Critical

2

"Listen," Dr. Jack Stapleton said with uncamouflaged irritation, "I'm lucky to have gotten on Dr. Wendell Anderson's schedule. Hell, he does all the knees for all the high-priced athletes in the city. There has to be a reason, and the reason is he's obviously the best. If I cancel for this Thursday, I might not get back on the schedule for months. The man is that busy."

"But you only tore your ACL a week ago," Dr. Laurie Montgomery said with equal emotion. "Obviously, I'm not an orthopedic surgeon, but it stands to reason that operating on your knee, which has been so recently traumatized, is taking added risk. For God's sake, your knee is still twice its normal size, and your abrasions haven't completely healed."

"The swelling has come down a lot," Jack said. "Did the doctor suggest you have the surgery this quickly?"

"Not exactly. I told him I want it ASAP, and he turned me over to his scheduling secretary."

"Oh, great!" Laurie said mockingly. "The date was set by a secretary."

"She must know what she's doing," Jack contended. "She's been working with Anderson for decades."

"Now, that's an intelligent assumption!" Laurie said with equal sarcasm.

"Another reason I don't want to cancel is that I was lucky enough to be assigned as Anderson's first case. If I have to have surgery, I want to be scheduled as the first case. The surgeon is fresh, the nurses are fresh, everybody's fresh. I remember when I was doing surgery back when I was practicing ophthalmology, I would have wanted to be my own first case."

"And where is this Angels Orthopedic Hospital?" Laurie questioned irritably. She ignored Jack's attempt at humor. "I've never even heard of it."

"It's north and not too far away from the University Hospital on the Upper East Side. It's relatively new – I don't know exactly when it opened, but less than five years ago. Anderson told me for the patients it's like checking in to the Ritz, which you can hardly say about either University or Manhattan General. He likes it because the doctors run the show, not some bureaucratic administrator. In the same amount of time, they can do twice the number of cases."

"Damn it, Jack!" Laurie complained. She turned away and glanced out the side window of the taxi at the rain-swept New York City streets. To say that Jack could be stubborn was putting it mildly, and when she was irritated, she considered "bullheaded" to be much closer to the truth. When they'd first started working together as forensic pathologists at the Office of the Chief Medical Examiner for the City of New York, she'd thought his wild bike riding to and from work and his brutish outdoor basketball playing with kids half his age were somehow charming. But now, twelve years later and married to the man for less than a year, she considered such risk-taking behavior by a fifty-two-year-old to be juvenile and even irresponsible now that he had a wife and a hoped-for child to consider. If truth be told, she wanted to delay his surgery not only to reduce surgical risk but also because she couldn't help believe the longer he stayed away from commuting on his bike and street basketball, the more chance he'd give it up altogether.

"I want to have my surgery Thursday," Jack said, as if reading her mind. "I need to get back to my normal exercise routine."

"And I want an intact husband. You could be killed carrying on the way you do."

"There's lots of ways to be killed," Jack responded. "As medical examiners, we both know that better than most."

"Put it off for a month," Laurie pleaded.

"I'm having the surgery," Jack said. "It's my knee."

"It's your knee, but we are supposed to be a team now."

"We are a team," Jack agreed. "Let's drop the subject. We can talk about it tonight if you insist."

Jack gave Laurie's hand a squeeze, and she squeezed back. Knowing Jack as well as she did, she took his willingness to suggest that they could bring the subject up again as a small victory.

When the traffic light changed at the corner of 30th Street and First Avenue, the cabbie made a wide left-hand turn and pulled to the curb in front of a dated six-story, blue-glazed brick building with aluminum-mullioned windows wedged between NYU Medical Center on one side and the Bellevue Complex on the other.

They had arrived at the Office of the Chief Medical Examiner, or OCME, where Laurie had worked for sixteen years and Jack twelve. Although Jack was older, forensic pathology had been a second medical career for him after a large HMO had gobbled up his private practice back when HMOs were in their heyday.

"Something's brewing," Jack commented. Ahead of them were several TV news vans parked at the curb. "Interesting deaths attract reporters like honey attracts flies. I wonder what's up."

"I think of reporters more like vultures," Laurie commented as she got out curbside, then reached back into the taxi to extract Jack's lengthy and awkward crutches. "They feed on carrion, are more destructive of evidence, and can be a hell of a nuisance."

Jack paid the driver while he gave Laurie credit for a more apropos and clever simile. Out on the street, he took the crutches, got them poked into his armpits, and started toward the stairs. "I hate taxis," he murmured under his breath. "They make me feel so vulnerable."

"That's a strong statement," Laurie scoffed, "coming from a person who thinks commuting on a bike and challenging the city traffic is appropriate."

As expected, there were a half-dozen reporters in the OCME reception area busily chatting and feasting on takeout coffee and doughnuts. Several TV cameras were perched on the aged magazines on the coffee table. The reporters briefly glanced at Laurie and Jack as they traversed the room. Jack could move quickly on the crutches. Since he could put weight on the injured knee without a lot of pain, he could have done without the crutches, but he didn't want to take any chance of re-injury. Marlene Wilson, the receptionist, buzzed Laurie and Jack into the ID room before any of the reporters recognized them.

Within the ID room were two groups of people occupying separate sides. One group was six Hispanic-appearing individuals of widely mixed ages. They looked enough alike to be members of the same family. Two were children, and were wide-eyed in the spooky alien environment. Three youngish adults were whispering to an elderly matronly-appearing woman who intermittently dabbed a tissue against her eyes.

The second group was a couple who could have been husband and wife and who, like the Hispanic children, appeared like deer caught in headlights.

Laurie and Jack passed through a third door into a separate room that housed the OCME's communal coffeepot. It was here that the medical examiner on call for the week went through the cases that had come in overnight and decided which cases needed to be autopsied and who out of the eleven doctors on staff would do the case. Laurie and Jack almost always arrived early, mostly at Jack's insistence, since Laurie was a night person and more often than not had trouble getting up in the morning. Jack liked to get in early to cherry-pick through the cases, requesting the most interesting. The other doctors didn't mind, because Jack always did more than his share as compensation.

Dr. Riva Mehta, Laurie's office mate, who had started at the OCME the same year as Laurie, was sitting at the ID room desk behind various stacks of large manila envelopes, each representing a different case. She nodded and smiled a greeting at Jack and Laurie. There were two other individuals in the room, both sitting in vinyl club chairs and concealed behind newspapers, with steaming mugs of coffee within arm's reach. Laurie and Jack knew who was behind the Daily News. It had to be Vinnie Amendola, the mortuary tech who had to come in prior to the other techs to help in the transition from the night shift to the day shift. Frequently he worked with Jack because Jack also liked to get a jump on the day down in the pit.

Neither Jack or Laurie knew who was hiding behind The New York Times, but they soon learned, when Jack's crutches clattered to the bare wooden floor as he tried to lean them up against one of the other two club chairs in the room. The noise was sharp, not too dissimilar from the sound of a gunshot. The New York Times dropped and exposed the surprised, tense, and chronically sleep-deprived face of Detective Lieutenant Lou Soldano. By reflex, the detective's right hand shot inside the lapel of his rumpled jacket. With his gravy-stained tie loosened and the top button of his wrinkled shirt unbuttoned, he had a decidedly disheveled appearance.

"Don't shoot!" Jack said, holding up his hand in mock surrender.

"Jesus," Lou complained as he visually relaxed. As was often the case, he sported a heavy five-o'clock shadow. It was apparent he'd not been to bed that night.

"Considering the reporters out in reception, I suppose we shouldn't be surprised to see you," Jack said. "How the hell are you, Lou?"

"As good as can be expected after spending most of the night out in the harbor. It's not something I'd recommend."

Lou had been Laurie's friend initially. Laurie and Lou had even dated after solving a case together, but their brief romance hadn't worked out. When Jack had come on the scene and ended up dating Laurie, Lou had been a strong advocate of their relationship. He'd even been part of their wedding the previous June. They were all good friends.

Laurie went to Lou and briefly touched cheeks before heading to the coffeepot.

Jack sat in a club chair next to Lou's and elevated his bum leg on the corner of the desk. Laurie called out to ask if Jack wanted any coffee. Jack gave her a thumbs-up sign.

