The cocci were perfect spheres, like eggs or dark spawn. Simple even for bacteria. There were no hairs or rotors or whips, which more sophisticated bacteria use to move around in the wash of chemical signals. The cocci did not need them because they did not move. They did not form complicated chains or strings or tetrads. They clumped. And they doubled. Tricks they had been repeating since the beginning of Life. Doubling every twenty minutes and clumping together in grapelike clusters. At the base of the Shark’s stalled tongue, in the smashed bone of his jaw, along the track left by the bullet. Clumped in clusters that numbered eight million and then sixteen million and an hour later one hundred and twenty eight million perfect peptidoglycan-plated spheres. All doing the thing they had always done. Perpetuating themselves. Twenty times smaller than the cells that surrounded them, they were nevertheless redoubtable enemies. Pushing out their poisons and their powerful enzymes, struggling against the onslaught of the Shark’s immune system and the vancomycin, breaking up the surrounding cells and tissue, until soon they were doubling and doubling in abscesses the size of walnuts—pockets of serum, dead cells, and obliterated tissue.
The curtain had been pulled around the Shark’s bed, and he was looking up at the ceiling, his eyes partially closed. He had gone into a coma at around four-thirty that morning. The duty nurse had discovered his condition when she had come to check his temperature. Ford pulled back the sheets and looked down at the young black boy. The contrast between the lean youthfulness of the torso and the ugly swelling of the neck and head was striking. It was like a Halloween mask, a monster’s head. It was the work of less than a week.
“I thought you might like to take a look before they took him away,” said Allen, keeping his voice to a whisper. “This is unusual, I think. I’ve never seen anything quite this fulminating.”
He leaned forward and pulled back the dead man’s dehydrated upper lip. Ford covered his nose and mouth and leaned forward himself, hardly able to believe the quantity of thick, yellow pus pushing through the wired teeth.
The two doctors were silent for a moment. Then Allen said, “I hope you agree we have to open him up. See exactly what happened inside.”
Ford nodded.
“The autopsy and lab reports are going to make for interesting reading,” said Allen. “I’d bet my bottom dollar this thing ate his tongue.”
PART TWO
SOMETIMES BAD MEANS BAD
1
THE WILLOWBROOK MEDICAL CENTER
Medical Director Russel Haynes took the emergency meeting in his office. He was a small man in his mid-fifties, with a puckered, sour-looking face and tightly curled gray hair he kept militarily short. To disguise his lack of stature, he tended to stay seated behind his teak veneer desk, which was always piled high with papers and reports. On the front edge of the desk, threatening to topple off, was a small marble plaque on which was written:
God grant me the serenity to accept the things I cannot change, courage to change the things I can and wisdom to know the difference.
The Code Yellow team and staff from the ICU were crammed into the space on the other side of Haynes’s paper barricade. Mary Draper was there along with Melvyn Hershy and Marvin Leonard, the radiologist. Marcus Ford sat close to the door next to Conrad Allen and three other interns who had been on duty when the Shark had entered the ICU. Dr. Lionel Redmond, the Willowbrook’s affable PR person, was also present. It was stiflingly hot in the office, and there was a strong smell of vanilla from a plastic air freshener Haynes kept on one of the bookshelves.
Although Haynes had called the meeting, it was Lucy Patou who was running the show. She was sitting in the corner on the couch Haynes slept on whenever the paperwork kept him from home. She had cleared herself a little space on a low coffee table and filled it with her own documentation. She looked keyed up.
The Shark’s death was not the only cause for alarm. Four other patients in the ICU were now showing signs of resistant infection, including the patrolman, Raymond Denny. Denny’s leg wound had failed to heal and was now inflamed and purulent, as was the cut into his saphenous vein. He, like the other problem cases, had been put onto vancomycin two days before. In every case the principal pathogen isolated from wound exudate was Staphylococcus aureus. What the staff was looking at was an outbreak.
After a few prefatory remarks from Haynes, in which he made it perfectly clear he expected everyone to cooperate with Dr. Patou one hundred and ten percent, she addressed them herself: “I don’t have to tell you why this meeting has been called, so we’ll get straight on to what we are going to do about what I think you’ll agree is a very grave situation.”
She checked them all over with her pale eyes, except for Ford, who was magically invisible to her.
“I’m treating this as an outbreak of methicillin-resistant Staphylococcus aureus, or MRSA. I know that Dr. Ford’s patient was given vancomycin prior to his death, but it seems to me far more likely that the vancomycin was prescribed too late, than that it was ineffective per se.”
“How can you be sure, Dr. Patou?” asked Ford, glancing across at Haynes’s face to make sure he wasn’t out of line.
“I can’t be sure. We can’t be sure. We are going to wait for the lab to tell us exactly what we are looking at in terms of resistance. The patrolman, Raymond Denny, is also receiving vancomycin, as are the other two infected patients. Their injuries are less serious, and I am counting on them responding to the vancomycin in the next few days.”
“What if they don’t?”
It was Draper who had spoken.
