Crisis (56 page)
"I'll take your word for it," Jack said. "I didn't expect we'd see anything as clear as the gross was."
"Now I've expanded from purely cardiotoxic agents to neurotoxic agents, since a lot of them do both. I tell you, it's fascinating stuff, especially how it dovetails with bioterrorism."
"Did you read the depositions?" Jack asked. He wanted to keep the conversation on track.
"Hey, you weren't gone that long. I think I've gotten a lot done. Give me a break!"
"We are running out of time. We have to stay focused."
"I'm focused, man," Latasha scoffed. "I'm not out driving around, learning something I essentially already knew, and getting beat on in the process."
Jack rubbed his face briskly with both hands in an attempt to dispel the cobwebs of fatigue that were interfering with his cognition and emotion. Being at all critical of Latasha was surely not his intent. "Where are those Diet Cokes? I could use a blast of caffeine."
Latasha pointed toward the door to the hall. "There's a vending machine in the lunchroom down on the left."
When the can of soda thudded down into the vending machine's opening, it was loud enough in the building's silence to make Jack jump. He was tired, but he was also tense, and he wasn't entirely sure why. It could have been because time was running out as far as the case was concerned, but it also could have been anxiety about returning to New York and all that it entailed. After flipping open the can of soda, Jack hesitated. Was caffeine advisable if he was already mildly uptight? Throwing caution to the wind, he downed the can, then burped. He rationalized that he needed his wits to be sharp, and for that, caffeine was what the doctor ordered.
Feeling a slight buzz since caffeine was not one of his vices, Jack reclaimed the seat across from Latasha and cherry-picked Craig's and Jordan's deposition transcripts from the debris around Latasha.
"I didn't read those depositions cover to cover," Latasha said. "But I did kinda breeze through them to make a list of Patience's symptoms."
"Really?" Jack questioned with interest. "That's what I was just about to do."
"I guessed as much, since that's what you suggested before your ill-fated drive out to the suburbs."
"Where is it?" Jack asked.
Latasha scrunched up her features in concentration while she riffled through some of the material in front of her. Eventually, she came up with a yellow legal pad. She handed it across to Jack.
Jack settled back in his chair. There was no order to the symptoms other than their being divided into two major groups: the morning of September eighth, and the late afternoon and early evening. The morning group included abdominal pain, increased productive cough, hot flashes, nasal congestion, insomnia, headache, flatulence, and general anxiety. The late afternoon/early evening group comprised chest pain, cyanosis, inability to talk, headache, difficulty walking, difficulty sitting up, numbness, a sensation of floating, nausea with a little vomiting, and generalized weakness.
"Is this all?" Jack asked, waving the pad in the air.
"You don't think that's enough? She sounds like most of my patients in third-year medical school."
"I just wanted to make sure it's all the symptoms mentioned in the depositions."
"It's all the ones I could find."
"Did you find any mention of diaphoresis?"
"No, I didn't, and I looked for it specifically."
"I did, too," Jack said. "Sweating is so typical of a heart attack, I couldn't believe it when I didn't see it on my first reading. I'm glad you didn't see it, either, because I thought maybe I'd just missed it."
Jack glanced back at the list. The trouble was that most of the entries had no modifiers, and the ones that did had modifiers that were too general and not descriptive enough. It was as if all the symptoms were equally important, which made it difficult to weigh each symptom's contribution to Patience's clinical state. Numbness, for instance, had little meaning without a description of location, extent, and duration, and whether it meant no feeling whatsoever or paresthesia, more commonly known as
pins and needles.
In such a circumstance, it was impossible for Jack to decide if the numbness was of neural or cardiovascular origin.
"You know what I find most interesting about this toxicology stuff?" Latasha said, looking up from a large textbook.
"No! What?" Jack said vaguely. He was preoccupied in deciding he would need to go back through the depositions himself and see what qualifiers existed for the symptoms mentioned.
"Reptiles," Latasha said. "It's a wonder how all their venoms evolved, and why there is such a difference in potency."
"It is curious," Jack said as he opened Jordan's deposition and began rapidly flipping through the pages to get to the section involving the events of September eighth.
"There are a couple of snakes whose venom contains a powerful specific cardiotoxin capable of causing direct myocardial necrosis. Can you imagine what that would do to the level of cardiac biomarkers?"
"Really?" Jack questioned with sudden interest. "What kind of snakes?"
Latasha cleared a trench through the material on the desk, and, after turning the textbook around, she pushed it over in front of Jack. She used her index finger to point to the names of two types of snakes on a table comparing snake venom virulence. "The Mojave rattlesnake and the Southern Pacific rattlesnake."
Jack glanced at the table. The two snakes she pointed out were among the most poisonous of those listed. "Very interesting," Jack said. His interest faded as quickly as it had arisen. He pushed the book back. "However, we are not dealing with an envenomation. Patience wasn't bitten by a rattlesnake."
"I know," Latasha said, taking the book back. "I'm only reading about venom to get ideas for various classes of compounds to consider. I mean, we are looking for a cardiotoxin."
"Uh-huh," Jack said. He had already gone back to the deposition and found the part he was looking for. He began to read more closely.
"Actually, the most interesting venomous animals are a group of amphibians, of all things," Latasha said.
"Really," Jack said without actually hearing. He'd come across the mention of abdominal pain in the deposition. Jordan testified it was "lower" abdominal pain, more on the left than the right. Jack amended Latasha's entry on the yellow legal pad.
"It's the Colombian poison dart frogs that take the cake," Latasha said, flipping the pages in the textbook until she came to the right section.
"Really," Jack repeated. He skipped ahead in Jordan's deposition until he got to where Jordan was talking about the evening symptoms. Jack was particularly looking for the section where Jordan talked about the numbness Patience had experienced.
