by Robin Cook
Arriving at the surgical residency program office, he said a quick hello to everyone. Sitting down at his desk, he found the list, drawing a line through Dawn Williams and Helen Moran, as he probably didn’t need to speak with them again. The remaining names were Martha Stanley, Connie Marchand, Gloria Perkins, Janet Spaulding, Betsy Halloway, Dr. Ava London, Dr. David Wiley, Dr. Harry Chung, Dr. Sid Andrews, Dr. Carl White, and Dr. William Mason. He put question marks over Wiley, Chung, Andrews, and White, recognizing that they were only ancillary actors in the drama and talking with them probably wouldn’t add anything to the central issue of fatal gastric regurgitation.
The only other name on the list wasn’t a specific individual but rather an organization. He wanted to get in touch with the Office of the Chief Medical Examiner. As an operative death, the body had been sent to the medical examiner as a matter of law. What Noah was hoping to learn was why the hell the heart would not start after being on bypass, even with an internal pacemaker. Noah was hoping for an explanation. He was certain the issue would come up at the meeting if an angry Dr. Mason wanted to make Noah the scapegoat.
Next Noah fired up the monitor on his desk and swung out the keyboard. After entering his password, he typed in Bruce Vincent’s name to get the man’s EMR. There wasn’t much, only the entries associated with his recent surgery.
Noah brought up the admission H&P, or history and physical. He recognized the author as Dr. Mason’s fellow, someone Noah had met. Although Noah tried generally to avoid Dr. Mason, he couldn’t completely when it came to his desire to become adept at pancreatic surgery. On a number of occasions Noah had had to swallow his pride and scrub in with the renowned surgeon to take advantage of his talent and learn his technique. Working with Dr. Mason meant working with his fellow, Dr. Aibek Kolganov, from Kazakhstan. Noah had not been impressed for a number of reasons, and now that he was looking at Bruce Vincent’s H&P, he was even less impressed. To Noah it was clearly one of those copy-and-paste jobs that can be found easily on the Internet.
As Noah’s eyes ran down the overly extensive list of negatives, he suddenly came across two positives in the gastrointestinal review of systems. One was mild reflux disease, and the other was mild bloating and constipation. But what really caught his attention was that the two positives were in a different font than the rest of the H&P. And by investigating a bit further, Noah could tell that the two positives had been added after the surgery!
Noah stared off into the middle distance, trying to absorb what he had just found. Changing a medical record after an adverse event was a huge no-no from a legal point of view. A short, humorless laugh escaped Noah’s lips. He shook his head at the implications. “Not good,” he murmured.
“Something wrong?” Gail Yaeger, the secretary, asked to be friendly. She was a sensitive person. Her desk was facing Noah’s, with only a half-dozen or so feet separating them.
“Maybe,” Noah said vaguely. “Thanks for asking. We’ll have to see.” Actually, he knew he had a problem. Or, more accurately, he knew the hospital had a problem that might result in a multimillion-dollar lawsuit, and once again Noah would be the messenger if he brought it up. It was yet another potential bomb. Everything about the case seemed to spell trouble.
Returning his attention to the monitor, Noah searched in vain for the junior resident’s admitting note to see if reflux and bloating were mentioned. He was surprised there was no note. He groaned. Here was yet another problem. Why wasn’t there a resident admitting H&P?
Noah then scrolled to the anesthesia record, which was mostly a computer-derived readout directly from the anesthesia machine. He looked at the recordings of the vital signs and the electrocardiogram. Everything was entirely normal right up until the first ventricular fibrillation episode. On the ECG Noah could plainly see the time of the shock from the defibrillator and that the heart rhythm returned to normal before the second fibrillation event. Soon after that he could see when the heart stopped fibrillating, followed by no electrical activity whatsoever when the iced saline was poured over the quivering organ.