“If they don’t, the Willowbrook will be making medical history and I will be contacting the CDC. At that point our response will be coordinated with them.”
The Centers for Disease Control, based in Atlanta, was the institution of last resort in cases of outbreaks of infectious disease. The CDC compiled statistics, carried out laboratory work on lethal pathogens, and even entered the field if circumstances called for it. Their experts were also available as consultants and, where necessary, as expert backup in situations requiring containment.
“In the meantime,” Patou continued, “we will approach this problem with the utmost caution. This will entail a number of measures which, though inconvenient, must be put into effect to safeguard our staff and the general public.”
There was a general movement in the room of people preparing themselves for bad news.
“Whatever the definitive characteristics of this thing turn out to be, what we appear to be looking at for now is a multiresistant strain of Staphylococcus aureus. Given the clustering of cases in ICU, we have to assume either a propensity for the pathogen to spread fairly easily or a common source of infection inside the hospital. This may turn out to be a member of staff or it may be a machine, a curtain, a mattress. Over the next few days I will be carrying out a survey of relevant staff and equipment. Now…”
She paused for a moment to consult her sheaf of notes.
“With a view to finding a broadcaster, I will be taking nose swabs from all staff in Trauma, in the ORs, and in ICU today. I will also be sampling air during operations performed by the suspect teams, and I will be sampling the OR floor with contact plates at the end of operations.”
“At the end of each operation?” asked Hershy.
“No, that won’t be necessary. I will also be culturing equipment, bedding, and other fomites in the ICU. Just in case I don’t get a result from the swabs or from the OR air samples, I will also be testing each one of you individually today. I know this is going to hamper you in your work, but it has to be done. We have set up an isolation room for this purpose. All it involves is undressing and going through some movements while we sample the air. As I have already explained to Dr. Ford”—she gave Ford a look—“this thing can be carried on the perineum, and we won’t necessarily pick it up unless we get tough.”
Allen and Ford exchanged a look.
“Men are more likely to carry this than women, so I am goi
ng to start with them. Dr. Ford has already agreed to go first.”
Several heads turned to look at Ford.
“I want the rest of you to agree on who comes at what time.”
“What about the infected patients?” asked Dr. Draper. “What do we do about them? They are a source too now, right?”
“I’ll come to that in a moment,” said Patou.
She exchanged one set of notes for another. She was going to get through this in her own time.
“Now, we can reduce the immediate danger by assuming that everybody is a carrier.” She looked around to see what effect this news might have. The room was completely silent. “This is not as serious as it sounds. All it means is that, starting tonight and for the next week, I want you all to take daily baths with an antibacterial agent.”
She reached down and produced a four-liter plastic bottle of what looked like industrial detergent, thumping it down on the coffee table. Nobody had noticed it until now. Mary Draper’s mouth dropped open.
“This is a hexachlorophene detergent. It probably doesn’t smell like your usual brand, but, as I keep saying, we have to get tough if we are going to beat this thing. I also have cetrimide shampoo, which I want you to use twice weekly. Finally, I will be supplying you with a nasal cream which contains one percent chlorhexidine and point five percent neomycin. You put the cream into the anterior nares—there’s no need to shove the stuff right up your nose. And you use it four times a day for one week.”
She looked around at them, a faint smile on her lips.
“Of course, it may turn out that we isolate our carrier immediately from today’s tests, the results of which should be ready by tomorrow lunchtime. At that point you can bring all the stuff back to me and proceed as normal.”
She put the detergent back on the floor.
“Now, regarding the infected patients. We will be cohorting them in the two isolation rooms adjacent to the ICU. It’ll be a squeeze, but as long as we don’t get any more cases in the immediate future, it should be manageable. We will continue whatever systemic support is necessary with sterilized equipment. The equipment used so far will, as I have already said, be cultured for evidence of contamination.”
There was a moment’s silence, and then Patou said, “Are there any questions?”
It was Conrad Allen who spoke: “Dr. Patou, your base assumption seems to be that this outbreak has been generated in-house.”
“That’s right. As I have already discussed with some of you, it is extremely unlikely that MRS A will have come in off the streets. In my experience, it just doesn’t happen like that.”
“You don’t feel there may be a connection between this outbreak and the problems we had a few weeks ago with the Streptococcus pneumoniae?” said Ford. “Remember one of those cases came in through General Surgery. It had nothing to do with the Trauma Unit.”
Patou smiled.
“We are all aware of your theories on this question, Dr.
Ford. Unfortunately, we have to deal with the reality of what is happening in the ICU, and as Dr. Haynes’s plaque says”—she reached across and took the marble plaque from Haynes’s desk, something nobody else in the room would have dared do—“give me the ‘courage to change the things I can.’ If your theory is correct, if South Central is shaping up as some kind of microbiological flashpoint, then we are obviously in a lot of trouble. I think it would be irresponsible to air your theory overmuch—in public, I mean—without having some pretty solid proof.”
Russel Haynes stood up.
