Weapon of Choice

by Patricia Gussin

  Father.

  Matthew was right. Victor was too exhausted even to think. He did need a few hours of sleep. He and Matthew had so much to talk about, but they could wait until he had more emotional and physical stamina. Maybe later in the day.

  Victor gently kissed Matthew’s forehead. No more fever, no more clamminess. His son had rallied, valiantly fighting the virus that ultimately would claim his life. But before then, I promise you the best life, the most comfort I can give you.

  On the way out of the unit, Victor stopped at the nursing station to make sure that they had his contact information. He was surprised to see Matthew’s primary doctor working on charts.

  The lanky, deeply tanned physician looked up and smiled. “Dr. Worth, I was hoping to have a word with you. Your son is doing extremely well.”

  “That’s great.”

  “So well, that I hoped you’d consider home care. He’ll have to be on IV antibiotics for another two weeks, but his lungs have cleared up. As you see, he’s no longer on oxygen. And—”

  “Yes, yes. I can manage the intravenous.” Victor assumed that Matthew would agree to live with him in Bethesda, but they’d not discussed it.

  “Just don’t try to do it yourself. You know what they say about treating relatives,” the doctor said. “If you could get a daily nursing service to come in, I’d consider discharging him on Monday. Other than that, Mr. Mercer has no restrictions. His staph infection responded beautifully to the methicillin, I must say. And Bactrim handled the pneumocystis. I wish all my patients showed such a good response. That Dr. Nelson in Tampa did an admirable job. If she hadn’t done that biopsy and nailed the diagnosis, your son might not be alive today. But you do know that Mr. Mercer will need ongoing care for—”

  “AIDS. Yes, I know,” said Victor. “I’ll make sure he gets the best.”

  Victor should have stopped at that, but he could not keep himself from asking, “About the staph infection. So it wasn’t antibiotic resistant at all?”

  “No, just the run-of-the-mill staph. You can see how well he responded to the antibiotic cocktail. If only we had a cure for the HIV virus—”

  All I wanted was revenge on Norman. But then to cover up, I infected a roomful of patients. And Matthew had never even needed ticokellin in the first place! Can anyone in Tampa connect me to those ICU patients? No—because I’ve destroyed the cultures. My entire life’s work, trashed. But to protect my son. I had to protect my son.

  “But, Dr. Worth, sir,” the younger doctor said, “you have to take care of yourself, too. You look exhausted.”

  “I’ll be back to see my son later today,” he said.

  Will I have time to take my discarded glassware to the landfill? To get the microbiology equipment out of my basement? Too drained to answer his own questions, Victor left the hospital.

  CHAPTER FORTY-TWO

  FRIDAY, NOVEMBER 29

  The patients in these beds were Laura’s responsibility. How could this have happened? In a daze, a trance almost, Laura stood and looked at bed after bed. “Yersinia pestis” stuck in her mind. The plague organism—the Black Death—killed almost half of Europe’s population in the Middle Ages, or was it the Renaissance? She wasn’t sure. A pandemic. Is that what she was facing now? Rapid onset. Highly lethal. Swiftly spreading. Carried by rats? Fleas? But there were no rats and no fleas in her ICU. Forget yersinia; the lab’s early culture results showed a staphylococcus. A staph highly resistant to all antibiotics.

  On the way to the seventh floor, Laura and Stacy had agreed that Stacy would impress upon her boss the seriousness of the situation and then start intensive isolation procedures, relying on public health protocols. Stacy was at the nursing station now, calling the CDC. Laura would take charge of patient care. Why, she wondered, was the ICU so eerily quiet. Seven beds—one empty as her beloved patient Bart Kelly was dead. Six patients, but only one nurse and no doctors? And only one clerk at the desk? How could that be? More like four nurses and as many aides would be minimum in addition to the usual complement of residents and medical students. A holiday weekend, yes, but the hospital must have adequate on-call coverage. This was unacceptable.

  Laura headed for the lone clerk, a dark-skinned woman whom Laura did not know. Unusual. She must have been called in from another floor. At least she was protected: cap, mask, gloves, full-length gown. Laura noticed an apple sitting alongside a stack of lab reports. “Don’t eat that,” she said, “and, where is everybody?”

  “Don’t know,” the clerk drawled, “I’ve never worked the ICU before.”

