by Robin Cook
“I know you,” he said, pointing at Jack. He was obviously searching for the name.
“Dr. Jack Stapleton.”
“Right! The medical examiner interested in the failed resuscitation case.”
“Good memory,” Jack commented.
“It’s the main talent I picked up in medical school. What can we do for you?”
“I need two minutes of your time, hopefully with Georgina O’Keefe. Is she here tonight?”
“She runs the show,” the admitting clerk said with a laugh. “She’s here.”
“I know this is not the best time,” Jack said. “But we exhumed the body, and I just did an autopsy. I thought you might like to know what was found.”
“Absolutely,” Matt said. “And this isn’t a bad time. We’re busy, but it’s all routine stuff that should have been seen in the outpatient clinic or a doctor’s office. There’s no critical emergencies at the moment. Come on back into the lounge. I’ll snare Georgina.”
For a few minutes, Jack sat by himself. He used the time to look back over the two pages that constituted a record of Patience’s ER visit. He’d pulled them from the case file while he’d been talking to Alexis.
“Welcome back,” Georgina bubbled as she swept into the room. Matt came in after her. Both were dressed in white jackets over green scrub clothes.
“Matt said you dug up Mrs. Stanhope and did an autopsy. Cool! What did you find? I mean, no one has ever given us this kind of feedback.”
“The interesting thing was that her heart appeared entirely normal. With no degenerative changes whatsoever.”
Georgina thrust the backs of her hands onto her hips with her elbows out. Her mouth formed a disappointed, wry smile. “I thought we were going to hear something startling.”
“It’s startling in its own way,” Jack said. “It’s rare with sudden cardiac death not to find pathology.”
“You came all the way over here to tell us you found nothing?” Georgina questioned with disbelief. She looked at Matt for support.
“Actually, I came to ask you if there was any chance she could have been given an overdose of any medication or maybe the wrong medication.”
“What kind of medication are you talking about?” Georgina asked. Her smile faded, replaced by a wary confusion.
“Anything,” Jack said. “Particularly any of the newer fibrinolytic or antithrombotic agents. I don’t know; are you people involved in any randomized studies involving heart attack patients? I’m just curious. There’s nothing like what I’m talking about on the order sheet.” Jack handed the two pages over to Georgina, who glanced at them. Matt looked over her shoulder.
“Everything we gave her is on here,” Georgina said, holding up the order sheet. She looked at Matt for confirmation.
“That’s it,” Matt agreed. “She was in extremis when she arrived, with practically a flatline on the cardiac monitor. All we tried to do was resuscitate her. We didn’t try to treat her MI. What was the point?”
“She didn’t get anything like digitalis?”
“No,” Matt said. “We couldn’t even get a heartbeat, even with dual-chamber sequential pacing. Her heart was completely unresponsive.”
Jack looked from Georgina to Matt and back again. So much for the overdose or wrong medication idea! “The only laboratory reports on the ER notes are blood gases. Were any other tests done?”
“When we draw blood for blood gases, we routinely also order the usual blood count plus electrolytes. And with heart attacks, we order biomarkers.”
“If they were ordered, how come there’s no mention of it on the order sheet, and why aren’t the results on the ER note? The blood gases are there.”
Matt took the sheets from Georgina and quickly looked them over. He shrugged. “I don’t know, maybe because they normally go in the hospital record, but since she died so quickly, she never got a hospital record.” He shrugged again. “I suppose they are not on the order sheet because it’s a standing order for all myocardial infarction suspects. I did mention sodium and potassium were normal in my note, so someone called the results to the ER desk.”
“This isn’t a big-city ER,” Georgina explained. “It’s rare to have a death here. Usually people get admitted, even those in bad shape.”
“Could we call the lab and see if they could possibly locate the results?” Jack asked. He did not quite know what to make of this serendipitous discovery or whether it would have any meaning, but he felt obligated to see where the lead would take him.
