Brainwaves Read online

  “Ah-huh,” Lori said, as if dismissing his remarks as irrelevant.

  “Look,” Rubin said, a slight edge to his voice, “this was not really a surgical death.”

  “Any death that occurs in the OR is a surgical death,” Lori shot back.

  “You’re not going to find a surgical cause to explain all this,” Rubin insisted.

  “You never know, do you?”

  Rubin glanced up at the wall clock again, wishing they could get the autopsy finished. He tapped his foot on the floor impatiently, hating to waste time. Where the hell was Dr. Blalock? “Why are they insisting that a forensic pathologist do this case?”

  “Because the patient’s father and uncle are big-time lawyers, and they don’t think Elizabeth Ryan should have died on the table.”

  “Shit,” Rubin hissed under his breath, disliking lawyers in general and malpractice lawyers in particular. He considered them vultures. “There was no malpractice here.”

  “Nobody said there was.”

  But they’ll look for it, Rubin was thinking, and in the process try to crucify a wonderful surgeon. He looked up

  at the clock once more. “How long will this autopsy take?”

  “Don’t be in a rush,” Lori advised. “Autopsies can teach you a lot.”

  “I know,” Rubin said. “It’s just that I want to scrub up for a rhizotomy with Dr. Moran at noon.”

  “I don’t think you’ll make it.”

  Lori began circling the corpse, starting at the head and examining its exterior. She saw nothing remarkable except for the window in the skull exposing the brain, studded with silver clips. Lori moved down the abdomen and pubis, looking for abnormal features but finding none. She stopped at Elizabeth Ryan’s legs, paying particular attention to the musculature of the thighs and calves. “Was she a runner?”

  Rubin shrugged. “I don’t know. Why?”

  “Because her legs are more muscular than her arms.”

  Rubin glanced over at the corpse’s legs and shrugged again. The muscles in her legs didn’t have a damn thing to do with her dying. “I sure would like to make it to that rhizotomy,” he said, more to himself than to Lori.

  “You’ll learn more from Joanna Blalock in twenty minutes than you will from a dozen surgeons talking all day,” Lori muttered, examining the thick calluses on the corpse’s feet.

  I’ll bet, Rubin wanted to say, but he held his tongue. No matter what she thought, he didn’t want to miss the surgical procedure. Christopher Moran was a wizard at rhizotomies. Surgeons from all over the world came to watch and copy his technique.

  The double doors leading into the autopsy room swung open and a

  strikingly attractive woman entered. She had soft, patrician features and sandy blond hair that was severely pulled back and held in place by a simple barrette. As she walked over, Rubin tried to determine her age. Mid-thirties, he guessed, wondering who she was.

  Lori followed the intern’s gaze and told him, “That’s Dr. Blalock.”

  Rubin’s eyes widened. The female forensic pathologist at the medical school he attended was a hefty, tough woman with a voice croaky from too many cigarettes. There was nothing hefty about this female. She was wearing a short white coat over her scrub suit, but Rubin could tell she had a great body. He wondered if she had a brain to match.

  Joanna Blalock waved to Lori, then turned to the intern. “You must be Dr. Rubin.”

  Rubin snapped to attention, his shoulders back. “Yes, ma’am.”

  “Dr. Moran’s office called and told us you’d be joining us,” Joanna said, reaching for a pair of latex gloves. “You’ll have to forgive me for being late, but I was tied up in a meeting.”

  “I just got here myself,” Rubin lied easily.

  “Good.” Joanna glanced over at the X-rays mounted on a nearby view box, then down at the corpse of Elizabeth Ryan. “Please give us a brief summary of the case, Dr. Rubin.”

  Rubin cleared his throat audibly. “She was a twenty-eight-year-old woman who presented with severe, generalized headaches. She was seen by Dr. Evan Bondurant and discovered to have a brain tumor. She was subsequently referred to Dr. Moran and at operation was found to have a highly malignant glioma. While we were mapping the brain, the

  patient suddenly convulsed. The bottom dropped out of her vital signs, and we couldn’t get her back.”

  “Was she seen by other consultants in the OR?”

