Complications (7 page)

T
o much of the public—and certainly to lawyers and the media—medical error is fundamentally a problem of bad doctors. The way that things go wrong in medicine is normally unseen and, consequently, often misunderstood. Mistakes do happen. We tend to think of them as aberrant. They are, however, anything but.

At 2
A.M.
on a crisp Friday in winter a few years ago, I was in sterile gloves and gown, pulling a teenage knifing victim’s abdomen open, when my pager sounded. “Code Trauma, three minutes,” the operating room nurse said, reading aloud from my pager display. This meant that an ambulance would be bringing another trauma patient to the hospital momentarily, and, as the surgical resident on duty for emergencies, I would have to be present for the patient’s arrival. I stepped back from the table and took off my gown. Two other surgeons were working on the knifing victim: Michael Ball, the attending (the staff surgeon in charge of the case), and David Hernandez, the chief resident (a general surgeon in his final year of training). Ordinarily, these two would have come to supervise and help with the trauma, but they were stuck here. Ball, a dry, cerebral forty-two-year-old, looked over at me as I
headed for the door. “If you run into any trouble, you call, and one of us will peel away,” he said.

I did run into trouble. In telling this story, I have had to change some details about what happened (including the names of those involved). Nonetheless, I have tried to stay as close to the actual events as I could while protecting the patient, myself, and the rest of the staff.

The emergency room was one floor up, and, taking the stairs two at a time, I arrived just as the emergency medical technicians wheeled in a woman who appeared to be in her thirties and to weigh more than two hundred pounds. She lay motionless on a hard orange plastic spinal board—eyes closed, skin pale, blood running out of her nose. A nurse directed the crew into Trauma Bay 1, an examination room outfitted like an OR, with green tiles on the wall, monitoring devices, and space for portable X-ray equipment. We lifted her onto the bed and then went to work. One nurse began cutting off the woman’s clothes. Another took vital signs. A third inserted a large-bore intravenous line into her right arm. A surgical intern put a Foley catheter into her bladder. The emergency-medicine attending was Samuel Johns, a gaunt, Ichabod Crane–like man in his fifties. He was standing to one side with his arms crossed, observing, which was a sign that I could go ahead and take charge.

In an academic hospital, residents provide most of the “moment to moment” doctoring. Our duties depend on our level of training, but we’re never entirely on our own: there’s always an attending, who oversees our decisions. That night, since Johns was the attending and was responsible for the patient’s immediate management, I took my lead from him. At the same time, he wasn’t a surgeon, and so he relied on me for surgical expertise.

“What’s the story?” I asked.

An EMT rattled off the details: “Unidentified white female unrestrained driver in high-speed rollover. Ejected from the car.
Found unresponsive to pain. Pulse a hundred, BP a hundred over sixty, breathing at thirty on her own . . .”

As he spoke, I began examining her. The first step in caring for a trauma patient is always the same. It doesn’t matter if a person has been shot eleven times or crushed by a truck or burned in a kitchen fire. The first thing you do is make sure that the patient can breathe without difficulty. This woman’s breaths were shallow and rapid. An oximeter, by means of a sensor placed on her finger, measured the oxygen saturation of her blood. The “O
₂
sat” is normally more than 95 percent for a patient breathing room air. The woman was wearing a face mask with oxygen turned up full blast, and her sat was only 90 percent.

“She’s not oxygenating well,” I announced in the flattened-out, wake-me-up-when-something-interesting-happens tone that all surgeons have acquired by about three months into residency. With my fingers, I verified that there wasn’t any object in her mouth that would obstruct her airway; with a stethoscope, I confirmed that neither lung had collapsed. I got hold of a bag mask, pressed its clear facepiece over her nose and mouth, and squeezed the bellows, a kind of balloon with a one-way valve, shooting a liter of air into her with each compression. After a minute or so, her oxygen came up to a comfortable 98 percent. She obviously needed our help with breathing. “Let’s tube her,” I said. That meant putting a tube down through her vocal cords and into her trachea, which would insure a clear airway and allow for mechanical ventilation.

