by Robin Cook
Werner shook his head.
“We’ll see,” said Philips. He walked out of the refrigerator, leaving the gurney for Werner to deal with. The diener waited until he heard the outer doors close. Then he grabbed the cart and gave it a powerful shove. It shot out of the refrigerator, sped halfway across the morgue, and crashed into the corner of the marble autopsy table, tipping over with a tremendous clatter. The IV bottle smashed into a million shards.
Dr. Wayne Thomas leaned against the wall, his arms folded across his chest. Lynn Anne Lucas was sitting on the old examining table. Their eyes were on the same level; his, alert and contemplative; hers, drained and exhausted.
“What about this recent urinary infection?” said Dr. Thomas. “It cleared up on the sulfa drugs. Is there anything else about that illness that you haven’t mentioned?”
“No,” said Lynn Anne, slowly, “except they did send me to a urologist. He told me that I had a problem of too much urine being in my bladder after I’d gone to the bathroom. He told me to see a neurologist.”
“Did you?”
“No. The problem cleared up on its own, so I didn’t think it mattered.”
The curtain parted and Dr. Sanger poked her head in.
“Excuse me. Someone called for a consult on a skull film.”
Thomas pushed off from the wall, saying he’d just be a minute. As they walked back to the lounge he gave Denise a thumbnail sketch of Lynn Anne’s case. He told her that he thought the X ray was normal but wanted confirmation about the pituitary area.
“What’s the diagnosis?” asked Denise.
“That’s the problem,” said Thomas opening the door to the lounge. “The poor thing has been here for five hours, but I can’t put it all together. I thought maybe she was a druggie but she’s not. She doesn’t even smoke grass.”
Thomas snapped the film up on the viewer. Denise scanned it in an orderly fashion, starting with the bones.
“I’ve been getting some crap from the rest of the ER staff,” Thomas said. “They think I’m interested in the case because the patient is a piece of ass.”
Denise broke off from studying the X ray to eye Thomas sharply.
“But that’s not it,” said Thomas. “There’s something wrong with this girl’s brain. And whatever it is, it’s widespread.”
Sanger redirected her attention to the film. The bony structure was normal, including the pituitary area. She looked at the vague shadows within the skull. For orientation purposes she checked to see if the pineal gland was calcified. It wasn’t. She was about to declare the film normal when she perceived a very slight variation in texture. Forming a small open area with her two hands, she studied the particular section of the film. It was a trick similar to the one she saw Philips do with the hole in the paper. Taking her hands away she was convinced! She’d found another example of the density change Martin had shown to her earlier on Lisa Marino’s film.
“I want someone else to see this film,” said Denise, pulling it from the viewer.
“You find something?” asked Thomas, encouraged.
“I think so. Keep the patient here until I get back.” Denise was gone before Thomas could reply.
Two minutes later she was in Martin’s office.
“Are you sure?” he asked.
“I’m pretty sure.” She handed the film to him.
Martin took the X ray but didn’t put it up immediately. He fingered it, afraid he would be faced with another disappointment.
“Come on,” said Denise. She was eager to have her suspicions confirmed.
The X ray slid under the clips. The light in the viewer blinked, then came on. Philips’ trained eye traced an erratic path over the appropriate area. “I think you’re right,” he said. Using the piece of paper with the hole in it, he examined the X ray more closely. There was no doubt that the same abnormal density pattern he’d seen on Lisa Marino’s X ray existed on this film. The difference was that on the new one it was less pronounced and not so extensive.
Trying to control his excitement, Martin switched on Michaels’ computor. He keyed in the name. Turning to Denise, he asked what the patient’s present complaint was. Denise told him it was difficulty in reading associated with blackout spells. Philips entered the information, then stepped over to the laser reader. When the little red light came on, he pushed in the edge of the film. The output typewriter snapped into action. Thank you, it said. Take a Nap!
While they waited, Denise told Martin what else she’d learned about Lynn Anne Lucas, but he was most excited about the fact that the patient was alive and in the emergency room.
