by Robin Cook
While Vinnie continued the preparations by getting out instruments, specimen bottles, preservatives, labels, syringes, and evidence custody tags, Jack and Lou went to the view box to look at the whole-body X-rays that Vinnie had put up. One was anterior-posterior; the other was lateral.
After checking the accession number, Jack gazed at the films. Then he said, “I think you are right.”
“Right about what?” Lou asked.
“It being small-caliber,” Jack said. He pointed to a cylindrical, half-centimeter-long translucent defect within the lower part of the skull’s image. Composed of metal, bullets totally absorb X-rays, and since X-rays are viewed as negatives, the image appears in the color of the background illumination.
“Twenty-two-caliber would be my guess,” Lou said, moving his face close to the film.
“I think you’re also right about it being execution-style,” Jack said. “From its position in the films, it’s undoubtedly lodged in the brain stem, where a professional killer would aim. Let’s take a look at the entrance wound.”
With Vinnie’s help, Jack rolled the corpse on its side. First, Jack took a digital photo. Then, with his gloved hand, he separated the hair covering the point where the bullet entered the victim’s head. Since the victim had bobbed around in the Hudson River, most of the blood had been washed away.
“It’s a near-contact wound,” Jack said. “But certainly not contact, since it’s a circular, not a stellate defect.” He took another photo.
“How far away?” Lou questioned.
Jack shrugged. “By the looks of the stippling, I’d say somewhere around twelve inches. Noticing the position of the entrance wound in relation to the bullet’s position on the X-ray, I’d guess the perpetrator was behind and above the victim, maybe with the victim seated. That’s seemingly confirmed by slightly more stippling below the entrance wound than above.”
“More weight to it being execution-style.”
“I’d have to agree.”
Jack took some measurements of the position of the wound, and another photo with a ruler in close proximity. Then, with a scalpel, he dislodged some of the embedded soot from within points of stippling. He put the material in a specimen tube. Finally, he took additional photos before motioning for Vinnie to allow the body to roll back into a supine position.
“What do you make of these deep slices across the thigh?” Lou asked, pointing to two parallel sharp cuts in the anterior aspect of the right thigh.
Jack took a photo before inspecting the wounds and palpating them. “They were certainly made by a sharp object,” he said, looking at the clean edges. “There’s no skin bridges. I’d guess they are propeller injuries, and I’d be willing to bet they were postmortem. I don’t see any extravasated blood within the tissues.”
“Do you think the victim could have been run over after being thrown from a boat?”
Jack nodded, but something more subtle caught his attention. Moving down to the ankles, he pointed out some oddly shaped abrasions.
“What is it?” Lou asked.
“I’m not sure,” Jack said. He went over to the counter and hefted a dissecting microscope detached from its base. Bracing his elbows on the edge of the table, he studied the subtle abrasions.
“Well?” Lou questioned.
“I’m going out on a limb,” Jack admitted, “but it looks as if his legs might have been tied with chains. There’s not only abrasions but also suspiciously shaped indentations.”
“Occurring after he was dead or before?”
“Whatever it was, it was after he was dead. I don’t see any blood in the tissues here, either.”
“It could have been he was chained to a weight and supposed to sink and stay sunk. Somebody could have screwed up.”
“Could be,” Jack said. “I’ll take a photo, even though it probably won’t show up.”
“If this was a screwup, it could be important to keep it quiet,” Lou said.
“How come?”
“If it is an organized-crime war, there will be more bodies. I’d want them to all come to the surface.”
“Our lips will be sealed,” Jack said.
“Hey, can’t we move this along?” Vinnie complained. “At this rate, with you two long-winded old farts carrying on, we’re going to be here all day.”
Jack let his arms go limp at his sides and stared at Vinnie as if shocked. “Are we keeping the super mortuary tech from something more important?” he questioned.
“Yeah, a coffee break.”
Jack switched his gaze to Lou and said, “See what I have to put up with around here? The place is going to the dogs.” He then reached up, adjusted the overhead microphone, and began dictating the external examination.
LAURIE SLIPPED David Jeffries’s file back into its envelope. It included a case worksheet, his partially filled-out death certificate, his inventory of medicolegal case records, two sheets for the autopsy notes, a telephone notice of his death as received by communications, his completed identification sheet, the PA’s investigative report, his lab slip for an HIV test, and the slips indicating that the body had been weighed, fingerprinted, photographed, and x-rayed. She had read the material over several times, as she had done with her second assigned case, Juan Rodriguez, but it was Jeffries she was more interested in.
Feeling appropriately prepared, she pushed back from her desk and headed toward the back elevator. Fifteen minutes earlier, she’d called down to the mortuary office and had had the good fortune to get Marvin Fletcher. She was pleased and recognized his voice instantly, as he was her favorite mortuary tech. He was efficient, intelligent, experienced, eager, and always in a good mood. Laurie had an aversion for those techs who were moody, such as Miguel Sanchez, or those who always seemed to be moving at half-speed, such as Sal D’ Ambrosio. She also was not fond of the sarcastic, black-humor repartee in which some of the other techs indulged. When she briefly described David Jeffries’s case, warning that it involved an infection and asking for the body to be put up for an autopsy, Marvin’s response had been simply: “No problem. Give me fifteen minutes, and it’s a go.”
