Contagion

1

NEW YORK CITY

“Excuse me,” Jack Stapleton said with false civility to the darkly complected Pakistani cabdriver. “Would you care to step out of your car so we can discuss this matter fully?”

Jack was referring to the fact that the cabdriver had cut him off at the intersection of Forty-sixth Street and Second Avenue. In retaliation Jack had kicked the cab’s driver-side door when they had both stopped at a red light at Forty-fourth Street. Jack was on his Cannondale mountain bike that he used to commute to work.

This morning’s confrontation was not unusual. Jack’s daily route included a hair-raising slalom down Second Avenue from Fifty-ninth Street to Thirtieth Street at breakneck speed. There were frequent close calls with trucks and taxicabs and the inevitable arguments. Anyone else would have found the trip nerve-racking. Jack loved it. As he explained to his colleagues, it got his blood circulating.

Choosing to ignore Jack until the light turned green, the Pakistani cabdriver then cursed him soundly before speeding off.

“And to you too!” Jack yelled back. He accelerated standing up until he reached a speed equal to the traffic. Then he settled onto the seat while his legs pumped furiously.

Eventually he caught up with the offending cabdriver, but Jack ignored him. In fact, he whisked past him, squeezing between the taxi and a delivery van.

At Thirtieth Street Jack turned east, crossed First Avenue, and abruptly turned into the loading bay of the Office of the Chief Medical Examiner for the City of New York. Jack had been working there for five months, having been offered a position as an associate medical examiner after finishing his pathology residency and a year’s fellowship in forensics.

Jack wheeled his bike past the security office and waved at the uniformed guard. Turning left, he passed the mortuary office and entered the morgue itself. Turning left again, he passed a bank of the refrigerated compartments used to store bodies prior to autopsy. In a corner where simple pine coffins were stored for unclaimed bodies heading for Hart Island, Jack parked his bike and secured it with several Kryptonite locks.

The elevator took Jack up to the first floor. It was well before eight in the morning and few of the daytime employees had arrived. Even Sergeant Murphy wasn’t in the office assigned to the police.

Passing through the communications room, Jack entered the ID area. He said hello to Vinnie Amendola, who returned the greeting without looking up from his newspaper. Vinnie was one of the mortuary techs who worked with Jack frequently.

Jack also said hello to Laurie Montgomery, one of the board-certified forensic pathologists. It was her turn in the rotation to be in charge of assigning the cases that had come in during the night. She’d been at the Office of the Chief Medical Examiner for four and a half years. Like Jack, she was usually one of the first to arrive in the morning.

“I see you made it into the office once again without having to come in feet first,” Laurie said teasingly. She was referring to Jack’s dangerous bike ride. “Coming in feet first” was office vernacular for arriving dead.

“Only one brush with a taxi,” Jack said. “I’m accustomed to three or four. It was like a ride in the country this morning.”

“I’m sure,” Laurie said without belief. “Personally I think you are foolhardy to ride your bike in this city. I’ve autopsied several of those daredevil bicycle messengers. Every time I see one in traffic I wonder when I’ll be seeing him in the pit.” The “pit” was office vernacular for the autopsy room.

Jack helped himself to coffee, then wandered over to the desk where Laurie was working.

“Anything particularly interesting?” Jack asked, looking over her shoulder.

“The usual gunshot wounds,” Laurie said. “Also a drug overdose.”

“Ugh,” Jack said.

“You don’t like overdoses?”

“Nah,” Jack said. “They’re all the same. I like surprises and a challenge.”

“I had a few overdoses that fit into that category during my first year,” Laurie said.

“How so?”

“It’s a long story,” Laurie said evasively. Then she pointed to one of the names on her list. “Here’s a case you might find interesting: Donald Nodelman. The diagnosis is unknown infectious disease.”

“That would certainly be better than an overdose,” Jack said.

