Chapter 1

New Orleans 2003

Mike Boudreaux’s gloved hands worked quickly and decisively to finish a gallbladder in operating room five. Paul Smythe, the anesthesiologist, entered from the corridor through swinging double doors. “Trouble in seven,” he said, his usually calm voice edged with urgency.

Boudreaux’s hands didn’t hesitate in the measured motions of the instrument tie. The toothed forceps gripped the tissue, and with a twist of the needle holder, the needle passed cleanly through with little resistance. “Who is it?” he asked Paul, without taking his eyes off the field.


“He ask for me?” Boudreaux asked.

Paul refused to answer a trivial question. He stared directly until Boudreaux met his gaze, and then he glanced in the direction of room seven to indicate the urgency.

Boudreaux finished one more tie and handed the instruments to the resident assistant. In seconds, he was in room seven. Except for the respirator and monitors, the room was silent. Clayton was bent over the OR table, his usual ruddy complexion now pale below the line of the blue surgical cap. The circulator stared at the floor, avoiding eye contact, her body slack from vexation and chagrin.

“Suction,” Clayton said with a tenuous voice. The scrub nurse passed the instrument with a hesitant, uncertain motion, sweat beading on his forehead. Clayton pressed a sponge up into the wound, pulled it away, then activated the suction. The resident gripped the retractors with a fine tremor that faintly rippled the tissue held by the blade, his anxious eyes diverted from the field.

Boudreaux moved to the table and the assistant shifted toward the foot of the table to give him room to see without breaking sterility. He couldn’t see any anatomy with the blood; a vessel had been cut. They needed better exposure.

There was no time to rescrub. From sterile packages the circulator dropped gown and gloves on a back table. Mike gowned and regloved, waiting for a look from Clayton. But Clayton worked mechanically with his eyes down, refusing to acknowledge Mike’s presence. This was Clayton Otherson, his professor and mentor during training, nationally prominent for his bold innovations and unmatched results for so many years, his senior partner for the last twelve years, now floundering in indecision, unable to find the right choices to save his patient’s life. Unthinkable.

The anesthetist, her face frustrated and angry, turned the monitor so he could see. The pulse was 138.

“I think I got it,” Clayton mumbled

Denial. The most dangerous response of the impaired physician.

“More blood’s coming,” Paul said directly to Mike, making adjustments to an IV, his gaze intent and away from Clayton.

With a firm nudge of his elbow, Mike moved the resident farther away from the action to gain a better view and access to expose the error. Clayton glared at him for the first time with red, rheumy eyes with a mixture of fear and humiliation.

Mike repositioned the retractors in the resident’s hands, opening the abdominal wall incision by three inches. Emerging thick layers of fat gleamed above pools of arterial blood that had lost its healthy hue. Suction and irrigation isolated the artery that was cut through. With a tie, Mike stopped the bleeding. He could feel Clayton’s humiliation, the humiliation of needing help that eroded confidence and self-image, and that would never fade. But this was no time for sympathy. Clayton was in no condition to continue, and with his eyes Mike indicated to the resident to act as assistant from his position, without making Clayton move away from the table, to let him preserve some dignity.

With the bleeding sources stopped and the field dry, Mike finished the repair and started closure. Clayton left the table to take off his gown and leaned against a back wall, his head down. The anesthetist turned a stopcock on an IV line and adjusted gas flow percentages. She glanced at Mike with relief. The monitors changed pace slightly. As the resident completed the last sutures, he waited to be sure the blood pressure was safe, then told the resident to remove the drapes and dress the incision.

“I’ll dictate,” Clayton said to the resident, without looking at Mike.

Clayton yearned to turn back the clock, to be in control again. Mike paused before leaving but there was nothing he could say to comfort Clayton, and he hurried out of the room.

At seven o’clock that evening on the administrative floor, Mike looked up as his office door opened without a knock. Paul Smythe, the anesthesiologist, handed him a folder with four stapled sheets of paper.

“It’s an incident report,” Paul said. “On Otherson.”

“Take it to Pat or Margaret, Paul,” Mike said. Paul looked worried and angry.

“Read the goddamn report, Mike. I don’t want any errors.”

The report detailed Clayton’s morning case. He looked up when he finished.

“Is this really necessary?”

“He’s impaired, Boudreaux. If you see something I’ve written that’s not right, change it.”

“You can’t know he’s impaired, Paul. One case is not a trend. And it’s a tricky label to put on any surgeon.”

“This is not the first. I’ve seen other cases of his that have gone wrong. He doesn’t know he’s in trouble, and then he freezes.”

“He’s the best there is. I’ve spent a career trying to achieve what he has.”

“Was the best. He’s dangerous, Boudreaux. I don’t know exactly why, but he needs to take a break.”

Mike stood. “Hold the report,” he said. “I’ll talk to him. And investigate if there’s a problem.”

Paul stared defiantly. “That’s not the way I’m going to handle this,” he said. He did not like Clayton, nor most surgeons for that matter, and he thought Clayton’s privileges should be suspended based on poor performance. But Mike knew this was not personal for Paul. Paul cared about his patients… not just his reputation. He was among the best in his specialty.

Paul took back the pages. “Don’t try to bury this, Boudreaux,” he said.

Mike glared. “I’m not your problem, Paul. Stay civil.”

“You’re chief of service with the duty to act. And don’t delay.”

“I’m not dishonest, Paul. I’ll do what needs to be done.”

Paul frowned and shook his head slowly. “I misspoke,” he said. “You’ll do what’s right. But he needs to step down… and I don’t see him doing it on his own.”



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