Marker

twenty-two

"Dr. Stapleton! Hey, Dr. Stapleton!"

Hearing his voice over the buzz of conversation and the sound of crying infants, Jack looked back at the emergency-room desk. With all the caffeine on board, he'd been pacing back and forth from the desk to the front doors, intermittently staring outside at the rain falling on the cement of the wheelchair ramp. As the time had passed, he had begun to think of switching to plan B, which was to give up on the Post-it quest, run back to the OCME, grab the material in Laurie's desk, and beat it back to the Manhattan General. It was two-thirty in the morning and he'd already been away for an hour and a half.

Jack could see Salvador waving for Jack to come back to the desk. Next to him was a girl who looked as if she were fifteen. She had straight, shoulder-length, light brown hair, parted in the middle and swept back on either side behind conveniently large ears. Her eyes were huge and separated by a narrow, upturned nose.

"This is Dr. Shirley Mayrand," Salvador said, motioning toward the cardiology resident as Jack quickly returned to the counter.

Jack was momentarily mesmerized by the woman's youthfulness. For the first time in his life, he felt old. Although he was pushing fifty, playing basketball with kids half his age made him forget how old he really was. As the cardiology resident on call, this woman in front of him had to have been through college, medical school, and a significant number of years as a resident.

"What can I do for you?" Shirley asked. To Jack, even her voice sounded prepubescent.

After Jack introduced himself, he fumbled with the page from Sobczyk's chart, placed it on the countertop, and folded out the electrocardiograph tracing.

"I'll leave you two," Salvador said and walked away.

"I know this is not much," Jack said, pointing to the strip of EKG, "but I was wondering if you could comment on it."

"It's awfully short," Shirley complained while bending over the tracing.

"Yeah, well, it's all we have," Jack said. He noticed that the part in Shirley's hair meandered around as it made its way from her forehead over the crown of her head.

"What lead is it?"

"Good question. I have no idea. It was a strip taken at the outset of an unsuccessful cardiac resuscitation."

"Probably one of the standard leads," Shirley remarked.

"Maybe so," Jack said.

The resident looked up. Jack realized one of the reasons her eyes appeared so big was that he could see the whites all the way around her corneas. It gave her the look of continuous, innocent surprise.

"I don't know what I can say," Shirley said. "You'd really have to show me more for me to be able to comment with any confidence."

"I assumed as much," Jack said. "But this tracing is from a patient who unfortunately is already dead, which you know since I said it was taken at an unsuccessful resuscitation attempt. My point is, it's not going to be to the patient's detriment if you take a wild guess, say, if you were forced to come up with some opinion. Anything."

Shirley looked back at the tracing. "Well, as you certainly have already noticed, it does suggest a widening of both the PR interval and the QRS complex, while the QTRS seems to have been fused with the T wave."

Jack gritted his teeth. Somehow, it seemed unfair that this petite, youthful woman made him feel both old and stupid. "Maybe," Jack suggested, "it would be best if you could limit your comments to something that I can understand. I mean, you could tell me your impression without telling me how you came to it."

"Well, it does suggest something to me," Shirley said, looking up at Jack. "But I have an idea."

"Okay! What is it?"

"Dr. Henry Wo, one of my attendings, happens to be here in the ER at the moment. He'd been called in to do an angiogram on a suspected acute myocardial infarction. Why don't we show it to him."

Jack was pleased. The possibility of getting an attending's opinion in the wee hours of the morning hadn't even occurred to him.

"Come on around into the ER proper!" Shirley said while leaning over the counter to point out the route Jack would have to take. "I'll meet you and take you back to the cath room, where he is working."

The elevator doors opened, and with a grunt, the orderly got Laurie's bed to roll out into the lobby on the sixth floor. Since there was a slight discrepancy between the level of the floor of the elevator and the lobby floor, there was a jolt, and Laurie grimaced from the pain it caused. It was apparent that whatever she'd been given for pain had all but worn off.

Although Laurie felt just as panicky as she had when she'd first left the PACU, she'd at least reconciled herself to the reality that there was little she could do until she got to use a phone. She'd asked the orderly where her belongings were, with the idea of getting a hold of her cell phone. Unfortunately, he'd said he had no idea.

