by Robin Cook
“I told you there have been at least four other deaths during epidural anesthesia. That’s very unusual. And for at least two of them, the initial symptoms were subtly different than one would expect from a reaction to a local anesthetic.”
“How so?” Seibert asked.
One of the other pathologists raised his head and called over, “Hey, Seibert, you goin’ to make that case your life’s work just because she’s got a good body?”
“Up yours, Nelson,” Seibert called over his shoulder. Then, to Jeffrey, he said, “He’s just jealous I got two in a row. But it evens out. My next one will probably be a sixty-year-old alcoholic who’d been floating in Boston Harbor for three weeks. You should see what that’s like. Ugh! The gas that comes out you could run your car on for a week.”
Jeffrey tried to smile, but it was difficult. The mental images these men talked in were almost as bad as the actualities.
Responding to the goading of the other pathologist, Seibert picked up a thick suture material swagged onto a strong cutting needle and began to suture Gail Shaffer’s Y-shaped autopsy wound. “Now where were we?” he said. “Oh yeah. How were the symptoms different?”
“Right after the Marcaine was given, the patients got a sudden and striking parasympathetic reaction with abdominal pain, salivation, perspiration, and even miotic pupils. It was only for a few seconds, then they had grand mal seizures.”
Harold had cut around Gail’s head with a scalpel. Then, with an awful ripping sound, he pulled the scalp down over the woman’s face. The skull was now exposed. Jeffrey tried to turn sideways to keep from seeing.
“Don’t you see those kinds of symptoms with a toxic reaction to local anesthetics?” Seibert asked. He was lifting the needle up over his head like a cobbler after each running stitch to take up the slack.
“Yes and no,” Jeffrey said. “The seizures for sure. Also the miotic pupils have been described in the literature, although for the life of me, I can’t explain it physiologically, and I’ve never seen it. But the transient salivation, the sweating and lacrimation, I’ve never even read about.”
“I think I’m getting the picture,” Seibert said. There was a sudden whirring noise and Gail’s body began to vibrate. Harold was using a power saw to cut off the crown of the head. Soon he’d be lifting out the brain. Seibert had to speak louder to be heard. “As I recall, local anesthetics block transmission at synapses. Any initial stimulation you might get is because inhibitory fibers can be blocked first. Am I remembering this right?”
“You’re impressing me,” Jeffrey said. “Go on.”
“And the blockage comes from keeping sodium ions from crossing membranes, am I right?”
“You must have gotten an A plus in neurophysiology in med school.”
“Hey, this is the kind of stuff I’m interested in,” Seibert said. “I was reviewing this for a case of myasthenia gravis. It also came up in a paper I read about tetrodotoxin. Did you know that stuff mimics the local anesthetics? In fact, some people were hypothesizing it might be a natural local anesthetic.”
Jeffrey vaguely remembered reading something to that effect, now that Seibert mentioned it.
The whirring of the power saw abruptly stopped. Jeffrey didn’t want to watch the next step, so he turned completely around.
“Anyhow,” Seibert said, “what I remember is that with epidural anesthesia, any alteration you’d expect to see would be with the sympathetic system, not the parasympathetic system, because of the risk of inadvertently injecting the stuff where spinal anesthesia goes. Is that right?”
“Right on the nose,” Jeffrey said.
“But isn’t the real worry that you can mistakenly inject the anesthetic agent directly into the bloodstream?”
“Exactly,” Jeffrey said. “And that’s where the problems with seizures and cardiac toxicity come into play. But there is no way to explain sudden marked parasympathetic stimulation. It makes you think there is some other drug involved. Something that not only causes seizures and heart toxicity, but also, for a brief instance, parasympathetic stimulation.”
“Wow!” Seibert exclaimed. “This is my kind of case. It’s like something a pathologist would think up.”
“I suppose,” Jeffrey said. “To tell the truth, I was thinking of an anesthesiologist.”
“Wouldn’t be a contest,” Seibert said, waving a pair of toothed tongs. “The pathologist is much more qualified to think up the best way to kill people.”
