Medical Error (26 page)

"Anna, sit down." Neil Fowler half-rose and motioned Anna to the visitor's chair across from his desk. "How are you doing?"

"Did Mike Simpson call you?" Anna asked.

"No, but I just got out of surgery." A faint line on Fowler's forehead from the elastic band of a surgical head cover and the wrinkles in his scrub suit confirmed this.

"Well, he just examined me. He thinks maybe I should be offanother week, because of my concussion."

Fowler frowned. "I was counting on your coming back to work sooner than that." He pulled a pad toward him and scribbled a note. "I guess I can change around some of the staffing schedules. You take your time and get well."

He shoved the notepad aside and leaned forward. "Anna, how are things in general? I mean, I got a call from the DEA and they've pretty much cleared you. Your new permit and number should be on your desk when you come back. But how about the other stuff? Your identity theft, for instance."

Anna ran her hand through her hair. "I haven't had time to deal with that. Now the Dallas police are threatening to charge me with Eric Hatley's murder. They say I gave him a drug I knew he was allergic to, then held back treatment so he'd die of anaphylaxis."

"That's nonsense!"

"Not the way they put it together. They say I was supplying him with Vicodin 'scripts, and he'd threatened to go to the police and blow the whistle."

Fowler seemed calm, but she noticed that his knuckles were white on the arms of his chair. "That's absolutely ridiculous. I hope you have a good lawyer."

Here we go again.
"Yes, Ross Donovan." Anna decided to meet the next comment head-on before Fowler could make it. "He's Laura Ernst's ex. He's had alcohol problems, but he's clean and sober now. I think he's doing a good job."

Lines creased Fowler's forehead. "Okay, but if you need a recommendation . . ."

"Thanks, but—"

"Dr. Fowler! Dr. McIntyre! You're needed in the ER."Fowler's administrative assistant stood in the doorway. "There's been an accident on Central Expressway. An eighteen-wheeler plowed into a loaded school bus, and that started a chain reaction pileup. Multiple casualties are on their way. They need all available surgeons in the ER stat."

Anna realized at once that she had two choices. She could beg off, citing residuals of her concussion, and buy herself another week before Green and Dowling could get to her. But an extra hand in the ER, maybe in the operating room, could mean life or death for someone. There was really only one choice, wasn't there?

"I'm on my way." Fowler was already shrugging into his white coat. "Anna, I don't guess you'll be coming, will you? I mean, if Mike told you to take another week off."

Anna's hesitation lasted only a second more. "No. Looks like you'll need all the help you can get. I'll come too."

In Anna's experience, the Emergency Room of Parkland Hospital was unlikely to be calm at the best of times. Even at three a.m., the waiting room was often crowded, the cubicles full. Today, the treatment rooms were occupied and the hallways filled with teenagers on gurneys. Will Fell and another junior surgery resident moved quickly from patient to patient, assessing injuries and performing triage.

Anna edged the door open and took in the scene in the waiting room. A harried security guard struggled to keep a tide of parents, all talking at once, from spilling into the treatment area. A senior nurse waved a stack of clipboards and pleaded, "Please let the doctors do their jobs. Take these forms and give us the medical history on your children. We may need to give them medications, and we need to know if they have any drug allergies." A chill ran up Anna's spine as she recognized that these words would always have added meaning for her.

She turned back to Neil Fowler, who stood at the junction of two hallways, directing traffic and letting the confusion flow around him like rushing water around a boulder. "What do you want me to do?" she asked.

He nodded toward a dark-haired, teenage girl who lay moaning at the end of the hall. "Will thinks she has internal injuries, maybe a lacerated spleen. Check her out. If she needs surgery, OR 6 will be ready by the time you get her up there."

Apparently, the girl's parents had somehow managed to slip into the treatment area. They stood beside her stretcher, holding her hand and murmuring in Spanish. The mother fingered a rosary; the father wiped away a tear.

Anna grabbed a passing medical student, one she recognized from his recent rotation through her surgery service."Matt, what are you doing right now?"

