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19

Tuesday, April 7, 9:38 A.M.

Lynn had been the one to insert the chest tube using local anesthetic. Michael had watched. It was far easier than when they had inserted the needle thoracotomy, because Hank, a third-year emergency medicine resident, had been the instructor and stayed with them through the procedure. It went without a hitch and both Lynn and Michael felt reasonably confident they were much better equipped to handle the emergency care of chest trauma cases in the future.

After Clark Weston had been stabilized, Lynn and Michael went back out into the ER proper to see if they could lend a hand with any other patients. To their surprise, what they found was that the emergency situation was essentially over. While they had been seeing to Clark Weston’s needs, the rest of the patients from the accident had been taken to the MUSC Medical Center while the ones that had arrived at Mason-Dixon had all been seen and were in the process of being treated.

While they were still at the ER desk, checking if there was anything else they could do to help, Lynn caught sight of Dr. Sandra Wykoff, who had also responded to the call to come to the ER. Impulsively running over, Lynn caught up with the woman as she was about to leave. Controlling her emotions, Lynn quickly reintroduced herself and again asked about getting together. Graciously the doctor agreed but said, “It has to be now since I’m about to begin a case. Will that work for you?”

“Absolutely,” Lynn said.

“Then come up to the anesthesia office on the second floor, next to surgical pathology. I’ll meet you there but don’t dawdle.”

“I’ll come right away,” Lynn assured her.

Rejoining Michael, Lynn snapped under her breath: “See the woman I was just talking with? That’s Wykoff, the anesthesiologist who screwed up with Carl.” She motioned with her head in the woman’s direction.

Michael watched Wykoff disappear before turning to Lynn. “Come on, sis, we’ve been over this. Be cool! For the tenth time, you don’t know there was any screwup.”

Lynn gave a short, mirthless laugh. “We’ll see,” she said. “The important thing is that she’s willing to see me now. Are you interested?”

“Since we missed the derm lecture, I guess I don’t have any excuse, and somebody has to keep you in line. But we’re going to go via the cafeteria so you and I get a few calories. I’m about out of gas and you’ve been on empty for hours.”

“All right, but it’s got to be takeout and fast,” Lynn said. “There is a narrow window of opportunity. She’s about to start a case. She even warned me ‘not to dawdle.’ Can you believe it? I don’t think I have ever heard anybody use the word dawdle.”

“You are certainly looking for ways to fault her,” Michael said. “Dawdle is a perfectly fine word. You catch my meaning, right?”

“I suppose,” Lynn agreed reluctantly.

Lynn was willing to take the risk of going via the cafeteria because she knew what food meant to Michael. She teased him on occasion that he was a growing boy. Taking the time now to get him some food was a way of showing her appreciation that he was willing to come with her to talk to Wykoff. As a realist, she knew she probably needed some protection from herself, and he was the one to provide it. She couldn’t help but feel anger toward the woman and knew that expressing it would certainly be counterproductive.

The visit to the cafeteria was appropriately short. They grabbed a couple of bread rolls and some fruit at the register to eat on the run. As far as Lynn was concerned, there was another reason it was good that they did not stay. In her fragile emotional state, she didn’t want to take the chance of running into anyone who might ask about Carl’s surgery.

Five minutes later when they arrived outside the anesthesia office door, Michael pulled Lynn aside. “Wait a second,” he said. “We have to think what to say if Wykoff asks why we are interested in Carl’s case and how it was we read her note. She’s bound to ask us, and we can’t use the anesthesia story.”

“Obviously,” Lynn said. Because of the detour to the cafeteria, even though it was short, she was particularly impatient to get inside the office. She was afraid of Wykoff being called out at any moment and cutting the meeting short.

“The only thing that comes to mind,” Michael continued, “is to say we are on a neurology rotation, which I suppose is a laugh. It means we use anesthesia for neurology and neurology for anesthesia.”

“I don’t know,” Lynn said hesitantly. She didn’t like the idea and struggled to find another. “I agree she might ask, just like she might be touchy about Carl’s disaster. The problem is that it’s too easy for an attending like Wykoff to find out we’re lying. All it would take is one phone call, and we’d be in deep shit, and all doors for finding out about Carl would slam shut. No, we have to come up with something else so we’re not lying. Why don’t we say we are researching hospital-acquired morbidity? At least it’s true.”

“I’m not sure saying we’re studying hospital-acquired morbidity would be much better,” Michael said. “With the administration, the idea of its own medical students researching something like that will go over like one of Ronald’s bad jokes.”

“Well, I can’t think of anything else,” Lynn said. “I think we’re stuck with the morbidity angle. That is, if she brings it up. Maybe she won’t. Come on! We have to get in there!”

“All right,” Michael said, throwing up his hands. “You’re the boss.”

“Hardly,” Lynn said. Facing the door, she hesitated. Not knowing if they should just go in or not, Lynn knocked, thinking it best to err on the conservative side. The sign on the door just said ANESTHESIA. A voice from inside called for them to come in.

It was a relatively small office without windows. There was no secretary. The space had four modern desks supporting computer terminals to be shared by all the anesthesiologists to handle their paperwork. A large bookshelf ran along the right wall and was filled with anesthesia texts and journals. Dr. Sandra Wykoff was sitting alone at one of the desks. As the students approached, she motioned for them to bring over a couple of the other chairs.

“So...” Dr. Wykoff said once they were seated, “who, may I ask, are you?” She was looking directly at Michael, and unlike many of the other attendings, she maintained eye contact.

“Another fourth-year medical student,” Michael said. He was impressed that she continued to stare at him.

“And you are researching the Vandermeer case along with Miss Peirce?” Dr. Wykoff’s tone was surprisingly matter-of-fact, neither friendly nor unfriendly.

“Yes,” Michael said. He didn’t elaborate. He wanted this to be Lynn’s ball game. All he was there for was hopefully to keep Lynn out of trouble.

“Why are you two interested in this case in particular?”

Michael noticed that the woman’s gaze had now appropriately shifted to Lynn.

The students exchanged a quick, nervous glance. It was Lynn who spoke up: “We have become aware of the huge problem about hospital-acquired morbidity. We think this case fits that category all too well.”

Dr. Wykoff nodded and paused, as if thinking. Then she said, “Have you read my note in the Vandermeer chart?”

Both Lynn and Michael nodded, afraid of what was coming, namely a question as to why they were looking at the chart and under whose authority. But to their relief it didn’t happen. Instead the doctor asked, “What is it about this case that you want to discuss?”

“What the hell happened?” Lynn blurted out, causing Michael to wince inwardly. “I mean, how could a healthy twenty-nine-year-old man having routine elective knee surgery end up suffering brain death?”

“If you read my note, then you already know that nothing out of the ordinary occurred,” Dr. Wykoff said, seemingly not taking offense. Michael was both surprised and relieved. “The case was entirely normal. I thoroughly checked the anesthesia machine before the case and after. It functioned perfectly in all regards. The sources for all the gases and the gases themselves have all been checked and rechecked. All the drugs and dosages have been checked. I have gone over the case with a fine-tooth comb. So have several other anesthesiologists. Nothing happened that would have contributed to the unfortunate outcome. It had to have been some sort of idiosyncratic reaction.”

“There had to have been a screwup,” Lynn snapped.

Lynn’s tone and words made Michael now visibly wince. Before the doctor had a chance to respond, he said, “We did see in your note and in the anesthesia record that the blood-oxygen saturation suddenly went down.” He deliberately spoke in a measured tone as a counterpoint to Lynn’s outburst. “Do you or anyone else have idea of what made that happen?”

“The oxygen level did go down,” Dr. Wykoff said. “But it only dropped to ninety-two percent, which isn’t that low, and, just as important, it immediately began to rise. Within minutes it was back to near one hundred percent. But to answer your question, I have no idea why it went down. The inspired oxygen concentration and the patient’s tidal volume had not changed.”

Lynn started to speak again but Michael gripped her arm to keep her quiet, saying, “We imagine it must have been a very disturbing case for you.”

“You have no idea!” Dr. Wykoff said, and paused before adding, “I had never had a serious complication before this case. It is my first.”

“In retrospect, would you have done anything differently?” Michael asked, wanting to keep the conversation going but without being accusatory.

Dr. Wykoff took another moment to continue. “I asked myself the same question. But, no, I wouldn’t have done anything differently. I handled the case the same way that I have handled thousands of others. There were no screwups! I can assure you of that.”

“There had to have been something,” Lynn interjected, despite Michael still gripping her arm. Although her voice wasn’t quite as strident, it was still harsher than Michael thought appropriate. “There had to have been something out of the ordinary that you did even if you didn’t think it could have made any difference.”

Dr. Wykoff silently stared at Lynn long enough to make Michael think Lynn had finally done it. He girded himself for an outburst from the doctor, but it didn’t happen. Instead, to his surprise and relief, Dr. Wykoff said, “There was something, but it was very minor and can’t have been significant. It is not something I did, but something I noticed. It did bother me when it happened.”

“Like what?” Lynn demanded, again with a bit too much emotion.

Michael desperately tried to think of something to say to cover up Lynn’s insensitivity, believing her carping tone was asking for trouble, not only for her but for him, too. The reality was that they had already seriously violated HIPAA by looking at Carl’s and Scarlett’s charts and photographing the anesthesia records, and here Lynn was doing her best to alienate a woman who was being unexpectedly cooperative with a couple of medical students even though struggling emotionally herself. Michael sensed that the woman was deeply troubled by what had happened, which along the lines of “misery loves company” was probably the reason she was willing to talk with them at all.

“It involved the technical equipment,” Dr. Wykoff said. She spoke calmly, to Michael’s relief, and then paused to stare off into the middle distance.

“You mean with the anesthesia machine?” Michael said. He tightened his grip on Lynn’s arm to keep her quiet. From the sounds of her breathing he sensed she was about to say something.

“Not the machine per se,” Dr. Wykoff said. “But with the monitor. I happened to see it only because I was concentrating on looking at the monitor at the moment it occurred. It was when the surgeon began drilling into the tibia. I wanted to make sure that the depth of analgesia was adequate. Since the periosteum has a lot of pain fibers, I was watching the vitals closely.”

“And what happened?” Michael asked.

“Let me show you,” Dr. Wykoff said. “It is actually part of the anesthesia record.” Dr. Wykoff directed her attention to the screen of the computer terminal and began punching in commands.

While she was busy, Michael gave Lynn’s arm an extra squeeze to get her attention. “Cool it, girl!” he mouthed along with a harsh expression when she looked at him. He was serious. Lynn responded by trying to get her arm back, but Michael would not let go. Under his breath he said, “Let me do the talking! You’re going to get us thrown in jail if you keep up! Seriously!”

“All right, here it is,” Dr. Wykoff said, interrupting. The doctor angled the monitor’s screen more toward the students. It was the image of the anesthesia machine — generated record in graphic form of what had been on the monitor during the case, including blood pressure, pulse, ECG, blood oxygenation, end tidal CO₂, expired tidal volume, and body temperature. Michael and Lynn stood up to get a better view, even though it was what they had already seen in Carl’s chart.

“Look closely,” Dr. Wykoff said. She enlarged the image and used a pen as a pointer. “Here is when the oxygenation fell from close to one hundred percent down to ninety-two. It’s at eight-thirty-nine, or sixty-one minutes into the operation. That was when the alarm sounded. And you can see the ECG simultaneously shows tenting of the T waves, suggesting the heart isn’t getting adequate oxygen. Now, that doesn’t make sense. An oxygenation saturation of ninety-two percent shouldn’t cause the immediate appearance of T waves in a normal, healthy heart. Also there’s no change in any of the other parameters, which would certainly happen if there was low enough oxygen to cause brain damage.”

“We saw that when we looked at the chart,” Michael said.

“It’s hard not to see it,” Dr. Wykoff said. “It jumps out at you, since the oxygenation tracing was essentially a straight-line until that instant. But the fall is not what I want to show you.” She used the cursor to move back along the oxygenation tracing to fifty-two minutes into the operation, where there was a slight vertical blip upward. “Do you see this?”

“I do,” Michael said. “It is a sudden notch upward, whereas the O₂ tracing otherwise is like a flat, smooth sine wave, varying between ninety-seven and one hundred percent. What does it mean?”

“Probably nothing,” Dr. Wykoff admitted. “But notice the notch upward occurred with all the tracings on the monitor: blood pressure, oxygen saturation, everything. It scared me when it happened because I was actually closely watching the pulse rate. If a patient feels any pain when the surgeon drills into the periosteum, the pulse rate goes up, meaning the anesthesia is light. Well, the pulse rate didn’t go up. Instead, while I was watching, the whole monitor blinked at the precise moment the slight vertical jump appeared.”

“Blinked?” Michael repeated. “Does that happen often?”

“Not in my experience,” Dr. Wykoff said. “But then again we anesthesiologists don’t spend a lot of time staring at the monitor. None of us does unless there is a specific reason. When it happened, it scared me, which is why I remember it.”

“Why did it scare you?” Michael asked. It seemed inconsequential to him.

“What scared me was the worry of losing the feed from all my sensors, meaning I would be without electronic monitoring. I was relieved when it didn’t blink again.”

“You had never seen anything like that before?” Michael asked. He bent close to look at the image as the anesthesiologist magnified the section. To him it still looked trivial.

“No, I haven’t,” Dr. Wykoff said. “But that doesn’t mean it doesn’t happen. Maybe it happens often. I don’t know. It is such a small change. Electronics are not my thing. But it can’t have any significance since all the vital signs, as you can plainly see, stayed completely normal right up to the moment the oxygenation alarm sounded. As I said, the reason I remember it is that we anesthesiologists are accustomed to continuous electronic monitoring. Giving anesthesia without it would be like flying an airplane blind.”

“Do you see it?” Michael asked Lynn.

“Of course I see it,” Lynn snapped.

Michael rolled his eyes and again tightened the grip he had on Lynn’s arm as he made her step back from the monitor. He regretted trying to bring her back into the conversation for fear she would ruin the rapport that had been established with Dr. Wykoff and maybe get them in trouble after all. He knew it was time to leave. “We want to thank you, Dr. Wykoff, for—” He didn’t get to finish. The door to the corridor burst open, and a man charged into the room.

Yanking off a surgical face mask, the newcomer headed for a computer terminal, but, catching sight of the others, he stopped short. It was apparent he had assumed the room to be empty. He was a powerful-looking, golf-tanned Caucasian man dressed in scrubs. Adding to his physical stature were big hands and muscular forearms. At first his expression was one of perplexity, but it quickly changed to aggravation. He looked back and forth between Michael and Lynn. Both knew who he was from their third-year surgery rotation. He was Dr. Benton Rhodes, the volatile, New Zealand — born chief of anesthesia who was renowned for having little love for medical students.

“We were just leaving,” Michael said quickly. He turned back to Dr. Wykoff. “Thanks for your time and willingness to talk to us about such a disturbing case. We appreciate it.”

“What case?” Dr. Rhodes demanded with his Anzac accent.

“Carl Vandermeer,” Lynn said defiantly.

“Vandermeer?” Dr. Rhodes repeated as if shocked. “Who are you two?”

“We’re fourth-year medical students,” Michael said quickly, urging Lynn toward the door. She resisted, fanning his fear that this unexpected encounter might not end well.

“What are your names?” Dr. Rhodes demanded.

“I’m Lynn Peirce and this is Michael Pender.”

Dr. Benton turned to Dr. Wykoff and shouted angrily in apparent disbelief: “You were discussing the Vandermeer case with these medical students? I don’t understand. Yesterday afternoon we were warned by the hospital counsel not to discuss the case with anyone.”

“They are interested in hospital-acquired morbidity,” Dr. Wykoff explained. “It is an important and legitimate issue, and they are our medical students.”

“I couldn’t care less who they are,” Dr. Rhodes continued to shout. “The case is not to be discussed with anyone, period!” Then, turning to the students, he snapped, “And I want you two out of here. But be warned! I am going to be giving your names to the hospital counsel. The order not to discuss the case with anyone now includes you. Don’t talk about it with anyone: friends, family, fellow students, whatever. Doing so will jeopardize your status as medical students. Do you understand? It is hugely important that I am very clear about this.”

“We understand,” Michael said, dragging Lynn toward the door. He wanted to get her out of the room before she said anything else.

20

Tuesday, April 7, 10:05 A.M.

As the door to the anesthesia office closed behind them, Michael and Lynn heard Dr. Rhodes’s tirade continue. The man was clearly beside himself with rage at Wykoff.

“Talk about burning bridges and making enemies,” Michael said as they headed down the central corridor. “That turned out to be a big-time fuckup.”

“It wasn’t our fault,” Lynn said, keeping her voice down as they passed people. “It was just bad luck that Rhodes showed up. Everything had been going fine until then.”

“One way or another, we’re not going to be able to go back to Dr. Wykoff. Of course it might have happened anyway, considering the way you were talking to her.”

“What is that supposed to mean?” Lynn said, taking offense.

“You were accusing her of screwing up, just like I told you not to do. That ain’t the way to keep your options open, girl. Take it from me. The reason that I never got shot or that I’m not in prison is that I learned early not to piss people off. The way you were acting, I’m surprised we got as much out of Dr.Wykoff as we did.”

“I’m the one who is pissed. I didn’t feel like giving her any slack.”

“And you certainly didn’t.”

“I still think she is hiding something. She has to have done something wrong. I’m sorry, but that’s the way I see it.”

“Well, I don’t,” Michael said. “My take is that she is hurting over the case and has no idea what happened. She wouldn’t have gone on about that blip. Electronic equipment has little burps like that, particularly video and sensory feed. It’s called a frame offset. My take is that she’s almost as desperate as you are to find out what the hell happened.”

“We are going to have to agree to disagree,” Lynn said. “And I’m bummed out we weren’t able to bring up either of the other cases, as similar as they seem to be. I also wanted to ask her what she thought of the idea of an anesthetic causing the protein abnormality Morrison has. And the fever she and Carl have. Hell, I’ve got a lot of questions that need answering. I think we should try to meet with the other anesthesiologists. Do you remember who did Ashanti’s case?”

Michael hated and pulled Lynn to a stop in the process. They were just abreast of the Surgical Pathology Department. He looked at her with disbelief. “You’re joking, of course. Tell me you’re joking!”

“No, I’m not joking. I think we should talk with the other anesthesiologists. Maybe they all made the same mistake. It could be the only way to find out. I’m not convinced they talk to each other when something like this happens. In that sense you are right: they are all defensive.”

“First of all, I don’t remember who the anesthesiologist was for Ashanti. But if I did, I wouldn’t tell you. You heard how pissed Dr. Rhodes was that we were discussing Carl with Wykoff. If he finds out you’re even thinking about talking with the other anesthesiologists, he’ll go berserk. He could get our asses kicked out of school. Wouldn’t that be nice now that we are within sight of graduating? I’m sure that a big reason he was so pissed is because Carl represents the third case.”

“Are you finished?”

“Yes, I’m finished. Let’s get changed and get out of here.”

They started walking again.

“I think we were lucky to get away pretty much unscathed,” Michael said.

“That’s not a given,” Lynn said. “What do you think the chances are that either Wykoff or Rhodes might say something to the nurses in the neuro ICU? It might occur to them to ask how it was we were able to look at Carl’s chart. If they do, it would be bad. We wouldn’t be able to go back, and I wouldn’t be able to follow Carl much less find out how this happened.”

“I think it’s hard to say what they might do. If they think about informing the nurses, they might. I believe it will come down to that, but in our favor, they have a lot on their minds. I’m sure they are running scared about a possibility of a serious lawsuit.”

“I don’t think Carl’s parents will sue,” Lynn said.

“I don’t think you can say that. With the dad being a lawyer — a litigator, no less — I personally think the chances are good. One of the malpractice guys will talk them into doing it supposedly as a way of keeping other people from falling victim to the same fate. I’m sure fear of a big lawsuit is why the hospital counsel is so concerned.”

They reached the main elevators and paused before going into the surgical lounge. Michael checked his watch. “We’re going to have to make tracks to get to the derm clinic. They are not going to be happy we missed the lecture. Thank God we can use the ER as an excuse. Listen, I’ll meet you out here after we change back into our street clothes.”

“I’m not going to any clinic,” Lynn said. “Particularly a derm clinic. In my state of mind there’s no way I could concentrate on looking at pimples and rashes.”

“What are you going to do? You’re not thinking of going back to talk to any anesthesiologists, are you?”

“No! I’ve got to make myself sleep, at least a few hours. I know I’m not thinking right, and I have a shitload of studying I want to get done. I need to learn more about those monoclonal gammopathies and multiple myeloma.”

“Suit yourself, but I’m going to the clinic. I don’t want to risk pissing off the admin at this point so close to graduation, especially with Rhodes possibly on our case.”

