Doing Harm (18 page)

“Okay, so … where did all that extra potassium come from then?”

“We’ll never know for certain. What we think happened is that the pharmacy computer made a mistake and gave out too much potassium. The pharmacist never realized it, and the computer never recorded it. Just between you and me, it wouldn’t be the first time something like this has happened. There was a near miss very similar to your case several months ago—a patient almost received a lethal dose of magnesium because the system gave out ten times the requested amount. The pharmacy dispensing system is old. Everything needs to be replaced.”

“Are you going to go looking for that extra potassium? Audit the system?”

“No. There’s no point. The extra bit of potassium that killed your patient is a drop in the ocean compared to what comes through this hospital every day. There’s no way we could ever definitively track it all down. More important, hospital leadership is not … overly anxious to draw any more attention to this whole thing. Safety issues. Bad press. The hospital is simply going to overhaul the entire pharmacy system.”

“Okay. Good for the hospital. What has any of this got to do with me? I wasn’t the one who put the extra potassium in the bag.”

“No, but … here’s the thing. The Committee is concerned that you have a pattern of ordering a lot of potassium for patients who don’t really need it. They think that you—uh, that you demonstrated poor clinical judgment that created an unsafe situation.”

“What the hell does that mean?”

“Well, the Committee went back and audited all of your medication orders over the last six months. It’s very easy to do these days. In fact, you can do it yourself. You probably already know how. ERIN tracks every order made by every doctor in the hospital. According to ERIN, in the weeks leading up to that patient’s death, you ordered IV potassium for a bunch of patients who didn’t need it.”

“
What?
What are you talking about?”

“Steve. Look. I’m just telling you the way it is. I saw the orders myself. During the first part of July, you ordered IV potassium for fifteen patients with completely normal potassium levels: fifteen patients, none of whom had any business getting IV potassium. They were small doses, and nobody got hurt, but the Committee was extremely concerned about the pattern.”

I have no idea what he’s talking about.

“I have no idea what the hell you’re talking about, Jason. Not a clue.”

“Look. Everyone just wants this whole thing to go away. Quietly. The word on the street is that the lawyers have already cut a deal. The patient’s dad—the rich guy—is anxious to avoid publicity of any kind, and he’s already accepted the results of our investigation—and, uh … your, uh, role in his death.”

My role in his death.

“So what does this mean for me?”

“The final conclusion of the Committee will be that your poor clinical judgment substantially contributed to this patient’s death.” His voice has become clipped and formal, like he’s reading the official report to me over the phone. “First, you allowed this patient to receive the wrong antibiotic in the operating room. The antibiotic caused the renal failure. Second, and more important, you put potassium in the TPN solution. Putting potassium in the TPN was a mistake, a mistake consistent with your prior erratic ordering pattern. The recommendation of the Committee will therefore be that you undergo remedial medical training. The hospital will temporarily suspend your operating privileges while you take some courses in the med school on electrolyte management and patient safety. For the duration of the suspension, you won’t be able to operate.”

“What? Screw that. I’ll be nothing more than a fucking med student again,” I say loudly. A well-dressed, middle-aged couple at the table next to mine glances sourly at me before continuing their conversation.

“Steve,” he says patiently, “if you do what they tell you, everything will eventually turn out okay. A slap on the wrist. They’ll put a disciplinary letter in your confidential personnel file, and you’ll be fully reinstated within a few weeks, once you’ve finished the remedial coursework. That’s it. That’s as far as it will go. You bend over and take it up the ass for a while, then it’ll be like it never happened.”

“And if I don’t? If I refuse to cooperate?”

“They’re going to kick you out of your residency program. They’re going to fire you.”

It’s like someone’s punched me in the face. My head reels; I grab the side of the table with my free hand to keep myself steady. I feel like I’m going to puke, and I mark the fastest way to the bathroom as a precaution. But then my initial shock is swept away by a rising tide of indignation and embarrassment. My vision steadies; my stomach settles.

“I can’t believe this, Jason. This is bullshit. This is complete bullshit.”