“Not in my book,” Laurie said. “But it’s yours if you want it. Personally I don’t care for infectious disease cases, never have and never will. When I did the external exam earlier, it gave me the creeps. Whatever it was, it was an aggressive bug. He’s got extensive subcutaneous bleeding.”

“Unknowns can be a challenge,” Jack said. He picked up the folder. “I’ll be glad to do the case. Did he die at home or in an institution?”

“He was in a hospital,” Laurie said. “He was brought in from the Manhattan General. But infectious disease wasn’t his admitting diagnosis. He’d been admitted for diabetes.”

“It’s my recollection that the Manhattan General is an AmeriCare hospital,” Jack said. “Is that true?”

“I think so,” Laurie said. “Why do you ask?”

“Because it might make this case personally rewarding,” Jack said. “Maybe I’ll be lucky enough for the diagnosis to be something like Legionnaires’ disease. I couldn’t think of anything more enjoyable than giving AmeriCare heartburn. I’d love to see that corporation squirm.”

“Why’s that?” Laurie asked.

“It’s a long story,” Jack said with an impish smile. “One of these days we should have a drink and you can tell me about your overdoses and I’ll tell you about me and AmeriCare.”

Laurie didn’t know if Jack’s invitation was sincere or not. She didn’t know much about Jack Stapleton beyond his work at the medical examiner’s office; her understanding was that no one else did either. Jack was a superb forensic pathologist, despite the fact that he’d only recently finished his training. But he didn’t socialize much, and he was never very personally revealing in his small talk. All Laurie knew was that he was forty-one, unmarried, entertainingly flippant, and came from the Midwest.

“I’ll let you know what I find,” Jack said as he headed toward the communications room.

“Jack, excuse me,” Laurie called out.

Jack stopped and turned around.

“Would you mind if I gave you a bit of advice,” she said hesitantly. She was speaking impulsively. It wasn’t like her, but she appreciated Jack and hoped that he would be working there for some time.

Jack’s impish smile returned. He stepped back to the desk. “By all means,” he said.

“I’m probably speaking out of turn,” Laurie said.

“Quite the contrary,” Jack said. “I honor your opinion. What’s on your mind?”

“Just that you and Calvin Washington have been at odds,” Laurie said. “I know it’s just a clash of personalities, but Calvin has had a long-standing relationship with the Manhattan General, as AmeriCare does with the mayor’s office. I think you should be careful.”

“Being careful hasn’t been one of my strong points for five years,” Jack said. “I have utmost respect for the deputy chief. Our only disagreement is that he believes rules to be carved in stone while I see them as guidelines. As for AmeriCare, I don’t care for their goals or methods.”

“Well, it’s not my business,” Laurie said. “But Calvin keeps saying he doesn’t see you as a team player.”

“He’s got a point there,” Jack said. “The problem is that I’ve developed an aversion to mediocrity. I’m honored to work with most people around here, especially you. However, there are a few whom I can’t deal with, and I don’t hide it. It’s as simple as that.”

“I’ll take that as a compliment,” Laurie said.

“It was meant as one,” Jack said.

“Well, let me know what you find on Nodelman,” Laurie said. “Then I’ll have at least one more case for you to do.”

“My pleasure,” Jack said. He turned and headed for the communications room. As he walked past Vinnie, he snatched away his paper.

“Come on, Vinnie,” Jack said. “We’re going to get a jump on the day.”

Vinnie complained but followed. While trying to retrieve his paper he collided with Jack, who had abruptly stopped outside of Janice Jaeger’s office. Janice was one of the forensic investigators, frequently referred to as PAs or physician’s assistants. Her tour of duty was the graveyard shift, from eleven to seven. Jack was surprised to find her still in her office. A petite woman with dark hair and dark eyes, she was obviously tired.

“What are you still doing here?” Jack asked.

“I’ve got one more report to finish.”

Jack held up the folder in his hand. “Did you or Curt handle Nodelman?”

“I did,” Janice said. “Is there a problem?”

