by Robin Cook
At that point, Jack began the internal portion of the autopsy. To proceed he used his favored modified Y incision that went from the point of the shoulders to the clavicular notch, and then down to the pubis through the surgical scar. He needed wire clippers to cut the wires holding the sternum together.
Once the body was flayed open, Jack’s first point of attack was the abdomen. Although the liver appeared to be entirely normal, he did see some very mild evidence of inflammation, with a small amount of extravasation of blood involving the gallbladder, the spleen, and the kidneys. The findings served to key off in his mind a distant association with hantavirus, even though he knew instinctively that hantavirus couldn’t be involved. Hantavirus pulmonary syndrome was extraordinarily rare, especially at that time of year in New York City. But the thought did raise again in his mind the idea of contagion.
Jack’s next job was to run the intestines, examining and palpating every inch while in situ. He found nothing abnormal. Then, while Vinnie and Carlos took the freed intestines over to the sink to wash them out, Jack turned his attention to the thorax. It was here that he thought he’d find some answers.
He decided to take the lungs and the heart out en bloc so he could examine them together, and the first hint of significant pathology was their weight. As Jack carried the mass of tissue, which also included the severed great vessels, over to a side table, he could tell they weighed maybe twice what he expected. What he assumed was that the swollen lungs were filled with edema fluid, and he was right. But it wasn’t only edema. Making a few slices into the lung, which burst open as if under pressure, and looking at the cross-sections, he could tell there was a significant amount of inflammation, with some bleeding and a lot of exudate, or what the general public might call pus. It was plainly obvious that the woman had died of massive pulmonary inflammation, which Jack now knew could not have been caused by a catastrophic problem with a heart valve. A suddenly failing heart valve would have filled the lungs with frank blood, not blood-tinged exudate. Consequently, Jack was back to the idea that a contagious disease might have killed this woman, and if that was the case, it had to be a particularly aggressive virus, maybe even similar to the strain of influenza that had killed a hundred million or more back in 1918. As he came back to this line of thinking, the expression “Be careful what you wish for” passed through his mind. Although he sorely needed a diversion from his problems at home, he certainly didn’t want it to be at the expense of a large number of innocent people. A new lethal influenza pandemic would wreak havoc in the city and around the world.
Taking a pair of scissors, Jack began cutting into the pericardium to expose the heart nestled between the two lungs. Usually this was an easy job, but not in this case, as there was considerable scar tissue, additional evidence that the woman had had heart surgery. As he slowly exposed the organ, he was in for another shock. The patient certainly had had open-heart surgery, but it wasn’t surgery on one of her valves, as he had assumed. To his surprise, Jack could see that the patient had had a total heart transplant.
“Vinnie, get over here and look at this!” Jack shouted.
Both Vinnie and Carlos rushed over to the table where Jack was working.
“Check this out,” Jack said, using the dissecting scissors as a pointer. “Look at these suture lines in the great veins and arteries. What you are looking at is a relatively recent total heart transplant, and it’s the newest bicaval transplant technique. I’m impressed. Back in the early days they used to attach the atria, but no longer.”
“So it wasn’t a heart valve problem that killed her,” Vinnie mused.
“I doubt it,” Jack said. “But it will be easy to prove one way or the other. Let me open the heart.” Cutting into the heart muscle, Jack exposed the interior chambers and spread the edges. “Obviously it wasn’t the valves. Check them out. They’re all perfect.”
“Could it have been sudden organ rejection that killed her?” Vinnie asked as he straightened up to let Carlos look. Vinnie had recalled a case that he and Jack had handled where the patient had had a massive and sudden rejection of a liver transplant.
“That’s a good question,” Jack said. This line of thought was one of the reasons he liked working with Vinnie. Despite Vinnie’s frequent grousing about working too hard, he occasionally contributed something significant to the conversation. Jack hadn’t yet thought of a rejection process being involved. With that in mind, Jack carefully examined the heart. When he was done, he shook his head. “It’s certainly not rejection of the heart. There’s no sign of inflammation whatsoever in the organ, nor in the pericardium.”
