It was the president's turn to speak again. "How should we be preparing to treat all of the people who develop Guillain-Barre syndrome?"
Stoker responded. "First and foremost, we need to figure out how to keep millions of people breathing. We must get our hands on more ventilators. We could go over the approximate numbers with your cabinet members, Mister President, ASAP."
"Is there anything we could do to reduce the severity of the illness so more people can avoid going on ventilators?" the president asked.
"Perhaps a little. If people get an injection of immune globulin early in the treatment, their disease course may be less severe. Patients can also have a plasma exchange. An infusion center removes a patient's blood and separates out some of the offending antibodies."
"The antibodies that attack the neurons," the president said.
"That's correct," Stoker said. "But, those treatments typically only help a little bit. Besides, if there are hundreds of thousands of people battling this disease, we will run out of immune globulin very early. I also doubt our medical system has the capacity to provide plasma exchange to so many people."
The president turned toward the other two physicians in the room. "So, more ventilators. Do you concur Dr. Musgrove And Dr. Rivera?"
Both doctors agreed without adding any additional commentary.
"Dr. Stoker, what are your impressions, as a psychiatrist, of Nikolas Antoniou?"
"They are the same impressions the Iranian intelligence community realized when they identified him in his youth. He's a callous, manipulative psychopath who's extremely intelligent and knows when to take the right risks. He's a ruthlessly brilliant sleeper terrorist. There are still some things bothering me about him, and I can't put my finger on it. He invested Iranian money, through an organization called a bonyad—"
Stoker's and Rivera's phones simultaneously vibrated.
The president held up a hand. "Please answer it. I know you're also concerned about your friend, Z." Even though they were sitting with the president of the United States, cabinet members, and the surgeon general, they both took a moment to glance at their phones. Z was very much on their minds, and they were anxious for an update. The message was from Dr. Hossein, Z's neurosurgeon.
CDC reports infection is apparently caused by very rare amoeba, Balamuthia mandrillaris. Usually 1 or 2 annual cases in the US. Now 60 new cases in last two weeks. Z appears to be #61.
"Mr. President, this changes everything," Stoker said. Suddenly, everything came together in Stoker's mind. "This bio attack just got more complicated, and more lethal."
"What do you mean?" the president asked.
"What I'm about to state is a theory," Stoker said. "But, it all makes sense. Our friend, Z, has just been diagnosed with a rare amoeba infection in his brain, Balamuthia mandrillaris. In the last two weeks, infections from this amoeba have skyrocketed to 61 cases. We usually see one or two cases per year. Two biological attacks are occurring at the same time. This is no coincidence."
The president turned to the secretary of Health and Human Services. "Can you verify those numbers, Secretary Bostock? The CDC is under your purview."
"I'm checking now," he replied.
The president motioned for Stoker to continue.
"Let me tell you the more salient details about Balamuthia mandrillaris. The initial symptoms of Guillain-Barre syndrome and Balamuthia mandrillaris can be very similar. What I'm saying here is the neurologic signs may overlap, in the initial stages, of both diseases. And this is very concerning to me. Wouldn't it be possible, if someone were to manufacture a very nasty Campylobacter jejuni, one who's virulence could be increased greatly, let's say a thousand-fold, we would see resultant Guillain-Barre syndrome with very heightened numbers, as we did in Mexico? Now, if one could take time, and know how to grow this amoeba, which we know as Balamuthia mandrillaris, which is very rare, and infect people in a very similar way, it could potentially cause chaos among physicians and medical professionals in figuring out the diagnosis between the two. How clever would it be to try to confuse us by these initial symptoms in which one organism could kill quickly, while the other is very survivable if a person is treated properly?"
The Health and Human Services secretary chimed in. "First of all, I've verified the amoeba figures. There are now sixty-two confirmed cases in the last two weeks—another was just reported. And, just like Dr. Stoker said, this organism commonly only infects one or two Americans per year. Until now, it's been extremely rare. And, let's not fail to overlook one crucial fact. It's lethal in more than ninety-five percent of cases. My people also assert it is much too early to report this or act on this Balamuthia data. But, I've just told my people to go jump. I recommend we not wait around for the statisticians to sharpen their pencils. Common sense must prevail here."
