It was just after four in the afternoon. Earlier in the day a light rain had moved in on the city, floating a slick of embedded oil up onto the highways. The result-a series of multivictim accidents-had kept him at work in the E.R. longer than he had wished.
Finally he had signed out to the senior resident Joe Silver had appointed-to take Reed's place, and agreed to split shifts with the man each day until a more permanent arrangement could be made.
Earlier in the day, Laura had phoned with a report of her call to the anatomy department and news of the probable murder of Thaddeus Bushnell.
Hoping to come up with an explanation for the similarities between the deaths of John Doe and Loretta Leone, Eric had battled back the urge to tell her right then of the horrible error he might have made. Very soon, though, they would have to have that talk.
With a growing sense of urgency, he piled the texts on the corner of a table and began. Within an hour his list of toxins was at forty.
Aconite, curare, botulin, belladonna, sapotoxin, physostigmine, tetrodotoxin, cyanide, arsenic, acetanilide, antimony, barbiturates, bee venom, mandrake root, muscarine, amanita, picrotoxin, reptile neurotoxin, strychnine…
One by one on index cards he fisted the substances, their toxic doses, routes of administration, sources, and principal symptoms. Each of them was capable of causing death by neurologic or cardiac paralysis, and by inference, specific doses of each might induce a marked metabolic slowdown. The task of sorting them out seemed overwhelming. But so, too, Eric reminded himself, were the hundreds of organic chemistry formulas he was once faced with memorizing.
An hour passed, then another, as he worked his way through his cards.
Bit by bit the list grew smaller.
For a time, one toxin or another would catch his fancy, only to be discarded by the question- How could both victims have been exposed? or Could the effect of the substance possibly stop after metabolic paralysis and before death? Amanita, a mushroom poison, was one of the leading candidates. So for a time were strychnine and the toad poison bufotoxin. But again and again, as if daring him to refute it, one substance kept cropping up. tetrodotoxin, a product found in certain species of puffer fish, and believed by one researcher at least to be the long-sought-after zombi poison.
In Japan certain chefs were certified by the government in the preparation of fugu, a puffer-fish sashimi dish that straddled the line between food and drug. The chefs, some of whom occasionally died from sampling their wares, sought to preserve just enough tetrodotoxin to cause flushing of the skin, tingling of the lips and extremities, and a mild euphoria. But numerous cases of puffer-fish poisoning had been documented, the effects being, in part, pulmonary edema due to cardiac slowing, respiratory failure, and marked metabolic depression.
Could Loretta Leone and John Doe somehow have inadvertently eaten fugu?
The idea made no sense.
Outside the library the gray evening gave way to ebony night.
Inside, the pile of journals on Eric's table grew. Amanita mushrooms, fugu, aconite plant alkaloid. One by one, Eric pared his list until finally only those three remained. Each, in the proper dosage, seemed capable of inducing a state of metabolic slowdown that might be indistinguishable from death.
Behind him the library door opened, then closed.
Eric did not look up. Moments later he felt a massive hand on his shoulder.
" Dr. Subarsky, — I presume," he said as he enated strychnine once and for all from his prospects.
"You are certainly a diligent little beaver," the biochemist said.
"Surely you must have something more exotic to do with your free time."
He dropped a load of books on a nearby table, settled. in across from Eric, and scanned the books he was using.
"Journal of Toxicology… Poisons of the World… Journal of Ethnopharmacology…
"See, I am doing something exotic," Eric said, realizing only then how much time had elapsed.
"And what, exactly, is that?"
Subarsky leaned back and propped his gunboat sneakers on the table.
I "I'm looking into the case of the lady that Reed Marshall pronounced dead Yesterday," Eric said.
"Ah, yes, the talk of the town. Nasty mistake the man made.
Nasty."
"I'm not so sure it was a mistake."
"Res ipsa loquitur," Subarsky said.
"what does that mean?"
"Roughly, 'the deed speaks for itself."' "David, how would you define death?"
Subarsky scratched at his beard. "The usual, I guess. Cessation of cardiac and neurologic activity-that sort of thing."
"What about all these reports I've been reading of people who had those findings for a time and then woke up?", "I can find you reports of dinosaur sightings in the Grand Canyon," Subarsky said.
"Well, I've been here for hours trying to put together a definition that fits all these reports, and you know what I keep coming up with?
Putrefaction.
That's what."
"If it doesn't rot, it ain't dead. I like it, Najarian. I like it.
Although I can see how it could make for a bit of a space problem from time to time."
"Seriously-"
"Seriously? Well, it seems to me that an M.D. degree and thirteen years of higher education qualifies you to use 'going to rot' as your standard."
"But Reed Marshall used that, and Reed Marshall was wrong."
"A fluke," Subarsky said. "One in a billion.
"I don't think so, David. Because you see, I may have made the same mistake."
Eric pulled out the E.K.G tracings and went over the two cases.
"And where is this John Doe now?" Subarsky asked.
"I don't know. Do you have some time?"
"For you? all the time in the world."
