“It’s Dr. Garnet. I’m calling to inquire how Dr. Popovitch is doing.”
“One moment please,” she said coolly and put me on hold.
Oh Jesus, I thought. Janet immediately sensed my alarm. “I’m on hold,” I whispered to her.
The phone clicked. “Earl, it’s Stewart Deloram speaking.”
My fear reached the screaming point.
“Stewart, why are you there?”
“I’m half back in the saddle, helping out a bit,” he said quickly. “But I’m afraid I’ve bad news. Michael’s sputum became purulent overnight. We’ve done Gram stains of course, and the only glimmer of hope is we can’t see staph. The pus may be debris from parts of the lung where the Legionella has knocked off the circulation, but in any case he’s not doing well.”
The words thudded on me like rocks at a stoning. I could barely speak. “Does Donna know?” I asked. Janet’s eyes widened in panic on hearing the question. “He’s alive,” I whispered, covering the mouthpiece for a second.
“Yes, of course. She’s handling it very well.”
There was nothing more to say. Stewart was initiating the routine to prepare the family for death.
“Stewart, I’m glad you’re there,” I told him, then hung up before he could ask me anything about the situation here.
This time Janet and I didn’t cry. I think we felt too emptied by the shock. We simply held each other and rocked.
* * * *
Williams had prevented a riot, but he hadn’t managed to defeat his greatest nemesis—panic. Despite his best attempts to get everyone to stay rational—the media, the crowds of people outside, and most of all me politicians—he couldn’t convince them that the isolation procedures and the plan to replace our own staff with outside personnel were measures enough to keep the patients safe.
It was a little after 10:00 when I found him standing by the same window I’d been looking out earlier. He was slumped against its frame, shaking his head, and staring at the scene below. “The mayor and governor folded to the pressure,” he said forlornly without turning his head. “They’ve ordered the evacuation of the patients.”
Below us was the largest number of ambulances I’d ever seen parked in one place. The drivers were lounging against the doors, chatting and waiting—all of them wearing masks, gowns, and gloves. Farther out a few dozen army trucks had been backed up to the edge of the parking lot, their tailgates down. Those drivers were also in protective gear as they relaxed, sat around, and in some cases even snoozed in their cabs. The media and crowds had pulled back toward the outer edge of the property. Half hidden in the mist, they stood quietly observing us, waiting for our next move, like a chorus fallen momentarily silent but still ready to offer its commentary.
“We’re to start moving out the patients at 10:30,” Williams informed me as he walked away.
* * * *
Once the word was given to get ready for the evacuation, the patients had gotten more nervous, not less. During the hurried preparations, I saw masks half tied, gowns left open at the back, and gloves not pulled up properly over the ends of sleeves. If by a remote chance one of the evacuees had already contracted the superbug, these half-assed measures wouldn’t be much protection against it being spread around once he or she got outside.
Those who could walk milled about the exits while waiting to leave, some pushing their own IV poles. Those who weren’t mobile sat in wheelchairs, orderlies standing at the ready. Staff had transferred the bedridden to stretchers and would roll them to the backs of the waiting trucks. It looked like the starting line for a bizarre race.
Williams had told me that hospitals all over the county were making isolation facilities available to receive our transfers; even military installations had opened up. Off-duty medical personnel from other institutions, called in to take over, would care for the patients we’d be sending them. The staff of UH, including those not in the target group, were meant to remain in quarantine here, until the culture results cleared them to leave.
At 10:30, floor by floor, they started out. Despite shouted orders to go slow, the people who could walk inexplicably rushed to get downstairs, crowded into elevators, or tried to pass the person in front of them as if a few seconds longer in the place could be fatal. The ones on wheels were at the whim of their drivers. The whole process was as frantic as if someone had cried, “Abandon ship!”
I was asked to join with other physicians to assess high risk patients in critical-care areas—unstable cardiacs, patients in shock, those on respirators, the list was endless—and pronounce on their suitability for transfer. It didn’t take long to see that in some cases the trip would kill them. On the issue of no risky transfers being made the physicians stood firm. ICU here would remain fully operational, security would be provided around the clock, and nobody would be allowed near any of the remaining patients without an order countersigned by two other doctors. Acute resuscitations would only be done by the two intensivists on site. In other words, no one could come close to a patient on his or her own initiative and slip them something.
We were also told there’d be no replacement of our ICU staff by outside people. The other hospitals were so overloaded by our patients—both the ones we’d sent them and our share of the new emergency cases that came in daily from all over the city—they no longer had personnel to spare.
Janet insisted on staying.
“ICU will be one of the safest places in the city,” she said sadly.
I told her that she was probably right but that I was keeping the private security guard at her door, just in case.
* * * *
I watched the final stages of the evacuation from what had become my usual vantage point on the third floor. Lines of patients were still winding their way across the grounds to the waiting trucks and ambulances. Overhead I could hear the sounds of helicopters, the staccato of civilian rescue craft mingled with the unmistakable wall-pounding window-rattling thudding of a large Blackhawk provided by the army. The fog had lifted enough for them to transport the sicker cases.
We’d lost. He’d won.
