Deadly Medicine (26 page)

Ward had agreed to review charts and attend the hospital’s Morbidity and Mortality meeting as a favor to both Judi and Abby. She didn’t relish the task, but understanding that it had to be done and that no one at Endless Mountains was qualified to do it, she’d agreed. And so, on her day off, she’d come to work and quickly became engrossed in a game of politics.

She’d arrived early to peruse charts, and as she walked the halls from the ER to the board room, no fewer than three physicians on staff had gone out of their way to speak to her about the patients whose care she was reviewing. All three held professional ties to the patients—two were the primary-care physicians, and the third was a surgeon who’d recently operated on one of the deceased. It quickly became evident that none of the three were as interested in the outcome of her probe as they were in vindicating themselves. All three spoke of non-compliance—missed appointments, failure to adhere to treatment plans, skipped medication doses—all factors that could have contributed to the patient deaths.

Two other physicians had also approached Ward. Both predicted the conclusions she would reach and wondered why the hospital bothered with such matters as peer review. “We all know hindsight’s twenty-twenty,” one of them had said. “At least you’ll get a free dinner out of it,” the other told her.

After four months of rural medicine, Ward was no longer shocked by the comments and coercion. The attitude among medical staff members was still frightening, though. Instead of regarding the process as it was intended—as a way to improve patient care and educate physicians and nurses to help them save lives—they were all threatened by it. Is this what malpractice suits had done to everyone? They’d become afraid to admit their mistakes, even to themselves, and lobbied their colleagues for reassuring pats on the back. Or was it worse than that? Was it all just about fragile egos?

Ward listened to them, all five respected physicians, and thanked them for their help in the matter. And then she promised herself to disregard everything everyone had told her, and all the gossip she’d heard, and to formulate her opinions based on the information contained within the pages of the medical records.

Confidentiality concerns made it necessary for her to do this work within the four walls of the hospital. While she might have taken advantage of Abby’s secure system at home, Ward knew that when she began probing into restricted patient files, an electronic fingerprint would be generated. That could create problems. If she accessed those charts under Abby’s name, would people question Abby’s motives for reading the charts? After all, her background was in business, not in medicine, and she couldn’t add much insight. And if Ward signed in using Abby’s online connections, would people speculate about the nature of their relationship as well as Ward’s motivations in the probe and the integrity of her findings?

Although both scenarios were ridiculous, she’d seen so much petty bullshit during her medical career that nothing surprised her. Therefore, she went into the hospital a few hours early instead of reading the records at Abby’s place. This way, there would be no questions about anything other than the medical care provided to the unfortunate patients who had died in the ER. And in the end, it was still much easier than during the old days. Back when she was a student, chart review meant spending hours in the medical-records department of the hospital, in a tiny cubicle with an uncomfortable chair, flipping through hundreds of pages to find the data she needed. Computers made it so much easier.

Ward’s list contained eleven names, the total of all the patients who’d died in the ER during April, May, and June. After the ER director’s illness, some others had picked up the slack, but apparently, they’d quit when the warm weather rolled around, leaving three months’ worth of charts to review.

First Ward asked Frankie for a list of all the patients who’d died in the department in the preceding year. Since she was only seeing a tiny snapshot, she thought a bigger picture would give valuable information. Since she was so new to the hospital, she wasn’t sure what was normal. Eleven deaths in the ER in Philly in one day wouldn’t have been unusual, but perhaps it was here. Of the eleven, Ward figured ten would have been from heart disease, drug overdose, and trauma. In the mountains, she didn’t think drugs would be a top killer, but nothing surprised her. Not since the bat attack, anyway.

Thanks to the wonders of modern technology, the list Frankie produced was beyond Ward’s expectations. As requested, the inquiry went back a year, and he’d sorted the deaths in the department into every conceivable category: first, by month, and then by cause of death, age, race, religion, time of day, attending physician, attending nurse, mode of arrival (ambulance or personal vehicle), time elapsed between arrival and death, and primary-care doctor. With all of that data, patterns were likely to emerge, patterns that would give her an idea of what was normal at Endless Mountains Medical Center.

