On one wall was a floorto-ceiling bookcase filled with volumes that Jeffrey recognized immediately. Most of them were standard texts for anesthesia.
The others dealt with more general medical topics.
In the center of the room stood an old partners' desk, heaped with papers and books. In the comer of the room was an Eames chair upholstered in black leather that had dried and cracked. Next to the chair was a tall stack of books.
Kelly was leaning against the doodamb with her arms folded as if she was reluctant to enter. "Quite a mess," she said.
"You don't mind if I look around?" Jeffrey asked. He felt a certain kinship with his dead colleague but did not want to trespass on Kelly's feelings.
"Be my guest," she said. "As I told you, I've finally come to terms with
Chris's passing. I've been meaning to clean this room for some time. I just haven't gotten around to it."
Jeffrey circled the desk. There was a lamp on it, which he turned on. He wasn't superstitious; he did not believe in the supernatural. Yet somehow he felt Chris was trying to tell him something.
Open on the desk's blotter was a familiar textbook: Goodman and Gillman's
Pharmacological Basis of Therapeutics. Next to it was Clinical Toxicology.
Beside both books was a pile of handwritten notes. Bending over the desk,
Jeffrey noted that the Goodman and Gillman was open to the section on
Marcaine. The potential adverse side effects were heavily underlined.
"Did Chris's case involve Marcaine as well?" Jeffrey asked.
"Yes," Kelly said. "I thought you knew that."
"Not really," Jeffrey said. He'd not heard which of the local anesthetics
Chris had used. Occasional complications were seen with all of them.
Jeffrey picked up the stack of notes. Almost immediately he felt a tickle in his nose. He sneezed.
Kelly put the back of her hand to her lips to hide her smile. "I warned you it might be dusty."
Jeffrey sneezed again.
"Why don't you get what you want and we can retreat to the family room,"
Kelly suggested.
Through watery eyes, Jeffrey picked up the pharmacology and toxicology books, along with the notes, and carried them out with him. He sneezed a third time before Kelly shut the study door.
When they got back to the kitchen, Kelly offered a suggestion. "Why don't you stay for an early dinner? I can whip us up something. It won't be gourmet, but it'll be healthy."
"I thought you were off to an aerobics class," Jeffrey said. He was delighted by her offer, but didn't want to inconvenience her any more than he already had.
"I can work out any day," Kelly said. "Besides, I think you need a little
TLC."
"Well, if it wouldn't be a bother," Jeffrey said. He was amazed by her kindness.
"I'll enjoy it," Kelly said. "Now you make yourself comfortable on the couch. Take your shoes off if you like."
Jeffrey took her at her word. He sat down and laid the books on the coffee table. He watched her for a moment as she bustled about the kitchen, looking in the refrigerator and various cabinets. Then he kicked off his shoes and settled back to shuffle through Chris's notes. The first thing he came across was a handwritten summary of the anesthetic complication in
Chris's tragic case.
'.I'm going to run to the store," Kelly said. "You just stay put.,,
"I don't want you going to any trouble," Jeffrey said, making a motion as if to get up. But it wasn't true. He loved the fact that Kelly was willing to make such an effort for him.
"Nonsense," Kelly said. "I'll be back in a flash."
Jeffrey wasn't sure if Kelly had said nonsense because she saw through his fib or because to her it was no trouble. She was gone in the blink of an eye. Jeffrey heard her start her car in the garage, pull out, and accelerate down the street.
He glanced around at the comfortable family room and kitchen, pleased that he'd made the decision to call Kelly. Aside from deciding not to kill himself and not to fly away, in the last twenty-four hours it was the best decision he'd made.
Settling back again, Jeffrey turned his attention to the summary of Chris's anesthetic complication:
Henry Noble, a fifty-seven-year-old white male, entered the Valley
Hospital to undergo a total prostatectomy for cancer. The request from
Dr. Wallenstern was for continuous epidural anesthesia. I visited the man the evening before his surgery. He was mildly apprehensive. His health was good. Cardiac status was normal with a normal
EKG. Blood pressure was normal. Neurological exam was normal. He had no allergies. Specifically, he had no drug allergies. He'd had general anesthesia for a hernia operation in 1977 with no problems. He'd had local anesthesia for multiple dental procedures with no problems. Because of his apprehension I wrote an order for 10 mg of diazeparn to be given by mouth one hour prior to coming to surgery. The following morning he arrived in good spirits. The diazepam had had good effect. The patient was mildly sleepy but could be roused. He was taken to the anesthesia room and placed in a right lateral position. An epidural puncture was made with an 18-gauge
Touhey needle without problems. There was no reaction to 2 cc's of Lido- caine utilized to facilitate the epidural stick. Confirmation of the epidural location was made with 2 cc's of sterile water with epinephrine.
A small-bore epidural catheter was threaded through the Touhey needle. The patient was returned to a supine position. A test dose of.5% Marcaine with a small amount of epinephrine was then prepared from a 30 ml vial. This test dose was injected. As soon as the test dose was injected the patient complained of what he )described as dizziness, followed by severe intestinal cramping. The heart rate began to increase but not to the extent expected if the test dose had inadvertently been injected intravenously.
Generalized muscular fasciculations then appeared, suggesting a hyperesthesia state. Massive salivation intervened, suggesting a parasympathetic reaction. Atropine was given intravenously. Miotic pupils were noted. The patient then had a grand mal seizure which was treated with succiny1choline and Valium intravenously. The patient was intubated and maintained on oxygen. The patient then had a cardiac arrest. The heart proved to be extremely resistant to drugs, but finally a sinus rhythm was achieved. The patient was stabilized but did not return to consciousness.
The patient was moved to the surgical intensive care unit, where he remained comatose for one week, suffering multiple cardiac arrests. It was also documented that the patient had a total paralysis following his anesthetic complication that involved not only the spinal cord but cranial nerves as well. At the end of the week, the patient had a final cardiac arrest from which the heart could not be started.
Jeffrey looked up from the notes. Reading Chris's terse history of his complication recreated the terror that Jeffrey had felt when he'd desperately fought to save Patty Owen. The memory was so poignant that it brought perspiration to Jeffrey's hands. What made it so poignant were the striking similarities in the two cases, and it wasn't just -the dramatic seizures and cardiac
arrests. Jeffrey could remember with startling clarity the moment he'd seen salivation and lacrimation that Patty had had. And besides that there was the abdominal pain and the small pupils. None of these responses were usual side effects of local anesthetics, although local anesthetics were capable of causing an extraordinarily wide range of adverse neurological and cardiac effects in a few unfortunate individuals.
Jeffrey studied the next page of the notes. There were a number of words printed in bold letters. Two of them were "muscarinic" and "nicotinic."
Jeffrey recognized them, mostly from his medical school days. They had to do with autonomic nervous system function. Then there was the phrase