“Actually, it does,” a voice said from behind Richard. He turned to see the medical director with his face pinched into a look of disapproval. Beside him was the man who’d spoken: Zane Bruxton.
The director managed to unclench his teeth long enough to introduce Bruxton to everyone except Jessie, whom of course he already knew. Bruxton then continued his response to Richard’s comment about the cost of Vasostasin.
“To bring any drug from conception to the marketplace is a hugely expensive endeavor,” he said. “Many millions of dollars. To be able to engage in that kind of developmental activity, a company has to establish an R&D set aside from the sale of its existing products. That money doesn’t go in anyone’s pocket. It’s plowed back into the creation of even better products that ultimately benefit the sick. Now, I’m sure I haven’t just said anything all of you didn’t already know. But in the case of Vasostasin, there’s a special problem that has a significant impact on its cost.
“We’re able to obtain the parent protein by recombinant technology—the insertion of the gene for its production into bacteria, which then manufacture prodigious quantities at relatively modest cost. But bacteria are not capable of adding sugars to proteins. Unfortunately, the parent protein, devoid of its sugars, is inactive. It is therefore necessary to add those sugars by a patented process one of our scientists developed several years ago. And that, my friends, is very expensive. So, Doctor Heflin, the pricing of Vasostasin is not as capricious as you might have imagined.”
“No, I see that now,” Richard replied, sheepishly. Feeling his pager vibrating in his pocket, he excused himself and went to the nearest house phone, where he was summoned to the hospital’s west wing to see a new admittance. After the hole he’d dug for himself with Bruxton, he was glad to have an excuse to make a dignified getaway.
Reaching the room where he’d been directed, Richard found a man of about thirty having a generalized seizure in his bed. Under the direction of Tom Faulk, one of the doctors who staffed the ER, the patient had correctly been placed on his side and allowed to ride out the seizure with no other interference.
“Hi, Tom. What do we know here?”
“Guy had a seizure in a local hardware store, then slipped into a coma. He just started that one after we paged you.”
“Any history available?”
“We called his home, but there was no answer.”
“Any medical information on him?”
“No.”
“What’s his name? Do we at least know that?”
“Ronnie Johannson. One of the medics who brought him in said he was a big high school football star around here.”
As they talked, the seizure, which involved all of the patient’s limbs, began to subside.
“Did you see this seizure start?” Richard asked.
“Yeah. It began in his left arm, then spread.”
This was a big clue, as seizures that begin focally and then generalize are usually acquired rather than genetic. Considering that Ronnie was once a football player, it seemed possible that an old head injury might be behind this.
Richard turned to the nurse standing by. “Let’s get him started on Dilantin, forty megs a minute up to a total of . . .” Richard guessed Ronnie’s weight at around one sixty. Drawing on numbers he’d stored in his head from years of treating epileptics in Boston, he settled on . . . “thirteen hundred megs.”
While the nurse set about preparing the Dilantin, Richard enlisted Faulk’s help in getting Ronnie onto his back. Before beginning his examination, Richard said to Faulk, “Since we can’t raise anybody at his home, how about trying to find some other relative?”
“Do you have any idea how many Johannsons there are in the phone book?”
“It’s a small town. Start with the hardware store where he was picked up. See if they know anything.”
Ronnie was now lying quietly.
Richard leaned down and called his name. “Ronnie, can you hear me? Ronnie . . .”
No response.
“Ronnie Johannson . . . Can you open your eyes?”
Still nothing.
Richard lifted Ronnie’s right eyelid and checked the pupil with his penlight. The green disk of Ronnie’s iris closed down. The other eye was equally reactive.
In any sudden onset of neurologic symptoms in an otherwise healthy individual, stroke has to be among the first things considered—either a burst vessel producing a clot that presses on the brain, or a clot within a vessel, denying blood to the region of the brain the vessel serves. Because patients with a bleed don’t usually present with seizures, Richard didn’t believe that Ronnie had blown a vessel.
Could it be the other kind of stroke? Richard didn’t know. And because Ronnie was unconscious, he couldn’t conduct the kind of neurologic exam that would help him find out. Actually, the seizures were Richard’s primary concern at this point. Even though Ronnie’s only movements at the moment were the rise and fall of his chest as he breathed, it was possible that his brain was still showing the wild spiking of epileptiform electrical activity. If so, the Dilantin Richard had ordered might not be sufficient to get this under control. Aware that the longer Ronnie’s brain was allowed to misfire, the harder it would be to stop it, Richard put the MRI scan he’d be wanting on the back burner and called the EEG lab.
“Ray . . . it’s Richard Heflin. Can you take a patient in about three minutes? Good. We’ll be there shortly.”
Before taking Ronnie to the lab, Richard conducted a quick neurological exam in which he discovered that when he rolled Ronnie’s head from side to side, the eyes compensated correctly in the opposite direction, suggesting that at least the brainstem was intact. This was supported by his observation that when he stroked either of Ronnie’s corneas with a wisp of cotton, there was a brisk blink reflex on the stimulated as well as the un-stimulated side. But when he stroked the soles of Ronnie’s feet with a tongue depressor, the toes on both feet lifted and splayed, indicating a dysfunction in both cerebral hemispheres.
