Charlatans

by Robin Cook

  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 sou
nds, 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 hu
rry. 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.