Critical

by Robin Cook

  Both Laurie and Riva looked up as Chet bounded into the room. He swirled his jacket over his head like a lariat and let it fly into one of the vinyl club chairs.

  “Where is everyone?” he asked, looking confused. He’d expected to see Jack.

  “Jack and Vinnie are already downstairs,” Laurie said. “You’re even more chipper than yesterday, and almost on time two days in a row. What gives? Don’t tell me you scored a dinner date with your new woman friend.”

  Chet stood up straight, flashed a Boy Scout signal with his raised right hand, and clicked his heels. “Scouts never lie. I did indeed, and I’m happy to report she was more intriguing and beautiful than I had remembered. I actually enjoyed talking with her.”

  “Listen to this, Riva! We are witnessing the possible stirring of maturity in this heretofore juvenile. He was content merely to learn about another human, female being.”

  “Now, I wouldn’t go that far,” Chet said. “I was still plotting to get her back to my apartment or me over to hers, but she cut me off with just dinner.”

  “Darn,” Laurie said, snapping her fingers in sham disappointment.

  “I have to thank you for your advice, Laurie. I’m sure the date wouldn’t have happened had it not been for your encouragement and advice.”

  “You’re very welcome,” Laurie said. She turned to Riva. “Thanks for these cases. They’re perfect.” Laurie started once again to leave.

  “She took me completely by surprise,” Chet continued, forcing Laurie to hold up. “She’s a doctor; she’s boarded in internal medicine. On top of that, she’s CEO of what has to be a multimillion-dollar company that builds and runs specialty hospitals. I mean she is one impressive lady.”

  Laurie experienced an unpleasant visceral contraction accompanied by a sensation akin to dizziness which resolved as quickly as it had appeared. She cleared her throat before asking, “Is her name by any chance Angela Dawson?”

  “It is!” Chet exclaimed. “Do you know her?”

  “Vaguely,” Laurie said with surprise. “I have met her, and unfortunately I have to say I wasn’t as impressed as you are.”

  “Why not?”

  “I’m afraid I don’t have time to explain now, but let me just say that I sensed her priorities as a businesswoman were trumping those of a physician.”

  Laurie knew Chet would undoubtedly have more questions, but she had to move on. Despite his protests, she excused herself. Walking quickly through communications, where notification of all the deaths of the city were received, she began to plan her day. With as little time as she had before Jack went under the knife, she would need to be efficient. The first stop was the forensic investigator’s office. Janice Jaeger had done the site visit on the new MRSA case, and Laurie wanted to question her. More than once, Laurie had learned something important from Janice’s wealth of experience that had not gotten into the report. Forensic investigators were tasked to include only facts, not impressions.

  Laurie found Janice finishing up after a long night. She was the sole PA officially working from eleven to seven but rarely left before eight. She was aided, if need be, by forensic pathology residents who rotated night call. If even more backup was needed or the case was particularly challenging, one of the medical examiners was also available.

  “Did I miss something?” Janice asked, as Laurie came up to her desk. Laurie got along famously with all the PA’s but particularly with Janice, who appreciated Laurie’s recognition of her work. More than any of the MEs, Laurie was constantly coming to her and asking questions and valuing her opinion.

  “I’m about to do Ramona Torres,” Laurie said. “I gathered from your note you made a site visit to the University Hospital.”

  “I did indeed.”

  “Did you sense anything about the case that you thought was interesting or unique but not appropriate for your report?”

  Janice smiled. Laurie was always asking her probing questions. “I did, actually,” Janice said. “I got the feeling the doctors were upset that they weren’t getting the Angels Healthcare septic patients soon enough to make a difference concerning survival.”

  “Did you make a visit to the Angels Healthcare Cosmetic Surgery and Eye Hospital?”

  “No, I did not,” Janice said. “Not in this case. Do you think I should have?”

  “I can’t say,” Laurie admitted. “But you have visited Angels Healthcare hospitals in conjunction with other MRSA cases.”

