At What Cost

by James L'Etoile

  “No. Tell me now! My son?” she said.

  Heads from other families turned in their direction. Most had sympathetic faces, while a few wore expressions that bore relief that the bad news wasn’t for them.

  “Okay, please sit,” Dr. Anderson said.

  John and Melissa retreated to the sofa, perching on the edge, their backs rod straight with morbid resignation.

  “I’m afraid I do have bad news.”

  Melissa tensed and grabbed her husband’s hand.

  The doctor moved to take her hand, but stopped when she pulled away. “First, Tommy is all right. But we had to stop the surgery.”

  “What happened?” John asked.

  “We had Tommy ready to go for the transplant, we made the initial incisions, peeled back the muscle tissue, and exposed the iliac artery for the graft. We removed the donated kidney from the container and flushed it in sterile solution. All textbook. Since this was planned as a heterotopic transplant, where Tommy’s existing kidneys were to stay in place, the next step was the graft.” The doctor scanned the waiting room and leaned in closer to John. “Then I took a second look at the donated kidney, thinking about what you said.”

  “About where it came from?” John said.

  “The UNOS system issues a unique identification number to each organ. The number issued for Tommy’s new kidney came from a harvest twelve hours ago. The kidney that I examined was older than that—much older. The kidney already showed signs of delayed graft function and swelling. The perfusate solution was full of particulate matter. It was like it wasn’t irrigated after harvest. That kidney wasn’t viable transplant tissue.”

  “Did you start to graft that kidney in my son?” John asked.

  “No. We caught the discrepancy in time. I closed Tommy back up, and he’s in the recovery room now. He will still need a transplant, but he has to recover and get strong enough to go through this again.”

  John fell back against the back of the stiff sofa. “When can we see him?”

  “Let’s give him another ten minutes, and then it should be fine.”

  “How? This wasn’t supposed to happen,” Melissa said.

  “I don’t know. The system is designed to prevent this kind of problem. When the donated kidney went on the UNOS database, your son’s name came up as an HLA zero mismatch, which means that it was a perfect tissue match for Tommy. It compared all the patients on the transplant list, and Tommy was the only exact match. There was no question that Tommy would end up with that donation. The thing that confounds me is how UNOS identified this as an organ harvested twelve hours ago. The condition of the tissue, swelling, and lack of elasticity is what I’d expect from a kidney well over seventy-two hours from harvest. Even with cold storage, the viability of the tissue declines rapidly.”

  “We need to get the kidney to the medical examiner for analysis,” John said.

  “Our lab has the tissue now and will share the results with them. Let’s go look in on Tommy.”

  The doctor stood and led them to the doors of the recovery room, a few yards from the surgical suite. He paused at the door. “This shouldn’t have happened. I can’t tell you how sorry I am. I was minutes from putting that kidney into your son. I wouldn’t have taken that extra look if it wasn’t for our conversation.”

  “But you prevented that from happening,” John said.

  “It shouldn’t have gone that far.”

  “Can we see him now?” Melissa pleaded.

  Dr. Anderson nodded and stepped back from the doorway.

  Melissa was first through the door. John was a step behind, and he melted when he saw Tommy with tubes, wires, monitors, and thickly packed gauze from the aborted surgery attached to him.

  “What would have happened if you hadn’t noticed and went on with the transplant?” John asked.

  Dr. Anderson’s scrubs wrinkled as he crossed his arms, revealing a small drop of blood on the surgeon’s chest. John noticed the stain and couldn’t look away from the spot, a small, insignificant droplet that told of Tommy’s journey.

  “The kidney would have failed, sooner rather than later. I would have given it a day or two, at most. Then, toxicity within Tommy’s system would have spiked. Fevers, sepsis, and infection would have been bad news with his compromised immune system.”

  “Any way he could have fought it off and pulled through?”

  “No chance. That tissue was a loaded gun. I’d be willing to bet that the lab results confirm the tissue was damaged and dying.”

