Outbreak

by Robin Cook

  “I’m afraid so,” answered Taboso. “He’s an ophthalmologist here at the hospital.”

  Turning to Dr. Austin, she asked, “Did you know the index case in L.A. was also a doctor? In fact he was an ophthalmologist!”

  “I was aware of the coincidence,” said Dr. Austin, frowning.

  “Does Dr. Zabriski do any research with monkeys?” asked Marissa.

  “Not that I know of,” answered Dr. Taboso. “Certainly not here at the hospital.”

  “No other physicians were involved in the L.A. outbreak that I can recall,” said Dr. Austin.

  “No,” said Marissa. “Just the index case. There were three lab techs and one nurse, but no other doctors.”

  Redirecting her attention to the chart, Marissa went through it rapidly. The history was not nearly as complete as that done on Dr. Richter at the Richter Clinic. There were no references to recent travel or animal contact. But the lab workup was impressive, and although not all the tests were back, those that were suggested severe liver and kidney involvement. So far everything was consistent with Ebola Hemorrhagic Fever.

  After Marissa finished with the chart, she got together the materials necessary for drawing and packing viral samples. When all was ready, she went down the hall with one of the nurses to the isolation area. There she donned hood, mask, gloves, goggles and booties.

  Inside Zabriski’s room, two other women were similarly attired. One was a nurse, the other a doctor.

  “How is the patient doing?” asked Marissa as she moved alongside the bed. It was a rhetorical question. The patient’s condition was apparent. The first thing Marissa noticed was the rash over the man’s trunk. The second thing was signs of hemorrhage; a nasogastric tube snaked out of the man’s nostril and was filled with bright red blood. Dr. Zabriski was conscious, but just barely. He certainly couldn’t answer any questions.

  A short conversation with the attending physician confirmed Marissa’s impressions. The patient had been deteriorating throughout the day, particularly during the last hour, when they began to see a progressive fall in the blood pressure.

  Marissa had seen enough. Clinically, the patient resembled Dr. Richter to a horrifying degree. Until proven otherwise, it had to be assumed that Dr. Zabriski and the other two subsequent admissions had Ebola Hemorrhagic Fever.

  The nurse helped Marissa obtain a nasal swab as well as blood and urine samples. Marissa handled them as she’d done in L.A., double bagging the material and disinfecting the outsides of the bags with sodium hypochlorite. After removing her protective clothing and washing her hands, she returned to the nurses’ station to call Dubchek.

  The phone conversation was short and to the point. Marissa said that it was her clinical impression that they were dealing with another Ebola outbreak.

  “What about isolation?”

  “They’ve done a good job in that regard,” reported Marissa.

  “We’ll be there as soon as possible,” said Dubchek. “Probably tonight. Meanwhile, I want you to stop all further lab work and supervise a thorough disinfection. Also have them set up the same kind of quarantine of contacts that we used in L.A.”

  Marissa was about to reply when she realized that Dubchek had hung up. She sighed as she replaced the receiver; such a wonderful working relationship!

  “Well,” said Marissa to Drs. Taboso and Austin, “let’s get to work.”

  They quickly set the quarantine measures in motion, arranging for the sterilization of the lab and assuring Marissa that her samples would be sent overnight to the CDC.

  As they left to attend to their tasks, Marissa asked for the charts on the other two patients. The nurse, whose name was Pat, handed them to her, saying, “I don’t know if Dr. Taboso mentioned this, but Mrs. Zabriski is downstairs.”

  “Is she a patient?” asked Marissa with alarm.

  “Oh, no,” said Pat. “She’s just insisting on staying at the hospital. She wanted to be up here, but Dr. Taboso didn’t think it was a good idea. He told her to stay in the first-floor lounge.”

  Marissa put down the two new charts, debating what she should do next. She decided to see Mrs. Zabriski, since she had very few details with regard to the doctor’s recent schedule. Besides, she had to stop by the lab to check the sterilization. Asking directions from Pat, Marissa rode down to the second floor on the elevator. En route she looked at the faces of the people next to her and guessed what their responses would be when they heard that there had been an Ebola outbreak in the hospital. When the doors opened on the second floor, she was the only one who got off.

