Critical

10

Armed with yet another MRSA case from Chet, Laurie retreated to her office, still marveling that a series of infections were occurring despite the fact that it was impossible for them to be doing so, and it made her wish she'd studied more epidemiology during her training. Silently, she reiterated to herself the primary reason it couldn't be occurring. First off, the patients were all seemingly healthy, and healthy people usually could deal with a small number of staph being introduced into their nose or mouth. Ergo, for primary pneumonia to occur, there would have had to have been a large enough dose of staph introduced in a relatively short time to overcome the patients' natural defenses. But as Laurie had learned that very day, the HVAC systems of the Angels Healthcare hospitals were designed so that such a scenario could not happen. Above and beyond the fact that staph cannot be aerosolized, it was impossible for there to be a sudden surge of airborne bacteria in a room whose air intake was through a HEPA filter, whose air was changed every six minutes, and whose occupants were tested clean for MRSA, and who were all wearing surgical masks.

From an epidemiological and scientific perspective, Laurie became progressively concerned that the MRSA problem in the Angels hospitals could not be caused naturally, and that understanding led her to the more unsettling notion that the outbreak had to be deliberate. Then suddenly Laurie had an idea. There was one person in the OR who could conceivably manage to cause the pneumonias, and that was the person giving the anesthesia. With control of the airway and often ignored, the anesthetist or the anesthesiologist could conceivably manage in some devilish fashion to introduce secretly enough viable staph deep into the respiratory tree to cause the fatal pneumonia.

With a sense of urgency, Laurie snapped up her matrix and was immediately relieved. The matrix was at an early stage, but even with the small number of entries she had, she saw that there were different anesthetists and different anesthesiologists. But then she had another thought. What if it wasn't a single person but rather a cabal of anesthetists or anesthesiologists who were involved in some sort of vicious contract dispute with Angels Healthcare? But the second she'd conceived the conspiracy theory, she dismissed it as the product of how desperate she was to find an explanation. She even mocked herself for entertaining such a ridiculous, paranoid hypothesis, and she immediately vowed not to confess to anyone, especially Jack, that she had thought of such a thing. And after she'd returned to rationality, she realized the hypothetical bad guys couldn't be anesthetists or anesthesiologists because a number of the cases were not primary necrotizing pneumonia but rather fulminant surgical-site infections resulting in toxic shock syndrome.

Having run out of ideas, Laurie went back to expanding her matrix and filling in the blanks. When she'd first walked into her office, there was a note from Cheryl stuck on her monitor screen that indicated that most of the records Laurie had requested from the various Angels hospitals were in her e-mail inbox and that the rest should arrive the following day. Laurie had also found the packages sent from the ME offices in Brooklyn and Queens containing the files of their six cases and, in a separate envelope, the case files of the two missing cases of Besserman and Southgate, which had not been in their office when Laurie had gotten the four others.

Laurie went into her e-mail and scrolled through all the hospital records Cheryl had amassed for her. One by one, she queued them up and sent them to the printer down in administration. For ease of reading, she wanted hard copies. Next, she organized the cases by hospital. Considering case files and hospital records, she had a lot of information, which made her wonder if she should computerize her matrix. Although the idea had merit, she decided to stick with the simple legal-pad variety for the time being.

When she thought she'd allowed enough time to pass she made a rapid trip down to the computer room and retrieved the stack of printed hospital records.

On the way back up in the elevator, she noticed it was nearing five, and wondered if and when Jack would be returning. As she got out on the fourth floor to stop in and see Agnes in the microbiology lab, she pulled out her cell phone to make sure it was turned on in case Jack called. It was conceivable he might be closer to home than to the OCME on his field trip, as Chet had called it, and head home afterward rather than return to the office.

"We're making headway," Agnes said. Laurie had caught her in the process of putting on her coat to go home. It had been another of her normal ten-hour days. Agnes went over everything she had done, which included reaffirming that all the cases in Laurie's series were definitely methicillin-resistant staphylococcus aureus. She then ticked off where she had sent David Jeffries's samples for more definitive subtyping: the state reference lab, the CDC, and Ted Lynch in the OCME DNA lab. She advised Laurie that the CDC would be more efficient than the state reference lab and that Laurie could expect to hear from them in two to three days – four, tops.