The orderly pushed her down the short corridor from the elevator lobby toward the nurse's station, which loomed like a beacon of bright light in the dimmed and mostly sleeping hospital. The recessed nightlights with frosted glass were spaced at intervals along the walls, about two feet off the floor.

After getting the bed up to the speed of a brisk walk, the orderly had to struggle to get it to stop abreast of the nurse's station. Once he did, he engaged the foot brake before leaving Laurie and approaching the counter over the nurses' station desk. Laurie could see the tops of two female heads-one with cropped hair, the other with a ponytail. Both women looked up when the orderly plopped Laurie's metal-covered hospital chart on the countertop.

"Got a patient for you people," the orderly said.

Laurie saw the woman with the cropped hair take the chart and read the name emblazoned on the front. She immediately stood up. "Well, well, Miss Montgomery. I must say, we have been wondering where you were."

The two nurses came around from behind the desk while the orderly walked back toward the elevators.

Laurie watched as the women approached her bed, each going to a separate side. Both were dressed in hospital scrubs. The one with the cropped hair had dark skin, almond-shaped eyes, and a narrow, aquiline nose. The other's complexion was paler, with broader features that gave a hint of an Asian mix. Since both faces were illuminated from below by the nightlights, only the bony prominences were clearly visible. The rest of their faces was lost in relative shadow. To Laurie, who was already anxious, they looked decidedly creepy.

"I need to use a phone," Laurie said, looking from one to the other, unsure if one was more senior than the other.

"Jazz, I'll take her down to the room and get her settled," the Asian-appearing woman said, ignoring Laurie's comment.

"That's good of you, Elizabeth," Jazz said, "but I think I'll take care of Miss Montgomery personally."

"Really?" Elizabeth questioned. She was obviously surprised.

"Hello!" Laurie said with some annoyance. "I need to use a phone!"

"Suit yourself," Elizabeth said to her colleague and walked back toward the nurses' station.

Jazz tossed Laurie's chart onto the foot of Laurie's bed and went behind to start pushing.

"Excuse me!" Laurie said, rolling her head back to keep Jazz in view. "It is very important for me to use the phone." She grimaced as the bed's brake was released, and again when the bed lurched forward down the long, dark hall.

"I heard you the first time," Jazz said. Her voice reflected the strain of pushing the bed. "I think I should remind you it's two-thirty in the morning."

"I know what time it is," Laurie snapped. "I have to call my doctor. I'm not supposed to be here. I was supposed to stay in the PACU until she came in to do her rounds in the morning."

"I hate to break this news to you," Jazz said. "But your doctor, like all the other doctors, is fast asleep. She doesn't want to be disturbed about some logistics problem."

"Stop this bed at once," Laurie commanded. "I'm not going to this room."

"Oh?" Jazz questioned, but she didn't so much as hesitate. She continued pushing Laurie's bed at a speed significantly quicker than the orderly. She was eager to get Laurie to her room. Earlier that evening, when Jazz had first come into the hospital, she had trouble locating Laurie. At first she thought perhaps Mr. Bob had made a mistake about the name of the hospital, but it turned out the problem was only a delay in Laurie's name being entered into the hospital computer system. Jazz had figured that out when she'd checked the ER log while getting the potassium ampoule.

"I demand that you stop," Laurie cried when Jazz ignored her. Laurie was forced to press her hand against her upper abdomen to control the pain. Yelling jarred her incision.

"I can see you are going to be a difficult patient," Jazz said with a short laugh. Actually, she felt the opposite. Laurie was going to be one of her easier sanctions, thanks to OB-GYN being full. Having Laurie on her floor while she was acting charge nurse made everything a snap.

At room 609, Jazz rapidly rotated Laurie a hundred and eighty degrees to push her bed into the room headfirst. As they crossed the threshold, Jazz flipped on the room's overhead light, making both women squint. Jazz maneuvered Laurie over next to the regular hospital bed, which was significantly wider than the gurney-like bed that Laurie currently occupied.

Laurie glared at the nurse, whose attitude she couldn't fathom.

She blanched when she caught sight of the woman's nametag: Jasmine Rakoczi. Despite the drugs still in her system, Laurie remembered it instantly as one of the names on Roger's list of people who had transferred from the night shift at St. Francis to the night shift of the Manhattan General!

