Authors: Daniel Palmer
That last line was Mr. Anderson’s last best hope. If the vessels that supplied blood to the man’s head were inflamed or damaged, it could cause his symptoms. The condition was also completely treatable. However, Lucy believed the real culprit behind Mr. Anderson’s troubles was something no department at White Memorial could cure. The biopsy did in fact show inflammation, some possible blockage there. But sometimes lab results offered rays of false hope. The symptoms outlined in the report were standard for another ailment, one that would be heartbreaking for both Mr. Anderson and his family.
“Well?” Becca asked after Lucy had finished her review.
“Seems cut and dried to me. Mr. Anderson has Alzheimer’s.”
Alzheimer’s disease had no official test that could be done on the living. Neuropathological signs of the disease, amyloid plaques and neurofibrillary tangles of tau, a protein involved in maintaining the internal structure of the nerve cell, could be confirmed only during autopsy. Diagnoses of Alzheimer’s relied largely on documenting mental decline. The medical report indicated symptoms consistent with that diagnosis, and given the patient’s advanced age, Lucy figured it would have been Becca’s first best guess as well.
“You don’t seem convinced,” Lucy said.
Becca buried her hands inside the pockets of her lab coat. “He’s not presenting in a typical fashion.”
“How so?”
“The tissue sample from the temporal artery biopsy showed severe inflammation, more than I expected, and some evidence of tissue death. Also, the patient complained of headaches and anxiety.”
“And you think it could be—what? His MRI was normal. No evidence of stroke, tumor, head injury, nothing structural like hydrocephalus.”
“Even without excess fluid in the brain, at minimum we should order an erythrocyte sedimentation rate, and I’d like to do a toxicology screen as well.”
“Which the insurance company is going to deny.”
“Which is why I want your help,” Becca said.
“Charm them with my infectious personality, is that it?”
Becca cleared her throat. “Well, something like that, I suppose.” Clearly, Becca felt she was on to something, but pathologists were not supposed to treat patients like internists.
Lucy appreciated this doctor’s doggedness, respected it. She also understood her frustration. The pathology lab, hidden in the bowels of White Memorial, was stocked with cutting-edge pathology equipment including cryostat machines, tissue processors, imaging systems, and a digital incubator. It was a large and well-lit space, complete with several workstations, each equipped with a powerful microscope. The lab could run almost any test or diagnostic requested by hospital doctors, but not without somebody to foot the bill. Like many hospitals its size, White Memorial operated on razor-thin margins, scrutinizing every penny.
Lucy considered her options. She knew one test would lead to another, and then another. Cliff Anderson’s doctor would come storming back here, pissed at having to do battle with the insurance company for tests he did not order.
“It’s Alzheimer’s, dammit. What don’t you get?”
The thought put a rare smile on Lucy’s face. Becca was right to question the dearth of testing, and the tissue death, while not indicative of temporal arteritis, was still unusual.
Why not do some more tests?
Lucy asked herself. After all, didn’t Mr. Anderson deserve the best that White Memorial had to offer?
“Let’s do whatever tests you think are necessary,” Lucy said. “We’ll sort it all out later.”
Becca’s broad smile was the big win of the day. Lucy loved her team, and it felt good to see them feel successful. Pathology was hardly a lonely profession, though many held that belief. A good path lab required smart docs like Becca to operate at a high level. What it did not require was direct involvement with patient care, and this suited Lucy just fine.
From down the hall, Lucy heard the familiar sound of gurney wheels on approach. It was a bellwether of sorts—the dead were coming. They showed up here even on Sundays.
Sure enough, Jordan Cobb, the six-foot-two hospital diener and longtime White Memorial employee, poked his head into the lab.
“Hey there, Docs,” Jordan said.
The diener always had a happy expression on his face despite the grim nature of his job. It was Jordan’s responsibility to collect the dead, move them to the morgue down the hall from the pathology lab, and clean each body prior to autopsy. It was a necessary job, but one many found unsettling. Not Jordan, though. He was unemotional about the work, the way Lucy would have been.
“Death is coming for us all,” Jordan once said to Lucy during his performance review. “I just hope whoever gets my body treats it with respect. That’s what’d I’d want, so I guess that’s what I do.”
He got a raise.