  “How did a decaying organ get into the transplant stream?”

  “I don’t know. The ramifications of this—this event threatens the foundation of this hospital and the hundreds of transplants we provide each year. As soon as I report this through the transplant committee, we may be cut off from the Organ Sharing Network until we reexamine every step in our process.”

  John leaned on the doorframe and wished he were the one strapped down with electrodes, cords, and tubes instead of his son. The botched surgery had sapped the reserves the boy held, yet he still needed a transplant to survive. In a perverse twist, he wouldn’t get the transplant until he regained some of his strength. Each succeeding day without a new kidney meant Tommy grew weaker and his blood more toxic. The boy’s body lost ground in his fight to get the transplant.

  Without looking away from his son, John said, “Do me a favor. Don’t report what happened to the transplant committee.”

  “What are you saying? I have to report the condition of the organ tissue we received. The consequence of failing to alert the Organ Sharing Network presents a risk to every patient waiting for a transplant.”

  John locked eyes with Anderson. “Give me twenty-four hours before you report to the committee. You don’t even have the lab results to confirm the report yet, do you?”

  “Well, no . . .”

  “You’d be like Chicken Little claiming the sky is falling without any evidence to back it up. Please, Doctor, I’m asking for twenty-four hours.”

  “I—I guess it can’t hurt. I don’t have any other transplant surgeries scheduled today. We have two possible cases tomorrow afternoon, the first at one o’clock and another at six, if the donated organs arrive. I must report before then. Why are you asking me to delay this?”

  “I need to find where the kidney came from and how it got into your system. If you had any part in changing the UNOS data to make this happen, I’ll find out.” John grabbed the doctor by the lapels of his white lab coat. “This is your only chance to come clean.”

  Dr. Anderson stood motionless and stone-faced. “Mr. Penley, you’re not thinking clearly. Let go of me, now.”

  John released his grip on the doctor’s coat.

  “I need to find out how this happened as much as you do,” the doctor said. “I’ll call the lab and have the samples brought to you.”

  “No, I’ll get them.”

  “You need to trust someone, Detective.”

  “Not when it comes to my kid.”

  TWENTY-ONE

  “I don’t care if you’re a cop. I’m not giving you anything from my lab.” The starched white smock flapped behind the laboratory supervisor when he blocked John’s path, an imitation of a protective goat-herder keeping a hungry coyote at bay.

  John noted the blue stitching on the lab coat that bore the supervisor’s name. “Listen, Martin . . .”

  “That’s Dr. Robinson to you. You can’t barge in here and take samples from my lab.”

  “The tissue sample Dr. Anderson sent you is evidence in a criminal investigation. I need the medical examiner to take custody and evaluate the sample,” John said.

  “Then get a warrant. I have my lab protocols that must be followed. I can’t release anything to you. I log in each and every tissue sample, log the testing, and log the disposition of the samples. We have a chain of custody here, and I simply can’t turn over a tissue sample because you say so.”

  “Show me the sample. That can’t violate an
y of your precious protocols. Can it?”

  “That’s highly irregular.” Dr. Robinson stiffened in protest.

  John probed the weakening bureaucrat. “If I get Dr. Kelly, the medical examiner herself, to tell you to release the tissue, is that within protocol?”

  “I—I suppose. However, my lab will no longer be responsible for any testing associated with that tissue. Dr. Kelly will have to provide any clinical assessment and tissue typing information that’s required.”

  “Agreed.” John pulled out his cell and hit the speed-dial entry for Dr. Sandra Kelly. “Why don’t you go track down the tissue sample while I speak to Dr. Kelly?”

  Dr. Robinson, tight jawed from being ordered about within his own space, slunk behind the counter and retreated to the lab confines. He swiped his key card, unlocking a glass door that separated the laboratory from the outer offices.

  Dr. Kelly came on the line after a few seconds. “Hi, Detective. I was just thinking about calling you. What’s on your mind?”

  “I need you to take a look at a tissue sample, a kidney.”

