Death Benefit

27.

COLUMBIA UNIVERSITY MEDICAL CENTER NEW YORK CITY MARCH 23, 2011, 7:38 P.M.

News of the Rothman/Yamamoto event spread rapidly through the Columbia medical community. George Wilson, like everyone else, had heard about it, and he could only imagine the effect it was having on Pia. Concerned, he had looked for her. It took some searching but George finally managed to track her down. She didn’t answer her cell phone and neither Will nor Lesley had seen her, so he had had to physically find her. George struck gold in the library stacks, a place he knew she found comforting. After some cajoling, Pia agreed to go with him back to the dorm cafeteria.

Pia was as distraught as she could ever remember being. She was especially upset because her emotions were so conflicted. Usually in her tumultuous life, distress had a definitive cause, but now she didn’t know whether to be upset about Rothman’s dire condition or angry at his carelessness in getting infected with the bacteria he’d been working on. And there was an undercurrent: Pia was terrified about her own future, which she thought she’d been so careful about but now seemed to be in the balance. She was also furious with herself for allowing Rothman to penetrate her well-constructed protective shell. And now she had the added distraction of George, who was trying to be solicitous but making things worse with all his questions.

“I can’t sit here anymore,” Pia said suddenly, interrupting George, but she didn’t care.

“You haven’t eaten anything,” George said, looking down at her tray. “You’ve got to eat.”

“I can’t eat,” Pia complained. “Feeling I’m in control is important to me. I don’t feel in control. My life is coming apart. I’ve got to see Rothman. I have to.”

Security was essential to Pia, as was control. At the moment she felt neither.

“Is he allowed to have visitors?”

“I don’t even know if he’s conscious. But I’m not a visitor, I’m concerned about the course of treatment he’s on.”

“I’ll come with you,” George said.

Pia didn’t know whether she wanted him to come or not.

“Don’t you have things to do?”

“Nothing important. I want to help you.”

“Whatever!”

Pia jumped up from the table, leaving her tray of food untouched. George stuck her turkey sandwich, still in its wrapper, in his jacket pocket and hustled after Pia. As she marched to the hospital, George trailed along in her wake. He tried to talk to her but gave up when she wouldn’t answer. She was on a mission.

The floor housing Rothman and Yamamoto was bustling with staff and orderlies. There were few patients in evidence. Most were too sick to be up and about. Pia found the resident on duty, Dr. Sathi De Silva. As the sole infectious disease resident, she had her hands full, not just with her two celebrity patients but a ward full of others, and several more people in the emergency room awaiting her attention. Pia and George were in their medical school white coats so Dr. De Silva accepted them as students most likely on their internal medicine rotation. Dr. De Silva took her teaching responsibilities very seriously, so when Pia started asking questions about Dr. Rothman, she stopped what she was doing. “To answer your question, both Dr. Rothman and Dr. Yamamoto are dangerously ill. They’re both delirious and uncommunicative.”

“I understand they’re on chloramphenicol. What’s your feeling about such a choice?”

Dr. De Silva shrugged. “I think it’s a good choice. Yes. It’s a unique situation because there are newer antibiotics, but in this case we have sensitivity studies that show the involved strains of salmonella to be uniquely sensitive. Dr. Springer believes it’s our best hope. We’re monitoring for side effects, but we haven’t seen anything. If there are any problems, we can always switch to one of the newer, third-generation cephalosporins.”

“Strange case,” Pia commented.

“One of the strangest,” Dr. De Silva agreed. “And not a little ironic.”

“Do we know how they got infected?”

“If we do, I haven’t heard anything. I know the CDC epidemiologists went through the lab and particularly the level-three containment area where the salmonella strain was kept. I think their initial concerns were about a malfunction of the hood, but apparently it was working fine. There was some bacteria in the hood itself, but you’d expect that. They took cultures, I know, and we’ll get results in twenty-four hours. I’m hearing all this secondhand. My job is to look after them.”

“Of course,” said Pia. “Has the CDC finished with the lab?”

