“C’mon, Yoshiki. Cough it out,” Carson ordered the sallow young man, who lay in his bed with his eyes closed.
Yoshiki coughed again, a stronger effort this time, and Carson could hear the phlegm gather in the young man’s mouth. Carson involuntarily gagged. He was thankful the respiratory mask covered his face, disguising the revulsion in his expression.
“You better suck it out,” he said to the nurse, who held a suction device in her hand, which she proceeded to stick into Yoshiki’s mouth. A loud gurgling emanated from the collection container on the wall.
“It’s bloody,” the nurse said.
Carson peered at the container. The phlegm was unmistakably red-tinged. He frowned. This wasn’t going the way he’d hoped.
He put the diaphragm of his stethoscope on the boy’s chest and listened to his breath sounds, which sounded as though his lungs were filled with the stuff he was trying desperately to cough out.
“What antibiotics do you have him on?”
“Chloramphenicol, Bactrim, moxifloxacin.”
The furrow between Carson’s brows deepened. All second-line agents, but what choice did they have? Yoshiki’s disease was resistant to the standard therapy. Carson pulled open the sliding glass door, slipped out of the isolation room, and removed the gloves, mask, and gown he had been wearing. The nurse followed.
“Did the lab call with the second set of drug sensitivities yet?” Carson asked, leaning over the computerized vital signs flow sheet as he tracked Yoshiki’s progress over the course of the day. It really wasn’t good. Yoshiki’s blood pressure was barely high enough to support his vital organs, and now his lungs were crapping out.
The nurse shook her head. Carson crossed his arms, thinking. It was pretty clear that Yoshiki was engulfed in sepsis, which meant the plague bacteria were overwhelming his body’s defenses. He needed a ventilator, and pretty soon his kidneys would go, and then his heart would fail, and then Yoshiki, young Japanese exchange student, was a goner. Carson had seen it before, rarely with the new antibiotics, and never with the plague, but definitely with other infections. He recognized the downward spiral.
What the fuck was going on?
Carson turned to the nurse, who stood next to him. “Call the ICU team. We’ve dicked around long enough. This guy needs to be put on a ventilator.” As an afterthought, he added, almost as if to himself, “And I’ll call Dr. Wang.”
Four
Andrea Vangsness cut her shopping trip short. Tricia was gung-ho, moving from one store to the other at the Meadowood Mall, but Andrea couldn’t shake her guilt that she was out shopping when Chuck was miserable and sick in bed at home. Besides, she felt the beginnings of a dull headache.
“Trish, I want to sit down a moment.”
Tricia, an athletic-looking former nurse, looked at her friend with concern. “You okay, dear? You’re looking a little pale.”
“Oh, I’m just a little worried about Chuck.” Andrea sat down on one of the mall benches, which held fake ferns in plant holders embedded in their seat backs. She fished around in her purse for a container of ibuprofen and the small bottle of Evian she’d put in there earlier.
“Chuck pretty sick?” asked Tricia.
Andrea popped three pills in her mouth, swallowed a little of the Evian, and answered, “He’s got a pretty bad flu, I think, and the poor guy has to work tonight. I keep telling him to call in sick, but you know how doctors are. They’d work with pneumonia, if you let them.”
“Ain’t that the truth,” said Tricia, whose surgeon husband was notorious for inhumanly long hours.
“Do you mind if I call him to see how he is?” Andrea pulled out her cell phone, dialed home, and waited. There was no answer.
Tricia shrugged. “He’s probably sleeping. James always turns off the ringer when he’s sleeping.”
“You’re probably right,” said Andrea, but a little ball of dread began to form in her chest, and after a moment, when Tricia suggested they resume shopping, Andrea demurred.
She hugged Tricia and left her at the entrance to Ann Taylor. Then she broke into a light trot in the parking lot with unaccountably achy legs. She hit redial on her phone.
“Chuck, it’s Andrea. Pick up the phone, honey. I need to talk with you.” She knew Chuck would think her silly for pleading in a voicemail, but she couldn’t help herself. “Chuck, please pick up. I really need to talk to you.”
