for signs of reaction. All he saw was a mild curiosity.
‘Removing the heart was the cause of death? It wasn’t done postmortem?’
‘No.’ McCabe told Spencer most of what Terri Mirabito had said about the cause and manner of Katie’s death, leaving out any mention of ligature or burn marks. Or of rape.
‘Dr. Mirabito’s right. Removing a heart is not that difficult. Not if you’ve got the proper tools — a scalpel, a reciprocating saw to cut the sternum, a retractor to spread the ribs. Pretty much any surgeon could do it, certainly any cardiac surgeon.’
‘Why do you think the murderer — whoever it was — might have wanted to cut out her heart?’
‘Me? I haven’t a clue. We both know there are all kinds of crazies in the world. I suppose some of them could be doctors. It was probably something sexual. From her picture, Katie was an attractive girl. People express their sexual fantasies in strange ways, but psychiatry’s not my field of expertise.’
‘You’re a transplant surgeon, right?’ asked McCabe. ‘You remove hearts for a living?’
‘Not exactly. I’m head of the transplant program here at Cumberland. The goal is to give people new hearts. In each case to save a life. That’s what turns me on. Harvesting — organ retrieval — is more often than not somebody else’s task.’
‘What’s it like? Cutting a heart out of a living human being? For a heart surgeon, is it simply all in a day’s work, or is it something somebody might get off on?’
‘You mean sexually?’
‘Yes.’
‘I don’t know. I can tell you it’s never all in a day’s work. Even when you know the heart will be used to save another life. On one level, the human heart is nothing more than a muscle that works like a small pump. Weighs less than a pound. Only a little bigger than your fist. Yet it beats a hundred thousand times a day. Pumps a couple of thousand gallons of blood. Unless we go out of our way to screw it up, it will, most likely, keep on doing that every day for seventy, eighty, even ninety years, often without routine maintenance. Show me another machine that can do anything like that.’ Spencer sounded genuinely excited.
‘You said on one level. What’s the other level?’
‘The other level is spiritual. Ancient people believed the heart was the seat of the soul. Some of us still do. When I do remove a heart, sometimes I hold it in my hand for a minute or two knowing it will give new life to a dying patient. An extraordinary feeling. Today, though the legal definition of death is death of the brain, some people still believe the soul resides, at least partly, in the heart.’
‘Are you one of them?’
Spencer smiled. ‘That, Detective, is my secret.’
‘You’ll be doing a transplant tonight?’
‘Yes. I’m waiting for a heart to be harvested in a hospital in New Hampshire sometime this evening. When it gets here, I’ll be putting it into the body of a forty-five-year-old high school teacher with a wife and two children. Without the transplant, he’d be dead before the end of the year.’
‘Do you think Katie Dubois might have been killed to harvest her heart for a transplant?’
Spencer looked up. ‘You mean as part of some sort of black market in organs?’
‘Yes.’
‘The answer is no.’
‘Why not?’
‘Couldn’t be done.’
‘You said yourself removing a heart wasn’t that difficult.’
‘It’s not. Any reasonably well-trained surgeon or pathologist can do it easily. Harvesting the heart isn’t the problem.’
‘So what is the problem?’
‘There are a lot of problems. For starters, there isn’t a transplant facility anywhere in this country that would accept a harvested heart without knowing precisely where it came from and under what circumstances the donor died, or without the participation of an organization called the United Network for Organ Sharing, which works through various regional OPOs — organ procurement organizations.’
‘That’s where you get your harvested hearts?’
Spencer seemed relaxed, on his own turf. ‘That’s where we have to get them. No choice. The OPOs have a monopoly. There are a couple of dozen of them in the United States. They divvy up the country geographically. Cumberland is the only hospital in Maine doing heart transplants, and all our hearts come through the New England Organ Bank in Newton, Mass.’
‘How does it work?’
‘When a heart becomes available, let’s say somebody is injured in an auto accident, they’re taken to the nearest hospital, which is probably not a transplant center. Then a lot of ifs come into play. If the patient dies and if the heart is healthy. Or if the patient is brain dead and if the heart is healthy. If the hospital’s trauma team can get permission from the victim’s family to harvest the organs. If all those ifs fall into place, the hospital informs the New England Organ Bank and prepares to harvest all usable organs, including the heart.’
‘Who decides who gets the heart?’
‘On any given day, the New England Organ Bank has a backlog of approved transplant patients waiting for hearts or, in some cases, for a heart-lung combination. Those who’d die first are at the top of the list. Geography is also a consideration. You don’t want the heart traveling any farther than it has to. Time in transit is an enemy to a successful transplant. When that’s all sorted out, the heart’s offered to the highest-priority patient with the right blood type and compatible tissue located in the nearest transplant center. Right now, today, there are over twenty- five hundred very sick people in the United States waiting for hearts. Many if not most of them will die waiting.’
‘An ideal situation for a black market, wouldn’t you say?’
‘For the sellers, sure.’
‘Also for the buyers,’ said McCabe. ‘You just said yourself a lot of people die waiting. Wouldn’t a few of them be willing to pay a substantial amount for a chance to jump the queue?’
Spencer paused for a minute, studying McCabe. ‘I’m sure they would,’ he said in a considered voice, ‘but who’s going to perform the transplant, and where? Any recognized transplant center would be crazy to even think about it. So would a qualified surgeon. The operation can’t be done by a surgeon acting alone, no matter how skilled or experienced, and it can’t be done on a kitchen table. When I transplant a heart, there are ten to twelve specialized people in the OR. All critical to the procedure. Plus a lot of sophisticated equipment. Most important is a heart-lung machine and a perfusionist to run it. The heart-lung machine circulates and oxygenates the patient’s blood and keeps him or her alive between the time the sick heart is removed and the healthy heart goes in and begins beating.’
‘What else is required?’
‘What else?’ Spencer shrugged. ‘A diagnostic lab to perform pre-op and post-op tests. A well-stocked blood bank. A facility for postoperative recovery and one-on-one care for at least a few days. You need an array of monitors. You need someone to prescribe and administer antirejection drugs and to watch the patient for signs of infection due to a compromised immune system. You need to be able to follow a fairly rigid postoperative protocol. I just don’t see how some kind of rogue surgeon could put all that together on his own.’
‘How long is a living heart viable after it’s harvested?’
‘Not long. Four or five hours. Our heart in New Hampshire will be placed in an iced saline solution in an ordinary picnic cooler, put on a helicopter, and flown directly here. While that’s being done, we’ll remove our patient’s diseased heart and attach him to the heart-lung machine until he receives his new heart. It’s all very tightly coordinated.’
Four or five hours. Terri Mirabito estimated Katie’s time of death as forty-eight to seventy-two hours before Lacey found her in the scrap yard. Since her body was found around 8:00 P.M. Friday, a transplant would have to have taken place sometime between 8:00 P.M. Tuesday and 8:00 P.M. Wednesday. Twenty-four hours. A big window.
‘How long does a transplant operation take?’
‘Depends how complicated. Anywhere from four hours to a whole day.’
McCabe resisted the temptation to ask Spencer where he was between Tuesday night and Wednesday night.
