Critical

by Robin Cook

  Laurie left the forensic investigator’s office and went to the stairs, avoiding the back elevator. She’d started the day with a selfish desire to talk Jack out of his imminent surgery. Now she was worried about his well-being, maybe even his life. Among herself, Besserman, and Southgate, there were seven cases of fatal MRSA necrotizing pneumonia within three months at three hospitals, one of which Jack was scheduled to enter, and all run by the same company. And worse yet, these cases were occurring despite what Besserman had described as aggressive infection-control measures. Although Laurie was the first to admit that she didn’t know too much about epidemiology, she knew enough to wonder if there might be a lethal, unknowing MRSA carrier, like a kind of Typhoid Mary, in the Angels Healthcare organization who was inadvertently spreading MRSA as he or she went from hospital to hospital in the course of his or her job. Laurie wanted a lot of information, and as stubborn as Jack was, she wanted it fast if she hoped to influence his mind-set.

  The next stop was microbiology, which was part of the laboratory complex on the fourth floor. Laurie found the taciturn, sinewy microbiologist Agnes Finn in her small, windowless office. Of all the employees of the OCME, Agnes’s appearance was the most stereotypic for working in a morgue from central casting’s point of view. Her grayish-yellow coloring contributed; it was as if she never saw the light of day. Yet, of all the supervisors, Laurie found Agnes to be the most helpful by far, always willing to go out of her way. It was as if she had no life outside the OCME.

  Laurie sat down and explained the situation, which elicited from Agnes a mini-lecture on MRSA, including everything Besserman had to say and then some. She explained in detail how staphylococcus was such a pluripotent microbe, and perhaps the most adaptive and successful human pathogen.

  “When you think about it from the bacteria’s point of view,” Agnes said, “it is truly a superbug, capable of killing someone in a frightfully short time while the same strain is able to merely colonize an individual, usually just within the nares. This is a convenient location for the bacteria, because every time the carrier puts his or her finger in their nose, their fingers are contaminated from where it can be spread to the next person.”

  “Is there an estimate as to how many people are so colonized?”

  “Absolutely. At any given time, a third of the world’s population carries staph; that’s about two billion people.”

  “Good Lord,” Laurie said. “Are there many strains of MRSA besides the hospital-acquired and the community-acquired?”

  “Very many,” Agnes said. “And they are evolving all the time in people’s noses and elsewhere, like moist skin surfaces, where they exchange genetic material.”

  “How are the strains differentiated in the laboratory?”

  “Many ways,” Agnes said. “Antibiotic resistance is one.”

  “But that’s not particularly sensitive, considering everything you’ve said.”

  “That’s correct. The more sensitive methods are all genetics-based: the simplest and most commonly employed being pulse-field gel electrophoresis, and the most complete being full genotyping. In between, there are a number of other sequence typing techniques all based on PCR.”

  “What can you do here in microbiology?”

  “Only the simplest: antibiotic resistance.”

  “If needed, where can the more complicated be done?”

  “The state reference lab can do the pulse-field gel electrophoresis. As for more specific typing, the CDC is the best bet. They are actually building a national library of MRSA strains, so they can give you a lot of information. They encourage submissions of isolates, and they can do it all. Of course Dr. Lynch in our DNA lab over in the new high-rise can do the various genetic typing, but we won’t be able to tell you much about the specific strain.”

  “Which of the genetic tests is the fastest? I’m up against a time constraint.”

  “Truthfully, I don’t know. What I do know is that our standard culture and antibiotic sensitives take twenty-four to forty-eight hours. Hospitals can do it much faster using monoclonal anti-body–based methods. Interesting enough, such machines came out of work for NASA.”

  Laurie shook her head. She was humbled. “Before today I thought I knew a reasonable amount about staph. But I was sorely mistaken.”

  “We all have to keep learning,” Agnes said philosophically. “What do you want to do about these specimens you’ve brought in?”

