Cloned Genes

By David Stone

The New England Journal of Medicine would sell more magazines with Doctor Caroline O’Reilly’s picture on the cover. She’s a rising star in trauma surgery at Massachusetts General Hospital. At five-foot-ten with red hair and green eyes she can look a man in the eye and know that he’ll be looking back. Still single at 36, but recently in love, she’s got her personal life and career in balance, until one day a special patient dies.

This one man’s death calls all her skill and judgment into question. Searching for answers she discovers a criminal conspiracy entwining the science and business of biotechnology. Thousands of patients and millions of dollars are at stake. Can she unravel the mystery in time?

• Language: English
• Publisher: David Stone
• Release date: Dec 16, 2012
• ISBN: 9781301015887

David Stone

About David K. Stone: I was born in 1956 in Denver, Colorado, five minutes after my twin brother Robert. Yes, we’re identical. As the youngest of five children, and with a co-conspirator always at hand, I had many childhood adventures. My father was a machinist and my mother a homemaker. We weren’t rich, but we never felt poor. Planning to become a veterinarian, I went to Colorado State University, where I earned a Bachelor of Science in Microbiology. In 1981 I moved to Massachusetts to attend Harvard Business School. Two results of that decision have shaped my life since. I met my wife Carol through a classified ad. “Wanted, rush typist. Contact the Editor, Harbus News.” And I got my first job as a Project Manager at Genetics Institute, one of the pioneering companies creating products from recombinant DNA technology. In 1989 I had a triple life crisis. My first child was born, I got a new job, and I moved from a Mac back to a PC. For the next ten years I followed the Biotechnology Industry as a research analyst for Cowen & Company. Life on Wall Street was better back then. I joined Flagship Ventures in 2000 and spent seven years investing in early-stage life sciences companies. Since 2006 I’ve been an independent consultant and investment banker, helping start-ups with strategy, finance and communications. Over nearly 30 years in biotechnology I’ve experienced cool science, colorful characters, gourmet food, international travel, and the full range of human emotions. So I’ve used these ingredients in my techno-thriller novel Cloned Genes. I hope you enjoy reading the book as much as I did writing it. I live in a 1710 colonial in Acton, Massachusetts called the Liberty Tree House. My wife and I own and manage Liberty Tree Farm. Besides our two children, we share the place with 19 horses, three cats and a few laying hens. If you are in the area, feel free to stop by.

Book preview

i. Identical Twins

Every living thing has DNA inside and so knows how to reproduce. The really little critters just copy themselves. Maybe that’s why there are more bacteria and yeasts than all the other life forms on the planet. We higher organisms can’t do that simple trick, although some people may be trying. We carry around twice the DNA we need. But we can make a child with only half of it, who must get half again from someone else. So our children seldom look like us. Yet roughly two in five hundred come out exactly the same. These identical twins have cloned genes.

~~~

ii. Professor Chakrabarty

Working at General Electric in the 1970s, a genetic engineer named Ananda Mohan Chakrabarty created a strain of bacteria that could digest crude oil. He thought these bugs might make money cleaning up spills, but a US patent examiner said the law would not allow a patent on living things. In 1980 the Supreme Court ruled otherwise. In setting the intellectual property foundation for the biotech industry, Chakrabarty became famous. Although by then he had returned to academia. And fearing environmental repercussions, GE never commercialized his invention.

~~~

iii. Bacterial Sepsis

The human gastrointestinal tract is filled with trillions of bacteria from hundreds of different species. The sheer mass of their cells makes up over a third of the contents of the large intestine. This teeming population of microbes normally does no harm, and even helps digestion and absorption of nutrients. Yet if chronic illness, an accident or a botched surgery lets bacteria into the bloodstream, all hell breaks loose. The immune system’s attempt to repel these invaders can shut down the lungs, liver and kidneys instead. And despite treatment, about a third of patients with severe sepsis end up dead.

Prologue – Boulder, Colorado

Alexander Hayman walked slowly down Arapahoe toward the old downtown section of Boulder. The sun had set and the Flatirons looked like shark’s teeth against the purple mountains that filled the western sky. He was headed for the Catacombs Bar in the basement of the Hotel Boulderado. He thought of the many times he’d been there since coming to CU as a graduate student.

