Harmful Intent

by Robin Cook

  “You gotta slow down,” David said with a bit less friendliness than he’d shown initially. “You’ll make the rest of us look bad.”

  Jeffrey smiled sheepishly. “I guess I’m just eager because it’s my first day. Don’t worry, I’ll calm down.”

  “I hope so,” David muttered. Then he turned and left.

  Jeffrey finished what he was doing in Central Supply, then pushed his cart the length of the OR corridor and out the swinging doors. Changing back to his housekeeping uniform, he pushed the cart down to the pathology department. He wanted to take advantage of the fact that David and the other cleaning personnel were lunching.

  He tried the passkeys in the door that led to the administrative section of pathology. The third key opened the door. Jeffrey was amazed where his uniform and passkeys could take him.

  The place was deserted. The only people around in that whole section of the hospital were the technicians in the chemistry, hematology, and microbiology labs. Jeffrey lost no time. Propping his mop up against the massive file cabinets, he searched for the pathology file on Patty Owen. He found it easily.

  He put the folder on a desk and opened it. Flipping through the pages, he found copies of the Medical Examiner’s autopsy report. He turned to the toxicology section, which had graphs of the results of the gas chromatography-mass spectroscopy of blood, cerebrospinal fluid, and urine. The only compound that was listed as having been found was bupivacaine, the generic name for Marcaine. No other chemicals had been found in her body fluids, at least none that the tests had discovered.

  Jeffrey went through the rest of the file, glancing at each page. He was surprised to find a number of eight-by-ten photos. Jeffrey pulled them free. They were electron micrographs made at Boston Memorial. Jeffrey’s curiosity was piqued: electron micrographs were certainly not done for every autopsy. He was sorry he wasn’t more skilled at interpreting electron microscope sections. As it was, he had a hard time deciding which end was up. After studying the micrographs carefully, he finally realized that he was looking at magnified images of nerve ganglia cells and nerve axons.

  Reading the descriptions on the back of each photo, Jeffrey learned that the electron micrographs showed marked destruction of the intracellular architecture. He was intrigued. These photos had not been exhibited during pretrial discovery. With the hospital involved as a defendant in the same case as Jeffrey, the pathology department had not been acting with Jeffrey’s best interest in mind. Jeffrey had not even been informed of the existence of these photos. If he and Randolph had, they might have been subpoenaed, not that Jeffrey had been particularly interested in possible axonal degeneration at the time of his trial.

  Seeing the axonal degeneration evident in Patty Owen’s electron micrographs made Jeffrey recall the axonal degeneration Chris Everson had described in his patient’s autopsy. What was so startling about the degeneration in both cases was that local anesthetics could not have been responsible. There had to be some other explanation.

  Jeffrey took the file to the copy machine and copied the parts he thought he’d need. These included the electron microscopic reports, although not the photos themselves. It also included the toxicology section with the gas chromatography and mass spectroscopy graphs. To properly decipher the graphs, he knew he would have to spend more time in the library.

  When he was finished with the copy machine, he found a large manila envelope and put the copies into it. Then he returned the original to its folder and refiled it. Jeffrey stowed the manila envelope on the lower shelf of his cleaning cart under some replacement rolls of toilet paper.

  Then Jeffrey turned his attention back to cleaning. He was excited about what he had found. The idea of a contaminant was still viable indeed. In fact, given the results of the electron micrographs, it was almost a certainty.

  As the night wore on, Jeffrey’s energy waned. By the time the sky began to brighten, he was thoroughly exhausted. He’d been running on nervous energy for hours. At six-fifteen, he took the opportunity of a phone in an empty social service office to give Kelly a call. If she had to leave the house by six forty-five, she was sure to be up.

  As soon as she came on the line, Jeffrey excitedly told her about the emergency eye case the morning of the Patty Owen disaster and that .75% Marcaine had been used. “Kelly, you were so right. I don’t understand why no one thought to look into such a possibility. Randolph didn’t, and I never did.” Then he told her about the electron micrographs.

  “Does that suggest a contaminant?” Kelly asked.

