The transfer from the delivery area to the OR suite was accomplished without incident. Jeffrey kept Patty on oxygen by mask during the short trip.
The OR had been advised as to the decision to do a Caesarean. By the time Patty was transferred, the room was almost set up for the procedure. The scrub nurse, already scrubbed, was busy laying out the instruments. The circulating nurse helped guide the gurney into the room and transfer Patty to the OR table. Patty still had the fetal monitor on, which was left in place for the time being.
Jeffrey wasn't as familiar with the evening personnel, and he hadn't met the circulating nurse before. Her name tag read: Sheila Dodenhoff.
“I'm going to need some .5% Marcaine,” Jeffrey told Sheila as he changed Patty from portable bottle oxygen to oxygen delivered through his Narcomed III anesthesia machine. He then reapplied the blood pressure cuff to Patty's left arm.
“Coming up,” Sheila said cheerfully.
Jeffrey worked quickly but deliberately. He checked off every procedure in his anesthesia record once it had been performed. In sharp contrast to most other doctors, Jeffrey prided himself on his exquisitely legible handwriting.
After hooking up the EKG leads, he attached the pulse oximeter to Patty's left index finger. He was replacing Patty's IV with a more secure intracath when Sheila returned.
“Here you go,” she said, handing Jeffrey a 30 cc glass vial of .5% Marcaine. Jeffrey took the drug and, as he always did, checked the label. He set the vial on top of his anesthesia machine. From the drawer, he took out a 2 cc ampule of spinal grade .5% Marcaine with epinephrine and drew it up into a syringe. Maneuvering Patty onto her right side, Jeffrey injected the 2 cc's into the epidural catheter.
“How's everything going?” a booming voice called out from the door.
Jeffrey turned to see Dr. Simarian holding a mask to his face while he held open the door.
“We'll be ready in a minute,” Jeffrey said.
“How's the little one's ticker?” he asked.
“At the moment, fine,” Jeffrey answered.
“I'll scrub up and we'll get this show on the road.”
The door swung shut. Jeffrey gave Patty's shoulder a squeeze while he studied the EKG and the blood pressure readout. “You okay?” he asked her, moving the oxygen mask to the side.
“I think so,” she said.
“I want you to tell me whatever you feel. Understand?” Jeffrey said. “Do your feet feel normal?”
Patty nodded. Jeffrey went around and tested her sensation. Coming back to the head of the table and checking the monitors again, he was sure that the epidural catheter had not moved and had not penetrated either the spinal canal or one of the pregnancy-dilated veins of Bateson.
Satisfied that all was in order, Jeffrey picked up the vial of Marcaine Sheila had brought him. Using his thumb, he snapped off the top of the sealed glass container. Once again he checked the label, then drew up 12 cc's. He wanted anesthesia to extend at least to T6, and preferably to T4. As he put the Marcaine down, his eyes caught Sheila's. She was standing off to the left, staring at Jeffrey.
“Is something wrong?” Jeffrey asked.
Sheila held his gaze for a beat, then spun on her heels and left the OR without speaking. Jeffrey turned to catch the eye of the scrub nurse, but she was still busy setting up. Jeffrey shrugged. Something was going on that he didn't know about.
Returning to Patty's side, he injected the Marcaine. Then he capped off the epidural catheter and returned to the head of the table. After putting down the syringe, he noted the time and the exact amount of the injection in the record. A slight quickening of the beep of the pulse brought his eyes up to the EKG monitor. If there was to be any change in the heart rate, Jeffrey expected a slight slowing from progressive sympathetic blockade. Instead, there was the opposite. Patty's pulse was speeding up. It was the first sign of the impending disaster.
Jeffrey's initial reaction was more of curiosity than concern. His analytical mind groped for a logical explanation for what he was witnessing. He glanced at the blood pressure readout and then the oximeter LED. They were all fine. He looked back at the EKG. The pulse was still quickening, and even more
disturbing, there was an ectopic, irregular heartbeat. Under the circumstances, that was not a good sign.
Jeffrey swallowed hard as fear clutched at his throat. It had only been seconds since he'd injected the Marcaine. Could it have gone intravenous despite the test dose result? Jeffrey had had one other adverse reaction to local anesthetic in his professional career. The incident had been harrowing.
