by Robin Cook
As tired as he was, Jeffrey could not get back to sleep after being awakened by the telephone. Had he been fully awake when it had rung, he probably wouldn’t have answered it. He’d not discussed how to handle phone calls with Kelly, but he was probably safer not picking up. Lying in bed, Jeffrey remained vaguely troubled by the caller. Who could have been asking for Chris? His first thought was that it had been a cruel prank. But it could have been someone trying to sell something. They could have gotten Chris’s name from some list. Maybe he wouldn’t mention the call to Kelly. He hated to dredge up the past just when she was beginning to put it behind her.
Jeffrey’s mind returned to considering the contaminant theory instead of dwelling on the mysterious caller. Rolling over on his back, he reviewed the details. Then he decided to get up and shower and shave.
While he was making coffee, he began to wonder if his anesthetic complication and Chris’s were isolated episodes or if there had been other similar incidents in the Boston area. What if the killer had tampered with Marcaine other times besides the two Jeffrey knew of? If he had, Jeffrey would have thought reports of such bizarre reactions would have filtered through the grapevine. But then again, look what had happened to him and Chris. They’d each been served with malpractice suits instantly. At that point, defense of the case had become of paramount importance, dwarfing other issues.
Remembering that the role of the Board of Registration in Medicine in the state of Massachusetts had been statutorially expanded to keep track of “major incidents” in health care facilities, Jeffrey called the board.
After a brief runaround, Jeffrey was put through to a member of the Patient Care Assessment Committee. He explained the sort of incidents he was interested in. She put him on hold for a few minutes.
“You said you are interested in deaths during epidural anesthesia?” she asked, coming back on the line.
“Exactly,” Jeffrey said.
“I can find four,” the woman said. “All within the last four years.”
Jeffrey was amazed. Four sounded like a lot. Fatalities during epidural anesthesia were extremely rare, especially after the .75% Marcaine was proscribed for obstetrical use. To have four occur in the last four years should have raised some red flags.
“Are you interested in knowing where they occurred?” the woman asked.
“Please.”
“There was one last year at Boston Memorial.”
Jeffrey wrote down “Memorial, 1988.” That had to be his case.
“There was one at Valley Hospital in 1987,” she said.
Jeffrey wrote that down. That case would have been Chris’s.
“Then the Commonwealth Hospital in 1986 and at Suffolk General in 1985. That’s it.”
That’s plenty, Jeffrey thought. He was equally amazed that all the episodes had been in Boston. “Has the Board done anything about these cases?” he asked.
“No, we haven’t,” the woman said. “If they had all occurred at one institution, it would have been put under review. But seeing that four different hospitals and four different doctors were involved, it didn’t seem appropriate for us to get involved. Besides, it’s indicated here that all four cases led to malpractice litigation.”
“What are the names of the doctors involved at the Commonwealth and Suffolk?” Jeffrey asked. He wanted to discuss the cases with these doctors in great detail to see how similar their experiences were to his. In particular, he wanted to know if they had been using Marcaine from a 30 cc ampule for the local anesthetic.
“The doctors’ names? I’m sorry, but that information is confidential,” the woman said.
Jeffrey thought for a moment, then he asked: “What about the patients or the plaintiffs in those cases? What were their names?”
“I don’t know if that is confidential or not,” the woman said. “Just one moment.”
She put Jeffrey on hold again. While he waited, Jeffrey again marveled about Boston having four deaths during epidural anesthesia and that he did not know it. He couldn’t understand why such a series of complications hadn’t become a topic of speculation and concern. Then he realized the explanation had to have been the unfortunate fact that all four had resulted in malpractice litigation. Jeffrey knew that one of the insidious effects of such litigation was the secrecy that the involved lawyers insisted on. He remembered his own lawyer, Randolph, had told him at the outset of his case that Jeffrey was not to discuss it with anyone.
“No one seems to know about this confidentiality issue,” the woman said when she came back on the line. “But it would seem to me it’s a matter of public record. The two patients were Clark DeVries and Lucy Havalin.”
