by Robin Cook
“How about starting on this instead?” Jack said. He pushed the Maria Lopez folder over to Vinnie. “Might as well get set up. Remember, the early bird…”
“Hold the clichés,” Vinnie said. He took the folder and let it fall open in his hands. “Frankly, I’m not in the mood for any of your sappy sayings. What bugs me is that you can’t come in here when everybody else does.”
“Laurie’s here,” Jack reminded him.
“Yeah, but this is her week for scheduling. You don’t have any excuse.” He briefly read portions of the folder. “Wonderful! Another infectious case! My favorite! I should have stayed in bed.”
“I’ll be down in a few minutes,” Jack said.
Vinnie irritably snapped up his newspaper and headed downstairs.
Laurie reappeared with an armful of folders and dumped them on her desk. “My, my, but we do have a lot of work to do today,” she said.
“I’ve already sent Vinnie down to get prepared for one of these infectious cases,” Jack said. “I hope I’m not overstepping my authority. I know you haven’t looked at them yet, but all of them are suspected plague but tested negative. At a minimum I think we have to make a diagnosis.”
“No question,” Laurie said. “But I should still go downstairs and do my external. Come on, I’ll do it right away, and you can get started.” She grabbed the master list of all the previous night’s deaths.
“What’s the story on this first case you want to do?” Laurie asked as they walked.
Jack gave her a quick synopsis of what he knew about Maria Lopez. He emphasized the coincidence of her being employed in central supply at the General. He reminded her that the plague victim from the day before had also worked in that department. They boarded the elevator.
“That’s kinda strange, isn’t it?” Laurie asked.
“It is to me,” Jack agreed.
“Do you think it’s significant?” Laurie asked. The elevator bumped to a stop, and they got off.
“My intuition tells me it is,” Jack said. “That’s why I’m eager to do the post. For the life of me, I can’t figure out what the association could be.”
As they passed the mortuary office Laurie beckoned to Sal. He caught up to them, and she handed him her master list. “Let’s see the Lopez body first,” she said.
Sal took the list, referred to his own, then stopped at compartment 67, opened the door, and slid out the tray.
Maria Lopez, like her late co-worker, Katherine Mueller, was an overweight female. Her hair was stringy and dyed a peculiar reddish orange. Several IVs were still in place. One was taped to the right side of her neck, the other to her left arm.
“A fairly young woman,” Laurie commented.
Jack nodded. “She was only forty-two.”
Laurie held Maria Lopez’s full-body X ray up to the ceiling light. Its only abnormality was patchy infiltration in her lungs.
“Go to it,” Laurie said.
Jack turned on his heels and headed toward the room where his moon-suit ventilator was charging.
“Of the other two cases you had upstairs, which one would you want to do if you only do one?” Laurie called after him.
“Lagenthorpe,” Jack said.
Laurie gave him a thumbs-up.
Despite his hangover, Vinnie had been his usual efficient self in setting up the autopsy on Maria Lopez. By the time Jack read over the material in Maria’s folder for the second time and had climbed into his moon suit, all was ready.
With no distractions from anyone in the pit besides himself and Vinnie, Jack was able to concentrate. He spent an inordinate amount of time on the external exam. He was determined to find an insect bite if there had been one. He was not successful. As with Mueller, there were a few questionable blemishes, which he photographed, but none he felt were bites.
Jack’s concentration was inadvertently aided by Vinnie’s hangover. Preferring to nurse his headache, Vinnie remained silent, sparing Jack his usual quips and running commentary on sports trivia. Jack reveled in the thought-provoking silence.
Jack handled the internal exam the same way he’d handled those of the previous infectious cases. He was extraordinarily careful to avoid unnecessary movement of the organs to keep bacterial aerosolization to a minimum.
As the autopsy progressed, Jack’s overall impression was that Lopez’s case mirrored that of Susanne Hard, not Katherine Mueller. Hence, his preliminary diagnosis remained tularemia, not plague. This only highlighted his confusion of how two women from central supply had managed to catch these illnesses while other, more exposed hospital workers had avoided them.