  “It makes it almost certain. The next step is to try to figure out what it could be and why it didn’t show up in the toxicology report.”

  “This whole thing scares me,” Kelly said.

  “Me too,” Jeffrey agreed. He then asked her if she knew anybody in pathology at Valley Hospital.

  “Not in pathology,” Kelly answered. “But I still know several of the anesthesiologists. Hart Ruddock was Chris’s best friend. I’m sure he’ll know someone in pathology.”

  “Could you give him a call?” Jeffrey asked. “See if he’d be willing to get copies of whatever the pathology department has on Henry Noble. I’d be particularly interested in EM studies or histology of nervous tissue.”

  “What will I say if he asks why I want it?”

  “I don’t know. Tell him you’re interested, that you were reading Chris’s notes and read that there was axonal degeneration. That should pique his curiosity.”

  “All right,” Kelly said. “And you better get back here and get some rest. You must be asleep on your feet.”

  “I’m exhausted,” Jeffrey admitted. “Cleaning is a hell of a lot more tiring than giving anesthesia.”

  Early that morning, Trent made his way down the OR corridor of St. Joseph’s Hospital with the doctored vial back in his briefs. He went through the same motions he had the previous morning, being especially sure no one was anywhere near Central Supply before he went in to switch the ampules. Since there were now only two ampules of .5% Marcaine in the open box, the chances that his ampule would be used that day were good, especially with two epidural cases listed on the big board. Of course, there was no guarantee Marcaine would be used, much less the .5%. But there was a good chance. The cases scheduled were a herniorrhaphy and a laparoscopy. If it was one or the other, Trent hoped his ampule would make it to the laparoscopy. It would be too perfect; that prick Doherty was listed as the anesthesiologist.

  Casually strolling back to the locker room, Trent hid the good ampule in his locker. Closing and locking the door, he thought about Gail Shaffer. Dealing with her hadn’t been as much fun as he’d anticipated, but in a way, Trent was grateful for the experience. Gail’s spotting him had impressed upon him the need to be vigilant at all times. He couldn’t afford to be careless. Too much was at stake. If he screwed up, there would be hell to pay. Trent couldn’t help but feel the authorities would be the least of his worries.

  The clock radio was set for six forty-five and tuned to WBZ. The volume was low, so Karen woke in stages. Finally her eyes blinked open.

  Karen rolled over and sat on the edge of the bed. She still felt drugged from the medication that Dr. Silvan had given her to help her sleep. The Dalmane had worked better than she’d anticipated.

  “Are you up?” Marcia called through the closed door.

  “I’m up,” Karen answered. She got to her feet unsteadily. Dizzy for a moment, she held on to her bed post to steady herself. Then she went into the bathroom.

  Despite a cottony feeling in her mouth and a dryness in her throat, Karen was scrupulously careful not to drink anything. Dr. Silvan had warned her not to. She didn’t even drink water when she brushed her teeth.

  Karen wished the day were ending, not beginning. Then her procedure would be over and done with. She knew it was silly, but she still felt apprehensive. The Dalmane couldn’t help that. She did her best to occupy her thoughts with the process of showering and dressing.

  When it c
ame time to head to the hospital, Marcia drove. For most of the drive, she did her best to keep up the conversation. But Karen was too distracted to respond. By the time they pulled into the hospital lot, they’d been driving in silence for some time.

  “You’re kinda scared, aren’t you?” Marcia finally said.

  “I can’t help it,” Karen admitted. “I know it’s silly.”

  “It’s not silly at all,” Marcia said. “But I guarantee you won’t feel anything. The discomfort will come later. But even then, it will be easier than you think. This is the worst part of it: the dread.”

  “I hope so,” Karen said. She didn’t like the fact that the weather had changed. It was raining again. The skies looked as gloomy as she was feeling.

  There was a special day-surgery entrance. Karen and Marcia were left waiting for a quarter of an hour along with several dozen others. It was easy to pick out the patients in the crowd. Instead of reading their magazines, they merely flipped through the pages.

