“We got an open fracture in the left lower leg,” Bill announced.
Julie cringed.
“Bill, I need a blanket under Sam’s head right away. Please, quickly.”
Bill stopped cutting and did as he was instructed.
“Dr. Devereux, can you continue to take c-spine?” Ashley asked.
Ashley sounded so calm, so composed, the way Julie was accustomed to being.
“Of course,” Julie said, keeping her hands to the sides of Sam’s head.
With careful, practiced movements, Ashley unzipped Sam’s jacket and took scissors from a belt pouch to cut open his shirt.
“Trachea is midline, and those neck veins do look slightly engorged,” Ashley said.
“Slightly? Check again,” Julie said. “It’s more than that.”
Those veins were a symptom of something, but of what?
“Yeah, I agree,” said Ashley. “How’s your breathing, Sam?”
Sam groaned and made another noise that sounded barely human.
“Let’s get oxygen on him,” Ashley ordered. “I’m going to get two IV Lactated Ringer’s going.”
Sam needed a lot more than the fluid and electrolyte replenishment. Looking down at the pant leg Bill had cut away, Julie saw where the bone had sheared through the skin. It was a hideous, jagged cut, crisscrossed with strands of frayed muscle and ringed by clumps of fatty tissue. The bone poked out from the middle of a five-inch gash in the leg. It was barely a speck of white adrift in a sea of blood. The Lactated Ringer’s infusion would replenish electrolytes, but contained no antimicrobial agents. With such an open wound, Sam’s risk of infection had markedly increased.
Ashley set her hands on Sam’s bare chest, an area of his body spared major cuts and abrasions thanks to his protective gear. Along with providing oxygen flow and bleeding control, stabilizing any chest wall defect was a first priority.
Julie thought back to the accident. Had Sam hit the pickup’s side mirror? Did the motorcycle land on top of him? A crushing impact of either type could be devastating. Ashley listened with her stethoscope, and Julie resisted the urge to rip the instrument from her ears to give a listen for herself.
Time was of the essence. It had been five minutes or so since Ashley and crew had arrived on the scene. In five more minutes, they should be in transit. If Ashley or Bill detected any major issue in Sam’s ABCCs, it would be a load-and-go situation for certain.
“Can you tell me where you are hurting?” Ashley asked.
No response.
“Sam, can you wiggle your toes at all?”
Sam groaned incoherently.
Bill dressed the leg wound while Ashley got the portable oxygen unit running and the mask secured in place. All of the essential equipment was bagged and at the ready, saving valuable time that might have been wasted running back and forth to the ambulance.
Once the IVs were hooked up, Ashley undid the snaps of Sam’s pants and palpated his abdomen.
“Abdomen is soft. We need to get a c-collar on him, then we need to log roll.”
“What about those jugular veins?” Julie asked. “I’m really concerned.”
“Then the sooner we get him to the hospital, the better,” Ashley said.
Not just any hospital, Julie thought.
Ashley got the plastic, bivalved shell secured in place around Sam’s neck while Julie continued to hold his head still. The entire process took less than a minute.
“Okay, are we ready to log roll?” Ashley asked.
Bill, having dressed the leg wound as best he could, nodded and took up position by Sam’s lower extremities. Ashley reached across Sam’s body so that she could get enough leverage to roll him onto his side.
“On my call, on three,” Ashley said. “One … two … three.”
Ashley and Bill pulled Sam onto his side, while Julie twisted her body to continue to support his head. As he rolled, Sam let out another loud groan. A firefighter tilted the cot and Ashley quickly inspected Sam’s posterior from head to toe before the backboard was brought up flush against his body.
“Lower on my count,” Ashley said. “One … two … three. Now we slide on three.”
Together they slid Sam onto the board. Ashley conducted another examination of the pelvis and lower extremities before the anti-shock garments, padded liners that could be inflated to protect the body during transport, were secured in place. Ashley removed Sam’s socks and shoes while Bill thoroughly assessed Sam’s body using inspection and palpation techniques. They checked his distal pulses once more as two firefighters secured the backboard straps around Sam at three points.
