Jack had so many questions he didn’t know what to ask first. At the same time, he wanted to try to be as tactful as possible and not squander his unexpectedly hospitable reception, which he was afraid might happen if he ventured too hastily into sensitive areas. Since one of the issues that both intrigued and bedeviled him the most was the apparent DNA match between Carol and the donor heart, he tried to think of the subtlest way to broach it. What popped into his mind on the spot was getting into a discussion about the motorcycle victim, as it would have had to have been an identical twin. Why such an extraordinary fact would have been kept a secret totally mystified Jack, but there had to have been a reason. Yet before he could put a guileful question together, the secretary returned with the coffee.
“Would you like cream or sugar?” Ted asked. He was solicitously holding both.
“Both, please,” Jack said. Then as soon as the secretary had departed, and the cream and sugar had been stirred into his cup, which gave him a few extra moments to think, he said, “Dr. Barton told me about the coincidence of the fatal motorcycle accident happening on the same day that Carol Stewart’s heart situation became critical. Was the victim related to Carol? Dr. Barton had told me it was a good match.”
“It wasn’t good, it was a fabulous match,” Ted said enthusiastically. “The best I have ever seen, and with the rarest AB-negative serology, which is the reason we pushed for a targeted or direct donation. There was a twelve-out-of-twelve HLA match, zero reactive antigen, and a negative cross-match. It doesn’t get any better than that.”
“Was the motorcyclist related to Carol?” Jack asked, still skirting the issue.
“I believe he was a Stewart, but I’m not positive,” Ted said. “Or he was related somehow. I personally don’t get involved in that, as we have our own organ-donation team who deals with the grieving parents, to separate donor issues from recipient needs. All I knew was the heart matched extraordinarily well. The fact that the kinship issue wasn’t stressed is because we have some hillbillies around here despite our proximity to the city. We might not have any families that are as hostile to each other as the McCoys and the Hatfields, but there are feuds, even within the same family.”
The alarm bells that this case had set off in Jack’s brain started ringing again. “So the motorcyclist was a male?” he asked, to be certain Ted hadn’t had a slip of the tongue.
“Yes,” Ted said. “Ninety percent of motorcycle driver deaths are men.”
“True,” Jack said. As a medical examiner, he was aware of the statistic. But that wasn’t the source of the silent ringing he was hearing. If the motorcyclist was a male, there was no way he could have been an identical twin. Jack was back to square one.
“The reason it was such a serendipitous situation,” Ted said, unaware of Jack’s mental state, “was that Miss Stewart had been on the UNOS waiting list for a year. With AB-negative she clearly wasn’t going to get an organ. Obviously, the motorcyclist’s serology was also AB-negative.”
“Dr. Barton mentioned that,” Jack said.
“Other questions?” Ted asked.
“Yes.” Jack struggled with what next to ask. “We were surprised when a toxicology screen revealed that Miss Stewart had no immunosuppressants in her system.” Reluctant to go for broke, which would have happened had he stayed on the topic of how closely the donor heart matched, he’d changed the subject to the immunosuppressant issue. Now more than ever he was certain that something was amiss with this case, and the cynic in him began to wonder if the hospitality he was experiencing was to placate him.
“It was for good reason you found no immunosuppressants,” Tedsaid. “She wasn’t on them. She had been doing so admirably, even with her active immune system, which she had, by the way, that we were able to lower and eventually eliminate immunosuppressants. It was a function of how well she had accepted the donor heart, which thrilled us. You have no idea.”
“Hello, hello,” a voice called, as two figures bounded into the room. The first was tall but slightly stooped, with striking, prematurely white hair. In contrast, his face was boyish, with a lantern jaw and bright blue eyes. He was attired exactly as Dr. Chris Barton had been the day before at MGH, in a long white doctor’s coat over scrubs, with a surgical mask dangling from his neck. The second man was similarly dressed but of Asian genealogy, with coal-black hair, small features, and a slight build. Both were smiling as if they had been laughing prior to coming into the room.
Jack and Ted stood as Ted introduced Dr. Stephen Friedlander and Dr. Han Lin to Jack, suggesting as he did so that they should all be on a first-name basis. Jack shook hands with both surgeons. At that point all four people took seats around the circular table.
Like a true surgeon, Stephen took control. He had a deep and commanding voice despite his boyish looks. “We are thrilled you surprised us by stopping by, Dr. Stapleton,” he said. “As I’m sure Ted has told you, we heard the efforts you had gone through to identify our patient, Carol Stewart. As sad as the news was, I personally want to thank you very much for what you did. From what I understand, Carol’s body might not have been identified until she missed her next follow-up visit here at our clinic and we reported it to Missing Persons. It is particularly sad, as I personally know she’s been estranged from her family and had some setbacks in her own social life. I know because she told me not that long ago on her last follow-up visit, which, by the way, was perfect on all accounts. There was absolutely no sign of any coming catastrophe.”
“As I told Ted,” Jack said, “it is part of the job of the medical examiner to identify the dead. At OCME we learned that lesson the hard way after 9/11.”
“At this point our goal needs to be finding out why she died,” Stephen continued. “Whatever it was, we do not want it to happen again. Since we know you did an autopsy, we are interested to hear your findings.”
“I have yet to sign the case out,” Jack said. He appreciated finally being asked, but with Laurie’s insistence on holding off on telling anyone, he wasn’t sure how much he wanted to say, especially until he got confirmation from Aretha. “I’m waiting on some tests.”
“We were concerned about a virus,” Stephen said. “We sponsored a second autopsy here this morning.”
“So I heard,” Jack said. “And what was found?”
“We believe she died of a cytokine storm,” Stephen said. “She had a strong immunological reaction to something in her system. Exactly what, we don’t know. We thought about a virus, but that doesn’t seem to be the case.”
“Sounds familiar,” Jack said. “I also suspected a virus—influenza, to be exact. But all the usual viruses have been ruled out with rapid screening tests, including influenza.”
“We know it wasn’t a virus,” Stephen said with conviction. He sat back in his chair, his arms folded across his chest. “We know it for certain.”
“And how is that?” Jack asked.
“We have access to electron microscopy, which is the benefit of having superb resources. We simply looked. Actually, Dr. Lin looked. Right now, he’s our most experienced electron microscopist. There’s no virus in her lung fluid. Case closed.”
“Yes, I looked for virus,” Dr. Lin said with a heavy accent. “No virus was present.”
“That’s curious,” Jack said. “We began seeing cytopathic changes suggestive of virus in human kidney cell tissue cultures within twenty-four hours of inoculation. The plan is to search for an unknown virus.” Although Jack tried to sound confident, he was shocked and dismayed to hear that no viruses were seen on microscopy. He wondered if Arethahad tried. He doubted it, as she surely would have told him. He didn’t even know if the Public Health Lab had an electron microscope.
“Undoubtedly you were seeing the results of a viral contaminant,” Stephen said confidently. “It happens all the time. If viruses had been present, they would have been seen on microscopy. Since there’s no virus present, running viral searches is a waste of time and money. Our forensic pathologist thinks the case needs to be signed out as a therapeutic complication, despite her surgery being more than three months ago. We agree and think you should do the same. We can share with you our electron photomicrographs for your records for confirmation. What we will be doing going forward is an extensive study of the proteins in the patient’s serum that must have come from the heart and keyed off the cytokine storm. We have that kind of capability. What we’ll be willing to do, if you are interested, is keep you in the loop and let you know what we find. I’m sure we will publish the results, and we’d welcome you as an author.”
