“Damn it, Michael!” I was snapping again. “I told you it was a ruse!” Once more I took a few seconds to try to calm down. “Have you talked to her yourself today?” I asked through clenched teeth.
“No, I haven’t seen her at all. But she’s obviously been feeding the gossip network,” he replied brusquely, letting me hear how miffed he was with her.
“Well if you had, Michael, she’d have told you she’s only saying that stuff to fool the creep who attacked me last night into thinking she’s backed off.” The receiver might have been Michael’s neck, I was squeezing it so hard. I relaxed my grip and watched the blood rush back into the skin around my knuckles. Still, I couldn’t let go of my fury with him for being so thick. “You didn’t see that woman’s lung. It made me scared for anyone at University Hospital, including Janet and you. Now I’m scared about what’s going to happen to poor Stewart. And I’m going to stay scared every time Janet goes to work and every time she comes home and goes near the baby.” I let my frustrations pour out of me. “Better yet, Michael, put yourself in Janet’s position. You don’t think she isn’t frightened, at least if not about herself, then certainly about Brendan?” Then I let fire my final shot. “Whether you’re right or, God forbid, she is—and I’m more and more convinced she is—you could at least give Donna and your unborn child the same concern.”
I heard Michael grunt like he’d been hit, then listened to him breathe for several seconds. “Ouch,” he finally answered. Then added, “God, how could I be so blind!” A few more seconds passed. “I’m such an asshole! Donna’s right, I’ve got the sensitivity of a run-away truck once I get my head set on a clinical problem.” He was speaking more and more rapidly and sounding increasingly chastised. “Damn, I’m sorry, Earl; I just never clued in on how this might be affecting Janet and you personally. Will you forgive me? And will Janet? Oh my God, Donna will kill me for this if she ever finds out I was so insensitive. I’ll find Janet and apologize to her myself. No! Better yet, I’ll send her flowers in the morning and then apologize. For God’s sake, don’t let her tell Donna.”
While his self-reproach built up steam, I recalled something about jackasses and two by fours, but now that I had his attention, I pushed. “Michael, it’s time to cash in all those markers you’ve chalked up with the accreditation board and get me named to this audit. Or threaten Cam if you have to. Tell him we’re sitting on another presumptive diagnosis of Legionella related to the Sanders case. Impress on him that I’m his best chance of finding answers before culture results make the outbreaks official. If he still isn’t moved to cooperate, tell him I’m going public by noon tomorrow unless I’ve got carte blanche to find out what’s going on over there.”
Michael’s silence was encouraging. Figuring I had him cornered, I hung up before he could change his mind.
I heard sirens approaching. There were at least two, maybe more. If they were all ambulances heading to our ER, I knew I’d be called to help within minutes. I was starting for the door and pulling my stethoscope out of my lab coat pocket when I noticed the MMB article slide out with it and fall to the floor. I paused to pick it up, glanced at the summary on the first page, then started to slip it back into my pocket. Had Miller been accurate in his précis of it? The blended wailings of the sirens were closer but no ambulance was here yet. Neither had Susanne run in to fetch me. I had a moment still.
Unfolding the article, again I skimmed through it. The brief synopsis described a case report from Japan of the world’s first-ever infection by a methicillin-resistant, vancomycin-inhibiting staphylococcus organism. The key word was inhibiting. It ultimately succumbed to vancomycin but only at very high doses. What had made this case alarming, the authors stated, was that in the past, organisms on the way to becoming fully resistant to a specific antibiotic had often demonstrated this inhibiting effect first. Historically, the emergence of a fully resistant strain of these organisms almost invariably followed, usually within two years. Should the same pattern repeat itself this time, the resulting staphylococcus bacteria, resistant to both vancomycin and methicillin, would be virtually untreatable. Any new antibiotics that might be useful were at least two or three years away from use in humans. The authors then brought the issue even closer to home. The first vancomycin-inhibiting strain of MRSA in the United States was reported by a hospital in Michigan, a second by a hospital in New Jersey. In both cases the organisms had responded to large doses of antibiotics, and no outbreaks anywhere in the world had been reported since.
