by Robin Cook
“There are a lot of terms that I don’t understand,” Michael said.
“Likewise,” Lynn said. “But it’s pretty clear that it isn’t good news, even if we don’t understand all the details. The summary says the CT scan showed severe diffuse brain edema while the summary of the MRI says that the hyperintense cortical signal indicates extensive laminar necrosis. That’s what Dr. Stuart expected. It all translates to extensive brain death . . .” Lynn trailed off, unable to finish her sentence.
“I’m sorry,” Michael said as sincerely as he could.
“Thank you,” Lynn said. Her voice caught. With such terrible news, she was trying not to cry. She was supposed to be a dispassionate medical student.
“Want to look at anything else in the chart?” Michael asked.
Lynn shook her head. As far as she was concerned, there wasn’t any point. The verdict was in. Whether Carl would regain some level of consciousness or not was uncertain, but even if he did, he was never going to be the person she knew. Best-case scenario was probably his entering a persistent vegetative state, a horrid situation that she had read up on the evening before. He would have brain stem function without input from the higher or cortical areas. It would mean he might have sleep-wake cycles but still would be completely unaware of self and environment and need total care until death. In short, he would endure a dehumanized existence. Inwardly she shuddered, wondering if she could cope.
Michael stood up and gave Lynn’s shoulder a reassuring squeeze. He took Carl’s chart back over to Dr. Erikson, who gave him Scarlett Morrison’s chart. He brought it back to where Lynn was sitting and placed it in front of her. She was in a trance, staring ahead. “You okay?” he asked.
“As good as can be expected,” Lynn responded. Her voice quavered. Then, as if waking up, she shook her head, adjusted herself in her seat to be more upright, and opened the second chart.
16.
Tuesday, April 7, 6:52 A.M.
At first they didn’t talk, but merely nodded to each other when they finished a page. The first question Lynn in particular wanted to know was why the neurology resident, Charles Stuart, hadn’t mentioned that there had been a very recent, similar case. The answer turned out to be simple: a different neurology resident, by the name of Dr. Mercedes Santiago, was involved. With what they both knew about interdepartmental communication, the Neurology Department might not know that there had been two similar cases until they had their grand rounds.
As Lynn and Michael read on, significant similarities between the cases began to surface. First of all, Scarlett Morrison was nearly the same age as Carl, and unmarried. Second, she was a healthy individual whose only problem was gallstones. Her surgery, like Carl’s, was elective, meaning it wasn’t an emergency. Her procedure had been a laparoscopic cholecystectomy, or a small-incision removal of her gallbladder. It had been done without complications, according to the operative note, just as Carl’s had been, and, like Carl’s, it had been a seven-thirty A.M. case, so everyone had been fresh and rested.
As they continued to read they noticed there was no handwritten anesthesia note by the anesthesiologist, Dr. Mark Pearlman, only a terse mention of the problem of delayed return of consciousness, followed by a list of the medications that had been tried in vain to reverse the sedative and the paralytic agents in case there had been an overdosage of either. For information about the course of anesthesia during the operation, Lynn and Michael had to turn to the record created in real time by the anesthesia machine.
What they learned was that, as in Carl’s case, the anesthesia had progressed normally until there was a sudden, unexplained decrease in the patient’s blood oxygenation about three-quarters of the way through the operation. Looking at the graph, they could see that the oxygenation fell precipitously from near 100 percent to 90 percent for a couple of minutes before returning to 98 percent. Just as with Carl, there had been a brief episode of heart irregularity from hypoxia at precisely the moment the oxygen saturation fell.
As they examined the record further, some specific differences from Carl’s case became apparent above and besides the fact that it had taken place in OR 18 instead of OR 12: First, the volatile anesthetic agent was desflurane instead of isoflurane; second, an endotracheal tube was used instead of a laryngeal mask; and third, a depolarizing muscle relaxant, succinylcholine, had been used to facilitate the intra-abdominal surgery. On the other hand, the preoperative medication, midazolam, and the induction agent, propofol, had been the same, with approximately the same doses administered according to weight.
