Side Effects

by Michael Palmer

  "A set of twins."

  "How's Beverly Vitale?"

  "Her blood count's down this morning. Twenty-five. She's due for a recheck in an hour or two. Any further drop, and we'll give her more blood."

  "Her GI tract?

  " Kate asked, speculating on the site of blood loss. "Probably. There's been some blood in every stool we've checked. She's on steroids, you know."

  "I do know. Withhold steroids, and her antibodies run wild, destroying her own clotting factors, use them, and she risks developing bleeding ulcers. It's one of those situations that makes me grateful I decided on pathology. Stan Willoughby and I reviewed the ovary sections this morning. His impression is that the findings are unique. He's doing some special stains now and has sent slides to a colleague of his at Johns Hopkins, whom he says is as good as anyone in the business at diagnosing ovarian disorders. He also is calling around town to see if anything like this has turned up in another department."

  "Etiology?"

  "No clues, Tom. Virus, toxin, med reaction. All of the above, none of the above, A and B but not C. She told you she wasn't on any meds, right?"

  "None except vitamins. The multivitamin plus iron we dispense through the Omnicenter."

  "Well I'm living proof those don't cause any problems. I've taken them for a couple of years. Make frail pathologist strong like bull." Kate flexed her biceps. "Make pathologist excellent teacher, too."

  "Why, thank you." Kate's green eyes sparkled. "Thank you very much, Tom." For a moment, she saw him blush. "How about we go say hello to Beverly. I'd like to make extra sure about one or two aspects of her history. Here, you can stick this salad in that refrigerator for later."

  "Provided the bacteria who call that icebox home don't eat it first,"

  Tom said. The two were heading down the hall toward the stairway when the overhead page snapped to life. "Code ninety-nine, Ashburton five-ohtwo, code ninety-nine, Ashburton five-oh-two."

  "Oh, Jesus."

  Tom was already racing toward the exit as he spoke. Kate was slower to react. She was almost to the stairway door before she realized that Ashburton 502 was Beverly Vitale's room. It had been a year, perhaps two, since Kate had last observed a cardiac arrest and resuscitation attempt. She was certified in advanced cardiac life support, but training and testing then had been on Resusciannie, a mannequin. Her practical experience had ended years ago, along with her internship. At the moment, however, none of those considerations mattered. What mattered was the life of a young woman who loved to make music. With an athlete's quickness, Kate bolted after Tom Engleson up the stairs from Ashburton Four to Ashburton Five. There were more than enough participants in the code. Residents, nurses, medical students, and technicians filled room 502 and overflowed into the hall. Kate worked her way to a spot by the door, from which she watched the nightmare of Beverly Vitale's final minutes of life. It was a gastric hemorrhage, almost certainly from an ulcer eroding into an artery. The woman's relentless exsanguination was being complicated by the aspiration of vomited blood. Cloaked in abysmal helplessness, Kate witnessed Tom Engleson, desperation etched on his face, issuing orders in a deceptively composed tone, the organized chaos of the white-clad code team, pumping, injecting, monitoring, reporting, respirating, suctioning, and through the milling bodies, the expressionless, blood-smeared face of Beverly Vitale. For nearly an hour the struggle continued, though there was never a pulse or even an encouraging electrocardiographic pattern. In the end, there was nothing but another lesson in the relative impotence of people and medicine when matched against the capriciousness of illness and death. Tom Engleson, his eyes dark and sunken, shook his head in utter futility. "It's over, " he said softly. "Thank you all. It's over."

