“Those authors actually said within two years. Full resistance to an antibiotic has developed in some bacteria only three months after the emergence of an inhibitory strain. And distance is no barrier to an organism these days. Jet travel’s just like an overnight shipping service for bugs; it can carry them from point A to anywhere on the planet within twenty-four hours. But this one probably didn’t get here from Tokyo.”
We joined a large group waiting for the elevator.
“What do you mean?” I demanded.
“I thought you said you read the article.”
I felt my face redden as I shook my head and admitted, “I only glanced at it.”
“Have you heard of the process called conjugation?” he asked.
Again I shook my head.
He folded his arms in front of his chest and began to explain. “Different types of bacteria in close proximity can pass genetic material from one organism to another. The nightmare scenario described in the article was a vancomycin-resistant enterococcus, VRE, passing its gene granting vancomycin resistance to methicillin-resistant staph. One of these genes—VanA—has already been inserted experimentally into the DNA of Staphylococci aureus in a laboratory. Though the researchers were using recombinant DNA techniques—adding specific enzymes to break the DNA strands of the VRE organism to isolate the VanA gene, then inserting that gene into the DNA strands of MRSA bacteria—their success in creating the superbug in a test tube strongly suggests the potential for the same transfer to occur naturally in real life through conjugation.”
He paused, like all good teachers do when they’re about to deliver a punch line.
“The circumstance by which it could happen in humans is chillingly simple,” he continued, looking down at me. “Both VRE and methicillin-resistant staph organisms can reside side by side in the human intestine. Since conjugation is a process occurring all the time, sooner or later it would release the specific genes conferring resistance in VRE, including VanA, and then incorporate these DNA fragments into the DNA of the methicillin-resistant staph organism. The next time this person didn’t wash his hands after wiping himself, the new bug would be in circulation.”
When the elevator door opened, nobody moved to get on. I’d been so intrigued by Williams’s description, I hadn’t noticed that the dozen or so people who were waiting with us had gone silent. His voice had easily carried to every one of them, and they were responding by backing away from me in my isolation outfit. The closure of ER and the transfer of patients by orderlies wearing ED protection already had the hospital buzzing. Rumors of this conversation would be like kerosene on fire. “Well, thank God we don’t have anything like that here,” I declared loudly, stepping into the elevator. “Makes our little MRSA case seem routine.”
I think I sensed the group relax a little, but not one of them got in the car with us.
“That was a slick recovery back there,” Williams complimented me after we’d reached the floor where the boardroom was located. “There’s enough possibility for panic as it is, without my setting it off. We can’t afford any; there’s so much to be done in the next hours and days.” We were trudging over the beige pile that stretched everywhere throughout the administration suites. “I keep forgetting how my voice carries. Comes from working with ducks; they don’t care what I say.” He glanced at me out of the side of his eyes and snapped his fingers. “That reminds me. I cut you off back in ER to keep you from scaring your own staff. You mentioned something much graver going on here than I suspected. It sounded serious.”
I’d already decided there was no way I could convince him here and now that Sanders was murdered. Besides, the containment exercise we were rushing into had to be carried out anyway, and knowing about the Phantom wouldn’t change how we’d do the screening.
We turned a corner and approached a massive set of double oak doors which, reaching as high as the ceiling, guarded the inner sanctum of the boardroom. The thought of those closed minds behind that set of doors only reinforced my decision. “It’s complicated,” I told him. “I’ll talk to you about it later, when we have more time.” To make him believe anything, I’d need him alone, and I’d certainly need him away from Rossit and Hurst. And I’d need him in a very private place where we wouldn’t be overheard or interrupted.
He shrugged. “Okay. It has to wait. Right now our job is to keep these turkeys in line,” he instructed, jerking his thumb toward where we were headed. “Administrators are always the biggest obstacle in any hospital outbreak—denying, blaming, covering their asses— like they can bluster the bugs to death.” Without breaking his step, he banged the tall panels open and strode through the high arched frame like a one-man assault team. “Morning!” his loud voice thundered even before the noise of the doors hitting the wall could die down. “I’m Dr. Douglas Williams from the CDC, and as of now I’m in charge of this investigation.”