President Riddell held up his hand, and everyone went silent for a moment. "Doctors Stoker and Rivera. Nobody sees this more clearly than you two. What do you recommend?"
"Stoker gets it better than anybody," Rivera said. "What should the nation do, Troy?"
"We're under attack from two different pathogens," Stoker said. "The key is helping doctors and healthcare professionals make the right diagnosis as early as possible. We need to release a guideline informing the medical community about their similar symptoms. For example, if a patient exhibits photophobia, or has soreness in their neck, the next step, most likely, would be a CT scan of their brain. Soreness of the neck along with photophobia is much more likely to be the Balamuthia amoeba. And therefore, Guillain-Barre could be ruled out. However, if we had a patient, for example, with a history of diarrhea and slowly progressive weakness—with no neck pain and no photophobia—most likely they would have the beginnings of Guillain-Barre syndrome. That’s what American doctors need to know right now."
"Surgeon General Musgrove," the president said, "let's make a chart to share with doctors and the rest of the medical community. Let's help them get the diagnoses ASAP for proper treatment. This is imperative." Then he nodded toward Stoker prompting him to continue outlining his strategy.
"When it comes to treatment, as most doctors know, this is the easier part. We have protocols in place for each specific diagnosis. For the amoeba, the most important drug is IV miltefosine. It's a drug with FDA orphan drug status, just approved in 2017, that has saved some amoeba victims' lives. Patients should also get I.V. fluconazole, albendazole, and clarithromycin. But, there is a bigger issue here. Most of these Balamuthia mandrillaris patients will also need ventilators. We're in serious trouble."
The surgeon general spoke up. "You know, if that's the case, this two-pathogen attack would be incredibly sinister. And, Dr. Stoker, that would make sense. That's an incredible deductive leap. But, it makes complete sense."
"However, if we need ventilators for Guillain-Barre syndrome patients and Balamuthia patients," Stoker said, "this is going to get ugly. We need to stock up on Ambu bags, devices we use to hand ventilate patients. Friends and family will have to learn how to ventilate victims by hand."
"Dr. Stoker," the president said. "You've given us incredible insight."
"Actually, many doctors I know would arrive at the same conclusion. Rivera and I have merely been in the right place at the right time. It just makes sense."
“The important thing is to get the IV drugs flowing into the amoeba-infected patients," the president said. "We also need to get our hands on more ventilators."
Secretary Bostock from the Department of Health and Human Services chimed in. "Mr. President, miltefosine is an orphan drug. We have a minimal supply of it. We need to manufacture more."
"The military has a small supply," the Secretary of Defense said. He had been quiet up to this point. "We also have the ability to spin up some medical services."
Secretary Danielson from Homeland Security spoke up. "We do not have stockpiles of miltefosine in our Homeland Security warehouses. After this blows over, we'll add them."
The presiden
t spoke up. "Okay, Dr. Stoker has outlined the plan. Now I'm issuing executive orders. We'll distribute the protocol about distinguishing between Guillain-Barre syndrome and the Balamuthia mandrillaris amoeba to health care professionals in the next twenty-four hours. We'll label the protocol version one point zero. And, let people know we'll revise it as we get smarter. Getting out a proper protocol fast is much better than a perfect protocol slow.
"We will direct billions of dollars into increasing our nation's supply of ventilators, Ambu bags, miltefosine, immune globulin, and any other critical drugs. I'll call in favors from other countries to lend us ventilators and other critical pharmaceuticals and supplies. We'll also amp up the capacity of infusion centers so they can do more plasma exchanges. I know you said the immune globulin and plasma exchanges only help a little. But, if they keep a few thousand people off ventilators, the spend will be worth it.
"Finally, I'll address the nation this evening. We're going to mobilize America, do everything we can, and overcome." The president turned to Stoker. "What else do you need from me?"
