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.
Energized by this new crusade, Jack sat back in his desk chair. He couldn’t help but think about his conversation with Laurie and how she said she’d be willing to try anything for JJ. “I think we’ll pass on chiropractic therapy,” Jack said out loud as he pulled his chair toward his computer monitor.
8
12:05 P.M., MONDAY, DECEMBER 1, 2008
NEW YORK CITY
(7:05 P.M., CAIRO, EGYPT)
Jack pulled up an eMedicine article dealing with vertebral artery dissection. He began skimming it, learning that VAD was the cause of twenty percent of strokes suffered in patients younger than forty-five years of age, occurring three times more often in females than males. Reading on, he noted that the typical presentation was occipital, or back of the head, headache. He turned to the last page for the causes. The very first risk factor listed was spinal manipulation, just as Chet had suggested.
Intrigued at what the incidence of VAD was from spinal manipulation specifically, Jack went back to his default search engine. A few seconds later, he was scanning through a plethora of articles. He quickly found an article he thought promising and clicked on it.
As he read it, he found it far more disturbing than the first as it was a systematic review of thirty-five actual cases of strokes caused by cervical spine manipulation that had been reported in the medical literature from 1995 to 2001. The vast majority involved chiropractors, and most of the lesions were vertebral artery dissections. Outcomes varied from full recovery in six percent of patients to varying levels of permanent neurological deficits or death in the remaining ninety-four percent. One of the listed patients who had died was a three-month-old baby girl.
Jack leaned back and stared up at the ceiling. What malady would lead parents to think an infant’s symptoms would be relieved by cervical neck manipulation, suddenly and forcibly twisting the infant’s neck beyond a point of normal resistance? And what had gone through the supposed therapist’s mind that gave him or her the audacity to do such a thing? Jack wasn’t just horrified—he was angry.
Moving on to the discussion section of the article, Jack read that there was evidence that the thirty-five cases discussed were only a small portion of such cases, since underreporting was apparently widespread. To back up this statement a survey of physician specialists at a meeting of the Stroke Council of the American Heart Association reported three hundred sixty unreported cases of stroke after spinal manipulations!
Placing his hands on either side of his head, Jack shook it in disbelief, questioning why this issue was not more commonly known. After puzzling over the situation for a few minutes and coming to no conclusion, Jack returned his attention to Keara Abelard’s case.
He angrily riffled through the mass of papers on his desk until he located the telephone number of Keara’s friend who’d allegedly recommended chiropractic. He dialed, then tried to calm himself as the call went through. He knew it could be counterproductive to intimidate Keara’s friend. When she answered, Jack identified himself and mentioned his official title in as poised a manner as he was capable. His introduction was greeted with silence.
“Are you still there?” Jack inquired. “You are Nichelle Barlow, aren’t you?”
“Are you calling from the morgue?” the woman asked, with obvious concern.
“I am. Are you Nichelle Barlow?”
“Yes,” she replied reluctantly, apparently trying to prepare herself for what couldn’t be good news.
“I got your number from Mrs. Abelard. I hope I’m not disturbing you.”
“It’s okay,” she said hesitantly. “Are you calling me about Keara?”
“I am. I suppose you weren’t out with her and her friends last night.”
“No, I wasn’t, but don’t tell me she . . .” Nichelle said but was unable to complete the sentence.
“Unfortunately, Keara passed away last night,” Jack said. “I’m sorry to be the bearer of bad news.”
“What happened?”
“She had a stroke.”
“A stroke?” Nichelle said with disbelief. “Keara was my age, only twenty-seven.”
“Strokes are more common the older one gets, but even children can have them.”
“I can’t believe this. Is this some kind of sick prank?”
“I’m afraid not, Ms. Barlow,” Jack said calmly. “The reason I’m calling is because I’m investigating your friend’s death. Any sudden passing of an individual in apparent good health and with no known cause falls under the jurisdiction of the medical examiner’s office. What I need is some information. You were aware that Keara was suffering from headaches?”
“That’s what she said. But I didn’t get the impression they were particularly bad. More nuisance than debilitating.”
“Did she describe them to you?”
“Sort of. She said they were behind her eyes, more on the right than the left. She said she gets them when she is under stress, and with her new job she said she was under a lot of stress.”
“Her mother told me you had suggested she see a chiropractor.” Jack kept his voice neutral to avoid casting blame.
“She said ibuprofen wasn’t helping, so I suggested my chiropractor.”
