“No,” Pete said. “The car was covered with snow too, and it’s a white car. It’d probably been there for hours. It was a wonder anybody could see it at all, especially in the dark in a snowstorm.”
“Who did see it?” I asked. “I mean, who reported it?”
“The state cops.”
“Were the lights on?” I asked.
“No.”
“Was the engine running or had someone turned that off too?”
“The ignition was on,” Bernie said. “But it had run out of gas.”
“Were the keys still in it?”
“Yes.”
“Fingerprints?” I didn’t really need to know that for the autopsy, but I was curious.
“Don’t know yet. It took a while to get a tow truck out in the middle of the night. We got it into the garage at three this morning, and a tech’s been working on it all day, so we should know something this afternoon.”
“That doesn’t make sense,” Rollie said. “Why turn off the lights and leave the engine running?”
“Maybe he was trying to commit suicide,” Pete suggested. “Or maybe he was just trying to keep warm. The muffler was buried in the snow. We’ve had that happen to kids who park in the snow to make out, leave the engine on to run the heater, and die of carbon monoxide poisoning.”
“Could it have been sitting there that long without being seen?” I asked.
Pete shrugged. “Maybe. Who knows? The state cops didn’t report it until ten o’clock, and it’s dark by five.”
I felt a flash of anger and glared at Rollie. “So how come you waited until one in the morning to call me?”
“Hey, don’t look at me,” Rollie said. “I called you as soon as I knew.”
I decided Hal didn’t need to know that, after the way he acted this morning. But Bernie answered the question I didn’t ask.
“Well, for one thing, that section of interstate’s in Jerome County. So the state cop reported it to the Jerome County Sheriff, but they turned it over to us as soon as they ran the license number and found out whose it was,” Bernie said. “All those things take time, especially after hours.”
“Even with computers?”
“Even with.”
Jay wore a brown tweed suit, a tan shirt, and a brown-and-green striped tie. His hair, what was left of it, wasn’t even messed up. I pointed out to Pete and Bernie the absolutely clean soles of his polished brown wingtips so they could photograph them before removing the shoes and bagging them. We removed the bags on his hands so that I could clean under his fingernails and put the material obtained in evidence bags. I found some blood, but no obvious chunks of skin, or anything like that.
We turned the body first on one side and then the other to look for any marks or trace evidence on the clothes. I found some blood on his shirt front and a few light-colored hairs on the back of his suit jacket, which Pete collected and put in an evidence bag.
“And I suppose if you couldn’t see any skid marks or tire tracks, you couldn’t see any footprints either?” I persisted.
“Footprints!” exclaimed Pete. “Why would there be footprints? Oh, you think there was someone else in the car with him?”
“Was he sitting in the driver’s seat?”
“Yes, he was. What are you getting at, Toni?”
“Because I don’t think he was driving,” I said. “Look at his shoes. They’re clean, even on the soles. He wasn’t wearing a coat or gloves or boots. Here he is, out driving in December in a snowstorm, and all he’s wearing is a suit—and his shoes aren’t dirty? I don’t think so. They should have been soaked. His pant legs should have been too. Was there a coat or boots in the car?”
Pete and Bernie looked at each other and shook their heads.
“Somebody else had to be driving the car,” I persisted. “Somebody had to put him in the car without getting his soles dirty, drive him here, move him into the driver’s seat, turn the lights off, leave him in the car with the engine running, and then disappear.”
“So,” Pete said, “this really is a homicide. Is that what you’re saying, Toni?”
“I don’t see what else it could be. Do you?”
“Oh, I agree,” said Pete, “but how? There aren’t any gunshot or stab wounds or ligature marks that I can see.”
“I guess we’ll find out,” I said, “when we get his clothes off.”
Rollie removed the suit jacket and pants, and Pete bagged them. We turned the body again to look for evidence or marks on the tan shirt but found none. Grossly bloody, foul-smelling stool stained the undershorts. I collected a sample of it and put it in a small specimen container.
