She heard a door whish open and turned to see a nurse wheeling a medication cart out of the patient’s room across the hall. “What happened?” Toby asked her. “When did Mr. Parmenter expire?”
“It was about an hour ago.”
“Why wasn’t I called for the code?”
“Dr. Wallenberg was here on the ward. He decided not to code him.”
“I thought the patient was being moved to the ICU.”
“They canceled the transfer. Dr. Wallenberg called the daughter, and they both agreed it didn’t make sense to move the patient. Or use extraordinary measures. So they let him go.”
It was a decision with which Toby could not argue; Angus Parmenter had been eighty-two years old and comatose for a week, with little hope of recovery.
She had one more question to ask: “Has the family given permission for the autopsy?”
The nurse looked up from her medication cart. “They’re not doing an autopsy.”
“But there has to be an autopsy.”
“The funeral arrangements are all made. The mortuary’s coming to pick up the body.”
“Where’s the chart?”
“The ward clerk’s already broken it down. We’re just waiting for Dr. Wallenberg to fill out the death certificate.”
“So he’s still in the hospital?”
“I believe so. He’s seeing a consult on the surgery floor.”
Toby went straight to the nurses’ station. The ward clerk was away from her desk, but she’d left the loose pages from Mr. Parmenter’s chart on the countertop. Quickly Toby flipped to the last progress note and read Dr. Wallenberg’s final entry.
Family notified. Respirations ceased—nurses unable to detect pulse. On exam, no heartbeat noted on auscultation. Pupils midposition and fixed. Pronounced dead 0558.
There was no mention of an autopsy, no speculation about the underlying illness.
The squeak of rolling wheels made her glance up as two hospital orderlies came out of the elevator, pushing a gurney. They wheeled it toward room 341.
“Wait,” said Toby. “Are you here for Mr. Parmenter?”
“Yeah.”
“Hold on. Don’t take him anywhere yet.”
“The hearse is already on its way over.”
“The body stays where it is. I have to talk to the family.”
“But—”
“Just wait.” Toby picked up the phone and paged Wallenberg to Three West. There was no answer. The orderlies stood waiting in the hallway, glancing at each other, shrugging. Again she picked up the phone and this time she called the patient’s daughter, whose number was listed in the chart. It rang six times. She hung up, her frustration now at a boil, and saw that the orderlies had wheeled the gurney into the patient’s room.
She ran after them. “I told you, the patient stays.”
“Ma’am, we were ordered to pick him up and bring him downstairs.”
“There’s been a mistake, I know it. Dr. Wallenberg’s still in the hospital. Just wait until I can talk to him about this.”
“Talk to me about what, Dr. Harper?”
Toby turned. Wallenberg stood in the doorway.
“An autopsy,” she said.
He stepped into the room, letting the door slowly whoosh shut behind him. “Are you the one who paged me?”
“Yes. They’re taking the body to the mortuary. I told them to wait until you could arrange for the autopsy.”
“There’s no need for an autopsy.”
“You don’t know why he coded. You don’t know why he became confused.”
“A stroke is the most likely cause.”
“The CT scan didn’t show a stroke.”
“The CT may have been done too early. And you wouldn’t necessarily see a brain stem infarct.”
“You’re guessing, Dr. Wallenberg.”
“What would you have me do? Order a head scan on a dead patient?”
The orderlies were watching the heated exchange with fascination, their gazes bouncing back and forth. Now the men’s eyes were focused on Toby, waiting for her answer.
She said, “Harry Slotkin presented with identical symptoms. Acute onset of confusion and what appeared to be focal seizures. Both these men lived at Brant Hill. Both of them were previously healthy.”
“Men in that age group are prone to strokes.”
“But there could be something else going on. Only an autopsy can determine that. Is there some reason you’re opposed to one?”
Wallenberg flushed, his anger so apparent Toby almost took a step backward. They eyed each other for a moment, then he seemed to regain his composure.
“There’ll be no autopsy,” he said, “because the daughter has refused. And I’m honoring her wishes.”
