Robin Cook - Crisis

"What did you find on that case?"

"A marked developmental narrowing of the posterior descending coronary artery. Apparently, a small thrombosis knocked out a good portion of the heart's conduction system in one fell swoop."

"Is that what you expect to find on this case?"

"It's high on my list," Jack said. "But I also think there is going to be some kind of septal defect causing a right-to-left shunt to account for the cyanosis." Then he added parenthetically, "What it's not going to tell us, I'm afraid, is why someone was so intent on us not finding out whatever it is we are about to learn."

"I think we're going to find widespread coronary disease and evidence of a number of previous small, asymptomatic heart attacks so that her conduction system was particularly at risk prior to the final event, but not compromised enough to show up on a standard ECG."

"That's an interesting thought," Jack said. He glanced across the table at Latasha, who continued to stare at the exposed heart. His respect for her kept growing. He just wished she didn't look nineteen. It made him feel over the hill.

"Remember, postmenopausal women have recently been shown to have different symptomatology than equivalent males when it comes to coronary heart disease! The case you just described is evidence of that."

"Stop making me feel ancient and uninformed," Jack complained.

Latasha made a gesture of dismissal with her gloved hand. "Yeah, sure!" she intoned with a chuckle.

"How about we make a little wager since neither one of us is in our home office, where such activity is frowned upon? I say it's going to be congenital and you say degenerative. I'm willing to put up five bucks in support of my idea."

"Whoa, big spender!" Latasha teased. "Five is a lot of cash, but I'll double you to ten."

"You're on," Jack said. After turning the heart over, he picked up a pair of fine forceps and scissors and went to work. Latasha supported the organ as Jack carefully traced and then opened the right coronary artery, concentrating on the posterior descending branch. When he'd traced it as far as the instruments would allow, he straightened up and stretched his back.

"No narrowing," he said with a combination of surprise and disappointment. Although he usually maintained an open mind diagnostically, for fear of being blinded by the positive finding, in this case he'd been quite certain of the pathology he'd encounter. It was the right coronary artery that supplied blood to most of the heart's conduction system, which had been knocked out by Patience Stanhope's heart attack.

"Don't despair yet," Latasha said. "The ten dollars is still in the balance. There's no narrowing, but I don't see any atheromatous deposits, either."

"You're right. It's perfectly clean," Jack agreed. He couldn't quite believe it. The entire vessel was grossly normal.

Jack turned his attention to the left coronary artery and its branches. But after a few minutes of dissection it was apparent the left was the same as the right. It was devoid of plaque and stricture. He was mystified and chagrined. After all he'd been through, it seemed a personal affront that there was no apparent coronary abnormality, either developmental or degenerative.

"The pathology has to be on the inside of the heart," Latasha said. "Maybe we'll see some vegetations on the mitral or aortic valve that could have thrown off a shower of thrombi that then cleared."

Jack nodded, but he was mulling over the probability of sudden cardiac death from a heart attack with no coronary artery disease. He thought it was extremely small, certainly less than ten percent, but obviously possible, as evidenced by the case in front of him. One thing about forensic pathology that he could always count on was seeing and learning something new.

Latasha handed Jack a long-bladed knife, waking him from a mini trance. "Come on! Let's see the interior."

Jack opened each of the heart's four chambers and made serial slices through the muscular walls. He and Latasha inspected the valves, the septa between the right and left sides of the heart, and the cut surfaces of the muscles. They worked silently, checking each structure individually and methodically. When they were finished, their eyes met across the table.

"The bright side is that neither of us is out ten dollars," Jack said, trying to salvage humor from the situation. "The dark side is that Patience Stanhope is keeping her secrets to herself. She was reputed to be less than cooperative in life, and she's staying in character in death."

"After hearing the history, I'm shocked that this heart appears so normal," Latasha said. "I've never seen this. I guess the answers are going to have to wait for the microscope. Maybe there was some kind of capillary disease process that involved only the smallest vessels of the coronary system."

"I've never heard of such a thing."

"Neither have I," Latasha admitted. "But she died of a heart attack that had to have been massive. We have to see pathology other than a small, asymptomatic colon cancer. Wait a second! What's that eponymous syndrome where the coronary arteries go into spasm?" She motioned to Jack as if she were playing charades, wanting him to come up with the name.

"I honestly have no idea. Now, don't spout some trivia that's going to make me feel inadequate."

"Prinzmetal! That's it." Latasha said triumphantly. "Prinzmetal angina."

"Never heard of it," Jack admitted. "Now you're reminding me of my brother-in-law, who's the victim in this disaster. He'd know it for sure. Can the spasm cause massive heart attacks? That's the question."

"It can't be Prinzmetal," Latasha said suddenly with a wave of dismissal. "Even in that syndrome, the spasm is associated with some stenoses of the vessel nearby, meaning there would be visible pathology, which we don't see."

"I'm relieved," Jack said.

"We have to figure this out one way or the other."

"That's my intention, but not seeing any cardiac pathology has me fooled and even embarrassed, considering all the fuss I've caused to do this autopsy."

"I have an idea," Latasha said. "Let's take all the samples back to my office. We can examine the heart under the stereo dissecting microscope and even do some frozen sections of the heart tis-sue to look at capillaries. The rest of the specimens will have to be processed normally."

"Maybe we should just go have some dinner," Jack said, suddenly wanting to wash his hands of the whole affair.

"I'll pick up some pizza on the way back to the office. Come on! We'll make it a party. There's one hell of a mystery here. Let's see if we can't solve it. We can even get a toxicology screen tonight. I happen to know the night supervisor at the lab at the university. He and I were an item a while back. Things didn't work out, but we're still acquaintances."

Jack's ears pricked up. "Run that by me again!" he said with disbelief. "We could get a toxicology screen done tonight?" Back in New York at the OCME, Jack was lucky to get one in a week.

"The answer is yes, but we'll have to wait until after eleven, when Allan Smitham begins his shift."

"Who's Allan Smitham?" Jack asked. The possibility of an immediate toxicology screen opened up another whole dimension of inquiry.

"We met in college. We took a lot of chem and bio classes together. Then I went to med school and he went to grad school. Now we work a few blocks apart."

"What about your beauty rest?"

"I'll worry about that tomorrow night. You have me hooked on this case. We have to save your brother-in-law from the evil lawyers."

Alexis answered on the fourth ring. Jack had called her number and put his phone on speaker before placing it on the rent-a-car's front passenger seat. He was on his way from the Langley-Peerson Funeral Home to the Newton Memorial Hospital. He'd decided to make a short visit before the three-to-eleven shift left for the day in hopes of catching Matt Gilbert and Georgina O'Keefe. It had been an impulsive decision when he and Latasha left the funeral home after finishing up with the autopsy. She had said she was going to stop at her apartment briefly to feed the dog, drop off the fluid samples at the toxicology lab with a message for Allan to call as soon as he got in, and pick up a couple of pizzas at an all-night joint before meeting him in the parking lot of the medical examiner's office. She had given Jack the opportunity to tag along, but the window of opportunity had made him decide to stop at the hospital instead.