Sisterhood (15 page)

“You’ll get no arguments from me, kid,” Janet said, reaching over and squeezing her hand reassuringly. Christine squeezed back. “It’s just too bad that we’re the ones who have to shoulder all the darn responsibility, that’s all.” Christine responded with a nod and a rueful shrug.

Perhaps Dahlia was right. Janet elected to push a bit further. “All that responsibility, and what do we have to show for it? Nothing.”

Christine spun toward her, eyes flashing. “Janet! What on earth do you mean, nothing?”

Time to retreat, Janet decided. For once in her life, at least, Dahlia had misjudged. Beall’s naive, idealistic flame had not yet been doused. She took pains to meet Christine’s gaze levelly. “I mean that after all these years, after all the hundreds, and now I guess thousands, of Sisterhood recruits, nothing has changed in the attitude of the medical profession.”

“Oh.” Christine relaxed.

“So until things change, we do what we have to do. Right?”

“Right.”

“Listen, Christine. Let’s have dinner sometime soon. We have a lot in common, you and I, but this is hardly the place to discuss our mutual interests. Check your schedule and I’ll check mine. We’ll set something up in the next few days. Okay?”

“Okay. And, Janet, thanks for your concern. I’m sorry I snapped at you. This day’s been a bitch, that’s all.”

Janet smiled warmly. “If you can’t snap at your sister, who can you snap at? Right?”

“Right.”

Janet rose. “I’ve got to get Charlotte taken care of. Her husband left word he won’t be coming in to see her. Call me at home anytime you need to talk.” With a wave she left. At least Dahlia would know she had tried. Beall simply wasn’t ready. Too bad.

Christine returned in time for the end of report. Restless and saturated with nursing and with Boston Doctors Hospital, she stood against a wall until the final patient had been discussed, then left before any of the
others. Ahead of her, waiting for the elevator, were Janet and an orderly. Between them, on a litter, lay the sheet-covered body of Charlotte Thomas.

Held fast by the scene and her reflections on it, Christine watched as the litter was maneuvered onto the elevator. Not until the doors had closed was she able to move again.

F
ox’s Golden Laws of Medicine defined
pathologist
as “The specialist who learns all by cutting corners to get straight to the heart of the matter, leaving no stone unturned (gall or kidney).”

As usual, the recollection of one of Gerald Fox’s immortal definitions forced a smile out of David. This despite his discomfort at the prospect of having to observe the autopsy on Charlotte Thomas.

He was already ten minutes late, but he knew that nothing would be completed except perhaps the preparation of Charlotte’s body and the first incision. Although Fox’s observations were usually right on the mark, David had never felt that his cynical maxim about pathologists was totally accurate. He thought back to his first exposure to forensic pathology, a lecture given by the county coroner just before David’s group of second-year medical students was ushered in to view their first autopsy.

“Cause of death, ladies and gentlemen,” the old pathologist had said, “that is what we in forensic medicine are asked to determine for our medical and legal colleagues. In fact, nobody other than God himself knows what causes a person to die. Nobody. Rather what we can
determine is the condition of each organ in a patient’s body at the time of his or her death. From this knowledge, we can deduce with some accuracy the reason for cessation of cardiac, cerebral, or pulmonary fonction—the only true causes of death.

“For example. If a patient is killed by a gunshot wound through the heart, we may say quite safely that death was due to cardiac standstill from a penetrating wound to the heart muscle itself. But what of the patient with a disease like cancer? We might be able to locate cancerous tissue in the liver, brain, lungs, or other organs and certainly, in one respect, may say that cancer is the cause of death. Determining the immediate cause, however, is nigh impossible. Did the heart stop because it was poisoned by some as yet unknown substance secreted by the cancerous cells? Or did lack of sufficient fluid volume, for reasons perhaps unrelated to the cancer itself, cause such an impairment in circulation that the heart could no longer fonction and simply stopped?

“You must keep this in mind whenever you read such diagnoses as ‘cancer,’ or ‘emphysema,’ or ‘arteriosclerosis’ as the cause of a patient’s death. They may have been a cause leading to death, but as to the direct cause of death—that, my friends, remains a mystery in the vast majority of cases.”