Everyone stayed in constant motion, and every action had a purpose, like a choreographed dance rehearsed thousands of times. Julie’s only job was to hold Sam’s head perfectly still until the blocks were put into place. It was the best job for her: her hands on him, touching him, comforting him.
“Sam, can you wiggle your toes or fingers for me?” Ashley asked.
He made no movement at all. Panic set in as Julie contemplated the extent of Sam’s injuries.
“Sam, we’re going to lift you now.” Whether he heard her or not, Ashley was going to give Sam the play-by-play. “You won’t fall, because you’re strapped in,” she said. “Okay, on my count of three we lift him onto the cot. Everyone got a good grip?”
Bill, Julie, and two firefighters nodded in unison. On three they lifted Sam onto a rolling stretcher. Additional straps were quickly secured around him.
As soon as Sam was loaded into the back of the ambulance, Julie pulled Ashley aside.
“I want to ride in the back with you,” she announced. “You’re going to need two people looking out for him during transport, anyway. And please—let’s bring him to White Memorial.”
Ashley did not look pleased with either request. “I have a third EMT who will ride with us. I’m sorry, but that’s our policy. And White Memorial is simply too far away.”
Julie’s eyes welled. White was smaller than some other Boston hospitals, but the trauma team was unsurpassed.
“Ashley, I’m begging you. It’s where he needs to be. We don’t have time to debate it. Please, just do it. You know it’s the right thing to do, and you know I can help.”
Bill had climbed into the back of the ambulance so he could assess and reassess Sam’s condition. He was looking for deformities, contusions, abrasions, and penetrating punctures, and constantly monitoring Sam’s vital signs.
“Hey, Ashley,” Bill called out. “I’m really worried about these distended jugular veins. This isn’t right. Yeah, it’s, uh … it’s not good at all.”
Ashley shot Julie a nervous glance.
“Climb in, Dr. Devereux,” Ashley said. “White Memorial, here we come.”
CHAPTER 9
The dead can speak. It just takes time and patience to learn their language. Dr. Lucy Abruzzo had spent her career studying this language, and as White Memorial’s chief of pathology, she spoke it better than anyone on staff. These days, bureaucracy and administrative duties took precedence over the lab work that had fed her passion for years. Lucy’s personality was better suited to working with tissue samples and cadavers than to managing budgets, personalities, and cost structures. But hospital CEO Roman Janowski was not somebody you turned down twice.
As a manager, she remained somewhat of an enigma. A detached personality, someone a bit aloof, she was well suited to the autopsy table, but around a conference room table that personality could be off-putting. Lucy was an infrequent contributor to any pre-meeting banter. Most jokes and pop culture references were lost on her, as someone who did not own a television. Away from the lab, Lucy read nonfiction compulsively, ran for distance, loved chess, and enjoyed cooking, but only when following a recipe. Improvisation was for wilderness medicine.
It was common for Lucy to be so overscheduled with meetings that she never had time for any actual pathology. Weekends were different, though. Lucy used Sundays to catch up on pa
perwork and assist in the lab. Someone was always here doing something.
The moment Lucy set foot in the lab, a powerful scent hit her nostrils. Someone was testing stool samples, probably looking for a toxin. The pathology lab was always full of unusual smells, and Lucy found them all oddly pleasing. Dr. Becca Stinson, a fresh-faced second-year pathology resident, waved Lucy over to her workstation.
Some cases Lucy’s team managed were difficult to crack, while others were more straightforward. The pathology of the human body could be like the mystery novels Lucy once favored. Bodies had unreliable narrators, red herrings, good guys and villains, and answers that could be proved beyond a reasonable doubt using the right tools and investigative logic. The case Becca was working was evidently a tough one to solve.
Lucy pushed her shoulder-length brown hair away from her narrow face and put on her tortoiseshell glasses so she could read the case file Dr. Stinson handed her. It looked straightforward.
