“It’s a pain in the ass is what it is,” said Ford, watching Allen now, waiting to see if he was going to get to whatever it was on his own. “The roster gets screwed up, for one thing. And anyway, I can’t see—”
“Marcus.”
Allen paused for a moment, frowned at his scribbled notes.
“I’ve been meaning to talk to you. I wanted to say it last night, but I … I just couldn’t get into it somehow.”
“What … what is it?”
Allen moved towards the door. He waited until they were outside in the corridor before speaking again.
“Look, I’ve been meaning to…”
“To speak to me, yes. I think we’ve established that.”
Allen laughed an uncharacteristic, nervous laugh. Then his face fell. Ford had never seen him look so serious.
“So,” said Ford. “What is it?”
Allen watched a nurse coming along the corridor.
“Is it Ellen?” asked Ford. “Is there something wrong at home?”
Allen looked back at him, a puzzled expression on his face.
“Has she spoken to you?”
“No. No … I just. I don’t know, you’ve been acting kind of strange lately, and I just thought…”
Again Allen looked away. He nodded a greeting as the nurse went past.
“Well, she isn’t too happy about our situation,” he said. “That’s for sure. It can be real hard. Sometimes … sometimes I get home and I’m too tired even to talk, even to eat. I sit down in front of the TV and watch the news about all the shooting I’ve been dealing with all day. You know how it is.”
Ford looked at the floor. He knew how demanding Ellen could be. She was very proud of Conrad, of what he had accomplished, and loved to hear Ford sing his praises, but she could be critical too and wasn’t above suggesting that Ford exploited her husband sometimes, using their friendship to exert pressure.
“Sure, I know,” said Ford, hoping that if he made sympathetic noises, Allen might get into a little more detail. “It’s hard. Carolyn used to hate it too. The hours, I mean.”
He looked up at Allen’s face, and waited for him to speak. But Allen seemed to have run out of steam now.
“Maybe we should call off the fishing trip,” said Ford. “Maybe you should take Ellen somewhere instead. Get away from it all. You know, just the two of you book into somewhere nice. The Kempinski in San Francisco is supposed to be romantic.”
Allen shook his head. Then he lifted his foot and put it down firmly, as though making a decision. But at that moment Ford’s pager sounded. He checked the number.
“We’d better get down to Trauma,” he said.
Three days after surgery, the Shark’s condition began to deteriorate. His temperature was spiking at 104 degrees and his white-blood-cell count shot up in response to bacteria in his system. Although he was still pretty much immobilized in bed, his discomfort was obvious. When Ford came to see him in the ICU, the dark, angry eyes never left his face.
There was distinct redness around the entry wound, which was warm to the touch and tender enough to close the Shark’s eyes and make the air whistle in his throat tube. There was also pus at the site of the entry wound and in the vacuum bottle of the surgical drain Ford had established as a precautionary measure. Fearing the formation of an abscess somewhere inside the missile track, Ford took a sample of the exudate drained from the entry wound and was able to identify a gram-positive coccus, which the lab later narrowed down to Staphylococcus aureus through fluorescent antibody staining and a blood plasma coagulation test.
The Shark wasn’t so lucky after all.
Not that staph infection was unheard of. The infection rate for so-called dirty wounds at the Willowbrook—all trauma wounds were classified dirty—was running at around fifteen percent, and staph was the most common pathogen in wounds of that type. It was a nasty bug that despite being present in the nostrils of around thirty percent of healthy adults was little understood in terms of its ability to wreak havoc in the human body. Through the production of a variety of toxins and enzymes, staph caused boils, abscesses, conjunctivitis, and a condition known as scalded skin syndrome in which the skin came away in sheets.
Ford’s immediate worry was that the infection appeared to have developed despite the high dose of a so-called scattergun antibiotic given to the Shark prior to surgical intervention. It wasn’t a reason to panic. Drug-resistant staph was unfortunately fairly common. It was one of the most successful bugs in the microbial war against antibiotics, a dark champion that had gone from being totally helpless against penicillin back in the early fifties to winning nine out of ten battles against the same drug by 1982.