Patients, not doctors, nurses, or any other kinds of staff, were the true lifeblood of a hospital. It was patients who gave the hospital its purpose, its mission, its reason to exist As I watched from my spot high above, they streamed out the doors, the long lines looking like rivulets of fluid flowing away from the sides of the wounded institution. In my mind I heard his terrible low rolling laugh, and I couldn’t help thinking that just as I’d seen him destroy Phyllis Sanders from within, cell by cell, I was seeing him exsanguinate University Hospital, bleed it out, patient by patient.
The only person I knew who had reason to hate this place so much was Cam Mackie.
Chapter 22
I kept having to steel myself for what lay ahead.
Just as the fate of Janet and Michael would be decided within the next forty-eight hours, so too would the outcome of the detainees at University Hospital. Some of those already infected with Legionella, if they were carrying staph, would be dead, while others would know they were dying. Others still would be told they were carrying death, even though they were not yet ill, and would be kept from leaving. Although the vast majority would ultimately go home, their cultures negative, the dreadful uncertainty affected everyone and hung over the hospital like a fearful shroud.
Meetings were hastily called to flesh out how the dying would be handled. How much should we tell them? Did they want a final visit with their family members? Should we allow them to touch? Could mothers hold their children one last time? Should we then culture the family members and hold them in quarantine? What about counseling? I saw people coming out of a planning session. Their eyes were huge and white in dark sockets.
Overhead the Blackhawk pounded the air with its rotors as it came and went, carrying away six stretchers at a time.
And all the while we struggled with how to stop the killer from infecting more victims.
“You have to figur
e out how he does it,” Riley kept demanding.
But no one could.
While Williams and the ID specialists continued to search for the unifying link in the archive files, Riley ordered me to visit every other department that Michael had been let into. “But take one of my men with you,” he added, glaring at me like a stern parent.
Even when Doris Levitz and her group from Atlanta finally arrived in the early afternoon, Williams managed to persuade them that their most pressing priority should be to help out with the work going on in the archives. I saw his point. Those files involved the largest amount of data to be gone through, and unlike Riley, I hadn’t dismissed the importance of what we might find there.
Every few hours I continued to call ICU at St. Paul’s. Michael remained in limbo, connected to life by a respirator, hovering near death. Deloram still clung to hope because he couldn’t find staph in the debris he kept suctioning out of Michael’s endotracheal tube. After I hung up, I remembered to take my third pill of erythromycin.
I checked in with my own ER and found out from Susanne that they were coping. I answered her questions about UH as best I could, but when she asked if Janet and Michael would be okay, my own fears were so near the surface I found it impossible to answer. The Blackhawk was thundering overhead on yet another of its trips, and I used the noise as an excuse to end the call, claiming I couldn’t hear.
I then joined in the paper chase and spent the afternoon tracking down what Michael had looked at. The Blackhawk continued to come and go, its sound making itself heard everywhere I went, including the basement. By evening, after about two dozen trips, I heard it no more.
The ID specialists were repeatedly called away to the special isolation ward as more nurses and orderlies developed signs of early Legionella. I learned from Williams that there were another ten cases and that some of the infected women I’d seen in the morning were already showing evidence of severe respiratory distress.
“Purulent sputum?” I asked.
“Not so far,” he answered.
During the evening Cam’s disappearance increasingly became the subject of whispered conversations throughout the hospital. From the fragments I heard, half the gossipers thought he was the killer, while the other half were as adamant as Janet about his innocence.
I made calls to ICU at St. Paul’s almost every hour now. Nothing had changed, but I felt certain I was on a death watch.
By 10:00 I could no longer keep my eyes open and had a cot put in Janet’s ICU cubicle beside her bed. After yet again checking her chart and grilling the nurses to confirm there’d been no change in her sputum, I fell asleep holding her hand.
* * * *
Michael lived through the night. I called St. Paul’s as soon as I woke up, using the phone at the nurses’ station so as not to disturb Janet. But his condition was otherwise unchanged from yesterday evening.
I showered in the surgeons’ changing room, switching my overripe clothing for OR greens and putting on clean protective gear. Another day in the dungeons, I told myself after grabbing a coffee and heading into the subbasement. The pleasure of the caffeine was doubled by the brief respite from the mask that I enjoyed each time I lifted it to drink.
Though it was only 7:00 A.M., I found Williams in the archives explaining to Riley what his group had found after working all night.
“...it wasn’t something the charts had in common that was there. It was something that wasn’t there.”
Riley nodded at me as I joined them. Williams went on speaking. “Each nurse had participated in a sterile procedure on a patient sometime during their last few days at work.”
“I thought you said all the stuff they did during that time was routine,” Riley said.
“We did. What wasn’t routine was that on each occasion, the sterile procedure had never been ordered by anyone.”
Now he had Riley’s attention. “Go on.”
“The procedures themselves were varied. A dressing change, a culture of a suture site, a bladder catheterization to obtain a sterile specimen. But in each case there was never an order for the procedure entered on the patient’s chart. Nor was there any clinical evidence of a suspected infection according to the doctor’s notes on any of the charts.”
