Mortal Fear

CHAPTER 1

The pain was like a white-hot knife starting somewhere in his chest and quickly radiating upward in blinding paroxysms to paralyze his jaw and left arm. Instantly Cedric felt the terror of the mortal fear of death. Cedric Harring had never felt anything like it.

By reflex he gripped the steering wheel of his car more tightly and somehow managed to stay in control of the weaving vehicle as he gasped for breath. He’d just entered Storrow Drive from Berkeley Street in downtown Boston, and had accelerated westward, merging with the maddening Boston traffic. The images of the road swam before him and then receded, as if they existed at the end of a long tunnel.

By sheer strength of will, Cedric resisted the darkness that threatened to engulf him. Gradually, the scene brightened. He was still alive. Instead of pulling over, instinct told him his only chance was to get to a hospital as fast as possible. By lucky coincidence the Good Health Plan Clinic was not too far off. Hold on, he told himself.

Along with the pain came a drenching sweat that started on Cedric’s forehead but soon spread to the rest of his body. Sweat stung his eyes, but he dared not loosen his grip on the steering wheel to wipe it away. He exited the highway onto the Fenway, a parklike complex in Boston, as the pain returned, squeezing his chest like a cinch of steel wire. Ahead cars were slowing for a traffic light. He couldn’t stop. There was no time. Leaning forward, he depressed the horn and shot through the intersection. Cars went by, missing him by inches. He could see the faces of the startled and enraged drivers. He was now on Park Drive with the Back Bay Fens and the scruffy victory gardens on his left. The pain was constant now, strong and overpowering. He could hardly breathe.

The hospital was ahead on the right, on the previous site of a Sears building. Only a little further. Please…. A large white sign with a red arrow and red letters that said EMERGENCY loomed above.

Cedric managed to drive directly up to the emergency room platform, braking belatedly and crashing into the concrete abutment, He slumped forward, hitting the horn and gasping for breath.

The first person to reach his car was the security guard. He yanked open the door and after a glance at Cedric’s frightening pallor yelled for help. Cedric barely choked out the words, “Chest pain.” The head nurse, Hilary Barton, appeared and called for a gurney. By the time the nurses and the security man had Cedric out of the car, one of the emergency room residents had appeared and helped maneuver him onto the stretcher. His name was Emil Frank and he’d been a resident for only four months. A few years previously he would have been called an intern. He too noticed Cedric’s cream-colored skin and profuse perspiration.

“Diaphoresis,” he said with authority. “Probably a heart attack.”

Hilary rolled her eyes. Of course it was a heart attack. She rushed the patient inside, ignoring Dr. Frank, who’d plugged his stethoscope into his ears and was trying to listen to Cedric’s heart.

As soon as they reached the treatment room, Hilary ordered oxygen, IV fluids and electrocardiographic monitoring, attaching the three main EKG leads herself. As soon as Emil had the IV going, she suggested to him that he order 4 mg. of morphine to be given IV immediately.

As the pain receded a little, Cedric’s mind cleared. Even though no one had told him, he knew he’d had a heart attack. He also knew he’d come very close to dying. Even now, staring at the oxygen mask, the IV, and the EKG machine as it spewed paper out onto the floor, Cedric had never felt so vulnerable in his life.

“We’re going to move you to the coronary care unit,” Hilary said. “Everything is going to be okay.” She patted Cedric’s hand. He tried to smile. “We’ve called your wife. She’s on her way.”

The coronary intensive care unit was similar to the emergency room as far as Cedric was concerned-and just as frightening. It was filled with esoteric, ultramodern electronic technology. He could hear his heartbeat being echoed by a mechanical beep, and when he turned his head he could see a phosphorescent blip trace across a round TV screen.

Although the machines were frightening, it was a source of some reassurance to know all that technology was there. Even more reassuring was the fact that his own doctor, who had been paged shortly after Cedric’s arrival, had just come into the ICU.

Cedric had been a patient of Dr. Jason Howard’s for five years. He had begun going when his employers, the Boston National Bank, insisted that senior executives have yearly physicals. When Dr. Howard suddenly sold his private practice several years previously and joined the staff of the Good Health Plan (GHP), Cedric had dutifully followed. The move required changing his health plan from Blue Cross to the prepaid variety, but it was Dr. Howard that had attracted him, not GHP, and Cedric had let Dr. Howard know it in no uncertain terms.

“How are you doing?” Jason asked, grasping Cedric’s arm but paying more attention to the EKG screen.

“Not… great,” Cedric rasped. It took several breaths to get out the two words.

“I want you to try to relax.”

Cedric closed his eyes. Relax! What a joke.

“Do you have a lot of pain?”

Cedric nodded. Tears were running down his cheeks.

“Another dose of morphine,” Jason ordered.