Jeffrey started to argue, then stopped, aware of the ridiculousness of deciding which specialty cultivated a more sophisticated killer. “There is something else about the two cases I’m talking about. At autopsy both showed damage to nerve cells and nerve axons. One of the cases even had some electron micrographs taken, showing marked ultrastructure damage to nerve and muscle.”
“No kidding?” Seibert said. He held up on his sewing. Jeffrey could tell he was fascinated. “So all we got to do is come up with a toxin that causes seizures and cardiac toxicity by screwing up nerve and muscle cells plus causes marked parasympathetic stimulation! At least initially. Hey, you know something—you’re right. This is like a test question on a first-year neurophysiology exam. I’m going to have to think about it for a while.”
“Do you know if Karen Hodges had the same type of initial symptoms?” Jeffrey asked.
Seibert shrugged. “Not yet. My usual modus operandi is to study the chart in detail after I’ve done the autopsy. I like to keep an open mind. That way I’m less apt to miss anything.”
“You don’t mind if I go look at the chart?” Jeffrey asked.
“Hell, no! As I said, be my guest. I won’t be long here.”
Glad to escape the oppressive smell of the autopsy room, Jeffrey made his way down to Seibert’s tiny office. The room was the homiest Jeffrey had seen in the morgue, with lots of personal touches. The desk was laden with a matching leather blotter, an in-and-out basket, a pen and pencil set, and picture frame. The picture in the frame was of Seibert with an attractive woman with a pixie haircut, and two smiling children. Clad in skiwear, the family had been posed with a wintry white mountain in the background.
In the center of the desk blotter were the two charts. The top one was for Gail Shaffer. Jeffrey put it aside. The bottom one was Karen Hodges’s. He picked it up and sat down in a vinyl chair. The anesthesia record was what he was most interested in.
The anesthesiologist’s name was William Doherty. Jeffrey vaguely knew him from medical meetings. Glancing down the page, Jeffrey saw that the anesthetic had indeed been Marcaine .5%. Judging by the dose, Jeffrey deduced that Doherty had been using a 30 cc ampule. Next Jeffrey perused a terse summary of the events. The summary instantly brought thoughts of the Patty Owen disaster to mind. Jeffrey shuddered as he read. Karen Hodges had initially suffered the same baffling parasympathetic symptoms before the onset of her seizure.
Jeffrey was overwhelmed with empathy for Doherty. He knew only too well what the man was going through. On an impulse, he used Seibert’s phone to place a call to St. Joseph’s Hospital. He asked for anesthesia, then waited for Dr. Doherty.
When Doherty picked up, Jeffrey told him how sorry he was for his experience the day before, saying that he could appreciate his anguish; he’d been through a similar episode.
“Who is this?” Dr. Doherty asked before Jeffrey could say another word.
“Jeffrey Rhodes,” Jeffrey said, using his real name for the first time in days.
“Dr. Jeffrey Rhodes from Memorial?” Doherty asked.
“Yes,” Jeffrey said. “I did want to ask you one question about the case. When you gave the test dose . . .”
“I’m sorry,” Dr. Doherty interrupted, “but I have very explicit orders from my attorney not to discuss the case with anyone.”
“I see,” Jeffrey said. “Has there already been a malpractice action filed?”
“No, not yet,” Dr. Doherty said. “But unfortunately we’re all expecting it. I really cannot d
iscuss it further. But I appreciate your call. Thank you.”
Jeffrey hung up the phone, frustrated that he couldn’t have the benefit of Dr. Doherty’s fresh experience. But he could understand the man’s motives for remaining so guarded. Jeffrey had received the same prohibition from his attorney with respect to Patty Owen’s case.
“I already have some ideas,” Seibert said as he breezed into his office dressed in a fresh scrub suit. Without the surgical gown, mask, and hat, Jeffrey got a good look at him for the first time. Seibert had an athletic build. His hair was sandy blond to go with his blue eyes. He had an angular, handsome face. Jeffrey guessed he was in his early thirties.