As Laurie rode down from the fifth floor to the basement morgue level, she thought of what she was going to find on Jeffries. According to the PA’s report, the man had had all the symptoms of a toxic shock–like syndrome: high fever, an obvious wound infection at both incision sites, diarrhea with abdominal pain, vomiting, severe prostration, low blood pressure, unresponsive to medication, low urinary output, rapid heart rate, and respiratory distress with some blood-tinged mucus. Laurie shuddered at the thought of how quickly the man had succumbed and how virulent the bacteria had to be. She also couldn’t keep herself from worrying about the case being a negative omen, involving, as it did, the exact same surgery Jack was facing, even the same knee. Jack had blithely dismissed the coincidence, but she couldn’t. It made her more committed than ever to talk Jack into at least delaying his surgery. She even saw a bright side to David Jeffries’s tragedy. Maybe if she found something different or unexpected at the post, it could help her change Jack’s mind, which was why she had requested the case. Generally, she tried to avoid cases involving fatal infection. She’d never admitted it to anyone, but they made her uneasy. Yet as she approached the locker room, she acknowledged that she felt more eager and keyed up about doing the case than she had ever felt about doing another.
Laurie changed quickly, first into scrubs and then putting on her disposable protective gear. Although the newer gear was less burdensome and limiting than the old moon suits, she occasionally groused about the equipment like everyone else, but, on this occasion, dealing with a fatal infection, she was pleased to have it. She carefully cleaned off the plastic face mask—even slight smudges bothered her—and turned on the fan before pulling the contraption over her head. Then, prepared, she pushed into the pit.
Stopping just inside the door, she surveyed the scene. Four tables were in use. The nearest supported the corpse of an extr
emely pale Asian-American male. Three people were grouped around the head, the scalp of which had been reflected forward and the skullcap of which had been removed. The bloody brain glistened in the raw light. Although Laurie couldn’t see any faces through the plastic face masks, she guessed it was Jack, Lou, and Vinnie, since they had started first.
The next table also had three people working, and as Laurie viewed them, her face flushed. She’d forgotten that the chief, Dr. Harold Bingham, was expected. He rarely came to the autopsy room, as most of his time was spent in administrative duties or testifying at high-profile trials. It was easy to pick him out, not only because of his almost square silhouette but because of his harsh baritone voice that suddenly reverberated throughout the tiled room. He was giving one of his impromptu lectures about how his current case reminded him of one of his innumerable previous cases. As he was carrying on, a slight figure standing on a stool opposite him, who Laurie surmised was her office mate, Riva, was actually doing the work. For her reward, Bingham intermittently interrupted his monologue to offer negative comments about her technique.
The next two tables had a pair of people working at each. Laurie had no idea who they were. The fifth table contained the corpse of an African-American male. Standing at the head of the table, a figure she assumed was Marvin waved toward her, and over the sound of Bingham’s raucous voice, he called out, “We’re set to go on table five, Dr. Montgomery!”
Bingham’s head snapped around toward Laurie, making her wish she could disappear. The overhead light glinted off his plastic face screen, blocking a view of his face, so she could not anticipate his frame of mind. “Dr. Montgomery, you are a half-hour late!”
“I’ve been going over my cases for this morning, sir,” Laurie said quickly, and as deferentially as possible. She could feel her heart rate bump up. Laurie had struggled with authority figures since childhood. “I also needed to speak with Cheryl Myers to get some missing data.” Cheryl Myers was a PA whom Laurie had slipped into the investigator’s office to see after leaving the ID room. Although Cheryl had written a generally good note for the construction death, Laurie’s second case, Laurie had noticed that the distance from the building the corpse had ended up after the fatal ten-story fall was not included. As Laurie had assumed, Cheryl had obtained the figure but had mistakenly left it out of the report.
“All that is supposed to be done before seven-thirty,” Bingham snapped.
“Yes, sir,” Laurie said, not interested in arguing. Unlike Jack, Laurie generally followed rules reflexively. However, the one mandating that autopsies start at seven-thirty sharp she generally ignored, since it conflicted with her belief that it was more important to know the case prior to doing the post. In an attempt to preclude any more conversation with Bingham about the issue, Laurie stepped directly up to Jack’s table and asked loudly how his case was going.
“Stellarly,” Jack quipped, “except the inconvenient fact that the patient died. The only bad side is that it has been dragging on. We’d have made significantly more progress if there was any decent help around here.”
“Screw you!” Vinnie said. “If you two old windbags hadn’t carried on like you’ve been doing, we could be up having coffee by now.”
“Gentlemen,” Bingham’s voice called out. “I’ll have no disrespect, nor profanity, in the autopsy room.”
Lest she incite any further comments from Jack and subsequent retorts from Bingham, Laurie quickly headed toward Marvin and her own case. As she passed Bingham’s table, she cringed for fear of being called over, but luckily Bingham had been distracted by what he called a “catastrophic mistake” on Riva’s part as she dissected the neck.
