Harmful Intent (26 page)

Casually strolling back to the locker room, Trent hid the good ampule in his locker. Closing and locking the door, he thought about Gail Shaffer. Dealing with her hadn't been as much fun as he'd anticipated, but in a way, Trent was grateful for the experience. Gail's spotting him had impressed upon him the need to be vigilant at all times. He couldn't afford to be careless. Too much was at stake. If he screwed up, there would be hell to pay. Trent couldn't help but feel the authorities would be the least of his worries.

 

The clock radio was set for six forty-five and tuned to WBZ. The volume was low, so Karen woke in stages. Finally her eyes blinked open.

Karen rolled over and sat on the edge of the bed. She still felt drugged from the medication that Dr. Silvan had given her to help her sleep. The Dalmane had worked better than she'd anticipated.

“Are you up?” Marcia called through the closed door.

“I'm up,” Karen answered. She got to her feet unsteadily. Dizzy for a moment, she held on to her bed post to steady herself. Then she went into the bathroom.

Despite a cottony feeling in her mouth and a dryness in her throat, Karen was scrupulously careful not to drink anything. Dr. Silvan had warned her not to. She didn't even drink water when she brushed her teeth.

Karen wished the day were ending, not beginning. Then her procedure would be over and done with. She knew it was silly, but she still felt apprehensive. The Dalmane couldn't help that. She did her best to occupy her thoughts with the process of showering and dressing.

When it came time to head to the hospital, Marcia drove. For most of the drive, she did her best to keep up the conversation. But Karen was too distracted to respond. By the time they pulled into the hospital lot, they'd been driving in silence for some time.

“You're kinda scared, aren't you?” Marcia finally said.

“I can't help it,” Karen admitted. “I know it's silly.”

“It's not silly at all,” Marcia said. “But I guarantee you won't feel anything. The discomfort will come later. But even then, it will be easier than you think. This is the worst part of it: the dread.”

“I hope so,” Karen said. She didn't like the fact that the weather had changed. It was raining again. The skies looked as gloomy as she was feeling.

There was a special day-surgery entrance. Karen and Marcia were left waiting for a quarter of an hour along with several dozen others. It was easy to pick out the patients in the crowd. Instead of reading their magazines, they merely flipped through the pages.

Karen had been through three magazines by the time she was called to a desk and greeted by a nurse. The nurse went over all the paperwork and made sure all was in order. Karen had been in for blood work and an EKG the day before. The consent form had already been signed and witnessed. An ID bracelet had already been printed up. The nurse helped Karen snap it on.

Karen was given a hospital johnny and a robe and shown to a changing room. She felt a mild wave of panic as she climbed onto the gurney and was moved to a holding area. At that point Marcia was allowed to join her for a few moments.

Marcia was holding the bag that contained Karen's clothes. She made some attempts at humor, but Karen was too tense to respond. An orderly came by and, after checking the chart at the end of the gurney as well as Karen's ID, he said, “Time to go.”

“I'll be waiting,” Marcia called as Karen was rolled away. Karen waved, then let her head fall back on the pillow. She thought about telling the orderly to stop pushing so she could get off. She could make it back to the dressing room, get her clothes from Marcia and put them back on, and calmly leave the hospital. The endometriosis wasn't that bad. She'd lived with it this long.

But she didn't do anything. It was as if she'd already been caught by an inevitable sequence of events that would play themselves out no matter what she did. Somewhere during the process of deciding on the laparoscopy she'd lost her freedom of choice. She was a prisoner of the system. The elevator doors closed. She felt herself being whisked upward, and the last chance for escape was cut off.

The orderly left Karen in another holding area with a dozen or so gurneys like her own. She glanced at the other patients. Most were resting comfortably with their eyes closed. A few were looking around just as she was, but they didn't look frightened, as she felt.

“Karen Hodges?” a voice called.

Karen turned her head. A doctor in surgical garb was by her side. He'd appeared so quickly she hadn't seen where he'd come from.

“I'm Dr. Bill Doherty,” he said. He was about her father's age. He had a mustache and kind brown eyes. “I'm going to be your anesthesiologist.”

Karen nodded. Dr. Doherty went over her medical history again. It didn't take long; there wasn't much to go over. He asked the usual questions about allergies and past illnesses. He then explained that her doctor had requested epidural anesthesia.

“Are you familiar with epidural anesthesia?” Dr. Doherty asked.

Karen told him that her doctor had explained it to her. Dr. Doherty nodded but carefully explained it again, emphasizing its particular benefits in her case. “This kind of anesthesia will give lots of muscle relaxation, which will help Dr. Silvan with his examination,” he explained. “Besides, epidural is safer than general anesthesia.”