As soon as the nurse got Ronnie’s IV started, they all headed for the EEG lab, where Ray Charles Collins, the medical instrument tech, fiddled with the rainbow assortment of spaghetti wires that made up the twenty-two leads he’d attach to Ronnie’s head.
“Looks like this one won’t be appreciatin’ my rapier wit,” Collins said.
“Unlike the rest of us, you mean?” Richard said, entering into banter he didn’t feel. “Let’s get him transferred.”
Richard and Collins moved Ronnie from the gurney onto the EEG table.
Even with his new laid-back lifestyle here in Wisconsin, Richard couldn’t bear to just hang around and watch for the twenty minutes it would take for Collins to get Ronnie wired. He could put that time to better use.
“He’s been having seizures,” Richard said to Collins. “So we’ve got him started on Dilantin. If he should have another one while you’re hooking him up, call Gloria here.” He turned to the young nurse. “If Ray calls you, get right down here and give the patient two megs of Ativan and page me. Okay?”
They both agreed, and Richard wrote his instructions in Ronnie’s chart. He then went into the next room and called his office, which was in a small medical building attached to the opposite wing of the hospital.
“Hi, it’s me. I’m in the EEG lab, but I’m going to make a quick run over to the Gustafsons’ and check on the Mrs. I should be back in twenty minutes. How’s my schedule for this afternoon?”
He learned that the single appointment on the books when he’d left to hear Bruxton had increased by one: a woman suffering from migraine headaches.
“Okay, thanks.”
On his way out, he told Collins, “I should be back by the time you’re ready to start. If I’m not, just go ahead.”
A minute later, Richard stepped int
o a gorgeous autumn morning with air as sharp as Baccarat crystal and so sweet it hurt. He thought briefly about Ronnie Johannson and how unfair it was for anyone to fall ill on such a day.
But when was life fair?
The months since he’d moved to Midland melted away.
“DOCTOR HEFLIN?”
“Yes?”
“I’m afraid I have some bad news for you. Your wife has been involved in a carjacking.”
Richard’s blood congealed in his vessels and his heart tried to escape through his mouth.
“There’s no good way to say this, but she’s been . . .”
“Hurt?” Richard said, hoping that by filling in a lesser word he could control what was happening.
“Doctor, she was shot . . . fatally, I’m afraid.”
A LOUSY PHONE call.
The cops hadn’t cared enough to send someone to tell him personally. She was just another entry in their records for the year, half a percentage point, a keystroke on a secretary’s computer, a call to be made and forgotten. To this day, no one had been charged with her murder.
He’d never forget their callous treatment and would never forgive the city for spawning her killer. With that one phone call, less than a minute out of his life, everything had changed, and he’d become filled with hatred, not just for Boston, but for himself and the practice he’d worked so hard to make one of the most successful in the city, the practice that had consumed him, stealing time he could have spent with Diane . . . his beautiful Diane. Even now, nearly two years from that phone call, the memory of it caused his eyes to blur.
Reaching his car, he got in and sat for a moment, reflecting on how Jessie had saved him, suggesting that he leave Boston and come here where they needed a neurologist and life was simpler.
Simpler indeed . . .
Where once he saw as many as twenty-five patients a day, he now saw four or five. And here he was making a house call, to a woman slowly recovering from a stroke that had left her partially paralyzed so she had trouble coming to his office. Might not even get paid for the visit . . . part of the reason why his income was about a third what it had been.
Five months ago, he’d been approached about finishing out the term of the newly deceased county coroner. The job required the officeholder to investigate all deaths in a long list of categories and arrange for autopsies when there were legal implications or there was any question about the cause. If it wasn’t a homicide or suicide, and there were no suspicious circumstances surrounding the case, it would be autopsied locally. The others would be sent to the forensic pathologist’s office in Madison for a complete workup. This sounded like more work than he could handle and still maintain his practice, slim as it was. There was also his little girl, Katie. He couldn’t be on call at night and leave her alone. When it was explained to him that the office averaged only five calls a week, and there were two deputy coroners who regularly took night call, and another who could be pressed into service to cover for him if he was with a patient, he reconsidered.
After some reflection on the proposition, he’d accepted, partly because the extra money, which wasn’t much, would help him provide for Katie. In addition, after what had happened to Diane, the thought that he might, in some small way, be responsible for keeping his new home free of crime appealed to him, even though the county had a murder only every ten or twelve years.
Then two months ago, he’d taken the call for Chester Sorenson, a dairy worker found drowned in a farm pond, clearly murder, though that had been kept under wraps. So far, there were still no leads on the killer. So much for his high hopes of being an instrument of justice.
But if you didn’t factor that in, or his modest financial picture, he was flourishing. Despite the flashback he’d just had, he was coping well with Diane’s death. He’d always considered himself a compassionate physician, but there was something about these people here that made him feel close to them—so that his concern for their welfare came more from his heart than his head.
