by Robin Cook
Noah gave the surgeon a quick rundown, saying that it was not looking good for the boy. “The temperature is now over one-oh-eight, despite everything that’s being done,” Noah added with growing alarm.
“I don’t like that mottled blue cyanosis,” Dr. Stevens said. “That’s a super-bad sign, suggesting disseminated intravascular coagulation.”
“More dantrolene,” Ava desperately called out to Allan. “The temperature is still rising.”
“There’s only one way to bring the temperature down,” Dr. Stevens said. “Put him on the pump and run the blood through an ice bath. That will do it. Of course, we’re not sure if his brain hasn’t already called it quits. We could do an EEG, but by the time we do that, it most likely would be too late.”
“You’re willing to put him on bypass?” Noah questioned. After the Vincent catastrophe, Noah was less willing to contemplate such heroics, especially after what Dr. Mason had said to him about it being Noah’s actions that had killed the hospital parking czar.
“If you’ll help, I’ll do it,” Dr. Stevens said.
In record time, with both Noah and Dr. Nakano assisting Dr. Stevens, Philip Harrison was put on cardiac bypass. Unfortunately, his temperature had reached 113 before the cooling could be instigated. As the final coup de grâce when the temperature had been brought down into the normal range, the heart would not start, agonizingly similar to the situation with Bruce Vincent. All the effort turned out to be in vain.
“Well, we gave it our best,” Dr. Stevens said an hour later. He was speaking to the entire group in the operating room. No one had left.
Everyone felt dispirited, having given their all, and said little as they filed out of the room. Dr. Stevens departed first, followed by Dr. Nakano. No one spoke.
Noah hung back, watching Ava as she shut down the anesthesia machine and made some final entries in the EMR. On several occasions, she cast a fleeting glance at Noah but didn’t say anything. Nor did he. The circulating nurse and the scrub nurse were in the area, starting to clean up the room. They didn’t speak, either.
Without a word, Ava suddenly turned around, pushed through a side door, and disappeared into the equipment room that housed the sterilizer and surgical supplies. After a moment of indecision, Noah followed her. He found her leaning against the sterilizer for support. She was still wearing her mask, but Noah could tell she had been crying. He approached her, feeling profound empathy for what she was obviously feeling. He put his arms around her and hugged her. She didn’t pull away.
“Do you think it’s wise for us to be seen like this?” Ava asked after a few moments.
“You’re right,” Noah said. He let go and looked back through the glass pane in the door. He was relieved, as he half expected to see either the scrub nurse or circulating nurse staring at them.
“He was only twelve,” Ava said, her voice faltering. “I don’t know if I can take this. This is my third death. I never thought anything like this would happen.”
“It’s not your fault,” Noah said with emphasis. “It has to mean the boy had a genetic predisposition. That’s all. You said you even asked about it in your pre-op interview. You can’t ask any more of yourself than that.”
“He’d had anesthesia a year ago without a problem,” Ava said. “I even used the same agents. He had eaten lunch. That was what I was worried about, not malignant hyperthermia.”
“There is no way you could have anticipated this,” Noah said. “You can’t blame yourself.”
“Maybe that is true, maybe it isn’t,” Ava said dejectedly. “But after this third case, I don’t know if I can continue with clinical anesthesia.”
“I can understand your feeling,” Noah said. “But let’s not make any snap decisions on the spur of the moment. Medicine is always risky. It’s the nature of the calling. Think of how slim the chances are that you had to face this problem. As I remember, it’s like one in twenty thousand cases.
“You have been victimized by statistics or, if you prefer, bad luck. It doesn’t speak to your competence as an anesthesiologist. Try to remember the thousands of cases you’ve done with great results and no problems. You are a great anesthesiologist. You wouldn’t be here if you weren’t. Don’t even think about throwing away all your training and effort.”
“I don’t know what I’ll do,” Ava said. She looked at her watch. It was after 4:00 in the afternoon. “I want to go home.”
