There was nothing at all notable until he came to a sheet of labs on Bill Elovitz. With all that had transpired over the past week, he hadn’t given the Charlestown man a thought. There were no blood tests that were specifically diagnostic of pulmonary hypertension, but because of the variety of the potential underlying causes of the condition, any findings were possible. He scanned the chemistries. Cholesterol and triglycerides, the lipids that contributed to arteriosclerosis were, not surprisingly, elevated. There were also some mild liver-function abnormalities, which could have been due to almost anything, but were most likely due to congestion of the liver from the back pressure of blood trying to make it through malfunctioning lungs, heart, or both. Nevertheless, Brian noted down the abnormal results on a card destined for Teri.
One of the unit nurses knocked and poked her head in.
“Everyone’s here,” she said. “Phil says we’ll be rounding in five minutes.”
“I’ll be there.”
With a few minutes remaining before rounds, he turned to the second page of Bill Elovitz’s labwork: hematology—the blood-cell counts. Immediately, one test caught his eye. The eosinophil cell count was elevated—quite elevated, actually. The so-called eos were a type of granular white blood cell that appeared red under the microscope with the most commonly used blood stain. They were abnormally increased in a number of disease conditions, including parasitic infections such as hookworm and trichinosis, and allergic reactions such as asthma, eczema, and hay fever. But also among the more common causes of eosinophilia was reaction to medication.
Brian stared at the result, then circled it, and noted it down on the Elovitz file card. Clinical findings consistent with pulmonary hypertension, coupled with marked eosinophilia in a patient taking an experimental drug. Maybe nothing, maybe something. No matter what, he still didn’t feel as if he were trying to force the square peg of Elovitz’s physical findings and eosinophilia into the round hole of the diagnosis.
He shoved the reports and a few journals into his briefcase and went out onto the ward. Phil Gianatasio, the teaching visit on the unit for the month, was in the process of herding the students, residents, fellows, and nurses over toward the first patient. Phil had been at the funeral, and had been a concerned friend as well, calling to check in, stopping over at the house twice, and once managing to talk Brian into going out for lunch.
Brian fell in with the group, but only heard a fraction of what was being said. Bill Elovitz’s shortness of breath and ankle swelling might never be proven to be anything other than congestive heart failure due to hardening of the coronary arteries. But now there was another finding to explain—an abnormal eo count.
Brian’s mind began ticking over the possibilities. As far as he could remember, the cases of PH associated with the toxic oil in Spain, as well as with the L-tryptophan and diet pills, all featured eosinophilia in the majority of the patients. Antibiotics, iodides, even aspirin—the list of drugs that produced reactions accompanied by some degree of elevation in the eo count was almost as extensive as the entire pharmacopoeia.
Freeman was right. The hospital was a much better place for him to be than stewing around alone at home.
“What do you think about that possibility, Brian?”
Phil stood across the bed from him, waiting. Brian grinned sheepishly.
“Lost in space,” he said. “I’ll try to be less distracted. Sorry.”
“As long as you’re there when my next case of thyroid storm comes walking in,” Phil replied.
The rest of patient rounds was uneventful. Brian did manage to stay better focused on the cases at hand, but at times he still couldn’t keep his mind from wandering to Jack, to Teri, or to Elovitz. Finally, the last case examined and discussed, Phil sent the team off to their various jobs.
“You’re covering the ward today?” he asked Brian.
“Yes.”
“You okay to do that?”
“I’m fine, really. I’m sorry for zoning out on you like that. I do have a lot on my mind. But I can handle the ward.”
“I trust you on that. Anything you want to talk about?”
“Actually, if you have time, there is. There’s some coffee in the pot in the lounge.”
“In that case,” Phil said, “I’m all over it.”
They settled in easy chairs opposite each other in the small lounge.
“Phil, I want to tell you about a case, and I want your opinion.”
“Shoot.”
“This is the man, Bill Elovitz, that you fixed me up with in the ER.”
“Miracle Man?”
“Exactly. I saw him in the Vasclear clinic just before Jack died. He’s a retired butcher and has a tattoo on his arm from the Nazi death camps. He was one of the prestudy Vasclear patients.”
“Phase One, right?”
“Yes, I believe so.”
“Proceed.”
“He was referred here a couple of years ago with classic cardiac history and findings. His course is that he got much better for a while after receiving Vasclear, then he started getting symptoms of coronary artery narrowing again. Finally, he had a small MI eight or nine months ago, for which he spent two days in the hospital and then signed out. He’s had a thing about hospitals ever since he was in the concentration camp.”
“I understand. Tell me more.”
“Well, he’s been coming to the clinic once a month for Vasclear treatment, but over the last four or five months, he’s developed ankle swelling and shortness of breath. He’s been treated for congestive failure with the usual stuff, but he’s been getting progressively worse. He’s still pretty mobile, but now he can’t always make a flight of stairs without stopping.”
“Okay,” Phil said, “I’m ready. You didn’t call me in here to present a run-of-the-mill case of congestive heart failure. What’s the catch?”
