by Robin Cook
“They were being monitored extremely closely. Each had his own nurse.”
“Closely? How did it happen that a medical student had to pick up on the signs of developing peritonitis?”
“That was a fluke. It would have been picked up very quickly. Trust me. Now, is there anything else I can help you with, any other hospital policy you might want to critique for me?”
Springer’s sarcasm was lost on Pia.
“This case confuses me,” Pia continued. “In fact, it’s one of the worst cases of salmonella or typhoid that I’ve ever come across.”
“In your vastly broad experience,” Springer said.
“In my experience, yes.”
“Well, what are you alluding to? I’m sure you’re alluding to something. So enlighten me, please.”
“One of the first things they told us when we got here was about diagnosis. ‘When you hear galloping hoofbeats, you should think of horses, not zebras.’ ”
“Yes, of course, it’s the oldest saw in medicine. What about it?”
“Should we be looking for zebras here, Dr. Springer?”
“We are not looking for anything here, Ms. Grazdani. But I am dying to know what it is that you are looking for. So enlighten me again.”
“Okay. Is it possible that this case represents some exotic form of an antibody/antigen reaction the body can have, like a Shwartzman reaction? In which case would it not have made sense to use Decadron or some similar anti-inflammatory agent, something potent, to try to head it off at the pass?”
“If that is your great revelation, well, I’m sorry to say it’s not much of one. Because we used Decadron in the evening when it became clear that the two researchers were approaching extremis. Perhaps you should review the patients’ charts before making accusations like that.”
“Of course. If I had been given access to the charts I wouldn’t have made the mistake. But I’m not making accusations, I just want to get to the truth, Dr. Springer.”
“We all do, Ms. Grazdani.”
Springer was suddenly overcome with fatigue. Talking with Pia Grazdani was frustrating, and he had more people he was going to have to deal with that afternoon who were going to be even more of a burden. There would be the inevitable press and the patients’ families. It was not going to be a good day, since ultimately, it was the patients he cared about.
“Do you think perhaps there could have been yet another bacteria involved besides salmonella, a bacteria or a virus that was being covered or camouflaged by the salmonella? And maybe it was this bacteria that was totally resistant to chloramphenicol and was the real killer?”
There was silence while Springer tried to control his anger. This was simply too much. His eyes drilled into Pia’s while she maintained her composure, waiting for an answer while looking down at her feet. Finally Springer exploded with bottled-up emotion.
“I cannot, for the life of me, imagine a more ridiculous scenario. We made the diagnosis by fulfilling Koch’s hypothesis. The illness was caused by salmonella, whose presence we ascertained in multiple ways, but most convincingly from blood culture. We classified the strain in multiple ways as well, particularly by DNA analysis. The offending organism was, without an ounce of doubt, the alpha strain of salmonella typhi that Rothman himself had had grown in space with the cooperation of NASA. There was no other pathogen, for Christ’s sake. The blood cultures only grew out the salmonella. Nothing else! Nothing at all!”
Undaunted, Pia changed the subject on a dime. “What about the hair loss? Does serious salmonella infection cause hair loss?”
Springer was having difficulty controlling himself, yet the woman seemed completely calm. “The stress of almost any severe illness, particularly one presenting with high fever, can cause hair loss. Anyway, what hair loss are you talking about?”
“I saw hair loss with Rothman before I discovered the rebound tenderness. The resident suggested it could be attributed to the chloramphenicol.”
“That’s not something I am aware of,” he said. And then, suddenly and angrily, “Oh, for God’s sake. You wait here!”
Springer bounded out of his desk chair, pushed past Pia, and disappeared. Pia stood in the room and waited. Within a few minutes, Springer reappeared and sat down, giving Pia a nasty look. Thinking she had probably maximized what she was going to get out of the conversation, Pia eyed the door.
“I told you to wait,” Springer said. “Stay there!” Confused, Pia did as she was told. There was silence except for Springer’s labored breathing. The man’s boiling, she thought. I’m not getting anywhere. Pia eyed the door again.
“Dr. Springer, I sincerely thank you for your time.”
“Stay where you are!” Springer said brusquely.
Pia rolled her eyes, confused. First he can’t wait to get rid of me, now he wants me to stay. . . . Then, bursting through the door came Dr. Helen Bourse, dean of students.
“Ah, Dean Bourse, it’s simply not possible for me to do my job if I am to be hounded by a medical student who thinks she should be running my department. She goes onto the floor and sees patients with no authorization, which I am sure could open us up to all manner of liability issues. She repeatedly questions my medical ability and second-guesses decisions that were made, and now she’s come up with an outlandish suggestion that we might have completely missed another organism which was responsible for Rothman’s and Yamamoto’s untimely deaths. First it was the choice of antibiotic, now it’s a second pathogen. This is outrageous and it has to stop.”
Pia looked at Springer, and she was unable to conceal the contempt she was feeling. He had run off like a coward and got the dean to come tell her off. She glanced at Bourse, who was standing arms akimbo, a hard expression on her face. She was angry and dumbfounded.
