Charlatans

by Robin Cook

  “I suppose I should have,” Noah said.

  “Of course you should have, you ass,” Ava said.

  “I missed you,” Noah said.

  A smile appeared on Ava’s face. “That’s the first nice thing you’ve said to me.”

  “It is true,” Noah said. “I missed you.”

  Ava put her arms around Noah’s neck and drew herself in close to him. “I’ll tell you what I think. I think you work way too hard. You have to give yourself a break. And I think you are stressed out and should work out with me. It will do you a world of good.”

  “Maybe you’re right,” Noah said.

  A half-hour later they were on tandem exercise bikes, riding through a program projected on a large screen that was supposed to match a portion of one of the stages of the Tour de France. Ava was riding with considerably more resistance than Noah, but that was a given. Both knew she was in far better shape.

  “What’s the story with Dr. Mason since I’ve been gone?” Ava said between breaths.

  “I only spoke with him once,” Noah managed. Hoping that Ava couldn’t see, he reduced the resistance of his bike by several digits. “It was right after the M&M. He came down into the pit and was fit to be tied.”

  “Not at all surprising,” Ava said. “By the way, you handled the M&M superbly, just like you did the previous one. Thank you.”

  “You’re welcome,” Noah said. He was pleased to hear her gratitude but wished she had texted it while she was away. “But the real credit on your behalf was Dr. Kumar. He couldn’t have been more supportive than he was.”

  “I was humbled,” Ava said.

  “It was sincere and deserved,” Noah said.

  “When Dr. Mason came down into the pit after the conference, did he say anything about me specifically?”

  “He did,” Noah said. “He more or less admitted that he couldn’t do anything about you since you were in a different department.”

  “Really?” Ava questioned with obvious appreciation. “That’s terrific! What a load off my mind to get him off my case. We’ll have to celebrate.”

  “I wish I could say the same,” Noah said. “If anything, I’m afraid he’s even more motivated to get me fired. Obviously, he at least partially blames me for getting you off the hook.”

  “Oh, come on!” Ava said. “There’s no way he could get you fired. Everyone knows what a narcissistic blowhard he is, particularly after his performance at the last M&M. Everyone thinks you’re the best resident the BMH surgical department has ever seen. I’ve heard the rumor myself.”

  “Rumors are rumors,” Noah said. “That’s all well and good, but reality can be much different. Dr. Mason is a powerful fixture of the Department of Surgery. Even Dr. Hernandez felt obligated to remind me of that inconvenient fact and advised me to get along with him, as if that was something easy to do. I’m going to be on thin ice until Dr. Mason finds another target. Right now, I’m the man.”

  Without any warning, Noah stopped riding his tandem and let his feet plop loudly to the floor. He was sweating profusely and his thigh muscles burned.

  “What’s the matter?” Ava asked. In sharp contrast, she didn’t even alter her rapid pedaling cadence.

  “I’m done,” Noah said. “I’m the first to confess I’m not in shape. That’s a future goal, maybe next year. Right now, I’m bushed. But this little mini-workout has been good. Thanks for suggesting it. I’m a lot calmer than when I first arrived. I’ll shower and go get us some food so when you get out of your shower we can eat.”

  “Okay,” Ava said agreeably. “But remember, I’ve got to do some floor exercises after I finish with the bike.”

  “No problem,” Noah said. He walked on wobbly legs into the nearby shower.

  25

  SUNDAY, JULY 30, 8:34 P.M.

  After they finished eating, Noah and Ava cleaned up, keeping the conversation light. Mostly they had talked about Ava’s opportunities to do touristy things in Washington. For her it had been unique because on her other visits to the District, she’d always been too busy. Noah had admitted that he’d seen her posts on her Gail Shafter Facebook page and had read all the comments out of desperation to hear about what she was doing. “You should have texted me,” Ava had said. “I would have told you directly.” Sensibly enough, Noah had not responded to that comment.