“Not that I know about yet,” Jack said with a chuckle. He knew Janice to be extremely conscientious, which made her ideal for teasing. “Was it your impression the cause of death was a nosocomial infection?”

“What the hell is a ‘nosocomial infection’?” Vinnie asked.

“It’s an infection acquired in a hospital,” Jack explained.

“It certainly seems so,” Janice said. “The man had been in the hospital five days for his diabetes before developing symptoms of an infectious disease. Once he got them, he died within thirty-six hours.”

Jack whistled in respect. “Whatever the bug was, it certainly was virulent.”

“That’s what worried the doctors I spoke with,” Janice said.

“Any laboratory results from microbiology?” Jack questioned.

“Nothing has grown out,” Janice said. “Blood cultures were negative as of four o’clock this morning. The terminal event was acute respiratory distress syndrome, or ARDS, but sputum cultures have been negative as well. The only positive thing was the gram stain of the sputum. That showed gram-negative bacilli. That made people think of pseudomonas, but it hasn’t been confirmed.”

“Any question of the patient being immunologically compromised?” Jack asked. “Did he have AIDS or had he been treated with antimetabolites?”

“Not that I could ascertain,” Janice said. “The only problem he had listed was diabetes and some of the usual sequelae. Anyway, it’s all in the investigative report if you’d care to read it.”

“Hey, why read when I can get it from the horse’s mouth?” Jack said with a laugh. He thanked Janice and headed for the elevator.

“I hope you are planning to wear your moon suit,” Vinnie said. The moon suit, the completely enclosed, impervious outfit complete with a clear plastic face mask, was designed for maximum protection. Air was forced into the suit by a fan worn at the small of the back, pulling air through a filter before circulating it within the headpiece. That provided enough ventilation to breathe but guaranteed sauna-like temperatures inside. Jack detested the setup.

As far as Jack was concerned the moon suit was bulky, restrictive, uncomfortable, hot, and unnecessary. He’d not worn one throughout his training. The problem was that the New York chief, Dr. Harold Bingham, had decreed that the suits be used. Calvin, the deputy chief, was intent on enforcing it. Jack had endured several confrontations as a result.

“This might be the first time the suit is indicated,” Jack said, to Vinnie’s relief. “Until we know what we are dealing with we have to take all precautions. After all, it could be something like Ebola virus.”

Vinnie stopped in his tracks. “You really think it’s possible?” he asked, his eyes opened wide.

“Not a chance,” Jack said. He slapped him on the back. “Just kidding.”

“Thank God,” Vinnie said. They started walking again.

“But maybe plague,” Jack added.

Vinnie stopped again. “That would be just as bad,” he said.

Jack shrugged his shoulders. “All in a day’s work,” he said. “Come on, let’s get it over with.”

They changed into scrubs, and then while Vinnie put on his moon suit and went into the autopsy room, Jack went through the contents of Nodelman’s folder. It had a case work sheet, a partially completed death certificate, an inventory of medical-legal case records, two sheets for autopsy notes, a telephone notice of death as received that night by communications, a completed identification sheet, Janice’s investigative report, a sheet for the autopsy report, and a lab slip for HIV antibody analysis.

Despite having spoken with Janice, Jack read her report carefully as he always did. When he was finished he went into the room next to the pine coffins and put on his moon suit. He took his ventilation unit from where it had been charging and hooked himself up. Then he set out for the autopsy room on the other side of the morgue.

Jack cursed the suit as he walked past most of the 126 refrigerated compartments for bodies. Being encased in the contraption put him in a bad mood, and he eyed his surroundings with a jaundiced eye. The morgue had been state of the art at one time, but it was now in need of repair and upgrading. With its aged, blue tile walls and stained cement floor it looked like a set for an old horror movie.

There was an entrance to the autopsy room directly from the hallway, but that wasn’t used any longer except to bring bodies in and out. Instead Jack entered through a small anteroom with a washbasin.

