Eyes swimming, Marge didn’t respond.
A few minutes later, the ER’s two nurses entered Drew’s room with a gurney. Sarchi went to Drew’s bed and stroked his hair.
“Drew honey, we need to get a better look at you so we can find out what’s wrong. So we’re going to put you in a Star Wars machine. It’s like a big doughnut with some pretty lights. We’ll strap you in just like you were flying a spaceship, only you’ll be lying down. Your mother will be there with you, and I’ll be in the control room monitoring the flight, which will be so gentle you won’t even know the machine is working.”
Drew’s eyes seemed less fearful. Hoping that this wasn’t just her imagination, Sarchi signaled for the nurses to put Drew on the gurney. When he was safely transferred, they wheeled him to the scan room.
The CT tech was a young man with a soft friendly face. He continued the spaceship analogy. “Yes sir, Captain. We’ve been waiting for you. Engineering says the ship is ready for flight.”
The scanner was a huge putty-colored square that practically filled one end of the small room. In its center was a round hole for the patient’s body. Were it not for a narrow beam of intense ruby light that ran in three directions across the face of the machine from the doughnut hole, it would have appeared inert.
Drew was placed on the scanner table on his back with his head pointing at the doughnut hole. Even though he couldn’t move, his head was put in a holder and surrounded by foam padding. A chin strap locked it firmly in place. The tech then covered Drew’s torso with a lead-lined blanket.
“Is that for me?” Marge said, gesturing to the rocking chair nearby.
“If you’d like to stay,” the tech said.
“I would.”
The tech pointed at a protective apron hanging on a peg behind her. “Just put that on.”
The tech looked back at Drew. “All right, Captain. If you’re ready, we’ll get under way. As I understand Star Fleet’s orders, we’ll be maintaining a speed of warp eight for the entire trip. At that speed we’ll reach our target very quickly.” He saluted, and Sarchi followed him into the scanner control room, where Lanehart was waiting. The tech took a seat in front of the CT control panel with its two monitors and began pushing buttons and flipping switches.
Pleased at how gentle he’d been with Drew, Sarchi said, “You’re a big ham, you know that?”
“Runs in the family, my dear,” the tech said, doing an imitation of W. C. Fields that proved her point. His fingers scurried over the keyboard, choosing functions that were then displayed on the left monitor. They watched as Drew’s head entered the doughnut.
An X-ray image of Drew’s skull and vertebrae of the upper neck appeared on the right monitor. The tech superimposed a series of parallel green lines on Drew’s skull to indicate the different levels where the scanner would X-ray Drew’s brain, and the first in a string of images simultaneously appeared on the screen.
It was an absolute marvel . . . instant pictures of an entire brain at a dose of X-rays far less than you used to get in a chest film. And when all the images were collected, if you wished, the computer could take you on a boat ride down the reconstructed interior of any vessel you chose.
As the ghostly images appeared on the screen, Sarchi bent closer, trying to read them. There were structures at each level she couldn’t name, but she had a pretty good working knowledge of the major landmarks.
There . . . the first appearance of the lateral ventricles, a division of the bizarrely shaped interconnecting cavities deep in every brain.
A little deeper was the internal capsule, the narrow boomerang-shaped collection of major fiber bundles surrounded by neuron accumulations known as the striatum.
As the machine probed deeper and deeper, Sarchi focused hard, looking for any telltale density where the image should be pale, but also alert for the opposite situation. A density could be a tumor, a pale zone, an area of degeneration, or a bleed.
But when the last image had been added to the collection, Sarchi had seen nothing abnormal. Apparently, Lanehart hadn’t either.
“Could I see them all again,” he said, “full size?”
The tech ran through each of the pictures again, changing them only when Lanehart asked. To Sarchi, everything still looked normal.
Finally, Lanehart turned to her and said, “I see nothing here to support a diagnosis of damage to the pons or anywhere else for that matter. It’s a little difficult though on a CT scan to see through the bone around the pons, so we should probably do an MRI in the morning.”
“If we are dealing with locked-in syndrome, what’s the treatment?”
“If it’s caused by a big bleed, you’re basically hosed. There’s always so much damage and so little hope for any recovery that no one even bothers removing the clot.”
“Even without the MRI, we know that’s not the case here.”
“Right. Which leaves trauma or ischemia-induced damage. In those cases, you still can’t do anything, but you can hope there’ll be some return of function after the acute phase passes.”
“That’s it?”
Lanehart shrugged.
With no effective treatment available, Sarchi wanted very much to believe Drew wasn’t suffering from locked-in syndrome. “If you can’t see any pontine damage on a CT, how likely is an MRI to show some?”
“Not very.”
“But there is a possibility?”
“I suppose.”
Wanting pontine damage completely off the list of differential diagnoses, Sarchi said, “It’s ridiculous that we don’t have an MRI tech on call.”
“That has been pointed out to Koesler,” Lanehart said. “But he said it’s a matter of money. The hospital can’t afford it.”
“Which is no excuse,” Sarchi snapped. “Whoever discussed it with him shouldn’t have accepted that.”
