Robin Cook 1982 - Harmful Intent Read online

  "I have the feeling I'm talking to an expert," Jeffrey said. "Have you been reading a bit of psychiatry on the side?"

  "Hardly," Kelly said. "Unfortunately, I learned about the importance of self-esteem the hard way, by experience." She took a sip of tea. For a moment she was lost in her own sorrowful reverie, staring out the bay window at the overgrown garden. Then, just as abruptly, she snapped out of her momentary trance. She looked at Jeffrey, without her smile. "I'm convinced it was through low self-esteem that Chris committed suicide. He couldn't have done what he did if he felt better about himself. I just know it. It wasn't the fact of the tragedy that pushed him over the edge. It certainly wasn't guilt. Chris was like you, in that he had nothing to feel guilty about. It was the sudden erosion of confidence, the damage done to how he thought about himself, that made Chris take his life. People have no idea how sensitive even the most accomplished doctors are to the impact of being sued. In fact, the better the doctor the more it hurts. The fact that the suit is baseless has nothing to do with it."

  "You're so right," Jeffrey said. "Back when I heard that Chris had killed himself, I was astounded. I knew what kind of man he was, what kind of doctor he was. Now his suicide doesn't astound me at all. In fact, from where I sit now, I'm surprised more doctors sued for malpractice aren't drawn to it. In fact, I tried it last night."

  "Tried what?" Kelly asked sharply. She knew what Jeffrey meant but she didn't want to believe it.

  Jeffrey sighed. He couldn't look at her. "Last night I tried to commit suicide," he said simply. "I came within an inch of doing the same thing that Chris did. You know, the succiny1choline and morphine trick. I had the

  IV running and everything."

  Kelly dropped her cup of tea. She lunged forward and, grabbing Jeffrey by his shoulders, she shook him. The Miove startled him. She caught him completely unaware.

  "Don't you dare do such a thing. Don't even think about it!"

  Kelly was glaring at him, still clutching his shoulders. Finally Jeffrey mumbled that she needn't worry, since he'd lacked the courage to go through with it.

  Kelly shook him again, reacting to his comments.

  Jeffrey didn't know what to do, much less say.

  Kelly kept shaking him, her passions inflamed. "Suicide is not courageous," she said angrily. "It is the opposite. It's the cowardly thing to do. And it's selfish. It hurts everyone you leave behind, everyone who loves you.

  I want you to promise me that if you ever have thoughts of suicide again, you'll call me immediately, no matter what time of day or night. Think of your wife. Chris's suicide filled me with such guilt, you have no idea. I was crushed. I felt that somehow I had failed him. I know that's not true now, but his death is something I'll probably never get over completely."

  "Carol and I are getting a divorce," Jeffrey blurted.

  Kelly's expression softened. "Because of the malpractice suit?"

  Jeffrey shook his head. "We'd planned it before all this started. Carol was just nice enough to put it off for the time being.,,

  "You poor man," Kelly said. "I can't imagine trying to deal with being sued for malpractice and a breakup of a marriage at the same time."

  "My marital problems are the least of my worries," Jeffrey said.

  "I'm serious about your promising me you'll call before you do anything foolish," Kelly said.

  "I'm not thinking..."

  "Promise!" Kelly insisted.

  "All right, I promise," Jeffrey said.

  Satisfied, Kelly got up and cleaned up the mess that she'd made when she'd dropped her teacup. As she picked up the pieces of broken china, she said:

  "I wish more than anything that I'd had the slightest indication of what

  Chris had been plan-

  ning. One minute it seemed that he'd been full of fight, talking about the anesthetic complication being secondary to a contaminant in the local, the next minute he was dead."

  Jeffrey watched Kelly as she threw the shards of china away. It took a few moments for her last words to sink in. When she returned and took her seat again, Jeffrey asked, "What made Chris think of a contaminant in the local anesthetic?"

  Kelly shrugged. "I haven't the faintest idea. But he seemed to be genuinely excited about the possibility. I encouraged him. Just before that he'd been depressed. Very depressed. The idea of a contaminant gave him a real boost.

  He spent several days poring over pharmacology and physiology textbooks. He made lots of notes. He was working on it the night he... I'd gone to bed.

  I found him the next morning with an IV in place, the bottle empty."

  "How awful," Jeffrey said.

  "It was the worst experience of my life," Kelly admitted.

  For an instant, Jeffrey envied Chris, not because he'd succeeded where

  Jeffrey had failed, but because he'd left behind someone who obviously loved him so deeply. If Jeffrey had followed through, would anyone be that sorry about it? Jeffrey tried to shake the thought. Instead, he considered the notion of a contaminant in the local anesthetic. It was a curious thought.

  "What kind of contaminant was Chris thinking about?" Jeffrey asked.

  "I really don't know," Kelly answered. "It was two years ago, and Chris never did go into much detail about if. At least not with me."

  "Did you mention his theory to anybody at the time?"

  "I told the lawyers. Why?"

  "It's an intriguing idea," Jeffrey said.