  When Ava was finished rinsing the dishes they had used, she leaned back against the sink, drying her hands. “For me the sudden trip to Washington turned out to be a godsend,” she said. “This last MH death almost put me over the top. Getting away was what I needed. The fact that the patient was a twelve-year-old boy made it so much harder for me to accept. Not that the others were easy, mind you.”

  “I can understand,” Noah said, as he put the plastic containers into the recycling bin. “I’ve always found pediatrics harder to deal with than other specialties. Life can be unfair, everyone knows that, but it seems particularly unfair when the patients are kids.”

  “I was again seriously considering giving up clinical anesthesia,” Ava said wistfully.

  “You mentioned that.”

  “While I was away I decided I’m going to use these three deaths to motivate me to work even harder than I have been on my anesthesia MOC.”

  “That is a very healthy way to deal with these tragedies,” Noah said. “There is always something more that we doctors need to learn for our patients.”

  “The one thing that makes this last case easier than the first two is that we don’t have to worry about the M&M. I don’t believe there is a single thing in this case that I would change. Nor is there anything that someone like Dr. Mason could challenge.”

  “Good point,” Noah said, but he couldn’t keep his mind from remembering Dorothy Barton’s remark about Ava not turning off the isoflurane when she should have. He wasn’t going to bring that up again but the remembrance keyed off another issue. “You said that the reason you knew so much about how to handle a malignant hyperthermia case was from using the WestonSim Center.”

  “Absolutely,” Ava said. “I ran the MH program a bunch of times.” She hung up the kitchen towel on the oven handle.

  “While you were gone, I went on the WestonSim Center website,” Noah said. “I was impressed with the building and the setup. It makes what we have at BMH seem rather pitiful. But while I was looking at their facts and figures, I noticed it didn’t open its doors until 2013.”

  For a few moments Noah and Ava stared at each other. Suddenly there was a sense of unease in the air like static electricity.

  “Are you doubting what I told you?” Ava asked challengingly.

  “I’m not doubting anything,” Noah said. “I just noticed the date, which is the year after you and I started at the BMH.”

  Ava laughed derisively. “Two thousand thirteen is the year that the center moved into its new building. The robotic human mannequins had been in the main hospital building since I was in college and had been regularly upgraded. I started using them way back when.”

  “Oh,” Noah said. “Okay. That explains that.”

  “Any other questions about my training and timing?” Ava said challengingly.

  “Well, since you asked, I’m still curious about how much experience you had during your residency training with the advanced video laryngoscope? Did you use them a lot?”

  “That seems like a pointed question,” Ava said. “Is this issue coming back? Why are you asking this?”

  “I’m just curious,” Noah said breezily. He could tell that Ava was annoyed again.

  “I don’t buy that,” Ava said with a definite edge to her voice. “What’s on your mind? What are you implying?”

  “Nothing in particular,” Noah said, struggling to come up with an explanation. “I’m just wondering if there are differences in anesthesia programs like there are in surgery.”

>   “Are you suggesting that my training at Brazos University might not be as good as your Ivy League background? I’m appalled. You were the one telling me it was all a myth just last Monday, and now you are questioning me because I didn’t train at a known medical center? Give me a break!”

  “While you were away I checked out the Brazos University Medical Center and the medical school. It was a way to feel closer to you because I missed you. And I was impressed. It looks like a terrific facility.”

  At that moment Ava’s phone rang. She snatched it up from the countertop and looked at the screen. “Oh, damn! It’s my NSC boss. He’s going to want to debrief me about the weekend. Do you mind? I should talk with him, but it might take a while. I’m sorry.”

  “Not a problem,” Noah said graciously. In truth, he felt a little like a boxer being saved by the bell. “Do what you need to do.”

  “It might take as long as an hour,” Ava said as the ringing continued. “I ended up seeing a lot of congressmen, including over dinner with two very important senators, including Orrin Hatch.”

  “Take your time!” Noah said. “I’ll head up to the study. You’ve got enough coffee table books up there to keep me busy all night.”

