Читать книгу Bad Blood - James Baehler - Страница 3

“Code blue! Code Blue!” echoed over the intercom at Barrington Community Hospital. When it was followed by “Surgical Intensive Care Unit,” Cliff Harris knew that whatever catastrophic event occurred had to involve the patient on whom he had just operated. It was 11:30 p.m. and his was the only patient admitted to surgery in the last hour. Dr. Harris was sitting in the surgical locker room sipping orange juice and fighting fatigue when he heard the Code Blue. He ran back to the intensive care unit. As soon as he entered he saw the two ICU nurses working frantically on his patient. “It’s your patient, Dr. Harris. I think he’s coding!”

Shaking his head to help prepare his mind for yet another emergency he said, “What happened?”

“He went into this rapid tachycardia,” said the younger nurse pointing to the cardiac monitor above the bed showing the accelerated heartbeat.

“Was he awake? Did he complain of any chest pain?” asked Harris.

The nurse said, “No, nothing like that.”

A glance at the cardiac monitor showed a heart rate over 140. At least it was a normal sinus rhythm and not a serious cardiac arrhythmia. Could this represent a cardiac insult such as a post-operative heart attack? The tracing did not show any obvious electrocardiographic evidence. Harris quickly listened with his stethoscope, but all he heard was a rapid and regular cardiac rhythm. The patient’s blood pressure on the monitor was 120 over 70. That was a surprise and a relief and it told Cliff that in spite of the rapid heartbeat, the patient was maintaining his blood pressure. He lowered Victor Wallberg’s bed sheet and found the abdomen distended even more than it had been before surgery. Victor’s skin, conjunctiva, and nail beds were pale. From all the diagnostic possibilities that whirled through his mind, Cliff focused on one: A post-operative bleed? How could that be? Things had gone so well; Wallberg had been dry and stable after the earlier surgery. Regardless of that, the man was now in serious peril. Something had to be done and it had to be done now. He turned to the nurses. “Let’s get him back to the OR, stat. Tell them we’re coming back. Call the lab. Get the blood I ordered earlier to the OR. How much urine in the Foley bag?”

The older nurse, after a quick check at the bag hanging on the other side of the bed, said crisply, “Thirty cc’s.”

“Empty and record the volume along with the exact time. I want to start surgery with an empty bag.”

“Yes sir.”

“Let’s move.”

This was no time for theorizing while his patient could be bleeding to death. If he was, it had to be stopped. On the way to the operating room Harris said to the nurses, “He’s bad. Something unusual has happened. I have to look for a bleeder.”

The operating team and the anesthesiologist were arriving as the patient was wheeled in to the OR. In less than five minutes Victor Wallberg was anesthetized and on the table. Harris opened the previous incision made at the first surgical procedure. He noted with surprise some oozing but had no time to tie off individual tiny bleeders in the subcutaneous fat. A few rapid and deft movements and the peritoneal layer became visible. It was blue and bulging with blood. His worst fears had been realized. He opened the peritoneum with a single delicate flick of his scalpel. Blood welled up from the abdominal cavity. Harris desperately tried to suction out the blood so he could identify the source of the bleeding. He was able to remove enough blood to evaluate his recently done small bowel anastamosis and it was intact. The reconnected ends of the small bowel showed no suture disruption. But that was about all he could discern as the blood seemed to appear from everywhere to obscure the surgical field. The more he suctioned, the more the blood seemed to flow.

Ten years of experience were brought to bear as Harris’s thought processes focused on the task at hand. He could find no bleeding vessel, admittedly a difficult task with what was happening to his patient. He knew he was headed for trouble. His lips were tightly closed, a look of intense concentration registered on his face.

Suddenly it hit him. He thought, ‘My God! This is a case of disseminated intravascular coagulation.’ He called to the anesthesiologist, “Sanjay, look at his fingers…quick.”

“Dark blue,” the anesthesiologist shouted back in alarm.

“Blood pressure?” asked Harris crisply.

“116 over 56.”

Still up, but lower thought Harris.

He called to the circulating nurse. “Check the Foley bag.”

She looked under the table and said, “Foley bag still empty.”

“Is blood dripping at a wide open rate?” Harris asked.

“Blood bag wide open.”