Piece by piece, Eric recounted his meeting with Laura, their visits to the Gates of Heaven and Thaddeus Bushnell, and their close call on the East Boston docks. Subarsky chewed on a pencil as he listened.
When Eric finished, his friend whistled softly.
"You have been into some shit, my man. I'll say that."
"David, I have no idea what's going on, but I think the derelict and Loretta Leone were poisoned."
"How?"
"Accident. Product tampering- Psycho. Define crazy any way You want, and I'll find you someone who fits the bill."
"And you think you stopped too soon in resuscitating the guy who may have, been your new flame's brother?"
"It's possible."
"I don't buy it."
"I don't expect you to, yet. That's what I'm doing here."
"And what have you come up with?"
"Lots of things. But what I keep coming up with is this." Eric slid his notes on tetrodotoxin across. Subarsky scanned them in a minute.
"So," he said, "once again the zombi poison rears its ugly head."
"You know about it?"
"Some. A few years ago there was a flurry of interest in it.
Even a best-selling book. But after a while articles began popping up in the scientific literature refuting most of the methods and claims."
"I know. I've read some of them."
"And you still suspect the drug?"
"Either alone or in some kind of combination.
Can a good toxicologist detect it?"
"Probably."
"What about amanita and aconite?"
"Probably.
"Well then, tomorrow I'm going to the pathology department to see if they can screen Loretta Leone's' blood. Then I think I'll try to set up an appointment with Dr. Darden."
"Ah, yes, White Memorial's resident Haitian.
Good idea."
"If anyone around here would know about the tetrodotoxin myth, he would."
"Agreed. But do you know if he's ever been near Haiti since he came to the States?"
"Actually, I do," Eric said. "There's a clinic in Port-all-Prince that he helped set up. From time to time he takes a
resident down with him."
"In that case, he may well be the man who can put you straight."
"What do you mean?"
"Well, I'm no expert in this particular area, but I can't believe any drug could do the things you're concerned about. As an Armenian, you have this overdeveloped, genetically inbred sense of responsibility.
That's what makes you such a terrific doctor. But along with it goes your equally inbred Armenian sense of guilt. And right now, that sense is saying that you might have been able to do something to prevent the death of your friend's brother."
"Well, I've known you for a long time, Eric, and I know that if something wasn't right about that case, you would have spotted it."
"Maybe so," Eric said. "But right now, my inbred Armenian intuition is telling me that I'm onto something."
"In that case, if you need my help in any way, just ask."
Subarsky scratched at his beard for a few seconds and then added,
"However, I am willing to wager a pitcher of Heineken that you are orbiting Mars on this one."
Eric gathered his notes.
"I'll take the bet," he said, "and believe me, I hope you win.
Tomorrow I'll hit Darden, the pathology department, and the County Library. I'll keep you posted."
"Do that," Subarsky said. "Just let me know if I or my trusty computer can be of any assistance. And in the meantime, I'll keep my telescope trained on Mars."
I'm at the hotel. Call if you get in before 10.
If not, call before you go to work in the a.m. Have not been to the — police yet, but plan to do so tomorrow a.m. Hope your library work went well.
Thank you for all you've done.
Love, L.
PS. Refrigerator and cupboards have been restocked. Hope I didn't disturb any great bacteriology experiment by discarding the milk carton.
The note was on Eric's pillow when he arrived home, along with a volume of exquisite photographs entitled Diving Off the Caymans. He flipped through the pages, wondering what it might be like to live in such a place. For so long his life had been on automatic pilot, locked on a single unerring course. Now, there was only uncertainty-uncertainty and a woman.
He set the book aside and spent a few minutes flipping through his notes. He had expected to find Laura waiting in the apartment, and now felt some relief to discover she was not. He had much to work through.
There remained little doubt that the man he had assumed was a derelict, the man he had pronounced dead and sent off to the Gates of Heaven Funeral Home, was Laura's brother. Now there was reason good reason-to believe he should have pressed on with his efforts that day, at least for a while longer.
And although the quality of his patient's life had been a major consideration, Eric knew that his order to stop the resuscitation had been based, at least in part, on his judgment of the value of that life as well. It was a judgment he, like Reed, would have to live with for the rest of his career. it was a bit after ten, so Laura's note left him an out-an excuse to delay sharing his conclusions until morning. But the more he thought about it, the more he wanted to get it over with, to tell her everything and to hope for her understanding. Both Scott and Loretta Leone.had been somehow poisoned, either by a psycho or an inadvertent exposure to some toxin.
Despite Dave Subarsky's doubts, that much seemed clear to him now.
He hoped Laura would see that although he might have made essentially the same mistake as Reed, the deck had been stacked against them both.
He paced the apartment for a time, wondering if other patients in other settines had suffered fates similar to their two cases. Finally, he called the Carlisle. The phone rang half a dozen times before-it was picked up. No o-the spoke.
'Hello?" he said. "Laura?"
Her sigh was audible.
