He entered the building through the 30th Street receiving dock where bodies were brought in, waved to the guard manning his security desk and then to the two evening-shift mortuary techs in their office. Taking the back elevator, he went up to the floor where he and the rest of the medical examiners had their offices. As he descended the hallway, the sound of his heels echoed loudly. Except for thebasement and the radio the guard had, the building was deathly quiet and seemed completely deserted.
The moment he turned on the light in his office, he saw the hard copy of Madison Bryant’s Bellevue hospital records front and center on his desk. As usual, Bart Arnold had been true to his word. Sitting down, Jack opened the record and started reading. There was a lot of material, beginning with transcripts of the EMTs’ communications with the Bellevue trauma team when they first arrived on scene at the subway station. Again, Jack was impressed with how lucky Madison was to have survived the initial fall onto the tracks and being passed over by the train, as well as to have avoided any contact with the highly electrified third rail.
What he was searching for in the records was any hint of cardiac problems, but there were none, not in the ambulance on the way to the Emergency Department trauma center or while in the Emergency Department itself. There were several electrocardiogram, or ECG, tracings from the time in the Emergency Department as well as in the OR when the stump of her leg was revised and sutured closed after the foot had been dismembered by the train.
The next part of the record documented her arrival and stay in the intensive-care unit. Jack carefully read all the entries by intensive-care hospitalists, doctors who specialized in intensive care, as well as intensive care nurses. There was a lot of material, as was usually the case. Once again there was no mention of any cardiac abnormalities whatsoever that might have been a harbinger of the ventricular fibrillation that abruptly occurred and had not been at all amenable to treatment even though the treatment was started within seconds. Turning to the lab values for her blood work and chemistries, Jack was curious to see if there was any recording of her electrolyte values prior to her heart attack since wide swings in electrolyte levels were well known to cause abnormal cardiac function, including ventricular fibrillation. However, all the values he saw were within the normal range.
Just when Jack was about to give up, thinking he was not going to find anything of note in Madison Bryant’s hospital record, he got another idea. With the enormous uptick in digital storage capacity, combined with the iCloud, Jack had in mind to see if there was any continuous recording in existence of Madison’s vital signs, including her ECG, prior to her fatal heart attack. Using his ability to log in to both the NYU and Bellevue databases, he looked up Madison Bryant’s record and was rewarded to find exactly what he was looking for: namely a record of her vital signs during her entire stay in the ICU. From the chart he knew the exact time of her cardiac arrest and was able to find that section without difficulty. As he had been told, the change was startlingly dramatic. The ECG was entirely normal until there was a sudden appearance of the erratic, sinusoidal, ventricular fibrillation when the heart’s conduction system went berserk. Going back and looking more carefully at the tracing, starting an hour before the fatal event, he searched for any changes, even subtle ones. Usually in such cases there were a few progressively aberrant heartbeats or other evidence that the cardiac conduction system was under stress from myriad possible sources, either structurally in terms of the coronaries or the heart valves or chemically from drugs or electrolyte changes. But there was nothing. There was absolutely no indication of the coming disaster, as Jack scrolled through the record. That was the case until the fibrillation suddenly erupted. Magnifying the tracings, he stared at several heartbeats just seconds before the final event, and when he did, he noticed some possible subtle changes. At first, he thought that maybe it was artifact, but he became more suspicious it was real when he watched the tracings a number of times in a row, particularly the three beats just prior to the onset of the fibrillation. By stopping the tracing to freeze-frame the heartbeats in question and then enlarging the image, he was able to study them, allowing him to measure the heights and the widths of the waves. Then moving the tracing to a normal earlier section, he compared the measurements.What became clear to him was that there was a progressive but subtle peaking of the T wave and a similarly subtle flattening of the P wave in the three beats before fibrillation started.
“Good Lord,” he voiced out loud. The slight but progressive changes he was seeing were reminding him of a case he’d been involved with along with Laurie more than a dozen years previously. It involved a nurse named Jasmine Rakoczi, who had been a serial killer at AmeriCare’s Manhattan General Hospital. She had been hired by an organization employed by a health insurance giant to kill off patients with inherited tendencies to develop expensive, serious diseases. As diabolical as the situation turned out to be, it had not totally shocked Jack or Laurie as they knew, like most health professionals, that health insurance companies love to collect premiums but hate to pay claims. Killing off clients destined to become seriously ill with chronic disease made a certain amount of sick sense to the company’s bottom-line.
