by L Jan Eira
A large dark luxury sedan drove by slowly. The car stopped in front of the McIntyre’s residence for a few seconds. Then, it drove on. Slowly. Observing. Stealthily searching. It would go around the block then stop short of the house. In the dark, quiet and still, like a jungle predator waiting for the right time to pounce on its prey, the car and driver would remain unnoticed.
Back inside the home, Sheila lay on Joe’s right shoulder gently, as if she could break him if she pressed with the full weight of her head. The TV was on.
Suddenly, Joe stood up shaking Sheila off him. He was profusely sweaty and his pupils shrunk to the size of a pinpoint. He became progressively agitated and began pacing back and forth through the small family room. Sheila stood and watched for a moment, unclear as to what she was witnessing.
“What’s wrong, honey?” she asked, her concern increasing.
“What? What d’ya say? Who’s there?” Joe said, breathing a mile a minute. He looked confused and upset. But at what? Why? Joe continued to pace, with increasing speed and vigor. He looked wild eyed. Sheila tried in vain to calm him. The more she persisted, the worse he got. He seemed to have forgotten who she was.
She dialed 911. By the time Sheila got off the phone with the EMS operator, Joe was climbing on and off the couch. He rumbled on about strangers watching him from here and there. He pointed wildly to the TV, a window and the hall leading upstairs. He searched around the room, first behind the TV, then under the pillows. Then he grabbed a vase.
“Who are you? Stay back,” Joe yelled. He then murmured something else, God knows what. Something Sheila could not make out.
“What baby? Tell me what’s bothering you?” Sheila questioned, tears now flowing down her face.
“Go away!” she heard him say, in between other incomprehensible phrases. He used the vase like a shield and weapon, whenever Sheila attempted to come closer. For a short period, she was able to touch him. His heart thumped hard and fast inside his chest.
“Sweetheart, your heart is pounding fast. Let me take you to the hospital,” she pleaded.
He turned to get away stumbling onto the ground. The vase broke in his hand, cutting him. Blood ran down his arm. Joe looked at his bleeding hand with confusion. A deep gash was visible from which crimson pulsated profusely with each heartbeat. This appeared to make him even more like a dangerous wounded animal, if that was possible. Not at all the calm, cool and collected man Sheila fell in love with many years before. Why was this happening?
Joe ran around the room aimlessly. Then, he paced frantically like a caged beast. He erratically looked around as he exited the family room stumbling towards the kitchen. As he entered the breakfast nook, he gave the appearance of a wild creature in unfamiliar surroundings cornered by perilous foes. He walked into the table scattering the plates they had just neatly arranged in the proper places earlier that evening. The pain caused Joe to stop and flinch. For a split second, Sheila connected with Joe, looking into his eyes. All she could see in those eyes was rage. By now, Joe’s speech was an incomprehensible jabber. He was pale with rivulets of sweat streaming down his face. His chest wall overlying his heart was visibly thumping, even through his shirt.
Sheila tried again to approach him using loving and soothing words. Wildly and with furious madness, Joe opened cabinet doors and pushed appliances off the kitchen counter, becoming increasingly startled as these items hit the tile floor. He then pulled out the drawers causing them to fall on the floor noisily. This exacerbated his fury and anger. The next thing Sheila saw was a large butcher knife, which sliced her face from her left temple to the lower portions of her neck. She suddenly stopped moving and took her last normal breath. Joe had plunged the huge knife deep into her thorax, causing a sucking chest wound and lacerating her right ventricle. Blood and air gushed out of the wound as he removed the bloodied blade.
Joe looked at her dying face and paused. As her brain function hastily dissipated into nothingness, Sheila’s last coherent thought was that she departed this world by the hand of the love of her life. She would never understand why. For a split second, Joe seemed to comprehend the gravity of the situation. He, too, met his demise, first dropping to his knees then falling flat on the kitchen tile floor smashing his face hard, the knife still in his hand. The impact caused a deep laceration on Joe’s chin. Sheila’s blood flowed and mixed with his, an expanding pool of blood surrounding both bodies.
