by Robin Cook
Stephen leaned over the open wound. “Do you mind if I palpate the pericardium?” he asked.
“Be my guest,” Jack said. He was surprised the surgeon had asked. It seemed out of character with his controlling personality.
“Feels like a normal amount of scarring,” Stephen said after running the balls of his fingers back and forth over the tissue a number of times. He then stopped and pointed. “This is where we closed the pericardium with a running suture.” He then straightened up and withdrew his hand. “Do you think this is about the same degree of scarring you saw when you did Carol’s post?”
Jack palpated the tissue between the lungs, imitating Stephen. He’d not done that with Carol until after he’d removed the lungs and the heart, so he couldn’t compare exactly, but it seemed equivalent, and he said so.
“Did you open Carol’s pericardium at this point?” Stephen asked.
“No,” Jack said. “I didn’t do that until I had removed the lungs and the heart en bloc. Do you want me to do the same here or would you like me to open the pericardium now, so you can see the heart in place?”
“I think he should use the same technique as he used with Carol,” Ted said, speaking up for the first time. “That’s the only way he will be able to truly compare the two.”
Stephen agreed. “Go ahead and follow your usual modus operandi.”
Using a pair of dissecting scissors rather than a scalpel, as he thought it safer, Jack proceeded to free up the lungs and the heart. He then lifted the entire mass up out of the thorax. He carried the weighty slab of flesh over to a nearby countertop and plopped it down on a scale.
“Is that heavier than usual?” Stephen asked, looking at the readout.
“Much heavier,” Jack said. He then started to open the pericardium exactly as he had done with Carol, to expose the heart itself. “You can see there is considerable fibrotic scarring, but it is to be expected.”
Both Stephen and Ted crowded in to take a look once the heart was fully exposed.
“My word, it looks entirely normal,” Ted said. “Perfect orientation. I’m impressed even more than I expected to be. It looks like a very happy heart.”
“I agree,” Stephen said. “I don’t mind saying so myself, but it was a perfect job.”
“And a perfect donor heart,” Ted added.
“How does it compare with Carol’s?” Stephen said, turning to Jack. “If you were pressed to say which one you thought had been accepted the best, which one would you say?”
“It would be hard to say,” Jack replied thoughtfully. “I’d say they were equivalent.”
“Let’s see the rest of the anastomoses,” Stephen said. “The aorta looks fine, but there could be a difference with the others.”
Jack pushed back the bloated right lung in an attempt to visualize the great veins called the superior and inferior vena cava. It was difficult because the lung was turgid with fluid.
“Why don’t you go ahead and remove the lungs,” Stephen said. “Just make sure the pulmonary anastomoses are proximal to the heart.”
At first Jack wasn’t sure what Stephen meant, but then he got it. Stephen wanted the connections he’d made when he’d done the transplant to be connected to the heart, not to the freed-up lung. Using the dissecting scissors again rather than the scalpel, Jack separated both lungs from the heart. The connections with the great vessels could all be seen. Jack stepped back to give Stephen and Ted more room. While they looked, Jack weighed each lung.
“They all look terrific to me,” Stephen said. “I hate to blow my own horn, but they are all masterfully done.”
“You’re getting good in your old age,” Ted teased. “But you’re right. They all look terrific, well healed and without the inflammation we agonized about. I don’t see any difference here with what we saw during Carol’s second autopsy. It seems as if our experiment is a draw. What are your thoughts?”
“I have to agree with you,” Stephen said. “How about you, Dr. Stapleton. Do you see any differences between Margaret’s anastomoses and Carol’s?”
“Not at all,” Jack said. “They look comparable to me.”
“So there we have it,” Stephen said. “We didn’t think there was going to be a difference, and there doesn’t seem to be.” He looked over at the institutional clock as if he was planning on leaving.