  “I’ll take one over to Ted Lynch in the DNA lab. I’d like one for you to culture, and the rest can go to the reference lab. I’m also going to want to get some frozen samples from some of Dr. Besserman’s and Dr. Southgate’s cases to compare. I’d like to know if they are from the same strain. I’m concerned about an unsuspecting carrier, particularly after what you’ve told me.”

  “Let me know the cases you are interested in. I’ll try to expedite the process. As for Ted Lynch, you’ll have to leave it to me to provide him with a pure culture for his DNA analysis.”

  With her head in whirl, Laurie hurried out of the lab and headed toward the faster front elevator. As she hit the up button repeatedly, in vain hope of speeding up the elevator’s arrival, she tried to plot the course of the rest of her morning. The first stop was going to be Maureen O’Connor in the histology lab, where Laurie intended to beg for David Jeffries’s lung sections to be processed into slides as quickly as possible; Laurie didn’t care about the rest of the slides at the moment, just the lung, since she had in mind to make some large photomicrographs if the pathology appeared as bad as she fully expected it would. She thought they would make terrific PowerPoints for the argument she intended to wage against Jack to get him to cancel his ACL repair.

  Laurie boarded the elevator and pushed the button for the fifth floor. She looked at her watch. It was close to ten. Exiting, she literally ran down the hall into histology and arrived mildly out of breath.

  “Uh-oh! Ladies,” Maureen scoffed in her heavy brogue, “I seem to sense another acute emergency from Miss Montgomery. Errr…that’s Mrs. Montgomery-Stapleton. Who’ll volunteer to tell her this time, her patient is already dead?”

  There was general laughter from the women who worked in histology. Thanks to Maureen’s good humor, it was a happy environment. Even Laurie found herself smiling despite her anxiousness. Like most humor, there was truth in Maureen’s comment. Laurie and Jack were the only pathologists on the ME staff who, on occasion, felt they needed a rapid turnover with their microscope slides. All the others were content to have them in due course.

  Maureen listened to Laurie’s request and explanation, and promised to do them herself. Within minutes, Laurie was back in the hall. She hurried down to Arnold Besserman and Kevin Southgate’s office. As she knocked, the door swung open on its own, and Laurie leaned inside.

  The interior of the office reminded Laurie of the two men’s polar political leanings. As the archconservative, Arnold had a desk that was the picture of neatness, with a single cardboard tray of slides on one side of his microscope and a new yellow legal pad on the other. Both were aligned perfectly parallel to each other along with a precisely sharpened pencil. Southgate’s side of the room was the opposite, with slide trays, unfinished case files, lab reports, and all manner of other documents piled on both his desk and file cabinet, leaving only a small arc of cleared horizontal space directly in front of his chair. A vast clutter of Post-it notes hung from the shade of his desk lamp like so much Spanish moss. It was a wonder to Laurie how the two men got along so well and for so long.

  After leaving a note on the door for either man to call her, Laurie went down the hall, knocking at the other medical examiners’ doors to do a quick survey of their recent MRSA experience. No one was in his office, which was entirely understandable, since the morning was the busy time in the pit, although she’d not seen George Fontworth, Paul Plodget, or his newly hired office mate, Edward Gonzales. Edward was a gifted forensic pathologist who was a product of OCME’s own program and New Yo
rk University.

  Momentarily thwarted in scaring up more MRSA cases at the OCME, Laurie retreated to her own office. Suddenly, remembering Arnold Besserman’s comment about Queens, Brooklyn, and Staten Island, all of which had their own ME offices, she realized her conclusion that there had been no fatal MRSA cases in any of the other city hospitals during the last three months or so was premature.

  With her Rolodex open, Laurie first called Dick Katzenburg, the chief of the Queens office. He’d helped Laurie in the past by coming up with cases that matched the two series of cases she had become deeply involved with. As the call went through, Laurie recalled that both those previous series of hers had surprisingly turned out to be homicides, which no one suspected, even she. The remembrance briefly stimulated the thought that the manner of death of her current series might not be accidental, especially considering that a third of the world’s population was colonized with staph organisms at any given time.

