Marker

by Robin Cook

“I’m glad,” Jack said. “Is it appropriate if I send some flowers?”

  “That’s completely up to you.”

  “Then I will.” Jack said. He paused, fidgeted, and then said hesitantly, “I don’t know if I should bring this up about your mother . . .”

  Then don’t, Laurie said to herself. She was disappointed. She had allowed herself to be set up after all. She didn’t want to talk about her mother.

  “. . . but I’m sure you are aware there is a hereditary aspect to breast cancer.”

  “I am,” Laurie said. She looked at Jack with exasperation, wondering where he was going with this conversation.

  “I don’t know if your mother has been tested for the markers indicating BRCA gene mutations, but the results would have significance concerning treatment. More important for you, it would have significance concerning prevention. One way or the other, I think you should definitely be tested. I mean, I don’t want to alarm you, but it would be prudent.”

  “My mother is positive for a BRCA mutation,” Laurie admitted. Some of her anger, although not her disappointment, abated when she realized that Jack was being solicitous about her health and not just her mother’s.

  “That’s an even greater reason for you to be tested,” Jack said. “Have you thought about it?”

  “I’ve thought about it,” Laurie admitted. “But I’m not convinced it would have much significance and may just add to my anxiety. I’m not about to have my breasts and ovaries removed.”

  “Mastectomy and oophorectomy are not the only preventive measures available,” Jack said. “Last night, I went on the Internet and read up on all this.”

  Laurie found herself almost smiling. She wondered if she and Jack had visited the same websites.

  “More frequent mammograms is another option,” Jack added. “Eventually, you might even consider tamoxifen treatment. But that’s down the road. Anyway, the bottom line is that it just makes sense. I mean, if this predictive information is available, you should do it. In fact, I would like to ask you to do it. No, I take that back. I would like to plead with you to do it . . . for me.”

  To Laurie’s surprise, Jack leaned forward and gripped her forearm with unexpected strength to emphasize his commitment to the cause.

  “You’re really convinced?” Laurie questioned, marveling at the “for me” part.

  “Absolutely! No question!” Jack responded. “Even if the only effect is to make you more prone to have regular checkups. That would be an enormously positive effect. Laurie, please!”

  “Is it a blood test? I don’t even know.”

  “Yes, it’s a simple blood test. Do you have a primary-care physician over at the Manhattan General, where we are now obligated to go?”

  “Not yet,” Laurie admitted. “But I can call my old college chum, Sue Passero. She’s on staff in internal medicine. I’m sure she could set me up.”

  “Perfect,” Jack said. He rubbed his hands together. “Should I call to make sure you do it?”

  Laurie laughed. “I’ll do it.”

  “Today.”

  “All right, for goodness’ sakes. I’ll do it today.”

  “Thank you,” Jack said. He released Laurie’s arm that he’d been firmly clutching. “Now that we’ve got that settled, I want to ask about whether we can compromise about your moving out of my apartment.”

  For a moment, Laurie was nonplussed. Just when she thought Jack wasn’t going to bring up their relationship, he did.

  “As I said,” he continued, “I missed you last night. Worst of all, my basketball game was a disaster. The defenses I had carefully erected against your absence had been undermined by a pregame run-in with a pair of your pantyhose.”

  “What pantyhose?” Laurie asked, raising her guard again. She purposefully didn’t laugh at Jack’s reversion to witty sarcasm. For her, there was nothing funny about suggesting that Jack’s prowess on the basketball court was a determining factor in her moving back to his apartment.

  “A pair you left in the bathroom. But don’t worry, they’re safely ensconced in the bureau.”

  “What do you mean by ‘compromise’?” Laurie asked dubiously.

  Jack fidgeted in his chair. It was apparent that he was uncomfortable with the question. Laurie let him take all the time he wanted. Finally, he made a gesture of confusion by hunching his shoulders and extending his free hand, palm up. “We’ll agree to make sure we discuss the issues on a regular basis.”

