Mortal Remains

by Peter Clement

  “Then Victor’s getting fired would be one big coincidence. Don’t tell me you believe that.”

  “No, not really. I’m saying there may be another reason.”

  “Such as?” he asked, waiting for her to continue. Then he figured he knew what she must be going to say. Earlier he’d told her of Earl’s astonishing revelation about Samantha and Walter McShane. “Okay, I have to admit, if the McShanes turned out to own a piece of Nucleus Laboratories – and they do have extensive business interests, if the Wall Street Journal’s to be believed – it might be her we’re after. But why our visit would make either of them fire Victor is even more unimaginable than it is for Chaz. Besides, there’s something that doesn’t fit about the idea of Samantha killing Kelly. There should have been a different dynamic involved.”

  “How do you mean?”

  “It didn’t sit right when Dr. Garnet suggested it, and now I remember why.” Earl’s testiness when Mark hadn’t embraced the idea outright also didn’t sit well, but he kept that irritation to himself. Someday soon, however, he intended to point out that as coroner on the case, he outranked chiefs of ER from Buffalo. “During my psychiatry rotation at NYCH, we saw court tapes of women on trial for killing their children in what were believed to be Munchausen by proxy syndromes. Now Samantha didn’t really fit that profile, but as Earl said, the dynamic of her playing a noble, self-sacrificing victim was similar. Well, here’s something else she might be kindred in. Each one of those women had accepted her sentence with eerie equanimity, all the while protesting her innocence, as if her incarceration were simply another hardship to endure as part of being a long-suffering mother. If we’re right about Samantha, she could have reacted that way, too, might even have reveled in standing accused by her daughter. It would have given her a chance at an ultimate performance, in court, before the cameras, playing the victim role of a lifetime – mother unjustly charged of terrible wrongdoings by the very child she’d so self-sacrificingly nursed through one mysterious illness after another. It’s unlikely that she would have given up such an opportunity, let alone killed to avoid it.”

  Lucy took a sip of tea and stared across the top of her mug, appearing to digest what he’d said. After a few seconds she looked over at him. “Interesting, but did you ever think it might not be your investigation of Kelly’s murder that’s got whoever runs that lab so upset, but something else?”

  That surprised him. “Something else?” Her open expression and glittering brown eyes were so lovely and vulnerable, he found them distracting. “Okay, what am I missing?”

  She swallowed, seeming uncertain whether to speak, and curled her legs more tightly under her.

  “Lucy?”

  Her gaze drifted off him and wandered the room. “Something I’ve been mulling over, but didn’t want to tell you until I could be sure what it meant. I can’t even say now how it fits in with either Kelly or the lab.” She again fell silent.

  For the two days he’d known her, this self-assured young woman hadn’t betrayed the slightest trace of indecision in her work. Yet here she was, hesitant to speak up. “Go on,” he said, his curiosity growing about what could fluster her so.

  “Well, it’s personal, so bear with me-”

  Mark’s home phone began to ring, interrupting her.

  He took the call on a wall-mounted extension near the back door of the kitchen. “Roper.”

  “Mark, this is Charles Braden calling.”

  He felt as if a bomb had exploded in his ear. “Ah, yes, Dr. Braden.”

  Lucy’s eyes widened into a you’ve-got-to-be-kidding-me look.

  He gestured her to join him in listening. “What can I do for you, sir?”

  She huddled at his side, their ears sharing the receiver

  “Well, you can not call me ‘sir’ for starters. Makes me feel ancient.”

  “Of course, sir – Dr. Braden.”

  “Call me Charles. I’d like that. Gives me the illusion of being closer to your generation than my own.” He finished with a jovial chuckle.

  “Give me a break,” Lucy muttered, her eyes shooting skyward in disbelief.

  Mark nudged her to keep quiet. “So what can I do for you, Charles?”

  “You know how word travels fast in our little community. I hear you’ve got a very attractive houseguest staying with you. Why not drop around for drinks tomorrow night, and bring her along. This sad business with Kelly has reminded me how out of touch we’ve grown. Your father was a regular guest in our home.”

