CHAPTER 25
The day after her meeting with Brandon Stahl, Julie made the short three-block walk from the ICU in the Tsing Pavilion to the Barstow Building, home to White Memorial’s famed Center for Cardiac Angiography, Angioplasty, and Arrhythmias, known as the C2A3. It was also where the director of C2A3, Dr. Gerald Coffey, kept a private office.
Dr. Coffey had been with White Memorial since the Pleistocene era, some staffers joked, but back in his day he had been at the forefront of new technical advancements in the field. He was a pioneer of acute myocardial infarction angioplasty, and had helped to perfect the procedure a decade before it became routine. He had completed his clinical training in cardiology at Harvard Medical School, his residency at Mass General Hospital, and a fellowship in cardiac medicine at Johns Hopkins, all best of the best.
The other cardiologists Julie had spoken with about Sam’s case suggested she direct her inquiry to Dr. Coffey, but he had been unavailable until now. It was good fortune that his schedule cleared at a time when she had new and perhaps startling information to share.
Julie’s legs ached as she hurried to make her appointment on time. She had spent the past five hours on her feet and desperately wanted to decompress in the hospital cafeteria with a cup of mud-colored coffee and The Boston Globe. Rare was the morning Julie had time to read the paper, and today was no exception.
Her Wednesday workday had begun just after sunrise, when she met with her ICU nursing staff and respiratory therapists before morning rounds. She was now on an extended lunch break. So far it had been a typically atypical day, with a variety of administrative issues and unpredictable patient ailments.
Julie took the elevator up to the third floor and proceeded down a quiet, carpeted corridor, dimly lit as any casino. She found Dr. Coffey’s office, fourth on the left, and checked the time. One minute before the hour. Good start. She knocked twice, and a voice softened with age told her to enter.
Dr. Coffey’s spacious office had a window and a view of the quad. Julie tried to contain her envy; her office was a refurbished maintenance closet, a quarter the size of this one, without any natural light. Dr. Coffey rose from his chair behind an expansive oak desk, giving Julie a look at his thin frame. He extended his hand. His grip was firm as Julie introduced herself. They had never met, but with so many physicians at White, that was no great surprise.
Everything in the office was impeccably neat, from Dr. Coffey’s desk to the bookshelves, to the fine mane of silver hair that topped a strong, square-shaped face. He wore black plastic glasses with thick lenses that magnified brown eyes set close to a snub nose. Underneath a white lab coat he wore a rose-colored shirt adorned by a solid red tie. The office walls were plastered with framed diplomas and certificates, as well as a large photograph of Dr. Coffey playing golf with the mayor of Boston. Another photo showed him inside the cockpit of a plane he piloted.
“Please have a seat,” Dr. Coffey said. “Can I offer you something to drink? Lemon water, perhaps?”
He has lemon water in his office?
“No, thank you,” Julie said.
Dr. Coffey went to a small refrigerator (he had a refrigerator, too), poured two glasses, and gave one to Julie.
“In case you change your mind,” he said. “Now, what can I do for you?”
“I want you to have a look at this EKG, if you wouldn’t mind.”
Julie produced several printouts from her purse and handed them to Dr. Coffey.
“The patient died,” she said. “These were recorded shortly before death.”
“You pulled this from an electronic medical record, I assume.”
“Yes,” Julie said. “The cloud-based system stores everything now.”
“Cloud-based.” Dr. Coffey said it with contempt. “To me a cloud is something puffy in the sky that one flies through.”
“It’s just a way of storing data,” Julie said, though she did not fully understand the cloud herself. Her son Trevor could explain it to them both.
“Have you ever flown a plane?”
“Can’t say that I have.”
He pointed to the picture on the wall of him in the cockpit of one. “No feeling like it,” Dr. Coffey said. “The only thing that makes me consider retirement is more time in the sky. That’s why I’m very protective of my schedule. Got to make the most of every minute.”
In her mind, Julie rolled her eyes. This was his not so subtle way of telling her to make it quick.
“I hope this won’t take up much of your time,” Julie said.
Dr. Coffey adjusted his glasses and cleared his throat, then took a sip of his lemon water.
“Very well,” he said. “Let me have a look.” He held the eight-by-ten printouts to his face, but did not study any image for long.
“Yes, I see the AVR elevated here, along with the anterior leads V2, V3, V4. Was the patient male or female?”
“Male.”
“Over forty?”
“That’s correct,” Julie said.
“So it’s atherosclerosis disease, buildup of plaque in the arteries.”
“But there’s no evidence of heart disease in the medical record,” Julie said.
“Please,” Dr. Coffey said dismissively. “Ten percent of patients have plaque we can’t see.”
“Can’t see? Really?”
“Think of a Twinkie,” Dr. Coffey said.
Julie looked baffled. “A Twinkie?”
“Yes. I use this analogy with my Harvard students every year. It connects with them. Now, imagine a large tube that has this Twinkie inside it, such that when you bend the tube where the Twinkie is, it cracks open, causing the white filling that represents free cholesterol to pour into the tube. That stimulates the clotting cascade and an acute thrombus forms. The body naturally produces elements like tissue plasminogen activator, which causes the clot to dissolve, and others that break the residual Twinkie plaque down like Pac-Man-gobbling ghosts. When you come back to the tube at the time of doing an angiogram, you find it clear of the filling and the Twinkie. But that’s only temporary. The Twinkie comes back, cracks open again, and gets gobbled up again.
“Now, and I’m just thinking out loud because the EKG is very nonspecific, this could be a coronary artery vasospasm.”
“And that is?”
“Smooth muscle constriction of the coronary artery,” Dr. Coffey explained. “You can have nonexertional chest pain with ST-segment elevation. Patients may perform normally on the stress test, but constricted blood flow could result in ventricular fibrillation.”
“Very well, but have a look at this. It’s the patient’s echo.”
Dr. Coffey reached across his desk and took the printout from Julie’s hand.
“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.”