Crisis

20

Alexis answered on the fourth ring. Jack had called her number and put his phone on speaker before placing it on the rent-a-car's front passenger seat. He was on his way from the Langley-Peerson Funeral Home to the Newton Memorial Hospital. He'd decided to make a short visit before the three-to-eleven shift left for the day in hopes of catching Matt Gilbert and Georgina O'Keefe. It had been an impulsive decision when he and Latasha left the funeral home after finishing up with the autopsy. She had said she was going to stop at her apartment briefly to feed the dog, drop off the fluid samples at the toxicology lab with a message for Allan to call as soon as he got in, and pick up a couple of pizzas at an all-night joint before meeting him in the parking lot of the medical examiner's office. She had given Jack the opportunity to tag along, but the window of opportunity had made him decide to stop at the hospital instead.

"I was hoping it was you," Alexis said when she heard Jack's voice.

"Can you hear me okay?" Jack asked. "We're on my speaker phone."

"I can hear you fine. Where are you?"

"I'm always asking myself that same question," Jack joked. His mood had flip-flopped from its nadir brought on by finding nothing relevant in Patience's autopsy to a near high. He had been energized by Latasha's enthusiasm and the prospect of getting the assistance of a toxicologist, and his mind had been picking up speed like an old-fashioned steam locomotive. Now ideas were flapping around inside his head like a flock of excited sparrows.

"You are in a rare mood. What's going on?"

"I'm in my rent-a-car on the way to the Newton Memorial."

"Are you all right?"

"I'm fine. I'm just going to duck in and ask a couple of questions to the ER people who handled Patience Stanhope."

"Did you do the exhumation and the autopsy?"

"I did."

"What did you find?"

"Other than a nonrelevant, from our perspective, cancer of the colon, I found nothing."

"Nothing?" Alexis questioned. The disappointment in her voice was apparent.

"I know what you are thinking, because I thought the same. I was depressed. But now I think it was an unexpected gift."

"How so?"

"If I'd found generic, garden-variety coronary disease, which is what I actually expected to find rather than something dramatic, which is what I'd hope to find, I would have left it at that. She had heart disease and had a heart attack. End of story. But the fact that she had no heart disease begs for an explanation. I mean, there is a slight chance that she had some fatal cardiac event that we're not going to be able to diagnose eight months after the fact, but now I believe the possibility is in our favor that there was something else involved, especially considering the resistance Fasano expressed about my doing the autopsy, and Franco trying to run me off the goddamn road, and, more significantly, the threat expressed to your children. How are they, by the way?"

"They're fine. They act very secure, and they're having a ball here at Grandma's. She's spoiling them as she always does. But back to your point: What are you really trying to say?"

"I don't know exactly. But here's some of my thoughts, whatever they are worth. Patience Stanhope's death and the resistance to my doing an autopsy could be two completely separate circumstances. Fasano and crew could be behind the threats, and purely for venal reasons. But somehow that doesn't make sense to me. Why would he go to the extent of breaking into your house and then blithely let me do the exhumation? It seems to me that the three events are separate and not connected. Fasano threatened me for the reasons he gave. Franco has this ego problem after I whacked him in the nuts, so my problems with Franco have nothing to do with Patience Stanhope. That leaves the break-in at your house unexplained."

"This is too complicated," Alexis complained. "If Tony Fasano wasn't behind terrorizing my children, then who was?"

"I have no idea. But I asked myself what the motivation might have been if it didn't involve Fasano and money. It's pretty clear that it would be an attempt to keep me from learning something, and what could be learned from an autopsy? One thing would be an overdose of medication or the wrong medication Patience Stanhope might have gotten at the hospital. Hospitals are big organizations with lots of stockholders, involving lots of money."

"That's crazy," Alexis said without hesitation. "The hospital wasn't behind my kids being victimized."

"Alexis, you wanted me to come up here to Boston and think out of the box, and that's what I'm doing."

"But the hospital?" she questioned with a whine. "Is that why you are on your way there now?"

"It is," Jack confessed. "I think of myself as a reasonable judge of character. I was impressed by the two ER people I spoke with Tuesday. They're forthright and devoid of artifice. I want to talk to them again."

"What are you going to do," Alexis asked scornfully, "ask them if they made some huge mistake that the hospital has to send people out to brutalize my children to try to cover up? That's ridiculous."

