Michael Palmer - The Last Surgeon

Five thousand entries for one year at the Singh Center.

“Each record is a mouse click away from more detailed information,” Jillian said. “Physicians’ notes, photographs, X-ray images, plus procedures performed, products used, and amount billed. Every scalpel, every box of gauze pads, every IV bottle. They’re all here.”

“Incredible,” Nick said, not bothering to mask his discouragement at such a vast amount of data on such a vast number of patients.

“Welcome to the wonderful world of electronic medical records,” Jillian said.

“Try the first one just so we can get an idea of what things look like.”

Without gathering any information on the patient in row one, Jillian clicked on the image tab and opened a photo of the frontal torso view of a naked woman. Reggie caught sight of the picture before she could remove it and quickly leaned in for a better look.

“Darn, but that chick’s got some mighty big-!”

“Reggie!” Junie snapped.

“And anyhow,” Jillian added, removing the photo and glaring at the youth with good humor, “she had them reduced. That’s this procedure code here.”

Nick sensed Jillian’s mounting tension as she opened the next record on the list. Her apprehension was understandable, he was thinking. Thanks to Reggie’s skill and the vulnerability of the electronic records system, they were committing an almost inexcusable invasion of privacy that would, quite possibly, cost Jillian and Nick their careers should they get caught. For the first time, he began to question his convictions.

Please, give us something. Anything.

Jillian merely sighed and began to scroll down the list. Nick did not recognize any of the names or most of the ICD codes as they flowed past. In his medical practice, he never dealt with lifts, reshaping, body contouring, liposuction, or breast work, so the unfamiliarity of the codes was understandable. Then, after a hundred or so patients, one ICD code caught his eye: 929.9. As a trauma surgeon, he knew that code well. Crushing injury of multiple sites.

“That one, Jill,” he said. “Please click on that one.”

The name of the patient was Giuseppe Renzulli. Nick remembered reading something on Paresh Singh’s Web site about his world-renowned reputation for tackling difficult reconstructive procedures, specifically shotgun wounds to the face. From what Nick read in the file and observed in the pre-op images, this particular case would have required a mastery beyond compare.

According to the physician notes in Renzulli’s record, the 929.9 was elaborated as a shotgun wound to the face. Most impressive were the stunning three-dimensional CT scans, each showing a sea of floating bone fragments and shotgun pellets, sandwiched between a cracked mandible and a remarkably intact frontal bone.

“Oh man, that’s gross!” Reggie exclaimed. “That dude dead?”

“According to this, he’s very much alive,” Nick answered.

He leaned over Jillian’s shoulder and read aloud from one of many physician dictations-the conclusion of the admission note by Paresh Singh.

The patient is a twenty-eight-year-old Caucasian male, with massive trauma to the neck and face from a self-inflicted shotgun wound. Definitive reconstruction and repair of nasal, orbital, maxillary, mandibular, and ethmoid fractures feasible, requiring multistaged reconstructive maneuvers. Primary access to fracture sites will be via transcutaneous vertical Lynch incision. 70% of fractures appear to be Type III.

Jillian turned away as he read. It was then Nick realized the man’s suicide attempt was another painful reminder of Belle. How could he be so insensitive? He placed a hand on her shoulder. She in turn reached across her body to take his hand in hers. The moment was brief, but the emotions within it were intense.

“How could somebody shoot themselves like that and not die?” Junie asked.

Nick flashed on one such case he had treated in Afghanistan, but before he said anything about it, he turned to Jillian.

“Talking about this okay?” he asked.

“Yeah, it’s okay,” she said, her tone bittersweet. “Thanks for asking.”

“A self-inflicted gunshot wound to the head is almost always fatal,” he explained, “that is, assuming the victim puts the gun in his or her mouth or presses it hard against the temple. But when a gun-a shotgun especially-is placed under the chin, the recoil can actually redirect the muzzle, causing massive trauma to the face, but avoiding any vital structures in the brain.”

“That’s gross,” Reggie said.

Nick took the mouse from Jillian and continued reviewing the file.

“For this guy, no doubt, fixing him was a massive undertaking. From these reports it looks as though he went through several multi-step reconstructive events, totaling about thirty operations.”

“That’s not the only total that was massive,” Jillian said. “Take a gander at the bill this case generated.”

Nick looked at where she was pointing and whistled.

“Half a million dollars for this work alone. No wonder Shelby Stone formed a partnership with these guys. Even if the patient defaults on their share of the bill, the insurance company owes a hefty six-figure payday for Singh, and a percentage of that goes to the mother hospital.”

“Well, that does explain how Paresh Singh can afford that marble fountain.”

“If they’re so well known for this type of work, I wonder how many shotgun injuries they reconstruct in a year?” Nick asked.

“I can tell you,” Jillian said. “I’ll just look it up by that ICD code.”

Jillian entered the numbers, keeping the scan limited to the twelve months beginning the approximate date Umberto disappeared.

“Keywords shotgun… and… face… and there you are.”

Four seconds after she hit the Enter key, twenty records were identified.

“Amazing,” Nick commented. “Maybe that’s what the J. Geils Band meant when they named their album Blow Your Face Out .”

“Who’s the J. Geils Band?” Reggie asked. “If I ain’t heard of them, they must be old.”

“With you, anything that wasn’t recorded last month is old.”

“Twenty cases in that one hospital doesn’t surprise me very much,” Jillian said. “Between fifty and fifty-five percent of all suicides are caused by guns, but there are over fifteen hundred attempted suicides in the U.S. alone each day.”

“That’s an incredible number,” Junie said.

“Sad, but true,” Jillian said.

Nick thought through the math.

“So, if Paresh Singh is world renowned for his ability to reconstruct faces after a shotgun blast,” he said, “it’s not inconceivable there could be at least a hundred such cases in the U.S. each year-probably more worldwide.”

“One-fifth of them sent to the best of the best makes sense to me.”

“Let’s look at these twenty,” Nick said, “but we’d better move quickly. Sooner or later someone’s going to catch on to the breach.”

Behind them, Reggie kept touching his face, as though trying to visualize how the gunshot wounds Nick described could actually be survivable.

The first five files they reviewed were grisly but also well documented. The skill of Paresh Singh was undeniable, although the residual facial damage in each case was still fairly striking. Nothing in those files jumped out at them as being out of the ordinary. Something troubled Nick about the sixth case, though, a patient named Edwin Scott Price from Plano, Texas.

The majority of suicide attempts with a firearm were males, thirty to fifty years old. Edwin Price was forty-five. But although he fit the profile, there was a feeling Nick could not shake while he was scanning the X-ray images, photos, and CT scans attached to Price’s file. Something about the record was familiar-not possible given that the electronic chart was one he’d never seen before, and the patient one he’d never heard of. The echoing concern nagged at him.