Checks and Balances

Chapter 9

It was close to 1:30 in the morning when Roy and Dr. Brackett entered his office. Roy took a seat as the doctor closed the door. All at once the doubts that Roy had came rushing back. He felt a mixture of fear, frustration, and even anger waring in his heart for dominance. There was no doubt that the senior paramedic had a plethora of questions rocketing around in his mind, but he held them all at bay and waited to hear what the head of the ER had to say. Dr. Brackett walked over to his desk, but as he passed the light boxes he flipped one of the switches to on. Roy's eyes were drawn to the x-rays hanging there turning a questioning frown to the doctor.

"Roy, I spent an hour fighting with administration over this. They don't want me discussing this situation with anyone, but that is not how I see it. Johnny is your partner and you and the fire department are the closest thing he has to family so in my opinion you have a right to know what happened today."

Roy felt like a balloon had burst inside of him. Something really had happened and it sounded serious. Roy couldn't keep the expression off his face. Dr. Brackett seemed to be studying him and he nodded slightly.

"I understand that you have questions, and I'm sorry I was so cryptic with you earlier, but honestly I needed to tend to Johnny and you had a call. Now I want you to take a look at that set of films."

Roy stood up and walked over to the light box and looked at the chest x-ray hanging there. He had no idea how to interpret what he was seeing. He could tell what the lungs, heart and ribs were, but he was no doctor. All he did know was that the answer to everything would be revealed by those images. Once again Roy began to feel doubt. Had Brackett actually missed something?

Dr. Brackett stepped over and joined Roy at the light box. "These are the films that you and Johnny brought back from radiology this afternoon."

Roy glanced down and saw the bottom corner where the name was and could clearly see Johnny's name there. Again he looked at the film and traced the lung edge with his eyes. He couldn't see anything wrong, but he really wasn't adept at reading the images. Dr. Brackett then flipped another switch which lighted up a different set of films. Roy's eyes opened wide at what he saw and suddenly everything fell into place. The other x-rays showed a set of lungs that were longer and it was clear that the patient was more slender than the set labeled with Johnny's name. Roy's eyes traced the contours of the right lung on the second set of films and he could see a distinct difference near the top.

"The films were mislabeled!" Roy said, as comprehension dawned. A thought occurred to Roy. "When did you find out about this?"

"Our chief radiologist came into the ER at quarter to eleven with Johnny's films marked with the wrong name. It took us a little while to piece together who the films belonged to. As soon as I realized it was Johnny I called the station, but by then you were already on the biophone with the base station."

Roy swiped his hand down his face and sat back down sighing. "Man, I... I'm sorry."

Dr. Brackett turned to Roy and frowned. "Sorry? Roy, what are you sorry for?"

"When I was here earlier, I had a feeling that something was off. Dixie left so quickly after the x-ray tech took the picture and you had a peculiar look on your face. I'd been thinking that you'd made a mistake. I didn't want to believe it, but I really was thinking that because it was so busy today that... well, it doesn't matter because it turns out it was a mix up in radiology."

Dr. Brackett's mouth twitched slightly. "I did make a mistake, Roy. Look at those two films. I have seen x-rays of Johnny on a number of occasions including the last departmental physical three months ago. I should have realized that the films I was looking at belonged to someone else."

Roy's stood up again stepping over to the light boxes and looked at the two different films on the view box. When they were placed side by side it was clear that Johnny's chest x-ray was longer and thinner than the other. The problem Roy had with the doctor's logic was that without them being right next to each other, how would anyone know? He himself had viewed the mislabeled films and assumed they were Johnny's. He never even questioned it.

"You were brought x-rays that had Johnny's name on them. You looked at the films and made a decision based on that information. Why were you supposed to keep this from me?"

"Isn't that obvious, Roy? The administration wants to keep this very quiet. I was asked to bring the films." Bracket cleared his throat. "Both sets up to the administration suite in the morning. That isn't going to happen. I don't want these films to go missing so they will remain right here in my office under lock and key."

Roy was stunned that Brackett would suggest some kind of cover up. "You really think that the films would disappear? It was a clerical error, or a processing error, or whatever, but it was just an error. They happen sometimes."

"That error nearly cost a man his life, Roy. The administration is worried about legal repercussions and I am concerned that they may be looking for a scapegoat."

Roy looked puzzled by that statement. "A scapegoat? Is someone going to lose their job over this? How did this happen anyway?"

Brackett sighed deeply. "That is the mystery. Johnny's films were taken by one tech and Mr. Clements films were taken by another tech, each of them working in their own room. There is only one darkroom in that control area so both sets of films were developed by the same darkroom tech, but this is a man who has worked here at the hospital for nearly 20 years and he has never mixed up ident cards and films before. He has a system of doing each exam separately to avoid just such an occurrence. The only time the films and ident cards were in the same place at the same time was when the films were set on the counter in the control area outside the darkroom, but one set of films was on one counter while the other set was on a different counter."

Dr. Brackett shook his head and sighed. "I even went down to radiology control to see how things were set up. The darkroom sits between two of the x-ray exam rooms; the ones that were used to take Johnny and Mr. Clements' studies. There is a counter along the left wall that is next to one of the exam rooms and the same holds true for the other side of the area. As the x-ray techs finished their exams they put the films they took with their ident cards and placed them on the counter next to the room they were working in. The only explanation that anyone can think of is that somehow the cards were knocked off of the counters and onto the floor and when they were put back they were put with the wrong sets of film cassettes. It's a reach but I cannot for the life of me figure out how else the mix up could have happened."

Roy followed what Dr. Brackett was saying and could clearly picture the scenario. "Does anyone beside the x-ray techs or darkroom tech work in that area?"