“I think you should see the inside of the lungs,” Jack said. Without waiting for a response, he got one of the long-bladed knives used in autopsies and made some slices into the lungs’ parenchyma, which under normal conditions were air-filled, light, and spongelike. As he made the cuts, the edema fluid burst forth, almost as if it had been under pressure. It was blood-tinged and mixed with exudate and bits of tissue.
“Whoa,” Ted exclaimed. “That’s rather dramatic. We didn’t see that with Carol’s lungs.”
“That’s because most of the fluid had drained out,” Jack said. “It gives you a better appreciation of what the immune system can do when it’s turned on to create a cytokine storm. It’s not a mystery why these people died so quickly. This is a nasty virus.”
“Are you still thinking this is caused by a virus?” Stephen asked. “We’re continuing to look into the protein angle, thinking of something like a prion.”
Jack started. The idea of a prion disease never occurred to him. But as soon as he considered it, he rejected it. “Prion disease only strikes neural tissue, not pulmonary tissue,” he said. “No, this must be a virus, but I admit there are some aspects that don’t make sense.”
“And what are they?” Stephen asked patronizingly.
“This is the fourth case that I have seen,” Jack said. “They are all exactly the same, which in my mind points to an infectious origin. If I had to guess, I’d say Carol Stewart is the index case, and she gave it to the others with whom she’d been intimate. For a number of reasons, I am thinking it is a retrovirus. Since she had just had a heart transplant and had never had any pulmonary problems, it is a reasonable guess she got it from the donor, who was carrying this unknown retrovirus that spreads via body fluids, like HIV.”
“That’s all very fanciful,” Stephen said in the same tone of voice. “I have to give you credit for being creative. But you haven’t told me what doesn’t make sense.”
“Margaret,” Jack said. “I’ve been told that she knew Carol but wouldn’t have been likely to share body fluids. That means that Margaret would have had to get it from her donor heart just like Carol, and unless this unknown retrovirus that’s never been seen was widespread, which it can’t be, the chances of that happening are infinitely small.”
“I can see where that is a problem,” Stephen said.
“How good a match was the donor heart that Margaret got?” Jack asked.
For a beat neither Stephen nor Ted responded. Finally, Ted spoke up. “It was an okay match, otherwise we wouldn’t have done it.”
“Where did it come from?” Jack asked. “Was it a local donation or from someplace far away?”
“That I’d have to look up,” Ted said. “I don’t remember offhand.”
“Was Margaret on high doses of immunosuppressants, unlike Carol?” Jack asked.
“No,” Ted said. “Just the normal amount.”
“From the looks of the heart here, there seems to be no inflammation whatsoever. I don’t have a lot of experience posting heart transplant recipients, but isn’t there usually some rejection phenomena going on that’s kept under control?”
“UNOS tries to make the best possible match to keep that at a minimum,” Ted replied.
“Sorry to interrupt,” Stephen said. “I want to thank you, Dr. Stapleton. This autopsy has been very enlightening, but I do have a transplant case starting in just a few minutes. If you’ll excuse me.” Without waiting for a response, he headed for the exit leading to the room to remove his protective gear
. Wordlessly Dr. Han Lin followed.
“And I have a clinic full of patients to see,” Ted said. “I also want to thank you for coming and helping us, Dr. Stapleton. You’ve provided us with important information. I hope we see you again real soon.” Then he headed for the same exit Stephen had used and disappeared.
Jack, still holding the long-bladed knife he’d used on the lungs, felt suddenly abandoned. The exit of the three doctors had been so sudden and unexpected that he’d scarcely had time to react. It also seemed to contradict their previous warm hospitality. It was as if they had gotten what they wanted and that was it. They clearly hadn’t been concerned with giving Jack an opportunity to ask any of his myriad questions. Now, as he looked across the room at Harvey, who had busied himself by supervising the removal of the skull cap to facilitate finishing the autopsy, Jack wondered if he might be able to provide any answers. Yet as Jack watched the man struggle with his current task, he wasn’t optimistic. In comparison to Stephen and Ted, Harvey seemed like a dunce. Plus, Jack was wary of the man after hearing him place a call to Wei Zhao as soon as Jack had left his office yesterday afternoon. Whatever hanky-panky might be going on at the Dover Valley Hospital, he feared Harvey was probably involved. Whether that was true of Stephen and Ted, he had no idea.
