by Robin Cook
“Somebody has to explain,” Chet said.
Laurie told Chet what she knew of Jack’s beating.
“And you’re still thinking of going over there?” Chet asked when she was through.
“I’ll be careful,” Jack said. “Besides, I haven’t exactly decided to go yet.”
Chet rolled his eyes to the ceiling. “I think I would have preferred you as a suburbanite ophthalmologist.”
“What do you mean, ophthalmologist?” Laurie questioned.
“Come on, you guys,” Jack said. He stood up. “Enough is enough. We’ve got work to do.”
Jack, Laurie, and Chet did not emerge from the autopsy room until after one in the afternoon. Although George had questioned the need to post all the meningococcal cases, the triumvirate had insisted; George relented in the end. Doing some on their own and some together, they autopsied the initial patient, one orthopedic resident, two nurses, one orderly, two people who’d visited the patient, including the nine-year-old girl, and particularly important as far as Jack was concerned, one woman from central supply.
After the marathon they all changed back to their street clothes and met up in the lunchroom. Relieved to be away from the mayhem and a bit overwhelmed by the findings, they didn’t talk at first. They merely got their selections from the vending machines and sat down at one of the free tables.
“I haven’t done many meningococcal cases in the past,” Laurie said finally. “But these today were a lot more impressive than the ones I did do.”
“You won’t see a more dramatic case of the Waterhouse-Friderichsen syndrome,” Chet said. “None of these people had a chance. The bacteria marched through them like a Mongol horde. The amount of internal hemorrhage was extraordinary. I tell you, it scares the pants off me.”
“It was one time that I actually didn’t mind being in the moon suit,” Jack agreed. “I couldn’t get over the amount of gangrene on the extremities. It was even more than on the recent plague cases.”
“What surprised me was how little meningitis was involved,” Laurie said. “Even the child had very little, and I would have thought at least she would have had extensive involvement.”
“What puzzles me,” Jack said, “is the amount of pneumonitis. Obviously it is an airborne infection, but it usually invades the upper part of the respiratory tree, not the lungs.”
“It can get there easily enough once it gets into the blood,” Chet said. “Obviously all these people had high levels coursing through their vascular systems.”
“Have either of you heard if any more cases have come in today?” Jack asked.
Chet and Laurie exchanged glances. Both shook their heads.
Jack scraped back his chair and went to a wall phone. He called down to communications and posed the same question to one of the operators. The answer was no. Jack walked back to the table and reclaimed his seat.
“Well, well,” he said. “Isn’t this curious. No new cases.”
“I’d say it was good news,” Laurie said.
“I’d second that,” Chet said.
“Does either of you know any of the internists over at the General?” Jack asked.
“I do,” Laurie said. “One of my classmates from medical school is over there.”
“How about giving her a call and seeing if they have many meningococcal cases under treatment?” Jack asked.
Laurie shrugged and went to use the same phone Jack had just used.
“I don’t like that look in your eye,” Chet said.
“I can’t help it,” Jack said. “Just like with the other outbreaks, little disturbing facts are beginning to appear. We’ve just autopsied some of the sickest meningococcal patients any of us has ever seen and then, boom! No more cases, as if a faucet had been turned off. It’s just what I was talking about earlier.”
“Isn’t that characteristic of the disease?” Chet asked. “Peaks and valleys.”
“Not this fast,” Jack said. Then he paused. “Wait a second,” he added. “I just thought of something else. We know who the first person was to die in this outbreak, but who was the last?”
“I don’t know, but we’ve got all the folders,” Chet said.
Laurie returned. “No meningococcal cases presently,” she said. “But the hospital doesn’t consider itself out of the woods. They’ve instituted a massive campaign of vaccination and chemoprophylaxis. Apparently the place is in an uproar.”
Both Jack and Chet merely grunted at this news. They were preoccupied with going through the eight folders and jotting down notations on their napkins.
“What on earth are you guys doing?” Laurie asked.
“We’re trying to figure out who was the last to die,” Jack said.
“What on earth for?” Laurie asked.
“I’m not sure,” Jack said.
“This is it,” Chet said. “It was Imogene Philbertson.”
“Honest?” Jack questioned. “Let me see.” Chet turned around the partially filled-out death certificate that listed the time of death.
“I’ll be damned,” Jack said.
“Now what?” Laurie asked.
“She was the one who worked in central supply,” Jack said.
“Is that significant?” Laurie asked.
Jack pondered for a few minutes, then shook his head. “I don’t know,” he said. “I’ll have to look back at the other outbreaks. As you know, each outbreak has included someone from central supply. I’ll see if it is a pattern I’d missed.”
“You guys weren’t particularly impressed with my news that there are currently no more cases of meningococcal disease over at the General.”
“I am,” Chet said. “Jack sees it as confirmation of his theories.”
“I’m worried it is going to frustrate our hypothetical terrorist,” Jack said. “It’s also going to teach him an unfortunate lesson.”
Both Laurie and Chet rolled their eyes to the ceiling and let out audible groans.
