Death Rounds

by Peter Clement

  “Hey, I’m not the bad guy here, and neither are you,” she reproached me gently as she finished pulling on her white lab coat over her otherwise revealing garb.

  “Sorry, Janet,” I said, reaching for her hand.

  She sat down on the side of the bed and continued to speak while stroking my head. “The good news is that after the meeting. Miller came up to me and asked that I tell you he’s sorry for reacting so harshly. He didn’t say anything more and he’s of course still looking pretty shaken about his mother’s death, but I think he may be seriously reconsidering his initial anger toward you. In fact, he seems instead to be focusing that anger more toward the organism we’re up against. He insisted on coming back to help set up all the screening that had to be done, and the man worked like a demon all day, pitching in with taking samples whenever he wasn’t running off to deal with some snag or other in the lab. I suppose it’s his way of striking back at what killed his mother.” She leaned over me, gave me a soft kiss, her lips still full from our lovemaking. “So you see, as I told you, things might work out with him after all,” she whispered.

  I felt a mix of relief, surprise, and puzzlement. “But if I’d clued in that first day, hit her with a dose of erythromycin before the staph took hold—”

  She silenced me by gently placing her fingers on my lips. “Stop beating yourself up. Wait until they find out in Atlanta about the incubation and prodrome of this bug and if anything you might have done would have made any difference.” Then she got off the bed and let herself out of the room.

  * * * *

  By noon Saturday, we had taken culture specimens from most of the remaining patients who were recalled for screening. We had not yet reached about fifty cases but would follow them up by home visits.

  By Saturday evening, preliminary culture results showed no vancomycin-resistant organisms in either staff or patients but suggested the possibility that a few of the hospital workers were carrying MRSA. Some of them were already under quarantine. Those at home were called in, and they all were subjected to bactericidal soaps and intranasal mupirocin ointment.

  By Sunday afternoon, all the cultures taken on Friday were confirmed to be negative for staphylococcus resistant to both vancomycin and methicillin. And there wasn’t any evidence of the vancomycin-inhibiting strain that had been discovered in Japan. The only positive findings were confirmations of the MRSA carriers already identified by the preliminary results. The ER itself was given a clean bill of health and would open that evening.

  All in all, as far as the men and women from Atlanta were concerned, it was an unbelievably good result. The superbug they’d been anticipating with such dread had come out of nowhere, claimed a single victim, and then vanished without a trace, at least without the sort of trace that could be detected by culturing nooks and crannies of rooms, sundry pieces of equipment, and the hands, nails, and nostrils of anyone who’d been near Sanders. At a 4:00 P.M. wrap-up meeting, everyone was clearly buoyant with surprise and relief.

  “We lucked out,” the gray-haired chairperson of their hospital infection group kept saying, slapping his colleagues on the back and congratulating them on a well-run operation. Rossit and Hurst watched this good cheer nervously at first, then seemed to realize that they were now likely to end up looking good, given how the operation had gone, and tentatively joined in the handshaking. For me, just getting to shed the protective gear we’d been stuck in for over two days was a cause for celebration. Particularly annoying had been the way my mask trapped the humidity from my breath, constantly steaming up my glasses.

  I found Hurst’s demeanor toward me controlled and cold as usual. I hadn’t seen him since he’d muttered his threat to be rid of me, but there was no evidence this evening of the overt malice I’d felt then. I had to admit, the more I’d thought about the encounter, the more I’d found it puzzling. Hurst rarely attacked me or anyone else directly, let alone announced his intention to do so. His preference was to sandbag his adversaries from behind the scenes, in ways that were easily denied and hard to prove. I would have expected him to simply let the blame for the Sanders case give him the excuse he needed to dump me as chief, without ever having to confront me directly. Had the angry words slipped out spontaneously, spurred by his fury about all the negative publicity for St. Paul’s? Or had he deliberately tried to rattle me, as some sort of distraction? His steely expression gave me no answers.

