Doing Harm (43 page)

The surface of the kitten poster, like the walls of the room, has recently been dusted, and it looks the cleanest I’ve just about ever seen it. It’s otherwise completely unchanged, in the exact same spot from which it’s kept its cloying vigil for the last several years, the rows of metallic screws affixing it in place to the wall.

I pull a pair of latex gloves out of my pocket, place them over my hands, and, selecting a screwdriver from the set I brought with me from the trunk of my car, remove the screws, one by one. It takes a while. I’m careful to save all the screws.

The section of wall behind the poster looks much the same as the remainder of the room, cracked and riddled with fissures. So expertly is the defect in the wall behind the poster concealed, so carefully are the edges of it worked to resemble the surrounding chinks in the hundred-year-old concrete, that I never would have found it with anything less than a concentrated, crack-by-crack search.

Tucked into one of the cracks, I find a folded piece of paper sealed in a plastic sandwich bag. I pry the bag from the crack, remove the paper from the bag, and carefully unfold it. A string of twenty random numbers, letters, and punctuation marks are neatly typed on the paper.

The password.

Now I truly understand Luis’s intent.
Compartmentalization.
In and of itself, the password means nothing. It’s only when it’s coupled with the server address, which had been securely ensconced in the safe deposit box a few blocks away, that it makes sense.

And then, in the wall where the password had been hidden, I find something else.

Something that changes everything.

All thoughts of confessing to Dr. Collier disappear. A plan starts to take shape in my mind.

But there’s something else I need to do first.

*   *   *

They arrive home from Providence just before dinner. Sally and I spend the next few hours getting Annabelle and Katie fed, bathed, dressed, and put to bed. Luckily, they’re both exhausted, so neither of them puts up much of a fight.

After the girls are asleep, I lead Sally into the living room and have her sit on the couch. I pull up a chair opposite her, take both of her hands in mine, and draw a deep breath as she waits, curious and expectant.

“Sally. There’s something I need to tell you…”

She takes it well enough, I guess. As well as could be expected. I don’t really have a frame of reference since I’ve never confessed to adultery before.

She doesn’t say anything, just stiffens, pulls her hands from mine, and wordlessly gets up from the couch. Typically Sally: calmly and coolly facing down an emotional crisis. She walks to the window and looks outside. Her back is toward me, and I can’t see her face as I come clean on everything—everything except the psychopathic murderer part, of course.

“Thank you,” she says wearily when I’m done. She doesn’t turn around.

“For what?” I ask, startled.

“For finally being honest with me.”

“Sally—”

“Don’t, Steve. Just … don’t.” She sighs, crosses her arms, and looks at the floor. “Is it really over? Between you two?”

“Yes.”

The next words out of her mouth cut like a serrated knife sliding between my ribs. “Tomorrow morning, I’m taking the girls and staying with my parents for a while. I need to think this through.”

“I understand.”

“No. No, I don’t think you do.” She drops her arms to her sides and clenches her fists. “That was her. In the restaurant. A few weeks ago. The woman who was with Ellie. Wasn’t it?”

I hang my head. “Yes.”

“I thought I caught a weird vibe between you two. Katie and Annabelle—” She shakes her head. “You know, it’s bad enough, what the two of you did.”

She whirls around to face me. “But if she comes near my babies again, I swear to God. I’ll kill her.”

I realize she’s upset right now. But the look on her face is enough to make me wonder if, deep down, she really means it.

CHAPTER 24

Thursday, August 27

I’m sitting in the front row of the Dome, trying to prepare myself for what comes next, mentally laboring to grasp the enormity of what I’m about to attempt. I still can’t conceive of how my life—which was going so well, so smoothly, so ordinarily at the beginning of the summer—could have taken so many unexpected turns, nor how I could have ended up contemplating the beginning of what will surely someday rank as one of the most bizarre nights of my life.

One thing is for certain: It all ends tonight. For better, or for worse, this whole terrible summer ends tonight.

