Death Benefit

32.

COLUMBIA UNIVERSITY MEDICAL CENTER NEW YORK CITY MARCH 24, 2011, 2:05 P.M.

As Pia sat and sat in the narrow waiting room of Dr. Helmut Springer, her determination to see him didn’t waver. Her tryst with George had succeeded in establishing in her mind what she needed to do. She had a burning need to know two things. The reason why Dr. Rothman became sick was one issue; another was why the vaunted and lauded Columbia medical staff had, in her mind, apparently screwed up his treatment. She knew she was only a fourth-year medical student, but from her perspective she couldn’t come up with a compelling reason why Dr. Rothman and Dr. Yamamoto should have died at all, let alone died less than a day after the men were admitted to the infectious disease ward at the hospital. It wasn’t as if they were in some backwoods operation-this was one of the absolute premier medical institutions in the world.

Though Springer probably wouldn’t be happy to see her, she was hopeful that if she talked with him he could aid her quest to find out what had happened. He was, after all, a world-renowned infectious disease specialist. She knew his reputation of not treating medical students with anything close to respect and she knew their meeting the day before had not ended well; still she was optimistic. If he didn’t know that she was the one who first recognized Rothman’s incipient peritonitis, she was going to tell him herself, thinking it should count for something.

After forty-five minutes of waiting, Springer’s receptionist finally announced to Pia that the doctor could see her now. Pia quickly entered his office. Springer was at his desk facing into the small room. There were no other chairs; it was Springer’s way of keeping meetings short.

“Dr. Springer, I’m sorry to bother you again, and I know I annoyed you the last time we met. I apologize for all that. But I’m a medical student, and if I can’t learn from my experiences, then I’m a pretty poor excuse for one. And I apologize for questioning-”

“Yes, yes,” Springer said, cutting Pia off midstream. Her apologies sounded rehearsed and there was nothing resembling contrition in her eyes. Worst of all, his schedule was completely full with residents, at that moment, awaiting his arrival in the emergency room. He cleared his throat. “From our last chat I suspect you believe you know better than some of the foremost authorities in the land what has taken place here. Well, I want to disabuse you of that notion. Also I’d like to say that I wouldn’t have even taken the time to see you this morning were it not for the fact that you discovered the early signs of peritonitis in Dr. Rothman. Dr. De Silva told me about a medical student who she assumed was on rotation catching rebound tenderness in Dr. Rothman’s abdomen, which had not presented itself previously. We’ll overlook the fact that this medical student was not, in fact, on rotation and had essentially broken into the ward and was wholly unauthorized to approach the patients. Of course, I later learned that this medical student was yourself.”

It took Pia a couple of seconds to realize that Springer was paying her a slight compliment, even if it was cloaked in a sardonic reprimand. Pia took it as an opening. “I fully admit it was, and perhaps I shouldn’t have been there,” she said. “But it was an important discovery with important consequences. The man was clearly getting worse, which makes one wonder why the original antibiotic was chosen.”

“Please,” Springer said, his face empurpling. “This is where we left off last time. I just indicated that we were grateful for your help, and now you’re back with this nonsense. I can’t win. Again, there is nothing to indicate that chloramphenicol wasn’t doing the best job under the circumstances. And, as we have said about fifty times, we were informed by the sensitivity studies carried out by Dr. Rothman himself that it was the correct choice of antibiotic. We are working under the assumption that Dr. Rothman’s work in the study was as thorough and accurate as was customary.”

Pia couldn’t believe what she was hearing. Was Springer attempting to shift some of the responsibility onto Rothman? In this case it seemed especially crass to even suggest blaming the victim. “So how come, considering those sensitivity studies, neither Dr. Rothman nor Dr. Yamamoto showed any sign of response to the chosen antibiotic?”

Springer closed his eyes for a moment. “The answer to your question is simple. The virulence of the involved strain of salmonella overwhelmed both the antibiotic and the patients’ defenses. Remember, antibiotics, contrary to myth, do not cure. It is the patient’s immune system that cures. Obviously with Rothman and Yamamoto, their immune systems were completely overwhelmed. Simple as that.”

