“You’re too far away,” he said.
“It’s right here, right in front of you. Come on, try and touch it.”
He raised his arm. It wobbled in midair, like a dancing cobra.
The phone rang. Maudeen reached for the receiver.
Angus Parmenter’s arm began to twitch, a violently rhythmic shaking that rattled the gurney.
“What’s he doing?” said Val. “Is he having a seizure?”
“Angus!” Toby grasped the man’s face and stared straight at him. He wasn’t looking at her; he was gazing at his own arm.
“Can you talk, Angus?”
“There it goes again,” he said.
“What? You mean the shaking?”
“That hand—whose hand is that?”
“It’s your hand.”
The shaking suddenly ceased. The arm flopped down like a deadweight onto the gurney. Angus closed his eyes. “There now,” he said. “All better.”
“Toby?” It was Maudeen, turning from the telephone. “There’s a Dr. Wallenberg on the line. He wants to talk to you.”
Toby took the receiver. “Dr. Wallenberg? This is Toby Harper. I’m the ER doctor on duty tonight.”
“You have my patient there.”
“You mean Mr. Parmenter?”
“I just got beeped about the ambulance transfer. What happened?”
“He was found confused at home. Right now he’s awake and the vitals are stable. But he’s got ataxia, and he’s disoriented times three. He doesn’t even recognize his own daughter.”
“How long has he been there?”
“The ambulance brought him in around nine.”
Wallenberg was silent for a moment. In the background, Toby heard the sound of laughter and voices. A party.
“I’ll be there in an hour. Just keep him stable till I arrive.”
“Dr. Wallenberg—”
The line had already gone dead.
She turned to the patient. He was lying very still, his eyes focused intently on the ceiling. Now his gaze shifted, first right, then left, as though he were watching a slow-motion tennis match.
“Let’s get this man a STAT CT scan,” said Toby. “And we’ll need some bloods drawn.”
Val pulled a fistful of glass tubes out of the drawer. “The usual? CBC and SMA?”
“Add a drug screen. He seems to be hallucinating.”
“I’ll call X-ray,” said Maudeen, reaching once again for the phone.
“Ladies,” said Toby. “One more thing.”
Both nurses looked at her.
“Whatever happens tonight, we’re not going to leave this guy alone, not for a second. Not till he’s transferred out of our ER.”
Val and Maudeen nodded.
Toby took hold of Angus Parmenter’s unrestrained hand and tied it firmly to the gurney siderail.
“Here come the cuts,” said the CT tech.
Toby stared at the computer screen as the pixels formed the first image, an oval with different shades of gray. She was looking at a cross section of Angus Parmenter’s brain. Thousands of X-ray beams directed at his cranium had been analyzed by computer, and the different densities of bone and fluid and brain matter had produced this image. The skull appeared as a thick white rim, like the rind of a fruit. Inside the rind, the brain showed up as grayish pulp, indented by black wormlike sulci.
A succession of images materialized on the screen, each one a slightly different cut of the patient’s cranium. She saw the anterior horns, two black ovals filled with cerebrospinal fluid. The caudate nuclei. The thalamus. There appeared to be no anatomical shifts, no asymmetry. No evidence of blood leakage into any part of the brain.
“I don’t see anything acute,” Toby said. “What do you think?”
Vince was not a physician, but he’d seen far more CT scans as an X-ray tech than Toby had. He frowned at the screen as a fresh cut appeared. “Wait,” he said. “That shot looks a little funny.”
“What?”
“Right there.” He pointed to a smudge at the center. “That’s the sella turcica. See how it’s not very clearly demarcated on this edge?”
“Could it be patient movement?”
“No, the rest of the shot’s perfectly clean. He didn’t move.” Vince picked up the phone and dialed the radiologist at home. “Hi, Dr. Ritter? Are the cuts coming across okay on your computer? Great. Dr. Harper and I are looking at them right now. We’re wondering about that last cut”—he typed on the keyboard, and the image reverted back to the previous screen—“that slice right there, see it? What do you think about the sella turcica?”
