Genesis

Chapter 37

May 11th

12:40 P.M.

This is big-time weird,” Vinnie said. He and Jack had paused just after they finished removing the clothes from Aria Nichols’s corpse, which was lying on table #1 in the autopsy room. Since there was only one other case going on at that moment all the way down on table #8, they felt like they were by themselves, facing the unique situation of autopsying the body of a person they had interacted with on a personal level just the day before. “I’ve always wondered what it would be like to autopsy someone I knew, and now I know I don’t like it.”

“Me, neither,” Jack said. “It’s a jolting reminder of the fragility of life. And it’s not just emotionally disturbing. From a professional point of view, it’s going to make it more difficult to maintain the objectivity that is required. It also makes me embarrassed that I’d found her unpleasant to deal with. Now that she’s dead, it seems so petty.”

“Unpleasant wouldn’t be the way I’d choose to describe her,” Vinnie said. “I think ‘snotty entitled bitch’ would be much closer to the truth.”

“Tone it down, big guy!” Jack said. Both Jack and Vinnie heard the door to the hallway burst open, and both turned to see someone coming in their direction. It was Chet McGovern. He’d pulled on a surgical gown over his street clothes and was holding a surgical mask against his face. He walked right up to the table and looked down on the naked corpse.

“Nice body,” he said. “What a waste.”

“Oh, please,” Jack complained at the utter inappropriateness of such a comment. “Let’s show a modicum of respect for the dead, particularly a colleague!”

“Hey, loosen up,” Chet said. “I was only trying to lighten the mood with a bit of black humor.”

“I hope that was the case,” Jack said. “But with a man of your off-hours reputation, who’s to know?”

“Okay, maybe I crossed the line,” Chet said. “I suppose under the circumstances it was out of place and out of line.”

“You got that right,” Jack said.

“Are you guys okay to do this case?” Chet said. “Having just worked with her yesterday, maybe you want me to find someone else to do the autopsy who hasn’t had anything to do with her.”

“We’ve got it under control,” Jack said. “To be honest, Laurie specifically asked me to take care of it, and I said I would. But thanks for asking.”

Once again, the door to the hall banged open, and all three men turned to see who it was. This time it was Marvin Fletcher, one of the mortuary techs, and he, too, came directly to table #1 and looked down at the corpse. “Holy shit, it is her! I heard about this and couldn’t believe it. I had to come and check if it was just a rumor.”

“It’s certainly not rumor,” Jack said.

“Obviously,” Marvin said. “It’s a shame, I guess, but I can’t say I was charmed by her. I also heard that she still had the needle embedded in her arm, just like the case I did with Dr. Montgomery and her just a few days ago.”

“That’s right,” Jack said. “We just removed the syringe, and as expected it tested positive for fentanyl. I assume you are talking about the Kera Jacobsen case?”

“That’s the one,” Marvin said. “We thought it meant she died really fast, probably with a big overdose of fentanyl.”

“That could be the case here, too,” Jack said. “Who knows, maybe they got the drug from the same source since they both worked at the NYU Med Center, and it contained more fentanyl than usual. Part of the overdose problem is that the concentration of fentanyl can vary, and as potent as it is, it doesn’t have to vary too much to be lethal.”

“We wondered the same thing,” Marvin said. Then he added, “Hey, do you mind if I stay and add my two cents?”

“That’s up to Vinnie,” Jack said. Personally he didn’t care if Marvin stayed, but he knew there were some competitive feelings among the mortuary techs, and he didn’t want to be party to it. He knew that Vinnie, as the senior tech, was sensitively possessive about his exclusive relationship with Jack, by far the busiest ME.

“Fine by me,” Vinnie said.

“All right, I’m out of here,” Chet said. “I’ll be interested to hear if you find anything unexpected.”

Ignoring Chet, Jack said to Vinnie and Marvin, “Okay, you guys, let’s knock this one out.”

For a few minutes, Chet stood and watched the sudden burst of activity, but feeling cold-shouldered and a twinge embarrassed at his attempt at black humor, he soon left to prepare for the afternoon conference.