  Marissa expected to find the evening shift in the lab and was surprised to see that the director, a pathologist by the name of Dr. Arthur Rand, was still in his office, even though it was after 8:00 P.M. He was a pompous older man, dressed in a plaid vest complete with a gold fob protruding from one of the pockets. He was unimpressed that Marissa had been sent by the CDC, and his facial expression did not change when Marissa said it was her clinical opinion that there was an outbreak of Ebola in his hospital.

  “I was aware that was in the differential diagnosis.”

  “The CDC has requested that no more lab tests be done on the involved patients.” Marissa could tell that the man was not going to make it easy for her. “We’ll be bringing in an isolation lab sometime tonight.”

  “I suggest you communicate this to Dr. Taboso,” said Dr. Rand.

  “I have,” said Marissa. “It’s also our opinion that the lab here should be disinfected. In the outbreak in L.A. three cases were traced to the lab. I’d be willing to help, if you’d like.”

  “I believe that we can handle our own cleanup,” said Dr. Rand with a look that seemed to say, Do you think I was born yesterday?

  “I’m available if you need me,” said Marissa as she turned and left. She’d done what she could.

  On the first floor she made her way to a pleasant lounge with its own connecting chapel. She was unsure how she would recognize Mrs. Zabriski, but it turned out she was the only person in the room.

  “Mrs. Zabriski,” said Marissa softly. The woman raised her head. She was in her late forties or early fifties, with gray-streaked hair. Her eyes were red rimmed; it was obvious she had been crying.

  “I’m Doctor Blumenthal,” said Marissa gently. “I’m sorry to bother you, but I need to ask you some questions.”

  Panic clouded the woman’s eyes. “Is Carl dead?”

  “No,” said Marissa.

  “He’s going to die, isn’t he?”

  “Mrs. Zabriski,” said Marissa, wanting to avoid such a sensitive issue, especially since she believed the woman’s intuition was correct. Marissa sat down next to her. “I’m not one of your husband’s doctors. I’m here to help find out what kind of illness he has and how he got it. Has he done any traveling over the last—” Marissa was going to say three weeks, but remembering Dr. Richter’s trip to Africa, she said instead, “—the last two months?”

  “Yes,” Mrs. Zabriski said wearily. “He went to a medical meeting in San Diego last month, and about a week ago he went to Boston.”

  “San Diego” made Marissa sit up straighter. “Was that an eyelid surgery conference in San Diego?”

  “I believe so,” said Mrs. Zabriski. “But Judith, Carl’s secretary, would know for sure.”

  Marissa’s mind whirled. Zabriski had attended the same meeting as Dr. Richter! Another coincidence? The only problem was that the conference in question had been about six weeks previous, about the same interval of time as from Dr. Richter’s African trip to the appearance of his symptoms. “Do you know what hotel your husband stayed in while he was in San Diego?” asked Marissa. “Could it have been the Coronado Hotel?”

  “I believe it was,” said Mrs. Zabriski.

  While Marissa’s mind was busy recalling the central role played by a certain hotel in Philadelphia during the Legionnaires Disease outbreak, she asked about Dr. Zabriski’s trip to Boston. But his wife did not know why he’d gone. I
nstead, she gave Marissa her husband’s secretary’s phone number, saying again that Judith would know that kind of thing.

  Marissa took the number and asked whether Dr. Zabriski had been bitten by, or had been around, any monkeys recently.

  “No, no,” said Mrs. Zabriski. At least none that she knew of.

  Marissa thanked the woman and apologized for bothering her. Armed with the secretary’s home phone number, she went to call Judith.

  Marissa had to explain twice who she was and why she was calling so late before the secretary would cooperate. Judith then confirmed what Mrs. Zabriski had told her: namely, that the doctor had stayed at the Coronado Hotel while in San Diego, that Dr. Zabriski had not been bitten recently by any animal, and, as far as she knew, that he’d not been around any monkeys. When Marissa asked if Dr. Zabriski knew Dr. Richter, the answer was that the name had never appeared on any correspondence or on his phone list. Judith said the reason that Dr. Zabriski had gone to Boston was to help plan the Massachusetts Eye and Ear Infirmary’s upcoming alumni meeting. She gave Marissa the name and phone number of Dr. Zabriski’s colleague there. As Marissa wrote it down, she wondered if Zabriski had unknowingly transferred the virus to the Boston area. She decided that she’d have to discuss that possibility with Dubchek.

