Cold Steel (5 page)

Something?

'Yeah, like a big stain.'

Do you know what colour it was or where he'd come from or where he went?

'Nah.' Emphatic. 'Nah, I watched him as far as that Indian takeaway down there,' a finger poked in the general direction, 'then he disappeared behind a big truck parked along the side of the road.'

Around eleven o'clock a driver coming back to base had seen someone similar, 'Running about like a chicken with its head cut off. Christ, he was going around in circles, then
shot off down the road. Big ugly-looking bastard, mean-looking. Totally spaced out if you ask me.'

He'd also been spotted by a bouncer in a pub along Pearse Street and a pizza delivery boy on a motorcycle remembered him vividly.

'He nearly ran straight inta me. Fuckin' wired to the moon, so he was. Shirt covered in blood.'

Blood, are you sure?

'Fuckin' sure. Either that or he missed his big mouth with the ketchup.' The delivery boy was so disgusted as he recalled the near accident he cleared his throat and spat a blob of phlegm onto the road. He was a small wiry youth with a thin face, reeking of cooking oil. 'And he had a tattoo on his head.'

On his head? You said he had long hair, how do you mean a tattoo on his head?

'On his forehead, ye dick.' A nicotine-stained finger went up to a spot above the delivery boy's left eyebrow. 'There.'

What was the tattoo like, did you get a good look at it?

'Are ye jokin' me? Get a good look at it!' The voice rose with incredulity. 'A big bastard covered in blood, wired to the moon and staggerin' about the place like a drunk and ye think I'm gonna start examinin' his face? On yer bike.'

But the scraps were helpful; taken along with all the other sightings and descriptions, a picture was forming.

6

5.00 pm

Dr Frank Clancy sat at his desk in the basement of the Mercy Hospital, deep in thought. The basement was the nerve centre of the hospital's laboratory and pathology work. Each day specimens of human tissue were brought there to be sliced, inspected and microscopically examined. Samples of blood, urine, sputum and faeces, along with swabs from outside and inside the body were analysed and reported. Grasped firmly in Clancy's right hand was a quarter A4 page with an FBC (full blood count) result on patient Harold Morell, ward three, four levels above.

As consultant haematologist to the Mercy Hospital Clancy was in overall charge of interpreting and advising on the many blood results churned out from the wards every day. He was a young man, just turned thirty-eight, with a shock of curly black hair. At six foot three, his boyish face was easily spotted around the wards. He had trained in Dublin, London and Chicago before being appointed to the prestigious consultant position three years previously. He frowned as he scanned the results for the sixth time in as many minutes, then turned to the PC in front of him and began tapping on its keyboard, pulling himself closer to the edge of the desk. He typed in
MORELL
first, then
HAROLD
,
followed by the same patient's date of birth and address
.
FILE NUMBER
276DE149
flashed on the screen. Clancy clicked on the
OPTIONS
button, then chose
HAEMATOLOGY
.
Within seconds all of Harold Morell's blood results appeared in chronological order. Clancy began scrolling to find the very first recorded FBC, a basic analysis reflecting his blood level and a count of the many sub-divisions of cells necessary to fight infection, allergies et cetera. It looked normal, dated 23/04/90 when Morell had first attended the out-patient department of the Mercy Hospital. Clancy checked to see what clinic he had been booked under.
CARDIAC
flashed on the screen. Next he scrolled slowly along the many blood tests ordered on Harold Morell in the years since. It took almost thirty minutes. They all looked basically normal, a rise in his white cell count reflecting an infection during one in-patient stay the only blip in an otherwise stable haematology pattern.

Clancy sighed and leaned back in his chair. He turned again to the blood result now lying innocently on the desk beside the PC, pulled a pair of reading glasses from the breast pocket of his white coat and perched them on his nose. Harold Morell's blood picture had changed, suddenly and dramatically. Dangerously and recently.

Clancy stood up, stretched and yawned, and walked slowly to a bench on which rested a row of microscopes. He sat down in front of one, flicked the light source and a tiny, intensely bright beam trained on a blood-red smeared glass slide set in place under the lens. Clancy slipped off his glasses and squinted down the eyepiece. With one hand he moved the slide about underneath, with the other he focused. Each time he shifted the slide a different view of the blood cells appeared. No matter which way it was moved the underlying picture was the same. Harold Morell's blood was severely depleted in white cells, those vital to fight off even the most trivial infection. There was an almost total absence of neutrophil polymorphonuclear leucocytes. He removed the slide and replaced it with a different one, this a bone-marrow smear.