“Be real! You really think they might deny graduation from missing a few crummy specialty lectures and clinics?”

“Who knows? What I do know is that it ain’t worth the risk. If there is a sign-in for attendance, I’ll add your name.”

“Thanks, bro. One other thing! Can I look at that photo of Ashanti’s anesthesia record on your desktop computer?”

Michael eyed Lynn and hesitated, as if debating. “I’d have to give you my room key. You might copy it and come in and molest me.”

“As tempting as that may be, I’ll give you my word to hold myself back. And I promise not to disturb your stash of smack.”

“You better not! All right, then, I’ll meet you out here at the elevators in five.”

While Michael was changing back into his street clothes, he found himself wondering what would have happened had he not accompanied Lynn to meet Wykoff. As bad as it had turned out, he was certain it would have been much worse if she had been on her own. As he saw it, no matter what he had said, she needed close monitoring, as she’d copped an attitude Michael was certain was destined to get her in real trouble and possibly him, too. Yet he could understand and sympathize. If what happened to Carl had happened to his girlfriend, Kianna Young, he’d be a basket case, too.

When Michael got back out to the elevator lobby, he was moderately surprised that Lynn was already there. He thought he had changed quickly and had expected to have to wait. He handed her his room key and said: “Would you mind making the bed and cleaning the bathroom while you are in there?”

“Fat chance, you male chauvinist,” Lynn said as she snatched the key. “I’m going to e-mail the photo of Ashanti’s record to myself and that’s it. Another request! Would you e-mail me the photos you took of Carl’s and Morrison’s records? Then I’ll have all three. By comparing them, maybe I’ll be able to find something unexpected.”

“I think the first thing you need to do is get some sleep.”

“Thank you, Doctor. Meanwhile do the e-mails.”

“Yes, ma’am,” Michael said, saluting.

21

Tuesday, April 7, 10:15 A.M.

Benton Rhodes slammed the door to his private office with such force that some of his framed diplomas on the walls tilted, requiring him to walk around and straighten them. He imagined that the concussive sound had probably jolted the Anesthesia Department secretary sitting at her desk just outside. She had been listening to dictation and typing on her monitor when he had walked by, and hadn’t seen him. Yet if he’d startled her, he didn’t feel the slightest bit guilty. When he was enraged, he often took it out on anybody and anything. The idea that he’d scared the secretary actually calmed him to a degree.

He was still dressed in scrubs, even though he had left the OR and descended to the admin area, where most of the department heads had their formal offices. But before he had left the floor, he’d ducked into the locker room to get his phone. Sitting down at his desk, he pulled it out of his pocket and went into his contacts. Then he paused. He didn’t know whom to call first about this latest stupid screwup.

For the life of him, Benton couldn’t understand how people could be so smart in some things and so stupid in others, which was why he had yelled at Sandra Wykoff. As dedicated an anesthesiologist as she was, he couldn’t comprehend how she could have misinterpreted the instructions from Bob Hartley, the hospital counsel, about not discussing the Vandermeer case with anyone. The lawyer couldn’t have been any clearer. Not discussing it with anyone meant no one, period. Especially not a couple of medical students rummaging around for a cause to make a name for themselves. “Hospital-acquired morbidity,” my ass, he thought glumly. The next thing they might do is put on Twitter or Facebook what they believed to be sage observations about the case. God, it would be a disaster!

Drumming his fingers on his desk, Benton thought that running the Mason-Dixon Medical Center’s Anesthesia Department was turning out to be more of a bother than he had bargained for. When he’d been recruited five years previously at the age of sixty-four, he had been in charge of the anesthesia department of a much larger, Ivy League center that did twice the surgical volume and had an anesthesiology residency program to boot. Yet it had somehow seemed easier in New England and without the anxiety he was dealing with here in Charleston. It was the South, for God’s sake, where he’d heard people were supposed to laze around and sip mint juleps. His goal had been a semi-retirement to enjoy life. Unfortunately it was not working out that way.

Making a decision, Benton pulled up Robert Hartley’s office number on his mobile but didn’t use it to make the call. Instead he dialed the number on his hospital landline, knowing he’d get better service from the law firm’s office help. The Mason-Dixon Medical Center was an important client.

As the call went through, Benton calmed down further. There had been some problems running the Anesthesia Department before, maybe not as big as the current fiasco, but problems nonetheless. Yet the perks he’d received from taking the job had been sweet, particularly the stock options. Their value had escalated, especially now that there was talk of a takeover of Middleton Healthcare by Sidereal Pharmaceuticals, owned by the billionaire Russian expatiate Boris Rusnak. If that happened, Benton could really retire in style.

As he expected, he was put through to Bob Hartley directly, and the lawyer picked up the phone almost before it had a chance to ring.

“What can I do for you, Benton?” Bob said. His voice was deep and reassuring. Over the years they had gotten to know each other well enough to be on a first-name basis.

“I’m afraid there’s been a breach in your directives to Dr. Wykoff. I thought you should know immediately.”

“That’s not good. What exactly happened?”

“I walked in on Dr. Wykoff having a chat about the case with a couple of fourth-year medical students. I couldn’t fucking believe it after what you said yesterday.”

“Did these medical students seek her out?”

“Yes. One of them bumped into Wykoff in the women’s locker room and asked out of the blue if she could talk about the Vandermeer case. And for some reason Wykoff agreed.”

“Do you have any idea why she agreed?”

“She says she is really upset about what happened and needed to talk about it as a kind of therapy. And get this: she said she thought of the medical students as family. Jesus Christ! Medical students. Can you fucking believe it?”

“How did the medical students hear about it? Do you know?”

“I have no idea.”

“Do you know why they are interested in the case?”

“Wykoff said they were concerned about the issue of hospital-acquired morbidity: people going into the hospital for one thing and getting something worse in the process. In that regard, I’m afraid Vandermeer is a prime example. Actually, it is a real issue.”

“Did the students mention the other two cases?”

“No, they did not.”

“Did you get their names?”

“I did. Michael Pender and Lynn Peirce. I briefly checked them out. Both are really good students in the very top of their class.”

“So they could be leaders, which might make it more of a problem. Do they have a history of being activists?”

“I have no idea, but nothing like that was suggested in either academic record.”

“Whom have you told about this?”

“You are the first.”

“I think you should tell Dr. Feinberg. The hospital president has to be aware, because if the media gets ahold of this, it could scuttle the takeover negotiations, and we certainly don’t want that to happen.”

“Of course not!”

“I assume you told the students that they are not to talk about the case with anyone, friends or family. I mean really told them.”

“I made it very clear.”

“Why is Dr. Wykoff being more of a problem than Dr. Pearlman or Dr. Roux? Those two have been extremely cooperative.”

“It is really hard to say. Believe me. It could be because it is her first major complication. Some doctors take it very personally. The one thing I can say is that she is not worried about a malpractice case. She is that confident she did nothing wrong.”

“She’s being naive. Malpractice cases can go either way, no matter what the particulars.”

“She’s also a workaholic who doesn’t socialize much and lives alone. Professionally she’s very reliable and conscientious, but something of an odd duck, at least in my estimation.”

“The other two anesthesiologists live alone, too.”

“What can I say? I don’t know why she is being uncooperative.”

“Do you think she should be terminated as a precaution after this violation of my directive?”

“I think we should wait and see how she responds from this point on,” Benton said. “She’s a damn good anesthesiologist and usually a team player. A lot depends on whether a lawsuit gets filed. But I’ll leave that decision up to Josh Feinberg. He’s being paid a fortune to deal with issues like this.”

“Sounds like a plan,” Bob said. “Thanks for letting me know. I’ll give it some thought. Something might have to be done with all these people if they don’t toe the line. I’ll talk with Josh after you clue him in. We’ll be in touch.”

With a sigh of relief, Benton replaced the receiver. He felt a lot better now that he had pushed the issue into Bob Hartley’s capable lap. Intuitively Benton knew he would feel even better after speaking with Josh, who would have no trouble making decisions about Wykoff. He also knew that Josh could talk to the dean about the students and nip that problem in the bud.

Getting up from his desk, Benton went out to his secretary and asked her to check to see if Dr. Josh Feinberg could spare a few minutes to see him right away. Benton wanted to do it before he went back up to the OR. With as many surgical cases going on as there were, he needed to be up there to put out sparks before they became fires.

A minute later Benton’s secretary leaned into his office. “Dr. Feinberg can’t see you until three P.M.”

“Okay, thanks,” he said. After getting all riled up he now felt let down. Yet what could he do? So he’d see the president at three. Until then he had other issues to deal with.

22

Tuesday, April 7, 10:43 A.M.

Despite her exhaustion, Lynn had taken a short detour to the cafeteria. After leaving Michael she reluctantly decided that hunger had trumped her lack of sleep. The calories from the banana and bread roll she had eaten en route to the meeting with Wykoff had quickly disappeared. She felt weak, a little dizzy, and even a bit nauseous.

With little fear of running into any of her close friends, because of the derm clinic, she opted to sit down at a table. Sensing she needed some protein, she ordered scrambled eggs and wolfed them down with a cup of herbal tea. The food helped enormously, and made her believe she could think much more rationally and less emotionally. It also made her dizziness and nausea go away, something she noticed particularly as she headed over to the dorm, passing literally and figuratively in the shadow of the hulking Shapiro Institute.

Just as she had done the previous day, she paused for a few moments, eyeing the structure. She thought about Scarlett Morrison being transferred into the institute, and the idea brought up the issue of Carl being sent over as well. She questioned what she would do if that happened, as she wasn’t family. It would mean she’d be reduced to getting updates from his parents. They had been gracious when she ran into them the day before, but that could change when they remembered that she had been the one to recommend he have his surgery at the Mason-Dixon rather than the Roper Hospital at MUSC. She might be left out in the cold. Lynn shrugged. She knew she was getting way ahead of herself. With a sense of resignation, she continued toward the dorm.

It felt weird going into Michael’s room without him. After closing the door behind her, she stood for a moment, taking in the familiar sights and aroma. Michael was far neater than she, and everything was in its place. Even the books were shelved according to subject matter. Over the years she had teased him about the fastidiousness in his lifestyle, just as he had given her grief about her lack of it.

Although it was a bit strange to be in the room without Michael, just being there also felt comforting. She had spent considerable time in his room, as he had in hers. Especially during the first two years, they had studied a lot together in one or the other’s room. Many of the other students had preferred the library or the student center for communal learning. Not Lynn and Michael. What made studying together so rewarding was that they silently pushed each other to make greater efforts than what they would have had they studied on their own.

She sat down at Michael’s computer. He had cobbled it together from various components to maximize the gaming experience. She had gone through a gaming period herself but had grown out of it. Not so with Michael. She knew that he still used it to relieve anxiety and difficult emotions that medical school was capable of engendering, especially for a black man in a southern, mostly white professionally staffed medical center. He had admitted to her that he often gamed for fifteen minutes or so late at night, explaining that when he was a teenager, gaming had been a much-needed escape from the pressures of the ’hood, and a way of dealing with aggression.

After turning on the system, Lynn pulled up pictures. Expecting to find a well-organized and well-thought-out photo filing system as further evidence of his compulsiveness, she found something quite different. The photos were organized merely by date, meaning the chronological order in which the photos were taken.

Remembering that Ashanti had had her surgery several months earlier, Lynn started looking at photos taken in January. To her surprise, she came across a series of pictures that had been taken on a Saturday-afternoon excursion to the gorgeous Middleton Place, the apparent namesake of Middleton Healthcare, a sixty-acre landscaped garden begun as a rice plantation in the seventeenth century and now listed as a National Historic Landmark. Michael, his girlfriend, Kianna, Carl, and she had gone.

Lynn’s breath caught as she found herself looking at a photo of herself and Carl and Kianna in a horse-drawn carriage. Michael was not in the photo because he was the photographer. It was a happier time: a sublime time.

For a second Lynn closed her eyes and let the reality of Carl’s coma flood her thoughts. She had been getting by on a ton of denial and intellectualization, but now the realization that his mind and memories were gone descended on her like an avalanche. For the first time since the tragedy had begun, she let herself be enveloped by raw emotion. She began to cry. And cry she did, with shuddering intensity like a summer thunderstorm.

After what seemed like an eternity, the tears slowed. Eventually Lynn managed to get up and get some toilet paper to dry her cheeks and blot her eyelids. The small amount of makeup she used came off in a dark, dirty smudge.

Regaining a semblance of control, she went back to shuffling through Michael’s extensive photo collection, avoiding pictures of Carl and herself as much as possible. It was difficult because there were a lot. She had forgotten they had double-dated with Michael and Kianna quite so often. There were photos of all sorts of things, including hundreds of shots of Charleston historic houses.

Eventually Lynn found the image she’d been searching for and brought it up onto the screen. It was entirely readable, especially since its compression had been slight, and she was able to enlarge sections. Satisfied, she e-mailed the image to herself in a large format. She wanted to preserve her ability to look at the details, particularly his vital signs. A moment later she heard the phone in her pocket announce she’d gotten the e-mail.

Lynn was back in her room a few minutes later. She took off her white coat and draped it over the reading chair, which also contained a ball of recently washed clothes. It always took her time to sort through the bundle when she brought it up from the laundry room in the basement. Sometimes she didn’t bother. On those occasions she just used the clothes as they were needed.

For a moment Lynn eyed her bed, which she made only when she washed her sheets, which wasn’t often. She had always thought she had better use for her time. Briefly Lynn considered lying down for just a few moments. Then she changed her mind. She knew that once she was horizontal, it might be difficult to get up.

Instead she sat down at her laptop and went into her e-mail inbox. There at the top was the JPEG she’d just sent to herself. Immediately below were two other e-mails from Michael. As promised, they were Scarlett Morrison’s and Carl’s anesthesia records. Lynn checked to be sure. Then she loaded all three into a flash drive, which she would take down to the student common room on the first floor to utilize the communal printer. But before doing so, she Googled gammopathy as she had done in the neuro ICU and immediately found the same article: “Monoclonal Gammopathy of Undetermined Significance.” She downloaded a PDF version into the same USB device. Then she downloaded Wikipedia articles on multiple myeloma and serum protein electrophoresis. The last article she knew she wanted was on monoclonal antibodies, but when she rapidly read through it before downloading it, she realized there was one more she needed. It was on hybridoma technology. From an immunology lecture in her second year she remembered that monoclonal antibodies were made by hybridomas.

So armed, Lynn went down to use the printer. She had to swipe the magnetic tape on her student ID to get the machine to operate. While the machine did its thing, she sat in one of the leather club chairs and practically fell asleep.

With her printouts in hand, she went back to her room and lay down on her bed. For a few minutes she debated which of the printed pages she should read first. She thought about looking at the anesthesia records but decided she needed a completely clear head for those. Instead she turned to the articles. She settled on the gammopathy article, since it would be a review, as she had already read it once before in the neuro ICU. After that, she planned to read the one on multiple myeloma. But the reality was that she managed only four or five sentences of the first article before falling into a deep, dreamless sleep.

23

Tuesday, April 7, 1:52 P.M.

With a sense of relief Sandra Wykoff left the PACU after making sure her second and final case was fully awake and functioning normally. It had been a hip replacement, and she was confident the patient would be going back to the fifth floor in short order. During both cases, when it came time for her to wake them up, she’d had a degree of anxiety, but both had awakened as expected, just as all the other cases she had done in her career, except for Carl Vandermeer’s.

Once out in the main hallway, Sandra walked down to check the whiteboard to make sure she had not been scheduled for another case since her first case had been canceled. Although she was confident Geraldine Montgomery, the OR supervisor, would have let her know, she wanted to be certain. After the tongue-lashing she’d suffered from Benton Rhodes that morning, she wanted to be absolutely certain she didn’t do anything to provoke the man further. She had known about his reputation for having a short fuse but until that morning had never experienced it personally.

The more Sandra thought about the Vandermeer case, the less harsh she became on herself. She was absolutely confident that she hadn’t done anything wrong during the procedure. She had not even taken so much as a shortcut, which she knew other people in the department did on occasion, particularly neglecting to manually check the anesthesia machine before each use. Most relied completely on the automatic check, which she thought was a mistake.

It had taken only a little more than an hour after Rhodes had stormed out of the communal OR anesthesia office for Sandra to be again totally convinced that whatever had happened during the Vandermeer operation was not her fault. She was absolutely sure of this, since she had, as she had told the students, gone back over the case in minute detail, questioning every step and consulting with several other anesthesiologists whose opinion she admired and trusted.

Sandra had even tried to have a conversation with Mark Pearlman, who had had a strikingly similar case the previous Friday, but he had refused to talk with her about his case or hers. He had chosen to follow Rhodes and Hartley’s orders to the letter, even to the extent of not talking to a fellow anesthesiologist. Sandra thought that was a mistake despite what the hospital counsel felt. She knew that complications often led to advances in medicine.

The long and short of it was that if there was a lawsuit, Sandra was confident that no one would find the hospital or herself culpable. And, contrary to what Benton Rhodes had said, she was sure that the two students were Mason-Dixon family and could be trusted. She had made the effort to call the dean of students to ask about Lynn Peirce prior to seeing her and had learned that Miss Peirce was going to graduate number one in her class, just as Sandra had done over at MUSC almost seven years before. There had been no reason not to talk to her and her classmate and perhaps salvage something from the disaster. Students had to learn that medicine was not all-powerful or completely predictable.

And there had been a positive aspect to the conversation with the students. For Sandra, talking about the case in detail had helped ameliorate the guilt that had been haunting her since the tragedy had struck and boost her confidence in her professional abilities. Confidence was important if she was to continue being an anesthesiologist.

The other thing the conversation with the students had done was remind her of the blip that had occurred on the monitor. It had been so insignificant, but considering it was the only thing about the case that was at all unusual, she now thought it was worth checking. The problem was that doing so necessitated calling Clinical Engineering, something she was reluctant to do, since it meant risking having to deal with Misha Zotov.

Steeling herself against such a possibility, Sandra walked back down the main OR corridor whence she had come and headed for the room where the extra anesthesia machines were stored. Her hope was to corral one of the Clinical Engineering technicians and ask a few questions about the blip she’d seen on the monitor. She wasn’t looking forward to going all the way down to the Clinical Engineering Department, located in the hospital basement, where she had first encountered the irritating Russian.

The good news was that Misha Zotov wasn’t in the room. The bad news was that no one else was, either. Turning around, Sandra retraced her steps to the main desk. It seemed that if she was going to ask about the blip, she would have to go to the Clinical Engineering office, after all.

At the busy main desk, Sandra got Geraldine’s attention and told her she was leaving the floor and that if she was needed for anything, she could be texted. Geraldine gave her a thumbs-up to indicate she got the message.

After retrieving a long white lab coat from her locker in the women’s lounge, Sandra was able to put off going down to the basement, at least for the time being. Thinking about Carl Vandermeer made her want to check on the man’s status. She had gone into the neuro ICU for a quick visit the previous afternoon before leaving the hospital and also early that morning on her way in to work. Although she was aware of the MRI and CT scan results and had read the neurology residents’ notes, she couldn’t help but harbor a bit of hope that there might be a change for the better, knowing how little hypoxia he had suffered.

Once in the neuro ICU, she went directly to cubicle 8. Seeing Carl, Sandra could immediately tell there had been no change in his condition. A nurse had rolled him onto his left side so that she could wash and powder his back. Sandra shuddered at the enormity of the situation for which she, on some level, was responsible for causing. She knew that dealing with a comatose patient required almost constant care and attention. She also knew that Carl would probably need a percutaneous gastric tube. Doing so required an operation. Sandra shuddered again, wondering how she would feel if it fell to her to do the anesthesia.

“Any improvement?” Sandra asked, even though she already knew the answer.

“Oh, yeah,” the nurse said optimistically. “He’s doing okay. A few minutes ago he sneezed.”

Good grief, Sandra thought but didn’t say. The patient’s having a sneeze was such a pathetic indication that Carl was doing okay. At the same time she understood that a sneeze was a positive sign, as it meant that at least the brain stem was functioning. She glanced up at the monitor. The temperature was elevated, as it had been that morning, but everything else was normal. She then left the cubicle and headed over to the central desk. En route she noticed that Scarlett Morrison, Mark’s coma case, was gone, as her cubicle was occupied by a man named Charles Humphries.

The previous afternoon she had had a short conversation with the head nurse, Gwen Murphy, about Carl, and again Sandra sought her out. “Any change with Vandermeer?” she asked, a bit of hope against hope.

“Nope,” Gwen said. “But on the bright side he is very stable. And the infectious disease consult hasn’t found any infection to explain his elevated temperature. And the fever has come down a bit.”

Sandra looked over at the cubicle where Mark Pearlman’s case had been. “I see Scarlett Morrison is gone. Did she go out to the neuro floor?”

