by Robin Cook
After Jack limped off, Marvin asked what Jack had meant about her having an ulterior motive.
“We’re having a disagreement about when he gets his knee repaired,” Laurie said without elaborating. “Now, let’s get back to work.”
“What have you got?” Arnold Besserman asked. Working at the next table, he’d overheard Laurie and Jack’s conversation. Arnold had been at the OCME longer than any of the other medical examiners. Although Jack dismissed him as long in the tooth, outdated, and haphazard, Laurie was friendly with him, as she was with most everyone else.
“Do you mind me interrupting?”
“Certainly not,” Laurie said sincerely. His stepping over to her table was what made working in the communal autopsy room enjoyable and stimulating for her.
“Quite an amazing case,” Laurie said. “Take a peek at this lung. I’ve never seen such dramatic nosocomial necrotizing pneumonia, and it apparently developed over less than twelve hours.”
“Impressive,” Arnold agreed as he looked at the cut surface of David Jeffries’s lung. “Let me guess: It’s a staph infection. Am I right?”
“You hit it on the nose.” Laurie was impressed.
“I’ve had three similar nosocomial cases over as many months, with the last one about two weeks ago,” Arnold said. “Maybe not quite as bad, at least not all of them, but bad enough. Mine were from a methicillin-resistant strain coming from outside the hospital but which apparently had hybridized with bacteria coming from within the hospital.”
“That’s exactly what my case apparently is,” Laurie said, even more impressed.
“The strain is called community-acquired MRSA, or CA-MRSA, to distinguish it from the usual nosocomial, hospital-acquired MRSA, or HA-MRSA.”
“I remember reading about it,” Laurie said. “Someone had a case five or six months ago, of a football player who picked it up in the locker room and had an infection that ate away a lot of his thigh.”
“That was Kevin’s case,” Arnold said. Kevin Southgate was another senior ME who’d joined the OCME only a year after Arnold had. As the old guard, Arnold and Kevin stuck together like a team, although opposites in their politics. Both were infamous around the office for constantly conspiring to take as few cases as possible. It was like they were working half-time full-time.
“I remember when he presented the case at Thursday conference,” Laurie said. Other than the informal but effective give-and-take in the autopsy room, the formal Thursday conference with its required attendance was the only other opportunity for all of the city’s nineteen MEs to share their experiences. Laurie, for one, lamented this situation because it hampered the OCME’s ability to recognize trends. She had complained about it, but without coming up with a solution, the issue had died. With the OCME doing more than ten thousand cases a year, there wasn’t time for more interaction, and there were no funds to hire more forensic pathologists than the one they had hired that year.
“The CA-MRSA bug is scary, as this case of yours aptly demonstrates,” Arnold said. “It’s been a mini-epidemic outside the hospital, like Kevin’s football player and even, tragically enough, some young, healthy children getting scrapes on the playground. Now it seems to be going back into the hospital. That’s the bad side. The good side is that it is sensitive to more antibiotics, but the antibiotics have to be started immediately because, believe it or not, being more sensitive to antibiotics has given the strain added virulence. Not making the complete line of defensive molecules for antibiotics like the HA-MRSA strains, these community-acquired strains are able to spend more time and effort making a soup of powerful toxins to enhance their virulence. One of them is called PVL, which I’m sure has played a role in your case here. PVL toxin chews up the patient’s cellular defenses, particularly in the lungs, and initiates an overwhelming and perverse release of cytokines, which normally help the body fight infection. Do you realize that as much as one-half of the destruction you are seeing in the lung sections you are holding comes from the victim’s own completely overstimulated immune system?”
“You mean like the cytokine storm they are seeing with people dying from H5N1 bird flu?” Laurie asked. The thought went through her mind that she would have to suggest to Jack that he might need to adjust the opinion he had of Besserman. He was embarrassing her by how much more he knew about MRSA than she.
“Exactly,” Arnold said.
“I’m afraid I’m going to have to do some serious reading about all this,” Laurie admitted. “Thanks for all the information. How is it that you are such an expert?”
Arnold laughed. “You’re giving me too much credit. But a month or so ago, Kevin and I got interested in the issue because of several cases we each had. We kinda challenged each other to learn about it. It’s a good example of the genetic versatility of bacteria and how quickly they can evolve.”
Laurie struggled to rein in her mind, which was bouncing from one topic to another. She looked down at the turgid, nearly solid slice of lung she was holding. She knew pathological bacteria were making a comeback, but what she was facing in terms of pathogenicity seemed beyond the pale.
“So the cases you mentioned earlier were necrotizing pneumonia?” she asked. “Just like this case appears to be.”
“That would be my guess, but I’d be even more certain if I looked at the microscope section of your case. I’d be glad to take a peek.”
Laurie nodded. “And Kevin’s cases were the same as yours?”
“Very much so.”
“Were his nosocomial also?”
“Of course. They were nosocomial but also involved the community-acquired strain, the same as mine.”
“Why didn’t you bring this up at Thursday conference?”
“Well, frankly, it was not that many cases, and everyone is aware of the burgeoning problem of staph, particularly antibiotic-resistant staph.”
