Pandemic

10

TUESDAY, 10:40 A.M.

With the Post-it Note Sergeant Murphy had given him pressed against his monitor screen to be in full view, Jack called Detective Pauli Cosenza at the Thirteenth Precinct. Jack had returned from the high-rise building and was back in his office. From having had to call police stations around the city as well as other city bureaucratic offices on many previous cases, Jack knew he would have to be patient. In anticipation, he had his feet up on the corner of his desk and was sipping a fresh mug of coffee as the call went through.

Using a pen, he absently made a mark on a scratch pad with each ring. As he did so, he vaguely wondered what Detective Cosenza might tell him. Jack was hoping for the best, as Cosenza was most likely the only member of the NYPD Missing Persons Squad specifically tasked with making an identification on the subway death. From experience, Jack was not particularly optimistic that he’d learn much. After twenty rings, he became even less hopeful, realizing there was a chance no one would answer the extension he was calling. After thirty rings, he began to consider calling the main number of the Thirteenth Precinct and asking for the detective, although from sore experience he knew that wasn’t necessarily better and was maybe worse.

After thirty-six rings, just when his patience was at an end, the phone was answered. And to Jack’s astonishment it was the detective himself rather than someone else lower on the totem pole.

For a brief moment Jack was flustered and tripped over his words as they spilled out too quickly. Having the phone answered just when he was about to hang up made him fear that if he didn’t speak fast enough the man might disconnect. Making an effort to slow down, Jack introduced himself, giving his name and position as a medical examiner at the OCME. He then told the detective that he had autopsied a youthful, unidentified woman the previous day who’d become sick on the R train and then had been declared dead at the Bellevue Hospital emergency room.

“I know the case,” Pauli said. His voice was flat and unemotional, as if he was bored to tears.

“Excellent!” Jack said. He remembered Sergeant Murphy saying the man wasn’t a ball of fire, so Jack purposefully tried to sound enthusiastic and upbeat. “I was told the case had been assigned to you.”

Hoping the man would pick up on the thread of conversation, Jack purposefully paused. Unfortunately, there was nothing but silence on the other end of the line. “Hello?” Jack questioned after a few beats. He feared they’d been disconnected.

“Hello yourself,” Pauli said.

“Am I wrong?” Jack questioned. “Was the case assigned to you or not?”

“It was assigned to me,” Pauli said.

“Okay, good. What’s happened so far? The OCME has not received any inquiries from family, coworkers, or friends. We still do not have an identification, and it’s important that we get one.”

“What do you mean, ‘What’s happened so far’?” Pauli questioned. “I got the report from the responding officer at the Bellevue ER and forwarded it down to One Police Plaza Missing Persons like I’m supposed to do. I also copied it to the OCME PD liaison, whatshisface.”

“You mean Sergeant Murphy?” Jack questioned.

“That’s the guy,” Pauli said.

“Okay,” Jack repeated. “What has Missing Persons done?”

“Not much, would be my guess, beyond adding the case to the list of missing persons. Just to give you an idea, we get around thirty-five missing-persons reports every day, three hundred sixty-five days a year. The Squad has a backup of almost thirteen thousand cases.”

“And what have you done as the assigned detective during this critical first twenty-four-hour period on this particular case?” Jack asked, struggling to keep sarcasm out of his voice. It was already clear to him that Pauli was giving him the classic runaround. The so-called assigned detective was just sitting at his desk doing nothing instead of investigating anything.

There was a short silence until Pauli said, “Look, Doc, I sent the material where I’m supposed to send it. Since then I’ve been waiting.”

“Waiting for what?” Jack questioned with obvious incredulity.

“I wait for more information. So far there’s almost zilch, you know what I’m saying? I got a sketchy description from a patrol officer and that’s it. I wait for prints, photos, and whatever you guys get from the autopsy in terms of descriptions of scars, tattoos, broken bones, you name it. When I get prints I run them locally, and if no hits are found, we run them on the state level up to federal. But I have to warn you. On a case like this with a snappily dressed broad, we rarely get hits. It’s up to family to come forward. Beyond all that, we wait for DNA info so we can run CODIS and NamUs. And to give you an idea of what I’m up against, I have a hundred and seven other missing-persons cases besides this one sitting here on my desk.”

Struggling to be civil, as it would be counterproductive to alienate the detective, Jack thanked him for his time. Jack then gave his mobile number on the outside possibility that Pauli might learn something that could be helpful in making an ID. Jack promised to do the same before ringing off.

