Richard Mabry - Medical Error

"Jeff," Anna said, "where's your staffman?"

"He… He's in the next room. We have every available OR going, so he has to stafftwo cases. But I'll be fine, Dr. McIntyre. Don't worry." The words expressed confidence that the eyes didn't back up.

No time to quibble. This was the team she had. "Okay, Jeff. Keep her as light as possible. Watch her blood pressure-I mean, watch it closely. Keep the fluids going, push the blood until we get the bleeding controlled."

"Right. She's got Ringer's running in one arm, a unit of unmatched O negative in the other, and the cross-matched blood is on its way up." He met her gaze. "I'm on top of this one. Really."

Anna turned back to the operative field. She picked up a gauze sponge with her left hand and held out her right."Scalpel."

She felt the familiar pressure as Karen slapped the instrument into her palm. "Matt, get a clamp in one hand, a sponge in the other. Clamp the largest skin bleeders. We can deal with them later. As soon as we get the abdominal cavity open, be ready with the suction. There'll be a lot of blood, and you have to keep it cleared out so I can see."

Anna could see the drops of sweat already dotting Matt's forehead. He'd done well as a medical student on her service, but she was asking him to take a huge step up in responsibility. Well, he'd either sink or swim, and she couldn't waste time worrying about it.

Now she worked on automatic pilot. Skin incision, through the subcutaneous fat-thank goodness the girl was thin. Separate the muscles. "Self-retaining retractor." Matt was doing well, better than she'd hoped.

"How's her pressure holding up?" Anna asked.

Murray's voice was steady. "She was shocky when we brought her in, but with fluids she's holding at about a hundred over sixty. One unit unmatched O negative already in, first unit of cross-matched blood going in now."

"Keep me posted," she said. "Here we go. Opening the peritoneum. Matt, ready with the suction. Karen, we'll need a stack of lap pads-"

"Already up, Doctor."

"Thanks." Anna grabbed one of the large gauze laparotomy pads. "We'll need a bunch."

She incised the peritoneum, the tough but thin covering around the abdominal contents. Immediately, dark blood welled into the incision. "Left upper quadrant, Matt. Looks like a ruptured spleen."

In a moment, the bleeding area was packed off. Now Anna was able to identify the problem: a laceration running diagonally across the spleen. This was what she'd hoped for, one of the best possible scenarios. The spleen was important but people could live quite nicely without one, since other parts of the body would take over its function of making blood cells and antibodies. All Anna had to do was clamp offthe blood vessels supplying the spleen and remove it. Problem solved.

Anna finally relaxed a bit. "Matt, you got a permit for splenectomy?"

"Splenectomy, partial resection of liver, bowel resection, whatever might be necessary."

"Good man. Okay, Karen. Let's get that spleen out of here. Bring up the vascular clamps." With the problem diagnosed and a solution in sight, Anna swung into teaching mode. "Matt, we're looking for the region where the blood vessels feed into the spleen. Tell me what it is and the procedure."

"The splenic artery and vein. After you ligate and divide those, you identify and clip the short gastric vessels."

As Matt described the anatomy involved, Anna's hands moved with efficiency and skill. This was what she knew, what she was good at, what she loved. It was good to be back.

She paused for a second as the thought crossed her mind. Soon, maybe as early as tomorrow, she'd be in an interview room with Dowling and Green. They'd already made it clear they were planning to charge her with the murder of Eric Hatley. It was very possible that she was performing her last operation. Well, if that was the case, she'd do a good job. And today she could add one more name to the list of patients who were alive because of her efforts.

"Rosa Hernandez. Fourteen years old. Exploratory lap, splenectomy. She's on her third unit of blood, just finishing her second bottle of Ringer's. Vitals are stable." As he gave his report to the nurse in the surgical Recovery Room, Dr. Murray's voice carried an authority Anna hadn't heard in it before. "Call me if you have any questions."

Anna wiped her palms on her scrub suit before offering her hand to Murray. "You did a nice job."

"Thanks, Dr. McIntyre." She noticed that his palms were still moist, but his handshake was firm. "I'm going to see if Dr. Jenkins needs my help in room four."

Anna watched him walk away. She knew that surviving the challenge of cases like this one supplied the building blocks of confidence that helped make a mature physician. She flashed on her own such experiences. She'd heard it said that to be a good trauma surgeon you had to be fearless. Her own opinion was that a little healthy fear never hurt. It was the doctors who were overconfident and thought they could do no wrong who always seemed to get into trouble.

"Dr. McIntyre?" Matt's voice at her elbow brought Anna out of her daydreaming.

"Yes, Matt?"

"I've handwritten an op note. I guess you'll dictate the formal one. Do you want to write the orders?"

Speaking of performing well under fire, Matt had done well also. She might as well let him spread his wings a bit more."Why don't you write the orders, then show them to me? I'll sign offon them. While you do that, I'll talk with the family."

The Hernandez family was huddled together in a corner of the surgery waiting room. Anna tried to put a smile on her face as she approached them. She knew the anxiety, the empty feeling in the pit of the stomach that came when the doctor walked toward you with news that could wreck your life forever. She'd experienced it herself when her father was in Intensive Care after his stroke. No high-stakes poker player ever tried to read the face of his opponents with any more intensity than Anna did that day. But it was only when the doctor looked down at Anna and her mother and began, "I'm sorry" that the news became obvious. She'd vowed that, if she had good news to convey, it would be evident to the family as soon as she walked through the door.

"Is she all right?" Mrs. Hernandez looked up at Anna, her anguish and pain reflected in her eyes.

Mr. Hernandez sat grim-faced and stoic, obviously prepared to hear the worst and support his wife if the dread words were uttered.

"Rosa is fine." Anna had more to say, but the words were cut offwhen Rosa's parents jumped to their feet and embraced, first each other and then her.

"Thank you, Doctor." Mrs. Hernandez wrung Anna's hand."Thank you for saving our daughter."

"Why don't you sit down and let me explain what we found?" Anna pulled up a chair so she'd be at eye level with Rosa's parents. "The force of the crash ruptured her spleen. We controlled the bleeding, then removed the spleen. It's a fairly common operation, sometimes done as an elective procedure for people with certain types of blood disorders. She'll function fine without it. We've replaced most of her blood loss, and she'll be able to build up the rest on her own."

They both began to speak at once. Anna held up a hand. "I'll answer all your questions, but first let me get back in and look at Rosa. She'll be in the Recovery Room until she's awake and stable. Either I or one of my staffwill look in on her a couple of times a day, and the nurses will notify us immediately if there's any change in her condition. Why don't you wait here? The nurse will come and get you when it's okay for you to see her."

Back in the recovery room, she found Matt writing in Rosa's chart. "How're you doing?"

"I think I've got it covered," he said. "See what you think."

She took the chart and scanned what Matt had written. It all looked good.