“Good idea,” Noah said. “Go home and do something to take your mind off all this. Go on social media!”
“Don’t make fun of me!” Ava warned.
“I’m not. You’ve told me how much you like it. Go do it. Do a video post for your Gail Shafter fan page and make your thousands of followers happy. I’ll come over as soon as I can tonight, and we can talk more. That is, if you’d like to talk more. Maybe in the short term we should do something completely different to take your mind off it, like go out to dinner and pretend to be normal people.”
Ava glanced up at Noah to see if he was being patronizing. “Okay,” she said quietly when she realized he was being sincere. Without another word, she brushed past Noah and exited out into the OR corridor. She didn’t look back.
Remaining where he was for a moment to get his own emotional bearings, Noah pushed back into the operating room. The cleanup had progressed. The two nurses had been joined by two orderlies. The MH cart and the cardiac-arrest cart were gone. He was mildly surprised that the dead boy was still on the operating table. He’d been covered by a fresh white sheet. Vaguely he wondered what the holdup was.
Stopping in the middle of the room, Noah winced at the thought of facing the parents of this child. He was thankful the job wasn’t his. Noah had had his share of deaths over the five years he’d been a resident. Most of them had been expected, but there had been two that were disturbing surprises that had made him more humble about his skills and the unpredictability of medical science. He remembered how it had affected him and how hard it had been to face the involved families. The remembrance made him even more sympathetic toward Ava, especially as his had been separated by more than a year. All three of Ava’s had been within a month.
Noah was about to leave the operating room when the circulating nurse approached him. He knew her reasonably well. Her name was Dorothy Barton. Noah thought of her as competent and knowledgeable but also moody and opinionated, such that he generally made it a point to avoid her. He was surprised when he saw her making a beeline in his direction. He wished he hadn’t dallied.
“Dr. Rothauser,” Dorothy said. She glanced over her shoulder as if concerned someone might be listening. “Can I have a word with you?”
“Of course,” Noah said. “How can I help?’
“Do you mind if we go into the supply room?”
“I guess not,” Noah said. It was an unexpected request. He followed her back into the room he’d just left. He wondered if she had seen him and Ava in an embrace, and if so, he tried to think up an explanation. But he needn’t have worried. She wanted to speak to him about Ava, but not in a way he could have anticipated.
“I noticed something that I think you should know,” she said. She was a heavyset woman shaped like a box, with broad features and thick lips. Her face mask was untied from behind her head and draped over her ample chest. “I’ve had the misfortune of being involved in two malignant hyperthermia cases. The first was at another hospital. So I know something about the condition and what should be done when it occurs. Dr. London did not turn off the isoflurane when the problem started.”
“Oh,” Noah commented. “Did she leave it on long?”
“No, not long, but it wasn’t until I’d come back to her after following her orders to send out the alarm, which I did by using the phone.”
“I see,” Noah said, but his attention was diverted by an insistent knocking on the wire-meshed glass pane in the door to the OR
corridor. Turning his head, Noah caught a glimpse of the last person he wanted to see, Dr. Mason. When the visibly livid surgeon saw Noah look in his direction, he angrily gestured multiple times for Noah to come out into the OR corridor on the double.
“Sorry, but I have to go,” Noah said hastily to Dorothy. “Thanks for the info and for being so attentive. I’ll certainly take it into consideration. But right now I’ve got to talk with Dr. Mason.”
Bracing for yet another tongue-lashing, Noah abandoned the surprised nurse and stepped out into the OR corridor.
“I hope you are fucking happy,” Dr. Mason snarled. “This is the last straw. This poor child’s death is one too many, and since you have been protecting this woman whose incompetence is directly responsible, it’s now on your shoulders, too.”
“This was a case of malignant hyperthermia,” Noah said, trying to remain calm in the face of Dr. Mason’s fury. He knew that by talking back to Dr. Mason, he was taking a chance of further inflaming the man, but he couldn’t help himself. “It was a bolt out of the blue, and it had nothing to do with anyone’s supposed incompetence.”
