Doing Harm (13 page)

Mr. Bernard’s not going to make it. I can tell right away by the way he looks.

Mr. Bernard is going to die tonight.

In fact, he’s pretty much dead already.

The medical resident overseeing the code is a mellow-looking guy with sandy brown, sleep-tousled hair. Standing quietly in a corner, gazing intently at the interns, he’s wearing a wrinkled University Hospital scrub top over a white T-shirt, tan Gap slacks, and white sneakers. I introduce myself and ask him what happened.

He hands me an EKG strip, his gaze fixed on the code team and Mr. Bernard. “This is what we got just before he went into torsades, then pulseless v-fib arrest.”

With my finger, I trace the dark, sharp peaks and valleys of Mr. Bernard’s heart rhythm running across the pink-and-white-colored strip of EKG paper.

“Hyperkalemia?”

“Yes.”

“Is that why he arrested?”

“Probably. The last K we got back was 8.1.”

Mr. Bernard’s heart stopped beating because he has too much potassium in his blood.

“And you guys treated him for it?”

“Sure.”

“You tried the usual stuff? Calcium gluconate, insulin, glucose?”

“Yeah. Of course. Nothing worked. By the time they called us, he was too far gone to be able to do much about it. Way too gone.” He stifles a yawn, then looks at me as if something has just occurred to him. “Hey, any reason you guys would have given him potassium today? This patient doesn’t have a history of kidney disease, but I noticed he has a recent history of acute renal failure. In this situation, at the top of my differential for acute hyperkalemia would be an exogenous source of potassium overwhelming renal filtration in the setting of low GFR.”

So he thinks Mr. Bernard’s been overdosed with potassium.

“Have you guys given him any potassium recently? You know, in his medications or IV fluids? I reviewed his medication history over the last few days, but didn’t see anything that popped out at me.”

I’m about to say no, of course not, why would I ever give a patient with kidney problems a dose of potassium, when I spot a half-empty TPN bag hanging on an IV pole next to Mr. Bernard’s bed.

The TPN bag reminds me of the conversation I had with Luis and GG in the cafeteria this morning.

When I told them to put potassium in Mr. Bernard’s TPN solution.

Despite Luis’s concern that Mr. Bernard’s kidneys might not be able to handle that much potassium all at once and that he would end up hyperkalemic.

Fuck.

For the second time today, my stomach drops through the floor, and I feel like I’m going to start throwing up again.

I look at the EKG again, then at Mr. Bernard’s lifeless body as GG rhythmically pushes on his sternum—
down, up, down, up
—keeping time with the anesthesia resident forcing oxygen into Mr. Bernard’s otherwise motionless lungs with the bright green Ambu bag—
weeha, weeha, weeha.
The activity in the room has slowed, most everyone now recognizing the futility of their efforts. Those not directly involved with resuscitating Mr. Bernard have either fallen back to the periphery of the room to watch expectantly or quietly wandered out the door and back to their usual jobs.

GG trades positions with a burly male nurse, who attacks Mr. Bernard’s chest with macho gusto, at one point jerking down a little too hard with one of his chest compressions. There’s a loud crack, like the sound of an enormous stick of celery being snapped in half, and Mr. Bernard’s sternum breaks cleanly down the middle, his chest collapsing like a deflated accordion. A few
oooohs
escape from the remaining crowd.

Defibrillator Resident tries shocking him again. Mr. Bernard barely twitches. They might as well be trying to electrocute a rock.

“Well … we did put some K in his TPN,” I admit reluctantly, as much to myself as to the medical resident, whose head now swivels from the code to me. “His serum levels had been running a little low, and we were trying to replete him.” I’m staring now at the half-empty TPN bag, and the medical resident follows my gaze. “He’s been hypokalemic lately, so we figured we’d just replete him by putting potassium in the TPN solution. We didn’t give him that much—just enough to get his blood levels back up. At least, that’s what we had calculated.”

Actually, I have no idea if Luis really calculated out the proper amount of potassium based on Mr. Bernard’s renal function or not. I hope he did. I suspect he just made an educated guess. That’s what we usually do. It’s normally not a problem.