Next, we removed the shirt and the underwear. Pete, with a grimace, bagged the shirt and the undershorts separately. Again we turned the body to examine the back. Postmortem lividity, the purplish discoloration of the skin that occurs after death when blood pools in the dependent parts of the body—in this case, the buttocks, backs of the thighs, and the feet—was magenta rather than the usual purple. I noted this with detachment, not really attaching any significance to it at the time. At that time, the only thought I had was that Jay had died sitting up.
Jay Braithwaite Burke looked like a starved orphan without his lawyerly clothes. His ribs and hipbones protruded, as did his Adam’s apple and his ears. His left pupil was “blown”—that is, fully dilated in contrast to the right, indicating a severe brain injury—but there were no bruises on the scalp to account for how he got it. Perhaps he’d been shaken, like a baby. His skin looked too tight for him. Large reddish-purple patches stained the skin of the chest, arms, and backs of the hands. Examination of the face showed a line of hemorrhage around the edges of the lips, and the lining of the mouth and the tongue appeared to be encrusted with blood. It was hard to hold the mouth open because of rigor mortis, but Pete and Rollie managed to hold it open long enough for Bernie to get a shot of it.
“Why does he look so bruised?” Rollie asked. “Do you suppose somebody beat him up?”
“I don’t think so,” I said. “This looks more like he’s been on anticoagulants or steroids. Or maybe he’s got leukemia or something, and his platelets are low. These aren’t bruises, they’re purpura.”
“What’s purpura?” asked Bernie.
“It’s this patchy hemorrhage under the skin that people get when they’re on blood thinners, or who have other bleeding disorders, or just because they’re old and their skin is so thin.”
At this point, we decided to do the rape kit before we messed anything up—a thoroughly disgusting procedure. It was just routine; we really didn’t think Jay had been raped, but one never knows, and it’s better to be safe than sorry. I swabbed the mouth, the armpits, the groins, and the anus; and put the swabs in separate, labeled containers; and combed the pubic hair and put the combings in an evidence bag. Pete took combings from the head hair too and put them in a separate bag.
Then I had to wipe the blood off the tongue to make sure he hadn’t just bitten it, which was even more disgusting; but the tongue wasn’t the source of the blood in the mouth. I did notice an unusually red color of the tongue and mucous membranes, however. He must have been really well oxygenated, I thought, to have such red blood postmortem. Or maybe Pete was right about the carbon monoxide.
At this point I became aware that Bernie Kincaid was standing extremely close to me, restricting my range of motion. I looked up at him, intending to tell him to move his ass out of my way, when his dark eyes met mine, and the expression in them made my mouth go dry.
“Detective Lieutenant Kincaid,” I said, still looking into his eyes, “do you know that you’re in my way?”
“Do you know that you smell really, really good?” he murmured back.
Whoa. That was completely un-Bernie Kincaid-like behavior. I reached around him, picke
d the cardiac needle out of my tool kit, and attached it to a syringe. I held it in front of me, point up, rather like a shield. “Back off,” I said. “Now.”
He backed off.
Next, I collected body fluids. With the cardiac needle, I drew blood from the heart. To my relief, it flowed freely into the syringe without any clots to get in the way. It looked unusually red for postmortem blood. I began to wonder about how long the car engine had continued to run after Jay had been moved into the driver’s seat. I also did a suprapubic aspiration above the pubic bone into the bladder to obtain urine, which was bloody too.
Next, I removed the brain. I found a large subarachnoid hemorrhage on the right side, which had caused a right-to-left shift, squeezing the right parietal lobe underneath the falx cerebri, the fibrous membrane that separates the right hemisphere from the left. I found a smaller hemorrhage on the left side, and pressure cones on the sides of the cerebellum. This occurs when increased pressure inside the skull pushes the brain backward, squeezing the brainstem into the foramen magnum, which leads to the spinal canal and is way too small for it. That accounted for the blown pupil.
