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“Absolutely,” Lynn said. Michael nodded.

“Okay,” Dr. English said, looking down at her desk and moving the stack of papers she had signed to the side. “That is all.” Without even looking up again, she reached for her phone and started speaking with her secretary about putting a call through to Dr. Feinberg.

Mildly surprised by the suddenness of the meeting’s end, but without needing any further encouragement, the two students quickly left. It wasn’t until they got back into the hustle and bustle of the hospital that they slowed enough to speak to each other. First they fist bumped. They had to talk loudly to be heard.

“That was a piece of cake,” Lynn said.

“Right on!” Michael said. “But it could have gone either way. It was a good thing we thought about what to say if she asked how we knew about Carl. That tipped the balance. It was like putting in a three-pointer at the buzzer from downtown to win the b-ball game. You did good, girl!”

“It’s weird she never mentioned Carl’s name.” The slight euphoria she’d felt from surviving the meeting with the dean was already beginning to evaporate.

“I noticed that, too. But what I found weirder is that we went in there expecting to get busted, and we come out with increased access to the hospital data bank. We might take advantage of that. Hospital-acquired infection is serious shit.”

“It might be,” Lynn said. She sighed. “But right now I’m not interested. Now I want to talk about Carl being sent to the Shapiro.” There was a sudden catch in her voice.

“Hold off, woman. Wait until we get back to the dorm. If there’s a chance you might bust out bawling, I don’t want people gaping at us. You know what I’m saying?”

Lynn got the message loud and clear and appreciated how he
worded it. The fact that someone with his intelligence and academic record could so easily flip back and forth from Oxford English to the language of the ’hood amazed her. It always did, and he knew it, which is why he did it, and only with her. For her it emphasized their closeness. With everyone else, including patients, he always spoke with the diction of a college English professor.

And she knew he was right about her possibly losing control. For the moment she had her act together, but she knew that might change when she started talking about what was in Carl’s limited and dismal future.

They cut through the nearly deserted clinic as they normally did. Only a few stragglers were still waiting to be seen. Outside it was a beautiful Charleston early evening. The sun was still reasonably strong, with another two hours of early-spring daylight left. After they had walked for several hundred feet through the landscaped inner courtyard with flowers busting out of their beds, Lynn slowed. Like she had the day before, she couldn’t help gazing at the hulking granite silhouette of the Shapiro Institute. The mere sight of it brought on the rush of emotion that she had been holding back.

“I cannot believe that Carl might be shut away in there,” Lynn said, losing the battle of fighting off tears. “He might even be going this evening.”

Hearing her voice tremble, Michael guided her off the main walkway and over to an empty park bench, half-hidden by shrubbery from the considerable pedestrian traffic. They sat down. They were far enough out of the way that the other students trekking back to the dorm didn’t see them, or if they happened to look in their direction, didn’t pay them any heed, which was good, because Lynn quickly lost it and suffered through an extended bout of tears. Michael didn’t say anything, thinking it best for her to let it out.

When Lynn finally had herself under control and could talk, he asked how she had found out that Carl might be going to the Shapiro.

“From Dr. Erikson,” Lynn managed. There were still catches in her voice, but she was succeeding in calming herself down.

“She called you?”

“No. I ran into her,” Lynn said. She found a tissue in one of her jacket pockets and carefully dried her eyes. “I went back to the neuro ICU before we met with the dean because I was worried that afterward I might not be allowed. I thought it might be the last time I got to see him for a long time. I also wanted to see what the serum electrophoresis test showed.”

“Was it abnormal?”

“It was, which is why Erikson was there doing a formal consult.”

“How abnormal?”

“Only mildly so far. Just a small spike in the gamma globulin curve, but my sense is that Dr. Erikson expects it to get worse. She was quite friendly to me this time, but I have to say, I find her strange and unpredictable.”

“How did she happen to tell you Carl might be transferred?”