  Williams was nowhere to be seen. “Probably back with his ducks,” one young woman from the CDC team told me jokingly when I inquired where he was. Her crack at his expense produced a few other laughs from her colleagues, but I doubted they were mocking him. Rossit’s recognition of him two days ago, even with all the obsequious antics, had suggested there was much more to Williams than some obscure study of botulism in ducks.

  The chairperson from the CDC called the meeting to order, but while some of the group excitedly reported on the work already under way in Atlanta to isolate VanA genes from the organism’s DNA, and others outlined the myriad studies that would be performed on the cultures and autopsy specimens taken from Phyllis Sanders, I was thinking of Legionella again.

  I’d dropped by the labs just before the meeting. Over the weekend the protracted process of special cultures and immunofluorescent staining procedures that I’d ordered on Sanders’s sputum had finally produced a positive result, but the result had gone unnoticed in all the excitement.

  If I could just get this group to consider the Legionella cases in their investigation, I thought, it might be a first step in getting them to realize what was really happening. When the discussion focused on how the CDC labs planned to investigate the aggressiveness of the superbug and determine which factors might predispose carders to becoming infected, I passed my results around the table and challenged, “What about the fact that Phyllis Sanders also had Legionella before the superbug took hold? And what about there being two other unexplained cases of Legionella at UH in the last six months? I take it you’re also aware that the physician caring for the Sanders woman himself came down with a presumed case of Legionella a few days ago, though his cultures aren’t ready yet. Are you going to look at this pattern?”

  Rossit and Hurst immediately scowled at me. For interrupting? Or for touching on what they preferred no one look at too closely?

  The distinguished chairperson from the CDC frowned as he regarded me from his end of the table. “What you’re raising are serious issues, of course, but I assure you the CDC is not here to deal with a few cases of Legionella. Your distinguished and most competent local ED authorities can and will guide you, as they always have, on such routinely reportable infections.” I presumed his emphasis on the word routinely was a not so subtle way of saying don’t bother him and his superstars with small potatoes. That stuff he obviously left to underlings.

  A young man wearing red suspenders to which a Buffalo Public Health ID badge was pinned seemed suddenly to recognize his role and piped in, “We’ll certainly be looking into those cases, Dr. Garnet. And I can assure you and the rest of this group that we’ll be spending some time at University Hospital, since Phyllis Sanders worked there. We’ve already suggested to Dr. Cam Mackie that all personnel at UH be screened immediately for staphylococcus, just to take no chances. Perhaps we can look into rechecking the place for Legionella at the same time, although Dr. Mackie assured us they’d already done that. Sanders could have acquired the Legionella anywhere. Whatever the case, I must tell you that we are most satisfied with Dr. Rossit’s measures in response to the unfortunate Legionella case involving your own ICU director.”

  Rossit beamed. Both he and Hurst had also seemed pleased about the attention University Hospital was scheduled to get.

  “Of course we will be determining the infectivity of this bug,” the chairperson said, bringing the discussion back to the big issues that he was here for.

  I tuned out the doctor-speak about the percentage of carriers likely to come down with the disease—as high a
s thirty-three percent in other strains—and thought about the Phantom. I shivered. We had to track him down...had to.

  After the meeting broke up, I was dying to get home and see Janet and Brendan, but I had a few more jobs to do. I managed to get the telephone number where Douglas Williams was staying from a member of the departing CDC team, claiming I wanted to thank the man for the help he’d given us on Friday. Then I went up to the library, plugged into the computer Med-Line program that indexed all major medical publications, and punched in the key words “infectious diseases,” “patterns of occurrence,” “vectors,” and the name “Dr. Douglas Williams.” This particular search program summoned a list more than three pages long of abstracts of articles. Glancing at the titles, I picked a few that particularly interested me, had the librarian dig them out, and spent the next hour reading. I learned a lot about what the man was good at from reviewing his previous work. I began to have a glimmer of hope that his expertise might be a whole lot more helpful than the CDC’s.

  Finally I stopped by ICU, but Stewart was sleeping. The nurses assured me he was stable and promised to tell him I’d dropped in to say hi.