Vinnie explained to Carlos that the pericardium was the tissue that covered the heart.
“The pathology is all in the lungs,” Jack said. He then showed the two men the cut surface of the interior of the lungs. “The lungs are completely full of fluid and exudate. I’m back to the influenza idea.”
“It looks like she fucking drowned,” Carlos said.
Jack gritted his teeth. He was old-school in respect to foul language. He knew that the younger generation thought of it totally differently, but that didn’t mean he would stand for it in a professional setting. “Listen, Carlos,” Jack snapped. He took an intimidating step in Carlos’s direction. “Tone the language down when you are around me. You get what I’m saying?”
“Sorry,” Carlos said. He backed up and rolled his eyes for Vinnie’s benefit.
Jack let it go.
“How would influenza kill so fast?” Vinnie asked, to defuse the situation. He was well aware of Jack’s sensitivities. “This patient might have gone from the first symptom to death within an hour. How could that happen?”
“Another good question,” Jack said. “Back in 1918 they had absolutely no idea. What we now know is that it’s a process called cytokine storm. It’s when the body’s immune system senses the virus antigens and then goes berserk, releasing a bevy of extraordinarily damaging hormonelike proteins.”
“What are you saying?” Vinnie questioned. “Are you talking about a kind of cellular hari-kari?”
“That’s a colorful way to put it,” Jack said. “But yes. It’s the person’s own immune system that suddenly cranks out these cytokines that irreversibly damage the lungs. The virus just sets it all in motion, so to speak.”
“Holy f—” Vinnie started to say but caught himself.
“I want samples of the lung fluid for culture,” Jack said, pretending he hadn’t heard. There was a definite urgency in his voice. “And I want samples from the main bronchi. Then I want all the usual samples. Let’s get this show on the road!”
“Now you’re talking,” Vinnie said. Since Vinnie’s employment responsibilities had him coming in before seven to smooth the transition from the night crew to the day shift, he was supposed to leave at three. Too often Jack kept him busy well beyond then. And Jack’s sudden ardor hinted that this was going to be one of those days.
4
MONDAY, 2:55 P.M.
Because of the possible contagious nature of the case, when the autopsy was complete Jack stayed around to be sure everything was handled according to protocol, including decontaminating the outside of the body bag, all the specimen samples, the jewelry containers, and the outsides of the moon suits. He thought it was too much responsibility to leave with Vinnie, especially with Vinnie having to deal with the newbie, Carlos, meaning Vinnie was figuratively working with one hand tied behind his back.
Since Jack was again considering the serious possibility of a new influenza strain, he returned to the front office. He still thought it best to clue Laurie in to the situation so that she could begin to formulate a plan for how to alert the appropriate city agencies if Jack’s worst fears were substantiated. But Jack was thwarted on this second attempt just as he had been on his first. As soon as he appeared, Cheryl informed him that Laurie was still on the same conference call.
> “It’s about the budget,” Cheryl explained in a forced whisper.
Jack couldn’t help but feel sorry for Laurie. He was impressed she was finding the patience and the stamina to stay on the phone, as he knew he’d find it impossible. Jack had trouble remaining on phone calls for anything over a few minutes. Apparently, Laurie had been on for hours.
After again telling Cheryl he’d be back, Jack decided to see that the specimens he’d taken during the autopsy got delivered to their appropriate laboratory destinations. The toxicology samples were easy, since it just required him taking them up to the sixth floor. All the other samples were a bit more difficult, since the other laboratories had been moved to the new building. To get them there required using the OCME van drivers when they weren’t out picking up bodies. To make it even more complicated, microbiology testing wasn’t done at the 421 OCME high-rise, but rather in a large building directly across First Avenue called the Public Health Laboratory, which was a separate city agency.
