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.