But the bug teeming inside the Shark’s wound was not necessarily of that sort. The fact that it had failed to respond to cephalosporin, the antibiotic initially used, did not mean it was invulnerable to other forms of attack. But because of the position of the wound and the potential for complications should a deep abscess form somewhere inside the Shark’s neck or mouth, Ford decided that he was not going to have the luxury of running through a series of drugs to find out which one worked best. There was a possibility that the cephalosporin resistance indicated broad resistance to other penicillin substitutes. This, Ford felt, ruled out the use of methicillin, a drug that, nine times out of ten, continued to be effective against staph.
In the end he decided on a radical change of tack. In his view, the Shark’s best chance of beating the pathogen was vancomycin. Administered intravenously, it was an unpleasant drug to take, and there was a risk of serious side effects. Because of this, it was rarely prescribed, and therein lay its power: the microbes didn’t see it often enough to develop defenses. Like penicillin, vancomycin inhibited cell-wall synthesis, but it did so using a different mechanism, one for which—Ford felt sure—the staphylococcus in the Shark would find no answer.
Ford instructed the attending nurse to set up bed number three for the administering of vancomycin and then paged Dr. Lucy Patou. The Willowbrook’s internal guidelines obliged him to notify the chief of infection control of any resistance problems, whatever the pathogen involved. The case would eventually come to Patou’s notice anyway through the hospital records, but by notifying Patou immediately, Ford was giving her an opportunity to institute any measures she might feel were necessary.
She came back to him immediately on one of the ICU phones, sounding professional and chilly. Ten minutes later they were in her office.
Not surprisingly, given the events of the past week, Patou was not in a very friendly mood, although, Ford was relieved to see, she did not raise the issue of his professional discourtesy. For most of the interview she looked down at her notes, meeting Ford’s gaze only when he had trouble recalling what exactly had gone on in the critical room, and then in OR. From time to time she leaned forward in her swivel chair to check her microcassette. It was there to remind him that this was all on the record.
She wanted to know everything about the Shark and procedure prior to the infection declaring itself. She did nothing to disguise the fact that she suspected a nosocomial source. After half an hour she came to her concluding questions.
“Regarding the closing stages of the operation, Dr. Ford, did you encounter any problems?”
Ford smiled.
“You mean did I leave any swabs in there, any IV tubing?”
Ignoring the gibe, Patou consulted her notes.
“You say you closed the soft-tissue injuries of the lining mucosa and worked outwards, finishing with the damaged jaw.”
She looked up.
“That’s right,” said Ford, “inside out, bottom up—the way I always do, Dr. Patou.”
“Using debridement, cutting away damaged tissue?”
“A little. But the missile track was actually very clean. I instituted a surgical drain to draw off any residual fluids or pus.”
“There were no fragments left inside?”
“Not that I noticed.”
Again she looked up.
“Not that you noticed, Dr. Ford?”
“Dr. Patou, rummaging around for fragments in this area is not recommended. A broad rule of thumb we surgeons use is that, all things being equal, a bullet ceases to cause damage when it ceases to move. Nothing showed up on the x ray. As these things go, it was a pretty clean wound. Getting shot in the neck is bad news because there are so many blood vessels. But provided the bullet misses the major ones, you’re in fair shape from an infection point of view precisely because the tissue is so well supplied with blood and thus oxygen.”
Patou gave a little sniff. She didn’t need an anatomy lesson.
“As for the exit wound,” Ford went on, “it was a little more complicated.”
Patou waited.
“The missile punched a hole through the left mandible. There was a degree of avulsion.”
“Avulsion?”
“Tissue, teeth, and bone fragments punched outwards.”
“And?”
“Well, it actually looked worse than it was. And I was able to … I basically molded the fragments with my fingers into the best anatomical position and wired his jaws together.”