Before even looking at the individual patient charts, she studied the data and started making sense of it. Forty deaths had occurred in the ER during the twelve-month period under review, an average of three-and-a-third deaths per month. The previous October had seen the lowest number, one. June had kept the undertakers busiest. Six people had died then. Three seemed to be the norm. Time of death favored dayshift by a two-to-one margin, and Ward didn’t know if that was significant. She’d have to look more closely at the causes of death with regard to day and time. More heart attacks and strokes happen during the morning, but more car accidents happen on the weekends, when more cars are on the road. Sex didn’t seem to be a significant variable—the split was about even, with twenty-two men and eighteen women on the list. Almost all were white and Christian, just like everyone else in the mountains. Most of the patients were older, with a variety of medical conditions that explained their deaths. Some, though, were young. Too young. The chart of an eight-year-old caught her eye, and she deliberately pushed it aside. She’d died in June, and if she completed her task in a chronological manner, Ward could avoid that one for at least a little while longer.

Three-quarters of people who died in the ER had taken their last ride in an ambulance rather than a car, and most of them had died within an hour of arrival at the hospital. Their family doctors and the ER docs who cared for them varied: fifteen different family doctors, and seven from the ER. When Ward broke down the numbers for the ER docs, nothing looked out of the ordinary. One doctor had seen eleven of the patients, another ten, one eight, one five, and the remaining docs had split up the others. She assumed the disparity had to do with the number of hours worked. The more patients a doctor sees, the more patients he’s going to pronounce dead. She would expect a full-time physician to have treated the majority of the deaths and a part-timer a smaller number, unless that part-time doc was seeing all the trauma victims on Saturday nights.

Glancing at her watch, she pushed the pile of paperwork aside and stood to stretch. She’d set aside four hours for this task and was beginning to fear she’d grossly underestimated the time she’d need. It was three thirty and she’d already been at it for more than an hour, though, and she hadn’t even touched the actual charts yet. Bending from the waist, she let her shoulders and head fall, feeling the stretch in the muscles of her neck and back. Touching her toes with her fingertips, she tried to force her head to her knees. Not even close. Daily yoga wasn’t enough to make her that flexible. Smiling, she stood, arched her back, and returned to the computer station.

Ward had camped in the boardroom, fearing the interruptions she’d face in the physicians’ lounge and the ER, and so she wouldn’t have to move when the meeting began. She took her place at the computer and logged in. She had three more hours before the room started to get noisy, giving her about fifteen minutes to review each chart. Some would be easy to get through. Reviewing massive brain hemorrhages and dissecting aneurysms and other catastrophic illnesses didn’t require much time. She would make sure the basics had been done—patients were seen promptly, proper tests were ordered and the results documented correctly. Other disease processes weren’t so straightforward, and she might need to spend more time going through them. There are always questions when someone dies, and Ward had to ask them. Was time wasted? Were the proper medications given and the proper tests ordered? Were mistakes made, such as giving the wrong medication or putting a breathing tube into the stomach? Was the doctor successful in his or her attempt to insert the tube or the IV? Was the correct diagnosis made?

Ward took her list, a pen, and some sheets of notepaper and got to work. The first patient on the list was a ninety-year-old man who’d developed indigestion after eating his nursing-home hash on the morning of April Fools’ Day. His heart rate and blood pressure were tanking by the time he got to the hospital, and he’d suffered a cardiac arrest within minutes of arrival. Everything conceivable was done, but nothing helped. After reviewing the chart, Ward decided that his care had been first rate and appropriate. She moved on to chart number two. A week later, a teenager was brought in, also near death. He’d hit a telephone pole and suffered massive facial and head trauma, so much so that the paramedics were unable to secure his airway with a breathing tube through the pools of blood and broken facial bones. Anticipating trouble after the medic’s radio report, the ER doctor had paged the surgeon, who was waiting in the ER when the patient arrived. In spite of the emergency airway the surgeon inserted into his trachea, the patient coded and couldn’t be revived.