"When you put it that way, it does sound far-fetched. But I'm going to do it anyway. The autopsy is not over. I mean, the gross dissection is over, but we're now going to see what toxicology can come up with and also look at the microscopic. I also want to corroborate exactly what medication Patience Stanhope was given so I can tell the toxicologist."

"Well, that sounds more reasonable than accusing the hospital of some ridiculous cover-up."

"The thought of an overdose or wrong medication is not my only idea. Do you want to hear it?"

"I'm listening, but I hope this next idea is more sane than your first."

Jack thought of some witty, sarcastic comebacks, but he controlled himself. "The hospital idea was predicated on Patience Stanhope's heart attack and the opposition to the autopsy being two separate although related circumstances. What if both involved the same person?"

There was a deliberate pause while Jack let this comment sink in.

"I'm not sure I'm following you," Alexis said finally. "Are you talking about someone causing Patience Stanhope's heart attack and then trying to prevent an autopsy to keep from being discovered?"

"That's exactly what I'm suggesting."

"I don't know, Jack. That sounds almost as crazy. I suppose you are talking about Jordan."

" Jordan is the first person that comes to mind. Craig said Jordan and Patience were hardly a loving couple, and Jordan is the big winner with her death. He certainly didn't waste any time in mourning. For all we know, he and his girlfriend were carrying on while Patience was still in the picture."

"How can someone cause a heart attack in someone on purpose?"

"Digitalis could do it."

"I don't know," Alexis said dubiously. "This seems equally farfetched. If Jordan was at all guilty, he certainly wouldn't initiate a malpractice suit, and he absolutely wouldn't have signed the exhumation authorization."

"I've thought of that," Jack said as he pulled into the parking area for the Newton Memorial Hospital. "I agree it doesn't seem rational, but maybe we're not dealing with a rational person. Maybe Jordan is getting a charge out of all this, thinking it is showing how much smarter he is than the rest of us. But this kind of supposition is jumping the gun. First, some kind of drug has to be found by toxicology. If we find something, then we'll have to work backwards."

"That's the second time you've said 'we.' Are you just using that as a figure of speech or what?"

"One of the medical examiners from the Boston medical examiner's office is generously helping."

"I trust you've spoken to Laurie," Alexis said. "Is she okay with you still being here?"

"She's not the happiest camper, but she's doing okay."

"I can't believe you are getting married tomorrow."

"Nor can I," Jack said. He nosed into a parking space overlooking the pond. His headlights illuminated a flock of bobbing waterfowl. "What happened at the trial this afternoon?"

" Randolph called two expert witnesses, one from Yale and one from Columbia. Both were credible but hardly exciting. Best of all, they were not at all phased by Tony, who tried to rattle them. I think Tony was hoping Randolph would call Craig back on the stand, but Randolph wisely didn't. Instead, Randolph rested. That was it. Tomorrow morning will be the summations, with Randolph leading off."

"Has your intuition changed any about what you think the final outcome will be?"

"Not really. The defense witnesses were good, but they were from out of town. Since Boston is such a medical mecca, I don't think the fact that they came from distant universities resonated well with the jurors. Tony's experts had more of an impact."

"You probably have a point, I'm sorry to say."

"If by some slim chance you do discover some criminality in regard to Patience Stanhope, it would probably save the day for Craig."

"Don't think for a moment that such a thought isn't in my mind. To be honest, it's my main motivation. How is Craig's mind-set?"

"Despondent, as usual. Maybe even a little worse. I worry a little with him home alone. When do you think you'll get back there?"

"I just don't know," Jack said, suddenly feeling guilty about not wanting to return to the Bowman home.

"Maybe you could check on him when you do. I don't like that alcohol-sleeping pill combination."

"Okay, I'll do that," Jack said. "I'm at the hospital now, and I have to run."

"No matter what happens, I truly appreciate all your efforts, Jack. You'll never know how much your support has meant to me these last few days."

"You still feel that way even though my meddling was responsible for what happened to the girls?"

"I don't hold that against you in the slightest."

After a few more sibling endearments that might have brought a tear to Jack's eye had they continued, they said good-bye. Jack flipped his phone closed and sat in the car for a minute, thinking about relationships and how they changed over time. It gave him a warm feeling to know that he and his sister were back to a semblance of their previous closeness, despite the years of separation while he'd struggled with his own despondency.

