Her name was Clarissa Lowe; she’d died two days before, about a week after undergoing a cervical spine diskectomy and fusion—an operation to remove a damaged disk from her neck and then fuse the two adjoining vertebrae together. The surgery was performed at the regional hospital in Crossville, a town of about ten thousand people, sixty miles west of Knoxville. The procedure had gone smoothly, according to the neurosurgeon’s notes, and the woman appeared to be recovering well by the time she was discharged the following morning. Then, three days later, she called the surgeon’s office, complaining of nausea, weakness, and pain in her neck. The doctor saw her that same afternoon in his office; not surprisingly, her neck appeared inflamed around the incision, but she wasn’t running any fever and her vital signs were normal, so he prescribed a stronger painkiller, recommended cold packs, and sent her home.
Eighteen hours later her panicked husband called 911. She’d vomited three times within an hour, he told the dispatcher—nothing but green liquid—and she was suddenly too weak to stand. By the time the ambulance arrived, she was going into shock; her pulse was fluctuating between 50 and 140 beats a minute, her blood pressure was alarmingly low, and her breathing was labored, though her temperature remained normal. An hour after arriving at the Crossville emergency room, she was fighting for breath, and within two she could no longer breathe on her own. The ER doc put her on a ventilator, started her on powerful antibiotics, and sent her to UT Hospital by ambulance. Ninety minutes later—as she was being wheeled into the ER in Knoxville—she died.
Garcia had briefed me on the woman’s surgery, complications, and death, but being briefed wasn’t the same as feeling prepared. Tightening my grip on the scalpel, I placed the tip on the woman’s chest, at the edge of her left armpit. Her body had been in the morgue’s cooler for the past twenty-four hours, so it was chilled nearly to freezing; beads of moisture were condensing on her clammy skin, and a few wisps of fog spooled upward from the corpse, pulled aloft by the morgue’s powerful ventilation system. Miranda and I had wedged a body block into place beneath the woman’s back; the curved block thrust the chest upward, as if the woman were offering herself to the scalpel as a sacrifice. I bore down, and the blade parted the flesh. Following the natural curve at the base of the left breast, I cut to the midline of the body, then made a mirror-image cut from the right side. The blade rose and dropped as it bumped across ribs. Where those two cuts joined at the breastbone, I began a new incision, this one running down the midline all the way to the pubic bone.
As the abdominal cavity opened, fluid—watery, almost clear but tinged with pink—poured from the incision. During my graduate training and my career, I’d seen twenty or thirty abdominal cavities opened, but I’d never seen one give off such a quantity of fluid. It sheeted down the sides of the abdomen, pooling at the foot of the autopsy table and then gurgling through the drain and into the sink below.
“Copious peritoneal effusion,” noted Garcia, confirming my sense that the amount of fluid was unusual.
“Estimated volume approximately one liter. Miranda, would you be so kind as to collect a sample?”
Miranda took a small plastic vial from the counter and held it beneath the drain, catching a bit of the liquid as it dribbled through, then screwed the cap tightly in place.
Garcia next asked me to peel back the chest flap. I did so by pulling the skin upward with my left hand, using the scalpel to extend the incisions from the armpits up to the shoulders so I could peel the skin and breast tissue away from the ribs. Laying the chest flap over the face, I swapped the scalpel for a rib cutter—a sharp stainless-steel cousin of the dull pruning shears in my garage at home—and cut through the ribs on both sides. The chest cavity gaped open, exposing the spongy lungs and the heart in its fibrous sac. Like the abdomen, the chest cavity oozed copious amounts of liquid. “No wonder she had trouble breathing,” I said, “with all this fluid pressing on her lungs.”
“There appears to be considerable edema around the heart, too,” said Garcia. “Let’s open the pericardial sac.”
I used the scalpel to finish cutting out the chest plate—the breastbone and the stubs of the ribs I’d sheared—and laid that aside, then sliced into the tough, grayish-white membrane surrounding the heart. Once again fluid gushed from the incision. Garcia was leaning in, his face practically in the corpse’s chest cavity. “Now let’s check the pulmonary artery,” he said.
I probed the tangle of tubing at the top of the heart, nestled just beneath the arch of the aorta. The pulmonary artery was a thick vessel that branched immediately into a T shape to carry blood to the lungs. Slicing through its fibrous wall, I slid the end of my little finger inside, feeling for a clot that might have choked off the flow of blood.
“I don’t feel anything,” I said.
“I didn’t think you would,” Garcia said. “Her death was rapid, but not rapid enough to be the result of a blood clot.” Next he asked me to check the retropharyngeal area, a cavity deep in the neck, directly in front of the spine. “She had no fever, irregular pulse, plummeting blood pressure—symptoms consistent with hemorrhage. Three or four liters of blood from a bleeding vessel could pool in the retropharyngeal area and nobody would know it unless they did a CT scan. But they didn’t; the ER physician in Crossville says they didn’t have time to scan her. So let’s go in and look. We probably need to Roke out her chest; do you know how to do that?”
Miranda asked the question before I could. “How to dowhat to her chest?”