Foreign Body

by Robin Cook

  “Alright. Let’s go over this again,” Arun said. “I’m really interested. You said you were considering poisoning.”

  “We are,” Jack admitted. “Because of time constraints we are approaching this case differently than usual. We are starting with a hypothesis and trying to prove if it is right or wrong. Normally, when we do an autopsy we try to keep an open mind so as not to miss anything. Here we are going to see if there is anything specifically confirming poisoning while we confirm or rule out the provisional diagnosis of a heart attack.”

  “We even have an idea about the specific agent,” Laurie said, straightening up from having made the initial incision. She then exchanged the scalpel for the hefty bone clippers.

  “Really!” both Arun and Neil voiced simultaneously.

  “We do,” Jack agreed, as Laurie clipped through the ribs. “First of all, we suspect a healthcare person to be the perpetrator. Having the deaths occur at more than one hospital, we expect it to be a doctor. Since we suspect a doctor, we have to think about drugs since doctors have access to drugs and all three patients had keep-open IVs running. Considering the history of cyanosis, particularly cyanosis that rapidly cleared on the third case during resuscitation, we have to think of curare-like substances used in anesthesia for muscle paralysis.”

  Laurie finished with the bone clippers and removed the sternum with Jack’s help.

  “Let’s go right for the heart,” Laurie said. “If there’s evidence of a major heart attack, we might have to completely revise our thoughts.”

  “I agree,” Jack said.

  “There’s quite a number of drugs that cause respiratory paralysis,” Neil said. “Do you favor some over others?”

  Laurie and Jack worked rapidly, each anticipating the other’s movements. Jack reached for a pan on a side table, and the en bloc dissection of the heart and lungs sloshed into it.

  “We do have one drug that we are going to test for specifically,” Jack said to Neil, while he watched Laurie free up the heart. “Again, thanks to the resuscitation effort on the third case, where they encountered hyperpyrexia and surprisingly elevated potassium, we’re going to concentrate our efforts on succinylcholine, which is known to cause both on occasion. At this moment, unless we find something very unexpected, that is the most promising agent.”

  “My gosh,” Arun said. “This is fascinating.”

  “There’s no heart disease here at all,” Laurie remarked. She’d made a series of slices into the cardiac muscle and along the tracks of the major coronary vessels. “Specifically, there’s no obstructive disease.”

  The other three looked over her shoulder. “There is a sprinkling of hemorrhages on the pericardium,” Jack said. “That’s not pathognomonic of succinylcholine poisoning, but it’s consistent.”

  “There are some on the pleural surfaces of the lungs as well,” Laurie said.

  “Arun, could you take some photos of this with Vijay’s camera?” Jack asked.

  “I certainly can.”

  After the photos were taken, Laurie prepared to take the samples for toxicology. Using separate syringes, she wanted urine, blood, bile, and cerebrospinal fluid.

  “There are two other reasons we’re thinking succinylcholine,” Jack said. “Succinylcholine makes the most sense from a purely diabolical point of view. If the perpetrator is a doctor, as we suspect, he or she would want to use the agent least capable of being detected, and succinylcholine certainly fits the bill. First of all, succinylcholine was probably used during the patients’ anesthesia, so even if succinylcholine happened to be found by the likes of us, its presence could be explained. And second, the body deals with succinylcholine very rapidly, which is why in an overdose situation, all you have to do is breathe for the patient for a short time and there’s a happy ending.”

  “But you are still going to run samples?” Arun commented, “even if the body metabolizes succinylcholine rapidly.”

  “Absolutely,” Laurie said, filling a syringe with bile. “If someone uses succinylcholine for nefarious purposes, they invariably inject a major amount, worried they might not be injecting enough. With a large dose, the body’s ability to handle it can be overpowered, so not only do you find a host of succinylcholine metabolites in body fluids, you often can find some of the drug itself.”

  “Succinylcholine has been used in a couple of high-profile forensic cases in the United States,” Jack said. “There was a nurse by the name of Higgs who killed his wife in Nevada, and an anesthesiologist by the name of Coppolino who killed his wife in Florida. In the Higgs case the drug was found in the wife’s urine, while with Coppolino it was isolated in muscle.”

