“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 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.”