by Robin Cook
“You might be right,” Noah said with a nod. He wasn’t going to try to guess what was on Bruce Vincent’s mind that fateful morning. Yet what Martha was saying made a certain amount of sense, even though Noah believed for a patient to have a full meal before any surgery was suicidal. “What about reflux disease? Did you ask him about that?”
“I didn’t. Nor do I generally ask patients about reflux symptoms. Maybe I should, but I think that’s an issue for the anesthesiologist to ask so they can gauge the degree.”
“Perhaps,” Noah said, being noncommittal. It wasn’t something he’d thought much about, yet it might be a good issue to bring up at the M&M to keep the discussion away from more problematic areas.
“Did you know that Bruce Vincent was working in the hospital parking garage the morning of his surgery like it was a normal day for him? I saw him myself.”
“I didn’t know that,” Noah said.
“That’s why he was late,” Martha said. “Supposedly, he had to solve a personnel problem because one of the parking attendants didn’t show up. Can you believe it?”
“I can’t,” Noah admitted. The case was becoming stranger by the minute, as most people were understandably intimidated the morning of their surgery. “Well, thank you for your time. If you think of anything else before Wednesday, please let me know.” He stood up.
“Okay. And good luck. I have a feeling this case is going to raise some hackles.”
“That’s my worry, too. Are you planning on attending the M&M Wednesday morning?”
“I wouldn’t miss it. I think it’s going to be a full house. At least that’s the general word. People are very upset. He was a popular guy.”
“Great,” Noah said, and moaned. He could feel his anxiety ratchet up a notch.
From Martha’s office, Noah walked into the area where patients changed out of their clothes and into patient garb. He again talked briefly with Helen Moran and learned nothing new, although he was reminded she was the one who marked Vincent’s right hip to avoid an operation carried out on the wrong side. With the way things were going, Noah thought that operating on the wrong side might have been the only way that the case could have been worse than it was.
In the pre-anesthesia section Noah searched for Gloria Perkins and Connie Marchand. Gloria was off for the day, but he did get to talk with Connie. She told him that she had asked Vincent all the usual questions, as Martha and Helen had, including if he had been NPO since midnight, meaning nothing-by-mouth.
“I assume he denied eating?” Noah said.
“Absolutely,” Connie said.
“Anything I should know that you didn’t write in the EMR?” Noah asked.
“I don’t think so,” Connie said. But then she corrected herself. “Come to think of it, I didn’t mention in my note that we had gotten several calls from the OR asking where Mr. Vincent was, and each request was accompanied by a friendly reminder that Dr. Mason doesn’t like to wait.”
“Martha Stanley got the same call. Is that typical?”
“Put it this way: It is not atypical for the OR to check on what was going on if a patient is significantly late. It just doesn’t happen very often, because patients are rarely late.”
“Then why did you mention it to me?” Noah asked.
“Only because I heard through the grapevine that Dr. Mason ended up keeping the patient waiting for an hour with the spinal in place. Personally, I don’t think that’s right, and I know a lot of other people feel the same, especially after the OR had called over here looking for him.”
Noah felt another unpleasant uptick of anxiety. The case was definitely morphing into an argument against concurrent surgery, which was going to irritate the hell out of Dr. Mason and a handful of other top surgeons, and Noah knew all too well who was going to suffer the consequences.
7
FRIDAY, JULY 7, 3:05 P.M.
After donning a surgical hat and mask, Noah walked from the pre-anesthesia holding area directly into the OR to check the main OR scheduling monitor that listed the day’s surgeries. Each entry had the estimated or actual start time, the patient’s name, the procedure, the surgeon, the anesthesia person, the scrub nurse, and the circulating nurse. When the surgery was completed the color changed from blue to yellow.
