by Robin Cook
Make sure you disinfect the outside of all the culture tubes and the histology specimen bottles,” Jack said to Vinnie at the conclusion of the meningitis case. “I’m serious. I don’t want to find out later that it didn’t happen and you saying you forgot, understand?”
“I got it,” Vinnie complained. “You already told me the same thing two minutes ago. What do you think I am, stupid?”
Vinnie caught Jack’s expression through the plastic face mask of his hood and quickly added: “Don’t answer that.”
Jack hadn’t planned on using a hood with a HEPA filter, but he could tell that Vinnie was uncomfortable without one, and his pride wouldn’t let him use one unless Jack did. So at the last minute Jack relented for Vinnie’s sake. As a rule, Jack didn’t like using a hood and the moon suit because they were cumbersome and hard to work in. But as the case proceeded, he was glad he’d changed his mind. The virulence of this particular strain of menin gococcus was impressive by dint of the damage it had done to the meninges and the brain itself.
Since they’d done the case in the decomposed room and there were no other mortuary techs around, Jack helped Vinnie get the body into a body bag and onto a gurney. After reminding Vinnie to inform the receiving funeral home that it was an infectious case, Jack removed the moon suit and hood, stripped off and disposed of the Tyvek coverall, and headed up to his office.
His first call was to the deceased teen’s private school. Although it was an OCME rule that the public relations office handled all official communication, Jack often took it upon himself to buck protocol. He wanted to be absolutely sure certain things got done, and alerting the school in this instance was one of them. With the evidence of the bacteria’s destructive power fresh in his mind, Jack spoke frankly to the headmaster, who assured him that the institution was taking the tragedy to heart. The city epidemiologist had already been there, and extensive decontamination and quarantine had begun. He was appreciative of Jack’s concern and effort, and said as much.
Jack’s next call was to Robert Farrell, one of Keara’s friends. After more than half a dozen rings, the man finally answered, apologizing for the delay. But his tone changed when Jack identified himself as a medical examiner.
“I understand you were one of a group out drinking last night along with Keara Abelard and brought her into Saint Luke’s emergency room.”
“We could tell she was really sick,” Farrell responded.
“Are you aware of the outcome?”
“The outcome of our bringing her to the ER?”
“I’m talking about her outcome.”
“I heard she died after we left.”
Jack’s cynicism antenna went up. “Did that surprise you?”
“Sure. She was young.”
“Young people don’t usually die.”
“That’s why I’m surprised.”
Jack cleared his throat to give himself a chance to think. His quick assessment was that Farrell was inappropriately defensive. As if to underline this impression, Farrell quickly added, “We didn’t give her anything, if that’s what you are implying. She wasn’t even drinking.”
“I wasn’t implying anything,” Jack said. He congratulated himself for taking a wide sampling of body fluids for toxicology despite the positive finding of bilateral vertebral artery dissection. He now wondered if she’d suffered a peculiar fall that could have sharply twisted, flexed, or extended her neck.
“How many of you brought her to the ER?”
“Three of us.”
Jack nodded.
“You guys were drinking but she wasn’t?”
“I think I want to talk to my lawyer before I answer any more questions,” Farrell said.
Jack pressed on. “How big was your group?”
“There were about a dozen of us, men and women. We went to this dive bar in the West Village. Can you just tell me what she died from?”
“We’re working on that. Did you witness the change in her behavior?”
“Yeah, one minute she was lively and talking, drinking a Coke, the next minute she was slurring her words and didn’t know where or who she was. Then she stood up, staggered a few steps, and fell. I literally caught her, which is why I ended up bringing her to the ER.”
“Why didn’t you call an ambulance?”
“We thought she was drunk, to tell you the truth. I didn’t learn until later that she was a teetotaler.”
In his imagination, Jack could picture the lining of Keara’s vertebral arteries balloon up and gradually choke off the blood supply to her brain. “Can you get me the names and phone numbers of the other people who made up this group?”
