Marker

by Robin Cook

  “Wait!” Laurie cried, before Jazz ducked out the door. When Jazz turned back to her, she added: “I want this IV out.”

  “Sorry,” Jazz said with a shake of her head. She came back into the room, and coming alongside Laurie, she hooked a hand under Laurie’s armpit. Without warning, she pulled Laurie back to where she had been in the bed. Laurie winced with the pain. She was also impressed with Jazz’s strength. “You were in shock when you came into the emergency room,” Jazz continued. “You need that IV in case you relapse. You need fluid, and you might need more blood.”

  “Another IV can be put in,” Laurie contended. “I want this one out. If you don’t take it out, I’ll pull it out myself.”

  Jazz stared at Laurie for a beat. “You are a feisty one, aren’t you? Well, you might have some trouble pulling that baby out. It’s a peripheral central line, which sounds a bit contradictory, but it’s a long catheter that’s been stitched under that little bandage covering the entry point. You’d be pulling away a sizable hunk of tissue if you were to yank it out.”

  “I want my doctor called,” Laurie said. “Otherwise, I’m going to take out this IV no matter what, get myself out of this bed, and walk out of here.”

  Jazz’s wry, brazen smile that she had left with earlier reappeared. “You are too much. Seriously! I read that you practically bled out this evening, and now a few hours later, you’re giving orders. I’ll tell you what I’ll do. I’ll call the doctor and explain exactly what you just told me. How does that sound?”

  “It would be better if I told her myself.”

  “Maybe, but that is problematic, since your phone is not yet set up. Anyway, I’ll make the call, explain the situation exactly, including your refusal to have blood drawn for a clotting study, and then I’ll be right back. How is that?”

  “It’s a start,” Laurie conceded.

  As Jazz walked out of the room, Laurie let her head fall back against the pillow. Her bed was cranked up about thirty degrees. Her heart was pounding in her temples, and the pain in her incision site was worse, and she now had the new concern that she might have torn a few stitches. Yet she felt as if her panic had peaked. She took a deep breath and let it out, trying to relax a degree. She even closed her eyes. Having Jazz get in touch with Laura Riley wasn’t as good as getting Jack on the line, but as she had said to Jazz, it was a start.

  twenty-three

  ONCE AGAIN, EVENTS DIDN’T progress as Jack would have preferred. David Hancock was at lunch but due back any minute. At first, Jack thought this news was someone’s idea of a joke, since it was in the middle of the night. That was before he remembered that people who worked the night shift lived in a completely opposite world time-wise, and for them, their middle-of-the-shift meal was lunch, no matter what the clock said.

  Jack paced the room until David Hancock appeared. He was a slight man of indeterminate genealogy. As if in compensation for the scant hair on the top of his head, he wore a scraggly, graying goatee and mustache, giving him a decidedly devilish look. He listened to Jack’s request without comment before taking the Post-it. While he looked at it, he noisily sucked his teeth.

  “Are you sure this is a laboratory test?” David asked, raising his eyes to Jack.

  Jack’s optimism about getting an answer took a nosedive. “Reasonably sure,” he said as he reached out to retrieve the note.

  David moved the Post-it from Jack’s reach as he continued to stare at it. “What made you think it was a laboratory test?”

  “It was part of the preoperative orders on a number of patients,” Jack said while looking over his shoulder at the door.

  “It wasn’t a preoperative order in this hospital,” David said.

  “No,” Jack agreed, nervously shifting his weight, trying to make up his mind if he should just turn around and leave. “It was at the Manhattan General and at the Saint Francis out in Queens.”

  “Pshaw,” David voiced disparagingly. “Two AmeriCare institutions.”

  Caught off guard by the lab supervisor’s comment, Jack leaned forward to get a better look at the man’s expression. “Do I detect a value judgment in your voice?”

  “You’d better believe it,” David said. “I’ve got a sister in Staten Island who works for the city, and she’s had some medical problems. AmeriCare has given her the runaround. It’s all a business with those people, and taking care of patients is the last thing on their mind.”

  “I’ve had my differences with them as well,” Jack admitted. “Maybe someday we could share war stories. But right now I’m interested in learning what kind of test an MASNP is.”