Noah’s goal was to find Dr. Ava London to see if he could speak with her when she finished for the day, which he knew was around 3:00. Although most of the anesthesiologists made it a point to hang around for a time after their shift to socialize in the surgical lounge, he had never once seen her participate during the entire five years he’d been a resident, which he knew happened to be nearly the same amount of time Dr. London had been on staff. Although she was always friendly when they worked on a case together, which had probably happened some fifty times over the years, he thought of her as consistently reserved and private, qualities that Noah respected because he thought of himself as being somewhat similar. Like Ava, he had never availed himself of the surgical-lounge chitchat sessions, even though most of the other residents did. Noah felt uncomfortable talking about his social life because he didn’t have one, though he suspected there was a big difference with Dr. London. With her constant tan even in the dead of winter, which she always politely refused to explain or gloat about to anyone, and the fact that she was lean and fit, Noah assumed she had a particularly active life outside of the hospital.
Noah found Dr. London’s name in OR 8, the same operating room where the Vincent debacle had occurred. She’d been scheduled to “pump gas,” which was the anesthesiologists’ humorous description of their job, for a bariatric surgery case that had started at 1:30 P.M. But just as Noah was reading the entry, its color changed from blue to yellow, conveniently signaling the case was over.
Thinking she’d soon appear in the PACU, or post-anesthesia care unit, Noah wandered in. Most of the beds were occupied as a testament to BMH’s surgical volume, even on a Friday afternoon. His intention was to wait for Dr. London to appear, which he assumed would be imminent. He was surprised to find her already there, signing off on her patient to the PACU staff. Noah walked over toward the foot of the bed. The patient was enormous. Noah estimated he was well over three hundred pounds. Noah had become good at estimating human weight after his rotation on bariatric surgery as a senior resident. He was well aware that handling such patients was an enormous challenge for the nursing staff.
Noah listened while Dr. London gave the last of her instructions to the PACU nurse and then did something that surprised him. She gave her mobile number with the comment that if there was any trouble whatsoever to give her a call. Noah was impressed. Such personal follow-up was not the rule, as there were always in-house anesthesiologists available 24/7.
When Dr. London was finished, she abruptly turned and practically collided with Noah. He assumed she was eager to be on her way, which he interpreted as less than auspicious. Since Friday afternoon was the beginning of the weekend in most people’s minds, Noah immediately worried he might not get to talk with her until Monday.
“I’m sorry,” Dr. London said. Her voice was soft and clear but with a touch of an accent that Noah had never been able to identify.
“Not at all,” Noah said. “It’s my fault for sneaking up on you.”
Dr. London stared at Noah with her striking blue eyes as if surprised by his comment.
“Well, I really didn’t sneak up on you,” Noah corrected. “But I did want to ask you if I could talk to you briefly.”
With a quick glance at her watch, suggesting she might have a pressing engagement, she asked what he wanted to speak to her about.
“The Bruce Vincent case,” Noah said. “I have to present it at next Wednesday’s M&M Conference. It is important that I get your input.”
Dr. London’s response was to look back at the nurse taking care of her last patient and then at the other nurses working around
the room. She was clearly suddenly ill at ease.
“I have been devastated by the Bruce Vincent case,” Dr. London confided in a lowered but emotionally strained voice. Her eyes zeroed in on Noah like lasers. “It was my first operative death. I went over the case a dozen times and found nothing, absolutely nothing, that I could have done differently. Well, that’s not entirely true. I could have waited for Dr. Mason to be in the room before starting the anesthesia. But he insists otherwise and is supported by Dr. Kumar. That’s the reality, so I don’t think I can add anything. I’m certain the outcome had nothing to do with anything I did or didn’t do.”
“Okay,” Noah soothed. He was completely taken aback by Dr. London’s unexpected vehemence. She was staring at him with uncamouflaged intensity. “I certainly empathize with you about it being your first operative death. I’m sorry, really I am, and I know it can be difficult. But I have to warn you that Dr. Mason plans on blaming Anesthesia. He told me directly. I would like to avoid what might cause a problem for you and the Anesthesia Department, but I need your help.”
“This is not a good place for us to talk,” Dr. London said. “Do you have a private office?”