  “Related to our current case?”

  “I think it is.”

  “How did you stumble upon this kidney? Find another shipping container?” she asked.

  “They tried to put this one in my son.”

  Silence.

  “The surgeon caught it before it was too late and saw that the kidney wasn’t viable.”

  “I need that organ,” she said.

  “I’m trying to persuade the lab supervisor at the hospital to turn it over.”

  “What’s his name?”

  “Martin Robinson. Know him?”

  “I’ve heard about him. Very by-the-book. More of an administrator and paper pusher than a clinical guy. Is he there? Let me talk to him. Put him on.”

  At that moment, Dr. Robinson returned from the lab. The lab super’s face bloomed pink, and his protruding Adam’s apple bobbed as he swallowed hard. “It’s missing.”

  “I’ll call you back,” John said to Dr. Kelly, and he disconnected the call. “Missing? What’s missing?”

  “The sample. The sample Dr. Anderson sent. The whole thing. It’s gone. There must be an explanation,” Dr. Robinson said. He rubbed his hands together to purge the imaginary stain of a potential scandal.

  “You said you kept a log. Let me see it,” John said.

  Robinson stepped around to his desk, opened a drawer, and pulled a thick, three-inch canvas binder from the bottom drawer. He placed it on the desk surface, opened the file to the last page of handwritten entries, and pointed. “Here is when the tissue sample came into the lab.”

  John read the neatly printed line. Tissue sample (human kidney) received from Dr. Anderson for ms, vs, and bc.

  “What’s that mean?” John asked.

  “Mass spectrometry, vivisection, and bacterial culture. Dr. Anderson wanted those actions completed. We take small samples of the tissue, review it by mass spec, and look for abnormal tissue, cellular crystallization, edema, and foreign bodies. Fluid and tissue are tested for bacterial infection, so we grow a culture to identify the type and strain of infection.”

  “Where did the organ go after you logged it in?”

  “Into refrigerated storage, locker number three.” Robinson pointed to the entry in the log book.

  “Show me,” John said.

  Robinson froze in place for a moment as he considered his precious protocols. The rigid rules failed him, and he needed damage control now. He gestured for John to follow him through the doors into the sterile work space.

  Expansive white work surfaces, stainless-steel tables, and glass-fronted cabinets dominated the lab. The work space appeared well ordered, clean, and empty. Hulking machines with lights, vials, and dials sat along the far wall, and four refrigeration units lined the end wall to the right. The refrigerated units had tall black numbers stenciled on the glass-front panels. Bottles, racks of test tubes, and plastic-wrapped specimen dishes with red biohazard labels decorated the shelves behind the glass.

  “Dr. Anderson’s tissue sample went into number three.”

  “Are you certain?”

  “Yes. I put it in there myself.”

  John walked to the refrigerated units and tugged on the handle of the one marked with the number three. It held tight. “Who else has access?”

  “Only the lab employees have access cards. Four technicians and me,” Robinson said.

  Slim, metallic card readers protruded from the wall next to each glass door. Robinson unclipped his access card from his lab coat and swiped it through the card-reader slot, and a green light appeared on the door. The lock popped open.

  “The sample was on the middle of the top shelf. I don’t understand how it went missing.”

  Robinson shut the door, and an audible click indicated the door had locked, but John pulled the handle to make certain.

  “The electronic lock system—can you access the history of who used an access card to open that door?” John asked.

  “I suppose so. I’ve never had reason to do that.” Robinson pivoted on his heel and took a step to a workstation. He woke up the computer with a shake of the mouse and entered his password into the secure hospital system. He scrolled down a menu of options and then clicked on the security item.

  The link required a second password, and the screen refreshed with a set of menu items specifically for the hospital laboratory.

  “Access log,” Robinson said as he clicked on the item. The screen flickered and scrolled out line after line of dates, times, and names of the staff who had entered the secured spaces of the lab. Robinson paused the screen when the access data for refrigerated storage came on the screen.

  “That can’t be right.”