While Jack was doing the external exam, Marvin mentioned that there were other apparent similarities to the Kera Jacobsen case, namely little or no evidence of dried saliva around the mouth, suggesting there had been very little foaming, which is typically seen with pulmonary edema. Jack found this particularly interesting because he was well aware that with fentanyl deaths, pulmonary edema was almost always a primary finding and remnants of foaming were invariably present. Also like with Kera, there was no scarring from previous episodes as usually seen with intravenous opioid, particularly heroin, overdoses. Although there was no scarring, there were signs of other venous punctures, but they all appeared to be new or relatively new, suggesting that Aria’s drug use, at least intravenous drug use, hadn’t been a long-term habit.

Once Jack made the usual Y incision and the internal aspect of the autopsy commenced, any strangeness that existed because of familiarity with Aria on a personal level vanished, and the team functioned with professional celerity. Since Vinnie and Jack had worked together so often, they could anticipate each other’s needs, and often they could go for periods with no conversation. Sensing that he wasn’t really needed, Marvin mostly stayed out of the way and functioned more as a gofer than an integral member of the team.

“My goodness,” Jack said as he lifted both lungs and put them onto the scale. “These babies feel entirely normal.” He then called out to Vinnie that their combined weight was 2.9 pounds.

“That is normal,” Vinnie said, writing it down.

“Jacobsen’s lungs were the same,” Marvin said. “Dr. Montgomery felt that there was minimal if any pulmonary edema.”

“I’d have to say the same with these,” Jack said. He took the lungs from the scale, placed them on a cutting board, and made a series of slices to look at the interior. “Yup, minimal edema, if any. That’s weird. The respiratory depression from the fentanyl had to be really rapid, almost like turning out the light. That makes me suspect we are dealing with a very powerful fentanyl analogue, like carfentanil or, even worse, the cis version of 3-methylfentanyl.”

“Don’t listen to him,” Vinnie said, talking to Marvin. “He wants to impress you.”

“Really,” Jack said. He knew Vinnie was teasing him, but he wanted to be sure the techs knew he was telling the truth. “Those analogues are up to ten thousand times stronger than morphine in all regards, including suppression of respiration. It’s the potency of fentanyl analogues and their ease of manufacture that’s the major cause of the rising opioid death rate.”

As the autopsy continued and no pathology was being found, Jack’s imagination began to be stimulated. Certainly, one of the ungodly powerful fentanyl analogues could explain Aria’s death and the lack of pathological findings. There was no question in his mind. The same could be said about Kera Jacobsen’s death, since no pathology was found there, either, as confirmed by Marvin. Could the same analogue be involved in both deaths? Jack thought the chances were high, so Toxicology had to bear the burden of making that determination. The drug Aria used and the drug Kera used had to be compared. If it was the same, the city authorities would have to be alerted to warn addicts. Such a situation of a particularly potent batch of drugs on the black market had happened in the past, resulting in a sharp uptick in the already high number of opioid deaths. The user community had to be informed.

This line of thinking plus the lack of signs of previous intravenous use motivated Jack to try something he normally wouldn’t have done on an obvious intravenous overdose case, and that was to test the stomach contents for fentanyl. His thought was that maybe Aria had taken some orally and had been disappointed in the result before switching to the intravenous route. While Vinnie and Marvin were washing out the intestines at the sink, Jack took a small syringe, pulled out a fluid sample from the stomach, which was easy since the organ was in plain view after the intestines had been removed, and used a fentanyl test strip. He was surprised when it tested positive.

When Vinnie and Marvin returned to the table, Jack told them what he’d found.

“What does that mean?” Vinnie asked.

“I have no clue,” Jack said. “Except it suggests that Aria ingested some fentanyl before injecting it.”

“That doesn’t make any sense to me,” Vinnie said.

“Did the stomach contents get tested on the Jacobsen case?” Jack asked Marvin.

“I don’t think so,” Marvin said.

