Roy looked taken aback, having built up a good head of indignation trying to justify himself and implying that an outsider who wasn’t on staff had no business berating him anyway. “Lousy,” he said after a few seconds, his face sullen. “She’s a three, exactly like the night we found her.”
A dead body would earn as much, just for being there.
“You ordered a CT scan?”
“What was the point? I thought I knew the diagnosis – a massive stroke – plus the lady was gorked.”
“Has your differential expanded any, after our discussion?”
He sighed heavily. Deflated, he seemed a shirt size smaller and an inch shorter, as did most kiddie-docs foolish enough to attempt a head-butt with a veteran rather than admit a mistake. “A CT will be done later today, sir,” he said, his unconditional capitulation made evident by the sudden disappearance of the word “but” from his vocabulary. “And an EEG.”
The former would visualize the extent of damage from a recent blood clot, if that was the cause. The latter, an electrical encephalogram, would pick up any remaining spark of electrical activity in the cortex of her brain, the stuff of walking and talking.
Earl asked Tanya to come back in the room. “You said she was found on the floor by the door?”
“Yes. We think she knew something wasn’t right and was trying to get help.”
“She didn’t use the call button?”
“They found it unplugged.”
“I think she must have pulled it out by accident when she reached for it,” Roy added.
Tanya’s brow arched, but she said nothing.
Earl followed her back toward the nursing station. “Anybody see Chaz Braden around here that night?”
She immediately slowed. “So you agree with me, that it’s possible he did this to her?” she whispered, once they were side by side.
“I agree only that it doesn’t look like a stroke, nothing more. For God’s sake, don’t go spouting crazy ideas.”
She gave him a “yeah, right” look.
“So did somebody see him?”
“No. I already checked. But that doesn’t mean he wasn’t on the floor. Coverage is minimal that shift, and he could easily have sneaked in.”
“Care to tell me now why you’re so down on him?”
“Why? My reasons have nothing to do with Bessie.”
“I want to know the extent of your beef with the man, and if that might cloud your judgment toward him.”
She walked a few steps farther without saying anything, then slowed her pace until they were walking alongside each other. “I worked in cardiac ICU before being transferred here. He’s a slimeball. Put his hands on me one night. I complained, and got transferred for my trouble. Not that I mind it here. I like old people. But my training is in critical care.”
He eyed the procession of elderly men and women tottering back and forth along the corridor and wondered how he’d feel if someone pulled him out of ER to plunk him down in their midst. “Quite a culture shock,” he said.
“But don’t think I’m fingering him just because I want to get even with the guy. I really liked Bessie. If someone did mess with her, all I’m after is to damn well make sure nobody just shuffles what happened here under the rug. They’re a little laissez-faire about relapses and death around this floor for my liking.”
Earl again sympathized. Geriatrics was a discipline of settling, becoming resigned to death; in critical care, however, as in ER, they defied it.
“There’s another person to whom she might have confided. Dr. Collins visited her that night.”
“Melanie?”
“Just a social call. Bessie wasn’t admitted under her this time. But she thought the world of Dr. Collins. Told me more than once how that woman’s fast action staved off her first stroke. She blamed her current doctors for not doing the same.”
“Why do you think she’d tell Melanie anything about Chaz?”
“Bessie had been in a mood to talk about him, and I don’t think she intended to be flattering. Since I didn’t have time to listen, maybe she bent Dr. Collins’s ear.”
Earl thanked her and took the elevator down to the ground floor where he slipped outside the Thirty-third Street entrance, determined to contact Melanie. In the harsh glare of winter sunlight, he joined the other cell phone users who restlessly circled and turned like pigeons flocked at the pedestal of a statue, their murmurings rising above the noisy morning traffic.
He had to settle on leaving her yet another message. Why wasn’t she answering her calls?
An attempt to reach Mark yielded the same out-of-order recording he’d gotten last night.
“The whole planet’s gone wireless, and I can’t talk to a soul,” he muttered, waiting for an operator to get him the man’s home number.
This time he got through.
“Roper.”
“Mark, it’s Earl Garnet. I’ve got news.”
“I hope it’s better than mine. But you first.”
Earl told him all about Bessie McDonald, including the possibility that a few weeks after Kelly’s disappearance his father might have pulled her chart along with that of the man who’d died of digoxin toxicity. As he talked, he heard an annoying series of clicks on the line. Probably the result of a poor connection, he thought, ignoring them.
10:30 A.M.
Hampton Junction
Mark could tell a lot about a medical resident’s skill after observing the person handle a single patient.
Watching Lucy O’Connor, he waited until a half dozen of his regulars had passed through her hands before he admitted she practiced medicine as well as he’d first thought, she was that good. Most trainees managed a small number of people while he saw to the bulk of the visits, the entire process made much longer by his need to review and sometimes revise what they did. So far Lucy had seen all the morning appointments by herself, doing it as efficiently and thoroughly as he normally would. On checking her work, he found himself discussing cases with her on the level of a colleague, and she referred to recent journal articles with ease. What impressed him most was how, while drawing on an academic knowledge base that he considered awesome, she kept her therapeutic decisions practical and her recommendations for referrals or tests tailored to what they had available in the sticks.