Patou looked momentarily alarmed. Ford realized he should have expected her not to like this. If she had ever studied surgical procedure, it was a long time ago. She had obviously forgotten how messy it could sound.
“That’s right,” said Ford. “I don’t know how much of med school you remember, Dr. Patou, but that’s how you do it. You don’t go in there with a knife and start stripping soft tissue away from the bone, putting in clamps and plates and so forth. You repair the gum and mucoperiosteal tissue as accurately as you can to minimize bone loss. If you debride too much, you just end up losing bone. Bone is tissue too, remember. It has to have blood.”
Patou seemed to be accepting his account, so Ford moved on.
“Once we got to the outside, I was able to verify the viability of injury flaps with pressure blanching.”
“Pressure blanching? What does that involve?”
Ford smiled. She wasn’t going to like this either.
“You pinch the tissue with your fingers, press the blood out. If the capillaries refill afterwards, you probably have healthy tissue there. I mean viable tissue. There was actually very little outright tissue loss. Then I closed him up.”
“You closed him up?”
“Not too tightly. Sew them up too tight and you can get distortion later on. That’s when they come back looking for you.”
He tried a smile, but Lucy Patou was not about to relax.
“And postoperatively?”
“He went into ICU with firm pressure dressings to stabilize soft tissues. Tube fed to maintain oral cleanliness. I took him off cephalosporin and put him onto vancomycin.”
Patou raised an eyebrow.
“That’s a pretty direct route,” she said.
Ford shrugged.
“I didn’t feel I could waste time finding out if something else worked.”
“Well, let’s hope he pulls through.”
“Amen to that.”
Patou pushed her notes aside and in doing so knocked over a framed photograph she kept on her desk. Ford caught a glimpse of a young boy’s smiling face, and it suddenly dawned on him that Patou was probably a single parent, just like him. He had no concrete reason for believing it, but seeing her alone with the child, it was like the last piece of a jigsaw. Suddenly a lot of things, a lot of impressions made sense. He had never really thought about Patou’s private life. Apart from the NIH conference, the only time he had ever seen her outside the walls of the Willowbrook she was coming out of a store at Farmer’s Market one Saturday morning. She had been carrying too many shopping bags, struggling with the weight, but keeping her usual tight-lipped dignity. Recalling the incident now, he felt his intuition was being confirmed. Of course she had been shopping on her own, she was living on her own, or living with this child, the kid in the photograph—her son probably. He experienced a little squeeze of fellow feeling, of compassion for her.
Patou looked up from her papers and caught something in his expression that made her narrow her eyes.
“So what went wrong, Dr. Ford?”
Ford sat back in his chair.
“You know the statistics, Doctor. It’s a dirty wound. There’s a one in six chance of infection.”
“So you think he brought it in with him?”
“Maybe.”
Patou made a wry mouth.
“Well, I’ll tell you the problem I have with that, Dr. Ford. The chances of a cephalosporin-resistant staphylococcus coming in off the street is rather less than one in six. In fact in the whole of Los Angeles County there are only around one hundred cases of multiresistant infections, and a large percentage of those are TB.”
“We don’t know that this is multiresistant. We’ve only tried one drug. It may be that methicillin would—”
“You’re right. We don’t know. But we have to err on the side of caution. As chief of infection control, I am obliged to do so.”
She fixed him with her cold green stare.
“No. I think it is more likely that he picked this thing up in OR. I know you don’t want to hear this, but there are, it seems to me, two pertinent considerations. Staphylococcus is unlikely to develop multiple resistance outside. That’s just the way it is, despite theories to the contrary.”
She waited a moment to let this sink in, to see if he had the nerve to get into any of his conference bullshit with her one-on-one. He said nothing.
“But inside the hospital,” she went on, “there is sufficient contact between the bugs and the drugs for resistance to develop. Now, as I’m sure you are aware, the most common vector of infection is dirty hands.”
Ford moved around in his chair, offended, despite himself, at being accused of poor hygiene. Patou went on, apparently oblivious.
“Fortunately in this hospital surgeons scrub for ten minutes before going into OR.”