“Come on, you guys,” Jack said. “Hear me out. Let’s just say for the sake of argument that I’m right about some weirdo spreading these microbes in hopes of starting an epidemic. At first he picks the scariest, most exotic diseases he can think of, but he doesn’t know that they won’t really spread patient to patient. They are spread by arthropods having access to an infected reservoir. But after a few flops he figures this out and turns to a disease that is spread airborne. But he picks meningococcus. The problem with meningococcus is that it really isn’t a patient-to-patient disease either: it’s a carrier disease that’s mainly spread by an immune individual walking around and giving it to others. So now our weirdo is really frustrated, but he truly knows what he needs. He needs a disease that is spread mainly patient-to-patient by aerosol.”
“And what would you choose in this hypothetical scenario?” Chet asked superciliously.
“Let’s see,” Jack said. He pondered for a moment. “I’d use drug-resistant diphtheria, or maybe even drug-resistant pertussis.Those old standbys are making some devastating comebacks. Or you know what else would be perfect? Influenza! A pathological strain of influenza.”
“What an imagination!” Chet commented.
Laurie stood up. “I’ve got to get back to work,” she said. “This conversation is too hypothetical for me.”
Chet did the same.
“Hey, isn’t anybody going to comment?” Jack said.
“You know how we feel,” Chet said. “This is just mental masturbation. It seems like the more you think and talk about this stuff the more you believe it. I mean, really, if it were one disease, okay, but now we’re up to four. Where would someone get these microbes? They are not the kind of thing you can go into your neighborhood deli and order. I’ll see you upstairs.”
Jack watched Laurie and Chet dispose of their trash and leave the lunchroom. He sat for a few moments and considered what Chet had said. Chet had a good point, one that Jack had not even considered. Where would someone get pathological bacteria? He rea
lly had no idea.
Jack got up and stretched his legs. After discarding his tray and sandwich wrappings, he followed the others up to the fifth floor. By the time he got to the office, Chet was already engrossed and didn’t look up.
Sitting down at his desk, Jack got all the folders together plus his notes and looked up the time of death of each of the women victims from central supply. To date, central supply had lost four people. Jack imagined that the department head would have to be actively recruiting to keep up with that type of attrition.
Next Jack looked up the time of death of each of the other infectious cases. For the times of death of the few he’d not autopsied, he called down to Bart Arnold, the chief PA.
When Jack had all the information it became immediately apparent that with each outbreak, it had been the woman from central supply to be the last to succumb. That suggested, but certainly didn’t prove, that in each instance those from central supply were the last to become infected. Jack asked himself what that meant, but couldn’t come up with an answer. Still, it was an extremely curious detail.
“I have to go back to the General,” Jack said suddenly. He stood up.
Chet didn’t even bother to look up. “Do what you have to do,” he said with resignation. “Not that my opinion counts.”
Jack pulled on his bomber jacket. “Don’t take it personally,” he said. “I appreciate your concern, but I’ve got to go. I’ve got to look into this strange central supply connection. It could just be a coincidence, I agree, but it seems unlikely.”
“What about Bingham and what about those gang members Laurie mentioned?” Chet asked. “You’re taking a lot of risk.”
“Such is life,” Jack said. He gave Chet a tap on the shoulder on his way to the hallway. Jack had just reached the threshold when his phone rang. He debated whether to take the time to answer it. It was usually someone from one of the labs.
“Want me to get it?” Chet offered when he saw Jack hesitate.
“No, I’m here, and I might as well,” Jack said. He returned to his desk and picked up the receiver.
“Thank God you are there!” Terese said with obvious relief. “I was terrified I wouldn’t get you, at least not in time.”
“What on earth is the matter?” Jack asked. His pulse quickened. He could tell by the sound of her voice that she was acutely upset.
“There’s been a catastrophe,” she said. “I have to see you immediately. Can I come over to your office?”
“What happened?” Jack asked.
“I can’t talk now,” Terese said. “I can’t risk it with everything that has happened. I’ve just got to see you.”
“We’re sort of in the middle of an emergency ourselves,” Jack said. “And I’m just on my way out.”
“It’s very important,” Terese said. “Please!”
Jack immediately relented, especially with Terese’s selfless response to his emergency Friday night.
“All right,” Jack said. “Since I was just leaving, I’ll come to you. Where would you like to meet?”
“Were you going uptown or downtown?” Terese asked.
“Uptown,” Jack said.
“Then let’s meet at the café where we had coffee on Sunday,” Terese said.
“I’ll be right there,” Jack said.
“Wonderful!” Terese asserted. “I’ll be waiting.” Then she hung up.
Jack replaced the receiver and self-consciously looked over at Chet. “Did you hear any of that?” Jack asked.
“It was hard not to,” Chet said. “What do you think happened?”
“I haven’t the faintest idea,” Jack said.
True to his word, Jack left immediately. Exiting from the front of the medical examiner facility, he caught a cab on First Avenue. Despite the normal afternoon traffic, he made it uptown in reasonable time.
The café was crowded. He found Terese sitting toward the rear at a small banquette. He took the seat opposite her. She didn’t make any motion to get up. She was dressed as usual in a smart suit. Her jaw was clenched. She looked angry.
