"What do you consider your biggest sacrifice?…

"I agree with that," Latasha said, recovering to a degree. "Now trouble, if it's going to happen, might depend on what we find."

"You have a point," Jack agreed. "Maybe it would be best if you don't help.

If anybody is going to be a target in any form or fashion, I want it to be me."

"What?" Latasha questioned with an exaggerated expression. "And let you boys have all the fun? No thanks! That's never been my style. Let's see what we find and then decide how best to proceed."

Jack smiled. He admired and liked this woman. She had smarts, pluck, and drive.

Bill and Tyrone lifted the corpse out of the casket, carried it over to the embalming table, and heaved it up onto the surface. With a bucket of water and a sponge, Bill gently rinsed away the mold. Like an autopsy table, the embalming table had lips around its periphery and a drain at the end to catch any wayward fluid.

Jack moved over to be on Patience's right while Latasha was on her left.

Both had donned their protective face and head gear. Tyrone excused himself to do his nightly security check. Bill retreated to the sidelines to be available if needed.

"The body's in fantastic shape," Latasha commented.

"Harold might be a tad stuffy, but he apparently knows his trade."

Both Jack and Latasha did their own silent external exam. When Latasha was finished, she straightened up.

"I don't see anything I wouldn't have expected," she said. "I mean, she went through a resuscitation attempt and an embalming, and there's plenty of evidence of that."

"I agree," Jack said. He'd been looking at some minor lacerations inside her mouth, which were consistent with having been intubated during the resuscitation. "So far, there's no suggestion of strangulation or burking, but smothering without chest compression still has to be kept in mind."

"It would be way low on my list," Latasha said. "The history pretty much rules it out, you know what I'm saying?"

"I'm with you," Jack said. He handed Latasha a scalpel. "How about you do the honors."

Latasha made the typical Y incision from the points of the shoulders to the midline and then down to the pubis. The tissue was dry like an overcooked turkey with a grayish-tan color. There was no putrefaction, so the smell was fusty but not offensive.

Working quickly and in tandem, Jack and Latasha had the internal organs exposed. The intestines had been completely evacuated with the embalming cannula. Jack lifted the firm edge of the liver. Beneath and affixed to its underside was the gallbladder. He palpated it with his fingers.

"We have bile," he said happily. "That will help with the toxicology."

"We've got vitreous as well," Latasha said, palpating the eyes through the closed lids. I think we should also take a sample of that."

"Absolutely," Jack said. "And urine, too, if we can get it from either the bladder or kidneys."

Each took syringes and took the samples. Jack labeled his while Latasha did the same with hers.

"Let's see if there's an obvious right-to-left shunt," Jack said. "I keep thinking the cyanosis issue is going to prove important."

Carefully, Jack eased away the friable lungs to get a look at the great vessels. After a careful palpation, he shook his head. "Everything looks normal."

"The pathology is going to be in the heart," Latasha said with conviction.

"I think you are right," Jack agreed. He called Bill over and asked if there were any stainless pans or bowls they could use for the organs. Bill produced several from a cabinet below the embalming-room sink.

Proceeding as if they were accustomed to working together, Jack and Latasha removed the heart and lungs en bloc. While she held the pan, Jack lifted the specimen out of the chest and placed it inside. She put the pan down on the table beyond Patience's feet.

"Lungs look normal," Jack said. He rubbed his fingers over the lungs'

surface.

"They feel normal, too," Latasha said as she gently prodded them in a few locations. "Too bad we don't have a scale."

Jack called Bill over and asked if a scale was available, but it wasn't.

"The weight feels normal to me," Jack said, hefting the block of tissue.

Latasha tried it but shook her head. "I'm not good at judging weights."

"I'm eager to get to the heart, but maybe we should first do the rest. What do you say?"

"Work first, play later: Is that your motto?"

"Something like that," Jack said. "Let's divide the job to speed things up.

One of us could do the abdominal organs while the other does the neck

dissection. For completeness' sake, I want to make sure the hyoid bone is intact, even though neither of us thinks strangulation was involved."

"If you are giving me a choice, I'll do the neck."

