Fatal Care

by Leonard Goldberg

  “Nope.”

  “Were there any episodes of loss of consciousness when he could have aspirated a foreign object?”

  Lori shook her head.

  “And he never worked around asbestos or anything else that would enhance an ex-smoker’s chances of developing lung cancer?”

  “There’s nothing like that in his records.”

  Joanna exhaled wearily, trying to think and put the pathologic clues together. But she’d been on her feet for over fourteen hours, and the effect of it was starting to show. “See if you can find somebody to do a frozen section on this pulmonary nodule.”

  “You want it done now?”

  “Now.”

  Lori walked over to a wall phone and began punching in numbers.

  Joanna moved around on her feet and tried to get the circulation going. Her fatigue seemed to be increasing by the minute. She had to resist the urge to go directly to the heart, where all the answers lay. With effort she forced herself to examine the lungs once more.

  The door to the special autopsy room opened, and Simon Murdock hurried in.

  “Have we got anything yet?” he asked.

  “He probably has lung cancer,” Joanna said.

  “But that didn’t kill him, did it?” Murdock asked quickly.

  “No. Lung cancer doesn’t kill suddenly unless it erodes into a major blood vessel.”

  Murdock nodded, breathing a sigh of relief. He was sorry that Oliver Rhodes was dead, but he’d be sorrier yet if Rhodes died of anything other than heart disease. It had to be heart disease that caused Oliver’s death. That was the condition that needed to be met for the Rhodes family to donate ten million dollars for a new cardiac institute at Memorial. “Have you looked at his heart yet?”

  “Not yet,” Joanna replied, spreading the lobes of the lungs apart so she could examine the central area where the lymph nodes were located. They weren’t enlarged. The cancer probably hadn’t spread beyond the nodule.

  Murdock glanced up at the wall clock. It was 10:40 P.M. “How much longer?”

  “As long as it takes,” Joanna said, focusing all of her attention on an area of thickened pleura. It looked like a scar, not a tumor.

  “Do I need to remind you that the Rhodes family is waiting?”

  “They’re going to have to wait a little longer.”

  Murdock’s face tightened. “There would be no delay at all had you not used up the afternoon on police work.”

  Joanna exhaled heavily. “That was a very important case, Simon.”

  “Nothing—I repeat—nothing is more important at Memorial than the Rhodes family,” Murdock snapped. “Do you understand that?”

  Joanna dropped the mass of lung tissue onto the stainless steel table. It landed with a loud thud. She moved in closer to Murdock. “I understand that the Rhodes family has suffered a tragic loss. And I understand that they want the autopsy results as soon as possible. But you and I arguing down here won’t get the work done any faster.”

  “That may be so,” Murdock countered. “But I still think your order of priorities is inappropriate. Your police cases should always come after your patients from Memorial.”

  “Not always,” Joanna said firmly. “Every now and then there are cases in which the search for evidence can’t wait. In some instances the evidence can change or even disappear with time.”

  “Those must be very rare exceptions.”

  “Well, a rare exception happened today.”

  Murdock gave her a long, hard look. “Maybe we should discuss this before the entire department of pathology.”

  “You just let me know when.” Joanna fixed her eyes on Murdock, disliking him even more than usual.

  They glared at each other, the tension rising close to the breaking point. Neither blinked or backed down.

  Lori McKay watched the confrontation, despising Murdock almost as much as she liked Joanna. He was a bully who seemed to enjoy manipulating people and keeping them under his thumb. And he did it to just about everybody at Memorial except Joanna. She never tolerated his abusive behavior and never backed down.

  The wall phone rang. Lori picked it up and spoke briefly; then she called over to Joanna, “It’s the pathologist on call. He wants to know if the frozen section can wait until morning.”

  Murdock asked, “What’s this all about?”

  “I want a frozen section study done on the pulmonary nodule we found,” Joanna explained, regaining her composure. “That way we’ll know tonight if Oliver Rhodes had lung cancer.”

  Murdock looked over to Lori. “You tell that pathologist he’d better get in fast if he values his job.”