“Thank you, Dr. Patou. On the issue of public information, this is probably as good a time as any to get our game plan in place. Now, an outbreak of multiple-resistant infection stands a fair chance of attracting the attention of the press, especially since a law enforcement officer is involved. If Officer…”
“Denny,” said Patou.
“If Officer Denny succumbs to this thing, and I pray to God he doesn’t, we may attract a degree of scrutiny. Now, I am nominating Dr. Patou to provide information to the media. She will work with Lionel on any press releases, while Lionel will, as always, field any telephone or fax inquiries.”
Haynes came round to the front of his desk and leaned on it.
“If we work as a team, we’ll get through this thing with the minimum of disruption,” he said.
2
Ford had just squeezed a fat loop of nasal cream into his right nostril when Nurse Gloria Tyrell came through on the interior phone announcing a visitor. The cream smelled of chlorine and produced a burning sensation that made his eyes water.
“Who is it?”
Gloria put on a truculent voice.
“What am I, your social secretary? Just straighten your tie, Mister, ‘cos she looks like she means business. And she’s on her way right now.”
“Gloria, what did…?”
There was a soft knock at the door and then Ford found himself looking at the woman from the NIH conference. If anything she was more impressive than before. She looked completely out-of-place in the bare, functional world of the Willowbrook. For a moment Ford could do nothing but stare.
“Dr. Ford? I hope I’m not disturbing you. I just thought I’d come and say hi on my way out.”
He stood up.
“Yes, yes please, come in. Sorry, for a moment there I couldn’t…”
“Place me? Helen Wray. We met at the…”
“Yes, no I know, I just didn’t expect to … I mean…”—he pointed to his nose and bloodshot eyes—“Sorry about the … It’s an antibacterial thing we’ve having to use, only I think I’ve overdone it. Here, have a seat.”
“You’re not sick, I hope.”
“No, no. It’s just a precaution. Our Control of Infection Officer thinks we’re breathing bugs over our patients—not that we are, don’t worry. It’s just…”
“Routine.”
“Exactly. Excuse me.”
He fumbled in his pocket for a handkerchief. He had definitely used too much cream. It had to look awful stuck up there.
Helen Wray sat down opposite the desk. She was dressed in a smart red jacket, a knee-length black skirt, and a white silk blouse through which the outline of her brassiere was faintly visible.
“I’ve just been meeting with your in-house pharmacy people,” she said.
“Oh, great.”
“Yes. We’re introducing some new formulations for Lodanol, our top analgesic, and I wanted to tell them about it.”
“Lodanol?” said Ford, keen to show interest. “Yes, I know it well. We use it to deal with postoperative pain. We like it. Less side effects than the steroidal antiinflammatories.”
“I’m glad you’ve found that. Well, now we’re about to launch two new formulations: a topical gel and a transdermal patch.”
Ford nodded positively, although he wasn’t sure about the benefits of either new product to him. The kind of operations patients underwent in the Trauma Unit required heavy doses of painkillers, doses that could only be administered intramuscularly or intravenously. A gel would be better suited to general conditions like arthritis and injuries like sprains.
“Well, I’m sure they’ll look with great interest at those,” he said. “I’m sorry, I’m forgetting my manners. Can I get you coffee or something?”
“If you’re sure it’s no trouble.”
“Of course not.” Ford stood up again. “There’s a machine right outside. We have freeze-dried instant coffee, freeze-dried instant tea, or freeze-dried instant hot chocolate-style beverage.”
“Oh … well…”
“It doesn’t matter which. They all taste the same pretty much.”
“I see. Well, how about some freeze-dried instant water?”
“I’ll see what I can do.”
He went out into the corridor and hastily fed a dollar into the big vending machine. Why had she come to see him? Was it something in his speech that interested her? That seemed unlikely, because she was clearly in sales, and people in
sales didn’t care about anything except selling. On the other hand, if that was the case, why had she been at the conference at all? The machine sucked up his crumpled dollar bill, thought about it for a moment, and then pushed it back at him. Ford cursed under his breath and reached into his pocket for another. Maybe she just wanted information. Maybe she was going to ask him to participate in some dreary marketing survey. As the machine dispensed two fizzing cupfuls of club soda, he realized that this was probably exactly what she was going to do. Hadn’t she launched straight into a marketing spiel about Lodanol? Or maybe she was looking for an endorsement for something, using her charms to get him on her side. Certainly a purely social visit was a little too much to hope for. Of course it was. He sighed and sipped at one of the club sodas. It tasted as flat as he felt.
“So you’re in marketing, then, I take it?” he said, sitting back down.
“I’m sorry,” she said, reaching into a slim briefcase. “I should give you my card. Here.”
Sure enough, under her name the card read: Assistant Director, Marketing (West Coast).
“So you probably visit a lot of hospitals, I imagine.”
“Well, some,” she said. “Actually, I don’t get out on the road as much as I’d like. It’s important to hear from the front line now and again. Clinical trials don’t tell you everything about how a drug really performs or how useful it’s likely to be.”
“I believe it. So you like to get as much information as you can from … well, people like me.”
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