Charlatans

1

SATURDAY, JULY 1, 4:45 A.M.

The smartphone alarm went off at 4:45 A.M. in Noah Rothauser’s small and sparse third-floor one-bedroom apartment on Revere Street in Boston’s Beacon Hill neighborhood. As a surgical resident at the Boston Memorial Hospital, it was the time Noah had been waking up just about every day except Sunday for five years. In the winter, it was pitch black and cold, since the building’s heat didn’t kick on until seven. At least now, in the summer, it was a bit easier to climb out of the bed because it was light in the room and a pleasant temperature, thanks to a noisy air conditioner in one of the rear-facing windows.

Stretching his sleepy muscles, Noah padded into the tiny bathroom buck naked. There had been a time when he wore pajamas as he had done as a child. But the habit had been abandoned when he came to appreciate that pajamas were just another piece of apparel he had to launder, and he wasn’t fond of taking the time to do laundry, as it required walking a block up the street to a Laundromat and then waiting around. It was the waiting he couldn’t abide. As a totally dedicated surgical resident, Noah chose to have little time for anything else, even personal necessities.

He eyed himself in the mirror, recognizing that he looked a little worse for wear. The evening before, he’d had a couple drinks, which was rare for him. He ran his fingers up the sides of his face to decide if he could get away without shaving until after his first surgical case. Often he shaved in the surgical locker room to allow him to get to the hospital that much earlier. But then he remembered today wasn’t a usual day, so there was no reason to hurry. Not only was it Saturday, with its usually light surgery schedule, but it was also July 1, the first day of the hospital year, called the Change Day, meaning a whole new batch of residents were beginning their training and the existing residents were advancing up the training ladder to the next level. For fifth-year residents, also considered chief residents, it was a different story. They were finished their training and were off to begin the next stage of their respective careers — everybody except Noah. By a vote of the surgical faculty, Noah had been proud to be selected to do a final year as the super chief resident who would run the Boston Memorial Hospital surgical department on a daily basis like a traffic cop at a very busy intersection. In most other surgical residency programs, a super chief status rotated among the fifth-year chief residents. BMH was different. The super chief was an added year. With the help of a full-time residency program manager, Marjorie O’Connor, and two coordinators under her, it was now Noah’s job to schedule all the residents’ rotations in the various surgical specialties, their operating room responsibilities, their simulation center sessions, and their on-call duties. On top of that, he was responsible for work rounds, chief-of-service rounds, and all the various weekly, biweekly, and monthly conferences, meetings, and academic lectures that made up the academic part of the surgical department’s program. As a kind of mother hen, he also had to make sure that all the residents were appropriately fulfilling their clinical responsibilities, dutifully attending all the teaching venues, and handling the pressures of the job.

Without the usual need to rush to the hospital, Noah opened the medicine cabinet over the sink and took out shaving cream and a razor. While he lathered his face, he found himself smiling. His new job sounded like an enormous amount of work and effort, especially since he would have his own patients and be doing his own surgery at the same time, but he knew he was going to love the year. The hospital was his world, his universe, and as super chief he was to be the alpha-male surgical resident. It was an honor and a privilege to have been selected for the position, especially since on its completion, he was assured by precedent that he would be offered a full-time faculty position. This was huge. For Noah, the opportunity to be a full-time attending surgeon at one of the world’s premier academic medical centers associated with one of the world’s premier universities was the pot of gold at the end of the rainbow. It had been his goal for as long as he could remember. Finally, all the work, effort, sacrifice, and struggles in college, medical school, and now as a resident were going to pay off.

With quick strokes of the razor Noah made short work of his overnight stubble, then climbed into the tiny shower. A moment later he was out and vigorously drying himself. There was no doubt that it was going to be a very busy year, but on the positive side he would not have any official night call, even though, knowing himself, he’d be spending most evenings in the hospital anyway. The difference was that he would be doing what he wanted to do with interesting cases that he’d get to choose. And equally important, he would not be bogged down with busy work, the typical bane of house officers or hospital residents, particularly surgical residents, since there was always some menial task that had to be done, such as changing a dressing, advancing a drain, or debriding a gangrenous wound. Noah would be able to designate others to do all that stuff. For him, the learning opportunities were going to be off the charts.

The only fly in the ointment, and it was a big fly and a nagging, persistent worry for Noah, was the responsibility he now had for the damn bimonthly surgical Morbidity and Mortality, or M&M, Conference. This conference was different from all the others, since Noah would not have the option of farming out any aspect of the responsibility to other residents. It was going to fall to him and him alone to investigate and then present all adverse-outcome cases, particularly those resulting in death.

Noah’s fear of the M&M Conference was not some irrational concern. Since the conference was specifically about cases that didn’t turn out well, often involving mistakes and individual shortcomings, blame and finger-pointing in an emotionally charged environment with dirty laundry hung out for everyone to see was the norm and not the exception. Considering the egotistical mind-set of many of the surgeons, the atmosphere could be explosive and a breeding ground for hard feelings, with the potential of creating enemies unless an underling scapegoat could be found. Noah had seen it happen over the last five years, and the scapegoat often was the messenger: the presenting super chief resident. Noah worried that the same could happen to him now that he was super chief, especially considering the Bruce Vincent fiasco. The case had trouble written all over it for many reasons, not least of which was that Noah had been involved. Although Noah had never second-guessed his decision to put the man on emergency bypass, he knew others might.

Adding to Noah’s concern, the death of the popular parking czar had the entire medical center in an uproar and gossip was rife. Prior to the event, Noah hadn’t even known the man, because Noah didn’t have a car and never had any reason to visit any of the hospital’s three garages. Noah walked to work, and when the weather was bad, he merely stayed in the on-call facilities, which were expansive and more inviting than his own apartment. He’d seen the kids’ photos on the cafeteria bulletin board but had never known whose children they were. Yet now he knew and understood he had been in a distinct minority of not being a Bruce Vincent fan, all of which was going to make the M&M Conference a standing-room-only affair.

The main reason Noah was fearful was that the Vincent case involved Dr. Mason, who Noah knew to be egotistical, quick to export blame, and outspokenly critical of Noah. Over the previous year and a half, Noah had made an effort to stay out of the man’s way as much as possible, yet now, with this next M&M coming in less than two weeks, they were on a definite collision course like a certain cruise ship and a giant wayward iceberg. Whatever Noah was going to find in his investigation of the case, he knew it was going to be a diplomatic nightmare. From the little the anesthesiologist had said at the time, it seemed to Noah that a considerable amount of responsibility had to be directed at Dr. Mason, who had been running two other concurrent surgeries. The concurrent-surgery issue alone was an emotionally charged hot-button issue within the department.

Noah ducked back into the bedroom and went to the bureau for underwear and socks. There were only three pieces of furniture in the room: the bureau, a queen-size bed, and a single bedside table that supported a lamp and a stack of medical journals. There were no pictures on the walls or any draperies over the two windows facing out into a rear courtyard. There were no rugs on the hardwood floor. If someone had asked Noah about the decor, he would have described it as spartan. But no one asked him. He didn’t have visitors and wasn’t there much himself, which was probably the reason he’d experienced a few break-ins since Leslie had left. At first such episodes had bothered him as a personal violation, but since he had almost nothing to lose, he came to accept it as part of city living with lots of impecunious students visiting the tenants above him. Mostly, however, he didn’t want to take the time or effort of finding a new apartment. In lots of ways he didn’t even consider it a home. It was more a place to crash a few times a week for five or six hours.

There had been a time several years ago when he’d felt differently, and the apartment had been warm and cozy with things such as throw rugs, framed prints of famous paintings on the wall, and curtains over the windows. There had also been a small writing desk covered with framed photos, and a second bedside table. But all that homey stuff had belonged to Leslie Brooks, Noah’s long-term girlfriend, who had come with Noah from New York to go to Harvard Business School after she graduated from Columbia in economics and he in medicine. She had lived with Noah until she finished her graduate degree two years ago, but after graduation had moved back to New York with all her stuff to a great job in finance.

Leslie’s departure had taken Noah by surprise, until she’d explained that she had come to the realization over the three years that his professional commitment was such that there was little room for her. Most surgical residents got progressively more time with their families as they advanced up the residency ladder. Not so with Noah. Each year his hours got longer by choice. There had been no rancor on either of their parts when they went their separate ways, even though Noah had been initially crushed, as he had come to assume they would marry at some point. Yet he quickly realized that she was right and he had been selfish with his time and attention. At least until he finished his graduate training, which he thought of as a 24/7 activity, he was metaphorically married to medicine and had spent very little time in her company and in the apartment.

On occasion Noah missed Leslie and looked forward to their monthly FaceTime phone calls, which she made the effort to continue. Each considered the other to be a true friend. Noah was aware she was now engaged, which tugged at his heartstrings when he thought about it. At the same time, he was thankful that she had been forthright about her needs, and he was relieved that her contentment was no longer his responsibility. At least until his residency was over, medicine was his overly demanding mistress. Ultimately, he truly wished the best for her.

From the closet Noah got a white shirt and a tie and went back into the bathroom to put them on. Once he was satisfied with the knot, which often took several attempts, he dealt with his rather thick, closely cropped dirty-blond hair by parting it on the left and brushing most of the rest to the right and off his face. Back when he had been a typical teenager, Noah had been vain and worried about his looks. He had spent a lot of time wanting to believe he was a stud, as a couple girls had referred to him. Although he wasn’t exactly sure what they had meant, he had taken it as a great compliment. Now he was not concerned about his appearance other than to look appropriately doctorlike, which he interpreted as being reasonably manicured, with clean, pressed clothes. He despised those residents who thought it a badge of honor to wear wrinkled, bloodstained outfits, especially scrubs, to advertise how hard they were working.

Noah was a bit more than six feet in height and still appeared athletic, even though he’d not had time for athletics since he’d graduated from college. Still weighing in at 165 pounds, he had never gained weight like some of his high school friends, despite not getting much aerobic exercise. He attributed his good luck to rarely taking the time to eat and to having decent genes, thanks to his father, which might have been the only positive thing he got from him. In the looks category, what made him the proudest was his chiseled nose separating emerald-green eyes. The eyes were a gift from his redheaded mother.

The final act of dressing before heading off to the hospital involved his white pants and white jacket, both of which he was known to change several times in the same day, taking advantage that they were cleaned and pressed by the hospital laundry. When he was fully ready, with his computer tablet in his side pocket, he checked himself in the mirror that hung in the living room. The mirror had belonged to Leslie, and why she had left it she had never explained, nor had he asked. Otherwise, the living room was almost as stark as the bedroom. The furniture consisted of a small threadbare couch, a coffee table, a floor lamp, a folding card table with two folding chairs, and a small bookcase. An elderly laptop sat on the card table as the sole remnant of his teenage love of computer gaming. The only wall decorations in the room were a simple brick mantel painted white and the mirror. Like the bedroom windows, the living room windows were bare. They looked out onto Revere Street and the typical Beacon Hill brick buildings opposite.

When Noah exited his building, it was only a little after 5:00 A.M. On a normal day, when he didn’t take the time to shave, he always left before 5:00, proof of the efficiency of his morning routine. This time of year, it was a pleasant temperature outside and nearly full daylight, although the sun itself had yet to rise. In the winter, it was another story, especially on snowy mornings. Yet he liked the walk in all seasons, as it gave him time to think and plan his day.

His usual route took him to the left, heading farther up Beacon Hill, which was a real hill and not just the name of the neighborhood. At Grove Street, he switched over to parallel Myrtle Street and continued climbing. As was fairly typical, Noah saw no other pedestrians until he crested the hill, at which time, as if by magic, people materialized, mostly dog walkers and joggers, although a few commuters appeared, too. As he passed the Myrtle Street playground, he was showered with the sounds of summer. Even though he was in the center of a major city, the bird population was considerable and the air was filled with chirps, trills, tweets, and warbles.

As he walked, Noah couldn’t keep from fretting about the damn M&M. Why it bothered him so much was his abiding fear of authority figures such as principals, college or medical school deans, influential teachers, and powerful surgical faculty members. In short, it was anyone who had the power to derail his strong urge to be a consummate academic surgeon. He’d always known it wasn’t a totally rational phobia, since he had been a top student from eighth grade on, but such an understanding didn’t reduce his anxiety. He’d had a fear of authority figures throughout his schooling, but it had ratcheted up in both college and medical school and had even gotten worse during his residency, especially after it had been hugely reawakened when he had been blindsided during his second year.

The unexpected irony for Noah was that his total 110 percent commitment to his surgical residency had not been without problems above and beyond the social sacrifices in relation to Leslie. With a certain amount of dismay, after his first year as a resident he came to realize that there were attendings who thought of him as overzealous, particularly the more openly narcissistic surgeons, such as Dr. William Mason. The super chief at the time, Dan Workman, took Noah aside to explain that it might be better for Noah to rein himself in to a degree. Without naming specific people, he said that there were faculty who thought of Noah as a little too good, too ambitious, and getting far too much acclaim and needing to be humbled.

Noah had been shocked until he came to understand where the animosity was coming from. As a first-year resident, Noah had started interfering with a certain surgeon’s private cases because of his attention to detail. By his thoroughness, he had the uncanny ability to discover additional problems when he did routine admitting history and physicals. These discoveries not only got a number of cases canceled but also suggested that the original workup had been incomplete or sloppy, a fact that certain attendings were not happy to learn and had advertised. In many ways, it was yet another example of blaming the messenger.

At first Noah had just dismissed the problem, since he felt confident he was putting patients’ needs first, which a doctor is supposed to do. If anything, the criticism spurred him to even greater efforts until he was taken down a peg. With his degree of commitment to excellence and patient care as evidenced by his effort and thoroughness doing routine admitting histories and physicals, Noah spent way too much time in the hospital. He was always there, always available, even when he wasn’t on call. Whenever a fellow resident asked him to cover, he always agreed. He didn’t even take a day off until literally ordered to do so by the super chief.

Noah knew full well his behavior was in constant violation of the work limits imposed by the Accreditation Council for Graduate Medical Education, known as ACGME, yet he felt the rationalization for the limitations in terms of patient safety did not apply to him. He needed little sleep, rarely felt tired, and, in contrast to more than half the other residents, wasn’t married and didn’t have children. At the time, he thought Leslie understood and was supportive.

Eventually someone brought Noah’s work ethic to the attention of Dr. Edward Cantor, the surgical residency program director. The result was a personal warning, which had a mild effect on Noah for a few days before he switched back to his usual schedule. Then, as Noah would say, the shit hit the fan. On two occasions, he was hauled before the Residency Advisory Board, which was particularly embarrassing since he sat on the board, as voted by his fellow residents, and hence had to recuse himself. On the first occasion, he got another warning and was told that his behavior would put the hospital’s total graduate medical education program in jeopardy if the media were to get wind of it.

For a few weeks Noah tried to restrain himself, but it was difficult. For him, being in the hospital was like an addiction. He couldn’t stay away. Three weeks later, Noah was back in front of the Residency Advisory Board, whose faculty members were furious. To Noah’s absolute horror, on this occasion he was threatened with dismissal and told that from then on he was on probation such that a third violation would result in his walking papers.

Noah had indeed been taken down a notch. From then on he proceeded with extreme care and devised all sorts of inventive strategies, such as signing out from the hospital and leaving from one door only to enter another. Luckily, as time passed, the threat of dismissal lessened. By the time he finished his third year, he began to ease up on all his machinations of eluding attention because senior residents were not followed as closely as junior residents. As for a vacation, he hadn’t taken one and no one seemed to have noticed.

Now it was 5:26 A.M. when Noah entered through the main entrance of the Stanhope Pavilion. As he always did, he felt a shiver of excitement just coming through the door. Every day was a new experience; every day he saw something he’d never seen before; every day he learned something novel that would make him a better doctor. For Noah, arriving at the hospital was like coming home.

2

SATURDAY, JULY 1, 5:26 A.M.

The very first thing that Noah did every morning after coming through the revolving door was board one of the elevators and head up to the surgical intensive-care unit located on Stanhope 4, the same floor with the operating rooms. Visiting the SICU was always number one on his agenda, whether he slept at home or in the surgical on-call facility, which was also on Stanhope 4. For obvious reasons, the patients in the intensive-care unit were the hospital’s sickest and most needy.

Like the Stanhope operating rooms, the intensive-care unit cubicles were arranged in a circle, defined by glass partitions, with a central desk from which the nursing supervisor could see into each cubicle by merely turning her head. The night shift supervisor was Carol Jensen, a certified critical-care nurse. She was no-nonsense like all the other supervisors, particularly when she was tired, and toward the end of a shift intensive-care nurses were always tired. It was one of the most demanding jobs in the entire hospital.

“You are a ray of sunshine, Dr. Rothauser,” Carol said as Noah came in behind the counter. The central desk, like the room, was circular.

“It is always nice to be appreciated,” Noah responded cheerfully. He took a seat in one of the swivel desk chairs. He understood what Carol mostly meant by her flattering metaphor: namely, that his arrival augured the ending of her shift and she would soon be on her way home. At the same time, he took it as a compliment. Noah had been told on more than one occasion, and even by Carol herself, that he was one of the nursing staff’s favorite residents. She’d explained that everyone appreciated that he was always available at a moment’s notice and was always cheerful, no matter the time of day or night, in contrast with other house staff who could be downright surly if they were exhausted, which they often were when on call at night. Even when Noah was in surgery, he’d made it known he didn’t mind talking over the intercom for an emergency consult on a patient. For nurses, particularly critical-care nurses like Carol, doctors being reachable was enormously important because problems could arise quickly and critical decisions had to be made or patients suffered. But what Carol didn’t say and what Noah was blissfully unaware of was that most of the other female nurses thought Noah was a bit of a mystery. As one of the more attractive, unattached male residents, he never gave even the slightest sexual spark or engaged in double-entendre wordplay, which was otherwise relatively rife within the hospital culture.

Noah’s eyes roamed around the unit. He saw that each cubicle had a nurse, some more than one, and all were busy. The patients were all totally bedridden, many with respirators as the only sign of life. For Noah, the fact that there were no doctors present was revealing and reassuring. “Looks like you have things wonderfully under control,” he said. The other reason nurses liked Noah was because he was appreciative of their role and the work they did. Noah often asserted that the nurses did nine-tenths of the work in the hospital and that residents were there merely to help.

“It has been a better night than usual,” Carol said.

“Any problems that I should know about?” Noah asked. He redirected his attention to the unit supervisor. He was surprised that she was staring at him.

“I don’t think so,” Carol said. “Let me ask you a question: How is it your white coat always looks so clean and pressed?”

“I change it often,” Noah said with a laugh.

“Why, exactly?”

“I think patients appreciate it. I know I would if I were a patient.”

“Curious,” Carol said. She shrugged. “Maybe you are right.”

“You’ll be getting several new surgical residents today,” Noah said.

“Don’t remind me.”

For nurses, July 1 was often a difficult time, especially in intensive-care units, where there was a steep learning curve for first-year residents. For a week or two the critical-care nurses joked that they had to direct almost the same amount of attention to the residents as they did to the patients to make sure the residents didn’t do anything untoward.

“Let me know if there are any problems,” Noah said.

Carol merely laughed. There would be problems. There always were.

“I mean any problems above and beyond the usual,” Noah added.

In the unit, Noah had two of his own patients whom he had operated on, both disaster cases that had had surgery at community hospitals and that had to be redone. Both patients had been airlifted in dire straits into the BMH and were now on respirators. Noah spoke with the nurses taking care of each one, checked the patients themselves briefly, particularly their sutured incisions and their drains, and then glanced at their SICU charts that hung off the ends of their gurneylike beds. Noah did all this in minutes but with attention to detail to be sure he wasn’t missing anything. While he was in the second cubicle, residents assigned to the SICU began arriving; their faces reflected their fatigue.

In terms of residents, the SICU was a kind of miniature United Nations. Critical Care had evolved into a specialty of its own, with its own residency program. At the same time, it was felt appropriate to continue to rotate junior surgical residents through the unit to gain the experience that it could provide. It was the same with anesthesia. What this meant for Noah was that a certain amount of diplomacy was necessary, as he technically did not have power over critical-care residents or anesthesia residents.

Lorraine Stetson and Dorothy Klim were the two surgical residents who had been assigned to the ICU for the previous month, and seeing Noah, they immediately came in to join him. Although the number of female surgical residents had climbed dramatically over the last ten years, it was rare for both ICU surgical residents on the same rotation to be female. Lorraine was a first-year resident who had miraculously transformed overnight into a second-year junior resident, thanks to it being July 1. Likewise, Dorothy was now a third-year senior resident. Noah got along well with both women, although Dorothy often made him feel uncomfortable. He didn’t know exactly why but assumed it had something to do with her appearance. In his mind, she looked more like a movie actress playing a role than a real surgical resident, even though he admitted such a thought was sexist.

“I’m sorry we were not here when you came in,” Dorothy said.

