Mercy (21 page)

“Do you notice the apical ballooning of the left ventricle? This echo was taken around the time the patient began complaining of chest pain.”

“Who is this patient?”

“Donald Colchester.”

Dr. Coffey thought a moment before a look of utter surprise came to his face.

“Colchester? The murder victim from—what? A few years back now. What do you have this for?”

“I’ll explain in a moment.”

“The nurse who killed him—”

“Brandon Stahl.”

“Right, Brandon Stahl, injected his patient with morphine, if my memory serves.”

“You’re correct. That was in the evidence.”

“I don’t have to explain to you that an opiate overdose has a high probability of causing a heart attack, do I?” Dr. Coffey looked at the echo more closely. “In this case I’d say Mr. Colchester had a coronary occlusion of the left anterior descending artery, the one that feeds the left ventricle.”

“So you wouldn’t say this was takotsubo cardiomyopathy?”

Dr. Coffey blinked several times rapidly. “Takotsubo cardiomyopathy? Why would you even say that? Is Mr. Colchester a menopausal woman subjected to some sudden stress event? No, of course not. It is what I said it is.”

“A coronary occlusion of the left anterior descending artery,” Julie said, repeating what Dr. Coffey had just told her.

“That’s right. And what are you doing digging up one of White’s most notorious skeletons, anyway? Does this have anything to do with that failed appeal?”

“In a way,” Julie said. “And I appreciate the word of caution.”

“Not enough to proceed with any, it seems,” Dr. Coffey said.

Julie allowed a slight smile. The Donald Colchester murder was one of the darkest days at White, and Dr. Coffey was right to think her line of inquiry was ill-advised. But some questions demanded answers, just as some convicts deserved their freedom.

“I want to show you something else. It’s the pathology report from my fiancé’s autopsy.”

“Oh dear. That’s right. Your fiancé was in that horrible motorcycle crash. I read that on a news bulletin that went around. I’m terribly sorry for your loss.”

“Thank you. I appreciate it. But have a look at these slides. You can see the same apical ballooning of the left ventricle. And here the ST elevation registers on his EKG.”

Dr. Coffey spent a moment examining the second set of printouts, these belonging to Sam.

“This is just more atherosclerosis. Both these men had heart attacks.”

“Both of them had healthy hearts.”

“You say healthy. Ten percent have plaque we don’t see, remember?”

“The Twinkie.”

“Yes, the Twinkie. But in one of these cases the man was murdered, so there’s no odd correlation here. Again, I’m sorry for your loss, but it is what it is. You hear hoofbeats you think of horses, not zebras, and you certainly don’t think of a unicorn.”

“You’re saying takotsubo is a unicorn?”

“Absolutely! What condition were these men in?”

“One had end-stage ALS, and the accident left my fiancé quadriplegic.”

“So they had long-term, chronic stress for sure.” Dr. Coffey paused. “But a
sudden
stress event? I doubt it. Wait a minute. I need to refresh myself.”

From a bookshelf, Dr. Coffey pulled a large medical tome and opened to a page he found using the index.

“Here we go,” he said. “Yes, that’s what I thought. Takotsubo is an abnormal contraction of the left ventricle that extends beyond just one blood vessel. And here’s the important part: a stressful trigger will cause an abnormal surge in adrenaline, constricting coronary arteries, which results in poor blood flow downstream. As the stress decreases, the arteries open up again, and the angiogram looks normal.”

“Meaning?”

“Meaning if either of them had an acute stress event, which I’m telling you they didn’t, when it was over their arteries would have opened up. Which is why takotsubo is so rarely fatal. These patients were men, not subjected to any sudden stress, who suffered
fatal
heart attacks,” Dr. Coffey said. “That’s not takotsubo. It’s an undiagnosed coronary disease in the case of your fiancé, and murder in the other.”

“Could you maybe pass these around to get some other thoughts?”

Dr. Coffey’s face became a little red. “I don’t have time to go through this again, and honestly I don’t need you badgering my cardiologists with your questions.”

“I’m sorry, I was just trying to understand.”

“Oh please,” Dr. Coffey said. “A graduate from a state medical school would understand.”

Julie tried not to look offended. “I happen to have graduated from a state medical school. UMass Medical School, to be exact.”

