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Tuesday, April 7, 5:45
A.M.

A
t first Michael tried to incorporate the thumping sound into a very enjoyable dream, but it didn’t work. Reluctantly he acknowledged that someone was intermittently knocking on his door. “Shit,” he said under his breath.

Assuming his tormentor was not going to go away, Michael swung his legs out from under the covers and glanced at the clock. It wasn’t even six, and the dermatology lecture wasn’t going to start until nine. “Shit,” he repeated, hoisting himself to his feet. He couldn’t imagine who could be disturbing him or why. Despite being clad only in skivvies, he threw the door wide open. To his surprise he was face-to-face with Lynn, who was sporting an exasperated expression that it had taken him so long to open the door. She was the last person Michael had expected to see.

The evening before, Michael had checked Lynn’s room on several occasions to see if she had returned. Her room was only three doors down the hall from his. When she hadn’t appeared by eleven
P.M.
, he had thought about calling or texting to make sure she was okay. He was also eager to tell her about his serendipitous
meeting up with Vladimir and getting into the Shapiro Institute. But by then he assumed she was going to spend the night at Carl’s and worried that she might already have been asleep or at the least needed some private time. After all, she had Michael’s mobile number if she had wanted contact.

“We need to talk!” Lynn said. She pushed past the surprised Michael and threw herself into Michael’s desk chair, turning on his desktop gaming computer. She was sporting a fresh white medical student’s coat.

“Why don’t you come on in and make yourself at home,” Michael said sarcastically.

“I want you to read an article, but first get your ass in the shower or whatever you do when you wake up. We need to check on Carl, and then go get some breakfast. I’m famished. I didn’t have anything to eat last night.”

“Nothing? Why not?”

“I was too busy. I learned a lot of shit that I want to throw at you. So get a move on!”

“Yes, sir!” Michael said, saluting. Michael’s father, of whom he only had the dimmest recollection, had been in the Marines, and was stationed at Parris Island, about five miles away from Beaufort, where Michael had grown up. He had only been four when his parents parted ways, but he still remembered his father saluting him on occasion as if he too were a Marine.

Michael quickly showered, shaved, and dealt with his hair, which didn’t need much attention. When he reemerged from the bathroom, Lynn was at the window, tapping her foot. It was apparent she was juiced and impatient and couldn’t have cared less that Michael was butt naked, save for his shower towel. He went to his bureau, got out clean drawers and socks, and then went to the closet for the rest of his threads and kicks. When he was finished, he informed Lynn, who seemed mesmerized by the view across the
harbor to Mount Pleasant, as if she had never seen the same panorama from her own room for almost four years.

“The article I want you to read is on your screen. Read it quickly and then let’s jet over to the hospital.”

Michael could tell that Lynn was in no mood to argue, so he took his seat and started reading. He was aware that Lynn had come up behind him, looking over his shoulder.

The article had the
Scientific American
logo at the top, which lent it strong credibility. Michael was well aware that the main trouble with the Internet was often not knowing the sources of material and hence its veracity. This article, however, was most likely legit. The title of the relatively short piece was “How Many Die from Medical Mistakes in U.S. Hospitals?” He was finished in less than a minute, and he looked up at Lynn.

“Oh, come on,” Lynn said. “You can’t be finished already.”

“Slam dunk,” Michael responded.

“Okay, smart-ass! What’s the upper limit of estimated deaths for people going into U.S. hospitals each year and suffering a ‘preventable adverse event,’ a euphemism if ever I heard one? They should call it like they did in the title: a goddamn mistake!”

“Four hundred and forty thousand,” Michael said without hesitation.

“Geez!” Lynn complained. “How the hell do you read so fast and still remember everything? That’s discouraging for us mortals.”

“Like I told you, my mamma taught me.”

“Mammas don’t teach that kind of skill. But regardless. Don’t you find that statistic startling and embarrassing? Like the article says, that would make deaths from hospital errors the third leading cause of mortality in this country.”

“So let me guess. You are now convinced that Carl suffered a mistake, or more accurately, a major screwup. Is that what I’m reading between the lines?”

“Of course!” Lynn said. “A strapping, athletic, healthy twenty-nine-year-old male has a simple knee operation and ends up in a coma. Somebody fucked up big-time, and if Carl doesn’t wake up, he’s going to change the statistic you just quoted to four hundred and forty thousand and one this year, and that’s after a routine ACL repair!”

