 
MAIMONIDES ROCKS

Steven Brozinsky, MD

Smashwords Edition

Copyright 2010 Steven Brozinsky, MD

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CHAPTER ONE

Noah Strong must have taken that exit ramp onto Fort Hamilton Parkway eight thousand times, but the afternoon's unexpected rain mixed with some oil on the roadway and just a wee bit too much speed caused him to lose control of the Volvo and careen down the embankment, flipping over three times for good measure.

Noah later swore that just like in the movies all of this seemed to happen in slow motion and when the car finally stopped he found himself upside down, fully conscious, and with his fastened seatbelt saving him from further harm. His left side hurt a little bit but he sensed he was not seriously injured.

CHAPTER TWO

Dr. Julius Berger had just finished orienting the new interns at Maimonides Medical Center in Boro Park. Once known as Israel Zion Hospital, Maimonides had witnessed exponential growth in the 1990s, fueled by generous benefactors, grateful patients and an incredibly bullish investment portfolio. Its physical plant and graduate programs in medicine and surgery were the envy of many New York City hospitals and Maimonides was increasingly more successful in recruiting top faculty and house staff from metropolitan area medical schools.

Dionne Clark was one of these stellar medical school graduates. She grew up in Bedford-Stuyvesant and earned a scholarship to Simmons College in Boston. She then attended Howard Medical School, graduating first in her class.

She was the only African American in Maimonides' new intern group, and Dr. Berger noticed her sitting by herself in the cafeteria, her starched white intern smock framing her sleek neck rather prettily. Her brand new miniature ophthalmoscope and otoscope where properly positioned in the breast pocket of her white jacket, just below her name tag and caduceus; a stethoscope was peeking out of her jacket's left hip pocket and the medical intern's Bible, "The Washington Manual," was bulging in her right hip pocket. This was the umpteenth edition of the book that Washington University in St. Louis had been publishing for decades, updating house staff on what they needed to know from asthma to zoster and everything in between. Dr. Clark certainly looked ready to begin her internship.

"So Dionne," asked Dr. Berger as he sat down across the table from her. "Was there anything in particular in medical school that made you choose medicine as opposed to pediatrics or OB/GYN or surgery?"

Dionne rescued him from his thinking what a lame line, "Do you remember who William Osler was, Dr. Berger?"

"He was the famous Hopkins doc early last century. I think he is known for his many aphorisms. I think he came from Canada and, by the way, from now on it's Julie, unless we are in front of a patient."

"Right Julie. And one of his famous sayings was 'Doctor, listen to the patient. He is telling you the diagnosis.'"

"And, what are we getting at?"

"Well, I was doing a cardiology clerkship at George Washington Hospital in D.C. early in my fourth year. I was one of three students who accompanied two interns, their resident and the chief of cardiology into the room of an elderly African- American man who had been admitted the night before with some congestive heart failure. This swarm of white coats and white faces scared the hell out of him. It was only my presence that calmed him down a little bit. Anyway, one of the interns tries to impress the Chief by describing what he thought was an S3 gallop and this guy puts the stethoscope on the patient's chest, closes his eyes to show he is really concentrating and spurts out 'Tennessee, Tennessee, Tennessee.'"

Dr. Berger knew what Dionne was alluding to. Pathologic heart sounds were different from the lubb-dupp that the lay public knew and these abnormal sounds, designated as S3 and S4, were frequently difficult to differentiate from one another. So, as he recalled from his medical student days, clinicians were taught that a cadence emphasizing the first syllable, such as the state Tennessee, might help differentiate the third heart sound while a cadence emphasizing the second syllable (Kentucky) would signify the fourth sound or S4. Berger nodded as he recalled this teaching gem from four years ago.

Dionne continued, "Now the resident begs to differ–that it was an S4 gallop–and he puts his stethoscope on the poor guy's chest, closes his eyes and taps out 'Kentucky, Kentucky, Kentucky.' Before the Chief could cast the deciding vote, the patient looked straight at me and in the ultimate William Osler moment, 'Honey, they're both wrong. It's Nor Carlina!'"

"Is that really a true story?"

"Absolutely. Cross my heart, I've got plenty more."

"I'd love to hear them," Dr. Berger said as he rose from the cafeteria table and shook her hand. For days afterward, he wondered whether it was his or Dionne's grasp which lingered just a split second longer than necessary.

CHAPTER THREE

The EMT paramedics had to be contortionists to safely extricate Noah Strong from the inverted automobile. Backboard, neck collar and head tape all had to be expertly applied so as to minimize any potential damage to the spinal cord. Noah was whisked by ambulance to Maimonides which had a state-of-the-art trauma unit. More victims of motor vehicle accidents than gun shots were cared for at Maimonides; the opposite was true at Brooklyn's other major trauma center at Kings County Hospital.

Noah was evaluated by the trauma surgeon and sent for a CT of the chest, abdomen and pelvis. Good news: one broken rib on the left but the spleen, heart, lungs, kidneys and liver were all fine.

After an overnight stay, Noah was allowed to go home. His father and mother, Leonard and Joan Strong, insisted that he stay with them at their apartment in Bensonhurst for a week rather than return alone to his duplex in Bay Ridge. Noah didn't need much convincing as his sore left side told him that he'd be out of commission for at least a few days anyway.

CHAPTER FOUR

Dionne's fellow interns were certainly an eclectic bunch. Most were from New York State medical schools but a few were from India, Pakistan and the Orient. Three or four had studied at Guadalajara or Bologna and had already worked a full year in a stateside hospital in a so-called fifth pathway program, which finally enabled them to secure a spot in an accredited internal medicine training program. Some of the United States graduates had spent their entire fourth year globe trotting, with electives in Hong Kong, London, Tel Aviv, Rome and Cape Town. Others had by their own choice slaved away as fourth-year interns at Kings County or Bellevue in Manhattan, hoping to get credit for that year and thereby shorten the time needed to qualify for the certifying examination in internal medicine.

Several of the interns were observant Jews attracted to Maimonides because of its offer of "Sabbath scheduling" whereby they were guaranteed to be off duty from Friday afternoon to Saturday evening. These doctors were not so affectionately called yommies, after the yarmulkes or skull caps that they wore.

Dionne and Julius' immediate supervisor was Chief Resident Joseph Bianchi. He was a redheaded, follicly-challenged Italian from New Jersey. He had trained at Saint Vincent's Hospital in Greenwich Village and reminded everybody of Sonny Corleone, the James Caan character in "The Godfather," both in appearance and temperament. Berger had survived his internship primarily by staying out of Bianchi's way.

Hospital folklore predicts that every intern class will have a loser. Usually this is a guy (rarely a woman). By August of Dionne's internship it was apparent that Teddy Benjamin would claim this dubious title.

It all started Benjamin's first night on call with a page from the emergency room resident, Dr. Kirsch, in early July. "Hi, Dr. Benjamin. I know we haven't met yet but you're lucky. I've got an incredibly interesting admission for you." Those were words to be dreaded by any intern. They generally connoted a very ill patient who would monopolize the doctor's time and energy. This admission was no exception. He had pneumonia, pancreatitis, and diabetic ketoacidosis--all three. Any one of these diagnoses was serious. The triple whammy all-too-often resulted in a critically ill horrendenoma.

Fortunately for Dr. Benjamin (and the patient), Teddy's supervising resident was Angelina Vitale-Schwartz. Angie had married a young dentist the same week she received her M.D. from Rutgers fourteen months previously. Her incredibly unflappable demeanor and steely-eyed work ethic were probably the reason Bianchi had paired her with Benjamin, who had just spent the previous year taking such non-taxing electives as radiology and dermatology. He was in over his head from the get-go.

"Dr. Schwartz, I need some help here. My new admission from the ER looks really bad! His temperature is 102.4 and he is tacking at 120. He is all scrunched up in a fetal position and won't let me examine him. I can't get a second IV line into him which the head nurse recommended and I--"

"Dr. Benjamin, did you read 'House of God'?"

"What?"

"I asked if you ever read 'House of God'."

"No, I haven't. But what's that got to do with this sick patient?"

"Everything! You don't need to write a book report but I expect you to read it by the end of your two months with me. Secondly, calm down! Your peeing in your pants won't help matters. Third, you are to call me Angie or Angelina or Dr. Vitale. Those are the names on my medical school diploma which my parents paid plenty for and for which I worked my ass off. Now, let's meet at the patient's bedside and figure out how you're going to save him."

He dutifully followed Dr. Vitale Schwartz' orders for the next sixty days and by September calculated that if he included his upcoming vacation he would have already completed, make that survived, twenty percent of his internship year. During the winter he served two months with Dr. Berger on the Private service, cementing his reputation as the worst intern and actually forcing two of the community internists to exact a promise from the Chief of Medicine, Dr. Greene, that Dr. Benjamin was to "neither interview, examine nor prescribe anything" for their hospitalized patients.

"House of God" had been published in 1978. It was a wickedly satirical account of an intern's twelve months at one of Boston's elite hospitals. Stress and sleep deprivation were recurring themes and its portrayal of the unseemly side of the medical profession did not garner too many fans at the American Medical Association. No wonder Angie Vitale urged Teddy Benjamin to read it that first day on the wards. Its author, Stephen Bergman, switched his career to psychiatry. Benjamin was so rattled by similar experiences at Maimonides that he, too, sought out a residency in psychiatry.

One of the enduring mysteries of "House of God" is what happened to the movie version. It starred Tim Matheson and Ossie Davis and a pre-Seinfeld Michael Richards and was completed in 1984. It was never released in theaters and few prints were ever made into other formats.

CHAPTER FIVE

Around the corner from the main complex of buildings that comprise Maimonides Medical Center was a three-story edifice which resembled a dormitory. In fact it was a dormitory of sorts. It housed the on-call rooms for generations of interns and residents. For more than seventy years it was a given that an intern's work day did not end at 5 p.m. No whistle blew; no time card was punched. Whether considered a rite of passage or an integral part of an intern's training, it was understood that the admitting team of intern and supervising resident would follow that day's emergency admissions through the night. These first few hours of a hospital stay were when the most critical decisions were made as to diagnosis and treatment. Thus, the on-call rooms were where the house officers would retire in an attempt to catch an hour or two of sleep in between admissions. It was rare to sleep through the night undisturbed. If there weren't an admission, there was a telephone call from the ward nurse. If there weren't a call from the nurse, there was a page for a "code 3" which meant a sudden summons to a cardiac arrest somewhere in the hospital.

Interns' conversations frequently mentioned that they had pulled an all-nighter, meaning that they never even made it to the on-call room. If an intern dozed off during morning rounds, you knew he most likely had been on call the night before. The presence of a five o'clock shadow at 8 a.m. told you the same thing. Somehow the female house officers always looked better than the men after a night on call. Maybe they were more efficient and managed to grab a few hours of sleep. Maybe they cared a bit more about their appearance and wouldn't dare show up for morning rounds without having showered.

This insanity of one hundred twenty-hour work weeks including the expectation of making critical patient management decisions when deathly tired came to an end following a widely publicized case in 1984.

Libby Zion was an eighteen-year-old college freshman when she presented to the New York Hospital emergency room on March 4, 1984 with some jerking movements and fever. She was admitted by an overworked intern who was covering forty patients in the hospital. Although the intern had a supervising resident, a series of miscommunications and poor management decisions resulted in Libby Zion dying. Her father, journalist, writer and attorney, Sidney Zion, sued. The malpractice trial took place in 1994. It captivated New York City for weeks. Its legacy was that interns and residents were forbidden from working more than eighty hours a week or from being on call more than twenty-four consecutive hours (New York State Department of Health Code, Section 405, a.k.a. The Libby Zion law). These recommendations were formally adopted by the Accreditation Council for Graduate Medical education in 2003 and made mandatory for all residency programs.

Those on-call rooms at Maimonides continued to be used however. Medical students from other schools taking electives at Maimonides stayed there for a month or two. A newly-married but overworked house officer might have a spouse pay a conjugal visit. A not-so-newly-married resident or fellow who was trysting with a nurse or pharmaceutical rep might take advantage of the building's Las Vegas-like mantra, "what happens here stays here." Security personnel asked few questions so long as a photo ID badge, successfully swiped, gained the user access to the floors above.

CHAPTER SIX

Five weeks after the accident and three weeks after he returned to his Bay Ridge home, Noah Strong felt well enough to resume the pickup basketball games he loved. He had been a bench warmer on the Lafayette High School team ten years previously. He did not play at all while attending Brooklyn College but the weekend games at the park in Bay Ridge gave him a good aerobic workout that also helped him unwind from the stresses of the position of IT head for a startup telecommunications company headquartered next to the Ferry Terminal near Battery Park in lower Manhattan.

While fighting for a rebound in a particularly physical contest, he took a violent elbow to the solar plexus that left him on the ground, gasping for air. He recovered after five minutes and was able to resume playing, thankful that he had apparently completely recovered from the injuries sustained in the rollover accident the previous winter.

CHAPTER SEVEN

After a few months in the emergency room, Dr. Ken Kirsch, the resident who steered that first admission to the inept Dr. Benjamin, rotated to the Private service in the Aaron Pavilion. Although the Private service contained mostly elective admissions of the attending staff of community internists, its lack of critically ill patients was more than made up for by the sheer number of patients the resident was required to see. One intern and one resident were responsible for some sixty patients in the Aaron Pavilion and adjacent Solomon Wing. Mind you, the Private internist wrote admitting orders and directed the workup of these patients, but the house staff needed to check labs, review scans and x-rays, and in general keep the docs in private practice up to speed on the progress of their patients.

Dr. Kirsch, known as KK, was the male counterpart of Dr. Vitale-Schwartz, at least in terms of coolness, efficiency and unflappability. He was always clean shaven and immaculately dressed. Unlike Vitale-Schwartz, he was kind to his interns, nice to the nurses and cordial to the attending staff. He volunteered to take call Yom Kippur so the yommies would have less difficulty obtaining coverage. Many of the octogenarian patients he cared for just couldn't wait to fix Dr. Kirsch up with their granddaughters. Not wanting to disappoint them, he feigned interest but claimed that his hospital training years and concomitant long hours prevented him from pursuing any romantic endeavors. Although the other interns and residents knew it, Dr. Kirsch thought it served no purpose to tell these patients that he was gay.

KK was very popular with the attending staff and hospital administrators as well. Laudatory letters congratulated them for having the good sense and excellent judgement to hire "such a fine young man" and an example of what a caring physician should be.

Maimonides almost always ran at one hundred percent occupancy. It was not at all unusual for a patient to be discharged in the morning, and have that bed filled with another admission by noon (generally from the emergency room) only to have that bed vacated once again when the new admission went to the operating room or, if his condition worsened, to the intensive care unit.

Beds were at such a premium for the elective admissions that a "life and death list" existed in the admitting office. The internists in private practice wanted their patients admitted to Maimonides, not one of the smaller hospitals located a few miles away. Rounding at more than one hospital was inconvenient and inefficient and most patients objected to being hospitalized at any place other than the "mecca." This life and death list was supposed to mean that a patient's life or limb would be threatened if hospitalization did not occur within twenty-four hours.

Nathaniel Bloom had a huge private practice. He had office hours from 10 a.m. to 10 p.m., Monday through Thursday and until 4 p.m. on Fridays with a one-hour lunch break. He rounded on his hospitalized patients beginning at 7 a.m. He had trained at Maimonides twenty years before. He gave selflessly to the house staff's education, volunteering to mentor them on the ward service two to three months every year. This rounding with the interns and residents kept him up to speed on the most recent medical advances. However, these rounds cut into his office hours and his income but he had such a love for medicine and Maimonides in particular that he did this teaching joyfully. The house staff adored him almost as much as his patients did. His stories, frequently laced with Yiddishisms, were hilarious. He drove an Audi, believing this would offend his elderly Jewish patients less than a Mercedes-Benz.

One day while on the Private service, Dr. Kirsch got a frantic page from the head nurse.

"Please, Dr. Kirsch, come quick. We just received a life and death admission of Dr. Bloom's. He called in and specifically requested that you see Mr. Guiseppe Spadafore in room 626 ASAP."

KK quickly finished the discharge summary on another patient and hurried to Mr. Spadafore's bedside. Sitting in a chair, reading an Italian language newspaper was an elderly white-haired gentleman. Dr. Kirsch noted that the patient's color was good, that he was in no apparent distress, and that temperature, pulse, blood pressure and respiratory rate measured just a few minutes before by the registered nurse were all normal. "Hi, Mr. Spadafore. Let me introduce myself. I am Dr. Kirsch. I will be your doctor while you are here at Maimonides but I will be following Dr. Bloom's recommendations and I promise to speak with him twice a day regarding your progress."

"Dr. Bloom?"

"Yes, Dr. Bloom, your private doctor."

"The one with that busy office on Bay Ridge Parkway? I think I saw him one time a couple of months ago. I did not like waiting in the office for two hours!"

Dr. Kirsch wasn't sure what was going on. "Mr. Spadafore, are you in pain? Did some x-rays or blood tests that Dr. Bloom did show a problem? Are you urinating okay? Have you been throwing up?"

"I am eating fine. I am going to the bathroom okay and nothing hurts. And I told you, I only saw your Dr. Bloom two months ago and I don't remember if he did any tests then. I don't think so."

Dr. Kirsch's physical examination of Mr. Spadafore confirmed his suspicions--that there was nothing that warranted a life and death admission. In fact this old guy had nothing wrong with him. Preliminary lab studies, EKG and chest x-ray corroborated that Mr. Spadafore was in danger of losing neither life nor limb.

The mild mannered KK was more than a little upset--pissed off was more like it--when he telephoned Dr. Bloom, "Nat." Residents were encouraged to call attendings by their first names. "Nat, I've got your patient Mr. Spadafore here in the Aaron Pavilion, 626. He seems healthy as a horse. What prompted your listing him as a life and deather? What am I missing?"

"KK, Guiseppe's son-in-law called me up yesterday and told me 'Dr. Bloom, pop looks a little depressed – maybe you should put him in the hospital for a few days and run some tests.'"

"Geez, Nat. You know how crazy busy it is here. Why in the world would you take this guy's son-in-law's request as a reason to hospitalize the patient without even seeing him first or having him evaluated by urgent care?"

"Well, it was more of an order than a request."

"Nat, what are you talking about? You yourself formulated the criteria for the life and death list. What the hell is life and death about Mr. Spadafore's admission?"

"KK, his son-in-law's name is spelled G-A-M-B-I-N-O."

"Oops. Roger that, Nat. I will take good care of your patient."

CHAPTER EIGHT

The Chief of Medicine at Maimonides was Dr. David Greene, a world renowned specialist in Guillain-Barré syndrome, a disease where one's immune system inexplicably attacks myelin, the sheath which bathes and protects the body's nerves. Profound weakness is the major symptom and hospitalization is necessary once the diagnosis is suspected. If the muscles that assist respiration are affected, a patient might need to be immediately placed on a mechanical ventilator to help him breathe. Most patients recover completely with the aid of plasmapheresis; the less fortunate ones have residual weakness for years and three to five percent will die of the disease. Dr. Greene received ample funding from the NIH to study Guillain-Barré and develop new treatments for it. Any patient within a fifty-mile radius of Maimonides afflicted with it or suspected of developing it because of the typical early symptoms of tingling, weakness and loss of sensation in the legs could be transferred to the Guillain-Barré's mini ICU. At any one time, there were three to five patients with the disease hospitalized at Maimonides. There was sufficient funding to salary a fellow in neuromuscular diseases. His charge was to admit these patients to Dr. Greene's service and enroll them in various clinical trials.

The neuromuscular fellow was Charles Cabot, a ridiculously rich Boston Brahmin who could trace his ancestors to prerevolutionary times. He never missed an opportunity to try to impress the nursing staff with his pedigree and his knowledge of Guillain-Barré, and usually in that order. He was a Harvard grad, both college and medical school, and let you know that too. He was bombastic and dogmatic and reminded everyone of Charles Emerson Winchester III, the fictional surgeon from TV's M.A.S.H. Although his personality left much to be desired, he really knew his stuff--both general internal medicine and especially neuromuscular diseases. He was not very impressive physically, however, with burnt out acne and a silly blonde pompadour topping his five-foot six-inch frame.

CHAPTER NINE

Although they had exchanged several 'good mornings' and shared an occasional sandwich at the noontime conference in the Golden Auditorium, Dr. Berger and Dr. Clark didn't get to work together until they were assigned to a six-week rotation in the emergency room. They attended to the medical problems such as chest pain, shortness of breath, out of control diabetes and high blood pressure. The department of surgery provided their own interns and residents to evaluate those patients with acute abdominal pain. The newly renovated emergency room ran much more smoothly than the one it replaced. An onsite lab and CT scanner cut workup time in half. A specially trained group of triage nurses and physicians' assistants saw to it that the sicker patients were examined promptly. The place was bright and cheerful. Morale was high. What had been a dreaded rotation previously was now among the ones interns and residents looked forward to the most.

At 4 a.m. the emergency room occasionally became so quiet that the house staff could catch a few minutes' sleep or schmooze with one another. Julie Berger and Dionne Clark hadn't really chatted much since that day in the cafeteria months before.

Recalling that prolonged handshake, Dr. Berger broke the ice, albeit somewhat clumsily. "Dionne, I still remember that story you told me about William Osler but tell me something about yourself."

"Like what?"

"Whatever you feel like telling me. This isn't an inquisition--I like to know more about my interns than where they went to school."

"Okay. I am from Brooklyn. You know that. My father worked his way up the Transit Authority from motorman to district supervisor. Early on, my mother worked as a domestic, what you'd call a cleaning lady, and her mom looked after me when I was an infant and toddler. When my mother became pregnant with my younger sister, she quit cleaning other people's apartments and stayed home with me. By then my dad was making a bit more money and he's the one who insisted my mother stay home. We were real close; we went to church together on Sundays and my parents put up with no nonsense from their two princesses; no parties, no boys--just school and piano lessons. We knew better than to come home with anything but As on our report cards. They were so proud when Simmons gave me a full ride for all four years."

"And your sister?"

"She is much more musically talented than I am. She is in Boston right now going for her M.F.A. from Emerson. And what's Dr. Berger's history in thirty seconds or less?"

"Born, bred, raised in Flatbush. Madison High School, Brooklyn College, SUNY Downstate for med school before coming here. My dad owns two bakeries and my mom never worked after my brother was born. He is six years older than I am. He is a high school math teacher and just got married. My dad was a baker for the Army brass in Saigon in the early 70s--never lifted a weapon his entire twelve months there."

Their conversation was cut short by the squawk box announcing that the ambulance was bringing in a bad cardiac. Funny. They never brought in a good cardiac. Numerous studies had documented a higher incidence of cardiac events between 4-7 a.m. than any other three-hour time period. Presumably, that early morning surge of adrenaline and steroids to get us ready for the upcoming day would frequently wreak havoc on unsuspecting but susceptible coronary arteries.

CHAPTER TEN

Better living through chemistry. That could easily have been the mantra of the pharmaceutical industry which developed a very cozy relationship (some say too cozy) with the medical profession in the 80s and 90s. More powerful antibiotics, newer drugs for hypertension, diabetes, acid indigestion, heart failure, cholesterol, etc., etc. overwhelmed most practitioners' abilities to keep up with the newest advances. Enter the friendly pharmaceutical sales rep. In the 1970s these were generally men with backgrounds and training in biochemistry, but as the competition heated up among companies, the sales forces needed more marketing oomph and the huge multinationals such as Merck and Pfizer hired college grads and M.B.A.s who met with doctors in their offices to extol the virtues of the newest blockbuster drug that had just been approved by the FDA. Memo pads and pens and trinkets with the company's logo and new drugs' name were dispensed to the doctor, receptionist, medical assistant, secretary and anyone else who ventured too close to the spiel.

Occasionally "freebies" such as theater tickets or seats behind home plate accompanied these sales pitches. What better way to secure the attention of the busy doctor than to have a beautiful young lady promote the benefits of a new medication. It was no accident that many former beauty pageant winners became the vanguard of wildly successful sales forces.

Alas, there was a significant backlash from the mucky mucks in academia, the FDA and Congress that resulted in many of these tactics being curtailed.

Maimonides enacted a compromise solution (after all, many of its researchers' grants were fueled by Big Pharma): Twice a month, the reps were allowed to set up a display in the conference room adjacent to the cafeteria. The house staff was encouraged to view these exhibits and 'ask meaningful questions about cost and effectiveness of newly marked drugs.' The reps tried to generate sufficient interest to get the house staff to lobby the pharmacy and therapeutics committee to get their company's new medication on the hospital formulary. This might generate a bonus and/or promotion for the rep.

The one detail rep who didn't participate in this kabuki dance was Allison Kincaid. She didn't have to. She was class all the way. Yes, she was drop dead gorgeous with blonde hair and green eyes, but she never seemed to be shilling for the company. Curiously, the female interns and residents liked her as much as the guys. Alli was friendly but never flirty. She dressed classily but never seductively. Only when pressed did she admit to graduating from Princeton and having spent her junior year at the Sorbonne. She earned an M.B.A. from Wharton and worked for Pfizer. She was primarily responsible for enlightening the house staff as to the benefits of Lipitor, their cholesterol lowering drug. Thank goodness Allison's sales manager had the good sense to make someone else, not Alli, responsible for promoting Pfizer's other blockbuster drug, Viagra. There was no wedding band or engagement ring on Miss Kincaid's left hand. Dr. Kirsch's theory was that the combination of her beauty, brains, self assurance, and overarching savoir-faire were so intimidating that any potential suitor, especially a house officer at Maimonides, would find Allison on too lofty a pedestal to dislodge and woo.

CHAPTER ELEVEN

Noah Strong figured that he had probably done too many sit ups. Although he preferred the full-court basketball games, crunches did help him regain and maintain those six-pack abs that his girlfriend Annie always complimented him on. She loved to trace their outline after their lovemaking and even got Noah to wax the hair off his belly so she could more easily feel them with her fingertips. Small sacrifice, he figured. But now he was hurting. He hadn't played basketball for a week and had no recent gymnastic encounters with Annie. All he had done were the crunches and now he was experiencing pain--particularly in the left upper quadrant. There was no diarrhea to suggest an intestinal flu, just a crampy discomfort he had never experienced before. He took a hot bath, laid down for a half-hour nap and the pain was completely gone. Maybe it had lasted a total of thirty minutes.

CHAPTER TWELVE

Dionne looked quite chipper as she approached Julie in the cafeteria. He was nursing a cup of coffee and Danish after a particularly grueling twelve-hour shift as the night float resident. Dr. Clark, on the other hand, was in the middle of her internship's only elective month--neurology. This was a veritable vacation as all she was requested to do was handle the medical problems of the newly admitted stroke and Guillain-Barré patients. The neurology residents took night call and Dr. Cabot was consulted by phone on any problems that they couldn't handle. Thus, Dionne worked Monday to Friday, 8 a.m. to 6 p.m., and had nights and weekends off. During intern orientation the summer before, all the new house officers were told how fortunate they were to have this "easy" month in their rotation and they were expected to make the most of it by reading, studying and attending any weekend seminar on any topic related to internal medicine anywhere in the five boroughs. The medical education office at Maimonides was only too happy to reimburse any tuition charges.

"I think I've got a small world story that will knock your socks off," Dionne said as she slid into the chair next to Julie, not opposite him.

"I'm listening."

"Well, it all depends on what your answer is."

"To what?"

"Is your brother's name Mitchell and your mother's name Natalie?" she asked, her voice rising giddily.

"Have you been rummaging through my personnel file or something?" Julie sounded more perplexed than annoyed.

"Well, are those their names or aren't they?"

"Yes they are, but how did you find that out?"

"My mother knows you."

"What?"

"Well, I had dinner at my folks' place two nights ago and I told my mom that I had met this very nice resident at Maimonides." Dionne explained as she gently placed her hand on Julie's. "So of course she asks me 'What's his name and where is he from?' and all the stuff that you'd expect a mother to ask when a daughter tells her about a young man she just met."

"Dionne, I'm missing something here. Forgive me. I just pulled an all-nighter. So you told your mom about me and now you know my brother and mother's name?"

"My mother knows all three of you--sort of."

"What are you talking about?"

"Dummy," she said sweetly. "I'll give you ten seconds to figure it out before I tell you."

Julie was too tired to try and figure it out. He gently caressed her wrist. "Just tell me."

"Do you remember that I told you my mom worked part-time as a cleaning lady when I was a toddler before my sister, Diana, was born?"

"Vaguely, yes."

"Well, guess what. One of the women she worked for was a Natalie Berger, who had two little boys. She remembers the older one, Mitchell, was in second or third grade and carried these math flashcards around with him all the time. Shy but smart. The younger son, Julius, was a preschooler who, I'm quoting mom now, was 'sweet as apple pie--Mrs. Berger would give him a padded hangar to give to me when I arrived to clean their apartment every two weeks so I could hang up my clothes and change into the smock and apron I wore when I cleaned.'--Julie, my mother first met you twenty-five years ago!"

"That's got to be one of the most incredible coincidences I have ever heard. Did you tell you mom I'm still as sweet as apple pie?"

"Of course I did Julie," as Dionne now started caressing Julie's wrist. "But don't you Jewish people have another word for it--bashert?"

Julie was all too familiar with bashert. During his internship, the grateful widow of Stephen Kaplan, the sporting goods king, kept hounding him to date their daughter Stephanie. Poor Mr. Kaplan had died a miserable death from pancreatic cancer at age forty-nine and Julie had gone the extra mile to delicately balance his pain meds to keep him comfortable yet alert enough to spend a few precious minutes each day with his wife and only daughter at his bedside. Perhaps it was her grief, but Leona Kaplan was convinced that the only possible explanation for Stephen's illness and death was for Stephanie to meet Dr. Julius Berger – bashert she called it. It was then that Julie actually looked up bashert in the Oxford English Dictionary. There were two definitions: one from the Yiddish implying fate or destiny and the other a common Jewish usage, "a person's soul mate, especially when considered as an ideal or predestined marriage partner."

Julie was tired. He did not want to say the wrong thing. He did not want to burst Dionne's bubble. Hell, he wasn't certain that a bubble even existed.

Thankfully Dionne rescued him from his dilemma.

"Don't worry silly boy. I am not proposing to you. We've both got too much on our plates right now for that nonsense. Now go home and get some sleep." And with that she gently kissed him on his cheek and headed off for morning rounds.

CHAPTER THIRTEEN

Maimonides was located in the northwest corner of Boro Park where many Hasidic Jews lived. They kept their homes neat and clean and were quite willing to rent out their basement apartments to the interns and residents at the hospital--so long as they were yommies. The Asians, Pakistanis and Indians could find similar accommodations in the homes of other ethnic groups--Italians, Norwegians--towards Sunset Park. Dr. Clark rented a small basement apartment several blocks north of the hospital. Its private entrance was through a rear door, down four steps, and through the boiler room. Dr. and Mrs. Lenkala Reddy rented a much larger basement apartment. He was the chief resident in general surgery. He had gone to school in India, trained there, and started a practice there. His wife, Vijaya, did her undergraduate work at Cornell and became enamoured with America. She convinced Lenkala that they might be better off in the states and so Dr. Reddy and his wife and two young daughters emigrated to New York where Dr. Reddy had to "retrain" in American hospitals, despite being an accomplished surgeon in Bangalore. Lenkala was tall and thin and quite soft spoken; the attending surgeons enjoyed scrubbing with him. More often than not he taught them something, rather than the other way around. A good Hindu, the miniscule tikla he placed between his eyebrows was visible only to Vijaya and himself.

Although several of the surgeons on staff had professed a desire to take on the new associate, Lenkala knew that an Indian might not be their first choice. He told Vijaya that they might have to relocate to a small town if a Maimonides surgeon didn't make a meaningful job offer. Neither Lenkala nor his wife was too pleased with the prospect of moving to Montana or Mississippi.

And then, the best recruiting secret in Maimonides history became a done deal. With TV cameras rolling for the six o'clock news, the president of the Board of Directors announced that Maimonides would soon become the new home of Gabriel Levi. Levi trained at Jerusalem's Hadassah Hospital in the 1980s just as laparoscopic surgery was revolutionizing the specialty. His eye-hand coordination was legendary and as he finished his formal training in Israel, he went to work for the manufacturers of laparoscopic equipment. Clever patents and stock options catapulted him to multimillionaire status and he became an even bigger celebrity than his Uncle Modecai who had fought alongside Ariel Sharon during the Sinai Campaign in 1956. Gabriel married a Miss Israel and quickly fathered two sets of twins. The Levis built a magnificent home near Montefiore's Windmill, just outside the Old City of Jerusalem. But the allure of surgery and innovation kept their grip on him. The arrangement that brought him to Maimonides was a year in the making and involved the NIH, its Israeli counterpart, Maimonides and Hadassah. It was engineered by a philanthropist in the Jewish community who insisted upon anonymity.

Maimonides would provide the space and personnel to allow Levi and his entourage to continue with his research into NOTES or Natural Orifice Transluminal Endoscopic Surgery. Research centers in San Diego, Baltimore and Rio de Janeiro were at the forefront of this new technique. Basically, NOTES allowed for surgery on intraabdominal organs to be performed without cutting through the skin. The abdominal cavity was accessed through natural orifices and usually it was a gastroenterologist or a surgeon skilled in endoscopic technique who would scope a patient and then purposely incise the lining of the stomach and then pass instruments through the stomach into the peritoneal cavity to do the operation. Most of the initial research was done on pigs but there were reports from overseas of successful appendectomies being performed through the mouth. In fact, it was at a surgical/gastroenterologic meeting in 2004 that a videotape of a transoral transgastric appendectomy was first shown. The final few frames of that video revealed the appendix being removed through the mouth! This was met with ooohs and aaahs from the huge audience.

It was thought that NOTES might play a revolutionary role in future surgical procedures and hence millions of dollars were being poured into research on the techniques and the instrumentation and the ways and means for insuring sterility of the surgical field to prevent peritonitis and the ways and means to secure a water-tight seal in the stomach once the appendectomy or cholecystectomy were completed.

If there were anything akin to a rock star in surgery, anywhere in the world, it was Gabriel Levi. With his trophy wife, Armani suits, scandal-free past and universally acclaimed laparoscopic skills, his exploits were just as likely to be written up in The Wall Street Journal as the International Journal of Surgery. Maimonides Medical Center would no longer be playing second fiddle to Mount Sinai or the Mayo Clinic.

Some of the perks promised Dr. Levi were chauffeured limos, private planes, incredible security, and a residential suite for the entire family at the Narrows Towers, a brand new thirty-story-high luxury apartment complex, overlooking the Verrazano Bridge and lower New York Harbor.

Levi had already been told of the talented Chief Surgical Resident Lenkala Reddy and personally offered him a position with his new NOTES team at Maimonides for the fall. Reddy was thrilled to accept. He'd have a guaranteed salary while building up a private practice and he'd be working with a legend. Vijaya was right. America was great.

CHAPTER FOURTEEN

Once a month Noah Strong had Friday night dinner at his parent's apartment in Bensonhurst. Joan and Leonard were more observant than religious. That generally meant Sabbath candles and broiled chicken with all the fixings. Noah actually enjoyed these evenings--his folks didn't bug him about Annie and he usually got to take home a shopping bag full of yummy leftovers. He was brought up to speed on the doings of his sister, Valerie, who was teaching school in Amherst while her "no goodnik" boyfriend, Phillip, was writing the great American novel. Noah knew that Phil wasn't such a bad guy: he truly cared for Valerie but his lack of motivation bothered the upwardly mobile Strong family. Neither Joan nor Leonard had graduated from college yet their children had advanced degrees. Well, maybe Phillip would make it big sometime, but teaching remedial English at night at a Massachusetts junior college wasn't exactly what they hoped their future son-in-law would have chosen as a career.

Just before Joan served dessert, Noah started feeling that upper abdominal discomfort. It soon progressed to painful cramps but Noah didn't want to alarm his parents. He calmly stated that he had eaten too much and was too full for dessert. He'd happily take half of his mom's homemade rhubarb pie home with him in his large doggie bag. Fifteen minutes after his cramps began and with the pain intensifying Noah kissed his parents goodbye and raced down the four flights of stairs to the lobby. When he reached his car which was parked a few blocks away, the pain was rapidly dissipating and by the time he got the keys in the ignition it had completely disappeared, leaving him with a mild residual soreness but the dread that he hadn't suffered the last of these episodes.

