Without the usual need to rush to the hospital, Noah opened the medicine cabinet over the sink and took out shaving cream and a razor. While he lathered his face, he found himself smiling. His new job sounded like an enormous amount of work and effort, especially since he would have his own patients and be doing his own surgery at the same time, but he knew he was going to love the year. The hospital was his world, his universe, and as super chief he was to be the alpha-male surgical resident. It was an honor and a privilege to have been selected for the position, especially since on its completion, he was assured by precedent that he would be offered a full-time faculty position. This was huge. For Noah, the opportunity to be a full-time attending surgeon at one of the world’s premier academic medical centers associated with one of the world’s premier universities was the pot of gold at the end of the rainbow. It had been his goal for as long as he could remember. Finally, all the work, effort, sacrifice, and struggles in college, medical school, and now as a resident were going to pay off.
With quick strokes of the razor Noah made short work of his overnight stubble, then climbed into the tiny shower. A moment later he was out and vigorously drying himself. There was no doubt that it was going to be a very busy year, but on the positive side he would not have any official night call, even though, knowing himself, he’d be spending most evenings in the hospital anyway. The difference was that he would be doing what he wanted to do with interesting cases that he’d get to choose. And equally important, he would not be bogged down with busy work, the typical bane of house officers or hospital residents, particularly surgical residents, since there was always some menial task that had to be done, such as changing a dressing, advancing a drain, or debriding a gangrenous wound. Noah would be able to designate others to do all that stuff. For him, the learning opportunities were going to be off the charts.
The only fly in the ointment, and it was a big fly and a nagging, persistent worry for Noah, was the responsibility he now had for the damn bimonthly surgical Morbidity and Mortality, or M&M, Conference. This conference was different from all the others, since Noah would not have the option of farming out any aspect of the responsibility to other residents. It was going to fall to him and him alone to investigate and then present all adverse-outcome cases, particularly those resulting in death.
Noah’s fear of the M&M Conference was not some irrational concern. Since the conference was specifically about cases that didn’t turn out well, often involving mistakes and individual shortcomings, blame and finger-pointing in an emotionally charged environment with dirty laundry hung out for everyone to see was the norm and not the exception. Considering the egotistical mind-set of many of the surgeons, the atmosphere could be explosive and a breeding ground for hard feelings, with the potential of creating enemies unless an underling scapegoat could be found. Noah had seen it happen over the last five years, and the scapegoat often was the messenger: the presenting super chief resident. Noah worried that the same could happen to him now that he was super chief, especially considering the Bruce Vincent fiasco. The case had trouble written all over it for many reasons, not least of which was that Noah had been involved. Although Noah had never second-guessed his decision to put the man on emergency bypass, he knew others might.
Adding to Noah’s concern, the death of the popular parking czar had the entire medical center in an uproar and gossip was rife. Prior to the event, Noah hadn’t even known the man, because Noah didn’t have a car and never had any reason to visit any of the hospital’s three garages. Noah walked to work, and when the weather was bad, he merely stayed in the on-call facilities, which were expansive and more inviting than his own apartment. He’d seen the kids’ photos on the cafeteria bulletin board but had never known whose children they were. Yet now he knew and understood he had been in a distinct minority of not being a Bruce Vincent fan, all of which was going to make the M&M Conference a standing-room-only affair.
The main reason Noah was fearful was that the Vincent case involved Dr. Mason, who Noah knew to be egotistical, quick to export blame, and outspokenly critical of Noah. Over the previous year and a half, Noah had made an effort to stay out of the man’s way as much as possible, yet now, with this next M&M coming in less than two weeks, they were on a definite collision course like a certain cruise ship and a giant wayward iceberg. Whatever Noah was going to find in his investigation of the case, he knew it was going to be a diplomatic nightmare. From the little the anesthesiologist had said at the time, it seemed to Noah that a considerable amount of responsibility had to be directed at Dr. Mason, who had been running two other concurrent surgeries. The concurrent-surgery issue alone was an emotionally charged hot-button issue within the department.
