By Keith Ablow
St. Martin's Press Copyright © 2004 Keith Ablow
All rights reserved.
Paramedics rushed John Snow into the Mass General emergency room at 4:45 A.M., unconscious, with shallow respirations. They had radioed ahead, reporting Snow as the victim of a self-inflicted gunshot wound to the chest. Snow's neurosurgeon, J. T. "Jet" Heller, thirty-nine, was one of the six doctors and five nurses who responded to the code red.
A medical intern named Peter Stratton had heard the gunshot on his way home from a night on call and dialed 911 from his cell phone. Police responded and found Snow collapsed in the alleyway in a pool of blood. His arms and legs were tucked close to his chest, fetal position. A black leather travel bag and a Glock 9mm handgun lay on the pavement beside him.
Snow was stabilized in the field, but his EKG flat-lined as he crossed the threshold into the E.R. The team shocked his heart back into rhythm three times, but his pulse never lingered longer than several seconds.
It was Heller who took the heroic steps, starting with a pericardiocentesis. Heart muscle is surrounded by a tough, membranous sac called the pericardium, stretched around it like a latex glove. But a bleed (a pericardial effusion) can occur between the muscle and the membrane, causing the pericardium to swell like a water balloon, putting pressure on the heart and preventing it from pumping. So when Snow's heart would respond to nothing else, Heller inserted a six-inch hypodermic needle under Snow's sternum and drove it down toward the heart at a thirty-degree angle, aiming to pierce the pericardium, siphon off any pooled blood and free the left ventricle to do its job. He tried seven times, but each time he pulled back on the syringe, he got nothing but air.
Snow's EKG had been flat line for over a minute.
"Should we call it?" a nurse asked.
Heller swept his long, blond hair back off his face. He stared down at Snow. "Get me a syringe filled with epi," he said.
Epinephrine was a cardiac stimulant sometimes administered intravenously to patients in cardiac arrest. No one moved to get it. They knew J. T. Heller had something much more invasive than an I.V. in mind, and they knew it was futile. Whether the bullet had ripped a hole in Snow's heart or transected his aorta, the wound had been fatal.
"He's gone, Jet," Aaron Kaplan, another of the doctors, said. "I know he's your patient, but ..."
"Get me the epi," Heller said, his sapphire blue eyes still fixed on Snow.
The team exchanged glances.
Heller pushed his way past the others to the code cart, rifled through the supplies, came up with a syringe full of epinephrine. He walked back beside Snow, squirted a bit of the epi into the air, then thrust the needle under Snow's sternum and emptied the 10cc directly into his left ventricle. He glared up at the monitor. "Beat, goddamn you!" He kept staring five, ten, twenty seconds. But there was only that flat line, that terrible hum.
Then Heller took the ultimate step. He reached to the bedside tray, picked up a scalpel and, with no hesitation, cut a six-inch transverse incision below Snow's sternum, reached into Snow's chest, grabbed hold of his heart and began open cardiac massage, rhythmically squeezing and letting go of the thick, muscular cardiac walls, trying to manually throw the heart back into gear.
"For Christ's sake, Jet," another doctor whispered, "it's over."
Heller pumped even more vigorously. "Don't quit on me," he kept muttering. "Don't you quit on me." But it was no use. Every time Heller stopped squeezing, Snow's EKG drifted back to a flat line.
Heller finally took his bloody, gloved hand out of Snow's chest. And as he did, Snow began to seize, his whole body trembling like a fish out of water, his teeth chattering, his eyes rolling back in his head. The seizure lasted just half-a-minute. Then Snow lay completely still, his eyes staring blankly at the ceiling.
Heller backed away from the gurney. He was soaked with sweat and blood. He stared at Snow, shook his head, as if in a daze. "You coward," he said. "You ..." He looked up at the others. "I'll call it." He glanced at the clock on the wall. "Time of death, 5:17 A.M."
Grace Baxter, owner of a toney Newbury Street art gallery, wife of George Reese, founder and president of the Beacon Street Bank & Trust, hugged herself to stop from shaking. Her internist had kept her on Zoloft and Ambien and a little Klonopin for about a year, but it was her very first hour of psychotherapy, and quite possibly the very first time someone had listened to her — really listened to her — for anything close to an hour. "I'm sorry to fall apart like this," she whispered. "But the medicines aren't working. I don't want to get up in the morning. I don't want to go to work. I don't want to get into bed with my husband at night. I don't want this life."
Dr. Frank Clevenger, forty-eight, glanced out the window of his Chelsea waterfront office at the line of cars creeping over the steel skeleton of the Tobin Bridge as it arched into Boston. He wondered how many of the people inside those cars really wanted to be going where they were headed. How many of them had the luxury of ending up somewhere where they would be expressing something genuine about themselves, or at least something that didn't make them feel like frauds, playing dress-up? How many of them would be returning to homes they wanted to live in? "Are you thinking of hurting yourself, Grace?" he asked gently, looking over at her.