After hanging up, Jack rocked back in his desk chair, stared up at the ceiling, and fumed for a few minutes to regain his composure. Even though he was a civil servant himself, he’d always found dealing with bureaucrats and government employees in general to be emotionally challenging, and Detective Cosenza was no exception. Jack had the sense that the man did as little work as humanly possible and merely shuffled papers around on his desk. But to make certain he had all the information, Jack called Sergeant Murphy to make sure the detective received what was now available — namely, the digital body photos, tattoo photos, and fingerprints.

When his mind was clearer and his emotions under control, Jack struggled to remember the name of Laurie’s friend who was a supervisor at PSAC, the NYC Public Safety Answering Center. He and Laurie had talked about the woman a few months ago because Laurie had learned she’d been moved to the new, fortresslike 911 PSAC II building in the Bronx. Previously she’d worked at PSAC I in Brooklyn. Jack remembered the woman as having been a big help to Laurie when Laurie had investigated the case involving the unidentified Japanese homicide victim. Jack thought she might be able to help him in a similar fashion, if he could only remember her name. He thought briefly about calling down to the front office and asking Laurie, but quickly changed his mind. Laurie would want to know why he wanted the number, and after their words yesterday afternoon and last night, Jack preferred she didn’t know what he was up to. Despite Laurie’s orders to the contrary, Jack was hoping the subway death would lead to some serious fieldwork.

The raucous ring of his office phone snapped Jack’s attention back to the immediate present. It was Sergeant Murphy.

“I got the responding transit patrolman’s name, badge number, and mobile phone,” Murph said. “You have a pencil and paper handy, or do you want me to text it?”

“I have pencil and paper,” Jack said. “Go for it.”

“His name is Dominic Golacki. Obviously, a nice Irish boy,” Murph joked. The sergeant had a renowned sense of humor. He spelled the name for Jack and then gave the badge and mobile numbers. “I was told he’s Polish.”

Jack was about to dial the number when he suddenly remembered the name of the 911 supervisor. It was Cynthia Bellows. Although Jack had the Brooklyn 911 call center phone number in his contacts, he didn’t have the new Bronx one. To get it, he called Sergeant Murphy back. A few minutes later he was talking to the operator of PSAC, and he asked to be put through to Cynthia’s line.

Half expecting he’d have to leave a number for a callback, Jack was pleased when he found himself on the line with the woman directly. He explained who he was, and, most important, that he was Dr. Laurie Montgomery’s husband, and then told the woman that Laurie had been promoted to be the chief medical examiner of New York City. Cynthia had not heard and was thrilled.

“I’m calling for a favor,” Jack said after the pleasantries. “I remember you did this for Laurie on at least one occasion. What I need is the name and mobile number of a nine-one-one caller. It happened just yesterday, and it came in from an R subway train. The call was to report a sick passenger.”

“Do you have the time of the call?” Cynthia asked. “We average around one hundred eighty EMS calls per hour.”

“I don’t have the exact time,” Jack admitted. “But I could find out the exact time the transit police were notified. Would that help?”

“Do you have an approximate time?”

“Yes. It was around ten A.M.”

“That might be good enough,” Cynthia said. “I’ll see what I can do. Give me a number and I’ll get back to you.”

After giving Cynthia Bellows his mobile number, Jack hung up his office phone. As soon as he did so, he chided himself for not asking Cynthia when approximately he might hear back from her. Probably due to his dislike of talking on the phone, he wasn’t good at it. Like a typical Luddite, he much preferred face-to-face interaction, although emails were becoming a close second and he was learning to appreciate texting.

Looking at Dominic Golacki’s mobile number, Jack thought about him being his next call. But he hesitated. Laurie had benefited greatly from the help of the transit police’s Special Investigation Unit, as they had provided her with the videotapes of the 59th Street IND subway station. It was from the videotapes that she had determined her case’s death had been a homicide, which broke open the case. Jack knew that subways now had continuous video recordings inside the trains, and, remembering Laurie’s successes, he thought about getting them. His idea was to watch the tapes and determine who had stolen the subway death’s phone and purse, which she undoubtedly had, in hopes of apprehending the individual and making an ID. But the more Jack thought about the idea, the less reasonable it seemed. Even if he got an image of the thief or thieves, the chances of finding them were slim at best. Besides, it would all take too much time, and time was of the essence.

