Contagion

5

It was overcast and threatening rain, but Jack didn’t mind. Regardless of the weather, the vigorous bike ride uptown to the Manhattan General was a pleasure after having stood all morning in the autopsy room imprisoned inside his moon suit.

Near the hospital’s front entrance Jack located a sturdy street sign to lock his mountain bike to. He even locked up his helmet and bomber jacket with a separate wire lock that also secured the seat.

Standing within the shadow of the hospital, Jack glanced up at its soaring facade. It had been an old, respected, university-affiliated, proprietary hospital in its previous life. AmeriCare had gobbled it up during the fiscally difficult times the government had unwittingly created in health care in the early 1990s. Although Jack knew revenge was far from a noble emotion, he savored the knowledge that he was about to hand AmeriCare a public relations bomb.

Inside Jack went to the information booth and asked about Dr. Carl Wainwright. He learned that the man was an AmeriCare internist whose office was in the attached professional building. The receptionist gave Jack careful directions.

Fifteen minutes later, Jack was in the man’s waiting room. After Jack flashed his medical examiner’s badge, which looked for all intents and purposes like a police badge, the receptionist wasted no time in letting Dr. Wainwright know he was there. Jack was immediately shown into the doctor’s private office, and within minutes the doctor himself appeared.

Dr. Carl Wainwright was prematurely white-haired and slightly stooped over. His face, however, was youthful with bright blue eyes. He shook hands with Jack and motioned for him to sit down.

“It’s not every day we’re visited by someone from the medical examiner’s office,” Dr. Wainwright said.

“I’d be concerned if it were,” Jack said.

Dr. Wainwright looked confused until he realized Jack was kidding. Dr. Wainwright tittered. “Right you are,” he said.

“I’ve come about your patient Donald Nodelman,” Jack said, getting right to the point. “We have a presumptive diagnosis of plague.”

Dr. Wainwright’s mouth dropped open. “That’s impossible,” he said when he’d recovered enough to speak.

Jack shrugged. “I guess it’s not,” he said. “Fluorescein antibody for plague is quite reliable. Of course, we haven’t yet grown it out.”

“My goodness,” Dr. Wainwright managed. He rubbed a nervous palm across his face. “What a shock.”

“It is surprising,” Jack agreed. “Especially since the patient had been in the hospital for five days before his symptoms started.”

“I’ve never heard of nosocomial plague,” Dr. Wainwright said.

“Nor have I,” Jack said. “But it was pneumonic plague, not bubonic, and as you know the incubation period is shorter for pneumonic, probably only two to three days.”

“I still can’t believe it,” Dr. Wainwright said. “Plague never entered my thoughts.”

“Anybody else sick with similar symptoms?” Jack asked.

“Not that I know of,” Dr. Wainwright said, “but you can rest assured that we will find out immediately.”

“I’m curious about this man’s lifestyle,” Jack said. “His wife denied any recent travel or visitors from areas endemic to plague. She also doubted he’d come in contact with wild animals. Is that your understanding as well?”

“The patient worked in the garment district,” Dr. Wainwright said. “He did bookkeeping. He never traveled. He wasn’t a hunter. I’d been seeing him frequently over the last month, trying to get his diabetes under control.”

“Where was he in the hospital?” Jack asked.

“On the medical ward on the seventh floor,” Dr. Wainwright said. “Room seven-oh-seven. I remember the number specifically.”

“Single room?” Jack asked.

“All our rooms are singles,” Dr. Wainwright said.

“That’s a help,” Jack said. “Can I see the room?”

“Of course,” Dr. Wainwright said. “But I think I should call Dr. Mary Zimmerman, who’s our infection-control officer. She’s got to know about this immediately.”

“By all means,” Jack said. “Meanwhile, would you mind if I went up to the seventh floor and looked around?”

“Please,” Dr. Wainwright said as he gestured toward the door. “I’ll call Dr. Zimmerman and we’ll meet you up there.” He reached for the phone.

