Ava said.

  “Dr. Stevens is on his way,” a voice answered over the PA.

  “Tell him not to bother scrubbing or it will be too late,” Noah yelled back. “I’m in the thorax and looking at the heart.” It had taken him less than two minutes to open the chest. The heart was quivering in uncoordinated fibrillation. “Get me some cold saline, Dawn! That might take care of the fibrillation until the pump is ready. How’s the pump prep coming, Peter?” Noah reached into the chest with his bare hand and began giving open cardiac massage by alternately squeezing and releasing the slippery organ. He thought it was worth trying to take advantage of what oxygen might still be available in the blood. Brain cells were exquisitely sensitive to a lack of oxygen.

  “I’m almost ready,” Peter said. He and a colleague had been working furiously to prime and ready the heart lung machine. Both knew time was extremely critical, and they were trying to do in minutes what normally took an hour.

  “You heard me about the heparin?” Ava asked.

  “I did, but there’s nothing we can do about it,” Noah shot back. “We’ll hope for the best.”

  Dawn reappeared with a liter-size bottle of cold, sterile saline. Noah advised her to go ahead and pour it over the heart while he was massaging. Gingerly, she started.

  “More!” Noah urged. “The faster the heart cools, the sooner it will stop fibrillating.”

  Dawn poured faster. Pouring cold saline over an exposed heart was a new experience for her, even though she had been an OR nurse for almost twenty years.

  “It’s working,” Noah said. He didn’t have to look at the ECG. He could feel the fibrillation abate.

  The door burst open and Dr. Adam Stevens, a cardiac surgeon, appeared. He stopped short, momentarily transfixed by the scene of a patient exposed to the waist with his chest flayed open while the circulating nurse was pouring fluid into the wound and a gloveless resident was massaging the heart. Betsy stepped off the stool she was standing on and held out a gown for Stevens, which he thrust his hands into while asking Noah for an explanation. Noah and Ava gave him a quick rundown as Betsy helped Stevens into sterile gloves.

  “Okay,” Stevens said. “Let’s get him on the pump. Are you ready, Peter?”

  “I think so,” Peter responded.

  “Thanks for coming in, Adam,” Mason said. “I’m sorry Anesthesia has created this mess. Unfortunately, I am needed elsewhere; otherwise, I’d stay and help. Dr. Andrews is here and can lend a hand. Good luck!” With a final glare at Ava, he left the room. Only Andrews responded with a wave. Everyone else was too busy, but they had heard him.

  “Hold up on the massage,” Stevens said to Noah. “It’s most likely futile, considering the oxygen saturation is so low. By the way: the cold saline was a good idea, not only to stop the fibrillation but also to wash out the wound. Now get a gown and some gloves on! I’ll put out some sterile drapes.”

  A moment later, Noah was back at the opposite side of the table, joining Andrews. By then Stevens and Andrews had the two arterial cannulas, which included one for the heart, and one venous cannula in the operative field, and Stevens was beginning to implant them. He started with the arterial ones first. One went into the aorta, after which the aorta was clamped, and the second one went into the heart for the cardioplegia fluid that would keep the heart from beating and lower its need for oxygen. The final venous cannula went into the major vein leading into the heart. A few minutes later, when Bruce was fully on the heart lung machine, the blood oxygenation and blood pressure rose quickly. “I want him cooled to at least thirty-two degrees centigrade,” Stevens told Peter. Peter responded that the patient would soon be at the target, as he was already at 35 degrees and the heart at 4 degrees.

  “Let us know when we can bronchoscope him,” Ava asked Stevens. By then the two anesthesiologists who’d brought in the cardiac defibrillator had left, convinced Ava had things as much under control as possible. In their place was a pulmonologist, or lung specialist, by the name of Dr. Carl White, who had come in to do the bronchoscopy and clean out the bronchial tubes.

  “Go ahead and bronch him,” Stevens said. “The sooner, the better. It’s to his advantage to be on the pump as little as possible.”

  The bronchoscopy went well. It was quickly determined that both bronchi had been almost totally occluded with a bolus of undigested bread, which was easily removed under direct visualization. When the blockage was gone, Ava was able to inflate and deflate the lungs with ease. “We’re good,” she said. She was pleased. The vital signs were now stable, as was the level of acid in the blood, which she had corrected earlier. She had also typed and cross-matched a significant amount of blood, which was
on hand if needed, but she doubted they would need it, as there had been very little blood loss.

