Critical

by Robin Cook

  “I heard from one of my colleagues the efforts that you have been making. I imagine it must be discouraging, especially since you have apparently had eleven such cases.”

  “Discouraging is not a strong enough word. Did you find out anything at autopsy that might help us? When you called, I was hoping that was going to be the case.”

  “I’m afraid not,” Laurie admitted.

  “Then why did you come over?”

  Laurie squirmed in her chair. Although the tone of the question was far from hostile, Laurie found herself questioning exactly why she was compelled to make the visit, and for a moment felt foolish.

  “I didn’t mean to put you on the spot,” Loraine said, sensing Laurie’s discomfiture.

  “It’s okay,” Laurie said. “After I did the autopsy this morning, I found out essentially by accident about all the other cases occurring over the last three and a half months. I just felt I had to do something. I’m afraid the OCME has let you and the rest of the city down by not being aware of the outbreak. It’s part of our job not to let something like this fall through the cracks.”

  “I appreciate your sense of responsibility, but in this case I don’t think it matters. We certainly have been aware, and believe me, we have done everything possible. And when I say everything, I mean everything, including the hiring of a full-time infection-control professional. And as the chairperson of this hospital’s interdepartmental infection-control committee, I personally jumped on the problem from day one. We’ve had input from everyone, including our medical staff, nursing, engineering, laboratory, you name it. Our committee has met just about every other week since the first MRSA case. We even shut down our ORs for a time and halted all surgery and invasive procedures.”

  “So I heard,” Laurie said. “I don’t have much training in epidemiology, but there are several things about this outbreak that bother me.”

  “Such as?”

  Laurie took a moment to organize her thoughts. She was afraid she might sound naïve, since she truly only had the basics in epidemiology. “For one thing, it has continued despite all your efforts at control; secondly, many of them are, like Jeffries, primary pneumonias, which I believe is unique for staph; third, they have apparently been occurring in only Angels Healthcare facilities. You do know that your sister hospitals are experiencing cases as well?”

  “Of course. I’ve had multiple meetings and frequent communication with my counterparts at our heart hospital and at our cosmetic surgery and eye hospital. I was also the one who strongly encouraged Angels Healthcare’s CEO, Dr. Angela Dawson, to hire the M.D./Ph.D. infection-control professional to coordinate our efforts, specifically because the problem was happening in all three of our institutions.”

  “Is that Dr. Cynthia Sarpoulus?”

  “That’s correct. Why do you ask?”

  “I recall one of my ME colleagues mentioning her name. He spoke to her a month or so ago.”

  “She’s one of the leaders in our specialty, and coauthored a major text on hospital-infection control programs. I was sure that, when I heard she’d been hired, we’d be out of the woods.”

  “But it hasn’t happened.”

  “It hasn’t happened,” Loraine agreed.

  “Well, back to my amateur concerns,” Laurie said.

  “I’d hardly call you an amateur, doctor,” Loraine said with a smile. “Please, continue!”

  “An hour or so earlier, I talked with a doctor at the CDC. She’d had the opportunity to subtype the staph from two of your cases that occurred more than a month ago at different hospitals. Using rather sophisticated genetic typing, they proved to be the same. She promised to confirm that with tests of even higher specificity and get back to me. To my informally trained epidemiological brain and contrary to what she thinks, it suggests to me a carrier is involved: a carrier who visits both hospitals. Do any of the Angels Healthcare personnel regularly visit all your hospitals?”

  “Wow,” Loraine remarked. She laughed in a fashion that indicated she was impressed. “Are you teasing me about not having epidemiologic training?”

  “Just the required exposure for my pathology residency,” Laurie said.

  “We have definitely considered a carrier to be the source of the problem. In fact, so much so that we have repeatedly cultured everyone: medical staff, service personnel, and particularly those individuals who regularly visit all three of our hospitals. One of the ways that our CEO founder conceived of keeping expenses down was to have centralized services like laundry, engineering, laboratory, nursing, and food service. Each service has a department head whose office is at Angels Healthcare’s central office but who travels on a regular schedule to all three hospitals. These people have been tested repeatedly for the exact reason you’ve suggested.”

  “Has anybody tested positive?”

  “Absolutely. About twenty percent positive, which is what one would expect in the normal population. In fact, slightly more on the medical staff. And everybody who tested positive has been treated with mupirocin until they tested negative.”

  “Did any of them test positive for the community-acquired MRSA?”

  “Oh, yeah. Quite a few.”

  “Do you know if the subtype was the same as what killed your patients?”

  “Our subtyping was by a VITEK system and only for antibiotic resistance, and yes, some were the same.”

  “Antibiotic resistance is not particularly sensitive in terms of differentiating substrains.”

  “I’m aware of that, but since we treated anyone positive for staph, we didn’t think it mattered.”

  “Maybe so,” Laurie said. “Did you have any of the isolates typed by the CDC?”

  “No, we didn’t.”

  “Why?”

  “That was a decision made by the home office. I suppose because we were treating everyone who was positive, as I said, so that characterizing it more served no purpose. Also, we were already instituting every known infection-control procedure.”

  “Did you let the CDC know you were experiencing this MRSA outbreak?”