One of the sirens had become much louder than the rest. Suddenly it cut out, and seconds later I heard the vehicle roar into the ambulance bay.
Getting ready to leave, I flipped over to the last page. A single item in the final list of recommendations was what I was looking for. Exactly as Miller had reported, in a case like his mother’s, in which a staphylococcal infection had failed to respond to vancomycin, the organism should be rechecked for this new trait of reduced susceptibility. There was even a hot-line telephone number at the CDC where any instances of the strain were to be reported immediately.
I tossed the article onto my desk. The rest of it looked rather technical and would require more time than I had at the moment. I had a hell of a lot more to worry about than some theoretical superbug coming at us from the other side of the world two years in the future.
But as I was heading out the door and running toward ER, on impulse I thought, why not call bacteriology and ask that vancomycin be included in Rossit’s special sensitivity tests already under way for the Sanders case? According to the CDC, the minimal inhibitory concentration method he was using—a determination of the times a culture of the organism can be diluted and still resist a given antibiotic—was the only reliable way to screen for the inhibiting strain. Rossit would probably be furious at me for meddling with his lab studies, but at least the gesture of adding the antibiotic to the group being checked might please Miller. After all, if Rossit hadn’t been so busy bad-mouthing me, he could have kept St. Paul’s up-to-date on this latest protocol for staph infections himself, the way Cam had done for University Hospital. I asked the clerk at triage to phone in the order.
The next hour I spent working with every available resident and doctor in ER resuscitating a dozen seniors suffering from smoke inhalation. Their residence had burnt to the ground. The culprit responsible for the fire, an eighty-year-old man repeatedly caught smoking in bed, was brought in later—a charred corpse held together by a body bag.
As I was filling out his death certificate, our telephone clerk transferred a call to where I was sitting. “Bacteriology department for you Dr. Garnet, line three.”
It was a technician.
“Dr. Garnet, I’m sorry to bother you, but the clerk told me you wanted the staph organisms from the Sanders case checked for an inhibitory effect on vancomycin?”
“That’s right.”
“Well, I thought I’d better tell you, it’s already been ordered.”
“Really? How come that’s not on her chart?”
There was a pause. “Gee, Dr. Garnet, I hope I’m not in trouble.” Another pause. By now I recognized the voice of the technician who’d done the initial Gram stain on Sanders’s sputum sample and who’d been so excited about finding staphylococci. “You see, it wasn’t exactly an order,” he continued, sounding sheepish. “It was actually more a suggestion from Dr. Mackie over at UH. He phoned yesterday morning, said he’d consulted on the case, and recommended we do the test since Harold’s mother wasn’t responding to treatment. It’s the routine in his department, and should be here too if you ask me.”
“Did you check with Dr. Rossit?” I asked, glad this innocent couldn’t see my wicked grin.
The complete silence on his end of the line answered my question. Finally the young man dared to say, “You know how he is, Dr. Garnet. Besides, Dr. Mackie’s going to be the new overall chief soon, isn’t he, when the merger goes through?”
Not if Rossit can help it, I
felt like warning him, for despite the popular expectation that Cam would prevail on merit, I’d seen hospital politics favor the Rossits of this world all too often. Ambition was an easier currency for boards and CEOs to manipulate than the harder mettle that resided in a man like Cam. I tried to keep my voice neutral when I replied, “You must have inside sources that I don’t.”
I’d been about to hang up when the tech said, “Dr. Garnet, I wonder if I could ask you a favor?”
I immediately felt my guard go up. “Yes?” I replied cautiously. Over the years, as a physician and a chief, I’d been asked a lot of favors. Most had been legitimate, but some, especially those from people I didn’t know, had been embarrassingly inappropriate and some had been outright illegal.
“Well, since you were going to order it anyway...”
“Would it help your peace of mind if I put my name on the order?” I volunteered, chuckling at the simplicity of the request.