Karen nodded. Then she asked, “Are you sure it will work and that I really won't feel anything when they're probing around?”

Dr. Doherty gave her arm a reassuring squeeze. “I'm absolutely sure it will. And you know something? Everybody worries that anesthesia is not going to work for them the first time they have it. But it always does. So don't worry, okay?”

“Can I ask one other question?” Karen asked.

“As many as you like,” Dr. Doherty answered.

“Have you ever read the book
Coma?
”

Dr. Doherty laughed. “I did, and saw the movie.”

“Nothing like that ever goes on, does it?”

“No! Nothing like that ever goes on,” he assured her. “Any more questions?”

Karen shook her head.

“All right then,” Dr. Doherty said. “I'll have the nurses give you a little shot. It will calm you down. Then when we know your doctor is in the dressing room, I'll have you brought down
to the operating room. And, Karen, you really won't feel a thing. Trust me. I've done this a million times.”

“I trust you,” Karen said. She even managed a smile.

Dr. Doherty left the holding area and went through the swinging doors into the OR suite. He wrote an order for Karen's tranquilizer, then went into the anesthesia office to take out his day's narcotics. Then he headed down to Central Supply.

In Central Supply, he picked up some IV fluids and, juggling the bottles, reached into the open box of .5% Marcaine and lifted out an ampule. Always careful about such things, he checked the label. It was .5% Marcaine all right. What Dr. Doherty didn't notice was the slight irregularity of the top, the part that he'd break off when he was about to draw up the drug.

 

Annie Winthrop was more tired than usual as she made her way up the walkway to the entrance of her apartment building. She had her umbrella up to shield her against the downpour. The temperature had dropped to the low fifties; it felt more like winter coming back than summer on its way.

What a night it had been: three cardiac arrests in the intensive care unit. It was a record for the last four months. Handling the three as well as taking care of the other patients had sapped everybody's strength—and patience. All she wanted to do was take a nice, hot shower, then climb into bed.

Arriving at her apartment door, she fumbled with her keys, dropping them in the process. Exhaustion made her clumsy. Picking them up, she put the right one into the lock. When she went to turn the key, she realized the door was already unlocked.

Annie paused. She and Gail always kept their door locked, even when they were inside the apartment. It was a rule that she and Gail had specifically discussed.

With mild apprehension, Annie turned the knob and pushed the door open. The lights were on in the living room. Annie wondered if Gail was home.

Annie's intuition made her hesitate on the threshold. Something was warning her of danger. But there were no sounds. The apartment was deathly quiet.

Annie pushed the door open wider. Everything seemed to be in order. She stepped over the threshold and immediately smelled a terrible odor. As a nurse she thought she knew what it was.

“Gail?” she called. Normally Gail was asleep when she got home. Annie walked toward Gail's bedroom and looked in
through the open door. The light was on in there too. The smell got worse. She called Gail's name again, then stepped through the door. The door to the bathroom was open. Annie went to the bathroom and looked in. She screamed.

 

Trent's assignment for the day was to circulate in room four, where a series of breast biopsies were scheduled. He thought it would be an easy day unless some of the biopsies turned out to be positive, but that wasn't expected. He was pleased with the assignment because it gave him the freedom to keep an eye on his Marcaine vial, something he'd not been able to do the day before.

The first biopsy was just beginning to be performed when the nurse anesthetist asked Trent to run down and get her another liter of Ringer's Lactate. Trent was only too happy to oblige her.

There were a number of staff members in Central Supply when Trent walked in. He knew he'd have to be particularly circumspect when he checked for his vial. But they didn't pay attention to him. They were busy setting up surgical packs to replace the ones to be used that day. Trent walked back to the area where the IV fluids were kept. The non-narcotic drugs were to his left.

Trent took an IV bottle from the shelf. Through the doorless entranceway of this section of Central Supply, he could see the others as they counted instruments for each pack.

With one eye on his fellow nurses, Trent let his hand slip into the open Marcaine box. He felt a thrill. There was only one ampule left and its rounded top was smooth. His ampule was gone.

Barely able to contain his excitement, Trent left Central Supply and headed back to room four. He gave the nurse anesthetist the IV bottle. Then he asked the scrub nurse if she needed anything. She said that she didn't. The case was going smoothly. The biopsy had already been sent for frozen section and they were closing. Trent told the scrub nurse he'd be right back.