His lab mates had taken him to the Catacombs to celebrate his first publication in Science magazine. After following his advisor to Syngentech he’d taken his project team to the Catacombs to toast the progress of their experimental drug, SGT 1101. As he arrived at the hotel, Alexander shook his head at these now painful memories. Tonight was more like a wake.

Alexander wound his way through the maze of dimly lit rooms under the hotel. His friends were waiting at their usual table in the back. Alice Lee looked up at him with red rimmed eyes. She slid over without speaking and he sat beside her. He ordered a beer and began to pick at a half-eaten basket of fries in the center of the table.

Did you like the little speech that Henri Saxon gave today? Bob Steinbaum asked. We’re going to conserve cash and focus on our most valuable assets. Such bullshit. He plans to fire most of the R&D staff and put the company up for sale is what that means.

Who do you think would buy us? Alice asked.

I don’t know, Alexander replied. Maybe one of the bigger West Coast firms would like a research outpost in Colorado. But it’s anybody’s guess which of our people or programs they’d want to keep. I suppose Saxon is out of a job one way or the other.

I’m quite sure the lucky bastard will land on his feet, said Ajit Singh. Funny how our CEO can sell all his shares two months before the 1101 trial goes bust. Meanwhile the rest of us get stuck with maybe a month’s severance and a bunch of worthless stock options.

You got that right, Bob said.

I heard Saxon had to sell the shares because of his divorce Alice said quietly. I don’t think anybody expected the Phase III trial to fail. All the analysts were recommending our stock. After we got such great results in Phase II, I really thought we’d found a cure for sepsis.

I did too. I was going to wait until we got FDA approval, then exercise my options and buy a house, Alexander said. So much for that plan.

Michael Ulevitch drained his Pilsner Urquel in one long pull and looked around the table. Well boys and girls … I guess you’ll just have to find some other way to make money cloning genes. Saxon wants me to keep digging through the trial data to see if we can find a sub-group that did better on 1101. But it’s a waste of time. Personally, I’m getting off this sinking ship before the rest of the rats start sending out resumes. He stood up and threw a twenty onto the table, then headed for the door.

As long as we’ve worked with him, that guy still gives me the creeps Bob said. But I guess he’s right about our needing to look for new jobs. There isn’t much besides Syngentech here in Boulder, so I’m thinking of looking in Boston or San Diego.

You mean you can’t decide whether you like to sweat in the summer and freeze in the winter or just be warm all the time? Alexander deadpanned. Tough call.

The others laughed but Bob just stared at Alexander.

Conversation stopped for a minute and Alice took Alexander’s hand under the table.

I’m sorry she said.

Sorry about what?

I’ve been meaning to tell you. About a month ago, I got an offer from that start-up in Philadelphia, Accelerated Genomic Development. I’ve been putting them off because I don’t really want to go, but with Syngentech falling apart it just seems like time to move on.

Alexander turned and looked into her face, searching for something to say. She held his gaze for a long moment. Then she looked down.

I’m going to move my stuff out of the apartment tomorrow.

He squeezed her hand gently, then let go.

Bob coughed softly, as if to clear his throat. I guess we’ll see you guys back at the lab. He and Ajit pushed back their chairs and disappeared into the shadows of the bar.

1

Five Years Later – Boston, Massachusetts

Caroline lay in her own soft bed, at the edge of sleep and dreaming. Her cheek was resting on Stephen’s shoulder, his warmth seeming to surround her. It was a new sensation, and yet somehow already familiar.

Then the long slender fingers of morning light slipped past her bedroom curtains and touched her face, breaking the spell. Stephen was not there. He had been gone three nights by now. But the faint reminder of his scent still clung to the spare pillow under her head.

Awake now, she lay there thinking of Stephen. In two months of late summer he had grown deep roots into her soul. Into places that no other man had touched.