The young man seemed relieved to see a familiar face. "Dr. McIntyre. I'm here to help."

"Okay, then you're mine. Come on. Let's check out this girl. She has one IV running. Start a second one in the other arm, and while you're doing it, draw blood for H&H, 'lytes, crossmatch for six units. Got it?"

"Yes, ma'am."

"Ma'am is your mother. I'm either Dr. McIntyre or Anna, depending on how well you do. Now move."

Matt whispered something to the girl's parents and they moved away, giving him room to work. Anna moved toward the head of the stretcher, looked down at the girl, and said, "I'm Dr. McIntyre. What's your name?" When the girl continued to moan, Anna said, "
¿Qué es su nombre?
"

"Her name is Rosa Hernandez." The words were almost whispered, the voice a low baritone with the faintest trace of accent. "And she speaks English, as do we. She's just too frightened to talk."

Anna turned to face the parents, who now stood at the foot of the gurney. The father took a step toward her, his jaw clenched, tears coursing down his cheek. The woman continued to finger her rosary.

"Listen," Anna said, "we think Rosa has internal injuries. I may need to stick a needle into her abdomen and see if there's blood there. If there is, that would mean she's had a serious injury and would require emergency surgery. We might have to remove her spleen, sew up a laceration of her liver, even—"

"Whatever it takes, Doctor." The father's voice was low and intense. "Whatever we need to sign, we will do it." He began to roll up his sleeve. "If you need my blood for her, tell me where to go so they can take it. Just do it."

"Thank you." She looked at Matt, who was handing offthe tubes of blood he'd drawn to a runner who'd take them to the lab. "Matt, get the Hernandez family to sign a permit for a four-quadrant abdominal tap, exploratory laparotomy, splenectomy, repair of internal injuries. You should know what to include. I'm going to find an empty cubicle and take Rosa in there."

"What about an MRI or a CAT scan?"

Anna was already pushing Rosa's gurney away. "Radiology's already overloaded and we can't wait. I'm going to do it the old-fashioned way. Four-quadrant belly tap. Find us when you've finished getting the paperwork done."

In the exam cubicle, Anna quickly gathered the supplies she'd need. After reassuring Rosa and injecting a local anesthetic, she inserted a long needle into the girl's abdomen in the right upper quadrant. The first tap yielded nothing. So far, so good. But on the second tap, when she drew back on the plunger the syringe filled with dark blood. Blood in the abdomen. Most likely a ruptured spleen. Maybe a lacerated liver. Perhaps even—please, God, no. Not a tear of the aorta. If that major vessel broke loose, Rosa could bleed to death in a matter of minutes. This was a surgical emergency.

Matt pulled aside the curtains. "Permit's signed. Hemoglobin's eight, 'crit twenty-five. The chems are cooking."

"What about—?"

"They're cross-matching blood for her now. I've asked for a unit of O negative stat, and I'll hang it as soon as it gets here."

"Okay, let's get her up to the operating room. We're going to OR six. You'll be my assistant."

16

A
NNA BROKE ALL SPEED RECORDS FOR A QUICK CHANGE INTO SCRUB clothes. Soon she stepped away from the scrub sink, her dripping arms held before her, her mind focused on the operation she was about to perform. "Let's go, Matt. That'll have to do."

She bumped through the door into OR Six, and then it hit her. This was where it all started—with Eric Hatley's operation and the events that followed in rapid-fire succession, events that now threatened to end her career. Well, she'd go out fighting. The place didn't matter. What mattered was what she did here.

As she gowned and gloved, Anna studied her surgical team. Karen, the scrub nurse, chose instruments from a sterile pan and arranged them on the green-draped rolling tray that would be placed across the operating table for easy access. Anna nodded to herself. Karen was a battle-tested veteran of the surgical wars, someone who could be depended on not to crack under pressure. But when she saw the circulating nurse, Anna winced. Keisha was a new hire, fresh out of nursing school. Would she panic at a critical moment?

Matt stepped to his spot across the operating table from her. Below his surgical mask, his Adam's apple moved twice. His shoulders rose and fell, and Anna could hear the sigh. She knew what he was feeling. She'd been there herself once.

