Death Rounds (28 page)

Rossit began, “We will open this special Death Rounds with a particular welcome to our distinguished visitors from the CDC, Drs. Doris Levitz and Douglas Williams.”

Williams nodded his acknowledgment to the greeting. Doris Levitz flashed the room an icy smile, pointedly ignoring Williams.

Most of the people who’d been watching Cam and me were now paying attention to the proceedings. A few had exchanged puzzled looks and whispered together before shrugging and turning toward Rossit But Cam remained standing, staring at Michael’s note.

“I also wish to welcome our colleague Dr. Mackie from University Hospital,” continued Rossit. “The unfortunate case we will examine today has touched both our institutions.”

At the mention of his name Cam gave a start. “Right,” he answered, then vaguely looked around. He walked stiffly to where some of the medical students were perched along the top of a counter. They made an opening for him.

The practice in these sessions was that the residents present the case. Rossit gave the floor to the young man who tended to Phyllis Sanders on her first visit. He stood and, reading nervously from prepared notes, related the apparent benign findings of both his clinical exam and the many lab tests he’d ordered. He then put her initial chest X ray up on a viewing screen, answered a few questions from the staff doctors about its negative readings, and sat down.

Rossit glanced at Hurst, turned back to the resident, and asked, “Tell me. Doctor, why did you order all these tests if you figured this woman wasn’t very sick?”

The resident flushed. “Well,”
he started, “she kept insisting I check her more carefully, that she was sicker than I thought.”

“Obviously she was right!” snapped Rossit, with a wave to the containers on the table.

The resident started at the callous remark. There were a few chuckles in the room, while others gasped. I felt myself bristle.

‘Tell me,” Rossit continued, “what was the attitude to this patient on that day?”

The resident’s mouth hung open. “Pardon?” he asked.

“You heard me,” persisted Rossit, his voice cold. “We all know how a demanding patient can be taxing on the staff of a busy ER. I want to know how the nurses and doctors reacted to her.”

“I don’t know how to answer that. Dr. Rossit.” The resident’s voice was strained. He looked in my direction, his eyes wide with alarm. Rossit’s reputation for savaging doctors included stories of how he occasionally ripped into residents. There wasn’t a sound in the room.

The little man leaned forward. “Did you consider her a GOOMER, Doctor?” he asked snidely.

I went molten. “Now just a goddamned minute, Rossit!” I bellowed, leaping out of my chair. GOOMER was a despicable acronym used by cruder members of my staff, sometimes, inexcusably, even by doctors, in referring to troublesome patients. It meant Get Out of My Emergency Room, and I loathed the term. Unfortunately, the residents inevitably learned it on the job, and some thought it cool.

Rossit flew back in his chair in exaggerated surprise at my reaction. Hurst made a pyramid with his fingers in front of his lips, but I caught a glimpse of his snide smile. The rest of the upturned faces around me simply looked dismayed.

“Would you care to add to that comment. Dr. Garnet?” asked Rossit, eliciting another round of chuckles from those in the audience who were fans of this kind of spectacle.

I cursed myself for getting suckered into a stupid outburst and tried to recover some shred of dignity. “I’m sorry for my loss of self-control, Dr. Rossit, but the term GOOMER is contemptible, and anyone working in my ER is taught to despise both the phrase and the attitude it stands for.” I managed to keep the tremor in my voice appropriate, but inside I was raging. “I also wish to point out that badgering the residents is no longer an acceptable way to teach!” Attack me, you prick, if you will. Hell, I’m the guilty one. But leave my students alone!

I heard a few murmurs of approval as I sat back down. Rossit shrugged, and we moved on.

At his invitation the young nurse beside Susanne stood up, introduced herself as Miss Johnston, and haltingly recounted the fateful moment when Phyllis Sanders got out of her ER bed, complained of being dizzy, and was wheeled from the department. While Rossit listened attentively, Johnston kept glancing over at him, her apprehension obvious. When he was about to ask questions again, Susanne leaned forward, cleared her throat loudly, and glared at him. He paused at the sound, eyed her warily, then gently explained that he simply wished Nurse Johnston to clarify a few details for him. It seemed even he knew one of the basic rules of medicine—never piss off the nurses.

