Keith Ablow - Compulsion

The third book in the Frank Clevenger series, 2002

Thanks are especially due my extraordinary editor, Charles Spicer, my gifted agent, Beth Vesel, and my publishers, Sally Richardson and Matthew Shear.

A number of people read drafts of this book and gave me valuable feedback. They are: Helena LeHane, Jeanette and Allan Ablow, Dr. Karen Ablow, Christopher Burch, Charles "Red" Donovan, Holly Fitzgerald, Marshall Persinger, Dr. Rock Positano, Dr. John Schwartz, and Emilie Stewart.

Nantucket 's own David Goodman of the Inquirer & Mirror and Nantucket Chief of Police Randy Norris made me feel at home on the island and shared with me a native's eye for detail.

Finally, I thank artist George Rodrigue for showing me the way.

Saturday, June 22, 2002

Lilly Cunningham looked up. I melted. She was twenty-nine years old, with pale blue eyes to get lost in. Her blond, curly hair would make any man want to touch it. Her strong forehead predicted intelligence and was perfectly balanced by the gentle slope of her nose. Then there were her full lips, dimples in her cheeks, her long, slender neck. A simple gold cross on a delicate chain pointed toward the curves of her chest and abdomen, rising and falling under a white sheet.

Part of me wanted to let my attention linger on Lilly's beauty, but the bigger part of me loves truth, which is almost always about something ugly. My eyes moved to her exposed thigh.

The flesh was inflamed from groin to knee. The skin had broken down in places, spreading like wet parchment, weeping pinkish fluid. Two serpentine black lines, in Magic Marker, each running twelve or fourteen inches through the muck, showed where her surgeon would make incisions to promote drainage.

A war was being fought. Battle lines had been drawn.

"I don't believe we've met," Lilly said, her voice straining.

"Dr. Clevenger," I said, still focused on her thigh. I stayed several feet from the bed, which is my habit when first seeing patients.

"Hmm. Shaved head, jeans, cowboy boots. You don't look like any doctor I've ever seen. Certainly not at Mass General."

I met her gaze. "What do I look like?"

She worked at a smile. "I don't know. An artist, maybe… or a bartender." She laughed, but weakly. "You have a first name?"

"Frank."

"Okay, then, Dr. Frank Clevenger. What's your line? Surgery? Internal medicine? Infectious disease?"

"I'm a psychiatrist."

She shook her head and turned toward the wall. "This is un-fucking believable."

I stood there a few moments, staring through the tangle of IV tubing that dripped amphotericin and vancomycin into Lilly's subclavian vein. A window just beyond the hanging bottles looked onto Boston 's Charles River at dusk, its waters blue-gray and utterly still. I tried again. "Do you mind if I ask a few questions?"

"You can do whatever you want. I don't care."

I heard a fusion of anger and surrender in her voice. And I sensed something more in the way she half-whispered, half-swallowed the word care. A hint of seductiveness. Her tone made me imagine that I could, quite literally, do whatever I wanted to her. I took a mental note of that feeling, wondering whether she provoked it in others-and why. I stepped closer to the bed. "Do you know why your doctors asked me to see you?"

"Probably because they keep screwing up," she complained, shaking her head and exhaling in exasperation. "They can't figure out what's wrong with me, so they're calling me crazy."

That was half right. Her doctors were calling her crazy, but they had figured out exactly what was wrong with her-at least, physically.

Drake Slattery, chief of the internal medicine department, had filled me in. He is a lumberjack of a man who wrestled for Duke, and the muscles of his crossed arms had begun to ripple as he spoke. "She presented about four months ago, fresh from her honeymoon on St. Bart's. Mild fever, red blotch on her thigh. I'm figuring some tropical insect took a bite out of her, left her with a little cellulitis. Nothing to write home about. Like an idiot, though, I trash my whole schedule to get her worked up and started on antibiotics right away."

"Is she that pretty?" I had asked.

He looked offended. "Professional courtesy; she's a nurse over at Brigham & Women's."

"Fair enough."

"And she happens to be gorgeous."

I smiled.

"So I dose her up on ampicillin, which seems to work," he said. "But then, two weeks later, she's back in the emergency room. The leg is puffed up twice normal size. She says she feels like someone's jamming a red-hot knife into her thigh. And she's running a fever of 103." His arms started rippling, again. "The ampicillin doesn't seem to cut it anymore, so I add a chaser of Rocephin. And the swelling goes down pretty quickly. All's well that ends well, right? Sometimes you have to go after the bugs with bigger guns."

Slattery was an avid hunter, which made it hard for me to like him, despite his rare combination of genius and dry wit. "You're the shooter," I said.

He winked. "Five days later, she's down in the ER again, bigger and redder than ever. Shaking like a leaf. Fever of 105. Now I'm worried. I don't know what to think. Lymphatic obstruction from a malignancy? Sarcoidosis? I even wondered about some weird presentation of AIDS. I never guessed what was really going on."

Over the next few months, Slattery admitted Lilly to Mass General four times, treating her with a dozen different antifungal and antibiotic agents. Some seemed successful, dropping her white blood cell count and stopping the chills and sweats that plagued her. But, inevitably, she would return to the emergency room within days, infected and feverish again.

A CAT scan of her leg showed no tumor. A bone scan revealed no osteomyelitis. Repeated blood cultures failed to turn up any offending bacterium. So Slattery finally had a surgeon biopsy the semitendinous and biceps femoris muscles of Lilly's leg. He forwarded the tissue samples to the bacteriology laboratory of the National Institute of Infectious Disease in Bethesda, Maryland. The report came in a week later: Pseudomonas fluorescens, a pathogen generally found in soil.

"We gave her husband the news first," Slattery had told me. "He broke down and admitted he'd found a frigging syringe caked with mud at the back of one of her drawers. Wrapped in a pair of her panties."

That image turned my skin to gooseflesh.

"Here we are busting our asses trying to keep this mental case from losing her leg," Slattery went on, "and it turns out she's been injecting herself with dirt."

"That might say something about how she sees herself," I said.

"To you, maybe. To me, it says she has no business being in the hospital. She's stealing-my time, not to mention the hospital's resources."

"I'd bet this case is all about stealing. But the key is to figure out what was stolen from her."

"You're the poet," Slattery had said wryly. "That's why I called you in."

I looked at Lilly lying in bed, still facing the wall. The technical term for her condition was Munchausen syndrome, intentionally creating physical symptoms in order to get attention from doctors. The name derives from Baron Karl Friedrich von Münchausen, a Paul Bunyan-like storyteller. Research studies have shown that a high percentage of patients with the disorder have, like Lilly, worked in the health care field.