The phone felt cool against her flushed cheek. She didn’t understand this panic, this bone-level certainty that doom was upon them, but the feeling grew all-consuming, and she drove the Suburban as if pursued. She kept reliving her departure from home that afternoon, the look on Chuck’s pale face, the awful cough. What if he did have pneumonia and needed to go to a hospital? He would call 9-1-1, wouldn’t he, if he was that sick?
She wove through traffic, taking the shortcut up McCarran Boulevard, up to their home in Skyline. Dimly, she heard a car honk at her, but it barely registered.
She coughed once, a phlegmy little cough. But her panic was so deep that Andrea didn’t even notice.
The ground squirrel was dead, which wouldn’t have been particularly remarkable to John Harr, except that it was the third dead one he had seen today. Gage sniffed at it, his muzzle buried in the rodent’s fur.
“Gage, don’t eat that. Don’t I feed you enough?” Harr nudged the dog away, but Gage was insistent. The German Shorthair sniffed and pawed at the dead animal.
Harr looked down, momentarily non-plussed. He didn’t have a problem with Gage eating an outdoor dog’s diet, but he drew the line at dead animals. Harr nudged the dog again, with his boot this time. “C’mon, Gage. Pick a live one.”
The German Shorthair backed up and looked up at his master pleadingly. Harr knew that if he didn’t do something with the carcass, Gage would come out here, a good mile and a half from the ranch house, searching for it later. And Harr wasn’t particularly interested in seeing his dog become coyote food. The coyotes ran the ranch at night, barking and yipping in the darkness, a seductive sound that Harr knew was an effort to lure the dog away from the safety of the ranch house.
“Back to the truck,” he said to the dog, who looked crushed.
They had come out to fix the fence that separated Harr’s property from the Jurgens’s spread to the north. Harr didn’t know why he bothered, since the cattle rarely wandered this direction, but Harr knew that good fences made good neighbors, and he had no desire to raise the ire of the Jurgens, whose holdings in the valley were vast.
Harr coaxed the dog into the back of the pickup, tied him up, and grabbed a shovel, his eyes offering the dog the apology he refused to speak.
It took only minutes to bury the ground squirrel. The soil was loose and dry already, and Harr wondered fleetingly if drought would turn the already arid landscape into a dust bowl this summer. In the best of years, it didn’t rain much in Harney County, maybe twelve inches a year, but the last two years had been drier than usual, and ranchers throughout the valley were already worrying about water holes.
Maybe that was why the ground squirrels were dying? Harr mentally shrugged. Who knew? It could be a million things: pesticide, illness, ground squirrel wars. Hell, he didn’t know. He just didn’t want his dog eating any dead carcasses.
Harr tossed the shovel into the back of the pickup, abandoning the fence project. He looked at Gage to see if the dog had noticed the carcass was gone, but the dog was oblivious.
Gage had his nose buried in his own coat, gnawing furiously.
Ah great, thought Harr. Fleas.
George Mack received the bad news just after dinner, and his first reaction was to pop a Tums. The acid in his stomach felt like it was burning a hole through his gut lining. He chased the Tums with water from the office water cooler and stood there for a moment, his arm draped over the blue inverted bottle while staring sightlessly at the floor.
It was probably time to call in the big boys, he thought.
Mack felt for the p
ack in his shirt pocket and pulled out a cigarette. He lit it numbly, looking out the window, before walking back across his office and easing his 250-pound body into the chair behind his old wooden desk.
He had some phone calls to make.
The first was to Singh, the ICU doctor at Washoe Valley Medical Center who had taken care of Yoshiki. Mack waited impatiently while the hospital operator paged Doctor Singh, who was working the evening shift.
“This is Doctor Singh.” The mellifluous voice of the intensive care physician floated across the telephone wires.
Mack skipped the niceties. “Singh, this is Mack. The sensitivities are back on Yahagi. The bug’s pan-resistant.”
There was a second of silence on the other end of the line. “What?” Singh said blankly.
“You heard me,” growled Mack. “It’s resistant to everything. Doxycycline, chloramphenicol, Bactrim, even moxifloxacin.”