  “Well, I have to admit I don’t know what it is with a hundred percent surety,” David began, “but my guess would be it is a medical genomics test.”

  Jack was taken aback. A half hour earlier Shirley Mayrand had made him feel old. Now he was afraid David was about to do the same thing in terms of knowledge. Jack was acquainted with the science of medical genomics, but his knowledge was limited to identity markers used in forensics. He knew the relatively new field, spurred by the decipherment of the entire human genome, was racing ahead at an exponential rate.

  “My guess would be that the MA stands for microarray, which is a high-throughput technology generally used for gene expression.”

  “Is it now?” Jack questioned innocently. He was already over his head and was embarrassed to admit it, although what David was saying was now relating to what Henry had said about the “positive MEF2A” on the other Post-it note.

  “You’ve got a funny expression, doctor. I mean, you do know what a microarray is, don’t you?”

  “Well, not exactly,” Jack admitted.

  “Then let me explain. Microarrays are a grid or checkerboard of minute spots of a mixture of varying but known DNA sequences usually affixed to the surface of a microscope slide. And we’re talking about a lot of spots. I mean thousands, such that they can give information on the expression of thousands of genes at any given moment.”

  “Really!” Jack said and then wished he hadn’t. He knew he was sounding stupid.

  “But I doubt the test you are questioning about is a test for gene expression.”

  “No?” Jack voiced meekly.

  “No, I don’t think so. My guess is that the SNP stands for single nucleotide polymorphism, which I’m sure you know is a point mutation in the human genome. Also as you know, thousands of SNPs have now been mapped so exactly throughout the human genome that they can be linked to specific mutated genes that are passed from generation to generation. Those SNPs that are so linked are called markers. They’re markers for the bad, mutated gene.”

  It was as if the proverbial lightbulb lit up in Jack’s mind. He hadn’t followed everything David was saying, but it didn’t matter. With trembling fingers, he hastened to get out the page from Sobczyk’s chart. When he did he pulled off the other wrinkled Post-it. He showed it to David. “Could this possibly be a result of an MASNP?”

  David took the second Post-it and scratched his head. “Positive MEF2A,” he read out loud. “Does that ring a bell? Hmmm.” He looked away and tapped his baldpate with a knuckle. Then he looked back at the Post-it. “Yes! I remember MEF2A. If I’m not mistaken, it’s a gene somehow associated with coronary arteries. I don’t know exactly how it is related, but I recall that if someone gets the mutated form of the gene, then the individual has a high probability of getting coronary artery disease. So to answer your question, ‘positive MEF2A’ could be the result of an MASNP test, meaning the test determined the individual had the specific SNP that was a marker for the mutated MEF2A gene.”

  Jack suddenly reached out and grabbed David’s hand and gave it a rapid, sincere shake. “Let’s get together some time! And thanks! I believe you might have solved a mystery.”

  “What kind of mystery?” David asked, but Jack was already running for the door.

  Having come into the lab through the emergency department, Jack used the same route on his way out. He gu
essed that there was another exit that might have been more convenient, but he didn’t want to take the time to inquire. The Post-it quest, as he called it, had turned out to be more successful than he’d imagined. He now thought he had both a possible motive and a possible, although unprovable, method for the deaths that Laurie had been so clairvoyantly documenting. All that he needed was to find out where Laurie had come up with the “positive MEF2A” to see if there were other markers with other patients.

  Jack burst through the double doors that separated the emergency department from its waiting room and partially collided with a man in a wheelchair who was being brought in for treatment. The man was wheezing, and his wheezing got worse with the fright of the near collision. Apologizing, Jack wished the man well and ran across the waiting room and out into the night. The rain had picked up, but he didn’t care. If what he was thinking was correct, AmeriCare was even more shockingly amoral and venal than he had imagined. And he was even gladder that Laurie was being held in the PACU and not allowed out on the hospital floors.

