“Maybe Dr. Erikson is the consult,” Lynn said.
“Could be,” Michael said. “But hematology and not infectious disease? It doesn’t compute.”
Quickly Lynn flipped through the chart to get to the results of the studies, in particular the MRI, only to learn that a CT scan had been done as well. Laying the chart flat, she and Michael read the reports. Michael finished first and waited for Lynn to do the same.
“There are a lot of terms that I don’t understand,” Michael said.
“Likewise,” Lynn said. “But it’s pretty clear that it isn’t good news, even if we don’t understand all the details. The summary says the CT scan showed severe diffuse brain edema while the summary of the MRI says that the hyperintense cortical signal indicates extensive laminar necrosis. That’s what Dr. Stuart expected. It all translates to extensive brain death...” Lynn trailed off, unable to finish her sentence.
“I’m sorry,” Michael said as sincerely as he could.
“Thank you,” Lynn said. Her voice caught. With such terrible news, she was trying not to cry. She was supposed to be a dispassionate medical student.
“Want to look at anything else in the chart?” Michael asked.
Lynn shook her head. As far as she was concerned, there wasn’t any point. The verdict was in. Whether Carl would regain some level of consciousness or not was uncertain, but even if he did, he was never going to be the person she knew. Best-case scenario was probably his entering a persistent vegetative state, a horrid situation that she had read up on the evening before. He would have brain stem function without input from the higher or cortical areas. It would mean he might have sleep-wake cycles but still would be completely unaware of self and environment and need total care until death. In short, he would endure a dehumanized existence. Inwardly she shuddered, wondering if she could cope.
Michael stood up and gave Lynn’s shoulder a reassuring squeeze. He took Carl’s chart back over to Dr. Erikson, who gave him Scarlett Morrison’s chart. He brought it back to where Lynn was sitting and placed it in front of her. She was in a trance, staring ahead. “You okay?” he asked.
“As good as can be expected,” Lynn responded. Her voice quavered. Then, as if waking up, she shook her head, adjusted herself in her seat to be more upright, and opened the second chart.
16
Tuesday, April 7, 6:52 A.M.
At first they didn’t talk, but merely nodded to each other when they finished a page. The first question Lynn in particular wanted to know was why the neurology resident, Charles Stuart, hadn’t mentioned that there had been a very recent, similar case. The answer turned out to be simple: a different neurology resident, by the name of Dr. Mercedes Santiago, was involved. With what they both knew about interdepartmental communication, the Neurology Department might not know that there had been two similar cases until they had their grand rounds.
As Lynn and Michael read on, significant similarities between the cases began to surface. First of all, Scarlett Morrison was nearly the same age as Carl, and unmarried. Second, she was a healthy individual whose only problem was gallstones. Her surgery, like Carl’s, was elective, meaning it wasn’t an emergency. Her procedure had been a laparoscopic cholecystectomy, or a small-incision removal of her gallbladder. It had been done without complications, according to the operative note, just as Carl’s had been, and, like Carl’s, it had been a seven-thirty A.M. case, so everyone had been fresh and rested.
As they continued to read they noticed there was no handwritten anesthesia note by the anesthesiologist, Dr. Mark Pearlman, only a terse mention of the problem of delayed return of consciousness, followed by a list of the medications that had been tried in vain to reverse the sedative and the paralytic agents in case there had been an overdosage of either. For information about the course of anesthesia during the operation, Lynn and Michael had to turn to the record created in real time by the anesthesia machine.
What they learned was that, as in Carl’s case, the anesthesia had progressed normally until there was a sudden, unexplained decrease in the patient’s blood oxygenation about three-quarters of the way through the operation. Looking at the graph, they could see that the oxygenation fell precipitously from near 100 percent to 90 percent for a couple of minutes before returning to 98 percent. Just as with Carl, there had been a brief episode of heart irregularity from hypoxia at precisely the moment the oxygen saturation fell.
As they examined the record further, some specific differences from Carl’s case became apparent above and besides the fact that it had taken place in OR 18 instead of OR 12: First, the volatile anesthetic agent was desflurane instead of isoflurane; second, an endotracheal tube was used instead of a laryngeal mask; and third, a depolarizing muscle relaxant, succinylcholine, had been used to facilitate the intra-abdominal surgery. On the other hand, the preoperative medication, midazolam, and the induction agent, propofol, had been the same, with approximately the same doses administered according to weight.
When Lynn had finished studying the record, she looked up at Michael, who was holding his camera out of sight of Peter and Dr. Erikson. He motioned to Lynn to hold up Morrison’s chart so that he could snap a picture of the anesthesia record without having to stand up. She did but in the process felt anxiously guilty. Michael took the picture and the camera disappeared in a flash.
Both Michael and Lynn glanced over at Peter and Dr. Erikson to see if either had noticed. They hadn’t. Lynn breathed a sigh of relief. Michael seemed immune.
“What do you make of the differences?” Michael asked.
“From my reading last night I know that recovery from desflurane is actually faster than from isoflurane, so that’s not significant. And an endotracheal tube is more secure than a laryngeal mask, so there is no problem there. And the use of a paralyzing agent shouldn’t be a problem as long as the patient is respired. I don’t find the differences significant.”
“Man, girl, you sure covered some ground with your reading last night.”
“It was a lot of hours,” Lynn said. At that point, she turned to the page in the chart that had the graph of Morrison’s vital signs, recorded since she had been brought to the neuro ICU. Lynn pointed to the tracing of body temperature that showed that Scarlett Morrison had had a significant spike in temperature the night after her surgery, just like Carl, reaching the same high point of 105º F. Although the temperature stayed elevated over Sunday and Monday, it had gradually fallen and was now at 100º F, which most people would consider mildly elevated.
“I’m amazed,” Lynn murmured. “So far the Morrison and Vandermeer cases seem clinically to be mirror images. Could that happen by chance?”
Michael shrugged. “And as far as I can remember, they are both similar to Ashanti’s. I’m pretty sure she had a fever, too. Do you think it could be some kind of new, unknown reaction to anesthesia that also causes a fever?”
“Who’s to know at this point,” Lynn replied. She turned to the blood work section. “Seems there was an increase in her white count to go along with the fever. That suggests an infection.”
Michael nodded. “But there isn’t an increase in neutrophils or a shift to the left.” Both medical students knew that in the face of an infection the body usually responded with an immediate increase of neutrophils, the body’s cellular defense against bacteria infection. A shift to the left indicated newly mobilized cells responding to an acute microbial attack.