“Heavens, no.”
“Is she a yoga enthusiast?” Jack was trying to cover all the bases.
“No, I don’t think so.”
“What about an automobile accident? Anything like that happen recently?”
“Heavens, no,” Mrs. Abelard repeated more forcefully.
“So she’d been completely well up until yesterday. No neck aches or headaches.”
“Well, now that you mention it, she did complain of some recent headaches. She’s been under stress because of a new job.”
“What kind of work?”
“Advertising. She’s a copywriter for one of the up-and-coming ad agencies in the city. It’s a new position, and a bit of a stressful situation. She’d been laid off recently, so she was feeling pressure to do her best in her new position.”
“Did she say where the headaches were centered, like in the front or back of her head?”
“She said they were behind her eyes.”
“Did she do anything about them?”
“She took ibuprofen.”
“And... did it help?”
“Not very much, so she asked one of her friends, and the friend recommended a chiropractor.”
Jack sat up in his chair. In the far reaches of his mind, he recalled a case he’d read about in an issue of the Forensic Pathology Seminars involving a chiropractor and stroke. “Did Keara go to this chiropractor?” Jack asked, while trying to recall the details of the published case. He remembered it dealt with the vertebral artery dissection, just as he’d found that morning in Keara.
“She did. As I recall, it was this past Thursday or Friday.”
“Did the visit help her headaches?”
“It did, at least initially.”
“Why did you say ‘at least initially’?”
“Because the headache located behind her eyes went away, but then she got a different one in the back of her head.”
“You mean like the back of her neck?”
“She said the back of her head. Now that I’m remembering the discussion, she also said she had a bad case of hiccups she couldn’t get over, and they were driving her crazy.”
“Do you happen to know the name of this chiropractor?” Jack asked, as he supported the phone receiver in the crook of his neck. With his hands free, he went on the Internet and Googled “dissection, vertebral artery.”
“I don’t. But I do know the name of the friend who recommended the doctor.”
“You mean the chiropractor,” Jack said reflexively, then regretted it. He didn’t want to take any chances of upsetting Keara’s mother. While the man may well have been a doctor of chiropractic, Jack knew many people thought they were medical doctors. Jack was leery of chiropractors, although he admitted he didn’t know too much about them.
“Her name is Nichelle Barlow,” Mrs. Abelard said, indifferent to Jack’s comment.
“Thanks for your cooperation,” he said, writing down the number. “You’ve been so generous, especially under such trying circumstances.”
Replacing the receiver, Jack stared blankly at the wall. Seventeen years ago when his first wife and children died, he remembered how long he had been in denial as friends and family had called. Shaking his head to free himself from such morbid thoughts, he forced himself to turn his attention to his computer screen, but he couldn’t concentrate. Instead he recalled the scene a couple of nights previous, of John Junior sobbing with what he and Laurie worried was bone pain from the tumor in the marrow cavities of his long bones. His tiny, perfectly formed infant hands seemed to gesture toward his legs as if hoping his parents could provide relief, but of course they couldn’t.
“Shit!” Jack yelled at the ceiling in hopes of shocking himself out of his downward-spiraling self-pity. At that point, a head poked in through the open doorway. It was Dr. Chet McGovern, Jack’s former office mate.
“Is that a reflection of your personal state of mind,” Chet joked, “or a general assessment of the current stock-market trend?”
“All of the above,” Jack said. “Come on in and take a load off.” Despite being preoccupied, Jack welcomed the diversion.
“Can’t do,” Chet said, with a lilt to his voice. “I met somebody Saturday night, and we’re meeting for lunch. She might be the one, my friend! She is hot.”
Jack waved him off. He’d become convinced Chet was never going to, find “the one.” Chet loved the chase too much to settle down.
“Hey, Chet,” Jack called to his retreating friend. “Have you ever had a vertebral artery dissection?”
“Yeah, one,” Chet said, returning to lean back into Jack’s office. “It was during my forensic pathology fellowship in L.A. Why?”
“I had one this morning. It stumped me until we opened the skull. There wasn’t much of a history, and there was no apparent trauma.”
“How old?”
“Young. Twenty-seven.”
“Check out if she’d seen a chiropractor in the last three days or so.”
“I think she did,” Jack said, impressed by Chet’s suggestion. “I think she might have seen one last Thursday or Friday. She died last night.”
“It could be significant,” Chet replied. “In my case, the association was easy to make, since the symptoms began moments after the cervical manipulation. But when I looked into the issue in general, I learned the symptoms of VAD can be delayed for days.
“Listen,” Chet added. “I’d love to talk more, but I got to go to meet my new honey.”
“You’re impressing me no end,” Jack said, jumping up and following Chet down the hall. “I vaguely remember reading about a case, but I’d never seen one.”
“I found it interesting,” Chet admitted as he walked, “and I thought I could get some kudos out of it from my chief, so I researched VAD and chiropractic a bit. I found it to be one of those associations which hasn’t sparked much interest, nor did it then for me. It turned out my chief went to the same chiropractor and swore by him, so my hand was forced to sign out the case as merely a therapeutic complication.”
“What is it that certain chiropractors do that makes VAD possible? Do you know?”
“I assume it is the force of their ‘adjustment technique,’” Chet explained. “It’s called a high-velocity, low-amplitude cervical thrust. Though it doesn’t happen often, there are apparently times when it can cause an internal tear in the vetebral artery, and the blood pressure does the rest. Sometimes the dissection extends all the way up into the basilar artery.”
“How often is not often?” Jack asked.
“I don’t remember exactly,” Chet admitted. “It was a few years ago. In the L.A. medical examiner files I think I found only four or five cases of VAD associated with chiropractic visits.” Chet stepped into the elevator, holding the door open with his hand. “Listen, Jack, I gotta go. I’m already late. We can talk more later if you want.” The doors closed, and he was gone.
For a moment Jack continued to stare at the blank elevator door. He was now intrigued, thinking he might have stumbled on the diversion he needed. If it turned out that Keara had gone to a chiropractor for her headache and had had cervical manipulation, there was a chance, he had no idea of how much chance, she’d suffered her vertebral artery damage there.
Turning around suddenly, Jack hastened back toward his office, mulling over the fact that he’d read of a case of VAD caused by cervical manipulation, and that Chet had had one himself as well as having found four or five in the L.A. medical examiner data bank. On top of that, Jack thought, he may presently have another. What it was all suggesting to him was that paying a visit to a chiropractor under certain circumstances was not necessarily a benign experience.
Although Jack admitted he didn’t know the details of chiropractic therapy, as a form of what was referred to as alternative or complementary medicine, he knew there was a question about its efficacy. He had always vaguely lumped together chiropractic, acupuncture, homeopathy, Ayurvedic tradition, Chinese herbal medicine, Transcendental Meditation, and a hundred others of what he considered questionable therapies based more on hope and the placebo effect than anything else. It surely wasn’t science, as far as he was concerned, but if people believed they got value for their dollar, it was fine with him. On the other hand if these therapies could be fatal, it was another story entirely, and he, as a medical examiner, had a distinct responsibility to blow the proverbial whistle.