Jack retraced his route back to the main hospital building. He took the elevator to the seventh floor, which he found was divided by the elevator lobby into two wings. The north wing housed internal medicine while the south wing was reserved for OB-GYN. Jack pushed through the doors that led into the internal-medicine division.

As soon as the swinging door closed behind Jack, he knew that word of the contagion had arrived. A nervous bustle was apparent, and all the personnel were wearing newly distributed masks. Obviously Wainwright had wasted no time.

No one paid Jack any attention as he wandered down to room 707. Pausing at the door, Jack watched as two masked orderlies wheeled out a masked and confused patient clutching her belongings who was apparently being transferred. As soon as they were gone, Jack walked in.

Seven-oh-seven was a nondescript hospital room of modern design; the interior of the old hospital had been renovated in the not-too-distant past. The metal furniture was typical hospital issue and included a bed, a bureau, a vinyl-covered chair, a night table, and a variable-height bed table. A TV hung from an arm attached to the ceiling.

The air-conditioning apparatus was beneath the window. Jack went over to it, lifted the top, and looked inside. A hot-water and a chill-water pipe poked up through the concrete floor and entered a thermostated fan unit that recirculated room air. Jack detected no holes large enough for any type of rodent much less a rat.

Stepping into the bathroom, Jack glanced around at the sink, toilet, and shower. The room was newly tiled. There was an air return in the ceiling. Bending down, he opened the cabinet below the sink; again there were no holes.

Hearing voices in the other room, Jack stepped back through the door. It was Dr. Wainwright clutching a mask to his face. He was accompanied by two women and a man, all of whom were wearing masks. The women were attired in the long, white professorial coats Jack associated with medical-school professors.

After handing Jack a mask, Dr. Wainwright made the introductions. The taller woman was Dr. Mary Zimmerman, the hospital’s infection-control officer and head of the like-named committee. Jack sensed she was a serious woman who felt defensive under the circumstances. As she was introduced, she informed him that she was a board-certified internist with subspecialty training in infectious disease.

Not knowing how to respond to this revelation, Jack complimented her.

“I did not have an opportunity to examine Mr. Nodelman,” she added.

“I’m certain you would have made the diagnosis instantly had you done so,” Jack said, consciously trying to keep sarcasm out of his voice.

“No doubt,” she said.

The second woman was Kathy McBane, and Jack was happy to turn his attention to her, especially since Ms. McBane had a warmer demeanor than her committee chairwoman. He learned she was an RN supervisor and a member of the Infection Control Committee. It was usual for such a committee to have representatives from most if not all the hospital departments.

The man was George Eversharp. He was dressed in a heavy cotton twill blue uniform. As Jack suspected, he was the supervisor of the department of engineering and was also a member of the Infection Control Committee.

“We certainly are indebted to Dr. Stapleton for his rapid diagnosis,” Dr. Wainwright said, trying to lighten the atmosphere.

“Just a lucky guess,” Jack said.

“We’ve already begun to react,” Dr. Zimmerman said in a deadpan voice. “I’ve ordered a list to be drawn up of possible contacts to start chemoprophylaxis.”

“I think that is wise,” Jack said.

“And as we speak, the clinical computer is searching our current patient database for symptom complexes suggestive of plague,” she continued.

“Commendable,” Jack said.

“Meanwhile we have to discover the origin of the current case,” she said.

“You and I are thinking along the same lines,” Jack said.

“I’d advise you to wear your mask,” she added.

“Okay,” Jack said agreeably. He held it up to his face.

Dr. Zimmerman turned to Mr. Eversharp. “Please continue with what you were saying about the air flow.”

Jack listened as the engineer explained that the ventilation system in the hospital was designed so that there was a flow from the hall into each room and then its bathroom. The air was then filtered. He also explained that there were a few rooms where the air flow could be reversed for patients with compromised immune systems.

“Is this one of those rooms?” Dr. Zimmerman asked.

“It is not,” Mr. Eversharp said.

