Josh went through the litany, using the checklist he’d made so he wouldn’t forget anything. Hay fever? No. Asthma? No. Hives? No. Madison couldn’t recall previously receiving any products made from horse serum.
The skin tests were negative, as Josh expected. Now it was time. A nurse brought in a small bag of sterile saline and Josh added DAT to it. He attached a needle to the tubing and piggy-backed the mixture into the IV already in Madison’s hand, then started the material flowing.
“Will you be checking back on me from time to time?” Madison asked.
Josh inclined his head toward the upholstered chair in the corner of the room. “No. That chair reclines. I’m going to sit in it for the next several hours.” Madison didn’t realize it, but Josh knew that if anything went wrong, minutes—no, seconds—
would count. He looked at the crash cart in the corner. It contained everything needed to treat emergencies, including an anaphylactic reaction. Atop it was a wrapped set of sterile instruments for an emergency tracheotomy, an operation to open the obstructed airway of a patient. From its external appearance, the red-painted Craftsman rolling cabinet didn’t look particularly unique, but at this moment it was the most important piece of equipment in the United States. And Josh was the most important person.
***
As Ethan Grant prepared to leave for the day, he went through his usual routine, scanning the petri dishes one by one, looking for anything out of the ordinary. He knew that, like that of an airline pilot, his job here in the bacteriology lab of Prestonwood Hospital might be routine most of the time, but it had the occasional moment when he needed every ounce of skill and experience, because he was dealing with, quite literally, a life-or-death situation.
The round, flat glass dish he lifted from the incubator contained a gel-like substance on which scattered colonies of bacteria grew. This was the culture from a swab or specimen that would help him identify the organism and then define the antibiotic to which it was sensitive.
This particular set of plates wasn’t even twelve hours old. It would probably be tomorrow or the next day before Ethan could definitively name the species of bacteria growing on them and say with certainty what antibiotics would work best to treat the patient from which the specimen came. But despite the short time involved, these colonies were already growing more vigorously than usual. Ethan toyed with the idea of making a slide to see if the organisms on the petri dish were the same as what he and Dr. Pearson saw earlier that day.
Before he could act on his thought, the phone rang. Ethan replaced the petri dish in the incubator and reached for the phone. The call was from a physician who suspected his patient was suffering from septicemia—bacteria infecting the bloodstream. Could Ethan check the blood cultures drawn the previous day?
Ethan looked at each of the three specimens carefully. It was too early to call them negative, but he could see no growth. He replaced the bottles and returned to the phone. “Doctor, they look negative. There’s no growth in any of them.”
“You’re sure?”
Of course I’m sure. I’ve been doing this for . . . Never mind. “Yes, sir.”
“Well, keep an eye on them.”
Ethan’s routine was the same followed by most, if not all, laboratories in the U.S.: monitor specimens for five days. If there was any indication of growth, he’d do a slide and Gram stain it. He could explain this to the doctor, but there was no need. The man was worried about his patient. Ethan could understand that.
After he hung up, Ethan wondered if he should follow through with making and examining another slide from the culture taken from Josh’s patient. Then he looked at the clock. It was already almost six, nearly an hour past time for him to leave. He decided to put that on the back burner until morning. It probably wasn’t important, anyway.
6
The next morning, Josh stood in the bathroom of his temporary hospital office and studied his reflection in the mirror. Finally, he shook his head and looked away. A night spent at the hospital watching a patient wasn’t unheard of for him, but it had been a while. He decided he hadn’t looked this haggard since pulling his last all-nighter as a senior medical student. Eyes red, a day’s growth of beard, his clothes wrinkled, and developing a definite scent that told him he needed to shower soon. Josh was a mess. That’s not the way an ex-president’s doctor is supposed to look.
Maybe later this morning he could visit the surgeon’s lounge and clean up, perhaps put on a clean scrub suit. But for now, Josh needed to get going.
He splashed water on his face, finger-combed his hair, and took a deep breath. Josh might hate the way he looked, but even more he hated the way he felt. He moved out of the bathroom, through his office, and into the hospital corridor. He’d grab a cup of coffee, check one more time on Madison, look in on Rachel, then make a quick trip home to shave, shower, and change.
A vibration in his pocket told Josh those plans might have to be put on hold. He pulled out his cell phone and saw the call was from a number inside the hospital.
“Dr. Pearson.”
“Doctor, this is Ethan Grant in the bacteriology lab. I’ve got something here I think you’ll want to see.”
“Can it wait?” Josh said. “I need to—”
“Sir, if it could wait, I wouldn’t have called,” Grant said.
Josh recognized the hint of peevishness in the technician’s tone. Grant had turned up something important, and now Josh was ignoring it. This man is trying to tell me something. I should listen to him.
“I’ll be right there,” Josh said. “Thanks for calling.”
There’d been no need to ask who the patient was. Since Josh only had one patient—well, two, if you counted Rachel—anyway, this could only have something to do with the cultures he’d sent to the lab yesterday. Despite telling Grant he’d be there shortly, Josh decided to make a quick stop at Madison’s room before he headed for the bacteriology lab. True, he’d only been out of Madison’s room for less than half an hour, but he felt as though he needed to keep a close eye on the man. If Josh let something happen— No, he didn’t want to think about that.
