Vital Signs

8

Struggling with their umbrellas in the wind, Marissa and Wendy passed into the courtyard of the Women's Clinic.

Entering the front door, they shook water from their coats.

Their rain-slicked hair was plastered to their foreheads.

"Do you know where the medical records department is?"

Marissa asked Wendy.

"I haven't the faintest idea," Wendy said.

"I'll ask."

While Marissa fought to close her umbrella, which had turned inside out in the wind, Wendy made her inquiries at the information booth. She motioned for Marissa to follow her to the elevators.

"Sixth floor," she said when Marissa joined her.

"I should have guessed," Marissa said.

"Rebecca Ziegler jumped from the sixth floor right after reading her records."

"Makes you wonder what she could have read."

Marissa nodded.

Once on the sixth floor, it was easy to find the department. The clatter of typewriters could be heard immediately outside the elevators. Marissa was relieved it was in the opposite direction from Linda Moore's office. For the moment, Marissa did not want to run into someone she knew.

There was no mistaking the medical records department. Dozens of file cabinets lined the room. There were three secretaries with headphones, typing dictation. A woman occupying the desk to the right of the entrance greeted Marissa and Wendy.

"Can I help you?" she asked. The woman, who was about fifty, Marissa guessed, had a name tag: Helen Solano, Medical Records Librarian.

In front of her was a computer terminal.

"I'm Dr. Blumenthal," Marissa said professionally.

"And this is Dr. Wilson."

Wendy nodded. Mrs. Solano smiled.

"We have a question for you," Wendy said.

"We're curious if the Women's Clinic record system is such that cases of a specific diagnosis such as fallopian tube blockage can be printed out."

"Absolutely," Mrs. Solano said.

"How about granulomatous blockage?" Marissa asked.

"That specific category I'm not certain of," Mrs. Solano said.

"I'd have to look it up in our diagnostic code. Let me see." She swiveled in her chair to face a bookcase filled with looseleaf manuals. She pulled one out and began flipping through.

"We do have a code for granulomatous infections of the fallopian tubes," Mrs. Solano said, glancing up from the manual.

"Wonderful," Marissa said with a smile.

"If it wouldn't be too much trouble, we'd like to get a printout with that diagnosis."

"No trouble at all," Mrs. Solano said.

Marissa and Wendy exchanged a satisfied glance.

"Where is your authorization requisition?" Mrs. Solano asked.

"We didn't think we needed one for research purposes," Wendy said.

"You need one for any purpose," Mrs. Solano explained.

"Fine," Marissa said.

"Who do we see to get the proper authorization?"

"There is only one person who can issue such a requisition," Mrs. Solano said.

"And that is Dr. Wingate, the director of the clinic."

Back at the elevators, Marissa shook her head at Wendy.

"Damn," she said.

"I thought we were home free when she told us they had the granulomatous diagnostic category."

"Me too," Wendy said.

"But now I'm thinking that your husband was right. I don't think we'll be able to persuade Wingate to give us the authorization."

"Let's not get discouraged so soon," Marissa said as they boarded the elevator.

Dr. Wingate's offices were on the second floor. He had one office as the director of the clinic and another as director of the in-vitro fertilization unit. Marissa and Wendy went to the first but were directed to the second. Dr. Wingate, they learned, was busy in the lab.

"I'll tell the doctor that you are here," the receptionist said.

Marissa and Wendy sat down.

"It's nice not to be here for another procedure," Wendy whispered. Marissa smiled in agreement.

"Dr. Wingate can see you now," the receptionist called out about a half hour later. She directed them down a long hall to the third door on the right.

Wendy knocked, Dr. Wingate told them to come in.

"Well, well!" he said, standing up from a lab bench and a microscope. Save for a desk and a couple of file cabinets, the room looked more like a lab than an office.

"I didn't know you two knew each other."

Wendy explained they had been friends in medical school.

"What can I do for you ladies today?" He motioned for them to be seated, although he remained standing.

"I have to tell you, I'm about to do a fertilization, so I don't have a lot of time."

"It won't take long," Marissa assured him. She gave him a quick rundown of how she and Wendy had discovered they had the same basic problem and how they'd found two other possible cases.

"Four cases of rare granulomatous fallopian tube infection consistent with TB is extraordinary," she said.

"Obviously we want to look into it. We are interested in this as a research project."

