Christine returned in time for the end of report. Restless and saturated with nursing and with Boston Doctors Hospital, she stood against a wall until the final patient had been discussed, then left before any of the others. Ahead of her, waiting for the elevator, were Janet and an orderly. Between them, on a litter, lay the sheet-covered body of Charlotte Thomas.
Held fast by the scene and her reflections on it, Christine watched as the litter was maneuvered onto the elevator. Not until the doors had closed was she able to move again.
CHAPTER X
Fox’s Golden Laws of Medicine defined pathologist as “The specialist who learns all by cutting corners to get straight to the heart of the matter, leaving no stone unturned (gall or kidney).”
As usual, the recollection of one of Gerald Fox’s immortal definitions forced a smile out of David. This despite his discomfort at the prospect of having to observe the autopsy on Charlotte Thomas.
He was already ten minutes late, but he knew that nothing would be completed except perhaps the preparation of Charlotte’s body and the first incision. Although Fox’s observations were usually right on the mark, David had never felt that his cynical maxim about pathologists was totally accurate. He thought back to his first exposure to forensic pathology, a lecture given by the county coroner just before David’s group of second-year medical students was ushered in to view their first autopsy.
“Cause of death, ladies and gentlemen,” the old pathologist had said, “that is what we in forensic medicine are asked to determine for our medical and legal colleagues. In fact, nobody other than God himself knows what causes a person to die. Nobody. Rather what we can determine is the condition of each organ in a patient’s body at the time of his or her death. From this knowledge, we can deduce with some accuracy the reason for cessation of cardiac, cerebral, or pulmonary fonction—the only true causes of death.
“For example. If a patient is killed by a gunshot wound through the heart, we may say quite safely that death was due to cardiac standstill from a penetrating wound to the heart muscle itself. But what of the patient with a disease like cancer? We might be able to locate cancerous tissue in the liver, brain, lungs, or other organs and certainly, in one respect, may say that cancer is the cause of death. Determining the immediate cause, however, is nigh impossible. Did the heart stop because it was poisoned by some as yet unknown substance secreted by the cancerous cells? Or did lack of sufficient fluid volume, for reasons perhaps unrelated to the cancer itself, cause such an impairment in circulation that the heart could no longer fonction and simply stopped?
“You must keep this in mind whenever you read such diagnoses as ‘cancer,’ or ‘emphysema,’ or ‘arteriosclerosis’ as the cause of a patient’s death. They may have been a cause leading to death, but as to the direct cause of death—that, my friends, remains a mystery in the vast majority of cases.”
A mystery. David hesitated outside the two opaque glass doors labeled AUTOPSY SUITE in gold-leaf letters. A sleepless night and chaotic morning had left him tense and uneasy. The prospect of Charlotte’s autopsy only aggravated those feelings.
Then there was Huttner. Cape Cod was only seventy miles away, close enough for him to make the drive up that morning without much difficulty. Whether or not he would choose to return there after witnessing the autopsy was a different story. David bet himself a long-overdue and much-feared trip to the dentist that Huttner would elect to stay in Boston and resume control of his practice. He had given some thought to turning the bet around so that at least he wouldn’t have to face the Novocain and drill if he lost the last two days of his adventure. In the end, however, he decided that if he lost he would be able to submerge the misery of a visit to the tooth merchant in other, more substantial miseries.
Needles of formalin vapor jabbed deep into his nostrils as he entered the suite. It was a long room, nearly twenty-five yards from end to end. High ceilings and an excess of fluorescent light obscured, in part, the fact that there were no windows. Seven steel autopsy tables, each fitted with a water hose and drainage system, were evenly spaced across the ivory-colored linoleum floor. In addition to the hose, used for cleaning organs during an autopsy and the table afterward, every station had its own sink, blackboard, and suspended scale. A large red number, from 1 to 7, inlaid in the floor, was the only characteristic individual to each one. That is, except for Station 4.
