Contagion

10

As a man of habit, Jack arrived in the vicinity of the medical examiner’s office at the same time each day, give or take five minutes. This particular morning he was ten minutes late since he’d awakened with a slight hangover. He’d not had a hangover in so long, he’d completely forgotten how miserable it made him feel. Consequently he’d stayed in the shower a few minutes longer than usual, and on the slalom down Second Avenue, he’d kept his speed to a more reasonable level.

Crossing First Avenue, Jack saw something he’d never seen before at that time of day. There was a TV truck with its main antennae extended sitting in front of the medical examiner’s building.

Changing his direction a little, he cruised around the truck. No one was in it. Looking up at the front door to the ME’s office, he saw a group of newspeople clustered just over the threshold.

Curious as to what was going on, Jack hustled around to the entrance bay, stashed his bike in the usual place, and went up to the ID room.

As usual Laurie and Vinnie were in their respective seats. Jack said hello but continued through the room to peek out into the lobby area. It was as crowded as he’d ever seen it.

“What the hell’s going on?” Jack asked, turning back to Laurie.

“You of all people should know,” she said. She was busy making up the day’s autopsy schedule. “It’s all about the plague epidemic!”

“Epidemic?” Jack questioned. “Have there been more cases?”

“You haven’t heard?” Laurie questioned. “Don’t you watch morning TV?”

“I don’t have a TV,” Jack admitted. “In my neighborhood owning one is just inviting trouble.”

“Well, two victims came in to us during the night,” Laurie said. “One is for sure plague, or at least presumptive since the hospital did its own fluorescein antibody and it was positive. The other is suspected, since clinically it seemed to be plague despite a negative fluorescein antibody. In addition to that, as I understand it, there are several febrile patients who have been quarantined.”

“This is all happening at the Manhattan General?” Jack asked.

“Apparently,” Laurie said.

“Were these cases direct contacts with Nodelman?” Jack asked.

“I haven’t had time to look into that,” Laurie said. “Are you interested? If you are, I’ll assign them to you.”

“Of course,” Jack said. “Which one is the presumptive plague?”

“Katherine Mueller,” Laurie said. She pushed the patient’s folder toward Jack.

Sitting on the edge of the desk where Laurie was working, Jack opened the folder. He leafed through the papers until he found the investigative report. He pulled it out and began reading. He learned the woman had been brought into the Manhattan General emergency room at four o’clock in the afternoon acutely ill with what was diagnosed to be a fulminant case of plague. She’d died nine hours later despite massive antibiotics.

Jack checked on the woman’s place of employment and wasn’t surprised with what he learned. The woman worked at the Manhattan General. Jack assumed she had to have been a direct contact of Nodelman. Unfortunately the report did not indicate in what department she worked. Jack guessed either nursing or lab.

Reading on in the report, Jack silently complimented Janice Jaeger’s work. After the conversation he’d had with her the day before by phone, she added information about travel, pets, and visitors. In the case of Mueller it was all negative.

“Where’s the suspected plague?” Jack asked Laurie.

Laurie pushed a second folder toward him.

Jack opened the second file and was immediately surprised. The victim neither worked at the Manhattan General nor had obvious contact with Nodelman. Her name was Susanne Hard. Like Nodelman, she’d been a patient in the General, but not on the same ward as Nodelman. Hard had been on the OB-GYN ward after giving birth! Jack was mystified.

Reading further, Jack learned that Hard had been in the hospital for twenty-four hours when she’d experienced sudden high fever, myalgia, headache, overwhelming malaise, and progressive cough. These symptoms had come on about eighteen hours after undergoing a cesarean section during which she delivered a healthy child. Eight hours after the symptoms appeared, the patient was dead.

Out of curiosity Jack looked up Hard’s address, remembering that Nodelman had lived in the Bronx. But Hard had not lived in the Bronx. She had lived in Manhattan on Sutton Place South, hardly a ghetto neighborhood.

Reading on, Jack learned that Hard had not traveled since she’d become pregnant. As far as pets were concerned, she owned an elderly but healthy poodle. Concerning visitors, she had entertained a business associate of her husband’s from India three weeks previously who was described as being healthy and well.

“Is Janice Jaeger still here this morning?” Jack asked Laurie.

“She was about fifteen minutes ago when I passed her office,” Laurie said.

Jack found Janice where she’d been the previous morning.

“You are a dedicated civil servant,” Jack called out from the threshold.

Janice looked up from her work. Her eyes were red from fatigue. “Too many people dying lately. I’m swamped. But tell me: Did I ask the right questions on the infectious cases last night?”

“Absolutely,” Jack said. “I was impressed. But I do have a couple more.”

“Shoot,” Janice said.

“Where’s the OB-GYN ward in relation to the medical ward?”

“They’re right next to each other,” Janice said. “Both are on the seventh floor.”

“No kidding,” Jack said.

“Is that significant?” Janice asked.

