by Robin Cook
“I could say the same,” Jack said.
“Have you ever been married?” Terese said. “That is, if you don’t mind me asking.”
“Yes, I was married,” Jack said.
“But it didn’t work out?” Terese said leadingly.
“There was a problem,” Jack admitted. “But I don’t really care to talk about it. How about you? Were you ever married?”
“Yes, I was,” Terese said. She sighed and looked out her window. “But I don’t like talking about it either.”
“Now we have two things we agree on,” Jack said. “We both feel the same about nightclubs and talking about our former marriages.”
Jack had given directions to be dropped off at the Thirtieth Street entrance of the medical examiner’s office. He was glad to see that both mortuary vans were gone. He thought their absence was a sign that there wouldn’t be any fresh corpses lying around on gurneys. Although Terese had insisted on the visit, he was afraid of offending her sensibilities unnecessarily.
Terese said nothing as Jack led her past the banks of refrigerated compartments. It wasn’t until she saw all the simple pine coffins that she spoke. She asked why they were there.
“They’re for the unclaimed and unidentified dead,” Jack said. “They are buried at city expense.”
“Does that happen often?” Terese asked.
“All the time,” Jack said.
Jack took her back to the area of the autopsy room. He opened the door to the washroom. Terese leaned in but didn’t enter. The autopsy room was visible through a windowed door. The stainless-steel dissecting tables glistened ominously in the half-light.
“I expected this place to be more modern,” she said. She was hugging herself to keep from touching anything.
“At one time it was,” Jack said. “It was supposed to have been renovated, but it didn’t happen. Unfortunately the city is always in some kind of budgetary crisis, and few politicians balk at pulling money away from here. Adequate funding for normal operating expenses is hard to come by, much less money to update the facility. On the other hand we do have a new, state-of-the-art DNA lab.”
“Where’s your office?” Terese asked.
“Up on the fifth floor,” Jack said.
“Can I see it?” she asked.
“Why not?” Jack said. “We’ve come this far.”
They walked back past the mortuary office and waited for the elevator.
“This place is a little hard to take, isn’t it?” Jack said.
“It has its gruesome side,” Terese admitted.
“We who work here often forget the effect it has on laypeople,” Jack said, though he was impressed with the degree of equanimity Terese had demonstrated.
The elevator arrived and they got on. Jack pressed the fifth floor, and they started up.
“How did you ever decide on this kind of career?” Terese asked. “Did you know back in medical school?”
“Heavens, no,” Jack said. “I wanted something clean, technically demanding, emotionally fulfilling, and lucrative. I became an ophthalmologist.”
“What happened?” Terese asked.
“My practice got taken over by AmeriCare,” Jack said. “Since I didn’t want to work for them or any similar corporation, I retrained. It’s the buzzword these days for superfluous medical specialists.”
“Was it difficult?” Terese asked.
Jack didn’t answer immediately. The elevator arrived on the fifth floor and the doors opened.
“It was very difficult,” Jack said as he started down the hall. “Mostly because it was so lonely.”
Terese hazarded a glance in Jack’s direction. She’d not expected him to be the type to complain of loneliness. She’d assumed he was a loner by choice. While she was looking, Jack furtively wiped the corner of an eye with his knuckle. Could there have been a tear? Terese was mystified.
“Here we are,” Jack announced. He opened his office door with his key and flipped on the light.
The interior was worse than Terese had expected. It was tiny and narrow. The furniture was gray metal and old, and the walls were in need of paint. There was a single, filthy window positioned high on the wall.
“Two desks?” Terese questioned.
“Chet and I share this space,” Jack explained.
“Which desk is yours?”
“The messy one,” Jack said. “This plague episode has put me further behind than ususal. I’m generally behind because I’m rather compulsive about my reports.”
“Dr. Stapleton!” a voice called out.
It was Janice Jaeger, the PA investigator.
