Rupture Page 5

  Eli could feel his mouth opening and his chin drop. He balled his right hand in a fist, quickly recounting the early morning hours. He had come in immediately, greeted the nurses, and put Landers at ease.This was preposterous.

  Fisher continued as he read from notes scribbled on a sticky pad. “Then, just as Korinsky started to repair the aortic rupture,” Fisher looked at Eli, like a judge about to deliver jail time, “you tore the liver and the patient exsanguinated.”

  Before stopping the impulse, Eli struck the top of Fisher’s desk. “That’s a damn lie.” The impact propelled a stream of coffee from Fisher’s cup, splattering across a stack of neatly arranged papers.

  Oh shit, Eli thought, his face burning with rage. He reached for the cup, to steady it, while trying to salvage the papers.

  “Leave it,” Fisher demanded as he pressed an intercom on his phone. “Julene, come in here please.”

  Fisher’s secretary entered the office with a wad of paper towels, as if she already knew.

  Fisher eased back from the edge of his desk, removed his glasses, and began to clean them with a white cloth from the drawer. Eli settled in his chair and tried to regain control, but rage still boiled inside.

  As Julene leaned over the desk, coffee dripping from the stack of papers, her tight blue skirt slid well above mid-thigh. She blotted and wiggled around until everything was tidy again. Eli glanced at Fisher. He seemed to be enjoying the show.

  Questions raced through Eli’s mind.Why had Korinsky called him in the first place? Why not one of his vascular surgery partners? And why concoct this absurd story for the chairman? Eli had faced fierce competition from surgeons before, a group always looking for an edge, more money, a promotion. But he had never faced an outright lie from a member of his own department. A falsification that ruined his reputation with his chairman, jeopardized his position, possibly his job, and had malpractice implications that he couldn’t even fathom at this point.

  Julene finished with the spill and left the room. Fisher’s eyes followed her backside until it disappeared behind the door. Then he growled, “Branch!”

  Eli’s attention snapped back to Fisher.

  “James Korinsky has been at Gates Memorial for over two decades. He is head of the Division of Vascular Surgery and chairs our committee on credentialing and privileges. I could go on and on.” He rotated a thick forearm to check the date on his watch. “You’ve been here, what, a week, barely? I would rethink your position on calling Dr. Korinsky a liar, and go hide in your lab while the smoke clears. Don’t you think?”

  Eli had no idea what to think. Only that he had come to the meeting to get a blessing from the chairman to start his clinical practice and his research laboratory. After sixteen years of school and training, the last eight spent in one of the finest surgical residencies in the country, all that anyone in his position could want was to have his own patients, decide who got what operation when, and reap the financial benefits, yes, but mostly enjoy the pure satisfaction of finally becoming a surgeon.

  Sure, he wanted his own laboratory; it was part of his dream of becoming a surgeon-scientist. But the research would take time, years even, before he was funded on his own through the National Institutes of Health. And until that happened, the last thing he wanted was to be banished to the laboratory, a move that would instantly brand him “rat doctor” among his colleagues.

  Fisher was still waiting for him to say something when Korinsky’s words struck Eli like a spotlight.

  “Got a meeting with the boss, do you?”

  He’d been set up. No doubt about it.

  Korinsky knew about the meeting because Eli, in the rush of Gaston’s operation, had volunteered the information. Now, the whole night was backfiring against him.

  “I’ve asked my secretary to cancel your clinics. That’ll free up some time. And you’ll still be in the call rotation, every third. I’ll add you to the trauma call so you can keep your hands wet, literally.” At this, Fisher made himself laugh.

  “Of course, without the clinical income of an elective practice, your salary will be cut. We’ll still fund a lab tech at the lowest salary level.”

  Eli could see his whole recruitment package dissolving before his eyes. At night, he would be surgeon to the local knife and gun club, a busy organization with an expanding membership. And during the day? Rat doctor with some inexperienced technician and barely enough money to buy a petri dish.