As Vince conferred with Dr. Ritter, Toby bent closer to the screen. What Vince had spotted was a very subtle change— so subtle she herself would have missed it. The sella turcica was a tiny pocket of thin bone housing the pituitary gland at the base of the brain. The gland itself was vital; the hormones it produced controlled a wide variety of functions, from fertility to childhood growth to the daily sleep-wake cycle. Could that tiny erosion of the sella turcica be the cause of the patient’s symptoms?
“Okay, I’ll do the coronal thin slices,” said Vince. “Anything else you want me to do?”
“Let me talk to Ritter,” said Toby. She took the receiver. “Hi, George, this is Toby. What do you think about that sella?”
“Not much,” said Ritter. She heard the squeak of his chair—probably leather. George Ritter liked his luxuries. She could imagine him ensconced in his study, surrounded by the latest in computer technology. “In a man this age, pituitary adenomas aren’t uncommon. Twenty percent of eighty-year-olds have them.”
“Big enough to erode the sella?”
“Well, no. This one’s gotten a little large. What’s his endocrine status?”
“I haven’t checked it. He just came in the ER with acute confusion. Could this be the cause?”
“Not unless the adenoma’s produced a secondary metabolic abnormality. Have you checked the electrolytes?”
“They’ve been drawn. We’re waiting for results.”
“If those are normal, and the endocrine status is okay, I think you’re going to have to look for some other reason for his confusion. This is too small a tumor to exert much anatomical pressure. I’ve asked Vince to do some thin-slice cuts on the coronal plane. That should define it a little better. You’ll probably want to send the patient out for an MRI, too. Who’s admitting him?”
“Dr. Wallenberg.”
There was a silence. “This is a Brant Hill patient?”
“Yes.”
Ritter gave an irritated sigh. “I wish you’d told me this earlier.”
“Why?”
“I don’t read X rays on Brant Hill patients. They use their own radiologist to interpret all their films. Which means I won’t get paid for this.”
“I’m sorry, I didn’t know that. Since when did this arrangement start?”
“Springer signed a subcontract agreement with them a month ago. Their patients aren’t supposed to go through the ER. The Brant Hill docs admit directly to the wards. How did this patient end up with you?”
“The daughter panicked and called nine one one. Wallenberg’s on his way in now.”
“Okay. Then let Wallenberg decide what to do about the coronal slices. I’m going to bed.”
Toby hung up and looked at Vince. “Why didn’t you tell me Brant Hill had a closed referral system?”
Vince gave her a sheepish look. “You didn’t tell me this was a Brant Hill patient.”
“Don’t they trust our radiology staff?”
“Our hospital techs shoot the films, but the Brant Hill radiologist interprets them. I guess they’re trying to keep the professional fees within their group.”
Hospital politics again, she thought. Everyone fighting for the same shrinking health care dollar.
She rose and looked through the viewing window into the CT scan room. The patient was still lying on the table, his eyes closed, his lips moving silently. The twitchi
ng of his right hand had not recurred. Nevertheless, he would need an EEG to rule out seizures. And probably a lumbar puncture. Wearily she leaned against the glass, trying to think of what she might have missed, what she could not afford to miss.
Ever since Harry Slotkin had vanished from her ER two weeks ago, she knew her performance was under scrutiny by the hospital board, and she had been even more compulsively thorough than usual. Every afternoon, she’d wake up wondering if this was the day they’d find Harry Slotkin’s body, if this was the day her name would once again be thrust into the public eye. The initial news coverage had been painful enough. The week of Harry’s disappearance, the tale of the missing patient had aired on all the local television stations. She’d managed to ride out that storm, and now it was old news, probably forgotten by the general public. But the minute they find Harry’s body, she thought, it will once again be a hot story. And I’ll be in the hot seat, battling both lawyers and reporters.
Behind her, a door opened and a voice said: “Is that my patient on the table?”