  “We did not.”

  “How about the Joint Commission on Accreditation of Healthcare Organizations? Did you notify them?”

  “No, we didn’t. The JCAHO only needs to be notified if our overall infection rate goes above four percent over our designated surveillance period.”

  “Which is what?”

  Laurie watched Loraine hesitate as if Laurie had asked a state secret. “You don’t have to tell me if you feel uncomfortable,” Laurie added. “I don’t even know why I’m asking.”

  “And I don’t know why I’m hesitating. Anyway, it is a year interval.”

  “But your rate could be above four percent if you considered the last three months.”

  “It’s possible,” Loraine agreed. “But I’ve not stopped to figure it out.”

  “How about the New York City Board of Health?” Laurie asked. “I presume you let them know.”

  “Of course,” Loraine said. “And the city epidemiologist, Dr. Clint Abelard, has made several site visits. He was impressed with everything we were doing and didn’t have any suggestions, which is not surprising, since we had tried everything.”

  “Very interesting,” Laurie commented. She felt better about coming for her visit, since Loraine hadn’t ridiculed her about any of her thoughts. At the same time, she was reluctant to mention any of her more outlandish ideas. “How about a tour. Your hospital is truly elegant, and not like any other I’ve ever seen.”

  “Sure,” Loraine said without hesitation. “We all are quite proud of it, especially since we are all owners.”

  “Really?” Laurie questioned. “How so?”

  “Our CEO, Dr. Dawson, gave all the employees a little stock when we signed on. It’s not much, but there is a certain symbolic value. Actually, that might change for the better in the near future. The company is scheduled to go public in a few weeks. If all goes well, our tiny amounts of stock could actu
ally be worth something.”

  “Well, I’ll say a little prayer for the IPO.”

  “Thanks,” Loraine said. “The rumor is that it is going to do very well.”

  “Can we do the tour now?” Laurie asked.

  “Certainly,” Loraine said. She stood and opened the door leading to the area occupied by the secretaries. Laurie followed.

  “What is it you’d like to see?” Loraine questioned as they left the admin area and emerged into the main lounge. “It’s fancier than other hospitals but otherwise basically the same.”

  “But no emergency room.”

  “Right, no emergency room. We’re a surgical hospital. We don’t want beds taken up with medical patients.”

  “How about an intensive-care unit?”

  “Not an intensive-care unit per se. If that kind of care is needed, we can isolate part of the PACU, or post-anesthesia unit. If the PACU is too full, we send patients to the University Hospital. It saves a lot of money.”

  “I’m sure it does,” Laurie agreed, but the idea of a surgical hospital not having a full-fledged ICU bothered her.

  They paused out in the main lobby area, standing in front of the elevators.

  “I cannot help but notice how quiet it seems to be,” Laurie said. “There are so few people.”

  “That’s because our census is very low, which has been progressive since the MRSA problem began. Of course, the worst was when the ORs were completely shut down. During that period we had the entire hospital staff, including the president, disinfecting everything.”

  “But the ORs are open now?”

  “Yes, they are open now except for the OR where Mr. Jeffries was operated on.”

  “Was he the only case done in the room yesterday?”

  “No, he wasn’t. There were two others after Mr. Jeffries.”

  “And they are well.”

  “Perfectly fine,” Loraine said. “I know what you are thinking. It has us baffled as well.”

  “Since your census is low, does that mean some of your staff doctors are choosing to do their surgery elsewhere?”

  “I’m afraid so.”

  “What about Dr. Wendell Anderson?”

  “He’s one of the brave ones, or should I say loyal. He’s still operating here on a regular basis.”

  Laurie nodded while fantasizing about tying Jack to the bed during his sleep Wednesday night. More than ever, she did not want him to have his operation.

  “What is it you’d like to see?” Loraine repeated.

  “How about starting out with your HVAC system?”

  Loraine did the equivalent of a double take. “Are you joking?”

  “I’m serious,” Laurie said. “Are the operating rooms and the PACU on a separate system from the main part of the hospital?”

  “Absolutely,” Loraine said. “This is a state-of-the-art facility. The HVAC for the operating rooms is designed to change each OR’s air every six minutes. There would be no need to do that for the whole hospital. Even the laboratory area has its own system, although not with that kind of flow.”

  “I’d still like to see it,” Laurie said. “Particularly the OR system.”

  “Well, I don’t see why not.” They boarded a waiting elevator. Loraine pressed the button for the fourth floor. She explained that the second floor was for outpatient services, the third was the OR and PACU as well as central supply, and the fourth was for the laboratory and engineering. Engineering included HVAC and the supply of various gases for the ORs and bedside. All the floors higher than the fourth were for patient rooms. The very top floor was a special VIP section, which had slightly larger rooms and more expensive décor. The service, she insisted, was the same.

  “Are all the Angels Healthcare hospitals similar?” Laurie asked.

  “Essentially identical, as will be the six hospitals slated soon to be constructed: three each in Miami and Los Angeles.”

