The Inquisitor (13 page)

Two of the dead had been DNRs, not expected to survive much longer. The third had rallied last week and had been slated to go home for a few days. A code had been called for her. None of the clinical notes for any of them indicated a thing out of the ordinary in their deaths, except that all three had been discovered pulseless and not breathing just before dawn.

As for the two people in a coma, it took little more than a cursory glance at their recent lab results to see they'd been in bad shape to begin with, both having started the slide toward metabolic meltdown that often accompanies cancer patients in decline. Nobody found it unusual that they couldn't be roused as the nurses passed out breakfast trays that morning.

He returned the dossiers to Yablonsky's care without comment. She'd hovered about him as he'd glanced through them, appearing as uneasy about him going over the five cases as she had with his questioning her about Elizabeth Matthews's death. Let her sweat, he thought, figuring it might trip her up if she had something to hide. Because if his instincts and math were right, somebody sure did.

"The nurses who reported the near-death experiences- I'd like a list of their names," he told her.

She swallowed. "That might take a few days."

"I want it in twenty-four hours."

He rode to the ground floor at the back of the elevator, scowling. No physician liked coincidences, especially when it came to explaining matters of life and death. People died when and where they did for specific reasons. Failure to know those reasons meant he'd missed something until proven otherwise. Yet here he had five patients able to talk with Stewart Deloram on Friday who were unable to talk to anyone by Monday.

Unusual? Maybe not, he tried to tell himself, all at once following a talent he'd honed to a fine edge over the years: to play devil's advocate with his instincts. People died every day on a terminal ward. And those expected to pass on soon might have slipped into comas last night. Certainly the outcome for any of the five patients in question, taken individually, wouldn't raise suspicions. Natural causes could explain each one. Hell, if he tried to make a case otherwise, Wyatt could accuse him of dreaming up conspiracy theories to divert attention away from the Matthews inquiry. Still…

He went directly to his office and sat down at his computer. Using his newfound powers as VP, medical, he entered the codes that let him access the records of all departments. He pulled up Palliative Care, intending to see how many other people had died up there overnight and whether the three deaths were part of a larger than usual number. Not that that would mean much in itself. Some days were simply bloodier than others. Nevertheless, it would be interesting to know.

As a quick way to find out, he looked up discharges for Palliative Care this morning. There were six.

Was that a lot? He had no idea. He clicked up the average number for other mornings over the last few months and got 2.7.

"So there were three-point-four more bodies than usual," he muttered, impatient with how absurd statistics could seem at times. He also bet there were other days when the count would be just as high, and sure enough, when he requested a tally, he found that at least a dozen times in the last twelve weeks the morning dead had numbered six or more.

Yet three deaths and two patients slipping into a coma continued to disturb him because of the odds.

If he'd done the multiplication right, out of the hundred patients in palliative care, the chances that this would happen to the five Stewart talked to, all other things being equal, were one in nine trillion.

Which meant someone must have had a hand in their outcome.

But of course all things were never equal with a ward full of cancer patients. These five might have been closer to death than Wyatt thought, and maybe Stewart, in his perpetual readiness to take affront, had been wrong about their near-death accounts being bogus. They could have actually experienced what they reported because each of them really was about to die, and their deterioration was only nature taking its course.

In terms of probability that made far more sense than scenarios suggesting foul Play-He began to feel sheepish about his initial reaction. Perhaps he'd let his imagination get the better of him. Having arrived on the floor convinced that Stewart had been hiding something, and unclear what Wyatt might be up to, if anything, he'd failed to coolly consider all the possibilities. What a dumb-ass medical-student move. He didn't usually jump to conclusions like that. Of course, his already being suspicious of Yablonsky didn't help matters any, having primed him to think the worst.

But he damn well would insist that Stewart level with him about what exactly he'd thought was bogus when he talked with the five patients. And if even a hint turned up that Wyatt had tried to undermine Stewart's or any other researcher's credibility, he'd nail his hide. Whoa, there he went, leaping ahead of himself again. Better yank his urge to be in everybody's business back under control. Otherwise there'd be no end to the nastiness he might find. He'd taken the position of VP, medical to make his job of running ER easier, not to replace it with chasing down hospital shenanigans full-time.

