Robin Cook: Harmful Intent

The crash cart arrived along with additional OR nurses. With lightning speed, they prepared the defibrillator. A nurse anesthetist also arrived.

She went directly to Jeffrey's side.

The oxygen content of Patty's blood went up slightly. "Countershock her!"

Jeffrey ordered.

Simarian took the defibrillator paddles from one of the nurses. He applied them to Patty's bare chest. Everyone stepped back from the OR table.

Simarian pressed the button. Since Patty was paralyzed with the succinylcholine, there was no apparent effect from the electric current except on the EKG screen. The fibrillation disappeared, but when the phosphorescent blip returned, it did not show a normal heartbeat. Instead, it traced a completely flat line with only a few minor squiggles.

"Restart massagel" Jeffrey ordered. He stared at the EKG. He couldn't believe there was no electrical activity. The muscu-

lar male nurse took over from Simarian and started compressing Patty's chest with good result.

The fetal monitor was still sounding. The child's heart rate was too slow.

"We gotta get the baby!" Simarian snapped again. He changed his gloves and hastily took additional drapes from the scrub nurse. He positioned them as best he could despite the cardiac massage. He grabbed a knife from the instrument table and went to work. Using a generous vertical incision, he sliced Patty's lower abdomen open. With the reduced blood pressure there was very little bleeding. A pediatrician arrived on the scene and prepared to take the baby.

Jeffrey's attention stayed with Patty. He suctioned her and was surprised at the amount of secretions even after the two doses of atropine. Checking

Patty's pupils, he was pleased they were not dilated. In fact, he was surprised to find them pinpoint. With oxygenation remaining up, Jeffrey decided to hold off introducing any more drugs into Patty's system until after the baby was delivered. Briefly, he explained what had happened to the nurse anesthetist.

"You think it's a reaction to the Marcaine?" she asked.

"That's all I can think of," Jeffrey admitted.

In the next minute a silent, blue, flaccid baby was pulled from Patty's abdomen. After the cord was severed, the child was quickly handed to the waiting pediatrician. He rushed the newborn to the infant care unit, where the baby was surrounded by his own resuscitation team. The nurse anesthetist joined that group.

"I don't like this flat EKG," Jeffrey said to himself as he injected a bolus of epinephrine. He watched the EKG. No response. He then tried another dose of atropine. Nothing. Exasperated, he drew an arterial blood sample and sent it off to the lab for a stat reading.

Ted Overstreet, one of the cardiac surgeons who had recently finished a bypass case, came in and stood next to Jeffrey. After Jeffrey explained the situation, Overstreet suggested opening her UP.

The nurse anesthetist came back to report that the baby was not in good shape. "The Apgar is only three," she said. "He's breathing and his heart is beating, but not well. And his muscle tone is not good. In fact, it's weird."

"How so?" Jeffrey asked, fighting a wave of depression.

"His left leg moves okay, but not his right. The right one is completely flaccid. With his arms it's just the opposite."

Jeffrey shook his head. Obviously the child had been oxygen deprived in utero and was now brain damaged. The realization was crushing, but there was no time to wallow in regret. Just then his chief concern was Patty and how to get her heart started.

The stat lab work came back. Patty's pH was 7.28. bnder the circumstances,

Jeffrey thought, that was pretty good. Next he injected a dose of calcium chloride. Minutes dragged like hours as everyone watched the EKG, waiting for some sign of life, some response to treatment. But the monitor traced a frustratingly flat line.

The male nurse continued the chest compressions and the ventilator kept

Patty's lungs Ned with pure oxygen. Her pupils remained miotic, suggesting her brain was getting enough oxygen, but her heart stayed electrically and mechanically still. Jeffrey repeated all the textbook procedures but to no avail. He even had Patty shocked again with the defibrillator set at 400 joules.

Once the pediatrician had the newborn stabilized, he had the entire infant care unit vacate the OR along with its attendant clutch of residents and nurses. Little Mark was on his way to the neonatal intensive care unit.

Jeffrey watched them go. He felt heartsick. Shaking his head in sorrow, he turned back to Patty. What to do?

Jeffrey looked up at Ted, who was still standing next to him. He asked Ted what he thought they should do. Jeffrey was desperate.

64 Like I said, I think we should open her up and work on the heart directly. There's not much to lose at this point."

Jeffrey watched the flat EKG for another moment. Then he sighed. "Okay.

Let's try it," he said reluctantly. He had no other ideas, and he didn't want to give up. As Ted pointed out, they had nothing to lose. It was worth a try.

Ted,gowned and gloved in less than ten minutes. Once he was prepared, he had the nurse stop compressing the chest so that he could rapidly drape and slice into it. Within seconds he was holding Patty's naked heart.

Ted massaged the heart with his gloved hand and even injected epinephrine directly into the left ventricle. When that failed to have an effect, he tried to pace the heart by attaching internal leads to the cardiac wall.

That resulted in a complex on the EKG, but the heart itself did not respond.

Ted recommenced the internal cardiac massage. "No pun intended," he said after a couple of minutes, "but my heart is no longer in this. I'm afraid the ballgame is over unless you guys have a heart transplant waiting around here. This one is long gone."

Jeffrey knew that Ted didn't mean to sound callous and that his apparently flip attitude was more of a defense mechanism than a true lack of compassion, yet it cut Jeffrey to the quick. He had to restrain himself from lashing out verbally.

For as much as he'd given up, Ted continued the internal cardiac massage.

The only sound in the OR came from the monitor recording the pacemaker's discharge and the low hum of the pulse oximeter as it responded to Ted's internal massage.

Simarian was the one who broke the silence. "I agree," he said simply. He snapped off his gloves.

Ted looked across the rapidly erected ether screen at Jeffrey. Jeffrey nodded. Ted stopped massaging the heart and pulled his hand from within

Patty's chest. "Sorry," he said.

Jeffrey nodded again. He took a deep breath, then turned the ventilator off. He looked back at the sorry sight of Patty Owen with her abdomen and chest rudely sliced open. It was a terrible sight, one that would stay with

Jeffrey for the rest of his life. The floor was littered with drug containers and wrappers.

Jeffrey felt crushed and numb. This was the nadir of his professional career. He'd witnessed other tragedies, but this was the worst, and most unexpected. His eyes drifted to his anesthesia machine. It too was covered with debris. Beneath the debris was the incomplete anesthesia record. He'd have to bring it up to date. In the fevered attempt to save Patty he'd had no time to do so. He looked for the half-empty vial of Marcaine, feeling an irrational antipathy toward it. Although it seemed unreasonable in light of the test dose results, he couldn't help but feel an allergic reaction to the drug was the root of this tragedy. He wanted to dash the vial against the wall, just to vent his frustration. Of course he knew he wouldn't actually throw the vial; he was too controlled for that. But he couldn't find it among the mess.

"Sheila," Jeffrey called to the circulating nurse who was starting the clean-up process, "what happened to the Marcaine vial?"