Mercy

by Daniel Palmer

  Those details, and others, Julie shared with the police during hours of interviews. The detectives did not know what to make of the takotsubo connection among Sam Talbot, Donald Colchester, and Tommy Grasso. Nor did Julie get the sense they viewed William Colchester as a suspect. The timing of Sherri’s murder and Julie’s meeting with her was most likely coincidental, one detective had said.

  Julie did not believe it for a second.

  “The funeral is on Sunday,” Michelle noted as she skimmed the article. “Are you going?”

  Julie’s face showed the strain of a string of difficult days. “Yes, of course,” she said. “I’m taking Jordan Cobb with me. He knew her—not well, but I think her murder really shook him up. I can’t get the image of that poor girl out of my mind. It’s just been awful.”

  Lucy set down her coffee. “You still think William Colchester was behind it?”

  “I do. To silence Sherri Platt,” Julie said. “She was going to open up to me; I’m sure of it. And I think that’s what got her killed. I think Colchester bribed her to lie on the witness stand. Heck, he tried to bribe me, said he would do something on his budget committee to benefit White Memorial, and then he told me people would get hurt if I didn’t back off.”

  “When did he say that?” Lucy asked.

  “He came to my home after I met with Jordan,” Julie said.

  “And the police weren’t a little concerned about that?” Michelle’s sarcasm had bite.

  “According to the detectives, Colchester had an alibi. He also said there’s been no communication or texts between Colchester and Sherri. They think there would have been something if he had offered Sherri a bribe. But I say, if Sherri was going to come clean about taking a bribe, it certainly gave Colchester a motive.”

  Lucy made a look of disgust. “So a crooked state representative will get away with murder?”

  “It’s possible,” Julie said. “The police have to do their jobs and I’ll do mine. There’s still a chance we can overturn Brandon’s murder conviction if we can somehow show there’s a pattern of rare heart attacks in seemingly healthy hearts.”

  “Won’t explain the morphine, or Sherri’s testimony,” Michelle said.

  “I don’t think anything can explain Sherri’s testimony now,” Julie answered.

  Lucy said, “I looked at the medical record Jordan sent me to review.”

  Julie shot Lucy a glance, her eyes showing concern. “You mean our helper. I don’t want his name getting out.”

  “All secrets are safe with me,” Michelle said. “I feel a connection to this, too. I want to be of help.”

  Julie gave Michelle’s arm a slight squeeze. Getting to know Michelle, the friendship that had formed, was one of the few bright spots to emerge in the aftermath of Sam’s accident.

  “What’s your take on Tommy’s file?” Julie asked.

  “My take is I’m not a cardiologist,” Lucy said. “How the heck did our helper learn so much?”

  Julie nodded her agreement. “It’s pretty remarkable.”

  “Well, the EKG does look unusual for a typical heart attack. I wish he’d had an echo done. Even without one, I wouldn’t dismiss a takotsubo incident, but I wouldn’t diagnose it, either.”

  “Someone deleted something in that record postmortem,” Julie reminded her.

  “Are you suggesting a cover-up?” Michelle asked.

  “My best guess is Dr. Coffey locked me out of Colchester’s file for a reason. But I know there were deletions in Sam and Tommy’s records, as well as Donald Colchester’s. And all three had the same unusual EKG, and we know for sure about left ventricle apical ballooning in two of the cases. Something isn’t right here. Not right at all.”

  “Forget the EKGs for a second,” Lucy said. “Explain to me how someone with chronic COPD like Tommy, a quadriplegic like Sam, and guy with advanced ALS all suffer a stress-induced heart attack. What kind of stress event could they have had? It’s honestly never made sense to me.”

  Julie sighed aloud and recalled how Dr. Coffey had said something very similar. Nothing was adding up. It never had. Takotsubo was an instant reaction to an extreme stimulus. These men were all debilitated in some capacity. What kind of stimulation could they have possibly experienced?

  Julie’s stomach rumbled. She had not eaten breakfast, and the line at the counter was not long anymore.

  “I’m going to grab a muffin,” Julie said. “I’ll be right back.”

