by Robin Cook
Marissa wiped her moist hand on her skirt, then picked up her pencil once more. “So,” she said, staring at the blank page. “Since no diagnosis has been made, what’s being considered?”
“Everything,” said Dr. Navarre.
“Influenza?” asked Marissa, hoping she wasn’t sounding overly simplistic.
“Not likely,” said Dr. Navarre. “The patients have respiratory symptoms but they do not predominate. Besides, serological testing has been negative for influenza virus in all seven patients. We don’t know what they have, but it is not influenza.”
“Any ideas?” asked Marissa.
“Mostly negatives,” said Dr. Navarre. “Everything we’ve tested has been negative: blood cultures, urine cultures, sputum cultures, stool cultures, even cerebrospinal fluid cultures. We thought about malaria and actually treated for it, though the blood smears were negative for the parasites. We even treated for typhoid, with either tetracycline or chloramphenicol, despite the negative cultures. But, just like with the antimalarials, there was no effect whatsoever. The patients are all going downhill no matter what we do.”
“You must have some kind of differential diagnosis,” said Marissa.
“Of course,” responded Dr. Navarre. “We’ve had a number of infectious disease consults. The consensus is that it is a viral problem, although leptospirosis is still a weak contender.” Dr. Navarre searched through his index cards, then held one up. “Ah, here are the current differential diagnoses: leptospirosis, as I mentioned; yellow fever; dengue; mononucleosis; or, just to cover the bases, some other enteroviral, arboviral or adenoviral infection. Needless to say, we’ve made about as much progress in the diagnostic realm as the therapeutic.”
“How long has Dr. Richter been hospitalized?” asked Marissa.
“This is his fifth day. I think you should see the patients to have an idea of what we are dealing with.” Dr. Navarre stood up without waiting for Marissa’s response. She found she had to trot to keep up with him. They went through swinging doors and entered the hospital proper. Nervous as she was, Marissa could not help being impressed by the luxurious carpeting and almost hotellike decor.
She got on the elevator behind Dr. Navarre, who introduced her to an anesthesiologist. Marissa returned the man’s greeting, but her thoughts were elsewhere. She was certain that her seeing the patients at that moment was not going to accomplish anything except to make her feel “exposed.” This issue had not occurred to her while taking the introductory course back in Atlanta. Suddenly it seemed like a big problem. Yet what could she say?
They arrived at the nurses’ station on the fifth floor. Dr. Navarre took the time to introduce Marissa to the night staff, who were making their initial preparations to change shifts.
“All seven patients are on this floor,” said Dr. Navarre. “It has some of our most experienced personnel. The two in critical condition are in separate cubicles in the medical intensive-care unit just across the hall. The rest are in private rooms. Here are the charts.” With an open palm, he thumped a pile stacked on the corner of the counter top. “I assume you’d like to see Dr. Richter first.” Dr. Navarre handed Richter’s chart to Marissa.
The first thing she looked at was the “vital-sign” sheet. Beginning his fifth hospital day, she noticed that the doctor’s blood pressure was falling and his temperature was rising. Not a good omen. Rapidly she perused the chart. She knew that she’d have to go over it carefully later. But even a cursory glance convinced her that the workup had been superb, better than she could have done herself. The laboratory work had been exhaustive. Again she wondered what in God’s name she was doing there pretending to be an authority.
Going back to the beginning of the chart, Marissa read the section entitled “history of the present illness.” Something jumped out at her right away. Six weeks previous to the onset of symptoms Dr. Richter had attended an ophthalmological convention in Nairobi, Kenya.
She read on, her interest piqued. One week prior to his illness, Dr. Richter had attended an eyelid surgery conference in San Diego. Two days prior to admission he’d been bitten by a Cercopitheceus aethiops, whatever the hell that was. She showed it to Dr. Navarre.
“It’s a type of monkey,” said Dr. Navarre. “Dr. Richter always has a few of them on hand for his ocular herpes research.”