“Nope!” Gwen repeated. “They took her directly to the Shapiro Institute. To be honest, they don’t really have the equipment or the manpower out on the neuro floor to handle a long-term comatose patient. At the Shapiro they are specifically set up to do it.”

“Seems awfully quick,” Sandra said. “She was here only three days.”

“As stable as she was, she didn’t need to be here in the ICU,” Gwen said. “And it’s better for everyone, the patient included, and the hospital bean counters also like it. Keeping someone here in the neuro ICU is ten times more expensive than it is over there.”

“Ten times! Wow! I knew there was a difference but not that much. That’s quite a stimulus.”

“It sure is. We’re hoping Vandermeer goes, too.”

“Really?” Sandra said with dismay. “But he just got here. Maybe he is going to improve.” In her mind, sending a patient over to the Shapiro Institute meant “pulling the plug” on hope, even if hope was unrealistic.

Gwen shrugged. “Not according to the neuro residents. It’s their feeling that getting him over to the Shapiro sooner rather than later is indicated, and we surely could use the bed.”

Feeling more depressed leaving the neuro ICU than she had when she had arrived, Sandra went back to the main elevators. She squeezed into the next down car as she had run out of excuses for postponing a visit to Clinical Engineering. Although the elevator was jammed when she boarded, descending from the first floor to the basement she was the only person left. When the elevator doors opened, she paused for a moment. Then she shook her head, feeling embarrassed at her timidity. If she ran into Zotov, she would just ignore him. She thought she was acting like a teenager.

Sandra first passed the Pathology Department and the morgue, and then the Informational Technology Department, where the hospital’s servers could be seen in their air-conditioned isolation. Next to IT was the central security office, and Sandra caught a glimpse of the banks of monitors fed by cameras sprinkled all over the medical center.

As she walked, Sandra reflected on why Misha Zotov bothered her so much. He reminded her of her ex-husband, Adam Radic, in both looks and mannerisms. Both were darkly complected, tall, muscular but slender with intense, lidded eyes and heavy beards. Both were also fawning to the point of overdoing it. With Adam, time had proved it had been an elaborate act. Somehow she was certain it would be the same with Misha.

Initially, when Sandra had first met Adam at the very beginning of her residency, she had been quite taken by his flattery and attention. She also had found him exotically attractive and much more sophisticated than she, having traveled and studied around Europe. He had come to America from Serbia to do a surgical fellowship. Believing his declarations of love were sincere, Sandra had fallen in love with him. For a highly motivated doctor like herself, it helped that he was a recognized and talented surgeon.

Within less than a year after they had started dating, she and Adam were married. But after the marriage things quickly changed, especially once Adam got his green card. He became a tyrant and had beaten her severely several times. Thanks to her father’s intercession, Sandra got divorced, but not without suffering considerable trauma. For her, the issue of domestic violence had become a distinct reality.

Sandra pushed through the door into Clinical Engineering. It was a large room with service benches piled with a mixture of all manner of hospital apparatuses, from anesthesia machines to respirators. It was all neat and orderly, with tools on Peg-Boards. The noise level was moderate, with various power tools competing with a background of classical music. At a table against the back wall two men played chess.

As Sandra’s eyes swept the room she estimated that there were about fifteen people at work, all dressed in white coveralls. Most continued doing what they were doing. A few looked up. Most of them resembled Misha Zotov. There were a few blond men, but they were a distinct minority. There were no women.

To Sandra’s mild dismay, Misha Zotov was one of those who looked up, as he was at the closest service bench, working on an anesthesia machine. She caught an expression of recognition on his face, and to her chagrin he immediately put down the tool he was using, stood, and started toward her.

Sandra’s eyes quickly scanned the room again, this time looking for Fyodor Rozovsky, the department supervisor. She had met him on her previous visit. It had been he who had answered her service-related question. Unfortunately he was nowhere to be seen.

“Ah, Dr. Wykoff,” Misha said, crowding her space. It sounded as if his English had improved, but he still spoke with a distinctive Russian accent. “You look beautiful. How can I help you?”

“Where is Fyodor Rozovsky?” Sandra asked. She took a step back, avoiding eye contact with the man. By inappropriately and presumably insincerely referring to her appearance, she could tell he had not mended his ways. She wanted nothing to do with the man. She glanced around the room yet again.

“He is in his office,” Misha said. “Please! I could get him for you. No trouble at all.”

“Thank you, but I’ll find him myself,” Sandra said curtly, and headed off. The office was in the back. Unfortunately Misha did not get the message and tagged along, continuing to try to engage her in conversation. Whether she answered or not didn’t make a difference. He was carrying on about the weather and how beautiful it was in Charleston with all the flowers and how bad it was in his hometown in Russia this time of the year. His English vocabulary had definitely expanded.

Sandra didn’t respond. It was amazing how much the man reminded her of Adam Radic, and the memory made her skin crawl. When she got to the door to the office, Misha was still behind her. The fact that she was ignoring him had no effect on him whatsoever. He was again suggesting they have a drink together at his favorite bar on the rooftop of the Vendue Inn, saying it was a great place to watch the sunset over the Charleston skyline. Sandra knew of the bar. It had been one of Adam’s favorite hangouts, but without her.

Sandra went into Rozovsky’s office. Without breaking a step, Misha accompanied her. Inside the office were a small service bench and several desks. One was occupied by the Clinical Engineering supervisor, and the others were empty.

Before Sandra could say anything, Misha pushed past her and engaged Fyodor in an animated conversation in Russian. Fyodor peered around Misha as Misha spoke. Sandra wondered what in God’s name Misha was talking about since she’d said next to nothing to him. Finally Misha finished and stepped to the side. Fyodor stood up and gestured to the straight-back chair Misha proceeded to pull over. “Please, Dr. Wykoff, sit down.” In contrast to Misha, he spoke with very little accent, and his English was very good. “I remember you. You came down to ask how often we did routine service on the anesthesia machines.”

Sandra sat and glanced over at Misha, hoping he would leave, but he didn’t. He was content to just stand there with a kind of smirk on his face, as if he expected some favor from her for having accompanied her into Fyodor’s office. As pushy as he was, she was glad she had not run into him alone upstairs.

“I have another question,” Sandra said, directing her attention to Fyodor.

“We are at your service, Doctor,” Fyodor said. As far as Sandra was concerned, even he exuded a suggestion of insincerity that made her uncomfortable.

“There was a very unfortunate anesthesia incident yesterday...” Sandra began, but then hesitated. She felt she needed to give some background, although Rhodes’s orders about not talking about the case made her reluctant to say very much. Yet she was talking to the people responsible for the performance of the anesthesia machine she had used, and she needed to be reassured.

As if sensing her quandary, Fyodor said, “We have heard about the event from Dr. Rhodes. First, we want to reassure you that the machine you were using had been serviced appropriately and in a timely manner. All its paperwork was in order. And as soon as we heard about the event, and following Dr. Rhodes’s orders, we brought the machine back here to our service center. We went over it extensively. I can assure you that it checked out perfectly, and it is back in service. There was no problem with the machine or its monitors, and Dr. Rhodes has been informed of this.”

Sandra nodded. Fyodor’s little spiel was more than she had expected. She didn’t know that Rhodes had asked to have the machine checked by Clinical Engineering, but it made sense. Perhaps she should have asked herself, but it didn’t matter, as it had been done.

“Do you have any additional questions?” Fyodor said.

“I think that covers it,” Sandra said, and started to rise. But then she hesitated. Settling back onto her chair, she said, “There is one other thing.”

“Please,” Fyodor said agreeably. He even managed an unctuous smile.

Similar to what she had said to the two medical students, Sandra then went on to describe the jump, or blink, or blip — she really didn’t know how best to describe it to these professionals — that she had seen on the monitor when the surgeon had begun drilling into the tibia. As she spoke, she sensed from his expression that Fyodor was disbelieving that such a thing could occur. In response, Sandra said that it could actually be seen on the machine-generated anesthesia record. “It is a very small change, but it is visible. If you bring up the Vandermeer anesthesia record on your terminal, I’ll show you.”

After a quick glance between Fyodor and Misha, which included a nod from Fyodor, Misha went to the computer monitor on Fyodor’s desk, brought up the record, and then stepped aside. Sandra then took over. As she had done when she’d been with the medical students, she zoomed in on the tracing of the vital signs. She pointed to the place fifty-two minutes into the case, where all the tracings notched upward. “There,” she said, pointing. “See the vertical jump? And when it happened, the monitor blinked, which caught my attention. It made me worry I was about to lose my feeds.”

“Interesting,” Fyodor said, leaning closer to the monitor. “I see what you mean. What do you think it is?”

“You are asking me?” Sandra questioned. “I don’t know. You people are the experts. To be truthful, I’m not all that knowledgeable about electronics. I came down here to ask you.”

Fyodor sat back and looked up at Misha for a beat. “I don’t know what it could be, but it can’t be anything significant.” Then his attention went back to the monitor. “The tracings all look totally normal before and after. What do you think, Misha?” Fyodor leaned back and caught Sandra’s surprised expression and explained, “I might be the department supervisor, but Misha is our key anesthesia machine technician. We brought him from Russia specifically to work on the anesthesia machines. He did a lot of the original coding for the model that we have here at the Mason-Dixon. He is what you say in English the go-to guy.”

Sandra was impressed by this news since she thought so highly of the anesthesia machine, although it still didn’t influence her negative visceral reaction to the man.

Misha made it a point to bend over and study the image on the monitor.

“I know it is small change,” she went on to explain, “but I had never seen it before, and since the case turned out to have such a terrible outcome, I just want to make sure it has no significance. I mean, if the patient had awakened after the case, I might not even have remembered it happened. Well, maybe that’s not totally true, since it did scare me about the possibility of losing my electronic monitoring.”

“It’s not important,” Misha said. He stood back up.

“But what was it?” Sandra persisted.

“It’s just a frame offset,” Misha said. “It’s nothing. It could happen from a number of things, like...” He gestured with his hands in the air, struggling to express himself with his English.

“Like what?” Sandra asked.

“What you have to remember is that the machine’s computer is constantly compressing data,” Fyodor said, coming to Misha’s aid. “You have no idea how much data is being constantly generated. So seeing little changes on a monitor is not surprising. There can be blips from hardware malfunction, like one of the hundreds of capacitors prematurely discharging, or from a software problem confronting momentary input overload or even from just too many applications running at the same time.”

Sandra nodded as if she understood. She didn’t, but it was clear they did not think a frame offset had any real significance. She was about to thank them and leave when the two men suddenly launched into an animated and spirited conversation in Russian. For Sandra it was like momentarily watching a Ping-Pong game up close, her eyes darting from one man to the other. Then, as suddenly as the heated discussion had started, it stopped.

Fyodor smiled. “Sorry, it is rude for us to speak Russian. We disagree on a small issue. No matter. The important point is that whatever caused this small frame offset you noticed certainly didn’t affect the anesthesia machine’s function.” He smiled again. “Is there anything else we can help you with, Doctor?”

“That’s it for the moment,” Sandra said. She stood up. “Thank you for your time.”

“We are here to serve,” Fyodor said. “Anytime you have a question, please come down or call. As you know, we have technicians available twenty-four hours, seven days a week.”

As she left the supervisor’s office, Sandra fully expected Misha to follow her. She had been mildly concerned about getting away from him, the way he had glommed onto her when she had first arrived. To her surprise and relief, he stayed inside the office with Fyodor.

Heading back to the elevators, Sandra thought she would go back up to the OR and see what she had been assigned for the following morning. If any of them were inpatients, she would go check them out. She would review the nascent electronic medical record for the ones having same-day surgery to get an idea of what the day would be like. The episode with Carl was making her more compulsive than ever. When she finished all that, she would head for home.

24

Tuesday, April 7, 2:41 P.M.

For a few minutes after Dr. Sandra Wykoff had left, silence reigned in the Clinical Engineering supervisor’s office. The only noise came from out in the service area and was the muted whine of various electric tools combined with a hint of classical symphonic music. The two Russian expats regarded each other while immersed in their own thoughts. Both were not happy, but for slightly different reasons.

Fyodor Rozovsky had been in Charleston for several years before he had recruited Misha Zotov. The men had known each other since childhood, having both grown up in Saint Petersburg. Also, both of them had attended the Moscow Institute of Physics and Technology. Fyodor had been brought to America almost a decade earlier, when Sidereal Pharmaceuticals had agreed to fund the Shapiro Institute. With Fyodor’s knowledge of computer coding and robotics, he had been clearly essential to the project’s success. His contributions had been such that after the Shapiro was successfully up and running, Middleton Healthcare happily offered him the opportunity to run Clinical Engineering for the entire medical center. The company felt that progressive automation was key for hospital-based medicine.

“I don’t like this,” Fyodor said. He was now speaking Russian, and his irritation was apparent. “Sergei Polushin is going to be as angry as a bear if this blip becomes a subject of general discussion in the Anesthesia Department.”

Sergei Polushin, a financial genius, was reputed to be the closest confidant to Boris Rusnak, the billionaire Russian oligarch who had created Sidereal Pharmaceuticals. Living in Geneva, Rusnak, with Sergei’s help, had aggressively merged a number of small drug firms by a series of rapid, hostile takeovers to build one of the world’s largest. More important, the company was poised to become the dominant player in the newest pharmaceutical gold mine: making and marketing biologics, or drugs made by living systems, not by chemistry. Sergei Polushin had been the force behind the Shapiro Institute, and continued to treat it as his personal fiefdom.

“I need to have a frank discussion with my team of programmers,” Misha said. Gone was any hint of the fawning facade he presented to Sandra. He was clearly as angry as Fyodor. “A frame offset like that is just sloppy programming. The trouble is I didn’t see it myself.”

“I don’t need to tell you, but Sergei will undoubtedly hold you responsible if this thing causes trouble.”

“You don’t need to tell me,” Misha said. “I will see that it is eliminated immediately. When is the next case scheduled?”

“Not until next week, so you have plenty of time. But it is important to get it fixed. The schedule is to do a case a week in all the Middleton Healthcare hospitals. There cannot be any bugs. Is it possible this same phenomena occurred with either of the two previous test cases?”

“I don’t know,” Misha said. “Let’s check the pilot case!” He grabbed a chair, sat, and used the terminal on Fyodor’s desk to pull up Ashanti Davis’s anesthesia record. When it was on the monitor, he magnified the central portion just as Sandra had done with Vandermeer’s.

“There it is,” Fyodor said. “That’s not good. Let’s check Morrison.”

Misha quickly did the same with Morrison’s anesthesia record as he had done with Davis’s. “Shit! There it is with Morrison as well. Sorry about that!”

“Fix it!” Fyodor said gruffly.

Misha exited the screen. “Luckily, no one has noticed the offset on either of the previous test cases.”

“Are you suggesting that it not be fixed?”

“I will see that it is fixed today. My point is questioning whether we should go back and try to eliminate the offset in all three documents.”

“Can you do that?”

Misha shrugged. “Actually, I don’t know. Probably, but then again we could make it worse, meaning leaving a fingerprint that it had been altered after the fact. I could have someone try before actually executing and show you in an hour or so what it would look like.”

“All right. But, most important, fix the bug itself.”

“Certainly. But that leaves the issue about Dr. Wykoff and whether she is likely to enlist the help of anyone else in explaining the frame offset.”

“That question has occurred to me, too. We know that both the chief of anesthesia and the hospital lawyer have urged the parties involved against loose talk. Talking about even a minor blip in the vital sign tracings would certainly qualify as loose talk.”

“That is true, but is it worth the risk? I’m afraid she has become a major liability. It seems to me that this is a circumstance where the services of Darko and Leonid are called for and sooner rather than later.”

Both Fyodor and Misha had met Darko Lebedev and Leonid Shubin. They knew the two had been members of the Soviet Special Forces and had served a number of years in Chechnya, tracking down and eliminating people Moscow deemed terrorists. They knew that Boris Rusnak had hired the two men away from the army early in Boris’s meteoric rise in the rough-and-tumble business world of post-Soviet Russia, where people of Darko and Leonid’s abilities and mind-set were a necessity. Fyodor and Misha were well aware that both killers had seen a lot of action. They also knew that Sergei Polushin had sent them to Charleston as a potential resource to support Sidereal’s considerable US investment.

Easing back in his chair, Fyodor let his eyes roam up to the ceiling and allowed his mind to wander. Misha had a point, and a good one. Dr. Sandra Wykoff represented a very weak link in what was otherwise a strong chain. She could set the program back, maybe even stop it for a time. It would be irresponsible for Fyodor to let such a risk continue, especially when it could easily be eliminated. Wykoff had been selected as one of the test cases specifically because she was a loner, as were the two other anesthesiologists that had been chosen before her. Misha had been tasked to try to get close to her, although that tactic had fallen flat. They had used Russian call girls with the other two male anesthesiologists to keep tabs on them, and that had worked well. But Sandra Wykoff had been different and now presented a real problem. There was no way to find out what she was thinking.

Fyodor tipped forward in his chair. He’d made up his mind. “I don’t like this woman,” he said.

“She is a high-and-mighty bitch,” Misha agreed. “I tried to be nice to her. Trust me! She thinks she is something special. She is going to be trouble.”

“All right,” Fyodor said. “She’s got to be taken care of. Do you want to talk with Darko and Leonid, or should I? I know they have been eager to be useful.”

“It will be my pleasure,” Misha said, getting to his feet. “I’ll call Darko as soon as I get my team of programmers busy.”

“Keep me informed,” Fyodor said.

“I will,” Misha promised.

25.

Tuesday, April 7, 3:04 P.M.

Benton was ushered into Josh’s posh digs by one of the president’s aides. It was a corner office looking out onto the manicured hospital grounds. It was as large and as well appointed as any Fortune 500 CEO’s and befitting Josh’s role as both president of the Mason-Dixon Medical Center and chairman of the board of Middleton Healthcare. Benton couldn’t help but be jealous. Josh was a new kind of doctor. He had gotten an MBA at the same time he’d gotten his MD to take advantage of health care’s being the biggest business in the United States, at $4 trillion a year and counting.

Benton also knew that Josh was holding down an annual salary of over $4 million, with hefty stock options to boot. Under his tenure, Middleton Healthcare had grown from twenty-four hospitals in the Southeast to thirty-two spread throughout the country. Equally as impressive, he had forged the lucrative alliance with Sidereal Pharmaceuticals. As a department head, Benton was aware that significant cash infusions from Sidereal were coming into Middleton’s coffers every month to bolster infrastructure.

From Benton’s perspective, Josh Feinberg didn’t look the part of an accomplished CEO or even a doctor. He was a slight man with an intense, gaunt face and shifty eyes more suggestive of a crooked used-car salesman than an accomplished hospital administrator. Although his suits were probably expensive, they hung on his bony frame like clothes on a wire hanger. But despite having less than a commanding appearance, Benton knew that Josh was a superb businessman, with his MBA from Benton’s Ivy League alma mater.

Before being recruited to take over Middleton Healthcare, Josh Feinberg had a stellar record of founding and managing a highly successful health-care consulting company called Feinberg Associates. Although functioning behind the scenes, this company had been responsible for a slew of medical products and procedures ranging from medical software to teeth-whitening strips. The source of its success was that it employed many hundreds of Russian PhD scientists who’d found themselves out of work after the dissolution of the Soviet Union.

Once at Middleton Healthcare, Benton was well aware that Feinberg had not only expanded the company but had also spearheaded the lucrative Sidereal Pharmaceutical connection. In the process, Feinberg had fostered a personal relationship with the otherwise reclusive billionaire Boris Rusnak. From the Russian’s reputation, Josh’s connection with the man might have been his biggest coup of all.

Josh offered Benton one of the chairs facing his massive desk, but Benton declined, saying he’d rather stand because he had to get back up to the OR and what he had to say wasn’t going to take much of Josh’s time.

“Have you spoken with Bob Hartley?” Benton asked, as a way to begin.

“No. Should I have?”

“No matter,” Benton said. “Let me clue you in.” He then had the same conversation he’d had with Hartley. Like Hartley, Josh took the story seriously, writing down the names of the medical students as Benton talked. The longest part of the conversation concerned Dr. Sandra Wykoff and what to do about her. Rhodes said she was a good anesthesiologist and committed to her work but somewhat of a loner and not always a team player. He admitted he didn’t have a full understanding of her.

“And you say Hartley will be getting in touch with me?” Josh asked.

“That’s what he said.”

“Good. About the two medical students looking into hospital-acquired morbidity: I’m sure that can be nipped in the bud. I’ll talk with the dean to make sure they toe the line. But on the off chance one or both don’t and persist with their inquiries, I want you to personally let me know immediately.”

“You mean if they contact Dr. Wykoff again?”