She had learned about boys in high school. Sweaty and exciting. In college she found love. Spending days and nights with Eric for a year she felt such passion should last forever. But Eric was a selfish lover. He dumped her when she started medical school. Since then she had held most men at arm’s length. And none for very long.

Stephen was different. They had met by accident and become close friends. Then something had changed. It felt natural but profound. Like the shifting colors in the sky at sunrise. Was it too soon to believe he was the one?

Pull yourself together girl, she thought, it’s Monday morning. Time to make coffee and get ready for work.

She stretched out her arms and legs and kicked off the covers.

Padding into the kitchen Caroline pulled a sack of Kenyan AA beans from the freezer and put two scoops into the grinder. She ground them to a fine powder and set the coffeemaker for a double espresso.

That should be enough to get my heart started.

While the coffee was brewing, she scrambled two eggs with sun dried tomatoes, a sprig of fresh basil from the window box and a few chunks of goat cheese. Some people found cooking a chore. For Caroline it was a form of relaxation. And it filled a void left behind by her childhood.

As she ate breakfast she flipped through the pages of a review article she was writing for Annals of Surgery. She knew this invited review was an honor. It could cement her reputation as a rising star in trauma surgery, so she wanted it to be perfect. When she reached the end of the manuscript, she smiled to herself. If she got the promotion she was aiming for this year, at age 36 Doctor Caroline O’Reilly would be the youngest division chief at Mass General.

Her parents would be so proud. If only they had survived. But then her life might have turned out differently. She had been a tall skinny kid at 12. All knees and elbows and long red hair in braids. Back then she had wanted to be a ballerina. Before a drunk driver took away her family and changed her plans. The memory of that night was like an old bruise. It only hurt if she touched it by mistake.

After a quick shower, Caroline put on a white blouse with cap sleeves and a long flowered skirt. Though she would spend most of her shift in androgynous surgical scrubs, she liked to at least start the day dressed as a woman. The Nike cross trainers didn’t exactly complement her ensemble, but they were a lot more comfortable than heels for the half-mile walk to work.

Carrying a small leather briefcase and a canvas bag with her change of shoes, she set off down Joy Street from her Mount Vernon Street condo on Beacon Hill. It was early September and although the sky was bright blue, the air was crisp with a hint of the coming change of seasons. Passing Mrs. McDougal’s house she admired the blaze of flowers on display in the window boxes. There were tall snapdragons, petite rows of pansies, cascading lobelia and several other flowers that Caroline could not identify. The woman must be eighty years old, but she still had a green thumb.

Just then she heard a squeal of tires, a loud bang and the rattle of flying glass. It had come from the direction of Cambridge Street. Acting on instinct, she gathered her skirt and ran.

When she arrived on the scene, she saw traffic backed up in both directions. An older Honda Civic was upside down with its front end wedged under a construction vehicle. A policeman who must have been working the detail was trying to make order out of chaos and a small crowd of gawkers was already gathering.

I’m a doctor. What happened? Caroline said as she approached the policeman.

Friggin typical Boston driver is what happened. He’s coming down here doing maybe forty when he sees this delivery truck at the crosswalk. Does he slow down and wait his turn? Hell no. The asshole just swings into the other lane to go around. Then he sees the pedestrians at the last minute and flips his goddamned car under that dump truck.

Caroline knelt beside the car and quickly examined the driver. He was a young man, maybe nineteen or twenty, dressed in a black T-shirt and jeans. He was semi-conscious and moaning. The air bag had deployed so his upper body looked OK, but his legs might be pinned under the dash. She checked his pulse and respiration rate, which seemed OK, but couldn’t do much more until the firemen arrived to cut him out of the wreck.

Glancing around, Caroline noticed the policeman helping a young woman in a white blouse and short yellow skirt to sit down on the curb. She appeared shaken up, but not seriously hurt. The woman had smooth skin and trim arms and legs. So her thick waist and full bosom looked slightly out of place. She’s about 25 and three or four months pregnant Caroline estimated.

Since she could do nothing more for the trapped driver Caroline went to check on the young woman. Her breathing was shallow. Her pulse was thready. Are you OK?