  “Two,” Rubin replied. “The cardiologist said the cause for her shock was non-cardiac. Then she was seen by Dr. Bondurant, who thought the patient had some type of encephalopathy.”

  Joanna motioned to Lori. “See if Dr. Bondurant wrote a note in the chart.”

  Lori quickly flipped through the chart, then flipped through it again before finding what she was looking for. “Here it is. I’ll read the note to you word for word. Tatient seen and examined. Shock and seizures most likely due to acute toxic encephalopathy. Appropriate tests and biopsy should uncover the causative agent. Will discuss with Dr. Moran and dictate complete consultation later.””

  Joanna turned to Rubin. “What tests did Dr. Bondurant want done?”

  Rubin shrugged. “I didn’t hear that part of the discussion.”

  Joanna made a mental note to discuss Evan Bondurant’s consultation with Moran. Then she glanced back at the X-rays. “I assume those metallic clips represent the resect able borders of the tumor.”

  “Correct,” Rubin answered.

  “How are they inserted?”

  “With a stapler.”

  “And to what depth?”

  “Just a few millimeters.”

  “That shouldn’t cause any damage, should it?”

  “No, ma’am.”

  Joanna began to slowly walk around the corpse, carefully examining its external features. The girl had

  been beautiful, Joanna thought, with a thin waist, a flat abdomen, and very muscular legs. The calf muscles were particularly pronounced. On the corpse’s buttocks was a small tattoo with the letters “NY” superimposed on each other. Quickly Joanna went back to the girl’s feet and saw the calluses and bunions she expected to find. “Was she a good ballerina?”

  “What?” Rubin asked, caught off guard.

  “Was she a good ballerina?” Joanna repeated.

  “I didn’t know she was into ballet.”

  “Did you ask?”

  “No.”

  “You should have,” Joanna said. “Knowing a patient’s occupation can sometimes be very helpful in making a diagnosis. For example, ballerinas fly through the air and do all sorts of gymnastics, and sometimes they fall and hit their heads. So, with a ballerina with a severe headache, one should first think of a subdural hematoma caused by a fall.”

  “Right.” Rubin nodded, but he was thinking that this girl didn’t have a subdural hematoma, she had a brain tumor. And that wasn’t caused by some damn fall. He gazed down at the corpse’s muscular legs and remembered Lori McKay inquiring whether the girl had been a runner. “Can I ask how you knew she was a ballerina? Those big muscles in her legs could be due to running or jogging.”

  “That’s possible, but not very likely,” Joanna said, and pointed at the corpse’s legs. “You can see that her lower extremities are quite muscular, but her calf muscles are the largest. In runners, the thighs have the biggest muscles; in ballerinas it’s the calves. That’s because ballerinas spend most of their time dancing on their toes, which exercises the gastrocnemius muscle primarily, and this causes the calf to enlarge. And because ballerinas dance on their tiptoes, they also have calluses under the first metatarsal heads and prominent bunions—just as this corpse has.”

  Lori groaned to herself. She had seen all the clues Joanna had, but hadn’t been able to put them together. A ballerina, damn it, not a runner.

  “And she lived in New York,” Joanna went on. “She might have been a member of the New York City Ballet.”

  Rubin blinked rapidly. “How do you know that?”

  Joanna pointed at the small tattoo on the corpse’s buttocks. “The NY tattoo she has.”

  Rubin smiled and shook his head. “That’s the logo for the New York Yankees. That only tells us she was a big fan of the team.”

  Joanna smiled back. “Which indicates she probably lived in the city, and worked there as well.”

  Lori reached for the patient’s hospital chart and opened it to the front page. She quickly scanned Elizabeth Ryan’s personal information, then nodded to Joanna. “Her profession is ballerina, her home address is in New York City.”

  Rubin stared at Joanna suspiciously, wondering if the forensic pathologist had prior knowledge of Elizabeth Ryan. Maybe she had watched the ballerina perform or had seen a picture of her somewhere.

  Lori saw the look of disbelief on the intern’s face. “I think we have a nonbeliever here, Joanna.”

  Joanna smiled thinly at Rubin. “You think I might have known about the patient before I started my examination?”

