The Society

CHAPTER 12

The inestimable blackness was pierced by sound-garbled voices captured by Will’s gradually increasing consciousness. Next came the ghastly sensation of choking-a tube the size of a redwood, clogging his throat.

Will tried to move his arms but met immediate resistance at the wrists. From his earliest days as a med student in the hospital, he had watched patients be intubated and put on a ventilator-some comatose, some semiconscious-and wondered what it could possibly have felt like. He had even asked some of them after they were on the way to recovery and had concluded that the degree of helplessness, pain, and horror of the situation was a function purely of how much medication they had received. From time to time, especially with emphysema cases, the relief of being able to get in enough air made the breathing tube tolerable. But mostly, the discomfort was quite frightening, especially in the initial hours, before there was any chance to learn to cope.

Will knew he would never again have to ask a patient about the sensation.

He thrust his tongue against the hard rubber airway that had been slipped into his mouth next to the tube and then taped in place to keep him from biting down. Awareness was rapidly returning, along with swirling memories of becoming sick, terribly sick, in the OR. He must have stopped breathing, or come damn close. The fact that the discomfort and panic seemed manageable suggested he was being medicated. Was this the first time he had been awake? With no little effort, he forced his eyelids apart. Even before his focus sharpened, he knew that he was in the ICU. The fluorescent lights over him were midday bright. Across the cubicle, two nurses were talking.

Was it a stroke, he wondered? Is that what had happened to him? A cerebral hemorrhage of some sort? Methodically, he tested his hands and arms, then his feet and legs. No problem moving anything.

The incision! He had gotten horribly dizzy and toppled over into the incision. He could envision the blood and the coils of intestine as he pitched downward toward them. But there the images stopped.

How long had he been out? What happened to his patient?

He opened his eyes wider. As his consciousness grew, so did the suffocating discomfort in his throat. He also became aware of another unpleasant sensation-the desperate need to pee. Easy, easy, he told himself. There was no way he could have been unconscious on a respirator in the ICU and not have had a catheter inserted to drain his bladder. Easy. The pressure and urgency was almost as dreadful as the tube. He had never been a hospitalized patient before. Now he wondered if he had been sympathetic enough with those who were.

The nurses were two whom he knew well, Anne Hajjar and Donna Lee. He banged the back of his hand against the guardrail.

Donna rushed over, clearly pleased to see him awake. Sharp features and close-cut blond hair, she was a new wife in her late thirties and a hardened veteran of the ICU wars. Like the other unit nurses, she called all but the most unapproachable physicians by their first name.

“Will, hi there, it’s Donna. Welcome to the land of the living.”

Will nodded that he understood.

“Are you in any pain?”

He twisted his hand and pointed toward the tube.

“Ken Millstein is taking care of you. Your blood gases are looking pretty good, so maybe he’ll be able to pull that tube out after all the labs are back. Meanwhile we can keep you medicated.”

Will shook his head. No. No medication. I can handle this. . just not too long.

“Okay, but you sort of woke up a little while ago and started tearing at the tube. That’s why we medicated you and put those restraints on.”

I understand.

“Go after the tube again like that and we’ll have to beat you with a stick. Do you know what happened to you?”

No.

“Apparently, you had a seizure of some sort while you were doing a case. You immediately lost consciousness, and then a few minutes later you stopped breathing altogether. You were rushed down to the ER, and they put the tube in there. Your EKG is normal, so it doesn’t look like a coronary, and your chest X-ray doesn’t show any sign of aspiration. Is there anything you need right now?”

Will wriggled the fingers on both hands and pointed back at the restraints.

“Anne?”

Anne Hajjar, willowy, brown-eyed, and eternally lighthearted, materialized at the opposite side of the bed from Donna and squeezed Will’s hand. Of all the nurses in the hospital, she was his favorite.

“Hey, big boy, we’re glad you’re coming around,” she said. “We were a little worried when they dragged you in here.”

“He wants the restraints off,” Donna said. “I told him if he pulled that tube out it would not go well for him.”

“I suspect it would be the last thing that shape he ever pulled,” Anne said, undoing the Velcro cuff and strap on her side.

As soon as the restraints were removed, Will brought his hands together and pretended to be writing on an imaginary pad. Donna left and quickly returned with a stack of progress-note paper on a clipboard and a Bic pen. At that moment, internist Ken Millstein moved in next to Anne. He was a slight, Harvard-trained doc about Will’s age, but half a foot shorter, with a rapidly receding hairline and a penchant for baggy suits. He and Will and their wives had been friends from their earliest days at Fredrickston General, and the Millsteins had been one of the very few couples who hadn’t found it necessary to side with one or the other of them after the divorce.

“Eventful day,” Millstein said.

I guess, Will wrote. How long have I been here?

“Two hours, give or take. You had us worried for a while there.”

How is my patient?