Marissa nodded. She glanced again at the laboratory values and noted that the patient had a low white count, a low ESR and low thrombocytes. Other lab values indicated liver and kidney malfunction. Even the EKG showed mild abnormalities. This guy was virulently sick.
Marissa laid the chart down on the counter.
“Ready?” questioned Dr. Navarre.
Although Marissa nodded that she was, she would have preferred to put off confronting the patients. She had no delusions of grandeur that she would uncover some heretofore missed, but significant, physical sign, and thereby solve the mystery. Her seeing the patients at that point was pure theater and, unfortunately, risky business. She followed Dr. Navarre reluctantly.
They entered the intensive-care unit, with its familiar backdrop of complicated electronic machinery. The patients were immobile victims, secured with tangles of wires and plastic tubing. There was the smell of alcohol, the sound of respirators and cardiac monitors. There was also the usual high level of nursing activity.
“We’ve isolated Dr. Richter in this side room,” said Dr. Navarre, stopping at the closed doorway. To the left of the door was a window, and inside the room Marissa could make out the patient. Like the others in the unit, he was stretched out beneath a canopy of intravenous bottles. Behind him was a cathode-ray tube with a continuous EKG tracing flashing across its screen.
“I think you’d better put on a mask and gown,” said Dr. Navarre. “We’re observing isolation precautions on all the patients for obvious reasons.”
“By all means,” said Marissa, trying not to sound too eager. If she had her way, she’d climb into a plastic bubble. She slipped on the gown and helped herself to a hat, mask, booties, and even rubber gloves. Dr. Navarre did likewise.
Unaware she was doing it, Marissa breathed shallowly as she looked down at the patient, who, in irreverent vernacular, looked as if he was about to “check out.” His color was ashen, his eyes sunken, his skin slack. There was a bruise over his right cheekbone; his lips were dry, and dried blood was caked on his front teeth.
As Marissa stared down at the stricken man, she didn’t know what to do; yet she self-consciously felt obliged to do something, with Dr. Navarre hanging over her, watching her every move. “How do you feel?” asked Marissa. She knew it was a stupid, self-evident question the moment it escaped from her lips. Nonetheless Richter’s eyes fluttered open. Marissa noticed some hemorrhages in the whites.
“Not good,” admitted Dr. Richter, his voice a hoarse whisper.
“Is it true you were in Africa a month ago?” she asked. She had to lean over to hear the man, and her heart went out to him.
“Six weeks ago,” said Dr. Richter.
“Did you come in contact with any animals?” asked Marissa.
“No,” managed Dr. Richter after a pause. “I saw a lot but didn’t handle any.”
“Did you attend anyone who was ill?”
Dr. Richter shook his head. Speaking was obviously difficult for him.
Marissa straightened up and pointed to the abrasion under the patient’s right eye. “Any idea what this is?” she asked Dr. Navarre.
Dr. Navarre nodded. “He was mugged two days before he got sick. He hit his cheek on the pavement.”
“Poor guy,” said Marissa, wincing at Dr. Richter’s misfortune. Then, after a moment, she added, “I think I’ve seen enough for now.”
Just inside the door leading back to the ICU proper, there was a large frame holding a plastic bag. Both Marissa and Dr. Navarre peeled off their isolation apparel and returned to the fifth-floor nurses’ station. Compulsively, Marissa washed her hands in the sink.
“What
about the monkey that bit Dr. Richter?” she asked.
“We have him quarantined,” said Dr. Navarre. “We’ve also cultured him in every way possible. He appears to be healthy.”
They seemed to have thought of everything. Marissa picked up Dr. Richter’s chart to see if his conjunctival hemorrhages had been noted. They had.
Marissa took a deep breath and looked over at Dr. Navarre, who was watching her expectantly. “Well,” she said vaguely, “I’ve got a lot of work to do with these charts.” Suddenly she remembered reading about a category of disease called “viral hemorrhagic fever.” They were extremely rare, but deadly, and a number of them came from Africa. Hoping to add something to the tentative diagnoses already listed by the clinic doctors, she mentioned the possibility.