  “Well, it will be interesting to see what our toxicologists can do at the All India Institute of Health Sciences. Our head guy has an international reputation.”

  “Is there some way to get those samples over there?” Laurie said, as she finished obtaining the last sample.

  “I’m sure there is,” Arun said. “I’ll get Jeet to take care of it. I’d imagine the clinical laboratory here at the Gangamurthy Hospital has a delivery service.”

  With two proficient prosectors at work, the autopsy proceeded apace until Laurie got to the kidneys. After checking them and determining them to be normal in situ, she lopped them out with the knife used for gross dissection. Using the same knife, she opened one with a bifurcating coronal slice, exposing the parenchyma and the calyx.

  “Jack, look at this!” she said excitedly.

  Jack looked over her shoulder. “That looks odd,” he said. “The parenchyma looks sort of waxy.”

  “Exactly,” Laurie said, with even more excitement. “I’ve seen this before. You know what it turned out to be?”

  “Amyloid?” Jack guessed.

  “No, silly. That pink stuff is in the tubules. It’s in the lumen, not in the cells. Maria suffered acute rhabdomyolysis!”

  “Arun!” Jack called excitedly, “call Jeet. We want a frozen section. If this is myosin and we’re dealing with an intoxication, as we suspect, this is practically pathognomonic for succinylcholine poisoning.”

  A half-hour later, Laurie was the first to get to look at the kidney sections. The autopsy had been finished and dictated. Specimens had been fixed, particularly of the kidney and the heart, and the slides would be made. Finally, the body had been placed in a proper mortuary cooler.

  “Well,” Jack demanded impatiently. Laurie seemed to be taking longer than usual peering into the microscope.

  “They are definitely pink casts in the tubules,” she said. She leaned back so Jack could look.

  “Rhabdomyolysis for sure!” Jack said. He straightened up. “Considering the history, I’d accept that as proof, even without toxicology.”

  Laurie got up so that Arun and then Neil could look in and see the myosin blocking the kidney tubules.

  “So, what are you going to do now?” Arun asked. He was exhilarated to be part of a forensic pathology case, just what he’d dreamed of when he was in high school, before the realities of the field in India had become known to him.

  “We should probably be asking you at this point,” Jack said. “In the United States, medical examiners operating in an independent capacity would approach either the police or the district attorney or both. This is clearly a criminal situation.”

  “I don’t know what should be done,” Arun admitted. “Perhaps I should ask one of my lawyer friends.”

  “Meanwhile,” Laurie said, “we should move quickly to strengthen the case. Hopefully, we’ll have scientific proof with the urine we sent to the All India Institute of Health Sciences toxicology department, but that’s only with one case. We need to get back to Queen Victoria Hospital and either get a hold of the second body somehow or at a minimum get a urine sample, and we should do the same with the body at the Aesculapian Medical Center. Three cases are much better than one. And we’d better hurry. Jennifer mentioned a noon deadline today.”

  “Alright, let’s do that first,”
Jack said. “We need proof on more than one body, especially in relation to succinylcholine poisoning. Hell, a body can produce a small amount of succinylcholine just from decomposing.”

  “I’ll take a couple of syringes from here so we’ll have them for our samples,” Laurie said.

  “Good thinking,” Jack said.

  With unmistakable excitement and a strong sense of common purpose, the foursome piled back into the van for the dash back to the Queen Victoria Hospital. Once again Arun was at the wheel.

  Neil pulled out his cell phone. “Now that it’s afternoon, I’ll give Jen a call,” he said. “I can’t imagine she could still be sleeping. I know she’s going to be excited about all this.”

  “Good idea,” Laurie said. “And let me speak to her as well.”

  Neil let the phone ring until voicemail picked up. He left a brief message for Jennifer to call him back. “She’s probably working out or swimming. I’ll try again in a little while.”

  “She could be having lunch,” Laurie suggested.

  “You’re right,” Neil said, pocketing his phone.