  As she hung up, Marissa suddenly remembered that she hadn’t called Ralph from the airport. He answered sleepily, and Marissa apologized both for waking him and for not getting in touch with him before she left Atlanta. After she explained what had happened, Ralph said that he would forgive her only if she promised to call him every couple of days to let him know what was going on. Marissa agreed.

  Returning to the isolation ward, Marissa went back to the charts. The two later admissions were a Carol Montgomery and a Dr. Brian Cester. Both had come down with high fevers, splitting headaches and violent abdominal cramps. Although the symptoms sounded nonspecific, their intensity gave sufficient cause for alarm. There was no reference to travel or animal contact in either chart.

  After gathering the material necessary for taking viral samples, Marissa dressed in protective gear and visited Carol Montgomery. The patient was a woman one year older than Marissa. Marissa found it hard not to identify with her. She was a lawyer who worked for one of the city’s large corporate firms. Although she was lucid and able to talk, it was apparent that she was gravely ill.

  Marissa asked if she had done any recent traveling. The answer was no. Marissa asked if she knew Dr. Zabriski. Carol said that she did. Dr. Zabriski was her ophthalmologist. Had she seen him recently? The answer was yes: she’d gone to him four days ago.

  Marissa obtained the viral samples and left the room with a heavy heart. She hated making a diagnosis of a disease with no available treatment. The fact that she’d been able to uncover information that mirrored the earlier outbreak was small compensation. Yet the information reminded her of a question that had troubled her in L.A.: Why did some of Dr. Richter’s patients catch the disease and others not?

  After changing into fresh protective clothing, Marissa visited Dr. Brian Cester. She asked the same questions and got the same replies, except when she asked if he was one of Dr. Zabriski’s patients.

  “No,” said Dr. Cester after a spasm of abdominal pain subsided. “I’ve never been to an ophthalmologist.”

  “Do you work with him?” asked Marissa.

  “I occasionally give anesthesia for him,” said Dr. Cester. His face contorted again in pain. When he recovered, he said, “I play tennis with him more often than I work with him. In fact I played with him just four days ago.”

  After obtaining her samples, Marissa left the man, more confused than ever. She had begun to think that fairly close contact—particularly with a mucous membrane—was needed to communicate the disease. Playing tennis with someone did not seem to fit that mold.

  After sending off the second set of viral samples, Marissa went back to Dr. Zabriski’s chart. She read over the history in minute detail and began the same type of diary she’d drawn up for Dr. Richter. She added what material she’d learned from Mrs. Zabriski and the secretary, knowing that she would have to go back to both of them. Although such work had not resulted in determining the reservoir of the virus in the L.A. outbreak, Marissa had hopes that by following the same procedure with Dr. Zabriski she might find some common element in addition to both doctors having been to the same eye conference in San Diego.

  It was after twelve when Dubchek, Vreeland and Layne arrived. Marissa was relieved to see them, particularly because Dr. Zabriski’s clinical condition had continued to deteriorate. The doctor taking care of him had demanded some routine blood work be done to determine the state of the patient’s hydration, and Marissa had been caught between the conflicting demands of treating the patient and protecting the hospital. She finally allowed those tests that could be done in the patient’s room.

  After a cursory greeting, the CDC doctors all but ignored Marissa as they struggled to get the mobile isolation laboratory functioning and improve the isolation of the patients. Dr. Layne had some large exhaust fans brought in, while Dr. Vreeland immediately went down to the administration area to discuss improving the quarantine.

  Marissa went back to her charts but soon exhausted the information they could supply. Getting up, she wandered to the isolation lab. Dubchek had removed his jacket and had rolled up his sleeves while he labored with the two CDC technicians. Some kind of electrical bug had developed in the automatic chemistry portion of the apparatus.