The ectopic beats were increasing in frequency. Why would the heart rate increase and why the irregular rhythm? If the anesthetic dose did go intravenously, why wasn't the blood pressure falling? Jeffrey had no immediate answers to these questions, but his medical sixth sense, born of years of experience, set off alarm bells in his mind. Something abnormal was occurring. Something Jeffrey was at a loss to explain, much less understand.
“I don't feel good,” Patty said, turning her head to talk out of the side of the mask.
Jeffrey looked down into Patty's face. He could see it was again clouded with fear. “What's the matter?” he asked, puzzled by these rapid events. He touched her shoulder.
“I feel funny,” Patty said.
“How do you mean, funny?” Jeffrey's eyes went back to the monitors. There was always the fear of allergy to the local anesthetic, although developing allergy in the two hours since the first dose seemed a rather farfetched notion. He noticed the blood pressure had risen slightly.
“Ahhhhh!” Patty cried.
Jeffrey's eyes shot to her face. Patty's features were twisted in a horrible grimace.
“What is it, Patty?” Jeffrey demanded.
“I feel a pain in my stomach,” Patty managed hoarsely through clenched teeth. “It's high up, under my ribs. It's different from the labor pain. Please . . .” Her voice trailed off.
Patty began to writhe on the table, drawing up her legs. Sheila reappeared along with a muscular male nurse who lent a hand in attempting to restrain her.
The blood pressure that had risen slightly now began to fall. “I want a wedge under her right side,” Jeffrey yelled as he got ephedrine from the drawer and prepared it for injection. Mentally he calculated how far he'd let the blood pressure drop before he'd inject the pressor agent. He still had no idea of what was happening, and he preferred not to act before he knew exactly what he was up against.
A gurgling sound brought his attention back to Patty's face. He pulled off her oxygen mask. To his surprise and horror she was salivating like a mad dog. At the same time she was lacrimating profusely; tears were streaming down her face. A wet cough suggested that she was also forming increasing amounts of tracheo-bronchial secretions.
Jeffrey remained the ultimate professional. He had been trained to deal with this type of emergency situation. His mind raced ahead, taking in all the information, making hypotheses, then ruling them out. Meanwhile, he dealt with the life-threatening symptoms. First he suctioned Patty's nasopharynx, then he injected atropine intravenously, followed by ephedrine. He suctioned Patty again, then injected a second dose of the atropine. The secretions slowed, the blood pressure plateaued, the oxygenation stayed normal, but Jeffrey still did not know the cause. All he could think of was an allergic reaction to the Marcaine. He watched the EKG, hoping that the atropine might have a positive effect on the irregular heartbeats. But they remained irregular. In fact, they became even more irregular as Patty's pulse quickened. Jeffrey prepared a 4 mg dose of propranolol, but before he could inject it, he noticed the muscle fasciculations that distorted Patty's features in a series of seemingly uncontrolled twists and spasms. The fasciculations rapidly spread to other muscles until her body became wracked by clonic jerks.
“Hold her, Trent!” Sheila cried to the male nurse. “Get her legs!”
Jeffrey injected the propranolol as the EKG began to register further bizarre changes, intimating there was diffuse involvement of the heart's electrical conduction system.
Patty spewed up green bile which Jeffrey quickly suctioned away. He glanced at the oximeter readout. That was still holding. Then the fetal monitor alarm began to go off; the baby's heart was slowing. Before anyone could react, Patty suffered a grand mal seizure. Her limbs flailed madly in all directions, then her back arched in awkward hyperextension.
“What the hell is going on?” Simarian shouted as he came flying through the door.
“The Marcaine,” Jeffrey shouted. “She's having some sort of overwhelming reaction.” Jeffrey didn't have time to elaborate as he drew up 75 mg of succinylcholine.
“Jesus Christ!” Simarian yelled, coming around the table to help hold Patty down.
Jeffrey injected the succinylcholine as well as an additional dose of diazepam. He was thankful that his compulsiveness had made him change the IV to a more secure one. The audio portion of the oximeter readout began to fall in pitch as Patty's oxygenation decreased. Jeffrey again cleared her airway and tried to bag her with the 100% oxygen.
Patty's seizure movements slowed as succinylcholine-induced paralysis took effect. Jeffrey slipped in an endotracheal tube, checked its position, and ventilated her well with the oxygen. The sound of the oximeter immediately returned to its higher pitch. But the fetal monitor was still sending out its alarm. The baby's heart had slowed and was not speeding back up.