“I haven’t the slightest idea,” Jack admitted. “Do patients from the OB ward mix with those on the medical ward?”

“You got me there,” Janice admitted. “I don’t know, but I wouldn’t imagine so.”

“Nor would I,” Jack said. But if they didn’t, then how did Susanne Hard manage to get sick? Something seemed screwy about this plague outbreak. Facetiously he wondered if a bunch of infected rats could be living in the ventilation system on the seventh floor.

“Any other questions?” Janice asked. “I want to get out of here, and I have this last report to finish.”

“One more,” Jack said. “You indicated that Katherine Mueller was employed by the General but you didn’t say for what department. Do you know if she worked for nursing or for the lab?”

Janice leafed through her night’s notes and came up with the sheet on which she’d recorded Mueller’s information. She quickly glanced through it and then looked back up at Jack. “Neither,” she said. “She worked in central supply.”

“Oh, come on!” Jack said. He sounded disappointed.

“I’m sorry,” Janice said. “That’s what I was told.”

“I’m not blaming you,” Jack said with a wave of his hand. “It’s just that I’d like there to be some sort of logic to all this. How would a woman in central supply get into contact with a sick patient on the seventh floor? Where’s central supply?”

“I believe it’s on the same floor with the operating rooms,” Janice said. “That would be the third floor.”

“Okay, thanks,” Jack said. “Now get out of here and get some sleep.”

“I intend to,” Janice said.

Jack wandered back toward the ID room, thinking that nothing seemed to be making much sense. Usually the course of a contagious illness could be easily plotted sequentially through a family or a community. There was the index case, and the subsequent cases extended from it by contact, either directly or through a vector like an insect. There wasn’t a lot of mystery. That wasn’t the case so far with this plague outbreak. The only unifying factor was that they all involved the Manhattan General.

Jack absently waved to Sergeant Murphy, who’d apparently just arrived in his cubbyhole office off the communications room. The ebullient Irish policeman waved back with great enthusiasm.

Jack slowed his walk while his mind churned. Susanne Hard had come down with symptoms after only being in the hospital for a day. Since the incubation period for plague was generally thought to be two days at a minimum, she would have been exposed prior to coming into the hospital. Jack went back to Janice’s office.

“One more question,” Jack called out to her. “Do you happen to know whether the Hard woman visited the hospital in the days prior to her admission?”

“Her husband said no,” Janice said. “I asked that question specifically. Apparently she hated the hospital and only came in at the very last minute.”

Jack nodded. “Thanks,” he said, even more preoccupied. He turned and started back toward the ID room. That information made the situation more baffling, requiring him to postulate that the outbreak had occurred almost simultaneously in two, maybe three locations. That wasn’t probable. The other possibility was that the incubation period was extremely short, less than twenty-four hours. That would mean Hard’s illness was a nosocomial infection, as he suspected Nodelman’s was as well as Mueller’s. The problem with that idea was that it would suggest a huge, overwhelming infecting dose, which also seemed unlikely. After all, how many sick rats could be in a ventilation duct all coughing at the same time?

In the ID room Jack wrestled the sports page of the Daily News away from a reluctant Vinnie and dragged him down to the pit to begin the day.

“How come you always start so early?” Vinnie complained. “You’re the only one. Don’t you have a life?”

Jack swatted him in the chest with Katherine Mueller’s folder. “Remember the saying ‘The early bird gets the worm’?”

“Oh, barf,” Vinnie said. He took the folder from Jack and opened it. “Is this the one we’re doing first?” he asked.

“Might as well move from the known to the unknown,” Jack said. “This one had a positive fluorescein antibody test to plague, so zip up tight in your moon suit.”

Fifteen minutes later Jack began the autopsy. He spent a good deal of time on the external exam, looking for any signs of insect bites. It wasn’t an easy job, since Katherine Mueller was an overweight forty-four-year-old with hundreds of moles, freckles, and other minor skin blemishes. Jack found nothing he was sure was a bite, although a few lesions looked mildly suspicious. To be on the safe side he photographed them.

“No gangrene on this body,” Vinnie commented.

“Nor purpura,” Jack said.

By the time Jack started on the internal exam, a number of the other staff had arrived in the autopsy room and half of the tables were in use. There were a few comments about Jack becoming the local plague expert, but Jack ignored them. He was too engrossed.

Mueller’s lungs appeared quite similar to Nodelman’s, with extensive lobar pneumonia, consolidation, and early stages of tissue death. The woman’s cervical lymphatics were also generally involved, as were the lymph nodes along the bronchial tree.

“This is just as bad or worse than Nodelman,” Jack said. “It’s frightening.”

“You don’t have to tell me,” Vinnie said. “These infectious cases are the kind that make me wish I’d gone into gardening.”

Jack was nearing the end of the internal exam when Calvin came through the door. There was no mistaking his huge silhouette. He was accompanied by another figure who was half his size. Calvin came directly to Jack’s table.

“Anything out of the ordinary?” Calvin asked, while peering into the pan of internal organs.