"I just want the pain to stop." She rocked back and forth in her seat. "And I don't want to hurt anyone ever again."
Irrational feelings of guilt were one of the hallmarks of major depression. Some patients actually came to believe they were responsible for the Holocaust or for all the suffering in the world. "Hurt them in what way?" Clevenger asked her.
She looked down. "I'm a bad person. A horrible, horrible person."
Clevenger watched tears start down her cheeks. She was thirty-eight and still exquisite, but her wavy, auburn hair, emerald green eyes and the perfect slope of her nose and cheekbones all said she had been otherworldly at twenty-six, when she had married George Reese, fourteen years her senior and already fabulously wealthy. Only now, with her physical presence just beginning to wane, was she confronting the fact that she wasn't in love with her husband or her work or her lifestyle — not the expensive cars or the private jet or the Beacon Hill townhouse or the vacation homes on Nantucket and in Aspen. She was beginning to suspect that beauty and wealth had carried her far away from her self and she didn't know the way back or whether there would be anything left of her if she ever made it back. "Sometimes hurting other people can't be avoided, Grace," Clevenger said. "Not if you intend to be a complete person yourself."
Baxter folded her hands on her lap. "When I married him, he let me keep my name. It was supposed to be a symbol that neither of us owned the other." Her fingers tugged at the three diamond tennis bracelets she wore on one wrist. Her thumb rubbed the face of the gold and diamond Rolex she wore on the other. "I hate these things," she said. "George gave them to me. Anniversary gifts. They might as well be handcuffs."
That comment made Clevenger wonder just how dark Grace's thoughts really were. Maybe she was floating an elegant metaphor for life in a gilded cage, but the fact that she had mentioned hurting someone and wearing handcuffs in the same minute worried him. Maybe she had something truly destructive in mind.
In the year since Clevenger had solved the Highway Killer case, catching serial killer Jonah Wrens before he could dump another decapitated body along some lonely stretch of asphalt, the gap between his forensic work and his psychotherapy practice had been closing. Not too many garden variety depressives and neurotics showed up at his door. Most of the people looking for him to heal them were struggling against the impulse to harm others.
Grace wouldn't be the first woman to feel imprisoned enough by her marriage to trade it for a jail cell. "Is there anyone you fantasize about hurting?" he asked her.
She squinted at the floor, clearly imagining something. Whatever it was made her blush. "No," she said. She looked up and smoothed imaginary wrinkles out of her skirt. "I just meant I want to be a better person. I want to learn to appreciate what I have."
That sounded like a dodge. People blush when one of their core truths is revealed. Something with roots in the soul. The name of a lover. A sexual preference. Even a deeply held personal goal. And it was looking more and more like the impulse to harm someone was part of Grace's core. That fact — more than her pat explanation that she had seen Clevenger talking about the Highway Killer on television and liked the looks of his jeans and black turtleneck and shaved head — might really explain why she had chosen to seek therapy from a forensic psychiatrist with a knack for getting inside the heads of killers.
"You can tell me," Clevenger prodded her.
"I have to go," Grace said, wiping her eyes. "I swear to you: I'm not a danger to anyone, including myself. I never have those thoughts."
That was what psychiatrists call a contract for safety, the words a potentially dangerous patient has to speak to avoid being involuntarily hospitalized — committed to a locked psychiatric unit. It made Clevenger wonder whether Grace knew her way around the psychiatric profession a little better than she let on. "I need to ask you quite directly: Do you have any intention of hurting your husband?"
"'Do I have ...' That's ridiculous." She stared at him, unblinking.
He returned her stare. "Fair enough."
She stood up, ran her fingertips down the row of gold buttons on her black Chanel jacket. "I'll call and schedule something in the next few days, if you have an opening."
Clevenger kept his seat. He wanted to make it clear that the decision to avoid going deeper was Grace's, and hers alone. She would have to turn her back on him. On the truth. "We still have ten minutes," he said.
She stood there several seconds, looking uncomfortable, as though Clevenger's silence might coax her back into her seat. But then she turned abruptly and walked out.
Clevenger watched through his window as she walked briskly to her car, a big, blue BMW sedan, with smoked windows. She fumbled in her handbag, shook it violently, reached in again. She started to cry. She finally pulled out her keys, threw open the car door and disappeared inside, slamming the door behind her.
"Does she get a refund?" North Anderson asked, from the doorway to Clevenger's office.
Clevenger turned to him.
"She looked worse on her way out than on her way in."