Everyone standing around the room immediately froze. Rossit and Hurst, who’d apparently been talking together, gaped at Williams. A half-dozen men and women I didn’t know—presumably the local city and state health officials Williams was expecting—stood with coffee cups suspended at various distances from their mouths.
“If you’ll all please sit down, we have a great deal of material to cover,” Williams added, lowering his voice but not his authority. The chiefs present, eight or nine of them representing the areas most affected by the scare, quickly began taking their seats. Sean was there for surgery and gave me a wink, but the usual twinkle in his eye was missing. Len Gardner, already sitting at the long mahogany table in front of a stack of documents, presumably records of the Sanders autopsy, smiled and nodded his greeting. Arnold Pinter, chief of internal medicine, looking more startled than usual, scrambled to find a chair near the far end where Hurst regularly sat and hunched down in his seat. The outside officials and the remaining chiefs from obstetrics, gynecology, anesthesia, geriatrics, neonatology, and pediatrics quietly found places for themselves.
I surveyed the expectant faces staring back at Williams. It looked to me as if he most definitely had his turkeys in line.
Except Rossit. “This is an extreme pleasure and a surprise to have you here, Dr. Williams,” he gushed as he rushed up and grabbed the man’s big right hand, trying to pump it with little effect.
While I watched, a frown began furrowing its way across Williams’s massive forehead.
Rossit took no notice and persisted, “I had no idea our problem would rate such a distinguished world authority as yourself.” Turning to the men and women around the table, he explained, “Dr. Williams is a genius at studying the transmission patterns of an infection and determining if a particular vector—rodents, fleas, ticks, that sort of thing—is behind its spread among humans. Why, his work in the Southwest on the Hanta virus...”
While Rossit lavished on the praise, Williams glowered down at him and appeared increasingly annoyed. I couldn’t help thinking that if he’d plucked Rossit up and put him on his shoulder, together they would have resembled the strong man and Tom Thumb from old circus posters.
“Let’s get to work!” Williams commanded, gruffly putting an end to Rossit’s blatant attempt to suck up to him.
The little man flushed and his chin began its familiar chewing motion, but he took his seat without uttering another word.
Fueled by my earlier speculation about Rossit, I found myself studying his face. Normally I would have dismissed his obsequious behavior as simply another try to win some political advantage or other. But this morning, the possibility of a darker agenda sprang to mind. If Rossit did know the secret behind Phyllis Sanders’s death and was trying to keep it hidden, wouldn’t he be eager to get into Williams’s good graces, I thought, and attempt to influence the investigation that might expose that secret?
Chapter 11
An eight-hundred-bed teaching hospital like St. Paul’s employs more than three thousand people. A challenge, a threat, or a clear and present danger to any commu
nity of that size can mobilize its citizens into actions beyond their daily routine. Usual jobs take on an added importance, and the change is evident immediately in the corridors. The pace of walking is quicker, carts of supplies arrive at their destinations faster, conversations are briefer and limited to orders or instructions. There’s a snap to everything. Even more unusual, meetings are kept short and to the point.
Not long into our own session with Williams, we were interrupted by the technician responsible for screening in ER. She reported that at least a dozen of our staff had symptoms of colds— runny noses, sore throats, coughs—but none of them was very ill at the moment. Williams nevertheless ordered these people quarantined and asked that I assign some of my emergency physicians to check them out. We both agreed they probably only had the flu, but if they had any purulent nasal discharge or sputum, we would have to sample it, Gram-stain it, and look at it under a microscope to make sure they weren’t actively infected by staph. Even if these slides were negative, showing no evidence of gram-positive cocci in clusters, this group still had a problem. Flu, or influenza, was also known to inflame and damage bronchial airways enough to let staphylococcus penetrate into the underlying lung tissue, just as the Legionella had done in Phyllis Sanders. Anyone with the flu who as a carrier was also harboring the fully resistant superbug was vulnerable to developing a full-fledged infection by the fatal organism. Along with everyone else, they would have to wait forty-eight hours for their culture results.
