Error in Diagnosis (7 page)

Centers for Disease Control and Prevention
Atlanta, Georgia

Jack had a pretty good idea that the spacious conference room he and Madison had just been ushered into had been the site of dozens of landmark medical conferences. On the walls, hanging in a semi-ordered fashion, were black-and-white photographs of some of the greatest names in the history of American medicine. Even for someone of Jack's accomplishments and national reputation, the experience was a humbling one.

Seated around a leather-topped conference table, eighteen of the brightest and most talented physicians in the country chatted while they awaited the arrival of the surgeon general. Jack and Madison found their name cards and took their seats.

Ten minutes later, with her usual entourage, Dr. Renatta Brickell entered the room. Before calling the meeting to order, she made her way around the table individually greeting and thanking each physician for attending. When she finished, she took her seat at the head of the table. She began by asking the attendees to briefly introduce themselves and give a synopsis of their backgrounds and special area of expertise. When the last of the group had complied, she interlocked her fingers and placed her hands on the table.

“I want to begin by wishing you all a happy holiday season. I met with President Kellar earlier today. He wants me to assure each and every one of you that there's nothing more important on his national agenda right now than the GNS outbreak. He extends his heartfelt thanks to all of you who have agreed to serve on this task force.” Renatta paused long enough to glance down at her notes. “By now, each of you should have received an e-mail summarizing our most current information on the disease. Based on those facts, we will be concentrating our efforts in three main areas: the first is the possibility that GNS is a contagious disease—most likely a virus. The second possibility is an environmental toxic exposure of some type. Right now the two leading candidates would be a toxin from e-waste or nanotechnology.” She paused for a few moments and then added, “I would like to leave a discussion of the third possibility until the end of the meeting.” She looked up from her notes and glanced around the room. “So, if there are no pressing questions, I'd like to begin by asking
Dr. Maddox to give us a brief update on the CDC's efforts to this point.”

Over the years, Jack had worked with Ezra Maddox, a virologist, on several occasions, mostly relating to outbreaks of meningitis. Jack found him to be plodding in his approach to problems, but not one to be sidetracked by minutiae. Bringing his own special brand of meticulous management to every project, he had long been recognized as a national authority on all types of epidemics, but especially viral ones.

“Thank you, Dr. Brickell,” Maddox said, straightening his paisley bow tie. “As part of an initial evaluation, we have cultured and evaluated hundreds of fluid and tissue samples. We realize that we are only a few days into this investigation, but as of this morning, all of those tests have failed to reveal a specific virus, bacteria or fungal agent as the cause of GNS.” He removed his bifocals and tucked them into the breast pocket of his sport coat. “It also bears mentioning that the symptoms we are seeing with GNS are only suggestive of a viral illness, certainly not diagnostic.”

For the next fifteen minutes Maddox elaborated on the CDC's findings. He concluded his remarks by repeating that they didn't have a single iota of evidence that GNS was a contagious disease. Maddox then opened the floor to questions, none of which were eye-opening.

The problem was the same—a lack of any definitive medical information about GNS, a reality Jack suspected would surface over and over again as the meeting progressed. Maddox's disheartened manner and dampened
voice betrayed the same frustration Jack suspected everybody in the room, including himself, was feeling. After answering the last question, Maddox turned the meeting back to the surgeon general.

“As I'm sure we're all aware, the outbreak of GNS in so many women over a wide geographic area raises the question of a possible toxic exposure. As I mentioned, there are two specific areas that should be discussed. I'd like to begin by asking Dr. Grandeson to give us an update on her work.”

Plain-faced with a sparse patch of freckles over the bridge of her nose, Mary Grandeson had devoted her entire professional life to the study of environmental toxins. In spite of a career filled with major scientific accomplishments and professional accolades, she religiously avoided the academic limelight. “Since the first cases of GNS were identified, we've been looking at all environmental toxins as a possible cause, but with a particular focus on microscopic toxins produced by nanotechnology.”

Jack's knowledge of nanotechnology was elementary at best. Essentially, the science was about twenty years old and dealt with consumer products, mostly cosmetic and electronic, that contained microscopic materials. Over the past several years, a rising concern had been raised by the scientific community that these microscopic components could possibly be toxic.

Dr. Grandeson's presentation was concise but comprehensive, giving an extensive review of nanotoxins with special emphasis on those that theoretically could be linked to GNS. She concluded by saying that it was possible a
nanotoxin could be responsible for GNS, but beyond that she had no evidence that pointed to a specific one.

“Which brings us to the second environmental toxin of concern,” Brickell said. “Is there any possibility that we might be dealing with an e-waste toxin?”

Grandeson answered, “Disposal of massive amounts of electronic equipment such as computers has become a major problem not only in this country but worldwide. This is especially true when these items are disposed of illegally. There are millions of them being dumped without regard for public safety on a daily basis. Their breakdown by-products can be extremely toxic to people, animals and the environment.”

“Any ideas regarding a specific source?” the physician sitting directly across from Jack asked Grandeson.