“Why?” Noah said. “Everything is copacetic here, and SICU rounds don’t start until six.”

“Still, I think we should have been available when you arrived.”

“No problem. It doesn’t matter. What matters is that you will be passing the baton to a brand-new first-year resident by the name of Lynn Pierce. Also to Ted Aronson, whom you obviously know. I want you to let me know if there are any problems whatsoever, particularly with Miss Pierce.” For first-year residents, starting off in the ICU before getting their feet wet in the program was often stressful for everyone.

“We met Lynn Pierce last night at the Change Party,” Lorraine said. “I think it is going to be fine. She’s actually excited about being thrown into the deep end of the pool. Those were her exact words. She thinks she lucked out.”

The famed Change Party was a yearly surgical department event held at the nearby Boston Marriott Long Wharf hotel on the evening of June 30, no matter what day of the week it occurred. The party’s main purpose was to send off the fifth-year residents with a fun-filled event that included a number of irreverent homemade videos, generally mocking the attending staff of BMH but in actuality celebrating them and the institution. As a command performance, Noah had attended the celebration, as he had previous Change Parties, but such gatherings weren’t his cup of tea. To be sociable and try to relax, he’d had several drinks, which had made him feel less than top-notch this morning.

Although the Change Party was to acknowledge the residents who were leaving, it was also secondarily an opportunity to welcome the twenty-four first-year residents who were about to join the BMH family. Only eight of the twenty-four were categorical residents, meaning they were expected to stay for all five years of surgical training. The other sixteen were planning on finishing only a year or two of surgical training before going on to various surgical subspecialties, such as orthopedics or neurosurgery.

During the course of the evening and despite generally feeling like a fish out of water, as he always did in large social situations, Noah tried to introduce himself to a few of the incoming surgical residents, a couple of whom he had met when they had come for their interviews before being accepted. One of them was Lynn Pierce, and he had been impressed with her, although she’d had a similar effect on him as Dorothy, making him wonder if physical attractiveness was now a criterion for the program.

“Are you going to stay for SICU rounds?” Dorothy asked.

“No,” Noah said. “Seems there is no need, and I have a lot on my plate before the welcoming ceremony this morning. And you guys are planning on attending, right? Remember, everyone is expected to show up.”

“We wouldn’t miss it for the world,” Dorothy said with a smile. “That is, unless the roof falls in here in the SICU.”

“Don’t count on it,” Noah said. “Be there!”

The welcoming ceremony was as preordained as the Change Party but a lot less fun. It was supposed to welcome the first-year residents, but Noah saw it more as an opportunity for the departmental bigwigs to hear themselves bloviate. Over the years he had come to understand that there was always a lot of posturing and jockeying going on in the front office of top academic surgical programs, and the surgery department at the BMH was no exception. Competition was the name of the game in medical academia, particularly in the surgical arena, and it never stopped. Luckily, Noah considered himself good at it.

As had been the case for the last four welcoming ceremonies he had attended, Noah was not looking forward to it. The first one had been different because he had been eager to start his residency. He had been so eager that he had found most of that June five years ago to be almost intolerable. The days had seemed to drag by from medical school graduation until July 1, despite his having been busy finding the Revere Street apartment and setting it up with Leslie.

From Noah’s perspective, this year’s welcoming ceremony was going to be more trying than usual. He was not going to be allowed to sit passively and persevere as he had the previous four years. As the new super chief resident, he was going to be asked by Dr. Carmen Hernandez, the chief of surgery, to say a few words. Unfortunately, this wouldn’t happen until after the chief and then Dr. Edward Cantor, the surgical residency program director, had exhausted everyone with long, boring speeches about the history and importance of general surgery and the BMH in the development of modern medicine. Noah knew that by the time he was introduced, the audience would be close to comatose.

Of course, Noah understood it made sense for him to address the group, since he was the new residents’ day-to-day boss. The structure of the surgical residency program was as simple as it was medieval. The first-year residents were the serfs, or, according to in-house parlance, the “grunts,” Noah their liege lord, Hernandez the king. Each year the residents ascended the rigid ladder, with increased perks and responsibilities.

Noah had never been fond of public speaking, particularly in a formal setting. He was fine if not brilliant in informal settings, such as on surgical rounds, considering his command of the medical literature to back up any point he was trying to make. The reason public speaking bothered him stemmed from his competitive quest for academic excellence, which he thought was put at risk in such a circumstance. He always had the fear that his mind might go temporarily blank or he’d inadvertently say something outlandish. It wasn’t necessarily a rational fear but real nonetheless, similar to his fear of social engagements like the Change Party. To make matters worse, he had been so busy preparing to assume the role of super chief that he hadn’t planned his remarks. He was going to have to improvise, which only increased the likelihood he’d say something inappropriate in front of the surgical hierarchy.

Leaving the SICU well before 6:00 A.M., Noah took an elevator up to general surgery on the eighth floor. Work rounds with junior and senior residents weren’t scheduled until 6:30, giving Noah time to check in with the night-call senior resident, Bert Shriver, a solid, dependable resident. Like everyone else, Bert had risen in stature overnight, if only in name. He was now a fifth-year chief resident. He gave Noah a quick rundown of the night. There had been two surgeries, both appendectomies that had come in through the ER, and the patients were doing fine. With all the surgical inpatients, there had been no problems whatsoever. There had been one consult from the internal medicine floor to do a cut-down on a patient who needed an IV but had no superficial veins.

“You’ll be at the welcoming ceremony, right?” Noah asked. As the new super chief, he was now responsible for no-shows.

“Wouldn’t miss it for all the tea in China,” Bert said with a grin. “Can’t wait to hear whatever pearls you have conjured up.”

Noah gave him the finger and an exaggerated dirty look.

Still with time to spare before general work rounds would begin, Noah used the phone in the nurses’ station to call the OR to see if anything had been scheduled behind his back. He had checked the evening before, prior to the Change Party, and had been told no surgeries would be scheduled until 10:30 A.M. His concern was that if surgeries had been scheduled overnight, which needed resident helping hands, it would be up to him to supply them. He was happy to learn that no cases had been added. For once, word had apparently gotten out so that the entire surgical department knew about the welcoming ceremony. Noah was pleased on one hand and a bit more nervous on the other. The implication that the ceremony might be even better attended than usual added to his anxiety about speaking.

Noah next went around to check in on his three private patients whom he had operated on. He thought it important for him to visit each at least twice a day to have direct, personal, face-to-face contact. Though he would see them again on work rounds, that was different, as it would be with the whole resident team. Noah had never been a patient himself, but he was sure that if he were, he’d want to have a few private moments with his doctor every day. His attitude about the importance of communication was one of the many reasons he was so popular.

Two of the three patients were still asleep when Noah entered their rooms, and Noah had to wake them up. During his first couple years as a surgical resident, Noah would not wake patients, thinking he was doing them a favor by letting them sleep. A dressing-down by a patient made him change his mind. Patients truly valued the personal, one-on-one time.

All three patients were doing fine, with one scheduled for discharge that afternoon. Noah spent a little more time with him to let him know what he could and could not do. He also assured him that he would see Noah and not another resident in the clinic for follow-up. The man had been a patient of the BMH for years and knew the ropes. Sometimes when residents rotated onto different services they didn’t get to follow patients they had taken care of on previous rotations. Noah had always made sure that didn’t happen to him. It was one of the benefits of the sheer number of hours Noah spent in the hospital, which married residents with families simply couldn’t do. Noah was never bothered by this added effort; in fact, he thought the opportunity gave him a leg up.

Work rounds went especially smoothly for a number of reasons, primarily because there were no problem cases that needed extended discussion as to future course of action. Another reason was that it was Saturday, when it was rare for attending surgeons to show up and try to turn work rounds into a variation of chief-of-service rounds, whose goal was teaching or at least pontificating. Work rounds, by definition, were a time to merely review the chief complaint, what had been done so far, and what was going to be done that day or in the near future, and then move on to the next patient.

The final reason the work rounds proceeded apace that morning was that the junior residents who did the actual presenting were now all second-year residents and knew the ropes. Presenting cases was a learned skill, which all had mastered, except for Mark Donaldson, who was obviously either not prepared or, worse yet, had somehow failed over the year to grasp an appropriate sense of what was important and what was not. Noah spared him the embarrassment of calling him out on the spot, which had been a typical pedagogical surgical-rounds teaching method honed by some attendings to the level of torture. Noah had hated it when he was a junior resident, even though it had rarely been directed at him. Nonetheless, Noah had vowed never to do it as he rose up the ladder. With the belief that persuasion was a far better teaching method than ridicule, he planned to take Mark aside at some appropriate time, probably later that day, and have a heart-to-heart discussion.

Since it was Saturday and there were to be no chief-of-service rounds, Noah had a bit of free time. The welcoming ceremony wouldn’t commence until 8:30 and it was now 7:00. After reminding all the other residents about attending the welcoming ceremony and after entering his progress notes on his three patients in the electronic medical record, or EMR, Noah took the elevator down to administration on the third floor.

In sharp contrast with the rest of the hospital, which operated on a 24/7 basis, the administration area was all but deserted on a Saturday morning.

Noah’s destination was the surgical residency program office, which was at the far end of a carpeted hall where all the graduate medical education offices of the various specialties were located. When he got to his office door he fished out the lone key he had in his pocket. It had been dutifully handed over to him a few days ago by Dr. Claire Thomas, the outgoing super chief responsible for shattering a few significant glass ceilings. She had been the first African American woman to be the BMH surgical super chief and was, as of that very day, the first African American woman on the BMH surgical faculty. Noah knew she was going to be a hard act to follow, as everyone liked and respected her, including Dr. Mason. She had never been chastised in front of the Residency Advisory Board by the program director, Dr. Cantor.

Using the key, Noah opened the door. He stepped over the threshold and closed the door behind him. For a moment, he just stood there and surveyed the room. There were five desks. One was for Marjorie O’Conner, the surgical residency program manager. She ran the show from a bureaucratic standpoint. Another smaller desk was for the coordinator, Shirley Berensen. Her area of concentration dealt with managing the complicated evaluation requirements to make sure the program retained its accreditation and residents reached appropriate milestones. Another desk was for Candy Wong, also a coordinator, who oversaw the equally complicated issue of resident duty hours and the on-call schedule. Miss Wong had been the person whose attention Noah had spent so much effort avoiding after he had been threatened with dismissal for violating duty hours when he was a junior resident. For Noah, there was a certain irony that now he would be working closely with her.

There were two more desks, both smaller than the coordinators’. One was for the secretary, Gail Yeager, and the other for Noah. Looking at them, Noah had to smile. The irony here was that he and the secretary were probably going to be the busiest people in the surgical residency program and yet had the least impressive real estate. But the worst part, from Noah’s perspective, was not the size of his desk, which had no significance to him, but rather that his desk was completely out in the open, meaning there was no privacy whatsoever except after hours and on weekends. For something like the conversation he needed to have with Mark Donaldson, the venue was completely inappropriate. For such situations, Noah was going to be forced to improvise.

Two days ago when Claire had given him the key to the surgical residency program door, Noah had brought in office supplies, along with a significant amount of paperwork, including his very initial ideas for the choices of faculty mentors for each of the new first-year residents. Every new resident was assigned a faculty mentor. Even though Noah had never utilized his mentor other than enjoying a few pleasant dinners at the man’s home, he still thought the program had merit. There were always a couple of first-year residents who found adapting to the role of a surgical resident challenging. Being a resident was a world of difference from being a medical student.

Sitting down at the desk, Noah took advantage of the preternatural stillness of the deserted office. He got out the list of first-year residents and the list of faculty members who had volunteered to be part of the mentor program and went back to trying to match them. Quickly it became apparent that there was too much guesswork involved, because Noah knew very little about the new arrivals. The only thing he knew for certain was their genders and the medical schools they had attended. On the other hand, he knew the faculty members reasonably well, maybe too well in some instances.

When Noah had done what he could, he turned to managing and planning the plethora of meetings and conferences. Of particular concern was the weekly basic science lecture, since it was going to be the first conference under his tutelage and was fast approaching in less than a week. The basic science lecture was held every Friday at 7:30 A.M., and he had yet to decide on a subject for the first meeting, much less a lecturer. What he didn’t admit was that he was avoiding even thinking about the even more worrisome and problematic M&M Conference.

Time went by quickly, and before Noah knew it, the alarm on his cell phone went off, shocking him back to reality. It was quarter past eight. He’d set the alarm in the rare eventuality he wasn’t called, texted, or paged for some problem someplace in the hospital, which was what he fully expected. During the early morning, there was always something that happened that needed his attention. Certainly, had he stayed on the surgical floor, he would have been inundated. Taking full advantage of the peace and quiet, he’d made progress and had now outlined the first three basic science lectures and had emailed appropriate potential lecturers to ask if they would lend a hand.

After putting away his paperwork, Noah headed out the door. His destination was the Fagan Amphitheater in the Wilson Building, which was reached by a pedestrian bridge located on the second floor of the Stanhope.

3

SATURDAY, JULY 1, 9:27 A.M.

“Thank you, and welcome to the best surgical residency program in the world,” Dr. Edward Cantor said with a wry smile to acknowledge he might be exaggerating to a degree. He was a tall, slender, angular man, fit and assertively intelligent. He picked up his notes from the Fagan Amphitheater’s lectern and sat down in the chair he had vacated twenty minutes earlier. It was one of five in the amphitheater’s pit. The others were occupied by Dr. Carmen Hernandez, chief of surgery, and Dr. William Mason and Dr. Akira Hiroshi, both associate surgical residency program directors. The fifth chair was noticeably empty.

The welcoming ceremony had started precisely at 8:30 A.M. as scheduled. Noah had entered from the second floor prior to its commencement with several minutes to spare and looked down into the pit to see Dr. Hernandez waiting at the lectern for 8:30 to arrive. The chief was a compulsive man, especially about time. The room was built as a typical half-circle medical-school amphitheater, with tiers of seats rising from the half-circle pit or arena a full story below, making it look like an ancient Greek or Roman theater. The room was nearly full, with the twenty-four newly minted and obviously eager first-year residents sitting front and center in the first row. They all had on glaringly white, highly starched coats similar to Noah’s. Over the whole scene was a surprisingly loud buzz of conversation as a testament to the room’s fine acoustics.

As Noah had begun to descend one of the amphitheater’s two rather steep stairways that divided the seating into thirds, his arrival caught the attention of the chief of surgery, who waved up to him and gestured toward the only empty chair in the pit. Noah had quickly signaled that he preferred to sit in the audience. It had been a snap decision predicated on his seeing that the empty chair was next to Dr. Mason. As nervous as he was about speaking in front of the packed amphitheater, Noah had no interest in compounding his anxiety by having to relate to his least favorite attending, so he took an aisle seat in the twelfth row. The fact that the empty chair was also next to Cantor’s also played a role. After the man had threatened to dismiss him for spending too much time in the hospital as a junior resident, Noah had never felt at ease in his presence.

The program progressed just as Noah had predicted. Dr. Hernandez carried on for almost a half-hour, letting Noah’s mind wander to all his newly acquired responsibilities. Unable to avoid observing Mason down in the pit, wearing one of his typical expressions of disdainful disinterest when he was not the center of attention, Noah had found himself mostly worrying about the damn M&M Conference and how the hell he was going to navigate the minefield he knew it represented. He had successfully avoided thinking about it all morning, until Mason’s presence made it impossible.

After the chief of surgery had spoken, the program director followed suit in an equally predictable fashion, enough to make Noah marvel that no one in the audience fell asleep. He could tell that Dr. Mason was not finding the program particularly stimulating, either, as he was constantly fidgeting in his seat and crossing and uncrossing his heavy legs.

The moment Dr. Cantor had taken his seat, Dr. Hernandez got up and returned to the lectern. After adjusting the microphone down to accommodate his height, he cleared his throat and said: “Now I want to introduce to you our brand-new super chief resident, Dr. Noah Rothauser.” With that he gestured up toward Noah.

As Noah got to his feet and began descending the steep stairs that lead down into the pit, he could feel the hairs on the back of his neck stand up, as well as his pulse begin to hammer in his temples. There was a smattering of applause and a few teasing catcalls and some playful laughter in the audience. Noah was popular not only with the nursing staff but also with his fellow residents. One of the reasons was practical: If ever anyone needed someone to cover for whatever reason, everyone knew Noah never turned anyone down regardless of the hour or the day of the week.

Noah kept his eyes down and concentrated on avoiding a fall, as that would be a scene he’d never live down. Not only were the amphitheater’s stairs abnormally steep, there was no handrail. Once in the pit, he walked directly to the lectern, feeling himself blush. Dr. Hernandez had returned to his seat.

After adjusting the microphone up, he still hunched over, then raised his eyes to gaze directly at the twenty-four brand-new first-year residents. He started to speak, but his voice came out in an otherworldly squeak, making him clear his throat. When he began again, he sounded relatively normal, at least to himself.

“I would like to add a welcome to you all,” he said while he made eye contact with each new resident in turn and gained confidence as he did so. “I had planned on giving a long, detailed speech about the history of surgery, but I believe that has been adequately covered by our own esteemed surgical professors, who are giants in their respective fields.” Noah briefly turned and nodded toward Hernandez and Cantor, both of whom smiled contentedly as the audience tittered in relief. Noah avoided looking at Drs. Mason and Hiroshi, although he had nothing against Hiroshi, with whom he never had much interaction.

“Instead I would just like to say you are about to begin the most exciting and demanding part of your extensive training, and leave it at that. I would like to add that I wish I could say my office door is always open for whatever reason you might have to pay me a visit, but unfortunately, I do not have an office.”

A few chuckles rapidly grew to a round of real laughter as a reaction to the pomposity of the previous speeches. Noah found himself smiling, too, although he worried that his off-the-cuff attempt at humor might offend Dr. Hernandez. A quick glance reassured him when he saw the chief was at least smiling.

“Office or not,” Noah continued, “I will always be available for whatever reason. Don’t be shy! I’m easy to find. Surgery here at the BMH is a team effort, and we expect everyone to be a team player. You all got your initial rotation assignments, so after the coffee and doughnuts served next door in the Broomfield Hall, we are off to the races. Thank you! And let’s have a fabulous year.”

Noah turned and faced Dr. Hernandez, who had risen to his feet. He was a square-built man, in some ways similar to Dr. Mason but a smaller version, with darker, thicker hair, an olive complexion, and a heavy mustache. In contrast to Dr. Mason’s bluster, he exuded an air of quiet confidence, which he maintained no matter the challenge in either the operating room or the boardroom. “I hope you didn’t take my attempt at humor as a complaint,” Noah said.

“Not at all,” Dr. Hernandez said. “It was unexpected, which made it funny. But you do have an office...”

“I have a desk,” Noah corrected. “Not an office.”

“I see,” Dr. Hernandez said, before his attention was hijacked by an attending surgeon who pulled him aside for a quick consult.

Noah noticed several of the new residents, including Lynn Pierce, coming down into the pit and heading in his direction. He couldn’t help but notice Lynn was wearing a very striking yellow summer dress under her white coat. With a minor wave of panic, Noah glanced back at the exit, but before he could beat a retreat, he felt a tap on his shoulder. He turned to face a nurse dressed in scrubs whom he had seen on occasion but with whom he had never spoken.

“Dr. Rothauser, I’m Helen Moran.”

“Hello, Helen,” Noah said.

“I don’t want to take much of your time,” Helen said. “I know you are busy, but I wanted to speak to you briefly about the Bruce Vincent case. I am one of the few people who didn’t personally know him, but I participated in getting him admitted. Rumor has it that he was a victim of the concurrent-surgery process. Is that true?”

Taking a deep breath, Noah tried desperately to organize his thoughts and figure out what to say. In truth, he didn’t want to say anything, as he had been trying to avoid even thinking about Bruce Vincent, but now, gazing into the indignant eyes of Helen Moran, that clearly wasn’t an option. Obviously, he was already being drawn into the minefield he was dreading. There had even been a few unflattering articles about concurrent surgery in the lay press.

“I have yet to investigate the case,” Noah said vaguely.

“I hope the case is going to be presented at next week’s M&M Conference.”

“I’m sure it will be,” Noah said. “It was a tragedy, which certainly needs to be aired to see if we can learn anything to keep it from happening again in the future.”

“Didn’t Dr. Mason have two other cases going at the exact same time? That’s what I heard.”

“I will be checking in on that for certain,” Noah said.

“I hope you do. I happen to know that was the situation, and I personally think that concurrent surgery shouldn’t be allowed here or anyplace. Plain and simple. Not in this day and age.”

“I’m not fond of the practice myself,” Noah said. “Now, if you can excuse me, I have to get over to Broomfield Hall.”

While Noah had been briefly speaking with Helen Moran, the covey of first-year residents that he had seen approaching had grouped themselves around him. The moment he was free, a batch of simultaneous questions erupted about the on-call schedule. Jokingly, Noah held up his hands as if he needed to protect himself, then pointed toward the exit. “How about we all go next door and get some coffee? I promise I’ll answer all your questions.”

