by Robin Cook
Suddenly, Laurie thought of something else she could do to avoid obsessing over what was happening to Jack. She thought of Dr. Collin Wylie in New Zealand and the possibility that he’d gotten the photomicrograph, and the possibility he’d had an opportunity to look at it, and if he had, whether he’d been able to recognize it and respond. There were a lot of ifs, but, undeterred, Laurie went to her e-mail. The main reason she’d not thought about doing so earlier was because the outgoing e-mail had been sent during the night, and she’d forgotten to factor in that New Zealand was on the opposite side of the world, meaning in Auckland it had been morning.
The moment after she’d clicked the appropriate icon and her e-mail opened, she saw it: [email protected]. Eagerly, Laurie opened it.
Dr. Montgomery: Greetings from Down Under
I received the photomicrographs from Peter, and I have already duly chastised him for not recognizing an acanthamoeba polyphaga cyst, although I gave him some slack because of the location. I have never seen one in the lung. If you want to see it better, use an iodine stain. As for the evanescent nodularity Peter mentioned, I can only assume that it represents encasement of more of the same MRSA as is seen free in the microscopic field. It has been recently demonstrated in Bath, England, that MRSA can invade and multiply within acanthamoeba, similar to legionella, the cause of Legionnaire’s disease. Since acanthamoeba normally eat bacteria, it is interesting to wonder how the MRSA and legionella have developed antiamoebic resistance, if you will, and how molecularly similar the process is to their antibiotic resistance. I will be back in the city on Monday. If I can be of any additional assistance please do not hesitate to contact me.
ALL THE BEST,
COLLIN WYLIE
As astonished as she was about what she was reading, Laurie had read the e-mail without blinking, and she had to make up for it by squeezing her eyes shut and then blinking several times in a row. She knew next to nothing about amoebas in general or acanthamoeba in particular. Leaning over, she pulled her Harrison’s Principles of Internal Medicine from the shelf and rapidly looked up acanthamoeba. The reference was short, and merely part of a general article about infection with free-living amoeba. It talked about acanthamoeba causing an encephalitis, but nothing about pneumonia. It also mentioned that the CDC had a fluorescein-labeled antiserum available for definitive diagnosis, which Laurie thought might be helpful to confirm Dr. Wylie’s impression.
Laurie replaced the textbook and scanned her shelf for a possible second source. Not seeing one, she repositioned herself at her monitor screen and Googled acanthamoeba. A large number of hits appeared in seconds. She chose a general one.
With a growing sense of urgency, Laurie scanned the first part of the article, which described the protozoa as one of the most common in soil and fresh water. It described some of its characteristics, including the fact that it was a free-living bacterivore but could on rare occasions cause infections in humans. The next paragraph elaborated this issue at length, and Laurie quickly skimmed it.
It was at that point that Laurie’s eyes encountered the caption of the next paragraph: Acanthamoeba and MRSA! With a surge of adrenaline coursing through her body, Laurie read an elaboration of what Dr. Wylie had mentioned, namely, that MRSA had recently been shown to be able to infect acanthamoeba. But in addition to what he’d cited, the article stated that the MRSA that emerged from the amoeba was frequently more virulent. And then, experiencing a reaction akin to a bolt of electricity passing through her, Laurie read that acanthamoeba cysts infected with MRSA can act as a mode of airborne dispersal for MRSA!
Laurie rocked back in her chair and stared blankly at her monitor screen. She was stunned. She’d been confident that MRSA could not be aerosolized, but now she was aware it could be, so all potential scenarios concerning how the MRSA was spread were back on the table, particularly the idea that the Angels hospitals HVAC systems could be involved.
With some difficulty, Laurie tried to calm herself. She had to think, and with her pulse racing and ideas flying around inside her brain, it was difficult. She took a few deep breaths, and after doing so, she remembered another reason she’d dismissed airborne spread as a serious possibility: The patients never breathed room air after being inducted. It was always bottled air or cleaned and piped-in air.