Jordan had the broad shoulders and thick neck of a football player, though he had never played any organized sport.
“Living in Dorchester is sport enough,” Jordan once said.
Lucy sometimes let Jordan watch her perform autopsies. He found it endlessly fascinating.
“Who’s our new houseguest?” Lucy asked.
Jordan lifted back the bedsheet and squinted his big brown eyes to read the toe tag. “Tommy Grasso. He’d been on life support, but they just pulled the plug. Funeral home will receive him tomorrow, so he’s going to storage, no autopsy needed, at least according to the paperwork here.”
Lucy glanced at the documents Jordan handed her and gave a nod. “Okay, wheel him and seal him,” she said.
“What’s happening in here?” Jordan asked. “It’s not my business, I know, but I usually don’t see you in the lab these days, Dr. Abruzzo.”
It was true. Lucy’s Sunday shifts had lately been less about the lab and more about that catch-up paperwork.
“Oh, Dr. Stinson and I are talking about doing some tests that aren’t officially sanctioned.”
“Hospital stuff, huh?” Jordan said with a shrug. He had an innocent, boyish-looking face, though quite handsome, and kept his dark hair cut short. The patch of hair on his chin helped him look closer to his true age, twenty-six.
“Yeah, Jordan, hospital stuff.”
Jordan wheeled Tommy away, and Lucy’s attention returned to Mr. Anderson’s case.
“I feel bad that you’re going to take some heat on this,” Becca said, “but I really think it’s the right thing to do.”
“I’m fine with it. Honest.”
At that moment, Jordan returned to the lab, no longer wheeling Tommy Grasso, but holding a slip of paper in his hand. “Hey, I found this in the hallway. I think it dropped out of one of your file folders, or something.”
Jordan handed the paper to Lucy. It was a test result for Cliff Anderson. Odd, because the only lab work Becca had done was that temporal artery biopsy. At first Lucy thought it might be a result from one of the tests Becca wanted to run. Maybe she’d already ordered them, and was doing the “ask forgiveness before permission” thing. But this was a heavy metal test, specific for cobalt, and the result was quite puzzling.
“Becca, who ran this test?” Lucy handed the sheet to Becca.
Becca stammered, “I—I don’t know.”
“Something wrong?” Jordan asked. He sounded genuinely concerned.
“No, nothing you did. It’s just this paper—this test result you found.”
“What is it?” Jordan asked.
“Well, according to these findings, Cliff Anderson has a cobalt level of twenty-four micrograms per liter of blood. It’s not enough to kill him, but it could certainly make him very ill,” Lucy said.
“Loss of motor coordination, memory troubles, tissue death, headaches, anxiety,” Becca added, sounding excited. “Sound familiar?”
“Has he had a hip replacement?” Lucy asked.
“I’d have to look up his full medical record. Give me a second.”
Becca left and Lucy reviewed the lab result again. The line that would normally indicate the doctor who requested the test was blank, as was the field for the technician who ran it.
“Guess it’s a good thing I found that paper,” Jordan said.
“Yes, it could be a very good thing,” Lucy said.
Becca returned soon after, with a surprised look on her face.
Lucy’s eyes went wide with anticipation. “And?” she asked.
“And seven years ago, it appears Mr. Anderson got a hip replacement from Aberdeen Hip Replacement Systems.”
“You know it?” Lucy asked.
“No,” Becca said. “But does the company matter?”
“Some hip replacements have been known to cause cobalt poisoning,” Lucy said.
“Is there a part number or something?” Jordan asked.
Becca showed him the tablet.
Jordan used his smartphone to run a search query for the part number displayed on Anderson’s medical record.
“It says here that the product was discontinued, but never recalled.”
“Why was it discontinued?” Lucy asked.
Jordan squinted to focus. “Says overuse. Metal-on-metal construction was supposed to help with failure rates, but instead caused an increase in met … metall … metallosis, if that’s the right word.”
Lucy’s expression was one of stunned disbelief. “Well, well, well. Cliff Anderson doesn’t have Alzheimer’s, he has cobalt poisoning.”
“Guess we’re not going to have to battle with the insurance companies after all,” Becca said.
“Glad I found that piece of paper,” Jordan said, with the proud smile of someone who had just done something important.