“Precisely. Whether they contact Dr. Wykoff or one of the other involved anesthesiologists, give me a heads-up. They could be a big problem, especially in the context of investigating hospital-acquired morbidity. We don’t want to stimulate any kind of unanticipated inspection by the Joint Commission with the way they are already busting our balls about access to the Shapiro Institute.”

“How will I get in touch with you if it’s off hours?”

“Text me!” Josh said. “I’ll have one of my aides give you my personal mobile number.”

“You got it,” Benton said. He felt flattered that Josh would be willing to give him his mobile number, but he wasn’t totally surprised. Josh had specifically and heavily recruited him five years earlier, and they had a somewhat social relationship.

“I certainly will take it from here. Thank you, Doctor.” As if by magic, the door to Josh’s office swung open. Standing on the threshold was Josh’s closest aide, Fletcher Jefferson. Josh gestured toward the man to let Benton know the meeting was over.

“You’re welcome,” Benton said, a bit surprised at being dismissed so summarily. If he hadn’t been flattered by the course of the meeting, he would have felt slighted. As he passed out of the room, Mr. Jefferson gave Benton a piece of paper. On it was Josh’s mobile number.

For several minutes after Dr. Rhodes had left, Feinberg played absentmindedly with his computer mouse, moving it in small circles to watch the cursor dance on his monitor. He hated picayune annoyances requiring his attention in the middle of big, momentous events. This current issue involving a spinster woman anesthesiologist and a couple of greenhorn medical students was a prime example.

Josh and Boris Rusnak currently were orchestrating a complete revolution in the pharmaceutical industry by modernizing and significantly improving the manufacture of biologics, and he needed to be on the top of his game. Biologics were where the industry was heading, thanks to the prices they were commanding and thanks to Middleton Healthcare’s alliance with Sidereal Pharmaceuticals. Since he and his team had forged this marriage, he was positioned at the very vortex of the change and stood to be rewarded beyond his wildest dreams. Within the hour he expected a conference call from Boris arranged by his chief aide, Sergei Polushin, and Josh already knew what was going to be discussed. They were going to propose that Sidereal double its projected antibody production by utilizing all thirty-plus Middleton Healthcare hospitals rather than the five that had been originally proposed. Such a situation would be huge and would essentially guarantee a merger between Sidereal and Middleton. With that kind of dependence, there was no way that Sidereal would allow Middleton Healthcare to go off on its own, as it would undoubtedly be courted by other multinational drug firms.

Pressing a button under the lip of his desk, the same button he’d pressed to end the meeting with Benton Rhodes, Josh waited for Fletcher to reappear. Seconds later he handed Fletcher the paper on which he had written the names of the two medical students.

“I want a rapid rundown on these kids,” Josh said. “I want to know where they live, where they are from, their family situations, and their significant others. Later I want details, but for now, the basics. Go!”

While he waited, Josh went back to fidgeting with his cursor. He knew that the upcoming call from Geneva might be the defining event in his life. Yet he wasn’t nervous, because he was prepared. Although he thought he knew what the agenda was going to be, he was ready to field a wide variety of curveballs. What he counted on was that Sidereal needed Middleton, and not vice versa.

After only five minutes, a muffled knock preceded Fletcher’s reappearance. He came directly to the front of Josh’s desk and put down a single sheet of paper. On it each student had a paragraph. Josh snapped up the paper and read it rapidly.

“Good,” Josh said, looking it over. “Perfect. They are both living in the dorm: that’s good. Both accomplished students: that’s good, since both have a lot to lose. Both on full scholarships: that’s helpful, too, as they probably are grateful. And they are good friends, which makes dealing with them easier: convince one, and that one would surely convince the other.”

Josh looked up. “Well done. Now, get the details!”

As Fletcher turned to leave, Josh reached for his phone. He knew that the best administrators knew how to delegate, and that was exactly what he was going to do. Thanks to Sergei Polushin, there was a resource to handle problems raised by the likes of Robert Hurley and now Sandra Wykoff and a couple of medical students. With a touch of a button Josh was on a direct line with Fyodor Rozovsky.

“There are a couple of other problems,” Josh said with no preamble, not even identifying himself. Names were not needed, as they knew each other’s voice, as the “project” required frequent contact, and they talked rather than e-mailed or texted to eliminate any potential paper trail. “The anesthesiologist, Sandra Wykoff, has become a true threat.”

“We are already aware,” Fyodor said. “She just visited us here in the service center to ask probing questions. It has already been decided, and an appropriate call has already been made. The problem will be solved tonight.”

Josh was taken aback that they were a step ahead but pleased. “I commend your efficiency.”

“We have only the best and most experienced personnel,” Fyodor said with pride.

“I guess commendation is in order for the solution to the previous Hurley threat.”

“Thank you. There were no problems.”

“One other thing while I have you on the phone. There is another minor problem that might be best handled by your experienced personnel. I’m sorry that all this is happening at the same time.”

“We are here to deal with problems. No need for an apology. What minor problem are you referring to?”

“There are now a couple of medical students, a male and a female, who are close friends. They have made a nuisance of themselves talking with Sandra Wykoff about the Vandermeer case. The motivation is because of a misplaced interest in the issue of hospital-acquired morbidity. This has to stop! I’ll try to address it through the dean of the school, but I thought you should be aware. Maybe a warning to one of them might be in order, although I will leave that up to you. I’ll send down the names and the particulars.”

“We will be looking for it. In the meantime, rest assured that the anesthesiologist will be taken care of. As for the students, we’ll have someone talk convincingly to the female. In Russia we found that was the best course of action with couples.”

“I’ll trust your judgment,” Josh said simply before disconnecting the line. He was pleased and relieved to have the issue about the rogue anesthesiologist already behind him. It was easy to delegate when one had the right people. With the most important part of this new problem already solved, he placed a call to the dean of the medical school, Dr. Janet English, about the rogue students. This conversation was even shorter and to the point. “Talk to them as soon as you can,” Josh said at the end. His mind was already back to anticipating the imminent conference call from Geneva.

“I will contact them immediately,” Dr. English said. “Consider it done.”

26.

Tuesday, April 7, 3:21 P.M.

The text tone wasn’t loud, but in the total silence of her room, it startled Lynn. At the moment it sounded she was in deep concentration, and had been for several hours. She had started out scanning the articles she had printed from the Internet and then had moved on to studying the printouts of the anesthesia records for Carl, Scarlett, and Ashanti. After finding something rather startling on the printouts, she had gone back to the images themselves on her computer screen, because it afforded magnification. What she had discovered and corroborated was that all three records had the little frame offset that had bothered Dr. Wykoff in Carl’s case, and, more surprising still, the frame offset had occurred at the exact same time: precisely fifty-two minutes into each operation!

As far as Lynn was concerned, she couldn’t imagine that the timing, being so exact, could be by chance. It was too Newtonian in a quantum world. Turning her attention back to the printouts, which she had placed side-by-side, she discovered something else that she had not noticed earlier when comparing the cases. This new finding was another similarity, but one that she might not have appreciated had she not been looking at all three cases together, and it was equally as startling and disturbing as the corresponding time of the frame offsets. Again, she didn’t know the significance, but was certain it too had to be important, and she couldn’t wait to tell Michael and get his take on both. It was at the moment of the second discovery that the text tone had sounded.

After recovering from the initial shock of the tone, Lynn snatched up her smartphone. With her heart thumping in her chest from being startled, she looked at the screen. What she expected to see was a text from Michael, maybe telling her she better get her ass over to the clinic. On any given day, he was the one who most often texted her. But the message wasn’t from Michael. Instead it was from Dr. Janet English, the medical school dean! With trepidation, Lynn read the text. It wasn’t long.

Slowly Lynn put the phone back down. A feeling of dread crept over her. She leaned forward and read the text again. Her heart rate, which had begun to slow from the initial start, now speeded up again. The question was, why would the dean of the school want to see her? Her initial thought was that it might be about her missing a few ophthalmology and dermatology lectures, but then she realized it couldn’t be something so benign. The message said she should come after the ophthalmology clinic, meaning the dean thought that Lynn was there, as she was supposed to be.

Lynn had never actually met the dean of the school face-to-face, despite her having been at the school for almost four years. She had seen her only from a distance at various medical school functions, as she had on her first day, when Lynn was a freshman and Dr. English gave the welcoming address at what was touted as the “white coat” ceremony. The dean was not known to be a particularly sociable individual. It was common knowledge that she preferred her admin functions and research interests over direct student contact, which she delegated to the dean of students.

Rather quickly Lynn began to worry that Rhodes and/or Wykoff had gone ahead and checked whether she and Michael were authorized to look at Carl’s chart in the neuro ICU. If the dean had been informed, she would be livid and was now summoning them to accuse them of a major HIPAA violation. Lynn could hear Michael’s reminding her it was a class 5 felony. Would the school prosecute them? Lynn had no idea. In a way she doubted it, as it would be a first offense, but who was to know. And if they did prosecute them, would it be the end of their careers in medicine? Lynn had no idea about that, either, but recognized there was a chance. She shuddered, having a major guilt trip about involving Michael.

Thinking of him, she wondered if he had gotten a similar text. Quickly she texted him and posed the question. She knew he was most likely in the ophthalmology clinic but guessed that he could probably manage to text her back. She was right. His text popped up on her screen within minutes:

Lynn quickly texted back.

Replacing her phone on her desk, Lynn was amazed Michael was taking this text from the dean in stride enough to use an emoticon. Under the circumstances, it seemed inappropriate and out of character. He had never used an emoticon before in any text he had sent her. Yet it did make her feel better. It certainly suggested he was relaxed about the dean’s demand that they appear in her office, and if that were the case, maybe she should be, too.

Yet even in the best-case scenario, that Dr. English wanted to meet with them merely to chastise them about talking with Wykoff, Lynn was enough of a realist to understand that afterward there was a good chance that Carl’s chart and even visiting him would be off limits. The staff in the neuro ICU might very well be forewarned, and that would be a major problem for Lynn.

Of course she wasn’t sure about anything. Was such paranoid thinking a form of denial her mind was using to avoid dealing with the reality of Carl’s coma and gloomy prognosis, and her own guilt? Was she jumping to unwarranted conclusions? Lynn didn’t know. And another thought occurred to her. Maybe she should do her investigating more on her own. She now recognized more than she had before that there might be a personal cost. If someone was going to take a fall, it should be her, and her alone, not Michael.

Lynn looked at the time. It was almost three-thirty. That meant that the neuro ICU day shift would have changed to the evening shift. There would be new people. Also there wouldn’t be a problem getting to the dean’s office by five. If she wanted to look at Carl’s chart again, which she did, now was the time to give it a try. All she could do was hope that the reason the dean wanted to see her and Michael didn’t have anything to do with their overt HIPAA violations.

27.

Tuesday, April 7, 3:40 P.M.

Forgoing the shower and change of clothes she had planned on, Lynn hustled over to the hospital. In her paranoia, she found herself worrying that the dean might have forewarned the neuro ICU staff about her activities even prior to the scheduled meeting in the dean’s office. Unfortunately there would be no way to know before walking in and giving it a try.

Deciding to continue with the anesthesia rotation ruse if she was asked what she was doing in the neuro ICU, she made another stop in the women’s surgical locker room to put on scrubs. Dressed as such, she didn’t stand out as a medical student.

Reaching the neuro ICU, she paused outside, just as she had done on previous visits, only this time it wasn’t because she feared what she was going to see vis-à-vis Carl but rather that she worried about her reception. Gathering her courage, she pushed in.

As the door closed behind her, she hesitated as her eyes quickly scanned the room. Ostensibly the ICU was the same as it had been that morning, with the same sounds and smells. As usual, the patients were for the most part stationary. The only activity in the room came from the nurses and aides going about their business. A few looked in Lynn’s direction, but no one registered any untoward response or recognition, and no one approached her. She felt encouraged and was able to relax a degree.

She glanced over to Carl’s cubicle from where she was standing. Except for his leg in the CPM, he was as immobile as he had been that morning. A nurse was adjusting his IV. Lynn considered going over to his bedside but decided against it, as it would accomplish little more than to possibly upset her, which she didn’t need. Looking over into Scarlett Morrison’s cubicle, she could see that the woman had been transferred. There was a new patient in her place, attended to by a neurology resident. Thankfully the resident wasn’t Charles Stuart, as that might have been potential trouble.

Turning her attention to the central desk, Lynn picked out the woman who was most likely Gwen Murphy’s equivalent on the evening shift. She was sitting in the charge nurse’s command seat. She didn’t look up as Lynn approached. Peter Marshall, the ward clerk, had left for the day. An attending physician was sitting with her back to Lynn, bent over a chart, dictating. Lynn did a double take. As chance would have it, it was Dr. Siri Erikson!

For a moment Lynn thought of hightailing it and returning later when the hematologist was gone. After having a mildly disturbing encounter with the woman that morning, Lynn wasn’t sure she wanted to risk another conversation. But, not knowing what was going to happen in the dean’s office in less than an hour, this might be her only opportunity. She had to take the chance.

After a reassuring breath, Lynn entered the circular desk area. She smiled pleasantly at the charge nurse, who looked up with a questioning, wrinkled brow. Lynn hoped her disguise would carry the day, as medical students were not a common sight in the neuro ICU late in the day and without a preceptor. Lynn could see her name. It was Charlotte Hinson. She was a heavyset blonde in her late thirties but with a sprinkle of freckles across her nose that made her look particularly youthful. “Can I help you?” she asked. Thankfully her tone was pleasant and not confrontational.

“I’ve come to check in on Dr. Stuart’s patient, Carl Vandermeer,” Lynn said, keeping her voice low. “I wanted to see the result of the serum electrophoresis.”

“You could have checked the EMR,” Charlotte said cheerfully. “It’s in there. It was mentioned at report. It would have saved you a trip.”

“I was in the neighborhood,” Lynn said, forcing another smile. If she could have looked at the electronic record, she certainly would have. Right from the beginning of this nightmare, she knew enough not to try to access Carl’s EMR. She might have gotten to see it once, but then her doing so would have been flagged immediately, and she would have heard from the security people in the Medical Records Department. The EMR were protected more diligently than the physical charts.

To be helpful, Charlotte gave the chart rack a spin, as it was within her reach, but both she and Lynn noticed the 8 slot was empty.

“I’ve got the Vandermeer chart,” Dr. Erikson said, overhearing the conversation. She had turned to face Lynn. “Miss Peirce, nice to see you again.”

“Thank you,” Lynn said. It seemed conversation was inevitable. “Sorry to be a bother yet again.”

“No bother! Please, sit down! I enjoyed our chat this morning. We can talk about the case together. I’ve been asked to do a formal consult on Mr. Vandermeer.”

To Lynn’s surprise, the woman seemed friendly, not at all like she had been that morning. After a brief hesitation, Lynn pulled a chair over and sat down. She felt she didn’t have a lot of choice if she wanted to avoid offending the mercurial hematologist. Dr. Erikson immediately pushed Carl’s chart over. It was open to the page with the results of the serum electrophoresis, just what Lynn wanted to see.

Lynn glanced at the graph of the serum proteins, separated by size and electric charge, which she now knew considerably more about, having just read the Wikipedia article within the hour. To her it looked like a squiggly range of mountains drawn by a child. A definite narrow spike in the gamma globulin range interrupted the otherwise smooth contour. The spike wasn’t nearly as tall as Morrison’s, but otherwise it was in a similar location.

“What do you think?” Dr. Erikson said.

“I guess I think that is not normal,” Lynn said. Medical students learned to hedge their bets. “What I don’t know is if it qualifies to be called a gammopathy.” She had also reread the gammopathy article and felt reasonably capable of holding up her side of a conversation.

“Does it surprise you?”

“I suppose so,” Lynn said. “If it is a gammopathy, he seems too young for it. I’ve read that gammopathies are not common until after age fifty, and he is only twenty-nine, the same age as Scarlett Morrison.”

“But this is not a gammopathy, merely a possible warning he might develop one. He will need to be followed. If the spike enlarges, we’ll have to do a bone marrow exam to access the plasma cell population.”

“What does it mean if it increases?”

“It depends on how high it goes. A spike like that means that he is producing a particular protein. In someone as young as this it would be called a ‘paraprotein abnormality of undetermined significance.’ But then again, the spike could be the precursor of something more serious, like multiple myeloma or a lymphoma.”

“Interesting,” Lynn said, to say something. She was tempted to mention Ashanti Davis and her diagnosis of multiple myeloma, but she held back for fear that Dr. Erikson would ask how she knew about the woman. Instead she said, “I’m afraid this is all a little over my head. But why do you think he has developed this paraprotein? This morning you said it didn’t have anything to do with anesthesia.”

“Absolutely not!” Dr. Erikson said with a touch of the same irritation she’d exhibited that morning, making Lynn inwardly cringe. “I am one hundred percent certain it had nothing to do with anesthesia.” Then, catching herself, she said more calmly: “I’m sure he had this serum protein abnormality, or at least a tendency for it, prior to his operation. No one knew because there hadn’t been any reason to do a serum electrophoresis. A low-level abnormal paraprotein like this would be entirely asymptomatic. I’m just surprised you bring up the anesthesia issue again. Has someone raised this idea in the Anesthesia Department?”

“Not that I have heard of,” Lynn said. She tensed. She certainly didn’t want to talk about the Anesthesia Department and possibly reveal she wasn’t taking an anesthesia elective.

“It’s an absurd association,” Dr. Erikson added. “But if you hear of any reference to gammopathy in any context in the Anesthesia Department, I would like to hear about it, just as I’d like to hear if you or anyone else comes up with any conclusions about how these two patients suffered comas.”

“Of course,” Lynn said to be agreeable, again tempted to mention that there had been a third case, not two, but she held back for the same reason she had earlier.

“In return, I’ll keep you abreast of any changes with this case. Now that there has been a formal consult, I will be following Mr. Vandermeer, even when he gets transferred over to the Shapiro.”

“What?” Lynn said explosively enough to cause Dr. Erikson to jump. Although Lynn’s voice hadn’t been that loud, it was magnified by the subdued environment in the ICU. It was a place where everyone was tense. When things went wrong, and they occasionally did, they went really wrong.

Although Lynn had understood there was a chance that Carl might be sent to the Shapiro Institute at some point, the fact that it might be imminent dismayed her. Even though she knew his prognosis for recovery was gloomy, she also knew that his being transferred to the Shapiro meant that the neurology team was giving up, and she would have to relinquish the modicum of hope she had been vainly trying to hold on to. With an attempt to modulate her voice, she asked: “When is this supposed to happen?”

“You seem upset?” Dr. Erikson questioned. She stared at Lynn.

“I had no idea a transfer was being considered,” Lynn said, trying to recover her composure and suppress her emotions. “Dr. Stuart, the resident, didn’t mention it.”

“I can’t imagine why,” Dr. Erikson said. “The neurology team suggested the move, and they’re in charge. Since the infectious disease consult has come up with nothing, it might be soon. If I had to guess, I’d say he might be transferred as early as this afternoon or this evening. Certainly by tomorrow morning at the latest. He hasn’t had a gastrostomy for nutrition yet, but Shapiro patients are routinely brought over here if surgery is indicated.”

“It seems so soon,” Lynn said despite herself.

“He’ll get better care over there for his condition,” Dr. Erikson said. “That’s the point.”

“Have his parents been informed?”

“Of course!” Dr. Erikson said. She looked at Lynn askance, questioningly. Then she added, “The parents are very much involved. I’ve have seen them in here on several occasions. I mean, everyone knows that admission to the Shapiro Institute is voluntary. The family has to agree. Most do when they learn how much it is for the patient’s benefit.”

“What about his blood count?” Lynn asked quickly to change the subject. “Have the lymphocytes continued to go up? What if this paraprotein problem continues?”

The hematologist didn’t answer immediately. She stared at Lynn with such intensity that Lynn thought the worst. She worried she had given herself away and that the very next question would be a demand to know exactly what Lynn’s relationship was with the patient. But to her relief, when Dr. Erikson spoke it was just to answer her question. “The white count has gone up to fourteen thousand, with most of it lymphocytes.”

“Interesting,” Lynn said insincerely. Suddenly all she wanted to do was get away. As upset as she was about Carl’s possibly being sent to the Shapiro, she truly feared that if the conversation continued, she’d end up exposing herself as hardly a disinterested party. But she stayed where she was. They talked for a short time about bone marrow function and the origin of the various blood proteins, but Lynn wasn’t concentrating. As soon as she could, she said she had to get back to the OR and excused herself.

“Remember to get in touch with me if you come to any conclusions,” Dr. Erikson called after her. “And I can keep you up-to-date about Vandermeer and Morrison. I’ll be following both patients at the Shapiro.”

Lynn nodded to indicate that she had heard and then quickly left the ICU. As she hustled down the central corridor, she tried to calm herself. She felt a sense of panic now that Carl might be physically taken away from her. It meant that she wouldn’t be able to check on how he was doing or the kind of care he was getting. First it had been his mind and memories that had been stolen, and now it was to be his body.