“Gordon is still in the OR with him. I think he called Jim Katz in to help finish the procedure. Apparently you got a ten from the Russian judge for that dive you took.”

Very funny.

“Any idea what could have happened? Because I sure don’t.”

None. I have never passed out before.

“Will, you didn’t just pass out. You stopped breathing. Your blood pressure was heading south when Steve Edelstein in the ER decided to go ahead and intubate you.”

Good man.

“Any medical history we should know about?”

Asthma as a child.

“Meds?”

None.

“Feel okay now?”

Groggy.

“No surprise there.” Millstein checked Will’s pupils, then examined his heart and lungs. “I’ll tell you what,” he said. “I’ve run so many labs that your HMO is probably going to put a bounty on my head. As soon as I have most of them back, I’ll get anesthesia in here and we’ll pull that tube.”

How about the catheter?

“First the tube. Sorry. You want the nurses to give you something?”

Just a little, Will wrote this time.

“Five of morphine, Donna. Repeat it as needed.”

Thanks.

“Just bear with us, my friend,” Millstein said. “We’re going to get to the bottom of this.”

With the help of the intravenous morphine, Will drifted in and out of a comfortable haze. At times he dreamed-a high-speed auto chase, a green-faced judge sentencing him to prison for something, swimming in perfectly blue Caribbean water alongside a woman who looked vaguely like Patty Moriarity. At one point, in the middle of a disturbing vignette in which his hands were about to be chopped off by someone, he awoke to see Gordo Cameron looming over him.

“Greetings, lad,” he said. “You sure gave me and the gang in the OR one hell of a fright there. I’m glad you’re coming around.”

How’d you do with the case?

“He should make it through the next few hours, but that’s all I can say at the moment. Jim came to the rescue and assisted. We had to repair a couple of torn vessels, then we went ahead and did the Whipple. He lost a fair amount of blood and dropped his pressure a couple of times.”

Did I tear the vessels?

“Your head hit the incision like a bloody meteor. Some vessels were bound to rupture. But, really, it was manageable. Once we got the bleeding controlled, we irrigated everything like crazy. There’s bound to be infection, but that’s what we have antibiotics and infectious-disease specialists for. Plus you just don’t look like someone with a lot of devil germs on his face. What on earth do you think happened?”

No idea.

“Well, don’t use up your energy writing. We can talk after that tube comes out. Who’s takin’ care of you?”

Millstein.

“Good man, Millstein. A little scrawny by my standards, but sharp. Well, lad, I’m going to head on over to the recovery room to check on our boy.”

Thanks, Gordo.

“Just don’t ever do that again. My poor knickers had to be permanently retired.”

Donna Lee appeared and pulled Cameron aside, beyond Will’s field of vision.

“I don’t believe it!” Will heard Cameron say. “I don’t-”

Will envisioned the nurse stopping Cameron short with a finger to her lips. He banged on the bed rail to get her attention.

What’s up?

“Nothing.” Donna’s tone was icy. “Dr. Millstein will be up to speak with you.”

Tube very uncomfortable. . could I have a little medication until he arrives?

“He’ll be here before long. Just close your eyes and relax until he gets here. And don’t touch that tube.”

The woman was gone before Will could write anything further. What could she have said that Gordo didn’t believe? Why was she refusing even a small amount of medication to help him deal with the tube? Why the sudden coldness? He shifted his position in bed and tried as best he could to ignore the discomfort in his throat and bladder.

For a time he lay there, trying to divert himself with thoughts of Kurt Goshtigian. He had a decent enough patient-physician relationship with the man, but their history was not a long one. Even if Goshtigian fully recovered from his Whipple procedure, a lawyer could certainly make a good case for Will having caused the need for additional surgery and powerful, potentially life-threatening antibiotics, as well as prolonged time under anesthesia. Still, no judge or jury could find him negligent when clearly some medical problem beyond his control or knowledge had caused the incident in the OR. Will took pride in the fact that despite a high-risk specialty, he had never yet been sued, but he hardly took the fact for granted. As a surgeon, the specter of a malpractice action was always hovering not far away.

Even without medication, Will began to drift off. Images of the OR floated about for a time, then gave way to a comforting darkness. Everything was going to be okay, he told himself. The diagnostic tests he would undergo over the days and weeks ahead would show no brain tumor, no vascular anomaly within his skull, no hemorrhage, and no irregular cardiac rhythm. The incident would be written off as a simple faint, caused by a virus, fatigue, dehydration, or factors never to be determined. Such a faint was known technically as vasovagal syncope, the sort of physiologic reaction that commonly accompanied stresses such as horrible news or a grisly sight. In such instances a sudden, powerful discharge of electricity along the large vagus nerve caused rapid dilation of the veins in the abdomen and legs and marked pooling of blood in those vessels. The resultant drop in blood pressure produced an instantaneous loss of consciousness. Fainting was the brain’s effort to protect its critical circulation by “insisting” that the body lie down.

