by Robin Cook
As soon as the output printer stopped, Philips pulled out the sheet. Like the first one, the report was very complete, and to Philips’ delight, the computer again described the density variation and recommended more X rays from different angles as well as another CAT scan.
Throwing his head back, Philips whooped with excitement, pounding the counter top as if it were a kettledrum. A few of Lisa Marino’s X rays slipped out from under the retaining clips and fell from the viewer screen. As Philips turned and bent down to pick them up, he spotted Helen Walker. She was standing by the door, watching him as if he were crazy.
“Are you all right, Dr. Philips?” asked Helen.
“Sure,” said Martin, feeling his face redden as he retrieved the X rays. “I’m fine. Just a little excited. I thought you were going to lunch?”
“I’ve been,” said Helen. “I brought a sandwich back to eat at my desk.”
“How about getting William Michaels on the phone for me.”
Helen nodded and disappeared. Philips put the X rays back up. Looking at the subtle white flecks, he pondered what it could mean. It didn’t look like calcium, and it was not oriented in a pattern like blood vessels. He wondered how he could go about determining if the changes were in the gray matter or cellular area of the brain called the cortex, or if they were in the white matter or fiber layer of the brain.
The phone buzzed and Philips reached over and picked up the extension. It was Michaels. Philips’ excitement was obvious as he described the program’s incredibly successful performance. He said it seemed able to pick up a type of density variation that had been previously missed. He spoke so quickly that Michaels had to ask him to slow down.
“Well, I’m glad it’s working as well as we expected,” said Michaels, when Martin finally paused.
“As well as expected? It’s more than I ever hoped.”
“Fine,” said Michaels. “How many old X rays have you run?”
“Really only one,” admitted Martin. “I ran two, but they were both from the same patient.”
“You’ve only run two X rays?” said Michaels, disappointed. “I hope you didn’t wear yourself out.”
“All right, all right. Unfortunately I don’t have much time during the day to spend on our project.”
Michaels said he understood, but implored Philips to run the program against all the skull films he’d read in the last few years, rather than being sidetracked by one positive finding. Michaels emphasized anew that at this juncture of their work, eliminating false negative readings was the most important task.
Martin continued to listen, but he couldn’t stop studying the spidery density changes on Lisa Marino’s X ray. He knew she was a seizure patient and his scientific mind quickly asked if there could be an association between the seizures and these subtle findings on the X ray. Perhaps they represented some diffuse neurological disease . . .
Philips terminated the conversation with Michaels with a new sense of excitement. He’d remembered that one of Lisa Marino’s tentative diagnoses was multiple sclerosis. What if he’d stumbled on a radiological diagnosis for the disease? It would be a fantastic find. Doctors had been looking for laboratory diagnosis of multiple sclerosis for years. Martin knew he had to get more X rays and a new CAT scan on Lisa Marino. It wasn’t going to be easy since she’d just been operated on, and he’d have to get Mannerheim’s approval. But Mannerheim was research-oriented and Philips decided to approach him directly.
He yelled through the door for Helen to get the neurosurgeon on the phone and went back to Lisa Marino’s X ray. In radiological terms the density changes were called reticular although the fine lines seemed to be parallel rather than net-like. Using a magnifying glass, Martin wondered if nerve fibers could be responsible for the pattern he was seeing. That idea didn’t make sense because of the relatively hard X rays that had to be used to penetrate the skull. His train of thought was interrupted by the buzzer. Mannerheim was on the phone.
Philips began the conversation with some usual pleasantries, ignoring the recent episode about the X rays in the OR. With Mannerheim it was always better to let such encounters slide. The surgeon seemed peculiarly silent so Martin continued, explaining that he was calling because he’d noticed some peculiar densities on Lisa Marino’s X rays.
“I think these densities should be explored and I’d like to get more skull films and another CAT scan as soon as the patient can tolerate it. That is, of course, if you agree.”
An uncomfortable pause followed. Philips was about to speak when Mannerheim snarled, “Is this some kind of a joke? If it is, it’s in very bad taste.”