A mystery. David hesitated outside the two opaque glass doors labeled
AUTOPSY SUITE
in gold-leaf letters. A sleepless night and chaotic morning had left him tense and uneasy. The prospect of Charlotte’s autopsy only aggravated those feelings.

Then there was Huttner. Cape Cod was only seventy miles away, close enough for him to make the drive up that morning without much difficulty. Whether or not he would choose to return there after witnessing the autopsy was a different story. David bet himself a long-overdue and much-feared trip to the dentist that Huttner
would elect to stay in Boston and resume control of his practice. He had given some thought to turning the bet around so that at least he wouldn’t have to face the Novocain and drill if he lost the last two days of his adventure. In the end, however, he decided that if he lost he would be able to submerge the misery of a visit to the tooth merchant in other, more substantial miseries.

Needles of formalin vapor jabbed deep into his nostrils as he entered the suite. It was a long room, nearly twenty-five yards from end to end. High ceilings and an excess of fluorescent light obscured, in part, the fact that there were no windows. Seven steel autopsy tables, each fitted with a water hose and drainage system, were evenly spaced across the ivory-colored linoleum floor. In addition to the hose, used for cleaning organs during an autopsy and the table afterward, every station had its own sink, blackboard, and suspended scale. A large red number, from 1 to 7, inlaid in the floor, was the only characteristic individual to each one. That is, except for Station 4.

On either side of that table six tiers of wooden risers had been built, identical to those in high school gymnasiums. At certain times the risers were filled with students in various stages of distress or fascination. At other times the stands held groups of residents in pathology or surgery, craning to study the dissecting skills of a senior pathologist. Station 4 was the center court of the Doctors Hospital Autopsy Suite.

At 8:15 on the morning of October 3, Stations 1, 4, and 6 were in operation, and a sheet-wrapped body rested on the table at Station 2. Wallace Huttner was standing, arms folded, at Station 4. The risers were empty but for a resident scheduled to post the body on table 2 and three medical students. As David approached, he caught sight of Charlotte’s open-mouthed, chalk-colored face. He bit at his lower lip, swallowed a jet of bile, and decided that it would be best to concentrate
on the rest of her anatomy. He could deal reasonably well with autopsies as long as he viewed them as examinations of parts of a body. The nearer he allowed himself to get to the human aspect, the more unpleasant the procedure became for him.

Ahmed Hadawi, a quick, dark little man with disproportionately huge hands, had made his initial incision and was elbow-deep in the chest cavity, busily separating the chest and abdominal organs from their attachments to the neck and body wall. He made a soft clucking noise with his tongue as he worked, but otherwise seemed without emotion or expression. Occasionally he bent over and murmured a few words into a pedal-operated Dictaphone.

Huttner nodded coolly in response to David’s greeting. His stance and manner bore no hint of the relaxed, interested, almost fatherly physician who had sat with David in the surgeons’ lounge just thirty-six hours before. After the nod, he returned his attention to the dissection, carefully avoiding further eye contact. David looked at the man helplessly. Then, as so often happened in difficult situations, the macabre portion of his humor took over. If he hugs himself any tighter, he thought, maybe he’ll just break into little pieces and I can cover his practice until someone glues him back together.

At that moment he caught another glimpse of Charlotte’s face. “Stop it, Shelton!” he screamed at himself. “This isn’t funny. Just stop it!” The mental slap was enough. He shifted his weight several times from side to side, then settled down, his attention focused on the pathologist.

“Now, then, we are ready to take a look at some things,” Hadawi said. The resident stepped down from the risers to get a better view and Huttner tightened his autoembrace a notch as the pathologist began pointing out the anatomical status of each of Charlotte’s organs as they existed at the instant of her death.

“The heart,” he began, “is moderately enlarged, with thickening of the muscle and dilatation of all chambers. There is a small, fresh puncture wound through the anterior left ventricle, which I assume is the result of Dr. Shelton’s commendably accurate intracardiac injection.”

David thought that the moment might be right for a modest smile and nod, but then realized that no one was looking at him. He smiled and nodded anyway.