“So there is no freak way plague bacteria could have gotten into the ventilation system and infected just this room?” Dr. Zimmerman asked…

“No,” Mr. Eversharp said. “The air induction in the hall goes into all these rooms equally.”

“And the chances of bacteria floating out of this room into the hall would be low,” Dr. Zimmerman said.

“Impossible,” Mr. Eversharp said. “The only way it could leave would be on some sort of vector.”

“Excuse me,” a voice called. Everyone turned to see a nurse standing in the doorway. She, too, had a mask pressed against her face. “Mr. Kelley would like you all to come to the nurses’ station.”

Dutifully everyone started from the room. As Kathy McBane stepped in front of him, Jack got her attention. “Who’s Mr. Kelley?” he asked.

“He’s the hospital president,” Ms. McBane said.

Jack nodded. As he walked he nostalgically reminisced that the head of the hospital used to be called an administrator and was frequently a person who’d had medical training. That was back when patient care was paramount. Now that business was king and the goal was profit, the name had changed to president.

Jack was looking forward to meeting Mr. Kelley. The hospital president was the on-site representative of AmeriCare, and giving him a headache was the equivalent of giving AmeriCare a headache.

The atmosphere at the nurses’ station was tense. Word of the plague had spread like wildfire. Everyone who worked on the floor and even some of the ambulatory patients now knew they had been potentially exposed. Charles Kelley was doing his best to reassure them. He told them there was no risk and that everything was under control.

“Yeah, sure!” Jack scoffed under his breath. Jack looked with disgust at this man who had the gall to utter such patently false platitudes. He was intimidatingly tall, a good eight inches taller than Jack’s six feet. His handsome face was tanned and his sandy-colored hair was streaked with pure, golden blond as if he’d just returned from a Caribbean vacation. From Jack’s perspective, he looked and sounded more like an unctuous car salesman than the business manager that he was.

As soon as Kelley saw Jack and the others approach, he motioned for them to follow him. Breaking off his consoling speech, he made a beeline for the safety of the utility room behind the nurses’ station.

As Jack squeezed in behind Kathy McBane, he noticed Kelley wasn’t alone. He was being shadowed by a slightly built man with a lantern jaw and thinning hair. In sharp contrast to Kelley’s sartorial splendor, this second man was dressed in a threadbare, cheap sports coat over slacks that appeared never to have been pressed.

“God, what a mess!” Kelley said angrily to no one in particular. His demeanor had metamorphosed instantly from slippery salesman to sardonic administrator. He took a paper towel and wiped his perspiring brow. “This is not what this hospital needs!” He crumpled the towel and threw it into the trash. Turning to Dr. Zimmerman and in contrast to what he’d just said out in the nurses’ station, he asked her if they were taking a risk just being on the floor.

“I sincerely doubt it,” Dr. Zimmerman said. “But we’ll have to make certain.”

Turning to Dr. Wainwright, Kelley said: “No sooner had I heard about this disaster than I learned you already knew about it. Why didn’t you inform me?”

Dr. Wainwright explained that he’d just heard the news from Jack and had not had time to call. He explained he thought it was more important to call Dr. Zimmerman to get corrective measures instituted. He then proceeded to introduce Jack.

Jack stepped forward and gave a little wave. He was unable to suppress a smile. This was the moment he knew he’d savor.

Kelley took in the chambray shirt, the knitted tie, and the black jeans. It was a far cry from his own Valentino silk suit. “Seems to me the Commissioner of Health mentioned your name when she called me,” Kelley said. “As I recall, she was impressed you’d made the diagnosis so quickly.”

“We city employees are always glad to be of service,” Jack said.

Kelley gave a short, derisive laugh.

“Perhaps you’d like to meet one of your dedicated fellow city employees,” Kelley said. “This is Dr. Clint Abelard. He’s the epidemiologist for the New York City Board of Health.”

Jack nodded to his mousy colleague, but the epidemiologist didn’t return the greeting. Jack got the sense that Jack’s presence was not wholly appreciated. Interdepartmental rivalry was a fact of bureaucratic life he was just beginning to appreciate.

