“It doesn’t mean you’re infected. Your chances of actually getting the disease have to be extremely small.”
“But still there. The chance is still there.” He looked at her, and she couldn’t contradict him. Nor could she offer any false reassurance. Silence, at least, was honest.
He turned off the microscope lamp. “It has a long incubation period. So it will be a year, two years until I know. Even at five years, I’ll still be wondering. Waiting for the first signs. At least it’s a relatively painless end. You start with dementia. Visual distortion, maybe hallucinations. Then you progress to delirium. And finally you slip into a coma . . .” He gave a weary shrug. “I guess it beats dying of cancer.”
“I’m sorry,” she murmured. “I feel responsible. . .”
“Why?”
“I insisted on the autopsy. I put you in a hazardous position.”
“I put myself in that position. We both do, Dr. Harper. It comes with the job. You work in the ER, someone coughs on you, you catch TB. Or you stick yourself with a needle and you get hepatitis or AIDS.” He removed the slide and set it in a tray. Then he pulled a plastic cover over the microscope. “There are hazards to every job, just like there are hazards to getting up in the morning. Driving to work, walking to the mailbox. Boarding a plane.” He looked at her. “The surprise isn’t that we die. The surprise is how and when we die.”
“There could be some way to stop the infection at this stage. Maybe a shot of immunoglobulin—”
“Doesn’t work. I checked the literature.”
“Have you discussed it with your doctor?”
“I haven’t mentioned this to anyone yet.”
“Not even your family?”
“There’s just my son, Patrick, and he’s only fourteen. At that age, he’s got enough things to worry about.”
She remembered the photo on the desk, the shaggy-haired boy holding up his prize trout. Dvorak was right; a boy of fourteen was too young to be confronted with a parent’s mortality.
“So what are you going to do?” she asked.
“Make sure my life insurance is paid up. And hope for the best.” He stood up and reached for the light switch. “There’s nothing more I can do.”
Robbie Brace answered the door wearing a Red Sox T-shirt and ratty sweatpants. “Dr. Harper,” he said. “You got here quick.”
“Thanks for seeing me.”
“Yeah, well, you’re not exactly catching us at our finest hour. Bedtime, you know. Lots of whining and bargaining going on.”
Toby stepped in the front door. Somewhere upstairs, a child was screaming. Not a distressed scream, but an angry one, accompanied by the sound of stamping feet and the crash of something hard hitting the floor.
“We are three years old and learning the meaning of power,” explained Brace. “Man, don’t you just love parenthood?” He latched the front door and led her up a hallway, toward the living room. Once again she was impressed by how big he was, his arms so muscular they could not hang straight from his shoulders. She sat down on a couch, and he settled into a well-worn recliner.
Upstairs the screaming continued, hoarser and punctuated by loud, dramatic snuffles. There was also a woman’s voice speaking, calm but determined.
“It’s the clash of the titans,” said Brace, glancing upward. “My wife, she stands a lot tougher than I do. Me, I just roll over and play dead.” He looked at Toby and his smile faded. “So what’s this about Angus Parmenter?”
“I’ve just come from the ME’s office. They have a preliminary diagnosis: Creutzfeldt-Jakob disease.”
Brace gave an amazed shake of his head. “Are they sure?”
“It still needs confirmation by a neuropathologist. But the symptoms do match the diagnosis. Not just for Parmenter. For Harry Slotkin as well.”
“Two cases of CJD? That’s sort of like having lightning strike twice. How could you possibly confirm it?”
“Okay, we can’t confirm Harry’s case because there’s no body. But what if two residents from Brant Hill did have CJD? It makes you wonder if there’s a common source of infection.” She leaned forward. “You told me Harry had a clean bill of health on his outpatient record.”
“That’s right.”
“Did he have any surgery in the past five years? A corneal transplant, for instance?”
“I don’t remember seeing anything like that in the record. I guess you could catch CJD that way.”
“It’s been reported.” She paused. “There’s another way it can be transmitted. By injections of human growth hormone.”
“So?”
