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 patient 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.