“So you would have pressed the point?”
“Of course.”
“Well, here comes your chance.” Lanehart gestured over her shoulder with his chin.
Turning, Sarchi saw Irwin Koesler, the hospital’s medical director coming their way, apparently touring the ER on one of his surprise visits. He stepped into the control room and curtly acknowledged all present by their last names.
Koesler was the best-groomed man Sarchi had ever seen, his silver hair perfectly coifed, his white coat and the shirt under it of blinding purity and wrinkle free, the knot of his tie expertly crafted. In addition to being the hospital’s medical director, he was also a board-certified pediatric nephrologist, designations he carried like a jeweled scepter. Around the corridors and wards, he was widely known as the “immaculate misconception.” It was said the only people he viewed as worth his time were his reflection and God, in that order. He looked through the window at Drew. “What’s the case?”
Lanehart let Sarchi handle it. “The boy is paralyzed from the neck down.”
“Have you pinpointed the cause?”
“Not yet. We’re trying to rule out pontine damage, but to do that completely we need an MRI.”
“How are his vitals?”
“He’s stable.”
“So he’s in no immediate danger.”
“If you mean in no danger of dying, that’s true.”
“Of course that’s what I meant. So, you’ll get the MRI first thing in the morning.”
Sarchi could feel Lanehart and the CT tech’s interest in the conversation sharpen. Here was her opportunity to tell Koesler how unacceptable that was. But as much as she believed he was wrong on this position, she couldn’t tell him to his face. “Yes,” she muttered. “In the morning.”
Then, to her horror, Lanehart said, “Actually, Doctor Seminoux thinks it’s ridiculous not to have an MRI tech on call at night.”
Koesler’s eye
s cooled. “Is that right?” he said, looking at Sarchi.
“No . . . not ridiculous,” she said. “It’s just . . . sometimes . . . it’d be convenient to . . . in this case, for example. I’d like to know for sure we’re not dealing with damage to the pons. That way we could concentrate on other diagnoses.”
“We can’t afford the extra staff,” Koesler said.
“I understand. I just . . . It’d be useful. That’s all I meant.”
“Anything else?”
“No. Nothing.”
“Good.”
He turned and left the room. When he was out of earshot, Sarchi turned to Lanehart. “What’s the matter with you?”
“Hey, I was only helping you express yourself.” He squinted at her. “What’s that?” He reached out, aiming a finger at her nose. “You’ve got something brown right on the tip . . .”
She pushed his hand away. “I didn’t hear you stand up to him.”
“I’m not the one who feels so strongly about needing an MRI tonight.”
“Don’t be so judgmental. He’s not only the medical director and head of the pediatric residency program, he’s one of the pediatric attendings. In three months, I’ll be on his admitting team again. Surely you know how miserable he can make my life.”
Lanehart threw up his hands. “If you can knuckle under like that and still respect yourself, I don’t mind.”
“It’s easy for you to talk. Your residency program isn’t even administered in this hospital.” Her defense of her behavior rang hollow even to Sarchi. It wasn’t the first time she’d taken a dive in the face of authority, and it wouldn’t be the last. It had never been something she’d been proud of, it was just who she was.
Getting her mind back where it belonged, she asked Lanehart to stick around for another few minutes, then stepped outside and told the nurses to take Drew back to his room.
“What did you find?” Marge asked.
“Nothing to worry us. I’m going to confer with Doctor Lanehart a bit. You go with Drew, and I’ll be there shortly.”
While the CT tech straightened up the scan room, Sarchi briefed Lanehart on the lab findings. Nothing he said in response lit up the room.
Large brain tumors and conditions that cause the brain to swell increase intracranial pressure. In such cases, if a spinal tap is done, the sudden loss of pressure from below causes a downward displacement of certain regions of the brain into compartments too small for them. The resulting compression causes irreparable neural damage, if not death. While there was still some question whether Drew had any pontine damage, the CT scan clearly eliminated any concern about proceeding to a spinal tap. This next diagnostic step would bear upon a number of nasty illnesses, including meningitis, a disease that could easily turn a brain into a cauliflower. Sarchi saw now that she’d been wrong earlier to compare this night to a runaway chocolate line. It was a house of horrors with more stops yet to come.
5
FOUR HUNDRED MILES from Memphis, Lee-Ann stepped out of the elevator into the subacute neuro ward of the Metro East Hospital. It was the second time in twelve hours she’d been there. But this time she was wearing a newly purchased housekeeper’s uniform. Her first visit had been a reconnoitering trip in which she’d learned that only six of the ward’s ten beds were occupied. This meant the night shift would likely consist of no more than two people. And that’s exactly what she saw at the nurses’ station. Noticing one of them looking her way, Lee-Ann reached into her bucket for her spray bottle of 409 and went after an imaginary heel mark on the beige tiled floor.
It was two thirty a.m., a half hour after the two women on duty should have made their rounds and turned to their paperwork. When Lee-Ann adjusted her position a minute later so she could surreptitiously check on them, that’s what they were doing.
So far, so good.
