Deadly Errors (5 page)

“Well then—”

“I’ll do it,” Tyler interrupted. “Just get the tray.”

Soon as the words flew from his mouth a feeling of panic shouldered aside his confident reply. Unlike the well-lit operating room where a few anesthesiologists allowed him to practice this skill, this area had poor lighting and he was wedged awkwardly between the scanner and the wall.

“All done.” The CT tech pulled the white sheet over Larry’s exposed genitals. Pale yellow urine flowed down the plastic tube toward the collection bag.

The nurse gently pushed Tyler aside as she wheeled a stretcher next to the scanner. She asked the group, “Ready to transfer him onto the stretcher?”

Using a plastic transfer board to bridge the gap between the scanner gantry and stretcher, they used the draw sheet under Larry to pull him onto the stretcher.

A moment later, the respiratory tech rushed in carrying a tray wrapped in a blue surgical sheet sealed with strips of autoclave-sensitive tape. She asked Tyler, “Where do you want this?”

Tyler sucked a deep breath, glanced around and nodded at a stainless steel Mayo stand against the wall. “Over there.”

She placed the package on the stand and expertly unwrapped it, keeping the contents sterile.

Just then Childs’s respirations stopped.

“Shit.” Tyler’s gut knotted.

The respiratory therapist shot him a nervous look. “You sure you can do this? I could put some O-2 on him until anesthesia gets here.” She didn’t sound convinced this was such a good solution.

Tyler glanced at the opened tray and back to Larry Childs. “We can’t wait.”

W
ITH DELIBERATELY UNHURRIED movements Tyler snapped a medium curved blade onto the laryngoscope handle.
Start to rush, you make mistakes
, he reminded himself. After checking to see if the light at the end of the blade worked, he pulled the chrome Mayo stand to the head of the stretcher. He told the respiratory tech who was struggling to keep Larry’s lungs full of oxygen by using a face mask and an AMBU bag, “Open me a seven point five.” Then to the nurse, “Suction ready?”

“Yes.”

He sucked a deep breath, trying to quell the anxiety making his hand tremble.
One shot’s all you get, pal … Aggravate the vocal cords into spasm and the resulting lack of oxygen will cause Larry’s brain to crush the brain stem.

He lifted Larry’s chin, tilting the entire head back toward him and opened the mouth. Laryngoscope in left hand, he slipped the silver blade into the mouth and over the tongue, inserting almost all the curved part before pulling straight up. The pale pink larynx popped into view, both vocal cords glistening in the light. Holding the scope steady, never losing sight of the cords, he held out his right hand. “Tube.”

And felt the smooth plastic contact his fingers.

Gently he worked the endotracheal tube over the steel blade and through the opened vocal cords. “Got it.” A paradoxical adrenaline rush hit, making him giddy.

Stethoscope to her ears, the short respiratory tech listened first to Larry’s left lung and then to his right. “Airway sounds good,” she said with palpable relief.

Tyler exhaled the deep breath trapped in his lungs since inserting the laryngoscope. He placed a bite block between Larry’s jaws and taped the tube into place.

As he stripped off his gloves the nurse asked, “His mother’s in his room. You want to talk with her now, or should I tell her you’ll be out later?” Her way of dumping responsibility of breaking the bad news on him rather than the ED physician. Nurses tend to protect their own, he knew. In the ED he was the outsider.

He glanced at the respiratory tech. She nodded toward the door. “I have him under control until anesthesia arrives.”

“Which room?”

“Trauma Six.”

Tyler sucked a deep breath, stepped out of the cramped scanner room, and stood in the hall wrestling with an explanation Larry’s mother might understand.

Radiation necrosis. That has to be it.

He considered this diagnosis more carefully. Four months ago Larry Childs became subject number twelve in a multi-center clinical trial evaluating highly focused radiation as an alternative to traditional surgery to obliterate seizure triggering brain tissue. The one-shot treatment came from the Z-Blade, a third-generation radiation device touted as state of the art.

A bolt of gut-churning anxiety hit.
Did I make a mistake? Did I do this to Larry?

No
, he reminded himself,
the system doesn’t allow only one person to determine treatment.
He mentally ticked off the steps required. He, Tyler, provided the tissue targeting volume. Then Nick Barber—the study’s Principle Investigator at the University of Pittsburgh—calculated and then electronically transferred the radiation dosage back to Larry Childs’s MMC chart. Only after Tyler confirmed this dose had the Z-Blade accepted it. Even then, the computer was programmed to never accept a dose outside a reasonable range without a cumbersome override entry. This technique was supposed to provide bulletproof protection from such errors.

No, he assured himself,
it’s something other than radiation necrosis that’s swelling Larry’s brain.

Despite reassuring himself, he couldn’t shake the nausea twisting his stomach.

F
ACE ETCHED WITH deep stress lines, Larry’s mother perched rigidly on the edge of a molded plastic chair, right hand clutching a magazine rolled into a tight baton. She glanced up as he approached, pessimistic fear immediately replacing the glint of recognition that flashed across her eyes. Tears followed in anticipation of Tyler’s words.

“Is he going to be all right?” she whispered tentatively.

He hedged. “I don’t know yet Mrs. Childs, I need more information.” He pulled a burnt-orange plastic chair next to hers, reached out, and placed a reassuring hand on her arm. “All I know is the left side of Larry’s brain is swollen and pressing on those deep areas that control his consciousness.”

“It’s the radiation, isn’t it.” Making it a statement, the fear in her eyes changing to self-incriminating anger. “Lord! I knew he shouldn’t have that radiation.”