Seibert went behind his desk and sat down. Leaning back, he lifted his feet and rested them on the corner of his desk. “What we are talking about is some kind of histotoxic depolarizing blocker. That would give an initial jolt as if you injected a bolus of acetylcholine into all the ganglionic synapses and motor end plates. Presto: parasympathetic symptoms before all hell breaks loose secondary to the nerve and muscle cell destruction. The only trouble is, it would also cause muscle twitches.”
“But there were muscle fasciculations!” Jeffrey said with growing interest. It sounded as if Seibert was really onto something.
“Doesn’t surprise me,” he said. Then he took his legs off the desk and tipped forward, looking at Jeffrey. “What about this latest patient? Did Karen Hodges have the kind of symptoms we’re talking about?”
“Exactly the same,” Jeffrey said.
“And you’re sure they couldn’t be caused by local anesthetics?”
Jeffrey nodded.
“Well, it’s going to be interesting to see the toxicology results.”
“I’ve had a look at the autopsies for two of the other four epidural fatalities. Toxicology was negative on both.”
“What were the names of the four cases?” Seibert asked, taking out a pen and legal pad.
“Patty Owen, Henry Noble, Clark DeVries, and Lucy Havalin,” Jeffrey said. “I’ve reviewed the autopsies for Owen and Noble.”
“I’m not familiar with any of these cases. I’ll have to check to see what we have in the files.”
“Any chance that some body fluid might still be available on any of them?” Jeffrey asked.
“We save frozen samples on selected cases for about a year. Which case was the most recent?”
“Patty Owen,” Jeffrey said. “If you got serum, could you run some tests for toxin?”
“You make it sound easy,” Seibert said. “Like I told you before, it’s pretty tough to find a toxin unless you’re lucky enough to have the specific antitoxin in some labeled form. You can’t just try a bunch of antitoxins shotgun style and hope for the best.”
“Is there any way of narrowing the range of possibilities?”
“Possibly,” Seibert said. “Maybe it would be worthwhile to come at the problem from another angle. If there was to be a toxin, how would these patients have gotten it?”
“That’s another issue entirely,” Jeffrey admitted. He was reluctant to outline his Doctor X theory just yet. “Let’s hold off on that for a moment. When you first came in here a moment ago, I thought you had something specific in mind.”
“I did,” Seibert said. “I was thinking of a whole class of toxins that have some toxicologists abuzz. They come from the skin glands of dendrobatid frogs from Colombia, South America.”
“Would they fill the specifications of the mystery toxin we’ve been discussing?”
“I’ll have to do some reading to be sure,” Seibert admitted. “But as near as I can remember, they would. They were discovered much the same as curare was. The Indians used to grind these frogs up and use an extract on their poison darts. Hey, maybe that’s what we got here: one of those Colombian Indians on the warpath.” Seibert laughed.
“Can you give me any references?” Jeffrey asked. “I’d like to do some reading myself.”
“Absolutely,” Seibert said. He started toward his file cabinet, then stopped in his tracks and turned around. “This discussion has got me thinking about the perfect crime cocktail. If I were to choose what to put in a local anesthetic, I’d use that sushi poison, tetrodotoxin. Since it has the same apparent effect as local anesthetics, no one would ever suspect anything. It’s the transient parasympathetic symptoms that have you worried. With tetrodotoxin you wouldn’t have any.”
“You’re forgetting something,” Jeffrey said. “I believe tetrodotoxin is reversible. It paralyzes the ability to breathe, but during anesthesia that doesn’t matter. You can breathe for the patient.”
Seibert snapped his fingers in disappointment. “You’re right, I forgot about that. It’s got to destroy the cells as well as block their function.”
Seibert continued to his file cabinet and pulled out the top drawer. “Now where the hell did I file that stuff?” he muttered. He shuffled through the files for a few minutes, obviously frustrated. “Ah, here it is,” he said, triumphantly pulling a folder from the drawer. “I’d filed it under ‘frogs.’ What an idiot.”
The folder contained a series of reprinted articles from a number of journals, some of which were common publications like Science. Others were more esoteric, like Advances in Cytopharmacology. For a few minutes the men were silent as they leafed through the many articles.
