by Robin Cook
13
TUESDAY, 2:35 P.M.
By the time Jack pulled his bike up to the OCME unloading dock, he had been reenergized. Instead of addling him, the unexpected reference to Emma’s diagnosis now only spurred him on to greater effort. Although he had struck out with the idea of a tattoo artist possibly identifying the subway death patient, he thought about using the tattoo as a way to get around the catch-22 described by the NYU heart transplant nurse coordinator. One of the things motivating him was the tattoo’s location on the volar surface of the woman’s arm, meaning it would have been right in the face of the anesthesiologist during the entire transplant procedure.
After stashing his bike in its usual location, Jack hastened to the back elevator. As he zipped past the mortuary office, Vinnie caught sight of him and called out a question. Jack didn’t hear it, but he didn’t care, either. Instead, he jumped on the elevator that happened to be waiting on the basement floor. The back elevator was the slowest of the lot, and Jack had learned over the years to nab it when it was available. Whatever Vinnie’s question was, it could wait, and if it couldn’t, Jack was certain he’d call now that he knew he was in the building.
Jack didn’t even bother to hang up his bomber jacket when he dashed into his office but rather just tossed it onto his worktable. He sat down at his desk and frantically searched within the surface debris for Nancy Bergmeyer’s mobile phone number. He remembered her giving it to him, and he remembered writing it down, but where? Being in a hurry, he didn’t want to be forced to go back to using the institution’s phone service, which he remembered being a lengthy process. Finally, he came across the scratch pad and there was the number.
Unfortunately, after several rings, he found himself switched to voicemail, forcing him to leave a message. As soon as he hung up, he also texted, to try to cover both bases. It worked. Before Jack even had a chance to hang up his jacket, his phone rang. It was Nancy Bergmeyer.
“Sorry to bother you again today,” Jack began.
“No bother,” Nancy said. “We have no case this week, and last week’s patient is doing exceptionally well.”
“I had an idea I wanted to run by you,” Jack said. “The patient I autopsied yesterday had a very distinct and colorful puzzle-piece tattoo on the volar surface of her right wrist. It would have been hard to miss when she was a patient, especially for anesthesia. What if I were to ask if your transplant program had had such a patient? How would you respond? It’s still a fishing expedition, but only for a very specific fish.”
“That is an interesting question,” Nancy replied. “I don’t think I know the answer to it. I suppose I’d have to run it by the hospital attorneys. And just to be sure, the OCME has subpoena power, doesn’t it?”
“Absolutely,” Jack said. “There’s no question of that.”
“You know, it might work,” Nancy admitted. “The more I think about it, the more I believe that if you just called up out of the blue and asked if we had transplanted during the last four months a young woman with a distinct puzzle-piece tattoo on the right wrist, I might have been willing to ask around and tell you straight off.”
“That’s what I want to hear,” Jack said. “Okay, that clinches it. I’m going to call around at the various heart transplant centers here in the metropolitan area and pose that exact question. Who would you recommend I ask to speak with?”
“My counterpart,” Nancy said. “As far as I know, all programs have a senior nurse coordinator who functions as a program director. We’re the ones who have an overview.”
“Thanks for your help. I really appreciate it.”
“Good luck,” Nancy said. “If I were you, I’d call Columbia-Presbyterian first. They do the most cases by far. I hope it works.”
“Me too,” Jack said. He disconnected, then moved over in front of his monitor. He Googled Maimonides Medical Center to find out if they did heart transplantation. If the subway death patient lived in Sunset Park, Brooklyn, Maimonides was the closest major hospital. To him that seemed a more important qualification than being the medical center that did the most cases. It was also true that somewhere in the back of his mind he recalled that the very first heart transplant done in the United States had been done at Maimonides. But he was in for a disappointment. Maimonides did not do heart transplantation, despite doing just about every other type of cardiac surgery.
