Error in Diagnosis

by Mason Lucas M. D.

  For the moment, Mike guarded his silence, looking at Jack through a barely perceptible veil of tears. “Tess isn’t going to die. It’s not her time. There are thousands of people out there with sick kids she hasn’t met yet who are going to desperately need her.” Without waiting for Jack to answer, Mike turned around and walked into Tess’s room.

  Jack’s instincts were telling him a cure was possible. But he suspected they didn’t have a lot of time, and in the absence of swift treatment options, GNS would turn out to be a fatal disease. Jack felt his resolve strengthening. He thought to himself that irrespective of how discouraging things appeared at the moment, he was light-years away from taking a knee on saving Tess Ryan’s life.

  15

  DECEMBER TENTH

  NUMBER OF CASES: 1,606

  NUMBER OF DEATHS: 1

  After a night plagued by restless sleep, Jack threw back the covers and got out of bed. Last evening, when he returned from dinner, there was a voice message from Madison informing him she would pick him up at seven fifteen to drive him to the airport. For obvious reasons, he assumed her offer was not the result of his charming personality but came at the behest of Helen Morales.

  Jack telephoned the ICU and spoke with the nurse taking care of Tess. She reported she’d had a stable night but was still unresponsive. Her rash was still present, but her muscle spasms had improved with heavy sedation. She also mentioned that as Dr. Fuller had predicted, almost all of the other women with GNS were showing the same new symptoms that Tess had exhibited. Word of the first GNS death had reached him the night before. The news only served to heighten the urgency of a situation that was already a ticking time bomb.

  While he finished getting dressed Jack flipped on the TV and did a quick lap. Every morning news program was featuring coverage of the outbreak with special attention to the first death. Feeling more and more discouraged with each story, he turned off the television and went downstairs. Having some time to spare, he walked through the lobby’s expansive atrium and exited the back of the hotel onto a terrace that overlooked a private marina. He strolled past an endless line of yachts, one more spectacular than the next. Some were already adorned with lights and other elaborate Christmas decorations for the yearly holiday boat parade on the Intracoastal Waterway due to take place in a couple of days. A sudden frenetic squawking pierced the air. Although he hadn’t lived in Florida for many years, he had no difficulty identifying the sound. Looking up, he watched a flock of wild parrots diving and climbing in synchronicity as if they were tethered together with a clear fishing line.

  After a few minutes, Jack headed back to the terrace and found a seat at a wrought iron table. Gazing without purpose across the waterway, his thoughts turned to Tess. His pulse quickened while in his mind’s eye he found himself intensely studying her disease, personifying it as if it were his sworn enemy, a phenomenon common amongst physicians. When an elderly couple engaged in a heated conversation strolled past, Jack was suddenly snapped back to the here and now. He glanced down at his watch. He stood up and headed back toward the front of the hotel to meet Madison.

  Standing under the arched stone entranceway, Jack watched the piercing rays of the sun streaming through the palm trees. He wasn’t paying particular attention when a black Mini Cooper convertible pulled up. It was only when he heard two quick taps of the horn that he bent over and looked in the passenger-side window.

  “Good morning,” he said.

  “It’s open,” Madison told him.

  The parking attendant, his lips pressed tightly together to stave off a smile, opened the door.

  “You don’t happen to have a shoehorn on you?” Jack whispered to him.

  After a series of maneuvers that would have made even the most seasoned Cirque du Soleil contortionist stand up and applaud, Jack managed to work his way into the passenger seat.

  “Great car,” he said. Madison didn’t smile or say anything. Undaunted, Jack went on, “I called the ICU when I got up. The nurse taking care of Tess told me she had a relatively stable night.”

  “I know. I called too.”

  “I assume you heard about the woman in Spokane who died.”

  “I did. Since then, two more have been reported. One from New Jersey and the other from New Mexico. Both the babies were delivered by emergency C-section and are alive.”

  Jack’s stomach rolled. “No, I hadn’t heard. I guess we can assume the topic will come up at today’s meeting.”

  During the ride to the airport, the conversation remained civil but strained. Waiting for their flight in the gate area, Madison continued to answer Jack’s questions with chopped answers and rare eye contact. The flight was more of the same. By the time they landed in Atlanta, whatever hope he had had that Madison was just having a bad day when they had first met had long evaporated.

  16

  Centers for Disease Control and Prevention

  Atlanta, Georgia

  Jack had a pretty good idea that the spacious conference room he and Madison had just been ushered into had been the site of dozens of landmark medical conferences. On the walls, hanging in a semi-ordered fashion, were black-and-white photographs of some of the greatest names in the history of American medicine. Even for someone of Jack’s accomplishments and national reputation, the experience was a humbling one.

  Seated around a leather-topped conference table, eighteen of the brightest and most talented physicians in the country chatted while they awaited the arrival of the surgeon general. Jack and Madison found their name cards and took their seats.