  Lucy rolled her eyes again.

  “Yes, sir, I mean, Charles. Those were certainly memorable parts of my boyhood.” He had to avoid looking at Lucy for fear he’d burst out laughing. “I’d love to drop over.”

  “Excellent. Shall we say around five?”

  “Perfect.”

  They hung up, and Mark whistled.

  “Talk about being invited into the lion’s den,” Lucy said, walking out of the kitchen.

  “Where are you going?”

  “Into Saratoga, to buy a dress.”

  “Do you want me to go with you?”

  She turned back, her mouth cocked in a sly grin. “There are some things, my dear Mark, that a woman does alone.” Pulling on her coat and shouldering her purse, she disappeared out the front door.

  Mark stood looking after her. Whatever Lucy had been on the verge of saying before the phone call, she obviously thought it could wait.

  Thursday, November 22, 3:30 A.M.

  The Plaza Hotel, New York City

  At first Earl wasn’t sure what woke him.

  Then the pain cut across his abdomen and doubled him in two.

  “Jesus Christ!” He moaned, writhing in a ball.

  His insides had been churning all evening. Once in bed, he’d tossed for a few more hours trying to fall asleep.

  No way this could be from stress.

  The cramps came in waves, hitting him like body blows. They were so closely spaced together that the pain from one hadn’t released its grip before the next struck.

  He got off the bed and tried to make it to the bathroom, but fell to the floor.

  Again and again and again the spasms struck, leaving him drenched in cold sweat and biting his lips to keep from screaming.

  He’d had his share of “tourista,” especially during conferences to faraway places, but never experienced anything like this. Must have picked it up at one of the fast-food joints he’d been eating at these last few days. The most likely cause would be Campylobacter from undercooked chicken or beef, he reasoned during a few seconds pause in his symptoms. If he could just buy some Cipro – damn! It was Thanksgiving, and most pharmacies would be closed. No matter. He’d get Melanie to get him some from the hospital, providing he could reach her. Then maybe he could still make the trip home, though the idea of being stuck on the can for the whole flight – “Oh, my God!” he muttered, a new onslaught sending him rolling on the floor again.

  This time it felt as if someone were twist-tying his intestines and dragging them through hot coals.

  By 5:00 A.M. he relented and called 911, requesting they take him to ER at New York City Hospital.

  The ambulance attendants tried strapping him down to the stretcher for the trip. He ended up breaking free and taking the ride coiled in a ball on the floor of the vehicle, threatening lawsuits, decertification, and free vasectomies with a dull scalpel on any man who touched him.

  In ER his ordeal got worse.

  “We can’t give you anything for pain until the surgical resident examines your abdomen,” said a young trainee in a short white coat who had to be the most junior student on the ER food chain. Christ, peach fuzz covered his cheeks.

  “I’m Earl Garnet, Chief of Emergency Medicine at St. Paul’s Hospital in Buffalo. Get me your staff person, or give me Demerol, damm it! And for your future edification, a surgical abdomen doesn’t present as cramps.”

  The boy looked unimpressed. “Does this hurt?” he asked, palpating de
ep into his lower right side, then abruptly lifting off.

  Nurses started IVs.

  A clerk wrote down his mother’s maiden name.

  Someone took custody of his wallet; someone else drained a dozen tubes of blood from his arm.

  “You haven’t got a fever, and your pressure’s fine,” a nurse reassured him.

  The surgical resident came, prodded his stomach a few times, then went off to consult with his staffman.

  Still no one gave him Demerol.

  “Not before the surgeon himself sees you.” It became a reoccurring chorus.

  “And where’s the surgeon?”

  “In the OR.”

  Where else?

  He flagged another passing nurse, easily catching her attention as they’d parked him in the middle of a busy main corridor. Sporting tousled brown hair and covered in freckles, she could have been the kid sister of the lowly resident who checked him in, until she turned and he saw the triple silver rings piercing her eyebrow. He thought of J.C. in his own department, and felt oddly reassured. “I want to speak with the doctor in charge,” he demanded for the second time since his arrival.

