I didn’t answer right away. The menace I’d felt from that hideous encounter was not at all in doubt, but if pressed, I had to admit I’d only assumed the attack was connected to the nurses, especially with Sanders’s death fresh on my mind. But I couldn’t rule out the possibility that I’d stumbled onto a completely unrelated creep.
“It would be a pretty big coincidence, but you’re right. It’s a possibility the attack tonight had nothing to do with the Phantom or Legionella”
My admission left us looking glumly at each other across a spread of white bedsheets. They reminded me of blank paper—a tabula rasa—waiting for answers that wouldn’t come.
It was an odd sort of letdown. If the attack was an unrelated fluke, then Janet hadn’t threatened anyone, wasn’t in any immediate danger, so far, but might be completely on the wrong track. In that case, we were probably no closer to discovering why two nurses had died and certainly weren’t any nearer to stopping a lunatic who could kill with Legionella.
Even more frustrating was that we had to live with the other possibility: we somehow had threatened a killer.
After a few moments, Janet raised her head. “I need you here, Earl. You’re the only one who believes me, and I’m certainly not getting anywhere working with Michael. You’ve got to get yourself officially named to his investigation. Then we can start from scratch, together, and maybe you’ll see something I’ve overlooked.”
“Don’t worry,” I told her, trying to sound more confident than I felt. “If Michael doesn’t listen to me, you can tell Donna on him. She’ll make him behave.”
* * * *
We got out of University Hospital’s ER by midnight. The CAT scan and a series of staff doctors declared that apart from an already forming bruise, the blow hadn’t done me much damage. On our way home Janet agreed she’d do no more prowling around until I could be with her. We again considered making a report about the attack to the police and again decided against it. Even if they believed me, which, despite Janet’s skepticism, they might, the crime they’d be investigating would be simple assault and nothing else. Besides, creating a fuss for the hospital would only make it harder for me to get the access I wanted to their records.
Later, in bed, I lay awake listening to Janet’s breathing and pictured that sinister figure in the hallway. Despite our second-guessing why he’d turned out the lights and come after me, I couldn’t stop thinking he was down there because Janet was checking into the Legionella cases and digging out the old files on victims of the Phantom. What would he have done to her if I hadn’t come along? Possibilities out of a nightmare flooded into my thoughts and burned away all possibilities of sleep. I got up, went downstairs to the living room, and paced to control my fears. No one, I swore, not Michael, not Cam, not anyone at University Hospital, was going to keep me from protecting my wife.
But after putting a few miles on the carpet and tripping innumerable times over Muffy, by 3:00 A.M. I still had no plan. That was when I remembered Phyllis Sanders’s autopsy was scheduled for 7:00.
* * * *
During twelve hours on a slab in the morgue the flesh of the dead becomes yellowed and white as the blood slowly drains toward the back and pools in the skin behind the head, shoulders, and hips. There it clots, suffusing those resting spots with large purple blotches—a telltale pattern of how the body was initially lying after death. Pathologists call this pattern dependent lividity, and it can reveal whether a body subsequently was moved into a different position and, if so, suggest foul play.
Phyllis Sanders had obviously spent an undisturbed night on her back. She now lay naked on the dissecting table under the harsh light of the operating lamp, awaiting her final medical procedure and hopefully a definitive diagnosis as to the cause of her death, if the purely medical cause of death could be called definitive. In her case, the possible cause of the cause—a dim figure in the shadows— wouldn’t be discovered here.
Her eyes were closed, her cheeks were slack and hollow, and her mouth was a gaping hole. Her gray hair lay splayed out over the glistening steel of the table’s surface and hung off its end, reminding me of how she’d looked in ER. I found myself wondering how they’d protect those long strands for the mortician if they planned to include her brain in the post. The standard cutting procedure would involve an incision around the back of her head from temple to temple and pulling the front half of her scalp forward over her face to expose the skull.