Agnes's comment about the CDC reminded Laurie that she had meant to call Dr. Ralph Percy about Chet's case, but a glance at her watch suggested she might be too late. After quickly thanking Agnes for everything she was doing, Laurie dashed up a flight to save time. Since she'd not gotten the number from Chet, she had to call directory assistance for the main CDC switchboard. When the CDC operator connected her to the doctor's line, Laurie got voice mail.

"Damn!" she murmured before Dr. Percy's outgoing message had terminated. The doctor had already left for the day, and Laurie was irritated at herself for not having called the moment she'd returned from Chet's. After the beep, Laurie gave her name, her direct-dial number, the patient's name, and the fact that she was interested in the MRSA typing he'd done for Dr. Chet McGovern. Then, as an afterthought, she mentioned she was a medical examiner and a colleague of Dr. McGovern.

"What's going on?" Riva asked. She'd returned to the office while Laurie had retrieved her printed documents and had overheard Laurie's voice-mail message.

"It's been one busy day," Laurie complained. "I wanted to talk to someone at the CDC, but he's left for the day."

"There's always tomorrow," Riva said.

"I hope you are not trying to aggravate me," Laurie said. Such a patronizing comment reminded Laurie of her mother.

"Oh, no. If anything, I was trying to calm you down. You look frazzled. I know you've been preoccupied most of the day."

"That's an understatement," Laurie said. She then told Riva what she'd been up to all day and why she wanted to talk with the doctor from the CDC.

"What about the woman at the CDC I dealt with?" Riva suggested. "Did you call her?"

"I did. She was helpful and said she'd get back to me."

"Why not try her? I'm certain she'd have access to Chet's case."

"Good idea," Laurie said. She had Silvia Salerno's number on a Post-it stuck to the edge of her monitor. As the direct-dial connection went through, she glanced at her watch. It was now significantly after five. Once again, she got voice mail. On this occasion, she didn't leave a message since the woman had already agreed to call her back. Laurie hung up the phone and shook her head.

"Two for two!" Riva said lightly. "They must have a curfew at the CDC!"

Laurie laughed. Riva's comment about the world-renowned CDC amused her, as unlikely as it was, and laughing for possibly the first time all day made her realize how tense she was.

Riva stood up and took her coat from behind the door. "I think I will follow the CDC's example and head home. Working with Bingham this morning on the police custody case exhausted me."

"Oh, yeah!" Laurie said. "As preoccupied as I've been, I forgot to ask you what the outcome was."

"Not good for the police or the city," Riva said, "although it could turn out to be a windfall for the family. The hyoid bone was fractured in several places, so there was obviously excessive force."

"The only good part is that Bingham will take over the inevitable political and legal fallout."

"That's true," Riva said. "We pathologists can only say it was a homicide. Whether justified will be up to a jury."

With her coat on, Riva said good-bye, but before she left Laurie asked, "If there are any more MRSA cases over the next week while you're assigning cases, would you give them to me?"

"I certainly will," Riva said before leaving.

Laurie turned back to her desk with the three stacks of case files from the three Angels Healthcare hospitals and the stack of printed hospital records. Over the next three minutes, she combined the case files with their hospital records. There were still a few hospital records missing, as Cheryl had indicated.

Putting her matrix in front of her, Laurie picked up David Jeffries's hospital record and began reading. As she read, she filled in the boxes that she'd not been able to do without the hospital record. Since she still felt the operating room had to be where he was infected, she read through the anesthesia record, paying attention to the detail. When she did so she came up with some additional categories that she had not thought of earlier, namely the OR room number, how long the operation took, duration of time spent in the PACU, and which drugs were given in the PACU. Reading through the nurses' notes, she found the names of the scrub nurse and the circulating nurse. With a ruler, she made more vertical lines to create boxes for this additional information.