Lynn knew all too well from her brief student introduction to the Shapiro Institute that only immediate family were allowed to visit a patient, and only for brief periods scheduled in advance. And the visits weren’t much. The family members could only observe their loved one through a plate-glass window in order to protect the inmate from outside contamination. Some families complained but ultimately they understood it was for the patients’ collective benefit.

Lynn shuddered to think of Carl locked away in such a dehumanized place, remembering her student visit two years before as if it were yesterday. The tour that she and her classmates had been given had been restricted to a conference room and then to one of three visitation rooms where family member visits took place, both located in the institute immediately beyond the connector to the main hospital. The area beyond the plate-glass window in the visitation room was like a stage set where the unconscious patient was placed on what looked to be a regular hospital bed but wasn’t, with its unique structure camouflaged by the bed linens. The patient transport was fully automated, reminiscent to Lynn of an assembly line in an automobile plant.

Lynn remembered a mannequin had been used, not a real patient. Lynn and her classmates had been duly impressed at the demonstration. There hadn’t been any real people involved. The whole back wall of the set had opened and the mannequin had arrived automatically by the use of robotic equipment, placed in the ersatz bed in a matter of seconds, and covered up to the neck with a sheet. At that point all the machinery folded back into the wall and disappeared. The students were told that the immediate family members didn’t see the comings and goings; they were brought in only after the patient was already positioned.

Lynn and her friends had speculated about what the rest of the Shapiro Institute must have been like to enable them to take care of a thousand or so vegetative patients, which is what they had been told was projected to be the average occupancy. They were never given specifics above and beyond told only that automation and computerization made it all possible.

After the mannequin demonstration, there had been a short question-and-answer session run by the individual responsible for the medical student tour. Lynn had asked why families chose to have their loved ones at the Shapiro in the face of such limited visitation. The answer had been simple. It was because the Shapiro’s record of keeping such patients alive was far superior to any other hospital or clinic. The tour guide had gone on to say that in most institutions, up to 40 percent of patients who were comatose from a variety of causes were dead in the first year, whereas the Shapiro had lost no patients in the first year of operation and had lost only twenty-two patients total after six years.

Lynn remembered that Michael had also posed a question, because the mannequin used in the demonstration was outfitted with what looked very much like a football helmet. As a college player himself, Michael was curious. The answer had been that the helmet was a breakthrough technology developed specifically for the Shapiro Institute and that all their patients were equipped with them. It was described as a wireless unit that monitored brain activity in real time and, more important, was also capable of stimulating portions of the brain.

Now, as Lynn approached the hospital elevators, her panic peaked with all these thoughts swirling in her head. She had to do something. She could not allow Carl to be stashed away in such a callous place with contact with her denied. All at once she impulsively decided, no matter what, she would visit him, and not in the restricted-visitation room, staring at him through a plate-glass window. If Carl was to be transferred, she would figure out a way to see him up close and personal. She would need to know exactly what was happening to him and exactly how he was being cared for. She didn’t know how she would manage it, but she would do it.

28.

Tuesday, April 7, 4:45 P.M.

Geez!” Michael complained. “You scared the hell out of me.” Lynn had come up behind him out of his line of sight in the waiting area of the ophthalmology clinic and without warning roughly yanked him out of earshot of the waiting patients. At the time he had been standing off to the side, busily texting her to find out exactly where she wanted to meet up.

“Carl is going to be transferred to the Shapiro,” Lynn blurted out in a forced whisper. The possibility had devolved to a reality in her mind.

“Okay, okay,” Michael soothed. He could immediately appreciate her panic.

“You know what kind of place that is,” Lynn pleaded. Now that she was talking with Michael, the emotion that she had held in check with Erikson threatened to take over.

A quick glance told Michael that a number of patients, who were still waiting to be seen, were taking notice of a young black man talking to a young, distressed white woman. Southern eyebrows of both whites and blacks rose.

“Come with me!” Michael said in a voice that did not brook dissent. He took Lynn by the arm and quickly led her back to an empty exam room and away from prying eyes. Since the clinic was almost over, there were lots of such rooms available. He shut the door.

“You gotta be easy, girl,” he urged. He put his hands on Lynn’s shoulders and looked her in the eye. “You know what I’m saying? You can’t jump the couch now. We got a meeting to go to where we need to be on our game. I don’t know why the dean wants to see us but it sure ain’t to pat us on the back.”

“But...” Lynn started.

“No buts! Pull yourself together. After the meeting we’ll hash out this Shapiro business. But now we gotta get our shit together and be cool.”

“You’re right,” Lynn said, wiping her eyes with a knuckle. “You’re always right, you bastard.”

“Now, that sounds like the Lynn I know. Listen! We gotta have some sort of a plan.”

“What do you think she is going to say to us?”

“Your guess is as good as mine. Chances are she heard from our new buddy, Benton Rhodes, and knows that we talked to Sandra Wykoff about the Vandermeer case. That’s at a minimum. It stands to reason, considering the time frame.”

“Do you think she is going to accuse us of a HIPAA violation?”

“I hope not, at least not yet. That’s why we need a way to explain how we heard the details about Carl’s anesthesia disaster.”

Lynn nodded. She knew Michael was right and was thankful he was being levelheaded, even if she wasn’t. There had to be a way for them to have heard of the details without violating HIPAA. Obviously the anesthesia ruse wouldn’t hold water with the dean. From the text both of them had received, it was obvious she knew they were on the fourth-year specialties rotation and not taking an anesthesia elective.

“Does the dean know you and Carl were an item?”

“I haven’t the faintest idea,” Lynn said. “I suppose it’s possible, since the dean of students certainly knew.”

“Yeah, but they are such different people. The dean of students is so personable and the dean of the school is so aloof and detached. It’s like they’re from different planets.”

“I have an idea,” Lynn said suddenly. “I could just say that one of the neurology residents told me about the case to show me the doll’s eye reflex. It’s not a lie, just not the whole story. But it rings true. I mean, this is a teaching hospital.”

“That’s a little weak,” Michael said. “Especially if she knows you and Carl were tight. It also begs the question of why you were talking to a neurology resident. But no matter. At least it’s a plan the dean might buy.” He looked at his watch. “The reality is we’re running out of time. This is not the kind of a meeting we should be late to. You got your act together?”

“I think so,” Lynn said. She took a tissue from a dispenser on the exam room countertop and blew her nose. “Let’s get it over with.”

The two students quickly used the connector to get into the main hospital building. The administration offices, including the dean’s offices, were on the first floor. As quickly as they could navigate the crowded main hallway, they entered the administration area through a door with a cut-glass insert. The atmosphere changed abruptly. It was serene, with a carpeted floor and framed original oil paintings on the walls. They passed the hospital administration offices and arrived in the academic area. Here the furnishings were not quite so opulent.

After giving their names to a staid secretary, they took seats. It was three minutes before five.

“We made it,” Lynn said in a whisper.

They ended up having to wait for a quarter of an hour. They didn’t talk after sitting down. The atmosphere was appropriately funereal to fan their fears. Both Lynn and Michael knew the dean of students well but not the dean of the medical school, whom neither had even met.

Lynn tried to relax as Michael appeared to be, but couldn’t for a variety of reasons, mostly centered around the disturbing idea of Carl’s being transferred to the Shapiro and the uncertainty of what they were facing with Dr. English.

“The dean will see you now,” the secretary finally said, gesturing toward the closed door that led into the office beyond. The two students approached the door, with Lynn slightly in the lead. They shared a glance. Both shrugged. Michael made a fist and pretended to knock in the air. Lynn actually did it. They heard a voice tell them to come in.

In keeping with the general decor in the immediate outer area, Dr. Janet English’s office was attractive but not as over the top as everyone knew the hospital president’s was. There was no mahogany paneling and the artwork was framed prints, not oil paintings. There was a desk and a sitting area for informal meetings. The students approached the desk. There were several chairs, but without being advised otherwise Lynn and Michael remained standing. The dean was finishing signing a stack of papers. After a moment, she looked up. It was obvious from her expression she was annoyed. She didn’t suggest they sit down.

Lynn guessed the dean was somewhere between fifty and sixty. Her complexion was dark. Likewise, her hair was the color of anthracite coal. Through her rimless spectacles, her eyes were like black marbles. If Lynn had been forced to guess, she would have said India was part of the dean’s genealogy.

“I got a major complaint about you,” Dr. English snapped. “You can understand how disappointed I was to learn that two of our best students are causing trouble — students on full scholarship, I might add. And to make matters worse, the trouble was bad enough to involve Dr. Feinberg, the president of the hospital and chairman of Middleton Healthcare. He was upset enough to call me personally to complain.”

There was a pause. Lynn felt an almost overwhelming urge to apologize. She was well aware that the financial support the school had extended to her had been key to her being able to attend medical school. But Michael was as financially dependent as she, and he wasn’t saying anything.

“I was told that you had taken it upon yourselves to question one of our attending anesthesiologists about a recent, very sensitive case. Is this true?”

Both Lynn and Michael started to speak at the same moment, then stopped. Lynn gestured for Michael to talk. She knew he was far better at diplomacy than she, even when she wasn’t as emotionally strung out and sleep deprived as she was now.

“We did talk with Dr. Sandra Wykoff,” Michael said. “But we weren’t, as you say, questioning her. We went to ask her about a case of delayed return of consciousness. As tragic as the case was, we thought that there had to be something for us students to learn.”

“Did you not think of the legal aspects?” Dr. English asked.

Lynn felt herself relax a degree. The dean did not seem to know that Lynn and Carl were romantically involved, which was probably good. Also her voice had moderated. The edge was already gone. It was another reminder for Lynn that Michael was clever at this kind of confrontation. She also noted he was using the King’s English, without the slightest hint of the ’hood.

“As doctors to be, we were thinking more about it from the patient’s perspective,” Michael added.

“I suppose that is commendable from a student’s point of view,” Dr. English said. “But unfortunately there is another aspect. The potential malpractice implications are horrendous when a healthy young man becomes comatose after a simple operation, even when there is no malpractice involved. Such a lawsuit could damage this hospital and affect its ability to take care of thousands of patients. In today’s litigious world, avoiding a lawsuit or controlling it if it does happen in a case like this has to be a prime consideration.”

“We certainly understand that,” Michael said.

“There had been a strict directive from our legal department that no one was to discuss this case.”

“We hadn’t heard that,” Michael said. “But now that we have, we certainly understand and will be cooperative.”

“How exactly had you heard the particulars about this case to begin with?” Dr. English asked.

Michael and Lynn exchanged a quick glance. So far the discussion had been going better than they had anticipated, especially with HIPAA not even being mentioned. But here was the question they feared. Michael nodded to Lynn to take over and try her idea.

“I was talking with the neurology resident on the case,” Lynn began. “He had offered to show me a doll’s eye reflex, which I had never seen before. That was when I had learned the details.”

Dr. English didn’t respond but nodded almost imperceptibly. After a pause she asked, “Did you see the reflex at least? Was it apparent?”

“Yes, I did see it. It was very dramatic.”

“Okay. This is all making more sense to me now. But tell me this: have you two talked about this case with anyone else, like with classmates or anyone besides Dr. Wykoff?”

Lynn and Michael looked at each other and both shook their heads and said no simultaneously.

“Good,” Dr. English said. “As I said, this case is extraordinarily sensitive from a legal perspective. Do not discuss it with anyone!” Dr. English poked a finger at each student in turn to hammer home her point. “If you fail to heed my warning and do discuss it with anyone, anyone at all, I will see to it that you are expelled. Needless to say, being expelled would be a tragedy for both of you, especially this close to graduation. I don’t know how to make it any clearer. I trust you understand the gravity of this?”

“Absolutely,” Lynn and Michael said in unison as if they had practiced the response.

“All right,” Dr. English said. “Let’s move on to another issue.”

Both Lynn and Michael tensed. They thought they were in the clear. Now they weren’t sure. Neither had any idea what was coming.

“When I spoke with the president he said one other thing. As a matter of explanation of your behavior he told me that you two were researching the issue of hospital-acquired morbidity. Is that true, and if it is, why, and why now?”

Lynn and Michael exchanged another glance. A slight nod from Michael encouraged Lynn to answer. “I came across an article recently from Scientific American, which presented some disturbing statistics. It estimated that four hundred forty thousand people die each year in hospitals from mistakes, and that a million leave the hospital with a significant medical problem they didn’t have before they were admitted.

“We were honestly flabbergasted. I mean, we’d heard about the problem during third-year medicine, but we had no idea of the numbers. When we heard about this current case, we thought it was another glaring example and wanted to try to understand how it could have happened.”

Again the dean didn’t respond immediately. She took off her glasses and rubbed her eyes. Then she put her glasses back on and said, “The statistics you quote are sobering. Hospital-acquired infections, or HAI, are the major problem. Did the article point that out?”

“Not specifically,” Lynn said. “It didn’t break the statistics down to specific causes.”

“Well, let me assure you that hospital-acquired infections are the crux of the matter. On a national scale, HAI rates are anywhere from five to ten percent of admissions in the best institutions. In the offending institutions, the rate can go much higher. Do you know what the HAI rate is for Middleton Healthcare hospitals, including this medical center?”

Lynn and Michael shook their heads.

“Let me tell you,” Dr. English said proudly. “Our combined rate is less than two percent.”

“That’s impressive,” Lynn said, and she meant it. Both she and Michael knew that the medical center made a big effort at infection control in many ways, including an active campaign encouraging hand washing and hand sanitizer use in addition to strict control of intravenous lines, respiratory machines, and catheters. Neither was aware of the true extent of the success.

“If you students are interested in hospital morbidity, you should look into nosocomial infection control. That is where you and your classmates could make a difference, not with an isolated case of delayed return to consciousness. Am I making myself clear?”

“Absolutely,” Lynn and Michael again said simultaneously. Their relief was palpable.

“In fact, I will make it easy for you,” Dr. English said. “I will contact IT and arrange for you both to have access to the hospital’s discharge statistics in our medical center system, provided that you adhere to one major condition: If you are going to talk with anyone outside of our community, particularly the media, I want you to run whatever it is by me first. Is that clear?”

“Absolutely,” the two students reiterated.

“We are justly proud of our success with infection control,” Dr. English continued. “But some of the statistics are not for general consumption. I hope you understand.”

This time both students nodded agreement without verbalizing.

“Good!” Dr. English said. “I will let the president know that you understand now about this unfortunate anesthesia case and the need not to discuss it. I can assure you that it is already being carefully investigated by the Anesthesia Department. If you are interested in hearing about the investigation and what is learned, I imagine I will be able to get the chief of surgery to invite you to the morbidity and mortality session when it will be discussed. Would that be of interest?”

“Absolutely,” Lynn said. Michael nodded.

“Okay,” Dr. English said, looking down at her desk and moving the stack of papers she had signed to the side. “That is all.” Without even looking up again, she reached for her phone and started speaking with her secretary about putting a call through to Dr. Feinberg.

Mildly surprised by the suddenness of the meeting’s end, but without needing any further encouragement, the two students quickly left. It wasn’t until they got back into the hustle and bustle of the hospital that they slowed enough to speak to each other. First they fist bumped. They had to talk loudly to be heard.

“That was a piece of cake,” Lynn said.

“Right on!” Michael said. “But it could have gone either way. It was a good thing we thought about what to say if she asked how we knew about Carl. That tipped the balance. It was like putting in a three-pointer at the buzzer from downtown to win the b-ball game. You did good, girl!”

“It’s weird she never mentioned Carl’s name.” The slight euphoria she’d felt from surviving the meeting with the dean was already beginning to evaporate.

“I noticed that, too. But what I found weirder is that we went in there expecting to get busted, and we come out with increased access to the hospital data bank. We might take advantage of that. Hospital-acquired infection is serious shit.”

“It might be,” Lynn said. She sighed. “But right now I’m not interested. Now I want to talk about Carl being sent to the Shapiro.” There was a sudden catch in her voice.

“Hold off, woman. Wait until we get back to the dorm. If there’s a chance you might bust out bawling, I don’t want people gaping at us. You know what I’m saying?”

Lynn got the message loud and clear and appreciated how he worded it. The fact that someone with his intelligence and academic record could so easily flip back and forth from Oxford English to the language of the ’hood amazed her. It always did, and he knew it, which is why he did it, and only with her. For her it emphasized their closeness. With everyone else, including patients, he always spoke with the diction of a college English professor.

And she knew he was right about her possibly losing control. For the moment she had her act together, but she knew that might change when she started talking about what was in Carl’s limited and dismal future.

They cut through the nearly deserted clinic as they normally did. Only a few stragglers were still waiting to be seen. Outside it was a beautiful Charleston early evening. The sun was still reasonably strong, with another two hours of early-spring daylight left. After they had walked for several hundred feet through the landscaped inner courtyard with flowers busting out of their beds, Lynn slowed. Like she had the day before, she couldn’t help gazing at the hulking granite silhouette of the Shapiro Institute. The mere sight of it brought on the rush of emotion that she had been holding back.

“I cannot believe that Carl might be shut away in there,” Lynn said, losing the battle of fighting off tears. “He might even be going this evening.”

Hearing her voice tremble, Michael guided her off the main walkway and over to an empty park bench, half-hidden by shrubbery from the considerable pedestrian traffic. They sat down. They were far enough out of the way that the other students trekking back to the dorm didn’t see them, or if they happened to look in their direction, didn’t pay them any heed, which was good, because Lynn quickly lost it and suffered through an extended bout of tears. Michael didn’t say anything, thinking it best for her to let it out.

When Lynn finally had herself under control and could talk, he asked how she had found out that Carl might be going to the Shapiro.

“From Dr. Erikson,” Lynn managed. There were still catches in her voice, but she was succeeding in calming herself down.

“She called you?”

“No. I ran into her,” Lynn said. She found a tissue in one of her jacket pockets and carefully dried her eyes. “I went back to the neuro ICU before we met with the dean because I was worried that afterward I might not be allowed. I thought it might be the last time I got to see him for a long time. I also wanted to see what the serum electrophoresis test showed.”

“Was it abnormal?”

“It was, which is why Erikson was there doing a formal consult.”

“How abnormal?”

“Only mildly so far. Just a small spike in the gamma globulin curve, but my sense is that Dr. Erikson expects it to get worse. She was quite friendly to me this time, but I have to say, I find her strange and unpredictable.”

“How did she happen to tell you Carl might be transferred?”

“It just came out in the conversation. She is one weird lady. I can’t read her at all. One minute she seems friendly, the next pissed. Maybe she doesn’t feel well because, frankly, she doesn’t look well. Anyway, remember I told you she asked me to let her know if we came to any conclusions about how Carl or Morrison became comatose. Well, today she added to the list. She wants me to tell her if I hear anyone in Anesthesia talking about gammopathy. Now, I find that strange. I mean, why is she asking me, a medical student? As an attending she could ask anybody she wanted to in the Anesthesia Department, including Rhodes.”

“It sure as hell means she bought into our ruse about anesthesia,” Michael said. “But she has to know that no one in Anesthesia is going to be talking about gammopathy. There is no way anesthesia and serum protein abnormalities can be related.”

“I’m not so sure,” Lynn said as finished drying her eyes. “There is something about all this that smells bad.”

“Oh, come on, girl! There’s nothing about anesthesia that is antigenic. It has been used in millions upon millions of cases without pumping up anybody’s immune system. There is no association.”

“Let’s put it this way,” Lynn said. “I’m just not sure. We have three cases in which it seems to have played some role.”

“Only one that we know for sure: Morrison.”

“Carl could be developing a gammopathy and Ashanti must have had one, too, if she has multiple myeloma. This can’t be by chance. Something is not right in all this. And I’ll tell you something else: If and when Carl goes into that place, come hell or high water, I’m going to go in there and visit him.”

“They are not going to let you visit,” Michael said. “They were very clear about that. Only immediate family is allowed, and you, my friend, are not immediate family.”

“I wouldn’t be satisfied with that kind of visit even if they let me,” Lynn said with a wave of dismissal. “I want to go into the place and actually see how Carl is being treated, not look at him through a plate-glass window.”

“Come on, girl! You can’t be serious. They are not going to let you do that.”

“I’m talking about breaking in. You told me you went through that door over there, which led into the network operation center.” Lynn pointed to the single entrance. “I’ll do the same and start from there.”

“You’re not serious, are you? Tell me you are not!”

“If Carl gets transferred, I’m going in there. I’ve made up my mind. I think I could do it. My sense, from what you told me of your visit yesterday, is that their security is pretty lax. I mean, you said so yourself. They probably haven’t had a security episode for the whole eight years they have been in operation. I mean, who would want to sneak into a holding facility for brain-dead people, for God’s sake?”