  Reaching First Avenue, Jack turned south. He squinted as he ran into the rain, and he could feel rivulets running down his face. He had a definite idea of where Laurie had come across the “positive MEF2A.” He just had to find it as the clincher. He thought he’d give himself fifteen minutes in Laurie’s office. If he was unsuccessful after fifteen minutes, he’d put it off until a later time and beat a retreat over to the Manhattan General. Even if Brunnhilde wouldn’t let him back into the PACU, he’d be content to park himself outside the door.

  Laurie woke up with a start. The fact that she had fallen asleep in the face of her anxiety scared her as much as the commotion that had awakened her. It was Jazz and Elizabeth, both of whom had breezed into the room, talking about another patient. Jazz came over to Laurie’s right, while Elizabeth rounded the foot of the bed and ended up on Laurie’s left.

  With effort, Laurie straightened herself upright. While sleeping, she had sagged over to the point that her shoulder was resting against the bed’s guardrail. She glared at both women in turn. She had a constant low-grade pain in her abdomen, and her mouth was bone-dry. Up in the PACU, she had been given ice chips, whereas in her current room, she’d been given nothing.

  “My gosh!” Jazz said with surprise, looking down at Laurie. “If we’d known you’d fallen asleep, we could have saved ourselves some trouble.”

  “Did you talk with my doctor?” Laurie demanded.

  “Let’s say I talked with one of them,” Jazz answered. Her brash smile reappeared as if she was enjoying teasing Laurie.

  “What do you mean, one of my doctors?” Laurie questioned.

  “I talked with Dr. José Cabreo,” Jazz said. “He happens to be available, whereas your Dr. Riley is undoubtedly sleeping.”

  Laurie felt her pulse quicken. She also remembered Dr. José Cabreo’s name from Roger’s lists. In fact, she had read the man’s credentialing record and had learned about his malpractice and addiction problems. There was no way she wanted anything to do with the anesthesiologist.

  “He was very upset to hear you were acting up,” Jazz continued. “He reminded me under no uncertain terms that the clotting study ordered for you must be done. He was also very disturbed about your threats to yank out your IV and climb out of your bed, drain and all.”

  “I don’t care what Dr. Cabreo thinks,” Laurie snapped. “You said you were going to call my doctor. I want to talk with Dr. Laura Riley.”

  “Correction,” Jazz said, holding up her index finger. “I said I would call the doctor, not your doctor. I should remind you that the anesthesia department still feels that they have responsibility for you to a large degree. You are technically in a postanesthesia state.”

  “I want my doctor!” Laurie growled through clenched teeth.

  “She’s a pistol, isn’t she?” Jazz said to Elizabeth.

  Elizabeth smiled and nodded.

  Jazz looked back down at Laurie and said, “Since it’s almost four A.M., you should be getting your wish in just a few more hours. Meanwhile, we intend to strictly follow Dr. Cabreo’s orders that he has been nice enough to communicate to us for your own protection.” Jazz nodded to Elizabeth.

  Laurie started to reiterate her feelings about Dr. Cabreo, but before she could complete a sentence, Jazz and Elizabeth simultaneously lunged for her forearms, pinning them to the bed. Shocked by this sudden, unexpected assault, Laurie struggled to free herself, but a combination of her pain and the nurses’ strength made it impossible. The next thing she knew, her wrists were secured in Velcro restraints, which were in turn affixed to the undercarriage of the bed. It had all happened so quickly, Laurie was dumbfounded.

  “There! Mission accomplished!” Jazz said to Elizabeth as she straightened up. “We can now relax with the confidence the IV will stay put and this uncooperative patient will not go wandering off.”

  “This is an outrage,” Laurie sputtered. She yanked ineffectually against the restraints, which only made the guardrail rattle. The restraints held firmly.

  “Dr. Cabreo doesn’t think so,” Jazz said with a smile. “The stress of surgery does disorient some people, and they need to be protected from themselves. At the same time, he was concerned you might be a little upset, so he ordered a nice, strong, quick-acting sedative.” From her pocket, she produced a syringe that was already prepared for an injection. She took off the needle cap with her teeth and held the syringe up to the light, tapping it gently with the nail of her right index finger.

  “I don’t want any sedative,” Laurie shrieked. She tried again to free her hands.

  “That’s just the kind of response the sedative is to prevent,” Jazz said. “Elizabeth, would you mind holding Miss Montgomery while I do the honors.”

