by Robin Cook
Michael nodded. The last thing he wanted to do was make Lynn more upset than she already was. Instead of arguing with her, he glanced down at the floor and picked up the nearest article. It was the article that he and Lynn had read in the neuro ICU after seeing the Morrison chart, the one titled “Monoclonal Gammopathy of Undetermined Significance.”
“So let me guess,” Michael said finally, as he quickly flipped through the printout for a second quick read. “You’re thinking that this paraprotein stuff has some significance.”
“I do!” Lynn said. “I have no idea how or why or anything. But it seems that a paraprotein was or is involved with all three patients. Well, we don’t know for sure if a paraprotein was involved with Ashanti, but the fact that she has multiple myeloma is at least suggestive. It’s the worst-case scenario for a paraprotein gammopathy.”
“Seems to me you are heading out into the stratosphere on all this, if you don’t mind my saying so,” Michael said. He shook his head as he reached down for another article. This one was titled “Monoclonal Antibodies.” He began to speed-read it.
“You might be right,” Lynn said. “But remember what you said was on the home page of Ashanti’s Shapiro EMR: drozitumab. Remember?”
“Of course I remember,” Michael said.
“Do you remember what drozitumab is?”
“Of course,” Michael repeated. He glanced irritably at Lynn. He was losing patience. She needed food, and she needed sleep. And he needed food, too. “What is this, a test?”
“Drozitumab is a monoclonal antibody, like you said this morning,” Lynn added, ignoring Michael’s mild peevishness. “It is used to treat a kind of muscle cancer, not multiple myeloma.”
“I said I remember,” Michael repeated.
“If Ashanti is given drozitumab and had a serum plasma protein test, it would show up as a paraprotein.”
“I suppose you are right. What’s your point?”
“I don’t know. I’m thinking out loud and asking you to do the same.”
Michael shook his head. “It’s a mystery. There are too many loose pieces.” He went back to reading the article on monoclonal antibodies.
“Why was drozitumab put on the front of Ashanti’s record?” Lynn asked.
“Like I said this morning, I have no idea. Do you?” Michael didn’t look up from his reading.
“No, I don’t,” Lynn admitted. “But if I had to guess, I’d say that maybe they are trying it as a treatment for multiple myeloma.”
Michael raised his eyes and looked at Lynn. “You mean like just trying it to see if it might work without any specific scientific rationale, sorta shotgun style? That’s questionable, my friend.”
“I know that doesn’t make any sense,” Lynn agreed. “Okay, scrap that idea! Maybe it is simpler. From reading these articles about monoclonal antibodies forming the basis of biologic drugs, I know they have been having some problems. Maybe they are giving Ashanti various forms of drozitumab to see which ones cause less of a reaction.”
“That sounds a lot more probable than the shotgun treatment idea. Of course it means they would be using her as a guinea pig. Do you really think that might be happening?”
“I’m suddenly thinking it is a possibility,” Lynn said.
“But it doesn’t explain the paraprotein problem.”
“I know. But maybe they want their immune systems stimulated for some reason. And Carl’s and Morrison’s immune systems are acting up, producing the paraprotein and their fevers. Their immune systems are acting as if they are being stimulated.”
“That’s all very hypertheoretical.”
“I know, but I’m convinced that something weird is going on. Maybe Sidereal Pharmaceuticals built Shapiro to use the patients for illicit clinical drug testing. It’s certainly a captive audience who wouldn’t complain. I mean, you have to admit, it makes diabolical sense. And if that’s what’s happening, it’s another reason I sure as hell don’t want Carl transferred there. Certainly not to be experimented on. No way!”
“God! That’s a creepy idea,” Michael said. The thought and implications raised a few hairs on his neck. “Do you really think that might be going on?”
Lynn shrugged. “I don’t know, but it’s an idea,” she said. “It would save time and money in drug development. Drozitumab is definitely a biologic, meaning made from living cells, and biologics are the newest and biggest thing in the pharmaceutical industry. And there is a race to perfect them and test them. And, in point of fact, biologics are Sidereal’s main product line!”
“No shit?” Michael said.
“Here, read this!” Lynn said as she picked an article off the bureau and handed it to Michael. It was titled “Biopharmaceutical.”
Michael took the article and began to speed-read it.
While Michael read, Lynn asked: “Do you remember exactly how monoclonal antibodies or biologics that drug companies sell are made?”
“Yeah! They’re made from mouse hybridomas. I just read it in the previous article. Also we had a lecture about it in second year. Why do you ask?”
“Because it’s the biggest reason that a lot of testing is needed,” Lynn said. “Since biologics are made from mouse cells, the drug companies have to humanize them to make them less allergenic for humans. That requires a lot of testing, particularly testing in humans. People in a vegetative state would be perfect subjects, especially if their immune systems were hyped up.”
“Wow!” Michael said, finishing the latest article. “I had no idea biologics are already a fifty-billion-dollar-a-year industry and climbing. I really had no idea.”