“How is it you happen to have all these?” Jeffrey asked.
“In my business, anything that causes death is interesting, especially something that does it as efficiently as these toxins. And how can you resist the names? Here’s one: histrionicotoxin.” Seibert put an article in front of Jeffrey. Jeffrey picked it up and began reading the extract.
“Here’s a lulu,” Seibert said, picking up an article and slapping it with his free hand. “This is one of the most toxic substances known to man: batrachotoxin.”
“Let me see that one,” Jeffrey said. He remembered the name from the many he’d come across in the chapter on toxins in Chris’s toxicology book. Jeffrey took the article and read the abstract. It sounded promising. As Seibert suggested, it functioned as a depolarizing agent on nerve junctions. It was also said to cause extensive ultrastructure damage to nerve and muscle cells.
Looking up from reading, Jeffrey held the article toward Seibert. “What about looking for this one in the serum of some of these cases?”
“That would be a tough one for sure,” he said. “It’s so goddamn potent. It’s a steroidal alkaloid, which means it can easily hide in the lipids and steroids of the cell. Maybe a muscle-tissue extract would be better than a serum sample, since the toxin is active on motor end plates. Probably the only way to find something like batrachotoxin is to figure out a way to concentrate it in a sample.”
“How would you go about doing that?”
“As a steroid, it would be metabolized by being gluconated in the liver and excreted by the bile,” Seibert explained. “So a bile sample might be good except for one minor problem.”
“And what’s that?” Jeffrey asked.
“The stuff kills so quickly, the liver never has a chance to process it.”
“One of the cases didn’t die as quickly as the others,” Jeffrey said, thinking of Henry Noble. “He apparently got a smaller dose and lived for a week. You think that would help?”
“If I had to guess, I’d say yes,” Seibert said. “His bile most likely would have had the highest concentration of anyplace in his body.”
“He died almost two years ago. I suppose there wouldn’t be any chance that his body fluid would still be around.”
Warren shook his head. “Not a chance. We only have so much room in our freezer.”
“Would it do any good to get to it by exhuming the body?” Jeffrey asked.
“Possibly,” Seibert said. “It would depend on the extent of decomposition. If the body was in reasonable shape, say if it had been buried in a shady spot and reasonably embalmed, it might work. But exhuming a body isn’t the easiest thing to do. You have to get a
permit and that ain’t always so easy. You have to get a court order or permission from the next of kin. As you might imagine, neither the courts nor the relatives are that willing.”
Jeffrey glanced at his watch. It was already after two. He held up the article he was holding. “Any chance that I could borrow this?” he asked.
“As long as I get it back,” Seibert said. “I can also give you a call about the toxicology results on Karen Hodges and on the serum sample from Patty Owen. Only trouble is, I don’t know your name.”
“I’m sorry,” Jeffrey said. “The name is Peter Webber. But it’s always hard to get me at the hospital. It would be easier if I called you back. When do you suggest I try?”
“How about tomorrow? When we’re this backed up we work weekends. I’ll see if I can speed things up since you’re so interested.”
Leaving the morgue, Jeffrey had to walk over to Boston City Hospital to get a cab. Climbing in, he told the driver to take him to St. Joseph’s. His idea was to try to time his day so that he could ride home with Kelly. As a supervisor, she had a parking place at the hospital.
During the ride, Jeffrey managed to skim the article on batrachotoxin. It was difficult reading because the article was highly technical. But he did learn that the toxin definitely caused irreversible damage to nerve and muscle cells, and while it didn’t specifically say that it produced salivation, lacrimation, and miotic pupils, it was highly suggestive. It did say that the toxin stimulated the parasympathetic system and produced muscle twitches.
At St. Joe’s, Jeffrey found Kelly at her usual location, the nurses’ station in the ICU. She was very busy. The ICU had recently gotten a new admission and the shift was changing.
“I’ve only got a second,” she said. “But I forgot to give this to you.” She handed Jeffrey a St. Joseph’s Hospital envelope.