“Dr. Springer said an hour ago that most of them were already headed back to Atlanta.”

Dr. De Silva’s cell phone beeped, and she glanced at a text message. “Oops, gotta go! Nice talking with you.”

“Can we see Dr. Rothman?”

“I don’t see any harm, but you’re not going to be seeing much,” Dr. De Silva said, already walking away. “As I said, he’s delirious. If you do go in, just make sure you put on all the gear and don’t bring anything out!”

Eagerly Pia set off toward Rothman’s room. George stumbled after her.

“What are you doing?” George complained. “You can’t go in there. He’s sick, he can’t tell you anything. Why take a chance?”

Pia didn’t answer. She suited up as per the Universal Precautions established by the CDC, which were posted on the outer door. George continued to try to talk Pia out of the visit, but she ignored him. He found a set of protective gear for himself and followed Pia into the room. As they passed through the door they could feel air entering with them.

Pia walked directly over to the bed. Several IVs were running, each laced with antibiotic.

“Dr. Rothman? . . . Dr. Rothman?”

Rothman stirred and half opened his eyes.

“Dr. Rothman, can you hear me?”

“What are you doing?” George’s nerve was failing him on many counts. Neither of them was on an internal medicine rotation, so they had no business or excuse to be there, and why was Pia trying to talk to Dr. Rothman? The man was delirious. Apart from the trouble they could get into, George was nervous about the salmonella that was making Dr. Rothman sick. The man looked gravely ill, with an ashen coloring and loose strands of hair matted to his pale forehead.

“He doesn’t look good at all,” Pia commented.

“Tell me about it,” George said nervously.

“My gosh, look! He’s losing some hair.” Pia pointed to tufts of hair on Rothman’s pillow, but George wasn’t interested. Rothman had become agitated now, twisting against his restraints while mouthing some words. Pia grabbed his chart and was flipping through the pages.

“His temperature’s up-not a lot, but up nonetheless.”

“Pia . . . let’s go!” George stage-whispered.

“You go, George, I’m not leaving. Not yet.” From working with Rothman, Pia had learned a great deal about typhoid fever and its cause, salmonella typhi. She knew the danger signs of the illness and the fact that the disease attacked the small bowel, concentrating in lymphoid tissue in the small intestine called Peyer’s patches. Rothman’s gown was pulled over to one side, and Pia exposed Rothman’s abdomen a little more. She slowly pushed in on his upper abdomen, and Rothman squirmed and moved his head from side to side.

“He’s definitely showing signs of discomfort, maybe pain in his abdomen,” Pia said. “This is not a good sign.”

George was beside himself. He could see a few people passing by in the outer hall through the wire-embedded windows in the two doors of the isolation room. He walked over and closed the blinds, hoping to buy Pia some time. When Pia suddenly let up on the pressure she was exerting, Rothman reacted slightly, to Pia’s surprise, as if that caused more discomfort.

“Did you see that? He recoiled. Would you say he recoiled?”

Pia repeated the maneuver and got the same result.

“He definitely recoiled.”

“Whatever it is you’re doing, it’s going to get both of us kicked out of school if we don’t leave right now. We’re pushing the limits on a couple of celebrity patients.”

“It’s rebound tenderness,” she said. “It’s a sign of peritonitis, inflammation of the lining of the abdominal cavity. It means the bacteria have penetrated the lining of the small intestine.”

Pia reached over and punched the intercom button. The nurse at the station picked up.

“Is Dr. De Silva available? If she is, get her in here stat. The patient has developed rebound tenderness.”

George was hopping from one foot to the other. Now she’s really done it, he thought.

At once, Dr. De Silva came in the room, palpated Dr. Rothman’s abdomen and confirmed Pia’s finding.

“And look, he’s losing some hair,” Pia said.

“That could be the chloramphenicol. But regardless, the rebound tenderness suggests the chloramphenicol is not controlling the infection. We’ll have to change the antibiotic. I’ll call Springer and get his suggestion. Thanks for your help.”

Dr. De Silva ducked out of the room.

