Error in Diagnosis (4 page)

Standing at the stern of the aging ferry, Jack watched a frenzied formation of seagulls swoop down to snatch bread chunks that had been tossed into the churning wake by a raucous group of tourists.

A product of modest means and an only child, Jack grew up in Fort Lauderdale less than two miles from the beach. As far back as he could remember, he had always loved spending time on the ocean. He preferred sailing catamarans but irrespective of the vessel, he liked being on the water. He enjoyed boating just about as much as he detested flying. Since the moment Mike had offered to send his plane, he had been unable to shake the lingering discomfort of traveling in a small corporate jet.

The ferry trip took just under an hour and, after a short but perilous ride in a taxi held together by daily prayers and superglue, the cab pulled up in front of the
general aviation terminal at the Saint Kitts airport. With no assistance from the apathetic driver, Jack retrieved his luggage from the trunk.

Through a heavy cloud of dust kicked up by the fleeing taxi, he saw Mike walking toward him. With peach-fuzz for a beard and cropped brown hair, Mike had barely attained the height of five foot six. His small stature had left him five inches shorter than Jack; a fact Jack had teased him about with regularity since they were teenagers.

With a container of coffee in hand, he gave Jack a firm one-armed hug.

“How's Tess doing?”

“I checked on her right before we left,” Mike answered with an uneasy half smile. “There's been no real change overnight.”

Mike took a step toward the plane but Jack put his hand on his shoulder. “How are you doing?”

“Tess was born a Christmas fanatic. The house is decorated like Rockefeller Center and she's been consumed with planning our yearly holiday party for the past two months,” he answered in a forced but even tone. “A few miles from here, the woman I cherish more than anything in this world is lying comatose in an ICU.” With a darting gaze, he asked, “How do you think I feel?”

Jack nodded a few times, but said nothing.

“I'm sorry, buddy,” Mike said.

Jack gave his best friend a reassuring smile. “No apology necessary.”

Mike managed a quick grin in return and then pointed
at the red-and-white Hawker parked on the tarmac. “C'mon, we can talk on the plane.”

Jack studied the eight-passenger aircraft. His slumped shoulders revealed his mounting angst.

“Where's the rest of it?” he asked.

“Don't tell me you're still afraid of flying.”

“I love flying. It's the crashing part that bothers me.”

Shaking his head, Mike now placed a hand on Jack's shoulder. “Relax. I have the two best pilots in the business.” Feeling only slightly reassured, Jack reached for his bags. Mike took his arm. “Just leave them. I promise they'll be in West Palm when we get there.” Mike tapped his lip and asked, “When did you shave the mustache off?”

“Last week.”

“Part of the new image?”

Jack responded by rolling his eyes. They climbed the stairway and stepped aboard. Jack ducked his head as he trailed Mike toward the back of the cabin. “Take that one,” he told him, gesturing at one of the cream-colored leather captain's chairs. Jack settled in and immediately yanked his seat belt across his lap. Mike looked at him askew, “You'll be more comfortable if you can still breathe.”

Jack took a brief look around. He had to confess the upscale appointments were nicer than anything in his apartment. His eyes flashed forward when he heard the whoosh of the cabin door being secured by the pilot. Being more accustomed to the glacially slow world of commercial aviation, he was astonished at how quickly things were moving.

The plane taxied out to the active runway and after a brief pause started its takeoff roll. With added power, the low hum of the engines became an earsplitting whine. Sixty seconds later the jet was in a steep climb, leaving the island of Saint Kitts far below. It wasn't until they leveled off above the clouds that Jack's pulse slowed to a normal rate.

“Something to drink?” Mike asked.

“No, thanks. I'm good,” he answered, noticing the small slit-like scar over Mike's eyebrow—an injury he had sustained in high school when Jack accidentally had caught him with an elbow in a heated one-on-one basketball game.

Jack had spent an hour online the previous evening learning as much as he could about the outbreak. From a medical standpoint the information was limited but there was enough to give him a sense of what questions to ask.

“Did you have any clue Tess was ill before you got the call?”

“Hell, Jack. I don't know. You're the last person I need to tell what Tess has gone through the last twelve years to get pregnant. Two second trimester miscarriages and traveling for weeks on end seeing every fertility expert in the country.” He lowered his chin. “I . . . I had no idea anything was wrong.”

Sensing his guilt, Jack said, “If it makes you feel any better, most of the doctors I know have a hard time deciphering between illness and a routine pregnancy. Assume
for a minute that Tess wasn't pregnant, would you say her behavior and mental functions have been normal?”