Just outside the house, a mysterious well-dressed stranger peeped inside through a side window. He had made sure the sedan was hidden on a side street. It was dark out, the sky increasingly fuliginous with the advancing nightfall. As the sirens approached, the visitor swiftly departed, making certain he continued to remain unnoticed.
It would be later determined at autopsy that Joseph Matthew McIntyre died of a massive brain hemorrhage, the cause of which remained unidentifiable.
*****
Four weeks ago
September 2
11:32 AM
It was almost lunchtime. The medical team took the elevator to the basement and the group walked toward the employee cafeteria. Jack and the students were going to meet Claire and John for lunch.
They went through the cafeteria line and each made their food selections.
“Do you need adult supervision here?” asked Jack as he approached the table where the students, John and Claire were sitting with their food trays. They had started to eat without him. Jack had stopped momentarily to talk to one of the medical attendings.
“Very funny, ha, ha, ha,” mocked Claire, continuing to eat.
“Are we flying to the game this Saturday?” asked John with his mouth still full.
“Oh yeah,” answered Jack. He turned to the students. “The three of us are flying to Columbus, Ohio to see the Crew play D.C. United. Any of you want to come along? We have room on the airplane.” Jack paused waiting for a reply.
“I didn’t know you were a pilot, Dr. Norris,” said Peter.
“Oh, yes. He’s a great pilot,” answered John. “He says any landing he can walk away from is a great landing. Right, Jack?”
“Sure, so the propeller got stuck on the tree top. Big deal, we got to the ground, right?” Jack persisted with the joke.
“What are you saying?” asked Claire concerned.
“He’s just kidding, honey,” Jack interjected. “You know I am a good pilot. I make those soft landings you like. Unless the wind blows us off the runway onto the grass.” Claire did not look amused. Deep inside her, there were still small butterflies about flying, though she would not admit it. She would fly when Jack asked her. But mostly, she did it for him, to be with him and go places with him.
“Jocularity—I recognize the style,” interrupted Claire mockingly with a serious tone of voice. She didn’t mind Jack’s usual jestful mannerisms, however, certain topics were off limits. Flying jokes were definitely one of them.
“I forgot, no joking about flying. Claire does not like flying jokes,” said Jack, facing all but Claire.
“So, what kind of plane do you fly?” asked Chris.
“Beechcraft Bonanza, A-36, the best single-engine airplane in the world. I love it,” answered Jack.
“I love flying. I can’t believe you fly and have your own plane. How cool is that?” said Chris enviously.
“You should come fly with me. Let me know when you want to go up. All I need to go flying is an excuse. Hey, want to come to the game this weekend?” asked Jack.
“I can’t. I promised my parents I would visit this weekend. It’s my little sister’s birthday,” answered Chris.
“So, what’s up in research, John?” asked Claire hoping to change the subject. She knew Jack could go on talking about flying and airplanes for hours.
“We’re doing some pretty neat research. I could tell you, but then—” John was rudely interrupted first by Claire, and then all the others joined in, “you’d have to kill us!”
“Seriously, you can tell us some stuff. W
hat are we going to do, sell your trade secrets to the Russians?” continued Claire.
“Nowadays, it’s not the Russians you have to worry about. It’s the terrorists,” said Peter.
“You guys cooking up weapons of mass destruction in the lab, these days?” asked Jack with a smirk on his face.
“Yeah, if you’re a rat,” said John. The whole group grinned. After a small pause John continued. “We’re working on a new drug for patients with congestive heart failure. It stimulates the cardiovascular system and we hope will improve heart function, reduce cardiac mortality and improve quality of life. Do you know how many rats we have killed just trying to figure out the proper dose? For a while, we called the stuff Rat Poison. It took us several months just to get in the ballpark. We’ll be starting human trials soon. I’m working on the IRB protocol right now.”