When she finished with David Jeffries's hospital record, she reached for another. It happened to be one of Paul Plodget's patients: a forty-eight-year-old man named Gordon Stanek. Like Jeffries, he was a patient of Angels Orthopedic Hospital. And as she'd done with Jeffries, she used the hospital record to fill in the boxes of her matrix. As she'd noticed earlier with Riva's two cases, the anesthesiologists were different. Unsurprisingly, she recorded that the other people involved with the patient, including the surgeon and the nurses, were also different, as was the operating room itself. Even the anesthesia was different. Although both patients had general anesthesia, the agents employed were different. There was also a difference in the way the anesthesia was administered. Jeffries had had an endotracheal tube, while Stanek had had a laryngeal mask airway.

Laurie sat back and glanced first at her matrix, then at all the case files and hospital records. It was going to be a long process. In the end, what she hoped to find was some kind of commonality they all shared.

Laurie was about to pick up another hospital record when a rhythmic thumping coming from the hallway caught her attention. It was low in pitch and distant, and had the building not been as quiet as it was, since it was after five, Laurie might not have heard it. Straightening up in her chair, Laurie cocked her head to try to hear better. Although the beat stayed the same, it was becoming progressively louder. It was as if someone was beating on the floor with a rubber mallet and coming closer and closer.

Irrational fear spread through Laurie like a jolt of electricity. The thought of jumping up and slamming and locking her door flashed through her mind, yet she was frozen in place.

"Hey, sweetie," Jack said as he appeared in the doorway and proceeded into Laurie's office on his crutches. Leaning over, he gave her forehead a kiss. "You'll never guess what I've been up to." He leaned his crutches up against Riva's file cabinet and sat down in her chair. "I've been having a ball," he added and started to explain but then stopped in mid-sentence when he looked closer at Laurie's expression. He leaned forward and waved his hand in front of her face. "Hey! Hello! Anybody home?"

Laurie batted his hand away. "As quiet as it is around here, you and your crutches scared me," she said, not sure for the moment if she was more relieved or miffed.

"How did I do that?" Jack asked with confusion.

"Because…" Laurie started to say, but then realized with some embarrassment how ridiculous it was for her to have been frightened by the sound of Jack's crutches on the corridor's vinyl floor. She guessed it was a symptom of how overwrought she was.

"I'm sorry," Jack said.

Laurie reached out and gave his knee a pat. "You don't have to apologize. If anybody is to blame, I am. I've had one hell of a day."

"No matter," Jack said, regaining the excitement with which he had arrived. "I wanted to tell you what I've been doing for the last couple of hours."

"I'd like to hear," Laurie said. "But you see all these case files and these printouts of hospital records on my desk?"

"Of course I see them," Jack interrupted. "It's hard to see your desk underneath them. But first let me tell you about the case you passed up."

"I think we should talk about these cases on my desk," Laurie said.

"In a minute!" Jack snapped. Then, in a more normal tone, he said, "God, you've got such a one-track mind."

You're the one to talk about a one-track mind, Laurie thought but did not say. Sometimes Jack could be a lesson in patience control.

"I'm the visitor. I'm the one who came to you, so my story goes first. Okay?"

"Fine," Laurie intoned in frustration.

"Anyway, thanks for passing up the Rodriguez case."

"You're welcome," Laurie said insincerely.

"The cause of death was straightforward, as I'm sure you assumed it would be. I mean, the victim, a construction worker, fell ten stories onto concrete from a building under construction."

"Can you get to the point!" Laurie complained.

Jack stared at Laurie for a beat. "You're in a crummy mood."

"No, I'm just a little impatient to talk about something which, with due respect, I think is more important."

"Okay, okay," Jack said. "So as not to hear about this for a week, tell your story!"

"No, I agreed for you to talk first, so finish! Just pick up the pace."

Jack smiled wryly before continuing. "The internal exam showed all sorts of blunt-trauma injury, including detached heart, ruptured liver, and bilateral compound fractures of the femurs. But I knew that wasn't going to help with the manner of death, so I visited the scene."

"I hope you didn't cause your own scene," Laurie quipped. "Because I did a site visit myself and inadvertently caused a scene, which has Bingham spitting bullets."