Tyler shook his head. “Whoa, let’s not get ahead of ourselves, Mrs. Childs. We don’t know that.” He caught himself from punctuating the sentence with “yet.”

The corners of her mouth turned south in an expression that rippled a taste of guilt down Tyler’s throat for not confirming her suspicion. He swallowed. But why speculate on a diagnosis now if not completely certain they weren’t dealing with something totally off the wall? Something like a Herpes infection, for instance.

“Ma’am, I need to take Larry to surgery to remove that temporal lobe, the one causing the seizures, to relieve the pressure off his brainstem. And I need to do this as soon as I can get an operating room geared up.”

“He’s going to die, isn’t he.”

He swallowed again. “Not if I can help it.”

Her pessimistic eyes said she didn’t believe he could.

“I’ll be right back with a consent form, Mrs. Childs. I’ll need you to sign it.”

“T
EEING UP A case this late in the day?”

Tyler pulled on his scrub shirt. He recognized Bill Leung’s tenor voice without turning. Bill, a senior partner in their group, occupied the locker flanking his.

“Long as you’re here, might as well give me your opinion on something.” Tyler cinched the pulls on the scrub pants then tied a bow, which he tucked inside the pants—a long-ingrained habit to prevent dangling ties from contaminating a sterile field. Finished dressing, Tyler reached into the narrow locker and came away with a white and brown MRI envelope.

“Here,” he said, handing it to his partner. At 57 Bill still looked like a Marine drill sergeant. Lanky, not an ounce of extra fat.
From running every day
, Tyler thought.
Compulsive about it.

Also clad in green scrubs, Bill held up a rectangular oak box the size of a small jewelry case. Loupes. Magnifying eyeglasses worn by most neurosurgeons. “Let me get rid of these first.” His partner spun the combination lock to his locker. A triangle of sweat darkened the midline of Bill’s scrub shirt by at least two shades.

“Tough case?”

Uttering a sigh weighted down with cynical fatigue, the veteran surgeon opened the gray metal door. “Aren’t they all?” After setting the mitered wood box on the single shelf he turned, hand extended. “Let me see those pictures.”

Tyler passed over the envelope and followed Bill into the adjoining tiled shower/toilet area. Without a backlit viewbox available the best place to examine the images would be against one of the frosted windows. Bill quickly sorted the films, zeroing in on the most telling. With his left hand pinning it flat against the window, he slipped on a pair of half-height reading glasses and leaned forward, chin up, to examine the images.

Bill gave a slow whistle with a headshake. Removing the film from the window, he turned expectant eyes on Tyler. “Herpes?”

“That your first choice?”

Bill peered over the top of his tortoise shell glasses at Tyler before stealing another glance at the film. “Could be anything, I guess … Glioblastoma, infection, you name it. All I see is a shit-load of edema …” tapping the film with an index finger, “no well-defined mass … yeah, herpes is the first thing comes to mind. Why? You going to tell me it’s CPC material?” Clinical Pathologic Correlation is a weekly conference at which difficult to diagnose cases are discussed.

Tyler recited Larry Childs’s history.

Bill slipped the film back into the envelope. “Well there you go. Seems to me like your patient has a bad case of radiation necrosis.” He paused. “Not that any case of radiation necrosis isn’t bad, mind you, it’s just that this looks
really
bad.” Envelope now intact, he handed it back to Tyler.

“I was afraid you were going to say that.” They headed back to their lockers. Tyler needed to slip on his shoes and grab his own set of loupes before heading for the operating room.

Bill pulled the sweat-stained scrub shirt over his head, balled it up and threw a double pump jumper toward a linen hamper. “Word of advice?”

Tyler watched the shirt miss and fall to a green clump on the floor. Tyler bent down, pulled a pair of air cushioned Nikes from the locker floor, then dropped his butt onto a wood stool. “What?” Tyler suspected he was going to advise not operating and wondered how much of his partner’s surgical conservatism came from wisdom and how much came from plain old grind-it-out fatigue of years in the OR.

“I wouldn’t do anything more than needle biopsy that Mother of All Edema.” Leung was sending him that dead-eye Chinese look Tyler found difficult to evaluate.

“I was planning on taking out his temporal lobe.” He started tying the laces.

Bill slipped off his pants and this time tried a hook shot. Missed again. “That, my friend, is a huge mistake.”

“Why so?” He jerked the knot tight and turned to the other shoe.

Bill’s face turned even more serious. “Kid’s temporal lobe isn’t your biggest problem here. Hell, with that scan the kid’s probably a goner anyway. The problem is you can bet your bippie that family will have some sleezeball lawyer licking his chops before the sun sets. You operate that kid and he’ll have you in the knee-chest position so fast it’ll make your head spin. And he won’t provide you the courtesy of using KY jelly, either.”

Tyler sighed. “Point noted, but that’s the risk we all take when we schedule cases.”

“Sure, but look at it this way. If it’s herpes the biopsy will show it and you can treat him with Acyclover. If not? Like I said, with a scan like that, he’s screwed blue and tattooed anyway. Best to keep as much distance from this tar baby as possible. Hell, even if it
is
herpes he looks like a goner. I just can’t see any upside to operating the kid.”

Loupes and MRI in hand, Tyler kicked the locker door. It slammed shut. He met his partner’s questioning eyes. “Way I see it, if it’s radiation necrosis, there’s nothing I can do to increase or decrease my odds of getting sued. It’s either going to happen or it’s not. But if I don’t take out that kid’s temporal lobe, he’s going to die. It’s that simple.”