  Karen had been through three magazines by the time she was called to a desk and greeted by a nurse. The nurse went over all the paperwork and made sure all was in order. Karen had been in for blood work and an EKG the day before. The consent form had already been signed and witnessed. An ID bracelet had already been printed up. The nurse helped Karen snap it on.

  Karen was given a hospital johnny and a robe and shown to a changing room. She felt a mild wave of panic as she climbed onto the gurney and was moved to a holding area. At that point Marcia was allowed to join her for a few moments.

  Marcia was holding the bag that contained Karen’s clothes. She made some attempts at humor, but Karen was too tense to respond. An orderly came by and, after checking the chart at the end of the gurney as well as Karen’s ID, he said, “Time to go.”

  “I’ll be waiting,” Marcia called as Karen was rolled away. Karen waved, then let her head fall back on the pillow. She thought about telling the orderly to stop pushing so she could get off. She could make it back to the dressing room, get her clothes from Marcia and put them back on, and calmly leave the hospital. The endometriosis wasn’t that bad. She’d lived with it this long.

  But she didn’t do anything. It was as if she’d already been caught by an inevitable sequence of events that would play themselves out no matter what she did. Somewhere during the process of deciding on the laparoscopy she’d lost her freedom of choice. She was a prisoner of the system. The elevator doors closed. She felt herself being whisked upward, and the last chance for escape was cut off.

  The orderly left Karen in another holding area with a dozen or so gurneys like her own. She glanced at the other patients. Most were resting comfortably with their eyes closed. A few were looking around just as she was, but they didn’t look frightened, as she felt.

  “Karen Hodges?” a voice called.

  Karen turned her head. A doctor in surgical garb was by her side. He’d appeared so quickly she hadn’t seen where he’d come from.

  “I’m Dr. Bill Doherty,” he said. He was about her father’s age. He had a mustache and kind brown eyes. “I’m going to be your anesthesiologist.”

  Karen nodded. Dr. Doherty went over her medical history again. It didn’t take long; there wasn’t much to go over. He asked the usual questions about allergies and past illnesses. He then explained that her doctor had requested epidural anesthesia.

  “Are you familiar with epidural anesthesia?” Dr. Doherty asked.

  Karen told him that her doctor had explained it to her. Dr. Doherty nodded but carefully explained it again, emphasizing its particular benefits in her case. “This kind of anesthesia will give lots of muscle relaxation, which will help Dr. Silvan with his examination,” he explained. “Besides, epidural is safer than general anesthesia.”

  Karen nodded. Then she asked, “Are you sure it will work and that I really won’t feel anything when they’re probing around?”

  Dr. Doherty gave her arm a reassuring squeeze. “I’m absolutely sure it will. And you know something? Everybody worries that anesthesia is not going to work for them the first time they have it. But it always does. So don’t worry, okay?”

  “Can I ask one other question?” Karen asked.

  “As many as you like,” Dr. Doherty answered.

  “Have you ever read the book Coma?”

  Dr. Doherty laughed. “I did, and saw the movie.”

  “Nothing like that ever goes on, does it?”

  “No! Nothing like that ever goes on,” he assured her. “Any more questions?”

  Karen shook her head.

  “All right then,” Dr. Doherty said. “I’ll have the nurses give you a little shot. It will calm you down. Then when we know your doctor is in the dressing room, I’ll have you brought down to the operating room. And, Karen, you really won’t feel a thing. Trust me. I’ve done this a million times.”

  “I trust you,” Karen said. She even managed a smile.

  Dr. Doherty left the holding area and went through the swinging doors into the OR suite. He wrote an order for Karen’s tranquilizer, then went into the anesthesia office to take out his day’s narcotics. Then he headed down to Central Supply.

  In Central Supply, he picked up some IV fluids and, juggling the bottles, reached into the open box of .5% Marcaine and lifted out an ampule. Always careful about such things, he checked the label. It was .5% Marcaine all right. What Dr. Doherty didn’t notice was the slight irregularity of the top, the part that he’d break off when he was about to draw up the drug.

  Annie Winthrop was more tired than usual as she made her way up the walkway to the entrance of her apartment building. She had her umbrella up to shield her against the downpour. The temperature had dropped to the low fifties; it felt more like winter coming back than summer on its way.

