“She was dismissed because she was having an affair with an attending? That doesn’t seem right.”
“No, the affair aspect came out after the fact. She was dismissed because she was abusing opioids, and I was the person who outed her. I was the messenger, so to speak, and Dr. Mason has never forgiven me. Ergo, I’m terrified I’m going to be the messenger again at the upcoming M&M. I want to avoid antagonizing Dr. Mason as much as I possibly can. But it is going to take some planning and diplomacy because I think you are right: The two people mostly responsible for Bruce Vincent’s death are Dr. Mason and the patient.”
“Okay, I understand where you are coming from,” Ava said. “What it boils down to is that ‘Wild Bill’ is not fond of either of us.”
“I’d use a stronger word for his opinion of me,” Noah said. “And what makes that so worrisome is that he is an associate surgical residency program director. As vindictive as he is, I would not be surprised if he tried to get me fired.”
“I don’t think you have to worry about that,” Ava said. “You are much too respected by everyone else.”
“I know that is the case generally,” Noah said. “But it doesn’t make me feel any better. Unfortunately, I’ve had a rather exaggerated fear of authority figures for as long as I can remember, particularly once I decided I wanted to be a surgeon way back in middle school.”
“And you see Dr. Mason as an authority figure?”
“Certainly,” Noah said. “He’s definitely an authority figure.”
“If you don’t mind my asking, did you have issues with your own father?”
“My father passed away when I was in high school,” Noah said.
“Now, there is a coincidence,” Ava said with a slight, disbelieving shake of her head. “So did mine.”
“I’m sorry,” Noah said.
“I’m sorry, too,” Ava said.
“Well, let’s get to the topic at hand and talk about specifics,” Noah said. “Just so you know, I have gone through Bruce Vincent’s EMR, and I have spoken with all the key people except Dr. Mason. The wimp that I am, I am leaving that ordeal for last.”
“That’s smart,” Ava said. “Having a conversation with him might turn out to be as difficult as the M&M itself.”
“That’s exactly how I see it,” Noah said. “I’ve got to be prepared for both. What I need from you is anything at all you might feel is important that I might not have gotten from other sources.”
Ava thought for a moment, pursing her lips. “You noticed there was no resident history and physical in the EMR.”
“Of course,” Noah said. “Martha Stanley explained to me that the resident was backed up when Mr. Vincent showed up forty minutes late.”
“And you noticed that in the history and physical that had come from Dr. Mason’s office, there was no mention of reflux disease or obstructive symptoms from the hernia.”
“Well, that is not entirely true,” Noah said. “Both were mentioned.”
“They weren’t,” Ava said with sudden emotion bordering on anger.
“They were, but they were added after the fact,” Noah said. “I could tell because they are in a different font than the rest of the H&P. I think they were added later to cover up that the H&P was one of those copy-and-paste jobs off the Internet.”
“Good grief!” Ava exclaimed. “This case keeps getting progressively worse. Do you think Dr. Mason did it?”
“I can’t imagine,” Noah said. “He certainly would know better. I think it had to have been his fellow, Aibek Kolganov. I can’t talk to him because he has already gone back to Kazakhstan. But if the issue comes up, which will not come from me, I will blame him.”
“That might be helpful,” Ava said.
“It would be a way of diverting blame from Mason, even though he is ultimately responsible for his fellow’s actions.”
“Maybe you should bring it up at the beginning of the discussion,” Ava said. “Since the hospital attorneys would want to stop any talk about it because of the malpractice implications, Dr. Hernandez might insist on moving on to the next case.”
“The discussion will surely not be restricted to that one issue,” Noah said. “There are too many others that are glaringly important. Case in point: the patient’s unknown history of reflux disease. Did you actually question the patient whether he had reflux disease?”
“Of course I did,” Ava said. “I wouldn’t have put it in the EMR if I hadn’t. I always ask about reflux disease. The patient out-and-out lied to me, just like he did about not eating.”
“How about obstructive GI symptoms? Did you ask about those?”
“No, I did not. That’s what the H&P is for. Tell me this: Do you know that Mason’s office specified the anesthesia Dr. Mason wanted?”
“I do,” Noah said. “He wanted spinal. And I know the patient had been informed as well by the pre-anesthesia call the day before.”
“I considered the anesthesia question seriously, as I always do, and decided there was no contraindication for spinal. And I assume you also know that Mason was not part of the pre-op huddle with me and the rest of the OR team?”
“I do,” Noah said. “And I know he didn’t appear for about an hour after you had given the spinal on the go-ahead by Janet Spaulding, who had been green-lighted by Dr. Mason. But I am not going to bring all this up because it’s going to ignite the concurrent-surgery issue, and Dr. Mason has specifically warned me not to do it.”
“It is going to be hard not to bring up an hour delay with the patient under anesthesia,” Ava said. “Everybody in the OR knew what was going on, since Dr. Mason had two other patients under anesthesia at the very same time. It was like an assembly line that ground to a halt.”
“Don’t I know,” Noah said. “There’s the tightrope for me. I just don’t want to bring it up. Maybe someone in the audience will, and they can be the messenger.”
“One thing I’d like to say upfront,” Ava said. She sat up straight and moved forward in her chair. “Emotionally, I’m a wreck because of this case. As I told you, it is my first operative death and hopefully my last.”
“Dealing with death is not easy,” Noah said. “I know how you feel, as I went through some agony my first year as a resident. You never get used to it, but you can learn to accept it as a possibility at any time, no matter that you do everything correctly, especially in certain specialties like oncology.”
“I didn’t expect it in anesthesia,” Ava said. “I thought attention to detail and staying up with the latest developments would be enough.”
“Death is part of the human condition, as it is with all life,” Noah said.
“Well, getting back to this case, I have to tell you that I went over every detail with several other staff anesthesiologists, including Dr. Kumar. And as I said before, apart from waiting to give the spinal until Dr. Mason was physically present, there is nothing I would have done differently.”