by Robin Cook
“It wasn’t good, it was a fabulous match,” Ted said enthusiastically. “The best I have ever seen, and with the rarest AB-negative serology, which is the reason we pushed for a targeted or direct donation. There was a twelve-out-of-twelve HLA match, zero reactive antigen, and a negative cross-match. It doesn’t get any better than that.”
“Was the motorcyclist related to Carol?” Jack asked, still skirting the issue.
“I believe he was a Stewart, but I’m not positive,” Ted said. “Or he was related somehow. I personally don’t get involved in that, as we have our own organ-donation team who deals with the grieving parents, to separate donor issues from recipient needs. All I knew was the heart matched extraordinarily well. The fact that the kinship issue wasn’t stressed is because we have some hillbillies around here despite our proximity to the city. We might not have any families that are as hostile to each other as the McCoys and the Hatfields, but there are feuds, even within the same family.”
The alarm bells that this case had set off in Jack’s brain started ringing again. “So the motorcyclist was a male?” he asked, to be certain Ted hadn’t had a slip of the tongue.
“Yes,” Ted said. “Ninety percent of motorcycle driver deaths are men.”
“True,” Jack said. As a medical examiner, he was aware of the statistic. But that wasn’t the source of the silent ringing he was hearing. If the motorcyclist was a male, there was no way he could have been an identical twin. Jack was back to square one.
“The reason it was such a serendipitous situation,” Ted said, unaware of Jack’s mental state, “was that Miss Stewart had been on the UNOS waiting list for a year. With AB-negative she clearly wasn’t going to get an organ. Obviously, the motorcyclist’s serology was also AB-negative.”
“Dr. Barton mentioned that,” Jack said.
“Other questions?” Ted asked.
“Yes.” Jack struggled with what next to ask. “We were surprised when a toxicology screen revealed that Miss Stewart had no immunosuppressants in her system.” Reluctant to go for broke, which would have happened had he stayed on the topic of how closely the donor heart matched, he’d changed the subject to the immunosuppressant issue. Now more than ever he was certain that something was amiss with this case, and the cynic in him began to wonder if the hospitality he was experiencing was to placate him.
“It was for good reason you found no immunosuppressants,” Ted said. “She wasn’t on them. She had been doing so admirably, even with her active immune system, which she had, by the way, that we were able to lower and eventually eliminate immunosuppressants. It was a function of how well she had accepted the donor heart, which thrilled us. You have no idea.”
“Hello, hello,” a voice called, as two figures bounded into the room. The first was tall but slightly stooped, with striking, prematurely white hair. In contrast, his face was boyish, with a lantern jaw and bright blue eyes. He was attired exactly as Dr. Chris Barton had been the day before at MGH, in a long white doctor’s coat over scrubs, with a surgical mask dangling from his neck. The second man was similarly dressed but of Asian genealogy, with coal-black hair, small features, and a slight build. Both were smiling as if they had been laughing prior to coming into the room.
Jack and Ted stood as Ted introduced Dr. Stephen Friedlander and Dr. Han Lin to Jack, suggesting as he did so that they should all be on a first-name basis. Jack shook hands with both surgeons. At that point all four people took seats around the circular table.
Like a true surgeon, Stephen took control. He had a deep and commanding voice despite his boyish looks. “We are thrilled you surprised us by stopping by, Dr. Stapleton,” he said. “As I’m sure Ted has told you, we heard the efforts you had gone through to identify our patient, Carol Stewart. As sad as the news was, I personally want to thank you very much for what you did. From what I understand, Carol’s body might not have been identified until she missed her next follow-up visit here at our clinic and we reported it to Missing Persons. It is particularly sad, as I personally know she’s been estranged from her family and had some setbacks in her own social life. I know because she told me not that long ago on her last follow-up visit, which, by the way, was perfect on all accounts. There was absolutely no sign of any coming catastrophe.”
“As I told Ted,” Jack said, “it is part of the job of the medical examiner to identify the dead. At OCME we learned that lesson the hard way after 9/11.”