"You're on."

For the next half-hour they worked silently in their respective areas. Jack used the sink to wash out the intestines. It was in the large intestine that he found the first significant pathology. He called Latasha over and pointed. It was a cancer in the ascending colon.

"It's small, but it looks like it penetrated the wall," Latasha said.

"I think it has," Jack agreed. "And some of the abdominal nodes are enlarged. This is dramatic proof that hypochondriacs do get sick."

"Would that have been picked up by a bowel study?"

"Undoubtedly. If she'd had one. It's in Craig's records that she continually refused his recommendation to do it."

"So it would have killed her if she didn't have the heart attack."

"Eventually" Jack said. "How are you doing with the neck?"

"I'm about done. The hyoid is intact."

"Good! Why don't you get the brain out while I finish up with the abdomen? We're making excellent time." Jack glanced up at the wall clock.

It was closing in on eight p.m., and his stomach was growling. "Are you going to take me up on the dinner offer?" he called to Latasha, who was on her way back to the table.

"Let's see what time it is when we finish," she called back over he shoulder.

Jack found a number of polyps throughout Patience's large intestine. When he was finished with the gut, he returned it to the abdominal cavity. "I do have to give Harold Langley credit. His job with Patience Stanhope would have made an ancient Egyptian embalmer proud."

"I don't have much experience with embalmed bodies, but the condition of this one is better than I expected," Latasha said as she plugged in the bone saw. It was a vibrating device designed to cut through hard bone but not soft tissue. She gave it a try. It produced a high-pitched whirring noise. She positioned herself at the head of the table and went to work on the cranium, which she had previously exposed by reflecting Patience's scalp down over her face.

Relatively immune to the racket, Jack palpated the liver, looking for metastases from the cancer in the colon. Not finding any, he made a series of slices through the organ, but it was seemingly clear. He knew that he might find some microscopically, but that would have to be at a later date.

Twenty minutes later, after the brain had been cleared of gross abnormality and a number of specimens from various organs were taken, the two pathologists turned their attention to the heart. Jack had cut away the lungs, so it was sitting in the pan by itself.

"It's like saving the best present for last," Jack said while gazing eagerly and intriguingly at the organ and wondering what secrets it was about to reveal. The size was about that of a large orange. The color of the muscle tissue was gray, but the greasy cap of adipose tissue was light tan.

"It's going to be like dessert," Latasha said with equal enthusiasm.

"Standing here looking at this heart reminds me of a case I did about half a year ago. It was a woman who collapsed in Bloomingdale's and whose heart couldn't be paced by an external pacemaker, just like Patience Stanhope."

"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."

20

NEWTON, MASSACHUSETTS

THURSDAY, JUNE 8, 2006

9:05 P.M.

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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.

"I was hoping it was you," Alexis said when she heard Jack's voice.

"Can you hear me okay?" Jack asked. "We're on my speaker phone."

"I can hear you fine. Where are you?"

"I'm always asking myself that same question," Jack joked. His mood had flip-flopped from its nadir brought on by finding nothing relevant in Patience's autopsy to a near high. He had been energized by Latasha's enthusiasm and the prospect of getting the assistance of a toxicologist, and his mind had been picking up speed like an old-fashioned steam locomotive. Now ideas were flapping around inside his head like a flock of excited sparrows.

"You are in a rare mood. What's going on?"

"I'm in my rent-a-car on the way to the Newton Memorial."

"Are you all right?"

"I'm fine. I'm just going to duck in and ask a couple of questions to the ER

people who handled Patience Stanhope."

"Did you do the exhumation and the autopsy?"

"I did."

"What did you find?"

"Other than a nonrelevant, from our perspective, cancer of the colon, I found nothing."

"Nothing?" Alexis questioned. The disappointment in her voice was apparent.

"I know what you are thinking, because I thought the same. I was depressed. But now I think it was an unexpected gift."

"How so?"