  Laura asked, “Has anybody called for more nurses and paged the on-call medical and surgical residents?”

  “I tried the nursing office, Dr. Nelson,” the woman said. “They said they would send more help, but—”

  “But?” Laura prompted.

  “Everybody’s scared. The word’s out that there’s a bad disease in here and that it’s spreading fast. I’m worried, too.”

  “We can’t leave our patients,” Laura said. “Just make certain that you and everybody else follows strict isolation procedures. And don’t forget to get rid of that apple. Nothing should go near your mouth.”

  The clerk looked stricken, her pupils dilating.

  “Soon, a stricter isolation process will be set up for anyone entering or leaving the ICU.” At least, Laura hoped that Stacy had the clout to get a state-of-the-art isolation program up and going.

  The clerk wrinkled her brow, skepticism in her eyes.

  “Thank you for staying,” Laura said. “Now, will you track down the director of nursing, the head of medical education, and the chief of staff. Wherever they are, find them. I need to speak with them directly. Meantime, I’m going to check out the patients.”

  “Yes, doctor,” the clerk said, sounding far from optimistic. “I’ll do my best.”

  Laura walked by Bed 1: empty, stripped to the mattress. Bart Kelly, one of her favorite patients, so vulnerable, so trusting, now dead. She still had to speak to his wife. Not now. You have to compartmentalize. Focus on the six patients in this room. But she had little success compartmentalizing Natalie. And someone else stuck in the back of her mind—the ICU patient with AIDS, Matthew Mercer. Amazing that he’d rallied sufficiently to be transported up north. How? Not ticokellin. Dr. Worth, Matthew’s father, had tried to commandeer ticokellin from Keystone Pharma. The drug company had refused him. A side effect, she couldn’t remember what side effect, had made them stop clinical trials. But suppose they were briefed on the situation at Tampa City Hospital, would they reconsider? Ask Stacy—anything about staphylococcal research was her expertise. Good bet this Dr. Worth from the NIH was in Stacy’s Rolodex; probably the Keystone Pharma research doctors, too. Stacy worked for the federal government, could she convince the FDA to intervene? Would ticokellin cure the six patients? And, if Natalie—

  As soon as she checked on the six ICU patients, she’d ask Stacy to call Keystone Pharma. In the meantime, where are the surgical residents? Why hadn’t Michelle called them in to cover this extraordinary emergency?

  Laura approached Bed 2. Hooked up to a ventilator, the nurse who’d had a hysterectomy looked moribund. Gray skin tone. Bloated, comatose. Toxic shock syndrome.

  The solitary nurse working in the ICU was busy suctioning the patient in the farthest bed across the unit, and Laura had not wanted to distract her. The middle-aged, overweight R.N. tried for a gruff persona, but Laura knew she was as compassionate as they came. The nurse was working on Trey Standish. She would keep her promise to Natalie. She rerouted her path toward Bed 7.

  “Dr. Nelson!”

  Laura couldn’t ignore the urgent tone in the clerk’s voice.

  “The E.R. needs you. STAT.”

  Before turning to face the clerk, Laura paused to observe the boy. Gray color, maximum ventilator setting, going into shock. Natalie was in love with this boy? Had actually visited him here in the ICU. For a moment, nothing else penetrated. Had Natalie been expos
ed to whatever this was?

  “Dr. Nelson, Roxanne Ruiz needs you. I was trying to reach her like you wanted, but she called here. She said to come to the E.R. It’s urgent.”

  Following procedure, Laura removed her protective clothing, then stepped outside the ICU, into the hallway. She found Stacy in a heated discussion with Duncan Kellerman. At least the infectious disease specialist hadn’t abandoned them.

  “On my way to the E.R. STAT call,” Laura explained, “but, Stacy, I have to talk to you about getting ticokellin.”

  “Already contacted Keystone Pharma,” Stacy said, “and the FDA. Will know more in an hour or so.”

  Laura should have realized that Stacy would think of ticokellin. They’d discussed it just a couple of days ago, in relation to Matthew Mercer.

  Taking the elevator down to the lobby, Laura headed for the E.R. Along with the surgical ICU, the E.R. came under her direct supervision. She needed to talk to Roxanne about getting more nurses in the ICU, but instead of returning Laura’s call, Roxanne had summoned her to the E.R. STAT. Why?