“Unfortunately, e-waste research is still in an embryonic stage. Much of what we think we know is guesswork at best. If GNS is being caused by an e-waste toxin, it would take us months, maybe years to discover its exact origin and how to eliminate it.”

“Can you at least speculate as to a possible mechanism of exposure?” the same physician inquired.

“Direct contact with the skin or oral ingestion is possible. But my best guess would be by inhalation. For that reason, we're carefully looking at the weather conditions across the country during the past few weeks.”

The notion that GNS could be caused by a virus or a potent toxin launched a long discussion. There was a host of theories advanced and concerns raised but no consensus was reached. Working through lunch, the presidential
task force was able to formulate a plan moving forward to coordinate their investigative efforts.

“It's almost three o'clock and I think we've just about exhausted our time for today,” Brickell announced to the group. “But prior to adjourning, I have two additional matters to share with you. The third possibility to explain GNS that I referred to at the beginning of the meeting is something I'm sure everyone in this room has thought about. The president called me early this morning and asked me to join him this evening at the Army War College to discuss the possibility that GNS is an act of bioterrorism. It is my understanding we'll be meeting with key personnel of the strategic studies unit on bioterrorism.”

“Can you give us a better idea of just how serious the president believes this threat to be?” Madison inquired.

“I think he believes it to be unlikely, but he's firm that even if it's a faint possibility, it has to be completely ruled out. The other problem we're facing is that now that we're seeing our first deaths . . . well, we're really under the gun to figure out how to stop the spread of this thing.”

From his basic knowledge of bioterrorism, Jack couldn't fathom how any individual or radical group could design a biological weapon that would specifically target pregnant women. But he was a scientist, and if he had learned one thing over the years, it was that anything was possible. The thought made his blood run cold. If GNS were the premeditated act of a terrorist group, the wholesale loss of human life could become staggering.

Brickell moved forward in her chair and tapped her fingertips together. “President Kellar has also asked me
to share with you his concern regarding the sensitive ethical and moral challenges we will all be facing. Perhaps the most important is the prospect of early termination of these pregnancies. Therefore, in the next few days, you will be advised of a series of meetings and webinars we're arranging with nationally renowned ethicists and religious leaders. We will also be talking with right-to- life and pro-choice organizations.” She forced a guarded smile to her face. “I again want to thank everybody for attending today. My office will advise you of the time and location of our next meeting. I understand that our progress has been somewhat discouraging to this point but it's imperative we remain positive and redouble our efforts to find the cause of GNS.”

After a few moments, everybody slowly stood up. A few small groups formed to discuss the distressing news. Jack waited for Madison to gather her things. Together, they started for the door.

His mind fixed on Tess and Mike, Jack said, “We can't assume these deaths are isolated events. My guess is there'll be many more before we figure this thing out.”

Although Brickell had already been descended upon by several other physicians, Jack was able to catch her eye and motion a quick good-bye. With a pained smile, she acknowledged Jack with a wave and returned to her conversation. The instant he stepped out into the hall, he reached for his cell phone and called the ICU at Southeastern State to check on Tess.

The boarding process of the flight back to Florida went smoothly and the departure was on time. It wasn't until they had been in the air for an hour and Madison had finished a glass of white wine that Jack decided the time was right to take another swipe at the piñata.

“How long have you been at Southeastern State?”

“Eight years. The last four as division chief.”

“Do you like it?”

“It's a great job.”

“That's pretty high praise. I'm not sure all of my colleagues at Ohio State would say the same about their positions.”

With a dry half smile, she said, “Southeastern State may be different than what you're used to. Everybody I work with is a caring professional who you can really trust.”

Although he wasn't going to ask her to elaborate, he
still couldn't figure out whether she was just congenitally unfriendly or if it was him who naturally made her skin crawl. Whatever her reason, it was clear the time to stop tap-dancing around her nasty attitude toward him had arrived.

Clearing his throat, he said, “I've never viewed myself as particularly paranoid, and this may sound a little strange to you, but ever since we met, I've gotten the feeling you—”

She turned and looked at him, her eyes boring into his. “We didn't meet yesterday, Jack. We met a long time ago.”

“Uh . . . really?” he asked, flogging his memory for some clue. He lowered his glass of sparkling water from his lips. Hoping she'd toss a hint in his direction, he went into a four-corner stall. “It's funny, but now that you mention it, I do have a recollection of us meeting—”

“Save the crap for somebody else, Jack. You don't have any idea who I am.”

She then laughed at him as if he were trying to pick her up by claiming he was a two-time winner of the Congressional Medal of Honor.

He grinned and then sighed in contrition. “Okay. You're right. I don't remember. Where did we meet?”

“At the University of Florida. I was a third year medical student rotating on neurology. You were the chief resident.”

Jack studied Madison's face again. All at once, he did have a fuzzy recollection of her.

“I may be confusing you with somebody else,” he began cautiously, “but weren't you using a different . . .”

“I was using my married name, Madison Casas.”

He raised his finger and pointed hesitantly at her hair. “You looked different . . . I mean you wore your . . .”