"If I'd found generic, garden-variety coronary disease, which is what I actually expected to find rather than something dramatic, which is what I'd hope to find, I would have left it at that. She had heart disease and had a heart attack. End of story. But the fact that she had no heart disease begs for an explanation. I mean, there is a slight chance that she had some fatal cardiac event that we're not going to be able to diagnose eight months after the fact, but now I believe the possibility is in our favor that there was something else involved, especially considering the resistance Fasano expressed about my doing the autopsy, and Franco trying to run me off the goddamn road, and, more significantly, the threat expressed to your children. How are they, by the way?"

"They're fine. They act very secure, and they're having a ball here at Grandma's. She's spoiling them as she always does. But back to your point: What are you really trying to say?"

"I don't know exactly. But here's some of my thoughts, whatever they are worth. Patience Stanhope's death and the resistance to my doing an autopsy could be two completely separate circumstances. Fasano and crew could be behind the threats, and purely for venal reasons. But somehow that doesn't make sense to me. Why would he go to the extent of breaking into your house and then blithely let me do the exhumation? It seems to me that the three events are separate and not connected. Fasano threatened me for the reasons he gave. Franco has this ego problem after I whacked him in the nuts, so my problems with Franco have nothing to do with Patience Stanhope. That leaves the break-in at your house unexplained."

"This is too complicated," Alexis complained. "If Tony Fasano wasn't behind terrorizing my children, then who was?"

"I have no idea. But I asked myself what the motivation might have been if it didn't involve Fasano and money. It's pretty clear that it would be an attempt to keep me from learning something, and what could be learned from an autopsy? One thing would be an overdose of medication or the wrong medication Patience Stanhope might have gotten at the hospital.

Hospitals are big organizations with lots of stockholders, involving lots of money."

"That's crazy," Alexis said without hesitation. "The hospital wasn't behind my kids being victimized."

"Alexis, you wanted me to come up here to Boston and think out of the box, and that's what I'm doing."

"But the hospital?" she questioned with a whine. "Is that why you are on your way there now?"

"It is," Jack confessed. "I think of myself as a reasonable judge of character.

I was impressed by the two ER people I spoke with Tuesday. They're forthright and devoid of artifice. I want to talk to them again."

"What are you going to do," Alexis asked scornfully, "ask them if they made some huge mistake that the hospital has to send people out to brutalize my children to try to cover up? That's ridiculous."

"When you put it that way, it does sound far-fetched. But I'm going to do it anyway. The autopsy is not over. I mean, the gross dissection is over, but we're now going to see what toxicology can come up with and also look at the microscopic. I also want to corroborate exactly what medication Patience Stanhope was given so I can tell the toxicologist."

"Well, that sounds more reasonable than accusing the hospital of some ridiculous cover-up."

"The thought of an overdose or wrong medication is not my only idea. Do you want to hear it?"

"I'm listening, but I hope this next idea is more sane than your first."

Jack thought of some witty, sarcastic comebacks, but he controlled himself.

"The hospital idea was predicated on Patience Stanhope's heart attack and

the opposition to the autopsy being two separate although related circumstances. What if both involved the same person?"

There was a deliberate pause while Jack let this comment sink in.

"I'm not sure I'm following you," Alexis said finally. "Are you talking about someone causing Patience Stanhope's heart attack and then trying to prevent an autopsy to keep from being discovered?"

"That's exactly what I'm suggesting."

"I don't know, Jack. That sounds almost as crazy. I suppose you are talking about Jordan."

"Jordan is the first person that comes to mind. Craig said Jordan and Patience were hardly a loving couple, and Jordan is the big winner with her death. He certainly didn't waste any time in mourning. For all we know, he and his girlfriend were carrying on while Patience was still in the picture."

"How can someone cause a heart attack in someone on purpose?"

"Digitalis could do it."

"I don't know," Alexis said dubiously. "This seems equally farfetched. If Jordan was at all guilty, he certainly wouldn't initiate a malpractice suit, and he absolutely wouldn't have signed the exhumation authorization."

"I've thought of that," Jack said as he pulled into the parking area for the Newton Memorial Hospital. "I agree it doesn't seem rational, but maybe we're not dealing with a rational person. Maybe Jordan is getting a charge out of all this, thinking it is showing how much smarter he is than the rest of us. But this kind of supposition is jumping the gun. First, some kind of drug has to be found by toxicology. If we find something, then we'll have to work backwards."