“Are you finding something there, Doc?” inquired Rollie, looking over my shoulder as I lowered the brain carefully into a bucket. It would have to fix in formalin for two weeks to make it firm enough to cut.
“I think I’ve found a possible cause of death,” I replied. “See how the brainstem is compressed? Those hemorrhages forced it into the spinal canal, and that could have caused him to stop breathing, because that’s where the respiratory center is.”
Rollie seemed satisfied with that answer, but I wasn’t. “Problem is, I can’t figure out what caused the hemorrhage,” I told him. “I don’t see any bruising on the scalp to indicate a blow to the head, so the smaller hemorrhage on the left probably isn’t a contrecoup injury.”
“A contra-what?”
“A contrecoup injury,” I explained, “is a hemorrhage caused by the brain bouncing off the other side of the skull cavity after a blow on the head. But I don’t see how anybody managed to hit him over the head without leaving a big honking bruise on the scalp.”
Rollie shrugged. “Don’t look at me. I haven’t a clue.”
I didn’t either. I gave up on the head and turned my attention to the body. I looked forward to getting into more familiar territory, neuropathology not being my forte. No, that didn’t quite cover it. I hated neuropathology with a passion.
During my residency, I had always dreaded the weekly Wednesday morning brain-cutting sessions with one or the other of the two visiting neuropathologists from the University of California at Irvine—both women, both brilliant, and each one bitchier than the other, at least to me. They always made me feel stupid and incompetent.
I never understood why female physicians had to be so nasty to each other. We’d all had to struggle to get where we were back when females were in the minority. You’d think we’d all be trying to support each other, not tear each other apart. But no, it was all about competition. Were these gals afraid that I’d grow up to take their jobs away from them, or what? Did they find me, a mere resident, that threatening?
Huh. How about that? Maybe they had been afraid of me. Now there was a thought. It made me smile right out loud. I wished I’d thought of it back then; it might have saved me a lot of grief.
I hauled the organ block up and out of the body cavity and arranged it on the cutting board. “Wow,” I remarked as I scissor-crunched my way down the aorta to the iliac bifurcation. “This guy’s got really bad arteriosclerosis for such a young, thin person. He’s hardly any older than I am and look at this!”
Rollie, Pete, and Bernie gathered round and peered at the pile of viscera in front of me. “Maybe he had a heart attack,” Pete said. “Can you tell?”
“Maybe,” I said. “And then again, maybe not.”
They watched in fascination as I dissected the coronary arteries, the carotids, the aorta, and the iliac and femoral arteries, all of which were clogged with calcified plaque. In fact, he had the beginnings of an aortic aneurysm.
Pete gestured at the mess on the cutting board. “But look at all that stuff,” he said. “How could he not have had one?”
“Well, just hang on until I cut the heart.”
I opened the heart, starting with the right atrium and going down through the tricuspid valve into the right ventricle, and then up through the pulmonic valve into the pulmonary artery, being careful to check for any clots; there weren’t any. Then I opened the left atrium, went down through the mitral valve into the left ventricle and then up through the aortic valve into the ascending aorta. After rinsing all the blood away and weighing the heart, which was of normal size and weight, I began to section the ventricles, looking for any discoloration that might indicate an infarct or dead tissue. There wasn’t any.
“So,” Pete said. “No heart attack, right?”
“Not necessarily,” I said. “If he’d had a heart attack and died right away, I wouldn’t see anything. It takes twelve to twenty-four hours even for microscopic changes to show up. Gross changes wouldn’t show up for forty-eight hours or more, assuming he survived that long. I’d have to find an actual coronary thrombosis, an actual blood clot in the coronary artery, to make that diagnosis, and I didn’t.”
“So we’ll never know?”
“Not unless something shows up in the slides,” I said.
“Huh,” Pete said. “I always thought you could tell right away.”
