by Nicholas Lim
She walked down the epistle aisle. Her heels tapped on familiar dates: 1917, the Spanish Flu; 1945, the tuberculosis epidemic.
She thought about drowning statistics. There were around four hundred across the country each year, a significant number alcohol-related, many due to concussions and broken necks after falling or diving; very few occurred in swimming incidents.
On the walls woodcuts of the Stations of the Cross marked the progression of another death. She crossed the transept and sat down in one of the front pews. She rubbed scrubbed fingernails with a thumb.
A crucifix was fixed high on the back wall of the apse. The Passion. She disliked the word. Garrett studied the injuries. The cause of death was indeterminate: either the wound in the side, if it had perforated the right lung or pericardium, or else cardiac arrhythmia or infarction provoked by hypovolemic shock, dehydration and exhaustion asphyxia. With limited ability to push up with the feet, each active diaphragmatic respiratory effort would have been tiring and agonizing. She felt annoyance at a customary inaccuracy: the ligaments and bones of the wrist can support the weight of a body hanging from them, but the palms cannot. One faith against a whole earth's unbelief, One soul against the flesh of all mankind.
She studied the conformity of the head and thought about the skull vault she had just opened. She needed a second opinion.
Door hinges squeaked from somewhere behind her and Garrett heard two sniffs and then humming. She glanced around the chapel. There was only one exit door. She sat perfectly still, eyes closed like a child hoping.
“Hello Christine!”
“Hi Arthur.” Garrett frowned. The man was normally like clockwork. This was not his regular time.
“It’s a busy evening! I’ve just seen Jim Da Costa in ER.”
“What was he doing there?”
“I was just passing through. I didn’t ask.” The Chaplain slid into the pew beside her and launched into a rambling story about palliative care and then one about hospital catering.
“But anyway, enough of me. How’re you, Christine? Working late?”
“Yes, long day. Just off home.”
“It’s good to catch you. You know my colleague at Guy’s tells me that he sees you often in his chapel.”
“It’s quiet there.”
“Like here.” The Chaplain tilted his head and sighted along his nose as if through a glass to scry objects out of the normal view. “I often think of you in your room, me in mine.” He glanced around his chapel. “I noticed you returned our cross. Your walls must be completely bare now.”
“They’re not bare. There’s a plaque.”
“A plaque. Right. What does it say?”
“Hic locus est ubi mors gaudet succurrere vitae.” Garrett waited a moment to tease the clergyman. “This place is where death rejoices to teach those who live.” She shrugged. “You’ll find it in autopsy rooms everywhere.”
Garrett tried to identify the smell the chaplain had brought in with him. Was it incense or aftershave?
“Any news of your son?” His voice was quiet.
“No.”
“It must be difficult for you.” Garrett turned her face away, but he continued to speak. “I was talking to Eva last week. You remember the trouble her cousin had, with those same people? Well, she told me a bit more about this clinical psychologist they used; apparently he’s something of an expert on them. I think he may be able to help.”
“Thank you but–”
“I’ve got his card somewhere here. She gave it me. Now where the devil – ah-ha! Prenderville. That’s right. Please, take it. Eva says he's a miracle worker. Her cousin swears by him; doesn’t know what they’d have done without him. And he has contacts. Anyway, he might be helpful.”
The chaplain left with his usual over-familiar squeeze of the shoulders. In his absence Garrett heard a record of other absences in quick succession as if spliced newsreels. She listened to them and waited. Sometimes now, occasionally, she heard just the silence. It was what she came here for. What was the word? vοούμενον. The thing itself. Garrett stood up and patted pockets for her car keys.
She stopped her battered estate car at the bottom of the exit ramp, at lights on red. An ambulance turned into the entrance and headed towards A&E. There was no other traffic on the roads; that was one advantage of working late – the quick run home. Garrett stared at the red traffic light and saw again the malaria pigmentation illuminated on the slide.