The end begins with a routine administrative denouement to Mrs. Samuelson’s demise: Morbidity and Mortality Report. M and M, as it’s often called, is a venerable surgical tradition. In our department, it’s a formal conference held on the third Thursday of each month, in the evening. Part debriefing, part quality-improvement program, and part mea culpa, it’s a venue for individual surgeons to acknowledge their mistakes, the purpose of which is for the collective surgical community to discuss the complications, determine what went wrong, and try to prevent what went wrong from ever happening again. The cases are selected personally by Dr. Collier from the pool of complications that occur each month.

Surgical complications spring from many sources. A strayed hand. Bad luck. An unforeseen anatomic variation. A lapse in judgment. The fickle flesh of a sick patient. A missed diagnosis. Or, in my own case, inexperience with a particular procedure. Regardless of the cause or who’s responsible, each and every surgeon takes a complication very,
very
personally.

I survey the auditorium, which is packed. M and M is always popular. Everyone in our department is here—professors, residents, med students—plus several surgeons from other hospitals. The room buzzes with conversation and short bursts of laughter. I catch a glimpse of GG, texting on her smartphone. She looks up and slips her smartphone in the front pocket of her white coat. Our eyes meet briefly, and she winks. I face forward again. Sitting in the front row with me are my fellow residents, who sip coffee and swap stories with one another. I keep to myself, focusing on the task at hand.

I nervously run my hand down the front of my newly starched white coat, tug at my tie, and try to keep from throwing up. Again. The butterflies in my stomach have already gotten the better of me once earlier this evening, and I’m hopeful that it won’t happen a second time, in front of all these people.

At precisely 6:00
P.M.
, Dr. Collier, looking regal in a tailor-made blue pin-striped suit and red power tie, checks his watch and rises from his usual seat in the far corner of the first row. He faces the audience and solemnly stretches his hand out for silence, palm extended outward like a traffic cop making the stop signal.

The moment Dr. Collier raises his hand, a preternatural calm settles over the audience, as if the whole room just entered the eye of a storm. Conversations stop midsentence. Cell phones snap shut. Necks crane up expectantly. As is his custom each week, Dr. Collier welcomes everyone, then reminds the residents and medical students participating in the research study that we’ll be receiving our next round of shots immediately after the conference in the hallway outside. Looking stricken, he adds that Luis’s family opted for a private service in LA and asks that we all remember him in our own way. He then leads the assembled group in another moment of silence for Luis.

The silence is deafening, the grief palpable. I think of GG out in the audience, amidst the legitimate mourners, no doubt solemnly bowing her head; and I grind my teeth so loudly that the resident sitting next to me glances at me curiously.

Once the moment is over, Dr. Collier is all business again. He gestures toward the chief residents and settles back into his seat.

I’m up first. Somebody dims the lights as I walk to the lectern. The room remains utterly quiet. But for the sharp report of my starched white coat, which produces a crisp whooshing sound with each forward sweep of my legs, I could be walking in a vacuum. And yet the silence is ripe, crammed with an expectant, tightly wound energy, a life breathed into it by all those people stuffed into the conference room, all of whom are completely focused now on me and what I’m about to say.

I reach the lectern, clear my throat, grab the laser pointer, clear my throat, adjust the computer keyboard, clear my throat again, adjust the microphone, and try to think of something else to adjust. The knot in my stomach pulls harder.

“Proceed, please, Dr. Mitchell,” Dr. Collier orders sternly.

I clear my throat one last time and advance the computer presentation to my first slide.

“Good evening. Our first case is a mortality following laparoscopic converted to open right adrenalectomy…”

“Louder!” a male voice calls out sharply from the depths of the audience.

I lean in toward the microphone. “Our first case this evening is a mortality following laparoscopic converted to open right adrenalectomy complicated by avulsion of the right adrenal vein and right renal hilum, myocardial infarction, fungal sepsis, and pulmonary air embolism.”

I advance to the next slide, trying to ignore the way the glowing dot emitted by the laser pointer, guided by my quivering hand, is hopping around on the projector screen like a frog on crystal meth.

