Fatal Care (7 page)

“It’s supposed to get heavy later on,” Sara said.

“The plants could use it.”

“Yeah.”

David lit a cigarette and glanced around the alley, making certain they were alone. “How did it go last night?” he asked, keeping his voice low.

“It was straightforward,” Sara told him. “He went down a dark street in a bad neighborhood where they deal a lot of drugs. They’ll think an addict killed him for his money.”

“You empty his pockets?”

Sara nodded. “I didn’t even leave small change.”

David handed her a thick manila envelope. “There may be a problem with the guy you iced on that yacht.”

Sara’s heart skipped a beat, but she kept her expression even. “Like what?”

“Like they’re going to do an autopsy on the guy.”

Sara shrugged. “They do that routinely in suspected drowning cases.”

“Is it routine to have the autopsy done by a renowned forensic pathologist at Memorial Hospital?”

“No,” she had to admit. “But that won’t change the diagnosis. The guy was holding his head as he went overboard. That meant he had plenty of time to suck seawater into his lungs before he died.”

“And that’s all they need to prove he drowned?”

Sara nodded again. “That’s what the pathology textbook I studied says.”

“Well, I hope you’re right,” David said evenly, but his eyes stayed cold as ice. “Because we don’t like screwups, do we?”

“No, we don’t.”

“I’ve got another job for you.” David pointed to the manila envelope. “The information is in there. It’s a doctor. A high-profile hit.”

“How high?”

“Big time,” David answered. “And it’s got to look like an accident. They’ll pay twenty grand, but they want it done within a week.”

Sara shook her head. “Accidents take time to happen. I’ll need a minimum of two weeks.”

“There’s a five-thousand-dollar bonus if it’s done within seven days.”

“Do you want it done right or not?”

David thought for a moment and then reached for Sara’s empty glass. “Okay. Take your time. But remember: it’s high-profile, and the cops will be all over it.”

Sara walked away, thinking about the next hit. A doctor. High-profile.
Do your homework
, she reminded herself.
Do it very carefully
.

Lori McKay looked down at the face of Oliver Rhodes and studied it. Even in death he appeared aristocratic, with his chiseled features and aquiline nose. And he had so much wealth and power to go along with it. But that was all gone. Oliver Rhodes was just another lifeless body now. He had died slumped over a steering wheel, like her own father had twenty years ago. Lori could barely remember her daddy’s voice and touch. It all seemed so long ago.

“Oh-oh!” Joanna said, holding up the lungs she had just resected from Oliver Rhodes’s chest. “Was he a smoker?”

“An ex-smoker,” Lori said, and moved in for a closer look. There was a white nodule on the superior aspect of the left lower lobe. It was firm and fixed with scattered hemorrhages on the periphery.

“What do you think?” Joanna asked.

“I’ll bet it’s malignant.”

“And he was an ex-smoker, huh?”

“That’s what his records say.”

Joanna reexamined the nodule. It was almost certainly a tumor, but there were other possibilities such as a walled-off abscess or foreign body. “Briefly review his medical history for me, would you?”

Lori walked over to a side table and picked up a large file card. “Mr. Rhodes was in perfect health until he had a myocardial infarction two years ago. His angiogram showed so many blocked vessels that bypass surgery was not possible. He suffered from chronic, progressive angina and had trouble walking across the room. A year ago he underwent an experimental coronary artery-cleansing procedure. Do you want details on that?”

“Please,” Joanna said, examining the other lobes of the lungs and the pleural membrane that covered them. There were no additional lesions.

Lori went to a second index card. “The cleansing procedure is done by running a catheter from the femoral artery up to the left main coronary. The big blockages are removed by a tiny laser that acts like a Roto-Rooter. Any debris is sucked out with a vacuum. Then they squirt in a lipolytic enzyme that cleans fatty deposits off the walls of the arteries. The results were spectacular. Within a few months he could jog and play tennis on a daily basis.”

“Did he have any fever or infections from these procedures?” Joanna asked. “Did he have anything that resembled pneumonia?”

“Nope.”

“Were there any episodes of loss of consciousness when he could have aspirated a foreign object?”

Lori shook her head.

“And he never worked around asbestos or anything else that would enhance an ex-smoker’s chances of developing lung cancer?”

