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“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.

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.

Stretching his sleepy muscles, Noah padded into the tiny bathroom buck naked. There had been a time when he wore pajamas as he had done as a child. But the habit had been abandoned when he came to appreciate that pajamas were just another piece of apparel he had to launder, and he wasn’t fond of taking the time to do laundry, as it required walking a block up the street to a Laundromat and then waiting around. It was the waiting he couldn’t abide. As a totally dedicated surgical resident, Noah chose to have little time for anything else, even personal necessities.

He eyed himself in the mirror, recognizing that he looked a little worse for wear. The evening before, he’d had a couple drinks, which was rare for him. He ran his fingers up the sides of his face to decide if he could get away without shaving until after his first surgical case. Often he shaved in the surgical locker room to allow him to get to the hospital that much earlier. But then he remembered today wasn’t a usual day, so there was no reason to hurry. Not only was it Saturday, with its usually light surgery schedule, but it was also July 1, the first day of the hospital year, called the Change Day, meaning a whole new batch of residents were beginning their training and the existing residents were advancing up the training ladder to the next level. For fifth-year residents, also considered chief residents, it was a different story. They were finished their training and were off to begin the next stage of their respective careers — everybody except Noah. By a vote of the surgical faculty, Noah had been proud to be selected to do a final year as the super chief resident who would run the Boston Memorial Hospital surgical department on a daily basis like a traffic cop at a very busy intersection. In most other surgical residency programs, a super chief status rotated among the fifth-year chief residents. BMH was different. The super chief was an added year. With the help of a full-time residency program manager, Marjorie O’Connor, and two coordinators under her, it was now Noah’s job to schedule all the residents’ rotations in the various surgical specialties, their operating room responsibilities, their simulation center sessions, and their on-call duties. On top of that, he was responsible for work rounds, chief-of-service rounds, and all the various weekly, biweekly, and monthly conferences, meetings, and academic lectures that made up the academic part of the surgical department’s program. As a kind of mother hen, he also had to make sure that all the residents were appropriately fulfilling their clinical responsibilities, dutifully attending all the teaching venues, and handling the pressures of the job.

Without the usual need to rush to the hospital, Noah opened the medicine cabinet over the sink and took out shaving cream and a razor. While he lathered his face, he found himself smiling. His new job sounded like an enormous amount of work and effort, especially since he would have his own patients and be doing his own surgery at the same time, but he knew he was going to love the year. The hospital was his world, his universe, and as super chief he was to be the alpha-male surgical resident. It was an honor and a privilege to have been selected for the position, especially since on its completion, he was assured by precedent that he would be offered a full-time faculty position. This was huge. For Noah, the opportunity to be a full-time attending surgeon at one of the world’s premier academic medical centers associated with one of the world’s premier universities was the pot of gold at the end of the rainbow. It had been his goal for as long as he could remember. Finally, all the work, effort, sacrifice, and struggles in college, medical school, and now as a resident were going to pay off.