Within minutes of the second dose, the pain became more tolerable. Dr. Howard was talking with the resident, making sure all the appropriate blood samples had been drawn and asking for some kind of catheter. Cedric watched him, reassured just seeing Howard’s handsome, hawklike profile and sensing the man’s confidence and authority. Best of all, he could feel Dr. Howard’s compassion. Dr. Howard cared.

“We have to do a little procedure,” Jason was saying. “We want to insert a Swan-Ganz catheter so we can see what’s going on inside We’ll use a local anesthesia so it won’t hurt, okay?”

Cedric nodded. As far as he was concerned, Dr. Howard had carte blanche to do whatever he felt was necessary. Cedric appreciated Dr. Howard’s approach. He never talked down to his patients — even when Cedric had had his physical three weeks ago and Howard had lectured him about his high-cholesterol diet, his two-pack-a-day cigarette habit, and his lack of exercise. If only I’d listened, Cedric thought. But despite Dr. Howard’s doomsday approach to Cedric’s lifestyle, the doctor had admitted that the tests were okay. His cholesterol was not too high, and his electrocardiogram had been fine. Reassured, Cedric put off attempts to stop smoking and start exercising.

Then, less than a week after his physical, Cedric felt as if he were coming down with the flu. But that had been only the beginning. His digestive system began acting up, and he suffered terrible arthritis. Even his eyesight seemed to deteriorate. He remembered telling his wife it was as though he had aged thirty years. He had all the symptoms his father had endured during his final months in the nursing home. Sometimes when he caught an unexpected glimpse of his reflection, it was as if he were staring at the old man’s ghost.

Despite the morphine, Cedric felt a sudden stab of white-hot, crushing pain. He felt himself receding into a tunnel as he had in the car. He could still see Dr. Howard, but the doctor was far away, and his voice was fading. Then the tunnel started to fill with water. Cedric choked and tried to swim to the surface. His arms frantically grappled the air.

Later, Cedric regained consciousness for a few moments of agony. As he struggled back to awareness, he felt intermittent pressure on his chest, and something in his throat. Someone was kneeling beside him, crushing his chest with his hands. Cedric started to cry out when there was an explosion in his chest and darkness descended like a lead blanket.

Death had always been Dr. Jason Howard’s enemy. As a resident at Massachusetts General, he’d carried that belief to the extreme, never giving up on a cardiac arrest until a superior ordered him to stop.

Now he refused to believe that the fifty-six-year-old man whom he’d examined only three weeks carlier and had declared generally healthy was about to die. It was a personal affront.

Glancing up at the monitor, which still showed normal EKG activity, Jason touched Cedric’s neck. He could feel no pulse. “Let me have a cardiac needle,” he demanded. “And someone get a blood pressure.” A large cardiac needle was thrust into his hand as he palpated Cedric’s chest to locate the ridge on the sternum.

“No blood pressure,” reported Philip Barnes, an anesthesiologist who had responded to the code call that automatically went out when Cedric arrested. He’d placed an endotracheal tube into Cedric’s trachea and was ventilating him with oxygen by compressing the Ambu bag.

To Jason, the diagnosis was obvious: cardiac rupture. With the EKG still being recorded, yet no pumping action of the heart, a situation of electromechanical dissociation prevailed. It could mean only one thing. The portion of Cedric’s heart that had been deprived of its blood supply had split open like a squashed grape. To prove this horrendous diagnosis, Jason plunged the cardiac needle into Cedric’s chest, piercing the heart’s pericardial covering. When he drew back on the plunger, the syringe filled with blood. There was no doubt. Cedric’s heart had burst open inside his chest.

“Let’s get him to surgery,” Jason shouted, grabbing the end of the bed. Philip rolled his eyes at Judith Reinhart, the coronary care head nurse. They both knew it was futile. At best they might get Cedric on the heart-lung machine, but what then?

Philip stopped ventilating the patient. But instead of helping to push the bed, he walked over to Jason and gently put an arm on his shoulder, restraining him. “It’s got to be cardiac rupture. You know it. I know it. We’ve lost this one, Jason.”

Jason made a motion to protest, but Philip tightened his hold. Jason glanced at Cedric’s ivory-colored face. He knew Philip was right. As much as he hated to admit it, the patient was lost.

“You’re right,” he said, and reluctantly let Philip and-Judith lead him from the unit, leaving the other nurses to prepare the body.

As they walked over to the central desk, Jason admitted that Cedric was the third patient to die just weeks after having a clean physical. The first had been another heart attack, the other a massive stroke. “Maybe I should think about changing professions,” Jason said half seriously. “Even my inpatients have been doing poorly.”

“Just bad luck,” Philip said, giving Jason a playful poke in the shoulder. “We all have our bad times. It’ll get better.”

“Yeah, sure,” Jason said.

Philip left to return to surgery.

Jason found an empty chair and sat down heavily. He knew he’d have to get ready to face Cedric’s wife, who would be arriving at the hospital at any moment. He felt drained. “You’d think by now I’d have gotten a little more accustomed to death,” he said aloud.

