Side Effects

by Michael Palmer

  "There are two tragedies in life, One is not to get your heart's desire, the other is to get it." And of course, "The Omnicenter, Complete patient care with complete caring patience." There were several others, most of which Kate had heard or read before. One, however, she could not recall having seen. Done in black Benedictine calligraphy, with a wonderfully ornate arabesque border, it said, "Monkey Work for the Monkeys."

  Zimmermann followed her line of sight to the saying. "A gift from Carl,

  " he explained. "His belief is that the energy of physicians and nurses should be directed as much as possible to areas utilizing their five senses and those properties unique to human beings-empathy, caring, and intuitiveness. The mechanics of our job, the paperwork, setting up of appointments, filling of prescriptions, and such, he calls 'monkey work.

  His machines can do those jobs faster and more accurately than any of us ever could, and it seems Carl teaches them more almost every day."

  "So, " said Kate, "he's named his computers… the Monkevs." Zimmermann said the last two words in unison with her. Kate sensed a letup in the uneasiness she had developed toward Carl Horner and began looking forward to meeting the man. "Now, " Zimmermann asked, "can you brief me on what you have found in these two patients of ours? I have reviewed their records and found little that might be of help to you."

  In the concise, stylized method of case presentation ingrained in physicians from their earliest days in medical school, Kate gave a one minute capsule of each woman's history, physical exam, laboratory data, and hospital course. "I've brought sections from the ovaries of both patients. I think there's a decent microscope in the lab downstairs," she concluded. Zimmermann whistled softly. "And the only link to this point is that both were patients here? " Kate nodded. "Well, I can't add much. Miss Rittenhouse had been an Omnicenter patient since nineteen seventynine. Nothing but routine checkups since then, except that she was within one missed appointment of being asked to go elsewhere for her gynecologic care. The contract we have our patients sign gives us that option."

  "I know. I signed one, " Kate said. The contract was another example of the patient-oriented philosophy of the Omnicenter. Fees were on a yearly basis, adjusted to a patient's income. There was no profit to be made from insisting on compliance with periodic routine visits, yet insist they did. "What about Beverly Vitale?"

  Zimmermann shrugged. "Six years a patient. Abortion here five years ago by suction. Had a diaphragm. Never on birth control pills or hormones of any kind. Always somewhat anemic, hematocrits in the thirty-four to thirty-six range."

  "She was on iron."

  "Yes. Dr. Bartholomew has had her on daily supplements since the day of her first exam."

  "Who was Ginger Rittenhouse's doctor? " Kate was grasping for any connection, however remote. "Actually, she was cared for by the residents, with the help of a faculty advisor. In this woman's case, it was me. However, there was never any need for me to be consulted. She became a patient just after I arrived. I saw her once, and she has had no trouble since." He grimaced at what he considered an inappropriate remark. "Excluding the obvious, " he added. DEAD END. Kate's mind's eye saw the words as she had written them. She glanced at her watch. There would be a surgical specimen processed as a frozen section in half an hour. Her reading would determine whether the patient underwent a limited or extensive procedure. Still, she felt reluctant to let go of the one common factor she had found. "I'm due back for a frozen in a short while, Bill. Do you think Voll could take me by to meet Carl Horner and his trained Monkeys?

  "Certainly, " Zimmermann said. "He's expecting us. By the way, I understand congratulations are in order."

  "For what?"

  "Well, word has it that you are to be the next chief of pathology."

  Kate laughed ruefully. "Welcome to the new game show, I've Got No Secrets. Actually, I don't even think my name has formally been presented for consideration yet, so you can hold the congrattllations.

  Besides, with the financial mess the department is in, I'm not sure condolences wouldn't be a better response. You don't suppose that Ashburton Foundation of yours has a few extra hundred thousand lying around, do you?"

  "I have no idea, Kate. Norton Reese handles that end of things. I am just one of the barge toters and bale lifters. You might talk to him, though. The foundation certainly has taken good care of us."