“I don’t know, man.” Farrell shied. “I don’t know if I want to get any more involved in all this than I already am.”
“Look, I’m not accusing anyone of any wrongdoing and I’m not accusing you of anything. I’m just trying to speak for the dead, which is what medical examiners do. I want Keara to tell us what killed her to try to save someone else from the same fate. There is some key piece of missing information involved here. Tell me, did you talk to her directly during the evening?”
“For a few minutes, but not any more than I talked to everyone else. I mean, like, she was a looker, so all the guys talked to her.”
“Did she mention anything at all about being in an auto accident in the last week or so?”
“No, nothing like that.”
“How about any falls she might have experienced: maybe even earlier last evening, like in the ladies’ room.” Jack didn’t think a fall was a likely culprit with no external evidence of injury, but he didn’t want to rule anything out.
“She didn’t mention it, no.”
Jack finally got the man to agree to make up a list of the other revelers from the previous night, along with their phone numbers. Farrell even promised to have it available by late afternoon.
Jack hung up, then sat at his desk, drumming his fingers on the blotter. Despite his initial suspicions, it now seemed to Jack there wasn’t a criminal angle. But he was sure there was some piece of Keara’s story that still eluded him. With no other excuse to postpone the call to Keara’s mother, Jack dialed the number. He knew too well the woman’s plight.
She picked up on the very first ring, her voice strong and expectant. Jack immediately assumed she was in the denial phase and there was still a part of her that hoped it might be a call from someone saying it was all a horrible mistake and that her daughter was just fine.
“This is Dr. Jack Stapleton. I’m calling from the Office of the Chief Medical Examiner.”
“Hello, Dr. Stapleton,” Mrs. Abelard said in a lilting but questioning tone, as if there was no reason for someone to be calling from the New York City morgue. “Can I help you?”
“You can,” Jack said, debating how to begin. “But first I want to express my deepest sympathies.”
Mrs. Abelard was quiet. Jack worried she might explode into a tirade with tears, heralding the second stage of grief, the anger stage. But there was only silence, interspersed by the woman’s intermittent breathing. Jack was afraid to say anything, lest he make a bad situation worse.
“I hope I’m not bothering you too much,” Jack said at length, but only after it had become obvious Mrs. Abelard was not about to respond. “I’m sorry to have to call.
“I know you were here at the morgue last night,” Jack continued. “And I’m sure it was difficult. I don’t mean to disturb you in this time of grief, but I wanted to let you know that I have carefully examined your daughter, Keara, this morning, and I can assure you she is resting peacefully.”
Jack grimaced at what sounded to him like a mawkish attempt at empathy. He wished he could hang up, collect himself, and call back. The idea that an eviscerated corpse was resting peacefully was so absurdly sappy that he was embarrassed it had come out of his mouth. It made him feel guilty that he’d stooped so low in his manipulating. Nonetheless, he forged on as he’d done with the reluctant Robert Fa
rrell. “What I’m trying to do is speak for your daughter, Mrs. Abelard. I’m certain she has something to say to help others, but I need more information. Can you help me?”
“You say she is resting comfortably?” Mrs. Abelard asked, breaking her silence. It was as if she believed her daughter had had some minor mishap.
“She’s at peace. But I’m wondering, did she experience any kind of neck injury recently?”
“Neck injury? Like what?”
“Any kind of injury at all,” Jack said. He felt like a trial lawyer trying to avoid leading the witness.
“Not a specific neck injury that I can recall, although she did fall from a swing when she was eleven and was bruised all over, including her neck.”
“I’m talking about an injury that might have occurred over the last few days,” Jack said, “maybe in the last week.”
“Heavens, no.”
“Is she a yoga enthusiast?” Jack was trying to cover all the bases.
“No, I don’t think so.”
“What about an automobile accident? Anything like that happen recently?”