“It’s no joke,” said Martin, bewildered.
“Listen,” shouted Mannerheim. His voice was rising, “It’s a bit late for Radiology to be reading X rays now. Christ!”
There was a click and a dial tone. Mannerheim’s egocentric behavior seemed to have reached new heights. Martin hung up the phone, thinking. He knew he couldn’t let his emotions intervene; besides, there was another approach. He was aware that Mannerheim didn’t follow his post-op patients that carefully, and that it really was Newman, the Chief Resident, who was responsible for their day-to-day management. Martin decided to get in touch with Newman and see if the girl was still in the recovery room.
“Newman?” asked the OR desk. “He’s been gone for some time.”
“Oh!” said Philips. He switched the phone to the other ear. “Is Lisa Marino still in the recovery room?”
“No,” said the OR desk. “Unfortunately she never made it.”
“Never made it?” Philips suddenly comprehended Mannerheim’s behavior.
“Died on the table,” said the nurse. “Tragedy, especially since it was Mannerheim’s first.”
Philips turned back to his viewer. Instead of seeing Lisa Marino’s X ray, he saw her face as it had been that morning in the patient-holding area outside of surgery. He remembered his image of a bird without its feathers. It was disturbing and Philips forced his attention back to the X ray. He wondered what could have been learned. Impulsively Martin slid off his stool. He wanted to go over Lisa Marino’s chart; he wanted to see if he could associate the pattern on the X ray with any clinical signs and symptoms of multiple sclerosis in Lisa Marino’s neurological workup. It wouldn’t take the place of more X rays, but it was something.
Passing Helen, who was eating a sandwich at her desk, he told her to call down to the angiography room and tell the residents to start without him and that he’d be there shortly. Helen swallowed rapidly and asked what she should tell Mr. Michael Ferguson about the supply room when he called back. Philips didn’t respond. He’d heard her but he pretended he hadn’t. “Fuck Ferguson,” he said to himself as he turned down the main corridor toward surgery. He’d learned to despise hospital administrators.
There were still a few patients waiting in the holding area when Philips arrived in surgery, but it was nowhere near so chaotic as the morning. Philips recognized Nancy Donovan, who had just come out from the OR suites. He walked over and she smiled.
“Had some trouble with the Marino case?” asked Philips sympathetically.
Nancy Donovan’s smile vanished. “It was awful. Just awful. Such a young girl. I feel so sorry for Dr. Mannerheim.”
Philips nodded, although he found it astounding that Nancy could sympathize with a bastard like Mannerheim.
“What happened?” he asked.
“A major artery blew right at the end of the case.”
Philips shook his head in understanding and dismay. He remembered the proximity of the electrode and the posterior cerebral artery.
“Where would the chart be?” asked Philips.
“I don’t know,” admitted Nancy Donovan. “Let me ask at the desk.”
Philips watched as Nancy spoke to the three nurses at the OR desk. When she came back she said, “They think it’s still in Anesthesia, adjacent to room number twenty-one.”
Returning to the surgical lounge, which
was now crowded, Philips changed into a scrub suit. Then he walked back to the OR area. The main corridor leading down between the OR rooms showed signs of the morning battles. Around each scrub sink were pools of water whose surfaces opalesced with a film of soap. Scrub sponges and brushes littered the edges of the sinks with a few scattered on the floors. On a gurney pushed to the side of the corridor was a sleeping surgeon. He’d probably been up all night operating and when he’d come out of his case, thought he’d use the gurney for a moment’s respite. Instead he’d fallen fast asleep and no one disturbed him.
Philips reached the anesthesia room next to OR #21 and tried the door. It was locked. Stepping back he looked through the small window of the OR room. It was dark, but when he pushed the door, it opened. He flipped a switch and one of the huge kettledrum operating lights came to life with a low electrical hum. It cast a concentrated beam of light straight down on the operating table, leaving the rest of the room in relative darkness. To Philips’ shock, OR 21 had not been cleaned since the Marino disaster. The empty operating table with its mechanical undercarriage had a particularly evil appearance. On the floor around the head of the table were pools of thickened blood. Bloodstained footprints radiated out in various directions.
