Pandemic

3

MONDAY, 12:20 P.M.

Jack dialed his mobile phone before he was even out of the 421 elevator, but he waited until the doors opened and he got a decent signal before he put the call through. He wanted to talk to Vinnie ASAP. Vinnie’s irritated voice came on the line after two rings. Over the years, Vinnie had gotten wise to Jack’s demanding nature, as Jack performed far more autopsies than any of the other doctors, by a long shot. When Vinnie saw it was Jack calling, it usually meant yet another trip back to the pit, no matter the time of day. If it was after three P.M., he avoided answering at all.

“A case should have come in recently,” Jack began, unable to keep the excitement from his tone.

“Aren’t we lucky,” Vinnie said. He’d also acquired a strong predilection for serious sarcasm from Jack. “Should I clap or cheer?”

“I’d like you to take your sorry ass into the cooler and let me know if it’s there yet,” Jack said. “It will be in a body bag and labeled JANE DOE or something similar. I’ll hold on.”

Jack arrived at his bike and waited. He smiled at the guard in the tiny booth that overlooked the entire loading area. The guard glanced at him askance, as if he’d never seen a doctor in a white coat using a bike in the city, even though with Bellevue and NYU Hospital in the immediate area there were doctors galore.

Maybe Jack’s impatience stemmed from his exhilaration after meeting with Bart, but it seemed to take Vinnie an age to accomplish such an easy task. Finally, he came back on the line.

“It’s here, zipped up tight. Don’t tell me you are thinking of us doing it today. It’s after twelve, and we’ve already done three cases. Why not spread the wealth?”

“This one has the makings of being an interesting case,” Jack said. “We might even become heroes. Who knows? It is a potentially contagious problem involving a woman who died on the subway.”

“Shit! Double whammy,” Vinnie complained. “You know how I hate contagion cases. Can’t you find another sap to torture? Why me?”

“I wouldn’t want to deny you the pleasure, and we are a team, my friend,” Jack said. It was true, to an extent. They had worked so often together that they often anticipated each other’s actions. “I want to do the case in the decomposed room, for safety’s sake.” The decomposed room was a separate, relatively small autopsy room usually reserved for decomposing corpses, to limit the smell of putrefaction. It had its own self-contained ventilation system with high-efficiency particulate filters and odor absorbers.

“What did I do to deserve this?” Vinnie questioned rhetorically, then sighed. “Well, the upside is that Carlos Sanchez will get a serious introduction to what being a mortuary tech is all about. Does this mean we’ll be in moon suits?”

“For sure,” Jack said. Moon suit was the in-house term for a one-piece isolation getup made of Tyvek that featured a hood and a self-contained HEPA filter with a battery-driven ventilation pack. Like spacesuits, they were cumbersome and difficult to work in. They were also hot and generally uncomfortable. Needless to say, they weren’t the most popular item of apparel at OCME.

“Weigh and X-ray the body in the body bag,” Jack added. “And don’t take the body out until I get over there and we’re ready to start. We can do the photographing and fingerprinting after the autopsy is under way.”

“Where are you?”

“I’m at 421, but I’m on my way back to 520. I’ll be there in minutes, so let’s get the show on the road.”

Hefting his bike up on his shoulder, Jack carried it down the half-flight of stairs from the receiving dock to the street level. Once on the bike, he pedaled up to First Avenue and turned north. He had to go only four blocks, so he made the best of it by accelerating to almost the speed of the traffic. By the time he turned into the receiving dock at the 30th Street building, he was breathing heavily from the exertion. It gave him a bit of a high, as if he’d had a cup of espresso.

When he passed the decomposed room, he glanced in through the small central wire-meshed window. The light wasn’t even on yet, meaning Vinnie needed more time to get set up. After storing his bike near the Hart Island coffins used for the unidentified dead, Jack made a quick trip up to the front office on the first floor. With the concern he felt about the potential ramifications of the upcoming case, he thought it best to at least let Laurie know there was a potential extraordinarily hot-button issue on the horizon. If it turned out the woman had died of a particularly lethal new strain of influenza, the involved city agencies in the Department of Health needed to know right away. Notifying them appropriately would be Laurie’s responsibility.