Noah ducked back into the bedroom and went to the bureau for underwear and socks. There were only three pieces of furniture in the room: the bureau, a queen-size bed, and a single bedside table that supported a lamp and a stack of medical journals. There were no pictures on the walls or any draperies over the two windows facing out into a rear courtyard. There were no rugs on the hardwood floor. If someone had asked Noah about the decor, he would have described it as spartan. But no one asked him. He didn’t have visitors and wasn’t there much himself, which was probably the reason he’d experienced a few break-ins since Leslie had left. At first such episodes had bothered him as a personal violation, but since he had almost nothing to lose, he came to accept it as part of city living with lots of impecunious students visiting the tenants above him. Mostly, however, he didn’t want to take the time or effort of finding a new apartment. In lots of ways he didn’t even consider it a home. It was more a place to crash a few times a week for five or six hours.
There had been a time several years ago when he’d felt differently, and the apartment had been warm and cozy with things such as throw rugs, framed prints of famous paintings on the wall, and curtains over the windows. There had also been a small writing desk covered with framed photos, and a second bedside table. But all that homey stuff had belonged to Leslie Brooks, Noah’s long-term girlfriend, who had come with Noah from New York to go to Harvard Business School after she graduated from Columbia in economics and he in medicine. She had lived with Noah until she finished her graduate degree two years ago, but after graduation had moved back to New York with all her stuff to a great job in finance.
Leslie’s departure had taken Noah by surprise, until she’d explained that she had come to the realization over the three years that his professional commitment was such that there was little room for her. Most surgical residents got progressively more time with their families as they advanced up the residency ladder. Not so with Noah. Each year his hours got longer by choice. There had been no rancor on either of their parts when they went their separate ways, even though Noah had been initially crushed, as he had come to assume they would marry at some point. Yet he quickly realized that she was right and he had been selfish with his time and attention. At least until he finished his graduate training, which he thought of as a 24/7 activity, he was metaphorically married to medicine and had spent very little time in her company and in the apartment.
On occasion Noah missed Leslie and looked forward to their monthly FaceTime phone calls, which she made the effort to continue. Each considered the other to be a true friend. Noah was aware she was now engaged, which tugged at his heartstrings when he thought about it. At the same time, he was thankful that she had been forthright about her needs, and he was relieved that her contentment was no longer his responsibility. At least until his residency was over, medicine was his overly demanding mistress. Ultimately, he truly wished the best for her.
From the closet Noah got a white shirt and a tie and went back into the bathroom to put them on. Once he was satisfied with the knot, which often took several attempts, he dealt with his rather thick, closely cropped dirty-blond hair by parting it on the left and brushing most of the rest to the right and off his face. Back when he had been a typical
teenager, Noah had been vain and worried about his looks. He had spent a lot of time wanting to believe he was a stud, as a couple girls had referred to him. Although he wasn’t exactly sure what they had meant, he had taken it as a great compliment. Now he was not concerned about his appearance other than to look appropriately doctorlike, which he interpreted as being reasonably manicured, with clean, pressed clothes. He despised those residents who thought it a badge of honor to wear wrinkled, bloodstained outfits, especially scrubs, to advertise how hard they were working.
Noah was a bit more than six feet in height and still appeared athletic, even though he’d not had time for athletics since he’d graduated from college. Still weighing in at 165 pounds, he had never gained weight like some of his high school friends, despite not getting much aerobic exercise. He attributed his good luck to rarely taking the time to eat and to having decent genes, thanks to his father, which might have been the only positive thing he got from him. In the looks category, what made him the proudest was his chiseled nose separating emerald-green eyes. The eyes were a gift from his redheaded mother.
