“Usually, you bring me more to work with,” Dr. Sandra Kelly said.
The metal case was splayed open on the autopsy table like a clamshell. The kidney, wrapped in its protective plastic cover on one side, seemed dwarfed by the size and bulk of the battery pack and pump on the other. A nest of tubes and wires ran within neat grooves and channels cut into a dense foam-insulated layer.
Dr. Kelly loosened a clamp on the part of the case that stored the kidney. “I feel like I should call in my auto mechanic for this part.”
“What’s the purpose of all this stuff? One of our sources said something about a trophy. Is that was this is?”
The doctor continued disassembling the protective layer of foam. “This is an organ harvested for transplant.”
“Don’t you have to get harvested organs for transplant to a hospital right away? Ambulances, helicopters, ice chests, and stuff?” John said.
“Sooner the better, certainly. If preserved properly, organs maintain their viability for hours. The research in this field is expanding so fast, and newer technology keeps organs viable for longer periods than anyone thought possible a few years ago.” Dr. Kelly worked the clear plastic container free from the case and placed it on the stainless-steel autopsy table.
“How long would something like that last?” Paula asked.
“Hard to say. Given the right circumstances, the health of the donor, and the methods used to cool and preserve the tissue—forty-eight hours, maybe more,” the doctor said.
“Two days from killing his victim to mailing out the parts and delivering them to their recipient,” Paula observed.
“Two days from harvest to executed sale,” John added.
The constant high-pitch thrum ceased as Dr. Kelly snapped the battery pack out of its housing. “Huh.”
“What?” John asked.
“No backup. Most perfusion pumps have a redundant battery backup in case one drains. This one doesn’t,” Dr. Kelly said.
“Perfusion?” John said.
“Perfusion pump. This one is cutting edge. They’re designed to push a specialized fluid through the organ to keep it viable for transplant. I’ll test this, but I’m willing to bet it’s Viaspan, Euro-Collins, or simple Ringer’s lactate.”
“Where can someone get a setup like that?”
“There’s a dozen manufacturers. You can find the pumps on eBay,” Dr. Kelly said.
“We should be able to track the purchase,” Paula said. “Can’t be too many people out there buying perfusion pumps.”
John picked up the battery pack, and the surface was hot to the touch. “What’s the significance of operating without a battery backup? I mean, other than the obvious—the pump stops working and the tissue dies.”
“The choice your suspect made is . . . interesting. I guess ‘interesting’ is the word I’m looking for.”
“Cutting up a body isn’t new, but usually it’s to cover up the crime,” John said.
“That’s not what I’m talking about. The choice to try to preserve the organ by machine perfusion over cold storage is puzzling,” the doctor said.
“It was cold when we opened it,” Paula said.
Dr. Kelly snapped off her latex gloves, leaned against a tall cabinet, and rubbed her temples. “I did an internship, longer ago that I’d like to admit, in cryogenic preservation.”
“As in freezing people?” John said.
“It’s a bit more complicated than that, but yes.”
“I thought that was all science fiction,” John said.
“That’s why I don’t bring it up very often. But the research in cryogenics has revealed useful techniques in related fields. You’re looking at one of them now. Machine perfusion.”
“What’s puzzling about that?” John said.
“There are two primary methods of preserving an organ for transplant. Cold storage and machine perfusion. Cold storage is exactly what it sounds like. The organ is immersed in a cold solution of Euro-Collins or Viaspan and maintained at a temperature of two to six degrees Celsius.”
“That cold? Won’t everything turn to ice?” John asked.
“The reduction to the static temperature is gradual, one degree per minute. The preservative solutions prevent cell crystallization,” Dr. Kelly said.
“The second method you mentioned—that’s the machine?” Paula said.
“A perfusion pump with a plasma protein fraction perfusate solution. It’s cold, but not as cold as the cold-storage solutions. If properly maintained, an organ can be kept up to five days.”
“Why would our guy choose machine perfusion over the antifreeze method?” John said.
“I don’t know,” Dr. Kelly said. “That’s more of a detective thing if you ask me. From the standpoint of a pathologist, I can say that an organ is viable for transplant for a finite amount of time.”
“So he chose to keep the organ viable longer?”
“Maybe, but without the battery backup, the pump will fail. Without the circulating cooled preservative solution, the level of intracellular sodium increases. The tissue then draws water into the cell structure, resulting in lethal cell swelling. The organ ultimately develops delayed graft function and becomes useless.”
“Okay then, from a pathologist’s standpoint, what happens when one of these cases gets to its destination?” Paula asked.