"But we need authorization from you," Wendy said.

"We want to see if there are additional cases."

"That I cannot do," Dr. Wingate said.

"The clinic policy is one of strict confidentiality. I cannot allow access to the patient files.

And that directive comes from the central office in San Francisco."

"But this may have public health implications," Marissa said.

' These cases might represent a new clinical entity like toxic shock."

"I can see that," Dr. Wingate said.

"And thank you for alerting us. We will be sure to look into it. I'm sure you understand my situation."

"We could talk to the women involved and get releases," Wendy said.

"I'm sorry, ladies," Dr. Wingate said with impatience creeping into his voice.

"I've told you out rules. You have to respect them.

And now I have to get back to work. Aren't both of you due to have your hormone levels checked soon?"

Both Wendy and Marissa nodded. Marissa said: "Can you at least think about it and let us know later?"

"I don't have to think about it," Dr. Wingate said.

"It is impossible for me to give you authorization. And that's final.

Now if you will excuse me."

At the elevators the women regarded each other.

"Don't tell me that Robert was right," Marissa warned.

"If you do, I'll scream."

On the first floor near the information booth, they stopped.

"Do you know anybody well enough on the staff here to get them to try to access the computer?" Wendy asked.

Marissa shook her head, "Unfortunately no, but I just had another idea that won't help our problem here but might answer some questions about Rebecca Ziegler. As a suicide, she must have gone to the medical examiner. They'd have done a post.

Maybe they looked at her fallopian tubes."

"It's worth a try," Wendy said.

"Let's go down to the city morgue and see. But first I'd better call my office and make sure things are going okay without me."

"I'll call the medical examiner," Marissa said.

Together they walked over to a bank of public phones. Wendy was finished first and she waited for Marissa to hang up.

"I'm still clear," Wendy told Marissa.

"Good," Marissa said.

"It was a lucky thing I called the ME's office. Although Rebecca Ziegler was an ME's case, they authorized the Memorial to do the post. Let's head over there."

After the disappointment and lack of success at the Women's Clinic, Marissa was encouraged to find that her friend Ken Mueller had done the post on Rebecca Ziegler. She was confident there wouldn't be any problem finding out the results.

"Ken is in the autopsy room," a secretary told Marissa.

"He just went in a few minutes ago and I don't expect him to be out for an hour or so."

"Which room?" Marissa asked.

Jhree," the secretary said.

"Can't we wait?" Wendy asked as they walked through pathology toward the autopsy area. Autopsies had never been a favorite of Wendy's. Some of her medical school recollections were already making her feel queasy.

"I think we'd better talk to him while we can," Marissa said.

But then as she was about to back into the autopsy room, she caught sight of Wendy's pale face.

"Are you okay?" she asked.

Wendy confessed that autopsies had never been her strong suit.

"You wait out here," Marissa said.

"I'll be quick. I'm not fond of them either."

Stepping through the door, Marissa was immediately assaulted by the offensive odor of the autopsy room. Her eyes scanned the room, coming to rest on two gowned and gloved men wearing protective goggles. Between the men was a pale nude body of a young male stretched out on a stainless-steel table.

"Ken?" Marissa called timidly. Both men looked up. They were in the process of eviscerating the corpse.

"Marissa, how are you!" Ken answered through his mask.

"Come on over here and meet the worst junior resident the Memorial has ever seen."

"Thanks a lot," Greg said.

Marissa advanced to the foot of the autopsy table. Ken formally introduced Greg to Marissa, changing his joking evaluation to one of high praise. Greg waved at Marissa with his scalpel.

"Interesting case?" Marissa asked to make conversation.

"They are all interesting cases," Ken said.

"If I didn't feel that way I would have gone into dermatology. Is this a social visit?"

"Hardly," Marissa said.

"I was told you did a post on a woman by the name of Rebecca Ziegler."

"Was that the woman who couldn't fly?" Ken asked.

Spare me the pathology humor," Marissa said.

"But yes, she was, the one who jumped from a sixth-story window."

I did the post," Greg said.

"Ken watched."

"It was an interesting case-" Ken said.

"You just said they were all interesting," Greg interrupted.

"All right, wise guy," Ken said to Greg. Then to Marissa he said: "This was a particularly interesting case. The woman ruptured her aorta."