  Lori relayed the message and then returned to the stainless steel autopsy table. She distanced herself from Murdock, fearing the man as much as she disliked him.

  “All right,” Joanna said, getting back to business, “let’s examine the heart.”

  Murdock put on reading glasses and moved in closer to the autopsy table.

  Joanna picked up the heart and carefully studied its size and consistency. It was smaller than she expected and had a healthy red color. There was no evidence of ventricular enlargement or scarring. The anterior surface of the heart glistened in the light. It weighed four hundred grams.

  “The heart is usually bigger in someone his age,” Joanna commented. “Particularly when there’s a history of cardiac disease.”

  “Don’t forget he had his coronary arteries cleaned out,” Lori said. “They’re like new.”

  “But this is the heart of an athlete,” Joanna went on. “You said he was a jogger. Right?”

  Lori nodded. “He ran a couple of miles on an almost daily basis, and he was an avid tennis player, too.”

  Joanna cut into the wall of the left ventricle and studied the cardiac musculature. “This heart looks like it belongs to someone twenty-five years old.”

  “A new set of coronary arteries can do wonders,” Lori said.

  “Maybe,” Joanna said, unconvinced. She had done autopsies on patients who had had coronary bypass surgery and died of other causes. Their grafts were still open and had provided excellent coronary blood flow. But their hearts never looked this good.

  “Is there any evidence of myocardial infarction?” Murdock asked worriedly.

  “Not so far.” Joanna sliced open a major coronary artery and studied its interior. There were no fatty deposits or occlusions. “The left main coronary looks very clean.”

  Murdock groaned to himself. No heart attack, no new institute. “Perhaps one of the other coronaries is blocked.”

  “Perhaps,” Joanna said. But the other coronary arteries appeared to be wide open with not even a hint of blockage. There was no evidence for a myocardial infarction. Joanna began thinking about noncardiac causes of sudden death in a middle-aged man. An acute cerebral hemorrhage topped the list. “Simon, we may have to examine Oliver Rhodes’s brain.”

  “The Rhodes family wants to avoid that,” Murdock said. “At the funeral service his body will be viewed.”

  Joanna shrugged. “We may have no choice but to open his skull.”

  She went back to the heart and split it apart, exposing the interventricular septum and the endocardial wall. There were postmortem blood clots blocking her view, so she swept them away.

  Then she saw it. A large pinkish red mass growing out of the septum. She looked over at Simon Murdock. “Oliver Rhodes did not have a myocardial infarction. But he did have a cardiac-related death.”

  Murdock’s eyes brightened. “Are you sure?”

  “Take a look at the superior aspect of the interventricular septum.”

  Joanna spread the heart open again and pointed at the large mass that involved the upper septum and extended down into the endocardial wall. “It’s a tumor.”

  Murdock stared at her quizzically. “Of the heart?”

  Joanna nodded. “It’s rare, but it happens.”

  Murdock snapped on a pair of latex gloves and felt the firm, fixed mass.
“How rare is it?”

  “I’ve been here over ten years, and I’ve seen only one case.”

  Lori leaned in for a closer view. “How do you know it’s not a metastatic lesion? Maybe it’s a metastasis from that pulmonary nodule.”

  “That’s a possibility,” Joanna conceded. “But I think it’s unlikely for several reasons. First, metastatic lesions to the endocardium are rare, even rarer than primary cardiac malignancies. Secondly, metastases from the lung to the heart are usually the result of direct extension and almost always involve the outer pericardium, not the endocardium. That having been said, the only way to really tell if it’s a primary tumor of the heart is by examining it under a microscope.”

  Lori nodded to herself, thinking aloud. “If it’s a primary heart tumor, it’ll be a sarcoma. If it’s a metastasis from the lung, it’ll be a carcinoma.”

  “Right.”

  Murdock asked, “Can you tell the difference between the two on frozen section?”

  “I would think so,” Joanna answered.

  Murdock glanced up impatiently at the wall clock. It was eleven. “Where the hell is the on-call pathologist?”

  “He should be here in a minute,” Lori said. “He lives close by.”

