Deadly Errors (7 page)

“Just asked you what his chances are?”

Tyler straightened up, relieving the cramps in his neck muscles from holding his head in an awkward position for so long. “Depends on the diagnosis. But no matter what, if the rest of this hemisphere looks like the crap I’m pulling out of here, it’s trashed.”

“But assuming it’s radiation necrosis like you suspect …”

Tyler started working again, sucking out gray mushy gunk from low in the lobe, trying to find tissue that wouldn’t crumble away and bleed unnecessarily. He decided to keep going until he could define the dura at the base of the brain. At least this would give him a solid landmark from which to judge any further dissection. The tissue bleeding increased, the small vessels just as rotten as the brain, making them almost impossible to coagulate. This was now a major worry. How the hell to stop the bleeding?

“Radiation necrosis sometimes subsides if you get the initial portion—the site the radiation targeted—totally removed. That’s the reason I’m going after this temporal lobe. If I can remove it, then sit on him with steroids for a couple of days, he might just have a chance.”

“Always the optimist, aren’t you, my friend. Anyway, that’s good to know.”

Tyler turned to the scrub nurse. “Surgicel.” A thin mesh-like material used to help control bleeding.

She handed him a folded towel with half-inch squares of the silver colored mesh. He picked up several squares with forceps and laid them individually over areas of oozing brain surface. Blood seeped through each one without slowing.

Michelle asked, “Did I hear you correctly when you said this poor boy has never had any prior radiation?”

“More Surgicel.” Then, to Michelle, “Look, Shellie can we talk about that later, right now I have a problem. I can’t get any hemostasis.”

“Oh dear.”

A hushed conversation between the scrub and circulating nurses stopped abruptly, leaving the steady piping of the heart monitor and the plodding whoosh of the respirator the only room noises. Both nurses looked at him with alarm. He ignored them.

Tyler covered the oozing area with more squares of Surgicel, then layered this area with several white cotton strips, each about two inches by a half inch, over them. He held these in place with his fingers as a roto-rooter ground away at his stomach lining.
Maybe I should’ve asked for help. Christ, maybe I should’ve listened to Bill.

“Shit,” he muttered. Tightness enclosed his heart. His hands started tingling and he realized he was hyperventilating, his facemask now soggy against his lips.

After thirty seconds he let up the pressure on the cotton strips, hoping they would stick against the Surgicel as a sign of clotting. They didn’t. They fell away as more blood started oozing again from the raw, crumbling brain.

“How much blood we have on hand?” he asked Michelle.

“Didn’t type and cross him, I’m afraid.”

“Oh, great!” Tyler said to the scrub nurse, “Irrigation.”

She handed him a blue rubber bulb, like you would use to baste a turkey. Gently, he squirted sterile saline over the brain surface, washing away the useless Surgicel.

“Load me up again, but this time cut them postage stamp size.” He rolled his neck, working out the kinks. “Sponge.”

Tyler held a sopping wet cotton sponge against the raw edge of the cavity as the scrub nurse cut more squares of the blood-clotting agent.

“Whatcha going to do?” Michelle asked.

He didn’t know, but he sure as hell wasn’t going to say that with both nurses listening. “We’re going to get it controlled.”

“But, how?”

He shot him a look. “Goddamnit, Shellie …”

The scrub nurse held out a folded blue surgical towel, the squares of Surgicel aligned in neat parallel rows. One by one he placed them over the oozing brain. Once the entire lemon-sized cavity was lined this way, he packed it with snugly with cotton sponges, then backed away from the operating table, both nurses avoiding eye contact.

He said, “Five minutes by the clock. Starting now.” He glanced up at the round face clock over the gleaming stainless steel autoclave and decided to give it every second of the five minutes to clot. Not one second less.

Michelle sidled up next to him as close as possible without contaminating his sterile surgical gown and whispered, “Thought about just closing him up and getting the hell out of there?”

Tyler looked at her. “You mean before we get the bleeding stopped?”

“Seems to me like that might not happen. Besides, you plan on staying here all night?”

“Jesus Christ, Michelle, it’d kill him,” he whispered while drilling her a look.

“Seems to me he’s a dead man either way you cut it,” Michelle snipped. “You wouldn’t be the first to bail out on a hopeless case. I’ve seen a few of your esteemed partners fold the tent and load the camel on lesser problems than this one.”

When Tyler didn’t answer she added, “Like the Nike ads used to say … just do it.”

“S
LICK … VERY SLICK. Where did you learn that one?”

Tyler glanced up. Michelle was peering over the drape at him. “Surgery 101. Apply pressure, wait, and try to strike a bargain with God.” He made no attempt to hide the huge relief from his voice. He used saline to irrigate the cavity where the tip of Larry Childs’s temporal lobe had been. He stopped irrigating and waited for the bubbles to clear. The water remained free of blood this time. “Time to play hockey.”

Michelle laughed. “Watch it, Tyler. You’ll ruin your image.”

Tyler held out his hand to the scrub nurse. “Load me up with dural silks and keep them coming as fast as you can.” Then to the anesthesiologist, “What image is that?”

“Doctor Dour. Surgeon Serious. The man who doesn’t joke around in the OR.”

Suture accepted, Tyler began the first stitch.
I haven’t always been like that
, he mused.
It wasn’t like that when I was with Nancy.

T
WENTY MINUTES LATER Tyler leaned over to inspect Larry Childs in the recovery room. The area was populated with only a few stragglers from end-of-the-schedule cases. “He’s not waking up. You given him anything since the OR?” After helping to load Larry Childs onto a recovery room stretcher, he’d ducked into the dressing room to dictate an op note. Now, standing over his patient, he tried again to evoke a response by pinching the skin over his chest. Nothing.