Noah finally accepted the fact that he needed to see a doctor. Those increasingly frequent bouts of pain had left him scared shitless – sometimes literally. His fraternity brother from AEPi at Brooklyn College had gone to med school locally. It wasn't too difficult to track him down.

~~~~~~~~~~

Dr. Julius Berger answered a page from the hospital operator which indicated an outside caller was waiting. "Hello, this is Dr. Berger, can I help you?"

"Julie, hi, this is your pledge master from AEPi. It's been five or six years. How the hell are you?"

"Noah, is that you? I'm fine. I am finishing my second year here at Maimonides. To what do I owe the honor of this phone call?"

Noah then explained some of what he had suffered through the past eight months. All he really wanted from Julie right now was a referral to a good doctor.

Julie did not hesitate for a moment. "Nat Bloom, Noah. He is a great guy, great teacher and a great diagnostician. He is very busy but when you call for an appointment mention my name. I may see him at grand rounds tomorrow so I will give him a heads up."

"Thanks, Julie. When this problem is solved we've got to get together. How's the busy doctor's love life?"

Dr. Berger could only offer a response that surprised even him. "Very interesting," he replied.

Dr. Bloom's office manager suggested that Noah come in at 9 p.m. the following Tuesday. She explained that yes, it was late for a doctor's appointment, but that another patient had cancelled freeing up the spot. Noah would be Dr. Bloom's last patient and could therefore spend as much time with him as necessary.

Dr. Bloom's waiting room was a Spartan, no frills affair. Current issues of People, Sports Illustrated and Hadassah were in the magazine rack. This wasn't the patient population that read The Economist or Travel + Leisure. Noah filled out the requisite forms and was escorted by the medical assistant to Dr. Bloom's office, the walls of which were adorned with photos of his family and Maimonides dignitaries. It was tastefully decorated and designed to put a worried referral at ease. This was were Dr. Bloom would warmly greet a new patient and take a medical history. It was only after this thirty- to forty-five minute interview that the patient was escorted to one of the exam rooms and diplomatically asked to undress. Those paper gowns left plenty to be desired.

Noah thought that Dr. Bloom seemed unusually tired. He certainly looked older than his forty-seven years. But then again Julie told him of the long hours Bloom worked. He scribbled a few notes while asking Noah a lot of questions about those painful episodes. Other than the car accident there was nothing of significance in Noah's past history. Noah was impressed with how carefully Bloom examined him from head to toe and everywhere in between. Dr. Bloom suggested they secure some routine blood and urine tests. He also ordered an upper GI series as the intermittent episodes of pain suggested a possible intestinal problem. A followup appointment was made for two weeks. Noah noted that Bloom kept opening and closing his fists during the hour-long encounter.

~~~~~~~~~~

Noah had been pain-free since seeing Dr. Bloom. Actually he had experienced no attacks since getting Julie's recommendation to see Dr. Bloom in the first place. Sort of like the toothache disappearing before going to the dentist.

Noah knew better than to cancel his x-ray study. He arrived at Maimonides' outpatient radiology suite and once again filled out a bunch of forms. He was given a locker to hang his jacket and shirts. For the upper GI series he did not need to take off his slacks. The x-ray technologist gave him a cloth gown to wear into fluoroscopy room number two. In came Dr. Meera Sadeghi, an Iranian-born, USA-trained radiologist. She introduced herself, reread Nat Bloom's ordering form and asked Noah a few questions about his symptoms. She then got to work, shooting x-rays in different positions as Noah drank the strawberry flavored barium. The esophagus and stomach looked okay as did the duodenum, the first part of the small intestines. She activated the fluoro every minute or so as Noah drank some more barium and it moved further down into the small bowel. The caliber of the small intestine appeared normal as did the transit time to the large intestine. For a split second Dr. Sadeghi thought she was seeing something in the right lower quadrant on fluoro but subsequent spot films revealed a normal pattern. Besides, the patient's pain was almost always in the left upper quadrant. In short, this was a normal upper GI small bowel series.

CHAPTER FIFTEEN

Chief Medical Resident Joseph Bianchi lived on Staten Island with his wife, Maria, and three daughters, ages one, three and five. If he timed the lights just right on Fort Hamilton Parkway it was a quick and easy commute onto the Verrazano Bridge and then onto the Staten Island Expressway and then exiting at Victory Boulevard with a few more turns to arrive at the two-family house he shared with his in-laws. The commute was even shorter when he frequently found reasons to stick around the hospital until after the evening rush hour.

Anyone within earshot of Dr. Bianchi's cell phone could sense that trouble was brewing at home. Maria would call three to four times a day and Joe would angrily respond that he did not want to be bothered at work by "stupid phone calls." Interns, residents and fellows rounding with Dr. Bianchi tried to look invisible as he yelled at his wife and abruptly hung up on her. What seemed so odd was that he made absolutely no attempt to hold these conversations in private.

Ken Kirsch and Allison Kincaid enjoyed each other's company in a "Will and Grace" sort of way. Dr. Kirsch would help Allison pack up her Lipitor exhibit and they'd get together for a cup of coffee in the cafeteria. They chatted about fashion and the arts, subjects that were not otherwise discussed too frequently on the wards at Maimonides. The lack of sexual tension made these biweekly conclaves that much more enjoyable for both of them.

It drove Joe Bianchi nuts that Allison was spending such quality time with the gay Dr. Kirsch. Bianchi was always using a different three-letter word to describe Kirsch, but of course only in his private thoughts. Once Bianchi tried to crash Allison and Kirsch's tete a tete in the cafeteria, only to be met by the iciest of stares from Miss Kincaid. Ever the diplomat, Ken later apologized to Allison for his chief resident's boorish behavior, confiding in her what practically everyone at Maimonides already knew: that Bianchi and his wife were probably having marital problems big time.

Spring had sprung at Maimonides. The interns and residents had long gotten used to the routine and were gaining increasing confidence in their ability to diagnose and treat very complicated medical problems. Most of the house officers had secured positions for the following year. All of the yommies were staying; the only intern who wouldn't be returning was Ted Benjamin who somehow garnered a psychiatry residency at Bellevue in Manhattan. Angie Vitale-Schwartz and Julie Berger would stay on for a third year. The division chief in hematology offered Joe Bianchi a fellowship slot, contingent upon his controlling his vesuvian temper. The Bostonian Dr. Cabot would be spending another twelve months as a fellow in neuromuscular diseases. Dr. Greene was quite happy with the clinical research that Cabot was conducting on the Guillain-Barré patients.

~~~~~~~~~~

Dr. Berger was reading some thyroid scans on the final Thursday afternoon of his month-long endocrinology elective. Dr. Clark was finishing a tough stint on the ward service under Angie Vitale. Angie just seemed to demand more from Dionne than she did the other interns.

A very weary Dr. Clark paged Dr. Berger, "Julie, I'm off this weekend. I checked your schedule and know you're off too."

"That's right. What's on your mind?"

"Please bring a change of clothes to work tomorrow. I'd like to get an early start on Saturday."

Julie wasn't sure he was connecting the dots. "Could you please repeat that?"

"You heard me. I'd like you to sleep over in my apartment tomorrow. We can walk over there right after sign-out rounds. They are predicting beautiful weather for the entire weekend. You can treat me to dinner at that restaurant in New Hope you've been raving about all year. I have tickets waiting for us at the Bucks County Playhouse."

"Whoa, you did what? How do know I don't have other plans, women's intuition?"

"You might say that Julie. I want to spend some time with you away from this place. I couldn't wait any longer for you to ask me."

Once again Julie remembered that prolonged finger tug during last year's intern orientation and Dionne's peck on his cheek a few months back.

"Anything else I should bring besides a change of clothes?"

"Use your brains, doctor."

CHAPTER SIXTEEN

Allison Kincaid's sales manager, Meryl Pierce, was quite happy with the figures coming in from the pharmacies in her district. For the past six months both the number of prescriptions for Lipitor and its total share of the highly competitive statin market were increasing, despite it not being the "preferred" cholesterol lowering drug on many private health insurance formularies. In those biweekly pharmaceutical displays at Maimonides, Allison generally chatted with two dozen or so community internists and family practitioners in addition to the entire house staff. Only a fool would think that Allison's looks had nothing to do with the success of her sales pitch.

Thus it came as a complete shock and surprise that Meryl, upon her return from the lobby ladies' room, found a red-faced Miss Kincaid screaming at one of the doctors. Alli was certainly not extolling the virtues of Lipitor but rather calling Dr. Joseph Bianchi a few choice words that had nothing to do with hyperlipidemia. This diatribe lasted for several minutes during which both Alli and Bianchi had to be restrained from making physical contact. It was witnessed by several attendings and house officers including Julie and Dionne and Angie and Cabot. Wow. What might Bianchi have said to get Alli so riled up? Her parting shot as Pierce was leading her away was "I'm going to sue your ass off, Bianchi." Not exactly what you'd expect to hear from someone who spent a year at the Sorbonne and graduated from Princeton. But then again, Miss Kincaid had also earned an M.B.A. from Wharton!

Dr. Cabot told his mentor Dr. Greene about what he had seen and heard. Dr. Greene summoned Dr. Bianchi to his office and closed the door, something his secretary said she had never seen him do.

By sign-out rounds a few hours later the entire house staff had learned of the fight. Not too many of them were siding with their chief resident.

CHAPTER SEVENTEEN

There were many incongruous sites on the streets of Boro Park. On this particular clear and cool April evening there were the Hasidic Jews in their Sabbath finery walking to synagogue, sharing the sidewalk with a biracial couple, something not seen too often on Ninth Avenue. Dionne had gotten permission from the owner of the house where she rented the basement apartment for Julie to park his car on the driveway Friday morning, before his 9 a.m. outpatient diabetes clinic. She had asked him if TV dinners would be okay as she was too tired and too busy to do food shopping. Of course Julie had said that it would be fine.

They didn't hold hands as they walked up 49th Street; they were getting enough stares as it was. The sun was setting as Dionne led Julie down the long driveway past his car. He stopped for a moment to retrieve his Valpac from the trunk. She fumbled for her keys to the back door as a stray cat scooted by. She then led Julie down the steps and around the boiler to her abode.

Julie surveyed Dionne's apartment as she poured them some tea to go with the two-by-two-inch peach cobbler dessert in the corner of their TV dinners. The furniture in the apartment included a full-size bed, night stand, desk and dresser. These were provided by the owner of the house and Dionne was responsible for kitchen appliances, linens and towels. The windows in the basement apartment were near the ceilings, all looking out onto the driveway. Dionne had hung some pretty curtains on them when she moved in the previous July. They helped brighten the place up considerably.

The two of them ate the cobbler in relative silence. Dionne rose from the table and pitched the trays into the trash can. "Julie, it's been a long two months. Angie Vitale was dissing nearly everything I did. That awful scene today between Bianchi and Alli Kincaid really upset me. I just want to take a long hot shower and go to bed."

What really upset her was Julie's apparent passivity. She had grabbed his hand ten months ago; she had bussed his cheek; she suggested he sleep over. She had no idea what he was really thinking.

"Dionne," he uttered slowly and softly. Her back was to him. She was afraid to turn around. She dreaded what he was about to say.

"Want company in the shower?"

She spun around with a smile and a sigh and said nothing. She just beckoned him to follow. They quietly stripped off their clothes and dumped them in a pile outside the bathroom. Julie started to say something but Dionne shushed him by putting a finger to his lips. She led him into the stall shower and turned on the water.

Julie turned her around and kissed her gently, then more forcefully. He than turned her around again so that he was facing her back. He picked up a bar of soap and began lathering up her neck, her shoulders, her back. He marveled at the contrast between the white soap bubbles and her chocolate-brown skin. He placed his chin on one shoulder, then the other, nuzzling her neck as he moved back and forth. Dionne was meeting his movements with a rhythm of her own. Julie reached around and cupped her breasts with his fingers. She grabbed his hands and guided them lower on her belly.

Still not a word passed between them. Dionne slowly turned around and now kissed Julie. She needed to stand on her tip toes to do so. She then knelt down in the shower and lathered him up from thighs to navel.

They fondled each other and shampooed each other until the water temperature started to drop. They barely had time to rinse each other off before the shower turned ice cold.

They giggled as they went dripping wet into the bedroom. Dionne handed him a plush towel. Julie grabbed something from his toiletry bag and placed it under a pillow. Still no dialogue until Dionne pointed to the bed. "Brand new sheets." They patted themselves dry and then began exploring each other's body under the covers. Dionne got up to turn off the light. Julie protested. There was enough light filtering in from the alley that he didn't protest too much. It was probably the same stray cat that greeted them on their arrival two hours earlier that then let out a mournful meow.

Dionne was blissfully enjoying Julie's nibbling and nuzzling her breasts. She then stayed absolutely still for about ten seconds before bolting upright. "Julie, what in the world are you humming?"

"I wasn't humming."

"Yes you were," Dionne laughed.

"Okay, guilty as charged. I'm sorry. With the light flickering in and that cat meowing, I couldn't help but think of 'Memory' from 'Cats.'"

"While you're making love to me? Talk about multitasking." She laughed a kind, sweet laugh. "I'm not angry with you. It's just so funny though. If that's part of your foreplay, carry on. But I know some Broadway musicals too."

"Huh?"

"Remember Julie Andrews in 'My Fair Lady' when she's fed up with Freddy and all his flowering sayings about love?"

"Yeah?"

"Remember what she said to him?"

"Tell me."

Dionne actually sang, "Don't talk at all, if you're on fire, show me." Dr. Clark looked Dr. Berger in the eye and then almost beseechingly, "Julie, show me now."

Fingers and lips and tongues resumed their caresses and probes. Julie reached under the pillow to retrieve what he had placed there when they first got into bed. Dionne watched as he removed something from a little felt pouch. "What's that?"

Now it was Julie's turn to say, "Shhh, just enjoy." The gadget was a miniature massager that easily clasped onto his index finger and then transmitted its vibrations to the fingertip. Dionne's staccato breaths and panting told Julie that he was clearly using it properly. A guttural "Don't stop whatever you do, don't stop" escaped her lips just before her toes curled and her body arched uncontrollably.

Dionne collapsed in Julie's arms, her sweating, spasming, speechless body just wanting to be held. Julie obliged. A half-hour later she had sufficiently recovered to poke Julie in the chest. "What about you?"

"I can wait until the morning; let's get some sleep." Dionne didn't object.

Julie was awakened Saturday morning by a gentle kiss on the lips. Dionne offered him a glass of orange juice. "Some liquid carbohydrate for quick energy. I'll make you breakfast later." Without pausing a moment she added, "Let's do that again."

And they did. But this time after an orgasm that was no less intense than the one the night before, Dionne had enough energy remaining for Julie. "Where do you want me?"

"On top."

"Good. Me too."

Julie showed the foil wrapped Trojan to Dionne as she nodded approvingly. He had it on in a second. Dionne mounted him and Julie gently pulled rather than pushed himself deep inside her. "God that feels so good."

Dionne soon sensed that she was the star of a beautifully choreographed ballet and before long it was Julie this time whose toes curled, back arched and body practically seized when he climaxed.

"That was absolutely incredible," Dionne whispered when she had finally caught her breath. "I generally don't grade my lovers and believe me I have slept with only a few men. But you were fantastic. That gizmo--can you get one for me?"

"On one condition--that you let me watch you use it."

Dionne laughed a nervous laugh. "You're either sick or kinky."

"Neither--I'm hopelessly heterosexual. You wouldn't understand--you grew up with a sister. When I was twelve or thirteen, I'd sneak a peek at my brother's Playboy magazines. Sure the playmate turned me on but the ultimate male fantasy is watching two beautiful women getting each other's rocks off. About once a year Playboy had a pictorial with girls on girls and those were the biggest sellers at the newsstands. The pictorials purposely left a whole lot to one's imagination but then the internet with pornographic web sites and high definition videos literally left nothing to the imagination."

"How do you know all this?"

"Dionne--it's a guy thing. My fraternity brothers would talk and joke about this for hours. I doubt that you ever had these discussions with your sister or the women at Simmons and certainly not the men at Howard. I was a psych major in college. I wrote my thesis on this--got Honors--A+." Dionne smiled, "I can only imagine the kind of research you did for that thesis."

"Hah-hah. It seems to me that a certain young intern I know has very recently benefited from some of that research."

"Touché! I am seeing a side of Julie Berger that I never fathomed existed."

"And?"

"I think I like what I see. Now how about some lox and eggs?!"

CHAPTER EIGHTEEN

On that very same Saturday morning, about twenty miles away, a totally different meeting was taking place. Allison Kincaid insisted upon it. Meryl Pierce, her sales manager, was able to arrange a conference at Pfizer's headquarters in Manhattan with one of Pfizer's inhouse attorneys, Douglas Richards, a specialist in labor relations. Alli told Pierce precisely what had transpired between her and Dr. Bianchi the day before. Pierce agreed that Bianchi's behavior constituted sexual harassment and that if he were a Pfizer employee he'd be in big trouble. But he worked for the Maimonides Medical Center, not Pfizer. That's why Kincaid wanted to get Richards' opinion on what, if anything, she could do. She reassured Richards that she would never claim Pfizer created a hostile work environment. She loved working for them and hoped to work at Corporate in a few years. Her problem was that cretin Bianchi. She had heard from other house officers what a creep he was and how nasty he was to his wife on the phone and how his upcoming hematology fellowship was not yet signed, sealed and delivered.

She certainly did not want to bring a law suit against Maimonides where she had already made friends and potentially important future contacts in administration. Maybe some archaic moral turpitude charge against Bianchi might get him to straighten out before it was too late.

Douglas Richards thought the process should be initiated with a suit naming Maimonides and its employee Dr. Bianchi, but that the Court would be immediately petitioned to allow the case to go to mediation. He was certain that the attorneys from Maimonides would agree to this as nasty publicity regarding their chief medical resident could more easily be avoided in a mediator's office than in a courtroom.

Thus, the wheels of justice were set in motion with the expectation that yes, they would grind exceedingly fine, but unlike in the famous expression, and with Richards' connections, those wheels would turn quickly.

Maimonides and Dr. Bianchi received certified letters three days later informing them of Miss Kincaid's intent to sue them for sexual harassment.

CHAPTER NINETEEN

After breakfast Julie wanted to shave but Dionne wouldn't let him. She loved the feel of his beard gently grating across her belly and her breasts. They made love again, this time without the gadget. It was no less satisfying. They took a quick shower, dressed and got into Julie's car for the drive to New Hope. Dionne glanced at her watch as Julie backed off the driveway. It was 11:30 a.m. So much for an early start. But both she and Julie sensed that something special had occurred over the past night and early morn. Something beyond the sex which yes, was indescribably delicious. Something that allowed Julie to fantasize, if even for a moment, about bashert. He had never done that before, ever. Dionne snuggled up to Julie as he drove over the Verrazano Bridge. She checked out the CDs in the car's four-disk changer: Andrew Lloyd Webber, The Beatles, Simon and Garfunkel, and a remastered, digitally-enhanced production of the musical that had opened at Broadway's Mark Hellinger Theatre in 1956. Julie's eyes were on the road but Dionne's gasp told him that she had found the "My Fair Lady" CD. "Spooky ain't it," he said and then dittied the "Twilight Zone" theme music.

The drive to New Jersey was a pleasant one. Even though it was a beautiful day the traffic on the Turnpike was light and the winds were favorable. Not for speed but for keeping the infamous odors near the Elizabeth refineries subdued to a tolerable level. Two decades of work by the EPA had helped too.

They only had time for a fifteen-minute stop at Flemington Furs. Dionne had never seen anything quite like it. Julie remembered his mother trying on dozens of coats here on Sunday afternoons long ago. He and his brother, Mitchell, would much rather have stayed home in Brooklyn but their dad had insisted on these family outings every few months or so. Now the numerous security guards watching for PETA fanatics took some of the joy out of the place.

They spent an hour in Lambertville visiting the quaint shops and art galleries. Julie pointed out the Hamilton Grill Room, his second choice for dinner that night in case Chez Odette in New Hope couldn't accommodate them. Chez Odette was actually the name of the restaurant started in the 1960s by Odette Myrtil. Julie had last been there several years ago when the ownership and name had changed to the River House at Odette's. It no longer had the wonderful piano bar atmosphere he remembered but the food was great.

As he and Dionne pulled up to Odette's he was horror struck. The place was boarded up. They got out of his car and read the laminated sign which was nailed to a tree. Apparently three floods from 2004-06 had forced the restaurant to close. In 2007 a local innkeeper and retired corporate executive bought the place and promised to reopen it by the summer of 2010. Engineers were to raise the entire property to what were hopefully flood-proof heights. Dionne couldn't believe that the gently flowing Delaware River thirty yards away could have caused so much damage. Dionne asked, "Julie, why didn't you phone ahead for dinner reservations? You would have been told that it was closed."

"Actually Dionne I was planning on calling last night and then again this morning but I got distracted, remember?"

She giggled. "That's okay. Call that Hamilton Grill now. I think we can wait until after the play to eat."

Julie had no difficulty making dinner reservations for 9:30 p.m. Curtain up at the Bucks County Playhouse was at 7 p.m. There were plenty of bed and breakfast inns nearby. The very first one they drove up to had a vacancy for the night. Dionne and Julie checked out the room and found it to their liking, especially the huge bathtub and king size bed. He registered them for the night with a credit card; the desk clerk didn't bat an eye as Dionne and Julie came down to the foyer an hour later, their hair still wet from the shower.

"You know Dionne, I didn't even ask you what we're seeing tonight. Please don't tell me it's 'Cats' or 'My Fair Lady.'"

"No Julie, that would really have freaked me out. We're seeing another oldie but goodie. I will keep you in suspense until we get there."

At 6:45 p.m. Julie drove into the huge parking lot at the Bucks County Playhouse. He dropped Dionne off at will call.

"This is really cool," he said as Dionne handed him the tickets. They were about to enjoy a revival of "The Fantastiks."

CHAPTER TWENTY

With unprecedented speed, the attorneys for Pfizer and Maimonides had agreed to an attempt to mediate the dispute between Kincaid and Bianchi (and by extension the Maimonides Medical Center). A conference room on the twenty-eighth floor of the Williamsburgh Savings Bank Building in downtown Brooklyn was secured to host the meeting. A retired immigration attorney, Ricardo Ponce, had agreed to serve as mediator and all parties accepted him as being neutral and disinterested. Pfizer and Maimonides had never faced off before in any sort of legal skirmish. In fact, Pfizer had a drug in the early stages of development for the treatment of Guillain-Barré which Dr. Greene was testing in a clinical trial. The last thing Maimonides needed was a long, drawn-out legal battle with the very company that was funding a good chunk of its research. Hollywood starlets might seek out negative publicity; hospitals never did.

The conference room had a magnificent view of New York Harbor and the Manhattan skyline. Ricardo Ponce introduced himself to Allison, Richards and Bianchi and the Maimonides attorney, Gerald Silver. This was not a malpractice case--Bianchi was happy to have Silver represent him at this early stage, and at no cost.

Ponce further reminded all assembled that mediation was an attempt to right a perceived wrong. If the parties were not able to come to an agreement here, they faced the prospect of a lengthy and costly trial that probably would not begin for at least two and a half years. No court stenographer was present and hence any discussion and any rebuttal would not be recorded. Therefore, none of these proceedings could be introduced as evidence should a trial be necessary to adjudicate the complaint.

"Basically," added Ponce, "My job is to get you to agree to disagree, not to kiss and make up. A trial involving a charge of sexual harassment can be extremely nasty, frequently with devastating accusations that neither party ever fully recovers from. You have both heard of a pyrrhic victory--that's the best either one of you could hope for if this thing is not settled here and now."

Kincaid nodded. Bianchi sighed and looked at his watch. It was difficult to believe that the altercation between Allison and Bianchi that precipitated all this had occurred only five weeks before.

CHAPTER TWENTY-ONE

The name of the patient he was accepting in transfer did not strike a bell. Dr. Cabot, the neuromuscular fellow, had received an urgent call from Dr. Jones, one of the student health services docs at NYU. A twenty-one-year-old coed at the Washington Square campus in Greenwich Village was complaining of worsening fatigue over the past several days and now had great difficulty even walking. She had recently been vaccinated against the human papilloma virus as protection against possible cervical cancer and the astute nurse practitioner worried that this scenario could be early Guillain-Barré. A transfer to Maimonides was arranged immediately for Abby Webster, a junior film major.

Dr. Cabot told the intern rotating through neurology to go home and that he would handle the admission. When the patient arrived Dr. Cabot scanned the reports from NYU that the EMT handed to him on Abigail Webster. Even that name didn't strike a bell until the patient called out "Charlie, is that you?"

Then it hit Dr. Cabot. "You're Sissy Webster, Donald's kid sister. Nobody ever called you Abigail or even Abby. No wonder I didn't recognize the name." This pronouncement was made just as much to inform the ICU staff as to reassure the patient.

"Charlie, I'm very scared. The nurse at NYU said I might be having this thing called Guillain-Barré and that a Dr. Greene in Brooklyn was the specialist I needed to see--quick. I barely had time to pack a few things and to call mother and father before they loaded me into the ambulance. They're freaking out that I wasn't medevaced to Massachusetts General Hospital. But Dr. Jones told them that this facility, Maimonides--am I pronouncing it right?--is the best place if I have Guillain-Barré."

The Websters were another Brahmin clan. Dr. Cabot had actually attended Phillips Academy in Andover with Sissy's next older brother, Donald. There were two older brothers, Adam and Quincy. In fact, all three boys were born within four years of one another and that was supposed to have been it for John and Pricilla. But apparently one of John's spermatozoa and Pricilla's ovum had other ideas. Their love child, blessing, surprise (take your pick) was born nine years after Donald.

Abigail was always called Sissy. Dr. Cabot wasn't sure when he had last seen her but it was with a mouthful of braces and a body devoid of curves. She had matured into a very attractive young lady. Charlie explained that he worked with Dr. Greene and that she was indeed fortunate to have been transferred to Maimonides. Sissy didn't need to ask Dr. Cabot to call and reassure her folks. They were astounded to hear that Donald's friend Charles Cabot would be the doctor primarily responsible for Sissy's care. Grateful too as they remembered how smart he was. Surely Sissy was in good hands.

CHAPTER TWENTY-TWO

Although Annie wasn't super cerebral she had street smarts and knew that something was seriously wrong with Noah. Those abs she loved were getting soft and his weight had dropped seven or eight pounds since she last saw him. Noah told her that he was undergoing some tests and that so far nothing bad had turned up. He reassured Annie that Dr. Bloom said that all the laboratory studies were negative and so were the x-rays.

Dr. Bloom himself was also feeling under the weather. In twenty years of private practice he had missed only one day at the office. But now his stomach was upset and he had a headache. He hadn't had any alcohol in the past three days so that couldn't be it. His office scale indicated that he had lost ten pounds in the past month, weight he could easily afford to lose but not this way. And those aching hands were bothering him more and more, making it difficult for him to use the old but reliable sphygmomanometer to personally take his patients' blood pressures, an activity that very few physicians performed any longer and which had become a hallmark of his practice.

CHAPTER TWENTY-THREE

Ken Kirsch had been visiting friends in San Francisco during his April vacation. When he returned to Brooklyn, Alli needed his shoulder to cry on. He couldn't believe that Bianchi had said all those awful things to her. Kirsch had never seen Alli so upset.

One of the friends Kirsch stayed with in San Francisco was Frank Dilello who had gone to med school with Bianchi for two years at SUNY Buffalo. They had served their internship together at Saint Vincent's in the Village before Frank went to the west coast and Bianchi to Maimonides.

Dilello thought that Kirsch had to be describing somebody else. The Joseph Bianchi he knew was cordial, courteous and even-tempered. The nurses at Saint Vincent's, many of whom had strict Catholic upbringings, voted him Intern of the Year. It made no sense that merely switching from one hospital's training program to another's would have exacted such a personality change. There was no hint of anti-Semitism in any of Bianchi's ill-tempered remarks. He maligned Jew, Asian and Gentile equally. Kirsch was wondering about all this on the plane trip back east. He had not yet even heard of the scene between Alli and Bianchi at the hospital.

Alli clued him in on most but not all of the details. As much as he wanted and needed to console Allison, KK didn't want to see Bianchi self destruct and have all those years of schooling and training go down the drain. Something must have happened to turn Dr. Joseph Bianchi from a universally admired Intern of the Year at Saint Vincent's to a universally despised chief resident at Maimonides.

Kirsch sensed Bianchi's homophobia. He and Allison had discussed it numerous times in the past. That was unlikely to be it, however. There were certainly more flagrantly gay folks at Saint Vincent's than at Maimonides.

At first Allison did not want to hear any more theories from KK as to what might have transformed Bianchi so drastically. After all, she had been subjected to disgusting behavior which she had only reluctantly shared with Meryl Pierce in order to get the ball rolling with the law suit. The absolute worst of Bianchi's accusations involved Allison and KK himself; she saw no point in giving Kirsch those salacious details.

Allison Kincaid was having trouble sleeping for the first time in her life. It was not Bianchi's verbal abuse that bothered her. It wasn't even his pinching her derrière, although that could technically be considered assault. KK had described a Joe Bianchi who was a solid medical student and excellent intern. What happened? It didn't seem like the problem originated at Maimonides. Bianchi had done two years of residency at Maimonides and had sufficiently impressed Chief Greene that he offered the chief resident slot to him.

Allison concluded that the change in Bianchi's personality must have been precipitated by a problem at home. But what could it be and was it really any of her business? She then recalled Eldridge Cleaver's famous line, "You are either part of the solution or part of the problem."

~~~~~~~~~~

KK had another unpleasant surprise waiting for him upon his return from San Francisco. He hadn't seen Nat Bloom for about a month and was horrified by his mentor's physical appearance. Pale skin, blood-shot eyes, ill-fitting pants. "Nat, you look awful. What is going on? And don't give me that crap about working too hard. You've always worked hard! And it's not flu season either."

Dr. Bloom smiled. Ever since that bogus life and death admission he and Kirsch had become friends in addition to colleagues.

"I'm not sure KK. I am running some tests on myself at the labs. Nothing scary yet except a slight anemia."

"Who are you seeing about this?" KK then rattled off the names of several of the other excellent internists at Maimonides.

"No one yet. I think I can order some of the preliminary investigations without getting anyone else involved."

"Nat, shame on you. You should know better. You are always reminding us of that trap when doctors attempt to diagnose and treat themselves or family members. Sort of like the attorney who decides to defend himself--you know, an ass for a client and a fool for a lawyer. Nat, you've told us that a hundred times. Come on, see one of your colleagues."

"I don't think it will do any good."

"Why not?"

"I think I've got pancreatic cancer."

It was as though someone had punched KK in the stomach.

CHAPTER TWENTY-FOUR

Sissy Webster's weakness worsened the first week in the hospital. She could no longer walk and Dr. Cabot was worried that the ascending paresis she was exhibiting might soon affect her diaphragm. If that happened, she'd need to be placed on a ventilator attached to a tube in her windpipe. That's what petrified Guillain-Barré patients the most--being totally alert and oriented but having your life dependent on a machine. Dr. Cabot and the ICU nurses were monitoring Sissy very carefully for any signs of respiratory distress. By the end of week one, other diagnostic possibilities to explain the weakness had been ruled out, including Lyme disease and myasthenia gravis.

Sissy's parents had been at her bedside every day. Her brother Donald would be coming down for the weekend. It wasn't the kind of reunion that either he or Cabot had envisioned.

Phillips Academy at Andover was the prototype of New England boarding schools. It was founded in 1778 and its motto was (and is) NON SIBI--not for self. Its graduates included Humphrey Bogart, Benjamin Spock, and both Presidents Bush. It went coed in 1972. Sissy had followed her brothers there before enrolling at Radcliffe but then transferred to NYU against her parents' wishes for her sophomore year because of her interest in film. Dr. Cabot tried to convince John and Pricilla that Sissy's illness could have developed anywhere and that the Big Apple was not to blame. However, witnessing their daughter's condition deteriorate on a daily basis made them rue the day they ever let her leave Massachusetts for New York.

Sissy was not responding to the usual treatment for Guillain-Barré. She was undergoing plasmapheresis and receiving high-dose immunoglobulins intravenously, yet the level and severity of her weakness was worsening. Once her oxygen saturation dropped into the 80s and her tidal respiratory volume plummeted, Cabot had no recourse but to order her intubated. When Donald arrived at Maimonides' intensive care unit he found his kid sister on a ventilator and his parents wide eyed with panic. Neither he nor Cabot were in any mood to reminisce about the good old days at the Phillips Academy.

CHAPTER TWENTY-FIVE

That Saturday night in New Hope was almost as memorable for Julie and Dionne as the night before in Boro Park. The Fantastiks received a well-deserved standing ovation from the audience. Everyone including the house officers from Maimonides was humming "Try to Remember" as they left the theatre. Dinner at the Hamilton Grill Room was exquisite--Julie had the filet and Dionne the Dover sole. Julie savored a glass of pinot noir and Dionne some white zinfandel. For dessert they shared a chocolate mousse. By the time they got to the bed and breakfast it was nearly midnight. The bathtub easily held the two of them for a wonderfully sensuous bubble bath. Dionne joked that the bath tub resembled the one in the Cialis commercials on TV; her playfully wandering toes told her that no Cialis would be needed tonight.

Julie's lovemaking was even more adventurous than Dionne could ever have imagined. A very exhausted but contented couple fell asleep under a down coverlet. Were it not for the aroma of fresh brewed coffee at 9 a.m. they might have slept the entire day away in that king size bed.

On the drive back to Brooklyn Dionne told Julie that it was the most enjoyable weekend she had ever spent. Julie took his right hand off the steering wheel and squeezed Dionne's thigh, "Me too--without a doubt."

Dionne mustered up the courage to ask what she thought was an obvious question, "Julie, we clearly had some chemistry going even before Friday night. We met nearly nine months ago. Why didn't you ask me out on a date? It seemed like I was always the one taking the initiative. Don't get me wrong. Now that I can see what you're capable of, and I don't just mean in bed, I'm glad I did. What gives?"

"Nothing other than being a little bit shy. Please, don't read any more into it than that. It is certainly not because you're Black. I have fantasized about making it with you for months but I didn't just want to shtup in the on-call rooms."

"Shtup?"

"You've been at Maimonides ten months and you haven't heard

'shtup'? It's Yiddish. It implies fuck more than it does making love. I didn't want our first time to be a shtup in a strange bed."

"Shtup," Dionne repeated slowly with the proper intonation. "It even sounds vulgar."

"Yup. My grandparent's generation had a favorite saying about premarital sex. You've seen photos and movies of Jewish weddings?"

"Sure."

"Well, the actual religious ceremony takes place under a canopy that is called a chuppah. So fifty, maybe sixty years ago the reason that many a wedding night meant one or two virgins fumbling with each other was 'no chuppah, no shtupah!'"

Dionne laughed and rubbed Julie gently on his thigh. "I'm sure glad this Jewish boy doesn't subscribe to that one."

"By the way Dionne, I remember your telling me that your mother recalled my brother Mitchell being the shy one. I don't think so--and if he were he certainly outgrew it. Otherwise he never would have caught and married Rosie. She was the shy one. Beautiful Vietnamese girl. Only daughter of a former South Vietnamese Airforce pilot. He and his wife were among the last to be evacuated as the North Vietnamese stormed Saigon. That famous photo of the helicopter on the roof of the embassy--Rosie's parents were on that line. Her folks really kept tight reins on her. Mitch met her in a graduate math class at Columbia. It was months before she would even give him the time of day. But he persisted and charmed his way into her heart, much to the initial dismay of Colonel and Mrs. Nguyen and Mr. and Mrs. Berger."

Julie parked on the street and walked Dionne into her apartment. She knew that he needed to get back to his place and prepare for a month as the night float resident on the ward service. She was about to do two months on the Private service. They had probably spent more time together the past forty-eight hours than they would for the next two months.

A big hug and a long kiss and Julie called as he bound up the steps to the alley, "Thanks for taking the initiative."

Dionne smiled, "You're welcome, and thank you for bringing the extra batteries!"