As Noah watched Helen recede in the direction of the door, there was another tap on his shoulder. This time it was significantly more forceful, causing Noah to have to take a step forward to maintain his balance. With a twinge of irritation, he spun around to complain, but then swallowed his words. He found himself facing Dr. Mason. The man’s expression had changed from boredom to a scowl.

“I heard what you said to that woman,” Mason growled. “Let me tell you, my friend! You’d better tread lightly about this Vincent case or you are going to be in big trouble.” To emphasize his point, Mason stabbed Noah a number of times in the chest with one of his thick index fingers.

“Excuse me?” Noah managed. He’d heard Mason clearly but needed a moment to process what was obviously a threat.

“You heard me, you freaking Goody Two-Shoes. Don’t you dare turn this Vincent disaster into a cause célèbre against concurrent surgery. If you do, you’ll be messing with the most powerful surgeons here at the BMH who need double booking to meet demand of their services. You hear what I am saying? And let me remind you: The muckety-mucks in Admin feel the same, since we bring in the cold cash to run this place. You got it?”

“I hear you,” Noah managed. He stared into Mason’s unblinking black eyes. The man had his considerable chin tucked back like a boxer’s. “I will investigate the case thoroughly and present the facts dispassionately. That’s all.”

“Bullshit, my friend. Don’t take me for a fool! You can skew the facts whatever way you please. But I am warning you, Anesthesia screwed up, plain and simple, by giving the wrong anesthesia, compounded by the patient himself, which should have been discovered by Admitting. Keep it simple or, believe me, you are going to be looking for work.”

“I will not skew the facts,” Noah said, gaining a smidgen of confidence. He knew intuitively that Mason was in the wrong in trying to dictate the outcome of the M&M Conference. Yet as a realist, Noah also knew he was now deep into the proverbial minefield.

“Really?” Mason questioned superciliously. “Well, let me tell you a fact. Bruce Vincent was alive when you came flying in and sliced open his chest like the cavalry arriving at the last second. The only problem is you killed the patient. That is a fact.”

Noah swallowed. His mouth had become dry. There was some truth to what Mason was saying, but had Noah not “sliced” into Vincent’s chest, Vincent would have been dead in about three or four minutes. It had been a gamble, but a gamble that had not paid off. Still, someone could make the argument that Noah had been too rash, and that maybe the patient should have been merely defibrillated externally and bronchoscoped as an emergency.

“You’d better think about it long and hard!” Mason growled. He poked Noah a final time, hard enough to force Noah to take a step back. Then Mason turned on his heel and churned angrily through the crowded pit and out of the amphitheater like a speedboat in a packed harbor, leaving Noah in his turbulent wake.

4

WEDNESDAY, JULY 5, 10:48 P.M.

A light rain was falling as the late-model black Ford van with its snub nose and rakish headlights pulled over to the curb on a dark residential street in Middletown, Connecticut. There was no lettering on the nondescript, workaday vehicle with Maryland tags. The headlights switched off, but the engine kept running to keep the air-conditioning functioning. There was only one pedestrian visible down near the end of the street, walking a small white dog. He quickly disappeared into one of the homes, leaving the street deserted. Lights were on in many of the modest two-story houses that lined both sides of the street, although mostly on the second floors. It was bedtime in most of the households.

There were two men in the van’s front bucket seats, dressed in lightweight summer suits with black ties: George Marlowe’s was dark gray; Keyon Dexter’s was black. Both men were in their late thirties, athletic appearing, and were clean cut in a military fashion, with short hair and closely shaved faces. Both had been in the Marines and had been deployed to Iraq, where they had met in a special cyber unit. Keyon was African American, with medium dark skin; George was Caucasian and blond. They were staring out the windshield at a Craftsman-style house with tapered columns supporting a hip-roofed porch two houses down and across the street from where they were parked. Incandescent light spilled out of the first-floor windows, but the overhead porch light was off and the second floor was dark.

“Check and see if he is online now,” Keyon said from the driver’s seat. “And while you are at it, recheck the GPS coordinates. We wouldn’t want to be arresting the wrong dude.”

They both chuckled at such a suggestion as George opened his laptop, booted it up, and then let the fingers of both hands rapidly type on his keyboard. He was clearly adept at keying his laptop.

“He’s online,” George said presently. “Probably trolling and causing mischief as usual. And we’ve definitely got the right house.” He closed the computer, reached around, and put the machine on one of the rear seats. The back of the van was filled with sophisticated electronic surveillance and computer equipment.

“So now we get to see the real Savageboy69,” Keyon said.

“My guess is that we are not going to find a stud,” George said. “Ten to one he’s going to be a boring, colorless, middle-aged guy.”

“You got that right,” Keyon said. “I’d wager him being a real candy-ass despite his online persona.” They both laughed again. They knew that in current lingo, Savage boy was the same as Fuck boy in the world’s teenage smartphone “connected culture” and in rap lyrics. Neither man could define the term precisely, although both knew exactly what it meant, something like the way they thought about the concept of pornography, which they also struggled to define but felt they knew when they saw it.

“I’m hoping he’s home alone,” Keyon said. “That will make things a lot easier and cleaner.”

They had already run the house through a number of databases to find out the current owner. It was Gary Sheffield, age forty-eight, who was divorced five years ago and worked for an insurance company as a statistician. He had no criminal record and no children.

“Are you ready?” George said.

“As ready as I’ll ever be,” Keyon said. He turned the van’s ignition off. Suddenly there was the sound of crickets, particularly when they opened the van’s doors. It was a warm summer night. The rain had stopped. From all directions came the hum of window air conditioners.

They walked quickly, but not too quickly, climbing the three steps of the house and positioning themselves on either side of the front door. They were professionals and had done this many times. George rang the bell, and the chimes could be heard through the door.

They waited. Just when George was about to ring the bell again, the overhead porch light came on. A moment later the door opened a crack and an eye peered out. “Can I help you?” Gary Sheffield said.

“I believe you can,” Keyon said. “Are you Gary Sheffield?”

“I am,” Gary said. “Who are you?”

“l am Special Agent Dexter of the FBI, and this is Special Agent Marlowe,” Keyon said. He held up his badge so Gary could plainly see it. George did the same. “We need to talk to you for a few minutes.”

The door opened fully. The blood had drained from Gary’s face. “What do you need to talk about?”

“We are part of the Cyber Action Team of the FBI,” Keyon said. “It has been brought to the Cyber Division’s attention that there has been significant felonious online activity perpetrated from this location. It needs to be investigated.”

“What kind of felonious activity?” Gary said in a hesitant, tremulous voice. He was, as his visitors assumed, of medium height, corpulent but not obese, with blotchy skin and thinning hair. He was not a stud.

“That is exactly what we have to talk to you about,” Keyon continued. “Now, we can arrest you and take you to the FBI field office, or you can let us in and talk with us and perhaps clear up this problem. It’s your choice, sir.”

Gary backed away, still holding on to the front doorknob.

Keyon and George entered a small foyer. Gary closed the door. He was visibly trembling. “We can sit in the living room,” he managed, gesturing to his left.

“We’ll stand, you sit,” George said, pointing toward the couch as all three entered the drab room. There was an open laptop on the coffee table displaying a dramatic photo of mountains as a screen saver. There was also an open bottle of beer.

Gary did as he was told. He reached out and shut the laptop.

“First off, I want to ask if you are alone in the house at the moment.”

“Yes, I am alone,” Gary said.

“Okay, good,” George said. “Second, I’d like to ask if you are familiar with cybercrime punishment here in Connecticut?”

Gary shook his head. He visibly swallowed.

“It is considered a serious offense, punishable by up to twenty years in prison.”

Gary stared back without blinking.

“Is there any other computer in this house,” Keyon asked, “other than the laptop here on the coffee table, a desktop or another laptop?”

“No.”

“Good,” Keyon said. “Now, we may have to confiscate this machine because what we suspect is that it has been used for serious cyberstalking, harassment, and threats to a thirteen-year-old girl by the name of Teresa Puksar. Does that name mean anything to you?”

“I suppose,” Gary said weakly.

George and Keyon exchanged a knowing glance.

“It seems that this online activity,” Keyon continued, “has been carried out by an individual whose user name is Savageboy69 and whose Facebook profile is under the name of Marvin Hard. Are either of those names familiar to you?”

Gary visibly swallowed again. He nodded.

“Okay, very good,” Keyon said. “We are making progress here. That’s encouraging.”

“So those are two of your online monikers?” George asked.

Gary nodded again.

“Do you use any other sock-puppet names?” George said.

“I used Barbara Easy for a while, but not for a long time.”

“Interesting,” George said with a wry smile. “A little gender role reversal. Very clever. Was it rewarding?”

Gary didn’t answer.

“Let’s get down to specifics,” Keyon said. “As Marvin Hard you managed to get Teresa Puksar’s IP address and then used it to get her real address. With that you threatened her with swatting if she didn’t send you nude pictures. Is that an accurate description of your activities?”

“Should I be talking to a lawyer?” Gary asked hesitantly.

“That is your call, Mr. Sheffield,” Keyon said. “But if you want to involve a lawyer at this early stage of our investigation, we will have to arrest you, confiscate this laptop, and take you to the FBI field office. Then, within twenty-four to forty-eight hours, you will be able to make a call to your attorney if you have one. Does this sound like the way you want to go? It’s up to you.”

“I don’t know,” Gary admitted. He felt like he was caught between a rock and a hard place.

“As I said at the door,” Keyon said, “we would like to clear all this up and be on our way. Arresting you creates a ton of paperwork for us. We’d prefer to avoid it. We need to finish our investigation, make sure you understand the kind of risks you are assuming with your trolling behavior, and make sure you mend your ways. In your favor, you didn’t try to meet up with this underage young lady. That’s good. At the same time, threatening her is certainly against the law. Exactly what you were going to do with the nude photos is another issue entirely. Luckily, at this stage, we can ignore the child-pornography problem. But there are a few things we need to ask you.”

“Like what?” Gary said.

“A key point,” Keyon said. “Are you working with anyone else? Have you communicated to anyone anything at all that you have learned about Teresa Puksar in your ongoing chats and messaging with her? Anything in particular that she has revealed to you or you have learned?”

“No,” Gary said. “What I do online is private. I don’t share it with anyone.”

“From some of your messages that I’ve read, I think that is a wise idea, Mr. Sheffield,” Keyon said. “You presented yourself as a twenty-year-old college student to Miss Puksar, but to me you seemed even younger than she. Be that as it may, right now we are mainly interested in one particularly important question: Have you communicated to anyone Miss Puksar’s physical address or her IP address? Now, don’t answer immediately! I want you to think for a moment, because it is very important. Have you told anyone Miss Puksar’s location or anything about where she lives?”

“I don’t have to think about it,” Gary said. “I haven’t told anyone.”

“Have you written Miss Puksar’s address on any paper or transferred it to any storage device or put it into your contacts? Think, Mr. Sheffield!”

“It is just in this laptop,” Gary said, pointing to the machine on the coffee table.

“How about your cell phone?” Keyon suggested.

“There’s no address in my cell phone,” Gary said. He was beginning to perk up, sensing he was pleasing his interrogators and that this scary episode was coming to an end.

“Show me!” Keyon said.

Gary straightened out his right leg and pulled his smartphone from his front pants pocket. He went into his contacts and pulled up Teresa Puksar. There was a phone number with a 617 area code. He showed the screen to Keyon, who nodded.

Keyon looked at George. There was a moment of nonverbal communication between them as they tried to decide if they were finished with the interview. Each nodded slightly, indicating that he was content, meaning that they had learned what they needed to know. Keyon used his right hand to form a make-believe gun with his index finger extended and thumb upright. He pointed it at George.

George took the hint, and in quick, smooth motion reached under the lapel of his jacket and pulled out a Smith & Wesson .38 Special revolver from a shoulder holster. A fraction of a second later the gun was pointing directly at Gary’s forehead. The report was loud in the small room with its unadorned plaster walls and ceiling. The soft-nosed bullet hit Gary in the middle of his forehead, snapping his head back and spraying the wall behind the couch with blood and bits of brain.

With a wave of his hand to disburse the smell of cordite, George reached out and picked up the laptop and the smartphone. “Let’s take some other crap besides his electronic gear to make it look like a robbery gone bad,” he said.

“Right on,” Keyon said as he pulled on a pair of gloves. He rolled the corpse to the side and got out the man’s wallet. Then he pulled off Gary’s Rolex.

5

FRIDAY, JULY 7, 10:02 A.M.

Noah walked out of the operating room area by pushing through the double swinging doors and headed into the surgical lounge. He was feeling relatively chipper after having ducked into each OR to check on the residents to see firsthand how they were faring in their surgery assist roles, particularly the first-year residents. Although he was reasonably confident there were no problems, since there had been zero complaints from the attending surgeons or the OR nurses the entire first week, he liked to check himself just to be certain, since he had been the one doing the assignments. There was nothing quite like just wandering into an OR unannounced and listening to the unedited banter between the surgeon and the residents and sensing the atmosphere. A lot could be deduced, especially when it could be augmented by a quick corroborating chat with the circulating nurse. Although a few of the surgeons recognized him out of the corner of their eyes, most didn’t. It was as if he was his own undercover agent.

In the surgical lounge Noah felt relaxed enough to grab a cup of coffee and stand by the window, gazing out at the busy Boston Harbor as he drank it. Although most of the activity on the water was commercial, there were a few pleasure boats with people enjoying the summer weather. For a brief moment he fantasized what it was going to be like once he finished his long, grueling, and totally immersive training in less than a year and attained his long-sought-after goal. Although he loved his role as a surgical resident, he knew he’d been metaphorically imprisoned in the hospital for five years, a fact brought painfully home by Leslie’s regrettable but understandable departure. Outside of the hospital he didn’t have life, and he was in his mind becoming something of a social recluse. After all was said and done, would he be able to resurrect some normal social abilities and enjoy himself like those people out there boating in the sunshine, or was he destined to always be a medical workaholic? He had no idea. It was going to take a lot of effort and maybe a bit of luck. The hope was that he could somehow meet a woman who would not be challenged by his single-minded commitment to medicine.

Noah sighed and turned his back on the outdoor scene and gazed around at the people who populated his reality. With no surgery scheduled, he could take a moment for the first time since he had arrived at the hospital at a quarter past five to reflect on how things were generally going in his isolated world. Professionally, things were remarkably okay. The morning had been busy as per usual, but without incident. The SICU was quiet and Carol Jensen was even complimentary about Lynn Pierce, the new first-year resident. The on-call senior resident had no complaints about the new junior residents during the night. Work rounds had gone well, and even the first-year residents’ presentations were surprisingly coherent and to the point, offering yet another bit of evidence that the Residency Acceptance Committee had done a bang-up job. Even the first basic science lecture that morning at 7:30 was a thumbs-up, according to feedback he’d gotten. And finally, Chief of Service rounds had gone better than he could have imagined. Dr. Hernandez had even given him a pat on the back at the conclusion as a rare but welcome compliment.

Noah felt good enough to treat himself to a second cup of coffee. He couldn’t have imagined the morning going any better, or the first week, even though he’d not been back to his apartment for six days. The only minor bumps in the road were a few quirks in the complicated duty schedule, but he and Candy Wong had worked out the kinks to everyone’s satisfaction. Noah had even had a chance to talk individually to all twenty-four first-year residents, commit their names to memory, get a feel for their aspirations and interests, and assign them appropriate faculty mentors. So even that burden was out of the way.

After rinsing out his mug, Noah planned on taking full advantage of the current unexpected pause in his responsibilities by changing out of his scrubs and heading for the library to read the journal articles he’d selected for Tuesday’s Journal Club meeting. But his plans were quickly undermined when he found himself cornered by the sink. Unbeknown to him, Dawn Williams, the circulating nurse in the Vincent case, had come up behind him, patiently waiting for him to finish with his mug. At almost six feet tall and slightly overweight, she wasn’t one to be lost in the crowd, especially when she was standing so close that her nose was within a foot of Noah’s. He knew her to be a hardworking, opinionated, and candid OR nurse.

“Do you have a moment, Dr. Rothauser?” she asked. Her voice was hushed and clipped, which Noah immediately interpreted as not a good sign.

“I suppose,” Noah said, unsure if he wanted his unexpected tranquillity rattled. The woman was obviously upset. He glanced around. The surgical lounge was busy but not overflowing. At the moment, no one was paying them any heed.

“I wanted to give you my two cents about the Bruce Vincent case,” Dawn continued, keeping her voice low. Noah couldn’t help but notice she wasn’t blinking.

“Should we go somewhere less crowded?” Noah suggested. The mention of Vincent’s name was enough to fire up his own pulse. Here was yet another situation that made him wish he had a private office. It was clear that whatever Dawn had to say was meant for his ears only.

“This is fine,” Dawn said. “No one is listening.”

“Okay. I’m all ears.”

“I know you are going to be presenting the case at next week’s M&M, so I would like to make sure you are aware that Dr. Mason didn’t even appear for about an hour after anesthesia had been started. He wasn’t part of the pre-op huddle. That should not happen, plain and simple, and had he been there, the outcome probably could have been different.”

“I am aware there was some delay,” Noah said diplomatically.

“He had three patients under anesthesia all at the same time,” Dawn snapped, her voice rising. When she realized how loud she’d become, she covered her mouth with her hand and glanced around to make sure no one was listening. “Sorry.”

“It’s okay,” Noah said. “I haven’t finished my investigation of the case, but I will be talking with everyone involved, including you if you have more to add. Thank you for coming forward.”

“I know there is an ongoing departmental debate about concurrent surgery,” Dawn continued in her hushed voice. “But this situation with Mr. Vincent was beyond the pale. I just wanted to be sure you knew. I think it has to be brought up.”

“I appreciate your telling me your opinion,” Noah said. “I will be sure to bring up all the facts about the case, including the delay.”

“Thank you for hearing me out,” Dawn said. “Mr. Vincent was a wonderful man. His passing is a tragedy that shouldn’t have happened. At least that is my feeling. I miss him every morning I drive into the hospital garage. Well, thanks for your time. And good luck. A lot of people are upset about this.”

“For good reason,” Noah said. “It is a tragedy when anyone dies in surgery, especially a young, healthy person and a beloved part of the BMH community. Again, thank you for speaking with me.”

“You are welcome.”

With that said, Dawn nodded slightly before turning and walking toward the lounge’s exit.

Cursing under his breath, Noah watched Dawn disappear. His sudden aggravation was not directed toward her. His irritation was directed at himself for having continued to put off working up the Vincent case and then fibbing about it, telling Dawn he hadn’t finished when he had barely started. He should have begun in earnest right after his mini-confrontation with Dr. Mason in the Fagan Amphitheater. Instead he’d been like the proverbial ostrich sticking its head in the sand, vainly hoping the whole mini-nightmare would somehow miraculously disappear. Since that was not going to happen, he had to get a move on and do the necessary legwork because the M&M Conference was looming the following Wednesday, only four full days away.

Reluctantly giving up a trip to the library, Noah ditched the idea of putting on his street clothes. Instead, to save time, he merely grabbed his white coat and pulled it on over his scrubs before taking the stairs down to Stanhope 2 en route to his all-too-public desk. The idea of heading to the library to prepare for the Journal Club was out the window. The unexpected exchange with Dawn had been the wake-up call he needed. Free time for him was a rare commodity.

He’d briefly started preparing for the M&M after the disturbing exchange with Dr. Mason by writing down all the people associated with the Vincent case, whether he thought he needed to interview them or not. But doing this wasn’t a real beginning but rather a way of controlling his immediate anger and anxiety. Once he’d finished, he’d put the sheet of paper away in one of his desk drawers and forgotten about it, which was easy, thanks to the tidal wave of more immediate responsibilities that engulfed him as the new super chief resident.

Arriving at the surgical residency program office, he said a quick hello to everyone. Sitting down at his desk, he found the list, drawing a line through Dawn Williams and Helen Moran, as he probably didn’t need to speak with them again. The remaining names were Martha Stanley, Connie Marchand, Gloria Perkins, Janet Spaulding, Betsy Halloway, Dr. Ava London, Dr. David Wiley, Dr. Harry Chung, Dr. Sid Andrews, Dr. Carl White, and Dr. William Mason. He put question marks over Wiley, Chung, Andrews, and White, recognizing that they were only ancillary actors in the drama and talking with them probably wouldn’t add anything to the central issue of fatal gastric regurgitation.

The only other name on the list wasn’t a specific individual but rather an organization. He wanted to get in touch with the Office of the Chief Medical Examiner. As an operative death, the body had been sent to the medical examiner as a matter of law. What Noah was hoping to learn was why the hell the heart would not start after being on bypass, even with an internal pacemaker. Noah was hoping for an explanation. He was certain the issue would come up at the meeting if an angry Dr. Mason wanted to make Noah the scapegoat.