"What's up?" Jack asked Lou. Since Lou had become a strong advocate of the contribution medical forensics played in homicide cases, he was a frequent visitor to the morgue, although he hadn't been there for more than a month. From experience, Jack knew that when he did come, there was a high probability it would be an interesting case. The previous day, Jack had had three routine autopsies, two natural deaths and one accidental. There'd been little challenge. Lou's presence augured that things might be different.

"It's been a busy night," Lou said. "There are three homicides I need help with. From my perspective, the most important one is a floater that we hauled out of the Hudson River."

"Do you have an ID on the victim?" Jack asked. Laurie came over and put Jack's coffee mug down. He mouthed a thank-you.

"Nope, not a clue, at least so far."

"Are you sure it was a homicide?"

"Absolutely. He was shot in the back of the head at close range with a small-caliber bullet."

"Sounds straightforward from a medical forensics point of view," Jack said with some disappointment.

"But not from mine," Lou said. "The body is that of a well-dressed Asian man, not some street person. What scares me is that this might be an organized crime-related hit. We know there's been some friction between the established crime syndicates and some up-and-coming Asian, Russian, and Hispanic gangs, particularly in regard to recreational drugs. If some kind of crime war over territory breaks out, a lot of innocent people get killed. I'm hoping you or Laurie could find something, some kind of break so we can nip this in the bud, before all hell breaks loose."

"I'll do my best," Jack said. "What else?"

"The next one's a sad story. A detective sergeant in Special Fraud, and a good guy, has a daughter who has been arrested for killing her good-for-nothing boyfriend with a baseball bat last night. His name is Satan Thomas, if you can believe it. She's been a disaster for the detective since she was a preteen, always hooking up with the dregs for boyfriends and into drugs and you name it. Anyhow, she denies killing the guy and says the boyfriend was using the baseball bat to trash the apartment. She even claims he came after her, which he'd done in the past. By the way, Satan's delightful family is camped out in the waiting room."

"You mean he'd been physically abusive to her."

"Apparently. She claims that when she fled, he was still busting up the place."

"Did it look like he died of blunt trauma?"

"Oh, yeah! I'm afraid it looks like he got bashed in the forehead with the bat."

Jack rolled his eyes. "Sounds bad for your detective friend, and even more so for the daughter." Jack felt depressed. Two out of three autopsies were going to be straightforward. Reluctantly, he asked for the details on the third case.

"This one is similar to the last, but it's the girl who got whacked. She, too, was in an abusive relationship, according to her parents, the Barlows, who are also still in the waiting room. Apparently, Sara Barlow and her boyfriend got into a row over the fact she didn't clean the apartment to his liking. He admits he slapped her around but claims that when he left to calm down, she was fine, just bawling and saying she'd do better. When he gets back, he claimed she was lying across the bed with her face and hands purple."

"Purple blotches or her whole face?"

"One of the patrolmen who responded to the scene insisted the boyfriend said the whole face, but when the patrolman viewed the body, all he saw was what he described as purple bruises."

"What about the hands?"

"He didn't say."

"Did you see the body?"

"I did. I happened to be in the area because of the detective's daughter's case, so I went over."

"And?" Jack questioned.

"Just looked like bruises to me, too. I was convinced he beat her up good."

"What about the hands?"

"I guess they could have been somewhat blue. What are you thinking?"

"I'm thinking this case might be interesting," Jack said, as he reached for his crutches and got to his feet. "How about we do it first."

"I'm more interested in the floater," Lou called after him. "I might not be able to stay awake for all three, so I'd appreciate the floater first."

Jack approached the desk. Riva was still going through the cases, suggesting it was going to be a busy day. Laurie had a couple of envelopes on her lap. She was sitting in the club chair next to Vinnie, who was still behind his paper.

Remembering the reporters in reception, Jack called back to Lou, asking which of the three cases had brought the reporters to the OCME so bright and early. Short of possibly the floater, Jack had a hard time imagining any of the three being particularly newsworthy. In a city the size of New York, sad, violent events were all too common.

"None of the ones I've talked about," Lou called back. "The media is salivating about a death in police custody in the Bronx of a man called Concepcion Lopez. It's going to be one of those excessive-force brouhahas, I'm afraid. What I was told was that the guy went ballistic with an overdose of cocaine."

Jack merely nodded, thankful Lou wasn't encouraging Jack to do it. Police custody cases invariably were political disasters, which Jack found trying. No one was ever satisfied with the report, always claiming a cover-up.

"I'll see you downstairs," Lou said, getting up out of his chair with some effort. "I want to stop in Sergeant Murphy's cubbyhole and see if a missing-person complaint has been filed for John Doe."

"Have you come across Lou's John Doe floater?" Jack asked Riva.

Riva was immediately able to put her finger on the case file, since it was on top of the pile of apparent homicides. She handed it to him.

"How about two blunt-injury cases?" Jack asked. "The names are Thomas and Barlow."

Riva had to hunt for these cases in the stack, which was uncharacteristically high.

"Ugly night in the Big Apple," Jack commented. "You'd think people could solve their differences more amicably."

Riva smiled politely at Jack's weak attempt at humor. It was too early in the morning to respond verbally. She found the folders, and handed them over as well.

"Mind if I do these cases?" Jack asked.

"Not at all," Riva said in her soft, silky voice. She was a petite, gentle Indian American with dark skin and even darker eyes.

"Who is going to do the police custody case?" Jack asked.

"The chief called and said he wanted to do it," Riva said. "Since I was on call, I guess I'll have to be the one to assist him."

"My condolences," Jack said. Although Dr. Harold Bingham had an encyclopedic knowledge of forensics, helping him on a case was always an exercise in frustration control. No matter what you did as the assistant, it was never right, and the case invariably dragged on interminably.

Jack was about to wake Vinnie up from his sports statistics-induced trance when Laurie looked up from her reading. In contrast to Jack, who was content to skim-read the case material prior to the autopsy, she liked to go over it in exquisite detail. Jack felt that too much attention to detail initially prejudiced his ability to keep an open mind, while Laurie felt that not going over the history increased the chances she'd miss something. They'd argued over the issue but had finally agreed to disagree.

"I think you should read this," Laurie said in a serious tone, extending a case toward Jack. "I think you will find it personally disturbing."

"Oh?" Jack questioned. He read the victim's name, David Jeffries, which he did not recognize. His brows knitted in confusion over Laurie's comment and tone as he slid out the contents of the envelope. "What do you mean, 'personally disturbing'?"

"Just read the PA's investigator's note," Laurie suggested. PAs were physician assistants who worked as forensic investigators. It was the OCME's policy that PAs visited the scenes when indicated rather than forensic pathologists. The Chief Medical Examiner, Dr. Harold Bingham, felt strongly that it wasn't an efficient use of the M.D.'s time, despite his recognition that in some cases a site visit was crucial to determine the mechanism and manner of death.

It took only a few sentences for Jack to understand. David Jeffries had died of a fulminant postoperative staphylococcus infection following an anterior cruciate ligament repair, due to a particularly nasty type of staph called methicillin-resistant staphylococcus aureus, or MRSA. Considering the argument he and Laurie were having over Jack's upcoming surgery, it seemed coincidentally relevant, even if it involved another hospital. "I know what is going through your mind," Jack said, "but it ain't going to change my mind. I've already taken into consideration the risk of postoperative infection. Fearmongering is not going to work."

"But this coincidence has to give you pause," Laurie said. She knew it would certainly give her more than pause if the situation were reversed and she was slated to have the surgery.

"Frankly, it doesn't," Jack said. "First, I'm not superstitious, and second, I specifically asked Dr. Anderson what his postsurgical infection rate was. He told me that the only postoperative infections he'd had over his entire career involved compound-fracture repairs, which are a totally different situation. Besides, this case you're showing me involved University Hospital." Jack tried to return the file to Laurie, but she wouldn't take it.

"If you'd read further, you'd see that's not the case."

"What do you mean?" Jack asked. He felt himself getting irritated about the surgery issue all over again. Laurie could be like a dog with a bone, which he found frustrating at times, although he knew people often accused him of having the same trait.