"That's the second time you've said 'we.' Are you just using that as a figure of speech or what?"

"One of the medical examiners from the Boston medical examiner's office is generously helping."

"I trust you've spoken to Laurie," Alexis said. "Is she okay with you still being here?"

"She's not the happiest camper, but she's doing okay."

"I can't believe you are getting married tomorrow."

"Nor can I," Jack said. He nosed into a parking space overlooking the pond.

His headlights illuminated a flock of bobbing waterfowl. "What happened at the trial this afternoon?"

"Randolph called two expert witnesses, one from Yale and one from Columbia. Both were credible but hardly exciting. Best of all, they were not at all phased by Tony, who tried to rattle them. I think Tony was hoping Randolph would call Craig back on the stand, but Randolph wisely didn't.

Instead, Randolph rested. That was it. Tomorrow morning will be the summations, with Randolph leading off."

"Has your intuition changed any about what you think the final outcome will be?"

"Not really. The defense witnesses were good, but they were from out of town. Since Boston is such a medical mecca, I don't think the fact that they came from distant universities resonated well with the jurors. Tony's experts had more of an impact."

"You probably have a point, I'm sorry to say."

"If by some slim chance you do discover some criminality in regard to Patience Stanhope, it would probably save the day for Craig."

"Don't think for a moment that such a thought isn't in my mind. To be honest, it's my main motivation. How is Craig's mind-set?"

"Despondent, as usual. Maybe even a little worse. I worry a little with him home alone. When do you think you'll get back there?"

"I just don't know," Jack said, suddenly feeling guilty about not wanting to return to the Bowman home.

"Maybe you could check on him when you do. I don't like that alcohol-sleeping pill combination."

"Okay, I'll do that," Jack said. "I'm at the hospital now, and I have to run."

"No matter what happens, I truly appreciate all your efforts, Jack. You'll never know how much your support has meant to me these last few days."

"You still feel that way even though my meddling was responsible for what happened to the girls?"

"I don't hold that against you in the slightest."

After a few more sibling endearments that might have brought a tear to Jack's eye had they continued, they said good-bye. Jack flipped his phone closed and sat in the car for a minute, thinking about relationships and how they changed over time. It gave him a warm feeling to know that he and his sister were back to a semblance of their previous closeness, despite the years of separation while he'd struggled with his own despondency.

As Jack climbed out of the car, the zeal that Latasha had generated came back in a rush. Alexis's comments had been a bit of a downer, but he didn't need her to tell him his ideas were preposterous. He was, as he had explained, thinking out of the box with a bunch of facts that were themselves seemingly implausible.

In contrast to his first visit, the emergency room was hopping. The waiting room was full, with almost every seat taken. A few people were standing outside on the ambulance-receiving dock. It was a warm, humid, almost summer night.

Jack had to wait in line at the admitting desk behind a woman holding a feverish infant in her arms. The child stared at Jack over the mother's shoulder with glazed eyes and a blank expression. As Jack moved up to the counter and was about to ask for Dr. Matt Gilbert, the doctor appeared. He tossed a completed ER admission note attached to a clipboard onto the desk when he locked eyes with Jack.

"I know you," he said, pointing at Jack. He was obviously searching for the name.

"Dr. Jack Stapleton."

"Right! The medical examiner interested in the failed resuscitation case."

"Good memory," Jack commented.

"It's the main talent I picked up in medical school. What can we do for you?"

"I need two minutes of your time, hopefully with Georgina O'Keefe. Is she here tonight?"

"She runs the show," the admitting clerk said with a laugh. "She's here."

"I know this is not the best time," Jack said. "But we exhumed the body, and I just did an autopsy. I thought you might like to know what was found."

"Absolutely," Matt said. "And this isn't a bad time. We're busy, but it's all routine stuff that should have been seen in the outpatient clinic or a doctor's office. There's no critical emergencies at the moment. Come on back into the lounge. I'll snare Georgina."