Jeffrey wrote the names down, thanked the woman, and hung up the phone. Back in the guest room Kelly had made up for him, Jeffrey pulled his duffel bag from under the bed and got out a couple of hundred-dollar bills. He would have to find the time to get some more clothes to replace the ones he’d had to leave at the Essex Hotel. Briefly he wondered what Pan Am had done with his small suitcase, not that it was a matter that was safe to pursue.
Next he called for a cab. He figured it was safe to take one as long as he did nothing to arouse the driver’s suspicions. The weather hadn’t improved since he’d come from the hospital that morning, so Jeffrey hunted for an umbrella in the front hall closet. By the time the cab arrived, he was waiting on the front steps, umbrella in hand.
Jeffrey’s first objective was to buy another pair of plano dark-rimmed glasses. He had the cab wait while he went into an optician’s along the way. His ultimate destination was the courthouse. It was eerie to be entering the building where only a few days earlier a jury had voted him guilty of the second-degree murder charge.
As he went through the metal detector, Jeffrey’s anxiety increased. It reminded him too much of his episodes at the airport. He did his best to appear calm. He knew that if he seemed nervous, he’d only attract attention to himself. Despite his good intentions, however, he was visibly shaking as he entered the clerk’s office on the first floor of the old building.
He waited for his turn at the counter. Most of the people waiting were lawyer types in dark suits whose pant legs were curiously too short. When one of the women behind the counter finally looked in his direction and said, “Next,” Jeffrey stepped up and asked how to go about obtaining the record of a specific lawsuit.
“Settled or unsettled?” the woman asked him.
“Settled,” Jeffrey said.
The woman pointed over Jeffrey’s shoulder. “Gotta get the docket number from the Defendant/Plaintiff file,” she said with a yawn. “That’s those looseleaf books. Once you have the docket number, bring it back here. One of us can get the case from the vault.”
Jeffrey nodded and thanked her. He went over to the shelves she had indicated. The cases were listed alphabetically year by year. Jeffrey started with the year 1986 and looked up Clark DeVries as the plaintiff. When he found the card for the case, he realized that the information he wanted was right there; he didn’t need the whole record.
The information card listed the defendants, the plaintiffs, and the attorneys. The anesthesiologist in the case was a Dr. Lawrence Mann. Jeffrey used a handy copying machine to make a copy of the card in case he needed to refer to the docket number later.
He did the same with the card he found for Lucy Havalin’s case. Her suit had been brought against an anesthesiologist by the name of Dr. Madaline Bowman. Jeffrey had had some professional dealings with Bowman, but hadn’t seen her in years.
Removing the copy from the copy machine, he checked to make sure it was entirely legible. As he did so, he noticed the name of the attorney was Matthew Davidson.
Jeffrey winced. The copy almost slid from his hands. Matthew Davidson had been the attorney who’d sued Jeffrey for malpractice on behalf of Patty Owen’s estate.
Jeffrey knew rationally that it was ridiculous to hate the man. After all, Davidson had only done his job, and the Patty Owen estate was
entitled to legal representation. Jeffrey had heard all these arguments. But they didn’t make any difference. Davidson had brought ruin to Jeffrey by bringing up the irrelevant minor drug problem that Jeffrey had had. The move had been unfair and had been done purely as a calculated maneuver to win the case. Justice and truth had not been the goal; there had been no malpractice. Jeffrey was certain of this now that he’d eliminated his own self-doubt and was more and more convinced a contaminant had been involved.
But Jeffrey had more to do at the moment than review past injustices. Changing his mind, he decided to look at the court records after all. Sometimes you didn’t know what you were looking for until you found it, Jeffrey told himself. Going back to the counter where he’d started, he gave the woman who’d directed him before the docket numbers.
“You gotta fill out one of those request forms on the counter over there,” she told him.
Typical bureaucracy, Jeffrey thought with some irritation, but he did as he was told. After he’d filled out the forms, he had to wait in line a third time. A different clerk handled his inquiry on this occasion. When he handed her the two forms, she looked at them and shook her head, saying, “It’ll take about an hour, at the very least.”
