Intervention

8

12:05 P.M., MONDAY, DECEMBER 1, 2008

NEW YORK CITY

(7:05 P.M., CAIRO, EGYPT)

Jack pulled up an eMedicine article dealing with vertebral artery dissection. He began skimming it, learning that VAD was the cause of twenty percent of strokes suffered in patients younger than forty-five years of age, occurring three times more often in females than males. Reading on, he noted that the typical presentation was occipital, or back of the head, headache. He turned to the last page for the causes. The very first risk factor listed was spinal manipulation, just as Chet had suggested.

Intrigued at what the incidence of VAD was from spinal manipulation specifically, Jack went back to his default search engine. A few seconds later, he was scanning through a plethora of articles. He quickly found an article he thought promising and clicked on it. As he read it, he found it far more disturbing than the first as it was a systematic review of thirty-five actual cases of strokes caused by cervical spine manipulation that had been reported in the medical literature from 1995 to 2001. The vast majority involved chiropractors, and most of the lesions were vertebral artery dissections. Outcomes varied from full recovery in six percent of patients to varying levels of permanent neurological deficits or death in the remaining ninety-four percent. One of the listed patients who had died was a three-month-old baby girl.

Jack leaned back and stared up at the ceiling. What malady would lead parents to think an infant’s symptoms would be relieved by cervical neck manipulation, suddenly and forcibly twisting the infant’s neck beyond a point of normal resistance? And what had gone through the supposed therapist’s mind that gave him or her the audacity to do such a thing? Jack wasn’t just horrified — he was angry.

Moving on to the discussion section of the article, Jack read that there was evidence that the thirty-five cases discussed were only a small portion of such cases, since underreporting was apparently widespread. To back up this statement a survey of physician specialists at a meeting of the Stroke Council of the American Heart Association reported three hundred sixty unreported cases of stroke after spinal manipulations! How could this be? Jack questioned.

Placing his hands on either side of his head, Jack shook it in disbelief, questioning why this issue was not more commonly known. After puzzling over the situation for a few minutes and coming to no conclusion, Jack returned his attention to Keara Abelard’s case.

He angrily riffled through the mass of papers on his desk until he located the telephone number of Keara’s friend who’d allegedly recommended chiropractic. He dialed, then tried to calm himself as the call went through. He knew it could be counterproductive to intimidate Keara’s friend. When she answered, Jack identified himself and mentioned his official title in as poised a manner as he was capable. His introduction was greeted with silence.

“Are you still there?” Jack inquired. “You are Nichelle Barlow, aren’t you?”

“Are you calling from the morgue?” the woman asked, with obvious concern.

“I am. Are you Nichelle Barlow?”

“Yes,” she replied reluctantly, apparently trying to prepare herself for what couldn’t be good news.

“I got your number from Mrs. Abelard. I hope I’m not disturbing you.”

“It’s okay,” she said hesitantly. “Are you calling me about Keara?”

“I am. I suppose you weren’t out with her and her friends last night.”

“No, I wasn’t, but don’t tell me she...” Nichelle said but was unable to complete the sentence.

“Unfortunately, Keara passed away last night,” Jack said. “I’m sorry to be the bearer of bad news.”

“What happened?”

“She had a stroke.”

“A stroke?” Nichelle said with disbelief. “Keara was my age, only twenty-seven.”

“Strokes are more common the older one gets, but even children can have them.”

“I can’t believe this. Is this some kind of sick prank?”

“I’m afraid not, Ms. Barlow,” Jack said calmly. “The reason I’m calling is because I’m investigating your friend’s death. Any sudden passing of an individual in apparent good health and with no known cause falls under the jurisdiction of the medical examiner’s office. What I need is some information. You were aware that Keara was suffering from headaches?”

“That’s what she said. But I didn’t get the impression they were particularly bad. More nuisance than debilitating.”

“Did she describe them to you?”

“Sort of. She said they were behind her eyes, more on the right than the left. She said she gets them when she is under stress, and with her new job she said she was under a lot of stress.”

“Her mother told me you had suggested she see a chiropractor.” Jack kept his voice neutral to avoid casting blame.

“She said ibuprofen wasn’t helping, so I suggested my chiropractor.”

“Did she take your advice?”

“It sounded like she was going to, but I don’t know for sure. The last time I spoke with her was last Wednesday.”

“What is this chiropractor’s name?”

“Dr. Ronald Newhouse. He’s a wonderful doctor.”

“When you say ‘doctor,’ you are aware he’s not a medical doctor?”

“He’s a doctor, he just can’t do surgery or prescribe drugs.”

Jack felt his anger seeping back, but he fought against it. He wasn’t going to be able to change Nichelle’s ideas about this, but he couldn’t let her misconception go completely unchallenged. “Your chiropractor calls himself a doctor, but he is a doctor of chiropractic, not a doctor of medicine. Can you tell me where Dr. Newhouse has his office?”