  Kate stepped into the carpeted, brightly lit corridor. "I'll say they have, " she said. The chance that Norton Reese would put himself out on behalf of her department was less than none. "Monkey Work for the Monkeys." The message was displayed throughout Carl Horner's computer facility, which occupied an area at the rear of the first floor several times the size of Marco Sebastian's unit. Ensconced in the midst of millions of dollars in sophisticated electronics, Carl Horner looked to be something of an anachronism.

  Beneath his knee-length lab coat, he was wearing a plaid work shirt and a pair of farmer's overalls. His battered work boots might just as well have received their breaking in on a rock pile as in the climate-controlled, ultramodern suite. Horner greeted Kate with an energetic handshake, thotlgh she could feel the bulbous changes of arthritis in every joint. Still the man, stoop shouldered and silver haired, had an ageless quality about him. It emanated, she decided, not only from his dress, but also from his eyes, which were a remarkably luminescent blue. "Dr. Bennett, I owe you my deepest apology. The error regarding the Rittenhouse file was nothing more-nor less-than a spelling mistake on my part."

  Kate smiled. "Apology accepted. Incident forgotten."

  "Have you found the explanations you were looking for?"

  "No. No, we haven't. Mr. Horner, could you show me around a bit?

  I'm especially interested in how the machines work in the pharmacy."

  "Carl, " Zimmermann said, "if you and Dr. Bennett don't mind, I'm going to get back to work. Kate, I plan to review those slides later tonight and to do some reading. Together, I promise that we shall get to the bottom of all this. Meanwhile, enjoy your tour. We're certainly proud of Carl and his Monkeys."

  Patiently, the old man took Kate through the filling of a prescription.

  "These cards are preprinted with the patient's name and code number and included with the patient's chart when she has her appointment.

  The doctors tear em up if they're not needed. As you can see, there are twenty-five separate medications already listed here, along with the codes for dosage, amount, and instructions. The machines dispense only these medications, and then only in the form of a generic — as good as any brand-name pharmaceutical, but only a fraction of the cost. The machines automatically review the patient's record for allergies to the medication prescribed, as well as any interaction with medications she might already be taking." Horner's presentation had all the pride of a grandmother holding court at a bridge party. "If there's any problem at all, the prescription is not filled and the patient is referred to our pharmacist, who handles the matter personally."

  "What if the physician wants to prescribe a medication other than the twenty-five on the card? " Kate asked. "Our pharmacy is fully stocked.

  However, because of the Monkeys, we need only one pharmacist on duty, and he or she has more time to deal with problems such as drug interaction and side effects."

  "Amazing, " Kate said softly. "Have the Monkeys ever made an error?"

  Horner's smile was for the first time somewhat patronizing. "Computers cannot make errors. There are programs backing up programs to guarantee that. Of course, human beings are a different story."

  "So I've learned." Kate's cattiness was reflex. There was something about Horner's limitless confidence in the wires, chips, discs, and other paraphernalia surrounding them that she found disquieting. "Tell me, where do the generics come from that the machines dispense?"

  "One of the drug houses. We hold a closed-bid auction each year, and the lowest bidder gets the contract."

  "Which one has it now? " Horner's answer had been somewhat
evasive, hardly in character with the man. She watched his eyes. Was there a flicker of heightened emotion in them? She couldn't tell. "Now? Redding has it. Redding Pharmaceuticals."

  "Ah, the best and the brightest." Kate was not being facetious. In an industry with a checkered past that included thalidomide and many other destroyers of human life, Redding stood alone in its reputation for product safety and the development of orphan drugs for conditions too rare for the drugs to be profitable. "Well, Mr. Horner, I thank you.

  Your Monkeys are truly incredible."

  "My pleasure. If there's anything else I can do, let me know."

  Kate turned to go, but then turned back. "Do you have a list of the companies that have held the contract in years past?"

  "Since the Omnicenter opened?"

  "Yes." For the second time, Kate sensed a change in the man's eyes.

  "Well, it won't be much of a list. Redding's the only one."

  "Eight auctions and eight Reddings, huh?"

  "No bids have even been close to theirs."

  "Well, thanks for your help."

  "No problem."