“VHF was already brought up,” said Dr. Navarre. “That was one of the reasons we called the CDC so quickly.”
So much for that “zebra” diagnosis, thought Marissa, referring to a medical maxim that when you hear hoofbeats, think of horses, not zebras.
To her great relief, Dr. Navarre was paged for an emergency. “I’m terribly sorry,” he said, “but I’m needed in the ER. Is there anything I can do before I go?”
“Well, I think it would be better to improve the isolation of the patients. You’ve already moved them to the same general area of the hospital. But I think you should place them in a completely isolated wing and begin complete barrier nursing, at least until we have some idea as to the communicability of the disease.”
Dr. Navarre stared at Marissa. For a moment she wondered what he was thinking. Then he said, “You’re absolutely right.”
Marissa took the seven charts into a small room behind the nurses’ station. Opening each, she learned that, besides Dr. Richter, there were four women and two men who presumably had the same illness. Somehow, they all had to have had direct contact with each other or been exposed to the same source of contamination. Marissa kept reminding herself that her method of attack on a field assignment, particularly her first, was to gather as much information as she could and then relay it to Atlanta. Going back to Dr. Richter’s chart, Marissa read everything, including the nurses’ notes. On a separate sheet in her notebook, she listed every bit of information that could possibly have significance, including the fact that the man had presented with an episode of hematemesis, vomiting blood. That certainly didn’t sound like influenza. The whole time she was working her mind kept returning to the fact that Dr. Richter had been in Africa six weeks previously. That had to be significant even though a month’s incubation was unlikely, given the symptomology, unless he had malaria, which apparently he did not. Of course there were viral diseases like AIDS with longer incubation periods, but AIDS was not an acute viral infectious disease. The incubation period for such a disease was usually about a week, give or take a few days. Marissa painstakingly went through all the charts amassing diverse data on age, sex, life-style, occupation and living environment, and recording her findings on a separate page in her notebook for each of the patients. Rather quickly, she realized that she was dealing with a diverse group of people. In addition to Dr. Richter, there was a secretary, a woman who worked in medical records at the Richter Clinic; two housewives; a plumber; an insurance salesman and a real estate broker. Opportunity for commonality seemed remote with a group this diverse, yet all of them must have been exposed to the same source.
Reading the charts also gave Marissa a better clinical picture of the illness she was dealing with. Apparently it began rather suddenly, with severe headaches, muscle pain and high fever. Then the patients experienced some combination of abdominal pain, diarrhea, vomiting, sore throat, cough and chest pain. A shiver went down Marissa’s spine as she thought about having been exposed to the disease.
Marissa rubbed her eyes. They felt gritty from lack of sleep. It was time to visit the rest of the patients whether she wanted to or not. There were a lot of gaps, particularly in activities of each patient in the days directly preceding their illness.
She started with the medical secretary, who was located in a room next to Dr. Richter’s in the ICU, and then worked her way through to the last patient to be admitted. Before seeing each case, she carefully dressed in full protective clothing. All the patients were seriously ill, and none felt much like talking. Still, Marissa went through her list of questions, concentrating on whether each patient was acquainted with any of the other people who were ill. The answer was always no, except that each one knew Dr. Richter, and all were members of the Richter Clinic health plan! The answer was so obvious she was surprised that no one seemed to have spotted it. Dr. Richter might have spread the disease himself since he might even have been in contact with the medical secretary. She asked the ward clerk to call for all the patients’ clinic outpatient records.
While she was waiting, Dr. Navarre called. “I’m afraid we have another case,” he said. “He’s one of the lab techs here at the clinic. He’s in the emergency room. Do you want to come down?”
“Is he isolated?” asked Marissa.
“As well as we can do it down here,” said Dr. Navarre. “We’re preparing an isolation wing upstairs on the fifth floor. We will move all the cases there the moment it is ready.”
“The sooner the better,” said Marissa. “For the time being, I recommend that all nonessential lab work be postponed.”
“That’s okay by me,” said Dr. Navarre. “What about this boy down here? Do you want to see him?”
“I’m on my way,” said Marissa.