“Sweet Jesus, Lynn, you’re jumping to conclusions. It’s not even twenty-four hours, and Carl is sure as hell not dead. Maybe when we go back, he’ll be sitting up in bed, taking nourishment, wondering how the hell Monday disappeared.”

“Wouldn’t that be nice,” Lynn said sarcastically. “The neurology resident thinks there was extensive brain necrosis. I hate to say this to burst your bubble, but Carl’s not going to be sitting up having breakfast this morning.”

“Medicine is an imperfect science. If we’ve learned anything over the last four years, it’s that. Everybody is unique according to their DNA. Maybe Carl reacted negatively in an unexpected way to the anesthesia and whatever else he was given. Maybe there was a mistake but maybe not. Maybe the anesthesia machine malfunctioned. Maybe a thousand things, but it wasn’t necessarily a medical error.”

“I think the anesthesiologist fucked up somehow,” Lynn said. “My intuition tells me this is a ‘people’ problem just like the article suggests, not an idiosyncratic reaction or a technical problem. Mistakes are made by people.”

“That’s a possibility, too. But there are lots of possibilities. There are system mistakes as well as people mistakes. Even computers make mistakes.”

“Well, I can tell you this,” Lynn said with conviction bordering on anger, “we are going to find out what happened, meaning who screwed up, and we are going to see that they are held accountable so it doesn’t happen again.”

“Hold on a second!” Michael said with a wry smile. “What do
you mean
we
, white man?” It was the punch line for the only joke Ronald Metzner had told during medical school that Michael had found truly funny. It was about the Lone Ranger and his Native American sidekick, Tonto, when the two of them found themselves caught in a box canyon, surrounded by a slew of bloodthirsty Indians intent on doing them in. The punch line was Tonto’s response to the Lone Ranger saying: “It looks like we are in deep shit.”

For a second Lynn was silent, hardly in the mood to respond to being reminded of one of Ronald’s stupid jokes. She was disbelieving and crestfallen at Michael’s attitude. “Aren’t you as pissed off about Carl’s condition as I am?” she demanded.

“My point is that in many respects it is a little early in this developing tragedy to go off the deep end, making all sorts of assumptions.”

“Well, I don’t know about you,” Lynn said, “but I can’t sit around on my butt, waiting for Carl to wake up, which I don’t think he is going to do, and let the trail go cold. I’m going to find out what happened, and I’m not going to rest until I do. I owe that to Carl. The way I got to where I am today is by being a ‘doer,’ just like you, I might add.”

“Listen! I can understand your feelings,” Michael said. “You have every right to be pissed. But as your friend and probably your closest friend, I have to try to rein you in. You could be jeopardizing your medical career. No one is going to take kindly to your efforts. Everybody is going to be touchy about this affair. And to make matters worse, let me remind you, violating HIPAA under false pretenses, which we have done, is a class-five felony. You’re going to be going for bad, girl. You know what I’m saying?”

“Are you finished?” Lynn asked, arms akimbo.

“For now,” Michael said. “Let’s get our asses over to the cafeteria. I think your blood sugar must be zero and it’s affecting your good sense.”

For a few minutes, Lynn held her tongue, but in the dorm
elevator she was back at it. “I find it extraordinary that we as medical students have been given so little information about hospital mistakes. And errors resulting in death are just the tip of the iceberg. Think of all the patients who go into the hospital for one thing and come out with another, totally different major health problem. That statistic is over a million. That’s obscene.”

“I don’t find it so surprising that such statistics are not ballyhooed,” Michael said. “A lot of hospitals, including this one, are owned by for-profit companies. Even the so-called nonprofit hospitals are money mills in disguise. That means there’s a built-in conflict of interest situation to avoid publicizing such statistics, like so many things in health care. Hospitals don’t want to talk about their shortcomings. We fledgling medical students are still under the delusion that medicine is a calling whereas, if truth be told, it is a business, a big business, and not a fair business from the public’s perspective. Most everybody is mainly out to make a buck.”

“I didn’t realize you were such a fucking cynic,” Lynn said.

“As a black man trying to break into an overwhelmingly white man’s profession, I have had to be a realist!”