  The Queens ME office answered, and Laurie asked for Dick. While she waited, she tapped her fingers nervously. She hoped he’d be available, which she thought was a reasonable expectation. In his role as chief of the satellite office, administrative duties often kept him at his desk and out of the autopsy room. As the time dragged on, she got out a fresh legal pad, and with the phone in the crook of her neck, she drew multiple vertical parallel lines, creating a checkerboard matrix in which she planned to add information about the MRSA cases as she learned it. With her two previous series, it had been the matrixes that had given her the insight she’d needed. Hoping for a similar outcome, she wrote David Jeffries on the top row, to the left of the indent line.

  Dick came on the line apologetic for keeping her waiting. After a bit of social chatter, Laurie asked if they had seen in the Queens office any MRSA nosocomial infections over the last three or even four months.

  “We have indeed!” Dick said without hesitation. “They weren’t my cases; they were Thomas Asher’s. I remember them because they were fairly ugly.”

  “Meaning?”

  “Necrotizing pneumonia. The victims, who were all healthy people, didn’t have a chance. Their histories reminded me of the stories of the influenza epidemic in 1918.”

  On the spur of the moment, Laurie felt a pang of selfish disappointment. The fact that other hospitals in the city were experiencing the same problem as the Angels Healthcare institutions would undoubtedly dilute the cases’ impact on Jack.

  “Do you know if they occurred at one hospital or at a number of hospitals?” Laurie inquired.

  “Just one. It was an orthopedic hospital. Why do you ask?”

  Laurie sat up straighter in her chair. “What was the name of the hospital?”

  “Angels something. I think Angels Orthopedic Hospital. They were all orthopedic cases.”

  A slight crooked smile turned up the corners of Laurie’s mouth. Instead of losing strength, the potential success of her argument with Jack notched upward.

  “There have been some cases here as well,” Laurie said, “including one I autopsied today. I’m going to look into it, even though I was told the hospital has been aggressively proactive in dealing with the problem.”

  “Let me know if I can help.”

  “Can you give me the names?”

  Laurie could hear the familiar sound of Dick’s keyboard. A minute later, he said, “Philip Moore, Jonathan Knox, and Eileen Dimalanta.”

  Laurie quickly added them to her matrix. “Have all three been signed out?”

  “Yup, so you can access them in the database.”

  “I’d still like to see the case files; hospital records, if you have them; and also a tissue sample, so I can have the strain accurately typed, if it hasn’t already been done.”

  “I’ll bring what I have over for Thursday conference.”

  “I’d prefer you messenger them over today. I’m under a time constraint.”

  “How so?”

  “A personal commitment,” Laurie said, not wishing to elaborate.

  Next, Laurie called Jim Bennett in Brooklyn and Margaret Hauptman in Staten Island. Although Margaret had had no MRSA cases, Jim had had three, like Dick. Two were necrotizing pneumonias like the others and were from the same hospital, but another one was fatal MRSA toxic shock syndrome secondary to a fulminant endophthalmitis, a massive infection inside the victim’s right eye, which had quickly followed a routine cataract extraction. Hanging up the phone, Laurie added Carlos Suarez, Matt Collord, and Kayla Westover to her rapidly growing matrix. Laurie was now convinced that something was wrong—something was very wrong.

  3

  APRIL 3, 2007

  10:20 A.M.

  Rodger Naughton will be with you shortly,” the priggish secretary said. “Would you mind taking a seat?” From Angela’s perspective, the woman seemed more like an automaton than a real person. As many times as Angela had been to Rodger’s office, she expected some small gesture of familiarity rather than cool indifference, and although Angela had anticipated the reception from having experienced it so often in the past, it still added to her discomfort.

  For as long as Angela could remember, she had been an independent person, loath to ask people for favors, always determined to do whatever it was herself. As she grew older, this characteristic extended to asking for money. Yet there she was, sitting in the columned splendor of the Manhattan Bank and Trust with her metaphorical tin cup, forced to beg for a loan.

