“But how can you be so sure?” Daniel asked.
“Because of the timing and because of the olfactory hallucination,” Dr. Nawaz said. “The smell he reported was an aura, and a characteristic of a temporal lobe seizure is that it begins with an aura. Other characteristics are hyperreligiosity, profound mood changes, intense libidinal urges, and aggressive behavior, all of which the patient demonstrated in the short time he was awake. It was a classic example.”
“What should we do?” Daniel asked, although he was afraid to hear the answer.
“Pray that it was a one-time phenomenon,” Dr. Nawaz said. “Unfortunately, with the intensity the focus undoubtedly had, I would be surprised if he doesn’t develop full-blown temporal lobe epilepsy.”
“There isn’t anything that can be done prophylactically?” Stephanie asked.
“What I’d like to do but know I can’t is image the treatment cells,” Dr. Nawaz said. “I’d like to see where they went. Maybe then we could do something.”
“What do you mean where they went?” Daniel demanded. “You told me with your experience using the stereotaxic frame for injections, you have never had a problem of not being where you were supposed to be.”
“True, but I have also never had a patient develop a seizure during a procedure like this,” Dr. Nawaz said. “Something is amiss.”
“Are you suggesting the cells might not be in the substantia nigra?” Daniel protested. “If so, I don’t want to hear it.”
“Listen!” Dr. Nawaz shot back. “You’re the one who encouraged me to go ahead with this procedure without the appropriate X-ray capability.”
“Let’s not argue,” Stephanie interjected. “The treatment cells can be imaged.”
All eyes turned to her.
“We incorporated a gene for an insect cell surface receptor in the treatment cells,” Stephanie explained. “We did the same thing with our mouse experiments, specifically for imaging purposes. We have a monoclonal antibody containing a radiopaque heavy metal devised by a contributing radiologist. It’s sterile and ready for use. It just has to be injected into the cerebrospinal fluid in the subarachnoid space. With the mice, it worked perfectly.”
“Where is it?” Dr. Nawaz asked.
“Over in the lab in building one,” Stephanie said. “It is sitting on our desk in our assigned office.”
“Marjorie,” Paul said. “Call over to Megan Finnigan in the lab! Have her get the antibody and bring it over here on the double.”
twenty-six
2:15 P.M., Sunday, March 24, 2002
Dr. Jeffrey Marcus was a local radiologist on the staff at Doctors Hospital on Shirley Street in downtown Nassau. Spencer had made a deal with him that he would cover the Wingate Clinic’s radiological needs on an ad hoc basis until a full-time radiologist could be justified. As soon as it was decided a CAT scan was needed for Ashley, Spencer had a nurse call Jeffrey. Since it was a Saturday afternoon, he was able to come immediately. Dr. Nawaz had been pleased because he was acquainted with Jeffrey from Oxford and knew him to have significant neuroradiological experience.
“These are transverse sections of the brain, starting at the dorsal edge of the pons,” Jeffrey said, pointing at the computer monitor with the eraser end of an old-fashioned, yellow number-two Dixon pencil. Jeffrey Marcus was an English expatriate who had fled to the Bahamas to escape England’s weather, just like Dr. Carl Newhouse. “We’ll be traveling cephalad in one-centimeter increments and should be at the level of the substantia nigra in one or two frames, at most.”
Jeffrey was sitting in front of the computer. Standing to his right and bending over for a better view was Dr. Nawaz. Daniel stood immediately to Jeffrey’s left. By the window facing into the CAT-scan room stood Paul, Spencer, and Carl. Carl was holding a syringe loaded with another dose of sedative, but it had not been necessary. Ashley had not awakened since the second dose and had slept through his craniotomy hole being stitched closed over a metal button, the stereotaxic frame being removed, and his being transferred to the CAT-scan table. At the moment, Ashley was lying supine with his head inside the opening of the giant, donut-shaped machine. His hands were crossed on his chest with the wrist restraints in place but not secured. The IV was still running. He appeared to be the picture of peaceful slumber.
Stephanie was in the background, away from the others and leaning against a countertop with her arms crossed. Unbeknownst to anyone, she was fighting back tears. She hoped no one would address her, because if they did, she feared that she would lose control. She thought about walking out of the room but then worried that doing so would draw too much attention, so she stayed where she was and suffered in silence. Without even looking at the upcoming CAT scan, her intuition told her there had been a major complication with the implantation, and it had broken the back of her emotional control, which had been strained by everything that had happened during the last month. She berated herself for not listening to her intuition back at the beginning of this farcical and now potentially tragic affair.
“Okay, here we go!” Jeffrey said, pointing again at the image on the monitor. “This is the midbrain, and this is the area of the substantia nigra, and I’m afraid there is no radiolucency one would expect from a heavy-metal-tagged monoclonal antibody.”
“Maybe the antibody has yet to diffuse from the cerebrospinal fluid into the brain,” Dr. Nawaz suggested. “Or maybe there is no unique surface antigen on the treatment cells. Are you sure the gene you inserted was expressed?”
“I’m certain,” Daniel said. “Dr. D’Agostino checked.”
“Maybe we should repeat this in a few hours,” Dr. Nawaz said.
“With our mice, we saw it within thirty minutes and maximum at forty-five minutes,” Daniel said. He looked at his watch. “The human brain is bigger, but we used more antibody, and it’s been an hour. We should see it. It’s got to be there.”
“Wait!” Jeffrey said. “Here’s some diffuse radiolucency laterally.” He moved the tip of the eraser a centimeter to the right. The spots of lucency were subtle, like tiny flakes of snow on a ground-glass background.
“Oh my God!” Dr. Nawaz blurted. “That’s in the mesial part of the temporal lobe. No wonder he had a seizure.”
“Let’s look at the next slice,” Jeffrey said, as the new image started to wipe out the old from the top, moving down the screen as if unrolling.
“Now it is even more apparent,” Jeffrey said. He tapped the screen with his eraser. “I’d say it is in the area of the hippocampus, but to precisely locate it, we’d have to get some air into the temporal horn of the lateral ventricle. Do you want to do that?”
“No!” Dr. Nawaz snapped. He straightened up, clasping his hands to his head. “How the bloody hell could the needle have been so far off? I don’t believe this. I even went back and looked at the X rays, remeasured, and then checked the settings on the guide. They were all absolutely correct.” He lifted his hands from his head and spread them in the air as if pleading for someone to explain what had happened.
“Maybe the frame moved a bit when we hit the doorframe with the OR table?” Carl Newhouse suggested.
“What are you saying?” Dr. Nawaz demanded. “You told me the table brushed the doorframe. What exactly do you mean by ‘hit’?”
“When did the OR table touch the doorframe?” Daniel asked. It was the first time he had heard anything about it. “And what doorframe are you talking about?”
“Dr. Saunders said it brushed,” Carl said, ignoring Daniel. “Not me.”
Dr. Nawaz looked over at Paul questioningly. Paul reluctantly nodded. “I suppose it was more of a hit than a brush, but it doesn’t matter. Constance said the frame was anchored solidly when she grabbed ahold of it.”