Laurie thought about this stumbling point. It seemed so definitive, or was it? With a mounting fear that her concerns were legitimate, she snapped her phone off the hook. Even though a quarter to eight might have been the worst time to call an anesthesiologist, as all the seven-thirty cases were being inducted, Laurie called over to the Manhattan General Hospital. She’d worked on a case with the MGH’s chief of anesthesia, Dr. Ronald Havermeyer, and he’d been extraordinarily helpful. Laurie was sure he, of all people, could reassure her about patients never breathing OR air and would be happy to do so. Additionally, his being chief meant that he was in a supervisory role and might be available.
Nervously tapping her fingers on her desktop, Laurie willed the connection to go through as quickly as possible.
“Dr. Havermeyer,” a voice finally said.
Laurie quickly explained who she was and without explaining why, asked her question.
“It’s true,” Dr. Havermeyer said. “The patient never breathes room air after induction until they get to the PACU, and even there they are often maintained on piped-in sources.”
“Thank you,” Laurie said.
“Not at all. I’m glad I could help.”
Laurie was about to hang up when Dr. Havermeyer asked why she wanted to know.
Quickly, Laurie sketched out her concern—namely, whether bacteria in the HVAC system could be responsible for postoperative nosocomial pneumonia.
“Are you talking about an extended period of breathing ambient air, or just three or four breaths over fifteen or twenty seconds?”
Laurie felt her throat go dry as she intuitively sensed she was about to hear something she did not want to hear.
“Because if it’s the latter, there usually is a time,” Dr. Havermeyer said. “When the surgeon gives the word and it’s time to wake the patient up, or at least terminate the anesthesia, the anesthetist frequently flushes the system with pure oxygen in order to get a faster turnover time for the OR. During the flush, the patient might take two, three, or even four breaths. So it’s possible.”
Laurie thanked the doctor and hung up.
Suddenly, her fears coalesced. MRSA could spread airborne if encysted with acanthamoeba, and patients having general anesthesia did, even if for only a few seconds, breathe ambient OR air. Laurie snapped up the paper on which she’d written the days of the week her cases had occurred. Her memory told her that orthopedic cases were on Monday and Thursday, and it was unfortunately true. It was also unfortunately true that it was Thursday that very day, the day Jack had to have his surgery.
With growing desperation, Laurie grabbed one of her cases’ hospital charts. Frantically, she searched for the anesthesia record to check the time anesthesia commenced. Anesthesia time was one variable she’d not included in her matrix. To her horror, it was seven-thirty-five a.m. Literally tossing the record to the side, Laurie grabbed another: seven-thirty-one a.m. Swearing under her breath, Laurie grabbed yet another: seven-thirty-four a.m.
“Damn!” Laurie shouted. She got another: seven-thirty a.m.
With four cases out of twenty-five enough for Laurie to fear for the worst in relation to Jack, she ran from her office and beat the elevator down button in hopes of hurrying its arrival. She checked her watch as she waited. It was just after eight. Jack’s procedure was supposed to take a little more than an hour, so she might make it if she got a taxi immediately. Luckily, First Avenue was a good place to get a cab in the morning because of the hospitals and other services in the area. What Laurie had decided was that she wanted to be in the Angels Orthopedic Hospital’s engineering spaces above the OR as soon as possible to make absolutely certain no one else did.
AS
MUCH AS Angelo thought he was depressed the previous evening, he now felt worse. They’d been waiting for almost two hours after arriving at six-fifteen, and still no Laurie Montgomery. Since she and her boyfriend had arrived the previous morning from 30th Street, he’d positioned the van so as to be able to see as far up the street as possible. Every time he’d see a taxi approach, his heart would speed up in anticipation, only to be disappointed again and again.
“I don’t think she’s coming to work today,” Angelo growled.
“Kinda looks that way,” Franco said while licking his finger to turn the page of his newspaper.
“As if you give a shit!”
Franco lowered his paper and glared over at Angelo, who’d turned to look back up 30th Street. He felt like lashing out at his partner in crime but didn’t. It wasn’t worth the effort. Instead, he started to go back to the paper when he caught sight of a figure bursting out from the OCME and descending the front steps as if being chased.
“It’s her!” Franco yelled.