“Really.” The medicine guy hesitates, his face expressionless as he considers this new bit of information and stares at the half-empty TPN bag. Then he shrugs, and says, “Well, you can’t be too sure that the TPN was the source of the K. Or at least the only source. I mean, if like you say, you didn’t put that much K in the bag, and that you really calculated it based on his most recent GFR.” He turns back toward me. “How much did you put in it?”

I haven’t the faintest idea how much potassium Luis put in the bag. “Umm … I’d have to go back and check our notes. See how we crunched the numbers again. We’ve had a lot of stuff going on today.”

“Right. Sure. It probably wasn’t that much.” The medicine guy’s voice is flat. His expression is blank. But the unspoken message I catch from his bloodshot eyes is pretty clear.
Stupid surgeon. Putting potassium in the TPN bag of a patient with acute renal failure. What an idiot.

The medicine guy’s reaction isn’t surprising. I’m sure he thinks he’s the smartest guy in the room. Medicine guys are the types of people who love memorizing obscure diagnoses and worthless facts, schooling themselves with bits and pieces of medical arcana that make them sound smarter. They love to know stuff like the species of scorpion that can cause pancreas inflammation—a handy piece of medical trivia that might help you out in case you ever happen to be stung by a scorpion while camping in certain areas of rural Mexico. (Or maybe not, since if you’re unlucky enough to develop pancreas inflammation from a scorpion sting while camping in certain areas of rural Mexico, you’re probably pretty much screwed no matter what you do.)

And most medicine guys are convinced that, as a group, surgeons are brainless Neanderthals who cut first and ask questions later. Surgeons, for their part, think that medicine guys are overeducated wimps who talk a good game but never do anything about it. (“Intellectual masturbation” sniffed a general surgeon I know as we walked past a bunch of medicine guys on rounds one time, who were earnestly discussing some obscure disease outside a patient’s room.)

Still, I’d better get used to the kind of withering look the medicine guy is giving me right now. I have a feeling it’s going to be happening to me a lot after tonight.

“Look,” the medicine guy says after an awkward pause. “The patient’s not responding at all, and we’ve been going at it now for almost twenty minutes, mostly because I wanted to let my junior residents and interns practice running a code. But I’m getting ready to call it. Is that okay with you?” He stifles another yawn and checks his watch.

I nod, numbly. He’s right.

“You’ll take care of all the death-certificate paperwork, right? That’s your responsibility, you know. It’s not my job. My attending will back me up on that.”

His reluctance is understandable. Death certificates are a pain in the ass to fill out.

“I’ll take care of it.”

“Good.” He gives the order to stop the resuscitation, formally pronounces the time of death, wishes me luck, and disappears.

Just like that, everyone stops, packs up their stuff, and clears out of the room: doctors, nurses, medical technicians. I step to one side as one of the nurses rumbles past me with the crash cart, loaded with the defibrillator and emergency medications.

Nobody looks back.

The junior residents and interns who ran the code clap each other on the back and compare notes as they saunter out the door.

Defibrillator Resident is euphoric. “Did you see me shock that guy?”

“That was
awesome,
” his companion replies enthusiastically. “Nice job. And you got to use the old manual defibrillator paddles! Old-school! Wow, what a rush. Too bad he didn’t make it…”

Then, abruptly, it’s just me, GG, and Mr. Bernard.

I slowly walk to the side of Mr. Bernard’s bed. The floor of the room looks like something out of a crack den, littered with empty syringes and medicine vials and used IV bags. I pick my way carefully through the debris. GG follows me and stands by my side. Together, we gaze down at Mr. Bernard.

He doesn’t look peaceful. The dead are supposed to look peaceful, but Mr. Bernard appears anything but. His head is tilted back at an unnatural angle, with his defiant chin pointed toward the ceiling, and his mouth is wide open, as if he’s trying to scream around the breathing tube still lodged in his throat; and all of his limbs are tensed, as if he’s trying to jump off the bed but can’t, his muscle proteins beginning to lock up in the early stages of rigor mortis. Ugly, dark streaks crisscross the ashen skin of his thin chest: electric burn marks, tattooed by the defibrillator. His sternum, snapped by the overzealous chest compressions, is caved in like a pothole on a city street and contrasts sharply with the steep convexity of his massively swollen belly.

