Death Rounds (16 page)

Not only had Rossit and I agreed there were no clinical indications for more antibiotics at the moment, the real irony was that he and I had then stood side by side and lectured the residents about the perils of overprescribing and cautioned them to rein in their urges to throw everything at an infection “just in case.”

Michael stayed silent, then asked, “Could Stewart have gotten it taking care of the Sanders woman?”

“Michael, you know secondary person-to-person spread has never been recorded,” I snapped back. “Now
you’re
inventing unheard of scenarios and all the while dismissing Janet because she’s dared to suspect something you’d never heard of!” I was losing patience by the minute with his stubborn refusal to admit what we might be up against.

“Earl, calm down. I meant could an accidental aerosol of
Legionella
have been created from a problem with the ventilation or from incomplete sterilization of equipment used on her.”

I took a deep breath and lowered my voice. “They’re checking that out now, but so far there’s been no evident breech of isolation and sterilization procedures.”

“But it’s possible,” he persisted.

“Not probable, Michael. Stewart’s young, healthy, even less likely than those three nurses to contract
Legionella.”

“Are they checking where he lives—”

“Yes, Michael, yes! You realize you’re going down the same blind alleys they already went down at University Hospital?”

This at last shut him up. But in the silence between us, I realized something.

I didn’t know why or where it happened specifically; perhaps it was last night when someone tried to crack my skull open. Or was it witnessing the utter devastation of Sanders’s lungs this morning? Or maybe it was seeing Stewart fall victim to an inexplicable infection a little more than an hour ago. But over the last twenty-four hours I’d passed from considering that a killer was possibly on the loose to absolute certainty that I was in pursuit of someone very real, very clever, and very evil. Perhaps it was the impossibility of making anyone else believe that murder had been committed that had made me so sure.

I’d begun to feel Janet and I were battling a superb defense—a protection set up by a killer who knew how the medical community would interpret and investigate these infections and deaths. A killer who was convinced that fidelity to science would practically forbid any investigator from thinking the infections were deliberately inflicted. It was as if the very bizarreness of the infections was a taunt, a tease, an arrogant flouting of the murderer’s method—a demonstration of the murderer’s certainty that no matter how strange or inexplicable the infections might be, adherence to accepted medical thought would prevail, and no one would ever suspect the killer’s existence because no one would dare contemplate that murder had ever been done.

Paranoia? Maybe, but that reaction described Michael’s behavior perfectly and Cam’s and probably anyone else’s I could think of whom we might try to tell about the Phantom.

I was so lost in thought, it took a few seconds to realize Michael was talking to me again.

“...but Janet’s been telling everyone what happened in the basement was just a panic attack.”

 “That’s only a ruse,” I answered, suddenly feeling hopelessly tired.

“I didn’t know you got panic attacks.”

“Will you forget goddamned panic attacks!”

“All right! All right! You don’t get panic attacks. But didn’t you hear
anything
I said yesterday about what this kind of Phantom talk could do to your credibility? Besides, Janet doesn’t exactly seem to be sharing your worry anymore. She’s broadcast all over the hospital that our audit is a waste of time, which, by me way, I don’t particularly appreciate. Just because I don’t buy her Phantom idea, we still have to find a source of—”

“Damn it, Michael!” I was snapping again. “I told you it was a ruse!” Once more I took a few seconds to try to calm down. “Have you talked to her yourself today?” I asked through clenched teeth.

“No, I haven’t seen her at all. But she’s obviously been feeding the gossip network,” he replied brusquely, letting me hear how miffed he was with her.

“Well if you had, Michael, she’d have told you she’s only saying that stuff to fool the creep who attacked me last night into thinking she’s backed off.” The receiver might have been Michael’s neck, I was squeezing it so hard. I relaxed my grip and watched the blood rush back into the skin around my knuckles. Still, I couldn’t let go of my fury with him for being so thick. “You didn’t see that woman’s lung. It made me scared for anyone at University Hospital, including Janet and you. Now I’m scared about what’s going to happen to poor Stewart. And I’m going to stay scared every time Janet goes to work and every time she comes home and goes near the baby.” I let my frustrations pour out of me. “Better yet, Michael, put yourself in Janet’s position. You don’t think she isn’t frightened, at least if not about herself, then certainly about Brendan?” Then I let fire my final shot. “Whether you’re right or, God forbid, she is—and I’m more and more convinced she is—you could at least give Donna and your unborn child the same concern.”