Angelo’s head spun around. He started to demand where when he caught sight of Laurie. She was standing at the curb, holding open a taxi door so a passenger could disembark.
“Holy shit!” Angelo yelled. He reached behind his seat for the ethylene, but Franco grabbed his arm.
“There’s no time,” Franco asserted. “We’ve got to follow her. Start the damn car!”
They watched while Laurie’s hand anxiously waved for the obese woman passenger to hurry. Laurie even resorted to giving the woman one of her hands and attempting to help by pulling, as if the woman were stuck. As soon as the woman was barely out of the way, Laurie threw herself into the cab and pulled the door shut. A moment later, the cab was off with a screech of rubber.
“My God!” Angelo said. “The guy must be a NASCAR nut.”
“Don’t lose them,” Franco cried, as he blindly reached for parts of the vehicle that could keep him from being thrown from his seat.
Angelo didn’t need to be reminded about not losing Laurie, and he had the accelerator to the floor. The aged van responded admirably, and it shot forward with its own screech of complaint from its tires.
Briefly, Angelo glanced in the rearview mirror to see if Richie was on the ball. He was, and was not too far behind.
“Do you think she stayed the night in the morgue?” Angelo questioned, as he wove in and out of the traffic.
Franco didn’t answer. He was too busy holding on and looking out for police cruisers. Luckily, he saw none. Soon Laurie’s taxi and Angelo’s van had to stop for a traffic light, and Franco had an opportunity to put on his seat belt.
WHEN LAURIE HAD finally managed to get into the taxi, she had hurriedly told the driver the name of the hospital, the address, and that she was a doctor. As a plea for speed, she’d said she was on a life-and-death emergency. The cab driver, who was a young individual, had taken the request to heart, and Laurie was pleased how quickly he took them up First Avenue. Although he’d not run any red lights as far as Laurie could tell, some of them had been debatably close and had required him to accelerate through the amber.
Unfortunately, going across town was different, and Laurie’s feet began a nervous tap as they were forced to wait for a taxi to unload ahead of them at the corner of Park Avenue. Not only did the stop increase her anxiety of being too late, it also gave her a chance to add to her fears. If it were true that all the cases involved the seven-thirty OR time slot, then it was understandable why Wendell Anderson had never had an MRSA case; he didn’t start his surgery until significantly later by choice, at least not before doing so, as a favor to Jack.
Laurie gritted her teeth. If she hadn’t been so anxious, she could have gotten angry at Jack all over again about his headstrong insistence on having his surgery that day.
As they neared the destination, having just turned down Fifth Avenue, Laurie got out more than enough money and poked it through the Plexiglas divider. She had the door open before the cab came to a complete stop, and she was out on the pavement in a flash, slamming the taxi door behind her. She ran toward the entrance but then slowed as she neared the liveried doorman for fear of making him suspicious and delaying her. Seemingly unperturbed by Laurie’s dash from the taxi, the man touched the brim of his hat as a kind of welcoming salute before giving the revolving door a push for her benefit.
Once inside, Laurie continued to force herself to walk at a nearly normal gait. She was conscious of her reception on Tuesday and did not want to call attention to herself, especially since there was a uniformed security man standing off to the side of the lobby. Laurie reached the elevators and pushed the call button. Looking up to the floor indicator, she could see that one car was nearing the lobby.
Out of the corner of her eye, to her chagrin, Laurie glimpsed the security man push off the wall and walk in her direction. Self-consciously, she looked the other way. She could sense his presence at her side but slightly behind.
The elevator arrived. With relief Laurie boarded and in the process pushed the fourth-floor button. For a beat she faced into the car, fearing the man was about to accost her, but he didn’t. Yet when she turned to face the elevator doors, he boarded and their eyes briefly met. They were the only two people in the elevator as the doors closed.
Laurie quickly shifted her gaze up to the cab’s floor indicator above the doors and held her breath. Expecting to be questioned at any moment, the doors closed, the elevator rose but then immediately stopped.
To her surprise and relief, the security man exited on the second floor, apparently having pressed the button when Laurie had been purposefully keeping her eyes on the floor indicator. When the doors re-closed, Laurie breathed a sigh of relief.