Kelley cleared his throat and then spoke to Wainwright and Zimmerman. “I want this whole episode kept as low-key as possible. The less that’s in the media the better. If any reporter tries to talk with either of you, send them to me. I’ll be gearing up the PR office to do damage control.”

“Excuse me,” Jack said, unable to restrain himself from interrupting. “Corporate interests aside, I think you should concentrate on prevention. That means treating contacts and ascertaining where the plague bacteria came from. I think you have a mystery on your hands here, and until that’s solved, the media is going to have a field day no matter what damage control you attempt.”

“I wasn’t aware anyone asked your opinion,” Kelley said scornfully.

“I just felt you could use a little direction,” Jack said. “You seemed to be wandering a bit far afield.”

Kelley’s face reddened. He shook his head in disbelief. “All right,” he said, struggling to control himself. “With your clairvoyance, I suppose you already have an idea of its origin.”

“I’d guess rats,” Jack said. “I’m sure there are lots of rats around here.” Jack had been waiting to use that comment since it had had such a good effect with Calvin that morning.

“We have no rats here at the Manhattan General,” Kelley sputtered. “And if I hear that you’ve said anything like that to the media, I’ll have your head.”

“Rats are the classical reservoir for the plague,” Jack said. “I’m sure they’re around here if you know how to recognize them, I mean find them.”

Kelley turned to Clint Abelard. “Do you think rats had anything to do with this case of plague?” he demanded.

“I have yet to begin my investigation,” Dr. Abelard said. “I wouldn’t want to hazard a guess, but I find it hard to believe that rats could have been involved. We’re on the seventh floor.”

“I’d suggest you start trapping rats,” Jack said. “Start in the immediate neighborhood. The first thing to find out is if plague has infiltrated the local urban rodent population.”

“I’d like to switch the conversation away from rats,” Kelley said. “I would like to hear about what we should do for people who had direct contact with the deceased.”

“That’s my department,” Dr. Zimmerman said. “Here’s what I propose…”

While Dr. Zimmerman spoke, Clint Abelard motioned for Jack to accompany him out to the nurses’ station.

“I’m the epidemiologist,” Clint said in an angry, forced whisper.

“I’ve never disputed that fact,” Jack said. He was surprised and confused by the vehemence of Clint’s reaction.

“I’m trained to investigate the origin of diseases in the human community,” he said. “It’s my job. You, on the other hand, are a coroner…”

“Correction,” Jack said. “I’m a medical examiner with training in pathology. You, as a physician, should know that.”

“Medical examiner or coroner, I couldn’t care less what term you guys use for yourselves,” Clint said.

“Hey, but I do,” Jack said.

“The point is that your training and your responsibility involve the dead, not the origin of disease.”

“Wrong again,” Jack said. “We deal with the dead so that they speak to the living. Our goal is to prevent death.”

“I don’t know how to make it much plainer to you,” Clint said with exasperation. “You told us a man died of plague. We appreciate that, and we didn’t interfere in your work. Now it is for me to figure out how he got it.”

“I’m just trying to help,” Jack said.

“Thank you, but if I need your help I’ll ask for it,” Clint said and strode off toward room 707.

Jack watched Clint’s figure recede, when a commotion behind him attracted his attention. Kelley had emerged from the utility room and was immediately besieged by the people he’d been speaking with earlier. Jack was impressed by how quickly his plastic smile returned and with what ease he sidestepped all questions. Within seconds, he was on his way down the hall toward the elevators and the safety of the administrative offices.

Dr. Zimmerman and Dr. Wainwright stepped out of the utility room deep in conversation. When Kathy McBane appeared, she was alone. Jack intercepted her.

“Sorry to have been the bearer of bad news,” Jack offered.

“Don’t be sorry,” Kathy said. “From my point of view, we owe you a vote of thanks.”

“Well, it’s an unfortunate problem,” Jack said.

“I’d guess it’s the worst since I’ve been on the Infection Control Committee,” she said. “I thought last year’s outbreak of hepatitis B was bad. I never dreamed we’d ever see plague.”

