Until Judgment Day (16 page)

T
UESDAY
, J
ANUARY
7, 11:30
A.M.
C
LEVELAND
, O
HIO

“
H
OW LONG HAVE
I
kept you waiting?” Doctor Satish Singh dropped into a high-backed swivel chair and placed several sheets of fax paper carefully in the center of his desk, aligning the edges with his fingertips. His office walls were festooned with diplomas and awards, among which was a Doctor of Medicine from Princeton University that Kathryn Mackay had carefully scrutinized while she paced his empty office.

“Half an hour.” She sat on edge of a leather recliner.

“Sorry. I hoped to review your medical history earlier, but I was called out on an emergency.”

Singh wore a starched white lab coat that accentuated his smooth coffee-with-cream skin, jet-black hair, and droopy mustache. He was short and extremely thin with a small, triangular face, pointy too-big ears that stuck out like bat wings, and eyelids that drooped lazily over chocolate-colored eyes.

“No problem. Thanks for seeing me on such short notice.” Despite herself, she did a double take at his appearance.

“I see you agree,” he said with a smile.

“Agree?”

“That I look like a middle-aged Mahatma Gandhi. Everyone thinks so except me. As an amateur college thespian, I rather thought I resembled Ben Kingsley, whose real name was Krishna Bhanji. I should be so lucky.

“But now I want to talk about you.” His easy smile was warm and fatherly. “May I call you Kathryn?”

“Please.”

He leaned forward, twiglike hands folded one inside the other. “The medical file Doctor Burton faxed to me shows no weight, heart, diabetes, hypertension, or other disorder. But, as she advised, your RH-antibody screen is positive. If the fetus is RH-positive—which it almost certainly is—your antibodies can pass through the placenta, attack its red blood cells, and cause erythroblastosis fetalis. It's called hemolytic disease of the newborn, or HDN.”

“We didn't discuss how bad it is, or what should be done about it,” she told him.

“That's why she referred you to me. Ultrasound will tell us if fluid has accumulated in the baby's belly, head, chest, or heart, indicating severe anemia. I'll extract amniotic fluid that our laboratory will evaluate using delta-OD 450 for the presence of bilirubin, a by-product of red-blood-cell breakdown. The bilirubin is stated as a ‘titer ratio.' If that ratio were to reach one-to-sixteen, I would consider your baby to be at serious risk.

“Assuming yours is now below that, our lab will establish a baseline. Burton will draw blood each week, air ship it to Cleveland Clinic, and our techs will plot each measurement against your baseline on a Liley Graph. If I see a rapid, significant upward trend, other measures should be taken at once.”

“Such as?”

“Cordocentesis—percutaneous umbilical blood sampling, or PUBS. Blood is drawn from the umbilical cord to directly measure the baby's actual antibody levels, so we know how severe the anemia is and how well, or poorly, the baby's system is compensating for the destruction of its red blood cells. I would recommend you return to Cleveland Clinic if that's necessary.”

“Couldn't Doctor Burton do it?”

“I want to be diplomatic here.” He hesitated. “She referred you to me for a reason, Kathryn. PUBS is complex even for a highly skilled perinatologist who performs them regularly. But ultimately it'll be your decision.”

“What do you do if the anemia
is
severe?”

“Intrauterine fetal blood transfusions—to provide the baby with fresh, oxygen-carrying red blood cells.”

“More than one?” she asked.

“Maybe several. They should be done at a high-risk-pregnancy specialty hospital like Cleveland Clinic's tertiary care center, in case a cesarean section is necessary.”

“How likely is that to occur?”

“In a fraction of cases, the procedure triggers premature uterine contractions.”

“Doctor Burton is qualified to perform a cesarean section, right?”

“The transfusions require a great deal of skill, Kathryn. Under these circumstances, even if the cesarean goes flawlessly, the baby might require specialized care. Why not make a decision later, in consultation with Doctor Burton, when and if it's necessary.”

He stood. “My nurse will prep you. She's a Registered Diagnostic Medical Sonographer who's performed thousands of ultrasounds. Almost as many as I have amniocenteses—you're in very good hands.”

 

Kathryn lay on the table watching a color monitor mounted atop the Hitachi 6000 Digital Doppler Ultrasound. In addition to the monitor, the PC-based system recorded the images on a hard drive for later review and printout.

The sonographer slid the transducer over her gelled belly while Singh recorded a detailed anatomic survey and fetal measurements. When he finished, he selected an amniocentesis site, which he marked with a strawlike tube that left a small indentation in the skin.

“There's no fluid buildup,” he said. “The fetus is developing perfectly.”

She crossed herself. “Thank you.”

