“Who’s the patient?” asked Geoff.
“His name is DeFranco. John DeFranco.”
“John DeFranco? The hang glider we sent down from the NSICU earlier today?” Geoff was incredulous.
“That’s right,” she said.
“What medication did you give him?”
“Just his usual dose of IV cimetidine.”
“Any sedatives, narcotics, new medications he might be allergic to?” asked Geoff.
“Nothing else,” Gail said.
Karen Choy was standing nearby, listening to the conversation. “Cimetidine has been reported to cause rare hallucinogenic reactions,” she said.
“Anything’s possible,” said Geoff. “I’ve got to get in there and see what’s going on. Wait here.” Geoff walked over to the security guard nearest the nursing station. “I’m Geoffrey Davis, Chief Resident. That man’s my patient, I need to be in there. I think I can help.”
“Strict orders from Sergeant Johnson. No one goes in,” said the guard.
“Tell him Geoff Davis is here. Please.”
The guard called in on his radio and waited for a response. The human chain of security guards parted, allowing Geoff to pass through. “Go ahead.”
Geoff ran down the hall to room 719. The door was closed. He heard loud voices, the words muffled by the door. The guard outside the door glanced at Geoff’s ID badge and nodded, allowing him entry. “I’d open it slowly if I were you. The guy’s crazy. He’s got a fork to her throat.”
Geoff acknowledged the advice and slowly entered the hospital room. There were three people inside. Randall Johnson stood next to the sink, attempting to negotiate with the man to release the hostage. John DeFranco stood by the far side of the bed, his head shaved, face beet red, beads of perspiration rolling down his forehead, his ribs wrapped in surgical tape. With his left arm he grasped a Philippine nurse around the neck. His right hand held a fork to her jugular. Geoff couldn’t believe this was the same man. Last time he saw DeFranco, he was comatose.
“Who the fuck is this? I told you no one else comes in!” yelled DeFranco, his voice quivering. His maddened gaze met Geoff’s.
“This is the doctor I told you about, John,” said Johnson calmly. He gestured towards Geoff. “He’s here to help you.”
DeFranco became more agitated, tightened his grip on the nurse’s throat.
Her chest heaved, her eyes widened like those of a petrified child. “Please let me go, I have a family, children who need me! They’re just babies!”
DeFranco pressed the fork more firmly, indenting her neck. The nurse whimpered uncontrollably.
“Shut up, just shut up! I’ve got a wife, kids, a family too, you know. You’ve screwed up my head so badly they don’t even know who I am!”
“Mr. Defranco, I’m Geoff Davis, one of your doctors. No one wants to hurt you. We want to help you get better, make things the way they were before your accident—”
DeFranco laughed. “Accident? You expect me to believe that, just like that cop over there, don’t you? It’s all part of the plan, isn’t it? You’ve kept me here, drugged me and fucked up my head, and now you tell me I had an accident! You think I’m that stupid?”
Geoff glanced for an instant at Johnson. Their gazes met, Johnson motioning with his eyes toward the window. That must be the plan. “Nobody thinks you’re stupid, Mr. DeFranco. But you did have a bad accident, hit your head in a hang gliding crash, and you have amnesia. You’ve been in a coma for a few days in the New York Trauma Center. Now, please put the fork down and let the nurse go. She didn’t do anything. If you’re angry at anyone, it’s me you should be angry at, not her.”
Geoff walked slowly toward DeFranco, extended his hand. “Take me instead.”
DeFranco backed up toward the window as Geoff approached, then he began to tremble. “Stay where you are! Don’t come any closer!” His tremor increased, his grip loosened on the nurse enough for her to break free. She ran toward the door, sobbing. DeFranco’s face paled, his legs wobbled. Geoff lunged forward to catch him.
Johnson grabbed his radio microphone, yelled, “Hold your fire! We’ve got it contained in here.”
John DeFranco collapsed into Geoff’s arms. His eyes rolled up into their sockets, blood frothed from his nose and mouth, his entire body convulsed in one final, gigantic spasm.