For a few minutes, Jack sat by himself. He used the time to look back over the two pages that constituted a record of Patience's ER visit. He'd pulled them from the case file while he'd been talking to Alexis.

"Welcome back," Georgina bubbled as she swept into the room. Matt came in after her. Both were dressed in white jackets over green scrub clothes.

"Matt said you dug up Mrs. Stanhope and did an autopsy. Cool! What did you find? I mean, no one has ever given us this kind of feedback."

"The interesting thing was that her heart appeared entirely normal. With no degenerative changes whatsoever."

Georgina thrust the backs of her hands onto her hips with her elbows out.

Her mouth formed a disappointed, wry smile. "I thought we were going to hear something startling."

"It's startling in its own way," Jack said. "It's rare with sudden cardiac death not to find pathology."

"You came all the way over here to tell us you found nothing?" Georgina questioned with disbelief. She looked at Matt for support.

"Actually, I came to ask you if there was any chance she could have been given an overdose of any medication or maybe the wrong medication."

"What kind of medication are you talking about?" Georgina asked. Her smile faded, replaced by a wary confusion.

"Anything," Jack said. "Particularly any of the newer fibrinolytic or antithrombotic agents. I don't know; are you people involved in any randomized studies involving heart attack patients? I'm just curious. There's nothing like what I'm talking about on the order sheet." Jack handed the two pages over to Georgina, who glanced at them. Matt looked over her shoulder.

"Everything we gave her is on here," Georgina said, holding up the order sheet. She looked at Matt for confirmation.

"That's it," Matt agreed. "She was in extremis when she arrived, with practically a flatline on the cardiac monitor. All we tried to do was

resuscitate her. We didn't try to treat her MI. What was the point?"

"She didn't get anything like digitalis?"

"No," Matt said. "We couldn't even get a heartbeat, even with dual-chamber sequential pacing. Her heart was completely unresponsive."

Jack looked from Georgina to Matt and back again. So much for the overdose or wrong medication idea! "The only laboratory reports on the ER

notes are blood gases. Were any other tests done?"

"When we draw blood for blood gases, we routinely also order the usual blood count plus electrolytes. And with heart attacks, we order biomarkers."

"If they were ordered, how come there's no mention of it on the order sheet, and why aren't the results on the ER note? The blood gases are there."

Matt took the sheets from Georgina and quickly looked them over. He shrugged. "I don't know, maybe because they normally go in the hospital record, but since she died so quickly, she never got a hospital record." He shrugged again. "I suppose they are not on the order sheet because it's a standing order for all myocardial infarction suspects. I did mention sodium and potassium were normal in my note, so someone called the results to the ER desk."

"This isn't a big-city ER," Georgina explained. "It's rare to have a death here. Usually people get admitted, even those in bad shape."

"Could we call the lab and see if they could possibly locate the results?"

Jack asked. He did not quite know what to make of this serendipitous discovery or whether it would have any meaning, but he felt obligated to see where the lead would take him.

"Sure," Matt said. "We'll have the clerk call up there. Meanwhile, we've got to get back to work. Thanks for coming by. It's strange you didn't find any pathology, but it's nice to know we didn't miss anything that could have saved her."

Five minutes later, Jack found himself in the tiny, windowless office of the evening laboratory supervisor. He was a large, heavyset man with heavily lidded eyes that gave him a sleep-deprived appearance. He was staring at his computer monitor with his head tilted back. His nametag read: "Hi, I'm Wayne Marsh."

"I don't see anything under Patience Stanhope, " Wayne said. He had been very obliging when the ER had called, and invited Jack up to his office.

He'd been impressed with Jack's credentials, and if he'd noticed the badge said New York rather than Massachusetts, he didn't mention it.

"I need a unit number," Wayne explained, "but if she wasn't admitted, then she didn't get one."

"What about through billing?" Jack suggested. "Somebody had to pay for the tests."

"Nobody's in billing at this hour," Wayne said, "but didn't you mention you have a copy of the ER record. That will have an ER accession number. I can try that."