“Heavens, no,” Mrs. Abelard repeated more forcefully.
“So she’d been completely well up until yesterday. No neck aches or headaches.”
“Well, now that you mention it, she did complain of some recent headaches. She’s been under stress because of a new job.”
“What kind of work?”
“Advertising. She’s a copywriter for one of the up-and-coming ad agencies in the city. It’s a new position, and a bit of a stressful situation. She’d been laid off recently, so she was feeling pressure to do her best in her new position.”
“Did she say where the headaches were centered, like in the front or back of her head?”
“She said they were behind her eyes.”
“Did she do anything about them?”
“She took ibuprofen.”
“And . . . did it help?”
“Not very much, so she asked one of her friends, and the friend recommended a chiropractor.”
Jack sat up in his chair. In the far reaches of his mind, he recalled a case he’d read about in an issue of the Forensic Pathology Seminars involving a chiropractor and stroke. “Did Keara go to this chiropractor?” Jack asked, while trying to recall the details of the published case. He remembered it dealt with the vertebral artery dissection, just as he’d found that morning in Keara.
“She did. As I recall, it was this past Thursday or Friday.”
“Did the visit help her headaches?”
“It did, at least initially.”
“Why did you say ‘at least initially’?”
“Because the headache located behind her eyes went away, but then she got a different one in the back of her head.”
“You mean like the back of her neck?”
“She said the back of her head. Now that I’m remembering the discussion, she also said she had a bad case of hiccups she couldn’t get over, and they were driving her crazy.”
“Do you happen to know the name of this chiropractor?” Jack asked, as he supported the phone receiver in the crook of his neck. With his hands free, he went on the Internet and Googled “dissection, vertebral artery.”
“I don’t. But I do know the name of the friend who recommended the doctor.”
“You mean the chiropractor,” Jack said reflexively, then regretted it. He didn’t want to take any chances of upsetting Keara’s mother. While the man may well have been a doctor of chiropractic, Jack knew many people thought they were medical doctors. Jack was leery of chiropractors, although he admitted he didn’t know too much about them.
“Her name is Nichelle Barlow,” Mrs. Abelard said, indifferent to Jack’s comment.
“Thanks for your cooperation,” he said, writing down the number. “You’ve been so generous, especially under such trying circumstances.”
Replacing the receiver, Jack stared blankly at the wall. Seventeen years ago when his first wife and children died, he remembered how long he had been in denial as friends and family had called. Shaking his head to free himself from such morbid thoughts, he forced himself to turn his attention to his computer screen, but he couldn’t concentrate. Instead he recalled the scene a couple of nights previous, of John Junior sobbing with what he and Laurie worried was bone pain from the tumor in the marrow cavities of his long bones. His tiny, perfectly formed infant hands seemed to gesture toward his legs as if hoping his parents could provide relief, but of course they couldn’t.
“Shit!” Jack yelled at the ceiling in hopes of shocking himself out of his downward-spiraling self-pity. At that point, a head poked in through the open doorway. It was Dr. Chet McGovern, Jack’s former office mate.
“Is that a reflection of your personal state of mind,” Chet joked, “or a general assessment of the current stock-market trend?”
“All of the above,” Jack said. “Come on in and take a load off.” Despite being preoccupied, Jack welcomed the diversion.
“Can’t do,” Chet said, with a lilt to his voice. “I met somebody Saturday night, and we’re meeting for lunch. She might be the one, my friend! She is hot.”
Jack waved him off. He’d become convinced Chet was never going to, find “the one.” Chet loved the chase too much to settle down.
“Hey, Chet,” Jack called to his retreating friend. “Have you ever had a vertebral artery dissection?”
“Yeah, one,” Chet said, returning to lean back into Jack’s office. “It was during my forensic pathology fellowship in L.A. Why?”
“I had one this morning. It stumped me until we opened the skull. There wasn’t much of a history, and there was no apparent trauma.”
“How old?”
