ISOLATION WARD
A Delacorte Press Book / March 2006
Published by
Bantam Dell
A Division of Random House, Inc.
New York, New York
This is a work of fiction. Names, characters, places, and incidents either are the product of the author’s imagination or are used fictitiously. Any resemblance to actual persons, living or dead, events, or locales is entirely coincidental.
All rights reserved
Copyright © 2006 by Joshua Spanogle
Delacorte Press is a registered trademark of Random House, Inc., and the colophon is a trademark of Random House, Inc.
Library of Congress Cataloging in Publication Data
Spanogle, Joshua.
Isolation ward / Joshua Spanogle.
p. cm.
1. Physicians—Fiction. 2. Group homes for people with mental disabilities—Fiction. 3. Women with mental disabilities—Fiction. 4. Virus diseases—Patients—Fiction. 5. Hospital patients—Fiction. 6. Baltimore (Md.)—Fiction. 7. Epidemics—Fiction. I. Title.
PS3619.P344I85 2006
813'.6—dc22
2005041743
Published simultaneously in Canada
www.bantamdell.com
eISBN: 978-0-440-33586-3
v3.0_r1
Contents
Title Page
Copyright Page
Epigraph
Baltimore
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
California
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Chapter 46
Chapter 47
Chapter 48
Chapter 49
Chapter 50
Chapter 51
Chapter 52
Chapter 53
Chapter 54
Chapter 55
Chapter 56
Chapter 57
Chapter 58
Chapter 59
Chapter 60
Chapter 61
Chapter 62
Chapter 63
Chapter 64
Chapter 65
Chapter 66
Chapter 67
Chapter 68
Chapter 69
Chapter 70
Chapter 71
Chapter 72
Chapter 73
Chapter 74
Chapter 75
Chapter 76
Chapter 77
Chapter 78
Chapter 79
Chapter 80
Chapter 81
Chapter 82
Chapter 83
Chapter 84
Chapter 85
Chapter 86
Chapter 87
Chapter 88
Chapter 89
Chapter 90
Chapter 91
Chapter 92
Chapter 93
Chapter 94
Chapter 95
Chapter 96
Chapter 97
Chapter 98
Chapter 99
Chapter 100
Chapter 101
Chapter 102
Chapter 103
Acknowledgments
About the Author
The history of medical innovation has shown us unwilling to resist tangible individual benefit even in the face of unknown risks.
From “Uncertainty in xenotransplantation: Individual benefit versus collective risk,” Nature Medicine 4, 141–144 (1998)
This is how it started. At least this is how it came to me over the telephone, 6:30 a.m. from a local health official trying to keep it together, fighting against little sleep and a ballooning fear that this might be The Big One.
A week and a half before, 4:15 p.m.: A thirty-one-year-old white woman presented to the Emergency Department with a sore throat, muscle pain in her legs and back, and a dry cough. She had a slight fever. The staff doctor thought it was garden variety flu, gave her some fluids and Tylenol, and sent her home.
Three days later, she was back at the hospital. The pain in her throat was worse; her tonsils were engorged and flaming red, flecked with pus. She’d added a good two degrees to the fever—this is Celsius now, so she’s up to about 104 Fahrenheit—and a collection of new, disturbing symptoms: abdominal pain, diarrhea, bleeding gums, bloody nose. Rectal exam showed bright-red blood, indicating hemorrhage in the lower gastrointestinal tract. She had severe pain in the muscles of her neck and back. The guys in the ED tapped her spine, analyzed her blood, and started her on IV fluids. She was beyond emergency room help, so they admitted her to the hospital.
The docs upstairs swabbed the throat, took blood and tried to culture some bacteria, ran ELISAs to find viral antibodies. No luck. They kept pumping fluids, balancing her electrolytes, and generally giving her what we call in the trade “supportive therapy.” It’s what you do when you can’t do anything else.
A day later, another young woman presented to the same ED with flulike symptoms: aches, fever, dry cough. Again, fluids and Tylenol, and the emergency medicine doc sent her home. The next day she was back: abdominal pain, muscle aches, high fever, vomiting, sore throat. Some bleeding in her gums. They admitted the woman and contacted the local health department. Still, though, no red flags went up.
Until the next day, when the skin of the first woman began to slough. It started as petechial hemorrhages—pinpricks of blood under the skin, a sign that tiny capillaries were leaking and bursting. But the pinpricks grew quickly into patches; the patches lifted off the underlying tissue, leaving raw, bloodied ulcers.
Then, early that morning, just after midnight, another young woman came into the emergency room. She, too, complained of flulike symptoms, and she was scared. It seemed that she lived with the woman who first presented, who was upstairs shedding her skin.
In the third case, the woman wasn’t sent home but was immediately admitted. That was at 2:41 a.m. Four hours later, I was taking it all in from Dr. Herbert Verlach.