Pia started to respond, but Springer cut her off. “Listen, we’ve been over this issue. And let me add that a department head at this hospital does not have this kind of conversation with a medical student. A department head does not have this kind of conversation at all-there are protocols to be observed, there are panels that are convened if there are questions about the diagnosis or treatment. It’s not clear in this case that there are any questions. Jesus, why am I justifying myself to you? This is not how we conduct business around here.”

Pia wasn’t picking up on Springer’s rising sense of outrage. She had him in the room and she wanted answers. “Why weren’t Rothman and Yamamoto being monitored more closely?”

“They were being monitored extremely closely. Each had his own nurse.”

“Closely? How did it happen that a medical student had to pick up on the signs of developing peritonitis?”

“That was a fluke. It would have been picked up very quickly. Trust me. Now, is there anything else I can help you with, any other hospital policy you might want to critique for me?”

Springer’s sarcasm was lost on Pia.

“This case confuses me,” Pia continued. “In fact, it’s one of the worst cases of salmonella or typhoid that I’ve ever come across.”

“In your vastly broad experience,” Springer said.

“In my experience, yes.”

“Well, what are you alluding to? I’m sure you’re alluding to something. So enlighten me, please.”

“One of the first things they told us when we got here was about diagnosis. ‘When you hear galloping hoofbeats, you should think of horses, not zebras.’ ”

“Yes, of course, it’s the oldest saw in medicine. What about it?”

“Should we be looking for zebras here, Dr. Springer?”

“We are not looking for anything here, Ms. Grazdani. But I am dying to know what it is that you are looking for. So enlighten me again.”

“Okay. Is it possible that this case represents some exotic form of an antibody/antigen reaction the body can have, like a Shwartzman reaction? In which case would it not have made sense to use Decadron or some similar anti-inflammatory agent, something potent, to try to head it off at the pass?”

“If that is your great revelation, well, I’m sorry to say it’s not much of one. Because we used Decadron in the evening when it became clear that the two researchers were approaching extremis. Perhaps you should review the patients’ charts before making accusations like that.”

“Of course. If I had been given access to the charts I wouldn’t have made the mistake. But I’m not making accusations, I just want to get to the truth, Dr. Springer.”

“We all do, Ms. Grazdani.”

Springer was suddenly overcome with fatigue. Talking with Pia Grazdani was frustrating, and he had more people he was going to have to deal with that afternoon who were going to be even more of a burden. There would be the inevitable press and the patients’ families. It was not going to be a good day, since ultimately, it was the patients he cared about.

“Do you think perhaps there could have been yet another bacteria involved besides salmonella, a bacteria or a virus that was being covered or camouflaged by the salmonella? And maybe it was this bacteria that was totally resistant to chloramphenicol and was the real killer?”

There was silence while Springer tried to control his anger. This was simply too much. His eyes drilled into Pia’s while she maintained her composure, waiting for an answer while looking down at her feet. Finally Springer exploded with bottled-up emotion.

“I cannot, for the life of me, imagine a more ridiculous scenario. We made the diagnosis by fulfilling Koch’s hypothesis. The illness was caused by salmonella, whose presence we ascertained in multiple ways, but most convincingly from blood culture. We classified the strain in multiple ways as well, particularly by DNA analysis. The offending organism was, without an ounce of doubt, the alpha strain of salmonella typhi that Rothman himself had had grown in space with the cooperation of NASA. There was no other pathogen, for Christ’s sake. The blood cultures only grew out the salmonella. Nothing else! Nothing at all!”

Undaunted, Pia changed the subject on a dime. “What about the hair loss? Does serious salmonella infection cause hair loss?”

Springer was having difficulty controlling himself, yet the woman seemed completely calm. “The stress of almost any severe illness, particularly one presenting with high fever, can cause hair loss. Anyway, what hair loss are you talking about?”

“I saw hair loss with Rothman before I discovered the rebound tenderness. The resident suggested it could be attributed to the chloramphenicol.”

“That’s not something I am aware of,” he said. And then, suddenly and angrily, “Oh, for God’s sake. You wait here!”