"Permission to interrogate Nikolas Antoniou even further," Stoker said. "If we're right, and these two pathogens are being used together, Nikolas has committed a huge sin of omission by not telling us."
"Let's think about it," Rivera said. "If he left us in the dark about the Balamuthia mandrillaris, there may be even more assaults we don't know about."
"Use your best judgment as physicians," the president said. "This is war, and we're under serious attack."
"We should also get Nikolas's family out of Saudi Arabia," Stoker said. "They are Americans, being held hostage there. That's just one more piece of leverage we can use to help Nikolas remember things he's been omitting."
"Get with the CIA, Dr. Stoker. Make it happen yesterday. The family may have critical intel," the president said. "And Dr. Stoker, I insist the spooks take you along on the mission. Having a psychiatrist on a hostage rescue will indeed help the victims. I also want to keep you in the center of things, like you have been. But, my motives for sending you go even deeper. We need more men like you, Stoker. While you'll never be in the CIA, building your relationship with the CIA will be very important in the future. I know because of Dr. Rivera's history."
"Yes sir, Mr. President," Stoker said.
"Are you really up to snuff on your training?" the president asked.
"Yes, sir. Thanks to my mentor, Rivera."
"If it weren't for you, Dr. Stoker, we would still be a month away from figuring all of this out."
Stoker's phone vibrated again. The message was from Z.
Using social media, identified three other Burning Man attendees who had brain biopsies and diagnosed with Balamuthia. I think Burning Man was a target.
"Z's been using social media. He's found three more cases from people who attended Burning Man. These are people who've also been positively diagnosed by a brain biopsy."
"Those people are three more reasons to execute our plan within the next few hours," the president said.
The president arose, and everyone else stood out of respect for him. "There's one more thing, Dr. Stoker. You're at the tip of the spear in this war. We want your wife to be secure and well cared for. I also don't want you worrying about her. I insist we transfer her to Bethesda Naval."
"I understand, Sir," Stoker said. "Thank you."
"Let's get Z there, too," the president ordered. "Get Allie and Z on the same transport."
"Yes, Sir!" came the enthusiastic reply from Glenn Brookfield, the Secretary of Defense.
"Thank you, Secretary Brookfield and Secretary Bostock. That will be all." The two men's images disappeared from the screen. The president spoke to Rivera, the Surgeon General, and the secretary of Homeland Security. "Can you please give Stoker and me the room?"
The three quickly complied and left Stoker speaking with the president. The president held out his hand, "May I please enter my contact information into your phone?"
"Of course, Mr. President," Stoker said, as he opened a new contact and handed his phone to the president.
"I'm putting my contact information under the name Ron Reagan. Call or text that number anytime. If I don't answer it, my special assistant or chief of staff will. I've also included my encrypted email address. But, it's almost always best to call me."
"Thank you, sir," Stoker said. "I will reach out if I need your help."
"Perfect," the president said. "Now, I'm going to share something with you. And, I'm going to ask you to read between the lines." The expression on his face turned grave, and he looked Stoker right in the eye. "We should never take the power of the presidential pardon lightly. That being said, if you ever find yourself in the situation where you need to make some tough decisions, always do what you need to do to save lives and defend our country. If you must break the law here and there, remember I'm here. Does that help you with your question about interrogating this Nikolas terrorist?"
"Yes, sir. Thank you, sir," Stoker said.
"I hate people who claim to be a good judge of character," the president said. "I love getting to know people who accomplish amazing things. Last winter, in South Dakota, you did an amazing job of uncovering some deep-seated corruption. In Mexico, you figured out what hostile Shiites were doing there. You followed enemy combatants to Chicago and blew their operations wide open. The game plan you just outlined will save millions of lives and curtail untold hours of misery. Nobody needs to judge your character. Your actions speak louder than words. Thank you, Dr. Stoker. Now go out there and win this war."
• • •
Sixty minutes later, Rivera and Stoker were in grim moods. They did not try to disguise the somber moment, as they sat with Z and Jessica in a hospital room. "Z, the test results from your brain biopsy are back from the CDC," Rivera said.