“Maybe I’ll ask Toxicology to do it,” Jack said.

The rest of the autopsy went quickly, especially since absolutely no pathology was found. At the very end, Jack thanked the two mortuary techs and left the autopsy room. Normally he would have stayed to give Vinnie a hand with the body and with cleaning up, but with Marvin there, he knew he wasn’t needed. Instead he picked up all the toxicology samples and, juggling them with a bit of difficulty, took them up to the sixth floor. There he found the head of Toxicology, John DeVries, in his spacious new office.

Back when Jack had been a new hire, he’d had issues with John, as he was a cantankerous individual struggling to run one of the key departments of the OCME with inadequate space and an inadequate budget. For his investigations, Jack needed answers, and he felt he needed them quickly. When the toxicology results weren’t forthcoming, he complained, and John’s response was to passive-aggressively delay the results even more. It became thornier still when the chief medical examiner got involved. There was even a time when Jack and John nearly came to blows.

Things changed dramatically after the new high-rise was opened, and many OCME departments moved into the slick new space. Toxicology stayed in the old building, and instead of occupying a few cramped rooms on a low floor, it moved into renovated space, consisting of the entire top two floors. And the Toxicology budget was increased commensurably, changing John overnight from an aging, cranky, gaunt, and bitter man into a younger-appearing, happier version of himself. In contrast to the “olden” days, Jack enjoyed running into the man or stopping into his new office on occasion.

“What do you have?” John asked graciously when Jack appeared at the door.

Jack explained the situation and his concern that the OCME had an obligation to the city’s addicted population to let them know if there was a new batch of particularly lethal drugs on the market. He explained the two cases of highly accomplished young women whose autopsy findings matched, making him feel that there might be a new fentanyl analogue out in the community, and that he needed to know if the two cases matched.

“We’ll get right on it,” John said, as he helped Jack unload his clutch of sample bottles from Aria’s autopsy.

“I have one more request,” Jack said.

“I would be surprised if you didn’t,” John said with a smile. “Ask away!”

Jack told him about his running the fentanyl test strip on a fluid sample of Aria’s stomach and getting a surprising positive result. “I’m wondering if you might run a speed test for fentanyl on the stomach contents of the first case, Kera Jacobsen. She was autopsied several days ago.”

“I’ll be happy to do so,” John said. He wrote down Kera’s name. “Where will you be in the next half hour or so?”

“I’ll be available,” Jack said. “Just call my mobile number.”

“I or Peter will be back to you shortly,” John said. Peter Letterman was the deputy director of Toxicology.

As Jack walked out to summon an elevator, he had to smile. The change in John DeVries had been nothing short of astonishing. It was now a pleasure to work with the man, whereas prior to his metamorphosis it had been a battle.

Retreating to his office, Jack tried not to think about what was going on in one of the Langone Medical Center’s hybrid operating rooms. He even avoided checking the time for fear he’d start worrying that he hadn’t gotten the call to tell him the procedure was over and there was nothing to worry about. Knowing himself, he needed to keep busy to mentally survive. As sad as it was, the autopsy on Aria Nichols had done the trick, but it was now over.

The growing stack of unfinished cases beckoned as did all the histology slides that needed to be reviewed, but he quickly nixed the idea. That kind of busywork didn’t require enough brainpower to keep him from thinking about things he didn’t want to think about, like Laurie’s biopsy being positive. He needed something else that was more demanding and used more parts of his brain, like the rarely used creative sections. Jack was totally aware that he was a man of action who needed physical exertion to keep himself focused, which was why he still liked to play sports rather than watch them.

Thinking about sports brought up the idea of heading home and getting in a bit of basketball despite his promise to Laurie. He felt his mental equilibrium trumped her worry that he might injure himself. He knew that a good run would surely take his mind off Laurie’s surgery. Jack liked the idea more and more until he checked the time.

“Damn,” he said out loud. It was 2:25 P.M., much too early for basketball. People didn’t start showing up on the court until at least 4:30. Unfortunately, checking the time had the negative effect he feared and was trying not to think about, namely that Dr. Cartier had not called him. If Laurie’s surgery had begun around noon, that meant it had been going on for more than two hours, not a good sign.