“It just came out in the conversation. She is one weird lady. I can’t read her at all. One minute she seems friendly, the next pissed. Maybe she doesn’t feel well because, frankly, she doesn’t look well. Anyway, remember I told you she asked me to let her know if we came to any conclusions about how Carl or Morrison became comatose. Well, today she added to the list. She wants me to tell her if I hear anyone in Anesthesia talking about gammopathy. Now, I find that strange. I mean, why is she asking me, a medical student? As an attending she could ask anybody she wanted to in the Anesthesia Department, including Rhodes.”

“It sure as hell means she bought into our ruse about anesthesia,” Michael said. “But she has to know that no one in Anesthesia is going to be talking about gammopathy. There is no way anesthesia and serum protein abnormalities can be related.”

“I’m not so sure,” Lynn said as finished drying her eyes. “There is something about all this that smells bad.”

“Oh, come on, girl! There’s nothing about anesthesia that is antigenic. It has been used in millions upon millions of cases without pumping up anybody’s immune system. There is no association.”

“Let’s put it this way,” Lynn said. “I’m just not sure. We have three cases in which it seems to have played some role.”

“Only one that we know for sure: Morrison.”

“Carl could be developing a gammopathy and Ashanti must have had one, too, if she has multiple myeloma. This can’t be by chance. Something is not right in all this. And I’ll tell you something else: If and when Carl goes into that place, come hell or high water, I’m going to go in there and visit him.”

“They are not going to let you visit,” Michael said. “They were very clear about that. Only immediate family is allowed, and you, my friend, are not immediate family.”

“I wouldn’t be satisfied with that kind of visit even if they let me,” Lynn said with a wave of dismissal. “I want to go into the place and actually see how Carl is being treated, not look at him through a plate-glass window.”

“Come on, girl! You can’t be serious. They are not going to let you do that.”

“I’m talking about breaking in. You told me you went through that door over there, which led into the network operation center.” Lynn pointed to the single entrance. “I’ll do the same and start from there.”

“You’re not serious, are you? Tell me you are not!”

“If Carl gets transferred, I’m going in there. I’ve made up my mind. I think I could do it. My sense, from what you told me of your visit yesterday, is that their security is pretty lax. I mean, you said so yourself. They probably haven’t had a security episode for the whole eight years they have been in operation. I mean, who would want to sneak into a holding facility for brain-dead people, for God’s sake?”

“It might be true that they have become lax but . . .”

“It stands to reason.”

“The trouble is, it’s a big huge risk. To be honest, I don’t think we should do this,” Michael said, becoming serious.

“What do you me ‘we,’ white man?” Lynn said with cynical laugh, referring to the Ron Metzner joke involving the Lone Ranger that Michael had reminded her of yesterday. “I’m going to do it myself. When we got those texts today from the dean, I realized that you shouldn’t take a fall, if that is what happens. This is my battle because Carl was my squeeze. If there is a consequence, it should be mine.”

“As your twin, it’s my job to keep you out of trouble. Let me decide how much risk I want to take. But you know something? The more I think about it, the more I might be exaggerating the fallout of going in there. Maybe the worst-case scenario might only be a slap on the wrist for trespassing. I mean, it is part of this institution, and we are legit medical students. Hell, the way we have been violating HIPAA is worse than our going into an area of the hospital that’s supposed to be off limits.”

“If Carl gets sent in there, I’m going in. I’ve made up my mind.”

“All right, you made up your mind. But tell me how you think you are going to pull it off.”

“I will need your help,” Lynn admitted. “Because the key is going to be your newfound friend, Vladimir whatever his name is.”

“Vladimir Malaklov, my Russian programmer buddy! What can he do?”

“Get me one of the scrub suits like we’ve seen on the people that work there. I don’t want to stand out if I bump into anyone, which is probably a given. Since he works in there, like you said, he probably has one, just chooses not to wear it. There must be a source for them, like there is for regular scrubs in the main hospital.”

