Richard resisted, a little uncomfortable with the mask, so Verbrugge let him hold it as he briefly increased the halothane ratio. When his patient had settled into sleep, Verbrugge placed an endotracheal, or ET, tube down Richard's windpipe, to assure proper delivery of gases and expiration of carbon dioxide. For monitoring purposes, he also inserted an internal stethoscope and temperature probe--a soft blunt tube--into Richard's esophagus.
Already, Verbrugge's conduct was raising eyebrows in the operating room.
Accepted standard of care calls for anethesiologists to listen to their patient's chest with a stethoscope after inserting an ET tube, to assure they have a properly placed airway. Verbrugge would later say he was "pretty sure" he did that. But two nurses who were standing nearby would later testify that they never saw Verbrugge use a stethoscope then or at any time during the operation.
Nor did they see Verbrugge hook the internal temperature probe to a monitor. When he tried to, he found the probe's connector wasn't compatible. He asked for a suitable monitor.
It arrived within five minutes. By then, however, Richard was being prepared and draped for surgery, since Verbrugge hadn't asked the nurses and surgeon to wait. To connect the probe to the monitor would now require Verbrugge to lift the drapes. "Thank you, it's too late," Verbrugge told the attendant.
Unlike the temperature probe, the internal stethoscope had no compatibility problem with its monitor. But Verbrugge also chose not to connect it. He feared possibly violating the "sterile field," Verbrugge would later explain, even though neither the surgeon nor nurses thought that a possibility.
Surgery began at 8:20 a.m., with Verbrugge lacking a way to reliably, continuously monitor Richard's temperature, breath and heart sounds. To many anesthesiologists this situation would be unimaginable; textbooks call the temperature probe "routine and essential." At the start, though, it didn't seem to matter.
For the first hour and half, as the surgeon drilled into Richard's ear, the operation was "very, very routine," Nurse Harrell later recalled. Only as time went by did Richard's carbon dioxide concentrations start rising. Although not dire, this trend suggested a potential problem with ventilation. Richard possibly wasn't exhaling carbon dioxide effectively.
Rather than closely monitor this condition, Verbrugge apparently stopped observing it. After 9:30 a.m., Verbrugge failed to record on his chart a single carbon dioxide value for the rest of the operation.
Verbrugge also apparently relaxed his monitoring of Richard's pulse. His handwritten chart between 9 and 10 a.m. shows a flat line for one stretch, while a monitor in the operating room was recording a steadily rising heart rate. By 9:40 a.m., Richard's pulse was 20% higher than at the operation's start.
Verbrugge says he was still monitoring Richard, he just wasn't fully charting what he observed. The nurses in the operating room think differently, and so does the administrative law judge who presided at Verbrugge's hearing.
Nurses Harrell and Karen Latson say they saw Verbrugge between 9:30 and 10 a.m. slumped in his chair, his head on his chin, his eyes closed, his arms crossed in front of him. On several occasions, Latson noted that his head bobbed from side to side.
Latson stared hard at Verbrugge, who didn't respond. She grew convinced he was asleep.
Harrell would later testify, "I was hoping he wasn't."
Verbrugge insists he was awake. At the conclusion of the hearing into Richard's death, however, administrative law judge Judith F. Schulman found that Verbrugge "on various occasions was asleep for short periods of time or otherwise failed to remain alert and vigilant."
Apparently, neither nurse said anything during this 30-minute span to Verbrugge or the surgeon. They felt reluctant to mix it up with Verbrugge, both would later explain, for they knew him all too well. Latson had worked with Verbrugge about 10 times over seven years. Harrell had worked with him regularly since 1976, an average of six to eight times a year.
"I didn't feel comfortable saying anything because I was afraid of a confrontation," Latson testified. "Because Dr. Verbrugge has been known to exchange words with some of the staff members in the O.R., and it's just not something that you would want to do."
Verbrugge "has always been difficult to communicate with . . . ," Harrell testified. "It was very hard to get figures from him. And he would always give an argument why he didn't have the figures . . . . I think over the years I'm reluctant to approach him about things because, No. 1, I'm either going to get an argument or, No. 2, he doesn't think my comment is valid."
No One to Question