“Were the involved hospitals fairly evenly distributed around the city?”
“No, they were all here in midtown Manhattan. I mean, there could have been cases in Queens or Brooklyn, since they would be sent to their respective borough morgues.”
“What hospitals here in Manhattan?”
“I can’t remember the exact breakdown from individual institutions, but all six came from three specialty hospitals: Angels Heart Hospital, Angels Cosmetic Surgery and Eye Hospital, and Angels Orthopedic Hospital.”
Laurie stiffened. It was as if Arnold had slapped her. “None from Manhattan General or University or any of the other big city hospitals?”
“Nope. Does that surprise you?”
“Yes and no,” Laurie said, taken aback by such a coincidence. There were a lot of hospitals in New York City. It begged the question: Why just three?
“Did you contact the hospitals, or look into the situation at all? I mean, why just those three hospitals?”
“Kevin and I thought it coincidental, so yes, we looked into it to a degree. I also asked for Cheryl Myers’s help as well. I called the Angels Orthopedic Hospital and spoke to a very nice woman whose name escapes me at the moment. I’d gotten the name from the hospital administrator. The individual I spoke with chaired the interdepartmental infection-control committee.”
“Was she helpful?”
“Absolutely. She said the hospital was well aware of the problem and had hired an infection-control professional, or at least the company that owned the hospital did. So I called this individual whose name I can’t forget was Dr. Cynthia Sarpoulus.”
“Was she helpful?”
“Well, I suppose, at least to an extent.”
“What do you mean?”
“She wasn’t terribly cooperative, although I suppose she was stressed and defensive under the circumstances. My assumption was that her employer, Angels Healthcare, which is the name of the company, had put the burden on her. Anyway, she essentially told me to butt out, and that the situation was well under control, thank you very much. You know the attitude, I’m sure. To her cre
dit, it sounded to me that she was on top of the problem. Against management’s objections, according to her, she had insisted all the ORs in all three hospitals be closed, which also according to her had everybody on her back. She then had all the ORs fumigated by an alcohol-based agent, which is what is recommended. She’d also instigated a rigorous hand-washing regimen. On top of that, she’d had the entire staff tested as potential carriers, and those who tested positive treated. I have to say I was impressed. They surely weren’t sitting around, wringing their hands.”
“Thanks for the information. Sorry to take so much of your time,” Laurie said.
“My pleasure,” Arnold said.
“Would you mind if I came up to your office later and got the names of the cases you’ve mentioned?”
“Not at all! I might still have a couple of the case files. You can also borrow the notes I made about CA-MRSA if you’d like. And you can talk with Kevin. Back when we were working on this, I think he also called over to one of the involved hospitals, but I don’t remember if he told me what he learned.”
After Arnold had stepped back to his table, Laurie looked over at Marvin, who had patiently waited through the whole conversation. “That was incredible,” she said.
“What, that he’s sweet on you?”
“No, silly! What he said. He’s not sweet on me!”
“That’s not the chatter around the morgue. It’s generally accepted both Southgate and Besserman would throw themselves in front of a subway train for you.”
“Nonsense,” Laurie said, although hearing she was even remotely the source of gossip made her uneasy. She never liked being the center of attention, which was why she had such trouble talking in front of a group.
By the time Laurie had finished with Jeffries, she’d found far more pathology than she had expected. Every organ was grossly involved with obvious destructive infection or at least inflammatory swelling. Within the heart, she found beginning infectious vegetations on the valves. In the liver, there were incipient abscesses, as well as in the brain and kidneys, suggesting the victim had had a massive bacteremia. There were even ulcers in the gut, attesting to the ease with which the bacteria spread.
“How long to the next case?” Laurie asked, as she and Marvin finished suturing the giant autopsy incision encompassing both David Jeffries’s chest and abdomen.
“As little time or as much time as you’d like,” Marvin said. “If you want a coffee break, I’ll stretch it out.”
“Actually, if you don’t mind, I’ll call you when I want to do it. Among other things, I want to see if Cheryl Myers is here and catch her before she goes out on a case.”
“Then I’ll take my time,” Marvin said. “Give me a call when you want to start.”
“Make sure you leave a note for whoever releases Jeffries’s body to inform the funeral home that a serious infection is involved and precautions should be taken.”
On her way out of the autopsy room, Laurie briefly stopped at Jack’s table.
“Ah! The doomsayer!” Jacked quipped at recognizing her. “Forsooth, Vinnie! Take heed! She’s surely here to terrify us with the grisly horrors of her nosocomial surgical-site infection case.”
Despite Vinnie’s reflective face mask, she could see him roll his eyes. She felt similarly. On occasion his creative but oft irreverent black humor was not amusing. After being married to him for almost a year, she now saw such behavior as defensive and a way to avoid what he was really thinking.
“I do have to talk with you about my case,” Laurie admitted. “There are some additional facts you should know.”
“How could I have guessed?” Jack questioned mockingly.
“But it can wait until you are more receptive.”
“Praise be to the Lord.”
“Where’s Lou?”
“He literally fell into a deep sleep leaning against the autopsy table between cases. I thought it best he head home, lest one of the mortuary techs mistake him for a corpse.”
