Charlatans

15

SUNDAY, JULY 16, 9:10 P.M.

The next four days did not rank among Noah’s favorites. To try to avoid obsessing over Ava’s disappearance and her total lack of communication, he buried himself in work. Not only did he do more surgery than his usual amount and see far more people in clinic, he found the time to plan the basic science lectures and Journal Club meetings for the entire next month. He also met with each first-year resident to hear his or her complaints and raves.

Even though he told himself he wasn’t going to hear from Ava, every time he got a text message or an email or even a phone call he thought it might be her and his heart quickened. Unfortunately, every time he was disappointed. In order to avoid looking for her in the OR each day, he made it a point to go back to the anesthesia office the day after she’d disappeared and ask the secretary when Ava was due back. To avoid stoking any gossip, he’d used the excuse that he had to talk with her about the Helen Gibson case. What he had learned was that she wasn’t scheduled until Monday.

Noah left the hospital by the main entrance and crossed the swath of greenery that covered the freeway tunnel on his way home. Once he was out of the hospital with all its demands on his attention, time, and energy, he was unable to stop his mind from mulling over his problems. Dr. Mason had made good on his threat to tell Dr. Hernandez about Noah and Ava possibly having an affair. Noah had become aware Thursday morning when he had gotten a message as he was scrubbing for his final surgery that he was wanted ASAP in the chief of surgery’s office.

The meeting had not been pleasant. It got off on the wrong foot because Noah had gone ahead and finished his last case and didn’t show up in the chief’s office for almost two hours. Clearly miffed despite Noah’s explanation for the delay, Dr. Hernandez started out by saying the hospital administration didn’t condemn fraternization or romance between hospital employees, as they are grown-ups, but it did frown on such relationships if they affected performance. He went on to say that it was Dr. Mason’s strong opinion that Noah had deliberately shielded Dr. London from blame in the Vincent case during the M&M Conference by not bringing up the fault of Anesthesia choosing to use a spinal rather than general anesthesia.

Noah had tried to defend himself by denying any attempt to shield Dr. London and by mentioning that Dr. Mason’s secretary had requested the spinal. But his attempts seemed to fall on deaf ears. Instead of listening, Dr. Hernandez had gone on to criticize Noah’s role in reawakening the concurrent-surgery debate, which had already been adequately vetted and cleared. At that point, Noah tried to remind the chief that the issue had been raised by a member of the audience and not by him.

“Let’s not quibble about the details,” Dr. Hernandez had said with a wave of his hand. “The point here in both these circumstances is that we expect you to side with the Department of Surgery as a potential member of the staff. Now, I don’t know what you have done to get under Dr. Mason’s skin, nor do I want to know. But whatever it was or is, I think it would be in your best interest to rectify it. You have been a wonderful resident, Dr. Rothauser. I would hate to see you ruin it in this final sprint to the finish line. Do I make myself clear?”

As Noah thought again about this brief meeting, it irritated and scared him. It was disheartening to see how blind the administration was to Dr. Mason’s personality flaws just because of his exceptional surgical skills. Noah had had to fight with himself not to bring up the Meg Green dismissal issue as the real cause of Dr. Mason’s discontent. That unfortunate affair was still a sore subject, and Noah feared bringing it up might make the situation worse.

Noah reached the eastern corner of the Boston Common and began to cut diagonally across the park, heading in the direction of the gold-domed Massachusetts State House. In contrast with the downtown area, which had been relatively deserted, the park was full of people enjoying the Sunday summer evening. Despite it being after nine P.M., there were still children in the kids’ playground. Noah felt distinctively out of place in his hospital whites, surrounded by healthy, normal people who he knew thought of his world as a scary place.

As bad as the meeting with Dr. Hernandez had gone, the meeting with Dr. Edward Cantor, the surgical residency program director, had been worse. Noah had been summoned a few hours after the meeting with the chief. As soon as Noah had arrived in the director’s office, it had been obvious that Dr. Mason had also passed on to him the story of Noah and Ava’s possible romance and his possible shielding of her at the M&M Conference.

“I don’t like this one bit,” Dr. Cantor had snapped. “It is not the role of the super chief surgical resident to protect a possibly incompetent anesthesia attending because of an affair.”

“Dr. London is far from incompetent,” Noah said before thinking. In retrospect, he should have stayed mostly quiet, as he had with Dr. Hernandez. By denying Ava’s incompetence, he was in a fashion affirming the allegation that he’d been protecting her.

“Her competence or lack thereof is not for you to decide,” Dr. Cantor said. “It is a different department. We wouldn’t tolerate anesthesia residents protecting possibly incompetent surgeons. Don’t do it. If you do, we will find someone else to take your place. It is as simple as that. And I want to remind you that any screwup by a junior resident, such as the lack of an H&P on the Vincent case, is on your shoulders. As super chief, you are responsible for junior resident performance, plain and simple. Are you clear on this?”

As Noah walked he had to smile wryly as he remembered this portion of the meeting. At the time, he’d considered reminding Dr. Cantor that he had not been the super chief when the Bruce Vincent case had occurred. It had been Dr. Claire Thomas. Luckily, he hadn’t done it, as it might have pushed the already upset man over the top.

Suddenly, Noah stopped. He was close to a flight of stairs that led up to Beacon Street that ran along the north side of the park. He had just by chance glanced behind him to take one more quick look around the pleasant summer evening scene in the Common. What had caught his attention was a man in a dark suit and tie. There weren’t many men in suits at that time of the evening. In fact, as he glanced around again, he didn’t see another.

What had caught Noah’s attention was more than just the suit. It was that he had the impression he’d seen the same man earlier, with his impressively trim physique and short, light hair. Noah had noticed the man, who had been standing alone at the side of the circular drive at the hospital’s main entrance. It was the suit at that time of night that made the man stand out, but Noah quickly forgot the incident until by chance he had taken this one last glance around the Common. Was it the same man? Noah didn’t know. But if it were, was it just a coincidence, or could the man be following him?

“Good grief,” Noah said out loud, mocking himself. “Now you’re having paranoid delusions. What a pathetic lame-brain.” Without giving the man in the suit another thought, Noah went up the stairs, taking them in twos and threes. At the top, he had to stop for the traffic on busy Beacon Street, joining a group of people waiting for the light to change. Most were dog walkers with their pets.

When the walk sign came on, the group surged forward. As Noah allowed himself to be carried along, he managed a quick glance behind him down the flight of stairs. At the bottom, he caught a fleeting look at the man in the suit. He was bent over, seemingly tying a shoe.

Noah paused on the other side of Beacon Street where it met Joy Street. His normal route took him up Joy Street to Pinckney, where he took a left. But at this time of night, Pinckney Street was quiet, with few pedestrians. Noah decided to continue on Joy Street and make a left on Myrtle, which was busier, with multifamily buildings and a playground. If he was being followed, as crazy as that sounded, he preferred people around.

A moment later the man in the suit appeared across the street. He was now waiting for the walk signal just as Noah had done. Noah turned and ascended Joy Street at a rapid walk. Since there was plenty of pedestrian traffic, he felt reasonably relaxed. He still thought that he was being paranoid in thinking that this man, whoever he was, was following him. It all had to be a coincidence. Why would someone be following him, a surgical resident? It made no sense.

But then a few minutes later when Noah ventured a look behind him, the same man was there, walking in the same direction as Noah and seemingly at the same pace.

At Myrtle Street Noah turned left. As he had expected, there were lots of pedestrians. There were even a few families still in the playground using the swings. As Noah crested Beacon Hill and started down on the other side, he looked behind him. The man was still there. Could it be a coincidence? Noah didn’t know, but he felt the chances were getting progressively slimmer. Revere Street, his street, ran parallel with Myrtle one short block to the north. There were several streets Noah could have taken, but he waited until Anderson Street because there was a convenience store on the corner, meaning more people.

Once on Revere Street, Noah had only a short way to go. Remembering hearing stories in the past about people being mugged when they paused at their front doors, searching for their keys, Noah made sure he had his in his hand. As he turned to his front door, he looked back. The man was still there, coming toward him, walking quickly.

In a rapid fashion, Noah keyed his front door, pushed it open, entered, and slammed it closed. He heard the reassuring click of the lock and breathed a sigh of relief. He’d not been aware he had been holding his breath. Then, going up on his tiptoes, he was able to see out one of two small glass panes in the upper panels of the building’s front door. In a moment the man in the suit appeared, but as Noah watched, he didn’t pause or even look in Noah’s direction. Instead, he passed by in a flash, heading down Revere Street, which meant the whole episode had been a product of his emotionally overwrought state.

Noah laughed at himself. He felt like a fool as he climbed his utilitarian staircase, heading for his lonely apartment. At that moment, he really missed Leslie Brooks and wished he’d made more effort in their relationship. If he had, maybe she would still be here. He keyed his apartment door and pushed it open. Inside he turned on the harsh overhead light, which was a cheap fixture with two hundred-watt bulbs.

After taking off his white coat, hanging it up, and kicking off his shoes, he went into the small kitchen and opened the refrigerator door. There wasn’t much in there, and what was didn’t appeal to him. It was to be another night without dinner. Instead of eating, he sat down at the folding table, booted up the old HP laptop, and went on Facebook. Although he knew it probably wasn’t an emotionally healthy thing for him to do, he had in mind to look over the many photos of Gail Shafter, including a couple baby pictures. But what he found was more interesting. It was a brand-new selfie of Ava pouting at the camera with the caption: Relaxing after a hard day’s work. She was clad in a luxurious terry-cloth robe. There was a logo on the breast pocket, but Noah couldn’t make it out. Checking the background, he thought it looked like an upscale hotel room. He wished there were some indication where it was. As he looked at it, it seemed awfully cruel to him that she had taken the time and effort to post a photo on Facebook for her myriad Facebook friends but didn’t have the time or inclination to send him a single text.

Looking down at the likes and comments, he was surprised at the number of people who reacted to the post. Most of the comments were short, like “hot” or “aesthetically flawless” or just a thumbs-up emoji, as if they were from teenagers. Noah shook his head at the inanity of it all. Knowing what he knew of Ava’s intelligence, education, and training, he couldn’t explain her attraction to such a superficial activity. Why did she bother? Did she get enjoyment from the responses she got, in particular the three comments saying her photo was hot?

Wondering if his suspicion that the authors of the short comments were as young as he envisioned, Noah decided to look at one of the commenters’ Facebook page. He chose Teresa Puksar’s because she was one of the people who wrote “hot” and because the surname jumped out as being unique. He’d seen the name before on his previous visits to Gail Shafter’s homepage, as she was one of a half-dozen or so people who were loyal followers of Gail Shafter and commented on every post.

“Just as I thought,” Noah mused when he had Teresa Puksar’s homepage on his screen and saw that Teresa Puksar was thirteen. Then he noticed some of the young girl’s photos as being overly provocative. There were even a few nudes with her coyly covering nipples and the genital area. Even so, Noah was shocked that Facebook allowed them, as they could be considered by some conservative people as child pornography.

At that moment, the silence in his apartment was shattered by the raucous sound of his front door buzzer. Concentrating as he was, Noah leaped at the sound. “What the hell?” he questioned when he recovered. No one ever rang his doorbell, especially not after ten on a Sunday night.

Confused, Noah got up and went to the window. He pressed his face against the glass to see what he could on the sidewalk in front of his building, but he didn’t see anybody. He wasn’t surprised, because there was an alcove at his building’s front door where the apartment buzzer was located. Whoever had rung was most likely standing in there. Raising his line of sight, he saw that there was a dark SUV pulled over to the curb on the opposite side of his street with its blinkers going. That wasn’t normal, either.

Noah straightened up. Who the hell could be visiting? All at once the memory of the man in the suit came back in a rush. He’d decided that the episode had been all in his paranoid imagination. But was it? Could this strange visitor somehow be associated?

Then the buzzer sounded again. Knowing that he wasn’t going to find out anything unless he went down to the front door, Noah put his shoes back on. He looked around for some sort of weapon to defend himself if need be, but then dismissed the idea as coming from a sick, paranoid mind.

When he got down to the front door, he debated what to do. Should he just open the door and face whoever was there? It seemed more prudent to call through the door and get some idea before opening up. “Who is it?” he yelled.

“It’s Ava,” a woman’s voice responded.

For a second, Noah was startled. It was as if his brain was momentarily scrambled. “Ava? Is that really you?” he asked incredulously. What he was doing was playing for time to recover. Without waiting for an answer, he struggled with the door to undo the dead bolt that was used after nine. A moment later he was staring at Ava, dressed in a businesslike pantsuit. The blond streaks in her hair gleamed in the harsh overhead entrance light.

For a moment neither spoke. Finally, Ava said, “Well? Can I come in?”

As if waking from a trance, Noah said, “Sorry! Sure, come in.”

“Upstairs?” Ava asked.

“Yes,” Noah said. “One flight.”

He followed her up the stairs, feeling confused. While he was thrilled to see her, he was furious that she had disappeared and totally ignored him. “The door is unlocked,” he said as they reached the landing.

He followed her inside his apartment and closed the door behind them. She had stopped a few feet from the door and let her eyes roam around the small, sparse room. “I’d describe this as minimalist,” she said.

“That’s being kind,” Noah said.

For a beat, they stared at each other. Noah was still fighting his emotions. All at once tears appeared in Ava’s eyes and spilled out onto her cheeks. Her hand shot up and covered her eyes, and for a moment she sobbed quietly, her shoulders shaking.

Noah was beside himself with indecision. He didn’t know how to respond. But then charity won out and he stepped forward and enveloped her in his arms. They stood that way for a few moments until Noah led her to the small couch and encouraged her to sit down.

“I’m sorry,” she managed. She wiped her tears from her cheeks with a knuckle, but it was a losing battle.

“It’s okay,” Noah said. He went back to his bathroom and brought out a small box of tissues. She took one and noisily blew her nose. She took another and wiped her eyes. This time she was more successful.

“I want to apologize to you for not contacting you,” she said when she was more in control.

“Thank you,” Noah said. “Why didn’t you?”

“I don’t know exactly,” Ava said. “At first I was just too distraught after being involved with another death. I’m still distraught, obviously. Anyway, I just wanted to get away and forget everything. I thought about quitting anesthesia.”

“No!” Noah said without hesitation. “Don’t say that. Not after all your training and effort. You are a talented anesthesiologist. You wouldn’t be on the BMH staff if you weren’t.”

“I never expected to be involved with one death,” Ava said. “Suddenly, it’s two. I thought that by constant studying, by constant attempts to make myself better, it wouldn’t happen. But it has.”

“You know the expression ‘medicine is more art than science,’” Noah said. “It’s true. As a doctor, even if you do everything exactly right, things can disintegrate into chaos. There are too many variables. It’s part of the human condition.”

“I thought I could be different. I thought dedication and commitment would be enough.”

“We are all in this together,” Noah said. “We do the best we can. That is all that can be expected of us. You didn’t do anything wrong on either case. I know. I was there.”

“You really think so? Honest?”

“Absolutely! No question. I think you are a terrific anesthesiologist.”

“Well, thank you. Your support means a lot to me.”

“But it’s not going to be easy to put all this to rest,” Noah said. “I had several run-ins with Dr. Mason. The first was right after the M&M and the second after the Gibson death. I’m afraid he’s still on our case.” Noah went on to tell Ava the details about the two confrontations, particularly about Dr. Mason’s accusation that Noah was purposefully protecting her. He then went so far as to tell her that Dr. Mason suspected that they were having an affair.

“Oh, no,” Ava said with consternation. “Why? How?”

“He has no evidence,” Noah said quickly, alarmed at Ava’s reaction. “He came up with the idea out of the blue when he was talking with me, saying he couldn’t understand why I was protecting you. He wants to put you down because you’ve rebuffed him, and obviously, he saw through my ruse at the M&M of avoiding the anesthesia issue entirely.”

“Do you think he has told anyone about his suspicions?”

“I know he has,” Noah admitted. “I got called on the carpet by both the head of the Surgery Department and the head of the surgical residency program.”

“They had the nerve to reprimand you for possibly having an affair with me?” Ava questioned with disbelief. She didn’t know whether to be insulted or more worried about the inevitable rumors.

“The possibility of an affair was just mentioned in passing,” Noah said. “The hospital doesn’t care. What both of them were irritated about was Dr. Mason’s complaint that I have been protecting you.”

“Oh my goodness,” Ava said. “This keeps getting worse. I hate to think we’ll become a source of gossip. What did you end up saying?”

“Not much,” Noah admitted. “I denied that I was protecting you, of course, because the implication was that I was doing something underhanded. I’m not doing anything I don’t think is right. You were certainly not to blame in either of these unfortunate cases, and I’m more than happy to say so.”

“Thank you again.”

“You’re welcome,” Noah said. “We need to get busy and plan the next M&M like we did for the last one because the Gibson case will need to be presented, and Dr. Mason most likely will be a bear. On the Vincent case his hands were tied because he was the surgeon. With the Gibson case, there’s no such luck. You’ll have to gird yourself. It might not be pretty, but at least the concurrent-surgery issue is not involved.”

“I’ll help you plan however I can,” Ava said. “Does this mean you’ve forgiven me?”

“Why didn’t you contact me? Why not a simple text saying you were all right?”

“At first I was just too overwrought and knew you wouldn’t be satisfied with a simple text. Then after a day or so I felt embarrassed I’d been so emotional. I thought it best to apologize to you in person. That’s why I’m here. I just got back to Boston and came straight here. I haven’t even been home yet. I’m sure you have been concerned, and I would have been concerned if it had been the other way around.”

“Where were you? It looked like a fancy hotel in your selfie.”

“Oh, good, you saw it. I really posted it for you to show you that I was all right.”

“I saw it,” Noah said. “But I couldn’t tell where you were.”

“Washington, D.C. It was the Ritz.”

“Were you playing tourist or working?”

“I was working,” Ava said. “The trip had been scheduled months ago. Actually, the timing was good. Being busy helped pull me out of an emotional nosedive.”

“What type of consulting do you do, if I can ask?”

Ava regarded Noah for a few beats. He sensed she was debating whether she wanted to tell him, which only fired up his curiosity. Whatever she was doing had to be exceptionally lucrative. Not every consultant stayed at the Ritz.

“I’m hesitating because I think you’re not going to approve,” Ava said.

“If you think telling me that is going to make me less interested, you’re wrong. Why would I not approve of your consulting work?”

“I consult for the NSC.”

“Really,” Noah said. He didn’t know if he was more shocked or impressed. “You consult for the National Security Council?” The National Security Council was the U.S. president’s principal forum for national-security and foreign-policy matters.

Ava had recovered enough from her earlier tears to laugh her usual laugh. “I wish. No, I work for the Nutritional Supplement Council. I’m a combination spokesperson/lobbyist. My NSC is a lobby group lavishly funded by the nutritional-supplement industry.”

“Okay,” Noah said. He nodded. “Now I understand why you questioned if I would approve. As a doctor, I do have strong negative feelings about the industry, which I equate to a bunch of snake-oil manufacturers and salesmen.”

“But on the positive side, they pay well,” Ava said.

“How did you happen to start working for them? I would think as a doctor you’d find it problematic. It’s a little like colluding with the enemy.”

“I started working for them from the day I received my combined M.D. and B.S. nutrition degree,” Ava said. “I’d run up a big debt from college and medical school. I had to pay my own way after my father died of a heart attack in my junior year of high school. The NSC and its deep pockets have been kind of a savior.”

“I suppose I can relate,” Noah said. “I’ve had my share of economic problems, some of which are still going on. As you know, my father also died of a heart attack when I was in high school, and I’ve got a huge debt as well. My mother helped when I was in college, but when I got to medical school, she came down with early-onset Alzheimer’s and lost her job. At that point the tables were turned, and I had to support her.”

“I’m sorry to hear that,” Ava said. “Sounds like you had it harder than I.”

“I guess your bosses at the NSC were pleased that you had both a B.S. and an M.D.,” Noah said. “Especially now, with you being on the BMH staff.”

“You have no idea,” Ava said. “They love me and treat me like a queen. My life would be totally different if it weren’t for the NSC. At the same time, I do them a big service. I’m probably the main reason the 1994 law that took the FDA off their back hasn’t been amended. That’s the law that absolves the industry from having to prove efficacy or even safety. It’s kind of a joke, really, but who am I to say. Besides, it is fun. I get to dine with senators and congressmen.”

“But you’re a doctor and a committed one. Why doesn’t that keep you awake at night?”

“Believe it or not, it’s what the American public wants. They are convinced they don’t want government bureaucrats messing with their pills, elixirs, and botanicals, whether they are worthless or not or even dangerous. They want to believe in the magic pill to make up for their unhealthy lifestyle. Taking a pill is a lot easier than eating right, exercising, and getting a decent night’s sleep.”

“Do you believe the public is that stupid?” Noah said.