By the time Jack entered the autopsy room Vinnie had Nodelman’s body on one of the eight tables and had assembled all the necessary equipment and paraphernalia necessary to do the case. Jack positioned himself on the patient’s right, Vinnie on the left.

“He doesn’t look so good,” Jack said. “I don’t think he’s going to make it to the prom.” It was hard to talk in the moon suit, and he was already perspiring.

Vinnie, who never quite knew how to react to Jack’s irreverent comments, didn’t respond even though the corpse did look terrible.

“This is gangrene on his fingers,” Jack said. He lifted one of the hands and examined the almost-black fingertips closely. Then he pointed to the man’s shriveled genitals. “That’s gangrene on the end of his penis. Ouch! That must have hurt. Can you imagine?”

Vinnie held his tongue.

Jack carefully examined every inch of the man’s exterior. For Vinnie’s benefit he pointed out the extensive subcutaneous hemorrhages on the man’s abdomen and legs. He told him it was called purpura. Then Jack mentioned there were no obvious insect bites. “That’s important,” he added. “A lot of serious diseases are transmitted by arthropods.”

“Arthropods?” Vinnie questioned. He never knew when Jack was joking.

“Insects,” Jack said. “Crustaceans aren’t much of a problem as disease vectors.”

Vinnie nodded appreciatively, although he didn’t know any more than he had when he’d asked his question. He made a mental note to try to remember to look up the meaning of “arthropods” when he had an opportunity.

“What are the chances whatever killed this man is contagious?” Vinnie asked.

“Excellent, I’m afraid,” Jack said. “Excellent.”

The door to the hallway opened and Sal D’Ambrosio, another mortuary tech, wheeled in another body. Totally absorbed in the external exam of Mr. Nodelman, Jack did not look up. He was already beginning to form a differential diagnosis.

A half hour later six of the eight tables were occupied by corpses awaiting autopsies. One by one the other medical examiners on duty that day began to arrive. Laurie was the first, and she came over to Jack’s table.

“Any ideas yet?” she asked.

“Lots of ideas but nothing definitive,” Jack said. “But I can assure you this is one virulent organism. I was teasing Vinnie earlier about its being Ebola. There’s a lot of disseminated intravascular coagulation.”

“My God!” Laurie exclaimed. “Are you serious?”

“No, not really,” Jack said. “But from what I’ve seen so far it’s still possible, just not probable. Of course I’ve never seen a case of Ebola, so that should tell you something.”

“Do you think we ought to isolate this case?” Laurie asked nervously.

“I can’t see any reason to,” Jack said. “Besides, I’ve already started, and I’ll be careful to avoid throwing any of the organs around the room. But I’ll tell you what we should do: alert the lab to be mighty careful with the specimens until we have a diagnosis.”

“Maybe I’d better ask Bingham’s opinion,” Laurie said.

“Oh, that would be helpful,” Jack said sarcastically. “Then we’ll have the blind leading the blind.”

“Don’t be disrespectful,” Laurie said. “He is the chief.”

“I don’t care if he’s the Pope,” Jack said. “I think I should just get it done, the sooner the better. If Bingham or even Calvin gets involved it will drag on all morning.”

“All right,” Laurie said. “Maybe you’re right. But let me see any abnormality. I’ll be on table three.”

Laurie left to do her own case. Jack took a scalpel from Vinnie and was about to make the incision when he noticed that Vinnie had moved away.

“Where are you going to watch this from, Queens?” Jack asked. “You’re supposed to be helping.”

“I’m a little nervous,” Vinnie admitted.

“Oh, come on, man,” Jack said. “You’ve been at more autopsies than I have. Get your Italian ass over here. We’ve got work to do.”

Jack worked quickly but smoothly. He handled the internal organs gently and was meticulously careful about the use of instruments when either his or Vinnie’s hands were in the field.