  Roxanne met her just inside the doctors’ entrance, “Laura,” she said, “we have two patients down here presenting with a fast onset, rapidly accelerating febrile illness. They’re both delirious, with tachycardia and dyspnea. We need to admit them. I’m opening up an infectious disease ICU.”

  Laura nodded. Did Natalie belong there, too? She needed to check on her daughter. “Agreed. Good idea,” she said, assuming that Roxanne wanted only her approval.

  “Both of these patients are on staff here,” Roxanne continued. “Both assigned to the surgical ICU.”

  “My God,” Laura said. “This is an epidemic.”

  “One is on our housekeeping staff. She was on duty yesterday, assigned to the ICU. The other is your chief resident, Michelle Wallace. She collapsed just inside the ladies’ room door in the residents’ on-call room.”

  “Oh Roxanne, what’s happening? Michelle? I had been wondering why she hadn’t called in more residents. Poor Michelle.” Laura turned toward Roxanne. “And what can we do about getting more nurses and support staff? I have a roomful of critical patients but I have only one nurse. Roxanne, we have to get help there. If you add an extra ICU, we’ll need even more extra staff. Can you do that?”

  “My office is calling in every staff nurse and every temp. But I’m getting one excuse after another. The grapevine here is on fire. Avoidance is the operative principle. Maybe Stacy could give us some key points we can use to convince staff we’re using the proper procedures to contain this bacteria. We need her to get the CDC down here ASAP. Send us as many infectious disease specialists as they can. I don’t have to tell you that Kellerman is in way over his head.”

  “Stacy mentioned that maybe we’d need a lockdown: Nobody comes in. Nobody leaves. We’ll need to have adequate staff in here before we lock down. Roxie, we have to care for these patients. Let’s close the E.R. to all but suspected cases of this rampant infection.”

  “I’ll start on that right away,” Roxanne said.

  “I need to convince Medical to call in all the medical interns and residents. And meantime,” Laura went on, “we have to redirect all noninfected patients and all obstetrics to other hospitals. I’m going to cancel all surgical cases across the board. Even before the CDC makes a recommendation.”

  “Do you want to see Michelle now?” Roxanne asked. “And the cleaning lady?”

  “Yes.”

  As she made her way through the emergency room, Laura sensed the underlying current of dread. Word spreads fast in a hospital. By now the on-duty staff would be talking among themselves about the virulent, resistant bacteria in the ICU patients. And they’d be scared. Naturally enough.

  “Not good.” Dan Marsh, the E.R. charge nurse, a stocky man with a military-style crew cut, met them as they approached an examining room roped off from the others. Michelle and an older lady, presumably on the housekeeping staff, lay on gurneys on opposite sides of the small room, both hooked up to monitors, both with intravenous lines.

  “We’ve kept them isolated from the other patients,” Dan explained. “Both have high temps, dyspnea, mottled rash, painful limbs.”

  Michelle had looked exhausted but still energetic on Wednesday’s rounds, just forty-eight hours ago. Now she was strapped on the gurney, making writhing motions, her eyes closed, moaning something unintelligible. Michelle’s blonde hair was lusterless, her skin marred by splotches of pale red and grayish tones.

  Dan handed Laura the chart. Twenty-eight years old. Vital signs: temp 104, pulse 126, BP 90/70. Mental status: confused, thrashing in apparent pain.

  “Is she getting antibiotics?” Laura bent to inspect the labels attached to the bag of intravenous fluids.

  “From the minute we got blood cultures,” Dan reassured her. “The internal medicine resident ordered them. Broad spectrum including methicillin and vancomycin,” he added without being prompted. “Same with Mrs. Miller, here.”

  He then led her across the small room, a cubicle, really.

  “Mrs. Miller is a longtime employee. She cleaned the E.R. back in the day. Age sixty, former smoker; now presenting with a high fever and escalating respiratory distress. She’s restless, on the verge of combative. We drew blood cultures, got the usual labs. Blood gases ordered. Portable lung x-ray shows dense bilateral infiltrates.”

  “Was she working in the ICU Thursday?” Laura asked. Everything had seemed fine on Wednesday; somehow the unit must have got contaminated on Thanksgiving Day.