“It might be true that they have become lax but...”

“It stands to reason.”

“The trouble is, it’s a big huge risk. To be honest, I don’t think we should do this,” Michael said, becoming serious.

“What do you me ‘we,’ white man?” Lynn said with cynical laugh, referring to the Ron Metzner joke involving the Lone Ranger that Michael had reminded her of yesterday. “I’m going to do it myself. When we got those texts today from the dean, I realized that you shouldn’t take a fall, if that is what happens. This is my battle because Carl was my squeeze. If there is a consequence, it should be mine.”

“As your twin, it’s my job to keep you out of trouble. Let me decide how much risk I want to take. But you know something? The more I think about it, the more I might be exaggerating the fallout of going in there. Maybe the worst-case scenario might only be a slap on the wrist for trespassing. I mean, it is part of this institution, and we are legit medical students. Hell, the way we have been violating HIPAA is worse than our going into an area of the hospital that’s supposed to be off limits.”

“If Carl gets sent in there, I’m going in. I’ve made up my mind.”

“All right, you made up your mind. But tell me how you think you are going to pull it off.”

“I will need your help,” Lynn admitted. “Because the key is going to be your newfound friend, Vladimir whatever his name is.”

“Vladimir Malaklov, my Russian programmer buddy! What can he do?”

“Get me one of the scrub suits like we’ve seen on the people that work there. I don’t want to stand out if I bump into anyone, which is probably a given. Since he works in there, like you said, he probably has one, just chooses not to wear it. There must be a source for them, like there is for regular scrubs in the main hospital.”

“How the fuck am I going to explain why I need a Shapiro suit?” Michael shook his head in disbelief.

“Be creative! Say you want it for a costume party. I don’t care. But tell him you need it in my size.”

“Shit, girl!” Michael complained. “Is that all?”

“No,” Lynn said. “I want you to give me Vladimir’s user name and password.”

Michael groaned out loud and then laughed sarcastically. “If I do that I think my friendship with my Russian buddy is going to be short-lived. Why do you need it?”

“Remember when we made our visit to the Shapiro, and they bragged that they had had only twenty-two deaths over six years? I’d like to find out what the causes of those deaths were. And how many people have died since our tour. And while I’m at it, I’d like to find out how many people woke up from their vegetative state and were discharged. In one of the articles I read last night, it says as many as ten percent of patients in a vegetative state from head trauma eventually achieve enough return to consciousness to go home. A few even completely recover. I wonder what that figure is for the Shapiro. They didn’t tell us that.”

“Please don’t tell me you are planning on trying to hack the Shapiro system from your laptop with Vladimir’s log-in! If you do that, they’d be onto you in a matter of hours, and you’ll be doing hard time in Bennettsville.”

“Don’t worry. I’m not that stupid. I’ll use a hospital terminal, preferably one in the IT Department. If Vladimir really has admin status, which he has to have to do what he’s doing, there wouldn’t be a red flag. And I also want to find out more about Ashanti Davis and how close her case matches Morrison’s and Carl’s.”

“Maybe we can find all this out using the access Dr. English said she would provide us.”

“Oh, please!” Lynn said mockingly. “She’s not going to give us access to Shapiro data. In fact, she probably will only be allowing us to look at data about infections and only in the main hospital. If I’m going to find out the kind of things I want to learn, I’ll need Vladimir’s log-in. I need carte blanche access.”

“You’re on a roll, girl. And I understand. You need to keep yourself busy, so I’m not going to say much. But tell me this: even if you’re sporting one of those Shapiro suits, how are you thinking of getting in?”

“You are going to help with that, too,” Lynn said.

Michael rolled his eyes. “Why did I bother asking?”

“You told me that the security of the door you went in has only a low-level, decade-old thumbprint touchscreen. That shouldn’t be much of a hurdle. You are going to get me Vladimir’s thumbprint. Do it when you invite him over to share your Jay-Z collection. I researched how to foil a generic fingerprint scanner with a bit of latex and wood glue. It’s amazing what you can get off the Internet. I already got the stuff I need.”

“My goodness!” Michael marveled with a shake of his head. He sat back against the bench, and, following Lynn’s line of sight, stared over at the Shapiro. “Okay! For the sake of argument, say this works. What’s the plan once you’re inside, just to wander around blindly and get fucking lost? The place is huge!”

“I’m working on that angle,” Lynn said.

“Lay it on me, girl!”

“Later,” Lynn said. “Right now I want to show you some other stuff that I discovered today when I was comparing the anesthesia records for all three cases. There are several disturbing points of similarity, and they are motivating me to up my efforts.”

“Like what?”

“I prefer to show you. The printouts are in my room. Come on!” Lynn grabbed Michael’s arm and pulled him to his feet.

29.

Tuesday, April 7, 5:37 P.M.

Despite suffering an emotionally exhausting bout of tears on top of her basic fatigue from having had only four hours of sleep over the last thirty-four, Lynn was now, according to Michael, “juiced.” Although she knew enough about psychology to guess that it represented another form of denial, she didn’t care. It gave her the feeling she was actively doing something rather than just passively being emotionally tortured.

Prior to her discussion with Michael about breaking into the Shapiro, the plan had been somewhat vague in her mind. Now she had a good idea of what she needed to do and what she needed Michael to do, and she was eager to get started. But before she did, she wanted to show Michael what had ignited her mounting unease about the whole situation. She thought it might motivate him to help her get what she needed from Vladimir. It had certainly motivated her.

Lynn keyed her door and pushed it open. Michael followed her inside but paused on the threshold. “Maybe I should get a hazmat suit,” he said, surveying the disarray. He was accustomed to her casual attitude toward domestic order, but this seemed beyond the pale. Computer printouts scattered on the floor, along with a number of textbooks, made it impossible to walk without stepping on them. More printouts cluttered most horizontal surfaces along with a mixture of soiled clothes and clean clothes with no readily apparent distinction. The bed was free of debris, although unmade.

“Very funny,” Lynn said. She pulled him into the room and kicked the door closed. “I know the place is a god-awful mess, but ignore it for the moment!” She guided him over to the desk chair, which was clear, like the bed, and made him sit. Pushing aside papers to create an open space on the desk in front of him, she put down all three anesthesia record printouts in a row so that they were visible at the same time.

“Okay,” Michael said. “What am I supposed to be looking at?”

“Remember this blip that Wykoff pointed out on Carl’s record?” Lynn asked, pointing it out.

“I call it a frame offset,” Michael said. “What about it?”

Using her index finger, Lynn pointed to the same upward jump in the vital signs on the other two printouts. “All three cases have the same distortion or whatever it is, and all at exactly the same time: fifty-two minutes into the case.”

“Yo!” Michael exclaimed, looking from one printout to the other. “Now, that’s a righteous pickup.” He glanced up at Lynn. “That’s big-time weird. What’s your take?”

“I haven’t the slightest idea,” Lynn admitted. “But it has to be significant. I wish I could ask Dr. Wykoff what she thinks.”

“That’s not going to happen.”

“Agreed,” Lynn said. “We can’t go to anybody in Anesthesia, at least not for the moment. We’re on our own to figure out what it might mean. But that’s not all. There’s one more surprise.”

“What? Was the timing of the low-oxygenation alarm the same, too?”

“No. It was close but slightly different in each case.”

For a moment Lynn didn’t move, just stared at Michael.

“Well?” Michael said impatiently. “You going to lay it on me or what?”

“You don’t see it?”

“You got the ball, twin. Either dribble, pass, or shoot!”

Again, with her index finger, Lynn pointed to a very small box in the right-hand corner of each record. It was labeled MACHINE, and in each case it had the same number: 37.

Michael again raised his eyes to Lynn’s. For a moment they regarded each other. It was Michael who broke the silence: “All three cases involved the same freaking anesthesia machine!” he exclaimed. “That’s also got to mean something.”

“The same anesthesia machine having the same blip at the exact same time in all three cases. Statistically that happening by chance is nil. With two cases, maybe, but with three, no way.”

Michael looked back down at the anesthesia records. “I agree. But what do we do about it? Should we tell someone, and if we should, who?”

“It’s got to be significant, which means something weird is going on, but I can’t come up with a single, even potentially plausible explanation. And there is nobody we can go to with this without incriminating ourselves big time. The only thing I can think of doing is getting more info out of Shapiro.”

“This timing thing is what amazes me,” Michael said, looking back at the records.

“It more than amazes me,” Lynn said with sudden ferocity. “My intuition is ringing alarm bells, especially when I combine this timing issue with what I have learned from all these other printouts.” Lynn wildly gestured toward all the articles littering the floor. “And then with Carl going there...”

“Whoa, girl!” Michael cautioned. “Get a grip! You have to slow down. Remember, Carl’s not been sent to the Shapiro yet.”

“Morrison has, and Carl’s case is just like hers.”

“True, but you’re jumping the gun, my friend. Listen, I don’t mean to sound patronizing, but you are under a lot of stress! I think you need some food and a good night’s sleep and then you can reboot. Let’s go back over to the hospital and get dinner.”

“Of course I’m stressed,” Lynn snapped. “And I know I’m exhausted. But I’m not sure I could sleep even if I tried. I mean, why are they rushing to transfer Carl and Morrison? It’s way too quick in my estimation. Maybe the same thing happened with Ashanti. But why? What’s the rush? It can’t just be economics. Maybe it’s for better care, but I just don’t know.” Lynn again gestured toward all the printouts scattered about her room. “These articles point out there are always a few patients who defy the odds and wake up. Carl’s problem is less than thirty-six hours old. Why transfer him so soon? What if he wakes up in the Shapiro? With all the automation that is involved over there, would someone even notice? Whether my getting in the Shapiro can answer such questions, I don’t know, but somehow I think there’s a chance. I have to do it!”

Michael nodded. The last thing he wanted to do was make Lynn more upset than she already was. Instead of arguing with her, he glanced down at the floor and picked up the nearest article. It was the article that he and Lynn had read in the neuro ICU after seeing the Morrison chart, the one titled “Monoclonal Gammopathy of Undetermined Significance.”

“So let me guess,” Michael said finally, as he quickly flipped through the printout for a second quick read. “You’re thinking that this paraprotein stuff has some significance.”

“I do!” Lynn said. “I have no idea how or why or anything. But it seems that a paraprotein was or is involved with all three patients. Well, we don’t know for sure if a paraprotein was involved with Ashanti, but the fact that she has multiple myeloma is at least suggestive. It’s the worst-case scenario for a paraprotein gammopathy.”

“Seems to me you are heading out into the stratosphere on all this, if you don’t mind my saying so,” Michael said. He shook his head as he reached down for another article. This one was titled “Monoclonal Antibodies.” He began to speed-read it.

“You might be right,” Lynn said. “But remember what you said was on the home page of Ashanti’s Shapiro EMR: drozitumab. Remember?”

“Of course I remember,” Michael said.

“Do you remember what drozitumab is?”

“Of course,” Michael repeated. He glanced irritably at Lynn. He was losing patience. She needed food, and she needed sleep. And he needed food, too. “What is this, a test?”

“Drozitumab is a monoclonal antibody, like you said this morning,” Lynn added, ignoring Michael’s mild peevishness. “It is used to treat a kind of muscle cancer, not multiple myeloma.”

“I said I remember,” Michael repeated.

“If Ashanti is given drozitumab and had a serum plasma protein test, it would show up as a paraprotein.”

“I suppose you are right. What’s your point?”

“I don’t know. I’m thinking out loud and asking you to do the same.”

Michael shook his head. “It’s a mystery. There are too many loose pieces.” He went back to reading the article on monoclonal antibodies.

“Why was drozitumab put on the front of Ashanti’s record?” Lynn asked.

“Like I said this morning, I have no idea. Do you?” Michael didn’t look up from his reading.

“No, I don’t,” Lynn admitted. “But if I had to guess, I’d say that maybe they are trying it as a treatment for multiple myeloma.”

Michael raised his eyes and looked at Lynn. “You mean like just trying it to see if it might work without any specific scientific rationale, sorta shotgun style? That’s questionable, my friend.”

“I know that doesn’t make any sense,” Lynn agreed. “Okay, scrap that idea! Maybe it is simpler. From reading these articles about monoclonal antibodies forming the basis of biologic drugs, I know they have been having some problems. Maybe they are giving Ashanti various forms of drozitumab to see which ones cause less of a reaction.”

“That sounds a lot more probable than the shotgun treatment idea. Of course it means they would be using her as a guinea pig. Do you really think that might be happening?”

“I’m suddenly thinking it is a possibility,” Lynn said.

“But it doesn’t explain the paraprotein problem.”

“I know. But maybe they want their immune systems stimulated for some reason. And Carl’s and Morrison’s immune systems are acting up, producing the paraprotein and their fevers. Their immune systems are acting as if they are being stimulated.”

“That’s all very hypertheoretical.”

“I know, but I’m convinced that something weird is going on. Maybe Sidereal Pharmaceuticals built Shapiro to use the patients for illicit clinical drug testing. It’s certainly a captive audience who wouldn’t complain. I mean, you have to admit, it makes diabolical sense. And if that’s what’s happening, it’s another reason I sure as hell don’t want Carl transferred there. Certainly not to be experimented on. No way!”

“God! That’s a creepy idea,” Michael said. The thought and implications raised a few hairs on his neck. “Do you really think that might be going on?”

Lynn shrugged. “I don’t know, but it’s an idea,” she said. “It would save time and money in drug development. Drozitumab is definitely a biologic, meaning made from living cells, and biologics are the newest and biggest thing in the pharmaceutical industry. And there is a race to perfect them and test them. And, in point of fact, biologics are Sidereal’s main product line!”

“No shit?” Michael said.

“Here, read this!” Lynn said as she picked an article off the bureau and handed it to Michael. It was titled “Biopharmaceutical.”

Michael took the article and began to speed-read it.

While Michael read, Lynn asked: “Do you remember exactly how monoclonal antibodies or biologics that drug companies sell are made?”

“Yeah! They’re made from mouse hybridomas. I just read it in the previous article. Also we had a lecture about it in second year. Why do you ask?”

“Because it’s the biggest reason that a lot of testing is needed,” Lynn said. “Since biologics are made from mouse cells, the drug companies have to humanize them to make them less allergenic for humans. That requires a lot of testing, particularly testing in humans. People in a vegetative state would be perfect subjects, especially if their immune systems were hyped up.”

“Wow!” Michael said, finishing the latest article. “I had no idea biologics are already a fifty-billion-dollar-a-year industry and climbing. I really had no idea.”

“It’s going to become really huge,” Lynn said. “It will top a hundred billion before long.”

“You really think so?”

“I do, and for two reasons. First, because biologics have a lot of promise to provide cures, as these articles say. Second, because drug companies here in the United States get to charge whatever the hell they please. It’s not like in the rest of the industrialized world, or should I say ‘civilized’ world.”

Michael nodded. “Which they are already doing with traditional drugs.” He picked up another article specifically about hybridomas.

“Exactly! And unfortunately it is not going to change with biologics, not with the money they throw around with their lobbyists.”

“You’re right about that,” Michael agreed. “By controlling Congress, drug companies in general are enjoying legalized robbery of the American public.”

“If Sidereal gets a jump in the biologics field by solving the allergy problem, they could dominate it and make an absolute fortune.”

Michael finished the fourth article and tossed it aside. “Okay, I suppose now I have an idea where you’re going with all this. Maybe a quick, undercover visit to the Shapiro might be just what the doctor ordered to see if they are using the patients as guinea pigs for biologics, not that I’m advocating it, mind you. I still think it is a crazy, risky idea. In the meantime, we got a more pressing problem. What to do about anesthesia machine thirty-seven? The Anesthesia Department should know about it if they don’t already. Actually, the more I think about it, the more I’m sure they already know. It’s too obvious to miss.”

“I agree,” Lynn said. “They have to know. Nor can there be anything wrong with the machine.” Lynn pointed back at the anesthesia records on her desk. “Look how the patients’ vital signs stayed completely normal in all three cases after the frame offset right up until the oxygen level fell! Same with all the other variables the machine was monitoring. Obviously the patients’ depth of anesthesia didn’t change. And remember: Wykoff specifically said she checked the anesthesia machine before Carl’s case and after.”

For a few minutes the two friends looked at the records and didn’t speak. Each tried to decide what it all meant.

“If we go to Rhodes with any of this he’s going to see red all over again,” Lynn said. “And he’ll want to know how we discovered it. What could we say without implicating ourselves in having violated HIPAA? After his reaction to our just talking with Dr. Wykoff, I think he’d go apeshit if he knew we had these anesthesia records. We can’t go to him until we know a lot more.”

“I hear you,” Michael said.

“Listen,” Lynn said. “How about texting your buddy Vladimir to see if you can get him to come over this evening. I want to move forward.”

“You’re serious about all this?”

“Very serious,” Lynn said. “Thinking about Carl possibly going in there without knowing what might happen to him is driving me crazy. I need a Shapiro outfit and his thumbprint.”

“I hope I don’t regret this,” Michael said as he got out his phone. Quickly he texted an invite for Vladimir to come over to his room for an impromptu Jay-Z party and a beer. With a flourish, he sent the message.

“Now, let’s see his user name and password,” Lynn said, getting out her own phone and preparing to add Vladimir to her contacts. Michael saluted before dutifully handing his phone over to Lynn with the information displayed. While she was busy adding the data into her phone, Michael’s phone chimed. A text came back from Vladimir accepting the invite and saying he would be bringing the Russian souvenir he had promised for Michael.

“Satisfied?” Michael asked.

“No,” Lynn said. “Text him back about the Shapiro scrubs.”

“Shit, girl!” Michael complained but did as she said. As an explanation for the request he used Lynn’s earlier suggestion, saying he and his girlfriend were going to a costume party. He pushed the SEND button, and then held the phone so Lynn could see it.

A minute stretched into another. Then a second text popped onto Michael’s screen: I stop and get outfits. Maybe I a little late. No problem.

“Seems that my Russian buddy is going to come through,” Michael said. “Now let’s go get some dinner.”

“Sounds like a plan,” Lynn said. “But I need to take a quick shower.” Without waiting for a response she went into her bathroom and closed the door.

“While we are over there, let’s go up to the OR and see if we can find number thirty-seven,” Michael shouted through the door.

“Finding it might not be so easy. With twenty-four ORs, there must be fifty or more machines.”

“Probably more, but no matter. We know number thirty-seven was used on Monday in OR Twelve. It could be still in there. Usually this time of day the OR is quiet. If it is not in twelve, we could check the storage room they use to keep the extra machines.”

“If we do find it, what would we do with it?”

“That’s a good question.” Michael shrugged. “I guess I’d like to find out if it has been used since Carl’s case. If so, and there hasn’t been any problem, I’ll sleep better.”

“I hear you,” Lynn yelled. “I’ll go with you up to the OR if you come with me to the neuro ICU and IT.”

“You got a deal,” Michael said. “But first I’m going to my pad and clean up, too.”

“Good idea. I’ll meet you downstairs.”

30.

Tuesday, April 7, 6:31 P.M.

Sandra Wykoff logged out. She’d been on one of the computer terminals in the OR anesthesia office for over an hour. She was perplexed. She had no idea what to make of what she had just learned, but she felt it had to mean something — but what?

After she had left Clinical Engineering she’d been paged by Geraldine Montgomery and asked if she could do an emergency case: an open reduction of a compound fracture in a teenage boy’s forearm. She had welcomed the diversion, and the case had gone well.

During the middle of the short case, when she had been on cruise control, she’d thought more about Vandermeer, Morrison, and Davis. After the surgery, she’d gone into the Anesthesia office and logged onto the computer to go over Morrison’s and Davis’s anesthesia records with the same attention to detail that she had given to Vandermeer’s in hopes of finding any similarities above and beyond the same anesthesia machine. For more than an hour nothing had caught her attention. Then suddenly she’d seen it: all three cases had the blip, or frame offset, and, more disturbing, all had it at exactly the same time after induction!

Staring off into the middle distance, Sandra wondered if such a finding could be significant. She couldn’t help but believe it had to be on some level. Why was the anesthesia machine doing it despite the machine’s being checked after each episode? Could it be a program error despite what she had been told down in Clinical Engineering? She doubted it, as it wasn’t happening with any of the other machines. She had already checked by examining the printouts of other cases she had done using different machines. There hadn’t been any frame offsets on any of the cases she’d looked at. She’d even found a few records from machine 37. They were all clean. The frame offsets had occurred with only the three cases of delayed return of consciousness.

With sudden resolve, Sandra stood up from the desk. She hurried back to the changing room to get out of her scrubs. Once she had her clothes on, she went down to the administrative area of the hospital. What she had in mind was to see if Benton Rhodes had left for the day. If he hadn’t, she wanted to show him this new finding. But his office was empty.

