Doing Harm (17 page)

She notices me noticing her, and a knowing smile plays about her lips.

I finally come to my senses and, with more reluctance than I care to admit, pull my leg away, cough, and become very interested in the cancer patient over her shoulder. GG settles back in her seat and returns to her bagel.

The moment is over.

Silence descends as she nibbles on her bagel, and I sip my coffee while gazing over her shoulder at the cancer patient.

“It’s kind of weird, though. You wouldn’t have thought we gave him enough potassium to cause the arrhythmia,” GG says thoughtfully.

“What?” The cancer patient is eating a doughnut now, smiling weakly as her companions urge her on with each bite.

“It’s just … you know, we really didn’t give him all that much potassium. It just seems like it shouldn’t have caused any problems.”

I put down my coffee and stare at her, surprised, the awkward exchange of a few minutes ago completely forgotten. Lately, during my hours of solitary brooding, I’ve circled back to that same thought myself several times, which first occurred to me the night Mr. Bernard died: the idea that we didn’t order enough potassium to have killed him. I’ve been hesitant to pursue it, because I haven’t wanted to falsely raise my hopes that there’s a way out of this mess that doesn’t involve my accepting complete responsibility. Besides, the Safety Committee’s relentless questioning has kept me off-balance.

“What makes you say that?”

She shrugs. “Did you know it takes 100 mEq of potassium chloride in 50 cc of normal saline to kill an average adult? Given all at once as an IV bolus?”

“Really? That much?” I ask, with genuine interest.

“Yeah. The Chief Medical Examiner for Boston told us that during one of our pathophysiology lectures. I know Mr. Bernard’s kidneys were still recovering. But still—we gave him way less than 2 mEq per cc. And we spread it out over several hours of infusing time.”

“Huh.” I gaze over her shoulder at the cancer patient. She wipes chocolate frosting mixed with sprinkles off her lips and says something I can’t hear. Her companions laugh heartily in response. “So then let’s talk hypothetically for a second. Mr. Bernard clearly died of hyperkalemia. But if we didn’t give him enough potassium, where did it all come from? What could have made his serum K go up? Something in his other medications? Potassium in one of the carrier fluids? Rhabdomyolosis? But, then, why would he have gotten rhabdo? All of those seem pretty unlikely.”

“What if he was accidentally given potassium by someone else, like the pharmacy?”

“Maybe. But I would think, I would
hope,
the pharmacy would have safety measures in place to prevent that kind of thing from happening. Or at least it should.”

The cancer patient finishes her doughnut. She looks tired but triumphant.

*   *   *

My conversation with GG stokes my curiosity. Is it really possible that we didn’t give enough potassium to Mr. Bernard to have killed him? I send GG home (though doubt she’s really going to leave) and, armed with a fresh cup of coffee, hunker down in my office. Over the next several hours, I examine all of Mr. Bernard’s blood-potassium levels and kidney-function test results in the days leading up to his death, which are still stored in the computer. Back when I was a medical student, I completed some advanced course work in nephrology, so I have experience with the kinds of calculations I need to make. I’m a little rusty at first, but after a while I’m able to chart out all of his blood-potassium levels and compare them to how well his kidneys were working in the hours leading up to his death.

The answer I finally arrive at, as the sun filtering through the windows softens into midafternoon, is clear: even accounting for Mr. Bernard’s renal failure, the amount of potassium we put in the TPN couldn’t have made his blood levels go up so high, so fast.

In other words, based on my (admittedly crude) calculations, we couldn’t have killed him.

I check my equations twice more to be sure, then lean back in my chair and chew on the tip of my pen, trying to contain the nascent excitement squirming in my chest. Part of my brain—the reasonable, cautious one—reminds me that it probably isn’t the best idea in the world to latch onto my amateur postmortem analysis. I mean, how could I have missed something so obvious, so straightforward, so right-in-front-of-my-face the whole time? Could it really be this easy? Numbers that don’t quite match up? Something even a medical student thought of? And what about the Safety Committee? Shouldn’t they have stumbled onto this by now? Why haven’t they mentioned it?

I heave a sigh and concede that this conclusion is probably too good to be true; and my initial excitement dies a quick, reluctant death.

But my curiosity does not.