“What’s an IRB?” asked Peter.
“Institutional Review Board,” answered John. “It’s a committee that reviews and approves all research. It’s made up of doctors, lawyers, clergymen, businesspersons and so on. All research has to be approved to make sure it’s ethical and subjects are duly informed of their participation in the study, risks, that sort of thing. Once I have the protocol written up, we’ll go before this board and get approval for human research with the drug. For now, the drug seems to be doing some good on rats, at least. If the dose is right. If we give too high a dose, the poor little creatures maul each other to death. Horrible stuff.”
“How do you research congestive heart failure in rats? Do you have a CHF rat model?” asked Peter.
“Yes, we create the model by ligating the LAD and causing an anterior infarct,” answered John.
“Doing what?” interrupted Claire looking at John, eyes petitioning for an explanation.
“We do open heart surgery on the rat and tie off the major artery that feeds the heart muscle, the LAD, or left anterior descending coronary artery. This causes a large heart attack in the front portion of the heart. The rats, subsequently, develop congestive heart failure. Then we can test our new drug.”
“Poor little things,” she returned, gloomily.
“Well, it’s better them than me. I know one day, I’ll be old and I’ll get congestive heart failure. I want doctors to know how to treat me and help me live better and longer,” said John.
“Have you seen some of these CHF patients? They really need help,” interjected Jack. The doctors and medical students nodded approvingly, all eyes on Claire.
“We also have this new gadget to study the heart muscle. It helps visualize the walls and see if there is infarcted or ischemic tissue there.” He then turned to Claire to define these terms for her benefit and continue with his explanation. “We are administering tiny air bubbles into the rats which allow us to improve visualization of the heart muscle. This permits determination of whether the muscle consists of healthy cells or cells about to die due to oxygen starvation or dead cells,” he paused to allow questions. Scanning the group for body language, John continued, “You should see the difference this stuff makes in helping us see what’s going on.”
“What type of imaging are you doing?” asked Jack.
“Ultrasound,” answered John.
“Neat,” exclaimed Peter. “Can we come down to the lab and see it?”
“Sure, come down today. Are you guys finished with rounds?” asked John.
“Almost,” answered Jack. “We’ll stop in later, if we have time.”
“I have a slow afternoon. I would love to see the lab, too, if it’s okay,” said Claire.
“Of course. I’ll see you later. I’m late for a meeting.” John got up and left at a fast pace.
Lunch over, the group dispersed. The medical team returned to rounds and Claire returned to the psychology department, where she had a patient to see in twenty minutes.
*****
3:12 PM
There was one more patient to see. The team gathered around the bed of the elderly woman, Pete’s patient. He began the bedside comments.
“This is Mrs. Joy Nathan. She is eighty-six and presented with an acute coronary syndrome three days ago. She had coronary angiography, which showed an occluded right coronary artery. This was angioplastied and stented two days ago. That was followed by atrial fibrillation. We were called on consult.”
“Doctor, what is arterial fibula?” asked the patient, her face showing signs of concern.
“Atrial fibrillation,” corrected Pete finishing the sentence for her. “It’s an electrical problem in your heart affecting the top two chambers. Instead of beating, they are quivering fast. That makes the bottom two chambers of your heart go fast and out of rhythm. It also puts you at risk for clots which can cause strokes.”
“Oh, I don’t want a stroke. My mother died of a stroke. My father lived with a stroke and I think my mother was better off than my poor father,” said Mrs. Nathan.
“We’ve started you on Coumadin and Lovenox. These are blood thinner medications that prevent clots from forming so you won’t have a stroke,” continued Pete.
“I noticed that you gave me a few new medicines,” she said.
“Yes, the other is a beta-blocker to lower your heart rate,” said Pete. “If your blood is thinned enough and your pulse is slower by tomorrow, we’ll give our okay for you to be discharged.”
