Julie nodded her agreement. “It’s pretty remarkable.”
“Well, the EKG does look unusual for a typical heart attack. I wish he’d had an echo done. Even without one, I wouldn’t dismiss a takotsubo incident, but I wouldn’t diagnose it, either.”
“Someone deleted something in that record postmortem,” Julie reminded her.
“Are you suggesting a cover-up?” Michelle asked.
“My best guess is Dr. Coffey locked me out of Colchester’s file for a reason. But I know there were deletions in Sam and Tommy’s records, as well as Donald Colchester’s. And all three had the same unusual EKG, and we know for sure about left ventricle apical ballooning in two of the cases. Something isn’t right here. Not right at all.”
“Forget the EKGs for a second,” Lucy said. “Explain to me how someone with chronic COPD like Tommy, a quadriplegic like Sam, and guy with advanced ALS all suffer a stress-induced heart attack. What kind of stress event could they have had? It’s honestly never made sense to me.”
Julie sighed aloud and recalled how Dr. Coffey had said something very similar. Nothing was adding up. It never had. Takotsubo was an instant reaction to an extreme stimulus. These men were all debilitated in some capacity. What kind of stimulation could they have possibly experienced?
Julie’s stomach rumbled. She had not eaten breakfast, and the line at the counter was not long anymore.
“I’m going to grab a muffin,” Julie said. “I’ll be right back.”
She asked the counterperson for a banana walnut muffin and realized she had been rude not to get something for her friends. She decided to surprise them with a breakfast treat and ordered two more of the same muffin. She brought the treats back to the table on a plate.
“I got one for each of us,” Julie said.
Lucy picked up her muffin, examined it closely, and set it back down.
“Do you know if this muffin has walnuts in it?” she asked.
“Yeah,” Julie. “It’s banana walnut, to be precise. I’ve had them before. They’re delicious.”
Lucy pushed the muffin away. “Oh, good. You promise to give me CPR?” She said this with a twisted grin.
Julie slapped her forehead. “Oh my gosh. I’m so sorry. I completely spaced.”
Michelle got it. “Nut allergy, I’m guessing.”
“Horribly allergic,” Lucy said. “Growing up I was the only girl in my school with an EpiPen in her backpack. Now they’re as common as erasers, it seems.”
Julie perked up and looked at Lucy in a curious way. She picked up the muffin and examined it closely, turning it over in her hand, studying it as though she’d never seen a muffin before.
“See if they’ll exchange it for a blueberry,” Lucy said.
“No, it’s not that,” Julie answered, her voice a little distant. “It’s what you said earlier. What kind of stress event could Sam and the others have experienced? It doesn’t make sense, right?”
“Right,” Lucy responded.
“What are you getting at?” Michelle asked.
Julie set the muffin back down on the plate. “Let me ask you this, Lucy. Could that acute coronary pathology have manifested as an allergic phenomenon?”
Lucy’s eyebrows lifted as she mulled this over.
“I never gave it any thought,” she said, “but I suppose it’s possible. It could have been an allergic reaction, yes.”
“Which means it might not be takotsubo after all,” Julie said with some excitement.
“Then what could it be?” Michelle asked.
“To be honest, I have no idea,” Julie said.
“It’s worth looking into,” Lucy agreed. “But there’s a problem with that theory.”
“Which is?” Julie could not mask her disappointment.
“We did slides of Sam’s heart muscle to look at the muscle fibers. If it was an allergic reaction, we should have seen mast cell activation and a differential increase of eosinophils.”
“What are mast cells and eosinophils?” Michelle asked.
“They’re both part of the immune system,” Lucy said. “Eosinophils are white blood cells that, along with mast cells, control mechanisms associated with allergy and asthma. If it was some sort of allergy, I would expect those cells to be present in large quantity. But that’s not what the slides showed.”
“Is there any chance the slides were done incorrectly?”
Lucy shrugged. Years in the autopsy business taught her that anything was possible.
“Sure. If the tech was distracted or a wrong stain was used, it’s possible.”
“Would you mind checking for me?”
“You’re my sister from another mister. Of course not.”
“Sounds like we’ve made some progress here,” Michelle said as she flipped a page in the newspaper.
“You know what I’m thinking.” Lucy’s expression showed concern.
“What?” Julie asked.
“I’m thinking, look at what happened to Sherri Platt. Julie, are you really sure you want to dig into this any deeper?”
CHAPTER 37
The automatic doors of the ICU swung open and in came Shirley Mitchell. Shirley was not Julie’s first patient to come back to the unit on a hospital bed, nor would she be the last. This time, instead of pneumonia coupled with peripheral artery disease, Shirley had returned to the ICU with serious GI bleeding. The nurses watched her carefully throughout the morning, but her bleeding persisted and her blood pressure had begun to drop. Shirley received one unit of blood and two more were on the way.
Julie put on her protective equipment: a blue plastic gown, gloves, and mask with a splatter shield. She would be prepared for any brisk bleeding. During the initial examination, Shirley was agitated, swatting at the nurses, refusing to have leads placed for telemetry, and making a grab to pull out the IV. At one point she yelled, “The movie is over and I don’t want any popcorn!”
Clearly, Shirley was not at all herself. Julie checked the readouts after the nurses finally attached her to the telemetry monitor, blood pressure cuff, and pulse oximeter.
Oxygen level was only about 87 percent on three liters nasal cannula. Her heart rhythm was irregular and fast, alternating between 115 to 120 with frequent bursts to the 140s. Blood pressure rang off as criticaclass="underline" seventy-eight over forty-four. They were behind. The bleeding was obviously profuse and Julie needed all hands on deck. She started with the litany of orders needed to save Shirley’s life.
“Nancy-hang two liters of nasal saline, wide open.”
“Vicky-call the blood bank and tell them to send two units of blood superstat. And to prep for four more units.”
Marie, the secretary, poked her head around the corner. “Dr. Devereux, I seated the family in the waiting room. I told them it would be a while until she stabilizes. Anything else you need?”
“Thanks, Marie, I’m good.”
Julie examined Shirley’s battered arms. No nurse would be successful in finding another IV site anytime soon. Placing a central line seemed inevitable. But to start, Julie needed to develop a plan of attack to stop the bleeding.
Her first phone call was to the gastroenterologist, Dr. Morgan. After some negotiation (necessary when dealing with a specialist) it was decided to proceed with a CT scan of the abdomen, to be followed by a colonoscopy after the patient stabilized. Dr. Morgan was betting on diverticulosis as the cause, which in 90 percent of cases would stop bleeding on its own. But when Julie got a call from the lab, plans needed to change quickly.
“Shirley Mitchell’s troponin is ten point four,” the lab tech reported. “And her hematocrit is only twenty-two.”
Julie, her face grave, announced the news to her team. The job of keeping the blood going into Shirley’s body from coming out was easy to say, but harder to do. Those labs indicated the job was far from complete. The CT came back as expected: nonspecific findings. Julie gave Dr. Morgan another call.
“I would consider a colo,” Dr. Morgan said, “but right now, with her lung disease and her heart in bad shape, it’s just too risky. She’ll arrest on my OR table.”