“Let me save you the embarrassment. I was blond, twenty-five pounds heavier and couldn't afford contact lenses and posh hair care.”

Jack was now certain he remembered her. But he recalled nothing of a problem between them, leaving him totally perplexed as to why she harbored such resentment for him. As the chief resident, he was much more involved in teaching than most of his fellow residents. Twice during his residency, he had won the Neurology Teaching Award, an accolade presented by the medical students to an outstanding resident teacher.

Seeing no way of putting it gently, he asked, “Did we have some kind of a problem?”

“You mean other than you being the reason I failed the rotation?”

“Wait a sec,” Jack said holding up his hand. “I was only the chief resident. I didn't have the authority to fail anybody. I didn't even assign grades. I was asked my opinion of each student's performance but the chief of neurology was the one who assigned the grades.”

“But you were the one who gave us our final practical oral examination.”

“That's true, but so what?”

“Are you saying you didn't discuss the results with the attending physicians in charge?”

“Of course I did, but I never failed anybody on the test.”

She looked at him with dubious eyes. “My written evaluation couldn't have been clearer. It said I had failed the final practical examination and therefore the entire rotation, which I would be required to repeat. Apart from being one of the most humiliating experiences of my life, I almost didn't graduate with my class. The failing grade also appeared in big bold letters on my transcript, which didn't help very much when I applied for OB-GYN residencies. I was so afraid I wouldn't get one, I wound up applying to thirty programs from Gainesville to San Diego. Needless to say, I didn't exactly get my first choice.”

In spite of her impassioned speech, Jack was certain he hadn't been the reason Madison failed her neurology rotation.

“I don't remember any student having to repeat the clerkship,” he informed her.

“Do you really think I would repeat it with you? I told you. I was so embarrassed I wanted to die. I signed up to repeat my neurology rotation at another hospital. And, not that this would matter to a person such as yourself, but I was going through a horrendous divorce at the time.”

“Why didn't you speak with me after you found out your grade?”

“What for? To hear the same kind of lame excuses and denials I'm hearing now?”

“You weren't the only student I had with a personal problem. I think I was always understanding and fair.”

In a droll voice she said, “You're right, Jack. You were very understanding—right up until the time you fed me
to the lions.” She picked up a napkin, crumpled it up and tossed it back on the tray table.

•   •   •

In spite of his best efforts, Jack was not recovering from the free fall.

He could understand Madison's anger, but they were debating something that had happened a long time ago. And as it turned out, failing her third year neurology clerkship had no negative effect on her career. She had successfully climbed the academic ladder and was now the chief of perinatology at a prestigious medical school.

But Jack was politically seasoned and knew the facts of a disagreement were not always what mattered. Who was right and who was wrong were oftentimes irrelevant. Sometimes, simply apologizing in the blind was the easiest and quickest solution to a problem.

“I'm very sorry for what happened,” he began in a calm tone. “I can honestly say I have no recollection of failing you on the final exam. But if the time you spent on the neurology service caused you any personal difficulties, I apologize.”

She grinned at him. “Does that lame sorrygram really make you feel any better? Because that's the most oblique apology I've ever heard.”

“I can't make you accept my apology. If you have a problem with me—fine. But I would like to get past it so we can work together.”

“While I appreciate that—”

“Look, it's going to be tough enough for us to figure
what's going on with these women. Dr. Morales expects us to work together in a productive manner. Certainly what we're facing with respect to GNS is a lot more important than any misunderstanding that took place between us umpteen years ago. Being at odds with each other will only make things more difficult. I'm asking you to accept my apology so that we can move on.”

Madison's expression changed slightly. From the loss of conviction on her face, Jack suspected she was giving serious consideration to his proposal.

“You're right,” she told him with conviction. “Dean Morales has certain expectations. I'm sure I can put my personal feelings aside so that we can work together.”

He nodded politely and said, “I appreciate you being so open-minded and accepting my apology.”

“I didn't say I accepted your apology. I said I'd work with you. If you're expecting a group hug and a chorus of ‘Kumbaya' around the campfire, you'll be waiting a long time.” Jack sat in guarded silence, taking in Madison's self-satisfied grin. It was as if she were happily basking in a bit of long-awaited payback. He actually found himself forced to hold back an optimistic smile. If a few verbal lashings at his expense were all Madison needed to square things between them, it would be a small enough price to pay. His ego had endured worse.

With a circumspect expression, he raised his glass in a mock toast.

“Even if you see it as a descent into the depths of hell—I appreciate your willingness to put your feelings aside and agree to work with somebody you truly despise.”

“I never said I despised you. I don't despise anybody. I just think you're an asshole—that's all.”

He took a swallow or two and then set his glass down.

“Did you really just call me an asshole?”

“Absolutely.”

Grinning on the inside, he shook his head. “I can't remember the last time a colleague called me an asshole.”

“Not to your face, maybe,” Madison said with a laugh. It was a response Jack deemed a minor breakthrough, even if it was only a small breach in her glacial exterior.