The little pathologist continued speaking as he dissected. “There is fairly advanced narrowing of all coronary arteries, although there is no gross evidence of recent damage such as might be caused by a myocardial infarction.” Margaret Armstrong’s interpretation of Charlotte’s electrocardiogram had been right on the button, David noted. “Keep in mind,” Hadawi added, “that evidence of an acute infarction—say, less than twenty-four hours old—is often seen only in microscopic examination of the heart muscle itself, and then only if we happen to catch just the right section.”

“I want to be notified as soon as those slides have been examined,” Huttner ordered, more, it seemed to David, out of a need to make some kind of statement than anything else. Hadawi glanced up at him and, with no more acknowledgment than that, turned his attention to the lungs. Immediately his stock as reflected in David’s eyes rose several points. Both lungs were more than half consolidated by the heavy fluid of infection. Even if there had been no other problems, it seemed entirely possible that Charlotte would have been unable to survive her extensive pneumonia.

The remainder of the examination was impressive mainly for what it did not show. Pending, of course, microscopic examination of the abdominal lymph nodes, Hadawi announced that he was unable to find any evidence of residual cancer in the woman’s body. The liver cysts, which had been misdiagnosed by the radiologist,
Rybicki, were scattered throughout the organ, and similar fluid-filled sacs were found in both kidneys. “Polycystic involvement of hepatic and renal parenchyma,” Hadawi said into his Dictaphone.

Finally the pathologist stepped away from the table. “I have a few remaining things to do on this body,” he said, “but they will have no bearing on my findings. To all intents and purposes, Wally, we are done. Most significant of what I have to tell you is that this woman’s pressure sore was extending beneath her skin to the point where I doubt that even with multiple grafts it ever would have healed. Infection of the sacral bones had already begun and would have been almost impossible to treat.

“She has enough coronary arteriosclerosis so that I feel her final event was probably a cardiac one. I intend to sign her out as cardiovascular collapse secondary to her pulmonary and bedsore infections. An additional stress undoubtedly came from her partial small bowel obstruction, which, as you saw, was due to adhesions from her recent surgery.”

David said, “Dr. Hadawi, Dr. Huttner, if we could sit down over here, there are a few questions that I have.” He could not bear the thought of having to discuss Charlotte’s case over her dissected body. Hadawi responded with a brief, understanding grin and took a seat on one of the risers. Huttner, who still held his arms around himself, followed reluctantly. David gauged the expression on his face as somewhere between disgust and fury. Nowhere in his eyes or manner was there a hint of disappointment or sympathy. Regardless of her underlying disease, Charlotte Thomas had walked into the hospital as Huttner’s patient, had been operated on, and had died. That made her a postoperative mortality. Her operation and the many complications that ensued would be discussed in depth at Surgical Death Rounds. Hardly a prospect that would sit well
with this man, David realized. He was far more accus tomed to asking the questions than to answering them.

“Now, David,” Hadawi said, “just what is it that troubles you about what you have seen?”

“Well, most of my concern centers about her heart, which seemed so unresponsive to everything that I tried during her Code Ninety-nine. It may have been simply that too much time elapsed between the moment of her cardiac arrest and the time I started working on her, but it just doesn’t feel like that. I wonder if perhaps her potassium could somehow have risen too high and caused a fatal cardiac arrhythmia.”

“That is always a possibility,” Hadawi said patiently. “I’ve saved several vials of blood. I’ll be happy to have her potassium level checked. However, you must keep in mind the limits of accuracy of such a measurement done in a postmortem patient—especially one who has received prolonged external cardiac compression.”

Finally Huttner spoke. It was no surprise to David that he was unwilling to surrender without a fight. “Look, Ahmed,” he said. His second and third fingers bobbed up and down at the man, but Hadawi showed no outward hint of being offended by the gesture. “I’m not totally satisfied with all this. Dr. Shelton here has a point. Since there’s nothing obvious on gross exam to explain this woman’s sudden death, then we should look further before signing her out as something so nonspecific as cardiovascular collapse. Maybe some nurse made a medication error on her and caused an allergic, anaphylactic reaction of some kind. She was known to be allergic to penicillin.”