  “My word,” Laurie said simply. She was impressed with the edifice but bemoaned that its luxury represented the enormous amount of money essentially being stolen on an ongoing basis from full-service hospitals like University or even General, which were already struggling to make ends meet. Angels Healthcare, like other specialty hospitals, was interested only in the paying patients with acute problems, not the uninsured or the chronically ill. Not only that, the fortunes being made by the businessmen owners were also being sucked out of the healthcare system and unavailable for patient care.

  “Here we are,” Loraine said as the elevator door opened. “Engineering is to the left.”

  In contrast to the elegant five-star hotel décor of the lobby, the fourth floor was the epitome of high-tech minimalist design. Everything was gleaming, high-gloss white, and the hallway was spotless. The women’s shoes clicked on the composite flooring, and the sound echoed off the bare walls. There were no pictures, no bulletin boards, only closed white doors. The only color came from city-mandated institutional exit signs with red letters at either end of the lengthy corridor.

  “I think I know why you are interested in seeing our HVAC system,” Loraine said as they walked.

  “Really?” Laurie questioned. She wasn’t entirely sure herself. What she knew of HVAC was the little she’d absorbed while the renovation of her and Jack’s brownstone had been under way.

  “You are thinking of airborne route of infection, which is another suggestion, as far as I am concerned, you are not the epidemiological amateur you profess to be. But let me reassure you, we have considered it also, and we have tested the water in the condensate pans for staph aureus on multiple occasions, including just this morning after yesterday’s tragedy.”

  “Have any of the tests been positive?”

  “No, none!” Loraine said emphatically. “Staph is not considered an airborne pathogen, but that did not stop us from considering it, and even though the tests were negative, we’ve drained all the pans and treated them.”

  “I didn’t think staph was spread by the airborne route, either,” Laurie said. “But the fact that a number of the cases seemed to have been primary pneumonias suggested the route of infection had to be airborne.”

  “I can’t argue with that,” Loraine said, “at least not from an academic perspective, but I can from a practical one. I chair an interdepartmental infection-control committee, which is just as its name suggests: interdepartmental. We have people from all departments, such as nursing, food service, engineering, and so forth. Currently, our representative from the medical staff is a surgeon, and when we were discussing the possibility of the staph being spread via the airborne route and believing the HVAC would be involved, he set us straight on an important fact. Patients undergoing endotracheal or laryngeal-mask-airway anesthesia, which all do in our hospitals when they have general anesthesia, never breathe operating-room air. The air they breathe always comes from the piped-in source.”

  “They never breathe ambient air?” Laurie questioned. There went her only theory as to how the MRSA victims were getting sick.

  “Never!” Loraine confirmed.

  Loraine stopped at one of the closed doors. An eye-level white plaque with incised black letters said: Engineering. “It’s going to be a little loud in here,” she warned.

  Laurie nodded as Loraine pushed open the heavy, insulated door. Once inside, Laurie scanned the large utilitarian high-ceilinged room. The walls and ceiling were concrete. A tangled web of piping, some insulated and some not, snaked out of various multicolored tanks and hung from the ceiling. Much larger ducts did the same after exiting or entering air handlers the size of small cars, each of which was mounted on rubber shocks.

  “Anything in particular you’d like to see?” Loraine shouted.

  “Which handlers service the ORs?” Laurie shouted back.

  Loraine led Laurie down the relatively narrow walkway between the meticulously maintained equipment. Halfway to the opposite wall, Loraine stopped and patted the side of one of the air handlers. “This is the one. The c
oolant comes from the condensers on the roof, and the hot water comes from the furnaces in the basement.”

  “How do you access the condensate pan?”

  “This access door,” Loraine yelled. She grabbed the handle and had to pull hard to break the suction. When the door opened, they heard a whistling noise.

  Laurie stuck her head into the opening and the wind wildly tossed her hair in all different directions. She had to grasp it to keep it out of her face.

  “That’s the condensate pan down there,” Loraine shouted, while pointing over Laurie’s shoulder to the base of the machine’s innards.

  Laurie nodded. She was interested because she knew air-conditioning condensate pans were a frequent source of airborne outbreaks, such as Legionnaires’ disease. She turned her head downstream into the mouth of the efferent duct, where she could see a mesh screen. “Is that a filter?” Laurie yelled.

  “There are two,” Loraine answered. She closed the door to the coils, and it snapped shut. She took several steps forward. There were two vertical slitlike openings. She pointed to the two of them with both index fingers. “The first is a standard filter for relatively large-sized particles. The second is a HEPA filter for particles down to the size of viruses. And to anticipate a question, we have on multiple occasions tested the HEPA filters for staph. Only twice did we get a positive result.”

  “Was it CA-MRSA?” Laurie questioned.

  “It was, but it was not meaningful.”

  “Why?”

  “Because the HEPA filter stopped it.”

  “What’s that access door beyond the HEPA filter?”

  “That’s the clean-out port of the efferent duct. We have all the ducting cleaned once a year.”

  After about six feet, the efferent duct split like the tentacles of a squid into multiple smaller ducts, each going to a separate OR, the PACU, and surgical lounge. Laurie could tell because each was labeled with an incised Formica plaque. Same as the main duct, each had a clean-out port. “When were the ducts cleaned last?”

  “When the ORs were shut down.”