Night Shift

Chapter 26

Wednesday, December 8, 9:17 a.m.

Juggling an armload of specimen bottles just as he had the day before, Jack got off the elevator on the sixth floor and managed to walk into John DeVries’s empty office in Toxicology without dropping any. Carefully he unloaded them, separated the toxicology specimens from those destined for Histology, and then arranged the toxicology bottles like toy soldiers in single file, front and center on John’s desk. Just as he was finishing, John walked in.

“Ah, more care packages!” John declared humorously. He was dressed in a laboratory coat, which he took off and hung up on an antique coatrack. “What do we have here?”

“Probably nothing particularly interesting. It’s a female nurse with a preliminary diagnosis of overdose. A bag of powder was found at the scene, which tested positive for fentanyl.”

“But you bringing the samples up here yourself tells me you suspect otherwise,” John said. He twisted the bottles around to line up the labels, telling him the source of each.

“You’re getting too sharp in your old age,” Jack quipped.

“I wish that were the case,” John said. “Okay, enough flattery. What’s the story here?”

“Detective Soldano was thinking the patient was a victim of homicide, considering aspects of the scene and some testimony. He felt so strongly that he even came in this morning to observe the post. As he explained to me, he’s taking the uptick in homicides personally and was convinced this was another one disguised as an overdose. Unfortunately for him, the post didn’t back him up.”

“I remember Detective Soldano,” John said. “You brought him up here one day and introduced us.”

“I did because he’s a big fan of forensics and particularly toxicology,” Jack explained. “Anyway, the autopsy, as I said, has seemed to confirm it was indeed an overdose with mild pulmonary edema being the only pathology. But because of his interest and because of the demographics of the case, he and I would like to know right away if it indeed was an overdose.”

“Why is it that so many of your cases are toxicological emergencies?” John questioned with a laugh. “All the other MEs seem to be content with the usual week to two-week delay in getting final results.”

Jack laughed in response. “I suppose that is a good question. I guess it’s because I take my job speaking for the dead seriously.”

“I can certainly vouch for that,” John said. “But it is a little late to help them since they are already dead.”

“It’s to prevent more deaths,” Jack explained. “That’s really what we MEs and you toxicologists ultimately hope to do.”

“Well said,” John remarked. “What’s this bottle labeled ‘skin lesion’?”

“Good thing you pointed that out,” Jack said. “I meant to explain it. It is a sample of a skin lesion, which is probably a small nevus, but since this case reminded me of yesterday’s, it occurred to me it might be an injection site. I’ll know once Histology makes some slides. If it is an injection site, it’s going to be key to know what had been injected.”

“Fair enough,” John said. “So, you’ll let me know what Histology tells you?”

“I will,” Jack said. “Now, what can you tell me about results from yesterday’s case?”

“It’s only been twenty-four hours,” John said, rolling his eyes. “Everything is still pending except the general screen, which was negative.”

“No!” Jack blurted. After all the thinking he’d been doing about cyanosis and the physiology of extremis, he’d been progressively sure Sue had taken a lethal drug, which he assumed had been fentanyl as it had become so common in causing overdoses because of its potency.

“You are surprised?” John questioned. “Why? You told me yesterday you thought the chances of the case being an overdose were zero. Obviously, you were correct, so why the surprise now?”

“Because I had rethought everything since I spoke to you, especially that the deceased had been cyanotic and had such characteristic pulmonary edema. The main reason I’d been against the idea was having known the woman personally and, I thought, relatively well, but when it comes down to it, who knows anybody well? Damn!” Jack added with growing emotion. “Now I have to go back and rethink everything all over again. Jesus H. Christ!”

“Sorry to be the bearer of bad news,” John said.

