Doing Harm (39 page)

“There’s no time,” an assured Southern twang observes from behind us. Sushil and I spin around to face the on-call CT surgery attending. He’s standing next to the supervising nurse, clad in scrubs.

That was fast. But of course, I remember—his call room is right down the hall. Literally right outside of the SICU. He must have been in bed.

If he was asleep, he certainly doesn’t look it now. Hands on his hips, calmly working a piece of gum in slow, deliberate motions, his self-assured demeanor anchors me against the rising tide of panic in the room. His salt-and-pepper hair, worn high and tight in a flattop, is perfectly coifed. His back is straight and his chin is up—military all the way. In fact, I seem to remember reading a piece in the hospital newsletter about his being an officer in the Army Reserve who’s done two combat tours in Afghanistan.

Exactly the kind of guy we need right now.

“You don’t have a fluoro set up here, son,” he drawls. “And it’ll take too long to snake a catheter blindly. She’s been in asystole for—what? Five, ten minutes now? Closed cardiac massage ain’t doin’ you a damn, son. She’s losing neurons by the second. Even if you do manage to thread a line into her atrium, it’ll take too long to suck out all that air. There’s too damn much. She needs percutaneous transcardial aspiration.”

Without waiting for a response, he turns to the supervising nurse. “Ellen, I need a cardiocentesis tray. The one with the eighteen-gauge spinal needle.” His tone is polite; but he radiates absolute, unassailable authority. He doesn’t ask Sushil or me our opinion, doesn’t open the floor for debate, doesn’t for a moment concede that there may be options at this point other than slamming a big-ass needle directly into Mrs. Samuelson’s heart.

As an attending, he’s now the senior doctor present—not to mention the one with the most experience in these kinds of situations. He now calls the shots. Sushil, of course, realizes this and humbly steps back—literally and figuratively—without another word. The nursing supervisor scurries off to grab the surgeon’s equipment.

I feel a tremendous surge of relief. Now I’m back on familiar turf. Surgery-type stuff. Cold steel to heal, baby. The CT surgeon can fix her. I know he can.

Ellen promptly returns with the cardiocentesis tray. The CT surgeon sizes me up as he prepares the equipment: a scalpel, a six-inch-long hypodermic needle, an empty syringe, sterile sheets, and iodine solution.

“Steve, right?”

“Er, yes, sir.” Even though I was never in the military, I stand up more straight. I can’t quite summon up the surgeon’s name. I wish I could. I can barely contain my surprise that he knows mine.

“I remember when you rotated with us on the cardiac-surgery service. You did a good job. Want to lend me a hand, son?”

“Sure.”

“Okay, then let’s move. Quick as a jackrabbit, son. Grab you a pair of sterile gloves and prep for a subxiphoid approach. I’m going to need you to stabilize the transthoracic echo for me while I aspirate the air. Let’s move!” Then, to the assembled code team, he adds, “Let’s move her back supine. Quickly, folks, quickly!”

The rest of the team responds by taking Mrs. Samuelson out of her left-side, head-down position and placing her on her back again. As for me, there’s no time for the kind of rigorous sterile prep jobs we normally perform in the OR before making an incision. Each moment we hesitate is more time Mrs. Samuelson’s oxygen-starved brain spends dying. I throw on a pair of sterile gloves, hastily splash the iodine on her chest and upper abdomen, and spread the sterile sheets across the lower half of her body, leaving a small window that exposes the skin at the base of her breastbone. With the scalpel, the surgeon nicks a patch of the skin that’s exposed through this window. Through the incision, Mrs. Samuelson’s blood runs dark and thick and sluggish, indicating that it’s low on oxygen.

Not a very promising sign.

“Hold compressions,” the cardiac surgeon says. The code-team nurse currently performing chest compressions stops.

And, according to the heart monitor screen perched over her bed, so does Mrs. Samuelson’s heart.

“Still asystolic,” the surgeon murmurs. Using the ultrasound cord shaped like the vacuum-cleaner attachment, he locates her heart the same way Sushil did, but much more quickly. “Steve, hold this for me right … here.” I grab the ultrasound cord, careful to prevent it from shifting from its current position.