“How the fuck am I going to explain why I need a Shapiro suit?” Michael shook his head in disbelief.

“Be creative! Say you want it for a costume party. I don’t care. But tell him you need it in my size.”

“Shit, girl!” Michael complained. “Is that all?”

“No,” Lynn said. “I want you to give me Vladimir’s user name and password.”

Michael groaned out loud and then laughed sarcastically. “If I do that I think my friendship with my Russian buddy is going to be short-lived. Why do you need it?”

“Remember when we made our visit to the Shapiro, and they bragged that they had had only twenty-two deaths over six years? I’d like to find out what the causes of those deaths were. And how many people have died since our tour. And while I’m at it, I’d like to find out how many people woke up from their vegetative state and were discharged. In one of the articles I read last night, it says as many as ten percent of patients in a vegetative state from head trauma eventually achieve enough return to consciousness to go home. A few even completely recover. I wonder what that figure is for the Shapiro. They didn’t tell us that.”

“Please don’t tell me you are planning on trying to hack the Shapiro system from your laptop with Vladimir’s log-in! If you do that, they’d be onto you in a matter of hours, and you’ll be doing hard time in Bennettsville.”

“Don’t worry. I’m not that stupid. I’ll use a hospital terminal, preferably one in the IT Department. If Vladimir really has admin status, which he has to have to do what he’s doing, there wouldn’t be a red flag. And I also want to find out more about Ashanti Davis and how close her case matches Morrison’s and Carl’s.”

“Maybe we can find all this out using the access Dr. English said she would provide us.”

“Oh, please!” Lynn said mockingly. “She’s not going to give us access to Shapiro data. In fact, she probably will only be allowing us to look at data about infections and only in the main hospital. If I’m going to find out the kind of things I want to learn, I’ll need Vladimir’s log-in. I need carte blanche access.”

“You’re on a roll, girl. And I understand. You need to keep
yourself busy, so I’m not going to say much. But tell me this: even if you’re sporting one of those Shapiro suits, how are you thinking of getting in?”

“You are going to help with that, too,” Lynn said.

Michael rolled his eyes. “Why did I bother asking?”

“You told me that the security of the door you went in has only a low-level, decade-old thumbprint touchscreen. That shouldn’t be much of a hurdle. You are going to get me Vladimir’s thumbprint. Do it when you invite him over to share your Jay-Z collection. I researched how to foil a generic fingerprint scanner with a bit of latex and wood glue. It’s amazing what you can get off the Internet. I already got the stuff I need.”

“My goodness!” Michael marveled with a shake of his head. He sat back against the bench, and, following Lynn’s line of sight, stared over at the Shapiro. “Okay! For the sake of argument, say this works. What’s the plan once you’re inside, just to wander around blindly and get fucking lost? The place is huge!”

“I’m working on that angle,” Lynn said.

“Lay it on me, girl!”

“Later,” Lynn said. “Right now I want to show you some other stuff that I discovered today when I was comparing the anesthesia records for all three cases. There are several disturbing points of similarity, and they are motivating me to up my efforts.”

“Like what?”

“I prefer to show you. The printouts are in my room. Come on!” Lynn grabbed Michael’s arm and pulled him to his feet.

Tuesday, April 7, 5:37
P.M.

D
espite suffering an emotionally exhausting bout of tears on top of her basic fatigue from having had only four hours of sleep over the last thirty-four, Lynn was now, according to Michael, “juiced.” Although she knew enough about psychology to guess that it represented another form of denial, she didn’t care. It gave her the feeling she was actively doing something rather than just passively being emotionally tortured.

Prior to her discussion with Michael about breaking into the Shapiro, the plan had been somewhat vague in her mind. Now she had a good idea of what she needed to do and what she needed Michael to do, and she was eager to get started. But before she did, she wanted to show Michael what had ignited her mounting unease about the whole situation. She thought it might motivate him to help her get what she needed from Vladimir. It had certainly motivated her.

