Mercy

CHAPTER 19

Autopsy means “see for yourself,” and that was precisely what Lucy Abruzzo intended to do with Sam Talbot’s body. She would see for herself what had killed him. Gowned, gloved, and masked, Lucy looked like any surgeon about to perform a procedure, except her patient required no anesthesia and she had no support staff on hand to assist. Lucy preferred it this way. She thrived in solitude, which was why she was equally comfortable running long distances or tackling virtual opponents in a spirited game of online chess.

The endeavor at hand was a chess match of a different sort: Lucy vs. death. But death was a wily opponent, and safeguarded its secrets the way a grand master could obscure a strategy until checkmate became inevitable.

The cavernous autopsy suite had an industrial look, with its gray-tiled flooring, fourteen-foot-high ceilings, and exposed ductwork. Lucy liked the utility of it all. Nothing here was wasted or decorative. Everything had a proper place and purpose. The room had three brand-new autopsy tables, plenty of good light, top-of-the-line instruments, and lab equipment organized neatly on stainless steel tables, or in glass-fronted cabinets securely mounted to the walls. Most everything here was new or in pristine condition, thanks in large part to Roman Janowski’s skill at keeping the hospital coffers flush with cash. It was a fine place to work, and Lucy was ready for the task at hand.

As was her tradition prior to beginning, Lucy’s eyes went to a sign in Latin that hung on a nearby wall. It read: Hic locus est ubi mors gaudet succurrere vitae. Translated, it meant: This is the place where death rejoices to help those who live. The words mattered a great deal, reminding Lucy of her purpose here. Indeed, it was the very essence of her profession.

Ultimately-in a clinical sense, at least-everyone died of the same thing. The heart stopped beating, and blood stopped circulating through the body, two processes necessary for sustaining life. But many factors could come into play as life ended, and therein lay the value of an autopsy.

Autopsies had helped reveal misdiagnoses, uncover new diseases, and educate doctors-and humble them, and befuddle them-about the vast intricacies of the human body. Doctors, by their nature, did not easily embrace the possibility of being wrong. Over the years, Lucy had dug up plenty of medical evidence to wrinkle more than a few white lab coats. She had gone into pathology for the same reason she’d devoured mystery novels as a child. Lucy simply loved to figure out the real answers.

Because Sam Talbot was so severely injured, his death had not been a complete surprise. Cost and resources meant autopsies were rarely done without a compelling reason, such as death under suspicious circumstances, pending litigation, or a health threat to the general public. This procedure was a favor to a friend who’d requested it. Julie needed closure-deserved it, given all she had endured-so the stakes were high. Lucy was the boss, and did not have to ask anyone’s permission to grant Julie’s request.

Jordan, the diener, had already prepared the body, so when Lucy entered the autopsy suite she was able to get right to work. From her quick assessment, it was obvious Jordan deserved another raise. The x-rays were all visible on the viewing screen, and Lucy’s tools, including the fine saws and scalpels she favored, had been laid out in perfect order.

Never had Lucy met a diener so committed to excellence. The word “diener” was German and meant “helper,” which described Jordan to a T.

Pressing on the foot pedal, Lucy activated the overhead microphone and recorded the date, time, and location of the procedure: White Memorial Hospital.

“This is Dr. Lucy Abruzzo performing an autopsy on Mr. Samuel Talbot, who was deceased on Friday, the fourteenth of October, at one thirty-five P.M.”

Lucy studied the X-ray images and rattled off her assessment as if she was reading from a book.

“Review of the X-rays demonstrates healing of the C4 burst fracture, type-two fractures to the ilium and pubis, left radial and ulnar fractures, right radial and ulnar fractures, and left olecranon fracture. Left femur fracture with rod in place, healing. All appear consistent with prior injuries, and no new findings identified. New hairline fracture noted in the sternum and fracturing anteriorly of bilateral ribs T5 through T8. Likely occurring during the resuscitation attempt.”

CPR was a violent procedure that often cracked ribs and fractured the sternum. Pathology drilled home one undeniable fact: death was painless; living was not.

Lucy examined the body with her keen observational skills.

“First visual inspection shows a well-developed, well-nourished male in his forties. He is six feet tall, weighs one hundred ninety-five pounds, hair color light brown. Mild bruising appears on anterior chest, also likely a resuscitation injury. Significant bruising noted on the abdomen, most likely the result of injections and treatment for his spinal injury. Slight atrophy noted in the lower extremities, also consistent with his prior injuries and clinical history.”

Julie had asked to observe this procedure, but ultimately agreed with Lucy that she’d be better served by reading the report. She did not need to see her fiancé cut open with a scalpel from the shoulder to the lower end of the sternum, and then cut again in a straight line over the abdomen to the pubis. What was seen could not be unseen, Lucy had warned.