  Simultaneously with hearing the report from the WEEI traffic helicopter of a monumental backup stemming from the Mystic/Tobin Bridge, Kate became part of it. Commuting to the city from the North Shore was an experience that she suspected ranked in pleasantness somewhere between an IRS audit and root canal work. Although Tuesday was normally a low-volume day, this morning she had encountered rain, sleet, snow, and even a bizarre stretch of sunlight during her thirty-mile drive, far too much weather for even Boston drivers to attack. With a groan, she resigned herself to being half an hour late, perhaps more, for the appointment Stan Willoughby had arranged for her at White Memorial Hospital. The pathology chief's call had punctuated another confusing, bittersweet morning with Jared. It seemed as if the intensity and caring in their relationship was waxing and waning not only from day to day but from hour to hour or even from minute to minute. In one sentence the man was Jared Samuels, the funny, sensitive, often ingenuous fellow she had married and still loved deeply, in the next he was calculating and distant, a miniature of his father, intransigent on points they should have been working through as husband and wife. At last, after an awkward hour of lighting brush fires of dissension and then scurrying to stamp them out, Jared had suggested a week or ten days together in Aruba, away from the pressures and demands of their careers. "What do you say, Boots? " he had asked, calling on the pet name she favored most of the four or five he used. "Aruba you all over." The expression in his eyes-urgency? fear? — belied his levity. "Aruba you too, Jared, " she had said finally. "Then we go?"

  "If Stan can give me the time off, and if you can stand the thought of trying to hang onto a woman swathe in Coppertone, we go."

  At that moment, Jared looked reborn. "Grumper-to-grumper, stall-and-crawl traffic headed in a snail trail toward the bridge, thanks to a fender bender in the left-hand lane." The Eye-in-the-Sky was sparing none of his cliches in describing the mess on Route 1 south.

  Kate inched her Volvo between cars, but gained little ground. Finally, resigned to the situation, she settled back, turned up the volume on the all-news station, and concentrated on ignoring the would-be Lothario who was winking and waving at her from the Trans-Am in the next lane. The news, like Stan Willoughby's call, dealt with the sudden death of Red Sox hero Bobby Geary, a homegrown boy who had played his sandlot ball in South Boston, not a mile from the luxurious condominium where he was found by his mother following an apparent heart attack. Stan's name was mentioned several times as the medical examiner assigned to autopsy the man who had given away thousands of free tickets and had added an entire floor to Children's and Infants' Hospital in the name of "the kids of Boston."

  "Kate, " Willoughby had begun, "I hope I'm not interrupting anything."

  "No, no. Just getting ready for work, " she had said, smiling at Jared, who was nude by the bathroom door dancing a coarse hula and beckoning her to the shower with a long-handled scrub brush. "Well, I don't want you to come to work."

  "What?"

  "I want you to go to White Memorial. You have an appointment in the pathology department there at eight-thirty. Leon Olesky will be waiting for you. Do you know him?"

  "Only by name."

  "Well, I called around town trying to see if anyone had seen a case similar to our Miss Vitale's. Initially there was nothing, but late last night Leon called me at home. From what he described, the two cases — his and ours-sound identical. I told him you'd be over to study his material."

  "How old was the woman? " Kate had asked excitedly. "I don't remember what he said. Twenty-eight, I think."

  I)m "Cause of death?"

  "Ah ha! I thought you'd never ask. Cerebral hemorrhage, secondary to minor head trauma."

  "Platelets?

  Fibrinogen? " Her hand was white around the receiver. "Leon didn't know.

  The case was handled by one of his underlings. He said he'd try to find out by the time you got there."

  "Can't you come?"

  "Hell, no. Haven't you heard the news about Bobby Geary?"

  "The ball player?"

  "Heart attack late last night. Found dead in bed. I'm posting him at ten-thirty. In fact, I'd like you back here before I finish, just in case I need your help."

  "You've got it. You know, you are a pretty terri
fic chief, Stanley. Are you sure you want to retire?"

  "Yesterday, if I could arrange it, Katey-girl. You hurry on back to Metro after you see Olesky, now. No telling what this shriveled brain of mine might miss."