Jack handed over the ER notes. Wayne typed in the number. "Here we go,"

he said as a record flashed up on the screen. "Dr. Gilbert was right. We did a full blood count with platelets, electrolytes, and the usual cardiac biomarkers."

"Which ones?"

"We do CKMB and cardiac-specific troponin T on arrival at the ER with repeats at six hours postadmission and twelve hours postadmission."

"Was everything normal?"

"Depends on your definition of normal," Wayne said. He twisted his monitor screen in its base so Jack could see it. He pointed to the blood-count section. "There's a mild to moderate rise in the white count, which is expected with a heart attack." His finger then went to the electrolytes. "The

potassium is at the upper edge of normal. Had she lived, we would have wanted to check that, for obvious reasons."

Jack inwardly shuddered at the mention of potassium. The frightening episode with Laurie's potassium during her ectopic pregnancy emergency was still fresh in his mind despite its being over a year ago. Then his eyes happened to notice the biomarker results. To his surprise, the tests were negative, and he immediately called it to Wayne's attention. Jack's pulse ratcheted up. Had he stumbled onto something significant?

"That's not unusual," Wayne said. "With improved response times to nine-one-one calls, we often get our heart attack victims into the ER within the three- to four-hour interval it takes for the biomarkers to rise. That's one of the reasons we routinely repeat the test at six hours. Jack nodded as he tried to sort out the discrepancy this new information provided. He didn't know whether he'd forgotten or never knew there was such a delay before biomarkers become positive. Not wishing to appear overly uninformed, he worded his next questions carefully. "Does it surprise you that an earlier bedside biomarker assay was positive?"

"Not really," Wayne said.

"Why not?"

"There are a lot of variables. First off, there's about a four percent false negative result as well as a three percent false positive. The tests are based on highly specific monoclonal antibodies, but they are not infallible.

Secondly, the bedside kits are based on troponin I, not T, and there's a lot of bedside kits on the market. Was the bedside assay for troponin I alone or with myoglobin?"

"I don't know," Jack admitted. He tried to remember what was written on the box in Craig's doctor's bag, but he couldn't visualize it.

"That would be important. The myoglobin component becomes positive faster, often within as little as two hours. What's the time frame on this

case?" He picked up the ER note and read aloud: "Patient's husband states chest pain and other symptoms developed between five and six p.m., probably closer to six." Wayne looked up at Jack. "She arrived in the ER

close to eight, so the time frame is about right as far as our results are concerned, since it was less than four hours. Do you know when the bedside assay was done?"

"I don't," Jack said. "But if I had to guess, it would be somewhere around seven thirty."

"Well, that does seem marginal, but as I said, the bedside tests are made by a host of companies with widely differing sensitivities. The kits also should be carefully stored, and I believe there's an expiration date. Frankly, that's why we don't use them. We much prefer the troponin T, since it's made by only one company. We get very reproducible results with a short turnaround time. Would you like to see our Abbott analyzer? It's a beauty. It measures absorbance spectrophotometrically at four hundred fifty nanometers. It's right across the lab if you want to take a gander."

"Thank you, but I think I'll pass," Jack said. He was getting in technically way over his head, and his visit at the hospital had already been twice as long as he had planned. He certainly didn't want to keep Latasha waiting.

He thanked Wayne for his help and returned quickly to the elevator. As he rode down to the first floor, he couldn't help but wonder if Craig's bedside biomarker assay kit had somehow been defective, either from improper storage or from being out of date, and had given a false positive. What if Patience Stanhope did not have a myocardial infarction? All at once, yet another dimension was opening up, particularly with the services of a toxicologist available. There were a lot more drugs that deleteriously affected the heart than those capable of simulating a heart attack.

Jack jumped into the car and quickly dialed Latasha's number. As he'd done with his call to Alexis, he put his phone on speaker and placed it on the passenger seat. By the time he was driving out of the hospital parking lot, Latasha answered.

"Where are you?" she asked. "I'm here in my office. I got two hot pizzas and two large Cokes. Where are you at?"

"I'm just leaving the hospital. I'm sorry it has taken as long as it has, but I learned something possibly important. Patience Stanhope's biomarker test was negative when it was read by the hospital analyzer."