“Are you going to need anything special?” Marvin asked as Laurie came up abreast of the fifth table. As prepared as Laurie was, she generally knew in advance when special needs were required for a case.
“A good supply of culture tubes,” Laurie said as she surveyed David Jeffries’s corpse. For fifty-one years of age, the man appeared to have been in good physical condition. There was no excess fat. In fact, his muscles, particularly the pectorals and quadriceps, had the definition of a much younger man.
Laurie grimaced behind her plastic face screen. Besides the obvious infection at the surgical sites on either side of the right knee, there was a sprinkling of small pustules all over his body, which given the time would have turned into abscesses or boils. Even more striking were areas of desquamation, particularly on his pelvis, with the skin sloughing in relatively large sheets.
“Are you looking at his hands?” Marvin asked.
Laurie nodded.
“What caused his skin to peel off like that?”
“Staph makes a lot of toxins. One of them causes skin cells to separate from their neighbors.”
“Ugh,” Marvin said.
Laurie nodded again. She’d seen staph infection before, but this was the worst.
“Anyway, to answer your question about culture tubes,” Marvin said, “I got plenty.”
“Did you get a good supply of syringes as well?”
“Yup.”
“All right, let’s do it,” Laurie said, as she pulled down the suspended microphone.
“Want to check out the X-ray? I put it up just in case.”
Laurie stepped over to the view box and gazed at the film. Marvin followed and looked over her shoulder.
“Our X-rays are mainly for foreign bodies and fractures,” Laurie said. “Even so, you can certainly appreciate the pneumonia and how diffuse it is. It looks like the lungs are filled with fluid.”
“Hmmm,” Marvin said. X-rays were a mystery to him. He couldn’t understand how doctors could see what they did in the foggy image.
Laurie went back to the body and completed the external examination. After making sure the endotracheal tube was where it was supposed to be in the trachea, she pulled it out. It had been placed by the doctors to ventilate him when he had begun to have trouble breathing. She cultured the bloody mucus adhered to it. Turning to the multiple IV lines, she made sure they were also properly placed and, after doing so, pulled them out and cultured them as well. Medical examiners insisted such tubes be left in place to be sure that they played no role in the patient’s death. She also cultured the pus issuing from the surgical site.
Once the external exam had been finished and dictated, Laurie began the internal with the standard Y-shaped incision starting at both shoulders, meeting at the midline, and then extending down to the pubis. She worked quietly, shunning the usual banter she normally exchanged with Marvin, who was an eager learner.
For a time, Marvin stayed quiet as well, correctly sensing Laurie’s awe at the virulence of the microbe that had played such havoc throughout David Jeffries’s body. It wasn’t until Laurie lifted out the heart and lungs and put them in the pan he was holding that he broke the silence. “Shit, man,” he commented. “This baby weighs a ton.”
“I noticed,” Laurie said. “I think we’ll find both lungs full of fluid.” After she removed the lungs and weighed each separately, she made multiple slices into them. Like fully soaked sponges, a mixture of edema fluid, blood, necrotic tissue, and pus emerged.
“Ye gods!” Marvin said. “That’s ugly.”
“Have you heard of the term flesh-eating bacteria?”
“Yeah, but I thought people only got that in their muscles.”
“This is a similar process, but in the lungs and much more lethal. Its official name is necrotizing pneumonia. You can even see beginning abscesses.” Laurie pointed to minute cavities with the tip of the knife.
“You guys look like you are having way too much fun,” Jack said, after silently coming up along Laurie’s right side.
Laurie let out a short, sarcastic laugh that was enough to briefly fog her face screen. She gave a quick glance at Jack before holding up the exposed cut surface of the lung for him to see. “If you call seeing the worst case of necrotizing pneumonia fun, then Marvin and I are having a blast.”
Jack used his gloved index finger to assess the turgidity of the lung section. “Pretty bad, I’d have to admit. Shows you what can happen if you smoke too many Cuban cigars.”
“Jack,” Laurie said, ignoring his attempt at humor, “why don’t you stay with us for a few minutes? I think you should see the full extent of this postoperative infection. This poor individual was being literally and rapidly digested from the inside out. This might be the worst or best advertisement for not having elective surgery I’ve ever seen.”
“Thanks for the invite, but I’ve got two more cases to do before Lou conks out,” Jack said. “Besides, I know how your mind works, especially with your not-so-subtle reminder the victim had surgery, meaning I know you have an ulterior motive for your kind invitation vis-à-vis my Thursday plans. So I’ll let you two have all the fun.” With a little wave, he started to leave.
“What about your first case?” Laurie asked, mindful of Lou’s interest. “What did you find?”
“Not a whole bunch. We recovered the twenty-two-caliber slug, for whatever that’s worth. Lou says it’s a Remington high-velocity hollow-point, but he could just be trying to impress me. The thing’s a bit mangled from penetrating the guy’s skull. There were also some abrasions and indentations on his legs, suggesting he’d been chained, perhaps attached to a weight. I think he was supposed to sink, which suggests he was thrown overboard out of a boat, not dumped into the water on shore. Lou thinks that’s important. Otherwise, the guy was healthy except for a slight cirrhosis of the liver.”