“I do,” Ava said. “Did you ever see the commercial that Mel Gibson did back when the supplement industry was lobbying Congress to pass the 1994 law?”

“I didn’t. Or if I did, I was in the sixth grade, and it probably went over my head.”

“I was in the seventh grade,” Ava said. “I didn’t see it back then, but one of my NSC bosses showed it to me last year. It is a classic. Mel Gibson’s house is raided by armed FDA agents acting like a SWAT team, and he’s arrested for taking vitamin C supplements. It’s hilarious, but it was very effective. The public really thinks the government wants to take away their beloved vitamins. You should watch the video.”

“I’ll have to check it out,” Noah said.

“You didn’t answer when I asked you if I’ve been forgiven for disappearing for a few days,” Ava said. “Was that intentional?”

“I suppose you are forgiven,” Noah said halfheartedly.

“That doesn’t sound so convincing,” Ava said.

“I was really worried about you,” Noah said.

“I understand, but I’m all right. I’ve mostly recovered, except for random episodes like when I first arrived here. But I think I am ready to go back to work tomorrow. And I’m interested in starting to plan for the next M&M whenever you are.”

“Okay,” Noah said, “you’re forgiven. I can appreciate how upset you must have been.”

“Thank you,” Ava said. “Now, what time is it?” She looked at her watch. “Oh, dear. It’s later than I thought. But how about coming back with me to my house? I have a car waiting outside.”

“That’s your SUV I saw earlier with its blinkers on?” Noah asked with surprise. The idea hadn’t even occurred to him. The idea of having a driver wait an indeterminate amount of time seemed excessively extravagant.

“It’s the car that the NSC arranged to pick me up at the airport. As I said, I came directly here. We could have a snack or a glass of wine if you would like. I’m wide awake.”

“Four forty-five A.M. is going to come all too quickly for me,” Noah said. “I’ve been working like a dog. I’ll have to take a rain check.”

“Fine,” Ava said as she stood. “Maybe tomorrow evening you can come over when you get out of the hospital, and we can have a bite. I’ve missed you.”

“Maybe,” Noah said. The real reason he was reluctant to take her up on her offer to go directly back to her house was that he wasn’t sure how he felt emotionally. He didn’t know if he wanted to get right back into the saddle after falling off the horse. “Sometimes Mondays are very busy, and I don’t get out until late,” he added as an afterthought.

“Well, let’s see how it goes,” Ava said. “Anyway, the offer stands.”

He walked her down to the front door. Like the first evening they had spent together, she surprised Noah by initiating a double-cheek kiss. Then, with him holding the door open, she said: “I’m really glad to see you, but in the hospital I think we should still play it safe and ignore each other. Dr. Mason’s suspicions might not be common knowledge, and it would be best not to give them any sort of credence. Okay?”

“Okay,” Noah managed. As usual, she had him off balance. “I’ve missed you as well. Welcome home!”

He watched her run across the street and open the SUV door. Before she climbed in she turned and waved. Noah waved back, then closed and dead-bolted the door. In contrast to her seeming burst of energy, he felt mentally and physically exhausted.

16

THURSDAY, JULY 20, 7:48 P.M.

Noah entered Toscano and approached the hostess desk. He told Richard, the handsome owner/manager whom he had formally met two nights ago, that he was there once again to pick up a take-out order. As he waited, Noah glanced around at the busy scene. All the tables and the lengthy bar were filled and a buzz of happy conversation and laughter permeated the room. None of the diners were thinking of sickness, injury, or death, which consumed Noah’s world on a daily basis. Usually he would have felt jealous of their normal lives and their facility at easy conversation. But tonight he wasn’t jealous in the slightest, as he was anticipating another delightful evening of his own.

The past Monday had been busy for Noah, even more than he had expected. So was the rest of the week. But any reluctance he might have entertained on Sunday night, the night Ava unexpectedly appeared at his door, about restarting his secret, intense relationship with her had progressively lessened. Although Monday morning he’d awakened still feeling that the prudent course would be to go slowly, as the day wore on he found himself becoming more and more excited about the prospect of seeing her that evening. Passing her several times in the surgery corridor, where they both scrupulously avoided any recognition of the other, only served to fan the embers of his passion into a full blaze. The secrecy alone lent a delicious libidinousness to the whole situation.

By the time Noah got to her house well after 9:00 P.M. Monday night, he was wound up like an old-fashioned clock. Apparently, it had been the same for her, because they ended up making love on the floor in the foyer just inside the inner door. In the background, they could hear occasional chatter by passing pedestrians out on the sidewalk as they were that close, but it didn’t affect their ardor in the slightest. After they were spent they lay for a time on the carpet runner, staring up at the hallway chandelier. It was a tender time as they reaffirmed how much they had missed each other, an emotion augmented by guilt on her part for not having texted him and worry on his part for not having heard from her.

Later, over take-out food, Noah had learned how hard it had been for Ava to do her consulting work while she was in Washington, since it meant meeting with or having meals with senators and congressmen who were members of key committees. She told Noah that she had suffered from a mild form of PTSD, or post-traumatic stress disorder, with persistent GI symptoms and recurrent nightmares about failing to get an endotracheal tube placed. She also confessed how close she’d come to calling Dr. Kumar to say that she was resigning.

Noah’s reaction to all this was similar to how he had responded the previous night in his apartment, reminding her of her board certification and that she had been hired by one of the country’s most prestigious hospitals. He told her that it had not been an accident that she had handled superbly more than three thousand anesthesia cases at BMH without a significant complication. He also reminded her that she had made several major contributions to the hospital. The first had been playing the key role behind the program of recapturing vast quantities of anesthetic gases rather than venting them into the atmosphere, which saved the hospital money and was also environmentally appropriate. The second had been that she had sat with him on the hybrid operating room committee, whose work resulted in the current remodel of the entire Stanhope Pavilion OR complex.

So far Noah had ended up staying overnight at Ava’s for the entire work week, arriving somewhere between 6:15 P.M. at the earliest, which happened on Tuesday, and 9:52 P.M. at the latest, which happened on Monday, and leaving each morning a tad before 5:00 A.M. Every night they had gotten take-out food from a Charles Street eatery and then spent hours talking while they ate and sipped a bit of wine.

In many ways, Noah found getting to know Ava like peeling an onion. Every time he learned something new, he found another layer, something he didn’t know or suspect, like the fact that she had a nearly photographic memory or that she was a talented computer coder, a skill she had picked up herself, mostly thanks to her love of computer gaming. Photographic memory and coding were aptitudes that Noah appreciated because he shared them.

Perhaps the most astounding new thing Noah learned about Ava was that she was fluent in Spanish, French, and German and spoke enough Italian to get along traveling the back roads in Italy. Why it surprised him was because language was not one of his fortes, and he had struggled through Latin and Spanish in high school courses. He also came to realize that, in contrast to himself, she had a sixth sense about reading people, something that came in particularly handy with her lobbying efforts. She explained to him how easy it was for her to discover a senator’s or a congressman’s opinion on a specific issue and then how to change it if it wasn’t in line with her NSC bosses’ desires.

“You never order dessert,” Richard, the restaurant owner, said. He interrupted Noah’s thoughts when he brought out the package of take-out food. “We have some delicious selections. How about I throw in some tiramisu on the house just so you can try it?”

“Thank you, but no,” Noah said. He doubted Ava would want it, even though she could certainly get away with it, considering the amount of exercise she did every day in her workout room. Noah didn’t feel the same about himself. With as little aerobic exercise as he got, he was lucky he hadn’t put on significant weight.

“Perhaps next time,” Richard said graciously, handing the credit card receipt to Noah.

Noah walked quickly up the hill to Louisburg Square. Now that he had the food he was in a hurry, and not just because he wanted the food to be hot but because he was even more eager than usual to see Ava. Earlier that afternoon they had practically collided with each other, with him pushing into the PACU and her coming out. At first both had been horrified, but when no one seemed to notice since it happened frequently to other people, they had both found it like a bit of slapstick comedy, since they’d been trying so hard to avoid each other.

Noah pushed the doorbell and in the far distance could hear the phone inside the house. The next thing he heard was the door lock clicking open. He’d learned that at any phone extension in the house it was possible to see who was at the door and then release the lock.

Once inside, Noah kicked off his shoes and took the main stairs down to the kitchen. Ava was busy setting out place mats, flatware, and napkins at the countertop table. To Noah she looked as fetching as usual, this time in sweatpants, a mock-neck tank top, and bare feet. Her hair was damp and her skin was glowing from a recent hot shower after her workout.

While Ava opened a bottle of wine and Noah unpacked the take-out food and put it on plates, they had a good laugh about their near collision at the PACU entrance that afternoon and how they’d both panicked.

“It’s a good thing Janet Spaulding didn’t see us,” Ava said, still giggling.

“It’s amazing how she seems to know everything that goes on in the OR,” Noah agreed.

Once they had started on their meal, Ava said: “I hate to bring up a sore subject, but have you spoken with Dr. Jackson?”

“Not yet,” Noah admitted.

“Any reason why?” Ava questioned. “The M&M is coming up quickly. Only three more work days before it’s here.”

“The same reason I put off talking with Dr. Mason for the last M&M,” Noah said. “I’m a coward.”

“I can understand,” Ava said. “It could be almost as bad as talking with Dr. Mason. He is not as narcissistic, but they share some of the same personality traits.”

“I know. That’s the reason I’ve put off having the meeting.”

“But it is important to know his mind-set,” Ava said. “I’d like to know if he’s still mad.”

“Me, too,” Noah said. “Have you heard anything from Dr. Kumar to make you think that Dr. Jackson complained to him?”

“Not a thing.”

“Okay, good,” Noah said. “I think his threats to talk with our bosses was just his venting in the heat of the moment. Dr. Hernandez hasn’t said anything to me, either. Best-case scenario is that Dr. Jackson realizes some of the blame falls on his shoulders. If that’s true, we are in a far better position than with Dr. Mason.”

“We need to find out how he feels to plan your presentation,” Ava said. “When do you think you will be talking with him?”

“Now that you’ve reminded me, I’ll try to do it tomorrow.”

“I hate to be pushy, but it could be important.”

Eager to change the subject, Noah said, “The first time I was here, when you were showing me your fabulous computer setup, you said something interesting after admitting how much you enjoyed social media and how much time you spend doing it. You said it’s allowed you to learn more about yourself than if you’d done psychoanalysis. Were you being serious?”

“I was very serious.”

“You also said that you would be willing to explain it to me sometime. Is this a good time?”

“As good a time as any,” Ava said. She sat back in her seat. “First, why I enjoy it so much? That’s easy. It fills a social void, which binge-watching Netflix doesn’t do, although I do that sometimes, too. I’ve already explained why I prefer not to socialize with colleagues — you excepted, of course. Since my work is so encompassing and I’m invariably out of town consulting or traveling when I’m off, I know almost no one here in Boston. Online, I have an entire complement of so-called ‘friends’ always waiting, probably a lot more varied and interesting than if I had acquaintances here in Boston who would undoubtedly be as busy as I am and unavailable when I was available. The online world is so much bigger than the invariably parochial real world, and it is always there, never sleeping and never too busy. And best of all, when you have had enough for whatever reason, you just click it off, no muss, no fuss.”

At that moment, Ava’s mobile phone filled the room with its raucous sound. After checking to see who was calling, she excused herself and went out of earshot to take the call. It was a typical interruption that Noah had learned to expect but hadn’t learned to like. While she was away, he thought about what she had said and wondered if he would rely on social media as much as she if he had as much free time as she did. She averaged a typical 40-hour-per-week schedule, whereas he averaged somewhere in the neighborhood of 120 hours per week at the hospital, far more than he was supposed to be doing.

Noah toyed with his food but didn’t eat, preferring to wait for her return. Unfortunately, this episode was longer than the usual. When she finally reappeared thirty-five minutes later, she was appropriately apologetic. While they microwaved their food to rewarm it, she explained that one of her major bosses at the NSC was all uptight about an article coming out in the Annals of Internal Medicine the following week. This article, similar to but larger than others that had come out since 1992, would be reporting on a study of almost a half million people over a decade that multivitamins and dietary supplements failed to show any benefits. Perhaps even more damning, it would state that megavitamins had shown a paradoxical increased risk of cancer and heart disease.

“No wonder your boss was upset,” Noah said, not bothering to suppress his delight. “That could be a death knell for the industry and maybe for your consulting.”

“Not in the slightest,” Ava mocked. “We lobbyists have learned how to deal with such studies. There have been others, and like what was done in the past, we’ll argue that the wrong amounts of vitamins or the wrong brands of supplements were used. Then we’ll say there was something wrong with the way the subjects were selected. After that we’ll blame the results on the big drug companies and fan conspiracy theories even to the point of suggesting big pharma was behind the study because they don’t want people to keep themselves well with relatively inexpensive supplements. The implication, of course, is that the drug companies want to sell more expensive prescription drugs. The public will eat it up. Besides, something like a medical journal article stays in the news feed for one cycle only, and then it disappears under the next scandal or disaster or tweet.”

“God! That’s discouraging,” Noah said.

“Ultimately, it is what the public wants, meaning an easy way out by taking a few pills rather than making the effort to maintain healthy lifestyles. Of course, for me it means I’ll have to go directly back to Washington to do damage control.”

With the food reheated, they sat back down at the counter. Night had completely fallen, and thanks to a run of superb weather, it was yet another picture-perfect evening. The glass sliders that lined the kitchen were folded back into their pockets, making it seem like the kitchen and the backyard were one single room. The floodlight illuminated the carefully planted garden. With the help of a few crickets, the fountain provided restful background noise.

“So you were telling me how social media fills a social need for you with no muss and no fuss.”

“Right,” Ava said. “But it’s a lot bigger than that. It gives me the opportunity to explore aspects of myself that I wasn’t even aware of.”

“Oh?” Noah questioned. Statements like that seemed to him to be on the weird side, especially coming from a fellow physician.

“In real life we’re all caught up in the reality of who and what we think we are,” Ava said. “We value consistency and so do our family and friends, who are more like us than we usually like to admit. That’s not the case in a virtual world. I can be whoever I want to be without any downside or consequence, with the benefit of learning more about myself.”

“So Gail Shafter, your Facebook and Snapchat persona, is not you with a different name?”

“No way,” Ava said with a unique laugh. “Although we’re the same age, she’s mired in a world that I was initially caught in right after high school but managed to escape. She’s stuck in a small town, working for a dentist who lords it over her, and she’s divorced after a failed marriage. She gives me a true appreciation of my life and what I’ve been able to become in the real world by a combination of hard work and chance. Compared to her, I am so lucky.”

“So it’s safe to say that when you’re on Facebook you’re Gail and not you?”

“Of course. It goes without saying, just like when I go on Facebook as Melanie Howard, I’m Melanie Howard.”

“Melanie Howard? Is that the name of another sockpuppet?”

“I don’t like the term sockpuppet or even smurf. They are too closely associated with uncivil online behavior. Melanie and I don’t do that. We don’t engage in any vicious trolling or any flaming whatsoever. That’s hardly the goal or the point. Melanie Howard is just another person in the virtual world trying to do the best she can within the limitations of her social circumstances, her personality, and her intelligence.”

“What’s she like?”

“In general, she’s the antithesis of me, or what I am afraid could have been me to some extent. She is the same age but a shy, unsophisticated, and gullible woman who is as desperately looking for love and companionship. Her boring job is as a secretary at a plumbing firm in Brownfield, Texas, working for an unappreciative boss who is constantly trying to hustle her. On the positive side, she’s attractive, with a warm, generous, and accepting heart, at least up to a point. Once that point is overstepped, she is as hard as steel.”

“Wow,” Noah said, not quite knowing what else to say. His original thought was that Ava used the name Gail Shafter just to protect her privacy, not because she wanted to experience a virtual life completely different from her own.

“Does this shock you?” Ava asked, looking at Noah with her head tilted slightly. She was smiling and obviously challenging him. “This is the twenty-first century,” she reminded him. “Almost two billion people use Facebook alone.”

“I’m just surprised,” Noah said. “Does it make you feel at all like an imposter with all these Facebook identities?”

Ava laughed. “Not in the slightest, because the word imposter has much too much of a negative connotation. I consider people like Melanie friends of mine and separate, real virtual identities for whom I merely act as the spokesperson so I can explore aspects of my own personality. I know that sounds a bit like ‘real artificial diamonds,’ but the current-day virtual world is challenging the real world in terms of relevance. What does real really mean? But if you insist on using the word imposter, remember that almost everyone on social media lies to puff themselves up and make their lives sound more exciting than they are. Even their supposedly candid pics are all Photoshopped. All they care about is the number of ‘likes’ they get. In that sense, most everyone today is an imposter. And what about you, Dr. Rothauser? Have you ever been an imposter to some degree, say, on a résumé?”

“Absolutely,” Noah said with such surety that it was Ava’s turn to be taken aback.

“Like all third- and fourth-year medical students,” Noah explained, “I had to pretend I was a doctor. If we didn’t do it, patients wouldn’t have put up with our fumbling antics.”

“Ah, yes, I remember it well. There were many times I felt guilty about the deception. But I was truthful if a patient asked.”

“Same with me,” Noah said. “What about dating websites, which you said you visited? Is that Gail and Melanie who go on them?”

“For sure,” Ava said. “I’d never go on a dating website for myself. They are entertaining, but there are too many weirdos out there hiding behind fake profiles. I know you said it worked for you, but that was a few years ago. Today most are just trolling for sex.”

“Has Gail or Melanie ever met up with any of the people they have interacted with online?” Noah asked.

“Of course not!” Ava said. “I’m surprised you’d even ask. That would have to be me, and I would never do it, even if I was trying to pass myself off as Gail or Melanie. It would be a huge mistake for dozens of reasons. Besides, it wouldn’t surprise me if half or more of the other people are smurfs as well. It’s officially admitted that at least ten percent of all the Facebook users are fake profiles. That’s somewhere around two hundred million. But as disturbing as that may sound, it doesn’t matter. It is the anonymity that is important. As soon as real people are involved face-to-face, anonymity goes out the window.”

“It all sounds confusing to me,” Noah said. “And not easy to do. When I was a teenager, I learned that the problem with lying was forgetting what you lied about. Do you ever get confused about who you are when you move from one to the other with these virtual identities?”

“I keep extensive files on them, which I update on a regular basis. I even have developed my own algorithms to alert me if I say something out of character. It is part of the challenge to be consistent.”

“You are really into this,” Noah said. He had trouble believing it was all worth the effort.

“I am,” Ava admitted. “As much or more than I was into gaming.”

“What about photos and all that? How is that handled?”

“That’s easy with all the profiles and photos available on the Internet and the capabilities of photo-editing apps. Believe me, it’s not hard.”

“One last thing,” Noah said. “I remember reading an op-ed piece not too long ago about people coming to believe their lies on social media. Some psychologists were worried about such distortions affecting someone’s sense of self. Do you see that as a problem?”

“It depends on your viewpoint,” Ava said. “There has always been a certain amount of embellishment that people have done to their histories, even before the Internet and social media. The opportunities are greater now, with technology effectively changing our culture. It is even changing medicine. Everybody is becoming somewhat of an imposter as well as progressively narcissistic. Some people might see that as a problem, others might view it as opportunity.”

“I have to admit it’s all fascinating,” Noah said. “While I’ve been locked up in the hospital these last five years, the world has changed.”

“And the speed of change is accelerating,” Ava said. “Listen, after your shower, I can take you up to the computer room and introduce you to Melanie Howard. In a half-hour or so, you’ll feel like she’s an old friend. You’ll know that much about her, and we’ll make sure to friend you. I can assure you that she is going to love you.”

“I’ll enjoy meeting Melanie,” Noah said while he and Ava carried their dishes to the kitchen sink. As they rode up squashed together in the elevator, Noah found himself remembering the movie Her, wondering exactly how he was going to feel about Melanie Howard. Would he see her as a separate, virtual person even though he knew it was Ava’s hand inside the sockpuppet?

17

THURSDAY, JULY 20, 10:21 P.M.

Keyon Dexter took exit 25 off Interstate 93 to Plymouth, New Hampshire. He was tired since he’d been driving for almost two hours from Boston. He had lost a coin toss with his partner, George Marlowe, that decided who would be the driver. On out-of-town trips, they both preferred to sit with the passenger seat pushed way back and reclined, so they could put their feet up on the Ford van’s dash. For almost a year they had been assigned to the Boston area by ABC Security out of Baltimore, Maryland, which had established a branch office in Boston in the Old City Hall building on School Street.

“Man, we are out in the boonies here,” Keyon remarked. “I was hoping we were finished with this mickey-mouse stuff after taking care of Savageboy.”

