by Robin Cook
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 rep
lies 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.