“That’s fine, dude, but it’s the kind of attitude that makes change impossible.”

Michael smiled. “You outta control, girl.”

“I’m angry,” Lynn admitted. She took a deep breath. “I’m sorry if I sound like a bitch. I’m really having a problem with this and learning what I have learned. I knew there were problems with American health care but not this bad.”

“That’s cool, Blondie, but you have to chill, at least in the short run.”

“I don’t see it that way. I’m going to find out what happened.”

“Let’s get you some vittles. Your cerebrum isn’t working much better than Carl’s, and I’ve got some interesting shit to tell you about.”

Tuesday, April 7, 6:12
A.M.

T
he sun was threatening to rise within the hour as Lynn and Michael exited their dorm building. It was promising to be another gorgeous spring day, with not a cloud in the pastel inverted bowl of the gradually lightening sky. But the fabulous weather was lost on Lynn, as her mind was churning. She had already decided for sure that if Michael wouldn’t help her find out the truth about Carl’s disaster, then she would do it herself. It was an absolute must to keep her demons at bay.

“You know what else I learned last night?” Lynn said. She had to talk louder than normal to compete with the cacophony of the birds announcing the coming dawn.

“I’m afraid to ask,” Michael responded.

“The usual major-complication rate for anesthesia for a healthy patient is one in two hundred thousand surgeries. If we take only your relative, Ashanti Davis, and Carl, that’s two in about five thousand cases, considering that about one hundred surgeries are done here per day. Do you know what kind of multiple that means?”

“I guess a lot,” Michael admitted. Doing math in his head was not one of his strong suits.

“It’s eighty times the normal. Eighty times! And we don’t even know if there weren’t others, which would make it even worse.”

“Speaking of Ashanti,” Michael said, no longer able to keep his news to himself. He could tell Lynn was getting juiced all over again. “I found out she is still hanging out in the Shapiro Institute with normal vitals but a bad diagnosis of multiple myeloma.”

“How the hell did you find out?”

“A strange way,” Michael said. “Yesterday afternoon I ducked out of the ophthalmology lecture, which was shit, by the way. Just a neuro-anatomy review, so you didn’t miss anything. On my way back to my room to look for the JPEG of Ashanti’s anesthesia record, I ended up in the Shapiro Institute.”

Lynn stopped in her tracks, looking at Michael as if he had just told her he had dined with the pope. “How in God’s name did you manage that?”

Michael laughed. “I got into a little one-on-one with a Russian dude who’s only been over here for a couple of months. He’s a computer wonk brought here to fix a glitch or two in the Shapiro computer network. He came out the Shapiro door just as I was eyeballing the place.” Michael pointed to the door in question.

“And you just started a conversation out of the blue?”

“It wasn’t much of one. The dude can’t speak English worth shit. We communicated with a Google translation app on his smartphone. But I knew you might not believe me, so I took a selfie.” Michael got out his phone and pulled up the photo. “He’s been working in the Shapiro network operations center.”

Lynn took the phone and studied the photo. “Which one is the Russian?” she asked.

Michael grabbed his phone back and pocketed it. “Smart-ass!”

“Did you get to see Ashanti?”

“Hell no! I just saw the inside of the Shapiro network
operations center and a couple of pages of her Shapiro electronic medical record.”

“And you are warning
me
about HIPAA violations,” Lynn said wryly.

“Hey, I didn’t hack the system. The Russian dude logged in legit.”

“You merely asked him, and he agreed.”

“I buttered him up a bit,” Michael admitted. “I gave him a Beats headset and told him I’d be willing to share my Jay-Z music file. I figured he had admin status with the network and could check out Ashanti sometime. I never expected him to invite me into the place on the spot.”

“Did you get his name? God! He could be so useful.”

“Vladimir Malaklov. I also got his e-mail and mobile number.”

“Fabulous! But wasn’t he concerned about security issues?”

“Didn’t seem to be. My guess is that he knows that security inside the institute is lax. I mean, I saw a video cam in the ceiling outside the NOC, but it didn’t bother him when we walked under it. Maybe he knows no one is watching the feed. And he said he has never seen another person in the network operations center the whole time he has been here.”

“Strange,” Lynn said. “I had the feeling that security was important for the Shapiro. That was what they implied during our tour, and the place is built like a bank vault.” She glanced at the massive but squat granite structure with not a window in sight from where they were standing.