“She seemed a little . . . a little confused maybe for the past couple of days, but I thought she was just preoccupied.”

“What was she confused about?”

“She mixed up some of her friends' names and messed up her daily schedule a few times. I mentioned it to her, but I think I embarrassed her. She kind of blew me off. You know Tess. She never complained about anything and I stupidly didn't press the issue.”

“Have you guys done any traveling in the last few weeks?”

Mike shook his head and then laced his fingers behind his head.

“Has Tess had any recent flu symptoms, like a cough or a fever or trouble breathing?”

“The Everglades aren't too far from the house. When we found out she was pregnant, we began taking a walk every evening. We had to stop a week or so ago. She said there was an odor in the air that was making her sick to her stomach and a little short of breath.”

“Did the symptoms go away when you stopped taking the walk?”

“Totally.”

“Is she taking any new medications, homeopathic compounds, herbal remedies—things like that?”

“Christ, Jack,” he said with a corded neck. “There are hundreds of women around the country with this thing.
I don't think this is about Tess's travel schedule or drinking herbal tea. None of this is fair. Tess is the kindest, gentlest human being in the . . .” With a pained expression, Mike turned his head and stared out the window.

“I've seen countless family members drive themselves crazy looking for justice when it comes to illness. It's never there.” It crossed Jack's mind to continue to try and persuade Mike to stop beating himself up, but he knew he'd be shouting at the rain.

Jack's mind continued to fill with a host of unanswered questions, but he could see Mike needed a break. He knew he could talk himself blue in the face trying to convince him that Tess would recover. But even as kids, their relationship had always been an honest one free of pretense. To blow sunshine in his best friend's direction would be at the very least transparent and at worst insulting.

In smooth air, the Hawker jetted effortlessly toward South Florida. With a strengthening sense of confidence, Jack lifted the shade and peered out. Below him, a gathering of willowy gray clouds partially obscured the white caps.

Mike had reclined his seat and was still looking out of his window. If asked, Jack would be the first to say that Mike was an intelligent and pragmatic man who hadn't achieved his success by requiring others to connect the dots for him. Thinking about their conversation, Jack realized two things. The first was that Mike hadn't asked him if Tess might die. The second was that his failure to do so wasn't an oversight.

Harbordale General Hospital
Spokane, Washington

Working in the ICU was the only job Lori Case had had since graduating nursing school. After fifteen years, she was a battle-hardened veteran who was completely unflappable. For the past two days, she had been taking care of Lizette Bordene, Harbordale General's fourth patient admitted with GNS. Lizette was the assistant manager of a small clothing boutique and the mother of two. Until a few days ago, she had never been seriously ill in her life.

Lori returned from her break to find Lizette's mother exactly where she'd left her, sitting forward in a small plastic chair at the foot of the bed.

“Why don't you go home and get some rest?” Lori suggested. “I'll call you if there are any changes.”

“I'm . . . I'm not sure. Maybe I should—”

Lori put her hand on Gail Bordene's shoulder. “Go ahead. She'll be fine. You need some rest.”

Gail reluctantly came to her feet. With an empty stare, she looked at her daughter. After a few seconds, she removed her purse from the back of the chair.

“I'll be back in a few hours. You have my cell phone number.”

“It's written on the board and it's in my phone book,” Lori assured Gail as she walked her to the door with her arm around her shoulders.

For the next two hours, Lizette's condition was stable. Lori had resigned herself to another long but uneventful shift. But all of that abruptly changed when, without any warning, Lizette's blood pressure went into an uncontrolled free fall.

The room instantly reverberated with a cacophony of alarms and alerts. Lori's eyes flashed to the cardiac monitor. In addition to a dangerously low blood pressure, her pulse was erratic. As a reflex more than anything else, Lori smacked the Code Blue button on the wall summoning the rapid response team. She had barely gotten back to the bedside when Dr. Stephen Arrani and two nurses charged through the door. Lori held Arrani in higher regard than most of the other doctors she worked with because he was knowledgeable and decisive, which were skills that seemed to be lost on many of the newer physicians.

“What's going on?” he asked, snatching the stethoscope that lay draped across his shoulders.

“She's crashing,” Lori told him, checking the IV
tubing. “Her pressure suddenly took a dive for no reason. It's down to sixty, and her cardiac rhythm's all over the place.”

“Looks ventricular. What was her last potassium level?” he asked, cranking up the oxygen to one hundred percent as he snugged the mask around Maggie's nose and mouth.