“Would you? That’ll be great! The test probably won’t come to anything, but I never know what Dr. Rossit is going to be angry about, especially these days.”
Another little sin on my tab wouldn’t matter much, I thought while hanging up.
* * * *
Before leaving that evening, I dropped in to see Stewart. It was an eerie feeling gowning up to visit him in the same glass chamber in which we’d put Phyllis Sanders.
At first Stewart appeared in surprisingly good spirits and seemed more intrigued by how he could have contracted Legionella than frightened by his infection. But as we talked about the conventional investigations into the organism’s source—I’d no expectations they’d find anything—I soon discovered Stewart’s underlying fear when he began to cough from the effort of speaking. As his hacking made him progressively short of breath, his eyes filled with alarm, and he asked, “Do you think when the pneumonia comes I’ll get as bad as she was?”
“Of course not Stewart,” I bluffed. “Early treatment’s the key to a mild and uneventful course. And remember, she had a secondary staph infection as well.”
He looked away without saying anything more and stared through the glass walls of his isolation room into the dim light of ICU. The gray semidarkness of evening was visible through the large outside windows behind the nurses’ station. He knew as well as I did that evolving respiratory conditions get worse at night. And as a physician, he knew what could go wrong. I figured he had to be thinking of the Legionella cases he’d seen in the past. It would have been impossible for him not to remember chest X rays he’d viewed that had shown the lungs whited out by the disease. He’d certainly have seen the remains of the infection at autopsy often enough, though I thanked God he hadn’t witnessed the particular horrors of Phyllis Sanders’s post today. Even with antibiotics on board, he had no way of knowing for sure what lay ahead for him.
All the while I desperately wanted to ask Stewart some leading questions about who might have done this to him. But should I? In his vulnerable state, he might not be as skeptical as his colleagues, and talking about the Phantom could needlessly add to his fears.
“Stewart,” I began, choosing my words carefully, “if the infection is related to the Sanders case, then your exposure had to have happened in the first hours after her admission. Was there ever anyone around you using an aerosol at that time?”
“No, I went through all that with Rossit.”
“Do you use any nose sprays for allergies?”
“Again, like I told Rossit, no.”
“Did anyone visit Sanders from UH on that first day?”
“Visitors? Besides her son? No. She was in no shape for visitors. You know that. Unless you consider Cam Mackie a visitor.”
“Was anyone else here, during those hours—an orderly, a nurse, someone dressed in isolation garb you might not have recognized— who shouldn’t have been?”
“What do you mean?”
“Could some unauthorized person have come in here and been around you and Sanders, and you not have realized it? In my own department all sorts of people in greens come and go—they’re almost invisible—without my noticing it.”
“I don’t know. It’s possible I suppose, but we’re a lot smaller and more controlled than ER. The nurses would be pretty quick to ask anyone they didn’t recognize what he or she was doing, especially if someone tried to get into this room,” he answered, sounding a little morose and looking around him. I suspected he still couldn’t quite believe he’d ended up a patient in his own domain.
“Is there anyone who you’ve seen around a lot outside of here who may have been following you or want to do you harm?”
“What!” He stared at me, an expression of amazement creeping over his pale face.
I immediately backed off. “Nothing, forget about it. I was just kidding—a bad joke about how shit disturbers like you and Sean could expect Hurst to keep an eye on you. You guys really got him nicely at the meeting today.”
He looked puzzled but seemed to accept the question as a failed attempt to make him laugh. I decided that I couldn’t ask him anything more without scaring him silly or leaving him convinced I was crazy.
When I stopped at the nurses’ station to check his chart, I learned everyone working in ICU had gone on oral erythromycin as prophylaxis against Legionella, despite Rossit’s best attempts to assure them it wasn’t necessary. Not a bad idea, I thought. Maybe Janet and Michael should do the same thing.
All the way home I kept wondering how someone from UH could have gotten near Stewart and infected him without his knowing. Despite his protests to the contrary, I was sure he’d be as oblivious as I to the legions of anonymous hospital workers who were around us every day. They could come and go like ghosts or like a phantom. I began to feel overwhelmed again by how nebulous our killer was. Might it be impossible to ever pull him from the shadows? Could he go on forever, moving undetected through the faceless echelons of a hospital, and continue to murder?