For a few seconds Harris continued his efforts. Just before he was about to call out his orders, the anesthesiologist said, “Blood pressure dropped. 70 over 40”

With that news, Harris knew his patient was going into shock. He had no time to lose. “Vasopressors,” he called. “Sanjay, get me a blood sample, stat? Then give…”

“I’m trying, but his veins are collapsing,” cried the anesthesiologist in dismay.

“Jugular, brachial, femoral. Get some blood from some place.”

“What blood are you needing?” asked the anesthesiologist anxiously.

“Platelet count, PT, APTT, fibrinogen, fibrin degradation products, type and cross match four more units, and hematocrit. And then…”

“I can’t get blood! I can’t get it!” cried the anesthesiologist.

Harris couldn’t wait. The patient was in extremis. He shouted, “Give him eight thousand units of heparin!”

The anesthesiologist stiffened. “What?”

“Heparin, eight thousand units…bolus, stat!” called Harris in a louder voice.

“The anesthesiologist shook his head in violent disagreement. “But he is already bleeding.”

“I know what I’m doing,” Harris shouted. “Just do it!”

The OR nurses stood transfixed, their eyes swiveling from Harris to the anesthesiologist who had not yet administered the heparin. “Do it, damn it!” Harris shouted.

Dr. Sanjay Madhava was frantic, “Heparin? He’s bleeding for God’s sake.”

“DIC,” Harris said, “the patient has DIC. Can’t you see that?”

“But they bleed with DIC. Heparin will make it worse!”

“They thrombose late,” Harris said with conviction. “The DIC will kill him unless we reverse it, so hurry up. We don’t have much time to lose. It’s his only chance.”

The anesthesiologist stood like a statue, eyes opened wide, mouth agape. Harris, in a voice the nurses had never heard, and with eyes blazing over his surgical mask, roared, “There’s no time for didactics, damn it! Am I going to have to scrub out and do it myself? There’ll be shit to pay if that happens.”

Shaken out of his immobility, the anesthesiologist reached over to his tray for a vial of heparin, inserted a syringe and extracted a dose. He reached up and inserted the tip of the syringe into the portal on the IV line closest to the insertion on the back of the patient’s hand. Slowly but steadily he depressed the plunger of the syringe until the cylinder was empty. The room was as silent as a tomb; none of the OR staff could ever remember Dr. Harris in a shouting match. The blood pressure maintained at 70 over 40 for a while. The cardiac rate began to slow. Harris worked feverishly suctioning blood and continuing to explore as best he could. Vasopressors were already in, but the blood pressure stubbornly refused to rise. Wallberg’s fingers remained cyanotic, the Foley bag remained empty showing no urine output. Abruptly, the cardiac rhythm slowed further and premature ventricular contractions developed. With horror-stricken eyes the doctors and nurses watched as an idioventricular rhythm developed.The patient was slipping into cardiac arrest. The monitor screen told its relentless story as Wallberg’s heart beat slower and slower and finally, a chaotic rhythm---ventricular fibrillation, the heart beating wildly out of control. Harris and his crew began frantic cardiopulmonary resuscitative measures. Adrenalin was injected directly into the heart. Harris called for defibrillator paddles and applied them to the patient’s chest. Wallberg jerked under the jolt of electricity but that was the only response. The chaotic rhythm on the heart monitor suddenly flattened out; the spiking demonstrating the heartbeats disappeared. More chest compression, more electrical jolts but still the patient remained unresponsive. The monitor showed a persistent flat line. After more long, discouraging minutes, Harris reluctantly signaled to the OR team that it was time to cease their efforts. The patient was dead.

Silently the tubings were removed and the body placed on a cart. No one spoke. When the task was done, the anesthesiologist, Sanjay Madhava, said bitterly, “Heparin? I sure hope you know what the hell you did.”

Wearily, Harris replied, “I knew very well what I did, Sanjay. When I’m a little less tired someday, I’ll explain it further to you.” Madhava turned away with a disbelieving shake of his head. Harris was now too fatigued to do anything more than dwell on the fact that he was now involved with his first intraoperative death. He was devastated and it showed on his face. He dreaded the coming talk with the patient’s wife. Slowly, he made his way from the operating room to the Waiting Area outside the ICU. He stopped for a moment and drew a deep breath before entering. One look at his stricken face and Marilyn Wallberg knew what had happened. She made as if to rise, but slumped back instead. Dr. Harris sat next to her and said, “I’m so very sorry, Mrs. Wallberg. Your husband developed uncontrolled bleeding and everything we tried didn’t stop it. We couldn’t save him.”

