Word by word, more meticulously even than on previous efforts, he picked through the chart. Family history- unremarkable, past medical history-usual childhood immunizations and diseases, nothing else of consequence, physical exam-normal except for an incarceratedinguirial hernia, operative and anesthesia notes-routine. Nurses' notes, 'patient brought into recovery from O. R. awake, alert, and smiling, vital signs normal, no evidence for respiratory depression, pupils equal and reactive, lungs clear.'
Remarkable. Absolutely remarkable. Zack read the notes once, and then again. Toby's total stay in the recovery room was less than thirty minutes. He asked for Suzanne's chart. Her anesthe ics and doses, when adjusted for weight, were virtually identical to Toby's, so were her recovery room nurses' notes. Total time in the recovery room, forty-five minutes. The g I'm of an idea began to take root. Zack checked the time.
Thirteen minutes until he met with Pearl. 'Excuse me, ' he called over to the librarian, 'are these records completely computerized? '
'For the last five years, yes, ' she said, setting aside the romance saga she was reading. 'I think they're working on the five years before that.'
'Well, supposing I wanted to get, say, a list of all the gallbladder patients operated on in the last three years?'
'No problem. Cholecystectomy is one of our codes, 3982, I think.'
'How about just the ones where Dr. Pearl was the anesthesiologist?'
The woman checked her manual. 'Dr. Jack Pearl. Physician 914. I can get the printout for you in just a minute, but it will take a while if you want me to pull the charts.' She patted her belly. 'As you can see, I'm walking for two.'
'Your last month?'
'Last two weeks, I hope.'
'Well, if it's too much trouble-'
'No, no. We both need the exercise.'
'I hate to make it harder on you, but could I have the first few right away, and then come back in, say, an hour to check on the rest?'
'Sure. At this hour of the morning, this place isn't exactly humming.'
She was already typing commands into the computer. By eight-thirty, Zack had scanned nine charts out of thirty-one. He slipped the notes he had taken into his folder and promised to return for the rest. Despite his lack of sleep, he felt energized-keyed up and very sharp. His idea had provided no definite answers. But now, at last, he knew he had some damn good questions. If Jack Pearl had made any attempt to straighten up his office before Zack's arrival, he had failed miserably. The small, windowless space between the O. R. suite and the recovery room was cluttered with journals and scraps of paper, and smelled heavily of coffee and stale cigarettes. Half-filled ashtrays, one with a butt still smoldering, graced two corners of the desk, and opened, cellophane-wrapped packets of Kleenex were everywhere. Pearl himself, sporting a wrinkled green polo shirt, was nearly dwarfed behind the pile of reprints, texts, and notebooks on his desk. The hand he extended was cadaverous. Regardless of how skillful an anesthesiologist Pearl was, it was difficult for Zack to imagine his fastidious brother hiring such a man. 'So, ' Pearl said, his voice an annoying cross between Peter Lorre and, perhaps, Carol Channing, 'I see you are an early morning person, too.'
'Actually, I'm more a mid-afternoon person, ' Zack replied. 'Thanks for making the time to see me.'
'No big deal. You want some coffee? There's a machine right down the hall.'
'No. thanks, though.'
Zack noticed a stained Mr. Coffee crammed to the side of one bookshelf, but saw no evidence of filters or coffee. 'So, Iverson, what's on your mind?'
Pearl, sniffling every twenty or thirty seconds, stubbed out what was left of the smoldering cigarette as he was cuing up a fresh one. He was a man in constant motion, wiping his nose, smoking, or fiddling with the papers on his desk. He was also, Zack felt, somewhat effeminate. Though they had done one case together, and had spoken briefly after Suzanne's surgery, this was their first contact of any substance. The office, for all its disarray, was somehow barren and sterile.
There were no diplomas or certificates on the wall, no photographs or mementos on the shelves. Zack felt an instant, immense curiosity about the little man, but he had already abandoned any notion of small talkeven nonthreatening questions about his background. Nothing in Pearl's manner encouraged such an approach. 'I need to discuss a case with you, ' Zack began. 'Okay, shoot.'
'It's an eight-year-old boy named Toby Nelms. Jason Mainwaring repaired an incarcerated hernia in him almost a year ago. You did the anesthesia.'
'No bells, ' Pearl said. 'Here's a Xerox of most of his chart.'
Zack passed the copy across and waited as Pearl flipped through it.
'Seems pretty cut and dried to me.' Pearl hesitated, and then looked up, his brow pinched in thought. 'Cut and dried. That was sort of a joke, wasn't it? ' He thought some more. 'Pretty good joke, too, if I do say so myself. Pretty good.'
His laugh was a cackle. Zack smiled, but otherwise made no attempt to join in. 'Pentothal and isoflurane. Is that pretty routine for cases like Toby's?'
'Routine enough, ' Pearl said. 'Why?'
'Well…' Zack rubbed at his chin and silently counted to five. 'I have reason to believe that the kid wasn't asleep during his surgery.'
Pearl's listless eyes flashed. 'That's ridiculous! ' he snapped. 'Maybe, but I think it's true. He remembers details of the operation that there's no reason for him to know. And to make matters even more interesting, for the past six months he's been reliving the whole thing.'
Pearl was ashen. 'What?'
'He's having flashbacks in which he reexperiences his surgery, only in a terrifying, distorted way. It's as if his preoperative fears have become fused with the actual procedure. Instead of having his hernia fixed, he has his testicles and his penis cut off, again and again. And each time, Jack, he feels the pain. Every bit of it.'
'That's… that's insane.'
'Is it?'
'Of course it is.' Pearl took a nervous drag from his cigarette and then blew his nose. 'He's lying, or… or he's been watching too much television.'
'I don't think so, Jack. And neither do the boy's parents. They're this close to instituting some sort of action against the hospital, and, I assume, against you and Mainwaring as well.'
'And you're encouraging them in this?
'
'Hell, no. The opposite.'
'Well, thank God for that, ' Pearl muttered. 'But I'm determined to get to the bottom of things. That's why I'm here. The kid's very sick from what he's going through. Very sick. In fact, he may be dying.'
Pearl whistled softly through his teeth. cc Well, ' he said, 'I can't help you much except to tell you that whatever is going on has nothing to do with his anesthesia. I've done thousands of cases with exactly the same stuff this boy got, and and nothing like this has ever happened.
Nothing.'
'As far as you know, ' Zack corrected. Pearl's expression was strange.
Zack tried to gauge the reaction against those he had anticipated.
Anger? Arrogance? Confusion?
Concern? Defensiveness? There was 'I no real match. Something was going on, though. Of that he was almost certain. The man was… was what?
'Look, Iverson…' Pearl ground out his cigarette and folded his hands on the desk. His fidgeting stopped. His gaze became more direct.'… I want to help you, I truly do. I want to help that kid. But there's really nothing I can say. He got routine anesthesia and had a routine operation. It's as simple as that. If you want to get to the bottom of whatever's going on, then you'll just have to head off in another direction, okay?'
In that moment, Zack understood. His muscles tensed. The sensation was so familiar. It was being on the side of a steep drop, looking for the handholds and crevasses that would guide the traverse of a rock, and then suddenly seeing the perfect line across. Jack Pearl's attempt at sounding concerned and accommodating had