  The mood in the OR, which had been tense, relaxed as Stevens and Noah prepared to take Bruce off the heart-lung machine after being on it for only a little more than ten minutes. At that point Ava had the patient on the ventilator with 100 percent oxygen, and everything appeared excellent, including electrolytes, acid-base balance, and vital signs. The first order of business was to warm the heart and discontinue the solution that kept the heart from beating. This was done by allowing blood at normal body temperature to flow through the heart. Next Stevens gradually undid the clamp across the aorta, which increased the blood to the coronary arteries, helping to warm the heart. At this point, Stevens fully expected the heart to begin beating, as it did in most bypass cases. Unfortunately, it didn’t happen. Undaunted, Stevens tried a series of shocks to the flaccid heart, but none worked. He then tried an internal pacemaker, but even that was unsuccessful.

  “What do you think it is?” Noah questioned. He could sense Stevens’s dismay.

  “I don’t know,” Stevens said. “I’ve never had a heart that wouldn’t even respond to a pacemaker after it was warmed up. It is not a good sign, to say the least.”

  “There was only a few minutes between the heparin being given and the heart going into fibrillation,” Noah said. “So he might not have been completely anticoagulated. Could that be the problem?”

  “I guess it is possible,” Stevens said. Then, to Ava, he added, “Let’s check the electrolytes again!” He was feeling a sense of mounting exasperation. He had tried all the tricks he knew, including having Ava give various heart stimulants and even lidocaine intravenously.

  Ava drew another blood sample and sent it off.

  “I don’t like this,” Stevens said after another ten minutes had passed. “I’ve got a bad feeling here. The heart has got to be in super-bad shape. How long did he fibrillate, Noah, when you were opening him up?”

  “I believe just minutes. The cold saline stopped it almost immediately.”

  Stevens looked over at Ava. “How about the first episode of fibrillation: How long was that?”

  “I’d guess two or three minutes,” Ava said. “That was how long it took for the crash cart to get in here.” She glanced down at the anesthesia record to be sure. “Actually, it was less than two minutes. It wasn’t long, because the cardioversion occurred with the first shock.”

  “That’s not a lot of time in both instances,” Stevens said. “I’m at a loss. Somehow the heart had to have been significantly damaged not to even respond to a pacemaker. We are running out of options. Also, I’ve got to get going on my own case.”

  No one responded to Stevens’s last comment. Everyone knew what he was implying: Maybe it was time to give up. The patient could not be kept on bypass continuously.

  The PA system came to life. “I’ve got the electrolyte results,” a female voice said. She then read them off. They were all relatively normal, without change from the first sample.

  “Well, it’s not the electrolytes,” Stevens said. “All right. Time for a few more tries.”

  Over the next few hours Stevens retried all the tricks he knew. There was never the slightest response. “I have never had a post-bypass heart not respond to a pacemaker like this. We haven’t gotten so much as a blip on the ECG.”

  “What about a transplant?” Noah suggested. “He’s a relatively young and healthy guy. We could put him on extracorporeal membrane oxygenation to tide him over.”

  “ECMO is not for long-term care,” Stevens said. “The reality is that there are three thousand people waiting for a heart on any given day. The average wait for a heart is four months. It varies according to blood type. What’s his blood type, Ava?”

  “B negative,” Ava said.

  “There you go,” Stevens said. “That alone limits the chances of a decent match. Also, since this heroic effort was started without sterility, the chances are better than even he’d have a post-op infection. We’ve given it our best shot, but I’m afraid it is time to face the facts. Turn off the pump, Peter! We’re done here.”

  Stevens stepped back from the table and snapped off his gloves and peeled off his surgical gown. “Thank you, everybody. It’s been fun.” He sighed in response to his own sarcasm, gave a little wave, and left the room.

  For a moment, no one moved. The only sounds came from the pulse-oximeter alarm and the ventilator.

  “Well, I guess that’s it,” Peter said. He turned off the heart-lung machine per Dr. Stevens’s order and started to clean up.

  Ava followed suit, switching off the ventilator and detaching the monitoring.