She looked at him, her features frozen into an expression that Harris couldn’t identify. He put his hand on her shoulder. She looked directly at Harris. “What caused the bleeding?” she whispered.”

Harris said, “I’m so sorry, Mrs. Wallberg. I’m certain that your husband developed disseminated intravascular coagulation. It’s a bleeding complication that once in a great while appears after major surgery. There was no way to anticipate it and no way to control it.”

Still unbelieving, she said, “But…but I don’t understand. I thought it was a simple operation.”

“The surgery was relatively simple, Mrs Wallberg but your husband then developed the DIC condition I just described and despite our best efforts, we couldn’t save him.”

Beginning to show anger as her eyes filled with tears, she said, “But how can that be? Aren’t you prepared for that sort of thing?”

“I’m sorry, Mrs. Wallberg but there is no way to prepare for disseminated intravascualar coagulation. It is an extremely rare condition that appears without warning and there is no way to prepare for it.”

In a despairing voice, she said through her sobs, “I don’t understand any of this. My husband was alive and well a few hours ago and now you tell me he’s dead and there was nothing anyone could do about it.”

Harris started to speak when she broke in. “What am I supposed to do now. I have two children to take care of and my husband is dead.” Her voice rose to a wail as she buried her head in her hands and wept uncontrollably.

Not knowing what else to say, Harris could only gently pat the grieving woman on the back as she sobbed.

Finally raising her head and speaking in a low voice Marilyn Wallberg said, “Why did Victor call you, of all people? After what happened between the two of you, why?”

“I thought the same thing, Mrs Wallberg. But it just told me how desperate he had become. Just speaking to him on the phone, I knew he was helpless to help himself. He wouldn’t have been able to get to his car. He had all the symptoms of a complete intestinal obstruction. Surgery was the only thing that could have saved him, but it was too late. He developed disseminated intravascular coagulation. He bled and clotted profusely. It couldn’t be reversed. We got him too late.”

Mrs. Wallberg stared straight ahead, eyes wide, her expression frozen. She shook her head. Then she said, bitterly, “I know him. He never went to doctors. He probably developed symptoms and when they got worse he was sure they’d go away. He always did things like that. Only this time he got fooled and it cost him his life.” She broke down again.

Harris said, “You may be right. If he had gone to a physician at the start of the symptoms, this might have been prevented.”

Bitterly, his widow said, “That wasn’t Victor’s style. Everything had to be done his way. He would never listen to anyone else or take anyone’s advice. He was always so sure he knew best.”

Harris said, “We need to learn more, Mrs. Wallberg. It can’t end here. Would you consider an autopsy?”

She straightened and without looking at Dr. Harris, shook her head and said firmly, “No autopsy. I’m not going to have Victor cut up when you say you already know why he died. In any event, he thought autopsy was butchery and I am not going to go against his beliefs.

“Mrs. Wallberg, the decision is yours and I understand and respect it.”

“Thank you, doctor.”

“Would you like some time alone with your husband?”

“Yes, I would like that.”

“Come with me,” Harris said, leading her out of the room.

“Is there anyone you would like me to call?” Harris said as they proceeded down the hall.

“Not right now, thank you,” was the reply. They reached the room where Wallberg’s body lay.

Harris said, “Please let me know if there’s anything else we can do.”

“Thank you, but I can’t think of anything right now.”

“I understand,” Harris said and turned away from the widow of a patient who had died under his knife. He went back to the surgery area where he dictated his surgical report. It was detailed and lengthy. Soon he would have to face the scrutiny of his fellow doctors as this was a surgical death, and all such are peer reviewed.

Harris now realized he had no way of getting home. It was 2:00 a.m. and he was scheduled to perform a 7:00 a.m. surgery that morning. To go home he would have to call his wife, wake her up and have her come to the hospital. It wasn’t worth it. He went to the dormitory area set aside for house staff on night call. He grimaced at his appearance in the mirror. He noted his disheveled hair. His gray eyes had lost their luster. The muscles of his wiry frame that he tried to maintain with semi-regular exercise seemed flaccid. His shoulders drooped making him look shorter than his six feet. He called the hospital operator and asked for a 6:15 AM wake up call. He fell exhausted into bed, his last thought on the man he had just operated upon; a man who had raped his wife.