“Sure,” Matt said. “We’ll have the clerk call up there. Meanwhile, we’ve got to get back to work. Thanks for coming by. It’s strange you didn’t find any pathology, but it’s nice to know we didn’t miss anything that could have saved her.”
Five minutes later, Jack found himself in the tiny, windowless office of the evening laboratory supervisor. He was a large, heavyset man with heavily lidded eyes that gave him a sleep-deprived appearance. He was staring at his computer monitor with his head tilted back. His name tag read: “Hi, I’m Wayne Marsh.”
“I don’t see anything under Patience Stanhope,” Wayne said. He had been very obliging when the ER called, and invited Jack up to his office. He’d been impressed with Jack’s credentials, and if he’d noticed the badge said New York rather than Massachusetts, he didn’t mention it.
“I need a unit number,” Wayne explained, “but if she wasn’t admitted, then she didn’t get one.”
“What about through billing?” Jack suggested. “Somebody had to pay for the tests.”
“Nobody’s in billing at this hour,” Wayne said, “but didn’t you mention you have a copy of the ER record? That will have an ER accession number. I can try that.”
Jack handed over the ER notes. Wayne typed in the number. “Here we go,” he said as a record flashed up on the screen. “Dr. Gilbert was right. We did a full blood count with platelets, electrolytes, and the usual cardiac biomarkers.”
“Which ones?”
“We do CKMB and cardiac-specific troponin T on arrival at the ER, with repeats at six hours postadmission and twelve hours postadmission.”
“Was everything normal?”
“Depends on your definition of normal,” Wayne said. He twisted his monitor screen in its base so Jack could see it. He pointed to the blood-count section. “There’s a mild to moderate rise in the white count, which is expected with a heart attack.” His finger then went to the electrolytes. “The potassium is at the upper edge of normal. Had she lived, we would have wanted to check that, for obvious reasons.”
Jack inwardly shuddered at the mention of potassium. The frightening episode with Laurie’s potassium during her ectopic pregnancy emergency was still fresh in his mind despite its being over a year ago. Then his eyes happened to notice the biomarker results. To his surprise, the tests were negative, and he immediately called it to Wayne’s attention. Jack’s pulse ratcheted up. Had he stumbled onto something significant?
“That’s not unusual,” Wayne said. “With improved response times to nine-one-one calls, we often get our heart attack victims into the ER within the three- to four-hour interval it takes for the biomarkers to rise. That’s one of the reasons we routinely repeat the test at six hours. Jack nodded as he tried to sort out the discrepancy this new information provided. He didn’t know whether he’d forgotten or never knew there was such a delay before biomarkers became positive. Not wishing to appear overly uninformed, he worded his next question carefully. “Does it surprise you that an earlier bedside biomarker assay was positive?”
“Not really,” Wayne said.
“Why not?”
“There are a lot of variables. First off, there’s about a four percent false negative result as well as a three percent false positive. The tests are based on highly specific monoclonal antibodies, but they are not infallible. Secondly, the bedside kits are based on troponin I, not T, and there’s a lot of bedside kits on the market. Was the bedside assay for troponin I alone or w
ith myoglobin?”
“I don’t know,” Jack admitted. He tried to remember what was written on the box in Craig’s doctor’s bag, but he couldn’t visualize it.
“That would be important. The myoglobin component becomes positive faster, often within as little as two hours. What’s the time frame on this case?” He picked up the ER note and read aloud: “Patient’s husband states chest pain and other symptoms developed between five and six p.m., probably closer to six.” Wayne looked up at Jack. “She arrived in the ER close to eight, so the time frame is about right as far as our results are concerned, since it was less than four hours. Do you know when the bedside assay was done?”
“I don’t,” Jack said. “But if I had to guess, it would be somewhere around seven thirty.”
