Contagion

23

Jack was irritated at himself. He’d had time to buy a new bike on Saturday, but he’d failed to do so. Consequently, he had to use the subway again to commute to work, although he’d considered jogging. The problem with jogging was that he’d have to have a change of clothes in his office. To give him the option in the future he brought some to work in a small shoulder bag.

Coming in from First Avenue, Jack again entered the medical examiner’s facility through the front entrance. As he passed through the glass door, he was impressed with the number of families waiting in the outer reception area. It was highly unusual for so many people to be there that early. Something must be up, he surmised.

Jack had himself buzzed in. He walked into the scheduling room and saw George Fontworth sitting at the desk Laurie had occupied each morning the previous week.

Jack was sorry Laurie’s week as supervisor was over. George had rotated to the position. He was a short, moderately overweight doctor of whom Jack had a low opinion. He was perfunctory and often missed important findings.

Ignoring George, Jack headed over to Vinnie and pushed down the edge of his newspaper.

“Why are there so many people out in the ID area?” Jack asked.

“Because there’s a minor disaster over at the General,” George said, answering for Vinnie. Vinnie treated Jack to a jaunty but disdainful expression and went back to his paper.

“What kind of disaster?” Jack asked.

George patted the top of a stack of folders. “A whole bunch of meningococcal deaths,” he said. “Could be an epidemic in the making. We’ve got eight so far.”

Jack rushed over to George’s desk and snapped up a folder at random. He opened it and shuffled through its contents until he came to the investigative report. Scanning it quickly, he learned that the patient’s name was Robert Caruso, and that he had been a nurse on the orthopedic floor at the General.

Jack tossed the folder back onto the desk and literally ran through communications to the offices of the PAs. He was relieved to see Janice was still there, putting in overtime as usual.

She looked terrible. The dark circles under her eyes were so distinct, she resembled a battered woman. She put her pen down and leaned back. She shook her head. “I might have to get another job,” she said. “I can’t keep this up. Thank God I have tomorrow and the next day off.”

“What happened?” Jack asked.

“It started on the shift before mine,” Janice said. “The first case was called in around six-thirty. Apparently the patient had died about six P.M.”

“An orthopedic patient?” Jack asked.

“How’d you know?”

“I just saw a folder from an orthopedic nurse,” Jack said.

“Oh, yeah, that was Mr. Caruso,” Janice said with a yawn. She excused herself before continuing. “Anyway, I started getting called shortly after I arrived at eleven. Since then it’s been nonstop. I’ve been back and forth all night. In fact, I just got back here twenty minutes ago. I tell you, this is worse than the the other outbreaks. One of the patients is a nine-year-old girl. What a tragedy.”

“Was she related to the first case?” Jack asked.

“She was a niece,” Janice said.

“Had she been in to visit her uncle?” Jack asked.

“Around noon yesterday,” Janice said. “You don’t think that could have contributed to her death, do you? I mean, that was only about twelve hours before her death.”

“Under certain circumstances meningococcus has a frightful capacity to kill, and kill incredibly swiftly,” Jack said. “In fact, it can kill in just a few hours.”

“Well, the hospital is in a panic.”

“I can imagine,” Jack said. “What was the name of the first case?”

“Carlo Pacini,” Janice said. “But that’s about all I know. He came in on the shift before mine. Steve Mariott handled it.”

“Could I ask a favor?” Jack asked.

“That depends,” Janice said. “I’m awfully tired.”

“Just leave word for Bart that I want you PAs to get all the charts of the index case in each of these outbreaks. Let’s see, that’s Nodelman with the plague, Hard with tularemia, Lagenthorpe with Rocky Mountain spotted fever, and Pacini with meningococcus. Do you think that will be a problem?”

“Not at all,” Janice said. “They are all active ME cases.”

Jack stood up and gave Janice a pat on the back. “Maybe you should go over to the clinic on your way home,” he said. “Some chemoprophylaxis might not be a bad idea.”

Janice’s eyes widened. “You think that is necessary?”

“Better safe than sorry,” Jack said. “Anyway, discuss it with one of the infectious disease gurus. They know better than I. There’s even a tetravalent vaccine, but that takes a few days to kick in.”