“I did, too,” George said. He put his feet down and slipped on his shoes, then straightened up the seat and pulled it forward to make it even with Keyon’s. “Hopefully once we take care of CreepyBoar we’ll have seen the end of it. The virtual proxy network that’s in place now should keep this kind of crap from happening in the future.”

“I don’t know,” Keyon said. “These kids are something else. They’ve grown up with this technology rather than having to learn it the hard way like we did. For them it’s second nature. They’re all a bunch of hackers in waiting. Maybe they’ll find a way to circumvent a VPN.”

“I suppose it’s possible. They are also clever in their username choices. CreepyBoar is pretty unique.”

“Do you think he’s going to be as easy as Gary Sheffield?”

“If I had to guess, I’d say yes. Why else would he be spending so much effort trying to meet up with a thirteen-year-old girl?”

“It takes all kinds,” Keyon said with disgust. “It also depends on whether he’s a faculty member or a student. What’s your guess?”

“Faculty member,” George said without hesitation. “Students have too much candy within reach. They don’t have to go trolling on the Internet.”

“I suppose you have a point,” Keyon said. “But online he says he’s an eighteen-year-old college student.”

“I don’t care what he says,” George snapped. “People make up all sorts of shit online. But maybe I’m just being hopeful. If it turns out to be a student, our job of cleaning up this particular mess gets a lot harder. Teenage boys in particular are always bragging about their exploits, so Teresa Puksar’s address and info might already be in lots of smartphones.”

“We can only be expected to do the best we can,” Keyon said.

They had come to Plymouth as dictated by their target’s IP address. But in contrast to Gary Sheffield, whose IP address gave them the man’s actual street address, with CreepyBoar, they were able to get only the Plymouth State University network’s location. What they needed to do was get on the university’s network to get CreepyBoar’s computer location, which was why they needed to do it at night. They wanted CreepyBoar to be at home.

When they came to a roundabout, they headed south on Main Street. It was a modest college town with mostly one- or two-story buildings. The university campus was on their right, stretching up a gradual hill. The center building was a square-shaped brick clock tower.

Using a detailed map they had downloaded from the Internet, they made a circle around the campus, or at least as much of a circle as they could. The architecture was an indeterminate mix, with most of the buildings made of red brick.

“Not a lot of activity,” George said.

“It’s their summer session,” Keyon said. “It’s probably a lot different during the normal academic year.”

They rode in silence. Each knew what the other was thinking. There was no way they would want to live in such a rural environment.

“All right,” George said when they had made a full loop around the college. “Now that we’ve got the lay of the land, let’s find a place to park and see if we get lucky.”

Keyon pulled into a spot on Main Street where there were a number of other vehicles. Most were pickup trucks. A few restaurants were still open, including one that looked like a 1950s diner. The other stores were closed.

Both men moved into the back of the van and powered up their gear. It didn’t take long once they were on the Plymouth.edu network. As they expected from already knowing CreepyBoar’s online habits, the target was busy at the computer. But what they didn’t expect was that it wasn’t a he. The computer belonged to a Margaret Stonebrenner.

“Well, I’ll be damned,” Keyon said.

“Let’s not jump to conclusions,” George said. “Maybe Margaret has a teenage son who is busy using his mother’s computer.”

“You’re right,” Keyon said.

They then ran Margaret Stonebrenner of 24 Smith Street through all the extensive databases they had access to. They soon learned she had no criminal record, and that she was an instructor in psychology who had been divorced since 2015 from Claire Walker, whom she had married in 2011. There had been a daughter from Claire’s previous marriage, but Claire ended up with full custody.

“There you go,” Keyon said. “At least we were right about her being a faculty member.”

“And wrong about the orientation,” George said. “It never occurred to me the mark might be gay. Why the hell was she trolling a teenage girl pretending to be a teenage boy? I’m shocked, although maybe it’s hard being gay in a small rural town. But what do I know?”

“You think you’re surprised,” Keyon said with a chuckle. “Think how poor Teresa Puksar would have felt if she’d agreed to meet.”

Keyon and George had a good laugh.

“I tell you,” George said when he had recovered, “I don’t know what this world is coming to. I’m only thirty-six, but considering how far out of it I am about all this LGBT stuff, I might as well be twice that. It’s crazy.”

After consulting their street map of Plymouth, the two men climbed back into the front bucket seats and set off toward Smith Street. It wasn’t far, as nothing in Plymouth was far. They first did a drive-by, noticing that 24 Smith Street was a small two-story white Victorian house with decorative bargeboard under the steeply angled eaves. The first-floor windows were illuminated, while those on the second floor were dark.

“Looks encouraging,” Keyon said. “Think she lives alone?”

“We can’t be that lucky two hits in a row,” George said. “But we can always hope.”

They parked the van on a neighboring cross street and hiked back. As they walked they checked out the nearby houses, most of which were dark. “People turn in early here in Plymouth,” Keyon said. “I guess there’s not a lot of nightlife.” He chuckled quietly at his understatement.

When they reached their destination, they glanced around at the immediate neighboring homes. Conveniently, they were all dark. Turning their attention to Margaret’s house, they could hear a noisy, old-fashioned window air conditioner, which they also thought advantageous. The sound of gunfire in the complete silence of a country town could carry far and wide. With that in mind, Keyon had brought along his Beretta semiautomatic pistol with suppressor. It was a surprisingly quiet weapon. The downside was that it was significantly bulky in its shoulder holster, and he wouldn’t have gotten away with wearing it in daylight.

As per usual, they positioned themselves on either side of the door, fake FBI badges at the ready. As there was no doorbell, George knocked. When no one responded, he knocked louder. This resulted in a carriage lamp going on right next to George, which he didn’t like. A moment later a female voice called through the door asking who was there.

On this occasion Keyon did the talking, essentially reiterating the FBI-agent spiel they gave Gary Sheffield about being part of the bureau’s Cyber Action Team. The difference was that Margaret didn’t open the door.

“What do you need to talk about?” Margaret asked.

Again, Keyon followed their usual protocol by explaining that there had been felonious cyber-activity emanating from the house that needed to be investigated.

“I would prefer that you come back tomorrow,” Margaret said. “How do I know you’re FBI agents?”

Keyon and George exchanged a worried glance. They also heard something else they didn’t like, a bark and growl, and it wasn’t from a miniature poodle.

“If you would open the door, we can show you our credentials,” Keyon said.

“I’ve never heard of FBI agents coming to someone’s door this time of night,” Margaret said. “I’m sorry. I’m here by myself.”

“Ma’am, we understand your reluctance, but if you don’t talk with us, we will have to come back with the local police and have you arrested. We are quite sure that we can clear this all up without that kind of embarrassment. But we can’t do it through the door.”

For a moment, there was silence marred only by the sound of the nearby window air conditioner. Keyon and George exchanged another glance, sensing they were losing control of the situation. Then they heard what sounded like the musical notes of a mobile phone being dialed.

“Shit!” George snapped, speaking up for the first time since they’d come onto the porch. He stepped back and raised his foot, kicking the paneled door with all the force he could muster just to the side of the doorknob. The old wood splintered and the door burst open. A second later they charged into the room, causing a shocked Margaret Stonebrenner to stumble backward. At the same moment, a large black German shepherd charged at George, who was first through the door.

Thanks to his Marine Corps training, which had included crowd control and dog attacks, George lifted his arms over his head to deny the shepherd a handy target. George absorbed the sizable dog’s attack and stayed on his feet. Although the dog was able to get a bite full of George’s right jacket sleeve, Keyon had his Beretta out and shot the animal twice in the chest. At first the bullets seemed to have had no effect, since the dog continued to shake its head, trying to tear George’s jacket. Then, with the same suddenness that the attack began, the dog let go of its hold on George’s sleeve, teetered for a moment, whimpered, and then sank to the floor. A moment later it rolled onto its side.

Seeing what had happened to her dog, Margaret began screaming, even as Keyon pointed the gun in her direction and yelled for her to shut up.

“You bastards,” she cried, her face a picture of terror and anguish. She started coming at Keyon with fire in her eyes. Keyon responded by shooting her in the forehead. The result was the same as it had been for Gary Sheffield. Margaret was knocked over backward onto the floor. For a second or two there was some quivering in her limbs. A moment later her sightless eyes stared up at the ceiling.

“Goddamn it,” George exploded. “Now we can’t question her.”

Before Keyon could respond, both heard a male voice coming from Margaret’s mobile phone. She had dropped it onto the hall carpet when she was shot. “This is the Plymouth Police Department. Is everything okay there, Miss Stonebrenner?”

Keyon snapped up the phone, turned it off, and pocketed it. “We have to get the fuck out of here.”

“We need her computer,” George said.

“I see it,” Keyon said. He pushed past George into the dining room, where an open computer sat on the table. Keyon slammed it shut and took it under his arm. There was also a woman’s purse. He snapped that up as well.

While Keyon was in the dining room, George hurriedly pulled on some latex gloves. Going to an open roll-top desk, he rifled through a few drawers, leaving them open, dumping one onto the floor. Then the two men hurried out into the night, slowing to a normal walk when they reached the street. As they headed for the van, they cast worried glances at the neighboring houses, but nothing had changed. The neighborhood seemed as quiet as it had been earlier.

“That was messy,” George said with disgust as he climbed into the van’s driver’s seat. It was his turn to drive. “Probably our worst job.” He snapped off the gloves before starting the engine.

“In this business, you never know what you’re going to get,” Keyon said. “Let’s not own up to what happened unless we are specifically asked. Let’s also hope the new VPN is as good as it’s claimed to be so this is our last job like this.”

“I’ll second that,” George said. “But you know what surprised me? How normal this Stonebrenner looked. I expected her to be more like the others, like Sheffield. Somebody you wouldn’t look at twice, living a boring humdrum life, kinda nerdy and dumb, relying on social media to have a life, even if only virtual. She didn’t strike me like that. And she didn’t buy our FBI story, not for a second.”

“Social media is taking over our culture,” Keyon said. “It’s not just the teenyboppers anymore. It’s everybody.”

To avoid driving back through town, George took a circuitous route to I-93 on their way back to Boston.

18

FRIDAY, JULY 21, 9:15 P.M.

For a bit of variety after exhausting the Toscano menu for five nights in a row, Noah was back in the Thai restaurant called King & I. He’d called in an order after leaving the hospital and talking briefly with Ava to get her preferences, and now he stood by the cashier to wait.

It had been a very busy Friday. It had started earlier than usual because Friday morning’s basic science lecturer had canceled, forcing Noah to give the important lecture on postoperative electrolyte maintenance, which required a bit of preparation. To do so, he’d awakened at 4:00 A.M. and managed to leave Ava’s without waking her.

Following the basic science lecture, Noah had four surgeries, including a complicated esophagectomy, or removal and replacement of the esophagus. It was a difficult procedure that he’d done only once before. Luckily it had gone well, although he didn’t have high hopes for the patient; esophageal cancer was a particularly difficult disease for the oncologists.

Although all the surgeries had gone well, there was one unfortunate occurrence. Although he generally tried to avoid running into Dr. Mason by keeping track of his schedule, that morning it had happened despite his best intentions. Noah had just finished his first case and was accompanying the patient along with the anesthesiologist to the PACU when Dr. Mason unexpectedly appeared out of a case that was supposed to take four hours yet had been under way for only less than two. Despite Noah’s attempts to indicate he was busy, Dr. Mason insisted he talk and pulled him aside. He then proceeded to rail Noah about the quality of residents Noah was assigning to Dr. Mason’s cases. “With the kind of patients I bring into this hospital, I shouldn’t have to deal with incompetence in the assistants I’m assigned,” Mason had spat. “And let me tell you, I’m going to bring this up with Dr. Herandez, Dr. Cantor, and Ms. Hutchinson.” Gloria Hutchinson was the president of BMH.

Of course, Dr. Mason’s complaints were baseless. If anything, Noah went out of his way always to provide as senior as possible residents for Dr. Mason, anticipating the man’s tendency to blame everyone around him whenever something out of the ordinary happened. It was also true that Noah had not received any complaints about surgical resident assistants from any other surgeon, and that included all twenty-four of the first-year people.

Noah had tried to end the conversation by asking Dr. Mason if he might provide Noah with a list of the residents he enjoyed working with so that Noah could attempt to assign those people to Mason. But instead of taking this peace offering, Dr. Mason had switched the subject of the conversation to the upcoming M&M.

“I hope to God you are not planning on shielding your incompetent lover like you so obviously did with the Vincent case,” Dr. Mason had snarled. “Because you are not going to get away with it this time. I had to hold my tongue during the last conference because I was the surgeon. Not so on this occasion. No free lunch this time.”

Once again, Noah had to endure being stabbed in the chest by Dr. Mason’s persistent index finger as the surgeon made his final point before he continued toward the surgical lounge.

“Your take-out is ready,” the King & I cashier said, pulling Noah back to the present.

Noah paid and left the restaurant. Charles Street was alive, with people enjoying themselves. As he walked he felt one with this world, which was unique for him. Anticipating spending another pleasant evening with Ava, he didn’t feel his usual sense of isolation from normal society, as he now had a life outside of the hospital. He smiled, thinking that maybe there was hope for him after all.

As he trudged up Pinckney Street on his way to Louisburg Square his thoughts went back to his busy day, which had included several important conversations that he was eager to share with Ava. After the run-in with Dr. Mason, which jolted him into remembering exactly how close the M&M Conference was, he first made it a point to investigate which junior resident had been assigned to the emergency room on that particular day. It was Dr. Harriet Schonfeld. He’d found her in the ER sewing up a laceration. He was pleased with what he had learned from her and looked forward to telling Ava.

Next Noah had met with the anesthesia resident, Dr. Carla Violeta, plus the circulating nurse and the scrub nurse on the Gibson case, but he didn’t learn anything from the three of them that he didn’t already know. Finally, following Ava’s encouragement the night before, he had arranged to meet with Dr. Warren Jackson, which he dreaded and had put off just as he had put off meeting with Dr. Mason before the last M&M. As an older surgeon who had trained at the same place Dr. Mason had trained, Dr. Jackson shared some of Dr. Mason’s unpleasant narcissistic traits, in particular an easily offended, arrogant attitude and a stubborn reluctance to accept any blame, even if warranted. To his surprise, Noah had found Dr. Jackson much more reasonable than Dr. Mason.

Ava was particularly happy to see Noah when he finally rang her bell and got buzzed in. It was nearly 10:00 P.M., and she admitted to being starved when Noah found her in the kitchen. She had opened a bottle of wine and had already drunk a quarter of it while she’d used her iPhone to go on Facebook while she waited. Noah apologized for being kept at the hospital because of a late-afternoon emergency.

They ate at their usual location, looking out at the garden. Noah was eager to tell her what he had learned but had to bide his time while she told him about several demanding cases she’d had that day that had required more anesthesia skill than the usual. Noah was impressed with how she had handled them. Her encyclopedic knowledge of anesthesia rivaled his command of the minutiae of surgery. After dinner they ended up in the study as per usual. Noah had come to understand why it was her favorite sitting room in the house. It was rapidly becoming his as well. Almost like Pavlov’s dogs, each took the exact same chair they’d occupied on previous evenings, as if responding to some internal directive.

“Okay, your turn,” Ava said, realizing how much she had been dominating the conversation. “Sorry for carrying on.”

“Not at all,” Noah said. “I’m intrigued by your command of your field.”

“I’ve had superb training,” Ava said, pleased.

“I have some good news and some bad news,” Noah said. “Which do you prefer first?”

“Let’s get the bad out of the way so we can rest on the good.”

“Unfortunately for me, I ran into Dr. Mason in the OR hallway,” Noah said. “He cornered me as usual and mouthed off with a complaint about the assistants I’ve been assigning him, which is all a bunch of nonsense. But more important, he warned me not to shield you during this M&M like he feels I did during the last M&M.”

“He said that specifically?” Ava questioned.

“Very specifically,” Noah said, “using the exact same words.” Noah did not add that Dr. Mason had referred to her as “your lover.” “He also remarked that he’d been muzzled at the last M&M, which wasn’t going to be the case this time.”

“Okay, that’s the bad news. What’s the good?”

“My meeting with Dr. Jackson wasn’t anything like I expected,” Noah said. “He actually admitted that he’d made a mistake pressuring the first-year resident into starting the case before you were in the room. He said he’d come to the realization after giving the episode more thought.”

“That’s terrific,” Ava said, her face lighting up. “Do you think he might be willing to say something to that effect at the conference?”

“I think so,” Noah said. “I also talked with Dr. Violeta.”

“I know,” Ava said. “She told me.”

“She’s willing to confirm being pressured,” Noah said. “So I won’t mind bringing it up.”

“You’ll have to bring it up,” Ava said. “It has to be established that I wasn’t in the room when the patient was given the paralyzing drug and had already arrested. Both are key.”

“You are right,” Noah agreed. “I’ll definitely mention it.”

“This is good news,” Ava said. “I feel better already about this M&M.”

“And I got more significant news today,” Noah said. “I talked with the junior surgical resident who handled the case in the ER. When I told her that the neck problem wasn’t in the electronic medical record, she was astounded and insisted that she had included it.”

“It wasn’t in the EMR,” Ava snapped. She sat up and moved forward in her chair, ready to do battle.

“It was, and it wasn’t,” Noah said. He reached out and put a calming hand on Ava’s thigh. “What we found were two EMRs for the same patient with an inversion of two letters in the spelling of the name, one with the problem described and another without it. Somehow the computer had made two records. I already visited IT about it, and one of their people is going to look into it, figure out how it happened and how to keep it from happening in the future.”

“That’s perfect,” Ava said. With a sigh of relief, she sat back in her chair. “That alone could eat up a good portion of the discussion time. Most of the staff are down on the EMR already and will love to offer their opinions.”

“Exactly my thoughts as well,” Noah said. “It’s looking good, like we’ll be able to get through this next M&M as well as we did with the first. What I plan to do is leave Helen Gibson for last, just like I did with Bruce Vincent. If I time it right, maybe there won’t be any discussion time and we won’t have to listen to Dr. Mason carry on.”

“I was just going to suggest as much,” Ava said. “I love it.”

“I do have one question for you, though,” Noah said. “Were you familiar with the video laryngoscope you were using that day? I know there are a number of different brands, each a little different.” Noah tried to use an offhand tone of voice as he asked this question, as if the idea just occurred to him. It was an issue that had been bothering him in the back of his mind since the event. He’d had the impression Ava had seemed less than adept with the instrument than she should have been, although he was the first to admit he might have been expecting the impossible. When Ava was using the device, the patient’s head had been bouncing all over the place from the cardiac massage, which would have made it difficult for anyone. Putting in an endotracheal tube on certain patients with restricted neck motion could be incredibly difficult, as Noah painfully knew from personal experience.

“Of course I was familiar with the McGrath laryngoscope,” Ava said with a touch of irritation. “Just like I’m familiar with all the other scopes on the market, such as the Airtraq or the GlideScope. They are all more similar than different, although I do prefer the GlideScope because it has a larger screen.”

“I see,” Noah said, nodding. That was already more than he knew about video laryngoscopes. But the issue of Ava’s struggles bothered him like a pebble in his shoe. He was also mildly troubled by something else he had learned. There was more time than he expected between the moment the first-year resident sent out the alarm that she was having trouble and needed help and Ava’s arrival in the room. Of course, Ava was observing another patient being put under general anesthesia at the time. Yet that induction had been carried out without any trouble whatsoever, so why didn’t Ava come right away? And why hadn’t Ava ordered a tracheostomy immediately when she saw how difficult it was to put in an endotracheal tube and the patient had already had a cardiac arrest from low oxygen?

“Are you aware of the time?” Ava said, interrupting Noah’s thoughts.

Noah glanced at his watch. “Oh, my gosh. It is almost midnight.”

“I don’t know how you function on so little sleep,” Ava said. “I need to go to bed. What do you say?”

“Fine by me,” Noah said agreeably, and he meant it, realizing he’d been on the go for just shy of twenty hours.

“You know something?” Ava asked suddenly in a sultry voice.

“What?” Noah asked innocently.

“This good news of yours turns me on.”

“Oh?” Noah commented innocently. He wasn’t sure he had heard correctly, or if he had, what he should do.

Ava solved Noah’s immediate dilemma by standing up, and to Noah’s surprise peeled off her blouse and dropped her jeans. She stood before him in a dark green, incredibly sexy bra-and-panties outfit the likes of which Noah had never seen, covering the least amount of dermatological acreage he thought possible. She sauntered over to Noah, who was momentarily paralyzed, and sat on the arm of his chair. He was dazzled by her pheromones.

“You know what I think we should do with all this good news?” she asked in the same husky voice.

“I’m beginning to get an idea,” Noah said, more than willing to play the game.

“Let’s make love right here, right now!”

An hour later, they were lying in Ava’s king-size bed, gazing up at the ceiling with Oxi and Carbi curled up at the foot. Although feeling great, Noah was struggling to stay awake after having gotten up that morning at 4:00 A.M. and working all day.