Michelle Lawrence, sitting at a stainless steel counter between two patient bays glanced up from the computer terminal she was typing on. “Give him anything? Heavens no. I ran him the last hour on just nitrous and oxygen.” She began playing with the mask still hanging around her neck.

“Good.” Tyler preferred his patients awake soon as possible after the end of the case so he could examine their brain function. Tyler continued to examine Larry in more detail.

The endotracheal tube was out and the kid was breathing on his own, so at least that much was okay. Tyler gently opened Larry’s eyelids. The left pupil remained dilated, the eye deviated to the left. No worse than pre-op but still a sign of damage to the third cranial nerve—probably from the shift of the temporal lobe before he decompressed it. The right eye also appeared to be the same as pre-op. Tyler rocked Larry’s head side to side. The left eye didn’t move, but the right did. Next, he pulled the cotton tip of a Q-tip into a wisp, which he used to gently brush each cornea. Both eye lids blinked a weak response. Larry’s respirations, however, were Cheyne Stokes. Abnormal, signifying a poor connection between the brainstem and cortex.

“Doctor Mathews?”

The RN assigned to Larry drifted over from her other patient. She wore a blue scrub suit with a gray hospital-issue stethoscope draped around her neck.

“Yes?”

“The family’s been increasingly inquiring about Larry’s condition for the last hour. They seem quite anxious. When can I tell them you’ll be down to talk to them?”

He’d become familiar with the various family members during discussions leading up to Larry’s enrollment in the radiation trial. He didn’t want to deal with Larry’s antagonistic sister right now.

“I’ll call down and talk to them. I don’t want to go face to face with his sister until I have a better idea how soon it’ll be before Larry wakes up.”

She seemed to accept this but wasn’t happy with his plan.

Tyler glanced at the anesthesiologist. “Hey Shellie, you interested in grabbing a bite before the cafeteria closes?”

The anesthesiologist checked her Swiss Army watch. “Sure. I have enough time. There’s a potential C-section cooking upstairs, but if we go now …” She slipped off the stool.

An idea hit. “Hold on a sec. Want to check something first.” He took the stool Michelle just vacated and logged onto the medical record system. He called up Larry Childs’s chart and moused the radiation therapy tab. A smaller window opened. Tyler blinked, moved in for a closer look. He realized a patina of sweat now coated his body in spite of the chill. An urge to vomit battled his self-control.

“Holy shit, Mathews, you okay?” Michelle reached out, grabbed his shoulder to steady him.

A tingling floated over his skin, his equilibrium faltered. He inhaled deeply and planted both palms squarely on the stainless steel counter for support.

He found his mouth too dry to speak so cleared his throat and swallowed. “Ah, can you tell me what the screen says?”

“Which one? The dialog box?”

He nodded, the dizziness starting to clear enough to release one hand from the counter.

A second later Michelle gave a slow whistle. “Oh dear… . Two hundred. That’s—”

Tyler grabbed her arm, whispered, “Hold it ‘till we get down stairs.” With a shaking hand he withdrew a pocket computer from his coat then fumbled with pulling the stylus free. Slowly, deliberately he worked through the screen to where he kept notes on research patients. He scrolled through the record to the entry he’d made when Nick Barber determined Larry Childs’s radiation dose. The number jumped out at him: 10 Gr.

He handed it to Michelle. “Check it out.”

She accepted the computer but kept staring at him. “Hey, you want to lay down or something?”

“Look at it, damnit.”

Michelle handed it back with a nod, her face drained of color. “You’re right. Let’s discuss this downstairs. You up to walking now?”

“I
F THAT ISN’T radiation necrosis then what the hell could it possibly be?” Michelle dragged the end of a French fry through red catsup mounded at the end of the oval plate. Her short precisely manicured fingernails were coated with clear lacquer.

Michelle waved the fry. “What I’m saying is that I don’t buy this business about herpes or a wildly malignant glioblastoma. Holy shit, the brain’s necrotic and he apparently received enough radiation to melt an aircraft carrier. What more is there to say?”

Tyler had also chosen the fish and chips. He took a bite of cod. It tasted like cardboard. He pushed his plate away and forced a swallow. “I know. It’s logical, isn’t it. Just hard to accept.”

“Okay then. The kid’s got a case of radiation necrosis. That’s the easy part. The next question is how the hell could that kind of overdose happen? Way you describe the protocol, it’s impossible. Besides, you showed me your palm computer. I’m no radiation therapist, but that dose is more like what I’d expect.”

The chill in Tyler’s gut intensified. “It has to be radiation necrosis. Can’t be anything else.” He looked at her. “Jesus, I couldn’t have made a mistake like that and typed it in wrong.”

She frowned at him. “For Pete sake, stop this mea culpa routine. You don’t make those kinds of errors. We both know how tight assed compulsive you are about things like this. I don’t for one minute believe you allowed that crazy a dose to blow right past you. No way, no how. Besides, the computer would’ve caught it and asked you to verify.”

“Then what else could’ve caused it?”

“What about dear old U Pitt? Don’t tell me they don’t have a license to screw up once in a while just like the rest of us mortals.” She popped another fry into her mouth.

“Sure, but the dosage value is double checked by the radiation therapists before being sent.
And,”
he remembered at the last minute, “the value has to be within safe ranges parameters or the U Pitt computer chokes and won’t allow the data transfer. And, like you just said, it’s the same with our computer. If it isn’t a reasonable value, we won’t accept it. “It’s a one-shot deal, you know, the zap. And believe me,
that
protocol’s bullet proof too. Had to be for NIH and the local IRB,” referring to the institutional review board that oversees human experimentation, “to sign off on it. No,” he shook his head thinking about it, “there’s no way in hell that kind of dosage mistake could’ve happened.”