Not much could be done to force oxygen through his bloody airway, and Ward sensed his care had gone above and beyond the standard.

The final patient seen in April was another heart-attack victim, and this one was completely unresponsive to every medication and maneuver the medics and the ER team had given him. Ward couldn’t find a single fault in the patient’s care.

She logged into the next chart and checked the time. She’d spent forty-five minutes on the three patients who’d died during the month of April. Right on schedule. Fortunately, the May cases were straightforward as well. She made it through most of June and couldn’t avoid it any longer. It was time to look at the eight-year-old’s chart.

Her name was Hailey, and Ward was unable to shake her sadness as she finished reading the notes that documented her final minutes of life on earth. A car had hit her when she’d run into the street, fracturing her femur. The medics had successfully inserted an IV and given fluids, but the IV had shifted at some point and stopped running. Her heart rate was fast and her blood pressure was low—a complication of the massive blood loss associated with femur fractures—necessitating another IV. The ER doctor had successfully inserted an IV into her subclavian vein, but within seconds of that maneuver, Hailey had coded. An extended course of CPR was unsuccessful, and after more than an hour of trying, the code was called.

On autopsy, a significant amount of air was found in her heart, a fatal complication of insertion of the subclavian catheter.

Ward leaned forward onto the computer table, rubbing both temples. It was hard to argue this case. Unlike the eight charts she’d reviewed before this one, where she could place no clear-cut blame, Hailey’s death could be directly attributed to the insertion of the line. No line, she lives. Line placed, she dies. Did that mean the doctor was at fault in her death for failing to check the line? Or was the nurse at fault for failing to purge air from the IV tubing? Was a venous air embolus an acceptable complication of IV insertion? Ward wasn’t sure. She knew it happened, but did that mean it was okay? She’d have to research that a little more. She also needed to decide if the line was really necessary in the first place. If the risk of a procedure is death, the procedure better damn well be a lifesaver. Yes, her blood pressure had been low, but had they tried other IV sites before jumping to the subclavian vein? If not, that would be the first recommendation she made to the board.

Picking up the phone, she dialed the ER. Shayna had been the nurse taking care of Hailey, and Ward had seen her earlier. Perhaps she’d have a minute to talk and share her take on the events.

“Hi, Ward, how’s it going?” Shayna asked in greeting.

“Great. I need a little help, though. I’m reviewing cases for the M & M meeting, and you took care of one of the patients. Hailey Conrad. Can I ask you a few questions?”

Shayna gave a deep sigh and was silent for a moment. “That was the most fuckin’ awful code I’ve ever been on,” she said a few seconds later.

“I can imagine,” Ward said softly, beating down her own little ghosts.

“We gave her blood, fluids, all the right meds. Nothing worked. We tried for like an hour, and we never even got a blip on the monitor. Once she coded, it was a like a fuse got tripped. Nothing.”

“I could see that from the chart, Shayna. You did all you could.”

Shayna sniffled. The cocky young nurse, with spiky hair and tattoos on her tattoos, was really a softy at heart. “Thanks.”

“Can I ask you a question?” Ward asked.

“Sure.”

“Why did Dr. Hawk put in the central line? Was there no other access?”

“Huh! That’s what I told him! I’m great at IVs, and he practically pulled the needle out of my hand so he could put in that subclavian. It was like he had an agenda, ya know? Do doctors have to do a certain number of procedures on kids to keep your licenses? ’Cuz that’s what it seemed like to me. Nothing was going to stop him from putting in that line. He got the kit out, opened his own gloves, even pulled out the bag of fluid and hung it himself.”

“So you didn’t prime the tubing for him?”

“No. He was on a mission, and he did it all himself. As a matter of fact, when I tried to help, he glared at me. Told me to check on the transfer, since we were going to have to send her out to have the fracture repaired. Our orthopedics wouldn’t even come in to see her.”