The cancer certainly contributed to Lance’s death, but the actual cause of death was a coagulation disorder. Lance had bled to death, just like his partner, Jay Braithwaite Burke.
It was not clear what had caused the coagulopathy. The coagulation factors are made in the liver, so it could have been caused by the condition of Lance’s liver.
It could have been DIC, disseminated intravascular coagulation, in which blood clotting is accelerated for some reason, using up all the coagulation factors in the blood. It frequently happens with massive tissue trauma, where tissue procoagulants are released; but it also happens with cancers, and pancreatic cancer is notorious for that. DIC is treated with heparin to prevent further clotting, and fresh frozen plasma to replace the clotting factors.
Or it could have been dilutional. Lance had received twelve units of blood, which was essentially an exchange transfusion. But he’d also received heparin and several units of fresh-frozen plasma, which should have helped but didn’t.
The last possibility was an overdose of an anticoagulant drug, but Lance had died in a hospital setting for more than adequate clinical reasons other than overdose for bleeding to death. Besides, the only anticoagulant drug that Lance was on was heparin, and heparin dosage is carefully monitored. Of course his doctor, George, still living in the last century, had used the PTT instead of anti-Xa, but the PTT had been meticulously kept in the therapeutic range, and everything was documented. If someone had snuck in and shot a bunch of undocumented extra heparin into Lance’s IV, the PTT would have showed it—unless it had been done all at once and Lance had died soon thereafter, before any more PTTs could be done.
Mike and I documented every step of the autopsy with photographs, and we took more than adequate samples of tissue and blood so that a complete laboratory coag workup could be done.
Maybe that would clear up the mystery, but I was skeptical. The mechanisms of blood coagulation were extremely complex, and lab tests to detect coagulation factor defects were fraught with preanalytical interferences—that is, factors that affect the blood before it gets tested—one of the more obvious ones being that the patient should not be on any anticoagulant drugs at all. And of course most of them were.
Lance being a case in point.
Mike and I lugged the specimen buckets back to the lab, where Mike took charge of them. I could have gone home at this point and probably should have, since Mum was there and possibly Hal, but I had a definite approach/avoidance conflict going on. So I decided to spend a little time trying to figure out who was taking rivaroxaban.
Lance? I didn’t remember seeing it in his medical record, but then I wouldn’t have known what it was if I had seen it. So I looked again. It wasn’t there. I suppose it would be a bit much to be taking oral heparin and injecting Lovenox too. I mean, why would one do both if one didn’t have to?
Kathleen and family had been admitted with hematemesis the day after they’d gone from Jodi and Elliott’s to Ruthie’s house. So if Lance didn’t have rivaroxaban, how about Ruthie?
I looked her up and hit pay dirt.
Ruthie had the same prothrombin mutation that Lance had. Did they meet in a coagulopathy support group, or what? She also had another genetically altered coagulation factor that causes increased blood clotting: Factor V Leiden. So George Marshall had her in a clinical trial on rivaroxaban.
So that’s why Lance and Ruthie didn’t have kids. Pregnancy itself is an additional risk factor for deep vein thrombosis. Ruthie’d had one pregnancy in her early twenties and gotten DVT, thrown pulmonary emboli, nearly died, and lost the baby. That was when she’d first been worked up. She hadn’t been able to take birth control pills either, because they also increase the risk of DVT, so she had a tubal ligation.
The news that she had both prothrombin mutation 20210 and Factor V Leiden had come later, as those mutations were unknown back when Ruthie got pregnant. Factor V Leiden wasn’t discovered until six years later, and the prothrombin mutation 20210 two years after that. Ruthie had first been tested for them four years ago.
Unfortunately for her, rivaroxaban hadn’t been approved for clinical trials until this year. Up until March of this year, Ruthie had used Lovenox, same as Lance.
Out of curiosity, I pursued the subject a bit further to see just how a hypothetical child of Ruthie and Lance might have fared genetically.