“You told me Brant Hill’s doing studies on hormone injections in the elderly. You said your patients have shown improvement in muscle mass and strength. Is it possible you’re injecting tainted growth hormone?”
“Growth hormone doesn’t come from cadaver brains anymore. It’s manufactured.”
“What if Brant Hill is using an old supply? Growth hormone infected with CJD?”
“The old growth hormone’s been off the market for a long time. And Wallenberg’s been using this protocol for years, ever since he was at the Rosslyn Institute. I’ve never heard of a case of CJD in any of his patients.”
“I’m not familiar with the Rosslyn Institute. What is that?”
“Center for geriatric research, in Connecticut. Wallenberg worked as a research fellow there for a few years, before he came to Brant Hill. Check out the geriatric literature—you’ll find a number of studies originating at Rosslyn. And half a dozen papers with Wallenberg’s name as author. He’s the guru of hormone replacement.”
“I didn’t know that.”
“You’d have to be in geriatrics to know that.” He rose from the chair, disappeared into an adjoining room, and came back out with some papers, which he set down on the coffee table in front of Toby. On top was a photocopied article from Journal of the American Geriatrics Society, 1992. There were three authors listed, and the first name was Wallenberg’s. The title of the article was: “Beyond the Hayflick Limit: Extending Longevity at the Cellular Level.”
“It’s research at its most basic,” said Brace. “Taking a cell’s maximum life span—the Hayflick Limit—and trying to prolong it with hormonal manipulation. If you accept the idea that our senescence and death is a cellular process, then you want to work toward prolonging cell life.”
“But a certain amount of cell death is necessary for health.”
“Sure. We shed dead cells all the time, in our mucous membranes and our skin. But we regenerate those. What we don’t regenerate are cells like bone marrow and brain and other vital organs. They grow old and die. And we die as a result.”
“And with this hormonal manipulation?”
“That’s the point of the study. Which hormones—or combination of hormones—prolong cell life span? Wallenberg’s been researching this since 1990. And he’s finding some promising results.”
She looked up at him. “That old man in the nursing home—the one who put up such a good fight?”
Brace nodded. “He probably has the muscle mass and strength of a much younger man. Unfortunately, Alzheimer’s has messed up his brain. Hormones can’t help that.”
“Which hormones are we talking about? You mentioned a combination.”
“The accepted research shows promise for growth hormone, DHEA, melatonin, and testosterone. I think Wallenberg’s current protocol involves various proportions of those hormones, plus maybe a few others.”
“You’re not certain?”
“I’m not involved with the protocol. I take care of only their nursing home patients. Hey, it’s all pie in the sky right now. No one knows what works. All we know is, our pituitaries stop producing certain hormones as we get older. Maybe the fountain of youth is some pituitary hormone we haven’t discovered yet.”
“So Wallenberg’s giving replacement injections.” She laughed. “Literally a shot in the dark.”
“It might work. Seems to me Brant Hil
l’s got some pretty healthy-looking eighty-year-olds zipping around on that golf course.”
“They’re also wealthy, they exercise, and they live a carefree life.”
“Yeah, well, who knows? Maybe the best predictor of longevity is a healthy bank account.”
Toby flipped through the research article, then lay it on the coffee table. Once again she looked at the publication date. “He’s been doing hormone injections since 1990, with no recorded case of CJD?”
“The protocol ran four years at Rosslyn. Then he came to Brant Hill and resumed the studies.”
“Why did he leave Rosslyn?”
Brace laughed. “Why do you suppose?”
“Money.”
“Hey, it’s the reason I came to Brant Hill. Nice paycheck, no hassles with insurance companies. And patients who actually listen to my advice.” He paused. “In Wallenberg’s case, I hear there were other things going on. Last geriatrics conference I attended, there was some gossip circulating. About Wallenberg and a female research associate at Rosslyn.”
“Oh. If it’s not money, it’s sex.”
“What else is there?”
She thought of Carl Wallenberg in his tuxedo, the young lion with amber eyes, and she could easily imagine him being the object of female desire. “So he had an affair with a research associate,” she said. “That’s not particularly shocking.”