“I don’t,” Noah said, again wishing such was not the case.
“I don’t, either,” Dr. London said. “Maybe we can find a place in the surgical lounge. We can at least sit and not stand out like sore thumbs.”
“Okay,” Noah said, even though he thought the idea ludicrous if she was looking for privacy. But then he remembered on Friday afternoons it was far less busy than during the week, especially in the summer, with a lot of doctors and nurses heading off to the Cape and the Islands.
“I’ll meet you there in ten minutes or so,” Dr. London said. “I have to finish up here.”
When Noah got to the surgical lounge, he realized his first fears were entirely founded. The room had been commandeered for an impromptu party for one of the OR nurses who was going off on a vacation cruise. There were even some bon-voyage decorations draped over the windows. Despite strong misgivings that Dr. London was not going to find the lounge any better than the PACU, Noah pulled a couple chairs into the far corner apart from the main crowd. Most of the revelers were grouped around a spread of snacks on the countertop at the kitchenette end of the room.
As she had promised, Dr. London soon appeared, and Noah could tell that she was not pleased to find a party under way. Nevertheless, she started toward Noah, who had waved to get her attention. He watched her as she approached. The way she carried herself reemphasized his impression of her as being lean and fit, as well as suggesting a certain confidence. At the same time, he again marveled at how little he knew about her, despite all the times they had worked together. The only thing he did know was that she was a highly competent board-certified anesthesiologist on the staff of one of the country’s premier tertiary teaching hospitals, which meant she had been seriously vetted. From Noah’s conversations with others, his sense was that no one knew too much about her. Although superficially friendly, she was indeed a private person.
“This is not what I had in mind,” Dr. London said as she took the seat catty-corner to Noah’s while glancing over her shoulder at the merriment.
“At least they are engrossed,” Noah said, just as OR supervisor Janet Spaulding spied them and immediately broke from the group and approached.
“Well, I wouldn’t believe this if I didn’t see it with my own eyes,” Janet said. “My two favorite party poopers comparing notes.” She laughed to convey that she was teasing. “It’s nice to see you two chatting. I don’t think I’ve ever seen either one of you socializing in here. But whatever, please join us. Don’t be strangers. We’re giving Janice a proper send-off.”
“Thanks, but I unfortunately have to get going,” Dr. London said before Noah could respond. “I’m already late for an engagement. Dr. Rothauser and I just needed to talk briefly about a case.”
“Well, if you change your mind, we have plenty,” Janet said, gesturing back toward the food and drink. She half waved before returning to the festivities.
Noah and Dr. London regarded each other. “This is not going to work,” Dr. London said as she pulled her bouffant surgical cap off her head, releasing a silky profusion of long, seriously blond-streaked hair from its workday confinement.
As a kind of reflex, Noah sucked in a bit of air and held his breath. With a certain amount of shock, he recognized that Dr. London was a surprisingly attractive woman who obviously cared about her appearance. Seeing her as alluring was something that had never occurred to him before, as he had never seen her without her dowdy head covering and surgical mask. Although there were a few women on the staff who caught his attention on occasion because something about their appearance clicked in what he humorously referred to as his reptilian brain, it had never happened with Dr. London. Why, he didn’t know, because suddenly in this starkly utilitarian lounge and hardly seductive environment she appeared rather exceptionally lovely. The halo of mostly blond hair framed a face dominated by intensely blue eyes, a narrow, pixielike upturned nose, full lips, and startlingly white teeth that contrasted with her blemish-free, healthy complexion. Totally unaware of the effect she was having, she used her fingers to tame her hair. Even that seemed coquettish to Noah.
“Can you think of someplace else we can go?” Dr. London asked. When Noah didn’t respond, she asked again a bit louder.
“Excuse me,” Noah said, averting his gaze. “Someplace else? Let me think—”
“Tell me this first!” Dr. London interrupted. “What exactly did Dr. Mason say to you about me in regard to the Vincent case?”