“He’s getting worse,” Pia said, looking at Rothman forlornly.

“Rebound tenderness isn’t a good sign, I know that,” George said. “But you’ve done all you can do. Let’s go. You heard her, she’s calling Springer.”

By the time George and Pia took off their gear and got back to the nurses’ station, Dr. De Silva was on the phone with Springer. Pia stood where she could hear Dr. De Silva’s half of the conversation. It sounded like Springer was doing most of the talking.

“Okay, ceftriaxone . . .” she said. “. . . And the hair loss . . . Right, of course we’ll stop the chloramphenicol…. Okay. I’ll see you soon, and I’ll call Dr. Miller.”

Dr. De Silva turned and saw Pia. She hung up the phone and redialed immediately. She covered the receiver with her left hand and talked to Pia as the phone rang.

“Dr. Springer’s on his way in. He wants to check the rebound tenderness for himself-Oh, hello. I need Dr. Miller. . . . Dr. Miller, this is Dr. De Silva in Infectious Diseases. I’m treating Dr. Rothman and Dr. Yamamoto. Dr. Springer would like a consult. We’re seeing rebound tenderness in Dr. Rothman and may have to remove the infected bowel…. No, just Dr. Rothman at the moment . . . His temperature is up slightly. Other levels-blood pressure, pulse, oxygenation-are the same. Okay, thanks.”

Dr. De Silva hung up the phone and exhaled. She was a small woman of Sri Lankan descent who prided herself on running a tight ship. She was embarrassed that a medical student had picked up an important sign that she’d missed. “I just checked him a few minutes before you two showed up. Temperature was holding steady,” she said, half to Pia, half to herself. She turned to Pia.

“It can come on very quickly. Dr. Miller, the chief surgical resident, is coming in. And Dr. Springer’s on his way over. So, who’s your preceptor? I should at least give you credit for what you found. And how did you know what to look for? I’m impressed.”

“Actually I’m not on internal medicine at the moment.”

“Are you on an infectious disease elective? If you are, I haven’t heard your name.”

“I’m not on an infectious disease elective either.”

George was desperately trying to get Pia to shut up. Out of Dr. De Silva’s line of sight he was frantically making a time-out gesture like a football official.

“Well, what brought you here?” Dr. De Silva asked.

“I just happen to know a lot about salmonella.”

“Really? From whom?”

“Dr. Rothman,” Pia said, as George grabbed her arm and literally pulled her away, angling her toward the elevators.

George felt a sense of relief as they left the hospital. With as busy as Dr. De Silva was, he hoped she wouldn’t say too much about the two mysterious med students, one of whom had been very helpful. Actually he doubted she would. He knew that there hadn’t been any negligence on Dr. De Silva’s part, but he knew that in the competitive atmosphere of the academic center, she was probably chagrined that she’d been, in a fashion, upstaged by a medical student. Pia had detected the change in Dr. Rothman’s condition before she did. But George’s relief was short-lived.

“I want to go back to the lab,” Pia said, stopping suddenly. They had just reached the corner where 168th Street turns into Haven Avenue. “I want to see if there are any clues as to why or how he got infected. He’s so careful, I don’t understand it. He’s so detailed and compulsive about his work, his organization, his technique, it’s all flawless. It doesn’t make sense.”

Still lurking in the back of Pia’s mind was the thought that Rothman had infected himself intentionally. But why would he involve Dr. Yamamoto? It couldn’t be the case, or could it? What she wanted to do was completely eliminate the idea as even a remote possibility. If Rothman died, it was going to be a betrayal of sorts, but she didn’t want it to be his betrayal. Betrayal by fate she thought she could ultimately handle. Personal betrayal by Rothman would be something entirely different.

George groaned inwardly. Visiting Rothman had been bad enough. Visiting a lab that was off-limits by order of the CDC was something else entirely. “The lab is closed,” George said in a fashion that wouldn’t brook discussion. “Order of the CDC. Let’s head up to your room. I saved the sandwich you didn’t eat.” To prove his point, George pulled the food from his pocket.