I heard Michael grunt like he’d been hit, then listened to him breathe for several seconds. “Ouch,” he finally answered. Then added, “God, how could I be so blind!” A few more seconds passed. “I’m such an asshole! Donna’s right, I’ve got the sensitivity of a run-away truck once I get my head set on a clinical problem.” He was speaking more and more rapidly and sounding increasingly chastised. “Damn, I’m sorry, Earl; I just never clued in on how this might be affecting Janet and you personally. Will you forgive me? And will Janet? Oh my God, Donna will kill me for this if she ever finds out I was so insensitive. I’ll find Janet and apologize to her myself. No! Better yet, I’ll send her flowers in the morning and then apologize. For God’s sake, don’t let her tell Donna.”

While his self-reproach built up steam, I recalled something about jackasses and two by fours, but now that I had his attention, I pushed. “Michael, it’s time to cash in all those markers you’ve chalked up with the accreditation board and get me named to this audit. Or threaten Cam if you have to. Tell him we’re sitting on another presumptive diagnosis of
Legionella
related to the Sanders case. Impress on him that I’m his best chance of finding answers before culture results make the outbreaks official. If he still isn’t moved to cooperate, tell him I’m going public by noon tomorrow unless I’ve got carte blanche to find out what’s going on over there.”

Michael’s silence was encouraging. Figuring I had him cornered, I hung up before he could change his mind.

I heard sirens approaching. There were at least two, maybe more. If they were all ambulances heading to our ER, I knew I’d be called to help within minutes. I was starting for the door and pulling my stethoscope out of my lab coat pocket when I noticed the
MMB
article slide out with it and fall to the floor. I paused to pick it up, glanced at the summary on the first page, then started to slip it back into my pocket. Had Miller been accurate in his précis of it? The blended wailings of the sirens were closer but no ambulance was here yet. Neither had Susanne run in to fetch me. I had a moment still.

Unfolding the article, again I skimmed through it. The brief synopsis described a case report from Japan of the world’s first-ever infection by a methicillin-resistant, vancomycin-inhibiting staphylococcus organism. The key word was
inhibiting.
It ultimately succumbed to vancomycin but only at very high doses. What had made this case alarming, the authors stated, was that in the past, organisms on the way to becoming fully resistant to a specific antibiotic had often demonstrated this inhibiting effect first. Historically, the emergence of a fully resistant strain of these organisms almost invariably followed, usually within two years. Should the same pattern repeat itself this time, the resulting staphylococcus bacteria, resistant to both vancomycin and methicillin, would be virtually untreatable. Any new antibiotics that might be useful were at least two or three years away from use in humans. The authors then brought the issue even closer to home. The first vancomycin-inhibiting strain of MRSA in the United States was reported by a hospital in Michigan, a second by a hospital in New Jersey. In both cases the organisms had responded to large doses of antibiotics, and no outbreaks anywhere in the world had been reported since.

One of the sirens had become much louder than the rest. Suddenly it cut out, and seconds later I heard the vehicle roar into the ambulance bay.

Getting ready to leave, I flipped over to the last page. A single item in the final list of recommendations was what I was looking for. Exactly as Miller had reported, in a case like his mother’s, in which a staphylococcal infection had failed to respond to vancomycin, the organism should be rechecked for this new trait of reduced susceptibility. There was even a hot-line telephone number at the CDC where any instances of the strain were to be reported immediately.

I tossed the article onto my desk. The rest of it looked rather technical and would require more time than I had at the moment. I had a hell of a lot more to worry about than some theoretical superbug coming at us from the other side of the world two years in the future.

But as I was heading out the door and running toward ER, on impulse I thought, why not call bacteriology and ask that vancomycin be included in Rossit’s special sensitivity tests already under way for the Sanders case? According to the CDC, the minimal inhibitory concentration method he was using—a determination of the times a culture of the organism can be diluted and still resist a given antibiotic—was the only reliable way to screen for the inhibiting strain. Rossit would probably be furious at me for meddling with his lab studies, but at least the gesture of adding the antibiotic to the group being checked might please Miller. After all, if Rossit hadn’t been so busy bad-mouthing me, he could have kept St. Paul’s up-to-date on this latest protocol for staph infections himself, the way Cam had done for University Hospital. I asked the clerk at triage to phone in the order.