  "I still have Chris's notes," Kelly said. "You're welcome to see them if you'd like."

  "I would," Jeffrey said.

  Kelly stood up and led Jeffrey back through the kitchen and dining room, across the foyer and through the living room. She stopped at a closed door.

  "I think I'd better explain," she said. "This was Chris's study. I know it probably wasn't all that healthy, but after Chris's death I just closed the door to this room and left everything the way it was. Don't ask me why. At the time it made me feel better, as if some part of him was still here. So be prepared. It might

  be a little on the dusty side." She opened the door and stepped aside.

  Jeffrey walked into the study. In contrast to the rest of the house, it was disheveled and musty. A thick layer of dust coated everything. There were even a few cobwebs hanging from the ceiling. The blinds were closed tight.

  On one wall was a floorto-ceiling bookcase filled with volumes that Jeffrey recognized immediately. Most of them were standard texts for anesthesia.

  The others dealt with more general medical topics.

  In the center of the room stood an old partners' desk, heaped with papers and books. In the comer of the room was an Eames chair upholstered in black leather that had dried and cracked. Next to the chair was a tall stack of books.

  Kelly was leaning against the doodamb with her arms folded as if she was reluctant to enter. "Quite a mess," she said.

  "You don't mind if I look around?" Jeffrey asked. He felt a certain kinship with his dead colleague but did not want to trespass on Kelly's feelings.

  "Be my guest," she said. "As I told you, I've finally come to terms with

  Chris's passing. I've been meaning to clean this room for some time. I just haven't gotten around to it."

  Jeffrey circled the desk. There was a lamp on it, which he turned on. He wasn't superstitious; he did not believe in the supernatural. Yet somehow he felt Chris was trying to tell him something.

  Open on the desk's blotter was a familiar textbook: Goodman and Gillman's

  Pharmacological Basis of Therapeutics. Next to it was Clinical Toxicology.

  Beside both books was a pile of handwritten notes. Bending over the desk,

  Jeffrey noted that the Goodman and Gillman was open to the section on

  Marcaine. The potential adverse side effects were heavily underlined.

  "Did Chris's case involve Marcaine as well?" Jeffrey asked.

  "Yes," Kelly said. "I thought you knew that."

  "Not really," Jeffrey said
. He'd not heard which of the local anesthetics

  Chris had used. Occasional complications were seen with all of them.

  Jeffrey picked up the stack of notes. Almost immediately he felt a tickle in his nose. He sneezed.

  Kelly put the back of her hand to her lips to hide her smile. "I warned you it might be dusty."

  Jeffrey sneezed again.

  "Why don't you get what you want and we can retreat to the family room,"

  Kelly suggested.

  Through watery eyes, Jeffrey picked up the pharmacology and toxicology books, along with the notes, and carried them out with him. He sneezed a third time before Kelly shut the study door.

  When they got back to the kitchen, Kelly offered a suggestion. "Why don't you stay for an early dinner? I can whip us up something. It won't be gourmet, but it'll be healthy."

  "I thought you were off to an aerobics class," Jeffrey said. He was delighted by her offer, but didn't want to inconvenience her any more than he already had.

  "I can work out any day," Kelly said. "Besides, I think you need a little

  TLC."

  "Well, if it wouldn't be a bother," Jeffrey said. He was amazed by her kindness.

  "I'll enjoy it," Kelly said. "Now you make yourself comfortable on the couch. Take your shoes off if you like."

  Jeffrey took her at her word. He sat down and laid the books on the coffee table. He watched her for a moment as she bustled about the kitchen, looking in the refrigerator and various cabinets. Then he kicked off his shoes and settled back to shuffle through Chris's notes. The first thing he came across was a handwritten summary of the anesthetic complication in

  Chris's tragic case.

  '.I'm going to run to the store," Kelly said. "You just stay put.,,

  "I don't want you going to any trouble," Jeffrey said, making a motion as if to get up. But it wasn't true. He loved the fact that Kelly was willing to make such an effort for him.

  "Nonsense," Kelly said. "I'll be back in a flash."

  Jeffrey wasn't sure if Kelly had said nonsense because she saw through his fib or because to her it was no trouble. She was gone in the blink of an eye. Jeffrey heard her start her car in the garage, pull out, and accelerate down the street.

  He glanced around at the comfortable family room and kitchen, pleased that he'd made the decision to call Kelly. Aside from deciding not to kill himself and not to fly away, in the last twenty-four hours it was the best decision he'd made.