“What is the Manhattan General’s experience in regard to nosocomial infections?” Jack asked.

Kathy shrugged. “Pretty much the equivalent of any large tertiary-care hospital,” she said. “We’ve had our methicillin-resistant staph. Of course, that’s an ongoing problem. We even had klebsiella growing in a canister of surgical scrub soap a year ago. That resulted in a whole series of postoperative wound infections until it was discovered.”

“How about pneumonias?” Jack asked. “Like this case.”

“Oh, yeah, we’ve had our share of them too,” Kathy said with a sigh. “Mostly it’s been pseudomonas, but two years ago we had an outbreak of Legionella.”

“I hadn’t heard about that,” Jack said.

“It was kept quiet,” Kathy said. “Luckily no one died. Of course, I can’t say that about the problem we had just five months ago in the surgical intensive care. We lost three patients to enterobacterial pneumonia. We had to close the unit until it was discovered that some of our nebulizers had become contaminated.”

“Kathy!” a voice called out sharply.

Both Jack and Kathy abruptly turned to see that Dr. Zimmerman had come up behind them.

“That is confidential information,” Dr. Zimmerman lectured.

Kathy started to say something but then thought better of it.

“We have work to do, Kathy,” Dr. Zimmerman said. “Let’s go to my office.”

Suddenly abandoned, Jack debated what he should do. For a moment he considered going back to room 707, but after Clint’s tirade, he thought it best to leave the man alone. After all, Jack had intended to provoke Kelley, not Clint. Then he got an idea: It might be instructive to visit the lab. As defensively as Dr. Zimmerman had responded, Jack thought it was the lab that should have been chagrined. They were the ones who missed the diagnosis.

After inquiring about the location of the lab, Jack took the elevator down to the second floor. Flashing his medical examiner’s badge again produced immediate results. Dr. Martin Cheveau, the lab director, materialized and welcomed Jack into his office. He was a short fellow with a full head of dark hair and pencil-line mustache.

“Have you heard about the case of plague?” Jack asked once they were seated.

“No, where?” Martin questioned.

“Here at the Manhattan General,” Jack said. “Room seven-oh-seven. I posted the patient this morning.”

“Oh, no!” Martin moaned. He sighed loudly. “That doesn’t sound good for us. What was the name?”

“Donald Nodelman,” Jack said.

Martin swung around in his seat and accessed his computer. The screen flashed all Nodelman’s laboratory results for the duration of his admission. Martin scrolled through until he got to the microbiology section.

“I see we had a sputum gram stain showing weakly gram-negative bacilli,” Martin said. “There’s also a culture pending that was negative for growth at thirty-six hours. I guess that should have told us something, especially where I see pseudomonas was suspected. I mean, pseudomonas would have grown out without any trouble way before thirty-six hours.”

“It would have been helpful if Giemsa’s or Wayson’s stain had been used,” Jack said. “The diagnosis could have been made.”

“Exactly,” Martin said. He turned back to Jack. “This is terrible. I’m embarrassed. Unfortunately, it’s an example of the kind of thing that’s going to happen more and more often. Administration has been forcing us to cut costs and downsize even though our workload has gone up. It’s a deadly combination, as this case of plague proves. And it’s happening all over the country.”

“You’ve had to let people go?” Jack asked. He thought that the clinical lab was one place hospitals actually made money.

“About twenty percent,” Martin said. “Others we’ve had to demote. In microbiology we don’t have a supervisor any longer; if we had, he probably would have caught this case of plague. With the operating budget we’ve been allotted we can’t afford it. Our old supervisor got demoted to head tech. It’s discouraging. It used to be we strove for excellence in the lab. Now we strive for ‘adequate,’ whatever that means.”

“Does your computer say which tech did the gram stain?” Jack asked. “If nothing else, we could turn this episode into a teaching experience.”

“Good idea,” Martin said. He faced the computer and accessed data. The tech’s identity was in code. Suddenly he turned back to Jack.