  Laurie’s heart sank. “That’s no compromise,” she said with a voice that reflected her discouragement. “Jack, we both know what the issues are. At this point, more talk is not going to solve anything. I know that sounds contrary to what I’ve usually said about the importance of communication. The fact of the matter is that I’ve been compromising from the beginning, and particularly over the last year. I think I understand where you are coming from, and I’m sympathetic, which is what has kept me in a circumstance that has not been satisfying my needs. It’s really as simple as that. I believe we love each other, but we’re at a crossroads. I’m not twenty-five anymore. I need a family; I need commitment. To use one of your expressions, the ball is in your court. It’s your decision. Talk is superfluous at this point. I’m not going to try to convince you, which, at this stage, talk would begin to sound like. And one final point: I didn’t leave in a moment of pique. It’s been a long time coming.”

  For a few minutes, they merely stared at each other without moving. Finally, Laurie was the one who moved. She leaned forward and gave Jack’s thigh a squeeze just above the knee. “This doesn’t mean I don’t want to talk in general,” she said. “It doesn’t mean we’re not friends. It just means that unless we can truly compromise, I’ll be better off staying at my apartment. And meanwhile, I’ll get back to my diversion.”

  Laurie stood up, smiled down at Jack without rancor, and then walked back through the communications room en route to the elevator.

  seven

  WITH A MIGHTY YAWN THAT brought tears to her eyes, Laurie put down her pencil, stretched, and then viewed her handiwork. She had created a matrix on a piece of graph paper that had the names of the four patients of her supposed series on the left-hand side of the page. Running along the top of the page and creating columns were all parameters of the cases that she thought might be important, including: the age of the patient, the sex of the patient, the type of surgery involved, the name of the surgeon, the anesthesiologist and anesthetic agent used, the sedative and pain medication employed, where in the hospital the patient was boarded, how the patient was discovered and by whom, the time the patient was discovered, who did the autopsy, any potentially relevant pathology, and the toxicology results.

  Currently, Laurie had preliminary entries in all the boxes of her matrix, except for the names of the surgeons and anesthesiologists, the type of anesthetic and drugs used, the toxicology results on the two cases she had posted, and any possible relevant pathology on Darlene Morgan. To fill in the empty boxes, she needed the hospital charts and the continued cooperation of Peter and Maureen. In the toxicology boxes of the two cases posted by Kevin and George, Laurie had written: negative screen, further testing pending.

  One piece of information that the matrix had already brought to her attention, which she thought important and mildly damning for her theory of a serial killer, was that the cases were not on the same ward. Two of the patients had been on the general surgical floor, while the other two had been on the orthopedic and neurosurgical floor. Since none of the patients had had neurosurgery and since one of the orthopedic cases had been on general surgery, Laurie had already called the Manhattan General admitting office for an explanation. The explanation turned out to be simple: Because the hospital operated at near capacity, beds frequently had to be allocated irrespective of the type of surgery.

  From the moment Laurie had left Jack in the ID room, she had been a human dynamo in regard to investigating the four patients. Her motivation was twofold. There was the conti
nued need for a diversion to keep from obsessing about her own problems, as Jack had surmised. That hadn’t changed. What had changed was a strong desire to vindicate her intuitive belief that these cases did not represent a coincidence. Jack’s blithe dismissal of the idea had been both belittling and galling.

  First, she had gone up to histology to see Maureen, who’d been happy to present her with a tray of McGillan’s HE-stained microscopic sections in less than twenty-four hours. With the burden of processing eight thousand autopsies a year, overnight histology-slide service was unheard-of. Laurie had thanked her profusely for her efforts and had immediately taken the slides back to her office to study them painstakingly. As she had suspected, she found no pathology in general, and specifically, she found the heart entirely normal. There were no signs of active or healed inflammation of the cardiac muscle or the coronary vessels, and she saw no abnormalities of the valves or conduction system.