  “Absolutely,” Janice said. “On a number of occasions.”

  “I’ve read several of your reports. What’s your general feeling about the hospitals and these recurrent MRSA cases?”

  Janice smiled again. “Do you want the truth?”

  “Of course! I wouldn’t be asking if I didn’t.”

  “I don’t know how to explain it, but I feel like something strange is going on. I mean, it’s nothing I can write in my report, but they keep having these infections and yet keep doing the surgery. Whenever I ask any type of question in this regard, they say that they are doing everything they possibly can. Meanwhile, people are dying.”

  “I’ve had the same response,” Laurie admitted. “Thanks for your opinion. Is Cheryl around?”

  “She’s out on a call. Bart Arnold is around. Do you want to speak with him?” Bart Arnold was the chief of forensic investigation and ran the department.

  “No. Just leave a message that I need the hospital record for Ramona Torres. They can e-mail it to me like they did with the others.”

  “Not a problem.”

  Laurie rushed all the way to the front elevators to save time: Not only were they faster, there were more of them. She bounded into her office, laid the three case files on her desk, and hung up her coat. Snatching up the phone, she called down to the mortuary office and asked for Marvin. When she got him on the line, she asked him if he would work with her again that day. She said she wanted to be expeditious. He agreed with his usual cheerful readiness. Laurie gave him Ramona Torres’s accession number, said she wanted to do her first, and then rang off.

  She looked at the clock. One of the first things she wanted to do that day was call the CDC, but fearing they might not be functioning as early as it was, she turned her attention to reviewing the day’s autopsy cases. That required rereading the case file of Ramona Torres. After doing so, she felt confident the post would be similar to David Jeffries’s. Putting that one aside, she picked up the first of the two sudden-death cases and pulled out the PA’s report.

  The patient’s name was Alexandra Zuben, age twenty-nine. She had visited the dentist for a root canal and had received the local anesthesia as Riva had described. At the very outset of the procedure, the patient suddenly had fallen unconscious. After she had been placed in a head-down position, she’d revived and insisted the procedure continue. A few minutes later, the same situation had developed, although on this occasion she did not revive, 911 had been called, and the patient had been rushed to the hospital, where she was found to have an arrhythmia, a markedly elevated blood pressure, and little or no respiratory efforts. She’d been put on a ventilator, but despite aggressive therapy, she had progressed to a cardiac arrest that could not be reversed. The emergency-room diagnosis had been recorded as respiratory failure compounded with cardiac failure secondary to severe allergic reaction and anaphylaxis to Novocain. The PAs concluded with the fact that a family member had said that the patient was remarkably healthy but had had, on occasion, several syncopal attacks involving palpitations, flushing, and heavy perspiration.

  Laurie slipped the PA’s report back into its folder. Her initial impression was that the emergency-room diagnosis was in error, and she had a reasonable idea of what she would find on the autopsy. Of particular note, she was reasonably certain she would not need any special equipment for the post.

  Next, Laurie took out the PA’s report on her third case. It was very short. It merely said that Ronald Carpentu had been on a semirecumbent stationary bike, which he used
most every day, and had suddenly collapsed. Immediate CPR had been given by the health club’s personnel but without success, 911 had been called, and the CPR was continued en route to the emergency room. On arrival, the patient was declared dead with the diagnosis of a severe heart attack.

  Laurie replaced the PA’s report. On this third case, she was quite certain the emergency-room diagnosis would prove to be correct, but there was still the question of why. Laurie guessed atheromatous heart disease. Again, she would not need any specialized equipment.

  Picking up the phone, she called down to the autopsy room. It rang six times, causing Laurie to drum her fingers on her desk. While she waited, she thought about the weird coincidence of her giving Chet advice about dating Angela Dawson, of all people.

  “Hello,” a voice said, sounding more like “Yellow.”

  Laurie asked for Marvin, and after only a few seconds, he came on the line. “Are we ready?” Laurie asked.

  “We’ve been ready for hours,” Marvin joked.