  What a night it had been: three cardiac arrests in the intensive care unit. It was a record for the last four months. Handling the three as well as taking care of the other patients had sapped everybody’s strength—and patience. All she wanted to do was take a nice, hot shower, then climb into bed.

  Arriving at her apartment door, she fumbled with her keys, dropping them in the process. Exhaustion made her clumsy. Picking them up, she put the right one into the lock. When she went to turn the key, she realized the door was already unlocked.

  Annie paused. She and Gail always kept their door locked, even when they were inside the apartment. It was a rule that she and Gail had specifically discussed.

  With mild apprehension, Annie turned the knob and pushed the door open. The lights were on in the living room. Annie wondered if Gail was home.

  Annie’s intuition made her hesitate on the threshold. Something was warning her of danger. But there were no sounds. The apartment was deathly quiet.

  Annie pushed the door open wider. Everything seemed to be in order. She stepped over the threshold and immediately smelled a terrible odor. As a nurse she thought she knew what it was.

  “Gail?” she called. Normally Gail was asleep when she got home. Annie walked toward Gail’s bedroom and looked in through the open door. The light was on in there too. The smell got worse. She called Gail’s name again, then stepped through the door. The door to the bathroom was open. Annie went to the bathroom and looked in. She screamed.

  Trent’s assignment for the day was to circulate in room four, where a series of breast biopsies were scheduled. He thought it would be an easy day unless some of the biopsies turned out to be positive, but that wasn’t expected. He was pleased with the assignment because it gave him the freedom to keep an eye on his Marcaine vial, something he’d not been able to do the day before.

  The first biopsy was just beginning to be performed when the nurse anesthetist asked Trent to run down and get her another liter of Ringer’s Lactate. Trent was only too happy to oblige her.

  There were a number of staff members in Central Supply when Trent walked in. He knew he’d have to be particularly circumspect when he checked for his vial. But they didn’t p
ay attention to him. They were busy setting up surgical packs to replace the ones to be used that day. Trent walked back to the area where the IV fluids were kept. The non-narcotic drugs were to his left.

  Trent took an IV bottle from the shelf. Through the doorless entranceway of this section of Central Supply, he could see the others as they counted instruments for each pack.

  With one eye on his fellow nurses, Trent let his hand slip into the open Marcaine box. He felt a thrill. There was only one ampule left and its rounded top was smooth. His ampule was gone.

  Barely able to contain his excitement, Trent left Central Supply and headed back to room four. He gave the nurse anesthetist the IV bottle. Then he asked the scrub nurse if she needed anything. She said that she didn’t. The case was going smoothly. The biopsy had already been sent for frozen section and they were closing. Trent told the scrub nurse he’d be right back.

  Emerging from room four, Trent hurried down to the big board. He was overjoyed at what he saw: the only epidural scheduled for seven-thirty was the laparoscopy, and Doherty was the anesthesiologist! The herniorrhaphy wasn’t scheduled until later in the day. His vial had to have been taken for the laparoscopy.

  Trent checked the laparoscopy’s location. It had been assigned to room twelve. He hurried back up the corridor and into the anesthesia alcove for room twelve. Doherty was there and so was the patient. Sitting on the top of a stainless-steel table was his ampule of Marcaine.

  Trent couldn’t believe his luck. Not only was the anesthesiologist Doherty, but the patient was a young, healthy girl. Things couldn’t have worked out better.

  Not wanting to be seen loitering in the area, Trent didn’t linger. He returned to the OR he’d been assigned to, but he was so agitated he could not stay still. He paced so furiously, the biopsy surgeon had to ask him to sit or leave the room.

  Normally such a command by a doctor would have enraged Trent. But not today. He was too excited thinking about what was about to happen and what he had to do. He knew he’d have to return to room twelve as soon as all hell broke loose and get the opened vial. That job was always a bit worrisome for Trent, although on the previous occasions the general pandemonium the reaction caused had always adequately diverted everyone’s attention. Still it was the “weakest link” in the whole operation. Trent did not want anyone to see him touch the vial.