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Monday Mornings: Chapter 1

By Dr. Sanjay Gupta, CNN Chief Medical Correspondent
updated 10:26 AM EDT, Wed March 14, 2012

Editor's note: The following is an excerpt from Dr. Sanjay Gupta's novel, "Monday Mornings," released in March by Grand Central Publishing.

(Special to CNN) -- THE EMTS CRASHED THROUGH the swinging bay doors of the emergency room. Wearing bright blue polyester jumpsuits with a yellow insignia on the left front pocket and standard-issue black boots, they were moving fast. It was impossible to miss the concern, and also the soot, on their young faces. Wherever they were, there had clearly been smoke, probably a fire. Between them was a woman on a gurney, in a silver reflective thermal cocoon. An IV bag, slowly dripping into plastic tubing connected to her arm, swayed wildly on a pole as they wheeled her toward the center of the crowded emergency room.

It was only when you saw the ER from the top that you understood the ingenuity of the layout. It was not a single room, but an apparent maze designed like a large round tire with a series of spokes. There were rooms around the periphery; patients were placed closer and closer to the middle depending on how critical they were. This woman was coming to the epicenter.

"I got an attempted suicide. Single vehicle into a telephone pole." The EMT's voice carried across the ER, above the urgent voices of doctors and nurses, the moans of patients, a crying baby, the beeping monitors, the adjoining waiting room's blaring television.

Dr. George Villanueva was the man who lived and worked in the center of the ER, and his eyes were on the woman even before the words reached him. Villanueva was a gargantuan man who sat on a swivel stool that was barely able to contain his significant girth. He gave the impression of an elephant in the circus -- or perhaps a supernova at the center of a solar system. He had followed the patient as soon as her small prone form came into his ER. From his perch, Villanueva immediately noted that her face, immobilized by a slightly crooked, hard plastic neck brace, was unlined. He guessed her age as twenty-five. She was pale. Her lips were almost bluish in tint. Her nose looked as though it might have been broken by the air bag, and deep bruises were beginning to bloom below the orbits of both eyes. "Raccoon's eyes," he muttered to himself.

It was an indication that the base of the young woman's skull had been smashed. He quickly counted the number of drips from the IV bag. "Too slow." The paramedics repeatedly squeezed a bag connected to a breathing tube, forcing air into her lungs. "Also too slow," he mumbled.

"Trauma Bay Eight," Villanueva shouted, sending the patient to the trauma bay near the center of the ER. The doctor's small brown eyes locked on the woman, his massive, watermelon-size head pivoting on his even more massive torso like some sort of giant Claymation figure. As the EMTs veered past Villanueva, he continued to make mental notes. He noticed that her eyes were open but pointing in slightly different directions, with one pupil a little larger than the other. She was weakly moving both her arms beneath the foil blanket. He glanced down to the catheter bag, draining the young trauma victim's bladder. It was nearly empty. Her heart monitor beeped too fast. Villanueva calculated 124 beats a minute.

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"What'd you say happened?" Villanueva called to the paramedics.

"Tried to flatten her Camry into a telephone pole. No skid marks. Didn't even try to stop. Suicide by car, without a doubt," the EMT answered without stopping, sweat dripping from his brow.

"Like hell," Villanueva said. He launched his 350-pound frame off his stool and caught up to the fast-moving EMTs. He moved with an extraordinary grace for such a big man, and the speed at which he crossed the tile floor was startling. There was still the glimpse of the agility that had made him the Detroit Lions second-round draft pick out of the University of Michigan. Now he strode step for step with the EMTs as they raced toward the trauma bay. Villanueva looked as though he were leading a sweep. He'd lasted four years in professional football before his relatively diminutive 275 pounds became a liability. By the time he left the league, even high schools had three-hundred-pounders on the offensive line. Of course, Villanueva's weight was now well into the acceptable range for an NFL offensive lineman. But instead of a helmet and pads, he wore size XXXL scrubs that strained to contain his midsection, which had grown to enormous proportions in the twenty-two years since he had left the NFL. Often the scrubs failed, and a small rim of belly was visible beneath his shirt. Villanueva's scrub pants were so tight that many of the nurses found them obscene. He usually had the decency to wear his white coat, which was the only thing big enough to cover the large man and all his parts. But today, the coat was lying bloodied and crumpled in another trauma bay. It was the casualty of an emergency resuscitation a few hours earlier.