Becca, who trained at a CrossFit gym and discussed it incessantly, had about four inches and twenty pounds (all muscle) on Lucy, whose arms and neck were thin from years of running. Though she was petite, Lucy probably could have held her own in the CrossFit arena. Years of cutting ribs and sawing bones had built up a lot of strength in those delicate arms.
Lucy studied the file intently for several quiet moments, her focus unwavering, the noxious odor no longer even registering.
The doctor’s report was succinct, just the way Lucy liked it.
The patient, Cliff Anderson, seventy-seven, has experienced progressive cognitive decline and increased incidents of lethargy, depression, and memory troubles. The patient has presented with decreased motor function, as exhibited by multiple recent falls at home. Physical and neurological examinations were both unremarkable. CT and MRI scans of the head did not reveal significant acute pathology and the EEG was negative for seizure-like activity. Cerebral angiography also negative for abnormalities. Temporal artery biopsy ordered to rule out temporal arteritis.
That last line was Mr. Anderson’s last best hope. If the vessels that supplied blood to the man’s head were inflamed or damaged, it could cause his symptoms. The condition was also completely treatable. However, Lucy believed the real culprit behind Mr. Anderson’s troubles was something no department at White Memorial could cure. The biopsy did in fact show inflammation, some possible blockage there. But sometimes lab results offered rays of false hope. The symptoms outlined in the report were standard for another ailment, one that would be heartbreaking for both Mr. Anderson and his family.
“Well?” Becca asked after Lucy had finished her review.
“Seems cut and dried to me. Mr. Anderson has Alzheimer’s.”
Alzheimer’s disease had no official test that could be done on the living. Neuropathological signs of the disease, amyloid plaques and neurofibrillary tangles of tau, a protein involved in maintaining the internal structure of the nerve cell, could be confirmed only during autopsy. Diagnoses of Alzheimer’s relied largely on documenting mental decline. The medical report indicated symptoms consistent with that diagnosis, and given the patient’s advanced age, Lucy figured it would have been Becca’s first best guess as well.
“You don’t seem convinced,” Lucy said.
Becca buried her hands inside the pockets of her lab coat. “He’s not presenting in a typical fashion.”
“How so?”
“The tissue sample from the temporal artery biopsy showed severe inflammation, more than I expected, and some evidence of tissue death. Also, the patient complained of headaches and anxiety.”
“And you think it could be—what? His MRI was normal. No evidence of stroke, tumor, head injury, nothing structural like hydrocephalus.”
“Even without excess fluid in the brain, at minimum we should order an erythrocyte sedimentation rate, and I’d like to do a toxicology screen as well.”
“Which the insurance company is going to deny.”
“Which is why I want your help,” Becca said.
“Charm them with my infectious personality, is that it?”
Becca cleared her throat. “Well, something like that, I suppose.” Clearly, Becca felt she was on to something, but pathologists were not supposed to treat patients like internists.
Lucy appreciated this doctor’s doggedness, respected it. She also understood her frustration. The pathology lab, hidden in the bowels of White Memorial, was stocked with cutting-edge pathology equipment including cryostat machines, tissue processors, imaging systems, and a digital incubator. It was a large and well-lit space, complete with several workstations, each equipped with a powerful microscope. The lab could run almost any test or diagnostic requested by hospital doctors, but not without somebody to foot the bill. Like many hospitals its size, White Memorial operated on razor-thin margins, scrutinizing every penny.
Lucy considered her options. She knew one test would lead to another, and then another. Cliff Anderson’s doctor would come storming back here, pissed at having to do battle with the insurance company for tests he did not order.
“It’s Alzheimer’s, dammit. What don’t you get?”
The thought put a rare smile on Lucy’s face. Becca was right to question the dearth of testing, and the tissue death, while not indicative of temporal arteritis, was still unusual. Why not do some more tests? Lucy asked herself. After all, didn’t Mr. Anderson deserve the best that White Memorial had to offer?