“I would like Dr. Springer to understand that I’m not trying to do his job,” Pia said in her defense. “I’m just trying to answer some questions that I would have thought were important ones. My sense here is that something is wrong.”
Neither Springer nor Bourse could believe the gall of the young woman. The question in both of their minds: Who the hell does she think she is? Springer found his voice first.
“Do you see what I’m talking about? This woman is off the wall. I’m going to talk with Groekest about the advisability of rescinding the position she was offered here as a resident/Ph.D. candidate. This is absurd.”
At the mention of the chief of the internal medicine department, Helen Bourse signaled with a snap of her head that Pia should leave Springer’s office. Pia was happy to oblige. Bourse then nodded to Springer to indicate that she had the situation under control. “I’ll get back to you. Sorry about this.” Bourse then followed Pia out of the office and into the hallway. Pia might be temporarily unbalanced, but Springer was a bully, and he’d made his point. Before Pia had a chance to say anything, Bourse lit into her.
“What the hell do you think you’re doing? When we spoke this morning, and I gave you time to get your head together, I don’t believe I said you should go see Dr. Springer and belabor the head of Infectious Diseases about his patients or his diagnosis. Where is your social sense? Good grief, woman! It’s common knowledge that Springer is not a fan of medical students in general, but this episode has pushed him over the edge. I have never heard him as exasperated as he was when he called.”
Pia started to speak, but Bourse wasn’t done with her.
“You’re fast developing a reputation as a troublemaker, Ms. Grazdani, and that will not look good on your résumé if it gets recorded. You are here, essentially, as a guest of the institution, and guests do not behave like this. If they do, they’re usually asked to leave. I gave you a couple of days to get over the tragic death of your mentor and that wasn’t supposed to be time for you to come in here and stir things up again.”
“But don’t you think these questions need to be answered?”
“No, I don’t, not if he doesn’t,” Bourse said, gesturing at the door.
/>
Pia started to speak again, but the dean had had enough. “Have you shown any signs of a fever?”
“No.”
“Then get yourself back to your room. If I hear you’re causing any more trouble over this unfortunate affair, I will think seriously about rescinding your welcome here as a medical student. Which would be something of a tragedy for you, considering you only have a couple of months left before you graduate. And it would be a tragedy for us because we’d be admitting we made a mistake in taking you in the first place. I don’t think Dr. Springer will go to Dr. Groekest on his own, but he might. So be careful, young lady. You are now officially on very thin ice. I must not have made myself clear last time we spoke. Am I making myself clear now?”
“Yes,” said Pia. “Perfectly.”
33.
COLUMBIA UNIVERSITY MEDICAL CENTER
NEW YORK CITY
MARCH 24, 2011, 4:45 P.M.
For Pia, being in trouble was as natural as breathing in and out. She’d spent most of her life under some kind of probationary supervision undertaken by people who didn’t know her, care to know her, or understand her situation. Long ago, Pia had wondered how it was that she was the one who ended up in front of some panel or other. She never instigated the trouble, she was always reacting to someone older and more powerful trying to take advantage. Somehow that fact got lost in the paperwork. More often than not, it was only she who suffered the inquisition and the punishment that followed. For her, injustice belonged with pain on the same one-way street.
By the time she reached age twelve, Pia had simply stopped questioning the way of the world as it concerned her. This was just how it was and how it was going to be. Over the years she’d come to know how the individuals of influence in her life operated. Dr. Springer was a familiar type. He was fiercely protective of his own reputation and would adopt any position that protected him, even at the expense of reason and fact. Quick to take offense, Springer had no backbone. When Pia pushed back and kept pushing, Springer literally ran away. He went and found someone who did have some fortitude—Dr. Bourse—and he hid behind her. Bourse was a different proposition. She wasn’t afraid, Pia could see that, and she wasn’t willing to take the easy way out and simply dispense with the problem—Pia—which she could have done.
Pia had spent the afternoon anxiously mulling over Springer’s behavior. She’d learned nothing. There was also the fact that no one seemed concerned about the medical issues she was raising, which couldn’t help but fan Pia’s semi-paranoid belief that the medical center, and the Infectious Diseases Department in particular, hadn’t looked after Rothman and Yamamoto properly. And how could anyone prove that some medical center personnel had nothing to do with their getting sick in the first place? Pia was starting to consider the idea that some kind of cover-up might be under way, orchestrated by Dr. Springer.
And Rothman was still emotionally in her head. If she hadn’t let him take such an influential role in her life, she wouldn’t have found herself in her current predicament. If you let people into your life, she thought, you were bound to hurt sooner or later.
A knock on her door jolted Pia out of her agitated state. It was George. Who else?
“What happened with Springer? I was so worried I couldn’t concentrate all day.”
“It was a disaster.”
“I’m sorry. I’m also sorry I didn’t offer to go with you, really I am. You shouldn’t have to do this all by yourself.”
“George, stop saying you’re sorry, please! Besides, I never expected you to come with me. In fact, I never gave it a thought. And after what happened, I’m glad you didn’t come. Springer was a lot angrier at me than he was the first time. He went and fetched the dean to tell me to stop interfering. And he threatened to go to Groekest if I didn’t.”