"Did you look at the fallopian tubes?" Marissa asked. She wasn't interested in gross injuries.

I looked at everything," Greg said.

"What do you want to knol?"

"Did you look at the slides yet?" Marissa asked.

"Of course," Greg said.

"She had granulornatous destruction of both tubes. I sent a bunch more slides off to be processed with various stains, but last time I looked they weren't back yet."

"If you're curious whether they looked like those slides you showed me months ago," Ken said, "they did. Exactly the same.

So our tentative diagnosis of her problem in her fallopian tubes was an old, resolved TB lesion. But of course, that was just an incidental finding. It didn't have anything to do with her death."

"You going to tell her about the other stuff?" Greg asked.

"What other stuff?" Marissa asked.

"Something that Greg and I have been mulling over," Ken said.

"I'm not sure we should tell you."

"What are you talking about?" Marissa insisted.

"Why wouldn't you tell me? Come on, you're making me curious."

"We can't make up our own minds," Greg said.

"There are a couple of things that are bugging us."

"Give me a try," Marissa pleaded.

"Well, don't say anything to anybody," Ken said.

"I might have to discuss it with the medical examiner, and I don't want him to hear it from anyone else first."

"Out with it," Marissa demanded.

"You can trust me."

"Everybody thinks pathology is cut and dry," Ken said evasively.

"You know, the last word, the final answer. But it ain't so.

Not always. There are times when your intuition is telling you something even though you cannot document it categorically."

"For chrissake, tell her," Greg said.

"All right," Ken said.

"We noticed that Rebecca Ziegler had a recent venipuncture in one of her arm veins."

"Oh, for goodness' sake!" Marissa said with exasperation.

"The woman was undergoing in-vitro fertilization. She was getting hormones and blood tests all the time. Is that what you've made this big buildup for? Please!"

Ken shrugged his shoulders.

"That's part of it," he said.

"If it were only that, we wouldn't be concerned. We know she'd been stuck a lot of times over the last months. There were marks all over her body. But this stick gave the appearance of being done just before she died. That makes it suspect. So we decided to expand our toxicology screen to look for drugs other than the usual hormones. As pathologists we're supposed to be suspicious."

"And you found something?" Marissa asked with horror.

"Nope," Ken said.

"Toxicology was clean. We're trying a few other tricks, but so far nothing has turned up."

"Is this some kind of joke?" Marissa said.

"No joke," Ken said.

"The other part of the puzzle is that she only had a few hundred cc's of blood in her chest."

"Meaning..

"When someone ruptures an aorta there is usually a lot of blood in the chest," Ken said.

"A bit more than a few hundred cc's. It's possible to have only that much, but it's not probable.

So finding only a few hundred cc's is not something concrete, it's just suggestive."

"Suggestive of what?" Marissa asked.

"Suggestive that she was already dead when she fell," Ken said.

Marissa was stunned. For a moment she couldn't speak. The implications were too horrendous.

"So you can see our problem," Ken said.

"If we say something like this officially, we have to have more proof. We have to come up with an explanation of what killed her before she fell. Unfortunately, we haven't found anything on gross or microscopic. We went over her brain extremely carefully and found nothing. The only eh ance is toxicology and so far we've gotten a big zip."

"What about her dying as she fell?" Marissa suggested.

"From fright or something?"

"Come on, Marissa, be serious," Ken said with a wave of his hand.

"That only happens in the movies. If she was dead before she hit the ground, then she was dead before she fell. Of course that means she was tossed out of the building."

"Maybe she hadn't paid her bill," Greg suggested jokingly.

"But with all due respect, I think we'd better get on with our present case before the body putrefies."

"If you want, I'll call you if we come up with anything," Ken said.

"Please," Marissa answered. She was in a daze as she headed for the door.

Ken stopped her by calling out: "Remember, Marissa, mum's the word. Don't say anything to anybody."

"Don't worry," Marissa called over her shoulder.

"Your secret is safe with me." But of course she'd have to tell Wendy.

At the door, Marissa paused again. Turning around, she called out to Ken.

"Do you have a chart on her?" she asked.

"Not really," Ken said.

"Just the stuff they wrote in the ER, which wasn't much."

"But I suppose the business office got some details for billing," Marissa said.

"I'm sure," Ken said.

"You didn't happen to know if they got her social security number?" Marissa asked.

"You got me there," Ken said.

