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Tuesday, April 7, 9:38
A.M.

L
ynn had been the one to insert the chest tube using local anesthetic. Michael had watched. It was far easier than when they had inserted the needle thoracotomy, because Hank, a third-year emergency medicine resident, had been the instructor and stayed with them through the procedure. It went without a hitch and both Lynn and Michael felt reasonably confident they were much better equipped to handle the emergency care of chest trauma cases in the future.

After Clark Weston had been stabilized, Lynn and Michael went back out into the ER proper to see if they could lend a hand with any other patients. To their surprise, what they found was that the emergency situation was essentially over. While they had been seeing to Clark Weston’s needs, the rest of the patients from the accident had been taken to the MUSC Medical Center while the ones that had arrived at Mason-Dixon had all been seen and were in the process of being treated.

While they were still at the ER desk, checking if there was anything else they could do to help, Lynn caught sight of Dr. Sandra
Wykoff, who had also responded to the call to come to the ER. Impulsively running over, Lynn caught up with the woman as she was about to leave. Controlling her emotions, Lynn quickly reintroduced herself and again asked about getting together. Graciously the doctor agreed but said, “It has to be now since I’m about to begin a case. Will that work for you?”

“Absolutely,” Lynn said.

“Then come up to the anesthesia office on the second floor, next to surgical pathology. I’ll meet you there but don’t dawdle.”

“I’ll come right away,” Lynn assured her.

Rejoining Michael, Lynn snapped under her breath: “See the woman I was just talking with? That’s Wykoff, the anesthesiologist who screwed up with Carl.” She motioned with her head in the woman’s direction.

Michael watched Wykoff disappear before turning to Lynn. “Come on, sis, we’ve been over this. Be cool! For the tenth time, you don’t know there was any screwup.”

Lynn gave a short, mirthless laugh. “We’ll see,” she said. “The important thing is that she’s willing to see me now. Are you interested?”

“Since we missed the derm lecture, I guess I don’t have any excuse, and somebody has to keep you in line. But we’re going to go via the cafeteria so you and I get a few calories. I’m about out of gas and you’ve been on empty for hours.”

“All right, but it’s got to be takeout and fast,” Lynn said. “There is a narrow window of opportunity. She’s about to start a case. She even warned me ‘not to dawdle.’ Can you believe it? I don’t think I have ever heard anybody use the word
dawdle
.”

“You are certainly looking for ways to fault her,” Michael said. “
Dawdle
is a perfectly fine word. You catch my meaning, right?”

“I suppose,” Lynn agreed reluctantly.

Lynn was willing to take the risk of going via the cafeteria because she knew what food meant to Michael. She teased him on occasion that he was a growing boy. Taking the time now to get him
some food was a way of showing her appreciation that he was willing to come with her to talk to Wykoff. As a realist, she knew she probably needed some protection from herself, and he was the one to provide it. She couldn’t help but feel anger toward the woman and knew that expressing it would certainly be counterproductive.

The visit to the cafeteria was appropriately short. They grabbed a couple of bread rolls and some fruit at the register to eat on the run. As far as Lynn was concerned, there was another reason it was good that they did not stay. In her fragile emotional state, she didn’t want to take the chance of running into anyone who might ask about Carl’s surgery.

Five minutes later when they arrived outside the anesthesia office door, Michael pulled Lynn aside. “Wait a second,” he said. “We have to think what to say if Wykoff asks why we are interested in Carl’s case and how it was we read her note. She’s bound to ask us, and we can’t use the anesthesia story.”

“Obviously,” Lynn said. Because of the detour to the cafeteria, even though it was short, she was particularly impatient to get inside the office. She was afraid of Wykoff being called out at any moment and cutting the meeting short.

“The only thing that comes to mind,” Michael continued, “is to say we are on a neurology rotation, which I suppose is a laugh. It means we use anesthesia for neurology and neurology for anesthesia.”

“I don’t know,” Lynn said hesitantly. She didn’t like the idea and struggled to find another. “I agree she might ask, just like she might be touchy about Carl’s disaster. The problem is that it’s too easy for an attending like Wykoff to find out we’re lying. All it would take is one phone call, and we’d be in deep shit, and all doors for finding out about Carl would slam shut. No, we have to come up with something else so we’re not lying. Why don’t we say we are researching hospital-acquired morbidity? At least it’s true.”