While he was waiting, Jeffrey sought out a bank of vending machines he’d seen on his way in. He got himself a quick snack of orange juice and a tuna sandwich. Then he parked himself on a bench in the rotunda and watched the comings and goings of the courthouse. There were so many uniformed policemen, Jeffrey actually started to grow used to seeing them. It was a kind of behavior therapy that went a long way in reducing his anxiety.
After a good hour had passed, Jeffrey returned to the clerk’s room. The records he was interested in had been pulled for him. He took the large manila folders over to a side counter where he could have enough room to peruse the documents. There was a huge amount of material. Some of it was in too thick a form of legalese for Jeffrey to absorb, but he was interested in seeing what was available. There were pages and pages of testimony in the record as well as a variety of filings and briefs.
Jeffrey flipped through the testimony. He wanted to find out what local anesthetic was involved in each case. He scanned the papers pertaining to the Suffolk General case first. As he’d suspected, the local had been Marcaine. Now that he knew where in the record to look, he quickly found what he was looking for in the Commonwealth Hospital case. There, too, the local had been Marcaine. If Jeffrey’s theory of a deliberate contamination was true, that meant that the killer, Boston’s own Dr. or Mr. or Ms. X, had already struck four times. If only Jeffrey could come up with proof before the killer struck again.
Jeffrey was about to return the papers dealing with the Commonwealth case to its manila envelope when he caught sight of the settlement decision. He shook his head in dismay. Like his, the settlement had been in the millions of dollars. What a waste, he thought. He checked the settlement in the other suit. It was even higher than Commonwealth’s.
Jeffrey put the files in a basket reserved for returns. Then he left the courthouse. It had finally stopped raining, but it was still overcast and chilly and it looked like it might pour at any minute.
Jeffrey caught a cab on Cambridge Street and told the driver he wanted to go to the Countway Medical Library. He sat back and relaxed. He was looking forward to spending a rainy afternoon in the library. One of the things he wanted to do was to read up on toxicology. He wanted to brush up on the field’s two main diagnostic tools: the gas chromatograph and the mass spectrograph.
10
THURSDAY,
MAY 18, 1989
4:07 P.M.
Kelly unlocked her front door and pushed it open with her foot. Her hands were full between her umbrella, a small bag of groceries, and a large envelope.
“Jeffrey!” she called, setting the envelope and groceries on the foyer table, pushing her silver tea service to the side. She put her umbrella on the tile floor of the powder room, then stepped back out and shut the front door. “Jeffrey!” she called again, wondering if he was there or not. As she turned back into the room, she couldn’t stifle a slight cry of surprise. Jeffrey was standing in the archway leading to the dining room. “You startled me,” she said with a hand pressed up against her chest.
“Didn’t you hear me?” he asked. “I answered back from the family room when you called my name.”
“Phew,” Kelly said, recovering her composure. “I’m just glad you’re here. I have something for you.” She picked up the envelope from the table and put it in Jeffrey’s hands. “I’ve also got a lot to tell you,” she added. She picked up the groceries and carried them into the kitchen.
“What’s this?” he asked, following her with the envelope in hand.
“It’s a copy of Henry Noble’s pathology file from Valley Hospital,” Kelly said over her shoulder.
“Already?” Jeffrey was impressed. “How on earth did you manage it so quickly?”
“It was easy. Hart Ruddock sent it over by messenger. He didn’t even ask why I wanted it.”
Jeffrey slipped the file out of the envelope as he was walking. There were no electron micrographs but then he didn’t expect them. They were not part of a routine autopsy. Even so, the file seemed skimpy. Jeffrey spotted a notation that more material was on file at the Medical Examiner’s office. So that explained it.
Kelly unpacked the groceries while Jeffrey retired to the couch in the family room with the files. He found a summary of the autopsy report that was at the Medical Examiner’s office. Reading it quickly, he saw that a toxicology screen had been done but that the findings had not highlighted anything suspicious. He also saw that on microscopic section there had been evidence of histologic damage to the nerve cells of the dorsal root ganglia as well as to the cardiac muscle.
