Jeffrey was about to return the papers dealing with the Commonwealth case to its manila envelope when he caught sight of the settlement decision. He shook his head in dismay. Like his, the settlement had been in the millions of dollars. What a waste, he thought. He checked the settlement in the other suit. It was even higher than Commonwealth's.
Jeffrey put the files in a basket reserved for returns. Then he left the courthouse. It had finally stopped raining, but it was still overcast and chilly and it looked like it might pour at any minute.
Jeffrey caught a cab on Cambridge Street and told the driver he wanted to go to the Countway Medical Library. He sat back and relaxed. He was looking forward to spending a rainy afternoon in the library. One of the things he wanted to do was to read up on toxicology. He wanted to brush up on the field's two main diagnostic tools: the gas chromatograph and the mass spectrograph.
Kelly unlocked her front door and pushed it open with her foot. Her hands were full between her umbrella, a small bag of groceries, and a large envelope.
“Jeffrey!” she called, setting the envelope and groceries on the foyer table, pushing her silver tea service to the side. She put her umbrella on the tile floor of the powder room, then stepped back out and shut the front door. “Jeffrey!” she called again, wondering if he was there or not. As she turned back into the room, she couldn't stifle a slight cry of surprise. Jeffrey was standing in the archway leading to the dining room. “You startled me,” she said with a hand pressed up against her chest.
“Didn't you hear me?” he asked. “I answered back from the family room when you called my name.”
“Phew,” Kelly said, recovering her composure. “I'm just glad you're here. I have something for you.” She picked up the envelope from the table and put it in Jeffrey's hands. “I've also got a lot to tell you,” she added. She picked up the groceries and carried them into the kitchen.
“What's this?” he asked, following her with the envelope in hand.
“It's a copy of Henry Noble's pathology file from Valley Hospital,” Kelly said over her shoulder.
“Already?” Jeffrey was impressed. “How on earth did you manage it so quickly?”
“It was easy. Hart Ruddock sent it over by messenger. He didn't even ask why I wanted it.”
Jeffrey slipped the file out of the envelope as he was walking. There were no electron micrographs but then he didn't expect them. They were not part of a routine autopsy. Even so, the file seemed skimpy. Jeffrey spotted a notation that more material
was on file at the Medical Examiner's office. So that explained it.
Kelly unpacked the groceries while Jeffrey retired to the couch in the family room with the files. He found a summary of the autopsy report that was at the Medical Examiner's office. Reading it quickly, he saw that a toxicology screen had been done but that the findings had not highlighted anything suspicious. He also saw that on microscopic section there had been evidence of histologic damage to the nerve cells of the dorsal root ganglia as well as to the cardiac muscle.
Kelly joined Jeffrey on the couch. He could tell she had something serious to tell him.
“There was a major anesthetic complication today at St. Joe's,” she said. “No one wanted to say much, but I understand it involved an epidural case. The patient was a young woman named Karen Hodges.”
Jeffrey shook his head sadly. “What happened?” he asked.
“The patient died,” Kelly said.
“Marcaine?” Jeffrey asked.
“That I don't know for sure,” Kelly said. “But I'll find out, probably tomorrow. The person that told me about it thought it was Marcaine.”
“Victim number five,” Jeffrey sighed.
“What are you talking about?”
Jeffrey told her of the fruits of his day's research, starting with his call to the Board of Registration in Medicine. “I think the fact that the deaths occurred at different hospitals increases the chances of a deliberate tampering. We're dealing with someone who's shrewd enough to know that more than one death during epidural anesthesia at any one institution would arouse suspicions and probably lead to an official inquiry.”
“So you really think someoneâsome personâis behind all this?”
“More and more,” Jeffrey said. “I'm almost certain a contaminant was involved. I went to the library today, and among other things I checked to be absolutely sure that local anesthetics in general and Marcaine in particular do not cause cellular damage, like the damage described in Henry Noble's autopsy or revealed in Patty Owen's electron micrographs. Marcaine just doesn't do it. Not Marcaine alone.”
“Then what could have caused it?”
“I'm still not sure,” Jeffrey said. “I did a lot of reading about toxicology and poisons at the library too. I'm convinced it
couldn't be some traditional poison, since they would have shown up on the toxicology screen. What I'm tending to think is that it would have to be a toxin.”