“I have to admit something,” Ava said suddenly. “I’m totally jealous of your Ivy League education. What a thrill it must have been for you to go to Columbia, MIT, and Harvard. I can’t imagine how proud you must be. And getting a Ph.D. like you did in just two years. It is remarkable.”

“I was lucky,” Noah said. “At the same time, I worked my butt off.”

“I wish I had had the opportunity,” Ava said wistfully. “Being here at the BMH, I feel embarrassed at having gone to such an unknown school. It seems that most everyone around here trained at a name institution like you.”

“I’m impressed with what you have been able to do,” Noah said sincerely. “I looked at your educational background on LinkedIn and learned you were in a combined six-year college and medical school program. In many ways, it’s more impressive than what I’ve done. My path was clear from middle school on. You said you weren’t motivated to go to college. What changed your mind?”

“Working for the dentist,” Ava said. “It made me realize I wasn’t going anyplace fast and that I’d be doing the same thing for the rest of my life. It was a rude awakening. Luckily, my boss, Dr. Winston Herbert, was recruited to start a dental program at Brazos University in 2001, which he did in 2002. Brazos U was a new school formed in the mid-nineties in Lubbock that was growing by leaps and bounds. They had started a medical school a few years later. Dr. Herbert brought me along with him when he became dean of the dental school, so I was in reality working for the university. Of course, he was taking advantage of me at the time, despite his being married and all.”

“I’m sorry,” Noah said. He felt anger at the thought of a man sexually abusing a teenager.

“It’s water over the dam,” Ava said. “I’m not bitter. In fact, I’m thankful. I wouldn’t be where I am today if it hadn’t been for Dr. Herbert. Being part of a growing university opened my eyes to so many things. And he was encouraging right from the start. He even started my interest in anesthesia.”

“Really?” Noah questioned. “How was that?”

“Dentists often can be very cavalier about anesthesia,” Ava said. “They feel comfortable using it in their offices without the kind of backup I demand now. And he let me do it almost from day one. Here I was giving anesthesia at age eighteen, knowing almost nothing about it. It terrifies me now when I think back, but I was fascinated by it. It’s what prompted me to go to college and then medical school. When I barely managed to graduate from Coronado High School, I never in a million years thought I’d go on to any form of formal education.”

“How did you manage, moneywise? Did your family help?” Noah asked.

Ava gave a short mocking laugh. “Not in the slightest. I never got along with my father.”

“Well, that’s another way we’re alike. I never got along with mine, either.”

“My mother remarried after my father died, but her new husband and I were like oil and water. I was on my own right after high school. Working for Dr. Herbert and the university was what made it all possible. I worked for him whenever I could throughout college and medical school.”

“What were you like as a child?” Noah asked. Though they shared a commitment to medicine, it was apparent to him that early on they were very different people. Once he’d seen the light in the first years of high school, he’d been overly committed to education and becoming a surgeon. It had consumed him, and it still did.

“I really don’t like talking about my past,” Ava said firmly. “It brings back too many painful memories. I’d much prefer to talk about the future. Or better still, your past.”

“What would you like to know?” Noah said.

“Everything,” Ava said. She pushed herself up on an elbow and looked at Noah. “I know we were born the same year, 1982. When I put it all together, I’m missing two years in your history.”

“You continue to impress me,” he said. “You’re correct. Medical school took me six years rather than the usual four. During my second year my mother got sick and had to leave her job, which was supporting me and my disabled sister. I had to get a job. Luckily, I got a job with the medical school so I could stay involved by attending lectures. When my mother passed away, I was able to rematriculate and finish medical school.”

“I’m sorry,” Ava said. “That must have been a struggle.”

“Like you said earlier, it’s water over the dam. You do what you have to do.”

“And tell me more about your Ph.D. thesis in genetics from MIT,” Ava said. “That’s really impressive. I’ve never heard of someone getting a Ph.D. so quickly. How on earth did you manage it?”

“It sounds more impressive than it was,” Noah said. “I had started it as an undergraduate project in bacterial reproduction, so I had a jump on it. But to be honest, I didn’t do it for the purest intentions. I did it with the hopes it would get me into Harvard Medical School, which it did. I was scared; when I’d finished my undergraduate degree in biology, I was turned down by both Columbia and Harvard Medical School. I knew I had to do something out of the ordinary.”

“You’re just being modest,” Ava said.

“I don’t think so,” Noah said. “I even fudged on it a bit, at least initially. But that’s another story.”

“What do you mean?”

“It doesn’t matter,” Noah said. “The whole project was more busy work than a real breakthrough, and in that sense somewhat of an embarrassment.”

“Sounds imposterish, if I can coin a new term, just like we were talking about last night.”

Noah pointed at Ava’s nose and said with a laugh, “Very clever. You got me! I suppose I am kind of a Ph.D. imposter.”

19

MONDAY, JULY 24, 2:35 P.M.

“For your first endoscopic gallbladder removal, that was well done, Mark,” Noah said to Dr. Mark Donaldson in operating room 24. Mark had just withdrawn the gallbladder out of one of the four tiny endoscopic incisions in the patient’s abdomen. The second-year resident had done a commendable job, and Noah knew it was important for him to be told. When one was a junior resident, praise from a senior, especially a super chief, was critical when it was deserved just as much as criticism when that was appropriate.

“Thank you, Dr. Rothauser,” Mark said while handing off the small, diseased organ to the scrub nurse. He then visibly relaxed a degree, as he had been tense through the entire hourlong procedure. Noah also relaxed. He, too, had been tense with the instruments mostly out of his hands, certainly more tense than if he had been doing the procedure himself. It was part of the strain of teaching surgery. Both residents were looking at the monitor, which gave them a good view of the raw gallbladder bed under the edge of the liver.

“You’re practically home free,” Noah said. “It looks good. All you have to do is suture up the bed to prevent adhesions, make sure there are no bleeders, then pull out the instruments.”

Mark set to work. Some inexperienced surgeons had trouble with coordination when looking at a monitor at eye level as their hands manipulated the instruments below, inside the patient’s body. Mark wasn’t one of these. Noah had never had any problem, either, which he attributed to his playing computer games where the play was carried out by manipulating a computer mouse off to the side while looking straight ahead at a monitor. This realization had given him some satisfaction that gaming hadn’t been as worthless as his mother had complained.

Once the gallbladder bed had been closed, Noah encouraged Mark to irrigate the area with saline and then suck up the fluid. It was the best way to look for any tiny leaking blood vessels that could cause big trouble after the surgery. A few moments later, when Mark was done with this last suturing chore, everything looked perfect. The case was essentially done.

“We are going to be withdrawing the instruments,” Noah said to the nurse anesthetist so she could begin lightening up on the anesthesia. Surgery was a team sport, and it was important to keep everyone informed.

At that moment, the PA system suddenly sprang to life. Everyone started and momentarily froze with their attention focused. Announcements over the inconspicuous speakers rarely occurred, but when they did, it meant something critical was happening. It was Janet Spaulding, and her voice was urgent: “We have an apparent malignant hyperthermia in room number ten. I repeat, we have a malignant hyperthermia in room number ten. The MH cart and all available personnel are needed immediately in room number ten.”

Although the anesthetist, the scrub nurse, the circulating nurse, and Mark immediately regained their composure and went back to work on the case at hand, Noah felt differently. Despite being involved in an ongoing operation and therefore not expected to respond, he desperately wanted to do so: Ava was the anesthesiologist assigned to room 10 for an emergency appendectomy on a twelve-year-old boy named Philip Harrison. Noah was aware of this because it had been up to him, as per usual, to assign a resident assistant for the surgeon, Dr. Kevin Nakano.

“Mark!” Noah said sharply. “Do you feel confident to close the incision sites on this case?”

“I suppose,” Mark said, a bit taken aback.

“It’s not hard,” Noah snapped. “But you must close the fascia, particularly at the incision in the umbilicus. We don’t want her to get a belly-button hernia. Understand?”

“Got it,” Mark said.

“I want to get down to room number ten in case I’m needed,” Noah said, as he stepped back from the operating table, snapping off his surgical gloves in the process. He nodded to the nurse anesthetist to make sure she knew he was leaving before the case had ended.

As he went through the OR room door, Noah struggled out of his surgical gown. He left it and the used gloves next to the scrub sink and started running down the hall toward room 10. What was propelling him with such urgency wasn’t necessarily the patient’s well-being but rather Ava’s. He had never seen a case of malignant hyperthermia, known as MH, but he knew a significant amount about the condition, a rare but life-threatening problem usually triggered by exposure to certain drugs used for general anesthesia. The body’s muscular machinery went into uncontrolled overdrive, potentially leading to organ failure and death.

What was worrying Noah was the possibility that Ava could be facing yet another anesthesia catastrophe so soon after experiencing two others that already had undermined her self-esteem and had her questioning her competence. Noah wanted to be present for moral support, if nothing else. Although he’d never seen a case of malignant hyperthermia personally, he’d participated on numerous occasions in practice sessions spearheaded by the Anesthesia Department for dealing with the critical emergency.

Noah burst into OR 10 and found himself in the middle of chaos. There were twenty people in the room along with the malignant hyperthermia cart, which contained all the potentially needed drugs and hardware to deal with the emergency. About half the people grouped around the patient were anesthesia residents; the rest were nurses, except for two surgical residents. Off to the side was the cardiac crash cart in case it was needed.

The frantic activity was centered on preparing the major treatment modality, a drug called dantrolene. Since the drug was unstable in solution, it had to be prepared on the spot just prior to use. While that was in process, other people were preparing a cooling blanket. Ice was brought in and put in a basin, into which bottles of IV fluid were placed. As suggested by the name of the condition, one of its critical hallmarks was a dangerous rise in body temperature that had to be controlled or, in irreverent resident parlance, the brain would be “fried.”

Dr. Kevin Nakano was standing off to the side with his sterile hands clasped over his sterile surgical gown. His eyes had the terrified look of someone who wanted desperately to do something but didn’t quite know what. The situation had been commandeered by the MH team. A sterile towel had been placed over the tiny incision site that Dr. Nakano had been in the process of closing when all hell broke loose. The appendix had already been removed.

Noah made his way through the crowd to the head of the table. Ava stood, her stool pushed to the side, tending to the anesthesia machine, which was ventilating the patient with 100 percent oxygen. Even so, the patient’s oxygen saturation was low, as evidenced by the oximeter alarm and the patient’s color, a mottled blue.

Noah and Ava exchanged a quick but knowing glance. He could tell immediately that she was beside herself with concern but in control, like a competent pilot in an emergency. Noah looked at the ECG and could see the boy’s heart was racing.

“What’s his temperature?” Noah asked over the tumult of voices in the room.

“One-oh-six and climbing,” Ava said. She shook her head. From her eyes alone Noah could sense she knew she was in the middle of a true emergency and was heartsick over the possible consequences. “He’s only twelve years old,” she managed.

“Scary!” Noah said. He was going to say more, but he was nudged aside by the most senior anesthesia resident who’d responded to the call, Dr. Allan Martin, the designated leader of the assembled MH group.

“Here’s the first hundred milligrams of dantrolene,” Allan said to Ava.

“Thank God!” Ava said, taking the medication and immediately attaching it to the IV line. “But I’m going to want three more doses prepared.”

“It is in process,” Allan assured her.

Noah watched as other members of the team properly positioned the cooling blanket for the now completely rigid boy. All his muscles were in tight contraction. It was as if he were made of wood.

The circulating nurse approached Ava from the other side and handed her a piece of paper.

“Allan,” Ava called. “The potassium is going up. I’m going to give glucose and insulin.”

Allan responded with a thumbs-up.

Noah managed to move back to Ava. After she had given the insulin, she had a moment of comparative calm.

“What was the first sign of trouble?” Noah asked.

“A sudden unexpected rise in end-tidal carbon dioxide,” Ava said. She was staring at the temperature readout.

“Oh,” Noah responded. He had expected something more dramatic and not quite so esoteric. “That was all?”

“That was just the first sign of trouble,” Ava said, staring at the temperature readout as if trying to make it go south by sheer force of will. “Then I noticed his jaw clenching. That was when I knew what was happening and called the alarm. By the time the MH team got here he was completely rigid. It came on really, really fast. I’m afraid it’s a severe case, which doesn’t make any sense. There’s no family history. I even asked the mother pre-op.”

“I’m sorry,” Noah said, not knowing what else to say. He could feel her anguish.

“The temperature is not responding to the first dose of dantrolene,” Ava said.

“Is that bad?” Noah asked.

“Of course it’s bad,” Ava said, as if angry. “It’s climbed to above one-oh-seven.”

Ava called over to Allan, asking for the next dose of dantrolene, but before it could be given the cardiac alarm went off. Twelve-year-old Philip Harrison’s heart went into fibrillation.

The team responded appropriately, since the cardiac crash cart was already in the room. The patient was successfully defibrillated, and a relatively normal heartbeat returned. The second dose of dantrolene was given. More tricks were also tried to get the patient’s temperature to reverse its relentless rise. It was at that point that Dr. Adam Stevens, the same cardiac surgeon who had helped Noah on the Bruce Vincent case, came into the room to see what was happening. He had just finished a case of his own. He saw Noah and made his way over to him.

“What’s happening?” Dr. Stevens asked.

Noah gave the surgeon a quick rundown, saying that it was not looking good for the boy. “The temperature is now over one-oh-eight, despite everything that’s being done,” Noah added with growing alarm.

“I don’t like that mottled blue cyanosis,” Dr. Stevens said. “That’s a super-bad sign, suggesting disseminated intravascular coagulation.”

“More dantrolene,” Ava desperately called out to Allan. “The temperature is still rising.”

“There’s only one way to bring the temperature down,” Dr. Stevens said. “Put him on the pump and run the blood through an ice bath. That will do it. Of course, we’re not sure if his brain hasn’t already called it quits. We could do an EEG, but by the time we do that, it most likely would be too late.”

“You’re willing to put him on bypass?” Noah questioned. After the Vincent catastrophe, Noah was less willing to contemplate such heroics, especially after what Dr. Mason had said to him about it being Noah’s actions that had killed the hospital parking czar.

“If you’ll help, I’ll do it,” Dr. Stevens said.

In record time, with both Noah and Dr. Nakano assisting Dr. Stevens, Philip Harrison was put on cardiac bypass. Unfortunately, his temperature had reached 113 before the cooling could be instigated. As the final coup de grâce when the temperature had been brought down into the normal range, the heart would not start, agonizingly similar to the situation with Bruce Vincent. All the effort turned out to be in vain.

“Well, we gave it our best,” Dr. Stevens said an hour later. He was speaking to the entire group in the operating room. No one had left.

Everyone felt dispirited, having given their all, and said little as they filed out of the room. Dr. Stevens departed first, followed by Dr. Nakano. No one spoke.

Noah hung back, watching Ava as she shut down the anesthesia machine and made some final entries in the EMR. On several occasions, she cast a fleeting glance at Noah but didn’t say anything. Nor did he. The circulating nurse and the scrub nurse were in the area, starting to clean up the room. They didn’t speak, either.

Without a word, Ava suddenly turned around, pushed through a side door, and disappeared into the equipment room that housed the sterilizer and surgical supplies. After a moment of indecision, Noah followed her. He found her leaning against the sterilizer for support. She was still wearing her mask, but Noah could tell she had been crying. He approached her, feeling profound empathy for what she was obviously feeling. He put his arms around her and hugged her. She didn’t pull away.

“Do you think it’s wise for us to be seen like this?” Ava asked after a few moments.

“You’re right,” Noah said. He let go and looked back through the glass pane in the door. He was relieved, as he half expected to see either the scrub nurse or circulating nurse staring at them.

“He was only twelve,” Ava said, her voice faltering. “I don’t know if I can take this. This is my third death. I never thought anything like this would happen.”

“It’s not your fault,” Noah said with emphasis. “It has to mean the boy had a genetic predisposition. That’s all. You said you even asked about it in your pre-op interview. You can’t ask any more of yourself than that.”

“He’d had anesthesia a year ago without a problem,” Ava said. “I even used the same agents. He had eaten lunch. That was what I was worried about, not malignant hyperthermia.”

“There is no way you could have anticipated this,” Noah said. “You can’t blame yourself.”

“Maybe that is true, maybe it isn’t,” Ava said dejectedly. “But after this third case, I don’t know if I can continue with clinical anesthesia.”

“I can understand your feeling,” Noah said. “But let’s not make any snap decisions on the spur of the moment. Medicine is always risky. It’s the nature of the calling. Think of how slim the chances are that you had to face this problem. As I remember, it’s like one in twenty thousand cases.

“You have been victimized by statistics or, if you prefer, bad luck. It doesn’t speak to your competence as an anesthesiologist. Try to remember the thousands of cases you’ve done with great results and no problems. You are a great anesthesiologist. You wouldn’t be here if you weren’t. Don’t even think about throwing away all your training and effort.”

“I don’t know what I’ll do,” Ava said. She looked at her watch. It was after 4:00 in the afternoon. “I want to go home.”

“Good idea,” Noah said. “Go home and do something to take your mind off all this. Go on social media!”

“Don’t make fun of me!” Ava warned.

“I’m not. You’ve told me how much you like it. Go do it. Do a video post for your Gail Shafter fan page and make your thousands of followers happy. I’ll come over as soon as I can tonight, and we can talk more. That is, if you’d like to talk more. Maybe in the short term we should do something completely different to take your mind off it, like go out to dinner and pretend to be normal people.”

Ava glanced up at Noah to see if he was being patronizing. “Okay,” she said quietly when she realized he was being sincere. Without another word, she brushed past Noah and exited out into the OR corridor. She didn’t look back.

Remaining where he was for a moment to get his own emotional bearings, Noah pushed back into the operating room. The cleanup had progressed. The two nurses had been joined by two orderlies. The MH cart and the cardiac-arrest cart were gone. He was mildly surprised that the dead boy was still on the operating table. He’d been covered by a fresh white sheet. Vaguely he wondered what the holdup was.

Stopping in the middle of the room, Noah winced at the thought of facing the parents of this child. He was thankful the job wasn’t his. Noah had had his share of deaths over the five years he’d been a resident. Most of them had been expected, but there had been two that were disturbing surprises that had made him more humble about his skills and the unpredictability of medical science. He remembered how it had affected him and how hard it had been to face the involved families. The remembrance made him even more sympathetic toward Ava, especially as his had been separated by more than a year. All three of Ava’s had been within a month.

Noah was about to leave the operating room when the circulating nurse approached him. He knew her reasonably well. Her name was Dorothy Barton. Noah thought of her as competent and knowledgeable but also moody and opinionated, such that he generally made it a point to avoid her. He was surprised when he saw her making a beeline in his direction. He wished he hadn’t dallied.

“Dr. Rothauser,” Dorothy said. She glanced over her shoulder as if concerned someone might be listening. “Can I have a word with you?”

“Of course,” Noah said. “How can I help?’

“Do you mind if we go into the supply room?”

“I guess not,” Noah said. It was an unexpected request. He followed her back into the room he’d just left. He wondered if she had seen him and Ava in an embrace, and if so, he tried to think up an explanation. But he needn’t have worried. She wanted to speak to him about Ava, but not in a way he could have anticipated.

“I noticed something that I think you should know,” she said. She was a heavyset woman shaped like a box, with broad features and thick lips. Her face mask was untied from behind her head and draped over her ample chest. “I’ve had the misfortune of being involved in two malignant hyperthermia cases. The first was at another hospital. So I know something about the condition and what should be done when it occurs. Dr. London did not turn off the isoflurane when the problem started.”

“Oh,” Noah commented. “Did she leave it on long?”

“No, not long, but it wasn’t until I’d come back to her after following her orders to send out the alarm, which I did by using the phone.”

“I see,” Noah said, but his attention was diverted by an insistent knocking on the wire-meshed glass pane in the door to the OR corridor. Turning his head, Noah caught a glimpse of the last person he wanted to see, Dr. Mason. When the visibly livid surgeon saw Noah look in his direction, he angrily gestured multiple times for Noah to come out into the OR corridor on the double.

“Sorry, but I have to go,” Noah said hastily to Dorothy. “Thanks for the info and for being so attentive. I’ll certainly take it into consideration. But right now I’ve got to talk with Dr. Mason.”

Bracing for yet another tongue-lashing, Noah abandoned the surprised nurse and stepped out into the OR corridor.

“I hope you are fucking happy,” Dr. Mason snarled. “This is the last straw. This poor child’s death is one too many, and since you have been protecting this woman whose incompetence is directly responsible, it’s now on your shoulders, too.”

“This was a case of malignant hyperthermia,” Noah said, trying to remain calm in the face of Dr. Mason’s fury. He knew that by talking back to Dr. Mason, he was taking a chance of further inflaming the man, but he couldn’t help himself. “It was a bolt out of the blue, and it had nothing to do with anyone’s supposed incompetence.”