“Hello, Cheryl,” Jack said in a chipper tone. Cheryl Sanford was the administrative secretary to the chief medical examiner, meaning she now reported to Laurie. For the whole time Jack had been a member of the OCME staff, she had been secretary to Dr. Harold Bingham, and Jack had had many interactions with her, as he’d been called to Bingham’s office more times than he liked to admit. Jack’s attitude toward rules was best described as selective. He thought rules were suggestions, and if they got in the way of his work, he often ignored them. Although he’d been proven to be inordinately effective as a medical examiner, his methods often got him in trouble with the front office, ergo many visits to the couch beside Cheryl’s desk while waiting to be reprimanded by the big boss. On one of those visits, Jack had learned that Cheryl was also a neighbor, living only a block away from Jack. At the same time, Jack had also learned that she was raising a teenage grandson who played basketball. Jack ended up getting the boy involved in the basketball games across from the Stapletons’ house in the public playground Jack had paid to have refurbished.

With his excitement brimming Jack didn’t stop to chat but rather headed directly for Laurie’s closed office door. Cheryl called out sharply enough to stop him in his tracks. “I wouldn’t go in there!” she warned, under no uncertain terms. “Dr. Montgomery is on a conference call with the mayor and members of the City Council and will be for some time. Can I give her a message?”

For a second Jack debated whether he should just push right in despite the warning.

“It has been a heated phone call,” Cheryl added.

“Okay,” Jack said. He realized he was jumping the gun in his enthusiasm, and Laurie had already asked him not to barge in as he had on one occasion a month ago. “Fair enough. Tell her I’m doing a post on an important case she should know about and that when I’m finished I’ll pop up and fill her in.”

“Should I tell her anything specific, like what kind of post it is?”

“No, it’s probably better if you don’t,” Jack said. The more he thought about the situation, the more he understood he’d need concrete laboratory confirmation of a new influenza strain if any official whistles were to be blown. Such news could cause a panic in the city, depending on who happened to get the info and what they did with it. Jack even felt a bit embarrassed he’d not given enough thought to what he had planned to do. As he walked out of the front office he felt distinctly thankful that Cheryl had saved him from himself.

In the public waiting area, Jack asked the receptionist, Marlene, to buzz him into the family ID area, where relatives gathered when they were required to identify their deceased family members. He was looking for Rebecca Marshall, one of the clerks trained to deal with bereaved families. He found her finishing up with a couple who had to identify one of their teenage sons, who had overdosed just that morning. Such tragic scenes were a daily occurrence not only in NYC but all across the country.

As soon as she was free, Jack took her aside. She was in late middle age and had a kind face and tightly curled silver-gray hair. “What can I do for you, Doctor?” Rebecca asked. She was one of those employees who was always eager to help, which was why Jack often sought her out.

“A case came in within the last hour,” Jack said. “The death of a relatively young woman on the subway. I haven’t seen the victim myself, but I spoke with Bart Arnold, who has. There was no ID. Have you heard about this case yet?”

“I haven’t,” Rebecca said.

“Bart said the woman was well dressed, so I imagine she’ll be missed rather soon. Would you keep an eye out for any information or inquiries? Making an ID as soon as possible is going to be important on many levels.”

“I’ll certainly keep a lookout,” Rebecca assured him. “And I’ll pass the word to the rest of the team. I’ll let Hank Monroe and Sergeant Murphy know as well, although they might have both already been given a heads-up. One way or the other, they can get things moving on their end as well.”

“I’d appreciate it,” Jack said.

Hurrying back downstairs, Jack looked into the decomposed room once again. Now the light was on and a black body bag was stretched out on the single autopsy table. Next to it was a separate metal stand with various instruments, specimen containers, preservatives, labels, syringes, evidence custody tags, and all sorts of other stuff needed for the autopsy. Jack was encouraged, but there was no Vinnie Ammendola or Carlos Sanchez. Guessing they were in the locker room donning moon suits, Jack hurried in himself.

When Jack arrived, Carlos was completely encased in one of the OCME’s level-A hazmat suits. Because of the glare of the overhead fluorescent lights off the helmet’s curved plastic face mask, Jack couldn’t see the man’s face, but he could sense that Carlos was terrified. He was standing motionless, with his arms stuck out to the sides at an angle from his body. Jack had to smile.

“He doesn’t like this,” Vinnie explained with a laugh as he stuck his legs into his suit and then pulled the back up over his shoulders.

“That’s apparent,” Jack said. He got his suit off its peg and unplugged the ventilation battery pack from the charger. “Relax, Carlos! The suit is designed to protect you, not hurt you.”

“There’s going to be dangerous bacteria in there?” Carlos couldn’t seem to control the quaver in his voice.

“We’re more worried about dangerous viruses,” Jack said.

“You mean like Ebola?” Carlos asked.

“Something like Ebola,” Jack agreed. “Viruses are viruses. What I’m thinking we might be dealing with is influenza. You’ve certainly heard of the flu virus.”