So I call my friend Richard, a young professor at University Medical School who specializes in kidney diseases. He owes me a couple of favors, not the least of which is that I introduced him to his fiancée, a fact about which I subtly remind him near the beginning of our conversation. I explain what I need and, even though it’s the weekend, he agrees to meet up with me.

We rendezvous at a Starbucks on Harvard Street about an hour later. I spring for a couple of lattes. We find a quiet table in the back and, after some perfunctory chitchat, I show him my equations, arrayed carefully on several sheets of paper. Using some apps on his smart-phone, Richard reviews them line by line, asking me pointed questions about how I crunched the numbers. Fortunately, for some reason, he doesn’t ask me why I want to know what I want to know, or grill me over the exact circumstances surrounding Mr. Bernard’s demise.

He works quickly, practically at light speed compared to my stumbling pace earlier in the day; next to him, I’m like a kindergartner wielding crayons, and he’s finished before my latte is even halfway gone. He makes a few corrections here and there, moves some decimal points around, and pokes a couple of small holes in my assumptions.

But, for the most part, Richard completely agrees—there’s no way Mr. Bernard’s blood potassium could have climbed as quickly as it did based solely on the amount of potassium that Luis and I ordered for him. He slides my papers back toward me across the table and finally takes a sip of the latte.

I don’t know if it’s the latte, his answer, or both, but my hands tremble markedly as I pick the papers up and place them carefully in my shoulder bag. Richard watches me with polite concern and asks me if there’s anything else I need. I tell him no and thank him for his help. He gives me a hard look, opens his mouth as if to say something, then snaps it shut. He shakes my hand and pushes himself away from the table.

As I watch him leave, the cautious part of my brain again tries to have its say.

It can’t be that easy!

But my ego, emboldened now, up off the mat and ready for some payback, quickly shouts that part of my brain down. It latches greedily onto this new development.

Of course it could be that easy.

A sudden surge of desperate manic energy roars through me, like swollen river rapids through a narrow mountain gorge, filling me with a euphoric sense of hope that, after the persistent gloom of the last two weeks, is practically intoxicating. My head spins. I want to pump my fists in the air and scream like one of those body-painted idiots at a football game.

Why? Because I’m giddy with the tantalizing prospect of absolution. After all, if I didn’t give Mr. Bernard enough potassium to kill him, it must have come from somewhere else.

It wasn’t my fault.

The questions now rush at my addled brain like baseballs firing toward me in an automated batting cage.
What made the potassium go up so high, so quickly? Where did all that potassium in his blood come from? If we didn’t give him too much potassium, then who did? And how? And what about the Safety Committee?

The Safety Committee.

Shit.

I completely forgot about the Safety Committee.

See? I told you,
cautious brain smirks.

Shut up,
ego replies.

I sit for a moment, thinking. If I was able to figure this out, there’s no way the Safety Committee wasn’t.

I pull out my cell and call Jason, my friend on the Committee. He answers right away. He’s friendly at first, but cools quickly as I reveal the underlying purpose of my call. Before he can hang up I quickly explain the discrepancy in the potassium levels and ask him if the Committee has found anything similar in its investigation.

The other end of the line is quiet for several long beats. My first thought is that the call dropped.

“Jason? Hello? Can you hear me?”

He makes a sound that’s somewhere between a grunt and a sigh. In my mind’s eye, I can picture him on the other end of the line as he thinks things over, his broad, handsome face scrunched up in concentration as he holds the cell phone next to his ear with one thick, muscular hand while absently and repeatedly running the fingers of the other through his thick, jet-black hair—a nervous tic that always surfaced in med school when he was answering a difficult question in class or poring over a particularly challenging problem in a textbook. He has absolutely nothing to gain and potentially a whole lot to lose by telling me anything. If I were in his position, I probably wouldn’t say a thing.

“Yeah, I’m here, dude. Look, Steve,” he says haltingly. “I’m really not supposed to talk to you about this. Technically, I’m not supposed to talk to you
at all.
If the Committee found out, I’d get into a lot of trouble. Real trouble.”

“I know, Jason. It’s just that things have been kind of rough for me lately, and I thought you could … that it wouldn’t hurt anybody to give me a little more information.”