“See any pathology in the brain?” Jack asked, as he returned to the autopsy table.
“None so far,” Harvey said. “I hope you don’t mind that I had the techs push ahead.”
“Not in the slightest,” Jack said, making up his mind that Harvey wasn’t a good bet as a source. “In fact, I think I’m done here and would like to ask you to please finish up. I have a number of important questions for the doctors that I didn’t get a chance to ask, and I’d like to catch them before they leave the morgue.”
“But you’re not done here,” Harvey said with a whine.
“I beg to differ,” Jack said. “All you have to do is check the brain and prepare some specimens for microscopic sections. That’s not asking a lot with your capable hands. I’ve certainly accomplished what Dr. Friedlander and Dr. Markham had in mind for me, and I assume this is a Morris County case.”
“No, it was signed out to the Dover Valley Hospital,” Harvey corrected. “And if you want to get paid, I want you to stay here and finish.”
“I think I’ll argue that point with the bursar instead of with you,” Jack said, immediately taking offense. He’d suspected Harvey of being lazy and a laggard, but this seemed beyond the pale, as it would take him only ten minutes or so. He’d even given the man a questionably deserved compliment.
“Suit yourself,” Harvey said morosely.
37
THURSDAY, 12:27 P.M.
Knowing he was only in marginal control of his emotions after what the day had already wrought, Jack made an effort to keep himself on an even keel despite Harvey Lauder. Moving quickly, he pushed through the door into the side room, hoping at least to catch Ted. Unfortunately, he wasn’t there. The room was designed to facilitate decontamination if the case had needed biosafety 3 protection. It was also where the latex gloves, the shoe covers, and the impervious gown were left for disposal and the face shield was left to be cleaned. Jack accomplished this on the run and then exited into the hallway. Picking up his pace, he power-walked down to the men’s locker room. Going through the door, he practically bumped into Ted, who was already on his way out. Ted was dressed as he had been the day before, in a white shirt, conservative Ivy League tie, and a long, highly starched white coat.
“I beg your pardon,” Jack said.
“Not at all,” Ted said. “Wow! You already finished the autopsy? You are very efficient, I must say.”
“I left the rest for Harvey,” Jack said. “It was mostly done. I have some questions for you, if you don’t mind.”
“I’m afraid I do mind,” Ted said. He pushed by Jack and opened the door to the hallway. “As I said in the autopsy room, I have a clinic full of patients that I ignored to observe the autopsy on Margaret. Thank you again for your help, but I really have to go.”
Before Jack could even respond Ted was out the door and it began to close. Jack straight-armed the door and ran after Ted. In his usual hyper fashion, Ted was moving at a rapid clip.
Catching up to the man with some effort, Jack reached out, grabbed his left arm just above the elbow, and pulled him to a stop.
To Jack’s shock, Ted responded by angrily yanking his arm from Jack’s grasp. “Don’t you dare lay a hand on me,” he snarled.
Taken aback by this unexpected response in light of Ted’s overly cordial behavior from their very first interaction, Jack raised his hands in a kind of surrender. “I’m sorry. I didn’t mean to offend you.”
“I don’t like to be manhandled,” Ted snapped as he smoothed the sleeve of his white doctor’s coat. Without waiting for a response from Jack, he recommenced walking quickly to the elevators, where he hit the call button multiple times.
Jack caught up to him a second time. “I have more questions I need to ask,” he said. His voice had an edge. He was both confused and put off by Ted’s surprising behavior, but mostly the latter.
“It will have to be another time,” Ted said. His eyes rose to see which elevator was going to arrive first.