“So, are you going to?”
“Going to what?”
“Stop interfering.”
“How can I? They’re the ones interfering, covering things up, not me. They’re sitting on something, I’m sure of it.”
“If you don’t mind me saying so, that sounds rather paranoid.”
“So be it. And remember, even paranoid people have real enemies.”
“So you got confronted by the dean again?”
“Afraid so.”
“What did she do?”
“Bawled me out big-time. Gave me a lecture about being a troublemaker. Threatened to have me kicked out of school.”
“Shit!” George commented.
Pia checked her watch. “Actually I was just about to go back to Rothman’s lab. I’m just waiting until it’s late enough. I don’t want to run into anyone, especially not the dean.”
“Pia, the last time I looked, the dean isn’t working security. They have a whole staff for that, and they caught us in about five minutes the last time we went to the lab. Bourse made it pretty clear you’re not supposed to go back to the lab. Now she’s spoken to you a second time. Maybe they’re right. You are crazy.”
“I think I have an aptitude for science, George. There are facts here, evidence that doesn’t add up. No scientist is going to just walk away from that.”
“Then tell me this: What are you going to do when you get kicked out of this place? That would make you an ex-scientist. Or not even. More like an ex-almost-qualified scientist. I don’t think there’s a great deal of demand for them in the job market today. You’re going to graduate in a couple of months, if you’re lucky. Yes, Rothman’s death is a bad experience, a terrible one, but you might be compounding it and throwing away a career before it’s even started.”
“Career? Right now I don’t see that I have a career. And I couldn’t live with myself if I gave up now. Do you know if Rothman’s lab is still officially closed?”
“How would I know? Well, I do know it’s closed to you.”
“The epidemiologists must be done by now,” Pia said, ignoring George’s point. “If they’re not still checking the place out, there’s no reason I can’t go. I do have stuff I left in there. The dean was upset that we went in when it was still officially closed. If it’s still officially closed, I won’t go in, I promise, but if it’s not off-limits, I will. At the very least I need to check the contents of that storage freezer in the level-three biosafety unit, which we didn’t get a chance to do last night, remember? I’m one of the few people who knows the code that Spaulding uses in the logbook for the storage freezer. I want to be sure that all the samples that should be in the freezer are in the right place.”
“Who’s Spaulding?”
“The head lab technician. Rothman and Spaulding used to argue about the state of the storage freezer. Rothman thought the freezer was a mess, Spaulding disagreed. Rothman was thinking of sacking him. But that wasn’t unusual—everyone thought they were about to get fired. Spaulding was the only one who pushed back.”
“This is all very interesting and maybe you might find something is amiss in the storage facility. But even if you did, then what? Remember, it’s not Rothman’s lab anymore. All that is history. Unfortunately. And you’re going to be history if you keep doing what you’re doing. And are you really suggesting that the senior lab tech might have had something to do with Rothman’s death? That’s crazy.”
“Actually, I don’t know what I’m thinking. I do have some wild ideas, like these two scientists plotted together to carry off a dual suicide.”
George looked at Pia with consternation.
“I’m kidding. I’m kidding. But there are so many things bouncing around inside my head right now, so many theories, and I can’t rule anything out. Maybe it’s something someone didn’t do rather than what they did do—what do they call that? A sin of omission, not commission. The only thing I know is that something about this whole situation is not right.”
“Of course the whole situation isn’t right, Pia—two people died. That can never be right. But it doesn’t mean there can’t be a simple and logical explanation for why it happened.”
“I don’t want to think Rothman had anything to do with his own illness. But I’d like to be sure. If he did, it will mean that he let me down. In a real way, he betrayed me. Rothman was very important to me, and it’s hard for me to admit that anyone has such an influence on my life. Now he’s gone, I feel like I’m starting at square one. And I don’t want it to be his fault.”
George nodded, but he was having a very hard time understanding Pia’s reasoning. Even if Rothman accidentally infected himself, why would that mean she should think less of him, that he “betrayed” her?
“It was Rothman’s idea to start the research track of my training, and it was going to be under his direction. Who’s going to do that for me now? I was going to be working in his lab for my Ph.D. Where am I going to go now? Once again I’ve been abandoned.”
George was a little taken aback at what sounded like self-centeredness in the face of Rothman’s and Yamamoto’s deaths. “I’m sure the university will find you another lab,” he said. “They found you another rotation. Will and Lesley are already doing theirs.”
“Maybe they’ll find me one, maybe they won’t.”
George hesitated for a moment. He knew there was a risk Pia would take what he was about to say the wrong way. But he decided to say it anyway. “Pia, I’m sorry, but I don’t understand how Rothman could have ‘betrayed’ you, as you put it. He got sick and died. It’s tough for me to understand you sometimes. I don’t think you should insert yourself into this where you don’t have to. If you’re now thinking Rothman’s death wasn’t an accident and that there’s a cover-up going on, I don’t see any other way for this to end but badly.”