“It is if there are three people involved.”
“Wallenberg, the woman, and who else?”
“Another M.D. at Rosslyn, a man. I understand things got pretty tense between them, and all three of them resigned. Wallenberg came to Brant Hill and resumed his research. Anyway, that makes it a full six years he’s been injecting hormones, with no catastrophic side effects.”
“And no cases of CJD.”
“None reported. Try again, Dr. Harper.”
“Okay, let’s look at other ways these two men might’ve gotten infected. A surgical procedure. Something relatively minor, like a corneal transplant. You might have overlooked that history in their outpatient charts.”
Brace made an exasperated sound. “Why are you hung up on this, anyway? Patients die on me all the time, and I don’t obsess over it.”
Sighing, she sank back on the couch. “I know it doesn’t change things. I know Harry’s probably dead. But if he did have Creutzfeldt-Jakob, then he was already dying when I saw him. And nothing I did could have saved him.” She looked at Brace. “Maybe I wouldn’t feel so responsible for his death.”
“So it’s guilt, is it?”
She nodded. “And a certain amount of self-interest. The lawyer representing Harry’s son is already taking depositions from the ER staff. I don’t think there’s any way I can avoid a lawsuit. But if I could prove Harry already had a fatal illness when I saw him—”
“Then the damages wouldn’t seem so severe in court.”
She nodded. And felt ashamed. Your dad was already dying, Mr. Slotkin. What’s the big deal?
“We don’t know Harry’s dead,” said Brace.
“He’s been missing for a month. What else would he be? It’s just a matter of finding his body.”
Upstairs, the crying had stopped, the battle finally won. The silence only accentuated their uneasy lapse in conversation. Footsteps creaked down the stairs, and a woman appeared. She was a redhead, so fair-skinned her face seemed translucent in the glow of the living room lamp.
“My wife, Greta,” said Brace. “And this is Dr. Toby Harper. Toby just dropped by for some shop talk.”
“I’m sorry about all the screaming,” said Greta. “It’s our daily tantrum. Tell me again, Robbie. Why did we have a kid?”
“To pass on the gift of our superior DNA. Trouble is, babe, she got your temper.”
Greta sat down on the armrest next to her husband. “That’s called determination. Not temper.”
“Yeah, well, whatever you call it, it’s hard on the ears.” He patted his wife on the knee. “Toby’s an ER doc over at Springer Hospital. She’s the one who stitched up my face.”
“Oh.” Greta nodded in appreciation. “You did a very nice job. He’ll hardly have a scar.” She suddenly frowned at the coffee table. “Robbie, I hope you offered our guest something to drink. Shall I put on some tea?”
“No, babe, that’s all right,” said Robbie. “We’re all finished here.”
I guess that’s my signal to leave, thought Toby. Reluctantly she stood up.
So did Robbie. He gave his wife a quick kiss and said, “This won’t take long. I’m just running over to the clinic.” Then he turned to Toby, who was looking at him in surprise. “You want to see those outpatient records, don’t you?” he asked.
“Yes. Of course.”
“Then I’ll meet you there. Brant Hill.”
11
“I knew you were gonna keep bugging me about this,” said Robbie as he unlocked the front door to the Brant Hill Clinic building. “Check this out, check that out. Man, I figured I’d just let you see the damn charts for yourself, so you’d know I wasn’t holding out on you.” They walked into the building and the front door slammed shut behind them, setting off echoes down the empty hallway. He turned right, and unlocked a door labeled: MEDICAL RECORDS.
Toby flipped on the lights and blinked in surprise at six aisles of filing cabinets. “Alphabetical?” she asked.
“Yeah. As are that way, Zs the other way. I’ll find Slotkin’s chart, you find Parmenter.”
Toby headed toward the Ps. “I can’t believe how many records you have. Does Brant Hill really have this many patients?”
“No. This is central records storage for all of Orcutt Health’s nursing homes.”
“Is that like a conglomerate?”
“Yeah. We’re their flagship facility.”