“It’s going to become really huge,” Lynn said. “It will top a hundred billion before long.”
“You really think so?”
“I do, and for two reasons. First, because biologics have a lot of promise to provide cures, as these articles say. Second, because drug companies here in the United States get to charge whatever the hell they please. It’s not like in the rest of the industrialized world, or should I say ‘civilized’ world.”
Michael nodded. “Which they are already doing with traditional drugs.” He picked up another article specifically about hybridomas.
“Exactly! And unfortunately it is not going to change with biologics, not with the money they throw around with their lobbyists.”
“You’re right about that,” Michael agreed. “By controlling Congress, drug companies in general are enjoying legalized robbery of the American public.”
“If Sidereal gets a jump in the biologics field by solving the allergy problem, they could dominate it and make an absolute fortune.”
Michael finished the fourth article and tossed it aside. “Okay, I suppose now I have an idea where you’re going with all this. Maybe a quick, undercover visit to the Shapiro might be just what the doctor ordered to see if they are using the patients as guinea pigs for biologics, not that I’m advocating it, mind you. I still think it is a crazy, risky idea. In the meantime, we got a more pressing problem. What to do about anesthesia machine thirty-seven? The Anesthesia Department should know about it if they don’t already. Actually, the more I think about it, the more I’m sure they already know. It’s too obvious to miss.”
“I agree,” Lynn said. “They have to know. Nor can there be anything wrong with the machine.” Lynn pointed back at the anesthesia records on her desk. “Look how the patients’ vital signs stayed completely normal in all three cases after the frame offset right up until the oxygen level fell! Same with all the other variables the machine was monitoring. Obviously the patients’ depth of anesthesia didn’t change. And remember: Wykoff specifically said she checked the anesthesia machine before Carl’s case and after.”
For a few minutes the two friends looked at the records and didn’t speak. Each tried to decide what it all meant.
“If we go to Rhod
es with any of this he’s going to see red all over again,” Lynn said. “And he’ll want to know how we discovered it. What could we say without implicating ourselves in having violated HIPAA? After his reaction to our just talking with Dr. Wykoff, I think he’d go apeshit if he knew we had these anesthesia records. We can’t go to him until we know a lot more.”
“I hear you,” Michael said.
“Listen,” Lynn said. “How about texting your buddy Vladimir to see if you can get him to come over this evening. I want to move forward.”
“You’re serious about all this?”
“Very serious,” Lynn said. “Thinking about Carl possibly going in there without knowing what might happen to him is driving me crazy. I need a Shapiro outfit and his thumbprint.”
“I hope I don’t regret this,” Michael said as he got out his phone. Quickly he texted an invite for Vladimir to come over to his room for an impromptu Jay-Z party and a beer. With a flourish, he sent the message.
“Now, let’s see his user name and password,” Lynn said, getting out her own phone and preparing to add Vladimir to her contacts. Michael saluted before dutifully handing his phone over to Lynn with the information displayed. While she was busy adding the data into her phone, Michael’s phone chimed. A text came back from Vladimir accepting the invite and saying he would be bringing the Russian souvenir he had promised for Michael.
“Satisfied?” Michael asked.
“No,” Lynn said. “Text him back about the Shapiro scrubs.”
“Shit, girl!” Michael complained but did as she said. As an explanation for the request he used Lynn’s earlier suggestion, saying he and his girlfriend were going to a costume party. He pushed the SEND button, and then held the phone so Lynn could see it.
A minute stretched into another. Then a second text popped onto Michael’s screen: I stop and get outfits. Maybe I a little late. No problem.
“Seems that my Russian buddy is going to come through,” Michael said. “Now let’s go get some dinner.”
“Sounds like a plan,” Lynn said. “But I need to take a quick shower.” Without waiting for a response she went into her bathroom and closed the door.
“While we are over there, let’s go up to the OR and see if we can find number thirty-seven,” Michael shouted through the door.
“Finding it might not be so easy. With twenty-four ORs, there must be fifty or more machines.”
“Probably more, but no matter. We know number thirty-seven was used on Monday in OR Twelve. It could be still in there. Usually this time of day the OR is quiet. If it is not in twelve, we could check the storage room they use to keep the extra machines.”
“If we do find it, what would we do with it?”
“That’s a good question.” Michael shrugged. “I guess I’d like to find out if it has been used since Carl’s case. If so, and there hasn’t been any problem, I’ll sleep better.”
“I hear you,” Lynn yelled. “I’ll go with you up to the OR if you come with me to the neuro ICU and IT.”
“You got a deal,” Michael said. “But first I’m going to my pad and clean up, too.”
“Good idea. I’ll meet you downstairs.”
30.
Tuesday, April 7, 6:31 P.M.
Sandra Wykoff logged out. She’d been on one of the computer terminals in the OR anesthesia office for over an hour. She was perplexed. She had no idea what to make of what she had just learned, but she felt it had to mean something—but what?
