“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 explainedcyanoticto 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 nameHelenon 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.”