Verlach was rattled, and anything that rattled him, an ex–Army doc, rattled me. As he rambled on, I could almost hear his mind ratcheting through the possible diagnoses for these women: Lassa fever, Ebola, Marburg, or one of the myriad other nasties against which we’re trying to protect the public. You tell yourself that the likelihood of its being anything really bad—or, worse, really bad and intentional—is pretty damned small. But that pretty damned small chance is what we’re paid to watch for. And paid to stop if we can.
I wondered how Verlach slept at night.
Anyway, I sleep like shit, so I’d been up for two hours by the time his call came. Before I was off the mobile phone, I was in my car, speeding through Baltimore’s morning r
ush, a tight feeling in my gut that this was not going to turn out well.
CHAPTER 1
St. Raphael’s was an old Catholic hospital, struggling to maintain its independence in the face of overtures—friendly and outright aggressive—from Johns Hopkins and the University of Maryland. The hospital sat in the middle of a decayed neighborhood in the southwestern quadrant of the city, surrounded to the north and west by housing projects and to the south and east by a mix of old factories and abandoned row homes. The hospital served the needy in the immediate area, but extended its reach to the working-class neighborhoods of Pigtown and Locust Point. The last I heard, it was hemorrhaging money and talks with Hopkins and Maryland had started up again, this time at St. Raphe’s behest. The former belle at the ball, now trying to dance with anyone who’d have her. Rumor had it the powers that be—admin at St. Raphe’s, the Catholic archdiocese, the city, Hopkins, U of M—were just going to shutter the old girl. As the dirty pile of bricks, streaked black and dotted with a few forlorn statues of St. Raphael, came into view, I thought a mercy killing might not be the worst thing.
Still, there was a soft spot in my heart for the place. I’d just spent two weeks at St. Raphe’s setting up a program to identify exactly the kinds of things that seemed to be happening. Outbreaks. Bioterror attacks. Bad things. St. Raphe’s, in other words, needed me. Not like Hopkins, which basically taught my employers, the Epidemic Intelligence Service at CDC, how to play their game. If every employee at CDC were suddenly to die or, worse, to take a job in the private sector, Hopkins probably felt it could rebuild the Centers from scratch. No, St. Raphael’s was a third-tier hospital in a city dominated by some of the best medicine in the world. My job was to get this old gal up to snuff.
Okay, my job. I am an officer in the Epidemic Intelligence Service, a branch of the Centers for Disease Control and Prevention. Apropos of my duties—to conduct surveillance for and investigations of outbreaks of disease—the title of officer is a fitting one. The cop jargon has been with us for a long time. Medical detectives was often used to describe officers in the service by those on the outside and on the inside, though the term long ago fell out of use, perhaps because it sounded a little too self-aggrandizing at the same time it sounded a little too trite. Anyway, that’s what we do. We look for and hunt down diseases.
As with many things—fashion, say, or diet plans—there is some circularity to the history of the EIS. Originally conceived at the start of the Korean War as an early-warning system for biological attack, the EIS has spent decades searching for things to do. And it’s done a pretty good job of finding them. The Service was instrumental in restoring public confidence after a polio vaccine scare in the fifties; it helped erase smallpox from the world; in the late nineties and early ’00s it tracked down and set up surveillance for West Nile virus. And now the country is back to freaking out about bioterrorism. Which is why I was in Baltimore, helping to patch a hole in the country’s disease-surveillance net. Normally, an old hospital wouldn’t merit much attention, but St. Raphe’s proximity to the nation’s capital scared the public health gods, who wanted to ensure that any outbreak in the area was identified quickly. So, they sent me to set up a surveillance program.
Me. I’m part of the Special Pathogens Branch, which is in the Division of Viral and Rickettsial Diseases, which, in turn, is part of the National Center for Infectious Diseases, one of the Centers in the Centers for Disease C & P. My knowledge doesn’t go too much deeper than that. Though I could spit out to you molecular biology of the family Arenaviridae, I couldn’t sketch the organizational chart of the CDC. I leave that to the brilliant bureaucrats and technocrats in Georgia and Washington. If there was a Nobel for institutional complexity, these guys would lock it up year after year.
I pulled my car into a no-parking zone near the Emergency Department and slapped the Baltimore City Health Department placard on the dashboard. I fished in the glove compartment and found my old CDC placard and put that out, too. Outbreak or no outbreak, the last thing I wanted to deal with was a towed car.
I ran through the automatic doors to the Emergency Department, pulling my ID around my neck as I went. The place was oddly serene; it was, after all, early morning, July, and a weekday. That was a good thing. Although Verlach was on edge, it seemed word hadn’t filtered out to the rest of the hospital or, God forbid, the press. The past few years—the anthrax fiasco, SARS—had taught the public health world the finer points of a 24/7 media with an insatiable appetite for the new, new thing.
There was a beige phone on the wall behind the nurses’ station. I grabbed it, pounded in the pager number for the hospital epidemiologist, and waited. Two minutes later, the phone rang. I picked it up before the first ring ended.
“Dr. Madison, it’s Nathaniel McCormick. I’m in the ED,” I said.