As soon as the typewriter ceased its rapid staccato, Philips tore off the report. He read it with Denise looking over his shoulder.
“Amazing!” said Philips when he’d finished. “The computor certainly agrees with your impression. And it remembered that it had seen the same density pattern on Lisa Marino’s X ray, and on top of that it asks me to tell it what this density variation is! This thing is God-damn amazing. It wants to learn! It’s so human it scares me. The next thing I know is that it will want to get married to the CAT scan computer and take the whole summer off.”
“Married?” said Sanger, laughing.
Martin waved her off. “Administrative worries. Don’t get me started! Let’s get this Lynn Anne Lucas up here and do the CAT scan and X rays I couldn’t do on Lisa Marino.”
“You realize it is a bit late. The CAT scan technician closes the unit down at ten and leaves. We’d have to call him in. Are you sure you want to do all this tonight?”
Philips looked at his watch. It was ten-thirty. “You’re right. But I don’t want to lose this patient. I’m going to see that she’s admitted at least for the night.”
Denise accompanied Martin back down to the ER, leading him directly into one of the large treatment rooms. She motioned for him toward the right corner, and pulled back a curtain separating a small examining area. Lynn Anne Lucas looked up with bloodshot eyes. She’d been sitting next to the table, leaning on it, with her head on her arm.
Before Denise could introduce Philips, her beeper went off and she left Martin to talk with Lynn Anne by himself. It was immediately apparent to him that the woman was exhausted. He smiled at her warmly, then asked if she would mind staying overnight so that they could get some special X rays in the morning. Lynn Anne told him she didn’t care, so long as she was taken out of the emergency room and could go to sleep. Philips gave her arm a gentle squeeze. He told her he’d arrange it.
At the main desk, Philips had to act like he was in a bargain basement, pushing, yelling and even hitting the countertop with an open palm to get the attention of one of the harried clerks. He asked about Lynn Anne Lucas, wanting to know who was in charge of the patient. The clerk checked the main roster and told him it was Dr. Wayne Thomas, who was currently down in room 7 with a stroke.
When Philips walked in he found himself in the middle of a cardiac arrest. The patient was an obese man who draped over the examining table like a huge pancake. A bearded black fellow, who Philips soon learned was Dr. Thomas, was standing on a chair giving the patient cardiac massage. With each compression Dr. Thomas’ hands disappeared into folds of flesh. On the other side of the patient, a resident was holding defibrillator paddles while he watched the tracing on the cardiac monitor. At the patient’s head, an anesthetist was ventilating him with an ambu bag, coordinating her efforts with Dr. Thomas.
“Hold up,” said the resident with the defibrillator.
Everyone backed up while he positioned the paddles over the conductive grease on the patient’s ill-defined thorax. When he compressed the button on top of the anterior chest lead, a surge of current raced through the patient’s chest, spreading electrical havoc. The patient’s extremities fluttered ineffectually like a fat chicken trying to fly.
The anesthetist immediately recommenced respiratory assistance. The monitor readjusted itself and a slow but regular tracing appeared.
“I got a good carotid pulse,” said the anesthetist with her hand pressing on the side of the patient’s neck.
“Good,” said the resident with the defibrillator. He hadn’t taken his eyes from the monitor, and when the first ectopic ventricular spike occurred, he ordered “seventy-five milligrams of Lidocaine.”
Philips walked over to Thomas and got his attention by tapping his leg. The resident climbed down from his chair and stepped back, although he kept an eye on the table.
“Your patient, Lynn Anne Lucas,” said Philips. “She has some interesting X-ray findings in her occipital area extending foward.”
“I’m glad you found something. My intuition has been telling me there’s something wrong with the girl but I don’t know what it is.”
“I can’t help with the diagnosis yet,” said Philips. “What I’d like to do is take more films tomorrow. How about admitting her for the night.”
“Sure,” said Thomas. “I’d love to but I’m going to take a lot of flak from the boys if I don’t have even a provisional diagnosis.”
“How about multiple sclerosis?”