“I’m going,” Pia said.

“What on earth do you think you’re going to turn up that the CDC hasn’t?”

“I don’t know, but I can’t do nothing. You can come with me or not, I’m going anyway. Of course two sets of eyes may be better than one.”

George realized Pia was asking for his help, however indirectly, which was a first. Still, it wasn’t an easy decision. He was okay with bending the rules, but not breaking them like this. He couldn’t afford to get kicked out of medical school. It had been his goal as long as he could remember, and he had his family to consider. But George had no time to ponder his decision. Pia had already turned around and was heading toward the research building.

“You’re not worried about getting typhoid fever?” he asked, catching up to her.

“I was in there this morning. And there’s protective gear we can put on just like we used in Rothman’s room.”

Pia entered the building. George followed. It was like making a decision without making a decision. They showed their IDs to the security man and headed for the elevators.

As George had expected, the door to the lab was crisscrossed with yellow caution tape. “See, just as I expected. We can’t go in.”

Pia didn’t respond. She merely peeled back the necessary tape and tried the door, which was locked. It didn’t deter her. Many times over the last three and a half years, Pia had been asked to take a reading in the lab at night, or monitor an automated experiment. She took the key she’d been given for those eventualities, opened the door, and stepped over the threshold.

“Pia, this is crazy,” George said. Reluctantly he came in after her. It was dark, and very quiet.

“Relax. The security cameras are out, they’ve been working on them again for days. Who’s going to come in now? I just want to check the refrigerated storage facility in the biosafety lab and take a peek at the logbook. And before you say it, I know the CDC has probably investigated all that. They might have even taken the logbook. Be that as it may, I need to make sure they didn’t miss anything.”

Pia turned on the minimal light necessary. It was a small lamp by the communal coffee machine. She then quickly checked her own office, and Rothman’s. George trailed after her like a shadow. As far as she could tell, nothing had been disturbed in either office. Pia pointed out Rothman’s desk to George. The in-tray, the few files, the pictures-everything was just so.

“See how orderly he is?” said Pia.

All George could think about was getting out of there. An air circulator kicked on and George jumped half out of his skin. He followed Pia to the biosafety level-3 room and they donned the protective gear once more. Pia used the coded punch pad to reach the lab itself. Since there were no windows, Pia turned on the overhead lights. The ventilation system was still running and there was an eerie calm in the place. Pia checked the logbook, which the CDC had not taken. There were the usual entries; the next to last one was Panjit Singh, when he went in that morning to set up. Then there was Rothman and Yamamoto’s entry. There was nothing abnormal. She then went to the refrigerated storage unit. Using a separate keypad, she was about to open it when she heard a noise that caught her attention.

“Did you hear that?” she whispered intently to George.

“Hear what?” George said nervously.

Pia held up a hand and went to the door and cracked it open. There were quiet sounds but unmistakable-voices in the lab outside. Voices getting louder.

“In here . . . c’mon,” she said urgently.

“Shit,” George said under his breath. He’d heard the voices. “Shit on a brick,” he mumbled to himself.

Silently but urgently Pia waved for him to follow her. George saw where they were heading and beat it out through an emergency exit in the far corner of the lab. The door complained when he pushed it open as it hadn’t been opened since it was installed back when the lab was last renovated. It had also been made airtight.

Pia followed close behind George. She might have stayed and faced the music had she been there by herself, but she was well aware of George’s utter fear of authority. Where that had come from, she had no idea.

The unit’s emergency door led to the lab storeroom where Pia and George pulled off their protective gear and stumbled out into the main part of the microbiology department that housed Rothman’s lab. Staff on the evening shift at the microbiology clinical lab were curious to see two young people running by, then stunned to see them followed a minute later by three figures in full hazmat gear.