“Of course I’ve heard of it, but it’s nothing compared to the likes of Ebola,” Carlos said.

“I wouldn’t be quite so cocky,” Jack said. “Influenza has killed infinitely more people than Ebola. Let’s put it this way: If this case is a new lethal strain of influenza, it could be as bad as or worse than if it were Ebola, because flu spreads much more rapidly than Ebola. Haven’t you ever heard of the 1918 flu pandemic? It killed more people than World War One and World War Two combined.”

“I don’t like the sound of this,” Carlos said. “Has anyone died here at OCME doing autopsies like this? I didn’t think this job was dangerous, just gross.”

“Oh, yeah, we’ve had a ton of deaths,” Jack said as he stuck his feet down into the legs of his suit. “We lose mortuary techs maybe once a month. That’s why you got hired.”

“Jesus, Dr. Stapleton!” Vinnie complained. “Don’t tell him that. You’re going to scare the shit out of him. We’ve never lost a mortuary tech, Carlos. He’s pulling your leg.”

“Listen, Carlos,” Jack said. “The reason you’re in this godawful torture contraption is to protect you. You’ll be fine. Just don’t stick a knife blade or a needle through the suit while we are doing the case. At the end, be sure to do exactly what we tell you to disinfect.”

“This is not what I expected this job would be like.” For a grown man, Carlos had an uncommon knack for imitating a whiny child.

“You’ll be fine,” Jack repeated. He hadn’t meant to scare the novice as much as he apparently had. At the same time, Jack didn’t particularly care. He wasn’t convinced Carlos was going to be a permanent addition to the team. There had been a handful of not-so-positive quirks about the man’s behavior that morning that didn’t sit right with Jack. One way or the other, he planned on saying something to Twyla Robinson, the chief of staff.

Once Jack was fully suited and his HEPA ventilation fan was turned on, he led the way out of the locker room, down the hall, and into the decomposed room. He could tell that Carlos was still seriously spooked, but Jack decided to let the guy stew. Jack was eager to get going.

In his typical efficient fashion, Vinnie had already put up on the view box the X-ray that he and Carlos had taken of the body through the body bag. Jack switched on the light. X-raying the body was routine for MEs. The X-ray was a way of making sure that things like bullets or broken-off knife blades weren’t missed, which had happened in the distant past. Jack certainly didn’t expect anything like that on this case. Still, he entertained a minor possibility of coming across something like an old fracture. Such a finding could possibly assist in making or confirming the patient’s identification. But to his surprise, Jack was immediately presented with a totally unexpected and significant discovery.

“Good grief.” He stared at the image. “Do either of you bums know what we’re looking at?”

“Looks like a bunch of twisted wires,” Vinnie said.

“Yeah, wires,” Carlos echoed.

“They are most definitely wires,” Jack said. “Wire closures wrapped around the woman’s sternum, holding it together.”

“Did she have surgery?” Vinnie asked.

“Without a doubt,” Jack said. “And if I had to guess, I’d say she had open-heart surgery. Most likely valvular surgery on either her mitral valve or her aortic valve.”

“Could that account for her death?” Vinnie asked.

“By all means,” Jack said. He tried to keep the disappointment out of his voice. If a sudden rupture or, more probable yet, a rapidly progressive inefficiency of a cardiac valve was the cause of the woman’s demise, then there wouldn’t be any ongoing issue. He wouldn’t be looking at a possible contagious case that could potentially threaten the city and occupy his mind by keeping him busy for days on end.

“Well, that would be good,” Vinnie said. “Right?”

“Of course,” Jack said. If Vinnie noted his lack of enthusiasm, he kept it to himself. “Let’s get to it.”

“If it is a heart problem, then we didn’t need to put on these goddamn miniature hothouses,” Vinnie said. All three men were already beginning to sweat.

They moved over to the autopsy table, with Jack on the patient’s right and Vinnie and Carlos on the left.

“Here’s how I want to proceed,” Jack began. “We’re still going to consider this a potential contagious case until proven otherwise. So we’ll unzip the body bag and fold it to the sides over the edge of the table. If the case does turn out to be contagious, we can merely fold the body bag back when we are done and treat the outside with hypochlorite. Agreed?”

“Okay,” Vinnie said. “But personally, I think the wire closures change everything.”

“Maybe,” Jack reluctantly conceded.

With all three men lending a hand, it took only a few minutes for the fully clothed body to be exposed.

“I think Bart was right with his assessment,” Jack said. “He thought she was about thirty, which looks spot-on to me. He also described her as well dressed, like she was going on a lunch date. He also thought she looked a tad cyanotic. Agreed?”

