“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 s
aid 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.