“Do you want to know your baby's sex?” Singh asked.

“Absolutely,” she said.

“You're carrying a boy.”

She closed her eyes and smiled.

“Do you want a local anesthetic to deaden the skin where the amnio needle will be inserted?”

“No, I'd rather be stuck once than twice.”

Singh swabbed the insertion site marked by the tube, and his nurse maneuvered the ultrasound probe until the monitor displayed the chosen path for the needle.

“You'll feel a slight pinch,” he told her, then inserted the needle. He watched its path on the monitor and guided it into a pocket of amniotic fluid.

“Are you all right, Kathryn?” he asked.

“I think so.”

He drew a little liquid, removed the syringe and squirted it down the sink drain, then attached a fresh syringe.

“The first half-cc is discarded because it might contain your skin cells from the needle,” he explained. “That would contaminate the fluid and perhaps cause the lab to analyze your chromosomes instead of the baby's.”

When the 30-cc syringe filled he pulled out the needle, drained the pale yellow fluid into sterile tubes, and asked her to verify her name on the labels. After she initialed them he applied a Band-Aid over the needle insertion site.

“That's it,” he said.

While Mackay dressed, Singh wrote notes in her medical file. He stopped and looked up when she entered.

“Please sit down,” he said. “How are you feeling?”

“I'm a little crampy.”

“Slight cramping like gas pain is normal. If you experience vaginal leakage, extremely severe cramps, fever, or bleeding, call my answering service immediately. Don't lift anything heavy for the next couple of days.”

“Trust me, I won't.”

“More than seventy-five chromosomal abnormalities can be diagnosed from fetal skin cells in the amniotic fluid, including Edward's or Down's syndrome trisomies. But the cells must be cultured and stimulated to grow, which takes a couple of weeks.”

“How will I find out?”

“I'll fax the results to Doctor Burton. The delta-OD 450 bilirubin analysis will be completed tonight. Where are you staying?”

“Right here at the InterContinental Hotel.”

“Go to your hotel, have a nice dinner, then get a good night's sleep. Call me after lunch tomorrow, and I'll tell you when you can go home.”

“
S
ORRY TO CALL YOU SO LATE,
”
Kathryn said into the phone, checking her watch. “I know it's almost midnight, but by the time I finished at Cleveland Clinic and checked into the hotel this evening, I was exhausted. I sat on the bed to take off my shoes and next thing I knew I was waking up a few minutes ago. I didn't even eat dinner.”

“When I didn't hear from you by five o'clock California time, I was worried something went wrong,” Dave Granz told his wife over the phone. “Are you and the baby okay?”

She lay on her bed still fully dressed, TV tuned to the Classic Movie Channel. In H.G. Wells'
The War of the Worlds,
terrified Londoners were fleeing the city, two days after the Martian cylinder landed.

“Ultrasound showed no fluid accumulation or other abnormalities they can detect visually.”

“I don't pray often, but I guess God heard me this time.”

“Let's hope He keeps listening. Doctor Singh drew amniotic fluid for testing. I'm supposed to call him after lunch tomorrow to learn the results. If everything checks out, my return flight leaves Cleveland-Hopkins at five.”

“Call me as soon as you know.”

“I will—promise.”

She punched the TV remote's Off button, sat up and yawned. “Are you interested in knowing whether we're going to have a son or daughter?”

“It's a boy—right?”

“Yes.”

“I kept my fingers crossed. Toes too.”

“That must've made you walk funny.” She laughed. “Is there anything going on there that I should know about?”

“I shouldn't worry you with it.”

“You just did. Tell me.”

“Another priest got snuffed last night. Father Jason Ryan. A jogger found the body early this morning.”

“Same shooter?”

“Hard to say, he got away clean.”

“Just like the others.”

“Right. Escalante and Miller think we ought to consider a copycat, but I'm not sure I agree.”

“I don't think we can afford to overlook the possibility,” she replied. “Has Doc Nelson determined time and cause of death?”

“Cause was obvious—the top of his head was blown away, brains were scattered all over the carport and the front of his car that was parked there. Nelson hasn't determined exact time of death yet, he's gonna do the autopsy tonight.”

“I'll call him tomorrow. Anything else?”

“One thing—maybe good news.”

“It's about time.”

“Bishop Davidson sent over a message. He's ready to testify. I guess jail wasn't such fun after all.”

“I'd better get him on the stand ASAP. Would you tell Escalante to round up the grand jurors, and convene them for eight o'clock Thursday morning, please.”

“Consider it done.”

“How are
you
feeling?” she asked.

The was a brief silence on the other end. “Fine, why?”

“Those headaches.”

“Forget it, they're nothing. It's you and our son I care about.”