In a minor fit of exasperation, Jack balled up the paper with Golacki’s number, and then shot it like a basketball into his wastebasket, which he’d placed on top of his file cabinet for exactly that purpose. Jack was tired of the telephone and tired of the subway death case thwarting him at every turn. Then, as if to mock him, his mobile rang with the fire-truck alarm that he had again forgotten to change.

“I found it,” Cynthia Bellows said without preamble when Jack answered. “You were very close on the time. The first call came in at 10:02 A.M. There were two others, but those people were informed that EMS had already been alerted. I have the caller’s name and mobile number if you are still interested.”

“Absolutely,” Jack said. It seemed like a minor success. The name was Tess Eggan. “Thank you muchly.”

“You are most welcome,” Cynthia said. “And give my best to Laurie and congratulate her for me on her promotion.”

“Will do, and thanks,” Jack said, even though he knew he was lying. He wasn’t going to tell Laurie that he’d been speaking with Cynthia. It would raise too many questions. Jack knew he was being at least partially childish, but he didn’t care.

As soon as he had disconnected from Cynthia, Jack put in a call to Ms. Eggan. As he expected, assuming the woman would be working, he had to leave a voice message. In it he carefully described himself as a senior medical examiner at the Office of the Chief Medical Examiner who wanted to talk with her briefly about her 911 call the previous day. He then left his mobile number. Just to be absolutely sure she got the number, he also texted it along with the main OCME number, in case she wanted to check if he was who he said he was.

With that done, Jack again rocked back in his chair and stared up at the ceiling. He wished there was more he could do, but for the moment he couldn’t think of anything. At the same time, he knew he shouldn’t be spending so much effort on the ID issue, since it was other people’s job, but he couldn’t help himself. He needed the diversion, as evidenced by his mind switching back almost immediately to Emma and, ultimately, to Dorothy. Was Emma’s diagnosis for certain or was it going to remain up in the air? Autism was not an easy diagnosis because it wasn’t a single disease with a telltale biomarker that could be confirmed in a medical laboratory. It was an impression, and via her pediatrician, Emma was still being evaluated. As far as Dorothy was concerned, Jack wondered if Laurie was going to have the strength to deal with the issue before Caitlin was driven to distraction and abandoned them.

“Hello! Dr. Stapleton!” a voice called out simultaneously with a knock on Jack’s partially open office door.

Jack rocked forward with a thump and found himself looking up into the face of a woman who looked more like a teenager than a college graduate. He vaguely recognized her as one of the newest medical-legal investigators. With the OCME physically split between two buildings, there wasn’t the familiarity that had previously existed among the departments, something Jack missed.

“Mr. Bart Arnold wanted me to run these slides over and give them to you in person,” the MLI said. She extended a microscope slide tray toward Jack, and then, with a toss of her head and its attached ponytail, she was gone.

Jack blinked. It had all happened so quickly, and had he not been holding the slide tray, he might have thought the brief encounter had been more in his mind than in reality. Looking at the slides themselves, Jack immediately understood why Bart had had them hand-delivered. They were the Jane Doe slides. Apparently, Bart had managed to motivate the Histology Department to exceptional efficiency. In Jack’s mind, getting mounted and stained histology slides in less than twenty-four hours might qualify for Guinness World Records. Jack knew that he had been a bit hard on the MLI supervisor, but maybe it was paying off.

Using the wheels on his desk chair, Jack moved over to his microscope and turned on the light source. The first slides he looked at were of the lungs. Even using low power, the amount of inflammation of the lung tissue was obvious. It was also apparent there was no real consolidation, as death had intervened before it could occur. Going to higher magnification, Jack could appreciate the hyperacute inflammatory cell infiltration of macrophages, granulocytes, immune dendritic cells, and natural killer cells that filled the lung’s alveolar spaces and septa. There was significant destruction. From Jack’s perspective, it was like looking at the aftermath of a horrendous microscopic battle that characterized a cytokine storm. If it was a virus, it was an impressively lethal one that made the immune system go into hyperdrive.

Next, Jack picked out the slides of the heart and was about to place the first under the microscope’s objective when his mobile phone scared him yet again, as he still hadn’t changed the ringtone back to something reasonable. Snapping up the phone, he answered curtly.

“Is this Dr. Stapleton?” a high, nasal-sounding voice asked.

“It is,” Jack said as he adjusted the ringtone.

“My name is Tess Eggan,” the woman said. “You left a voice message for me to call you back about my nine-one-one call yesterday.”