“Well, that does seem marginal, but as I said, the bedside tests are made by a host of companies with widely differing sensitivities. The kits also should be carefully stored, and I believe there’s an expiration date. Frankly, that’s why we don’t use them. We much prefer the troponin T, since it’s made by only one company. We get very reproducible results with a short turnaround time. Would you like to see our Abbott analyzer? It’s a beauty. It measures absorbance spectrophotometrically at four hundred fifty nanometers. It’s right across the lab if you want to take a gander.”
“Thank you, but I think I’ll pass,” Jack said. He was getting in technically way over his head, and his visit at the hospital had already been twice as long as he had planned. He certainly didn’t want to keep Latasha waiting. He thanked Wayne for his help and returned quickly to the elevator. As he rode down to the first floor, he couldn’t help but wonder if Craig’s bedside biomarker assay kit had somehow been defective, either from improper storage or from being out of date, and had given a false positive. What if Patience Stanhope did not have a myocardial infarction? All at once, yet another dimension was opening up, particularly with the services of a toxicologist available. There were a lot more drugs that deleteriously affected the heart than those capable of simulating a heart attack.
Jack jumped into the car and quickly dialed Latasha’s number. As he’d done with his call to Alexis, he put his phone on speaker and placed it on the passenger seat. By the time he was driving out of the hospital parking lot, Latasha answered.
“Where are you?” she asked. “I’m here in my office. I got two hot pizzas and two large Cokes. Where are you at?”
“I’m just leaving the hospital. I’m sorry it has taken as long as it has, but I learned something possibly important. Patience Stanhope’s biomarker test was negative when it was read by the hospital analyzer.”
“But you told me it was positive.”
“That was from a bedside biomarker kit,” Jack said. He carefully explained what he’d learned from the lab supervisor.
“What it all comes down to,” Latasha said when Jack was finished, “is that now we’re not sure she had a heart attack, which would be consistent with what we found during the post.”
“Precisely, and if that is the case, the toxicology is going to be key.”
“I already dropped the samples off at the toxicology lab with a note for Allan to give me a call.”
“Perfect,” Jack said. He couldn’t help but marvel at how lucky he was to have Latasha helping him. If it hadn’t been for her, he might have given up after finding nothing in the heart.
“I guess this puts the mourning husband in the crosshairs,” Latasha added.
“There are still some inconsistencies,” Jack said, remembering Alexis’s points against Jordan’s being the bad guy, “but generally I agree, as trite and venal as it sounds.”
“When will you be here?”
“As soon as I can. I’m coming up to Route Nine. You’re probably a better judge than I. Why don’t you start on the pizza while it’s hot.”
“I’ll wait,” Latasha said. “I’ve got myself busy making us some frozen sections of the heart.”
“I’m not sure I’ll be eating much,” Jack said. “I’ve gotten myself psyched. I feel like I’ve had ten cups of coffee.”
When Jack flipped his phone shut, he checked the time. It was almost ten thirty, which meant Latasha’s friend would soon be arriving at the toxicology lab. Jack hoped he’d have a lot of free time, since Jack could imagine keeping him busy most of the night. Jack had no illusions about the power of toxicology to detect poisons. It was not as easy a process as it was often portrayed in the popular media. For large concentrations of the usual drugs there usually was no problem, but for trace amounts of more toxic and lethal compounds that could kill a person in very small dosages, it was like finding the proverbial needle in a haystack.
Jack stopped at a traffic light and impatiently drummed his fingers on the steering wheel. The warm, soft, humid June air wafted in through the missing window. He was glad he’d taken the time to visit the hospital, although he now felt embarrassed about the idea of a hospital cover-up. Nonetheless he rationalized that the idea had indirectly led to his questioning whether Patience Stanhope had suffered a heart attack.
The light turned green, and he moved on. The problem was she still might have had a heart attack. Wayne had admitted that even with his vaunted absorbance analyzer, the rate of false negatives was higher than false positives. Jack sighed. There was nothing about this case that was simple and straightforward. Patience Stanhope was proving to be a problem patient even in death, which reminded him of his favorite lawyer joke: What’s the difference between a lawyer and a prostitute? The prostitute stops screwing you when you die. From Jack’s perspective, Patience was assuming some annoying lawyerlike qualities.