  White Memorial Hospital, an architectural polyglot of more than a score of buildings, was the flagship of the fleet of Harvard Medical School affiliated hospitals. Overlooking the Charles River near the North End, WMH had more research facilities, professors, grants, and administrative expertise than any hospital in the area, if not the world. Metropolitan Hospital had once held sway, reportedly supplying ninety percent of all the professors of medicine at all the medical schools in the country, but that time had long since been buried beneath an avalanche of incompetent administrators, unfavorable publicity, and corrupt city politicians. Although Metro had made a resurgence of sorts under the guidance of Norton Reese, there was little likelihood of its ever recapturing the prestige, endowments, and fierce patient loyalty of the glory days, when at least one man was known to have had "Take Me To Metro" tattooed across his chest. It had been some time since Kate had had reason to visit the pathology unit at White Memorial, and she was uncomfortably impressed with the improvements and expansion that had occurred. Equipment her department congratulated itself on acquiring, this unit possessed in duplicate or triplicate. Corridors and offices were brightly lit, with plants, paintings, and other touches that made the work environment less tedious and oppressive. Almost subconsciously, Kate found herself making mental lists of things she would press to accomplish as chief — of pathology at Metro. Leon Olesky, a mild, Lincolnesque man, brushed off her apologies for her tardiness and after exchanging compliments about Stan Willoughby, left her alone in his office with the material from the autopsy of Ginger Rittenhouse. On a pink piece of paper by his elegant microscope were the data on the woman's blood studies. Only two of many parameters measured were abnormal, fibrinogen and platelets. The levels of each were depressed enough to have been life threatening.

  Her hands trembling with anticipation, Kate took the first of the ovarian sections and slid it onto the stage of the microscope. A moment to flex tension from the muscles in her neck, and she leaned forward to begin another journey through the yellow-white light. Forty-five minutes later, the one had become three. Leon Olesky hunched over one set of oculars of the teaching microscope, controlling the focus with his right hand and moving the slide with his left. Across from him, in the seat Kate had occupied, was Tom Engleson. "You know, " Olesky said, "if Stan hadn't called me about your case, the findings on our young woman would have slipped right past us. I mentioned the matter last night at our weekly department conference, but no one responded. An hour later, Dr.

  Hickman came to my office. Young Bruce is, perhaps, the brightest of our residents, but at times, I'm afraid, a bit too quick for his own good."

  Kate sighed. Olesky's observations described many of the so-called hotshot residents she had worked with over the years. "I'll take methodical over genius any day of the week, " she said. "Both is best,"

  Olesky responded, "but that's a rare combination, indeed.

  I might mention, though, that it is a combination your mentor feels he is lucky to have found in you."

  "Methodical, yes, " Kate allowed, "but I've yet to receive a single membership application from Mensa."

  "She's only the best in the hospital, " Tom interjected somewhat impetuously. "Finish telling us about your resident."

  Kate withheld reaction to Engleson's enthusiasm, sensing that what she felt was, in equal parts, flattered and embarrassed. "Well, it seems our Dr. Hickman was uncertain about the pathology he was seeing in this woman's ovaries. However, rather than think that the finding might be unique, he assumed, although he won't say so in as many words, that the condition was one he should have known about, and hence one he would look foolish asking for help with. Since the cause of death was unrelated to the ovaries, he chose to describe his findings in the autopsy report and leave it at that."

  "No harm done, " Kate said. "Quite the contrary, in fact. This event may be the pinprick Hickman's ego needs so he can reach his full potential as a physician. It will make even more of an impression if, as Dr. Willoughby and now yours truly, suspect, this pathology turns out to be one never before described."

  Kate and Tom exchanged excited glances. "How would you explain its showing up in two women in the same city at about the same time?" she asked. The professor's eyes, dark and deeply serious, met first Engleson's and then Kate's. "Considering the outcome of the illness in both individuals, I would suggest that we work diligently to find an answer to that question. At the moment, I have none."

  "There must be a connection, " Engleson said. "I hope there is, young man."

  Olesky rose from his stool. "And I hope the two of you will be able to find it. I have a class to teach right now at, the medical school. This evening, I leave for meetings in San Diego, and from there, I go to the wedding of my son in New Mexico. My office and our department are at your disposal."

  "Thank you, " they said. Olesky replaced his lab coat with a well-worn mackintosh. He shook hands first with Engleson and then with Kate. A final check of his desk and he shambled from the office. Kate waited for the door to click shut. "I'm glad you were able to get here so quickly,

  " she said. "Did you have any trouble getting the records people to let you take Beverly's chart out of the hospital?"

  "None. I just followed Engleson's first law of chutzpah. The more one looks like he should be doing what he's doing, the less anyone realizes that he shouldn't. I'll have to admit that the crooks with moving vans and uniforms who pick entire houses clean thought of the law before I did, but I was the first one I know to put it in words. Are you okay? I went to find you after the code was over yesterday, but you were gone.