The surgeon takes the needle, now connected to the large syringe, and expertly plunges it through the skin incision, aiming it toward Mrs. Samuelson’s head at a forty-five-degree angle to her skin. It’s the surest, quickest way to the heart from here. He promptly sinks the needle halfway underneath her breastbone.

A thin, bright, white line simultaneously appears on the ultrasound video monitor—the tip of the needle. The surgeon moves the needle forward, deeper into Mrs. Samuelson, more slowly and cautiously now, using the ultrasound images to guide the tip through the thick outer musculature of her heart. Twice, he needs to redirect the needle tip before finding the correct path into the heart’s hollow center. He positions the tip directly in the middle of the right ventricle—the chamber that blood flows through before entering the lungs—then freezes in place. Carefully holding the needle in place with his thumb and forefinger, he draws back the plunger of the syringe.

I grit my teeth.

This is it.

The syringe promptly fills with air.

“It’s working,” I say excitedly.

“We’ll see, son,” the surgeon replies flatly. He finishes pulling back the plunger, carefully unscrews the syringe off the needle, and hands the syringe to me.

“Quickly, Steve, reset the syringe for me, son.”

We repeat the process three more times, each time withdrawing about 60 cc of air from Mrs. Samuelson’s heart. On the fifth attempt, when he pulls back the plunger, the syringe starts to fill with blood. With breathtaking speed, he withdraws the needle, hands it to me, places his hands on her sternum, and starts performing chest compressions.

The whole process—from the time he first asked the nurse for the needle to when he began compressions—couldn’t have taken more than ninety seconds.

But when the brain is deprived of oxygen, ninety seconds can be like ninety years.

Please, Mrs. Samuelson.

You can make it.

Silence grips the room. Everyone is either staring at the surgeon regularly pushing on Mrs. Samuelson’s heart or, like me, gazing at the heart monitor in anticipation of what we’ll see when he stops. Right now, the compressions are casting wavy, sinusoidal peaks in the line running across the monitor, like a series of rolling hills viewed in profile.

“Okay,” he says after several minutes, “let’s see what we’ve got. I’m holding compressions.”

Every eyeball in the room fixates on the heart monitor.

As the wavy bumps characteristic of the chest compressions disappear, the heart curve flattens out into a line so straight it’s like it was traced with a ruler.

Several agonizing seconds tick by. Nothing happens. The line remains as unbroken as the horizon.

Dammit!

I grind my teeth in frustration. I want to scream at the top of my lungs.

Fuck!

And then, just as the surgeon is about to resume the chest compressions—

It’s the faintest of blips at first. Barely a minor distortion in the precise geometry of the line. But the next one, occurring a few seconds after the first, is bigger and stronger. The next one, stronger still.

And then, like the bursting of a dam, the beats are coming one on top of another, confident and sure, charging across the screen.

The electric signatures of normal heartbeats.

Those regularly interspersed hills, peaks, and valleys are the most beautiful things I’ve ever seen.

Mrs. Samuelson’s heart is beating again.

The feeling is indescribable.

Mrs. Samuelson is alive.

She’s going to make it.

I beat her. I beat GG.

Most of the ten people or so assembled in the room heave a collective breath of relief. A few smiles appear. One of the nurses pats another one on the back.

But the cardiac surgeon seems less sure. He stares at the screen for a full thirty seconds, watching her heart rhythm reestablish itself, hands poised over her chest, ready to initiate compressions again.

Her heart rate eventually stabilizes at 120 beats per minute. A little on the fast side, but still—she’s had a lot of epinephrine, and considering what she’s been through, it’s not all that bad. Meanwhile, elated, I start planning my next move. How will GG react when she realizes her plan didn’t work? Will she concede defeat? Is there a way I can gather evidence that she caused this?

Finally, satisfied, the surgeon slowly drops his hands to his sides.

“Okay. Once she’s a little more stable, we can take a step back and reevaluate her status, maybe think about gettin’ her down to the hyperbaric oxygen chamber to blow off any residual air—” His voice trails off.

Puzzled, I follow his gaze back to the cardiac monitor.

Mrs. Samuelson’s heartbeat is slowing.

Ninety beats per minute.

The surgeon’s eyes narrow.

Forty beats per minute.

He calmly repositions his hands back over her chest.

Ten beats per minute.

The other members of the code team shift uneasily.

Zero.

The geometrically straight heart line has returned.