Microbiology led into the anatomy department and George and Pia crashed through the connecting doors and into the familiar surroundings. As first-year students they had spent a good deal of time in the department. George was leading, but he didn’t know exactly where he was going. All he knew was that he wanted to avoid getting caught. He ducked into the darkened anatomy room, dimly illuminated by night-lights. For the benefit of the current first-year students who were taking anatomy at the time, the room was well stocked with cadavers, most covered with oilcloth shrouds. Several torsos sat upright on the head teaching table. They’d been cut across the upper chest and then halved in a sagittal section so that half the gullet and half the brain were visible. George was eye-level with the torsos, the exposed whites of their eyes seeming to glow in the half-light.

George and Pia ducked behind the long teaching table, but there was nowhere to hide. A moment after their arrival, the banks of ceiling lights flickered and came on. Three security guards in hazmat suits stormed into the room. Pia stood up and George, very reluctantly, followed suit.

The security men were angry, demanding Pia’s and George’s identification cards. They then made several calls on their radios before turning back to the students. George was cowering, Pia taking it all in stride. “You’re coming with us,” said the nearest figure to George, grasping his arm and marching him out of the room. Pia was escorted out behind him.

The group wended their way past the few onlookers in the clinical microbiology lab and down to the street via a service elevator. George’s mind was racing but he couldn’t think of any way Pia could talk her way out of this. As they walked across the campus, the group attracted a lot of stares and comments from passersby. Some of them wondered if they were watching some med-student prank.

George and Pia were taken through a featureless corridor in the hospital bowels to the security department. They walked past a bank of TV screens being monitored by two bored-looking men, down another corridor and into a small office with a handwritten sign on the door: DUTY OFFICER. Standing up, watching a couple of monitors mounted on the wall, was David Winston, the man who’d taken charge in the lab earlier that day. He recognized Pia, having helped her when she fainted in the street.

“Ah, you again. I see you’re feeling better than when I last saw you.”

“Mr. Winston,” Pia said. “My friend and I were just retrieving some of my belongings from my office.”

Winston referred to a list on a clipboard resting on his desk.

“Miss Grazdani, and . . .” He looked at George.

“George Wilson.”

“George Wilson. Not on my list. You a fourth-year student as well?”

George nodded.

“Well, you’ll be taking antibiotics too,” Winston said. “Folks, there’s a protocol we use in these situations. You broke into a secure, potentially contaminated area. I actually saw you do it myself, sitting right here. The cameras might not be operating inside the lab, but outside they work just fine. So I see two people go into the lab, and I have to send three of my guys in full body gear to go in and find you. And it turns out to be you two. So the protocol is, I make a call to the dean of students, who loves to hear from me, as you might imagine. It’s just a heads-up because my next call is to my friends at the Thirty-third Precinct, and I’ll have a full and frank conversation about criminal trespass.”

George was aghast. If the police got involved, he was screwed.

“I don’t know why you guys went in there, and I’m not going to ask. The CDC might have cleared it, but the caution tape was still over the door. Especially you, Miss Grazdani, as you were specifically told the lab would be off-limits. Frankly, I’m dumbfounded. But I’ve never understood medical students since I took over this job heading the center’s security.”

Pia started to speak, but Winston held out his hand to silence her and called the dean of students. He explained the situation. He then listened for a good two minutes and hung up the phone.

“She’s coming down. I don’t know who I’d rather deal with if I were you, the dean or the Thirty-third.”

Winston showed George and Pia into a small side room and closed the door. George was too agitated to speak; Pia started pacing around the room. She couldn’t sit still. After what seemed like an age but was in fact thirty minutes, the door opened and a tall, dark-haired woman in sweats and a ski jacket came in and shut the door behind her. Her name was Helen Bourse. She had been dean of students for almost a decade and was well liked but hardly a pushover.

“What the hell did you think you were doing? You two have made me cash in more favors than I actually own, stopping Mr. Winston from having you arrested. I want you to convince me I did the right thing.”

“I’m so sorry, Mrs. Bourse,” George said. He took one look at Pia’s defiant face and decided he should speak for the both of them.

“We’re very sorry.”

“So what in God’s name were you doing there? In a lab that was sealed and potentially contaminated.”

