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 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!”