Lynn keyed her door and pushed it open. Michael followed her inside but paused on the threshold. “Maybe I should get a hazmat suit,” he said, surveying the disarray. He was accustomed to her
casual attitude toward domestic order, but this seemed beyond the pale. Computer printouts scattered on the floor, along with a number of textbooks, made it impossible to walk without stepping on them. More printouts cluttered most horizontal surfaces along with a mixture of soiled clothes and clean clothes with no readily apparent distinction. The bed was free of debris, although unmade.

“Very funny,” Lynn said. She pulled him into the room and kicked the door closed. “I know the place is a god-awful mess, but ignore it for the moment!” She guided him over to the desk chair, which was clear, like the bed, and made him sit. Pushing aside papers to create an open space on the desk in front of him, she put down all three anesthesia record printouts in a row so that they were visible at the same time.

“Okay,” Michael said. “What am I supposed to be looking at?”

“Remember this blip that Wykoff pointed out on Carl’s record?” Lynn asked, pointing it out.

“I call it a frame offset,” Michael said. “What about it?”

Using her index finger, Lynn pointed to the same upward jump in the vital signs on the other two printouts. “All three cases have the same distortion or whatever it is, and all at exactly the same time: fifty-two minutes into the case.”

“Yo!” Michael exclaimed, looking from one printout to the other. “Now, that’s a righteous pickup.” He glanced up at Lynn. “That’s big-time weird. What’s your take?”

“I haven’t the slightest idea,” Lynn admitted. “But it has to be significant. I wish I could ask Dr. Wykoff what she thinks.”

“That’s not going to happen.”

“Agreed,” Lynn said. “We can’t go to anybody in Anesthesia, at least not for the moment. We’re on our own to figure out what it might mean. But that’s not all. There’s one more surprise.”

“What? Was the timing of the low-oxygenation alarm the same, too?”

“No. It was close but slightly different in each case.”

For a moment Lynn didn’t move, just stared at Michael.

“Well?” Michael said impatiently. “You going to lay it on me or what?”

“You don’t see it?”

“You got the ball, twin. Either dribble, pass, or shoot!”

Again, with her index finger, Lynn pointed to a very small box in the right-hand corner of each record. It was labeled MACHINE, and in each case it had the same number: 37.

Michael again raised his eyes to Lynn’s. For a moment they regarded each other. It was Michael who broke the silence: “All three cases involved the same freaking anesthesia machine!” he exclaimed. “That’s also got to mean something.”

“The same anesthesia machine having the same blip at the exact same time in all three cases. Statistically that happening by chance is nil. With two cases, maybe, but with three, no way.”

Michael looked back down at the anesthesia records. “I agree. But what do we do about it? Should we tell someone, and if we should, who?”

“It’s got to be significant, which means something weird is going on, but I can’t come up with a single, even potentially plausible explanation. And there is nobody we can go to with this without incriminating ourselves big time. The only thing I can think of doing is getting more info out of Shapiro.”

“This timing thing is what amazes me,” Michael said, looking back at the records.

“It more than amazes me,” Lynn said with sudden ferocity. “My intuition is ringing alarm bells, especially when I combine this timing issue with what I have learned from all these other printouts.” Lynn wildly gestured toward all the articles littering the floor. “And then with Carl going there . . .”

“Whoa, girl!” Michael cautioned. “Get a grip! You have to slow down. Remember, Carl’s not been sent to the Shapiro yet.”

“Morrison has, and Carl’s case is just like hers.”

“True, but you’re jumping the gun, my friend. Listen, I don’t mean to sound patronizing, but you are under a lot of stress! I think you need some food and a good night’s sleep and then you can reboot. Let’s go back over to the hospital and get dinner.”