  “Okay,” Ava said. “I’ll be up as soon as I can.” She then clicked on the phone and held it to her ear. “Howard, hold on just a second.” Then to Noah she mouthed, “See you!” and gave him a wink.

  As Noah headed for the main stairs, he was aware of Ava already describing her dinner Saturday night at the Washington, D.C., Capital Grille as she headed over to the sitting area of the expansive kitchen. He was glad to put a bit of space between them. He’d not expected her to react so sensitively to the laryngoscope issue. All he wanted to know was if it was in common use during her residency. Her response made him wonder just what she would say if he voiced all his misgivings.

  In the study Noah pawed through the books on the coffee table. It was an eclectic selection of large-format hardcover travel and art books. He picked up one that was both. It was an encased two-volume extravaganza called Venice: Art and Architecture. As he went to sit down, another idea occurred to him. He remembered Ava saying she’d been on the computer when he had arrived. He glanced at his watch. It had only been five minutes or so since he had left the kitchen.

  Placing the books on the ottoman, Noah walked back out into the hall and peered down the main stairs. He strained to hear Ava’s voice as she talked on the phone, but he couldn’t. The house was still except for an almost imperceptible hum of the air-conditioning system. Advancing a few feet more, Noah glanced into the computer room. From where he was standing he could see the machine was on but apparently in sleep mode. After yet another glance down the stairs and a brief listen for any sign of Ava, Noah quickly made a beeline for the computer chair. Although he knew he shouldn’t do what he had in mind, he couldn’t help himself. Her reaction to his simple questions about her residency training had fanned his curiosity about how extensive it had been. Although having been selected for a staff position in the BMH Anesthesia Department spoke volumes concerning the quality of her training, Noah was eager to get some specifics. Anesthesia residents, like surgical residents, at least at BMH, had to maintain case logs. Noah wanted to see hers, and see if it compared with those at BMH in terms of number of cases and type. Noah kept his case logs as a Word document and constantly updated it. He assumed Ava would have done the same and trusted it would still be on her system.

  With a sudden impulsivity born of a nagging confusion about Ava and her training, Noah woke up the sleeping machine. It was easy, by merely typing 1 six times in lieu of a security code, which he knew from his first visit that Ava had never bothered to install. Expecting he’d have to go to documents to search, Noah was surprised to find the screen filled with an uncompleted letter to Howard Beckmann of the Nutritional Supplement Council. Unable to help himself, Noah began reading the letter. What caught his attention was the reference to the 1994 Dietary Supplement Act, or DSHEA, in bold letters. This was a law that Noah knew all too well, as it promoted quackery for profit by giving the supplement industry free rein to avoid effective monitoring by the FDA.

  To Noah’s utter dismay, the letter talked about the need to launch political and personal defamatory targeting of those few congressmen and senators who had voiced opposition to the DSHEA and wanted to repeal it or significantly amend it. As engrossed as he was in reading, he was totally unaware when Ava appeared in the doorway. He wasn’t even aware when she charged into the room and looked over his shoulder.

  “What do you think you are doing?” she screamed. She grabbed Noah’s arm and spun him around in the swivel chair to face her. Her face was a ghostly pale blue, as the only illumination in the room was from the central computer screen.

  “I was just going to . . .” Noah began, but in the press of the moment, he couldn’t decide whether he should be truthful, and his hesitation enflamed Ava even more.

  “That is personal correspondence you are reading,” Ava yelled, pointing over Noah’s shoulder. “How dare you!”

  “I’m sorry,” Noah managed. “I thought you were going to be occupied for a time, and after our discussion downstairs, I had it in mind to look at your resident case log, or at least see if you had one.”

  “Of course I have one,” Ava snapped irritably. “So you are still looking down your nose at where I got my anesthesia training. That adds insult to injury, making this violation of my privacy even worse. I can’t believe you.”

  “I’m sorry,” Noah repeated. He started to get up, but Ava reached out and forced him back down on the computer chair.