The final act of dressing before heading off to the hospital involved his white pants and white jacket, both of which he was known to change several times in the same day, taking advantage that they were cleaned and pressed by the hospital laundry. When he was fully ready, with his computer tablet in his side pocket, he checked himself in the mirror that hung in the living room. The mirror had belonged to Leslie, and why she had left it she had never explained, nor had he asked. Otherwise, the living room was almost as stark as the bedroom. The furniture consisted of a small threadbare couch, a coffee table, a floor lamp, a folding card table with two folding chairs, and a small bookcase. An elderly laptop sat on the card table as the sole remnant of his teenage love of computer gaming. The only wall decorations in the room were a simple brick mantel painted white and the mirror. Like the bedroom windows, the living room windows were bare. They looked out onto Revere Street and the typical Beacon Hill brick buildings opposite.
When Noah exited his building, it was only a little after 5:00 A.M. On a normal day, when he didn’t take the time to shave, he always left before 5:00, proof of the efficiency of his morning routine. This time of year, it was a pleasant temperature outside and nearly full daylight, although the sun itself had yet to rise. In the winter, it was another story, especially on snowy mornings. Yet he liked the walk in all seasons, as it gave him time to think and plan his day.
His usual route took him to the left, heading farther up Beacon Hill, which was a real hill and not just the name of the neighborhood. At Grove Street, he switched over to parallel Myrtle Street and continued climbing. As was fairly typical, Noah saw no other pedestrians until he crested the hill, at which time, as if by magic, people materialized, mostly dog walkers and joggers, although a few commuters appeared, too. As he passed the Myrtle Street playground, he was showered with the sounds of summer. Even though he was in the center of a major city, the bird population was considerable and the air was filled with chirps, trills, tweets, and warbles.
As he walked, Noah couldn’t keep from fretting about the damn M&M. Why it bothered him so much was his abiding fear of authority figures such as principals, college or medical school deans, influential teachers, and powerful surgical faculty members. In short, it was anyone who had the power to derail his strong urge to be a consummate academic surgeon. He’d always known it wasn’t a totally rational phobia, since he had been a top student from eighth grade on, but such an understanding didn’t reduce his anxiety. He’d had a fear of authority figures throughout his schooling, but it had ratcheted up in both college and medical school and had even gotten worse during his residency, especially after it had been hugely reawakened when he had been blindsided during his second year.
The unexpected irony for Noah was that his total 110 percent commitment to his surgical residency had not been without problems above and beyond the social sacrifices in relation to Leslie. With a certain amount of dismay, after his first year as a resident he came to realize that there were attendings who thought of him as overzealous, particularly the more openly narcissistic surgeons, such as Dr. William Mason. The super chief at the time, Dan Workman, took Noah aside to explain that it might be better for Noah to rein himself in to a degree. Without naming specific people, he said that there were faculty who thought of Noah as a little too good, too ambitious, and getting far too much acclaim and needing to be humbled.
Noah had been shocked until he came to understand where the animosity was coming from. As a first-year resident, Noah had started interfering with a certain surgeon’s private cases because of his attention to detail. By his thoroughness, he had the uncanny ability to discover additional problems when he did routine admitting history and physicals. These discoveries not only got a number of cases canceled but also suggested that the original workup had been incomplete or sloppy, a fact that certain attendings were not happy to learn and had advertised. In many ways, it was yet another example of blaming the messenger.
At first Noah had just dismissed the problem, since he felt confident he was putting patients’ needs first, which a doctor is supposed to do. If anything, the criticism spurred him to even greater efforts until he was taken down a peg. With his degree of commitment to excellence and patient care as evidenced by his effort and thoroughness doing routine admitting histories and physicals, Noah spent way too much time in the hospital. He was always there, always available, even when he wasn’t on call. Whenever a fellow resident asked him to cover, he always agreed. He didn’t even take a day off until literally ordered to do so by the super chief.
Noah knew full well his behavior was in constant violation of the work limits imposed by the Accreditation Council for Graduate Medical Education, known as ACGME, yet he felt the rationalization for the limitations in terms of patient safety did not apply to him. He needed little sleep, rarely felt tired, and, in contrast to more than half the other residents, wasn’t married and didn’t have children. At the time, he thought Leslie understood and was supportive.