As Josh moved toward the elevator, part of him was curious about what the bacteriology technician had found. However, since it probably wasn’t good, the other part of him dreaded finding out.
***
Rachel slowly emerged from a troubled sleep and started to stretch, only to discover that she could move her left arm only a short distance. She opened her eyes and looked around. It took a minute for her to orient herself, then it all came back to her. She was in a hospital, and the reason her left arm was restrained was to keep her from inadvertently pulling the IV out of the vein in the back of that hand.
Rachel’s eyes traveled to her left, up the IV tubing to the plastic bag of fluid, then to the smaller bag hanging next to it on the other arm of the twin pole. It was empty, which meant she’d received the full dose of diphtheria antitoxin. Were the proteins, at this moment, circulating through her body doing battle with the toxins released by . . . what was the name of the bacterium? She’d learned it in nursing school, but it danced just outside her memory. Was inability to remember another side effect, either of the infection or the treatment?
“Good morning. How are you feeling?”
Rachel was frustrated with having to look beyond the mask and face shield and depend on voice recognition to identify the speaker, but she hoped that wouldn’t last much longer. “I guess I’m all right, Dr. Neeves. Is everything looking okay?”
Rachel wished she could see the doctor’s expression. Instead, her answer came in the form of a shrug. “I’ll know more after I have a look at you,” Dr. Neeves said.
As she prepared to examine Rachel, Neeves said, “Look, Rachel, we both know this is serious. You’re a health care professional. I’ll level with you all the way. And in the meantime, why don’t you call me Allison?”
Rachel nodded and sat up straighter in bed in preparation for Allison’s exam.
First, the doctor used the flashlight and one of the tongue depressors from a jar sitting on Rachel’s bedside table. “Not so much exudate,” she said, “but the throat’s still pretty red—maybe a bit redder than before. And there seems to be a bit more swelling back there. Any problem breathing or swallowing?”
“Not really,” Rachel replied.
Allison picked up the stethoscope that hung at the foot of Rachel’s bed. “Let’s have a listen to your chest.”
Rachel went through the routine she knew so well—except she usually was standing by to assist the doctor instead of being the person following commands to take deep breaths. She watched the doctor’s eyes, which were about all Rachel could see of Allison’s expression over the mask, but there was no clue there.
“It’s probably too early to expect much change,” Allison said after hanging the stethoscope on the foot of Rachel’s bed again. “I’m troubled that your fever’s still hovering around a hundred and four. Every time we give you something to knock it down, it climbs right back up within a few hours.” She frowned—that expression was easy for Rachel to see. “But so far, even with increasing swelling in the throat, your airway seems okay. Let’s see if the diphtheria antitoxin makes some difference today.”
“How long will I have to be in isolation?” Rachel asked.
“Conventional wisdom is to isolate patients with diphtheria until they’ve been on antibiotics for at least two days.” Allison shrugged again. “I’ll see if Dr. Pearson agrees. If he does, maybe we can discontinue the precautions tomorrow.” She made a half-turn toward the door. “Any other questions?”
Rachel felt foolish for asking, but the question had been niggling at her since the doctor came in. “Just one,” she said. “What’s the name of the diphtheria organism? I can’t remember it, and it’s driving me crazy.”
***
“Mr. Madison, how do you feel?” Josh asked as he entered the ex-president’s hospital room.
Madison managed a smile, but it was evident to Josh it was a politician’s gesture, with no real emotion behind it. “I’m still here, so I guess that’s something.”
Josh moved quickly to the side of his patient. The main IV continued to drip at a “keep open” rate, but the smaller bag that had delivered the diphtheria antitoxin was empty and its line was turned off. “Let’s have a look at you.”
After the exam, Josh said, “I’m sorry to say I don’t see much progress, but it’s still early. Let’s see how the diphtheria antitoxin affects you today.”
“Do I get another dose?” Madison asked.
“No, everything I’ve been able to find says one dose is all that’s necessary. We’ll continue the antibiotics to kill out any residual organisms. And if your temperature comes down and there’s less redness and swelling of your throat tomorrow, I’ll think about discontinuing the isolation precautions.”
“Good,” Madison said. “The rest of the group that went to South America with me should be on their way back soon, and I want to confer with them. It’ll be a lot easier if they don’t have to go through this silly mask/face shield/gown/gloves drill.”
“I don’t like it any better than you do, Mr. Madison, but that’s the routine that’s called for.”
After a few more words, Josh stepped outside and began to divest himself of the isolation garb. He scrubbed his hands a little longer than usual, although there was really no reason to do so. Josh hoped he could discontinue the isolation precautions soon. Madison had been on antibiotics for twenty-four hours, which was probably long enough to destroy all but the hardiest of the Corynebacterium diphtheriae in the average patient’s body.
Josh pondered whether he should look in on Rachel, but decided he’d have to delay that until he checked out what the bacteriology technician had found. And, after all, even though Rachel was his girlfriend, Josh couldn’t escape the knowledge that his primary allegiance was to his most important patient
. . . the one he’d just left.