The elevator then rose up to the fourth floor. As the doors opened, Laurie dashed out and ran headlong down the aseptically white corridor. Coming up to the engine room door, she hesitated, praying she was wrong and that her suspicions and fears were a product of an overly active imagination. Looking at her watch, she saw it was eight-forty; the timing would be correct.
Grasping the doorknob and with a bit of effort, Laurie pushed into the engineering room and was immediately enveloped in the throaty, deep hum of the machinery in the heavily insulated, high-ceilinged room.
The heavy door made a loud mechanical click that caught the attention of a surgically masked, hooded, and gowned figure who straightened up from where he had been otherwise hidden among the ducting. In one hand he held a wrench, hardly a surgical instrument, in the other a stoppered Erlenmeyer flask.
In took only a second for Laurie to believe her worst fears were confirmed. Shouting “No!” at the top of her lungs, she raced toward the man, who took a few steps back as if he were going to flee but then changed his mind and stood his ground. Laurie ran into him at full speed with her hands clawing at his mask and ripping it away. Instantly, she recognized who it was. It was Walter Osgood.
The unexpected contact forced Walter to stagger back. As he desperately tried to grasp something to keep him on his feet, he dropped both the wrench and the flask. The wrench clattered safely to the floor but the flask smashed into a dozen shards. The contained white powder was ignominiously dumped onto the floor.
Laurie screamed like a banshee and pounded Walter, who tried to protect himself by raising his crossed arms and briefly allowing Laurie to hit against them. She even got an arm through to his face, striking it as hard as she could, which jolted him out of his inaction. With a surge of defensive anger, he balled his hand into a fist and swung it wide in a roundhouse blow, catching Laurie above the ear. Laurie went down hard. Still, she shook herself and then tried to get up but felt her head yanked painfully to the side. Walter had roughly grabbed a handful of her hair and was dragging her. With Walter twice her size and weight, it was difficult for Laurie to resist, but she reached up and hit and then scratched his forearms. Walter’s reaction was to strike her again, almost as hard, with his left hand.
She tried to break the
hold he had on her hair as he pulled her over to a door. Opening it with his left hand, he dragged her inside. She tried to kick his legs, but he released the grip he had on her hair and hit her again on the side of her head with his fist. As she flopped back supine, he dashed back out through the door. Although dizzy, Laurie regained her feet and lunged for the doorknob only to feel and hear it make a loud mechanical click. She was locked in.
Walter gingerly touched the side of his face. Pulling his fingers away, he saw a small amount of blood. Quickly, he retrieved his N95 mask and secured it to his face, despite the fact that one of its ties had been snapped apart when Laurie had torn it off. Next, he ran to a large, deep sink, where he found a towel. Wetting it, he rushed back to the smashed flask and, being careful not to cause even the slightest air disturbance, laid the wet towel over the white powder.
Ignoring Laurie’s muffled yells as she pounded on the storeroom’s door, Walter pulled out his cell phone. He was pleased there was a signal. Quickly, he dialed the emergency number in Washington. Once again, it had to ring a number of times. As he waited, he winced at the new crashing sounds coming from the storeroom. Laurie was apparently throwing large metal containers against the door, which was more worrisome than her previous yelling or pounding against the door with her fists. Walter was concerned someone might hear the commotion, despite the extensive sound insulation with which the room had been equipped. There was no doubt in Walter’s mind that Dr. Montgomery had to be removed, and she had to be removed quickly.
Finally, the phone was answered. Walter had no patience with the heretofore cloak-and-dagger routine. When the man started to ask whether Walter was on a cell phone, Walter yelled that he didn’t have time for such intrigue. “I’ve got Dr. Laurie Montgomery locked in a storeroom in the OR HVAC room,” he yelled. “Should I let you listen to her yelling and screaming and pounding on the walls? This whole mess is over if she’s not dealt with. Do you understand what I’m saying? Whoever your best negotiator, as you called him, is, he’s doing a hell of a lousy job. She burst in here and ruined my sample, so today’s attempt isn’t going to happen. I warned you about this two days ago.”