Since Jack wanted answers ASAP, particularly as to whether a dangerous respiratory virus was involved, he decided to do the deliveries himself. In order to have a specific destination, meaning a real person, for the virus cultures, he used his mobile phone to call the Virology Department of the Public Health Laboratory. After speaking with several secretaries, he finally managed to get through to one of the virologists. Her name was Dr. Aretha Jefferson.
“I’m one of the medical examiners,” Jack explained, after introducing himself.
“I’ve heard of you,” Aretha said, to Jack’s surprise. And then, to his further surprise, she added, “I understand you play basketball at the playground on West 106th Street. Are you that Jack Stapleton?”
“I am,” Jack said. “I didn’t know I was quite so famous. How did you hear about me?”
“I live on the Upper West Side,” Aretha explained. “I played basketball at UConn as an undergrad and kept it up through grad school. I have been looking for a game since I took this job in the city. I was planning on trying to get in touch with you to ask if there was any chance of my coming by your playground some evening.”
“It’s not my playground,” Jack said. New York never ceased to amaze him. It was a huge city, yet in some ways it felt like a small town.
“That’s not what I heard,” Aretha said with a laugh. “Anyway, I’d like to meet you and your friends, in hopes of getting into a game or two.”
“I’d be happy to meet you,” Jack said. “And maybe we can exchange favors. The reason I’m calling is that I have some lung and bronchial specimens, as well as serum and cerebrospinal fluid from an autopsy I just did, that I need to be tested. The woman died of a respiratory problem. I’m concerned about a possibly virulent influenza and would like to run a rapid screen test as well as a more detailed analysis ASAP. Can you help me?”
“Certainly,” Aretha said. “That’s what we’re here for. Have them sent over. We’ll take care of them.”
“Thank you,” Jack said. “Actually, I’d like to bring them over myself and deal with you directly. Would you mind? You see, the sooner I get an answer, the better. I’m concerned it might be a new strain and I don’t want these samples to disappear down a bureaucratic rabbit hole.”
“No problem,” Aretha said. “When would you like to do this?”
“Would now be okay?” Jack said. He knew he was being overly pushy, but he thought the situation demanded it. It seemed particularly opportune that he could potentially do her a favor as well. Between city agencies things always worked better when there was a personal relationship and a give-and-take.
“Why not,” Aretha said. “It will give me a chance to meet you in person. Are you familiar with the Public Health Laboratory building?”
“I’m not,” Jack admitted.
“The easiest way would be for you to come in the back entrance off Twenty-sixth Street and take the service elevator directly up to the third floor. That’s where our level-three lab is located, where the testing will be done. I can meet you there.”
“Perfect,” Jack said. “I’m on my way.”
Initially Jack debated using his bike again for the quick high it invariably gave him, but decided against it. He worried there wouldn’t be a safe place for it when he went into the Public Health Laboratory unless he brought along his ponderous collection of chains and locks. Instead he merely ducked directly out of 520 onto First Avenue with a shoulder bag full of specimens and jogged the four blocks down to 26th Street. Although there was ancient-appearing scaffolding erected around the massive Public Health Laboratory building, Jack was able to find the service entrance with comparative ease. As he rode up in the battered service elevator, he guessed the building was from approximately the same era as the old OCME structure.
As the elevator doors opened, Jack was greeted by a tall, youthful, and athletic-appearing African American woman with bright eyes and an equally bright smile. Her hair was meticulously done in cornrows with colorful beads. She introduced herself with infectious alacrity and pumped Jack’s hand. Without hesitation she took the samples Jack had taken out of his shoulder bag and handed over her business card.
“I put my mobile number on the back,” Aretha said. “How about you give me yours?”
Jack took out one of his business cards and added the number. He handed it to Aretha.
“I’ll run rapid tests for the usual culprits,” she told him. “That will certainly include the standard influenza strains, SARS, MERS, and even the new bird flu, plus the usual run-of-the-mill respiratory villains. I should have some results in a few hours.”