“There’s nothing like that in his records.”

Joanna exhaled wearily, trying to think and put the pathologic clues together. But she’d been on her feet for over fourteen hours, and the effect of it was starting to show. “See if you can find somebody to do a frozen section on this pulmonary nodule.”

“You want it done
now
?”

“Now.”

Lori walked over to a wall phone and began punching in numbers.

Joanna moved around on her feet and tried to get the circulation going. Her fatigue seemed to be increasing by the minute. She had to resist the urge to go directly to the heart, where all the answers lay. With effort she forced herself to examine the lungs once more.

The door to the special autopsy room opened, and Simon Murdock hurried in.

“Have we got anything yet?” he asked.

“He probably has lung cancer,” Joanna said.

“But that didn’t kill him, did it?” Murdock asked quickly.

“No. Lung cancer doesn’t kill suddenly unless it erodes into a major blood vessel.”

Murdock nodded, breathing a sigh of relief. He was sorry that Oliver Rhodes was dead, but he’d be sorrier yet if Rhodes died of anything other than heart disease. It had to be heart disease that caused Oliver’s death. That was the condition that needed to be met for the Rhodes family to donate ten million dollars for a new cardiac institute at Memorial. “Have you looked at his heart yet?”

“Not yet,” Joanna replied, spreading the lobes of the lungs apart so she could examine the central area where the lymph nodes were located. They weren’t enlarged. The cancer probably hadn’t spread beyond the nodule.

Murdock glanced up at the wall clock. It was 10:40 P.M. “How much longer?”

“As long as it takes,” Joanna said, focusing all of her attention on an area of thickened pleura. It looked like a scar, not a tumor.

“Do I need to remind you that the Rhodes family is waiting?”

“They’re going to have to wait a little longer.”

Murdock’s face tightened. “There would be no delay at all had you not used up the afternoon on police work.”

Joanna exhaled heavily. “That was a very important case, Simon.”

“Nothing—I repeat—nothing is more important at Memorial than the Rhodes family,” Murdock snapped. “Do you understand that?”

Joanna dropped the mass of lung tissue onto the stainless steel table. It landed with a loud thud. She moved in closer to Murdock. “I understand that the Rhodes family has suffered a tragic loss. And I understand that they want the autopsy results as soon as possible. But you and I arguing down here won’t get the work done any faster.”

“That may be so,” Murdock countered. “But I still think your order of priorities is inappropriate. Your police cases should
always
come after your patients from Memorial.”

“Not always,” Joanna said firmly. “Every now and then there are cases in which the search for evidence can’t wait. In some instances the evidence can change or even disappear with time.”

“Those must be very rare exceptions.”

“Well, a rare exception happened today.”

Murdock gave her a long, hard look. “Maybe we should discuss this before the entire department of pathology.”

“You just let me know when.” Joanna fixed her eyes on Murdock, disliking him even more than usual.

They glared at each other, the tension rising close to the breaking point. Neither blinked or backed down.

Lori McKay watched the confrontation, despising Murdock almost as much as she liked Joanna. He was a bully who seemed to enjoy manipulating people and keeping them under his thumb. And he did it to just about everybody at Memorial except Joanna. She never tolerated his abusive behavior and never backed down.

The wall phone rang. Lori picked it up and spoke briefly; then she called over to Joanna, “It’s the pathologist on call. He wants to know if the frozen section can wait until morning.”

Murdock asked, “What’s this all about?”

“I want a frozen section study done on the pulmonary nodule we found,” Joanna explained, regaining her composure. “That way we’ll know tonight if Oliver Rhodes had lung cancer.”

Murdock looked over to Lori. “You tell that pathologist he’d better get in fast if he values his job.”

Lori relayed the message and then returned to the stainless steel autopsy table. She distanced herself from Murdock, fearing the man as much as she disliked him.

“All right,” Joanna said, getting back to business, “let’s examine the heart.”

Murdock put on reading glasses and moved in closer to the autopsy table.

Joanna picked up the heart and carefully studied its size and consistency. It was smaller than she expected and had a healthy red color. There was no evidence of ventricular enlargement or scarring. The anterior surface of the heart glistened in the light. It weighed four hundred grams.

