Intervention

5

8:41 A.M., MONDAY, DECEMBER 1, 2008

NEW YORK CITY

(3:41 P.M., CAIRO, EGYPT)

Goddamn it, Vinnie,” Jack Stapleton growled. Jack was along the left side of the body of Keara Abelard. He’d been bent over the woman’s back for more than twenty minutes, carefully biting off pieces of the cervical transverse processes with his ron geurs, trying to expose the two vertical arteries as they coursed up through the neck. The arteries pierced each vertebra laterally before making an S-curve around the atlas, or first cervical vertebra.

“Sorry,” Vinnie said, but without sufficient remorse.

“Can’t you see what the hell I’m trying to do?”

“Yeah, I know what you’re trying to do. You’re trying to expose both vertebral arteries.”

Keara’s neck was pressed down on a wooden block, her face pointing down at the floor, on the table, her brainless calvarium pointing at the autopsy room’s door. The brain sat alone on a cutting board at the foot of the table.

Vinnie stood at the end of the table with his hands on either side of Keara’s head, trying to stabilize it as Jack nipped off pieces of bone. It was a slow process. The idea was to expose the arteries without damaging them. Jack recorded his progress with a series of digital photos.

“If you can’t hold the head still, I’m going to have to find someone who can. I don’t want to make this my life’s work.”

“All right already,” Vinnie complained. “I got the message. For a second there I was thinking about the Giants and the worry they’re not even making the Super Bowl much less winning it.”

Jack closed his eyes and silently counted to ten. He knew he was being tough on Vinnie. Holding on to a body part while Jack nibbled away was a grunt’s job, and he would have hated to do it himself. Still, the case had to get done. The problem was, his emotional instability was causing him to be less patient than usual.

“Just try to focus a little more,” Jack said, making a conscious effort to calm his voice. “Let’s get this over with.”

“Got it, boss,” Vinnie said, tightening his grip on the woman’s head.

The rest of the autopsy room was a beehive of activity with all eight tables in use, but Jack was oblivious to it all. He now had a preliminary diagnosis as to the cause of Keara’s death, and his attention was focused. The arteriogram showed an almost complete blockage of both vertebral arteries, the source of much of the brain’s blood supply. The blockage appeared to have occurred over a relatively short period of time. But why? Was it a natural occurrence, as in some sort of emboli, or accidental, like an injury? The fact that it was so symmetrical was the most difficult to explain. It was a unique case for Jack, and he had eased up on himself for not thinking of doing a vertebral arteriogram before removing the brain. It had been a mistake but ultimately not detrimental.

Twenty minutes later, Vinnie leaned down to view Jack’s handiwork. “It’s looking good to me,” he said.

Jack straightened up, pleased. The field looked like an anatomy textbook illustration of the course of the vertebral arteries, particularly at the base of the skull. “Can you see the bluish discoloration and swelling around the S-curves on both sides?” Jack asked. “Come around to get a better look.”

Vinnie traded places with Jack. From that vantage point he could see what Jack was referring to. Each vertebral artery had a two- to three-inch section with a swollen bluish cast, the right slightly more pronounced than the left. “What do you think it is?” Vinnie said.

Jack shrugged. “Looks to me like an injury of some kind, but since there was zero bruising on her neck, it’s a bit strange. In fact, she had no signs of trauma of any form. And it’s peculiar how symmetrical it is.”

“Could it be a whiplash injury, something like that?”

“I suppose it could, but there’d be the history of the automobile accident. When I glanced through the medicolegal investigation report, there’d been no mention of any auto accident. I think I might be in for a bit of investigative work myself. There has to be an explanation.”

“What now?”

“More photos,” Jack said, reaching for the digital camera. “Then we’re going to remove both arteries and check the interiors.”

Ten minutes later Jack had the vessels on the cutting board with the brain. They looked like two small headless red snakes who’d swallowed something blue. The discoloration was more apparent than when the arteries had been in situ.