“Get a grip!” Jack voiced through clenched teeth. He knew he had to think about something else, and the only thing that came to mind was the autopsy he’d just finished on Aria Nichols. As a kind of mental game, he carefully, step by step, went over the entire procedure, forcing himself to remember all sorts of insignificant details from the external exam all the way through to the bitter end. Ultimately, he admitted to himself that the only significant finding was the lack of evidence of pulmonary edema, a kind of positive negative. Such a thought at least brought a passing smile to his face since he was a major fan of wordplay and double entendre, which the phrase positive negative surely represented. Remembering the lack of pulmonary edema reminded him of the apparent similarities between Aria Nichols’s case and Kera Jacobsen’s and what that might mean beyond the worry that both women possibly had gotten their drugs from the same deadly source. Was it just a weird coincidence or did it presage an even greater rash of overdoses in the city than what they were already seeing? He also found himself pondering the weird irony that Aria had participated in Kera’s autopsy as a further association between the two cases.

The sudden ringing of his phone jarred him out of his thoughts. It was John DeVries. “The Jacobsen gastric sample was positive for fentanyl,” he said. “Was that expected?”

“Yes and no,” Jack said. “As I mentioned, it was positive on the case we did today and there were other similarities between the two cases. I don’t know what it means, if anything.”

“I just thought I’d ask,” John said.

“Let me ask you a question,” Jack said. “Is there a fast test for 3-methylfentanyl?”

“No, the rapid tests don’t differentiate between the various analogues.”

“That’s too bad,” Jack said. “The autopsies on these two women suggest they died very rapidly, which scares me to think it involved one of the super-potent analogues.”

“We’ll know as soon as we have our results from liquid chromatography and mass spectrometry.”

“But that takes time,” Jack moaned. “You know me, I want the results yesterday.”

John laughed. “I can vouch for that, remembering our battles in the days of yore. Give me the case accession numbers and I’ll see if I can speed things up.”

“I only have handy the accession number of the case I did today,” Jack said. “But I can get the other one easy enough.”

“Don’t bother,” John said. “Just give me the names again and I’ll look them up.”

“Aria Nichols was today,” Jack said. “Kera Jacobsen was the one done a few days ago.”

“I’ll see if I can have the results early next week,” John said.

“Much appreciated, John,” Jack said.

Marveling anew at John’s personality change, Jack went back to going over the details of Aria’s autopsy, and without knowing why, he started thinking about the autopsy he’d let Aria do on Madison Bryant. What came to mind was the vulgar tirade Aria had let loose the moment she’d seen Madison Bryant on the autopsy table, complaining about Madison avoiding helping her on the Jacobsen case by getting hit by a train and dying. At the time, it was Aria’s obscene language and total lack of human warmth or empathy that had caught Jack’s attention. Currently, instead of the profanity, he was stuck on how the three cases were interrelated.

Tipping forward in his desk chair, Jack put in a call to Bart Arnold. Thinking about Madison Bryant reminded him that he’d not seen the hospital chart that he’d called for after the autopsy yesterday. Besides, Bart had asked him to provide a follow-up with Aria’s autopsy.

As was usually the case, Jack got Bart on the phone immediately. As the department head, he rarely did cases himself, with Aria’s being an exception, so contrary to the other MLIs who were out on scene most of the day, Bart spent the vast majority of his workday at his desk.

After identifying himself, Jack said: “I finished Aria Nichols’s autopsy. Except for a lack of the usual pulmonary edema seen in fentanyl overdoses, there was nothing striking about it.”

“Thanks for letting me know,” Bart said. “And from this end, the mother didn’t add anything particularly relevant other than insisting she’d had no idea her daughter was a ‘goddamn druggie.’ Those were her words.”

“Like mother, like daughter,” Jack said. “What about the Bellevue hospital records for Madison Bryant? Any luck? I want to see them and not just the digital record.” Jack made no effort to hide his frustration.

