Resistant

by Michael Palmer

  Easy, buddy, he said to himself. Easy.

  “I have a question,” Harvey Plimpton said when Scupman had finished.

  “Yes, of course, then I really must be off.”

  “You’ve shown us a number of frightening bacteria. Is there one species in particular that you are most terrified of contracting?”

  “That’s an easy one,” Scupman said, his hands now clasped together beatifically. “Many of my colleagues might argue that any of several virulent strains of carbapenem-resistant enterobacter are the most lethal of all. It’s true that these are certainly terribly powerful bugs. For me personally, though, without question, to contract the newest strain of Streptococcus pyogenes, cause of the condition known as necrotizing fasciitis; to be eaten alive from the inside out; to go from one limb amputation to another, would far and away be the worst death imaginable.”

  CHAPTER 5

  It takes discipline to confront the most horrible truths.

  —LANCASTER R. HILL, A Secret Worth Keeping, SAWYER RIVER BOOKS, 1941, P. 110

  This was it.

  For the foreseeable future, Jennifer Lowe vowed, this was the last time she was going into an operating room. It had been eight days since Becca Seabury’s right arm had been amputated. Now, the teen was back in the OR. This time it was going to be her right leg.

  Becca was toxic. Really toxic. In addition to her leg, there was evidence of infection in her core—her lungs and heart, and the structures surrounding them. It had been horrible to watch. Jennifer had been at her side every day—ten- or twelve-hour shifts. No days off. Jennifer’s supervisor at White Memorial had warned her against making any other schedule changes with the other nurses, but she went ahead and did it anyhow. She had been on two- or even three-week medical missions to the Congo where she essentially worked twenty-four-seven.

  “I have an apartment and a new mattress waiting at home,” she would tell anyone who wanted her to take a break. “What do these people have?”

  It wasn’t the hours surrounding Becca’s care that were getting to her, it was the helplessness and frustration. It was the waiting. She shifted where she was standing on a riser in order to get a better view over the surgeon’s right shoulder. This case had been incredibly draining on the entire team since the original, triumphant repair of Becca’s arm, but the development of infection had been toughest on Dr. Beebe. He seemed to have aged significantly since the first call from the ortho floor that something was going wrong with their star patient.

  “Scalpel … suction … clamp … another clamp … scalpel … retract more, please…”

  To Jennifer, Dr. Beebe’s words were like white noise. The only thing she felt the least bit relieved about was that Becca was deeply anesthetized.

  “Hemostat … more suction, please … right here … suck right here, please. Bart, her blood’s looking a little dusky. Is everything okay?”

  “Oh-two sat is down some. I’m working on it.”

  Beneath her surgical mask, Jennifer felt her own respirations increase. Subconsciously, she rubbed at the V between the third and fourth fingers of her left hand. The eczema, for that is what she was certain it was, seemed to be getting a bit more intense—a bit more itchy. Given the disease that was ravishing her patient, it would have been foolish for her not to consider the possibility that she was incubating the same thing. But if it looked like a duck and quacked, it was a duck. And this rash looked like eczema.

  Just in case, Jennifer had done some reading about the bacteria infecting Becca’s incision and surgical repair—the bacteria some in the press had dubbed the Doomsday Germ. The medical world, and the patients themselves, had been asking for trouble since the invention of penicillin, and more and more, the bacterial world had been delivering in the form of resistance.

  There were effective treatments for some viral illnesses, such as herpes and influenza, but no antibiotics that worked for bronchitis, most middle ear infections, or a common cold. First-year medical students were warned not to use antibiotics unless a specimen had been obtained and a bacteria cultured from it. Ideally, the specimen should also be sent for antibiotic sensitivities. Yet each year, over and over again, thousands of times, millions, tens of millions, antibiotics were prescribed by physicians who wanted to keep their patients satisfied, and to keep them from bolting to another doctor.