When he finished with the internal exam and had taken the samples he wanted, he put aside a special sample of lung to take up to Agnes Finn. Once he had similar samples from Joy Hester and Donald Lagenthorpe, he planned to have them all sent immediately to the reference lab to be tested for tularemia.
By the time Jack and Vinnie had commenced stitching up Maria Lopez, they began to hear voices in the washroom and out in the hall.
“Here come the normal, civilized people,” Vinnie commented.
Jack didn’t respond.
Presently the door to the washroom opened. Two figures entered in their moon suits and ambled over to Jack’s table. It was Laurie and Chet.
“Are you guys finished already?” Chet said.
“It’s not my doing,” Vinnie said. “The mad biker has to start before the sun is up.”
“What do you think?” Laurie asked. “Plague or tularemia?”
“My guess is tularemia,” Jack said.
“That will be four cases if these other two are tularemia as well,” Laurie said.
“I know,” Jack said. “It’s weird. Person-to-person spread is supposed to be rare. It doesn’t make a lot of sense, but that seems par for the course with these recent cases.”
“How is tularemia spread?” Chet asked. “I’ve never seen a case.”
“It’s spread by ticks or direct contact with an infected animal, like a rabbit,” Jack said.
“I’ve got you scheduled for Lagenthorpe next,” Laurie told Jack. “I’m going to do Hester myself.”
“I’m happy to do Hester as well,” Jack said.
“No need,” Laurie said. “There aren’t that many autopsies today. A lot of last night’s deaths didn’t need to be posted. I can’t let you have all the fun.”
Bodies began arriving. They were being pushed into the autopsy room by other mortuary techs and lifted onto their designated tables. Laurie and Chet moved off to do their own cases.
Jack and Vinnie returned to their suturing. When they were finished, Jack helped Vinnie move the body onto a gurney. Then Jack asked how quickly Vinnie could have Lagenthorpe ready to go.
“What a slave driver,” Vinnie complained. “Aren’t we going to have coffee like everybody else?”
“I’d rather get it over with,” Jack said. “Then you can have coffee for the rest of the day.”
“Bull,” Vinnie said. “I’ll be reassigned back in here helping someone else.”
Still complaining, Vinnie pushed Maria Lopez out of the autopsy room. Jack wandered over to Laurie’s table. Laurie was engrossed in the external exam but straightened up when she caught sight of Jack.
“This poor woman was thirty-six,” Laurie said wistfully. “What a waste.”
“What have you found? Any insect bites or cat scratches?”
“Nothing except a shaving nick on her lower leg,” Laurie said. “But it’s not inflamed, so I’m convinced it’s incidental.
There is something interesting. She has definite eye infections.”
Laurie carefully lifted the woman’s eyelids. Both eyes were deeply inflamed, although the corneas were clear.
“I can also feel enlarged preauricular lymph nodes,” Laurie said. She pointed to visible lumps in front of the patient’s ears.
“Interesting,” Jack commented. “That’s consistent with tularemia, but I didn’t see it on the othe
r cases. Give a yell if you come across anything else unusual.”
Jack stepped over to Chet’s table. He was happily engrossed in a multiple gunshot wound case. At the moment he was busy photographing the entrance and exit wounds. When he saw Jack he handed the camera to Sal, who was helping him, and pulled Jack aside.
“How was your time last night?” Chet asked.
“This is hardly the best time to discuss it,” Jack said. Conversation in the moon suits was difficult at best.
“Oh, come on,” Chet said. “I had a blast with Colleen. After the China Club we went back to her pad on East Sixty-sixth.”
“I’m happy for you,” Jack said.
“What did you guys end up doing?” Chet asked.
“You wouldn’t believe me if I told you,” Jack said.
“Try me,” Chet challenged. He leaned closer to Jack.
“We went over to her office, and then we came over here to ours,” Jack said.
“You’re right,” Chet said. “I don’t believe you.”
“The truth is often difficult to accept,” Jack said.