“I got the hard copy here on my desk,” Bart said. “Sorry! I can have someone run them over to 520 within the hour if you’d like. Are you in your office?”

“I am,” Jack said. “Send them over!”

“Any word from Dr. Montgomery yet?” Bart asked.

The innocent question felt like a stab in the back for Jack, who had been actively trying to avoid thinking about Laurie. He had to clear his throat to steady himself mentally. “Not yet, but soon.”

“Give her my best when you speak with her,” Bart said.

“I will,” Jack said. As he hung up the phone, he felt suddenly irritable. He wasn’t angry with Bart but rather angry that Laurie had had the bad luck to inherit the mutated BRCA1 gene. If that hadn’t happened, at that very moment she would have been down in her office taking care of business instead of being on one of the NYU Langone Medical Center’s operating tables.

“Hey partner, wassup?”

Jack looked up to see Chet’s silhouette filling the doorway to the hallway.

“Not much,” Jack said, purposefully avoiding the truth that he was desperately trying not to think about Laurie.

“I wanted to apologize for my flippancy down in the pit,” Chet said.

“It’s already been forgotten,” Jack said with a wave of dismissal.

“Thanks,” Chet said. “Find anything of note on Aria’s autopsy?”

“No, unless you think finding no pulmonary edema on a fentanyl overdose is noteworthy.”

“Since it is found in ninety-six percent of fentanyl overdoses, I’d say it is noteworthy,” Chet said. “Interestingly enough, it was the same on the Jacobsen case. Are you aware of that?”

“Yes, Marvin reminded us,” Jack said. “It makes me worry both were killed with one of the extraordinarily potent fentanyl analogues. I think the explanation for the lack of pulmonary edema is that both died so rapidly there wasn’t time for it to develop.”

“That’s an interesting supposition,” Chet said.

“As long as you’re here, let me run something by you,” Jack said. “There’s an interesting association between the Jacobsen, Bryant, and Nichols cases.”

“How so, other than Jacobsen and Nichols being overdoses?” Chet asked.

“There’s a curious tangled web of sorts,” Jack said. “Or at least there might be a tangled web. Jacobsen and Bryant were coworkers and fast friends. Nichols did the Jacobsen autopsy and, according to Laurie, was motivated to find the father of the unexpected fetus. Apparently, Bryant was going to help her but ended up getting hit by a train and dying in the hospital. All this happened over three days.” Jack fell silent, staring at his former office roommate.

Chet shifted his weight. “Are you thinking that there is some underlying connection here?” he said.

“I’m not sure what I’m thinking or asking,” Jack said. “To be honest, I’m uptight about Laurie and her surgery.”

“Oh, right!” Chet said. “I heard that was happening today. How did it go? Is everything okay?”

“The problem is that I haven’t heard boo,” Jack said. “I thought I would have heard from the surgeon by now. The longer I have to wait, the more anxious I become. Of course, I don’t know when the case started. I mean, there might have been a delay as Laurie’s case was scheduled as a to-follow case. In that situation there are frequent delays. Anyway, to keep my mind occupied I’m obsessed with these autopsies on these three women and a possible association that I’m not seeing. To put it bluntly, I’m wondering if I’m missing something that ties them together.”

“If you want my opinion, I think you’re overthinking,” Chet said. “To me, the associations you mention sound like just a couple of tragic coincidences rather than a conspiracy. As for Laurie’s situation, would you like me to make some calls? I’m relatively certain I could find out what’s happening with her surgery. My experience is that to-follow cases are always delayed because OR schedulers want the patients to wait, not the doctors, if you know what I mean. If I find out for you, you won’t be sitting here stewing.”

“Thanks, but I suppose I could call myself,” Jack said. “But I’m hesitant. Stupidly enough, I’m superstitious about calling whether it’s you or me. I know that sounds crazy, but what can I say.”