  It hadn’t been that long since the first reports of this new strain of bacteria had surfaced. Although the name some reporter had given it was frightening and catchy, it still wasn’t even the stuff of front-page headlines. A case here, another case there. Just another antibiotic-resistant microbe. No one really seemed that worried about it. In fact, Becca Seabury was only the fifth documented case in Boston, only two of them at White Memorial, one of the busiest hospitals in the world. In addition, all the cases Jennifer read about, in Boston and other places, were like Becca’s—large, open fractures or post-op wounds.

  The MRSA bacteria—methicillin-resistant staph aureus—was much more prevalent, and from all she could tell, was gradually coming under control. She had the sense that the Doomsday Germ, a coccus with peculiar staining patterns, was an aberrancy—the sort of infectious agent like chicken pox that caused a minor illness in most, but went absolutely, lethally berserk in a few others.

  Eczema. That was what was itching her hand. Nothing more, nothing less.

  Please God. Let Becca make it through this. Let her get better and lead her life with what limbs she has left, and what the prosthetics people can make for her.

  “Bart, how are we doing?” Beebe was asking in a soft voice. “Bleeding’s stopped here, but I’m not completely happy with her color.”

  “Working on it, Chandler. Pressures down a bit. I’ve started some dopamine.”

  “I’m ready with the oscillator, Bart. Go or no?”

  There was a break in the exchange.

  Prolonged silence, penetrated only by the beep of the oxygen saturation monitor.

  “Go,” the anesthesiologist said finally.

  Please, Jennifer pleaded once more.… Please.

  At that moment, Beebe looked back at Jennifer.

  “Jennifer, you holding up okay?”

  “As well as can be expected, I guess,” she answered through her mask.

  “Given Becca’s overall condition things are going as well as can be expected, but this is the hardest part now. I’m going to use the oscillating saw to separate Becca from this infection. After the infection is gone she’ll start getting better. I know you probably know all this, but given how much you have invested in her care, I wanted to be sure.”

  “I’ve seen an oscillating saw used before.”

  Jennifer purposely didn’t add that it had been an incredibly stressful, unpleasant experience for her.

  “Okay, so you know the kind of noise it makes—sort of like a dentist’s drill.”

  Like a hundred dentists’ drills.

  “I know,” she said.

  Jennifer’s jaws clenched at the first screech of the powerful oscillating saw, an instrument whose blade cut by rapid back-and-forth movements rather than by rotation. She had never done well in dentists’ offices. She was a brave—some had even said fearless—nurse, but the noise and knowing what was going on beneath the huge saucer-shaped lights caused her to avert her eyes. Limiting the sterile field with drapes depersonalized things a bit, but this was a person who had come to be like a younger sister to her.

  The amputation of Becca’s leg at a spot just below her hip was almost complete when trouble began. Jennifer looked up just in time to see it develop on the monitor screen—extra heartbeats, almost certainly ventricular premature beats. First one, then a pair, then a burst of four together. Her own pulse leaped.

  “Bart?” Beebe asked in his surgical voice. “What’s the deal?”

  “We’ve got sudden VPBs and a pressure drop. I’m giving her amiodarone.” Jennifer tensed even more. Amiodarone was used to suppress the irritability of Becca’s heart,
and to stabilize her suddenly unstable rhythm. The VPBs could just go away, or they could be the beginning of something very bad.

  “Janet, call cardiology,” the anesthesiologist said to the circulating nurse.

  By the time Jennifer Lowe checked the monitor screen again, the pressure was forty. Becca was crashing—complete cardiovascular collapse. Her heart, compromised by infection, had gone as far as it could go.

  “Looks like she’s about to code, Chandler. You’re going to have to close as fast as possible.”

  Oxygen saturation plunging.

  Pressure thirty.

  Extra heartbeats increasing, then suddenly changing into a rapid, totally irregular sawtooth rhythm.

  “V. fib,” the anesthesiologist called out. “Call a code blue now. Start chest compressions, get the code cart, and get ready to defibrillate.”