  “He’s managing victims from a bus accident,” she called without breaking stride.

  “Then phone Melanie Collins.”

  This got her to pause. “The Chief of Internal Medicine? I don’t think so.”

  The fiery vengeance in his stomach shot to a new level, and he let out a loud groan, curling into a ball again. “Call her, please!” he managed to gasp between clenched teeth a few seconds later, his skin once more soaked with perspiration. “I’m a friend. Say that I need her help now!”

  Whether his appearance, his use of “please,” or his claim of being a personal acquaintance to an important doctor convinced her, he couldn’t tell. She nevertheless walked to the nearest phone and made a call. She spoke a few words into the receiver, then stopped, a dumbfounded expression slowly spreading across her face like a connect-the-dot drawing.

  “Dr. Collins will be right in,” she told him with newfound respect.

  “Thank you,” he said, and forced a grin that must have made him resemble the grim reaper.

  Twenty minutes later Melanie arrived at his bedside flanked by peach-fuzz and the ring-wraith. An additional bevy of students, interns, and residents formed a semicircle around them.

  “Earl, I’m so sorry,” she said, patting his shoulder.

  “Me too. I didn’t mean to haul you in here-”

  “Don’t think anything of it.” She gave a thousand-watt smile and turned to her following. “Now, gang, let’s give our distinguished guest a show of how to do it right. What’s the presentation here?”

  “Abdominal pain, crampy, generalized, and acute onset,” peach-fuzz called out.

  “Any vomiting or diarrhea?”

  “No, ma’am.”

  “Vitals?”

  “No fever, normal BP, but pulse is 120.”

  “Yours would be fast too, if you had the kind of pain that I know it would take to bring this man into ER. Any abdominal findings on exam?”

  “Abdomen’s soft, no rebound, no masses, no bruit, but increased bowel sounds.”

  “Urine?”

  “Normal.”

  “Rectal?”

  “Negative.”

  “You checked for occult blood?”

  “None.”

  “So what’s your thinking?”

  “Well, first off I’d consider this to be pain from a hollow organ rather than a solid structure, given its colicky nature-”

  “I don’t want to reread the entire text on abdominal pain, so let’s bypass the general stuff and pinpoint the most likely possibilities. Yes it’s colicky, and originates from something hollow. But the lack of nausea and there being no focal, right-upper-quadrant tenderness means we don’t even have to think gallbladder, and with a normal urine, it isn’t renal. Any history of hypertension, Earl?”

  He shook his head no, wishing she hadn’t chosen him to grandstand on. But he was imminently grateful to her for coming in and getting things going, and if he had to endure a few minutes of being a teaching specimen, so be it. Besides, it wasn’t entirely a waste. The latest rage in teaching hospitals was for the teachers to take a turn on the other side of the white coat. He’d let the residents know he’d had his, thank you very much, when he got back to Buffalo.

  “So, his lack of risk factors, along with the absence of a pulsatile mass, means an aortic aneurysm is unlikely,” she continued. “The patient being male, what’s left that’s hollow?”

  “GI!” responded a bearded man at the back.

  “Sold!” Earl said, figuring it was time to wrap up the bidding on his diagnosis.

  But Melanie hadn’t finished putting on her show. “Right. And since there’s no vomiting, we can assume the problem doesn’t lie in the upper gastrointestinal tract, which leaves us with?”

  “Lower,” her audience said in unison.

  Get on with it, Earl nearly told her, his innards clamping down on themselves again.

  “Now I know this thought process sounds oversimplistic, but it’s what should have zipped through your heads in the first few seconds you saw this patient, and everyone’s focus ought to have been on the lower GI for a nonsurgical problem from the get-go. Okay, what’s the differential? But this time start with the most probable. Don’t bother me with stuff about tumors, obstruction, ischemia, or chronic things like inflammatory bowel disease. And for God’s sake don’t begin with rare genetic disorders like porphyria. I hate having to look up those damn metabolic pathways.”