“Of course I’m stressed,” Lynn snapped. “And I know I’m exhausted. But I’m not sure I could sleep even if I tried. I mean, why are they rushing to transfer Carl and Morrison? It’s way too quick in my estimation. Maybe the same thing happened with Ashanti. But why? What’s the rush? It can’t just be economics. Maybe it’s for better care, but I just don’t know.” Lynn again gestured toward all the printouts scattered about her room. “These articles point out there are always a few patients who defy the odds and wake up. Carl’s problem is less than thirty-six hours old. Why transfer him so soon? What if he wakes up in the Shapiro? With all the automation that is involved over there, would someone even notice? Whether my getting in the Shapiro can answer such questions, I don’t know, but somehow I think there’s a chance. I have to do it!”

Michael nodded. The last thing he wanted to do was make Lynn more upset than she already was. Instead of arguing with her, he glanced down at the floor and picked up the nearest article. It was the article that he and Lynn had read in the neuro ICU after seeing the Morrison chart, the one titled “Monoclonal Gammopathy of Undetermined Significance.”

“So let me guess,” Michael said finally, as he quickly flipped through the printout for a second quick read. “You’re thinking that this paraprotein stuff has some significance.”

“I do!” Lynn said. “I have no idea how or why or anything. But it seems that a paraprotein was or is involved with all three patients. Well, we don’t know for sure if a paraprotein was involved with Ashanti, but the fact that she has multiple myeloma is at least suggestive. It’s the worst-case scenario for a paraprotein gammopathy.”

“Seems to me you are heading out into the stratosphere on all this, if you don’t mind my saying so,” Michael said. He shook his
head as he reached down for another article. This one was titled “Monoclonal Antibodies.” He began to speed-read it.

“You might be right,” Lynn said. “But remember what you said was on the home page of Ashanti’s Shapiro EMR: drozitumab. Remember?”

“Of course I remember,” Michael said.

“Do you remember what drozitumab is?”

“Of course,” Michael repeated. He glanced irritably at Lynn. He was losing patience. She needed food, and she needed sleep. And he needed food, too. “What is this, a test?”

“Drozitumab is a monoclonal antibody, like you said this morning,” Lynn added, ignoring Michael’s mild peevishness. “It is used to treat a kind of muscle cancer, not multiple myeloma.”

“I said I remember,” Michael repeated.

“If Ashanti is given drozitumab and had a serum plasma protein test, it would show up as a paraprotein.”

“I suppose you are right. What’s your point?”

“I don’t know. I’m thinking out loud and asking you to do the same.”

Michael shook his head. “It’s a mystery. There are too many loose pieces.” He went back to reading the article on monoclonal antibodies.

“Why was drozitumab put on the front of Ashanti’s record?” Lynn asked.

“Like I said this morning, I have no idea. Do you?” Michael didn’t look up from his reading.

“No, I don’t,” Lynn admitted. “But if I had to guess, I’d say that maybe they are trying it as a treatment for multiple myeloma.”

Michael raised his eyes and looked at Lynn. “You mean like just trying it to see if it might work without any specific scientific rationale, sorta shotgun style? That’s questionable, my friend.”

“I know that doesn’t make any sense,” Lynn agreed. “Okay, scrap that idea! Maybe it is simpler. From reading these articles about
monoclonal antibodies forming the basis of biologic drugs, I know they have been having some problems. Maybe they are giving Ashanti various forms of drozitumab to see which ones cause less of a reaction.”

“That sounds a lot more probable than the shotgun treatment idea. Of course it means they would be using her as a guinea pig. Do you really think that might be happening?”

“I’m suddenly thinking it is a possibility,” Lynn said.

“But it doesn’t explain the paraprotein problem.”

“I know. But maybe they want their immune systems stimulated for some reason. And Carl’s and Morrison’s immune systems are acting up, producing the paraprotein and their fevers. Their immune systems are acting as if they are being stimulated.”

“That’s all very hypertheoretical.”

“I know, but I’m convinced that something weird is going on. Maybe Sidereal Pharmaceuticals built Shapiro to use the patients for illicit clinical drug testing. It’s certainly a captive audience who wouldn’t complain. I mean, you have to admit, it makes diabolical sense. And if that’s what’s happening, it’s another reason I sure as hell don’t want Carl transferred there. Certainly not to be experimented on. No way!”