Earlier, in ward three above, Clancy had sat behind
Harold Morell as the gravely ill patient lay on his side in his bed with the curtains drawn for privacy.

'You're going to feel a boring pain in your lower back now, Mr Morell,' he'd warned as he positioned his patient.

'Go ahead, doctor, do whatever you have to do.'

Morell had sounded weak and resigned. Gone was the strength of voice that had ordered men around building sites. He'd been a foreman and site inspector for years, a tall, burly man with hands like shovels.

Clancy had scrubbed to sterile standards, then donned surgical gloves and face mask and carefully swabbed Morell's lower back with antiseptic. He'd glided his trained fingers along the patient's back and upper pelvis, feeling for bony landmarks. Finally satisfied, he'd mentally marked the entry point and quickly injected local anaesthetic. The long point of the needle had dispersed the anaesthetic along most of the skin and immediate underneath tissue, down to bone. Next Clancy had slowly inserted the sharp-pointed, stainless-steel wide bore trochar until its tip met Harold Morell's pelvic bone.

'Okay now, Mr Morell, steady yourself.'

He'd sensed the older man stiffen in the bed. Slowly and delicately the trochar was turned until it bored through solid bone.

'Jesus Christ,' Morell had grunted through gritted teeth.

By the time he'd felt the pain it was all over. The trochar had passed right through bone and into marrow. Soft, treacly liquid had seeped out to be collected and analysed. It was this same marrow Clancy was now inspecting. There was virtually no evidence of the early forms of the white cells. Having few white cells in peripheral blood, that which could be drawn from a vein, was bad enough. But no sign of regeneration of white cells in marrow, the power house of blood formation, was even more ominous.

'Agranulocytosis, no doubt about it,' Clancy murmured to himself.

Agranulocytosis was the medical term for an almost
total lack of white cells in peripheral blood and bone marrow. Some doctors preferred the alternative label, neutropaenia, for the same condition. Clancy always opted for the longer version. He thought it sounded grander.

He picked up a Dictaphone and began recording his findings. As he spoke he flicked the pages of Harold Morell's in-patient chart. Morell was a sixty-one-year-old male with a seven-year history of angina, a condition of narrowing of the inside bore of the arteries around his heart such that it became momentarily deprived of sufficient blood from time to time. When this happened Morell had experienced pain and a sensation of tightening in the chest. He'd been admitted to the Mercy Hospital for tests, then further investigations and finally a coronary angiogram. Here a special dye had been injected into Morell's heart arteries to highlight their calibre and detect any sign of narrowing.

Clancy looked at the entries in the chart, noting the procedures that had been performed by cardiologist Linda Speer. He studied her findings:
'Stress ECG showed ST depression in the inferolateral leads. While not diagnostic these changes suggest underlying ischaemia.'
Next came the coronary angiogram result:
'Immediately after injection of the right coronary artery the patient experienced acute cardiac pain with ST elevation. Treated in the usual way with atropine, nitrglycerine and sub-lingual nifedipine. The pain settled after about six minutes. Critical coronary artery disease found involving principally the mid portion of the left anterior descending artery and mid portion of the right coronary artery. There is 50% stenosis in the proximal portion of the circumflex artery. Left ventriculography confirmed normal left ventricular function.'
Then her final recommendation: 7
have discussed this patient with Mr Marks with a view to coronary artery bypass.'

Morell had been sent home to await a suitable slot on the cardiac surgery operating programme but became suddenly unwell with unstable angina within a week and
readmitted as an emergency. Clancy turned to the operation notes on Morell's chart.

Pre-operative diagnosis: Unstable angina pectoris, recent
anterior myocardial infarction within 12 hours, streptokinase therapy. All secondary to three vessel
c
oronary artery disease.

Operative procedure:
U
rgent CABG
x
3 (LIMA to
LAD, VG to RCA3, VG to OM1)

Surgeon: Dan Marks

Anaesthetist: W. Carter

Assistants: N. Dowling and L. Speer

Perfusionist: L. Moloney

Complications: Re-sternotomy for bleeding

Notes:

Harold Morell was admitted with
a small anterior infarction where he was given streptokinase with a good result. Operated on later the next day, some 16 hours after admission. Three grafts placed, he has excellent distal vessels. In the immediate post-operative period Mr Morell bled a lot and the operation site was re-explored. Nothing important discovered and the bleeding settled. It may have been due to the
t
hrombolytic therapy. Post-operative recovery uneventful.

