Робин Кук - Charlatans

With that said, Dawn nodded slightly before turning and walking toward the lounge’s exit.

Cursing under his breath, Noah watched Dawn disappear. His sudden aggravation was not directed toward her. His irritation was directed at himself for having continued to put off working up the Vincent case and then fibbing about it, telling Dawn he hadn’t finished when he had barely started. He should have begun in earnest right after his mini-confrontation with Dr. Mason in the Fagan Amphitheater. Instead he’d been like the proverbial ostrich sticking its head in the sand, vainly hoping the whole mini-nightmare would somehow miraculously disappear. Since that was not going to happen, he had to get a move on and do the necessary legwork because the M&M Conference was looming the following Wednesday, only four full days away.

Reluctantly giving up a trip to the library, Noah ditched the idea of putting on his street clothes. Instead, to save time, he merely grabbed his white coat and pulled it on over his scrubs before taking the stairs down to Stanhope 2 en route to his all-too-public desk. The idea of heading to the library to prepare for the Journal Club was out the window. The unexpected exchange with Dawn had been the wake-up call he needed. Free time for him was a rare commodity.

He’d briefly started preparing for the M&M after the disturbing exchange with Dr. Mason by writing down all the people associated with the Vincent case, whether he thought he needed to interview them or not. But doing this wasn’t a real beginning but rather a way of controlling his immediate anger and anxiety. Once he’d finished, he’d put the sheet of paper away in one of his desk drawers and forgotten about it, which was easy, thanks to the tidal wave of more immediate responsibilities that engulfed him as the new super chief resident.

Arriving at the surgical residency program office, he said a quick hello to everyone. Sitting down at his desk, he found the list, drawing a line through Dawn Williams and Helen Moran, as he probably didn’t need to speak with them again. The remaining names were Martha Stanley, Connie Marchand, Gloria Perkins, Janet Spaulding, Betsy Halloway, Dr. Ava London, Dr. David Wiley, Dr. Harry Chung, Dr. Sid Andrews, Dr. Carl White, and Dr. William Mason. He put question marks over Wiley, Chung, Andrews, and White, recognizing that they were only ancillary actors in the drama and talking with them probably wouldn’t add anything to the central issue of fatal gastric regurgitation.

The only other name on the list wasn’t a specific individual but rather an organization. He wanted to get in touch with the Office of the Chief Medical Examiner. As an operative death, the body had been sent to the medical examiner as a matter of law. What Noah was hoping to learn was why the hell the heart would not start after being on bypass, even with an internal pacemaker. Noah was hoping for an explanation. He was certain the issue would come up at the meeting if an angry Dr. Mason wanted to make Noah the scapegoat.

Next Noah fired up the monitor on his desk and swung out the keyboard. After entering his password, he typed in Bruce Vincent’s name to get the man’s EMR. There wasn’t much, only the entries associated with his recent surgery.

Noah brought up the admission H&P, or history and physical. He recognized the author as Dr. Mason’s fellow, someone Noah had met. Although Noah tried generally to avoid Dr. Mason, he couldn’t completely when it came to his desire to become adept at pancreatic surgery. On a number of occasions Noah had had to swallow his pride and scrub in with the renowned surgeon to take advantage of his talent and learn his technique. Working with Dr. Mason meant working with his fellow, Dr. Aibek Kolganov, from Kazakhstan. Noah had not been impressed for a number of reasons, and now that he was looking at Bruce Vincent’s H&P, he was even less impressed. To Noah it was clearly one of those copy-and-paste jobs that can be found easily on the Internet.

As Noah’s eyes ran down the overly extensive list of negatives, he suddenly came across two positives in the gastrointestinal review of systems. One was mild reflux disease, and the other was mild bloating and constipation. But what really caught his attention was that the two positives were in a different font than the rest of the H&P. And by investigating a bit further, Noah could tell that the two positives had been added after the surgery!

Noah stared off into the middle distance, trying to absorb what he had just found. Changing a medical record after an adverse event was a huge no-no from a legal point of view. A short, humorless laugh escaped Noah’s lips. He shook his head at the implications. “Not good,” he murmured.

“Something wrong?” Gail Yaeger, the secretary, asked to be friendly. She was a sensitive person. Her desk was facing Noah’s, with only a half-dozen or so feet separating them.

“Maybe,” Noah said vaguely. “Thanks for asking. We’ll have to see.” Actually, he knew he had a problem. Or, more accurately, he knew the hospital had a problem that might result in a multimillion-dollar lawsuit, and once again Noah would be the messenger if he brought it up. It was yet another potential bomb. Everything about the case seemed to spell trouble.

Returning his attention to the monitor, Noah searched in vain for the junior resident’s admitting note to see if reflux and bloating were mentioned. He was surprised there was no note. He groaned. Here was yet another problem. Why wasn’t there a resident admitting H&P?

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.