“I’m not sure saying we’re studying hospital-acquired morbidity would be much better,” Michael said. “With the administration, the
idea of its own medical students researching something like that will go over like one of Ronald’s bad jokes.”

“Well, I can’t think of anything else,” Lynn said. “I think we’re stuck with the morbidity angle. That is, if she brings it up. Maybe she won’t. Come on! We have to get in there!”

“All right,” Michael said, throwing up his hands. “You’re the boss.”

“Hardly,” Lynn said. Facing the door, she hesitated. Not knowing if they should just go in or not, Lynn knocked, thinking it best to err on the conservative side. The sign on the door just said
ANESTHESIA
. A voice from inside called for them to come in.

It was a relatively small office without windows. There was no secretary. The space had four modern desks supporting computer terminals to be shared by all the anesthesiologists to handle their paperwork. A large bookshelf ran along the right wall and was filled with anesthesia texts and journals. Dr. Sandra Wykoff was sitting alone at one of the desks. As the students approached, she motioned for them to bring over a couple of the other chairs.

“So . . . ,” Dr. Wykoff said once they were seated, “who, may I ask, are you?” She was looking directly at Michael, and unlike many of the other attendings, she maintained eye contact.

“Another fourth-year medical student,” Michael said. He was impressed that she continued to stare at him.

“And you are researching the Vandermeer case along with Miss Peirce?” Dr. Wykoff’s tone was surprisingly matter-of-fact, neither friendly nor unfriendly.

“Yes,” Michael said. He didn’t elaborate. He wanted this to be Lynn’s ball game. All he was there for was hopefully to keep Lynn out of trouble.

“Why are you two interested in this case in particular?”

Michael noticed that the woman’s gaze had now appropriately shifted to Lynn.

The students exchanged a quick, nervous glance. It was Lynn who spoke up: “We have become aware of the huge problem about
hospital-acquired morbidity. We think this case fits that category all too well.”

Dr. Wykoff nodded and paused, as if thinking. Then she said, “Have you read my note in the Vandermeer chart?”

Both Lynn and Michael nodded, afraid of what was coming, namely a question as to why they were looking at the chart and under whose authority. But to their relief it didn’t happen. Instead the doctor asked, “What is it about this case that you want to discuss?”

“What the hell happened?” Lynn blurted out, causing Michael to wince inwardly. “I mean, how could a healthy twenty-nine-year-old man having routine elective knee surgery end up suffering brain death?”

“If you read my note, then you already know that nothing out of the ordinary occurred,” Dr. Wykoff said, seemingly not taking offense. Michael was both surprised and relieved. “The case was entirely normal. I thoroughly checked the anesthesia machine before the case and after. It functioned perfectly in all regards. The sources for all the gases and the gases themselves have all been checked and rechecked. All the drugs and dosages have been checked. I have gone over the case with a fine-tooth comb. So have several other anesthesiologists. Nothing happened that would have contributed to the unfortunate outcome. It had to have been some sort of idiosyncratic reaction.”

“There had to have been a screwup,” Lynn snapped.

Lynn’s tone and words made Michael now visibly wince. Before the doctor had a chance to respond, he said, “We did see in your note and in the anesthesia record that the blood-oxygen saturation suddenly went down.” He deliberately spoke in a measured tone as a counterpoint to Lynn’s outburst. “Do you or anyone else have idea of what made that happen?”

“The oxygen level did go down,” Dr. Wykoff said. “But it only dropped to ninety-two percent, which isn’t that low, and, just as
important, it immediately began to rise. Within minutes it was back to near one hundred percent. But to answer your question, I have no idea why it went down. The inspired oxygen concentration and the patient’s tidal volume had not changed.”

Lynn started to speak again but Michael gripped her arm to keep her quiet, saying, “We imagine it must have been a very disturbing case for you.”

“You have no idea!” Dr. Wykoff said, and paused before adding, “I had never had a serious complication before this case. It is my first.”

“In retrospect, would you have done anything differently?” Michael asked, wanting to keep the conversation going but without being accusatory.