"What's the matter?" Jazz questioned as she lowered the guardrail on the appropriate side. She couldn't help but notice Laurie's startled reaction. "Something amiss?"

Without waiting for an answer, Jazz pushed Laurie alongside the hospital bed. She grabbed the top edge of Laurie's blanket and whipped it off with a flick of her wrist, catching Laurie by surprise and exposing her to the world. She was clad only in a hospital Johnny, with her bare knees, lower legs, and feet sticking out. A bulge over the right lower part of her abdomen covered the dressing applied to her incision, and a surgical drain snaked out from under the edge of the gown and entered a plastic device that maintained a negative pressure. A streaking of blood was evident within the tubing.

"Okay," Jazz said dispassionately. "Scoot over there, and we'll get you nice and comfortable." She then went to the head of the bed and transferred Laurie's IV bottle to the pole on the hospital bed.

Laurie didn't move. The panic she'd felt from being taken from the PACU had ratcheted up a notch after seeing Jazz's nametag. She was paralyzed with fear. For all she knew, Jazz could be the serial killer.

"Come on, sister," Jazz said. She stepped back around to Laurie's side and looked down at her. "Let's move your butt over onto the bed."

Laurie stared back with the most defiant look she could manage. It was all she could think of doing.

"If you want to be uncooperative, I'll have to get Elizabeth down here, and we'll move you one way or the other. This isn't a negotiation."

"I want to speak to the charge nurse," Laurie blurted.

"Well, isn't that convenient," Jazz laughed. "You're already talking to her. I am the charge nurse. At least the acting charge nurse, which is the same thing."

Laurie's sense of desperation went up yet another notch. She felt progressively snared in a treacherous web of terrifying circumstance.

"Now, why don't you want to move?" Jazz questioned with obvious frustration. She extended her hand over Laurie to point out the room's amenities. "Check out that comfortable bed with all its controls. You can crank yourself into just about every position you can imagine and then some. You've got a TV, a pitcher for water with no water since you're still NPO, a call button for us slaves… all the comforts of home. What else can you ask for?"

Laurie's eyes involuntarily took in what Jazz described and did a double take. Sitting on the nightstand was a telephone! She questioned why she had not thought about it until that second. The orderly had even mentioned it. It would be her lifeline. Gritting her teeth, Laurie rose up on her elbows and began moving her backside over toward the hospital bed. Then she repositioned her legs and repeated the maneuver, inching herself across the divide.

"Very good," Jazz said. "I see you've decided to be cooperative. I'm pleased for both of us."

As soon as Laurie was in the hospital bed, Jazz moved across the suction device for Laurie's drain. She pulled up the cover that had been positioned across the foot of the bed and let it settle across Laurie's chest. She then took Laurie's blood pressure and pulse. As she did this, Laurie watched her intently. Jazz avoided eye contact.

"Okay," Jazz said, finally making eye contact as she lifted up the guardrail with a jolt. "Everything seems in order other than your pulse is a little on the high side. I'll mosey on back to the desk and go over your orders. I'm sure you have something ordered for pain on an as-needed basis. Are you in need, or are you fine at the moment?"

Laurie was amazed at the lack of normal human warmth in Jazz's voice and actions. Ostensibly, there wasn't anything specific that Laurie could complain about other than her requests being ignored, yet there was a worrisome detachment that seemed incredibly out of place, and as such, it added to her already considerable unease. There was something definitely strange about Jasmine Rakoczi.

"Cat got your tongue?" Jazz questioned with a wry smile. She spread her hands waist-height. "That's okay with me. You don't have to talk if you don't want to. Frankly, it makes my job that much easier if you don't. But if you change your mind, you've got your call button. Of course, when you get around to pressing it, I might be involved with someone a bit more communicative."

With a final smile that Laurie interpreted as brazenly indifferent, Jazz walked out of the room.

Being careful not to move too quickly, Laurie reached out over the bed's side rail and lifted the phone. The effort required her to tighten her abdominal muscles, which caused significant discomfort. Gritting her teeth in the face of the pain, she managed to move the phone from the night table to the bed. She put it next to her, and then struggled to remember Jack's cell phone number in the face of her anxiety and the drugs she'd had. It took her a moment, but then it reassuringly popped into her mind. She then snatched up the phone receiver and put it to her ear.

