12
WEDNESDAY, JULY 12, 8:37 A.M.
“On to the next case,” Noah said into the microphone. “Appropriately enough, it is the fifth and last page of the handout.” There were a few titters from the audience reflecting their tenseness about what was coming. Noah had written out the key facts on each of the cases to be presented for the M&M and had provided them to everyone as they arrived.
Noah was back in the Fagan Amphitheater. This time he was alone in the pit, standing at the lectern, looking up at the tiered room whose upper reaches were lost in shadow. As expected, the room was full to overflowing, which had intimidated him at first, especially with all the big guns of the department, including Dr. Hernandez, Dr. Mason, and Dr. Cantor, filling the first and second rows. Ava was there, too, about ten rows back off to the left, dressed in her usual hospital garb concealing her trim, athletic body and a bouffant cap covering her striking hair. All the rest of the seats of the entire amphitheater were occupied as well. There were even people standing way up in the back a full story above, leaning on the railing. Everyone had come for this last case: the Bruce Vincent disaster.
Up until that point the conference had gone extremely well. So far, Noah had presented four cases. The first involved bariatric surgery on a six-hundred-pound man who’d developed a leak where the intestine had been joined to the stomach pouch. Diagnosis of the problem had been difficult and the patient had passed away from complications following reoperation. The second case had been a spinal surgery in which an implant had migrated and caused serious neurological damage. The third involved a gallbladder removal followed by deep vein thrombosis, or clotting, with death from a large clot or embolism traveling up to the lungs. The fourth case had been a multiresistant bacterial infection following an appendectomy in a teenage girl. She had died of sepsis.
What pleased Noah was that the discussions that ensued after each of the cases had gobbled up over an hour of the conference time in their totality. The one that had dominated had been the tragic sepsis case, since everyone was alarmed about the spread of antibiotic-resistant bacteria and unsure what to do about it. That discussion alone had used up more than thirty minutes, and now, as Noah was about to begin the Vincent case, there was just slightly over twenty minutes of the conference left. What Noah planned was taking almost half of the time for the presentation, leaving a mere ten minutes for the discussion. Although he was well aware that a lot of trouble could still occur in ten minutes, he was counting on controlling the discussion as much as possible by steering away from difficult topics.
Over the three days before the conference, Noah and Ava had gone over the methodology he was to use, honing it after she had suggested it Saturday night. Every evening after leaving the hospital he would secretly head over to her house, staying with her every night except last night, which he had to spend in the hospital, dealing with multiple trauma victims following a major car crash on the Massachusetts Turnpike.
All in all, it had been an incredible three days for Noah. During his invariably busy days he and Ava would occasionally run into each other in the hospital, since Ava also had to work the weekend. She covered one weekend approximately every other month, sharing the burden with the rest of the Anesthesia staff. But when Noah and Ava would cross paths in the hospital, they made it a point to give only a casual offhand greeting, and only if it was appropriate. Otherwise, they ignored each other. Noah found their playacting strangely titillating, as it contrasted so sharply with their nightly passion.
As Noah proceeded to present the Bruce Vincent case, he took advantage of its intricacies to use up as much time as possible, describing step by step Bruce’s extraordinary activities on the morning in question, including parking cars, solving the problem of an absentee garage employee, and, worst of all, eating a full breakfast. Noah even carefully enumerated each item Bruce had consumed, which included French toast, fruit cocktail, orange juice, bacon, and coffee. Noah was able to do this because he had interviewed the cashier who had taken Bruce’s money on the fateful morning and, astonishingly enough, had remembered exactly what Bruce had had on his tray.
After a surreptitious glance at his watch, Noah described Bruce’s admission process. He purposely did not mention any names so as not to cast any blame. What he did do was mention exactly how many times Bruce was asked whether he had followed orders to be NPO, and how many times Bruce had lied. Next Noah brought up the issue that no junior surgical resident history and physical had been done, explaining that Bruce had been forty minutes late when he arrived at Admitting and that the resident was busy seeing those patients who were not late. Noah concluded that section of the presentation by saying that there was a history and physical that had been done within the previous twenty-four hours that fulfilled the hospital’s standing pre-op requirements. He did not make any reference to the quality of the H&P nor that it had been doctored, but he did say that the review of systems was negative, including the gastrointestinal system, as that had been the way it was when Ava had read it.
Noah paused at this stage of his presentation and glanced around at the audience, hoping someone would comment on the admission process or Bruce’s behavior, but no one did. Noah was a little concerned that Dr. Mason might chime in even though it was a BMH tradition that the surgeon involved in the case being presented did not make statements unless asked specific questions. Noah avoided even looking at Dr. Mason, lest it encourage him to break the precedent.
When no one raised a hand to be recognized, Noah continued on by describing in detail the difficulty the surgeons encountered during the operation in attempting to release a small portion of the wall of the large intestine caught up in the hernia, which necessitated a decision to go into the abdomen.
“This is a crucial fact in this case,” Noah said. “To go into the abdomen it was necessary to switch from spinal anesthesia to general anesthesia. The first step of this process was to place an endotracheal tube. When this was attempted, the patient regurgitated his stomach contents and aspirated a massive amount of undigested food.”
Noah again paused briefly at this point in his presentation to allow what he had just said to sink in. He and Ava had decided it was particularly critical that the audience recognize the unfortunate and critical role the patient had played in his own demise, something they knew Dr. Mason felt strongly as well.
Noah then went on to describe the cardiac arrest, the briefly successful resuscitation, followed by a second cardiac arrest as the oxygen content of his blood fell precipitously. “At that point,” Noah said, “it was clear to everyone the patient was on the brink of death with nonfunctioning lungs and that the only way possible to save him was to put him on emergency cardiac bypass.” Noah did not mention that it had been only he who had made this decision. Instead, he said that once the patient was on bypass his blood oxygenation was quickly restored to normal, making it possible to clean out the aspirated food from his pulmonary system by bronchoscopy. “Unfortunately,” Noah continued, “even though the lungs were now functioning normally, the heart could not be restarted, no matter what was tried by a skilled cardiac surgeon over a several-hour period. At that point the patient was declared dead. Why the heart would not restart is not yet known. An autopsy was carried out by the medical examiner as required of all operative deaths, but the findings are not yet available as of yesterday afternoon.”