  Next, she had gone down to the fourth-floor toxicology lab, where she’d run into a minor setback by bumping into John DeVries. Thanks to the bad blood between them and John’s territoriality, he’d demanded to know what she was doing wandering around in his laboratory. Not wishing to get Peter in trouble with his boss, Laurie had to be creative. She happened to have been standing next to the mass spectrometer, so she said she had never completely understood mass spectrometry and was hoping to learn something about it. Mollified to a degree, John had provided her with some printed literature before excusing himself to go down to the serology lab.

  Laurie had found Peter in his windowless, Lilliputian office, and his eyes lit up when he saw her. Although Laurie didn’t remember Peter from their life prior to the OCME, Peter remembered her when they both had attended Wesleyan University in the early eighties. He had been two years behind her.

  “I ran a toxicology screen on McGillan,” Peter had said. “I didn’t find anything, but I have to warn you that sometimes compounds can hide out in the peaks and valleys on the readout, particularly when the concentration is very low. It would be a big help if you gave me more of a hint of what you are looking for.”

  “Fair enough,” Laurie had said. “Since the autopsies on these patients suggested they suffered a very rapid demise, their hearts had to suddenly stop pumping blood. I mean, one minute everything was fine, and the next minute there was no circulation. That means we have to eliminate cardiac toxins like cocaine and digitalis, and any other drugs that can cause changes in the heart rate, either by affecting the center that initiates the beat or the conduction system that spreads the impulse around the heart. On top of that, we even have to rule out all the drugs that are used to treat abnormal cardiac rhythms.”

  “Wow! That’s a rather big list,” Peter had commented. “The cocaine and the digitalis I would have seen, because I know where to look on the readout, and they’d have to be big doses to do what you are talking about. The others, I don’t know, but I’ll look into it.”

  At that point, Laurie had asked about Solomon Moskowitz and Antonio Nogueira, whose autopsies had been done several weeks earlier. She told Peter that the cases mirrored McGillan’s. Using his keypad in front of his monitor and his password, Peter accessed the laboratory database. Both toxicology screens had been normal, but he offered to run them again now that he had a ballpark idea of what she was looking for.

  “One other thing,” Laurie had said when she was about to leave. “I did another case this morning whose samples should be on the way up. Again, it was strikingly similar to the others, which tells me there’s something weird going on over at the Manhattan General. Since I can’t find any pathology, I’m afraid the major burden is going to be on your shoulders to find out what it is.”

  Peter had said he’d do his best.

  After her visit to toxicology, Laurie had gone up to George’s office to get a look at Antonio Nogueira’s folder. George had surprised her by having copies of the salient portions waiting for her. Kevin had not been so accommodating, but he didn’t mind if Laurie made copies. Taking the material back to her office, Laurie had gone over it in detail, filling in her matrix as she went along.

  Taking the sheet containing the matrix and twisting around in her chair, Laurie waited for Riva to hang up on a call she was on with a local doctor about her hit-and-run case that morning.

  “Check this out!” Laurie said, extending the graph paper to her officemate as she hung up the receiver.

  Riva took the sheet and studied it, then looked over at Laurie. “You’re being very industrious. This is a great way to organize this information.”

  “I’m fascinated by this puzzle,” Laurie admitted. “I’m also intent on figuring it out.”

  “I suppose this is why you were pleased when you found no pathology on Morgan, meaning you had yet another case.”

  “Precisely!”

  “So what is your thinking at this point?” Riva asked. “With all this effort, you must have a better idea.”

  “I think I do. It’s become pretty clear to me that the mechanism of death was ventricular fibrillation for all four. The cause is another matter, as is the manner.”

  “I’m listening.”

  “Are you sure you want to hear? I mentioned my ideas to Jack, and he was irritatingly dismissive.”

  “Try me!”

  “All right! In a nutshell, since I’ve decided that the mechanism of death was ventricular fibrillation or cardiac standstill, and since the hearts have been structurally normal, the cause of death has to be some arrhythmia-producing drug.”

  “That seems pretty reasonable,” Riva said. “Now what about the manner of death?”

  “This is the most interesting part,” Laurie said. She leaned forward and lowered her voice as if she were afraid someone might hear. “I’m thinking the manner of death is homicide! In other words, I think I have stumbled onto the handiwork of a clever serial killer in the Manhattan General.”

