by Robin Cook
Jack was nearing the end of the internal exam when Calvin came through the door. There was no mistaking his huge silhouette. He was accompanied by another figure who was half his size. Calvin came directly to Jack’s table.
“Anything out of the ordinary?” Calvin asked, while peering into the pan of internal organs.
“Internally this case is a repeat of yesterday’s,” Jack said.
“Good,” Calvin said, straightening up. He then introduced Jack to his guest. It was Clint Abelard, the city epidemiologist.
Jack could make out the man’s prominent jaw, but because of the reflection off the plastic face mask, he couldn’t see the fellow’s squirrelly eyes. He wondered if he was still as cantankerous as he’d been the day before.
“According to Dr. Bingham you two have already met,” Calvin said.
“Indeed,” Jack said. The epidemiologist did not respond.
“Dr. Abelard is trying to discern the origin of this plague outbreak,” Calvin explained.
“Commendable,” Jack said.
“He’s come to us to see if we can add any significant information,” Calvin said. “Perhaps you could run through your positive findings.”
“My pleasure,” Jack said. He started with the external exam, indicating skin abnormalities he thought could have been insect bites. Then he showed all the gross internal pathology, concentrating on the lungs, lymphatics, liver, and spleen. Throughout the entire discourse, Clint Abelard stayed silent.
“There you have it,” Jack said as he finished. He put the liver back into the pan. “As you can see it’s a severe case, as was Nodelman’s, and it’s no wonder both patients died so quickly.”
“What about Hard?” Clint asked.
“She’s next,” Jack said.
“Mind if I watch?” Clint asked.
Jack shrugged. “That’s up to Dr. Washington,” he said.
“No problem,” Calvin said.
“If I may ask,” Jack said, “have you come up with a theory where this plague came from?”
“Not really,” Clint said gruffly. “Not yet.”
“Any ideas?” Jack asked, trying to keep sarcasm out of his voice. It seemed Clint was in no better humor than he had been the day before.
“We’re looking for plague in the area’s rodent population,” Clint said condescendingly.
“Splendid idea,” Jack said. “And just how are you doing that?”
Clint paused as if he didn’t want to divulge any state secrets.
“The CDC is helping,” he said finally. “They sent someone up here from their plague division. He’s in charge of the trapping and analysis.”
“Any luck so far?” Jack asked.
“Some of the rats caught last night were ill,” Clint said. “But none with plague.”
“What about the hospital?” Jack asked. He persisted despite Clint’s apparent reluctance to talk. “This woman we’ve just autopsied worked in central supply. Seems likely her illness was nosocomial like Nodelman’s. Do you think she got it from some primary source in and around the hospital, or do you think she got it from Nodelman?”
“We don’t know,” Clint admitted.
“If she got it from Nodelman,” Jack asked, “any ideas of a possible route of transmission?”
“We’ve checked the hospital’s ventilation and air-conditioning system carefully,” Clint said. “All the HEPA filters were in place and had been changed appropriately.”
“What about the lab situation?” Jack asked.
“What do you mean?” Clint said.
“Did you know that the chief tech in micro actually suggested plague to the director of the lab purely from his clinical impression, but the director talked him out of following up on it?”
“I didn’t know that,” Clint mumbled.
“If the chief tech had followed up on it he would have made the diagnosis and appropriate therapy could have been started,” Jack said. “Who knows; it could have saved a life. The problem is that the lab has been downsizing because of pressure from AmeriCare to save a few bucks, and they don’t have a microbiology supervisor position. It got eliminated.”
“I don’t know anything about all that,” Clint said. “Besides, the case of plague still would have occurred.”
“You’re right,” Jack said. “One way or the other you still have to come up with the origin. Unfortunately, you don’t know any more than you did yesterday.” Jack smiled inside his mask. He was getting a bit of perverse pleasure out of putting the epidemiologist on the spot.
“I wouldn’t go that far,” Clint muttered.
“Any sign of illness in the hospital staff?” Jack asked.