Chapter 12
“When do you think DeFranco’s path report will be ready, Suzanne?” Geoff asked. Suzanne Gibson, the neuropathology fellow, had completed her pathology residency at Georgetown University Hospital. She had to have done exceptionally well to get this plum of a fellowship at the NYTC. Two hundred applicants for one position. To the best of Geoff’s knowledge, the NYTC had never taken anyone from Georgetown before. Harvard, Yale, Columbia, but not Georgetown.
At a table in the corner of the cafeteria, they were trying to converse above the din of the late morning crowd. Geoff washed down a bite of gooey blueberry pie with a gulp of black coffee. The Trauma Center was noted for many things, but the cafeteria’s cuisine was not one of them. Geoff, otherwise health conscious, had a penchant for blueberry pie, even the kind so full of corn starch and sugar one could barely taste the blueberries.
“I did the gross sections this morning,” Suzanne replied. “Nothing out of the ordinary. Just neuronal swelling, probably secondary to his initial head injury. The microscopics should be ready tomorrow, the amygdaloid electron micrographs the following day.”
Suzanne paused, lifted her cup with both hands, sipped her green tea. She looked at Geoff over the top of the cup, smiled. “It’s a pretty amazing story, Geoff. If it wasn’t all over the hospital, I’d have a hard time believing you. First the crazy rabbi on the train, now this guy. You’ve had quite a time lately.”
“That borders on understatement.”
“I’m still not sure what you’re after, Geoff. I mean, the guy just plain flipped out.”
“I think there’s something more going on here—what I’m not yet sure. John DeFranco had no prior history of mental illness. He was recovering from his head injury in a normal way, had come out of his coma just fine. Before we transferred him to the ward, he was oriented enough to his surroundings to know he was at the Trauma Center. He wasn’t agitated in the least. That’s why I’m confused.”
Suzanne set down her cup, rested her chin on her hand. “I assume you’ve already poured through his chart, lab tests, scans and all. Anything stand out as out of the ordinary?”
“Nothing. His labs, vital signs, admission MRI and PET scans were all pretty ordinary, consistent with his injury and course while he was on our service in the NSICU. Only things I haven’t had a chance to review yet are his pre-transfer ICP readings and PET scan. I’m sure there aren’t any surprises there. That’s why I’m so interested in what you may find.”
“It’s a rather unusual request you’re making, to do electron microscopy on the amygdaloid area of the brain in a routine post mortem,” Suzanne said.
“It’s not a routine post mortem.”
“Okay, the protocol’s not strictly routine since the medical examiner’s office has to be involved, but this is simply an autopsy, not a research project. Who’s going to fund the electron microscopy work? You know the Medical Examiner’s office won’t buy off on it.”
“Put it on the Neurosurgery Department’s tab. I’m sure Dr. Pederson won’t mind.”
“You can sign your name to that one, Geoff. I don’t need any trouble with Pederson. He’s a pretty powerful guy around here. I still have another year to go on my neuropathology fellowship, and I’d like to—”
“Suzanne, I’m not talking about robbing a bank. Just doing some additional testing.”
“I doubt you’re going to find anything structurally abnormal on the micros or the EM. I didn’t see an
y evidence of neurological disease or a brain tumor.”
“What about any abnormal biochemistry?”
“Biochemical assay? You mean drug levels—cocaine, amphetamines, that sort of thing?”
“I was referring to neurotransmitters. Dopamine, serotonin, GABA, endorphins.”
“Neurotransmitters? Now you’re really reaching. There are hundreds of potential neurotransmitters in the human brain. That’s a research project in and of itself. It would take weeks just to isolate the ten most active substances, several weeks more to quantitate them. If you knew specifically what you were looking for, and we got hold of the brain tissue soon enough, I might be able to identify—.”
“What’s ‘soon enough’?”
“All depends which substance you’re after.”
“How about endorphins?”
“Fifteen, thirty minutes. Tops.” Suzanne paused for a moment, studying Geoff with her keen brown eyes, then added sardonically, “So, the hang glider was a runner, was he?”