Scrolling down farther, Noah came next to several entries typed in by Dr. Ava London, the anesthesiologist, which had interesting syntax with multiple superlatives and no acronyms or contractions. The first entry was prior to the ultimately fatal regurgitation episode and included that the patient’s health was superb with no medical problems whatsoever, and that the patient had absolutely no allergies, took no single drug on a daily basis, had taken no food or drink by mouth since midnight, had never had anesthesia for any reason, and . . . Suddenly Noah’s eyes stopped. He’d come across a particularly cogent negative stating that the patient had no history of any digestive system problems like reflux or heartburn, meaning that Dr. London had specifically asked about these symptoms and the patient denied it, just as he had denied having eaten breakfast when he clearly had done so.
Noah knew this was a very significant point that probably exonerated Anesthesia, despite Dr. Mason’s claim to the contrary. If the patient had been truthful about either issue, he probably would still be alive. It also called attention to the after-the-fact entry in the admitting H&P apparently done by Dr. Mason’s fellow. Noah inwardly groaned. How was he going to present all this without totally alienating Dr. Mason? Unfortunately, he had no idea.
Returning to Dr. London’s initial entry, he read that Bruce Vincent had complained of moderate anxiety, mostly associated with concern that he had been extremely late to Admitting and that Dr. Mason might be angry about possibly waiting. Now Noah had to laugh, knowing that Dr. Mason ended up keeping the anesthetized patient and the whole team waiting for more than an hour.
The rest of Dr. London’s initial entry was straightforward and clinical about giving the patient midazolam for his anxiety, giving the spinal without any problem using bupivacaine, and putting the patient asleep with propofol.
Dr. London’s second entry was a bit more terse and more clinical, mentioning massive regurgitation, extensive aspiration, and sudden cardiac arrest during the placement of the endotracheal tube when the patient was being switched from spinal anesthesia to general anesthesia. She then went on to describe the defibrillation, the blood thinning with heparin, the placement of the patient on cardiopulmonary bypass, and finally the bronchoscopy. She listed all the medications that were tried in vain to get the heart to commence beating. The final sentence gave the time the bypass machine was turned off and the patient declared dead.
Noah took a deep breath. Just reading about the episode brought it back in vivid detail, at least the part he experienced. It had been an extremely upsetting episode for everyone.
Next Noah turned to the nurses’ notes and read what had been entered in Admitting by Martha Stanley, whom Noah had known since he’d been a junior resident. Using the usual acronyms, Martha had tersely noted that the H&P, the ECG, and the basic blood work were all in order. She also wrote that the patient had no allergies, no medications, no anesthesia, and was NPO since midnight, and the hernia was on the right side. There was no mention of reflux disease.
There were notes from two other nurses involved in the admitting process: Helen Moran and Connie Marchand. Both indicated in the EMR that they had asked the same questions as Martha Stanley and had gotten the same responses, particularly about Mr. Vincent not having eaten anything. Also, neither of these nurses mentioned possible reflux disease. The only thing unique about Helen Moran’s note was that she was the one who had marked Bruce Vincent’s right hip with the permanent marker to make sure the surgery was done on the correct side.
Next Noah turned to the operative reports. There were four. The first was dictated by Dr. Sid Andrews and described the attempt to repair the inguinal hernia. That was straightforward until the part about the knuckle of intestine caught up in the hernia and the failed attempts to reduce it externally. The second operative report had been dictated by Dr. Adam Stevens and described putting the pa
tient on bypass. It, too, was straightforward. The third note was dictated by Noah about opening the chest. He didn’t need to read that. The final entry was by the pulmonologist, Dr. White, who described the bronchoscopy procedure and the removal of the aspirated material from the patient’s lungs.
As a final investigation of Vincent’s EMR record, Noah glanced over the blood work, particularly the electrolytes. It was all normal, including the sample taken after the patient had been on the bypass machine. It was frustrating, as Noah still had no idea why the heart wouldn’t restart beating after the bronchoscopy. At the time, he had hoped it was a potassium problem, which would have made a certain amount of sense and which could have been addressed. The problem was that by not knowing, he had no idea if there was something they should have done differently.