  Riva started to say something, but Laurie held up her hand and moderated her voice. “As soon as I get the hospital charts, I’ll be able to fill in the rest of my matrix that will include the preop drugs, the anesthetic agent, as well as the postoperative medication. We’ll talk again and see what your response is. Personally, I don’t think the extra information is going to make any difference. The occurrence of four cases of fatal ventricular fibrillation unresponsive to resuscitation in young, healthy people undergoing elective surgery in the same hospital using customary protocols within a couple of weeks is too much of a coincidence.”

  “It is a very busy hospital, Laurie!” Riva said, simply not wanting to argue.

  Laurie breathed out forcibly. In her sensitized state, she interpreted Riva’s tone as condescending and not all that different from Jack’s. Laurie reached out and snatched her matrix from Riva’s hand.

  “It’s just my opinion,” Riva said, sensing Laurie’s reaction.

  “You’re entitled to your opinion,” Laurie said, swinging back around to face her desk.

  “I don’t mean to irritate you,” Riva said to Laurie’s back.

  “It’s not your problem,” Laurie said without looking back. “I’m a bit thin-skinned these days.” She turned around again and faced Riva. “But let me tell you this: What made those previous incidences involving serial killers in healthcare facilities go on for so long was a low index of suspicion.”

  “I think you are right,” Riva said. She smiled, but Laurie did not return the peace gesture. Instead, she spun back around and picked up the phone. She might have found it aggravating to share her ideas with Jack and Riva, but the process of vocalizing them had put everything more in focus and had served to make her even more confident that she was correct. Her friends’ objections had done nothing to shake her beliefs. She was now even more committed to her serial-killer scenario. As such, she realized that even if it were premature in the sense of having no definitive proof, it was incumbent on her to see that someone over at the Manhattan General was informed. Unfortunately, from bitte
r experience she knew that such a decision was not hers to make. It had to come from administration and go through public relations. Consequently, she dialed Calvin’s extension and asked Connie Egan, Calvin’s secretary, for a moment of Calvin’s time.

  “The deputy chief is due to leave for an Advisory Board luncheon in a few minutes,” Connie said. “If you want to try to catch him, I’d advise you to come down immediately. Otherwise, you’ll be looking at sometime after four, and even that is dependent on his getting back here, and there’s no guarantee of that.”

  “I’ll be right down,” Laurie said. She hung up and got to her feet.

  “Good luck,” Riva said, overhearing the conversation.

  “Thanks,” Laurie responded without a lot of sincerity. She picked up her matrix.

  “Don’t be disappointed if Calvin is even more dubious than I,” Riva called after her. “And he might bite your head off with such a suggestion of criminality. Remember, he has a soft spot for the Manhattan General, since he trained over there as a medical student and resident in its former life as a major university-affiliated teaching hospital.”

  “I’ll keep that in mind,” Laurie yelled back. She felt a little guilty about her behavior toward Riva. Being in such a bad mood was out of character for Laurie, but she couldn’t help herself.

  For fear of missing Calvin, she wasted no time. She took the front elevators and in less than five minutes, she was walking into the administration area. A number of people were seated on a long couch, waiting to see the chief, whose office door was closed and guarded by his secretary, Gloria Sanford. Laurie could remember a few times sitting there herself, waiting to be bawled out for doing something she was now avoiding by going to see Calvin. Laurie had been a good deal more headstrong, as well as apolitical, when she had first started at the OCME.

  “You can go right in,” Connie said as Laurie approached her desk. Calvin’s door was ajar. He was on the phone with his legs perched on the corner of his desk. As Laurie came in, he motioned with his free hand for her to take one of the two chairs facing him. Laurie’s eyes glanced around the familiar room. It was less than half the size of Bingham’s and didn’t connect with the conference room. Still, it was mammoth when compared to the space Laurie had to share with Riva. The walls were covered with the usual array of diplomas and awards and pictures with major city politicians.