“I examined him, obviously,” Bob said. “Since I’d seen almost a dozen similar cases, I’d become worried I was confronting some kind of strange, possibly contagious outbreak. Similar to the other cases I’d seen, the only positive findings involved the nervous system: definite confusion and a total inability to count backward, which is a test I use as a quick screen for mental capacity. I also noticed some superficial muscle spasms in his arms and legs as well as some very mild ataxia. Anyway, there was nothing I could hang my hat on to suggest a specific diagnosis, so I sent him off to the Clinton Hospital for an emergency MRI brain scan and a neurology consult, which we can get once a week up here in the sticks.”
“Did the MRI show anything?” Laurie questioned.
“Nothing,” Bob said. “It was read as normal and was confirmed by a second radiologist in Saratoga Springs.”
“What was the neurologist’s impression?” Laurie asked.
“Same as with the other patients,” Bob said. “He was diagnosed probable early Alzheimer’s, but at this point I can’t help but question it. If it was early Alzheimer’s, why did he and the two others die so damn quickly, and why did the first two patients test negatively when I sent their samples to NMS Labs? And the other live patients I currently have with similar stories are all doing progressively poorly. Alzheimer’s patients don’t go downhill so rapidly or die in a week or two.
“Anyway, I’m mystified and a little scared. This situation is just like that mysterious episode of fatal brain disease in New Brunswick, Canada, reported in theNew York Timesin 2024 only it’s happening here, in my Essex Falls, during my watch. I’m the only doctor in town and I’m supposed to keep people healthy. Up in Canada they thought they were dealing with a possible weird outbreak of Creutzfeldt-Jakob disease, but the tests came back negative. Here we think we’re dealing with an outbreak of early-onset Alzheimer’s, but the tests have come back negative. Up in Canada the cases mysteriously stopped, but so far that doesn’t seem to be what is happening here, so we have to figure this out before more people get sick and more people die.”
“Well, let’s see what we can learn from this autopsy,” Jack said. “Which brings us to the question of how you would like to handle it. Do you want to do the autopsy while Laurie and I watch and comment, or would you prefer one of us to do it, and you ask questions as we go along? It’s your call.”
“Hmm,” Bob said. “That hadn’t occurred to me. Do you folks have a preference? I’m not sure I do.”
“We think it’s your call,” Laurie said. “Of course, it could also be some mixture of the two.”
“After giving it a quick thought, I believe it would be best forone of you to go ahead and do it rather than I,” Bob said. “Maybe you could talk it through as you go along, so I understand your reasoning for each step. It will be far more efficient that way. Besides, I’d feel incredibly nervous under the watchful eyes of two experts.”
“We’d be easy on you,” Jack said with a laugh. “But we’re happy to do it. My suggestion is for Laurie to be in the driver’s seat, as she’s been starved of autopsies ever since she became chief.”
“Fine with me,” Bob said.
“Laurie?” Jack questioned. “Are you okay being the prosector?”
“Is the sky blue?” Laurie humorously retorted. Immediately taking the lead, she went through a rapid but complete external examination of the body, verbally noting all irregularities, scars, and tattoos. This portion required rolling the body on its side to inspect the dorsal surface. She then inspected the inside of the mouth and the condition of the teeth, describing out loud her thought processes.
“So much for the external examination,” she said. She then asked Melanie for one of the scalpels that had been laid out along with the other instruments. “I’ll be using the typical Y-shaped autopsy incision,” Laurie announced before doing so, cutting from the points of both shoulders, meeting at the midline, and then incising through the skin all the way down to the pubis so that the omentum and a portion of the intestines were visible. “Okay, how about you guys create the skin flaps on either side of the thorax while I do the same up to the base of the neck. My idea here is to progress rather rapidly through this part of the autopsy unless we encounter unexpected pathology. Obviously, considering the history, the most critical part will be when we open the cranium to expose the brain. Is that okay with you, Bob, or would you prefer I go slower?”
“It’s fine with me,” Bob said. “I’ve read about doing autopsies butI’ve never seen a professional do one. If there’s something I don’t understand, don’t worry, I’ll certainly speak up.”
As Laurie suggested, she worked quickly but carried on a running commentary as she did so, especially when she got to the point of using the bone shears to cut through the ribs to expose the heart and lungs. She then increased her commentary as she went through the entire process of exposing the heart, clamping off various vessels before stopping to draw blood samples from the left atrium. While she was at it, she took other biological samples from the eyes, gall bladder, and kidneys.
After finishing with the thorax, having removed the heart and the lungs and examined them in detail, particularly the coronary arterial system, she went on to the abdomen, first removing the esophagus, stomach, and intestines and showing Bob the best way to open them up and rinse them out to examine their full length.
“I’m impressed with how fast you are able to do this,” Bob commented as he watched Laurie “run the intestines,” meaning check their entire length inch by inch for any abnormality. She did find some polyps, which she sampled.
“It comes with practice,” Laurie explained. “I’ve never stopped to try to figure out just how many autopsies I’ve done over the years. It’s a lot even though I haven’t been doing that many recently. And Jack has done even more than I, a lot more. He’s a glutton for punishment when it comes to autopsies. He does more than anyone else at the OCME, hands down.”
“That’s because I make it a point to arrive early every day and cherry-pick the best cases,” Jack explained from where he was standing over at the autopsy table.
After finishing with the examination of the GI system, Laurie and Bob left the laundry-like sink and returned to the autopsy table.She went on to examine and remove all the abdominal organs except the pancreas, which she left in place after carefully palpating it and taking a tissue sample, continuing to explain every step as she went along. Each individual organ was weighed, meticulously examined, and dissected. The only abnormalities she encountered were an enlarged spleen, which she thought was otherwise normal in appearance, and a single stone in the gall bladder. Then, taking a new scalpel, Laurie carried out a neck dissection to expose the thyroid gland and carotid arteries.
“That part’s done,” Laurie said, straightening up to stretch her back. “Any questions before I close up?”
“I don’t think so,” Bob said. He glanced at the clock, amazed at how fast Laurie had been able to proceed despite her ongoing commentary. He then watched with equal respect as she returned the organs to their approximate original locations, replaced the sternal flap, and then very rapidly sewed up the body using a running suture.
“All right,” Laurie said, hyperextending her back for a moment before placing the needle holder back on the instrument tray. She rubbed her gloved hands together in anticipation. “Now for payoff time, at least for this autopsy: the brain. Do you have a head block?”
“Yes, we do,” Bob said. “Let me get it.” He disappeared for a moment into the changing room.
“We’ve never bothered to use the head block,” Melanie explained.
“It makes the removal of the brain at bit easier,” Laurie said.
Bob reappeared almost immediately with a sizable block of wood. While Jack lifted Stanley Kramer’s head and shoulders with Melanie lending a hand, Laurie inserted it under his neck, adjusting his head up at a forty-five-degree angle. “There are a number ofways of removing the brain, but I’ll show you how we generally do it at the OCME,” she said. Then, explaining as she did it, she took a scalpel and made an incision from ear to ear around the back of the patient’s head. Using the same scalpel and a pair of forceps, she created a large flap of scalp, which she folded over the face, exposing the entire boney top of the cranium.
Without even being asked, Melanie handed Laurie the electric Stryker saw, which made a high-pitched raucous sound, especially as it cut into bone. “You have to be very careful along the temples,” Laurie explained, nearly shouting. “The bone is significantly thinner in those areas, and it is easy to damage the underlining dura or, worse yet, the brain itself.” At that point everyone was glad they were wearing face shields, as tiny bits of bone flew in all directions.