  “I didn’t say that,” Rubin said defensively.

  “But you thought about it.”

  Rubin gestured with his hands, palms out. “I guess so.”

  “Well, let’s see if we can convince you that we are for real down here,” Joanna said, studying the intern’s forearm, then his face and brow. “Do I know anything about you, Dr. Rubin?”

  “You know I’m a neurosurgery intern.”

  “Other than that?”

  “No.”

  “So I’ve never seen you or investigated your past. Correct?”

  “Correct.”

  “Having established that, may I tell you the few things I know about you?”

  Rubin shrugged. “Of course.”

  “You joined the Marines when you were in college. Initially you were an enlisted man, but you were out of place and this may have caused you to be involved in a good number of fights. Eventually you saw the light and became an officer. I think you were in the Marines for at least eight years before you decided to return to college and apply for medical school.”

  Rubin stared at Joanna, stunned by the accuracy of her information. “How do you know all these things?”

  “Observation,” Joanna said simply. “I knew you had been a Marine because of the faded tattoo on your forearm, which reads Semperfi That of course is the motto of the Marines. In all likelihood you enlisted, because tattoos are usually seen on enlisted men, not officers. You’re reasonably bright and well spoken, and you wouldn’t have acquired those traits in the Marines. So it’s safe to assume you joined the Marines out of college.”

  “How can you be so sure I didn’t join after college?” Rubin asked.

  “Because with a college degree you would have gone into the service as an officer,” Joanna replied. “The scars about your eyebrows tell us about the fights you’ve had, and these no doubt occurred while you were an enlisted man. I suspect your background was different from the other enlisted men and this caused some of the fights.”

  “Jesus,” Rubin hissed softly, his eyes fixed on Joanna. “How do you know I became an officer?”

  “You have the bearing of an officer—your posture, your presence, your speech. And again, your intelligence.” Joanna pointed at the faded tattoo on Rubin’s forearm. “I would guess you attempted to have your tattoo removed by laser after you returned to college, maybe when you received the notice that you had been accepted to medical school.”

  “And what told you I had been in the Marines for at least eight years?”

  “Your age,” Joanna said. “You’re at least eight years older than your fellow interns. So we need something to fill that eight-year gap. It had to be your service in the Marines.”

  “And you won most of your fights,” Lori chimed in.

  “How can you be so sure of that?” Rubin asked.

  “Because the only marks of your fights are scattered scars on your eyebrows,” Lori explained. “Also your nose is not bent and there’s no evidence of split lips. Those are the signs of a man who wins more than he loses.”

  Rubin’s eyes darted back and forth between the two women. “I feel like running for my life.”

  “You’ll have to forgive us, Dr. Rubin,” Joanna said, smiling at the intern’s amazement. “But, as you can see, we do this for a living. We’re trained to do it. And I think we’re at the top of our game because we went to a Sherlock Holmes meeting last night.”

  Rubin knitted his brow. “A Sherlock Holmes meeting?”

  Joanna nodded. “It’s a society of Sherlock Holmes admirers. We meet twice a month and try to emulate the world’s best-known detective. It’s great fun and it also helps us in our professional lives. It teaches us to observe and to interconnect our observations.”

  “And of course Dr. Blalock is heads and hats above the rest of us,” Lori added.

  Joanna ignored the compliment. “That’s the reason I took you through this little exercise. Now is the time for you to learn how to observe. You have to watch carefully and pay particular attention to anything that’s unusual or abnormal. Every time you examine a patient, remember the ballerina’s legs and the tattoo on your arm. Remember to observe. It’ll make you a better surgeon.”

  “I’ll keep that in mind,” Rubin said sincerely.

  Joanna went back to the head of the table and looked down at the corpse’s brain. “I take it she was thoroughly evaluated by internal medicine prior to surgery.”

  Rubin nodded. “She was in perfect health except for the brain tumor. They cleared her for surgery.”

  “And the first sign that Elizabeth Ryan was in trouble was when she suddenly convulsed on the table.”

  “Right.”

  “And she never had seizures before. Right?”

  “Right.”