  Ten minutes later, with her usual entourage, Dr. Renatta Brickell entered the room. Before calling the meeting to order, she made her way around the table individually greeting and thanking each physician for attending. When she finished, she took her seat at the head of the table. She began by asking the attendees to briefly introduce themselves and give a synopsis of their backgrounds and special area of expertise. When the last of the group had complied, she interlocked her fingers and placed her hands on the table.

  “I want to begin by wishing you all a happy holiday season. I met with President Kellar earlier today. He wants me to assure each and every one of you that there’s nothing more important on his national agenda right now than the GNS outbreak. He extends his heartfelt thanks to all of you who have agreed to serve on this task force.” Renatta paused long enough to glance down at her notes. “By now, each of you should have received an e-mail summarizing our most current information on the disease. Based on those facts, we will be concentrating our efforts in three main areas: the first is the possibility that GNS is a contagious disease—most likely a virus. The second possibility is an environmental toxic exposure of some type. Right now the two leading candidates would be a toxin from e-waste or nanotechnology.” She paused for a few moments and then added, “I would like to leave a discussion of the third possibility until the end of the meeting.” She looked up from her notes and glanced around the room. “So, if there are no pressing questions, I’d like to begin by asking Dr. Maddox to give us a brief update on the CDC’s efforts to this point.”

  Over the years, Jack had worked with Ezra Maddox, a virologist, on several occasions, mostly relating to outbreaks of meningitis. Jack found him to be plodding in his approach to problems, but not one to be sidetracked by minutiae. Bringing his own special brand of meticulous management to every project, he had long been recognized as a national authority on all types of epidemics, but especially viral ones.

  “Thank you, Dr. Brickell,” Maddox said, straightening his paisley bow tie. “As part of an initial evaluation, we have cultured and evaluated hundreds of fluid and tissue samples. We realize that we are only a few days into this investigation, but as of this morning, all of those tests have failed to reveal a specific virus, bacteria or fungal agent as the cause of GNS.” He removed his bifocals and tucked them into the breast pocket of his sport coat. �
�It also bears mentioning that the symptoms we are seeing with GNS are only suggestive of a viral illness, certainly not diagnostic.”

  For the next fifteen minutes Maddox elaborated on the CDC’s findings. He concluded his remarks by repeating that they didn’t have a single iota of evidence that GNS was a contagious disease. Maddox then opened the floor to questions, none of which were eye-opening.

  The problem was the same—a lack of any definitive medical information about GNS, a reality Jack suspected would surface over and over again as the meeting progressed. Maddox’s disheartened manner and dampened voice betrayed the same frustration Jack suspected everybody in the room, including himself, was feeling. After answering the last question, Maddox turned the meeting back to the surgeon general.

  “As I’m sure we’re all aware, the outbreak of GNS in so many women over a wide geographic area raises the question of a possible toxic exposure. As I mentioned, there are two specific areas that should be discussed. I’d like to begin by asking Dr. Grandeson to give us an update on her work.”

  Plain-faced with a sparse patch of freckles over the bridge of her nose, Mary Grandeson had devoted her entire professional life to the study of environmental toxins. In spite of a career filled with major scientific accomplishments and professional accolades, she religiously avoided the academic limelight. “Since the first cases of GNS were identified, we’ve been looking at all environmental toxins as a possible cause, but with a particular focus on microscopic toxins produced by nanotechnology.”

  Jack’s knowledge of nanotechnology was elementary at best. Essentially, the science was about twenty years old and dealt with consumer products, mostly cosmetic and electronic, that contained microscopic materials. Over the past several years, a rising concern had been raised by the scientific community that these microscopic components could possibly be toxic.

  Dr. Grandeson’s presentation was concise but comprehensive, giving an extensive review of nanotoxins with special emphasis on those that theoretically could be linked to GNS. She concluded by saying that it was possible a nanotoxin could be responsible for GNS, but beyond that she had no evidence that pointed to a specific one.

  “Which brings us to the second environmental toxin of concern,” Brickell said. “Is there any possibility that we might be dealing with an e-waste toxin?”

  Grandeson answered, “Disposal of massive amounts of electronic equipment such as computers has become a major problem not only in this country but worldwide. This is especially true when these items are disposed of illegally. There are millions of them being dumped without regard for public safety on a daily basis. Their breakdown by-products can be extremely toxic to people, animals and the environment.”

  “Any ideas regarding a specific source?” the physician sitting directly across from Jack asked Grandeson.

  “Unfortunately, e-waste research is still in an embryonic stage. Much of what we think we know is guesswork at best. If GNS is being caused by an e-waste toxin, it would take us months, maybe years to discover its exact origin and how to eliminate it.”

  “Can you at least speculate as to a possible mechanism of exposure?” the same physician inquired.

  “Direct contact with the skin or oral ingestion is possible. But my best guess would be by inhalation. For that reason, we’re carefully looking at the weather conditions across the country during the past few weeks.”

  The notion that GNS could be caused by a virus or a potent toxin launched a long discussion. There was a host of theories advanced and concerns raised but no consensus was reached. Working through lunch, the presidential task force was able to formulate a plan moving forward to coordinate their investigative efforts.