“We gotta get the baby!” Simarian yelled. He grabbed sterile gloves from one of the side tables and yanked them on.
Jeffrey was still watching the blood pressure, which had started to fall again. He gave Patty another dose of ephedrine. The blood pressure started back up. He glanced at the EKG; it had not improved with the propranolol. Then to Jeffrey's horror, just as he was watching, the EKG disintegrated into senseless fibrillation. Patty's heart had stopped beating.
“She's arresting!” Jeffrey shouted. The blood pressure fell to zero. Both the EKG and the oximeter alarms began shrieking stridently.
“My God!” Simarian yelled. He had been hastily draping the patient. He moved up to the table and started external cardiac massage by compressing Patty's chest. Sheila put out the word to the OR desk. Help was on its way.
The crash cart arrived along with additional OR nurses. With lightning speed, they prepared the defibrillator. A nurse anesthetist also arrived. She went directly to Jeffrey's side.
The oxygen content of Patty's blood went up slightly. “Countershock her!” Jeffrey ordered.
Simarian took the defibrillator paddles from one of the nurses. He applied them to Patty's bare chest. Everyone stepped back from the OR table. Simarian pressed the button. Since Patty was paralyzed with the succinylcholine, there was no apparent effect from the electric current except on the EKG screen. The fibrillation disappeared, but when the phosphorescent blip returned, it did not show a normal heartbeat. Instead, it traced a completely flat line with only a few minor squiggles.
“Restart massage!” Jeffrey ordered. He stared at the EKG. He couldn't believe there was no electrical activity. The
muscular male nurse took over from Simarian and started compressing Patty's chest with good result.
The fetal monitor was still sounding. The child's heart rate was too slow. “We gotta get the baby!” Simarian snapped again. He changed his gloves and hastily took additional drapes from the scrub nurse. He positioned them as best he could despite the cardiac massage. He grabbed a knife from the instrument table and went to work. Using a generous vertical incision, he sliced Patty's lower abdomen open. With the reduced blood pressure there was very little bleeding. A pediatrician arrived on the scene and prepared to take the baby.
Jeffrey's attention stayed with Patty. He suctioned her and was surprised at the amount of secretions even after the two doses of atropine. Checking Patty's pupils, he was pleased they were not dilated. In fact, he was surprised to find them pinpoint. With oxygenation remaining up, Jeffrey decided to hold off introducing any more drugs into Patty's system until after the baby was delivered. Briefly, he explained what had happened to the nurse anesthetist.
“You think it's a reaction to the Marcaine?” she asked.
“That's all I can think of,” Jeffrey admitted.
In the next minute a silent, blue, flaccid baby was pulled from Patty's abdomen. After the cord was severed, the child was quickly handed to the waiting pediatrician. He rushed the newborn to the infant care unit, where the baby was surrounded by his own resuscitation team. The nurse anesthetist joined that group.
“I don't like this flat EKG,” Jeffrey said to himself as he injected a bolus of epinephrine. He watched the EKG. No response. He then tried another dose of atropine. Nothing. Exasperated, he drew an arterial blood sample and sent it off to the lab for a stat reading.
Ted Overstreet, one of the cardiac surgeons who had recently finished a bypass case, came in and stood next to Jeffrey. After Jeffrey explained the situation, Overstreet suggested opening her up.
The nurse anesthetist came back to report that the baby was not in good shape. “The Apgar is only three,” she said. “He's breathing and his heart is beating, but not well. And his muscle tone is not good. In fact, it's weird.”
“How so?” Jeffrey asked, fighting a wave of depression.
“His left leg moves okay, but not his right. The right one is completely flaccid. With his arms it's just the opposite.”
Jeffrey shook his head. Obviously the child had been oxygen deprived in utero and was now brain damaged. The realization was crushing, but there was no time to wallow in regret. Just then his chief concern was Patty and how to get her heart started.
The stat lab work came back. Patty's pH was 7.28. Under the circumstances, Jeffrey thought, that was pretty good. Next he injected a dose of calcium chloride. Minutes dragged like hours as everyone watched the EKG, waiting for some sign of life, some response to treatment. But the monitor traced a frustratingly flat line.