“The activity starts long before that point,” John said. “Blood typing and tissue-matching data are collected and goes into a national data registry. UNOS, the United Network for Organ Sharing, manages the allocation of transplant organs across the nation. Patients connect with a transplant center and a surgical team and wait for a match. When information comes from UNOS, the doctors and patients get notified. Transplantable organs, the recipient, and the surgical team all converge at a hospital with a transplant center.”
Dr. Kelly’s eyes softened. “How is Tommy doing, by the way?”
“What? What about Tommy?” Paula said.
John sighed. “Tommy has end-stage renal failure. He needs a kidney transplant.”
Paula’s eyes betrayed her shock. “How long . . . ?”
John leaned against a counter and faced Dr. Kelly. “He’s hangin’ in there. It’s been three and a half years of waiting and transplant surgeries getting cancelled at the last moment. I can see why people turn to the black market to get around the UNOS wait list.”
Dr. Kelly leaned on a counter. “It’s not only the black market. There’s an explosion in demand for human tissue. It’s big business, especially in private hospitals overseas. It’s spawned an entire industry—transplant tourism.”
“Transplant tourism?” Paula asked.
“I’ve looked into it. Transplant patients travel to resort hospitals, get the surgery, and come back for postop care. China, Iran, Israel, and the Philippines have transplant destinations, and it ain’t cheap,” John said.
The doctor nodded. “Private hospitals, mostly. Iran’s system is operated by nonprofits in the country, and they pay the expenses for both the patient and the donor. Iran actually has a waiting list of kidney donors.”
“The catch is, you have to be an Iranian citizen. I checked,” John said. He gestured to the swollen hunk of flesh. “How much would something like that be worth on the black market?”
“Depends. I’ve heard it’s different from country to country, but on average, ten thousand dollars will get you one straight off the showroom floor,” Dr. Kelly said.
“I bet there’s no paper trail for that transaction,” Paula said.
John’s brow knitted. “Doc, if someone uses an off-the-books connection, how can they be sure where these organs come from? And what about the condition of the parts by the time they get there?”
“That’s the risk you take when you deal with those kinds of connections. The private overseas hospitals are legitimate, so your chances of getting a matched, viable organ are decent. The black-market transactions—well, let’s say, no one asks too many questions.”
“I’d imagine if someone paid enough to make sure they got a transplantable organ, they’d be pissed off when it doesn’t survive the trip,” John said.
“That’s where the black market works in your suspect’s benefit. He gets paid up front. He doesn’t have to worry about what happens when the organs are delivered, and there’s not much the receiving end can do about it. And if your guy is trafficking in Asia, India, or Europe, there may be no way to track his transactions.”
“But he only stays in business as long as the ‘merchandise’ meets expectations wherever he ships them to. If word got out that he sold bad product, that would be the end of his enterprise. That brings me back to the battery pack. A single battery, with no backup, means the shipment was not intended for a prolonged journey,” John said.
“Long enough. Mario Guzman told us he and Cardozo delivered their crates to the air cargo terminal. There would have been plenty of battery life to ship one of these to Asia. Or this creep just didn’t care,” Paula added.
“Could he get the organ into the legitimate medical supply chain locally? What kind of medical facility could pull off a transplant surgery?” John said.
“You’re talking about two points along a linear process, the beginning and the end. There is so much more that happens in between to ensure that the organ supply chain remains untainted. The UNOS processes exist to prevent someone from introducing contamination from a black-market connection where there is no telling what condition it’s in or the condition of the donor.
“A kidney transplant isn’t technically difficult. But what legitimate hospital would put their accreditation and license at risk?” Dr. Kelly asked.
“How would they know?” John countered.
“You can’t simply walk in off the street with a human heart or kidney in a dirty Ziploc bag and expect the transplant team to accept it as legitimately donated tissue. It doesn’t work that way. The system tracks the tissue. There are tests and protocols,” Dr. Kelly said.
“Do they come with an ‘Inspected by Number 43’ sticker, like my boxers?” John quipped.
“In a manner of speaking, yes, smartass, they do. The data show the transplant center, when the organ was harvested, and where the organ came from. In some cases, there will be additional donor detail.”
“What kind of detail?” Paula asked.
“Anything that may assist the transplanting surgeon—live donor versus deceased or any health concerns that may require additional caution to prevent infection and rejection. The point being, the system alerts the transplant team to a specific organ tagged for delivery. The allocation protocols in UNOS are rigid to protect the patient from getting the wrong organ or one without any chance of viability after transplant.”
“If the transplant doctors got the alert from UNOS, they wouldn’t question the origin of the donated organ,” John said.
