“Okay, good,” Ava said. She connected the newly created breathing tube to the anesthesia machine and began respiring the patient with 100 percent oxygen.
Just as the entire team was beginning to feel upbeat, disaster struck. Without warning, the patient’s heart reverted back to fibrillating, causing the cardiac alarm to resound. The oxygen level in the blood that had been rising now reversed course, necessitating a flurry of activity. After a short period of external massage that required one of the residents to climb up and kneel on the operating table, Helen received another shock from the defibrillator.
Once again there were some restrained cheers while everyone watched the cardiac monitor. The fibrillation stopped. But any sense of celebration quickly evaporated when the heart’s normal rhythm didn’t reinstate. Instead, the heart was stubbornly electrically silent, and the cardiac monitor traced a flat, unchanging straight line. Now there was no heartbeat, a situation known as asystole, which was disturbingly reminiscent of Bruce Vincent. Quickly the resident climbed back up onto the OR table to recommence closed-chest massage. At the same time the anesthesia team started various medications in hopes of restoring a heartbeat.
A few moments later, cardiologist Dr. Gerhard Spallek entered the OR, struggling to secure his surgical mask. After hearing the details, he said: “My guess is that we have had what amounts to a major heart attack secondary to the low oxygen levels. It doesn’t bode well, but here’s what we can try.”
Under his direction a few more drugs were used in an attempt to stimulate the heart. Meanwhile, the external cardiac massage was continued, as was the 100 percent oxygen, keeping the blood oxygen levels reasonable. When the additional medication wasn’t successful, Gerhard proceeded to thread an internal pacemaker wire in through the patient’s right internal jugular vein. Even that wasn’t successful to initiate a heartbeat.
“That’s it,” Gerhard declared. “The heart is not responding in the slightest. There’s no doubt it was severely damaged. I’m afraid the patient is gone. I’m sorry I could not be of more help. Thank you for allowing me to participate.” With a respectful half bow, he pulled open the door and left the room.
The resident who had been giving the external cardiac massage climbed down from the operating table.
“This is an outrage,” Dr. Jackson said the moment the door closed behind the cardiologist. Throughout the ordeal he’d been totally silent, standing off to the side with his hands clasped across his chest, watching with growing concern but apparently keeping hope alive that he would be repairing the patient’s damaged leg. “Just so everyone knows, I am going to be talking with Dr. Kumar about this”—he struggled for words—“this disaster. This patient is a thirty-two-year-old healthy mother of four. I’m appalled this could happen here at the BMH. We’re not out in the boonies someplace.”
Noah was sorely tempted to bring up the issue of his inappropriately pressuring the first-year anesthesia resident to begin the case before Ava as the supervisor was in the room, but he held his tongue. He felt it wasn’t the time or place, as the man was already irate and it would serve no purpose other than to inflame the situation.
“In all my experience I have never seen a more difficult patient to intubate,” Ava said with a voice that seriously quavered. Noah understood immediately that she was making an attempt to support Carla, which impressed him because he could tell from getting to know her that she was devastated by the episode herself. Up until the Vincent case she’d never had an operative death. Now she had been involved in two.
“What made it so goddamn hard?” Dr. Jackson spat. “You’re supposed to be professionals at putting in endotracheal tubes.”
“It was a combination,” Ava managed. Her voice broke with emotion, almost anger. She took a deep breath to calm herself.
“It is apparent that her neck is deformed,” Noah said, coming to Ava’s rescue. He didn’t want the conversation to get out of hand. “It is flexed and fixed. And the patient is moderately obese. That contributes. Isn’t that right, Dr. London?”
Ava nodded.
“Well, wasn’t that taken into consideration?” Dr. Jackson snapped, looking directly at Ava. “This is your specialty, for God’s sake.”
“I didn’t know about the neck,” Carla said. From the sound of her voice, she was as anguished as Ava.
“You mean to tell me it wasn’t in the ER resident admitting note?” Dr. Jackson demanded.
“It wasn’t,” Carla managed. “There was nothing about neck problems.”
“Good God!” Dr. Jackson voiced. He turned to Noah. “This morning we hear about a resident who didn’t even do an admitting note. Now we hear about a resident leaving out a mighty important finding that’s indirectly caused this patient’s death. That’s your department, Mr. Super Chief. Sounds like I’ll need to talk to Dr. Hernandez as well as Dr. Kumar.”
“I will certainly look into it,” Noah said. Inwardly, he groaned. At that morning’s M&M he’d barely avoided a personal disaster, and now he was facing another potential one for the next M&M.
“You’d better!” Dr. Jackson barked. He tore off his gloves and threw them to the floor. He did the same with his surgical gown. After that juvenile show of misplaced anger, he left the room.
While Doctors Wilson and Wong gathered up the cardiac-arrest paraphernalia and Dawn disgustedly picked up the discarded gloves and gown, Noah turned to Ava and Carla, particularly looking at Ava. He wanted to say something supportive if not give her a reassuring hug, but he didn’t dare. Instead he merely nodded, hoping to communicate his concern in some nonverbal way. “Sorry,” he said simply. He held her eyes for a moment with his own, but she didn’t react. Then he, too, left the room.
As Noah hurried back to room 18 he thought again of the next M&M, wondering if they were going to be his bane for the entire year. At least on this case he wasn’t going to be harassed by the concurrent-surgery issue, which was a definite plus. On the negative side, he would be dealing with an unleashed Dr. Mason, who normally was an active participant in M&M discussions. Noah knew full well that during the next one, Dr. Mason wouldn’t be constrained as he had been that morning in his role as the involved surgeon. What Noah was already worrying about was Dr. Mason’s reaction to Ava’s being involved in yet another death, because he obviously still blamed Vincent’s on her.
Intent on getting back to OR 18 as soon as possible to apologize and explain his absence in case they hadn’t heard, Noah practically collided with Dr. Mason, who had just emerged from room 15. He was in the process of removing his surgical mask and not looking where he was going. Noah’s heart skipped a beat.
“Ah!” Dr. Mason exclaimed, seeing who he was confronting. “Just the person I wanted to find.”