  Murdock gazed down at the opened chest of Oliver Rhodes. One man’s death was another man’s gain, he thought. That’s the way it always was. Oliver’s death would give Memorial a new heart institute—if his death was cardiac related. And it was, according to Joanna Blalock. Murdock wondered how a heart tumor caused someone to die suddenly. Mortimer Rhodes would want to know that, too. “Joanna, how does a tumor like this induce sudden death?”

  “By inducing an arrhythmia,” Joanna told him. “This tumor has invaded deeply into the interventricular septum where the heart’s conduction system is located. All electrical impulses travel from the atria to the ventricles via the septum. If the septum is diseased, such as by an infiltrating tumor, the conduction system goes haywire and you end up with severe cardiac arrhythmias.”

  Murdock gave the explanation thought as he peeled off his gloves. “Can that be proved here?”

  “No,” Joanna said. “But it’s the most likely sequence of events.”

  “So there’s no doubt in your mind that Oliver’s death was cardiac in nature?”

  “No doubt at all.”

  The ventilation system clicked on, and Murdock felt the air stir in the special autopsy room where contaminated cases were done. He leaned against the wall and organized his thoughts. Once the frozen sections confirmed the diagnosis, he would call Mortimer Rhodes. After that, Oliver’s body would be meticulously sewn together and sent to the funeral home in the early morning hours. Then a carefully worded statement would be released to the press. There would be no need for Murdock to mention the new institute to Mortimer Rhodes. The old man would bring up the subject himself.

  The door opened, and a portly, balding middle-aged man entered. He was wearing a long white laboratory coat over a green scrub suit. His name tag read DENNIS GREEN, M.D. — ASSOCIATE PROFESSOR OF PATHOLOGY.

  “Thanks for coming in, Dennis,” Joanna said.

  “No problem.” Green nodded to Joanna and then to Murdock, who didn’t bother to nod back. “What have you got?”

  “We’re doing an autopsy on Oliver Rhodes,” Joanna replied. Then she sneezed and reached for a tissue.

  Green glanced over at the body, thinking that Oliver Rhodes looked a lot larger in life than in death. He turned his attention back to Joanna. “And?”

  “And,” Joanna continued, wiping her nose, “he has a pulmonary lesion and a heart lesion that appear to be malignant. We want that confirmed on a frozen section.”

  Green looked at Joanna strangely. “You called me in to do a frozen section on a dead man who has carcinoma of the lung that metastasized to the heart?”

  “It’s not so straightforward,” Joanna explained. “I think he’s got a primary malignancy of the heart.”

  “Well, well,” Green said, becoming interested. “Do you think it’s a rhabdomyosarcoma?”

  “That would be my guess,” Joanna said. “And it may be metastatic to the lung.”

  “Or the lung may just be a run-of-the-mill carcinoma,” Green thought aloud. “He may have two separate cancers.”

  “Exactly.”

  Joanna picked up two small bottles containing small fragments of tissue. One was labeled A, the other B. “A is the lung; B is the heart.”

  Green took the specimens from her. “I’ll be back in a flash.”

  Murdock waited for Green to leave and then asked Joanna, “Is he as good at this as people say he is?”

  “He’s the best,” Joanna assured him. “The oncology surgeons always ask for him to do their cases.”

  Murdock stretched his neck, trying to relieve some of the tightness. “Was there a reason you found it necessary to mention the name of Oliver Rhodes to Dr. Green?”

  “I wanted him to know why I was dragging him out in the middle of the night to do frozen sections on a corpse.”

  The cell phone inside Murdock’s coat chirped. With a weary sigh, he reached for it. Mortimer Rhodes was on the other end. “Yes, Mortimer. . . . We’re almost done, and it seems that Oliver’s death was cardiac in nature. . . . Yes, yes. But we are confirming it with microscopic studies at this very moment. . . .”

  Joanna gestured to Murdock and softly whispered for him to ask Rhodes if there was any family history of unusual cancers.

  “And Mortimer,” Murdock continued, “there was one other disturbing finding. It seems that Oliver had a somewhat unusual lung cancer, as well. Is there any history of uncommon cancers in your family? . . . No. I see. Well, we should complete all the studies within the hour. Should I call you back then? . . . As soon as I have the results.”