  Horner's parting handshake and smile seemed somehow more forced than had his greeting. Kate watched as he ambled off, feeling vaguely uneasy about the man, but uncertain why. She glanced at her watch. The frozen section was due in ten minutes, and the patient would be kept under anesthesia until her diagnosis was made. Aside from alerting Bill Zimmermann as to what was going on, her Omnicenter visit had accomplished essentially nothing. Still, the clinic remained the only factor common to two dead women. As she walked through the lobby to retrieve her coat, Kate ran through the possible routes by which the ovarian and blood disorders might have been acquired. Finally, with time running short, she stopped at the reception desk, and wrote a note to Zimmermann. Dear Bill-Thanks for the talk and the tour. No answers, but perhaps together we can find some. Meanwhile, I'm sending over some microbiology people to take cultures, viral and bacterial, if that's okay with you. They will also check on techniques of instrument sterilization-perhaps a toxin has been introduced that way. Let me know if you come up with anything. Also, check your calendar for a night you could come north and have dinner with my husband and me. I'd enjoy the chance to know you better. Kate She sealed the note in an envelope and passed it over to the receptionist. "Could you see to it that Dr. Zimmermann gets this?

  " The woman smiled and nodded. Kate was halfway to the tunnel entrance when she stopped, hesitated, and then returned. She reclaimed the note, tore the envelope open, and added a PS. And Bill… could you please get me ten tablets of each of the medications dispensed by the Monkeys.

  Thanx. K.

  "Well, what do you say, Clyde. Can I count on you or not?"

  Norton Reese set aside the paper clip he was mangling and stared across his desk at the chief of cardiac surgery. Clyde Breslow was the fourth department head he had met with that day. The previous three had made no promises to help block Kate Bennett's appointment, despite delicately presented guarantees that their departments would receive much-needed new equipment as soon as her nomination was defeated. In fact, two of the men, Milner in internal medicine and Hoyt, the pediatrician, had said in as many words that they were pleased with the prospect of having her on the executive committee. "Bright new blood, " Milner had called her. Breslow, Napoleonic in size and temper, watched Reese's discomfort with some amusement. "Now jes' what is it about that little lady that bothers you so, Norton? " he asked in a thick drawl that often disappeared when he was screaming at the nurses and throwing instruments about the operating room or screaming at the medical students and throwing instruments about the dog lab. "She refuse to spread those cute little buns of hers for ya or what?"

  "The bitch made me look bad in front of the board of trustees, Clyde.

  You should remember that. It was your fucking operating microscope that caused all the trouble. I'll be damned if I'm going to have her on my executive committee."

  "Whoa, there, Norton. Your executive committee? Now ain't you gettin' just the slightest bit possessive about a group you don't even have a vote in?"

  "Look, Clyde, I've had a bad day. Do you back me on this and talk to the surgical boys or don't you?"

  "Now that jes' depends, don't it?"

  "The extra resident's slot? Clyde, I can't do it. I told you that."

  "Then maybe you jes' better get used to seeing that pretty little face of Katey B.'s at the meetin's every other Tuesday."

  Reese snapped a pencil in half. "All right. I'll try, " he said, silently cursing Kate Bennett for putting him in a position to be manipulated by a man like Breslow."

  "You do that. Know what I think, Norton? I think you're scared of that woman. That's what I think. A looker with smarts is more than you kin handle."

  Without warning, Reese exploded. "Look, Clyde, " he said, slamming his desk chair against the wall as he stood, "you have enough fucking trouble remembering that the heart is above the belly button without taking up playing amateur shrink. Now get the hell out of here and get me some support in this thing. I'll do what I can about your goddamn resident."

  With a plastic smile, Clyde Breslow backed out of the office. Reese sank into his chair. Frightened of Kate Bennett? The hell he was.

  He just couldn't stand a snotty, do-gooder kid going around trying to act grown up. She ought to be home keeping house and screwing that lawyer husband of hers. "Mr. Reese, there's a call for you on two." The secretary's voice startled him, and lunging for the intercom, he spilled the dregs of a cup of coffee on his desk. "Tlammit. Bettv. I told you no calls."