Toby turned and was startled to see a strikingly tall man in a tuxedo. He glanced at Vince, his gaze quickly taking in the CT tech, and just as quickly dismissing him. Then he strode to the viewing window and stared through the glass at Angus Parmenter. “I didn’t ask for a CT. Who ordered it?”
“I did,” said Toby.
Now Wallenberg focused on her, as though finally realizing she was worth his attention. He was no older than forty, yet he regarded her with an expression of clear superiority. Perhaps it was the tuxedo; a man who looked as if he’d stepped off the pages of GQ had every reason to feel superior. He reminded Toby of a young lion, his brown hair perfectly clipped and swept back like a mane, his eyes like amber, alert and not particularly friendly. “Are you Dr. Harper?”
“Yes. I wanted to save you some time on the workup. I thought I’d order the CT.”
“Next time, let me order my own tests.”
“But it seemed more efficient to get it done now.”
The amber eyes narrowed. He seemed about to make a retort, then thought better of it. Instead he simply nodded and turned to Vince. “Please get my patient back on the gurney. He’s being admitted to the third floor, medical wing.” He started to leave the room.
“Dr. Wallenberg,” said Toby. “Did you want to hear the results of your patient’s CT scan?”
“Was there anything to report?”
“A small erosion of the sella turcica. It appears he has a pituitary adenoma growing.”
“Was there anything else?”
“No, but you’ll probably want to order thin-slice tomography. Since he’s already lying on the CT table—”
“It won’t be necessary. Just get him upstairs and I’ll write the admitting orders.”
“What about the lesion? I know the adenoma’s not an emergency, but it may require surgical removal.”
With a sigh of impatience he turned to face her. “I am fully aware of the adenoma. Dr. Harper. I’ve been following it for two years now. Thin-slice tomography would be a waste of money. But thank you for your suggestion.” He walked out of the room.
“Geez,” muttered Vince. “Who shoved the pole up his ass?”
Toby looked through the viewing window at Angus Parmenter, who was still babbling quietly to himself. She didn’t agree with Wallenberg; she thought further X-ray studies were indicated. But the patient was no longer her responsibility.
She looked at Vince. “Come on. Let’s get him on the gurney.”
7
The sign on the door was stenciled in soft blue on gray: PRENATAL COUNSELING. Molly could hear the sound of a telephone ringing in the room beyond, and she hesitated in the hallway, her hand clutching the knob as she listened to the faint murmur of a woman’s voice beyond the closed door.
She took a breath and walked in.
The receptionist didn’t see her at first; she was too busy talking on the phone. Afraid to interrupt this very busy woman, Molly stood on the other side of the desk, waiting to be noticed. At last the receptionist hung up and looked at her. “Can I help you?”
“Um, I’m supposed to talk to someone. . .”
“Are you Molly Picker?”
“Yeah.” Molly gave a relieved nod. They were expecting her. “That’s me.”
The receptionist smiled, the sort of smile that starts off at the mouth, but then gets no further. “I’m Linda. We spoke on the phone. Why don’t we go in the other room?”
Molly glanced around the reception area. “Am I gonna see a nurse or something? ’Cause maybe I’m s’posed to pee first.”
“No, today we’re just going to talk, Molly. The rest room’s out in the hall if you need to use it right away.”
“I guess I can wait.”
She followed the woman into the adjoining room. It was a small office with a desk and two chairs. On one wall was a giant poster of a pregnant woman’s belly, drawn as if that belly were sliced right down the middle, so you could see the baby resting inside, its chubby little arms and legs curled up, its eyes closed in sleep. On the desk was a plastic model of a pregnant womb, a 3-D puzzle that could be taken apart layer by layer, belly, womb, and then baby. There was also a big picture book open to a drawing of an empty baby stroller, which seemed like a strange image to display.
“Why don’t you have a seat?” Linda said. “Would you like a cup of tea? A glass of apple juice?”
“No, Ma’am.”
“Are you sure? It’s really no trouble.”