“Oh, yes, of course,” Jack said, mildly flustered. He’d been so entranced by the microscopic inflammatory carnage that he’d forgotten.

“Since you’re a medical examiner, I suppose that doesn’t bode well for the woman I called about.”

“It doesn’t,” Jack agreed. “Unfortunately, the woman was moribund by the time she was taken from the train and was essentially dead on arrival at the Bellevue Hospital emergency.”

“What a tragedy,” Tess said. “She was young. She looked about my age and very attractive. She even had a hairstyle somewhat similar to mine. Early on, I almost spoke with her. I was tempted.”

“Are you saying you were on the train with her for a while?”

“I was,” Tess said. “I live in Bay Ridge, where the R originates. She got on soon after, in Sunset Park. It was either the fifth or sixth stop, meaning Fifty-third Street or Forty-fifth Street. I don’t remember exactly.”

“Had you ever seen her before on the train?” Jack asked. He was encouraged.

“I never have. And I would have remembered.”

“Did she act as if she was well when she boarded?”

“Completely. At that point the train wasn’t yet crowded. I was hoping she’d sit next to me, but she didn’t. She sat in a seat nearby, but not next to anyone.”

“Was she carrying anything?”

“Yes. She had a small, stylish backpack.”

“How about a phone?”

“Yes. I saw her use her phone soon after she boarded.”

“When she was brought in to Bellevue, she had no backpack and no phone,” Jack said. “And that is the core of the problem. We have no identification. No family members, or coworkers, or friends have reported her missing.”

“That’s terrible,” Tess said. “I can’t imagine why no one would call about her. And about her backpack and phone: Someone must have stolen them.”

“We are equally confused why no one has called.”

“What did she die of?”

“That’s still to be determined,” Jack said. He was tempted to ask Tess if she felt any kind of symptoms whatsoever, but he didn’t. He didn’t want to alarm her, and since he had her phone number, he knew he could alert her if it developed that it was necessary. Instead, he asked, “Do you know when she began to get sick?”

“I don’t,” Tess said. “I started to read my book, which is how I spend my time on the subway. And the train got crowded, as it usually does. The next thing I knew was that she was gasping for breath. I think it was around the time we had reached the East River. But I’m not sure. Then I saw her collapse on the floor at the Union Square station. That was when I called nine-one-one.”

“Thank you for your help,” Jack said. Tess had certainly confirmed his fear that the victim had gotten on the train feeling quite normal, only to be on death’s door by the time she got into Manhattan. Jack thought again of the stories he’d heard about the 1918 influenza pandemic. He found the similarity disturbing.

“If I think of anything else, I’ll call back,” Tess said graciously. “It is such a sad story.”

Jack disconnected the call and for a moment thought about what he had learned, which wasn’t much. Possibly the victim lived in Sunset Park, Brooklyn, although there was no way to be certain. He wondered if there was any chance that some flyers describing the deceased and placed at both the 53rd Street and 45th Street subway stations would result in any calls. He doubted it. The trouble with the idea was that it would take too long just to figure out which city agency would execute it. Besides, his intuition told him it would have a low chance of success. Instead, Jack found himself back to thinking about the victim’s heart transplant. Since that history put her in a very special, small group, he thought there was a good chance it could solve the identity issue. He just didn’t know how exactly to use the information and do it quickly.

While his mind played with that idea, he returned to looking at the histology slides. The next slides he was interested in examining were those of the heart. Although there had been no signs of inflammation grossly, he wondered what he was going to see microscopically. The case was full of surprises.

Using low magnification, Jack scanned the first slide. It looked entirely normal, almost too normal, considering the woman had essentially drowned in her own body fluids. Switching to high power, he was able to confirm that there was absolutely no inflammation whatsoever. Now he had proof the woman did not suffer from organ rejection, although he still thought there was an outside chance her death could have been caused by a bizarre form of graft-versus-host disease, even though scientifically it made no sense to him.

The rest of the heart slides were as normal as the first, including sections through the sutured portions of the aorta, the pulmonary arteries and veins, and the large veins of the body. Everything had healed superbly with no inflammation. From everything Jack could see, it had been a perfectly performed heart transplant, and the patient should have lived a relatively normal life-span.

Turning next to the organs where he had seen some suggestion of mild inflammation during the autopsy, Jack found consistent microscopic evidence of the same. That included the kidneys, the spleen, and the gallbladder. Again, it suggested to him a viral illness, but a nonspecific one, and the amount of inflammation wasn’t enough to cause the woman any symptoms, much less her death.

