Pandemic

36

THURSDAY, 11:30 A.M.

As far as Jack was concerned, the Dover Valley Hospital autopsy room was not only a joy to look at, it was a pleasure to use. There was even classical music piped in quietly in the background, reminiscent of how Jack had liked to perform eye surgery in his former life. Having it during an autopsy was a first for Jack. He hadn’t even thought of piped music at the OCME, but now he considered making a suggestion to the design committee responsible for coming up with the plans for the new autopsy room.

There were seven people in the room, which included the two mortuary techs Harvey had mentioned and whom Jack had not formally met. Everyone was dressed in the same light green impervious gowns with full face shields. Jack was on the patient’s right, which was his choice, along with Stephen. Directly across from Jack was Harvey, along with Ted. Dr. Han Lin was standing at the head of the table. The two mortuary techs floated. Jack had the instrument tray brought over to his side, as he preferred to pick up instruments himself rather than having them handed to him by Harvey. It was his strong belief that handing off instruments was a source of accidents, which Jack made a point to avoid.

Once he’d finished the external exam with Beethoven’s Piano Concerto No. 3 playing almost subliminally in the background, Jack picked up the scalpel. After asking Stephen if it mattered to him if Jack cut through the woman’s well-healed thoracotomy scar, Jack carried out a modified Y autopsy incision just as he had done on Carol Stewart.

Jack worked quickly and efficiently. Although he knew everyone present was interested exclusively in the heart, he followed his usual routine and first did the abdomen. Jack never varied the order he followed in his autopsies, to make sure he never forgot any step. He explained this to his audience, and they all said they understood. Stephen and Ted acted subdued as the case progressed, which was understandable, as autopsies were not part of their normal routine, and to the uninitiated they were brutal.

After checking the entire length of the digestive tract in situ, Jack removed the intestines and handed them off to one of the techs to wash out. He then inspected the rest of the abdominal contents. The only pathology he found were the signs of mild inflammation with extravasated blood in the gallbladder, spleen, and kidneys. He informed the group that Carol Stewart had the same findings, which he explained were later determined by microscopic section to have a mild amount of disseminated intravascular coagulation.

“Was it about the same amount of inflammation with Carol?” Ted asked, as Jack held up the cut surface of the kidney so it could be more clearly seen.

“I’d say nearly identical,” Jack said. “When I first saw it, I thought of hantavirus, as it’s a typical finding in those particular organs in fatal hantavirus pulmonary syndrome. But rapid tests for hantavirus were negative, as were tests for all the other respiratory viruses.”

“Can we move along here?” Stephen said. “Han and I have a case on a live person pending at noon.”

Jack didn’t respond. He was already working significantly faster than he knew most prosectors functioned. In his current sensitive state, he couldn’t help but be mildly annoyed at Stephen’s increasingly impatient and condescending air, which was becoming progressively apparent and which hadn’t been present yesterday.

Taking the heavy-duty wire cutters he’d requested at the outset of the case, Jack proceeded to cut through the wires holding Margaret’s sternum together. They made a distinctive metallic snap as each one was cut. Harvey then participated by pulling each wire out with a pair of pliers. When the last wire was cut, the sternum split apart with an audible pop.

Using a couple of towels against the jagged cut surfaces of the sternum, Jack yanked them apart with a decisive cracking noise, which he knew was the sound of breaking ribs. The thorax was now completely exposed and mostly filled by the pale, swollen lungs. Shielded by its scarred pericardial cover, the heart was not yet in view. Jack left the towels in place to avoid anyone cutting themselves on the sharp edges of bone.

Stephen leaned over the open wound. “Do you mind if I palpate the pericardium?” he asked.

“Be my guest,” Jack said. He was surprised the surgeon had asked. It seemed out of character with his controlling personality.

“Feels like a normal amount of scarring,” Stephen said after running the balls of his fingers back and forth over the tissue a number of times. He then stopped and pointed. “This is where we closed the pericardium with a running suture.” He then straightened up and withdrew his hand. “Do you think this is about the same degree of scarring you saw when you did Carol’s post?”

Jack palpated the tissue between the lungs, imitating Stephen. He’d not done that with Carol until after he’d removed the lungs and the heart, so he couldn’t compare exactly, but it seemed equivalent, and he said so.