"Oh, thank God," she said. "Eric, I just got a call from some man who threatened me. All he kept saying was 'It's not over. We want the tape." I screamed at him that I didn't know what he was talking about, but he hung up. I don't know what's going on, but if his aim was to frighten me, he did a very good job "I'll be right over."
"You don't have to do that."
"I want to. I was sort of surprised that you weren't here."
"I'm sorry. I thought it-might be better if I spent some time alone. I just started feeling as if I was growing to depend on you too much."
"Laura," he said.,I'm depending on you too.
Believe me I am. There're some things I need to tell You about.
When I do, I think you'll see that in some ways I have as much at stake in getting to the bottom Of all this as you do. I'd really like-to come over now."
"What things?"
"Face to face?"
She hesitated."
"I'll be here," she said finally.
Laura sat cross-legged on the bed and listened impassively as Eric recounted in detail his actions and thoughts on the morning the derelict was brought in.
"I knew," she said, when he had finished. — "That first night we were together, I could see a shadow cross your face every time you talked about that resuscitation."
"For what it's worth, I'm sorry. We see so many cardiac arrest so many People brought in essentially dead after a coronary-that unless a case is strikingly different from all the others, we don't have even the slightest suspicion that something other than natural causes might be involved."
"Should you?"
"Well, I guess if we're perfect we should."
"I didn't mean it like that, and you know it," she snapped. "Eric, please. I just want to understand." He looked at her sheepishly.
"Sorry," he said. "Let me think how to explain this… Okay.
There's a concept in diagnostic medicine called index of suspicion. put in simplest terms, means, if YOU don't think of it, index of suspicion and it. The better a physician is, the more you'll never diagnostic Possibilities he considers and sifts through in a case. If you think every case of middle-aged cardiac arrest had a coronary occlusion you'll never diagnose a cocaine overdose in a fifty-five-Year-old corporation president."
"Believe it or not, the worst Physician can usually do the right thing, or at least not do something harmful, or even. eighty-five percent of the time. It's that other five or ten percent that separates great from run-of-the-mill in our business."
"most of us think of doctors so differently from that." know. And the misconceptions-the lofty expectations that the public has of us-are largely our own doing. For we as physicians have fostered the notion that things are or aren't, simply because we say SO. And the public buys into it-or at least a large segment of it does-because people want the security of knowing that there's someone they can Turn to who has all the answers. But please don't think I'm copping out or trying to make excuses for my actions last February.
I'm just trying to help you understand what was ahead. I… I just didn't have a clue or suspicion that something might might be going on.
She ached to hold him, to tell him that she understood. But. she felt unable to get past the life had been in his hands that brother… that the man whose winter morning was, in all likelihood, him.
Suddenly she found herself thinking she had once been in with a diver whose skill and competence. she had misjudged. He ended up wedged in a narrow tunnel with his air supPly all but used up. Luckily, she had sensed trouble and located him just a minute or two from disaster.
She was able to buddy-breathe him up to the surface, but the outcome could easily have gone the other way.
She wondered how her life would have changed, how she would have responded had he not made it out of that tunnel affve. The manager of her club, People diving with her day after day-they had more interest in seeing her as human, as fallible, than she did Eric.
When she finally turned back to him, tears glistened in her eyes.
"i wish you hadn't stopped trying," she said.
"I know. I wish he could have that morning back. Believe me "
I do.
And I know it doesn't help Scott, but I'm determined never to make judgments on the value of anyone's life again."
"And never to ignore the Possibility that what seems ordinary may not be true. "That too." She put her arms around him and touched her lips to his ear.
"Fair enough," she whispered.
"There it is, pal. Cleveland, Ohio.
Eddie Garcia swigged down the last of a thermos of coffee and wiped his mouth with the back of his hand. He was glad to be nearing the end of the run but was anxious about his passenger.
Soon, he would have to drop Bob off, in the econ of the dirty bus terminal, and go about unloading his rig. The man was no more prepared or equipped to strike out on his own than a kindergartener.
For a time during the journey, Eddie had tried to help him remember something, anything. But beyond recurring references to East Boston, a woman named Gideon, and her horse, he got nowhere. He Pressed questions about Bob's limp and about his family, his service record. and he asked about other things minor. Connections to his past. He guided the semi off the interstate an working his way through darkened, successively narrower streets. he would spring-for one last meal, — . and give him directions to the bus terminal. He'd also give him forty bucks to get him to East Boston.
"You feel okay?" Eddie asked.
"Uh-huh."
Scott squinted as his mind. tried to put together the images swirlin but Nothing connected.
Nothing at all. They turned onto a side street barely wide enough for driving. A man was waving a stop sign at them. He was dressed in work clothes and a plaid hunting overshirt. Garcia brought the semi to a stop and rolled down the window.
"Mornin," he said. "what's up?"
The man, husky, with close-cropped hair, walked to the window, pulled a revolver from his waistband, and held it pointed at Eddie's face.
"Open the door," he growled. "No sudden moves."
A second man, brandishing a shotgun, appeared by the passenger door, and a third stepped just in front of them.
Extreme Measures Page 19