Laurie's heart skipped a beat. There was no dial tone! Frantically, she pressed the disconnect button, hoping for the familiar sound. There was nothing. The phone was dead. Just as frantically, she grabbed the nurse's call button and pressed it, not once but several times in a row.

Although getting an attending's opinion on Sobczyk's short segment of EKG tracing seemed like a great idea, Jack hadn't factored in the attending's availability. When Jack and Shirley got back to the cath room, Jack found out that Dr. Henry Wo was in the middle of his catheterization. Jack was forced to resort to additional caffeine-driven pacing in the corridor, punctuated by frequent glances at his watch. Shirley stood by stoically. If she was aware of Jack's restless agitation, she didn't mention it.

It wasn't until almost three A.M. that Henry came out of the room, snapped off his latex gloves, and removed his mask. He was a rotund Asian man with flawless skin and dark, closely cropped hair. He snapped up Jack's hand and pumped it enthusiastically as Shirley introduced them. Shirley mentioned the quandary about the short EKG segment, and Jack handed over the page from Sobczyk's chart with the tracing attached.

"I see, I see," Henry said, nodding his head and smiling as he glanced at the EGK strip. "Very interesting. Is this all we have?"

"I'm afraid so," Jack said. He recounted the brief story, as he knew it, concerning the failed resuscitation attempt. He added why he thought that even a guess on their part might be helpful.

"It's dangerous to say too much with so little," Henry said while again studying the tracing. He then looked up at Shirley. "Dr. Mayrand, perhaps you could tell us what you were thinking?"

Shirley reiterated what she had said to Jack about the various waves, intervals, and complexes while Henry continued to nod. When Shirley had finished, Henry asked her if she had any idea of what might have accounted for such alterations.

"The conduction system seems to be failing," Shirley said. "Perhaps that means the sodium pumps within the cells of the bundle of His are not functioning or perhaps overwhelmed, resulting in a deleterious alteration in membrane potentials."

Jack again gritted his teeth. He had a sudden urge to throw a tantrum. Shirley's short monologue painfully reminded him of the academic gibberish he'd endured in medical school. In the grip of coffee-enhanced anxiety, Jack had little tolerance for such didactic mumbo jumbo and was about to make his impatience known when Henry took the words out of his mouth.

"I think Dr. Stapleton is interested in some particular agent that might account for what we are seeing on this short strip of EKG. Am I correct, Dr. Stapleton?"

Jack nodded enthusiastically.

"Well," Shirley said, visibly uncomfortable in being put on the spot, "I'm sure there are a number of drugs that could create this type of picture, including toxic amounts of most of the arrhythmia drugs. But I think it could have possibly been caused by a sudden electrolyte imbalance, particularly potassium or calcium. But that's about all one could say."

"Well said," Henry complimented. He handed the page from Sobczyk's chart with the EKG tracing back to Jack.

Jack took the paper from Henry, mulling over what Shirley had said. She hadn't added anything new, but the words "sudden electrolyte imbalance" gave him an idea. The reason he and others had dismissed the possible role of potassium was because the lab had reported that the victims' potassium levels had all been normal. Now that Jack thought about it, what the lab was saying specifically was that the postmortem potassium levels were normal. As everyone knew, potassium levels soar after death because the body's vast potassium store is intracellular and is maintained by an active transport system. After death, the transport system stops and the potassium immediately leaks out. Any sudden increase in potassium in an individual by an injected bolus prior to death would be effectively masked. Jack had to admit that if someone wanted to kill off patients, it would be an insidiously clever way to do it.

"If you happen to find any additional EKG recordings, let us know," Henry was saying. "Perhaps we could be more definitive with more leads. Just let us know."

"One other thing," Jack said, catching sight of Laurie's two Post-its attached to the back of the page. "Do either of you know what this laboratory test is?" He pulled off the Post-it with "MASNP" written on it and handed it to Henry. Henry glanced at it, shook his head, and looked at Shirley. Shirley shook her head as well.