"But if you want to look, the chart is on my desk."

Marissa pulled open the door and left the autopsy room.

"My feeling is that we can't assume it's true," Wendy said, twirling her ice cubes in her mineral water.

"Thinking Rebecca Ziegler was killed and then tossed out of a window is too preposterous.

It can't be true. The amount of blood in a chest after an aortic rupture has to be defined by a bell-shaped curve. Rebecca Ziegler was just at one end of the curve. That has to be the explanation."

Wendy was sprawled in the corner of the couch in Marissa's study. Taffy Two was sitting on the floor, hoping for another Goldfish cocktail cracker. Marissa was at her desk.

They were waiting for Gustave to arrive. He'd had late-afternoon emergency surgery, but was due any moment. At Wendy's urging, the women had decided to get together with their husbands for a casual dinner of pizza. They were hoping that if the men got to know each other, they might decide to come to one of the Resolve meetings. Wendy thought that would be extremely helpful. Marissa wasn't so sure.

"At least I got her social security number from her chart," Marissa said.

"If we can figure out a way to get into the Women's Clinic records, we can see what poor Rebecca read on her last day. That is, if she read anything."

"Here you go again with that wild imagination of yours," Wendy said.

"So now you think they took her upstairs, bumped her off, then tossed her out the window. Come on, it's too farfetched even to consider."

"Regardless," Marissa said.

"We'll let it go for the time being.

At least we did find out that she had the same infectious process in her tubes. That we know for sure."

Suddenly Marissa fumbled through her papers, searching for the phone numbers for Marcia Lyons and Catherine Zolk.

Calling each woman in turn, Marissa learned what she intuitively suspected: both women confirmed that their internists had talked about their taking isoniazid. The internists had been worried about TB.

Hanging up the phone, Marissa said: "Now we have five definite cases. Damn Wingate and his confidentiality. We can't make many statistical inferences from five cases. We have to find out if there are more."

"Ut's be fair," Wendy said.

"Wingate is following orders from above. Maybe he has already started looking into it."

"I hope so," Marissa said.

"Meanwhile, let's check our own hospitals and see if we can come up with more cases. You take the General and I'll take the Memorial."

Taffy Two took off at the sound of the doorbelL barking madly. Wendy swung her feet to the floor.

"That must be Gustave," she said as she stood up and stretched. She checked her watch; it was almost nine P.M.

Marissa was struck by Gustave's stature. From her five-foot height, he towered over her like a giant. He was a six-foot-six, squarely built man with very blond, curly hair. His eyes were a soft pastel blue.

"Sorry I'm so late," Gustave apologized after being introduced to Marissa and Robert. Robert had come out of his study at the sound of the bell.

"We had to wait for anesthesia before we began out case."

"It makes no difference at all," Marissa assured him. She told Robert to see what Gustave wanted to drink while she and Wendy called for the pizza.

When the pizza arrived, they all gathered around the table in the family room off the kitchen. The men were drinking beers.

Marissa was pleased but a little surprised that Robert was enjoying

Gustave's company. He usually didn't get along with doctors.

"We haven't heard about your visit to the Women's Clinic today," Robert said when there was a lull in the conversation.

Marissa looked over at Wendy, She wasn't sure if she wanted to get into a discussion about their visit, knowing that she'd have to hear Robert's "I told you so."

"Come on," Robert urged.

"What happened?" Turning to Gustave, Robert explained that the women had tried to access the clinic's computer.

"We asked and they said no," Wendy admitted.

"I'm not surprised," Robert said.

"Were they nasty about it?"

"Not at all," Wendy said.

"We had to go to the director of the clinic, the same man who runs the in-vitro unit. He said it was a policy made at the home office in San Francisco."

"I think it is shortsighted," Marissa said, finally speaking up.

"Although we didn't find anything out at the clinic, we did learn that there are five cases, and five cases of a rare problem in one geographical location deserves to be investigated."

"Five cases?" Gustave questioned.

"Five cases of what?"

Wendy quickly filled Gustave in on the situation, explaining it involved her apparent TB of the fallopian tubes.

"So we went back to the clinic to see if there are other cases,"

Marissa explained.

"But they would not let us search their files for reasons of confidentiality."

"If you were running a clinic," Robert asked Gustave, "would you let a couple of people off the street come in and access your records?"

Absolutely not," Gustave agreed.