The chances that their offspring would have either one of those mutations were better than one would think: one in fifty Americans is heterozygous for the prothrombin 20210 mutation, meaning the mutation is on only one of two sets of chromosomes; and one in four thousand Americans is heterozygous for factor V Leiden.
Unfortunately, both mutations are inherited as an autosomal dominant, meaning it only takes one mutation for a person to have the condition; so the chance of one person having both mutations would be one in twenty thousand.
Furthermore, the risk of deep vein thrombosis with 20210 would be two to three times that of a normal person. Add Factor V Leiden, and it becomes ten to twenty times the risk.
With a couple like Lance and Ruthie, there’s a 75 percent chance that their child would have 20210, and 25 percent for factor V Leiden. Even worse, there’s a 25 percent chance that their child could be homozygous for prothrombin 20210, meaning the mutation is on both sets of chromosomes, doubling the risk.
On top of that, the child could also be homozygous for prothrombin 20210 and heterozygous for Factor V Leiden, making the risk of DVT … well, you do the math.
I didn’t want to do the math. Jeez, I thought, any child of theirs would be a walking, talking blood clot—that is, if it ever made it out of the uterus.
So Ruthie had the wherewithal to poison the Burkes with rivaroxaban, but that didn’t necessarily mean that she had done it.
How could I find out?
Well, for one thing, none of the Burkes were taking rivaroxaban. Were they? Not the children, surely, but perhaps it wouldn’t hurt to check Kathleen. If she wasn’t taking it, then all I had to do was check their anti-Xa levels. If any of them had anti-Xa, it would mean there was heparin in their blood.
There was no mention of rivaroxaban in Kathleen’s medical history. She had no history of bleeding or DVT—at least not until this past Wednesday.
And we still had blood samples on all of them from when they were in the hospital, samples that were now only slightly over the forty-eight-hour limit. All that meant was that the test might not be accurate, but all I was interested in was whether anti-Xa was present or absent, and the samples ought to be just fine for that purpose.
It was now nearly eight o’clock, and Mum was at home alone, unless Jodi and Elliott had gone over to keep her company. She knew I was doing an autopsy and that I’d be late, because I had called her earlier. By now the tech on call had left, and so had Mike.
In the chemistry refrigerator, I found racks of blood tubes from Wednesday and pulled out the coag tubes for Kathleen and the kids. Brenda had spun down Lance’s coag tube when Mike gave it to her earlier, and pulled off the plasma. I retrieved that tube from today’s rack. In the cupboard I found requisitions and ordered anti-Xa’s on all of them. I put the tubes in a rack together in the refrigerator and left the requisitions on the desk with a note: Do ASAP and call me!
Then I went home.
Mum and Jodi were watching a movie on DVD.
Hal wasn’t home. I called his cell.
It went straight to voice mail.
Saturday, December 20
Chapter 19
A man always has two reasons for what he does;
a good one, and the real one.
—J. Pierpont Morgan
Hal didn’t come home Friday night either.
Jodi and Elliott came over, and Mum made breakfast for all of us.
Elliott took me to task. “I heard you did an auto
psy last night.”
I nodded.
“On Lance Brooks,” he continued.
“Yes, so?”
“Are you freakin’ nuts? Are you aware that Ruthie Brooks is suing the hospital?”
“We thought she might,” I said.
Elliott sighed. “You usually call me about things like that. Why didn’t you this time?”
“I don’t call you,” I informed him. “Hal does. And Hal isn’t here. Hal knows nothing about this. And furthermore, I didn’t do it alone; Mike and I did it together, and we took pictures, and drew lots of blood, and we found nothing to indicate any fault on the part of the doctors. They did everything they could do, and it wasn’t enough.”
“Are you aware that I’m the hospital’s legal counsel?”
Whoa. “Since when?” I demanded.
“Since the beginning of the year,” Elliott said. “I thought you knew. Doesn’t that stuffed shirt Monty Montgomery keep you guys informed?”