As Jack drove, he mulled over his promise to check in on Craig, who was probably at that time already in a deep, drug-and-alcohol-induced slumber. Jack wasn’t excited about the idea and thought it unnecessary since, in his estimation, Craig was not suicidal in the slightest, and, as an intelligent physician, Craig was well aware of the power of the medications he was taking. On the other hand, the good side of making such a visit would be a chance for Jack to check what kind of biomarker kit Craig used and whether it was outdated. Until he had that information, he couldn’t intelligently decide whether or not there was a higher than usual chance the result had been a false positive.
21
BOSTON, MASSACHUSETTS
Friday, June 9, 2006
1:30 a.m.
For almost five minutes Jack had watched the hands of the institutional wall clock as they implacably jumped staccato-fashion toward one thirty a.m. With the final leap of the minute hand, Jack took a breath. He hadn’t realized he’d not been breathing for the final seconds, since the time was a mini-milestone. Exactly twelve hours hence he would be married, and all the years he’d avoided the issue would be history. It seemed inconceivable. Except for the relatively recent past, he’d practically institutionalized being by himself. Was he capable of marriage and thinking of two people instead of one? He didn’t really know.
“Are you all right?” Latasha asked, yanking Jack back to reality by reaching out and briefly gripping his forearm.
“Fine. I’m fine!” Jack blurted. She’d startled him.
“I thought you were having an absence seizure. You didn’t move a muscle for the last few minutes. You didn’t even blink. What on earth were you thinking that had you so mesmerized?”
Despite being an intensely private person, Jack almost told Latasha what had been on his mind to get a fresh viewpoint. Such a reaction surprised him, even though he acknowledged having developed a strong affinity toward the woman. Except for his detour to the Newton Memorial Hospital, they had been closely working together for some six hours and had fallen into a natural familiarity. When Jack had arrived at the Boston medical examiner’s office, they’d taken over what was supposed to be the library, but the shelves were mostly empty, in hope of future funding. The room’s major asset was a large library table, onto which Jack had spread the contents of Craig’s malpractice file and organized
them so he’d be able to find anything in particular if there was a need. At the far end of the table were open pizza boxes, paper plates, and large cups. Neither had eaten much. Both had been consumed by the conundrum of Patience Stanhope.
They had also carried in the dual-headed stereo-dissecting microscope and, sitting on opposite sides of the table, had spent several hours opening and tracing all the coronary arteries. Like their larger and more proximal brethren, all the distal vessels were normal and clear. Jack and Latasha had paid particular attention to those branches serving the heart’s conduction system.
The last stage of examining the heart was to be the microscopic. They’d taken specimens from all areas of the heart but again concentrated in and around the conduction system. Before Jack had arrived, Latasha had made a series of frozen sections from a small sampling, and the very first thing they had done on his arrival was to stain them and then put them out to dry. At the moment, they were in the wings waiting for their cue.
Just after they’d finished staining the slides, Allan Smitham had called. He had apparently been pleased to hear from Latasha, at least it seemed so to Jack from the side of the rather personal conversation he was forced to hear, even though he was trying not to. He felt uncomfortable that he was intruding, but the good news was that Allan was eager to help and would run the toxicology screen immediately.
“I didn’t come up with any new ideas,” Jack said in response to Latasha’s question about what was on his mind. Back when his eyes had strayed to the clock and its staccato movement had hypnotized him into thoughts of his intimidatingly imminent marriage, he was supposed to have been trying to think up new theories about Patience. He’d related to Latasha all his old theories by essentially repeating what he’d told Alexis on the phone en route to the hospital. Throwing all pretenses of self-respect to the wind, he included the drug overdose/wrong drug idea, even though in hindsight it sounded inane, almost dim-witted, and Latasha had responded appropriately.