“Excuse the interruption,” I said, “but where did Deborah Fillmore live?” Fillmore was the name of the second patient to present to the hospital. The third patient was Bethany Reginald.
Dr. Singh blinked. “I was planning to present Deborah Fillmore next.”
I could feel the eyes on me. The presentation of patients follows relatively strict protocol, and I was breaking it by derailing us from Helen Jones to Deborah Fillmore. Where these women lived was important, though. All of us sitting through twenty minutes of presentation was not.
“Dr. Singh,” I said, “where did Deborah Fillmore and Bethany Reginald live?”
Verlach’s fingers were raking nervously through his mustache.
“Dr. McCormick,” Jean Madison told me, “Dr. Singh will finish her case presentations—”
“With all due respect, Dr. Madison, we’re trying to piece together an exposure history. The environment in which these women lived—”
“—can wait, Dr. McCormick,” she said.
“Not really, it can’t.” I turned back to Dr. Singh. She looked at Dr. Madison and back at me. Finally, she said, “Bethany Reginald shared a room with Helen Jones at Open Arms. Deborah Fillmore lived in another group home, called Baltimore Haven.”
“Thank you,” I said.
Though I wanted to follow this line—environmental exposures—I didn’t want to be lynched by a bunch of upset doctors. So I began to scribble notes in a small notebook I always carried with me. Dr. Singh finished up with the case presentation for Helen Jones. The group began to ask questions—about blood tests, cultures. All very good questions, but it was taking too long and it was driving me crazy.
I turned to Verlach. “You know the travel history of the other women?”
“No travel,” he said, keeping his eyes straight ahead.
“You’ve been to the homes?”
“No, Nate.” I could tell Verlach was also getting antsy with the pace of things.
“We need to get a move on. We need to talk to the other girls and get over to the homes—”
“Dr. McCormick,” someone said sharply. I looked up. Gary Hammil was glaring at me now. Was I on everyone’s shit list? “You’ll be able to present us with a differential for Ms. Jones?”
“Yes.”
“Good. Would you indulge us, then, with your wisdom?”
I glanced at Verlach, who seemed incredibly tense; I couldn’t tell if he was annoyed with me or with the medical pissing match that was unfolding in front of him.
“Dr. Hammil, I believe that my time here is best spent in the field, trying to prevent any more transmissions from taking place. We have a geographic cluster, which affords us a starting place, a good one—”
“Dr. McCormick—”
“And your medical team is top-notch here. I don’t know what I could add in terms of the care for these women.”
“Dr. McCormick!” An angry flush crawled up Jean Madison’s neck to her face. “You are here at the invitation of this hospital. Your behavior here risks jeopardizing the relationship between our hospital and your employer in Atlanta. You risk being uninvited by—”
“Actually, Jean, Dr. McCormick is now here at the invitation of Public Health. His role has changed.” Verlach spoke quietly. “Dr. McCormick, why don’t you give us a differential for Ms. Jones? Since we’re assuming the cases are linked, your differential should suffice for the two other patients.”
Jean Madison sniffed, “In the interest of thoroughness, Herb, I think we should treat the cases as individuals.”
“We can’t afford the time now,” Verlach said. “You worry about the women. Public Health will worry about public health. Dr. McCormick?”
I stood and walked to the whiteboard. Dr. Singh took her seat.
The differential diagnosis, the crux of medical—as opposed to surgical—practice. The differential is basically your list of best guesses. For example, if someone comes to your office with diarrhea, your differential is very broad, ranging from amoebic infections to Crohn’s disease to stress. Then, as new tests come in, you narrow it down. Eventually, you arrive at a diagnosis. That’s how it’s supposed to go, anyway.
“Okay,” I said, taking a marker. “At the top of my differential . . .”
I wrote VHF in big red letters. “The viral hemorrhagic fevers,” I said. I talked quickly as I wrote, trying to bring these guys—who may have known Ebola only from books and movies—up to speed on the dizzying number of viruses that make us bleed: Marburg, Junin, Congo-Crimean hemorrhagic fever, Lassa, dengue, and so on and so on.