I … I think so. That guy almost hit us and I must have fallen trying to get out of the way. I just need to rest a minute. Then her eyes rolled back in her head and she went limp in Caroline’s arms.

Officer. Get over here. I need your help.

What’s wrong?

I need to get this woman to MGH right now.

I’ve called for fire and EMS twice already, but they’re having trouble getting down here because of all the stopped traffic. It’s jammed clear up to the rotary at Charles Circle.

She can’t wait. Help me get her into your car.

How’s that gonna help? We’re stuck here he protested as they placed the unconscious young woman into the front seat of his cruiser and strapped her in place with the shoulder harness.

Now get in and drive.

I can’t leave the scene. The Sergeant will have my badge.

Ever since she was a teenager people had been trying to tell Caroline what couldn’t be done. She had learned that this was often a matter of opinion. Hands on her hips, she looked the young policeman up and down. He wasn’t moving.

Fine. I’ve always wanted to drive a police car.

She jumped in, started the car and drove onto the sidewalk, leaving the astonished policeman in her wake. Honking the horn because she didn’t know how to use the siren, Caroline made her way to the corner of Russell Street where she could escape the traffic jam and drove quickly through the back streets to the ambulance entrance at MGH.

She jumped out and went to the passenger side.

Dr. O’Reilly, did you steal a police car? said one of the startled orderlies.

Shut up and give me a hand here.

He grabbed a stretcher and hurried over.

Once they got inside the ER, Caroline commandeered a nurse and an empty treatment room. They stripped off the young woman’s clothes and examined her more carefully. She was dehydrated and had a bad bruise on her right knee. They administered oxygen and a liter of ringer’s lactate. The young woman came around as Caroline was starting an ultrasound examination.

What happened to me? Is my baby OK?

The baby looks fine. You were nearly hit by a reckless driver out on Cambridge Street. When you blacked out we brought you to Mass General.

I don’t remember the ambulance ride.

Caroline smiled.

It was short. You were lucky to be so close to the hospital. And I’m glad you weren’t seriously hurt.

After the young woman’s husband arrived Caroline watched them talking through the door of the treatment room. His obvious devotion to his wife and unborn child raised a lump in Caroline’s throat.

Someday, she thought, before I get too old.

The rest of her day was filled with routine cases. A construction worker had fallen off some scaffolding. He might have shaken off the ten foot drop if he hadn’t picked an upright survey stake to land on. Caroline patched up the hole in his thigh and sent him home with pain meds and antibiotics. A skinny kid on a skateboard misjudged the steps by City Hall. A CT scan confirmed he luckily hadn’t broken anything. She added a couple of rows of stitches to his collection of body piercings. And another Boston driver relocated a street lamp with his car. In the process of sudden deceleration, he’d aspirated a chunk of plastic from the dashboard. Caroline used a bronchoscope to retrieve it from his right lung. Then at three o’clock she was called to an emergency surgery. As she scrubbed in, the surgical coordinator briefed her on the case.

The patient is a white male, age 34, unconscious but stable. He was an unrestrained passenger in the back of a cab that got T-boned at an intersection in South Boston. He has lacerations to the head and face, possible broken ribs, and penetrating trauma to the right side of the abdomen.

Do we have his medical records?

No. He’s a US citizen, but it looks like he arrived earlier today on a flight from Switzerland. The name on his passport is Alexander Hayman.

Caroline froze. Alexander Hayman was the name of Stephen’s twin brother. She’d never met him, but Stephen had said his brother was living in Europe somewhere. Could this be him?

If it was him, should she be the one to operate? Although there was no hard and fast rule, it was considered bad practice for a surgeon to operate on a family member. Emotions could interfere with clear thinking and cloud one’s judgment. Of course, Alexander wasn’t a family member. Not yet. And he never would be if she stood around and let him die.

The surgery was a grueling five hour ordeal. She had to remove his spleen, repair a perforated ileum, and patch up a damaged section of his liver. As she painstakingly closed the lacerations on his face, a task that required seventy-two tiny sutures, she could not help but notice how much he looked like Stephen. At least he had looked like Stephen. Despite her best work, people probably wouldn’t have trouble telling them apart now.