  Before I could call, I was rushed to the OR to do an emergency C-section."

  "I was okay." She paused. "Actually, I wasn't. It hurt like hell to see her lying there like that. I can't remember the last time I felt so helpless." At the thought, the mention of the word, Arthur Everett's grotesque face flashed in her mind, his reddened eyes bulging with the effort of forcing himself inside her. Yes, I do, she thought. I do remember when. "How about you? " she asked. Engleson shrugged. "I think I'm still numb. It's like I'm afraid that if I let down and acknowledge my feelings about her and what happened, I'll never set foot in a hospital again."

  Kate nodded her understanding. "You know, Tom, contrary to popuiar belief, being human doesn't disqualify you from being a doctor. Are you married? " Engleson shook his head. "I think it's hard to face some of the things we have to face and then have no one to talk them out with, to cry on, if necessary, when we get home." She thought about the difficult morning with Jared and smiled inwardly at the irony of her words. "Had you known Beverly outside the hospital?"

  "No. I met her when she came into Metro. But I thought about trying to start up a relationship as soon as she His voice grew husky. He cleared his throat. "I understand, " Kate said. "Look, maybe we can talk about our work and our lives in medicine some day soon. Right now, we've got to start looking for some common threads between these women. I'm due back at Metro in, " she checked her watch, "-shoot, I've only got about twenty minutes."

  Tom was thumbing through the thin sheaf of papers dealing with Ginger Rittenhouse. "It shouldn't take long to check. They have next to no information here. Ginger Louise Rittenhouse, twenty-eight, elementary school teacher, lived and worked in Cambridge, but she was running along the Boston side of the river when she collapsed. Apparently she lived long enough to get an emergency CAT scan, but not long enough to get to the OR."

  "Married?". Kate asked. "No. Single. That's the second time you've asked that question about someone in the last two minutes." He narrowed one eye and fingered his moustache. "You have, perhaps, a marriage fixation?"

  Kate smiled. "Let's leave my fixations out of this. At least for the time being, okay? What about family? Place of
birth? Next of kin? Did they document any prior medical history?"

  "Hey, slow down. We obstetricians are hardly famous for our swift reading ability. No known medical history. Next of kin is a brother in Seattle. Here's his address. You know, world's greatest hospital or not, they take a pretty skimpy history."

  "It doesn't look like they had time for much more, " Kate said solemnly.

  There had to be a connection, she was thinking. The two cases were at once too remarkable and too similar. Somewhere, the lives of a teacher from Cambridge and a cellist from a suburb on the far side of Boston had crossed. "Wait, " Engleson said. "She had a roommate. It says here on the accident floor sheet. Sandra Tucker. That must be how they found out about her family."

  Kate again checked her watch. "Tom, I've got to go. I promised Dr.

  Willoughby I'd help out with the post on Bobby Geary. Do you think you could try and get a hold of this Sandra Tucker? See if our woman has seen a doctor recently or had a blood test. Don't teachers need yearly physicals or something?"

  "Not the ones I had.. I think their average age was deceased."

  "Are you going to call from here? " Engleson thought for a moment and then nodded. "Fine, give me a ring when you get back to Metro. And Tom'?

  Thanks for the compliment you paid me before." She reached out and shook his hand, firmly and in a businesslike manner. Then she left. With the pistol-shot crack of bat against ball, thirty thousand heads snapped in horror toward the fence in right center field. "Jesus, Katey, it's gone,

  " was all Jared could say. The ball, a white star, arced into the blue-black summer night sky.

  On the base paths, four runners dashed around toward home. There were two out in the running, the ninth running. The scoreboard at the base of the left field wall in Fenway Park said that the Red Sox were ahead of the Yankees by three runs, but that lead, it appeared, had only seconds more to be. Kate, enthralled by the lights and the colors and the precision of her first live baseball game, stood frozen with the rest, her eyes fixed on the ball now in a lazy descent toward a spot beyond the fence. Then into the corner of her field of vision he came, running with an antelope grace that made his movements seem almost slow motion.