“Three deaths in three weeks?” Dr. Mason practically shouted. “If that’s not incompetence, I don’t know what is.”

Noah thought of a good retort for his last comment, but he wisely held his tongue.

“This has gone too far,” Dr. Mason snapped. “I’ll tell you what I’m going to do. I’m going to have a heart-to-heart conversation with the chief of Anesthesia. I was tempted to do so after the first two disasters, but now I’m going to do it for certain. I want her to be given her walking papers and be gone. And then I’m going to do the same with Dr. Cantor about you. Your days are numbered. Three preventable deaths are totally unacceptable.”

Dr. Mason stared at Noah, defying him to defend himself. When it was apparent Noah wasn’t going to try, Dr. Mason spun on his heel and stomped away.

Noah watched the man recede and then disappear from the OR suite, presumably heading to the surgical lounge. Noah was momentarily paralyzed. The death of the boy, the worry about Ava, and now these threats from Dr. Mason combined to make him feel drained of emotion. He didn’t think Dr. Mason would be any more successful on this occasion in getting Ava or himself fired, but it was anxiety-producing and worrisome because it was making a bad situation that much worse, especially since Dr. Hernandez had specifically ordered him to do something about the poor relationship he had with Dr. Mason.

Noah sighed and shook his head. He had no idea how to deal with Dr. Mason even in the best of circumstances. With the M&M coming up the day after tomorrow, which Dr. Mason threatened to make memorable, combined with this new malignant hyperthermia death, Noah feared things were going to get worse before they got better.

20

MONDAY, JULY 24, 7:15 P.M.

As Noah climbed Ava’s front steps, he glanced at his watch, realizing that it wasn’t the best time for him to be arriving, since she would still be involved with her workout. He’d been held up when one of his post-op patients had spiked a fever.

Noah had not spoken with Ava after she had walked out of the supply room. He’d thought about calling her to ask if he should stop for take-out food as per usual, but he’d decided against it, thinking it best to leave her alone, hoping she had found something to occupy her mind.

After pressing the doorbell, Noah prepared himself for a wait and possibly the need to ring the bell several times. He knew that Ava and her trainer invariably had music blaring in the workout room as they went through their routine. He was surprised when the door buzzed open almost immediately, and even more surprised to confront Ava when he entered.

“Hello,” Noah said, giving her a hug. She didn’t respond but didn’t turn away, either.

“Are you okay?” Noah asked. He stepped back and looked at her. Her face was unnaturally flaccid, almost expressionless.

“I’ve been better,” she said. Her voice was flat and lifeless.

“I thought for sure you’d be working out.”

“I canceled the session,” Ava said. “I wasn’t up to it.”

“Are you depressed?” Noah asked.

“Obviously.”

“What can we do to cheer you up? Are you hungry? I can bring us back some take-out or we could go out like normal people. What do you say?”

“I’m not hungry. But you can go and get yourself something.”

“I can wait. Let’s talk. Should we go up to the study?”

“Whatever.”

Once they were in their customary chairs, Noah tried to think of what to say. He knew he wasn’t particularly good at psychiatry or talk therapy of any sort. As a surgeon who was accustomed to facing problems head-on with action, he’d never given the field much thought or credence. Yet he felt he knew a bit about depression, having recently dealt with a mild case himself after Leslie Brooks walked out of his life. More important, he had also managed to deal successfully with the issue when his mother had been diagnosed with early Alzheimer’s and he had to drop out of medical school. “Let me ask you this,” he began. “Have you ever had any problem with depression?”

“Yes,” Ava said. “In middle school, mostly around the time I told you I got cyberbullied. Depression, eating problems... I had the usual complement of symptoms associated with poor self-esteem.”

Noah inwardly recoiled, sensing he was already out of his comfort zone, the way he imagined a psychiatrist might feel if he were suddenly forced to do an appendectomy. “Other than the online harassment, was there ever any specific event that made you depressed?”

Ava didn’t answer right away but rather stared at Noah while nodding almost imperceptibly, as if she were struggling with Noah’s question and debating how or whether to respond. Noah resisted a strong impulse to say something to ease the moment, but he was glad he didn’t.

“There was an event that really bowled me over and made me seriously depressed,” Ava said finally. “It was when my oil-executive controlling bastard of a father committed suicide by blowing his brains out. I was just sixteen, a junior in high school.”

Almost as if he had been slapped in the face or sloshed with ice water, Noah felt himself start, shocked at being reminded of his metaphor that getting to know Ava was like peeling an onion. Here was yet another peel, another layer, and another surprise. He cleared his throat, frantically thinking of how he should respond. “I thought you said he died of a heart attack?”

“That’s what I have told anyone who has asked,” Ava said. “Maybe I’ve even told myself at times, but the reality is that he shot himself, and I got really depressed and almost lost it. The whole mess embarrasses the hell out of me, and I don’t like to talk about it.”

“My goodness,” Noah said, to say something.

“The other time I got truly depressed was when I was twenty,” Ava said. Her flat facial expression began to morph into anger. “I was recently married, and my new husband just walked out. Men didn’t treat me very well when I was young and vulnerable.”

“To say the least,” Noah said, thinking about her dentist boss taking advantage of her.

“And you wonder why I stick to a virtual life on social media?” Ava said with a wry smile. “It is infinitely safer to be the one controlling the mouse.”

“I guess I understand better now,” Noah said. “Were you married for long?”

Ava laughed derisively. “Just long enough for my husband to get a green card. He was in the country on a student visa but wanted to stay. I was merely a means to an end.”

“Did you meet him at Brazos University?”

“I did, days after I got there with Dr. Winston. He was a surgical resident like you, but from Serbia.”

“I’m sorry,” Noah said. Her former husband being a surgical resident made him feel weirdly complicit.

“It feels like it happened in another life,” Ava said. “How about you? Have you ever had some major life-changing episode make you depressed?”

Happy to get Ava out of her shell and talking, Noah was willing to be equally open. Like she, he didn’t like to talk about such things, and he said as much, but then went on to describe how depressed he felt when his mother started showing signs of dementia and he had to take a leave of absence from medical school. And more recently he mentioned how disconsolate he’d felt following Leslie Brooks’s unexpected departure.

“Did Leslie leave totally out of the blue like my bastard of a husband?” Ava asked irritably.

“No,” Noah admitted. “For quite a while she had been upfront about my work hours and never having any time for her, and it was getting worse, not better.”

“Still, it is a blow to self-esteem.”

“Tell me about it,” Noah said with a self-mocking laugh.

“Self-esteem is critical,” Ava said. “I’ve been thinking about it all afternoon. I realize it’s why I can’t leave clinical anesthesia even after these three unfortunate episodes. For me, being a practicing anesthesiologist is too much of my self-image.”

“I’m glad to hear you say that,” Noah said. He repeated what he’d said before about how good an anesthesiologist she was and what a tragedy it would be for her to throw away all the training she had been through.

“Thank you for saying that,” Ava said. “Your support has certainly influenced my thinking. But on all three cases, I truly believe I did all the right things... Well, maybe I should have waited for Dr. Mason to get into the room before starting the anesthesia on the Vincent case... but even so, I think I did everything as well as anybody in the department, even Dr. Kumar.”

“I’m sure you did,” Noah said.

“The problem is there’s still a chance I could become a departmental scapegoat with Dr. Mason on my case. Is that still your impression?”

Noah thought quickly how he should respond after having just spoken with Dr. Mason. Since Ava seemed to have pulled herself out of her most current nosedive, he didn’t want to give her reason to regress, yet she needed to know the truth. “He’s still upset with both of us,” Noah said. “Not only did he warn me Friday about not protecting you at the M&M, he sought me out this afternoon after the malignant-hyperthermia episode. He said he is going to speak with Dr. Kumar.”

“As if he hasn’t already,” Ava said. “The bastard. I tell you, one of the reasons I’m concerned about being dumped is that I didn’t train at one of the overrated Ivy League institutions like most everybody else.”

“That doesn’t matter,” Noah said. “In many ways it is a myth about Ivy League institutions being better than other places. You and Brazos University are a prime example. Tell me about your residency training! How many cases did you do in total?”

“I don’t like to feel I have to justify my training,” Ava said indignantly. “Nor justify myself. It irritates me to death, as if I’m struggling to stay in a discriminatory, old-boys’ club. I’d rather talk about my grades on my Anesthesia boards, which were better than most of my BMH colleagues, and my daily progress with anesthesia MOC. I put in more effort to stay current than anyone else in the entire department. Trust me! On Anesthesia rounds I’m always the one who brings up new developments, not the Ivy League graduates with their supposedly gilded diplomas.”

“Okay, okay. I understand completely,” Noah said, raising his hands as if he thought he needed to defend himself. Ava always seemed to surprise him. Only on Friday she had voiced the wish that she had had an Ivy League background, and now she was decrying it. “Some people do feel their training makes them superior. All of which means we must protect you from this narcissistic, spiteful blowhard, Dr. Mason. In specific terms, it means being prepared for this next M&M.”

“Are you prepared?” Ava asked.

“I think so,” Noah said. “As we talked about Friday night, I’ll present it last after four other cases. Dr. Hernandez suspected I had presented the Vincent case last to limit discussion. Still, I think it is important to take the risk. With the IT Department talking about how two separate electronic records were created and Dr. Jackson being reasonable about his role in the outcome, I think we should be okay. Those two issues should use up the discussion time. Of course, a lot depends on Dr. Mason and what he says. Whatever it is, I’m going to have to make an effort to sound neutral. I hope you understand that.”

“Do you think today’s MH case will even be mentioned?”

“Not by me,” Noah said. “If it does come up by Dr. Mason, I’ll say that I haven’t investigated it yet, and it will be presented at the next M&M.”

“In a way it is too bad,” Ava said. “I couldn’t have handled a case of MH any better than I did, despite the terrible outcome.”

“That reminds me,” Noah said. “Are you friendly with the circulating nurse on the case, Dorothy Barton?”

“Nobody’s friendly with Dorothy Barton,” Ava said. “She’s an odd duck. She even asked me one day if I was gaining weight. Now, that is one hell of a catty thing for a woman to say to another, especially someone who obviously struggles with her own weight.”

“Well, she’s not a fan,” Noah said. “After the MH case she took me aside to tell me that you didn’t turn off the isoflurane immediately, which I guess is crucial.”

“What?” Ava practically shouted. Her legs dropped off her ottoman, and she slid forward in her chair. “What the hell is she talking about? Absolutely I turned off the isoflurane instantly, the absolute second I noticed a sudden jump in the end-tidal carbon dioxide. And of course it is crucial. It was probably the isoflurane that triggered the whole problem in the first place.”

“I figured as much,” Noah said. “But I’ve never seen a case.”

“You don’t have to have seen a case to know that,” Ava snapped. She gave Noah a ten-minute monologue about the rare condition, demonstrating an extraordinarily in-depth knowledge of MH and how to treat it. Noah was both taken aback and impressed, especially as someone who prided himself as a source of medical minutiae helpful for making points on teaching rounds. She was even able to quote the latest statistics and cited the last lengthy review article about the condition in The New England Journal of Medicine.

“Wow!” Noah said when Ava finally fell silent. “I’m amazed at your knowledge about MH, as rare as it is.”

“I know anesthesia,” Ava said, as she slid back in her chair and raised her feet onto the ottoman.

“But to have that much information at your fingertips is truly unique. Did you handle a number of cases during your training?”

“No, I’ve never seen an actual case until today,” Ava admitted. “But I was well schooled in how to handle it because of the simulation center that we had at Brazos University Medical Center. It’s called the WestonSim Center, as it was named after a West Texas oil baron who donated it. It’s truly state-of-the-art. In comparison, it makes the simulation center here at BMH seem as antiquated as a pinball arcade.”

Noah had to laugh. He knew the simulation center at BMH wasn’t up to par, as the hospital hadn’t designated adequate space or computer time. It was a problem he was working on.

“The anesthesia mannequin had a malignant hyperthermia program, which I took advantage of many times when I was a resident.”

“I guess it paid off,” Noah said. “And I guess Dorothy Barton is envious of your ripped figure.”

Ava laughed with real humor, which made Noah feel like he had accomplished what he had hoped — namely, to pull her out of her depressive thoughts.

“That must be the explanation,” Ava said.

“Any chance your appetite has improved?” Noah asked.

“It has,” Ava said. “And you?”

“I could eat something,” Noah said.

“Let’s not do the take-out thing,” Ava said. “I don’t have a lot of food in the house, but there are eggs, bacon, and toast. How does that sound?”

“Perfect,” Noah said, and he meant it.

21

WEDNESDAY, JULY 26, 8:44 A.M.

“Okay,” Noah said. “Let’s move on to the last case. This is a thirty-two-year-old woman who had been hit by a car on the corner of State Street and Congress Street and suffered a compound fracture of her right tibia and fibula. If everyone can turn to the final page of the handout, I will begin.”

Noah was back in the Fagan Amphitheater facing another packed M&M Conference. It wasn’t as crowded with standees as the previous conference, but most of the seats were taken. As was the case two weeks ago, the first two rows front and center had all the big guns of the department, including Dr. Hernandez, Dr. Mason, and Dr. Cantor. As far as Noah was concerned, they were the big three.

The previous day in the middle of the afternoon, Noah had been ordered again to Dr. Hernandez’s office, which had made his heart race, as such an ordeal always did. After the run-in with Dr. Mason the afternoon before, it wasn’t hard to guess the reason for the call. When Noah arrived, he was moderately surprised to find Dr. Cantor there as well. Although he had expected the worst, the meeting turned out not to be as bad as it could have been. Dr. Hernandez had done most of the talking, with Dr. Cantor merely nodding at key points. The message had been simple and to the point. Dr. Mason wanted Noah gone.

“I can tell you straight out,” Dr. Hernandez had said with Noah literally standing on the carpet in front of the man’s desk, “I don’t totally understand Dr. Mason’s reasons for his beliefs, but he is convinced that Dr. London is incompetent and you are complicit in protecting her and therefore bear some responsibility for three deaths. Be that as it may, I made a point to talk privately with Dr. Kumar, mentioned Dr. Mason’s feelings, and asked him straight out if Dr. London was up to snuff, and he has assured me that he personally had vetted her and is completely confident of her performance.

“Which brings us to your circumstance...”

Expecting the worst, Noah remembered having cringed at that point, but it wasn’t necessary. Dr. Hernandez had gone on to say that because of Noah’s meritorious record as a resident, he and Dr. Cantor could currently prevail over Dr. Mason’s wishes, meaning Noah would not be dismissed. Yet he warned Noah to be extremely careful and not rock the boat, particularly in regard to Dr. Mason. He went on to add that the surgeon wasn’t the easiest person to deal with, yet because of his skill and reputation he was a force to be reckoned with.

“Dr. Cantor and I want to be certain,” Dr. Hernandez had concluded, “that you will not treat Dr. London’s role in the upcoming M&M tomorrow with anything but factual truth and candor.”

“Absolutely,” Noah had said without hesitation. There was no way he was prepared to lie. As he left Dr. Hernandez’s office he’d been thankful that he hadn’t been asked if he was having an affair with Ava. If he had been asked, he had been prepared to be honest, although he had no idea what he would have done or said if he were ordered to break it off.

“Does anyone have any questions so far?” Noah asked after a pause a few minutes into his presentation. He looked up from his notes and let his eyes roam around the audience. Briefly he made eye contact with Ava. So far he had just given Helen Gibson’s complete medical history, which included four normal pregnancies and a serious bike accident resulting in a cervical neck fracture. As he had done when presenting the Vincent case, he was trying to use up time even though there was only a smidgeon more than fifteen minutes left before the conference would have to end.

When there were no questions, Noah went on to present the rest of the case, beginning with Helen Gibson’s arrival in the ER up to her untimely death. He recounted everything that had happened without embellishment just as he had promised Dr. Hernandez, including the two salient facts: that the attending surgeon had pressured the first-year anesthesia resident to begin anesthesia before her supervisor was in the room and that two separate EMRs, with slightly different names and slightly different information, had been inadvertently produced so that the anesthesia resident was unaware of the patient’s cervical problems. He pointed out that according to an international rating system, the patient represented the worst-case scenario in regard to placing an endotracheal tube because of her prior history of neck trauma and moderate obesity.

Just as Noah was about to turn over the discussion to the IT representative who was going to talk about exactly how the two separate EMR records had been created, Mason loudly demanded to be recognized. Reluctantly, Noah gave him the floor.

“Excuse me, Dr. Rothauser,” Dr. Mason said in his booming voice. “You have put off this particularly tragic case to last to limit discussion time. I know this, and I am certain other members of the faculty do, too. And we know why.” He then went on to do his best to fault Ava’s performance, throwing the usual accepted academic decorum to the wind by personally disparaging and discrediting her and openly accusing Noah of protecting her and possibly carrying on a secret liaison.

A muted collective gasp emanated from the otherwise passive audience. Everyone was stunned, no one more so than Noah. He was expecting trouble from Dr. Mason, but this was ridiculous. When Mason continued on with his ad hominem outburst, a number of people hissed, as most everyone in the audience knew Ava on some level, liked her, and thought of her as totally competent. Up until these last two M&Ms, her name had never come up in a single adverse-outcome case.

When Dr. Mason finally fell silent, Noah struggled with what he should say. Luckily, Dr. Kumar stood up and worked his way to the aisle before descending into the pit. He was a tall, handsome man with a heavy mustache who had grown up in the Punjab region of India. Noah was more than glad to step aside and allow the chief of Anesthesia to take over the lectern.

In sharp contrast to Dr. Mason’s muckraking style, Dr. Kumar lavished praise on Ava, citing her incredible performance on the anesthesia boards as evidence of her terrific training. He also mentioned that he had personally observed her providing anesthesia on numerous occasions when she first joined the staff and found her performance to be exemplary. He said it was his professional opinion that the way she handled the current case and the Vincent case were similarly commendable. Then, to everyone’s surprise, he lavished equivalent praise on Dr. Mason, calling him a brilliant surgeon and a tribute to the hospital, and he offered to meet with him to discuss his concerns about Dr. London or about anyone on the anesthesia team.

At this point, most of the people in the audience clapped.

“The woman was involved in yet another death just two days ago,” Mason blurted out. “That’s three deaths in so many weeks. I find that unacceptable.”

There was more hissing.

“I have already reviewed the case from Monday,” Dr. Kumar said calmly. “It was a fulminant malignant hyperthermia episode. Again, it is my belief that Dr. London and the entire MH protocol worked admirably.”

Dr. Kumar then went on to give an extended explanation of how the Anesthesia Department handled supervising residents and nurse anesthetists. He did this to explain why Ava was not in the room at the time when Helen Gibson’s anesthesia was initiated, because she was in another room supervising another resident. Staff anesthesiologists were expected to supervise up to two residents and four anesthetists simultaneously.

While Noah listened to Dr. Kumar’s staffing explanations, he thought back to when he’d first burst into the operating room when Helen Gibson was already in extremis. The fleeting impression of Ava fumbling with the advanced video laryngoscope nagged at him. Should he have perhaps mentioned this impression to someone like Dr. Kumar, or was the fumbling due to the patient’s head bouncing around from the external cardiac massage? And what about why she hadn’t ordered an emergency tracheostomy or used a large-bore needle with jet ventilation?

“Thank you for allowing me to speak,” Dr. Kumar said to Noah, stepping away from the lectern and interrupting Noah’s thoughts.

“You are entirely welcome, sir,” Noah said hurriedly. He returned to the lectern and looked up at the restive audience who’d erupted into many individual whispered but animated discussions.

“I’d like to say something,” a voice called out.

Noah looked in the direction of the request. It was Dr. Jackson. Noah pointed to him, giving him the floor.

“I know it is generally not the involved surgeon’s role to speak at an M&M unless asked a specific question, but I feel I should do so in this case. I never did get to operate on the deceased, even though I am the surgeon of record. What I’d like to say is that I made a mistake by actively urging the anesthesia resident to start the anesthesia before her staff supervisor was present. In my defense, the case involved a compound fracture. In such circumstances the chances of infection increase the longer the surgery is delayed. Nonetheless, I shouldn’t have forced the issue.”

There was a smattering of muted applause as people appreciated Dr. Jackson’s mea culpa, since it was as unexpected as Dr. Mason’s inappropriate comments. For a second, Noah locked eyes with Ava. She was one of the people who was quietly clapping. Noah wondered if it was for Dr. Jackson or for Dr. Kumar. Both had helped exonerate her.

After a quick glance at his watch and seeing it was already after 9:00 A.M., Noah concluded the M&M. The audience stood up immediately. Most everyone had to get to surgery, as they were already late for their scheduled 9:00 A.M. cases.

