Critical

7

Laurie's eyes were glazed over as she stared blankly out of the taxi's side window as it raced northward on Second Avenue. She was totally preoccupied with her MRSA series, which had started out as a possible way of convincing Jack to postpone his knee surgery but which had morphed into something else entirely. She still intended to use the issue with Jack, but now she sensed there was a wider significance, and the possibility electrified her. Her conception of the role of the medical examiner was to speak for the dead to help the living. Suddenly, she saw her current series as a means to do just that. If she could figure out why these MRSA deaths were occurring in such a cluster, she could presumably save potential victims.

Thinking in such a vein had a disheartening aspect. Why hadn't the OCME picked up on the problem sooner? Laurie pondered the question for a moment before guessing the reason: a low index of suspicion, which Laurie assumed would have influenced her, too, concerning David Jeffries, had the personal aspect not intervened.

Laurie knew that as many as ten percent of all patients entering the hospital come away with a hospital-acquired infection, meaning about two million patients a year, resulting in nearly ninety thousand deaths in the United States alone. Of these infections, about thirty-five percent were staph, many of which were MRSA. In short, the problem was just too common to cause much of a stir, especially with bacteria on the rise.

A sudden crash jolted Laurie from her reflections. Had she not had her seat belt on, her head would have hit the ceiling.

"Sorry!" the cabbie said, glancing at Laurie in his rearview mirror to see if she was okay. "Potholes from the winter."

Laurie nodded. She appreciated the apology, as unexpected as it was, but not the driving style.

"Maybe you could slow down," she suggested.

"Time is money," the turbaned driver answered.

Knowing the futility of trying to influence the taxi driver's mind-set, Laurie went back to her musing. She was on her way to the Angels Orthopedic Hospital, which was sited on Fifth Avenue on the Upper East Side, and surprisingly enough, approximately directly across Central Park from where she and Jack lived. Over the previous two hours she'd been frantically busy, and, despite a mild fear for her life in the cab, she appreciated the forced respite and time to organize her thoughts that the ride offered. She'd finally been able to meet with Arnold Besserman and Kevin Southgate, and had gotten the names of their six cases and four of the six case files and hospital records. Arnold had even given her the personal monograph he'd written on MRSA, which Laurie had quickly read.

Laurie now knew more about the bacterium than she'd ever known, even more than she had just before taking her forensic pathology boards, for which she had crammed in her old collegiate style, with all sorts of esoteric facts, including some about MRSA and other staph organisms. As Agnes had said, staphylococcus aureus was an extraordinary and versatile pathogen.

With the accession numbers of Arnold's and Kevin's cases plus those of George Fontworth, Laurie had relayed them all to Agnes Finn. Laurie wanted Agnes to retrieve their frozen samples for culture and subtyping just as she was already doing with Laurie's case that morning and Riva's cases. Laurie thought it was important to see how closely they all matched.

Laurie had then made some important phone calls with the numbers Cheryl had gotten for her. First, she called Loraine Newman at the Angels Orthopedic Hospital. Laurie found her as accommodating as both Arnold and Cheryl had described. The woman graciously agreed to a meeting that very afternoon at two-thirty.

Next, Laurie had called a woman at the CDC by the name of Dr. Silvia Salerno, who was associated with the CDC's national library of MRSA strains that had been formed to identify genetic patterns in the subtype, in hopes of influencing prevention and control strategies. In addition, she was part of the CDC's Web-based National Healthcare Safety Network and had been the person to whom Riva had been referred. It was she who had had Riva's isolates subtyped.

"If I am not mistaken, they were a community-acquired MRSA, or what we call CA-MRSA," Silvia had said when Laurie had asked if she remembered the cases. "Let me look it up. Okay, here it is. CA-MRSA, USA four hundred, MWtwo, SCCmecIV, PVL. Now I remember it very clearly. That is a particularly virulent organism, maybe one of the most virulent we've seen, particularly with the PVL toxin."

"Do you recall Dr. Mehta mentioning that her two cases came from two separate hospitals?"

"I don't. I assumed it was the same institution."

"It was definitely two hospitals. Does that surprise you?"

"It suggests the two individuals knew each other or they each knew a third person."

"Meaning you believe these were not nosocomial infection?"

"Technically, for an infection to be considered nosocomial, the patient has to have been in the hospital for more than forty-eight hours."

"But that's only a technical definition. I mean, the patients could have gotten them from the hospital."

"Of course. The definition is more for statistical reasons than scientific, but getting such an infection within twenty-four hours of admission would suggest to me that they were part of the patient's own flora."

Laurie described her series, all of whose victims had died of MRSA within twenty-four hours and, of those whose subtyping was available, had died of community-acquired MRSA, which Silvia said backed up her contention that the bacteria were most likely brought in by the patients. Regardless, Silvia had specifically said she was interested in the cases and had been surprised not to have heard of the cluster. Offering to help in any way she could, she took Laurie's direct-dial office number, and promised to get back to her after she'd asked around to see if anybody at the CDC had heard about the outbreak. She'd also promised to have a second look at Riva's samples to determine if they were the exact same strain or merely close.

Finally Laurie had called the Joint Commission on Accreditation of Healthcare Organizations. Cheryl had not been able to get her a specific person to talk with, and after Laurie had been switched around numerous times, each time being given the name of someone else who could supposedly help her, she had given up, defeated for the moment by the bureaucratic mind-set.

Arriving at her destination, the taxi pulled up to the curb and stopped, and Laurie handed over the fare and the tip. As she climbed from the cab, she looked up at an impressive, modern highrise of green-tinted glass held in place by vertical ribs of green granite. The name, Angels Orthopedic Hospital, was inscribed into a pediment-shaped marble lintel over the front doors. A liveried doorman stood on the sidewalk. A sloping driveway led to a receiving dock, a service entrance, and a multistory parking garage in the rear.

The interior was even more impressive. It was more like walking into a Ritz-Carlton than a hospital, exactly as Jack described that morning. The floor was a mixture of hardwood and marble, and the information booth looked like a concierge desk, with two uniformed men sitting side by side in suits and ties. But what caught Laurie's eye more than the decor was the lack of people. There was no hustle and bustle like a normal hospital. Other than the two men at the information booth, there were only two people in the large lounge area sitting opposite each other on opposing, elegantly upholstered couches.

Laurie went up to the information booth and received the full attention of both gentlemen. She asked for Loraine Newman, mentioning her name and that she had an appointment.

"Certainly, ma'am," one of the men said. He picked up the phone, and after a brief conversation directed Laurie to a pair of interior doors to the left of the bank of elevators. "Miss Newman is waiting for you in administration."

Laurie followed the directions and pushed through the designated doors. The administration area was more utilitarian than the lounge area but still sumptuous compared to any hospital Laurie had ever been in. It was a wide, long room with glass-enclosed offices on either side, each fronted by individual secretarial desks. Most all the desks were occupied, but it didn't appear that much work was being done. Only a few of the secretaries were typing into their monitors, while most were chatting in subdued tones.

One of the secretaries caught sight of Laurie and asked if she could help her, but before Laurie could respond, a glass door to an office opened and an energetic woman wearing a white coat over a brown turtleneck sweater and skirt called out to her. She introduced herself as Loraine Newman before ushering her inside.

"Let me have your coat!" Loraine said. She was Laurie's height and build and even approximate age but had different coloring compared to Laurie's blond complexion. "Please take a seat," she said, as she placed Laurie's coat on a hanger and hung it inside a small closet.

Laurie sat down, and Loraine went behind her desk and did the same.

"I've never met a medical examiner," Loraine said with a smile. "I'm awed by what you guys do."

