by Robin Cook
“Remember, postmenopausal women have recently been shown to have different symptomatology than equivalent males when it comes to coronary heart disease! The case you just described is evidence of that.”
“Stop making me feel ancient and uninformed,” Jack complained.
Latasha made a gesture of dismissal with her gloved hand. “Yeah, sure!” she intoned with a chuckle.
“How about we make a little wager since neither one of us is in our home office, where such activity is frowned upon? I say it’s going to be congenital and you say degenerative. I’m willing to put up five bucks in support of my idea.”
“Whoa, big spender!” Latasha teased. “Five is a lot of cash, but I’ll double you to ten.”
“You’re on,” Jack said. After turning the heart over, he picked up a pair of fine forceps and scissors and went to work. Latasha supported the organ as Jack carefully traced and then opened the right coronary artery, concentrating on the posterior descending branch. When he’d traced it as far as the instruments would allow, he straightened up and stretched his back.
“No narrowing,” he said with a combination of surprise and disappointment. Although he usually maintained an open mind diagnostically, for fear of being blinded by the positive finding, in this case he’d been quite certain of the pathology he’d encounter. It was the right coronary artery that supplied blood to most of the heart’s conduction system, which had been knocked out by Patience Stanhope’s heart attack.
“Don’t despair yet,” Latasha said. “The ten dollars is still in the balance. There’s no narrowing, but I don’t see any atheromatous deposits, either.”
“You’re right. It’s perfectly clean,” Jack agreed. He couldn’t quite believe it. The entire vessel was grossly normal.
Jack turned his attention to the left coronary artery and its branches. But after a few minutes of dissection it was apparent the left was the same as the right. It was devoid of plaque and stricture. He was mystified and chagrined. After all he’d been through, it seemed a personal affront that there was no apparent coronary abnormality, either developmental or degenerative.
“The pathology has to be on the inside of the heart,” Latasha said. “Maybe we’ll see some vegetations on the mitral or aortic valve that could have thrown off a shower of thrombi that then cleared.”
Jack nodded, but he was mulling over the probability of sudden cardiac death from a heart attack with no coronary artery disease. He thought it was extremely small, certainly less than ten percent, but obviously possible, as evidenced by the case in front of him. One thing about forensic pathology that he could always count on was seeing and learning something new.
Latasha handed Jack a long-bladed knife, waking him from a mini trance. “Come on! Let’s see the interior.”
Jack opened each of the heart’s four chambers and made serial slices through the muscular walls. He and Latasha inspected the valves, the septa between the right and left sides of the heart, and the cut surfaces of the muscles. They worked silently, checking each structure individually and methodically. When they were finished, their eyes met across the table.
“The bright side is that neither of us is out ten dollars,” Jack said, trying to salvage humor from the situation. “The dark side is that Patience Stanhope is keeping her secrets to herself. She was reputed to be less than cooperative in life, and she’s staying in character in death.”
“After hearing the history, I’m shocked that this heart appears so normal,” Latasha said. “I’ve never seen this. I guess the answers are going to have to wait for the microscope. Maybe there was some kind of capillary disease process that involved only the smallest vessels of the coronary system.”
“I’ve never heard of such a thing.”
“Neither have I,” Latasha admitted. “But she died of a heart attack that had to have been massive. We have to see pathology other than a small, asymptomatic colon cancer. Wait a second! What’s that eponymous syndrome where the coronary arteries go into spasm?” She motioned to Jack as if she were playing charades, wanting him to come up with the name.
“I honestly have no idea. Now, don’t spout some trivia that’s going to make me feel inadequate.”
“Prinzmetal! That’s it,” Latasha said triumphantly. “Prinzmetal angina.”
“Never heard of it,” Jack admitted. “Now you’re reminding me of my brother-in-law, who’s the victim in this disaster. He’d know it for sure. Can the spasm cause massive heart attacks? That’s the question.”
