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Authors: Carol Cassella

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BOOK: Oxygen
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Her heart granted her this grace period of apparent health until it turned some physiological corner of irreversible damage and she became aware of a breathlessness when she mopped her floors, a pain in her chest while weeding her rose garden. By the time Lori and I were in high school she’d marshaled a standard list of excuses for missing picnics or walks or trips to the lake. Even then her quiet pride, her maternal endurance, kept her symptoms a private matter, each year without medical intervention diminishing any chance to reverse her decline. She kept her symptoms hidden until I began to notice how she paused in the middle of our staircase every time she carried up the socks, books, sweaters or shoes that we, her family, ungraciously dropped in the middle of our kitchen.

But it wasn’t until I was in medical school that I understood it well enough to insist—in a newly respected voice, propped up by my fresh white coat—that she see a cardiologist and take advantage of what modern medicine could offer her. By then her only choice was open-heart surgery.

Her cardiologist explained that she would likely do well after the surgery. Yes, her risks were higher than they would have been in the early stages, but without the surgery her risks were higher still. My family turned to me to translate this foreign dialect of choice and consequence. And I could—even in that infancy of my medical life—explain ventricular hypertrophy, valvular areas and gradients, cardiac output, cardiopulmonary bypass. Those words I could look up in my
Stedman’s Medical Dictionary,
dissect down to their Latinate origins and offer their meanings up to my parents like gifts, proof that my education had worth. What I could
give them, and what they needed most, was the perspective of experience, the critical filter of judgment that might have made their choice clear: without heart surgery she would almost certainly die within two years.

Somehow the choice seemed to paralyze them, having grown up in a world where illness rarely offered options. We talked in circles. I tried to persuade her, using simplified words and penned sketches of her circulatory system. She turned to my father, as always, for his opinion. He asked me to explain it all again, as if a more thorough description might guarantee her life would be saved. My mother sank into a depression that stalled her ability to see a future either way.

Then one morning she rose from her favorite chair and collapsed to the floor with a crushing weight in her chest. The pain so ripped the breath from her that she couldn’t cry out. My father heard the shattering teacup and ran to the living room. She was still talking when we reached the hospital. But much of her heart was dying. The stiffening muscular wall that had granted her one last decade of life had grown so thick it squeezed shut its own blood vessels—retribution for its malfunctioning valves.

She was rushed into intensive care, the very unit where I was assigned to learn the intricate balancing of medication drips and electrical wires and breathing machines that can save a life or merely painfully prolong it. There was a chance still, said her cardiac surgeon. If the stress on her heart could be lightened enough to allow some healing, some trickle of oxygen-rich blood to its inner core, she might survive the surgery.

They slipped a small pump through the flesh of her groin into her femoral artery and up into her aorta to lodge just beyond her flailing valve. The pump was timed to the electrical rhythms of my mother’s heart, inflating and deflating to siphon the blood forward, out to her body and her brain.

I sat in the half-light and listened to the rhythmic thudding of the mechanical pump, muffled through the layers of her living flesh. I envisioned the submarine-shaped pump expanding and contracting in the bright blood of her aorta, its cord snaking down the pulsing vessel to erupt from her groin and connect her to the machinery. The sound lulled me into a realm where memories of my life with her and hope for my future could weave together, connect as a continuous line, without the scar of grief I knew her death would leave inside me.

My father circled the floor like a confined animal, repeating the same questions over and over. I kept trying new words, new metaphors that might make the mystery of her failing body comprehensible to him. But as days went by and her kidneys stopped cleansing her bloodstream, her liver quit manufacturing enzymes and proteins, her bone marrow stopped creating new blood cells, waiting for surgery became moot. Now we were waiting for death.

A meeting was gathered of her medical team, my sister, my father and myself. This time her cardiologist’s words were chosen haltingly, chosen to be soothing but without hope. He gently guided my father to the understanding that he must end this artificial extension of his wife’s life.

I’m sure my mother never suspected she was raising a doctor. Female doctors were rare in her world. She taught me the things she believed I would need in my life: how to sew a bias-cut tie as a gift for my father one Christmas—a wide garishly flowered thing he wore once out of courtesy; how to separate the white from the yolk when making meringues, slithering the contents of the raw egg from half shell to half shell until the golden center swam naked in its clear membrane; how to pluck my eyebrows, put on a bra and pull sheer stockings up my legs without snagging the interlaced filaments.