  A collective chuckle came from the group.

  “Enteritis, colitis, or both,” one of the young men said.

  “Very good. The probable cause?”

  “Viral or bacterial contamination from food,” he replied.

  “Which bacteria?”

  “Campylobacter jejuni, salmonella, shigella.”

  “Treatment?”

  “Hydration, electrolyte management, particularly potassium replacement, Cipro, and painkillers!” He spoke with the certainty of someone on a roll.

  Yes! Earl wanted to yell out. You can replace peach-fuzz as my doctor.

  “Not so fast,” Melanie said. “Is there any danger in giving ciprofloxacin at this point?”

  Oh, Melanie, he wanted to shout, surely old Earl Garnet didn’t have to be treated by the book. Come on, give the Cipro. As physician to physician. Cut corners.

  The bearded resident seemed at a loss for words.

  “Any reason to wait for stool culture results before treating?” Melanie prompted.

  The man stroked his chin as if contemplating a chess move, then shrugged.

  Melanie searched the crowd for any other takers. There were none. “Okay, here’s the teaching nugget of this case. The severity of Dr. Garnet’s pain plus an apparent delay in the onset of the inevitable diarrhea makes me think this might be an organism other than the more common ones you listed. With them, the diarrhea usually follows closely on the heels of the pain. But with some of the enterohemorrhagic E. coli, where toxins are the culprit, they need time to work, and there can be the sort of delay we see here. In other words, the agent infecting Dr. Garnet may be none other than E. coli 0157:H7, which can not only cause a hemorrhagic colitis, but in 10 percent of cases, introduce toxins which attack the kidneys to produce a hemolytic uremic syndrome. The latest evidence suggests antibiotics may actually increase the risk of complications, so we hold the Cipro.”

  There wasn’t a round of applause, but the appreciative nods as her audience dispersed and returned to their various duties were as good a stamp of approval as a teacher could get for first-rate bedside teaching. Earl had to admit he’d not heard of the subtle nuance she was making, but it made sense, and her zeroing in on it impressed him,

  “Hope you didn’t mind me putting you through that,” she said, while checking the IV bag flowing into his arm – normal saline with an added dose of potassium
– “but I wanted to set them straight after the inexcusable delay they put you through.”

  Be gracious, he told himself. “Hey, our residents are the same until we whip them into shape. You’ve nothing to apologize for, and thank you again for getting out of bed.” And since he had her attention: “Melanie, I’ve also been trying to call you to clear up a misunderstanding-”

  “Now you just stay quiet, and I’ll have you comfortable in minutes.” She pulled a syringe out of her lab pocket, stuck it in the side portal of his IV line, and began to push in the plunger. “No allergies I take it?”

  “None. What are you giving me. Demerol?”

  “You, my friend, get the big M.”

  “Morphine?”

  She nodded.

  But morphine, powerful analgesic that it was, doctors seldom used for acute abdominal pain in ER. It could obtund consciousness to the point of suppressing respiration and cause serious drops in blood pressure. Neither of which was a good thing where issues such as staying awake enough to keep breathing or avoiding aspiration of vomit or fighting a low blood pressure from dehydration were concerned. Of course there were exceptional cases, but he didn’t want to be one of them. “Listen, Melanie, I’m not that bad. Don’t give me special treatment – Whoa!”

  The potent opiate affected him immediately, taking away not only his abdominal spasms but every ache and pain he had, physical or emotional. He felt his brain slip into a warm puddle, where it floated without a care in the world.

  “I’ll make sure the nurses keep you well topped off,” said a voice from the other side of the universe.

  Must be God talking. Sounded like his kind of woman, one who knew her business.

  Chapter 14

  Thursday, November 22,

  11:45 A.M.

  Hampton Junction

  Mark stood on the back porch, sipping a cup of coffee that had come from the bottom of the pot. Along the horizon, a gray, humpbacked line of clouds strained toward the east, dragging their shaggy tendrils over the hills. The cold wet aroma of snow hung in the air.