Tuesday, July 2, 2:55 p.m.
Contrary to what Mitt had hoped, almost three hours of sleep didn’t make him feel markedly better. Quite the contrary, at least when his phone rang to wake him up and for about fifteen minutes thereafter. But after splashing a bit of cold water on his face and stretching his arms and back muscles, he started to rally. By the time he got out to the elevator lobby, Mitt felt almost human.
Unfortunately, feeling almost human had its downside. As he boarded the elevator, he relived the despair he’d felt when it was determined that Ella Thompson’s heart wasn’t going to restart and there was nothing to be done. In retrospect the episode ultimately freaked him out almost as badly as when Benito Suárez’s aorta blew.
Mitt had rather innocently allowed himself to be talked into studying medicine as a way to help people by making them well, certainly not to cause their deaths. What was bothering him was the nagging realization that if Ella Thompson had refused to get her mitral valve fixed or if he hadn’t cleared her for surgery with his admitting history and physical, she’d be alive at that moment, probably home and interacting with her great-grandchildren instead of being stretched out on a slab at the medical examiner’s office, where he guessed she was at the moment.
And as if those thoughts weren’t bad enough, as he rode in the elevator, he started thinking about his renowned medical forebearers and the surprising revelation that although they’d been highly skilled and respected, ultimately they all had been on the wrong side of history. Could that really have been the case? He didn’t know, but he vowed to look into it, especially since Dr. Harington was so certain. He thought he’d start by asking his father, who’d always prided himself on being the family historian. Mitt decided to raise the question that night when he called his parents. He didn’t know what he’d learn, but at least he could count on sympathy, especially from his mom.
Arriving at the eleventh floor and heading into the OR suite, he made a beeline toward the surgical lounge and the locker room. Mitt wanted to be sure to dutifully change into a clean pair of scrubs, even if his current scrubs would be covered by the sterile surgical gown. He didn’t know if it was required, but it seemed to him to be a good idea. Contrary to his famous relative Otto Fuller, he believed wholeheartedly in the “germ theory.”
But as he was traversing the surgical lounge he stopped. Unexpectedly he spotted Dr. Harington talking with someone over at the communal coffeepot. She was in civvies and a long white coat while her companion was in scrubs with a stethoscope slung around his neck and a tourniquet looped around his pants’ tie. Making a sudden change of plans, Mitt veered in their direction and approached the pair. He didn’t have much time, as Dr. Rodriguez had admitted that he’d waited until the last minute to call and the patient was already in the operating room.
The man Dr. Harington was conversing with was the first to see Mitt approach, and he interrupted Dr. Harington and gestured in Mitt’s direction.
“Ah, Dr. Fuller,” Dr. Harington said, her face brightening when she caught sight of him. “What a pleasant coincidence. I was just talking about you. Meet Dr. Winthrop, our head of Anesthesia, and, Dan, meet one of our brand-new first-year surgical residents.”
Mitt shook hands with the Anesthesia chief but immediately turned to Dr. Harington. “Sorry, I only have a minute since I’m late for my case, but I wanted to ask you for a favor. I’m interested in that unpublished article by Robert Pendleton. Do you think you could email it to me or send a link? To be honest, what you said about my medical ancestors was a surprise, and I’d like to look into it.”
“Most certainly,” Dr. Harington said. “I’ll be happy to do so. Does Communications have your email address?”
“They do,” Mitt said.
“Consider it done,” Dr. Harington said. “Meanwhile, I have to tell you that Dr. Winthrop is almost as much a Bellevue history devotee as I.”
“Yes, indeed,” Dr. Winthrop said, jumping into the conversation. “Pamela has told me you are a direct descendant of four of our illustrious Bellevue doctors. I think that is terrific. More than terrific. It’s an honor to have a member of such a well-known professional family again among us. Welcome aboard!”
“Thank you,” Mitt said, unsure of what else to say. “But after what Dr. Harington told me about their stances on some important issues, I’m not so sure how well it speaks for me.”
“Nonsense,” Dr. Harington said, breaking into the conversation. “We can’t judge our professional forebearers in hindsight. No way! They were all great in their own time, and all made significant contributions to Bellevue and medicine in general.”
“Maybe so,” Mitt said. He wasn’t going to get into an argument over the issue, especially not until he learned more about the reliability of the source. “I have to get to my case, but it was nice to meet you, Dr. Winthrop.”
“The pleasure’s mine,” Dr. Winthrop said.
“I’m sorry our case this morning didn’t have a better outcome,” Dr. Harington said. “I hope you scrub in with me again in the near future.”
“I do, too,” Mitt said, and meant it. Even though he was still upset over how matter-of-factly she’d terminated the case with Ella Thompson, he did appreciate the general atmosphere of her OR in contrast to that of Dr. Washington.
