Bacteria don’t have brains like higher forms of life, but it sure felt like Tom’s Acinetobacter was plotting against our every move. If Tom were here—and by that, I mean really here—he would scoff at my anthropomorphism. After all, bacteria are just doing what they do to survive. We had relegated them to the bottom rung of the food chain, but they were showing us how shortsighted we’d been.
Despite modern-day advances in technology, one sign of success on a Petri plate hadn’t changed since Félix d’Hérelle’s day. You wanted to see the telltale sign that the phage was killing off the bacteria around it. Those Swiss-cheese-like plaques with clear zones around them that look like halos. We were all praying for halos.
The challenge ahead would be twofold. First, to track changes in Tom’s bacterial isolate, indicating resistance mutations by the A. baumannii, and then, if needed, to tweak the phage cocktails in strategic ways that could keep the phages’ selective pressure on the bacteria. This was painstaking lab work, and it took time. Staff at both labs were still working around the clock, eschewing the usual distinction between work and after hours.
As the TICU team quickly got more comfortable with the phage therapy protocol, the nurses began handling Tom’s phage cocktail infusions, administering the phage preparations into Tom’s abdominal drains and his IV line, with the dosing schedule now reduced to twice a day. With no immediate window on the action between the phages and their prey, all we could do was watch Tom and the periodic lab reports for any indication of change, for better or for worse. So far, so good. Or at least an absence of bad.
Randy wrote in her notes: “Has had no immediate adverse reaction to infusions.” Hurry up and wait was the order of the day. Days. Tom had been battling this bug for just over one hundred of them thus far, and counting.
23
LYSIS TO KILL
March 18, 2016
At the center of the low pulsing beeps and lights of the bedside monitors, Tom lay motionless and silent, as still and wasted away as a human being can be on this side of death. His gaunt, pale body looked like an abandoned battlefield, post-apocalypse. But in truth, the battle had just begun. The Texas phage cocktail infused through Tom’s abdominal drains was barely four days along, followed by the Navy’s IV phage twenty-four hours ago. Now we watched and waited for the first lab reports that would give us a glimpse of how the phages were faring.
Chip called it the Darwinian dance, but that’s a lyrical way to describe a ground war that is more scorched earth and a battle to the death, all of it in a microbial universe. I’d like to say, “in a galaxy far, far away,” but it wasn’t. It was right here, ravaging Tom’s body from the inside out. Tom was the battleground, the field of action where the Acinetobacter and phages were staging this Armageddon, a tactical war between them with stealth strategies and advanced genetic weaponry. In a sense, from their microbial point of view, this isn’t even about Tom. This is one-on-one a battle between virus and bacteria, each one purely focused on its own survival.
Since the girls had returned, I’d spent the mornings through lunchtime with Tom, and they’d taken back-to-back shifts with him in the afternoon, sometimes with Danny. We all had our own routines, but at night, we reconvened at the house and talked over wine, often too tired to do more than stare like zombies at the TV, which was typically endless episodes of Forensic Files. Tonight, not even the TV offered a way out. We felt trapped in our own Twilight Zone. Our desperate hope that this novel phage therapy treatment would work was matched only by the fear that it would fail.
It was easy to feel untethered from time and reality. Now and again, someone would say something that would yank us back and down. Many of the medical concerns we raised must have sounded piteously naïve to anyone looking at Tom’s situation from the outside. A few weeks earlier, we’d expressed concern about the continued use of opiates for pain management, since we didn’t want Tom to become addicted. When we mentioned this to Meghan, always a straight-shooter with us, she’d shaken her head and said, “That’s the least of our concerns right now.”
Then there was the conversation I’d had with Randy that afternoon. I had a hunch I knew the answer, but I’d asked anyway. It was important to Tom.
“If Tom dies, can any of his organs be used for donation?”
She’d looked at me like I had two heads.
“No,” she said. “Not with this kind of infection. Too dangerous.”
“Even his corneas?”
“Even those,” she replied.
That bastard bacterium. A. baumannii was calling the shots, and even if he died it was going to rob him of his one last wish—that his death contribute in some way through organ donation. I thought of how strong and robust a man Tom had been a few short months ago, and now every last part of him was dying and would be discarded.