Next Noah fired up the monitor on his desk and swung out the keyboard. After entering his password, he typed in Bruce Vincent’s name to get the man’s EMR. There wasn’t much, only the entries associated with his recent surgery.

Noah brought up the admission H&P, or history and physical. He recognized the author as Dr. Mason’s fellow, someone Noah had met. Although Noah tried generally to avoid Dr. Mason, he couldn’t completely when it came to his desire to become adept at pancreatic surgery. On a number of occasions Noah had had to swallow his pride and scrub in with the renowned surgeon to take advantage of his talent and learn his technique. Working with Dr. Mason meant working with his fellow, Dr. Aibek Kolganov, from Kazakhstan. Noah had not been impressed for a number of reasons, and now that he was looking at Bruce Vincent’s H&P, he was even less impressed. To Noah it was clearly one of those copy-and-paste jobs that can be found easily on the Internet.

As Noah’s eyes ran down the overly extensive list of negatives, he suddenly came across two positives in the gastrointestinal review of systems. One was mild reflux disease, and the other was mild bloating and constipation. But what really caught his attention was that the two positives were in a different font than the rest of the H&P. And by investigating a bit further, Noah could tell that the two positives had been added after the surgery!

Noah stared off into the middle distance, trying to absorb what he had just found. Changing a medical record after an adverse event was a huge no-no from a legal point of view. A short, humorless laugh escaped Noah’s lips. He shook his head at the implications. “Not good,” he murmured.

“Something wrong?” Gail Yaeger, the secretary, asked to be friendly. She was a sensitive person. Her desk was facing Noah’s, with only a half-dozen or so feet separating them.

“Maybe,” Noah said vaguely. “Thanks for asking. We’ll have to see.” Actually, he knew he had a problem. Or, more accurately, he knew the hospital had a problem that might result in a multimillion-dollar lawsuit, and once again Noah would be the messenger if he brought it up. It was yet another potential bomb. Everything about the case seemed to spell trouble.

Returning his attention to the monitor, Noah searched in vain for the junior resident’s admitting note to see if reflux and bloating were mentioned. He was surprised there was no note. He groaned. Here was yet another problem. Why wasn’t there a resident admitting H&P?

Noah then scrolled to the anesthesia record, which was mostly a computer-derived readout directly from the anesthesia machine. He looked at the recordings of the vital signs and the electrocardiogram. Everything was entirely normal right up until the first ventricular fibrillation episode. On the ECG Noah could plainly see the time of the shock from the defibrillator and that the heart rhythm returned to normal before the second fibrillation event. Soon after that he could see when the heart stopped fibrillating, followed by no electrical activity whatsoever when the iced saline was poured over the quivering organ.

Scrolling down farther, Noah came next to several entries typed in by Dr. Ava London, the anesthesiologist, which had interesting syntax with multiple superlatives and no acronyms or contractions. The first entry was prior to the ultimately fatal regurgitation episode and included that the patient’s health was superb with no medical problems whatsoever, and that the patient had absolutely no allergies, took no single drug on a daily basis, had taken no food or drink by mouth since midnight, had never had anesthesia for any reason, and... Suddenly Noah’s eyes stopped. He’d come across a particularly cogent negative stating that the patient had no history of any digestive system problems like reflux or heartburn, meaning that Dr. London had specifically asked about these symptoms and the patient denied it, just as he had denied having eaten breakfast when he clearly had done so.

Noah knew this was a very significant point that probably exonerated Anesthesia, despite Dr. Mason’s claim to the contrary. If the patient had been truthful about either issue, he probably would still be alive. It also called attention to the after-the-fact entry in the admitting H&P apparently done by Dr. Mason’s fellow. Noah inwardly groaned. How was he going to present all this without totally alienating Dr. Mason? Unfortunately, he had no idea.

Returning to Dr. London’s initial entry, he read that Bruce Vincent had complained of moderate anxiety, mostly associated with concern that he had been extremely late to Admitting and that Dr. Mason might be angry about possibly waiting. Now Noah had to laugh, knowing that Dr. Mason ended up keeping the anesthetized patient and the whole team waiting for more than an hour.

The rest of Dr. London’s initial entry was straightforward and clinical about giving the patient midazolam for his anxiety, giving the spinal without any problem using bupivacaine, and putting the patient asleep with propofol.

Dr. London’s second entry was a bit more terse and more clinical, mentioning massive regurgitation, extensive aspiration, and sudden cardiac arrest during the placement of the endotracheal tube when the patient was being switched from spinal anesthesia to general anesthesia. She then went on to describe the defibrillation, the blood thinning with heparin, the placement of the patient on cardiopulmonary bypass, and finally the bronchoscopy. She listed all the medications that were tried in vain to get the heart to commence beating. The final sentence gave the time the bypass machine was turned off and the patient declared dead.

Noah took a deep breath. Just reading about the episode brought it back in vivid detail, at least the part he experienced. It had been an extremely upsetting episode for everyone.

Next Noah turned to the nurses’ notes and read what had been entered in Admitting by Martha Stanley, whom Noah had known since he’d been a junior resident. Using the usual acronyms, Martha had tersely noted that the H&P, the ECG, and the basic blood work were all in order. She also wrote that the patient had no allergies, no medications, no anesthesia, and was NPO since midnight, and the hernia was on the right side. There was no mention of reflux disease.

There were notes from two other nurses involved in the admitting process: Helen Moran and Connie Marchand. Both indicated in the EMR that they had asked the same questions as Martha Stanley and had gotten the same responses, particularly about Mr. Vincent not having eaten anything. Also, neither of these nurses mentioned possible reflux disease. The only thing unique about Helen Moran’s note was that she was the one who had marked Bruce Vincent’s right hip with the permanent marker to make sure the surgery was done on the correct side.

Next Noah turned to the operative reports. There were four. The first was dictated by Dr. Sid Andrews and described the attempt to repair the inguinal hernia. That was straightforward until the part about the knuckle of intestine caught up in the hernia and the failed attempts to reduce it externally. The second operative report had been dictated by Dr. Adam Stevens and described putting the patient on bypass. It, too, was straightforward. The third note was dictated by Noah about opening the chest. He didn’t need to read that. The final entry was by the pulmonologist, Dr. White, who described the bronchoscopy procedure and the removal of the aspirated material from the patient’s lungs.

As a final investigation of Vincent’s EMR record, Noah glanced over the blood work, particularly the electrolytes. It was all normal, including the sample taken after the patient had been on the bypass machine. It was frustrating, as Noah still had no idea why the heart wouldn’t restart beating after the bronchoscopy. At the time, he had hoped it was a potassium problem, which would have made a certain amount of sense and which could have been addressed. The problem was that by not knowing, he had no idea if there was something they should have done differently.

Noah sat back in his chair. The question was how to proceed and who to talk to first. He couldn’t quite decide, but he knew who would be the last person: Dr. Mason. Noah was certain that any conversation with him was going to be confrontational from the start, so he needed to have all his ducks in a row. From what Dr. Mason had said in the amphitheater, it was painfully obvious he was not about to accept any blame and fully intended to see that it was directed elsewhere, mostly at Anesthesia, Admitting, and the patient. With that reality in mind, Noah decided it would be best to talk with Dr. Ava London next to last. He didn’t know her well, as he had always found her superficially friendly but distant. Knowing Dr. Mason’s intention of using her as a scapegoat was going to make talking to her almost as difficult as talking with Dr. Mason, especially after she had already expressed her opinion that Mason was largely responsible. The idea of being caught in the middle of crossfire between two BHM attendings spelled potential disaster as far as Noah was concerned.

Deciding to start from the beginning, meaning where Bruce Vincent began his fatal admission, Noah stood up with the intention of heading to Surgical Admitting on the fourth floor to see Martha Stanley. He thought it best to just show up rather than call. But his plans changed when his mobile phone buzzed in his pocket. It was Dr. Arnold Wells, a new senior resident covering the emergency room.

“Thank God you picked up!” Arnold blurted. “Noah, I’m over my head here with a flail chest and major head trauma from a head-on collision. It’s a disaster. I need help now!”

“On my way!” Noah shouted, shocking everyone in the surgical residency program office.

The fastest route down to the emergency room was the stairs, and Noah took them in twos and threes while struggling to keep his stethoscope, tablet, and collection of pens and other paraphernalia from flying out of his pockets. Although it wasn’t far distance-wise, by the time he ran into the ER he was out of breath from exertion. He didn’t have to ask where the injured patient was, as one of the admitting clerks frantically pointed to Trauma Room 4. Noah barged through a gaggle of EMTs coming out of the room.

The patient was a mess. His clothes had been cut down the front and pushed to the side. His unrestrained arms and legs were wildly flailing. A large-bore IV was running. The major visible trauma was to the head and face, with the right eye socket empty and bloody and a major gash down to the bone that started in the middle of his forehead and extended up into his hairline. Tiny bits of yellow material could be seen that might have been brain. Arnold was attempting to use a bag-valve mask to provide positive pressure respirations, but the center of the man’s chest was bruised and showing paradoxical movement.

“Good God,” Noah murmured. His mind was in overdrive, as this clearly was a hypercritical situation.

6

FRIDAY, JULY 7, 1:40 P.M.

For the second time that day, Noah pushed through the double doors to exit the BMH operating room suite. The first time had been mid-morning, after he’d made his covert check on all the first-year residents who were assisting in surgery. He remembered feeling good that all was going well. This time he felt even better, despite looking like hell and wearing bloodstained scrubs. On this occasion leaving the OR, he was reveling in the unique feeling that he thought surgery and maybe only surgery could provide. He had been sorely challenged with a difficult case of forty-three-year-old John Horton, who arrived at the emergency room at death’s door from a head-on collision on Interstate 93. As an obviously intelligent and educated man, as Noah later learned, who worked as an analyst at a major investment firm, John should have been wearing his seat belt in his classic car that wasn’t equipped with air bags. Unfortunately, he wasn’t. As a result, John’s unchecked body had rammed full force at sixty-plus miles per hour into the steering wheel, which fractured and disarticulated his sternum, before catapulting out through the windshield.

When Noah had first arrived in the trauma room, his trained mind had instantly analyzed the situation, and he acted by reflex with the same decisiveness that had propelled him to slice into Bruce Vincent’s chest. Instinctively knowing that oxygen would be the determining factor if this patient was going to live, Noah called for an emergency tracheostomy set and ordered the patient to be given IV fentanyl for pain. While Arnold continued to struggle with the bag-valve mask connected to 100 percent oxygen, Noah completed the emergency tracheostomy, then connected a positive pressure respirator. Immediately, blood oxygen levels went up to a reasonable level, giving Noah time to examine the patient with the help of several X-rays. It was immediately apparent the man had multiple rib fractures, a fractured sternum, a fractured skull, and extensive internal injuries.

After stabilizing the patient as much as possible with several units of blood, Noah had him brought up to surgery. With the help of the chief neurosurgical resident, who saw to the skull fracture, and an ophthalmologist, who located the missing eye in the man’s maxillary sinus, Noah went into the abdomen to remove a damaged spleen and repair the liver. By then the wealthy patient’s private doctor had been located; he, in turn, alerted a private thoracic surgeon as well as a neurosurgeon, both on the BMH staff, who came in and relieved Noah.

Whatever was going to happen to John Horton, Noah had the rewarding sense of knowing that he and Arnold had saved the day and kept the patient alive at the most critical hour. To have the knowledge and skill to accomplish such a feat was what had propelled Noah into medicine in general and then surgery in particular. He knew that such a feeling was mostly denied to those who went into internal medicine. They might on occasion cure someone of something with the right therapy, but it was never so immediate as it was with surgery, and therefore more difficult to take the credit. Whether John Horton was going to live or die Noah didn’t know, considering the extent of his head injury plus his cardiac and pulmonary contusions. But at least now the man had a fighting chance, thanks to Noah’s intervention. For Noah it was a heady, deeply satisfying feeling that justified all the sacrifices he’d had to make to be where he was.

Unfortunately, Noah’s euphoria lasted for only another ten minutes, or at least until he got into the locker room and saw the list of people he needed to talk with about Bruce Vincent protruding from the pocket of his white jacket. Putting on fresh scrubs, he emerged from the men’s locker room fully motivated to get back to the Vincent affair. Emergency surgery notwithstanding, he recognized further procrastination was no longer an option. Since he was already on the fourth floor, he headed over to Surgical Admitting.

“I always have time for you,” Martha said when Noah appeared at her office door and asked if he might have a word. She was a pleasant but nondescript-appearing woman of indeterminate age with frizzy hair and a florid complexion. Noah appreciated her bent to wear scrubs to advertise she was an integral part of the surgical team, which she was.

“What can I do for you?” she asked once Noah was seated.

Noah outlined what he knew about the Bruce Vincent case and mentioned that he had read her notes in the man’s EMR. He told her he had to present the case at next week’s M&M Conference and wondered if there was anything she thought he should know.

Martha toyed with a paperclip while she thought about Noah’s question. “I suppose you want to know why there is no resident H&P.”

“That would be helpful. I noticed it was missing. It is bound to come up.”

“We had a number of patients all come in just before Bruce Vincent showed up, so the resident was behind. Really behind. Since Mr. Vincent was forty minutes late, I had already gotten a call from the OR asking where the hell he was. The suggestion was that ‘Wild Bill’ was champing at the bit, and we all know what that can lead to. To speed things up, I moved Mr. Vincent along without seeing the resident, who never knew about the case. There was a recent H&P by Mason’s fellow, which is all that is needed by the book.”

“True, but it’s accepted practice to have the additional check by a junior resident. This is a good case for the rationale why.”

“I understand, but under the circumstances I thought it okay to move him on. The H&P was entirely negative.”

“I gather you specifically asked him if he had had anything to eat.”

“Absolutely. No question. I always do. He lied to me, that is clear. The question is why, because it had to be deliberate, meaning it wasn’t as if he just forgot not to eat. If I had to guess, I’d say it was because he thought he knew more than he did.”

“I don’t follow.”

“He was a bit anxious about being late when I reminded him Mason could be a bear about waiting and that Mason had two big pancreatic cases that morning besides his hernia repair. But about his surgery, Mr. Vincent was cool as a cucumber and mentioned he was scheduled for a spinal, which is why I believe he thought he could get away with eating whatever he wanted. I think this is an example that a little learning can be a dangerous thing. My sense is that Mr. Vincent thought he knew enough about anesthesia to game the system.”

“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.

“Until later,” Dr. London said. “I hope to see you tonight.” She handed over the sheet of paper before disappearing into the women’s locker room.

For the very first time since Noah had been fretting about the upcoming M&M Conference, he felt a glimmer of hope that he might possibly be able to survive his presentation with minimal fallout. At least now he had a BMH attending who was on his side, even possibly a collaborator of sorts, willing to counter Dr. Mason’s interpretation and his apparent desire to divert the conversation away from the real issues. Vaguely, he wondered why she believed Dr. Mason did not like her and whether he’d find out that evening, provided, of course, he could leave the hospital. At least her house was close to the BMH if he had to get back in a hurry.

After checking his watch to be sure he had enough time before afternoon work rounds, he headed back into the OR. His intention was to find the two anesthesia residents, Wiley and Chung. What he wanted to learn was the inside, “resident” scoop on the Vincent case, and whether the general feeling of the anesthesia residents corroborated Dr. London’s beliefs about her performance. There was always a resident grapevine that was invariably more truthful than the involved attending’s interpretation.

8

FRIDAY, JULY 7, 8:15 P.M.

It was still light outside when Noah exited his apartment building on his way to Louisburg Square, one of the tonier sections of Beacon Hill and sharply different from his much more modest Revere Street environs. When he’d finally gotten out of the hospital, he had decided to dash back to his apartment to get out of his hospital whites and take a quick shower. After all, it had been fifteen hours he’d been on the go.

Noah had put on a pair of jeans and a polo shirt that were reasonably clean. He chose them because he thought they were flattering. He’d considered wearing his only jacket and a tie but had dismissed the idea as too old-fashioned and proper. As he was dressing he admitted to himself that he was energized but nervous about the upcoming visit with Dr. Ava London above and beyond the need to prepare for the damn M&M. She had unnerved him at their little tête-à-tête in the surgical lounge, and now that he was actually en route he felt the same way. Instead of trying to understand his reaction, he concentrated on the destination. Over the five years he had been in Boston, he had walked through Louisburg Square innumerable times and had wondered what the houses were like on the inside. Now he was going to find out. He was also curious about Dr. London and how she would act in her home environment.

Noah had hoped to be out of the hospital much earlier, and he had become progressively worried Dr. London might have evening plans and change her mind about seeing him. The problem had been a surgical consult that had gone bad, requiring Noah to smooth the feathers of one of the internal medicine chief residents who had requested the consult. It ended up being more of a personality clash than anything else, but it took time for Noah to resolve the issue without causing anyone to lose face. For Noah, it was yet another learning experience to emphasize that diplomacy was one of the major jobs of a super chief resident, a skill that he knew was going to be sorely tested at the M&M.

As Noah walked up Pinckney Street, he thought about what the two anesthesia residents had told him that afternoon when he’d cornered them in the anesthesia office. They said that the case had been a widespread topic of conversation right after the incident, and everyone without exception backed Dr. London’s interpretation. For the most part, they blamed the debacle on Dr. Mason’s cavalier attitude and willingness to have three patients under anesthesia at the same time while he flitted back and forth from room to room. As Noah trudged up the hill, he briefly wondered if he should mention what he’d learned to Dr. London, as it was certainly supportive, but almost immediately he decided against the idea. Since he was just getting to know her, he reasoned it would not be diplomatic to admit he was spying on her behind her back.

Reaching the square that was actually a rectangle, Noah stopped long enough to appreciate its suddenness as an unexpected oasis in the middle of a warren of brick tenements, brick sidewalks, and black macadam pavement that made up the rest of Beacon Hill. With its soaring elms, it was a true hideaway of lush greenery surrounded by an imposing wrought-iron fence. There were a few children playing on the enclosed lawn, and their shouts reverberated off the brick façades of the surrounding town houses.

Number 16 was on the downhill side of the square, whose long axis was oriented perpendicular to the rise of the hill. After climbing a half-dozen granite steps, Noah faced an imposing mahogany door. Searching for a doorbell and not finding one, he entered the foyer. There he found a bell. He pushed it. When nothing seemed to happen, he was tempted to try it again while suppressing a sudden worry that he was going to be stood up. After all, he’d not provided his mobile number. He’d thought about texting Dr. London earlier to say he would be late but had decided against it, at least partially for superstitious reasons.

Suddenly the door was pulled open fast enough to create a mild breeze that ruffled his hair. Standing in front of him at the base of an elegant carpeted staircase was Dr. London, who appeared far different than he was accustomed to seeing her. Instead of baggy scrubs, bouffant cap, and face mask, she had on form-fitting black yoga pants and an athletic tank top. For fear of making a fool of himself, he glued his attention to the woman’s blue eyes to avoid staring elsewhere.

“Welcome, Doctor,” Dr. London said with a gracious sweep of her hand, gesturing through an archway immediately to her right. “Please come in!” In sharp contrast to her professional froideur in the hospital, she seemed remarkably hospitable. There was not a speck of staff-versus-resident condescension.

“Thank you, Dr. London,” Noah managed, glad to be able to redirect his eyes into the room. He found himself in a large, high-ceilinged living room that extended from ten-foot-tall double-hung windows in the home’s bow front all the way to the rear of the house, where there were French doors. The decor was restrained Georgian with period moldings. To Noah’s eyes everything seemed new, as if it had just been constructed. On the south wall were a pair of period black-marble fireplaces. Partially dividing the room into two spaces were several fluted Corinthian columns. In the section of the room facing the square were two large, dark green sofas facing each other. Between them was a marble coffee table with several stacks of large, colorful books. On the walls were a collection of gilt-framed oil paintings. In the back section of the room beyond the columns stood a grand piano. The air was cooled and dehumidified.

“First and foremost,” Dr. London said as she followed Noah, “let’s dispense with the formalities. Please call me Ava, and I presume I can call you Noah.”

“By all means,” Noah said. He allowed his eyes to look back at his hostess, but he immediately redirected them to the surroundings. It was going to take a few minutes for him to adjust to her outfit, which he jokingly thought could have come from a spray can. He had sensed she had an athletic figure. Now he was sure of it. The definition of the muscles of her legs was all too apparent. Same with her arms but slightly less so. Sudden movement on the staircase captured his attention. Two sizable cats streaked down the stairs to race into the room. Both stopped and cautiously sniffed Noah’s leg.

“I hope you aren’t allergic to cats,” Ava said.

“No, not at all,” Noah said. He bent down and let each cat smell his outstretched hand. One was grayish-blue with striking yellow eyes, the other gray-and-white striped with blue eyes. “Beautiful cats.”