"We don't get out much," Laurie said. "Most of our scene work is done by our forensic investigators." She inwardly winced, recognizing Bingham would surely not appreciate what she was doing.

"How can I help you?" Loraine asked. "I suppose you are here because of yesterday's unfortunate MRSA death."

"That and more," Laurie answered. "I did the autopsy on Mr. Jeffries this morning. The extent of his infection was dramatic, to say the least, especially how quickly it consumed him."

"You have no idea how upset we are, and not only about the tragic loss of a life of an otherwise healthy man but also because it has occurred despite our making maximum effort to prevent it."

"I heard from one of my colleagues the efforts that you have been making. I imagine it must be discouraging, especially since you have apparently had eleven such cases."

"Discouraging is not a strong enough word. Did you find out anything at autopsy that might help us? When you called, I was hoping that was going to be the case."

"I'm afraid not," Laurie admitted.

"Then why did you come over?"

Laurie squirmed in her chair. Although the tone of the question was far from hostile, Laurie found herself questioning exactly why she was compelled to make the visit, and for a moment felt foolish.

"I didn't mean to put you on the spot," Loraine said, sensing Laurie's discomfiture.

"It's okay," Laurie said. "After I did the autopsy this morning, I found out essentially by accident about all the other cases occurring over the last three and a half months. I just felt I had to do something. I'm afraid the OCME has let you and the rest of the city down by not being aware of the outbreak. It's part of our job not to let something like this fall through the cracks."

"I appreciate your sense of responsibility, but in this case I don't think it matters. We certainly have been aware, and believe me, we have done everything possible. And when I say everything, I mean everything, including the hiring of a full-time infection-control professional. And as the chairperson of this hospital's interdepartmental infection-control committee, I personally jumped on the problem from day one. We've had input from everyone, including our medical staff, nursing, engineering, laboratory, you name it.

Our committee has met just about every other week since the first MRSA case. We even shut down our ORs for a time and halted all surgery and invasive procedures."

"So I heard," Laurie said. "I don't have much training in epidemiology, but there are several things about this outbreak that bother me."

"Such as?"

Laurie took a moment to organize her thoughts. She was afraid she might sound naive, since she truly only had the basics in epidemiology. "For one thing, it has continued despite all your efforts at control; secondly, many of them are, like Jeffries, primary pneumonias, which I believe is unique for staph; third, they have apparently been occurring in only Angels Healthcare facilities. You do know that your sister hospitals are experiencing cases as well?"

"Of course. I've had multiple meetings and frequent communication with my counterparts at our heart hospital and at our cosmetic surgery and eye hospital. I was also the one who strongly encouraged Angels Healthcare's CEO, Dr. Angela Dawson, to hire the M.D./Ph.D. infection-control professional to coordinate our efforts, specifically because the problem was happening in all three of our institutions."

"Is that Dr. Cynthia Sarpoulus?"

"That's correct. Why do you ask?"

"I recall one of my ME colleagues mentioning her name. He spoke to her a month or so ago."

"She's one of the leaders in our specialty, and coauthored a major text on hospital-infection control programs. I was sure that, when I heard she'd been hired, we'd be out of the woods."

"But it hasn't happened."

"It hasn't happened," Loraine agreed.

"Well, back to my amateur concerns," Laurie said.

"I'd hardly call you an amateur, doctor," Loraine said with a smile. "Please, continue!"

"An hour or so earlier, I talked with a doctor at the CDC. She'd had the opportunity to subtype the staph from two of your cases that occurred more than a month ago at different hospitals. Using rather sophisticated genetic typing, they proved to be the same. She promised to confirm that with tests of even higher specificity and get back to me. To my informally trained epidemiological brain and contrary to what she thinks, it suggests to me a carrier is involved: a carrier who visits both hospitals. Do any of the Angels Healthcare personnel regularly visit all your hospitals?"

"Wow," Loraine remarked. She laughed in a fashion that indicated she was impressed. "Are you teasing me about not having epidemiologic training?"

"Just the required exposure for my pathology residency," Laurie said.

"We have definitely considered a carrier to be the source of the problem. In fact, so much so that we have repeatedly cultured everyone: medical staff, service personnel, and particularly those individuals who regularly visit all three of our hospitals. One of the ways that our CEO founder conceived of keeping expenses down was to have centralized services like laundry, engineering, laboratory, nursing, and food service. Each service has a department head whose office is at Angels Healthcare's central office but who travels on a regular schedule to all three hospitals. These people have been tested repeatedly for the exact reason you've suggested."

"Has anybody tested positive?"

"Absolutely About twenty percent positive, which is what one would expect in the normal population. In fact, slightly more on the medical staff. And everybody who tested positive has been treated with mupirocin until they tested negative."

"Did any of them test positive for the community-acquired MRSA?"

"Oh, yeah. Quite a few."

"Do you know if the subtype was the same as what killed your patients?"

"Our subtyping was by a VITEK system and only for antibiotic resistance, and yes, some were the same."

"Antibiotic resistance is not particularly sensitive in terms of differentiating substrains."

"I'm aware of that, but since we treated anyone positive for staph, we didn't think it mattered."

"Maybe so," Laurie said. "Did you have any of the isolates typed by the CDC?"

"No, we didn't."

"Why?"

"That was a decision made by the home office. I suppose because we were treating everyone who was positive, as I said, so that characterizing it more served no purpose. Also, we were already instituting every known infection-control procedure."

"Did you let the CDC know you were experiencing this MRSA outbreak?"

"We did not."

"How about the Joint Commission on Accreditation of Healthcare Organizations? Did you notify them?"

"No, we didn't. The JCAHO only needs to be notified if our overall infection rate goes above four percent over our designated surveillance period."

"Which is what?"

Laurie watched Loraine hesitate as if Laurie had asked a state secret. "You don't have to tell me if you feel uncomfortable," Laurie added. "I don't even know why I'm asking."

"And I don't know why I'm hesitating. Anyway it is a year interval."

"But your rate could be above four percent if you considered the last three months."

"It's possible," Loraine agreed. "But I've not stopped to figure it out."

"How about the New York City Board of Health?" Laurie asked. "I presume you let them know."

"Of course," Loraine said. "And the city epidemiologist, Dr. Clint Abelard, has made several site visits. He was impressed with everything we were doing and didn't have any suggestions, which is not surprising, since we had tried everything."

"Very interesting," Laurie commented. She felt better about coming for her visit, since Loraine hadn't ridiculed her about any of her thoughts. At the same time, she was reluctant to mention any of her more outlandish ideas. "How about a tour. Your hospital is truly elegant, and not like any other I've ever seen."

"Sure," Loraine said without hesitation. "We all are quite proud of it, especially since we are all owners."

"Really?" Laurie questioned. "How so?"

"Our CEO, Dr. Dawson, gave all the employees a little stock when we signed on. It's not much, but there is a certain symbolic value. Actually, that might change for the better in the near future. The company is scheduled to go public in a few weeks. If all goes well, our tiny amounts of stock could actually be worth something."

"Well, I'll say a little prayer for the IPO."

"Thanks," Loraine said. "The rumor is that it is going to do very well."

"Can we do the tour now?" Laurie asked.

"Certainly," Loraine said. She stood and opened the door leading to the area occupied by the secretaries. Laurie followed.

"What is it you'd like to see?" Loraine questioned as they left the admin area and emerged into the main lounge. "It's fancier than other hospitals but otherwise basically the same."

"But no emergency room."

"Right, no emergency room. We're a surgical hospital. We don't want beds taken up with medical patients."

"How about an intensive-care unit?"