What was reminding Jack of this notoriously depraved case was that the nurse had employed a demonically clever way to kill the victims, namely by using potassium chloride injected intravenously in a large bolus. The effect was to cause ventricular fibrillation, just as he was seeing on Madison Bryant’s tracing, and it was preceded by the same subtle changes. To be sure his memory was serving him appropriately, Jack used the Internet to look up potassium chloride and the changes it caused to the ECG. Quickly he ascertained that it was as he remembered.
Going back to Madison Bryant’s ECG tracing, he watched it several more times in a row, confirming to himself that a bolus of potassium chloride could have been involved. It certainly didn’t prove the existence of KCl in this instance, but it suggested a definite possibility. That led him to question whether a health insurance company could have been involved as it had been in the Rakoczi case. But he didn’t think so. Except for having lost her foot, Madison Bryant by allaccounts had been doing well and wasn’t going to be a lifetime healthcare burden. Thinking it had to be something else and not a random event, Jack went back to his previous thoughts of an association between the deaths of Kera Jacobsen, Madison Bryant, and Aria Nichols. What if they were all connected, and the overdoses were staged and not real? Although opioid deaths were so common and occurring on all strata of society, there was reason to suspect that Kera’s and Aria’s deaths could have been staged, especially when it seemed that neither one had been using IV drugs very long. And considering Madison’s death, maybe whoever pushed her in front of the train had something to do with her death in the ICU?
As he thought about these possibilities, he felt his heart rate pick up. If Madison had been purposefully given a bolus of potassium chloride, it had to have been done in the intensive care unit by someone in the healthcare community, like the nurse he and Laurie had exposed, or by an orderly, or by a doctor. People were always coming and going in the ICU, and although oversight of patient care was relatively constant, for those patients doing well, there were times when they were not being monitored by personnel but more by technology equipped with alarms. What that meant was that there were times when someone could administer a bolus of potassium chloride and get away with it.
“Oh my God!” Jack said as he raised his gaze to stare at his office wall with unseeing eyes. A new horror and new worry were taking form in his brain. If the three deaths were somehow connected with Bryant and Nichols being killed possibly to cover the death of Jacobsen, Laurie might very well be at risk since she had done the autopsy on Kera Jacobsen and had been supervising Aria Nichols’s investigation of the case. And the really scary part of that idea was that because of unfortunate timing, Laurie was now an inpatient in essentially the same medical center with an intravenous line in place in a private room, meaning she, too, could be at risk far more than if she were in the Bellevue ICU.
With a sudden sense of panic, Jack leaped up, turned out his office light, and then ran down the hallway to the front elevators. He had no idea of the veracity of his rather wild and possibly paranoid suppositions, but there was one thing that he was absolutely sure of. Despite Laurie’s objecting to his staying the night in her hospital room, he was going to do it anyway. If there was any risk whatsoever, he wanted to be there to make sure it didn’t happen.
Retracing his steps by heading north on First Avenue, he power walked the length of the NYU Langone Medical Center, noticing that most of the visitors had left from the Tisch Hospital as there were far fewer people, taxis, and rideshare vehicles clogging the entranceway. It was the same at the Kimmel Pavilion. Even the Kimmel elevator was distinctively less crowded. Same with the hallway on the eighth floor. Although there were still a few family members in some of the rooms, thanks to the hospital’s very tolerant position on allowing visitors pretty much twenty-four/seven, it was relatively quiet.
When he reached the door to 838, he noticed it was only ajar by three or four inches. Quickly but quietly, he pushed it open just enough to step within and then close it behind him. Inside the room it was quite dark with only a tiny bit of light spilling out of the slightly open door to the bathroom, where there was a night light. The only other illumination was from the monitor behind the bed still dimly displaying Laurie’s ECG. The beeping had been turned off. All the window shades had been lowered.
Approaching the bed on his tiptoes, Jack looked down at Laurie’s sleeping form. She was on her back with her face mostly lost in the shadow of her framing hair. In contrast to that evening when he had arrived, she was now quietly snoring and seemed the picture of total repose, thanks to the sleeping pills, the pain medication, and the remnants of anesthesia she’d had that day. A definite sense of relief spread over Jack, seeing that she was safe and that nothing had happened to her since he left and had conjured up the possibility she was in dangerbecause of her association with Kera Jacobsen and Aria Nichols. Watching her calmly sleeping made him question the validity of his fears and whether he was suffering from paranoia to have imagined such a scenario.