For a moment Sandra debated having the hospital operator contact Dr. Rhodes. But then she had second thoughts, considering the harangue she’d endured earlier. What she didn’t know was whether her boss was aware of this time similarity. It was entirely possible, and if he was, her bothering him after hours was probably not the best idea. It was common knowledge the chief didn’t like to be disturbed at home unless absolutely necessary.

“Tomorrow is time enough,” Sandra said under her breath.

Retracing her steps back into the hospital proper, she headed for the garage. She was looking forward to getting home to unwind with a glass of wine. She still felt unnerved, guilty to a degree, and generally out of sorts from yesterday’s disaster. Would she ever completely get over it? The run-in with Dr. Rhodes hadn’t helped. Nor had Vandermeer’s continuing coma. She’d always thought that conscientiousness, meaning close attention to detail and no shortcuts, would shield her from such an experience. Obviously she had been wrong.

From the bustling first floor of the medical center, Sandra exited out into the quiet parking facility. During the hospital shift change around three in the afternoon the garage was a beehive of activity. Then between five and six there was another burst of activity, although not as intense. By six o’clock, activity fell off precipitously, only to recommence around eight, when visiting hours ended and then again around eleven, when the night staff came to replace the evening shift.

As Sandra walked to her car in the silence of the deserted garage, she was aware of the sharp clicking sound her heels made as they echoed off the concrete. It was an unsettling reminder that she was alone. She glanced around as she walked in hopes of seeing someone, but she didn’t. She had always found garages after hours to be intimidating. To rein in her imagination she forced herself to think about getting home and taking a hot bath. As she pressed her comfort access key to open her BMW’s doors, she wondered about the best way to tell Rhodes of her new finding without aggravating him. As the department head whose job it was to review all three cases, it was probably something he should have seen. If he hadn’t, she vaguely worried with his irascibility whether he might take the possible oversight personally and blame the messenger.

Sandra climbed into the driver’s seat, pulled the door closed, and reached over her shoulder for her seat belt. At the same time her right foot depressed the brake pedal in anticipation of starting the engine. It was all by reflex. She’d done it a million times. But she didn’t get the seat belt. Instead her heart leaped into her throat, as the passenger-side front door and driver’s-side rear door were both suddenly yanked open. A fraction of a second later two large men in dark business suits leaped into the car in a flurry of activity.

Sandra started to scream in shocked terror, but it never got out. A gloved hand had come around from behind and clasped itself over the lower part of her face, suppressing what would have been a piercing cry. What came out was a muffled gurgle. At the same time and by the same hand her head was roughly compressed back against the headrest. Simultaneously the man in the front passenger seat thrust a needle into her thigh and injected its contents. It was over in a second.

Unable to breathe, Sandra reached up and desperately tried to pull the hand away from her face. She couldn’t. The man was too strong. The next instant, the man beside her snatched the electronic key from her hand and started the car. A moment later the image of the parking garage through the windshield blurred and dimmed. Then her body went limp.

To Darko Lebedev’s delight he had gotten the call from Misha Zotov just before three P.M. giving him and Leonid Shubin their orders. After such a long down period with no action whatsoever, there were two new jobs to be done, and one was to be the second hit in so many days. The second was to be merely a strong warning for a female medical student to mend her ways, or at least those had been Misha’s words. Darko understood, and he couldn’t have been more pleased with both assignments. He knew Leonid would feel the same.

For the hit, the orders had been simple. The woman was to just disappear, and her car was to be taken by a driver Misha would provide out to a hospital in Colorado, where the target’s ex-husband worked. There the car was to be abandoned. As it had been explained to Darko, the idea was to focus suspicion concerning the woman’s disappearance on the former spouse and center the investigation out of state. The only other stipulation was that Misha wanted the woman to be brought drugged but alive and left with him for a few hours. He’d said he had a score to settle with the uppity bitch.

Along with the orders had come the information that Darko needed to plan both jobs. That included where Sandra Wykoff lived, the make and model of her car, and the number and location of her parking slot in the garage. He’d also been informed that she lived alone, rarely entertained, and seldom went out at night. Misha had explained that there was a lot of information available about the woman because she had been carefully vetted by security before she had been selected as one of the initial anesthesiologists in the program.

To Darko it had all sounded as if the hit would be a relatively easy task, even though, like the intimidation assignment, it had to happen immediately, that very day. It meant they had to work quickly and without the benefit of prolonged research and observation, which was the way he liked to do things. It also meant that the hit had priority.

For the second job, intimidating Lynn Peirce, Darko had arranged for help from one of the Russians who worked for the hospital security, named Timur Kortev. He’d sent the man to the medical dorm with Lynn’s photo to keep tabs on her so that when Darko was finished with Wykoff, he’d know where to find the student. He counted on her being in her room at the dorm, but he wanted to be sure. He didn’t want to waste time and risk going into her room if she wasn’t there.

For the hit, the first thing that Darko and Leonid had done was check out Wykoff’s home. Accordingly they had driven out to her condo development in North Charleston. What they discovered was that it was less than opportune for their purposes. She lived in a rather narrow row house, sharing common walls with two other units. This situation magnified the chance that there would be witnesses. For her to disappear, supposedly of her own accord, no one could see them take her. The only good thing was that there was a sliding glass door onto a lanai in the back. In their experience, such doors were easy to breach. The men had decided that if they were to be forced to go into her house, that was how they would enter, but they weren’t happy about it.

Returning to the hospital, they checked out Sandra’s vehicle. Their thought was that if she came out in a press of people, they would follow her, hoping she would make a stop or two on the way home so that they could improvise. As it turned out, they had been in luck. She’d come out after the rush and by herself.

Speaking in Russian, Darko said: “Let’s get her in the backseat. Do you see anybody?” Sandra had collapsed against him.

“No one,” Leonid said, checking out the rear window.

“Let’s do it!”

Both men exited the car and quickly pulled Sandra’s limp form from the front seat and got it into the back. Darko spread a small blanket over her that had been in the car. Both men climbed back into the vehicle. With Darko behind the wheel, they pulled out of the garage after the automatic gate opened for them. A moment later they stopped behind a nondescript white van. Leonid got out.

“See you at Misha’s,” Leonid said, before running ahead and climbing into the van. A moment later he drove out into the street heading north. Darko followed in Sandra’s car, with her unconscious on the backseat.

Misha and many of the other Russians working in Clinical Engineering, IT, and the security staff of the Mason-Dixon Medical Center lived in a residential development bought by Sidereal Pharmaceuticals. It was located in a secluded area to the east of a small town called Goose Creek. A few, like Misha and Fyodor, had stand-alone houses. The others, like Darko and Leonid, were in a condominium complex. Except for Fyodor, all had been ordered to leave wives and girlfriends back in Russia, at least for the time being.

31.

Tuesday, April 7, 7:15 P.M.

Wait a second,” Michael said, pulling Lynn to a stop. Coming up from the cafeteria, following a quick dinner, they had just emerged from the stairwell on the second floor of the hospital. Their mission was to find anesthesia machine 37, mostly for Michael’s benefit. Ahead was the open door to the surgical lounge occupied by what appeared to be a sizable portion of the evening OR staff. From where they were standing they could see that the TV was tuned to a game show. “I hate to have to constantly bring this up, but we need an excuse of what we’re doing up here if anybody asks. It’s hardly a med-student hangout. Any ideas?”

Lynn thought for a moment. “You’re right. And no need to excuse yourself. I’m glad you think of these details. Let’s say that we just spoke with the dean about hospital-based infections, which is true, and now we are looking into the issue. We don’t have to be specific.”

“Smooth!” Michael said with admiration. “It’s amazing how you can bend the truth.”

“I’ve been learning from a master.”

Michael laughed at the backhanded compliment.

Armed with an idea of what to say if confronted, the two students entered the surgical lounge. Only one orderly out of the half dozen people even looked up. No one made a move to speak with them. Everyone in the room was glued to a news brief that had suddenly interrupted the regular programming. Instead of the game show, a couple of the local news anchors had come on the air to report that the Mount Pleasant police were investigating a horrific home invasion that had occurred sometime the previous night in Mount Pleasant but had just been reported.

Lynn and Michael paused. Their attention was immediately drawn to the lurid details. Like everyone else, they listened with rapt attention.

The scene on the television shifted from the evening-news set to a young women correspondent holding a microphone and standing outside a suburban house on a wooded lot. In the background, multiple police cars and other emergency vehicles were parked at odd angles, with their emergency lights flashing. “I am standing outside of 1440 Bay View Drive, Mount Pleasant,” the correspondent said. “Behind me you can see this home where the Hurley family resided. All we know now is that sometime last night this family experienced a devastating home invasion involving burglary, assault, rape, and murder. The entire family, including two children, was killed. At this time we do not know the details of this tragedy and have been told that the Mount Pleasant chief of police will be making a statement shortly. The killings were discovered by Mr. Hurley’s assistant, who came to investigate when his boss failed to show up for work. Mr. Hurley is a successful lawyer here in Mount Pleasant. Mrs. Hurley, a third-grade teacher at the Charles Pinckney Elementary School, had also been missed, but everyone at the school thought her absence was due to a recent illness. Mrs. Hurley had been hospitalized for a few days at the Mason-Dixon Medical Center for food poisoning a little more than a week ago. School officials knew that during her hospitalization she had been diagnosed with some kind of blood disorder and that after discharge she had not been feeling one hundred percent. When she failed to show up for work, it was assumed it was because of this new illness. Back to you, Gail and Ron.”

As the two news anchors picked up the story and began talking about the possible similarities to the case involved in Truman Capote’s In Cold Blood and a more recent case in Connecticut, the surgical lounge erupted in multiple shocked conversations.

“Good God!” Lynn said to Michael. “What is this world coming to?”

“If it can happen in Kansas and Connecticut, it can happen here,” Michael said. “At least it’s a good time for us to look for number thirty-seven with everyone hung up watching the tube.”

“I suppose,” Lynn said. “But what do you make of the woman having been diagnosed with a blood disorder here at our hospital? Do you think it’s possible she had a gammopathy like Morrison and possibly Carl?”

“I suppose it is possible. Infectious gammopathy! That would be a new one!”

“I’m trying to be serious,” Lynn said.

“And I’m trying to lighten you up,” Michael said. “Let’s change our clothes and get this over with. I’ll meet you in five.”

“You got it!”

Lynn got out of her clothes and quickly pulled on scrubs. She couldn’t stop thinking about the tragedy in Mount Pleasant. It unnerved her to be reminded that human beings harbored the capacity for such terrible things. In the middle of these disturbing thoughts, she wondered exactly what kind of blood disorder the murdered mother might have had. Could it involve a paraprotein? When she got back out to the surgical lounge, Michael was already there, watching the TV news alert like everyone else.

“The irony is that the guy was a personal-injury lawyer,” Michael whispered when Lynn joined him.

“What else did you learn?”

“Not much. I’ve only been out here for a minute or two.”

“Anything more about the protein abnormality the wife had?”

“Nothing.”

“Come on! Let’s get this little errand over with.”

After donning booties, the two students pushed into the OR proper. All the lights were blazing, but the place was deserted, even the main desk. Everyone seemed to be back in the surgical lounge. There were no cases going on. As Lynn and Michael passed the PACU they did hear some music drift out into the hallway, but they avoided looking into the room. Although they had a story to offer for what they were doing, they still preferred not to bump into anyone.

“How should we go about this?” Lynn asked. “Should we just check every room, maybe you on the right and me on the left?”

“Let’s check twelve first and go from there.”

“I wonder how many patients leave this hospital with a diagnosis of a blood protein abnormality,” Lynn said as they walked.

“I’m wondering the same thing,” Michael said.

They got to twelve and had to put on the lights. The anesthesia machine was off to the side. Lynn struggled with an emotional reaction she didn’t expect, wondering if she was looking at the machine responsible to some degree for Carl’s tragedy. Michael walked directly over to it.

“It’s number thirty-seven,” Michael said, having bent over to read the service record.

For a few beats the two students stared at the machine with its profusion of dials, gauges, flow meters, vaporizers, and monitors. Three cylinders of compressed gas were hanging off the back.

“Okay,” Lynn said. “Now that we found it, what do you want to do?”

Michael shrugged. “I suppose I’d just like to make sure it has actually been used.”

“That’s easy. We can just go back to the main desk and see if there were any cases in this OR today. I’m sure there were, but come on!”

With no one at the main desk to tell them otherwise, the two students checked the surgical log. OR 12 had been busy. There had been a hernia, a lumbar fusion, and a mastectomy. Apparently there had been no problems. All the patients had gone back to their respective rooms after short stays in the PACU.

“Satisfied?” Lynn asked.

“I guess I’ll have to be. What do you want to do now?”

“Let’s head up to the neuro ICU while we’re still in scrubs,” Lynn said. “I have to find out about Carl’s possible transfer, but if you don’t want to come, I understand.”

“I’m with you for the long haul, girl!”

As they waited for the elevator they could see that the TV in the surgical lounge was back to its original game show. They rode up to six in a mostly empty car. When they got off, the only other person still in the elevator was a uniformed member of hospital security.

Like the rest of the hospital, the neuro floor was comparatively tranquil. Visiting hours were about to end at eight, so good-byes were being exchanged by the visitors who were staying until the last moment. A few patients were wandering about for exercise, pushing IV poles in front of them.

Lynn and Michael didn’t speak until they got to the doors leading into the ICU.

“Maybe I should make it easier for you,” Michael said. “I could go in and see if he is there.”

“Maybe that’s a good idea,” Lynn said. The closer they had come, the more nervous and emotional she felt. Michael sensed it.

“Okay, I’ll be right back,” Michael said. “Try to chill.”

All Lynn could do was roll her eyes, as there was no way she was going to relax. After the doors closed behind Michael, she did try to take her mind off Carl’s status by thinking about what she was going to do for the rest of the evening. Having told Frank Giordano that he needn’t worry about Carl’s cat, she was obligated to go back to Carl’s house. It wouldn’t be difficult to get there because she had driven Carl’s Cherokee to the hospital that morning.

Lynn checked the time. She also wanted to call her architect friend up in Washington, DC, to see if he had any bright ideas about navigating around inside the Shapiro Institute, since his firm did commercial building design, including health-care facilities. She figured it best that it was not too late when she called as he was married with two young kids. Lynn had known him in college, when they’d had a brief affair that ended pleasantly. Over the years they’d stayed in touch. His name was Tim Cooper.

Lynn had anticipated that Michael would come back out from the ICU immediately. She didn’t know how to interpret that he didn’t. Either Carl was still there or he wasn’t. Lynn guessed that Michael had gotten himself involved in a conversation. Was that good news or bad? She didn’t know. To keep from thinking the worst, she pulled out her mobile phone. She had Tim’s number in her contacts and as a diversion decided it was a good time to make a call, as she could make it quick. It turned out to be a good time for Tim, too, and he answered on the first ring.

As soon as they got through the pleasantries, she turned the conversation over to why she was calling. She started by asking him if he had ever heard of the Shapiro Institute.

“I certainly have,” Tim said. “It was quite a project. It was done by a design firm from Chicago called McCalister, Weiss, and Peabody, which specializes in automation. They generally design automotive assembly plants, although they have done a number of medical labs. It was a coup for them to do a health care facility.”

“Do you know anybody at that firm?”

“I do. Why do you ask?”

Lynn explained that she was going to be visiting the Shapiro Institute and wanted to have an advance idea of its layout. She asked if Tim would be willing to call his acquaintance and see if he could possibly get her a floor plan.

“I’d be happy to,” Tim said without hesitation. “But I have a better idea. As I recall, the Shapiro is within the Charleston City Limits. Am I right?”

“It is,” Lynn said.

“If you want plans, go down to the Charleston Building Commission. They’ll have a full set available. All public buildings like hospitals have to have blueprints on file, including an as-built set. They have to be submitted to get an occupancy permit, and it’s public information.”

“I never knew that,” Lynn admitted.

“Most people don’t,” Tim said.

Pleased to have learned what she had, and certain that Michael would soon be appearing, Lynn wrapped up her conversation with Tim. It wasn’t difficult. She told him she was in the hospital at that very moment, about to go into the intensive care unit. Both agreed they would talk soon.

Replacing her phone in her jacket pocket, Lynn looked at the ICU door. She shook her head. Her patience was exhausted. She stepped forward with the intent of going in when the door opened. It was Michael on his way out.

32.

Tuesday, April 7, 7:58 P.M.

By merely seeing Michael’s expression, Lynn could tell instantly that Carl was gone. She felt a wave of emotion bubble up inside her.

“I’m sorry,” Michael said. “My bad!”

“It’s not your fault,” Lynn managed, fighting back tears.

“It’s my bad for taking so long and having to give you bad news on top. Carl was transferred about an hour ago. What kept me was that I ran into our third-year neurology preceptor. He was all excited about my residency plans. Seems that he did his neurology at Mass General in Boston and insisted on giving me all sorts of tips. I couldn’t get away. Sorry!”

Lynn nodded multiple times, as if agreeing with what Michael was saying. Actually she wasn’t listening. Now that she knew for sure Carl had been sent to the Shapiro, she wasn’t at all surprised. Although she had tried to think more positively before she’d gotten the news, deep down she knew it was going to happen. There had been a disturbing inevitability about it. And thinking in this vein changed her emotional response from sadness to angry determination.

“Let’s go!” Lynn said with sudden resolve, interrupting Michael in midsentence as he talked about what he had been told concerning housing in Boston. Without warning, she turned and strode off. Michael had to make an effort to catch up with her.

“What’s the program?” Michael asked. Having to dodge patients in the hallway made it difficult to stay alongside her.

“I’m going down to IT and see if I can log on to one of their computers,” Lynn said. “This is war! I have to find out more about the Shapiro and what’s going on over there. If it is some kind of unethical drug-testing facility, I’m going to get Carl out of there ASAP. I don’t know how I’ll do it, but hell will freeze over before I let him be a human guinea pig.”

A number of hospital visitors and even a member of hospital security were waiting at the elevators, as the end of visiting hours had arrived. Michael would have liked to keep Lynn talking, to get her to calm down and keep her out of trouble, but he couldn’t without people overhearing. Lynn was ignoring him and staring into the middle distance, her mind obviously in overdrive.

Michael thought Lynn would get off on two to change out of the scrubs and give him a chance to talk to her. But she didn’t. It wasn’t until everybody got off on the main floor that he had the chance.

“I think we should go back to the dorm and chill,” Michael said as soon as the elevator doors closed and they were alone. “You got to cut the system a little slack here before you do something that gets us in real trouble. We’ve already got the medical school dean and the chief of anesthesia bent out of shape. Listen! We can always come back and visit IT later if you insist. I really think you should calm down first.”

“You can go back to the dorm,” Lynn snapped. The elevator bottomed out and the doors opened. Lynn got out with Michael on her heels.

“I’m not going back to the dorm until you do,” Michael said defiantly.

“Suit yourself,” Lynn said as they passed the Pathology Department and the morgue. Suddenly she stopped. “Why are you so intent on helping me now? You’ve told me that, growing up, you were always risk avoidant. We both know what I am planning on doing down here is a risk. It’s another serious violation of HIPAA, made even worse by fraudulently using someone else’s access. This is much worse than looking at Carl’s chart, which you reminded us is a class-five felony. This is way more serious. Why are you doing this?”

“I’m helping you because we’ve been helping each other for almost four years.”

“That doesn’t cut it, dude,” Lynn said. “Neither one of us has ever broken the law for the other. That’s never been asked. Legally, a class-five felony has mandatory jail time.”

“Okay, my friend. I’m doing it because I really feel for you. I feel your pain losing Carl. I’m doing it because I believe that if the roles were reversed and Kianna was involved, you’d do it for me.”

For a few minutes the two students looked at each other, their minds churning.

“I don’t know whether I’d do it or not for you,” Lynn said, trying to be honest.

“As my mamma used to say, ‘That don’t make no never mind for me.’ I wouldn’t have known I’d do it, either, but I’m doing it. And I’m convinced, no matter what you say, you’d do it for me. It’s called trust. We have that kind of a relationship.”

There was another short period of silence as the two continued to stare at each other.

“Okay,” Lynn said finally. “Maybe you are right. Maybe I would do it. Who’s to know? In the meantime, let’s get on with it!”

Just then a security guard appeared from behind them. Lynn and Michael held their collective breath, but the man ignored them and disappeared into the security office fifty feet ahead. Only then did they recommence walking.

Just beyond the security office they came to the Informational Technology door. They knew that the department was staffed 24/7, although it was common knowledge that there was only a skeleton crew after hours. Lynn tried the door. As she expected, it was unlocked.