CHAPTER TWENTY-SIX

Noah had gone three weeks without any further attacks. Perhaps this crazy thing was finally over and done with. He called Julie to thank him again for the referral. So long as there were no symptoms Dr. Bloom was agreeable to just watch and wait. Julie thought that sounded reasonable. Maybe he and Annie could meet Dionne. Julie had told Noah about her and dinner reservations were made for Not Lundy's.

Lundy's was a landmark seafood restaurant in Brooklyn's Sheepshead Bay neighborhood. It was huge. Both Noah's and Julie's parents and grandparents enjoyed many a delicious meal there. The place was jammed on Mothers' Day and especially after June high school graduations. It occupied two floors and could serve two thousand five hundred people at once. No reservations ever accepted. If you wanted a table you staked one out and hovered over the folks who were finishing off their coffee and dessert. Not exactly a high class way of being seated for dinner but that's how it was done for decades and everyone accepted it. After all, the food was mouthwatering, from the biscuits and Manhattan clam chowder to the Huckleberry pie and extra rich Sealtest ice cream.

The restaurant closed in 1977 after the last of the original brothers who founded it, Irving Lundy, died. Cumbersome litigation followed and it reopened in 1995 but all Brooklynites agreed that it was not the same. It closed for good in 2007 and was being turned into a gigantic grocery store. Anyway, some bright, ambitious, Culinary Institute of America graduates and their clever attorney managed to circumvent copyright statutes and opened Not Lundy's a few blocks further east on Emmons Avenue. It soon had a reputation for excellent food, good service, and although it lacked the charm of the original Lundy's it did accept reservations!

CHAPTER TWENTY-SEVEN

Allison knew the idea was crazy. She knew that Richards, the Pfizer attorney, wouldn't approve. He might even resign from the case and tell her that Pfizer would no longer represent her, that she'd have to hire a lawyer privately using her own money. There was the remote chance that the whole thing might backfire terribly, jeopardizing her future with the company. She mulled over the idea endlessly, finally concluding that she had to do it.

There was actually a listing in the Staten Island phone book for Joseph and Maria Bianchi. Allison called around 11 a.m., figuring Bianchi wouldn't be home. She was right. A woman answered.

"Hello."

"Hi, this is Allison Kincaid. Is this Maria?"

"Yes it is. What can I do for you?" Not 'how dare you call me at home,' or 'you have some nerve calling me.'

Allison was thinking that maybe Bianchi hadn't even told his wife of the altercation and the summons.

"I do some work at Maimonides."

"Oh, Joey mentioned that the department of medicine hired a new administrative assistant."

"No, that's not me. I work for Pfizer, the drug company. Twice a month I set up an exhibit near the lobby for the interns and residents to learn about our newest medications. Your husband hasn't mentioned that to you?"

"No, but that's not surprising. He generally tries to leave the hospital behind him when he comes home. We have enough to deal with here. So why are you calling me? Joey's probably at Maimonides right now."

It was obvious that Bianchi hadn't told Maria what had happened. Allison knew that what she said next would be critical to the success of her mission.

"Maria, Dr. Bianchi and I had a little misunderstanding the last time I was at the hospital." Alli gritted her teeth as she told that white lie. "I figured he would have told you about it but maybe not. One of the other doctors at Maimonides has a friend who remembers your husband from med school and Saint Vincent's and--I'm sorry Maria, I'm not making any sense."

"Are you having an affair with Joey?"

Allison laughed at the absurdity of the idea. "Oh God no, I'm sorry if you got that impression from my faltering. I swear that I've never touched your husband." Alli knew that the opposite wasn't quite true. "Maria, several of the doctors at Maimonides have noticed a change in Dr. Bianchi over the past few months. It's really none of my business but my argument with him the other day didn't end pleasantly and I'm wondering if there is anything going on at home that I can help with. I don't want to be responsible for his losing that hematology fellowship."

No sooner had Allison uttered those words than she realized she may have gone too far.

"Miss Kincaid, you're right. What's going on under this roof is none of your business. And for now I'll take you at your word that you're not sleeping with Joey. Now that you've upset me by suggesting the fellowship might be in jeopardy, why did you call? What do you want from me?"

"Please, meet me for lunch. I'm a good listener." Then Allison took the biggest chance of all. "I've got a feeling that you need to get something off your chest." Allison fully expected to have the phone slammed down after that brilliant statement. She held the receiver a few inches from her ear but there was no crashing sound, only a ten-second pause then,

"Continental Diner on Avenue M, noon on Monday. My mom can watch the girls for a few hours. And please, whatever you do, don't tell Joey I've agreed to meet with you."

"Of course I won't. Don't worry. I'm not crazy."

Although it was called the Continental Diner it served primarily American fare: burgers, shakes, tuna melts, french fries, etc., etc., and of course the soup du jour. It had about eighteen stools at a long counter and waitress service at two dozen or so tables and booths. The restaurant was always full at dinner time with families from the nearby apartment buildings on Ocean Parkway. At noon during the week it was just starting to fill up with the lunchtime crowd from the shops and stores along Avenue M. Several tables were generally taken up by the blue-haired ladies who had just spent the morning playing bridge or mahjong.

Allison arrived promptly at 12 p.m. and was asked by the hostess "table, booth or counter?" About half the tables and booths were already occupied and a few people were at the counter. Allison told the hostess that she was waiting for someone and that they would prefer a booth when her friend arrived. She didn't mind standing near the door until Bianchi's wife came in. It gave her time to peruse the restaurant's six-page menu.

She realized that Maria had no way of getting in touch with her if she would be late. By 12:20 p.m. Allison had looked at the menu ten times and her watch twenty. She checked her voicemail on a hunch that Maria had called Pfizer. No such luck. By 12:30 p.m. Allison figured that Maria was a no show and gave her business card to the hostess on the outside chance that a late-arriving Maria might still want to talk with her. As Allison started to leave a young woman got up from the stool she had been sitting on at the counter the entire time Allison had been at the restaurant. They couldn't have been more than fifteen feet from one another. She tapped Allison on the shoulder, "You must be Miss Kincaid. I'm Maria Bianchi."

Allison turned around, practically speechless. Standing there in front of her was an attractive, well-groomed, modestly made up, stylishly attired woman who could easily have been the owner of one of the nearby women's clothing shops. Allison finally stammered, "Why didn't you introduce yourself sooner? You saw me come in here half an hour ago."

"And why didn't you ask me if I might be Maria Bianchi? Not frumpy enough? Too buff to be the mother of three and long-suffering wife of bad boy Bianchi?"

Wow, was she ever right, thought Allison. "I'm sorry. Preconceived notions and stereotypes are really awful. Never in a million years did I think you could be Dr. Bianchi's wife. Please accept my apology. I don't want to get off on the wrong foot with you. I'm sure it took a great deal of courage for you to meet me in the first place."

Maria smiled and shook Allison's hand. "Apology accepted. Let's sit down and have some lunch. Can I call you Alli?"

"Please do."

With little prompting from Alli, Maria launched into an abridged version of the Joe and Maria story. They met at Richmond Hospital on Staten Island after Joey's first year of med school in Buffalo. She was finishing up her master's degree in special education and he was doing an elective in pediatrics. They spent a wonderful summer together and he proposed to her before he headed back up to Buffalo for his second year. He was successful in petitioning SUNY Buffalo to let him serve his third year of clerkships at SUNY Downstate. Maria secured a teaching job in Brooklyn and they got married midway through his third year. Jenna was born in October of his senior year.

Maria opened her wallet to show Allison some photographs. There was their wedding portrait. Despite five years and three pregnancies Maria hadn't gained an ounce. Bianchi had lots more red hair on his wedding day than he had now.

Maria flipped over the plastic sleeve and there was a recent photo of the three girls, each with red hair. There was no doubting who the papa was. The two little ones had goofy grins on their face; Jenna had a blank look on hers.

The fourth year of med school was fantastic. Joey took easy electives with no night nor weekend call and doted on his infant daughter like there was no tomorrow. He also found plenty of time for his bride as Maria's parents were willing and able to baby sit twice a week. What a glorious ten months. Joey was happy, Maria was happy and Jenna was thriving. Joey even got the internship he wanted at Saint Vincent's and Maria a part-time teaching job. As Maria started to put her wallet away, Allison espied her driver's license: she and Maria were exactly the same age.

Maria continued with her saga. Joey's internship was a lot harder than his senior year in med school. He had less time for Jenna but still managed to impregnate his wife. Jessica was to be born in the fall of Joey's first year of residency at Maimonides. About that time something happened to Jenna. Her speaking in short sentences ceased and then absolutely regressed to babbling. She stopped interacting with the other children in her play group. At first Joey blamed himself because internship and residency meant far fewer hours for him to be with his daughter than the last year of medical school. But Maria's training in special ed led her to fear the worst. Those fears were confirmed when she and Joey had Jenna evaluated by a specialist. The diagnosis was autism. Joey was devastated. His whole demeanor started to change. What didn't help were his parents giving him grief over the worsening condition of their granddaughter. They had never heard of autism and refused to accept that this could be the reason Jenna's behavior was deteriorating. Maria got pregnant again, with Joy being born a mere eleven months after Jessica.

Allison wondered how many times Maria had delivered this summary of the Bianchi family's woes. She was reciting it with such detachment. Almost on cue that detachment ended, "Alli, I don't know what you're thinking but let me tell you this. I love my girls dearly and don't regret for a moment getting pregnant with Joy, just as Jenna's autism diagnosis was being confirmed. I have always wanted three or four kids. So did Joey. I have always envisioned having my children early and then going back to teaching when they were in school. Can you imagine what this has done to Joey and me? Do you have any idea? He wasn't voted Intern of the Year at Saint Vincent's for nothing. Last year as his world came crashing in on him he told Dr. Greene what was going on. To this day I don't think he's told anyone else at Maimonides about Jenna. Thank God nobody was pining for the chief resident slot. In an attempt to give us some stability, Joey gladly accepted it when it was offered to him. It has been an incredibly tough slog. My parents have been great. Joey's folks are starting to come around. Joey has broken down and cried many times this year. That's not easy for a wife to see. He is a good man. We are good Catholics and I really believe we will get through this."

Maria dabbed at the tears that had welled up in her eyes and were now rolling down her cheeks. When she regained her composure she added, "I'm sorry to have laid all that on you just now. But you were right on last week--I did need to get some of that off my chest. Your turn now Alli--tell me about, as you put it, that little misunderstanding you had with Joey at the hospital."

Allison felt like the ultimate shit. Like she was really going to tell Maria half of what had happened, she thought to herself. But out loud she said, "You know Maria, in the long scheme of things, I think I've been making a mountain out of a mole hill. I mean Dr. Bianchi didn't even tell you about it. I tend to be a bit too sensitive and was having a bad day. We had some words. That was all. It's over. And let me reassure you again, nothing is going on between us."

"The lady doth protest too much, me thinks."

Allison giggled. "Hamlet, right?"

"Ah, a scholar too. Right you are," said Maria giggling.

"I believe I like you Miss Kincaid."

"I know I like you, Mrs. Bianchi. After all, we were born on the same day, same year!"

They passed on dessert and left the diner after giving each other a hug and a kiss. They promised to "do lunch" again sometime next month.

CHAPTER TWENTY-EIGHT

The agreement that Allison and Bianchi hammered out that Saturday was unique in both its creative process and final product. It was mostly Allison's idea and in fact she presented it to Ponce with neither Richards, Silver nor Bianchi interrupting.

In return for her dropping the charges of sexual harassment against Bianchi and Maimonides, Dr. Bianchi was to offer a public apology in Golden Auditorium to the hospital's nursing and house staff. No topic for the brief speech was to be advertised in advanced and it was to be scheduled for an hour that would maximize attendance by the nurses, interns, residents and fellows. Bianchi would not have to address the specifics of his conduct regarding Miss Kincaid but would "apologize for behavior not worthy of a highly visible member of the Maimonides family and not at all representative of the Maimonides mission." The only other requisite for Dr. Bianchi to have Allison drop the charges was his agreeing to see a psychologist or psychiatrist at least twice a month for the next six months. His acknowledgement of the need for this counseling could be omitted from his verbal apology. And that was it. Unlike General Patton's apology after he slapped the soldier suffering from battle fatigue, there was to be no press coverage or official account of Bianchi's short speech.

Ponce was somewhat incredulous as in all his years of mediating, his charge was to exact compromise after compromise from the warring parties until the deal was reached. Here was Miss Kincaid offering Bianchi a chance to avoid all sorts of misery. It seemed like a no-brainer. There was certainly no reason for Gerald Silver to object to the proposal as Maimonides would not be cast in any sort of unfavorable light whatsoever. Astoundingly, Bianchi said that he wanted to "think about it" and confer with his attorney in private. Ponce gave Silver a look as the attorney and client left the conference room for that private meeting in the hallway. Silver had no doubt as to what message that look conveyed.

In the hallway, Bianchi told Silver that his wife Maria had been begging him to "get some help." Maybe Miss Kincaid's proposal would make Maria happy in addition to saving his career.

"Deal!" Mr. Silver beamed as they reentered the conference room a minute later. Handshakes all around including a genuinely warm one between Allison and Bianchi.

What was left unsaid was why Allison had changed her mind. Eldridge Clever was right on, she mused.

CHAPTER TWENTY-NINE

Julie and Dionne checked their schedules and found a Friday evening where they both would be off duty. Julie picked her up at the hospital after sign-out rounds at about 6 p.m. and drove to Sheepshead Bay to meet Annie and Noah for dinner. Dionne was anxious to meet Julie's non-doctor friends. Julie was eager to debut his girlfriend. Whether it was needed or not he had given Noah a heads-up on Dionne.

Julie hadn't seen Noah in years and the two of them gave each other a bear hug when the couples met in the lounge at the restaurant. Dionne and Annie were somewhat more reserved with their greeting. They smiled and rolled their eyes when the guys started in with stories from their days at Brooklyn College and AEPi. Annie suggested that she and Dionne go powder their noses. When they returned five minutes later they already knew plenty about each other. Their table was soon ready and in seemingly no time a ninety-minute feast was about to be concluded with Not Lundy's signature dessert, Not Mud Pie. Two bottles of white wine had been consumed with dinner and the four of them were relaxed, enjoying each other's company when Noah suddenly doubled over in pain. He tried to laugh it off but Julie and Annie would have none of it.

The closest hospital was Coney Island Hospital. Julie drove Noah there and the girls followed with Annie driving Noah's car. Julie had phoned ahead to the radiology service and explained who he was and what he wanted. Maimonides and Coney Island Hospital actually had combined training programs in OB/GYN and pediatrics; it was not unusual for a house officer at one place to do some training at the other, even in medicine and surgery.

What Julie wanted was to have Noah x-rayed while he was having the pain. Unusual air/fluid patterns on a plane film of the abdomen, which could be done within a few minutes of Noah's arrival there, could then justify ordering a CT scan which might provide a definitive diagnosis.

As Julie pulled into the emergency room driveway Noah said, "Julie, you're not gonna believe this but the pain is gone. Poof. All of a sudden, it's gone!" Julie replied, "Good. But let's get that damn x-ray anyway." The x-ray was shot less than five minutes after the pain had disappeared and about twenty minutes after it had started. Julie and Dionne reviewed the x-ray themselves--they did not need a radiologist to tell them that it was normal.

"I'm sorry guys. We never got to finish that Not Mud Pie. Anyone want to go back there?" Nobody did.

Dionne tried to comfort Annie who had freaked out by her boyfriend's appearance when the pain began: pale, sweating profusely, and barely able to catch a breath. She pleaded with Julie, "Please help your fraternity brother. I've been hearing about these attacks but this is the first one I've seen and I don't want to see another. That Dr. Bloom Noah is seeing hasn't done a thing. Julie, please!"

The two couples walked to the hospital lobby. Julie explained as best he could exactly what expectant treatment was and that up until now Dr. Bloom's choosing that course of action made sense. But now that he witnessed the ten minutes of agony his friend had just suffered through, maybe something more proactive was needed.

Noah assured everyone that he felt well enough to drive and he and Annie went back to his place in Bay Ridge. He wanted to have sex but Annie was afraid the activity might precipitate another attack. Bummer! Now Noah knew for sure that this thing needed to be solved and ASAP!

Julie took Dionne back to his studio apartment in Flatbush. It was on Marlborough Road where fifty-year-old but well-maintained, six-story apartment buildings were lined up side to side. The nearby commercial areas were Cortelyou Road to the north and Newkirk Plaza to the south. Excellent restaurants with cuisine from far off places were opening on a weekly basis. This neighborhood was now superseding Brooklyn Heights and Park Slope as the "in" place to be, especially if you could not afford Manhattan. An express subway station at Newkirk Plaza meant you could be in Greenwich Village in twenty minutes and Midtown Manhattan in thirty.

Julie wanted to give Dionne a walking tour of the neighborhood Saturday morning when all the shops would be open. They'd both be due back at Maimonides Saturday evening. Dionne could tell that Julie was quite upset over Noah's mysterious malady. She could hardly believe it when Julie told her that by his estimate those attacks had been going on for about a year. Julie told Dionne what his idea was and that he'd bounce it off of Nat Bloom in the morning. Having a plan, even a preliminary one, made Dr. Berger feel a little better.

It had been too long since that wonderful weekend in New Hope; a night of passionate and acrobatic lovemaking would make him feel a whole lot better. Dionne was happy to provide just what the doctor ordered.

CHAPTER THIRTY

Dr. Ken Kirsch asked Nat Bloom why he thought he had pancreatic cancer.

"KK, I've been in practice over twenty years and have seen way too many pancreatic CAs. I don't know if it's the diet here in Brooklyn or genetics or smoking or a combination of the three but most of the ones I've diagnosed started out with symptoms just like mine. They all died within nine months of diagnosis. The only ones who made it were the few whose cancer knocked off the bile duct--they developed painless jaundice and had a chance for a cure with major surgery."

KK knew that Dr. Bloom was referring to a five- to six-hour operation involving the removal of part of the stomach, the duodenum, the part of the pancreas containing the cancer, and the delicate reimplanting of the bile and pancreatic ducts into a loop of small intestine. Newer surgical techniques and better postop care had improved survival statistics over the past thirty years but the diagnosis of pancreatic CA was still generally accepted as a death sentence.

KK asked Bloom, "What's your CA19-9? What did the CT scan show?" The former was a tumor marker which, although not specific for pancreatic CA, was generally elevated in the disease. The scan revealed the location of the tumor within the pancreas and whether liver metastases were present. In fact, Professor Randy Pausch from Carnegie Mellon University showed a slide of his CT scan as he opened his "Last Lecture" which detailed how he and his wife and two young children came to deal with the disease which claimed his life at age forty-seven. That last lecture was seen by millions of people on You Tube and remained a New York Times bestseller for months after his death.

Nat Bloom answered, "Well, the CA19-9 was minimally elevated and I haven't gone for the CT scan yet."

"Are you crazy, Nat?" KK yelled. "How can you be so sure you've got pancreatic CA without a CT scan or sky high CA19-9?"

"I just know. I feel it in my bones--figuratively and literally," he laughed. "Besides, I haven't gone for a scan here at Maimonides because I don't want everyone to know that I'm dying. I don't want to wind up looking like Randy Pausch or Patrick Swayze. I have checked my life insurance policy. They won't pay up in the event of suicide if it's within two years of the date coverage began. Well, guess what, I took that policy out three years ago so my wife and kids will be okay I guess."

"Nat, stop! You're talking like a mad man. You might be a great diagnostician but I don't see how you've concluded you have CA of the pancreas. Look, I know the chief of radiology at Brookdale Hospital. I took an elective there during my third year of medical school. Let me talk to him about Brookdale doing your CT. Nobody knows you there. Besides, they have a brand new sixty-four-slice rapid scanner that can do your study with a special pancreatic protocol with minimal radiation exposure."

"KK," Nat Bloom laughed again. "If I've got pancreatic CA, who gives a shit how much radiation I get from the CT scan?"

KK laughed too. Nat had a point. But he sensed that his mentor had blown this particular diagnosis big time. KK phoned Brookdale in Bloom's presence and easily got through to Dr. Brandon Suster, who remembered KK from that elective nearly three years previously. Suster agreed to personally guide Bloom through the registration process and he guaranteed that privacy issues would be respected in such a fashion that even HIPAA would be impressed.

The scan would be done in three days. KK got Bloom to promise that he wouldn't do anything rash in the meantime. Pancreatic CA was notorious for being heralded by depression, sometimes weeks or months before other symptoms became manifest. KK was hoping and praying that Nat Bloom's obvious depression had nothing to do with a possible intraabdominal malignancy.

CHAPTER THIRTY-ONE

It was approaching crunch time with Sissy Webster. Two weeks on the ventilator meant that the tube in her wind pipe might soon start to erode the tracheal rings. If her breathing didn't improve over the next twenty-four hours she might need a tracheostomy, something Cabot, Sissy and her parents would like to avoid if at all possible. But waiting too long to perform it could result in tracheal stenosis and a lifetime of breathing difficulties even if she completely recovered from the Guillain-Barré.

Dr. Greene was only one of three researchers in the States who had an Institutional Review Board approved clinical trial for the use of methoxy-psoralen in treating Guillain-Barré patients with persisting paralysis.

It was hoped that this chemical, a radical of the compound already used in treating resistant cases of psoriasis, when added to a patient's plasma and exposed to ultraviolet light might boost a column's ability to extract the proteins which were targeting myelin. Impaired myelin could not protect the nerves it was shielding and hence the resultant weakness and paralysis. But would it work? Dr. Greene agreed with Cabot that Miss Webster had reached a stage of illness stipulated in the protocol and that it was worth a try. Up until now it had only been studied in laboratory animals.

The research pharmacy carefully prepared the mixture, triple checked the dosage, and Dr. Cabot personally supervised its plasmapheresis, exposure to ultraviolet light, and reinfusion.

Improving tidal respiratory volumes would be the logical indication that the experimental treatment was working. No one had a clue as to how long it would be before the patient might demonstrate a beneficial effect, if at all.

Maybe because he had never used the compound before, maybe because it was Donald's sister, maybe because Charlie Cabot's New England veneer was being scraped off by the prospect of this pretty girl dying did he decide to keep a vigil at Sissy's bed side. He wanted to be the first to witness a miracle or be the first to announce its apparent failure. As it turned out, he didn't have long to wait.

CHAPTER THIRTY-TWO

Julie wanted to get Nat Bloom's okay on his plan to secure a diagnosis in Noah's case: although there was no particular rhyme nor reason to the attacks, at least two had occurred after overeating; once at his parents' apartment in Bensonhurst months ago and the most recent attack after the big meal at Not Lundy's. Julie suggested that Noah drink sixteen ounces of thin barium and then consume a large Maimonides Medical Center cafeteria dinner. If the meal precipitated an attack all Noah would need to do was hop in the scanner. There would be no need to waste precious minutes drinking additional contrast--the requisite barium would already be there. Nat thought the plan was well thought out and complimented Julie on it.

Dr. Berger needed to work on the logistics coordinating the ingestion of the barium with the lunchtime opening of the cafeteria and the availability of Dr. Sadeghi in radiology.

An almost party-like atmosphere existed as Julie, Dionne and Annie cheered Noah on as he drank the barium and then ate a hot open turkey sandwich with string beans and mashed potatoes and cranberry relish. A larger crowd than usual was in the cafeteria that day as Gabriel Levi was visiting Maimonides to inspect the laboratory facilities that were being constructed under his personal supervision. Noah polished off the meal with some ice cream and a large burp. But no pain. One hour. Two hours. He recalled his mother's expression about a watched pot never boiling.

By 3:30 p.m. it was apparent that Julie's great idea was a bust. He and Dionne were already back on the wards and Levi's entourage was long gone.

"Come on, Annie. Let me take you home. It was a nice try but it didn't work."

Just as the couple reached Noah's car, he stopped dead in his tracks. A grin and a grimace crossed his face simultaneously, "Annie, page Julie. Tell him I'm going to radiology. It's starting." Within sixty seconds Julie was on the phone with Dr. Sadeghi. She was waiting for Noah when he came running in. No forms to fill out--that could be done later. Noah was lying beneath the CT scanner exactly four minutes after the pain began. It was now intensifying. Paradoxically, he was thrilled with the anticipation that the end of this fourteen-month ordeal might finally be in sight.

Dr. Sadeghi entered the control room and looked at the preliminary films with Julie and Dionne. Julie pointed to something, "What's that?" with a bit of urgency in his voice. Dr. Sadeghi countered with a smile as she recognized the pattern evolving on subsequent cuts, "Very interesting!"

~~~~~~~~~~

Some fifteen miles away on the other side of the borough Dr. Nathaniel Bloom was about to undergo his own CT scan in the Brookdale Hospital's state-of-the-art, sixty-four-slice scanner. Dr. Suster personally started the IV for the intravenous contrast and saw to it that only sixteen ounces of thin barium were ingested orally. That's all they would need to best outline the target organ--the pancreas. KK had insisted on accompanying Dr. Bloom. The rapid-firing scanner finished the study in ninety seconds. KK was in the control room when Suster walked in with the early films. Bloom was slowly changing from the hospital gown into his clothes in the restroom down the hall. "Dr. Kirsch, look at that pancreas," Suster beamed, clearly impressed with the superior image quality of his new two million dollar scanner. "I don't think there is any doubt as to what we're dealing with here."

CHAPTER THIRTY-THREE

The head nurse in the ICU was Sandra Rogoff. Sandy, as everyone called her, started at Maimonides as a candy striper when she was a fifteen-year-old high school sophomore. She happened to be volunteering in the old decrepit emergency room when a young man was brought in by ambulance in full cardiac arrest. The paramedics had an IV in and were attempting to get air into his lungs with an AMBU bag. The EMT was thumping on his chest as the gurney was whisked into the Code Room. Sandy was mesmerized by what followed: endotracheal intubation, cardioversion, repeat cardioversion, and on orders of the emergency room physician, administration of intravenous medications with the eventual appearance of synchronized green blips on the cardiac monitor where a flat line had existed but a few minutes before. Sandy was hooked from that moment on. She knew she wanted to be an emergency room or ICU nurse and she never deviated from that goal. At Age twenty-six she had a bachelor's degree and a master's in critical care nursing and was the youngest charge nurse in Maimonides history.

She had probably spent more hours monitoring Sissy Webster than anyone, including Dr. Cabot. About thirty minutes after the reinfusion of the methoxy-psoralen-treated plasma, Sandy noticed that the patient-generated tidal volumes were increasing with practically each breath. She was savvy enough to hit the print button on the monitor so a record would be obtained. She turned to confer with Dr. Cabot. He had dozed off and was missing all of this! She looked back at the patient who was wide-eyed where she had been sleeping just seconds ago. Sissy took matters into her own hands--literally--and yanked out the endotracheal tube. Alarms went off and Cabot awoke with a start. For a moment he was disoriented and then that disorientation turned to terror as he saw his prize patient without an endotracheal tube and not attached to a ventilator. Sandy had to restrain him from doing something stupid.

"Charlie, stop. She's okay--she extubated herself--her color is great--she is breathing on her own. Look at her O2 sats. They're rising--94, 95, 96."

"When did all this happen?"

"Just within the last few minutes. Look, I've got a record of it. The tidal volume started going up--all generated by her own inspiratory effort about ninety seconds ago. You missed it; you fell asleep and missed it. But we got it all on paper. Charlie, the strangest thing--she looked at me with a look that said 'watch this' and pulled out the tube. It's like she knew what she was doing."

"I did know what I was doing," came a hoarse voice from the bed. "All of a sudden I felt stronger. I knew I didn't need that tube any longer. I hope I didn't mess things up."

Dr. Cabot smiled for the first time in days. This was nothing short of a miracle. Not only was Sissy improving by the minute but thanks to Sandy everything was fully documented. He couldn't wait to call Dr. Greene. Charles Cabot was already thinking ahead to the Society's annual meeting in a few months. Surely this case was worthy of a presentation during the Plenary Session. He gave Sandy and Sissy each a kiss on the forehead.

CHAPTER THIRTY-FOUR

June in hospital training programs is a time of flux. New interns fresh from medical school graduation are arriving with varying levels of skill and experience and new residents and fellows might be taking the place of doctors going to other training programs or out into the world of private practice. The only constant is the sick patient and the need for continuity of care.

The chief resident in medicine is usually someone from within the training program as was Joe Bianchi. But succeeding Bianchi this year would be Dr. Seth Rubin, an NYU medical school grad who had trained for three years at Sinai. He wasn't interested in a subspecialty fellowship but wanted the administrative and teaching experience a chief residency would provide. He was a fervent advocate of Tikkun Olam and was seriously considering working for the Joint Distribution Committee.

Tikkun Olam is a Hebrew term meaning "repairing the world." In order to overcome evil and injustice, Jews take it upon themselves to pursue thoughts and deeds which will help in achieving a better world.

One agency which helps to foster the concept of Tikkun Olam is the Joint Distribution Committee. It has been in existence since 1914 and its goals are rescue, relief, renewal and support of Israel.

It had also made headlines in helping non-Jewish causes such as the rebuilding of Rwanda and fostering relief in post- tsunami South Asia.

Although not orthodox by any means, Seth Rubin thought these were worthy goals to pursue and that's what he planned to do after the chief residency year.

Drs. Bianchi and Chief Greene were giving Dr. Rubin a tour of the facilities in late June. The three of them entered the medical intensive care unit and practically bumped into Sandy Rogoff. Rubin and Rogoff stared at each other with such intensity that Bianchi offered, "You two know each other?"

After several seconds' silence nurse Rogoff managed to stammer, "No sir. I don't believe we've ever met." Rubin confirmed that their paths had never crossed.

Chief Greene smiled broadly. Years of studying Guillain-Barré had not blinded him to the thunderbolt phenomenon.

CHAPTER THIRTY-FIVE

"Intussusception. That's what that is," said Dr. Sadeghi, pointing to the image on the view box. "An ileal-ileal intussusception." Both Julie and Dionne remembered the term from their rotation through pediatrics a few years previously. A portion of the small intestine was telescoping into itself, causing a temporary obstruction. So that's what had been causing poor Noah's attacks for the past year. When the telescoping reversed itself the attacks subsided and the patient might be symptom-free until the next episode.

Noah joined Drs. Berger, Clark and Sadeghi in the control room. They showed him the unmistakable "bulls eye" configuration on the images that made the diagnosis. Only one problem--and potentially a big one. In kids, intussusception was usually spontaneous; nothing led the telescoping except a very mobile intestine. In adults, however, some abnormality usually caused the intestine to practically turn inside-out as it telescoped. This abnormality could be something simple like a little fatty tumor called a lipoma or something more serious like a malignancy.

As good as Noah's study was in demonstrating the intussusception, it did not reveal what was causing it. Only surgery would.

Julie called Dr. Bloom and Dr. Reddy and brought them both up to speed. Reddy had this incredible brainstorm: Gabriel Levi was in town. He had his New York State license and provisional surgical privileges at Maimonides. Why not have Levi and him do the case together?

Julie reassured Noah that if the usually sedate Reddy was so forcefully vouching for Levi, then he must really be good. Minor problem. Noah had a stomach full of food and barium. No anesthesiologist would dare put Noah under for at least another six hours. Actually that would work out fine as Levi was to be guest of honor at a New York Surgical Society dinner in Manhattan. Noah called his parents and told them the story. The surgery was scheduled for 10 p.m.

At 9:50 p.m. Dr. Gabriel Levi came into the near empty lobby and introduced himself to Joan and Leonard Strong. He reassured them and Annie that he had reviewed the case in detail with Dr. Bloom and Dr. Reddy (who was already scrubbing up in the OR) and that Noah was in good hands. He would come out and speak with them immediately after the surgery.

~~~~~~~~~~

Meanwhile, Noah's physician, Dr. Bloom, was back home digesting the results of his afternoon CT scan. Dr. Suster marveled at the detail and clarity of the pancreas protocol. "No wonder they used to call the pancreas the sweet bread." He pointed out the delicate lattice work of lobules from the head of the pancreas to its tail. The gland was completely normal. Bloom felt relieved and chagrined at the same time. KK was not so kind. "You owe me big time for putting me through all this. Pancreatic CA, my ass. Here you were practically threatening to OD or blow your brains out because of a disease you don't even have. You're going to see Ollie Yocum ASAP--don't even think of giving me an argument."

Oliver Yocum was the geographic full-time chief of gastroenterology at Maimonides. He arrived at Maimonides just about the time Bloom was completing his residency. Yocum was a thinker who was not nearly so procedure oriented as his fellows might have wanted. They had given him the moniker "no scope 'em Yocum."

Bloom promised KK that he would call Yocum first thing in the morning. And then the realization that he might not be dying hit him like a ton of bricks. Dr. Bloom's hysterical crying forced KK to chauffeur him home in the Audi.

~~~~~~~~~~

Drs. Reddy and Levi entered the lobby waiting area about 11 p.m. They were still in scrubs and both of their caps were soaked through with sweat. Reddy played the straight man and stood expressionless as the world-renowned surgeon announced "What a great case." Not exactly what Noah's parents or Annie wanted to hear.

"It was a Meckel's," he continued. Julie and Dionne hugged each other with relief. Levi explained with great flare and diplomacy precisely what a Meckel's is. "It is the most common congenital abnormality of the gastrointestinal tract, effecting two percent of the population, twice as many males as females. But only two percent ever develop complications. The auto accident and the elbow in the solar plexus during that basketball game had nothing to do with it. This diverticulum is a little pouch about three to five centimeters long within the final two feet of the small intestine. For some reason, after twenty-odd years it decided to turn itself inside out and drag the ileum behind it with it. That's what was causing these attacks your son was experiencing for the past year. Sometimes these diverticula contain acid producing cells and a bleeding ulcer can result. Dr. Reddy tells me that one of the baseball pitchers with the San Diego Padres, Chan Ho Park, had this problem a few years ago."

Reddy remained in the lobby to answer a few questions while Gabriel went back to the surgeon's dressing area and changed into the Armani suit he had worn earlier in the evening. He could have been on the cover of GQ. "What a wonderful start to what I trust will be a long and successful tenure at Maimonides. I feel privileged to have scrubbed with Dr. Reddy on this most interesting case. Noah is quite fortunate to have you as parents and you three as friends." After handshakes all around, he was gone.

CHAPTER THIRTY-SIX

Drs. Cabot and Greene were amazed at Sissy Webster's progress. A day after she extubated herself she was walking, albeit haltingly. Her leg muscles were weak from nonuse, and not Guillain-Barré. The physical therapist had done a great job while Sissy was bedbound. Her professors at NYU were quite accommodating in allowing her to regain her strength and submit her papers and projects at the end of August, before starting her senior year. Cabot spent three full hours with Sissy the day before Donald came down to take her back to the Webster's summer place in Hyannis. The fellow in neuromuscular diseases was collecting every conceivable piece of data to demonstrate the dramatic effect of the experimental therapy. Sissy loved all the attention Charlie was paying her.

CHAPTER THIRTY-SEVEN

Joe Bianchi's mea culpa to the nursing staff, interns and residents was what Abe Lincoln thought his Gettysburg Address would be--"Little noted nor long remembered." But it satisfied the terms of the agreement. KK heard it from start to finish and told Alli that Bianchi really seemed sincere when he even added an apology to his absent wife and daughters--that he would try to be a better husband and father. Alli transmitted that promise to Maria the next time they had lunch at the Continental Diner. Joe had just started counseling and she would be joining those sessions when the psychologist said so. Even Jenna's downward spiral seemed to have leveled off.

~~~~~~~~~~

Angie Vitale-Schwartz, starting her third postgraduate year, wasn't sure what she wanted to do. Should she apply for a subspecialty fellowship and, if so, which one? She knew she didn't have the diplomatic skills or patience to be a chief resident. She doubted she would even be considered a viable candidate by Dr. Greene. The only subspecialty that vaguely interested her was gastroenterology. She worked out an arrangement with Drs. Greene and Yocum in which she would staff the weekly gastroenterology clinic for the entire year and follow inpatient consultations should they be readmitted for any reason. This way she could get a better feel for what a consultative GI practice was like and perhaps apply for a fellowship two years hence. Yocum had observed Angie's no-nonsense, cool-as-a-cucumber demeanor during her first two years at Maimonides. She knew her stuff, that was for sure. Perhaps the compassion she would need to acquire to successfully treat irritable bowel syndrome and diarrhea would smooth out the rough edges and round her into a more complete physician. Yocum was eager to see how the year would turn out.