The next hour I spent working with every available resident and doctor in ER resuscitating a dozen seniors suffering from smoke inhalation. Their residence had burnt to the ground. The culprit responsible for the fire, an eighty-year-old man repeatedly caught smoking in bed, was brought in later—a charred corpse held together by a body bag.

As I was filling out his death certificate, our telephone clerk transferred a call to where I was sitting. “Bacteriology department for you Dr. Garnet, line three.”

It was a technician.

“Dr. Garnet, I’m sorry to bother you, but the clerk told me you wanted the staph organisms from the Sanders case checked for an inhibitory effect on vancomycin?”

“That’s right.”

“Well, I thought I’d better tell you, it’s already been ordered.”

“Really? How come that’s not on her chart?”

There was a pause. “Gee, Dr. Garnet, I hope I’m not in trouble.” Another pause. By now I recognized the voice of the technician who’d done the initial Gram stain on Sanders’s sputum sample and who’d been so excited about finding staphylococci. “You see, it wasn’t exactly an order,” he continued, sounding sheepish. “It was actually more a suggestion from Dr. Mackie over at UH. He phoned yesterday morning, said he’d consulted on the case, and recommended we do the test since Harold’s mother wasn’t responding to treatment. It’s the routine in his department, and should be here too if you ask me.”

“Did you check with Dr. Rossit?” I asked, glad this innocent couldn’t see my wicked grin.

The complete silence on his end of the line answered my question. Finally the young man dared to say, “You know how
he
is, Dr. Garnet. Besides, Dr. Mackie’s going to be the new overall chief soon, isn’t he, when the merger goes through?”

Not if Rossit can help it, I felt like warning him, for despite the popular expectation that Cam would prevail on merit, I’d seen hospital politics favor the Rossits of this world all too often. Ambition was an easier currency for boards and CEOs to manipulate than the harder mettle that resided in a man like Cam. I tried to keep my voice neutral when I replied, “You must have inside sources that I don’t.”

I’d been about to hang up when the tech said, “Dr. Garnet, I wonder if I could ask you a favor?”

I immediately felt my guard go up. “Yes?” I replied cautiously. Over the years, as a physician and a chief, I’d been asked a lot of favors. Most had been legitimate, but some, especially those from people I didn’t know, had been embarrassingly inappropriate and some had been outright illegal.

“Well, since you were going to order it anyway...”

“Would it help your peace of mind if I put my name on the order?” I volunteered, chuckling at the simplicity of the request.

“Would you? That’ll be great! The test probably won’t come to anything, but I never know what Dr. Rossit is going to be angry about, especially these days.”

Another little sin on my tab wouldn’t matter much, I thought while hanging up.

* * * *

Before leaving that evening, I dropped in to see Stewart. It was an eerie feeling gowning up to visit him in the same glass chamber in which we’d put Phyllis Sanders.

At first Stewart appeared in surprisingly good spirits and seemed more intrigued by how he could have contracted
Legionella
than frightened by his infection. But as we talked about the conventional investigations into the organism’s source—I’d no expectations they’d find anything—I soon discovered Stewart’s underlying fear when he began to cough from the effort of speaking. As his hacking made him progressively short of breath, his eyes filled with alarm, and he asked, “Do you think when the pneumonia comes I’ll get as bad as she was?”

“Of course not Stewart,” I bluffed. “Early treatment’s the key to a mild and uneventful course. And remember, she had a secondary staph infection as well.”

He looked away without saying anything more and stared through the glass walls of his isolation room into the dim light of ICU. The gray semidarkness of evening was visible through the large outside windows behind the nurses’ station. He knew as well as I did that evolving respiratory conditions get worse at night. And as a physician, he knew what could go wrong. I figured he had to be thinking of the
Legionella
cases he’d seen in the past. It would have been impossible for him not to remember chest X rays he’d viewed that had shown the lungs whited out by the disease. He’d certainly have seen the remains of the infection at autopsy often enough, though I thanked God he hadn’t witnessed the particular horrors of Phyllis Sanders’s post today. Even with antibiotics on board, he had no way of knowing for sure what lay ahead for him.