“Thank you,” Ava said. “They are my buddies. Yellow eyes is Oxi, short for oxygen, and blue eyes is Carbi, short for carbon dioxide.”

“Very clever,” Noah said. “Have you had them for a long time?”

“Relatively,” Ava said. “I got them from the animal shelter.”

“Well, they certainly lucked out,” Noah said.

“I think I got the better end of the bargain,” Ava said. “Can I get you anything to drink? There is a bar off to the right as part of the library.”

“You have a library?” Noah questioned. He didn’t know if she was joking or not. Having a library was not part of his vocabulary.

“Of course. This is a rather big house, even though from the front it appears modest. The building’s footprint has what is called an L off the back.”

“Modest is not the adjective I would choose.”

Ava laughed in a sincere, crystalline manner. “Everything is relative.”

“Do you live in the whole house?”

“As opposed to what?”

“Are there apartments?”

“I see what you mean,” Ava said with another laugh. “No, there are no rental units. It is a single-family house. I just happen to be a family of one with two cats.”

“How many floors?”

“Six.”

“Not bad!” Noah said. “It’s very impressive. I like the period decor.” The house was far bigger than he would have guessed from seeing its façade, which made it look as if it were three stories, not six. He wondered what it would be like to occupy such a place, thinking his entire apartment probably would fit in the room he was standing in.

“Are you interested in architecture and design?”

“I suppose,” Noah said, even though he had never given the idea much thought, as evidenced by his apartment.

“Would you like to see the house?” Ava asked. “I would be happy to give you a quick tour. Creating it has been a labor of love for me. Since I spend a lot of time in the house when I am in Boston, I wanted it to reflect me and my lifestyle as kind of a homebody. The renovation has only been finished for less than a year.”

“I’d love to see the house,” Noah said.

They started on the first, or basement, floor, which was level with the garden in the back. Noah was shown a full guest studio with its own kitchen. Next was a full workout room with several stationary bikes, a treadmill, a half-dozen weight machines, and a rack of free weights. “Here’s where I spend six-thirty to seven-thirty every evening I’m in town,” Ava said. “Just like I did today. That’s why I’m still in my workout clothes. I was afraid to get into the shower, for fear you would arrive the moment I did.”

“Do you travel out of town frequently?” Noah asked.

“I do,” Ava said. “As often as I can. In fact, almost every weekend. I take full advantage of my freedom. It’s one of the benefits of anesthesia as a medical specialty. When I’m off, I am really off.”

“Good point,” Noah said. “What do you do about your cats?”

“My housekeeper, Maria, comes every day when I’m out of town. She loves Oxi and Carbi.”

“Where do you usually go?”

“It depends if it is business or pleasure,” Ava said.

“What do you mean ‘business’?” Noah asked. The question popped out before he even thought of whether it was appropriate. “Are you on an anesthesia staff at another hospital as well?”

“Not at all,” Ava said without offense. “I couldn’t do that. Dr. Kumar wouldn’t tolerate it. I do consulting.”

“Interesting,” Noah responded. He wanted to ask more but felt it too probing, and Ava was already climbing the stairs to the next level.

The second floor, which was half underground on the Louisburg Square or front side of the building, housed a large, modern kitchen with all the usual appliances, a dining room, and a full maid’s apartment.

“I don’t have a maid,” Ava said in response to Noah’s shocked expression. “When I did the design for the renovation I was thinking of resale as well as my own needs.”

“Interesting,” Noah repeated. He was more than impressed. Knowing a little about real estate values, he doubted Ava could afford such a manse even on anesthesiologist’s salary. Her consulting business had to be extremely profitable. It was either that or she had inherited a fortune.

The third floor was where Noah had entered when he’d come in through the front door, so they continued up the main stairs to the fourth. It was here that Noah was most impressed. The main portion of the house without the back L comprised two rooms. The front and slightly larger room was an inviting, dark green study with several desks, a floor-to-ceiling bookcase, a sitting area with comfortable overstuffed club chairs with ottomans, an expansive coffee table with a number of colorful coffee table books, a collection of framed photographs of Ava in various athletic venues, and lots of light streaming through large windows. Noah could imagine spending a lot of time in such a space.

“Do you mind if I check out your photos?” Noah said.

“Not at all,” Ava said. She laughed with pleasure at Noah’s interest.

Noah’s eyes ran over the entire lot, one more interesting than the last. He could tell most were selfies taken with a selfie stick. There were a few group shots, but the others were solo, with Ava smiling into the camera as if she were as happy as a lark. She seemed to have the same expression in all of them and her hair was always perfect. There was something oddly impersonal about them. “I guess you’re quite a sports enthusiast,” Noah commented.

“I like sports and travel,” Ava said. “Now let me show you another room.” She gestured back out into the hallway.

In contrast, the rear room was dark and uninviting until Ava turned on the light. Then Noah’s face lit up like a child’s at Christmas seeing the decorated tree for the first time. The entire room was devoted to a computer setup the likes of which Noah had never seen except in his dreams. “I’m so jealous,” he said as he stepped over the threshold. There were three monitors sitting on a broad desk against the far wall and angled so all three could be seen by someone at the desk with just a minor turn of the head. A bank of electronics, including a server, were on open shelving to Noah’s left. Large speakers stood on either side of the desk. Several of the latest virtual-reality headsets sat on top of it. The windows at the rear of the house were shuttered to keep out the light. The ceiling was covered with acoustical tile.

“This is my favorite room in the house,” Ava said with pride as she noted Noah’s reaction. “I spend every evening in here when I am in Boston, sometimes as much as four hours. I lose track of time.”

“I can see why it’s your favorite room,” Noah said. “I think it would be mine, too, if I had the time. Are you a gamer?”

“Not as much as I used to be as a teenager,” Ava said. “But I still play once in a blue moon, mostly League of Legends, despite the misogyny involved. From your reaction, I guess you’re a gamer, too.”

“I used to be,” Noah said. “I played League of Legends when it first came out while I was in medical school, but not since becoming a resident. No time.”

“I didn’t play when I was a resident, either,” Ava said.

“This setup certainly suggests you play more than occasionally,” Noah said. “What level did you get to?”

“Silver Two, but I haven’t kept it up. Instead, I’m into virtual reality. I also use the system every day for MOCA. Are you familiar with MOCA, Maintenance of Certification for Anesthesia?”

“Of course,” Noah said. He knew that the various specialty boards in medicine, such as the American Board of Anesthesia, require its diplomats to recertify every ten years. One way to do it was online, but Noah was aware most people put it off until the last few months and then binged. The fact that Ava was doing it every day was a sign of true commitment. “And you really do it every day?” Noah asked, just to be sure.

“Every day without fail,” Ava said. “Even when I’m traveling. I have to be up on all the latest trends. Plain and simple, I make a real effort to be the very best anesthesiologist possible.”

“I hear you,” Noah said. “I feel the same about surgery. Seems that we are equally committed to our specialties, like two peas in a pod.”

Ava laughed in her unique fashion. “Two peas in a pod! I love that metaphor. We share a definite similarity, knowing your reputation. But to be completely honest, the MOCA only takes me about a half-hour a day. What I mostly use this setup for nowadays is social media, which I do most every day. I know it’s a bit of overkill for just social media, but what can I say.”

“What do you mean by ‘social media’? Like Facebook?”

“The entire gamut: Facebook, my YouTube channel, Snapchat, Twitter, Instagram, Tumblr, Pinterest... you name it. But mostly Facebook, which certainly dates me. To tell you the truth, social media has become my game of choice. When I was a teenager in the late nineties I got addicted to SixDegrees and AOL Instant Messenger for social reasons to manage my reputation, or so I thought, which in retrospect was a disaster, as it truly took over my life in a bad way. Now I’m addicted to it as entertainment and to stay connected. I’m fascinated by it like a lot of people. It is certainly driving our culture.”

“You mean you go on it every day?”

“Usually,” Ava said. “And even at the hospital, I occasionally sneak a peek on my mobile in between cases to respond to snaps and tweets. When I’m here in the house, I’m either working out, doing MOCA, eating, or doing social media. What can I say? I’m addicted, I admit, but I tell you, I have learned more about myself doing social media than I would have if I’d spent years doing psychoanalysis.”

“Really?” Noah questioned with skepticism. “I think you’d have to explain that to me. I mean, I use Facebook and Snapchat a bit, but I don’t think I have learned anything about myself from doing it.”

“I’d be happy to explain,” Ava said. “But that will take some time. I think we should stick to the M&M problem for now.”

“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.

“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.”

“So when are you going to talk with Dr. Mason?”

Noah shrugged. “I guess as soon as I can. He has patients in the hospital right now, and when he does, he usually comes in on Saturday. I’ll try to work up my courage and talk to him tomorrow.”

“Tread lightly, my friend,” Ava said with obvious empathy.

A wry smile appeared on Noah’s face. “Tread lightly! Those were the same words Dr. Mason used when he warned me about my presentation.”

“Sorry,” Ava said. “Let me change that to: ‘Prepare well’! To help you, we should get together again after you speak with Dr. Mason. I am here this weekend, so let me know if you get to speak with him. Meanwhile, I will give the whole mess more thought. I’m certain you will, too. The more prepared you are, the better. Agreed?”

“Absolutely,” Noah said.

“This case is disturbing for both of us,” Ava said. “Nonetheless, it’s been great talking with you. Thank you for being willing to come over here to my home. I’m really glad you approached me. I had thought about approaching you but felt reluctant. I’m not sure why.” She shrugged. “Let’s stay in touch. I’ve given you my mobile number. How about texting me so I have yours? Do you use Facebook or Snapchat?”

“I use Facebook a bit more than Snapchat,” Noah said. “Mostly FaceTime, to be honest.”

“We can use Facebook. The name I use is Gail Shafter.” Ava gestured for Noah to precede her out of the room. They started down the main stairs.

“You don’t use your real name?”

“I don’t,” Ava admitted. “On LinkedIn I do, but on the other social-media sites I don’t. I’ll explain it more to you sometime if you are interested.”

“I’m interested,” Noah said.

“I don’t think we should be seen talking together in the hospital come Monday, when I will be back for my next shift. It would surely start the gossip mill we both can’t stand. We also don’t want Dr. Mason to get wind that we have been talking. Agreed?”

“Absolutely,” Noah said. “One last thing: Assuming I am successful in corralling Dr. Mason tomorrow, what time would you like to get together?”

“How about tomorrow night at the same time, at eight,” Ava said. “We could even get take-out again if you are up for it.”

“That would be terrific,” Noah said. “Apart from an unexpected disaster at the hospital, I will be here.”

They had reached the front door, and being the social nerd he knew he was, he felt suddenly flustered and self-conscious about how to end this pleasant evening. He hadn’t expected to like her as much as he did. Should he shake hands, give her a hug, or what? Luckily, Ava came to his rescue. She leaned forward and pressed her cheeks one after the other against his and made a hushed kissing sound, making him realize how much more cosmopolitan she was than he.

“Thank you again for coming over,” Ava said, straightening back. “You have made my evening.”

Noah could feel himself blush. “And you mine,” he managed. “It’s been a delight.” Then, gathering up his courage, he said, “One last question: You have a charming accent, but I just can’t place it. Where are you from?”

“You’re too kind,” Ava said with a laugh. “Lubbock, Texas. And you?”

“Scarsdale, New York,” Noah said. “Westchester County.”

Fearing he was acting like a smitten teenager, Noah mumbled a good night. Halfway down the front steps he turned and waved. Ava waved back and closed the door.

“What a jerk,” Noah mumbled, castigating himself for his social awkwardness. Yet he felt great. As he walked back toward his apartment in the soft summer night, he felt an excitement he’d not felt since high school with his very first love, Liz Nelson. Right under his nose had been a person with whom he now felt a strong connection of mutual interests, particularly a 100 percent commitment to medicine, not just as a career but as a way of life. He had been impressed when he overheard her give her mobile number to the nurse in the PACU and when he learned she religiously worked on her anesthesia recertification every day. He was also impressed that she had rescued cats from the animal shelter. And on top of all that, Noah had to admit that she was a pleasure to look at, even seductive. Noah had no idea if their friendship would continue and maybe even grow after the M&M, but if it did, he was confident he would never have to explain to Ava why he had to spend as much time at the hospital as he did. In that important way, Ava would be the opposite of Leslie Brooks, who had never understood.

Arriving at his building on Revere Street, Noah hesitated before keying the front door. For a moment he considered dashing over to the hospital just to check on things. But then he admitted he was being far too compulsive. If there was a problem that the chief resident, Tom Bachman, couldn’t handle, he would have called. Noah sensed that his showing up unannounced and unrequested might be interpreted by Tom as a lack of confidence, something Noah did not want to communicate. Once again, Noah was realizing just how much diplomacy and psychology were involved in being the super chief.

After entering his apartment and closing the door, Noah stood for a moment, surveying the room. In comparison with Ava’s place, it was a joke. The postage-stamp size, the lack of furnishings and decoration, and, most important of all, the lack of any personal touch were striking. He couldn’t help but remember all the framed pictures of Ava in her study, which he could still see in his mind’s eye, such as those in sporty venues such as ski areas and scuba-diving locales. There was even one of her about to skydive and another of her about to bungee-jump, activities that Noah thought were certifiably crazy. At the same time, he gave her credit for being adventuresome, since he certainly wouldn’t do either one. Most of the other photos were just smiling selfies Ava had taken at various tourist attractions such as the Coliseum in Rome and the Taj Mahal in Agra. Vaguely he wondered if she went on these trips solo, and if she didn’t, why a companion wasn’t in any of them.

Thinking about Ava’s mansion and the money it represented, Noah again wondered exactly what her business connections were that could support such a lifestyle, since he was certain, the more he thought about it, that her anesthesia salary would not be enough. Her explanation that her business involved “consulting” was unclear. He wondered if her outside work involved anesthesia in some way. If their friendship did blossom, he’d ask her. One of the qualities that he particularly liked about her was her apparent self-confidence and openness in who she was, something Noah felt he lacked except for his role of being a doctor.

Trying to tamp down his excitement of a potential new relationship with an attractive, sexy, and impressively intelligent woman with mutual interests and a similar value system, Noah sat down at his card table and booted up his HP laptop. Hungry for more information, he was eager to check out Ava’s Facebook page under the name of Gail Shafter. As the comparatively ancient machine labored through its routine, Noah had to smile at the difference between his computer and Ava’s setup. It was as stark as their living styles.

When Gail Shafter’s page came up, Noah was fascinated. There were lots of photos going back to Ava’s childhood. There were even some of the same selfies that Ava had on the wall of her study, as if Gail Shafter was a globetrotter as well. Looking at the “friends” category, he was duly impressed that she had 641, which made him laugh when he thought about his own page. He couldn’t remember exactly, but he thought he had about ten. Then Noah looked at the “about” information and saw that Gail Shafter had gone to high school in Lubbock, Texas, and now worked for a dentist in Iowa. What Noah found most interesting was trying to decide what was real and what wasn’t.

Something else caught his attention. There was a fan page listed over to the left on Gail Shafter’s homepage. When he clicked on it he found Gail Shafter’s Nutrition, Exercise, and Beauty page, where he found multiple videos of Ava significantly disguised, providing tips on all sorts of subjects involving makeup, exercise, and general health. But what surprised him the most was when he clicked on “likes,” he found that she had 122,363 followers! No wonder she spent so much time on social media. It was a command performance.

Next he pulled up her LinkedIn page. This was decidedly professional. He was interested to read that she had attended Brazos University in Lubbock, Texas, in a combined B.A./M.D. program with an undergraduate major in nutrition. She then went on to an anesthesia residency at the Brazos University Medical Center. Noah thought that nutrition was an interesting major for a premedical student, as nutrition was one of those subjects that medical school did a poor job teaching. He thought it was a smart choice and wondered if nutrition had anything to do with her consulting business.

Glancing over the rest of the material, Noah suddenly burst out laughing. In the skills and endorsement section, he noticed that Gail Shafter was one of the people who gave Ava a positive endorsement as to her anesthesia skills. “Why not?” Noah remarked out loud. He knew what he had found was an example of sockpuppetry, which some people looked down on, but in this instance he thought it was humorous.

After turning off his computer, Noah got to his feet and stretched. He then headed into the bedroom, knowing that 4:45 A.M. would come all too quickly.

10

SATURDAY, JULY 8, 10:52 A.M.

So far the morning had gone brilliantly, but Noah knew it was about to head south. He was on his way across the pedestrian bridge that connected the Stanhope Pavilion with the Young Clinic Building, where Dr. William Mason had an office. Noah was facing a semi-impromptu meeting with “Wild Bill” for 11:00 A.M. that had been arranged when Noah had run into the surgeon by happenstance on the general surgical floor less than an hour earlier. When Noah had asked if he could have a moment of his time, Mason had responded gruffly that he would be available around eleven in his clinic office for a short time. Noah didn’t know exactly what to expect, but the chances the interaction would turn out pleasant were essentially nil.

Noah had arrived at the hospital as per usual around five and gone straight to the surgical intensive-care unit. He was particularly interested to see how John Horton was getting on, even though he was a private patient under the moment-to-moment care of the critical-care people. It was comforting to see that he was doing reasonably well. The same was true with all the other SICU patients. It had also been nice to hear that Carol Jensen, as a unit supervisor, continued to be complimentary about the new residents.

Leaving the SICU, Noah had met up with the residents who had been on call overnight. No problems there. The Saturday-morning work rounds had gone smoothly, although with the new residents it had taken much longer than usual. When Noah had run into Dr. Mason around 10:00, work rounds were just ending, even though they had started at 7:30. As expected, the newbies had yet to master the technique of quick but thorough bedside presentations. That being said, all in all, Noah felt very good about how the first full week of his super chief residency had gone. He wasn’t surprised. He’d always been a fast learner. It was the coming second week that had him worried.

Saturday clinic was a mere shadow of its normal weekday self, and the Young Building was comparatively empty. Noah was the only one in the elevator as he rode up to the fifth floor, home of the General Surgery Clinic. Although he was certainly not looking forward to the next fifteen minutes or so, what bolstered his courage was a sense of secret camaraderie that Ava was now providing. It was reassuring to not be alone in regard to the looming M&M.

Noah walked directly back to where he knew Dr. Mason had a small office that also functioned as an exam room. The man’s real office was in the much plusher Franklin Building, which catered to the likes of Arab sheiks, billionaires, and heads of state and had been named after one of Mason’s former patients, who’d financed it.

Noah knocked on the open door and stepped over the threshold. Dr. Mason was dressed in a light blue seersucker jacket, a white shirt, a bow tie, and dark slacks. He was sitting at the small wall-mounted desk, typing on a keyboard. To his right was an exam table. Hearing Noah’s knock on the open door, he swung around and pointed to one of two generic molded plastic chairs. He didn’t say anything but rather tipped back and interlaced his fingers across his expansive chest. His expression was a half-scowl with pursed lips. Noah was not encouraged.

Taking one of the indicated seats, Noah faced his bête noire as he struggled to decide where to begin. The trouble was he was there because of protocol. He was expected to interview the involved surgeon as part of investigating the case. In reality, he didn’t expect to learn anything that he didn’t already know. “Thank you for seeing me,” Noah said, hoping at least to start out the discussion in a friendly, mutually respectful fashion. In the back of his mind he was hearing Ava’s characterization of the man. To Noah, her description of him as a serious narcissist seemed spot-on, meaning that under the circumstances there was zero chance for any reasonable interaction. Not only was the man presumably still furious at Noah’s outing of his reputed lover, he was clearly challenged by Noah’s work ethic and jealous of the kudos Noah was getting in the process.

When Dr. Mason did not respond or even change his facial expression at Noah’s pleasantry, Noah took a deep breath and pressed on: “I’ve gone over the Bruce Vincent record and have spoken with most of the people involved except you. What I’d like to ask is whether there is anything that you might be able to tell me that I might not know.”

“I suppose you saw there was no resident admitting note?” Dr. Mason snapped.

“I did,” Noah said. “And I know why. I spoke at length with Martha Stanley, who said—”

“Yeah, I know,” Mason interrupted. “The poor overworked bastard was backed up. Bullshit on that excuse.” Dr. Mason was now stabbing the air with a thick index finger. “He fucked up, plain and simple. I tell you, with the residents nowadays it’s amazing any of us senior men get anything done. When I was a resident that wouldn’t have happened, and we saw way more patients than you guys do today and were on call every other night.”

Noah was well aware that a number of the senior surgeons bemoaned how easy they thought the residents of today had it, but he resisted questioning the idea. Attempting to calm Dr. Mason, who was already riled, Noah said, “My understanding is that the lack of a resident H&P was a decision made by Ms. Stanley. The junior resident was totally unaware and didn’t even know that Mr. Vincent passed through Admitting.”

“Well, then it’s Ms. Stanley who is to blame. If the junior resident had done what he is supposed to do, all this wouldn’t have happened.”