Stepping away from the lectern, Noah turned to the representative from the IT Department. She had been sitting in the lone chair in the amphitheater’s pit for the entire conference, waiting to speak her piece about the Helen Gibson case.

“I’m terribly sorry,” Noah said. “I didn’t expect we would run out of time.”

“No problem,” the woman said graciously. “I actually enjoyed listening. I’ve never been to an M&M Conference. As a layperson, I’m glad to hear these tragedies are not ignored.”

“We try our best to learn from each one,” Noah said. “Thank you for coming and for your time. I’m sorry we didn’t get to hear your presentation.”

Noah turned to look up, in hopes of catching Ava’s eye. He was certain she had to be pleased. Instead, he found himself facing an angry and empurpled Dr. Mason, who was beside himself with barely contained rage. He was heedless of all the other bigwigs, who had already descended into the pit and were standing around, socializing in small groups.

“You think you are so goddamn smart,” Dr. Mason jeered, poking his face within inches of Noah’s. “Maybe you’ve gotten your prissy girlfriend off the hook because she is in a different department, but let me assure you, I’m sure as hell not finished with you. Not by a long shot. If I have anything to say about it, you are out of here!”

Sensing it was best to remain silent, Noah just blankly stared back. Dr. Mason glowered at him with narrowed eyes. Then, with even more ostentatious drama than after the prior M&M, he stormed out of the room.

By reflex, Noah hazarded a glance in the direction of the nearest group of surgical attendings and caught them rolling their eyes for his benefit. It was apparent they had overheard Dr. Mason and were being supportive. It gave Noah a modicum of confidence that staff members were cognizant of Dr. Mason’s personality shortcomings, but Noah was still nervous. As Dr. Hernandez had said the day before, Dr. Mason was a force to be reckoned with. Unfortunately, Noah had no idea how to help his case, as he was caught in the web of Dr. Mason’s narcissistic ego.

22

WEDNESDAY, JULY 26, 3:10 P.M.

It had been a busy day for Noah. After the M&M Conference, he’d headed over to the Stanhope and up to the OR along with a good portion of the rest of the attendees. En route he’d had several people compliment him on the program, and even a few had remarked how surprised they were about Dr. Mason’s outburst, which was reassuring.

Despite Dr. Mason’s comment to him after the conference was over, Noah felt very good about how things had gone in general, and he imagined Ava did, too. For Dr. Kumar to have supported her the way he had was certainly a tribute to her standing in the department, and it had to have buoyed her lagging self-confidence about her clinical abilities. And Dr. Jackson had certainly come through in a commendable fashion.

After making certain all was copasetic with the day’s surgical-resident assist schedule, Noah had started his own four operative cases. As his assistant for the day, he had chosen third-year Dr. Dorothy Klim. She was a terrific resident with whom Noah enjoyed working. This was the first time they’d operated together since Noah had assumed his super chief role. They made a good team, as she could anticipate Noah’s technical needs as any good assistant does, so the cases proceeded apace. Such efficiency always made the nurses happy, so it ended up being a pleasant day for all involved, including the patients.

In between each case, Noah dictated the procedure as he always did. Some surgeons put off the dictation until their last case was over, but Noah liked to do it right away to be certain he didn’t forget any details. During each round trip to and from the surgical lounge where the dictating booths were located, Noah kept an eye out for Ava on the rare possibility they could interact on some superficial level, but it wasn’t to be.

Leaving his final scheduled case for the day, an open cholecystectomy, or gallbladder removal, Noah again looked for Ava. Seeing that it was past 3:00 when her shift ended, he checked the PACU, where he had run into her the day they had their first real conversation. But she wasn’t there. Checking the scheduling board, he saw that her last case had finished almost an hour earlier, meaning she’d most likely left the hospital on time.

Disappointed not to have even made eye contact during the day, Noah looked forward to seeing her that evening at her house. Although he’d been staying with her almost every night since she’d gotten back from Washington, he hadn’t the previous night, due to emergency surgery that had kept him in the hospital. As he sat down in one of the dictating booths, he found himself fantasizing about the upcoming evening. There was a wine shop on Charles Street appropriately called Beacon Hill Wine, and he planned on stopping in and getting a bottle of champagne to celebrate the outcome of the M&M. At least she was out of the woods, even if he wasn’t.

Just before Noah began his dictation, he made up his mind to call Ava a bit later to find out her thoughts about take-out that night. He even entertained the possibility of their going out to an actual restaurant, either that night or over the coming weekend. He had no idea how she might respond, but it seemed like a fun idea. And why not? Wasn’t the cat out of the bag? With what Dr. Mason had publicly said at the M&M, it probably wasn’t possible to maintain the secrecy of their affair even if they continued overtly to ignore each other in the hospital.

When Noah was finished with the dictation, he went back into the PACU to make sure everything was fine with the cholecystectomy patient. When he had left the OR, the operation hadn’t been totally over. The six-inch incision in the right upper abdomen was still open. This was standard protocol in a teaching hospital. With the open gallbladder removal, Noah had brought in a first-year resident to provide traction. When the key part of the operation was done, it was standard protocol for the most senior resident, meaning Noah, to leave so that the next senior resident, Dr. Klim, could teach the first-year resident basic suturing technique.

Noah briefly glanced over the postoperative orders, which the first-year resident had written, again under the auspices of the third-year resident. This was par for the course and hadn’t changed in years. Medical education in general hadn’t altered much over the last century, despite everything else involving medical science and technology being drastically different.

Noah hurried back to the surgical lounge to change into his whites. He had an enormous amount of work to do above and beyond work rounds and seeing his private patients. Now that the M&M was over, there was a lot of catching up to be done, which he intended to do and still leave the hospital close to 6:00. If it was at all possible, his hope was to get to Ava’s before she started her workout so that by the time she was finished showering, he’d have their celebratory feast, including champagne, ready to be enjoyed.

Almost at the exact moment he hurriedly pushed into the men’s surgical locker room, Noah felt his phone buzz with a text. Curious who might be texting him on his phone rather than his hospital tablet, which was where he received the vast majority of his messages, Noah pulled out his phone and was happy to see it was a text from Ava. With a mixture of titillation tinged with relief to finally connect with her, he opened it.

Noah stopped in his tracks, his euphoria evaporating. With almost total disbelief, he read over the message multiple times. It was brief: On a business trip for a few days. Will text when I return.

Noah sank down on a low bench, still holding the phone in his hands, staring at the screen in dismay, amazed that Ava would be insensitive enough to send such a short, emotionally unexpressive text. Under the circumstances, it seemed almost deliberately cruel. Either that or she lacked empathy, although either explanation seemed equivalently heartless. Immediately, the question rose in his mind about how long she had known about this trip or whether it was something that had happened that afternoon as a response to a lobbying emergency, if there was such a thing. He hoped it was the latter, because if it wasn’t, she should have told him she was going the moment she’d heard about it.

As Noah thought more about this totally unexpected development, he realized she must have some days off, as she had worked more than a week straight, including the entire past weekend. At the time, Noah hadn’t questioned it, because he worked every day and every weekend as a matter of course. The idea it was rare for her to work more than five days in a row hadn’t even entered his mind. But why didn’t she bring it up last night that she was scheduled to be off tomorrow?

“It must have been an emergency,” Noah said out loud in a vain attempt to buoy his sagging emotions. “Surely she must have been in a rush, and I’ll be hearing from her with all the details.” But the attempt to make himself feel better didn’t work. It would have been so easy for her to express some emotion; even just a few words would have made a complete difference.

He tried to rally his injured self-esteem by coming up with another potential explanation. With all the time she devoted to social media, maybe it didn’t even cross her mind that he might be sensitive about not being told in advance. Her constant communicating in a virtual world without all the rich, nonverbal aspects of real-time, face-to-face interaction had probably made her less sensitive to nuances of other peoples’ feelings. By her own admission, she spent most of her free time in a world where everything could be handled by a mere click of the mouse, and whatever interaction was in progress was gone without consequence. Considering all the wonderful intimacy they had enjoyed together that week, there was no way she would have wanted to upset him. It had to be more oversight than purposeful.

Feeling a strong need to be proactive rather than just sitting there feeling sorry for himself, Noah leaped to his feet. He quickly changed out of his scrubs and into his normal hospital clothes. He even decided to stop by the laundry and get a freshly cleaned and pressed white jacket to look his best. For Noah, work had always been his fallback. It had been the way he’d handled Leslie’s departure.

Fifteen minutes later, Noah was on the surgical floor, rallying the troops by calling for afternoon work rounds to begin earlier than usual. With a burst of energy, he goaded all the residents to the max, demanding particularly thorough and up-to-date presentations on all the patients as they went room to room. He quizzed everyone on the latest journal articles apropos of each case, turning afternoon work rounds into teaching rounds.

When rounds were done, Noah visited each of his own inpatients and had lengthy conversations about their progress and what they should expect over the next few days, discharging three of them. Noah then visited two patients who were scheduled for surgery the next morning. Both had been transferred from hospitals in the western part of the state, where their surgery had been botched and needed to be redone.

With no more work to be done on the surgical floor, Noah retreated down to his desk in the surgical residency program office. Since it was now well after 5:00 P.M., he happily found the place empty. His intent was to read the journal articles for the following day’s Journal Club, but instead of calling them up on the monitor as planned, he had a different idea. Although his initial intention was to visit the Annals of Surgery, he googled Brazos University instead.

The website was impressive. There were more than two hundred photos of modern buildings of red brick, concrete, and glass. He was surprised to see as much grass as he did, since he thought of West Texas as being desertlike. He could see the flat terrain surrounding the city and the horizon with a sky that seemed larger than life. He had never been to Texas, and there was nothing about the pictures that beckoned him. He wasn’t much of a traveler. The farthest south he’d ever been was South Carolina, but that was when he was a teenager.

Next Noah looked at the Brazos University Medical Center website. The hospital appeared even more modern than the rest of the university, suggesting that it was a relatively late addition. Within the website, the WestonSim Center had its own section, advertising itself as one of the world’s premier robotic-simulation centers for medical teaching after its opening in 2013. When Noah clicked on it and looked at the exterior photos of the extremely modern glass-sheathed building and read the description of the 30,000-square-foot behemoth, he had to agree. It was a sweet setup, a quantum leap better than what was available at BMH, which had to fight for space in the Wilson Building’s basement. Looking at the many photos of the WestonSim Center interior, Noah was even more impressed by the mock-up sets that looked amazingly realistic, including two fully functioning operating rooms, a delivery room, an intensive-care unit with multiple beds, and three ER trauma spaces. Noah could easily imagine Ava in all of them, taking advantage of their potential for teaching anesthesia technique and how to handle such emergencies as malignant hyperthermia.

Next Noah checked if the hospital and the medical school had all the appropriate certifications from the various accreditation organizations. It did, including the ACGME, or Accreditation Council for Graduate Medical Education. That was the key one, meaning the medical school and the residency training program were entirely qualified.

After several hours of frantic activity since leaving the OR but with nothing but busy work left to keep him occupied, Noah glanced at the time. It was now almost seven-thirty in the evening, and still there had been no additional text from Ava. With painful resignation, Noah began to accept that he wasn’t going to hear any more from her like he had hoped. It seemed that the curt, original text might be all he was going to get until she returned.

Feeling exceptionally weary, depressed, and confused, Noah stood up from his desk. He hadn’t felt this bad since Leslie Brooks had bailed out and left him with a denuded apartment. He struggled with the question of what he should do, whether he should go back to his bleak apartment or stay in the on-call facilities in the hospital. Technically, Noah wasn’t on call, but he knew there was plenty of room if he wanted to stay. Since he was in no condition to make a rational decision, he ended up staying in the hospital by default.

23

SATURDAY, JULY 29, 4:50 P.M.

After spending Wednesday, Thursday, and Friday nights in the on-call facility in the Stanhope Pavilion, Noah finally felt the need to go back to his apartment Saturday afternoon when he finished everything he could think of doing in the hospital. By then he was entirely caught up in all aspects of his wide-ranging responsibilities as the super chief surgical resident. Even the basic science lecture and the Journal Club agendas for the following two weeks were already done, as was the resident on-call schedule for the months of August and September.

In his whirlwind of work energy, Noah had accomplished more than he thought possible but had run out of things to do, and he began to feel as if people were wondering why he was still hanging around. To make matters worse, on Thursday and Friday nights the on-call chief residents had pointedly asked Noah what he was doing in the hospital on-call room facility, which had a lounge area as well as multiple bedrooms. It was clear both residents were concerned that their competence was being questioned by his presence. In both instances, Noah had reassured them they were doing fine and left it at that, but there was a lingering sense they didn’t believe him.

Unfortunately, for the entire period, he’d not heard a word from Ava. He’d hoped he’d get a text or something, but by Friday he acknowledged it wasn’t going to happen. On several occasions over the last three days he had pointedly argued with himself whether he should text her or even try to call her, but on each occasion his pride had won out. He felt it was her responsibility to get in touch with him, since she was the one who had left. Under the circumstances, his reaching out would undermine the small amount of social self-esteem he was trying vainly to maintain.

But coming back to his sparse apartment did little to buoy his spirits. To him it looked worse than usual in its emptiness, which magnified his loneliness and reminded him how much he missed Ava. At the same time the situation was forcing him to question if his feelings for her were being reciprocated, as he could not imagine leaving her such a curt message if the situation had been reversed. Yet he urged himself to cut her a little slack, remembering that she was a unique, extraordinarily self-motivated individual who came from a background completely different from his, who had suffered a father’s suicide when she was in high school and a failed marriage around age twenty. He knew it was important for him to keep all this in mind because it was how he explained what he termed her “teenagelike” attachment to social media.

Thinking about Ava and her self-centeredness, he wondered if social media was making people narcissistic because of the opportunities for self-promotion or if narcissists were attracted to social media for the same reason. He knew that one of the hallmarks of narcissism was a lack of empathy, which was still how Noah viewed Ava’s terse text and her lack of follow-up communication. If Ava’s love of social media was making her egocentric, he could hold out hope that she had no idea how much emotional distress she was causing him and might very well be sincerely apologetic when told.

With nothing better to do and thinking that it would at least make him feel closer to Ava, he booted up his old laptop and went to Gail Shafter’s homepage. To his chagrin he immediately saw that Gail had posted on Friday, which meant that Ava had enough free time to be on social media yet not enough time or inclination to send him a simple text. The post was about Gail having an “OMG fabulous” opportunity to visit Washington, D.C., complete with a smiling selfie of Ava with a baseball hat covering her blond-streaked hair in front of the Lincoln Memorial and another in front of the new National Museum of African American History. At least he now knew that Ava had indeed gone back to Washington for her lobbying work. After studying the photos, which reminded him of the many in her study, Noah clicked on Gail Shafter’s fan page. He was relieved to see that at least Ava hadn’t found the time to do one of her beauty tips.

Returning to the homepage, Noah reread the post, which talked about what a treat the city was for tourists, how many fun things there were to do and see, and how it was possible to run into famous politicians, with a list of those Gail had managed to see. He then read some of the comments. It was surprising how many people responded in a single day. There were ninety-two likes and almost three dozen comments. Noah read the comments, which were interesting in their banality and how they all seemed paradoxically to exalt simultaneously individualism and tribal group think. There were even replies to the comments and even a few replies to the replies. There was no doubt in Noah’s mind that the dialogue in the virtual space was far different from how it was in the real world.

Suddenly Noah laughed in disbelief. He noticed that one of the particularly favorable comments was from Melanie Howard, meaning Ava had taken the time to comment on her own post. And then Gail Shafter had replied, praising Melanie. Knowing how intelligent Ava was, he was mystified by her behavior.

Progressively fascinated, Noah began looking at the various home pages of the people who had commented on Gail’s post, reading some of their posts, looking at the groups they favored, and clicking on their friends. It was like following a geometric progression in an endless, ever-expanding universe. In the process, he came across comments about all sorts of things, including the newsfeeds and even discussions about some of the ads that Facebook had inserted to expand their bottom line.

Since Gail Shafter and Melanie Howard were Ava’s fake profiles and not real people, he wondered if Ava had any more fake characters, and if she did, why would it be worth the effort? Following in that line of thinking, Noah began to wonder how many of the profiles he was looking at were also fakes. There was no way to know.

Going back to Gail’s homepage, Noah looked at the gender makeup of those people who had commented on Gail’s latest post. Surprisingly, he saw that it was approximately even between males and females. He had expected it would be mostly females without questioning why. Then he found himself glancing at the thumbnail photos accompanying the comments and noticed that the age of those who used photos of themselves rather than pets or infant children were roughly in the twenty-to-forty range until his eye stopped on one that he recognized. It was Teresa Puksar, a family name that Noah had never come across except on a previous visit to Gail’s Facebook page, and he wondered about its ancestry. Clicking on the photo, he went back to Teresa’s homepage. Glancing again at her risqué photos and looking at her friends, he noticed that there were very few around her age. Noah was both perplexed and put off. He questioned if Teresa’s parents had any idea what their daughter was doing on social media.

As Noah spent more time in Ava’s virtual world, he couldn’t help but start questioning who was the real Ava London. Prior to their relationship, did the social-media world he was now visiting truly take the place for her of real-time, normal, face-to-face interactions? That was what she had implied, yet it hardly seemed possible, considering the vast difference between what he and Ava had been sharing over the previous three weeks and what he considered a vacuous substitute. Yet the issue raised a worrisome idea: Maybe Noah was wrong. Maybe they hadn’t been sharing what he so wanted to believe. Being “in love” certainly didn’t mesh with her flying off with essentially no explanation or the slightest endearment like “I’m sorry I have to go” or “I miss you.” And what about there being so little apparent gratitude for the considerable effort he’d made for her regarding both M&M Conferences, particularly after this last one?

All at once Noah’s eye rose from his laptop, and he stared blankly out the window. Suddenly, an even more disturbing thought entered his mind. Was this whole relationship with Ava a sham? Could Ava have been merely using him to navigate the rough waters of the M&M Conferences because of her irrational fear of being terminated from her dream position on the BMH anesthesia staff?

“Hell, no!” Noah blurted out with conviction. Almost as soon as the idea had occurred to him, he rejected it as a pathetic reminder of his own social insecurity. He’d never been with a woman more open, giving, and comfortable with her body than Ava. Thinking that such intimacy could be less than sincere reflected more on him than on her.

Yet as Noah went back to staring out the window, he couldn’t keep his mind away from those nagging misgivings that continued to trouble him about tiny aspects of Ava’s professional behavior in all three anesthesia deaths. In the Vincent case, did she truly do her own careful questioning of the patient regarding whether he’d eaten or whether he had any GI symptoms with his hernia? Did she critically evaluate the kind of anesthesia to use or just blindly follow Dr. Mason’s secretary’s wishes? During the Gibson case, was she struggling with the advanced video laryngoscope or was the problem that the patient’s head was bouncing all over from the cardiac massage? Why did she not do a tracheostomy? And concerning the Harrison case, did she turn off the anesthetic agent immediately or was there a delay, as suggested by the circulating nurse?

As soon as these questions resurfaced, Noah couldn’t help but remember Ava’s response when he’d mentioned the nurse’s comment on the Harrison case. The remembrance made him smile. Ava had been irate and had launched into a detailed monologue of malignant hyperthermia that had put his knowledge and understanding of the condition to shame. She had even said that it had probably been the anesthesia gas that had triggered the condition, so certainly she would have turned it off the second she suspected what was happening. He remembered she’d told him what had alerted her. It had been something so esoteric about carbon dioxide that Noah couldn’t even remember.

Just to reassure himself, Noah went back on his laptop and googled malignant hyperthermia. A few minutes later he confirmed that she had been right. It probably had been the isoflurane to blame. Since she said that she had learned about the condition by using the WestonSim Center at Brazos University Medical Center, Noah went back to their website. He reread all the material that was available. He was again impressed, especially since Ava had validated the concept that simulation experience was tremendously valuable. He thought he’d bring the issue up at the next Surgical Residency Advisory Board meeting as he was a sitting member. Stimulating the hospital to expand the BMH simulation center would be a valuable contribution of the board.

It was at that moment with the WestonSim Center still on his laptop screen that Noah’s mobile phone rang. Trying to rein in his hopes that it would be Ava, he struggled to get it out of his pocket. As soon as he did, his heart sank. It wasn’t Ava. It was Leslie Brooks making her bimonthly FaceTime call. When she did it, it was always on a Saturday afternoon. For a moment Noah held the phone in his hand, wondering if he should answer. His disappointment it wasn’t Ava was so strong that he worried Leslie might sense it, and it would then be an unkindness to her, who he knew only had his best interests at heart. He wasn’t in the mood to hear how great things were for her in New York or how happy she was with her fiancé, who showered her with attention. Thinking it would only make his circumstance that much worse by comparison, he hesitated, but by the fifth ring he relented and answered. He was, after all, desperate for companionship.