Noah sat back in his chair. The question was how to proceed and who to talk to first. He couldn’t quite decide, but he knew who would be the last person: Dr. Mason. Noah was certain that any conversation with him was going to be confrontational from the start, so he needed to have all his ducks in a row. From what Dr. Mason had said in the amphitheater, it was painfully obvious he was not about to accept any blame and fully intended to see that it was directed elsewhere, mostly at Anesthesia, Admitting, and the patient. With that reality in mind, Noah decided it would be best to talk with Dr. Ava London next to last. He didn’t know her well, as he had always found her superficially friendly but distant. Knowing Dr. Mason’s intention of using her as a scapegoat was going to make talking to her almost as difficult as talking with Dr. Mason, especially after she had already expressed her opinion that Mason was largely responsible. The idea of being caught in the middle of crossfire between two BHM attendings spelled potential disaster as far as Noah was concerned.
Deciding to start from the beginning, meaning where Bruce Vincent began his fatal admission, Noah stood up with the intention of heading to Surgical Admitting on the fourth floor to see Martha Stanley. He thought it best to just show up rather than call. But his plans changed when his mobile phone buzzed in his pocket. It was Dr. Arnold Wells, a new senior resident covering the emergency room.
“Thank God you picked up!” Arnold blurted. “Noah, I’m over my head here with a flail chest and major head trauma from a head-on collision. It’s a disaster. I need help now!”
“On my way!” Noah shouted, shocking everyone in the surgical residency program office.
The fastest route down to the emergency room was the stairs, and Noah took them in twos and threes while struggling to keep his stethoscope, tablet, and collection of pens and other paraphernalia from flying out of his pockets. Although it wasn’t far distance-wise, by the time he ran into the ER he was out of breath from exertion. He didn’t have to ask where the injured patient was, as one of the admitting clerks frantically pointed to Trauma Room 4. Noah barged through a gaggle of EMTs coming out of the room.
The patient was a mess. His clothes had been cut down the front and pushed to the side. His unrestrained arms and legs were wildly flailing. A large-bore IV was running. The major visible trauma was to the head and face, with the right eye socket empty and bloody and a major gash down to the bone that started in the middle of his forehead and extended up into his hairline. Tiny bits of yellow material could be seen that might have been brain. Arnold was attempting to use a bag-valve mask to provide positive pressure respirations, but the center of the man’s chest was bruised and showing paradoxical movement.
“Good God,” Noah murmured. His mind was in overdrive, as this clearly was a hypercritical situation.
6
FRIDAY, JULY 7, 1:40 P.M.
For the second time that day, Noah pushed through the double doors to exit the BMH operating room suite. The first time had been mid-morning, after he’d made his covert check on all the first-year residents who were assisting in surgery. He remembered feeling good that all was going well. This time he felt even better, despite looking like hell and wearing bloodstained scrubs. On this occasion leaving the OR, he was reveling in the unique feeling that he thought surgery and maybe only surgery could provide. He had been sorely challenged with a difficult case of forty-three-year-old John Horton, who arrived at the emergency room at death’s door from a head-on collision on Interstate 93. As an obviously intelligent and educated man, as Noah later learned, who worked as an analyst at a major investment firm, John should have been wearing his seat belt in his classic car that wasn’t equipped with air bags. Unfortunately, he wasn’t. As a result, John’s unchecked body had rammed full force at sixty-plus miles per hour into the steering wheel, which fractured and disarticulated his sternum, before catapulting out through the windshield.
When Noah had first arrived in the trauma room, his trained mind had instantly analyzed the situation, and he acted by reflex with the same decisiveness that had propelled him to slice into Bruce Vincent’s chest. Instinctively knowing that oxygen would be the determining factor if this patient was going to live, Noah called for an emergency tracheostomy set and ordered the patient to be given IV fentanyl for pain. While Arnold continued to struggle with the bag-valve mask connected to 100 percent oxygen, Noah completed the emergency tracheostomy, then connected a positive pressure respirator. Immediately, blood oxygen levels went up to a reasonable level, giving Noah time to examine the patient with the help of several X-rays. It was immediately apparent the man had multiple rib fractures, a fractured sternum, a fractured skull, and extensive internal injuries.