“At this point our goal needs to be finding out why she died,” Stephen continued. “Whatever it was, we do not want it to happen again. Since we know you did an autopsy, we are interested to hear your findings.”
“I have yet to sign the case out,” Jack said. He appreciated finally being asked, but with Laurie’s insistence on holding off on telling anyone, he wasn’t sure how much he wanted to say, especially until he got confirmation from Aretha. “I’m waiting on some tests.”
“We were concerned about a virus,” Stephen said. “We sponsored a second autopsy here this morning.”
“So I heard,” Jack said. “And what was found?”
“We believe she died of a cytokine storm,” Stephen said. “She had a strong immunological reaction to something in her system. Exactly what, we don’t know. We thought about a virus, but that doesn’t seem to be the case.”
“Sounds familiar,” Jack said. “I also suspected a virus—influenza, to be exact. But all the usual viruses have been ruled out with rapid screening tests, including influenza.”
“We know it wasn’t a virus,” Stephen said with conviction. He sat back in his chair, his arms folded across his chest. “We know it for certain.”
“And how is that?” Jack asked.
“We have access to electron microscopy, which is the benefit of having superb resources. We simply looked. Actually, Dr. Lin looked. Right now, he’s our most experienced electron microscopist. There’s no virus in her lung fluid. Case closed.”
“Yes, I looked for virus,” Dr. Lin said with a heavy accent. “No virus was present.”
“That’s curious,” Jack said. “We began seeing cytopathic changes suggestive of virus in human kidney cell tissue cultures within twenty-four hours of inoculation. The plan is to search for an unknown virus.” Although Jack tried to sound confident, he was shocked and dismayed to hear that no viruses were seen on microscopy. He wondered if Aretha had tried. He doubted it, as she surely would have told him. He didn’t even know if the Public Health Lab had an electron microscope.
“Undoubtedly you were seeing the results of a viral contaminant,” Stephen said confidently. “It happens all the time. If viruses had been present, they would have been seen on microscopy. Since there’s no virus present, running viral searches is a waste of time and money. Our forensic pathologist thinks the case needs to be signed out as a therapeutic complication, despite her surgery being more than three months ago. We agree and think you should do the same. We can share with you our electron photomicrographs for your records for confirmation. What we will be doing going forward is an extensive study of the proteins in the patient’s serum that must have come from the heart and keyed off the cytokine storm. We have that kind of capability. What we’ll be willing to do, if you are interested, is keep you in the loop and let you know what we find. I’m sure we will publish the results, and we’d welcome you as an author.”
“That’s very good of you,” Jack said, trying to keep his tone neutral. “I appreciate the gesture.” Actually, it sounded to him as if they thought they could buy him off with nothing more than an authorship of a study that might get published and might not. Worse yet, from Stephen’s body language, Jack sensed that the meeting was coming to an end despite his serious effort of being tactful and avoiding confronting them directly.
“Well,” Stephen said, slapping his thighs in preparation of getting to his feet. “Consider it a standing offer.”
Clearing his thro
at and deciding to go for the jugular, come what may, Jack leaned forward and said: “I think I should mention to you one test that was done in our lab whose results we already have in hand. We ran DNA analysis on both the patient and the heart to upload the profiles into CODIS in hopes of helping the identification process. A hit on either would have been helpful. To our shock both profiles were the same. Especially with twenty loci as the new standard, that is statistically impossible. Do you folks find that as surprising as we do?”
Both Stephen and Ted laughed, but it wasn’t entirely sincere to Jack’s ear. Stephen spoke up: “Of course we find that surprising, since we, too, know it is statistically impossible. Obviously, you should run the tests again. Surely there was a mix-up with the samples. I mean, we knew it was a great match, which we attributed to the possible kinship of the parties involved. I guess that’s why we were able to wean her off immunosuppressants so quickly.”