“What's Emma doing?”

“Homework. Want me to call her?”

“No, let her study.” She stretched and yawned again. “I'm sooo tired—and I still have cramps from the amnio. As soon as we get off the phone, I'm going to wash my face, brush my teeth, and go back to sleep.”

“Good idea. You're sure you're all right?”

“No, I miss my family.”

“I love you, Kate.”

“Me, too. Talk to you tomorrow.”

 

Wednesday morning dawned cold and clear. After watching the morning news and taking a long, luxurious shower, Kathryn ate lunch at The Watermark restaurant on the Cuyahoga River's East Bank. Afterward, she strolled through the narrow, vertical-sided streets of Cleveland's Entertainment District, where she stopped at an imported-foods store to buy Dave and Emma a three-jar box of Swiss fudge ice-cream topping and French raspberry preserves for herself. At the bookstore next door she picked up a baby-care book. Down the street she found an exclusive maternity boutique and bought a beautiful but pricey Italian wool business suit.

At three-thirty
P
.
M
. she walked to a small park near the water. She chose a bench that was off by itself, under a naked sycamore tree on a knoll looking over the rippling, intensely blue Cuyahoga. She recalled reading that the river had once been so polluted that it caught fire.

She thought of her husband and the intricacies of life, crossed her fingers, drew in a deep breath, and dialed Doctor Singh's office to find out whether later this afternoon she would be catching a cab back to Building M at the Cleveland Clinic, or to Cleveland-Hopkins International Airport.

C
ONTINENTAL
A
IRLINES FLIGHT 755
angled steeply up off the Cleveland-Hopkins tarmac at exactly five
P
.
M
. The icy blue water of Lake Michigan was giving way to the Chicago, Illinois—Gary, Indiana megalopolis when Mackay pulled the in-flight phone out of its holder on the seat back in front of her and slid her credit card through the magnetic reader.

Doctor Morgan Nelson answered from his morgue office and asked if she was still in Cleveland.

“I'm on my way home. How did you know where I was?”

“Your husband observed Ryan's autopsy last night.”

“That's what I called about.”

“First I want to know what Singh told you.”

“You know Singh?”

“I know
of
him.”

“The fetus has no fluid accumulation or abnormalities, but my titer ratio's one-to-sixteen.”

“You really piss me off, Kate.”

“And you make me feel so glad I called.”

“With a titer ratio that high you had no business leaving Cleveland Clinic.”

“That's exactly what Singh said, and exactly how impolitely he said it. Based on your subtle diplomacy, I take it you agree that one-to-sixteen's critical?”

“Of course—not that it matters whether my unexpert opinion concurs with the country's preeminent perinatologist.”

“It matters to me. You're my friend, and I trust your opinion.”

“Yeah? Then take my advice, based on that opinion.”

“Which is?”

“When your plane lands at San Francisco, catch a return flight and get your butt back to Cleveland. Odds are high you'll lose your baby without continual oversight by the best doctor available.”

“Diedre Burton's good.”

“She's not a specialist.”

“She knows what she's doing though, right?”

“I judge a doctor's competence by how many screw-ups come under my knife. I've never autopsied one of hers, but a good doctor calls in greater expertise when she's over her head. She called in Singh. What does that tell you?”

“That she's cautious.”

“No, it tells you she's a good enough doctor to know she might not be able to handle it, ethical enough to admit it, and a good enough friend to refer you to the best.”

“I can't move to Cleveland for six months.”

“I specialize in dead people, Katie, not live pregnant patients. But if I did, and one of them didn't follow my advice to stay where I could give her the benefit of my expertise, I'd refuse to treat her.”

“That's exactly what Singh did,” she said with a sigh. “When I told him I had to return home he said he couldn't accept me as a patient, and faxed the ultrasound, amnio, and lab results to Burton.”

“Why did you ask my advice?”

“I guess I hoped you might say something to make me feel better.”

“A friend doesn't tell you what you want to hear just to be touchy-feely—if he does, he's not your friend.”

“Morgan—”

“A friend tells you the truth, and the truth is your baby's life is at risk. Like I said before, you piss me off sometimes.”

“But you still love me?”

“Once in a while.” He paused. “Goddamn stubbornness must be the quality that you and Dave found so appealing in each other. He won't follow my advice either.”

“What do you mean?”

“I told him to have an MRI after he smashed his head in that Thanksgiving accident. Last night he said he hasn't gotten around to it yet. What does
‘hasn't gotten around to it yet'
mean?”

“He says he feels fine.”

“My aching ass!”

“I take it you don't believe him?”