Kelly joined Jeffrey on the couch. He could tell she had something serious to tell him.
“There was a major anesthetic complication today at St. Joe’s,” she said. “No one wanted to say much, but I understand it involved an epidural case. The patient was a young woman named Karen Hodges.”
Jeffrey shook his head sadly. “What happened?” he asked.
“The patient died,” Kelly said.
“Marcaine?” Jeffrey asked.
“That I don’t know for sure,” Kelly said. “But I’ll find out, probably tomorrow. The person that told me about it thought it was Marcaine.”
“Victim number five,” Jeffrey sighed.
“What are you talking about?”
Jeffrey told her of the fruits of his day’s research, starting with his call to the Board of Registration in Medicine. “I think the fact that the deaths occurred at different hospitals increases the chances of a deliberate tampering. We’re dealing with someone who’s shrewd enough to know that more than one death during epidural anesthesia at any one institution would arouse suspicions and probably lead to an official inquiry.”
“So you really think someone—some person—is behind all this?”
“More and more,” Jeffrey said. “I’m almost certain a contaminant was involved. I went to the library today, and among other things I checked to be absolutely sure that local anesthetics in general and Marcaine in particular do not cause cellular damage, like the damage described in Henry Noble’s autopsy or revealed in Patty Owen’s electron micrographs. Marcaine just doesn’t do it. Not Marcaine alone.”
“Then what could have caused it?”
“I’m still not sure,” Jeffrey said. “I did a lot of reading about toxicology and poisons at the library too. I’m convinced it couldn’t be some traditional poison, since they would have shown up on the toxicology screen. What I’m tending to think is that it would have to be a toxin.”
“Aren’t they the same thing?”
“No,” Jeffrey said. “A poison is more a general term. It applies to anything that causes damage to cells or interrupts cellular function. Usually when someone thinks of a poison they think of mercury or nicotine or strychnin
e.”
“Or arsenic,” Kelly added.
“Exactly,” Jeffrey said. “They’re all inorganic chemicals or elements. A toxin, on the other hand, although a type of poison, is the product of a living cell. Like the toxin that causes toxic shock syndrome. That comes from bacteria.”
“Are all toxins from bacteria?” Kelly asked.
“Not all,” Jeffrey said. “Some very potent ones come from vegetables, like ricin from the castor bean. But people are most familiar with toxins that come in the form of venoms, like from snakes, scorpions, or certain spiders. Whatever was put into the Marcaine, it had to be extremely potent. It had to be something that could be fatal in minute amounts and at the same time mimic local anesthetics to a great degree. Otherwise its presence would have been suspected. The difference, of course, would be that it destroys nerve cells, not just blocks their function like local anesthetics.”
“So if it was injected along with the Marcaine, why wouldn’t it show up with the toxicology testing?”
“For two reasons. First, it’s probably introduced in such minute amounts there is very little in the tissue sample to be detected. Second, it’s an organic compound that could hide among the thousands of organic compounds that normally exist in any tissue sample. What’s used to separate all the compounds in a toxicology lab is an instrument called a gas chromatograph. But this instrument doesn’t separate everything cleanly. There’s always overlaps. What you wind up with is a graph featuring a series of peaks and valleys. Those peaks can reflect the presence of a number of substances. It’s the mass spectrograph that actually reveals what compounds exist in a sample. But a toxin could be obscured in one of the gas chromatograph’s peaks. Unless you suspected its presence and knew to search for it specifically, you wouldn’t find it.”
“Wow,” Kelly said. “So if someone is behind this, he’d really have to know what he was doing. I mean, he’d have to be familiar with basic toxicology, don’t you think?”
Jeffrey nodded. “I gave it some thought on my way home from the library. I think the murderer has to be a doctor, someone with a pretty extensive background in physiology and pharmacology. A doctor would also have access to a variety of toxins and to the Marcaine vials. To tell you the truth, my ideal suspect would likely be one of my closest colleagues: a fellow anesthesiologist.”