“Might have been.”
“What’s with the endorphin assay?”
“Just a theory,” Geoff replied.
“And what might that be?”
“Something to do with endorphin levels and schizophrenia. It’s a bit obscure, but it’s in the literature, and we confirmed it in the PET lab. It seems that some violent schizophrenics have exceedingly high levels of endorphins in the limbic area of the brain, particularly in the thalamic and amygdaloid regions.”
“Interesting,” Suzanne replied. “Are you saying that DeFranco was schizophrenic? You just told me he had no history of mental illness.”
“No, but what if his head injury, or the coma, or some medication given to him, inadvertently caused an imbalance in his brain’s endorphins, resulting in a schizophrenic-like pattern in his amygdala? His behavior was just like a violent schizophrenic’s in those final moments. I saw it in his eyes. Just like the rabbi on the train. I bet if we were able to assay both their brain’s endorphins, they’d be out of whack.”
“Well, you may be right, but we never look at that fine a level of detail on autopsies,” Suzanne said. “I might be able to run an endorphin assay on DeFranco’s brain tissue, but unfortunately what’s left of the rabbi’s brain has long since been pickled. There’s no way to do any biochemical assays at this point. Nothing in his chart indicated any history of mental illness, either.”
“Chart?” asked Geoff. “What are you talking about?”
“The rabbi was admitted for twenty-four hour observation a few months ago after a minor head injury. A concussion sustained in a scuffle with some skinheads at a JDL rally.”
“Do you still have the chart?”
“Of course. I will until I’m done with his report.”
“Do me a favor, Suzanne. Don’t send it back to medical records.”
“Another favor. Now you owe me two.”
“You name it.”
“I have tickets to the Joffrey Ballet next Friday night—”
Their conversation was interrupted by the shrill beep of Geoff’s pager.
“Can’t even have a cup of coffee around here without that stupid thing going off.” He removed the pager from his belt and lifted it to his ear to hear the garbled message.
“Dr. Davis, NSICU stat. Dr. Davis—”
“Guess I’m wanted.”
“You certainly are. Think about Friday.”
“I will.” Geoff rose abruptly from the table, grabbed his tray.
“Just as friends, Geoff, nothing more.” She looked up at Geoff, brushed back her shoulder-length auburn hair, smiled.
“Got to run, Suzanne. Call me when you get the final report on DeFranco, and please don’t forget about the rabbi’s chart.”
“It’s a good thing I have a strong ego. I’ll call you.”
Geoff slurped the remaining drops of coffee, dumped his tray on the conveyor, and bolted through the cafeteria door and up the back hallway towards the service elevator.
There were only two patients still on the critical list, Smithers and the girl. His mind clicked off their most recent status reports, system by system. Jessica was further along in her recovery, stable for several days now. Smithers was not. There had to be something wrong with the cop. But what? His vitals and intracranial pressure had been stable. Geoff had yet to review yesterday’s PET scan personally, but the preliminary report Karen had given him this morning indicated a waning level of endorphins in his reticular formation. All evidence pointed towards recovery. Geoff was puzzled. It just didn’t jive.
Geoff’s thoughts were interrupted by the voice of the hospital operator through the intercom in the elevator: “Code blue, NSICU. Code blue, NSICU”.
“Shit, I’m too late,” he muttered aloud as he pounded the elevator wall with his fist in frustration. Smithers seemed to be doing so well. Geoff stared up at the floor numbers as the elevator rose skyward toward the tenth floor for what seemed like an eternity. Six, seven. His jaw was clenched, his leg muscles tensed. Nine, ten! The elevator leveled off at the tenth floor with a bounce, and the doors slid open. Geoff dashed across the hallway, nearly flew through the double doors and into the NSICU.
“What the hell’s going on with Smithers?” he blurted aloud. There was a flurry of activity around the bed in the far corner of the room. No one responded, let alone turned around to acknowledge him. IV bottles were dripping, the drawers of the red crash cart opening and slamming frantically shut. Geoff heard Kapinsky’s voice bark an order from across the room. “Pulse is slowing to fifty. Give her another 0.5 mg of atropine.”