When Lynn had finished studying the record, she looked up at Michael, who was holding his camera out of sight of Peter and Dr. Erikson. He motioned to Lynn to hold up Morrison’s chart so that he could snap a picture of the anesthesia record without having to stand up. She did but in the process felt anxiously guilty. Michael took the picture and the camera disappeared in a flash.
Both Michael and Lynn glanced over at Peter and Dr. Erikson to see if either had noticed. They hadn’t. Lynn breathed a sigh of relief. Michael seemed immune.
“What do you make of the differences?” Michael asked.
“From my reading last night I know that recovery from desflurane is actually faster than from isoflurane, so that’s not significant. And an endotracheal tube is more secure than a laryngeal mask, so there is no problem there. And the use of a paralyzing agent shouldn’t be a problem as long as the patient is respired. I don’t find the differences significant.”
“Man, girl, you sure covered some ground with your reading last night.”
“It was a lot of hours,” Lynn said. At that point, she turned to the page in the chart that had the graph of Morrison’s vital signs, recorded since she had been brought to the neuro ICU. Lynn pointed to the tracing of body temperature that showed that Scarlett Morrison had had a significant spike in temperature the night after her surgery, just like Carl, reaching the same high point of 105º F. Although the temperature stayed elevated over Sunday and Monday, it had gradually fallen and was now at 100º F, which most people would consider mildly elevated.
“I’m amazed,” Lynn murmured. “So far the Morrison and Vandermeer cases seem clinically to be mirror images. Could that happen by chance?”
Michael shrugged. “And as far as I can remember, they are both similar to Ashanti’s. I’m pretty sure she had a fever, too. Do you think it could be some kind of new, unknown reaction to anesthesia that also causes a fever?”
“Who’s to know at this point,” Lynn replied. She turned to the blood work section. “Seems there was an increase in her white count to go along with the fever. That suggests an infection.”
Michael nodded. “But there isn’t an increase in neutrophils or a shift to the left.” Both medical students knew that in the face of an infection the body usually responded with an immediate increase of neutrophils, the body’s cellular defense against bacteria infection. A shift to the left indicated newly mobilized cells responding to an acute microbial attack.
“But look,” Lynn said, “the increase in the white count is with lymphocytes, not neutrophils. Doesn’t an increase in lymphocytes usually happen later in an infection as a hormonal immune response?”
“That’s the way it’s supposed to work.”
“And look, the lymphocyte count went up progressively with each passing day. What do you make of that?”
“I need to cheat,” Michael said. He pulled out his tablet and Googled meaning of increased lymphocytes. Thanks to the Internet, he had multiple results in a fraction of a second. He read the conditions out loud: “Leukemia, mono, HIV, CMV, other viruses, TB, multiple myeloma, vasculitis, and whooping cough.”
When Lynn didn’t respond to his list, Michael glanced at her. She was busy reading the results of the infectious disease consult. “No source of infection was found,” she said. “Chest was clear on X-ray, urine normal, no infection of the o
perative incisions, no nothing.”
“Did you hear the list of what causes an increase in lymphocytes?” Michael asked.
Lynn shook her head. “Sorry. Come again!”
Michael repeated the list. Lynn listened and thought for a moment. “Well, we can ignore most. I suppose ‘other viruses’ and ‘vasculitis’ are the most probable.”
“Yeah,” Michael agreed, “but doesn’t something jump out at you?”
“What do you mean?”
“Multiple myeloma causes an increase in lymphocytes. That caught my eye because of what I learned yesterday—that Ashanti has multiple myeloma. Maybe Morrison has it, too.”
“Now, that would be too much of a coincidence,” Lynn said. “I’ve never seen a case of multiple myeloma and don’t know much about it other than it involves too many plasma cells. Isn’t it rather rare?”
