by Robin Cook
It was a good thing she had warned him. Going down the tight spiral staircase was more challenging than going up. He took his time, with one hand grasping the steep bannister and the other hand wrapped around the central pole, especially during the portion when he seemed to be looking straight down six stories to a neighboring granite patio.
To Noah’s astonishment and relief, once they got into the bedroom and the French doors closed, Ava was as much the aggressor as he was. After getting rid of the decorative pillows and the cats, they quickly made short work of each other’s clothes and collapsed onto Ava’s bed.
As if regaining consciousness several minutes later, Noah suddenly became aware of the surroundings. The bedroom lights were on and the draperies for the French doors were fully open. Concerned that Ava would find the situation untenable, as it was her house and her neighbors, Noah pushed himself up on an elbow. Looking down at Ava, who smiled up at him, he thought he’d never seen anyone so beautiful and so sexy. “Should I get the lights?” he said, almost in a whisper. The last thing he wanted to do was compromise the atmosphere, but he didn’t want her to feel uncomfortable.
“Who cares about the lights,” Ava said. She reached up and pulled Noah down onto her.
Her strength and her passion, which seemed to mirror his own, impressed him greatly. Forget the lights, he thought, and allowed himself to be lost in the moment.
Almost an hour later, they rested in each other’s arms. After a few minutes Ava excused herself. “I’ll be right back,” she said. And then playfully added: “And don’t you move!” Without the slightest concern for her nakedness, she slid off the bed and disappeared into the master bath. She didn’t even close the door.
Noah felt delirious with pleasure, almost drunk. He looked around the room. It was like a dream, too perfect to be true. He had never had the pleasure of being with a woman who seemed so comfortable with her body. There was no way Leslie would have been willing to make love with the lights on, and during the few times they had had sex during the day, she immediately insisted on covering herself with the sheet the moment they were done. It wasn’t that Leslie didn’t have a good figure, because she did. Yet Leslie had always acted somewhat embarrassed about the whole process, the exact opposite of Ava. Vaguely, Noah wondered who was more typical, because as an adult, he’d not had that much experience. He’d had more experience as a teenager, but those episodes were over before they started.
Ava returned after a few moments just as naked as she was when she had left. Noah had half expected her to reappear in a robe or some other covering. Instead, she seemed to revel in her nudity. Noah couldn’t have been more pleased, as it made him more comfortable at having resisted the temptation to pull on his own clothes.
Jumping onto the bed, Ava proceeded to tickle Noah, further surprising him with how relaxed and natural she was. It was as if they had been intimate for some time rather experiencing their first episode. It helped that Noah was an easy target since he’d been exceptionally ticklish from as far back as he could remember.
When the tickling was over, to Noah’s relief, Ava sat up. “I hate to be a spoilsport,” she said, “but sex makes me ravenous. How about we try the elevator and go down to the kitchen for some munchies?”
A few moments later and still as naked as a jaybird, Noah found himself pressed up against Ava face-to-face in the smallest elevator he’d ever been in. They kissed again as they silently and effortlessly descended.
To Noah’s surprise they ended up on the ground floor instead of the kitchen floor. “I’m going to get us some terry robes from the guest apartment,” Ava explained. “Hold the elevator door open. I’ll be right back.”
Noah did as he was told. He couldn’t believe what had happened. In one unexpected evening he had a sense that the anxiety-producing, upcoming M&M Conference might possibly be under control, and, more important, he might have found a new love. He was hard put to decide which was more incredible. Could it be true, or was this all a dream? If it was, Noah didn’t want to wake up.
12
WEDNESDAY, JULY 12, 8:37 A.M.
“On to the next case,” Noah said into the microphone. “Appropriately enough, it is the fifth and last page of the handout.” There were a few titters from the audience reflecting their tenseness about what was coming. Noah had written out the key facts on each of the cases to be presented for the M&M and had provided them to everyone as they arrived.
Noah was back in the Fagan Amphitheater. This time he was alone in the pit, standing at the lectern, looking up at the tiered room whose upper reaches were lost in shadow. As expected, the room was full to overflowing, which had intimidated him at first, especially with all the big guns of the department, including Dr. Hernandez, Dr. Mason, and Dr. Cantor, filling the first and second rows. Ava was there, too, about ten rows back off to the left, dressed in her usual hospital garb concealing her trim, athletic body and a bouffant cap covering her striking hair. All the rest of the seats of the entire amphitheater were occupied as well. There were even people standing way up in the back a full story above, leaning on the railing. Everyone had come for this last case: the Bruce Vincent disaster.
Up until that point the conference had gone extremely well. So far, Noah had presented four cases. The first involved bariatric surgery on a six-hundred-pound man who’d developed a leak where the intestine had been joined to the stomach pouch. Diagnosis of the problem had been difficult and the patient had passed away from complications following reoperation. The second case had been a spinal surgery in which an implant had migrated and caused serious neurological damage. The third involved a gallbladder removal followed by deep vein thrombosis, or clotting, with death from a large clot or embolism traveling up to the lungs. The fourth case had been a multiresistant bacterial infection following an appendectomy in a teenage girl. She had died of sepsis.