“Last night he had a skull-splitting headache. I asked how often he has 'em, but he shined me on. I had to remind him to pay attention to the autopsy. It was as if his body was parked at the curb while his mind was racing around the track. And he kept staring off into nowhere with a vacant look in his eyes, like a nineteen-sixties drugged-out, space-cadet hippie. He was drooling, too, and said ‘huh?' whenever I talked to him.”

“You're exaggerating. Besides, there's a lot going on right now, Doc—my pregnancy, these damn murder investigations. He was preoccupied.”

“You might be right. My concern's based on a couple hours' casual, nonclinical observation, under less than ideal conditions. But when I asked if he's been suffering memory lapses, he said, ‘Yeah, now you mention it. I can't figure out where my off-duty weapon is. It's a Beretta .25. I must've lost it.'”

“Seriously?”

“Yep. I asked when was the last time he saw it. He said he unholstered it the night of the shootout and accident, and hasn't seen it since. I asked if he reported it missing, and he says, ‘Yeah, but I bought a new one—cost enough to pay for an infant car seat, a year's supply of baby food, and a truckload of disposable diapers.”'

Nelson paused. Mackay waited to see if he was finished. He wasn't. “Have you noticed any unusual behavior on Dave's part?” he asked.

“Some.”

“He might be epileptic, Kate.”

“There's no epilepsy in his family.”

“Epilepsy's a sort of medical black hole, but we know it's more likely to result from severe head trauma or brain tumor than genetics. Since he's reluctant to take an MRI, you've got to insist.”

“What if the MRI determines he
is
epileptic?”

“Then we know. There's no cure, but seizures can be mitigated with antiseizure medicine. Most epileptics lead relatively normal lives as long as they're diligent about taking their meds. When they get forgetful, the seizures increase in frequency and intensity, and they could eventually kill him.”

“What should I look for to know if he's having a seizure?” she asked.

“Involuntary, repetitive muscle movement—twitching, jerking, lipsmacking, chewing, excessive saliva production. As the episodes increase in severity, he might lose consciousness.”

“For how long?”

“Usually a few seconds, two to three minutes at most. You'll think he's daydreaming, or not paying attention.”

“As you did last night.”

“Exactly. But in rare cases, episodes might last hours. During prolonged
status epilepticus
episodes he might function without knowing what he's doing, and he won't be able to recall afterward what he did. Like I say, rare but not unheard of.”

“You're frightening me very badly, Morgan.”

“Imagine how he feels—something's wrong but he doesn't know what it is, or how serious it might be.”

“He might realize he's sick?”

“He's a smart man. Even if he doesn't
know
, he probably
senses
it.”

“Then why would he refuse treatment?”

“Denial—pride—fear of losing his job if anyone finds out he's sick.”

“How would someone find out, even if it were true?”

“Don't be naive, there are ways. As a physician I must tell you that epilepsy might render him incapable of being sheriff. If I've come to that conclusion as his friend, imagine what a nasty political opponent could make out of it. Watch him closely, Katie, and get your husband and the father of your unborn child in for an MRI. That's my advice as a doctor
and
a friend.”

“I'll try,” she promised.

“You'd better do more than try.”

“Dammit, Doc, what more can I do? I've hassled him until he's on the verge of rebellion. You know Dave almost as well as I do. The harder I push, the more he resists. If I push much harder, he'll dig his heels in and
never
see a doctor, just to prove he doesn't need me or anyone else telling him what to do.”

“You're probably right,” Nelson conceded.

She hesitated. “Besides, your advice is based on just one bad night.” She hesitated. “I'm hoping nothing's wrong with Dave except lack of sleep and stress.”

“I'd like to believe that, but I don't,” Nelson answered.

She punched the button on the arm rest, leaned the seat back as far as possible, and squeezed her eyes shut. “Sorta makes Ryan's autopsy seem unimportant, but why don't you tell me what you turned up.”

“Time of death was about ten
P
.
M
. Cause was a single gunshot, but it was no routine head shot.”

“Explain.”

“The shooter stuck the barrel in Ryan's mouth. I found gunpowder stippling and muzzle-gas burns in the throat. Entry wound was in the soft palate. The slug penetrated the medulla oblongata on the brain stem, took a chunk out of the anterior cerebellum, transited the posterior cerebrum, exploded the skull before exiting the back of the skull, and lodged in the carport's concrete floor. Trajectory indicates Ryan was lying on his back.”

“They recover the slug?”

“No, and that's interesting. The concrete had a hole in it under the exit wound but there were gouge marks around it. The shooter dug the bullet out with a knife and took it with him.”

“Smart.”

“Yes, and cruel.” The line was silent for a few seconds before Nelson added, “When the cops catch whoever's murdering these men they'd better shoot first and ask questions second.”