“Agreed,” said Vinnie, who then explained cyanotic to Carlos.

Meanwhile, Jack looked at the label of the coat that had been tucked into the body bag separately. It was from Bergdorf Goodman. Jack was hardly a clothes horse, but he knew when he was looking at something expensive. He then noticed the woman’s unique hairstyle and how it was carefully undercut along the left side of her head, with dark roots. On the top of the head and on the right side the hair was moderately long and professionally bleached to an attractive blond. The condition of the hair suggested a lot of professional attention. She was also wearing a Cartier watch, diamond stud earrings, and a narrow ring encrusted with pavé diamonds.

Jack took some scissors and handed a pair to Vinnie. “Let’s cut her out of her clothes and leave them in place for now.”

“Fair enough,” Vinnie said. He handed the scissors to Carlos and then instructed him in how to cut the clothes along the seams. Carlos worked on the woman’s left side, while Jack took the right. They started on the arms.

As Jack cut the right arm of the woman’s blouse from the wrist up to the armpit, he immediately saw the tattoo on the inner surface of the forearm and stopped cutting. “This should be helpful in terms of ID,” he said, twisting the arm into a supine position to expose the tattoo in its entirety. “Look at this! Isn’t this unique. It’s a tattoo of a puzzle piece in perspective. And this colorful portion of the tattoo is where the piece is supposed to have come from. I’m not a tattoo fan, but this is very clever.”

“You’ve never seen anything like that?” Vinnie questioned in an amazed and disparaging tone. “You’re more out to lunch than I thought.”

“You’ve seen something like this before?”

“Sure. Rainbow colors are often a symbol of gay pride. Pretty common these days to see tattoos that feature them.” He slanted a look at Jack. “Look on Pinterest if you don’t believe me.” He knew full well Jack had no idea what Pinterest was. “And you see the name Helen on the puzzle piece? I’d guess this woman was a lesbian and Helen was her partner.”

“Well, we live and learn,” Jack said. “I suppose that means we’ll be hearing from Helen in the not-too-distant future.”

When the woman’s chest was exposed, Jack halted the cutting again to inspect the impressive pink scar that ran down the midline. “Well,” he said, “this median sternotomy is certainly going to help with the ID issue. I’d say this scar is only about three months old. She must have had open-heart surgery just this past summer, and it would be my guess that she had it here in the city.”

“Can we move along with this autopsy,” Vinnie complained. “I don’t want to be here all day.”

Jack didn’t say anything but went back to cutting the clothes and peeling them back. While Jack was finishing, Vinnie took off the jewelry and put it all aside. It would be disinfected and carefully notated, to be available for the next of kin.

When the body was completely exposed, Jack checked to make sure the endotracheal tube was in the trachea and then removed it. Then he did an extensive and careful external exam. Except for two more tattoos, which included a stylized palm tree in the small of her back and what seemed to be a small Chinese character on the inside of her right ankle, there was no other pathology or markings. Jack took photos of all the tattoos.

At that point, Jack began the internal portion of the autopsy. To proceed he used his favored modified Y incision that went from the point of the shoulders to the clavicular notch, and then down to the pubis through the surgical scar. He needed wire clippers to cut the wires holding the sternum together.

Once the body was flayed open, Jack’s first point of attack was the abdomen. Although the liver appeared to be entirely normal, he did see some very mild evidence of inflammation, with a small amount of extravasation of blood involving the gallbladder, the spleen, and the kidneys. The findings served to key off in his mind a distant association with hantavirus, even though he knew instinctively that hantavirus couldn’t be involved. Hantavirus pulmonary syndrome was extraordinarily rare, especially at that time of year in New York City. But the thought did raise again in his mind the idea of contagion.

Jack’s next job was to run the intestines, examining and palpating every inch while in situ. He found nothing abnormal. Then, while Vinnie and Carlos took the freed intestines over to the sink to wash them out, Jack turned his attention to the thorax. It was here that he thought he’d find some answers.