“The fact that you don’t is what makes you a good doctor,” said Judith, attending to the paperwork associated with a death.

Jason accepted the compliment, but he knew his attitude toward death went far beyond the profession. Just two years ago death had destroyed all that Jason held dear. He could still remember the sound of the phone at quarter past midnight on a dark November night. He’d fallen asleep in the den trying to catch up on his journals. He thought it would be his wife, Danielle, calling from Children’s Hospital, saying she’d be delayed. She was a pediatrician and had been called back to the hospital that evening to attend to a preemie in respiratory distress. But it had been the turnpike police. They called to say that a semi coming from Albany with a load of aluminum siding had jumped the central divider and rammed into his wife’s car head-on. She had never had a chance.

Jason could still remember the trooper’s voice, as if it had been yesterday. First there’d been shock and disbelief, followed by anger. Then his own terrible guilt. If only he’d gone with Danielle as he sometimes had, and read at Countway Medical Library. Or if only he’d insisted she sleep at the hospital.

A few months later he’d sold the house that was haunted by Danielle’s presence and his private practice and the office he’d shared with her. That was when he had joined the Good Health Plan. He’d done everything Patrick Quillan, a psychiatrist friend, had suggested he do. But the pain was still there, and the anger, too.

“Excuse me, Dr. Howard?”

Jason looked up into the broad face of Kay Ramn, the unit secretary.

“Mrs. Harring is in the waiting room,” Kay said. “I told her you’d be out to talk with her.”

“Oh, God,” Jason said, rubbing his eyes. Speaking to the relatives after a patient died was difficult for any doctor, but since Danielle’s death, Jason felt the families’ pain as if it were his own.

Across from the coronary care unit was a small sitting room with outdated magazines, vinyl chairs and plastic plants. Mrs. Harring was staring out the window that faced north toward Fenway Park and the Charles River. She was a slight woman with hair that had been allowed to go naturally gray. When Jason entered, she turned and looked at him with red-rimmed, terrified eyes.

“I’m Dr. Howard,” Jason said, motioning for her to sit. She did, but on the very edge of the chair.

“So it is bad…” she began. Her voice trailed off.

“I’m afraid it is very bad,” Jason said. “Mr. Harring has passed away. We did all we could. At least he didn’t suffer.” Jason hated himself for voicing those expected lies. He knew Cedric had suffered. He’d seen the mortal fear in his face. Death was always a struggle, rarely the peaceful ebbing of life portrayed in film.

The color drained from Mrs. Harring’s face, and for a moment Jason thought she would faint. Finally, she said, “I can’t believe it.”

Jason nodded. “I know.” And know he did.

“It’s not right,” she said. She looked at Jason defiantly, her face reddening. “I mean, you just gave him a clean bill of health. You gave him all those tests and they were normal! Why didn’t you find something? You might have prevented this.”

Jason recognized the anger, the familiar precursor to grief. He felt great compassion for her. “I didn’t exactly give him a clean bill of health,” he said gently. “His lab studies were satisfactory, but I warned him as I always did about his smoking and diet. And I reminded him that his father had died of a heart attack. All these factors put him in a high-risk category despite his lab values.”

“But his father was seventy-four when he died. Cedric is only fifty-six! What’s the point of a physical if my husband dies just three weeks later?”

“I’m sorry,” Jason said softly. “Our predictive abilities are limited. We know that. We can only do the best we can.”

Mrs. Harring sighed, letting her breath out. Her narrow shoulders sagged forward. Jason could see the anger fading. In its place came the crushing sadness. When she spoke, her voice was shaking. “I know you do the best you can. I’m sorry.”

Jason leaned forward and put his hand on her shoulder. She felt delicate under her thin silk dress. “I know how hard this is for you.”

“Can I see him?” she asked through her tears.

“Of course.” Jason got to his feet and offered her a hand.

“Did you know Cedric had made an appointment to see you?” Mrs. Harring said as they walked into the corridor. She wiped her eyes with a tissue she’d taken from her purse.

“No, I didn’t,” Jason admitted.

“Next week. It was the first available appointment. He wasn’t feeling well.”

Jason felt the uncomfortable stirring of defensive concern. Although he was certain no malpractice had been committed, that was no guarantee against a suit.

“Did he complain of chest pain when he called?” Jason asked. He stopped Mrs. Harring in front of the CCU door.

“No, no. Just a lot of unrelated symptoms. Mostly exhaustion.”

Jason breathed a sigh of relief.

“His joints ached,” Mrs. Harring continued. “And his eyes were bothering him. He was having trouble driving at night.”

Trouble driving at night? Although such a symptom did not relate to a heart attack, it rang some kind of a bell in Jason’s mind.

“And his skin got very dry. And he had lost a great deal of hair—”

“Hair naturally replaces itself,” Jason said mechanically. It was obvious that this litany of nonspecific complaints had nothing to do with the man’s massive heart attack. He pushed open the heavy door to the unit and motioned Mrs. Harring to follow him. He guided her into the appropriate cubicle.

