Cassi shook her head. “No. Some have been cyanotic like this case, some seemed to have died from cardiac arrest, some from respiratory failure, and some from convulsions.”
Robert began the usual Y-shaped autopsy incision, starting high on the shoulder and connecting with the open-chest incision. Joan could hear the blade scrape across the underlying bony structures.
“What about the kind of surgery?” asked Joan. She heard ribs crack and closed her eyes.
“They’ve all had open-heart surgery but not necessarily for the same condition. We’ve checked anesthesia, duration of pump time, whether or not hypothermia was used. There were no correlations. That’s been the frustrating part.”
“Well, why are you trying to relate them?”
“That’s a good question,” said Cassi. “It has to do with the mentality of a pathologist. After you’ve done an autopsy, it’s very unsatisfying not to have a definitive cause of death. And when you have a series of such cases, it’s demoralizing. Solving the puzzle is what makes pathology rewarding.” Involuntarily Joan’s eyes stole a quick glance at the table. Bruce Wilkinson appeared as if he’d been unzipped. The skin and subcutaneous structures of the chest and thorax had been folded back like the leaves of a gigantic book. Joan felt herself swaying.
“The knowledge is important,” Cassi went on, unaware of Joan’s difficulties. “It can have a direct benefit to future patients if some preventable cause is discovered. And in this situation, we’ve noticed an alarming trend. The initial patients seemed to have been older and much sicker. In fact, most were in irreversible coma. Lately though, the patients have been under fifty and generally healthier, like Mr. Wilkinson here. Joan, what’s the matter?” Cassi had turned and finally noticed that her friend seemed about to faint.
“I’m going to wait outside,” said Joan. She turned and started for the door, but Cassi caught her arm.
“Are you all right?” asked Cassi.
“I’ll be fine,” said Joan. “I just need to sit down.” She fled through the stainless steel door.
Cassi was about to follow when Robert called for her to look at something. He pointed at a quarter-sized contusion on the surface of the heart.
“What do you think of that?” asked Robert.
“Probably from the resuscitation attempt,” said Cassi.
“At least we agree on that,” said Robert as he directed his attention back to the respiratory system and the larynx. Deftly he opened the breathing passages. “No obstruction of any sort. If there had been, that would have explained the deep cyanosis.”
Jerry grunted and said, “Goin’ to be pulmonary embolism. I’m sure of it.”
“It’s a bad bet,” said Robert, shaking his head.
Switching his attention lower, Robert examined the main pulmonary vessels and the heart itself. “These are the bypass vessels sewn in place.” He leaned back so Cassi and Jerry could take a look.
Hefting a scalpel, Robert said: “Okay, Dr. Donovan. Better put your money on the table.” Robert bent over and opened the pulmonary arteries. There were no clots. Next he opened the right atrium of the heart. Again the blood was liquid. Finally he turned to the vena cava. There was a bit of tension as the knife slipped into the vessels, but they too were clear. There were no emboli.
“Crap!” said Jerry in disgust.
“That’s ten dollars you owe me,” said Robert smugly.
“What the hell could have bumped this guy off?” asked Jerry.
“I don’t think we’re going to find out,” said Robert. “I think we’ve got number eighteen here.”
“If we are going to find anything,” said Cassi, “it will be inside the head.”
“How do you figure?” asked Jerry.
“If the patient was really cyanotic,” said Cassi, “and we haven’t found a right-to-left circulatory shunt, then the problem has to be in the brain. The patient stopped breathing, but the heart kept pumping unoxygenated blood. Thus cyanosis.”
“What’s that old saying?” said Jerry. “Pathologists know everything and do everything but too late.”
“You forgot the first part,” said Cassi. “Surgeons know nothing but do everything. Internists know everything but do nothing. Then comes the part about pathologists.”
“And what about psychiatrists?” asked Robert.
“That’s easy,” laughed Jerry. “Psychiatrists know nothing and do nothing!”