“I drew one a couple of hours ago. It was normal.”

By this time, a respiratory therapist and a pharmacist had dashed into the room and had taken up their assigned positions for a Code Blue.

“Looks like she's in V-tach,” Arrani said. “Give her a dose of lidocaine.”

“I've already drawn it up,” the pharmacist said, handing the syringe to Lori who immediately injected it into the IV port. Silence settled over the room as everyone's eyes locked on the monitor waiting to see if the medication would correct the irregular heart rhythm.

“She's still in V-tach,” Arrani announced, his voice building in intensity.

“Her pressure's down to thirty,” Lori said.

“Start chest compressions,” Arrani ordered. “And get a ventilator set up. She's going to need it.”

Lori was all too familiar with the razor-sharp pinch in the pit of her stomach she was now feeling. As a seasoned ICU nurse, she had taken care of countless patients who had taken an unexpected turn for the worse, but it was something she had never gotten used to.

“She's not breathing. We need to tube her right now,” Arrani said, craning his neck in the direction of the door. “Who's here from anesthesia?” Carrie Sherman,
the nurse anesthetist on call, moved to the head of the bed. “Are any of the obstetricians in house?” he asked.

“I saw Dr. Crossman up on labor and delivery about twenty minutes ago,” Carrie answered. “He was just finishing up a delivery. He's probably still here.”

“Tell the unit secretary to find him stat. If we can't get her heart rhythm back to normal and her blood pressure up in the next five minutes, she's going to need a crash C-section.”

While Arrani continued to shout out orders, Lori carefully slid a metal scope in Lizette's mouth. The highly practiced maneuver brought her vocal cords into clear view. She reached for a curved plastic tube and eased it between the cords and down into her windpipe. As soon as she had it securely taped into place, she connected it to the ventilator. Lizette was now completely dependent on the machine for every breath of air that filled her lungs.

“Her pressure's still thirty,” Arrani called out. “We're losing her. Where the hell's Crossman?” He turned back to Lori. “Give her an amp of epinephrine and keep going with the chest compressions.”

Arrani's words were still suspended in air when Jim Crossman burst into the room with his chief resident in tow. Crossman was one of only three obstetricians on staff who agreed to cover the trauma center. After responding to dozens of critically injured pregnant women who were the victims of serious car accidents, gunshot wounds and stabbings, he was no stranger to performing a crash C-section to save the baby of a dying mother.

“Somebody talk to me,” Crossman said, making his way to the bed.

“She's a thirty-year-old with GNS,” Arrani answered between quick breaths.

“How far along is she?”

“Twenty-nine weeks.”

“What happened?”

“She went into V-tach and her blood pressure dropped.” He shook his head. “I'm trying, but I can't get it back up.” His eyes shifted to the cardiac monitor. “She's going to arrest.”

“How long has her blood pressure been that low?” Crossman asked.

“Four minutes.”

“Any chance you can reverse all this in the next minute or so?”

“I doubt it.”

“Keep up the chest compressions,” he ordered. “If we don't keep Mom's heart pumping, the baby doesn't have a chance.”

At that same moment, two nurses from the operating room with a huge metal box of sterile instruments came through the door.

“I think we should get her ready and move her to the operating room,” Arrani said.

“The operating room is two floors away,” Crossman reminded him. “From what I'm looking at, she wouldn't survive a change of socks at the moment, let alone a trip to the OR. We're doing the section right here.” He stole
a quick glance around the room. “I need everybody who doesn't absolutely need to be here to get the hell out right now. What do you say, Carrie? Can I start?”

“Go. She's not going to move.”

By this time, his scrub nurse, Kate, had carved a path to the front of the room and had set up two sterile trays of instruments.

“We're ready,” she told him.

“Somebody call the neonatal ICU,” he said, slipping on his sterile gown and gloves. “Dr. Armbrister's on call. Tell her to get her butt down here right now.”

The stalwart look on his face left no room for misinterpretation. His decision to proceed with the emergency C-section was not up for discussion. “Don't stop for me,” he told Dr. Arrani. “The sooner you get her heart rhythm fixed, the better chance she and the baby have of surviving.”

He then reached his hand behind him. Kate handed him a sterile metal basin filled to the top with iodine prep solution. There was no time for the usual neat application of a coat or two. Crossman tossed the entire contents of the basin across Lizette's abdomen. And then, except for the rhythmic snap of the backboard with each compression of her chest, the room again became silent.