Cedric had been covered with a clean white sheet. Mrs. Harring put her thin, bony hand on her husband’s head.

“Would you like to see his face?” Jason asked.

Mrs. Harring nodded, tears reappearing and streaming down her face. Jason folded back the sheet and stepped back.

“Oh, God!” she cried. “He looks like his father did before he died!” She turned away and murmured, “I didn’t realize how death aged a person.”

It doesn’t usually, Jason thought. Now that he wasn’t concentrating on Cedric’s heart, he noticed the changes in his face. His hair had thinned. And his eyes appeared to have receded deep into their orbits, giving the dead man’s face a hollow, gaunt look, a far cry from the appearance Jason remembered when he’d done Cedric’s physical three weeks earlier. Jason replaced the sheet and led Mrs. Harring back to the small sitting room. He sat her back down and took a seat across from her.

“I know it’s not a good time to bring this up,” he said, “but we would like permission to examine your husband’s body. Maybe we can learn something that will help someone in the future.”

“I suppose if it could help others…” Mrs. Harring bit her lip. It was hard for her to think, much less make a decision.

“It will. And we really appreciate your generosity. If you’d just wait here, I’ll have someone bring out the forms.”

“All right,” Mrs. Harring said, with resignation.

“I’m sorry,” Jason told her again. “Please call me if there is anything I can do.”

Jason found Judith and told her that Mrs. Harring had agreed to an autopsy.

“We called the medical examiner’s office and spoke to a Dr. Danforth. She said they want the case,” Judith told him.

“Well, make sure they send us all the results.”

Jason hesitated. “Did you notice anything odd about Mr. Harring? I mean, did he appear unusually old for a man of fifty-six?”

“I didn’t notice,” Judith said, hurrying away. In a unit with eleven patients, she was already involved in another crisis.

Jason knew that Cedric’s emergency was putting him behind schedule, but Cedric’s unexpected death continued to disturb him. Making up his mind, he called Dr. Danforth, who had a deep resonant voice, and convinced her to let the postmortem be done in house, saying death was due to a long family history of heart disease and that he wanted to compare the heart pathology with the stress EKGs that had been done. The medical examiner graciously released the case.

Before leaving the unit, Jason used the opportunity to check another of his patients who was not doing well.

Sixty-one-year-old Brian Lennox was another heart attack victim. He had been admitted three days previously, and although he’d done well initially, his course had taken a sudden turn for the worse. That morning when Jason had made rounds he had planned to move Lennox from CCU, but the man was in the early throes of congestive heart failure. It was an acute disappointment for Jason, since Brian Lennox had to be added to the list of Jason’s inpatients who had recently gone sour. Instead of transferring the patient, Jason had instituted aggressive treatment for the heart failure.

Any hope of a rapid return by Mr. Lennox to his previous state was dashed when Jason saw him. He was sitting up, breathing rapidly and shallowly in an oxygen mask. His face had an evil grayness that Jason had learned to fear. A nurse attending him straightened up from adjusting the IV.

“How are things going?” Jason asked, forcing a smile. But he didn’t have to ask. Lennox lifted a limp hand. He couldn’t talk. All his attention was directed toward his breathing efforts.

The nurse pulled Jason from the cubicle into the center of the room. Her name tag said Miss Levay, RN. “Nothing seems to be working,” she said, concernedly. “The pulmonary wedge pressure has gone up despite everything. He’s had the diuretic, the hydralazine and the nitroprusside. I don’t know what to do.”

Jason glanced over Miss Levay’s shoulder into the room. Mr. Lennox was breathing like a miniature locomotive. Jason didn’t have any ideas save for a transplant, and of course, that was out of the question. The man was a heavy smoker and undoubtedly had emphysema as well as heart trouble. But Mr. Lennox should have responded to the medication. The only thing Jason could imagine was the area of the heart involved with the heart attack was extending.

“Let’s get a cardiology consult stat,” Jason said. “Maybe they’ll be able to see if the coronary vessels are more involved. It’s the only thing I can think of. Maybe he’s a candidate for bypass.”

“Well at least it’s something,” said Miss Levay. Without hesitation, she went to the central desk to call.

Jason returned to the cubicle to dispense some compassion to Brian Lennox. He wished he had more to give but the diuretic was supposed to reduce fluid while the hydralazine and nitroprusside were supposed to reduce pre-load and after-load on the heart. All of this was geared to lower the effort the heart had to expend to pump the blood. This would allow the heart to heal after the insult of the heart attack. But it wasn’t working. Lennox was slipping downhill despite all the efforts and all the technology. His eyes now had a sunken, glazed appearance.