“Holy shit,” said Singh.
“And it gets worse. We got a second confirmed case out of the Evergreen Club Lodge. A guy at Sierra Tahoe Hospital. Confirmed by culture.” Mack stubbed out the cigarette in an ashtray on his desk. The air was thick with smoke. He lit another cigarette. “About the only thing we got going for us is that none of these cases had lung involvement. So not contagious, unless you go sticking your fingers in buboes.”
Singh was silent.
“For god’s sake, don’t go speechless on me,” Mack barked.
“It’s worse than you think,” said Singh quietly.
“What the hell do you mean by that?”
“Chuck Vangsness is here. The ER doc that took care of Yoshiki Yahagi. He came in about an hour ago with pneumonia. He’s in the intensive care unit right now.”
Five
“Hey, we got a consult!”
The way Andy said it made him sound loopy, as though it was so slow in the Infectious Disease Department at LA County that a consult heralded big changes.
Susan tried hard not to laugh at the fourth-year med student. “What is it?”
“Listen,” Andy said as he pressed the message playback on the phone.
“Hi, this is Jenna Niven. I’m one of the medicine residents, and I have a consult for you. It’s a twenty-nine-year-old guy from up at Lake Arrowhead. Has a high fever, hypoxic, came in this morning. Real sick. It looks like he has a bubo in his right armpit. We’re thinking it’s plague, but we wanted you guys to take a look at it. We put him in isolation, just to be safe. Would you call me back? My pager number is two-one-three, eight-nine-zero-zero.”
Susan lifted her eyebrows. “Sounds intriguing. Want to take a look?”
“Yeah!”
Susan was astounded. So much enthusiasm. It boggled the mind. “Maybe we ought to call Ezra first, though. It’s not every day that you see a case of plague.” Susan smiled.
“Yeah, yeah,” said Andy quickly. “We don’t want to keep Ezra out of it. Wow. A case of plague.”
In truth, Susan wasn’t so sure it was plague. She had heard stories about a plague case surfacing at LA County fifteen years earlier, but plague just wasn’t that common anymore. There were maybe a handful of cases nationally each year, and they usually occurred out in the boonies, not in modern cities like Los Angeles.
“I’m calling the fellow,” Andy said as he punched in Ezra’s pager number into the phone.
“Go get ‘em, tiger.”
Andy turned to her. “Have you ever seen plague?”
“Nope.”
“Is it contagious?”
“If you’re bitten by a flea.”
“Then why did they put him in isolation?”
“Because a form called pneumonic plague can be contagious person to person, but I think the last case of that here was in the 1920s. It’s extremely rare.”
“Oh,” He looked so disappointed, Susan felt like laughing.
The phone rang. Andy nearly dove on it. “Ezra? It’s Andy. You’re not going to believe this. We got a consult. For plague! Some guy from Lake Arrowhead. Yeah. I’m sitting here with Susan. Yeah, she says she’ll go with me. Okay. All right. Good-bye.” Andy turned to her. “He doesn’t think it’s real. He wants us to go check it out.”
“Good,” said Susan. “It will be a first case of plague for me, too.”
Jenna hadn’t exaggerated. The guy was sick. The admitting team had placed him in the medical intensive care unit. Susan looked through the sliding glass door of the isolation room. The man didn’t look like he was breathing very well. His chest heaved with each breath, the muscles in his chest wall and neck straining. Susan knew it was only a matter of time before he wound up on the ventilator.
Jenna was standing at the nursing station, talking with the ICU attending and the nurse. They were poring over blood gas values. Susan pitied her fellow resident. Three days ago, this would have been Susan, trying to make the right decision, worried about the imminent crash of the patient.
“You going to intubate him?” Susan asked.
“I think we have to. He’s oxygenating like crap. His pO2 is sixty on a non-rebreather, and he’s tiring out.” Jenna handed Susan the blood gas values.
“Wow,” said Susan. “Was he this sick when he came in?”
“No, but nearly. You on ID this month?”
“Yeah.”