Instead of going institution by institution, Jack Googled “heart transplantation in NYC metropolitan area” and then wrote down a list of the centers, along with the phone number of each program. He eliminated, for the time being, Westchester Medical Center, as it seemed just too far out in suburbia for someone who lived in town, and particularly in Brooklyn. That left seven centers that were possibilities, including two that were across the Hudson River in New Jersey. To be systematic, Jack started to the north, with Montefiore Medical Center.
Jack didn’t know what to expect his reception would be, but he was pleasantly surprised. Since he had been involved in clinical medicine, a true sense of competition and customer service had replaced older, unpleasant hospital employee attitudes. It didn’t take long for him to be speaking with Nancy Bergmeyer’s equivalent. His name was Curtis Freehold. He, too, was a certified nurse practitioner and the director of the Montefiore Heart Transplant Program.
After introducing himself as a medical examiner, Jack quickly explained why he was calling, giving all the necessary details about the victim, including a description of the puzzle-piece tattoo. He then asked if such a patient had been seen in the Montefiore program in the last four or five months.
“I personally don’t remember such a patient,” Curtis said thoughtfully. “But most of the day-shift nurse coordinators are here in the unit and I’d be happy to ask around. Our anesthesia team is available as well. I can ask them, too. Do you mind holding on? It won’t take a moment.”
“Not at all,” Jack said. He was encouraged. Not only was Curtis pleasant and helpful, but he didn’t mention HIPAA at all.
While he waited, he thought about calling Aretha back. He knew she said she would call him as soon as she knew something, but he was impatient. As Laurie had reminded him, getting a verifiable diagnosis of a specific virus was key, and probably significantly more critical than the ID. As Laurie had also reminded him, he couldn’t be sure how Aretha intended to proceed if she determined a virus was indeed present from her tissue cultures. Would that take a day or a week or a month? Jack had no idea.
“Looks like I’m striking out,” Curtis said, coming back on the line. “We even have a couple tattoo fans here in the unit, so I’m pretty certain the patient you’re searching for didn’t get her transplant here with us. I’m sure it would have been noticed. Sorry.”
“Thanks for checking,” Jack said.
“Leave me your number,” Curtis suggested. “I’ll put a note on the bulletin board, which we all look at every day. If someone has a different take, I’ll give a shout.”
Jack gave his mobile number and rang off. Going back to his list, he got the number of Columbia-Presbyterian and placed the call. The experience was similar to Jack’s call to Montefiore. It was apparent to Jack that the programs were rivals on some level and coached in customer satisfaction. It was certainly a new age. Back when Jack was an ophthalmologist, just calling to schedule surgery at his hospital center had often been unpleasant because of hospital employee attitudes.
Once again, Jack got someone high up in the program’s hierarchy on the line and posed his question. The response was just as helpful as at Montefiore, although in the end the director wasn’t quite as definitive as Curtis had been. She openly said she doubted that a patient that fit the description had been treated, but she couldn’t be certain. Also like Montefiore, she promised to get back to him if the situation changed.
While on hold with Mount Sinai Medical Center, the next hospital on his list, Jack thought again abo
ut Aretha and wondered anew what the tissue cultures were showing. The one thing that made him feel reasonably comfortable was that there had not been any similar deaths. He had told Bart he was to be notified immediately if there were. If this subway death was the index case of a new pandemic, it was at least taking its merry time getting going. Reluctantly, he couldn’t help but wonder if Laurie was right after all in holding off on sounding an alarm.
“It doesn’t seem like we’ve had any patients with memorable tattoos,” Harriet Arnsdorf, the Mount Sinai heart transplant director, said when she got back on the line. “Everyone I’ve spoken with insists that they would have remembered what you described.”
“I appreciate your asking around,” Jack said, once more leaving his mobile number just in case.