  Less than five minutes later, Laurie was suited up and staring down at Ramona’s corpse. As with David Jeffries, an endotracheal tube and a number of intravenous lines were still in place. But the most striking thing was the extensive bruising over much of her body from the liposuction.

  “You are motivated today,” Marvin said, in a reference to how quickly Laurie had gotten down to the basement level, changed into her barrier protective gear, and come into the autopsy room. Besides her case, there was only one other under way, and that was the floater. Laurie hadn’t even stopped to see how it was going.

  “I want to be as efficient as I can,” Laurie admitted. “I promise I won’t leave you high and dry like I did yesterday. I apologize again. I got sidetracked and lost all idea of the time.”

  “No sweat,” Marvin said, seemingly embarrassed that Laurie felt she needed to apologize.

  Laurie palpated Ramona’s skin and looked at it closely. It had a spongy feel, and there were multiple tiny abscesses such that Laurie felt that had she lived, she would probably have sloughed off a large part of her epidermis.

  After taking a number of photographs, Laurie began the case. She worked quickly and silently. When Marvin asked questions, she answered as if preoccupied, and he soon stopped. Since they worked together so often, there was little need to talk.

  As with David Jeffries, the most notable pathological finding, besides the extensive cellulitis, was in the lungs. Both were fluid-filled and contained innumerable small abscesses that would have coalesced into larger and larger ones had the patient lived. As with Jeffries, the necrosis was substantial.

  When the final suture had been placed, closing the autopsy incision, Laurie stepped back from the table. She glanced around the room. Now, all eight tables were being utilized. Looking over near the door, she could see that Jack, Lou, and Vinnie were still involved with the floater.

  “That was one of the fastest autopsies I’ve seen,” Marvin commented, as he began to clean up.

  “How soon can you have the next case?” Laurie asked.

  “Fifteen minutes or so,” Marvin said. “Do you have a preference as to which one of the two should be next?”

  “It doesn’t matter,” Laurie said. “I wouldn’t fault you if you don’t believe me, but I’m going upstairs to make one phone call, and then I’ll be back.”

  Marvin smiled.

  Laurie stopped briefly at Jack’s table and jokingly asked why he was taking so long. Jack was known to be one of the fastest prosectors.

  “Because these two windbags talk like a couple of old ladies,” Vinnie said disgustingly.

  “We’re being thorough,” Jack said. “Even before the micro and the lab contribute, we know this young woman was raped rather brutally.”

  “Which raises the question,” Lou said, “was it a rape followed by a homicide, or was it a homicide and an incidental rape?”

  “Unfortunately, the autopsy is not going to provide us with an answer to that question,” Jack said.

  Laurie excused herself and exited via the washroom to ditch her gloves and Tyvek disposable suit. Her face mask she wiped clean with alcohol and left it in her locker. Intent on not keeping Marvin waiting, she dashed upstairs.

  Back in her office, Laurie dialed Dr. Silvia Salerno at the CDC. As the call went through, she wedged the phone between her head and shoulder to free her hands. Shuffling through the case files on her desk, she located Chet’s case, Julia Francova. She opened it up with the hopes of being able to add the subtyping of the patient’s MRSA.

  When the phone wasn’t answered immediately, Laurie looked at the time. It was now going on nine, and she was certain the CDC had to be open for business. “Come on, come on!” Laurie urged. “Answer the damn phone.”

  Just when she thought about checking to see if the CDC had a paging system, the line was picked up. It was Silvia, and she was mildly out of breath. She immediately apologized, saying she had been in a neighboring office.

  “I hope I’m not bothering you,” Laurie said. “I know you said you’d be calling me, but the sooner I have some information, the better.”

  “Don’t be silly,” Silvia said. “You certainly aren’t bothering me, and I was planning on calling this morning. I did check on those two MRSA cases of Dr. Mehta’s. They are the same organism, and I can say that with definite certainty. Because we are adding these strains to the national library of MRSA, we go out of our way to characterize them, and we do this with multiple genetic methods, such as high-throughput amplified fragment-length polymorphism analysis. I could send you a list of the other methods we use.”

