by Robin Cook
“You are so right,” Noah said. He felt his pulse rise. As entertained as he was by Ava and her impressive house, it had momentarily slipped his mind why he was there. “Where should we sit?”
“Before we get down to business,” Ava said, “would you like to see some of the capabilities of my computer system, particularly in virtual reality? It will only take a moment if you are interested.”
“Sure,” Noah said. “Why not?”
Ava had Noah sit in the chair in front of the three monitors. Leaning over him, she booted up the system. Noah couldn’t help but notice she had not bothered to put in a decent security code, as she awakened the computer by merely typing the number 1 six times. Yet he wasn’t surprised. When he’d first entered the building he’d noticed her newly renovated house had a modern and highly sophisticated security system.
For the next sixty seconds Noah was treated to a display of graphics and audio that took his breath away. “Okay, I’m convinced,” he said when the demonstration was over. He raised his hands in mock surrender. “It’s terrific, and I’m jealous. I’ve got to have a system like this before I die.”
Ava laughed. She was pleased. “I can put you in touch with the people who installed it if you’re serious,” she said.
“Maybe in a year,” Noah said. He could at least dream.
“Anytime you’re ready,” Ava said. Then she pointed upstairs. “There are two more floors, but it’s just bedrooms and bathrooms, boring stuff. But I will be happy to show it to you if you would like.”
“Thank you, but no, thanks,” Noah said. “I’m overwhelmed as it is.”
“Okay, let’s get down to work. How about we sit in the office? For just relaxing and chilling, that’s my favorite room.”
“Sounds good to me,” Noah said.
They left the computer room and walked back into the study. It was getting dark outside, and through the elm trees in the square Noah could see that lights had come on in the buildings on the other side of the greensward.
“You didn’t say what you would like to drink,” Ava said, but before Noah could respond, she added, “Wait a second! What a terrible host. I didn’t think to ask whether you have eaten dinner tonight.”
“No, I haven’t,” Noah admitted. There were lots of nights he just skipped dinner when he got back to his apartment from the hospital.
“Nor have I,” Ava said. “How about we rectify that? Do you like Thai food?”
“Who doesn’t like Thai food?” Noah questioned.
“I’ll call down to King and I on Charles Street and order take-out. And if you wouldn’t mind walking down there and getting it, I’ll have a chance to jump in the shower and become a bit more presentable.”
“Happy to go,” Noah said. All at once, he realized he was starving.
9
FRIDAY, JULY 7, 9:42 P.M.
When Noah returned with the take-out food, Ava greeted him at the door dressed much more appropriately in a fitted, tailored white blouse and stylishly distressed blue jeans. The outfit had made Noah considerably more comfortable than the clinging yoga pants and tank top. They had eaten the Thai food at a high-topped counter in the kitchen overlooking the small garden. The conversation had remained away from the M&M problem and concentrated on the issue of why both of them thought it best to avoid social ties with fellow hospital personnel. They had agreed it was far too professionally incestuous and could only create problems in the long run, since the hospital was an inveterate gossip mill.
Following their dinner, they had retreated to the upstairs study, taking glasses of wine and settling into the velvet-upholstered club chairs catty-cornered to each other. Despite a couple drinks at the recent Change Party, Noah rarely drank alcohol, as he was never completely sure he wouldn’t be called into the hospital. But given that one of his best chief residents was on call, he was as sure as he’d ever been that he would not be called.
“So,” Ava said, once they were ensconced in the plush easy chairs. “How should we begin?”
“I guess I’d first like to follow up on something you mentioned earlier today,” Noah said. “You said that Dr. Mason was not fond of you. If I am not being too nosy, could you tell me why you feel that way? I mean, everyone knows he frequently asks for you to be his anesthesiologist.”
“You’re not being too nosy,” Ava said. “But before I explain, I also said I believe the man has a dysfunctional personality. To be specific, I believe he has a serious narcissistic personality problem. Actually, I know he has one. Are you familiar with the symptoms?”
“Relatively,” Noah said. He knew a bit about the condition, as did everyone who’d gone through medical school, but his course in psychiatry was way back in second year, some eight years ago.
“Well, let me refresh your memory,” Ava said. “I’m up on it, because having to deal with the likes of Dr. Mason has forced me to go back and review the profile. But before I go any further, I need to make one thing clear. What I am about to say is for your ears only. I want to be certain that nothing will be repeated to anyone, especially to anyone at BMH. Are you good with that?”