“Mrs. Samuelson was a fifty-three-year-old woman with a past medical history significant only for hypercholesterolemia who initially presented with bilateral lower extremity edema and new onset hypertension.”

Next slide.

I spend the following five minutes summarizing the last few weeks of Mrs. Samuelson’s life, succinctly and dispassionately reducing all of her suffering to a series of glowing lines on a PowerPoint presentation.

The operation.

Next slide.

The bleeding.

Next slide.

The heart attack and fungal infection.

Next slide.

The brief recovery.

Next slide.

The final, terrifying moments of her life.

And then I’m done. I put down the laser pointer and look expectantly at the audience. That was the easy part. Now it’s time for the question-and-answer period. During the next few minutes, the way I respond to the questions that are about to sail toward me like live grenades could conceivably help salvage what’s left of my career—or scuttle it completely.

Dr. Collier rises from his seat and turns partly around, positioning himself so that he can face both the audience and me at the same time. He clasps both hands behind his back. “I think we can lay aside the issue of the air embolism, which is a sensitive patient-care matter currently under investigation by the Safety Committee. Let’s start instead with the operation, which initiated the series of events eventually leading to this patient’s demise. Dr. Mitchell, what was your first thought when you encountered that bleeding?”

My first thought was: Holy fucking shit. What the fuck have I done?

Behind the lectern, I dig my fingernails into my palms. “My first thought was to identify the source of the bleeding.”

“Of course it was, Dr. Mitchell,” he says, waving his brown hand impatiently. “Of course. But with bleeding that catastrophic, it’s probably best to get control of the IVC first. How can you normally accomplish that laparoscopically?”

“Well, it’s difficult, but possible. When this kind of vascular injury occurs, pressure can be applied to the area of injury, with dissection then performed around it to obtain greater exposure. Another laparoscopic port can also be placed to assist.”

“Why was that not attempted here?”

I remember back to my initial panic on that horrible day: watching Mrs. Samuelson’s blood wash across the surgical field, flailing about inside her abdomen with laparoscopic instruments, struggling fruitlessly to find the origin of the bleeding. My stomach churns, and my heart pounds. I taste bile in the back of my throat.

Concentrate.

“It was, Dr. Collier. Unfortunately, due to the catastrophic nature of the injury, vascular control was lost very quickly, and adequate visualization of the surgical field could not be reachieved.”

Another voice emerges from the crowd, a cultured female one. “What about temporarily increasing the intra-abdominal pressure to twenty, or even twenty-five mmHg? That might have helped by temporarily sealing the tear.”

“Yes,” I say, turning toward the source of the voice, which I recognize as belonging to one of our senior faculty members. “That was not attempted.”

“Why?”

“The bleeding was brisk, and our attention was focused on locating the injury.”

“So, in other words, you did not think of it at the time.”

I hesitate for a fraction of a second. “No, ma’am. We didn’t think of it.”

The room grows quiet again as they digest my answer.
So far, so good.
But I know that I’m walking a tightrope, trying to strike the proper tonal balance between repentance and cold, forensic analysis.

Then Larry stands up and says in a clear, even voice, “This was my patient.” Larry talks of the technical challenges involved with trying to peel the tumor off the IVC and his erroneous assumption that it would be a relatively easy operation to perform laparoscopically. He talks of the many nights since that he’s lain awake, obsessively thinking about this case and worrying about the patient’s family. He says that if he were to do it all over again, he would have used a much larger incision from the beginning and not attempted to perform the case laparoscopically.

He finishes by noting that he should also have provided more direct supervision for the residents assisting him with the operation. He doesn’t mention my name.

He sits down.

Silence.

Dr. Collier and the rest of the professors nod thoughtfully. The tone of the room has changed from one of expectation and confrontation to one of empathy and reflection. Every single one of them has faced a similar situation. They’ve been through the fire themselves, and they understand. I get the sense that I’ve successfully faced a kind of initiation, a rite of passage into an exclusive club. I’ve faced up to my failure and learned from it so that the next patient will benefit from my hard-won experience.