“I just remembered something,” he said. “My head tech thought of plague in relation to a patient just yesterday and asked me what I thought. I’m afraid I discouraged him by telling him the chances were somewhere on the order of a billion to one.”

Jack perked up. “I wonder what made him think of plague?”

“I wonder too,” Martin said. Reaching over to his intercom system, he paged Richard Overstreet. While they waited for the man to arrive, Martin determined that Nancy Wiggens had signed out on the original gram stain. Martin paged her as well.

Richard Overstreet appeared within minutes. He was a boyish, athletic-looking individual with a shock of auburn hair that fell across his forehead. The hair had a habit of slipping over his eyes. Richard was ever pushing it back with his hand or throwing it back with a snap of his head. He wore a white jacket over surgical scrubs; his jacket pockets were crammed with test tubes, tourniquets, gauze pads, lab chits, and syringes.

Martin introduced Richard to Jack, then asked him about the short discussion they’d had about plague the day before.

Richard seemed embarrassed. “It was just my imagination getting the best of me,” he said with a laugh.

“But what made you think of it?” Martin asked.

Richard swept his hair from his face and for a moment left his hand on the top of his head while he thought. “Oh, I remember,” he said. “Nancy Wiggens had gone up to get a sputum culture and draw the man’s blood. She told me how sick he was and that he appeared to have some gangrene on the tips of his fingers. She said his fingers were black.” Richard shrugged. “It made me think of the black death.”

Jack was impressed.

“Did you follow up on it at all?” Martin asked.

“No,” Richard said. “Not after what you’d said about the probability. As behind as we are in the lab, I couldn’t take the time. All of us, including me, have been out drawing blood. Is there some kind of problem?” Richard asked.

“A big problem,” Martin said. “The man did have plague. Not only that, but he’s already dead.”

Richard literally staggered. “My God!” he exclaimed.

“I hope you encourage safety with your techs,” Jack said.

“Absolutely,” Richard said, regaining his composure. “We have biosafety cabinets, both type two and three. I try to encourage my techs to use one or the other, especially with obviously serious infectious cases. Personally I like the type three, but some people find using the thick rubber gloves too clumsy.”

At that moment Nancy Wiggens appeared. She was a shy woman who appeared more like a teenager than a college graduate. She could barely look Jack in the eye as they were introduced. She wore her dark hair parted down the middle of her head, and like that of her immediate boss, Richard, it constantly fell across her eyes.

Martin explained to her what had happened. She was as shocked as Richard had been. Martin assured her she was not being blamed but that they should all try to learn from the experience.

“What should I do about my exposure?” she questioned. “I was the one who got the specimen as well as the one who processed it.”

“You’ll probably be taking tetracycline by mouth or streptomycin IM,” Jack said. “The hospital infection-control officer is working on that at the moment.”

“Uh oh!” Martin voiced under his breath but loud enough for the others to hear. “Here comes our fearless leader and the chief of the medical staff, and both look unhappy.”

Kelley swept into the room like an irate general after a military defeat. He towered over Martin with his hands on his hips and his reddened face thrust forward. “Dr. Cheveau,” he began with a scornful tone. “Dr. Arnold here tells me you should have made this diagnosis before…”

Kelley stopped mid-sentence. Although he was content to ignore the two microbiology techs, Jack was a different story.

“What in God’s name are you doing down here?” he demanded.

“Just helping out,” Jack replied.

“Aren’t you overstepping your mandate?” he suggested venomously.

“We like to be thorough in our investigations,” Jack said.

“I think you have more than exhausted your official capacity,” Kelley snapped. “I want you out of here. After all, this is a private institution.”

Jack got to his feet, vainly trying to look the towering Kelley in the eye. “If AmeriCare thinks it can do without me, I think I’ll run along.”

Kelley’s face turned purple. He started to say something else but changed his mind. Instead he merely pointed toward the door.

Jack smiled and waved to the others before taking his leave. He was pleased with his visit. As far as he was concerned, it couldn’t have gone better.