Jason put his hand on Brian’s forehead and pushed the hair back from his perspiring brow. To Jason’s surprise, some of the hair came out in his hand. Momentarily confused, Jason stared at it, then he carefully pulled on a few other strands. They came out as well with almost no resistance. Checking the pillow behind Brian’s head, Jason noticed more hair. Not an enormous amount but more than he would suspect. It made him wonder if any of the medications he’d ordered had hair loss as a potential side effect. He made a mental note to look that up in the evening. Obviously hair loss was not a major concern at the time. But it reminded him of Mrs. Harring’s comment. Curious!

After leaving word that he should be called after the cardiology consult on Brian Lennox and after one more masochistic glance at the sheet-wrapped corpse of Cedric Harring, Jason left the coronary care unit and took the elevator down to the second floor, which connected the hospital with the outpatient building. The GHP Medical Center was the impressive central facility of the large prepaid health plan. It incorporated a four-hundred-bed hospital with an ambulatory surgery center, separate outpatient department, a small research wing, and a floor of administrative offices. The main building, originally designed as a Sears office building, had an art deco flair. It had been gutted and totally renovated to incorporate the hospital and the administrative offices. The outpatient and research building was new, but it had been built to match the old structure, with the same careful details. It was built on pillars over a parking lot. Jason’s office was on the third floor, along with the rest of the department of internal medicine.

There were sixteen internists at the GHP Center. Most were specialists, though a few like Jason maintained a generalized practice. Jason had always felt that the whole panoply of human illness interested him, not just specific organs or systems.

The doctors’ offices were spread around the perimeter, with a central desk surrounded by a waiting area with comfortable seating. Examining rooms were clustered between the offices. At one end were small treatment rooms. There was a pool of support personnel who were supposed to rotate positions, but in actual fact the nurses and secretaries tended to work for one or another of the doctors. Such a situation promoted efficiency since there could be some adaptation to each doctor’s eccentricities. A nurse by the name of Sally Baunan and a secretary by the name of Claudia Mockelberg had aligned themselves with Jason. He got along well with both women, but particularly Claudia, who took an almost motherly interest in Jason’s well-being. She had lost her only son in Vietnam and contended that Jason looked just like him despite the age difference.

Both women saw Jason coming and followed him to his office. Sally had an armload of charts of waiting patients. She was the compulsive one, and Jason’s absence had disturbed her carefully planned routine. She was eager to “get the show on the road,” but Claudia restrained her and sent her out of the room.

“Was it as bad as you look?” Claudia asked.

“Is it that obvious?” Jason said as he washed his hands at the sink in the comer of the room.

She nodded. “You look like you’ve been run over by an emotional train.”

“Cedric Harring died,” he said. “Do you remember him?”

“Vaguely,” Claudia admitted. “After you got called to the emergency room, I pulled his chart. It’s on your desk.”

Jason glanced down and saw it. Claudia’s efficiency was sometimes unnerving.

“Why don’t you sit down for a few moments,” Claudia suggested. More than anyone else at GHP, Claudia knew Jason’s reaction to death. She was one of only two people at the Center in whom Jason had confided about his wife’s fatal accident.

“We must be really behind schedule,” Jason said. “Sally will get her nose bent out of shape.”

“Oh, screw Sally.” Claudia came around Jason’s desk and pushed him gently into the seat. “Sally can hold her water for a few minutes.”

Jason smiled in spite of himself. Leaning forward, he fingered Cedric Harring’s chart. “Do you remember last month the two others who died just after their physicals?”

“Briggs and Connoly,” Claudia said without hesitation.

“How about pulling their charts? I don’t like this trend.”

“Only if you promise me you’re not going to let yourself”—Claudia paused, struggling for a word—“get into a dither over this. People die. Unfortunately it happens. It’s the nature of the business. You understand? Why don’t you just have a cup of coffee.”

“The charts,” Jason repeated.

“Okay, okay,” Claudia said, going out.

Jason opened Cedric Harring’s chart, glancing through the history and physical. Except for his unhealthy living habits, there was nothing remarkable. Turning to the EKG and the stress EKG, Jason scanned the tracing, looking for some sign of the impending disaster. Even armed as he was with hindsight, he could find nothing.

Claudia came back and opened the door without knocking. Jason could hear Sally whine, “Claudia…” but Claudia shut the door on her and came over to Jason’s desk. She plopped down Briggs’s and Connoly’s charts in front of him.

“The natives are getting restless,” she said, then left.

Jason opened the two charts. Briggs had died of a massive heart attack probably similar to Harring’s. Autopsy had shown extensive occlusion of all of the coronary vessels despite the EKG done during his physical four weeks prior to his death being as normal-looking as Harring’s. Also like Harring’s, his stress EKG had been normal. Jason shook his head in dismay. Even more than the normal EKG, the stress EKG was supposed to pick up such potentially fatal conditions. It certainly suggested that the executive physical was an exercise in futility. Not only was the examination failing to pick up these serious problems, but it was giving the patients a false sense of security. With the results being normal, there wasn’t motivation for the patients to change their unhealthy lifestyles. Briggs, like Harring, had been in his late fifties, was a heavy smoker, and never exercised.