“Maybe she doesn’t understand how important this is. If I spoke to her—”
“Don’t even think about it, Dr. Harper. You’d be invading her privacy.” He turned to the orderlies, his dominance fully reasserted. “You can bring him downstairs now.” He shot a last dismissive glance at Toby, then he left the room.
In silence Toby watched as the orderlies wheeled the gurney toward the bed and braked it in place.
“One, two, three, move.”
They slid the corpse onto the gurney and secured it in place with a chest strap. It was not for safety but for aesthetics. Gurneys could be bumped, ramps could be steep, and one didn’t want dead bodies accidentally tumbling onto floors. Above the corpse, a false mattress pad was clamped into place, then a long sheet draped over the whole contraption. A casual observer passing it in the hall would think it was merely an empty stretcher.
They wheeled the body out of the room.
Toby stood alone, listening to the receding squeak of the wheels. She thought of what would happen next. Downstairs, in the morgue, there would be paperwork to complete, authorization forms and releases to be signed. Then the deceased would be loaded into a hearse and transported to the mortuary, where the body fluids would be drained and replaced with embalming fluid.
Or would it be a cremation? she wondered. A fiery reduction to carbon ash and trace elements, leaving behind no answers?
This was her last chance to learn Angus Parmenter’s diagnosis. And maybe Harry Slotkin’s diagnosis as well. She picked up the phone and once again called the patient’s daughter.
This time a voice answered with a soft “Hello?”
“Mrs. Lacy? This is Dr. Harper. We met last week, in the Emergency Room.”
“Yes. I remember.”
“I’m very sorry about your father. I just learned the news.”
The woman gave a sigh, more a sound of weariness than of grief. “We were expecting it, I suppose. And to be perfectly honest, it’s something of a. . . well, a relief. That sounds awful. But after a week of watching him. . . like that. . .” Again she sighed. “He wouldn’t have wanted to live that way.”
“Believe me, none of us would.” Toby hesitated, searching for the right words. “Mrs. Lacy, I know this is a bad time to talk to you about this, but there’s really no other time to do it. Dr. Wallenberg told me you didn’t want an autopsy. I understand how hard it is for the family to give permission for something like this. But I really feel, in this case, it’s vital. We don’t know what your father died of, and it may turn out to be—”
“I didn’t object to an autopsy.”
“But Dr. Wallenberg said you refused one.”
“We never discussed it.”
Toby paused. Why did Wallenberg lie to me? She said, “May I have your permission for an autopsy, then?”
Mrs. Lacy hesitated only a few seconds. Softly she said: “If you think one is necessary. Yes.”
Toby hung up. She started to call the Pathology Department next, then decided against it. Even with the family’s permission, no Springer pathologist would perform the postmortem—not when the attending physician objected.
Why is Wallenberg so determined to avoid an autopsy? What is he afraid they’ll f
ind?
She looked at the telephone. Decide. You have to decide now. She picked it up and dialed directory assistance. “City of Boston,” she said. “The office of the medical examiner.”
It took a moment to obtain the phone number, another few moments to get through to the right extension. While she waited, she could picture the progress of Angus Parmenter’s body toward the morgue. The ride down the elevator. The door whishing open to the basement level. The corridor with its groaning water pipes.
“Medical examiner’s office. This is Stella.”
Toby snapped to attention. “I’m Dr. Harper at Springer Hospital in Newton. May I speak to the chief medical examiner?”
“Dr. Rowbotham is on vacation, but I can connect you with our deputy chief, Dr. Dvorak.”
“Yes, please.”
There were a few clicks, and then a man’s voice, flat and weary, said: “This is Dr. Dvorak.”
“I have a patient who just expired,” she said. “I think an autopsy is indicated.”
“May I ask why?”
“He was admitted here a week ago. I saw him in the ER when he came in by ambulance—”
“Were there traumatic injuries?”
“No. He was confused, disoriented. There were cerebellar signs. Early this morning he had a respiratory arrest and died.”
“Do you suspect foul play of any kind?”