As the paramedics slid the injured woman from the gurney to the examination table, Villanueva and an ER nurse converged on the spot. Villanueva reached down and quickly adjusted the woman's neck brace so it was perfectly straight, then glanced at the closest EMT.

"Turn up her oxygenation, increase her ventilation, get her some more fluids, and call the neurosurgeons. This wasn't a friggin' suicide attempt. She just had a bomb go off in her head! Stop screwing around. Let's go!"

The nurse hesitated for a split section, considering whether to deny that she was screwing around, thought better of it, and began moving around the injured woman, turning a large valve to increase the flow of pure oxygen through a clear mask.

The paramedics looked at each other and shook their heads in wonder as though they had just seen their favorite magician performing another mind-bending trick. Then they began retracing their steps through the emergency room, their radios squawking, and their black laced-up boots leading the way.

Villanueva's impulsive diagnoses were the stuff of legend around Chelsea General. His quick thinking and physical agility earned him the nickname El Gato Grande-the Big Cat-or simply Gato. Dr. George Villanueva himself spoke only a smattering of Spanish, and he hadn't gone by his given name, Jorge, since he was six and started school. Still, the Gato Grande nickname stuck.

Earlier that same shift, Villanueva had been on his stool watching the actions of two emergency room doctors in a close-by trauma bay. They were arguing back and forth when their patient's blood pressure started to plummet. If you had been watching Villanueva closely, you would've seen a flush appear on his cheeks and a nearly imperceptible squint in his eyes. It was vintage Villanueva, and not a look you would ever want directed at you. A second later he'd had enough and burst into the room while the two emergency room doctors were unsuccessfully trying to revive a man in his sixties. One of them had his mouth to the patient's ear and was shouting, "Sir, can you open your eyes?"

"No . . . he can't . . ." Villanueva angrily mumbled as he strode toward the slumped man, almost gliding on the balls of his feet. He grabbed a bottle of iodine in his left hand and an enormous sixteen-gauge Cook needle in his right.

He told the ER doctor to "please step aside" and when the man didn't react fast enough, Villanueva swept the MD aside with his forearm, the way he might have handled a defensive back in his previous career. Before the doctor could protest, Villanueva had pulled the patient's shirt open and was squirting iodine onto his left chest to sterilize the area. A second later Villanueva plunged the needle deep into the man's chest. A faint smile crossed his face as the needle found its mark. He pulled back on the plunger, and the syringe started to fill with bright red blood.

"Cardiac tamponade," he said to no one in particular. "Five. Four. Three. Two. One." Villanueva paused. Nothing happened. He gave another squint to the monitor next to the patient. "One half." Suddenly the patient's blood pressure and heart rate normalized as the pressure was relieved around his heart. The patient's skin started to pink up. "Zero."

Villanueva turned and walked away.

The other doctors in the room were stunned. They had missed the problem, almost costing the man his life.

"There was nothing to suggest this man had a tamponade," the ER doctor stammered to the receding Gato Grande. Villanueva didn't look back, instead tearing off his now-bloodied white coat and throwing it into a passing bin of laundry.

THE JACKETLESS VILLANUEVA STRUTTED back across the emergency room toward his stool, his head held high as he passed the nurses admitting, the kid getting his head stapled, the group of obstetricians trying to coax a young fetus to stay in its mother's womb, the drunk who fell off his roof, and a businessman in a suit who had been complaining of chest pain. A medical student who looked as though he'd be much more at home in the library stacks than the ER caught up to Villanueva. The student carried a clipboard and a quizzical expression. He was now rapidly turning his head back and forth between the young woman Villanueva had diagnosed with "bomb in head," and Gato himself.