Jack dashed back to the ID room and asked George for Carlo Pacini’s folder.

“It’s not here,” George said. “Laurie came in early, and when she heard about what was going on, she requested the case. She’s got the folder.”

“Where is she?” Jack asked.

“Up in her office,” Vinnie responded from behind his paper.

Jack hustled up to Laurie’s office. Contrary to the way Jack worked, she liked to go over each folder in her office before doing the autopsy.

“Pretty frightening, I’d say,” Laurie said as soon as she saw Jack.

“It’s terrifying,” Jack said. He grabbed Laurie’s officemate’s chair, pulled it over to Laurie’s desk, and sat down. “This is just what I’ve been worrying about. This could be a real epidemic. What have you learned about this index case?”

“Not much,” Laurie admitted. “He’d been admitted Saturday evening with a fractured hip. Apparently he’d had a brittle bone problem; he’d had a whole string of fractures over the last few years.”

“Fits the pattern,” Jack said.

“What pattern?” Laurie asked.

“All the index cases from these recent outbreaks have had some sort of chronic illness,” Jack said.

“A lot of people who are hospitalized have chronic illnesses,” Laurie said. “In fact, most of them. What does that have to do with anything?”

“I’ll tell you what’s on his paranoid, sick mind,” Chet said. Chet had appeared at Laurie’s door. He stepped into the room and leaned against the second desk. “He’s got this thing about AmeriCare and wants to see conspiracy behind all this trouble.”

“Is that true?” Laurie asked.

“I think it’s less that I want to see conspiracy than it’s staring me in the face,” Jack said.

“What do you mean by ‘conspiracy’?” Laurie asked.

“He has this notion that these unusual illnesses are being spread deliberately,” Chet said. Chet summarized Jack’s theory that the culprit was either someone at AmeriCare trying to protect its bottom line or some crazy person with terrorist inclinations.

Laurie looked questioningly at Jack. Jack shrugged.

“There are a lot of unanswered questions,” Jack offered.

“As there are in just about any outbreak,” Laurie said. “But really! This is all a bit far-fetched. I hope you didn’t mention this theory to the powers that be over at the General.”

“Yeah, I did,” Jack said. “In fact I sort of asked the director of the lab if he was involved. He’s rather disgruntled with his budget. He immediately informed the infection-control officer. I imagine they’ve let the administration know.”

Laurie let out a short, cynical laugh. “Oh, brother,” she said. “No wonder you’ve become persona non grata around there.”

“You have to admit there’s been an awful lot of questionable nosocomial infection at the General,” Jack said.

“I’m not even so sure about that,” Laurie said. “Both the tularemic patient and the patient with Rocky Mountain spotted fever developed their illnesses within forty-eight hours of admission. By definition, they are not nosocomial infections.”

“Technically that’s true,” Jack admitted. “But…”

“Besides, all these illnesses have been seen in New York,” Laurie said. “I’ve done some recent reading myself. There was a serious outbreak of Rocky Mountain spotted fever in eighty-seven.”

“Thank you, Laurie,” Chet said. “I tried to tell Jack the same thing. Even Calvin has told him.”

“What about the series of cases coming from central supply?” Jack asked Laurie. “And what about the rapidity with which the patients with Rocky Mountain spotted fever developed their illnesses? You were questioning that just this Saturday.”

“Of course I’d question those things,” Laurie said. “They’re the type of questions that have to be asked in any epidemiological situation.”

Jack sighed. “I’m sorry,” he said. “But I’m convinced something highly unusual is going on. All along I’ve been worried that we might see a real epidemic crop up. This outbreak of meningococcus may be it. If it peters out like the other outbreaks, I’ll be relieved, of course, in human terms. But it will only add to my suspicions. This pattern of multiple fulminant cases, then nothing, is highly unusual in itself.”

“But this is the season for meningococcus,” Laurie said. “It’s not so unusual.”

“Laurie’s right,” Chet said. “But regardless, my concern is that you’re going to get yourself into real trouble. You’re like a dog with a bone. Calm down! I don’t want to see you fired. At least reassure me you’re not going back to the General.”