"No idea," Henry said. He handed the piece of yellow paper back to Jack. "But I know someone who probably would: David Hancock, the night lab supervisor. The lab's conveniently right down the hall." Henry pointed to a door no more than twenty feet away. "I know he's here tonight, because he helped me earlier."

Jack took back the Post-it and reattached it to the page next to the other one. With the lab so close, he thought it would be worth taking the time to duck in and see if David Hancock was available.

"I don't know what kind of test an MASNP is, but I do know what MEF2A is," Henry said, catching sight of the second slightly wrinkled Post-it.

"Oh?" Jack questioned. He wasn't even sure where Laurie had come up with the acronym.

"That's a gene," Henry said. "It produces a protein that controls the cascade of events that assures the health of the coronary arteries' inner lining."

"Interesting," Jack said vaguely, wondering how it could be associated with Laurie's series, or if it was associated at all. "What would a positive MEF2A mean?"

"Now, that's a bit misleading," Henry admitted. "When they write 'positive MEF2A in the literature, what they really mean is positive for the marker for the mutated form of MEF2A. In that case, it is someone who produces a defective protein and, as a consequence, will have a high probability of experiencing coronary artery disease, such as my patient tonight. He's positive for the MEF2A marker, and here he is, having had an acute myocardial infarction, even though we've tried to avoid it by keeping his LDL cholesterol as low as possible."

"Well, I'm sure this will all be helpful," Jack said, although in reality he had no idea. When he got back to the Manhattan General and got to see Laurie, he'd have to ask her about where she'd found the acronym and then, if appropriate, tell her what he'd learned.

Jack thanked both Henry and Shirley, and quickly headed down toward the laboratory door, hoping David Hancock would be conveniently available. As he entered the lab, he glanced at his watch, and his level of anxiety inched upward. It was twenty-two after three.

Laurie pressed the nurse's call button several more times. She had lost count of how many times she had pressed it since Jazz had left, and the fact that no one responded made her feel even more vulnerable. It occurred to her that Rakoczi was being purposefully passive-aggressive, as she had suggested she might be when she'd left. Laurie looked down at her hand holding the call button. She was shaking.

To add to her anxiety, Laurie's pain from her surgery had gotten worse, particularly after moving herself from the gurney to the bed and then lifting the telephone. Earlier, she felt it only when she moved, but now it was constant. There was no doubt that she needed some analgesia, but she was reluctant to ask for it because of the inevitable hypnotic effects. Under the circumstances, Laurie didn't want to be any more obtunded than she was already. She had to keep her wits if she was to have any chance of protecting herself until Jack got there.

Just when Laurie had decided to see what it would be like for her to get out of bed and stand up, someone came sweeping into the room. It wasn't Jazz or Elizabeth. It was another woman even more swarthy than Jazz, with long, straight, black hair held back with a clip. She carried a large tray by its handle. The tray was divided into numerous cubbies filled with blood tubes, syringes, and the like.

"Laurie Montgomery?" the woman questioned while glancing at a requisition form.

"Yes," Laurie said.

"I need to draw some blood for some clotting studies." The woman put her tray on the foot of Laurie's bed, took out the proper color-coded stoppered tubes, and came alongside Laurie, dangling a tourniquet.

"I need a telephone," Laurie said as the woman picked up Laurie's arm and began searching for veins and patting those she saw to check if they'd be appropriate for venipuncture. "The one here by my bedside doesn't have a dial tone."

"I can't help you with your telephone," the woman said in a high, singsong voice. "I'm just a laboratory tech." She found a vein that she thought was promising and applied the tourniquet.

Laurie was about to explain at least a part of her dilemma when she caught sight of the woman's laboratory nametag. It said Kathleen Chaudhry. Like Rakoczi, it was a rather unique name. Also like Rakoczi, it was a name on Roger's list of people who had transferred from St. Francis during the suspect period. And like Rakoczi, Laurie thought she too could be the serial killer.

Laurie yanked her arm away from Kathleen such that the lab tech took a shocked step back. Kathleen quickly regained her equilibrium. "Calm down!" she said. "I'm just going to draw a little blood."

"I don't want my blood drawn," Laurie stated. She was adamant and her voice reflected it. She felt paranoid but for good reason. It was as if she was being tormented, surrounded by potential serial killers.