“The requirement is that there needs to be an up-to-date history and physical, which was the case. Your fellow Dr. Kolganov had done one the day before that Ms. Stanley thought was adequate.” Noah thought briefly about bringing up the deficiencies of Kolganov’s H&P as a copy-and-paste job with after-the-fact doctoring but quickly decided against it. Dr. Mason was supposed to have been supervising the man’s work and was therefore ultimately responsible. Once again the blame would fall on Dr. Mason’s shoulders.

“Then the system has to be changed,” Dr. Mason barked. “Residents should see all surgical patients prior to surgery, particularly same-day surgery.”

“That can be a good subject for the discussion of the case,” Noah said.

“You bet your ass,” Dr. Mason agreed.

“Let me ask you this,” Noah said. “Did you see and examine the patient before surgery?”

Dr. Mason rocked forward in his chair with such suddenness that the chair squeaked in protest. “What the hell are you implying with a question like that? Of course I saw the patient before surgery. I see every one of my patients before surgery.”

“I’m not implying anything,” Noah said defensively. “I didn’t know how much of the pre-op process you delegated to Dr. Kolganov.”

“Rest assured, my precocious friend, I examine all my patients thoroughly. Especially since Dr. Kolganov was not going to be part of the surgery. He was needed elsewhere for one of my much more serious cases.”

“Then you were aware that Mr. Vincent had had some symptoms of bowel obstruction,” Noah said, ignoring Dr. Mason’s condescending remark.

“Of course,” Dr. Mason said. “It was even mentioned in the referral note from his GP. It was why we were doing the goddamned operation.”

“And yet you still favored spinal anesthesia?”

“I didn’t favor any particular anesthesia,” Dr. Mason snapped. “That is what anesthesiologists are for. They don’t mess around in my area of expertise during the surgery, and I sure don’t mess in theirs.”

“But your office requested spinal,” Noah said. He knew this issue was going to come up no matter what, and he had to know the details.

“On the few hernias I have done over the years, spinal was used. I’m sure that was what my secretary was conveying. It is still up to the anesthesiologist to determine what is best.”

“You may be right,” Noah conceded but held back what he wanted to say — namely, that anesthesiologists needed all the facts, which plainly were not available in this circumstance for a multitude of reasons, least of which was that Dr. Mason was not available for the pre-op huddle.

“What else?” Dr. Mason demanded. He had returned to tipping back in his chair, fingers again interlocked. His earlier anger had dissipated and the pursed-lipped scowl had returned.

“It seems to me,” Noah said, trying to organize his thoughts and be as diplomatic as possible, “the patient didn’t take his upcoming surgery as seriously as he should have.”

Dr. Mason laughed derisively. “That’s the understatement of the year. I heard he was forty minutes late to Admitting. The guy was working that morning. I saw him myself. He even parked my car. But worse yet, he ate a goddamn full breakfast and then lied about it. I tell you, you try to do a guy a favor and he kicks you in the teeth.”

“Was he informed of the seriousness of what he was facing?”

Dr. Mason tipped forward again and eyed Noah. Instinctively, Noah leaned back as much as his chair would allow.

“I told him I was going to operate on him,” Dr. Mason said slowly, emphasizing each word. “What went on in his pea brain, I have no idea. But listen, my friend. We are wasting time here. Tell me! Did you talk to Dr. Ava London, the uppity bitch?”

“Yes, I have,” Noah admitted, trying to maintain a neutral expression. Knowing what he did, he was appalled at Dr. Mason for calling Ava an uppity bitch.

“Well, she is the one mostly responsible for this catastrophe,” Dr. Mason snapped. “And to tell you the truth, I don’t know if she should be on the staff here at BMH. I don’t know if she is qualified.”

“She is board-qualified in anesthesia,” Noah offered.

“Yeah, well, I don’t know how good anesthesia boards are to let someone like her pass. I’ve never been all that impressed with Dr. London, nor have some of the other staff. I’ve tried to be nice to her, but there is some disconnect in her personality. Frankly, she is a cold fish.”

I’m sure you have tried to be nice to her, Noah thought sarcastically but didn’t say.

“I want you to make it crystal clear at the M&M that general anesthesia should have been used on this patient at the get-go. If it had been, we could have gone into the abdomen when we needed to do so. Admittedly, the patient might have regurgitated anyway during induction since his stomach was so full, but who’s to know. At least it would have happened at the beginning of the case and not at the middle, and it would have been an anesthesia fatality, not a surgical one. It’s aggravating to have this screw up my statistics.”

“So you think Anesthesia is solely responsible?” Noah said, trying to keep disbelief out of his voice.

“The lion’s share,” Dr. Mason said. “Of course the patient didn’t help, and Admitting should have discovered the man had eaten a full breakfast. Making sure the patient has been NPO is a major responsibility for them, everybody knows that.”

“Thank you for your time,” Noah said. He got to his feet.

“Let me warn you once again, my friend. Do not turn this case into a discussion about concurrent surgery. That is not the issue here. The fact that I was held up for a few minutes in one of my major cases because of a congenital abnormality was not a factor in Bruce Vincent’s death. You get my point?”

“I believe I do,” Noah said.

“Good,” Dr. Mason said. “It is nice to have you as our super chief resident. It would be a tragedy if your year was prematurely terminated.”

A cruel smile appeared on Dr. Mason’s face. He didn’t stand up.

Noah nodded a final time, then turned and left. As he punched the elevator button out in the hall he became aware that his heart was racing. Although he knew he shouldn’t have been surprised, he had not expected Dr. Mason to be quite so specific with his threat. Noah’s worst-case scenario would be losing his position at BMH this close to the end of what had been a long odyssey and practically a lifelong dream.

Once again, he was the only person in the elevator. With trembling hands he took out his mobile phone and texted Ava: Met with the enemy. Bad as expected. Will fill u in 2nite. Almost immediately the three little blinking bubbles appeared on his screen. As the elevator door began to open, a message popped up: At least you got it over with. I can’t wait to hear what he said. The message was followed by a smiley-face emoji.

Feeling relatively chipper from Ava’s text, despite the meeting with Dr. Mason, Noah emerged from the elevator onto the second floor of the Young Building, which served as the triage center for the BMH clinical services. His intent was to use the pedestrian bridge to get back to the Stanhope Pavilion. His destination was the fourth floor, to see if he could locate the chief anesthesia resident. For several days he’d entertained the idea of possibly interviewing Dr. Kumar, but after Ava had told Noah that he and Dr. Mason were close friends, Noah decided against it. Although both Dr. Wiley and Dr. Chung had corroborated Ava’s interpretation of the Vincent case, Noah wanted confirmation from someone higher up just to be sure.

11

SATURDAY, JULY 8, 7:39 P.M.

Knowing he was early, Noah slowed down as he entered Louisburg Square. He noticed the ambient light was significantly greater than it had been the evening before with the sun higher in the sky. Sunset wasn’t going to occur for another half-hour. There were more children playing in the grass enclosure, and their shouts and laughter echoed in the confined area. Bright sunlight bathed the façades of the town houses on the upside of the hill, whereas those on the lower side, where number 16 was located, were in comparatively dark shadow.

A few doors away from his destination, Noah stopped and looked at his watch and wondered what to do. He was going to be twenty minutes early, and he didn’t want to seem too eager. Of course, he was too eager. He admitted it. As the day had passed, he’d gotten progressively more excited about returning to Ava’s that evening. And the excitement wasn’t just because of the M&M issue, although it contributed. He was looking forward to spending more time with Ava just to be with her, a feeling he couldn’t remember experiencing since he’d been a teenager. But as she’d already made clear her reluctance to form social relationships with fellow hospital personnel, he knew he had to proceed slowly, lest he scare her away. Arriving early could send the wrong message.

As he was standing there dithering, he saw Ava’s door open. With a sense of panic, he tried to decide what to do and whether he should turn around and flee. Before he could make a move, Ava stepped out onto her stoop, saw him, and waved.

Noah hesitantly waved back and restarted walking toward her. A moment later a second figure appeared from inside her house. It was a light-complected, clean-cut man, maybe forty, but what caught Noah’s attention was that he was even more athletic-appearing than Ava, which was saying something. He was wearing loose-fitting black workout pants with a white V-neck T-shirt that appeared to be a size too small. Even from where Noah was, he could see that the man’s biceps were straining the fabric. Noah felt instantly inadequate as he mentally compared his own body image to this physical Adonis. It was like day and night. When Noah got to the base of the stoop, the man came down the steps. There was a distinctive spring to his gait. With a slight, friendly smile he nodded to Noah as he passed. Noah nodded back and mounted the granite stairs.

“See you tomorrow, same time,” Ava called after the man.

The man didn’t answer or even turn around. He merely waved over his shoulder as he climbed into a black Suburban parked in front of Ava’s house.

“You’re early,” Ava said cheerfully as Noah gained the top step.

“Sorry,” Noah said. “Fearing I was going to be late, I rushed. I guess I didn’t need to, but it was a little after seven by the time I was able to leave the hospital.” He had indeed rushed to get home, practically jogging the entire way. He’s also taken a very quick shower, fearing for the worst about being late, but then here he was being early. He’d been keyed up all day and still was.

“You made good time,” Ava said. “Come in! Sorry about my being in my workout clothes yet again. We went over the allotted time we had set, and I didn’t expect you for at least another twenty minutes or so.”

“Who is ‘we’?” Noah asked as he entered the foyer. The inner door was also ajar.

“That was my personal trainer,” Ava said. She followed Noah inside.

“So you believe in personal trainers,” Noah said. He felt a sense of relief that the man with the buff body was a hired hand.

“I do. Don’t you?”

“Not really. Anybody can say they are a personal trainer. I think there are a lot of charlatans out there.” Noah silently chided himself for being jealous.

Ava laughed her sparkling laugh. “So you think you can tell?”

“I can’t,” Noah said. “That’s the problem. There is a legitimate certification, but not all of them have it. I think you have to be careful to get what you pay for.”

“My trainer is certified. I’m sure of it. He’s very good and very motivating.”

They ended up standing at the base of Ava’s main staircase. As he had done on his previous visit, Noah made a point of keeping his eyes on hers and not allowing his line of vision to stray elsewhere. He liked the yoga pants but didn’t want it to be obvious. The two cats reappeared, sniffed Noah disdainfully, then disappeared.

“So we’re back to where we were last night,” Ava said flirtatiously. “I need to take a shower and change. You can make yourself at home in whatever room you’d like, or we can do what we did last night.”

“Meaning?” Noah asked.

“We talked about doing take-out again tonight. I know you were the one to go and get it last night, so it is unfair to ask you to do it again, but...”

“I’d be happy to do it,” Noah offered eagerly.

“That would be terrific. Why don’t we try Toscano tonight?”

“I didn’t know they did take-out.” Noah was aware of the Italian eatery on Charles Street as a Beacon Hill favorite and had eaten there with Leslie on several occasions.

“They most certainly do,” Ava said. “I’ve used them many times. Give them a call! Order whatever you want and get the same for me. I’m not choosy. I have some great Italian white wine in the fridge. It will be a treat. How do you feel about your on-call team tonight? As good as last night?”

“They’re fine,” Noah said. He had checked, trying to plan ahead. The in-house chief resident on call was Cynthia Nugent, who Noah thought was just as competent as Tom Bachman, if not more so. Once again he felt confident he wouldn’t be called unless the sky fell in.

“Then you might be willing to have a glass or two of wine.”

“I will enjoy it,” Noah said. It was an amazing feeling to be with someone who truly understood his responsibilities without his having to explain them.

Slightly less than an hour later, Ava and Noah were back at the counter table in the kitchen. Night had fallen and a floodlight illuminated Ava’s tiny garden, which included a fountain. Since the sliding glass doors were open, the sound of the water could be heard over the classical music that was quietly playing in the background from hidden speakers. Noah had ordered quite a feast, and Ava had opened a chilled bottle of Falanghina Greco.

“Will it ruin your enjoyment of your dinner if we start talking about serious stuff?” Ava asked with a playful smile. She was dressed in a mostly white butterfly-print summer dress, which Noah thought was charming. In contrast, he was wearing almost the same thing he had the night before. He had agonized for a time after his shower about wearing something different, but his choices were limited. He had briefly thought about wearing his resident whites just because he felt the most comfortable in them and thought he looked his best, but had nixed the idea as totally ridiculous. He’d mocked himself for being so pitifully insecure.

“As you like,” Noah said. He, too, was interested in getting it out of the way.

“You said in your text that your meeting with Dr. Mason was as bad as expected. Care to elaborate?”

Putting down his wineglass, Noah took a deep breath. “Just as we feared, we’re definitely in his crosshairs. He threatened to have me fired if I turn the case into a discussion of the concurrent-surgery issue.”

“Good God,” Ava said with emotion. “He literally threatened to have you terminated?”

“Well, not in so many words. What he said was that it would be a tragedy if my super chief resident year was prematurely terminated, which I take as the same thing.”

“The bastard,” Ava snapped. “I’m sorry. What about me? Did he talk about me specifically or about Anesthesia in general?”

“I’m afraid it was about you specifically,” Noah said. “You were so right last night when you described him as having a narcissistic personality problem. The man is a classic case. As you suspect, it’s pretty obvious that he was and is insulted by your rebuffing him. The man is out of control.”

“So what did he say, exactly? You don’t have to mince words. I can take it. I just want to know what I am up against.”

“Again, he said you were mostly responsible for what happened,” Noah said, lowering his voice as if someone might overhear. “It is so obvious that he is incapable of accepting any blame whatsoever. And by his putting the blame on you, it has him questioning if you should be on the BMH staff.”

“Why? Because of my personality or my qualifications?”

“I’m afraid a little of both,” Noah said reluctantly. The last thing he wanted to do was hurt Ava’s feelings, yet he felt obligated to speak the truth. “Dr. Mason said you were a cold person, which made me bite my tongue, knowing what I know.”

“Thank you,” Ava said sincerely.

“You’re welcome,” Noah said. “With respect to your qualifications, I reminded him you had passed your anesthesia boards, at which point he questioned the anesthesia boards. I’m telling you, the man is out of control.”

For a few moments Ava stared out at the fountain in her garden. It was obvious to Noah that she was upset and turning the news over in her mind. Noah felt bad for her, but he felt worse for himself. He still didn’t think it likely that Dr. Mason could get her fired even if Dr. Mason was good friends with Ava’s boss. Whereas with himself, Noah was concerned Dr. Mason could possibly get him dismissed or, at a minimum, make his position tenuous if he put his mind to it. After all, he was an associate director of the surgical residency program and therefore was one of just three people in charge.

Ava redirected her attention back to Noah. “Let me guess,” she said. “Dr. Mason thinks I should have given general anesthesia even though it had been communicated that he wanted spinal.”

Noah nodded. “He claims not to have asked for spinal, and that his secretary merely included it because it had been used on the last hernia he’d done a hundred years ago. He said it is Anesthesia’s job to determine the appropriate anesthesia, and he didn’t care which was used.”

Ava took a deep breath. “You do have your work cut out for you.”

“Don’t I know,” Noah agreed. “I keep thinking it is going to be like walking in a minefield.”

“Did he bring up the patient and his role in this tragedy?”

“He certainly did. Actually, considering everyone involved in this case, Dr. Mason might be the angriest at the patient. He described him as having a ‘pea brain’ despite the man’s beloved employee reputation around the hospital. Deep down, Dr. Mason certainly knows it was the patient’s fault by eating a full breakfast and lying about it. But Dr. Mason also faults Admissions for not being more aggressive and finding it out.”

“All right,” Ava said, suddenly motivated. “Let’s talk specifics.” She sipped her wine and then took a bite of her dinner. “I’ve given this situation a lot of thought since yesterday evening,” she said. “First off, I think you have to understand it will be counterproductive to get into any kind of argument with this man, because if he gets mad, we can both lose. You are going to have to present the case with that restriction in mind.”

“Easier said than done,” Noah responded. “He got mad this morning, and I was trying to be as diplomatic as I could.”

“So what did he get mad at? Let’s analyze it.”

At that moment Ava’s mobile phone chimed, indicating she was getting a call. She picked up the phone, noticed who was calling. Immediately she pushed back from the counter. “Sorry,” she said to Noah. “I’ve got to take this.”

“Quite all right,” Noah said. He watched her leave the room, vaguely wondering who could be calling after nine on a Saturday night. For him it would have been easy to guess: the hospital. But he knew Ava was not on call. Noah toyed with his food, thinking it was impolite to eat without her. In the distance, he could just barely hear her voice, although at one point it became decidedly louder, as if she were angry.

After about five minutes Ava returned, placed her phone facedown on the counter, and climbed back onto her seat. “Sorry about that,” she said. “I know taking calls makes me a less-than-perfect hostess. But what can you do? Silly business sometimes interferes.”

“Is everything all right?” Noah questioned.

“It’s fine,” Ava said, with a wave of her hand. She smiled reassuringly. “Now, where were we?”

“You were asking what Dr. Mason got mad at when I spoke to him this morning.”

“Right. So tell me!”

“I’d have to say he got the maddest when he was talking about the lack of a resident history and physical because the resident was backed up. Dr. Mason is one of those old-school surgeons who is convinced we residents today have it easy while he and his contemporaries worked themselves to the bone.”

Ava nodded. “I know the type. But it is interesting that he would zero in on that issue. I think that is important to remember. What else did he get mad at, specifically?”

“When I questioned him if he had personally examined the patient.”

Ava laughed. “Knowing what we do about his temperament, are you surprised such a question made him angry?”

“I suppose not,” Noah admitted, smiling in the face of Ava’s laughter. In retrospect, he lambasted himself for not being more circumspect. He should have worded the question to Dr. Mason differently so it wouldn’t have been interpreted as being critical. When dealing with a narcissist it is crucial to avoid any suggestion of blaming. “I was trying to be diplomatic but failing.”

“I’d say!” Ava responded. “Tell me this: Did he bring up again any nonsense of you being responsible for the death since you put the patient on bypass?”

“No, he didn’t.”

“At least that’s reassuring,” Ava said. “I’m starting to get an idea of how you should present this case.”

“Really?” Noah questioned. He sat up straighter. She was impressing him again, and he was eager to hear what she had in mind.

“Keeping him from getting mad is going to be key,” Ava said. “That’s number one. Number two, you have to steer the discussion away from the concurrent-surgery issue. That’s mainly for your sake. And number three, you have to avoid the issue of Anesthesia, meaning me, supposedly making the wrong decision about spinal versus general anesthesia.”

“That’s easier said than done,” Noah complained. “The facts are facts. I can’t change them.”

“What you will have to do is keep away from the troublesome facts. For instance, there is no reason to mention that the patient had been under anesthesia for an hour or more. As bad as that was, it didn’t contribute to the death. Instead, emphasize the two points Dr. Mason is most emotional about — namely, the lack of a resident H&P and that the patient ate a breakfast that Admitting didn’t uncover. If you are clever and mildly verbose, those two issues could be an hour discussion in and of themselves. Tell me! How many cases are scheduled for the conference?”

“Five so far,” Noah said. “There could be more.”

“Perfect,” Ava said. “Listen! Save Vincent’s case until last. Since the M&M has to be adjourned in an hour and a half without fail since surgery is scheduled and everybody has to get to the OR, you can run out of time. What do you think?”

Noah toyed with his food while he pondered Ava’s suggestion. The more he thought about it, the better he liked it, because it could work. The scheduling of the presentations was totally up to him. He had initially thought of doing the Vincent case first since there was so much interest in it, but there was no reason he couldn’t do it last, and if no one knew it was going to be last, no one, like Dr. Hernandez, could complain and try to change it. There was a good chance that whatever the discussion was, it could be prematurely terminated.

“I think you have some good points,” Noah said.

“I do, too,” Ava agreed. She picked up her wineglass and motioned with it toward Noah. They clinked glasses. “We have a few more days to plan, but I think we’re making headway. To your success!”

After getting the serious stuff out of the way, Ava and Noah switched to more lighthearted banter as they finished their dinner and cleaned up the plates and flatware. Ava dominated the conversation, since she was full of stories about her recent travels and athletic episodes, such as her latest bungee-jumping excursion. Noah had been amazed to hear that she had flown all the way to New Zealand to do it, although she also used the trip to scuba-dive in shark cages off the southern coast of Australia. Noah was fascinated but also intimidated, as it made his life seem all that more insular and hospital-bound. The last trip he had taken had been more than two years ago, and only to New York City. He’d gone with Leslie to see a play, and only for a single Saturday night. At the time he had been reluctant to go, since he had several patients he’d operated on in the hospital. Although he had arranged for people to cover for him, it didn’t seem right, since he couldn’t help but put himself in his patients’ shoes.

“How about we head up to the study and relax?” Ava offered when the kitchen was back to spic-and-span. “We can have a cordial if you’d like.”

“Thank you, but I think I’ll pass on the cordial. Sorry. Two glasses of wine are enough for me.”