  Joanna looked down at the brain through the window in the skull. “Something happened in there to cause seizures. But what?”

  “Maybe it was the toxic encephalopathy that Dr. Bondurant wrote about,” Rubin guessed.

  “That’s a very general term,” Joanna told him. “It only says that something noxious is injuring the brain. And there are a hundred different things that could do that.”

  Rubin asked, “Is there any way to narrow down the list of possible diagnoses?”

  Joanna nodded. “Whatever caused this syndrome did it very quickly. So we have to look for acute causes. Does that help you any?”

  Rubin shrugged. “Not really. But I don’t think it was surgically induced. We weren’t even stimulating the brain when it happened.”

  “Something caused her to convulse acutely and die,” Joanna mused. “But what?”

  “Maybe the tumor,” Rubin suggested.

  Joanna shook her head. “That shouldn’t cause her to suddenly convulse, and it surely wouldn’t kill her. Not unless—” She stopped in mid-sentence, thinking the problem through and making sure there were no flaws in her reasoning. “Suppose, Dr. Rubin, there was a sudden pressure on the tumor.”

  “That could cause the seizure,” Rubin said. “But it wouldn’t kill her.”

  “That depends on what caused the pressure,” Joanna coaxed.

  Rubin squinted his eyes, concentrating, trying to come up with an answer. But his mind stayed blank.

  “We’re talking about a catastrophic event here,” Joanna clued him on. “It would have to be something

  that suddenly increases the intracerebral pressure and kills.”

  Rubin’s eyes brightened. “A cerebral hemorrhage would do that.”

  “And why would she hemorrhage?”

  “Her tumor could have eroded into a blood vessel.”

  “Very good, Dr. Rubin!” Joanna congratulated him. “We’ll make a pathologist out of you yet.”

  Rubin wetted his lips, still thinking. “Do you think that’s what happened?”

  “That’s the presumptive diagnosis that fits best.”

  Rubin nodded his agreement. “It’s so simple and straightforward.”

  “And that’s what bothers me.”

  “Why?”

  “Because we never see simple and straightforward cases down here.”

  The doors to the autopsy room swung open and a young secretary entered. She stood on her tiptoes until she saw Joanna, then hurried over.

  “Dr. Blalock,” the secretary said breathlessly, “Dr. Murdock just called and wants you to come over to the Brain Research Institute stat. He said it was urgent.”

  “Did he say why?”

  “No, ma’am.”

  Joanna turned to Lori and Rubin, thinking about her tight schedule for most of the day. “We’ll have to postpone this autopsy until four p.m. Is that convenient for you, Dr. Rubin?”

  “No problem,” Rubin said, delighted he would now be able to scrub in on the rhizotomy at noon.

  Joanna stripped off her gloves and walked quickly toward the door, the secretary a step behind her. “Did

  Dr. Murdock give any clue why he needed me so urgently?”

  “No, ma’am. But I think I know.” “Then be a sport and share it with me.” The secretary stopped and stared at Joanna. “Didn’t you hear what happened at the BRI?” “No,” Joanna said impatiently. “What?” “Dr. Karen Crandell committed suicide.”

  3

  Joanna stepped off the elevator and entered the Brain Research Institute. A policeman standing guard recognized her and gave her a half salute.

  “Lieutenant Sinclair is waiting for you in the fire escape!” he said, and lifted up the crime-scene tape.

  Joanna ducked under the yellow tape and hurried down the corridor. She passed opened doors, ignoring the secretaries and technicians who were peeking out, hoping to learn more about the suicide of Karen Crandell. Joanna wondered why she was needed so urgently if it was a suicide. And why was Jake Sinclair here? He was Los Angeles’s premier homicide detective, called in only for difficult, high-profile cases. Something had to be amiss.

  Ahead, the fire escape door opened and Simon Murdock, the dean of the medical center, emerged. He saw Joanna in the corridor and walked over.

  “Thank you for coming so promptly,” Murdock said.

  “I take it this had to do with Karen Crandell’s suicide?”

  “It does,” Murdock said, looking around to make certain no one was within earshot. “I think we need your assistance.”