Brian took a sip of coffee, then said, “My ears may be a little out of practice after a year and a half without a stethoscope in them, but there’s the possibility they may be rested, too. I heard a loud right-ventricular fourth heart sound, an increase in the pulmonic component of the second sound, and murmurs of both pulmonic and tricuspid insufficiency.”
“Pulmonary disease?”
“Phil, he sounded exactly like the one pulmonary hypertension patient I’ve ever diagnosed.”
Gianatasio’s expression seemed to tighten, though almost imperceptibly. He turned and set his coffee on the table, but a bit sloshed onto his hand. He wiped the drop off with his other hand, and when he turned back to Brian, he was the old Phil again.
“PH is a tough call to make without a shitload of studies,” he said. “Even with them sometimes. But hey, would I question the ears of the man who diagnosed Stormy from the bedside in the heat of battle?”
“There’s more,” Brian said, still wondering about Phil’s queer reaction and whether it had even happened. “I just found some Woodwork in my pile that was drawn on the guy ten days ago. His eos are fourteen percent. His total white-cell count is normal—ninety-five hundred.”
“Fourteen percent of ninety-five hundred’s not that much of an elevation when you consider the actual number of cells.”
“Phil, zero to three percent is normal.”
“I know. It still doesn’t impress me. I’d check it again. And I’ll bet you a pan pizza it comes back under five. Eo counts bounce all over the place. The first thing to do with an unexpected abnormality in a lab test is to repeat it.”
“I will. You sound like you don’t make too much of this.”
“Too early to tell, Bri. I assume you ordered a few gazillion dollars’ worth of tests.”
“Something like that.”
Brian was beginning to feel some irritation at his friend’s flippancy. Then, suddenly, Phil was on his feet.
“Well,” he said, “I gotta go earn a living. Brian, there have been over two hundred cases treated with beta Vasclear since the double-blind study began, to say nothing of the
two hundred in the gamma group that got the lower dose. None of them has had so much as a rash that’s been pinned on the drug. I think you’re on a zebra hunt with this PH stuff. Keep me posted, okay?”
“I’ll do that.”
Brian stayed in the lounge for several minutes, feeling annoyingly unfulfilled by the exchange. Then he took his briefcase to the computer terminal in the on-call room. He was able to get Bill Elovitz’s home number off the man’s front sheet without going through anyone at the record room. An older woman answered on the fourth ring.
“Hello, Elovitz residence.”
“Hello,” Brian said. “This is Dr. Holbrook calling from White Memorial Hospital. I wonder if I could speak with Bill Elovitz, please.”
There was a prolonged silence before he heard the woman’s partially muffled voice say, “Devoran, it’s a doctor from White Memorial. He wants to speak to Bill.”
A woman responded in the background, but Brian could not make out anything she was saying.
“Doctor, what was your name?”
“Holbrook. Dr. Brian Holbrook. Look, if you want to call me here at the hospital to verify that’s where I’m calling from, the number is—”
“That won’t be necessary, Doctor. I’m Mrs. Levine, the next-door neighbor. I … I think I met you when Bill got hurt.” She began to sob. “Bill Elovitz is dead, Doctor. He was killed five days ago—shot during a holdup at the little market down the street from here.”
CHAPTER TWENTY-ONE
THE MORNING WAS PAINFULLY LONG. SEVERAL TIMES, Brian simply asked the nurses to handle as many of the problems as they could, and went to lie down in the on-call room. Maintaining enough energy at work had never been a problem for him. But now, the raw wound from Jack’s death, the night just past with Teri, and the disturbing news about Bill Elovitz had him feeling drained.
Maybe Freeman had been wrong about his returning to work this soon.
As a murder victim, Elovitz would almost certainly have been autopsied. Brian made a note to check with the medical examiner’s office about the results. Next he called the record room and found that none of the important tests he had ordered had been done before Bill’s death.
Finally, he dozed off and floated through a disturbing, disjointed dream involving, as best as he could piece it together, football, death camps, the Blues Barn, and his tenth-grade geometry teacher. He was awakened not by his pager or the phone, but by a soft knock on the door—once, then again.
“It’s okay, come in,” he called out, wondering illogically if it might be Teri.
The door opened partway and Phil poked his head in. He looked clearly troubled. Brian had called him immediately with the news about Bill Elovitz. There had been nothing the least bit flippant in Phil’s reaction—just a soft whistle, a prolonged silence, and a few words of genuine dismay.
“You got time to talk?” he asked now.
“Am I in trouble?”
“Why do you ask that?”
“I don’t know. Just paranoid, I guess. The last time someone knocked on my door like that asking if I had time to talk, it was the DEA.”
“Well, you’re not in trouble that I know of. But I do need to talk with you. Chris Glidden has agreed to cover the ward for an hour.”
“Sounds serious. Just give me a little time to put my body back in working order.”
“How about meeting me in my office in, say, ten minutes?”
Phil was gone before he could reply. Brian pulled himself together and tried calling Teri at the Marriott, but she had checked out as she had told him she was going to. She must be somewhere in the hospital going over records, or else over at Newbury Pharmaceuticals. Word was out in the papers and all over the news that the President was planning to come to White Memorial for the Vasclear signing ceremony. Time was running out for Teri to find any reason to postpone the event.