"Not diplomatic me!" Jack said. "Actually, everyone had a ball. What I did was fill a plastic body bag with sand courtesy of the contractor so that it was the same weight as the victim. Then, up on the tenth floor…"

"I hope you didn't climb ten stories on your injured knee," Laurie interjected.

"No!" Jack said as it if was totally out of the question. "They took me up in the construction elevator. Up there, I checked where the guy was working when he fell. Ironically enough, he was putting up temporary guardrails. With a guy down on the ground with a stopwatch, we first rolled the bag off the ledge like what would happen if Mr. Rodriguez had accidentally fallen. And do you know how far away from the building the bag ended up?"

"I can't imagine."

"Six feet, and it took two and a half seconds. When we heaved the body bag off as if he were pushed or leaped on his own accord, guess where it landed in two-point-six seconds?"

"Please, just tell me your story?"

"Twenty-one feet on the nose. Pretty cool, huh? It proves it wasn't an accident."

"What if he stood at the edge of the building, closed his eyes, and took a baby step?"

"Wouldn't happen. He wouldn't want to hurt himself by hitting the building on the way down."

"You're sure of that?"

"I am. I thought about it myself once, a few months after the plane crash."

"Oh," Laurie merely said. It was an area she didn't want to revisit at the moment. Jack still struggled with depression on occasion.

"I'm going to sign the case out as suicide. Do you know why?"

"I can't guess," Laurie said. "Why?" Despite her initial pique, she was interested. "Why not homicide? He could have been pushed or thrown."

"Because on external exam, he had healed scars across both wrists. He'd attempted suicide before. This time, he used a more efficacious and guaranteed method."

"Very interesting," Laurie said with questionable sincerity. "Now, can I speak?"

"Of course," Jack responded. "But I think I know what you are going to say."

"Do you?" Laurie questioned, with a touch of superciliousness.

"You are going to tell me by the looks of all these case files that there has been a surge at Angels Orthopedic of MRSA postoperative infections, and that I have to cancel my surgery or at least reschedule it for some indeterminate later date. Am I close?"

"You are right on the nose," Laurie said, "but, smarty pants, I think you should hear the details."

"Can't we do it over a bite to eat somewhere along Columbus Avenue?"

"I want to tell you now," Laurie insisted. "These MRSA cases are truly a mystery. In my opinion, what is happening actually cannot be happening, either naturally or intentionally."

Jack's eyebrows raised when Laurie mentioned the idea that the MRSA was being spread intentionally. He asked her if she truly thought it was possible. When she said yes, he didn't dismiss the idea out of hand. Laurie had a track record of ferreting out several equally bizarre situations some years earlier that everyone else had dismissed.

"Okay. Let's hear the unexpurgated version, and I promise not to interrupt."

First, Laurie handed over her unfinished matrix and then went on to tell Jack everything she did that day, and everything she'd learned and everything that was pending. She finished up with:

"There shouldn't even be a discussion whether or not you should proceed with your operation. You shouldn't, plain and simple."

"Well, I'm sorry that Blowhard Bingham gave you a hard time. I think your visit to the Angels Orthopedic Hospital should be a source of commendation, certainly not the opposite. I'm intrigued myself by all you have told me, except for your final conclusion. Now, don't argue with me!"

Laurie had tried to complain.

"I let you speak without interruption, so let me have the same courtesy. I have been proactive today anticipating your attempting to change my mind, so I've learned some things as well. First off, these MRSA infections in your series are not technically nosocomial, since they are not within the time period of forty-eight hours."

"That's true," Laurie agreed, "but that definition is more for statistical purposes."

"The forty-eight-hour limit is because infections within that time very often are from organisms carried in by the patient. And that will undoubtedly turn out to be the case with your series, and my reason for believing that is twofold: One is because of what you have learned in your investigation – namely, that the contamination cannot be occurring naturally or by intention, ergo, it is being brought in by the patients; secondly, the cases all seem to be community-acquired MRSA, which by definition comes from the community, or in other words from outside the hospital."

"Can I say something now?" Laurie questioned.

