“I’m talking about some idiopathic reaction that has yet to be noticed.”
“No!” Michael said finally but firmly. “There’s nothing about anesthesia that could be antigenic. I’d like to say yes to get you off your collision course of thinking someone screwed up. But anesthesia agents have been used in too many people over too long a time for there to be an unrecognized immunological reaction that causes fever and monoclonal antibodies. Much less puts people into a coma. No way. Sorry, girl!”
“I knew you were going to say that.”
“I say it because it’s the truth. Now, let’s get down to the cafeteria. We have a dermatology lecture at nine.”
“I’m not finished,” Lynn said. She turned off her tablet and pocketed it. Next she turned to Morrison’s MRI. It was similar to Carl’s, showing extensive laminar necrosis. Closing the chart, Lynn looked over at Dr. Erikson, who was still alternatively writing a chart and dictating with her phone.
“I want to look at Carl’s chart again,” Lynn said impulsively, getting to her feet and picking up Scarlett Morrison’s chart in the process.
“But why?” Michael complained. He grabbed the arm of Lynn’s coat to restrain her. “Why risk it? Nothing will have changed.”
“We didn’t look at his blood work,” Lynn said, detaching her sleeve from Michael’s grasp. “And maybe she wrote something in the chart. If she did, I’d like to see it.”
17
Tuesday, April 7, 7:20 A.M.
Excuse me,” Lynn said as she came up to Dr. Erikson. She extended Morrison’s chart. “Thank you for calling our attention to this case. It is very similar to Vandermeer’s, and we should be following it for sure.”
The hematologist glanced up briefly.
“Should I put Morrison’s chart back in the rack or do you want it here with you?” Lynn asked.
Dr. Erikson pointed toward the desk next to her. “Here is fine,” she said distractedly without looking back up at Lynn.
“I hate to trouble you,” Lynn said, “but we would like to take another quick glance at Vandermeer’s. There’s something we missed.”
Dr. Erikson’s head popped up, and she regarded Lynn with icy blue eyes, and her nostrils flared. For a moment Lynn thought the woman was going to angrily deny her access to the chart. But then her expression softened.
“If it is a bother, we can come back later,” Lynn added quickly. Although she had not noticed it before, now that her attention had been drawn to the woman’s face, Lynn thought that the doctor did not look well. The paleness of her skin was striking, almost translucent, and her cheeks looked hollow. Beneath her eyes were purplish, dark circles. “I just thought you might be finished with it.”
“It’s not a bother,” Dr. Erikson said. She separated Carl’s chart from those in front of her and extended it toward Lynn, asking: “What year medical students are you two?”
“We’re fourth-year,” Lynn said. Her pulse quickened in anticipation of possible trouble. Now that she was close to the hematologist, she could see that the woman wasn’t exactly overweight, as she had thought earlier. It was more that her abdomen was distended, as if she might be four or five months pregnant, which seemed inappropriate, considering her age.
“And you are on a rotation in anesthesia?”
Lynn nodded. “The specialties are our final rotation before graduation.” She hoped Dr. Erikson would assume anesthesia was considered a specialty at Mason-Dixon, even though it wasn’t: just ophthalmology, ENT, and dermatology.
“Have you come to any conclusions why these patients have suffered comas?” Dr. Erikson asked.
“No, we haven’t,” Lynn said. She was nonplussed, wishing she had not gotten herself into conversation. “Have you any ideas?”
“Of course not,” Dr. Erikson snapped. “I’m a hematologist, not an anesthesiologist.”
Lynn wanted to leave but felt caught as Dr. Erikson was still holding on to Carl’s chart and staring at her with unblinking intensity. After a moment of strained silence the hematologist asked another question: “Do you have any hunches as to what might have happened?”
“Not so far,” Lynn said.
“If you come up with any particular ideas, let me know!” Dr. Erikson said. It was more of an order than a request. Finally she let go of Carl’s chart.
Relieved, Lynn said, “We’ll be happy to let you know if something occurs to us.”
“I’ll be counting on it,” Dr. Erikson said. Then she pulled a professional card from one of her pockets and handed it to Lynn. “Here are my contacts. Let me know right away if you come to any conclusion.”
“Thank you,” Lynn said, taking the card and glancing at it. She smiled uncomfortably and was about to flee back to Michael when Dr. Erikson added, “Do you have any questions for me?”
Despite her fatigue, Lynn tried to come up with a question. She desperately wanted to leave but thought it best to play the medical-student role and keep the conversation academic rather than take the risk of having it turn to what she and Michael were really doing: namely, violating rules and looking at unauthorized charts. “Well...” she began, “in your consult note in Morrison’s chart you mentioned a possible monoclonal gammopathy. Do you think that was caused by her having had anesthesia?”
“Absolutely not!” Dr. Erikson said with a dismissive chuckle, as if it were the most ridiculous idea she had heard in a long time. “There is no way anesthesia could cause a gammopathy. The patient had to have had the condition prior to her surgery. It just hadn’t been recognized. With an asymptomatic gammopathy, the only way it can be discovered is by a serum electrophoresis, a test she never had had until I ordered one because of her unexplained fever.”
“I see,” Lynn said, trying to think up another question. “Are you doing a hematology consult on Carl Vandermeer?”
“Why do you ask?” Dr. Erikson said.
“Because you have his chart and you did a consult on Scarlett Morrison.”
“The answer is no,” Dr. Erikson said. “I am only seeing the patient as a courtesy since the nursing staff has told me the patient has had a temperature elevation, like Scarlett Morrison, with no apparent signs of infection.”
“Do you think that her fever is due to her gammopathy?”
“Now, that is an excellent question,” Dr. Erikson said.
Lynn breathed a sigh of relief. Now she knew she could break off the conversation without leaving behind an irritated attending who otherwise might be tempted to ask questions and blow their cover.
“An immune response can indeed cause a temperature elevation,” Dr. Erikson said in a didactic monotone. “There is no way to know for sure, but since an infection has been ruled out, I think it is safe to say the elevated temperature is due to her gammopathy.”
“Is something stimulating her immune system and keeping her temperature elevated?”
“I would have to assume there was. Perhaps it’s the stress of what happened to her. But I really don’t know.”
“Is there any treatment for her gammopathy?”
“It is not necessary to treat it unless the elevated protein interrupts kidney function or if the gammopathy progresses to a blood cancer.”
“You mean like multiple myeloma.”
“Exactly. Multiple myeloma, lymphoma, or chronic lymphocytic leukemia.”
“Since Vandermeer has an elevated temperature and no immediate signs of infection, do you think he has a gammopathy?”
Dr. Erikson didn’t answer immediately, and Lynn feared the volatile woman was getting irritated all over again as her eyes had narrowed and her nostrils flared. Lynn berated herself for not leaving when she had the opportunity.