Flashback

CHAPTER FOURTEEN

The surgical residents at Boston Muni traditionally spoke of exhaustion in terms of the Wall-the moment when a physician ceased to function with any creative effectiveness. Throughout training, one was either approaching the Wall, up against it, or, when operating solely on the gritty-eyed fuel of caffeine and nervous energy, beyond it. At 6,45, when his clock radio switched in on the final two verses of an a cappella version of "Au Clair de la Fontaine, " Zack could distinctly remember seeing three, four, and five o'clock flash on its digital display. His bedside light was still on. The crossword puzzle book with, perhaps, a dozen or so items out of one hundred thirty filled in, rested in his chest. The pencil was still wedged between his fingers. Across the room, Cheap dog, quite ready to begin the day, was perched on his hind legs, his paws resting on the windowsill, the nub of lis tail twitching at the prospect of joining some action in the backyard. It wasn't supposed to be like this. Zack's first thought of the morning was the same as the last he. should remember from the night just past.

Boards of trustees… hospital buybacks… rules on length of 4@ay … policies on who gets admitted and who doesn't… enemies allies… realty trusts… Golden Circles… interlocking @. Directorates… as if the stresses, pressures, and crises of day-to-day nedicine weren't enough.. 1 Perhaps, he mused, the real villain in the piece wasn't Frank, or the Judge, or Norman, or even Ultramed. Perhaps it was his own naivetehis idealistic notions of illness and injury and the healing arts. Perhaps that was what needed overhauling. Emotionally as well as physically drained, he shuffled to the bathroom to shave and shower, pausing to pull a quarter from behind Cheap dog's ear before letting him out. The Wall, he knew, was just a few hours away. Save for the lone librarian, the Ultramed-Davis record room was deserted. With thirty minutes remaining before his appointment with Jack Pearl, Zack had decided to give Toby Nelms's chart one last go-through. Although he still felt numb and deflated from the madness of the previous night, the morning, at least, had gotten off to a decent start. After getting Cheap dog settled on his run, he had chosen a route to the hospital that took him past a broad field of tiger lilies, lavender, and black-eyed Susans.

For years Annie Doucette had allowed scarcely a day to pass without setting fresh flowers on the dining room table and mantel of the Iverson home. During her hospitalization, the family had done its best to repay her in kind. Gathering up an armload bouquet, Zack had amused himself by composing cards he would have liked to have propped up by the vase in her ICU cubicle. To Annie, with deepest apologies. Ultramed… To Annie, my temporary patient, from Don, your temporary doctor. In repayment for your humiliation, heart attack and broken hip. In sharp contrast to the surreal chaos of the early morning hours, the unit had been bright and tranquil. Annie, the Haldol largely out of her system, was fully oriented and even a bit feisty. Although she was sluggish from the analgesia she was receiving for her hip, she had talked in detail of her son and grandchildren, and of Zack's family. Of the thirty-six hours preceding her fall, she remembered nothing, except to reiterate her determination not to be sent to "any death-trap nursing home."

Donald Norman's cookbook cardiology had, for the moment at least, proven adequate, and while Annie's cardiac status remained shaky, it was not critical. All in all, Zack had left the unit sensing that if anyone her age could make it through the ordeal she was facing, Annie Doucette could. The record room librarian, an alert young brunette who was nearing the end of a pregnancy, seemed grateful to have company. Zack signed for Toby's chart and brought it to one of several Formica-walled dictation carrels, The manila folder he set to one side contained the notes and the trickle of articles he had begun to amass on the more obscure complications of the two anesthe ics the boy had received. None of those sources had offered so much as a clue to his bizarre condition.

Word by word, more meticulously even than on previous efforts, he picked through the chart. Family history-unremarkable, past medical history-usual childhood immunizations and diseases, nothing else of consequence, physical exam-normal except for an incarceratedinguirial hernia, operative and anesthesia notes-routine. Nurses' notes, "patient brought into recovery from O. R. awake, alert, and smiling, vital signs normal, no evidence for respiratory depression, pupils equal and reactive, lungs clear."

Remarkable. Absolutely remarkable. Zack read the notes once, and then again. Toby's total stay in the recovery room was less than thirty minutes. He asked for Suzanne's chart. Her anesthe ics and doses, when adjusted for weight, were virtually identical to Toby's, so were her recovery room nurses' notes. Total time in the recovery room, forty-five minutes. The g I'm of an idea began to take root. Zack checked the time.

Thirteen minutes until he met with Pearl. "Excuse me, " he called over to the librarian, "are these records completely computerized? "

"For the last five years, yes, " she said, setting aside the romance saga she was reading. "I think they're working on the five years before that."