“I can’t say that,” Jack said. “Not with this new outbreak. This one doesn’t depend on some arthropods that aren’t around. This is an airborne problem, and as far as I’m concerned, it changes the rules.”

“Just a moment,” Laurie said. “What about that warning you got from those thugs?”

“Now what?” Chet questioned. “What thugs?”

“Jack had a cozy visit from some charming members of a gang,” Laurie said. “It seems that at least one of the New York gangs is going into the extortion business.”

“Somebody has to explain,” Chet said.

Laurie told Chet what she knew of Jack’s beating.

“And you’re still thinking of going over there?” Chet asked when she was through.

“I’ll be careful,” Jack said. “Besides, I haven’t exactly decided to go yet.”

Chet rolled his eyes to the ceiling. “I think I would have preferred you as a suburbanite ophthalmologist.”

“What do you mean, ophthalmologist?” Laurie questioned.

“Come on, you guys,” Jack said. He stood up. “Enough is enough. We’ve got work to do.”

Jack, Laurie, and Chet did not emerge from the autopsy room until after one in the afternoon. Although George had questioned the need to post all the meningococcal cases, the triumvirate had insisted; George relented in the end. Doing some on their own and some together, they autopsied the initial patient, one orthopedic resident, two nurses, one orderly, two people who’d visited the patient, including the nine-year-old girl, and particularly important as far as Jack was concerned, one woman from central supply.

After the marathon they all changed back to their street clothes and met up in the lunchroom. Relieved to be away from the mayhem and a bit overwhelmed by the findings, they didn’t talk at first. They merely got their selections from the vending machines and sat down at one of the free tables.

“I haven’t done many meningococcal cases in the past,” Laurie said finally. “But these today were a lot more impressive than the ones I did do.”

“You won’t see a more dramatic case of the Waterhouse-Friderichsen syndrome,” Chet said. “None of these people had a chance. The bacteria marched through them like a Mongol horde. The amount of internal hemorrhage was extraordinary. I tell you, it scares the pants off me.”

“It was one time that I actually didn’t mind being in the moon suit,” Jack agreed. “I couldn’t get over the amount of gangrene on the extremities. It was even more than on the recent plague cases.”

“What surprised me was how little meningitis was involved,” Laurie said. “Even the child had very little, and I would have thought at least she would have had extensive involvement.”

“What puzzles me,” Jack said, “is the amount of pneumonitis. Obviously it is an airborne infection, but it usually invades the upper part of the respiratory tree, not the lungs.”

“It can get there easily enough once it gets into the blood,” Chet said. “Obviously all these people had high levels coursing through their vascular systems.”

“Have either of you heard if any more cases have come in today?” Jack asked.

Chet and Laurie exchanged glances. Both shook their heads.

Jack scraped back his chair and went to a wall phone. He called down to communications and posed the same question to one of the operators. The answer was no. Jack walked back to the table and reclaimed his seat.

“Well, well,” he said. “Isn’t this curious. No new cases.”

“I’d say it was good news,” Laurie said.

“I’d second that,” Chet said.

“Does either of you know any of the internists over at the General?” Jack asked.

“I do,” Laurie said. “One of my classmates from medical school is over there.”

“How about giving her a call and seeing if they have many meningococcal cases under treatment?” Jack asked.

Laurie shrugged and went to use the same phone Jack had just used.

“I don’t like that look in your eye,” Chet said.

“I can’t help it,” Jack said. “Just like with the other outbreaks, little disturbing facts are beginning to appear. We’ve just autopsied some of the sickest meningococcal patients any of us has ever seen and then, boom! No more cases, as if a faucet had been turned off. It’s just what I was talking about earlier.”

“Isn’t that characteristic of the disease?” Chet asked. “Peaks and valleys.”

“Not this fast,” Jack said. Then he paused. “Wait a second,” he added. “I just thought of something else. We know who the first person was to die in this outbreak, but who was the last?”

“I don’t know, but we’ve got all the folders,” Chet said.