  “I’ve trusted you,” Ava yelled. “I’ve opened my home to you and this is how I’m rewarded? If I were a guest in your apartment, it wouldn’t even dawn on me to go into your computer.”

  “You are right,” Noah said. “I don’t know why I did it. Well, maybe I do. I think you are a terrific anesthesiologist and have said so many times. But there are some . . . I don’t know exactly how to word this . . . but I have some misgivings that I’d like to get off my mind.”

  “Like what?” Ava snarled.

  “Maybe this isn’t the best time to talk about this,” Noah said. He tried to stand again, but Ava wouldn’t let him. She was in a rage, hovering over him.

  “It’s now or never,” Ava snapped. “Explain yourself!”

  “It’s just a few little things,” Noah said with a sigh. “Like with the Gibson case, it seemed you were struggling with the video laryngoscope. Now, I know the patient’s head was bouncing around from the cardiac massage, but it just looked like you weren’t as familiar with the instrument as I would have guessed.”

  “What else?”

  “On the same case, I wondered why you hadn’t secured an airway some other way, like with a needle tracheostomy with high-pressure oxygen.”

  “Anything else? Let’s hear it all!”

  “With the Harrison case I keep wondering why Dorothy Barton told me you hadn’t turned off the isoflurane as fast as you should have.”

  “Are you saying you take her word over mine?” Ava questioned with disbelief.

  “No, not at all. It’s just . . . what can I say? They are misgivings. That’s the only word I can think of, and I’d rather get them off my mind.”

  “I’m the anesthesiologist, not you,” Ava said angrily. “When I got in on the Gibson case the patient had already arrested. A needle tracheotomy wouldn’t have sufficed, especially since I didn’t know what the problem was and couldn’t be sure that expiration would have been adequate. An endotracheal tube would have been immeasurably better, and I came close to getting one in. As for Miss Barton, I think her problematic personality speaks volumes. I turned that damn isoflurane off the second I suspected malignant hyperthermia. But you know something, I shouldn’t have to justify my professional behavior to you. My anesthesia peers went over th
ese cases, and they were discussed at our rounds. You, of all people, are supposed to be on my side. This is absurd.”

  “I am on your side,” Noah said. “I’ve been on your side from the beginning. As proof, look how I handled both M&M Conferences. I couldn’t have been any more on your side than I was. I wouldn’t have done that if I didn’t believe in your competence.”

  For the first time since Ava had surprised Noah, she broke off, angrily staring at him. She was furious and breathing heavily. A moment later, she looked back down. “You shouldn’t have gone into my computer, especially reading my correspondence. I have a right to privacy in my own home.”

  “I know,” Noah admitted. “I’m sorry. You are perfectly justified to be upset. I don’t know what came over me. It won’t happen again.”

  “It better not,” Ava warned. “And now I want you to leave.”

  It was Noah’s turn to be shocked. He had not expected to be dismissed, even though he recognized he was guilty of a serious faux pas. The idea of returning to his depressing apartment seemed harsh punishment indeed.

  “Are you sure?” Noah pleaded.

  Ava nodded. “I need some space to calm down. I’ve been betrayed before by a cunning, scheming husband, and I don’t like the feeling.” She backed up, giving Noah some room.

  “I haven’t betrayed you,” Noah said, getting to his feet. “I think you are a great and exceptionally motivated anesthesiologist. And certainly my personal feelings for you haven’t changed one iota.”

  “I want you to leave,” Ava said. “Violating my trust and questioning my training feels like a betrayal.”

  Noah did not want to leave. He’d missed her terribly over the previous four days. For a moment, they just stared at each other, with Noah trying desperately to think of a way to make amends. He’d been caught with his hand in the cookie jar and was now being banned to his room. “You’ll call or text if you change your mind?” Noah said. “I can just come back.” Inwardly, Noah cringed. It was a pitiful, pleading comment, and he hated himself as soon as it escaped his lips.