The second patient, Rupert Connoly, had died of a massive stroke. Again, it had been a short time after an executive-style physical, which in his case had also revealed no alarming abnormalities. In addition to a generally unhealthy lifestyle, Connoly had been a heavy drinker, though not an alcoholic. Jason was about to close the chart when he noticed something he had missed before. In the autopsy report the pathologist had recorded significant cataract development. Thinking that he’d not remembered the man’s age correctly, Jason flipped to the information page. Connoly was only fifty-eight. Now cataracts were not entirely unknown at fifty-eight, but it was nonetheless rare. Turning to the physical, Jason checked to see if he’d noted cataracts. Embarrassingly he’d failed to include them, noting he described the “eyes, ears, nose, and throat” as being within normal limits. Jason wondered if he were getting sloppy in his “old” age. But then he noticed he described the retinas as appearing normal as well. In order to have visualized the retinas, Jason would have had to have sighted through a cataract. Not being an ophthalmologist, he knew his limitations in this regard. He wondered if certain kinds of cataracts impede the passage of light more than others. He added that question to his mental list of things to investigate.

Jason stacked the charts. Three apparently healthy men had all died a month after their physicals. Jesus, he thought. People were often scared of going to hospitals. If this got out, they might stop getting checkups.

Grabbing all three charts in his arms, Jason emerged from his office. He saw Sally stand up in the central desk area and look at him expectantly. Jason silently mouthed “two minutes” as he walked the length of the waiting area. He passed several patients whom he treated with nods and smiles. He slipped into the hall leading to Roger Wanamaker’s office. Roger was an internist who specialized in cardiology and whose opinion Jason held in high esteem. He found the man leaving one of the examination rooms. He was an obese man with a face like an old hound dog with wattles and lots of extra skin.

“How about a sidewalk consult?” Jason asked.

“It’ll cost ya,” Roger teased. “Whatcha got?”

Jason followed the man into his disheveled office.

“Unfortunately, some pretty embarrassing evidence.” Jason opened the charts of his three late patients to the EKG sections and placed them in front of Roger. “I’m ashamed to even discuss this, but I’ve had three middle-aged men die right after their fancy executive physicals showed them in pretty good health. One was today. Cardiac rupture after a massive MI. I did the physical exam three weeks ago. This is the one. Even knowing what I do now, I can’t find even a bit of trouble or any of the tracings. What do you think?”

There was a moment of silence while Roger studied the EKGs. “Welcome to the club,” he finally said.

“Club?”

“These EKGs are fine,” Roger said. “All of us have had the same experience. I’ve had four such cases over the last few months. Just about everybody who’s willing to bring it up has had at least one or two.”

“How come it’s not come up?”

“You tell me,” Roger said, with a wry smile. “You haven’t exactly been advertising your experience, have you? It’s dirty laundry. We’d all rather not call attention to it. But you’re acting chief of service. Why don’t you call a meeting?”

Jason nodded glumly. Under the aegis of the GHP administration, which made all of the major organizational decisions, chief of service was not a desirable position. It was rotated on a yearly basis among all the internists, and had fallen onto Jason’s shoulders two months previously.

“I guess I should,” Jason said, collecting his charts from Roger’s desk. “If nothing else, the other doctors should know they’re not alone if they’ve had the same experience.”

“Sounds good,” Roger agreed. He heaved his considerable bulk to his feet. “But don’t expect everybody to be quite as open as you are.”

Jason headed back to the central desk, motioning to Sally to ready the next patient. Sally took off like a sprinter. He then turned to Claudia.

“Claudia, I need a favor. I want you to make a list of all the annual physicals I’ve done over the last year, pull their charts, and check on their state of health. I want to be sure none of the others have had serious medical problems. Apparently some of the other doctors have been having similar episodes. I think it’s something we should look into.”

“It’s going to be a big list,” Claudia warned.

Jason was aware of that. In its desire to promote what it called preventive medicine, GHP had been strongly advocating such physicals and had streamlined the process to take care of the maximum number of people. Jason knew that he did, on the average, between five and ten a week.

For the next several hours, Jason devoted himself to his patients, who treated him to an endless stream of problems and complaints. Sally was relentless, filling examining rooms the moment the previous patient vacated. By skipping lunch, Jason was actually able to catch up.

In the middle of the afternoon, as Jason was returning from one of the treatment rooms where he had done a sigmoidoscopy on a patient with recurrent ulcerative colitis, Claudia caught his attention and motioned for him to come over to the central desk. She was sporting a cocky smile as Jason approached. He knew something was brewing.

“You have an honored visitor,” Claudia said with pursed lips, imitating a Lily Tomlin character.

“Who?” Jason asked, reflexly scanning the adjacent waiting room area.

“He’s in your office,” Claudia said.