The night before, we’d kindled a low flame in the firepit at twilight. Carly and Frances lamented again that we might not get a chance to hear his voice, so I pulled out my phone.
“I saved some voice mails,” I confessed, and the girls both chimed in that they had, too. So, we all sat and played them on our phones, one by one.
Carly had one that she treasured that wasn’t like the goofy messages her dad often left for her, saying something ridiculous in a funny accent. It was just an ordinary message letting her know we’d just returned from a trip and to give us a call when she could. She loved that it was a “normal Dad” message. We were all aching to hear that voice again.
Listening, I was shocked at how full of life his voice had been just a few months before, and now we were lucky to get a raised eyebrow or a hand squeeze. I’d have given anything now to hear Tom utter the most ordinary, ordinary, ordinary things again. Or just to believe in this moment that I’d ever hear his voice again.
I’d told Chip that I had a feeling the phages would work, and I’d meant it when I said it. But when the dark had closed in on the day, it was as if the setting sun had pulled my spirit, and Tom’s, down with it to the underworld where the demons waited: Pain. Frustration. Grief. Guilt. The knowledge that this intervention was my idea—my fault—was becoming too much to bear. And fear of what lay ahead. Robert had told me years ago, after Steve had died and I was struggling with that loss, that in spiritual terms, I had experienced every major challenge and had acquired every skill I needed to manage whatever problems I faced ahead. “If you can see that any new challenge you face is just a variation on the ones you’ve overcome, you will succeed—and become a more enlightened being in the process,” he’d said. Right now, I was anything but enlightened. In the dark, I broke down in tears, feeling the fool for ever having thought this scheme stood a chance.
Twenty-four hours later, I felt foolish for ever having doubted.
Carly had gone down for her usual afternoon shift at one p.m., but she was gone longer than usual. I was napping on the couch with Bonita, and Frances was in her bedroom meditating, when Carly burst through the front door bubbling with excitement. I had to do a double-take, it had been so long since anyone effused like this. Tom had come to—awakened from his coma! He’d been groggy, still intubated, so unable to speak. But he’d raised his head off the pillow, kissed her hand, nodded to Danny standing by her, then, exhausted, drifted off to sleep—just sleep, Carly insisted, not a coma. Although only for a few minutes, Tom had awakened. He was back.
The ICU experience, wherever you are in it, has a way of leveling all drama—clinical or otherwise—probably to keep everything at a manageable hum. The sounds, the temperature, the conversational tones—everything is calm until it isn’t, and then the staff handles those moments so expertly, they can make the most chaotic turn seem somehow contained. The same applies to the happier turns—like a patient coming out of a coma after two months. It’s a good day when a patient in the ICU makes progress, and today the nurses, attending physicians, and others offered their quiet high-fives, fist pumps, and hugs, sharing their own relief and joy. Meanwhile, at peace in the calm, qu
iet TICU cocoon, Tom got to sink quickly back to sleep, and we all got to rest easier that night, just knowing that he could. The cats cuddled close, and I surrendered to sweeter dreams than I’d imagined possible for a long time.
Tom: Interlude VII
There is a pecking order even in death. The blowflies know this, as do I. Of the necrophagous insects that feed on animal and human remains, the blowfly is among the first to arrive. Female blowflies laden with eggs are preferentially attracted by death volatiles, minute concentrations of gases like dimethyl trisulfide that are produced soon after death. Larvae hatching from their eggs emerge to start their feeding frenzy before the flesh fly lands. Ants or house flies typically appear in the next succession wave, paying their respects in a receiving line where the groom is devoured instead of the wedding cake. Sometimes, burying beetles accompany them, carrying tiny mites that snack on blowfly larvae. Since blowfly larvae produce ammonia that is toxic to the beetle, the mite keeps the larvae in check, an example of classic symbiosis. You scratch my antennae, and I scratch yours.
Blowflies prefer to slurp juices from bodies that are already decomposing, so the swarm hovers over me, waiting. Their beating wings create a deafening symphony; the sound of decay. A few of the anxious ones take turns sucking at my mucous membranes: eyes, nose, mouth, anus. My clothes are in tatters after so much time in the desert, offering me no protection. I keep walking, so they eventually depart en masse to search for a more accommodating victim.