  “Are you getting all this, Eli?” Fisher asked, staring into his protégé’s glazed eyes.

  Eli couldn’t believe what he was hearing. Though his head was spinning, he sucked it up, military style.

  “Yes, sir.”

  “We’re not talking forever. Let’s reevaluate in six months, maybe a year, see how things are.”

  Fisher glanced at the door to indicate the meeting was over and Eli stood.

  “We’ve put a lot into you, Branch.” The chairman straightened the papers on his desk and Eli felt as if more was coming. He was reaching for the doorknob when Fisher looked up with an icy stare.

  “Don’t screw this up.”

  CHAPTER SEVEN

  GATES MEMORIAL HOSPITAL

  PATHOLOGY DEPARTMENT

  TUESDAY MORNING

  8:21 A.M.

  Meg Daily was seated behind the microscope, just ten feet in front of him, balanced on a stool with rollers that forced an inward curve to her back as if she were racing a motorcycle full throttle. Black hair fell over her shoulders in a straight shot before a sassy upward flip on the ends. She inched forward, just slightly, to realign her vision through the scope, a pair of blue scrub pants fitting snug and cinched tight at the waist.

  How long can I just stand here and stare?

  The previous afternoon, when he wasn’t throwing imaginary darts at Fisher’s head, Eli had wondered about the face hidden behind her surgical mask. He took a few steps to his right and leaned forward while trying to stay out of her peripheral vision. The silhouette of her face was obscured by strands of black hair that brushed olive skin, full lips poised in perfect concentration.

  “Can I help you?” she said, eyes still focused without so much as a twitch.

  Eli cleared his throat. “Oh, yes, Dr. Daily.”

  At this, she swiveled to face him, hands on her knees. The black pen in the pocket of her scrub top jiggled with animation.

  “I’m wondering if you had a chance to look at the aortic specimen.”

  “Good timing, Dr. Branch. I’m looking at it now.”

  “Eli, please.”

  To this she said nothing and returned her gaze to the scope.

  To his right, a Formica table was pushed against the wall. In the center of the table sat a metal tray about the size of a cookie sheet with a yellow slab of wax coating the bottom. Meg had washed the device and pinned it to the wax much like a frog readied for dissection in a middle-grade science class. It was a cylindrical cloth tube reinforced with a metallic mesh. Meg had left a cuff of native aorta at each end of the graft, their inside layers smooth and glistening like macaroni.

  “The device is intact, the steel matrix sound, no warping or fracture. I’ve examined the lining—no signs of sheer.”

  While she remained buried in the microscope, Eli looked around her office. Her small desk had a metal top with a stack of papers in the center. A single picture frame off to the side showed a girl—four, maybe five years old—a gray tabby cat snuggled close to her face.

  He glanced at Meg’s left hand.

  No ring.

  Maybe, as a pathologist, she doesn’t wear one. Formalin and diamonds? Not a good combination.

  But her hand was soft and slender, poised with a flesh-toned polish, not one of years dipped in preservative. With feline swiftness, she refocused the scope and stood, with an open-hand gesture toward the instrument. Eli leaned over the eyepiece into a hint of perfume.

  Or maybe she just smells that good, all natural, like when she first wakes up in the morning, li
ke when she —

  “Eli?”

  “Yeah, what?” He realized he had been staring through the double lens as though an endless tunnel.

  “What do you see?” she said with a half smile that made his face burn.

  “Oh, very interesting,” he offered at last. Eli bent over the microscope again until his eyelashes just brushed the lens. He focused on the slide and wished now that he had attended all those microscopy labs in med school.

  “Here, let me show you something,” she said.

  Eli stood, and in the process of switching places, a tassel of Meg’s hair brushed his cheek.

  She selected another glass slide from the collection in a metal tray, slid it under the microscope, and searched for a preselected image.

  “Yes, here it is.”

  She looked up from the instrument and motioned Eli to another eyepiece connected to the main microscope directly opposite hers.