By the time they took Alexander to a room around ten pm, Caroline’s shift had ended. She sat by his bedside and listened to the steady rhythm of the heart monitor. At midnight he was still unconscious and his blood pressure was lower than Caroline would have liked, but he seemed stable enough for her to go home and get some sleep.

Call me if anything changes she said to the night duty nurse as she left the floor.

Caroline walked home in the dark and slept until seven. There was no time to make breakfast. She showered and dressed and returned to work.

All through Tuesday morning, Caroline waited for signs of improvement, but by two pm Alexander’s lungs were failing. She inserted a trachea tube and put him on a ventilator, ordered another course of a broad spectrum antibiotic and sent blood to the lab for bacterial cultures. She tried several times to reach Stephen, but his cell phone kept going straight to voicemail.

In between her other cases, Caroline replayed Alexander’s surgery in her mind. Had she done everything correctly? She’d located and closed a hole in his small intestine. But maybe there was some other damage that she’d missed. There were too many things going wrong at once. Despite the antibiotics she’d prescribed, he was showing ominous signs of a bloodstream infection. If she could not find a way to turn the tide soon, this might progress to multiple organ failure.

By seven pm she decided that she had to do something. A colleague of hers was just starting a clinical trial of a potential new treatment protocol for sepsis syndrome. He wasn’t at the hospital that day, but his study coordinator was working on another floor. Caroline went to find her.

Mandy, I’m glad you’re here. I need to ask you about that study Victor’s working on using vasopressin and dopamine for sepsis patients.

I didn’t know you were involved in the study.

I’m not. But I have a patient in the surgical ICU who looks like he’s headed for multiple organ failure and I’m ready to give Victor’s protocol a try.

I’m sorry Dr. O’Reilly, but I don’t think that’s a good idea. You could prescribe the drugs off-label. But we’re just in the early stage of the sepsis trial so I can’t really give you any guidance on what to expect with your patient. Can’t this wait until Victor gets back?

Dammit Mandy, my patient may be dead by tomorrow. Just get a dose of each of the drugs from the pharmacy and meet me in Room 506. I’ll talk it over with Victor in the morning.

Since the sepsis protocol was still experimental, Caroline could only guess what dosages to use. With Alexander’s condition worsening, she opted for an intravenous bolus of each drug at the highest dose allowed by the trial protocol. She hoped the vasopressin would raise his blood pressure, while the dopamine should increase his cardiac output. Then she settled into the chair beside his bed again to wait for a response.

She was dozing fitfully when the alarms went off. Alexander’s heartbeat had become erratic and his blood pressure was dangerously low. Despite the ventilator, he still wasn’t getting enough oxygen in his blood.

I need some help in here she yelled toward the nurses’ station. And bring a crash cart.

Then Alexander’s heart stopped.

She leaned over his bed and began chest compression, knowing this might exacerbate his broken ribs.

When the crash cart arrived they tried frantically to shock his heart back into sinus rhythm.

Give me the paddles

Charging

Clear

Again

Each time the electric shock from the cardiac defibrillator sent a convulsion through Alexander’s chest but his heart would not respond.

It’s no use doctor. He’s gone.

Caroline took a deep breath and held it.

Then she said time of death, two twenty-three am.

Caroline was numb. She watched as the orderlies began to remove Alexander’s body. How had she failed to save him? How would she explain his death to Stephen?

Then she saw it. As the orderlies lifted his body, she saw a small brown patch on Alexander’s shoulder. Her heart leapt into her mouth. It was only a harmless birthmark, but it should not have been there. This was the birthmark that only Stephen had.

2

Caroline fled the hospital, not bothering to change her clothes. The night air was cool but she felt as if her body was on fire. She walked rapidly from force of habit, enduring a crushing pain in her chest while her breath came in ragged sobs. The narrow streets were dark and empty. She felt desperately alone.