"But you told me it was positive."

"That was from a bedside biomarker kit," Jack said. He carefully explained what he'd learned from the lab supervisor.

"What it all comes down to," Latasha said when Jack was finished, "is that now we're not sure she had a heart attack, which would be consistent with what we found during the post."

"Precisely, and if that is the case, the toxicology is going to be key."

"I already dropped the samples off at the toxicology lab with a note for Allan to give me a call."

"Perfect," Jack said. He couldn't help but marvel at how lucky he was to have Latasha helping him. If it hadn't been for her, he might have given up after finding nothing in the heart.

"I guess this puts the mourning husband in the crosshairs," Latasha added.

"There are still some inconsistencies," Jack said, remembering Alexis's points against Jordan's being the bad guy "but generally I agree, as trite and venal as it sounds."

"When will you be here?"

"As soon as I can. I'm coming up to Route Nine. You're probably a better judge than I. Why don't you start on the pizza while it's hot."

"I'll wait," Latasha said. "I've got myself busy making us some frozen sections of the heart."

"I'm not sure I'll be eating much," Jack said. "I've gotten myself psyched. I feel like I've had ten cups of coffee."

When Jack flipped his phone shut, he checked the time. It was almost ten thirty, which meant Latasha's friend would soon be arriving at the toxicology lab. Jack hoped he'd have a lot of free time, since Jack could imagine keeping him busy most of the night. Jack had no illusions about the power of toxicology to detect poisons. It was not as easy a process as it was often portrayed in the popular media. For large concentrations of the usual drugs there usually was no problem, but for trace amounts of more toxic and lethal compounds that could kill a person in very small dosages, it was like finding the proverbial needle in a haystack.

Jack stopped at a traffic light and impatiently drummed his fingers on the steering wheel. The warm, soft, humid June air wafted in through the missing window. He was glad he'd taken the time to visit the hospital, although he now felt embarrassed about the idea of a hospital cover-up.

Nonetheless he rationalized that the idea had indirectly led to his questioning whether Patience Stanhope had suffered a heart attack.

The light turned green, and he moved on. The problem was she still might have had a heart attack. Wayne had admitted that even with his vaunted absorbance analyzer, the rate of false negatives was higher than false positives. Jack sighed. There was nothing about this case that was simple and straightforward. Patience Stanhope was proving to be a problem patient even in death, which reminded him of his favorite lawyer joke: What's the difference between a lawyer and a prostitute? The prostitute stops screwing you when you die. From Jack's perspective, Patience was assuming some annoying lawyer-like qualities.

As Jack drove, he mulled over his promise to check in on Craig, who was probably at that time already in a deep, drug-and-alcohol-induced slumber.

Jack wasn't excited about the idea and thought it unnecessary since, in his

estimation, Craig was not suicidal in the slightest, and, as an intelligent physician, Craig was well aware of the power of the medications he was taking. On the other hand, the good side of making such a visit would be a chance for Jack to check what kind of biomarker kit Craig used and whether it was outdated. Until he had that information, he couldn't intelligently decide whether or not there was a higher than usual chance the result had been a false positive.

21

BOSTON, MASSACHUSETTS

FRIDAY, JUNE 9, 2006

1:30 A.M.

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For almost five minutes Jack had watched the hands of the institutional wall clock as they implacably jumped staccato-fashion toward one thirty a.m.

With the final leap of the minute hand, Jack took a breath. He hadn't realized he'd not been breathing for the final seconds, since the time was a mini-milestone. Exactly twelve hours hence he would be married, and all the years he'd avoided the issue would be history. It seemed inconceivable.

Except for the relatively recent past, he'd practically institutionalized being by himself. Was he capable of marriage and thinking of two people instead of one? He didn't really know.

"Are you all right?" Latasha asked, yanking Jack back to reality by reaching out and briefly gripping his forearm.

"Fine. I'm fine!" Jack blurted. She'd startled him.

"I thought you were having an absence seizure. You didn't move a muscle for the last few minutes. You didn't even blink. What on earth were you thinking that had you so mesmerized?"