Reversing course, he made his way over to the sleeper couch positioned directly under the huge monitor that was now as black as night. After lifting one of the pillows to make sure it was a foldaway bed, he stood up and tried to decide whether to open it. The concern was that if he wasn’t careful, it might make a considerable racket and possibly awaken Laurie. Wanting to avoid that at all costs, he abandoned the idea. Instead, he turned around and merely silently lowered himself into a sitting position. Looking over at Laurie, who was about twelve feet away, he was relieved she hadn’t stirred. His plan was to stay there and keep watch all night.
After only a few minutes sitting in the dark, Jack sensed how tired he was. It wasn’t surprising, considering he had awakened before five that morning and had had a busy and emotional day. And as quiet as the hospital room was, he began to worry about falling asleep. Such a thought made him seriously question whether his presence alone could protect Laurie, given the rapidity with which potassium chloride was capable of eliciting a fatal ventricular fibrillation. Such a thought begged the question of whether someone could come into the room and inject Laurie even while Jack was there. The fact that he’d apparently proved that Madison Bryant had essentially died after three heartbeats was a dramatic confirmation of these fears. He had to think of something, but he had no great ideas. Could he stay awake somehow all night? He didn’t know that, either, but being realistic, he doubted it. The real problem was that he had no way of judging how probable his suspicions were or whether they were a distorted product of his overtired, emotional, and paranoid mindset. Maybe he should have a talk with the nursing supervisor when she came on duty at eleven or...
... five minutes later Jack shocked himself by being jolted awake after having slowly crumpled against the right arm of the small sleep sofa and then falling off onto his hands and knees on the floor. As quietly as he could, he scrambled to his feet, furious with himself. He’d worried about falling asleep, and now he had proved it was a real concern. Once again, he looked over at Laurie’s sleeping form in the half-darkness. Luckily, she was still quietly snoring and obviously still fast asleep despite the noise he’d made plopping off the couch onto the floor. He had to think of something before he really fell into a deep sleep and wasn’t lucky enough to fall off the couch in the process. Jack was well aware that he was a heavy sleeper, which probably had something to do with the amount of exercise he got on a regular basis. When Jack was really tired, even coffee wasn’t helpful. In medical school he’d been able to fall asleep standing up on occasion. Was there anything he could think of or do to make sure Laurie was safe? Was she really in jeopardy or was his imagination working overtime? There were many questions. Trying to think, he slowly sank back down onto the couch and leaned his head against the cushion. He could feel sleep threaten, and to avoid it overtaking him, he opened his eyes to their limits and took a deep breath...
CHAPTER 42
May 12th
3:05A.M.
The alarm on his phone went off at exactly 3:05A.M., and Carl turned it off. He hadn’t needed it to awaken him as he was already awake and pumped up about what he had to accomplish in the next half hour or so. On the previous occasion, when he was finally ready to take care of the Madison Bryant threat, he’d been apprehensive. But not on this occasion. In keeping with the adage “practice makes perfect,” Carl was confident that he would be able to eliminate with equal ease the even more worrisome threat Dr. Laurie Montgomery posed. His previous, hypothetical belief that a large intravenous bolus of potassium chloride would be the perfect surreptitious method to eliminate a human being had been proven beyond any doubt with the way it had worked with Madison Bryant. Even with the woman as a patient in an intensive care unit surrounded by intensivist doctors and nurses and her body later being subjected to an autopsy by forensic pathologists, no one had had any inkling of what had actually transpired. And tonight, with Laurie Montgomery, it wasgoing to be a breeze with her being in a private room instead of the busy ICU. In many respects it was going to be too easy, without the intricacies of the challenge the Madison Bryant situation presented.
Despite his confidence, he did not shortchange himself on his disguise. He made the same amount of effort with the black wig, dark heavy glasses, and long white doctor’s coat complete with a hemostat, a pair of scissors, a penlight, and several pens on prominent display in the breast pocket. The KCl-filled syringe was nestled in the depths of his coat’s right-side pocket. Once he was ready, he made one last check in the medical center database to confirm his destination. As he suspected, Laurie Montgomery’s room was still listed as 838. Thus prepared and after a final check on his disguise using his full-length mirror to make certain no one would recognize him, he left his office.
Although he could have gotten to the eighth floor of the Kimmel Pavilion any number of ways through the labyrinthine medical center that stretched nearly from 34th Street in the north to just shy of 30th Street in the south, he chose to walk outside. Despite his confidence in his disguise, he preferred not to run into anyone he knew, which was always a possibility within the well-lighted main corridors. As a major medical center with surgery going on around the clock, surgeons in particular were often in the hospital at all hours. Since Surgery and Pathology often had to work in tandem, he was acquainted with a number of them. Carl also avoided entering through the main Kimmel Pavilion lobby entrance for fear it would be too quiet, and he might attract the attention of one of the security personnel who might feel obligated for some unknown reason to check his med center ID. Instead he entered back into the medical center through the Emergency Department, where there was more activity twenty-four/seven.
