Robin Cook: Harmful Intent

Satisfied that all was in order, Jeffrey picked up the via] of Marcaine

Sheila had brought him. Using his thumb, he snapped off the top of the sealed glass container. Once again he checked the label, then drew up 12 cc's. He wanted anesthesia to extend at least to T6, and preferably to T4.

As he put the Marcaine down, his eyes caught Sheila's. She was standing off to the left, staring at Jeffrey.

"Is something wrong?" Jeffrey asked.

Sheila held his gaze for a beat, then spun on her heels and left the OR without speaking. Jeffrey turned to catch the eye of the scrub nurse, but she was still busy setting up. Jeffrey shrugged. Something was going on that he didn't know about.

Returning to Patty's side, he injected the Marcaine. Then he capped off the epidural catheter and returned to the head of the table. After putting down the syringe, he noted the time and the exact amount of the injection in the record. A slight quickening of the beep of the pulse brought his eyes up to the EKG monitor. If there was to be any change in the heart rate, Jeffrey expected a slight slowing from progressive sympathetic blockade. Instead, there was the opposite. Patty's pulse was speeding up. It was the first sip of the impending disaster.

Jeffrey's initial reaction was more of curiosity than concern. His analytical mind groped for a logical explanation for what he was witnessing. He glanced at the blood pressure readout and then the oximeter

LED. They were all fine. He looked back at the EKG. The pulse was still quickening, and even more disturb-

ing, there was an ectopic, irregular heartbeat. Under the circumstances, that was not a good sign.

Jeffrey swallowed hard as fear clutched at his throat. It had only been seconds since he'd injected the Marcaine. Could it have gone intravenous despite the test dose result? Jeffrey had had one other adverse reaction to local anesthetic in his professional career. The incident had been harrowing.

The ectopic beats were increasing in frequency. Why would the heart rate increase and why the irregular rhythm? If the anesthetic dose did go intravenously, why wasn't the blood pres:. sure falling? Jeffrey had no immediate answers to these questions, but his medical sixth sense, born of years of experience, set off alarm bells in his mind. Something abnormal was occurring. Something Jeffrey was at a loss to explain, much less understand.

"I don't feel good," Patty said, turning her head to talk out of the side of the mask.

Jeffrey looked down into Patty's face. He could see it was again clouded with fear. "What's the matter?" he asked, puzzled by these rapid events. He touched her shoulder.

"I feel funny," Patty said.

"How do you mean, funny?" Jeffrey's eyes went back to the monitors. There was always the fear of allergy to the local anesthetic, although developing allergy in the two hours since the first dose seemed a rather farfetched notion. He noticed the blood pressure had risen slightly.

"Ahhhhh!" Patty cried.

Jeffrey's eyes shot to her face. Patty's features were twisted in a horrible grimace.

"What is it, Patty?" Jeffrey demanded.

"I feel a pain in my stomach," Patty managed hoarsely through clenched teeth. "It's high up, under my ribs. It's different from the labor pain.

Please..." Her voice trailed off.

Patty began to writhe on the table, drawing up her legs. Sheila reappeared along with a muscular male nurse who lent a hand in attempting to restrain her.

The blood pressure that had risen slightly now began to fall. "I want a wedge under her right side," Jeffrey yelled as he got ephedrine from the drawer and prepared it for injection. Mentally he calculated how far he'd let the blood pressure drop before he'd inject the pressor agent. He still had no idea of what was happening, and he preferred not to act before he knew exactly what he was up against.

A gurgling sound brought his attention back to Patty's face. He pulled off her oxygen mask. To his surprise and horror she was salivating like a mad dog. At the same time she was lacrimating profusely; tears were streaming down her face. A wet cough suggested that she was also forming increasing amounts of tracheo-bronchial secretions.

Jeffrey remained the ultimate professional. He had been trained to deal with this type of emergency situation. His mind raced ahead, taking in all the information, making hypotheses, then ruling them out. Meanwhile, he dealt with the lifethreatening symptoms. First he suctioned Patty's nasopharynx, then he injected atropine intravenously, followed by ephedrine. He suctioned Patty again, then injected a second dose of the at- ropine. The secretions slowed, the blood pressure plateaued, the oxygenation stayed normal, but Jeffrey still did not know the cause. All he could think of was an allergic reaction to the Marcaine. He watched the

EKG, hoping that the atropine might have a positive effect on the irregular heartbeats. But they remained irregular. In fact, they became even more irregular as Patty's pulse quickened. Jeffrey prepared a 4 mg dose of pro- pranolol, but before he could inject it, he noticed the muscle fas- ciculations that distorted Patty's features in a series of seemingly uncontrolled twists and spasms. The fasciculations rapidly spread to other muscles until her body became wracked by clonic jerks.

"Hold her, Trent!" Sheila cried to the male nurse. "Get her legs!19

Jeffrey injected the propranolol as the EKG began to register further bizarre changes, intimating there was diffuse involvement of the heart's electrical conduction system.

Patty spewed up green bile which Jeffrey quickly suctioned away. He glanced at the oximeter readout. That was still holding. Then the fetal monitor alarm began to go off, the baby's heart was slowing. Before anyone could react, Patty suffered a grand mal seizure. Her limbs flailed madly in all directions, then her back arched in awkward hyperextension.

"What the hell is going on?" Simarian shouted as he came flying through the door.

"The Marcaine," Jeffrey shouted. "She's having some sort of overwhelming reaction." Jeffrey didn't have time to elaborate as he drew up 75 mg of succinylcholine.

"Jesus Christf" Simarian yelled, coming around the table to help hold Patty down.

Jeffrey injected the succiny1choline as well as an additional dose of diazepam. He was thankful that his compulsiveness had made him change the

IV to a more secure one. The audio portion of the oximeter readout began to fall in pitch as Patty's oxygenation decreased. Jeffrey again cleared her airway and tried to bag her with the 100% oxygen.

Patty's seizure movements slowed as succinylcholine-induced paralysis took effect. Jeffrey slipped in an endotracheal tube, checked its position, and ventilated her well with the oxygen. The sound of the oximeter immediately returned to its higher pitch. But the fetal monitor was still sending out its alarm. The baby's heart had slowed and was not speeding back up.

"We gotta get the baby!" Simarian yelled. He grabbed sterile gloves from one of the side tables and yanked them on.

Jeffrey was still watching the blood pressure, which had started to fall again. He gave Patty another dose of ephedrine. The blood pressure started back up. He glanced at the EKG; it had not improved with the propranolol.

Then to Jeffrey's horror, just as he was watching, the EKG disintegrated into senseless fibrillation. Patty's heart had stopped beating.

"She's arresting!" Jeffrey shouted. The blood pressure fell to zero. Both the EKG and the oximeter alarms began shrieking stridently.

"My God!" Simarian yelled. He had been.hastily draping the patient. He moved up to the table and started external cardiac massage by compressing

Patty's chest. Sheila put out the word to the OR desk. Help was on its way.