After his minor detour to talk with Dr. Harington, Mitt dashed urgently into the locker room, bursting through the swinging doors. Once inside, he slipped out of his doctor’s coat and pulled off his scrub top before grabbing a new scrub set, all on the fly. The coat went into his locker, the clean scrubs on his body, and the soiled scrubs in the appropriate bin before he ran back out of the locker room, across the lounge, and into the inner portion of the OR suite.
Before starting his scrub at the sink outside of OR #4, he quickly glanced through the wire-embedded glass window into the operating room. At that exact moment, Dr. Rodriguez and Dr. Arthur Reston, the attending surgeon, whom he’d yet to meet, were in the process of draping Roberto Silva’s scrubbed and antiseptic-painted abdomen. As Mitt feared, he was going to be a bit late, which wasn’t the way he wanted to start a relationship with another of the Bellevue attending surgeons.
Although he was eager to get into the OR, Mitt scrupulously followed the scrubbing rules he’d been shown by Dr. Van Dyke the day before. Almost five minutes later, he pushed backward into the OR, holding his hands aloft and accepting a sterile towel from the scrub nurse. To his surprise, she introduced herself as Kathy, which was a first for Mitt. Kathy then helped Mitt don his sterile gown and gloves. In due course, the circulating nurse tied the gown behind his neck while introducing herself as well. Her name was Caroline. Although he was nervous about being late, he felt more relaxed after being welcomed by both nurses. That hadn’t happened on his first two cases.
Now completely prepared, Mitt approached the operating table. The patient had been fully draped, with just a small area on the upper part of the abdomen exposed. The attending surgeon was standing on the patient’s right side while Dr. Rodriguez was on the left. Both men had their hands crossed and pressed up against their chests, waiting. Mitt wondered if they had been waiting for him.
“I’m sorry I’m late,” Mitt said.
“No problem,” Dr. Rodriguez said. “As you can probably see, we’re in a holding pattern on orders from Anesthesia.”
Mitt nodded. When he’d entered, he’d noticed that instead of one anesthesiologist there were two, but at that very moment, Dr. Winthrop, whom Mitt had so recently met, also hurriedly entered the room, tying his face mask over the top of his head as he did so. He joined the others and the three gathered in hushed but tense conversation. Mitt could hear that the pinging of the cardiac monitor was not its usual metronomic rhythm but rather irregular, with short, distinct pauses.
“Dr. Reston, meet Dr. Michael Fuller, one of our first-year residents,” Dr. Rodriguez continued.
“Welcome to the program,” Dr. Reston said. He was a sizable man, even larger than Dr. Rodriguez, with a deep, gravelly voice. “Why don’t you go over to the other side and join Dr. Rodriguez. I think that’s where you’ll be the most help.”
“Certainly,” Mitt said. He skirted Kathy and her instrument tray and rounded the foot of the operating table. Dr. Rodriguez moved to the side, creating more space between himself and the anesthesia screen. As Mitt slipped into position directly across from Dr. Reston, he hoped he’d not end up being blocked by Dr. Rodriguez as he’d been on his first case. He’d heard that pancreatic surgery was difficult, and he was eager to be able to see how it progressed. Although the three hours of sleep he’d just gotten had definitely helped his situation, he knew he was still truly tired, and he feared how he’d respond if boredom became an issue.
“Dr. Rodriguez was telling me that you are a direct descendant of a number of Bellevue Hospital luminaries,” Dr. Reston said, looking directly across at Mitt. “I’m impressed. It must give you a lot of satisfaction to follow in their footsteps.”
“I’m not sure how I feel,” Mitt said truthfully. “Just this morning, I was told that they might have been reactionary on some important advances.”
“Oh, that’s not fair,” Dr. Rodriguez said, jumping in to defend Mitt’s ancestors. “We can’t judge our medical forebearers because of what we now know. They were doing the best they could with the state of science as it was at the time.”
“Dr. Harington said something similar about the unfairness of hindsight,” Mitt said. He appreciated Dr. Rodriguez’s support while at the same time feeling uneasy about his genealogy being out in the open, for good or bad. It was something he’d hoped to avoid. “But for me, it can’t help but color my feelings if it is true.”
“Dr. Rodriguez told me that one of your ancestors could do a mid-thigh amputation in nine seconds and another was only the second person in the world to perform a mitral valve fracture. Those are some pretty impressive facts, if I do say so myself.”
“I suppose,” Mitt said to be agreeable. He sensed that Dr. Reston had a very high opinion of himself. In hopes of changing the subject, Mitt added, “What’s the problem here? Is Anesthesia having some difficulties?”