Emerging from room four, Trent hurried down to the big board. He was overjoyed at what he saw: the only epidural scheduled for seven-thirty was the laparoscopy, and Doherty was the anesthesiologist! The herniorrhaphy wasn't scheduled until later in the day. His vial had to have been taken for the laparoscopy.

Trent checked the laparoscopy's location. It had been assigned to room twelve. He hurried back up the corridor and into the anesthesia alcove for room twelve. Doherty was there and
so was the patient. Sitting on the top of a stainless-steel table was his ampule of Marcaine.

Trent couldn't believe his luck. Not only was the anesthesiologist Doherty, but the patient was a young, healthy girl. Things couldn't have worked out better.

Not wanting to be seen loitering in the area, Trent didn't linger. He returned to the OR he'd been assigned to, but he was so agitated he could not stay still. He paced so furiously, the biopsy surgeon had to ask him to sit or leave the room.

Normally such a command by a doctor would have enraged Trent. But not today. He was too excited thinking about what was about to happen and what he had to do. He knew he'd have to return to room twelve as soon as all hell broke loose and get the opened vial. That job was always a bit worrisome for Trent, although on the previous occasions the general pandemonium the reaction caused had always adequately diverted everyone's attention. Still it was the “weakest link” in the whole operation. Trent did not want anyone to see him touch the vial.

Trent looked up at the clock and watched the second hand sweep around its face. It was all going to happen in a matter of minutes. A shiver of pleasure swept down his spine. He loved the suspense!

With sirens blaring, the ambulance carrying Gail Shaffer turned into the emergency area of St. Joseph's Hospital and backed to the unloading dock. The EMTs had called ahead on the mobile phone to alert the emergency room as to what kind of case was coming in, requesting cardiac and neurological backup.

When the EMTs had initially reached Gail's apartment, after responding to the call placed by her roommate, Annie Winthrop, they had quickly deduced what had happened. Gail Shaffer had suffered a grand mal seizure while in the shower. They believed she'd had some warning the seizure was coming on since her roommate had insisted that the water had been turned off. Unfortunately, Gail hadn't been able to get out of the tub quickly enough, and she'd hit her head many times against the faucet and the tub. She had multiple scalp and facial wounds and a particularly deep gash high on her forehead at her hairline.

The first thing the EMTs had done was to get Gail out of the bathtub. As they did, they had noticed a total lack of muscle tone, as if she were completely paralyzed. They'd also detected a marked abnormality of her heart rate. Its rhythm was totally irregular. They'd tried to stabilize her by starting an IV and giving her 100% oxygen.

As soon as the ambulance doors were open, Gail was swiftly taken to one of the trauma units in the ER. Thanks to the EMTs' call, a neurology resident and a cardiology resident were on hand when she arrived.

The crew worked feverishly. Gail was clearly holding on to life by the thinnest of threads. The heart's electrical conduction system, responsible for coordinating its beating, was severely impaired.

The neurologist quickly corroborated the EMTs' initial
impression: Gail was suffering from an almost total flaccid paralysis, which included the cranial nerves. What was particularly strange about the paralysis was that a few muscle groups still elicited some reflexive behavior, but there seemed to be no governing pattern as to which still did. It was random.

The consensus soon became that Gail had suffered a grand mal seizure secondary to an intracranial bleed and/or brain tumor. This was the provisional diagnosis despite the fact that the cerebrospinal fluid was clear. One of the internal medicine residents dissented. She thought the whole episode was due to some kind of acute drug intoxication. She insisted that a blood sample be drawn for an analysis of recreational drugs, particularly some of the newer synthetic types.

One of the neurology residents also had reservations about the provisional diagnosis. It was his feeling that a central lesion couldn't explain the paralytic problem. He sided with the internal medicine resident in suspecting an acute intoxication of some sort. But he wouldn't speculate further until he reviewed the results of additional tests.

Everyone agreed about the head trauma. The physical evidence was all too clear. A portal X-ray made everybody wince. The wound at the hairline had fractured into one of the frontal sinuses. But it was felt that not even such severe trauma was enough to explain Gail's condition.

Despite Gail's precarious cardiac status, an emergency NMR was scheduled. The neurology resident had been able to cut through the bureaucratic red tape and smooth the way. With several residents in tow, Gail was taken to radiology and slid into the huge, doughnut-shaped machine. Everyone was a bit worried that the magnetic field might affect her unstable cardiac conduction system, but the urgency of settling on an intracranial diagnosis superseded all other concerns. Everyone involved in the case remained glued to the screen as the first images began to appear.