“I hate this,” Verlach said.
He and I walked quickly toward the isolation unit. Both of us had cut out of the meeting after my presentation.
“I hate this political bullshit,” he continued.
“Thanks for running interference,” I said. We pushed into the vestibule and began to suit up in the biohazard gear.
“You don’t help things, you know. Your approach to this.”
“You know what, Herb? I really don’t give a shit.”
Verlach paused in the midst of pulling on his gown; he looked as if he were about to pop me. Instead, he began to laugh.
“You’re a piece of work, Dr. McCormick. You really are. You either got some balls on you or you’re dumb as a post.”
“Balls,” I said.
“Well, we’ll see which it is, won’t we?” He was still laughing as he pulled on his respirator.
CHAPTER 6
Helen Jones was more alive than she had been an hour earlier, alive enough, at least, to talk to me.
Shoe-leather epidemiology—what I was doing that day—is not brain surgery. It’s not even cardiology. It’s police work. There are more questions like “Where were you Thursday night? What did you eat? Who were you with?” than there are like “What did the MRI say?”
So there I was, in my space suit, talking to our index case: Helen Jones, thirty-one, Caucasian, slightly overweight, lucid, mentally handicapped. She was very sweet, very tired, and—now that she was alert—very suspicious of me.
In fact, she said, “You are scary.”
“I hope not.”
“You are.”
“Well, even if you think I’m scary, I want to help you. And so I can do that, Helen, you need to help me.”
“You look like a monster,” she objected.
“I’m not a monster, I’m a doctor.” There was irony in there somewhere.
It went like this for forty minutes. But despite the suspicions and Helen’s cognitive limitations, over the course of the interview, we were able to establish a few things: Helen lived in a group home for the mentally handicapped located on the edge of the gentrified neighborhood of Federal Hill. Eight other residents, all female, lived in the home, and all the residents ate their morning and evening meals together and “prayed together before each one.” She made her lunch each day in the kitchen at the home—always peanut butter and jelly, some carrots, and a Coke. As Dr. Singh had mentioned earlier, Helen shared a room with Bethany Reginald, who was now in the room next door, talking to Herb Verlach.
I asked, and Helen said they weren’t allowed to have any pets or animals. With other residents, she took the bus to work each morning; she worked in the laundry department of a nursing home outside the city. At the mention of her workplace, my stomach tightened a little; the last thing we wanted was some hemorrhagic fever ripping through the shoddy immune systems in a nursing home. She couldn’t remember the name of the home.
I asked her if she saw any animals—mice or cats or dogs, ever, even once—at the group home or at the nursing home. She winced and said she saw a rat once where she worked and, she added, a couple of cats and dogs around her residence.
Had she ever been ill before? She couldn’t remember. I asked if she had ever been in a hospital before. She didn’t know what I meant. “A place like this,” I said. Helen shook her head. We covered what we could of family, weekends off. We covered mail rec
eived and personal hygiene. Trying to pry something loose, I revisited food and animals. The clock on the wall crept toward ten o’clock. I needed to move.
“Do you have sex?”
Helen shook her head rapidly, which I took for misunderstanding.
“Has another man or woman ever touched you in your private parts?”
She shook her head.
“Have you touched them in their private parts?”
She blushed.
“These are weird questions, aren’t they?” I asked, trying to reconnect.
“Yes.”
“I don’t like to ask them, Helen, but I have to. Sometimes doctors have to ask funny questions so they can help.” I cleared my throat. “Okay, Helen, this one’s really funny: has a man ever put his penis—his private parts—into your body?”
Helen didn’t laugh. “God doesn’t like that,” she declared. Then she pulled the sheet around her neck and closed her eyes.
Unwisely, I took that for a no.
Verlach was in the hallway, sitting on a metal chair, scribbling notes. “Another meeting,” he said without looking up.
“What meeting?”