"Their skin secretions contain some of the most toxic substances known to man," Latasha said. "And they have an immediate toxic affect on heart muscle. Are you familiar with batrachotoxin?"
"Vaguely," Jack said. He found the reference to numbness, and it was apparent from Jordan's description that it was paresthesia, not the absence of feeling, and it involved her arms and legs. Jack wrote the information on the yellow pad.
"It is the worst toxin of all. When batrachotoxin comes in contact with heart muscle, it stops all activity immediately." Latasha snapped her fingers. "In vitro, one minute cardiac myocytes are pumping away, and the next instant, after exposure to a few molecules of batrachotoxin, they are completely stopped. Can you believe that?"
"It's hard to believe," Jack agreed. He found Jordan's reference to floating and, interestingly, it was associated with the paresthesia and had nothing to do with being in liquid. It was a sensation of not being grounded and floating in air. Jack wrote the information on the yellow pad.
"The poison is a steroidal alkaloid rather than a polypeptide, for whatever that's worth. It's found in several frog species, but the one that has the highest concentration is called
Phyllobates terribilis.
It's aptly named, since one tiny frog has enough batrachotoxin to kill a hundred people. It's mind-boggling."
Jack found the section where Jordan discussed Patience's weakness, which, it turns out, didn't refer to a diminution of any particular muscle group. Rather, the weakness was a more global problem. It started with difficulty walking and progressed to difficulty sitting up in short order. Jack added the information to the yellow pad.
"There's something else you should know about batrachotoxin if you don't already. Its molecular mode of action is to depolarize electrical membranes like heart muscle and nerves. And do you know how it does it? It does it by affecting sodium transport, something you thought was esoterica. Remember?"
"What was that about sodium?" Jack asked as Latasha's comments penetrated his concentration. When Jack was thinking hard about something, he often could be oblivious to his surroundings, as Latasha had experienced.
"Batrachotoxin latches onto nerve and muscle cells and causes the sodium ion channels to lock in the open position, meaning the involved nerves and muscles stop functioning."
"Sodium," Jack repeated, as if in a daze.
"Yes," Latasha said. "Remember we were speaking ..."
All of a sudden, Jack leaped to his feet and scrabbled madly through the litter spread around the table. "Where are those papers?" he demanded in a minor frenzy.
"What papers?" Latasha questioned. She had stopped speaking in mid-sentence and had leaned back in her chair, surprised by Jack's abrupt impetuosity. In his haste, he was knocking deposition transcripts off the table.
"You know!" he blurted, struggling to come up with the right word. "Those ... those papers!"
"We've got a lot of papers here, big guy. God! How many Diet Cokes did you drink anyway?"
"Screw it!" Jack sputtered. He gave up on his search. Instead, he reached out toward Latasha. "Let me see that toxicology text!" He demanded rashly.
"Sure," Latasha said, mystified at his transformation. She watched as he riffled through the pages of the massive tome to get to the index. Once there, he hastily ran his fingers down the columns until he found what he was looking for. Then he went back to rapidly leafing through the book so fast that Latasha had a fear for its integrity. He found the correct page and was silent.
"Would it be asking too much for you to tell me what you are doing?" Latasha scoffed.
"I think I've had what you would call a eureka moment and I would call an epiphany," Jack muttered while continuing to read. "Yes!" he cried after a few moments, raising a triumphant fist in the air. He slammed the book closed and looked across the table at Latasha. "I have an idea of what to ask Allan to look for! It's weird, and if it is present, it might not fit all the facts as we know them, but it fits some of the most important ones, and it would prove Craig Bowman did not commit medical negligence."
"Like what?" Latasha demanded. She couldn't help but feel some irritation that Jack was being so coy. She was in no mood for games at almost five o'clock in the morning.
"Check out this strange symptom you wrote," Jack said. He reached over with the yellow pad and pointed to the notation "sensation of floating."
"Now, that's not your run-of-the-mill complaint of even the most dedicated hypochondriac. That suggests something truly weird was going on, and if Allan is able to find what I'm thinking, there would be the suggestion that Patience Stanhope was either a die-hard sushi fan or a crazed devotee of Haitian voodoo, but we're going to know differently."
"Jack!" Latasha said irritably. "I'm too tired for this kind of joking."
"I'm sorry" Jack said. "This apparent teasing is because I'm afraid I might be right. This is one of those situations, despite the effort involved, where I'd rather be wrong." He reached out for her. "Come on! I'll tell it to you straight while we hurry over to Allan's lab. This is going to go right down to the wire."
23
BOSTON, MASSACHUSETTS FRIDAY, JUNE 9, 2006 9:23 A.M.
Jack nosed his worse-for-wear Hyundai to the curb behind a brown UPS truck. It was a loading area on busy Cambridge Street in front of a long, arcaded, curved building facing Boston City Hall. Jack thought the chances of getting a parking ticket, even though he was planning on being as fast as he could, were close to one hundred percent. He was hoping the car wouldn't be towed, but in case it was, he took his carry-on bag with him along with a large envelope with the return address of the Office of the Chief Medical Examiner printed in the upper-left-hand corner.
He charged up a flight of stairs that penetrated the building and emerged into the courtyard fronting the Suffolk County Superior Court. Wasting no time, Jack sprinted over to the entrance. He was slowed down by security and the need for his carry-on, envelope, and cell phone to go through the X-ray machine. At the elevators, he made sure he pushed into the very next car.
As the elevator rose, Jack managed to glance at his watch. The fact that he was to be married in four hours wasn't lost on him, and the fact that he was in the wrong city gave him considerable anxiety. When the elevator arrived on the third floor, Jack tried to be as polite as he could as he struggled to get off. If he didn't know better, he would have thought the other passengers were deliberately impeding him.