"But how?" was all the med student could muster. He pulled his pen from his pocket and prepared to write. Villanueva abruptly grabbed the pen and the clipboard, and even loosened the student's tie for good measure before stopping and facing him.

"Don't write. Listen and learn from the master," he said. He winked at an attractive nurse standing at the station. "I knew she needed more oxygen because her skin was pale and her lips were blue, that's an easy one." He was in full professor mode now, standing tall and upright, using his entire six-foot-two frame to project across the emergency room. As intimidated as all the students were by him, he was the reason the best of them from all over the country chose to come to Chelsea General. In the world of medicine, it is tough to call anyone the "best" at anything, but that wasn't the case here. Villanueva was the most celebrated trauma chief in the country, hands down.

"Always remember to look at the Foley catheter bag," he instructed the medical student. "These patients should be making plenty of urine. If they aren't, it means they need more fluid." The med student looked for something to write with before remembering Villanueva had his pen and clipboard. "Don't worry about writing this stuff down," Villanueva said again, reading the student's mind. "Just immerse yourself in this situation and you will never forget." The med student nodded like a true believer.

"By the way, how old is this woman?" Villanueva asked. The med student scurried over to Trauma Bay 8, checked the chart, and returned.

"Twenty-six," he said. Squint. "No wait, her birthday's in December. She's twenty-five." Villanueva smiled to himself.

"Now, I bet you're wondering how I knew this little lady had a bomb explode in her brain," Villanueva called for all to hear, enjoying his moment center stage. Truth was, a lot of people who pretended to be disinterested in the bombastic Villanueva were craning their necks trying to garner a little of his amassed wisdom.

He quickly grabbed a penlight from the student's jacket. Villanueva himself never carried anything -- no stethoscope, no tongue depressors, nothing to write with, certainly no penlight. He just grabbed what he needed from the closest victim. The penlight was simple white with no pharmaceutical advertising on the outside. Everyone knew how Villanueva felt about freebies from Pharma companies. "No such thing as a free lunch," he had once shouted across the ER at an attractive woman drug representative as she scurried out of the ER. A single bright light emerged when he pushed the button, and he pointed it at the woman's eyes.

"This young lady has a ruptured cerebral aneurysm. See here, a little disconjugate gaze," he said.

"Disconju-what?" the med student replied.

"It means her eyes aren't quite lined up." Another squint. "Jesus, what are they teaching you these days? You think between the sensitivity training and the financial investment classes, they could teach you some medicine." The med student blushed. "Oh, and her pupil on the right is larger than the one on the left. It means the aneurysm was pushing on one of the nerves in her brain that controls eye movements."

"Oh, I get it." A light went off in the med student's brain. "The aneurysm ruptured while she was driving. Rendered her unconscious. That's why she crashed her car . . ." He trailed off.

"Yes!" Villanueva shouted. "Like I said, she had a bomb go off in her head. Speaking of which, did anyone page Neurosurgery?"

"Yes, Dr. Villanueva," an unseen female voice answered from across the room.

"Well, where the hell are they?"

"On his way," the same faceless voice said.

"Which one of those overpaid and underutilized guys is it this time?" Villanueva asked.

"Dr. Wilson."

Squint.

"Oh boy! I am surprised all you nurses haven't already run to the powder room to doll up your hair and put on some lipstick," Villanueva bellowed. "Oh, Dr. Wilson, can I help you, anything at all . . . really, Dr. Wilson . . . anything at all." He had an alarmingly good falsetto.

The nurses giggled and shook their heads.

"Hey," Villanueva said to the medical student. "Since I taught you all that, why don't you go and get me a sandwich?" The student looked around, trying to figure out if Villanueva was joking or not. To no one in particular, the doctor called out, "And will someone please page pretty boy Wilson again?"