  Settling back again, Jeffrey turned his attention to the summary of Chris's anesthetic complication:

  Henry Noble, a fifty-seven-year-old white male, entered the Valley

  Hospital to undergo a total prostatectomy for cancer. The request from

  Dr. Wallenstern was for continuous epidural anesthesia. I visited the man the evening before his surgery. He was mildly apprehensive. His health was good. Cardiac status was normal with a normal

  EKG. Blood pressure was normal. Neurological exam was normal. He had no allergies. Specifically, he had no drug allergies. He'd had general anesthesia for a hernia operation in 1977 with no problems. He'd had local anesthesia for multiple dental procedures with no problems. Because of his apprehension I wrote an order for 10 mg of diazeparn to be given by mouth one hour prior to coming to surgery. The following morning he arrived in good spirits. The diazepam had had good effect. The patient was mildly sleepy but could be roused. He was taken to the anesthesia room and placed in a right lateral position. An epidural puncture was made with an 18-gauge

  Touhey needle without problems. There was no reaction to 2 cc's of Lido- caine utilized to facilitate the epidural stick. Confirmation of the epidural location was made with 2 cc's of sterile water with epinephrine.

  A small-bore epidural catheter was threaded through the Touhey needle. The patient was returned to a supine position. A test dose of.5% Marcaine with a small amount of epinephrine was then prepared from a 30 ml vial. This test dose was injected. As soon as the test dose was injected the patient complained of what he )described as dizziness, followed by severe intestinal cramping. The heart rate began to increase but not to the extent expected if the test dose had inadvertently been injected intravenously.

  Generalized muscular fasciculations then appeared, suggesting a hyperesthesia state. Massive salivation intervened, suggesting a parasympathetic reaction. Atropine was given intravenously. Miotic pupils were noted. The patient then had a grand mal seizure which was treated with succiny1choline and Valium intravenously. The patient was intubated and maintained on oxygen. The patient then had a cardiac arrest. The heart proved to be extremely resistant to drugs, but finally a sinus rhythm was achieved. The patient was stabilized but did not return to consciousness.

  The patient was moved to the surgical intensive care unit, where he remained comatose for one week, suffering multiple cardiac arrests. It was also documented that the patient had a total paralysis following his anesthetic complication that involved not only the spinal cord but cranial nerves as well. At the end of the week, the patient had a final cardiac arrest from which the heart could not be started.

  Jeffrey looked up from the notes. Reading Chris's terse history of his complication recreated the terror that Jeffrey had felt when he'd desperately fought to save Patty Owen. The memory was so poignant that it brought perspiration to Jeffrey's hands. What made it so poignant were the striking similarities in the two cases, and it wasn't just -the dramatic seizures and cardiac

  arrests. Jeffrey could remember with startling clarity the moment he'd seen salivation and lacrimation that Patty had had. And besides that there was the abdominal pain and the small pupils. None of these responses were usual side effects of local anesthetics, although local anesthetics were capable of causing an extraordinarily wide range of adverse neurological and cardiac effects in a few unfortunate individuals.

  Jeffrey studied the next page of the notes. There were a number of words printed in bold letters. Two of them were "muscarinic" and "nicotinic."

  Jeffrey recognized them, mostly from his medical school days. They had to do with autonomic nervous system function. Then there was the phrase

  "irreversible high spinal blockade with cranial nerve involvement," followed by a series of exclamation points.

  Jeffrey heard Kelly's car pull up the drive and enter the garage. He glanced at his watch. She was a fast shopper.

  The next item in Chris's pile was an NMR-nuclear magnetic resonance-report on Henry Noble during the time he was paralyzed and comatose. The results recorded were normal.

  "Hi," Kelly called brightly as she came through the door. "Miss me?" She laughed as she dumped a parcel on the kitchen countertop. Then she stepped up to the back of the couch and looked over Jeffrey's shoulder. "What does all this stuff mean?" She pointed to the words and phrases Jeffrey had been reading.

  "I don't know," Jeffrey admitted. "But these notes are fascinating. There are so- many similarities between Chris's case and mine. I don't know what to make of it."

  "Well, I'm glad someone's getting some use out of that stuff," Kelly said as she went back into the kitchen. "It makes me feel less weird for having saved it all."

  '.1 don't think your saving it was weird at all," Jeffrey said, turning to the next page. It was a typed summary of Henry Noble's autopsy, which had been performed by the medical examiner. Chris had underlined the phrase

  "axonal degeneration seen on microscopic sections" and had followed it up with a series of question marks. Then he'd underlined the phrase "toxi- cology negative" and capped it off by an emphatic exclamation point.

  Jeffrey was mystified.

  The rest of the notes were outlines of articles taken mostly from the

  Goodman and Gillman book on pharmacology. A quick glance suggested to

  Jeffrey that they chiefly dealt with the function of the autonomic nervous system. He decided to look

  at the material later. He stacked the papers and set them on the table with the two medical volumes serving to an
chor them.

  Jeffrey joined Kelly by the kitchen sink. "What can I do?" he asked her.

  "You're supposed to be relaxing," Kelly said as she rinsed the lettuce.

  "I'd prefer to help," Jeffrey said.

  "Suit yourself. How about firing up the barbie on the back porch? The matches are in that drawer." Kelly pointed with a lettuce leaf

  Jeffrey grabbed a book of matches and went outside. The barbecue was one of those domed types powered by a cylinder of propane. He quickly figured out how the valve worked and lit it, then closed the dome.