CHAPTER THIRTY-EIGHT

Jeff Friedman had it all. A 3.92 GPA from Tufts from which he graduated summa cum laude just a month before, near perfect LSATs, a beautiful girlfriend and, most important of all, an acceptance letter from Yale Law. Not bad for a kid from Coney Island whose parents hadn't even gone to college.

Jeff and several of his buddies from Tufts celebrated their graduation by flying to San Francisco and then going river rafting down the Tuolumne, just west of Yosemite. The rafts flipped a few times and they all got soaked but they had a blast.

Jeff returned to Brooklyn where he was planning on spending the summer doing some research for a professor at the Brooklyn Law School.

But then the diarrhea started. At first Jeff figured he might have picked up a bug when his raft was submerged. He called his friends to see how many of them were sick. None were. The diarrhea worsened despite Jeff's eliminating dairy products and spicy foods. Then came the cramps, something he had never experienced before. He kept this all from his parents but when the bleeding started he tried to nonchalantly tell his folks that he had a "little intestinal ailment" and needed to see a specialist.

In twelve days he had gone from a perfectly healthy twenty-two-year-old to a young man having eight to ten bloody diarrheal stools daily. He had lost seven pounds and now his knees were hurting.

CHAPTER THIRTY-NINE

Dr. Julius Berger was feeling great at the start of his PGY3 year. Everyone involved in Noah's case gave him credit for the idea of the "megameal" which caused the Meckel's to intussuscept and helped generate a diagnosis. He and Dionne were having a wonderful time together, both in and out of bed. Her residency would mean less fatigue and more time off than the internship just completed. He was starting to envision a future with this young lady, something he could not have even imagined when he first met her during orientation twelve months ago.

~~~~~~~~~~

Joe Bianchi kept a low profile as he commenced his hematology-oncology fellowship. The division chief, Dr. Barbara Novack, was quite pleased with the feedback she was getting from patients and her own hem-onc nurses. Whatever problem or problems he was rumored to have had a few months ago had apparently been solved. A whole new crop of interns had absolutely no knowledge of the short-fused former chief resident.

~~~~~~~~~~

Dr. Cabot was busy collecting all the data from the Sissy Webster case. He was a bit surprised when a certified letter requiring his signature acknowledging receipt arrived from Sissy with a Hyannis postmark. Why would she have sent it certified? To say he was shocked when he read it would be an understatement.

~~~~~~~~~~

Alli and Maria continued their twice monthly lunch dates. They found that they had plenty in common besides a birth date. They were fast becoming good friends and confidantes.

CHAPTER FORTY

Dr. Oliver Yocum was examining Dr. Nathaniel Bloom when his office manager buzzed in on the intercom, "I'm sorry for interrupting Dr. Yocum but there is a young man on the line who sounds a bit frantic. You've never seen him or any family members before and..."

"Muriel, stop right there. Remember HIPAA statutes. Have Dr. Vitale see the patient this afternoon in the clinic. She can present his case to me then. Remind him that this is a teaching hospital and if he needs to be seen ASAP, that's how we'll do it. I don't care whether he's got private insurance or not."

Muriel confirmed that the arrangement was acceptable to Mr. Jeffrey Friedman and an appointment was made for 3 p.m. Dr. Angelina Vitale-Schwartz would see the new patient's name pencilled in on the printed clinic schedule a few hours later. It was a name she would never forget.

~~~~~~~~~~

Dr. Yocum finished examining Dr. Bloom and suggested they return to his consultation room to chat. It was similar to Nat's in terms of all the photographs of family and Maimonides honchos but it also had several intricate models of the digestive system, happily provided by various pharmaceutical companies in those halcyon days before the FDA and AMA put a stop to the practice, theorizing that these gifts might influence doctors' prescribing practices.

"Nat, I have gone over everything--your labs, the CT scan from Brookdale. I don't find anything that alarms me by my palpating your belly. Why did you think you had pancreatic CA--never mind. Don't bother telling me. When was the last time you saw a doc before me?"

"I don't know--probably around eleven years ago. I do get a yearly CBC, metabolic panel, PSA and lipid profile. They've always been okay until the low hemoglobin this year."

"Just what I thought. Another doctor who recommends a yearly physical--but not for himself. Look, Nat, I think we should do both an endoscopy and colonoscopy. My fellows would probably faint if they heard me recommending both to you. Your anorexia mandates that we look at your stomach. And although you're not of Irish ancestry, there is an entity called seronegative celiac sprue--so when I do the upper, I can take biopsies from the duodenum and rule that out."

"Okay, I'll buy that. But why the colonoscopy? My bowels are the only things that are working just fine. Maybe a little diarrhea but I'm not bleeding, my anemia is not iron-deficient and there's no family history."

"Nat, how old are you?"

"Come on Ollie, you know, forty-eight next month."

"Then you should have a screening colonoscopy."

"My insurance company will cover that when I turn fifty."

"And I'm sure the moment you hit fifty you'll come running to me--just like you've had an annual checkup by a nonexistent internist. Now tell me about that rectal bleeding you've been experiencing."

"What? I just told you I wasn't bleeding."

"Just a little blood on the toilet paper when you wipe?" Dr. Yocum asked with a wink.

"No I told you. Why do you keep asking me?"

"Let me spell it out for you Nat. You're insured with a company I've had multiple problems with over the years. I had a patient who went on a three-month round-the-world cruise on the QE2. It was her twenty-fifth wedding anniversary and her daughter had entered her parents' names in some sort of promotional contest for Cunard Lines. Well my patient wins the friggin' contest. But she wanted to go on this once-in-a-lifetime cruise knowing that her colon was okay. There was no family history, no bleeding, just a cancer phobia. So we moved up the date of her screening colonoscopy and my silver anniversary present to her was the good news that her colon was fine--just a few diverticula--no polyps, no nothing! Guess what? Those bastards at the insurance company wouldn't pay for the exam."

"Why not?"

"Because by moving the date up I wound up scoping her one week before she turned fifty, instead of one week after."

"And they refused to pay?"

"Yup--I took them to small claims court and the magistrate sided with them. Can you believe it?"

Dr. Bloom had never seen Dr. Yocum so incensed.

"That's why you're having a colonoscopy at age forty-eight Nat. Because you're bleeding. It's not a screening exam, get it?"

"Get it."

CHAPTER FORTY-ONE

The clinic nurse handed Dr. Vitale the face sheet on the new patient. He was a twenty-two-year-old Caucasian man with a chief complaint of bloody diarrhea. Angie surveyed the preliminary data which the nurse had obtained: height, five feet ten inches; weight, one hundred sixty-five pounds; blood pressure, 110/60; pulse, one hundred twelve; and temperature, 99.8.

She then entered the exam room and introduced herself. She tried to not be put off by Jeff's immediate question, "When am I seeing Dr. Yocum?"

Dr. Vitale explained that she would be taking a thorough history and doing a complete physical exam and then present her findings to Dr. Yocum who would make suggestions as to laboratory tests, x-rays, presumptive diagnosis and initial treatment.

Jeff acquiesced and apologized for possibly insinuating that Dr. Vitale wasn't up to the task.

"No offense taken," said Angie and she extended her right hand to formally make initial patient contact as she had done hundreds of times before. But Jeff's handshake, although strong, told her that his temperature was probably higher than the 99.8 on the face sheet. She made a mental note to check it again before she presented the case to Yocum.

She spent thirty minutes taking the history, learning that Jeff was of eastern European Ashkenazi Jewish ancestry. He had the usual childhood diseases, never had any digestive system complaints, and there was no family history of inflammatory bowel disease such as Crohn's disease or ulcerative colitis. He was a nonsmoker, nondrinker and was taking no prescription medications--just some over-the-counter Imodium because of the diarrhea.

The physical examination was limited a bit by Jeff's polite refusal to allow Dr. Vitale to do a genital or rectal exam. Angie didn't make a big deal out of it and just before she presented Mr. Friedman's case to Dr. Yocum she had a clinic nurse get a second set of vital signs. Blood pressure: 106/56. Apical pulse rate, now 120. And Angie was right about the temperature--it now registered 101.2. Angie sensed that this young man was really quite ill. She relayed her findings to Dr. Yocum with skill and aplomb, only occasionally referring to the notes she had taken. Even the patient was impressed with the clarity and accuracy with which this young female doctor had conveyed his story.

Yocum asked a few questions of his own and diplomatically asked Angie to leave so he could complete the physical exam. He told the patient that he and Dr. Vitale would confer for a minute or two outside and then come back in to the exam room and include him in the conversation. Dr. Yocum did his very best to hide the concern he was already feeling about this obviously very sick young man.

CHAPTER FORTY-TWO

One could not describe Sissy Webster's certified letter to Dr. Charles Cabot as anything but a mash note. She professed her deep love to "the knight in shining armor who saved her from the dragon of Guillain-Barré." It was eloquent but scary. It went well beyond what a grateful patient should say in a thank you. Her suggesting that the two of them rendezvous for a weekend on Martha's Vineyard that summer convinced Charlie of the inappropriateness of the entire epistle.

Of course he had noticed that she had matured into an attractive young woman but she was his patient, not his lover, and he knew that he did absolutely nothing that might be construed as taking sexual advantage of his position. He considered telling Donald about Sissy's letter but decided against it. What he chose to do was ignore it. Responding might unnecessarily fan some flames. Hopefully the passage of time and further recovery from the Guillain-Barré would enable Sissy to see how silly her fantasies and behavior were. So he had kissed her on the forehead. Gee whiz--he kissed Sandy Rogoff too. Sandy would certainly vouch for him if push came to shove. Now Charlie was angry at himself for that paranoid ideation.

CHAPTER FORTY-THREE

Dionne told Julie that her mom was throwing a surprise fifty-fifth birthday party for her dad in a few weeks and that she'd be delighted to have Dr. Berger attend the festivities.

Dionne was quite surprised by Julie's response. "I'd love to meet your family. Tell me when and where and I'll be there with bells on."

"Ditch the bells. And don't bring any wine or candy. My folks don't drink and they both have diabetes. A plant for the backyard would be a nice gift. Father is into gardening. Aren't you nervous about meeting them?"

"Should I be? Have you been telling them bad things about me?" he said with a smile.

"Of course not. But they sense there is something beyond finishing my internship that has me so happy lately."

"Dionne, listen. I've got to meet your folks sooner or later. This sounds like a great opportunity to meet them in a low pressure atmosphere. Will your sister be there?"

"She might have an audition--she's trying to change the date without ruffling any feathers."

"Don't tell me--it's with the Philharmonic."

"From you're lips to God's ears--gosh, that's an expression I picked up this past year from both the Jewish and Italian patients at Maimonides. Let me tell you some others--rachmones--that means compassion; nishtkefelecht--that means no big deal; and shul means synagogue. And of course there's the one that you taught me--shtup. And finally, the one that I've heard several patients state in referring to me--schvartze. Anyway, my sister is auditioning with a small group in Boston--they need a flutist."

"Dionne," Julie said with concern. "Do you know what that term means, schvartze?"

"It's a black person--I'm a schvartze."

"No you're not. It's a very derogatory term for an African-American. Its vulgarity approaches that of the N word. Don't ever refer to yourself as a schvartze--that's awful. Whoever called you that is a bigot. It's worse than calling a Jew a kike or an Italian a whop."

"Okay, okay. I hear you loud and clear. I thought it was a term of endearment. Some old guy, a patient from Brighton Beach, called me his little schvartze a few months ago."

"Trust me, it's not a term of endearment."

CHAPTER FORTY-FOUR

Angie Vitale had not seen a case of fulminant ulcerative colitis in her two previous years at Maimonides. Ollie Yocum had seen dozens during his training at the Cleveland Clinic and dozens more since coming to Maimonides in the 1980s.

Dr. Yocum reviewed the preliminary lab data on Jeff Friedman with Dr. Vitale. The WBC was elevated at twenty-two thousand, indicating severe inflammation and/or infection. The hemoglobin was 11.5, demonstrating a mild anemia. An oldie but goodie called the sed rate was fifty-eight with the normal range being zero to twenty. The albumen was slightly depressed suggesting impending malnutrition.

As Yocum pointed out to Vitale, these lab values did not make the diagnosis--they merely confirmed their clinical impression that Mr. Friedman was in need of urgent hospitalization--now. No life and death list for him.

Despite millions of dollars spent yearly on the study of ulcerative colitis, a definite cause has never been proven. A combination of hereditary and environmental factors is thought to play a role. Jeff Friedman was of eastern European Jewish ancestry and the disease is more common in this group than others. No one is sure why. Jeff also fell into the typical age group (fifteen to thirty) when patients suffer their first attack. Again, no one is sure why.

Yocum knew that this would be a great teaching case for Dr. Vitale. He assured Angie that the next few days would be stressful for both of them and difficult for the patient but that with attention to detail she would learn more about the management of a patient with fulminant colitis than some folks do during a two-year gastroenterology fellowship. The first order of business was accomplished surprisingly easily: one phone call by Yocum to the admitting office and presto--a bed materialized in the intensive care unit.

~~~~~~~~~~

The chief medical resident, Seth Rubin, made more visits to the intensive care unit than good patient care and administrative duties demanded. When Sandy took her break, Dr. Rubin was there. Whereas Sandy had previously eaten her lunch in the ICU staff lounge, she was now spending her lunch half hour in the cafeteria with Dr. Rubin. The nurses who worked under her in the intensive care unit had never seen her so cheerful and they were happy for her. After all, she had always treated them (she referred to them as "my girls") fairly and never played favorites. She devised a plan for handling the scheduling requests of nurses that was so simple yet so good that it was soon adopted by the other special care units throughout the hospital. She herself worked a week of nights every other month so she could keep in personal touch with what unique problems her nurses had to deal with on the graveyard shift.

Although Seth was new to Maimonides, his friendliness was in sharp contrast to Dr. Joe Bianchi. Seth attended morning report daily and had constructive recommendations re the cases that were presented. He was rarely critical. KK and Julie Berger and Dionne Clark and the other residents thought that Maimonides had lucked out by getting him. The fact that he and Sandy were hitting it off so well made them like him even more as they were all quite fond of Sandy. There was a hit song from the 1950s, "Everybody Loves a Lover," that Doris Day recorded--everyone at Maimonides from the new yommie interns to the senior attending physicians could see a romance blossoming in their midst. The song had it right: everyone smiled when they saw Seth and Sandy together.

CHAPTER FORTY-FIVE

Jeff Friedman was admitted to the intensive care unit with a diagnosis of toxic colitis. He was less than half the age of the other patients in the unit who were there because of heart attacks, strokes, and exacerbations of emphysema. His admission orders were written by Dr. Vitale and checked by Dr. Yocum. He was to be NPO (nothing by mouth) and had stools sent to the laboratory for culture. Two-view (supine and upright) x-rays of the abdomen were to be done and intravenous fluids administered. Two intravenous antibiotics were to be given and intravenous steroids were to be started with a very high dose of methylprednisolone. Dr. Yocum performed a limited sigmoidoscopy at the bedside: clearly a colitis. He did some biopsies from the inflamed rectal mucosa.

Yocum reasoned that Dr. Vitale's coolness under fire would be invaluable. He had Angie read up on toxic colitis and answer Friedman's questions at the bedside. She handled the assignment flawlessly--not only with the patient but with his parents. She rattled off pertinent statistics and detailed what Dr. Yocum's game plan was for the next forty-eight hours in managing this serious illness. She planted the seed that emergency surgery might be necessary if Jeff's condition worsened despite a full-court press. Jeff's father, a big-time Knicks fan, appreciated the basketball analogy. Jeff and his parents were starting to trust Dr. Vitale and she sensed that with her commitment to gastroenterology for the coming year an important doctor-patient relationship was being forged.

Empathy and compassion were not qualities you acquired from reading The New England Journal of Medicine.

~~~~~~~~~~

Sandy Rogoff's parents were justly proud of their daughter. Their only regret these past few years was that Sandy had virtually no life away from nursing--first her studies including summer school and then the multiple seminars that allowed her to secure her master's degree at such a young age.

When Sandy told them about Seth Rubin they were thrilled. They allowed themselves one week of happiness before they started to worry how crushed Sandy would be if Dr. Rubin dumped her. They worried that he might be pressuring her sexually and then they worried that she might get pregnant. In short, whatever could conceivably go wrong with their daughter's nascent love life they worried about.

Sandy was still living with her parents. Room and board and laundry were three items she rarely had to think about. Privacy had never been a concern as there hadn't been a suitor of any sort until now. Sandy was a virgin and other than some passionless groping by a boy in high school on a blind date eight years ago, she had virtually zero sexual experience. There were fantasies and romance novels ("with bodices torn asunder") but never the real thing--not even close. She needed to talk with someone who 1. would appreciate her predicament and 2. give her some practical advice.

Seth had been an absolute doll up until now--a gentleman with smarts and a sense of humor. But Sandy knew that their relationship would and should soon be progressing to include some physical intimacy. Heck, she wanted it to. She just didn't want to be a complete klutz between the sheets.

CHAPTER FORTY-SIX

By the morning of day three in the hospital's intensive care unit--sixty hours since admission--Jeff Friedman's condition had not improved. He was still tachycardic with a pulse rate of one hundred twenty, still febrile to 100.4 degrees, but now his abdomen was ominously silent with an actual decrease in the bloody diarrhea. Dr. Yocum pointed out some worrisome findings on the abdominal x-rays. Radiographs were very important now as the high-dose steroids could mask signs of inflammation that might otherwise appear if the colon suffered a perforation. Thus, the order for twice daily x-rays. It would border on malpractice to delay emergency surgery because a perforation went unrecognized.

It looked as though the steroids were not working. The only other medication to try now was intravenous cyclosporine--a powerful immunosuppressant agent that had significant kidney toxicity. Its beneficial effect was usually noted within two to three days, much sooner than the month generally needed for the other immunosuppression drugs, Purinethol and azathioprine, to demonstrate any improvement. With Yocum's approval Angie called in a surgeon to consult on the case. Dr. Gabriel Levi and his new associate, the former Chief Resident Lenkala Reddy, responded promptly. A bedside conference was held between the patient, Yocum, Vitale and the surgeons. Just a few weeks ago Jeff was having the time of his life river rafting down the Tuolumne. Now he couldn't believe what these doctors were recommending--that if there were no improvement after forty-eight hours on the cyclosporin the surgeons would be forced to remove his entire colon. They were not concerned about Jeff's starting at Yale Law being in jeopardy. They were concerned about Jeff's life being in jeopardy should that colon perforate.

CHAPTER FORTY-SEVEN

Former Playboy playmate, Jenny McCarthy, had a young son with autism. She wrote a book about it and went on the talk show circuit and spent many months researching the disease. She like many others concluded that the multitude of early childhood vaccinations might be the reason so many more cases were being reported in the past twenty years. Because of her brains, eloquence and continuing physical beauty her slant on autism was being detailed in supermarket checkout stand magazines as well as more reputable venues.

Maria Bianchi spent hours learning about autism. Thanks to sessions with his psychologist, a much more docile Joe Bianchi actually encouraged his wife's research and occasionally brought home the most current pediatric literature on the subject.

They started Jenna on a special diet--cutting way down on wheat and dairy. Maria wasn't about to try some of the really crazy cures offered by the scam artists to desperate parents. Some of these included Lupron, a drug that was ordinarily used for treating prostate cancer, chelation therapy, and hyperbaric oxygen. They all had testimonials on very slick web sites. Through her contacts in special ed circles, Maria was able to secure the latest information on cognitive psychology techniques that might allow them to get through to Jenna. It could have been all consuming but Maria made sure she and Joe made time for themselves and Jessica and Joy. Those lunch dates with Allison Kincaid twice a month were a godsend.

CHAPTER FORTY-EIGHT

It wasn't at all unusual for Mr. and Mrs. Clark to catch a Saturday afternoon movie. They would ordinarily go out for a quick bite afterwards but Helen told Malcolm that they needed to go home first as she had forgotten her reading glasses. Malcolm didn't have a clue as to what was going on in their little house on Bedford Avenue.

As they entered the foyer, thirty people jumped up and shouted "Surprise, Happy Birthday!" Mr. Clark was genuinely surprised. Helen and Dionne had coordinated things perfectly. There in his living room were friends and family and colleagues from work. There was a young man whom he had never met before but it had to be that doctor at Maimonides that his daughter couldn't stop talking about. He stepped forward and offered Julie his hand, "Hi, I'm Malcolm Clark--Dionne's father."

"Hello sir. I'm Julius Berger. I've had the pleasure of working with your daughter this past year. You and your wife have raised a very special young lady. Happy Birthday."

The fare at the party was Middle Eastern--humus, baba ghanoush, lamb, shawarma, and for dessert baklava. The Aladdin restaurant on Flatbush Avenue was known for its exquisite catering and no one was disappointed.

Julie mingled extraordinarily well with the other guests. They knew that this was Dionne's boyfriend. There was no tension, no whispering, no pointing and everyone managed to chat with Julie during the party. About the time half the guests had left Malcolm Clark pulled Julie aside and asked, "Does the name James Chaney mean anything to you?"

"It strikes a dull bell. Tell me who he is."

"How about the names Andrew Goodman and Michael Schwerner?"

Now Julie knew who Chaney was. "Goodman and Schwerner were Jews from New York who joined up with Chaney, a black student from Mississippi, in the early 60s to help increase voter registration. They were murdered by the Klan. Why do you ask me about them?"

"Chaney was my cousin. He was about ten years older but he always had time to inquire as to how little Mal was doing. We were all devastated when he disappeared."

"As I recall the three of them were tortured before they were killed. It was awful. Didn't they just convict the mastermind of the whole plot?"

"You've got a good memory, Julie. Yes. Edgar Ray Killen was indicted for the murders and the Mississippi Supreme Court reconfirmed the manslaughter verdict for that bastard. He is around eighty now and will probably die in prison."

"I'm sorry for your loss."

"And I'm sorry for yours."

"Sir?"

"Goodman and Schwerner. They were Jewish. They were killed trying to help black folks obtain basic civil rights. My people and yours have a lot in common in the persecution arena. I've read several books on the Holocaust. Almost impossible to comprehend that such evil existed."

"And still exists today."

"Amen. Tell me Julius, are you religious?"

Julie figured he'd be asked that question sooner or later. "Do I believe that there is a supreme being up there ultimately controlling what transpires down here? No. I went to Hebrew school two afternoons a week and Sunday mornings for four years where I learned about Jewish history and culture. I'm very proud of my heritage. I love the Jewish holidays where we celebrate that heritage, especially Chanukah and Passover. I love our passion for trying to improve things--to right the wrongs we witness in our own communities and across the globe. We're only two percent of the population in the United States but we have a much larger profile than that in education, medicine, the arts, entertainment, finance and politics. I imagine that Goodman and Schwerner and many other Jews were active in the early civil rights movement because they knew that confronting discrimination was the only way to overcome it. I may not go to synagogue as often as I should but my parents' and grandparents' bequest of Judaism is safe with me."

Malcolm Clark smiled and put his hands on Julie's shoulders. "Be honest young man, you rehearsed that before coming here."

Julie smiled back, "All except the part about Goodman and Schwerner. You gave me that one."

And the two of them laughed a laugh that was heard across the living room. Dionne and her mom came over inquiring as to what was so funny. Her father replied, "Private joke young lady. But I can see why you like this guy so much."

Amazing, thought Dionne. Julie had won over daddy in just a few hours. Mom liked Julie from the moment she met him--twenty-six years ago!

CHAPTER FORTY-NINE

It was a tossup as to who was more nervous on the morning of day three of Jeff Friedman's cyclosporine therapy--the patient or his doctor. Jeff felt no worse and perhaps just a bit better as he now had some hunger pangs. He could tell them apart from the ulcerative colitis cramps. But he had been told that all bets were off as to subjective findings dictating decision-making because of the high dose of steroids which could cover up a multitude of disasters.

Angie made the ICU her first stop on morning rounds. Jeff's WBC had dropped, the sed rate had dropped, and the hemoglobin was holding steady. She reviewed that morning's x-rays with the early bird radiologist and there was definite improvement.

She bounded into his room with a smile on her face, "Mr. Friedman, the objective parameters are looking better. How do you feel?"

"I'm hungry for the first time since I was admitted."

"That's a good sign."

Dr. Vitale put her stethoscope on the patient's belly and smiled. "I hear bowel sounds. That's good too. I think we may have dodged a bullet here. Let me check with Dr. Yocum about giving you something to eat."

So Dr. Vitale and her patient had successfully withdrawn from the precipice--this time. Dr. Yocum warned her not to get overly optimistic--that ulcerative colitis was very unpredictable and that Mr. Friedman was bound to have something other than smooth sailing over the next year.

Actually, Jeff's condition improved so dramatically that he was able to go home from the hospital five days later on a tapering dose of steroids and oral cyclosporin in addition to Lialda, a new gel matrix formulation of mesalamine, the medication that for decades had been a mainstay in the treatment of ulcerative colitis. Jeff was still hopeful of starting law school in a few weeks.

~~~~~~~~~~

Just a few hours after Jeff Friedman went home with his parents, Dr. Bloom entered the outpatient endoscopy suite for his procedures. His wife accompanied him. Yocum reviewed with the two of them his reasons for doing both procedures. Nat wondered aloud why the fellows called Ollie "No Scope 'em Yocum" when he was about to be hosed from both ends. The endoscopy, maybe because the anorexia and weight loss. But there was no real justification for the colonoscopy which was really a premature screening exam. Like most patients, Nat complained about the gallon of that salty solution he had to drink the night before to clean out his colon. Its pineapple flavoring did little to conceal the taste.

Ollie kept his promise to Nat and Norma that he would personally be performing the exams, not the GI fellow. Dr. Yocum administered some intravenous fentanyl and intravenous midazolam after the endoscopy nurse did a "time out" to make absolutely certain they have the right patient on the examining gurney. This seemed a bit silly as Yocum had known Bloom for twenty years but he went along with this charade of properly identifying the patient rather than incur the wrath of the outpatient nursing supervisor.

Dr. Yocum paged Angie and suggested she observe the procedures. The GI fellow would be there too.

The proper titration of the medications had rendered Dr. Bloom sedated but conscious. The midazolam had a terrific amnesic effect and Bloom was unlikely to remember anything about the procedures.

Yocum expertly passed the endoscope into the esophagus which appeared normal. So did the stomach--no gastritis nor ulcers nor tumors. As he maneuvered the scope into the duodenum the GI fellow piped in, "That looks a bit unusual." Yocum countered, "Sh," and asked the endoscopy nurse for the biopsy forceps. He took several photographs before he took multiple tissue specimens. He told both Angie and the GI fellow that he'd go over the findings with them after both procedures had been completed, while Dr. Bloom was in the recovery room.

After he withdrew the endoscope, Yocum assisted the endoscopy nurse in turning the gurney around for the colonoscopy. He administered just a bit more midazolam and introduced the colonoscope into the rectum. At least Nat did a good job getting cleaned out. The prep was very good. Visualization was excellent and Nat's colon was easy to negotiate. As he rounded the hepatic flexure and peered down into the ascending colon, the image on the monitor was crystal clear. Even Angie knew what it was. There, adjacent to the appendix was a two centimeter fungating tumor.

"Shit," said Yocum under his breath. Dr. Bloom's got colon cancer!"

CHAPTER FIFTY

Dionne had just finished writing some orders on an ICU patient who had been admitted the night before with chest pain and an abnormal EKG. The cardiology fellows had been consulted and would probably be cathing him before noon.

Sandy Rogoff tapped Dr. Clark on the shoulder, "Can I ask you a few questions?"

"Sure, this guy's pretty stable. What's up?"

"No, I mean in private. It's not about this patient. It's personal."

Dionne liked Sandy a lot. She had little clue what might be bothering her. Like practically everyone else at Maimonides she gathered that Sandy was madly in love with the new chief resident, Seth Rubin.

Dionne and Sandy went into the staff lounge which was empty. Sandy barely spoke above a whisper. "It's about Dr. Rubin and me."

"You seem so happy together. Is there a problem?"

"No, he's wonderful and we do have strong feelings for each other."

"So what's the problem?"

"I think he's thinking about suggesting we have some sex."

Dionne was taken aback. "Sandy, you've been hot and heavy with this guy for weeks now. You mean you haven't been intimate?"

"No we haven't. We've barely spoken about it. I told him I was a virgin and I'm worried that he might be wondering why rather than looking forward to being the one! I'm also worried that he'll be disappointed in me as a lover."

"Sandy, you worry way too much. I think he'd be thrilled to teach you a few things. He certainly doesn't seem like a bull in a china shop. Trust me, guys like being in control, or at least thinking they're in control. The two of you should go away for a weekend--get away from here. There's a lovely bed and breakfast in New Hope, Pennsylvania I can personally recommend."

"Is that how you and Dr. Berger did it?"

"Excuse me?"

"I'm sorry, that was really dumb of me to say that. Please forgive me."

Dionne softly put her hand under Sandy's chin. "Sandy, if you and Seth have half the fun and give each other half the pleasure Julie and I experienced a few months ago, you will have had an unforgettable weekend. And I haven't used the future perfect tense since my senior thesis at Simmons!"

Sandy laughed, "Dionne, thank you for listening. And FYI, I think you've got quite a catch there in Dr. Berger."

"So do I. Now let me know if you two plan on going to New Hope."

CHAPTER FIFTY-ONE

Once again a thought entered Allison Kincaid's mind and wouldn't leave. She sensed that this idea was crazy too but meeting Maria Bianchi a few months ago had worked out just fine, hadn't it?

"What's wrong, Alli," Maria asked as she watched her friend poke at a small piece of apple pie. "It's not stale is it?"

"No, it's plenty fresh. That's not it. I have been thinking..."

"Uh oh, when Alli Kincaid thinks it's usually a whopper," she laughed. "Tell me, what is it?"

"I'd like to meet your little girls--all of them."

"I think that's something I'd have to clear with Joe. He already knows you and I are friends."

"What?"

"Alli, I had to tell him. Jenna's illness--I can say it--Jenna's autism has brought us closer together. We're not hiding things from each other like we were a few months ago. He has known for five or six weeks that we have lunch on a regular basis."

"And?"

"He is okay with it. He has told me all about the sexual harassment charge and how it was then your idea to withdraw the charges. Forcing him to accept counseling probably saved his job and maybe our marriage. So if I haven't formally thanked you for all of that, let me do it now. Only one thing."

"What's that?"

"Actually, Joe and I were talking about it last night. You're bright and beautiful and ambitious. You didn't get to where you are by being miss goody two shoes. Why in the world are you being so nice to the Bianchis? Don't get me wrong. I love you like a sister. You're certainly not responsible for Jenna's autism or whatever problems we might be having as a result. It can't be guilt. And now you want to meet my girls. What gives?"

"Maria, don't you think I've asked myself those same questions?"

"And did you discover an answer?"

"Yes I did--human nature."

"You'll have to do better than that."

"I spent my junior year in college in Paris at the Sorbonne, studying nineteenth century French playwrights. My faculty advisor at Princeton recommended that course. It was terrific. Those few weeks enabled me to become fluent in French."

"Alli, what does this have to do with the price of tea in China?"

"Oops, sorry for wandering, but I reviewed my notebooks from that course and came across the answer to your question. I remember it being very profound then and even more so now."

"What are you talking about?"

"There was a playwright in the middle of the century whose name was Eugene Labiche. Most of his plays were about the middle class. There is a famous line from one of them--pardon my French accent--'Les hommes ne s'attachent point à nous en raison des services que nous leur rendons, mais en raison de ceux qu'ils nous rendent.'"

"Which means?"

"It loses something in the translation but basically it says that we don't really befriend those folks who have helped us but rather those people whom we have helped."

"I see. So it makes you feel a little bit better about yourself because you have helped Joe and me?"

"Yes--is that so terrible?"

"Of course not, unless you're expecting something from us in return, which obviously you're not."

"Maria, there's a resident at Maimonides, Dr. Ken Kirsch. Everyone calls him KK. I'm sure Joe has mentioned his name to you over the past two years. He's bright and funny and insightful and we've had lots of long talks about life and love, including my relationship with you and Joe."

"And?"

"Well, he thinks this WASP from Rhode Island probably has some Jewish blood in her. He is always kidding me about how I'm scheming to help the Bianchis. He calls it my own personal tikkun olam."

"Your what?"

"Tikkun olam. It's a Hebrew expression that means to make the world a better place."

"Heavy. If your meeting Jenna and her sisters will further your own personal Tikkun olam, I'm all for it. Just let me double check with Joe, okay?"

"Okay."

CHAPTER FIFTY-TWO

Immediately prior to the procedures, Ollie Yocum had secured Nat's okay to discuss the endoscopic findings with "a responsible adult" afterwards. The patient was, of course, always part of that discussion but the amnesic effect of the sedative medication frequently resulted in patients being taken home by this responsible adult but not remembering a thing about the procedure (which was good) or the conversation afterwards (which was not so good).

Nat was chatting with his wife, Norma, in the recovery room consultation alcove when Ollie came in.

"Nat, there's no way I can sugar coat this. There is a lesion in the cecum. I'm sure it's a CA. We will have the biopsy results back within forty-eight hours but there's an operation in your future. The good news is that the Brookdale CT scan got a good look at your liver and upper abdomen and there is no evidence of any mets."

Nat stroked his wife's arm as she started tearing up. "And those other weird symptoms--do you think they're part of a paraneoplastic syndrome?"

"Could be, but I haven't seen your particular constellation of symptoms with a small colon cancer. Certainly not the arthralgias in your hands."

"Leave it to an internist to have something unusual. And the upper?"

"Geez, I almost forgot. No ulcers or gastritis but your duodenal mucosa looked a little funky. We did some biopsies there too."

"Come on Norma, take me home. I'm hungry and the good doctor here says I can eat whatever I want, right?"

"Right, but keep the portions small until tomorrow."

"Killjoy."

CHAPTER FIFTY-THREE

Charlie Cabot received another mash note from Sissy. At least this one wasn't sent certified but it did ask why he hadn't responded to the first one. In the interim, Charlie had researched the subject. The prohibitions about doctor/patient liaisons varied from state to state, but all agreed that a psychiatrist could never become involved with a patient, past or present. For other practitioners the rules were a bit fuzzy but generally speaking allowed a "personal relationship" provided that no contact between the parties had occurred for at least two years since the last "professional" encounter. It was expected that the treating physician would make "every effort" to find another doctor to tend to the patient's medical issues once any hint of a budding romantic relationship developed.

Charlie liked the Websters. Heck, he liked Sissy when she was a tomboy but never thought of her as anything but a sick patient when she was paralyzed from the Guillain-Barré. These two letters were textbook transference. He decided that he had to talk to Donald. They spent an hour on the phone with Charlie trying to explain what he thought was going on with Sissy without resorting to jargon and psychoanalytical babble.

"Donny, I hope this doesn't affect our friendship or our families'. Whether I like your sister or find her attractive is not the issue. Technically, I just cannot have any contact with Sissy for at least another twenty months or so. Please explain why to her. There's a neuromuscular specialist at Massachusetts General Hospital that I've spoken with who can see her if any medical problems develop."

Donald assured his friend that he understood the predicament that he was in and that he would have a long heart-to-heart with his kid sister.

CHAPTER FIFTY-FOUR

Dr. Vitale saw Jeff Friedman in the GI clinic twice that summer and once just before he headed off to Yale Law. He had gained back half the weight he had lost and was now done with the steroid taper. The cyclosporine had been discontinued and in its place another immunosuppressant agent, 6-mercaptopurine, had been started. Dr. Yocum had recommended that Jeff continue taking Lialda, the mesalamine product. Only two to three caplets daily would be necessary and Jeff could take them all at the same time. That was bound to improve his compliance as the older mesalamine products needed to be taken several times daily, something a busy law student might forget. A blood test would need to be done monthly to make certain the 6-mercaptopurine wasn't wiping out Jeff's bone marrow or the Lialda Jeff's liver. Angie contacted Student Health Services at Yale and everything was arranged.

Jeff was still not feeling a hundred percent but with each passing week he was regaining his strength and figured he was ready for the rigors of an L1 at Yale. Dr. Yocum was thrilled to find out that Angie had given Mr. Friedman her cell phone number. Dr. Vitale was becoming what her Jewish patients would call a mensch.