I folded my arms defensively across my chest. “Not very well, apparently. And I talked to Monty before we did that autopsy too. He said there was nothing to worry about, and he told me the hospital’s legal counsel also said there was nothing to worry about. So was that you, or was he just talking through his hat?”
Elliott ignored my question. “So what killed him? What was the cause of death? I haven’t seen a freakin’ report.”
“That’s because there isn’t one yet. For God’s sake, Elliott, we just did it yesterday! We always provide a preliminary report within two working days. That’s Tuesday. So quit nagging me!” I was on my feet now, and Elliott got up and pushed me back into my chair.
“Toni, for God’s sake, take it easy! I’m on your side, remember? I just wondered what the freakin’ cause of death was.”
“Hey! Quit pushing my wife around!”
Startled, Elliott let go of my shoulders as if he had been burned, and Jodi and I spun around to see Hal, who had just walked into the kitchen. None of us had heard the garage door opening.
Hal took me in his arms and kissed me with emphasis. “Hi, sweetie,” he whispered, holding me tight. I was about to whisper back when I saw who was standing behind him.
Tall. Leggy. Tanned. Long, blonde hair. Oh, no, it can’t be. He wouldn’t dare. “What’s she doing here?” I hissed.
Hal reached out with one long arm and pulled the girl closer. I tried to pull away, but he kept the other arm firmly around me as he announced, “Everyone, I’d like you to meet my daughter Barbara, otherwise known as Bambi. This is my wife, Toni, and these are our best friends, Elliott and Jodi Maynard, and my mother-in-law, Fiona Day.”
Daughter?
Shyly, Bambi extended her hand to me and said, “Please call me Bambi. I hate Barbara.”
Picking my jaw up off the ground and not knowing what else to do, I took her hand, which felt like ice. Her blue eyes met mine, and in them I saw the scared child underneath the California surfer-girl exterior, and before I knew it, I’d pulled her into my arms, and she was sobbing on my shoulder.
“Hal,” I said over her shoulder, “you’ve got a shitload of explaining to do.”
“I suppose I have,” Hal agreed. “But I need to have some catch-up time with my wife first.”
Betcher ass you do, you bastard.
The three of us went upstairs. Bambi wanted to take a shower and get into some clean clothes, so while she was doing that, Hal and I shut ourselves in the master bedroom and turned on the radio to muffle our voices. Hal sat on the edge of the bed and patted the bed next to him.
Reluctantly, I perched tentatively on the very edge of the bed. This was a Hal that I didn’t know, and I didn’t know how to act. However, we had a lot of territory to cover and very little time. I waited impatiently for him to speak. He seemed to take an inordinately long time to formulate exactly what to say.
“Well?” I finally said, unable to contain myself any longer.
“Bambi’s parents were here this weekend,” he began. “Bambi wanted me to meet them. You could have knocked me over with a feather when I discovered that Bambi’s mother was none other than Shawna.”
Shawna. Hal’s first wife. The one he cheated on with me and then divorced to marry me. Once a cheater, always a cheater, Mum had warned me; but after seventeen years without even a hint that Hal had cheated on me, I’d become complacent, thinking that he never would. Had Mum been right all along? Mum, who had told me just the other day that she didn’t think I needed to worry about Hal? If Mum had changed her mind and believed that I could trust Hal, why couldn’t I? I wanted so badly to be able to trust him. Please God, let it be.
Anyway, getting back to the conversation at hand, Hal and Shawna didn’t have children, I thought. In fact, their marriage was already in trouble long before I ever met Hal—for that very reason. Hal wanted them and Shawna didn’t. So where did this one come from? “Really,” I said skeptically. “Shawna’s here. How nice.”
Hal sighed. “Not really. Shawna and her husband, Marty, and their two sons are here to spend some time with Bambi for Hanukkah.”
“Hanukkah’s not till tomorrow,” I said, just to be obstinate.
“Toni …”
“And she wanted them to meet her new boyfriend,” I said sarcastically.