"If you must."

"The CA-MRSA, or community-acquired, has definitely shown up as a problem in hospitals, and that's been over a number of years at an ever-increasing rate."

"That may be so, but I believe the fact that the bug is the CA-MRSA exclusively lends more credence to my theory. But be that as it may, I also called Dr. Wendell Anderson's office and spoke to his scheduling nurse. Thinking of you, I asked her whether it would be possible, if I put off the surgery, to again be scheduled at the seven-thirty slot. She said it would be up to the doctor, because he always starts at eight-thirty or nine and that he was doing me a favor by coming in early on Thursday."

"Well then let's delay it," Laurie said.

"I don't want to delay it. That's the point. Yet I wanted to ask in case I changed my mind, but I didn't."

"Why not?" Laurie demanded with obvious irritation at Jack's intransigence.

"Because the sooner it gets done," Jack growled, "the sooner I'll be on the bike and on the b-ball court."

"Jesus Christ!" Laurie exclaimed, throwing up her hands in frustration. "How can you be so foolishly stubborn?"

"I'll tell you how," Jack snapped back. "Before I hung up with Anderson's secretary, I asked her to have Anderson call me back, which he did within the hour. I put the questions to him very directly. First, I asked him if he knew about the MRSA in the Angels hospitals. He said he did, and he admitted there was a significant mystery to it, because he told me all the infection-control mechanisms that the hospital had instituted at great expense. He said infections had decreased but were still occurring at a much-reduced rate. He also told me that he had himself instituted some control measures above and beyond what the hospital was doing."

"What were they?"

"On his own cases he insists the anesthesiologist give supplemental oxygen, maintain the patient's body temperature, and even monitor and maintain glucose levels."

"Has he had any recent postoperative infection?" Laurie asked incisively.

"I'm glad you asked that question," Jack said smugly. "Although I know it's an egotistical sore point with surgeons, I asked him directly if he had. Surprisingly enough, he said he's only had three postoperative infections in all his career, and all three had been open compound fracture repairs, meaning the cases were dirty to begin with. Also, all three were at University Hospital, not Angels Orthopedic."

"So he's not had an MRSA case."

"Well, I don't know what the bacteria was involving his cases at University, but the point is, he's had no infection problem at Angels."

Laurie stared off. She could sense she was losing the argument.

"I even went a step further," Jack said. "I asked him from one doctor to another if he would go ahead and have the surgery as scheduled given the timing in relation to my injury and the fact that Angels is struggling with an MRSA problem." Jack paused for maximum impact.

"And?" Laurie was forced to say. She wanted to know.

"He said in a heartbeat he would do it. And furthermore, he said he wouldn't operate at Angels if he didn't feel that confident. He said the only thing he would personally do was use an antibiotic soap for several days before the procedure. When I admitted to already doing that, he said I'd be fine. He also said that when I go in for my pre-op bloodwork tomorrow, that he would arrange that I be screened for MRSA, and that if I turned out to be a carrier, he would insist I be treated and that the operation would be delayed. The last thing he said was that he'd see me Thursday morning at seven-thirty a.m., and I'd be back on my bike in three months and playing b-ball in six."

Laurie looked over at her pile of cases and hospital records. She felt a mixture of frustration, anger, and despondency. Jack had certainly made some cogent points, especially talking directly to his surgeon, who was highly regarded and rather famous for operating on celebrity athletes. Yet still, Laurie could not help but feel it was a wrong decision to proceed with the surgery under the circumstances. It would be okay if it were an emergency, but as elective surgery, it still seemed crazy to her.

"Come on!" Jack said, standing up and touching her shoulder in the process.

As if she were in molasses, Laurie got to her feet.

Jack handed her matrix back to her. "I still think you should proceed with investigating this series. There has to be an explanation, and I for one would certainly like to hear it."

Laurie nodded, took the matrix, and tossed it casually onto the rest of the debris on her desk.

Jack wrapped his arms about her and hugged her. "Thanks for caring," he said.

Laurie hugged back.

"I love you," Jack said.

"I love you, too." Laurie said.