"The patient had had his surgery eleven hours earlier at Angels Orthopedic Hospital, not University Hospital. The reason he ended up at the University Hospital was to treat his septic shock and fulminant staphylococcal pneumonia."

"Really?" Jack's eyes went back to the PA's note. Although he trusted that Laurie would never make such a thing up he had to read it himself.

"This has to worry you," Laurie said. "The fact that they had to transfer a critically ill patient at all doesn't speak very highly for the Angels Orthopedic Hospital. What kind of hospital outsources its dirty laundry? The patient apparently died in the ambulance. That's crazy!"

"New treatments for septic shock require specialized personnel," Jack said. He was distracted by what he was reading. The rapidity with which the patient's infection progressed was shocking. Jack, as the OCME's putative infectious-disease guru, from having made several – what he called lucky – diagnoses on cases of infectious disease ten years ago, couldn't help but be impressed. In fact, he started to wonder if Mr. Jeffries had had a more truly infectious disease like Rocky Mountain spotted fever.

"Was the infectious agent unequivocally proved to be staph aureus?" Jack asked. He tried to remember what other known diseases caused such a rapidly fulminant course.

"Not by culture but by a monoclonal-based automate diagnostic system. Both the incision site and the lungs tested positive for methicillin-resistant staph, and interestingly enough, it was a strain associated with what they call 'community-acquired staph,' not the kind of antibiotic-resistant staph that has been plaguing hospitals over the last ten or fifteen years."

"Which means the patient probably brought the bug in with him rather than acquired it in the hospital."

"Could be," Laurie agreed. "But there's no way to know. Doesn't this bother you at all? I mean, the victim was roughly your age, had suffered the same injury, and was going to have the same operation at the same hospital. It would sure make me think twice. That's all I can say."

"To be honest, a postoperative infection had been one of my concerns," Jack said. "Maybe even the biggest, which is why I asked Dr. Anderson about his record and why I have been using antibacterial soap ever since the accident. I'm going to be damn sure I'll not be bringing any bacterial hitchhikers into the hospital if I can help it."

Jack flicked the back of Vinnie's newspaper hard enough to startle the man.

"Quit it!" Vinnie groused when he'd recovered from his shock and saw who was the culprit. "Please, God, don't let the self-proclaimed super forensic sleuth insist on breaking the rules by starting early," Vinnie added sarcastically and with seeming disrespect. In point of fact, there was enough mutual respect between Vinnie and Jack to allow for such teasing banter, and technically they were breaking the rules. By decree from Chief Bingham, autopsies were supposed to start at seven-thirty sharp, although they never did. Jack was always early, thanks in part to Vinnie's willingness to cut short his coffee break while all the other medical examiners, including Laurie, were always late because Bingham or the deputy chief, Calvin Washington, were rarely there to enforce the edict.

"The supersleuth wants the super mortuary tech down in the pit," Jack said to the back of Vinnie's paper. Defiantly, Vinnie had gone back to his reading.

Laurie asked Riva if she could do David Jeffries's autopsy.

"Of course," Riva said. "But it's going to be a busy day. You'll have to take at least one more. Do you have a preference?"

"Sure," Laurie said absently. She was back to rereading David Jeffries's history.

"Come on, Vinnie," Jack called, leaning on his crutches at the doorway leading into the communications room. Vinnie had become reabsorbed in his paper.

"I'm here!" a voice called out. "The day can now officially begin."

All eyes turned to the door leading out to the main part of the ID room. Even Vinnie, who was passive-aggressively avoiding Jack, lowered his paper to see who had arrived. It was Chet McGovern, Jack's office mate. "Have you guys left anything mildly interesting? Hell, I'd have to camp here overnight to avoid getting your rejects." After ditching his coat on an empty chair, he stepped behind Riva to paw through some of the folders. Jokingly, as if a schoolmarm, Riva hit his hand using a foot-long wooden ruler.

"You're in a good mood, sport," Jack said. "What's the occasion? How come you're here so early?"

"I couldn't sleep. I met a woman last night at my health club who's an impressive businesswoman. I had the feeling she's a CEO or something. I woke up this morning early, trying to figure out how to get her to go out with me."

"Ask her," Laurie suggested.

"Oh, sure, in case I hadn't thought of that."

"And she said no?"

"Sort of," Chet said.

"Well, ask her again," Laurie said. "And be direct. Sometimes you men can be rather vague to protect your fragile egos." Chet saluted, as if Laurie were his superior officer.

"Come on! You lazy good-for-nothing," Jack said after returning to where Vinnie was sitting and snatching his paper out of his hands. Vinnie scrambled after Jack, who managed to keep the newspaper away from Vinnie until they reached the clerical room beyond communication. There was a brief tug-of-war amid laughter.

The battle for the newspaper over, Jack gave Vinnie the John Doe case file and asked him to put up the body, meaning prepare the body for the autopsy. Meanwhile, Jack stuck his head into Sergeant Murphy's closet-like NYPD office. The aging, amiable cop looked up from his computer screen. He'd been assigned to the OCME forever. Jack was fond of the man, as was everyone else. Murphy was one of those rare individuals who managed to get along with everyone. Jack admired the trait and wished some of it could rub off on him. Over the years, he'd become progressively intolerant of perfunctory bureaucrats with mediocre administrative or professional skills, and he was unable to hide his feelings, as much as he tried. In his mind, there were too many such tenured people hiding out in the OCME.

"Have you seen Detective Soldano?" Jack asked.

"He was here earlier but left to go down to the morgue," Sergeant Murphy said.

"Did he ask you about the unidentified floater that came in last night?"

"He did, and I told him the only missing-person report filed overnight was for a woman."

Jack thanked the sergeant and managed to catch up to Vinnie, who'd summoned the back elevator. Downstairs, Jack found Lou in the locker room, already suited up in a Tyvek coverall, which had replaced the far more bulky protective moon suits except for known exceptionally infectious cases.

As Jack quickly changed into scrubs, Lou couldn't help but notice the swelling and discoloration of Jack's injured knee.

"That doesn't look so good," Lou commented. "Are you sure you should be doing these posts?"

"Actually it's gotten better," Jack said. "I just have to baby it until Thursday, when it's scheduled to be repaired. That's what the crutches are for. I could do without them, but using them is a constant reminder."

"You're having it operated on so soon?" Lou questioned. "My ex-brother-in-law had an ACL tear, and he had to wait six months before having it fixed."

"The sooner I have it, the better, as far as I am concerned," Jack said as he climbed into a Tyvek coverall. "The quicker I get back to my bike and, hopefully, my b-ball, the saner I'll be. The competition and the physical exercise keep my demons at bay."

"Now that you remarried, are you still tormented by what happened to your family?"

Jack stopped and stared at Lou as if he couldn't believe Lou had asked such a question. "I'm always going to be tormented. It's just a matter of degree." Jack had lost his wife of ten years and two daughters, aged ten and eleven, to a commuter plane crash fifteen years earlier.

"What does Laurie think of you having surgery so soon?"

Jack's lower jaw slowly dropped open. "What is this?" he questioned with obvious irritation. "Is this some kind of conspiracy? Has Laurie been talking to you about this behind my back?"

"Hey!" Lou voiced, raising his hands as if to fend off an attack. "Calm down! Don't be so paranoid! I'm just asking, trying to be a friend."

Jack went back to finishing his suiting up. "I'm sorry to jump on you. It's just that Laurie has been on my case to postpone my surgery since it was scheduled. I'm a little touchy about it because I want the damn thing fixed."

"Understood," Lou said.

With hoods in place and tiny, battery-powered fans recirculating the air through high-efficiency particulate air, or HEPA, filters, the two men entered the windowless autopsy room, which had not been upgraded for almost fifty years. The eight stainless-steel autopsy tables bore witness to the approximately five hundred thousand bodies that had been painstakingly disassembled to reveal their forensic secrets. Over each table hung an old-fashioned spring-loaded scale and a microphone for dictation. Along one wall were Formica countertops and soapstone sinks for washing out intestines, and along another wall were floor-to-ceiling glass-enclosed instrument cabinets, the contents of which looked like something that should have been in a house of horrors. Next to them were backlit x-ray view boxes. The whole scene was awash in a stark blue-white light coming from banks of ceiling-mounted fluorescent fixtures. The illumination appeared to suck the color out of everything in the room, especially the ghostly pale corpse on the nearest table.