I insisted on leaving the meeting and personally delivering Williams’s verdict to the affected people in ER. I tried to reassure them that we were simply taking precautions but watched uneasily, fearing the worst for them, while they bravely made cracks about being off to Club Med and were led away into one of the wards previously closed by Hurst As an added precaution, I advised the physicians who would be examining them to make sure no one had signs of a Legionella prodrome.
They were debating how to decolonize anyone found to be a carrier when I returned upstairs. The usual measures involved little more than repeatedly cleansing their hands and nails with bactericidal soaps and applying copious amounts of mupirocin ointment, a salve normally used for cuts and scrapes of the skin, to the mucous membranes of their noses. Unfortunately, these treatments were notoriously ineffective in eradicating nasal carriage sites.
“With the new strain, they may have no effect at all,” Williams advised solemnly. Incredibly, there were no other conventional de-contamination techniques to help modern hospitals deal with carriers. “If any of your personnel do prove to be harboring the superbug, we might try some experimental alternatives, albeit unsavory ones,” he added. “For example, slipping a tube through me mouth, up over the back edge of the palate, and into the posterior nasopharynx, then flushing a concentrated saline solution or bactericidal soap anteriorly through the passages would, theoretically, lavage the organisms out the front of the nose.”
The thought of it made me gag.
Williams then decreed that we’d have to screen all patients who’d been in the ER since Monday, including the friends and relatives who accompanied them. I knew from our statistics that four days’ worth of ER visits was nearly eight hundred patients, most of them having had at least one other person with them. “Are you aware of the work hours and resources we’ll need to culture sixteen hundred people?” I demanded, my eyes locked directly on Hurst. I didn’t want him giving us only half of what we’d need.
For my trouble I was told to set up forty culturing stations in the hospital auditorium and to man them with my remaining staff from emergency—doctors, residents, nurses, aides, orderlies, technicians, and clerks—who were not showing any symptoms of the flu. But they were to continue wearing protective garb, in case there were any carriers among them.
“Of course the cost of screening emergency department personnel and patients will be paid out of your ER budget,” Hurst declared, avoiding my stare. He turned toward Rossit and muttered something behind his hand.
When Rossit replied, his voice was just loud enough for me to hear snippets of what he was saying. “...if he’d treated the goddamned Legionella...might have avoided this mess...”
I felt my face flush all the way into my ears as I controlled my anger.
ER itself would remain closed until cultures taken from all the sites tested on the premises proved negative and the facility had been washed down with bactericidal soaps, just for good measure.
The meeting concluded with everyone dispersing to carry out dozens of tasks. Off-duty personnel from the rest of the hospital were summoned to help process all the specimens we would be collecting. Additional microscopes and culturing equipment had to be scrounged up from all over the city. Since bench space in the bacteriology lab would be overcrowded with people doing Gram stains and plating cultures, tables were set up in the corridors where rows of technicians prepared to examine hundreds of slides under the many borrowed microscopes. Volunteers were found to keep the records straight, sort the collected data, and enter the results into computers.
Yet as I watched so many of my colleagues mobilize against this organism, I was increasingly haunted by the fact that none of them knew it could be wielded by a killer. My resolve to make Williams see what I feared we were really up against grew by the hour.
But in the committee, we continued to lie. Our cover story explaining the massive screening effort was particularly disingenuous. “We’re evaluating existing isolation practices, making sure none of our patients or visitors in ER are at risk, by testing our response to a recent case of methicillin-resistant staphylococcus.” Maybe, technically, it wasn’t exactly a falsehood, but it sure as hell wasn’t the truth, and I felt dirty each time I repeated it
Finally, Williams attempted to limit outside publicity. “No bulletins over the airwaves,” he insisted. “Better we initially contact everyone we can by phone, keep the explanation low key, but stress they are obliged to come in to St Paul’s by order of the health department.” We recruited every secretary in the hospital to do the telephoning, and by 9:30 we were organized enough to begin calling in the first groups of patients.