After disconnecting, Jack sat back and rethought his approach. He was down to his last Manhattan-based heart transplant center, Manhattan General Hospital, before he would be trying the Beth Israel Medical Center in Newark, New Jersey. He couldn’t help but feel a tad let down after the initial excitement of thinking that combining the heart transplant situation with the puzzle tattoo might lead to an ID breakthrough. Perhaps sending a photo of the puzzle tattoo would be more effective in jogging memories than a verbal description. With that thought in mind, Jack took a pic with his phone of the puzzle-piece photo, with the idea of texting it to the rest of the program directors he spoke with.
As the call went through to the MGH Heart Transplant Program, which he noted was advertised as an integral part of the MGH Zhao Heart Center, Jack couldn’t help but remember that MGH was certainly not his favorite hospital. The reason was that it was owned by AmeriCare, a large, publicly traded health insurance and provider organization that in the distant past had played a role in forcing him out of clinical ophthalmology and into forensic pathology. As a medical examiner, Jack did not have to bill health insurance companies, which he had learned to blame for ruining American medicine by turning it into a huge for-profit enterprise, to the detriment of patients and doctors alike.
Although it took somewhat longer than it had with the other three medical centers to get an appropriate person on the line, eventually Jack found himself talking with Bonnie Vanderway, MGH’s Heart Transplant Program’s clinical director. Jack immediately launched into his now practiced spiel, introducing himself professionally, describing the deceased in general terms, including a mention of the heart transplant three or four months ago, and emphasizing the pressing need for the OCME to make an identification. He didn’t bother to explain why. As for the cause of death, he said it was yet to be determined.
“The one thing in our favor is that the body does have some unique identifying markings above and beyond its distinctive thoracotomy scar,” Jack continued. “What I’m talking about are three widely separated tattoos. One of them is rather eye-catching. It’s also on the underside of her right wrist, which would have been in plain sight with an IV. What I’m hoping is that you or one of your colleagues might remember this tattoo if this patient had had a transplant in your program. But rather than describe it, I’d like to send you a pic, provided you’re willing to look at it. You’ve heard the phrase ‘a picture is worth a thousand words.’”
“Of course, everyone has heard that expression,” Bonnie said with a short laugh. “Sure. Send it on!” She gave Jack her mobile number, and Jack responded by sending her the photo. A moment later her phone sounded, indicating an incoming message. “I’m opening it now,” she said.
“Take your time,” Jack said.
“Wow,” Bonnie replied almost immediately. “This is colorful and eye-catching. And you know something? I think I remember it.”
“Really?” Jack questioned casually. He didn’t want to get his hopes up.
“I’m not entirely sure,” Bonnie said. It was apparent to Jack that she was still studying the photo. “I think I remember seeing it in the CSR, or cardiac surgery recovery room, but just in passing. It was probably the colorful aspect that briefly caught my attention. When we’re in the CSR we’re pretty focused on our individual patients.”
There was a pause as she gathered her thoughts. “I wish I remember distinctly, but I’m afraid I don’t. But this I can tell you: It wasn’t my patient. I’m also a nurse coordinator, so I have my own patients in addition to my supervisory functions. Let me ask around. Do you want to hold on, or should I call you back?”
“I’ll hang on,” Jack said. Sensing he might be close to success, he didn’t want to let Bonnie figuratively out of his grasp. With the phone pressed up against his ear, he kicked back in his chair. Lifting his feet up and placing them next to his microscope, he tried to decide what he would do if he lucked out. The problem was that he had no idea how cooperative MGH would be. He’d dealt with the hospital on a few difficult cases in the past and had found them less than helpful and had subsequently gotten himself in hot water with Bingham. That was one of the field episodes Laurie was referring to yesterday. AmeriCare was an exceptionally profitable business, and their flagship hospital, Manhattan General, was run accordingly. Jack had had particular difficulty getting information out of the hospital, because bad news, which deaths usually involve, can impact the bottom line. As a consequence, Jack had gotten into a heated clash with the hospital’s president. Making matters particularly dicey, the hospital president was politically tight with the NYC mayor, who was essentially the OCME’s boss.