“Yeah. Yeah. I know, man. I’m sure it sucks for you right now. Well … I guess it’s okay to let you know, at this point.” I suck in my breath and clutch the phone harder. “You can’t repeat to anyone what I’m about to tell you, Steve, okay? Really, man. I’m serious about this. You really can’t. For real. I would get into a lot of fucking trouble. I had to sign a nondisclosure agreement. It’s serious business. If it ever got out I talked to you, I’d be in a world of hurt. We both would.”

“I understand.” I swallow hard, trying to imagine how much more hurtful my current world can possibly become.

“Okay, so, the Committee met again yesterday. We’re pretty much done, Steve. And I think you should know that the reason why we’re moving so fast is that, apparently, your patient was quite a VIP. Or at least the son of one. His father is some reclusive billionaire who’s given tens of millions to University Hospital. Anonymously. He keeps a very low profile, but has some serious fucking clout. So the hospital CEO and medical-school dean are really putting the screws to us to take care of this quickly and quietly.”

Mr. Bernard? The son of a billionaire?
He never told me he even had a family. I wonder what his backstory was. Maybe he didn’t want his family to worry about him while he was in the hospital. Maybe he was too proud to ask for help when he was sick. Maybe he was a prodigal son—a prodigal son who’ll now never have an opportunity to return home.

“Steve? You still there, man?”

“Yeah, yeah. It’s just … he never talked about his father. The patient, I mean.”

“Sure. Okay. Whatever. So, the autopsy confirmed that your patient most likely died from a catastrophic cardiac arrhythmia secondary to hyperkalemia. No surprises there. All the tissue assays were consistent with that diagnosis, and the rest of the autopsy findings were unremarkable. His medications checked out, too. But there was one thing that really jumped out.”

I swallow. Hard. “Which was what?”

“The total parenteral nutrition—TPN—solution, which was the presumed source of the potassium that killed your patient.”

“What do you mean?” I clench my fist.

He lowers his voice. “The concentration of potassium in the TPN was at least a hundred times greater than the amount you had ordered for him. Possibly more.”

“Really.” I unclench my fist.

“Yeah. Really. We’ve checked it four times now at three different labs.”

“So…”

“So you’re right. The numbers don’t jibe. It was the massive amount of potassium in the TPN solution that killed your patient. There was enough in there to have killed a horse. But you didn’t order that potassium. It all came from somewhere else.” He pauses. “I’m impressed you came up with that on your own.”

I feel like dancing around the room. “Thanks, Jason,” I say, forcing myself to sound calm. “It’s something that’s been on my mind a lot lately.”

“I can only imagine. But … there’s something else I think you should know.”

The discomfiture in his voice makes my palms start sweating. Suddenly, I don’t feel like dancing anymore.

“What?”

There’s a long pause, long enough for me to again think that the call dropped.

“Jason? Are you still there? Hello?”

“Yeah, dude, I’m still here. I told you this much, so I guess it can’t hurt to tell you the rest.”

“Tell me what?”

“I just don’t want you to be blindsided when the official report comes out.”

“Blindsided by
what,
Jason?”

“By the rest of the report. By what it’s going to say about the extra potassium in your patient’s TPN bag. Where it came from.”

“Okaaaaay. So, where did it come from?”

He quickly explains that hospital pharmacists prepare each individual TPN bag based on the doctor’s orders. A pharmacist checks the orders, withdraws the exact amount of each ingredient from the pharmacy’s computer-controlled storehouse, then combines all the ingredients into a single, sterile solution with the help of a semiautomated assembly line. The Committee believes that the pharmacist who prepared Mr. Bernard’s TPN solution may have accidentally put in too much potassium.

Great, I reply. So it was the pharmacist’s fault.

Except, Jason continues, the computer-controlled storehouse is like a big ATM machine. The pharmacist keys in the exact amount of each ingredient desired—of potassium, sodium, whatever—and gets back only that amount from the storehouse. The computer keeps a strict digital record of each transaction, allowing the pharmacy to keep track of how much is coming in and how much is going out. According to the computer record, the pharmacist who prepared Mr. Bernard’s TPN that day withdrew from the computer-controlled storehouse the exact amount of potassium that had been ordered.