The Inquisitor (19 page)

"Actually, I wondered if anyone saw Michael. Maybe he's working in his office?"

"One moment. I'll check."

He took a deep breath and watched the trees outside his window toss in the wind as yet another storm threatened. Their leafy branches swept back and forth in front of the streetlamps, covering and uncovering the lights in a frenzied semaphore.

"I'm sorry, Dr. Garnet, but no one's seen him."

Tuesday, July 15, 7:00 a.m.

Pathology Conference Room, St. Paul's Hospital

The remains of Elizabeth Matthews lay in open Tupperware containers arranged end to end along the length of a massive polished oak table. Earl scanned her ocher-colored liver, a pair of charcoal-tinted smoker's lungs, two glistening gray kidneys, and a maroon heart coated with yellow fat, the four cardiac chambers sliced open like the inner compartments of a large red pepper. A separate tray displayed the piece de resistance: an amorphous knobby-shaped mass of pearl-colored tumor that had penetrated the ovaries and uterus, reducing much of the structures to an unrecognizable reddish brown mush. The final two specimens, a coil of bowel and the halves of her brain, were parked to one side, too anticlimactic for comparison.

Pre-SARS, the aroma of fresh coffee would partly cut the acrid fumes at these sessions, but not anymore. Nothing was served at morning rounds these days. Signs posted throughout the hospital read NO EATING ON THE JOB, and cartoons of people raising their masks to gobble down donuts bore stamps of big red circles with lines slashed through them. Most found this new form of prohibition harder to take than the clampdown on cigarettes. Smokers were a minority. Restrictions on food left everyone hungry, in caffeine withdrawal, and snarly as hell.

Even so, death rounds remained popular with staff and trainees. A pathologist's knife spared nobody in exposing the final diagnosis and laid bare the mistakes of all, from the loftiest chief to the lowliest student. The combined prospect of picking up teaching pearls and witnessing the great equalizer of a public stripping-down usually packed them in.

Except today Earl had invoked his powers as VP, medical and limited participation to the players directly involved in the case. What he had in mind required them and only them, not a general audience. Hurst had gladly gone along with the ruling, never even questioned it, always eager to keep anything controversial as secret as possible, SARS or no SARS. And it still wasn't clear if Mr. Matthews would launch a lawsuit.

Earl looked around at the invited guests.

On this side of the table Thomas Biggs sprawled in a chair a few spaces away. Dressed in a crisp white coat, he sleepily inspected the open containers from under drooping eyelids, the aftereffect of a recent string of night calls.

Beside him Jimmy sat upright and alert, leaning forward and raring to go, but wearing a king-sized frown, obviously baffled at why he'd been included.

Everyone else had chosen to sit opposite Earl, face-off style.

Midpoint in the lineup, Paul Hurst formed his graceful fingers into an elongated triangle and absently beat a tattoo with them on the front of his mask.

His sister, Madelaine Hurst, director and chief of all things to do with nursing at St. Paul's, occupied the place at his right side. No surprise there. She always took that position, either oblivious of or indifferent to its symbolic right-hand-man implication. An asthenic woman with austere gray eyes, and known to protect her domain as fiercely as her brother defended the hospital, she clamped her steel gaze on Earl. It felt cold and hard as shackles.

Next to her sat Mrs. Quint, seemingly relaxed, her expression a thousandfold more congenial than her boss's. Earlier she'd even wished Earl good morning. But her corpulent figure exuded an air of authority, and as acting supervisor at the time of the incident, she'd be defending her "girls" just as vigorously as Madelaine

Hurst would.

The most openly hostile pair, Peter Wyatt and Monica Yablonsky, glared at him in unison from the far end of the table. Having placed themselves near the large, wall-mounted video screen that would be used for the upcoming presentation, they'd picked the prime spot to make sure everyone else would witness their show of disapproval.

Predictable, Earl thought.

Stewart Deloram, however, surprised him. He'd positioned himself at Paul Hurst's left elbow and, with surprising charm, cozied up to him from the minute they sat down together, chatting breezily while studiously avoiding eye contact with Earl.

Now what could that be all about?