She arrived home unaware of how she got there. Inside the light from a street lamp made jagged patterns across the floor. The silent walls seemed to be mocking her. As she pushed open the bedroom door a wave of exhaustion crashed over her. She dropped her keys on the floor and threw herself on the bed hoping the dark would close over her. But sleep would not come. She lay there in agony.

Caroline knew this pain. She had felt it before. It hung on her body like a dead weight. It made her bones ache. Through years of struggle she had torn off the heavy garment. She had sealed it in a box, buried it deep and stamped her feet on the sod over it. But somehow the demon had escaped.

She was waking up in that hospital room again. The first hospital she could remember being in. Noisy. Cold. A smell like bathroom cleaner.

Where are my Mom and Dad?

Hush child. You need to rest now.

The nurse’s hand felt heavy on Caroline’s shoulder.

I don’t want to rest. I want to see my parents.

You can’t see them right now. Just lie still. You’ve got to mend that broken arm.

She tried to lift her head, but her neck hurt too.

Why not? Where are they?

The nurse looked away, then back at Caroline. Her face was trying to be kind. But her eyes looked strange.

I’m sorry honey. Your parents... They aren’t here.

What do you mean? I saw them in the ambulance.

She brushed the hair from Caroline’s face.

Your Mom and Dad were hurt real badly. The doctors did all they could.

Something inside her snapped. A roaring sound filled Caroline’s ears. Hot tears poured down her face.

You’ve got to be a brave girl now. Your whole life is still ahead of you.

I don’t want to be brave. I want to go home.

But they wouldn’t let her go home. They had sent her to live with strangers.

This couldn’t be happening again. It must all be a horrible mistake. Stephen had been right here beside her just days ago.

She was curled up on the couch in her apartment. Stephen was sitting on the floor reading aloud from a book of poems by Robert Frost. The windows were open and a soft breeze carried in the scent of the ocean.

She leaned down and kissed his ear. He laughed and turned his head. Then his lips met hers in a long and delicate caress. She slid down beside him on the floor. He started to read from the book again, but she poked him playfully in the ribs. He tried to tickle her in return and they wrestled like puppies until their arms and legs were intertwined. She felt giddy and carefree.

They explored each other’s bodies like curious children. He made love to her for the first time that afternoon and they slept together that night. The hours had run together like a dream.

Now Stephen was gone. She was alone in the world again. Just like when her parents had died.

The woman from social services had taken Caroline to a yellow house in Dorchester. Gus and Vivian Crowley lived there. So did four other kids. None of them were Crowleys. When the woman from social services was gone Vivian took Caroline out to the back porch and shut the kitchen door.

You seem like a smart girl. So you might as well know how things work.

Caroline nodded. She had no idea what Vivian was talking about.

Gus and I spent twenty years taking care of our own kids. I need another brat to look after like I need a hole in my head. But since Gus started having back trouble we need the money to pay our bills. You give us any trouble and I promise I’ll trade you in faster than a pair of shoes that don’t fit.

Caroline swallowed a lump in her throat. She wasn’t going to let this horrible woman see her cry. But soon enough she was angry instead. These people weren’t her parents. They had no right to tell her what to do. The second time that Caroline came home late from school Mrs. Crowley had made good on her promise.

At her third foster home Caroline had tried a new approach. She started following all the rules. Maybe if she behaved herself and did well in school she could have a real family again. She got straight As. She set her sights on medical school. But no-one wanted to adopt a teenager with emotional problems. She buried her grief in her studies. For a long time that had given focus and meaning to her life. But now the pain was back.

I became a doctor so I could save lives, she thought. The time it mattered most I failed. I’ve saved so many strangers, but not Stephen. He was such a beautiful man. Why couldn’t I save him?

She stared at the ceiling and thought of the warmth of Stephen’s embrace. How quickly his love had overtaken and changed her life. He was like a sudden rain shower that fills the air with sound and leaves behind the scent of a thousand growing things. Now cruel death had taken him and hollowed out her soul.

When Caroline awoke on Wednesday the sun had already travelled well across her bedroom floor. Her mouth was dry. Her head ached. She went to the kitchen in search of black coffee and aspirin.