“I’ll say,” Dr. Reston sniped, lowering his voice so as not to be heard over the anesthesia screen. “Somehow anesthesia has managed to create an arrhythmia. The patient’s ticker was just fine until they got ahold of him. But what can you do? They’re all a bunch of monkeys as far as I’m concerned.” He rolled his eyes for emphasis, making Mitt wonder if there were competitive feelings between Bellevue surgeons and anesthesiologists, at least from Dr. Reston’s perspective.
Almost as if responding to Dr. Reston’s snide comment, suddenly the cardiac alarm went off, replacing the irregular pinging of the cardiac monitor. Thanks to the tile walls and floor, the sound was particularly piercing. Everyone in the room started, nurses and doctors alike.
“My God!” Dr. Winthrop blurted loud enough for everyone to hear. “We’ve got ventricular fib! Call an arrest! Get the OR crash cart in here!”
While the anesthesiologists snatched off all the operative drapes and tossed them onto the floor, completely exposing the naked and intubated patient, Caroline dashed over to the intercom and depressed the button. “Code red!” she shouted into the speaker grate several times.
Both Dr. Reston and Dr. Rodriguez merely backed away from the OR table against opposite walls while keeping their gloved hands pressed up against their chests. Luckily they had not started the surgery. Mitt was aghast and momentarily paralyzed, with his eyes thrown open to their limits. Quickly recovering, he, too, retreated out of the way and joined Dr. Rodriguez.
The anesthesiologists didn’t waste any time. One of them rushed up alongside the OR table, pulling the anesthesia stool along with him. Then, after locking the stool’s wheels, he climbed up on it and began closed-chest cardiac massage. The ventilator was still functioning and breathing for the patient. A moment later, the door from the hallway burst open and two more anesthesiologists rushed into the room pushing the crash cart. One of them positioned the cart next to the operating table while the other plugged the defibrillating unit into a wall socket.
With trained efficiency and little need for talk, the defibrillator was prepared. Once it was ready, the anesthesiologist who had been giving the closed-chest cardiac massage stepped off the stool he was standing on and took the paddles. He placed one on the patient’s sternum and the other along the patient’s left rib cage. “Clear,” he called out before pressing the button.
The patient’s body convulsed. All eyes looked up at the ceiling-mounted cardiac monitor. The blip, which had been tracing erratic chicken scratches across the screen, disappeared with the defibrillator’s discharge. In a reverent silence, all waited for the blip to reappear, which it did almost immediately. Unfortunately, it was just as erratic, meaning the heart was still fibrillating.
The team of anesthesiologists recommenced the cardiac massage while the defibrillator reset itself. Then they repeated the process, but to no avail. The fibrillation continued. Various drugs were tried, and then a cardiologist arrived on an emergency consult. He offered some additional suggestions, but nothing worked. Presently the fibrillation indeed did stop, but what intervened was asystole, meaning no electrical activity whatsoever. At that point an external pacemaker was tried, but it failed to initiate a heartbeat.
“What about an attempt at open-chest cardiac pacing?” Dr. Winthrop finally asked Dr. Reston; both men, along with Dr. Rodriguez and Mitt, were still watching the unfolding drama from the sidelines, maintaining their sterility. Two of the anesthesiologists who had responded to the emergency had left, but not Dr. Winthrop or the two who had originally been in on the case. One of those was back to giving closed-chest massage. The consulting cardiologist was also still in the room.
“I don’t know,” Dr. Reston said with a shrug. “What does Cardiology think?”
“It couldn’t hurt,” the cardiologist said, “but I sincerely doubt it will help. I’m astounded we’ve been unsuccessful in getting any response. It almost seems like something’s going on here that I don’t understand. It’s weird.”
“As a G.I. specialist, it’s been a long time since I opened up a chest,” Dr. Reston said.
“I participated in one just this morning,” Dr. Rodriguez chimed in.
“Well, there you go,” Dr. Reston said. He gestured toward the patient. “Be my guest.”
“Fine by me,” Dr. Rodriguez said. He turned to Caroline. “Get us a chest pack, fresh drapes, and we’ll give it a go.”
Mitt watched the preparations with a growing sense of unreality. He intuitively knew he was witnessing a very unusual series of events on just his second day as a surgical resident.
It took Caroline and Kathy only a few minutes to get everything ready, and while they were busy accomplishing what needed to be done, the closed-chest massage continued unabated, and the ventilator continued to alternately inflate the lungs, maintaining the blood oxygenation at an appropriate level.
“Okay,” Dr. Rodriguez said to Dr. Reston and Mitt when all was prepared to his liking. “This has got to be fast. The second the closed-chest massage is stopped, Caroline will quickly paint the chest with chlorhexidine, after which you two quickly drape the patient. Then I’ll move in immediately with a scalpel followed by the bone saw. Obviously, there’ll be no bleeding with no heartbeat, so that’s not going to be a problem. Then, as soon as I expose the heart, Dr. Reston, how about you be prepared to start open-heart massage. While you are doing that, I’ll get the pacemaker ready to function. Are we good to go?”