As Jack climbed out of the car, the zeal that Latasha had generated came back in a rush. Alexis's comments had been a bit of a downer, but he didn't need her to tell him his ideas were preposterous. He was, as he had explained, thinking out of the box with a bunch of facts that were themselves seemingly implausible.

In contrast to his first visit, the emergency room was hopping. The waiting room was full, with almost every seat taken. A few people were standing outside on the ambulance-receiving dock. It was a warm, humid, almost summer night.

Jack had to wait in line at the admitting desk behind a woman holding a feverish infant in her arms. The child stared at Jack over the mother's shoulder with glazed eyes and a blank expression. As Jack moved up to the counter and was about to ask for Dr. Matt Gilbert, the doctor appeared. He tossed a completed ER admission note attached to a clipboard onto the desk when he locked eyes with Jack.

"I know you," he said, pointing at Jack. He was obviously searching for the name.

"Dr. Jack Stapleton."

"Right! The medical examiner interested in the failed resuscitation case."

"Good memory," Jack commented.

"It's the main talent I picked up in medical school. What can we do for you?"

"I need two minutes of your time, hopefully with Georgina O'Keefe. Is she here tonight?"

"She runs the show," the admitting clerk said with a laugh. "She's here."

"I know this is not the best time," Jack said. "But we exhumed the body, and I just did an autopsy. I thought you might like to know what was found."

"Absolutely," Matt said. "And this isn't a bad time. We're busy, but it's all routine stuff that should have been seen in the outpatient clinic or a doctor's office. There's no critical emergencies at the moment. Come on back into the lounge. I'll snare Georgina."

For a few minutes, Jack sat by himself. He used the time to look back over the two pages that constituted a record of Patience's ER visit. He'd pulled them from the case file while he'd been talking to Alexis.

"Welcome back," Georgina bubbled as she swept into the room. Matt came in after her. Both were dressed in white jackets over green scrub clothes.

"Matt said you dug up Mrs. Stanhope and did an autopsy. Cool! What did you find? I mean, no one has ever given us this kind of feedback."

"The interesting thing was that her heart appeared entirely normal. With no degenerative changes whatsoever."

Georgina thrust the backs of her hands onto her hips with her elbows out. Her mouth formed a disappointed, wry smile. "I thought we were going to hear something startling."

"It's startling in its own way," Jack said. "It's rare with sudden cardiac death not to find pathology."

"You came all the way over here to tell us you found nothing?" Georgina questioned with disbelief. She looked at Matt for support.

"Actually, I came to ask you if there was any chance she could have been given an overdose of any medication or maybe the wrong medication."

"What kind of medication are you talking about?" Georgina asked. Her smile faded, replaced by a wary confusion.

"Anything," Jack said. "Particularly any of the newer fibrinolytic or antithrombotic agents. I don't know; are you people involved in any randomized studies involving heart attack patients? I'm just curious. There's nothing like what I'm talking about on the order sheet." Jack handed the two pages over to Georgina, who glanced at them. Matt looked over her shoulder.

"Everything we gave her is on here," Georgina said, holding up the order sheet. She looked at Matt for confirmation.

"That's it," Matt agreed. "She was in extremis when she arrived, with practically a flatline on the cardiac monitor. All we tried to do was resuscitate her. We didn't try to treat her MI. What was the point?"

"She didn't get anything like digitalis?"

"No," Matt said. "We couldn't even get a heartbeat, even with dual-chamber sequential pacing. Her heart was completely unresponsive."

Jack looked from Georgina to Matt and back again. So much for the overdose or wrong medication idea! "The only laboratory reports on the ER notes are blood gases. Were any other tests done?"

"When we draw blood for blood gases, we routinely also order the usual blood count plus electrolytes. And with heart attacks, we order biomarkers."

"If they were ordered, how come there's no mention of it on the order sheet, and why aren't the results on the ER note? The blood gases are there."

Matt took the sheets from Georgina and quickly looked them over. He shrugged. "I don't know, maybe because they normally go in the hospital record, but since she died so quickly, she never got a hospital record." He shrugged again. "I suppose they are not on the order sheet because it's a standing order for all myocardial infarction suspects. I did mention sodium and potassium were normal in my note, so someone called the results to the ER desk."