  She asked the counterperson for a banana walnut muffin and realized she had been rude not to get something for her friends. She decided to surprise them with a breakfast treat and ordered two more of the same muffin. She brought the treats back to the table on a plate.

  “I got one for each of us,” Julie said.

  Lucy picked up her muffin, examined it closely, and set it back down.

  “Do you know if this muffin has walnuts in it?” she asked.

  “Yeah,” Julie. “It’s banana walnut, to be precise. I’ve had them before. They’re delicious.”

  Lucy pushed the muffin away. “Oh, good. You promise to give me CPR?” She said this with a twisted grin.

  Julie slapped her forehead. “Oh my gosh. I’m so sorry. I completely spaced.”

  Michelle got it. “Nut allergy, I’m guessing.”

  “Horribly allergic,” Lucy said. “Growing up I was the only girl in my school with an EpiPen in her backpack. Now they’re as common as erasers, it seems.”

  Julie perked up and looked at Lucy in a curious way. She picked up the muffin and examined it closely, turning it over in her hand, studying it as though she’d never seen a muffin before.

  “See if they’ll exchange it for a blueberry,” Lucy said.

  “No, it’s not that,” Julie answered, her voice a little distant. “It’s what you said earlier. What kind of stress event could Sam and the others have experienced? It doesn’t make sense, right?”

  “Right,” Lucy responded.

  “What are you getting at?” Michelle asked.

  Julie set the muffin back down on the plate. “Let me ask you this, Lucy. Could that acute coronary pathology have manifested as an allergic phenomenon?”

  Lucy’s eyebrows lifted as she mulled this over.

  “I never gave it any thought,” she said, “but I suppose it’s possible. It could have been an allergic reaction, yes.”

  “Which means it might not be takotsubo after all,” Julie said with some excitement.

  “Then what could it be?” Michelle asked.

  “To be honest, I have no idea,” Julie said.

  “It’s worth looking into,” Lucy agreed. “But there’s a problem with that theory.”

  “Which is?” Julie could not mask her disappointment.

  “We did slides of Sam’s heart muscle to look at the muscle fibers. If it was an allergic reaction, we should have seen mast cell activation and a differential increase of eosinophils.”

  “What are mast cells and eosinophils?” Michelle asked.

  “They’re both part of the immune system,” Lucy said. “Eosinophils are white blood cells that, along with mast cells, control mechanisms associated with allergy and asthma. If it was some sort of allergy, I would expect those cells to be present in large quantity. But that’s not what the slides showed.”

  “Is there any chance the slides were done incorrectly?”

  Lucy shrugged. Years in the autopsy business taught her that anything was possible.

  “Sure. If the tech was distracted or a wrong stain was used, it’s possible.”

  “Would you mind checking for me?”

  “You’re my sister from another mister. Of course not.”

  “Sounds like we’ve made some progress here,” Michelle said as she flipped a page in the newspaper.

  “You know what I’m thinking.” Lucy’s expression showed concern.

  “What?” Julie asked.

  “I’m thinking, look at what happened to Sherri Platt. Julie, are you really s
ure you want to dig into this any deeper?”

  CHAPTER 37

  The automatic doors of the ICU swung open and in came Shirley Mitchell. Shirley was not Julie’s first patient to come back to the unit on a hospital bed, nor would she be the last. This time, instead of pneumonia coupled with peripheral artery disease, Shirley had returned to the ICU with serious GI bleeding. The nurses watched her carefully throughout the morning, but her bleeding persisted and her blood pressure had begun to drop. Shirley received one unit of blood and two more were on the way.

  Julie put on her protective equipment: a blue plastic gown, gloves, and mask with a splatter shield. She would be prepared for any brisk bleeding. During the initial examination, Shirley was agitated, swatting at the nurses, refusing to have leads placed for telemetry, and making a grab to pull out the IV. At one point she yelled, “The movie is over and I don’t want any popcorn!”

  Clearly, Shirley was not at all herself. Julie checked the readouts after the nurses finally attached her to the telemetry monitor, blood pressure cuff, and pulse oximeter.

  Oxygen level was only about 87 percent on three liters nasal cannula. Her heart rhythm was irregular and fast, alternating between 115 to 120 with frequent bursts to the 140s. Blood pressure rang off as critical: seventy-eight over forty-four. They were behind. The bleeding was obviously profuse and Julie needed all hands on deck. She started with the litany of orders needed to save Shirley’s life.