“Whatcha got?” Chet McGovern asked, looking over Jack’s shoulder. Chet was also an associate medical examiner, having been hired in the same month as Jack. Of all the colleagues he’d become the closest to Jack, since they shared both a common office and the social circumstance of being single males. But Chet had never been married and at thirty-six, he was five years Jack’s junior.

“Something interesting,” Jack said. “The mystery disease of the week. And it’s a humdinger. This poor bastard didn’t have a chance.”

“Any ideas?” Chet asked. His trained eye took in the gangrene and the hemorrhages under the skin.

“I got a lot of ideas,” Jack said. “But let me show you the internal. I’d appreciate your opinion.”

“Is there something I should see?” Laurie called from table three. She’d noticed Jack conversing with Chet.

“Yeah, come on over,” Jack said. “No use going through this more than once.”

Laurie sent Sal to the sink to wash out the intestines on her case, then stepped over to table one.

“The first thing I want you to look at is the lymphatics I dissected in the throat,” Jack said. He had retracted the skin of the neck from the chin to the collarbone.

“No wonder autopsies take so long around here,” a voice boomed in the confined space.

All eyes turned toward Dr. Calvin Washington, the deputy chief He was an intimidating six-foot-seven, two-hundred-and-fifty-pound African-American man who’d passed up a chance to play NFL football to go to medical school.

“What the hell is going on around here?” he demanded half in jest. “What do you people think this is, a holiday?”

“Just pooling resources,” Laurie said. “We’ve got an unknown infectious case that appears to be quite an aggressive microbe.”

“So I heard,” Calvin said. “I already got a call from the administrator over at the Manhattan General. He’s justly concerned. What’s the verdict?”

“A bit too soon to tell,” Jack said. “But we’ve got a lot of pathology here.”

Jack quickly summarized for Calvin what was known of the history and pointed out the positive findings on the external exam. Then he started back on the internal, indicating the spread of the disease along the lymphatics of the neck.

“Some of these nodes are necrotic,” Calvin said.

“Exactly,” Jack said. “In fact most of them are necrotic. The disease was spreading rapidly through the lymphatics, presumably from the throat and bronchial tree.”

“Airborne, then,” Calvin said.

“It would be my first guess,” Jack admitted. “Now look at the internal organs.”

Jack presented the lungs and opened the areas where he’d made slices.

“As you can see, this is pretty extensive lobar pneumonia,” Jack said. “There’s a lot of consolidation. But there is also some necrosis, and I believe early cavitation. If the patient had lived longer, I think we would be seeing some abscess formation.”

Calvin whistled. “Wow,” he said. “All this was happening in the face of massive IV antibiotics.”

“It’s worrisome,” Jack agreed. He carefully slid the lungs back into the pan. He didn’t want them sloshing around, potentially throwing infective particles into the air. Next he picked up the liver and gently separated its cut surface.

“Same process,” he announced, pointing with his fingers to areas of early abscess formation. “Just not as extensive as with the lungs.” Jack put the liver down and picked up the spleen. There were similar lesions throughout the organ. He made sure everyone saw them.

“So much for the gross,” Jack said as he carefully replaced the spleen in the pan. “We’ll have to see what the microscopic shows, but I actually think we’ll be relying on the lab to give us the definitive answer.”

“What’s your guess at this point?” Calvin asked.

Jack let out a short laugh. “A guess it would have to be,” he said. “I haven’t seen anything pathognomonic yet. But its fulminant character should tell us something.”

“What’s your differential diagnosis?” Calvin asked. “Come on, Wonderboy, let’s hear it.”

“Ummmm,” Jack said. “You’re kinda putting me on the spot. But okay, I’ll tell you what’s been going through my head. First, I don’t think it could be pseudomonas as suspected at the hospital. It’s too aggressive. It could have been something atypical like strep group A or even staph with toxic shock, but I kinda doubt it, especially with the gram stain suggesting it was a bacillus. So I’d have to say it is something like tularemia or plague.”