  "I know you did, sir. I'm sorry. It's Mr. Horner from the Omnicenter. He says it's very important."

  Reese sighed. "All right. Tell him to call me on three seven four four."

  He blotted up the coffee and waited for his private line to ring. It was unusual for Carl Horner to call at all. Omnicenter business was usually handled by Arlen Paquette, Redding's director of product safety. In the few moments before 3744 rang, he speculated on the nature of a problem that might be of such concern that Horner would call. None of his speculations prepared him for the reality. "Mr. Reese, " Horner said,

  "I'm calling on behalf of a mutual friend of ours." Cyrus Redding's name was one Horner would never say over the phone, but Reese had no doubt whom he meant. "How is our friend?"

  "A bit upset, Mr. Reese. One of your staff physicians has been nosing about the Omnicenter, asking questions about our pharmacy and requesting Dr. Zimmermann to send her samples of the medications we dispense."

  The word "her" brought Reese a bone-deep chill. "Who is it? " he asked, already knowing the answer. "It's the pathologist, Dr. Bennett. She's investigating the deaths of two women who were patients of ours."

  "Damn her, " Reese said too softly to be heard. "Horner, are you.. I mean, is the Omnicenter responsible for the deaths?"

  "That appears to be negative."

  "What do you mean appears to be? Do you know what's at stake?

  Paquette promised me nothing like this would happen." Reese began feeling a tightness in his chest and dropped a nitroglycerine tablet under his tongue, vowing that if this discomfort was the start of the big one, his last act on earth would be to shoot Kate Bennett between the eyes. "Our friend says for you to remain cool and not to worry.

  However, he would like you to find some effective way of… diverting Dr. Bennett's interest away from the Omnicenter until we can fix up a few things and do a little more investigating into the two deaths in question."

  "What am I supposed to do? 7' "That, Mr. Reese, I do not know. Our friend suggests firing the woman."

  "I can't do that. I don't hire and fire doctors, for Christ's sake."

  "Our friend would like something done as soon as possible. He has asked me to remind you that certain contracts are up for renewal in less than a month."

  "Fuck him."

  "Pardon?"

  "I said, all right. I'll think of something." Sudden
ly. he briohtened.

  "In fact, " he said, reaching into his desk drawer, "I think I already have."

  "Fine, " Carl Horner said. "All of us involved appreciate your efforts.

  I'm sure our friend will be extremely beholden when you succeed."

  Reese noted the use of when' instead of if, but it no longer mattered.

  "I'll be in touch, " he said. Replacing the receiver, he extracted a folder marked "Schultz/Geary." Inside were a number of newspaper articles, the official autopsy report, signed by Stanley Willoughby and Kathryn Bennett, MDS, and an explanatory note from Sheila Pierce. Also in the folder were a number of laboratory tests on a man named John Schultz-a patient who, as far as he or Sheila could tell, never existed in Metropolitan Hospital. While the chances of some kind of coverup weren't a hundred percent, they certainly seemed close to that. Sheila, he thought as he readied a piece of paper in his typewriter, if this works out, I'm going to see to it that you get at least an extra night or two each month. "To Charles C. Estep, Editor, The Boston Globe."

  Reese whispered the words as he typed them. He paused and checked the hour. By the time he was done with a rough draft, the pathology unit would be empty. A sheet of Kate Bennett's stationery and a sample of her signature would then be all he needed to solve any number of problems.

  The woman would be out of his hair, perhaps permanently, and Cyrus Redding would be-how had Horner put it? — extremely beholden. "Dear Mr.

  Estep…"

  As Norton Reese typed, he began humming "There Is Nothing Like a Dame."

  Thursday 13 December

  "Do you think God is a man or a woman, Daddy?"

  Suzy Paquette sat cross-legged on the passenger seat of her father's new Mercedes 450 SL, parked by the pump at Bowen's Texaco. Behind the wheel, Arlen Paquette watched the mid-morning traffic glide by along Main Street, his thoughts neither on the traffic nor on the question he had just been asked. "Well, Daddy?"