Springer bounded out of his desk chair, pushed past Pia, and disappeared. Pia stood in the room and waited. Within a few minutes, Springer reappeared and sat down, giving Pia a nasty look. Thinking she had probably maximized what she was going to get out of the conversation, Pia eyed the door.

“I told you to wait,” Springer said. “Stay there!” Confused, Pia did as she was told. There was silence except for Springer’s labored breathing. The man’s boiling, she thought. I’m not getting anywhere. Pia eyed the door again.

“Dr. Springer, I sincerely thank you for your time.”

“Stay where you are!” Springer said brusquely.

Pia rolled her eyes, confused. First he can’t wait to get rid of me, now he wants me to stay. . . . Then, bursting through the door came Dr. Helen Bourse, dean of students.

“Ah, Dean Bourse, it’s simply not possible for me to do my job if I am to be hounded by a medical student who thinks she should be running my department. She goes onto the floor and sees patients with no authorization, which I am sure could open us up to all manner of liability issues. She repeatedly questions my medical ability and second-guesses decisions that were made, and now she’s come up with an outlandish suggestion that we might have completely missed another organism which was responsible for Rothman’s and Yamamoto’s untimely deaths. First it was the choice of antibiotic, now it’s a second pathogen. This is outrageous and it has to stop.”

Pia looked at Springer, and she was unable to conceal the contempt she was feeling. He had run off like a coward and got the dean to come tell her off. She glanced at Bourse, who was standing arms akimbo, a hard expression on her face. She was angry and dumbfounded.

“I would like Dr. Springer to understand that I’m not trying to do his job,” Pia said in her defense. “I’m just trying to answer some questions that I would have thought were important ones. My sense here is that something is wrong.”

Neither Springer nor Bourse could believe the gall of the young woman. The question in both of their minds: Who the hell does she think she is? Springer found his voice first.

“Do you see what I’m talking about? This woman is off the wall. I’m going to talk with Groekest about the advisability of rescinding the position she was offered here as a resident/Ph.D. candidate. This is absurd.”

At the mention of the chief of the internal medicine department, Helen Bourse signaled with a snap of her head that Pia should leave Springer’s office. Pia was happy to oblige. Bourse then nodded to Springer to indicate that she had the situation under control. “I’ll get back to you. Sorry about this.” Bourse then followed Pia out of the office and into the hallway. Pia might be temporarily unbalanced, but Springer was a bully, and he’d made his point. Before Pia had a chance to say anything, Bourse lit into her.

“What the hell do you think you’re doing? When we spoke this morning, and I gave you time to get your head together, I don’t believe I said you should go see Dr. Springer and belabor the head of Infectious Diseases about his patients or his diagnosis. Where is your social sense? Good grief, woman! It’s common knowledge that Springer is not a fan of medical students in general, but this episode has pushed him over the edge. I have never heard him as exasperated as he was when he called.”

Pia started to speak, but Bourse wasn’t done with her.

“You’re fast developing a reputation as a troublemaker, Ms. Grazdani, and that will not look good on your resume if it gets recorded. You are here, essentially, as a guest of the institution, and guests do not behave like this. If they do, they’re usually asked to leave. I gave you a couple of days to get over the tragic death of your mentor and that wasn’t supposed to be time for you to come in here and stir things up again.”

“But don’t you think these questions need to be answered?”

“No, I don’t, not if he doesn’t,” Bourse said, gesturing at the door.

Pia started to speak again, but the dean had had enough. “Have you shown any signs of a fever?”

“No.”

“Then get yourself back to your room. If I hear you’re causing any more trouble over this unfortunate affair, I will think seriously about rescinding your welcome here as a medical student. Which would be something of a tragedy for you, considering you only have a couple of months left before you graduate. And it would be a tragedy for us because we’d be admitting we made a mistake in taking you in the first place. I don’t think Dr. Springer will go to Dr. Groekest on his own, but he might. So be careful, young lady. You are now officially on very thin ice. I must not have made myself clear last time we spoke. Am I making myself clear now?”

“Yes,” said Pia. “Perfectly.”