“That’s right. The notification comes through the UNOS system as an online message. It’s a closed system—a message goes to the transplant center, and a return message verifies the contact.”
“Okay, so I can’t call from the corner liquor store and claim I’m from UNOS with an organ to sell?” Paula added.
“No, and UNOS isn’t involved in any financial transaction. The system is designed to collect all the information regarding the need for various transplants across the country and then allocate and notify when a match occurs in the system,” the doctor said.
“If I wanted to get a harvested black-market organ to a legit hospital without the transplant center getting suspicious, how could I do that?” John asked.
“Someone on the inside would have to be deliberately manipulating the data, but no doctor would take the risk using something outside that protocol.”
“What if instead of our killer selling to someone on the inside, he had access to the UNOS database? He could use the data to hunt for potential clients. It explains how this guy knew about Tommy. My son’s need for a kidney is in the UNOS database.”
“How many people know about what he’s going through?” Paula said.
John rubbed the bridge of his nose. What he wouldn’t give for a cigarette right now. “Family and a few others. Melissa and I wanted him to feel like a normal kid as much as possible. He doesn’t need some Facebook stalker spreading his story all over the Internet.”
“Or friends at school treating him differently,” Dr. Kelly said.
“Exactly.”
“Insurance representatives, pharmacists, hospital staff, his doctors,” Paula continued. “Anyone involved in his care, or someone they talked to about him, knows what Tommy needs.”
“That doesn’t explain this,” John said, tapping the organ transport case with his finger. “This is more than someone talking about my son. This was damn near gift wrapped for him. Doc, can you tell me if this is a match for my son?”
“I’ll look at the tissue type against Tommy’s.”
Dr. Kelly placed the plastic-boxed kidney on the small pedestal and flicked a switch. A flat-panel monitor projected a display of the organ at higher magnification. “I’ll run what I can on this tissue and see if I can find out more. I doubt that I’ll be able to get any identification. Maybe DNA, but that could take days, if it’s even in the system. Whoever harvested this wasn’t too careful. There is some evidence of crushing on the main artery at the point of dissection. He used scissors rather than a scalpel.”
“So?” John asked.
“The damage to the vascular tissue was avoidable, if he knew what he was doing.”
“Either he didn’t care or didn’t know any better,” Paula said.
Dr. Kelly flicked off the light over the damaged organ, and the glisten that gave the tissue purpose faded.
“Who has access to the UNOS data?” John said.
“I’m not certain, but a number of people at the transplant centers have access to patient and donor information.”
“I’ve worked with the staff at Central Valley Hospital. It’s hard to think that any of them would be involved in black-market organ harvesting,” John said.
“Money is one hell of a motivator,” Paula said.
“Don’t forget Delta Medical Center and Southland Hospital have transplant programs too,” Dr. Kelly reminded them.
“The system is interconnected, right?” John asked.
“The transplant centers are connected to the same data, but it’s a closed system, so only they can access it.” Dr. Kelly grabbed a blank autopsy chart that depicted the outline of the human form, where lines and dots translated into graphic illustrations of gaping lacerations and gunshot wounds. She scribbled a note on the back of the form and handed it to John. “Trisha Woods works over at Central Valley Hospital. You know her?”
“Yeah, I do. She handled all the paperwork for us when the doctors put Tommy in the transplant program.”
“Tricia is the UNOS expert at the place. If there were a way to beat the system, she would know. And I trust her.”
“We’ll check in with her. Can you give her a call and let her know that we’re pursuing something related to UNOS and not . . .”
“Using her services for personal reasons?” Dr. Kelly finished.
“I can’t do anything to put Tommy’s place on the list at risk. If they thought that I tried to manipulate the process . . .”
“Don’t worry, I’ll make the contact. Now if you don’t mind, I need to get some tissue samples of this little bugger up to the lab,” Dr. Kelly said.
John and Paula left Dr. Kelly in the autopsy suite and meandered back to the parking lot. At the car, Paula looked across the hood and locked eyes with her partner.
“Were you ever gonna tell me about Tommy?”
“What’s to tell? It’s not your problem.”
“That’s not what I meant. I’m your partner now.”
“What would telling you do? He’d still need a kidney.”
Paula’s eyes narrowed. “You should have said something. Your son is on a transplant list, and our killer knows about it. If you could get Tommy on the top of the list, would you?”
“Start screwing around with that list and people die. Who could live with that?”
Paula nodded and silently got into the car.
John didn’t know if his answer satisfied her. In truth, he wasn’t sure how far he’d go.