Live Free or Die-ARC

by John Ringo

  She had graduated, valedictorian, lettered in track, amazingly unpregnant, from Rocori Senior High School in Stearns County, MN, where the teenage pregnancy rate was 17% and the drop-out rate was 30%.

  Valedictorian of Rocori SHS and a 1538 SAT had not been enough to get Dixie into a top-flight college. It had been enough to get her a full scholarship to University of Minnesota where she graduated, cum laude, with a degree in microbiology. Then had come medical school where she still managed to run six miles every day.

  As an intern, however, personal fitness took a back-seat to simple survival. There was a move afoot to disband the half basic-training-hell half slave-labor that comprised the two year internship required to become a resident which was, in turn, required to get an MD. There simply were not enough people willing to go through the process. Especially since with the rise of HMOs and now increasing levels of governmental payment scales, intrusion and 'support', it didn't pay for beans even when you did get your MD. Dixie was looking at $130,000 in student loans and a net take-home of $50,000.

  Which was why, just as soon as she got out of internship hell, she was planning on getting a specialty degree.

  Friday was her light day. She arrived at the sprawling Mayo facility at 6AM, changed into scrubs and started rounds. At 9AM she went to the free clinic where she would work until 9PM. Then back to the main hospital until midnight, if she was lucky enough to get out on time, then to her—shared—apartment. Saturday she had duty for 24 hours.

  And to make matters even better, since she had completed her first year of internship she now had four brand new interns, who couldn't figure out how to put on a Band-Aid straight, to train.

  At the moment, though, she was doing rounds. The process was so simple she could do it, had done it, in her sleep. People who couldn't afford private general practitioners or who thought they were dying and couldn't get into their private practitioners, came into the Free Clinic. It wasn't exactly free, but it was close. It was, at the least, cheap.

  Most of them weren't, in fact, terribly sick. Given that the medical profession was trying very hard to keep anti-virals from becoming as useless as antibiotics, there wasn't much to be done with influenza. Besides, by the time people came to the clinic they were already fully symptomatic and throwing anti-virals at flu at that point was pointless.

  Cuts, scrapes, flu, colds, hypochondriacs, people with minor urinary tract infections they were positive were the first signs of syphilis. That was the general run of what came through the clinic. That and people where Dixie's job was just to hold off the reaper for another day or month or year, old people who were headed down that long, greasy, ramp. Half the time they just wanted somebody to tell them they weren't dying today. They generally tried to avoid Dixie if they knew the drill.

  If her initial diagnosis indicated something life-threatening she referred the person to a specialist and they were off her plate. The rest was slap a band-aid on, prescribe some pretty useless anti-biotics and move on.

  Walk to the room, take down the chart, check the information provided by nurses who, generally, had been doing this longer than Dixie, from many of whom she'd learned most of her skills, walk in, say hi, double check the basic diagnostic information, write a treatment regimen, walk to the next examination room. Repeat again and again and again until you collapse. Start all over again the next day.

  She took down the chart and glanced at it. Female, 47, Caucasian, overweight. Slight fever, otherwise normal vitals. Patient had a small lesion on the inner left wrist. No sign of injury. Area inflamed indicating infection. No report of pain.

  Dixie walked in and nodded at the woman.

  "Hello," Dixie said, speaking quickly and smiling brightly. Don't let them get a word in until you have to or women like this would talk all day. "I'm Doctor Pfau. You didn't sustain any injury?"

  "No," the woman said, holding out her hand with the wrist up. "It started like a little pimple thing. I popped it but it won't heal. I think it's a spider bite . . ."

  "Possible but not life threatening even then," Dixie said, looking at the spot. She had a sudden moment of déjà vu and paused. Her day was filled with cuts, scrapes, lesions and every damned thing else people could do to themselves. But she had seen something very similar recently. She'd have to check the database. "Even if it is a spider bite, the problem is usually the infection rather than the toxin. I'll prescribe an antibiotic and you'll need to keep it treated until it clears up. Okay?"

  "Okay," the woman said. There was always that flash of relief. They weren't going to die today. "Thank you."

  "You're welcome," Dixie said, scribbling on the chart. Since she was an intern, she did the process herself. Express and a quick swab of betadyne cleared out the slight pus in the area and it could be covered by a medium adhesive bandage. Remarkably, there didn't seem to be any pain. An infection like that was normally at least slightly sensitive. That triggered the memory. She'd treated an identical lesion two days ago. Same spot, same size, same lack of pain response. Which was one of those coincidences you run across with a million sick monkeys.

  "There you go. I've filled out a prescription for antibiotics and the nurse will give you a tube of antibiotic cream and some bandages. If it doesn't clear up in five days, come back in and we'll take a closer look at it. If it increases notably in size or becomes extremely painful come in immediately." There was a slight possibility that it was the bite of a brown recluse which could be a problem. Ditto necrotizing fasciitis. There were, in fact, three hundred and eighty-six different diseases, many of them life threatening, that it could be. A well versed hypochondriac could probably list every one. None of them, however, were likely. And most would respond to the treatment.