"Not an intensive-care unit per se. If that kind of care is needed, we can isolate part of the PACU, or post-anesthesia unit. If the PACU is too full, we send patients to the University Hospital. It saves a lot of money."

"I'm sure it does," Laurie agreed, but the idea of a surgical hospital not having a full-fledged ICU bothered her.

They paused out in the main lobby area, standing in front of the elevators.

"I cannot help but notice how quiet it seems to be," Laurie said. "There are so few people."

"That's because our census is very low, which has been progressive since the MRSA problem began. Of course, the worst was when the ORs were completely shut down. During that period we had the entire hospital staff, including the president, disinfecting everything."

"But the ORs are open now?"

"Yes, they are open now except for the OR where Mr. Jeffries was operated on."

"Was he the only case done in the room yesterday?"

"No, he wasn't. There were two others after Mr. Jeffries."

"And they are well."

"Perfectly fine," Loraine said. "I know what you are thinking. It has us baffled as well."

"Since your census is low, does that mean some of your staff doctors are choosing to do their surgery elsewhere?"

"I'm afraid so."

"What about Dr. Wendell Anderson?"

"He's one of the brave ones, or should I say loyal. He's still operating here on a regular basis."

Laurie nodded while fantasizing about tying Jack to the bed during his sleep Wednesday night. More than ever, she did not want him to have his operation.

"What is it you'd like to see?" Loraine repeated.

"How about starting out with your HVAC system?"

Loraine did the equivalent of a double take. "Are you joking?"

"I'm serious," Laurie said. "Are the operating rooms and the PACU on a separate system from the main part of the hospital?"

"Absolutely," Loraine said. "This is a state-of-the-art facility. The HVAC for the operating rooms is designed to change each OR's air every six minutes. There would be no need to do that for the whole hospital. Even the laboratory area has its own system, although not with that kind of flow."

"I'd still like to see it," Laurie said. "Particularly the OR system."

"Well, I don't see why not." They boarded a waiting elevator. Loraine pressed the button for the fourth floor. She explained that the second floor was for outpatient services, the third was the OR and PACU as well as central supply, and the fourth was for the laboratory and engineering. Engineering included HVAC and the supply of various gases for the ORs and bedside. All the floors higher than the fourth were for patient rooms. The very top floor was a special VIP section, which had slightly larger rooms and more expensive decor. The service, she insisted, was the same.

"Are all the Angels Healthcare hospitals similar?" Laurie asked.

"Essentially identical, as will be the six hospitals slated soon to be constructed: three each in Miami and Los Angeles."

"My word," Laurie said simply. She was impressed with the edifice but bemoaned that its luxury represented the enormous amount of money essentially being stolen on an ongoing basis from full-service hospitals like University or even General, which were already struggling to make ends meet. Angels Healthcare, like other specialty hospitals, was interested only in the paying patients with acute problems, not the uninsured or the chronically ill. Not only that, the fortunes being made by the businessmen owners were also being sucked out of the healthcare system and unavailable for patient care.

"Here we are," Loraine said as the elevator door opened. "Engineering is to the left."

In contrast to the elegant five-star hotel decor of the lobby, the fourth floor was the epitome of high-tech minimalist design. Everything was gleaming, high-gloss white, and the hallway was spotless. The women's shoes clicked on the composite flooring, and the sound echoed off the bare walls. There were no pictures, no bulletin boards, only closed white doors. The only color came from city-mandated institutional exit signs with red letters at either end of the lengthy corridor.

"I think I know why you are interested in seeing our HVAC system," Loraine said as they walked.

"Really?" Laurie questioned. She wasn't entirely sure herself.

What she knew of HVAC was the little she'd absorbed while the renovation of her and Jack's brownstone had been under way.

"You are thinking of airborne route of infection, which is another suggestion, as far as I am concerned, you are not the epidemiological amateur you profess to be. But let me reassure you, we have considered it also, and we have tested the water in the condensate pans for staph aureus on multiple occasions, including just this morning after yesterday's tragedy."

"Have any of the tests been positive?"

"No, none!" Loraine said emphatically. "Staph is not considered an airborne pathogen, but that did not stop us from considering it, and even though the tests were negative, we've drained all the pans and treated them."

"I didn't think staph was spread by the airborne route, either, Laurie said. "But the fact that a number of the cases seemed to have been primary pneumonias suggested the route of infection had to be airborne."

"I can't argue with that," Loraine said, "at least not from an academic perspective, but I can from a practical one. I chair an interdepartmental infection-control committee, which is just as its name suggests: interdepartmental. We have people from all departments, such as nursing, food service, engineering, and so forth. Currently, our representative from the medical staff is a surgeon, and when we were discussing the possibility of the staph being spread via the airborne route and believing the HVAC would be involved, he set us straight on an important fact. Patients undergoing endotracheal or laryngeal-mask-airway anesthesia, which all do in our hospitals when they have general anesthesia, neve: breathe operating-room air. The air they breathe always comes from the piped-in source."

"They never breathe ambient air?" Laurie questioned. There went her only theory as to how the MRSA victims were getting sick.

"Never!" Loraine confirmed.

Loraine stopped at one of the closed doors. An eye-level white plaque with incised black letters said: Engineering. "It's going to be a little loud in here," she warned.

Laurie nodded as Loraine pushed open the heavy insulated door. Once inside, Laurie scanned the large utilitarian high-ceilinged room. The walls and ceiling were concrete. A tangled web of piping, some insulated and some not, snaked out of various multicolored tanks and hung from the ceiling. Much larger ducts did the same after exiting or entering air handlers the size of small cars, each of which was mounted on rubber shocks.

"Anything in particular you'd like to see?" Loraine shouted.

"Which handlers service the ORs?" Laurie shouted back.

Loraine led Laurie down the relatively narrow walkway between the meticulously maintained equipment. Halfway to the opposite wall, Loraine stopped and patted the side of one of the air handlers. "This is the one. The coolant comes from the condensers on the roof, and the hot water comes from the furnaces in the basement."

"How do you access the condensate pan?"

"This access door," Loraine yelled. She grabbed the handle and had to pull hard to break the suction. When the door opened, they heard a whistling noise.

Laurie stuck her head into the opening and the wind wildly tossed her hair in all different directions. She had to grasp it to keep it out of her face.

"That's the condensate pan down there," Loraine shouted, while pointing over Laurie's shoulder to the base of the machine's innards.

Laurie nodded. She was interested because she knew airconditioning condensate pans were a frequent source of airborne outbreaks, such as Legionnaires' disease. She turned her head downstream into the mouth of the efferent duct, where she could see a mesh screen. "Is that a filter?" Laurie yelled.

"There are two," Loraine answered. She closed the door to the coils, and it snapped shut. She took several steps forward. There were two vertical slit-like openings. She pointed to the two of them with both index fingers. "The first is a standard filter for relatively large-sized particles. The second is a HEPA filter for particles down to the size of viruses. And to anticipate a question, we have on multiple occasions tested the HEPA filters for staph. Only twice did we get a positive result."

"Was it CA-MRSA?" Laurie questioned.

"It was, but it was not meaningful."

"Why?"

"Because the HEPA filter stopped it."

"What's that access door beyond the HEPA filter?"

"That's the clean-out port of the efferent duct. We have all the ducting cleaned once a year."

After about six feet, the efferent duct split like the tentacles of a squid into multiple smaller ducts, each going to a separate OR the PACU, and surgical lounge. Laurie could tell because each was labeled with an incised Formica plaque. Same as the main duct, each had a clean-out port. "When were the ducts cleaned last?"

"When the ORs were shut down."

Laurie nodded. Looking down toward the end of the walkway between the equipment, she saw another door. "Where does that door lead?"

