Death Rounds

by Peter Clement

  “Mr. Miller, I apologize for questioning you on the phone about this, but your mother’s infection puzzles me. It’s not typical, and perhaps you can help us find the answers. Do you want to meet me in ICU?”

  “Sure, but what do you mean ‘not typical’?”

  “The prodrome was unusually quick.”

  “What did the Gram stain show she has? Come on, Dr. Garnet, what are you not telling me?”

  Damn! I’d really wanted to do this face-to-face, but I didn’t want to cut him off. He was sounding increasingly alarmed.

  “I’m afraid the Gram stain of her sputum showed staphylococcus,” I said as calmly as I could.

  “Staph!” he exclaimed, incredulous. “My mother has a staph pneumonia?”

  I listened to him breathing a few seconds as he presumably digested the odds against his mother’s survival. As a chief technician, he’d certainly have enough medical knowledge to know how grave her prognosis was. “Look, Mr. Miller, come over, and let’s talk here—”

  “Do you think it was hospital acquired? You know she’d been on vacation for five days.” His voice was becoming much more agitated, but he seemed determined to continue on the phone. “Don’t leave me hanging,” he ordered.

  I had to reply. “Yes, I was worried that it was a hospital-acquired organism,” I began, “and that she might have MRSA, so I covered her with vancomycin.” Let him satisfy his immediate need for answers, I decided. It might help him prepare for seeing his mother so ill. “Even with her being on vacation,” I continued, “she could have been carrying dormant organisms from the hospital in her upper respiratory tract, as you’re no doubt aware. Have you had any recent problems with staphylococcus infections at University Hospital?”

  “Not lately, but we have had MRSA in the past. I know because I’m on the infection control board, along with your wife, Janet.”

  I cringed at his innocent use of Janet’s name. It was like an unwitting rebuke, and I prayed he’d never know how I’d resented his mother for making the same reference yesterday. “Your mother said she was in good health until the morning of her first visit here. As far as you know, was that accurate?”

  “Yes. She hadn’t anything wrong with her that I knew of, apart from her smoking.”

  “Might she have minimized a five-day flulike illness? Ignored the symptoms? Not mentioned them to you?”

  I heard a gentle chuckle. “Dr. Garnet, my mother never minimized anything.” His voice relaxed a little; it was lower, less strained. Perhaps having a clinical discussion, even over the phone, was helping him get over his initial shock.

  So I continued with my questions. To be honest, I found myself especially wanting to know the details of what had happened to her after I’d sent her home. That her son had talked to her so many hours after I’d discharged her and she still wasn’t very sick somehow made me feel less guilty. “Last night, did she complain to you about dizziness?”

  “Not really. She said she felt a bit unsteady. But I assumed it was the usual lightheadedness that went with the flu. Why?”

  Careful now, I thought before answering, still not wanting to hang myself legally. “Her prodrome, and this may be off the wall, well, it suggested another not so common but very bad infection.”

  “What are you talking about?” His voice rose sharply.

  Damn! I was upsetting him again, I thought, as I tried once more to calm him. “Mr. Miller, please, it’s all supposition right now. Come over, and we can talk further, right after you see your mother.”

  “What rare and very bad infection?” he demanded, his anger now clearly evident.

  Great choice of words, Garnet, I cursed to myself. “Mr. Miller, I repeat, I have no proof, and ID thinks I’m nuts even bringing it up—”

  “Answer me!” he snapped.

  “It reminded me of Legionnaires’ disease,” I finally admitted.

  “Oh Jesus!” he said, and hung up on what sounded like a sob.

  * * * *

  I’d retreated to my office, a cubby hole located in a back corridor away from ER. My secretary, Carole Lamont, had phoned in sick for me day, so thankfully I was alone.

  I sat at my desk without the lights on and wondered what else I could do wrong. A small window in my outside wall was too grimy to see through, but it let in a little gray illumination. The effect was positively cheery compared to my mood.