While Vinnie continued the preparations by getting out instruments, specimen bottles, preservatives, labels, syringes, and evidence custody tags, Jack and Lou went to the view box to look at the whole-body X-rays that Vinnie had put up. One was anterior-posterior; the other was lateral.

After checking the accession number, Jack gazed at the films. Then he said, "I think you are right."

"Right about what?" Lou asked.

"It being small-caliber," Jack said. He pointed to a cylindrical, half-centimeter-long translucent defect within the lower part of the skull's image. Composed of metal, bullets totally absorb X-rays, and since X-rays are viewed as negatives, the image appears in the color of the background illumination.

"Twenty-two-caliber would be my guess," Lou said, moving his face close to the film.

"I think you're also right about it being execution-style," Jack said. "From its position in the films, it's undoubtedly lodged in the brain stem, where a professional killer would aim. Let's take a look at the entrance wound."

With Vinnie's help, Jack rolled the corpse on its side. First, Jack took a digital photo. Then, with his gloved hand, he separated the hair covering the point where the bullet entered the victim's head. Since the victim had bobbed around in the Hudson River, most of the blood had been washed away.

"It's a near-contact wound," Jack said. "But certainly not contact, since it's a circular, not a stellate defect." He took another photo.

"How far away?" Lou questioned.

Jack shrugged. "By the looks of the stippling, I'd say somewhere around twelve inches. Noticing the position of the entrance wound in relation to the bullet's position on the X-ray, I'd guess the perpetrator was behind and above the victim, maybe with the victim seated. That's seemingly confirmed by slightly more stippling below the entrance wound than above."

"More weight to it being execution-style."

"I'd have to agree."

Jack took some measurements of the position of the wound, and another photo with a ruler in close proximity. Then, with a scalpel, he dislodged some of the embedded soot from within points of stippling. He put the material in a specimen tube. Finally, he took additional photos before motioning for Vinnie to allow the body to roll back into a supine position.

"What do you make of these deep slices across the thigh?" Lou asked, pointing to two parallel sharp cuts in the anterior aspect of the right thigh.

Jack took a photo before inspecting the wounds and palpating them. "They were certainly made by a sharp object," he said, looking at the clean edges. "There's no skin bridges. I'd guess they are propeller injuries, and I'd be willing to bet they were postmortem. I don't see any extravasated blood within the tissues."

"Do you think the victim could have been run over after being thrown from a boat?"

Jack nodded, but something more subtle caught his attention. Moving down to the ankles, he pointed out some oddly shaped abrasions.

"What is it?" Lou asked.

"I'm not sure," Jack said. He went over to the counter and hefted a dissecting microscope detached from its base. Bracing his elbows on the edge of the table, he studied the subtle abrasions.

"Well?" Lou questioned.

"I'm going out on a limb," Jack admitted, "but it looks as if his legs might have been tied with chains. There's not only abrasions but also suspiciously shaped indentations."

"Occurring after he was dead or before?"

"Whatever it was, it was after he was dead. I don't see any blood in the tissues here, either."

"It could have been he was chained to a weight and supposed to sink and stay sunk. Somebody could have screwed up."

"Could be," Jack said. "I'll take a photo, even though it probably won't show up."

"If this was a screwup, it could be important to keep it quiet," Lou said.

"How come?"

"If it is an organized-crime war, there will be more bodies. I'd want them to all come to the surface."

"Our lips will be sealed," Jack said.

"Hey, can't we move this along?" Vinnie complained. "At this rate, with you two long-winded old farts carrying on, we're going to be here all day."

Jack let his arms go limp at his sides and stared at Vinnie as if shocked. "Are we keeping the super mortuary tech from something more important?" he questioned.

"Yeah, a coffee break."

Jack switched his gaze to Lou and said, "See what I have to put up with around here? The place is going to the dogs." He then reached up, adjusted the overhead microphone, and began dictating the external examination.

LAURIE SLIPPED David Jeffries's file back into its envelope. It included a case worksheet, his partially filled-out death certificate, his inventory of medicolegal case records, two sheets for the autopsy notes, a telephone notice of his death as received by communications, his completed identification sheet, the PA's investigative report, his lab slip for an HIV test, and the slips indicating that the body had been weighed, fingerprinted, photographed, and x-rayed. She had read the material over several times, as she had done with her second assigned case, Juan Rodriguez, but it was Jeffries she was more interested in.

Feeling appropriately prepared, she pushed back from her desk and headed toward the back elevator. Fifteen minutes earlier, she'd called down to the mortuary office and had had the good fortune to get Marvin Fletcher. She was pleased and recognized his voice instantly, as he was her favorite mortuary tech. He was efficient, intelligent, experienced, eager, and always in a good mood. Laurie had an aversion for those techs who were moody, such as Miguel Sanchez, or those who always seemed to be moving at half-speed, such as Sal D'Ambrosio. She also was not fond of the sarcastic, black-humor repartee in which some of the other techs indulged. When she briefly described David Jeffries's case, warning that it involved an infection and asking for the body to be put up for an autopsy, Marvin's response had been simply: "No problem. Give me fifteen minutes, and it's a go."

As Laurie rode down from the fifth floor to the basement morgue level, she thought of what she was going to find on Jeffries. According to the PA's report, the man had had all the symptoms of a toxic shock-like syndrome: high fever, an obvious wound infection at both incision sites, diarrhea with abdominal pain, vomiting, severe prostration, low blood pressure, unresponsive to medication, low urinary output, rapid heart rate, and respiratory distress with some blood-tinged mucus. Laurie shuddered at the thought of how quickly the man had succumbed and how virulent the bacteria had to be. She also couldn't keep herself from worrying about the case being a negative omen, involving, as it did, the exact same surgery Jack was facing, even the same knee. Jack had blithely dismissed the coincidence, but she couldn't. It made her more committed than ever to talk Jack into at least delaying his surgery. She even saw a bright side to David Jeffries's tragedy. Maybe if she found something different or unexpected at the post, it could help her change Jack's mind, which was why she had requested the case. Generally, she tried to avoid cases involving fatal infection. She'd never admitted it to anyone, but they made her uneasy. Yet as she approached the locker room, she acknowledged that she felt more eager and keyed up about doing the case than she had ever felt about doing another.

Laurie changed quickly, first into scrubs and then putting on her disposable protective gear. Although the newer gear was less burdensome and limiting than the old moon suits, she occasionally groused about the equipment like everyone else, but, on this occasion, dealing with a fatal infection, she was pleased to have it. She carefully cleaned off the plastic face mask – even slight smudges bothered her – and turned on the fan before pulling the contraption over her head. Then, prepared, she pushed into the pit.

Stopping just inside the door, she surveyed the scene. Four tables were in use. The nearest supported the corpse of an extremely pale Asian-American male. Three people were grouped around the head, the scalp of which had been reflected forward and the skullcap of which had been removed. The bloody brain glistened in the raw light. Although Laurie couldn't see any faces through the plastic face masks, she guessed it was Jack, Lou, and Vinnie, since they had started first.

The next table also had three people working, and as Laurie viewed them, her face flushed. She'd forgotten that the chief, Dr. Harold Bingham, was expected. He rarely came to the autopsy room, as most of his time was spent in administrative duties or testifying at high-profile trials. It was easy to pick him out, not only because of his almost square silhouette but because of his harsh baritone voice that suddenly reverberated throughout the tiled room. He was giving one of his impromptu lectures about how his current case reminded him of one of his innumerable previous cases. As he was carrying on, a slight figure standing on a stool opposite him, who Laurie surmised was her office mate, Riva, was actually doing the work. For her reward, Bingham intermittently interrupted his monologue to offer negative comments about her technique.

The next two tables had a pair of people working at each. Laurie had no idea who they were. The fifth table contained the corpse of an African-American male. Standing at the head of the table, a figure she assumed was Marvin waved toward her, and over the sound of Bingham's raucous voice, he called out, "We're set to go on table five, Dr. Montgomery!"