~~~~~~~~~~

The inflammatory bowel disease researchers continued to disagree on the roles environment and heredity played in the cause of ulcerative colitis and in its response to treatment. Why did some patients dramatically improve when treated while others, given the identical therapy, fail to improve? Why did some patients go into a prolonged remission after one attack while others had multiple flares and occasionally ones so severe that hospitalization was necessary? Ollie Yocum was fascinated by all this. He received IRB-approval to research the hereditary aspect of his ulcerative colitis patients. He read about a private company in Mountain View, California named 23 and Me. (We all have twenty-three pairs of chromosomes.) This company had been awarded Time Magazine's "Invention of the Year" for "pioneering retail genomics." What they did was sequence any person's genome provided you pay them three hundred ninety-nine dollars and submit a vial of saliva from which they extracted your DNA.

Yocum contacted them and got them to lower their price to two hundred dollars in return for his sending them hundreds of saliva samples and promising them a coauthorship if the data generated seemed worthy of future publication in a peer-review journal.

Jeff Friedman and his parents were very happy with the care he had received. It was the least he could do to furnish Dr. Yocum with a vial of his spit before heading off to New Haven.

~~~~~~~~~~

Dr. Yocum was interviewing an applicant for the following year's fellowship slot when Muriel, his office manager, buzzed in, "I know you asked that I don't interrupt but Dr. Yermakov is on the line and he says it can't wait."

Dr. Alexy Yermakov was one of the senior pathologists at Maimonides. He had defected prior to the collapse of the Soviet Union and was acclaimed as one of the most astute GI pathologists in the world. He was quite a catch for Maimonides and, although nearing eighty, continued to work two days a week and consult on the more perplexing cases. Ollie Yocum picked up the phone, "Hi Alexy, good to hear from you. What's up?"

"Very interesting biopsy on Dr. Bloom."

"What's so interesting about a colon cancer? You've probably seen thousands."

"Not the colon, Oliver. The duodenum. The duodenum."

"You mean Nat's got sprue? I thought that was a possibility but..."

"No, Oliver, it's not sprue. Vy don't you come down to the lab and look at the slides vith me."

Oliver Yocum chuckled. Alexy always reverted to a Russian-accented English when he got excited. Dr. Yocum suggested that the fellowship applicant tag along. He paged Dr. Vitale and told her to meet them in Yermakov's office.

~~~~~~~~~~

Dr. Yermakov warmly welcomed Drs. Yocum, Vitale and Smith, the fellowship applicant, to his office. It wasn't often that he had visitors. He asked Yocum to sit at the double-headed microscope but Angie requested that she get to look at the slides first, "I earned some extra money in the histology lab at Rutgers when I was in med school. Let's see if I remember anything."

Dr. Yermakov smiled at the enthusiastic resident, "Just describe what you see. Don't jump to any conclusions."

Angie adjusted the eye pieces on the binocular microscope and started scanning several slides, adroitly moving them across the microscope stage and adeptly switching from low power to high and back. "I see some foamy histiocytes and the lamina propria is infiltrated by inflammatory cells."

"Excellent," chimed in Yermakov. "Go on."

"The mucosal architecture is distorted a little bit, too."

Dr. Vitale then switched slides and added, "The periodic acid-Schiff stain is highlighting multiple sickle-shaped fragments. Actually some of them are round."

"Oliver, your Dr. Vitale vould make a superb pathologist."

Angie actually blushed at the compliment. "Thank you Dr. Yermakov. All I did was describe what's on the slides. I know it's abnormal but it isn't celiac sprue."

"Oliver, your diagnosis based on Dr. Vitale's magnificent description?"

"Alexy, let me have a look myself."

Yocum and Angie exchanged places. After a minute or two of silently perusing the slides, Yocum shook his head in wonderment, "Do you mean, Alexy, that in addition to colon cancer our colleague Dr. Bloom has Whipple's Disease?"

"Precisely!"

Drs. Vitale and Smith looked at each other with an expression that told Yermakov and Yocum that the two young doctors had never heard of this disease. Yocum delved into his memory banks. "Whipple's is rare. I saw one case at the Cleveland Clinic twenty-five years ago. None since. It is caused by a bacteria and hits white males much more than any other group. Its major symptoms are joint pain, weight loss and diarrhea. Dr. Bloom had all three but Whipple's is so rare that I honestly never considered it. Wow."

"And the treatment?" asked Angie.

"It may have changed in twenty-five years--but as I recall it's fairly straight forward--antibiotics for a full year. tetracycline or sulfur usually does the trick."

"So, let me get this straight," summed up Angie, "Dr. Bloom gets these atypical symptoms and he drives Dr. Kirsch crazy thinking he is going to die of pancreatic cancer. KK brow beats him into seeing you who finds a colon cancer on a marginally indicated colonoscopy while making the diagnosis of Whipple's Disease, something you haven't seen in ages."

"In other words, Dr. Vitale, you might say that Dr. Bloom's Whipple's Disease saved his life--it enabled us to find that colon cancer at what will probably be a curable stage. Lucky guy."

"Ah, the joys of clinical medicine," intoned Dr. Yermakov. "My only regret about going into pathology."

CHAPTER FIFTY-FIVE

Julie loved watching Dionne while she was sleeping. It seemed as though she possessed a Mona Lisa smile. He wondered what she might be dreaming. He unconsciously started humming that Nat King Cole signature song and Dionne's eyes opened with a start, "Are you humming again?"

"No, I am not," Julie asserted defensively.

"Do you remember what we did the last time I caught you humming?"

Julie thought for a split second, "Sure do. Are you going to punish me again the same way?"

"Double! For humming and for waking me up."

Not surprisingly, Dr. Berger relished the punishment.

Afterwards, they showered together in the cramped stall shower in Julie's apartment. There was no rush to get to the hospital as they were both on electives and their respective clinics didn't start until 9 a.m.

They held hands as they walked to the bus stop on Foster Avenue. In twenty minutes they'd be at Maimonides and not have to worry about parking. The melting pot of Brooklyn was easily visualized as the bus went from Flatbush to Bensonhurst and then on to Boro Park. White collar to blue collar to Hasidic black tunics and hats. Dionne's enjoying the sites was interrupted by Julie, "How would you like to meet Mitchell and Rosie?" It had been weeks since Julie had met her parents and she was waiting for Julie to return the favor. "That might be an easier get together than my parents. I think you and Rosie will hit it off great."

"Say when. Is Rosie a math teacher too?"

"Uh huh. In a middle school two blocks away from Mitchell's high school. They've got an easy commute and have all the same holidays off. Nice perks too. Mitchell tells me that Rosie just joined the sisterhood at their temple."

"Rosie from Vietnam goes to synagogue?"

"Didn't I tell you that--sorry, that must have been Noah and Annie. Rosie's folks were Catholic but were not practicing at all. Rosie wasn't interested in religion until she met Mitch. She had never seen a Jew until she went to college. She met plenty of them in graduate school at Columbia. When she finally succumbed to my brother's charms, she became fascinated by Judaism. What started out as a curiosity turned into a commitment. Mitch tells me it really bummed her parents out when she told the Nguyens she wanted to convert to Judaism--this was long before he proposed to her. My folks, on the other hand, were thrilled when they heard that."

"Julie, why are you telling me all this now? No ulterior motive?"

"No, no, no. I just wanted you to know where Rosie's coming from. It's not every day that you meet an almond-eyed beauty who speaks accentless English and Modern Hebrew but not a word of Vietnamese. She and Mitch can't wait to meet you."

"And what have you told them about me?"

"Whadda ya think?"

"You tell me."

"That I've been spending a lot of time with a young lady who isn't Jewish and isn't white. Not exactly who Grandma Berger would have picked to be Julie's love interest! But she is a doctor."

Dionne laughed. "Well, one out of three isn't bad for starters. Tell you what. Let's join them for Friday night services at their temple and then go out to dinner at that Italian restaurant on 86th Street--Sorrentino's."

"Are you sure that's how you want to meet Mitch and Rosie?"

"Absolutely. Plus it would probably be a treat for the congregation to see the Berger brothers together in shul for the first time since you were thirteen. It would be a mitzvah to meet your mispocheh on shabbat."

"That's really scary."

"What is?"

"You've got the accent and intonation down perfect!"

CHAPTER FIFTY-SIX

Allison Kincaid decided to dress very casually for her visit to the Bianchi's. Princeton sweatshirt over designer jeans and hair in a ponytail. Very little makeup. Maria met her at the door and gave her a big hug. "My do we look preppy--actually, Alli, you could probably put on anything and look terrific. Come on in. Joe's in the den with the girls."

The den was actually a huge family room lined with bookcases and cabinets. Games and dolls and gadgets and cushions were strewn about. A forty-inch flat screen TV was on the wall nearest the kitchen. Thankfully it wasn't turned on as Alli didn't want to compete with Saturday morning cartoons. Joe was playing with Jessica and Joy and Jenna was stacking cubes which had numbers on one face, letters on another, a vertically oriented scene on the third, and a huge bean stalk on the fourth. Alli smiled. She actually remembered those cubes from her childhood.

Joe stood up and extended his hand. "Hello Alli, welcome to our house. Girls, stand up and introduce yourselves."

The two little ones giggled and sweetly blurted out what they had obviously been practicing all morning. Jenna continued stacking and unstacking the cubes, oblivious to Allison's presence. Alli thought that maybe there was a split second of eye contact between the two of them, but she wasn't sure.

"Do you want to see a picture book that goes with a song?" Alli asked. "Yes, yes," squealed Jessica and Joy. Alli plopped a CD into a portable player she had brought and asked the girls to sit on her lap. They looked up to their mother and father who nodded approvingly. Alli opened the book and simultaneously hit the play button and the Bing Crosby recording of "Teddy Bear's Picnic" started playing. The Bianchi girls had never heard it before and loved it. They insisted that Allison play it again, which she did. Jenna continued stacking and unstacking on the other side of the room.

By the time Allison played the disc for the fourth go-round, Joy and Jessica were giggling and doing a pretty good job of turning the pages and keeping up with the chorus,

"Picnic time for teddy bears

The little teddy bears are having--"

And then, from across the room, in perfect pitch, perfect cadence, and perfect pronunciation,

"A lovely time today.

Watch them, catch them unawares,

And see them picnic on their holiday.

See them gaily dance about.

They love to play and shout.

And never have any cares.

At six o'clock their mommies and daddies

Will take them home to bed

Because they're tired little teddy bears."

Jenna never took her eyes off the cubes as she finished the chorus and the remaining stanzas. If she had, she would have noted looks of utter astonishment and joy on the faces of Joseph, Maria and Allison. No one said a word. You could hear the proverbial pin drop when the Bing Crosby-Jenna Bianchi duet ended. Joy and Jessica ran to hug their sister who had resumed playing with the cubes, completely ignoring their attempts to get her attention.

The three adults looked at each other. Maria broke the ice with a voice that cracked with emotion, "Oh my God, did you see that? Did you hear that? For a few seconds Jenna was back! Joey, I can't believe it. Our little Jenna was back! No one will believe it when we tell them what happened. Thank God Alli witnessed it or else everyone will think we've completely lost it."

Dr. Joseph Bianchi started crying. He had to stifle the tears because Joy and Jessica asked Maria why Daddy was so sad. Maria hastily explained that he was actually laughing--that he was so happy that Jenna was singing and that made him laugh and that sometimes when people laugh so hard it looks like they're actually crying. The little girls easily swallowed that explanation, especially when Daddy picked them up and gave them a smiley hug.

Allison stood up with a countenance of awe. Whatever little mascara she had applied earlier was now running down her cheeks. Maria gave her a bear hug and in between their sobs kept uttering, "Thank you Alli, thank you Alli." Now it was Joey's turn to explain to Jessica and Joy that Alli and Mommy were very happy, too. And Jenna quietly and deliberately stacked and unstacked the cubes.

CHAPTER FIFTY-SEVEN

The question surprised Sandy. Seth asked if her passport were current.

"Sure, I renewed it two years ago when my parents gave me a present for my master's degree. One week in London. It was wonderful. I went with a girlfriend from nursing school. Why do you ask?"

"Come with me to Israel next month. The weather will still be good and the bulk of tourists will be gone. It should be great. There is a tour for under-thirties that the American Jewish Congress has organized. Want to see the itinerary?"

Sandy excitedly looked at the brochure. Jerusalem. Tel Aviv. Haifa. The Galilee. Tiberius. The Dead Sea. Eilat. And five star hotels throughout.

"I'd love to go with you. I'm sure I can clear it with nursing. I've got lots of vacation time saved up. What a wonderful idea. Thank you!"

There were just two things Sandy needed to do besides updating her wardrobe for the trip. One was to get her parents' blessing and that was quite easy. They actually encouraged her to go with Dr. Rubin. She was far beyond needing their permission.

The other thing was to follow through on Dr. Clark's suggestion. It wasn't exactly a quid pro quo but in return for her accompanying Seth to Israel in early November, she wanted him to spend a weekend with her in New Hope. Dr. Rubin, of course, acceded to her wishes.

Sandy told Dionne of their plans and Dionne presented her with a gift-wrapped little box tied with a red ribbon.

"What's this?" asked Sandy.

"It's a red bendl. That's what Julie says people call it. It's supposed to bring good luck and ward off evil wishers and protect you from harm."

"No, no. I know what a red bendl is. What's in the box?"

"Oh! That's a present from me and Julie. Make sure you bring it to New Hope--and Israel. In fact, you might want to unwrap it a night or two before you two go away on that weekend," said Dionne with a big smile.

"Anything else?"

"You know those pen lights that we use in the ICU to check pupillary reflexes--the ones that run on triple-A batteries?" Dionne managed to say with a straight face.

"Yes, what about them?"

"Take a few of them with you."

"Whatever for?"

"Trust me, you'll see." Julie was right, Dionne thought. Giving Sandy a six-pack of Duracells would have really been gauche.

CHAPTER FIFTY-EIGHT

Dr. Yocum had warned Angie that Jeff Friedman might not sail through his first year at Yale Law. The severity of that initial attack during the summer, including the need for steroids and cyclosporine, all suggested a rocky future course. That prediction was based upon decades of experience with other ulcerative colitis patients.

Further strengthening Yocum's prediction of trouble ahead were the data he was amassing from 23 and Me. Although far from complete and with too few patients to reach statistical significance, a trend was developing that Yocum found fascinating. He was hoping to present it at the big Digestive Disease Week meetings the following May in San Diego.

By analyzing the DNA in that vial of saliva, 23 and Me was able to determine that the Friedman line's Y chromosome could be traced back to a single mutation in the Middle East ten to twenty-thousand years ago. That ancestor's Y chromosome put the Friedmans into Haplogroup G, which is shared by about one hundred million people world wide and ten-percent of Ashkenazis. The descendants of this proto-Friedman had additional mutations of their Y chromosome, and branched off into subgroups G1 and G2. The Friedmans are G1s, and it is estimated that they have about one to three million other "cousins" out there, many of whom are still in the Middle East. Yocum's preliminary analysis of the data suggested the G2 subgroup of ulcerative colitis patients exhibited a considerably milder disease. Friedman and other G1 cousins were more likely to suffer serious flares, require hospitalization, and lose their colon.

Thus, Dr. Vitale was not too surprised when her cell phone rang in late October with a mildly frantic Jeff Friedman on the line. The small talk about the rigors of law school lasted about thirty seconds. He was doing okay in class, but urgency and diarrhea where forcing him to sit near the lecture halls' exit doors and even miss a few minutes of several sessions the past week. He wasn't nearly so sick as when he originally presented after the river rafting excursion and certainly wanted to avoid a repeat of that scenario.

Angie promised Friedman she would confer with Dr. Yocum and get back to the law student ASAP.

Yocum reminded Angie that Friedman's presentation and course the previous summer predicted something other than mild disease. His starting to flare in New Haven could be heralding some tough times ahead. Yocum told her in confidence about the DNA analysis. He made suggestions to Dr. Vitale which she conveyed to the patient, namely to increase the Lialda to four tablets daily and start using cortisone enemas for the urgency. Angie tried to remain her trademark cool and calm when she spoke with Jeff on the phone. But she was rattled. Imagine how he must be feeling, she wondered. They would keep in touch by phone.

~~~~~~~~~~

Sandy tried not to smile when she started telling Dionne about the weekend she had just spent with Seth Rubin in New Hope. "It's all your fault we missed the first act at the Bucks County Playhouse. They seated us just as the Sky Masterson character was singing 'Your eyes are the eyes of a woman in love,' and Seth and I just looked at each other."

"Wasn't that the part Marlon Brando played in the movie version of 'Guys and Dolls?' I think Jean Simmons played Sister Sarah. Why were you two late? Weren't my directions to New Hope okay?"

"They were fine," Sandy blushed. "But your instructions regarding that little present with the red bendl were even better, and the pen lights--very cleverrrr. Seth bet me that that had to be Dr. Berger's idea."

"Seth wins. But why did you miss the first act?" Dr. Clark then slapped herself in the forehead. "Never mind, I don't need to hear all the details."

Sandy blushed again and leaned over as she whispered in Dionne's ear, "Thank you, thank you, thank you. That trip to Israel with Seth can't come too soon. Thank Dr. Berger for both of us." And off Nurse Rogoff went to see how "her girls" had fared during the three days she was gone.

CHAPTER FIFTY-NINE

Noah Strong had completely recovered from the surgery and was feeling terrific, both physically and mentally. His IT company was about to sign a sweetheart deal with a consortium headquartered in New Zealand. If everything proceeded as planned, the company would be bought out by a multinational conglomerate in about eighteen months with Noah pocketing a seven-figure golden parachute. He couldn't speak in any detail about these plans since SEC snoops were everywhere on Wall Street. He would have to fly to Auckland at least once a month to personally supervise the quality control procedures and inspect the manufacturing process. His sponsors wanted Noah to be the point man; they did not want some cowboy with an ill begotten MBA screwing things up.

Annie had some totally unexpected good news too. Her spinster aunt had left her one hundred thousand dollars in her will. Annie was flabbergasted. Aunt Martha was as quirky as they come. She lived in an old house in Beacon, New York on the Hudson River about ninety minutes north of the City. She shared that house with a dozen cats and hundreds of books of crossword puzzles. She could completely knock off the New York Times Sunday magazine puzzle in less than an hour. Annie hadn't seen her in years but always phoned her on her birthday. Annie informed Will Shortz, the puzzle guru at The New York Times about her and Will sent Martha a huge birthday card with a box of bon bons and the most recent Sodoku compendium.

Annie always dreamed of owning her own dessert shop in Bay Ridge. The Italian bakeries lacked something; the Scandinavian sweet shops lacked something else. Annie had amassed a slew of recipes and knew how to blend Scharffen Berger dark chocolate with fresh fruit to create all manner of sinfully delicious desserts. Noah and Dionne and Julie and Sandy and Seth and KK and Allison had sampled her creations and thought them exquisite. Even the generally reserved Dr. Angelina Vitale-Schwartz went gaga over Annie's treats when she brought a box of them to Maimonides.

Now she had the money from dear Aunt Martha to realize her dream. She already had a name for the shop, "Annie's Assets." And then, two weeks after her missed period, the home pregnancy test told her that all of her plans might need to be placed on hold.

~~~~~~~~~~

Nat Bloom started taking Bactrim, a sulfa containing antibiotic, twice daily. Whether it was mind over matter or not, the discomfort in his wrists and hands started to improve. He had little difficulty securing coverage for his practice. Five internists would each spend a day a week in Dr. Bloom's office and supervise a medical resident "on loan" from the internal medicine clinic at Maimonides. This was just fine with Dr. Greene as it gave his residents a taste of what the office practice of a busy internist in Brooklyn is like. The internists were happy to help Nat out any way they could as Dr. Bloom had been a mentor to all of them.

Dr. Bloom chose Dr. Levi to perform his right hemicolectomy. Besides getting a world class laparoscopic surgeon, this allowed Nat to avoid the predicament of selecting one of his Maimonides surgical colleagues over another.

CHAPTER SIXTY

Rabbi Simcha Levine had been the spiritual leader of congregation Beth El in Flatbush for thirty years. He was absolutely thrilled when Mitchell Berger came to Friday night services for the first time in years, accompanied by a lovely young lady who Mitchell introduced to him as his friend from graduate school, Rosie Nguyen. That was nearly two years ago when Rosie had already expressed an interest in learning more about Judaism. By the time Mitchell proposed to Rosie she had already decided to convert, not to placate Mitchell or his parents but because she sensed a comfort and love in Judaism that her family's brand of Catholicism never provided. Rabbi Levine was only too happy to shepherd Rosie through the conversion process. So rather than being assimilated into the Gentile community, Mitchell was returning to the Jewish community and bringing a prize catch with him. Rabbi Levine knew that Jews by Choice such as Rosie were committed to the religion and more apt to keep a kosher home and make certain that their children receive a Jewish education.

Rabbi Levine hadn't seen Dr. Julius Berger since Mitchell and Rosie's wedding. He nodded a hello to Julie as he entered the synagogue with Mitchell and Rosie. The Rabbi couldn't help but notice a very pretty, modestly attired, African American woman who was holding hands with Julie. She was chatting with Rosie and both of them exchanged greetings with the congregation, many of whom wished them a Sabbath of peace, "shabbat shalom."

Rosie and Mitchell had met Julie and Dionne just a half hour before services and took an immediate liking to her. The four of them walked on a beautiful Indian summer evening the half mile from Mitch and Rosie's apartment to the temple. It was quite an interesting sight: The Berger brothers side by side and strolling behind them by about five yards Rosie and Dionne, fast becoming good buddies. One from Saigon, one from Bedford-Stuyvesant. Rosie gave Dionne a quick heads up on what to expect at services, "Actually it will be easy--just follow my lead."

Dionne enjoyed the services more than she had ever expected to. The congregation was warm and unreservedly friendly as Julie introduced her to everyone afterward. Rabbi Levine spent more time speaking with her than anyone else that evening. She was beginning to see why Rosie was so turned on by these people and their religion. She was particularly taken by Rabbi Levine's goodbye, "Dionne, I would consider it an honor if you and Julie attended services more often. My wife, Rivka, and I would really like to get to know you better."

Dinner at Sorrentino's was wonderful. It was a family-owned restaurant and had been so for sixty years. It had the stereotypical red and white checkered tablecloths and on Friday and Saturday evening an octogenarian accordionist kept the patrons entertained. The food was always presented on large plates to accommodate the huge portions. Although Sorrentino's prided itself on old family recipes from Sicily and Tuscany, the chefs were happy to create whatever a well-traveled and knowledgeable customer requested.

The Berger brothers asked Rosie and Dionne if they had any particular preferences. The answer being no, Mitchell gave the waiter carte blanche for the entire meal and wine selection. Just no espresso as Dionne and Julie had responsibilities at Maimonides at 8 a.m.

After a three-hour feast and animated conversation, the four of them stood to leave the restaurant which by now was three-quarters empty. Both Mitchell and Rosie gave Dionne a hug and a kiss. Julie and Mitchell gave each other loud high fives and Mitchell gave Julie a fist pump as they said goodbye. Dionne was uncharacteristically silent as she sat down next to Julie in his car. "A penny for your thoughts," Julie asked more tenderly than matter-of-factly.

"I was just thinking. I could have served my internship anywhere. But I chose Maimonides. After tonight I wonder if someone else had a hand in that decision. I have never been happier."

Julie answered that pronouncement with a soft kiss on Dionne's forehead, "Me too."

CHAPTER SIXTY-ONE

Dr. Bloom's surgery went off without a hitch. Dr. Gabrielle Levi really didn't need Dr. Reddy's assistance as the procedure was a straight forward removal of the ascending colon and anastomosing the distal ileum to the proximal transverse colon. All of this was done laparoscopically using state-of-the-art equipment, some of which had actually been invented by Levi. Closed-circuit TVs were set up in the tiny conference room outside the OR. Bloom had previously given his permission for any interested doctors to view the "Levi and Lenkala Show" as he called the operation. It was masterful surgery. All marveled at Levi's technique and speed. There was never a wasted motion. Levi called out as the specimen was removed, "Good news, I palpate no worrisome lymph nodes and the cancer hasn't even puckered the serosa. I bet this is so early a stage that chemo won't even be a consideration."

The final pathology report confirmed Levi's prediction: Dr. Nathaniel Bloom's colon cancer was confined to the mucosa and no lymph nodes were involved. The surgery was one hundred percent curative. The patient went home on the third postop day with plans to resume limited office hours in a month.

CHAPTER SIXTY-TWO

None of Maria Bianchi's extensive research on autism had revealed anything resembling the skill that Jenna had demonstrated. Maybe ten percent of autistic children are labeled savants but these kids could play a piano concerto after hearing it once or add up columns of ten-digit numbers faster than a calculator. Maria had seen no reports of the singing that Jenna had done.

Allison Kincaid was so moved by that Saturday morning performance that she made dozens of tapes of other children's songs. Most fell on deaf ears, but on rare occasion Jenna would accompany the tape just as she had done with the "Teddy Bear's Picnic." Neither the subject, nor the tune, nor the musical accompaniment had any bearing on which song she decided to sing. She seemed to pay a bit more attention to the tapes when they were played--she was somewhat less intense with her stacking the cubes and her eyes darted upward as though she were silently mouthing the words. Unfortunately, there was absolutely no hint of any conversational breakthrough and, other than those few moments of "singing along," Jenna continued to exist in a world of her own. Maria and Joe Bianchi wondered if a key existed to unlocking the doors in their daughter's brain that slowly closed shut a few years ago. If indeed there was a key, it seemed to be tied up with music and that's the avenue they decided to pursue.

CHAPTER SIXTY-THREE

Seth and Sandy met several people on the long EL AL flight from JFK to Tel Aviv who would be on that American Jewish Congress Tour with them. There were couples, married and unmarried, and singles. Many were Federal employees from the Washington, DC area. As school was in session, none were teachers nor students. After a brief nap at the hotel, the group assembled in the lobby and was introduced to their tour guide, Aharon Goren. He had fought against Hezbollah in Southern Lebanon just a few summers earlier and served with the Israeli Defense Forces in Gaza. His English was flawless and he informed Sandy and Seth and the rest of the "under-thirties group" that the next ten days would be among the most memorable of their lives. This was not to be a leisurely tour of swimming pools and spas. The Israeli government figured that if even a small percentage of young tourists were sufficiently turned on by what they saw and experienced to consider emigrating to Israel, then their subsidizing of these tours was well worth the effort. Indeed, over the past thirty years Jews from South Africa, Rhodesia, Europe and the former Soviet bloc, in addition to North America had made Israel their permanent home.

A breakneck pace was maintained for the entire trip. A brand new air conditioned motor coach moved the group from city to city. Government officials gave short speeches at each venue. There was certainly ample time for the usual touristy locales and digital cameras with fancy telephoto lenses were snapping pictures everywhere, from the Golan Heights to the Western Wall.

By day's end, the group was both exhilarated and exhausted but looking forward to the morrow's adventures, which were outlined by Aharon just as the group retired for the night.

All the five-star hotels had luxurious bathroom suites with huge sunken tubs. Seth and Sandy sampled every Dead Sea concoction as they soaked the day's aches and pains away before slipping under the fanciest of Egyptian cotton sheets for an hour of lovemaking and then falling asleep with their bodies still entwined. Just before she finally dozed off, Sandy smiled at how far she and Seth had come since that weekend in New Hope. Dr. Rubin was smiling too, recalling when he first met Sandy in the ICU at Maimonides.

The King David Hotel in Jerusalem was world famous. It was built in 1931 and offered magnificent views of Yemin Moshe and the Old City. Seth had consulted with Gabriel Levi as to the most romantic spot at the hotel. Levi did not ask why but made a bet with himself as to what Dr. Rubin had in mind. A secluded fifth-floor veranda overlooking the beautiful lush gardens was just as Gabriel had promised. After dinner on their final night in Israel, Seth led Sandy to the veranda's entrance and asked her to close her eyes. He then took her hand and gently guided her to the railing overlooking the three thousand-year-old city.

"Open your eyes Sandy. I don't want to get too emotional but look at this place. I cannot imagine sharing its wonders someday with anyone but you. I know it's been less than five months but I feel like I've known you forever. This country, this city, these ten days with you have been like a dream. Let's come back here next year as man and wife. Yes, I'm asking you to marry me."

Sandy turned around to face him. Tears were running down her cheeks and her body was trembling. "Seth, I'll have to think about it--okay, I've thought about it," Sandy laughed nervously. "Of course I'll marry you. You've made me the happiest woman in all of Jerusalem tonight." And with that pronouncement, they sealed the future with an embrace and kiss that drew applause from the two other couples who had wandered onto the veranda.

Dr. Rubin then sank to one knee and removed a diamond from his pocket. "This was my great grandmother's." Seth slid the antique engagement ring onto Sandy's finger. It fit perfectly. More applause and a chorus of Mazel Tovs from the crowd on the balcony as Sandy drew Seth up and held his head in her hands while she kissed him again, this time with her tears reflecting the light sparkling from the beautiful ring.

CHAPTER SIXTY-FOUR

Doctor Bradley Perkins was not exactly in the Marcus Welby mold. He had served as a grunt in Vietnam at age eighteen and was wounded during the 1968 Tet Offensive. He returned to the states and attended college and medical school and remained in the Army Reserves after he opened his office as a family practitioner. He was summoned to active duty during Dessert Storm in 1991 and spent several months in Saudi Arabia. That photo of him and General H. Norman Schwarzkopf was proudly displayed in his office waiting room. But that deployment to the Middle East was costly: Many of his patients found other doctors while he was away. He compensated for that loss of income by amassing a huge nursing home practice on Staten Island and in Brooklyn. Many of these patients had no family, many were demented, and many were "not to be resuscitated." These latter three characteristics made it quite easy for Dr. Perkins to submit a bill to Medicare for "services rendered." Those services frequently consisted of a thirty-second visit to the patient's bedside and a preprinted sheet placed on the patient's chart with several boxes checked to satisfy any government reviewer that the charge Perkins submitted was justified.

Occasionally (no one knew exactly how often), a charge would be submitted and a progress note placed even though the doctor had not even seen the patient.

The head nurse at one of these nursing homes personally observed this fraudulent activity and reported it to the nursing home director who confronted Dr. Perkins with the evidence. In return for the director's not reporting this to the State Medical Board, Dr. Perkins promised to "clean up his act." He was embittered by the entire experience. After all, he had served his country during two wars and now some Filipina nurse and a Jew nursing home director who had never put on a uniform were ruining his life.

One specific area in which he pledged improvement was the return of phone calls. These were usually requests from nurses for a laxative for Mr. Smith or an antacid for Mrs. Jones. Sometimes these requests were for modification of an existing analgesic regimen. Here Dr. Perkins needed to be a bit more careful and ask a few questions. The last thing he needed was for an emphysema patient to stop breathing because a narcotic had been prescribed or for a patient with chronic liver disease to be given too much Tylenol.

Dr. Perkins was not immune to the charms of the attractive sales reps. He had only met Allison Kincaid once--more than two years ago when she first started working for Pfizer. At that time Celebrex was the medication she was detailing, not Lipitor. Dr. Perkins vaguely remembered that Celebrex was supposed to be safer than traditional NSAIDs such as Motrin or Naprosyn. Thus, when a Victory Memorial skilled nursing facility nurse called at 11:00 p.m. to inform him that Mrs. Kirsch's back pain was no longer being controlled by Tylenol, he ordered Celebrex. That proved to be his undoing--and almost Mrs. Kirsch's.

CHAPTER SIXTY-FIVE

Annie did not want to alarm Noah while he was in New Zealand. She'd be picking him up at JFK in three days anyway. Those three days, however, were pure torture for Annie as she confided in no one else and all she could do was rehash her available options over and over and over again.

Annie gave Noah a kiss when he cleared customs and told him she had something to show him back at his apartment. She did not want to discuss it until they got back home. Noah was so jet lagged that he didn't object and was happy to catch a few winks on the forty-five-minute ride on the Belt Parkway from JFK to Bay Ridge.

"So what do you want to show me, sweetie?" Noah asked as he carried his suitcase into the apartment.

"Just wait a minute Noie," Annie requested as she took a tiny package off the counter top and went into the bathroom. She came out a minute later and showed the telltale blue stripe to Noah. He knew immediately what it signified.

"Oh my God, Annie. You're pregnant. How long have you known?"

"About ten days. I'm about three weeks past my last period and my boobs are just starting to tingle a bit."

Noah gave her a big hug. "Oh boy, do we have some decisions to make!"

Annie was relieved that Noah wasn't being a jerk about the pregnancy. Someone else might have accused her of being careless with the oral contraceptives or demanding an answer to "how could this happen?" But Annie knew deep down that Noah was too kind and gentle to harbor any such thoughts and she was a bit angry at herself for considering (for even a moment) those reactions by Noah as a possibility.

"Annie, a wise person--my college ethics professor--advised me many years ago to never make major decisions when ill or tired. I'm falling asleep standing up. That melatonin didn't do squat. We need to talk about this--obviously--but not now. Come to bed with me and tomorrow I'm all yours."

Annie thought that quite reasonable. Actually, she pretty much predicted exactly what Noah's initial reaction to the news would be. She had been through some tough times with him, but an intussuscepting Meckel's diverticulum couldn't hold a candle to this one.

CHAPTER SIXTY-SIX

Jeff Friedman barely made it through that first semester of law school at Yale. Increasing the Lialda and using the cortisone enemas did not really improve matters. His classmates marveled at his intestinal fortitude (they all chimed in "no pun intended") and they provided him with excellent notes for the lectures he missed. He was having six to eight bloody bowel movements a day and survived the embarrassment of a proctor accompanying him to the bathroom during finals. He knew there was no way he could return for the spring semester unless his condition dramatically improved. He spoke with either Dr. Vitale or Dr. Yocum three times a week in early December. Somehow his professors deemed his exams and essays worthy of a passing grade. He made an appointment to see Yocum as soon as he got back to Brooklyn. He knew he was already maxed out on the Lialda and the 6-mercaptopurine. It was obvious that he was getting worse, not better. He read up on Remicade, the medication that had been used for years in rheumatoid arthritis and Crohn's disease patients and which had only recently been approved for ulcerative colitis. He figured that Dr. Yocum would be suggesting they try it. At least that is what Dr. Vitale had told him.

CHAPTER SIXTY-SEVEN

KK was serving as the night float resident in the intensive care unit when he was paged to the emergency room by Dr. Jacob Saltzman, one of the yommie interns.

"Dr. Kirsch, we have an elderly nursing home patient here who was found on the floor in a pool of blood. The aid witnessed her passing a bloody stool and then fainting. She looked real bad when the ambulance brought her in--shocky and tachy, but I got two large-bore IVs in right away and after a 500 cc normal saline bolus, her pressure came up a bit. We've got her typed and crossmatched for four units of packed cells. She will definitely need an ICU bed. Her hemoglobin is 8.5 and I suspect it will drop further with equilibration and dilution from the IV fluids. She looked too unstable to me for this to be a lower GI bleed from diverticulosis, so I passed a nasogastric tube and the returns are coffee ground. I think this is an upper GI bleed with rapid transit. Probably an ulcer."

KK was very impressed with Dr. Saltzman's demeanor and concise assessment of the situation.

"Good work, Jacob. I will be down to see her in five minutes. Why don't you call the GI fellow STAT--it sounds like this lady will need to be scoped early tomorrow morning, as soon as we resuscitate her with some more fluids and packed cells. What's her name?"

"What a coincidence! Same as yours. Kirsch. Fanny Kirsch."

KK froze in his tracks. Fanny Kirsch was his eighty-eight year-old grandmother.

KK ran down to the code room in the emergency area. There was his bubbe. She looked pale as a ghost and the nasogastric tube continued to drain brown material. At least she recognized her grandson, "My Kenny, thank God they took me to Maimonides. I know you'll take good care of me. I don't feel so good."

"Just rest grandma, let me look at your chart and try to figure out what happened to you."