“Okay,” Bonnie said without preamble when she came back on the line. “I was right. We did have a thirtyish female patient with a tattoo that looked like this pic you sent. I spoke with the nurse coordinator on the case, Tatiana Popov, and showed her the image, and she remembers the tattoo distinctly and thinks there’s a good chance it could have been this individual.”
“Is the time frame correct?” Jack asked.
“Gosh, that I didn’t ask. Hold on!”
Jack could hear Bonnie yell in the background, asking how long ago the case was. He couldn’t hear the muffled response, but Bonnie came back on the line immediately. “That seems to fit as well.”
“Fantastic,” Jack said. “If I give you my email, would you send me all the patient details?”
“Hmmm,” Bonnie said. There was a pause. Then she added: “I don’t think I can do that, not right away.”
“Why not?” Jack questioned, even though he didn’t want to hear.
“Well, we’re specifically told by our executive director not to give out any patient information until we run all requests by the legal department, unless it is for immediate family. You know, with HIPAA and all, our hands are tied. The hospital admin is strict about this, and I don’t want to get fired. Maybe I shouldn’t have even told you about possibly recognizing this tattoo.”
“As a medical examiner investigating a medical examiner case I have subpoena power,” Jack said. Although it was true, Jack didn’t want to be forced into that route as it would invariably take too much time. If the ID was going to have an effect on this subway death case, he needed the information now, not next week. There was nothing speedy about the legal route.
“I know that,” Bonnie said. “Still, there are institutional rules that we have to follow. Besides, this wasn’t what I would call a normal case.”
“Oh?” Jack asked. “How do you mean?”
“It was a direct referral on the day of surgery from a hospital out in New Jersey that has an association with our Zhao Heart Center.”
“A direct heart transplant referral?” Jack questioned. “That sounds unique. Is such a thing a frequent occurrence?”
“No, not to my knowledge,” Bonnie said. “This was the first for me, and I’ve been here for almost two years and at a previous program for five years. But regardless of how she got here, it’s tragic to hear she’s passed away. And I’m sure all the people here associated with her case will feel the same, even though the patient was here for a much shorter time
than usual. You can’t help but get to know these people intimately. I know Tatiana couldn’t believe it when I told her why I was asking about the tattoo. She reminded me the patient had done so well. She had been brought in here near death and four or five days later could have walked out if we hadn’t made her use the wheelchair.”
“Interesting,” Jack said. He thought it was more than just interesting, but he didn’t know quite what to say and was racking his brain to think of something. He didn’t want Bonnie to hang up, which worried him as a distinct possibility with her sudden legal concerns. “What exactly do you mean by a ‘direct’ referral?”
“All the patients we operate on have to be accepted into our program and get on the OPTN, or Organ Procurement and Transplant Network, list for a heart. But that didn’t happen in this case. She had been in the program of a New Jersey hospital that was in the process of obtaining its certification as a transplant center. I never knew the clinical details of this woman’s case, like whether she had an implanted left ventricular assist device or not. As I said, she was not my patient. But what I remember hearing is that her clinical situation took a very sudden nosedive to the point that she needed an immediate transplant if she was going to live. And, like a miracle, the hospital where she was being followed came up with a targeted donation that was a good match. Since her hospital lacked certification, the patient and the cleared organ were airlifted here for the surgery.”
“What’s a targeted donation?” Jack asked.
“It is when the donor or, in this case, the donor family stipulates who the recipient is going to be. It is not very common with hearts, but it happens. It’s usually in situations where the families are either related or know each other. I don’t know what the circumstance was in this case. All I heard was that it was the result of a motorcycle accident. For those of us in the transplant business, motorcyclists are probably our most reliable resource.”
“What you’re saying is that the transplant was done at MGH but none of the preliminary work that’s normally required was.”