Bingham's head snapped around toward Laurie, making her wish she could disappear. The overhead light glinted off his plastic face screen, blocking a view of his face, so she could not anticipate his frame of mind. "Dr. Montgomery, you are a half-hour late!"

"I've been going over my cases for this morning, sir," Laurie said quickly, and as deferentially as possible. She could feel her heart rate bump up. Laurie had struggled with authority figures since childhood. "I also needed to speak with Cheryl Myers to get some missing data." Cheryl Myers was a PA whom Laurie had slipped into the investigator's office to see after leaving the ID room. Although Cheryl had written a generally good note for the construction death, Laurie's second case, Laurie had noticed that the distance from the building the corpse had ended up after the fatal ten-story fall was not included. As Laurie had assumed, Cheryl had obtained the figure but had mistakenly left it out of the report.

"All that is supposed to be done before seven-thirty," Bingham snapped.

"Yes, sir," Laurie said, not interested in arguing. Unlike Jack, Laurie generally followed rules reflexively. However, the one mandating that autopsies start at seven-thirty sharp she generally ignored, since it conflicted with her belief that it was more important to know the case prior to doing the post. In an attempt to preclude any more conversation with Bingham about the issue, Laurie stepped directly up to Jack's table and asked loudly how his case was going.

"Stellarly" Jack quipped, "except the inconvenient fact that the patient died. The only bad side is that it has been dragging on. We'd have made significantly more progress if there was any decent help around here."

"Screw you!" Vinnie said. "If you two old windbags hadn't carried on like you've been doing, we could be up having coffee by now."

"Gentlemen," Bingham's voice called out. "I'll have no disrespect, nor profanity, in the autopsy room."

Lest she incite any further comments from Jack and subsequent retorts from Bingham, Laurie quickly headed toward Marvin and her own case. As she passed Bingham's table, she cringed for fear of being called over, but luckily Bingham had been distracted by what he called a "catastrophic mistake" on Riva's part as she dissected the neck.

"Are you going to need anything special?" Marvin asked as Laurie came up abreast of the fifth table. As prepared as Laurie was, she generally knew in advance when special needs were required for a case.

"A good supply of culture tubes," Laurie said as she surveyed David Jeffries's corpse. For fifty-one years of age, the man appeared to have been in good physical condition. There was no excess fat. In fact, his muscles, particularly the pectorals and quadriceps, had the definition of a much younger man.

Laurie grimaced behind her plastic face screen. Besides the obvious infection at the surgical sites on either side of the right knee, there was a sprinkling of small pustules all over his body, which given the time would have turned into abscesses or boils. Even more striking were areas of desquamation, particularly on his pelvis, with the skin sloughing in relatively large sheets.

"Are you looking at his hands?" Marvin asked.

Laurie nodded.

"What caused his skin to peel off like that?"

"Staph makes a lot of toxins. One of them causes skin cells to separate from their neighbors."

"Ugh," Marvin said.

Laurie nodded again. She'd seen staph infection before, but this was the worst.

"Anyway, to answer your question about culture tubes," Marvin said, "I got plenty."

"Did you get a good supply of syringes as well?"

"Yup."

"All right, let's do it," Laurie said, as she pulled down the suspended microphone.

"Want to check out the X-ray? I put it up just in case."

Laurie stepped over to the view box and gazed at the film. Marvin followed and looked over her shoulder.

"Our X-rays are mainly for foreign bodies and fractures," Laurie said. "Even so, you can certainly appreciate the pneumonia and how diffuse it is. It looks like the lungs are filled with fluid."

"Hmmm," Marvin said. X-rays were a mystery to him. He couldn't understand how doctors could see what they did in the foggy image.

Laurie went back to the body and completed the external examination. After making sure the endotracheal tube was where it was supposed to be in the trachea, she pulled it out. It had been placed by the doctors to ventilate him when he had begun to have trouble breathing. She cultured the bloody mucus adhered to it. Turning to the multiple IV lines, she made sure they were also properly placed and, after doing so, pulled them out and cultured them as well. Medical examiners insisted such tubes be left in place to be sure that they played no role in the patient's death. She also cultured the pus issuing from the surgical site.

Once the external exam had been finished and dictated, Laurie began the internal with the standard Y-shaped incision starting at both shoulders, meeting at the midline, and then extending down to the pubis. She worked quietly, shunning the usual banter she normally exchanged with Marvin, who was an eager learner.

For a time, Marvin stayed quiet as well, correctly sensing Laurie's awe at the virulence of the microbe that had played such havoc throughout David Jeffries's body. It wasn't until Laurie lifted out the heart and lungs and put them in the pan he was holding that he broke the silence. "Shit, man," he commented. "This baby weighs a ton."

"I noticed," Laurie said. "I think we'll find both lungs full of fluid." After she removed the lungs and weighed each separately, she made multiple slices into them. Like fully soaked sponges, a mixture of edema fluid, blood, necrotic tissue, and pus emerged.

"Ye gods!" Marvin said. "That's ugly."

"Have you heard of the term flesh-eating bacteria?"

"Yeah, but I thought people only got that in their muscles."

"This is a similar process, but in the lungs and much more lethal. Its official name is necrotizing pneumonia. You can even see beginning abscesses." Laurie pointed to minute cavities with the tip of the knife.

"You guys look like you are having way too much fun," Jack said, after silently coming up along Laurie's right side.

Laurie let out a short, sarcastic laugh that was enough to briefly fog her face screen. She gave a quick glance at Jack before holding up the exposed cut surface of the lung for him to see. "If you call seeing the worst case of necrotizing pneumonia fun, then Marvin and I are having a blast."

Jack used his gloved index finger to assess the turgidity of the lung section. "Pretty bad, I'd have to admit. Shows you what can happen if you smoke too many Cuban cigars."

"Jack," Laurie said, ignoring his attempt at humor, "why don't you stay with us for a few minutes? I think you should see the full extent of this postoperative infection. This poor individual was being literally and rapidly digested from the inside out. This might be the worst or best advertisement for not having elective surgery I've ever seen."

"Thanks for the invite, but I've got two more cases to do before Lou conks out," Jack said. "Besides, I know how your mind works, especially with your not-so-subtle reminder the victim had surgery, meaning I know you have an ulterior motive for your kind invitation vis-a-vis my Thursday plans. So I'll let you two have all the fun." With a little wave, he started to leave.

"What about your first case?" Laurie asked, mindful of Lou's interest. "What did you find?"

"Not a whole bunch. We recovered the twenty-two-caliber slug, for whatever that's worth. Lou says it's a Remington high-velocity hollow-point, but he could just be trying to impress me. The thing's a bit mangled from penetrating the guy's skull. There were also some abrasions and indentations on his legs, suggesting he'd been chained, perhaps attached to a weight. I think he was supposed to sink, which suggests he was thrown overboard out of a boat, not dumped into the water on shore. Lou thinks that's important. Otherwise, the guy was healthy except for a slight cirrhosis of the liver."

After Jack limped off, Marvin asked what Jack had meant about her having an ulterior motive.

"We're having a disagreement about when he gets his knee repaired," Laurie said without elaborating. "Now, let's get back to work."

"What have you got?" Arnold Besserman asked. Working at the next table, he'd overheard Laurie and Jack's conversation. Arnold had been at the OCME longer than any of the other medical examiners. Although Jack dismissed him as long in the tooth, outdated, and haphazard, Laurie was friendly with him, as she was with most everyone else.

"Do you mind me interrupting?"

"Certainly not," Laurie said sincerely. His stepping over to her table was what made working in the communal autopsy room enjoyable and stimulating for her.

"Quite an amazing case," Laurie said. "Take a peek at this lung. I've never seen such dramatic nosocomial necrotizing pneumonia, and it apparently developed over less than twelve hours."

"Impressive," Arnold agreed as he looked at the cut surface of David Jeffries's lung. "Let me guess: It's a staph infection. Am I right?"

"You hit it on the nose." Laurie was impressed. "I've had three similar nosocomial cases over as many months, with the last one about two weeks ago," Arnold said. "Maybe not quite as bad, at least not all of them, but bad enough. Mine were from a methicillin-resistant strain coming from outside the hospital but which apparently had hybridized with bacteria coming from within the hospital."