He sat in the stillness of his office and felt the place weigh on him. Eight hundred beds, eight hundred souls, and if he weren't careful, every one of them would land a problem in his lap. And to think that just two days ago Jimmy had accused him of being too little involved with the rest of St. Paul's. Earl wondered if the real danger wasn't that he might get too entangled and be sucked dry. Because when he sensed something wrong, he couldn't let it slide.

But it was one thing to let the workings of an ER consume him. The tenacity that drove him not to quit on a patient took hold when trouble hit. His reflex as an ER physician was to leap on a problem the way he would a bleeder, well before it got out of hand. Yet he took the challenges in stride and inevitably, one way or another, found solutions. It all happened on a scale that never threatened to overpower him.

He leaned back in his chair and regarded the spartan furnishings- a steel-gray standard hospital-issue desk, two simple chrome chairs covered in black Naugahyde for visitors, a solitary potted plant that somehow survived the closed space and poor light from a grime-coated window the size of a cafeteria tray- and chuckled. The hospital CEO had offered him surroundings "much more suitable" to his new position, but he'd declined the upgrade, having always found it an advantage to demand sacrifice and best efforts from people if he himself worked out of an austere setting. The trick now would be to keep his perception of what needed fixing just as free of clutter.

He'd have to compartmentalize like never before, carefully choose his causes, and forget about charging off on wild hunches.

Keep everything at scale.

As for Yablonsky, well, he'd deal with her at death rounds.

Except something about her bothered him. She had definitely been edgy as he looked through those five files. Of course, just being around him could make her nervous, especially if his double-dose theory regarding Matthews was true. Yet..

Another event niggled at him- her reaction to the word cluster the evening before Matthews's death.

In a medical context doctors used it frequently, referring to a grouping of any unusual incidents or diseases, even symptoms and signs. So it had an unpleasant connotation to begin with, but not one that should have upset an experienced nurse. Unless…

He knew one context in which the term cluster carried a resonance that gave him a chill.

He dialed the nursing station and asked for Dr. Biggs. "Hello, Thomas. I wonder if you could go to our teaching files and dig out an article for me. It's one of the epidemiologic chestnuts on CPR in the New England Journal that I present to the residents every year, so you'll probably remember it." A lot of nurses would too, including Monica Yablonsky. The nursing director had asked him to give sessions about it with her staff on several occasions.

"Sure. What's the title?"

" 'Mysterious Clusters of Deaths in Hospitals.'"

Earl hung up and returned to checking discharge statistics for palliative care, going a lot farther back than three months.

Jane Simmons bought the kit at a pharmacy far from her apartment where no one knew her. She needn't have gone to the trouble. The salesgirl didn't so much as look up during the purchase.

In the privacy of her bathroom, she applied the drop of urine and waited.

In one minute she'd know.

Reruns of the last six weeks tumbled through her mind.

She'd missed before. Rather, it had come late a few times, by as much as two weeks. She'd assumed that this time she'd skipped a cycle altogether but that her period would arrive any day now. She'd been so careful to use the foam with her diaphragm and insist he wear a condom. It never occurred to her that they could have messed up. "The problem arrives when you forget," Dr. Graceton had reassured her in recommending the switch after the damn pill kept causing nausea, even after many tries on different types and dosages.

But there had been times in the middle of the night when she woke with him entering her again. God help her, she loved yielding to him in that half-asleep state. Even then she remained aware enough to feel he'd put on protection, and the diaphragm would still be in place from when they'd made love hours earlier, then fallen asleep in each other's arms.

The trouble was she hadn't added more foam.

Thirty seconds.

She looked out the open door at the rest of her apartment. It didn't seem so bright anymore. The paintings she'd chosen for color rather than any specific artist looked drab and cheap, every bit the pathetic imitations they were. Strange how baubles meant to comfort lost their luster when real trouble hit.

Ten seconds.

She felt so stupid sitting there on the tile floor, her future in the hands of a reagent to detect the chemistry of an embryo implanted in her womb. It would be six weeks old now, little more than a ball of cells, but the tissue already beginning to differentiate into what would become brain, heart, and skin. She hugged her knees and began to rock slightly, the way she had as a little girl whenever something worried her.

Such little problems then: homework, what boy would or wouldn't talk to her, exams. Even her worries an hour ago now seemed insignificant: paying bills, what groceries to get. All little stuff. Her only big concern had been what would happen to Dr. G. That still mattered.