The scene made Martin feel sick, reminding him of unpleasant episodes in medical school. He shuddered and the feeling passed. Purposefully avoiding the gore, he rounded the table and went through the swinging door into the anesthesia room. With his foot, he kept the door ajar so he could see to turn on the light. But the room wasn’t so dark as he’d expected. The door into the hall was open about six inches, allowing some light to enter from the corridor. Surprised, Philips turned on the overhead fluorescent lights.
In the center of the room, which was half the size of the OR, was a gurney supporting a shrouded body. The corpse was covered by a white sheet, save for the toes, which stuck out obscenely. Philips would have been all right had it not been for the toes. They advertised that the covered mound was indeed a human body. On top of the body, casually placed, was the hospital chart.
Breathing shallowly, as if the presence of death was contagious, Philips skirted the gurney and fully opened the door to the corridor. He could see the sleeping surgeon and several orderlies. He glanced in both directions, wondering if he had tried the wrong door earlier. Unable to figure out the discrepancy, he decided to ignore it, and returned to the chart.
He was about to open it when he was seized by a compulsion to lift the shroud. He knew he did not want to look at the body, yet his hand reached out and slowly pulled back the sheet. Before the head was uncovered, Philips closed his eyes. When he opened them he found himself looking at the lifeless, porcelain face of Lisa Marino. One eye was partially open revealing a glazed and fixed pupil. The other was closed. On the right side of her shaved head was a carefully sutured horseshoe-shaped incision. She had been cleaned up from the operation and no blood was visible. Philips wondered if Mannerheim had done that so he could say she died after and not during surgery.
The cold finality of death swept Martin’s mind like an arctic wind. Quickly he covered the hairless head and carried the chart over to the anesthesiologist’s stool. Like most patients at a university’s hospital, Lisa Marino already had a thick chart even though she’d been in the hospital for only two days. There were long workups by various levels of residents and medical students. Philips flipped past wordy consults from Neurology and Ophthalmology. He even found a note by Mannerheim but the scribble was totally illegible. What Martin wanted was the final summary by the Chief Neurosurgical resident, Dr. Newman.
In summary the patient is a twenty-one-year-old Caucasian female with a one-year history of progressive temporal lobe epilepsy, who entered the hospital for a right temporal lobectomy under local anesthesia. The patient’s seizure disorder has been totally unresponsive to maximum medical therapy. The seizures have become more frequent, usually heralded by an aura of obnoxious odor, and characterized by increasing aggressiveness and sexual acting out. Seizure loci have been mapped in both temporal lobes but significantly more on the right by EEG.
There has been no history of trauma or known brain insult. The patient has enjoyed good health until present illness although several atypical Pap smears were reported.
Other than the abnormal EEG findings, the entire neurological workup has been normal.
All laboratory work, including cerebral angiography and CAT scan have been normal.
Subjectively the patient has reported some visual perceptual problems, but these have not been confirmed by either neurology or ophthalmology. The patient has also repeated transient paresthesias and muscle weaknesses, but these have not been documented. A diagnosis of multiple sclerosis with seizures is entertained but not confirmed. The patient was presented at Neurology/Neurosurgery grand rounds, and it was the combined opinion that she was a good candidate for a right temporal lobectomy.
[Signed] George Newman
Philips replaced the chart gingerly on top of Lisa Marino as if she still had sensation. Then he fled back to the lounge to change into his street clothes. He had to admit that the chart hadn’t been as rewarding as he’d hoped. It had mentioned multiple sclerosis as he’d remembered, but offered no information that could take the place of additional X rays or another CAT scan. As Philips finished dressing he kept picturing Lisa’s pale death mask. It reminded him that she would probably be autopsied, having died during surgery. Using the wall phone, he called Dr. Jeffrey Reynolds in Pathology, a friend and former fellow student, and told him about the case.
“Haven’t heard about it yet,” said Reynolds.