Dr. Brackett shrugged his shoulders. "I honestly have no idea. The radiology administrator along with the hospital administration are conducting an investigation to try and figure out what happened. What concerned me was something that was said about you actually."

Roy paled slightly. "Me?"

Dr. Brackett stood up and took the x-rays off the view box and slid them into a large manila x-ray envelope as he spoke. "There was some talk of an investigation into the thoracostomy performed by a paramedic."

Roy was shocked by this news and a little angry. Before he could say anything Dr. Brackett continued, obviously seeing the emotions play across his most senior paramedic's face. "There is no need to worry, Roy. You're covered; by me! You were acting under my direct orders and I will not let anyone try to serve you up as a way to get around the hospital's culpability in this situation. Besides, if anyone should take the blame, it should be me. I am the one who cleared Johnny for duty. It was my responsibility to know what I was looking at, and no matter what happens, the buck stops here."

Roy didn't know what to say. Dr. Brackett is the one who cleared Johnny for duty, but he had been given the wrong films. That really wasn't Dr. Brackett's fault, but he didn't know whose fault it was; maybe no one's. It was human nature to want to blame someone. He felt angry that he had nearly lost his partner and best friend over some stupid error, but people make mistakes. He had made plenty over the course of the years. Even in this situation Roy was at fault. He had made a mistake by passing off or ignoring symptoms that he should have recognized. Maybe the hospital should be investigating him, and asking why he didn't realize that there was a problem in the first place.

Dr. Brackett tapped Roy's arm bringing him out of his thoughts. "Roy, you all right?"

"How is he?" Roy asked, to divert attention away from him and back to Johnny where he felt it belonged.

"He's in the ICU. I took him off the respirator once the chest tube was inserted and his right lung began to re-inflate. I don't want him to become dependent on it. The danger of another bronchial spasm is minimal now, but he still needs to be closely monitored."

Roy could see a slight twitch in the corner of Dr. Brackett's mouth. He had known the doctor long enough now to realize that he was holding something back. "So he's breathing on his own. Is he awake, can I see him?"

Dr. Brackett sighed as he flipped the light switch off on the view boxes. "He isn't awake, Roy. He's in a coma."

Despair washed over Roy like a wave making his knees go weak and he moved to sit down. "A coma?"

All of his training hadn't prepared him for the onslaught of medical facts that battered his brain; oxygen deprivation, hypoxia, brain damage, coma, death. Roy was once again pulled from his morose thoughts when Dr. Brackett placed a hand firmly on his shoulder.

"Roy, you have to remain positive. Johnny could wake up in the next five minutes, or..."

Roy wasn't fooled by the false hope that Dr. Brackett wasn't pulling off very convincingly. "...or he may never wake up, and if he does, will he have brain damage?"

"I can't answer that, Roy. I reviewed the tape of the call. From the time you first contacted the base station to the insertion of the thoracostomy needle it was 6 minutes and 53 seconds. During that time you were forcing ventilations and even though he wasn't really moving any air, he was still getting some oxygen. You found him right away after he collapsed because he pulled the internal alarm. He was hopefully only anoxic* for 2 or 3 minutes at most."

A small glimmer of hope blossomed in Roy's chest. Johnny had obviously been conscious when he made his way from his bunk to the alarm pull. "Can I see him?"

"The nursing staff have been given strict instructions that only the next of kin are allowed to see him or be given any information about him, but I'll take you up to ICU myself. You'll only be able to stay for a couple of minutes though."

"That'd be great, Doc. I can't stay long anyway. I'm still on duty."

Johnny was a sorry sight to behold. A sheet was pulled up just past his waist leaving his chest bare. The room was quite warm which seemed oddly in contrast to any other time Roy had visited the ICU. Chest leads for the heart monitor were taped across his upper chest with ground leads at the bases on either side of his ribs. A chest tube firmly taped in place, where the needle thoracostomy had been earlier and attached to a suction collection unit was a gruesome reminder of how close they had come to losing him. His color was much better than it had been the last time Roy had seen him, but his unnatural stillness was unnerving. Johnny was always in motion even when he slept, tossing and turning most nights.

"Can I have a minute with him?" Roy didn't even turn around when he asked, he just moved forward and took a hold on a limp hand as Dr. Brackett moved out of the room silently.

"Johnny, you have to pull through this. I should have seen what was happening. Dr. Brackett thinks it's his fault, but he wasn't with you all day; I was. I'm so sorry, Pally." His voice trailed off into a whisper and he closed his eyes offering up a silent prayer to whatever God might hear him. "I'll come back in the morning to see how you're doing."

Dr. Brackett stepped back into the room and took Johnny's chart from the end of the bed, but addressed Roy before he opened it up and looked through it.

"Roy, you look exhausted. I know how long this day has been. Go back to the station and get some rest. He'll still be here in the morning."

"What about you, Doc. You're past a 24-hour shift at this point aren't you?"

"Not to worry. I plan to catch some sleep in my office. That couch is a lot more comfortable than it looks. I'm not going anywhere until Johnny is moved out of ICU."

Roy stepped away from the bed and turned to leave, but as he passed Dr. Brackett he stopped and spoke without looking at the doctor. "This wasn't your fault, Doc. You're not going to do Johnny any good if you're too tired to function."

Roy could hear the smile in Dr. Brackett's voice. "Hey, that's my line! Get out of here hose jockey!"

TBC

* Hypoxic-Anoxic Brain Injury - http: / . com/releases/2006/08/060824224201 . htm (Take out spaces to follow address to research)

It is now known that a mild hypoxic condition prior to anoxia actually protects the brain from more serious injury by triggering the release of specialized proteins HIF1 and PHD2 that protect the brain cells from a full anoxic episode. For definition: Hypoxic refers to a partial lack of oxygen; anoxic means a total lack of oxygen.