Shit, what would he think of her now? And Dr. Graceton. She'd been so kind, taking her on as a new patient- doubtless because Dr. G. had spoken to her.

Or her mother. She'd been ecstatically proud to have a daughter who would be the first woman in the family to have a profession, as opposed to her own lifetime of waiting on tables at the local Denny's, double shifts galore after Dad died.

Now this.

And how would Arliss, her little brother, take it? They'd planned to escape Grand Forks together. First she'd get out through nursing, then he'd follow, and she'd help with the money for his college tuition. He'd been crazy about animals since they got their first puppy, and he dreamed of becoming a vet. If she stopped work, his future crashed as well.

And most of all, what would Thomas think?

Or would she tell anyone? She could just get rid of it privately, with no one she cared about the wiser.

She stared at the indicator dot.

It turned blue as a newborn's eyes.

Later that same evening, 5:45 p.m.

CEO's office, St. Paul's Hospital

Dr. Paul Hurst threw down the article Earl had shown him. "But they're supposed to die. It's a terminal ward."

"I still thought you should know."

"On the basis of… what did you say? A fall in average length of stay from twenty-seven days to twenty-four about three months ago, and a point-five increase in the number of deaths reported each morning? That's infinitesimal."

"Not exactly. It's a rise of fourteen deaths a month, all of them occurring at night. And three months before that there had been a similar change, an increase of about eleven deaths a month, again mainly at night. In the previous years, the rate appeared to hold steady, about three-point-three deaths a day, and only half of them on that shift."

Hurst rolled his eyes at the ceiling. "Will you listen to yourself? You sound like my stockbroker pitching nonexistent returns. Besides, it could be that patients are admitted at a later stage of the disease these days and therefore die sooner once they're here. Hell, it sounds like something you should applaud, a reduced length of stay and more efficient use of beds. You spearheaded that trend everywhere else in the hospital to keep ER from getting overcrowded. Why not in palliative care?"

Most doctors were comfortable with inevitable death, considering it as natural as life, but Earl had never heard one of his profession suggest it be celebrated as part of efficient bed use. The majority were aware enough of their own mortality not to be so callous. However, there were exceptions.

Paul Hurst, originally a general surgeon, had had his first heart attack in his mid-forties and had looked ashen ever since. That had been twenty years ago. At the time he stopped practicing medicine and assumed the post of VP, medical, having made the dubious calculation that hospital politics would be less stressful than the OR.

It hadn't worked out that way.

Earl had become his enemy a decade ago by exposing an accounting scandal Hurst had attempted to cover up. In the aftermath Hurst had tried to get Earl fired more than once, and failed.

But during the last few years, once Hurst had succeeded in getting what he'd been after all along, to be CEO of St. Paul's, a watchful state of quiet had existed between the two men. Not a truce exactly, but more an admission that Earl Garnet gave as good as he got- that had been the consensus of those who followed hospital power games the same way they did baseball.

Their pronouncement had given Earl no small amount of satisfaction.

"Sure, it could be later admissions," he conceded, picking up the New England Journal article and shoving it back at Hurst. "I just want to make sure we haven't got our own angel of death up there taking it on herself to ease their suffering."

The report had made national headlines in the mid-eighties. It appeared after a case in New York City where police charged a nurse with poisoning children on a pediatric ward with intravenous digoxin, yet a court of law found her innocent. A group of epidemiologists subsequently looked at several hospitals with clusters of unexplained cardiopulmonary arrests; their goal was to provide a tool that would prevent such wrongful accusations in the future or, in the case of actual foul play, more accurately pinpoint the culprit. For each of the institutions they examined, they plotted all such mysterious occurrences against the work schedule of the nurses who'd had access to the patients; in several instances they found a particular nurse who had been on duty when most of the deaths occurred. The results led to the successful prosecution of four serial killers, one of whom had been active in two states. Ever since, any unexplained rise in a hospital's mortality rate had administrators nervously eyeing their nursing rosters.

Hurst grabbed the article from him and tapped the opening paragraph with his gloved hand. Even enclosed in latex, his surgeon's fingers matched the rest of him- long and thin. "I suggest you take another look at the criteria for what you're insinuating." He peered over the top of stylishly small eyeglasses with wire frames and read, " 'Suspicions should be raised only when clusters of deaths and cardiopulmonary arrests occur that are either unexpected in timing or inconsistent with a patient's previous clinical course.'" He broke off and again threw the paper back on his massive mahogany desk. "You haven't shown any of that."

