by Robin Cook
“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.”
&n
bsp; 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?
11
TUESDAY, 12:38 P.M.
Like most people, Jack thought of himself as having a reasonable amount of self-knowledge. A realist, he knew that some of his personality traits were not ideal, like his limited patience with lazy, self-indulgent people—a designation he unfortunately gave to most of the people he had to deal with. But there was one trait he prided himself on that had stood him in good stead, and that was determination. When he got something in his craw, such as this subway death case, he didn’t give up easily.
Turning on his monitor, Jack brought up the digital images of the three tattoos on the woman’s body. He looked at each carefully and was again impressed by the puzzle piece. Vinnie had said something about Pinterest, so that seemed like a good place to start. He was somewhat hesitant to sign up, not knowing if he’d be bombarded with unwanted emails, but he took the risk. Once he was on the site, he searched for “puzzle piece tattoo.” He was surprised by the variety available, including permutations of the one on the woman’s arm. Then he searched for “puzzle piece tattoo rainbow” and found the exact image, complete with the rainbow colors in the puzzle piece’s base, just as Vinnie had said.
He then Googled palm tree tattoos and discovered they were also extremely popular, even more so than the puzzle piece. He was interested to find that they appropriately stood for beach life, summer, and relaxation. Researching for the meaning of the Chinese character, he learned it meant “love.” He then read a long Wikipedia article about tattoos and how their popularity had grown in mainstream culture.
Jack sat back in his chair and thought about what he’d read and about tattoos in a general sense. He’d never understood why someone would be tempted to permanently mar his or her body with ink, what with the risks of infection or just a subsequent change of heart. But having seen the profusion of images on Pinterest, some of which, like the puzzle piece, were quite clever, he thought of the activity in a slightly different light. He was no more tempted to get a tattoo himself than he’d ever been, but he’d come to recognize that there was more artistry involved than he’d previously thought, which made him believe the tattooists probably thought of themselves as artists and not as mere technicians. Following that line of thinking made him wonder if the artists recognized one another’s work. With everything else going against him, Jack thought it was another possible line of attack in the ID effort.
Tipping forward again, Jack sent the three images he’d taken of the tattoos with zero compression down to the printer in the front office. He wanted some high-resolution photos. Then he Googled tattoo establishments in lower Manhattan and found a highly rated one not that far away called Tattoo Art and Piercings. Checking their website, he learned they had three supposedly vaunted tattoo artists. It was on the West Side, but his Trek would get him there in a flash. Grabbing his bomber jacket, he left his office to head down to get the photos. As he waited for the elevator, he worried about running into Laurie, who had already warned him about not making any field trips. He was in no mood to get into another argument. Unfortunately, since it was lunchtime, the possibility of a confrontation wasn’t a hypothetical concern. But he decided it was a risk he had to take, because for what he had in mind, he needed good pics.
Jack zipped into the front office and headed for the printer, with the idea of making it a very quick in-and-out visit. He waved a casual hello to Cheryl, who was on the phone, which he thought was auspicious because it precluded any conversation. But a moment later he noticed Laurie’s door was ajar, forcing him to make a snap decision of whether to proceed or retreat. An instant later the decision became academic when Laurie caught sight of him through the open door and waved at him to come into her office.
Jack got the photos first. They were as clear as a bell, with good color. He then went into the inner sanctum and tried to gird himself. In retrospect, he did feel a bit guilty for having snuck out of the apartment that morning without so much as leaving a note.
“I’m glad to see you, and it’s good timing,” Laurie said. She was sitting at her desk with blueprint architectural plans spread out in front of her. “I have a few minutes before my next conference call. I missed you this morning.” She spoke with a sincere and uncritical tone. Jack felt relieved, especially having been caught red-handed wearing his bomber jacket and advertising he was on his way out of the OCME. “I ended up oversleeping,” Laurie added. “I suppose I was counting on you waking me up before you left, which isn’t fair. It was my own fault. As usual, I stayed up much too late going over all that budget nonsense.”
“It was too early when I left,” Jack said. “The subway death had me awake before five. I was eager to get in here to find out why I hadn’t been called about an ID, but the explanation turned out to be pretty simple. There’d been no ID because there had been zero calls from family or friends.”
“That’s strange,” Laurie said. “Especially the way you described her. She certainly wasn’t a homeless person.” Laurie stood up from her desk, walked around Jack, and closed her office door for privacy. Then she stood on her tiptoes and gave him a peck on the cheek. Jack took it as a gesture of reconciliation and felt encouraged.
“It’s more than strange,” Jack said. “And it’s driving me to distraction.”
“And now that it has been more than twenty-four hours, it’s beginning to remind me of my Japanese subway homicide, which took days to get an ID. You remember the case, don’t you?”
“Absolutely, and I thought the exact s
ame thing,” Jack said. “And since ‘imitation is the sincerest form of flattery,’ I’ve been faithfully reenacting your efforts.”
Laurie failed to suppress a laugh. “Isn’t that ironic. I remember at the time you made fun of what I was doing and thought I was wasting my time.”
“Guilty as charged,” Jack confessed. “But in my defense, I haven’t gone to the extent of getting transit videotapes. My victim certainly wasn’t the victim of a homicide.”
“Then how did you imitate me?”
“I called your nine-one-one supervisor friend, Cynthia Bellows, just like you did. By the way, she said hello and offered congrats for your becoming chief. Just like you did, I got the name and number of the person who made the nine-one-one call from the R train. Talking with her, I confirmed that the victim had appeared entirely normal when she boarded the train in Sunset Park, Brooklyn. I also learned she had a backpack and a phone, which obviously got stolen.”
“Did you make the effort to talk with the assigned Missing Persons detective?”
“I did,” Jack said. “But Detective Pauli Cosenza was no help at all. I had the feeling the lazy bum just pushed papers around his desk. Just to get ahold of him I had to let the phone ring almost forty times.”
“My Missing Persons detective contact was also no help on the first call. I even remember his name: Detective Stedman. But the second time I called, he was like a different person. Maybe you should give your PD contact another chance.”
“Maybe,” Jack said. “But I’m far from optimistic. I did tell Sergeant Murphy to make sure the detective got all the information from here as it becomes available, like the fingerprints and these photos of the victim’s tattoos.” Jack handed the three photos to Laurie.
“I’m not a tattoo fan by any means,” Laurie said as she studied each photo in turn. “But these are rather tasteful and interesting, and I guess she was a lesbian.”
“That’s the assumption, for whatever it’s worth,” Jack said.