Anderson had been Clevenger's partner at Boston Forensics for the past two years. He was a former Baltimore cop turned private investigator, a black man who looked a decade younger than his forty-four years, probably because he was addicted to weightlifting — three hours every day. There wasn't an ounce of fat left on his body. The only hints that he'd lived the tough life he had were the jagged scar over his right eye and the slight limp to his left leg, the former from a suspect wielding a knife, the latter from one with a .45. Both of them had ended up facedown on the pavement. The one with the knife went to jail. The one with the gun went to the morgue.
"She's living a lie," Clevenger said, glancing at Baxter's car pulling past the chain-link fence and gate that separated the Fitzgerald Shipyard — where Boston Forensics made its home — from the rest of Chelsea. "That hurts. More and more every day."
"The truth will set you free," Anderson said. "Unless you're guilty." He smiled the winning smile that made people like him and open up to him, as easily in Boston as they had in Baltimore. Because he liked people, with all their foibles. "We got a call from a Detective Mike Coady, out of Boston P.D."
"What's up?" Clevenger asked.
"You know that guy about to have brain surgery at Mass General?"
"Sure, scheduled for it this morning. John Snow. He was front-page in The Globe again."
"His surgery's been canceled."
"Dead? From what?"
"They found him in an alleyway between a couple of buildings at the hospital. Took a 9mm slug to his chest."
"Jesus. They have the shooter?"
"Coady thinks so — Snow himself."
"He committed suicide?"
"No witnesses. The bullet came from Snow's own gun."
"So what does Coady need us for?" Clevenger asked.
"The Medical Examiner won't officially rule out murder," Anderson said. He crossed his massive arms. "Coady has a backlog of eleven open murder cases."
"So the good detective wants me to come up with a convenient psychological profile, posthumously, to fit the suicide theory," Clevenger said. He shook his head. "I'll call and tell him to live or die on the ballistics report."
Anderson shrugged. "I could poke around, see if there's any talk on the streets, just to get a flavor of the thing."
"Why waste the energy, if all Coady wants is a rubber stamp to close the case?"
"Nobody really believes we rubber-stamp anything."
"Maybe that's why he's hoping we do this time. Instant credibility." He picked up the receiver. "Got his number?"
"Sure," Anderson said. But he just stood there.
Clevenger looked at him askance. "What?"
"You know how you sometimes get a gut feeling? I mean, maybe I'm buying all the hype on this Snow guy, but he was about to travel some medical ground that's never been traveled before. He was gonna make history. Every reporter in the country was angling for an interview with the guy post-op. I'm no shrink, but I figure that kind of momentum can carry you through some pretty bad days. And he shoots himself in an alleyway, a stone's throw from the O.R.? That doesn't make a whole lot of sense."
"You don't think he killed himself."
"I think that's the answer Coady is looking for. It might be the right one. But a man took a bullet to the chest this morning, and my gut tells me to get the whole story."
"From a dead man."
"If the truth was easy to come by," Anderson said, "Coady wouldn't have called you in the first place."
Clevenger climbed into his black Ford F-150 pickup and started the drive over the Tobin Bridge to Boston. He had arranged to meet Detective Mike Coady at the morgue on Albany Street at noon. If he was going to get inside John Snow's head, he figured he might as well start with his corpse — the last page of his life story — and work backwards.
What he knew already about Snow he had learned from newspapers and television. Snow was an aeronautical engineer who had received his Ph.D. at Harvard, rising through the ranks of academia to become — at thirty-two — the youngest person to ever win a full professorship at the Massachusetts Institute of Technology's famed Lincoln Lab. A few years later he left M.I.T. to start Snow-Coroway Engineering, headquartered in Cambridge. And over the next two decades he had seen his inventions in the fields of radar technology and rocket propulsion net more than one hundred million dollars from firms like Boeing and Lockheed Martin.
But Snow's genius seemed to have come at a price. He suffered seizures, as though the combined force of knowledge and inspiration swirling through his mind sometimes surged too intensely. And these were not the subtle, absence seizures that made a person stare off into space. They were tonic-clonic, grand mal seizures that made Snow collapse, unconscious, breathing like a bellows, his limbs jerking wildly, his teeth clamping shut, sometimes tearing through his tongue.
According to a 20/20 segment on Snow, he had had his first seizure at age ten while struggling to solve an equation his calculus tutor had laid before him, an equation that would have frustrated most mathematicians. When Snow snapped his pencil in two, the tutor apologized for asking too much of him. But then he noticed that Snow had scrawled the correct answer at the bottom of the page — and that his rigid limbs were beginning to shake. (Continues...)
Excerpted from Murder Suicide by Keith Ablow. Copyright © 2004 Keith Ablow. Excerpted by permission of St. Martin's Press.
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