“I visited the Bannons,” Jack said. “It was their son who was the donor for Carol Stewart’s heart. I got the impression that they might have been paid. Do you know anything about that?”
“Absolutely not,” Ted said. He moved down to the second elevator, as the lights indicated it was on its way. “My role was with the recipient, as you already know. Like all centers, we keep a sharp separation between the recipient interests and those of the donor, to avoid even the appearance of unethical behavior.”
The elevator arrived and the doors opened. Ted quickly boarded.
“How do you explain that Carol and the donor heart she was given matched with their CODIS profiles?” Jack asked. “We ran the test twice.”
“I haven’t a clue,” Ted said. He hit the button for the second floor. The doors began to close.
Jack grabbed the edge of the elevator door and stopped it from closing. “How did it happen that Dr. Wei Zhao is the executor of Carol Stewart’s estate?”
“I wouldn’t know,” Ted said. “Let go of the door or I will call security!”
Reluctantly, Jack let go of the elevator door. It responded by opening. “I need answers to these questions,” he said. “I’m not going to give up until I get them.”
“You’re asking the wrong person,” Ted said. “Ask Dr. Zhao. Maybe he can help you.”
A moment later, Jack was staring at the blank, closed elevator doors. He felt a building rage compounded by the frustration of not understanding the sudden attitude change of Dr. Ted Markham. One minute he’d been warm and welcoming, the next cold and distant. Jack hadn’t been as surprised by Stephen’s sudden personality change. He’d never seemed particularly sincere to Jack.
As he walked back to the morgue locker room, Jack tried to remember what exactly he had said when both doctors suddenly morphed from being interested observers to wanting to leave. It had happened right after he’d posed the question of whether or not some evidence of rejection phenomena was expected to be seen with heart transplants. Jack had done only one other heart transplant autopsy prior to Carol Stewart. It had been way back during his training in Chicago, but he distinctly remembered seeing some signs of inflammation both in the pericardium and in the heart itself. And he remembered that case had been described as a fairly good match.
As Jack pulled on his chambray shirt and began to knot his knit tie, the required concentration calmed him down a degree. “What a day,” he complained out loud. Intuitively he knew anger and acting out wouldn’t help him get through the next five or six hours, as it never did. Instead he tried to think of what his options were. They seemed limited. He coul
d go back to the city and try to participate in some way with the identification of the virus, but the moment he thought of the idea, he dismissed it. Bioinformatics was something he knew close to nothing about. When he thought about going home, he dismissed it out of hand. There was no way he would be willing to sit around and make small talk with Sheldon and Dorothy Montgomery. Of course, he could try to relate to Emma, but that might make him more depressed than he already was. He could spend some time with JJ, but JJ didn’t get home from school until after 4:30.
Hooking an index finger under the tab of his bomber jacket, Jack slung it over his shoulder and walked out of the morgue locker room. As frustrating as his visit seemed to be becoming, he thought he wouldn’t leave Dover Valley Hospital just yet. Going through his mind was Ted’s suggestion. Maybe he should be directing his questions to Wei Zhao. The problem was how to do it. With the level of security the man insisted on, it wasn’t as if Jack could walk up and ring his doorbell. Yesterday, it clearly had been Ted and Stephen who had gotten him the invite to the man’s house. Maybe that could work again, and with Stephen in surgery, it left Ted.
Returning to the elevators, Jack took one up to the second floor. His destination was Ted’s office, which he knew the exact location of, thanks to the man’s hospitality yesterday. Jack didn’t know what he was going to say after the unflattering brushoff the man had given him at the elevator, but he trusted something would come to mind. He was convinced one of his strengths was the ability to wing it in any given situation.
Walking through the Zhao Heart Center, Jack could see that Ted had not been exaggerating. The clinic was crowded with patients waiting to be seen. Jack passed the check-in counter, heading for Ted’s private office. Jack thought it would be far more successful to talk with Ted’s secretary, who had gotten Jack’s coffee the day before, than with one of the clinic clerks.