Dr. Coffey pursed his lips together. “Then try to understand this. We’re all under pressure to perform financially and do what’s in the best interest of our patients. I suggest you focus on caring for yours, and let me focus on caring for mine. I gave you the answer, so there’s nothing more to say. I have another appointment elsewhere, so I’m going to have to end our meeting now.”

“I’m sorry to be a bother,” she said.

“And I’m going to hold on to these,” Dr. Coffey said, slipping the printouts into his desk. His expression bordered on apoplectic. “White Memorial doesn’t need a PR nightmare from some rogue ICU doctor making unsubstantiated claims about things she knows nothing about. And I sure as hell don’t need Roman Janowski breathing down my neck thinking my department in any way condones your misguided exploration.”

Julie stood shakily and backed toward the door. Coffey’s rancor had jarred her, leaving her a bit off-kilter. This qualified as a sudden stress event, for sure. Maybe her heart would have a sudden onset of apical ballooning.

“Now, I’m sorry for being so harsh,” Dr. Coffey added in a much softer tone. “You’ve lost your fiancé and I understand your need for closure. But I have a department to run, and what you’re doing with this Colchester business threatens to make my life and my job more difficult.”

“I assure you that’s not my intention.”

“Then prove it by dropping this matter entirely. Colchester was murdered, and his killer is in prison where he belongs. Your fiancé died of undiagnosed heart disease. That’s it. That’s the story. Though I do find it interesting.”

“What is that?”

“You have a bit of a reputation here at White as a crusader, so I know all about your stance on patient self-determination. Do you condone what Brandon Stahl did to poor Mr. Colchester?”

“I am in favor of examining the laws with regard to a patient’s right to die. I don’t condone murder.”

“Very well. At the risk of being a bit cold-hearted here, I would think part of you would be grateful your fiancé was no longer suffering.”

Julie seethed on the inside, but managed to keep her anger in check. “To be candid, Dr. Coffey, I don’t need you to tell me what to think or feel, thank you very much. And you can have those printouts if you want them. I’ll print out more if I need.”

Julie stormed toward the door, but stopped when Dr. Coffey called her name. She turned around, expecting him to apologize.

“Remember, Julie, unicorns don’t exist.”

Julie thanked him for his time, even if she chose not to believe him.

CHAPTER 26

Julie left Dr. Coffey’s office feeling ambushed and shaken. His explanation had some logic to it. Digging up unpleasant memories could call into question the competency of the cardiology department. After all, the group had access to the echo and EKG before Brandon Stahl’s trial. Why not bring it forward? Dr. Coffey had a sterling reputation to protect, which could explain his inaction and his discomfort with Julie’s findings.

Or perhaps Sam did have undiagnosed heart disease. And if that were true, Brandon Stahl was a murderer. Regardless of Julie’s personal beliefs on patient self-determination, the law clearly stated that Brandon had no business killing Donald Colchester. Go to jail; go directly to jail.

What Julie wanted now was a cup of tea and some company. What she got were two text messages in short succession, from different senders. They could not have come at a better time.

The first text came from Lucy:
Checking in. What’s going on? How are you doing?

The second text came from Michelle:
Off to meet Keith for lunch but want to know how it went with Dr. C. Any progress?

Michelle’s text was bit more specific. She knew Julie had a meeting with Dr. Coffey.

Julie texted back:
Didn’t go as hoped. Will explain later.

Michelle:
I’ll see Keith at dinner. Let’s meet for lunch in fifteen. Okay?

Julie called and invited Lucy to join them in the cafeteria in the basement of the Tsing Pavilion. Ten minutes later, Julie found Lucy, and the two women embraced with genuine affection. Neither felt they saw each other enough.

Both wore white coats over professional-looking outfits. Not all the docs here were dressed the same. A recent trend sought to do away with lab coats and neckties, because some studies cited them as culprits in the spread of infectious diseases.

Julie thought that was rubbish. The real villain was lack of basic hygiene. If all physicians took the time to wash their hands properly, those coats and ties would be as clean as any article of clothing.