"Another HVAC room, pretty much the same as this one except that it also houses our electrical generators. Beyond that is a doorway into a vestibule with a pair of service elevators and a back stairwell."

Laurie nodded again, and then walked back to the other side of the air handler that served the ORs. Similar to the efferent side, there was a clean-out port for cleaning the return duct. She then looked back at Loraine and shrugged her shoulders. "I can't think of any more questions. It's a very impressive system. And thanks for the lecture on air handlers. You seem to know your stuff."

"Part of our training in hospital infection control included learning more than we wanted to know about heating and ventilation," Loraine yelled. She then pointed back the way they'd come.

As soon as the heavy insulated door closed behind the women, the silence of the seemingly empty hospital enveloped them like an invisible blanket. Laurie tried to fix her hair, which at the moment gave her the appearance she'd been out riding in a convertible.

"I'd like to see a patient room," Laurie said. "Provided you have the time. I don't want to monopolize your afternoon."

"With as few patients as we have currently, I certainly have the time."

"How about David Jeffries's room."

"I think it's being thoroughly cleaned. We can look in, but I'm sure housekeeping will be there."

"Then another room will be fine."

Five minutes later, Laurie stood in one of the standard rooms.

In keeping with the five-star hotel decor in the lounge area, the room was equivalently decorated and furnished. The bed and the rest of the furniture were hardly the usual hospital issue. The television was a flat-screen model, which was set up without extra charge to have blue-ribbon cable service as well as Internet access. There was even an upholstered couch that unfolded into a bed in case a family member wanted to stay over. But what impressed Laurie the most was the bathroom. "Oh, my goodness," she said as she glanced in. It was done in marble and had a second flat-screen TV. "Do you have trouble getting some patients to leave?"

"It's far better than my bathroom. I can assure you of that."

With no specific reason to visit the room, Laurie made a mild show of inspecting the position of the vents in the room for the HVAC system. There were several high near the ceiling and several low near the baseboard. It was the same in the bathroom.

"I guess that's it," Laurie said.

"Any other part of the hospital you'd like to see?"

"Well…" Laurie said hesitantly. Having had her rather vague but pet theory that the MRSA victims were being infected in the OR trashed by a combination of the presence of the HEPA filter and even more so by learning the patients undergoing general anesthesia never breathed ambient air, Laurie was convinced her site visit was a complete bust from the standpoint of solving the mystery of the MRSA outbreak. She certainly hated wasting any more of Loraine's time, even though the woman was graciously accommodating, even to the point of seeming to enjoy giving the tour. Laurie could tell she was proud of the institution.

"You are not keeping me from anything," Loraine said, guessing the reason for Laurie's hesitation.

"If that's the case, then I suppose I wouldn't mind seeing the OR area, particularly one of the ORs itself."

"We'll have to change into scrubs."

"I do it every day."

As they retraced their steps back toward the elevators, Laurie noticed the paintings lining the walls were real oils and not prints. While they waited for an elevator, Laurie glanced at the nearby nursing station. Behind it was a bank of high-tech flat-screen monitors, enough to serve every room. All were dark. Four nurses and an orderly were relaxing at the station: Three were in desk chairs, the other two sitting on the desk itself. There was intermittent laughter.

"They are acting as if there are no patients on this floor," Laurie said.

"There aren't," Loraine responded. "That's why I brought you here."

"Knowing how expensive it is to run hospitals, I'd hazard that the CFO, whoever he or she is, must be sweating bullets."

"That I don't know. Luckily, it is not my responsibility, and I don't often talk with the bigwigs."

"Has anyone lost their job?"

"I don't believe so. A number of people have taken a voluntary leave of absence, but the administration is counting on the low census turning around immediately. Our ORs are all back online."

"Except the OR David Jeffries was operated on in."

"It wasn't open for today while it's being thoroughly cleaned, but it will be open tomorrow."

Laurie was tempted to ask if the morrow's patients scheduled for that particular OR would be told of David Jeffries's fatal experience, but she didn't. It would have been a provocative question, to which Laurie already knew the answer. Too often, patients were denied information that they had the right to know if the concept of informed consent was to be truly honest.

The decor of the OR floor and the OR suite itself, except for the doctors' lounge, looked to Laurie as she expected a NASA building to look: aseptically functional. It was also like the hall above: all white, with the same composite floor. The walls, however, were tile. In contrast, the doctors' lounge was mostly soothing green, and also in contrast to the rest of the hospital, there was a lot of activity in the OR area, because the day shift was leaving and the evening shift arriving.

The women's locker room was equally lively. Loraine gave Laurie a set of scrubs and directed her to a locker. While both women changed, Laurie overheard a short conversation Loraine had with an acquaintance who was going off duty. Loraine asked her if there'd been many cases that morning.

"It was slim pickings," the woman said. "I'm afraid everyone is getting a bit bored with all the sitting around. We were only running two out of the five rooms."

Five minutes later, Laurie and Loraine pushed into the OR and the double doors swung closed behind them, cutting off the chatter from the surgical lounge.

To Laurie's left was a blank OR scheduling blackboard, which suggested there were no cases under way. To Laurie's right was the OR desk, fronted by a chest-high countertop, behind which Laurie could see just the tops of two hooded heads. Beyond the OR desk was the open doorway into the PACU. The central corridor stretched out approximately eighty feet to a far wall.

Loraine advanced to the desk, and the two women seated behind looked up. "Dr. Sarpoulus!" Loraine said. She was surprised to see her infection-control superior. "I didn't know you were here."

"Is there some reason you should know?" Cynthia questioned, with an edge to her voice.

"Well, no, I suppose not," Loraine responded. She switched her attention to the other woman, whose nametag read: Mrs. Fran Gonzales, OR Supervisor. "Fran, I have a guest here who wanted to take a peek at our OR." Loraine motioned for Laurie to step up to the counter, and Loraine introduced her as a New York City medical examiner.

Before Fran could respond, Cynthia's head popped back up. She'd returned to studying the OR scheduling log, which she and Fran had been busily doing before Laurie and Loraine had appeared. "You are a medical examiner?" she questioned, with even more edge to her voice than when she'd spoken with Loraine.

"I am," Laurie confirmed.

"What the hell are you doing here?"

"I'm ah…" Laurie began, but hesitated. She was taken aback by Cynthia's tone and challenging glare. Laurie couldn't help but remember Arnold's description of the woman as not being terribly cooperative, as well as defensive, and essentially telling him to butt out. The last thing Laurie wanted was some sort of a confrontation, knowing she was, to a certain extent, overstepping her bounds by making the site visit. Steve Mariott, the evening PA, had visited the hospital the night before, after Jeffries's death had been called into the OCME.

"Well?" Cynthia questioned impatiently.

"I autopsied a case this morning of a patient who'd been operated on yesterday here at Angels Orthopedic Hospital and who had died of an exceptionally aggressive MRSA infection."

"We are well aware of that, thank you very much," Cynthia snapped.

Laurie glanced briefly at Loraine, who appeared as surprised as Laurie. "When I canvassed my colleagues, I discovered you'd had a number of similar cases. I thought it was appropriate to come over here, and see if I could help."

Cynthia laughed cynically. "And just how did you think you could help? Have you been trained in epidemiology, infection control, or even in infectious diseases?"

"My training is in forensic pathology," Laurie said defensively. "My exposure to epidemiology has not been extensive, but my understanding is that in an outbreak of this sort, one of the first things that should be done is to accurately subtype the organisms."