All hell breaks loose again. The surgeon starts pumping her chest and calling for more epinephrine. The team redoubles its efforts, the energy in the room even more intense and focused.

But this time it feels different.

This time, it feels like she’s really gone.

The surgeon agrees with my silent assessment. “She’s got the smell of death on her, son,” he murmurs to me. “The smell of death.”

Still, he keeps it up for another fifteen minutes after that, every few minutes pausing to check if her heart has jump-started again. We give her several more doses of epinephrine.

Nothing.

The line on the monitor remains stubbornly, monotonously flat, like a highway stretching away through the desert. The color of Mrs. Samuelson’s skin matches the metallic gray light of early dawn outside.

Eventually, the surgeon shakes his head and stops. After nearly twenty minutes of continuous chest compressions, he hasn’t even broken a sweat.

“That’s it. We’re done.”

He calls the time of death.

“Well, can’t say we didn’t try. Thanks for your help, son.”

So that’s it.

Mrs. Samuelson is dead.

I lose.

“Is the family here?” the CT surgeon asks evenly, removing his gloves.

“We called them as soon as we initiated the code,” the supervising nurse responds. “They’re assembled in the waiting room.”

Oh crap.
Mrs. Samuelson’s family. How can I possibly face them now?

“I’ll talk to them,” the surgeon says. With a loud snap, he launches each dirty glove into a nearby red-colored trash can. “But I need someone who knows the patient to come with me. Would that be you?” He points to Sushil, who’s been taking care of Mrs. Samuelson since she first arrived in the SICU after her operation.

Sushil nods. “Sure. I’ll come with you. How about you, Steve? You’ve been with them from the beginning. Do you want to come, too?”

The last thing in the world I want to do right now is speak with Mrs. Samuelson’s family. I’ve completely failed them not just once, but twice. I can’t do it. I shake my head.

Sushil, clearly surprised, looks like he’s about to say something, then shrugs and looks at the surgeon. The surgeon looks from Sushil to me, then back to Sushil.

“Okay, then. Let’s go, son.”

Shell-shocked and utterly defeated, I drop into a chair at the nursing station and watch as they go out to deliver the news. As the automatic doors leading into the waiting room swing open, I glimpse Mrs. Samuelson’s anxious family, standing expectantly in a tight knot near the door.

The doors close.

The seconds tick by.

And then the scream—incoherent and anguished and only barely muffled by the closed automatic doors—stabs through the SICU. It feels like a white-hot knife rammed into my belly. I squeeze my eyes shut and wait for it to end.

But it doesn’t. The initial scream transitions into a prolonged wail punctuated by disbelieving cries of
no
and
but she was better.
I recognize in that agonized howl the voice of the youngest daughter; and, indeed, as Sushil and the cardiac surgeon return to the SICU, I see through the briefly opened doors the rest of the family gathering tightly around her, comforting her as she sobs uncontrollably, their own faces vivid with grief.

“Well,” says the cardiac surgeon flatly, to no one in particular, “that could have gone better. Good thing the preacher was there. Thanks for your help, everyone.” Without another word, he wanders off toward his call room, as unflappable and cool as when he first appeared.

Sushil, on the other hand, looks thoroughly depressed and unnerved. He ignores me as he walks by, toward another patient’s room. But I know what he’s thinking.

Coward.

Maybe. But if he only knew what I’d done, knew that I had gambled with Mrs. Samuelson’s life—and lost. Spectacularly. I prop my elbows on the counter in front of me and rest my face in my hands.

“Dr. Mitchell?”

I peer upward through the gaps in my interlaced fingers. It’s Carol. She gingerly places my white coat, laptop, and computer bag on the counter.

“I think these are yours. You left them in Mrs. Samuelson’s room.”

“Thanks, Carol.”

“Sure. You know, Dr. Mitchell, if you still want to talk to the family, we’re going to let them back here in a few minutes to pay their respects before we take her—you know, downstairs.”

Downstairs.
Just like Mr. Bernard.

I nod and stand up, intending to slink out through the back door to avoid Mrs. Samuelson’s family. I put on my white coat and absently slip my right hand into the front pocket. It hits something hard and cylindrical. I frown, puzzled. I don’t normally keep things in those pockets. I close my fingers around the object and pull it out to examine it.