“Administration this time, then that should about do it for St. Raphael’s. For this morning, at least.”
“No one told me.”
“I’m telling you. I just found out myself. Just got paged.”
I looked at the door, then back to Verlach in his space suit. Climbing in and out of the gear was slightly less awkward than getting it on in a Yugo. Maybe not a Yugo. More like a Porsche Boxter, parked in a pull-off on a mountain road in the Alps, the sun setting, some yodeling in the background, Jennifer Garner ripping off her . . . But, I digress; threats of admin meetings drive me to fantasy.
“I just put this stuff on,” I said.
He kept on writing. “They don’t care.”
I thought about that for a moment. “You go, Herb. Let me finish here. This thing isn’t going to wait. Besides, I don’t . . . Let’s just say it might be better if I’m not there. I don’t think they like me.”
“Still, you should be there.”
“Still, they don’t like me.”
Through the plastic shield, I could see the corners of Verlach’s eyes wrinkle. He was smiling. “So that’s why they teach you your attitude in Atlanta? To get out of admin meetings?”
“No, the attitude is all mine. Getting out of meetings is one of the perks.”
Verlach stood and began to feed his notes into the fax machine. “They didn’t page you?”
“No.”
“Then you’re off the hook. Even so, I don’t think it was an accident you weren’t called but are still expected to be there. They’re going to give you hell for not showing up.”
“Dealing with political bull is not one of my talents. Catching hell from Jean Madison seems to be.”
The fax beeped, signaling the transmission had gone through. Verlach put his notes in a folder labeled Fillmore, Deborah. “All right,” he said, “just do me a favor, Nate. Tread lightly, okay? I’m not going to keep shitting in my backyard, and I don’t want you shitting in it either.”
“Point taken. No pooping.”
He chuckled, then left the room.
CHAPTER 7
Deborah Fillmore should have been in the intensive care unit. Why she wasn’t I understood, but it was not medical judgment that had placed her on the medicine floor, far from the team that cares for the nearly dead.
A nurse was in the room, changing an IV bag. I introduced myself and asked how the patient was.
“You’re the expert,” she said. So this is how it would be, I thought. Word does travel fast.
Ms. Fillmore, a black woman, twenty-seven years old, pretty face, lay unconscious on her back. Two central IV lines—one in her upper chest and one in her groin—snaked from under the sheet to bags on a stand next to her. I had to hand it to the team at St. Raphael’s. Getting lines into someone in Deborah Fillmore’s state is difficult and, depending on the severity of the disease, unwise; the blood vessels keep collapsing and shredding each time a needle is stuck into them. But it seemed someone on the team was what we call in the business a “sniper,” someone who can nail those difficult veins.
Debbie Fillmore had been intubated, and the ventilator filled the room with a hissing and clicking as it forced gas into her lungs. Three monitors bleeped, keeping track of heart rate, oxygen level in her blood, blood pressure, respiration rate, and oxygen delivery. A Foley catheter ran to a bag hung on the side of the bed, half-filled with urine. The medical team was worried about shock; the bags and the monitors were there to assess and maintain this young woman’s blood pressure high enough to keep her alive.
I bent over the bed and looked at Deborah’s lips and face. Even without moving the ventilator tube from her mouth, I could see the bloody spots of hemorrhage. I touched her forehead; she was blazing hot: 40.2 Celsius, according to the monitor. About 105 Fahrenheit.
I undid the tape that held the vent tube to her face and pushed the plastic to the side. I couldn’t see much.
“Do you have a penlight?” I asked the nurse.
“No.”
“Try to find me one, please,” I said.
She glowered at me. “Nurse,” I said, using the word in a way she’d hate but needing to reestablish the hierarchy. “There is a light in Helen Jones’s room. I need that light. Now.”
She huffed out of the room. I was quickly enlarging my list of enemies. But if there’s one thing I’ve learned from life thus far, it’s not making enemies that’s the problem; it’s making the wrong enemies.