I’m practically shouting into my cell phone now. The couple at the next table has stopped talking and is glaring at me with open hostility. A few other patrons surreptitiously size me up over the tops of their laptops and lattes. “I … okay, yeah, I let the guy get the Cefotetan in the operating room. It was stupid. I admit it. But I did not order potassium on any other patients. I swear to God I didn’t. I’m going to fight this.”

“Don’t shoot the messenger, okay? I’m really going out on a limb here by giving you all of this information. And I tried, man. I tried to get them to go easier on you. But those potassium orders you wrote…”

“I didn’t write those fucking orders!”

“Look, I know it sucks—”

“You don’t know shit!”

“Fine,” he huffs. “But before you get all worked up,
Doctor,
you might want to take a look at those potassium orders yourself.”

He hangs up.

“That’s exactly what I’ll do!” I scream into the now-dead connection before flinging my phone on the table. The middle-aged couple casts one final, baleful scowl at me as they head outside, and as the rest of the seats in the general vicinity discreetly empty. The acne-laden baristas confer anxiously behind the counter, no doubt trying to decide which one of them is going to ask me to leave.

But I don’t care. I know exactly how to audit my own electronic medical orders. I pull my laptop out of my bag and boot it up. My fingers flying furiously over the keyboard, I remotely access ERIN, key in my account ID and password, and pull up the medication-ordering system. Spitting invectives at Jason, I quickly locate all of the medication orders I’ve written since June. The data scroll rapidly across the screen as I work my way through June and July.

And suddenly, there they are.

Potassium orders.

A whole series of them. Starting in the middle of July. Stopping the day before Mr. Bernard died.

I blink, and my jaw goes slack. I can’t believe what I’m seeing.

Holy shit.
You have
got
to be kidding me.

Fifteen patients with normal potassium blood levels.

Fifteen orders for IV potassium.

All made by me.

Date: July 16. Patient: HS. Medication: Potassium Chloride. Dose: 30 mEq IV.

Date: July 17. Patient: LP. Medication: Potassium Chloride. Dose: 20 mEq IV.

Date: July 17. Patient: GN. Medication: Potassium Chloride. Dose: 20 mEq IV.

And so on.

All told, according to the computer, in just under ten days, I ordered a total of 300 mEq of intravenous potassium—a whopping amount of potassium by any measure—all in separate, small doses for fifteen patients with normal potassium levels. All for patients who didn’t need potassium.

I lean back in my chair, stunned, my jaw slack.

How the hell could this have happened? Could I have ordered that much potassium without realizing it? Not likely. I could never have written fifteen separate orders like that and just forgotten about it. I’m busy, but I’m not that busy. Besides, it’s Luis who writes most of the medication orders for our patients.

Computer glitch? Maybe. But that would have had to be one major fucking glitch.

An absurd suspicion occurs to me: Could somebody have hacked the system and faked the orders? Deliberately set me up? Made me look bad just to draw attention away from the hospital’s flawed pharmacy dispensing system?

My pager goes off, derailing my train of thought.

Now what?

Steve,
it reads,
have patient with multiple GSW 2 pelvis. OR 6. ASAP. Thx. Dan, gen surg.

GSW 2 pelvis.
Gunshot wound to the pelvis. A trauma. I have to get back to University Hospital right away.

By the time one of the baristas has finally worked up the nerve to approach me, anxiously wringing her hands, I’ve already shut down my laptop and packed it away in my shoulder bag.

“Never mind.” I brush past her brusquely. “I was just leaving.”

*   *   *

Thirty minutes later, I’m in a fresh set of scrubs and walking into OR 6, which is humming with activity. To my surprise, GG is already there. I don’t know how she heard about this patient, but she’s sitting at a table in a corner of the room at a computer, energetically filling out electronic paperwork. I nod appreciatively at her, and she pauses long enough to give me a thumbs-up.

At the center of the room, a couple of general-surgery guys are hovering around a small man lying on the operating table. One of them is Dan—the chief resident, married to Sally’s friend—the same one I saw banging the brunette nurse in the call room a few weeks ago.

As I move closer to the operating table, I realize that the patient lying on top of it is not a man but a young kid, barely a teenager. He’s completely naked except for a bunched-up, bloodied hospital gown that covers his genitalia like a fig leaf on an old Greek statue.

