“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.”
“Grabbed it?” Dr. Nawaz yelled. “What necessitated her having to grab the frame?”
There was an uncomfortable pause as Paul and Carl exchanged glances.
“What is this, a conspiracy?” Dr. Nawaz demanded. “Somebody answer me!”
“There was kind of a whiplash effect,” Carl said. “I was in a hurry to get the patient back on the monitor, so we were pushing the table rather quickly. Unfortunately, it wasn’t aligned with the OR doorway. After the bump occurred, Constance came over to support the frame. She was still gowned and gloved. At that point, we were concerned about contamination, since the patient had awakened and his hands weren’t restrained. But there wasn’t any contamination.
”
“Why didn’t you tell me all this when it happened?” Dr. Nawaz snapped.
“We did tell you,” Paul said.
“You told me the table brushed the door frame. That is a far cry from hitting it hard enough to cause whiplash.”
“Well, whiplash might be an exaggeration,” Carl said, correcting himself. “The patient’s head fell forward. It didn’t snap back or anything like that.”
“Good God!” Dr. Nawaz mumbled with discouragement. He sat down heavily in a desk chair. He pulled off his surgical hat with one hand and gripped his scalp with the other while he shook his head in frustration. He couldn’t believe he’d allowed himself to get caught up in such a burlesque affair. It was now clear to him that the stereotaxic frame had to have slightly rotated as well as tipped down, either on impact or when the scrub nurse grasped it.
“We’ve got to do something!” Daniel said. It had taken him a moment to recover from the revelation about the OR table’s collision with the doorframe and its possible tragic consequences.
“And what do you suggest?” Dr. Nawaz questioned derisively. “We’ve mistakenly implanted a host of rogue, dopamine-producing cells in the man’s temporal lobe. It’s not like we can go back in there and suck them out.”
“No, but we can destroy them before they arborize,” Daniel said, with a flicker of hope beginning to crackle like a fire in his imagination. “We have the monoclonal antibody to the cell’s unique surface antigen. Instead of attaching the antibody to a heavy metal like we did for X-ray visualization, we bind it to a cytotoxic agent. Once we inject this combination into the cerebrospinal fluid, bam! The misplaced neurons are annihilated. Then we merely do another implantation on the patient’s left side, and we’re home free.”
Dr. Nawaz smoothed back his shiny black hair and gave Daniel’s idea a moment of thought. On the one hand, the idea of potentially rectifying a disaster for which he shared a significant responsibility was enticing, even if the method was unorthodox, but on the other hand, his intuition told him he shouldn’t allow himself to be dragged in any further by doing yet another highly experimental procedure.
“Do you have this cytotoxic antibody combination on hand?” Dr. Nawaz asked. There was no harm in asking.
“No,” Daniel admitted. “But I’m certain we could get it concocted on a rush basis by the same firm that supplied us with the antibody heavy-metal combination, and then have it overnighted.”
“Well, you let me know if and when you get it,” Dr. Nawaz railed as he stood up. “I said a second ago that we couldn’t go back in and suck out the misplaced treatment cells. The unfortunate irony is that if nothing is done and the patient ends up with the kind of temporal lobe epilepsy he most likely will, he’ll probably have to undergo something along those lines in the future. But it would be serious, ablative neurosurgery, requiring the removal of a lot of brain tissue with high attendant risk.”
“That strengthens the rationale for doing what I have proposed,” Daniel said, progressively warming to the idea.
Stephanie abruptly pushed away from the countertop and headed for the door. Her fragile emotions and fear of calling attention to herself notwithstanding, she couldn’t bear to hear another word of this exchange. It was as if the conversation involved an inanimate object rather than an iatrogenically stricken fellow human being. She was particularly appalled at Daniel, because she could tell that despite the dreadful complication, he was still maneuvering like a modern medical Machiavelli, in blind pursuit of his own entrepreneurial interests despite the moral consequences.
“Stephanie!” Daniel called, seeing her heading for the door. “Stephanie, why don’t you call Peter up in Cambridge and have him . . .”
The door closed behind Stephanie, cutting Daniel’s voice off. She began to run down the hall. She fled toward the ladies’ room, where she hoped she could cry in peace. She was upset about a lot of things, but mainly because she knew that she was as responsible as anyone for what had happened.
twenty-seven
7:42 P.M., Sunday, March 24, 2002
“Now, I do not mean to be a bother to you talented folks,” Ashley said, drawing out the words in his prototypal drawl. “And I do not mean to seem unappreciative of all your efforts. I apologize from the bottom of my heart if it distresses you, but there is no way I can stay here tonight.”
Ashley was sitting up in a hospital bed with the back cranked up as high as it would go. Gone was the hospital johnny, and in its place was his wacky tourist outfit. The only evidence of his recent surgery was a double-wide bandage on his forehead.