I was dressed in greens, mask, and gloves and pacing impatiently, having been in the chilled room for ten minutes and wondering what the delay was. On the steel counters surrounding me were the rows of tubes and glass beakers that would hold specimens of her various bodily fluids. Other bottles filled with colored liquids stood waiting to receive tissue samples from her major organs. Spread out near the deep sinks at the end of one of these counters was an array of large Tupperware containers, each half filled with formaldehyde, where the major organs themselves would be placed once they were removed in their entirety. The overhead vents hummed and did their best, but even through my mask the familiar fumes of the preservative stung my eyes and bit into my nose. Every now and then I also got a whiff of the unmistakable odor of early rot.
Scalpels, probes, pickups, forceps, bone cutters, and a rotary saw lay neatly arranged on a steel cart placed near the woman’s chest. This being an ID case, a plentiful supply of swabs and culture sets were on a separate tray within easy reach. All that was needed was a pathologist.
Finally I heard the sound of approaching voices coming from the changing room on the other side of the doors to the autopsy suite. As the conversation grew louder, I realized a heated argument was taking place.
“I don’t give a goddamn about whatever juice you managed to pull from upstairs! Down here you’re on my turf, this is my case, and it’s my policy that any attending physician or resident not only can be present but should be encouraged to be present at an autopsy of his or her patient—”
The doors swung open and the thin figure of Len Gardner, already in full protective gear, strode into the room. Of medium height and build, he was in his early fifties. He should have been chairperson of his department but was far too frank and honest to have any political support at St. Paul’s. “Oh, hi. Earl,” he commented cheerfully, winking at me over the top of his mask. He gave his head a little nod in the direction of whoever was following him, the corners of his eyes wrinkling merrily with the smile I couldn’t see. Then he suddenly stared at my forehead. “Hey, that’s quite a bruise. What happened?”
“I hit a door in the dark,” I mumbled.
In huffed Gary Rossit, also fully garbed, but the visible portions of his face and neck were deeply flushed. The effect made his head look like a round beet enclosed in a cap and mask. “Garnet’s handling of this case is under review, and I insist you comply with my wishes and bar him—” He broke off when he saw me, his forehead flushing even redder.
I felt my own face grow warm. “You wouldn’t be trying to keep me away from the post, would you Dr. Rossit?” I snapped. Having caught him in the act of doing exactly that, I was furious. But I gritted my teeth knowing my mask at least partially kept him from seeing how well he’d succeeded in making me livid.
He glared back up at me, his pupils widening as I watched.
“You are both welcome to stay,” Len interjected sternly, giving us a precautionary glance that made it clear he wouldn’t tolerate his domain being used as a battleground. He reached overhead and snapped on the microphone to record his running commentary of the autopsy. Rossit eyed the device, the blacks of his eyes growing even bigger, but kept silent. Whatever he had to say against me, I guessed he still preferred it said behind my back and off the record.
Apparently satisfied that we would behave, Len stepped to the business side of the table, picked up his scalpel, and looked down at his subject. “The patient is a fifty-seven-year-old female with no external markings except needle punctures at the documented IV sites
—the right and left forearms—below the junction of the lateral and middle thirds of the right clavicle, and at an arterial line inserted in her left wrist. The central line has been left in place for verification of position.”
This initial inspection included documentation that the various lines had been properly inserted in her veins. Antibiotics injected outside a vessel would simply collect in the surrounding tissue where they’d pool and fail to reach the site of the infection.
“Likewise the endotracheal tube has been cut and the lower end left in place...”
Len grasped her windpipe between his thumb and third finger at the thyrocricoid—a tiny area in the upper end of the trachea covered by a thin membrane—and brought the tip of his scalpel blade down to make a vertical slice. As the skin and tissue parted, the orange tube so expertly inserted by Michael two days ago came into view. I recalled my own hesitancy trying to intubate her, which had necessitated his taking over.
“...incision through the cricothyroid membrane reveals a properly positioned endotracheal tube...”
And so it went: the preliminary to what we were all here to see— her lungs.