All in all, logistically, it was an impressive response, but the truth remained that in an age of miracle drugs we were reduced to fighting this bacteria with little more than the weapons our forefathers used against pestilence—soaps, salves, and isolation.
* * * *
Her eyes tearing, her face grimacing in pain, she was trying to pull away from me. “Mommy!” she screamed. I got the culture swab out of her nose just as she started to sob uncontrollably.
“What are you doing to her?” cried her mother, sliding protective arms around the little girl’s chest and head while glaring angrily at me. The child’s name was Cynthia, she was six years old, and she’d had the misfortune of being in our ER for a sore throat the same day Phyllis Sanders had been admitted. She was in her mother’s lap, and they were both seated in front of me at one of the culturing stations. The testing of hands, nails, and nostrils—one swab per site—took minutes. The reassuring and comforting took forever. After an hour I’d barely managed to take samples from six people.
“I’m sorry,” I said to her mother. Then, facing the little girl, I cajoled, “Cynthia, you’re a brave young lady. I know it’s unpleasant, so take a little break before we do the other nostril.” While I talked, I inserted the swab I’d just taken into a tube of charcoal culture medium.
“No, I don’t want it,” cried Cynthia, burying her face in her mother’s shoulder.
Her mother cradled her head and rocked her slightly. “Couldn’t we leave it. Doctor? You’ve got samples from me, and after all, you said the chances of us getting it were remote. Why hurt her again?”
“We must get one more, I’m afraid,” I told the mother. To the back of Cynthia’s head, I added, “A few more seconds, and I’ll be through. You know, when they checked me this morning, I yelled twice as loud as you did.”
She peeked out a
t me.
“And I’ve got special friends in the cafeteria who will give ice cream to anyone braver than me.”
She studied my eyes. Being masked, gowned, and gloved, my appearance didn’t lower people’s anxiety any, but Cynthia must have seen something she liked, because a minute later I had my samples. “My name’s Garnet,” I told Cynthia’s mother. “Tell the cafeteria to put the ice cream on my tab.”
“Can I tell them I was braver than you?” asked Cynthia eagerly, exuberant now that her trial was over.
I laughed. “You sure can.”
“When will we know the results, Doctor?” asked her mother.
“The cultures take two days. As I said, it’s unlikely we’ll find anything.”
“But what happens if you do?”
“Oh, usually they use bactericidal soaps for the hands, and there’s an ointment that can be applied topically for organisms found in the nose,” I replied casually, trying to sound matter-of-fact.
“Thank you. Doctor,” said Cynthia’s mother, appearing comforted as she turned toward the exit and followed her daughter, who was already skipping happily out me door.
I finished labeling my specimens from Cynthia and summoned the next person in line. An elderly black woman with a cane slowly made her way to my table. “Hi, I’m Dr. Garnet,” I greeted her, “and I just need to take a few cultures. Rest assured there’s nothing to worry about. Now, if you’ll tilt your head back...” As I explained the procedure and set to work, I thought, Lord help us if anyone becomes infected and these people find out how they were lied to.
* * * *
Other problems were already starting.
The quarantined group had initially been cooperative, concerned for their own safety and not wanting to endanger their families at home. But then Rossit had begun insisting they have their noses lavaged right away without waiting for the culture results, contrary to what Williams had suggested. Suddenly the cover story that we were simply checking the effectiveness of our MRSA containment procedures was no longer sufficient to ensure everyone’s submission, even to the reasonable measures that Williams had intended. First there was a murmur, then a howl of protest against our authority to violate their personal liberty, subject them to forced confinement, and impose treatments on them without their consent.
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