  * * * *

  The phone woke me near midnight mat same evening. I was in my own bed at home, but at first I’d briefly thought I was back in that accursed room at the hospital where I’d spent the last two nights. I fumbled with the receiver, heard a nurse from St. Paul’s excitedly identify herself, and shook myself out of a deep sleep to concentrate on her words.

  “...yet he’s febrile, in acute respiratory distress, and shocky, just like the Sanders woman,” she exclaimed, “but he won’t let us intubate him until you get here.”

  I instantly thought of Deloram. “You mean Stewart’s going shocky?” I blurted out, immediately wide awake and sitting bolt upright. “But he was stable when I--”

  “No, Dr. Garnet, I’m calling from ER!” she exclaimed, her voice suddenly cracking with what sounded like barely controlled sobs. “It’s Dr. Popovitch. He was brought in by ambulance a few minutes ago. He’s septic, wheezing like hell, and everyone’s afraid he’s about to shut down his airway and have a respiratory arrest. But he’s refusing to let anyone intubate him until he can talk to you. Please hurry. He’s so hypoxic he’s out of his head. He keeps insisting someone has deliberately infected him.”

  * * * *

  My drive into St. Paul’s was a blur of rain, speed, and gut-tying fear. Michael, septic, in shock just like Sanders, the nurse had said. How could he have let anyone near enough to infect him? Was he going to die like Sanders? Who was next?

  Half the time I couldn’t see through the torrents pouring over the windshield despite the wipers, but there was little traffic, and each time I thought of Michael’s arresting before I got there I went faster. The car shuddered and pulled from side to side as the wheels plowed through deep collections of water lying across the road. My hands strained to control the steering wheel but I refused to slow down.

  “Damn your stubbornness, Michael!” I yelled as spray roared up against the underside of the car. But it was myself I blamed. Why hadn’t I screamed my bloody head off days ago and forced everyone to face what Janet had suspected from the beginning? We might have frightened off the Phantom. Why the hell had I even listened to Michael’s concerns about my credibility and what Rossit could do to my career?

  The car nearly careened out of control as I sped down the off ramp and flew through the deserted downtown streets. Don’t die, Michael. Don’t you damn well die, I swore, tears welling up in my eyes and blurring my vision even more.

  * * * *

  He stopped breathing seconds after I ran into the resuscitation room. I think he might have seen me as I burst through the door. His bearded face was lolling, his eyes were bulging as he stared in my direction, and one of his arms, hanging down off the stretcher, rose limply toward me, then dropped back. Despite a forest of IVs pumping him with fluid, the vascular collapse from sepsis had left his huge body looking as if it were made from glistening rolls of paste. Circled around him, a silent group of green-clad residents and nurses in protective gear stood alongside their neatly arranged trays of tubes, scopes, and ventilation equipment, waiting to resuscitate him from what was clearly an imminent arrest.

  His eyes seemed to slide toward this array of instruments that would soon be in him and his facial muscles jerked into what appeared to be a look of terror, but it was the start of a seizure accompanying the complete halt of his respirations. It quickly spread through the rest of his body, curling and uncurling his limbs into cruel shaking spasms, then dropping him like a lifeless doll.

  The team was already on him. They struggled to pry open his jaws still clamped shut in the seizure’s aftermath. While pulling on my own protective gear, I watched the monitors as his pulse dropped to thirty and his oxygen levels plummeted. Alarm bells started going off one after the other as other vital signs fell.

  “We can’t get his mouth open to intubate,” yelled an anesthesia resident in panic.

  Another resident at his side was trying to shove a trachea! tube into Michael’s nose and attempt a blind intubation down through his nasopharynx. In his nervousness, he forced the delicate maneuver, failed to get the airway, and produced a hemorrhage. It didn’t last long. The near dead don’t have the blood pressure it takes to bleed. All the monitors were flat but for an occasional heartbeat.

  The nurses were beside themselves, screaming useless instructions.

  “For Christ’s sake, get a tube in him!”