“The only part that might have been contaminated was the biosafety unit,” Pia said, interrupting George, who’d started to respond. “We took the necessary precautions. I wanted to look for myself. I just can’t understand how Dr. Rothman managed to get infected, knowing him as I do.”

“So you weren’t picking up your stuff as you told Mr. Winston. And what, you’re suddenly epidemiologists? We had a team of actual epidemiologists check out the lab today both from here and from the CDC. They combed the place, including the biosafety unit.”

“What did they find?”

“Nothing, but that’s not the point.”

“I’ve been working in there on and off for over three years. I wanted to check it out. If something was different, I might have been able to see it, probably better than strangers from Atlanta.”

Some of Bourse’s vinegar lost its acid. She realized that Pia had a point. Still, it didn’t justify what these two otherwise gifted students had done, something totally foolish and out of character. After a pause she asked, “Well, what did you find?”

“Nothing, but we were interrupted. Do you have a report from the epidemiologists?”

“Certainly not from the CDC. Not yet. But I spoke to the head of our own team. Apparently nothing was found amiss.”

Dr. Bourse knew that Dr. Rothman was closer to this student than to anyone in the whole medical community. She knew quite a bit about Pia, more than she guessed Pia surmised. Bourse had had access to all the deliberations of the admissions committee, which she had pored over in great detail. Up until the call from Winston, she’d had high hopes for her, hopes she wanted to maintain. For Pia, Bourse’s intent was to try to keep the damage from the evening’s escapade and poor judgment to a minimum. Such was the burden of being dean of students. Earlier that evening Bourse had had to deal with an even more difficult issue: A third-year student had been caught stealing prescription drugs from the medical floors. Bourse turned her attention to the second delinquent. At least he met her eye, which she couldn’t get from Pia. “So what’s your excuse?” she asked George, with a certain resignation in her voice.

“No excuses. I was helping my friend,” he said as evenly as he could.

Dr. Bourse studied George. He too was a top student, more liked in general than Pia, who could be considered standoffish. Bourse was well aware of George’s apparent infatuation with Pia, so she took his excuse at face value. Once again she marveled at how such an apparently accomplished young man like George could be reduced to such a lovelorn teenager that he’d risk his future like this. If Bourse had allowed Winston to have him arrested, it could have affected his becoming a doctor.

“All right,” Bourse said. She took a deep breath and regarded the ceiling for a moment to clear her head. “Here’s what we’re going to do. You’re going to go back to your rooms and stay there. You won’t fraternize with anyone or talk about this episode with anyone. You’ll monitor your temperatures and take your antibiotics as directed. George, I’ll make sure you get some. And I’ll see both of you in my office at seven tomorrow morning. We’ll discuss your elective then, Ms. Grazdani. Mr. Wilson, tomorrow you will return to Radiology. Both of you will also say a prayer for me and thank the Lord that I’m in a benevolent mood. I’ll now go and square this away with Mr. Winston. If I can.”

With the dean out of the room, George let out a deep sigh and sat back in his chair. “Oh my God, I thought we were dead. If the police aren’t involved, it’s just an internal thing. It won’t be on our records. It’ll be like this never happened.” George looked at Pia, who didn’t respond. Her face was a blank, her mind clearly still back at the lab.

“You can’t let this drop?” George questioned.

“Of course I can’t let it drop,” Pia shot back. “Something had to have happened. Something out of the ordinary.”

“What about one of the technicians messing up, either by accident or design? I mean, Rothman was like a bull in the proverbial china shop. I imagine there are a lot of people who aren’t crying tonight about what happened to him.”

Pia shook her head. “There were people in the lab who found him unpleasant. But the same people admired him greatly. I can’t imagine anyone in the lab being involved in any underhanded way.”

“So what are you thinking?”

“I don’t know what to think,” Pia said. Her mind was swirling. Her first concern was whether or not Rothman would pull through. At the same time she was reconsidering the two possibilities for what had happened: Rothman contaminated himself by accident, or he did it deliberately. But then, another idea started to take shape in her mind. She realized there was a third possibility she hadn’t yet considered.