“Did you open Carol’s pericardium at this point?” Stephen asked.

“No,” Jack said. “I didn’t do that until I had removed the lungs and the heart en bloc. Do you want me to do the same here or would you like me to open the pericardium now, so you can see the heart in place?”

“I think he should use the same technique as he used with Carol,” Ted said, speaking up for the first time. “That’s the only way he will be able to truly compare the two.”

Stephen agreed. “Go ahead and follow your usual modus operandi.”

Using a pair of dissecting scissors rather than a scalpel, as he thought it safer, Jack proceeded to free up the lungs and the heart. He then lifted the entire mass up out of the thorax. He carried the weighty slab of flesh over to a nearby countertop and plopped it down on a scale.

“Is that heavier than usual?” Stephen asked, looking at the readout.

“Much heavier,” Jack said. He then started to open the pericardium exactly as he had done with Carol, to expose the heart itself. “You can see there is considerable fibrotic scarring, but it is to be expected.”

Both Stephen and Ted crowded in to take a look once the heart was fully exposed.

“My word, it looks entirely normal,” Ted said. “Perfect orientation. I’m impressed even more than I expected to be. It looks like a very happy heart.”

“I agree,” Stephen said. “I don’t mind saying so myself, but it was a perfect job.”

“And a perfect donor heart,” Ted added.

“How does it compare with Carol’s?” Stephen said, turning to Jack. “If you were pressed to say which one you thought had been accepted the best, which one would you say?”

“It would be hard to say,” Jack replied thoughtfully. “I’d say they were equivalent.”

“Let’s see the rest of the anastomoses,” Stephen said. “The aorta looks fine, but there could be a difference with the others.”

Jack pushed back the bloated right lung in an attempt to visualize the great veins called the superior and inferior vena cava. It was difficult because the lung was turgid with fluid.

“Why don’t you go ahead and remove the lungs,” Stephen said. “Just make sure the pulmonary anastomoses are proximal to the heart.”

At first Jack wasn’t sure what Stephen meant, but then he got it. Stephen wanted the connections he’d made when he’d done the transplant to be connected to the heart, not to the freed-up lung. Using the dissecting scissors again rather than the scalpel, Jack separated both lungs from the heart. The connections with the great vessels could all be seen. Jack stepped back to give Stephen and Ted more room. While they looked, Jack weighed each lung.

“They all look terrific to me,” Stephen said. “I hate to blow my own horn, but they are all masterfully done.”

“You’re getting good in your old age,” Ted teased. “But you’re right. They all look terrific, well healed and without the inflammation we agonized about. I don’t see any difference here with what we saw during Carol’s second autopsy. It seems as if our experiment is a draw. What are your thoughts?”

“I have to agree with you,” Stephen said. “How about you, Dr. Stapleton. Do you see any differences between Margaret’s anastomoses and Carol’s?”

“Not at all,” Jack said. “They look comparable to me.”

“So there we have it,” Stephen said. “We didn’t think there was going to be a difference, and there doesn’t seem to be.” He looked over at the institutional clock as if he was planning on leaving.

“I think you should see the inside of the lungs,” Jack said. Without waiting for a response, he got one of the long-bladed knives used in autopsies and made some slices into the lungs’ parenchyma, which under normal conditions were air-filled, light, and spongelike. As he made the cuts, the edema fluid burst forth, almost as if it had been under pressure. It was blood-tinged and mixed with exudate and bits of tissue.

“Whoa,” Ted exclaimed. “That’s rather dramatic. We didn’t see that with Carol’s lungs.”

“That’s because most of the fluid had drained out,” Jack said. “It gives you a better appreciation of what the immune system can do when it’s turned on to create a cytokine storm. It’s not a mystery why these people died so quickly. This is a nasty virus.”

“Are you still thinking this is caused by a virus?” Stephen asked. “We’re continuing to look into the protein angle, thinking of something like a prion.”

Jack started. The idea of a prion disease never occurred to him. But as soon as he considered it, he rejected it. “Prion disease only strikes neural tissue, not pulmonary tissue,” he said. “No, this must be a virus, but I admit there are some aspects that don’t make sense.”

“And what are they?” Stephen asked patronizingly.