“We ran it twice,” Jack said. “And for the CODIS results to match, it would have had to have been identical twins. Obviously it wasn’t identical twins, since they were of different sexes, as Ted confirmed. There have been cases of identical twins being separated at birth, but that could not have been the case in this instance. In theory we’re facing a miracle here, but in reality it is more of an enigma that needs to be explained. The rapidity of Carol’s death reminded me of the influenza pandemic of 1918. To be entirely honest, I’m worried about a new pandemic.”
Jack sat back and watched the three people sitting at the table with him. Although Dr. Lin seemed unfazed, the other two were clearly discomfited, raising Jack’s curiosity and reminding him of the Shakespearean quote, “Something is rotten in the state of Denmark.”
“Could you excuse us for a moment?” Stephen asked.
Jack shrugged. “Of course.”
Stephen and Ted both stood and left the room. It sounded as if they were arguing as the door closed behind them. Jack stared across the table at Dr. Lin, who smiled back at him. Jack tried to guess the man’s age but couldn’t. He looked particularly youthful, but Jack knew that couldn’t be the case, as the man was already a surgeon. His face was seemingly devoid of facial hair of any sort. Judging from the man’s accent, Jack assumed he was from China. To make conversation, Jack asked if that was the case.
“Yes, I am from China,” Dr. Lin said. He smiled broadly. “I’m from Jiao Tong University School of Medicine.”
“Are you in training?” Jack asked.
“Yes, I am training in cardiac surgery,” Dr. Lin said. “My institution sends someone here to Dover every year for transplant work.”
“Do you get good training here?”
“Oh, yes, the best,” Dr. Lin said.
Jack looked up as Stephen and Ted returned. Whatever their disagreement had been, it seemed to have totally passed. Although they had clearly been uptight when they left, there had been a definite transformation. They were literally laughing as they retook their seats.
“Well, you are in for a treat, my friend,” Stephen said, clapping his hands together with exuberance.
“That sounds encouraging,” Jack said. “I’ve been in need of a treat for years.”
“Ted and I both came to the conclusion simultaneously,” Stephen continued. “We thought that to properly show our collective appreciation of your efforts, you should meet the boss, the brains of the whole operation, Dr. Wei Zhao. Of course, it depends on your interest. What I mean to say is that there is no compulsion involved. How does the idea strike you?”
“My dance card has some leeway,” Jack said. Here was yet another surprise. Being offered the chance to meet the man of the hour was perhaps the last thing that Jack had expected on his visit.
“Perfect,” Stephen said. “And I’m happy to report that we have already called our Han emperor, and he is delighted to meet you.”
“I’m touched,” Jack said. “When might this happen?”
“In about an hour,” Stephen said. “Here’s what Ted and I propose. We’ll take you on a tour of our hospital or GeneRx. Your call. The meeting with Dr. Zhao will take place in our boss’s home office, which is a short fifteen-minute drive. Are you game?”
“Absolutely,” Jack said. “Sounds like a delightful afternoon.”
19
WEDNESDAY, 10:45 A.M.
The tour turned out to be far more interesting than Jack had imagined. Since he’d seen enough hospitals in his life, he chose to pass the time seeing GeneRx. As he had never visited a pharmaceutical company, much less one specializing in biopharmaceuticals, he didn’t have anything to compare it to. But there was one thing for certain: He’d never seen quite so many biotech engineers all in the same place, and it seemed as if they were mostly Asian and not just Chinese. There were many Indians as well. And all appeared remarkably young, just like Dr. Lin. The only surprising thing during the tour was going through the gatehouse, which required everyone but Jack to show their ID badges. The process made Jack wonder how many pharmaceutical companies had equivalent security.
But even more impressive than the drug company was the Farm Institute, which was physically attached to GeneRx and in the same architectural style. Since it was the inhabiting transgenic goats, sheep, pigs, cows, and chickens who would be manufacturing all the enormously profitable drugs, they were being treated in high style by an army of caregivers and veterinarians. Some of the animals were in posh, completely sterile environments. Although Jack wasn’t shown it, he was told the institute even had its own slaughterhouse, despite it sitting empty ninety-nine percent of the time, and also a miniature rendering plant to recycle the protein. The whole operation was entirely self-contained.