Her?
It was only then Geoff realized Smithers was resting comfortably in the bed to his left. He was not the one in trouble. Geoff pushed his way through the mass of interns and medical students crowding around the bed of the little girl.
He turned to Kapinsky. “What the hell’s going on?”
“Must be massive cerebral edema. One minute she was sitting up, playing games in bed, then wham! She let out a violent shriek and started babbling incoherently. Her pupils blew, and she went into cardiac arrest.”
“Why didn’t you call me right away?”
“I paged you stat as soon as it happened, Geoff. It all came down in just a few minutes.”
“Mannitol’s here, Howard,” announced an out-of-breath Karen Choy who had just run up five flights of stairs from the pharmacy.
“Run it in full blast,” Geoff said, taking charge.
The monotonous beep of the monitor suddenly slowed.
“Pulse dropping to forty!” announced one of the interns.
Geoff looked up at the cardiac monitor. She was about to go into complete heart block. “Give her an amp of epi. Stat!”
Kapinsky withdrew the six-inch cardiac needle from the package and attached it to the palm-sized vial of epinephrine. Outlining Jessica’s small sternum with his index finger, he carefully guided the huge needle through the chest wall and into her heart with a pop. He withdrew the plunger, and seeing the ominously dark blood fill the syringe knew he was in the ventricle. He pushed the vial with the palm of his hand and injected the epinephrine directly into her heart chamber just as the monitor alarm sounded, indicating her heart had stopped beating. He withdrew the needle quickly and stared at her chest, looking for a sign her heart was starting to beat.
“Start compressions,” Geoff ordered, alternating his gaze between Jessica and the monitor.
Flat line. No change. What the hell went wrong?
Suddenly the horizontal line of the monitor began to dance wildly.
“V-fib!” said Kapinsky.
“Give her fifty milligrams of lidocaine!”
An intern popped the vial and pushed the lidocaine as fast as the IV line could take it. Geo
ff studied the monitor for any hint of a normalizing heart rhythm.
“No change. Keep the compressions going, Karen,” Geoff said. “Lets give it another minute.”
“Geoff, you know that cardiac arrest secondary to massive cerebral edema and brainstem compression is irreversible. We’re treating the symptoms, not the cause.”
“Damn it, Kapinsky. I don’t need your lectures now! This isn’t an exercise for your neurosurgical boards. She just got the mannitol a few minutes ago. We need to give her brain a chance to respond.”
“Something made her brain swell suddenly like that, and mannitol’s not going to help.”
Geoff turned away from Kapinsky and looked at the monitor. V-fib. No change. He knew Kapinsky was right, but he had to do something.
“Charge the defibrillator. Set it at 100.” Geoff grabbed the paddles, rubbed them together to spread the conductive gel. “Stand back!”
Karen Choy stopped her chest compressions, and everyone backed away from the bedside as Geoff applied the paddles.
He squeezed the red button, and Jessica’s little body wrenched violently upward, then fell. Geoff looked at the monitor. No change.
“Again!” he yelled. “At 200.”
“Isn’t that kind of high for a child?” Karen Choy asked.
“Just do it!”
Geoff applied the paddles, pressed again. With a jolt, Jessica’s back arched and her jaw clenched in one massive spasm of muscular contraction. She landed with a muffled thud off the edge of the bed board.
“Still flat, Geoff. Nothing.” Karen was still poised over Jessica.
Geoff stared at the monitor for what seemed an eternal minute. He looked at Jessica, whose once rosy cheeks were now blue. Pink, frothy saliva foamed from the corner of her mouth. He approached her cautiously, reached down and stroked her forehead, brushing blonde curls off her brow. Her skin was cool and clammy. With his thumb and index finger, Geoff raised her lids to check her pupils with his penlight. Fixed and dilated. She was likely brain dead. The only thing keeping her “alive” was the CPR being administered by the code team. They could go on for hours like this but—a movement!
The Endorphin Conspiracy Page 9