  When they pulled into the Queen Victoria, Arun drove immediately around to the rear and backed into same spot.

  After eagerly climbing from the van, the group hastily entered the hospital, opening both of the double doors in the process. The elderly man’s chair was vacant.

  “Maybe he’s having lunch,” Laurie suggested.

  “I hope so,” Jack said. “I’ll feel guilty if he lost his job over our mischievous activities.”

  Arun was in the lead. They had to walk single file because the lunchtime cafeteria line snaked all the way out into the hall. They stopped at the cooler where Maria had been stored.

  “Should we just ignore everyone and go in?” Arun questioned.

  Jack and Laurie exchanged a glance. “You go in, Arun,” Laurie said. “Let’s not make this a scene.”

  Laurie, Jack, and Neil moved down the hall a little way. No one paid them any attention.

  Arun didn’t even get all the way in before he could tell that Benfatti was gone. The cooler was bereft of corpses. He backed out and shut the door. He told the others the bad news.

  “There goes our chances for a trifecta,” Jack said.

  “Let me run upstairs and find out what’s going on,” Arun said.

  “While Arun’s doing that, why don’t we go up and have a bite to eat in the coffee shop?” Laurie suggested. “Depending on what he finds out, there might not be another chance.”

  “Good idea,” Arun said. “I’ll meet you in there.”

  It took Arun a little longer than he expected, but he also found out more than he had anticipated. By the time he entered the coffee shop, the others already had their sandwiches. The moment he sat down, the waitress appeared at his side. He ordered a sandwich as well.

  As soon as the waitress left, he leaned forward over the table. The others leaned in as well. “This is incredible,” he said in a low voice, making certain no one else could hear. He looked from one to the other. “First of all, the hospital is furious that Maria Hernandez is gone. They are so furious, that the old man downstairs has been fired.”

  “Damn,” Jack voiced. “I was afraid of that.”

  “They are also sure that the medical examiners from New York City stole it. Curiously, though, they haven’t filed an FIR against you guys.”

  “What’s an FIR?” Laurie asked.

  “It’s a First Information Report,” Arun explained. “It’s the first thing that must be done if you want the police to do something. But the police hate to file them because it means work.”

  “Who are you getting this from?” Jack asked.

  “I’m getting it from the hospital CEO,” Arun said. “His name is Rajish Bhurgava. We are reasonably good friends. I’ve known him from our school days.”

  “If they know we took the body, why aren’t they filing the FIR?” Laurie asked.

  “I’m not sure I understand, but he said it had something to do with someone very high in the health ministry, a man by the name of Ramesh Srivastava, who’d ordered him not to file. It has to do with fear of the media.”

  Laurie, Jack, and Neil shared a sustained glance to see if anyone wanted to respond to what Arun had said. Laurie was the only one who spoke up. “Maybe this Ramesh is on the trail of the healthcare serial killer and is afraid of the media alerting him or her too soon in the investigation.”

  Jacked looked askance at Laurie.

  “Well, it’s just a guess,” Laurie offered.

  “Let’s go on to the next, more important, part,” Arun said. “Both Benfatti and the body from the Aesculapian Medical Center hospital, Lucas, have been removed by a magistrate’s writ that gives the hospitals the right not only to get them out of the hospital but also to dispose of them as a public nuisance and public danger. But the weirdest part is that they have somehow arranged to have them cremated at the main burning ghat of Varanasi.”

  “I’ve heard this word ghat,” Jack said. “What does it mean?”

  “In this sense, it means stone steps on a riverbank,” Arun said. “But it also means a hilly range of mountains.”

  “We’re aware of this Varanasi plan,” Laurie said. “The hope is that it is special enough to placate the involved families. But I can tell you it didn’t have that effect when it was originally offered, at least with two of the families.”

  “So where is Varanasi from here?” Jacked asked.

  “It is southeast of Delhi, about halfway to Kolkata,” Arun said.

  “How far?”

  “Four to five hundred miles,” Arun said. “But it’s all by major highway.”

  “Would the bodies going by truck?” Jack asked.