“Fifth Avenue between Sixty-fourth and Sixty-fifth. Hold on and I’ll get you the telephone number.”

In a moment Nichelle came back on the line. After she gave Jack the number, he asked, “How long have you been a patient of his?”

“About eight years. He’s been my savior. I see him for almost everything.”

“What do you see him for specifically?”

“Whatever ails me: sinusitis, mostly. That and gastric reflux. I’d be a wreck if it weren’t for Dr. Newhouse.”

“Ms. Barlow,” Jack began, then paused. For a moment he mulled over what he wanted to say. “I’m curious to know how your chiropractor treats your sinusitis.”

“He adjusts me. Usually he works on my cervical vertebrae, but sometimes my lumbar. I’ve got one hip higher than the other, and my back is a mess, but it’s definitely getting better. You should see the changes in my X-rays. It’s remarkable.”

“Does he take spine X-rays often?” Jack asked, horrified at the thought. The radiation required for spinal radiology was significant.

“Most every visit,” Nichelle said proudly, as if she thought the more X-rays, the better. “He’s a very, very thorough doctor. The best that I’ve ever been to, truly.”

Jack cringed at this inappropriate glowing assessment of someone who was treating sinusitis undoubtedly caused by an overgrowth of bacteria with potentially dangerous cervical manipulation and unneccessary radiation to boot! Even if the machine was digital, over time the dose would add up.

“Thank you for your help, Ms. Barlow,” Jack said, making an effort to avoid the temptation to contradict the woman. The fact that a seemingly intelligent and educated person could hold such off-the-wall opinions in this day and age was a mystery to him. But he didn’t dwell on it.

Jack disconnected rather abruptly. He knew that had he not done so, he surely would have ended up lecturing Nichelle about her need to apply a modicum of her intelligence to her health-care choices. She was admittedly using her chiropractor as a GP. Without even replacing the handset, he began dialing Ronald Newhouse’s office. At about the halfway point he stopped, paused, then put the receiver it its cradle. He still felt enraged, and in that state of mind he was prescient enough to know he couldn’t have a coherent conversation. The idea that the man truly believed he could treat a sinus infection with spinal adjustment was execrable. The man had to be a charlatan.

To calm himself, Jack turned to composing an e-mail asking the thirty-plus other New York City medical examiners if they’d had any cases of VAD, particularly chiropractor-induced VAD. He was about to send the message when he decided to expand the request to deaths involving all types of alternative medical therapy, including but not limited to homeopathy, acupuncture, and Chinese herbal medicine.

Jack then searched the Barnes & Noble website for alternative-medicine titles and was amazed at the number available. Reading through the descriptions, he noted that there seemed to be many more pro than con, despite what he felt was the shaky underpinning of the various therapies. This only added to his curiosity, especially in an era when conventional medicine was moving toward more evidence-based therapy.

One title struck him: Trick or Treatment. He called one of the Barnes & Nobles on the West Side and asked that a copy be put aside. He was motivated to rectify his shameful ignorance of the subject.

Feeling more like himself, Jack went back to telephoning Ronald Newhouse. Again, halfway through the dialing process, he stopped and hung up the phone. He suddenly decided a site visit was in order, even though he knew very well that the powers-that-be frowned on site visits by the MEs. The OCME protocol called for site visits to be made by the well-trained medicolegal team, not medical examiners, unless extraordinary circumstances demanded the presence of a trained forensic pathologist. Although Jack guessed that neither the deputy chief nor the chief would see the current situation as one of those “extraordinary circumstances,” he decided to do it anyway. He had an irresistible urge to look the chiropractor in the eyes while he explained how spinal manipulation could cure sinusitis. He also wanted to see his expression when he told the guy he’d killed Keara Abelard, treating her for a garden-variety tension headache.

It had been a while since he last made a site visit. Back when he was newly hired, especially when he was involved in a complicated infectious-disease case, he made a lot of them, and almost got himself fired several times. The chief, Dr. Harold Bingham, had come within inches of dismissing Jack for willful insubordination.

As he waited for the elevator, Jack realized that if Ronald Newhouse had treated Keara with the suspected cervical manipulation, Jack wasn’t required to put “therapeutic complication” as the manner of death on the death certificate, which would be what everyone from Bingham on down would expect. He didn’t even have to put “accidental,” which was the designation for such a case before “therapeutic complication” had been devised in the mid-nineties. Jack realized he could put “homicide” as the cause of death, then turn the case report over to the DA as was done in more typical cases of criminality. “What a stir that would cause,” Jack said to himself with a mischievous smile as he boarded the elevator. And thinking in that vein, he thought that perhaps such a “political bomb” was what was needed to draw attention to the dangers of cervical manipulation.