"I'm board-certified in internal medicine with a subspecialty in infectious diseases and have a Ph.D. in epidemiology. As far as your comment about subtyping, you are correct but only if such information is needed to decide on a targeted method of control. In our situation, it wasn't needed, since our CEO insisted that we use a global control strategy. Our interest was not in saving money by restricting ourselves to a target approach. I spoke with one of your colleagues a number of weeks ago after he'd autopsied one of our MRSA cases. I assured him we were well aware of the problem and aggressively engaged in solving it, and thanked him for the call."

"That's all well and good," Laurie said, with her own dander rising. "Having had the dubious honor to autopsy the unfortunate individual this morning, I can say with some conviction that you have been unsuccessful in your control efforts."

"That might be the case, but we surely don't need interference. Your job is to tell us cause of death and anything else we might not know pathologically. The fact of the matter is that we are well aware of both the cause and mechanism of death, and we are doing everything humanly possible to control this unfortunate outbreak. What is it you wish to accomplish by visiting the operating room? What do you want to see?"

"To be totally honest, I don't know," Laurie said. "But I can assure you that there have been thousands of times that site visits have either helped or been crucial in a forensic investigation. Mr. Jeffries is officially a medical examiner's case, and I am duty-bound to investigate it fully, which in this case means viewing the scene of his proximate cause of death. Odds are, he was exposed to the bacteria that led to his demise in the operating room where he'd had his surgery."

"We'll see about that," Cynthia said, getting to her feet. "I'll have you talk with someone with considerably more authority than I. I insist you wait outside in the surgical lounge. I will be right back."

Without another word or even a glance over her shoulder, Cynthia walked quickly to the double doors and departed.

Laurie and Loraine exchanged another surprised and confused glance.

"I'm sorry," Loraine said. "I don't know what's come over her."

"It's certainly not your fault."

"She is under a lot of pressure," Fran, the OR supervisor, said. "She's been intense from the first, and it's only gotten worse. She's taking the whole problem very personally, so try not to do so yourself, Dr. Montgomery. She's even been at my throat on occasion."

"Who is she going to fetch?" Loraine questioned. "Mr. Straus, the hospital president?"

"I have no idea," Fran said.

"Let's go back to the lounge," Loraine suggested to Laurie.

"I think that might be a good idea," Laurie said. She felt anxious from an adrenaline surge engendered by the unexpected confrontation and its potential consequences.

As they walked, Loraine added, "Dr. Sarpoulus has always been uptight, as Fran suggested. Are you sure you want to stay? She was very rude."

"I'll stay," Laurie said, with some misgivings. What motivated her was the hope of being able to smooth things over with someone more rational than Cynthia Sarpoulus. Leaving on an unpleasant note certainly would not be helpful if she had additional questions, and there might even be a complaint made about her visit. Laurie specifically wanted to avoid such a possibility.

Back in the surgical lounge, Laurie accepted some coffee and crackers from Loraine. As busy as she'd been, she'd skipped lunch and was famished.

"So it was the CEO's decision not to characterize more fully the staph strains involved in the outbreak?"

"I guess," Loraine said. "I thought it had been Cynthia's decision, but I guess not."

Laurie had more questions, but her thoughts were interrupted by Cynthia's reappearance. By her expression, her mood had not mollified. Her sharply defined, full lips were pressed firmly together, and she walked with obvious determination. Behind her came a man and a woman. The woman was of medium height, with blemish-free pale skin, aristocratic features, and a helmet of short, thick hair. She was dressed in an elegant business suit and walked with a decidedly commanding resoluteness while still managing to exude classic femininity.

The man was her antithesis, not only in gender but in his general appearance and the way he moved. He wore a rumpled plaid wool jacket with leather elbows, the kind that Laurie had always associated with academia. Instead of resoluteness, he projected an air of wariness, with his pale eyes constantly on the move as if he were in a potentially hostile environment.

"Dr. Montgomery," Cynthia said triumphantly. "May I present Dr. Angela Dawson, the CEO of Angels Healthcare, and Dr. Walter Osgood, department head of clinical pathology. I believe you should direct your comments to them."

"What seems to be the trouble?" Angela demanded. From her tone, it was obvious Laurie's presence was not to her liking.

"I'm afraid I have no idea," Laurie said, as she got to her feet. Since they were nearly the same height, she and Angela literally saw eye to eye.

Loraine scrambled to her feet. "If there is any fault concerning Dr. Montgomery's presence, surely it is mine," she said. "Dr. Montgomery called me after she had autopsied Mr. David Jeffries. She asked to come to the hospital for a visit as part of her investigation. I invited her. She only asked to see our OR HVAC system in the engineering spaces, a typical patient room, and the OR itself. I didn't see any problem in that. I suppose I should have run it by Mr. Straus beforehand."

"As president of the hospital, that would have been wise," Angela agreed. "It would have saved us this embarrassment." Then, turning to Laurie, she said, "You do understand that this is private property."

"I understand," Laurie said. "But David Jeffries is a medical examiner case, and by law, I have subpoena power for documents and whatnot, and to visit the scene in order to investigate fully the cause and manner of death."

"There is no doubt legal recourse for you to carry out your duty, but barging in here is not one of them. Someone has already visited us from your office the previous evening and was shown appropriate hospitality. I will be very happy to discuss this with the chief of the OCME, Dr. Harold Bingham, whom I have had the pleasure of meeting on several occasions."

Laurie felt a chill descending her spine. Despite knowing she ultimately had the legal right to make the visit, the very last thing she wanted was for Bingham to be dragged into this ridiculous brouhaha over nothing, especially since she knew from past experience he'd probably side with the hospital.

"Thank you for your industriousness," Angela continued. "I'm sure your motivation was to help us, but as you can imagine, this problem has taken a terrible toll not only on some of our patients but on our institution, and, frankly, we are inordinately sensitive to the crisis. When I call Dr. Bingham, I will mention that we are not averse to you or anyone from the OCME visiting our OR, but we will require a warrant and that whoever is designated be tested as a carrier for MRSA. As part of our attempt to deal with this horrible problem, we insist that everyone entering the OR suite be clean."

"I had not thought of that," Laurie said, with a touch of guilt. Never once did it cross her mind that she could be a carrier herself, especially from having autopsied an individual just that morning who was chock-full of the bacteria.

"We, on the other hand, are extremely aware of it. But the point is we are not trying to limit your investigation. At the same time, we are certain your visiting our OR would not be enlightening in the slightest. The epidemiologist for the New York City Board of Health, Dr. Clint Abelard, who is a public servant like yourself, has inspected our OR on two occasions and found nothing. Of course, he wasn't allowed in until it was assured that he was not an MRSA carrier."

"I wasn't aware an epidemiologist had been involved until I got here," Laurie said. "Obviously, he's much more qualified than I. I'm sorry to have caused any misunderstanding. I hope I haven't inconvenienced you too much."

"You haven't. Dr. Sarpoulus, Dr. Osgood, and I were here attending the monthly medical staff meeting. It's not as if we had to come all the way from our home office."

"I'm pleased."

"There's one other point I wanted to make. You have questioned our decision not to accurately subtype the particular strains of the involved MRSA causing us such havoc. To explain, I've asked Dr. Osgood to accompany me to meet you. I know Dr. Sarpoulus has alluded to the reasons, but Dr. Osgood can explain it better, as he is boarded in both clinical pathology and microbiology. It's important for you to understand we have done every possible thing in our power to rid ourselves of this problem. Anything else would be irresponsible."

FIFTEEN MINUTES LATER, Angela and Cynthia were in a cab heading south on Fifth Avenue. Walter had stayed behind to meet with the orthopedic hospital's laboratory supervisor. Angela and Cynthia had ridden in silence, with Angela staring out the side window of the taxi and noticing that the trees of Central Park had the very first suggestion that spring was around the corner.