"That's exactly what my case apparently is," Laurie said, even more impressed.

"The strain is called community-acquired MRSA, or CA-MRSA, to distinguish it from the usual nosocomial, hospital-acquired MRSA, or HA-MRSA."

"I remember reading about it," Laurie said. "Someone had a case five or six months ago, of a football player who picked it up in the locker room and had an infection that ate away a lot of his thigh."

"That was Kevin's case," Arnold said. Kevin Southgate was another senior ME who'd joined the OCME only a year after Arnold had. As the old guard, Arnold and Kevin stuck together like a team, although opposites in their politics. Both were infamous around the office for constantly conspiring to take as few cases as possible. It was like they were working half-time full-time.

"I remember when he presented the case at Thursday conference," Laurie said. Other than the informal but effective give-and-take in the autopsy room, the formal Thursday conference with its required attendance was the only other opportunity for all of the city's nineteen MEs to share their experiences. Laurie, for one, lamented this situation because it hampered the OCME's ability to recognize trends. She had complained about it, but without coming up with a solution, the issue had died. With the OCME doing more than ten thousand cases a year, there wasn't time for more interaction, and there were no funds to hire more forensic pathologists than the one they had hired that year.

"The CA-MRSA bug is scary, as this case of yours aptly demonstrates," Arnold said. "It's been a mini-epidemic outside the hospital, like Kevin's football player and even, tragically enough, some young, healthy children getting scrapes on the playground. Now it seems to be going back into the hospital. That's the bad side. The good side is that it is sensitive to more antibiotics, but the antibiotics have to be started immediately because, believe it or not, being more sensitive to antibiotics has given the strain added virulence. Not making the complete line of defensive molecules for antibiotics like the HA-MRSA strains, these community-acquired strains are able to spend more time and effort making a soup of powerful toxins to enhance their virulence. One of them is called PVL, which I'm sure has played a role in your case here. PVL toxin chews up the patient's cellular defenses, particularly in the lungs, and initiates an overwhelming and perverse release of cytokines, which normally help the body fight infection. Do you realize that as much as one-half of the destruction you are seeing in the lung sections you are holding comes from the victim's own completely overstimulated immune system?"

"You mean like the cytokine storm they are seeing with people dying from H5N1 bird flu?" Laurie asked. The thought went through her mind that she would have to suggest to Jack that he might need to adjust the opinion he had of Besserman. He was embarrassing her by how much more he knew about MRSA than she.

"Exactly," Arnold said.

"I'm afraid I'm going to have to do some serious reading about all this," Laurie admitted. "Thanks for all the information. How is it that you are such an expert?"

Arnold laughed. "You're giving me too much credit. But a month or so ago, Kevin and I got interested in the issue because of several cases we each had. We kinda challenged each other to learn about it. It's a good example of the genetic versatility of bacteria and how quickly they can evolve."

Laurie struggled to rein in her mind, which was bouncing from one topic to another. She looked down at the turgid, nearly solid slice of lung she was holding. She knew pathological bacteria were making a comeback, but what she was facing in terms of pathogenicity seemed beyond the pale.

"So the cases you mentioned earlier were necrotizing pneumonia?" she asked. "Just like this case appears to be."

"That would be my guess, but I'd be even more certain if I looked at the microscope section of your case. I'd be glad to take a peek."

Laurie nodded. "And Kevin's cases were the same as yours?"

"Very much so."

"Were his nosocomial also?"

"Of course. They were nosocomial but also involved the community-acquired strain, the same as mine."

"Why didn't you bring this up at Thursday conference?"

"Well, frankly, it was not that many cases, and everyone is aware of the burgeoning problem of staph, particularly antibiotic-resistant staph."

"Were the involved hospitals fairly evenly distributed around the city?"

"No, they were all here in midtown Manhattan. I mean, there could have been cases in Queens or Brooklyn, since they would be sent to their respective borough morgues."

"What hospitals here in Manhattan?"

"I can't remember the exact breakdown from individual institutions, but all six came from three specialty hospitals: Angels Heart Hospital, Angels Cosmetic Surgery and Eye Hospital, and Angels Orthopedic Hospital."

Laurie stiffened. It was as if Arnold had slapped her. "None from Manhattan General or University or any of the other big city hospitals?"

"Nope. Does that surprise you?"

"Yes and no," Laurie said, taken aback by such a coincidence. There were a lot of hospitals in New York City. It begged the question: Why just three?

"Did you contact the hospitals, or look into the situation at all? I mean, why just those three hospitals?"

"Kevin and I thought it coincidental, so yes, we looked into it to a degree. I also asked for Cheryl Myers's help as well. I called the Angels Orthopedic Hospital and spoke to a very nice woman whose name escapes me at the moment. I'd gotten the name from the hospital administrator. The individual I spoke with chaired the interdepartmental infection-control committee."

"Was she helpful?"

"Absolutely. She said the hospital was well aware of the problem and had hired an infection-control professional, or at least the company that owned the hospital did. So I called this individual whose name I can't forget was Dr. Cynthia Sarpoulus."

"Was she helpful?"

"Well, I suppose, at least to an extent."

"What do you mean?"

"She wasn't terribly cooperative, although I suppose she was stressed and defensive under the circumstances. My assumption was that her employer, Angels Healthcare, which is the name of the company, had put the burden on her. Anyway, she essentially told me to butt out, and that the situation was well under control, thank you very much. You know the attitude, I'm sure. To her credit, it sounded to me that she was on top of the problem. Against management's objections, according to her, she had insisted all the ORs in all three hospitals be closed, which also according to her had everybody on her back. She then had all the ORs fumigated by an alcohol-based agent, which is what is recommended. She'd also instigated a rigorous hand-washing regimen. On top of that, she'd had the entire staff tested as potential carriers, and those who tested positive treated. I have to say I was impressed. They surely weren't sitting around, wringing their hands."

"Thanks for the information. Sorry to take so much of your time," Laurie said.

"My pleasure," Arnold said.

"Would you mind if I came up to your office later and got the names of the cases you've mentioned?"

"Not at all! I might still have a couple of the case files. You can also borrow the notes I made about CA-MRSA if you'd like. And you can talk with Kevin. Back when we were working on this, I think he also called over to one of the involved hospitals, but I don't remember if he told me what he learned."

After Arnold had stepped back to his table, Laurie looked over at Marvin, who had patiently waited through the whole conversation. "That was incredible," she said.

"What, that he's sweet on you?"

"No, silly! What he said. He's not sweet on me!"

"That's not the chatter around the morgue. It's generally accepted both Southgate and Besserman would throw themselves in front of a subway train for you."

"Nonsense," Laurie said, although hearing she was even remotely the source of gossip made her uneasy. She never liked being the center of attention, which was why she had such trouble talking in front of a group.

By the time Laurie had finished with Jeffries, she'd found far more pathology than she had expected. Every organ was grossly involved with obvious destructive infection or at least inflammatory swelling. Within the heart, she found beginning infectious vegetations on the valves. In the liver, there were incipient abscesses, as well as in the brain and kidneys, suggesting the victim had had a massive bacteremia. There were even ulcers in the gut, attesting to the ease with which the bacteria spread.

"How long to the next case?" Laurie asked, as she and Marvin finished suturing the giant autopsy incision encompassing both David Jeffries's chest and abdomen.

"As little time or as much time as you'd like," Marvin said. "If you want a coffee break, I'll stretch it out."

"Actually, if you don't mind, I'll call you when I want to do it. Among other things, I want to see if Cheryl Myers is here and catch her before she goes out on a case."

"Then I'll take my time," Marvin said. "Give me a call when you want to start."

"Make sure you leave a note for whoever releases Jeffries's body to inform the funeral home that a serious infection is involved and precautions should be taken."

On her way out of the autopsy room, Laurie briefly stopped at Jack's table.

"Ah! The doomsayer!" Jacked quipped at recognizing her. "Forsooth, Vinnie! Take heed! She's surely here to terrify us with the grisly horrors of her nosocomial surgical-site infection case."