“Three deaths in three weeks?” Dr. Mason practically shouted. “If that’s not incompetence, I don’t know what is.”
Noah thought of a good retort for his last comment, but he wisely held his tongue.
“This has gone too far,” Dr. Mason snapped. “I’ll tell you what I’m going to do. I’m going to have a heart-to-heart conversation with the chief of Anesthesia. I was tempted to do so after the first two disasters, but now I’m going to do it for certain. I want her to be given her walking papers and be gone. And then I’m going to do the same with Dr. Cantor about you. Your days are numbered. Three preventable deaths are totally unacceptable.”
Dr. Mason stared at Noah, defying him to defend himself. When it was apparent Noah wasn’t going to try, Dr. Mason spun on his heel and stomped away.
Noah watched the man recede and then disappear from the OR suite, presumably heading to the surgical lounge. Noah was momentarily paralyzed. The death of the boy, the worry about Ava, and now these threats from Dr. Mason combined to make him feel drained of emotion. He didn’t think Dr. Mason would be any more successful on this occasion in getting Ava or himself fired, but it was anxiety-producing and worrisome because it was making a bad situation that much worse, especially since Dr. Hernandez had specifically ordered him to do something about the poor relationship he had with Dr. Mason.
Noah sighed and shook his head. He had no idea how to deal with Dr. Mason even in the best of circumstances. With the M&M coming up the day after tomorrow, which Dr. Mason threatened to make memorable, combined with this new malignant hyperthermia death, Noah feared things were going to get worse before they got better.
20
MONDAY, JULY 24, 7:15 P.M.
As Noah climbed Ava’s front steps, he glanced at his watch, realizing that it wasn’t the best time for him to be arriving, since she would still be involved with her workout. He’d been held up when one of his post-op patients had spiked a fever.
Noah had not spoken with Ava after she had walked out of the supply room. He’d thought about calling her to ask if he should stop for take-out food as per usual, but he’d decided against it, thinking it best to leave her alone, hoping she had found something to occupy her mind.
After pressing the doorbell, Noah prepared himself for a wait and possibly the need to ring the bell several times. He knew that Ava and her trainer invariably had music blaring in the workout room as they went through their routine. He was surprised when the door buzzed open almost immediately, and even more surprised to confront Ava when he entered.
“Hello,” Noah said, giving her a hug. She didn’t respond but didn’t turn away, either.
“Are you okay?” Noah asked. He stepped back and looked at her. Her face was unnaturally flaccid, almost expressionless.
“I’ve been better,” she said. Her voice was flat and lifeless.
“I thought for sure you’d be working out.”
“I canceled the session,” Ava said. “I wasn’t up to it.”
“Are you depressed?” Noah asked.
“Obviously.”
“What can we do to cheer you up? Are you hungry? I can bring us back some take-out or we could go out like normal people. What do you say?”
“I’m not hungry. But you can go and get yourself something.”
“I can wait. Let’s talk. Should we go up to the study?”
“Whatever.”
Once they were in their customary chairs, Noah tried to think of what to say. He knew he wasn’t particularly good at psychiatry or talk therapy of any sort. As a surgeon who was accustomed to facing problems head-on with action, he’d never given the field much thought or credence. Yet he felt he knew a bit about depression, having recently dealt with a mild case himself after Leslie Brooks walked out of his life. More important, he had also managed to deal successfully with the issue when his mother had been diagnosed with early Alzheimer’s and he had to drop out of medical school. “Let me ask you this,” he began. “Have you ever had any problem with depression?”
“Yes,” Ava said. “In middle school, mostly around the time I told you I got cyberbullied. Depression, eating problems . . . I had the usual complement of symptoms associated with poor self-esteem.”
Noah inwardly recoiled, sensing he was already out of his comfort zone, the way he imagined a psychiatrist might feel if he were suddenly forced to do an appendectomy. “Other than the online harassment, was there ever any specific event that made you depressed?”