She taught me all the things my sister has put to excellent use in her life, all the complexities of stabilizing a home and joining two people and the generation they create together into a new and whole family—critical facts that make families work, passed from woman to woman, never tested or graded or ranked, but invaluable nonetheless. I stored them up to share with my own daughter someday, after the temporarily consuming labor of medical training was finished. Once I regained some control over my life, after my residency, I always knew, I would rejoin the intended stream of marriage and motherhood. I never meant to dam myself off from those. I just knew they would require careful scheduling.


After the first week
people stop telling me how sorry they are or asking me if I’m holding up all right. Instead of being a disaster shared with everyone who works in the operating rooms at First Lutheran, it gradually becomes the silently screaming secret that sends an awkward hush over groups of surgical techs and nurses chatting at the coffee bar the minute I show up. I ask a question about the schedule, offer an opinion on the new epidural kits, give the most intentionally bland comment on the weather, and the responses return stained with pity.

The other anesthesiologists at the hospital are bolder: “It happens to a lot of good doctors; I might have made all the same decisions”; “I know how you must feel. But for the grace of God I could have been assigned to that room”; “You have to get up and go on, Marie.” Only the vaguest shadow of judgment in their eyes, only the slightest drop in their voices dangles the question of doubt.

Within a few days after Jolene’s funeral it becomes obvious that my closer friends are working harder so I can get out of the hospital earlier. Joe, Will, even Sandy McLaughlin, who is usually so private and self-contained, all seem to be coincidentally discovering my late case has been transferred into one of their rooms. They wind up unexpectedly free right around noon with nothing better to do than send me out to pick up Thai food for everyone. It’s hard not to care that I’m never assigned any pediatric cases.

One morning the garage elevator opens and Brad gets in. As soon as he sees me I can tell he wishes he’d taken the stairs. It’s the first moment I admit to myself that I’ve been avoiding him in the cafeteria and conference room. He nods at me and pushes the button for the next floor up, even though we both have to get to the fourth floor operating rooms. When the doors open, though, I get out with him in the deserted vestibule of basement offices.

“Brad.” I hesitate, stretching for safe words. “Look. I never got a chance to tell you how sad I am that you’re caught up in this. It was just…bad timing. Bad luck.” I intend to stop with that, I know I should stop, but there isn’t a soul around to hear us. “I don’t think anything could have made a difference, on either of our parts, but if you noticed something, even some change that didn’t seem important at the time…”

He is beet red, shaking his head. “I can’t. I’m sorry, Marie. My lawyer says I can’t say anything to anyone except a shrink or a priest.” He reaches past my head to push the elevator button, and I feel my own face grow hot.

“Your lawyer? Why did you talk to a lawyer?”

He shrugs and pushes the button again. “I just needed to know where I stand. When…if a suit’s filed.” He steps inside the elevator and looks directly at me for the first time. His eyes seem sad, or disappointed, or maybe just afraid. “Marie, I’m the new guy here. I don’t have any record to stand on. Who are they gonna try to hang?” The doors close between us and the cables hum as he is hoisted away.


A week to the day after Jolene’s death I need to leave early to meet with my malpractice case representative and Joe comes in to take over my thyroidectomy.

“Got your speech ready?”

“I guess. Do I look nervous?”

He puts an arm around my shoulder, his mouth at my ear. “Just remember. You’re paying

“Yeah. It’s easy to forget that right now. Sort of feels like she’s the whole jury.”

I tell him my patient’s medical history and allergies and my anesthetic plan for her. I’m about to leave when I remember her primary request of me. “She really wants her dentures back in as soon as she’s awake,” and I point out the clear container holding a perfect plastic grin.


Caroline Meyers-Yeager, my malpractice claims manager, is a petite woman, somewhat older than myself, wearing a crisply fitted ivory silk suit that matches her equally crisp blond hair. Her clipped New York accent cuts to the bone of historical payouts for pediatric deaths and the statistical odds against prevailing in front of a jury if this comes to trial. I’m sitting opposite her desk, unable to swallow the tea her assistant brought, uncomfortably aware that I haven’t combed my hair in hours.

She listens to my well-rehearsed synopsis of Jolene’s anesthetic and code—the version my own bathroom mirror confirmed I’d performed flawlessly. “I’ve gone over my notes repeatedly,” I tell her in my most objective and collected voice. “The most likely explanation is anaphylaxis.”