“Maybe security was big in the beginning, but since there haven’t been any problems over the eight or so years it has been in operation, they’ve let things slide. Even security for the outside door isn’t much. Thumbprint touchscreen access. That technology is really out of date.”

“So how did you learn she has multiple myeloma?”

“Vladimir brought up her home page, and I got to click on her health status and then vital signs and complications. I would have
liked to look further, but I knew I’d be pushing my luck. I did take a screen shot of her complications page.”

“Let me see it!”

Michael pulled out his phone again and brought up the image. Lynn tried to examine it. “It’s a bit hard to read out here.”

“It’s better indoors,” Michael agreed.

“I can’t believe you managed this,” Lynn repeated.

“Her home page had Cluster 4-B 32.”

“I see. What does it mean?”

“Not a clue. The home page also says drozitumab plus four active. I didn’t know what the hell
drozitumab
was but looked it up last night. Drozitumab is a human monoclonal antibody used to treat cancer.”

“Maybe that is what they are using to treat her multiple myeloma.”

“I doubt it,” Michael said. “In the articles I read, it was developed for a type of muscle cancer.”

“Then I don’t know what it refers to,” Lynn said. She handed the phone back to Michael. “But tell me: didn’t this Vladimir have any concerns about patient confidentiality?”

“No. My sense is that he knows zip about our HIPAA rules. They probably don’t have anything like that in Russia. He doesn’t even have a secure user name or password that anyone who knows a few details about him couldn’t figure out. His user name is his e-mail address, and his password is his mobile number combined with his family name.”

“You amaze me. You sure you weren’t trained by the CIA?”

“You could have done the same thing. I’m telling you: he wasn’t concerned about security. I was standing there in full view of what he was doing while he typed in his user name and password. He didn’t give a shit.”

“So Ashanti is still in a coma,” Lynn said as she started walking again.

“Must be ’cuz she’s still in the Shapiro,” Michael said, falling in beside her.

“You didn’t learn anything about her coma, looking at her EMR? What a missed opportunity.”

“I’m telling you, I didn’t want to push him or my luck on the first go-around.”

“I’m not criticizing. It’s amazing you learned what you did.”

“I was surprised myself,” Michael admitted. “And I’m planning on hitting him up again.”

As they approached the door to the clinic building, Lynn asked, “What about the photo of Ashanti’s anesthesia record? Did you find it?”

“I did,” Michael said. “It was in my photo folder on my desktop. As I said, it looked a lot like Carl’s, but I want to print them both out so that I can really compare.”

“I’m eager to see it when you do.”

“I’ll think about it,” Michael teased.

They walked through the mostly deserted clinic. The only people they saw were housekeeping, polishing the floor and wiping down the chairs with antiseptic.

When Lynn and Michael crossed the connecting pedestrian bridge and entered the hospital proper from the clinic building, they were immediately enveloped in a crowd. Although the clinic was still closed, the hospital itself was a different story. Another busy day was already in the making.

As Michael headed toward the cafeteria, Lynn went in the opposite direction, toward the elevators. Michael was the first to notice their cross-purposes, and he turned, caught up to Lynn, and pulled her to a stop. People jostled them as they stood in the middle of the main hospital corridor. “I thought we were going to the cafeteria,” he said. He had to speak louder than usual over the general din.

“We need to check on Carl first,” Lynn said. “This is the best time. The shift will be changing, and they will be less likely to question our presence.”

“Good point,” Michael conceded. “But your blood sugar? You sure you can hang in there?”

“I’ll be fine,” Lynn assured him. “Come on!”

They started toward the elevators. It was difficult to stay together. Lynn talked to him over her shoulder. “Even with the shift changing in the ICU, someone might say something to us. If they do, let’s use the anesthesia explanation you came up with yesterday. I thought it was brilliant. But to lend it more credibility, we should put on scrubs and look the part.”

“Now, that’s slick,” Michael agreed. Instead of joining the throng waiting for an elevator, they went to the stairs. In the surgical lounge they separated.