“Aren't they the same thing?”
“No,” Jeffrey said. “A poison is more a general term. It applies to anything that causes damage to cells or interrupts cellular function. Usually when someone thinks of a poison they think of mercury or nicotine or strychnine.”
“Or arsenic,” Kelly added.
“Exactly,” Jeffrey said. “They're all inorganic chemicals or elements. A toxin, on the other hand, although a type of poison, is the product of a living cell. Like the toxin that causes toxic shock syndrome. That comes from bacteria.”
“Are all toxins from bacteria?” Kelly asked.
“Not all,” Jeffrey said. “Some very potent ones come from vegetables, like ricin from the castor bean. But people are most familiar with toxins that come in the form of venoms, like from snakes, scorpions, or certain spiders. Whatever was put into the Marcaine, it had to be extremely potent. It had to be something that could be fatal in minute amounts and at the same time mimic local anesthetics to a great degree. Otherwise its presence would have been suspected. The difference, of course, would be that it destroys nerve cells, not just blocks their function like local anesthetics.”
“So if it was injected along with the Marcaine, why wouldn't it show up with the toxicology testing?”
“For two reasons. First, it's probably introduced in such minute amounts there is very little in the tissue sample to be detected. Second, it's an organic compound that could hide among the thousands of organic compounds that normally exist in any tissue sample. What's used to separate all the compounds in a toxicology lab is an instrument called a gas chromatograph. But this instrument doesn't separate everything cleanly. There's always overlaps. What you wind up with is a graph featuring a series of peaks and valleys. Those peaks can reflect the presence of a number of substances. It's the mass spectrograph that actually reveals what compounds exist in a sample. But a toxin could be obscured in one of the gas chromatograph's peaks. Unless you suspected its presence and knew to search for it specifically, you wouldn't find it.”
“Wow,” Kelly said. “So if someone is behind this, he'd really have to know what he was doing. I mean, he'd have to be familiar with basic toxicology, don't you think?”
Jeffrey nodded. “I gave it some thought on my way home from the library. I think the murderer has to be a doctor, someone with a pretty extensive background in physiology and pharmacology. A doctor would also have access to a variety of toxins and to the Marcaine vials. To tell you the truth, my ideal suspect would likely be one of my closest colleagues: a fellow anesthesiologist.”
“Any idea as to why a doctor would do such a thing?” Kelly asked.
“That might never be determined,” Jeffrey said. “Why did Dr. X kill all those people? Why did the person put the poison in the Tylenol capsules? I don't think anyone knows for sure. Obviously they were unstable. But saying that poses more questions than it answers. Maybe the reasons would lie within the irrational psyche of a psychotic individual who is mad at the world or mad at the medical profession or mad at hospitals and in his distorted thinking believes that this is an appropriate way to exact revenge.”
Kelly shivered. “It terrifies me to think of a doctor like that on the loose.”
“Me too,” Jeffrey said. “Whoever it is could be normal most of the time but suffer psychotic episodes. He or she might be the last person you'd suspect. And whoever it is, they would have to be in a position of trust to have access to so many hospital operating rooms.”
“Do many doctors have privileges in such a range of hospitals?” Kelly asked.
Jeffrey shrugged. “I haven't the faintest idea, but checking is probably the next step. Could you get a printout from St. Joe's of the entire professional staff?”
“I don't see why not,” Kelly said. “I'm very good friends with Polly Arnsdorf, the director of nursing. Would you want an employee list as well?”
“Why not,” Jeffrey said. Her question made him think of the extraordinary access he had at Boston Memorial thanks to his position on the housekeeping staff. Jeffrey shuddered, realizing the magnitude of a hospital's vulnerability.
“Are you sure that we shouldn't go to the police?” Kelly asked.
Jeffrey shook his head. “No police, not yet,” he said. “As convincing as all this sounds to us at the moment, we have to remember that we still don't have a lick of evidence to support our theory. So far it's pure speculation on our part. As soon as
we get some evidence that's real, we can go to the authorities. Whether it would be the police or not, I'm not sure.”
“But the longer we wait, the more chance there will be that the killer will strike again.”
“I know,” Jeffrey said. “But without more evidence or the slightest idea of who the killer is, we're not exactly in a position to stop him.”