Len’s scalpel made a sweeping cut from her upper right chest across to her sternum and down to her pubis. Her flesh pouted open along the path of the blade, the cleanly sliced edges forming a bloodless trench the color of sushi. He made a similar cut above her left breast, joining his initial incision and completing a Y that would allow him access to both thoracic cavities and the abdomen. His expert use of the blade had penetrated not only dermis but also more than half an inch of glistening subcutaneous fat. Abandoning the knife for a large pair of tissue spreaders—an instrument resembling scissors with curved blunt probes instead of blades—he deftly widened and deepened the fleshy trench along its length. In the thoracic region it took him seconds to reveal the white striations of sinew and the pearl gray sheen of underlying bone. Working lower down over her belly, he brought into view the darker gray of peritoneum—a fibrous sheath holding back her intestines and other contents of her abdominal cavity. He continued to give succinct explanations of all he did, the easy flow of technical jargon consistent with his years of experience.
“Double glove if you haven’t already. I’m going through the chest wall,” Len advised us.
Both lungs were liable to be full of pus. The extra layer of latex was protection against an incidental tear midst such septic material. Rossit and I complied, reaching for the dispenser box at the same time; then we both impatiently insisted the other hurry up and use it first. I caught a glimpse of us struggling to pull rubber over rubber in our reflection from the glass doors of a nearby cabinet. Positioned back to back, we looked like dualists gloving up to mark off twenty paces. I heard Len muttering behind his mask—something about rectal orifices.
Len picked up the rotary bone saw—a hand-sized tool fitted with a two-inch round saw blade—and switched on the motor. He bent over his patient again and touched the top of each rib with the whirling saw blade, making only a partial cut so as not to disturb the structures underneath. At each contact with bone there came a high-pitched whine, not unlike a dentist’s drill, that made me cringe.
While Rossit and I watched, he reached for his rib cutters, stainless steel shears any florist or chef would die for, and finished snipping completely through the ribs. Their freed ends sprang upward, allowing access to the lungs.
“Good God!” he exclaimed, stepping back from the cloying stench that rose out of the open cavity, staggering all of us, even with our masks.
Swallowing and trying not to gag, 1 peered at the right lobe. The surface, already blackened by years of cigarette smoking, was blistered with abscesses—some of them open and draining. The entire organ was floating in a yellow pool of debris similar to what I’d suctioned out of her airway two days ago. The left lung appeared much the same, with the exception of the top half of the upper lobe.
“She must have been breathing and oxygenating through that until she died,” pronounced Len, pointing at this partially spared segment. His voice lost its practiced neutrality. He spoke slowly, clearly shaken.
The extent of the spread of the infection and the degree of tissue damage we stared at was truly alarming. Len nevertheless picked up his scalpel and proceeded to prepare the trachea, lungs, heart, and esophagus for removal en bloc. Identifying each major vessel and structure as he cut, he freed, then lifted this large dripping assembly from the chest cavity and placed it on an adjacent smaller table equipped with a drain. As he went to work on her right lung, removing it from the rest of the dissection, I swallowed a few more times and managed to ask, “Have you ever seen an infection this aggressive before?”
“No,” Len answered quickly, then added, “except...well, at least not recently, not in patients who weren’t immunocompromised somehow, and even then, not as completely unchecked as this...” His voice trailed off, and the lines in his forehead formed into deep vertical furrows as he looked up from his work. “But I saw cases somewhat similar during my residency in the early seventies, when methicillin-resistant staphylococcus first emerged, before vancomycin became the treatment of choice. Those pneumonias went fast too.” He looked back down and resumed his cutting. “But you had this lady on vancomycin, didn’t you?”
“Among other things,” I stated quietly, glancing at Rossit. I hoped the mere mention of what I’d ordered wasn’t enough to start him on another diatribe about my use of antibiotics.
“Any signs of resistance so far, Gary?” Len asked without looking away from the incisions he was making.