“There are several nurses who are febrile and who are quarantined,” Clint said. “As of yet there is no confirmation of them having plague, but it is suspected. They were directly exposed to Nodelman.”
“When will you be doing Hard?” Calvin asked.
“In about twenty minutes,” Jack said. “As soon as Vinnie gets things turned around.”
“I’m going around to check on some other cases,” Calvin said to Clint. “You want to stay here with Dr. Stapleton or do you want to come with me?”
“I think I’ll go with you, if you don’t mind,” Clint said.
“By the way, Jack,” Calvin said before leaving. “There’s a bevy of media people upstairs crawling all over the outer office like bloodhounds. I don’t want you giving any unauthorized press conferences. Any information coming from the ME’s office comes from Mrs. Donnatello and her PR assistant.”
“I wouldn’t dream of talking to the press,” Jack assured him.
Calvin wandered to the next table. Clint stayed at his heels.
“It didn’t sound as if that guy wanted to talk with you,” Vinnie said to Jack when Calvin and Clint were far enough away. “Not that I can blame him.”
“That little mouse has been spleeny since I first met him,” Jack said. “I don’t know what his problem is. He’s kinda a weird duck, if you ask me.”
“Now there’s the pot calling the kettle black,” Vinnie said.
11
THURSDAY, 9:30 A.M., MARCH 21, 1996 NEW YORK CITY
“Mr. Lagenthorpe, can you hear me?” Dr. Doyle called to his patient. Donald Lagenthorpe was a thirty-eight-year-old African-American oil engineer who had a chronic problem with asthma. That morning, just after three A.M., he’d awakened with progressive difficulty breathing. His prescribed home remedies had not interrupted the attack, and he’d come into the emergency room of the Manhattan General at four. Dr. Doyle had been called at quarter to five after the usual emergency medications had had no effect.
Donald’s eyes blinked open. He hadn’t been sleeping, just trying to rest. The ordeal had been exhausting and frightening. The feeling of not being able to catch his breath was torture, and this episode had been the worst he’d ever experienced.
“How are you doing?” Dr. Doyle inquired. “I know what you have been through. You must be very tired.” Dr. Doyle was one of those rare physicians who were able to empathize with all his patients with a depth of understanding suggesting he suffered from all the same conditions.
Donald nodded his head, indicating that he was okay. He was breathing through a face mask that made conversation difficult.
“I want you to stay in the hospital for a few days,” Dr. Doyle said. “This was a difficult attack to break.”
Donald nodded again. No one had to tell him that.
“I want to keep you on the IV steroids for a little while longer,” Dr. Doyle explained.
Donald lifted the face mask off his face. “Couldn’t I get the steroids at home?” he suggested. As thankful as he was about the hospital’s having been there in his hour of need, he much preferred the idea of going home now that his breathing had returned to normal. At home he knew he could at least get some work done. As was always the case, this asthma attack had come at a particularly inconvenient time. He was supposed to go back to Texas t
he following week for more fieldwork.
“I know you don’t want to be in the hospital,” Dr. Doyle said. “I’d feel the same way. But I think it is best under the circumstances. We’ll get you out just as soon as possible. Not only do I want to continue giving you IV steroids, but I want you breathing humidified, clean, nonirritating air. I also want to follow your peak expiratory flow rate carefully. As I explained to you earlier, it is still not completely back to normal.”
“How many days do you estimate I’ll have to be in here?” Donald asked.
“I’m sure it will only be a couple,” Dr. Doyle said.
“I’ve got to go back to Texas,” Donald explained.
“Oh?” Dr. Doyle said. “When were you there last?”
“Just last week,” Donald said.
“Hmm,” Dr. Doyle said while he thought. “Were you exposed to anything abnormal while you were there?”
“Just Tex-Mex cuisine,” Donald said, managing a smile.
“You haven’t gotten any new pets or anything like that, have you?” Dr. Doyle asked. One of the difficulties of managing someone with chronic asthma was determining the factors responsible for triggering attacks. Frequently it was allergenic.