“Here goes nothing,” Jack said. Steadying each blood vessel between the thumb and forefinger of his left hand, he used his right to make a careful incision through one side of each artery’s wall. He then opened both of them lengthwise, spreading them out on the cutting board inside out.

“Would you look at that?” he said, still holding the scalpel.

“What am I looking at?” Vinnie questioned.

“It is called a dissection,” Jack said. “A bilateral dissection of the vertebral arteries. I’ve actually never seen it.”

Using the handle of the scalpel, Jack pointed to a spot just before the arteries’ S-curve where they looped up and over the first cervical vertebra. “Can you see this tear in the intima, or the inside lining of the blood vessel? In both arteries there is a tear at the point between the atlas, or first vertebra, and the axis, or second cervical vertebra. In such a situation, what happens is that arterial pressure forces blood into the tear and balloons the lining of the arteries away from the vessel’s fibrous wall, eventually blocking the vessel’s lumen. The brain is then deprived of a major portion of its blood supply and bingo, lights out.”

“Meaning curtains for the victim.”

“I’m afraid so,” Jack agreed.

With the pathology determined, the rest of the autopsy continued apace. Twenty minutes later, Jack exited the autopsy room to learn that Dr. Besserman had assigned him a second autopsy, the private-school meningitis case. While he waited for Vinnie to set it up, Jack ditched his soiled Tyvek suit and took Keara Abelard’s chart into the locker room.

Making himself comfortable, Jack carefully reread Janice Jaeger’s medicolegal investigation report. As he had noted earlier when he’d skimmed the record, the woman had been brought into the emergency room by her drinking buddies with the sudden onset of confusion and spasticity, leading to unconsciousness. From Janice’s choice of syntax, Jack could tell that she had not spoken with the friends directly but rather had gotten her information from a combination of the Saint Luke’s ER record, one of the ER nurses, and one of the ER docs. Typical of Janice, the report was complete, with no mention of an auto accident.

Switching to the ID sheet, Jack saw that it had been Keara’s mother who’d made the identification. The woman lived in Engle wood, New Jersey, and Jack glanced at her phone number with its 201 area code.

Impulsively, Jack got to his feet. It was clear he needed more information than what he had. With the OCME record in hand, he used the back stairs to get up to the first floor, and, passing though the SIDS investigation area, he walked into the expanded medicolegal space. He found Bart Arnold, the chief of forensic investigation, at his desk in cubbyhole number one. He and Jack had an excellent working relationship, as Jack was one of the few medical examiners willing to give the investigators the credit they deserved by letting them know he couldn’t do his job without their help.

“Morning, Dr. Stapleton. Is there a problem?” Bart asked, seeing the case file under Jack’s arm.

“Hey, Bart, I was wondering if during your shift-change report session this morning Janice happened to mention anything memorable about Keara Abelard?”

Bart looked at his list of the night’s cases. “Nope, not that I can remember. It seemed routine to her, but definitely a case that fell under OCME jurisdiction.”

“I couldn’t agree more,” Jack said. “But there’s so little history.”

“She mentioned that the ER docs felt the same, which is why they left word with Janice to get a callback. They want to know what’s found.”

“I didn’t see a note to that effect in the record.”

“I believe Janice knows the doc in question and was going to do it herself rather than obligating you.”

“Do you know if she spoke to the mother when the mother came in to make the identification?”

“That I don’t know. If I had to guess, I’d say no, because Janice is so thorough — if she’d spoken with the mother, she would have written it down. But why don’t you call her and ask? What’s the problem, not enough info?”

Jack nodded. “It’s a curious case. The woman died from occlusion of both her vertebral arteries. Unless she had had some connective-tissue disease like Marfan syndrome, which I seriously doubt, she had to have suffered serious trauma. Her vessels dissected, meaning the lining came off, blocking them up. Vinnie suggested whiplash injury from an auto accident, and he might be right. I think her friends or her mom might have some information. It could be extremely important. If someone ran into the back of her, he or she would now be looking at possible manslaughter, even murder, if the parties knew each other and there was some kind of conflict or controversy between them. I’d give the mother a call myself, but I’d hate to bother her if Janice has already spoken with her.”