En route to the ER, Marissa could not shake the feeling that they were on the brink of a major epidemic. Concerning the lab tech, there were two equally disturbing possibilities: the first was that the fellow had contracted the illness in the same fashion as the others, i.e., from some active source of deadly virus in the Richter Clinic; the second, more probable in Marissa’s estimation, was that the lab tech had been exposed to the agent from handling infected material from the existing cases.
The ER personnel had placed the new patient in one of the psychiatric cubicles. There was a Do Not Enter sign on the door. Marissa read the technician’s chart. He was a twenty-four-year-old male by the name of Alan Moyers. His temperature was 103.4. After donning protective gown, mask, hat, gloves and booties, Marissa entered the tiny room. The patient stared at her with glazed eyes.
“I understand you’re not feeling too well,” said Marissa.
“I feel like I’ve been run over by a truck,” said Alan. “I’ve never felt this bad, even when I had the flu last year.”
“What was the first thing you noticed?”
“The headache,” said Alan. He tapped his fingers against the sides of his forehead. “Right here is where I feel the pain. It’s awful. Can you give me something for it?”
“What about chills?”
“Yeah, after the headache began, I started to get them.”
“Has anything abnormal happened to you in the lab in the last week or so?”
“Like what?” asked Alan, closing his eyes. “I did win the pool on the last Lakers game.”
“I’m more interested in something professional. Were you bitten by any animals?”
“Nope. I never handle any animals. What’s wrong with me?”
“How about Dr. Richter? Do you know him?”
“Sure. Everybody knows Dr. Richter. Oh, I remember something. I stuck myself with a vacu-container needle. That never happened to me before.”
“Do you remember the patient’s name on the vacu-container?”
“No. All I remember is that the guy didn’t have AIDS. I was worried about that, so I looked up his diagnosis.”
“What was it?”
“Didn’t say. But it always says AIDS if it is AIDS. I don’t have AIDS, do I?”
“No, Alan, you don’t have AIDS,” said Marissa.
“Thank God,” said Alan. “For a moment there, I was scared.”
Marissa went out to find Dr. Navarre, but he was occupied with
a cardiac arrest that had just been brought in by ambulance. Marissa asked the nurse to tell him that she was going back to the fifth floor. Returning to the elevators, Marissa began organizing her thoughts to call Dr. Dubchek.
“Excuse me.”
Marissa felt a tap on her arm and turned to face a stocky man with a beard and wire-rimmed glasses. “Are you Dr. Blumenthal from the CDC?” asked the man.
Nonplussed at being recognized, Marissa nodded. The man stood blocking her entrance to the elevator. “I’m Clarence Herns, with the L.A. Times. My wife works the night shift up in the medical ICU. She told me that you were here to see Dr. Richter. What is it the man has?”
“At this point, no one knows,” said Marissa.
“Is it serious?”
“I imagine your wife can answer that as well as I.”
“She says the man is dying and that there are six other similar cases, including a secretary from medical records. Sounds to me like the beginnings of an epidemic.”
“I’m not sure that ‘epidemic’ is the right word. There does seem to be one more case today, but that’s the only one for two days. I hope it will be the last, but no one knows.”
“Sounds scary,” said the reporter.
“I agree,” said Marissa. “But I can’t talk any longer. I’m in a hurry.”
Dodging the insistent Mr. Herns, Marissa boarded the next elevator and returned to the cubicle behind the fifth-floor nurses’ station and put through a collect call to Dr. Dubchek. It was quarter-to-three in Atlanta, and she got Dubchek immediately.
“So, how’s your first field assignment?” he asked.
“It’s a bit overwhelming,” said Marissa. Then, as succinctly as she could, she described the seven cases she’d seen, admitting that she had not learned anything that the Richter Clinic doctors didn’t already know.
“That shouldn’t bother you,” said Dubchek. “You have to keep in mind that an epidemiologist looks at data differently than a clinician, so the same data can mean different things. The clinician is looking at each case in particular, whereas you are looking at the whole picture. Tell me about the illness.”