Thomas stroked his beard. “Multiple sclerosis. That’s a little out on a limb.”
“Is there any reason it couldn’t be multiple sclerosis?”
“No,” said Thomas. “But there isn’t much reason to suggest it either.”
“How about very early in its course.”
“Possibly, but multiple sclerosis is usually diagnosed later when its characteristic pattern becomes apparent.”
“That’s just the point. We’re suggesting the diagnosis earlier rather than later.”
“All right,” said Thomas, “but I’m going to specifically say in my admitting note that Radiology suggested that diagnosis.”
“Be my guest,” said Philips. “Just be sure to write on the order sheet that CAT scan and polytomography are to be done tomorrow. I’ll take care of scheduling it from Radiology.”
Back at the desk Philips endured the crowd long enough to obtain Lynn Anne Lucas’s emergency room chart and hospital record. He took both into the deserted lounge and sat down.
First he read Dr. Huggens’ and Dr. Thomas’ workups. There was nothing exciting. Next he looked at the chart. By the color coding on the edge of the pages, he noticed there was a radiology report. He opened the chart to that page, which described a skull X ray at age eleven secondary to a roller-skating mishap. The X ray had been read by a resident Philips knew. He’d been several years behind Philips and now was in Houston. The X ray was described as normal.
Working backward through the chart, Philips read entries over the last two years related to upper respiratory infections treated at the dispensary on campus. He also glanced over a series of GYN clinic visits where mildly atypical Pap smears had been noted. Philips had to admit to himself that the information was not so informative as it should have been because of the embarrassing amount of general medicine he’d forgotten since his house staff days. From 1969 to 1970 there were no entries on the chart.
Philips returned the chart to the ER desk before starting back to his office. He took the stairs by twos, his energy level spurred by a wonderful sense of investigative excitement. After the disappointment with Marino, the discovery of Lucas was that much more titillating. Back in his office, he pulled down the dusty internal medicine textbook and looked up multiple sclerosis.
As he had remembered, the diagnosis of the disease was circumstantial. There was no consistent laboratory aid save for autopsy. The obvious and immense value of a radiological diagnosis again occurred to Philips. He read on, noticing that the classic features of the disease included abnormalities in vision as well as bladder dysfunction. After reading the first two sentences of the next paragraph, Philips stopped. He went back and read them aloud:
Diagnosis may be uncertain in the early years of the disease. Long latent periods between a minor initial symptom, which may not even come to medical attention, and the subsequent development of more characteristic ones may delay the final diagnosis.
Philips grabbed the phone and punched out Michaels’ home number. With a sensitive radiological diagnosis, delay of the final diagnosis would be avoided.
It was only after the phone had already started to ring that Martin glanced at his watch. He was shocked to realize it was after eleven. At that moment Michaels’ wife, Eleanor, whom Philips had never met, answered the phone. Philips immediately launched into a lengthy apology for calling so late although she did not sound as if she’d been asleep. Eleanor assured him that they never retired before midnight and put her husband on the line.
Michaels laughed at what he called Philips’ adolescent enthusiasm, when he learned that Martin was still in his office.
“I’ve been busy,” explained Philips. “I’ve had a cup of coffee, something to eat, and taken a nap.”
“Don’t let everybody see those printouts,” said Michaels, laughing anew. “I programmed some obscene suggestions as well.”
Philips went on to tell Michaels excitedly that the reason he was calling was that he’d found another patient in the ER, named Lynn Anne Lucas, who had the same abnormal density pattern he’d seen on the Marino film. He told Michaels that he had not been able to follow up on Marino, but was going to get definitive films in the morning. He added that the computer had actually asked him to tell it what the abnormal density changes were. “The Goddamn thing wants to learn!”
“Remember,” said Michaels, “the program approaches radiology the same way you do. It’s your techniques that it utilizes.”
“Yeah, but it’s already better than me. It picked up this density variation when I didn’t see it. If it uses my techniques, how do you explain that?”