What was a lethal strain of cerebral malaria – with parasite levels she had never heard of – doing in England? The returning thought annoyed her. She had a knack for leaving work at work.
“Horses, not zebras.”
The lights turned amber then green. Garrett shifted into first.
It was an import or relapse. Garrett glanced in the rear view. Deaths by drowning were mainly male; ninety-five percent of swimming-related deaths were male. So by the numbers, the she should have been a he. Unusual, but then again, not that far off the curve.
The lights turned red again.
Garrett reversed up the exit ramp. At the top she made a one-point turn.
She walked around the table three times before starting, by her fixed habit.
The second body was of a tall, well-muscled young man. The head looked back at her with the blank regard of a statue. Dreadlocks snaked away in rough ropes. But what caught Garrett’s attention was the colour of the skin – all the colours – of intricate tattoos, livid in places like bruises. Rare un-inked patches appeared as the bare canvas of a painting in progress.
Garrett continued to circle the table. She bent to inspect the blue fingernails of a strong hand; well-defined tendons linked knuckles and finger joints. There was ante-mortem bruising in the palm; non-circulating blood from damaged veins had pooled in the capillary beds. The hand held a brief image of final pain, of a grip strong enough to break skin.
One fresh tattoo stood out on the left shoulder, the healing incomplete. Garrett approached for a closer look then took a quick step back. Her lips opened. Her pulse, rarely above sixty-five, reached a hundred and forty.
The new tattoo was of a small eye, the pupil black and iris a veined green, surrounded by rays like a child's sun.
Garrett held herself still for a full minute. Her breath entered and left her in small gasps. She waited for her heart to calm before continuing.
She prepared the post instruments with quick efficiency. The routine of it calmed her further. She slipped on her glove and selected the prosector's knife.
After the Y incision she did not move for a long time.
***
“Fifty cc, Benzodiazepine.”
The consultant anaesthetist hesitated and asked Mr Da Costa to repeat his prescription.
“Yes, Benzodiazepine,” Da Costa said. His voice was sharp, clear about priorities. If they didn’t thin the blood immediately, they’d lose the patient.
Isolation Room 401L hummed with activity. Da Costa, the Brighton Royal’s Head of Clinical Pathology, had been called in to help with an unusual case.
A currently-unidentified female in her mid-twenties had been found five hours earlier wandering delirious on a beach. By the time she had been admitted to the hospital, she was suffering from seizures. The fits had steadily escalated in severity until the patient had begun repeatedly to lose consciousness. Initial blood work had shown, in addition to high levels of alcohol and traces of Diethylamide, the presence of malaria parasites.
“Fifty cc, Benzodiazepine,” the anaesthetist intoned, measuring out the dose. A nurse prepared the woman’s right forearm. The needle slipped into a vein.
As he watched, in a dry, black and always-sane corner of his mind Da Costa mused on his prescription and the pharmacological peculiarity that the most effective drug for thinning blood was also a popular and powerful anti-depressant. Watching the girl he noted that mood alteration was not a rapid side-effect.
The girl's eyes were open, staring unseeing at the white
-tiled hospital ceiling. Occasionally she would blink in spasms that convulsed her whole face. Her mouth was half open, lips stretched back over her teeth as if in parody of a diva mid aria, but in truth frozen in the rictus of a pain which gripped her entire body. Her hands clenched bed sheets, knuckles down. Only her legs moved, kicking out spasmodically like the limbs of an experimental frog whose nervous system continues to fire after its spinal cord has been severed.
“Temperature is now 106, pulse arrhythmia increasingly pronounced,” the anaesthetist observed.
Da Costa's gaze flicked over to the monitor displays. He noted the increasingly erratic waveforms on the ECG. “Increase IV quinine dihydrochloride to twenty mg and maintain hydration, Dex ten.”
An intercom beeped.
“Jim, the CBC smears are ready.”
“Thank you Janice.”
Da Costa punched up the results on a monitor at the foot of the bed.