On either side of that table six tiers of wooden risers had been built, identical to those in high school gymnasiums. At certain times the risers were filled with students in various stages of distress or fascination. At other times the stands held groups of residents in pathology or surgery, craning to study the dissecting skills of a senior pathologist. Station 4 was the center court of the Doctors Hospital Autopsy Suite.
At 8:15 on the morning of October 3, Stations 1, 4, and 6 were in operation, and a sheet-wrapped body rested on the table at Station 2. Wallace Huttner was standing, arms folded, at Station 4. The risers were empty but for a resident scheduled to post the body on table 2 and three medical students. As David approached, he caught sight of Charlotte’s open-mouthed, chalk-colored face. He bit at his lower lip, swallowed a jet of bile, and decided that it would be best to concentrate on the rest of her anatomy. He could deal reasonably well with autopsies as long as he viewed them as examinations of parts of a body. The nearer he allowed himself to get to the human aspect, the more unpleasant the procedure became for him.
Ahmed Hadawi, a quick, dark little man with disproportionately huge hands, had made his initial incision and was elbow-deep in the chest cavity, busily separating the chest and abdominal organs from their attachments to the neck and body wall. He made a soft clucking noise with his tongue as he worked, but otherwise seemed without emotion or expression. Occasionally he bent over and murmured a few words into a pedal-operated Dictaphone.
Huttner nodded coolly in response to David’s greeting. His stance and manner bore no hint of the relaxed, interested, almost fatherly physician who had sat with David in the surgeons’ lounge just thirty-six hours before. After the nod, he returned his attention to the dissection, carefully avoiding further eye contact. David looked at the man helplessly. Then, as so often happened in difficult situations, the macabre portion of his humor took over. If he hugs himself any tighter, he thought, maybe he’ll just break into little pieces and I can cover his practice until someone glues him back together.
At that moment he caught another glimpse of Charlotte’s face. “Stop it, Shelton!” he screamed at himself. “This isn’t funny. Just stop it!” The mental slap was enough. He shifted his weight several times from side to side, then settled down, his attention focused on the pathologist.
“Now, then, we are ready to take a look at some things,” Hadawi said. The resident stepped down from the risers to get a better view and Huttner tightened his autoembrace a notch as the pathologist began pointing out the anatomical status of each of Charlotte’s organs as they existed at the instant of her death.
“The heart,” he began, “is moderately enlarged, with thickening of the muscle and dilatation of all chambers. There is a small, fresh puncture wound through the anterior left ventricle, which I assume is the result of Dr. Shelton’s commendably accurate intracardiac injection.”
David thought that the moment might be right for a modest smile and nod, but then realized that no one was looking at him. He smiled and nodded anyway.
The little pathologist continued speaking as he dissected. “There is fairly advanced narrowing of all coronary arteries, although there is no gross evidence of recent damage such as might be caused by a myocardial infarction.” Margaret Armstrong’s interpretation of Charlotte’s electrocardiogram had been right on the button, David noted. “Keep in mind,” Hadawi added, “that evidence of an acute infarction—say, less than twenty-four hours old—is often seen only in microscopic examination of the heart muscle itself, and then only if we happen to catch just the right section.”
“I
want to be notified as soon as those slides have been examined,” Huttner ordered, more, it seemed to David, out of a need to make some kind of statement than anything else. Hadawi glanced up at him and, with no more acknowledgment than that, turned his attention to the lungs. Immediately his stock as reflected in David’s eyes rose several points. Both lungs were more than half consolidated by the heavy fluid of infection. Even if there had been no other problems, it seemed entirely possible that Charlotte would have been unable to survive her extensive pneumonia.
The remainder of the examination was impressive mainly for what it did not show. Pending, of course, microscopic examination of the abdominal lymph nodes, Hadawi announced that he was unable to find any evidence of residual cancer in the woman’s body. The liver cysts, which had been misdiagnosed by the radiologist, Rybicki, were scattered throughout the organ, and similar fluid-filled sacs were found in both kidneys. “Polycystic involvement of hepatic and renal parenchyma,” Hadawi said into his Dictaphone.