“How could unordered things be done to patients, and no one catch on?” asked Riley.
Williams explained. “These procedures are so ordinary, a nurse wouldn’t even check a chart to see if there was a request.”
“Wouldn’t the person asking have to be a doctor?”
“No, anyone in the care chain—another nurse, an assistant nurse, a medical student—could catch the targeted nurse, say that a culture or a dressing change was to be done on so-and-so, and ask the nurse to help. Even a porter might turn up with a requisition and claim the lab had sent him to pick up a sterile urine specimen from the lady in room such and such—that they’d lost the one from a few days ago. A nurse would oblige.”
“What if someone did notice there was no written order?”
“Mistakes aren’t common, but mix-ups do occur. Sometimes the old joke about getting the enema meant for the person in the bed next to you isn’t far from the truth. Occasionally the confusion has serious consequences, like medication being given to the wrong patient. But on the level we’re talking about, these procedures are very benign, common as dishwater, and, apart from the bladder catheterization, wouldn’t cause any upset even if the patient knew they’d been done in error. What’s puzzling is that these procedures all required the nurse in each case to don protective gear. Their contact with the killer must have occurred when they weren’t protected.
Riley’s eyes widened. “One of those nurses. Brown, is alive. Does she remember anything about it?”
“Unfortunately no, but we only talked with her briefly. Perhaps you’ll want to spend more time questioning her. As I said, though, with the procedures themselves being so ordinary, it’s unlikely a nurse would remember doing one or another. We even called the patients. They couldn’t recall such minor events either; this isn’t surprising given everything else that was probably done to them while they were here.”
“But the person initiating the procedure could be with the nurse he’d targeted while that procedure was being done?”
“Like we said—another nurse, a resident, a porter waiting for the specimen—anyone of them could be in the room and none of them would have their presence recorded on the chart.”
“Can either of you think of how someone could use those procedures to infect the nurse?” Riley asked us.
“Unfortunately, not yet,” Williams answered.
I simply shook my head.
Riley remained excited, despite our failure to furnish him with the killer’s technique. “I can get my officers to go over old duty rosters and question everyone present on the wards when those unauthorized procedures were done,” he declared. “With exact times and dates, it’s just possible someone might remember something!” He looked over at me. “Did you get to those other areas where Popovitch had been?”
“Yes I did,” I answered. “It turns out that Cam had been there as well. He’d left Nurse Brown’s chart out in staff health, and in the repository where they keep former records of the deceased, I discovered he’d left out the old charts of Sanders and the OR nurse. But I didn’t find anything as dramatic as what Dr. Williams came up with.”
“You didn’t disobey me and go back there alone?” Riley snapped, his eyes suddenly clouding over.
“I had one of your men posted on the door, as you ordered,” I reassured him. I reached under my gown, slipped my cellular phone out of my pocket, and held it up for him to see. “Besides, I can always dial nine-one-one.”
Williams laughed, but the scowl on Riley’s face only deepened. Since the attack on me and Williams, Riley had been adamant about precautions for our security. He would have been even less pleased to hear what I hadn’t mentioned—that his man had been repeatedly called away to help his
colleagues settle the frequent disputes that we’d seen breaking out all over the hospital. Not surprisingly, with the patients gone and nothing to occupy them, many of the staff were finding the wait an unbearable strain, especially those confined to the wards where the Legionella cases were breaking out. There was also trouble involving a few people with previously unknown drug or alcohol dependencies, and some particularly nasty encounters occurred when some of them started going into withdrawal. Whatever the cause, squabbles sometimes became physical and required the intervention of many police officers at a time. I’d finally sent Riley’s man to fetch the portable from my car, just in case I needed help fast during one of the frequent times he was away. Since ICU and the isolation wing were the only parts of the hospital still functioning, I’d felt it was safe to use the device this far from those places.
“Please continue,” Riley said.
“Everyone here thought it was blind luck that two weeks before contracting her pneumonia Phyllis Sanders had been screened for staph and found to be negative. My own wife commented on how fortunate that was, because it meant the hospital only had to screen the OB patients and newborns who were on the ward during that two week period. What’s odd is that when I checked the charts of Brown and the OR nurse, they also had negative screening results dated two weeks before they contracted Legionella.”
“What’s the significance of that?” Riley asked.
“The fact they were screened is not unusual. With MRSA’s being a problem in a lot of hospitals these days, such screening is common. But the timing for all three, I think that might be more than coincidence.”
He sighed. “Can’t you just tell me what it means?” He was starting to sound impatient again. Being forced to rely on medical experts for information rather than doing his own investigative work seemed to be driving him crazy.
“I wish I could. A clerk named Madge in staff health who was called in to help was pretty talkative after she’d ended up sitting around doing nothing all day. Through her I was able to check out the whole process by which screening is carried out. I wanted to see how it could be used to target three specific nurses at precisely two weeks before each left on vacation, but frankly I’m mystified. The whole operation is so loose—wards are done randomly and many people are involved in the taking of specimens—that I’ve no idea how the killer could have manipulated the routine so precisely. Maybe your men could interview Madge and find something I missed.”
Death Rounds Page 36
