If the case had belonged to one of the private staff men, the discussion would have progressed very differently. The same points would have been made, but the physician would have been reassured that the diagnosis of hemopericardium was difficult and he’d done the best he could.
Thomas had realized early in the game that the monthly death conference served more to relieve guilt than to punish, unless the offender was a resident. Lay people might have thought the death conference served as a kind of watchdog, but unfortunately such was not the case, as Thomas cynically observed. And the next case proved his point.
Dr. Ballantine was mounting the podium to present Herbert Harwick. When he finished, an obese pathology resident quickly ran down the results of the autopsy, including slides of the individual’s brain, of which little remained.
Mr. Harwick’s death was then discussed but with no mention that his trauma in the OR was the possible result of Dr. Ballantine’s inept surgery. The general feeling among the attendings was, “There but for the grace of God go I,” which was true to an extent. What made Thomas sick was that no one remembered that six months previously Ballantine had presented a similar case. Air embolism was a feared complication that at times occurred no matter what one did, but the fact that it occurred so often and at an increasing frequency to Ballantine was always ignored.
Equally amazing, as far as Thomas was concerned, was that nothing was said about Harwick’s actual death in the ICU. As far as Thomas knew, the patient had been stable for an extended period of time before the sudden arrest. Thomas looked at the members of the audience and puzzled why they remained silent. It reconfirmed for him that bureaucracy and its committee method of dealing with problems was no way to run an organization.
“If there’s no further discussion,” said Ballantine, “I think we should move on to the next case. Unfortunately I’m still in the dock.” He smiled thinly. “The patient’s name is Bruce Wilkinson. He is a forty-two-year-old white male who had suffered a heart attack and who had shown focally compromised coronary circulation, suggesting he was a good candidate for a triple bypass procedure.”
Thomas straightened up in his chair. He remembered Wilkinson very clearly, particularly the night he’d attempted to resuscitate him. He could still see the surrealistic scene in his mind’s eye.
Ballantine droned on, presenting the case with much too much detail. The chin of the surgeon sitting next to Thomas slumped onto his chest and his deep, regular breathing could be heard as far away as the podium. Finally Ballantine got to the end and said, “Mr. Wilkinson did extremely well postoperatively until the night of the fourth postoperative day. At that time he died.”
Ballantine looked up from his papers. His face, in contrast to its expression when they were discussing the previous case, had assumed a defiant expression as if to say, “Try to find a mistake here.”
A slight, well-dressed pathology resident got up from the first row and stepped behind the podium. He adjusted the small microphone nervously and bent over, thinking he had to speak directly into it. A high-pitched, irritating electronic sound resulted, and he backed away with apology.
Thomas recognized the man. It was Robert Seibert, Cassi’s friend.
As soon as Robert began his presentation of the pathology, all evidence of his nervousness disappeared. He was a good speaker, especially when compared with Ballantine, and he had organized his material so that only the significant points were mentioned. He showed a series of slides and pointed out that, although the patient had been described as having been deeply and grossly cyanotic at the time of death, there was no airway obstruction. He next presented a photomicrograph that showed that there was no alveolar problem in the lungs. Another series of slides showed there were no pulmonary emboli. Another series of photomicrographs was presented that showed there was no evidence that there had been a rise in left or right atrial pressure prior to death. The final series of pictures indicated that the bypasses were skillfully sutured in place and that there was no sign of recent myocardial infarction or heart attack.
The lights came back on.
“All this shows…” said Robert, pausing as if for effect, “that there was no cause of death in this case.”
The audience responded with surprise. Such a statement was completely unexpected. There were even a few laughs as well as a comment from one of the orthopedic men who asked if this had been one of those cases that had awakened in the morgue. That inspired more laughter. Robert smiled.
“Must have been a stroke,” said someone behind Thomas.
“That is a good suggestion,” said Robert. “A stroke that shut down the breathing while the heart pumped the unoxygenated blood. That would cause deep cyanosis. But that would mean a brain-stem lesion. We went over the brain millimeter by millimeter and found nothing.”
The audience was now silent.
Robert waited for more comments, but there were none. Then he leaned forward and spoke into the microphone: “With permission I’d like to present another slide.”
Cleverly he’d caught the imagination of the gathering.
Thomas had an idea of what was coming.
Robert switched off the lights, then switched on the projector. The slide showed a compilation of seventeen cases, containing comparable data on age, sex, and points of medical history.
“I’ve been interested in cases such as Mr. Wilkinson for some time,” said Robert. “This slide is to show that his is not an isolated case. I have found four similar cases myself over the last year and a half. When I went back in the files, I found thirteen others. If you’ll notice, they have all had cardiac surgery. In each circumstance, no specific cause of death was found. I’ve labeled this syndrome sudden surgical death, or SSD.”
The lights came back on.
Ballantine’s face had turned bright red. “What do you think you are doing?” he spat at Robert.
Under different circumstances Thomas might have felt sorry for Robert. His unexpected presentation did not fit within the rather narrow protocol for a death conference.
Glancing around the room, Thomas saw many angry faces. It was an old story. Doctors did not like to have their expertise questioned. And they were reluctant to police their own.
“This is a death conference, not a Grand Rounds,” Ballantine was saying. “We’re not here for a lecture.”
“In discussing the case of Mr. Wilkinson, I thought it would be enlightening…”
“You thought,” repeated Dr. Ballantine sarcastically. “Well, for your information you’re here as a consult. Did you have something specific to say when you presented this list of supposed sudden surgical deaths?”
“No,” admitted Robert.
Although Thomas preferred to stay silent at such meetings, he had to ask a question: “Excuse me, Robert,” he called. “Did all the seventeen cases have deep cyanosis?”
Robert could not have been more eager to field a question from the audience. “No,” he said into the microphone. “Only five of the cases.”
“That means that the physiologic cause of death was not the same in all these cases.”
“That’s true,” said Robert. “Six had convulsions prior to death.”
“That was probably air embolism,” said another surgeon.
“I don’t think so,” said Robert. “First of all, the convulsions occurred three or more days after surgery. It would be hard to explain that kind of delay. Also when the brains were autopsied, no air was found.”
“Could have been absorbed,” said someone else.
“If there had been enough air to cause sudden convulsions and death,” said Robert, “then there should have been enough to see.”