"I intend to check further."

"Oh, Jesus!" He reached up as if to rub his eyes, then, as if the sight of the gloves made him think otherwise, made a pyramid with his fingers in front of his mask.

Earl had watched this gesture at hundreds of meetings over the years, albeit without the protective gear. It usually preceded Hurst making a calculated move to undercut anyone who dared oppose him. He braced for what his longtime opponent would say next. As he waited, the incongruity of two men completely garbed in OR wear amid the luxurious setting of a wood-paneled room, inch-thick broadloom, and floral-covered antique chairs that any museum would die for made the moment surreal.

"You know, Earl," Hurst began, his voice uncharacteristically weary, "despite our former differences, I welcomed your appointment as VP, medical, even spoke on your behalf to the board."

A chill ran through Earl. When Hurst started to butter someone up, look out. "Yeah, right," he said with a sarcastic laugh, to serve notice he wouldn't be fooled.

"No, I'm serious. You care about this old place as much as I do. We just sometimes differ on what's best for it."

Really? That would be because you're a control freak who cares a little too much about St. Paul's and much too little about patients, Earl quipped to himself, keeping his mouth shut.

"And I couldn't think of a tougher team than you and me to get St. Paul's through this SARS mess. So what do you say we bury the hatchet and fight the real enemy together?" He stood, reached across the cluttered broad expanse of the desk, and held out his hand.

Earl hadn't expected the gesture. He looked at the waiting palm as if regarding a venomous snake.

"Come on, Earl. It's the right thing to do, and you know it. You're the most brilliant, hardheaded son of a bitch I ever went up against. There's no telling what we could accomplish by working together."

Earl made the shake, though tentatively.

"Now, about this business in Palliative Care. Let me ask you something: would you be so ready to investigate the place if you weren't the doctor involved in the Matthews case?"

Earl immediately went back on the defensive, feeling suckered. "Now wait a minute, this isn't about me trying to save my ass."

"Just give me an honest answer. That's all I ask. Would you press ahead, or wait and see what happens at death rounds?"

Earl hesitated, taken by the earnestness in Hurst's voice, yet not sure that the man wouldn't try to snooker him.

"Come on now. The evidence of clusters isn't that strong. And you know the effect that kind of inquiry would have on the nurses. Do you really want to distract them like that now, when the slightest lapse in the SARS protocol could be a death sentence?"

Earl hesitated, then reluctantly conceded that Hurst had a point. "No, I guess I'd wait."

"Good. Then I'll see you at death rounds. How's Janet doing, by the way? Planning to work until the last minute, same as last time?"

"She's fine," he replied, feeling as uneasy with the old man's new friendliness as he ever had with their previous snarling matches.

6:50 p.m.

The pathology lab occupied a cul-de-sac in the subbasement that had to be the oldest, most out-of-the-way part of the hospital. Though the facilities themselves had been renovated, the passageway leading to them hadn't. Residents called it "the tunnel." Even the lighting belonged to another era. Naked bulbs in green metal shades provided cones of yellow illumination at fifty-foot intervals while the spaces in between remained in relative darkness.

Janet Graceton hurried along the poorly lit corridor. The faint yet unmistakable aroma of decomposition emanated from the heavy wooden door to the morgue. She paid the scent little heed, being more aware, as always, of the plexus of pipes and cobwebs that ran the length of the ceiling not a foot above her head. She'd never seen the spiders that made their home up there, but more than once she'd wondered how they survived where no other insects flew or crawled. What did they eat? She refused to believe the lore handed down through generations of technicians- that scraps from the dissecting tables provided the necessary nutrition and that the resident arachnids had achieved the size of bread-and-butter plates. But inevitably, each time she walked through here on her way toward the pathology labs, scurrying noises from those darker recesses sounded all too close, and she picked up the pace.

Farther on, the autopsy suites stood empty with their doors open, the stainless-steel tables gleaming and ready for business. Here the pungent odors of chemical preservatives lingered in the air, easily breaching her mask. The sting that spread along the lining of her nose brought on a case of watery eyes.