 

Bill Doherty held the 5 cc glass syringe up to the light in the anesthesia alcove and gently tapped the edge. The few bubbles adhering to the sides floated to the surface. The syringe contained 2 cc's of spinal-grade Marcaine with epinephrine.

Dr. Doherty was far along in administering the continuous epidural on Karen Hodges. Everything was going smoothly and according to plan. The initial puncture had not given her the slightest pain. The Touhey needle had performed beautifully. He
had demonstrated to his satisfaction that the Touhey needle was in the epidural space by the lack of resistance on the plunger of the small glass syringe when he pressed. A test dose he had administered had also confirmed it. And finally, the small catheter had slid into place with deceptive ease. All that remained was to confirm that the catheter was in the epidural space. Once he had, he could proceed with the therapeutic dose.

“How are you doing?” Dr. Doherty asked Karen. Karen was on her right side, turned away from him. He would turn her supine after administering the anesthesia.

“I guess I'm doing all right,” Karen said. “Are you finished? I still don't feel anything.”

“You're not supposed to feel anything yet,” Dr. Doherty said.

He injected the test dose, then blew up the blood pressure cuff. The pressure didn't change, nor did the pulse. While he waited, he made a small bandage to fit around the catheter. After several minutes he tried the blood pressure again. It hadn't changed. He tested the sensation in her lower legs. There was no anesthesia, meaning that the catheter was surely not in the space where spinal anesthesia was given. He was pleased. The catheter had to be in the epidural space. All was ready for the main injection.

“My legs feel totally normal,” Karen complained. She was still worried the anesthesia would not work on her.

“Your legs are not supposed to feel different at this point,” Dr. Doherty assured her. “Remember what I told you when we started.” He'd been careful to tell Karen what to expect. But he wasn't surprised that she'd forgotten. He was patient with her and knew she was apprehensive.

“How are we all doing?”

Dr. Doherty looked up. It was Dr. Silvan, dressed in scrubs.

“We'll be ready in ten minutes,” Dr. Doherty said. He turned back to his stainless-steel table, picked up the 30 cc ampule of Marcaine, and checked the label again. “I'm just about to inject the epidural,” he added.

“Good timing,” Dr. Silvan said. “I'll scrub up and we'll get started. The sooner we do, the sooner we'll be finished.” He patted Karen's arm, careful not to disturb the sterile drape Dr. Doherty had set up. “You relax, you hear?” he said to Karen.

Dr. Doherty broke the top off the ampule. He drew the Marcaine up with a syringe. From force of habit he tapped the edges of this larger syringe to remove any air bubbles, even though putting air into the epidural space would not cause a problem. The motion was more from force of habit.

Bending slightly, Dr. Doherty connected the syringe with the epidural catheter. He began a steady injection. The narrow gauge of the catheter provided some resistance, so he pushed firmly against the plunger. He had just emptied the syringe when Karen suddenly moved.

“Don't move yet!” Dr. Doherty scolded.

“I have a terrible cramp,” Karen cried.

“Where?” Dr. Doherty asked. “In your legs?”

“No, my stomach,” Karen said. She moaned and straightened out her legs.

Dr. Doherty reached for her hip to steady her. A nurse who'd been standing by for assistance reached over and grasped Karen's ankles.

Despite Dr. Doherty's attempts to restrain her with his free hand, Karen rolled over onto her back. She pushed herself up on one elbow and looked at Dr. Doherty. Her eyes were wide with terror.

“Help me,” she cried desperately.

Dr. Doherty was confused. He had no idea what was going wrong. His first thought was that Karen had simply panicked. He let go of the syringe. With both hands, he grabbed Karen by the shoulders and tried to force her back down onto the gurney. At her end, the nurse tightened her grip on Karen's ankles.

Dr. Doherty decided to give Karen a dose of IV diazepam, but before he could get it, Karen's face became distorted by undulating fasciculations of her facial muscles. At the same time, saliva bubbled out of her mouth and tears flowed from her eyes. Her skin was instantly wet with perspiration. Her breathing became stertorous and phlegmy.

Dr. Doherty went for the atropine. As he was administering it, Karen's back arched. Her body went rigid, then exploded in a series of convulsing fits. The nurse rushed to Karen's side to prevent the woman from throwing herself to the floor. Hearing the commotion, Dr. Silvan came in from the scrub sink to try to help.

Dr. Doherty got out some succinylcholine and injected it into the intravenous line. He then injected diazepam. He turned on the flow of oxygen and held the mask over Karen's face. The EKG began to register irregularities of conduction.