Despite Vinnie's reflective face mask, she could see him roll his eyes. She felt similarly. On occasion his creative but oft irreverent black humor was not amusing. After being married to him for almost a year, she now saw such behavior as defensive and a way to avoid what he was really thinking.

"I do have to talk with you about my case," Laurie admitted. "There are some additional facts you should know."

"How could I have guessed?" Jack questioned mockingly.

"But it can wait until you are more receptive."

"Praise be to the Lord."

"Where's Lou?"

"He literally fell into a deep sleep leaning against the autopsy table between cases. I thought it best he head home, lest one of the mortuary techs mistake him for a corpse."

"Which case are you doing now?" Laurie asked, to change the subject.

"Sara Barlow, and it's a hell of a lot more interesting than the John Doe floater."

"How so?"

"See the obvious bruises on the face and the upper arms. Obviously, she'd been beat up a lot over time, but do you think any of them could have been fatal, as the police assumed?"

"Probably not, but were there any on the anterior chest?" Laurie asked. She couldn't see because the chest walls were butterflied open. From a case she had when she'd first started at the OCME, she knew that blunt injuries that one would not expect to be lethal could be if they occurred on the chest. "Any reason to suspect commotio cordis?"

"Nope! Chest was clean. What if I tell you there was extensive pinkish pulmonary edema, injected eyes, and sloughing of the tracheal epithelium."

"What's your presumptive diagnosis?" Laurie asked with a sigh.

Sometimes she found Jack's forensic guessing games tedious, and this was one of them.

"What if I told you our clever PA, Janice Jaeger, found a mixture of rather strong, open cleaning products in a glass-enclosed shower stall with a bucket of water and a damp cloth? Earlier, when she had viewed the body, she noticed the knees of the woman's jeans were wet, and the victim was not wearing any socks or shoes."

"I'd have to know if the cleaning products contained hypochlorite, which many do, and if others contained acid, which a lot do, and if she had ignored the warning not to mix them, and did."

"Bingo!" Jack said. "Chlorine gas, the first chemical-warfare agent used in World War One, did her in, not her boyfriend. It's amazing to me how many people blithely ignore product warnings. Anyway, Lou will be pleased it is not another homicide he has to worry about."

"Not unless the boyfriend was the one who insisted she use the deadly products, and use them together."

"Now that's a twist I hadn't even thought of," Jack admitted.

"Well, you boys enjoy yourselves," Laurie said, as she headed toward the exit. She felt no pleasure at having guessed the right answer to Jack's quiz. She would have been much happier if he were not in such a distractingly playful mood, whether real or feigned. It amazed and irritated her that he didn't see or was purposely ignoring the corollary between her case and his proposed surgery.

Instead of leaving Jeffries's specimens for the staff to bring up to the appropriate labs, as was the normal routine, Laurie took them herself. She wanted to talk to both the head of microbiology, Agnes Finn, and the head of histology, Maureen O'Connor, to try to move things along. But first she stopped on the first floor and went into the PA's office. Knowing they were often out in the field, Laurie was pleased to find Cheryl Myers still at her desk.

"Can I help you with something else?" Cheryl questioned. She was a striking African-American woman who wore her hair in tight, bead-encrusted cornrows. She was part of the old school at the OCME. In fact, she'd been working there long enough to put her two boys through college.

"I hope so," Laurie said. "Earlier, I was speaking with Dr. Besserman about some infection cases at three hospitals run by a company called Angels Healthcare. He said he asked you to look into it. Do you recall?"

"Are you talking about the MRSA pulmonary cases?"

"Those are the ones! Did you make a site visit?"

"No! What he asked me specifically was to obtain hospital records, so I merely called and spoke to the medical records department in each hospital. It was easy to get the charts, because Angels hospitals have their medical records computerized. The material was e-mailed over. I didn't need to make a visit."

"Were the hospitals cooperative?"

"Very cooperative. I even got an unsolicited call back from a very helpful woman by the name of Loraine Newman."

"Who is she?"

"She is the chairperson of the orthopedic hospital's infection-control committee."

"Dr. Besserman mentioned her," Laurie said. "He commented on how genial she was as well. Why did she call back?"

"Just to leave her name and direct-dial number in case I needed anything else. She said she was very concerned about the problem. She told me that prior to the MRSA outbreak, they'd had no nosocomial problems to speak of. She said the situation was keeping her awake at night. To tell you the truth, she sounded a little desperate."

"Did she mention a Cynthia Sarpoulus?"

"Not that I can recall. Who is she?"

"I've just posted another case of MRSA that came in from Angels Orthopedic Hospital," Laurie said, ignoring Cheryl's question. "I'd like Loraine Newman's phone number."

"Not a problem," Cheryl said. With a few clicks of her computer mouse, she had it on her screen.

"I need some other numbers," Laurie said. "The CDC in Atlanta has an MRSA program as part of its National Healthcare Safety Network. I'd like you to get me a name and phone number of one of its epidemiologists. I'd also like you to call the Joint Commission for Accreditation of Healthcare Organizations and get me a name and number for someone in surveillance of mandated hospital infectious-control programs."

"I'll do my best," Cheryl said.

"The name of my case is David Jeffries," Laurie continued. "I'd like his hospital record."

"That will be easy," Cheryl said. "But I'm not sure I understand who it is you want to talk to at the joint commission. Could you give me a better idea?"

"The joint commission requires hospitals to have infection-control committees for accreditation. What I want to find out is whether there is any policing of these committees and whether any reporting of outbreaks is required between formal inspections. I know this is a bit unusual," Laurie said, "but I'm pressed for time."

"I'm happy to help," Cheryl said good-naturedly.

Laurie left the forensic investigator's office and went to the stairs, avoiding the back elevator. She'd started the day with a selfish desire to talk Jack out of his imminent surgery. Now she was worried about his well-being, maybe even his life. Among herself, Besserman, and Southgate, there were seven cases of fatal MRSA necrotizing pneumonia within three months at three hospitals, one of which Jack was scheduled to enter, and all run by the same company. And worse yet, these cases were occurring despite what Besserman had described as aggressive infection-control measures. Although Laurie was the first to admit that she didn't know too much about epidemiology, she knew enough to wonder if there might be a lethal, unknowing MRSA carrier, like a kind of Typhoid Mary in the Angels Healthcare organization who was inadvertently spreading MRSA as he or she went from hospital to hospital in the course of his or her job. Laurie wanted a lot of information, and as stubborn as Jack was, she wanted it fast if she hoped to influence his mind-set.

The next stop was microbiology, which was part of the laboratory complex on the fourth floor. Laurie found the taciturn, sinewy microbiologist Agnes Finn in her small, windowless office. Of all the employees of the OCME, Agnes's appearance was the most stereotypic for working in a morgue from central casting's point of view. Her grayish-yellow coloring contributed; it was as if she never saw the light of day. Yet, of all the supervisors, Laurie found Agnes to be the most helpful by far, always willing to go out of her way. It was as if she had no life outside the OCME.

Laurie sat down and explained the situation, which elicited from Agnes a mini-lecture on MRSA, including everything Besserman had to say and then some. She explained in detail how staphylococcus was such a pluripotent microbe, and perhaps the most adaptive and successful human pathogen.

"When you think about it from the bacteria's point of view," Agnes said, "it is truly a superbug, capable of killing someone in a frightfully short time while the same strain is able to merely colonize an individual, usually just within the nares. This is a convenient location for the bacteria, because every time the carrier puts his or her finger in their nose, their fingers are contaminated from where it can be spread to the next person."

"Is there an estimate as to how many people are so colonized?"

"Absolutely. At any given time, a third of the world's population carries staph; that's about two billion people."

"Good Lord," Laurie said. "Are there many strains of MRSA besides the hospital-acquired and the community-acquired?"

"Very many," Agnes said. "And they are evolving all the time in people's noses and elsewhere, like moist skin surfaces, where they exchange genetic material."

"How are the strains differentiated in the laboratory?"

"Many ways," Agnes said. "Antibiotic resistance is one."

"But that's not particularly sensitive, considering everything you've said."