“No, she wanted them to meet the professor she’s working for. I told you before, Toni. She’s my lab assistant, not my girlfriend.”
Oh, right. Why am I having trouble believing that? With difficulty, I managed to keep my mouth shut, but I’m sure my face showed my skepticism.
“Anyway, Shawna informed me that she was already pregnant when she married Marty and that I was Bambi’s real father.”
“And you didn’t know that until now?” I asked. “Did Marty know?”
“No,” Hal said. “He still doesn’t, and I hope he never finds out, because unless he and Shawna have a stronger marriage than Shawna and I had, this could tear it apart.”
“Why didn’t she tell you that she was pregnant with your child before she divorced you? Wouldn’t you have had to give her child support?”
Hal looked uncomfortable. “Not if she was married to somebody else. I guess she figured that Marty wouldn’t marry her if he knew, and since she hasn’t ever told him up to now, I’d guess that was the case.”
“I suppose Marty has money?”
“More than God. He owns a car dealership in Newport Beach. Mercedes, BMW, stuff like that.”
Newport Beach is a wealthy coastal town. Lots of doctors from UC Irvine live there. A Mercedes dealership there would be a gold mine.
I had to ask, even though I already suspected. “So you were still fucking Shawna at the same time you were fucking me?”
“Well, I still had to maintain my relationship with Shawna so she wouldn’t suspect anything. It was supposed to be a no-fault divorce. If she’d known about you and me, she could have charged me with adultery and taken me for everything I had and then some. So I kept fucking her right up until we filed for divorce and I moved out.”
“Hmph.” I wasn’t sure how I should feel about that, but it was a long time ago. I decided to let that subject drop. “So what did she do, just take you aside and drop it on you, just like that?”
“Pretty much.”
“Why bother?” I wondered. “She could have just let you go on thinking Bambi was Marty’s daughter. Couldn’t she?”
Now Hal looked really uncomfortable. “I think she was trying to start a fight. She wanted to see how I’d react to finding out I’d been fucking my own daughter.”
Aha! Now we’re getting somewhere. “So you have been fucking Bambi,” I accused. So much for trust.
“No,” Hal said. “I haven’t; and even if I’d wanted to, I sure as hell wouldn’t now.”
“D
id she tell Bambi too or leave that for you to do?” I was pretty sure I knew the answer to that one. Shawna never did anything she didn’t need to do. Dumping it on Hal was typical of her, from what he’d said about her over the years.
“It was pretty traumatic for her, finding out about her real father at this late date—especially after making a pass at me the other day. That had to be embarrassing. We spent a lot of time talking. It got pretty emotional. That’s why I didn’t come home. Obviously I couldn’t just leave her there with Shawna and Marty, and I certainly couldn’t bring her here.”
“You couldn’t call me and let me know what was going on?”
“I don’t see how,” Hal said. “What would I have said? How would you have taken it? Can you see us having this conversation over the phone? With your mother listening? And maybe Jodi and Elliott?”
He had a point there, I had to admit. However, I had one more question. We might as well get it all out in the open while we had the chance, I figured. With all that was going on, there’d be precious little opportunity from now on. “Did you think about having sex with her? Did you want to?”
Hal turned his palms up. “To be honest? Sure, it occurred to me, and sure, I thought about it. She’s a beautiful girl, and she’s the image of Shawna at that age, so yeah, I thought about it. Of course I thought about it; I’m not dead, you know.” He sounded like Mum. “But I divorced Shawna to marry you. Why would I jeopardize what I have with you just to repeat history? Why would I risk losing everything I hold dear just to have a fling with a student?”
“It would be a stupid thing to do,” I remarked.
“It would,” Hal agreed. “And I didn’t do it. Now, what about you and Bernie Kincaid?”
So he doesn’t trust me either. The thought made me feel like crying. Did the thought that I didn’t trust him make Hal feel that way too? “What about me and Bernie Kincaid? Nothing’s changed since the last time you asked me that!”
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