“Let’s do whatever tests you think are necessary,” Lucy said. “We’ll sort it all out later.”
Becca’s broad smile was the big win of the day. Lucy loved her team, and it felt good to see them feel successful. Pathology was hardly a lonely profession, though many held that belief. A good path lab required smart docs like Becca to operate at a high level. What it did not require was direct involvement with patient care, and this suited Lucy just fine.
From down the hall, Lucy heard the familiar sound of gurney wheels on approach. It was a bellwether of sorts—the dead were coming. They showed up here even on Sundays.
Sure enough, Jordan Cobb, the six-foot-two hospital diener and longtime White Memorial employee, poked his head into the lab.
“Hey there, Docs,” Jordan said.
The diener always had a happy expression on his face despite the grim nature of his job. It was Jordan’s responsibility to collect the dead, move them to the morgue down the hall from the pathology lab, and clean each body prior to autopsy. It was a necessary job, but one many found unsettling. Not Jordan, though. He was unemotional about the work, the way Lucy would have been.
“Death is coming for us all,” Jordan once said to Lucy during his performance review. “I just hope whoever gets my body treats it with respect. That’s what’d I’d want, so I guess that’s what I do.”
He got a raise.
Jordan had the broad shoulders and thick neck of a football player, though he had never played any organized sport.
“Living in Dorchester is sport enough,” Jordan once said.
Lucy sometimes let Jordan watch her perform autopsies. He found it endlessly fascinating.
“Who’s our new houseguest?” Lucy asked.
Jordan lifted back the bedsheet and squinted his big brown eyes to read the toe tag. “Tommy Grasso. He’d been on life support, but they just pulled the plug. Funeral home will receive him tomorrow, so he’s going to storage, no autopsy needed, at least according to the paperwork here.”
Lucy glanced at the documents Jordan handed her and gave a nod. “Okay, wheel him and seal him,” she said.
“What’s happening in here?” Jordan asked. “It’s not my business, I know, but I usually don’t see you in the lab these days, Dr. Abruzzo.”
It was true. Lucy’s Sunday shifts had lately been less about the lab and more about that catch-up paperwork.
“Oh, Dr. Stinson and I are talking about doing some tests that aren’t officially sanctioned.”
“Hospital stuff, huh?” Jordan said with a
shrug. He had an innocent, boyish-looking face, though quite handsome, and kept his dark hair cut short. The patch of hair on his chin helped him look closer to his true age, twenty-six.
“Yeah, Jordan, hospital stuff.”
Jordan wheeled Tommy away, and Lucy’s attention returned to Mr. Anderson’s case.
“I feel bad that you’re going to take some heat on this,” Becca said, “but I really think it’s the right thing to do.”
“I’m fine with it. Honest.”
At that moment, Jordan returned to the lab, no longer wheeling Tommy Grasso, but holding a slip of paper in his hand. “Hey, I found this in the hallway. I think it dropped out of one of your file folders, or something.”
Jordan handed the paper to Lucy. It was a test result for Cliff Anderson. Odd, because the only lab work Becca had done was that temporal artery biopsy. At first Lucy thought it might be a result from one of the tests Becca wanted to run. Maybe she’d already ordered them, and was doing the “ask forgiveness before permission” thing. But this was a heavy metal test, specific for cobalt, and the result was quite puzzling.
“Becca, who ran this test?” Lucy handed the sheet to Becca.
Becca stammered, “I—I don’t know.”
“Something wrong?” Jordan asked. He sounded genuinely concerned.
“No, nothing you did. It’s just this paper—this test result you found.”
“What is it?” Jordan asked.
“Well, according to these findings, Cliff Anderson has a cobalt level of twenty-four micrograms per liter of blood. It’s not enough to kill him, but it could certainly make him very ill,” Lucy said.
“Loss of motor coordination, memory troubles, tissue death, headaches, anxiety,” Becca added, sounding excited. “Sound familiar?”
“Has he had a hip replacement?” Lucy asked.
“I’d have to look up his full medical record. Give me a second.”
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