“If I remember correctly, it’s not that rare,” Michael said. “Of course everything is relative. I remember the one lecture in pathology that included multiple myeloma.”
“You remember the lecture we had in pathology about multiple myeloma?” Lynn questioned with a touch of dismay.
“I don’t remember a lot, and not much more than that it involves plasma cells, like you said. But I do remember that among the brothers it is one of the top ten causes of cancer death. Maybe that’s why I remember it. Anyway, of all the conditions that I just read that cause an increase in lymphocytes, I couldn’t help but notice it.”
“I wonder if it is because of the increase in lymphocytes that Dr. Erikson is seeing the patient,” Lynn questioned.
“Makes sense,” Michael agreed. “Do you think we should risk asking her?”
Lynn looked over at the attending, who was still bent over a chart, dictating a note most likely for the EMR. A few minutes earlier she had been writing a note. Until the hospital fully adopted the computerized record and gave up on the physical chart, consults had to do both and complained bitterly.
“I don’t think we dare,” Lynn said after a pause. “If we actually engage her in a conversation, she’s bound to ask us more details of why we are here. As you said, people are going to be sensitive about these cases.”
“Right on, girl!”
“Let’s see if she wrote a note in this chart. That could answer the question.”
Redirecting her attention to the chart in front of her, Lynn turned to the continuation notes, where progress reports were placed. The last note was from Dr. Erikson. The handwriting wasn’t good.
Thank you for asking me to see this patient again. As noted on my previous [illegible word], the patient has had a persistently elevated body temperature, although it has gradually subsided and is today at 100º F. Her blood count continues to show a moderate and [illegible word] lymphocytosis, currently at over 6,300 lymphocytes per mcl, representing 45 percent of the white count. I am pleased to see that no source of infection has been found. Total globulins are [illegible word] elevated. Protein electrophoresis shows a small and narrow gamma globulin spike, which suggests the [illegible word] of a developing monoclonal gammopathy (MGUS). However, I do not see this possibility or her persistent fever as contraindication for her scheduled transfer to the Shapiro Institute. I believe such a transfer will be in her best [illegible word], and I will continue to follow her. Dr. Siri [illegible word but presumably Erikson]
“What the fuck is a gammopathy or MGUS?” Michael asked with frustration. “I hate it when consults throw around these shit-ass esoteric words and acronyms to make you feel incompetent.”
“My turn to cheat,” Lynn said as she pulled out her tablet and Googled gammopathy. Although she didn’t know the exact meaning, she had a good idea. She selected the Wikipedia choice, and, placing her tablet on the desk, they both read the article titled “Monoclonal Gammopathy of Undetermined Significance.”
When Lynn was finished Michael asked: “What’s your take, besides knowing what MGUS stands for?”
“I’m so tired I’m having trouble thinking,” she confessed.
“It’s not surprising. You’re exhausted and you’re starving. Come on! Let’s go down and get you something to eat. You’re running on empty.”
“In a minute,” Lynn said, trying to rally herself. “At least I understood that MGUS involves a group of lymphocytes overproducing the same antibody. What surprises me is reading how prevalent it is, and I barely remember it even being mentioned in pathology.”
“But it is only prevalent in people over fifty. This patient is twenty-eight.”
“True,” Lynn said. “And I guess it’s not that serious.”
“It’s not serious unless it develops into multiple myeloma. It makes me wonder if Ashanti started out with this MGUS, which then led to the multiple myeloma.”
“I guess that is a possibility,” Lynn said. “Let’s look at the test Erikson mentions in her note: the protein electrophoresis. I know something about that from having used it to follow a patient with acute hepatitis last year in our medicine rotation.”
Lynn flipped back to the section of the chart for laboratory tests. It didn’t take her long to find the proper page with the results of the protein electrophoresis. The levels of the various plasma proteins were listed and also portrayed in a graphic schematic. She and Michael concentrated on the schematic. In the far right-hand portion where a smooth mound representing the gamma globulins was expected, there was a small, narrow peak at the mound’s crest.