The anaesthetist came to stand with him. “Christ. Platelet count twenty bph! Paresitemia ninety-five percent! I've never seen anything like it! Her blood is completely colonised.”
Interrupted by sudden movement, the two men turned. The woman had convulsed, her whole body in spasm. The nurse and both residents held her down as another convulsion shuddered down through her body. Moments later she was still, and the air was filled with the ECG’s continuous hum of lost pulse.
Da Costa moved to the bedside. “Twenty mg BP,” he ordered calmly. “Go to slow IV, benadryl, cortisone and amniophylline.”
“She's going cyanotic.”
“Positive pressure oxygen. Charge.”
The woman’s lips were turning blue and her eyes no longer blinked. Her body spasmed now only under the repeated shock of resuscitation attempts. The team worked efficiently and without mistake to the legal limit.
In the pause after death no-one spoke. Da Costa stared down angrily at his empty hands. He always felt anger. He had figured out once, a long time ago, that it was really helplessness. Not that the knowledge helped. The anger did not change with understanding.
The continuous tone of the ECG filled the air like a reproach.
***
“Gladys. Got your message.”
“Well?”
“We lost her.”
Da Costa dropped down heavily into one corner of a large leather sofa opposite the desk of Gladys Morgan, the Brighton Royal’s day manager. Morgan’s PA poked her head around the door.
“Christine Garrett is here.”
“Send her in.”
“Er, and Colin Jenkins is on the line again.”
“Not now.”
The sharp word dismissed the PA too. Thin and bony, and with a smile full of teeth, Morgan was sharp at all her edges. The nurses called her The Shark, and had invented various carnivorous explanations as to why she was still childless.
“Come in Christine. You’ve caught up on Jim’s case?”
Garrett nodded to Da Costa.
“Look you two, I’m looking at three fatal cases of malaria in twenty-four hours. What the hell is going on?”
Morgan looked at Da Costa. Da Costa looked at Garrett.
“For God’s sake Jim,” Morgan said. “You saw the admitted patient. You start.”
“Initial visual blood work appeared to show malaria falciparum parasites–”
“–but there are significant anomalies,” Garrett said. “In my opinion, enough to call the diagnosis into question.”
Morgan leant forward.
“Really? Well if it’s not malaria then what is it?”
“At the moment, I couldn’t say.”
Morgan looked irritated. Garrett passed around sheaves of printouts.
“It’s definitely a blood parasite,” Da Costa said.
Morgan nodded at the top sheet of photos. Dark grains freckled the interiors of most of the purple-dyed erythrocytes crowding the slide boxes.
“Yes,” Garrett said. “But there are many blood parasites. Trypanosomiasis, leshmania, babesiosis, trypanosoma, filariasis–”
“From the cell forms on the slides it looks most like malaria,” Da Costa said.
“Yes. But the anomalies are not trivial,” Garrett said.
Morgan laid thin forearms right over left along the desktop and compressed her lips. She was annoyed with both her chief microbiologist and her senior visiting epidemiologist. It was an unusual circumstance for all of them. Morgan looked to these two in particular for scientific certainty – a type of reassurance – and was used to getting it. Right now, from where she was sitting they were only adding to her difficulties.
“Look, I’m guessing Jenkins has heard about these deaths. The county medical examiner doesn’t make social calls. Not to me anyway. Damn it, I don’t know how he knows so soon.” Garrett made no comment. They all knew there were few institutions in which the virus of new gossip propagated faster than a hospital. “He’ll be phoning back in a minute and he’ll be after some answers.” Morgan leaned back in her chair and studied Garrett. “Before I have that conversation, perhaps you can clarify the ‘anomalies’ that are troubling you?”
“Okay,” Garrett said. “Let’s start with the high parasitemia.” Morgan frowned. “The count of parasite attacks on red blood cells. In non-falciparum malaria, parasitemia rarely exceeds two percent. With falciparum, yes it can be considerably higher, sometimes over fifty percent, but nothing like what we’re seeing. Practically every cell’s colonized.”