He propped his phone up against the laptop. She looked terrific as usual. He could always tell she made sure her hair was in place and her makeup was perfect when she called. After their initial hellos, Leslie was sensitive enough to comment that he didn’t look like he had been getting enough sleep. He agreed, saying that he had averaged only four or five hours over the last few nights.

“That’s ridiculous,” Leslie said. “You are in charge now. You are supposed to be delegating work to others, not doing it all yourself.”

“The reason I haven’t been getting enough sleep is not because of work,” he said, deciding to be forthright. He was in the need for some sympathy, and Leslie was the only person in the world with whom he felt he could be honest as she already knew his weaknesses. “I’ve met someone and started a rather intense relationship for the last three weeks.”

“That’s terrific!” Leslie said without hesitation. “Who is she, if you don’t mind my asking?”

“She’s a colleague,” Noah said, being intentionally vague. “She’s also a doctor and is as committed to medicine as I am.”

“That is a good start,” Leslie said. “You guys should get along fine. The only problem might be finding time together outside of the hospital, if she’s as busy as you are.”

“She’s an attending on the faculty,” Noah said. “So she has predictable hours. It’s my schedule that’s still the problem, but she completely understands the demands on me.”

“So now I understand why you look sleep-deprived,” Leslie said with a laugh. “That’s not the Noah I remember from our last few years together.”

Noah laughed himself as he understood Leslie’s implication. “That’s not the reason I’m sleep-deprived. I’m afraid I’ve been jilted just when I thought everything was going terrifically.”

“If you want my opinion, which I’m sensing, maybe you should tell me what’s happened with a bit more detail.”

Noah described his relationship with Ava as openly as he could. He also explained what sparked his current distress. What he left out for privacy reasons were Ava’s name, her medical specialty, her personal history, and where she had gone on her recent trip. Noah did want Leslie’s opinion, in hopes that she would tell him that he was reading more into Ava’s lack of communication than he should, and that Ava would return and all would be back to normal. Unfortunately, that wasn’t what happened.

When Noah finished his brief monologue, Leslie merely stared at him, slowly shaking her head.

“Well?” Noah questioned. “Aren’t you going to say something?”

“I’m not sure what I should say,” Leslie admitted. “I can guess what you want to hear.”

“I can guess what I want to hear, too,” Noah said. “But I think I need honesty.”

“Okay,” Leslie said. She pointed at him as if lecturing. “Now, don’t get mad at me when you hear my opinion. Promise?”

“Promise,” Noah said, sighing. He sensed what was coming, and he felt like terminating the call.

“I would advise you to be careful with this person,” Leslie said. “Suddenly disappearing twice with no real explanation after you and she had been intimate and essentially living together, even if only for weeks, is not normal behavior by a long shot. And having it happen right after you made significant efforts on her behalf makes it even more bizarre. She sounds to me like a manipulative person, and if she is as manipulative as she sounds, she might have a personality disorder. What you have been describing is not normal behavior in the very beginning of a romantic relationship.

“Now,” Leslie continued, “I know I might sound as if I’m going out on a limb here when my only qualification is having taken an introductory 101 psychology course in college, but I can’t help it. I don’t want you to be hurt.”

“That’s not what I wanted to hear,” Noah said. He looked away. For a second he did not want to see Leslie’s knowing expression. He also knew Leslie was coming to her conclusions without being aware of any of the significant details of Ava’s life, which he didn’t feel comfortable revealing.

“I’m just trying to be honest with the facts you’ve given me,” Leslie said. “I hope I am wrong. But you didn’t tell me what she was doing on these two occasions she disappeared. Do you know?”

“Generally, I know,” Noah said. “She moonlights as a lobbyist for the nutritional-supplement industry.”

“Now, that is truly ironic,” Leslie said. Having lived with Noah and knowing full well his low opinion of what he called the thirty-four-billion-dollar-a-year snake-oil industry, the idea that he was dating someone who worked for them was farcical. “Where did she go?” she asked.

“On both trips she went to Washington, D.C.,” Noah said. He was thinking he wanted to get off the phone. His talk with Leslie wasn’t helping but rather making him more depressed, as she was lending credence to his own fears.

“From all that you have told me, it seems oxymoronic for a doctor to be working for the nutritional-supplement industry,” Leslie said. “At the same time, they must love her. Her credentials give them credibility they don’t deserve.”

“You got that right,” Noah said. “I think they keep pretty close tabs on her. Almost every night she gets at least one call, and apparently they pay her a king’s ransom. She could never afford the house she occupies on her faculty salary, nor the pleasure travel she does. But they get what they pay for. She is extremely intelligent, attractive, personable, has a good sense of humor, and has an undergraduate degree in nutrition, an M.D., and is on the BMH faculty. My sense is that she, and maybe she alone, keeps the politicians from altering the 1994 law that freed the industry from any sensible control by the FDA. She said as much.”

“Sounds like they hit a gold mine with her,” Leslie admitted. “I wish I could say the same for you. For self-preservation, I think you should take things slowly and very carefully and not let your needs and emotion overshadow your judgment. That’s my advice.”

“Thank you for your insight, Mother,” Noah said with obvious sarcasm, although he knew that she was most likely right. He hadn’t realized how much he needed love in his life before the chance meeting with Ava.

“You asked me to be honest,” Leslie said.

After he had terminated the FaceTime session, Noah tossed his cell across the room onto the threadbare couch as a controlled gesture of displeasure. The conversation wasn’t what he had hoped, and it stimulated him to remember other things about Ava that seemed mildly inconsistent, such as her keen social skills and ability to read people that contrasted with her mildly antisocial behavior in the hospital. It also seemed to clash with her professed preference for social media over face-to-face interactions. As their relationship grew, Noah had become progressively aware that she was not friendly with anyone in the hospital except him. At first he took this as a compliment and thought of it as another way they were similar. But as time had passed, he began to realize there was a difference. Noah was superficially friendly with everyone, whereas she kept everyone at arm’s length. And such thinking reminded him of something else he’d noticed reading her entries in the EMRs of Vincent, Gibson, and Harrison. Her syntax was somehow vaguely unique, which he had ended up attributing to her having trained in West Texas and not in one of the more mainstream academic medical centers.

Noah stood up and retrieved his phone. He almost wished the hospital would call him to give him an excuse to go back. Here it was almost seven o’clock on a Saturday night, and he had nothing to do. It was pathetic. He was even caught up on all his medical journal reading for the first time in his life. Finally, out of desperation he decided he’d go down to the popular bar at Toscano’s that he’d seen on all those evenings when he’d picked up take-out food. Maybe he’d feel hungry enough to eat something. Maybe he could even find someone who might be willing to talk with him.

24

SUNDAY, JULY 30, 4:12 P.M.

Despite being caught up with all his work, Noah managed to spend the entire Sunday in the hospital. There had been some interesting emergency surgery involving a group of bicyclists who had been run into by an aged driver who claimed he hadn’t seen them. He’d also reviewed all the surgical inpatients in the hospital by reading every EMR in their totality, which was something he had never done. He was amazed and disturbed at the number of minor problems he uncovered, which resulted in a flurry of emails to the involved residents demanding they be more attentive to details.

As Noah finished up Monday’s resident-assist surgical schedule, his phone buzzed in his pocket. Getting the phone out, he was taken aback to see it was a text from Ava. The text was equally terse as the one that he had gotten on Wednesday. All it said was: Arrived home. Exhausted but come over if you can.

For a few minutes Noah just stared at the nine words. He didn’t know what to think. There were certainly no endearments, but there was an invitation. The question was should he go, and if he did, when? Ultimately, he decided he would go but would keep Leslie’s cautionary words and his own misgivings in mind. Wishing to sound nonchalant and maintain some self-respect, he typed: Will be finishing up shortly. Will stop by. After reading it several times and deciding it was as emotionally noncommittal as her message, he sent it.

Almost immediately the thumbs-up emoji flashed onto his screen.

Noah didn’t break any records getting to Ava’s house. He’d finished up with the surgical schedule and then rounded on his four private patients, including one scheduled to have surgery the following morning. By the time he climbed the steps in front of Ava’s house and rang her bell, it was almost 6:15.

The door buzzed open, and Noah entered the inner foyer. Ava was nowhere to be seen, but several minutes later she appeared at the top of the main stairs. She came down quickly. “Hey!” she called out, bubbly. She was in her black yoga pants and tank top. Without a second’s hesitation, she gave him a double-cheek kiss as if everything was entirely normal and nothing had happened. “Sorry! I was on the computer.”

“No need to apologize.”

“I’m glad you made it before I got on the exercise bike. Do you want to work out with me? My trainer isn’t here.”

“I think I’ll pass,” Noah said. He had exercise clothes there at her house, but he was in no mood to exercise.

“Do you want to come down to the exercise room with me or wait up in the study?”

“I’ll come down,” Noah said. “If you don’t mind.”

“Mind?” Ava questioned. She looked at him askance. “Why would I mind?”

“I don’t know,” Noah said, being truthful. He didn’t know why he had said it. Ava already had him off guard. He hadn’t known what to expect from her, but certainly he didn’t expect her to act so normal.

Still looking at him sideways, she asked: “Are you okay? You’re acting a little... strangely.”

“I’m feeling a little strange,” Noah said.

“Why? What’s happened?”

Noah let out a sigh. “Ava, you disappeared without a word for three or four days. I think it is entirely reasonable for me to act a bit strangely.”

“That’s not true!” Ava said with emphasis. “What on earth are you talking about? I texted you I was going.”

“You texted me, but it wasn’t much of a text,” Noah said.

“I was in a hurry. I got a call from Washington that they needed me immediately. As soon as I got it, I texted you to let you know I had to leave.”

“But you never followed up,” Noah said.

“Yeah, well, you never texted me back,” Ava said defensively. “I thought I’d get something like ‘fly safely’ or ‘good luck with your meetings.’ But I got nothing. It crossed my mind that maybe you needed a little break. To tell you the truth, as hot and heavy as we’d become, I thought I was doing you a favor leaving you alone to get some work done. I’d been selfishly monopolizing all your free time.”

Noah stared at Ava with disbelief. Had he manufactured all this emotional turmoil he’d been suffering? Was he that socially inept or was it the ease of current messaging technology that was at fault? Was it that instant connection raised expectations with more chance of misunderstanding? He tried to remember why he hadn’t responded to her first text but could only recall it had something to do with childish, hurt pride.

“You knew that I had to go to Washington sometime soon,” Ava continued with irritation. “It was just a week ago that I got the call about the damning article coming out in The Annals of Internal Medicine. You remember: the hugely unflattering one about a new nutritional supplement study. Don’t tell me you forgot!”

“I remember,” Noah admitted.

“So you knew I had to go to Washington in the near future, and I texted you I had to leave on a business trip. You don’t need to be a rocket scientist to put two and two together.”

“Well, maybe I overreacted,” Noah said.

“Why didn’t you text me or call me to tell me you were upset?” Ava demanded.

“I suppose I should have,” Noah said.

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

“I missed you,” Noah said.

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

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

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

“Maybe you’re right,” Noah said.

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

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

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

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

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

“I was humbled,” Ava said.

“It was sincere and deserved,” Noah said.

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

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

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

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

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

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

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

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

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

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

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

25

SUNDAY, JULY 30, 8:34 P.M.

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

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

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

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

“You mentioned that.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Like what?” Ava snarled.

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

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

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

“What else?”

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

“Anything else? Let’s hear it all!”

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

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

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

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

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

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

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

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

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

“Are you sure?” Noah pleaded.

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

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

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

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

“I’m not going to change my mind,” Ava said.

Twenty minutes later, when Noah entered his apartment and collapsed dejectedly onto his tiny couch, he was furious with himself for not resisting the temptation to go on Ava’s computer. How could he have been so stupid? And then, to make matters worse, how could he have been even stupider to bring up his misgivings about her professional performance as an explanation? It had been like adding fuel to a goddamn fire.

“You are fucking hopeless,” he said out loud to himself while he knocked his head multiple times with the knuckles of his fist. He knew he was terrible at navigating relationships, but this evening’s performance was a study in ineptitude, especially since they were just getting over a major misunderstanding, for which he now realized he was as guilty as she was. He should have responded to her initial text and let her know how he felt.

Noah wondered how long it would take for Ava to come around, if she was going to come around. He recognized there was a chance she’d decide he wasn’t worth all the angst, preferring her social media activities as much easier and cleaner. Gloomily, his mind switched over to the letter he’d read on her computer screen. In some ways having graphic proof that she was figuratively in bed with the nutritional-supplement industry was almost equally as disturbing as being sent home. Prior to reading the letter he’d made a specific effort to ignore her involvement. Now he couldn’t. She was recommending defaming people who he felt were on the responsible side of the issue. That was serious.

26

FRIDAY, AUGUST 4, 3:50 P.M.

The melodic alarm on Noah’s smartphone went off, breaking his concentration. He was on the eighth floor of the Stanhope Pavilion in what was still called the chart room, even though charts were relics of the past. Now all the information on each patient was in their EMR stored in the central computer, so the chart room should have been called the monitor room, but tradition played a significant role at BMH and the old name stuck. Noah had been busy going over all the appropriate inpatient records in preparation for work rounds that would begin at their usual time of 5:00 P.M., but in his usual compulsive manner, he liked to be up on all the patients even before rounds began.

Noah had set his alarm to meet with Dr. Kumar, chief of Anesthesia, and he didn’t want to be late or, worse yet, forget. Noah stood up and pulled on a freshly pressed white jacket. He was nervous about the upcoming meeting. Deciding on doing it had not been easy, and he had argued the pros and cons for almost two days before making the plans.

Clicking off the monitor, Noah headed for the elevators. Dr. Kumar had scheduled the meeting in his department chair office in Administration on the third floor. Although Noah would have preferred to meet someplace on the surgical floor to keep things more casual, Dr. Kumar had insisted, and Noah had been forced to agree, so even the formal setting was adding to Noah’s unease.

The past week had not been Noah’s favorite. As a disturbing replay of the previous weekend, Noah had not heard from Ava. To avoid any repeat of the misunderstanding that had contributed to that unpleasant situation, Noah had sent her several texts, starting Sunday night. Each time he’d thrown any pretext of pride out the window and had apologized effusively for what he had done and, more or less, pleaded to get together to talk it out. Ava had responded once, late Tuesday afternoon in her signature terse style: I need a break.

Wednesday Noah had changed tactics. He texted her that he thought they should at least get together to plan the following week’s M&M Conference, but she didn’t respond. It was becoming perfectly clear what she meant by “a break” was no contact. When they had had encountered each other by chance in the OR, she’d even avoided eye contact.

In the beginning of the week Noah had struggled with a mixture of regret and remorse, but by Wednesday, when she chose not to respond to his text about the M&M, his feelings began to shift. Although he admitted he’d made a mistake violating her trust by accessing her computer, he began to sense the punishment was more than the offense warranted. The idea resurfaced that there was a disconnect with her current behavior and the intimacy he thought they had shared. Such thinking brought back Leslie’s warnings and his own concern that Ava might have been using him. It also reawakened his nagging misgivings about her training and competence. Feeling a flash of irritation over her lack of communication, he found himself wondering something he never thought he’d question: Could Dr. Mason be right about Ava?

From Noah’s perspective, the problem with such an idea was that she had been hired by one of the best anesthesia departments in the country, which meant that she’d been seriously vetted way beyond having just passed the anesthesia boards and obtained a Massachusetts medical license. At a minimum, a complete file of her training, including letters of recommendation, would have been required. It was that fact that made him overcome his reservations about approaching Dr. Kumar.

Noah pushed into the crowded elevator, which was occupied mostly by nurses leaving the hospital at the end of their shift. In contrast to the usual elevator silence, there was a lot of conversation. Noah stayed near the door, as he was only going to the third floor and not the ground floor.

As the elevator descended, Noah thought more about the past week and why it was going to go down emotionally as one of his worst. Although he had tried the same defense mechanism for his heartache that he had used over the weekend, namely by concentrating on his work, he’d had less to do because he had done so much from Thursday through Sunday. He’d also felt reluctant to stay in the on-call room again, so he’d gone back to his apartment each night. The result was comparatively too much free time on his hands to keep from mulling over the situation with Ava. And on top of that, he’d had another one of his paranoid reactions.

Although Noah couldn’t have been certain, it seemed to him that the same man in the dark suit who had followed him a couple weeks earlier reappeared and followed him again late Tuesday evening. This time Noah had taken a particularly circuitous route, going through Louisburg Square to gaze longingly up at Ava’s lighted study window. Each time he had turned a corner and glanced back the man had been there, seemingly talking on a cell phone. Noah had first noticed him in the Boston Common. When Noah had arrived back at his building on Revere Street, he’d pulled off the same maneuver of getting his door quickly locked behind him, only to see the man again walk by without so much as a glance in Noah’s direction.

Although Noah had again attributed this episode to his overwrought emotional state, he didn’t impute it to his imagination when he got upstairs to his apartment to find his door had been forced. Since it had happened five times over the past two years, most likely thanks to the woman college student who lived above him and who had a lot of after-hours fellow-student male visitors to whom she gave front door keys, he wasn’t terribly surprised or concerned, a testament to how the human mind could adapt to an inconvenience if it happened often enough. After the first four episodes, he’d complained to the landlord, who’d patched his door, but after the last he hadn’t even bothered to do that. After all, there wasn’t much to steal in his unit beyond his aged laptop. He didn’t even have a TV. Although he’d been initially thankful his computer was still on the card table on this occasion, he did become moderately concerned when he realized someone had been using it!

As a surgeon, Noah had some compulsive traits, like a lot of his colleagues. One of the traits involved how he dealt with his tools, and in his mind tools included electronics. He was very particular about the way he handled his laptop, which had caused a good deal of merciless teasing by Leslie, who thought it silly that he insisted it be lined up with the edges of the table. Frequently she’d move it just to playfully aggravate him. Tuesday night it was as if Leslie had been there.

Recognizing someone had been on his computer, Noah had immediately checked his bank account information. When that had seemed okay, he’d checked his browser’s history to find that it had been wiped clean, including what he had done the previous night. It was apparent someone had used his computer and then had covered his tracks. After checking all his documents, including his surgical case log, which thankfully didn’t include any personal patient information, Noah hadn’t known what to make of the incident and had tried not to dwell on it, although it had fanned his paranoia.

When the hospital elevator arrived on Stanhope 3, Noah got out. As he hurried along the administration corridor, he checked his watch. He still had a full five minutes before the scheduled 4:00 meeting.

It turned out that Dr. Kumar was about twenty minutes late, but he was gracious about it. He came directly over to where Noah was waiting in a common waiting area and apologized. He explained he’d been called in on a problematic cardiac surgery case and had come down as soon as he was free. Noah assured him there was no problem, explaining he’d enjoyed the brief respite from a typically busy day. Dr. Kumar then led Noah into his office, the decor of which had an Indian motif. There was a collection of framed Mughal miniatures on the walls.

“Please have a seat,” Dr. Kumar said in his charmingly melodic Indian accent. He was dressed in a long white coat over scrubs that emphasized his darkly burnished skin tone. He went around and sat behind his desk, putting his elbows on the surface and clasping his hands below his chin.

“I assumed when you requested this meeting that the subject would be Dr. Ava London,” Dr. Kumar said. “That’s why I thought it best to meet down here rather than upstairs. Let me say at the outset, there is no need for you to worry about her tenure here at BMH, despite Dr. Mason’s recent comments. He is a passionate man, but I have spoken with him about Dr. London since his outburst at the M&M, and I believe he feels differently now. Does that put your mind at ease? And, by the way, I believe you handled both M&M conferences superbly, from the Anesthesia Department’s point of view.”

“Thank you,” Noah said. “I tried my best to present the facts.”

“You did a superbly diplomatic job.”

“I thank you again,” Noah said. “I did want to talk with you about Dr. London, but for a different reason.”

“Oh?” Dr. Kumar questioned. He visibly stiffened. His clasped hands lowered to the desk surface.

“There were a few aspects of Dr. London’s performance that I did not mention in my presentations but which I feel is my ethical duty to bring to your attention.”

“I’m listening,” Dr. Kumar said, with his voice changed. It had hardened a degree, but Noah pressed on.

Noah started with the Gibson case, followed by the Harrison and then finally the Vincent, describing in as much detail as possible his mild, and purely subjective, misgivings about Ava’s performance. When he was finished, a heavy silence reigned. Dr. Kumar stared back at him with his penetratingly dark, unblinking eyes, making Noah uncomfortable. The man had not shown any reaction during Noah’s monologue.

Noah felt an irresistible urge to add: “With the Gibson case I was directly involved, meaning I saw the situation. With the other two cases, what I’m relating is hearsay from a circulating nurse or Dr. London.”

