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 know.
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.”
“You might be right,” Noah said with a nod. He wasn’t going to try to guess what was on Bruce Vincent’s mind that fateful morning. Yet what Martha was saying made a certain amount of sense, even though Noah believed for a patient to have a full meal before any surgery was suicidal. “What about reflux disease? Did you ask him about that?”
“I didn’t. Nor do I generally ask patients about reflux symptoms. Maybe I should, but I think that’s an issue for the anesthesiologist to ask so they can gauge the degree.”
“Perhaps,” Noah said, being noncommittal. It wasn’t something he’d thought much about, yet it might be a good issue to bring up at the M&M to keep the discussion away from more problematic areas.
“Did you know that Bruce Vincent was working in the hospital parking garage the morning of his surgery like it was a normal day for him? I saw him myself.”
“I didn’t know that,” Noah said.
“That’s why he was late,” Martha said. “Supposedly, he had to solve a personnel problem because one of the parking attendants didn’t show up. Can you believe it?”
“I can’t,” Noah admitted. The case was becoming stranger by the minute, as most people were understandably intimidated the morning of their surgery. “Well, thank you for your time. If you think of anything else before Wednesday, please let me know.” He stood up.
“Okay. And good luck. I have a feeling this case is going to raise some hackles.”
“That’s my worry, too. Are you planning on attending the M&M Wednesday morning?”
“I wouldn’t miss it. I think it’s going to be a full house. At least that’s the general word. People are very upset. He was a popular guy.”
“Great,” Noah said, and moaned. He could feel his anxiety ratchet up a notch.
From Martha’s office, Noah walked into the area where patients changed out of their clothes and into patient garb. He again talked briefly with Helen Moran and learned nothing new, although he was reminded she was the one who marked Vincent’s right hip to avoid an operation carried out on the wrong side. With the way things were going, Noah thought that operating on the wrong side might have been the only way that the case could have been worse than it was.
In the pre-anesthesia section Noah searched for Gloria Perkins and Connie Marchand. Gloria was off for the day, but he did get to talk with Connie. She told him that she had asked Vincent all the usual questions, as Martha and Helen had, including if he had been NPO since midnight, meaning nothing-by-mouth.
“I assume he denied eating?” Noah said.
“Absolutely,” Connie said.
“Anything I should know that you didn’t write in the EMR?” Noah asked.
“I don’t think so,” Connie said. But then she corrected herself. “Come to think of it, I didn’t mention in my note that we had gotten several calls from the OR asking where Mr. Vincent was, and each request was accompanied by a friendly reminder that Dr. Mason doesn’t like to wait.”
“Martha Stanley got the same call. Is that typical?”
“Put it this way: It is not atypical for the OR to check on what was going on if a patient is significantly late. It just doesn’t happen very often, because patients are rarely late.”
“Then why did you mention it to me?” Noah asked.
“Only because I heard through the grapevine that Dr. Mason ended up keeping the patient waiting for an hour with the spinal in place. Personally, I don’t think that’s right, and I know a lot of other people feel the same, especially after the OR had called over here looking for him.”
Noah felt another unpleasant uptick of anxiety. The case was definitely morphing into an argument against concurrent surgery, which was going to irritate the hell out of Dr. Mason and a handful of other top surgeons, and Noah knew all too well who was going to suffer the consequences.