Laurie returned. “No meningococcal cases presently,” she said. “But the hospital doesn’t consider itself out of the woods. They’ve instituted a massive campaign of vaccination and chemoprophylaxis. Apparently the place is in an uproar.”

Both Jack and Chet merely grunted at this news. They were preoccupied with going through the eight folders and jotting down notations on their napkins.

“What on earth are you guys doing?” Laurie asked.

“We’re trying to figure out who was the last to die,” Jack said.

“What on earth for?” Laurie asked.

“I’m not sure,” Jack said.

“This is it,” Chet said. “It was Imogene Philbertson.”

“Honest?” Jack questioned. “Let me see.”

Chet turned around the partially filled-out death certificate that listed the time of death.

“I’ll be damned,” Jack said.

“Now what?” Laurie asked.

“She was the one who worked in central supply,” Jack said.

“Is that significant?” Laurie asked.

Jack pondered for a few minutes, then shook his head. “I don’t know,” he said. “I’ll have to look back at the other outbreaks. As you know, each outbreak has included someone from central supply. I’ll see if it is a pattern I’d missed.”

“You guys weren’t particularly impressed with my news that there are currently no more cases of meningococcal disease over at the General.”

“I am,” Chet said. “Jack sees it as confirmation of his theories.”

“I’m worried it is going to frustrate our hypothetical terrorist,” Jack said. “It’s also going to teach him an unfortunate lesson.”

Both Laurie and Chet rolled their eyes to the ceiling and let out audible groans.

“Come on, you guys,” Jack said. “Hear me out. Let’s just say for the sake of argument that I’m right about some weirdo spreading these microbes in hopes of starting an epidemic. At first he picks the scariest, most exotic diseases he can think of, but he doesn’t know that they won’t really spread patient to patient. They are spread by arthropods having access to an infected reservoir. But after a few flops he figures this out and turns to a disease that is spread airborne. But he picks meningococcus. The problem with meningococcus is that it really isn’t a patient-to-patient disease either: it’s a carrier disease that’s mainly spread by an immune individual walking around and giving it to others. So now our weirdo is really frustrated, but he truly knows what he needs. He needs a disease that is spread mainly patient-to-patient by aerosol.”

“And what would you choose in this hypothetical scenario?” Chet asked superciliously.

“Let’s see,” Jack said. He pondered for a moment. “I’d use drug-resistant diphtheria, or maybe even drug-resistant pertussis. Those old standbys are making some devastating comebacks. Or you know what else would be perfect? Influenza! A pathological strain of influenza.”

“What an imagination!” Chet commented.

Laurie stood up. “I’ve got to get back to work,” she said. “This conversation is too hypothetical for me.”

Chet did the same.

“Hey, isn’t anybody going to comment?” Jack said.

“You know how we feel,” Chet said. “This is just mental masturbation. It seems like the more you think and talk about this stuff the more you believe it. I mean, really, if it were one disease, okay, but now we’re up to four. Where would someone get these microbes? They are not the kind of thing you can go into your neighborhood deli and order. I’ll see you upstairs.”

Jack watched Laurie and Chet dispose of their trash and leave the lunchroom. He sat for a few moments and considered what Chet had said. Chet had a good point, one that Jack had not even considered. Where would someone get pathological bacteria? He really had no idea.

Jack got up and stretched his legs. After discarding his tray and sandwich wrappings, he followed the others up to the fifth floor. By the time he got to the office, Chet was already engrossed and didn’t look up.

Sitting down at his desk, Jack got all the folders together plus his notes and looked up the time of death of each of the women victims from central supply. To date, central supply had lost four people. Jack imagined that the department head would have to be actively recruiting to keep up with that type of attrition.

Next Jack looked up the time of death of each of the other infectious cases. For the times of death of the few he’d not autopsied, he called down to Bart Arnold, the chief PA.

When Jack had all the information it became immediately apparent that with each outbreak, it had been the woman from central supply to be the last to succumb. That suggested, but certainly didn’t prove, that in each instance those from central supply were the last to become infected. Jack asked himself what that meant, but couldn’t come up with an answer. Still, it was an extremely curious detail.