Next were several large rooms lined with workbenches, their silver surfaces also spotlessly shiny. On them stood dozens of microscopes, stacks of flat, wide cases containing rows of glass slides, and innumerable racks loaded with bottles of reagents or stains in colors that rivaled those of Brendan's first-grade art class.

The people who used all these tools to make diseased tissues and cells yield up their secrets had long since left for the day.

She walked up to the door with Len Gardner's name on the opaque glass and knocked.

No answer.

She'd had a pass card to his premises for years, always needing to slip in after hours to pick up path reports. Using it now, Janet entered the anteroom where his secretary normally worked. She had also done what sensible folks did in the evening: gone home to her family. At least Janet presumed so, having delivered all three of the woman's children, two girls and a boy. Their pictures adorned an otherwise empty desk. The sight of them set off a pang for her own son, and for the ten millionth time she grappled with her anxiety over being an absent mother. From the beginning she'd refused to try to rationalize her guilt. The only explanation that mattered she owed to Brendan, and while words might comfort adults, the sole language that soothed his psyche involved the feel of her arms and the sound of her voice as she held him.

She crossed to the inner door and knocked again.

Still no answer.

She opened it a crack and peeked in. Not that she expected to find Len, but he'd promised to leave her a pathology report on one of her patients. The woman waited upstairs with her husband to know if her ovarian cancer had spread beyond what Janet had been able to remove.

Among the clutter of papers she saw an envelope with her name on it propped against a stack of files.

She ripped it open, scanned the contents, and knew that the woman would be dead in six months.

She walked back out to the deserted corridor and slumped against the wall.

Nothing loomed heavier than the task of saying, "I'm sorry, but the news is bad." She steeled herself, preparing to give the support required from her, yet dreaded the moment when, as soon as she walked in the room, the couple's last hopes would shatter against the look in her eye. She'd never learned to mask that dark gaze. It inevitably emerged when it came time to pass a death sentence.

Her unborn son stirred in her and delivered a sharp kick, a reminder of his presence, as if she'd needed any. By this time of day, her belly pulled so heavily on her that she felt it had doubled in weight and size. But such a cherished load to carry and a lifetime of working with thousands of other pregnant women didn't lessen the wonder of it any. She'd pretty well decided to take maternity leave much earlier this time. Why not? She could be with Brendan more, and when he came home from school they could make plans together for his new little brother. They'd also enjoy evenings and weekends uninterrupted like never before in his young life. Hell, why not give him that-

An odd popping noise and the tinkle of falling glass interrupted her thoughts. The sounds had come from the far end of the tunnel, near the elevators. As she looked along the islands of light, she realized that that section of the corridor had fallen into complete darkness.

Had a lightbulb blown down there?

She heard more glass break, but heavier, like that of a jar or bottle, and this smash had some force behind it.

What the hell?

She pushed off from where she'd been leaning. "Hello? Is somebody there?" She peered toward the distant murk but could see no one.

Yet a soft brushing shuffle no louder than a whisper echoed out of the darkness. Paper shoe covers on the floor? She couldn't be sure. "I said, is someone there?"

In the distance the door to a lit stairwell swung open and a silhouetted figure left the basement.

"Hey!"

The door closed behind, leaving her alone once more.

Somebody must have knocked something over in the dark, somebody who shouldn't have been down here in the first place, judging by their quick exit. No matter. She'd advise maintenance to clean up the broken glass before anyone got cut.

She started toward the elevators, hoping there'd be enough light to see her way once she got that far.

She'd walked well past the wooden door to the morgue, her mind focused on what she'd say to her patient, when she noticed a peculiar yet familiar odor that hadn't been there when she came in. Mildly irritating at first, it soon penetrated her nose and seared the back of her throat.

That's awful, she thought, and pressed her mask to her face, hoping to block out the fumes.

But the irritation continued, and her eyes began to burn.

She squinted into the darkness ahead, wondering if she could make the elevator. Probably. She couldn't see it directly, but the soft glow of the button looked to be about fifty feet away. Hold her breath and run for it, she decided.

After a few strides she immediately felt worse. What had that idiot spilled? She knew the storerooms down here contained no end of toxic liquids. The fluids that preserved organs and tissues in death were lethal to them in life, and any woman working down here who got pregnant went on immediate leave.