“Whoa!” Calvin exclaimed. “You’re coming up with some pretty arcane illnesses for what was apparently a hospital-based infection. Haven’t you heard the phrase about when you hear hoofbeats you should think of horses, not zebras?”

“I’m just telling you what’s going through my mind. It’s just a differential diagnosis. I’m trying to keep an open mind.”

“All right,” Calvin said soothingly. “Is that it?”

“No, that’s not it,” Jack said. “I’d also consider that the gram stain could have been wrong and that would let in not only strep and staph but meningococcemia as well. And I might as well throw in Rocky Mountain spotted fever and hantavirus. Hell, I could even throw in the viral hemorrhagic fevers like Ebola.”

“Now you’re getting out in the stratosphere,” Calvin said. “Let’s come back to reality. If I made you guess which one it is right now with what you know, what would you say?”

Jack clucked his tongue. He had the irritated feeling he was being put back in medical school, and that Calvin, like many of his medical-school professors, was trying to make him look bad.

“Plague,” Jack said to a stunned audience.

“Plague?” Calvin questioned with surprise bordering on disdain. “In March? In New York City? In a hospitalized patient? You got to be out of your mind.”

“Hey, you asked me for one diagnosis,” Jack said. “So I gave it to you. I wasn’t responding by probabilities, just pathology.”

“You weren’t considering the other epidemiological aspects?” Calvin asked with obvious condescension. He laughed. Then, talking more to the others than Jack, he said: “What the hell did they teach you out there in the Chicago boonies?”

“There are too many unknowns in this case for me to put a lot of weight on unsubstantiated information,” Jack said. “I didn’t visit the site. I don’t know anything about the deceased’s pets, travel, or contact with visitors. There are a lot of people coming and going in this city, even in and out of a hospital. And there are certainly more than enough rats around here to support the diagnosis.”

For a moment a heavy silence hung over the autopsy room. Neither Laurie nor Chet knew what to say. Jack’s tone made them both uncomfortable, especially knowing Calvin’s stormy temperament.

“A clever comment,” Calvin said finally. “You’re quite good at double entendre. I have to give you credit there. Perhaps that’s part of pathology training in the Midwest.”

Both Laurie and Chet laughed nervously.

“All right, smartass,” Calvin continued. “How much are you willing to put on your diagnosis of plague?”

“I didn’t know it was customary to gamble around here,” Jack said.

“No, it’s not common to gamble, but when you come up with a diagnosis of plague, I think it’s worthwhile to make a point of it. How about ten dollars?”

“I can afford ten dollars,” Jack said.

“Fine,” Calvin said. “With that settled, where’s Paul Plodgett and that gunshot wound from the World Trade Center?”

“He’s down on table six,” Laurie said.

Calvin lumbered away and for a moment the others watched him. Laurie broke the silence. “Why do you try to provoke him?” she asked Jack. “I don’t understand. You’re making it more difficult for yourself.”

“I can’t help it,” Jack said. “He provoked me!”

“Yeah, but he’s the deputy chief and it’s his prerogative,” Chet said. “Besides, you were pushing things with a diagnosis of plague. It certainly wouldn’t be on the top of my list.”

“Are you sure?” Jack asked. “Look at the black fingers and toes on this patient. Remember, it was called the black death back in the fourteenth century.”

“A lot of diseases can cause such thrombotic phenomena,” Chet said.

“True,” Jack said. “That’s why I almost said tularemia.”

“And why didn’t you?” Laurie asked. In her mind tularemia was equally improbable.

“I thought plague sounded better,” Jack said. “It’s more dramatic.”

“I never know when you are serious,” Laurie said.

“Hey, I feel the same way,” Jack said.

Laurie shook her head in frustration. At times it was hard to have a serious discussion with Jack. “Anyway,” she said, “are you finished with Nodelman? If you are, I’ve got another case for you.”

“I haven’t done the brain yet,” Jack said.

“Then get to it,” Laurie said. She walked back to table three to finish her own case.