“Internally this case is a repeat of yesterday’s,” Jack said.

“Good,” Calvin said, straightening up. He then introduced Jack to his guest. It was Clint Abelard, the city epidemiologist.

Jack could make out the man’s prominent jaw, but because of the reflection off the plastic face mask, he couldn’t see the fellow’s squirrelly eyes. He wondered if he was still as cantankerous as he’d been the day before.

“According to Dr. Bingham you two have already met,” Calvin said.

“Indeed,” Jack said. The epidemiologist did not respond.

“Dr. Abelard is trying to discern the origin of this plague outbreak,” Calvin explained.

“Commendable,” Jack said.

“He’s come to us to see if we can add any significant information,” Calvin said. “Perhaps you could run through your positive findings.”

“My pleasure,” Jack said. He started with the external exam, indicating skin abnormalities he thought could have been insect bites. Then he showed all the gross internal pathology, concentrating on the lungs, lymphatics, liver, and spleen. Throughout the entire discourse, Clint Abelard stayed silent.

“There you have it,” Jack said as he finished. He put the liver back into the pan. “As you can see it’s a severe case, as was Nodelman’s, and it’s no wonder both patients died so quickly.”

“What about Hard?” Clint asked.

“She’s next,” Jack said.

“Mind if I watch?” Clint asked.

Jack shrugged. “That’s up to Dr. Washington,” he said.

“No problem,” Calvin said.

“If I may ask,” Jack said, “have you come up with a theory where this plague came from?”

“Not really,” Clint said gruffly. “Not yet.”

“Any ideas?” Jack asked, trying to keep sarcasm out of his voice. It seemed Clint was in no better humor than he had been the day before.

“We’re looking for plague in the area’s rodent population,” Clint said condescendingly.

“Splendid idea,” Jack said. “And just how are you doing that?”

Clint paused as if he didn’t want to divulge any state secrets.

“The CDC is helping,” he said finally. “They sent someone up here from their plague division. He’s in charge of the trapping and analysis.”

“Any luck so far?” Jack asked.

“Some of the rats caught last night were ill,” Clint said. “But none with plague.”

“What about the hospital?” Jack asked. He persisted despite Clint’s apparent reluctance to talk. “This woman we’ve just autopsied worked in central supply. Seems likely her illness was nosocomial like Nodelman’s. Do you think she got it from some primary source in and around the hospital, or do you think she got it from Nodelman?”

“We don’t know,” Clint admitted.

“If she got it from Nodelman,” Jack asked, “any ideas of a possible route of transmission?”

“We’ve checked the hospital’s ventilation and air-conditioning system carefully,” Clint said. “All the HEPA filters were in place and had been changed appropriately.”

“What about the lab situation?” Jack asked.

“What do you mean?” Clint said.

“Did you know that the chief tech in micro actually suggested plague to the director of the lab purely from his clinical impression, but the director talked him out of following up on it?”

“I didn’t know that,” Clint mumbled.

“If the chief tech had followed up on it he would have made the diagnosis and appropriate therapy could have been started,” Jack said. “Who knows; it could have saved a life. The problem is that the lab has been downsizing because of pressure from AmeriCare to save a few bucks, and they don’t have a microbiology supervisor position. It got eliminated.”

“I don’t know anything about all that,” Clint said. “Besides, the case of plague still would have occurred.”

“You’re right,” Jack said. “One way or the other you still have to come up with the origin. Unfortunately, you don’t know any more than you did yesterday.” Jack smiled inside his mask. He was getting a bit of perverse pleasure out of putting the epidemiologist on the spot.

“I wouldn’t go that far,” Clint muttered.

“Any sign of illness in the hospital staff?” Jack asked.

“There are several nurses who are febrile and who are quarantined,” Clint said. “As of yet there is no confirmation of them having plague, but it is suspected. They were directly exposed to Nodelman.”

“When will you be doing Hard?” Calvin asked.

“In about twenty minutes,” Jack said. “As soon as Vinnie gets things turned around.”

“I’m going around to check on some other cases,” Calvin said to Clint. “You want to stay here with Dr. Stapleton or do you want to come with me?”

“I think I’ll go with you, if you don’t mind,” Clint said.

“By the way, Jack,” Calvin said before leaving. “There’s a bevy of media people upstairs crawling all over the outer office like bloodhounds. I don’t want you giving any unauthorized press conferences. Any information coming from the ME’s office comes from Mrs. Donnatello and her PR assistant.”

“I wouldn’t dream of talking to the press,” Jack assured him.

Calvin wandered to the next table. Clint stayed at his heels.

“It didn’t sound as if that guy wanted to talk with you,” Vinnie said to Jack when Calvin and Clint were far enough away. “Not that I can blame him.”

“That little mouse has been spleeny since I first met him,” Jack said. “I don’t know what his problem is. He’s kinda a weird duck, if you ask me.”

“Now there’s the pot calling the kettle black,” Vinnie said.