Nat Bloom was his grandmother's internist and had seen her through several bouts of pneumonia and congestive heart failure. She had borderline diabetes and hypertension and was on several medications at the assisted living wing of the Victory Memorial Convalescent Center. Nat hadn't seen her last month because of his cancer surgery and requested that the facility contact whomever was on call for new admissions should Mrs. Kirsch develop any problems. Little did he know that Dr. Bradley Perkins would be the physician the graveyard shift nurse would call three weeks ago when Mrs. Kirsch's back pain worsened.

KK was able to reconstruct all of this by reviewing the records which accompanied his grandmother from Victory Memorial. And there it was as plain as day: A telephone order three weeks old for Mrs. Fanny Kirsch to receive a daily dose of Celebrex 200 mg for ongoing back pain. KK knew that getting bent out of shape now would not help his grandmother but he vowed to "chat" with this Dr. Perkins once his grandmother recovered.

For now, he wrote an order for a Protonix drip, personally called Dr. Yocum (who had already been contacted by the GI fellow), and notified his father. By the time Fanny Kirsch was admitted to the ICU, the blood transfusions were underway and her color seemed to be improving. An emergency endoscopy would be done by Dr. Yocum at 7:30 the following morning.

By the time Dr. Yocum and the GI fellow arrived in the intensive care unit, Mrs. Kirsch had received a three-unit transfusion of packed red blood cells and over 1500 cc of normal saline. Her pulse and blood pressure had stabilized but the nasogastric aspirate continued to be brown with occasional wisps of pink.

Endoscopy had changed from a purely diagnostic modality during Yocum's fellowship days three decades ago to a procedure with potentially lifesaving therapeutic capabilities. Fortunately, Dr. Yocum had kept up with these newest techniques despite his disdain for those gastroenterologists who gamed the system by performing marginally indicated endoscopies and colonoscopies. Sometimes it appeared to Yocum that the mere presence of a mouth or an anus was reason enough to subject a trusting but ill-informed patient to one of these invasive examinations.

However, Mrs. Kirsch's presentation clearly mandated an emergency endoscopy. Numerous studies over the past twenty years had demonstrated that hospital stays could be shortened, transfusion requirements lessened, and survival increased if an emergency endoscopy could stop the bleeding and prevent re-hemorrhaging.

KK was present to watch Yocum endoscope his grandmother; Angie Vitale had come in early to watch too. She and Dr. Yocum would be meeting with Jeff Friedman that afternoon. The GI fellow would be assisting Yocum. After the requisite "time out" to confirm that it was indeed Mrs. Fanny Kirsch who was about to be scoped, Dr. Yocum had the ICU nurse administer 25 mcg of fentanyl and 1 mg of Versed intravenously.

Adequate sedation having been achieved, Dr. Yocum expertly passed the scope into the esophagus. It was normal. No real surprise there. As the scope entered the stomach the image on the TV monitor made Angie gasp and KK utter, "Oh my God!"

~~~~~~~~~~

Noah awoke and eased himself out of bed without disturbing Annie. He had a glass of orange juice and started brewing some coffee. He was jet lagged and terribly conflicted. Everything in New Zealand was going incredibly smoothly and now Annie's pregnancy was bound to complicate matters. He, too, thought briefly about their options but his musings were interrupted by Annie.

"Thanks for making the coffee. It smells so good! You okay?"

"I just don't know Annie. What are we going to do?"

"Let's talk. But first hold me. I missed you. A lot. Maybe the early hormone surges are kicking in. But I really need a hug and a kiss."

Noah was happy to oblige. In fact the hugs and kisses led to some passionate lovemaking with the two of them at least temporarily oblivious to the little embryo firmly implanted in Annie's uterus.

~~~~~~~~~~

What had prompted the gasp from Angie and the exclamation from KK was an arterial spurter. The usually cool and unflappable Dr. Vitale was amazed at how calm Dr. Yocum was as he narrated what was transpiring in Mrs. Kirsch's stomach.

"We are in the antrum. There is an ulcer on the posterior wall. We just dislodged a clot that was partially adherent to the base of the ulcer. That red streak spurting across the screen is an arterial pumper. Probably a branch of the right gastric artery. Jeremy, quick, 1/10,000 epinephrine and a sclerotherapy needle."

Dr. Yocum barked that order to his fellow but Dr. Jeremy Marks was thinking ahead and was already handing the requested catheter to Dr. Yocum.

As Yocum injected several cc of the diluted epinephrine into the tissue surrounding the ulcer he noted, "Now watch the mucosa blanch; we've diminished the blood flow to the area but we need to directly attack the vessel that was spurting across the screen a minute ago or there's a ninety-percent chance it will re-bleed. Jeremy, clips."

Once again, Dr. Marks anticipated what his mentor would be doing next. Yocum passed the clip-tipped catheter through his scope and then instructed Marks to open, close and deploy 3 cm-long metallic clips. These mini clothespin-like clamps had been perfectly aimed by Yocum and deeply embedded directly onto the culprit artery. The bleeding suddenly stopped. Dr. Yocum irrigated the area with a forceful stream of water. The clips held. There wasn't even any oozing.

"That should do it," Dr. Yocum said as he handed the scope to Dr. Marks, tore off the paper gown he had worn during the procedure, and walked out of Fanny Kirsch's ICU cubicle. At no time did he raise his voice or break a sweat.

KK and Angie looked at each other. KK asked Marks, "Is he always that good?"

"Always! And the amazing thing is that he's not a big fan of endoscopy. You've just witnessed a master at work."

KK took his grandmother's hand. She was starting to wake up from the sedation. "Bubbe, you're going to be okay."

Dr. Vitale walked out with Dr. Marks. She was quite impressed with Dr. Yocum. His interaction with Jeff Friedman that afternoon would impress her even more.

CHAPTER SIXTY-EIGHT

Annie suggested that before any discussion whatsoever, they each make a list as to what they thought the options were regarding the pregnancy and their relationship. Abortion ASAP, marriage now, keep the baby, marriage later were common to both lists. The only option on Annie's list but not Noah's was putting the baby up for adoption. That surprised Noah.

"Annie, why in the world would you want to do that? This baby couldn't be coming at a worse time. You want to get that dessert shop started and I'll be half way around the world the first few months of its life. I don't want to sound selfish but it's not like we were careless or took chances. It's just bad luck that you somehow managed to ovulate despite taking the Pill. We were trying very hard not to get you pregnant. Why go through a pregnancy if we don't want a baby now? Why go through the risk of pregnancy and the trauma of labor and the head trip we'd undoubtedly experience if you--we--put the baby up for adoption?"

"Noie, I'm not sure I could go through with an abortion. Maybe this baby was just meant to be!"

"Annie, okay, you're nervous and worried about the abortion. Okay, we can talk about that but let's not get into that this baby was 'meant to be.' I don't want fatalism playing any role in the decision we make. And let me repeat, the decision WE make."

"Noie, what do we do now? Who do we talk to? My sister, your sister?" Annie laughed nervously. "Oprah?"

"Annie, we can kick it around with anyone and everyone but the decision is ultimately ours and woe to anyone who doesn't support our decision. We'll probably be second guessing ourselves enough. We don't need anyone else pretending they know what's best for you or me."

"Noie, I need you. Please stay with me."

"Shame on you for even thinking I might do otherwise. We're in this together. I'm not going anywhere. You're stuck with me."

"Then tell me what you think of this." Annie pulled a few wedges of kiwi-embedded dark Ghirardelli from a foil-lined tote bag. She had sprinkled the chocolate with some macadamia nut shavings.

Noah Strong sampled one and then demanded a second and then a third wedge. He smiled, "Annie, somehow we have to get you that dessert shop! Baby or no baby."

"I just chose a name for it!"

"The baby?"

"No silly, the dessert. It'll be 'Noah's Favorite.'" And with that Annie let Noah suck the chocolate off her fingertips.

CHAPTER SIXTY-NINE

Julie waited for Dionne outside the house staff library. That's where she signed out to the night float resident covering the ward service. Julie was doing a month of rheumatology and was done for the day.

"Hi Julie, what's up?"

"My folks want to meet you. They called and said that Mitch and Rosie had nothing but wonderful things to say about Julie's girlfriend. They want to see for themselves."

"Is that okay with you?"

"Of course it is. Why wouldn't it be?"

"Julie, how come you didn't take the initiative and ask me to meet your folks before now?"

"Dionne, please. We know how retarded I am when it comes to taking the initiative sometimes. I have never introduced any former girlfriends to my parents. You're much more than a girlfriend. You know that."

"Do I?"

"What are you talking about? Of course you are. My folks were very cold to Rosie when Mitch first introduced her to them. Maybe I've been trying to avoid a repeat of that performance. Maybe now that they've fully accepted Rosie and that Mitch and Rosie have told them how nice you are, maybe they realize that they should welcome you with open arms and not repeat the mistakes they made in the past. Maybe that's why I had you meet Mitch and Rosie first. If my folks are expressing a desire to meet you based on what my brother and his wife told them, then great. I'd love to have you meet them now."

"Really?"

"Really. How about Friday night? Dinner at my folks' apartment."

"Shabbat dinner at the Bergers'?"

"Dionne, you didn't win me over with your Yiddish. You won't have to throw in any Yiddish to win my folks over."

"Have I won you over?"

This time Dr. Berger took the initiative. He didn't care that several interns and residents were nearby. He put his arms around Dr. Clark and gave her a kiss, the likes of which none of the other doctors had ever witnessed before.

CHAPTER SEVENTY

Cutbacks in Pfizer's sales force meant more work for Allison Kincaid. She had to cut back on the luncheons with Maria Bianchi but promised to spend one Saturday morning a month on Staten Island at the Bianchi's household. Jenna was doing about the same. Those musical awakenings were few and far between and totally unpredictable. If she heard a tune and lyrics that she liked she could sing it flawlessly only to suddenly return to her own world as soon as she finished. Maria, Joe and the autism experts were baffled by this behavior. There were no precedents in the literature. There were no guidelines on how to proceed. All Maria and Joe and Maria's parents could do was shower Jenna with love and attention. Even Joy and Jessica sensed that their sister was someone "special."

Allison still thought that Jenna was making eye contact with her when she arrived on those Saturday mornings.

~~~~~~~~~~

Seth and Sandy's engagement was celebrated by the entire Maimonides community. Sandy's "girls" loved the ring and Sandy never tired of showing off the heirloom. She glowed in her happiness. Although new to Maimonides, Seth Rubin had proven himself to be a fair and able chief resident, and the house officers under his command greatly appreciated those attributes. He was also a patient teacher and everyone sensed that he'd make a wonderful father someday. It was a match made in heaven.

Their families hit it off beautifully and no one quarrelled with Seth and Sandy's desire for a June wedding at the Brooklyn Botanic Garden.

CHAPTER SEVENTY-ONE

Jeff Friedman arrived ten minutes early for his appointment with Dr. Yocum. Muriel escorted him to Yocum's office, rather than one of the exam rooms. Dr. Vitale arrived a moment later.

"Hi, Dr. Yocum wanted me to sit in on his meeting with you today. I hope that's okay."

"Like you said when we first spoke on the phone--Maimonides is a teaching hospital--sure it's okay with me. Dr. Yocum teaching you anything worthwhile?"

"We've worked together on several interesting cases these past few months. Yours is near the top of the list. Your phone calls tell me you're not doing that well. You look a little ragged. I'm sure he will be discussing treatment options with you and..."

Dr. Yocum strode briskly in to the office and hung his white coat on one of those old wooden coat racks. He then shook his patient's hand and sat down behind his antique desk and opened Jeff's Maimonides patient record.

"Mr. Friedman, we have a lot to talk about. Some of what I will be suggesting may surprise you. When you leave here today I insist that you get a second opinion from any of these three specialists at Mount Sinai--and the sooner the better. Assuming it's okay with you, Dr. Vitale is going to listen to our conversation."

"I've already told her that's fine. Now what are we going to do about my colitis. It's flaring and there is no way I can go back for the spring semester like this."

"What's your definition of flaring?"

"I'm going seven maybe eight times during the day and at least once at night. Always liquidy, almost always bloody, and urgency that's almost caused me to soil myself. Increasing the Lialda and using the cortisone enemas have barely helped. We need to do something else."

"Like what?"

"With all due respect, you're the doctor. Dr. Vitale said you'd probably be talking to me about Remicade."

"What do you know about Remicade?"

"Basic Google stuff. It's been used for rheumatoid and psoriatic arthritis and Crohn's disease. A couple of years ago it was approved by the FDA for ulcerative colitis."

"Do you know how it works?"

"Sort of. Dr. Yocum, once again, with all due respect I'm looking to you for answers, not questions."

Dr. Vitale-Schwartz kept her mouth shut and observed the interplay between doctor and patient.

"Mr. Friedman, we all have regulatory proteins called cytokines--messenger molecules--if you will, circulating in our blood stream and being deposited in our tissues. One of these has inflammatory activity, which is good. It helps fight off nasty infections and maybe even destroys early cancer cells. It's called tumor necrosis factor or TNF. Think of it as a watchdog. Unfortunately, like an overzealous watchdog, it occasionally becomes too active and starts attacking the body's own tissues rather than an outside invader. These actions give rise to the so-called autoimmune diseases like rheumatoid arthritis and psoriatic arthritis and to a lesser extent Crohn's. For decades we've used steroids to neutralize these inflammatory cytokines but those steroid side effects are awful. Long-term treatment of your colitis with steroids constitutes malpractice. It's a nonstarter.

Fifteen years or so ago a biotech company invented--created--produced--take your pick--an antibody that neutralizes the biologic activity of that inflammatory cytokine. In other words it has anti-TNF properties. It's called infliximab--its trade name is Remicade. It's not a pill. It is given as an intravenous infusion."

"Sounds like the perfect drug for me. Why haven't we used it up until now?"

"Not so fast young man. When you were admitted last summer, you were real sick and needed a quick fix. You came this close to having an emergency colectomy." Yocum put his thumb and forefinger a millimeter apart. "The cyclosporine is what saved you but it can't be used long-term because of the risk of kidney damage and high blood pressure. If, and it's a big if, Remicade works in ulcerative colitis, it's only about fifty percent of the time and it generally takes two to three weeks for any beneficial effect to kick in."

"Okay, so I see why you didn't use it last summer. Why not now? I'm sick but I'm not that sick."

"Great question--and my answer is why you're going to get a second opinion."

"Your answer being--"

"Because I don't think it will make a difference. It carries side effects and risks and our hoping it will work may cost us valuable time and make your surgery a bit more risky."

"Surgery! What surgery?"

"Jeffrey, I'm recommending that you undergo a colectomy. We have a world class surgeon right here in Dr. Levi. You met him briefly last summer when it looked like you'd need to have it done emergently. But then the cyclosporine did its magic."

"What's risky about my taking Remicade?"

"You might have a bad allergic reaction to the infusion itself. Secondly, remember I said your body's TNF helps fight off infection?"

"Yeah?"

"Well, by neutralizing that TNF with Remicade you run the risk of developing an opportunistic infection. The one we worry about the most is TB but there are plenty of others that can be real nasty. Also, should you respond nicely to the Remicade and not develop an opportunistic infection, we're not even sure how long you should remain on the drug."

"Why not forever?"

"Remember what I said – TNF may play a role in preventing early cancers from gaining a foothold. There have been many cases of lymphoma--Hodgkin's disease type malignancies occurring in patients who have been on Remicade."

"Can't we increase the Purinethol that I'm taking? I'm tolerating it fine." For the first time there was a hint of desperation in Jeff Friedman's voice.

"I'm afraid not. That last blood test you had in New Haven shows a high level of the active metabolite. If we raise the dose we risk shutting down your bone marrow."

"Geez, any other reason I should not even try the Remicade and let Dr. Levi operate instead?"

"Two more. What are you, twenty-three, twenty-four? Let's say miracle of miracles, whether it's the Lialda or Purinethol or Remicade or a combination thereof, we get you through law school and into the real world with a job, and maybe a wife and a kid or two and a mortgage by the time you're thirty-six. After ten years of ulcerative colitis your risk of developing colon cancer increases substantially. Even if the colitis is not active and you're doing fine, the risk is still there. Cancer that develops on a background of ulcerative colitis is frequently a very bad actor that can sneak up on you and your doctor. We know based on the tests we've already done that your entire colon is involved. That adds to the cancer risk too. Jeffrey, you're single and otherwise healthy. Your parents and friends can help you get through this now. No one is really dependent upon you now. That's all likely to change by the time you're thirty-six. I'm sure Yale would grant you a medical leave for a semester. Instead of suffering flare after flare, the potential side effects of powerful medications, the ever increasing risk of colon cancer, you can be cured--I repeat, cured--with a colectomy. You won't need to have a colostomy. Dr. Levi will fashion an internal reservoir out of a portion of your small intestine and attach that to the rectal sphincter. You'll be sitting on the toilet to move your bowels. Maybe five times a day but with no urgency and no bleeding. Your life should return to normal within five months and with no need for all the pills you're taking now. Maybe an Imodium or two to cut down on stool frequency but that's it."

Jeffrey Friedman was succumbing to Dr. Yocum's onslaught of facts and figures.

"Okay, okay. You said there were two additional reasons I should consider surgery rather than continuing with medication. What's the other one?"

Dr. Angelina Vitale-Schwartz sensed that she was in the presence of a great clinician. A few hours earlier Yocum was a masterful technician, placing those clips on KK's grandmother's bleeding ulcer. But the skill he was demonstrating now was so much more profound. He was tailoring his language and terminology specifically for this particular patient. He was compassionate but forthright with his answers. He made eye contact with Jeff Friedman throughout their dialog.

"The other reason, Jeffrey, has to do with that vial of saliva you gave us before heading off to Yale."

Wow, thought Angie, here comes the coup de grace.

"We sent it to a company in California that did extensive DNA analysis on it. They were able to place your genetic blueprint in the same group of other ulcerative colitis patients I've had over the years who are also descendents of eastern European Ashkenazi Jews."

"And?"

"Well, the numbers are still small and may not yet reach statistical significance but the trend is definite. Medical therapy, even after Remicade became available, did not work. Almost all of them needed their colons removed."

It occurred to Angie that Dr. Yocum's arguments were like an attorney's summation to a jury. Apparently Jeff Friedman was receiving identical vibes. He said with a wry smile, "Maybe you should have been a litigator."

Yocum didn't miss the opportunity. "No, quite the contrary young man. By my becoming a doctor, your doctor--we may be increasing the chances of your becoming a successful lawyer someday."

Dr. Yocum had certainly given Jeffrey Friedman a lot to digest. Friedman promised to secure that second opinion at Sinai and get back to Yocum ASAP.

After Friedman left, Dr. Yocum corralled Angie and asked her "Now, what do you think gave me more pleasure today, clipping that spurting artery this morning or having that chat just now with Mr. Friedman?"

Oliver Yocum didn't wait for an answer. He just smiled contentedly and headed off to clinic.

CHAPTER SEVENTY-TWO

Fanny Kirsch rapidly recovered from the bleeding ulcer. Within three days, she was eating normally and ambulating with her walker. Her hemoglobin had stabilized and she was discharged back to Victory Memorial--off the Celebrex and on Prilosec. On admission, blood had been drawn to see if she had the bacteria in her stomach that was frequently associated with ulcer disease. That serologic test returned negative for Helicobacter pylori.

KK couldn't ignore the fact that an inappropriately prescribed medication nearly killed his grandmother. He decided to follow through on his concerns and placed a call to Dr. Perkins'office. He listened to a recording stating office hours and that the office was closed from 12-2 p.m. for lunch. KK looked at his watch. It was 2:15 p.m. He left a message identifying himself and politely requesting that Dr. Perkins return the call at his earliest convenience.

It was 2:30 p.m. the following afternoon when KK was paged by the Maimonides operator for an outside call.

"Hi, this is Dr. Kenneth Kirsch."

"Good Friday afternoon, Dr. Kirsch. Brad Perkins returning your call."

"Dr. Perkins, there was a patient at Victory Memorial. Fanny Kirsch--my grandmother actually, who had some worsening back pain a few weeks ago and the staff called you."

"To be honest with you, I don't remember the call. I've got lots of nursing home patients. Was there a problem?"

"Well, you prescribed Celebrex 200 mg daily and did not specify a stop date."

"And?"

"She developed a gastric ulcer that eroded into an artery and she had a massive hemorrhage. She needed IV fluids, transfusions, and an emergency endoscopy to stop the bleeding."

"Well, I'll be damned. I thought Celebrex didn't cause ulcers like Motrin or Naprosyn did. That's probably why I prescribed it."

KK could not believe what he had just heard. Celebrex certainly could cause ulcers, albeit to a lesser extent than the other nonsteroidal antiinflammatory agents. There was a black box warning on the package insert and in the PDR mentioning this. The warning also stated that the elderly were at particular risk and that the drug should be used with caution. KK, ever the diplomat, responded politely,

"That's not quite true, Dr. Perkins. It can cause ulcers. And my grandmother tested negative for H. pylori so we know that it didn't play a role."

"Tested negative for what?"

"Helicobacter pylori."

"Never heard of it. What's that?"

That pronouncement from Dr. Perkins stunned KK. It was absolutely inconceivable that any physician still practicing medicine hadn't heard of H. pylori. H. pylori, rather than excess acid is thought to play the major role in ulcer disease. Its description by an Australian pathologist, Barry Marshall, in the early 1980s was greeted with ridicule and derision. But twenty years later, Dr. Marshall had the last laugh, being awarded the Nobel Prize in Medicine for its discovery. H. pylori was constantly in the medical literature, both peer review and "throw away" journals, with various antibiotic regimens being prescribed and revised for its eradication. It was also thought to play a role in certain malignancies of the stomach. There were articles in the lay press and it was frequently discussed on the internet. Perkins' apparent total ignorance of its existence shook KK to his core. Rather than get into a discussion with him about H. pylori, KK responded "I just received an emergency page to the ICU. You can Google H. pylori. My grandmother is doing fine now thanks. Gotta go."

KK hung up the phone. His temples were throbbing. Someone had to do something about this Dr. Perkins. KK made an appointment to see the chief of medicine, Dr. Greene, first thing Monday morning.

CHAPTER SEVENTY-THREE

Dionne was more nervous than she thought she'd be. At least Julie had given her a heads up regarding what was special about this particular Friday night: It was the beginning of the Jewish festival of Chanukah, which celebrated the victory of Mattathias and his son, Judah the Maccabee, over the armies of the despotic megalomaniac Antiochus IV in 165 BCE.

She spent a few minutes reviewing its high points on Wikipedia before she met Julie for the drive to the Flatbush apartment of Natalie and Howard Berger.

Julie's parents met the couple at the door. Howard had a mustache and a firm handshake and Natalie reminded Dionne of June Cleaver from those old "Leave it to Beaver" reruns: She was neatly dressed, had obviously been to the beauty parlor earlier in the day, and was sporting a beautiful pearl necklace.

"It's so nice to finally meet you, Dionne. We've heard so much about you from Mitchell and Rosie. Julie here has been keeping pretty much mum about who he goes out with. But you've lasted longer than anybody!"

"Ma" protested Dr. Berger.

"Natalie" protested Mr. Berger.

"That's okay" responded Dionne calmly. "Maybe your son and I have a lot in common. Maybe that's why, as you put it, I've lasted longer than his other girlfriends."

Mrs. Berger was taken aback by Dionne's bluntness. Howard Berger was thrilled she didn't melt in his wife's presence. Natalie suggested that they all retire to the dining room and light the candles before sitting down to dinner. Mrs. Berger lit the single candle on the Chanukah lamp or Menorah as she and her husband and son chanted the blessings in Hebrew for the first night of the holiday. When they had finished Julie nodded to Dionne who then proceeded to recite from memory the English translation of those prayers. She did it flawlessly.

"Thank you, Dionne. What a pleasant surprise" said a genuinely touched Howard Berger.

"That was very nice, Dionne. I'm really very happy Julie finally brought you to meet us. I hope you weren't offended by my earlier remarks."

"Absolutely not. Good parents should take an interest in who their children are seeing."

"How's your mom doing? I haven't seen her in over twenty years. She is one fine woman."

"That's exactly what she said about you. When I first told Mother I had met a doctor at Maimonides named Julius Berger her eyes lit up and we soon figured out that she had worked for you when Mitchell and Julie were little boys. Small world."

Natalie Berger than lit the Sabbath candles and recited the blessing. Once again, Dionne followed with the English version.

Howard sliced the Sabbath bread or challah after saying the traditional prayer and passed a few slices around the table. Julie said the blessing for the wine and the four of them each took a sip of the sweet Manischewitz. Dionne did not offer any translations for these latter two blessings. Julie figured and Dionne agreed that that would be gilding the lily.

Natalie took Dionne by the hand and smiled. "Come! Help me in the kitchen. Let Julie and his father catch up on old news."

Howard Berger looked mildly astonished. "Julie, did you just see what I saw? Your mother inviting a stranger into her kitchen!"

"I told you she was special, Dad. I figured Mom would be a tougher nut to crack than that, but Dionne has a knack for effortlessly putting everyone she meets at ease."

"And you, son?"

"Oh, Dad. She's got me hook, line and sinker."

Howard Berger smiled as the ladies brought four bowls of steaming hot soup in from the kitchen.

~~~~~~~~~~

The conversation at dinner was monopolized by Julie and Dionne. Howard and Natalie Berger were quite content to listen to the stories their son and his girlfriend had to tell about their experiences and adventures at Maimonides. Some were funny, some were poignant, but in actuality they allowed the Bergers to learn something new and intriguing about the young lady their son was obviously crazy about. She was bright, articulate, compassionate and, judging by the way she was holding Julie's hand, quite enamored with their son.

After tea and dessert, Dionne paid Natalie Berger the ultimate compliment. "I don't do much cooking but you must give me the recipe for whatever you did to the halibut. It just melted in my mouth. I've never tasted anything so delicious. And those potato pancakes--what do you call them--latkes?--to die for!"

Natalie beamed from ear to ear and looked at her husband and son with mock indignation, "At least someone around here appreciates the time I spent in the kitchen this evening. Thank you, I'll write those two recipes out for you right now. Howard and Julie can load the dishwasher. Let's you and me sample a piece or two of that chocolate you brought from Bartons. That was so thoughtful. Thank you."

Mrs. Berger led Dionne from the table to the living room. Dionne looked back at Howard and Julie. Father and son were sitting there, each with their mouths open, each in awe of what they had just witnessed.

It was around eleven o'clock when Julie announced that they really needed to be leaving. Hugs all around and a very heartfelt thank you from Dionne to the Bergers for the delicious dinner and their wonderful hospitality.

Howard and Natalie walked the couple to the elevator. "Julie, I'll be very upset with you if you don't bring this lovely young lady around here more often" said Natalie sternly.

"Me too" said Howard.

"Me three" laughed Dionne, which prompted a gentle shove from Julie and approving nods from his parents.

~~~~~~~~~~

Later that night, Howard and Natalie Berger were staring up at the ceiling in their bedroom, talking about how incredibly different things were now compared with when they were courting.

"Natalie, all of this reminds me of Tevya and Golde from 'Fiddler' discussing how times have changed."

"I feel the same way Howard, but maybe we should count our blessings. If you told me twenty-five years ago that our boys would grow up and marry gentiles I would have died. Now Mitchell has married an oriental girl whose parents are from Vietnam and it's obvious that Julie likes this Dionne. Mitch and Rosie have told us that if they have children, God willing, they'll be raised Jewish. That was very nice of Dionne to say those prayers tonight. She seems very respectful of our religion. Like she told us, a year and a half at Maimonides has opened her eyes."

"Natalie, I haven't told you this yet but now's the perfect time. Remember when Mitch told us what a wonderful dinner he and Rosie had with Julie and Dionne a few weeks ago, the night they first met her?"

"Yeah, so?"

"Guess what they did before going to Sorrentino's."

"I don't know. Tell me."

"The four of them went to Friday night services at Beth El. Rabbi Levine met Dionne and they really hit it off. Julie asked me not to tell you this just yet--he didn't want to get your hopes up prematurely. But my guess is that if Julie ever asks her to marry him, she will convert to Judaism."

"From your lips to God's ears. And now that I've met her--gosh she's just so nice. Would it be too much to ask that both our daughters-in-law be Jewish? One oriental and one black but both Jewish?"

"Maybe not Golde, er, Natalie but please get the adjectives right--it's 2008. Asian, not oriental and African-American, not black."

"Right you are Tevya" she laughed, and the two of them hummed a few bars of "Anatevka" before falling asleep.

~~~~~~~~~~

"Dionne, do you have any idea how terrific you were tonight?" asked Julie as the two of them left the Bergers' apartment building and got into his car.

"No, tell me" she said with a smile.

"First, you didn't back down when my mom greeted you with that less-than-friendly remark. Then the blessings in English. Then accompanying her into the kitchen. Let me tell you--no one does that. Asking for her recipes. You get an A+ for effort and an A+ for results."

"I didn't know I was being graded. So do you think your parents believe I'm worthy of you?"

"Are you kidding? That comment by the elevator. They really meant that. You really impressed them. In just a few hours you got Howard and especially Natalie Berger to like you. I figured it would take days. Dionne, you make it so easy for people to like you. It's a special gift. Don't ever lose that. My folks aren't bad people--maybe overly protective of their sons, but even they warmed up to you in record time. I thought I had an easy time of it meeting Mr. and Mrs. Clark at your dad's birthday party a few months ago, but you actually seemed to be enjoying yourself tonight."

"I was enjoying myself. Don't you see, Julie, I've wanted for so long to meet the people who have made you you. I wasn't acting tonight. I wasn't trying to butter your folks up. They may be simple but they're not stupid. They would have seen right through that in a New York minute. They're warm and courteous and thoughtful. It's no accident you turned out the way you did. I saw those qualities in you when we first met. That's why I put up with your being such a wallflower at the beginning.

"Was it worth the wait?" Julie asked as he parked his car on Marlborough Road, across the street from his apartment.

"What do you think?" If there were any doubt as to that question's answer, it was easily erased with the kiss that Dionne planted on Julie's lips.

Just about the time Howard and Natalie were humming "Anatevka," Dionne and Julie were humming a tune of their own.

CHAPTER SEVENTY-FOUR

On Monday morning, Dr. Kirsch told his chair of medicine about the conversation with Dr. Perkins.

"Tell me, Dr. Kirsch. Would you be here telling me all this if the patient weren't your grandmother?"

"Believe me Dr. Greene, I've thought long and hard about that. I'd like to think that the answer is yes. Far be it from me to cast dispersions on someone in private practice who might not be up to speed on the current trends in diagnosis and treatment. But, sir, you've got to admit, to have never heard of H. pylori. Where has Dr. Perkins been? What, if anything, has he been reading? Even the throw away journals we all get every week have an article or two about it now and then."

"What would you like to do about your concerns, KK?"

"Me? Nothing. I mean I don't think there's anything I can do as a trainee. But if I do absolutely nothing then I'm part of that conspiracy of silence the public is always talking about. Our profession is criticized, and maybe rightly so, for doing a lousy job of policing ourselves. If this Dr. Perkins is as incompetent as I worry he might be, then someone needs to speak up. His patients may be at risk. I don't want to sound melodramatic but with one phone call he ordered a drug that gave my grandmother a bleeding ulcer. What about the patients he sees every day in his office? What about all the nursing home patients he told me he has? I certainly don't want to take away his livelihood but it seems to me I have some sort of obligation to all those folks. Dr. Greene, you have connections. You've been here for a long time. Maybe you can make some inquiries at the nursing home where Dr. Perkins has patients. If no one has any complaints, then I'll just shut up and consider the Celebrex, H. pylori business an isolated episode and never mention it again. But my gut feeling is that there are other Fanny Kirschs out there who may have already been hurt by him or may be at risk in the future if he is as out of touch as I think he is. If three months from now an old guy from Victory Memorial is sent to our emergency room and the workup reveals that Dr. Perkins' care or lack thereof was directly responsible, and we had done nothing to prevent that, I'd feel awful. Please, Dr. Greene, could you look into this?"

"KK, do you see that plaque on the wall next to the picture of me and Nat Bloom?" Dr. Greene pointed to an item on the wall behind him. Dr. Kirsch needed to stand up and walk around Dr. Greene's desk to read it. He then smiled and said to Dr. Greene, "Thank you, I take it you'll make some inquiries?"

"Yes I will young man, but this is strictly between you and me. Is that understood?"

"Absolutely, yes sir, and thank you again."

KK then left Dr. Greene's office just as the chief peered up at the plaque and whisked some imaginary dust from its frame. In beautiful cursive was the two thousand-year-old quotation from the spiritual leader Hillel, "If not now, when; if not us, who?"

CHAPTER SEVENTY-FIVE

Annie awoke unusually calm. It was almost as if she had made the decision in her sleep. She had envisioned her dessert shop and Noah's transcontinental sojourns but there was no baby anywhere in those snippets. She called Noah and left a message on his cell phone, "Noie, I have made up my mind. Details tonight. I will be at your place 7 p.m. I'll bring pizza and a salad."

~~~~~~~~~~

Jeff Friedman called Dr. Angie Vitale-Schwartz on her cell phone. He asked if she could arrange a joint meeting with Drs. Yocum and Levi.

"Yesterday I lucked out and was able to get that second opinion consultation from one of the colitis specialists at Sinai that Dr. Yocum had recommended. I am leaning towards surgery but I need a few questions answered. My parents want to come too."

Angie promised she'd get back to him ASAP and then called Muriel who in turn contacted Dr. Gabriel Levi's administrative assistant and an appointment was made for three days hence in Levi's office, and she confirmed all this with the patient and secured his permission to sit in on the discussion. Actually, Jeff Friedman was rather nice about it, "Dr. Vitale, you know my case almost as well as Dr. Yocum--maybe even better in certain aspects. I want you there. I think my folks might feel better if not everyone in the room were a heavy hitter."

"I'll be there. I may not say anything but I'll be there."

"That's all I'm asking. Thank you."

~~~~~~~~~~

Dr. Cabot was looking ahead to the next academic year. The Guillain-Barré research was going quite well and generating papers in peer review journals. Dr. Greene encouraged him to present that fascinating case report about Sissy at the Neurological Society plenary session and he was mobbed by dozens of clinicians for hours afterwards. There was ample funding for a higher salary and an appointment as a clinical instructor at Downstate. The only communication he had from the Websters was a heads-up from Donald that his sister would be sending Charles something she had been working on.

A few weeks later a package arrived with an NYU Film School return address label. It was a DVD. There was no accompanying letter and Cabot tossed it into his briefcase. If he were to view it at all it would be at his apartment, not at Maimonides. Just in case there were something really inappropriate on it, he hadn't invited anyone to look at it with him.

~~~~~~~~~~

Although Sorrentino's was the restaurant to go to for a three-hour, gut bulging feast, Spumoni Gardens on 86th Street had the best pizza in Brooklyn. Annie ordered a medium extra cheese and mushrooms and a large salad. She strode triumphantly into Noah's duplex just as he was arriving home from the city. "Let's eat first," she said and kissed Noah gently on the forehead. Noah Strong tried to guess what decision or decisions Annie had arrived at by observing her body language, her speech, her eyes. All to no avail. He just couldn't tell. He realized that he'd have to wait until after dinner.

"Noie, please don't interrupt until I'm finished. I've been working on this all day. I'm pretty confident that we're going to be together five years from now but I'm not one hundred percent sure. With my Aunt's money I can open that dessert shop--it will involve long hours and lots of sweat and tears but I really think it can be successful. You've got this terrific opportunity with that conglomerate but you'll be in New Zealand for long stretches of time and probably half jet lagged when you're not. What sense is there in having a baby now? Would I be able to give it all the love and attention it deserves? Would you? Sweetie, now is not the time. If we've cemented our relationship two or three years from now, I'd be thrilled and honored to have you knock me up again. I don't want to have a baby now. I don't want to risk resenting its presence, thinking that its existence might have prevented your making the most of that deal or my making as great a success of that dessert shop as possible. Selfish? I really don't think so. Sensible? Yes, and the longer I carry this embryo, the more difficult it's going to be. Adoption? Noie, I couldn't go through that head trip. I'm sorry."

"Why are you sorry? Possible adoption was on your list, not mine. Annie, I've been with you nearly two years. You might very well be the one. But I agree with you--this baby shouldn't be the thing forcing us to condense our own personal timetables. Let's have a baby in two or three years assuming we're still together and right now I'd bet even money on that. So what do we do now?"

"I called Planned Parenthood today. They referred me to a clinic where I have an appointment next week."

"I want to go with you."

"I wouldn't have it any other way. Now, let's enjoy dessert." And Annie retrieved some Not Mud Pie from the freezer which she had picked up at Not Lundy's earlier in the day. "Your damn Meckel's cost me a slice of this a few months ago. Not tonight. Tonight Annie and Noah start getting proactive." And within four minutes, two large wedges of Not Mud Pie were gone.