  Murdock put the cell phone down and then wavered on his feet for a moment. He steadied himself with a hand on the wall. Slowly he eased himself down onto a metal stool.

  Joanna saw the peaked look on his face and hurried over. “Are you all right, Simon?”

  “Just a little tired,” Murdock said. “It’s been a long day.”

  “For all of us.”

  Murdock tilted his head back against the cool wall, thinking about the death of his own son and the autopsy they did on the boy. “It’s very difficult to talk to a father about the death of his son.”

  “I know,” Joanna said, studying Murdock’s heavily lined face. He was in his late sixties but seemed older with his snow-white hair and stooped posture. And like Joanna, he, too, had put in a long fifteen-hour day. Too long, Joanna thought, now wondering why she always seemed to take on more work than she could handle. Three cases at once—Oliver Rhodes, the drowning victim, and the Russian with the dead fetuses—were too much, way too much. She’d be lucky to get home before midnight.

  The door swung open, and Dennis Green returned.

  “It’s straightforward,” he announced. “There are two different cancers in Mr. Rhodes. The lung is an adenocarcinoma; the heart, a sarcoma.”

  Joanna asked, “Was it a rhabdomyosarcoma?”

  “Probably,” Green replied. “I’ll know for sure when we do the routine stains.”

  Murdock pushed himself up from the stool. “And you believe that caused his death?”

  “Oh, yeah,” Green said with certainty. “It was a nasty-looking malignancy that extended way into the septum. He died a cardiac death beyond any question.”

  Joanna shook her head sadly. “And his heart looked so good from the outside, like the heart of an athlete. And his coronary arteries were wide open.”

  “It’s kind of ironic,” Lori said, more to herself than to the others. “He undergoes a risky procedure to clean out his coronary arteries so he’ll have a heart that will last for another fifty years. Instead, the organ that was supposed to prolong his life ends up killing him.”

  Green’s eyebrows went up. “He underwent that experimental artery-cleansing procedure? The one
where they use the enzyme?”

  Joanna nodded. “He had it done a year ago. So what?”

  “So he represents the second case of cancer I’ve seen in this group. That’s what.”

  “Are you telling us that you’ve seen two sarcomas of the heart in patients who’ve undergone this procedure?” Joanna asked carefully.

  Green thought back and then shook his head. “The first patient had her cerebral arteries cleaned out and later developed an astroblastoma.”

  “A what?” Murdock asked.

  “An astroblastoma,” Green answered. “It’s a very rare form of brain cancer.”

  The group went silent, each person lost in his or her own thoughts. The ventilation system overhead clicked off. The air became still.

  “We’ve got trouble here,” Joanna said gravely.

  “Not necessarily,” Murdock said at once. “We have only two cases of cancer occurring in this group.”

  “Two cases of very rare cancer occurring in a very small group,” Joanna corrected him. “That’s not happenstance, Simon.”

  “But it doesn’t prove cause and effect,” Murdock argued.

  Joanna ignored him, trying to put the pieces of the puzzle together. Two rare cancers pop up in patients whose only common denominator is that they both had their arteries cleaned. But how could that cause a malignancy? “How many people have had this procedure?”

  “The NIH allowed us to do ten patients initially,” Murdock replied. “The results were so encouraging, they granted permission for us to include another twenty patients in the study.”

  Joanna quickly calculated numbers in her head. Of the thirty patients in the artery-cleansing study, two had developed malignancies. A cancer rate of one in fifteen—an astronomical incidence. “You’ll have to report this to the NIH, Simon.”

  “Oh, I will,” Murdock said, his mind racing ahead. The NIH would insist that the artery-cleansing study be discontinued until the matter was thoroughly investigated by a scientific committee at Memorial. And the news was certain to be leaked to the press, who would have a field day throwing mud at Memorial. Then there would be the multimillion-dollar lawsuits that were sure to follow. And, until all questions were answered, there would be no new cardiac institute in memory of Oliver Rhodes. The consequences of an adverse finding by the committee would be staggering.