“Well, you can,” I told him, “if the patient lives long enough for the dead tissue to turn all yellow and mushy, which would be several days. If the infarct is large enough and goes all the way through the ventricular wall, it can even rupture. There’s no mistaking that at autopsy.”
Pete whistled. “Does that happen often?”
“I’ve only seen it once.”
The normal-sized liver and spleen indicated that he probably didn’t have leukemia.
Blood filled the lungs and bronchi, as well as the esophagus, stomach, small intestine, and colon. As I slit open the bowel and evacuated its tarry-black, malodorous contents into the sink, Bernie Kincaid, with his hand over his mouth, fled the room to get away from the overpowering stench. Rollie turned on the fan.
Few things in medicine smell worse than decomposing blood, especially in the GI tract where bacteria, stomach acid, and pancreatic enzymes break it down.
Gritting my teeth, I collected samples of stomach and small bowel contents, and washed the rest of the blood away. The esophagus had a longitudinal full-thickness tear with hemorrhage into the posterior mediastinum, which contains the thoracic aorta, superior vena cava, and a whole lot of lymph nodes.
With an inward smile, I recalled the “five birds of the mediastinum,” a silly trick we’d used in medical school to remember its anatomy: the esophagoose, the vagoose, the azygoose, the hemiazygoose, and the thoracic duck.
In this case, the esophagoose had ruptured. “That’s called Mallory-Weiss syndrome.” I had to raise my voice to be heard over the noise of the fan. “It usually results from forceful vomiting. This looks like he vomited blood and aspirated it. Was there any blood in the car?”
“Nothing obvious,” replied Pete, “but it did smell like somebody’d been sick in it. Maybe if we look for it, we could find some traces. Where’s all that coming from?”
Good question; it seemed to come from everywhere. The mucosa lining the stomach showed diffuse hemorrhage without any ulcers or other lesions, as did the mucosa of the small intestine and colon. I saw no big ulcers or tumors anywhere to explain the bleeding. It just oozed from everywhere—all of it bright cherry-red.
Maybe the brainstem herniation wasn’t the cause of death after all. “I think we need to get a carboxyhemoglobin on this blood,” I said.
“You think he died of carb
on monoxide poisoning?” Rollie asked.
“I do; and therefore he had to be still breathing when the car went off the road, which should narrow down the time of death for you.”
“So, if he was still alive,” Rollie persisted, “how do you know he didn’t just lose control of the car and die accidentally?”
“I think he was still alive but unconscious,” I replied. “I don’t think he could have been conscious with that subarachnoid hemorrhage and brainstem herniation. Maybe someone lost control of the car, but it wasn’t him.”
“How can you be so sure?” asked Bernie, who had come back into the room.
“You’ll know for sure if his fingerprint is on the light button. He wasn’t wearing gloves.”
“What would that prove?” Bernie asked. “It’s his car.”
“But what if it was someone else’s fingerprint? Or what if there aren’t any at all?”
Bernie nodded. “I see. Pete, you better get on the horn and make sure that Corey checks that,” he said. Pete obligingly hauled out his cell phone and did so.
The body of the once-powerful Jay Braithwaite Burke was now an empty shell. We took a chunk of liver tissue to add to the blood, urine, stomach, and small bowel contents I had already collected. Just out of curiosity, I had filled a purple-top and a blue-top tube for hematological and coagulation studies, and a green-top for the carboxyhemoglobin, which the hospital lab could do.
I put samples of the organs into buckets for transport back to the lab, and Rollie began to sew the body back together. Bernie and Pete collected their stuff in preparation to go back to the police station. Pete started out the door, but Bernie hung back.
“Want me to come by the lab and let you know about the fingerprints?”
I looked up. He had that same look in his eyes again. What was up with that?
“No, I’m just going to drop this stuff off and go straight home,” I said.
“Need any help with that stuff?”
“No, thanks, I can handle it.” I carefully avoided looking into his eyes.
“Okay, see you later.” He left.
Too Much Blood Page 3