“Security told me you were here when I just came through the receiving bay,” she said after being introduced to Terese. “I’ve been trying to reach you at home.”
“What’s the problem?” Jack asked.
“The reference lab called this evening,” Janice said. “They ran the fluorescein antibody on Susanne Hard’s lung tissue as you requested. It was positive for tularemia.”
“Are you kidding?” Jack took the paper from Janice and stared at it with disbelief.
“What’s tularemia?” Terese asked.
“It’s another infectious disease,” Jack said. “It’s similar in some ways to plague.”
“Where was this patient?” Terese asked, although she suspected the answer.
“Also at the General,” Jack said. He shook his head. “I truly can’t believe it. This is extraordinary!”
“I’ve got to get back to work,” Janice said. “If you need me to do anything just let me know.”
“I’m sorry,” Jack said. “I didn’t mean to have you stand here. Thanks for getting this to me.”
“No problem,” Janice said. She waved and headed back to the elevators.
“Is tularemia as bad as plague?” Terese asked.
“It’s hard to make comparisons,” Jack said. “But it’s bad, particularly the pneumonic form, which is highly contagious. If Susanne Hard were still here she could tell us exactly how bad it is.”
“Why are you so surprised?” Terese asked. “Is it as rare as plague?”
“Probably not,” Jack said. “It’s seen in a wider area in the U.S. than plague, particularly in southern states like Arkansas. But like plague it’s not seen much in the winter, at least not up here in the north. Here it’s a late-spring and summer problem, if it exists at all. It needs a vector, just like plague. Instead of the rat flea it’s usually spread by ticks and deerflies.”
“Any tick or deerfly?” Terese asked. Her parents had a cabin up in the Catskills where she liked to go in the summer. It was isolated and surrounded by forest and fields. There were plenty of ticks and deerflies.
“The reservoir for the bacteria is small mammals like rodents and especially rabbits,” Jack said. He started to elaborate but quickly stopped. He’d suddenly recalled that afternoon’s conversation with Susanne’s husband, Maurice. Jack remembered being told that Susanne liked to go to Connecticut, walk in the woods, and feed wild rabbits!
“Maybe it was the rabbits,” Jack mumbled.
“What are you talking about?” Terese asked.
Jack apologized for thinking out loud. Shaking himself out of a momentary daze, he motioned for Terese to follow him into his office and to take Chet’s chair. He described his phone conversation with Susanne’s husband and explained about the importance of wild rabbits in relation to tularemia.
“Sounds incriminating to me,” Terese said.
“The only problem is that her exposure to the Connecticut rabbits was almost two weeks ago,” Jack mused. He drummed his fingers on his telephone receiver. “That’s a long incubation period, especially for the pneumonic form. Of course, if she didn’t catch it in Connecticut, then she had to catch it here in the city, possibly at the General. Of course, nosocomial tularemia doesn’t make any more sense than nosocomial plague.”
“One way or the other the public has to know about this,” Terese said. She nodde
d toward his hand on the phone. “I hope you are calling the media as well as the hospital.”
“Neither,” Jack said. He glanced at his watch. It was still before midnight. He picked up the phone and dialed. “I’m calling my immediate boss. The politics of all this are his bailiwick.”
Calvin picked up on the first ring but mumbled as if he’d been asleep. Jack cheerfully identified himself.
“This better be important,” Calvin growled.
“It is to me,” Jack said. “I wanted you to be first to know you owe me another ten dollars.”
“Get outta here,” Calvin boomed. The grogginess had disappeared from his voice. “I hope to God this isn’t some kind of sick joke.”
“No joke,” Jack assured him. “The lab just reported it in tonight. The Manhattan General had a case of tularemia in addition to its two cases of plague. I’m as surprised as anyone.”
“The lab called you directly?” Calvin said.
“Nope,” Jack said. “One of the PAs just gave it to me.”
“Are you in the office?” Calvin asked.