“I’ll appreciate a call as soon as you have the results,” Jack said. He couldn’t have been more encouraged and pleased. “Could you test for hantavirus, too? I know the chances are probably zero, but there was some inflammation in the gallbladder, spleen, and kidneys, like what is seen with hantavirus.”
“I’ll run all the rapid tests,” Aretha promised. “It’s actually automated. If there’s a known virus present with a decent titer, meaning there’s enough of it, it will pop up. And if it killed the woman, it’s got to be a decent titer, especially since you got it directly from the lungs. Now, with that decided, is there any chance you’ll be playing basketball tonight?”
“I’m not sure,” Jack said. He was impressed with Aretha’s tenacity. “Sorry, but my daughter is having some health issues. I’ll have to see. But I could call some of the other guys and set it up for you, whether I come out or not.”
“I think I’ll wait until you are available,” Aretha said. “I’m an old hand at street b-ball and know the politics can be dicey.”
“You’re right in general,” Jack said. “But our court is neighborly and everyone is pretty laid-back. And there is no gender issue, if that’s your concern. There was a few years ago, but that’s not the case now. Skill is the determining factor for both sexes, which shouldn’t be a problem if you played college ball for UConn. But if you’re reluctant to show up on your own, I’ll give you a call if I can get out there tonight. I could definitely use a run.”
“I’ll keep my fingers crossed,” Aretha said. “Meanwhile, I’ll get to work on your samples. I’ll also inoculate some cell cultures just to let you know over the next couple days if any viruses are present. That might be helpful if the rapid tests are negative.”
“I appreciate your help,” Jack said. “This could be important, especially if it is a new influenza strain.”
After promising to get together at some point at the playground across from Jack’s house, Jack returned to the street. From the Public Health Laboratory, he merely had to cross First Avenue and skirt a small park to get to 421. In less than five minutes he was back on the fifth floor, sitting across from Bart Arnold.
“This case you turned me on to is getting progressively more interesting,” Jack said. “I just finished the autopsy. Thanks for cluing me
in.”
“What did you find?” Bart asked. He leaned forward, all ears.
“First of all, the woman had had a recent heart transplant,” Jack said.
“No!” Bart said. He laughed briefly in disbelief and shook his head. “There’s always surprises in this job. Who would have guessed to look at her. And is that what you think killed her: something going haywire with the transplant?”
“No, the transplant couldn’t have looked any better than it did. It appeared like the heart of an athlete, with absolutely no signs of inflammation or rejection whatsoever. All the pathology was in the lungs, which showed a huge amount of inflammation from what I’m guessing was a cytokine storm secondary to a viral pneumonia, possibly influenza.”
“Having had a recent heart transplant, she must have been on high-dose immunotherapy,” Bart said.
“No doubt,” Jack said. “I’m sure Toxicology will confirm that.”
“But if she were on high-dose immunotherapy, wouldn’t that preclude her having a cytokine storm? Wouldn’t immunotherapy block a cytokine storm or at least keep it in check?”
As soon as Bart said the words, Jack knew he was absolutely right. All heart transplant patients took high doses of immunotherapy to block rejection, which probably would have blocked the immune response that triggered a cytokine storm. Jack had let his excitement get the better of him. All at once he was back to square one.
“Did I rain on your parade?” Bart asked, looking a smidgen guilty at the change in Jack’s expression.
“I suppose, to a degree,” Jack said, trying to reorganize his thinking. “Well, we’ll have to wait and see what Toxicology will tell us. And what we learn from Virology. I just left lung and bronchial samples over at the Public Health Laboratory. We should have some preliminary results in a few hours. Meanwhile, have you had any luck getting any more information on the patient? It’s going to be important to have a social history if there’s a need for any quarantining and prophylactic antivirals. Did the Bellevue ER come up with a purse or a phone or anything?”