Turning back to Susanne’s protégée, he managed to elicit a piece of information that I was curious about.

“Phyllis Sanders was an experienced nurse,” he commented. “Did she protest that her orthostatic dizziness was important and should be checked out?”

Nurse Johnston flushed. “Yes.”

“And what did you do then?” There wasn’t a hint of judgment in his voice.

The young woman swallowed, looked over at me, and answered, “I told her that Dr. Garnet was one of the best physicians in the hospital and that she could trust his judgment.” Her voice quavered. “I also assured her that if he said it was safe for her to leave, she could go home without worrying about anything.” At that point her tears flowed down her cheeks. She reached for a tissue and dabbed at her eyes. “Sorry,” she muttered.

She sat down and Susanne put a comforting arm around her narrow shoulders. The silence in the room was like ice.

Rossit let it hang there for what seemed like an eternity. Hurst studied the people across from him, his mouth completely hidden behind his fingertips.

“Now for the return visit,” said Rossit somberly.

The story of the resuscitation went by like a bad dream. Referring to our ER record, Rossit made it a point to note that Michael had stepped in to take over the intubation. “Was there any particular anomaly in her airway that made it a difficult procedure for you, Dr. Garnet?” he asked.

I shook my head, answering, “No,” choosing to ignore his insinuation that I’d flubbed a key step in the resuscitation for no good reason. I knew that he was deliberately trying to chip away at me, but there was nothing I could do about it. I would only make things worse if I rose to his bait and tried to defend myself.

Rossit took it on himself to outline Sanders’s clinical course in ICU. Up to the point of her death, he’d measured her lab values every few hours, and his review of these results reduced her dying to a process of numbers. “By the time we got her, death was inevitable,” he concluded. Here I had to agree with him.

Next Rossit turned the session over to Len Gardner, who nipped open the Tupperware containers and began explaining his autopsy findings. He started with Sanders’s lungs, demonstrating features unique to the destructive process of both
Legionella
and staphylococcus. I’d no need to view any of it again.

My eyes wandered instead to the other specimens—Sanders’s liver, spleen, kidneys, intestine, and brain—in which I could see abscesses.

“. . . hematogenous spread by septic emboli,” Len explained, switching on his slide projector to show us death at the cellular level.

A feathery pink-and-blue dotted image of normal lung as it appeared under a microscope filled the screen at the far end of the room. Len then clicked the slide carousel forward and portraits of the little killers themselves appeared—slim red-stained rods for
Legionella,
bulky blue clusters of “grapes” for staphylococcus. The most telling image of all came next. It revealed clusters of staphylococci pouring through a tear in the lining of a small airway and flooding into the underlying lung tissue. Closer inspection showed the damaged area was already teeming with rods
of Legionella.
“It’s a two-step process,” explained Len.
“Legionella
prepares the way; staph ends the day,” he added, putting the deadly serious teaching point into a silly rhyme, which none in the room would ever forget.

The next few slides demonstrated over and over where each of these organisms had visited other tissues in other parts of Sanders’s body. They flashed by like snapshots taken of a pair of travelers at different stops on their voyage.

The room broke into applause at the end of Len’s presentation. “He’s terrific,” said Williams, his huge hands contributing greatly to me show of appreciation.

I sat there thinking that the Phantom had virtually slaughtered her from within, cell by cell, organ by organ. I glanced over at Rossit and Hurst. They looked relaxed and unconcerned, occasionally whispering together and smiling. If either of them was involved in the killing, it was hard to imagine they could show such indifference before so graphic a display of the victim’s remains. Cam on the other hand was transfixed, his expression grim, his eyes locked on the table as Len recovered the lineup of entrails in their containers.

While Rossit introduced Dr. Levitz to reveal the culture results, my attention remained on Cam. His behavior had me completely baffled. When Janet had told me he’d scoffed at her suggestion about the Phantom, I’d assumed she’d encountered the same scientific skepticism we’d initially run up against in Michael. But Cam’s reaction this morning was clearly a lot more than that, and I had no idea why. I also didn’t know how I could continue my search for what Michael had discovered at UH if Cam made good on his threat to report me for last night’s visit. Even if he didn’t go to the extent of pressing criminal charges but said anything at all about it to his CEO, I’d be lucky if I could get shown the way to a washroom in his hospital, let alone be given access to yet another roomful of confidential records.