Discharge Drugs:
Adizem 120mgs
daily: D/N
Aspirin 300 mgs daily.

A thought flickered as Clancy read. Linda Speer had assisted at the operation. That was unusual. Cardiac surgeons preferred fellow surgeons during operations, men and women with similar technical skills. Speer was
certainly a world-class cardiologist, expert at examining and interpreting cardiographs, heart scans, angiograms and such like. Surgeon she most certainly was not. Clancy mulled this over, then dismissed his reservations as old-fashioned. He recognised more than anything else the notes reflected a straightforward and uncomplicated heart operation.

Harold Morell's pre-, intra- and post-operative treatments and management were excellent, of the highest international standards. Indeed he'd made such good progress he'd been discharged home after six days and scheduled for a follow-up angiogram three months later. Unfortunately he'd had to be readmitted as an emergency only four days previously when a simple throat infection had turned unaccountably life threatening. In the admitting ward, Morell had been feverish, sweating and shivering violently. He'd been prostrate with the illness and almost succumbed but for the timely intervention of intravenous antibiotics. As he'd rallied the treating doctors had started to delve deeper into the illness and discovered his rare and unusual blood disorder. That's when Frank Clancy had been called in.

Clancy flicked to the drugs treatment page in the chart. His lips puckered as he read. Morell was only on a standard anti-anginal tablet, Adizem 120 milligrams once a day, and D/N Aspirin. Clancy knew D/N Aspirin was routinely used in post-operative heart patients, it 'thinned' their blood thus allowing it flow more easily through narrowed arteries. D/N was the manufacturing pharmaceutical company's shorthand for day/night, their product a slow-release aspirin that maintained therapeutic levels in the bloodstream twenty-four hours a day. D/N Aspirin, a USA product, was not in the Mercy Hospital drug formulary but still a recognised and acceptable pharmaceutical agent.

Clancy turned to the daily notes, searching for any other drug regime that might not have been entered into the
pharmaceutical therapy pages. There was nothing. An unusual reaction to a treatment drug was the most likely explanation for Harold Morell's sudden and life-threatening blood picture. Yet, puzzled Clancy in the gloom, the medication he's on couldn't cause agranulocytosis. He sat back again, taking his glasses off and pinching the bridge of his nose. He looked aimlessly around the laboratory, as if somehow there might be an explanation for Morell's sudden blood change hiding behind the test tubes.

'Agranulocytosis,' he muttered to himself, 'that's the third case in as many months.' He spun the swivel chair round and around. 'What is going on?'

Clancy glanced at his watch and groaned. He was an hour behind time at least. He knew he'd be home late, his wife glaring at the clock, the dinner probably burned as usual.

Frank Clancy was married to a pretty brunette, Anne, six years his junior. They'd met at university where she'd been reading modern languages and he'd been swotting on pathology. They'd ended up studying each other and married within a year. Anne had followed him on the post-graduate training rounds of London and Chicago. She'd had their first child, Martin (aged eight), in England and the second, Laura (aged four), in Seattle. They'd gone there for a medical conference, only Anne went into early labour. Laura was born during the break between a lecture on leukaemia and a slide show on marrow transplants. The Clancy family had returned to Ireland when the Mercy Hospital position had been offered. Anne Clancy was delighted with the thought of a stable unit at last. But work pressures caused early tensions. Frank Clancy was a workaholic. He roamed the hospital wards later than most colleagues, made himself constantly available for worried telephone calls from his team. Anne and the children came to resent the late-night discussions on spiking temperatures or mismatched blood transfusions. Clancy had recently made a solemn vow to
scale back on his workload. As usual things weren't working out to plan.

He heaved a resigned sigh, then turned to the PC on the desk. Fingers itching, he typed in
AGRANULOCYTOSIS
,
followed by
SEARCH
,
followed by 01/01/97
THROUGH TO
13/05/98.
He waited as the hard disk memory ticked over. Then, onto the clear blue screen two names flickered:

Mary Hyland.

James Murphy.

This was followed by their addresses, dates of birth, next of kin and first attendances at the Mercy Hospital. Clancy remembered both patients vividly, could even see their faces in his mind. Each had been transferred to his care as they re-presented to the hospital. Each had developed a sudden and unexplained agranulocytosis. Both had finally succumbed to recurring infections, living only weeks from onset of initial illness.

Clancy then typed in the question he most wanted answered, which clinic they had originally been booked under:

CARDIAC

CARDIAC

'I thought so,' he muttered.