“Don’t be silly, it’s not your fault,” Jack said, while his mind churned with a kaleidoscope of thoughts relating cyanosis, pulmonary edema, and the associated physiology. Suddenly, these thoughts dovetailed in the curious associative fashion that only the human mind can do. As a result, the name Carl Wingate popped unbidden into his consciousness, and Jack knew why... the man was not a fan of Sue or Cherine, was an odd duck in his estimation, but, more important, he was an anesthesiologist, and anesthesiologists used a drug called succinylcholine on a daily basis. Succinylcholine, or SUX as the medical profession frequently called it, paralyzed people almost instantly with just a tiny amount, and unless the anesthesiologists or anesthetists breathed for the patient, the patient would become cyanotic and die.

“All right, thanks for stopping by,” John said agreeably as he started to pick up the specimen bottles. “I’ll have the techs run a general drug screen on this new case. If I crack the whip again, I should have at least a preliminary reading by this time tomorrow.”

“Wait a second!” Jack said. “I’ve just had another thought. What’s the status of detecting succinylcholine? Has that improved of late?” Like any ME, Jack knew that detecting the powerful drug was inordinately difficult because the body very quickly degraded it into compounds that were indigenous to the human body. He also knew that Histology might have something to contribute even if changes weren’t pathognomonic or specific for succinylcholine poisoning.

John paused picking up the sample containers and smiled. “Sounds like you have been reading some recent detective stories. Yes and no, as far as success in detecting it goes. There have been some successes in several recent legal cases by looking for specific metabolites with high-performance liquid chromatography — mass spectrometry, but it isn’t easy and often fails and can be challenged in court. Do you have reason to suspect it in either of these cases?”

“Maybe both,” Jack said, warming to the idea, as Sue certainly had had an injection and even Cherine might have had one combined with both having some degree of cyanosis as well as mild pulmonary edema.

“We can certainly try,” John said. “But that will take real time, probably at least a week, provided I can afford to put someone on it right away.”

“Let’s give it a whirl,” Jack said. He remembered when he had been talking with Lou earlier in the locker room, the thought had passed that if both Sue’s and Cherine’s manner of death were homicides, which they certainly would be if succinylcholine was involved, it probably would have been caused by the same person, raising the specter of a medical serial killer. Succinylcholine certainly wasn’t something available at the local pharmacy.

“Okay,” John said. “We’ll get on it, but don’t be pestering me. Let me call you, okay?”

“Fine,” Jack said agreeably. With his mind in overdrive, he was eager to plan what he was going to do during the single day that he had promised Lou. First off, he needed whatever slides were ready, and then he was going to set up a meeting with Ronnie Cavanaugh. There was no doubt in his mind that he was making significant progress on what was becoming one of his more interesting cases out of an inordinately large repertoire.

After quickly but sincerely thanking John for his help and saying goodbye, Jack took the remaining specimen bottles and made his way to Histology.

“Ah, my favorite ME,” Maureen said with a big smile as Jack came into her office. Her cheeks were noticeably redder from the cooler weather.

“Ah, you say that to all the MEs,” he said, pretending to be dismissive.

“You are wrong!” Maureen said with a laugh. “You’re the only ME who visits us, which I love. It makes us feel appreciated. And now it appears you are bearing gifts.”

“More work, I’m afraid,” Jack said. Just as he had the previous day, he lined up the specimen bottles on Maureen’s desk. There were quite a few more than he’d dropped off in Toxicology, which was the reason he usually made his visits in reverse order, but he’d wanted to give John as much of a head start as possible.

“I’ve got slides from yesterday’s case right here for you,” Maureen said. She turned around in her swivel desk chair to take a slide tray off the countertop behind her. As soon as Jack was finished unloading the specimen bottles, he took the tray from her.

“I appreciate getting this so soon,” Jack said.

“I hope Dr. Montgomery isn’t too devastated by her friend’s death,” Maureen said, becoming serious.

“She’s okay,” he confided. “Luckily she’s got a lot on her plate to keep her mind occupied.”

“I’ve made it a point to keep that little bit of information private.”

“I’m sure the chief appreciates it,” Jack said.

“What’s the story on these new specimens? Any specific staining requests?” Maureen glanced at the labels.