Levitz began her introductory comments concerning VanA genes, the conjugation process, and inhibitory strains, but for me the words quickly became a buzz.

Perhaps Janet could carry out what I’d intended to do myself— check the personnel files of the people on the list I’d compiled in the archives and look for the names of patients who’d made complaints against them. But would Cam try and stop her too?

If you think I’m going to let you or Janet undermine University Hospital and harm me or my department by dragging up those old Phantom stories...

If she did agree to go on searching through charts, she’d have to make sure Cam didn’t know about it.

As I watched him sitting with the medical students, he stole another look at Michael’s note, then crumpled it up and dropped it in a nearby wastebasket, pointedly scowling at me as he did so.

You can’t simply toss this away. Cam, I thought, feeling annoyed at his gesture and wondering all the more why he was so determined to keep us from
dragging up those old Phantom stories.

Levitz continued to drone on in the background about organisms exchanging genetic materials in someone’s intestine.

I tried to stop myself from rushing to conclusions about Cam’s motives the way I had with Rossit and Hurst. Unlike those two, he certainly had no reason to be linked to the Phantom. I also knew Janet thought the world of him, and often I trusted her judgment of someone more than my own. In deference to her, I decided not to speculate about a man who was both her colleague and friend. It felt more comfortable to give him the benefit of the doubt, until Janet or I found out what was bothering him.

At that moment Levitz delivered her punch line. “...a confirmed superbug, a vancomycin- and methicillin-resistant staphylococcus...”

All around me were gasps and exclamations of surprise. “My God!” “Why didn’t they tell us?” “Are we safe?”

Rossit and Hurst immediately joined Levitz in uttering assurances about the negative screening results.

“Why were we lied to?” someone yelled.

‘To avoid panic,” boomed Williams at my side, adding his voice to the other three giving reassurances and calming people. With his help the uproar gradually subsided, and Rossit slowly reclaimed control of the meeting.

“Dr. Levitz,” he began, “I’ll ask you in your capacity as a representative of the CDC to pronounce on the last issue of this case. It’s our policy in Death Rounds to assess if the death under review was preventable or not.”

Without hesitation and pointedly not looking in my direction, she answered, “The only way we can stop this organism is through prevention. This woman’s staph infection might never have gotten a toehold in her lung had
Legionella
been diagnosed properly, then treated aggressively during her first visit, and the CDC feels our report of this case must signal that message to other physicians everywhere in the country. Accordingly, unless studies into the organism’s aggressivity categorically prove otherwise, our write-up in the
Mortality Morbidity Bulletin
will stress that the initial attending physician might have averted the woman’s death if he had acted appropriately.”

I felt she’d cut my windpipe. No amount of mental preparation could take away the actual blow of being judged responsible for a preventable death in front of my peers. But she’d done worse than that. It seemed I was going to be made an example of—turned into the CDC’s poster boy—for letting the bug of the decade into the United States.

For the next few seconds I sat immobile, feeling my face burn and sensing every eye in the room turned on me. I felt Williams’s large hand press on my arm and heard his voice declare something loudly to those around us, but I wasn’t paying attention. While he talked, I stared straight ahead, not wanting to face anyone I knew, certainly not anyone who worked with me or whose opinion I cared about I started to resent Williams’s prolonging the ordeal by talking on and on. Why didn’t he just shut up, I thought, so everybody would leave and I could run the hell out of here?

But he didn’t shut up, and despite my trying to tune out everything around me, some of what he was saying filtered through.

“I think you’re all missing a piece of a bigger picture here,” he insisted. “If you count them up—this patient Phyllis Sanders, Drs. Deloram and Popovitch from St. Paul’s, and two other nurses from University Hospital who I’ve been told were diagnosed as having
Legionella
earlier this year—you’ve got a concentrated pattern of
Legionella
infections in a group of five otherwise healthy hospital workers that hasn’t been explained. Dr. Rossit, you and your colleagues have got a responsibility to look at this group as a whole.”