The voice that came over the phone was faint, muted. “And I’m up on M-2. What the hell are you doing down there?”
CHAPTER 2
M-2 was a single hallway flanked by double-occupancy rooms. The white linoleum floor was long ago scuffed to gray, the beige walls streaked with a grime that never quite vanished, despite the best efforts of housekeeping. It was the mirror image of M-1, the medicine unit directly below it, except that the end of M-2 was capped by a set of metal double doors.
A laser-printed sign was taped to the doors: ISOLATION AREA: CONTACT PRECAUTIONS MANDATORY. AUTHORIZED PERSONNEL ONLY. QUESTIONS? CALL BIOTERROR/OUTBREAK PREPAREDNESS AT x 2134. THANK YOU!
Now, no one’s ever accused me of being understated, but I thought introducing a loaded word like bioterror might be a wee bit alarmist.
The isolation unit was split into two areas. I was in the first, a small vestibule with two sinks, a big red biohazard trash bag, and trays of gowns, goggles, gloves, and shoe covers. Three opened boxes of half-mask, negative-pressure respirators sat on a rolling cart. The respirators filtered down to five microns, about the size of, say, hantavirus. I was glad to see they were sufficiently worried.
This type of arrangement—a small, cordoned section of the hospital—was a holdover from the bad old days of tuberculosis. Not all hospitals had them anymore; most places just isolated the sick in private hospital rooms. But here was a short hallway flanked by four rooms, two on each side, cut off from the rest of the building, dedicated to keeping the infectious and infirm from the rest of us. A good little quarantine area.
After suiting up and finding my size respirator, I opened another set of doors at the back of the room. As the door cracked, I could hear a rush of air, felt a suck against the disposable gown. The negative-pressure system—pressure greater outside than inside, to prevent small particles from being blown into the rest of the hospital—was working. The air would be passed through a filter, then blown outdoors.
I made sure the respirator was fast against my face; then I pushed open the door and walked inside.
Three figures, looking like aliens in their protective getup, were talking in the middle of the hallway. Besides the people, there was nothing here but a crash cart, a large biohazard waste can, and a table with a fax machine, paper, and pens. The crash cart was filled with drugs, paraphernalia for placing a central line, basically anything we’d need if a patient’s heart stopped or, in medical parlance, if they “crashed.” The fax was directly connected to another machine at the nurses’ station outside the biocontainment zone. Notes, orders, and the like would be sent from there to the other fax. It’s how we planned to get around carting contaminated medical records back and forth into the hospital. St. Raphe’s, like many places, was still in the dark ages of paper records.
Despite their masks, I recognized the female Dr. Madison and Dr. Verlach, who was black. The third man, an older white guy, I didn’t recognize. I stepped up to the group, which made sort of an amoeboid shift to accommodate me.
“Antibodies?” Verlach asked, his speech raspy and tinny through the respirator.
“Not yet. Nothing specific,” Dr. Madison
said. “No idea what it is. . . .”
Finally, the three looked at me. Verlach said, “Dr. McCormick, you know Jean Madison. This is Gary Hammil—” He pointed at the man I didn’t know. “He’s the new Chief of Infectious Diseases at St. Raphael’s.”
Ah. The new Chief of ID. St. Raphe’s had been casting around for someone for months; they must have netted Dr. Hammil in the past few days. Nice of them to tell me.
I looked at Hammil. “Nothing like diving in headfirst.”
“Especially when the pool has no water,” he said. We both forced a laugh.
“Dr. McCormick is on loan to us from CDC,” Verlach explained.
“Okay, thanks for the introductions,” Jean Madison said, annoyed. Then, to me, “Tissue, blood, saliva have all gone to the labs here.”
“Here?” I asked.
“Baltimore City.”
I looked at Verlach. He said, “Fastest turnaround. We sent samples to the state lab, too.”
Hammil asked, “What do they have at the city labs?”
Verlach looked at the floor. “Um, we don’t have much, mostly run-of-the-mill. But state is pretty stocked. Tests for the filoviruses, Marburg and Ebola. I think they have Lassa, Rift Valley, Rocky Mountain spotted fever, Q fever. More. They don’t have everything, but they have a lot, actually.”
“Well, CDC is there if you need us,” I said. CDC had resources—modes of analysis, genetic libraries of pathogens—that far outstripped those of Baltimore City or Maryland State. We had, in fact, the largest repository of disease-specific tests in the world at our headquarters in Atlanta. We also had the largest repository of actual bugs. Not a place to take your kids when they’re in the oral stage.
Madison spoke quickly. “Thank you, but I think we can handle this here.”
Gary Hammil said, “Jean—”
“We have access to the state labs,” she interrupted. “We don’t need to call in the federal government.”
A word about CDC’s relationship with everybody else in medicine and public health: our jurisdiction is everywhere and nowhere. Really. We intervene only at the request of individual counties and states. If there’s no request, CDC stays out of it. And though there are a million reasons why someone would want to ask for help from Atlanta, there are a million reasons why they wouldn’t, most of them having to do with control.
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