I felt a little less hopeless when I remembered Cam had been with Stewart and Sanders during those critical hours. Maybe he had recognized someone he knew from University Hospital, someone he might normally pay no heed to at UH but who may have stuck out in his mind because he or she was at St. Paul’s. I’d ask him tomorrow.
It was only at the entrance to my house that I asked the big question. Why was Stewart chosen as a victim? I couldn’t think of any conceivable motive pertaining solely to him. Then a nasty possibility concerning myself popped unbidden into my head. Perhaps it was a demonstration, a show of power, a message from the killer that he could get anyone he wanted, including people on my turf, and I couldn’t do a thing about it.
The relief Janet showed when she learned I’d soon be with her at UH quickly evaporated when I told her what had happened to Stewart. She was also as disturbed as I was about the implications of the attack. Like me, she no longer included an if during our discussions of the killer.
I related the rest of the day’s events during our dinner together, although it felt more like a debriefing than table talk. I wanted to make sure I hadn’t overlooked anything significant.
Janet was quiet afterward, then said, “There is something that doesn’t add up. It’s Rossit. Why would he want the amalgamation to go ahead?”
I’d been too preoccupied about Stewart to have given much thought to Rossit’s peculiar antics at the meeting. “How do you mean ‘doesn’t add up’ ?”
“Whatever he’s cooking up with Hurst, given the likelihood he’ll lose his job as chief to Cam once the merger goes through, I’d have figured he’d be cheering you on, not threatening you or anyone else who was trying to stop the amalgamation.”
I leaned back as I thought more about Rossit. “He may not be as completely out of the running against Cam as everyone thinks,” I finally answered.
“What?”
“Politics can be screwy, and Hurst might figure it would be easier to make deals with a self-serving guy like Rossit than it would be with Cam.”
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br /> “That sucks,” Janet said.
“It supersucks when you think he’s probably making the same calculation about every chief, including yours truly, and will only support those he’s sure he can control.”
“Christ!” she muttered, downing her drink—club soda, in deference to both recent and planned efforts at keeping Brendan from being an only child.
“If Rossit thinks he’s got some kind of arrangement with Hurst,” I resumed, “then he might see the merger as an opportunity and not a threat.”
Janet received this observation with raised eyebrows, leaned back, and seemed to savor it for a while. “I see what you mean,” she finally allowed.
I picked up my own drink, a Black Russian, acknowledged that the rules of pregnancy weren’t fair by raising my glass to Janet, then swirled the ice, took a sip, and added, “What I don’t get is Rossit’s extraordinary ardor in trying to nail me for the Sanders case. It’s gone way beyond his usual mean streak, and for the life of me, I can’t see how my downfall could benefit him.”
Janet had winced at the word downfall. “Has he ever teamed up with Hurst before, during any of these other vendettas he’s carried out?”
The image of Rossit and Hurst huddled together, whispering and pointing toward me, sprang to mind. I shuddered, then answered, “No, at least not that I know of.”
Janet settled back in her chair and twirled the stem of her glass with her left hand. “So,” she began, holding out her right thumb, about to start counting something, “Rossit has outdone even his own smarmy standards in his attempt to crucify you.” She held up her index finger alongside her thumb. “He’s even recruited Hurst’s help, an unusual step for him, to get you into Death Rounds almost immediately.” Her middle finger joined the other two. “And he’s a fan of the merger, as though against all odds he has some trick up his sleeve whereby he could prevail over Cam.” Four fingers were now in the air. “Hurst’s support could be part of that trick, but Rossit’s got to know my hospital’s going to fight as hard as yours to dominate the merger. He’s got to be counting on something more than Hurst’s getting his wish list to help him win the day.” The fifth finger she pointed at me, with an expectant look. It was my turn to provide a piece of the puzzle. “What could be Rossit’s additional hidden trick?” she asked.
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