But Angela was thinking less about nature and more about her problems with Angels Healthcare, which seemed to grow with each passing day. The last thing she expected at this late date was a problem with the medical examiner's office. The concern was publicity, which had been a worry from the start. Back when the MRSA cases first occurred, she'd made it a point to contact the chief medical examiner, to convince him that they were on top of the problem to the extent of having reported it to the New York City Department of Health and encouraging the epidemiologist to come to the hospital.

Angela turned to Cynthia. "What was your take on that medical examiner? Did she strike you as an independent sort?"

"Absolutely. Why else would she come out and visit our hospital when there was no mystery about the cause of death. I didn't like her there while we're trying to keep a lid on this affair. That's why I came down to get you. I thought it was something you should handle."

"I'm glad you did. I considered her a threat the moment I laid eyes on her. I don't know exactly why, but she struck me as very focused and driven, and, to compound it, very intelligent. Did you see how she made eye contact? Most people caught in a similar circumstance would have been cowed to some degree."

"She did the same to me," Cynthia said. "I definitely challenged her the moment I heard she was a medical examiner."

"She worries me," Angela admitted. "If she manages to get any of this MRSA problem into the press, it will certainly come to the attention of institutional investors as part of their due diligence. If that happens, more than likely the IPO will have to be postponed, or if it's not, it certainly won't be successful."

"I think you did a terrific job talking to her."

"You think so? Really?"

"I do. First, you mixed just enough condemnation and commendation, threat and praise, to put her off balance. Second, your warning about calling her boss definitely affected her negatively; I don't think she will be making any more visits, whether announced or not. And finally you made her understand that there are a number of people working on solving the problem who have much more epidemiological training than she has. I'm sure she feels she'd fulfilled her responsibility."

"I hope you are right," Angela said, not fully convinced.

"I'm sure I am. I was impressed. You were brilliant. You really played her like a violin."

Angela shrugged. She wasn't so sure. Her intuition was telling her the opposite, and that Dr. Laurie Montgomery was going to be a problem. Angela wondered if she should talk to Michael about her. But then, after another short session staring out the taxi's window, Angela suddenly pulled her cell phone from her Louis Vuitton bag, slipped it open, and speed-dialed her secretary.

"Loren? Get me Dr. Harold Bingham's number."

To Cynthia, she said, "I want to be totally certain Dr. Laurie Montgomery behaves."

DR. WALTER OSGOOD was nervous. The whole time he'd been talking with his supervisor of the Angels Orthopedic Hospital's clinical laboratory, Simon Friedlander, he kept thinking about the surprise visit from the woman medical examiner. He'd explained to her why he'd advised not to bother testing the MRSA to determine their explicit subtype. The woman had nodded repeatedly as if she'd understood, yet he sensed she hadn't agreed. It was subtle but definite, and it worried him.

When he'd finished the meeting with Simon, which had been stressful because of his nervous preoccupation with Dr. Laurie Montgomery's visit, Walter asked if he could use Simon's office to make a private phone call. Sitting at the man's desk, he noticed a family photo. One of Simon's sons was the same age as Walter's only child. Before making his call, Walter picked up the framed photo so he could see the boy's image more clearly. He was an obviously healthy child, with a shock of unruly blond hair and a purposefully silly but happy expression. Walter fought off a sudden surge of sadness, anger, and envy. He put the photo back down, closed his eyes, and took a deep breath to rein in his emotions involving the unfairness of life. At the moment, his son was far from healthy, having been diagnosed with a rare, severe form of Hodgkin's disease requiring what his health insurer deemed "experimental" treatment. At the moment, Walter's son had no hair and had lost a quarter of his former weight.

Opening his eyes, Walter took out his wallet and extracted a small piece of paper with a single phone number with a Washington, D.C., area code. It was supposed to be for emergencies only, and he debated if this qualified. Making a sudden decision, he picked up the receiver and dialed.

On the other end, the phone rang a number of times, and Walter wondered what he'd say if he got voice mail. Just when he thought the phone wouldn't be answered, it was. A deep, wary voice said, "What is it?" There was no hello.

"This is Walter Osgood," Walter began, but he was immediately cut off.

"Are you on a landline?"

"I am."

"Hang up and call this number," the voice said. He rattled off a phone number and hung up.

Walter rapidly wrote the number on the edge of an envelope addressed to Simon. He then dialed the number. The same voice immediately answered. "You were not supposed to call me unless there is an emergency. Is that the case?"

"How do I know what constitutes an emergency?" Walter snapped. "As far as I'm concerned, if it isn't now, it will be."

"What is it?"

"A New York City medical examiner by the name of Laurie Montgomery came to the Angels Orthopedic Hospital asking questions."

"Why is that an emergency?"

"She'd autopsied a patient who'd died yesterday from MRSA. She wanted to go into the OR, and had even been up in the engineering spaces."

"So what?"

"That's easy for you to say. I don't like it. The next thing, it could be in the papers."

"What's her name again?"

"Dr. Laurie Montgomery from the Office of the Chief Medical Examiner. What are you going to do?"

"I don't know. But I'll keep you informed, and you do the same."

The line disconnected. Walter glanced at the receiver as if it could answer his question. Then he lowered it into its cradle. The strangest part was that he didn't even know the man's name.

Walter carefully erased the phone number he'd written on the envelope on Simon's desk before walking out into the lab.

LAURIE'S TAXI WAS now speeding south on Second Avenue toward the OCME and running the lights. But instead of concern about her safety, other than being certain her seat belt was secure, Laurie was obsessed with her surprising visit to Angels Orthopedic Hospital. Nothing had been as she'd expected.

The edifice was far more luxurious than she'd imagined. And the cast of characters had run the gamut from congenial to rude, and the CEO of Angels Healthcare, whom she never expected to meet, was definitely in the latter category. Laurie wondered if the woman would act on her thinly disguised threat to call Bingham. Under New York City law, a medical examiner definitely has the right, while investigating a case, to do what is needed to protect the public, and visiting an OR where there had been eleven infectious deaths over three months would certainly fall into that category.

If anything, the visit had only intensified her urge to talk Jack out of his surgery, at least until the MRSA mystery had been solved. Although Angela Dawson had expressed a remorse for the toll the outbreak had taken on their patients, she seemed just as concerned about the institution itself. It was as if the two were equivalent, which shocked Laurie. She could not believe that under the circumstances, the hospital was continuing to do surgery, that the reduced revenues were on a par with lost lives. The CEO had been introduced to Laurie as a doctor, which Laurie had assumed to be medical doctor, but now she thought it must be Ph.D., not M.D. It just didn't seem possible for her to be otherwise.

She tried to focus on the outbreak, but the contradictions were confusing. Although she knew the airborne spread of staphylococcus was possible, it wasn't common, mainly because staph cannot be aerosolized like anthrax or other airborne bacterial threats. Staphylococcus remains viable for a very short time outside a warm, moist, nutrient-rich environment, and when a few errant molecules did land within someone's nose or mouth, it behaved itself admirably and almost never caused problems. Yet in her series of mostly primary pneumonia, it had to have been airborne, and it had to have been a large dose. But that meant the patients had to have been exposed in the operating room to a relatively large amount of the pathogen. The trouble with that scenario was that the HVAC system was outfitted with HEPA filters that caught viruses a hundred times smaller than bacteria, and even if a few got through, the air in the OR changed every six minutes. On top of that, the patients undergoing general anesthesia never breathed the ambient air. In short, Laurie told herself it was impossible. Her series could not happen either naturally or purposefully.

"We are here at your destination, ma'am," the cabbie said through the Plexiglas divider.