“Which case are you doing now?” Laurie asked, to change the subject.
“Sara Barlow, and it’s a hell of a lot more interesting than the John Doe floater.”
“How so?”
“See the obvious bruises on the face and the upper arms. Obviously, she’d been beat up a lot over time, but do you think any of them could have been fatal, as the police assumed?”
“Probably not, but were there any on the anterior chest?” Laurie asked. She couldn’t see because the chest walls were butterflied open. From a case she had when she’d first started at the OCME, she knew that blunt injuries that one would not expect to be lethal could be if they occurred on the chest. “Any reason to suspect commotio cordis?”
“Nope! Chest was clean. What if I tell you there was extensive pinkish pulmonary edema, injected eyes, and sloughing of the tracheal epithelium.”
“What’s your presumptive diagnosis?” Laurie asked with a sigh. Sometimes she found Jack’s forensic guessing games tedious, and this was one of them.
“What if I told you our clever PA, Janice Jaeger, found a mixture of rather strong, open cleaning products in a glass-enclosed shower stall with a bucket of water and a damp cloth? Earlier, when she had viewed the body, she noticed the knees of the woman’s jeans were wet, and the victim was not wearing any socks or shoes.”
“I’d have to know if the cleaning products contained hypochlorite, which many do, and if others contained acid, which a lot do, and if she had ignored the warning not to mix them, and did.”
“Bingo!” Jack said. “Chlorine gas, the first chemical-warfare agent used in World War One, did her in, not her boyfriend. It’s amazing to me how many people blithely ignore product warnings. Anyway, Lou will be pleased it is not another homicide he has to worry about.”
“Not unless the boyfriend was the one who insisted she use the deadly products, and use them together.”
“Now that’s a twist I hadn’t even thought of,” Jack admitted.
“Well, you boys enjoy yourselves,” Laurie said, as she headed toward the exit. She felt no pleasure at having guessed the right answer to Jack’s quiz. She would have been much happier if he were not in such a distractingly playful mood, whether real or feigned. It amazed and irritated her that he didn’t see or was purposely ignoring the corollary between her case and his proposed surgery.
Instead of leaving Jeffries’s specimens for the staff to bring up to the appropriate labs, as was the normal routine, Laurie took them herself. She wanted to talk to both the head of microbiology, Agnes Finn, and the head of histology, Maureen O’Connor, to try to move things along. But first she stopped on the first floor and went into the PA’s office. Knowing they were often out in the field, Laurie was pleased to find Cheryl Myers still at her desk.
“Can I help you with something else?” Cheryl questioned. She was a striking African-American woman who wore her hair in tight, bead-encrusted cornrows. She was part of the old school at the OCME. In fact, she’d been working there long enough to put her two boys through college.
“I hope so,” Laurie said. “Earlier, I was speaking with Dr. Besserman about some infection cases at three hospitals run by a company called Angels Healthcare. He said he asked you to look into it. Do you recall?”
“Are you talking about the MRSA pulmonary cases?”
“Those are the ones! Did you make a site visit?”
“No! What he asked me specifically was to obtain hospital records, so I merely called and spoke to the medical records department in each hospital. It was easy to get the charts, because Angels hospitals have their medical records computerized. The material was e-mailed over. I didn’t need to make a visit.”
“Were the hospitals cooperative?”
“Very cooperative. I even got an unsolicited call back from a very helpful woman by the name of Loraine Newman.”
“Who is she?”
“She is the chairperson of the orthopedic hospital’s infection-control committee.”
> “Dr. Besserman mentioned her,” Laurie said. “He commented on how genial she was as well. Why did she call back?”
“Just to leave her name and direct-dial number in case I needed anything else. She said she was very concerned about the problem. She told me that prior to the MRSA outbreak, they’d had no nosocomial problems to speak of. She said the situation was keeping her awake at night. To tell you the truth, she sounded a little desperate.”
“Did she mention a Cynthia Sarpoulus?”
“Not that I can recall. Who is she?”
“I’ve just posted another case of MRSA that came in from Angels Orthopedic Hospital,” Laurie said, ignoring Cheryl’s question. “I’d like Loraine Newman’s phone number.”
“Not a problem,” Cheryl said. With a few clicks of her computer mouse, she had it on her screen.
“I need some other numbers,” Laurie said. “The CDC in Atlanta has an MRSA program as part of its National Healthcare Safety Network. I’d like you to get me a name and phone number of one of its epidemiologists. I’d also like you to call the Joint Commission for Accreditation of Healthcare Organizations and get me a name and number for someone in surveillance of mandated hospital infectious-control programs.”
“I’ll do my best,” Cheryl said.
“The name of my case is David Jeffries,” Laurie continued. “I’d like his hospital record.”
“That will be easy,” Cheryl said. “But I’m not sure I understand who it is you want to talk to at the joint commission. Could you give me a better idea?”
“The joint commission requires hospitals to have infection-control committees for accreditation. What I want to find out is whether there is any policing of these committees and whether any reporting of outbreaks is required between formal inspections. I know this is a bit unusual,” Laurie said, “but I’m pressed for time.”
“I’m happy to help,” Cheryl said good-naturedly.