When the tour was over, they returned to the hospital parking lot, where it was quickly decided that two cars should be taken for the trip to Zhao’s home. Stephen would drive his own, with the idea that Jack would be staying longer than the others. After a short discussion, it was determined that Ted would ride with Jack, and Han would go with Stephen.
With that decided, they were on their way, driving north on Lake Denmark Road. At first Jack tried to keep up with Stephen, but it quickly became obvious Stephen drove significantly faster on the curvy, rural road with his Porsche Panamera than Jack in Warren’s top-heavy Escalade. And with Ted in the car for directions if needed, Jack was content to fall behind. There was no reason to hurry. The scenery was a bit of autumnal splendor similar to what Jack recalled from his childhood in Indiana. Except for Central Park, New York City was not a place to appreciate fall colors.
“This area is a lot less developed than I would have imagined,” Jack said, looking out at the stretches of apparently virgin hardwood forest interspersed with rolling hills and small lakes that again recalled Warren’s laconic description of the area.
“It’s thanks to the Picatinny Arsenal,” Ted said. “They have a lot of land. It’s like a nature preserve.”
Both men made it a point to avoid bringing up the subject of the strange CODIS profile match and kept the conversation light. Jack was thrilled with the idea of meeting the billionaire Wei Zhao and didn’t want to put it in jeopardy by forcing the issue. He was confident there would be plenty of time.
For his part, Ted was happy to regale Jack with all the reasons working for Dover Valley Hospital was the best possible position for a doctor in any specialty, truly combining both clinical medicine and the latest high-powered evidence-based research. “Dr. Zhao is a true visionary, with the resources to back it up,” Ted explained. “This place is the future of medicine with his leadership and commitment. You should think about coming out here. It’s a great work environment and living style. We have access to the city for what it has to offer culturally.”
“I can’t imagine there’s a lot of demand for a forensic pathologist like me,” Jack said.
“I wouldn’t be so sure,” Ted responded.
“Is Dr. Zhao a med
ical doctor?” Jack questioned.
“No, he’s a double Ph.D.,” Ted said. “In both molecular biology and genetics.”
“How old is he?” Jack asked, without even knowing why.
“I’m not sure exactly,” Ted said. “If I had to guess, I’d say late sixties. But he doesn’t look it.” Then, pointing ahead, he added, “Slow down. It’s the next left turn.”
They turned off the main road, heading northwest on a road marked as private. Then, to Jack’s surprise, they came to another security gate. Ahead, they could see Stephen’s Porsche disappear around a bend, as it had already been cleared. As Jack pulled up to the gate and lowered his window, he wondered if Wei Zhao was a particularly paranoid individual. Such in-your-face security seemed a bit excessive.
After scrutinizing Ted’s ID badge and then checking Jack’s name against a list on a clipboard, the traffic gate rose. Pulling ahead, Jack’s curiosity got the best of him and he said, “Why all the security around the man’s house? I suppose I can understand it around GeneRx, with all the industrial competition in the drug industry, but out here it seems a bit excessive.”
“It’s been explained to us as having something to do with strained relations between Mr. Zhao and the People’s Republic of China,” Ted said. “He is a very wealthy man and prefers to live here in New Jersey even though his factories in China produce a host of brand-named drugs or ingredients for a large portion of the industry worldwide.”
After a few twists and turns beneath a canopy of peach-colored oak foliage, the scene suddenly opened up to reveal an impressive house designed in a kind of contemporary Tudor style. With the modernity of the hospital and research building, Jack had expected something similar and more Asian in decor, with something like Japanese gardens. Instead, the house and the grounds had a decidedly English look, with a riot of flowers and shrubs. The roof was slate. Beyond the house was a small lake or pond surrounded by oak and maple trees.