  “What is it?” John asked.

  Robinson’s finger shook as he pointed to the screen. “Here, precisely at 1:35, I opened the locker. That’s when I secured Dr. Anderson’s specimen. Twelve minutes later, the same locker opened. That’s not possible.”

  John looked over the doctor’s shoulder, and the computer indicated that at 1:47, a staff member by the name of Marsha Horn opened the locker.

  “Where is Marsha Horn? I need to talk to her,” John said.

  “You can’t.”

  “What do you mean, I can’t?”

  Dr. Robinson swallowed hard and said, “Marsha’s dead. She was the lab supervisor before me. I didn’t know her, but from everything I’ve gathered, she was a good supervisor and ran a tight lab. She died in a car accident about two years back,” Robinson said.

  “So how can you explain a dead woman stealing a tissue sample out of your lab?”

  “I can’t.”

  John looked around the lab quickly, assessed that there were no surveillance cameras and only two exit doors. A door in the back of the lab was marked for emergency use only and claimed that an alarm would sound if opened.

  “Did Dr. Anderson call to tell you to get rid of the sample?”

  “What? No.”

  “Who else is working here today?”

  “I’m down to two assistants, and one is on vacation. So today, it’s Zack Weber and me.”

  “Where’s Zack?” John asked.

  “I sent him down to admin. They’re holding some of our equipment requests hostage.”

  John glanced at the emergency-exit door, and an uneven section on the doorframe caught his attention. He strode across the lab and grabbed the door handle.

  Dr. Robinson yelled, “Wait, the alarm!” when John tugged on the handle.

  The door slipped open without a crescendo of bells and buzzers.

  “The door wasn’t shut completely. The alarm should have gone off,” John said. He slid his fingers along the metal doorframe and found thin strips of metallic tape attached to the sensors.

  “Where does this exit go?”

  “Stairwell, roof to basement,” Robinson said.

  John poked his head around the back of the door and saw no hint of
a keypad or access-card reader, only a simple push bar designed for quick release in the event of an emergency evacuation. The telltale smell of cigarette smoke lingered in the stairwell.

  “Are the doors alarmed all the way down?”

  Before Robinson responded, the front electric door unlatched. A thin, scruffy-bearded man pushed through the door and dropped a file folder on the nearest counter. His eyes, magnified through thick lenses, blinked and shifted from Dr. Robinson to John.

  “Zack, this is Detective Penley.”

  “Is there a problem, Dr. Robinson?” Zack asked. His voice cracked when he spoke.

  Zack used a thumb to slide his glasses back up to the bridge of his nose. He crossed his arms and uncrossed them. Then he hiked up his lab-coat sleeves that were four inches too long. Zack fidgeted with the pens in his breast pocket before gathering up the files from the counter. The awkward mannerisms painted Zack as the kind of person most at home in a lab, where nothing required social interaction.

  “We have experienced a breach of lab security,” Robinson offered.

  “Really? Who broke in?”

  “How long have you worked in the lab, Zack?” John asked.

  Zack kept his eyes on the paperwork. “Four years.”

  “So it’s safe to say you know your way around this place fairly well?”

  “Uh, yeah, safe to say,” Zack said.

  “Then you can tell me when the alarm on the fire-exit door was bypassed,” John pressed.

  The goggle-eyed lab assistant’s face bounced up from the file in his hands. “I—I don’t know anything about that,” he said.

  “Sure you do, Zack. You said you know your way around here. You’d notice something like that. Besides”—John pointed to a bulge in Zack’s lab coat pocket—“there’s a cigarette butt on the stairwell landing, and I’d bet that it’s one of yours.”

  “There’s no cigarette butt out there,” Zack protested.

  “How would you know that?” John countered.

  His lip twitched.

  “You know Marsha Horn?” John asked. “You worked here when Marsha ran the lab, right?”

  “Uh-huh, so?” Zack replied.

  “So how is it that Marsha accessed the refrigerated storage a couple hours ago?”