Nevertheless, a movement had sprung up among the younger set to shun traditional attire altogether. Two camps had formed, those with coats and those without, and each wore their allegiance like Sneetches vying to be the coolest on the beaches. Julie and Lucy were old school. Roman Janowski was old school as well; he should have been opposed to dressing down, but he was shrewd when it came to recruiting talent. He made White Memorial a hip place to work.

Doctors dealt with life-and-death issues, and clothing choice had no relationship to patient outcome. But it represented a subtle shift in attitude that seemed to mirror a not-so-subtle shift in the business of medicine.

White Memorial was just another hospital in a long chain of health-care providers to migrate from a traditional HMO structure to become an accountable care organization. Julie did not expend much of her energy on the business side of medicine. She had enough to manage in the ICU, and the MBAs were best suited to make sure that more cash came in than went out. But Julie did not live with her head lodged under a rock, either. She had read up on ACOs in an attempt to ascertain if it was just HMO-style managed care disguised by another name. After some serious contemplation, Julie concluded that ACOs were an evolution to a better way of doing medicine.

There was reasonable concern that the ACO model would lead to an increase in hospital mergers, greater consolidation of market powers, and higher prices. So far Julie had not noticed much of a change since White Memorial adopted the model. ACO or HMO, Julie still had plenty of sick people who needed her care.

Michelle showed up later than expected, introductions were made, and it was not long before the three women were drinking their respective beverages and chatting like old friends.

Julie caught them up on her contentious conversation with Dr. Coffey.

“He said what?” Michelle asked.

“He said that I’m chasing unicorns,” Julie repeated.

Lucy was incredulous. “After he insulted her med school training. What an ass. You showed him the echo and EKG, I assume.”

“Of course I did. But he’s not at all convinced they mean anything.”

“Well, Sam had a clean heart,” Lucy said. “That should mean something to him.”

“It’s a Twinkie thing,” Julie said.

Lucy appeared perplexed. “A Twinkie thing?”

Julie spent some time going over what Dr. Coffey had explained to her about the vanishing sponge cake.

“So what, then? Abandon the search?”

Michelle’s question hit Julie hard. It was a reasonable one to ask, although the idea of accepting Dr. Coffey’s explanation did not sit well. If it had just been Sam’s case, Julie might have dropped the matter entirely. There was, however, this business with Brandon Stahl and his secret admirer to consider. The trio discussed this in detail as well.

“Who do you think gave Brandon Colchester’s file?”

Julie shrugged. “That’s a good question, Lucy. Nobody knows. It was someone who not only had access to the medical records system, but had a lot of knowledge as well.”

Lucy pondered that. “You know, I have a thought there.”

“Yeah?”

“I think this secret admirer of Brandon’s may have paid me a visit as well.”

“How so?” Julie was quite curious.

“Something to do with a cobalt poisoning case. I got results from a mysterious lab test that just happened to lead us to a correct diagnosis. I think I have an idea who might have sent me those test results, too. I’ll do some digging and let you know.”

“That’s wonderful. Thank you, Lucy.”

“Do you believe Brandon?” Michelle asked.

“He was very convincing. I guess I want to believe him.”

Michelle reflected on this. “If he’s telling the truth, then he has the worst luck imaginable.”

“How so?” Julie asked again.

“Well, he gets caught on tape offering to kill Colchester, which honestly I find deplorable, but that’s beside the point. Then Colchester dies of heart failure, but has the whole vanishing Twinkie thing, and Brandon gets sent away for murder. If that’s how it went down, it’s a shocking injustice.”

“You’re forgetting they found morphine in Brandon’s apartment,” Lucy said. “That taints him more than just a little in my mind.”

“Mine too, I guess,” Julie said.

Lucy said, “Let’s agree Brandon didn’t inject Colchester with a fatal dose of morphine, like he says. Then we’re still talking a very significant medical anomaly here. Two fatal cases in one hospital is more than just a unicorn, it’s a damn Pegasus.”

“Explain,” Julie said.

“Sam had a clean heart, and Brandon’s echo, from what you told me, was clear of any blockages. This Twinkie thing is ten percent of heart failure cases at most. Isn’t that what you said?”

“Well, that’s what Coffey told me.”

“Ten percent chance of it happening twice in the same hospital is an anomaly in my book. I’d love to get a look at that echo.”