~~~~~~~~~~

There was no trailer nor title to Sissy Webster's DVD. There she was in a close-up with the peaches and cream complexion that Charlie Cabot recalled from Sissy's tomboy days but which was missing when she was hospitalized at Maimonides the summer before. Her hair was shiny and straight and cascaded over her shoulders. Just a faint hint of eyeliner. Gorgeous white teeth. Yet somehow she looked a little crestfallen. After maybe fifteen seconds she smiled and spoke directly into the camera.

"Charlie, I'm so sorry. I could easily blame the Guillain-Barré or the medication or the prolonged hospitalization but I won't. My behavior was inexcusable. Those letters I sent you were crazy. Maybe that was a stupid way to express my gratitude. Please forgive me. I don't want this to put a strain on our families' relationship or your and Donald's friendship. I promise you my head is on straight now. I fully understand that as my treating physician you're not permitted to have a social relationship with me and I'm not even sure you would ever want to. I just wanted to show you what I've been up to at NYU--both with my film class and dancing. Here are some highlights from both. The "Faces and Emotion" project got me an A. My dancing is more for fun and exercise than anything else but one of my friends insisted that I let him record it. Enjoy. No feedback necessary."

Sissy's visage then faded from the screen and was replaced by the title of her project, "Faces and Emotion." It was ten minutes of intimate close-ups of two students, one young man and one coed. The forehead, the eyes, the nostrils, the lips, the mouths' corners, the eyebrows changed imperceptibly slowly to allow one emotion to morph into another. Sissy was the lighting designer and the cinematographer. The work was exquisite. There was a barely audible soundtrack which segued seamlessly from emotion to emotion. The piece de resistance was obviously meant to denote sadness. It was evening. The models were peering out the window into the darkness. It started to rain. There were flashes of lightning. As the raindrops spilled down the windows, their shadows rolled down the faces of the boy and girl. A few blinks of the eyes but no real tears--just the raindrops. Wow, thought Dr. Cabot. This is good.

There were five seconds of credits and then suddenly Sissy Webster was wearing a pink leotard and smiling coyly at the camera. She was dancing with abandon. Stylishly modern, classically ballet and everything in between, she athletically roamed a huge stage. She reminded Cabot of Julia Stiles in the Juilliard auditions sequence from the 2001 film "Save the Last Dance." Splits, jumps, pirouettes while the music echoed whatever moves she was making. It was a magnificent seven minutes of choreography and then the camera zoomed in on Sissy's face, which was beet red, drenched in sweat and emanating pure joy. A few breathless nods to the camera, a final smile and the DVD was over.

Dr. Charles Cabot had to watch it again. In fact he watched it two more times that night.

~~~~~~~~~~

Jeff Friedman and his parents were cheerfully greeted by Gabriel Levi's administrative assistant and escorted into a very plush consultation room. There were photos and diplomas on the walls and several boxes, still unpacked, on the floor. There were enough chairs to accommodate everyone. Yocum and Angie and the GI fellow arrived shortly after the Friedmans. Levi came in last. Introductions all around. Then Friedman spoke first,

"I saw Dr. Milstein at Mount Sinai three days ago. We had a long talk. He reviewed everything with me. He said he might have given Remicade a try but that it was not unreasonable to proceed to a colectomy now. I think all that data about the saliva DNA analysis may have swayed him. He said your manuscript was very impressive."

"He had my manuscript?"

"Right there on his desk. Said he had received it just the day before."

"What a coincidence. Listen up everyone. I did not send my manuscript to Dr. Milstein. I sent it to the Journal of Gastroenterology for consideration for publication. Typically the editors send manuscripts on a particular topic to physicians considered experts in that field. Two or three usually. These referees will then render an opinion as to publish, not publish, or more often than not they'll suggest a revision or two. Jeffrey, I don't even want to hear what he had to say about the paper. That's not why we are here today. You decided on the operation, Dr. Vitale tells me. Dr. Levi and I are here to answer any questions you or your parents might have. Gabriel."

Dr. Levi then proceeded to describe what the operation entailed. He reassured the patient and his parents that he had a wealth of experience with this particular procedure and that Jeff's youth, otherwise good health, slender body habitus, and lack of current systemic steroids all portended uncomplicated surgery and a rapid and full convalescence. He drew pictures of how that internal pouch would be created from Jeff's own small intestines. This was a bit too much for Jeff's mother who broke into tears. Angie consoled her, much to the surprise of Dr. Yocum and even Angie herself. Jeff had obviously been doing his homework,

"Dr. Levi, what about this pouchitis I've been reading about. Am I going to be trading one problem for another?"

"Good question young man. An inflamed pouch can result in urgency and bleeding but to a considerably lesser extent than you've been having with the ulcerative colitis. It's easily treated with oral antibiotics. Every single one of my patients who has had a siege of pouchitis has said it was much easier to get through than recurring flares of the ulcerative colitis. Any other questions. From anyone here? No? Well let my administrative assistant come in and we'll get this scheduled for next week."

The surgery was obviously more intricate than Noah Strong's Meckel's diverticulectomy or Nat Bloom's right hemicolectomy but once again Levi's surgical skills were on display in the conference room outside the OR. Three hours from creation of pneumoperitoneum to removal of trocars, with negligible blood loss. Jeff Friedman went home on the sixth postoperative day. His diseased colon would never bother him again.

CHAPTER SEVENTY-SIX

The waiting room at the Planned Parenthood Clinic was filled with women of all ages from teens to forties. Molded plastic chairs lined the walls which were adorned with posters of Ansel Adams photographs. Noah was one of the few men present. There were information booklets on Planned Parenthood services printed in English, Spanish, French, Russian, Tagalog, and Vietnamese. Annie signed the register and within five minutes she and Noah were escorted to a brightly lit consultation room. Those awful film-noir images of dirty, dimly lit cubicles with coat hangers and hushed voices were replaced by soft music and the nurse practitioner who answered all their questions in a straight forward manner.

A urinalysis indicated that Annie was pregnant and an ultrasound which lasted no more than thirty seconds confirmed the pregnancy was intrauterine. Neither Annie nor Noah had any interest in viewing the images. Annie and Noah had already read about the so-called abortion pill but did not interrupt as the nurse practitioner described how the process worked.

Annie would be given a 200 mg pill of mifepristone before leaving the clinic. The drug, called Mifeprex, blocks the action of progesterone which is needed to keep the embryo attached to the lining of the uterus. The next day, in the privacy of her home, Annie would take 800 mcg of misoprostol which would cause powerful uterine contractions and expel the now detached embryo out of the uterus. Annie would experience severe cramping and bleeding, similar to a heavy period. And that was it. Annie would need to return to the clinic two weeks later for a repeat pregnancy test and ultrasound to confirm that the process was complete.

The nurse practitioner quoted some statistics for Annie and Noah. One fourth of early abortions in the U.S. are using this two-drug combination and a recent study of two hundred twenty-eight cases showed it to be 98.5 percent effective--i.e., a D&C would not be needed. Furthermore, the risk of infection had been reduced from one in 1,000 to 0.06 in 1,000. Simple. Almost too simple. But in her heart of hearts Annie knew that this was the right decision for her--and Noah. According to Planned Parenthood, one hundred eighty-four thousand American women used Mifeprex the year before. Annie knew that each of them had her own particular story to tell but she had absolutely no misgivings as she swallowed the mifepristone in the presence of the nurse practitioner.

She and Noah left the clinic holding hands. Noah was smart enough to offer physical comfort only. Annie did not need further words of encouragement at this point.

Noah insisted that Annie stay at his place in Bay Ridge. He came home from work early the next afternoon. They had a light lunch and at around 3 p.m. Annie swallowed the misoprostol tablets. She and Noah lay down to watch some soap operas but about an hour later she got up, silently, and went to the bathroom. It was happening. No screams, no yells and no responses to Noah's pleadings if she were okay. In thirty minutes she opened the door, came out and kissed a very worried Noah Strong on the forehead. Annie's cramps were fading but her eyes continued to moisten with tears. "It wasn't so painful as I thought it would be but I think it's over Noie. Please hold me."

Annie was drenched in sweat as Noah grabbed her and escorted her to the couch. He kissed her gently on the bridge of her nose and lay down on the floor beside her.

Two weeks later at the Planned Parenthood Clinic the ultrasound and HCG levels confirmed that the so-called medical abortion process was indeed complete.

CHAPTER SEVENTY-SEVEN

Dr. Angie Vitale-Schwartz had seen Jeff Friedman twice in the clinic following his surgery. These visits flip-flopped with Friedman's seeing Dr. Reddy in the surgery clinic. The patient was doing remarkably well. He had regained all the weight he had lost, was taking no medications and was having no problems whatsoever with that S-pouch reservoir. Yale Law was completely accommodating in regards to his resuming his studies in the fall, and in the meantime, there were several law school professors who needed assistance on research projects and they were more than willing to pay Jeff a stipend. Jeff's girlfriend was long gone, having left when he first got sick.

"So much for a fair weather friend," he told Angie unashamedly.

~~~~~~~~~~

Seth Rubin had two older brothers. Marcus had eloped with his college sweetheart the day after graduation. They were now happily married and living in New Jersey with their two children, a cat and a dog. Glenn married a lovely young lady who had been widowed when her husband, a bond trader at Cantor Fitzgerald, was killed in the 9-11 terrorist attack on the World Trade Center. She was left with two little boys and then had an absolutely precious daughter, April, with Glenn. As much as Seth's mom, Roberta, loved her daughters-in-law and delighted in her grandchildren, she had always wanted to be intimately involved in the planning of a wedding. The boys' bar mitzvahs were ancient history and, besides, a wedding was decidedly different. Fortunately, Sandy Rogoff's mom, Karen, and Roberta Rubin got along fabulously. Karen, the perennial worry wart, was quite willing to cede some decision making regarding the wedding to the more experienced Mrs. Rubin. Roberta was therefore very happy to be a codirector and coproducer of the ceremony, menu, photography, flowers, and music. Sandy also got along famously with her future mother-in-law and all the preparations were going smoothly. Indeed, there were plenty of decisions to be made regarding the particulars of the actual religious ceremony but even here Roberta and Karen seemed to be in agreement.

Sandy's home away from home for the past decade had been Maimonides; Seth had been there less than a year but was so very popular with the house staff, nursing staff, attending staff and administration that it seemed much longer. Seth and Sandy had originally planned on having a guest list of one hundred fifty but the numbers of friends and colleagues from Maimonides grew so quickly that the list swelled to nearly three hundred. That was fine with Roberta Rubin--the more the merrier! She and her husband promised the Rogoffs that they would pay for anything beyond one hundred fifty. The rabbi who had officiated at the bar mitzvah of the Rubin boys had retired and moved to Florida years ago. The Rogoffs were not members of a synagogue and when Sandy heard from Dionne what a lovely couple Simcha and Rivka Levine were, she and Seth met with them and were ecstatic to have the rabbi agree to officiate at the wedding, which was set for a Sunday in mid June.

~~~~~~~~~~

Angie received an e-mail at home from Dr. Yocum. He needed to talk with her first thing Monday morning, before she started rounding on the ward service as the senior resident.

"Angie, the young man who was coming here in July as a first year GI fellow called me late Friday. His mother is quite ill and he decided that family obligations necessitated his remaining in Boston. That opens up a slot here and I would be very pleased if you took it. Your inquisitiveness and growth this year have been exceptional. I don't believe the GI division or Maimonides would be settling if you accepted the offer. Talk it over with your husband and let me know by the end of the week."

"Wow, thank you. I'm very flattered. I was planning on working at an urgent care but this sounds terrific. I promise to have an answer for you by Wednesday."

Angie knew that the decision was really all hers anyway. Her dentist husband, Raymond, hadn't been a great a source of encouragement since the day they got married. She sensed that they were going through the motions at home, that what had been a torrid affair when she was a junior in med school and he just starting his dental practice was rapidly cooling off. He didn't seem the least bit interested in hearing about the fascinating cases she had been working on with Oliver Yocum. Their sex life had become more mechanical and when Angie brought these latter two issues to his attention, he responded by bellowing he didn't want to talk about it.

Angie was terribly worried that she might have married the wrong guy. She had yet to discuss her concerns with anyone. The vow she made was two-fold: not to become pregnant and not to mess around with anyone else until she knew for sure in which direction her marriage was heading.

~~~~~~~~~~

Dionne had signed on the dotted line to serve her PGY3 at Maimonides. She had received excellent evaluations from the senior residents and attending staff and was evolving into a reliable, competent, compassionate internist. There was talk of the American Board of Internal Medicine soon accrediting a geriatric fellowship at Maimonides and Dionne's remaining there would give her an advantage over other applicants.

Julie had asked her to move in with him. For once he was taking the initiative. She was happy to do so. His apartment in Flatbush was nicer than the basement apartment she had lived in since starting her internship. Plus it wasn't too far from the synagogue where she would be studying with Rabbi Levine. The conversion to Judaism was her idea, just as it had been Rosie's long before Mitchell had proposed to her. Dionne had little doubt that Julie would soon be asking her to marry him. His future professional plans were still a little up in the air. He was considering several job opportunities in the metropolitan area and was hoping to make a final decision within a month or two.

~~~~~~~~~~

Dr. Greene asked KK to join him for dinner at his home. This was in Manhattan Beach, an enclave of beautiful houses south of Emmons Avenue, separated from the busy shopping district of Sheepshead Bay by a tiny inlet where a few fishing boats were moored. Dr. Greene was a tenor in the Brooklyn. Doctors' Choir and also an amateur chef. He was encouraged by his late wife to pursue these hobbies. It was not at all unusual for him to host dinner parties, sometimes for as many as eight or ten interns and residents, sometimes for as few as one or two.

KK was not too surprised to see that he was the only guest this evening.

Dr. Greene got right to the point over hors d'oeuvres.

"KK, we have two things I need to talk to you about. First of all, I'm not aware of your plans come July."

"That's because I haven't finalized them. One of the cruise ship lines has offered me a job as a ship's doctor. I get to travel and the pay is okay. I don't have any real obligations here in the states. There is only one thing that's making me hesitate to accept the job."

"What's that?"

"Well. I'm not really interested in private practice. I was thinking of a career in academic medicine and I don't think a year as a ship's doctor would enhance my resume."

"You might be right there, KK. Maybe I have a solution for you. Next year, we may have a program in geriatrics. Two slots. Dionne Clark has actually expressed an interest. I think the two of you would make a great fellowship team."

"I'm sure we would. She's a good doctor. I was her resident for three months on the ward service last year and we worked together in the emergency room this year. Her judgement is superb. The nurses think she's wonderful. You may not be aware of this, Dr. Greene, and it's really not relevant but it's not a secret either. She and Julie Berger are living together. She is studying with a rabbi. I wouldn't be surprised if they get married next year."

"Trust me, KK. I'm more aware of my house staff's romantic exploits than you might think."

"But even if I accept your fellowship offer what do I do until then, ship's doctor, locum tenens, urgent care? None of them will increase my changes of landing a position in academic medicine."

"You could be my chief resident."

KK wasn't sure he had heard Dr. Greene. "Chief resident? I thought Julie had that sewed up months ago."

"Well, he had. But Nat Bloom came to me recently and asked my permission to speak with Julie about his joining him in practice. Nat needs to slow down a bit, KK, you know that better than anyone. Nat's been a fixture around Maimonides for more than twenty years. I wasn't about to say no to his request. Anyway, they're still talking about it. If Julie joins Nat in practice, I want you to be my chief resident. It would be a perfect segue into that geriatric fellowship and would keep your exemplary resume intact."

"What can I say? I'd consider it an honor to serve as your chief resident. Any idea when Julie will give you a definite answer, one way or the other?"

"He said by the end of next week."

"Wow, thank you again. I presume mum's the word until all of this sorted out."

"That is correct. Now, remember I said there were two things we needed to discuss?"

"Yes?"

"Well the following is even more confidential than the Berger/Bloom negotiations. It would appear that your hunch about Dr. Perkins was correct. A former resident of mine--you don't need to know who--is good friends with the medical director at the nursing home. It didn't take too much convincing to have the medical director look at the charts of the patients who died at Victory Memorial over the past three years. All together there were maybe one hundred eighty charts that an impartial reviewer from Upstate looked at. He knew none of the doctors and was not told what to look for."

"And?"

"Well, this internist from Syracuse pored over these charts for sixty hours and came to the conclusion that only one doctor had delivered substandard care but that the level of that substandard care was so abysmal that 'although it wasn't his province to do so, (he) would recommend that Dr. Perkins be subject to disciplinary action by the Medical Board of New York State.' When the director received the report he was very upset. Apparently, he had given Dr. Perkins a little break in not reporting him to the authorities when some billing irregularities were discovered last year. Well, he wasn't about to ignore these new allegations. So two weeks ago he confronted Dr. Perkins with all this and suggested he get legal counsel. Two days ago, Perkins sent a certified letter to all the hospitals and nursing homes that he admits to stating that effective immediately, due to a medical disability, he was resigning from their staffs and assigning his patients to Drs. X, Y and Z for ongoing care. If you telephone his office now, you get a comparable message on the machine."

"Wow, I wonder why he's not fighting it."

"Who knows? Maybe he knew that any formal investigation would reveal even more scary skeletons in his closet. By resigning now he gets to keep his license but I can't imagine his doing much more than insurance physicals. I can live with that. You'd better be able to."

"Sure I can. At least all those other grandmothers out there are a little safer with Perkins no longer prescribing Celebrex for back pain. Thank you for all the trouble you went to, Dr. Greene."

"No, no. You're the one who should be thanked KK. All too often we look the other way when one of our colleagues has a bad outcome saying 'there but for the grace of God go I.' But Perkins' actions were so beyond the pale that even a resident in training--you--sensed that something had to be done. This was not a witch hunt. We have had an outside reviewer with no ax to grind come to the conclusion that Dr. Perkins should no longer be practicing medicine. KK, your sense of right and wrong is one of those subjective qualities that will make you a successful chief resident."

"If Julie joins Nat, I'm yours."

~~~~~~~~~~

There was another invitation awaiting KK's attention. When Dr. Kirsch returned to his apartment after that dinner with Dr. Greene a message from Allison Kincaid was on his answering machine. She, too, wanted to have dinner with him but she insisted on two things--that KK choose the restaurant and that she pick up the tab.

KK called Alli back and recommended a restaurant in Greenwich Village, Danal. It served Mediterranean/French cuisine and its owner, Danny, had recently moved it from 10th Street to Fifth Avenue near 13th. KK also suggested they make it for lunch on Saturday. Alli was planning on visiting the Bianchis Saturday morning but a brunch at Danal's at around 2 p.m. was agreed upon. KK, who knew Danny well, told Alli he'd meet her there.

Jenna Bianchi was doing just a little better. She wasn't nearly so intense while she stacked her blocks and found songs a bit more frequently that her little brain decided to sing. Alli was certain now that Jenna did make and maintain some eye contact with her and Maria noticed this too. All three Bianchi girls and their mom seemed so sad when Alli said goodbye around 1 p.m.

"Thanks for coming again, Alli. You have no idea how much these visits mean to us."

"And you probably have no idea how much these visits mean to me. You are such an amazing woman. You're not only coping with all this, you seem to be thriving."

Alli gave Maria a big hug before settling into her car. They both had tears in their eyes.

~~~~~~~~~~

KK took the subway into Manhattan and spent the morning visiting some of his old haunts in the Village. Out-of-print book stores, antique shops on Broadway, Washington Square Park with its chess players and frisbee tossers--the neighborhood seemed stuck in a time warp. NYU had taken possession of a few more buildings but otherwise the area hadn't changed much. Allison was waiting in front of the restaurant when he arrived at 1:55 p.m.

"KK, good to see you and great suggestion to make it a Saturday lunch--parking was so much easier."

"I used to spend a lot of time in the Village when I was in college and med school. I always get great vibes here. I'll bet you love Danal's too. The food is great, the place quiet, almost intimate, and Danny never rushes you out. So what does Miss Kincaid want to chat about today?" asked KK as he opened the door for her.

"KK, I've been doing a lot of thinking...."

"Oh, no, Alli not again," chimed in Dr. Kirsch with a little laugh. But he could immediately tell from the forlorn expression on her face that something was really bothering Allison.

Danny personally greeted the couple and after some small talk and menu suggestions he headed for the kitchen, leaving Alli and KK at their table overlooking the foot traffic on Fifth Avenue.

"KK, we've been friends for maybe two years now but I've never asked you when you first sensed that you were gay."

"And why are you asking me now? I'm not upset, just curious."

"You'll see why by the time we have dessert."

"Okay, Alli. I was in high school. I just wasn't participating in the same conversations and games the other guys were. There was plenty of talk about how far you got on a date--first base--second base--you know, that sort of stuff...but it didn't interest me. For a while I thought maybe I was a late bloomer but that wasn't the case. I didn't have sexual fantasies about doing it with a girl like my male classmates did. I certainly didn't have fantasies about a sexual encounter with guys either. I just enjoyed women's company more and never felt any sexual tension with them. In the old days I might have been called a sissy. But I liked art and music more than football and chugging beer. It wasn't until college that I met men with similar interests. We became very good friends. We'd have talks into the wee hours of the morning about all this. I'm just wired differently than straight guys. Although I've really adored many women--you're on that list--my visceral emotional attachments have been to men. Hollywood still hasn't got it right. 'Brokeback Mountain' came close but even that concentrated a bit too much on the physical. It's a lot more complicated than that. But I'm happy with who I am. Enough about me. What's in Alli's past?"

"I've told very few people about Stefano."

"Stefano?"

"Stefano Medici--yes, those Medicis. Do you remember I spent my junior year in college at the Sorbonne?"

"Sure, you've mentioned it a dozen times. French literature. Nineteenth century playwrights. Becoming fluent. But you've never mentioned Stefano."

"KK, he was an Adonis, from Rome with a lineage going back centuries. Top student at University of Bologna and then he came to the Sorbonne to study art history. I think his family was incredibly tight with the mucky mucks at the Vatican and Stefano was being groomed to preside over the treasure trove of Vatican artwork. After the dweebs and grinds at Princeton, he was incredible. I wasn't looking for a relationship--I was there to study. What was I, twenty-one? He was twenty-three or twenty-four and the most attentive, caring, funny, bright, inquisitive--I could go on and on--man I had ever met. He had no trouble sweeping me off my feet. We soon became intimate and no one has come close to giving me the pleasure he gave me in bed. My God. The expression Latin Lover had to have originated with him. The most interesting thing is how we communicated. His English was rudimentary and my Italian was nonexistent. We spoke French and it seemed so natural. How I managed to pass my course while falling in love in Paris is beyond my comprehension. I had never been so happy."

"No fairy tale ending I take it. What happened?"

"One day he was gone. Poof. Summoned back to Rome by his parents. No goodbye kiss. No letter. No explanation whatsoever. His roommate told me that Stefano promised to contact me in due time, but he never did. I was heartbroken. I had to return to Princeton for my senior year. The Sorbonne mailed a newsletter to all the recent students updating them on everyone's exploits and accomplishments. It was in French of course. And around Christmas--I was home with my family in Rhode Island--and the Sorbonne paper arrived detailing the wedding of Stefano Medici to some Cathy Catholic, officiated by the Pope himself!"

"No way!"

"Needless to say, I was numb. My folks had no idea why I was so upset. I confided a little bit to my sister but nowhere near to the extent you're getting today. I led my parents to believe I was upset over not having definite career plans post graduation. But my grades, GREs and some great letters from my professors got me into Wharton's MBA program. The guys I met at Wharton were only interested in securing top-paying jobs as investment bankers or stock analysts. Boring. Unimaginative between the sheets too. I missed Stefano so much. We meshed so beautifully but I guess it wasn't meant to be. I subsequently found out that the girl he married also came from a prominent family with a pedigree going back generations. The Holy See was quoted as to how happy and thrilled they were to see the Vatican's treasures managed by such a bright and articulate young man as Stefano Medici. What they left unsaid was how happy they were he married a devout Catholic and not some WASP from Rhode Island!"

"Come on, Alli, did you two ever really discuss marriage?"

"Not exactly but some of the things he said led me to believe that that might be in the future. Don't you think, KK, that I've asked myself a million times whether I misinterpreted his intentions. Did I lose something in the translation? Remember, my definition of fluency is not having to translate--he was speaking in French and I was thinking in French. Was I his final fling?"

"I'm so sorry for you Alli. But what does this have to do with my sexual orientation?"

Before Alli could answer the waiter cleared away their entrée plates and told them what was available for dessert. Both KK and Alli ordered the three-flavor sorbet.

"Well, it's only recently that I've developed strong feelings for someone, not so much in a sexual sense but I just want to be with this person more and more, to share my ups and downs with this person, to really open my heart like I haven't done since Stefano."

"And might this person be Kenneth Kirsch, M.D.?" asked KK with a smile as he stroked Allison's hand across the table.

"Oh God, oh no, I'm so sorry to have led you like that. No, no, no. It's not you KK but I need your advice. That's why I asked about your sexual awareness."

"My advice about what. Who's this person?"

"I'm wondering whether I might be bisexual. It's Dr. Bianchi's wife, Maria."

KK was more surprised than shocked. He gently retook Allison's hand, actually both hands. "Listen carefully, Alli. Having sympathy and empathy doesn't make you bisexual. You admire Maria and from what you've told me she's had to deal with, that's quite commendable and appropriate. Whatever his true intentions, this Stefano jilted you and hurt you badly. You've been gun shy ever since and maybe now I know why. From what you tell me of your short but sweet affair with Stefano, you're hopelessly and eternally heterosexual. I don't buy for a minute that you might be bisexual, but even if you were, what could you do about it? Profess your love to Maria in front of Joe and their daughters? I don't think so. Alli, get that idea out of your pretty head. You're vulnerable, you've been hurt, you're confusing emotions. Do be her good friend. Do be her confidante, but I assure you there's a lucky guy out there who will someday make your Stefano a distant and fuzzy memory."

Alli mulled over KK's words as they finished the sorbet.

"KK, why couldn't you have been straight. You're so smart. You're so nice. You're so good for me."

"Alli, if I were straight we would not be having this conversation."

"Tell me, what would we be doing instead?" Alli asked with a smile.

KK knew that she already knew the answer but he blurted it out anyway, causing the waiter to blush as he placed the check on the table in front of him.

"We'd be fucking each others' brains out, night and day and twice on Sunday."

"No argument there--and lunch is on me, remember?" Alli grabbed the check, stood up and gave KK a big hug. "Thank you KK, I needed that. I really did."

"My pleasure, as always. Would you like to walk around the Village? I can give you my personal guided tour."

"I'd like that very much. Thank you again, KK. I really mean that."

"I know Alli, so do I."

CHAPTER SEVENTY-EIGHT

Wedding invitations were sent out in late April. More than half the invitees had connections to Maimonides. KK received an invitation that included a guest as did Dr. Greene. KK called Alli immediately and asked if she would accompany him to the Rogoff/Rubin nuptials. She didn't hesitate a moment before saying yes.

Dr. Greene thought long and hard about whom he might ask to join him. He had not been socializing much since his wife died but a light bulb went off in his head and he made some phone calls and finally got the person he was looking for. Yes, yes she would be thrilled to be Dr. Greene's date for that Sunday afternoon in June.

Dr. Angie Vitale's invitation was addressed to her husband, Dr. Raymond Schwartz, D.D.S., and herself. Raymond pointed out that he was already registered for a postgraduate course in Atlantic City that weekend and that he "had no intention of going to a wedding where I won't know anybody anyway." He insisted that Angie go without him and even gave his okay for Angie to ask someone to go with her in his stead. "I'm sure you can find someone who would like a free meal and some entertainment."

Angie could only think of two things--what a real jerk her husband was proving himself to be and whom she'd ask to accompany her, and then it hit her--Jeff Friedman. She still had his cell phone. She called and left a voicemail. Jeff Friedman returned her call the next day and yes, he'd be honored and thrilled to escort her. It would also give him the opportunity to see many of the Maimonides doctors and nurses who had cared for him months previously; now he would be able to interact with them as a fully recovered, healthy wedding guest rather than a sick patient.

~~~~~~~~~~

Sissy Webster had told her parents about the wonderful ICU nurse at Maimonides who was at her bedside when the miracle occurred. John and Priscilla contacted the nursing office and made a sizable donation to the Nursing Education Fund to honor Sandy Rogoff. Months later the administrative assistant to the head of nursing let the Websters know that Sandy had become engaged and the Websters then contacted Karen Rogoff and Roberta Rubin and asked if there were anything they could do to make the upcoming wedding an affair to remember. Sandy and her mom and future mother-in-law were trying to do something special with flower girls. Would the Websters be willing to pay for the girls' dresses? Affirmative. How about as many as eight? Affirmative again. And who would those eight flower girls be? Seth Rubin's niece, Glenn's daughter April, followed by the former chief resident's little girls Jenna, Jessica and Joy, followed by two sets of Gabriel Levi's twin daughters. Was Roberta Rubin worried that this was a bit over the top? Not in the least. And the Bianchis and Levis were not at all upset that someone they'd never met would be footing the bill for their daughters' dresses and matching shoes.

Marcus Rubin would be his brother's best man and Sandy's cousin, Ariel, would be maid of honor. Marcus' son, Adam, would be the sole ring bearer. The three groomsmen were a boyhood friend of Seth's, Glenn, and Dr. Greene. Sandy's bridesmaids were to be a friend from nursing school, another cousin, Zoey, and much to her surprise when asked to do so, Dr. Dionne Clark.

CHAPTER SEVENTY-NINE

Annie went full speed ahead in establishing the dessert shop. Annie's Assets opened for business less than two months after her abortion. Licences from the city and health department were secured with uncanny speed as Annie completed the requisite forms in person rather than by mail and paid the licensing fees by money order. Her biggest expenses were the special ovens and freezers. She had promised all along that she would not skimp on ingredients: Swiss chocolate, Fancy Patent flour, and premium nuts and fruit were a must. Her shop was quaint and cozy, accommodating thirty people at one time. A lunchtime business was supplemented in the evening by the crowd exiting the Dyker movie theatre about a block away.

She and Noah brought day-old leftovers to the doctors' lounge at Maimonides where the reviews were uniformly raving. By late May, cash flow was positive but Annie was hoping to do more special and custom order dessert catering.

~~~~~~~~~~

Everything had gone incredibly smoothly with Sandy's and the bridesmaids' dresses. The owner of the Brooklyn Bridal Shop, Brenda Reiss, had been a patient at Maimonides the year before and spent a scary couple of days in the intensive care unit with severe gallstone pancreatitis. When Sandy and her mom first went looking at dresses, Brenda recognized Sandy and immediately promised to put together a package that no one in New York City could match. Sandy looked terrific in everything she tried on. It was a difficult decision, but a Vera Wang gown won out. The bridesmaids would wear mint dresses by Melissa Sweet. Brenda was most accommodating in opening early or staying late for the bridesmaids' measurements and subsequent fittings. All the flower girls needed to do was have Mommy send in dress size and shoe size and Brenda would take care of the rest.

The men in the wedding party had it easier: Black tie for everybody. The tuxes didn't even have to match.

Sandy and Seth had chosen a band after hearing it perform at another wedding. Five excellent musicians and two really good singers.

Roberta Rubin dealt with the florist and arranged for unique centerpieces and a beautiful lattice work of orchids, begonias, roses and lilies to decorate the chuppah.

So as not to offend anyone who might be more observant, bar mitzvah and wedding receptions generally served fish (usually salmon) as the entrée, rather than meat or poultry. Roberta's idea, and quickly agreed to by Karen and Sandy, was to have a dairy brunch. Guests would arrive at 11 a.m., not for the ceremony but an hour-long nibbling of Danish and rugaluch with orange juice and coffee or hot chocolate as the only beverages. The wedding party would have arrived much earlier, allowing the photographer to take pictures in the more flattering early morning light and before the expected heat of a June afternoon which might cause hair to frizz and brows to sweat.

Immediately after the forty-minute ceremony would be the reception. The caterer at the Brooklyn Botanic Gardens Palm House would have three chefs custom making omelets and souffles for anyone who so desired. There would of course be the usual bagels, lox, smoked white fish, Israeli salads and fresh strawberries, kiwi, pineapple, yogurt of all flavors and scrumptious pastries. The Palm House was actually a Victorian greenhouse "where the magic of the setting is enhanced by the finest cuisine, expertly prepared and beautifully presented."

Zagat had given the restaurant an excellent rating.

Roberta and Karen and Seth and Sandy had planned as best as possible. Of course, they would have no control over the weather and some minor glitches were all but inevitable.

~~~~~~~~~~

The first glitch, and as it turned out the only one, occurred nine days before the wedding. The dessert chef at the Palm House had flown over the handlebars of her bicycle and fractured her right collar bone and left wrist. The very next day her apprentice, a young man who had studied at the Culinary Institute of America in Hyde Park, underwent an emergency appendectomy. The caterer notified Roberta, Karen and Sandy by e-mail and outlined the options available to them. Sandy then had a brainstorm: Why not use Annie's Assets? The caterer was reluctant to do so but after she sampled Annie's delicious creations she easily changed her mind. The Palm House's state-of-the-art facilities plus no-expense-spared ingredients added to Annie's magical touch and imagination would result in a dessert selection that was exquisite and which everyone would talk about for weeks after the affair. The three-tiered wedding cake itself, previously contracted by a different vendor, was indeed delicious but wound up playing second fiddle to Annie's Assets.

~~~~~~~~~~

Early June in Brooklyn was hazy, hot and humid. The meteorologists' prediction of a fast-moving cold front swooping down from Canada Saturday night came true. There were violent thunderstorms but by the time the sun rose on Sunday morning, the temperature had dropped into the fifties and the humidity into the forties. The sky had never been more blue nor the flowers and blossoms at the Brooklyn Botanic Gardens more brilliant.

~~~~~~~~~~

KK had suggested that Alli sleep over at his place Saturday night. He insisted that she sleep in his bed. He would sleep on the couch. As beautiful as Allison was, nothing could prepare KK for the sight of Miss Kincaid when she emerged from KK's bedroom after showering, doing her hair, dressing and sparingly applying her makeup. She was wearing a red satin fan dress which left her right shoulder bare. She could easily pass for a Victoria's Secret model, and she knew it.

"Last chance, KK, are you sure you're not straight?"

"Don't tempt me, that's not fair," KK laughed. "Are you sure my Grandmother Fanny didn't put you up to this?"

~~~~~~~~~~

Angie Vitale buzzed Jeff Friedman up to her apartment. Whenever he had seen her before, she had always been wearing her white coat over a blouse and skirt or slacks. Hair in a ponytail or in a bun. Little or no makeup.

"Wow," escaped his lips in an audible gasp as she opened the door. There, standing in front of him was Dr. Angelina Vitale Schwartz, not some homely medical resident but an absolutely gorgeous creature in a strapless party dress with frills below the waist. Its pale pink contrasted perfectly with her olive skin. Her raven hair cascaded over her shoulders.

"You sure don't look like my doctor," is all he could manage to say.

"I'll take that as a compliment. And at least for today it's Angie and Jeff, okay?"

"Sure. I don't mean to sound tongue tied but I can't believe how great you look. Your husband is a very lucky man."

Dr. Vitale wondered how she might respond to that statement,

"Well that lucky man is ninety miles away in Atlantic City learning all about dental veneers so let's not give him a second thought. Today you and I are going to celebrate Sandy and Seth's wedding with a bunch of folks from Maimonides, many of whom you've already met. You look terrific yourself--this will be a sort of triumphant return for you. Let's have a blast."

~~~~~~~~~~

The bridesmaids' dresses were Grecian Goddess in style. Julie's breath was taken away when he saw the finished product on Dionne. That bare brown shoulder and collar bone were ever so enticing and Dr. Berger couldn't resist a little nuzzling.