Jason shifted his eyes toward his office. The door was closed. It wasn’t like Claudia to put someone in there. He looked back at his secretary. “Claudia?” he questioned, extending her name out as if it were more than three syllables. “How come you allowed someone in my office?”

“He insisted,” said Claudia, “and who am I to refuse?”

Obviously whoever it was had offended her. Jason knew her that well. And whoever it was certainly had some kind of stature at GHP. But Jason was tiring of the game. “Are you going to tell me who it is or am I supposed to be surprised?”

“Dr. Alvin Hayes,” Claudia said. She batted her eyes and made a sneer. Agnes, the secretary who worked for Roger, snickered.

Jason waved at them in disgust and headed for his office. A visit by Dr. Alvin Hayes was a unique occurrence. He was the GHP token and star researcher, hired by the Plan to promote its image. It had been a move reminiscent of the Humana Corporation’s hiring Dr. William DeVries, the surgeon of artificial-heart fame. GHP, as a health-maintenance organization (HMO), did not support research’ per se, yet it had hired Hayes at a prodigious salary in order to expand and augment its image, especially in the Boston academic community. After all, Dr. Alvin Hayes was a world-class molecular biologist who had been on the cover of Time magazine after having developed a method of making human growth hormone from recombinant DNA technology. The growth hormone he had made was exactly like the human variety. Earlier attempts had resulted in a hormone that was similar but not exactly the same. It had been considered an important breakthrough.

Jason reached his office and opened the door. He could not fathom why Hayes would be paying him a visit. Hayes had all but ignored Jason from the day he had been hired over a year previously, despite the fact they’d been in the same Harvard Medical School class. After graduation they had gone their separate ways, but when Alvin Hayes had been hired by GHP, Jason had sought the man out and personally welcomed him. Hayes had been distant, obviously impressed by his own celebrity status and openly contemptuous of Jason’s decision to stay in clinical medicine. Except for a few chance meetings, they ignored each other. In fact, Hayes ignored everyone at the GHP, becoming more and more what people referred to as the mad scientist. He’d even gone to the extreme of letting his personal appearance suffer by wearing baggy, unpressed clothes and allowing his unkempt hair to grow long like a throwback to the turbulent sixties. Although people gossiped, and he had few friends, everyone respected him. Hayes worked long hours and produced an unbelievable number of papers and scientific articles.

Alvin Hayes was sprawled in one of the chairs facing Jason’s antique desk. About Jason’s height, with pudgy, boyish features, Hayes’s unkempt hair hung about his face, which appeared more sallow than ever. He’d always had that peculiar academic pallor that characterizes scientists who spend all their time in their laboratories. But Jason’s clinical eye noted an increased yellowishness as well as a lax-ness that made Hayes look ill and overly exhausted. Jason wondered if this was a professional visit.

“Sorry to bother you,” Hayes said, struggling to his feet. “I know you must be busy.”

“Not at all,” Jason lied, skirting his desk and sitting down. He removed the stethoscope draped around his neck. “What can we do for you?” Hayes appeared nervous and fatigued, as if he hadn’t slept for several days.

“I have to talk to you,” he said, lowering his voice and leaning forward in a conspiratorial fashion.

Jason flinched back. Hayes’s breath was fetid and his eyes had a glassy, unfocused look that gave him a slightly crazed appearance. His white laboratory coat was wrinkled and stained. Both sleeves were pushed up above his elbows. His watch fitted so loosely that Jason wondered how he kept from losing it.

“What’s on your mind?”

Hayes leaned farther forward, knuckles resting on Jason’s blotter. He whispered, “Not here. I want to talk with you tonight. Outside of GHP.”

There was a moment of strained silence. Hayes’s behavior was obviously abnormal, and Jason wondered if he should try to get the man to talk to his friend Patrick Quillan, thinking a psychiatrist might have more to offer him. If Hayes wanted to talk away from the hospital, it couldn’t be about his health.

“It’s important,” Hayes added, striking Jason’s desk impatiently.

“All right,” Jason said quickly, afraid Hayes might throw a tantrum if he hesitated any longer. “How about dinner?” He wanted to meet the man in a public place.

“All right. Where?”

“Doesn’t matter.” Jason shrugged. “How about the North End for some Italian food?”

“Fine. When and where?”

Jason ran down the list of restaurants he knew in the North End section of Boston, a warren of crooked streets that made you feel you’d been mystically transplanted to southern Italy. “How about Carbonara?” he suggested. “It’s on Rachel Revere Square, across from Paul Revere House.”

“I know it,” Hayes said. “What time?”

“Eight?”

“That’s fine.” Hayes turned and walked somewhat unsteadily toward the door. “And don’t invite anyone else. I want to talk with you alone.” Without waiting for a reply, he left, pulling the door shut behind him.

Jason shook his head in amazement and went back to his patients.