Even though no one was in the large office, all the lights were on, just like in the OR. The room had a half dozen workstations with terminals, presumably for programmers. At one terminal was a coffee mug and some open manuals. In contrast to all the other monitors, which sported the usual hospital screen saver, this monitor had what looked like a spreadsheet. From where they were standing a bit of vapor could be seen rising out of the mug.

“Someone’s working here,” Lynn said.

“Very observant, Sherlock,” Michael said with a touch of sarcasm.

Along one wall were fixed windows looking into the room beyond, filled with large upright computer servers. Against the back wall was a row of private offices. Lynn made a beeline for the last office. A small plaque at eye level on the door said ALEXANDER TUPOLEV, DEPARTMENT HEAD. Without hesitation, Lynn opened the door and stepped in, holding it ajar for Michael. Then she closed the door and locked it.

“Hell, girl, what the fuck are you doing?” Michael said nervously. Shell-shocked, as if he had been duped into robbing a bank, he gazed around the modern office, with its minimalist decor. There was a large, freestanding desk totally devoid of clutter. There was also a desk-height countertop along one wall. On it were several computer terminals, each with a printer, and each fronted with Herman Miller Aeron chairs. “We can’t be caught in here.”

“This is the safest place for us to be for what we are doing,” Lynn said as she went directly to one of the computers and quickly made herself at home. She took out her cell phone and brought up Vladimir’s ID and password that Michael had given her. She placed the phone on the counter so that she could see the screen. “Considering it is eight o’clock at night, I was ninety-nine-point-ninety-nine percent sure Mr. Tupolev would not be in here. I sincerely doubt anyone will come knocking, provided we are quiet as mice. But if you want to bag it, I imagine the coast is still clear. I’ll meet you back at the dorm.”

“I’ll stick,” Michael said. He grabbed a chair and pulled it over as Lynn typed the user name, vm123@zmail.ru. And the password, 74952632237malaklov.

“The moment of truth,” Lynn said just before hitting ENTER. To her satisfaction, the log-in went flawlessly. She was in the hospital system with admin status.

“Slam dunk,” Michael said. “Okay, whatever you’re going to search for, do it fast! It would be sweet to get out of here before whoever is working in the outer office comes back.”

Lynn nodded. She knew what she wanted in general but in her rush hadn’t thought of specifics. “Let’s see: for starters, we should find out how many patients in the Shapiro have a gammopathy like Morrison.”

“We should also find out more about Ashanti Davis,” Michael suggested. “Like, why she is being given the drozitumab antibody. That should tell us if they are using her as a human guinea pig.”

“Right!” Lynn said. As per usual Michael’s insight was to the point.

“We should also get Shapiro death stats,” Michael said.

“For sure,” Lynn said. “It will be very interesting if we can learn the cause of death for each patient who passed away over the eight years they have been in operation. It’s also going to be interesting to find out how many patients have been discharged. No one thought to ask that when we had our tour.”

“Start with Ashanti,” Michael said. “It will give us an idea of what we are up against. Maybe we won’t even have to go into the Shapiro if we can somehow prove they are doing unethical drug testing.”

Lynn nodded and quickly typed in Ashanti Davis in the search window and hit ENTER. Both students were optimistic and both were disappointed when a message popped up saying there was no file for Ashanti Davis.

Undeterred, Lynn retyped the name and added Shapiro Institute. Immediately a window appeared but not the file they’d hoped for. Within the window it said: ACCESS DENIED! SEE IT ADMINISTRATION.

“Shit!” Lynn said. “I guess Shapiro records can only be accessed on Shapiro terminals.”

“Mothafuckas!” Michael said.

“I was so psyched,” Lynn said, making fists with both hands.

“Well, that’s that,” Michael said. He rolled his chair back and went to the door. Carefully he cracked it, peered out, then opened it farther to get a better view. “The coast is still clear,” he called back to Lynn. “Let’s jet our asses out of here while we still can.”

“Okay,” Lynn said. “But just a second.” She was busy typing. A moment later the printer next to her sprang to life and kicked out several pages. Lynn logged out, grabbed the papers, and joined Michael at the door.

“Let’s run,” Michael said.

A few minutes later, as they were abreast of the Pathology Department, they passed a rather large man who’d come out of the elevator, carrying a take-out bag from the cafeteria. When they got onto the elevator Michael said: “That guy looked like Vladimir’s twin. Must be the guy holding down the IT fort. Damn Russians are taking over.”

“That reminds me,” Lynn said, checking her watch. “You have company coming.”

“No problem,” Michael said. “I’ve been watching the time. What did you print out?”

“I didn’t want our visit to be a complete wash. I looked up the percentage of patients being discharged from the Mason-Dixon Medical Center with a diagnosis of a gammopathy that was discovered while they were in the hospital.”

“That’s all?”

“No! I also queried about the incidence of multiple myeloma.”

“What did you learn?”

“One percent of people being discharged have a paraprotein abnormality that was discovered during their stay.”

“That seems way high,” Michael said.

“Seems high to me, too, but I’m going to have to find out what the incidence is in the United States in general. I think it’s in that article we read about gammopathy, but I don’t remember what it was.”

“What about multiple myeloma? What percentage of patients being discharged have multiple myeloma?”

“That’s point one percent.”

“Point one percent of people being discharged have multiple myeloma?” Michael asked with surprise. “That seems way high, too.”

“I know. It can’t be right,” Lynn said. “Like with gammopathy, I’m going to have to look up the incidence in this country. It’s not a common cancer; at least I don’t think it is.”

They took the stairs to get up to the first floor, then crossed over the pedestrian bridge to the deserted clinic building.

“I found out something interesting while you were in the neuro ICU,” Lynn said. She told Michael about the call to Tim Cooper and that she could probably get detailed plans for the institute from the Charleston Building Commission.

“Cool,” Michael said. He was impressed with her resourcefulness but didn’t want to encourage her. He was still hoping she’d change her mind.

“I’m going to stop in tomorrow morning on my way here to the hospital,” Lynn said as they exited into the courtyard gardens. It was a balmy spring night.

“You’re going back to Carl’s tonight?” Michael asked. He was a bit surprised, as it was now going on nine. He could imagine how tired she was.

“I don’t have a choice,” Lynn said. “I promised to feed Carl’s cat. I had told Frank Giordano I’d take care of the poor thing.”

“As late as it is, why not call Frank and renege? He lives down there, South of Broad. I’m sure he wouldn’t mind. This is no time for you to be out riding your bike.”

“I’m not riding my bike. It’s not even here. I left it at Carl’s and drove his Cherokee this morning.”

“So I have to party with our Russian buddy by myself?”

“I could stay if you want,” Lynn said. “And then go.”

“No need,” Michael said. “If you are going to Carl’s, you should do it sooner rather than later. Are you sure you want to stay again in that big house by yourself?”

“It will make me feel closer to him,” Lynn said. She stopped walking and looked over at the Shapiro Institute. “God! It pains me no end to think of Carl in there.” Once again her voice caught.

Michael put his arm around her and pulled her toward him to give her a reassuring hug. “Try not to think about it now. We’ll figure it out. We’ll make sure that he is being cared for appropriately and not being used as a test object. I promise!”

“Thank you, bro,” Lynn managed.

33.

Tuesday, April 7, 9:52 P.M.

Darko and Leonid tossed the shovels into the back of the van. Leonid added the pickax they had shared. Both pulled off their gloves and coveralls and tossed them in, on top of the tools. They were in a deeply wooded area with Spanish moss hanging like festoons from all the trees. Both the men were fatigued and perspiring profusely from the rapid, nonstop work. There had been no conversation between them to slow them down. Nearby was a dismal swamp, and the creatures of the night were making a racket. Mosquitoes had made their job all the more difficult.

They had scouted the location six months earlier for just this kind of job. They wanted an unpopulated place so as not to attract any attention and with earth firm yet soft enough to dig a grave. It also had to be accessible by a passable dirt road. They had found it about twenty-five miles due west from the Charleston International Airport, on the grounds of an abandoned farm, partially surrounded by extensive wetlands. Although it was only an hour out of Charleston, it could have been on the dark side of the moon.

They had worked with planned dispatch, using the headlights of the vehicle to do it all properly. When they had finished, the plot appeared untouched. They even added some local plant seed. Considering the way things grew at that time of year, they were confident that all traces of their activity would quickly disappear. Satisfied, they had gotten into the van and headed back toward Misha’s, where Wykoff’s car was waiting in the garage to embark on its westward journey.

After a quarter hour, with the van’s air conditioner on at full blast and with several Marlboros smoked, the men started to feel normal enough to begin a conversation. As usual, they spoke in Russian.

“The grave digging went well,” Darko said. He was at the wheel.

“Hardly a challenge,” Leonid said in agreement. “Except for the humidity and the mosquitoes.”

“You remember I have another job tonight,” Darko said.

“I remember, but you didn’t elaborate.”

“I have to threaten a female medical student to get her to mind her own business. She and a friend have been asking too many questions about anesthesia. It’s going to be a pleasure. From the photo Misha got for me from hospital security, she’s a piece of ass.”

Leonid chuckled. “Sounds like a choice assignment. Why not share the wealth?”

“You need to finish up with this Wykoff job. When we get back to Misha’s, you have to drive her car back to her town house and pack a bag and make it look like it was done in haste.”

“I know the routine,” Leonid said.

“When you return to Misha’s with the luggage, the driver will be there to take the car to Denver.”

“Where will you be?”

“I don’t know for sure,” Darko said with a shrug, “but I presume at the medical student’s dorm. Or I might be finished. If so, we could meet at the Rooftop for a vodka. Check and see if your phone has a mobile signal yet!”

Leonid got out his cell phone and turned it on. “There’s a signal. It’s not great — one bar. Wait! Now there’s two bars. Who do you want me to call?”

“Timur Kortnev. Put him on speakerphone.”

As the call went through, neither man talked. The sound of the distant ringing could be heard. Four rings, then five. Leonid was about to disconnect when Timur answered. He sounded mildly out of breath. He, too, spoke in Russian.

“Sorry,” Timur said. “I needed to change location before I answered.”

“Did you make visual contact with the girl?”

“Yes. I’ve been following her and her friend all evening. It hasn’t been easy.”

“Why? Where has she gone?”

“First the two of them went over to the hospital cafeteria. But then they went up to the OR. I have no idea what they did there. Following that, they went to the neuro ICU. She didn’t go in. but her friend did.”

“And then she went back to the dorm?”

“No. They stopped at the computer center.”

Darko had the distinct feeling that the warning he was to deliver to Lynn Peirce was becoming more critical.

“Do you know what they did in the office?”

“I don’t. There was no one there. The person on duty was up in the cafeteria at the time.”

“Did they then go back to the dorm?”

“Yes, but only briefly.”

“So she’s not there now?”

“No. About eight-thirty she left again. She went into the garage and then drove off in a Jeep. I had to scramble to commandeer a security vehicle so I could follow.”

“Was she with her friend at this point?”

“No, she was alone.”

“Where did she go?” Darko glanced over at Leonid. Darko didn’t like surprises, and all this was a surprise.

“She went into a single-family house on 591 Church Street down here in the very south of Charleston. I was trying to look in the front windows when you called.”

“Is she is alone?”

“I think so. The house was dark when she arrived and no one has come to visit. She turned on many lights initially, but now they are mostly off.”

“Okay,” Darko said with a smile. When he heard Lynn Peirce was, strangely, moving around the medical center, he’d become concerned. Now, alone in a private house, it seemed as if she wanted to make his job easier. “Any idea of whose house it is?”

“Yes. It belongs to Carl Vandermeer, one of the program’s test cases.”

Darko recoiled. Like a few people close to Sergei Polushin, he knew a bit about the program. He also stood to profit immensely from the Sidereal stock he’d been given over the years. He knew why he had been tasked to kill Sandra Wykoff. She was asking too many questions about her patient, Carl Vandermeer. And now this Lynn Peirce was staying in the man’s house!

Without realizing he was doing it, Darko pressed down on the van’s accelerator. Intuitively, he sensed his second job of the evening might be as important as the first. He was also counting on its being significantly more fun than being eaten by mosquitoes at the edge of a swamp.

34.

Tuesday, April 7, 11:11 P.M.

Lynn could not believe what she had just discovered. In shocked wonderment she tipped back in Carl’s desk chair to stare at the ceiling and think about the implications. It seemed that every time she studied the anesthesia records, she came across something new. On this occasion she was even more flabbergasted than she’d been that afternoon and immediately the question arose in her mind whether the phenomena she’d just found could be the result of an intermittent software glitch inside the anesthesia machine. But almost as soon as the idea occurred to her, she shook her head. The anesthesia machine had been used on innumerable cases, including a few that very day. Why would it happen only on three if it was a software problem? She couldn’t imagine it could be a glitch. Instead, if anything, she told herself it might be a hack. Was that possible? She didn’t know and would have to ask Michael, as he might know. But one way or the other, what she had stumbled on was yet another horrifying hint that what had happened to Carl, Scarlett Morrison, and Ashanti Davis might not have been an accident or a screwup. This finding was in the same unsettling category as the coincidental unexplained frame offset that had occurred at exactly the same time in all three cases. In fact, it was more disturbing, suggesting the unthinkable: This whole nightmare might be deliberate!

Lynn had gotten to Carl’s house at about a quarter to nine. Pep had been ecstatic to see her and had purred with such ferocity, Lynn had dropped everything and fed her right away. Once the cat had been taken care of, Lynn wandered around the house, going from room to room, thinking about Carl.

In retrospect, such reminiscing was probably not a good idea. Same with her coming back to Carl’s house at all. As Michael had suggested, she should have called Frank to take care of the cat because being there made her sense of bereavement overwhelming. Everything in the house reminded her of her stricken lover and his unique personality, his keen intelligence, his love of life, and even his compulsive neatness, which was a step beyond Michael’s. With a bit of embarrassment she remembered some of the petty quarrels they had had about how she hung up her bath towel and sometimes left her underwear on the bathroom floor.

With these thoughts in mind, the extent of her loss had weighed on her, and Lynn became depressed. It had gotten to the point of wondering who was worse off, she or Carl. What saved the day from such negative self-fulfilling reminiscence was the sudden realization that she couldn’t just wander around feeling sorry for herself. Instead she had to make a concerted effort to occupy her mind as she had done the evening before. To that end she had gone into Carl’s bathroom first and taken a long, hot shower. She’d stayed under the hot torrent long enough to dilute the day’s emotions. Following the shower, she’d donned one of Carl’s oversize bathrobes and gone into his study. At his desk she’d turned on the PC and went online.

What she had done first was find out how many people in the general population had blood serum protein abnormalities or gammopathies. The issue had been gnawing at her ever since she’d read Morrison’s chart and since she found out that Carl was seemingly developing it. Adding to her curiosity was finding out, from the otherwise disappointing visit to the IT Department, how many people discharged from the Mason-Dixon Medical Center had been diagnosed with that condition while they had been an inpatient.

What she had learned surprised her. Although the Mason-Dixon had far fewer episodes of hospital-based infections, as Dean English had pointed out, the hospital was off the charts when it came to the incidence of blood serum abnormalities. When Lynn looked into multiple myeloma, she’d found the same situation. Patients coming from the Mason-Dixon had five times the national rate for both problems. Lynn had no explanation for such discrepancies. Could it have something to do with the hospital or the lab? She had no idea, but she had definitely decided she had to bring up the subject with Michael to get his take.

At that point, to continue to keep herself from falling back to obsessing over Carl and feeling sorry for herself in the process, she’d turned her attention back to the anesthesia records she had brought from her room. Studying the printouts from a new and unique perspective had led to her shocking new discovery.

Lynn tipped forward again, taking her eyes away from staring blankly at the ceiling. The mere thought that Carl’s disastrous condition might not have been an accident made Lynn’s blood run cold. It was such an unnerving idea that she wondered if she was becoming delusional. Was her fragile emotional state turning her into a conspiracy theorist?

Intent on proving herself wrong, she went back to what she had been doing. Spread out in front of her on Carl’s desk were sections of vital-sign tracings from each of the three cases. With a pair of scissors she’d found in Carl’s top desk drawer — after briefly looking again at the engagement ring — she had cut them out of the anesthesia record graphs. The segments she had chosen showed the blood pressure, pulse, oxygen saturation, and ECG of each patient from the moment of the frame offset to the sudden fall in blood oxygen. Her idea was to look for slight alterations in the vital signs in all three cases to see if there were any similarities. What she hadn’t anticipated was that by isolating these portions and just looking at one of them before comparing all three, she was able to see something that apparently everyone else had missed, including herself.

To confirm what she thought she had noticed, Lynn took the cut-out segment of Carl’s record and proceeded to cut it up into smaller pieces, each representing one minute of anesthesia time. Once she was done, she took all the pieces and arranged them in a vertical column so that she could compare one to the other. Once she did this, what she thought she had seen earlier became even more apparent. There was definite periodicity, meaning the tracing repeated itself. Every minute the recording of the vital signs had been looped, meaning the same one-minute segment was playing over and over, from the moment of the frame offset until the oxygen saturation suddenly dropped.

Printing another copy of Carl’s anesthesia record and taking one of the minute segments she’d cut out, Lynn was able to match the repeating segment. It had come from the minute time period just prior to the frame offset.

Lynn was stunned. For a moment she didn’t move or even breathe as her mind churned. What she had discovered was definitely real, and the implications were more than disturbing. One thing she understood: from the moment of the frame offset until the fall in the blood oxygen, the anesthesia machine wasn’t monitoring Carl’s vital signs. Instead it was constantly replaying the same, normal segment and masking what was really happening to her lover while the monitors suggested everything was normal. “My God!” she said out loud. With copies of Scarlett Morrison’s and Ashanti Davis’s records, she quickly determined it was the same.

Grabbing her mobile phone, Lynn speed-dialed Michael’s number. Her pulse was racing as the call took its time going through. She looked at the clock. It was almost eleven-thirty. It was late, but Michael usually stayed up until midnight. The distant phone rang four times. On the fifth Michael picked up.

“Yo!” Michael said with no preamble, knowing it was Lynn. “Vlad here is just about to bag it. Can I catch you in a moment?”

“I need to talk,” Lynn said with unmistakable urgency.

“You all right?”

“I’m not sure.”

“Are you in mortal danger this very second?” There was a touch of sarcasm in his tone, which wasn’t all that unusual.

“Not literally, but I just discovered something that has me totally unglued and will blow your mind.”

“Okay, I got you covered, but I need five. I’ll be right back to you.” He then disconnected.

Feeling moderately panicky after her metaphoric lifeline was summarily terminated, Lynn put her phone down. She did it slowly. Her mind was going a mile a minute. As bad as the implications were about Carl’s, Morrison’s, and Davis’s anesthesia disasters not being accidents or even episodes of malpractice, the added issue of the serum protein abnormality popped back into her head.

Could the gammopathy and the looping of the anesthesia record be related? It didn’t seem possible, but if there was one thing that Lynn had learned about medical diagnostics during her four years of medical school, it was that even when you were faced with a patient with disparate and seemingly unrelated symptoms, more often than not the underlying problem was one disease.

A sudden noise, not necessarily loud but somehow foreign, registered in Lynn’s ears. It came from the floor below, either from the living room or the foyer. It was more like a vibration of the whole structure of the house than just a sound carried in the air. Trying to figure out its origin, Lynn held her breath, listening intently. Her first thought was that it was a book falling and landing flat. Her second thought was perhaps Pep had jumped from a piece of furniture onto the floor. But Lynn quickly ruled out Pep as the culprit when she caught sight of the cat fast asleep in the club chair by the fireplace. Seeing that the animal’s keen senses had not been disturbed gave her a bit of encouragement, but it didn’t last.

Alone in the large, aging house, Lynn had been careful to make sure she had completely closed and securely locked the front door when she had arrived. Although she had turned on a number of lights during her despondent wanderings, she had turned them all off. As far as she knew, the only lights on in the whole house were the two library-style brass lamps on Carl’s desk in front of her. Even the corners of the study were lost in shadow.

Then there was another noise, a faint creak. Was it her imagination from her heightened sensitivity from not having identified the first noise? Then, almost instantly, came a rapid series of creaks from the ancient wood flooring in the foyer below, followed by another rapid series of noises from the stair treads. With a shudder of fear, Lynn sensed she was not alone. Someone was coming up the stairs!

In a panic Lynn snatched up her mobile phone. Quickly she tapped in 911. But then she hesitated to place the call. It suddenly had occurred to her that she was the trespasser, and the people coming might be Carl’s parents or a neighbor with a key who knew what had happened to Carl and were responding to the light in the study.

Unfortunately for Lynn these thoughts came more from hope than reality, and her hesitation cost her the chance to call for help. In the next instant a large figure dressed in black with a black balaclava silently flashed into sight from the dark hallway. Worse yet, clutched in the individual’s hand was an automatic pistol with a silencer. Lynn’s heart leaped into her chest.