"Not now Julie," cooed Dionne as she gently pushed him away.

"Later then?" asked Julie with a raised eyebrow.

"Only if you behave yourself at the wedding," said Dionne with an admonishing smile.

Julie thought to himself "if she only knew" but answered, "Okay, okay, I can wait."

~~~~~~~~~~

Dr. Greene had told Sandy Rogoff and no one else who his guest would be. Sandy thought it was a wonderful idea and promised not to tell anyone. Because Dr. Greene was one of Seth's groomsmen, he needed to arrive early for pictures. He had made arrangements for a car service to pick his guest up at the Manhattan Beach Hotel and get her to the Brooklyn Botanic Gardens by 11 a.m.

~~~~~~~~~~

The entire bridal party was punctual and the photographer was very efficient. All the formal photography was completed a full half hour before guests started arriving at the Gardens. The walkways were still damp from the overnight rain but the place looked and smelled awesome. Mini Danishes and rugaluch, all baked that morning under Annie's supervision, were gobbled up as quickly as the staff presented them on ornate silver trays. Orange juice, coffee, espresso, hot chocolate or tea were the only beverages served--no alcohol on Sandy's order until the reception.

At about 11:15 a.m., a stunning young lady made a beeline to Dr. Greene, who was chatting with Dr. Levi and his wife. Sissy Webster turned heads as she gently grabbed Dr. Greene's arm. She was wearing a midnight blue, draped waist prom dress which did not exactly hide her ample cleavage.

"Gabriel, Esther, let me introduce Abigail Webster to you. She was the first patient in our Guillain-Barré study last year. As you can see, she's done quite well."

Gabriel gave Sissy a warm handshake and Esther bussed her gently on the cheek. Sissy pulled Dr. Greene aside, "I don't see him. Are you sure he's coming?"

"He told me he was."

"Is he bringing a date?"

"He told me he wasn't."

"Dr. Greene, I'm just so nervous. I've grown up so much since Charlie last saw me. I hope he knows that. I hope he looked at that video I sent him. Let me thank you again for inviting me and keeping it a secret. What a surprise it will be. And Sandy has asked me to sing a song. She already cleared it with the band. You'll be introducing me."

Just then Dr. Greene smiled and lofted his eyebrows and tilted his head to the left. Sissy turned around and about twenty feet away was Dr. Charles Cabot, looking quite spiffy in a Brooks Brothers tuxedo. He had finally ditched that pompadour for a more flattering style. He was chatting with Dr. Vitale and Jeff when Angie asked, "Who's that pretty girl with Dr. Greene?"

Charlie turned around and could not believe his eyes. His mouth opened wide, "Oh my God, that's Sissy."

"Who?" asked Angie.

"Sissy Webster. A patient in the ICU last year. You never covered her. She had--HIPAA prevents me from going any further. Actually, she's an old family friend from Boston."

"Looks like whatever was wrong with her didn't leave any long lasting side effects. She's a knockout. And look Dr. Cabot, sorry, Charlie, she's waving to you," noted Jeff.

Angie said with mock disdain, "Is that all you guys think about--looks? Okay, she's got a great staircase, but does she have anything upstairs?"

"Oh yes," volunteered Charlie. "She's very talented." He proceeded to tell Angie and Jeff about the DVD she had sent him months before. Of course, he said nothing about the mash letters.

Dr. Greene and Sissy approached Charlie and Angie and Jeff. There were handshakes and hugs all around.

Dr. Greene asked Dr. Cabot if he had brought a guest. When Charlie answered no, Dr. Greene volunteered that he wasn't much of a dancer and he would be thrilled if Charlie would squire Miss Webster around the dance floor during the reception.

"It would be my great pleasure to do so." Dr. Cabot put two and two together very quickly. If his boss, the highly respected, revered and august chief of medicine at the Maimonides Medical Center had invited Sissy to be his guest, it had to be for the express purpose of getting the two Bostonians together again. If Dr. Greene were the instigator, then perhaps Charlie would not have to wait another year before having a "relationship" with a former patient.

~~~~~~~~~~

Jenna, Jessica and Joy Bianchi looked adorable in their matching baby blue dresses. Their flaming red hair and blue eyes were beautifully highlighted by what they wore. Maria and Joe Bianchi sat their daughters down at a little table and kept them happy by feeding them some delicious munchies that Annie had baked that morning. Maria and Alli were admiring each other's dresses when Joe took KK aside.

"KK, this might not be the proper venue but please let me apologize."

"For what?"

"For being such a prick when I was chief resident. There was a lot going on at home with my coming to grips with Jenna's autism and I just dumped on you and Julie Berger, probably because you two didn't seem to have a problem in the world. Not very mature on my part. I'm sorry."

"Hey Joe, apology accepted. That's water under the bridge anyway. Alli tells me that all the Bianchis are doing a whole lot better and that she and Maria have become best friends. I think we're sitting at the same table at the reception. Why don't you two sit with us during the ceremony?"

"That would be great so long as Maria can sit on the aisle so she can take pictures when the girls come down with their little baskets."

Allison pointed out a particularly good looking young man to KK. She figured he must be one of the groomsman as he wore a boutonniere identical to the one Dr. Greene was sporting. He wasn't wearing a wedding band so it was unlikely that he was Seth's brother, Glenn.

Alli kiddingly whispered to KK, "If he's gay, he's yours. If he's straight, he's mine."

KK responded, "Let's find out then." And before Alli could protest, Dr. Kirsch strode over to Dr. Rubin and the groomsmen and engaged in a minute's conversation before Dr. Rubin had to excuse himself--it was time to sign the ketubah. Now KK was chatting with Seth's boyhood friend and gesturing towards Allison. The groomsman gave a little wave and then he and Dr. Greene and Dionne and the other bridesmaids all disappeared into the ready room as the ceremony was to begin in about ten minutes.

KK returned to Allison's side. Alli asked, "Why didn't you bring him over and introduce me?"

"The entire wedding party had to get ready for the procession. You saw that. But don't worry. He seems as intrigued by you as you are by him. He definitely wants to meet you. Sandy's bridesmaids haven't captivated him."

"He told you that already?"

"Not exactly, but I can tell from the way he was looking at you he is very interested."

"What's his name? What does he do? I'd like to know something about him before you introduce the mystery man."

"He is James Carpenter. He and Seth have been friends since grade school. Alli, he is a bit of a Renaissance man."

"What exactly do you mean?"

"Well I didn't get the details--you can do that later. But he graduated from Cornell where he played varsity baseball. He got his Ph.D. from Brown last year and just joined the NYU faculty."

"Anything else?"

"He is a classical guitarist."

"Wow, is there anything he doesn't do?"

"That's for you to find out, my dear."

~~~~~~~~~~

All during the pre-ceremony juice, coffee and Danish hour, a string trio was playing love songs from Broadway musicals. The violin, viola and cello played softly and flawlessly. Only when the bridal party disappeared into the ready room did a flutist join the trio for the wedding processional. Julie had spoken to Sandy who had secured permission from both the string trio and later the band for this particular flutist to play with them.

As the wedding guests were being seated for the actual ceremony, Rabbi Levine, Sandy, Seth and two witnesses signed the ketubah. This traditional wedding contract was written in Aramaic and details the husband's obligation to his wife--namely to provide food, clothing, shelter and pleasure. Like many couples, Seth and Sandy had actually commissioned an Israeli artist to create a ketubah exclusively for them. It was exquisite. The rabbi and witnesses practiced writing their names in Hebrew several times before actually signing the ketubah with a special pen and scribe's ink.

The final custom before the actual ceremony was for Seth to veil Sandy, making certain that she was indeed the woman he was about to marry. In the Bible, Jacob did not see his bride's face beforehand and was tricked into marrying the wrong sister, Leah, instead of Rachel.

Two hundred eighty or so guests sat on white painted wooden chairs that had been placed on a beautifully manicured lawn--it resembled the first cut off the fairway at Augusta National. There were fourteen rows of twenty seats each, ten on either side of the center aisle which was wide enough for three people to walk comfortably abreast.

At precisely noon, the violin, viola, cello and flute started playing Pachelbel's "Canon in D." KK was seated next to Alli who was next to Maria who was on an aisle in the fifth row. Joe Bianchi was seated behind her and he wielded a small camcorder while Maria had a new digital camera. All the seats had four-page booklets on them letting the guests know a little about a Jewish wedding and who was in the procession.

First down the aisle was Rabbi Levine. He wore a blue suit and a red tie and a beautiful handmade skull cap. He gave a nod of recognition to Julie who was sitting in the second row. As the rabbi mounted the two steps to the wedding canopy or chuppah, the couples' surviving grandparents came down the aisle. They were then escorted to reserved seats in the first row. Next came the three groomsmen in rapid succession, Glenn Rubin, James Carpenter and Dr. Greene. Alli thought that James Carpenter winked at her as he strode down the aisle. KK thought so too. Dr. Greene waved to and smiled at Charlie Cabot and Sissy Webster, who were sitting together.

All this was occurring under a cloudless sky and brilliant sunshine. Many of the guests were wearing sunglasses. That resulted in some amusing photos where it looked like the assembled crowd was viewing a 3-D movie rather than attending a wedding.

The groomsmen situated themselves to the left of the chuppah. Next came Marcus Rubin, Seth's best man. The musicians continued to play the same piece as the groom walked down the aisle, flanked by his parents. He didn't appear to be one bit nervous, and Roberta was in all her glory, smiling, touching extended hands briefly and in general kvelling like she had never been able to do before as neither Marcus nor Glenn had this kind of affair when they got married.

Next came the flower girls, eight of them! What a treat for them and the guests. Joy and Jessica held hands with Jenna who was in the middle. On the outside were one set of Dr. Levi's twin daughters. Behind them were Glenn's daughter and the other set of Levi's twins. They were precious and they executed their job perfectly, sprinkling rose petals from their little baskets as they practically skipped down the aisle.

Maria and Joe were secretly worried about Jenna but she was terrific. She might not have smiled but she seemed to enjoy the attention and she looked at her parents so videos and photos could preserve the day. Then again, when Jenna saw Alli, she might have cracked a little smile. At least KK and Alli thought so. That smidgen of recognition gave Alli and Maria goose bumps. The flower girls, their duty done, sat down in the first row, intermingling with the grandparents.

Adam Rubin, the ring bearer, went zipping up the aisle all too quickly.

Seth and his parents and his best man had already climbed the two steps to the chuppah and stood to Rabbi Levine's right.

Alice, a friend of Sandy's from nursing school, and Zoey were the first two bridesmaids down the aisle. Next came Dionne who nearly stopped dead in her Jimmy Choo shoes as she reached the right side of the chuppah. There, playing the flute with the string trio, was her sister, whom she had not seen in months. Diana managed a big smile while still playing.

Dionne turned around and went looking for Julie in the second row. There he was with a huge Cheshire cat grin on his face, letting her know that yes, he was responsible for that little surprise.

Sandy's cousin, Ariel, walked elegantly down the aisle, holding a beautiful hand-tied posy bouquet in front of her. As she took her place under the canopy, the strings and flute stopped.

"Don't expect 'Here Comes the Bride,'" whispered KK to Alli.

"Why not?"

"Because Richard Wagner was a virulent anti-Semite. You'll never hear his 'Wedding March' at a Jewish wedding."

The musicians started to play "Air on the G String" by Bach. Everyone turned around as Sandy and her parents turned the corner and started walking down the aisle. Everyone stood in unison as an absolutely radiant Sandra Rogoff took her final stroll as a single woman. Her Vera Wang gown could not have been more flattering. Her bouquet of stephanotis could not have been more dazzling.

When the Rogoffs arrived at the chuppah, Seth came down the steps to meet them. Sandy's parents hugged him and gave their daughter a kiss before they ascended the steps to stand opposite Seth's parents, to the rabbi's left.

The groom then took his bride's hand and escorted her up the steps. She handed her bouquet to her maid of honor and proceeded to circle Seth three times. The meaning of the circling was explained in that booklet as was the kiddish and the seven blessings.

Rabbi Levine had officiated at hundreds of weddings but made the Rogoffs and Rubins feel special by offering details of Seth and Sandy's one year together, including that wonderful trip to Israel, where Seth had proposed.

Whatever wasn't adequately explained in the booklet (and that was very little), Rabbi Levine was able to clarify. The wedding ceremony in English and in Hebrew was familiar to many of the guests. It was the non-Jews, however, who were most enthralled by it. Allison, Sissy Webster, the Reddys, Charles Cabot, Maria and Joe Bianchi found the entire experience majestic and uplifting.

Rabbi Levine noted that even the gentiles among the guests were familiar with the final act of the ceremony--the groom's shattering a glass under his foot. The Rabbi explained that this ancient custom is to symbolize the destruction of the original Temple in Jerusalem and "that even on this afternoon's joyous occasion, we remember that tragedy." A more modern interpretation is to remind Seth and Sandy of the fragility of life and love and that marriage should never be taken for granted. "Before Seth shatters this glass, let me introduce Diana Clark to you, a sister of Sandy's bridesmaid, Dionne, who will play 'Im Eschkachech,' the song that reiterates Jews' responsibility to never forget Jerusalem."

The string trio offered a few bars of an introduction and then Diana played that most haunting melody. When she finished, there was absolute silence. A few birds were singing in the nearby trees.

And the rabbi put the glass, now safely wrapped in a linen napkin, on the ground.

Seth stomped on it with his right foot and smashed it to smithereens to a hearty chorus of Mazel Tovs. A long, lingering kiss between the bride and groom was followed by more shouts of Mazel Tov as the bridal party descended the chuppah and headed to the greenhouse ballroom for the reception.

~~~~~~~~~~

The wedding guests were taking in the beauty of the Palm House Ballroom: immaculate linens, gorgeous floral centerpieces and a freshly lacquered parquet floor along with sparkling, spot-free glassware. Cute place cards decorated with a tiny stethoscope and nurse's cap told folks where they'd be sitting.

Before Diana joined the band on the stage, she found Dionne and Julie and gave her sister a big hug and kiss.

"Dionne, I haven't seen you in months. Wasn't that sneaky good of Julie to call me a few weeks ago? Turned out I was available today and the bride got the okay from the other musicians. I just loved that look on your face when you first saw me. By the way, you look fantastic in that dress!"

"Thank you. That was a wonderful surprise. Sometimes this guy does things that absolutely amaze me. Any other surprises in store for me today, Dr. Berger?" asked Dionne looking Julie squarely in the eye.

Julie deadpanned, "Ask me no questions and I'll tell you no lies."

"I need to join the band now for the first dance. I'm sure I'll see you two later," called Diana as she headed up to the stage. Dionne did not see the wink she gave Julie.

As Seth and Sandy bounded into the ballroom the bandleader announced, "Now for the first time as husband and wife, here are Seth and Sandy Rubin." The couple waved to their guests as the band played the introduction to "A Moment Like This." Seth then took Sandy in his arms and they gracefully moved about the dance floor to the cheers and applause of all. The young lady who sang did a creditable job but she was no Kelly Clarkson.

After thirty seconds or so, Seth paused, tilted his bride back nearly ninety degrees and gave her a kiss. More cheers. The bandleader then asked Sandy and Seth's parents to join them and then the rest of the bridal party on the dance floor. As this first dance ended, the drums started beating and trumpets started blaring in preparation for a ten-minute hora which left its participants breathless and drenched in sweat. The bride and groom had been hoisted high on chairs to everyone's delight. Finally, the hora was over and the guests returned to their assigned tables. Angie and Jeff, Allison and KK, Dionne and Julie, Maria and Joe were joined by Sandy's cousin Zoey and Seth's friend James. Nearby, at another table for ten were Dr. Greene and Sissy, the Levis, the Yocums, the Reddys, Charlie Cabot and Barbara Novak, the head of hematology.

The band played continuously while the guests went to the buffet for brunch. The three chefs making omelets were kept very busy but managed to keep their heads above water. Between the eggs and fish and fruit and salads everyone found something to his liking.

Allison was more interested in James Carpenter than she was in the bagel and lox on her plate. Zoey and James were sitting across the table from KK and Alli.

"Hello, again James," began KK. "Let me introduce you to everybody at the table. Here are Joe and Maria Bianchi--Joe was Seth's predecessor as chief resident last year. This is Julie Berger and Dionne Clark who are medical residents. Angie Vitale here will be a gastroenterology fellow next year and her--

"My date for the wedding is my friend Jeff Friedman," said Angie. "My husband couldn't make it. He is at a dentistry seminar in Atlantic City."

"I imagine you already met Zoey and Dionne. What gorgeous bridesmaid dresses. And last but by no means least is Allison Kincaid, a fellow Ivy Leaguer."

"Oh really? Where did you go?"

"Princeton and then Wharton. KK tells me you played baseball at Cornell."

"That's right. Short stop for three years."

"I'm from Rhode Island--Red Sox Nation territory. But when I moved to New York I warmed up to the Yankees. Now I love them. Damon and A-Rod are my heros."

Zoey may or may not have been interested in the groomsman but it was clear to everyone at the table that James and Alli really had something going.

"I'm a big Yankee fan too. In fact, in my welcome packet to NYU there was a voucher I could exchange for two tickets to any game this month. I know they are home next weekend. Care to go with me?"

"That would be great!"

KK looked at the Bianchis who looked at Julie and Dionne. Everyone had smiles on their faces which connoted, "Whoa, was that date made in record time or what?"

Angie took a sip of champagne and asked Jeff if he'd like to dance.

"Sure," was his reply and they headed to the dance floor. Angie had another sip of champagne when they returned.

The eight flower girls and ring bearer were situated at a nearby table with a clown who had been hired for the afternoon. He did a great job keeping them fed and entertained. As a result, the Bianchis and Levis were able to relax and enjoy themselves. In fact, everyone seemed to be having a great time. The mood was so festive, the music at just the right decibel level and the food delicious, especially the desserts and miniature pastries.

During a lull in the music, the bandleader asked Dr. Greene to come up on the stage. He told the crowd that he had known Sandy for years and that he was there when the bride and groom first laid eyes on each other a year ago when he and Dr. Bianchi introduced Dr. Rubin to the ICU staff.

"You should have seen the look on their faces. I knew right then that I'd be singing at their wedding someday."

That verbal cue was followed by Diana's beautiful flute introducing "Sunrise, Sunset." Several of Dr. Greene's senior colleagues knew he was in the Brooklyn Doctors' Choir but most people at the reception did not, and the chief of medicine wowed everyone with his rich tenor rendition of that all-time favorite from "Fiddler." When he finished, Roberta Rubin and Karen Rogoff had tears in their eyes. Dr. Greene gestured politely to his accompanist who took a bow and then he gave Seth a bear hug and Sandy a kiss. Everyone present stood and applauded.

When she regained her composure, Sandy took the microphone from Dr. Greene.

"Dr. Greene, that was so wonderful. I had no idea you could sing like that. Seth and I will never forget how nice you've been to us this past year. Maimonides has been very good to me. It's where I volunteered as a teenager, found my passion in nursing and met my beloved."

Sandy got all choked up as she finished that sentence and Seth smothered her in a hug and a kiss. More cheers from the guests. Dr. Greene came back to the microphone.

"Sandy, Seth, you're right. Maimonides has been a special place for so many people--staff and patients alike. Now HIPAA can take a hike on this one but the young lady accompanying me this afternoon has a special present for you--and for us."

With that introduction, Sissy Webster climbed the steps to the stage and took the microphone from Dr. Greene. There were a few wolf whistles which she ignored. "Hi, my name is Abigail Webster. I was a patient at Maimonides last year. I was in the ICU for weeks. I was on a ventilator and nearly died. This angel, Sandy, was at my side when the miracle occurred which brought me back to life. Dr. Greene and Dr. Cabot--please stand up Dr. Cabot--saved me."

Charlie Cabot stood up for a moment and gave a brief wave to Sissy and the wedding guests.

Sissy resumed her little speech. There were no more wolf whistles.

"When we see a couple so in love as Sandy and Seth it makes us feel so good inside. Whatever ups and downs they might have in the future, we know that love will endure. It is eternal. There is a song I'd like to sing in their honor--to let them know, to let all lovers know, that true love will survive the winds of time."

Diana and the band played a few bars and the talented Miss Webster started singing "I Will Wait for You." Her rich, pleading, mournful alto was so powerful that all chatter ceased and everyone listened with rapt attention. She was so good that a few people actually thought she was lip synching to the Connie Francis recording from the 1960s. Sissy looked at the bride and groom at the beginning of her song, Dr. Greene in the middle and her most constant eye contact, as she sang the last two lines, was with Charlie Cabot.

Anyone watching could tell that, although she had dedicated the song to Seth and Sandy, there was clearly someone else she was singing to. When she finished there was dead silence for about five seconds broken by a little girl's voice--Jenna Bianchi's!--singing the final refrain. This resulted in wonderful laughter from everyone and a bow from Sissy towards Jenna. All present stood and applauded Sissy who deeply appreciated the adulation but more importantly the smile on Charlie Cabot's face as he gently tapped the center of his chest with his right palm.

Seth took the microphone back. "Are we the luckiest couple in the world or aren't we? First my boss, Dr. Greene, and now Miss Webster. And that flower girl over there. Ladies and gentlemen, let me introduce Jenna Bianchi to you--she is the daughter of my predecessor as chief resident, Joe Bianchi and his lovely wife Maria."

Maria and Joe had already rushed to Jenna's side when she started singing and now the three of them waved to the crowd.

Seth continued, "And I have it on good authority that Maria will have little difficulty remembering our wedding date because it's also her birthday."

"Not only mine," responded Maria, "but my best friend here too, Alli Kincaid." Alli stood up and smiled and yelled, "Same day, same year!"

"What year?" barked a would-be heckler. Alli and Maria looked at each other and nodded and responded in unison, "None of your business."

More laughter and cheers as Maria and Alli exchanged high fives before sitting down.

James Carpenter danced several times with Alli. KK couldn't help but notice that with each successive dance there was less and less daylight between their bodies.

Charlie Cabot squired Sissy around the dance floor several times, much to their mutual delight and Dr. Greene's, who saw his grand scheme paying dividends and coming to fruition.

Jeff Friedman left the table for a few minutes to say hello to Drs. Yocum, Levi and Reddy. They were all happy to see how good he looked. There was now no doubt whatsoever that the colectomy five months previously was the right decision. Jeff returned to the table in time to observe Angie quaff down another four ounces of champagne.

He led her to the dance floor but used the excuse that the wedding cake was about to be served to reverse direction and immediately return Angie to her seat. She was just a bit sloshed.

When the waiter placed coffee cups in front of KK and Alli, she politely responded "Merci beaucoup." James Carpenter then asked, "Ah, vous parlez francais?"

Further conversation led to the discovery that he had been at the Sorbonne just one year before Alli. "What a coincidence," James added. "Hey, if you were there the year after me, you must have known that guy who got married by the Pope. It was written up in the Sorbonne newspaper. Big wedding in Rome as I recall."

"Vaguely. I don't think he finished the semester." Alli gave KK a kick under the table. He didn't need to be told to keep his mouth shut.

Practically everyone left over a little bit of their wedding cake, not because it wasn't good; it was delicious. But the chocolate and fruited desserts were just out of this world. Of course, the wedding cake was needed for that traditional photo of Seth and Sandy simultaneously pushing a piece into each others' mouth, but all the guests would have been just as happy to feast only on Annie's creations. She really outdid herself.

With the blessing of the caterer, Sandy, who was assuming more of a role of an emcee than a bride at her own wedding reception, went back on the stage and shushed everybody.

"Raise your hands if these were the best desserts you've ever tasted."

Three hundred hands went up. The drummer banged on his drums and each of the band members raised both arms as though signaling a touch down.

"Turn around everybody. Look over there." Sandy pointed to an alcove near the kitchen where Annie was supervising the final touches on yet another tray of scrumptious treats.

"That's Annie of Annie's Assets, a dessert shop that just opened in Bay Ridge."

Annie was exhausted. She was wearing a white chef's hat and smock and waved. Noah Strong, who was lending moral support and helping out a little in the kitchen, gave a silent clapping of his hands and then an affectionate arm around her waist.

When Julie and Dionne spied Noah, they hustled up to the stage and whispered in Sandy's ear. Sandy then explained, "Another Maimonides connection. Kiss my grits HIPAA! See that young man with Annie? Drs. Berger and Clark here tell me that he was the first person Dr. Levi operated on at Maimonides. Dr. Reddy assisted. Is this place special or what? Thank you Annie, I have no doubt your dessert shop will be a rousing success. Don't look now but the caterer here at the Palm House at the Brooklyn Botanic Gardens is drawing up an exclusive contract for you as we speak."

Jeff Friedman did not want Dr. Angelina Vitale-Schwartz to embarrass herself any further in front of her colleagues. He asked KK to watch her for a moment as he politely told the Rubins and Rogoffs that he and Angie had a great time at the wedding but that she was a bit under the weather and that he'd better get her home.

He returned to the table and said goodbye to the other couples. He practically had to carry Angie out. She was beyond tipsy. She was somewhere in between besotted and blitzed.

The band played another two songs, s-l-o-w dancing, which Alli and James and Sissy and Charlie greatly enjoyed. Sandy resumed her cheerleading for Maimonides and asked KK to say a few words. He winked at Alli and Julie and Dionne as he left the table and mounted the stage.

"I am honored that this beautiful bride and handsome groom have asked me to clarify a few things on their wedding day. As many of you know, I was planning on spending next year as a cruise ship doctor and Dr. Berger over there was going to be chief resident as soon as Seth and Sandy flew off to a honeymoon in London and a year in Israel. Well, just last week someone paid Dr. Greene a visit and it went something like this."

KK turned his back to the audience, put on a pair of dark glasses and stuffed a napkin into his inside jacket pocket, creating an exaggerated bulge. He then turned around and in a spectacular imitation of Marlon Brando's gravelly voice as Vito Corleone,

"Ey, Dr. Greene. Wit all due respect, my doctor, Nathaniel Bloom, says he's been workin' too hard. He wants to slow down a little. He'd like Dr. Berger to join him in practice but you've got Dr. Berger signed up to be da chief resident. I got some friends in Bay Ridge who feel you might be convinced to rethink that decision, if y'know wad I mean?"

KK then tapped his index finger to the side of his nose and kept it there for five seconds before lowering it to touch the bulge in his jacket.

The ballroom erupted in laughter with Drs. Nathaniel Bloom and David Greene leading the guffaws. As KK removed the sunglasses, the napkin and eliminated the accent he started again,

"Well, maybe not quite like that but I get to be chief resident and Julie, my colleague for the past three years, gets to join the preeminent Brooklyn internist in private practice. I'd call that a win-win situation."

KK descended the stage to the cheers and applause of nearly three hundred people. It was more than three hours since Seth and Sandy kissed under the chuppah but other than Angie and Jeff, no one had left the reception. They were just having too terrific an afternoon to head home. Alli and James and the Bianchis complimented KK on his performance as he returned to the table.

There had already been several memorable occurrences--Dr. Greene's singing, Sissy's serenading, little Jenna Bianchi's warbling, and KK's imitating The Godfather. The most memorable event of the afternoon was yet to come. Jeff and Angie were the only ones who would miss it.

~~~~~~~~~~

While waiting for the valet parking attendant to retrieve his car, Jeff had to listen to a very drunk Dr. Vitale say one nasty thing after another about her husband. She then proceeded to throw up and soil the bottom of her pink party dress. She fell asleep in his car and slumped against the passenger door. When Jeff reached her street, he was able to find a parking spot right in front of the building. He looked in her little purse and found the keys to the lobby. No one was there nor in the elevator and he was able to get Angie into her apartment without anyone noticing them. He was sure of that. He didn't know when her husband would be coming home and figured it was now or never.

CHAPTER EIGHTY

Sandy and Seth announced that they wanted to do something a little different to show their appreciation for the groomsmen and bridesmaids. Alice, Zoey, Dionne, James, Glenn, Dr. Greene, Marcus and Ariel were asked to come up to the stage. In seemingly no special order, Seth and Sandy alternated telling a brief story or anecdote about the people in their bridal party. They were then each given a little box wrapped in blue paper and tied with a red bendl as they returned to their seats. Purely by happenstance, or so it initially seemed, Dr. Dionne Clark was the lone remaining member of the bridal party on the stage and Sandy approached her with a big smile.

"Dionne, I cannot begin to tell everyone here what a wonderful friend you've been these past two years. I'm going to need some assistance. Dr. Berger, could you please come up here and help me?"

Julie winked at KK and Alli as he popped up from his seat and actually sprinted to the stage. Everyone sensed that they were about to witness something special, especially considering the staid, predictable, almost boring anecdotes they had all just listened to.

Dionne knew something was up. She turned around to look at Diana who gave a very unconvincing "I don't know" shrug of her shoulders.

Julie took the microphone, "Listen everybody. I didn't want to steal Sandy and Seth's thunder but when I bounced this crazy idea off Sandy, she insisted we do it just like this."

By now Dionne was starting to quiver. Seth and Sandy surrounded her as Julie continued speaking to the wedding guests who were now all on their feet.

"Maybe we don't have Jay Leno in the wings or a TV audience of millions but Dionne and I are surrounded by the people we care most about."

The football fans and "Law and Order" aficionados knew immediately what Dr. Berger was referring to--the very public March 2000 marriage proposal on the "Tonight Show" by National Football League cornerback Jason Sehorn to actress Angie Harmon.

Julie got down on one knee in front of a now trembling Dr. Clark. "Dionne, I have adored you from the moment we first met. You just light up my life and I cannot imagine spending that life with anyone but you. Will you marry me?"

And he placed a little blue box with a red ribbon in her hands. She was crying, more overwrought than she had ever been. Finally she squeaked, "Yes." And then more firmly and loudly, "Of course, yes," as she pulled Julie to his feet and kissed him, oblivious to the three hundred people who were cheering and applauding. Shouting "Mazel Tov" at the top of their lungs were Rabbi Levine and his wife Rivka. Dionne then kissed Sandy and Seth and wiggled her index finger at Diana who was the only person in the ballroom other than the bride and groom who knew of Julie's intentions.

For their closing song, the band and Diana played "Some Enchanted Evening" from "South Pacific." It was the perfect finale to an unbelievable afternoon.

~~~~~~~~~~

Jeff Friedman carried Angie into her bedroom and removed her dress. She was not wearing a bra. Angie didn't seem to object. Jeff looked in her dresser and found a Rutgers T-shirt and placed it over her head and shoulders taking one final and furtive glimpse at her perfect breasts. He gently placed her under the blanket, rinsed out the stained dress with cold water and hung it on a garment hanger in the bathroom to dry. He placed her keys and purse on the kitchen table and looked at her one more time before leaving the apartment. Her color was good and she was breathing easily. He wasn't a doctor but figured she'd be okay. She'd probably wake up with a monster hangover but he knew it was safe to leave. Better that than meet the dentist. Once again, no one was in the elevator nor the lobby and Jeff managed to drive away unseen. It was only at the first red light that he realized he was sweating profusely and shaking uncontrollably.

~~~~~~~~~~

Jeff left a message on Dr. Vitale's secure voicemail at the hospital. "In case you were wondering, no we didn't!"

Angie was very embarrassed when she finally got the nerve up to call Jeff on Tuesday. "I'm so sorry. I hope I didn't ruin Sunday afternoon for you. I don't remember much after I threw up. Actually, I don't remember too much before that either."

"It wasn't so bad," lied Jeff. "We left early and I told everyone you weren't feeling well. I don't think they noticed that you were plastered."

"And you undressed me? That was gutsy of you. Thank God Raymond didn't walk in while you were doing that," Angie laughed.

"That was a chance I had to take. I couldn't exactly put you to bed in the dress you threw up on."

"Thank you for being such a gentleman. I sincerely mean that. It's really none of your concern but Raymond and I had a long talk last night--we're going for counseling and we will try to get our marriage back on the right track."

"Sounds like a good idea to me. Listen, Dr. Vitale, you're a very good doctor and a very nice person. Dr. Yocum wouldn't have asked you stay on next year if he thought you were a loser. I hope you and your husband can work things out."

"Thank you again. And good luck in law school. Promise me one thing, though."

Jeff thought the upcoming request might have something to do with Angie's debacle at the wedding reception or his "impeccable" behavior at her apartment afterwards, "Sure, anything within reason. Shoot."

"Don't ever become a plaintiff's malpractice attorney," laughed Angie.

"That's a promise I'll have no trouble keeping. Take care of yourself Dr. Vitale."

"Don't you think after Sunday afternoon you should call me Angie?"

"Take care of yourself Angie. I'll make an appointment for an office visit during my winter break."

"See you then, bye."

CHAPTER EIGHTY-ONE

Maimonides experienced a very smooth transition in late June. KK took over as chief resident. Seth and Sandy settled into their apartment in Jerusalem after an all-too-brief honeymoon in London. Dionne's schedule had her supervising the private service and Charlie Cabot was the ward attending physician. Joe Bianchi began his second year of hematology fellowship and expressed an interest in doing an additional year in pediatric hematology. Gabriel Levi's NOTES research program had captured additional funding. Angie immersed herself in her fellowship and in salvaging her marriage.

Dr. Nathaniel Bloom needed to have the printer re-do all the business cards announcing his association with Dr. Julius Berger. The office stationery too, along with the listing in the telephone directory and the Medical Society.

What prompted all this was Nat's overhearing his receptionist answering the phone the very day Julie officially joined him.

"Good morning, Drs. Bloom and Berger. Can I help you?" Nat almost died when he heard that and asked Julie to listen as the receptionist answered the next call.

"What do you think Julie?"

"I hate to say it Nat, but it sounds like an Australian fast food restaurant!"

"Exactly," agreed Dr. Bloom. "We've got to change all that and fast." So the entire office staff was instructed to answer the phone, "Drs. Berger and Bloom." It didn't roll off the lips like Smith & Wesson or Sonny & Cher or Horn & Hardart or Bloom & Berger, but anyone calling the office could be reassured that they had dialed the right number. It only took a few days to re-do all the printed stuff anyway. Dr. Bloom's ego had no problem being listed second.

~~~~~~~~~~

A week after the wedding, Allison Kincaid telephoned KK. He had spent that Sunday orienting some of the new yommie interns. He was happy to hear Alli's voice.

"KK, I didn't thank you enough for taking me to the wedding. It was a real treat to chat with Maria and Joe and hear Jenna do her thing. Julie's proposing to Dionne like that was something I'll never forget. And, I met James."

"Ah, yes, James. Did he take you to the Yankee game, as he promised he'd do in front of our entire table?"

"Oh yes he did. At the new Yankee Stadium. Great seats too. And our Yankees won. Derek Jeter hit a walk-off home run in the bottom of the ninth. He then asked me back to his apartment. A remodeled, one-bedroom job in Peter Cooper Village, near 23rd Street. He can walk to work at NYU from there. He had just moved in the day after the wedding. Plenty of boxes filled with books were still on the floor."

"And?"

"Well he played the guitar for about thirty minutes. KK, do have any idea how romantic and erotic the classical guitar can be?"

"No, tell me."

"Well, let's put it this way. Derek Jeter wasn't the only short stop to hit a home run that night!"

"Alli, you didn't!"

Alli squealed, "Oh yes we did! And it was fantastic!"

"Alli, are you sure you're not rushing things?"

"KK, I appreciate your looking out for me but it has been six or seven years since I was a coed at Princeton. Besides, I don't think James has a cutie warming up in WASPville."

"Alli, just be careful. I don't want to see you get hurt again."

"Don't you worry, Dr. Kirsch, chief resident in medicine at the Maimonides Medical Center in Brooklyn New York. I think your prediction about some lucky guy coming along someday, causing me to forget some unhappy times may be coming true."

"I presume the unhappy times you're referring to are the aftermath of Stefano."

"Who?"

###

ABOUT THE AUTHOR:

"Maimonides Rocks" is Steve Brozinsky's first novel. Dr. Brozinsky is a Board certified gastroenterologist with a practice in Chula Vista, California. He was born, bred, raised and educated in Brooklyn, and actually trained at Maimonides in the mid 70s. He has published a memoir in the Brooklyn College alumni magazine (2002) and sends letters to the editor of The New York Times on a regular basis (one published).