The other doctors had been standing back listening to the exchange between the elderly woman and the medical student. Then, the group left the room giving the patient reassuring smiles.
“How have her numbers been? Is she fully anticoagulated?” asked Jack as they reached the hall outside room 817, where a cart with many patient charts was waiting.
“I have them right here,” said Pete. He proceeded to dig into his pockets. First, his lab coat pockets, then he put down his clipboard to facilitate the process and dug deep into his front pant pockets, then the shirt pocket and finally the pockets in the back of his trousers. All grinned at this amusing display of disorganization. Finally, Pete returned to the clipboard he had put down over the chart-rack.
“Hah, here they are.” Pete removed several papers, which he spread out on display over the chart stand in front of them. Several fell off on the floor. Pete bent down to pick them up causing more to fly off. The other two medical students joined the process. As this scene, befitting a Three Stooges episode, was unfolding, Jack looked up the lab values on his handheld Palm Pilot.
“Hey, Larry, Curly, and Moe,” interrupted Jack shaking his head. “Here’s the INR. It’s one-point-four-seven today. What do you want to do, Pete?” he asked.
“I’ll give her five of Coumadin, today,” he answered with authority.
“Okay, write the order so we can get out of here,” said Jack, as he dialed a number on the phone at the nurses’ station.
“I’d like to make an appointment, please,” he said in a serious voice a few seconds after dialing. “When’s the next available appointment for Dr. Claire Norris? I have a patient for her; a med student with an aversion to orderliness.” By then they could all see that he was playing a joke. He forced a smirk. “Are you ready to meet us downstairs?” he asked. “Okay, we’ll be there in a few.”
Pete had written his order and placed the chart in one of the appropriate slots for charts with orders. Chris pushed the rack with all the other charts and, with Peter’s help, in no time, all the charts were where they belonged. The group walked towards the stairs. On the way down, they discussed the clinical issues relating to Coumadin therapy and the need for frequent monitoring using INRs—International Normalized Ratios.
“Perfect timing,” said Chris as he opened the door for Claire and all others to enter the research laboratory. Having walked a few feet into the lab, they were spied by John Connor who strolled towards them greeting them.
“Welcome to my home away from home. I just purchased a new scent spray. I hope you like it,” said John taking in a big breath through his nostrils. All imitated him and in doing so, exp
erienced the typical odor that was the animal lab. They walked toward the ultrasound room, first passing through the animal lab where the smell intensified significantly. As they passed by the rat cages, John spoke more about the CHF experimental drug. A sign indicating the purpose of the work in this area was on display: Experimental Drug LFJ659.
“This is Rat Poison, the drug I was telling you about at lunch,” said John continuing to walk. The others followed him. “LFJ659 is being tested to try to improve the quality of life in patients with CHF. It stimulates heart contractions and improves blood flow through the circulation. The mechanism of action remains unknown but it is different than any other known cardiovascular treatment. The drug seems to improve CHF in the rat model. We’ll see what it does in humans when we get that phase started. I will need your help to recruit patients for this study, okay?” asked John looking back at the students who nodded. They entered the ultrasound room.
“Here we have an echocardiogram of a rat. This is not too different structurally from that of a human. Just smaller.” As he talked, John touched the appropriate buttons on the ultrasound machine and the screen came alive, revealing a little rat heart beating rapidly.
“This is faster than I’m used to seeing,” said Peter. Jack nodded agreeingly.
“The normal heart rate of a small mammal is much faster than an adult human,” explained John. Despite being faster, Jack was confident he could read the rat’s echocardiogram. The ultrasound on the screen showed the heart chambers allowing visualization of the heart valves and major blood vessels entering and leaving the heart.
For the benefit of the students and Claire, John pointed out the structures visualized on the screen.
“This is the left ventricle,” he said using a pen as a pointer. “This is the left atrium and this the right side of the heart.” After a short pause to allow the information to sink in, he continued: “Who can name this valve?”