As word went out, help started to arrive. They wheeled Karen into the OR to have more room. The succinylcholine stopped
her seizure. Dr. Doherty intubated her. He checked her blood pressure and found that it was falling. Her pulse was irregular.

Dr. Doherty injected more atropine. He'd never seen such salivation and lacrimation. He attached a pulse oximeter. Then Karen's heart stopped.

A code was called and more hospital staff descended on room twelve to offer assistance. After the number attending swelled to more than twenty, there were too many to notice out in the alcove when a hand reached for the half-full vial of Marcaine, dumped the contents down a nearby drain, and spirited away the empty vial.

 

Kelly put down the phone in the intensive care unit. The call left her feeling acutely distressed. She'd just been informed they were getting an admission from the emergency room. But that wasn't what had upset her. What bothered her was that the patient was Gail Shaffer, one of the OR nurses. A friend.

Kelly had known Gail for some time. Gail had dated one of the residents in anesthesia at Valley Hospital who'd been a student of Chris's. Gail had even been over to the Eversons' home for the annual dinner Kelly threw for the anesthesia residents. When Kelly had made the switch to St. Joe's, Gail had been nice enough to introduce her to a number of people there.

Kelly tried not to let her personal feelings get in the way. It was vital she remain professional. She called out to one of the other nurses who would help with the admission, telling her to get bed three ready for a new occupant.

A team of people brought Gail into the intensive care unit and helped get her set up with a monitor and a respirator. Her own breathing efforts were not satisfactory to keep her blood gases in a normal range. As they were working, Kelly was brought up to date.

There still was no diagnosis, which made Gail that much tougher to treat. The NMR had been negative except for the fracture into the frontal sinus. This ruled out a tumor and/or an intracranial bleed. Gail had not regained consciousness, and her paralytic state had deepened rather than resolved. The gravest, most immediate threat to Gail's condition was her unstable cardiac status. Even that had worsened. In radiology she'd scared everyone with runs of ventricular tachycardia that made people fear she was about to arrest. It was almost a miracle she had not.

By the time Gail was fully set up in the ICU the results of
the cocaine test came back. It was negative. A broader screen for recreational drugs was pending, but Kelly was quite sure that Gail did not use drugs.

The team who'd brought Gail to the ICU was still there when Gail arrested. A countershock to her heart eliminated the fibrillation but resulted in asystole, meaning there was no electrical activity or beat whatsoever. A pacemaker threaded into her heart from a cutdown in her groin restored a heartbeat of sorts, but the prognosis was not good.

 

“I've faced a lot in this line of work,” Devlin said angrily. “Guns, knives, a lead pipe. But I wasn't expecting to get shot in the ass with some Amazonian arrow poison. From a guy who was handcuffed, no less.”

Michael Mosconi could only shake his head. Devlin was the most efficient bounty hunter he knew of. He'd brought in drug pushers, hit men, Mafioso dons, and petty thieves. How he could be having so much trouble with this piss-ant doctor was beyond Mosconi. Maybe Devlin was losing his touch.

“Let me get this straight,” Mosconi said. “You had him in your car, handcuffed?” It sounded crazy.

“I'm telling you, he injected me with some stuff that paralyzed me. One minute I was fine, the next I couldn't move a muscle. There wasn't anything I could do about it. The guy's got modern medicine working for him.”

“Makes me wonder about you,” Mosconi muttered with irritation. He ran a nervous hand through his thinning hair. “Maybe you should think about changing your line of work. What about becoming a truant officer?”

“Very funny,” Devlin said, but he clearly was not amused.

“How do you think you're going to be able to handle a real criminal if you can't bring in a skinny anesthesiologist?” Michael said. “I mean, this is a major screwup. Every time the phone rings I have palpitations that it's the court, saying they're forfeiting the bond. Do you understand the seriousness of all this? Now, I don't want any more excuses—I want you to get this guy.”

“I'll get him,” Devlin said. “I have someone tailing the wife. But more importantly, I put a bug on her telephone. He's got to call sometime.”

“You have to do more than that,” Michael said. “I'm scared the police might be losing interest in keeping him from getting
out of the city. Devlin, I can't afford to lose this guy. We can't let him slip away.”

“I don't think he'll be going anyplace.”

“Oh?” Michael questioned. “Is this some new intuitive power you've developed, or is it wishful thinking?”

Devlin studied Michael from his seat on Michael's uncomfortable couch. Michael's sarcasm was beginning to get on his nerves. But he didn't say anything. Instead he leaned forward to get at his back pocket. He pulled out a bunch of papers. Putting them on the desk, he unfolded them and smoothed them out.