“The heart is usually bigger in someone his age,” Joanna commented. “Particularly when there’s a history of cardiac disease.”

“Don’t forget he had his coronary arteries cleaned out,” Lori said. “They’re like new.”

“But this is the heart of an athlete,” Joanna went on. “You said he was a jogger. Right?”

Lori nodded. “He ran a couple of miles on an almost daily basis, and he was an avid tennis player, too.”

Joanna cut into the wall of the left ventricle and studied the cardiac musculature. “This heart looks like it belongs to someone twenty-five years old.”

“A new set of coronary arteries can do wonders,” Lori said.

“Maybe,” Joanna said, unconvinced. She had done autopsies on patients who had had coronary bypass surgery and died of other causes. Their grafts were still open and had provided excellent coronary blood flow. But their hearts never looked this good.

“Is there any evidence of myocardial infarction?” Murdock asked worriedly.

“Not so far.” Joanna sliced open a major coronary artery and studied its interior. There were no fatty deposits or occlusions. “The left main coronary looks very clean.”

Murdock groaned to himself. No heart attack, no new institute. “Perhaps one of the other coronaries is blocked.”

“Perhaps,” Joanna said. But the other coronary arteries appeared to be wide open with not even a hint of blockage. There was no evidence for a myocardial infarction. Joanna began thinking about noncardiac causes of sudden death in a middle-aged man. An acute cerebral hemorrhage topped the list. “Simon, we may have to examine Oliver Rhodes’s brain.”

“The Rhodes family wants to avoid that,” Murdock said. “At the funeral service his body will be viewed.”

Joanna shrugged. “We may have no choice but to open his skull.”

She went back to the heart and split it apart, exposing the interventricular septum and the endocardial wall. There were postmortem blood clots blocking her view, so she swept them away.

Then she saw it. A large pinkish red mass growing out of the septum. She looked over at Simon Murdock. “Oliver Rhodes did not have a myocardial infarction. But he did have a cardiac-related death.”

Murdock’s eyes brightened. “Are you
sure
?”

“Take a look at the superior aspect of the interventricular septum.”

Joanna spread the heart open again and pointed at the large mass that involved the upper septum and extended down into the endocardial wall. “It’s a tumor.”

Murdock stared at her quizzically. “Of the
heart
?”

Joanna nodded. “It’s rare, but it happens.”

Murdock snapped on a pair of latex gloves and felt the firm, fixed mass. “How rare is it?”

“I’ve been here over ten years, and I’ve seen only one case.”

Lori leaned in for a closer view. “How do you know it’s not a metastatic lesion? Maybe it’s a metastasis from that pulmonary nodule.”

“That’s a possibility,” Joanna conceded. “But I think it’s unlikely for several reasons. First, metastatic lesions to the endocardium are rare, even rarer than primary cardiac malignancies. Secondly, metastases from the lung to the heart are usually the result of direct extension and almost always involve the outer pericardium, not the endocardium. That having been said, the only way to really tell if it’s a primary tumor of the heart is by examining it under a microscope.”

Lori nodded to herself, thinking aloud. “If it’s a primary heart tumor, it’ll be a sarcoma. If it’s a metastasis from the lung, it’ll be a carcinoma.”

“Right.”

Murdock asked, “Can you tell the difference between the two on frozen section?”

“I would think so,” Joanna answered.

Murdock glanced up impatiently at the wall clock. It was eleven. “Where the hell is the on-call pathologist?”

“He should be here in a minute,” Lori said. “He lives close by.”

Murdock gazed down at the opened chest of Oliver Rhodes. One man’s death was another man’s gain, he thought. That’s the way it always was. Oliver’s death would give Memorial a new heart institute—if his death was cardiac related. And it was, according to Joanna Blalock. Murdock wondered how a heart tumor caused someone to die suddenly. Mortimer Rhodes would want to know that, too. “Joanna, how does a tumor like this induce sudden death?”

“By inducing an arrhythmia,” Joanna told him. “This tumor has invaded deeply into the interventricular septum where the heart’s conduction system is located. All electrical impulses travel from the atria to the ventricles via the septum. If the septum is diseased, such as by an infiltrating tumor, the conduction system goes haywire and you end up with severe cardiac arrhythmias.”