What pleased Noah was that the discussions that ensued after each of the cases had gobbled up over an hour of the conference time in their totality. The one that had dominated had been the tragic sepsis case, since everyone was alarmed about the spread of antibiotic-resistant bacteria and unsure what to do about it. That discussion alone had used up more than thirty minutes, and now, as Noah was about to begin the Vincent case, there was just slightly over twenty minutes of the conference left. What Noah planned was taking almost half of the time for the presentation, leaving a mere ten minutes for the discussion. Although he was well aware that a lot of trouble could still occur in ten minutes, he was counting on controlling the discussion as much as possible by steering away from difficult topics.
Over the three days before the conference, Noah and Ava had gone over the methodology he was to use, honing it after she had suggested it Saturday night. Every evening after leaving the hospital he would secretly head over to her house, staying with her every night except last night, which he had to spend in the hospital, dealing with multiple trauma victims following a major car crash on the Massachusetts Turnpike.
All in all, it had been an incredible three days for Noah. During his invariably busy days he and Ava would occasionally run into each other in the hospital, since Ava also had to work the weekend. She covered one weekend approximately every other month, sharing the burden with the rest of the Anesthesia staff. But when Noah and Ava would cross paths in the hospital, they made it a point to give only a casual offhand greeting, and only if it was appropriate. Otherwise, they ignored each other. Noah found their playacting strangely titillating, as it contrasted so sharply with their nightly passion.
As Noah proceeded to present the Bruce Vincent case, he took advantage of its intricacies to use up as much time as possible, describing step by step Bruce’s extraordinary activities on the morning in question, including parking cars, solving the problem of an absentee garage employee, and, worst of all, eating a full breakfast. Noah even carefully enumerated each item Bruce had consumed, which included French toast, f
ruit cocktail, orange juice, bacon, and coffee. Noah was able to do this because he had interviewed the cashier who had taken Bruce’s money on the fateful morning and, astonishingly enough, had remembered exactly what Bruce had had on his tray.
After a surreptitious glance at his watch, Noah described Bruce’s admission process. He purposely did not mention any names so as not to cast any blame. What he did do was mention exactly how many times Bruce was asked whether he had followed orders to be NPO, and how many times Bruce had lied. Next Noah brought up the issue that no junior surgical resident history and physical had been done, explaining that Bruce had been forty minutes late when he arrived at Admitting and that the resident was busy seeing those patients who were not late. Noah concluded that section of the presentation by saying that there was a history and physical that had been done within the previous twenty-four hours that fulfilled the hospital’s standing pre-op requirements. He did not make any reference to the quality of the H&P nor that it had been doctored, but he did say that the review of systems was negative, including the gastrointestinal system, as that had been the way it was when Ava had read it.
Noah paused at this stage of his presentation and glanced around at the audience, hoping someone would comment on the admission process or Bruce’s behavior, but no one did. Noah was a little concerned that Dr. Mason might chime in even though it was a BMH tradition that the surgeon involved in the case being presented did not make statements unless asked specific questions. Noah avoided even looking at Dr. Mason, lest it encourage him to break the precedent.
When no one raised a hand to be recognized, Noah continued on by describing in detail the difficulty the surgeons encountered during the operation in attempting to release a small portion of the wall of the large intestine caught up in the hernia, which necessitated a decision to go into the abdomen.
“This is a crucial fact in this case,” Noah said. “To go into the abdomen it was necessary to switch from spinal anesthesia to general anesthesia. The first step of this process was to place an endotracheal tube. When this was attempted, the patient regurgitated his stomach contents and aspirated a massive amount of undigested food.”
Noah again paused briefly at this point in his presentation to allow what he had just said to sink in. He and Ava had decided it was particularly critical that the audience recognize the unfortunate and critical role the patient had played in his own demise, something they knew Dr. Mason felt strongly as well.
Noah then went on to describe the cardiac arrest, the briefly successful resuscitation, followed by a second cardiac arrest as the oxygen content of his blood fell precipitously. “At that point,” Noah said, “it was clear to everyone the patient was on the brink of death with nonfunctioning lungs and that the only way possible to save him was to put him on emergency cardiac bypass.” Noah did not mention that it had been only he who had made this decision. Instead, he said that once the patient was on bypass his blood oxygenation was quickly restored to normal, making it possible to clean out the aspirated food from his pulmonary system by bronchoscopy. “Unfortunately,” Noah continued, “even though the lungs were now functioning normally, the heart could not be restarted, no matter what was tried by a skilled cardiac surgeon over a several-hour period. At that point the patient was declared dead. Why the heart would not restart is not yet known. An autopsy was carried out by the medical examiner as required of all operative deaths, but the findings are not yet available as of yesterday afternoon.”
Noah again paused for a moment and glanced around the room. No one moved. Everyone was clearly caught up in the emotion of the circumstance.
“This was a very disturbing case for everyone involved and for the entire hospital,” Noah said reverentially. “Bruce Vincent was an enormously respected member of the hospital community. In keeping with the goals of the Morbidity and Mortality Conference, it would be fitting to Mr. Vincent’s memory if we could come up with changes that could be instituted to avoid deaths like his in the future. What I propose we discuss is the need for we healthcare providers to impress on our patients the absolute necessity for them to be NPO for at least seven to eight hours prior to surgery and why.”