That's what I tried to explain to the ladies last night," Robert said.

"The clinic is only operating in a reasonable, ethical, and legal fashion. I would have been shocked if they had given any information at all."

"We are hardly 'people off the street," Wendy said heatedly.

"We're doctors as well as patients."

Being two of the five in your own series hardly makes you objective," Gustave pointed out.

"Especially with the hormones you women have been taking."

"I'll drink to that," Robert said, raising his beer bottle.

Wendy and Marissa exchanged frustrated glances.

After wiping his mouth with the back of his hand, Robert turned back to Marissa.

"Five cases?" he said.

"Last night you mentioned four."

Rebecca Ziegler had the same problem," Marissa answered.

"No kidding," Robert said. Turning to Gustave, he said, "She was the woman who committed suicide over at the Women's Clinic. She went berserk in the waiting room just as Marissa and I arrived, the very day she jumped. I tried to restrain her but she slugged me."

"Wendy told me about her," Gustave said.

"You tried to restrain her before she jumped?"

"Nothing so dramatic," Robert said.

"She was about to attack a receptionist. Seems the receptionist wouldn't let her see her records. It wasn't until later that she jumped out of the window.

And that was from the top floor, not the waiting room."

Gustave nodded.

"Tragic case," he said.

"It may be more tragic than you think," Marissa blurted without thinking.

"Wendy and I learned something else today. Rebecca

Ziegler might not have committed suicide. She might have been murdered. That's how reasonable, ethical, and legal the Women's Clinic is being run."

As soon as Marissa had mentioned this shocking possibility she regretted it. There were a number of reasons she shouldn'i have said anything, her promise to Ken foremost among them.

She tried to change the subject to tuberculosis, but Robert wouldn't let it go.

"I think you'd better explain," he insisted.

Realizing her mistake, Marissa decided she had no choice but to tell the whole story. After she'd finished, Robert sat back in his chair and looked at Gustave.

"You're a doctor," he said.

"What do you think of what you just heard?"

"Circumstantial," Gustave said.

"Personally, I think those two pathologists are letting their forensic imaginations run wild. As they said themselves, there is no concrete proof. They have a ruptured aorta. That certainly is lethal. Probably the heart was in diastole at the moment of impact, so that it was filling when it was shocked into stopping. The only bleeding came from back flow, meaning the blood that was in the aorta itself."

"Sounds reasonable to me," Robert said.

"Gustave is probably right," Marissa agreed, glad to get off the subject. She wasn't about to bring up her own question regarding the fact that Rebecca had hardly acted depressed in the waiting room.

"Even so," Marissa continued, "Rebecca's death makes us even more eager to access the Women's Clinic's computer. I'd love to read what's in her record; what she saw had to contribute to her death."

"Maybe we could find some whiz-kid hacker over at MIT," Wendy said.

"It would be classic if we could get at their files from offsite."

"That would be fantastic," Marissa agreed.

"But what's more realistic is for you and me to sneak in there at night and just use one of the terminals. Someone could do that at the Memorial with only a little creativity."

"Hold on," Robert said.

"You guys are getting way out of hand. Unauthorized access of someone's private computer files is considered grand theft in Massachusetts. If you do something crazy like that, you could find yourselves felons."

Marissa rolled her eyes.

"That's no joke," Robert said.

"I don't know what's in your minds."

"Wendy and I happen to think this TB salpingitis is extremely significant," Marissa told him.

"We think it ought to be followed up. We seem to be the only ones willing to do it. Sometimes risks have to be taken."

Gustave cleared his throat.

"I'm afraid I'm in agreement with

Robert on this one," he said.

"You can't be serious about breaking into the clinic files. Despite your motivations, it would be a crime nonetheless."

"The problem is truly one of priorities," Marissa said.

"You men don't realize how important this issue could be. By following up on it we are being responsible, not the reverse."

"Maybe we should change the subject," Wendy suggested.

"I think it should be settled before you women get into serious trouble," Gustave said.

"Be quiet, Gustave!" Wendy snapped.

"These five cases may be the tip of an iceberg," Marissa said.

"As I've already said, it reminds me of the discovery of toxic shock syndrome."

"That's not a fair comparison," Robert said.

"It's not like anyone's died."

"Oh yeah?" Marissa challenged.

"What about Rebecca Ziegler?"