Vasovagal syncope, Will thought, as sleep enfolded him. Yes, that’s it. That’s what they’re going to conclude.

“Will?”

Ken Millstein stood by Will’s left hand. Standing beside Millstein, Anne Hajjar looked down at Will with the stony impassivity of a sphinx. On the right side of the bed was anesthesiologist Ramon Bustamante, also looking grim.

Will opened his eyes and managed a weak thumbs-up, to which neither the nurse nor the physicians reacted.

Something’s wrong, he thought. Something’s. .

“Will, Dr. Bustamante’s here to remove the tube; after that we’ll talk.”

The Philippine anesthesiologist moved forward and used a syringe to deflate the balloon cuff that held the tube in place below Will’s vocal cords. The inflated cuff also prevented him from aspirating his stomach contents into his lungs.

“Mrs. Hajjar, you have the backup tube ready?” Bustamante asked.

“Right here.”

“You tested the balloon?”

“Yes.”

“Suction?”

“Ready.”

“Okay, then, Doctor,” the anesthesiologist ordered unemotionally. “Cough when I say so. . and. . now!”

Will coughed feebly and the redwood tree instantly vanished from his throat. He sputtered and gagged as the nurse suctioned his mouth and throat with a hard plastic tube. Then, eyes tearing, he sagged back against the pillow, sucking in drafts of sweet air. Bustamante listened to his chest, assured himself that neither lung had collapsed, then turned and left without a word. Anne Hajjar slipped oxygen prongs into Will’s nostrils, did a blood-pressure check, nodded to Millstein that it was satisfactory, and quickly followed the anesthesiologist out of the cubicle.

For fifteen seconds, Millstein just stood there looking down at Will.

“Feel able to talk?” he asked.

Will cleared his throat as forcefully as he could manage.

“Sure,” he rasped, nearly overcome now by apprehension.

“Okay. I’ve gotten most of the lab work back, including a comprehensive panel I requested for drugs of abuse.”

“That would be negative.”

“Well, you can say so, Will, but it wasn’t.”

Will felt his heart sink.

“That’s impossible.”

“You lit up for fentanyl, Will. Big time.”

Fentanyl-one of the most powerful of all narcotics. It was used as a painkiller via a time-release patch and in an IV to put patients to sleep in the OR before they were intubated. It was highly addictive and too often an instrument of death in those anesthesiologists who chose to experiment with it by sequentially pushing up the dose they injected into themselves.

“I tell you, that’s impossible. I’ve never taken any painkillers stronger than Tylenol.”

“Two different samples,” Millstein said. “Fentanyl confirmed in both of them by emergency gas chromatography and mass spectrophotometry. Large amounts were in your blood when you passed out, Will. There is absolutely no doubt in anyone’s mind about that.”

Will found the bed control and raised himself upright.

“This is absolutely insane! I didn’t take anything.”

“I don’t see how that can be true,” Millstein said evenly. “I can try and help you, Will, but only if you tell the truth.”

The chilliness of the nurses and the anesthesiologist was certainly explained. Fear and anger tightened the muscles at the base of Will’s skull. A jet of bile rose in his throat.

“You’ve known me for years, Ken. You’ve got to believe me.”

Millstein shook his head slowly.

“I don’t know what to make of this, Will. I’ve learned to repeat abnormal tests that don’t fit, and that’s just what I did here. But if I don’t trust our lab when a test is repeated with the same results, I might as well pack up and find another profession.”

“It wasn’t my blood,” Will said desperately.

Again Millstein shook his head. Will could see now the deep sadness in his eyes.

“We ran a urine, too. Straight from your catheter. Chain-of-custody handling. No breaks in the chain. It was positive, too. Strongly positive, I might add, and you know how rapidly fentanyl is cleared from the body. Will, with all that’s involved, this is way beyond me. I’ve reported everything to Sid Silverman, and he’s called the police. They’ll be here shortly if they’re not here already.”

“Jesus,” Will said. Silverman, the president of the hospital, was in bed with several managed-care companies and had been openly critical of the Hippocrates Society and Will in particular. “I’m in no shape to deal with fucking Silverman or the police. Let me out of here, dammit! I’ll sign out AMA! Bring me the form.”

He leaned forward, then just as quickly fell back as a spear of pain thrust itself through one eye and out the back of his skull.

“Easy, Will.”

“No! I’m out of here!”

Mindless of the IV lines and catheter, Will battled through the headache, grabbed the side rails, and pulled himself forward again, scrambling toward the foot of the bed.

“Hands!” Millstein cried out, restraining him with surprising strength.

In seconds, the room was full of uniformed bodies, each trying to hold him down. A hand clutching a filled syringe moved into Will’s sight. Helplessly, he watched as the needle was slipped into a port of his IV and the syringe emptied.

Moments later, a gentle, pleasant wave washed over him and he sank back into a dark, welcoming sea.