Almost immediately, Martha Stanley raised her hand to be recognized. Noah called on her.
“I couldn’t agree more,” Martha said. She then launched into a protracted self-reproachful statement of how it wasn’t enough to go through a list of questions just to check them off as she had unfortunately done when she had tried to speed Bruce Vincent through the process.
As Noah listened and occasionally nodded in agreement, he felt like running up the steps and giving Martha a hug. She was doing exactly what Noah and Ava had hoped someone would do—namely, chewing up the minutes on an issue everyone could agree on. Furtively, he glanced at his watch. There were only three or four minutes left before he could announce that the M&M was over. Already he saw a few people leaving who had been standing at the railing. He allowed himself to glance in Ava’s direction. For an instant they locked eyes. She flashed a brief thumbs-up, keeping her hand pressed against her chest so as not to be obvious. Noah nodded.
When Martha finished her monologue, a number of hands went up. Noah recognized a woman sitting to Martha’s immediate right.
“I agree with Martha,” the woman said. “But I think we should add to the list of what we ask. We always ask about whether they have eaten and if they have any allergies to medication and if they have ever had surgery and anesthesia, but we never ask if they have reflux disease. It seems to me that is an important piece of information.”
“I certainly agree,” Noah said. He then pointed to the person sitting on the opposite side of Martha who waved her hand insistently. Only then did he recognize who it was: Helen Moran, who had cornered him in that very pit after the welcoming ceremony. Noah’s heart skipped a beat as she began talking. He knew what was coming but couldn’t think of any way to stop it.
“Excuse me, Dr. Rothauser,” Helen said, “but I think you have left out an important aspect of this case that certainly could be used to memorialize Mr. Vincent. Isn’t this a prime example of the problems associated with concurrent surgery? My understanding is that Mr. Vincent was subjected to over an hour of anesthesia time before Dr. Mason showed up because he had two other people under anesthesia at the very same time. That’s atrocious. It would serve Mr. Vincent’s memory if concurrent surgery was eliminated here at the BMH.”
All at once the almost somnolent atmosphere of the room exploded in conversation. A few people even yelled out their opinion on the issue. Articles in the lay press, particularly The Boston Globe, had ignited the general public’s opinions either for or against, but on average mostly against.
Out of the babble, one nurse yelled out: “Dr. Rothauser. Is it true Mr. Vincent had to wait an hour under anesthesia?”
Noah raised both hands and fanned the air in an attempt to quiet the crowd. He avoided looking at Dr. Mason as he scanned the audience. “Please,” he said into the microphone several times. “Allow me to explain.” The effect was immediate, and for the most part the crowd settled.
“There was a delay,” Noah said. “Yet—”
He planned to say that the delay had no impact on the unfortunate outcome, but he was drowned out after Helen shouted: “I think an hour is more than a delay. If it had been me or a member of my family on that table, I would have raised holy hell.”
A number of people clapped. Nervously, Noah looked at his watch. It was now 9:00. Did he dare to conclude the conference under these circumstances? He didn’t know. Glancing back up at the restive audience, he saw that Dr. Hernandez had gotten to his feet and was climbing down into the pit. Noah gladly stepped from the lectern when the chief approached and indicated he wanted to speak.
“Let me say a few words,” Dr. Hernandez said over the commotion. He had to repeat the phrase several times before the audience finally calmed down enough f
or him to be heard.
While the chief of surgery was waiting to say a few words, Noah’s eyes scanned the audience to find Dr. Bernard Patrick, an orthopedic surgeon who had strong feelings against concurrent surgery. When their eyes briefly met, the man nodded. At least he was pleased the issue had been raised.
“I would like to say that I wish this last case had been the first case,” Dr. Hernandez said, causing Noah to wince. He couldn’t help but worry that the chief might guess the reason it was last. “Obviously, this tragedy has touched all of us here at BMH. The Surgical Department spent many hours looking at this case very carefully, as we do all deaths, but particularly so because the patient was a friend and colleague of ours. It is unfortunate that there was a delay in the arrival of the surgeon, Dr. Mason, but it is felt by all that the delay did not contribute to the unfortunate outcome and the cause of the delay was a legitimate complication elsewhere.
“The concurrent-surgery issue has been looked into with considerable care by the Surgical Department, the BMH administration, and by me, as well as the American College of Surgeons, and we will continue to do so. We strongly feel it is in the best interests of our patients but will be monitored. The Massachusetts Board of Medicine agrees but has demanded that our surgeons document when they enter and when they leave various ORs in situations requiring concurrent surgery. With that said, and since it is after nine A.M., this M&M Conference is adjourned.”
The audience immediately erupted into pockets of animated conversation as people got to their feet. Dr. Hernandez turned to Noah. “My sense is that you put the Vincent case last to limit discussion. Am I right?”
With his mind racing around for a noncommittal answer but not finding one, Noah guardedly admitted the truth. “I suppose that was the intent,” he said. “I knew emotions were high because of the patient’s reputation.”