The unit consisted of the nurses’ station backed by a chart room where the attendings could work when they rounded, and ten rooms arranged in a U on the perimeter. The room Lee-Ann was most interested in was in the worst possible location, directly opposite the nurses’ station. As hard as she’d thought about it, she’d been unable to come up with a flawless plan to get in there unseen. So, as she pursued another phantom mark on a tile that took her deeper into the unit, she stayed alert for the right moment.
For the next ten minutes, Lee-Ann made sure she stayed within earshot of the two women on duty. Then, very close to when she thought it might happen, one of them said, “I’m going to take my break before we have to round again.”
“You’re staying on the floor?” the other asked.
“Yeah. Call me if you need help.”
The one dressed like a nurse’s assistant left the station and went to a windowless room tucked into a small alcove next to the elevators.
Lee-Ann picked up her bucket, hurried down the hall, and went around the corner of the U. Hidden from view by the chart room behind the nurses’ station, she pushed open the door to a patient’s room and peeked inside. Seeing that the occupant was awake, she tried the next room.
Better. Much better. For this patient, heavily bandaged about the face, didn’t stir when she looked in. Believing someone so badly hurt was likely in a drugged sleep, Lee-Ann went inside and approached the foot of the bed.
“Are you awake?”
No response.
She reached out and grasped the patient’s leg through the sheet and rocked it, repeating her question.
Still no reaction.
In the dim light, she moved toward the head of the bed and picked up the patient’s IV line, which she kinked and tucked under him. Back in the hall she resumed her housekeeping act. In short order, the patient’s IVAC alarm went off.
When the nurse left her station to see what was wrong, Lee-Ann darted into Greta Dunn’s room, where, just as she had been told at the desk, the woman was still in a coma. It was unlikely Dunn would ever be able to identify her or anyone else again, but Lee-Ann wanted to be absolutely certain. She reached into the pocket of her smock for the preloaded syringe she’d brought and unsheathed the needle. Forcing her hands to perform without shaking, she slid the needle into the injection port on Dunn’s IV and delivered a bolus of potassium chloride into her blood.
Knowing she had only seconds to make her escape, Lee-Ann grabbed her bucket, threw the syringe inside, and darted from the room. She bolted for the stairwell, then paused on the other side of the closed door to listen. She’d taken perhaps three ragged breaths when Greta Dunn’s heart monitor began to squeal.
6
DREW’S MRI SCAN the next morning was completely normal. Likewise, the laboratory analysis of his spinal fluid provided no clues to the cause of his condition. The final results of the drug screen came back negative, and his new blood work produced values no different than those from the previous night.
“And so far, his blood and urine cultures haven’t grown anything,” Sarchi said to Kate McDaniels, her attending.
“Of course, it’s early yet on those. So what should we do now?” Kate asked.
“I’d like to try a Tensilon test.”
Kate was by far the most fashionable attending in the hospital. Somehow, she always looked elegant, even in scrubs and a lab coat. In part it was her hair, slate gray without apology and always carefully arranged in a French twist. But mostly it was the way she carried herself, as if her ancestors had owned a country. She was an excellent teacher, leading you to knowledge instead of stuffing it into you. She was also patient, allowing her residents time to form their own ideas about the cases they worked. She did not, however, have a poker face. When she was pleased, you knew it, when she wasn’t, you knew that as well. Sarchi now saw that Kate had been thinking of a Tensilon test herself.
“What’s a Tensilon test?” Marge asked, joining them in the hall.
“A way to determine if Drew has a condition known as myasthenia gravis,” Sarchi replied. “It’s an autoimmune disorder in which for some unknown reason, antibodies are made against the proteins in muscle cells that receive messages from nerves. The test involves the administration of a drug that prevents the breakdown of the normal chemical messenger between nerve and muscle so that the antibodies blocking communication can be overcome. It’s a quick test and very dramatic. If this is the cause of Drew’s paralysis, we’ll know just a few minutes after the test is done.”
“So the problem isn’t in his brain?”
“We still can’t rule that out entirely.”
“But the CT and MRI scans . . .”
“They simply eliminated some obvious things.”
“And now you think the problem is in his muscles?”
It was hard enough to deal with Drew being paralyzed. Having to justify her every thought to Marge was draining what energy Sarchi had left after being up all night. Still, she could appreciate Marge’s position, and because of that, took no offense at the critical tone of her last question.
“There are many potential explanations for Drew’s condition,” Sarchi said patiently, trying to keep her own anxiety out of her voice. “When we pursue a particular possibility, it doesn’t necessarily mean we believe that’s the cause. It’s detective work. We gather the clues, and eventually they’ll point to the culprit.” She took Marge gently by the shoulders and looked into her eyes. “Okay?”
Marge took a deep breath and nodded.
Ten minutes later, a runner brought a vial of Tensilon up from the pharmacy. While Kate loaded a syringe, Sarchi went to Drew and closed his right hand around her finger.
“Drew honey, I want you to do something for me. I want you to squeeze my finger as hard as you can.”
Though she obviously had Drew’s attention, she felt no response.
The Killing Harvest Page 4