Anna breathed a silent prayer. Time to get moving. "Okay, prep and drape. Keisha, give her belly a couple of passes with Betadine. Matt, help Karen with the drape sheet. Anesthesia, are we ready?"

"Yes, ma'am."

Anna focused on the man sitting at the head of the operating table. Even with the surgical mask covering the bottom of his face, the voice and the eyes confirmed his identity: JeffMurray, the junior resident who'd given Eric Hatley's anesthetic.

"Jeff," Anna said, "where's your staffman?"

"He . . . He's in the next room. We have every available OR going, so he has to stafftwo cases. But I'll be fine, Dr. McIntyre. Don't worry." The words expressed confidence that the eyes didn't back up.

No time to quibble. This was the team she had. "Okay, Jeff. Keep her as light as possible. Watch her blood pressure—I mean, watch it closely. Keep the fluids going, push the blood until we get the bleeding controlled."

"Right. She's got Ringer's running in one arm, a unit of unmatched O negative in the other, and the cross-matched blood is on its way up." He met her gaze. "I'm on top of this one. Really."

Anna turned back to the operative field. She picked up a gauze sponge with her left hand and held out her right."Scalpel."

She felt the familiar pressure as Karen slapped the instrument into her palm. "Matt, get a clamp in one hand, a sponge in the other. Clamp the largest skin bleeders. We can deal with them later. As soon as we get the abdominal cavity open, be ready with the suction. There'll be a lot of blood, and you have to keep it cleared out so I can see."

Anna could see the drops of sweat already dotting Matt's forehead. He'd done well as a medical student on her service, but she was asking him to take a huge step up in responsibility. Well, he'd either sink or swim, and she couldn't waste time worrying about it.

Now she worked on automatic pilot. Skin incision, through the subcutaneous fat—thank goodness the girl was thin. Separate the muscles. "Self-retaining retractor." Matt was doing well, better than she'd hoped.

"How's her pressure holding up?" Anna asked.

Murray's voice was steady. "She was shocky when we brought her in, but with fluids she's holding at about a hundred over sixty. One unit unmatched O negative already in, first unit of cross-matched blood going in now."

"Keep me posted," she said. "Here we go. Opening the peritoneum. Matt, ready with the suction. Karen, we'll need a stack of lap pads—"

"Already up, Doctor."

"Thanks." Anna grabbed one of the large gauze laparotomy pads. "We'll need a bunch."

She incised the peritoneum, the tough but thin covering around the abdominal contents. Immediately, dark blood welled into the incision. "Left upper quadrant, Matt. Looks like a ruptured spleen."

In a moment, the bleeding area was packed off. Now Anna was able to identify the problem: a laceration running diagonally across the spleen. This was what she'd hoped for, one of the best possible scenarios. The spleen was important but people could live quite nicely without one, since other parts of the body would take over its function of making blood cells and antibodies. All Anna had to do was clamp offthe blood vessels supplying the spleen and remove it. Problem solved.

Anna finally relaxed a bit. "Matt, you got a permit for splenectomy?"

"Splenectomy, partial resection of liver, bowel resection, whatever might be necessary."

"Good man. Okay, Karen. Let's get that spleen out of here. Bring up the vascular clamps." With the problem diagnosed and a solution in sight, Anna swung into teaching mode. "Matt, we're looking for the region where the blood vessels feed into the spleen. Tell me what it is and the procedure."

"The splenic artery and vein. After you ligate and divide those, you identify and clip the short gastric vessels."

As Matt described the anatomy involved, Anna's hands moved with efficiency and skill. This was what she knew, what she was good at, what she loved. It was good to be back.

She paused for a second as the thought crossed her mind. Soon, maybe as early as tomorrow, she'd be in an interview room with Dowling and Green. They'd already made it clear they were planning to charge her with the murder of Eric Hatley. It was very possible that she was performing her last operation. Well, if that was the case, she'd do a good job. And today she could add one more name to the list of patients who were alive because of her efforts.