She leaned forward. “You are not going to believe this,” she said in a forced whisper.
“Did the president and the CEO not like your presentation?” Jack asked. It was the only thing he could think of.
Terese made a motion of dismissal with her hand. “I canceled the presentation,” she said.
“Why?” Jack asked.
“Because I’d had the sense to schedule an early breakfast with a woman acquaintance at National Health,” Terese said. “She’s a vice president in marketing who I happened to have gone to Smith College with. I’d had a brainstorm about leaking the campaign to some higher-ups through her. I was so confident. But she shocked me by telling me that under no circumstances would the campaign fly.”
“But why?” Jack asked. As much as he disliked medical advertising, he’d considered the ads Terese had come up with the best he’d seen.
“Because National Health is deathly afraid of any reference to nosocomial infections,” Terese said angrily. Then she leaned forward again and whispered. “Apparently they have had some of their own trouble lately.”
“What kind of trouble?” Jack asked.
“Nothing like the Manhattan General,” Terese said. “But serious nonetheless, even with a few deaths. But the real point is that our own account executive people, specifically Helen Robinson and her boss, Robert Barker, knew all this and didn’t tell me.”
“That’s counterproductive,” Jack said. “I thought you corporate types were all working toward the same end.”
“Counterproductive!” Terese practically shouted, causing the nearby diners to turn their heads. Terese closed her eyes for a moment to collect herself.
“’Counterproductive’ is not the term I’d use,” Terese said, keeping her voice down. “The way I’d describe it would make a sailor blush. You see, this was not an oversight. It was done deliberately to make me look bad.”
“I’m sorry to hear this,” Jack said. “I can see it’s upsetting for you.”
“That’s an understatement,” Terese said. “It’s the death of my presidential aspirations if I don’t come up with an alternative campaign in the next couple of days.”
“A couple of days?” Jack questioned. “From what you’ve shown me about how this process works, that’s a mighty tall order.”
“Exactly,” Terese said. “That’s why I had to see you. I need another hook. You came up with this infection idea, or at least you were the source of it. Can you come up with another concept? Something that I can construct an ad campaign around. I’m desperate!”
Jack looked off and tried to think. The irony of the situation didn’t escape him; as much as he despised medical advertising, here he was racking his brains for some sort of an idea. He wanted to help; after all, Terese had been so willing to help him.
“The reason I think medical advertising is such a waste of money is that it ultimately has to rely on superficial amenities,” he said. “The problem is that without quality being an issue there just isn’t enough difference between AmeriCare and National Health or any of the other big conglomerates.”
“I don’t care,” Terese said. “Just give me something I can use.”
“Well, the only thing that comes to my mind at the moment is the issue about waiting,” Jack said.
“What do you mean, ‘waiting’?” Terese asked.
“You know,” Jack said. “Nobody likes waiting for the doctor, but everybody does. It’s one of those irritating universal annoyances.”
“You’re right!” Terese said excitedly. “I love it. I can already see a tag line like: No waiting with National Health! Or even better: We wait for you, you don’t wait for us! God, that’s great! You’re a genius at this. How about a job?”
Jack chuckled. “Wouldn’t that be a trip,” he said. “But I’m having enough trouble with the one I have.”
“Is there something wrong?” Terese asked. “What di
d you mean when you said you were in the middle of an emergency?”
“There’s more trouble at the Manhattan General,” Jack said. “This time it’s an illness caused by meningococcus bacteria. It can be extremely deadly, as it has been in this instance.”
“How many cases?”
“Eight,” Jack said. “Including a child.”
“How awful,” Terese said. She was appalled. “Do you think it will spread?”
“I was worried at first,” Jack said. “I thought we were going to have a bona fide epidemic on our hands. But the cases just stopped. So far it hasn’t spread beyond the initial cohort.”
“I hope this isn’t going to be kept a secret like whatever killed the people at National Health,” Terese said.
“No worry on that account,” Jack said. “This episode is no secret. I’ve heard the hospital is in an uproar. But I’ll find out firsthand. I’m on my way over there.”
“Oh, no you’re not!” Terese commanded. “Is your memory so short that Friday night is already a blur?”
“You sound like several of my colleagues,” Jack said. “I appreciate your concern, but I can’t stay away. I have a sense that these outbreaks are deliberate, and my conscience won’t let me ignore them.”
“What about those people who beat you up?” she demanded.
“I’ll have to be careful,” Jack said.
Terese made a disparaging sound. “Being careful hardly sounds adequate,” she said. “It’s certainly not consistent with how you described those hoodlums Friday night.”
“I’ll just have to take my chances and improvise,” Jack said. “I’m going over to the General no matter what anybody says.”
“What I can’t understand is why you are so agitated about these infections. I’ve read that infectious diseases are generally on the rise.”
“That’s true,” Jack said. “But that’s not due to deliberate spread. That’s from the injudicious use of antibiotics, urbanization, and the invasion of primeval habitats.”
“Give me a break,” Terese commented. “I’m concerned about you getting yourself hurt or worse, and you’re giving me a lecture.”
Jack shrugged. “I’m going to the General,” he said.