She jots a note or two on a long yellow legal pad. “But she had no history of allergies.”

“Not in her record. Her mother didn’t know of any.”

She frowns and skims her notes. “You’ve done a good job with your charting. Very detailed—Donnelly will like that. But if you had to question your own diagnoses”—now she flashes a more conspiratorial smile—“if you were your own cross-examining prosecutor, is there anything that doesn’t fit?”

I start to answer her, consciously composed, but she catches the flicker of doubt. “It’s OK,” she says. “Nothing we say here is discoverable.”

“Her heart rate.” I pause and bite my lip. “It should have gone up at first. Before her oxygen level dropped. That’s the one thing that doesn’t make sense.”

“How significant do you think that is?”

I remind myself that for all her experience in the legalities of medicine, she isn’t a doctor. “I’m not sure. I gave her a narcotic, fentanyl, and that might have kept it from going up.”

She raises her eyebrows and waits. I add, “In the whole picture? It probably doesn’t mean anything at all.” Despite this blind alley, it is a relief to finally admit this fraction of doubt in a protected space. “Regardless, the autopsy should confirm anaphylaxis, if I’m right about that.”

She nods and takes a sip out of her own teacup; her lipstick stays perfect. “Let’s hope so. Keep in mind that whether you did everything right or not, First Lutheran has a vested interest in keeping this quiet, which means settling even if that implies some error. The degree of your error or competence primarily impacts the dollar amount of that settlement.”

“When do you expect the autopsy results to be back?”

“Weeks, usually. We’ll go forward on the presumption that they don’t indicate any act of negligence.”

It’s the first time anyone’s spoken that word to me out loud. I’ve said it to myself. I even looked it up: “failure to exercise the care that a reasonably prudent person would exercise in like circumstances.”

“Ms. Jansen hasn’t actually sued me, though, has she?”

“No,” she states with a finality that makes me almost relax. Then she continues. “But I expect she will. And if she does, she won’t sue just you, she’ll sue the hospital and everyone in that operating room. And if she sues this will get into the newspapers and cost us that much more.”

“I understand,” I say, not really sure I understand at all.

“This needs to be quick.” She is back to all business, her fingers locked across her thin waist. A diamond on her left ring finger sprays flecks of light across my file. “I’m sure you know what a claim like this will do to your database, but we can’t risk a trial. First Lutheran can’t risk it and neither can you. If we settle we at least have some control over the costs. Remember, your policy has a cap. There’s really no winning this, it’s purely a matter of how much we pay her.”

“What would happen if a settlement went above my cap?”

Her eyebrows dart upward for a second, and I realize how naive my question must sound.

“Well, anything above your cap would have to come out of your own assets.”


Will Hanover is on call tonight. Well after eight o’clock I go back to the hospital and knock on the call room door, hoping he isn’t still in the operating rooms. I hear the bed springs squeak under the pitiful excuse for a mattress we all rotate using.

“Hi, Will. I’m sorry, were you trying to rest?”

He runs a hand over his hair and scratches his scalp. “Not at all. I was reading the paper. We’re starting an ex lap in an hour or so—waiting for the patient’s son to get here.”

“Who’s the surgeon?” I ask.

“Marconi. Poor lady is eighty-six with an ischemic bowel.”

“Do you need any help setting up?”

He laughs. “So you dressed up in your nice clothes and came back to the hospital to help me set up my operating room?” He shakes his head. “How did your meeting go today?”

I shrug and shove my hands into my coat pockets. “OK. I guess. How did you hear?”

“Joe. Want a cup of coffee?”

At a corner table in the cafeteria, I finally ask, and Will tells me the details of a lawsuit he went through in his first year of practice at a hospital in Portland. “It was a bilateral carotid in an obese woman. Not the best surgeon; I was fresh out of residency. I wanted to leave her intubated at the end and the surgeon insisted I pull out the tube. I was right, and he was wrong, but I didn’t stand my ground.”

He pulled out her breathing tube in the recovery room after she was fully awake, but she thrashed and her blood pressure skyrocketed. The carotid sutures ruptured and she bled into the tissues of her neck, closing off her airway. He couldn’t get the breathing tube back in.

“She died?” I ask.

“Worse. She was vegetative for eight years before she died. I wanted to settle but it got too contentious. The family’s lawyer pitted the hospital and me and the surgeon against each other so it went to trial. The award went way past my malpractice coverage. I didn’t have much money at the time, but I lost what I had.”