Johns, the attending, wanted to do the intubation. He picked up a Mac 3 laryngoscope, a standard but fairly primitive-looking L-shaped metal instrument for prying open the mouth and throat, and slipped the shoehornlike blade deep into her mouth and down to her larynx. Then he yanked the handle up toward the ceiling to pull her tongue out of the way, open her mouth and throat, and reveal the vocal cords, which sit like fleshy tent flaps at the entrance to the trachea. The patient didn’t wince or gag: she was still out cold.

“Suction!” he called. “I can’t see a thing.”

He sucked out about a cup of blood and clot. Then he picked up the endotracheal tube—a clear rubber pipe about the diameter of an index finger and three times as long—and tried to guide it between her cords. After a minute, her sat started to fall.

“You’re down to seventy percent,” a nurse announced.

Johns kept struggling with the tube, trying to push it in, but it banged vainly against the cords. The patient’s lips began to turn blue.

“Sixty percent,” the nurse said.

Johns pulled everything out of the patient’s mouth and fitted the bag mask back on. The oximeter’s luminescent-green readout hovered at 60 for a moment and then rose steadily, to 97 percent. After a few minutes, he took the mask off and again tried to get the tube in. There was more blood, and there may have been some swelling, too: all the poking down the throat was probably not helping. The sat fell to 60 percent. He pulled out and “bagged” her until she returned to 95 percent.

When you’re having trouble getting the tube in, the next step is to get specialized expertise. “Let’s call anesthesia,” I said, and Johns agreed. In the meantime, I continued to follow the standard trauma protocol: completing the examination and ordering fluids, lab tests, and X rays. Maybe five minutes passed as I worked.

The patient’s sats drifted down to 92 percent—not a dramatic change but definitely not normal for a patient who is being manually ventilated. I checked to see if the sensor had slipped off her finger. It hadn’t. “Is the oxygen up full blast?” I asked a nurse.

“It’s up all the way,” she said.

I listened again to the patient’s lungs—no collapse. “We’ve got to get her tubed,” Johns said. He took off the oxygen mask and tried again.

Somewhere in my mind, I must have been aware of the possibility that her airway was shutting down because of vocal cord
swelling or blood. If it was, and we were unable to get a tube in, then the only chance she’d have to survive would be an emergency tracheotomy: cutting a hole in her neck and inserting a breathing tube into her trachea. Another attempt to intubate her might even trigger a spasm of the cords and a sudden closure of the airway—which is exactly what did happen.

If I had actually thought this far along, I would have recognized how ill-prepared I was to do an emergency “trache.” As the one surgeon in the room, it’s true, I had the most experience doing tracheotomies, but that wasn’t saying much. I had been the assistant surgeon in only about half a dozen, and all but one of them had been non-emergency cases, employing techniques that were not designed for speed. The exception was a practice emergency trache I had done on a goat. I should have immediately called Dr. Ball for backup. I should have got the trache equipment out—lighting, suction, sterile instruments—just in case. Instead of hurrying the effort to get the patient intubated because of a mild drop in saturation, I should have asked Johns to wait until I had help nearby. I might even have recognized that she was already losing her airway. Then I could have grabbed a knife and done a tracheotomy while things were still relatively stable and I had time to proceed slowly. But for whatever reasons—hubris, inattention, wishful thinking, hesitation, or the uncertainty of the moment—I let the opportunity pass.

Johns hunched over the patient, trying intently to insert the tube through her vocal cords. When her sat once again dropped into the 60s, he stopped and put the mask back on. We stared at the monitor. The numbers weren’t coming up. Her lips were still blue. Johns squeezed the bellows harder to blow more oxygen in.

“I’m getting resistance,” he said.

The realization crept over me: this was a disaster. “Damn it, we’ve lost her airway,” I said. “Trache kit! Light! Somebody call down to OR 25 and get Ball up here!”

People were suddenly scurrying everywhere. I tried to proceed deliberately, and not let panic take hold. I told the surgical intern to get a sterile gown and gloves on. I took an antiseptic solution off a shelf and dumped a whole bottle of yellow-brown liquid on the patient’s neck. A nurse unwrapped the tracheostomy kit—a sterilized set of drapes and instruments. I pulled on a gown and a new pair of gloves while trying to think through the steps. This is simple, really, I tried to tell myself. At the base of the thyroid cartilage, the Adam’s apple, is a little gap in which you find a thin, fibrous covering called the cricothyroid membrane. Cut through that and—
voilà!
You’re in the trachea. You slip through the hole a four-inch plastic tube shaped like a plumber’s elbow joint, hook it up to oxygen and a ventilator, and she’s all set. Anyway, that was the theory.