“I have to go back to the General,” Jack said suddenly. He stood up.

Chet didn’t even bother to look up. “Do what you have to do,” he said with resignation. “Not that my opinion counts.”

Jack pulled on his bomber jacket. “Don’t take it personally,” he said. “I appreciate your concern, but I’ve got to go. I’ve got to look into this strange central supply connection. It could just be a coincidence, I agree, but it seems unlikely.”

“What about Bingham and what about those gang members Laurie mentioned?” Chet asked. “You’re taking a lot of risk.”

“Such is life,” Jack said. He gave Chet a tap on the shoulder on his way to the hallway. Jack had just reached the threshold when his phone rang. He debated whether to take the time to answer it. It was usually someone from one of the labs.

“Want me to get it?” Chet offered when he saw Jack hesitate.

“No, I’m here, and I might as well,” Jack said. He returned to his desk and picked up the receiver.

“Thank God you are there!” Terese said with obvious relief. “I was terrified I wouldn’t get you, at least not in time.”

“What on earth is the matter?” Jack asked. His pulse quickened. He could tell by the sound of her voice that she was acutely upset.

“There’s been a catastrophe,” she said. “I have to see you immediately. Can I come over to your office?”

“What happened?” Jack asked.

“I can’t talk now,” Terese said. “I can’t risk it with everything that has happened. I’ve just got to see you.”

“We’re sort of in the middle of an emergency ourselves,” Jack said. “And I’m just on my way out.”

“It’s very important,” Terese said. “Please!”

Jack immediately relented, especially with Terese’s selfless response to his emergency Friday night.

“All right,” Jack said. “Since I was just leaving, I’ll come to you. Where would you like to meet?”

“Were you going uptown or downtown?” Terese asked.

“Uptown,” Jack said.

“Then let’s meet at the café where we had coffee on Sunday,” Terese said.

“I’ll be right there,” Jack said.

“Wonderful!” Terese asserted. “I’ll be waiting.” Then she hung up.

Jack replaced the receiver and self-consciously looked over at Chet. “Did you hear any of that?” Jack asked.

“It was hard not to,” Chet said. “What do you think happened?”

“I haven’t the faintest idea,” Jack said.

True to his word, Jack left immediately. Exiting from the front of the medical examiner facility, he caught a cab on First Avenue. Despite the normal afternoon traffic, he made it uptown in reasonable time.

The café was crowded. He found Terese sitting toward the rear at a small banquette. He took the seat opposite her. She didn’t make any motion to get up. She was dressed as usual in a smart suit. Her jaw was clenched. She looked angry.

She leaned forward. “You are not going to believe this,” she said in a forced whisper.

“Did the president and the CEO not like your presentation?” Jack asked. It was the only thing he could think of.

Terese made a motion of dismissal with her hand. “I canceled the presentation,” she said.

“Why?” Jack asked.

“Because I’d had the sense to schedule an early breakfast with a woman acquaintance at National Health,” Terese said. “She’s a vice president in marketing who I happened to have gone to Smith College with. I’d had a brainstorm about leaking the campaign to some higher-ups through her. I was so confident. But she shocked me by telling me that under no circumstances would the campaign fly.”

“But why?” Jack asked. As much as he disliked medical advertising, he’d considered the ads Terese had come up with the best he’d seen.

“Because National Health is deathly afraid of any reference to nosocomial infections,” Terese said angrily. Then she leaned forward again and whispered. “Apparently they have had some of their own trouble lately.”

“What kind of trouble?” Jack asked.

“Nothing like the Manhattan General,” Terese said. “But serious nonetheless, even with a few deaths. But the real point is that our own account executive people, specifically Helen Robinson and her boss, Robert Barker, knew all this and didn’t tell me.”

“That’s counterproductive,” Jack said. “I thought you corporate types were all working toward the same end.”

“Counterproductive!” Terese practically shouted, causing the nearby diners to turn their heads. Terese closed her eyes for a moment to collect herself.

“ ‘Counterproductive’ is not the term I’d use,” Terese said, keeping her voice down. “The way I’d describe it would make a sailor blush. You see, this was not an oversight. It was done deliberately to make me look bad.”