Arriving on the eighth floor, Carl was immediately encouraged by the general peacefulness as he walked quickly and silently down the long, dimly lit hallway. At that moment on that particular floor it was as if the hospital was deserted, save for an occasional nurse or aidecoming out of one distant room and then quickly disappearing into another. Most of the rooms he passed were silent and dark, although there were a few where the lights were on and even a few where the quiet sound of the TVs drifted out into the corridor. Near the far end of the corridor he could plainly see the nurses’ desk because it stood out starkly as the only area brightly illuminated. Behind the counter-high barrier, he could just make out several heads either of nurses, aides, or clerks, who were most likely busy with data entry or paperwork.
Slowing down and then stopping when he came abreast of room 838, he noticed the door was nearly closed with but a half-inch gap between the door and the jamb. Pausing for a moment, he reached into his pocket to fondle the syringe loaded with the KCl just to reassure himself it was there waiting for him. After glancing up and down the hallway to make sure the coast was completely clear and his presence hadn’t attracted any attention, he used just the tips of his fingers to push gently against the door, slowly and silently opening it. Progressively the darkened room came into his view and ultimately the hospital bed. What caught Carl’s eye first, in addition to the dark-haired woman sleeping in the bed, was that her ECG was being continuously displayed on a monitor mounted in the wall behind and above the head of the bed. He thought this was convenient as it would immediately reflect the ventricular fibrillation and sound an alarm. Carl liked the idea of an alarm being involved as it would provide an explanation of why he had dashed into the room, if anyone were to ask. The other important thing he noticed was that there still was an intravenous line snaking into Laurie’s arm. If that had been removed, he might have had to scrap the entire plan and come up with a new idea. But he had been confident it would be there as normal protocol dictated it.
With a final glance up and down the corridor, he pushed open the door enough to allow him to step silently into the room. Pausing for a moment to allow his eyes to fully adjust to the relative darkness, he glanced around at the rest of the interior. Suddenly he froze. With anunpleasant sense of shock, he noticed a second occupant in the room. Curled up in a fetal position on a small couch was a man who Carl immediately assumed was Laurie Montgomery’s husband, Jack Stapleton, with whom he’d spoken on the phone that afternoon.
Carl’s first inclination was to immediately flee as this was an unexpected and unfortunate change in the circumstances. But he hesitated, silently telling himself that perhaps it wasn’t quite as bad as he had initially feared and might actually help to deflect attention once the feverish activity of the resuscitation attempt was initiated. On top of trying to save the patient, the resuscitation team and the floor nurses inevitably would have to deal with the aggrieved husband.
What had brought all this to his mind after the initial concern was recalling how rapidly the fibrillation would occur. Just like he had done in the ICU, Carl would start resuscitation immediately. By the time the husband would wake up, orient himself, and get over to the bedside, Carl could already be giving external cardiac massage, saying he’d heard the alarm while passing by in the hallway. If anything, the husband, as a physician himself, would surely participate, perhaps by giving mouth-to-mouth respiration. Suddenly Carl was so confident, he found himself smiling at the mental image of him and the husband trying to save the doomed Laurie. Carl knew full well that once the bolus of KCl was in her system and wasn’t immediately reversed, there was no way for the cardiac conduction system to function, no matter what any resuscitation team tried to do.
For another minute Carl continued to stand in the middle of the dark room as he rethought the entire scenario. When he did so, he was even more convinced that having Stapleton unexpectedly present actually afforded a way around the problem of his getting away after the deed had been done. It had worked like a charm in the ICU, but that was because there were so many people involved. Here on the private floor there would be far fewer people, particularly fewer staff doctors since the entire resuscitation team was composed of residents,mostly in internal medicine, and Carl’s presence would stand out, especially if someone questioned whether he had any private patients on the floor. As for Jack Stapleton recognizing him, he thought the chances were essentially zero. He doubted they had ever met, but even if they had, with his wig and dark glasses, Carl didn’t even recognize himself.
Fully reassured of his plan, he silently advanced up along the right side of Laurie’s bed. For a moment, as he listened to Laurie’s regular breath sounds in the darkness, he glanced up at the ECG as it metronomically traced its normal squiggle across the screen. He inwardly smiled as he anticipated that in a few seconds the tracing would suddenly change into the sinusoidal jumble of ventricular fibrillation, meaning the entire heart’s electrical conduction system had devolved to pure chaos.