“She died in the OR around noon,” said Philips. “Although they took the time to sew her up.”
“Not uncommon,” said Reynolds. “Sometimes they rush them down to the recovery room to pronounce them dead just so it doesn’t mess up their operative statistics.”
“Will you be doing a post?” asked Philips.
“Can’t say,” said Reynolds. “It’s up to the examiner.”
“If you did a post,” continued Philips, “when would it be?”
“We’re really busy right now. Probably early this evening.”
“I’m very interested in this case,” said Philips. “Look, I’ll hang around the hospital until the autopsy is done. Could you leave word that I’m to be paged when they do the brain?”
“Sure,” said Reynolds. “We’ll order in and have a real party. And if there is no autopsy, I’ll let you know.”
Cramming everything into his locker, Philips ran out of the lounge. Ever since he’d been an undergraduate, he suffered from unreasonable anxiety whenever he was behind in his work. As he ran back through the busy hospital, he felt that same old unwelcome feeling. He knew he was overdue in the angiography room and that the residents would be waiting; he knew he had to call Ferguson as much as he’d like to ignore the son-of-a-bitch; he knew he’d have to talk to Robbins about the techs who wanted to take off the whole freakin summer; and he knew Helen had a dozen other emergencies waiting for him at the office.
As he ran past the CAT scanner, Philips decided to make a quick detour. After all, what was two more minutes when he was already so late. Entering the computer room, Philips welcomed the breath of cool air conditioning required to keep the computers functioning. Denise and the four medical students were grouped around the TV-like screen, totally absorbed. Standing behind them was Dr. George Newman. Philips came up to the group, unnoticed, and looked at the screen. Sanger was describing a large left subdural hematoma, and pointing out to the students how the blood clot had pushed the brain over to the right. Newman interrupted and suggested the blood clot might be intracerebral. He said he thought the blood was inside the brain and not on its surface.
“No! Dr. Sanger is right,” said Martin. Everyone turned, surprised to see Philips in the room. He bent over, and using his finger, described the classical radiological features of a subdural hematoma. There was no question tha
t Denise was correct.
“Well, that settles it,” said Newman good-naturedly. “I’d better take this fellow to surgery.”
“The sooner the better,” agreed Philips. He also suggested where Newman should make the hole through the skull to facilitate removal of the clot. He was about to ask the Chief Resident some questions about Lisa Marino, but thought better of it and let the surgeon leave.
Before Martin rushed off himself he took Denise aside. “Listen. To make up for standing you up at lunch, how about a romantic dinner?”
Sanger shook her head and smiled. “You’re up to something. You know I’m on call here at the hospital tonight.”
“I know,” admitted Martin. “I was thinking of the hospital cafeteria.”
“Wonderful,” said Denise, sarcastically. “What about your racketball?”
“I’m canceling it,” said Philips.
“Then you’re really up to something.”
Martin laughed. It was true that he only canceled racketball for national emergencies. Philips told Denise to meet him in his office to go over the day’s X rays after she’d finished the CAT scan schedule. She could bring the medical students if they wanted to come. Back in the hall, they said quick goodbyes, then Philips left. He again broke into a run. He wanted to get up a good head of steam so that when he passed Helen he’d be an unstoppable blur.
7
Waiting in a long line to check in, Lynn Anne Lucas wondered if it had been a good idea to come to the emergency room. Earlier she had called student health, hoping to be seen on campus, but the doctor had left at three, and the only place she could get immediate care was the emergency room at the hospital. Lynn Anne had debated with herself about waiting until the following day. But all she had to do was pick up a book and try to read to convince herself to go at once. She was scared.
The emergency room was so busy in the late afternoon that the queue just to check in moved at a snail’s pace. It seemed as if all of New York were there. The man behind Lynn Anne was drunk, dressed in rags, and reeking of old urine and wine. Each time the line would move forward, he would stumble into Lynn Anne, grabbing at her to keep from falling. In front of Lynn Anne was a huge woman, carrying a child completely swathed in a dirty blanket. The woman and child were silent, waiting their turn.