"That's correct. The more sensitive methods are all genetics-based: the simplest and most commonly employed being pulse-field gel electrophoresis, and the most complete being full genotyping. In between, there are a number of other sequence typing techniques all based on PCR."

"What can you do here in microbiology?"

"Only the simplest: antibiotic resistance."

"If needed, where can the more complicated be done?"

"The state reference lab can do the pulse-field gel electrophoresis. As for more specific typing, the CDC is the best bet. They are actually building a national library of MRSA strains, so they can give you a lot of information. They encourage submissions of isolates, and they can do it all. Of course Dr. Lynch in our DNA lab over in the new high-rise can do the various genetic typing, but we won't be able to tell you much about the specific strain."

"Which of the genetic tests is the fastest? I'm up against a time constraint."

"Truthfully, I don't know. What I do know is that our standard culture and antibiotic sensitives take twenty-four to forty-eight hours. Hospitals can do it much faster using monoclonal antibody-based methods. Interesting enough, such machines came out of work for NASA."

Laurie shook her head. She was humbled. "Before today I thought I knew a reasonable amount about staph. But I was sorely mistaken."

"We all have to keep learning," Agnes said philosophically. "What do you want to do about these specimens you've brought in?"

"I'll take one over to Ted Lynch in the DNA lab. I'd like one for you to culture, and the rest can go to the reference lab. I'm also going to want to get some frozen samples from some of Dr. Besserman's and Dr. Southgate's cases to compare. I'd like to know if they are from the same strain. I'm concerned about an unsuspecting carrier, particularly after what you've told me."

"Let me know the cases you are interested in. I'll try to expedite the process. As for Ted Lynch, you'll have to leave it to me to provide him with a pure culture for his DNA analysis."

With her head in whirl, Laurie hurried out of the lab and headed toward the faster front elevator. As she hit the up button repeatedly, in vain hope of speeding up the elevator's arrival, she tried to plot the course of the rest of her morning. The first stop was going to be Maureen O'Connor in the histology lab, where Laurie intended to beg for David Jeffries's lung sections to be processed into slides as quickly as possible; Laurie didn't care about the rest of the slides at the moment, just the lung, since she had in mind to make some large photomicrographs if the pathology appeared as bad as she fully expected it would. She thought they would make terrific PowerPoints for the argument she intended to wage against Jack to get him to cancel his ACL repair.

Laurie boarded the elevator and pushed the button for the fifth floor. She looked at her watch. It was close to ten. Exiting, she literally ran down the hall into histology and arrived mildly out of breath.

"Uh-oh! Ladies," Maureen scoffed in her heavy brogue, "I seem to sense another acute emergency from Miss Montgomery. Errr… that's Mrs. Montgomery-Stapleton. Who'll volunteer to tell her this time, her patient is already dead?"

There was general laughter from the women who worked in histology. Thanks to Maureen's good humor, it was a happy environment. Even Laurie found herself smiling despite her anxiousness. Like most humor, there was truth in Maureen's comment. Laurie and Jack were the only pathologists on the ME staff who, on occasion, felt they needed a rapid turnover with their microscope slides. All the others were content to have them in due course.

Maureen listened to Laurie's request and explanation, and promised to do them herself. Within minutes, Laurie was back in the hall. She hurried down to Arnold Besserman and Kevin Southgate's office. As she knocked, the door swung open on its own, and Laurie leaned inside.

The interior of the office reminded Laurie of the two men's polar political leanings. As the archconservative, Arnold had a desk that was the picture of neatness, with a single cardboard tray of slides on one side of his microscope and a new yellow legal pad on the other. Both were aligned perfectly parallel to each other along with a precisely sharpened pencil. Southgate's side of the room was the opposite, with slide trays, unfinished case files, lab reports, and all manner of other documents piled on both his desk and file cabinet, leaving only a small arc of cleared horizontal space directly in front of his chair. A vast clutter of Post-it notes hung from the shade of his desk lamp like so much Spanish moss. It was a wonder to Laurie how the two men got along so well and for so long.

After leaving a note on the door for either man to call her, Laurie went down the hall, knocking at the other medical examiners' doors to do a quick survey of their recent MRSA experience. No one was in his office, which was entirely understandable, since the morning was the busy time in the pit, although she'd not seen George Fontworth, Paul Plodget, or his newly hired office mate, Edward Gonzales. Edward was a gifted forensic pathologist who was a product of OCME's own program and New York University.

Momentarily thwarted in scaring up more MRSA cases at the OCME, Laurie retreated to her own office. Suddenly, remembering Arnold Besserman's comment about Queens, Brooklyn, and Staten Island, all of which had their own ME offices, she realized her conclusion that there had been no fatal MRSA cases in any of the other city hospitals during the last three months or so was premature.

With her Rolodex open, Laurie first called Dick Katzenburg, the chief of the Queens office. He'd helped Laurie in the past by coming up with cases that matched the two series of cases she had become deeply involved with. As the call went through, Laurie recalled that both those previous series of hers had surprisingly turned out to be homicides, which no one suspected, even she. The remembrance briefly stimulated the thought that the manner of death of her current series might not be accidental, especially considering that a third of the world's population was colonized with staph organisms at any given time.

The Queens ME office answered, and Laurie asked for Dick. While she waited, she tapped her fingers nervously. She hoped he'd be available, which she thought was a reasonable expectation. In his role as chief of the satellite office, administrative duties often kept him at his desk and out of the autopsy room. As the time dragged on, she got out a fresh legal pad, and with the phone in the crook of her neck, she drew multiple vertical parallel lines, creating a checkerboard matrix in which she planned to add information about the MRSA cases as she learned it. With her two previous series, it had been the matrixes that had given her the insight she'd needed. Hoping for a similar outcome, she wrote David Jeffries on the top row, to the left of the indent line.

Dick came on the line apologetic for keeping her waiting. After a bit of social chatter, Laurie asked if they had seen in the Queens office any MRSA nosocomial infections over the last three or even four months.

"We have indeed!" Dick said without hesitation. "They weren't my cases; they were Thomas Asher's. I remember them because they were fairly ugly."

"Meaning?"

"Necrotizing pneumonia. The victims, who were all healthy people, didn't have a chance. Their histories reminded me of the stories of the influenza epidemic in 1918."

On the spur of the moment, Laurie felt a pang of selfish disappointment. The fact that other hospitals in the city were experiencing the same problem as the Angels Healthcare institutions would undoubtedly dilute the cases' impact on Jack.

"Do you know if they occurred at one hospital or at a number of hospitals?" Laurie inquired.

"Just one. It was an orthopedic hospital. Why do you ask?"

Laurie sat up straighter in her chair. "What was the name of the hospital?"

"Angels something. I think Angels Orthopedic Hospital. They were all orthopedic cases."

A slight crooked smile turned up the corners of Laurie's mouth. Instead of losing strength, the potential success of her argument with Jack notched upward.

"There have been some cases here as well," Laurie said, "including one I autopsied today. I'm going to look into it, even though I was told the hospital has been aggressively proactive in dealing with the problem."

"Let me know if I can help."

"Can you give me the names?"

Laurie could hear the familiar sound of Dick's keyboard. A minute later, he said, "Philip Moore, Jonathan Knox, and Eileen Dimalanta."

Laurie quickly added them to her matrix. "Have all three been signed out?"

"Yup, so you can access them in the database."

"I'd still like to see the case files; hospital records, if you have them; and also a tissue sample, so I can have the strain accurately typed, if it hasn't already been done."

"I'll bring what I have over for Thursday conference."

"I'd prefer you messenger them over today. I'm under a time constraint."

"How so?"

"A personal commitment," Laurie said, not wishing to elaborate.

Next, Laurie called Jim Bennett in Brooklyn and Margaret Hauptman in Staten Island. Although Margaret had had no MRSA cases, Jim had had three, like Dick. Two were necrotizing pneumonias like the others and were from the same hospital, but another one was fatal MRSA toxic shock syndrome secondary to a fulminant endophthalmitis, a massive infection inside the victim's right eye, which had quickly followed a routine cataract extraction. Hanging up the phone, Laurie added Carlos Suarez, Matt Collord, and Kayla Westover to her rapidly growing matrix. Laurie was now convinced that something was wrong – something was very wrong.