Rossit darted his eyes my way, then just as abruptly looked back across the table. “The organism in her sputum was coagulase positive, confirming staph aureus, and the preliminary disc diffusion screen suggested methicillin resistance,” he admitted to the top of Len’s head. The way he coldly rattled off the technical terms indicated he resented being made to reveal that vancomycin seemed to have been the right choice after all.
Well, well, I thought, feeling a flash of satisfaction. Rossit would be forced to put his attack against my prescribing patterns on hold, at least until we received confirmatory tests.
He admitted as much when he added, “But that procedure isn’t as accurate as the minimal inhibitory concentration method using a full twenty-four hour incubation and broth dilution.” This mouthful of terms made him pause for breath. “Any intelligent comment about Dr. Garnet’s choice of therapy will have to wait until tomorrow,” he concluded sarcastically, finally looking at me.
“Yeah, yeah, Rossit,” I shot back, “and heaven help me if the minimal inhibitory concentration method doesn’t validate the use of vancomycin! Get a grip, Gary! You’ll probably end up having to admit it was a reasonable call.”
‘The erythromycin, even rifampin—was there any antibiotic you didn’t think of?” he retorted.
Len was ignoring our spat.
“...slicing through the hilum, severing the main stem bronchus, pulmonary artery, and divisions of the pulmonary vein, thereby completing the removal of her right lung...”
He lifted the sodden organ, placed it on several pieces of paper towel, then cradled it in his gloved hands and set it on a balance for weighing. After recording the reading, he sliced open each of the lung’s three lobes, spreading the meaty halves and inspecting their interior. His hands moved slowly, so as not to spray any organisms into the air.
Suddenly his running commentary ended in midsentence. He stood frozen, transfixed by what he saw.
His unexpected reaction immediately made Rossit and me shut up, and we both strained forward to see what he’d found.
Across from me I heard Len whisper, “Holy shit!” Rossit muttered something else on my right. But my eyes were fixed on the horror in Len’s hands.
The inside of the lung was virtually destroyed. Its entire central structure—arteries, veins, and airways—had been converted into a brownish black mush. No circulatory pathways remained that might have carried
antibiotics to the sites of the infection. But even if they had, the destruction of tissue visible to the naked eye meant the airways leading to alveoli, the microscopic sacs where life-giving oxygen passed into the blood, were no more. What little tissue had survived was confined to the periphery of each lobe. It had a reddish color—the sign of diffuse inflammation—and was coated with blood-streaked bubbles, a result of the leaky lung syndrome I’d suspected during her resuscitation. In the middle section of the lobes were more dark cavities where the abscesses we’d seen penetrating the lung’s surface first developed. Any remnants of tissue still intact around these holes had a coating of yellow slime.
I stood mesmerized by what I saw and didn’t realize at first that Len had resumed speaking.
“. . . the congested tissue appears diffusely inflamed and exudes a serous sanguineous fluid in the outer segments. Slightly deeper is extensive evidence of early cavitation. Most of the central parenchyma and vascular structures, however, have been replaced by liquefied necrotic debris—”
His voice wavered, and he stumbled over the dry terminology, which, while accurate, belied the enormity of what had happened to Phyllis Sanders.
“The debris gives the appearance of two infectious processes, one causing a diffuse lobar pneumonia, the other a more consolidated infection, with evidence of phagocytic tissue destruction more typical of staphylococcal organisms—Jesus Christ! What the hell’s going on here?” he finally broke off and simply stood staring down at what defied his attempt at a cold clinical description.
For a few seconds no one spoke.
Then I realized what I’d heard—two processes.
“Could it be Legionella, Len, followed by staph?” I blurted out, clearly startling him out of his fugue. I glanced at Rossit. He was simply standing there, repeatedly swallowing, with his eyes riveted on the open lung. Two processes. Try and rip into me for mentioning Legionella now, Rossit, I thought, almost giddy with the possibility of suddenly turning the tables on the obnoxious little man.
Death Rounds Page 9