As Caroline’s mind began to stir, the devastating events of the last two days all seemed like a terrible dream. Scenes from the hospital played over and over in her brain, but the edges were fuzzy and the sequence kept changing. The pain of Stephen’s death was real and inescapable. But nothing else made sense.

On Friday, Stephen had told her he was going to Chicago for a conference. What was he doing in Switzerland? Why was he travelling on Alexander’s passport? And why had he lied to her?

It was almost noon. She had been on call since 7 am, but her phone had stayed silent all morning. Caroline stood at the kitchen counter eating cold cereal out the box. She couldn’t go on like this.

I’ve got to put my life back together. But before I can bury Stephen I need to know what happened to him. First I’ll have to find a way to reach Alexander.

~~~

While Caroline was still sleeping, Victor Pasternak arrived at the hospital at precisely eight am. He stowed his lunch in the break room refrigerator, left his bag in his office and exchanged his sport jacket for a white lab coat. Then he went to the medical ICU to check on the progress of the patients enrolled in the sepsis trial.

Good morning Mandy.

Good morning Dr. Pasternak.

How are our patients this morning? Has Mrs. Johnson’s renal function declined any further?

No. She seems to be doing better today. It was pretty quiet on the floor last night.

That’s good. Let me just have look at the charts.

There was one thing. Has Dr. O’Reilly spoken with you this morning?

No, I haven’t seen her. Why?

Well, it’s not really my business, but she came to me last night asking about the sepsis trial. She wanted to try the protocol on a patient who’s not enrolled in the study. I said she ought to talk with you, but she wouldn’t wait.

Well she’s a grown up doctor. I suppose she can do whatever she wants. She usually does.

Of course she can. It’s just that I heard her patient died early this morning. I thought you should know.

Thanks Mandy. I’ll look into it.

Victor gathered a pile of charts and returned to his office. He closed the door to think about what to do next. Dr. Caroline O’Reilly, what a pain in the ass. She’s so damned sure of herself that she’s always ready to shoot first and ask questions later. I’ve just gotten my study underway smoothly when she charges in. She borrows my protocol in the middle of the night and promptly loses a patient.

Now I’ll be the one answering questions from the IRB committee. It took us three months to get the protocol approved to begin with. Now my study could be delayed for months even though Caroline’s patient wasn’t part of the trial. Probably didn’t fit the entry criteria either. What a mess.

I may as well start reviewing the case report to see what happened. If it looks like the death was treatment related, we may need to modify the protocol or add to the exclusion criteria. Of course if Caroline made a bad call then the Quality and Safety Committee may want to review the case too. I wouldn’t mind helping that process along. It would make an interesting entry in the file for someone who thinks she’s in line to be our next Division Chief. I’ve got ten years more experience and better management skills than she’ll ever have.

~~~

It was about one pm by the time Caroline arrived at the hospital. She needed to contact Alexander, but didn’t know how to reach him. Stephen had been travelling on Alexander’s passport. It would be with his clothes and personal effects in the safe in the Emergency Department. Maybe she could find Alexander’s contact information there.

Walking through the acute area, she could see the ED was doing a booming business. The treatment rooms were full and patients were spilling over to the stretcher stations along the hallway. She made her way out front to the admitting desk.

Hi Pat. How’s it going? Looks like you got plenty of customers today.

Oh, things aren’t much crazier than usual, but thanks for asking. What’s up?

I came to look at the personal items you’re holding for Alexander Hayman. He died this morning and I’m trying to reach his next of kin. Thought I might find an emergency contact in there.

Sure. I’m sorry he didn’t make it. Let me get the bag out of the safe. You can look through it back here.

Caroline opened the bag and put the contents on the counter. She found the remains of a dark blue suit, a white shirt and a red silk tie. These were in ragged pieces, hastily cut off his body by the ED nurses. The only thing worth saving was a pair of shiny black shoes. She blinked back tears remembering how handsome he’d looked in an outfit just like this on their first date. He had taken her to the symphony.

Alexander’s passport was there, but it wasn’t much help. He had neglected to fill out the emergency contact information section inside. A ticket envelope was still in the suit coat pocket. Stephen had indeed flown from Basel Switzerland to Boston on Monday, the day of the accident.