“This is the fourth case that I have seen,” Jack said. “They are all exactly the same, which in my mind points to an infectious origin. If I had to guess, I’d say Carol Stewart is the index case, and she gave it to the others with whom she’d been intimate. For a number of reasons, I am thinking it is a retrovirus. Since she had just had a heart transplant and had never had any pulmonary problems, it is a reasonable guess she got it from the donor, who was carrying this unknown retrovirus that spreads via body fluids, like HIV.”

“That’s all very fanciful,” Stephen said in the same tone of voice. “I have to give you credit for being creative. But you haven’t told me what doesn’t make sense.”

“Margaret,” Jack said. “I’ve been told that she knew Carol but wouldn’t have been likely to share body fluids. That means that Margaret would have had to get it from her donor heart just like Carol, and unless this unknown retrovirus that’s never been seen was widespread, which it can’t be, the chances of that happening are infinitely small.”

“I can see where that is a problem,” Stephen said.

“How good a match was the donor heart that Margaret got?” Jack asked.

For a beat neither Stephen nor Ted responded. Finally, Ted spoke up. “It was an okay match, otherwise we wouldn’t have done it.”

“Where did it come from?” Jack asked. “Was it a local donation or from someplace far away?”

“That I’d have to look up,” Ted said. “I don’t remember offhand.”

“Was Margaret on high doses of immunosuppressants, unlike Carol?” Jack asked.

“No,” Ted said. “Just the normal amount.”

“From the looks of the heart here, there seems to be no inflammation whatsoever. I don’t have a lot of experience posting heart transplant recipients, but isn’t there usually some rejection phenomena going on that’s kept under control?”

“UNOS tries to make the best possible match to keep that at a minimum,” Ted replied.

“Sorry to interrupt,” Stephen said. “I want to thank you, Dr. Stapleton. This autopsy has been very enlightening, but I do have a transplant case starting in just a few minutes. If you’ll excuse me.” Without waiting for a response, he headed for the exit leading to the room to remove his protective gear. Wordlessly Dr. Han Lin followed.

“And I have a clinic full of patients to see,” Ted said. “I also want to thank you for coming and helping us, Dr. Stapleton. You’ve provided us with important information. I hope we see you again real soon.” Then he headed for the same exit Stephen had used and disappeared.

Jack, still holding the long-bladed knife he’d used on the lungs, felt suddenly abandoned. The exit of the three doctors had been so sudden and unexpected that he’d scarcely had time to react. It also seemed to contradict their previous warm hospitality. It was as if they had gotten what they wanted and that was it. They clearly hadn’t been concerned with giving Jack an opportunity to ask any of his myriad questions. Now, as he looked across the room at Harvey, who had busied himself by supervising the removal of the skull cap to facilitate finishing the autopsy, Jack wondered if he might be able to provide any answers. Yet as Jack watched the man struggle with his current task, he wasn’t optimistic. In comparison to Stephen and Ted, Harvey seemed like a dunce. Plus, Jack was wary of the man after hearing him place a call to Wei Zhao as soon as Jack had left his office yesterday afternoon. Whatever hanky-panky might be going on at the Dover Valley Hospital, he feared Harvey was probably involved. Whether that was true of Stephen and Ted, he had no idea.

“See any pathology in the brain?” Jack asked, as he returned to the autopsy table.

“None so far,” Harvey said. “I hope you don’t mind that I had the techs push ahead.”

“Not in the slightest,” Jack said, making up his mind that Harvey wasn’t a good bet as a source. “In fact, I think I’m done here and would like to ask you to please finish up. I have a number of important questions for the doctors that I didn’t get a chance to ask, and I’d like to catch them before they leave the morgue.”

“But you’re not done here,” Harvey said with a whine.

“I beg to differ,” Jack said. “All you have to do is check the brain and prepare some specimens for microscopic sections. That’s not asking a lot with your capable hands. I’ve certainly accomplished what Dr. Friedlander and Dr. Markham had in mind for me, and I assume this is a Morris County case.”

“No, it was signed out to the Dover Valley Hospital,” Harvey corrected. “And if you want to get paid, I want you to stay here and finish.”

“I think I’ll argue that point with the bursar instead of with you,” Jack said, immediately taking offense. He’d suspected Harvey of being lazy and a laggard, but this seemed beyond the pale, as it would take him only ten minutes or so. He’d even given the man a questionably deserved compliment.

“Suit yourself,” Harvey said morosely.