“God! That’s a creepy idea,” Michael said. The thought and implications raised a few hairs on his neck. “Do you really think that might be going on?”

Lynn shrugged. “I don’t know, but it’s an idea,” she said. “It would save time and money in drug development. Drozitumab is definitely a biologic, meaning made from living cells, and biologics are the newest and biggest thing in the pharmaceutical industry. And there is a race to perfect them and test them. And, in point of fact, biologics are Sidereal’s main product line!”

“No shit?” Michael said.

“Here, read this!” Lynn said as she picked an article off the bureau and handed it to Michael. It was titled “Biopharmaceutical.”

Michael took the article and began to speed-read it.

While Michael read, Lynn asked: “Do you remember exactly how monoclonal antibodies or biologics that drug companies sell are made?”

“Yeah! They’re made from mouse hybridomas. I just read it in the previous article. Also we had a lecture about it in second year. Why do you ask?”

“Because it’s the biggest reason that a lot of testing is needed,” Lynn said. “Since biologics are made from mouse cells, the drug companies have to humanize them to make them less allergenic for humans. That requires a lot of testing, particularly testing in humans. People in a vegetative state would be perfect subjects, especially if their immune systems were hyped up.”

“Wow!” Michael said, finishing the latest article. “I had no idea biologics are already a fifty-billion-dollar-a-year industry and climbing. I really had no idea.”

“It’s going to become really huge,” Lynn said. “It will top a hundred billion before long.”

“You really think so?”

“I do, and for two reasons. First, because biologics have a lot of promise to provide cures, as these articles say. Second, because drug companies here in the United States get to charge whatever the hell they please. It’s not like in the rest of the industrialized world, or should I say ‘civilized’ world.”

Michael nodded. “Which they are already doing with traditional drugs.” He picked up another article specifically about hybridomas.

“Exactly! And unfortunately it is not going to change with biologics, not with the money they throw around with their lobbyists.”

“You’re right about that,” Michael agreed. “By controlling Congress, drug companies in general are enjoying legalized robbery of the American public.”

“If Sidereal gets a jump in the biologics field by solving the allergy problem, they could dominate it and make an absolute fortune.”

Michael finished the fourth article and tossed it aside. “Okay, I suppose now I have an idea where you’re going with all this. Maybe a quick, undercover visit to the Shapiro might be just what the doctor ordered to see if they are using the patients as guinea pigs for biologics, not that I’m advocating it, mind you. I still think it is a crazy, risky idea. In the meantime, we got a more pressing problem. What to do about anesthesia machine thirty-seven? The Anesthesia Department should know about it if they don’t already. Actually, the more I think about it, the more I’m sure they already know. It’s too obvious to miss.”

“I agree,” Lynn said. “They have to know. Nor can there be anything wrong with the machine.” Lynn pointed back at the anesthesia records on her desk. “Look how the patients’ vital signs stayed completely normal in all three cases after the frame offset right up until the oxygen level fell! Same with all the other variables the machine was monitoring. Obviously the patients’ depth of anesthesia didn’t change. And remember: Wykoff specifically said she checked the anesthesia machine before Carl’s case and after.”

For a few minutes the two friends looked at the records and didn’t speak. Each tried to decide what it all meant.

“If we go to Rhodes with any of this he’s going to see red all over again,” Lynn said. “And he’ll want to know how we discovered it. What could we say without implicating ourselves in having violated HIPAA? After his reaction to our just talking with Dr. Wykoff, I think he’d go apeshit if he knew we had these anesthesia records. We can’t go to him until we know a lot more.”

“I hear you,” Michael said.

“Listen,” Lynn said. “How about texting your buddy Vladimir to see if you can get him to come over this evening. I want to move forward.”

“You’re serious about all this?”