Jack used Vinnie’s arrival with Lagenthorpe’s corpse as an excuse to return to his table. Jack pitched in to help set up the case because it was preferable to further grilling by Chet. Besides, it made it possible to start the case that much sooner.
On the external exam the most obvious abnormality was the freshly sutured, two-inch-long appendectomy incision. But Jack quickly discovered more pathology. When he examined the corpse’s hands he found subtle evidence of early gangrene on the tips of the fingers. He found some even fainter evidence of the same process on the man’s earlobes.
“Reminds me of Nodelman,” Vinnie said. “It’s just less, and he doesn’t have any on his pecker. Do you think it’s plague again?”
“I don’t know,” Jack said. “Nodelman didn’t have an appendectomy.”
Jack spent twenty minutes diligently searching the rest of the body for any signs of insect or animal bites. Since Lagenthorpe was a moderately dark-skinned African-American, this was more difficult than it had been with the considerably lighter-skinned Lopez.
Although Jack’s diligence didn’t reward him with any bite marks, it did make it possible for him to appreciate another subtle abnormality. On Lagenthorpe’s palms and soles there was a faint rash. Jack pointed it out to Vinnie, but Vinnie said he couldn’t see it.
“Tell me what I’m looking for,” Vinnie said.
“Flat, pinkish blotches,” Jack said. “Here’s more on the underside of the wrist.”
Jack held up Lagenthorpe’s right arm.
“I’m sorry,” Vinnie said. “I don’t see it.”
“No matter,” Jack said. He took several photographs even though he doubted the rash would show up. The flash often washed out such subtle findings.
As Jack continued the external exam he found himself progressively mystified. The patient had come in with a presumed diagnosis of pneumonic plague, and externally he resembled a plague victim, as Vinnie had pointed out. Yet there were discrepancies. The record indicated he’d had a negative test for plague, which made Jack suspect tularemia.
But tularemia seemed implausible because the patient’s sputum test had shown no free bacteria. To complicate things further, the patient had had severe enough abdominal symptoms to suggest appendicitis, which he proved not to have. And on top of that he had a rash on his palms and soles.
At that point Jack had no idea what he was dealing with. As far as he was concerned, he doubted the case was either plague or tularemia!
Starting the internal exam, he immediately came across strong presumptive evidence that substantiated his belief. The lymphatics were minimally involved.
Slicing open the lung, Jack also detected a difference even on gross from what he’d expect to see in either plague or tularemia. To Jack’s eye Lagenthorpe’s lung resembled heart failure more than it did infection. There was plenty of fluid but little consolidation.
Turning to the other internal organs, Jack found almost all of them involved in the pathological process. The heart seemed acutely enlarged, as were the liver, the spleen, and the kidneys. Even the intestines were engorged, as if they had stopped functioning.
“Got something interesting?” a husky voice demanded.
Jack had been so absorbed, he hadn’t noticed that Calvin had nudged Vinnie aside.
“I believe I do,” Jack managed.
“Another infectious case?” another gruff voice asked.
Jack’s head swung around to his left. He’d recognized the voice immediately, but he had to confirm his suspicion. He was right. It was the chief!
“It came in as a presumed plague,” Jack said. He was surprised to see Bingham; the chief rarely came into the pit unless it was a highly unusual case or one that had immediate political ramifications.
“Your tone suggests you don’t think it is,” Bingham said.
He leaned over the open body and glanced in at the swollen, glistening organs.
“You are very perceptive, sir,” Jack said. He made a specific effort to keep his patented sarcasm from his voice. This was one time he meant the compliment.
“What do you think you have?” Bingham asked. He poked the swollen spleen gingerly with his gloved hand. “This spleen looks huge.”
“I haven’t the faintest idea,” Jack said.
“Dr. Washington informed me this morning that you’d made an impressive diagnosis on a case of tularemia yesterday,” Bingham said.
“A lucky guess,” Jack said.
“Not according to Dr. Washington,” Bingham said. “I’d like to compliment you. Following on the heels of your astute and rapid diagnosis of the case of plague, I’m impressed. I’m also impressed you left it up to me to inform the proper authorities. Keep up the good work. You make me happy I didn’t fire you yesterday.”