Except for a bit of blood drawn out by gravity, Lucy’s expert incisions produced almost no bleeding. A dead body has no blood pressure. Lucy was grateful that this was a limited autopsy, one that did not have to include the brain. It seemed invasive, especially on someone she knew, to open up the “black box” and poke around inside Sam’s skull.

“After standard Y incision is made, there appears to be perimortem fracturing of the sternum and ribs anteriorly, as described on the X-ray.”

Sam’s cause of death would not be found in the bones. It was time for Lucy to cut the cartilage joining the ribs to the breastbone so she could enter the chest cavity and get to the organs. The bone saw whirred to life and made the necessary cuts almost effortless.

It was proving difficult, Lucy found, to remain her typically detached self. After all, she had lunched with Sam and Julie, had greeted him warmly when he came to the hospital for a visit, and had planned to attend their wedding. Now she was using rib spreaders and cranking the handle so she could open up his sternum and bones to get a good view of the inside of his chest.

She closed off her personal feelings, shut them down the way she could tune out pain on a long run, and began her inspection of the internal organs.

“Pericardial sac intact. Lungs appear normal. Minimal pleural fluid noted and sent for analysis.” She made a new incision in the pericardium to conduct her examination of the heart. “Minimal fluid noted,” she said. “The heart appears normal in size.”

Then she moved over to the main vein, the inferior vena cava that carried blood from the lower body to the heart, and made another cut. “IVC appears normal in caliber and intact. After incision, no clot noted. Blood sent for routine toxicology and chemical analysis.”

Gathering samples for the labs was something Lucy would deal with after the fact, but she was required to record her observations in keeping with proper procedure.

Now Lucy turned her attention to the pulmonary arteries, an area of interest to her. Evidence had pointed to an acute myocardial infarction-a heart attack-on the basis of Sam’s EKG when he coded. But he had no indication of underlying, preexisting coronary disease, and the hole in Sam’s heart from the pericardiocentesis had been repaired. Lucy suspected a fatal pulmonary embolism as cause of death, a clot traveling from veins in the legs to the lungs, completely stopping blood flow.

With this in mind, Lucy felt the pulmonary arteries, but detected no palpable clot. She made her incision.

“The left and right pulmonary arteries are clear.”

Interesting.

She inspected the arteries lower down, in case the clot had been dispersed.

“Incision and inspection to the third-order branches are clear of clot,” Lucy observed.

Whatever had caused his heart to stop beating was not going to be found in the lungs. Lucy removed both lungs, one at a time, and weighed them before turning her attention to the heart.

“Visual inspection of the heart shows normal size,” she said.

She removed the organ and placed it on the scale. The heart weighed 385 grams, 35 grams more than the normal range. She placed the heart on the stainless steel table. Lucy felt uneasy, unusual for her, but then again she did hold the heart of her friend’s fiancé in her hand. The moment for sentimentality was short; she had a job to complete.

“The circumference and appearance of the valves are normal,” Lucy said. “The ventricular wall appears normal in texture and width.” She searched hard for clues. A subtle scar could be a nidus for an arrhythmia, or an irregular heartbeat that would have caused his ultimate death.

She looked again and noticed something unusual this time. The left ventricle appeared to be dilated. She inspected the bulge more closely.

“There is some bulging noted of the septum into the left atrium,” Lucy said into the recording. The recording would pick up the excitement in her voice. “The right ventricular wall is normal in configuration, size, and thickness. The coronary arteries are patent with minimal atherosclerotic changes. Biopsy will be sent for chemical analysis, viral cx, and staining.”

Lucy turned the heart over in her hands and studied the ballooned ventricle with intense interest. The anatomy here was incredibly unusual, even for a doctor who had held plenty of hearts in her hand.

“No significant coronary artery stenosis,” Lucy said. “Nor is there significant fibrosis in the ventricular transverse sections near the apical or basal segment.”

This was in line with Sam’s medical history. If he had an underlying heart condition, Lucy would have expected to see abnormal narrowing in the arteries. Everything looked normal except for the apical ballooning of the lower part of the left vertical.

The bulging ventricle resembled a takotsubo, a pot with a bulbous base used by Japanese fishermen to trap octopuses. It was from this that the condition derived its name: takotsubo cardiomyopathy. It was a highly unusual coronary condition, one Lucy had never before seen in an autopsy. She might not have been able to identify its pathology were it not for her near-photographic memory. What made the discovery even more unusual was that takotsubo cardiomyopathy was almost always associated with older women, as much as 90 percent of the time.

Patients with takotsubo experienced a weakening of the left ventricle, the heart’s main pumping chamber, usually as the result of severe emotional or physical stress-or intense fear. More tests would have to be done for Lucy to make a conclusive diagnosis. But she believed Sam’s lab results would reveal that he had been literally scared to death.