As Lynn entered the women’s locker room, it was still well before seven, yet it was a busy place. Most of the women donning scrubs were nurses just coming on duty. The surgeons scheduled for seven-thirty cases wouldn’t arrive until around seven-fifteen, after making rounds on their post-op patients. Lynn found an empty visitors’ locker, and as she began to unbutton her blouse, the intercom crackled to life from a ceiling-mounted speaker. Since everyone had mobile phones, it wasn’t used much. The voice belonged to the head nurse out at the main desk in the OR: “Dr. Sandra Wykoff! This is Geraldine Montgomery. Are you in the changing area?”

“I am,” Dr. Wykoff said, talking loudly and directing her voice up toward the ceiling. As a courtesy, the buzz of voices coming from the other women in the room quieted.

Lynn turned around. The name provided instant recognition. Sandra Wykoff had been the anesthesiologist on Carl’s case. Lynn stared at the woman, who was no more than five or six feet away. She was petite, a good six inches shorter than Lynn, with small, sharp features and mousy hair, who nonetheless projected an intensity of purpose. Her bare arms were thin but muscular, making Lynn think she kept herself in shape, something that Lynn did as well. It was Lynn’s immediate impression that Sandra Wykoff was not someone easily intimidated despite her short stature.

“Dr. Wykoff,” Geraldine continued over the intercom, “you must
have your mobile ringer turned off. I have Dorothy Wiggens from Same-Day Surgery Admitting on the other line. They have been trying to contact you.”

Lynn watched Wykoff fish her phone from her pocket and check it, “You are so right,” she said. “Apologize for me!”

“It isn’t a problem, except they wanted to let you know your first case has been canceled. The patient forgot her pre-op instructions and had a full breakfast.”

“Okay, I got it. I appreciate your letting me know.”

“We’ll let Dr. Barker, your second case, know as well. It is now scheduled for late morning. Maybe it can be moved up. We’ll keep you informed.”

“That would be terrific. Thank you.”

As if on cue, the moment the intercom clicked off, the murmur of other conversations in the locker room recommenced.

Dr. Wykoff looked over at Lynn, who was regarding her with a wide-eyed gaze. “Better to find that out in admitting rather than up here in the OR,” Dr. Wykoff said to make conversation.

“I suppose,” Lynn answered. She looked away, suddenly realizing she had been staring. What to do, was the question. It seemed much too serendipitous not to take advantage of this fortuitous meeting. She had spent a number of hours during the night reading up on standard anesthesia procedure, so she felt confident she could hold up her end of a technical conversation about Carl’s case. Yet was this the time and the place to bring up what would undoubtedly be a touchy subject, as Michael had reminded her? Lynn donned her white coat over her scrubs and closed the locker in which she had put her clothes. Impulsively she decided to give conversation a try. “Excuse me, Dr. Wykoff,” she began, still unsure of what she was going to say, especially while struggling to keep her emotions in check.

After closing her own locker, Dr. Wykoff directed her strikingly bright blue eyes at Lynn.

“I understand you were the anesthesiologist attending Carl Vandermeer yesterday,” Lynn said.

Instantly Dr. Wykoff’s eyes narrowed and bore into Lynn’s. She didn’t respond immediately but proceeded to look Lynn up and down, as if appraising her. She then warily nodded and said: “I was the attending. Yes. Why do you mention it?”

“I read your note in the chart in the neurology ICU yesterday. I need to talk to you about the case.”

“Really?” Dr. Wykoff questioned with a whiff of guarded incredulity. “And who are you?”

“My name is Lynn Peirce. I am a fourth-year medical student.” She specifically avoided making any reference to why she had been in the neuro ICU and why she had been looking at the chart. She knew that the excuse of being on an anesthesia rotation wouldn’t play with an anesthesia attending.

“Why exactly do you want to discuss this unfortunate case?” Dr. Wykoff asked warily.

“I’ve learned that a million people a year go into a hospital with one complaint and then end up with another serious medical issue they didn’t have before being admitted. I think it is an important issue that we medical students aren’t taught. The Vandermeer case might apply.”

“I suppose we could talk,” Dr. Wykoff said as she relaxed a degree. “But this is not the time or the place. You heard that my seven-thirty case has been canceled. If my next case is not moved up, I suppose I could speak with you this morning.”

“I would appreciate it,” Lynn said. “How will I get in touch with you?”

“Ask Geraldine at the OR desk. She’ll know where I am.” Then the anesthesiologist walked out.