I threw some drapes over her body, leaving the neck exposed. It looked as thick as a tree. I felt for the bony prominence of the thyroid cartilage. But I couldn’t feel anything through the layers of fat. I was beset by uncertainty—where should I cut? should I make a horizontal or a vertical incision?—and I hated myself for it. Surgeons never dithered, and I was dithering.

“I need better light,” I said.

Someone was sent out to look for one.

“Did anyone get Ball?” I asked. It wasn’t exactly an inspiring question.

“He’s on his way,” a nurse said.

There was no time to wait. Four minutes without oxygen would lead to permanent brain damage, if not death. Finally, I took the scalpel and cut. I just cut. I made a three-inch left-to-right swipe across the middle of the neck, following the procedure I’d learned for elective cases. Dissecting down with scissors while the intern held the wound open with retractors, I hit a vein. It didn’t let loose a lot of blood, but there was enough to fill the wound: I couldn’t see anything. The intern put a finger on the bleeder. I called for suction. But the suction wasn’t working; the tube was clogged with clot from the intubation efforts.

“Somebody get some new tubing,” I said. “And where’s the light?”

Finally, an orderly wheeled in a tall overhead light, plugged it in, and flipped on the switch. It was still too dim; I could have done better with a flashlight.

I wiped up the blood with gauze, then felt around in the wound with my fingertips. This time, I thought I could feel the hard ridges of the thyroid cartilage and, below it, the slight gap of the cricothyroid membrane, though I couldn’t be sure. I held my place with my left hand.

James O’Connor, a silver-haired, seen-it-all anesthesiologist, came into the room. Johns gave him a quick rundown on the patient and let him take over ventilating her.

Holding the scalpel in my right hand like a pen, I stuck the blade down into the wound at the spot where I thought the thyroid cartilage was. With small, sharp strokes—working blindly, because of the blood and the poor light—I cut down through the overlying fat and tissue until I felt the blade scrape against the almost bony cartilage. I searched with the tip of the knife, walking it along until I felt it reach a gap. I hoped it was the cricothyroid membrane, and pressed down firmly. I felt the tissue suddenly give, and I cut an inch-long opening.

When I put my index finger into it, it felt as if I were prying open the jaws of a stiff clothespin. Inside, I thought I felt open space. But where were the sounds of moving air that I expected? Was this deep enough? Was I even in the right place?

“I think I’m in,” I said, to reassure myself as much as anyone else.

“I hope so,” O’Connor said. “She doesn’t have much longer.”

I took the tracheostomy tube and tried to fit it in, but something seemed to be blocking it. I twisted it and turned it, and finally jammed it in. Just then Ball, the surgical attending, arrived. He rushed up to the bed and leaned over for a look. “Did you get it?” he asked. I said that I thought so. The bag mask was plugged onto the open end of the trache tube. But when the bellows were compressed
the air just gurgled out of the wound. Ball quickly put on gloves and a gown.

“How long has she been without an airway?” he asked.

“I don’t know. Three minutes.”

Ball’s face hardened as he registered that he had about a minute in which to turn things around. He took my place and summarily pulled out the trache tube. “God, what a mess,” he said. “I can’t see a thing in this wound. I don’t even know if you’re in the right place. Can we get better light and suction?” New suction tubing was found and handed to him. He quickly cleaned up the wound and went to work.

The patient’s sat had dropped so low that the oximeter couldn’t detect it anymore. Her heart rate began slowing down—first to the 60s and then to the 40s. Then she lost her pulse entirely. I put my hands together on her chest, locked my elbows, leaned over her, and started doing chest compressions.

Ball looked up from the patient and turned to O’Connor. “I’m not going to get her an airway in time,” he said. “You’re going to have to try again from above.” Essentially, he was admitting my failure. Trying an oral intubation again was pointless—just something to do instead of watching her die. I was stricken, and concentrated on doing chest compressions, not looking at anyone. It was over, I thought.