“My girlfriend got a new cat,” Donald said. “It has made me itch a bit the last few times I’ve been over there.”
“When was the last time?” Dr. Doyle asked.
“Last night,” Donald admitted. “But I was home just a little after eleven, and I felt fine. I didn’t have any trouble falling asleep.”
“We’ll have to look into it,” Dr. Doyle said. “Meanwhile I want you in the hospital. What do you say?”
“You’re the doctor,” Donald said reluctantly.
“Thank you,” Dr. Doyle said.
12
THURSDAY, 9:45 A.M., MARCH 21, 1996
“For chrissake!” Jack murmured under his breath as he was about to start the autopsy on Susanne Hard. Clint Abelard was hovering behind him like a gnat, constantly switching his weight from one leg to the other.
“Clint, why don’t you step around the table and stand on the other side,” Jack suggested. “You’ll be able to see much better.”
Clint took the suggestion and stood with his arms behind his back opposite from Jack.
“Now don’t move,” Jack mumbled to himself. Jack didn’t like Clint hanging around, but he had no choice.
“It’s sad when you see a young woman like this,” Clint said suddenly.
Jack looked up. He hadn’t expected such a comment from Clint. It seemed too human. He had struck Jack as an unfeeling, moody bureaucrat.
“How old is she?” Clint asked.
“Twenty-eight,” Vinnie said from the head of the table.
“From the looks of her spine she didn’t have an easy life,” Clint said.
“She had several major back surgeries,” Jack said.
“It’s a double tragedy since she’d just given birth,” Clint said. “Now the child is motherless.”
“It was her second child,” Vinnie said.
“I suppose I shouldn’t forget her husband,” Clint said. “It must be upsetting to lose your spouse.”
A knifelike stab of emotion went down Jack’s spine. He had to fight to keep from reaching across the table and yanking Clint off his feet. Abruptly he left the table and exited to the washroom. He heard Vinnie call after him, but he ignored him. Instead Jack leaned on the edge of the sink and tried to calm himself. He knew that getting angry with Clint was an unreasonable reaction; it was nothing but pure, unadulterated transference. But understanding the origin did not lessen the irritation. It always irked Jack when he heard such clichés from people who truly had no idea.
“Is there a problem?” Vinnie asked. He’d stuck his head through the door.
“I’ll be there in a second,” Jack said.
Vinnie let the door close.
As long as he was there, Jack washed and regloved his hands. When he was finished he returned to the table.
“Let’s get this show on the road,” he said.
“I’ve looked the body over,” Clint said. “I don’t see anything that looks like an insect bite, do you?”
Jack had to restrain himself from subjecting Clint to a lecture like the one Clint had given to him. Instead, he merely proceeded with his external exam. Only after he’d finished did he speak.
“No gangrene, no purpura, and no insect bites as far as I can see,” Jack said. “But by just looking at her I can see some of her cervical lymph nodes are swollen.”
Jack pointed out the finding to Clint, who then nodded in agreement.
“That’s certainly consistent with plague,” Clint said.
Jack didn’t answer. Instead he took a scalpel from Vinnie and quickly made the typical Y-shaped autopsy incision. The bold cruelty of the move jolted Clint. He took a step back.
Jack worked quickly but with great care. He knew that the less the internal organs were disturbed, the less chance that any of the infecting microbes would be aerosolized.
When Jack had the organs out, he turned his attention first to the lungs. Calvin had drifted over at this point and towered behind Jack as he made his initial cuts into the obviously diseased organ. Jack spread open the lung like a butterfly.
“Lots of bronchopneumonia and early tissue necrosis,” Calvin said. “Looks pretty similar to Nodelman.”
“I don’t know,” Jack said. “Seems to me there is an equal amount of pathology but less consolidation. And look at these nodal areas. They almost look like early granulomas with caseation.”
Clint listened to this pathological jargon with little interest or comprehension. He remembered the terms from medical school, but had long since forgotten their meaning. “Does it look like plague?” he asked.