  “For sure,” Arun said. “It’ll only take eleven and a half hours or so. They will most likely be cremated late tonight or early in the morning. The burning ghats go twenty-four hours a day. But I have to say, it is unusual. Being cremated at Varanasi is generally limited to Hindus. For them, it is exceptionally good karma. If Hindus die in Varanasi and are cremated there, they immediately achieve moksha, or enlightenment.”

  “They must have bribed someone,” Laurie suggested.

  “Without doubt,” Arun said. “They would have to have bribed one of the leading Doms for certain. The Doms are the caste that has exclusive rights over the cremation ghats. Or maybe they bribed one of the Hindu Brahmins. The hospitals would have had to bribe one or the other, or both.”

  “What’s the city like?” Jack asked.

  “It’s one of the most interesting in India,” Arun said. “It is the oldest continuously occupied city in the entire world. Some believe people have been living there for five thousand years. For Hindus, it is the holiest of cities, and especially auspicious for rites of passage, like childhood milestones, marriages, and death.”

  “What would be the chances of us meeting up with the two corpses if we were to fly to Varanasi?” Jack asked.

  “Now, that’s a question I can’t answer,” Arun said. “I guess reasonably well, especially if you would be willing to spread around a few additional bribes.”

  “What do you think?” Jack asked Laurie. “It would be good to get at least urine samples, even if we can’t do full autopsies.”

  “Are there flights to Varanasi?” Laurie asked Arun. The idea of a nearly twelve-hour journey was hardly enticing.

  “There are, but I have no idea when they leave. Let me check.”

  While Arun was making his call, Laurie turned to Neil. “Under normal circumstances, we’d ask if you guys wanted to come. But I still think it best Jennifer stays in the hotel.”

  “I agree,” Neil said.

  Arun flipped the phone closed. “Several flights have already gone. The last flight is at two-forty-five.”

  Both Laurie and Jack checked their watches. It was twelve-forty-five. “That’s only two hours. Could we make it?” Laurie asked.

  “I think so,” Arun said, “if we hur
ry.”

  “Are you coming?” Laurie asked Arun, as she stood and tossed her napkin on the remains of her sandwich. She also put out more cash than necessary for the lunch.

  “I’m having more fun than I’ve had in years,” Arun said. “I wouldn’t miss it.” As he stood up, he reopened his phone and reconnected with his travel agent. “Thanks for the sandwich,” he mentioned to Laurie while his call went through. As they walked to the elevator, he gave instructions to get them three business-class tickets on the flight to Varanasi and two rooms at the Taj Ganges. He gave Jack’s and Laurie’s names.

  When they got to the van, Arun had just finished the arrangement and said he’d meet Jack and Laurie at the Indian Airlines counter at the domestic airport. Then he rushed off to his car.

  Jack, Laurie, and Neil piled into the van, Jack behind the wheel. He even left a little rubber in the Queen Victoria driveway, but the rapid driving stopped abruptly at the street. They had forgotten the noontime traffic.

  “When we get to the hotel, I’ve got to take the time to give myself the HCG trigger shot,” Laurie said. She was sitting in the front passenger seat.

  “Oh, right,” Jack responded. “It’s good you remembered. I’d totally forgotten.”

  “You’d also better remember to take along these syringes here on the backseat,” Neil said. The bag with the sterile syringes was next to him, wedged between the seat and the seat back.

  “Good point,” Laurie said. “I might have forgotten them, which would have left us high and dry. Hand them up here!”

  Neil passed the bag to Laurie.

  “Sorry you and Jennifer can’t come with us,” Laurie said over her shoulder.

  “That’s okay. I’ll use the afternoon to start looking into booking our return flights. I think the sooner Jennifer is out of here, the better.”

  “Have her decide on what to do with her grandmother right away,” Laurie said. “And then call over to the Gangamurthy Medical College and get it arranged.”

  “She’s pretty well decided on cremation, so we’ll do that right away.”

  With Jack and Laurie keyed up about their upcoming trip, conversation lapsed for the twenty minutes it took to get back to their hotel. Even when they arrived, they didn’t speak as they hurried into the lobby.