“Yeah, but the question remains,” Lucy said. “Who knew enough about Cliff Anderson to request we run this test?”
“And who the heck ran it?” Becca added.
The siren’s persistent wail rattled Julie’s nerves and made it impossible to concentrate. Ashley, more accustomed to the noise, appeared unfazed by the racket as she conducted a thorough secondary trauma survey on Sam.
Julie had ridden in the back of ambulances before, but only as part of her training. She did not remember them being so claustrophobic. She found the constant jostling unnerving.
To put an exclamation mark on that thought, the ambulance lurched forward. Julie, occupied with Sam’s heart rate and pulse oximeter readouts, tumbled to the floor.
“Are you all right?” Ashley asked.
Julie quickly got back to her feet. Her gaze went to the heart rate monitor, which showed a jump from 97 to 125 in less than a minute.
“What’s going on with that?” Ashley said, and began to reassess Sam anew.
Sam’s heart rate continued to tick upward: 125, 130, 145 …
Julie had a gut feeling it had everything to do with those distended jugular veins. Through one of the windows between the hard plastic struts that made up the cervical collar, Julie could see those veins were even more grotesquely engorged than before. Blood filled them from Sam’s sternum to his jawline. It was a clear sign of impaired blood return to the heart.
His breath sounds were still solid, though, and the pulse oximeter read 96 percent, which was in line with the ten liters of oxygen flowing into Sam’s face mask.
Julie recalled all of the anatomy she knew about the heart. It was an ingenious circulatory system that regulated blood flow from areas of high pressure, with less space for the blood to flow, to areas of low pressure, which included the body’s veins. In a healthy person those jugular veins should be flat, with no noticeable bulge.
The bulge on Sam’s neck was a clear indication that the whole system was in disarray. If pressure built up in the heart’s right atrium, the first chamber to receive blood returning from the body, blood could begin to back up into the veins leading to it. That included those jugular veins, which drained the head and arms.
Julie centered her thoughts.
“His heart rate is still climbing,” Ashley announced. “One fifty-five. His pulse is thready. I’m really worried he’s going to arrest.” Her calm exterior seemed to be fraying.
“It’s those veins,” Julie said, softly, almost to herself. “Something is causing the pressure to increase in his circulatory system. It’s not building from inside the heart, but from outside of it.”
The ambulance shimmied and shook. Its siren screamed. All of it combined to make it difficult for Julie to focus on a differential diagnosis. She fought the distractions, churning through the limited possibilities. Topping the list was a tension pneumothorax, common in chest trauma. A collapsed lung, pushing against the heart, could squeeze the vessels and the heart itself toward the opposite side of the chest. If enough air pressure built, blood could not enter the heart and it would back up into Sam’s veins. But those breath sounds simply did not support the theory.
What then?
“Dr. Devereux, heart rate is at one hundred sixty-five. BP down from one hundred to eighty-five.”
Blood pressure dropping, heart rate going up.
What’s the damn cause, here?
“He’s going to arrest any second!” Ashley’s voice betrayed her fear.
Julie looked down at Sam and saw that his lips, ears, and nose had begun to turn an alarming shade of blue. She tried to get a carotid pulse, but checking was near impossible with the collar around Sam’s neck.
“Can you get a pulse here?” Julie spat out the words.
Even Ashley, more experienced working around the c-collar, was hampered. It did not help matters that the ambulance swung violently from left to right as it zoomed around slower-moving traffic.
“Careful, Bill!” Ashley barked. “We’re in crisis here.”
Sam’s readouts continued to go wild. His heart rate was nearing 200 and his blood pressure was down to eighty over sixty.
“I can’t get a pulse,” Ashley yelled. “We’ve got to start CPR now! He’s in PEA.” Pulseless electrical activity. Sam’s heart was not pumping blood, but it still had a rhythm observable on the electrocardiogram. Julie knew she had only a minute or so before asystole ensued—what most people would call flatline.
Something held Julie back. A feeling, same as the one she’d had with the BC quarterback, Max Hartsock. Something simply was not right, and CPR was going to be a potentially tragic waste of time.
“Heart rate at two oh one and no pulse!” Ashley called out. “Forty milligrams vasopressin, ready to go.”