IN A DARKENED CALL ROOM, Ty Wilson sat, eyes closed, motionless and very still. There was a window cracked, and the smell of freshly fallen leaves wafted through the air. In the distance, the ripple of the Huron River could be heard. Other than that, the room was absolutely silent. His scrubs were a deep shade of blue, seemingly designed to match Wilson's eyes. They also fit him perfectly, with no extra folds or wrinkles. He was on his knees, with his back straight as a dead man's EKG. The neurosurgeon visualized his breath as he inhaled. In through the nose and then around the sinuses. First the maxillary and then the ethmoid sinuses, followed by the frontal sinuses. He visualized the breath going down the trachea, anterior to the esophagus. "About fourteen millimeters anterior to the esophagus," Wilson had told his therapist.

"I don't think you necessarily need to go into that level of detail," the therapist had replied. "Actually . . . I do," Wilson said.

Now he visualized the breath making its way into the progressively smaller bronchioles and then slowly getting absorbed into the bloodstream. It was his form of relaxation. Meditation didn't really fit with his image of being a neurosurgeon, which was why Wilson mainly practiced it in the solitude of the call room. His beeper went off again. Gato needs you. Now.

Wilson opened his eyes, stood and walked out of the room. A minute later, when he pushed through the ER's swinging doors, he looked every bit like a USC quarterback in to run the two-minute drill and win the game. He was tall and fit, with wavy dark hair and those blue eyes, which had a hypnotic effect on nurses, patients, just about anyone locked in his gaze. Villanueva, as it turned out, was an exception.

"Trauma Bay Eight," Villanueva called to him. Villanueva glanced down at his beeper, which had just gone off. It said simply, 311. 6.

The medical student had returned with his sandwich and was peering over Villanueva's shoulder at his beeper.

"What do all those numbers mean?"

Villanueva quickly crammed his pager back on his scrub pant waistband.

"What are you, a spy or something?" Villanueva took the sandwich and started eating, garbling a thank-you through his full mouth.

"No, just trying to learn," the med student answered. "From the master," he added, laughing.

Villanueva cackled. "Good, kid, I like that." He thought about it for a second. "Those numbers represent an invitation to the most secret and best-guarded meetings that ever take place in a hospital," he whispered. "Every few weeks, a select group of surgeons get together and discuss mistakes."

The student's eyes widened. "What kind of mistakes?"

"All kind of mistakes. Morbidity and Mortality, some call it. Others call it Death and Complications. I call it the Someone Effed Up Conference. Capiche?"

"Can I come?" the student asked.

"You one hundred percent, absolutely, without a doubt cannot come," replied Villanueva. "Did you not hear me when I said this was a secret meeting? Strictly invitation-only. No other doctors, no administrators, and certainly no friggin' lawyers! This conference is for us, and us only."

IN THE TRAUMA BAY, Wilson assessed the situation in just a few seconds. As he started to examine the young woman, he agreed with everything Villanueva had said. It was a classic case of chicken-and-egg in the world of neurosurgery. Doctors at many hospitals around the country would have heard the woman's story and deduced in a matter of moments that the blood in her brain was a result of the car accident. They would also deduce that since she'd been in a single-car crash into a telephone pole, she was trying to kill herself. The truth was far different. The aneurysm, a small blister on the surface of an artery, had suddenly let loose, spraying blood throughout her brain. She had likely felt a sudden thunderclap headache, and within seconds was rendered unconscious. That was why she'd crashed her car. In this case, the aneurysm was the chicken. The car accident was the egg. The science of deduction, and Ty knew there was no one better at it than Villanueva.

Ty's beeper went off again. Like Villanueva's, it read 311. 6. He took the message like a punch, sucking in air involuntarily. Tomorrow morning, he was going to be where no doctor at Chelsea General wanted to be. Ty forced himself to breathe out slowly, then caught Villanueva's eye across the room. He wanted to see if the trauma chief had gotten the page. One glance at Villanueva's expression of near pity, and Ty knew he had. Damn, Ty thought. The last thing he wanted was the fat man feeling sorry for him.

Villanueva muttered to himself, "Poor bastard."

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