  “Anything I can do?” called Marissa.

  “Not that I can think of,” said Dubchek without looking up. He immediately began conversing with one of the technicians, suggesting they change the sensing electrodes.

  “I would like a minute to go over my findings with you,” called Marissa, eager to discuss the fact that Dr. Zabriski had attended the same San Diego medical meeting as Dr. Richter had.

  “It will have to wait,” said Dubchek coolly. “Getting this lab functioning takes precedence over epidemiologic theories.”

  Going back to the nurses’ station, Marissa seethed. She did not expect or deserve Dubchek’s sarcasm. If he’d wanted to minimize her contribution, he had succeeded. Sitting down at the desk, Marissa considered her options. She could stay, hoping he might allow her ten minutes, at his convenience, or she could go and get some sleep. Sleep won out. She put her papers in her briefcase and went down to the first floor to rescue her suitcase.

  The operator woke Marissa at seven o’clock. As she showered and dressed, she realized that her anger toward Dubchek had dissipated. After all, he was under a lot of stress. If Ebola raged out of control, it was his neck on the line, not hers.

  When she arrived back at the isolation ward, one of the CDC lab techs told her that Dubchek had gone back to the hotel at 5:00 A.M. He didn’t know where either Vreeland or Layne was.

  At the nurses’ station things were a bit chaotic. Five more patients had been admitted during the night with a presumptive diagnosis of Ebola Hemorrhagic Fever. Marissa collected the charts, but as she stacked them in order, she realized that Zabriski’s was missing. She asked the day nurse where it was.

  “Dr. Zabriski died just after four this morning.”

  Although she’d expected it, Marissa was still upset. Unconsciously, she had been hoping for a miracle. She sat down and put her face in her hands. After a moment she forced herself to go over the new charts. It was easier to keep busy. Without meaning to, she caught herself touching her neck for swelling. There was an area of tenderness. Could it be a swollen lymph node?

  She was pleased to be interrupted by Dr. Layne, the Director of the CDC’s Hospital Infectious Disease Program. It was obvious from the dark circles under his eyes, his drawn face and the stubble on his chin that he had pulled an “all-nighter.” She smiled, liking his slightly heavyset, rumpled looks. He reminded her of a retired football player. He sat down wearily, massaging his temples.

  “Looks like this is g
oing to be just as bad as L.A.,” he said. “We have another patient on the way up and another in the ER.”

  “I’ve just started looking at the new charts,” said Marissa, suddenly feeling guilty for having left the night before.

  “Well, I can tell you one thing,” said Dr. Layne. “All the new patients seem to have gotten their disease from the hospital. That’s what bothers me so much.”

  “Are they all patients of Dr. Zabriski’s?” asked Marissa.

  “Those are,” said Dr. Layne, pointing at the charts in front of Marissa. “They all saw Zabriski recently. He apparently inoculated them during his examinations. The new cases are both Dr. Cester’s patients. He’d been the anesthesiologist when they had surgery during the last ten days.”

  “What about Dr. Cester?” asked Marissa. “Do you think that he contracted the disease the same way that Dr. Zabriski did?”

  Dr. Layne shook his head. “Nope. I talked at length with the man, and I found out that he and Zabriski were tennis partners.”

  Marissa nodded. “But would such contact count?”

  “About three days before Dr. Zabriski became ill, Dr. Cester borrowed his towel between sets. I think that’s what did it. Transmission seems to depend on actual contact with body fluids. I think Zabriski is another index case, just like Dr. Richter.”

  Marissa felt stupid. She had stopped questioning Dr. Cester just one question short of learning a crucial fact. She hoped that she wouldn’t make the same mistake again.

  “If we only knew how the Ebola got into the hospital in the first place,” said Dr. Layne rhetorically.

  Dubchek, looking tired but clean-shaven and as carefully dressed as always, arrived at the nurses’ station. Marissa was surprised to see him. If he’d left at five, he’d hardly had time to shower and change, much less get any sleep.

  Before Dubchek could get involved in a conversation with Layne, Marissa quickly told both doctors that Zabriski had attended the same San Diego medical conference as Richter had and that they had stayed in the same hotel.