"This isn't a big-city ER," Georgina explained. "It's rare to have a death here. Usually people get admitted, even those in bad shape."

"Could we call the lab and see if they could possibly locate the results?" Jack asked. He did not quite know what to make of this serendipitous discovery or whether it would have any meaning, but he felt obligated to see where the lead would take him.

"Sure," Matt said. "We'll have the clerk call up there. Meanwhile, we've got to get back to work. Thanks for coming by. It's strange you didn't find any pathology, but it's nice to know we didn't miss anything that could have saved her."

Five minutes later, Jack found himself in the tiny, windowless office of the evening laboratory supervisor. He was a large, heavyset man with heavily lidded eyes that gave him a sleep-deprived appearance. He was staring at his computer monitor with his head tilted back. His nametag read: "Hi, I'm Wayne Marsh."

"I don't see anything under Patience Stanhope," Wayne said. He had been very obliging when the ER had called, and invited Jack up to his office. He'd been impressed with Jack's credentials, and if he'd noticed the badge said New York rather than Massachusetts, he didn't mention it.

"I need a unit number," Wayne explained, "but if she wasn't admitted, then she didn't get one."

"What about through billing?" Jack suggested. "Somebody had to pay for the tests."

"Nobody's in billing at this hour," Wayne said, "but didn't you mention you have a copy of the ER record. That will have an ER accession number. I can try that."

Jack handed over the ER notes. Wayne typed in the number. "Here we go," he said as a record flashed up on the screen. "Dr. Gilbert was right. We did a full blood count with platelets, electrolytes, and the usual cardiac biomarkers."

"Which ones?"

"We do CKMB and cardiac-specific troponin T on arrival at the ER with repeats at six hours postadmission and twelve hours postadmission."

"Was everything normal?"

"Depends on your definition of normal," Wayne said. He twisted his monitor screen in its base so Jack could see it. He pointed to the blood-count section. "There's a mild to moderate rise in the white count, which is expected with a heart attack." His finger then went to the electrolytes. "The potassium is at the upper edge of normal. Had she lived, we would have wanted to check that, for obvious reasons."

Jack inwardly shuddered at the mention of potassium. The frightening episode with Laurie's potassium during her ectopic pregnancy emergency was still fresh in his mind despite its being over a year ago. Then his eyes happened to notice the biomarker results. To his surprise, the tests were negative, and he immediately called it to Wayne 's attention. Jack's pulse ratcheted up. Had he stumbled onto something significant?

"That's not unusual," Wayne said. "With improved response times to nine-one-one calls, we often get our heart attack victims into the ER within the three- to four-hour interval it takes for the biomarkers to rise. That's one of the reasons we routinely repeat the test at six hours. Jack nodded as he tried to sort out the discrepancy this new information provided. He didn't know whether he'd forgotten or never knew there was such a delay before bio-markers become positive. Not wishing to appear overly uninformed, he worded his next questions carefully. "Does it surprise you that an earlier bedside biomarker assay was positive?"

"Not really," Wayne said.

"Why not?"

"There are a lot of variables. First off, there's about a four percent false negative result as well as a three percent false positive. The tests are based on highly specific monoclonal antibodies, but they are not infallible. Secondly, the bedside kits are based on troponin I, not T, and there's a lot of bedside kits on the market. Was the bedside assay for troponin I alone or with myoglobin?"

"I don't know," Jack admitted. He tried to remember what was written on the box in Craig's doctor's bag, but he couldn't visualize it.

"That would be important. The myoglobin component becomes positive faster, often within as little as two hours. What's the time frame on this case?" He picked up the ER note and read aloud: "Patient's husband states chest pain and other symptoms developed between five and six p.m., probably closer to six." Wayne looked up at Jack. "She arrived in the ER close to eight, so the time frame is about right as far as our results are concerned, since it was less than four hours. Do you know when the bedside assay was done?"

"I don't," Jack said. "But if I had to guess, it would be somewhere around seven thirty."

"Well, that does seem marginal, but as I said, the bedside tests are made by a host of companies with widely differing sensitivities. The kits also should be carefully stored, and I believe there's an expiration date. Frankly, that's why we don't use them. We much prefer the troponin T, since it's made by only one company. We get very reproducible results with a short turnaround time. Would you like to see our Abbott analyzer? It's a beauty. It measures absorbance spectrophotometrically at four hundred fifty nanometers. It's right across the lab if you want to take a gander."