“Absolutely,” Noah said with conviction. He was appreciating Ava London more and more. He had come to her home feeling like a defenseless lone warrior facing an imminent crisis and hoping for a lifeline. Now he was feeling as if he had a comrade-in-arms who was a full BMH attending with skin in the game. There was no doubt in his mind that they could help each other, as she seemed to be socially astute, really smart, and possibly as committed to medicine as he was. On top of that, she was far nicer to be with than he had expected and a pleasure to even look at, especially now that she had showered and donned clothes that he didn’t feel embarrassed to appreciate. Noah couldn’t help but notice that she had taken the time and apparently cared enough about his visit to put on a touch of makeup, just enough to accentuate her eyes and complexion.
“People with a serious narcissistic personality problem are like bulls in a china shop,” Ava said. “They cause all sorts of trouble for most everyone they interact with, especially if someone doesn’t feed their insatiable need for admiration or, worse yet, insults or criticizes them. At the same time, they can be very successful, and Dr. Mason is a perfect case in point. He’s a truly famous world-class surgeon. There is no doubt about it, and he gets a lot of deserved kudos for his skill, but it is not enough for him. It’s never enough for someone with his needs. He might be a fantastic pancreatic surgeon, but he is also excessively arrogant, entitled, domineering, and vindictive, and capable of exploding at the slightest provocation.”
“Which is why he has earned the nickname ‘Wild Bill,’” Noah said.
“Precisely,” Ava said. “He is a walking time bomb.”
Noah found himself nodding in agreement. What Ava was putting into words was exactly his take on Dr. Mason and the reason he was terrified about the upcoming M&M Conference. There was no doubt in Noah’s mind he was going to be in the unstable man’s crosshairs.
“Unfortunately, I am one of those people who have insulted him,” Ava said.
“Literally?” Noah asked with astonishment.
“No, not literally,” Ava said. “He has tried to come on to me multiple times. He has even called me twice here in my home in the evening, asking to come over with the excuse that he was in the neighborhood and wanted to talk about a patient. I have never been interested in a social relationship with anyone at the hospital, much less someone like Dr. Mason. There was no way I was going to allow him into my life, especially with him being married on top of everything else. I’ve tried to be diplomatic, but it’s hard, because he is so cocky and insistent and incapable of taking no for an answer. I am sure he has taken my continued refusal as an ongoing insult, especially now that he is backed into a corner with this Bruce Vincent case and needs a fall guy or girl.”
“I’m sorry,” Noah said.
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“No need for you to be sorry,” Ava said. “The biggest worry for me is that Dr. Mason and Dr. Kumar are really buddy-buddy. I don’t want to lose my job, which might happen if Dr. Mason manages to blame the Vincent death on me. Losing my job would be a personal disaster. From my first year in medical school, it has been my dream to be on the BMH staff.”
“I’m sorry, because it is sexual harassment,” Noah said.
“I agree. Thank you for recognizing it.”
“What I find ironic about your story,” Noah said, “is that the main reason Dr. Mason dislikes me also has a romantic element.”
Ava’s mouth dropped open, and she stared back at Noah in shocked surprise.
“Wait a second!” Noah said, holding up his hands as if to ward off an attack. He laughed. “Don’t get me wrong. There’s no potential romance between Dr. Mason and me.”
“Okay,” Ava said, regaining her composure. “I don’t mean to jump to conclusions, but I suppose you are aware there have been some rumors about you and your social preferences. You are considered a very eligible bachelor, but it is noticed you don’t flirt with any of the available OR women.”
“I’m aware of the rumors, and it doesn’t bother me,” Noah said. “I’m not gay, not that anything would be wrong if I were.”
“Fair enough,” Ava said. “You said Dr. Mason doesn’t like you: explain. I mean, it is common knowledge that you are considered one of the best residents at BMH.”
“Do you remember Margery, or Meg, Green? She was a surgical resident almost three years ago.”
“I remember her,” Ava said. “What about her? As I recall, she left rather suddenly.”
“She certainly did,” Noah said. “She was dismissed from the program. What no one knew was that she and Dr. Mason were having some sort of an affair. The full details were never revealed, but it had to be the case.”
“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.”
“I can appreciate that,” Noah said. “Let me ask you a question about my part in this fiasco. After going over this case as you have, do you think I was right when I went ahead and put the patient on emergency cardiac bypass?”
“I do,” Ava said. “No question. Had you not done so, the patient absolutely would have died before we could have bronchoscoped him and got oxygen into his lungs. His oxygen saturation was awful. He was in cardiac arrest. Putting him on cardiac bypass was a necessary and heroic decision, and you should be commended for it even if ultimately it was unsuccessful.”
“Dr. Mason threatened to suggest I was the one who killed the patient,” Noah said, with his own touch of emotion.
“Nonsense,” Ava snapped. “That’s because he was embarrassed he didn’t or couldn’t do it. He was just standing there wringing his hands as the patient’s oxygen level was plummeting.”
“Thank you,” Noah said. “I appreciate your opinion. It is reassuring.”