  With a smile not too dissimilar from Jazz’s, Elizabeth grasped Laurie’s shoulders and leaned her considerable weight over her. Laurie tried to squirm, but it was to no avail. She felt the cold alcohol pledget swipe across the skin of her upper arm, followed by a pinch and a short, sharp pain. Jazz straightened up, replacing the cap on the used needle.

  “Sleep tight!” Jazz said. She waved to Elizabeth, and the two women walked out of the room.

  A helpless moan escaped from Laurie’s lips as she settled back onto the pillow. Earlier, with her pain and the effects of the drugs she’d been given, she had believed it would have been impossible for her to feel more helpless than she already had, but she was wrong. She was now literally tied to the bed like a potential sacrificial victim. She had no idea what kind of injection she’d been given. For all she knew, it was a poison and the struggle was already over. If it was a sedative, as Jazz had claimed, then soon she was destined to be that much more vulnerable.

  Although Jack was in superb aerobic shape from both basketball and biking, he was out of breath when he skidded to a stop in front of the elevators in the OCME. He’d heard Carl Novak yell out his name as Jack ran past the security office, but Jack didn’t slow down. No one was in the mortuary office. Jack struck the elevator button repeatedly, as if doing so would speed up its arrival.

  As he waited, he tried to think of what Laurie could have possibly done with the CD she’d burned in Roger’s office. It had to have been on the CD that Laurie had come across the MEF2A reference. The elevator arrived and Jack jumped on. The CD hadn’t been with the charts or the lists, and he hadn’t seen it in her desk drawers. The only place he hadn’t looked was the four-drawer file cabinet. He glanced at his watch. It was five minutes past four. He’d now been gone from the Manhattan General a little more than three hours, which he felt was the upper limit of what he was comfortable with. As he had decided, he was going to hold himself to fifteen minutes for the CD search.

  The elevator bumped to a stop, and it seemed to take an inordinately long time for the door to open. Impatiently, Jack hammered at it with the base of his fist. In its own time it slid open, and Jack took off down the darkened hallway. Like a cartoon character, he almost mi
ssed the door into Laurie’s office because of how quickly he was running. He had to grab the jamb to keep from sliding past on the heavily waxed floor. Once inside Laurie’s office, he started with the top drawer of the file cabinet.

  After five minutes of vain searching, Jack slid the bottom drawer closed and stood up. He scratched his head, puzzling over where on earth she would have put the damn CD. He glanced at Riva’s desk but dismissed it as a possibility. There would be no reason for her to store it there. A better possibility was that he had missed it when he’d gone through Laurie’s desk, so he sat down and searched all her drawers again. This time he was particularly thorough, believing the CD had to be in there somewhere.

  Jack sat up again after closing the last drawer. “Damn,” he voiced out loud. He looked at his watch. He had less than five minutes of his allotted time left. As he looked back up at the desk surface with the idea of going through the stack of charts to see if the CD had inadvertently gotten into one, his eyes noticed the tiny yellow light on the frame of Laurie’s computer monitor. Although the screen was dark, the light suggested that the computer was booted but the monitor had powered itself down.

  With his right index finger, Jack hit one of the keys on the keyboard. Instantly, the screen illuminated, and Jack found himself looking at a page of Stephen Lewis’s record, listing the results of all his laboratory tests. The print was small, and Jack had to fumble with the reading glasses he’d secretly gotten. With the glasses on, he was able to read the print, and his eye went down the column on the left-hand side of the page. Eventually, he came to “MASNP,” and running his finger along horizontally, he found “positive MEF2A.”

  With a shake of his head at his stupidity of not looking for the CD in Laurie’s CD drive, Jack took hold of Laurie’s mouse and spent the next several minutes scrolling through the digital record of various patients in Laurie’s series. What he found didn’t surprise him. With every case that he looked at from both the Manhattan General and St. Francis, he found that the MASNP test was positive for a marker for any one of a number of deleterious gene mutations. Some he recognized, but others he did not. When he got to Darlene Morgan’s chart, he got a particularly chilling wake-up call. Her MASNP was positive for the BRCA1 gene!