After stabilizing the patient as much as possible with several units of blood, Noah had him brought up to surgery. With the help of the chief neurosurgical resident, who saw to the skull fracture, and an ophthalmologist, who located the missing eye in the man’s maxillary sinus, Noah went into the abdomen to remove a damaged spleen and repair the liver. By then the wealthy patient’s private doctor had been located; he, in turn, alerted a private thoracic surgeon as well as a neurosurgeon, both on the BMH staff, who came in and relieved Noah.
Whatever was going to happen to John Horton, Noah had the rewarding sense of knowing that he and Arnold had saved the day and kept the patient alive at the most critical hour. To have the knowledge and skill to accomplish such a feat was what had propelled Noah into medicine in general and then surgery in particular. He knew that such a feeling was mostly denied to those who went into internal medicine. They might on occasion cure someone of something with the right therapy, but it was never so immediate as it was with surgery, and therefore more difficult to take the credit. Whether John Horton was going to live or die Noah didn’t know, considering the extent of his head injury plus his cardiac and pulmonary contusions. But at least now the man had a fighting chance, thanks to Noah’s intervention. For Noah it was a heady, deeply satisfying feeling that justified all the sacrifices he’d had to make to be where he was.
Unfortunately, Noah’s euphoria lasted for only another ten minutes, or at least until he got into the locker room and saw the list of people he needed to talk with about Bruce Vincent protruding from the pocket of his white jacket. Putting on fresh scrubs, he emerged from the men’s locker room fully motivated to get back to the Vincent affair. Emergency surgery notwithstanding, he recognized further procrastination was no longer an option. Since he was already on the fourth floor, he headed over to Surgical Admitting.
“I always have time for you,” Martha said when Noah appeared at her office door and asked if he might have a word. She was a pleasant but nondescript-appearing woman of indeterminate age with frizzy hair and a florid complexion. Noah appreciated her bent to wear scrubs to advertise she was an integral part of the surgical team, which she was.
“What can I do for you?” she asked once Noah was seated.
Noah outlined what he knew about the Bruce Vincent case and mentioned that he had read her notes in the man’s EMR. He told her he had to present the case at next week’s M&M Conference and wondered if there was anything she thought he should kn
ow.
Martha toyed with a paperclip while she thought about Noah’s question. “I suppose you want to know why there is no resident H&P.”
“That would be helpful. I noticed it was missing. It is bound to come up.”
“We had a number of patients all come in just before Bruce Vincent showed up, so the resident was behind. Really behind. Since Mr. Vincent was forty minutes late, I had already gotten a call from the OR asking where the hell he was. The suggestion was that ‘Wild Bill’ was champing at the bit, and we all know what that can lead to. To speed things up, I moved Mr. Vincent along without seeing the resident, who never knew about the case. There was a recent H&P by Mason’s fellow, which is all that is needed by the book.”
“True, but it’s accepted practice to have the additional check by a junior resident. This is a good case for the rationale why.”
“I understand, but under the circumstances I thought it okay to move him on. The H&P was entirely negative.”
“I gather you specifically asked him if he had had anything to eat.”
“Absolutely. No question. I always do. He lied to me, that is clear. The question is why, because it had to be deliberate, meaning it wasn’t as if he just forgot not to eat. If I had to guess, I’d say it was because he thought he knew more than he did.”
“I don’t follow.”
“He was a bit anxious about being late when I reminded him Mason could be a bear about waiting and that Mason had two big pancreatic cases that morning besides his hernia repair. But about his surgery, Mr. Vincent was cool as a cucumber and mentioned he was scheduled for a spinal, which is why I believe he thought he could get away with eating whatever he wanted. I think this is an example that a little learning can be a dangerous thing. My sense is that Mr. Vincent thought he knew enough about anesthesia to game the system.”