Laurie paid the fare and, still in a semi-trance from the staphylococcus conundrum, climbed from the cab and mounted the steps of the OCME. Once inside, she was surprised to see Marlene, still at her post.

"Aren't you supposed to be off duty at three?" Laurie questioned.

"My relief called in to say she was going to be a few minutes late," Marlene said in her soft southern accent.

Laurie nodded and headed toward the ID room door.

"Excuse me, Dr. Montgomery. I'm supposed to tell you when you come in that Dr. Bingham wants to see you in his office ASAP."

Laurie felt her face flush. Intuitively, she knew that Angela Dawson had to have already called and complained about her visit. With Laurie's long-standing aversion to confrontations with superiors, she was not looking forward to being called on the carpet, if that was what was about to happen. It wasn't that she felt guilty in any way, it was her fear of losing control of her emotions. Such a reflex response had started when she was a preteen and had never entirely gone away. At that time, she had suffered a horrific confrontation with her autocratic father, who had unjustly blamed her for her older brother's death from a drug overdose. Since that awful episode, it was as if her response to confrontation was hardwired and beyond her control. As she approached Bingham's secretary, Mrs. Sanford, she could feel the involved synapses firing and setting herself up for the fall.

"You are to go right in," Mrs. Sanford said.

Laurie glimpsed the secretary's face as she passed by the woman's desk in hopes of getting a hint of what to expect, but Mrs. Sanford seemed to avoid eye contact.

"Shut the door, Dr. Montgomery!" Bingham bellowed from behind his massive and cluttered desk. Laurie did as she was told. The chief's use of such formality suggested the worst.

"Sit down!" he said, equally forcibly.

Laurie sat. She could tell her face was flushed, but she had no idea how obvious it was. She hoped it wasn't. What bothered her the most about her reflex emotionalism was the concern that people would interpret it as a sign of weakness. Laurie knew she was not a weak person. It had taken a while for her to be sure of it, but now that she was sure, it rankled her that she couldn't control behavior that suggested otherwise.

"I'm disappointed in you, Laurie," Bingham said, with a slightly more mellow tone.

"I'm sorry to hear that," Laurie said. Although there was a slight quaver to her voice, she felt encouraged. She'd managed to hold back any embarrassing tears.

"You have been so dependable of late. What's happened?"

"I'm not sure I understand your question."

"I just got off the phone with a Dr. Angela Dawson. She was furious that you showed up unannounced at one of her private hospitals, demanding entry into unauthorized areas. She even threatened to call the mayor's office."

Having overcome her emotions for the time being, Laurie allowed a more appropriate irritation to emerge. In her mind, Bingham should have been commending her resourcefulness and supporting her rather than siding with a businessperson who was obviously more concerned about her institution than her patients.

"Well?" Bingham demanded impatiently.

Understanding that it was as important to control her anger as her tears, Laurie calmly explained why she had gone to the hospital and what she had learned about the MRSA deaths that were occurring at Angels Healthcare hospitals despite commendable infection-control efforts. She told Bingham that she hadn't arrived unannounced but had been invited by the chairperson of the infection-control committee, who had been hospitable and happy to give Laurie a tour.

Bingham harrumphed into a partially closed fist. He studied Laurie with his rheumy eyes. He was, Laurie thought, partially mollified by hearing the other side of the story.

"How many times have I or Dr. Washington told you that it is OCME policy that the PAs do the footwork and that you, as a medical examiner, stay here and do the cases?"

"Several times," Laurie admitted.

"Ha!" Bingham barked. "Without exaggeration, it has to be more like a half a dozen times. We have world-class forensic investigators. You are to utilize them! Let them slog through city hospitals and crime scenes. We need you here. If you are not busy enough, I can rectify that."

"I'm busy enough," Laurie averred, thinking about all the cases she had outstanding, waiting for additional information to come in.

"Then get back to work and get more cases signed out!" Bingham said, with a ring of finality. "And stay away from Angels Healthcare hospitals." With the matter taken care of, he reached into his in box and pulled out a handful of letters that needed his signature.

Laurie stayed in her seat. Bingham ignored her as he began to read the first letter.

"Sir," Laurie began. "May I ask you a few questions?"

Bingham looked up. His face registered surprise that Laurie was still seated in front of him. "Make it fast!"

"I couldn't help but be surprised you weren't more taken by the number of these MRSA cases that I mentioned and the fact that the how and the why have not been determined. Frankly, I am mystified and concerned."

"They are obviously therapeutic complications," Bingham said. "The how I have no idea, although I know several epidemiologists are working on it. And the number: Well, I knew there were quite a few, but I was not aware it had reached the twenties."

"How did you hear about them?"

"From two sources, first from Dr. Dawson, several months ago. She wanted me to know that she'd contacted the Department of Health and had the city epidemiologist on the case. Then from a surgeon friend of mine. He's one of the investors in the company as well as on the Angels Orthopedic staff. In fact, he had been doing most of his affluent-patient cases there before this MRSA problem started. He's been keeping me abreast of the situation because a year or so ago he'd talked me and Calvin into picking up some of the founders' stock."

"What?" Laurie demanded. "You are an investor in Angels Healthcare?"

"Certainly not a heavy investor," Bingham said. "When my friend Jason recommended it because he had learned it was going to go public, I had my broker check it out. He thought it looked promising. He actually took a larger stake than I."

Laurie's jaw slowly dropped open. She stared at Bingham with astonishment.

"What's got into you?" Bingham questioned. "Why are you acting so surprised? Specialty hospitals are serving a need."

"I'm shocked," Laurie admitted. "Do you know this Dr. Angela Dawson?"

"I can't say I know her. I'd spoken with her, as I just mentioned, and even met her at a mayoral function. She's very impressive. Why do you ask?"

"Is she an M.D. or Ph.D.?"

"She's an M.D. She has her boards in internal medicine." Laurie was even more taken aback.

"You have a strange expression, Laurie. What are you thinking?"

"I'm thinking it is a little weird for you to be essentially ordering me to stay away from Angels Healthcare hospitals when you are an investor and there is a problem going on."

The web of capillaries on Bingham's nose dilated. "I resent the implication," he boomed out.

"I don't mean to sound insubordinate," Laurie added quickly. "I'm actually thinking of your best interests. It might be best for you to recuse yourself."

"You better be careful, young lady," Bingham snapped patronizingly while pointing one of his thick fingers at Laurie. "Let's get this straight. I'm not in any form or fashion restricting your investigation of your case, especially not for my investment. I'm just telling you not to go to those hospitals yourself, angering politically connected people, and putting me in a difficult situation. All I'm saying is to use the forensic investigators to do your legwork, as I've been telling you for years. Are we clear on this?"

"Quite clear," Laurie said. "But I'd like you to know that my intuition is telling me there is something decidedly odd going on."

"Maybe so," Bingham reluctantly agreed. He was clearly more irritated now than when Laurie had first arrived. "Now get out of here and get back to work so that I can get back to mine."

Laurie did as she was told, but before she could open the door, Bingham called out, "Actually, it's my recollection your intuition has always been right, so keep me informed and, for God's sake, stay away from the press."

"I'll do that," Laurie promised. There had been a few times in the past when she had unknowingly leaked confidential information to the media.

In the elevator on the way up to the fifth floor, Laurie couldn't decide if she was pleased with herself for holding back her tears or disgusted with herself for provoking Bingham. She was leaning in the direction of the latter. It had served no purpose whatsoever to accuse him of impropriety; she didn't believe it herself. Her response had been from shock that her own chief was supporting an organization whose ethics seemed questionable at best.

With both her emotional and her rational brain in turmoil, Laurie bypassed her office for Jack's. She needed a little reassurance from having been abused by Bingham and the powerful and politically connected Angela Dawson. But Jack's desk chair was disappointingly empty.