I loosened the gown around Debbie’s neck, careful not to disturb the central lines. Large, dark plaques spread down her chest, over her breasts, down her trunk. Her neck—with its spawn of huge lymph nodes—looked as if it had been crafted out of clay by a kindergartner with dexterity problems. Whatever had infected this young woman was attacking almost everything.
The nurse appeared with a penlight. She thrust it at me.
“Thank you,” I said.
She didn’t respond. Pulling the vent tube to the side, the penlight in my other hand, I peered into Debbie’s throat. I almost dropped the light, jerking my hands back as if I had touched something hot, which, in a way, I had.
The mouth was alive with little hemorrhages. The tonsils, nearly the size of golf balls, were slicked in a thick gray-yellow pus, like they had been coated with mortar. They looked about to burst.
Seeing what these diseases do to a body always jangles me, makes me uneasy, makes me furious. Added to that unpleasant emotional mix was that I felt the victims here—the mentally handicapped—were cursed both with disease and a tragically hobbled understanding of it. I mean, try to put yourself in Debbie Fillmore’s sloughing skin: You feel magnitudes worse than you’ve ever felt in your life and you really don’t know what’s going on. You don’t fully understand why people in white are jamming needles into you, why everyone looks like an astronaut. You might not even understand what disease is, why your skin is lifting off in ugly patches.
That is terror, ladies and gentlemen, pain amped by a lack of comprehension.
Rage, not the most admirable quality in a physician, was, nevertheless, a reason I was in that room, a reason I became a doctor. Rage that Helen Jones and Debbie Fillmore lay bleeding, rage that the Blind Watchmaker of a God allowed such poison to evolve. Rage at my own impotence, at spending years of life working with pathogens and yet unable to lift a finger to help—
The nurse cleared her throat, and I realized I was sweating like a pig in the space suit, the muscles in my arm rigid.
Calm down, McCormick, I told myself.
I closed the mouth and reattached the tape on Deborah Fillmore’s face, swore quietly.
I looked at the nurse, remembered our previous static, and offered her an olive branch of sorts. “What do you think?” I asked.
“What do I know?” she shot back. “I’m just a nurse.�
�
This was not the time for her to bait me, and I tried to decide between an angry fusillade and a more conciliatory response. But I felt my pager vibrate. I never look a gift horse in the mouth, so I seized the opportunity and left the room and the stewing nurse.
CHAPTER 8
I undressed just enough to expose the pager. Verlach. I used the phone in the vestibule and called him.
“Congratulations, McCormick. You are now no longer the least popular person in this hospital,” Verlach said.
“Great. My PR firm must have delivered.”
“We’re shutting the place down.”
“The wing?”
“The whole hospital.”
“Whoa.” This was a surprise. I mean, it was a good thing—a very prudent thing—but still . . .
Anyway, I had to hand it to Verlach. The man moved fast. I told him that.
“We don’t screw around here.” He forced a laugh. “Still, it’s too bad you weren’t there to take the heat. I live in this town.”
“Maybe not for long. They pull out the rope for you?”
“Just about. The hospital president said, and I quote, ‘I’ll have your balls in a jar if we’re not open in five days.’ He mentioned he’d have your balls, too.”
“Well, tell him I sent mine back to Atlanta for safekeeping. Look, Herb, this thing is bad. Debbie Fillmore . . .” I paused.
“I know. That’s why I’m shutting this place down.”
“Okay. And with the tempo of this so far, we should be ready for more.”
“Yes. We’ll use the hospital as quarantine.”
“Good.” I thought for a moment. “Herb, the bug has hallmarks. We have hemorrhage in the mucous membranes; hemorrhage in the lungs and trunk. Nothing on the face. It looks like everything and nothing; I can’t get a bead on exactly what it’s attacking.”
“Yeah, I know.”
“Face sparing, but it gets the mouth. . . .” I contemplated how I was going to mention the unmentionable. Then I just went for it. “In the meeting, anybody mention bioterrorism?”
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