I know a thing or two about flies. A different fly species infested me once. After spending three months in the Colombian jungle with several other graduate students in 1972, we returned home with more than postcards. Each of us was crawling with exotic parasites. The few mosquito bites on the back of my thigh had started out as minor irritations. Several weeks later they were infected masses the size of golf balls, then baseballs. I kept telling the doctor that whatever it was, it was eating me. I could feel it feeding, especially at night. Occasionally, it hit a nerve and my leg would jump like a marionette being manipulated by a sadistic puppeteer. At such times, I would slap at my bulging thigh and the thing would lie dormant for a little while. The doctor thought I was nuts at first, but when a one-inch pupae with three double rows of epidermal spines suddenly emerged while I was on the examining table, he was stunned. Turns out I had been afflicted with an infestation of Dermatobium hominis, a botfly that ingeniously captures mosquitoes and lay its eggs on their underbelly. When the mosquito bites its host, the newly hatched botfly larvae crawl into the wound, feed on their host’s flesh, and then pupate. Yum.
The laws of nature are simple: eat or be eaten. Die and decompose. I made a conscious decision. I want to live.
I followed the hooded horde of swarming flies. Lead me to salvation or another carcass, but a place where life once flourished is one where there is at least a remnant of hope left. As I walk in perpetuity, I feel the sand of the desert becoming spongy beneath my toes. The air becomes moist; my nostrils flare. I swallow, my membranes hungrily absorbing every droplet. Up ahead is a bog; the sphagnum moss hangs over trees with skeletal steel limbs. I have been here before, but when? The light is dimmer now, the heat less oppressive. Above the swamp, a phosphorescent orb appears and beckons me. A will o’ the wisp? The colors are violet, green, and blue, flecked with orange. I hear music and see its colors: I know this is synesthesia, which I haven’t experienced in decades. Come closer, the orb seems to say. I draw nearer, and the drone of the flies becomes a hum.
Voices, not flies. People.
My eyes flutter, then open. My senses are suddenly bombarded with stimuli: bright light, a red plastic biohazard container, yellow gowns and blue gloves, antiseptic, the incessant beep of the cardiac monitor, the drip of the ventilator hose, the glint of the IV pole, the buzz and blink of the fluorescent light on the ceiling, the rasp of bedsheets on my skin, the brown mossy curtain of my TICU room. Bed 11. I stretch my spine. Although I feel my fingers, my feet are strangely numb.
I hear laughter, followed by a shriek of delight from a willowy figure that I instantly recognize is Carly. She rushes toward me, and I drink in her scent. I am instantly reminded of the day she was born.
I lift my head from what must be my pillow, and I reach out to her hand. I bring it to my lips and kiss it.
I am finally certain that I am alive.
24
SECOND-GUESSING
March 20–21, 2016
What the fuck?!”
My mother would say she didn’t raise me to have a mouth like a sewer. But when I stood at the foot of Bed 11 early in the morning of March 20, those were the first words out of my mouth.
The night before, Carly had been so thrilled after Tom had awakened and recognized her and Danny, however weakly. For the first time in months, we went to sleep excited and deliriously happy. And when I’d called the TICU this morning to check on Tom as I usually did every morning at five a.m., the charge nurse, Mary, said that the evening had been uneventful, in a good way. Convinced the nightmare was almost over, I practically skipped from the parking lot to the TICU, expecting to see Tom awake, at last.
What I was not expecting was what I saw. Tom was unconscious and his face was as pale as the white sheet that covered him. His skin was clammy and feverish. His heart rate was 135. Very tachy. And his blood pressure was dropping like a stone. I gowned up in seconds and rushed over to him.
“Tom! Honey! Can you hear me? It’s Steff… if you can hear me, can you squeeze my hand or open your eyes?”
No response. All I could hear were the sudden alarms of the cardiac monitor. The numbers for heart rate and blood pressure were now flashing. Ray, his day nurse, instantly appeared from the neighboring room to see what was going on.