  “I’ve lost his pressure. Pump him!”

  “What about atropine for the bradycardia?”

  But what he needed was an airway and ventilation. I finished snapping on my gloves, stepped to the head of the stretcher, and shoved aside the residents. “Give me a soft nasal pharyngeal tube,” I ordered the nearest nurse. She handed me a flexible six-inch hollow piece of latex the size of my little finger. I added some lubricant and slid it easily up the nostril that wasn’t bleeding. I felt it readily curve down along the contours of the nasopharynx and its tip push past me base of his tongue which had fallen back to block his airway. There was a slight rushing noise through the near end of the tube that was still sticking out of his nose. His chest muscles and diaphragm were reflexively starting their movements of breathing again, now that the way to the lungs was open. But the effort was weak. We helped him out with a ventilating bag, the residents pressing the mask to his face to avoid leaks while I forced oxygen through the nasal tube into his airway and filled his lungs. His pulse and blood pressure rose immediately, the seizure in his jaw broke, and his mouth dropped open, the muscles slack. Within minutes we had him intubated the regular way, on a respirator, and ready for ICU.

  The nurse who’d spoken to me on the phone led me into the corridor outside the resuscitation room. Her eyes were red, and she still was having trouble keeping her voice from shaking.

  “Will he make it?” she asked.

  “I hope so” was all I could tell her.

  Then she started to cry and turned away. “I’m sorry,” she said, fumbling for a tissue, “but I’ve never had to resuscitate one of our own before. And Michael’s such a powerhouse here. It’s hard to see him like mat...” Her voice trailed off, and she had to use her tissue again. “He was barely able to talk more than a whisper,” she continued when she had control over her tears, “and even then, he could only gasp out a word at a time. As I said, he was obviously delirious. But he was desperate to speak with you. He got increasingly afraid he wouldn’t hold out until you got here and begged for a pen and notepad.” She reached into her pocket and handed me a folded piece of paper.

  I thanked her, quickly turned away, and unfolded what was a scrawled message. The Phantom is real. Check the charts! The pattern!

  PART TWO

  Prodrome

  Chapter 12

  A glance at my watch told me it was 1:00 A.M. I was at a loss what to do. I wanted to know what charts Michael had been checkin
g— wanted to see them for myself—but didn’t even know for sure which charts he meant. Janet said on Friday he’d gone to look at the records of the Phantom’s first victims—the same records Janet had wanted me to see the night I got attacked in the subbasement. But he’d done that a couple of days ago. Had he found something else in the meantime? Had he been poking around during the weekend?

  “Dr. Garnet,” one of the nurses said, touching my arm.

  I was leaning against the wall just outside the resus room, still staring at Michael’s note, lost in desperate thoughts.

  “Dr. Garnet,” I heard her repeat, “we put Dr. Popovitch’s wife, Donna, in the grieving room, to give her some privacy. She came in with him in the ambulance and is obviously upset. Could you speak to her about her husband?”

  At that moment an orderly wheeled Michael out of resus and down the corridor toward the elevator that would take him to ICU. He was completely still, the tube protruding from his mouth distorting his lips and cheeks into a grotesque sneer that made me think of the rictus of death. “Oh, Michael, my poor friend,” I said softly, watching the winking lights of the monitors recede up the dark passage.

  I tried to prepare what I would say to Donna as I crossed the waiting area. Even at this hour there were more than two dozen people in the place, waiting either to see a doctor or to receive lab results and the final verdict of their examination.

  When I opened the door to the grieving room. Donna looked up, saw me, and said, “No!”

  “He’s alive, Donna,” I quickly told her. “We got him full of IVs; he’s breathing on a respirator and being pumped full of erythromycin as we speak.” I walked over and put my arm around her shoulders, continuing to talk, afraid to give her time to ask questions. I didn’t trust my usual capacity to hide from a family member how frightened I was for his or her critically ill loved one. “He’ll be in ICU and you can see him there in a few minutes. But remember, he’ll be sedated to keep him comfortable on the respirator. When he gets a bit better...”