Ava didn’t answer right away but rather stared at Noah while nodding almost imperceptibly, as if she were struggling with Noah’s question and debating how or whether to respond. Noah resisted a strong impulse to say something to ease the moment, but he was glad he didn’t.
“There was an event that really bowled me over and made me seriously depressed,” Ava said finally. “It was when my oil-executive controlling bastard of a father committed suicide by blowing his brains out. I was just sixteen, a junior in high school.”
Almost as if he had been slapped in the face or sloshed with ice water, Noah felt himself start, shocked at being reminded of his metaphor that getting to know Ava was like peeling an onion. Here was yet another peel, another layer, and another surprise. He cleared his throat, frantically thinking of how he should respond. “I thought you said he died of a heart attack?”
“That’s what I have told anyone who has asked,” Ava said. “Maybe I’ve even told myself at times, but the reality is that he shot himself, and I got really depressed and almost lost it. The whole mess embarrasses the hell out of me, and I don’t like to talk about it.”
“My goodness,” Noah said, to say something.
“The other time I got truly depressed was when I was twenty,” Ava said. Her flat facial expression began to morph into anger. “I was recently married, and my new husband just walked out. Men didn’t treat me very well when I was young and vulnerable.”
“To say the least,” Noah said, thinking about her dentist boss taking advantage of her.
“And you wonder why I stick to a virtual life on social media?” Ava said with a wry smile. “It is infinitely safer to be the one controlling the mouse.”
“I guess I understand better now,” Noah said. “Were you married for long?”
Ava laughed derisively. “Just long enough for my husband to get a green card. He was in the country on a student visa but wanted to stay. I was merely a means to an end.”
“Did you meet him at Brazos University?”
“I did, days after I got there with Dr. Winston. He was a surgical resident like you, but from Serbia.”
“I’m sorry,” Noah said. Her former husband being a surgical resident made him feel weirdly complicit.
“It feels like it happened in another l
ife,” Ava said. “How about you? Have you ever had some major life-changing episode make you depressed?”
Happy to get Ava out of her shell and talking, Noah was willing to be equally open. Like she, he didn’t like to talk about such things, and he said as much, but then went on to describe how depressed he felt when his mother started showing signs of dementia and he had to take a leave of absence from medical school. And more recently he mentioned how disconsolate he’d felt following Leslie Brooks’s unexpected departure.
“Did Leslie leave totally out of the blue like my bastard of a husband?” Ava asked irritably.
“No,” Noah admitted. “For quite a while she had been upfront about my work hours and never having any time for her, and it was getting worse, not better.”
“Still, it is a blow to self-esteem.”
“Tell me about it,” Noah said with a self-mocking laugh.
“Self-esteem is critical,” Ava said. “I’ve been thinking about it all afternoon. I realize it’s why I can’t leave clinical anesthesia even after these three unfortunate episodes. For me, being a practicing anesthesiologist is too much of my self-image.”
“I’m glad to hear you say that,” Noah said. He repeated what he’d said before about how good an anesthesiologist she was and what a tragedy it would be for her to throw away all the training she had been through.
“Thank you for saying that,” Ava said. “Your support has certainly influenced my thinking. But on all three cases, I truly believe I did all the right things . . . Well, maybe I should have waited for Dr. Mason to get into the room before starting the anesthesia on the Vincent case . . . but even so, I think I did everything as well as anybody in the department, even Dr. Kumar.”
“I’m sure you did,” Noah said.
“The problem is there’s still a chance I could become a departmental scapegoat with Dr. Mason on my case. Is that still your impression?”
Noah thought quickly how he should respond after having just spoken with Dr. Mason. Since Ava seemed to have pulled herself out of her most current nosedive, he didn’t want to give her reason to regress, yet she needed to know the truth. “He’s still upset with both of us,” Noah said. “Not only did he warn me Friday about not protecting you at the M&M, he sought me out this afternoon after the malignant-hyperthermia episode. He said he is going to speak with Dr. Kumar.”