“Well, here’s the short version before we go stick a breathing tube down his throat. He’s a twenty-nine-year-old contractor from Lake Arrowhead, doing his regular contracting thing fixing up vacation homes, and he starts getting sick four days ago. Fever, muscle aches, malaise. He thinks he has the flu and doesn’t do anything about it until yesterday, when he feels so shitty, he can’t get out of bed. So his girlfriend brings him in to Lake Arrowhead Medical Center, and they find a bubo under his arm. So they draw some blood cultures, give him a couple of doses of gentamicin, and arrange for a helicopter ride over here. I think they knew some bad things were brewing in this guy.”
“So that’s all he’s received? A couple doses of gentamicin?”
“Yeah. I suppose we could throw him on some doxycycline. He’s pretty sick. What do you think?”
“Anything on the cultures?”
“Oh yeah. It’s the real thing. Our friend from the Middle Ages, the honest-to-god plague.”
Susan was impressed. “Yeah, let’s give him doxycycline. I think he can use all the help he can get. And let me call Ezra.”
Ezra paced in the Infectious Disease office. “I think this guy has plague pneumonia,” he said. “Did you see his chest X-ray?”
Susan had. It showed the whiteout pattern of Acute Respiratory Distress Syndrome. The Arrowhead contractor’s lungs were filled with blood and pus.
“Do you think he’ll make it?” Andy asked. He sat before a computer. The screen showed an article about Yersinia pestis.
“Dunno,” said Ezra. “The mortality rate of plague pneumonia is greater than fifty percent. That’s with treatment. Imagine what it was like back in the time of the Black Death. They had no treatment back then. That’s why a third of Europe died.”
“A third?” Andy looked up from the computer screen.
“Yeah. It took nearly five years to do it, but that’s what historians think. Twenty-five million dead in five years. Farmland went back to weed. Governments broke down. Whole cities emptied out. The plague would die out during the winter and kick back up in the spring, and the survivors had no idea what was causing it, so they pretty much went crazy trying to stop it.”
“Like how?” asked Susan.
Ezra went to the bookcase, pulled out a book called The Great Mortality, and tossed it at her. “Like the flagellants. It’s all in there. They were these medieval German guys who walked around in groups of hundreds, wearing hooded robes with red crosses on them. They believed the plague was punishment for human sin. They thought if they beat themselves, they could atone for that sin and maybe somehow stop the plague. They’d go from town to town and hold a public self-beating twice a day. They’d beat th
emselves with these iron studded whips until they were bloody. And when they were done, they’d round up some Jews to scapegoat and kill them.”
Andy’s face showed revulsion. “That’s terrible.”
“Yeah, and the worst part was that the plague had nothing to do with sin or Judaism. It had everything to do with rats and fleas. The rats had the plague and the fleas lived on the rats. Humans got it by being bitten by fleas.”
“So our patient got bitten by a flea?”
“I would assume so,” said Ezra. “But the flea probably didn’t live on a rat. Improved sanitation has pretty much gotten rid of rats. Nowadays, the host is usually some other kind of wild rodent, like a ground squirrel or a prairie dog—"
“There are no prairie dogs at Lake Arrowhead,” said Andy.
“No, but there are lots of ground squirrels. Most of the plague cases we see these days are out in rural areas. We only have our patient because Arrowhead felt they didn’t have the facilities to treat him.”
Susan looked up suddenly. “I’ve never seen plague before. But isn’t he the second or third case this year?”
Ezra’s eyes glowed. “Exactly! Plague is rare in the US. Less than twenty cases a year spread out across the western United States. But this year, we’ve already seen three cases in California alone, and it’s only May!”
“Three cases? Where?”
“Don’t you read? It’s all over the internet. There are three cases in the Lake Tahoe area, and now one here. It’s an epidemic!”
“Ezra!” Susan was shocked by his enthusiasm.
Ezra must have seen the horror on her face, because he toned down his next words. “All right, so maybe not an epidemic, but definitely a banner year for plague. I bet this will get Public Health up in a tizzy.”
DRYP Trilogy | Book 1 | DRYP [The Final Pandemic] Page 7