“It can’t be Prinzmetal,” Latasha said suddenly with a wave of dismissal. “Even in that syndrome, the spasm is associated with some stenoses of the vessel nearby, meaning there would be visible pathology, which we don’t see.”
“I’m relieved,” Jack said.
“We have to figure this out one way or the other.”
“That’s my intention, but not seeing any cardiac pathology has me fooled and even embarrassed, considering all the fuss I’ve caused to do this autopsy.”
“I have an idea,” Latasha said. “Let’s take all the samples back to my office. We can examine the heart under the stereo dissecting microscope and even do some frozen sections of the heart tissue to look at capillaries. The rest of the specimens will have to be processed normally.”
“Maybe we should just go have some dinner,” Jack said, suddenly wanting to wash his hands of the whole affair.
“I’ll pick up some pizza on the way back to the office. Come on! We’ll make it a party. There’s one hell of a mystery here. Let’s see if we can’t solve it. We can even get a toxicology screen tonight. I happen to know the night supervisor at the lab at the university. He and I were an item a while back. Things didn’t work out, but we’re still acquaintances.”
Jack’s ears pricked up. “Run that by me again!” he said with disbelief. “We could get a toxicology screen done tonight?” Back in New York at the OCME, Jack was lucky to get one in a week.
“The answer is yes, but we’ll have to wait until after eleven, when Allan Smitham begins his shift.”
“Who’s Allan Smitham?” Jack asked. The possibility of an immediate toxicology screen opened up another whole dimension of inquiry.
“We met in college. We took a lot of chem and bio classes together. Then I went to med school and he went to grad school. Now we work a few blocks apart.”
“What about your beauty rest?”
“I’ll worry about that tomorrow night. You have me hooked on this case. We have to save your brother-in-law from the evil lawyers.”
20
NEWTON, MASSACHUSETTS
Thursday, June 8, 2006
9:05 p.m.
Alexis answered on the fourth ring. Jack had called her number and put his phone on speaker before placing it on the rent-a-car’s front passenger seat. He was on his way from the Langley-Peerson Funeral Home to the Newton Memorial Hospital. He’d decided to make a short visit before the three-to-eleven shift left for the day in hopes of catching Matt Gilbert and Georgina O’Keefe. It had been an impulsive decision when he and Latasha left the funeral home after finishing up with the autopsy. She had said she was going to stop at her apartment briefly to feed the dog, drop off the fluid samples at the toxicology lab with a message for Allan to call as soon as he got in, and pick up a couple of pizzas at an all-night joint before meeting him in the parking lot of the medical examiner’s office. She had given Jack the opportunity to tag along, but the window of opportunity had made him decide to stop at the hospital instead.
“I was hoping it was you,” Alexis said when she heard Jack’s voice.
“Can you hear me okay?” Jack asked. “We’re on my speaker phone.”
“I can hear you fine. Where are you?”
“I’m always asking myself that same question,” Jack joked. His mood had flip-flopped from its nadir, brought on by finding nothing relevant in Patience’s autopsy, to a near high. He had been energized by Latasha’s enthusiasm and the prospect of getting the a
ssistance of a toxicologist, and his mind had been picking up speed like an old-fashioned steam locomotive. Now ideas were flapping around inside his head like a flock of excited sparrows.
“You are in a rare mood. What’s going on?”
“I’m in my rent-a-car on the way to the Newton Memorial.”
“Are you all right?”
“I’m fine. I’m just going to duck in and ask a couple of questions to the ER people who handled Patience Stanhope.”
“Did you do the exhumation and the autopsy?”
“I did.”
“What did you find?”
“Other than a nonrelevant, from our perspective, cancer of the colon, I found nothing.”
“Nothing?” Alexis questioned. The disappointment in her voice was apparent.
“I know what you are thinking, because I thought the same. I was depressed. But now I think it was an unexpected gift.”
“How so?”