  Like a video put into fast forward, the action in the OR increased immediately. From her place on the riser, Jennifer watched transfixed. She was skilled at all aspects of resuscitation, but she was there as an observer, not part of the code team. Much as she desperately wanted to help, she knew that there were more than enough hands. Too many people in a code was asking for trouble. The best thing she could do at this point was to stay out of the way.

  But she knew from the moment they called a code blue, that Becca was doomed. In essence, the resuscitation had begun as she was put to sleep and intubated. There was not much to be done that would get at the reason her heart was giving up.

  “I don’t see any end tidal carbon dioxide, Danielle. Chest compressions need to be deeper and faster.”

  “We’re almost closed, Bart. How’s she doing?”

  “Horrible. Ready to defibrillate, Mary.”

  “Pads on. What settings?”

  “Two hundred joules. Everybody ready? I’m clear, everybody clear. Shock.”

  Jennifer saw Becca’s body jolt. The monitor remained unchanged.

  V. fib.

  “Restart chest compressions,” the anesthesiologist called out. “Give her one milligram of epinephrine and continue compressions for two minutes.”

  Jennifer knew there was no way the team was going to give up without a fight, especially with a teenager’s life at stake. Another twenty minutes would be conservative.

  From where she stood, she could see Becca’s face. Her eyes had been taped shut through the entire case, but even with that and the breathing tube, and the compressions and the action swirling around her, Jennifer thought there was a serenity there.

  She stood motionless as the violent compressions continued, punctuated by more drugs and shocks. Then finally, after what seemed an eternity, it was over. The anesthesiologist, clearly shaken, checked the clock, thanked the team, and stated the precise time.

  Beneath her mask, Jennifer finally felt the flood of tears begin. Still, she stood there, unaware that she was rubbing at the odd rash between her fingers.

  CHAPTER 6

  Should a person offer to plow a farmer’s field for no fee, the farmer would be a fool to plow it for himself.

  —LANCASTER R. HILL, 100 Neighbors, SAWYER RIVER BOOKS, 1939, P. 24

  “I’m afraid I’ve not progressed as far as I had hoped.”

  Dr. Andrew Pollack’s voice came through the speakers with perfect clarity, not at all distorted this time. The latency from the last encryption program had made conversation almost inaudible. At least, Kazimi thought glumly, this was one thing going right.

  “Just send me what you have,” he said.

  “You’re going to be disappointed, Kaz.”

  Kazimi hesitated. Three years into all this, and he still had not grown accustomed to being called by that name, even though he was—at least according to his driver’s license, passport, birth certificate, social security number, and those associated with him personally or online—the person called Ahmed Kazimi. Those perfect documents were not the product of some fly-by-night backroom forger, but came courtesy of the federal government of the United States of America. As for the Stanford microbiologist who had been born with another name, that man was simply missing—vanished one day into thin air, and presumed by the police, the university, and all those who knew him, to be dead, drowned while sailing in his small sloop.

  “Lately, I’ve come to expect disappointments,” Kazimi replied finally.

  “Well, at least we’re not dealing with a real crisis.”

  Kazimi fought the urge to correct Pollack, who was convinced that he was part of an online task force made up of military men, scientists, and even bestselling writers of fictional suspense. Their mission, conceived and orchestrated by the president himself, was to create scenarios involving bioterrorism and then to devise ways to counter the danger. Kazimi skillfully bounced a soccer ball on one foot while awaiting the brilliant Northwestern University entomologist’s data transmission. It had taken years of constant effort, but finally Kazimi and his virtual team of experts were making real progress in developing a macrolide/beta lactam antibiotic to treat the Gram-positive fluctuation of the bacterium dubbed the Doomsday Germ. To his continued dismay, coming up with an effective treatment for the Gram-negative fluctuation continued to elude them.