“Young. Twenty-seven.”
“Check out if she’d seen a chiropractor in the last three days or so.”
“I think she did,” Jack said, impressed by Chet’s suggestion. “I think she might have seen one last Thursday or Friday. She died last night.”
“It could be significant,” Chet replied. “In my case, the association was easy to make, since the symptoms began moments after the cervical manipulation. But when I looked into the issue in general, I learned the symptoms of VAD can be delayed for days.
“Listen,” Chet added. “I’d love to talk more, but I got to go to meet my new honey.”
“You’re impressing me no end,” Jack said, jumping up and following Chet down the hall. “I vaguely remember reading about a case, but I’d never seen one.”
“I found it interesting,” Chet admitted as he walked, “and I thought I could get some kudos out of it from my chief, so I researched VAD and chiropractic a bit. I found it to be one of those associations which hasn’t sparked much interest, nor did it then for me. It turned out my chief went to the same chiropractor and swore by him, so my hand was forced to sign out the case as merely a therapeutic complication.”
“What is it that certain chiropractors do that makes VAD possible? Do you know?”
“I assume it is the force of their ‘adjustment technique,’” Chet explained. “It’s called a high-velocity, low-amplitude cervical thrust. Though it doesn’t happen often, there are apparently times when it can cause an internal tear in the vetebral artery, and the blood pressure does the rest. Sometimes the dissection extends all the way up into the basilar artery.”
“How often is not often?” Jack asked.
“I don’t remember exactly,” Chet admitted. “It was a few years ago. In the L.A. medical examiner files I think I found only four or five cases of VAD associated with chiropractic visits.” Chet stepped into the elevator, holding the door open with his hand. “Listen, Jack, I gotta go. I’m already late. We can talk more later if you want.” The doors closed, and he was gone.
For a moment Jack continued to stare at the blank elevator door. He was now intrigued, thinking he might have stumbled on the diversion he needed. If it turned out that Keara had gone to a chiropractor for her headache and
had had cervical manipulation, there was a chance, he had no idea of how much chance, she’d suffered her vertebral artery damage there.
Turning around suddenly, Jack hastened back toward his office, mulling over the fact that he’d read of a case of VAD caused by cervical manipulation, and that Chet had had one himself as well as having found four or five in the L.A. medical examiner data bank. On top of that, Jack thought, he may presently have another. What it was all suggesting to him was that paying a visit to a chiropractor under certain circumstances was not necessarily a benign experience.
Although Jack admitted he didn’t know the details of chiropractic therapy, as a form of what was referred to as alternative or complementary medicine, he knew there was a question about its efficacy. He had always vaguely lumped together chiropractic, acupuncture, homeopathy, Ayurvedic tradition, Chinese herbal medicine, Transcendental Meditation, and a hundred others of what he considered questionable therapies based more on hope and the placebo effect than anything else. It surely wasn’t science, as far as he was concerned, but if people believed they got value for their dollar, it was fine with him. On the other hand if these therapies could be fatal, it was another story entirely, and he, as a medical examiner, had a distinct responsibility to blow the proverbial whistle.
Energized by this new crusade, Jack sat back in his desk chair. He couldn’t help but think about his conversation with Laurie and how she said she’d be willing to try anything for JJ. “I think we’ll pass on chiropractic therapy,” Jack said out loud as he pulled his chair toward his computer monitor.
8
12:05 P.M., MONDAY, DECEMBER 1, 2008
NEW YORK CITY
(7:05 P.M., CAIRO, EGYPT)
Jack pulled up an eMedicine article dealing with vertebral artery dissection. He began skimming it, learning that VAD was the cause of twenty percent of strokes suffered in patients younger than forty-five years of age, occurring three times more often in females than males. Reading on, he noted that the typical presentation was occipital, or back of the head, headache. He turned to the last page for the causes. The very first risk factor listed was spinal manipulation, just as Chet had suggested.