“Or her,” Kelly said grimly.
Jeffrey nodded. “Or her.”
“So what can we do to speed things up?”
“What are the chances you could get a professional staff and an employee list from Valley Hospital? It would be best if the list was contemporary to the period during which Chris lost his patient.”
Kelly whistled. “That's a tall order,” she said. “I could call Hart Ruddock back, or I could try a few of the nursing supervisors I know who are still there. One way or the other, I'll give it a shot tomorrow.”
“And I'll try getting the same at the Memorial,” Jeffrey said. He wondered where in the hospital he'd have to go to get such a list. “The sooner we have this information the better.”
“Why don't I call Polly right now?” Kelly suggested, checking the time. “She usually stays until five or so.”
While Kelly went into the kitchen to use the phone, Jeffrey thought about the horror of another epidural disaster at St. Joe's that day. It confirmed his contaminant theory. He was surer than ever that a Dr. X was at large in the Boston area.
Although Jeffrey thought that a doctor was the most likely perpetrator, he acknowledged that anyone with pharmaceutical experience could have tampered with the Marcaine; it didn't have to be an M.D. The problem was access to the drug, and that made him wonder about someone in pharmacy.
Hanging up the phone, Kelly rejoined Jeffrey in the family room. She didn't sit down. “Polly said I can get the list. No problem. In fact, she said that if I wanted to come right over and get it, I could. So I said I would.”
“Wonderful,” Jeffrey said. “I only hope we get the same cooperation at the other hospitals.” He got to his feet.
“Where are you going?” she asked.
“With you.”
“No, you're not. You're staying here and relaxing. You look haggard. You were supposed to get some sleep today, and
instead you went to the library. You stay here. I'll be back in a jiffy.”
Jeffrey did as he was told. Kelly was right, he was exhausted. He lay down on the couch and closed his eyes. He heard Kelly start the car and pull out, then he heard the electric garage door close. The house became quiet save for the ticking of the living room's grandfather clock. Out in the yard a robin squawked.
Jeffrey opened his eyes. Sleep was out of the question; he was much too restless. Instead, he got up and went into the kitchen to use the phone. He called the Medical Examiner's office to ask about Karen Hodges. As an anesthetic complication, her fatality would have fallen into the Medical Examiner's province.
The secretary at the Examiner's office told him that Karen Hodges's autopsy was scheduled for the following morning.
Next, Jeffrey called information to get the numbers for Commonwealth Hospital and Suffolk General. He called Commonwealth first. When the operator there picked up, Jeffrey asked for the anesthesia department. Once connected, he asked if Dr. Mann was still in the hospital.
“Dr. Lawrence Mann?”
“That's right,” Jeffrey said.
“Hell, he hasn't worked here for well over two years.”
“Could you tell me where he's working?” Jeffrey asked.
“I'm not sure exactly. Someplace in London. But he's not practicing medicine anymore. I believe he's in the antiques business.”
Another casualty of the malpractice process, Jeffrey thought. He'd heard of other doctors who'd given up medicine after being sued, however frivolously. What a waste of education and talent.
Next he placed a call to the anesthesia department of Suffolk General Hospital. A cheerful female voice answered the department's phone.
“Is Dr. Madaline Bowman still practicing at the hospital?” Jeffrey asked.
“Who is this?” the woman asked, her tone decidedly less cheerful.
“Dr. Webber,” Jeffrey said, making up a name.
“Sorry, Dr. Webber,” the woman said. “This is Dr. Asher. I didn't mean to sound rude. Your question took me by surprise. Not many people have asked for Dr. Bowman recently. I'm afraid she committed suicide several years ago.”
Jeffrey slowly hung up the phone. The killer's casualties weren't only the victims on the operating table, Jeffrey thought
grimly. What a trail of destruction! The more he thought about it, the more he was sure someone was behind this string of seemingly unrelated medical disasters: someone with access to the ORs of the hospitals involved; and someone familiar with at least basic toxicology. But who? Jeffrey was more determined than ever to get to the bottom of it.
Walking back through the house, Jeffrey went into Chris's study. He picked up the toxicology text that he'd glanced at on his first visit to Kelly's and brought it back to the family room. Stretching out on the couch, and kicking off his shoes, he opened the book to the index. He wanted to check the listings under the entry for Toxins.