  “Nancy—hang two liters of nasal saline, wide open.”

  “Vicky—call the blood bank and tell them to send two units of blood superstat. And to prep for four more units.”

  Marie, the secretary, poked her head around the corner. “Dr. Devereux, I seated the family in the waiting room. I told them it would be a while until she stabilizes. Anything else you need?”

  “Thanks, Marie, I’m good.”

  Julie examined Shirley’s battered arms. No nurse would be successful in finding another IV site anytime soon. Placing a central line seemed inevitable. But to start, Julie needed to develop a plan of attack to stop the bleeding.

  Her first phone call was to the gastroenterologist, Dr. Morgan. After some negotiation (necessary when dealing with a specialist) it was decided to proceed with a CT scan of the abdomen, to be followed by a colonoscopy after the patient stabilized. Dr. Morgan was betting on diverticulosis as the cause, which in 90 percent of cases would stop bleeding on its own. But when Julie got a call from the lab, plans needed to change quickly.

  “Shirley Mitchell’s troponin is ten point four,” the lab tech reported. “And her hematocrit is only twenty-two.”

  Julie, her face grave, announced the news to her team. The job of keeping the blood going into Shirley’s body from coming out was easy to say, but harder to do. Those labs indicated the job was far from complete. The CT came back as expected: nonspecific findings. Julie gave Dr. Morgan another call.

  “I would consider a colo,” Dr. Morgan said, “but right now, with her lung disease and her heart in bad shape, it’s just too risky. She’ll arrest on my OR table.”

  “But, Jim, she needs a better blood count to stop the heart attack, which won’t happen unless you get in there and stop the bleeding.”

  “Seriously, Julie, this lady is a train wreck. I don’t need the quality safety committee after me when she dies from the colonoscopy. Call interventional radiology, I think Kim is on. She’ll help you.”

  Julie picked up the phone and was connected to Dr. Kim Sung in interventional radiology. Arrangements were made and soon enough Shirley was carted off to radiology. After two hours, Julie took a call from Dr. Sung.

  “Hey Julie, I tried my best. I coiled a couple of places, but she is oozing everywhere. She’s like a pincushion. Nothing seemed to help. I think you’ve got to get surgery in on this. I have a page for you. Sorry I couldn’t get it done.”

  Julie thanked Dr. Sung for her efforts, but had her doubts about the surgery. If GI would not consider a colonoscopy because of Shirley’s cardiac and pulmonary risk factors, it was likely she would get even more pushback from surgical consults.

  Only one option remained—Shirley would have to stay in the ICU, get drugged up, get more swollen, and deal with the pain and bleeding as it came and went like the tides. Julie could provide little in the way of meaningful therapy.

  Shirley was brought back to the ICU and awake when Julie checked up on her again. Her eyes were open, but dull as if they were covered with film. Her short hair lay matted and without luster. Her lips were two bloodless threads on a starkly sallow face.

  “Shirley, how are you holding up?” Julie asked.

  “I want to die,” Shirley managed to say in a weak, gravelly voice.

  The words hit Julie hard, and of course she thought of Sam.

  “Well, we don’t want that to happen,” Julie said.

  “I do. The pain is horrible. I want to be with my Bobby. I want to go with him.”

  Bobby was Shirley’s husband of fifty years. There were children and grandchildren in the picture, some now in the waiting room, but in this condition Shirley took no joy from them. Everything hurt, and hurt horribly.

  Julie locked eyes with Amber, the young nurse who had cared for Shirley the last time. Shirley’s predicament was indeed dire, and Julie believed the sick woman was justified in her wish to end her suffering. All Julie could do now was manage the pain with a little help from Dilaudid.

  While conducting her exam, Julie noticed significant erythema on the back of Shirley’s left hand ringing the 18-G IV. It had not been present at the last check. The red inflammation looked similar to Sam’s outbreak of hives, but distinct enough for Julie to know it was not the same condition.

  “How long has she had this redness?” Julie asked Amber, a tinge of concern in her voice.