“No,” he said. “But I would appreciate getting slides on this particular specimen ASAP.” Jack found and lifted the specimen bottle containing the slice through the potential nevus or injection site, handing it to Maureen. “Whatever is found histologically will influence what John does up in Toxicology.”

“Okay,” Maureen said agreeably. “I’ll put someone on it right away.” She placed the bottle apart from the others.

“Okay, thanks, Maureen,” Jack said. He raised the slide tray she had given him. “And thanks for this. The chief thanks you, too.”

Exiting the Histology Department, he made his way down to his office using the stairwell to avoid having to wait for an elevator. He put the slide tray that Maureen had just given him next to his microscope before hanging up his jacket on the hook behind his door. Plopping himself down in his desk chair, he pulled out his phone and clicked on Bart Arnold’s name, whom he had called the day before at 6:03 p.m. As the call went through, Jack put his mobile on speaker and placed it on his desk. Then he stripped off the rubber band from around the Sue Passero slide tray and lifted its cover. The numerous slides were arranged in two vertical columns with their origins carefully labeled. He lifted out several from the heart. He’d look at the lungs second and then the rest.

“Bart Arnold here,” Bart said.

As Jack introduced himself, he turned on his microscope light and fitted one of the slides onto the mechanical stage with the stage clip. “Have you had a chance to look into the monthly death rate that we’ve gotten from the Manhattan Memorial Hospital over the previous two years?” Jack was now running the objective down with the coarse adjustment wheel to practically touch the slide.

“Yes, Janice Jaeger was able to spend some time on it last night in the wee hours of the morning because things were slow.”

“Great,” Jack said. He truly appreciated Janice Jaeger’s thoroughness. “What did she find?” He put his eyes to the microscope’s oculars and peered in while backing up with the fine control. Out of the visible blur, sudden pink images emerged of cardiac cellular structure.

“The number of cases referred to the OCME was pretty uniform during the first year,” Bart said. “Then it started to change. At first it was a relatively slow change but then picked up speed.”

“Ouch! I was afraid of that,” Jack said. He sat back, questioning how such a fact could jibe with the hospital’s reported decrease in the mortality ratio. Obviously, it couldn’t, and although indirect, more deaths lent weight to Sue’s concern about a possible medical serial killer. “Exactly how much has it gone up?”

“Gone up?” Bart questioned. “It hasn’t gone up. It’s gone down, and it’s gone down considerably.”

Stunned almost as much as he’d been up in John’s office learning Sue’s drug screen had been negative, Jack tried to adjust to this information that was the opposite of what he’d expected. Although deaths being referred to the OCME from the MMH going down didn’t necessarily eliminate the chances a medical serial killer existed, it certainly and significantly reduced them, especially when it confirmed the mortality ratio, which had also gone down, meaning the two statistics did indeed jibe.

“Are you still there?” Bart questioned when Jack failed to respond.

“Yeah, I’m here,” he said. He felt oddly depressed, as if everyone was working against him. First Cherine died, then John threw him a curveball, and now Bart. It was as if facts and circumstance were mocking him. Of course, he knew such thoughts were ridiculous, but he couldn’t help but feel them at least for the time being.

“Is there anything else you’d like us to do?” Bart asked. “Would any breakdown of the various causes of death help you?”

“No, but thank you,” Jack said. “I’ll be back to you if I think of anything.”

“We’re here when you need us,” Bart said, and then he hung up.

Jack leaned farther back, causing his desk chair to creak, and stared up at the blank ceiling, thinking it was symbolic of his current state of mind. He’d started the day in a fit of excitement, feeling as if he were on the edge of solving the whole mystery, and now he seemed no better off than he’d been the day before when he’d finished Sue’s rather unremarkable autopsy.

Tipping forward again, he eyed his microscope and the open tray of histology slides. He reminded himself that he’d originally thought there was a chance that histology would add some important information. With that thought in mind, he wheeled forward and returned to staring into the microscope’s oculars.