Finally the pathologist stepped away from the table. “I have a few remaining things to do on this body,” he said, “but they will have no bearing on my findings. To all intents and purposes, Wally, we are done. Most significant of what I have to tell you is that this woman’s pressure sore was extending beneath her skin to the point where I doubt that even with multiple grafts it ever would have healed. Infection of the sacral bones had already begun and would have been almost impossible to treat.
“She has enough coronary arteriosclerosis so that I feel her final event was probably a cardiac one. I intend to sign her out as cardiovascular collapse secondary to her pulmonary and bedsore infections. An additional stress undoubtedly came from her partial small bowel obstruction, which, as you saw, was due to adhesions from her recent surgery.”
David said, “Dr. Hadawi, Dr. Huttner, if we could sit down over here, there are a few questions that I have.” He could not bear the thought of having to discuss Charlotte’s case over her dissected body. Hadawi responded with a brief, understanding grin and took a seat on one of the risers. Huttner, who still held his arms around himself, followed reluctantly. David gauged the expression on his face as somewhere between disgust and fury. Nowhere in his eyes or manner was there a hint of disappointment or sympathy. Regardless of her underlying disease, Charlotte Thomas had walked into the hospital as Huttner’s patient, had been operated on, and had died. That made her a postoperative mortality. Her operation and the many complications that ensued would be discussed in depth at Surgical Death Rounds. Hardly a prospect that would sit well with this man, David realized. He was far more accus tomed to asking the questions than to answering them.
“Now, David,” Hadawi said, “just what is it that troubles you about what you have seen?”
“Well, most of my concern centers about her heart, which seemed so unresponsive to everything that I tried during her Code Ninety-nine. It may have been simply that too much time elapsed between the moment of her cardiac arrest and the time I started working on her, but it just doesn’t feel like that. I wonder if perhaps her potassium could somehow have risen too high and caused a fatal cardiac arrhythmia.”
“That is always a possibility,” Hadawi said patiently. “I’ve saved several vials of blood. I’ll be happy to have her potassium level checked. However, you must keep in mind the limits of accuracy of such a measurement done in a postmortem patient—especially one who has received prolonged external cardiac compression.”
Finally Huttner spoke. It was no surprise to David that he was unwilling to surrender without a fight. “Look, Ahmed,” he said. His second and third fingers bobbed up and down at the man, but Hadawi showed no outward hint of being offended by the gesture. “I’m not totally satisfied with all this. Dr. Shelton here has a point. Since there’s nothing obvious on gross exam to explain this woman’s sudden death, then we should look further before signing her out as something so nonspecific as cardiovascular collapse. Maybe some nurse made a medication error on her and caused an allergic, anaphylactic reaction of some kind. She was known to be allergic to penicillin.”
Hadawi was obviously used to dealing with Huttner’s ego. He merely shrugged and said, “If you wish, I shall be happy to order a penicillin level on her blood. Is there anything else you would like?”
Huttner seized the chance to avoid a Surgical Death Rounds presentation as a drowning sailor might grasp a passing chunk of driftwood. A medication error would provide him with instant absolution.
“Yes, there are some other things I think should be done,” Huttner said with a professorial tone that included several significant pauses. He seemed actually to be savoring his own words. “I think she should have a complete chemical screen. Antibiotic levels, electrolytes, toxins—the works.”
“With no specific idea of what we’re searching for, that will be quite expensive,” Hadawi said softly, as if anticipating the eruption that would follow even this mild objection.
“Damn the money, man,” Huttner fired, his fingers jabbing even faster than before. “This is a human life we’re talking about here. You just do the damn tests and get me the results.”
“As you wish, Wally.”
Huttner nodded his satisfaction, then started to leave. As he passed David, he snapped his fingers. “I almost forgot, David,” he said over his shoulder. “The Cape Vascular Conference really wasn’t all that it was cut out to be. I’ve decided not to go back. Thank you for your help yesterday. I think there’s a meeting in January I might want to attend. Perhaps we can work out another coverage arrangement then.”