  I’d botched Sanders’s first visit. My attempt to comfort her son was worse than a disaster. Instead of reassuring him as I’d hoped, I’d frightened him even more with my questions and talk of Legionnaires’ disease. Why hadn’t I just kept my goddamned mouth shut?

  Because I was increasingly impatient to know everything about this infection that had tricked me.

  Maybe Rossit was right. My guilt was making me overcompensate and screwing up my judgment.

  I’d better warn ICU that Mr. Miller was on his way over, nicely primed, I thought, reaching for my phone. Stewart Deloram, their chief, would have to deal with him personally. If there was any hope of settling him down, Stewart could do it. I’d learned firsthand when I’d once been a patient of his how supportive he could be. Perhaps, despite the mess I’d made of things. Miller could still trust the ICU staff enough to help him cope with what lay ahead for his mother.

  “Dr. Deloram is in the main auditorium attending an administrative meeting,” his secretary announced.

  “Shit!”

  “I beg your pardon!”

  “Sorry. I just remembered where I’m supposed to be. I’ll find him there.”

  I ran out the door and headed for the huge reception hall. The meeting I’d forgotten in my preoccupation with Sanders was a doozy. The boards of St. Paul’s Hospital and University Hospital had decided it would save money if they completely amalgamated the administration of the two institutions. The gathering I was rushing to was a combined assembly of all chiefs to begin the process of naming a common chairperson for each clinical department. It was the political equivalent of sudden death. For weeks now administrators and department heads at every level had been squaring off and vying to keep their turf. There’d be winners and losers, and needless to say, the struggle for ascendancy was sometimes outright nasty.

  I had mixed feelings about it all. The losers would remain department directors in their own hospital under the authority of an absentee chairperson. In my case, if I lost out to my counterpart at University Hospital, I’d still be in charge of ER at St. Paul’s and there’d be a whole lot fewer meetings. But without the mantle of being chief, I’d have no way of protecting emergency services from loopy policies adopted in other parts of the hospital. In a time of cutbacks, I’d had my fill of them.

  I hurried through a double set of doors and entered a noisy group of about a hundred people. They were standing, talking animatedly, and balancing paper plates of cocktail wieners and glasses of variously colored juices—the luncheon fare of austerity. Our home crowd was still decked out in their lab coats; the visitors wore suits. Obviously the formal part of the assembly was over.

  I immediately started looking for Deloram. A few of my acquaintances razzed me for being late and joked that I’d already lost my job, but they didn’t seem very merry. I also greeted a few friends of Janet’s whom I’d met at various University Hospital functions, but I didn’t stop to talk. I found Deloram at the edge of the crowd near me stage, conversing earnestly with Sean Carrington, the chief of surgery. Whereas Deloram was medium sized, dark haired, and meticulously groomed. Scan was tall with permanently tousled red hair and a bushy mustache—a sort of Yosemite Sam in a white coat.

  “Earl!” he greeted me enthusiastically. “What say we settle this nonsense like the old gladiator movies. Pair us off right here, using wienie toothpicks—‘We who are about to die’ and all that stuff.”

  In spite of my problem, I couldn’t help but grin. The man always tried to keep us laughing.

  “Sorry, Sean, but I need Stewart here for an emergency,” I announced, ste
pping up and gently taking Deloram by the arm to steer him toward a nearby doorway.

  “Of course,” said Sean, turning away. “I was just going back to the food table.”

  “What’s up?” Deloram asked as soon as we were out of earshot.

  I hastily explained all about Sanders, and my bungled attempt to talk to her son. “You’d better hurry,” I concluded. “It won’t take him long to get here.”

  “I’ll handle him,” he said curtly, handing me his unfinished plate of wieners and some kind of green juice. ‘Try not to worry,” he called over his shoulder as he rushed out the door.

  I was left eyeing the remains of his lunch, wondering if I should eat something. The increasing tightness in my stomach said no, and I dumped everything in a nearby bin.

  I did rejoin Sean at the food table, where he was busily loading up with brownies. Other people were starting to leave, and thankfully Rossit was nowhere to be seen.

  ‘They should take those out of your pay,” I teased, pretending to grab at Sean’s plate.