“Now that’s a backhanded compliment,” Jack said. He chuckled, and so did Bingham.
“Where’s the Martin case?” Bingham asked Calvin.
Calvin pointed. “Table three, sir,” he said. “Dr. McGovern’s doing it. I’ll be over in a second.”
Jack watched Bingham long enough to see Chet’s double take when he recognized the chief. Jack turned back to Calvin. “My feelings are hurt,” he said jokingly. “For a moment I thought the chief came all the way down here and suited up just to pay me a compliment.”
“Dream on,” Calvin said. “You were an afterthought. He really came down about that gunshot wound Dr. McGovern is doing.”
“Is it a problem case?” Jack asked.
“Potentially,” Calvin said. “The police claim the victim was resisting arrest.”
“That’s not so uncommon,” Jack said.
“The problem is whether the bullets went in the front or the back,” Calvin said. “Also there were five of them. That’s a bit heavy-handed.”
Jack nodded. He understood all too well and was glad he wasn’t doing the case.
“The chief didn’t come down here to compliment you, but he did it just the same,” Calvin said. “He was impressed about the tularemia, and I have to admit I was too. That was a rapid and clever diagnosis. It’s worth ten bucks. But I’ll tell you something: I didn’t appreciate that little ruse you pulled in the chief’s office yesterday about our bet. You might have confused the chief for a moment, but you didn’t fool me.”
“I assumed as much,” Jack said. “That’s why I changed the subject so quickly.”
“I just wanted you to know,” Calvin said. Leaning over Lagenthorpe’s open corpse, he pushed on the spleen just as Bingham had done. “The chief was right,” he said. “This thing is swollen.”
“So’s the heart and just about everything else,” Jack said.
“What’s your guess?” Calvin asked.
“This time I don’t even have a guess,” Jack admitted. “It’s another infectious disease, but I’m only willing to bet it’s not plague or tularemia. I’m really starting to question
what they are doing over there at the General.”
“Don’t get carried away,” Calvin said. “New York is a big city and the General is a big hospital. The way people move around today and with all the flights coming into Kennedy day in and day out, we can see any disease here, any time of the year.”
“You’ve got a point,” Jack conceded.
“Well, when you have an idea what it is, let me know,” Calvin said. “I want to win that twenty dollars back.”
After Calvin left, Vinnie moved back into place. Jack took samples from all the organs and Vinnie saw to it that they were placed in preservative and properly labeled. After all the samples had been taken, they both sutured Lagenthorpe’s incision.
Leaving Vinnie to take care of the body, Jack wandered over to Laurie’s table. He had her show him the cut surfaces of the lungs, liver, and spleen. The pathology mirrored that of Lopez and Hard. There were hundreds of incipient abscesses with granuloma formation.
“Looks like another case of tularemia,” Laurie said.
“I can’t argue with you,” Jack said. “But this issue of person-to-person spread being so rare bugs me. I don’t know how to explain it.”
“Unless they all were exposed to the same source,” Laurie said.
“Oh sure!” Jack exclaimed scornfully. “They all happened to go to the same spot in Connecticut and feed the same sick rabbit.”
“I’m just suggesting the possibility,” Laurie complained.
“I’m sorry,” Jack said. “You’re right. I shouldn’t jump on you. It’s just that these infectious disease cases are driving me bananas. I feel like I’m missing something important, and yet I have no idea what it could be.”
“What about Lagenthorpe?” Laurie asked. “Do you think he had tularemia as well?”
“No,” Jack said. “He seems to have had something completely different, and I have no idea what.”
“Maybe you are getting too emotionally involved,” Laurie suggested.
“Could be,” Jack said. He was feeling a bit guilty about wishing the worst for AmeriCare regarding the first case. “I’ll try to calm down. Maybe I should go do more reading on infectious diseases.”
“That’s the spirit,” Laurie said. “Instead of stressing yourself out, you should treat these cases as an opportunity to learn. After all, that’s part of the fun of this job.”