"Well, supposing I wanted to get, say, a list of all the gallbladder patients operated on in the last three years?"

"No problem. Cholecystectomy is one of our codes, 3982, I think."

"How about just the ones where Dr. Pearl was the anesthesiologist?"

The woman checked her manual. "Dr. Jack Pearl. Physician 914. I can get the printout for you in just a minute, but it will take a while if you want me to pull the charts." She patted her belly. "As you can see, I'm walking for two."

"Your last month?"

"Last two weeks, I hope."

"Well, if it's too much trouble-"

"No, no. We both need the exercise."

"I hate to make it harder on you, but could I have the first few right away, and then come back in, say, an hour to check on the rest?"

"Sure. At this hour of the morning, this place isn't exactly humming."

She was already typing commands into the computer. By eight-thirty, Zack had scanned nine charts out of thirty-one. He slipped the notes he had taken into his folder and promised to return for the rest. Despite his lack of sleep, he felt energized-keyed up and very sharp. His idea had provided no definite answers. But now, at last, he knew he had some damn good questions. If Jack Pearl had made any attempt to straighten up his office before Zack's arrival, he had failed miserably. The small, windowless space between the O. R. suite and the recovery room was cluttered with journals and scraps of paper, and smelled heavily of coffee and stale cigarettes. Half-filled ashtrays, one with a butt still smoldering, graced two corners of the desk, and opened, cellophane-wrapped packets of Kleenex were everywhere. Pearl himself, sporting a wrinkled green polo shirt, was nearly dwarfed behind the pile of reprints, texts, and notebooks on his desk. The hand he extended was cadaverous. Regardless of how skillful an anesthesiologist Pearl was, it was difficult for Zack to imagine his fastidious brother hiring such a man. "So, " Pearl said, his voice an annoying cross between Peter Lorre and, perhaps, Carol Channing, "I see you are an early morning person, too."

"Actually, I'm more a mid-afternoon person, " Zack replied. "Thanks for making the time to see me."

"No big deal. You want some coffee? There's a machine right down the hall."

"No. thanks, though."

Zack noticed a stained Mr. Coffee crammed to the side of one bookshelf, but saw no evidence of filters or coffee. "So, Iverson, what's on your mind?"

Pearl, sniffling every twenty or thirty seconds, stubbed out what was left of the smoldering cigarette as he was cuing up a fresh one. He was a man in constant motion, wiping his nose, smoking, or fiddling with the papers on his desk. He was also, Zack felt, somewhat effeminate. Though they had done one case together, and had spoken briefly after Suzanne's surgery, this was their first contact of any substance. The office, for all its disarray, was somehow barren and sterile.

There were no diplomas or certificates on the wall, no photographs or mementos on the shelves. Zack felt an instant, immense curiosity about the little man, but he had already abandoned any notion of small talkeven nonthreatening questions about his background. Nothing in Pearl's manner encouraged such an approach. "I need to discuss a case with you, " Zack began. "Okay, shoot."

"It's an eight-year-old boy named Toby Nelms. Jason Mainwaring repaired an incarcerated hernia in him almost a year ago. You did the anesthesia."

"No bells, " Pearl said. "Here's a Xerox of most of his chart."

Zack passed the copy across and waited as Pearl flipped through it.

"Seems pretty cut and dried to me." Pearl hesitated, and then looked up, his brow pinched in thought. "Cut and dried. That was sort of a joke, wasn't it? " He thought some more. "Pretty good joke, too, if I do say so myself. Pretty good."

His laugh was a cackle. Zack smiled, but otherwise made no attempt to join in. "Pentothal and isoflurane. Is that pretty routine for cases like Toby's?"

"Routine enough, " Pearl said. "Why?"

"Well…" Zack rubbed at his chin and silently counted to five. "I have reason to believe that the kid wasn't asleep during his surgery."

Pearl's listless eyes flashed. "That's ridiculous! " he snapped. "Maybe, but I think it's true. He remembers details of the operation that there's no reason for him to know. And to make matters even more interesting, for the past six months he's been reliving the whole thing."

Pearl was ashen. "What?"

"He's having flashbacks in which he reexperiences his surgery, only in a terrifying, distorted way. It's as if his preoperative fears have become fused with the actual procedure. Instead of having his hernia fixed, he has his testicles and his penis cut off, again and again. And each time, Jack, he feels the pain. Every bit of it."

"That's… that's insane."

"Is it?"

"Of course it is." Pearl took a nervous drag from his cigarette and then blew his nose. "He's lying, or… or he's been watching too much television."

"I don't think so, Jack. And neither do the boy's parents. They're this close to instituting some sort of action against the hospital, and, I assume, against you and Mainwaring as well."

"And you're encouraging them in this?

