“That’s up to Vinnie,” Jack said. Personally he didn’t care if Marvin stayed, but he knew there were some competitive feelings among the mortuary techs, and he didn’t want to be party to it. He knew that Vinnie, as the senior tech, was sensitively possessive about his exclusive relationship with Jack, by far the busiest ME.
“Fine by me,” Vinnie said.
“All right, I’m out of here,” Chet said. “I’ll be interested to hear if you find anything unexpected.”
Ignoring Chet, Jack said to Vinnie and Marvin, “Okay, you guys, let’s knock this one out.”
For a few minutes, Chet stood and watched the sudden burst of activity, but feeling cold-shouldered and a twinge embarrassed at his attempt at black humor, he soon left to prepare for the afternoon conference.
While Jack was doing the external exam, Marvin mentioned that there were other apparent similarities to the Kera Jacobsen case, namely little or no evidence of dried saliva around the mouth,suggesting there had been very little foaming, which is typically seen with pulmonary edema. Jack found this particularly interesting because he was well aware that with fentanyl deaths, pulmonary edema was almost always a primary finding and remnants of foaming were invariably present. Also like with Kera, there was no scarring from previous episodes as usually seen with intravenous opioid, particularly heroin, overdoses. Although there was no scarring, there were signs of other venous punctures, but they all appeared to be new or relatively new, suggesting that Aria’s drug use, at least intravenous drug use, hadn’t been a long-term habit.
Once Jack made the usual Y incision and the internal aspect of the autopsy commenced, any strangeness that existed because of familiarity with Aria on a personal level vanished, and the team functioned with professional celerity. Since Vinnie and Jack had worked together so often, they could anticipate each other’s needs, and often they could go for periods with no conversation. Sensing that he wasn’t really needed, Marvin mostly stayed out of the way and functioned more as a gofer than an integral member of the team.
“My goodness,” Jack said as he lifted both lungs and put them onto the scale. “These babies feel entirely normal.” He then called out to Vinnie that their combined weight was 2.9 pounds.
“That is normal,” Vinnie said, writing it down.
“Jacobsen’s lungs were the same,” Marvin said. “Dr. Montgomery felt that there was minimal if any pulmonary edema.”
“I’d have to say the same with these,” Jack said. He took the lungs from the scale, placed them on a cutting board, and made a series of slices to look at the interior. “Yup, minimal edema, if any. That’s weird. The respiratory depression from the fentanyl had to be really rapid, almost like turning out the light. That makes me suspect we are dealing with a very powerful fentanyl analogue, like carfentanil or, even worse, the cis version of 3-methylfentanyl.”
“Don’t listen to him,” Vinnie said, talking to Marvin. “He wants to impress you.”
“Really,” Jack said. He knew Vinnie was teasing him, but he wanted to be sure the techs knew he was telling the truth. “Those analogues are up to ten thousand times stronger than morphine in all regards, including suppression of respiration. It’s the potency of fentanyl analogues and their ease of manufacture that’s the major cause of the rising opioid death rate.”
As the autopsy continued and no pathology was being found, Jack’s imagination began to be stimulated. Certainly, one of the ungodly powerful fentanyl analogues could explain Aria’s death and the lack of pathological findings. There was no question in his mind. The same could be said about Kera Jacobsen’s death, since no pathology was found there, either, as confirmed by Marvin. Could the same analogue be involved in both deaths? Jack thought the chances were high, so Toxicology had to bear the burden of making that determination. The drug Aria used and the drug Kera used had to be compared. If it was the same, the city authorities would have to be alerted to warn addicts. Such a situation of a particularly potent batch of drugs on the black market had happened in the past, resulting in a sharp uptick in the already high number of opioid deaths. The user community had to be informed.
This line of thinking plus the lack of signs of previous intravenous use motivated Jack to try something he normally wouldn’t have done on an obvious intravenous overdose case, and that was to test the stomach contents for fentanyl. His thought was that maybe Aria had taken some orally and had been disappointed in the result before switching to the intravenous route. While Vinnie and Marvin were washing out the intestines at the sink, Jack took a small syringe, pulled out a fluid sample from the stomach, which was easy since the organ was in plain view after the intestines had been removed, and used a fentanyl test strip. He was surprised when it tested positive.
When Vinnie and Marvin returned to the table, Jack told them what he’d found.
“What does that mean?” Vinnie asked.
“I have no clue,” Jack said. “Except it suggests that Aria ingested some fentanyl before injecting it.”
“That doesn’t make any sense to me,” Vinnie said.
“Did the stomach contents get tested on the Jacobsen case?” Jack asked Marvin.
“I don’t think so,” Marvin said.
“Maybe I’ll ask Toxicology to do it,” Jack said.
The rest of the autopsy went quickly, especially since absolutely no pathology was found. At the very end, Jack thanked the two mortuary techs and left the autopsy room. Normally he would have stayed to give Vinnie a hand with the body and with cleaning up, but with Marvin there, he knew he wasn’t needed. Instead he picked up all the toxicology samples and, juggling them with a bit of difficulty, took them up to the sixth floor. There he found the head of Toxicology, John DeVries, in his spacious new office.
Back when Jack had been a new hire, he’d had issues with John, as he was a cantankerous individual struggling to run one of the key departments of the OCME with inadequate space and an inadequate budget. For his investigations, Jack needed answers, and he felt he needed them quickly. When the toxicology results weren’t forthcoming, he complained, and John’s response was to passive-aggressively delay the results even more. It became thornier still when the chief medical examiner got involved. There was even a time when Jack and John nearly came to blows.
Things changed dramatically after the new high-rise was opened, and many OCME departments moved into the slick new space. Toxicology stayed in the old building, and instead of occupying a few cramped rooms on a low floor, it moved into renovated space, consisting of the entire top two floors. And the Toxicology budget wasincreased commensurably, changing John overnight from an aging, cranky, gaunt, and bitter man into a younger-appearing, happier version of himself. In contrast to the “olden” days, Jack enjoyed running into the man or stopping into his new office on occasion.
“What do you have?” John asked graciously when Jack appeared at the door.
Jack explained the situation and his concern that the OCME had an obligation to the city’s addicted population to let them know if there was a new batch of particularly lethal drugs on the market. He explained the two cases of highly accomplished young women whose autopsy findings matched, making him feel that there might be a new fentanyl analogue out in the community, and that he needed to know if the two cases matched.
“We’ll get right on it,” John said, as he helped Jack unload his clutch of sample bottles from Aria’s autopsy.
“I have one more request,” Jack said.
“I would be surprised if you didn’t,” John said with a smile. “Ask away!”