Phil’s office on the seventh floor was very much junior-faculty—tight space, metal shelves for bookcases, and a view not of the Charles, but across the center of the hospital, including the skeleton of a building under construction and the latticework of scaffolding around the stained-glass Hippocrates Dome. Brian had stopped at a machine canteen on the way up and bought a couple of nondescript, sugar-coated, cellophane-wrapped pastries. He tossed one on Phil’s desk.
“Here,” Brian said. “This is a bribe in case you were lying about my not being in any trouble.”
Phil set the pastry aside—a bad sign.
“I didn’t lie about that,” he replied, “but I did lie about something else. Sit down, please.”
Brian cleared some papers off a Scandinavian Design–type chair and settled in. Phil, usually a fairly natty dresser, and always composed, looked haggard and stressed. His tie was loosened, and there was a small coffee stain by the collar of his shirt.
“Easy does it, Phil,” Brian said. “Short of wasting someone, there’s not much you could have done that I haven’t done in spades. Regardless of what you have to tell me, I’m not into judging people anymore.”
Gianatasio composed himself with a deep breath.
“I’m sorry I acted so detached earlier when you told me about that poor guy you thought had pulmonary hypertension. The truth is, I didn’t know what to do with the information. You see, a couple of years ago, back when Vasclear was still in Phase One trials, I encountered another Vasclear patient I thought might have pulmonary hypertension. I scrounged around and found his name. It was Ford, Kenneth Ford. I saw him only once in the clinic, but I keep a little card file on interesting cases I see, and he was in it. His physical findings were almost identical to the ones you described hearing and seeing in your man—ankle edema, shortness of breath, tricuspid- and pulmonic-valve insufficiency, everything.”
“What happened?”
“I … I did what we’re supposed to do. I spoke to Art Weber about him. He told me there had been several allergic-type rashes with the drug, which he and his chemists had determined were due to an ingredient used in the chemical-stabilization portion of the synthesis. After that, the process had been overhauled, the contaminant removed, and no problems had been reported until this Ford guy. Weber and I checked his record carefully, and sure enough he had started on the drug before the synthesis was modified.”
“So what happened to the guy? How has he done?”
“Brian, listen. I’ve been on a tenure track since I arrived here. Now I’m just about to get approved. Tenure at Boston Heart and the medical school. The plum of plums, every academic cardiologist’s dream, and I’m about to realize it. You know as well as I do that I’m not the brightest bulb on the academic light board by any stretch, so I’ve had to resort to working that much harder than anyone else, keeping my nose clean, and most of all, playing by the rules. And at Boston Heart, one of the biggest rules of all is not going off half-cocked when it comes to research results on any BHI product or drug. I’ve really got to be careful.”
“I understand, Phil. I really do. Tell me, though, this Ford fellow, did they ever definitively diagnose pulmonary hypertension in him?”
Phil looked up at the drop ceiling.
“I … I don’t know,” he said. “Weber promised me he’d speak with Carolyn and that she would take over Ford’s care and decide whether his situation was reportable or not. I never made any effort to follow up on the case, and then I sort of forgot about it—until this morning. Bri, I feel like shit about this. I really do.”
“I can tell. You did right to get it off your chest, Phil. And the truth is, we really don’t know whether either of these guys actually had PH.”
“That is true. And maybe we should let sleeping dogs lie. I think you know, Brian, but I want to warn you again. This drug is their baby. I can’t even begin to estimate how much is riding on it. The first thirty seconds it’s on the open market, it will probably bring in more money than they pay the two of us together in a year.”
“I know.”
Brian left it at that, sensing his frien
d was just too tense right now to handle any witty remarks about their salaries.
“Pickard, Jessup, Weber—they all seem to like you a lot,” Phil went on. “And you’ve done a couple of stellar things since you got here. But they’re all tough as nails when they’re cornered in an academic argument, or when someone makes trouble for them or threatens to cost them money. I’ve seen examples of it a number of times since I’ve been here. You have no way of knowing this, but Pickard and Jessup came to me after you admitted sending in the FDA report on that Ward-Dunlop catheter. Brian, they were going to can you. Right then and there. No second chances. No concerns about your future with the Board of Medicine, your kids, nothing. Here you saved my thyroid lady and Jessup’s patient, and they were prepared to send you into medical purgatory just for not making a team-oriented decision.”
“What saved me?”
“Probably a little of everything. I said my piece on your behalf. And you made a hell of an impression on Pickard. I think he finally persuaded Jessup to give you another chance. But it was touch and go for a while.”
“So, it would seem we’ve both got reasons for thinking things through pretty carefully.”
“That depends.”
“On what?”
A bit more relaxed, Phil could resist the pastry no longer. He opened it and took a big bite before answering.
“On how much you enjoy renting cars and how much I would want to be working the counter alongside you.”
Brian thought about Teri and her boss, searching for anything that they might use to postpone the general release of Vasclear. He thought about her warning that it was much more difficult to pull a drug off the market than it was to keep it from getting there in the first place. And finally, he thought about the hundreds of lives that might be saved every single day Vasclear was being prescribed.
“Phil, we can’t just let it drop,” he said.
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