He headed toward the lab, wondering if his unease was related to guilt at not being attentive to Rachel or to the news he was afraid he would receive from the lab technician. As Josh punched the elevator button, he decided he’d know soon enough.
***
Ethan Grant looked up as the lab door opened and Dr. Josh Pearson walked in. He’s not going to like what I have to show him.
“Okay, I’m here,” the doctor said. “What’s this I need to see?”
Dr. Pearson, unshaven, his clothes wrinkled, showed evidence of long hours with no sleep. The lab tech felt sorry for him. What he had to show him wasn’t going to make Pearson any happier, either.
Ethan rose from the counter where he’d been using a binocular microscope to scan a Gram-stained slide. “Let me show you,” he said. He moved to a large cabinet with glass doors, opened one of them, and removed a petri dish.
Pearson made no move to take the shallow, covered glass dish Ethan held out. Instead, he bent until his face was a foot from it and studied its contents. Finally, he straightened and said, “I’m afraid it’s been too long since I had bacteriology. It looks like this is a blood agar plate, and it’s almost completely covered with bacterial colonies. What about it?”
“To begin with, it’s totally unusual for Corynebacterium diphtheriae to grow this rapidly. I would normally wait twenty-four hours, then inoculate tellurite-enriched agar with some of the material from the original culture. That would further enhance colony growth. I’d eventually do a stain, basing the final identification on colony characteristics and microscopic morphology of the bacteria.”
“Didn’t we already confirm a diagnosis of diphtheria?” Pearson asked.
“True, the morphology of the bacteria we saw on the slide from the original throat swab are Gram-positive bacilli with clubbing at one end. That, combined with the clinical picture, is generally enough to justify starting treatment for diphtheria. But I don’t stop there. I keep going until I have the diagnosis nailed down. That’s why I’m still working on this.”
“And have you found something more?” Pearson asked.
Ethan put down the plate and picked up another, this one with perhaps a dozen filter paper discs scattered around its surface. “We know that the diphtheria bacillus should respond to penicillin and erythromycin, sometimes to a few other antibiotics, although that varies, but ‘should’ isn’t always dependable, so I do sensitivity studies, seeing how various antibiotics prevent bacterial growth.”
Grant held out the new petri dish for Pearson’s inspection. “This one was plated less than twenty-four hours ago, and as you can see, the colonies have already grown so rapidly they almost fill the dish.” He used his pen to point. “Each of those white filter paper discs is impregnated with a different antibiotic. Normally, a sensitivity study isn’t ready to be read this early, but this one’s unusual.”
Pearson looked at the petri dish, then he took it from Ethan’s hand and studied it more closely. “Where are penicillin and erythromycin?”
Ethan pointed. “There and there. But it really doesn’t matter, does it? There’s no zone of inhibition anywhere.”
“So that means—”
“Yes, sir. That means the organism infecting your patient is growing so much more rapidly than the Corynebacterium diphtheria that it’s covering over that bacteria. And whatever this other organism is, it’s resistant to every antibiotic in our arsenal.”
***
David Madison awoke from a fitful doze when he heard the door of his room open. Despite good eyesight, he couldn’t identify the person who entered. He’d complained to Dr. Pearson about the face shield, mask, and gown all his visitors had to wear, but until now, using height and mannerisms, he’d generally been able to identify the few people cleared to enter his room: two nurses, one orderly, and his chief of security, Jerry Lang. This new visitor was taller and thinner than Lang, and his walk was different from Dr. Pearson’s. Madison didn’t recognize him, and he had a bad feeling a
bout it.
He felt silly challenging the person like a sentry on post, but then again, he’d learned in his years in the White House to have a high index of suspicion in some situations. This one qualified. Madison cleared his throat and said, “Who are you?”
The intruder—because that’s what Madison was beginning to think of this person as—didn’t respond, but continued his slow advance across the room. When he was six feet from the foot of the bed, his hand disappeared for a moment beneath the hem of the yellow isolation gown he wore.
“What are you doing?” Madison asked. He was concerned not only by the visitor’s failure to respond to his question, but by the raspy tone he detected in his own voice. Pearson had warned him to watch for difficulty breathing. Was what he was experiencing now due to fright or to a progression of his disease?
The man’s hand emerged holding a small pistol with a long, thick barrel. Still without a word, he pointed it at Madison, who thought he could see the man’s finger tighten on the trigger.
It was probably useless to make a grab at the weapon, but Madison determined to try. He gathered himself for the effort. His left hand was encumbered just enough by the IV in his vein that Madison leaned a bit to the left as he tried to sit up. Then gunfire shattered the relative hush in the hospital room.
7
Mr. President, are you okay?” Jerry Lang stood half in and half out of the doorway of Madison’s room, his service pistol in his right hand. The smell of gunpowder hung in the air. Lang addressed his question to the man in the bed, but his eyes never left the shooter who lay facedown on the floor, his pistol near his outstretched hand.
“I’m not hurt, if that’s what you mean.” David Madison’s voice was weak, but still bore a hint of its commanding tone. “But you can’t come in here like that, not gowned and masked.”
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