  “Yes. She put in a full day. Had the rest of the long weekend off. Started to get sick during the night. She lives alone—a neighbor stopped by—”

  As for Michelle, she’d worked in that ICU all day long yesterday, doing postsurgical checks. And Natalie, Laura realized, had been inside that ICU, at least for a short period of time.

  Laura looked from one patient to the other. The older woman’s breathing was ragged, but then age and a smoking history would make her lungs more susceptible. Yet Michelle looked more anxious, her mental status worse that Mrs. Miller’s.

  “Get me out of here,” the woman grunted, her eyes unfocused, her free arm flailing. “I know you. You’re Dr. Nelson. I gotta tell you somethin’. Get me out of here. I’m burnin’ up.”

  “Now, Bunnie, calm down,” Dan urged.

  Laura recognized the name “Bunnie.” She’d heard it bantered around the ICU, but she’d never bothered to make the acquaintance of this particular member of the housekeeping staff. For shame.

  “Bunnie,” she said, careful not to come in physical contact with the woman until she was wearing protective gear, “what is it you wanted to tell me?” Was Bunny suffering from delirium or was she mentally competent?

  Bunnie’s attention seemed to drift. Laura didn’t have much time, but the woman seemed to want to communicate something.

  “Bunnie? What is it?” Laura leaned as close as she could while preventing contact.

  “Saw a man.” Bunnie’s words were garbled, but that’s what it sounded like. “Doin’ sumthin’ to the patients.” The later part came out more clearly.

  “Yes,” Laura prompted. “Doing what, Bunnie?”

  “Don’t know. Just leanin’ over. Like he was feedin’ them or sumthin’.”

  “Who was this man?” Laura asked. What was this all about?

  “Don’ know. A doctor, maybe.”

  “Lots of doctors in the ICU, do you know him?”

  “Musta been new.”

  From across the room, Laura and Dan heard a loud moan. They rushed to Michelle’s side. She had managed to slip out of a restraint and yank out her IV, upending the pole. Her plastic bag of IV fluid had hit the tile floor and blood was dripping onto it.

  “We’re setting up an alternative ICU,” Laura said. “Let’s transport these two up there now. Admit to Dr. Kellerman’s service. I’ll call him, get the orders. Then would you help Roxanne Ruiz to get this E.R. locked down to all but patients like these.
” She looked from Bunnie to Michelle. How many more would there be?

  As Dan called for help to restrain Michelle, Laura left for the pediatric floor, making one stop at the ICU for a quick update. She needed to see Natalie. To make sure her daughter’s condition had not worsened. What could she do to help her daughter, to help her resident? She was powerless against this lethal microbe. With all her surgical skills, she had no weapon to bring to bear on a microscopic organism that was proving resistant to all the sophisticated chemicals specifically designed to destroy it.

  Then it hit her: where was her colleague, Ed Plant?

  CHAPTER FORTY-THREE

  FRIDAY, NOVEMBER 29

  Stacy had not been directly involved, but she’d read the reports about the outbreak of necrotizing fasciitis in a Lubbock, Texas, dialysis center a year ago. Caused by group A streptococcus, the disease ravaged chronic kidney patients. Invasive pneumonia struck rapidly and spread just as fast; victims suffered gangrenous flesh and muscle destruction, septic shock, and organ failure. Yet until nine patients had died a horrible death, the center failed to contact the CDC. The lesson: when in doubt, do not equivocate; call in the cavalry. And that’s what Stacy had just done. She’d called her boss, who’d called his boss, who’d notified the director. Until fifteen minutes ago, Stacy had never spoken to the director of the CDC. Now she’d disrupted the woman’s holiday weekend. Had she overreacted?

  The Tampa City Hospital cases reminded Stacy in some ways of the catastrophe last year. High fever, myositis causing extreme pain in the extremities, and a necrotizing pneumonia. But Tampa ICU patients were spared the flesh-eating necrotizing fasciitis that had struck in the Lubbock center. The Texas epidemic was caused by a strep organism and Tampa’s by a staph. Both were lethal—but neither as lethal as the staph that were incubating in the restricted section of her lab at the CDC. If her staph ever got out in a hospital like this, infected patients would already be dead, along with staff and anybody who’d come in contact with the patients, including visitors.