And the local vote was unanimous.
“I like her!”
“She’s wonderful.”
“Not like those other ‘kids’ they usually send you.”
So he sat at his desk with time on his hands while Lucy worked the examining room. Besides using the opportunity to arrange for a loaner Jeep with his insurance company and make a stab at the piles of unopened mail, he kept trying to make sense of everything Earl had told him.
That his father had gone after those same two charts didn’t surprise him. After all, it was evident from Kelly’s file he’d had an interest in them. What that interest had been, he still hadn’t a clue.
The coincidence of Bessie McDonald slipping into a coma the night after Kelly’s body was identified – that left him incredulous. He couldn’t help but speculate how someone could have arranged for her to convulse herself into the far side of oblivion. As ideas popped into his head, he grabbed a pencil and started to jot a few down.
Strychnine?
Convulsions were a hallmark of its lethal effects. Not only would it be detected on testing but also would leave a telltale rictus grin on the victim’s face. Not much of a choice if the “relapse” were to be taken as natural.
What about something that caused seizures but wasn’t normally thought of as a poison? There were a lot of medications with convulsions as a side effect that wouldn’t initially be thought of as an agent to test for, as long as no one suspected unnatural causes. Lidocaine, the antiarrhythmic and lo-cal anesthetic, for instance, could cause prolonged seizures if given intravenously in large enough doses. But it or other drugs wouldn’t be so likely to escape notice in a forensic investigation.
After all, a suspicious toxicologist could think up just as many agents as any poisoner when it came to screening for the pharmacology of deliberately induced status epilepticus. Would Chaz, for instance, have been reckless enough to assume no one would consider the woman’s coma to be the result of foul play?
Maybe… or maybe not.
Mark grabbed his copy of Harrison’s Principles of Internal Medicine off his bookshelf and opened it to the section on seizures. Finding a table listing their causes, he considered other possibilities.
Trauma – too obvious.
Alcohol – too messy.
Recreational drugs – too obvious and messy.
Metabolic disturbances: Hypocalcemia; hypomagnesemia; hyponatremia – now here was something.
Some of these could be induced by medication, but persist after the offending pills were discontinued.
Take severe hyponatremia, a low sodium level in the blood, as an example. It could be brought on in susceptible individuals by certain diuretics, even at normal dose levels.
But that couldn’t be the case here. It would have taken days, maybe weeks to make it happen, not twenty-four hours. Unless Chaz, or someone, hadn’t waited for the police to confirm Kelly’s identity before making his move against Bessie. After all, he knew what the result would be, and it made sense to act ahead of time – no, that didn’t work either. The blood tests they’d done on Bessie the morning they found her would have revealed the drop in sodium.
Of course, there was the possibility of induced hypoglycemia. A shot of short-acting insulin could start a nondiabetic’s blood sugar heading downward in less than an hour, the maximum effect occurring within five to six hours. Since the nurses hadn’t been able to pin down the precise time of the seizure, the insulin could have been wearing off after they found her, and the intravenous dextrose she received would have masked any lingering effects. As for the time sequence, she would have had to receive the injection before midnight. Chaz could easily have concocted a reason to be in the hospital at that hour, though he’d have been taking a chance slipping into her room himself. So maybe he’d arranged for someone else to do his dirty work – He threw down his pencil and crumpled up his notes. Listen to me, he thought. Last night’s attack had him so chomping at the bit to nail Chaz, he was becoming obsessed with the man, dreaming up ludicrously wild scenarios about him.
For the hundredth time he eyed the phone, willing Dan to call with word on what he’d found at the wreck and whether he’d talked with Braden. Phoning the sheriff himself wasn’t exactly an option, having already bugged him so many times Dan had told him to back off.
He returned to opening his mail, trying to keep his mind off it all.
A few envelopes down the pile he found the letter from the Dean’s Office with Lucy O’Connor’s records and an accompanying letter explaining the change of schedule. Skimming through her résumé, he read she had completed medical school at McGill in Montreal, but had applied to the NYCH family medicine program after seven years in the field with a group called Médecins du Globe.
Wow, Mark thought, immediately recognizing the name. Those people were the Marines of medicine. Working out of Paris, the organization was known worldwide and had received the Nobel Peace Prize for going into areas of conflict all over the planet to treat civilian casualties. Anybody involved with them worked under the most grueling of situations. Not only would the job have been mentally devastating – a lot of volunteers returned with post-traumatic stress disorders – but physicians sometimes died, killed either by bullets or the diseases they were treating – cholera, dengue, Lhasa fever, and a host of other infectious horrors he’d read about but never faced firsthand.
No wonder she knew her stuff… and karate.
What also struck him was how quickly she’d been accepted into the two-year program at NYCH. She’d only approached them in June of the previous year, less than three weeks before the usual July 1 start of any residency. Her introductory letter stated she’d completed her current tour of duty with Médecins du Globe earlier than expected and inquired if they had any vacancies. The last-minute request for a position came with a half dozen glowing recommendations from her current colleagues and former professors at McGill. NYCH had immediately snapped her up.