  “Use the teaching scope so we can view at the same time.”

  Awkwardly, Eli bent toward the view piece. He had viewed cells in his lab hundreds of times, always sitting at the machine, his hands at the controls. Not since his second year of medical school had he been instructed to watch through the teaching scope. He preferred to switch places with her each time, more opportunities for accidental contact.

  “I marked it for you,” she said.

  Eli focused on a small blue smudge made by the tip of a marking pen. It isolated a colony of cells arranged in a rosette pattern.

  “Do you see it?”

  Eli diverted his eyes off the lens and across at Meg. The eyepiece blocked his view of her face, but Eli watched the tiny movements of her eyebrows and long dark lashes. There was a glance from large brown eyes, up quickly and then back to the eyepiece.

  “Sure, I see it,” Eli said, attempting to recover. “The big blue dot.”

  “And the cells beside it.”

  “Yes.”

  “I scraped them off the graft.”

  Eli knew it was common for native cells to migrate and stick on a prosthetic device. In fact, endotheliazation was a requisite process. Surgeons depended on it to keep the graft open.

  “Endothelial cells?”

  “Very good, Sherlock. But not just endothelial. There’s a second population of cells. Bizarre shape. If I didn’t know better, I’d say the cells look malignant.”

  Eli examined the cells more closely. Each nucleus appeared dark against a light cytoplasm speckled with densely packed granules. “They’re turned on,” he said.

  Silence.

  He looked at her, above the scope, and decided to wait her out.

  Finally, she rephrased his description. “You mean mitotically active?”

  Eli took a moment to choose his words. “If you wish, but I say they’re packing a load and about to blow.”

  Meg shifted in the seat and crossed her legs, tightly, toes hooking her calf. “It’s interesting you say that because some cells have already blown. Let me find them.”

  Back to the scope, Eli watched as high-powered fields blew past in a blur until his equilibrium was shot and he had to look away. A clock above a stainless steel sink showed 8:55. He had a cholecystectomy on a middle-aged schoolteacher at nine o’clock, the only operation remaining on his elective schedule since Fisher, his chairman, had cut off his private practice.

  “Here,” she said, somewhat louder, as if her words were held under pressure. “These cells lying just on the edge of the native aorta.”

  Eli located a group of cells in the center of the field. He tried to discern the difference in these cells before Meg told him.

  “The granules are disrupted, gone,” she said emphatically, in a higher pitch. “Do you see that?”

  Eli tried to raise his level of enthusiasm to match that of Meg’s.Speaking of turned on. But he didn’t yet understand the significance.

  “It’s like these cells have shot their —” She stopped and cleared her throat, “The cells have unloaded their cargo, as though programmed to burst upon contact with the intimal layer of aorta.”

  Although Eli felt a new level of interest, he responded, “So?”

  Meg Daily had obviously planned the sequence, this escalating series of molecular clues, taken the time to build the story, the characters choreographed a few microns apart on a world of glass. Now Eli felt it building to a climax.

  “See these tiny holes in the aortic wall?” she asked.

  Eli found the section of riddled aorta, moth-eaten as Meg had described it.

  “There are more,” she said, “not quite full thickness though, like something had eaten through or was eating through the aorta.”

  “Like a little alien,” Eli said with a laugh.

  “No, these are not the holes of mechanical failure.”

  No sense of humor. “I was only kidding.”

  “More like a chemical dissolution.”

  Eli thought about how serious she was, so completely into her work. The more technical terms she used—detailed morbid description—the more endearing she became. The moment was rudely interrupted by the high-pitched wail of his beeper.

  The OR.

  “Something doesn’t make sense,” Meg continued, listing her observations as she tried to fit the story. “The graft is intact. There was no migration. No thrombus that may have increased the intraluminal pressure. And the rupture occurred at both proximal and distal implantation sites.”

  Eli took over.