“Sure am,” Jack said. “Working my fingers to the bone.”
“Tularemia?” Calvin questioned. “I’d better read up on it. I don’t think I’ve ever seen a case.”
“I read up on it just this afternoon,” Jack admitted.
“Make sure there are no leaks from our office,” Calvin said. “I won’t call Bingham tonight, because there’s nothing to be done at the moment. I’ll let him know first thing in the morning, and he can call the commissioner, and she can call the Board of Health.”
“Okay,” Jack said.
“So you are going to keep it a secret,” Terese said angrily as Jack hung up the receiver.
“It’s not my doing,” Jack said.
“Yeah, I know,” Terese said sarcastically. “It’s not your job.”
“I already got myself in trouble over the plague episode for calling the commissioner on my own,” Jack said. “I don’t see any benefit by doing it again. Word will be out in the morning through the proper channels.”
“What about people over at the General who are suspected of having plague?” Terese questioned. “They might have this new disease. I think you should let everyone know tonight.”
“That’s a good point,” Jack said. “But it doesn’t really matter. The treatment for tularemia is the same as the treatment for plague. We’ll wait until morning. Besides, it’s only a few hours away.”
“What if I alerted the press?” Terese asked.
“I’ll have to ask you not to do that,” Jack said. “You heard what my boss said. If it were investigated, the source would come back to me.”
“You don’t like advertising in medicine and I don’t like politics in medicine,” Terese said.
“Amen,” Jack said.
16
FRIDAY, 6:30 A.M., MARCH 22, 1996
Despite having gone to bed much later than usual for the second night in a row, Jack was wide awake at five-thirty Friday morning. He began mulling over the irony of a case of tularemia appearing in the middle of a plague outbreak. It was a curious coincidence, especially since he’d made the diagnosis. It was a feat certainly worth the ten dollars and twenty-five cents that he stood to win from Calvin and Laurie.
With his mind churning, Jack recognized the futility of trying to go back to sleep. Consequently he got up, ate breakfast, and was on his bike before six. With less traffic than usual, he got to work in record time.
The first thing Jack did was to visit the ID room to look for Laurie and Vinnie. Both had yet to arrive. Passing back through communications, he knocked on Janice’s door. She appeared even more beleaguered than usual.
“What a night,” she said.
“Busy?” Jack asked.
“That’s an understatement,” she said. “Especially with these added infectious cases. What’s going on over there at the General?”
“How many today?” Jack asked.
“Three,” Janice said. “And not one of them tested positive for plague even though that’s their presumed diagnosis. Also, all three were fulminant cases. The people all died within twelve or so hours after their first symptoms. It’s very scary.”
“All of these recent infectious cases have been fulminant,” Jack commented.
“Do you think these three new ones are tularemia?” Janice asked.
“There’s a good chance,” Jack said. “Especially if they tested negative for plague as you say. You didn’t mention Susanne’s diagnosis to anyone, did you?”
“I had to bite my tongue, but I didn’t,” Janice said. “I’d learned in the past by sore experience that my role is to gather information, not give it out.”
“I had to learn the same lesson,” Jack said. “Are you finished with these three folders?”
“They’re all yours,” Janice said.
Jack carried the folders back to the ID room. Since Vinnie had not arrived Jack made the coffee in the communal pot. Mug in hand, he sat down and began going through the material.
Almost immediately he stumbled onto something curious. The first case was a forty-two-year-old woman by the name of Maria Lopez. What was surprising was that she worked in central supply of the Manhattan General Hospital! Not only that, but she had worked on the same shift as Katherine Mueller!
Jack closed his eyes and tried to think of how two people from central supply could possibly have come down with two different fatal infectious diseases. As far as he was concerned, it could not be a coincidence. He was convinced their illnesses had to be work-related. The question was how?