“If I’d found generic, garden-variety coronary disease, which is what I actually expected to find rather than something dramatic, which is what I’d hoped to find, I would have left it at that. She had heart disease and had a heart attack. End of story. But the fact that she had no heart disease begs for an explanation. I mean, there is a slight chance that she had some fatal cardiac event that we’re not going to be able to diagnose eight months after the fact, but now I believe the possibility is in our favor that there was something else involved, especially considering the resistance Fasano expressed about my doing the autopsy, and Franco trying to run me off the goddamn road, and, more significantly, the threat expressed to your children. How are they, by the way?”
“They’re fine. They act very secure, and they’re having a ball here at Grandma’s. She’s spoiling them as she always does. But back to your point: What are you really trying to say?”
“I don’t know exactly. But here’s some of my thoughts, whatever they are worth. Patience Stanhope’s death and the resistance to my doing an autopsy could be two completely separate circumstances. Fasano and crew could be behind the threats, and purely for venal reasons. But somehow that doesn’t make sense to me. Why would he go to the extent of breaking into your house and then blithely let me do the exhumation? It seems to me that the three events are separate and not connected. Fasano threatened me for the reasons he gave. Franco has this ego problem after I whacked him in the nuts, so my problems with Franco have nothing to do with Patience Stanhope. That leaves the break-in at your house unexplained.”
“This is too complicated,” Alexis complained. “If Tony Fasano wasn’t behind terrorizing my children, then who was?”
“I have no idea. But I asked myself what the motivation might have been if it didn’t involve Fasano and money. It’s pretty clear that it would be an attempt to keep me from learning something, and what could be learned from an autopsy? One thing would be an overdose of medication or the wrong medication Patience Stanhope might have gotten at the hospital. Hospitals are big organizations with lots of stockholders, involving lots of money.”
“That’s crazy,” Alexis said without hesitation. “The hospital wasn’t behind my kids being victimized.”
“Alexis, you wanted me to come up here to Boston and think out of the box, and that’s what I’m doing.”
“But the hospital?” she questioned with a whine. “Is that why you are on your way there now?”
“It is,” Jack confessed. “I think of myself as a reasonable judge of character. I was impressed by the two ER people I spoke with Tuesday. They’re forthright and devoid of artifice. I want to talk to them again.”
“What are you going to do,” Alexis asked scornfully, “ask them if they made some huge mistake that the hospital has to send people out to brutalize my children to try to cover up? That’s ridiculous.”
“When you put it that way, it does sound far-fetched. But I’m going to do it anyway. The autopsy is not over. I mean, the gross dissection is over, but we’re now going to see what toxicology can come up with and also look at the microscopic. I also want to corroborate exactly what medication Patience Stanhope was given so I can tell the toxicologist.”
“Well, that sounds more reasonable than accusing the hospital of some ridiculous cover-up.”
“The thought of an overdose or wrong medication is not my only idea. Do you want to hear it?”
“I’m listening, but I hope this next idea is more sane than your first.”
Jack thought of some witty, sarcastic comebacks, but he controlled himself. “The hospital idea was predicated on Patience Stanhope’s heart attack and the opposition to the autopsy being two separate although related circumstances. What if both involved the same person?”
There was a deliberate pause while Jack let this comment sink in.
“I’m not sure I’m following you,” Alexis said finally. “Are you talking about someone causing Patience Stanhope’s heart attack and then trying to prevent an autopsy to keep from being discovered?”
“That’s exactly what I’m suggesting.”
“I don’t know, Jack. That sounds almost as crazy. I suppose you are talking about Jordan.”
“Jordan is the first person that comes to mind. Craig said Jordan and Patience were hardly a loving couple, and Jordan is the big winner with her death. He certainly didn’t waste any time in mourning. For all we know, he and his girlfriend were carrying on while Patience was still in the picture.”
“How can someone cause a heart attack in someone on purpose?”
“Digitalis could do it.”