“I’m not thirsty, thank you, Ma’am.”
Linda sat down across from Molly so that the two of them were looking directly at each other. The woman’s smile had changed to an expression of concern. She had light blue eyes that, with a little makeup, might have been pretty were they not staring from a face that was so bland and humorless. Nothing about this woman—not her suburban housewife perm or her high-necked dress or her tight little mouth—set Molly at ease. She might as well be from another planet, for all the ways they were different. She knew the other woman sensed that difference as well, could see it by the way Linda sat behind her desk, her shoulders squared, her bony hands folded before her. Molly suddenly felt the need to tug down the hem of her skirt, to cross her arms over her chest. And she felt a twinge of something she hadn’t felt in a long time.
She felt ashamed.
“Now,” said Linda. “Tell me about your situation, Molly.”
“My, uh, situation?”
“You said on the phone you’re pregnant. Are you having symptoms?”
“Yes, Ma’am. I think so.”
“Can you tell me what they are?”
“I, uh. . .” Molly looked down at her lap. The short skirt was riding up her thighs. She squirmed a little in her chair. “In the morning, I’m sick to my stomach. I gotta pee all the time. And I haven’t had my monthly in a while.”
“How long since your last period?”
Molly shrugged. “I’m not real sure. I think it was back in May.”
“That’s over four months ago. Didn’t it worry you, being so late?”
“Well, I didn’t really keep track, you know. And then I got that stomach flu and I thought that’s why I was late. And also, I—I guess I didn’t want to think about it. About what it might mean. You know how it is.”
Linda obviously didn’t know. She just kept looking at Molly with those pinched eyes. “Are you married?”
Molly gave a startled laugh. “No, Ma’am.”
“But you did have. . . sex.” The word came out like a throat clearing, a low, choked sound.
Molly fidgeted in her chair. “Well, yeah,” she answered. “I’ve had sex.”
“Unprotected?”
“You mean like do I use rubbers? Yeah, sure. But I guess I. . . had an accident.”
Again, the woman made that throat-clearing sound. She folded her hands on the desk. “Molly, do you know what your baby looks like right now?”
Molly shook
her head.
“You do understand it is a baby you’re carrying?” The woman slid the picture book toward Molly and flipped to a page near the beginning. She pointed to an illustration, a miniature baby all wrapped around itself in a small fleshy ball. “At four months, this is what he looks like. He has a little face and little hands and feet. See how perfect he is already? He’s a real baby. Isn’t he cute?”
Molly shifted uneasily.
“Do you have a name for him yet? You should give him a name, don’t you think? Because you’re going to start feeling him move around inside you real soon, and you can’t just call him hey you. Do you know the father’s name?”
“No, Ma’am.”
“Well, what was your daddy’s name?”
Molly swallowed. “William,” she whispered. “My daddy’s name is William.”
“Now that’s a nice name! Why don’t we call the baby Willie? Of course, if it’s a little girl, we’d have to change it.” She smiled. “There are so many nice names for girls these days! You could even name her after yourself.”
Molly looked at her in bewilderment. Softly she asked: “Why’re you doing this to me?”
“Doing what, Molly?”
“What you’re doing. . .”
“I’m trying to offer you a choice. The only choice. You’ve got a baby in there. A four-month-old fetus. The Good Lord has given you a sacred responsibility.”
“But, Ma’am, it wasn’t the Good Lord who fucked me.”
The woman gasped, her hand flying to her throat.
Molly squirmed in her chair. “I think maybe I should go—”
“No. No, I’m only trying to lay out the options for you— all of them. You do have choices, Molly, and don’t let anyone tell you differently. You can choose life for that baby. For little Willie.”
“Please don’t call him that.” Molly stood up.
So did Linda. “He has a name. He is a person. I can put you in touch with an adoption agency. There are people who want your baby—thousands of families just waiting for one. It’s time to think about someone besides yourself.”
“But I gotta think about myself,” whispered Molly. “’Cause no one else does.” She walked out of the office, out of the building.
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