“As I said, why not give Janice a call?”

With his left hand, Jack twisted up the bezel of his watch tied with the cincture of his scrub pants. “It’s a quarter to ten. Isn’t that too late?”

“She’s a perfectionist. She’ll want to help you out,” Bart said, handing him Janice’s home number. “Call her! Trust me!”

Using the front stairs, Jack hurried up to his office. After propping open his office door, he placed Janice’s card in the center of his blotter and pulled over his phone. Before he dialed the woman, he called down to Vinnie.

“I’m bringing in the body of the kid as we speak,” Vinnie said. “Five minutes and we’ll be ready to go. Calvin, our lovable deputy chief, wants us to do it in the decomposed room.” The decomposed room was a separate, small autopsy room with a single table. It was used mostly for putrid bodies.

“Make sure we have plenty of culture tubes,” Jack said. “See you in five.” He disconnected.

He was about to dial Janice’s number when the photo he had on his desk of Laurie and John Junior caught his eye. It had been taken at a happier time, the day Laurie and the baby were leaving the hospital after the delivery. At the moment there had been no symptoms or signs of the disaster that was to come.

Impulsively, Jack reached out, grabbed the photo, and tossed it into his bottom drawer, pushing it closed with his foot. “God!” he murmured. It was embarrassing how quickly he could be yanked back into a depressing thought, especially since Laurie was the one bearing ninety-nine percent of the burden. He wondered how she’d been able to do it. At least he’d been able to go to work to take his mind off the reality of the disaster.

For a moment Jack rubbed his eyes, causing a squishy sound from both sockets. With his elbows on the desk, he then roughly massaged his scalp. He was back to realizing how much he needed to find something professional to occupy his mind to rein in his fragile emotions.

Opening his eyes, Jack snatched up the telephone receiver and angrily poked the sequence of buttons corresponding to Janice’s phone number. When she answered, he snapped back with his name in such a way that he knew he sounded angry. Before Janice could even respond, he excused himself. “That didn’t come out right,” he said. “I’m sorry.”

“Is something the matter?” Janice questioned. As conscientious as she was, her first concern was that she’d done something terribly wrong.

“No! No!” Jack assured her. “My mind was elsewhere for a second. I hope I’m not disturbing you.”

“Not at all. I can’t sleep for three or four hours after getting off shift.”

“I’m looking for more information on Keara Abelard.”

“I’m not surprised. There was so little available. Such a sad case, so young, attractive, and seemingly healthy.”

“Did you speak to any of the woman’s friends who brought her into the ER?”

“I didn’t have a chance. They had already left by the time I got there. I was able to get a name and number of one of them, Robert Farrell. I put it down at the bottom of the page.”

“Did you get to speak with her mother when she came in to make the ID?”

“I wanted to but got called out on another case before she arrived. And then when I returned, she’d already left. I’m sure Bart would be more than happy to follow up.”

“What I think I’ll do is call myself. My curiosity has been tweaked.”

“If you change your mind, I’m certain one of the day investigators would do it.”

“Thanks for your help,” Jack said.

“No problem,” Janice replied.

Jack disconnected with the forefinger of his left hand while still holding on to the receiver. With his right hand he pawed through the OCME record, looking again for the ID sheet for Mrs. Abelard’s phone number. The second he found it, the phone rang under his hand. It was Vinnie, saying all was ready down in the decomposed room.

After a moment’s hesitation, Jack replaced the receiver on the cradle. There was no rush to speak with Mrs. Abelard, as it was not a call he relished having to make. He was happy to put it off until he finished the next autopsy, although had he any inkling about what he’d learn from the mother, he wouldn’t have put off the call for a second. Mrs. Abelard was going to tell him something he never would have guessed.