“Hey, don’t be sorry. I’m impressed with your self-restraint. Your dedication is awe-inspiring. I’d want you to be my doctor any day.”

“Thank you,” Noah said.

While trailing Ava as they headed up the second flight of stairs from the kitchen level, Noah worked up his courage to ask: “Hey, do you take your trips solo or with friends?” He made it sound as if the idea just occurred to him, whereas he’d been wondering about it since he’d heard about all her travels the previous evening. He didn’t know what answer he wanted to hear.

“It depends,” Ava said. “My fun trips like to New Zealand and the previous one to India I went alone. With my business travel, I’m usually accompanied.”

“Seems to me it would be more fun the other way around,” Noah said.

“You have a point,” Ava said. “Are you interested in going with me when I go back to New Zealand for a repeat bungee-jump?” She laughed in her unique and charming fashion.

“I wish,” Noah said. “If you don’t mind my asking, are your business trips because of your nutrition background?”

Ava stopped several steps short of the landing outside the study and turned around to face Noah, who was forced to stop as well. She was smiling, but her tone was accusatory. “Have you been spying on me?”

“In a fashion,” Noah confessed. “I looked at your LinkedIn page. I was impressed that you majored in nutrition. I think it is a neglected area of expertise when it comes to doctors.”

“I agree,” Ava said. Her voice had returned to normal. “That’s why I chose it as an undergraduate major. But to answer your question, my business trips do involve my background in nutrition, at least indirectly.”

Ava didn’t elaborate, but rather turned back around and continued up the stairs. Noah followed her into the study. He was dying to ask her more about her business, which he assumed had to be remarkably successful, but he felt reluctant. He didn’t want to push it. While she went over to get a bottle of Grand Marnier and a glass from a bookshelf, he took the same velvet club chair he’d occupied the night before. He watched her, fascinated by the way she moved, which was accentuated by her flared dress. He was hypnotized by her entire persona.

“Are you sure you don’t want just a nip?” Ava said, holding up the liquor bottle in Noah’s direction. She took the other club chair.

“Thank you, no,” Noah said. “I also visited your Gail Shafter Facebook page and the fan page. I was truly amazed at the number of your followers.”

“I have to admit I have a lot of fun with it. I’ve even gotten some offers to advertise products.”

“Have you done that?” Noah asked.

“No, I haven’t,” Ava said. “I do it for pleasure, not for business.”

“I got a chuckle when I saw that Gail Shafter endorsed you on your LinkedIn page.”

Ava treated Noah to another one of her laughs. “Guilty as charged,” she said. “I just couldn’t help myself.”

“Last night you offered to explain to me why you use a fake name on Facebook. If you’re willing, I’d like to hear.”

“Purely for a sense of freedom,” Ava said. “The beauty of the virtual online world is anonymity. Using a made-up name magnifies that and enhances my freedom. I’m sure you have heard the expression: On the Internet no one knows you are a dog.”

It was Noah’s turn to laugh. “No, I haven’t heard that. But I get it.”

“Using a made-up name allows me to avoid my own hang-ups,” Ava explained. “I don’t have to be me. I can project onto Gail Shafter whatever identities I want. And using my avatar, technoself, I can do it without fear of being judged. If someone doesn’t like my digital me and acts like a troll, I can block them. In real life I can’t do that. And social media can be wonderfully dynamic, whereas real-life social interaction tends to be static.”

“I’ve never heard the term technoself. Is that something new?”

“In the tech world, nothing is new. As soon as something is out, like a new app, the next day it is old. Things are changing at warp speed. So no, it is not new. In fact, technoself studies have become an entire interdisciplinary domain of scholarly research. It is where our culture is going. We are all becoming cyborgs with our devices, particularly with our phones.”

“You’re making me feel old.”

“In the teenage mind, you are old. They are the ones who are driving the pace.”

“You mentioned you were addicted to social media when you were a teenager, and it was a disaster. How so?”

“I became obsessed with my digital reputation to the detriment of everything else, including my schoolwork. At one point, I got cyberbullied on SixDegrees to the point I couldn’t go to school for a week. Well, it wasn’t called cyberbullying back then, just harassment. But it was a disaster. I did so poorly academically that I didn’t even think about going to college after high school. I had to work, so I worked for a dentist. Luckily, I quickly saw the light.”

“Is that why Gail Shafter works for a dentist?” Noah asked.

“You got it. It’s something I know about.”

“What about dating apps and websites? Do you use them?”

“Of course. Why not? They are particularly fun. Especially now with the swipe-right-or-swipe-left feature. Hot-or-not, what a great game! It empowers even the most pitiful creeps. Online, anyone who is digitally clever can be popular or even famous. Look at the Kardashians.”

“Have you ever met anyone in real life that you met on a dating app?”

“Hell, no! I’d never in a million years do that. Everybody lies on those sites. I like to play around with them, but I’d never actually look for anyone on Tinder or any of the others. We’re all becoming narcissistic charlatans to one degree or another. Meeting up with someone you met online would be too risky. Besides, it would defeat the whole anonymity thing.”

“Aren’t you worried somebody sufficiently enamored with Gail Shafter and armed with technical knowhow could get Gail’s address here on Louisburg Square?”

“There was a time when that might have happened because I had a proxy server that turned out to be almost worthless. But my computer people set me up with a proper encryption. There’s no worry now. And what about you?”

“What do you mean?”

“Have you ever used a dating app or website?”

Noah didn’t answer right away. Like most people, he had, but questioned if he should admit it to Ava. What convinced him to come clean was that she readily admitted she’d used them herself so there would be no judgment. “Actually, I did use OkCupid for a couple of weeks not long after it came out. So I used it once.”

“Uh-oh,” Ava voiced. She flashed a knowing smile. “This is sounding serious. Did you meet someone online and then meet up with them in person?”

“I did,” Noah admitted. “Her name was Leslie Brooks. She was a Columbia undergrad. We ended up living together for the last year of my medical school, and then she came up here to Boston to go to Harvard Business School.”

“Sweet,” Ava said with sincerity. “I guess there are some successes. Are you guys still together?”

“Nope,” Noah said. “She left two years ago for a finance job in New York.”

“Four years together; that’s impressive. Are you still seeing each other?”

“No,” Noah said simply. “She couldn’t really adjust to my commitment to medicine, which I don’t blame her for. In retrospect, she was counting on my hours getting less as I advanced up the training ladder, like it does for most people. Unfortunately, for me they got more, so she bailed out. She’s engaged now.”

“I think only those of us in medicine understand,” Ava said. “So who are you seeing now?”

“No one,” Noah said. Inwardly he cringed, wondering if Ava would think of him as socially hopeless.

“That doesn’t seem appropriate for a healthy man like yourself,” Ava said with a slight, mischievous smile. “As a fellow doctor, I’d like to ask how you manage.”

Noah stared back at Ava. He agonized for a beat, questioning if he should take the bait. “I’m resourceful,” he said after a pause. “There is always online porn.”

Ava roared with laughter and clapped her hands. “You are a trip, Dr. Rothauser. Now I have to wonder which of us is more addicted to the Internet.”

“There’s no way I am addicted,” Noah said. He found her mirth contagious and was laughing at himself even though he questioned why he had said what he did. He was thankful she had taken the comment in a nonjudgmental, humorous fashion.

After putting down her liquor glass, Ava leaned forward. “Last night I showed you most of my house. But there is one cool thing I did not show you. Interested?”

“Sure,” Noah said with a shrug. “Give me a clue.”

“I put a deck on the top of the building and the view is to die for. And it’s a beautiful summer night.”

He followed her up two flights of the central, nautilus-like stairway that spiraled from the very first floor. When they gained the sixth and final floor and pretending to be out of breath, Noah said, “With all these stairs you don’t need to work out.”

“Sometimes I take the elevator,” Ava said.

“Elevator? I didn’t know you had an elevator.” Noah had never been in a private home that had an elevator.

“The doors are disguised so as not to be intrusive,” Ava explained. She pointed to the wall to their immediate right. “Here’s one here.”

All Noah could see was a door-sized, rectangular, grooved outline that even cut through the dado and its trim. “Wow,” he said. “I never would have guessed. But there’s no call button.”

“It’s WiFi,” Ava said. “Welcome to the tech world.”

As Noah followed Ava into the room, he berated himself for acting like such a simpleton. Looking around, he guessed he was in the master bedroom. It was a large space occupying the entire width of the house. The west wall was a bank of French doors with the lights of the city visible through the multipanes just above the row of buildings that lined the next street down the hill.

“This is my bedroom,” Ava said proudly.

“Very nice,” Noah said. In actuality, he thought it was a lot more than nice. The room had a high cathedral ceiling, and the bed was at least a king and was set against the north wall; both cats were curled up against decorative pillows. Behind the bed was a trompe l’oeil mural of an open window looking out onto a European mountain scene. The south wall had a period marble fireplace similar to those in the living room. A second door on the east wall led into the marble master bath. The lighting was subdued, giving the room an overall restful ambience.

“And the view is terrific,” Noah added.

“You haven’t seen nothing yet,” Ava said playfully. She opened one of the French doors, stepped out onto a narrow balcony, and gestured for Noah to follow.

Moving from the air-conditioned, dehumidified interior, Noah could feel the summer warmth and moisture. He looked out at the view, noticing he could see into multiple apartments in the buildings on the other side of the alley. “Very nice,” he repeated.

“This way,” Ava said, as she tugged his arm to follow her. At the northern end of the narrow balcony was a black wrought-iron circular staircase that led up into the darkness.

As Noah climbed after Ava, he felt a touch of acrophobia. Just over the low handrail as he went up he could see down six floors into a neighboring garden. A moment later he was up on the very top of Ava’s house, standing on a raised deck with a more substantial handrail. The view was truly spectacular, with a good portion of the city of Boston spread out in front of him. From where he was standing he could see over the tops of the buildings in the foreground. In the middle distance was a wide stretch of the Charles River that made it appear more like a lake than a river. “You are right, this is to die for,” Noah said.

“You’re looking directly at MIT,” Ava said.

“Where?” Although he had spent two years at the famed school getting his Ph.D., it was hard to pick out the details from the panorama he was viewing.

“Straight ahead,” Ava said. She pointed with her left hand while she put her right hand on Noah’s shoulder to pull him closer. She also pushed against him so that he could sight directly along the length of her arm.

“Okay,” Noah managed. But he was no longer trying to distinguish which buildings of the thousands he could see belonged to MIT. Instead, he was acutely aware of Ava’s hand in the crook of his neck and shoulder with her forearm pressed against his back. He was even more aware of her body pressed up against his. She was busy describing various buildings so he could orient himself to the MIT campus, but he wasn’t listening to her voice. He was listening to his body, which was sending alarm bells to his brain. And the messages were not going to the higher-function areas involved with rational thought.

“Can you see the dome?” Ava asked, referring to the building at the very center of MIT.

As if he were being manipulated by some exterior force, Noah turned toward Ava and looked dreamily into her eyes. As there wasn’t that much difference in their heights, their faces were close. Ava responded by also turning her body toward him. “I’m getting the message that you are not all that interested in looking at MIT,” she said.

Noah didn’t answer. Instead he leaned forward in slow motion, turning his head to the side in the process. Ava’s head tipped back. A moment later their lips came together as they embraced.

It was a long, sustained kiss. At its conclusion Noah slowly leaned back, although their arms continued to envelop each other. His eyes were fixed on hers, although in the half-light he could only assume hers were on his. Noah sensed an overpowering urge to make love to her. It had been a long time since he had had such feelings, and the sheer intensity of the desire caught him by surprise. Previously he had worried that arriving early might have scared her off. Now he was worried that if she knew the fierceness of his passion, she would be literally frightened. It was so encompassing that it even scared him to a degree.

“I think we should go down to my bedroom,” Ava said. “Will you be okay navigating the stairs?”

“I think so,” Noah croaked. Reluctantly, he let go of her.

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, fruit 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 for 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.”

“I don’t know whether it was clever or stupid,” Dr. Hernandez remarked. “I’ll have to think about it more.” With that said, he left the amphitheater.

Taking a deep breath, Noah turned to see if he could catch Ava’s eye. As upset as he felt at the concurrent surgery surfacing, at least he thought she’d be pleased that he had managed to avoid the whole anesthesia choice issue and any blame that could be directed toward her. But she was already on the stairs, heading away from him, on her way to the main exit on the upper level. It was at that moment that Noah saw Dr. Mason climbing down into the pit. For a brief second Noah considered bolting out the exit that Dr. Hernandez had used. But it was too late. Dr. Mason would have caught him one way or the other, so he stayed where he was.

With a kind of rolling gait because of his girth, Mason bore down on Noah. His heavy face was set in his typical scowl. “You are your own worst enemy, Dr. Rothauser,” Mason snapped when he came up to Noah, crowding him and forcing Noah to take a step back. “I warned you not to skew the facts, which you most certainly did. You didn’t even mention that Anesthesia gave the wrong fucking anesthesia, a key point in the whole case. Who the hell are you protecting and why?”

“I’m not protecting anyone,” Noah said, knowing he was lying. “Least of all the patient, despite his popularity. He was the one mostly responsible for what happened, and I made that very clear. I also talked about the Admitting people and their role. Those are the two parties that you brought up to me when we spoke.”

Dr. Mason cocked his head to the side, looking at Noah askance and twisting his face into a wry smile. “You’re a goddamn liar. When we talked about this we were standing right here in this pit and then in my clinic office. I said specifically that Anesthesia screwed up plain and simple on both occasions. That’s what I said. Then I added something about the patient and Admitting, but it was Anesthesia’s fault, stupid, and this death should have been an anesthesia death, not a surgical one!”

“I did the best I could,” Noah said. He didn’t know what else to say. He had the sense that if he apologized, it wouldn’t help and would maybe even make things worse.

“Bullshit,” Dr. Mason snapped back. “Worst of all, you let the discussion disintegrate into the concurrent-surgery issue, something I specifically warned you not to do. If this thing blows up again around here, I’m going to hold you responsible, and you are out of here. You understand what I’m saying?”

“I think so,” Noah croaked.

“You know what really irks me about you is that you are one of those holier-than-thou, prissy snobs who thinks he is better than everybody else, like Meg Green, for instance, one of the best goddamned residents we had around here. You got her busted because she was taking Oxycontin for her shoulder.”

“She was abusing it,” Noah said.

“So you said,” Dr. Mason said, lowering his voice. “You are on thin ice, my friend. Just keep that in mind.”

13

WEDNESDAY, JULY 12, 2:10 P.M.

After using a disposable nail cleaner and tossing it into the toe-operated waste can, Noah began to scrub his hands for his final scheduled case of the day. He was with his assistant at the scrub sink between operating rooms 18 and 20 with a hood and surgical mask in place. He had been in 18 since coming up to the OR after the M&M Conference and had been busy and efficient. Already he’d completed a colectomy, or the excision of a portion of the large intestine, a removal of a benign but sizable liver tumor, and a hemorrhoidectomy. The first two patients were doing well and back in their respective rooms. The only one who wasn’t was the last case. He was still in the PACU, or post-anesthesia care unit, but he had been cleared to leave and was only waiting for a bed to become available on the general surgical floor. The next and final case on Noah’s schedule was a breast biopsy with a possible full mastectomy, depending on the results of the biopsy.

As the day had progressed, he’d felt better. Noah loved being in the operating room. With his natural technical ability and confidence, it was in the OR that he felt the most at home. It was his sanctuary where everyday concerns faded. Although the interaction with Dr. Mason after the M&M had been unnerving, it could have been worse. His warning was contingent on the concurrent-surgery issue blowing up again, but the chances of that happening, in Noah’s estimation, were close to nil. As Dr. Hernandez had mentioned in his short speech that morning, the matter had been fully vetted by the BMH hierarchy, the Massachusetts Board of Medicine, and even national surgical organizations, despite a number of patient advocate people being emotionally against it. What was clear to Noah was that the sticking point in his relationship with Mason was Meg Green’s departure and Noah’s role in that regrettable episode.

“I enjoyed the M&M Conference this morning,” Mark Donaldson said, interrupting Noah’s thoughts. Mark had been tapped to help Noah for the upcoming case. On the previous three cases that day, Noah had been assisted by one of the new first-year residents, but since she was scheduled for clinic starting at 3:00 P.M., Noah had called on Mark to come up and relieve her.

Over the previous week and a half, Noah had made it a point to assign the new residents to assist him in surgery so that he could evaluate their skills. So far he’d been exposed to a third of the group and was pleased with their performance. There was no doubt in his mind that they were a solid, talented bunch, which boded well for Noah’s tenure as the super chief. Often it was the new crop of residents who gave the super chief the most headaches as they adjusted or didn’t adjust to the demands of the program.

“I appreciate you telling me you enjoyed the conference,” Noah said, continuing his scrub. It was the fourth time he had done it that day, but he remained compulsive about following protocol, just as he did with everything else in medicine. But with hand washing he was particularly careful. The specter of postoperative infections was Noah’s biggest worry. He did everything possible to avoid them.

In between his surgeries, Noah had kept an eye out for Ava, surreptitiously, so as not to call attention. He certainly wasn’t about to ask anyone about her whereabouts. When he didn’t happen to run into her, he checked the scheduling monitor. When he didn’t see her name, he checked out the Anesthesia schedule. It was there that he learned why she wasn’t on the surgical monitor. It was her turn to supervise anesthesia residents and nurse anesthetists in rooms 6, 8, and 10. This kind of supervisory role was done on a rotating basis among all the staff anesthesiologists except the chief, Dr. Kumar.

Noah had no intention of talking with Ava even if he ran into her, for fear of starting rumors. Janet Spaulding, the OR supervisor, had an uncanny ability to be aware of everything that was going on in the department, professionally and otherwise. It hadn’t been a coincidence that she had come over to chat when she had noticed Ava and Noah sitting together in the surgical lounge the previous Friday.

Just before Noah had started scrubbing for this final case, he managed to catch a glimpse of Ava by glancing into OR 10 as he passed by. Although it had been a fleeting glimpse, he was certain it was she, standing behind a nurse anesthetist who was busy intubating a patient. Noah doubted that she had seen him. For a host of reasons he was eager to see her that night, especially to get her take on the M&M. He was certain she had to be pleased.

Holding his hands up, Noah began scrubbing his forearms as the final part of the process. He was close to finishing when the intercom system suddenly came to life. A disembodied but urgent voice called out: “Code blue in OR number eight!”

Nearing the end of the scrub process but continuing to keep his hands aloft to avoid any potentially contaminated water from running down onto them, Noah took a step back from the sink so he could look in the direction of OR 8. Almost immediately, a couple of anesthesia residents appeared, running toward the room in question. One was Dr. Brianna Wilson, pushing the cardiac crash cart with a defibrillator as well as a collection of medications and other equipment. The other resident was Dr. Peter Wong, who pushed a second cart that Noah was later to learn was specifically for difficult airway-management situations.

By reflex born of a willingness to help in any emergency, Noah tossed his scrub brush into the sink and took off toward OR 8, realizing that it was one of the rooms in which Ava was supervising either a resident or nurse anesthetist. He hoped that she wasn’t involved directly in another major complication, knowing just how emotionally traumatic the Bruce Vincent case had been for her.

Using his shoulder to push through the OR door, Noah kept his scrubbed hands raised just in case he was called on to jump into the operation. Just inside the door, he paused to assess the situation. The ECG alarm was going off and the monitor showed ventricular fibrillation. The pulse-oximeter alarm was also going off, adding to the cacophony in the room and urgently announcing the blood oxygen was low.

The patient was a significantly obese Caucasian woman who Noah would later learn was a thirty-two-year-old mother of four named Helen Gibson. Instantly, he could tell it was an emergency trauma case. There was a compound fracture of her right lower leg, suggesting an auto accident of some kind. A bit of bone protruded through the skin.

Ava stood at the head of the table. She was struggling with an advanced video laryngoscope, trying to intubate the patient, who Noah could tell was not breathing. To Ava’s right was a first-year anesthesia resident named Dr. Carla Violeta, who attempted to aid Ava by pushing down on the patient’s neck at the point of the cricothyroid cartilage. Normally a bit of pressure at that location would make the entrance to the trachea easier to see. The problem was that a second anesthesia resident was giving external cardiac massage by forcibly and rapidly compressing the woman’s sternum, causing the entire body, including the head, to bounce around. Getting an endotracheal tube into a difficult-to-intubate patient under such conditions was almost impossible. Noah could tell the patient fit the difficult category by her head being tilted forward rather than back, suggesting a cervical neck problem.

The anesthesia residents who’d rushed in with the two carts were busy getting the defibrillator prepared. Standing to the side all gowned and gloved and ready to operate was Dr. Warren Jackson. Noah knew him all too well. He wasn’t quite as bad as Dr. Mason, but he was no polished gentleman, either. He, too, was an old-school, demanding, and temperamental surgeon who had trained back in the good old days when he apparently had been abused and now felt it was his duty to abuse. Noah could sense the man was irritated, as usual.