"

"Hell, no. The opposite."

"Well, thank God for that, " Pearl muttered. "But I'm determined to get to the bottom of things. That's why I'm here. The kid's very sick from what he's going through. Very sick. In fact, he may be dying."

Pearl whistled softly through his teeth. cc Well, " he said, "I can't help you much except to tell you that whatever is going on has nothing to do with his anesthesia. I've done thousands of cases with exactly the same stuff this boy got, and and nothing like this has ever happened.

Nothing."

"As far as you know, " Zack corrected. Pearl's expression was strange.

Zack tried to gauge the reaction against those he had anticipated.

Anger? Arrogance? Confusion?

Concern? Defensiveness? There was "I no real match. Something was going on, though. Of that he was almost certain. The man was… was what?

"Look, Iverson…" Pearl ground out his cigarette and folded his hands on the desk. His fidgeting stopped. His gaze became more direct."… I want to help you, I truly do. I want to help that kid. But there's really nothing I can say. He got routine anesthesia and had a routine operation. It's as simple as that. If you want to get to the bottom of whatever's going on, then you'll just have to head off in another direction, okay?"

In that moment, Zack understood. His muscles tensed. The sensation was so familiar. It was being on the side of a steep drop, looking for the handholds and crevasses that would guide the traverse of a rock, and then suddenly seeing the perfect line across. Jack Pearl's attempt at sounding concerned and accommodating had missed badly. He was frightened-absolutely white with fear. The quieter and more composed he became, the more Zack knew he was squirming. Something was going on. His blade had hit a nerve. Now, it was time to give it a twist. "Jack, I'm interested in something, " he said. "Suzanne Cole was wide awake when she reached the recovery room. The nurse's notes in his chart say that Toby Nelms was, too. How do you do that?"

Pearl shrugged. "I just pay attention, that's all. I monitor vital signs more frequently than most anesthesiologists, so I can keep the level of anesthesia right on the edge. A rise in pulse or blood pressure, and I just turn up the gas a bit. It's a matter of experience and technique."

"But why is it that you only seem to use that technique and experience on Mainwaring's cases?"

The anesthesiologist's hand flickered toward the pack of cigarettes and then drew back. Where minutes before he had been in constant motion, now he was rigid. "That's nonsense, " he said. "The recovery room nurses don't think so. They tell me his cases always come out of the O. R. lighter than the rest of ours."

"Iverson, just what is it you're driving at?"

Easy, now, Zack warned himself. One step at a time. No slips. "Look, Jack, " he said. "I don't want to make trouble for anyone.

I just want to help this kid."

"Well, throwing darts at me isn't helping anyone. You're… you're barking up the wrong tree. And frankly, your innuendoes are starting to annoy me."

Zack sighed. "Listen, just give me a couple more minutes and I'll be out of your hair. All I want you to do is look this over and tell me what you make of it."

With what he hoped was just enough theatrical flair, Zack slid the notes he had just prepared from his folder and handed them across. Pearl scanned the sheet for only a few seconds before he snatched up his cigarettes. His hands were shaking and his heavy breathing blew out the match before it could ignite his smoke. "Just what in the hell is this supposed to be? " he asked. "You know what it is, Jack. It's a summary of nine of the gallbladder cases you've done the past two years. I have another twenty or so charts being pulled right now, and I suspect they'll confirm what this list already suggests."

Pearl looked ill. "Which is?"

"Which is, Jack, that despite having the same procedure, and receiving, at least according to your notes, exactly the same anesthesia, Jason Mainwaring's cases came out of the O. R. looking as if they had never been asleep, whereas Greg Ormesby's were normal. Look at the recovery room times. Mainwaring's cases were transferred out anywhere from one to six hours faster than Ormesby's… They didn't get the same anesthesia, Jack, did they."

It was a statement, not a question. "You're crazy, " Pearl said, thrusting the chart back at him. "Those patients got exactly what I said they got. Now why don't you just take this… this garbage, and get out of here."

"Okay, Jack. But you know I can't let this thing lie."

Pearl's hands were again folded tightly on his desk. "You do whatever you want, Iverson. I've got nothing to worry about because I haven't done anything."

For the first time since their session began, Zack began to have some doubts. A boy was dying. He had laid that on the table. Yet Jack Pearl, if he knew anything, had refused to budge. Could he have been that far off base about the anesthe ic? About the whole situation? Or was the pallid little anesthesiologist some sort of monster?

Only minutes before, answers had seemed so close. Now… "Have it your way, Jack, " he said, rising. "You know how to reach me if you think of anything."

"I won't, " Pearl said. "So just take your witch-hunt somewhere else."

"He's eight, Jack. Eight years old."

"Get out."