  "Thank you, Doctor," the woman said.

  "Again, you're welcome," Dixie said, scribbling the treatment on the chart. "And we're done. Don't get this wrong but I hope I don't see you again soon and I'm sure you feel the same." She smiled to show it was a joke and walked out of the room.

  Two hours later she pulled down a chart, wishing she could take a break and get a run in, and paused.

  Male. 23. African-American. 5' 7". 135 lbs. Slight fever, otherwise normal vitals. Small lesion on the inner left wrist. No sign of injury. Area inflamed indicating infection. No report of pain.

  Okay, three no-pain response lesions in three days was odd. Three in exactly the same spot? The term 'epidemic' sprung to mind and she dismissed it. The problem was . . . She realized she didn't know what she was dealing with anymore. There were hundreds of infections and parasites that could cause the basic symptoms. However, with the exception of the brown recluse, most of them were tropical. Or in the case of syphilis, sexual. And although a few of them were location specific, syphilis again for example, none of those were the underside of the left wrist. She checked again. Yeah, it was the left.

  She walked into the room slowly.

  "Hello," Dixie said, just as carefully. "I'm Doctor Pfau. You didn't sustain any injury that might account for this infection?"

  Dixie walked out into the waiting room and looked around. As usual it was packed.

  "Hello!" she said loudly to cut through the chatter, arguments and screaming children. "My name is Doctor Pfau and I would like your attention! Thank you. How many people are here because they have a small sore on the inside of their left wrist and could you raise your hand so I can see it?"

  Seven people, some of them clearly surprised, raised their left hands.

  "Thank you. We'll be seeing all of you very sh . . ."

  "Doctor," one of the nurses said, walking up and speaking quietly. "We need you in Six."

  Dixie nodded at the crowd and walked back into the hallway quickly.

  "Fever of one-oh-five," the nurse said. "Labored breathing. Slight incoherency. Complaining of bodily aches."

  Dixie pulled down the chart and looked at it as she walked into the room. Low blood pressure for a guy his age and physical condition. He looked like he was
'residence disadvantaged' and they were normally high BP. Heart rate was right off the chart.

  "I need an IV run," Dixie said the moment she looked at the patient. What the nurse had left out was yellowed eyes and skin. The guy was probably in the terminal stages of hepatitis. "Get a cart in here. We're admitting him. Sir, do you have any history of hepatitis?" She gloved and pulled out a syringe to get a blood sample.

  "No," the homeless man said. "I been strong as a horse my whole life, Doctor. This is the first time I ever been sick. You saying I need to go to the hospital?"

  "You're in the hospital," Dixie said. "What I'm saying is you need to stay so we can get you fixed up. You're clearly extremely sick." She wrapped his arm and pulled the cap off the syringe.

  "You gonna take my blood?" the man said, thickly.

  "I need to get a blood sample so we can figure out exactly what is wrong with you," Dixie said.

  "I don . . ." the man said and his arm came up. It seemed less like a block of the syringe than an involuntary twitch but it had the effect of sending the syringe across the room. "I . . . AAAAAAHHH!" As it barely missed her face she automatically noted . . . a small lesion on the inside of the left wrist.

  "Sir," Dixie said, grabbing his arm and trying to restrain it. "You need to calm down, sir . . ."

  "IT HURTS!" the man screamed. He started scrabbling at his jacket, scratching as if he was trying to scratch inside his body. "OH GOD!"

  Dixie yanked the door open. "I need some help in here! Where's that IV?"

  Nurses came flooding in the room as the man started to convulse, still screaming. He seemed to scream so hard it should have ripped his throat right out. Before they could even get the IV inserted or a shot of Dilaudim in him, the thrashing stopped and the man dropped limp.

  "Code Blue!" Dixie shouted, feeling for a pulse at the carotid. "I need a crash cart!"

  "ER pronounced him DOA." Dr. Benjamin Koch was the free clinic attending hospitalist. He had the job of not only ministering to patients but also keeping an eye on the various interns and residents that did most of the grunt work. "What happened?"

  "I've been thinking about that," Dixie said. She knew her nickname was 'The Grinder.' New interns, visitors who were informed of it, new employees, all thought it referred to some super-sexual ability. They quickly found out it meant that she ground through anything or anyone in her way like an industrial machine. Her other nickname was 'The Robot.' She didn't feel particularly machine-like at the moment. "None of the symptoms make sense. Convulsions, tetany. But you don't get yellowing of the eyes and skin. That indicates liver."

  "Could have been a combination," Dr. Koch said, shrugging. "From what I've gleaned he was . . . residence disadvantaged?"

  "He was a bum, yeah," Dixie said. "But he said he'd never been sick in his life. And for all he was sick, you can tell the sickly ones. He looked otherwise fairly healthy for a bum. But we've got another problem that's more important."

