The patient was a significantly obese Caucasian woman who Noah would later learn was a thirty-two-year-old mother of four named Helen Gibson. Instantly, he could tell it was an emergency trauma case. There was a compound fracture of her right lower leg, suggesting an auto accident of some kind. A bit of bone protruded through the skin.
Ava stood at the head of the table. She was struggling with an advanced video laryngoscope, trying to intubate the patient, who Noah could tell was not breathing. To Ava’s right was a first-year anesthesia resident named Dr. Carla Violeta, who attempted to aid Ava by pushing down on the patient’s neck at the point of the cricothyroid cartilage. Normally a bit of pressure at that location would make the entrance to the trachea easier to see. The problem was that a second anesthesia resident was giving external cardiac massage by forcibly and rapidly compressing the woman’s sternum, causing the entire body, including the head, to bounce around. Getting an endotracheal tube into a difficult-to-intubate patient under such conditions was almost impossible. Noah could tell the patient fit the difficult category by her head being tilted forward rather than back, suggesting a cervical neck problem.
The anesthesia residents who’d rushed in with the two carts were busy getting the defibrillator prepared. Standing to the side all gowned and gloved and ready to operate was Dr. Warren Jackson. Noah knew him all too well. He wasn’t quite as bad as Dr. Mason, but he was no polished gentleman, either. He, too, was an old-school, demanding, and temperamental surgeon who had trained back in the good old days when he apparently had been abused and now felt it was his duty to abuse. Noah could sense the man was irritated, as usual.
By some coincidence, the circulating nurse was Dawn Williams, who’d been in OR 8 on the Vincent case. Seeing Noah burst in, she immediately rushed over. “We got another doozie of a problem,” she said. “The first-year resident went ahead and tried to intubate the patient before Dr. London got in here. Dr. London was supervising another intubation in the next room.”
“Let me guess,” Noah said. “Dr. Jackson pressured her.”
“You got it,” Dawn said. “He was really on her case something awful.”
“Okay, clear,” Dr. Wilson called out. She was holding the paddles of the fully charged defibrillator and moved to the side of the patient. The resident giving the cardiac massage lifted his hands in the air. Ava stepped back from the head of the table, and Carla stopped pushing on the woman’s neck.
There was a distinctive thud as the defibrillator discharged. Simultaneously, Helen’s body lurched on the operating table as the electric charge spread through her and caused widespread muscular contractions. All eyes were glued to the ECG monitor except for Ava’s. She immediately reinserted the tip of the video laryngoscope and went back to trying to get an endotracheal tube placed.
Noah hurried over to Ava’s side while a subdued cheer arose from the residents who’d brought the crash cart. The fibrillation had stopped. The patient’s heart was now beating with a normal rhythm.
“What’s the problem?” Noah quickly asked Ava.
“We can’t respire this patient,” Ava shouted. “She’s paralyzed and can’t be bagged for some reason. And I can’t get an airway because I can’t see what the hell I’m doing.”
“It looks like her neck is flexed,” Noah said.
“It is, and it’s fixated. In terms of visibility of the trachea, it’s the worst I’ve ever seen: Mallampati Class Four Grade Four.”
“What the hell is Mallampati?” Noah said. He’d never heard the term.
“It’s a grading system for visualization of the trachea,” Ava snapped. Then to Carla she said: “Try pushing on the neck again. I almost had it a moment ago, before the shock.”
Feeling a rising panic, Noah glanced at the ECG monitor. He didn’t like the looks of it, fearing the heart was about to fibrillate again. He looked at the pulse-oximeter readout, whose alarm was still sounding. The oxygen level in the patient’s blood had barely changed. In fact, the patient’s color, which had been a slight shade of blue when he’d arrived, was getting worse. There was no doubt in Noah’s mind that the situation was rapidly deteriorating. To his right was the second cart, with various laryngoscopes, tracheal tubes, and other intubating equipment, plus an emergency cricothyrotomy kit that contained the paraphernalia needed to create a new opening into the lungs through the neck, bypassing the nose and the mouth.
With the same resolve that Noah had demonstrated when he’d stormed in on the Bruce Vincent case, he suddenly knew what he had to do. He snapped up the cricothyrotomy kit and tore it open. Without taking the time to put on sterile gloves, he grabbed a syringe outfitted with a catheter from the kit’s contents, pushing around to the patient’s right side, crowding Ava and Carla out of the way. Angling the tip of the catheter toward the patient’s feet, he placed its needle end into the depression below the patient’s Adam’s apple and decisively pushed it directly into the patient’s neck. There was a popping sound. When Noah pulled back on the syringe’s plunger and the syringe filled with air, he knew he was in the right place. Quickly he passed a guide wire through the catheter, then a dilator to enlarge the opening, and a moment later a breathing tube.
“Okay, good,” Ava said. She connected the newly created breathing tube to the anesthesia machine and began respiring the patient with 100 percent oxygen.
Just as the entire team was beginning to feel upbeat, disaster struck. Without warning, the patient’s heart reverted back to fibrillating, causing the cardiac alarm to resound. The oxygen level in the blood that had been rising now reversed course, necessitating a flurry of activity. After a short period of external massage that required one of the residents to climb up and kneel on the operating table, Helen received another shock from the defibrillator.
Once again there were some restrained cheers while everyone watched the cardiac monitor. The fibrillation stopped. But any sense of celebration quickly evaporated when the heart’s normal rhythm didn’t reinstate. Instead, the heart was stubbornly electrically silent, and the cardiac monitor traced a flat, unchanging straight line. Now there was no heartbeat, a situation known as asystole, which was disturbingly reminiscent of Bruce Vincent. Quickly the resident climbed back up onto the OR table to recommence closed-chest massage. At the same time the anesthesia team started various medications in hopes of restoring a heartbeat.
A few moments later, cardiologist Dr. Gerhard Spallek entered the OR, struggling to secure his surgical mask. After hearing the details, he said: “My guess is that we have had what amounts to a major heart attack secondary to the low oxygen levels. It doesn’t bode well, but here’s what we can try.”
Under his direction a few more drugs were used in an attempt to stimulate the heart. Meanwhile, the external cardiac massage was continued, as was the 100 percent oxygen, keeping the blood oxygen levels reasonable. When the additional medication wasn’t successful, Gerhard proceeded to thread an internal pacemaker wire in through the patient’s right internal jugular vein. Even that wasn’t successful to initiate a heartbeat.
“That’s it,” Gerhard declared. “The heart is not responding in the slightest. There’s no doubt it was severely damaged. I’m afraid the patient is gone. I’m sorry I could not be of more help. Thank you for allowing me to participate.” With a respectful half bow, he pulled open the door and left the room.
The resident who had been giving the external cardiac massage climbed down from the operating table.
“This is an outrage,” Dr. Jackson said the moment the door closed behind the cardiologist. Throughout the ordeal he’d been totally silent, standing off to the side with his hands clasped across his chest, watching with growing concern but apparently keeping hope alive that he would be repairing the patient’s damaged leg. “Just so everyone knows, I am going to be talking with Dr. Kumar about this” — he struggled for words — “this disaster. This patient is a thirty-two-year-old healthy mother of four. I’m appalled this could happen here at the BMH. We’re not out in the boonies someplace.”