Within a few minutes, he was again absorbed in his work, and the bizarre episode with Hayes slipped into his unconscious. The afternoon drifted on without unwelcome surprises. At least Jason’s outpatients seemed to be doing well and responding to the various regimens he’d ordered. That gave a needed boost to his confidence that the Harring affair had undermined. With only two more patients to be seen, Jason crossed the waiting room after having done a minor surgical procedure in one of the treatment rooms. Just before he disappeared into his office to dictate the procedure, he caught sight of Shirley Montgomery leaning on the central desk and chatting with the secretaries. Within the clinical environment, Shirley stood out like Cinderella at the ball. In contrast to the other women, who were dressed in white skirts and blouses or white pants suits, Shirley wore a conservative silk dress that tried but failed to hide her attractive figure. Although few people could guess when seeing her, Shirley was the chief executive officer of the entire Good Health Plan organization. She was as attractive as any model, and she had a PhD in hospital administration from Columbia and a master’s degree from the Harvard Business School.

With her physical and mental attributes, Shirley could have been intimidating, but she wasn’t. She was outgoing and sensitive and as a result she got along with everyone: maintenance people, secretaries, nurses, and even the surgeons. Shirley Montgomery could take personal credit for providing a good portion of the glue that held GHP together and made it work so smoothly.

When she spotted Jason, she excused herself from the secretaries. She moved toward him with the ease and grace of a dancer. Her thick brown hair was swept back from her forehead and layered along the side into a heavy mane. Her makeup was applied so expertly that she didn’t seem to be wearing any. Her large blue eyes shone with intelligence.

“Excuse me. Dr. Howard,” she said formally. At the very comers of her mouth there was the faint hint of a smile. Unknown to the staff, Shirley and Jason had been seeing each other on a social basis for several months. It had started during one of the semiannual staff meetings when they had met each other over cocktails. When Jason learned that her husband had recently died of cancer, he felt an immediate bond.

During the dinner that followed, she told Jason that one morning three years ago her husband had awakened with a severe headache. Within months he was dead from a brain tumor that had been unresponsive to any treatment. At the time they had both been working at the Humana Hospital Corporation. Afterward, like Jason, she had felt compelled to move and had come to Boston. When she told Jason the story, it had affected him so deeply that he’d broken his own wall of silence. That same evening he shared his own anguish concerning his wife’s accident and death.

Fueled by this extraordinary commonality of emotional experience, Jason and Shirley began a relationship that hovered somewhere between friendship and romance. Each knew the other was too emotionally raw to move too quickly.

Jason was perplexed. She had never sought him out in such a fashion. As usual, he had only the vaguest notion of what was going on inside her expansive mind. In so many ways she was the most complicated woman he’d ever met. “Can I be of assistance?” he asked, watching for some hint of her intent.

“I know you must be busy,” she was saying now, “but I was wondering if you were free tonight.” She lowered her voice, turning her back on Claudia’s unwavering stare. “I’m having an impromptu dinner party tonight with several Harvard Business School acquaintances. I’d like you to join us. How about it?”

Jason immediately regretted having made plans to eat with Alvin Hayes. If only he’d agreed to see the man for drinks.

“I know it’s short notice,” Shirley added, sensing Jason’s hesitation.

“That’s not the problem. The trouble is that I promised to have dinner with Alvin Hayes.”

“Our Dr. Hayes?” Shirley said with obvious surprise.

“None other. I know it sounds peculiar, but he seemed almost distraught. And though he’s hardly been friendly, I felt sorry for the man. Dinner was my suggestion.”

“Damn!” Shirley said. “You’d have enjoyed this group. Well, next time…”

“I’ll take a rain check,” Jason said. She was about to leave when he remembered his conversation with Roger Wanamaker. “I probably should tell you I’m going to call a staff meeting. A number of patients have died of coronary disease which our physicals have missed. As acting chief of service I thought I should look into it. Dropping dead within a month of receiving a clean bill of health from us doesn’t make for good PR.”

“Dear God,” Shirley said. “Don’t go spreading rumors like that!”

“Well, it’s a bit unnerving when someone you’ve examined with all your resources and declared essentially healthy comes back to the hospital with a catastrophic condition and dies. Avoiding such an event is the whole purpose of the executive physical. I think we should try to increase the sensitivity of our stress testing.”

“An admirable goal,” Shirley agreed. “All I ask is that you keep it low key. Our executive physicals play a major role in our campaign to lure some of the larger corporate clients in the area. Let’s keep this an in-house issue.”

“Absolutely,” said Jason. “Sorry about tonight.”

“Me too,” Shirley said, lowering her voice. “I didn’t think Dr. Hayes socialized much. What’s up with him?”

“It’s a mystery to me,” Jason admitted, “but I’ll let you know.”

“Please,” Shirley said. “I’m one of the main reasons GHP hired the man. I feel responsible. Talk to you soon.” She moved off, smiling to nearby patients.

Jason watched her for a moment, then caught Claudia’s stare. She guiltily looked down at her work. Jason wondered if the secret was out. With a shrug he went back to his last two patients.