  "Which is?" Dr. Koch asked.

  "We've got a large number of patients with identical symptoms," Dixie said. "At least seven. A lesion on the inside of the left wrist. No pain response. For that matter . . . our DOA had one."

  "All on the left wrist?" the attending said. "That's . . . odd."

  "Identical," Dixie said, holding out her wrist to show him. She paused. "Oh . . . hell."

  There was what looked like a pimple on her left wrist.

  "I think . . . we'd better call CDC," Dixie said.

  "I'll page the epidemiologist."

  "I need you to hold your arm very very still for me, okay?"

  Dr. Doug "Jojo" Johannsen was the chief epidemiologist of the Mayo Clinic. He'd spent years working around the world for the WHO and CDC tracking down emerging diseases and potential pestilences. And he'd seen his fair share of odd maladies. But this was one of the few he'd ever seen that were location specific. Even then, most such things were location specific for a particular reason. They were affecting lymph nodes for example. They weren't specific to a more or less random spot on the body. And he assuredly hadn't expected for them to turn up in the US.

  For that matter, as soon as he'd seen the number of cases being reported in not only the clinic but ER and even among workers at the hospital, he'd called CDC to report a potential outbreak. Only to find the main line, which had fourteen people manning it normally, busy. So he'd called three colleagues he knew, personally. All of their office phones were busy. So then he'd called their cell phones. Busy.

  So he'd spent three more minutes making overseas phone calls to colleagues associated with the WHO. All of whom their phones were busy.

  At that point, he'd sent out a standard email, put down the phone and gotten to work.

  "No problem," Dixie said. The pimple had already popped. "There's no pain."

  "Which is why I'm thinking parasite," Dr. Johannsen said, bringing the camera for the microscope down. "There's definitely a suite of bacteria there, but I don't think that's the central problem."

  "What I'd like to figure out is how I got a parasite," Dixie said. "I guess it could have been from that first patient."

  "Hmmm . . ." Dr. Johannsen said. "Fascinating."

  "Going to leave me in limbo?" Dixie asked.

  Dr. Johannsen swung the monitor around so she could look. At the very bottom of the small sore was what appeared to be something like a centipede.

  "And that is . . . ?" Dixie asked. She had seen and done some very gross things as an intern but this was something gross happening to her body.

  "That is a nematode," Dr. Johannsen said, swinging the monitor back around. "Which appears to be feasting on the bacteria colony in the lesion. I don't recognize the particular species but there are experts who might. Presumably it carries some of the bacteria with it. It does gross damage to the affected tissue, the bacteria then have a residence and it then feasts upon the bacteria. I've seen this before but rarely in the US. Similar infestations in tropical regions. Primarily in New Guinea. Now hold very very still."

  He took a pair of fine tweezers and pulled the worm out of the wound.

  "There," he said in a satisfied tone, placing the nematode in a jar and sealing it. "I'll send that to some friends and they can identify the species."

  "So it is a zebra," Dixie said. Quite often, new interns would look at a set of symptoms and identify them as some rare disease found only in remote areas when they were looking at a simple combination of fairly normal problems. Identification of a rare disease instead of common was referred to as 'spotting a zebra.' It was generally a mistake. "What's it doing in the US? What's it doing in me? I was meticulous in my hygiene procedures with Patient Zero."

  "That is the question," Dr. Johannsen said. "Which is up to the CDC and WHO to determine. But the treatment is simple. Disinfect the area and maintain integrity. There may be a reoccurrence. The nematode may leave cysts which will make it necessary to continue treatment for up to two weeks. Any strong disinfectant should kill it, though, and usually kills the cysts. And any antibiotic will kill the bacteria. Keep enough Neosporin on the wound, for that matter, and the nematode should die of malnutrition."

  "So disinfect and bandage was the right choice," Dixie said, relieved.

  "But it will have to be maintained," Jojo said. "That will be the problem I suspect. It certainly is in places where this is more common. And it's not normally . . ." He paused as his pager went off. "I'm sorry, I'm getting a page from the morgue. I take it you can clean it yourself."

  "I can," Dixie said. "But can I come al . . ." Her pager went off and she looked at it. "I'm getting paged there, too."

  "How's the wrist?" Dr. Koch asked, stopping them both outside the morgue.

  "I cleaned it on the way down," Dixie said, showing him the bandage. "What's up?"

  "It's your DOA," Dr. Koch said, his face grim. "The morgue called a contamination. You eaten lately?"

  "No," Dixie said.

  "Good. You won't puke in your respirator. We need to
rig up."

  * * *

  Dixie wasn't even sure she was looking at the same patient. Same height, same hair color from what she could remember. A sort of dirty, dishwater, gray-brown.

  His clothing had been removed at some point and she had had her usual tour of the morgue so seeing a body on the slab wasn't the problem. The problem was the condition of the body.