“That’s easy to spot,” Michael said. “So the woman’s immune system is producing a specific antibody. What do you think is causing it?”
“Has to be an antigen of some kind. And maybe the antigen that stimulated the first lymphocyte to produce the specific immune globulin is still in Scarlett Morrison’s body, continuing to stimulate more and more antibodies. What do you think of that?”
“It’s definitely a possibility unless that first lymphocyte just went a little berserk, if you know what I am saying.”
“You mean, sorta like a cancer cell.”
“Something like that,” Michael said. “The cellular machinery to produce an antibody got turned on, and someone forgot to turn it off.”
“Going back to your question about whether the anesthesia could have caused the fever. Now the question is if the anesthesia could have turned on this monoclonal antibody?”
Michael stared at Lynn, understanding perfectly where she was coming from. She desperately needed an explanation for Carl’s sorry state and was willing to grasp at straws.
“I’m talking about some idiopathic reaction that has yet to be noticed.”
“No!” Michael said finally but firmly. “There’s nothing about anesthesia that could be antigenic. I’d like to say yes to get you off your collision course of thinking someone screwed up. But anesthesia agents have been used in too many people over too long a time for there to be an unrecognized immunological reaction that causes fever and monoclonal antibodies. Much less puts people into a coma. No way. Sorry, girl!”
“I knew you were going to say that.”
“I say it because it’s the truth. Now, let’s get down to the cafeteria. We have a dermatology lecture at nine.”
“I’m not finished,” Lynn said. She turned off her tablet and pocketed it. Next she turned to Morrison’s MRI. It was similar to Carl’s, showing extensive laminar necrosis. Closing the chart, Lynn looked over at Dr. Erikson, who was still alternatively writing a chart and dictating with her phone.
“I want to look at Carl’s chart again,” Lynn said impulsively, getting to her feet and picking up Scarlett Morrison’s chart in the process.
“But why?” Michael complained. He grabbed the arm of Lynn’s coat to restrain her. “Why risk it? Nothing will have changed.”
“We didn’t look at his blood work,” Lynn said, detaching her sleeve from Michael’s grasp. “And maybe she wrote some
thing in the chart. If she did, I’d like to see it.”
17.
Tuesday, April 7, 7:20 A.M.
Excuse me,” Lynn said as she came up to Dr. Erikson. She extended Morrison’s chart. “Thank you for calling our attention to this case. It is very similar to Vandermeer’s, and we should be following it for sure.”
The hematologist glanced up briefly.
“Should I put Morrison’s chart back in the rack or do you want it here with you?” Lynn asked.
Dr. Erikson pointed toward the desk next to her. “Here is fine,” she said distractedly without looking back up at Lynn.
“I hate to trouble you,” Lynn said, “but we would like to take another quick glance at Vandermeer’s. There’s something we missed.”
Dr. Erikson’s head popped up, and she regarded Lynn with icy blue eyes, and her nostrils flared. For a moment Lynn thought the woman was going to angrily deny her access to the chart. But then her expression softened.
“If it is a bother, we can come back later,” Lynn added quickly. Although she had not noticed it before, now that her attention had been drawn to the woman’s face, Lynn thought that the doctor did not look well. The paleness of her skin was striking, almost translucent, and her cheeks looked hollow. Beneath her eyes were purplish, dark circles. “I just thought you might be finished with it.”
“It’s not a bother,” Dr. Erikson said. She separated Carl’s chart from those in front of her and extended it toward Lynn, asking: “What year medical students are you two?”
“We’re fourth-year,” Lynn said. Her pulse quickened in anticipation of possible trouble. Now that she was close to the hematologist, she could see that the woman wasn’t exactly overweight, as she had thought earlier. It was more that her abdomen was distended, as if she might be four or five months pregnant, which seemed inappropriate, considering her age.
“And you are on a rotation in anesthesia?”