For the next several minutes, Jack carefully scanned multiple sections of the heart. As had been suggested by the totally negative gross examination of the organ, the microscopic sections were also boringly routine. There were a few pockets of errant red blood cells, but he reasoned they were probably artifact due to the slicing of the samples with the microtome. More important, the cellular structures all appeared completely normal, as did the cardiac capillaries and coronary arteries. There was only a tiny bit of possible thickening in one artery cross section, but he knew it wasn’t any more than what might be seen in an adolescent’s heart. There was absolutely nothing that would have supported a diagnosis of a heart attack.

Next he looked at the sections of the lungs. Except for some extra fluid, which was expected with pulmonary edema, and a few extra red blood cells, they were unremarkable. Same with the rest of the organs of the body.

When he was finished looking at the slides, he closed the tray, returned the rubber band around it, and put it aside. He felt unnaturally becalmed, which for Jack in his current life was a totally foreign mental state. He was accustomed to constant action and, if anything, a strong tailwind pushing him to greater efforts. It was a lifestyle and mindset he’d developed to pull out of the paralyzing depression the loss of his first family had caused. As a result, Jack had become averse to standing still or, as he called it, vegetating. He found himself lamenting that Ronald Cavanaugh worked the night shift because it meant he’d probably be sleeping all day.

Glancing at his watch, Jack tried to imagine what time he might hear from the nurse, as he distinctly remembered him saying he’d call sometime today. Since Ronnie’s shift went from 7:00 p.m. to 7:00 a.m., it stood to reason that he’d sleep at least to the middle of the afternoon, so it probably wouldn’t be until 3:00 or even 4:00. He sighed. As keyed up as he was, he was at a loss for how he was going to weather the wait. His line of sight moved to the stack of autopsy folders and the unexamined trays of slides on his desk. He could easily spend the hours completing multiple cases, and he probably should, but he realistically doubted he’d be able to concentrate, and if he couldn’t concentrate, he reasoned that he might not perform at the level he required of himself.

Instead of signing out cases, Jack picked up his phone and stared at the text Ronnie had sent him during the night: Here’s my number. I look forward to continuing our conversation. He typed out a reply. Thank you for your contact. I look forward to continuing our conversation as well. I’m available as soon as it is convenient for you.

Only a moment after Jack had hit the send button, his phone rang, making him start. In a mild panic he looked back at the screen, wondering if in some weird technological way Ronnie was responding instantly. But it wasn’t Ronnie calling. It was Laurie.

Jack let his phone ring for several cycles just to allow his brain to readjust, then answered.

“Where are you?” she demanded. Her tone was insistent, angry, and incriminating.

“I’m back at the St. Regis for more French toast,” he said, but then regretted it just as he’d done yesterday. The problem was that such sarcasm had become reflex over the years as a kind of defense mechanism. Often it was effective, but with Laurie it rarely worked, and he knew it would only serve to aggravate her more than she clearly already was. Sometimes he was his own worst enemy.

“I’m not even going to respond to that,” Laurie said. “Are you in the pit?”

“No, I happen to be up here in my palatial office. You sound a bit out of sorts.”

“I am out of sorts!” she snapped. “Get your ass down here! I want to talk with you! You, my friend, are again in the doghouse.”

“Can we put it off for an hour or so? I’m expecting the pope to stop by shortly.” Jack winced, knowing he was undoubtedly making the situation worse. But he couldn’t help himself. She was pushing his buttons, acting like the Laurie he’d come to dislike: boss Laurie.

“Get down here!” she yelled before disconnecting.

“Now what?” he questioned as he tossed his phone onto the desk and went back to staring up at the ceiling. He wanted to give himself a moment to let his irritation subside. He tried to think of what she was now angry about, but he couldn’t imagine unless it was about his playing detective. That morning everything had been hunky-dory. He’d even managed a pleasant conversation with Dorothy, who had gotten up uncharacteristically early.

When he felt he was reasonably under control and able to deal with whatever it was that Laurie was upset about, he grabbed his jacket. As he walked down the hallway to the elevator, he put it on. He didn’t rush