“Oh God, Will. I’m so sorry.”

He stirs his coffee and takes a minute to answer. “The money’s not the hard part. The hard part is convincing yourself that you should ever be allowed to take care of people again. The hospital, the insurance company—they all fixate on the dollars. But you’re the one who tries to go to sleep every night with that patient’s face floating over your head.” The cafeteria is almost deserted; it smells of bleach and detergent and overheated coffee. The janitor begins vacuuming our section and we’re quiet until he leaves.

“This lady, she had nine kids, eleven grandkids—every time I went by the ICU in the days after it happened, her room was filled with people. Wouldn’t even consider turning off the ventilator. All praying and waving a Bible over her, waiting for her to wake up.”

He looks up at me and folds his hands in his lap. “I shouldn’t say that, should I? I don’t mean to offend anyone by it.”

I shake my head. “I was raised Catholic but we dropped it all when I was a teenager. So how did you get through it?”

“Youth. Jenny, my wife, was great—we had to sell our house. Phil Scoble gave me this job, which I was very grateful for at the time. And I’ve never gone against my own medical instincts again. If there’s any good outcome, it’s that.” He sits back in his chair. “So on to you. Was this your attorney today?”

“No. My malpractice claims manager. She wants to settle it as quickly as she can—the mother hasn’t sued me, but everyone’s expecting that.”

He nods. “Well. Yours ought to be more straightforward. I know you can’t talk about it—I sure remember that part—but it doesn’t sound like you made any mistakes. It’s remarkable how many months these things can drag on, though. Lawyers bill by the hour.”

I wish I could smile at this. “Phil’s been supportive. Even Frank.”

He nods again, more pensively. “Phil’s a decent guy. Just…” He stops.

“Just what?”

He flinches for an instant. “Nothing. Personal philosophy. Always remember they’ll sacrifice the soldier before they’ll lose the war.” His pager goes off and he has to leave for the operating room. The coffee feels like it’s burning right through my stomach.


The following morning I’m called before the hospital’s Internal Quality Control panel to present Jolene’s case. Someone pours juice for me; I pick up my glass and a quake of tremors spirals across the surface. In voices tempered with sympathy, a panel of strangers in white coats convert my chart notes and dictated description of the catastrophe into a series of checked boxes on a standardized intraoperative death report. The chairman, a doctor who retired from First Lutheran before I went to college, shakes my hand as we leave the room. “This is all formality, Dr. Heaton. The doctors against the lawyers.” He drops his voice to a whisper. “My daughter is a pediatrician. Got sued for giving a kid his measles vaccination. She walked away from her practice afterward. It’s like everybody’s forgotten how to make an honest living.”

That evening, after my last patient is in the recovery room, I meet with the Physician Committee for Mortality and Morbidity. This time I sit at the end of a table filled with my own colleagues and friends—Sandy, Will, Peter Janovich, Sean Marconi—surgeons, anesthesiologists and internists assigned to objectively analyze my role in Jolene’s death. Phil presides over the hearing. Finally I’m allowed to discuss the details of the case with other doctors—people who can understand all the possible consequences and rationale for the drugs and CPR I gave Jolene. With the record of her surgery and anesthetic in front of me, and the notes I composed after her death, I explain every incremental change in her status and the intervention I chose to correct it. I keep looking across at Phil, trying to interpret each nod or sigh or pause. Slowing the events down like this, removing the panic, it’s clear to me—to everyone here—that I missed nothing, that I responded appropriately and promptly to every alarming number as it flashed on my monitor. No one points any damning fingers or flags my personnel file with condemnations. Phil concludes by commending my quick recognition of the crisis, my cool allegiance to emergency protocols, my stoic return to work, how appropriately I am putting remorse into its proper professional perspective. There can be nothing to fault, except that Jolene still died.

Will stops me on the way out. “That went pretty well, don’t you think?”

I lean against the wall and hug the copies of Jolene’s notes against my chest. “Better than I’d expected.”

“So maybe there won’t be any lawsuit. Phil told me nobody’s filed anything.”

He looks so hopeful, it’s hard not to be inspired. “Well, if this committee didn’t flay me alive, maybe the lawyers won’t smell enough money to come running, huh?”

BOOK: Oxygen
10.48Mb size Format: txt, pdf, ePub

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