By some coincidence, the circulating nurse was Dawn Williams, who’d been in OR 8 on the Vincent case. Seeing Noah burst in, she immediately rushed over. “We got another doozie of a problem,” she said. “The first-year resident went ahead and tried to intubate the patient before Dr. London got in here. Dr. London was supervising another intubation in the next room.”

“Let me guess,” Noah said. “Dr. Jackson pressured her.”

“You got it,” Dawn said. “He was really on her case something awful.”

“Okay, clear,” Dr. Wilson called out. She was holding the paddles of the fully charged defibrillator and moved to the side of the patient. The resident giving the cardiac massage lifted his hands in the air. Ava stepped back from the head of the table, and Carla stopped pushing on the woman’s neck.

There was a distinctive thud as the defibrillator discharged. Simultaneously, Helen’s body lurched on the operating table as the electric charge spread through her and caused widespread muscular contractions. All eyes were glued to the ECG monitor except for Ava’s. She immediately reinserted the tip of the video laryngoscope and went back to trying to get an endotracheal tube placed.

Noah hurried over to Ava’s side while a subdued cheer arose from the residents who’d brought the crash cart. The fibrillation had stopped. The patient’s heart was now beating with a normal rhythm.

“What’s the problem?” Noah quickly asked Ava.

“We can’t respire this patient,” Ava shouted. “She’s paralyzed and can’t be bagged for some reason. And I can’t get an airway because I can’t see what the hell I’m doing.”

“It looks like her neck is flexed,” Noah said.

“It is, and it’s fixated. In terms of visibility of the trachea, it’s the worst I’ve ever seen: Mallampati Class Four Grade Four.”

“What the hell is Mallampati?” Noah said. He’d never heard the term.

“It’s a grading system for visualization of the trachea,” Ava snapped. Then to Carla she said: “Try pushing on the neck again. I almost had it a moment ago, before the shock.”

Feeling a rising panic, Noah glanced at the ECG monitor. He didn’t like the looks of it, fearing the heart was about to fibrillate again. He looked at the pulse-oximeter readout, whose alarm was still sounding. The oxygen level in the patient’s blood had barely changed. In fact, the patient’s color, which had been a slight shade of blue when he’d arrived, was getting worse. There was no doubt in Noah’s mind that the situation was rapidly deteriorating. To his right was the second cart, with various laryngoscopes, tracheal tubes, and other intubating equipment, plus an emergency cricothyrotomy kit that contained the paraphernalia needed to create a new opening into the lungs through the neck, bypassing the nose and the mouth.

With the same resolve that Noah had demonstrated when he’d stormed in on the Bruce Vincent case, he suddenly knew what he had to do. He snapped up the cricothyrotomy kit and tore it open. Without taking the time to put on sterile gloves, he grabbed a syringe outfitted with a catheter from the kit’s contents, pushing around to the patient’s right side, crowding Ava and Carla out of the way. Angling the tip of the catheter toward the patient’s feet, he placed its needle end into the depression below the patient’s Adam’s apple and decisively pushed it directly into the patient’s neck. There was a popping sound. When Noah pulled back on the syringe’s plunger and the syringe filled with air, he knew he was in the right place. Quickly he passed a guide wire through the catheter, then a dilator to enlarge the opening, and a moment later a breathing tube.

“Okay, good,” Ava said. She connected the newly created breathing tube to the anesthesia machine and began respiring the patient with 100 percent oxygen.

Just as the entire team was beginning to feel upbeat, disaster struck. Without warning, the patient’s heart reverted back to fibrillating, causing the cardiac alarm to resound. The oxygen level in the blood that had been rising now reversed course, necessitating a flurry of activity. After a short period of external massage that required one of the residents to climb up and kneel on the operating table, Helen received another shock from the defibrillator.

Once again there were some restrained cheers while everyone watched the cardiac monitor. The fibrillation stopped. But any sense of celebration quickly evaporated when the heart’s normal rhythm didn’t reinstate. Instead, the heart was stubbornly electrically silent, and the cardiac monitor traced a flat, unchanging straight line. Now there was no heartbeat, a situation known as asystole, which was disturbingly reminiscent of Bruce Vincent. Quickly the resident climbed back up onto the OR table to recommence closed-chest massage. At the same time the anesthesia team started various medications in hopes of restoring a heartbeat.

A few moments later, cardiologist Dr. Gerhard Spallek entered the OR, struggling to secure his surgical mask. After hearing the details, he said: “My guess is that we have had what amounts to a major heart attack secondary to the low oxygen levels. It doesn’t bode well, but here’s what we can try.”

Under his direction a few more drugs were used in an attempt to stimulate the heart. Meanwhile, the external cardiac massage was continued, as was the 100 percent oxygen, keeping the blood oxygen levels reasonable. When the additional medication wasn’t successful, Gerhard proceeded to thread an internal pacemaker wire in through the patient’s right internal jugular vein. Even that wasn’t successful to initiate a heartbeat.

“That’s it,” Gerhard declared. “The heart is not responding in the slightest. There’s no doubt it was severely damaged. I’m afraid the patient is gone. I’m sorry I could not be of more help. Thank you for allowing me to participate.” With a respectful half bow, he pulled open the door and left the room.

The resident who had been giving the external cardiac massage climbed down from the operating table.

“This is an outrage,” Dr. Jackson said the moment the door closed behind the cardiologist. Throughout the ordeal he’d been totally silent, standing off to the side with his hands clasped across his chest, watching with growing concern but apparently keeping hope alive that he would be repairing the patient’s damaged leg. “Just so everyone knows, I am going to be talking with Dr. Kumar about this” — he struggled for words — “this disaster. This patient is a thirty-two-year-old healthy mother of four. I’m appalled this could happen here at the BMH. We’re not out in the boonies someplace.”

Noah was sorely tempted to bring up the issue of his inappropriately pressuring the first-year anesthesia resident to begin the case before Ava as the supervisor was in the room, but he held his tongue. He felt it wasn’t the time or place, as the man was already irate and it would serve no purpose other than to inflame the situation.

“In all my experience I have never seen a more difficult patient to intubate,” Ava said with a voice that seriously quavered. Noah understood immediately that she was making an attempt to support Carla, which impressed him because he could tell from getting to know her that she was devastated by the episode herself. Up until the Vincent case she’d never had an operative death. Now she had been involved in two.

“What made it so goddamn hard?” Dr. Jackson spat. “You’re supposed to be professionals at putting in endotracheal tubes.”

“It was a combination,” Ava managed. Her voice broke with emotion, almost anger. She took a deep breath to calm herself.

“It is apparent that her neck is deformed,” Noah said, coming to Ava’s rescue. He didn’t want the conversation to get out of hand. “It is flexed and fixed. And the patient is moderately obese. That contributes. Isn’t that right, Dr. London?”

Ava nodded.

“Well, wasn’t that taken into consideration?” Dr. Jackson snapped, looking directly at Ava. “This is your specialty, for God’s sake.”

“I didn’t know about the neck,” Carla said. From the sound of her voice, she was as anguished as Ava.

“You mean to tell me it wasn’t in the ER resident admitting note?” Dr. Jackson demanded.

“It wasn’t,” Carla managed. “There was nothing about neck problems.”

“Good God!” Dr. Jackson voiced. He turned to Noah. “This morning we hear about a resident who didn’t even do an admitting note. Now we hear about a resident leaving out a mighty important finding that’s indirectly caused this patient’s death. That’s your department, Mr. Super Chief. Sounds like I’ll need to talk to Dr. Hernandez as well as Dr. Kumar.”

“I will certainly look into it,” Noah said. Inwardly, he groaned. At that morning’s M&M he’d barely avoided a personal disaster, and now he was facing another potential one for the next M&M.

“You’d better!” Dr. Jackson barked. He tore off his gloves and threw them to the floor. He did the same with his surgical gown. After that juvenile show of misplaced anger, he left the room.

While Doctors Wilson and Wong gathered up the cardiac-arrest paraphernalia and Dawn disgustedly picked up the discarded gloves and gown, Noah turned to Ava and Carla, particularly looking at Ava. He wanted to say something supportive if not give her a reassuring hug, but he didn’t dare. Instead he merely nodded, hoping to communicate his concern in some nonverbal way. “Sorry,” he said simply. He held her eyes for a moment with his own, but she didn’t react. Then he, too, left the room.

As Noah hurried back to room 18 he thought again of the next M&M, wondering if they were going to be his bane for the entire year. At least on this case he wasn’t going to be harassed by the concurrent-surgery issue, which was a definite plus. On the negative side, he would be dealing with an unleashed Dr. Mason, who normally was an active participant in M&M discussions. Noah knew full well that during the next one, Dr. Mason wouldn’t be constrained as he had been that morning in his role as the involved surgeon. What Noah was already worrying about was Dr. Mason’s reaction to Ava’s being involved in yet another death, because he obviously still blamed Vincent’s on her.

Intent on getting back to OR 18 as soon as possible to apologize and explain his absence in case they hadn’t heard, Noah practically collided with Dr. Mason, who had just emerged from room 15. He was in the process of removing his surgical mask and not looking where he was going. Noah’s heart skipped a beat.

“Ah!” Dr. Mason exclaimed, seeing who he was confronting. “Just the person I wanted to find.”

Instantly, Noah’s fears were confirmed. Mason knew. It was confirmation that bad news traveled quickly around the OR, especially when the PA system played a role.

“I’ve got a case in room number eighteen and I’m awfully late,” Noah said. He tried to detour around his antagonist, but Dr. Mason blocked his way.

“So, my friend,” Dr. Mason said sarcastically, “are you proud of yourself now?”

“Excuse me?” Noah asked. He was confused. Proud? Why would he be proud after what had happened?

“You get to take some credit for what just happened in OR number eight,” Dr. Mason explained. He was sporting a nasty smile. “You more than anyone else have been supporting that incompetent bitch of an anesthesiologist, and now you are being rewarded with another unnecessary death.”

“Dr. London was only the supervisor on the case,” Noah said, but as soon as he said it, he wished he hadn’t.

“And you think that exonerates her? Bullshit. She shouldn’t be supervising anyone. Somebody needs to supervise her. We’re supposed to be one of the best hospitals in the whole damn country, if not the best, and we lose two healthy young people in two weeks? There’s something wrong with this story.”

“There were complications,” Noah said.

“Complications, my ass. I heard that she couldn’t even get a goddamn endotracheal tube in. Simple as that. I never heard of an anesthesiologist who couldn’t get an endotracheal tube in, not with all the tricks they have up their sleeve.”

“Dr. London wasn’t even in the room when the problem began,” Noah snapped.

“That’s an explanation? Give me a break! Where the hell was she?”

“She was supervising an induction on another case,” Noah said. “It’s an Anesthesia rule that the supervising anesthesiologist be in the room throughout the induction process. The attending surgeon on the case in question was insistent a new first-year anesthesia resident start even though the supervisor wasn’t immediately available.”

“So it was Dr. Jackson’s fault?” Dr. Mason questioned superciliously. “That’s bullshit. That’s like me being to blame for the Bruce Vincent fiasco.”

“I’m not saying it was Dr. Jackson’s fault,” Noah said. “But what I am saying is that he shouldn’t have been encouraging a new resident to break the rules.”

“Let me ask you something, Dr. Rothauser,” Dr. Mason said. “Why do you protect this bitch? I don’t understand. You’re a smart man. I mean, I’ve been asking myself this question over and over.”

“I’m not protecting anyone,” Noah said. “I try to see the whole picture and get all the facts. I will certainly be investigating this case, as it will obviously need to be presented and discussed.”

“Wait a second!” Dr. Mason said. A slight smile formed with his narrow lips. “I’m suddenly seeing the light. I bet I know why you are protecting her. You want to know what I think?”

“I’m not protecting her,” Noah said. “I don’t protect anyone who doesn’t deserve it.”

“Here’s what I think,” Dr. Mason said. “Have you been banging her? Tell me straight! Have you and she been getting it on? One thing I can give her credit for is having a decent body, and she’s got a house in a hell of a neighborhood.”

Noah’s mouth went dry, and for a moment words abandoned him. He stared at Dr. Mason with shock, wondering just how he had known. He and Ava had been so careful, almost obsessed with their secrecy.

“Okay,” Dr. Mason said derisively, noticing Noah’s deer-in-the-headlights response. “Why didn’t I guess this before, I haven’t the foggiest, but it all makes sense. Of course, I don’t know how you got to first base since she is such a cold fish. So I have to give you credit where credit is due.”

“This is ridiculous,” Noah managed. He realized Dr. Mason was guessing, and Noah lambasted himself for hesitating to respond.

“I should have guessed,” Dr. Mason snapped, ignoring Noah’s attempt at denial. “You’re so transparent it’s a joke. And let me tell you this: It doesn’t help your image in my mind. I don’t know why, but it really pisses me off big-time.”

I know why, Noah thought but didn’t dare say. As a narcissist, Dr. Mason would see Noah’s success with Ava as the reason she had spurned him, and that was probably the reason he’d come up with the accusation. It was better than admitting Ava might not find him attractive.

“Maybe you’d better start packing your bags,” Dr. Mason said, reverting back to poking Noah in the chest with one of his thick index fingers as he’d done in the past. “I’m going to make sure that Dr. Hernandez knows about this.”

Dr. Mason then literally pushed Noah out of the way and continued down the OR corridor, heading toward the surgical lounge.

Noah watched him go, feeling a mixture of anger and disgust toward the man. His threat to tell the chief about his suspicions of Noah and Ava having an affair could have serious consequences. Although Noah couldn’t imagine it could threaten his job, it would certainly affect his relationship with Ava. She had made it clear that she prized her privacy, and Noah agreed with her. But was it a legitimate concern over the long haul? Noah doubted that their being circumspect about their interactions in the hospital was going to be enough to shield their affair. Eventually someone in the hospital community was bound to see him coming or going from Ava’s Louisburg Square home since a number of them lived in the Beacon Hill neighborhood. It was only a matter of time.

“What a bastard,” Noah mused out loud as he hurried toward OR 18. Ava described a narcissist like Dr. Mason as a bull in a china shop. Noah thought the simile should be a lot stronger and be about people, not dishes. Spontaneously he came up with a rabid gorilla at a picnic. The thought made him smile. It was to be the last time he smiled for the day.

14

WEDNESDAY, JULY 12, 9:31 P.M.

Noah had hoped to get out of the hospital much earlier, but it wasn’t to be. At around 5:30 he’d been informed that several organs were available because of a motorcycle accident on the Cape that afternoon and that a kidney was on its way to the BMH. Noah had been pleased, although certainly not for the motorcyclist. Although he’d ridden one as a teenager, as a resident he’d learned to see motorcycles as a method of nonintentional suicide for the riders and, as a result, a gift to those needing organs.

Once it had been confirmed that the organ was on the premises, the sixteen-year-old girl recipient was inducted under anesthesia, and by the time the gifted organ arrived in the OR, Noah was nearly ready for it. It was a happy time for everyone, including Noah, who had known the patient for several years as she had waited. What made it particularly exciting was that the organ was a particularly good match, with an outstanding prognosis for the patient.

The kidney operation had been the highlight of Noah’s day. It was one of those episodes that confirmed for him that he had made the right career choice and more than justified all his efforts. It had even nearly erased the bad feelings associated with the unfortunate death of Helen Gibson and the confrontation with Dr. Mason, although Noah had yet to communicate on any level with Ava after the disaster in OR 8.

Noah had tried between surgeries to casually run into Ava to be assured she was okay, a shrug or a nod to suggest she was coping, but he hadn’t seen her. After he’d finished his last scheduled case, he’d made a concerted search for her around the entire OR area. It wasn’t unusual for anesthesiologists to remain after hours, even though it wasn’t Ava’s habit. Noah finally went so far as to ask for her in the Anesthesia office, where he was told she had left for the day. It was at that point that Noah had resorted to digital means to contact her.

The first thing he had done was text her. While he waited for her response, he’d started afternoon work rounds with the residents on the surgical floor. When rounds were done and she hadn’t responded, he texted her again, indicating it was urgent that she respond. Meanwhile, he’d started seeing his own inpatients, including the patients he’d operated on earlier. Between the colectomy and the hemorrhoid, he’d tried to call her. Not only had she not answered, but after listening to her stock outgoing message, he’d been told that her voice-message box was full.

Feeling frustrated by the technology that promised immediate contact but wasn’t delivering, Noah tried Facebook messaging, then went back to seeing his post-op patients. It wasn’t the best time to visit, since most were eating dinner, but still they were glad to see him. More important, there were no complications such as fevers or complaints of pain, and they were even complimentary about the food. Noah wasn’t surprised. Hospitals today, even tertiary teaching hospitals like the BMH, knew they were in competition and made an effort with their food service. It was just as Noah was seeing his last patient that the kidney notification had come through.

With the surgical call team prepared to take over for the night, Noah left the hospital through the main entrance. It was a warm summer evening and the sidewalks were busy. He crossed the green space created when the Big Dig had put the main north-south traffic artery underground. From there he walked through a portion of downtown Boston to emerge at the northeastern tip of the Public Garden. It was Noah’s usual route when heading home. But he wasn’t heading home. He was heading to Ava’s house.

He entered Louisburg Square from the opposite direction than when he was coming from his apartment. Ava’s building looked dark and uninviting.

Noah climbed her stoop. He entered the foyer. There was an overhead light, but it wasn’t on. To find the doorbell he had to go by feel. He pressed it and listened. In the far distance, he could hear a phone ringing, which was the way Ava’s doorbell worked, since it was tied into the phone system. It rang six times. No one answered.

“Shit,” Noah said. “Where the hell are you?” Out of frustration he pounded on the door. The moment he stopped, a heavy silence returned.

After a long sigh, he went back through the outer door. Stepping into the street, he walked over to the fence that circled the greensward and then looked back up at Ava’s house. There had been no change. All the windows were dark, including the three dormers on the top sixth floor. Although he couldn’t see any of the windows in the L portion of the house nor the workout room, he felt confident she was either not home or hiding from the world. Knowing what he did about her, he doubted the latter. There was nothing about her that suggested she was the depressive type. Besides, what could he do even if she was keeping to herself? It was her house. He couldn’t break down the door and look for her.

For a moment Noah debated what to do, but ultimately he recognized he didn’t have much choice. He had to either go back to the hospital if he wanted any companionship whatsoever or go back to his apartment. Under the circumstances, both destinations seemed pathetic. If he went back to the hospital, as the super chief resident he would be hard put to explain why he was there, and people would most likely ask. He had no idea what he would say, and it might turn out to be embarrassing. As for his apartment, at least he wouldn’t have to explain himself, although the idea of being there was far from enticing for a multitude of reasons.

Finally, as the least bad idea, he decided on his apartment and began to head in its direction. As he walked he found himself back to wondering if Ava could be seriously depressed, but then dismissed it again. He was convinced she was a doer like himself. When the chips were down and things weren’t going your way, you didn’t cry and mope. You sucked it up and worked harder.

As he climbed the stark stairs in his building, he couldn’t help but compare the experience with going up the stairs in Ava’s home with its mahogany handrail, hand-turned balusters, and custom carpeting. Yet the thought surprised him. Had four days and three nights spoiled him?

When he got into his unit, the comparisons were even more dramatic. It was like night and day. He couldn’t quite believe the barrenness and impersonal nature of the place.

Trying to ignore the decor or the lack of it, he sat down at the miserable folding table and booted up his HP, still wondering when he’d hear from Ava and wishing he’d inquired about her schedule when he’d visited the Anesthesia office. Quite suddenly, the disturbing thought came to him that she might have some time off and be away on one of her frequent trips without telling him.

After quickly checking if he had gotten any emails or Facebook messages on his computer that might have mysteriously eluded his phone, Noah sent another email to her. He struggled with the phrasing so as not to sound as irritated as he felt. In many respects, it was rude and unempathetic of her to ignore him like this. She had to know he would be beside himself with concern.

Then he picked up his mobile phone, and against his better judgment, he typed her yet another short text, urging her to text back and included a sad-face emoji. But then he held up for a moment with his finger poised to hit the send button, trying to talk himself out of doing it. He’d already sent her a half-dozen unanswered texts.

In an attempt to salvage a modicum of self-esteem, he deleted it instead and tossed the phone onto the table in disgust. He wondered when he would hear from her, whether the next day or the day after that or if at all. Could the next time he saw her be in the OR corridor, ignoring each other and passing like two ships in the night? He had no idea, but he realized it was a possibility, as were a half-dozen other scenarios. Not since high school when his first love had suddenly turned her affections elsewhere had he been quite so confused, irritated, and worried all at the same time.

“Maybe I’m in love,” Noah questioned out loud. As lonely as he’d been over the last two years, he knew he was possibly a needy, love-starved nerd who’d been swept off his feet over the previous three or four days by an exceptional woman who had been hiding out in plain sight.