When Dr. Kumar still didn’t respond, Noah said: “My motivation for coming to you is for you to hear my concerns and either substantiate them or dismiss them as you see fit. I haven’t said anything to anyone else and don’t plan to do so.”

“I find this all very troubling indeed,” Dr. Kumar snapped. “These are all very vague and, as you say, subjective observations. Our department and I have looked into these three cases with close attention to detail and found nothing wrong. If anything, Dr. London handled them very appropriately, if not superbly. Consequently, I can’t help but take your comments as a value judgment of my leadership skills and my competence as an administrator, since I was personally responsible for hiring Dr. London.”

Noah was flabbergasted. Instead of being thankful of his efforts, Dr. Kumar was taking his visit as a personal affront.

“There is only one question about Dr. London’s résumé,” Dr. Kumar said angrily, “and that is that she trained at a new, relatively unknown institution. But because of that, I and the faculty hiring committee went over her application with great care. And something else you might not know: Dr. London scored remarkably well on her anesthesia boards, both written and oral. I spoke to several of the examiners directly. She’s also passed muster with the Massachusetts Board of Medicine.”

“I certainly knew she had passed her anesthesia boards,” Noah said. “And I had heard she had done exceptionally. I am not surprised. She knows the science remarkably well.”

“We wouldn’t have hired her otherwise,” Dr. Kumar said with obvious annoyance. “And let me say this: If you continue to defame Dr. London by talking with others about these unsubstantiated and, frankly, vague impressions, you could be putting yourself and the hospital in a difficult legal situation. Am I making myself clear?”

“Perfectly clear,” Noah said. He stood up. It was painfully obvious that coming to Dr. Kumar had been a big mistake.

“Dr. Mason told me that it was his impression that you and Dr. London were having an affair,” Dr. Kumar added. “Is that now on the rocks, and are you coming to me out of spurned lover’s spite? Honestly, that’s what it sounds like.”

Noah stared at the Anesthesia chief with total disbelief. It was such an outrageous idea that Noah suddenly questioned if Dr. Kumar himself was a spurned lover of Ava’s. And what about Dr. Mason? Could his anger be from spite based on more than just having his advances rebuffed? From the little Noah had told Leslie about Ava, she had classified Ava as a manipulative person with a possible personality disorder. Could Leslie be right? Yet the moment the shocking idea of Ava’s possible promiscuousness occurred to him, Noah immediately dismissed it out of hand, sensing his paranoia was running away with itself. Dr. Kumar was not behaving like a spurned lover in the slightest. He wasn’t putting Ava down but rather the absolute opposite. He was truly convinced of Ava’s competence, as well as his own leadership abilities for having hired her. And it was his leadership that Noah was challenging by voicing his misgivings.

“My only motivation is my ethical duty,” Noah said. The last thing he wanted to do was get into any kind of discussion about his relationship with Ava. “Thank you for your time.”

Noah started to leave, but Dr. Kumar stopped him. “One last piece of advice: In the future, if you have any concerns about people in my department, I advise you to go through channels. You should speak with your chief, Dr. Hernandez, and not to me. Am I making myself clear?”

“You are,” Noah said. “Thank you for seeing me.” He turned and left. As he headed back to the elevators, he mocked himself for previously thinking that he was making progress in the diplomatic arena. It seemed that handling staff egos at the BMH was certainly not his forte. In retrospect, there was no doubt in his mind that it had been a remarkably poor decision to seek out the Anesthesia chief. Worriedly, he wondered if Dr. Kumar would mention their tête-à-tête to Dr. Hernandez. Unfortunately, he thought the chances were better than good.

27

MONDAY, AUGUST 7, 2:38 P.M.

Mondays were always difficult for Noah, even though he’d spent the entire weekend at the hospital, searching for things to do to avoid obsessing over Ava’s continued silence. Although he was completely caught up on all his responsibilities, the Monday surgical schedule was particularly heavy as every attending wanted OR time and pressured Noah to provide it. Everyone felt it was far better to get their cases done earlier in the week, the better so that by the end of the week patients could be sent home, which was more pleasant for patients and surgeons alike. To add to his burden, Noah had three of his own cases. Luckily, those had gone well, so he now had time to finish one of the projects he’d started over the weekend.

Changing out of his scrubs, Noah headed to the surgical residency program office. The administration area was in full swing, especially around the hospital president’s massive corner office. As Noah passed the anesthesia office he cringed, thinking of the unpleasant meeting he’d had with Dr. Kumar Friday afternoon. So far there had been no fallout, but Noah was quite certain it would happen, maybe even later that day.

Noah’s goal was to pick up some files from Shirley Berenson, the surgical residency program coordinator, who managed the complicated resident evaluation process upon which the program’s accreditation depended. Every month each resident was evaluated as to his or her progress in a wide variety of arenas, such as surgical skills, patient care, medical knowledge, attendance, timeliness, and a host of other subjective attributes such as professionalism and communication skills. As super chief, it was Noah’s responsibility to get the completed forms from all chief residents evaluating the residents under their tutelage for the month. Noah had done this on Saturday. On Sunday, he had used this material to help him fill out his own evaluations of all fifty-six residents, including all the chief residents, and put all the paperwork in Shirley’s inbox. Since it was Noah’s first attempt at this process, it had taken him longer than he’d expected. And he wasn’t finished.

Shirley had told him that she would collate all the material, fill out the required regulatory forms, make four separate copies of the complete report, and have them all done by noon. At that point it was Noah’s job as super chief to deliver a copy to Drs. Hernandez, Cantor, Mason, and Hiroshi. Why it had to be the super chief to act as delivery boy, Noah didn’t know, but he assumed it was a holdover from days past, when a certain amount of hazing was part of surgical training. The next year, by tradition, Noah was to become a member of the BMH staff, and accordingly he had to be appropriately humbled before he joined the august community.

Noah had no problem with tradition and liked it to a degree. There was something reassuring about it as a direct connection with the hospital’s venerable past. Delivering copies of the resident evaluation report to Dr. Hernandez and Dr. Cantor was easy. Their offices were right there in the administration area, and Noah handed copies to their secretaries, who were literally around the corner from the surgical residency program office. It was the last two heavyweights that required a certain amount of effort because their offices were in the swanky Franklin Building.

Noah looked at his watch as he crossed the pedestrian bridge. It was a little after 3:00, so he was confident that he wouldn’t run into Wild Bill at his office, since he’d still be in surgery, having been scheduled for three big cases. Even though he was a remarkably fast surgeon who relied on his fellow to open and close, Noah was relatively certain he’d still be occupied.

As he walked, Noah thought about Ava and how he hadn’t seen her that morning, nor even her name on the surgical schedule, suggesting that she was not working that day. On Saturday night, after he’d left the hospital later than 9:00 P.M., Noah had again detoured through Louisburg Square, even though he had tried to talk himself out of doing it. En route he’d argued with himself whether he would have the courage to ring her bell if he saw a light in her study, but he needn’t have bothered. There’d been no light in the study or in any other window, suggesting she was again out of town, most likely back in Washington. With a heavy heart, yet rationalizing that it was for the best, Noah had continued on to his drab apartment. At least he didn’t have the impression he’d been followed, making him feel as if his paranoia was under control.

Dr. Mason’s office was on the eighth floor and Dr. Hiroshi’s was on the sixth. To speed up the process and get Dr. Mason’s delivery out of the way sooner rather than later, he took the elevator to the eighth floor with the idea of then using the stairs to get down to the sixth. Entering Dr. Mason’s posh, mahogany-clad domain, Noah headed directly for his secretary, Miss Lancaster. She was somewhere in her fifties, with an impressive ash-blond chignon piled on her head. She had an imperious manner that caused her to treat surgical residents like hired help. Noah had had to deal with her in the past and had never found it pleasant.

As Noah approached, Miss Lancaster was on the phone, angrily dealing with someone who apparently wished to see Dr. Mason as soon as possible. “I’m sorry, but Dr. Mason is a busy man,” Miss Lancaster scolded. “No, he will not call you back.”

Noah held up the resident evaluation report, which he knew that Miss Lancaster surely recognized, as it was a monthly tradition and had a distinctive red cover. The secretary looked at Noah over the top of her reading glasses. There was no recognition or any semblance of graciousness. Instead, she merely nodded irritably toward the open door into Dr. Mason’s inner sanctum and then gestured with her free hand as if shooing away a pest. She didn’t interrupt her conversation with what Noah assumed was a desperate patient, most likely dealing with a recent diagnosis of pancreatic cancer. “Have your doctor call me,” Miss Lancaster snapped into the phone. “But first make sure that the CT scans are sent so Dr. Mason can review them before speaking with your doctor.”

Feeling considerable empathy for the patient, Noah resisted the temptation to say something appropriately harsh to Miss Lancaster. She was treating the caller outrageously. After having recently filled out all the evaluations of the residents, he wished there was a mechanism for doing the same with staff secretaries.

Dr. Mason’s corner office appeared to Noah the way he imagined the office of a CEO of a major international corporation would look, as a reflection of the amount of money the man brought to the hospital. It was ridiculously large, commanded an impressive view of Boston Harbor, and was also paneled in mahogany. The furniture in the sitting area was upholstered in a soft, premium leather. Covering the walls were a profusion of framed diplomas, both earned and honorary. The desk size matched the renowned surgeon’s ego.

For a second Noah debated where to put the resident evaluation report as he noticed correspondence waiting Dr. Mason’s signature on the table in front of the couch. Still, Noah decided to put his report front and center on the desk, but as he approached with the report outstretched something caught his eye. Lying on the desk off to the side was a bound Ph.D. thesis. Noah did a double take. To his shock, he thought he recognized it. It looked like his!

Noah dropped the evaluation report on the desk’s blotter, and then after a glance over his shoulder to make sure Miss Lancaster was still preoccupied with her phone conversation, he reached out and snapped up the bound thesis. A second later he confirmed it was indeed as he suspected: Genetic Control of the Rate of Binary Fission in Escherichia Coli by Noah Rothauser. Someone, presumably Dr. Mason, had inserted a number of Post-it bookmarks.

After another fleeting glance in Miss Lancaster’s direction, Noah opened the bookmarked pages. They marked various tables of data. One table in particular made Noah’s heart leap in his chest. For a brief second he thought about taking the thesis to get it out of Dr. Mason’s hands, but immediately he decided against the idea. Miss Lancaster’s eagle eye would undoubtedly see him carrying it, as it would be difficult to conceal. The only way possible would be to hold it under his white coat, but that would be awkward and most likely wouldn’t work. And even if he succeeded in getting it by her, she’d remember it had been sitting on the desk when Noah had visited. Reluctantly, Noah replaced the thesis, convinced that taking it would only serve to call attention to it and probably make things worse.

28

TUESDAY, AUGUST 8, 1:13 P.M.

“Dr. Rothauser?” the OR intercom announced. “This is Janet Spaulding. I just got a call from Dr. Hernandez. He wants to know how long you might be. He would like you to meet with him as soon as possible.”

Noah straightened up suddenly, as if a bolt of electricity had descended his spine. Once again he was being summoned to the principal’s office, and it made his heart race. It had been two weeks to the day that he’d been texted to see Dr. Hernandez out of the blue. Although that meeting had gone well, Noah had no idea why the chief wanted to see him yet again, but it couldn’t be good news. It was certainly out of the ordinary for such a request to come through the OR intercom. “Tell him I’m finishing up now and I’ll be available in a half-hour or so. Where does he want to meet?”

“His departmental office,” Janet said.

“Got it,” Noah replied. He tried to calm himself, but it was difficult. He was watching Dr. Lynn Pierce, a first-year resident, sew up the skin under the watchful eye of Dr. Arnold Wells, a third-year senior resident. Dr. Pierce was doing a credible job even though it was her first time doing so. She had spent her first month in the SICU, or surgical intensive-care unit, where she had done a superb job. Now she was rotating on the gastrointestinal service.

The operation had been a pancreatectomy, Dr. Mason’s specialty, and Noah was pleased with his performance. He’d used Dr. Mason’s technique to the letter and had accomplished the difficult surgery almost as quickly as Dr. Mason, a tribute both to the technique and Noah’s dexterity. Noah was known as one of the fastest residents when it came to doing surgery. It wasn’t that he rushed. It was just that he knew the anatomy cold and had exceptional hand-eye coordination. There was never any wasted motion.

“Would you guys mind if I duck out?” Noah asked. He couldn’t stand the tension of not knowing why the chief wanted to see him, especially by having him paged in the middle of an operation.

“Not at all,” Arnold said. Lynn didn’t respond, as she was concentrating on her suturing.

After a quick chat with the anesthesiologist about post-op orders on the patient, Noah hurried toward the men’s locker room to change out of his scrubs. As he powerwalked the length of the OR suite, it occurred to him that the most likely explanation was that Dr. Kumar had finally gotten to Dr. Hernandez to complain about Noah’s importunate Friday-afternoon visit. Racking his brains, Noah tried to think up some elaborate explanation of why he had gone directly to the chief of Anesthesia bypassing Dr. Hernandez. Unfortunately, Noah didn’t feel very creative, since he was exhausted and already on edge.

The previous night Noah had slept little, unable to stop fretting about his Ph.D. thesis being on Dr. Mason’s desk. For the life of him, he couldn’t figure out why or how it had gotten there and why there were bookmarks at various data tables. Recalling Dr. Mason’s threat to do his best to have Noah dismissed, there could be only one explanation. Was that something Noah had to worry about? He didn’t know, but it had made him feel extremely agitated.

Unable to sleep with his mind in turmoil, Noah had gotten up at three in the morning and had returned to the hospital. For lack of anything else to do, he’d started his prep for the next M&M Conference, even though by doing so he’d also had to contend with thoughts of Ava. When he had done the Tuesday resident surgical schedule, he’d seen that she was assigned to cases on Tuesday, meaning she was back from wherever she had gone. It had made him wonder if he’d run into her by chance, and if he did how he would react, but it hadn’t happened.

Noah took the stairs to get down to the third floor, once again anxious about heading to a confrontation with someone who had the power to derail his career ambitions. Obviously, it was a fear he was never to outgrow.

When Noah presented himself in front of Dr. Hernandez’s charming secretary, Mrs. Kimble, who was the antithesis of Miss Lancaster, he was asked to take a seat in the common administrative waiting area. She said she would come and get him when Dr. Hernandez was ready. Her pleasant attitude seemed entirely normal, which Noah took as a good sign. As he sat down he felt a bit more at ease. Another idea had occurred to him. Maybe Dr. Hernandez wanted to congratulate him on his first resident evaluation report, which Noah had turned in the day before. Noah did feel confident the report had been done with appropriate attention to detail, and it was entirely positive, which was unique. Contrary to most years, none of the first-year residents were having any difficulty adapting to the rigors of the program.

With these thoughts in mind, Noah was feeling confident until a small parade of additional authority figures appeared, including Dr. Cantor, Dr. Mason, Dr. Hiroshi, and, strangely enough, Gloria Hutchinson, the president of the hospital. Chatting together, all of them trooped into Dr. Hernandez’s office and disappeared behind a closed door.

Now Noah’s anxiety returned in a rush as the minutes ticked by. Were all these bigwigs going to be part of the meeting with Noah, or was Noah merely waiting until their meeting with Dr. Hernandez was over? If it was to be the former, something rather extraordinary was afoot, especially with Dr. Mason’s presence. If it was the latter, things might turn out okay. Noah took his pulse, which was normally in the sixty-per-minute range. Now it was one hundred and ten, and he could feel it in his temples.

Tossing aside an old issue of Time magazine, Noah concentrated on Mrs. Kimble. He’d concluded that her behavior was key. To his dismay, a few minutes later, after hanging up her phone, she pushed back from the desk and stood. As she started in Noah’s direction, he could feel his pulse rate jump from its already fast pace.

“Dr. Hernandez can see you now,” Mrs. Kimble said with the same pleasantness she’d used before. This time Noah wasn’t fooled. The meeting was going to be with the whole group.

When Noah got into the inner office, his worst fears seemed justified. Dr. Hernandez did not get up as he usually had in the past, and he exuded an alarming intensity. Dr. Cantor and Dr. Hiroshi were sitting by the window in side chairs. Gloria Hutchinson was on the couch, looking as serious as Dr. Hernandez. Next to her was Dr. Mason with an expression of pompous self-satisfaction. But worst of all, from Noah’s viewpoint, was catching sight of his wayward thesis perched on Dr. Hernandez desk. This impromptu meeting was not about the resident evaluation report, or his misguided meeting with Dr. Kumar, but something far more serious.

With no seat available and no verbal direction from Dr. Hernandez, Noah stopped in the middle of the room. He felt agonizingly vulnerable, facing not one but four authority figures. His heart was racing. When no one spoke or moved, Noah felt pressured to break the silence: “You wanted to see me, sir?” The pitch of his voice was higher than he would have liked.

“That’s correct,” Dr. Hernandez snapped angrily. Then, in his signature bombastic style, he launched into a mini-lecture about how seriously the surgical department took ethical breaches, emphasizing that the BMH, as one of the country’s premier tertiary-care and teaching programs, was obliged to set a high standard for professional integrity and honesty.

As Dr. Hernandez droned on, Noah glanced at the other people in the room. Most had assumed a glazed look, except for Dr. Mason, who was enjoying every second. A sudden slapping sound yanked Noah’s attention back to Dr. Hernandez. The chief’s hand was now resting on the top of Noah’s Ph.D. thesis.

“With these standards in mind, we are faced with a major problem,” Dr. Hernandez continued. He picked up the slender volume and held it aloft, reminiscent of a preacher with a bible. “It has been brought to the department’s attention that there is falsified data in this thesis, which we understand played a significant role in your acceptance to Harvard Medical School. Is that your understanding, Dr. Rothauser?”

Noah stared with disbelief at the chief. He couldn’t believe this was happening. He felt like he was teetering on the edge of a precipice. “Yes,” he said after a short pause. “I believe that my thesis made the Admissions people look more positively at my application.”

“Then perhaps your acceptance was based on falsehood,” Dr. Hernandez said. “If that is the case, we have a serious dilemma that requires attention. So I ask you directly, does this thesis of yours contain falsified or contrived data?”

“To a degree,” Noah said, struggling to decide how to answer.

“That seems inordinately evasive,” Dr. Hernandez snapped. “I think the question deserves an unambiguous answer. Yes or no!” He glowered at Noah.

“Yes,” Noah said reluctantly. “But let me explain. By working day and night I was able to complete my Ph.D. work in two years. For it to be officially part of my medical school application, I had to hand in my thesis on a specific date. To make that date, I was forced to make some very modest outcome predictions for my final confirming experiment, whose results had already been proven by previous work. Those estimates remained in the hard copies I submitted, one of which you are holding. When the final data was available within the month, which was more positive than my conservative estimates, I changed the digital version, which is the version that is online and cited in the literature.”

“In other words,” Dr. Hernandez said while still holding Noah’s bound thesis in the air, “there is definitely falsified data in this work.”

“Yes,” Noah repeated. “But—”

“I’m sorry,” Dr. Hernandez said, interrupting Noah in a tone of voice that was the opposite of being sorry. “This is not the time for explanations of why purposely falsified material exists in a Ph.D. thesis. The fact that it does forces our hand. From this moment, Dr. Rothauser, you are suspended from your duties as super chief resident pending an ad hoc hearing of the Residency Advisory Board. The board will adjudicate the situation and determine if the suspension will be reversed or made permanent. The board will also decide if the Massachusetts Board of Medicine should be advised.

“That will be all, Dr. Rothauser. Needless to say, we are all shocked and disappointed.”

Noah was the one who was the most shocked. He couldn’t believe he was being summarily dismissed and, worst of all, suspended. He was momentarily paralyzed. He’d expected something bad, but more in line of being formally censured for ignoring proper channels and meeting with Dr. Kumar to question the competence of one of his staff members.

“That will be all, Dr. Rothauser,” Dr. Hernandez repeated irritably. He tossed Noah’s bound thesis onto his desk in an overt display of indignation.

“What about my patients?” Noah pleaded, finding his voice. He had six post-operative patients in the hospital at that moment, several still in the PACU, and he had surgical cases scheduled for the week.

“Your patients will be taken care of by others,” Dr. Hernandez said. “You should leave the hospital until this issue is resolved. Dr. Cantor will be in touch with you in due course.”

Noah literally stumbled out of the chief of surgery’s office, totally stunned. In a semi-trance, he walked the length of the corridor toward the elevators. He couldn’t believe that Dr. Mason had succeeded in accomplishing what he had threatened. As Ava had reminded him, his reputation as a resident among staff, fellow residents, and patients was sterling. The whole situation was a nightmare.

For Noah, the potential implications of being permanently dismissed from his residency and losing his medical license was the worst news imaginable, akin to being diagnosed with an untreatable cancer. Suddenly, everything he had worked for since he’d decided on medicine as a career was in jeopardy. It was as if his life was unraveling.