"Thank you, but I think I'll pass," Jack said. He was getting in technically way over his head, and his visit at the hospital had already been twice as long as he had planned. He certainly didn't want to keep Latasha waiting. He thanked Wayne for his help and returned quickly to the elevator. As he rode down to the first floor, he couldn't help but wonder if Craig's bedside biomarker assay kit had somehow been defective, either from improper storage or from being out of date, and had given a false positive. What if Patience Stanhope did not have a myocardial infarction? All at once, yet another dimension was opening up, particularly with the services of a toxicologist available. There were a lot more drugs that deleteriously affected the heart than those capable of simulating a heart attack.

Jack jumped into the car and quickly dialed Latasha's number. As he'd done with his call to Alexis, he put his phone on speaker and placed it on the passenger seat. By the time he was driving out of the hospital parking lot, Latasha answered.

"Where are you?" she asked. "I'm here in my office. I got two hot pizzas and two large Cokes. Where are you at?"

"I'm just leaving the hospital. I'm sorry it has taken as long as it has, but I learned something possibly important. Patience Stanhope's biomarker test was negative when it was read by the hospital analyzer."

"But you told me it was positive."

"That was from a bedside biomarker kit," Jack said. He carefully explained what he'd learned from the lab supervisor.

"What it all comes down to," Latasha said when Jack was finished, "is that now we're not sure she had a heart attack, which would be consistent with what we found during the post."

"Precisely, and if that is the case, the toxicology is going to be key."

"I already dropped the samples off at the toxicology lab with a note for Allan to give me a call."

"Perfect," Jack said. He couldn't help but marvel at how lucky he was to have Latasha helping him. If it hadn't been for her, he might have given up after finding nothing in the heart.

"I guess this puts the mourning husband in the crosshairs," Latasha added.

"There are still some inconsistencies," Jack said, remembering Alexis's points against Jordan 's being the bad guy "but generally I agree, as trite and venal as it sounds."

"When will you be here?"

"As soon as I can. I'm coming up to Route Nine. You're probably a better judge than I. Why don't you start on the pizza while it's hot."

"I'll wait," Latasha said. "I've got myself busy making us some frozen sections of the heart."

"I'm not sure I'll be eating much," Jack said. "I've gotten myself psyched. I feel like I've had ten cups of coffee."

When Jack flipped his phone shut, he checked the time. It was almost ten thirty, which meant Latasha's friend would soon be arriving at the toxicology lab. Jack hoped he'd have a lot of free time, since Jack could imagine keeping him busy most of the night. Jack had no illusions about the power of toxicology to detect poisons. It was not as easy a process as it was often portrayed in the popular media. For large concentrations of the usual drugs there usually was no problem, but for trace amounts of more toxic and lethal compounds that could kill a person in very small dosages, it was like finding the proverbial needle in a haystack.

Jack stopped at a traffic light and impatiently drummed his fingers on the steering wheel. The warm, soft, humid June air wafted in through the missing window. He was glad he'd taken the time to visit the hospital, although he now felt embarrassed about the idea of a hospital cover-up. Nonetheless he rationalized that the idea had indirectly led to his questioning whether Patience Stanhope had suffered a heart attack.

The light turned green, and he moved on. The problem was she still might have had a heart attack. Wayne had admitted that even with his vaunted absorbance analyzer, the rate of false negatives was higher than false positives. Jack sighed. There was nothing about this case that was simple and straightforward. Patience Stanhope was proving to be a problem patient even in death, which reminded him of his favorite lawyer joke: What's the difference between a lawyer and a prostitute? The prostitute stops screwing you when you die. From Jack's perspective, Patience was assuming some annoying lawyer-like qualities.

As Jack drove, he mulled over his promise to check in on Craig, who was probably at that time already in a deep, drug-and-alcohol-induced slumber. Jack wasn't excited about the idea and thought it unnecessary since, in his estimation, Craig was not suicidal in the slightest, and, as an intelligent physician, Craig was well aware of the power of the medications he was taking. On the other hand, the good side of making such a visit would be a chance for Jack to check what kind of biomarker kit Craig used and whether it was outdated. Until he had that information, he couldn't intelligently decide whether or not there was a higher than usual chance the result had been a false positive.