The rest of the slides were pretty much normal. When he was finished, Jack returned them all to the slide tray, keeping them organized by organ systems. He put the slide tray on the corner of his desk with the idea of showing the lung slides to his former officemate, Dr. Chet McGovern. Jack and Chet frequently shared interesting cases. Jack wanted to know if Chet had ever seen what Jack was planning on calling a cytokine storm and whether he had any idea of what could have caused it.

Returning to the ID conundrum and that the victim had had a recent heart transplant, Jack Googled heart transplant centers in the New York metropolitan area. He was surprised and daunted by how many there were, including NYU Langone Medical Center, which was situated right next door to the OCME. Since the two institutions had a formal connection, with NYU Pathology residents rotating through the OCME for their forensic pathology, Jack called the heart transplant referral line for some general information.

After being transferred a number of times, causing significant delay, Jack finally found himself talking to Nancy Bergmeyer, a certified nurse practitioner who functioned as a transplant nurse coordinator and as director of the program. Jack immediately sensed from her commanding voice that she was a no-nonsense, well-informed individual. After making sure the woman had a few minutes available, he launched into an explanation of why he was calling: “Yesterday, I autopsied a female in her late twenties or early thirties who died of a very rapidly developing pulmonary disease. My worry is that it might have been infectious. The problem is, we have no ID, and we really need one quickly.” He went on to say that he’d determined the woman had had a heart transplant three or four months earlier, which made him wonder if that fact could help make an identification.

“It’s possible,” Nancy said. “But it probably won’t be as easy as you might believe, and it likely would take more time than you might imagine. In this day and age of strict adherence to HIPAA rules protecting medical records, we can’t offer anything to someone like yourself or even law enforcement on a fishing expedition. It’s a catch-22 in that you are looking for a name, but we can’t give you anything unless we have authorization, meaning a warrant or a subpoena, and to get a warrant or a subpoena a name is needed. And what you are talking about involves a lot of patients. To give you an idea of the number, somewhere around fifteen to twenty percent of the heart transplant recipients are in the age bracket of your patient.”

“Yikes! This is what I was afraid of,” Jack admitted. “How many heart transplants are done in the metropolitan area in a year?”

“I’d say two to three hundred,” Nancy said. “There would be more if it wasn’t limited by the supply of organs.”

Jack whistled under his breath. It was obvious the transplant club had more members than he had bargained for, magnifying the difficulties. “Let me ask you this: Post-transplant care is pretty intense, correct?”

“Absolutely. For the first month we see them every week at a minimum, with cardiac biopsies as needed. Up until three months, every other week at a minimum. After three months, maybe every other month. Of course, the patients are seen more often if problems develop, like acute rejection or arrhythmias or high blood pressure.”

“So post-transplant patients generally remain near their transplant center,” Jack said. He was thinking that if the subway death patient lived in Sunset Park she probably had had her surgery in the metro area.

“I’d say that was the case. At least, that has been our experience.”

“At autopsy this patient’s heart looked perfect. There was no sign of any inflammation whatsoever. From what you are saying, she might not be scheduled to be seen for a month or two.”

“That would be an appropriate assumption. If what you’re thinking is that it might take some time before she is missed in terms of her post-op appointments, you are probably correct.”

Suddenly Jack remembered the surprising toxicology result. “One other thing of note: Toxicology determined she had no immunosuppressant drugs on board. Is that surprising?”

“It is more than surprising,” Nancy said with obvious incredulity. “I think you should run the tests again. She had to be on immunosuppressants to avoid acute rejection. It’s standard procedure.”

“What if the heart happened to be a particularly good match?”

“It would have to be from an identical twin,” Nancy said with equal skepticism. “And if that had happened here in NYC, it would have made the headlines or even the front page of the Daily News! Maybe with a kidney, but not a heart, for obvious reasons. She had to have been on immunosuppressants. Even if it had been a decent match. No question.”

Jack thanked Nancy for her time.

“No problem,” Nancy said. “Do you want my mobile number, in case you have any other questions?”

“I would,” Jack said. He wrote it down on his scratch pad and then rang off.

“Damn!” Jack shouted at no one, and he slapped the surface of his desk with an open palm hard enough to make his keyboard jump. He felt frustrated. But then, out of the blue, an idea popped into his head: What about the tattoos?