Charlatans

by Robin Cook

  “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 an
d 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.