“I’m sorry to hear this,” Jack said. “I can see it’s upsetting for you.”

“That’s an understatement,” Terese said. “It’s the death of my presidential aspirations if I don’t come up with an alternative campaign in the next couple of days.”

“A couple of days?” Jack questioned. “From what you’ve shown me about how this process works, that’s a mighty tall order.”

“Exactly,” Terese said. “That’s why I had to see you. I need another hook. You came up with this infection idea, or at least you were the source of it. Can you come up with another concept? Something that I can construct an ad campaign around. I’m desperate!”

Jack looked off and tried to think. The irony of the situation didn’t escape him; as much as he despised medical advertising, here he was racking his brains for some sort of an idea. He wanted to help; after all, Terese had been so willing to help him.

“The reason I think medical advertising is such a waste of money is that it ultimately has to rely on superficial amenities,” he said. “The problem is that without quality being an issue there just isn’t enough difference between AmeriCare and National Health or any of the other big conglomerates.”

“I don’t care,” Terese said. “Just give me something I can use.”

“Well, the only thing that comes to my mind at the moment is the issue about waiting,” Jack said.

“What do you mean, ‘waiting’?” Terese asked.

“You know,” Jack said. “Nobody likes waiting for the doctor, but everybody does. It’s one of those irritating universal annoyances.”

“You’re right!” Terese said excitedly. “I love it. I can already see a tag line like: No waiting with National Health! Or even better: We wait for you, you don’t wait for us! God, that’s great! You’re a genius at this. How about a job?”

Jack chuckled. “Wouldn’t that be a trip,” he said. “But I’m having enough trouble with the one I have.”

“Is there something wrong?” Terese asked. “What did you mean when you said you were in the middle of an emergency?”

“There’s more trouble at the Manhattan General,” Jack said. “This time it’s an illness caused by meningococcus bacteria. It can be extremely deadly, as it has been in this instance.”

“How many cases?”

“Eight,” Jack said. “Including a child.”

“How awful,” Terese said. She was appalled. “Do you think it will spread?”

“I was worried at first,” Jack said. “I thought we were going to have a bona fide epidemic on our hands. But the cases just stopped. So far it hasn’t spread beyond the initial cohort.”

“I hope this isn’t going to be kept a secret like whatever killed the people at National Health,” Terese said.

“No worry on that account,” Jack said. “This episode is no secret. I’ve heard the hospital is in an uproar. But I’ll find out firsthand. I’m on my way over there.”

“Oh, no you’re not!” Terese commanded. “Is your memory so short that Friday night is already a blur?”

“You sound like several of my colleagues,” Jack said. “I appreciate your concern, but I can’t stay away. I have a sense that these outbreaks are deliberate, and my conscience won’t let me ignore them.”

“What about those people who beat you up?” she demanded.

“I’ll have to be careful,” Jack said.

Terese made a disparaging sound. “Being careful hardly sounds adequate,” she said. “It’s certainly not consistent with how you described those hoodlums Friday night.”

“I’ll just have to take my chances and improvise,” Jack said. “I’m going over to the General no matter what anybody says.”

“What I can’t understand is why you are so agitated about these infections. I’ve read that infectious diseases are generally on the rise.”

“That’s true,” Jack said. “But that’s not due to deliberate spread. That’s from the injudicious use of antibiotics, urbanization, and the invasion of primeval habitats.”

“Give me a break,” Terese commented. “I’m concerned about you getting yourself hurt or worse, and you’re giving me a lecture.”

Jack shrugged. “I’m going to the General,” he said.

“Fine, go!” Terese said. She stood up. “You’re being that ridiculous hero I was afraid you’d be.” Then she softened. “Do what you must, but if you need me, call me.”

“I will,” Jack said. He watched her hurry out of the restaurant, thinking that she was a bewildering blend of ambition and solicitude. It was no wonder he was confused by her: one minute attracted, the next minute mildly put off.

Jack tossed down the remains of his coffee and stood up. After leaving an appropriate tip, he, too, hurried out of the café.