Робин Кук: Charlatans

Pleased at their success, Dr. David Wiley and Dr. Harry Chung pushed the defibrillator out of the way and joined Ava at the head of the table. As they watched the ECG to make sure the rhythm was stable, she told them what had happened: “Massive regurgitation and aspiration when I tried to intubate. Obviously, the patient had a full meal this morning despite denying having had anything by mouth. He flat out lied to me and the admitting nurse. As you can see in the suction bottle, I’ve sucked out over three hundred cc’s of fluid and undigested food, including bits of bacon and other poorly chewed material.” She pulled out the suction catheter and connected an ambu bag to the endotracheal tube. The ambu was attached to 100 percent oxygen. Immediately she began attempting to respire the patient by compressing and releasing the bag.

“Jesus,” Dr. Mason complained. “This was supposed to be a simple hernia.”

“Has it been about eight minutes since you gave the muscle relaxant?” Harry asked, looking at the anesthesia record and ignoring Dr. Mason.

“About that,” Ava said. “I’m hoping we’ll be okay in that regard. I gave him a full five minutes with pure O2 before the succinylcholine.”

“How does the resistance feel when you breath him?” David asked.

“Not good,” Ava admitted. She was thinking about the raised resistance the moment David brought it up. It was subtle but definite. It was a sensitivity born of experience of breathing for thousands of patients under all sorts of circumstances. With the succinylcholine on board, there should have been very little resistance to expanding the lungs. “To be sure, you try, while I listen to his chest.”

David took over the ambu bag while Ava used the stethoscope.

“Breath sounds are terrible bilaterally,” Ava said.

“I agree there is too much resistance,” David said. “The bronchi must be full of vomitus and seriously occluded. I don’t think we have much choice. We are going to have to bronch him.”

Suddenly the pitch of the oximeter alarm began to fall again, indicating that too little oxygen was getting into the blood with the bronchial blockage, despite David’s efforts.

The door to the OR opened and in rushed Dr. Noah Rothauser, a senior surgical resident who was scheduled to be the super chief surgical resident come the first of July, less than a week away. He was tying a face mask over the top of his head. Practically everyone knew Noah. It was generally felt that he was the best surgical resident the BMH had ever produced. A few jealous colleagues wondered if he was too good, as he had consistently gotten the highest grades recorded on the biannual American Board of Surgery In-Service Exams. He was known to be a tireless worker, extraordinarily knowledgeable for a resident, decisive, and remarkably congenial for a surgeon. As was typical of his commitment, the moment he’d heard about the code while he was in the surgical lounge, he came running to see if he could lend a hand.

The scene that confronted Noah wasn’t auspicious. The two surgeons were standing immobilized a step back from the table that was tilted in a head-down position. Their hands were clasped in front of their chests. The patient was supine, naked from his head to his umbilicus, with his hospital gown bunched up under his chin. His color was a disturbing shade of slate blue, and his chest didn’t seem to be moving. Three anesthesiologists were grouped around the patient’s head, and one of them was yelling for the circulating nurse to get a bronchoscope stat while trying to use an ambu bag.

“What’s going on?” Noah asked urgently as Dawn rushed out the door for the bronchoscopy setup. Noah heard the pitch of the oximeter alarm falling, and then at that very moment he heard the blood-pressure alarm go off. By instinct honed from experience he knew that the situation was critical and the patient’s life was hanging in the balance.

“We have one hell of an emergency,” Ava blurted, confirming Noah’s impression. “The patient aspirated a ton of gastric contents and arrested. His bronchi are seriously blocked. He’s not getting enough oxygen and has already arrested once.”

Noah’s eyes darted from Ava and the other two anesthesiologists to Mason and Andrews and then down at the patient. The patient’s color was getting worse by the second. “There’s no time for bronchoscopy,” Noah snapped. By reflex, his intuitive, can-do surgical personality hijacked his mind. Although he was a mere resident in the presence of a celebrated attending surgeon on a private case, he took control. The first order of business was to sound another alarm even before another cardiac arrest occurred, which he guessed was imminent. Turning and looking through the window toward the main desk and knowing that he could be heard if he made enough of a commotion, he shouted mayday three times followed by: “We need a cardiac surgeon, a perfusionist, and a thoracotomy setup immediately!” Then, with no hesitation whatsoever, he grabbed scissors directly off the sterile instrument tray with a bare hand and proceeded to cut through Bruce’s gown that was bunched up around his neck. He threw the scissors to the side. “Heparinize the patient while there is still a heartbeat!” Noah shouted to the anesthesiologists. “We have to get him on cardiopulmonary bypass.” Still without sterile gloves, as he didn’t want to take the time to put them on, he proceeded to prep Bruce’s chest with antiseptic, frantically sloshing the dark fluid over a wide area and onto the floor.

Ava and the two other anesthesiologists hesitated for a moment, then fell to work. It was clear to them that Noah was right. The only chance of saving the patient was to get him on the “pump.” More than anything else, he needed oxygen, and he needed it now, since his oxygen saturation was below 40 percent and falling. The bronchoscopy would have to wait.

Moments later Dawn rushed back into the room along with another nurse carrying the thoracotomy setup and Peter Rangeley, a perfusionist, who would run the pump. Luckily, in this modern hybrid operating room, the equipment was readily available on one of the utility booms suspended from the ceiling. It was up to Peter Rangeley to prime the system with a crystalloid solution and be sure all the air was expunged from the arterial lines.

Once Noah had the thoracotomy setup available to him after it had been opened by Betsy, he wasted no time, even though a cardiac surgeon had yet to arrive. Still without gloves, Noah took a scalpel from Betsy and made a vertical incision down Bruce’s sternum, cutting directly to the bone to save time. With the blood pressure as low as it was, there was little bleeding. Noah then took the pneumatic sternum saw and proceeded to cut through the sternum from top to bottom. Bits of tissue and blood spattered his chest. As he got close to finishing with the noisy saw, the cardiac alarm went off.

“He’s in ventricular fibrillation,” Ava shouted.

“The cardioplegia solution will take care of the fibrillation,” Noah yelled back. “Since he is not breathing, we can’t take the time to defibrillate.” Then, as Noah put in the sternal retractor and began cranking its blades apart, he shouted up at the PA system: “Have you found us a cardiac surgeon?”

“I’m not sure he is completely heparinized with his heart fibrillating,” Ava said.

“Dr. Stevens is on his way,” a voice answered over the PA.

“Tell him not to bother scrubbing or it will be too late,” Noah yelled back. “I’m in the thorax and looking at the heart.” It had taken him less than two minutes to open the chest. The heart was quivering in uncoordinated fibrillation. “Get me some cold saline, Dawn! That might take care of the fibrillation until the pump is ready. How’s the pump prep coming, Peter?” Noah reached into the chest with his bare hand and began giving open cardiac massage by alternately squeezing and releasing the slippery organ. He thought it was worth trying to take advantage of what oxygen might still be available in the blood. Brain cells were exquisitely sensitive to a lack of oxygen.