  “What pay,” he mumbled, his mouth full.

  “Seriously, what happened here today?”

  He swallowed a few times. “No specific appointments yet. But Hurst made it pretty clear he intended to give up the chair of some services in order to keep anesthesia and internal medicine chaired by St. Paul’s.”

  “Terrific!” I groaned, not surprised. Paul Hurst was a former surgeon and now our VP medical and acting CEO. He pretty well ran the hospital the way he liked. The two chiefs of the departments in question were wimps he could easily control. Sean and I, however, challenged him whenever we felt he was out of line and were right enough times that he couldn’t fire us. “Obviously he’s found a new way to cut us down to size,” I added.

  “Oh, what makes you think that?” replied Sean, pointing to draw my attention to the center of the room. There was Hurst, tall, gray-haired, and pale as always, laughing heartily with Arnold Pinter, the diminutive chief of internal medicine. Arnold usually slouched, and from a distance he reminded me of a field mouse on the lookout for hawks, except today. He was grinning broadly and looking as happy as I’d ever seen him.

  The two men suddenly caught sight of Sean and me watching them. As if to underline my suspicions, they immediately stopped smiling, turned, and walked away with their heads huddled together.

  “Maybe they’re afraid we can read lips,” Sean commented.

  We made small talk after that, but I sensed he was worried. For all his clowning around, I knew that he loved being a surgeon, and that being chief of surgery was his passion.

  Minutes later the page came booming over the PA.

  “Dr. Garnet! Call ICU immediately! Dr. Garnet! Call ICU!”

  It was loud enough to momentarily hush the room, but conversations started up again as I ran for a wall phone. In my rush I dropped the receiver while punching in the familiar numbers. It was Deloram who picked up.

  “Earl?” he asked, obviously expecting my call. I could hear shouting in the background.

  “What the—”

  “He beat me here. Earl, and what’s worse, the nurses had shown him the chart, as a professional courtesy. The note Rossit had circled practically jumped out at him, and he’s livid. Worse, he wants to transfer his mother out of here and back to University Hospital. The trip’s out of the question—she’s too unstable—but I can’t talk sense to the man.”

  Christ, I thought. Then I saw a familiar head towering above all the others in the room. “Stewart, there’s someone here Miller will listen to. Cam hasn’t left yet. Tell Miller he’ll be up in a minute!” I ordered, hanging up without waiting for his reply.

  I made my way through the thinning crowd toward the blond-haired, slim man I’d spotted. In his mid-thirties and dressed in a navy blue sports jacket, tan pants, and a light blue shirt open at the collar, he resembled more a movie star than what he was—chief of the Department of Infectious Diseases and director of laboratory services at University Hospital. In any group he was a head taller than the rest and had to continually lean down to hear what others were saying. That he spent a lot of time surrounded by physicians and residents was a tribute to his brilliance. And unlike Rossit, he was every bit a gentleman.

  I’d met him several times with Janet and had even been lucky enough to be seated near him at several of her hospital dinner parties. His funny stories were legendary. More pertinent was that he was Miller’s ultimate supervisor.

  Having no time for niceties, I pushed through the circle of people around him. “Excuse me, Cam,” I interrupted, drawing irritated stares from the people I jostled. Cam himself smiled and said, “Hi, Earl. How come your lovely wife isn’t here? We could make her chief of everything and solve—”

  “I’m sorry, Cam. We’ve got a big problem in ICU with one of the nurses from your hospital. It’s an ID case, and we need your help fast.”

  His smiling face immediately became serious. “Of course,” he replied. “Excuse me, everyone; it’s back to reality.” There were appreciative chuckles from his audience as he strode away with me and we headed toward the door. I almost had to run to keep up. I talked as we went.

  “Her name is Phyllis Sanders, and of course you know her son, Harold Miller.”

  “Harold? Certainly I know him. We just named him our director of laboratory technicians. He’s very conscientious. His mother works in OB doesn’t she?”