“Good to go,” Dr. Reston said.
Mitt, who felt he was completely out of his element, tried to follow Dr. Reston’s lead in helping to drape the patient the second Caroline finished with the antiseptic. Luckily the draping was just rudimentary, so Mitt’s inexperience wasn’t apparent. There was no attempt to bother creating an anesthesia screen.
As he promised, Dr. Rodriguez moved in practically before the drapes had completely settled, slicing open the skin down to the bone in one determined swipe. Next, the bone saw made short work of cutting through the sternum lengthwise, sending tiny bits of flesh flying in all directions. With a pair of dissecting scissors, he opened the pericardium. A second later, Dr. Reston shoved in his gloved hand, grasped the heart, and began to compress and release it. The open-chest massage was effective enough that the patient’s skin tone improved a shade even though it had never truly gone pallid thanks to his being respired with 100 percent oxygen.
Unfortunately, it was soon obvious to everyone involved that despite all their efforts, the heart was not about to cooperate and recommence beating.
“I’ve run out of ideas,” the cardiologist said while spreading his hands apart, palms heavenward.
“I’m going to stop the open-chest massage,” Dr. Reston announced.
“I would,” the cardiologist agreed.
“What actually happened before I got in here?” Dr. Winthrop asked the original assigned anesthesiologist loud enough for everyone to hear as Dr. Reston withdrew his hand. The attending surgeon stepped back from the OR table and began taking off his gown and gloves.
“Nothing that could have predicted this,” the anesthesiologist said. “The induction and intubation had been entirely normal, and I was about to give the green light to start the case when there were a couple of premature ventricular contractions. Then there was a series, which made me call in Ralph and then you. You saw how the PVCs led to fibrillation despite the beta-blockers. I’m at a loss,” he said, throwing up his hands. “It was as if something cardiotoxic had been suddenly injected into the IV, but obviously nothing had been injected. And there was no history of heart disease and the preop ECG was entirely normal. It’s all a mystery to me.”
Dr. Rodriguez followed Dr. Reston’s lead by pulling off his gown and gloves. But he did it angrily. “I can’t believe this,” he said to no one in particular. “Good God! This is my second operative death in the same day, and I’ve never had one before in the entire four years I’ve been a surgical resident.”
“Caroline, let the front desk know what’s happened in here,” Dr. Reston called out to the circulating nurse. She responded with a thumbs-up.
Dr. Reston, Dr. Rodriguez, the anesthesiologists, and the cardiologist all walked out as a group still loudly carrying on about the case, leaving Mitt and the two nurses in a sudden silence after the OR door closed. Caroline used the intercom to report to the front desk what had happened. Kathy turned her attention to all the instruments that needed to be separated since those from the abdominal pack and chest pack had become intermixed.
Mitt again felt shell-shocked, like he had after Ella Thompson’s case and the Benito Suárez fiasco. Standing there motionlessly, still wearing his sterile gown and gloves, he couldn’t stop staring down into Roberto Silva’s open chest wound with the man’s lifeless heart in plain sight. He was seized by an almost irresistible urge to reach out, grasp the organ, and try his hand at open-chest massage, desperate to see if by any slim chance he could get it to function.
Tormenting him in the background was the realization that he, Mitt Fuller, was the only connection all three cases shared at the moment of their death, other than all being in the same hospital. Such a disturbing thought begged the question of how and why, but he had no answers. Instead, he merely shook his head at having to face a third death in his initial three surgeries as a resident: the first one hours after the surgery, the second near the end of the surgery, and this one before the surgery could even start. Was this the beginning or the end of a very dubious and upsetting record? He would have been totally shocked to hear that any other surgical resident had ever had such an experience.
“Dr. Fuller?” Caroline questioned. “Are you okay?”
“Umm, yes, I’m okay,” Mitt managed while forcing a weak smile behind his face mask. Caroline’s question had pulled him out of his trance.
“Sorry to be a bother, but would you mind removing your gown and gloves so I can take care of them with all the others?”
“Oh, of course not. I’m sorry,” Mitt said. He untied the front as Caroline reached up to do the same with the tie behind his neck. She then helped him pull off the gown. Mitt removed the gloves and handed them over. “Thank you. I’m sorry. I’m a little bummed out.”
“We all are,” Caroline said.
As Mitt headed for the OR door, he untied his face mask and let it fall onto his chest, as it was still tied behind his neck. Pulling open the heavy door, he stepped out into the main OR hallway. As he headed for the surgical lounge, all he could think about was the upcoming surgery on Bianca Perez. Was she going to die, too?