The room was one of the Wingate’s inpatient rooms, and it appeared more like a hotel than a hospital. The colors were all bright tropical hues, particularly the walls, which were peach, and the drapes, which were a combination of seafoam green and hot pink. Daniel was standing to Ashley’s immediate right in his efforts to dissuade the senator from leaving the clinic. Stephanie was standing at the foot of the bed. Carol Manning was ensconced in a purple club chair near the window with her shoes on the floor and her feet tucked in underneath her.
After the CAT scan, Ashley had been brought to the room and put in the bed to sleep off his sedation. Both Dr. Nawaz and Dr. Newhouse had left after they were certain Ashley was stable. Both had given Daniel cell phone numbers to be called if and when there was a problem, particularly a seizure recurrence. Dr. Newhouse had also left a vial of the fentanyl and diazepam combination that had been so effective, with the instructions that two cc’s should be given either intramuscularly or intravenously if the need arose.
Technically, Ashley was under the care of an impeccably groomed nurse by the name of Myron Hanna, who had been the Wingate Clinic’s recovery room nurse back in Massachusetts. But Daniel and Stephanie had stayed at the bedside, along with Carol Manning, for the four hours it had taken Ashley to wake up. Paul Saunders and Spencer Wingate had stayed for a while as well, but they had left after an hour with assurances that they too could be reached if needed.
“Senator, you are forgetting what I told you,” Daniel said with as much patience as he could muster. At times, it seemed that dealing with the senator was like dealing with a three-year-old.
“No, I understand there was a little problem during the procedure,” Ashley said, quieting Daniel by laying his hand on Daniel’s folded arms. “But I feel fine now. In fact, I feel like the spring chicken that I know I’m not, which is a tribute to your Aesculapian powers. You told me before the implantation that I might not notice much change for a few days, and even then it might be gradual, but that is clearly not the case. In comparison to how I felt this morning, I’m already cured. My tremor is almost gone, and I am moving with considerably more ease.”
“I’m glad you feel that way,” Daniel said with a shake of his head. “But it’s probably due more to your positive attitude or to the strong sedatives you were given than anything else. Senator, we believe you need more treatment, as I told you, and it is safer to remain here in the clinic, with all the medical resources at our fingertips. Remember, you had a seizure during the procedure, and while you were having the seizure, you acted like a completely different person.”
“How could I act like someone else? I have trouble enough being myself.” Ashley laughed, although no one else did. He looked around at the others. “What is wrong with you people? You all are behaving like this is a funeral rather than a celebration. Is it truly hard for you to believe how good I feel?”
Daniel had told Carol that the treatment cells had been placed inadvertently in an area slightly wide of where they were intended. Although he had downplayed the seriousness of the complication, he did tell her about the seizure episode and his worry that there might be more, and he admitted to the need for more treatment. Because of the presence of the restraints on Ashley’s wrists and ankles, he had even acknowledged the collective concern about what was going to happen when Ashley woke up. Luckily, such worries were proved to be unfounded, since Ashley a
wakened with his normal, histrionic personality as if nothing had happened. The first thing he did was insist the restraints be removed so he could get out of bed. Once that was accomplished and the slight dizziness went away, he demanded to put on his street clothes. At that point, he was ready to go back to the hotel.
Sensing he was losing the argument, Daniel glanced at Stephanie and then at Carol, but neither elected to come to his aid. Daniel looked back at Ashley. “How about we negotiate,” he said. “You stay here in the clinic for twenty-four hours, and then we’ll talk again.”
“Obviously you’ve had scant experience negotiating,” Ashley said with another laugh. “But I will not hold that against you. The fact of the matter is that you cannot keep me here against my will. It is my desire to go back to the hotel, as I informed you yesterday. Bring whatever kind of medication you think I might need, and we can always come back here if need be. Remember, you and the ravishing Dr. D’Agostino will be conveniently right down the hall.”
Daniel glanced up at the ceiling. “I tried,” he said with a sigh and a shrug.
“Indeed you did, Doctor,” Ashley admitted. “Carol, dear, I trust our limo driver is still outside, waiting for us?”
“As far as I know,” Carol said. “He was when I checked an hour ago, and I told him to stay until he heard from me.”
“Excellent,” Ashley said. He swung his legs over the side of the bed in a manner that surprised everyone, including himself. “Glory be! I do not think I could have done that this morning.” He stood up. “Well then, this country boy is ready to return to the pleasures of the Atlantis and the splendor of the Poseidon Suite.”
Fifteen minutes later in the parking area in front of the Wingate Clinic, a discussion ensued about the travel arrangements. Eventually, it was decided that Daniel would ride with Ashley and Carol in the limo while Stephanie would drive the rent-a-car. Carol had offered to ride with Stephanie, but Stephanie assured her she would be fine and actually preferred to be alone. Daniel had the vial of the sedative combination, several syringes, a handful of sealed individual alcohol pledgets, and a tourniquet in a small, black, zippered pouch compliments of Myron. Armed with the medication, Daniel felt it was imperative for him to remain in Ashley’s presence in case of a problem, at least until Ashley was safely in his suite.