Len Gardner, habitually occupying the oversized chair at the other end of the table, rose to his feet. "We might as well begin," he said, and with a touch of a finger to his laptop computer, the wall-mounted screen sprang to life. A swirl of pink lines and blue dots appeared, the primal color scheme pathologists use when staining body tissues so that they will be visible under a microscope. This particular pattern, wavy mauve strands reminiscent of a van Gogh, were woven beneath an array of tiny purple dots worthy of a Monet. Together they depicted normal uterine muscle lined with disintegrated mucosa.

Len clicked through a series of such images- the strands of muscle and sheets of mucosa appearing successively more shredded- to document the tumor's relentless progress. "Invasion by increments," he described it, "destroying Elizabeth Matthews's reproductive system cell by cell."

Earl recalled the ghastly distortions on the woman's wan face as she'd endured what they were seeing.

As the demonstration continued, Stewart occasionally whispered something in Hurst's ear and pointed to the screen, seemingly adding his own spin to the narrative. He still hadn't looked in Earl's direction.

Len moved on to pictures that confirmed the cancer hadn't yet disseminated throughout the rest of her body, flicking through shots of the other vital organs and showing them to be free of any metastatic spread. "Certainly her neoplasm had not reached a stage such that it would be incompatible with life," he emphasized.

Laying down his laser pointer, he removed the tumor from its container and, sticking here and there with a steel stylet as long as a knitting needle, demonstrated in macroscopic terms the assault on Elizabeth Matthews's womb.

"Any questions?" he asked when finished.

No takers.

Earl often worried how voyeuristic and sicko these sessions would seem to the outsider. Yet they remained at the heart of learning medicine, exposing the profession's victories and errors with a certainty that no other part of the discipline could provide. Should they ever suffer the ax of public outrage because the media exposed them to lay scrutiny, doctors wouldn't be flying blind, but it would be as if they'd lost an eye.

Len gestured to Stewart. "Dr. Deloram has volunteered to present and interpret the biochemistry of the case, including the postmortem drug screens."

"Thanks, Len." Stewart stood up, and with a click of a remote, a slide projector mounted on a steel table began to whir noisily. A few more clicks, and its carousel advanced with a loud rattle. Pushing another button, he caused a movie screen to descend from the ceiling and come to a stop above the video monitor.

It's a wonder he didn't play the theme from 2001, Earl thought.

Enlarged charts of lab values sprang into focus on the white surface.

"As you can see, aside from a raised calcium level, the result of the tumor having eaten into the bones of her pelvis," Stewart began, "the hematological and biochemical values remained mostly normal until the time of death. In other words, as Dr. Gardner has so elegantly demonstrated, multiple organ failure had not yet become part of the picture." More numbers flicked by. "Specifically, I draw your attention to the patient's normal liver and kidney function, since this will have a bearing on our ruling about the cause of death." He turned to address the nurses. "You no doubt recall that morphine is broken down in the liver and excreted in the kidney. After looking at these standard values, a physician might reasonably conclude the patient ought to have been able to metabolize a dosage increase of the magnitude Dr. Garnet ordered, especially since previously prescribed amounts of the narcotic hadn't treated the woman's pain."

He paused and cast a glance at each of the women, eyebrows raised like a mime telegraphing that he expected a response.

Mrs. Quint gave a reluctant nod of agreement.

Madelaine Hurst simply stared back at him, unwilling to yield up so much as a blink.

Monica Yablonsky had the startled look of deer blinded by a poacher's light. She started to fidget with her glasses.

Attaboy, Stewart, Earl thought. So far so good.

"And I take it that all present are aware of the sequence of events leading up to this woman's demise," Stewart continued, "Dr. Garnet's doubling of her morphine dose, the times that the nurses administrated it, and the patient's vital signs throughout?"

Nobody indicated otherwise.

"Fine. Now while a lethal level of morphine undoubtedly killed this woman, the source of that toxic concentration is not at all clear."

What?

"The amount present in her blood at the time of death might indicate that approximately double the amount Dr. Garnet prescribed may have been administered to the patient, but this explanation isn't that certain."

Wait a minute. What's this "not all that clear" and "isn't that certain" crap?