He decided to take the lungs and the heart out en bloc so he could examine them together, and the first hint of significant pathology was their weight. As Jack carried the mass of tissue, which also included the severed great vessels, over to a side table, he could tell they weighed maybe twice what he expected. What he assumed was that the swollen lungs were filled with edema fluid, and he was right. But it wasn’t only edema. Making a few slices into the lung, which burst open as if under pressure, and looking at the cross-sections, he could tell there was a significant amount of inflammation, with some bleeding and a lot of exudate, or what the general public might call pus. It was plainly obvious that the woman had died of massive pulmonary inflammation, which Jack now knew could not have been caused by a catastrophic problem with a heart valve. A suddenly failing heart valve would have filled the lungs with frank blood, not blood-tinged exudate. Consequently, Jack was back to the idea that a contagious disease might have killed this woman, and if that was the case, it had to be a particularly aggressive virus, maybe even similar to the strain of influenza that had killed a hundred million or more back in 1918. As he came back to this line of thinking, the expression “Be careful what you wish for” passed through his mind. Although he sorely needed a diversion from his problems at home, he certainly didn’t want it to be at the expense of a large number of innocent people. A new lethal influenza pandemic would wreak havoc in the city and around the world.

Taking a pair of scissors, Jack began cutting into the pericardium to expose the heart nestled between the two lungs. Usually this was an easy job, but not in this case, as there was considerable scar tissue, additional evidence that the woman had had heart surgery. As he slowly exposed the organ, he was in for another shock. The patient certainly had had open-heart surgery, but it wasn’t surgery on one of her valves, as he had assumed. To his surprise, Jack could see that the patient had had a total heart transplant.

“Vinnie, get over here and look at this!” Jack shouted.

Both Vinnie and Carlos rushed over to the table where Jack was working.

“Check this out,” Jack said, using the dissecting scissors as a pointer. “Look at these suture lines in the great veins and arteries. What you are looking at is a relatively recent total heart transplant, and it’s the newest bicaval transplant technique. I’m impressed. Back in the early days they used to attach the atria, but no longer.”

“So it wasn’t a heart valve problem that killed her,” Vinnie mused.

“I doubt it,” Jack said. “But it will be easy to prove one way or the other. Let me open the heart.” Cutting into the heart muscle, Jack exposed the interior chambers and spread the edges. “Obviously it wasn’t the valves. Check them out. They’re all perfect.”

“Could it have been sudden organ rejection that killed her?” Vinnie asked as he straightened up to let Carlos look. Vinnie had recalled a case that he and Jack had handled where the patient had had a massive and sudden rejection of a liver transplant.

“That’s a good question,” Jack said. This line of thought was one of the reasons he liked working with Vinnie. Despite Vinnie’s frequent grousing about working too hard, he occasionally contributed something significant to the conversation. Jack hadn’t yet thought of a rejection process being involved. With that in mind, Jack carefully examined the heart. When he was done, he shook his head. “It’s certainly not rejection of the heart. There’s no sign of inflammation whatsoever in the organ, nor in the pericardium.”

Vinnie explained to Carlos that the pericardium was the tissue that covered the heart.

“The pathology is all in the lungs,” Jack said. He then showed the two men the cut surface of the interior of the lungs. “The lungs are completely full of fluid and exudate. I’m back to the influenza idea.”

“It looks like she fucking drowned,” Carlos said.

Jack gritted his teeth. He was old-school in respect to foul language. He knew that the younger generation thought of it totally differently, but that didn’t mean he would stand for it in a professional setting. “Listen, Carlos,” Jack snapped. He took an intimidating step in Carlos’s direction. “Tone the language down when you are around me. You get what I’m saying?”

“Sorry,” Carlos said. He backed up and rolled his eyes for Vinnie’s benefit.

Jack let it go.

“How would influenza kill so fast?” Vinnie asked, to defuse the situation. He was well aware of Jack’s sensitivities. “This patient might have gone from the first symptom to death within an hour. How could that happen?”

“Another good question,” Jack said. “Back in 1918 they had absolutely no idea. What we now know is that it’s a process called cytokine storm. It’s when the body’s immune system senses the virus antigens and then goes berserk, releasing a bevy of extraordinarily damaging hormonelike proteins.”

“What are you saying?” Vinnie questioned. “Are you talking about a kind of cellular hari-kari?”

“That’s a colorful way to put it,” Jack said. “But yes. It’s the person’s own immune system that suddenly cranks out these cytokines that irreversibly damage the lungs. The virus just sets it all in motion, so to speak.”

“Holy f—” Vinnie started to say but caught himself.

“I want samples of the lung fluid for culture,” Jack said, pretending he hadn’t heard. There was a definite urgency in his voice. “And I want samples from the main bronchi. Then I want all the usual samples. Let’s get this show on the road!”

“Now you’re talking,” Vinnie said. Since Vinnie’s employment responsibilities had him coming in before seven to smooth the transition from the night crew to the day shift, he was supposed to leave at three. Too often Jack kept him busy well beyond then. And Jack’s sudden ardor hinted that this was going to be one of those days.