After she had left Clinical Engineering she’d been paged by Geraldine Montgomery and asked if she could do an emergency case: an open reduction of a compound fracture in a teenage boy’s forearm. She had welcomed the diversion, and the case had gone well.
During the middle of the short case, when she had been on cruise control, she’d thought more about Vandermeer, Morrison, and Davis. After the surgery, she’d gone into the Anesthesia office and logged onto the computer to go over Morrison’s and Davis’s anesthesia records with the same attention to detail that she had given to Vandermeer’s in hopes of finding any similarities above and beyond the same anesthesia machine. For more than an hour nothing had caught her attention. Then suddenly she’d seen it: all three cases had the blip, or frame offset, and, more disturbing, all had it at exactly the same time after induction!
Staring off into the middle distance, Sandra wondered if such a finding could be significant. She couldn’t help but believe it had to be on some level. Why was the anesthesia machine doing it despite the machine’s being checked after each episode? Could it be a program error despite what she had been told down in Clinical Engineering? She doubted it, as it wasn’t happening with any of the other machines. She had already checked by examining the printouts of other cases she had done using different machines. There hadn’t been any frame offsets on any of the cases she’d looked at. She’d even found a few records from machine 37. They were all clean. The frame offsets had occurred with only the three cases of delayed return of consciousness.
With sudden resolve, Sandra stood up from the desk. She hurried back to the changing room to get out of her scrubs. Once she had her clothes on, she went down to the administrative area of the hospital. What she had in mind was to see if Benton Rhodes had left for the day. If he hadn’t, she wanted to show him this new finding. But his office was empty.
For a moment Sandra debated having the hospital operator contact Dr. Rhodes. But then she had second thoughts, considering the harangue she’d endured earlier. What she didn’t know was whether her boss was aware of this time similarity. It was entirely possible, and if he was, her bothering him after hours was probably not the best idea. It was common knowledge the chief didn’t like to be disturbed at home unless absolutely necessary.
“Tomorrow is time enough,” Sandra said under her breath.
Retracing her steps back into the hospital proper, she headed for the garage. She was looking forward to getting home to unwind with a glass of wine. She still felt unnerved, guilty to a degree, and generally out of sorts from yesterday’s disaster. Would she ever completely get over it? The run-in with Dr. Rhodes hadn’t helped. Nor had Vandermeer’s continuing coma. She’d always thought that conscientiousness, meaning close attention to detail and no shortcuts, would shield her from such an experience. Obviously she had been wrong.
From the bustling first floor of the medical center, Sandra exited out into the quiet parking facility. During the hospital shift change around three in the afternoon the garage was a beehive of activity. Then between five and six there was another burst of activity, although not as intense. By six o’clock, activity fell off precipitously, only to recommence around eight, when visiting hours ended and then again around eleven, when the night staff came to replace the evening shift.
As Sandra walked to her car in the silence of the deserted garage, she was aware of the sharp clicking sound her heels made as they echoed off the concrete. It was an unsettling reminder that she was alone. She glanced around as she walked in hopes of seeing someone, but she didn’t. She had always found garages after hours to be intimidating. To rein in her imagination she forced herself to think about getting home and taking a hot bath. As she pressed her comfort access key to open her BMW’s doors, she wondered about the best way to tell Rhodes of her new finding without aggravating him. As the department head whose job it was to review all three cases, it was probably something he should have seen. If he hadn’t, she vaguely worried with his irascibility whether he might take the possible oversight personally and blame the messenger.
Sandra climbed into the driver’s seat, pulled the door closed, and reached over her shoulder for her seat belt. At the same time her right foot depressed the brake pedal in anticipation of starting the engine. It was all by reflex. She’d done it a million times. But she didn’t get the seat belt. Instead her heart leaped into her throat, as the passenger-side front door and driver’s-
side rear door were both suddenly yanked open. A fraction of a second later two large men in dark business suits leaped into the car in a flurry of activity.
Sandra started to scream in shocked terror, but it never got out. A gloved hand had come around from behind and clasped itself over the lower part of her face, suppressing what would have been a piercing cry. What came out was a muffled gurgle. At the same time and by the same hand her head was roughly compressed back against the headrest. Simultaneously the man in the front passenger seat thrust a needle into her thigh and injected its contents. It was over in a second.
Unable to breathe, Sandra reached up and desperately tried to pull the hand away from her face. She couldn’t. The man was too strong. The next instant, the man beside her snatched the electronic key from her hand and started the car. A moment later the image of the parking garage through the windshield blurred and dimmed. Then her body went limp.
• • •
To Darko Lebedev’s delight he had gotten the call from Misha Zotov just before three P.M. giving him and Leonid Shubin their orders. After such a long down period with no action whatsoever, there were two new jobs to be done, and one was to be the second hit in so many days. The second was to be merely a strong warning for a female medical student to mend her ways, or at least those had been Misha’s words. Darko understood, and he couldn’t have been more pleased with both assignments. He knew Leonid would feel the same.