"A fall in blood pressure could have resulted in a delayed uptake of the first injection that had been given around nine that evening. Later, should the pressure recover and the uptake of the drug into the patient's bloodstream return to normal, both the remnants of that shot and the entirety of the second dose would enter the circulation simultaneously, leading to the toxic levels that killed her."

No! Wrong! Wrong! Wrong!

"Even though the nursing records indicate no such fluctuations in her vitals," Stewart continued in a fluid, singsong delivery more appropriate to a travelogue than a death review, "they might have come and gone undetected. And to reiterate Dr. Gardner's findings that the woman's cancer, while undoubtedly painful, had not yet brought her near death, it's a known fact that morphine itself can drop a patient's blood pressure. So we are left with two possible scenarios: either someone doubled the second injection, or undetected fluctuations in blood pressure led to a delay in the absorption of the first, leading to an accumulation of the two shots."

Earl leapt to his feet. "What the hell are you talking about?"

Stewart sat down and studied the table between them.

"That's garbage, Stewart, and you know it."

Stewart said nothing, still avoiding eye contact, but Earl saw the black of his pupils grow wider.

Like a variation on Pinocchio's nose, the lying son of a bitch. "Why are you doing this, Stewart?"

"Doing what?"

"You know damn well. All that 'fluctuating pressure' bullshit." But Earl had already guessed the reason: to provide a scenario that could give Hurst an out. Not a good one with legs, but enough to confound the findings and keep the table from reaching a definitive conclusion. Then the whole mess would end in limbo, and he'd avoid a public scandal.

"Patients fluctuate wildly near death," Stewart said with a shrug. "They can be nearly comatose one day and rally the next, the improvement there for no more apparent reason than a need to say good-bye, and it all happens with no change in their metabolic numbers. It's a part of cancer we don't understand, almost as if bad humors were at work-"

"Level with me, you son of a bitch." Earl nearly grabbed him by the collar.

"How can you be sure it isn't so?" Paul Hurst said, maintaining his finger pyramid as he looked up at Earl. His voice remained as calm as a pond locked in ice. "Actually, both scenarios seem reasonable to me. Do you have proof to support one over the other?"

"There were never any serious dips in Matthews's blood pressure, not that night, not ever," Earl said, controlling his anger.

"Not recorded, no. But without continuous monitoring, how can you say for sure?"

"It's unlikely as hell, and you know it." He turned to Len. "Do you agree with this?"

The pathologist's scowl said it all. "Of course not. No way shock had anything to do with this woman's death. Stewart, this is a crock."

"Hey," the intensivist said, locking eyes with him, "I'm just laying out all the possibilities. You guys decide which one's most probable." He sounded miserable.

"You were told to pull this stunt, weren't you?" Earl said. "I might have expected as much from some." He gestured toward the Hursts. "But you?"

Stewart shook his head as if denying the accusation and finally looked directly at Earl. The pitiful gloom in his eyes admitted everything. "Don't you understand? A hung jury here gets you off the hook too," he said, as if that justified what he'd done. "This way neither you nor the nurse can be officially cited for negligence. The matter dies."

Paul squinted imperiously over the top of his bifocals at Len. "Of course, as a former surgeon I know enough never to go against the pathologist as far as cause of death is concerned. Morphine overdose, right? There we are in agreement?"

"Yes. But I repeat, shock did not play a role in that overdose."

"And the minutes will record your opinion. As for the rest, we'll just have to agree to disagree on this one."

His arrogance took Earl's breath away. In a court of law he'd never get away with such a bald-faced attempt to distort the facts. But death rounds had no legal status. Touted as a sacred crucible of final clinical truths, nothing guarded its integrity but good faith between physicians.

The constriction in Earl's gut coiled even tighter. He looked over at Yablonsky. She blanched and began to use her glasses as worry beads.

"Do you have anything to say, Monica?" he asked. "This leaves you much more out on a limb than it does me, and you know it."

Jimmy shot him a disapproving glance, as if to tell him to cut his losses and run.

Madelaine Hurst hunched forward, and her brow acquired the sharp-edged contours of a hawk's. "Now see here, Dr. Garnet-"