  “It’s almost three o’clock and I think we’ve just about exhausted our time for today,” Brickell announced to the group. “But prior to adjourning, I have two additional matters to share with you. The third possibility to explain GNS that I referred to at the beginning of the meeting is something I’m sure everyone in this room has thought about. The president called me early this morning and asked me to join him this evening at the Army War College to discuss the possibility that GNS is an act of bioterrorism. It is my understanding we’ll be meeting with key personnel of the strategic studies unit on bioterrorism.”

  “Can you give us a better idea of just how serious the president believes this threat to be?” Madison inquired.

  “I think he believes it to be unlikely, but he’s firm that even if it’s a faint possibility, it has to be completely ruled out. The other problem we’re facing is that now that we’re seeing our first deaths . . . well, we’re really under the gun to figure out how to stop the spread of this thing.”

  From his basic knowledge of bioterrorism, Jack couldn’t fathom how any individual or radical group could design a biological weapon that would specifically target pregnant women. But he was a scientist, and if he had learned one thing over the years, it was that anything was possible. The thought made his blood run cold. If GNS were the premeditated act of a terrorist group, the wholesale loss of human life could become staggering.

  Brickell moved forward in her chair and tapped her fingertips together. “President Kellar has also asked me to share with you his concern regarding the sensitive ethical and moral challenges we will all be facing. Perhaps the most important is the prospect of early termination of these pregnancies. Therefore, in the next few days, you will be advised of a series of meetings and webinars we’re arranging with nationally renowned ethicists and religious leaders. We will also be talking with right-to- life and pro-choice organizations.” She forced a guarded smile to her face. “I again want to thank everybody for attending today. My office will advise you of the time and location of our next meeting. I understand that our progress has been somewhat discouraging to this point but it’s imperative we remain positive and redouble our efforts to find the cause of GNS.”

  After a few moments, everybody slowly stood up. A few small groups formed to discuss the distressing news. Jack waited for Madison to gather her things. Together, they started for the door.

  His mind fixed on Tess and Mike, Jack said, “We can’t assume these deaths are isolated events. My guess is there’ll be many more before we figure this thing out.”

  Although Brickell had already been descended upon by several other physicians, Jack was able to catch her eye and motion a quick good-bye. With a pained smile, she acknowledged Jack with a wave and returned to her conversation. The instant he stepped out into the hall, he reached for his cell phone and called the ICU at Southeastern State to check on Tess.

  17

  The boarding process of the flight back to Florida went smoothly and the departure was on time. It wasn’t until they had been in the air for an hour and Madison had finished a glass of white wine that Jack decided the time was right to take another swipe at the piñata.

  “How long have you been at Southeastern State?”

  “Eight years. The last four as division chief.”

  “Do you like it?”

  “It’s a great job.”

  “That’s pretty high praise. I’m not sure all of my colleagues at Ohio State would say the same about their positions.”

  With a dry half smile, she said, “Southeastern State may be different than what you’re used to. Everybody I work with is a caring professional who you can really trust.”

  Although he wasn’t going to ask her to elaborate, he still couldn’t figure out whether she was just congenitally unfriendly or if it was him who naturally made her skin crawl. Whatever her reason, it was clear the time to stop tap-dancing around her nasty attitude toward him had arrived.

  Clearing his throat, he said, “I’ve never viewed myself as particularly paranoid, and this may sound a little strange to you, but ever since we met, I’ve gotten the feeling you—”

  She turned and looked at him, her eyes boring into his. “We didn
’t meet yesterday, Jack. We met a long time ago.”

  “Uh . . . really?” he asked, flogging his memory for some clue. He lowered his glass of sparkling water from his lips. Hoping she’d toss a hint in his direction, he went into a four-corner stall. “It’s funny, but now that you mention it, I do have a recollection of us meeting—”

  “Save the crap for somebody else, Jack. You don’t have any idea who I am.”

  She then laughed at him as if he were trying to pick her up by claiming he was a two-time winner of the Congressional Medal of Honor.

  He grinned and then sighed in contrition. “Okay. You’re right. I don’t remember. Where did we meet?”

  “At the University of Florida. I was a third year medical student rotating on neurology. You were the chief resident.”

  Jack studied Madison’s face again. All at once, he did have a fuzzy recollection of her.

  “I may be confusing you with somebody else,” he began cautiously, “but weren’t you using a different . . .”

  “I was using my married name, Madison Casas.”

  He raised his finger and pointed hesitantly at her hair. “You looked different . . . I mean you wore your . . .”

  “Let me save you the embarrassment. I was blond, twenty-five pounds heavier and couldn’t afford contact lenses and posh hair care.”

  Jack was now certain he remembered her. But he recalled nothing of a problem between them, leaving him totally perplexed as to why she harbored such resentment for him. As the chief resident, he was much more involved in teaching than most of his fellow residents. Twice during his residency, he had won the Neurology Teaching Award, an accolade presented by the medical students to an outstanding resident teacher.

  Seeing no way of putting it gently, he asked, “Did we have some kind of a problem?”

  “You mean other than you being the reason I failed the rotation?”