Ava drew another blood sample and sent it off.
“I don’t like this,” Stevens said after another ten minutes had passed. “I’ve got a bad feeling here. The heart has got to be in super-bad shape. How long did he fibrillate, Noah, when you were opening him up?”
“I believe just minutes. The cold saline stopped it almost immediately.”
Stevens looked over at Ava. “How about the first episode of fibrillation: How long was that?”
“I’d guess two or three minutes,” Ava said. “That was how long it took for the crash cart to get in here.” She glanced down at the anesthesia record to be sure. “Actually, it was less than two minutes. It wasn’t long, because the cardioversion occurred with the first shock.”
“That’s not a lot of time in both instances,” Stevens said. “I’m at a loss. Somehow the heart had to have been significantly damaged not to even respond to a pacemaker. We are running out of options. Also, I’ve got to get going on my own case.”
No one responded to Stevens’s last comment. Everyone knew what he was implying: Maybe it was time to give up. The patient could not be kept on bypass continuously.
The PA system came to life. “I’ve got the electrolyte results,” a female voice said. She then read them off. They were all relatively normal, without change from the first sample.
“Well, it’s not the electrolytes,” Stevens said. “All right. Time for a few more tries.”
Over the next few hours Stevens retried all the tricks he knew. There was never the slightest response. “I have never had a post-bypass heart not respond to a pacemaker like this. We haven’t gotten so much as a blip on the ECG.”
“What about a transplant?” Noah suggested. “He’s a relatively young and healthy guy. We could put him on extracorporeal membrane oxygenation to tide him over.”
“ECMO is not for long-term care,” Stevens said. “The reality is that there are three thousand people waiting for a heart on any given day. The average wait for a heart is four months. It varies according to blood type. What’s his blood type, Ava?”
“B negative,” Ava said.
“There you go,” Stevens said. “That alone limits the chances of a decent match. Also, since this heroic effort was started without sterility, the chances are better than even he’d have a post-op infection. We’ve given it our best shot, but I’m afraid it is time to face the facts. Turn off the pump, Peter! We’re done here.”
Stevens stepped back from the table and snapped off his gloves and peeled off his surgical gown. “Thank you, everybody. It’s been fun.” He sighed in response to his own sarcasm, gave a little wave, and left the room.
For a moment, no one moved. The only sounds came from the pulse-oximeter alarm and the ventilator.
“Well, I guess that’s it,” Peter said. He turned off the heart-lung machine per Dr. Stevens’s order and started to clean up.
Ava followed suit, switching off the ventilator and detaching the monitoring.
Noah stayed where he was, looking down at the flaccid heart that had failed everyone, but mostly the patient. Although he didn’t question Stevens’s decision that it was time to quit, Noah wished there had been something else to try in hopes of a different outcome for the patient’s benefit and Noah’s, too. Noah’s intuition was telling him loud and clear that there was a very good chance this unfortunate case was going to be real trouble once he became the “super chief” surgical resident in less than a week. As super chief, it was going to fall to him to investigate and then present this death at the bimonthly Morbidity and Mortality Conference, where it was sure to become a hotly debated episode. From what Noah had already gleaned from Dr. London, there was clear fault on the part of the patient for failing to divulge having eaten a full breakfast despite orders not to do so, and for Dr. William Mason for failing to communicate key information, due at least partly to his running two other concurrent surgical cases.
From Noah’s perspective, what made the situation so worrisome were two unfortunate realities. The first was that “Wild Bill” was known to be a remarkably narcissistic man, fiercely protective of his reputation, and notoriously vindictive. Dr. Mason wasn’t going to be happy to have his role in this unfortunate case made public and would be looking for scapegoats, which might include Noah. Second, Dr. Mason was one of the few members of the surgical hierarchy who wasn’t impressed with Noah, and Mason was the only one who overtly disliked him. Dr. Mason had said as much, and as an associate director of the surgical residency program had already tried to get Noah fired a year ago, after they’d had a serious run-in.
Noah glanced over at Dr. London. She returned his gaze. What he could see of her usually tanned face was pale; her eyes were wide and staring. To Noah, she looked as shell-shocked as he felt. Unexpected deaths were hard to bear, particularly when they involved a previously healthy individual undergoing simple elective surgery.
“I’m sorry,” Noah said, unsure of what he was apologizing for but feeling the need to say something.
“It was a gallant effort,” Dr. London said. “Thank you for trying. It is a tragedy that shouldn’t have happened.”
Noah nodded but didn’t respond verbally. He then followed Stevens out of the operating room.
BOOK 1
1
SATURDAY, JULY 1, 4:45 A.M.
The smartphone alarm went off at 4:45 A.M. in Noah Rothauser’s small and sparse third-floor one-bedroom apartment on Revere Street in Boston’s Beacon Hill neighborhood. As a surgical resident at the Boston Memorial Hospital, it was the time Noah had been waking up just about every day except Sunday for five years. In the winter, it was pitch black and cold, since the building’s heat didn’t kick on until seven. At least now, in the summer, it was a bit easier to climb out of the bed because it was light in the room and a pleasant temperature, thanks to a noisy air conditioner in one of the rear-facing windows.