  Amber looked at Julie, a little flummoxed. “I just noticed it now,” she said.

  Julie called for a stat surgical consult and while waiting, began her procedures. She placed an internal jugular central venous access line and right radial arterial line. Shirley would need aggressive resuscitation for hemorrhagic shock using fluids and pressors. A full panel of lab work was repeated. Results came back fast, and one got Julie’s attention right away. Shirley’s blood gas reading showed her oxygen level was now below sixty millimeters of mercury, which meant respiratory failure. Shirley actually looked worse than her blood gas indicated. She was pale and sweaty, mottled on her arms and legs. Julie called out to the staff: “We need to intubate in here!”

  Additional nursing staff charged into Shirley’s room. Tammy, the respiratory therapist, began bagging Shirley with an ambu bag while Julie set up her endotracheal tube. One nurse was drawing up etomidate and another busied herself with the suction tubing.

  The intubation went as smoothly as expected given the circumstances. Shirley was heading toward unconsciousness and very little sedation was needed. Her blood pressure, however, tanked, as usually happens after an intubation, and additional boluses were given.

  The surgeon, a handsome man with a Harvard pedigree, finally arrived to do his assessment.

  It’s about time, Julie thought.

  He was immediately distracted by Shirley’s arm.

  “Julie, good thing you called. Looks like she has a NSTI infection.”

  Necrotizing soft-tissue infections were increasingly more common at hospitals everywhere, for reasons Julie could not quite fathom. Poor woman. Not only did she have hemorrhagic shock, but septic shock as well. One hour later, Shirley was on her way to the OR for emergency debridement, a procedure she was deemed fit enough to survive despite her fragile condition. The timing of Shirley’s departure coincided with the end of Julie’s workday, but she was not headed for home. She had a stop to make first.

  MCI Cedar Junction.

  * * *

  LUCY FOUND Dr. Becca Stinson with her eyes pressed against the lens of a microscope. She tapped the young resident on the shoulder, which caused a bit of a scare, bu
t got her attention.

  “Becca, do you have a minute?” Lucy asked.

  The question was rhetorical. Everyone always had a minute for the boss.

  “Yes, of course,” Becca said.

  Lucy brought a clipboard that held printouts with the lab order for Sam Talbot’s stains. She handed the clipboard to Becca. “Do you recall doing these stains?”

  As part of their training, residents learned the equipment and procedures by doing tests typically handled by the lab techs. For Becca and her peers, processing stains and reviewing path slides was as common a practice as checking e-mail. Equally common were long hours without sunlight. Lucy noticed Becca’s peaked complexion and how her wide eyes had rings around them, a mark of too many hours gazing through a microscope. Lucy brought the paper trail of Sam’s extensive lab tests, hoping a quick review would refresh Becca’s overtaxed memory.

  “This is Sam Talbot, Julie Devereux’s husband, right?” Becca said, while leafing through the pages.

  “Fiancé,” Lucy corrected. “And yes, that’s right. I was wondering if you remember anything about the stain.”

  Becca’s expression went blank. “Like what?”

  “Specifically if the eosinophils in the stain showed up pink.”

  Becca strained, trying to recall.

  “I think that’s right. It was a long time ago, though. I thought I had put something about allergic reaction in my lab report, but it’s not what’s indicated in the report you handed me, so I guess I’m mistaken.”

  “Take a look at this, then. It’s the actual slide.”

  Lucy went to the digital slide scanner and in no time had the slide of Sam’s heart on the display screen for Becca’s review. It was the same image Lucy had studied in her office after the autopsy and again moments ago. A sea of purple dots covered darker patches to indicate denser tissue morphology. Each slide was like a little painting, and Lucy found the variations, the differing contrasts, and abstract shapes endlessly fascinating. Like paintings, each slide had a story to tell, but the interpretations were seldom subjective. White Memorial used an automated system to apply the H&E stains, the gold standard for this procedure, and the slide on the screen clearly showed elevated neutrophils. The purple coloring was a common occurrence in myocardial infarctions, but also supported Lucy’s takotsubo theory. End of story. If Sam had experienced some sort of allergic reaction, as Julie speculated, the eosinophils in the slide would have stained pink during the chemical reaction, but such was not the case.