Eventually someone brought Noah’s work ethic to the attention of Dr. Edward Cantor, the surgical residency program director. The result was a personal warning, which had a mild effect on Noah for a few days before he switched back to his usual schedule. Then, as Noah would say, the shit hit the fan. On two occasions, he was hauled before the Residency Advisory Board, which was particularly embarrassing since he sat on the board, as voted by his fellow residents, and hence had to recuse himself. On the first occasion, he got another warning and was told that his behavior would put the hospital’s total graduate medical education program in jeopardy if the media were to get wind of it.
For a few weeks Noah tried to restrain himself, but it was difficult. For him, being in the hospital was like an addiction. He couldn’t stay away. Three weeks later, Noah was back in front of the Residency Advisory Board, whose faculty members were furious. To Noah’s absolute horror, on this occasion he was threatened with dismissal and told that from then on he was on probation such that a third violation would result in his walking papers.
Noah had indeed been taken down a notch. From then on he proceeded with extreme care and devised all sorts of inventive strategies, such as signing out from the hospital and leaving from one door only to enter another. Luckily, as time passed, the threat of dismissal lessened. By the time he finished his third year, he began to ease up on all his machinations of eluding attention because senior residents were not followed as closely as junior residents. As for a vacation, he hadn’t taken one and no one seemed to have noticed.
Now it was 5:26 A.M. when Noah entered through the main entrance of the Stanhope Pavilion. As he always did, he felt a shiver of excitement just coming through the door. Every day was a new experience; every day he saw something he’d never seen before; every day he learned something novel that would make him a better doctor. For Noah, arriving at the hospit
al was like coming home.
2
SATURDAY, JULY 1, 5:26 A.M.
The very first thing that Noah did every morning after coming through the revolving door was board one of the elevators and head up to the surgical intensive-care unit located on Stanhope 4, the same floor with the operating rooms. Visiting the SICU was always number one on his agenda, whether he slept at home or in the surgical on-call facility, which was also on Stanhope 4. For obvious reasons, the patients in the intensive-care unit were the hospital’s sickest and most needy.
Like the Stanhope operating rooms, the intensive-care unit cubicles were arranged in a circle, defined by glass partitions, with a central desk from which the nursing supervisor could see into each cubicle by merely turning her head. The night shift supervisor was Carol Jensen, a certified critical-care nurse. She was no-nonsense like all the other supervisors, particularly when she was tired, and toward the end of a shift intensive-care nurses were always tired. It was one of the most demanding jobs in the entire hospital.
“You are a ray of sunshine, Dr. Rothauser,” Carol said as Noah came in behind the counter. The central desk, like the room, was circular.
“It is always nice to be appreciated,” Noah responded cheerfully. He took a seat in one of the swivel desk chairs. He understood what Carol mostly meant by her flattering metaphor: namely, that his arrival augured the ending of her shift and she would soon be on her way home. At the same time, he took it as a compliment. Noah had been told on more than one occasion, and even by Carol herself, that he was one of the nursing staff’s favorite residents. She’d explained that everyone appreciated that he was always available at a moment’s notice and was always cheerful, no matter the time of day or night, in contrast with other house staff who could be downright surly if they were exhausted, which they often were when on call at night. Even when Noah was in surgery, he’d made it known he didn’t mind talking over the intercom for an emergency consult on a patient. For nurses, particularly critical-care nurses like Carol, doctors being reachable was enormously important because problems could arise quickly and critical decisions had to be made or patients suffered. But what Carol didn’t say and what Noah was blissfully unaware of was that most of the other female nurses thought Noah was a bit of a mystery. As one of the more attractive, unattached male residents, he never gave even the slightest sexual spark or engaged in double-entendre wordplay, which was otherwise relatively rife within the hospital culture.