As Jack climbed out of the car, the zeal that Latasha had generated came back in a rush. Alexis's comments had been a bit of a downer, but he didn't need her to tell him his ideas were preposterous. He was, as he had explained, thinking out of the box with a bunch of facts that were themselves seemingly implausible.
In contrast to his first visit, the emergency room was hopping. The waiting room was full, with almost every seat taken. A few people were standing outside on the ambulance-receiving dock. It was a warm, humid, almost summer night.
Jack had to wait in line at the admitting desk behind a woman holding a feverish infant in her arms. The child stared at Jack over the mother's shoulder with glazed eyes and a blank expression. As Jack moved up to the counter and was about to ask for Dr. Matt Gilbert, the doctor appeared. He tossed a completed ER admission note attached to a clipboard onto the desk when he locked eyes with Jack.
"I know you," he said, pointing at Jack. He was obviously searching for the name.
"Dr. Jack Stapleton."
"Right! The medical examiner interested in the failed resuscitation case."
"Good memory," Jack commented.
"It's the main talent I picked up in medical school. What can we do for you?"
"I need two minutes of your time, hopefully with Georgina O'Keefe. Is she here tonight?"
"She runs the show," the admitting clerk said with a laugh. "She's here."
"I know this is not the best time," Jack said. "But we exhumed the body, and I just did an autopsy. I thought you might like to know what was found."
"Absolutely," Matt said. "And this isn't a bad time. We're busy, but it's all routine stuff that should have been seen in the outpatient clinic or a doctor's office. There's no critical emergencies at the moment. Come on back into the lounge. I'll snare Georgina."
For a few minutes, Jack sat by himself. He used the time to look back over the two pages that constituted a record of Patience's ER visit. He'd pulled them from the case file while he'd been talking to Alexis.
"Welcome back," Georgina bubbled as she swept into the room. Matt came in after her. Both were dressed in white jackets over green scrub clothes.
"Matt said you dug up Mrs. Stanhope and did an autopsy. Cool! What did you find? I mean, no one has ever given us this kind of feedback."
"The interesting thing was that her heart appeared entirely normal. With no degenerative changes whatsoever."
Georgina thrust the backs of her hands onto her hips with her elbows out. Her mouth formed a disappointed, wry smile. "I thought we were going to hear something startling."
"It's startling in its own way," Jack said. "It's rare with sudden cardiac death not to find pathology."
"You came all the way over here to tell us you found nothing?" Georgina questioned with disbelief. She looked at Matt for support.
"Actually, I came to ask you if there was any chance she could have been given an overdose of any medication or maybe the wrong medication."
"What kind of medication are you talking about?" Georgina asked. Her smile faded, replaced by a wary confusion.
"Anything," Jack said. "Particularly any of the newer fibrinolytic or antithrombotic agents. I don't know; are you people involved in any randomized studies involving heart attack patients? I'm just curious. There's nothing like what I'm talking about on the order sheet." Jack handed the two pages over to Georgina, who glanced at them. Matt looked over her shoulder.
"Everything we gave her is on here," Georgina said, holding up the order sheet. She looked at Matt for confirmation.
"That's it," Matt agreed. "She was in extremis when she arrived, with practically a flatline on the cardiac monitor. All we tried to do was resuscitate her. We didn't try to treat her MI. What was the point?"
"She didn't get anything like digitalis?"
"No," Matt said. "We couldn't even get a heartbeat, even with dual-chamber sequential pacing. Her heart was completely unresponsive."
Jack looked from Georgina to Matt and back again. So much for the overdose or wrong medication idea! "The only laboratory reports on the ER notes are blood gases. Were any other tests done?"
"When we draw blood for blood gases, we routinely also order the usual blood count plus electrolytes. And with heart attacks, we order biomarkers."
"If they were ordered, how come there's no mention of it on the order sheet, and why aren't the results on the ER note? The blood gases are there."
Matt took the sheets from Georgina and quickly looked them over. He shrugged. "I don't know, maybe because they normally go in the hospital record, but since she died so quickly, she never got a hospital record." He shrugged again. "I suppose they are not on the order sheet because it's a standing order for all myocardial infarction suspects. I did mention sodium and potassium were normal in my note, so someone called the results to the ER desk."
"This isn't a big-city ER," Georgina explained. "It's rare to have a death here. Usually people get admitted, even those in bad shape."
"Could we call the lab and see if they could possibly locate the results?" Jack asked. He did not quite know what to make of this serendipitous discovery or whether it would have any meaning, but he felt obligated to see where the lead would take him.
"Sure," Matt said. "We'll have the clerk call up there. Meanwhile, we've got to get back to work. Thanks for coming by. It's strange you didn't find any pathology, but it's nice to know we didn't miss anything that could have saved her."
Five minutes later, Jack found himself in the tiny, windowless office of the evening laboratory supervisor. He was a large, heavyset man with heavily lidded eyes that gave him a sleep-deprived appearance. He was staring at his computer monitor with his head tilted back. His nametag read: "Hi, I'm Wayne Marsh."
"I don't see anything under Patience Stanhope," Wayne said. He had been very obliging when the ER had called, and invited Jack up to his office. He'd been impressed with Jack's credentials, and if he'd noticed the badge said New York rather than Massachusetts, he didn't mention it.
"I need a unit number," Wayne explained, "but if she wasn't admitted, then she didn't get one."
"What about through billing?" Jack suggested. "Somebody had to pay for the tests."
"Nobody's in billing at this hour," Wayne said, "but didn't you mention you have a copy of the ER record. That will have an ER accession number. I can try that."
Jack handed over the ER notes. Wayne typed in the number. "Here we go," he said as a record flashed up on the screen. "Dr. Gilbert was right. We did a full blood count with platelets, electrolytes, and the usual cardiac biomarkers."
"Which ones?"
"We do CKMB and cardiac-specific troponin T on arrival at the ER with repeats at six hours postadmission and twelve hours postadmission."
"Was everything normal?"
"Depends on your definition of normal," Wayne said. He twisted his monitor screen in its base so Jack could see it. He pointed to the blood-count section. "There's a mild to moderate rise in the white count, which is expected with a heart attack." His finger then went to the electrolytes. "The potassium is at the upper edge of normal. Had she lived, we would have wanted to check that, for obvious reasons."
Jack inwardly shuddered at the mention of potassium. The frightening episode with Laurie's potassium during her ectopic pregnancy emergency was still fresh in his mind despite its being over a year ago. Then his eyes happened to notice the biomarker results. To his surprise, the tests were negative, and he immediately called it to Wayne 's attention. Jack's pulse ratcheted up. Had he stumbled onto something significant?