Dr. Wykoff took another moment to continue. “I asked myself the same question. But, no, I wouldn’t have done anything differently. I handled the case the same way that I have handled thousands of others. There were no screwups! I can assure you of that.”

“There had to have been something,” Lynn interjected, despite Michael still gripping her arm. Although her voice wasn’t quite as strident, it was still harsher than Michael thought appropriate. “There had to have been something out of the ordinary that you did even if you didn’t think it could have made any difference.”

Dr. Wykoff silently stared at Lynn long enough to make Michael think Lynn had finally done it. He girded himself for an outburst from the doctor, but it didn’t happen. Instead, to his surprise and relief, Dr. Wykoff said, “There was something, but it was very minor and can’t have been significant. It is not something I did, but something I noticed. It did bother me when it happened.”

“Like what?” Lynn demanded, again with a bit too much emotion.

Michael desperately tried to think of something to say to cover up Lynn’s insensitivity, believing her carping tone was asking for trouble, not only for her but for him, too. The reality was that they had already seriously violated HIPAA by looking at Carl’s and
Scarlett’s charts and photographing the anesthesia records, and here Lynn was doing her best to alienate a woman who was being unexpectedly cooperative with a couple of medical students even though struggling emotionally herself. Michael sensed that the woman was deeply troubled by what had happened, which along the lines of “misery loves company” was probably the reason she was willing to talk with them at all.

“It involved the technical equipment,” Dr. Wykoff said. She spoke calmly, to Michael’s relief, and then paused to stare off into the middle distance.

“You mean with the anesthesia machine?” Michael said. He tightened his grip on Lynn’s arm to keep her quiet. From the sounds of her breathing he sensed she was about to say something.

“Not the machine per se,” Dr. Wykoff said. “But with the monitor. I happened to see it only because I was concentrating on looking at the monitor at the moment it occurred. It was when the surgeon began drilling into the tibia. I wanted to make sure that the depth of analgesia was adequate. Since the periosteum has a lot of pain fibers, I was watching the vitals closely.”

“And what happened?” Michael asked.

“Let me show you,” Dr. Wykoff said. “It is actually part of the anesthesia record.” Dr. Wykoff directed her attention to the screen of the computer terminal and began punching in commands.

While she was busy, Michael gave Lynn’s arm an extra squeeze to get her attention. “Cool it, girl!” he mouthed along with a harsh expression when she looked at him. He was serious. Lynn responded by trying to get her arm back, but Michael would not let go. Under his breath he said, “Let me do the talking! You’re going to get us thrown in jail if you keep up! Seriously!”

“All right, here it is,” Dr. Wykoff said, interrupting. The doctor angled the monitor’s screen more toward the students. It was the image of the anesthesia machine–generated record in graphic form of what had been on the monitor during the case, including blood
pressure, pulse, ECG, blood oxygenation, end tidal CO
2
, expired tidal volume, and body temperature. Michael and Lynn stood up to get a better view, even though it was what they had already seen in Carl’s chart.

“Look closely,” Dr. Wykoff said. She enlarged the image and used a pen as a pointer. “Here is when the oxygenation fell from close to one hundred percent down to ninety-two. It’s at eight-thirty-nine, or sixty-one minutes into the operation. That was when the alarm sounded. And you can see the ECG simultaneously shows tenting of the T waves, suggesting the heart isn’t getting adequate oxygen. Now, that doesn’t make sense. An oxygenation saturation of ninety-two percent shouldn’t cause the immediate appearance of T waves in a normal, healthy heart. Also there’s no change in any of the other parameters, which would certainly happen if there was low enough oxygen to cause brain damage.”

“We saw that when we looked at the chart,” Michael said.

“It’s hard not to see it,” Dr. Wykoff said. “It jumps out at you, since the oxygenation tracing was essentially a straight-line until that instant. But the fall is not what I want to show you.” She used the cursor to move back along the oxygenation tracing to fifty-two minutes into the operation, where there was a slight vertical blip upward. “Do you see this?”

“I do,” Michael said. “It is a sudden notch upward, whereas the O
2
tracing otherwise is like a flat, smooth sine wave, varying between ninety-seven and one hundred percent. What does it mean?”