  Noah stayed where he was, looking down at the flaccid heart that had failed everyone, but mostly the patient. Although he didn’t question Stevens’s decision that it was time to quit, Noah wished there had been something else to try in hopes of a different outcome for the patient’s benefit and Noah’s, too. Noah’s intuition was telling him loud and clear that there was a very good chance this unfortunate case was going to be real trouble once he became the “super chief” surgical resident in less than a week. As super chief, it was going to fall to him to investigate and then present this death at the bimonthly Morbidity and Mortality Conference, where it was sure to become a hotly debated episode. From what Noah had already gleaned from Dr. London, there was clear fault on the part of the patient for failing to divulge having eaten a full breakfast despite orders not to do so, and for Dr. William Mason for failing to communicate key information, due at least partly to his running two other concurrent surgical cases.

  From Noah’s perspective, what made the situation so worrisome were two unfortunate realities. The first was that “Wild Bill” was known to be a remarkably narcissistic man, fiercely protective of his reputation, and notoriously vindictive. Dr. Mason wasn’t going to be happy to have his role in this unfortunate case made public and would be looking for scapegoats, which might include Noah. Second, Dr. Mason was one of the few members of the surgical hierarchy who wasn’t impressed with Noah, and Mason was the only one who overtly disliked him. Dr. Mason had said as much, and as an associate director of the surgical residency program had already tried to get Noah fired a year ago, after they’d had a serious run-in.

  Noah glanced over at Dr. London. She returned his gaze. What he could see of her usually tanned face was pale; her eyes were wide and staring. To Noah, she looked as shell-shocked as he felt. Unexpected deaths were hard to bear, particularly when they involved a previously healthy individual undergoing simple elective surgery.

  “I’m sorry,” Noah said, unsure of what he was apologizing for but feeling the need to say something.

  “It was a gallant effort,” Dr. London said. “Thank you for trying. It is a tragedy that shouldn’t have happened.”

  Noah nodded but didn’t respond verbally. He then followed Stevens out of the operating room.

  BOOK 1

  1

  SATURDAY, JULY 1, 4:45 A.M.

  The smartphone alarm went off at 4:45 A.M. in Noah Rothauser’s small and sparse third-floor one-bedroom apartment on Revere Street in Boston’s Beacon Hill neighborhood. As a surgical resident at the Boston Memorial Hospital, it was the time Noah had been waking up just about every day except Sunday for five years. In the winter, it was pitch black and cold, since the building’s heat didn’t kick on until seven. At least now, in the summer, it was a bit easier to climb out of the bed because it was light in the room and a pleasant temperature, thanks to a noisy air conditioner in one of the rear-facing windows.

  Stretching his sleepy muscles, Noah padded into the tiny bathroom buck naked. There had been a time when he wore pajamas as he had done as a child. But the habit had been abandoned when he came to appreciate that pajamas were just another piece of apparel he had to launder, and he wasn’t fond of taking the time to do laundry, as it required
walking a block up the street to a Laundromat and then waiting around. It was the waiting he couldn’t abide. As a totally dedicated surgical resident, Noah chose to have little time for anything else, even personal necessities.

  He eyed himself in the mirror, recognizing that he looked a little worse for wear. The evening before, he’d had a couple drinks, which was rare for him. He ran his fingers up the sides of his face to decide if he could get away without shaving until after his first surgical case. Often he shaved in the surgical locker room to allow him to get to the hospital that much earlier. But then he remembered today wasn’t a usual day, so there was no reason to hurry. Not only was it Saturday, with its usually light surgery schedule, but it was also July 1, the first day of the hospital year, called the Change Day, meaning a whole new batch of residents were beginning their training and the existing residents were advancing up the training ladder to the next level. For fifth-year residents, also considered chief residents, it was a different story. They were finished their training and were off to begin the next stage of their respective careers—everybody except Noah. By a vote of the surgical faculty, Noah had been proud to be selected to do a final year as the super chief resident who would run the Boston Memorial Hospital surgical department on a daily basis like a traffic cop at a very busy intersection. In most other surgical residency programs, a super chief status rotated among the fifth-year chief residents. BMH was different. The super chief was an added year. With the help of a full-time residency program manager, Marjorie O’Connor, and two coordinators under her, it was now Noah’s job to schedule all the residents’ rotations in the various surgical specialties, their operating room responsibilities, their simulation center sessions, and their on-call duties. On top of that, he was responsible for work rounds, chief-of-service rounds, and all the various weekly, biweekly, and monthly conferences, meetings, and academic lectures that made up the academic part of the surgical department’s program. As a kind of mother hen, he also had to make sure that all the residents were appropriately fulfilling their clinical responsibilities, dutifully attending all the teaching venues, and handling the pressures of the job.