Suddenly Jack’s mobile rang loud enough to make him jump. “It’s Laurie’s surgeon,” Jack said to Chet after taking a peek at the screen. Chet flashed a thumbs-up and left. Jack clicked on the call and put the phone to his ear.

“Hello, Doctor,” he said, trying to sound upbeat while crossing his fingers. It was a throwback gesture to his childhood. He’d never met Claudine Cartier but knew of her by reputation. She was one of the busiest general surgeons.

“Hello, Dr. Stapleton,” Claudine said. In his hypersensitive state, she sounded upbeat, which was encouraging. “I wanted to let you know that Laurie is in the PACU and is doing just fine. Everything went well, including the endoscopic oophorectomy.”

“Fabulous,” Jack said. “What was the result of the breast biopsy?”

“The biopsy was positive,” Claudine said. “The preliminary path diagnosis is carcinoma with medullary features. It is not a common tumor, except with patients having the BRCA1 mutation.”

“I see,” Jack said, trying not to let his sudden disappointment and distress show. He’d hoped and trusted the biopsy would be negative or if it had to be positive that it would be a more benign, intraductal variety.

“There was also a microscopic amount of the tumor in the sentinel lymph node but none in the other of the half dozen or so nodes that were removed. I think that’s very encouraging, especially considering the small size of the primary tumor.”

“Did you do a total mastectomy on the involved side?” he asked.

“We did,” Claudine said. “And what we call a preventive mastectomy on the other side. And with the help of Dr. Roberta Atkins, a superb plastic surgeon, we did bilateral breast reconstruction. I’m very pleased with the final result, and I believe Laurie will be, too.”

“So, what’s next?” Jack asked. He felt a little weak and supported his head with his free hand, elbow on the desk.

“I will leave that up to Dr. Wayne Herbert, the oncologist,” Claudine said. “I believe he will be happy hearing about the small size of the primary tumor and the minimal nodal involvement.”

“How long will Laurie be in the PACU?” Jack asked.

“That’s up to the anesthesiologist,” Claudine said. “I’d guess an hour or so. The anesthesia went very smoothly, and Laurie woke up quickly.”

“Thank you,” he said.

“You’re welcome,” Claudine said.

Jack disconnected the call and sat for a few minutes staring ahead. It certainly wasn’t what he wanted to hear, but in retrospect it wasn’t terrible news, and Claudine definitely sounded content. With a sudden need for human contact, Jack pushed back from his desk and hiked down the hall to Chet’s office.

“The news wasn’t terrible, but it wasn’t great, either,” he said, standing in the doorway.

“Come on in and tell me what you learned!” Chet said. He lifted a stack of case folders off his office chair and stashed them next to his microscope.

Jack stepped into the office and sank into the chair. He then summarized for Chet in a kind of depressed monotone what the surgeon had told him.

“I’d say that sounds like pretty good news to me,” Chet said. “Come on, man! Buck up! Small tumor, one node, hell, that’s child’s play for today’s oncologists. You should be glad it was found this early.”

“I suppose you’re right,” Jack said, trying to rally.

“When will you be able to see her?”

“In a couple of hours or so, is my best guess,” he said. “She just got into the surgical recovery room after a pretty lengthy anesthesia.”

“You know what you should do?” Chet said suddenly with conviction. “You should get your ass out of here. Go home, see your kids, and then when Laurie is back in her hospital room, go and see her! That’s what you should do. Otherwise you are going to drive yourself bananas sitting in that office of yours trying to keep your mind busy by looking at histology slides and filling out death certificates.”

“Maybe you’re right,” Jack said. The idea of some exercise had a humongous appeal. So did seeing Emma and maybe even JJ, if he got home early enough. And there was always the chance of a bit of basketball. He stood up. “Thanks, Chet. I needed that.”

“Don’t mention it,” Chet said. “I’m sure Laurie is going to be fine. Why don’t you text her to give you a call as soon as she hooks back up with her mobile. She’ll get it when she gets back to her room.”

“That’s another great suggestion,” Jack said, and meant it. The fact that he’d not thought about doing it himself made him appreciate that he wasn’t thinking normally.