“Consistent,” Calvin said. “Let’s look at the liver and the spleen.”
Jack carefully pulled these organs from the pan and sliced into them. As he’d done with the lung, he spread open their cut surfaces so everyone could see. Even Laurie had stepped over from her table.
“Lots of necrosis,” Jack said. “Certainly just as virulent a case as with Nodelman or with the case I did earlier.”
“Looks like plague to me,” Calvin said.
“But why was the fluorescein antibody negative?” Jack said. “That’s telling me something, especially combined with the lung appearance.”
“What’s with the lungs?” Laurie asked.
Jack moved the liver and the spleen aside and showed Laurie the cut surface of the lung. He explained what he thought of the pathology.
“I see what you mean now that you mention it,” Laurie said. “It is different from Nodelman. His lungs definitely had more consolidation. This looks more like some sort of horribly aggressive TB.”
“Whoa!” Calvin said. “This isn’t TB. No way.”
“I don’t think Laurie was suggesting it was,” Jack said.
“I wasn’t,” Laurie agreed. “I was just using TB as a way of describing these infected areas.”
“I think it is plague,” Calvin said. “I mean, I wouldn’t if we hadn’t just had a case from the same hospital yesterday. Chances are it is plague regardless of what their lab said.”
“I don’t think it is,” Jack said. “But let’s see what our lab says.”
“How about double or nothing with that ten dollars,” Calvin said. “Are you that sure?”
“No, but I’ll take you up on it. I know how much the money means to you.”
“Are we finished here?” Clint asked. “If so, I think I’ll be going.”
“I’m essentially finished,” Jack said. “I’ll do a little more on the lymphatics, and then I’ll be obtaining samples for the microscopic. You won’t be missing anything if you take off now.”
“I’ll head out with you,” Calvin said.
Calvin and Clint disappeared through the door to the washroom.
“If you don’t think this case is plague, what do yo
u think it is?” Laurie asked, looking back at the woman’s corpse.
“I’m embarrassed to tell you,” Jack said.
“Come on,” Laurie urged. “I won’t tell anybody.”
Jack looked at Vinnie. Vinnie held up his hands. “My lips are sealed.”
“Well, I’d have to fall back on my original differential I had for Nodelman,” Jack said. “To narrow it down more than that, I have to again go out on thin ice. If it isn’t plague, the nearest infectious disease both pathologically and clinically is tularemia.”
Laurie laughed. “Tularemia in a twenty-eight-year-old postpartum female in Manhattan?” she questioned. “That would be pretty rare, although not as rare as your diagnosis yesterday of plague. After all, she could have a hobby of rabbit hunting on weekends.”
“I know it’s not very probable,” Jack said. “Once again I’m relying totally on the pathology and the fact that the test for plague was negative.”
“I’d be willing to bet a quarter,” Laurie said.
“Such a spender!” Jack joked. “Fine! We’ll bet a quarter.”
Laurie returned to her own case. Jack and Vinnie turned their attention back to Susanne Hard. While Vinnie did his tasks, Jack finished the lymphatic dissection he wanted to do, then took the tissue samples he felt appropriate for microscopic study. When the samples were all in the proper preservatives and appropriately labeled, he helped Vinnie suture the corpse.
Leaving the autopsy room, Jack properly dealt with his isolation equipment. After plugging in his rechargeable ventilator battery, he took the elevator up to the third floor to see Agnes Finn. He found her sitting in front of a stack of petri dishes examining bacterial cultures.
“I’ve just finished another infectious case that’s suspected plague,” he told her. “All the samples will be coming up shortly. But there is a problem. The lab over at the Manhattan General claims the patient tested negative. Of course, I want to repeat that, but at the same time I want you to rule out tularemia, and I want it done as quickly as possible.”
“That’s not easy,” she said. “Handling Francisella tularensis is hazardous. It’s very contagious to laboratory workers if it gets into the air. There is a fluorescein antibody stain for tularemia, but we don’t have it.”