“Not really, but—”
“Then your own hospital pathologist can certainly perform the autopsy. You don’t have to report a death to our office unless the patient dies within twenty-four hours of being admitted.”
“Yes, I realize it’s not your usual coroner’s case. But the attending physician refuses to order a postmortem, which means our pathologist won’t do it. That’s why I’m calling you. The family has already agreed to it.”
She heard a long sigh and the shuffle of papers, could almost see the man at his desk, tired and overworked, surrounded by countless reminders of death. A joyless profession, she thought, and Dr. Dvorak had the voice of an unhappy man.
He said, “Dr. Harper, I don’t think you’re quite clear on the role of our office here. Unless there’s a question of foul play or public health—”
“This could be a public health issue.”
“How so?”
“It’s the second case I’ve seen in my ER this month. Two elderly men, both presenting with acute confusion, cerebellar signs, and focal seizures. And here’s what troubles me: these two patients lived in the same retirement complex. They drank the same water, ate in the same dining room. They probably knew each other.”
Dr. Dvorak said nothing.
“I don’t know what we’re dealing with here,” said Toby. “It could be anything from viral meningitis to garden pesticides. I would hate to overlook a preventable illness. Especially if other people are at risk.”
“You say there were two patients.”
“Yes. The first one was in my ER three weeks ago.”
“Then the autopsy on that first patient should provide your answers.”
“There was no autopsy on the first patient. He vanished from the hospital. His body’s never been recovered.”
The man’s silence gave way to a soft exhalation. When he spoke again, she could hear the new undertone of interest. “You said you’re at Springer Hospital? What’s the patient’s name?”
“Angus Parmenter.”
“And is the body still there?”
“I’ll make sure it is,” she said.
She ran four flights down the stairwell and emerged in the basement. One of the overhead fluorescents was flickering like a strobe light, and her legs seemed to move in a jerky click-click-click of freeze frames as she hurried down the hall to a door labeled: AUTHORIZED PERSONNEL ONLY. She stepped into the morgue.
The lights were on, and a radio on the attendant’s desk was playing, but there was no one in the anteroom.
Toby entered the autopsy lab. The stainless steel table was empty. Next she checked the cold room, the refrigerated locker where bodies were stored prior to autopsy. A chill vapor, faintly malodorous, swirled out of the locker. The smell of dead meat. She flipped on the light and saw two gurneys. She went to the first one and unzipped the shroud, revealing the face of an elderly woman, eyes open, the sclerae shockingly red from hemorrhages. Shuddering, she closed the shroud and went to the second gurney. It was a large corpse, and a foul odor rose up as she slid the zipper open. At her first sight of the man’s face, she jerked away, fighting nausea. The flesh of the corpse’s right cheek had melted away.
Necrotizing streptococcus, she thought, the flesh devoured by bacteria.
“This area is off limits,” a voice said.
Turning, she saw the morgue attendant. “I’m looking for Angus Parmenter. Where is he?”
“They wheeled him out to the loading bay.”
“They’re taking him already?”
“The hearse just arrived.”
“Shit,” she muttered and dashed out of the morgue.
A quick jog down the hall brought her to the loading bay doors. She pushed through, and the morning sunlight caught her full in the face. Blinking against the glare, she quickly took in the situation: the orderly, standing by the empty gurney. The hearse, as it pulled away. She dashed past the orderly and ran alongside the moving hearse, rapping at the driver’s window.
“Stop. Stop the car!”
The driver braked and rolled down his window. “What is it?”
“You can’t take the body.”
“It’s been authorized. The hospital released it.”
“It’s going to the medical examiner.”
“No one told me. As far as I know, the family’s already made arrangements with the mortuary.”
“This is now a medical examiner’s case. You can check with Dr. Dvorak at the ME’s office.”
The driver glanced back at the loading bay, where the orderly stood watching in puzzlement. “Gee, I don’t know. . .”
“Look, I’ll take full responsibility,” she said. “Now back up. We have to unload the body.”