“What the hell happened, Ray?” I snapped. It wasn’t yet seven thirty a.m., so his shift had started only moments ago. He was just as shocked as I. Ray ran a hand over his shaved head. The tiny bit of growth that was just beginning to show signs of gray against his dark skin gave him a fashionably grizzled look. By the look of how events were unfolding today, he was about to gain a few more gray hairs. My hair-trigger impatience didn’t help, but his focus, as always, was laser-like on Tom. He hurriedly donned gown and gloves, adjusted Tom’s pressor settings, and allowed me to look over his shoulder at the morning’s lab values on the computer.
I yelped. “WBCs are 69,000! Is that a typo? Or a lab error?” By now I knew that the average range for an adult’s white blood cell count was 4,500 to 11,000 cells per microliter. Tom’s WBC count had increased slightly the day after phage therapy began, but that was expected. Today’s WBC count represented an astronomical increase. Ray quickly scrolled through the numbers on the screen. The look on his face said it all.
“Holy crap,” Ray said under his breath, giving his head a shake. “I’ve never seen a WBC count that high, and it increased from 14,000 to 69,000 just overnight. Let me page the critical care doc on call.”
I felt numb. Inside, I was kicking myself. I should have driven back to the hospital last night as soon as I heard that Tom had woken up. As exhausted as I was, at least I would have seen him awake. If last night’s brief glimpse of consciousness was the last Tom would ever experience, I had missed it. Dammit. Why had I been so naïve to think that Tom was out of danger, given how rocky his recovery had been so far?
I recalled the famous neurologist Dr. Oliver Sacks, whose memoir was made into the movie Awakenings. As a younger man, Dr. Sacks had been treating patients who had fallen ill during an epidemic of a neurological condition called encephalitis lethargica that struck an estimated half million people during the first quarter of the twentieth century. Its cause was a major medical mystery until recently, when studies implicated an enterovirus typically found in the gut, like polio. Patients with encephalitis lethargica typically developed Parkinson’s-like symptoms and catatonia, a comalike state. Sacks discovered that by administering the neurotransmitter L-DOPA, he could miraculously awaken his patien
ts from their fugue. Tragically, L-DOPA’s effects were temporary. It was agonizing to watch these patients—along with their loved ones and their doctors who stood by helplessly—as they slipped back into a catatonic state, one by one. I knew what it felt like now to watch your loved one sink from sight that way. In Sacks’s book, they saw it coming, and those last goodbyes were beyond gut-wrenching. At this moment, all I could think was that I might never have that chance.
While my brain tried to process the possible reasons for Tom’s cataclysmic crash, I flitted around his room at lightning speed, trying to do something. I moistened the quick-cooling cloth and placed it on his forehead. I set the fan to high and positioned it on his face. But when I placed an ice pack under each of Tom’s armpits, I noticed that several of the ostomy bags attached to his drains were unusually full. The bag draining the pseudocyst was collecting a dark brown murky liquid that was peppered with what looked like coffee grounds. I held up the bag to show Ray.
“The pseudocyst drain has been putting out one hundred milliliters of fluid a day, which has always been yellowish-brown,” I nattered. When all else failed, I went into scientist mode; it gave me the illusion of control. My voice sounded mechanical, like Dr. Tempe Brennan in the TV show Bones. “If the bags were emptied on night shift like usual, then the pseudocyst has put out about five hundred milliliters of this dark brown gunk in the last eight hours. That’s got to tell us something. And what are all of those brown flecks?”
“I’m no doctor, but those coffee-ground-like flecks are usually a sign of coagulated blood,” replied Ray, as he inspected the contents of the ostomy bags and emptied them, saving a sample from each. Of course, I wasn’t a doctor, either, but I suspected that the doctor on call or Chip would place an order that their contents be cultured. I took a photo of the ostomy bags with my cell phone and texted it to Chip, along with a shot of the cardiac monitor, which showed blood pressure 75/34, respiratory rate 35, and heart rate 121. Those hemodynamics were terrible. I tried not to jump to conclusions, but I couldn’t help myself. The signs were all there. This was septic shock. Again.
The Perfect Predator Page 24