Morgan studied the top sheet of photos lying on her desk without touching it.
“Then there’s the extreme pathology,” Garrett said. “Jim, you attended the last death. But all three would have occurred fast–”
“–why?” Morgan interrupted.
“The severity of the brain attack. I’ve completed all three autopsies. They’re the same. Extreme cerebral haemorrhaging.”
Morgan stared sternly at the images of the cells, as if about to order them to speak.
“And we haven’t talked about transmission.”
“Yes. Malaria is a blood infection passed via a very specific vector, the anopheles mosquito,” Da Costa said.
“So you’re saying these insects are in southern England?” Morgan asked.
“There’ve been no reports,” Garrett said.
“We have three cases,” Da Costa said. “It wouldn’t require a large population.”
Morgan pursed her lips. “Is there no other way of catching the disease?”
“There are recorded incidents of rare, trans-placental infection,” Da Costa said. “But none of these victims is a new-born baby.”
Morgan repeated something Garrett had said, slowly, thinking aloud. “Blood infection.” She asked sharply, “Could our blood supplies be infected?”
“Remember all three patients were symptomatic before they got to us,” Garrett said. “But I just had random samples tested from all group banks.” She shook her head.
Morgan stretched her lips at Garrett and visibly relaxed. She looked at Da Costa.
“Do you agree with Christine?”
“I don’t like these unexplained factors.”
Morgan waited but Da Costa said no more.
Garrett put her printouts down. “Gladys, remember I worked for two years with the WHO SEAN. I was based in Gujarat so I saw my fair share of malaria deaths, including from the falciparum strain. Our cases, they don’t quite conform. The cells on the slides certainly look like falciparum,” Garrett nodded at Da Costa. “But the questions about infection, the speed and degree of the parasitemia, the brain attack, the lack of resistance–” Garrett gave one shake of her head. “Something about these deaths feels wrong.”
Feels wrong? Since when had her senior epidemiologist become touchy-feely? Morgan stared at Garrett over her glasses. She relied on her judgement. During the legionnaire’s disease crisis two years back, well, she had steered her through it. And Da Costa was stubbornly level-headed, one of the most experienced members of her scientific staff a
nd a man not easily rattled. She didn’t like what she was seeing.
“What shall I say to Jenkins?”
Garrett glanced at Da Costa then said the last thing Morgan had expected to hear from her. Hospitals – particularly large general hospitals with the staff and budgets of small multinationals – were notoriously self-sufficient. They built their reputations on what they could handle.
“Ask him for some help.”
Dudec sat on a white plastic chair in the cramped pathology admin office typing data into a form. When Garrett had returned from her meeting with Morgan he had volunteered to add the priority lab request to the CDSC notification. He was regretting wanting so much to please. He hated forms.
The computer gurgled for a moment as the anti-virus program started its daily scan. The machine was old and very slow. Dudec completed the forms, attached them to an email, hit Send and stood up. He could hear Christine Garrett in the adjoining room. He wondered if he should suggest a quick drink. He noticed a single golden hair on the carpet. It was hers. He thought about the way she moved around the autopsy tables, beautiful and strict. He shook his head. Stop it. Time to shut down and go home. He turned round, stabbed an impatient finger at the computer’s power switch and headed for the door.
The anti-virus scan had not completed. It had taken so much of the machine’s resources that the notification message remained unsent when the computer shut down.
Chapter 2
Imagine you are riding the waves of your breaths. Breathe in…Out… In…Out…You are floating on the seas of sensation. Now imagine a coastline, cliffs in the distance. You see a sandy beach. Breathe in…Out…
You arrive on the beach. A path follows a stream inland. Take it. You walk under trees then come out into a valley. What do you see?
Christmas turned his head slightly, eyes closed. He saw what he always saw: sheep, trees, flowers.