In his mind’s eye, Jack revisited central supply. He could picture the shelving and the aisles, even the outfits the employees wore. But nothing came to mind as a way for the employees to come in contact with contagious bacteria. Central supply had nothing to do with the disposal of hospital waste or even soiled linen, and as the supervisor had mentioned, workers there had little or no contact with patients.
Jack read the rest of Janice’s investigative report. As she’d done with the cases since Nodelman, she included information about pets, travel, and visitors. For Maria Lopez, none of the three seemed a factor.
Jack opened the second folder. The patient’s name was Joy Hester. In this case Jack felt there was little mystery. She’d been an OB-GYN nurse and had had significant exposure to Susanne Hard just prior to and after the onset of Susanne’s symptoms. The only thing that bothered Jack was recalling that he’d read that person-to-person transmission of tularemia rarely occurred.
The third case was Donald Lagenthorpe, a thirty-eight-year-old petroleum engineer who’d been admitted to the hospital the previous morning. He’d come in through the ER with a refractory bout of asthma. He’d been treated with IV steroids and bronchodilators as well as humidified air and bed rest. According to Janice’s notes, he’d shown steady improvement and had even been campaigning to be released, when he’d had the sudden onset of a severe frontal headache.
The headache had started in the late afternoon and was followed by shaking chills and fever. There was also an increase in cough and exacerbation of his asthmatic symptoms despite the continued treatment. At that point he was diagnosed to have pneumonia, which was confirmed by X ray. Curiously enough, however, a gram stain of his sputum was negative for bacteria.
Myalgia also had become prominent. Sudden abdominal pain and deep tenderness had suggested a possible appendicitis. At seven-thirty in the evening Lagenthorpe had undergone an appendectomy, but the appendix proved to be normal. After the surgery his situation became progressively grave with apparent multisystem failure. His blood pressure dropped and became unresponsive to treatment. Urine output became negligible.
Reading on in Janice’s report, Jack learned that the patient had visited isolated oil rigs in Texas the previous week and had literally been tramping around in desert conditions. Jack also learned that Mr. Lagenthorpe’s girlfriend had recently obtained a pet Burmese cat. But he’
d not been exposed to any visitors from exotic places.
“Wow! You’re here early!” Laurie Montgomery exclaimed.
Jack was shocked out of his concentration in time to see Laurie sweep into the ID room and drape her coat over the desk she used for her early-morning duties. It was the last day of her current rotation as supervisor in charge of determining which of the previous night’s cases should be autopsied and who would do them. It was a thankless task that none of the board-certified doctors enjoyed.
“I’ve got some bad news for you,” Jack said.
Laurie paused on her way into communications; a shadow passed over her usually bright, honey-complected face.
Jack laughed. “Hey, relax,” he said. “It’s not that bad. It’s just that you owe me a quarter.”
“Are you serious?” she asked. “The Hard case was tularemia?”
“The lab reported a positive fluorescein antibody last night,” Jack said. “I think it’s a firm diagnosis.”
“It’s a good thing I didn’t bet any more than a quarter,” Laurie said. “You are amassing some impressive statistics in the infectious arena. What’s your secret?”
“Beginner’s luck,” Jack said. “By the way, I have three of last night’s cases here. They’re all infectious and all from the General. I’d like to do at least two of them.”
“I can’t think of any reason why not,” Laurie said. “But let me run over to communications and get the rest.”
The moment Laurie left, Vinnie made his appearance. His face was a pasty color and his heavily lidded eyes were red. From Jack’s perspective he appeared as if he belonged in one of the coolers downstairs.
“You look like death warmed over,” Jack said.
“Hangover,” Vinnie remarked. “I went to a buddy’s bachelor party. We all got whacked.”
Vinnie tossed his newspaper on a desk and went over to the cupboard where the coffee was stored.
“In case you haven’t noticed,” Jack said, “the coffee is already made.”
Vinnie had to stare at the coffee machine with its full pot for several beats until his tired mind comprehended that his current efforts were superfluous.