I thank GG for her help. She looks like crap: utterly spent, with flushed cheeks and beads of sweat running down her face, hair tousled, her chest still heaving up and down from the effort of the code. Most people don’t realize how physically demanding it is to perform chest compressions. I’m sure her arms and shoulders are going to be sore as hell tomorrow. Her exhaustion seems as much emotional as physical: There are big dark circles under her eyes, and she looks very, very sad. Still, underneath the sadness, something else, too, stirs. I can see it in her eyes. A manic energy; something close to exhilaration, even.

Strange. But I’ve seen that reaction before. Hell, I’ve
felt
it before: that rush you get while trying to snatch a life back from death’s clutches, win
or
lose. It’s like those medicine interns just now, high-fiving each other, jazzed about the defibrillator. It was probably GG’s first time at a code, and you remember your first code the way you remember other big events in your life, like your first kiss. It’s that intense.

I tell her to go home and get some sleep. Instead of protesting, as she normally would, insisting that she stay and help, she just mumbles thanks and shuffles away.

Now it’s just me and Mr. Bernard.

I stare at him for a long time.

I think of the DO NOT REMOVE scrawled on his penis.

I think of alligator farms.

I think of unfinished business.

I wonder whether right now he’s in the deepest sleep ever or chatting with Jerry Garcia.

“All finished, Doc? I need to take him downstairs.” A big man stands indifferently at the door, his huge hands on his hips, cracking gum. He’s wearing a dirty white lab coat with the word “Pathology” embroidered across the left pocket in cursive. There’s a metal gurney parked in the corridor behind him. He’s waiting to take Mr. Bernard to the basement.

To the morgue.

Jesus, that was fast.

The nurses must have called him a long time ago, while the code was still running but its outcome appeared inevitable. I can’t really blame them. Nobody likes having a dead body hanging around a busy hospital floor.

I nod numbly and glance at Mr. Bernard one last time as the man starts cramming the metal gurney and his own massive frame through the doorway. Then I remember that I still don’t know how much potassium Luis actually put in the TPN solution. I pick my way through the debris over to the IV pole and read the label stuck to the front of the half-empty TPN bag hanging next to the bed.

Potassium chloride: 20 mEq.

In one liter of fluid.

Only 20 mEq of potassium, in this volume of fluid, is hardly any potassium at all. Practically nothing. I guess Luis had, just like he said he would, erred on the side of caution by putting only a little bit of potassium in the TPN solution.

Strange, though.
Just 20 mEq of potassium shouldn’t have been enough to cause hyperkalemia. But, then, I’ve seen weirder things happen in the hospital. I push the question from my mind. Right now, I’ve got more important things to worry about.

I leave the room as the guy from Pathology starts heaving Mr. Bernard (Mr. Bernard’s
body
, I correct myself) onto the metal gurney, then walk down the hall to the nurses’ station, where a mountain of paperwork—incident reports, death-certificate applications, medical charting, adverse-event notes—awaits me. It’s always that way after a patient dies.

But the first thing I have to do is call Mr. Bernard’s lady friend—his designated contact, it turns out; Mr. Bernard didn’t report any immediate family on his admission paperwork—and let her know what happened. I pull the phone number from Mr. Bernard’s chart and dial it. I’m immediately routed to her voice mail and wonder what the protocol is here.

What should I do? Leave a message telling her what happened?

Hi, it’s Dr. Mitchell from University Hospital. Just wanted to call and let you know that I, like, killed your boyfriend tonight. I gave him too much potassium. Yeah. That’s right. Potassium. You know. It’s the same stuff that comes in bananas. It stopped his heart cold. Potassium does that. In fact, it’s what the state uses to kill condemned prisoners by lethal injection. It’s supposed to be a pretty humane way to go. Anyway, sorry about that. Give me a call back when you get a chance. Thanks.

I leave a message saying that something serious has happened to Mr. Bernard and that she needs to call the hospital answering service immediately.

I then call Andrews at home. By now it’s pretty late. The call wakes him up. I decide to tell him the whole story: renal failure, TPN, potassium, hyperkalemia, cardiac arrest. Everything. Better, I figure, to just come clean up front.

Andrews is understandably pissed and screams at me for several minutes, ranting so loudly at some points that I have to hold the receiver away from my ear to keep his raspy shouts from shredding my eardrum. He finishes by promising me that I
haven’t heard the end of this
before the line goes dead.