Noah struggled to reprogram his brain. He felt acutely embarrassed that he was acting like a besotted teenager. He raised his eyes from looking down at his hands in his lap. “Actually, he didn’t name you specifically. He said that Anesthesia screwed up by giving the wrong anesthesia.”
“He didn’t say anything about his office stipulating the anesthesia he wanted or that no one knew the patient had had GI symptoms associated with bowel obstruction?”
“I don’t think so,” Noah said. He wasn’t certain. On the spur of the moment, he couldn’t remember. His mind wasn’t functioning up to speed.
“I did not screw up,” Dr. London said bluntly, with emotion bordering on anger. “As I said, I went over the case with a fine-toothed comb. Except for waiting for him to be physically present before starting the anesthesia, I wouldn’t have done anything differently.”
“He did say the patient and Admitting people contributed,” Noah said, suddenly remembering Mason’s exact words.
“That is an understatement, considering what the patient ended up vomiting,” Dr. London said. She bent closer to Noah, close enough that he could appreciate her perfume. “He had eaten a huge breakfast. But listen! I’m glad you came to me. With Dr. Mason saying what he did, we definitely have to talk, because you have to present this case very carefully to keep it from becoming a disaster for both of us.”
Noah nodded. He was surprised but pleased. He had expected her to be defensive and distant, maybe even wary and unhelpful. Quite the contrary, she was sounding as if she were totally in his camp, seeing the up-and-coming M&M just as he did: a potential calamity.
“Unfortunately, I don’t think we should be seen talking together about this here in the hospital, because it could easily smack of collusion or even conspiracy,” Dr. London said. “You understand?”
“I do. I hope you understand that I’m going to be on a tightrope, and I need all the help I can get.”
“The way I see it, we are both going to be on a tightrope.”
“Why do you believe you are on a tightrope?” Noah questioned. He was mystified. “You say you have gone over the case and wouldn’t do anything differently. You are a board-certified staff anesthesiologist. Dr. Mason could not do anything to you. I’m different. I’m only
a surgical resident, and he already doesn’t like me, and he is part of the surgical residency program hierarchy.”
“I find him a difficult person to deal with,” Dr. London admitted. “Personally, I think the man has a personality disorder, but let’s not go into that now. The problem is he and my boss, Dr. Kumar, are bosom buddies. To make matters worse, Dr. Mason is not fond of me, either.”
“How can you say that?” Noah asked. “Word has it he often asks for you.”
Dr. London waved her hand as if shooing away a bothersome fly. “Let’s not get into it now. Here’s my suggestion: Are you off tonight?”
“Sort of,” Noah said, surprised by the question. “As the super chief, I’m never completely off. There are a chief resident, a senior resident, and a junior resident on call tonight. I just have to be available if disaster strikes.”
“Okay, good,” Dr. London said. “I live nearby in Beacon Hill. Louisburg Square, to be exact.”
“I know Louisburg Square,” Noah said, sitting up a bit straighter. “I live on the hill, too. On Revere Street.”
“Then we are practically neighbors,” Dr. London said. She leaned closer and lowered her voice a bit more. “Here’s my suggestion: When you finish here at the hospital this evening, drop over to my house. It is number sixteen. We’ll be able to talk freely. What do you say?
“Thank you,” Noah said, taken aback. It was an unexpected offer. He also noticed she said “house” and not “apartment.” Single-family homes were the exception on Beacon Hill. “I’ll be glad to come by your place. I appreciate your offer.”
“You are welcome,” Dr. London said, getting to her feet. “Let me give you my mobile number so you can text me if something comes up and you can’t make it.” She stepped over to the phone table and scribbled her number down on a piece of paper. Noah watched her. He was momentarily dumbfounded. He hadn’t expected any of this. When she walked back to where he was sitting, holding the paper out in front of her, he could see from the way she moved that she definitely had an athletic body. It was even apparent in her baggy scrubs, although he had never noticed it before.