His voice, David thought, held every bit as much sincerity as Don Juan saying, “Of course I’ll respect you in the morning.”
CHAPTER XI
In his selection of a hospital, as in all the other affairs in his life, Senator Richard Cormier was his own man. While many Washington politicians considered it a status symbol to be cared for at Bethesda Naval or Walter Reed, Cormier overruled the objections of his aides and insisted that he be operated on by Dr. Louis Ketchem at Boston Doctors. “Always trust your own kind,” he said. “Louie’s an old war-horse just like me. Either he does the cutting or I don’t get cut.”
The walls of Cormier’s room were covered top to bottom with cards, and cartons containing several hundred more were stacked neatly in one corner. In addition to a nurse and the senator, the presence of a secretary and two aides helped to create an atmosphere almost as chaotic as that perpetually found in his Washington office.
“Senator Cormier, I must give you your preop meds, and these people will have to leave your room.” The nurse, an ample matron named Fuller, projected just the right amount of authority to get the senator to comply with the request.
Cormier ran his fingers through his thick, silver hair and squinted up at the nurse. “Ten more minutes.”
“Two,” she said firmly.
“Five.” The bargaining brought a sparkle to his eyes.
“All right, five,” she said. “But one minute longer and I use the square needle to give you this medication.” She bustled out of the room, turning at the doorway to give Cormier a glare that said she was serious. The senator winked at her.
“Okay, Beth, time to get packed up,” he said, to his secretary. “Remember, I want a thank-you sent to everyone who put a return address on his card. I signed what seemed like a thousand of them yesterday, but if you run out, have some more printed up and I’ll sign them after the operation. Gary, call Lionel Herbert and tell him to fly up here for a meeting the day after tomorrow. Tell him to be prepared to make some concessions on that energy package or, by God, it’s back to the drawing board again for his boss and those oil people he’s so damn friendly with. Bobby, call my niece and tell her I’m fine, not to worry, and, most of all, not to be upset that she couldn’t leave the kids to fly here. I’ll call her myself as soon as they let me back near my phone. Oh, and Bobby, have you got all the names of people who sent flowers? I want to send each of them a personal note.
Do you think it would hurt anyone’s feelings if I told them to send candy next time? This place looks like a funeral parlor and smells like a bordello.”
Bobby Crisp, a young lawyer as sharp and eager as his name, smiled over at his boss. “You must be getting more confidence in me, Senator,” he said. “This is only the fourth time you’ve told me to do the same thing. Back when I first started working for you, it was seven. Everything’s taken care of. I’ll have the list ready for you as soon as you’re ready to write, which will probably be half an hour after you come out of the anesthesia, if I know you. By the way, do you know someone named Camellia?”
“Who?” Cormier asked.
“Camellia. See those pink and white flowers over there on the table? They came this morning with a note that just said ‘Thank you for everything. Camellia,’ ”
“Men,” Beth said scornfully. “Those pink and white flowers, as you call them, are camellias. Let me see that note.” She read it and shrugged. “That’s what it says, all right.”
“Thanks for checking,” Crisp said. “I got low marks in reading throughout law school.”
“Now, now, settle down, you two,” Cormier said. He rubbed his chin. “Camellia’s a strange enough name so that I should remember it. Camellias from Camellia, eh? …” His voice drifted off as he tried to connect the name with a person. Finally he shook his head. “Well, I guess a little memory lapse here and there is a small price to pay for the frustration I’m able to cause on The Hill with the rest of my senility. Whoever she is, she’ll just have to live without a thank-you note.”
At that moment Mrs. Fuller reappeared at the door. “I said five minutes, and it’s already more than that,” she said. “I swear, Senator, you are the most obstinate, cantankerous patient I’ve ever had.”
“Okay, okay, we’re done,” Cormier said, waving the other three out of his room. “You know, Mrs. Fuller, if you don’t sweeten up soon, you’re going to move from the sleek cruiser class into the battle-ax category.” He smiled at her and added, “But even then you’ll still be my favorite nurse. Go easy with that needle, now.”
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