The driver shrugged. “Whatever you say,” he muttered and shifted into reverse. “But someonez’s gonna catch hell for this. And I sure hope it isn’t me.”
8
Lisa was flirting with him again. It was one of the daily irritations that Dr. Daniel Dvorak had learned to tolerate: his female assistant’s eyelash-batting glances through the protective goggles, her insatiable curiosity about his private life, and her obvious frustration that he chose to ignore her advances. He didn’t understand why she should find him so interesting; he suspected her attraction to him was nothing more than the challenge of a silent man.
An older man, he admitted to himself with resignation as he eyed his youthful assistant. Lisa had no wrinkles, no gray hairs, no sagging epidermis. At twenty-six she was, in the immortal words of his own teenage son, a blond babe. And what does my boy call me behind my back? he wondered. Old fart? Fuddy duddy? To a fourteen-year-old like Patrick, forty-five must seem as distant as the next ice age.
But we’re all closer to death than we realize, thought Dvorak, gazing at the naked body on the morgue table. The overhead lights shone down, harsh and unforgiving, emphasizing every wrinkle and mole on the corpse’s skin. The gray hairs on the chest. The black seborrheic keratoses on the neck. The inevitable changes of aging. Even blond and buff Lisa would someday have liver spots.
“Looks like we have an outdoorsman,” he commented, running a gloved finger across a rough patch of skin on the corpse’s forehead. “Actinic keratoses. He has sun damage here.”
“But pretty nice pectorals for an old guy.” Lisa, of course, noticed such details. She was a health club addict, had started the gym craze two years ago, and her quest for physical perfection had reached the point where she talked incessantly about abs and lats and reps. It was the code of the muscle obsessed, who seemed to prefer one-syllable words. Often Dvorak would see Lisa glancin
g at her own reflection in the mirror over the sink. Was the hair perfect? Did that blond forelock curl just so? Was the tan holding, or would she need another twenty minutes on her apartment rooftop? Dvorak found her youthful preoccupation with good looks both amusing and bewildering.
Dvorak seldom looked in a mirror anymore, and that was only to shave. When he did look at himself, he was always surprised to see that his hair was now as much silver as black. He could see the passage of years in his face, the deepening lines around his eyes, the permanent frown etched between his eyebrows. He also saw how tired and drawn he’d become. He’d lost weight since his divorce three years ago, had lost even more weight since his son, Patrick, had left for boarding school two months ago. As layers of his personal life had peeled away, so had the pounds.
This morning, Lisa had commented on his new gauntness. Lookin’ good these days, Doc! she’d chirped, which only confirmed how blind the young were. Dvorak didn’t think he looked good. When he looked in the mirror, what he saw was a candidate for Prozac.
This autopsy was not going to improve his mood.
He said to Lisa, “Let’s turn him over. I want to examine his back first.”
Together they log-rolled the corpse sideways. Dvorak redirected the light and observed dependent mottling, consistent with the postmortem pooling of blood, as well as pale areas on the buttocks where the weight of the body had compressed the soft tissues. He pressed a gloved finger against the bruiselike discoloration. It blanched.
“Livor mortis not fixed,” he noted. “We’ve got an abrasion here, over the right scapula. But nothing impressive.”
They rolled the corpse onto its back again.
“He’s in complete rigor mortis,” said Lisa.
Dvorak glanced at the medical record. “Time of death recorded at five-fifty-eight. It’s consistent.”
“What about those bruises on the wrists?”
“Looks like restraints.” Dvorak flipped through the record again and saw the nurse’s note: Patient remains agitated and in four-point restraints. If only all his postmortems came with the circumstances of death so well documented. When a body was wheeled into his autopsy room, he felt fortunate just to have a positive identification, even more fortunate if the body was both intact and free of odors. To deal with the worst odors, he and his assistants donned protective suits and oxygen units. Today, though, they were working with standard gloves and goggles, on a cadaver that had already been screened in the hospital for HIV and hepatitis. While autopsies were never pleasant, this one would be relatively benign. And probably unrewarding.
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