Stephen’s cell phone was there too. Caroline opened it and pressed the power button hoping Alexander’s number would be inside. The battery was dead.

A watch, a money clip, and a ring of keys were all that was left. This is no use. Caroline began to put Stephen’s belongings back in the bag.

Thanks Pat. There was nothing here. I guess the cops will have to find his next of kin.

Just then a pair of walking wounded burst through the door. Two young men with bloody faces were yelling at each other. Two policemen were keeping them apart.

Caroline pocketed Stephen’s keys and closed the bag.

She walked quickly back through the emergency department, feeling self-conscious as Stephen’s keys pressed against her thigh. I’ve never stolen anything before. Well not since middle school. Those first two foster families were such jerks. Anyway I’m only borrowing Stephen’s keys. I’ll find a way to return them later.

She spent the next two hours in her office catching up on paperwork. Between the hospital administration and the insurance companies there were always more forms to fill out. She left the hospital a little after three pm.

Caroline knew where Stephen lived. She had dropped him off once in front of his condo after they’d taken a drive up the coast, but she’d never been inside. Like most neighborhoods in Boston, you couldn’t park on the street by his building without a resident permit. So she’d take the subway.

She boarded the Red Line at Charles Street and rode one stop to Park Street. Upstairs the Green Line platform was filling up with people. It was like a giant cattle chute with train tracks on both sides. A man stood beside the information booth playing badly on an acoustic guitar. Pressing into the throng she squeezed into a Boston College car and grabbed an overhead strap.

The train went above ground after Kenmore Square and rumbled down Commonwealth Avenue stopping every two or three blocks. Across the aisle a boy and girl were kissing with their eyes open. The kids on either side were texting and didn’t seem to care. But the scene reminded Caroline of the first time that Stephen kissed her.

It had been on their third date. They went to lunch at a little café in the Back Bay. Afterward he suggested a walk through the Public Garden. The bronze statue of George Washington was gleaming in the sun. Ranks of brightly colored flowers surrounded it like an honor guard.

They retreated to a quiet corner under the trees and stood in the shade. He seemed pensive and she turned to look at his face. Though Caroline felt at ease with Stephen, it was hard for her to guess his thoughts.

It’s so beautiful here. I’m glad we came, she said.

The flowers always remind me of my mother. She was a devoted gardener when I lived at home.

Where is she now?

She died two years ago. Ovarian cancer. My father passed six months later from a broken heart.

She took his hand in hers.

I’m so sorry. I didn’t realize. I know how you must feel.

Are your parents alive?

They died when I was twelve. I’ve been pretty much alone in the world since then. That is until I met you.

He moved closer and bent his head down to her. She closed her eyes. His lips met hers so gently that they barely touched. And yet the feeling was electric.

Then they had walked on as if nothing had happened.

The sun was still high and the air was warm when Caroline got off the streetcar at Harvard Avenue. She walked past a row of bars and small cafes. A tangy aroma from the Soul Fire barbeque made her stomach rumble. She turned left on Glenville, where the shops gave way to apartment blocks, and then right on Park Vale Avenue.

The narrow one-way street was lined with low rise brick buildings. Built back in the 1920s some had names like The Spofford displayed proudly on their cornice work. Others had elaborate entrances set off by gothic columns. Stephen’s building was just number nine.

Caroline’s hand shook a little as she picked one of Stephen’s keys and tried the lock. It wouldn’t turn. Just then a man opened the door from inside.

Oh sorry I didn’t see you.

She smiled awkwardly as he held the door open.

Come on in.

Caroline nodded and hurried up the stairs to the door marked 2B. She tried the same key again and this time the lock turned easily. She went inside, closed the door and leaned against it to catch her breath. In the stillness of the apartment her heart was pounding in her ears.

The front hall opened on a living room to the right. She could see a black leather sofa and two matching chairs arranged around a glass coffee table. A bookcase on the opposite wall held stereo speakers and a TV. A small dining table was visible in the pool of light from the