She said this as though she didn’t believe it for a second.
“And wear sterile gloves and gowns, and face masks,” added Ford.
Patou acknowledged this with a nod. She waited a beat and then asked, “Do you suffer from eczema, Dr. Ford?”
The question caught Ford off guard. For a moment he was at a loss for words. Patou went on. Clipped, cool, looking him straight in the eye.
“Or any other lesions? Boils, fungal infections of the groin?”
Ford felt the blood rise in his face.
“No … No, I don’t believe I do.”
Patou brought her notes together and shuffled them into a neat stack.
“I’m obliged to consider the possibility that somebody in OR passed the staphylococcus to Mr … to the patient. Eczema can be a factor in a carrier haboring high concentrations of bacteria.”
“You’re saying I’m a carrier?”
“A broadcaster, more to the point. Someone who sheds large numbers of staphylococci into the air. And, no, I’m not saying that you are. I’m saying that you, or someone else on the team that attended the patient, may be.”
She smiled.
“Staphylococcus can be isolated in the anterior nares of around thirty percent of healthy individuals,” she said, “and occasionally the perineum.”
“The perineum?” Ford could hardly believe his ears.
“That’s right, Doctor. You know, that little strip of skin between the anus and the genitals?”
Ford could see that Patou was beginning to enjoy herself. Allen had been right. She was planning to culture his ass. Involuntarily he clenched his buttocks.
“Other areas get contaminated from a carrier site. The face and neck, sometimes the hair and hands of a nasal carrier. Or the buttocks, abdomen, and um … the fingers in the case of a heavy perineal carrier.”
Ford was beginning to feel very dirty.
“But with lesions of one sort or another, contamination can be more—
”
“Yeah, I’m beginning to get the picture, Dr. Patou. Well, I don’t have any lesions or fungal infections of the perineum. Not the last time I looked, anyway.”
Patou smiled brightly.
“Fine! That’s great. In that case testing you will probably be a very straightforward matter.”
Ford sat up straight.
“Testing me?”
“That’s right. You and the other members of the team. Well, it’s the only way to be sure about this.”
“What kind of test are we talking about?”
“It’s very simple. Broadcasting is measured by air sampling in a small room or plastic chamber while the person in question carries out some standard exercises—without their clothes, naturally.”
Ford swallowed.
“You want me to take my clothes off in a plastic cubicle while you suck the air out.”
Patou nodded encouragingly.
“But we’re all wearing gowns, masks, gloves, for Christ’s sake. Even if one of us did have some organism, it wouldn’t be able to get onto the patient.”
Patou was shaking her head, disappointed at this lack of cooperation.
“Unfortunately, standard protective clothing doesn’t stop infection from happening. But, now that you mention it, there is a form of plastic diaper on the market that surgeons with this problem wear when operating.”
Ford briefly considered the prospect of standing under the OR lights for six hours wearing plastic diapers.
“Let’s do the test,” he said.
In the early hours of Sunday morning the Shark woke with the feeling that his whole body was on fire. He blinked up through stinging eyes at the white ceiling, squeezing his fists, focusing on a strip of shadow thrown across from the curved curtain track. It was getting harder to hang on to the here and now, to be present, to be where he knew his body was. In bed. At the Willowbrook. He kept seeing the Chicano bitch who had shot him, seeing her vividly in the moment she bit her teeth together in a sort of angry smile, pushing the gun at his face. Sometimes she was more real to him than the bed. He kept seeing the white doctor, Ford, kept hearing his voice telling him how lucky he had been. Colored lights jerked behind his eyes. He dreamed that he was shouting and then woke up with his jaws wired solid, all sensation in his face gone, so that his whole head felt like a stone and the only thing that was still human were his eyes. He drifted in and out of consciousness, coming to in the mesh of tubes with the feeling that they were there to stop him floating away forever. And all the kaleidoscope craziness wasn’t just the drugs they had given him to kill the pain. Somehow he knew that.
OMEGA Page 7