“Easy. Remember, the computer digitizes the image into a two-hundred-fifty-six by two-hundred-fifty-six grid of pixel points with gray values between zero and two hundred. When we tested you, you only could differentiate gray values of zero to fifty. Obviously the machine is more sensitive.”
“I’m sorry I asked,” said Philips.
“Have you run the program against any old skull X rays?”
“No,” admitted Philips, “I’m about to start.”
“Well, you don’t have to do everything in one night. Einstein didn’t. Why not wait until morning?”
“Shut up,” said Philips good-naturedly and hung up.
Armed with Lynn Anne Lucas’s hospital number, Philips found her X ray file with relative ease. It contained only two recent chest films and the skull series taken after the roller-skating accident when she was eleven. He put one of the old lateral skull films up on the viewer next to the X ray taken that evening. Comparing them, Philips ascertained that the abnormal density had developed since age eleven. To be perfectly certain, Philips fed one of the older films into the computer. It concurred.
Philips put Lynn Anne’s old X rays back into the envelope and put the new ones on top. Then he put the package on his desk, where he knew Helen wouldn’t touch it. Until Lynn Anne had her new studies, there was nothing else to be done on her case.
Martin wondered what he should do. Despite the hour he knew he was still too excited to sleep and besides he wanted to wait for Denise. He was hoping she’d come by his office when she finished whatever she was doing. He thought about paging her, but then thought better of it.
He decided to pass the time by getting some old skull X rays from the file room. He thought he might as well start the process of checking the computer program. In case Denise came back before he did he left a note for her on the door. “I’m in Central Radiology.”
At one of the terminals of the hospital’s central computer he painfully typed out what he wanted: a printout of the names and unit numbers of all patients having had skull X rays in the last ten years. When he was finished he pushed the “enter” button and swung around in the chair to face the output printer. There was a short delay. Then the machine spewed out paper at an alarming rate. When it finally stopped, Philips f
ound himself holding a list of thousands of names. Just looking at it made him feel tired.
Undaunted, he sought out Randy Jacobs, one of the department’s evening employees, hired to file the day’s X rays and pull the films needed for the following day. He was a full-time pharmacy student, a talented flautist, and an out-of-the-closet gay. Martin found him sharp-witted, ebullient, and a fabulous worker.
To start, Martin asked Randy to pull the X rays on the first page of the list. That represented about sixty patients. With his usual efficiency, Randy had twenty lateral skull films on Philips’ alternator in as many minutes. But Philips did not run the films on the computer as Michaels had asked. Instead he began to examine them closely, unable to resist the temptation to look for more of the abnormal densities he had discovered on Marino and Lucas’s X rays. Using his paper with the hole as a screening device, he began to go from one film to another, advancing the viewing screens as needed by depressing the electrical lever with his foot. He’d processed about half of the X rays when Denise arrived.
“All your big talk about wanting to leave clinical radiology and you’re looking at X rays when it’s almost midnight.”
“It is a bit silly,” said Martin, leaning back in his chair and rubbing his eyes with his knuckles, “but I had these old films pulled and I thought I’d check to see if I could find another case like Lucas or Marino.”
Denise came up behind him and rubbed his neck. His face looked tired.
“Have you found any?” she asked.
“No,” said Philips. “But I’ve only looked at a dozen or so films.”
“Have you narrowed down your field?”
“What do you mean?”
“Well, you’ve seen two cases. Both are recent, both are women, and both are about twenty.”
Philips looked at the row of films in front of him and grunted. It was his way of acknowledging that Denise had a good point without saying so. He wondered why he hadn’t thought of it himself.
She followed him back to the main computer terminal maintaining a steady stream of commentary about the busy evening in the ER. Philips listened with half an ear while he made his entry. He asked for the names and unit numbers of female patients, aged fifteen to twenty-five, who’d had skull films within the last two years. When the output printer came alive it only typed one line. It told Philips that the data bank was not keyed to retrieve skull films by sex. Philips adjusted his demand on the keyboard. When the printer reactivated, it typed at a vicious rate, but only for a short interval. The list comprised only a hundred and three patients. A quick scan suggested that somewhat less than half were female.