  “Thank you, but I don’t believe that will be necessary,” Laurie said. She had no idea what Silvia was talking about. “But I do have another case, which had been sent to you people a number of weeks ago for typing. Specifically, it was sent to a Dr. Percy.”

  “Dr. Percy is a colleague. What was the referring doctor’s name?”

  “Dr. Chet McGovern. He’s a colleague of mine here at the OCME.”

  “What was the patient’s name?”

  Laurie spelled out the name to avoid any confusion.

  “Hang on for a minute.”

  Laurie could hear the familiar sound of Silvia’s keyboard, making her wonder how anything got done before digital computers.

  “Yes, here it is,” Silvia said. “Interesting! It’s also CA-MRSA, USA four hundred, MWtwo, SCCmecIV, PVL, exactly like the two previous cases. Is it from the same institution?”

  “It’s from one of the same institutions,” Laurie said. “Remember, the first two were from two separate hospitals.”

  “Yes, I remember. Concerning the two cases at the same institution, are they close to each other in time, maybe even the same date?”

  Laurie turned to her unfinished matrix, but she did have the data from Mehta’s case from the Angels Cosmetic Surgery and Eye Hospital. The patient’s name was Diane Lucente, and like Ramona, she’d had liposuction. Laurie checked the date of Diane’s death and Chet’s case. “No,” Laurie said. “They occurred almost three weeks apart.”

  “How odd,” Silvia said. “I guess you know how genetically versatile staphylococcus is.”

  “I’m on a rather steep learning curve,” Laurie admitted. “But I was informed of that yesterday.”

  “I find that the exact subtype being separated by institution and time quite amazing. All three must have been in contact with the same carrier.”

  “Did you have this specific subtype in your collection before Dr. Mehta sent you the isolate?”

  “Yes, we did. As I told you last time, it is one of the most virulent subtypes we’ve seen for all sorts of test animals as well as humans.”

  “Do you send out cultures of these organisms?”

  “We do. We support any number of researchers willing to work with these organisms.”

  “Have you ever sent this particular organism to New York City?”

  “I don’t know offhand, but I can fi
nd out.”

  “I’d appreciate it,” Laurie said. The nagging concern of the bacteria being spread purposefully resurfaced in Laurie’s brain, yet the old arguments against such an idea resurfaced as well, each essentially canceling the other.

  “I have asked around the center if anyone was aware of the cluster of MRSA cases you are investigating, but no had heard about it.”

  “Is that odd or not?” Laurie asked.

  “No. It’s up to the individual institutions if they want to contact us for assistance. There’s no mandatory reporting to us, but there probably is to the state or city authorities.”

  “Did you get the other isolates I had our microbiology department overnight to you?”

  “Yes, I did. They are in the works. I shall have some results in two to three days—four, tops.”

  Laurie thanked the woman for her help and rang off. For a moment, she sat at her desk and went over the conversation. She had to admit that the call had deepened the mystery, not solved it.

  Suddenly remembering the time, she leaped up from her desk and dashed for the elevator. She was afraid she had once again kept Marvin waiting despite her promise not to do so.

  CARLO FOLLOWED BRENNAN out of the electronics store on Lexington Avenue in Manhattan. Brennan had purchased a GPS tracking device from a company that specialized in marine as well as terrestrial applications. Once outside, they found that it had started to sprinkle, so they ran for the black GMC Denali.

  “I’m glad to see it started to rain,” Carlo said, as he revved the engine before pulling out into the traffic.

  “How come?” Brennan asked, absorbed in slitting the cellophane wrapping of the box containing the tracking device. He loved electronic contrivances and had had a ball picking out the item. He’d spent such a long time discussing with the salesman the pluses and minuses of the array of tracking devices the store carried that Carlo had become totally bored.

  “Because there’ll be less chance of people hanging around the marina. I don’t want anyone seeing us hiding the thing on the boat. You know what I’m saying?”