"Your doctor has ordered these tests," Kathleen said. "It is for your own good. It will just take a second. You'll barely feel it, I promise."

"I'm not having any blood drawn," Laurie said unequivocally. "I'm sorry. There's no use in trying to talk me into it."

"Okay, have it your way," Kathleen said, throwing up her hands. "Fine with me. I'll just have to let the nurses know."

"You do that," Laurie said. "And while you're at it, tell one of the nurses to come back down here immediately."

After making it a point to express her frustration by literally tossing the blood tubes haphazardly into her tray, Kathleen walked out of the room.

Once again, the heavy silence of the sleeping hospital closed in around Laurie. She was now beginning to question her sanity. Had those names really been on Roger's lists, or was her overwrought mind making it all up? Laurie wasn't sure, but she knew one thing without a shred of doubt: She wanted Jack to come in and get her the hell out of there.

Steeling herself against the pain, which was made worse with any movement of her abdominal muscles, Laurie began to inch herself down toward the foot of the bed. She wanted to get beyond the side rails and try standing. She'd only gotten halfway when Jazz breezed in.

"Hold on there, girl," Jazz said. "Where do you think you're going?"

Laurie stared at her with uncamouflaged scorn. "I need to find some nurses who will respond to the call button."

"Let me tell you something, dearie," Jazz said. "You are not the only patient on the floor, and you are hardly the sickest. We have to prioritize, which I'm sure you'd understand if you stopped to think for one lousy minute. What is it you want, pain meds?"

"I want a telephone," Laurie said. "The one on the night table has no dial tone."

"Getting your phone functioning is the mission of the day-staff communications department. This is the nursing night shift. We don't have time for that kind of stuff."

"Where are my belongings?" Laurie demanded. Everything could be solved if she could get her hands on her cell phone.

"Surgery must still have them."

"I want them down here this minute."

"You do have a lot of demands," Jazz ridiculed. "I have to give you that. But listen, sweetheart! Surgery happens to be very busy tonight, which means we're going to be busy. They will get to your crap when they have the time. Now, if you'll excuse me, I've got patients to see."

"Wait!" Laurie cried, before Jazz ducked out the door. When Jazz turned back to her, she added: "I want this IV out."

"Sorry," Jazz said with a shake of her head. She came back into the room, and coming alongside Laurie, she hooked a hand under Laurie's armpit. Without warning, she pulled Laurie back to where she had been in the bed. Laurie winced with the pain. She was also impressed with Jazz's strength. "You were in shock when you came into the emergency room," Jazz continued. "You need that IV in case you relapse. You need fluid, and you might need more blood."

"Another IV can be put in," Laurie contended. "I want this one out. If you don't take it out, I'll pull it out myself."

Jazz stared at Laurie for a beat. "You are a feisty one, aren't you? Well, you might have some trouble pulling that baby out. It's a peripheral central line, which sounds a bit contradictory, but it's a long catheter that's been stitched under that little bandage covering the entry point. You'd be pulling away a sizable hunk of tissue if you were to yank it out."

"I want my doctor called," Laurie said. "Otherwise, I'm going to take out this IV no matter what, get myself out of this bed, and walk out of here."

Jazz's wry, brazen smile that she had left with earlier reappeared. "You are too much. Seriously! I read that you practically bled out this evening, and now a few hours later, you're giving orders. I'll tell you what I'll do. I'll call the doctor and explain exactly what you just told me. How does that sound?"

"It would be better if I told her myself."

"Maybe, but that is problematic, since your phone is not yet set up. Anyway, I'll make the call, explain the situation exactly, including your refusal to have blood drawn for a clotting study, and then I'll be right back. How is that?"

"It's a start," Laurie conceded.

As Jazz walked out of the room, Laurie let her head fall back against the pillow. Her bed was cranked up about thirty degrees. Her heart was pounding in her temples, and the pain in her incision site was worse, and she now had the new concern that she might have torn a few stitches. Yet she felt as if her panic had peaked. She took a deep breath and let it out, trying to relax a degree. She even closed her eyes. Having Jazz get in touch with Laura Riley wasn't as good as getting Jack on the line, but as she had said to Jazz, it was a start.