  The only bright side was that Rodger’s personality was quite the opposite of Miss Darton’s. From their first encounter, Angela had found him to be friendly, helpful, and all around remarkably simpatico. Under different circumstances she would have looked forward to seeing him, but not today. From the moment she’d awakened, through getting Michelle off to school amid the continuing belly-button-piercing debate, through talking with the lead counsel about the previous day’s MRSA death, and through reassuring Cynthia Sarpoulus that no one blamed her for the continuing infection problem, Angela had tried to come up with a strategy to talk Rodger into giving her a sizable personal loan or giving Angels Healthcare a commercial loan.

  Unfortunately, she’d been unsuccessful in coming up with any ideas short of getting down on her knees and begging. As dire as the situation was, she’d do it if she thought it would help.

  “Mr. Naughton will see you now,” Miss Darton said. The only change in her expression was a slight lift to her eyebrows and a flutter of her eyelids.

  Feeling like she was headed to the principal’s office after having been nabbed committing an infraction such as smoking a cigarette in the girls’ room, Angela headed into Rodger’s office.

  “Angela!” Rodger called out with alacrity as he bounded out from behind his desk with his hand outstretched. “So glad to see you. This is a treat. Normally, I have to deal with your CFO, not that I dislike Bob Frampton. He is very much a gentleman, but if I had my druthers, I’d prefer to deal with you directly. Now, don’t you tell him that!” He laughed as he shook Angela’s hand vigorously and guided her toward a seat facing his desk.

  Angela sat and observed Rodger as he returned to his tufted leather high-backed desk chair. He was a handsome, boyish man with a carefully groomed appearance. He had fine, closely trimmed blond hair and pale blue eyes. His position at the bank was one of several healthcare relationship managers. As a business with no discernible ceiling to its growth, healthcare was of great interest to banks in general and to the Manhattan Bank and Trust in particular. When Angela had come to the bank five years previously to arrange for Angels Healthcare’s first construction loan, she had been assigned to Rodger. Over the ensuing years, Rodger had worked with the company as its liaison with the bank, earning considerable money for the bank in the process. During this time, Angels Healthcare had built three multimillion-dollar hospitals, which had been veritable cash cows until the recent MRSA outbreak. It was this reality that Angela planned to emphasize and hopefully exploit.

  “How is your daughter?” Rodger ask
ed with sincerity rather than merely to make conversation.

  “Other than some preteen angst, she’s okay,” Angela said, while her mind struggled with how to begin the quest for yet another loan. “And yours?” She knew Rodger had a girl a year older than Michelle, but that was the extent of her knowledge of the man’s private life.

  “She’s struggling with the same issues. I’m learning that teenage daughters can be a handful.”

  Angela remembered her own teenage struggles all too clearly. It was during that stressful middle-school interval that her problems with her father had come to a head, never to be truly resolved.

  “Angela,” Rodger said. “I’m assuming you are here today about the call I made to Bob, your CFO. I want to reassure you it was pro forma bank policy. The margin on Angels Healthcare loans comes to my attention automatically when it nears a specific point. The problem, of course, is the bridge loan we arranged a little over a month ago, combined with the recent sale of bonds from your company’s management account. It is bank policy that I, as your relationship manager, make the call. Rest assured, I am not calling any of the company’s loans.”

  “I appreciate that,” Angela said, groaning inwardly. His comments, although solicitous in trying to put her at ease, had the opposite effect. Rodger was, in effect, telling her that Angels Healthcare had no more credit. Regardless, Angela cleared her throat and added, “But your call to Bob was not the reason for my visit.”

  “Oh,” Rodger said. He leaned back in his chair. “How can I help you?”

  “I know you are aware of our upcoming IPO,” Angela began. “Its scheduled closing is just a little more than two weeks away, so we are in the quiet period, meaning I cannot divulge any specifics. Let me just say that we have been assured the IPO will be successful.”

  “I’m happy for you,” Rodger said. “An underwriting guarantee! Wow!”

  “Congratulations may be a little premature. The short-term problem which prompted our need for a bridge loan a month ago has cost considerably more to fix than we had predicted. We need another bridge loan, but only for three weeks. The interest doesn’t matter, and we can pay it up front.”