"Where's Jack?" Laurie asked Chet, whose eyes were glued to his microscope. He hadn't heard her come in.

"He's out on one of his field trips," Chet said, looking up from his work.

"Meaning?"

"You know Jack: The more controversy, the better! He posted a case where the three involved stakeholders are at each other's throats over the manner of death. It was a construction worker at a high-rise site who fell ten stories onto concrete."

"I know the case," Laurie said. "What's he up to?" As irritated as Laurie had made Bingham, she hoped Jack would be discreet, a virtue he often ignored.

"How should I know. He said something about re-enacting the crime, but short of his jumping off the building himself, I have no idea what he meant."

"When he comes back, tell him I was looking for him."

"Will do," Chet said agreeably.

Laurie was about to leave when she remembered to ask Chet about his MRSA case.

"Right," Chet responded. "Jack had mentioned you were interested in it, so I got it out." He pulled himself along his desk with his chair's casters squeaking shrilly enough to make Laurie wince. He grabbed a case file from the top of his file cabinet and handed it to her. "The name was Julia Francova."

"Terrific," Laurie exclaimed. "I'm glad you still had it." She slid out the contents to make certain it was another Angels Healthcare case.

"What's the big interest?"

"I had a similar case this morning," Laurie explained. "There have been quite a few over the last three months or so: twenty-four, to be exact. It hadn't appeared on anyone's radar screen, since the cases have been widely distributed among the staff, including cases in Queens and Brooklyn."

"I didn't know about any others," Chet admitted.

"Nor did anyone else. I'm looking into it, and I'm psyched. There is something weird about these cases, and I'm going to figure it out if it kills me. I've already managed to provoke our fearless leader."

"Let me know if I can help. The reason I still have the case is that I've been waiting for the CDC to get back to me before signing it out."

"Don't tell me you sent an isolate for subtyping," Laurie questioned while trying to keep her excitement in check.

"I did. I sent a sample to a Dr. Ralph Percy. I got him through the CDC's central switchboard."

"That's more than terrific. I'll call Dr. Percy for you, and I'll put the results in the case file. It will save you a step."

Eager to add yet another name to her matrix, Laurie again tried to leave. This time, Chet called her back.

"I took your advice you gave me this morning and called my new lady friend this afternoon," Chet said.

"And? What happened?"

"I was shot out of the sky, and I was as direct as you suggested I be. I put my ego out there on the table, but she blew me off. I had even sent some flowers to soften her up, but no luck."

"Was she rude?"

"No. Actually, I'm exaggerating. She was pretty nice about it, even though I stuck my foot in my mouth with my opening ploy. She had confided to me the evening before that she was desperately trying to raise a couple of hundred thousand dollars for the company she works for. I started the conversation by saying I'd found the money in my bedside table, and I wanted to invest."

"Bad strategy."

"Obviously. She said she felt I was mocking her."

"I think I would have felt the same," Laurie agreed. "How did you leave things?"

"Open-ended. I gave her my cell phone number."

"She's not going to call," Laurie said with a wry chuckle. "That's asking too much. You'd be making her feel like the aggressor. You have to call her back and apologize for your supposed joke."

"You mean I should call her back after she shot me down twice."

"If you want to go out with her, you have to call. If she didn't want you to call she would have said so."

"When do you think I should do it?"

"Whenever you'd like to see her. It's up to you."

"Do you think I should call her back again today? I mean, isn't that a little too pushy?"

"I wasn't a party to your conversation," Laurie said. "But you said you left things open-ended. There's a slight risk she might be perturbed, but I think the chances are better than even she'll be flattered. Call her! Take a chance," Laurie said as she backed out into the hall. "Obviously, you want to see her. What do you have to lose?"

"The rest of my self-esteem."

"Oh, baloney!" Laurie said, heading toward her office.

Chet put his hands behind his head and leaned back, staring up at the ceiling. He felt indecisive, yet he trusted Laurie's counsel. She was smart, intuitive, and, above all, female. With sudden resolve, he tipped forward, got out the Post-it note on which he'd written the number of Angels Healthcare, and placed the call. He wanted to do it quickly, before he lost his nerve.

As on the previous call, he had to go through the operator to get Angela's secretary. Then, after identifying himself appropriately, he was put on hold. While he waited, he debated whether to be humorous or serious, but ultimately decided to be merely straightforward. When Angela finally came on the line, he simply told her that he'd been thinking of her and had just had another conversation with his colleague, who'd again urged him to call.

When Angela didn't immediately respond, Chet quickly added, "I hope I'm not annoying you. I was reassured that wouldn't be the case. She said there was always a small risk but that in all likelihood you'd be flattered. When I told her I had given you my cell number, she laughed and said you wouldn't call."

"It sounds to me that your colleague is socially astute."

"I'm counting on it," Chet said. "Anyway, I'm calling for two reasons: The first is to apologize for my earlier insensitive attempt at humor."

"Thank you, but an apology is not necessary. Actually, I overreacted because I am a bit desperate and preoccupied. Your apology is accepted. What's the second reason for your call?"

"I thought I'd ask you out to dinner again. I promise it will be the last time, but you have to eat, and perhaps a break from your routine will give you some fresh insight to where you can find the capital you need."

"Your persistence is indeed flattering," Angela said with a chuckle. "But I really am wickedly busy. But I appreciate the call, especially since I imagine as a doctor you still have a waiting room full of patients."

"That might be true," Chet said, slipping into his defensive humor, "but they are all dead."

"Really?" Angela questioned. She assumed there was humor involved but didn't get it. "I don't understand."

"I'm a medical examiner," Chet answered. "It was supposed to be funny. Actually, I'm free anytime this evening, starting now. What I have left to do, I could always come back later to finish."

"Do you work here in Manhattan?"

"I do. I've been here for twelve years. I know it's not as sexy as being a brain surgeon, but in my book it's intellectually more challenging. Every day we learn something and see something we've never seen before. Neurosurgeons pretty much do the same thing every day. Truthfully, doing craniotomies day in and day out would drive me batty. I suppose the company you work for employs clinical pathologists…" Chet trailed off, unsure how Angela was responding to his line of work. In his experience, women were either fascinated or turned off. There was little middle ground. Unfortunately, Angela didn't respond to his last sentence, which was purposefully a half question. For a moment there was a pause, which progressively made Chet uncomfortable. He worried he'd made a faux pas by bringing up his medical specialty.

"Are you there, Angela?" Chet questioned.

"Yes, I'm here," Angela responded. "So you work at the OCME under Dr. Harold Bingham?"

"That's correct. Do you know him?"

"To a degree. Do you also work with a Dr. Laurie Montgomery?"

"I do. In fact, she just left my office. It's funny you should ask. She happens also to be my social adviser."

"You know, I just remembered something," Angela said to change the subject. "Just a few minutes before you called, I'd had a call from my daughter. She called from her best friend's house. She'd been invited to stay for dinner and was asking if she could. I said yes."

"Does that mean that you might be rethinking your evening plans?" Chet questioned, trying not to get his hopes up.

"It does," Angela said. "Maybe you are right about a change in routine, and you are certainly right about the need to eat. Today I only managed a sandwich on the run."

"Does that mean you'll join me for dinner?"

"Why not," Angela said, as a declarative statement, not as a question.

For the next few minutes, they discussed a time and place. At Angela's suggestion, they decided on the San Pietro on 54th Street between Madison and Fifth. Chet had never heard of it, but Angela told him it was one of those best-kept New York secrets. She said she'd make a reservation for seven-fifteen, and Chet agreed with alacrity.