“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. Sincethat 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 asubpoena 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.”
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.”