“I don’t know,” Alexis said dubiously. “This seems equally far-fetched. If Jordan was at all guilty, he certainly wouldn’t initiate a malpractice suit, and he absolutely wouldn’t have signed the exhumation authorization.”
“I’ve thought of that,” Jack said as he pulled into the parking area for the Newton Memorial Hospital. “I agree it doesn’t seem rational, but maybe we’re not dealing with a rational person. Maybe Jordan is getting a charge out of all this, thinking it is showing how much smarter he is than the rest of us. But this kind of supposition is jumping the gun. First, some kind of drug has to be found by toxicology. If we find something, then we’ll have to work backwards.”
“That’s the second time you’ve said ‘we.’ Are you just using that as a figure of speech or what?”
“One of the medical examiners from the Boston medical examiner’s office is generously helping.”
“I trust you’ve spoken to Laurie,” Alexis said. “Is she okay with you still being here?”
“She’s not the happiest camper, but she’s doing okay.”
“I can’t believe you are getting married tomorrow.”
“Nor can I,” Jack said. He nosed into a parking space overlooking the pond. His headlights illuminated a flock of bobbing waterfowl. “What happened at the trial this afternoon?”
“Randolph called two expert witnesses, one from Yale and one from Columbia. Both were credible but hardly exciting. Best of all, they were not at all phased by Tony, who tried to rattle them. I think Tony was hoping Randolph would call Craig back on the stand, but Randolph wisely didn’t. Instead, Randolph rested. That was it. Tomorrow morning will be the summations, with Randolph leading off.”
“Has your intuition changed any about what you think the final outcome will be?”
“Not really. The defense witnesses were good, but they were from out of town. Since Boston is such a medical mecca, I don’t think the fact that they came from distant universities resonated well with the jurors. Tony’s experts had more of an impact.”
“You probably have a point, I’m sorry to say.”
“If by some slim chance you do discover some criminality in regard to Patience Stanhope, it would probably save the day for Craig.”
“Don’t think for a moment that such a thought isn’t in my mind. To be honest, it’s my main motivation. How is Craig’s mind-set?”
“Despondent, as usual. Maybe even a littl
e worse. I worry a little with him home alone. When do you think you’ll get back there?”
“I just don’t know,” Jack said, suddenly feeling guilty about not wanting to return to the Bowman home.
“Maybe you could check on him when you do. I don’t like that alcohol–sleeping pill combination.”
“Okay, I’ll do that,” Jack said. “I’m at the hospital now, and I have to run.”
“No matter what happens, I truly appreciate all your efforts, Jack. You’ll never know how much your support has meant to me these last few days.”
“You still feel that way even though my meddling was responsible for what happened to the girls?”
“I don’t hold that against you in the slightest.”
After a few more sibling endearments that might have brought a tear to Jack’s eye had they continued, they said good-bye. Jack flipped his phone closed and sat in the car for a minute, thinking about relationships and how they changed over time. It gave him a warm feeling to know that he and his sister were back to a semblance of their previous closeness, despite the years of separation while he’d struggled with his own despondency.
As Jack climbed out of the car, the zeal that Latasha had generated came back in a rush. Alexis’s comments had been a bit of a downer, but he didn’t need her to tell him his ideas were preposterous. He was, as he had explained, thinking out of the box with a bunch of facts that were themselves seemingly implausible.
In contrast to his first visit, the emergency room was hopping. The waiting room was full, with almost every seat taken. A few people were standing outside on the ambulance-receiving dock. It was a warm, humid, almost summer night.
Jack had to wait in line at the admitting desk behind a woman holding a feverish infant in her arms. The child stared at Jack, over the mother’s shoulder, with glazed eyes and a blank expression. As Jack moved up to the counter and was about to ask for Dr. Matt Gilbert, the doctor appeared. He tossed a completed ER admission note attached to a clipboard onto the desk when he locked eyes with Jack.