"And, we're not going to sugar coat this," Stoker chimed in. "You have a dangerous amoeba living in your brain called Balamuthia mandrillaris."
"But the good news," Rivera said, "is the I.V. medications we've been giving you are almost a perfect match for killing off this organism."
"I'm going to be okay?" Z asked.
Rivera hesitated for a moment, so Stoker jumped in. "You're in a fight for your life. We caught this sooner than average, and you've been getting the right drugs. But, this rare amoeba kills more often than not."
"It's a little worse than fifty-fifty?"
Stoker looked Z in the eye. "No, the death rate is quite a bit higher than fifty percent. It's closer to ninety percent."
Z said nothing. He was so stunned he could not speak. He closed his eyes, and his whole body visibly started to shake. Jessica also trembled, but she refused to cry. Z bowed his head for a moment and inhaled a few times deeply, helping the trembling to subside. When Z opened his eyes, they were determined. "I just transformed my fear into a fight. How do we defeat this bug?"
• • •
"Forget something?" Stoker asked. He was sitting across the interrogation table from Nikolas. Agent Ahmadi stood beside Stoker. Rivera looked on from behind the one-way glass from the control room.
"Can you please be a little more specific?" Nikolas asked.
"Sure," Stoker said as he stood and walked out of the interrogation room.
He returned a few seconds later with a test tube full of liquid. The test tube was from Nikolas's lab in the basement of Hotel Esatto. It contained ordinary tap water and nothing else. But Nikolas didn’t know what it held. "Nikolas Antoniou," Stoker said in an exaggerated game show host voice. "It's time to play Name That Pathogen." Stoker walked up to Nikolas, grabbed his shoulders, lifted him up, and pinned his back against the metal desk. Then Stoker climbed on top of him and pinned his knee to Nikolas's chest. He spoke in a low, menacing voice. "Here's your first clue. I have this test tube we found in your lab." Stoker held the test tube above Nikolas and used his thumb to pop the lid off. "Let's pour this in your nose." Stoker put his thumb on Nikolas's nose and shoved his nose upw
ard, and his head followed easily. Terror blazed in Nikolas's eyes as he flailed and protested.
"These little guys inside this liquid will start eating their way along your olfactory nerve pathway until they reach your brain. Then they'll set up shop in there." Stoker held the test tube above Nikolas's nose. "Now, name that pathogen."
"Balamuthia mandrillaris," Nikolas said.
"Winner!" Stoker said. "That's correct!"
Ahmadi took the vial out of Stoker's hand. She held it above Nikolas's nose and started tipping it as if she was going to pour it in a nostril. "I remember what you told us, on the sailboat in the harbor on Lake Michigan. You said you were willing to tell us everything. You purportedly didn't need any encouraging or persuading. You just wanted to tell the truth. At least that's what you claimed. But, omitting facts is just as bad as lying. There were more layers of the onion, but you wanted us to think we had an apple."
"Yes," Nikolas said. The truth was he was holding back. He knew so much more of the bonyad director's plan. "I was telling you the most important information, first."
"You must think we're senseless.” Stoker scoffed. “And, we would be idiots if we bought this crap—your claim you were merely prioritizing. But, because I'm such a Neanderthal, let me put this to you plainly. Tell us everything, all the information, right now! No omissions. If there are any other assaults beyond these two pathogens, tell us. If there are attacks outside of biological warfare, tell us. If there are any other actors—our counterparts—tell us. If there are any other terrorist groups or countries involved, you need to spill it all. We want the whole big picture. Now talk! Because the deal with your family is off until we have the whole story."
"Your greatest threat is the Campylobacter jejuni bacteria. It is the easiest to propagate and spread. We could not make as much of the Balamuthia amoeba, and the amoeba has a lower infection rate. Yes, I did omit that pathogen, but there are no other pathogens I have not already told you about."
"What about non-biological attacks?" Stoker asked. "Do you know of any other attacks or acts of terror or war?"
Silent Strike Page 27