Obviously they had an opening, he thought, knowing many posts went unfilled these days since HMOs were making the healing profession less attractive than an MBA. But she also must have impressed the admissions board as much as she was in the process of wowing him. They wouldn’t take just anybody.
He was about to put the papers away when he spotted the correspondence regarding her rural rotation. It was dated November 6, two weeks ago exactly, requesting the program director to allow her to switch her slot so as to do her rural training period as soon as possible. To facilitate the change, she’d even foregone her own vacation. Her manning the wards at the time the hospital would be most short of house staff was her offer, not the insistence of the director.
I’m flattered, he thought. He proceeded to file everything where he’d be able to find it again when her three months were up and it was time to fill in the evaluation forms. But from the looks of her, he could have filled them out now. It would be A+ right across the board.
He tried to get through another few letters, but once more his thoughts turned to Bessie McDonald and ways of inducing a coma.
Within minutes he was arguing with the head nurse of the geriatric wing at NYCH, insisting they check their short-acting insulin supplies to see if any were missing.
11:00 A.M.
Medical Records,
New York City Hospital
“Dr. Garnet,” Lena Downie whispered at his shoulder, “it’s the call you’ve been expecting from Dr. Collins.”
Finally! he thought, following in Lena’s wake as she led him to a phone behind the front counter. She had the rolling gait of a female John Wayne.
“Melanie?”
“Earl! Sorry I didn’t get back to you earlier, but I’ve been up to my ass in crocodiles with budget meetings last night and rounds this morning-”
“Hey, don’t apologize. I’ve been there many times.”
“What can I do for you?”
“Bessie McDonald, a former patient of yours, is the woman whose M and M report was in Kelly’s file. Mark said he spoke to you about it Sunday night, but didn’t have the name yet.”
“Bessie? Well, my, God. That’s a weird coincidence. I knew she’d had a relapse two weeks ago. The nurses on her floor notified my office that she was found comatose one morning at 4:00 A.M. I’d even dropped in for a long overdue visit the day before, and she was fine – well, you know how these things go. I just assumed she must have thrown another embolus. But it was her chart Mark asked about? This is really strange. Do they know what happened to her?”
“The CT shows no infarcts, so it’s probably metabolic, but-”
The sight of Lena hovering nearby interrupted him. “I need to talk with you in private,” he said instead.
“Sure. I’ve got rounds until five. How about we meet at my apartment? I can make us a pitcher of the best martinis you ever had, and we can discuss whatever you want with no interruptions.”
“Sounds good.”
She gave him the directions.
Back at his desk, he returned to what he’d been doing since morning – reexamining Bessie’s old records from 1974 to the present. The reason? Tanya Wozcek had gotten him thinking the worst. Yet he’d gone over everything a second time and still couldn’t find a single entry that suggested an error in her management back then. At least not the kind that gets written down.
So he’d gone searching through the rest of her old charts, checking subsequent admissions to see if she had any tendency to develop any transient metabolic states that might have spiked her digoxin level, yet been missed in ‘seventy-four because they came and went: things like renal failure from dehydration; side effects of other medications; interactions with those drugs – he
looked for them all.
The result? Nothing.
That left only two other possibilities: the sort of accident that occurs in the syringe, a nurse drawing up too much digoxin – or what Janet had suggested, a deliberate overdose. Given that the same woman now lay in a coma, also unexplained, tilted him toward the latter.
However, the records here only went up to the admission under Melanie four years ago, the one Tanya had mentioned. The more recent entries would be in her active chart on the floor. Should he go back upstairs and poke through them too? He glanced at his watch and saw it was nearly 1:00 P.M. He might as well, to be complete. After all, he had the rest of the afternoon before Melanie got off duty. He could also try to reach the people whose resident numbers were on the old M and M reports, if the teaching office could track them down for him. Who knew what bizarre piece of information one of them might remember that would prove useful?
Before closing the chart, he took a final glance through the clinical notes Melanie had written at the time of the first embolus, refreshing his memory about what had been done so he could more easily pick up the threads of the patient’s story when he got to the floor.
Precise, to the point, and clear, they documented why she had thought McDonald’s symptoms were the result of a clot, not a bleed, and warranted immediate thrombolitic therapy. Earl was impressed. The symptoms and signs distinguishing one from the other were subtle. In his own ER he’d seen seasoned neurologists dither over similar cases, then not insist as authoritatively as they should have for an immediate CT, thereby wasting precious minutes. Not Melanie. “Eyeball to needle time” as the residents called it, or the duration from when they first saw the patient to the infusion of a clot buster, had taken three-quarters of an hour, which meant she hadn’t squandered a second in making her own diagnosis and getting radiology to prove it. “Well done, Melanie,” he said under his breath.
As he walked out the door, Lena gave him a frosty good-bye, making it clear she hadn’t appreciated his denying her a chance to eavesdrop.
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