“So how many nursing homes do they run?”
“A dozen, I think. We all share billing and referral services.”
Toby found the cabinet for the Ps and thumbed through the charts. “I can’t find it,” she said.
“I found Slotkin’s.”
“Well where’s Parmenter?”
Brace reappeared in her aisle. “Oh, I forgot. He’s deceased, so they probably moved that file to the inactives.” He walked to a set of cabinets at the back of the room. A moment later he closed the drawer. “Must’ve been culled. I can’t find it. Why don’t you just concentrate on Harry’s chart? Look it over to your heart’s content and prove to yourself I haven’t missed anything.”
She sat down at an empty desk and opened Harry Slotkin’s file. It was organized in a problem-oriented format, with Current Illnesses listed on the first page. She saw nothing surprising here: benign prostatic hypertrophy. Chronic back pain. Mild hearing loss secondary to otosclerosis. All the expected ravages of old age.
She flipped to the past medical history. Again, it was a typical list: Appendectomy, age thirty-five. Transurethral resection of the prostate, age sixty-eight. Cataract surgery, age seventy. Harry Slotkin had been, for the most part, a healthy man.
She turned to the clinic visits record, which contained the doctors’ notes. Most were routine checkups, signed by Dr. Wallenberg, with an occasional subspecialist note by Dr. Bartell, a urologist. Toby turned the pages until she paused over an entry dated two years before. She could barely decipher the doctor’s name.
“Who wrote this?” she asked. “The signature looks like a Y something.”
Brace squinted at the illegible handwriting. “Beats me.”
“You don’t recognize the name?”
He shook his head. “Occasionally we get outside docs coming in for specialty clinics. What’s the visit for?”
“I think it says ’deviated nasal septum.’ Must be ENT.”
“There’s an ENT specialist named Greeley here in Newton. That signature must be a G, not a Y.”
She knew the name. Greeley occasionally consulted in the Springer ER.
She turned to the lab section, where Harry’s most recent bl
ood counts and chemistries were recorded on a computer printout. All were in the normal ranges.
“Pretty good hemoglobin for a guy his age,” she noted. “Fifteen’s better than mine.” She turned to the next page and paused, frowning at a printout with the letterhead: Newton Diagnostics. “Wow, you guys don’t believe in cost control, do you? Look at all these labs. Radioimmunoassays for thyroid hormone, growth hormone, prolactin, melatonin, ACTH. The list goes on and on.” She flipped to the next page. “And on. The panel was done a year ago, and three months ago as well. Some lab in Newton is raking it in.”
“That’s the panel Wallenberg orders on all his hormone-injection patients.”
“But the hormone protocol’s not mentioned anywhere in this chart.”
Brace fell silent for a moment. “It does seem strange, doesn’t it? To be ordering all these tests if Harry wasn’t on the protocol.”
“Maybe Brant Hill’s padding the pockets of Newton Diagnostics. This patient’s endocrine panel probably cost a few thousand dollars.”
“Did Wallenberg order it?”
“Doesn’t say on the lab report.”
“Look at the order sheets. Cross-check the dates.”
She flipped to the section labeled: Physician’s Orders. The sheets were carbon copies of the doctors’ handwritten orders, each signed and dated.
“Okay, the first endocrine panel was ordered by Wallenberg. The second panel was ordered by that guy with the bad handwriting. Dr. Greeley—if that’s who this is.”
“Why would an ENT order an endocrine panel?”
She scanned the rest of the order sheets. “Here’s that signature again, dated almost two years ago. He ordered preop Valium and six A.M. van transport to Howarth Surgical Associates in Wellesley.”
“Preop for what?”
“I think this says ’Deviated nasal septum.’” Sighing, she closed the chart. “That wasn’t very helpful, was it?”
“So can we get out of here? Greta’s probably getting pissed at me about now.”
Ruefully she handed back the chart. “Sorry for dragging you out here tonight.”
“Yeah, well, I can’t believe I went along with it. You don’t really need to look at Parmenter’s record, do you?”
Life Support Page 17