  “So, the barbs on the graft poked holes, weakened the wall, and it ruptured. Makes sense to me. All these patients have diseased aortas. Looks like cheese a rat’s chewed on.”

  “But the barbs didn’t cause these holes. They were intact and in the proper position.”

  “What are you getting at?” Eli asked. He knew that if he delayed any longer, he would be late to the OR. Punctuality was tracked and recorded for each surgeon; Big Brother always watching.

  Meg looked through the scope again as if for confirmation. “These cells, the funny-looking ones, are attached to the aorta just above and below where the graft was, and where the holes are, but not in any other location.” She stopped and looked at Eli to make sure he was listening. “As though the cells were put there, implanted. I’ve never seen anything like it.”

  Eli thought her last statement was a little pretentious.She couldn’t be more than thirty-five. How many had she seen?

  “Dr. Daily,” Eli said with great conviction to finish the discussion. “This was an old man with a bad problem. His time had come.” As he said this, Eli was surprised at how quickly he could formulate such a cold, clinical solution.

  “What do you know about this patient, really?”

  As he thought of Gaston, Eli began to wonder just what he did know about the man. His beeper went off, the OR calling again.

  “Is she on the table?” he asked after answering the call from a wall phone. “Be right there.”

  He hung up the phone and said, “There’s quite a story behind the man, actually.”

  Meg’s full attention turned to Eli. He secured the top button of his white coat and said, “I’d be glad to tell you about it sometime.”

  But Dr. Daily was peering through the scope again, absorbed in cells and holes and rat cheese.

  Eli walked toward the door. Just before opening it, she stopped him.

  “And Dr. Branch,” she said, brown eyes cresting over the scope. “I prefer Meg.”

  CHAPTER EIGHT

  GATES MEMORIAL HOSPITAL

  PATHOLOGY DEPARTMENT

  10:36 A.M.

  “Dr. Daily, there’s a phone call for you.” Ms. Conch spoke through a barely cracked door in the autopsy suite.

  She could see that the doctor was midway through the autopsy; a fifty-four-year-old man found dead in his apartment, the body decomposing over the past week, the smell eventually seeping under the door. She had removed the abdominal organs and was weighing the liver, a glistening brown slab swinging on the tray
like an order filled by the butcher.

  “Take a message, please.”

  Ms. Conch paused a moment to consider the life of this new female pathologist who had been at Gates Memorial only two months. She knew virtually nothing about her except that Dr. Daily was a single mother who rushed in after dropping her four-year-old diabetic daughter at day care each morning and rushed back home in the evening.

  As the chief anatomic pathologist, Meg Daily was called routinely throughout the day, mostly by residents and medical students needing autopsy results. Although this phone call originated from outside the medical center, it was not the first call Ms. Conch had received from the day care. The tone of the caller’s voice let Ms. Conch know it would not be pleasant.

  “It’s the day care lady. Says Margaret isn’t feeling well, blood sugar’s low.”

  Meg placed the liver in a plastic bucket and looked at Ms. Conch, who had her full attention. “Transfer it in here, please.”

  A moment later, with a gloved hand streaked in blood, Meg removed the receiver of the wall phone. Ms. Conch heard her say, “How low is it, Ms. Williams?”

  Ms. Conch watched her reaction through the observation window. Dr. Daily closed her eyes and her body became rigid.

  “Thirty-six! Well, give her some juice, please.” The doctor’s eyes shot wide open. “What’s she doing right now?” She took a step forward. “Okay, Ms. Williams, you need to call an ambulance. Call nine-one-one, right now!”

  Ms. Conch continued to listen as the doctor began to pace, flipping the phone cord like a whip.

  “Yes, you have to. I’ll meet her in the ER.”

  Meg slammed the receiver down and ripped off her gloves.

  Ms. Conch cracked the door again. “What can I do?”

  Dr. Daily looked at the body on the table, the abdomen and chest splayed open with individual organs waiting to be weighed and examined. “Bring me a large drape. I’ll just have to cover him until I get back.”