  At least Kazimi had the endless resources of the federal government at his disposal. The lab where he worked was located in the basement of a brownstone in Brightwood, a quiet Washington neighborhood near the District’s northern tip. To ensure secrecy, the government, at his suggestion, agreed to hide the lab in plain sight. Nobody, not even the resourceful One Hundred Neighbors, would presume to look for a government-run microbiology laboratory in a residential neighborhood.

  Before he vanished, the lab had been built to Kazimi’s exacting specifications. He had incubators, freezers, an electron microscope, biological safety cabinets, plus several computers. What he did not have—at least not yet—was a viable treatment for the Doomsday Germ.

  “Have you received my transmission?” Pollack asked.

  Kazimi thought he heard a slight phase shift in Pollack’s voice—the equivalent of a digital quaver. Perhaps it was just his ears playing tricks again. Fourteen hours working with few breaks in a basement lab, with no access to sunlight, and rare direct human contact, could do that to a man. Yes, it was just his ears playing tricks, he decided. The data Pollack sent came through the decryption program just fine.

  “I’ve received it,” Kazimi said.

  “You’ll see that my latest approach does appear to inhibit bacterial protein synthesis, and that I’m also inhibiting ribosomal translocation. The main problem continues to be speed—killing the little beasties fast enough to overwhelm their ability to mutate and gain resistance. If we can accomplish that, the very elements that have been working against us will be working for us.”

  “Very good,” Kazimi responded. “Give me a minute to review the findings in more detail.”

  He saw the problem in a matter of seconds. Another scientist may have needed a day or two to spot the glitch, like finding a needle in a haystack of data, but not Kazimi.

  “The bacteriostatic agent you have been using is getting in the way,” he said.

  “Perhaps … No, wait. I see what you mean. I see exactly what you mean. Let me test the drug with a different one.”

  “And with none at all.”

  Again Kazimi thought he heard something in Pollack’s transmission—an electronic shimmer that briefly distorted his voice.

  Had they been compromised?

  The architects of the Doomsday Germ were not to be underestimated. They had created an organism more sophisticated than anything he had ever seen. He would not have been all that surprised if they had somehow gained access to these secure transmissions. If so, it might result in an acceleration of the timetable they’d issued.

  Kazimi shuddered at the thought and debated whether to include this new suspicion in his daily report. A false alarm could raise concerns about his mental state. He’s hearing things, they might say, becoming paranoi
d. Every person, even someone with his penchant for solitude, has a breaking point. He feared tipping the scales in a way that could risk his involvement with the project. He had come too far, given up too much, not to see this to the end.

  “Nothing to be disappointed about,” he said, rubbing at the grit stinging his eyes. “You’ve done well, Dr. Pollack.”

  “And how about the other players in the game?”

  The game.

  Again Kazimi felt a pang of guilt for the ongoing deception, but it was a necessary precaution. Nobody could know about the very real threat facing America. The only people, as far as he was aware, who knew the specifics of his research were the president, the vice president, and a few select members of the president’s cabinet. The CIA and FBI, each investigating things from different angles, had to have amassed vast amounts about One Hundred Neighbors, but the inner circle with full knowledge of the threat the terrorists were presenting was limited to the most essential personnel. Even the smallest leak about the threat facing the nation would likely cause panic on an epic scale.

  “Do you have another piece of the problem for me to try, or would you prefer I keep working on this one?” Pollack went on.

  “Yes, keep working. The others will have a look at these data as well. We’re doing great.”

  Another lie. Kazimi had been dishing them out like Halloween candy ever since he gave up his life to go underground. The truth was they were fast running out of time.

  “You know, I’m really enjoying this little exercise of ours,” Pollack said. “Much more so than I thought when you first approached me. I’m glad I decided to come aboard.”

  There it was again—an audible phase shift in Pollack’s voice. Kazimi decided this was definitely something to go on his report. He might be wrong, but it was worth the risk. Even if it turned out to be nothing, NSA experts would probably have a new encryption program installed by morning.