He’s already asleep, his smooth, pubescent features obscured by the plastic endotracheal tube secured in his mouth. His eyes are taped closed, a single strip placed vertically over each eyelid. The tape, a common practice in the OR to protect the eyes from drying out during operations, always makes me think of ancient Greek funerals, when family members placed coins over the eyes of the departed so they could pay the ferryman Charon to cross the river Styx into Hades, the land of the dead. It’s a creepy analogy, I know. So I don’t exactly go around sharing it with people at work.

Dan approaches me, his handsome face and straight blond hair obscured by his surgical mask and cap. We exchange pleasantries.

“So.” He jerks his thumb toward the kid on the operating table. “Sorry to bother you. Thanks for coming up so quickly.”

“No problem. What’s up?”

“Healthy fourteen-year-old black male with multiple GSWs to the abdomen and pelvis. The usual bullshit: Said he was standing on a street corner, minding his own business, when some guys he didn’t know just came up to him and shot him for no good reason. Anyway, he’s been hemodynamically stable, but the CT showed multiple bowel injuries, so we’re exploring him. A few of the bullets also hit his, uh, his…” He gestures vaguely toward the bunched-up gown covering the kid’s genitals, then coughs.

“Penis? Testicles?”

“Yeah, his penis.” He coughs again. “And testicles. I think. It’s a fucking mess down there, and we were more worried about his abdomen, so I didn’t take a very good look.”

“Okay.” I put on a pair of gloves and walk over to the table. Bullet-entry wounds can look deceptively unimpressive. Three are scattered across this patient’s lower abdomen: irregular puncture marks in the skin, each one no bigger across than my fingernail. I gingerly pull off the bloodied hospital gown covering his groin and let it fall to the floor.

Here, in the area previously covered by the gown, the wounds are a lot more obvious. One of the more seasoned scrub nurses, laying out instruments on a table behind me, stops to peek over my shoulder and whistles. GG, who’s joined me at my side, gasps.

One of the bullets has entered the skin near the base of the kid’s penis and torn a path like a gopher through moist soil down nearly the entire length on the left side, exiting near the tip through a large, ragged hole located right next to the catheter that’s draining urine from his bladder. Another bullet (or the same one, maybe, but it’s hard to tell with all the dried blood and shredded skin; in any case, the question is pretty much academic) has ripped through the left side of his scrotum. A bloody, pulpy mess—the remains of the left testicle—pokes out of the torn skin. Through the same gaping hole in the skin, I catch a glimpse of the right testicle, which looks okay.

I’m abruptly struck with an image from an old World War II movie I saw once. It’s a scene in which a GI gets one of his balls blown off by a land mine, and his grizzled, been-there-done-that sergeant tosses the emancipated testicle away over his shoulder and assures the poor guy that his other testicle is just fine and that everything’s going to be okay because
that’s why God gave us two, soldier.

I tell Dan that the kid’s going to need some work and to call me when his team finishes fixing the intestines. GG affirms she’s going to stay and help. I call Dr. Jones, the professor who’s on call, and then Sally (just back from Providence) to let her know that I likely will just sleep in the hospital tonight. GG and I then head to the cafeteria to grab some dinner. With time to kill, and the potassium weighing heavily on my mind, I take her into my confidence, telling her all about my conversations earlier that day with my friend the kidney doctor and Jason. She listens intently, wide-eyed, hanging on my every word, vowing to help me solve the mystery of where the potassium came from.

GG and I meet up with Dr. Jones in the OR a few hours later, after Dan’s team is done. Jones is really pissed about having to come to the hospital tonight, something about leaving in the middle of his daughter’s engagement dinner. Very old-school and very cranky, he keeps mumbling stuff like “Why can’t these people just shoot each other in the head and save us the trouble?” and “Well, the sooner we fix him up, the sooner he can go back to selling drugs and shooting his friends.”

By the time we’re done, I’m firmly decided to stay overnight in the hospital. I dispatch GG to the medical-student sleeping rooms and trudge to my dingy call room, where I’m greeted once again by its dusty kitten denizen on the poster hanging on the pockmarked wall. The room is eerily quiet—no drunks or amorous couples tonight—just the occasional speeding car or distant police siren echoing along the deserted city streets below my window.