  “That’s right. She’s in her fifties, smokes, but otherwise has no major risk factors. I saw her yesterday in ER and sent her home with what seemed like a mild, one-day history of the flu. She’d been on vacation and lived nearby, so she came to us instead of going to your staff health service. Unfortunately, she was returned to us by ambulance this morning in septic shock due to pneumonia.”

  We swung through the doors to the stairwell and started up. He took the steps two at a time. He showed no reaction to what I’d just told him.

  “The Gram stain showed staph,” I puffed, “but the short prodrome bothered me.” We swung around the first landing and continued toward the second. “It reminded me of something else. ID here thinks I’ m crazy, but...” I had to stop speaking for a few seconds to catch my breath while we continued to run. Cam was half a staircase ahead of me. “It made me think of Legionella,” I said, far too loudly.

  He stopped in midstride.

  “Pardon?” he said, turning to look down at me as I caught up to him.

  “I know it’s foolish. Cam, but when you see the labs and review her initial symptoms...” I trailed off.

  I’d expected him to be bemused, skeptical even, though not as rude as Rossit had been. Instead, he was staring at me as if he’d seen Banquo’s ghost.

  “Cam, are you all right?” I asked, dismayed at the shaken expression on his face.

  “It’s not foolish at all. Earl,” he said finally. “If you’re right, and frankly I hope you’re not, then she’d be the third perfectly healthy nurse from our hospital in the last six months to have contracted Legionella.”

  Chapter 4

  It was my turn to feel astonished.

  “But that—that’s impossible,” I stammered after getting over my initial shock. “It’s against the odds. And Janet’s said nothing about Legionella’s being a problem at your hospital. Besides, we’d all have known about—”

  “That’s what’s so bizarre, Earl,” he interrupted, turning and continuing up the stairs. “We don’t have a problem with Legionella. We checked everywhere, for each case, and there was no source we could find. Neither nurse had been involved in treating patients with Legionella, no other staff members had the disease, and no pools of the organism could be found in water distribution sites throughout the building. Believe me, we looked, especially after the second case. We had to conclude they weren’t nosocomial infections.”

  He stopped at the third floor landing and held the door for me. He obviously knew where our ICU was. “The really creepy thing is the timing,” he added. �
�Those two nurses also developed their symptoms shortly after going on vacation.”

  “What?” I exclaimed, stopping. “Go on. You’re kidding me.”

  “I’m afraid not. The first became ill five days after leaving work, the second within seven days of the start of her holiday.” He gestured we should continue walking.

  “Did they vacation together?” I asked, starting along the corridor.

  “No such luck. There were snide jokes about shared hot tubs, but in fact they didn’t even know each other. One worked in ICU; the other was an OR nurse. Nothing in common whatsoever, and they were away at different times. The second case spooked us so much we even had an ID team check out her home and where she’d vacationed, but again, there was nothing. That’s why I hope you’re wrong. It’s going to shake up a lot of people at our hospital, including me, if this is a third case.”

  He pressed the metal disk outside the sliding doors.

  “Did they recover?” I asked.

  “One died. The ICU nurse not only survived but is back on the job,” he answered, lowering his voice as we stepped into our own ICU.

  It was quiet. Deloram was leaning against a desk in the nursing station, his arms folded. Beside him stood a young man dressed in a green isolation gown who I presumed was Harold Miller. He had closely cropped blond hair and, though of medium height, broad shoulders and a compact muscular physique that was evident even with the loose clothing. He immediately looked up as we entered. Beside him was little Gary Rossit.

  I felt my stomach turn. Rossit looked furious to see Cam on his turf.

  “Harold,” said Cam, quickly striding up and putting his hands on the man’s shoulders. “I happened to be here and heard about your mother. I just wanted to drop by and offer my support.”

  Miller mumbled, “Thank you.”

  Rossit seemed about to protest.

  Cam gestured to him, “I’ve always said Dr. Rossit here is one of the best ID experts in Buffalo. I’d trust him to care for me or a member of my family anytime.” He glanced around and found a place to sit down. “What do you think of this case, Gary?” he asked.