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 all accounts 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.