He’d adapted so well to the community that, like many of its inhabitants, he kept a garden. In it he’d grown a pumpkin that weighed forty pounds. He knew how big it was because he’d taken the bathroom scales out and weighed it. Oddly, he was as proud of that pumpkin as almost anything he’d ever done.
It turned out that Richard was wrong about not getting paid for visiting Sara Gustafson, because when he left her home, she insisted that he take three jars of homemade strawberry rhubarb jam with him.
He was welcomed back to the EEG lab by the sound of an air blast as Collins dried the adhesive holding an electrode to Ronnie’s scalp just behind his left ear.
“What do all great comedians and all great doctors have in common?” Collins asked.
“Tell me,” Richard said.
“Timing.” Collins grinned at Richard’s look of incomprehension. “That was the last electrode,” he explained.
“So maybe we should go on the road together.”
“Okay, but you’ll want separate rooms, ‘cause frankly, Doc, I fart like crazy in my sleep.”
“I hear all great comedians do that.”
“What about great doctors?”
“They don’t. How’s he been?”
“Completely zonked, but he hasn’t had another seizure.”
“Good. Maybe the Dilantin’s got him stabilized.”
The two men went back into the next room, where the hospital’s Nihon Kohden EEG machine sat against a wall with a big window in it so they could see the patient while recording. Looking at the old Nihon war-horse made by a company that had gone out of business years ago, Richard thought briefly of Zane Bruxton and how if he ever felt another surge of generosity, he could buy the hospital a Nicolet Bravo, one of those state-of-the-art digital jobs.
Collins sat at the machine and turned it on, sending a wide tongue of lined paper sliding under the recording pens that clattered for a moment like knitting needles before settling down to work. Collins ran a few calibration pages, then a few more that proved the instrument was functioning properly.
Collins hit a button and the pens began tracing sixteen lines representing Ronnie’s brain waves, each line corresponding to the area of cortex between two of the electrodes on Ronnie’s scalp. The machine was capable of being set in a variety of patterns, or montages, combining electrodes in different ways so that the entire brain could be mapped. The analysis they’d be conducting consisted of six montages. With eighteen pages of recordings needed for each montage, Ronnie’s case would generate a hundred and eight pages of ink scrawls.
As the first tracings rolled past, Richard noted with relief that Ronnie’s EEG was showing no evidence of wild epileptiform activity; so far so good on that count. On the other hand, his brain waves were slower than normal and of lower amplitude, nothing terribly diagnostic, but considering that it had now been long enough since his last seizure for his brain to be showing a normal pattern, this wasn’t a good sign.
All the succeeding montages showed the same thing—slow waves of low amplitude—and Richard saw no evidence of asymmetry in this pattern, no region of the brain that seemed to be the focal point of the problem.
So maybe it wasn’t a stroke. But what was it?
Then they set the instrument on montage four. With the pens clattering and the instrument churning pages into the box on the floor, Collins got up and went to Ronnie’s side, where he took Ronnie’s left thumb and pressed hard on the nail with a reflex hammer.
Back at the Nihon, Richard drew a slash mark and the letters LT on the recording.
Collins then repeated the maneuver on Ronnie’s right thumb. Again, Richard marked the recording as it flew past. Collins did that entire routine once more, then clapped his hands three times next to Ronnie’s left ear.
Richard marked the recording.
After three claps at Ronnie’s other ear, the entire clapping routine was repeated. Collins then leaned down and called Ronnie’s name loudly three times in each ear. This too, was repeated.
When Collins returned to the Nihon, he found Richard slumped in his chair, for Ronnie’s tracings had not shown the slightest response to any of the stimuli Collins had provided. Since it was now long past the time when Ronnie’s brain should have ceased to show any residual effects from his last seizure, this was extremely worrisome.
“I didn’t see any physical response at all,” Collins said. “How’d he do on paper?”
“Lousy.”
The phone rang and Collins took it, then handed it to Richard. “It’s for you.”
Harboring a very bad feeling about this case, Richard accepted the phone. “Heflin.”
“This is Faulk. We located Johannson’s wife.”
“This isn’t going to be a good day for her,” Richard said.
“You can say that again. She’s down here in the ER in a coma.”
5
HOLLY MADE HER way through the passageway from the plane and stepped into the Dallas–Fort Worth airport, where she spotted Susan Morrison standing by a small piece of black luggage.
“How was your flight?” Susan asked when Holly reached her.
“Quick and uneventful. Yours?”
“The guy sitting next to me threw up.”
“Doesn’t that entitle you to triple frequent flyer miles?”
“You’re certainly in good spirits,” Susan said.
“Nervous actually.”
“When’s your flight home?”
“Four o’clock tomorrow.”
“I’m out at five.” Susan picked up her bag and gestured in the direction of the terminal. “We’d better get moving if we’re going to be there by two. I hear they’re doing a lot of work on the interstate that’s really slowing traffic. And I’ve got to pick up something in the baggage claim area before we leave.”
“You checked a bag? We’re only going to be here a day.”
The Lethal Helix Page 4